Updated: 9/14/2022

Traumatic Anterior Shoulder Instability (TUBS)

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  • summary
    • Traumatic Anterior Shoulder Instability, also referred to as TUBS (Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery), are traumatic shoulder injuries that generally occur as a result of an anterior force to the shoulder while its abducted and externally rotated and may lead to recurrent anterior shoulder instability.
    • Diagnosis is made clinically with the presence of positive anterior instability provocative tests and confirmed with MRI studies that may reveal labral and/or bony injuries of the glenoid and proximal humerus (Hill-Sachs lesion).
    • Treatment may be nonoperative or operative depending on the chronicity of symptoms, the presence of risk factors for recurrence, and the severity of labral and/or glenoid defects. In high-risk populations, surgery is often offered after a single dislocation event.
  • Epidemiology
    • Incidence
      • one of most common shoulder injuries
        • 1.7% annual rate in general population
    • Demographics
      • have a high recurrence rate that correlates with age at dislocation
        • up to 80-90% in teenagers (90% chance for recurrence in age <20)
    • Risk factors
      • markedly higher incidence in
        • military patients
        • contact athlete patients
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • anteriorly directed force on the arm when the shoulder is abducted and externally rotated
      • pathoanatomy
        • "on-track" versus "off-track" concept of Hill-Sachs lesion (instability as a bipolar concept)
          • Hill-Sachs defect is "off-track" and will "engage" on the glenoid if the size of the Hill-Sachs defect > glenoid articular track (HSI > GT)
          • conversely, the Hill-Sachs defect is "on track" and will NOT "engage" if the size of the Hill-Sachs defect < glenoid articular track (HSI < GT)
          • Glenoid Track (GT) = 0.83D-d (D = diameter of inferior glenoid, d = width of anterior glenoid bone loss)
          • Hill-Sachs Interval (HSI) = HS+BB (HS = width of the Hill-Sachs, BB = width of bony bridge)
          • may have implications regarding surgical management
            • goal is to convert on off-track lesion into an on-track lesion
    • Associated injuries
      • orthopaedic
        • labrum & cartilage Injuries
            • is an avulsion of the anterior labrum and anterior band of the IGHL from the anterior inferior glenoid.
            • is present in 80-90% of patients with TUBS
          • humeral avulsion of the glenohumeral ligament (HAGL)
            • occurs in patients slightly older than those with Bankart lesions
              • also found in female collegiate athletes
            • associated with a higher recurrence rate if not recognized and repaired
            • an indication for possible open surgical repair
          • glenoid labral articular defect (GLAD)
            • is a sheared off portion of articular cartilage along with the labrum
            • presence is a risk factor for failure following arthroscopic stabilization procedures
          • anterior labral periosteal sleeve avulsion (ALPSA)
            • can cause torn labrum to heal medially along the medial glenoid neck
            • associated with higher failure rates following arthroscopic repair
            • common finding in patients with recurrent instability managed nonoperatively
              • 97% of patients with recurrent instability have either a Bankart or ALPSA lesion
        • fractures & bone Defects
          • bony bankart lesion
            • is a fracture of the anterior inferior glenoid
            • present in up to 49% of patients with recurrent dislocations
            • higher risk of failure of arthroscopic treatment if not addressed
            • defect >20-25% is considered "critical bone loss" and is biomechanically highly unstable
              • stability cannot be restored with soft tissue stabilization alone (unacceptable >2/3 failure rate)
              • requires bony procedure to restore bone loss (Latarjet-Bristow, other sources of autograft or allograft)
              • recent studies suggest critical bone loss may be as low as 13.5%
              • each dislocation event causes, on average, 6.8% bone loss
              • glenoid takes on an inverted-pear appearance as bone loss increases
                • 89% failure rate following arthroscopic repair in patients with this glenoid morphology
          • Hill-Sachs defect
            • is a chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim.
            • is present in 80%-100% of traumatic dislocations and 25% of traumatic subluxations
            • is not clinically significant unless it engages the glenoid
          • greater tuberosity fracture
            • is associated with anterior dislocation in patients > 50 years of age
            • increases risk of recurrence
          • lesser tuberosity fracture
            • is associated with posterior dislocations
        • nerve injuries
          • axillary nerve injury
            • is most often a transient neurapraxia of the axillary nerve
            • present in up to 5% of patients
        • rotator cuff tears
          • 30% of TUBS patients > 40 years of age
          • 80% of TUBS patients > 60 years of age
      • medical
        • global hyperlaxity (i.e. Ehlers-Danlos Syndrome, collagen disorders)
          • often associated with atraumatic instability
          • global hyperlaxity confers an odds ratio (OR) of 2.68 for the development of anterior shoulder instability
          • individuals with global hyperlaxity have a 3x higher rate of recurrent instability
        • patients with global hyperlaxity are less likely to develop capsulolabral lesions
  • Anatomy
    • Glenohumeral anatomy
    • Static restraints
      • bony anatomy
      • capsule 
      • glenohumeral ligaments
      • labrum
        • labrum contributes 50% of additional glenoid depth
    • Dynamic restraints
      • rotator cuff muscles
      • long head of biceps tendon 
    • Anterior static shoulder stability is provided by
      • Anterior band of IGHL (main restraint)
        • provides static restraint with arm in 90° of abduction and external rotation
      • MGHL
        • provides static restraint with arm in 45° of abduction and external rotation
      • SGHL
        • provides static restraint with arm at the side
  • Classification
      • Anteroposterior Translation Grading Scheme
      • Grade 0
      • Normal glenohumeral translation
      • Grade 1+
      • Humeral head translation up to glenoid rim 
      • Grade 2+
      • Humeral head translation over glenoid rim with spontaneous reduction once force withdrawn 
      • Grade 3+
      • Humeral head translation over glenoid rim without spontaneous reduction
      • Sulcus Test Grading Scheme
      • Grade 1
      • Acromiohumeral interval < 1cm
      • Grade 2
      • Acromiohumeral interval 1-2 cm
      • Grade 3
      • Acromiohumeral interval > 2cm
      • Instability Severity Score
      • Variable
      • Parameter
      • Score
      • Age
      • < 20 years
      • > 20 years
      • 2
      • 0
      • Degree of sports participation
      • Competitive
      • Recreational/none
      • 2
      • 0
      • Type of sport participation
      • Contact/forced overhead
      • Other
      • 1
      • 0
      • Shoulder Hyperlaxity
      • Hyperlaxity (anterior/inferior)
      • Normal
      • 1
      • 0
      • Hill sachs on AP x-ray
      • Visible on external rotation
      • Not visible on external rotation
      • 2
      • 0
      • Glenoid contour loss on AP x-ray
      • Loss of contour
      • No lesions
      • 2
      • 0
      • Clinical Implications 
      • Total Possible = 10
      • An acceptable recurrence risk of 10% with arthroscopic stabilization.
      • < 6 points
      • A score of > 6 points has an unacceptable recurrence risk of 70% and should be advised to undergo open surgery (i.e. Laterjet procedure).
      • > 6 points
  • Presentation
    • History
      • patients often recount a traumatic event leading to a dislocation
      • important to clarify whether patient needed a formal reduction, or if they spontaneously reduced
    • Symptoms
      • traumatic event causing dislocation
      • feeling of instability
      • shoulder pain complaints
        • caused by subluxation and excessive translation of the humeral head on the glenoid
    • Physical exam
      • load and shift
        • Grade 0 - normal glenohumeral translation
        • Grade I - translation to the glenoid rim, without dislocation 
        • Grade II - shifts over glenoid rim, spontaneously reduces
        • Grade III - shifts over glenoid rim, does not spontaneously reduce
      • apprehension sign
        • patient supine with arm 90 degrees abducted and 90 degrees externally rotated
        • positive when patients experiences apprehension
        • positive sign in mid-ranges of abduction is highly suggestive of concomitant glenoid bone loss
      • relocation sign
        • decrease in apprehension with anterior force applied on shoulder during apprehension testing
      • sulcus sign
        • tested with patient's arm at side
      • generalized ligamentous laxity
        • increased risk of recurrent instability in patients with hyperlaxity
        • assess via Beighton's criteria (score > 4)
        • shoulder specific laxity defined as
          • hyperexternal rotation at side > 85 degress
          • hyperabduction > 105 degrees (Gagey's maneuver)
          • OR > 2+ load shift in 2 or more planes (anterior, posterior, inferior)
  • Imaging
    • Radiographs
      • see imaging of shoulder
      • recommended views
        • a complete trauma series needed for evaluation
          • true AP
          • scapular Y
          • axillary
      • optional views
        • West Point view
          • shows glenoid bone loss
        • Stryker view
          • shows Hill-Sachs lesion
    • CT scan +/- arthrogram
      • indications
        • helpful for evaluation of bony injuries and calculation of glenoid bone loss
        • arthrogram usually reserved for patients who are unable to undergo MRI i.e. patients with pacemakers and/or cochlear implants
      • due to limited soft-tissue contrast, CT arthrogram not as effective at visualizing internal soft-tissue derangements as MR arthrogram
    • MRI
      • indications
        • best for visualization of labral tear
        • has been validated as an imaging modality through which to assess bone loss
    • MR Arthrogram
      • increases sensitivity and specificity (86-91% and 86-96%) for detecting soft-tissue injuries when compared to conventional MRI (44-100% and 66-95%)
  • Treatment
    • Nonoperative
      • acute reduction, ± immobilization, followed by therapy
        • indications
          • management of first-time dislocators remains controversial
            • current ASES recommendations are for surgical intervention for athletes aged 14 to 30 at the end of their competitive season if they have positive apprehension testing and bone loss
        • reduction
          • simple traction-countertraction is most commonly used
          • other reduction techniques include:
            • Kocher: arm at side in external rotation is forward-flexed and then internally rotated
            • Hippocratic: traction against a heel placed in the patients axilla
            • Stimson's: weight is hung from the affected arm of a patient in the prone position
        • immobilization
          • studies have not shown any benefit of immobilization > 1 week for decreasing recurrence rates
          • some studies show immobilization in external rotation decreases recurrence rates in patients < 40
            • thought to reduce the anterior labrum to the glenoid leading to more anatomic healing
            • subsequent studies have refuted this finding and the initially published results have not been reproducible
        • physical therapy
          • strengthening of dynamic stabilizers (rotator cuff and periscapular musculature)
        • outcomes
          • goal is return to sport within 7 to 21 days
          • military and overhead and/or contact athletes experience an unacceptably high rate of recurrent instability
          • risk factors for re-dislocation are
            • age < 20 (highest risk)
            • male
            • contact sports
            • hyperlaxity
            • glenoid bone loss >20-25%
            • greater tuberosity fractures
    • Operative
      • Arthroscopic Bankart repair +/- capsular plication
        • indications
          • relative indications
            • first-time traumatic shoulder dislocation with Bankart lesion confirmed by MRI in athlete younger than 25 years of age
            • high demand athletes
            • recurrent dislocation/subluxation (> one dislocation) following nonoperative management
            • < 20-25% glenoid bone loss
            • remplissage augmentation with arthroscopic Bankart may be considered if Hills-Sachs "off-track"
        • techniques
          • at least three (preferably four) anchor points shoulder be used
          • paramount that labrum is fully mobilized prior to repair
        • outcomes
          • results now equally efficacious as open repair with the advantage of less pain and greater motion preservation
          • increased failure rates seen in patients with global hyperlaxity, glenoid bone loss, or too few fixation points
            • too many anchors does pose a risk for fracture through the anchor holes (postage stamp fracture)
      • Open Bankart repair +/- capsular shift
        • indications
          • Bankart lesion with glenoid bone loss < 20-25%
          • revision stabilization following failed arthroscopic Bankart repair without glenoid bone loss >20%
          • can be considered when there is a concomitant acute glenoid fracture, or if the patient is hyperlax and requires a formal capsular shift during the same procedure
          • humeral avulsion of the glenohumeral ligament (HAGL)
            • can also be performed arthroscopically but is technically challenging
        • technique
          • generally accessed through a deltopectoral approach
          • can fix bony bankart with screws or suture in a linear or bridge technique
        • outcomes
          • results are equivalent to arthroscopic repair, although patients have more pain and less range of motion postoperatively
          • patients with greater than 13.5% glenoid bone loss have higher rates of recurrent instability
      • Latarjet (coracoid transfer) or Bristow Procedure
        • indications
          • chronic bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid)
            • in the setting of glenoid bone loss, excessive stress is transferred to labrum and attenuated anterior soft tissues, increasing the risk of failure of labral repair alone
          • transfer of coracoid bone with attached conjoined tendon and CA ligament
          • Latarjet procedure performed more commonly than Bristow
          • Latarjet triple effect = bony (increases glenoid track), sling (conjoined tendon on top of subscapularis), capsule reconstruction (CA ligament)
        • technique
          • deltopectoral approach
          • subscapularis is split
        • outcomes
          • over recurrent instability rate ranges from 0% to 8%
          • good to excellent outcomes are seen in over 90% of patients
      • Autograft (tricortical iliac crest or distal clavicle) or allograft (iliac crest or distal tibia)
        • indications
          • bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid)
          • revision of failed latarjet
        • technique
          • can be performed arthroscopic or open
          • distal tibia gaining popularity since graft is a true osteochondral graft
        • outcomes
          • 89% healing rate at a mean of 1.4 years
      • Remplissage + Bankart Repair 
        • indication
          • engaging large (>25-40%) Hill-Sachs defect
          • "off-track" Hill-Sachs lesions with <20-25% glenoid bone loss
        • technique
          • posterior capsule and infraspinatus tendon sutured into the Hill-Sachs lesion
          • may be performed with concomitant Bankart repair
          • by decreasing size of Hill-Sachs, converts on off-track lesion into an on-track lesion
        • outcomes
          • when compared to latarjet with 2-year outcomes, remplissage + bankart had lower recurrent instability rates (1.4% vs. 3.2%) despite greater bipolar bone loss
      • Bone graft reconstruction for Hill Sachs defects
        • indication
          • engaging large (>40%) Hill-Sachs lesions
        • technique
          • allograft reconstruction
          • arthroplasty
          • rotational osteotomy
        • outcomes
      • Tendon transfers 
        • indication
          • chronic, irreparable subscapularis tear 
        • technique
          • latissimus dorsi
            • may better replicate line of pull of native subscapularis
          • pectoralis major - sternal head
        • outcomes
      • Historical procedures: Putti-Platt / Magnuson-Stack / Boyd-Sisk
        • indications
          • led to over-constraint and arthrosis
        • technique
          • goal is to tighten subscapularis
          • Putti-Platt is performed by lateral advancement of subscapularis and medial advancement of the shoulder capsule
          • Magnuson-Stack is performed with lateral advancement of subscapularis (lateral to bicipital groove and at times to greater tuberosity)
          • Boyd-Sisk is transfer of biceps laterally and posteriorly
        • outcomes
          • high rate of post-operative stiffness and subsequent osteoarthritis
            • typical presentation of open procedure performed in 1970s-80s, now with presenting complaint of pain and stiffness from glenohumeral OA, especially lack of ER, and signigicant posterior glenoid wear and retroversion
          • high rate of recurrent instability with Boyd-Sisk
  • Techniques
    • Acute Reduction +/- Immobilization followed by physical therapy
      • indications
        • relaxation of patient with sedation or intraarticular lidocaine is essential
      • techniques
      • pros/cons
      • complications
    • Arthroscopic Bankart Repair + Capsular plication
      • indications
      • approach
        • shoulder arthroscopic approach
      • technique
        • drive through sign might be present prior to labral repair and capsulorraphy
        • studies support use of > 3 anchors (< 4 anchors is a risk factor for failure)
      • complications
        • recurrence, most often due to unrecognized glenoid bone loss or lack of concomitantly addressing "off-track" HS lesion
        • stiffness, especially in external rotation, further loss of ER may occur with the addition of remplissage
          • over-tightening increases the risk of post-capsulorrhaphy arthropathy, especially in older patients
        • axillary nerve injury
          • axillary nerve is on average 12mm from infra-glenoid tubercle
        • chondrolysis (from use of thermal capsulorraphy which is no longer used)
    • Open Bankart repair +/- capsular shift
      • indications
      • approach
        • shoulder anterior (deltopectoral) approach
      • technique
        • subscapularis transverse split or tenotomy
        • open labral repair and capsulorraphy
        • capsular shift
          • inferior capsule is shifted superiorly
      • complications
        • recurrence
          • most often due to unrecognized glenoid bone loss
        • subscapularis injury or failed repair
          • post-operative physical exam will show a positive lift off and excessive ER
        • stiffness 
          • caused by overtightening of capsule
          • leads to loss of external rotation
          • treat with Z lengthening of subscapularis
        • axillary nerve injury
          • iatrogenic injury with surgery (avoid by abduction and ER of arm during procedure)
        • arthritis
          • usually wear of posterior glenoid
          • may have internal rotation contracture
          • seen with Putti-Platt and Magnuson-Stack procedures
    • Latarjet or Bristow Procedure
      • indications
      • approach
        • shoulder anterior (deltopectoral) approach
        • can be performed arthroscopically
      • technique
        • coracoid transfer to anterior inferior glenoid bone defect
        • traditional or congruent arc technique for coracoid graft placement
        • after harvest, coracoid is passed through a split in the distal 1/3 or middle 1/2 subscapularis
        • traditional versus congruent arc technique
          • in the congruent arc technique, the undersurface of the coracoid ends up articulating with the humeral head
        • graft can be placed intraarticularly (capsular repaired to CA ligament stump) or extraarticularly (capsule repaired to native glenoid rim)
          • concerns exist for increased rates of subsequent osteoarthritis with intraarticular placement, although this isn't fully supported by high-quality literature
        • generally higher than arthroscopic or open Bankart, some studies report up to 25% incidence
        • nonunion
        • graft lysis
          • up to 90% of patients undergo some degree of resorption within the first six months
        • hardware problems
        • stiffness, particularly in external rotation
        • glenohumeral osteoarthritis
          • will rapidly occur with lateral overhang of graft into the joint space
          • occurs in up to 38% of patients
        • nerve injury
          • majority are traction or contusion neuropraxias and resolve spontaneously
            • treat with observation for 3-6 weeks; delayed EMG if deficits persist
          • musculocutaneous nerve
            • occurs during instrumentation around the conjoint tendon
            • pieces conjoint tendon, on average, 5.6 cm distally to the tip of the coracoid
          • axillary nerve
            • occurs during graft fixation
            • located, on average, 12mm from infra-glenoid tubercle
    • Autograft (tricortical iliac crest or distal clavicle) or allograft (iliac crest or distal tibia)
      • indications
      • approach
      • technique
      • complications
    • Remplissage + Bankart Repair
      • indications
      • approach
      • technique
      • complications
    • Bone graft reconstruction for Hill-Sachs defects
      • indications
      • approach
      • technique
      • complications
    • Tendon transfers 
      • indications
      • approach
      • technique
      • complications
    • Historical procedures: Putti-Platt / Magnuson-Stack / Boyd-Sisk
      • indications
      • approach
      • technique
        • Putti-Platt is performed by lateral advancement of subscapularis and medial advancement of the shoulder capsule
        • Magnuson-Stack is performed with lateral advancement of subscapularis (lateral to bicipital groove and at times to greater tuberosity)
        • Boyd-Sisk transfer of biceps laterally and posteriorly
      • outcomes
        • Putti-Platt and Magnuson-Stack both lead to decreased external rotation and increased loading on the posterior glenoid, which can lead to post-capsulorraphy arthropathy
  • Complications
    • Recurrence
      • often due to unrecognized glenoid bone loss treated with a soft tissue only procedure (especially with glenoid bone loss >20-25%)
      • can be due to poor surgical technique (ie, < 4 suture anchors)
      • increased risk with preoperative risk factors including age < 20, male sex, contact/collision sport, ligamentous laxity, and unrecognized glenoid and/or humeral head bone loss (critical bone loss or "off-track" lesion)
      • medical management should be exhausted prior to surgery in patients with seizures, as there is a high recurrence risk even when bony augmentation techniques are used
      • unrecognized pan-labral tear
        • high incidence of posterior and/or combined front-to-back tears in the military population
    • Shoulder pain
      • overtightening during labral repair can lead to post-capsulorrhaphy arthropathy
    • Nerve injury
      • musculocutaneous (most common)
      • axillary
    • Stiffness
      • especially in external rotation (particularly with Latarjet and additional remplissage)
    • Infection
    • Graft lysis (Latarjet)
      • present in up to 90% of patients at six-months
    • Hardware complications
      • anchor pull-out (Bankart repair)
      • screw pull-out (Latarjet)
    • Chondrolysis
      • historically due to use of thermal capsulorraphy (now contraindicated) or intra-articular pain pumps (now contraindicated)
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(OBQ19.96) A 61-year-old male presents to your office for evaluation of his right shoulder. He sustained the injury shown in Figure A three weeks ago after trying to catch himself as he fell off a dock. He was subsequently treated in the emergency department and discharged home. Which of the following provocative maneuvers indicates the most common associated pathology in this age cohort?

QID: 213998
FIGURES:

O'Brien's test

5%

(73/1366)

Apprehension sign

18%

(252/1366)

Drop arm test

69%

(938/1366)

Bear hug test

7%

(89/1366)

Spurling's maneuver

1%

(9/1366)

L 3 A

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(OBQ18.210) A 24-year-old football player presents with recurrent shoulder instability. An arthroscopic labral repair in isolation without a bony procedure would result in a higher failure rate if performed for which of the following imaging studies?

QID: 213106
FIGURES:

Figure A

2%

(51/2181)

Figure B

2%

(43/2181)

Figure C

11%

(238/2181)

Figure D

79%

(1719/2181)

Figure E

5%

(104/2181)

L 3 A

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(OBQ18.165) A 17-year-old basketball player presents to your office with persistent shoulder soreness following a fall during a game 2 months ago. Immediately following this incident, a teammate manipulated the shoulder, which resolved his pain and allowed him to finish the game. His current radiograph is shown in Figure A. Based on his MRI shown in Figure B, what structure is torn, what is the eponym for this lesion, and at what position does it most contribute to stability?

QID: 213061
FIGURES:

Anterior-inferior labrum, Bankart lesion, external rotation with shoulder abducted at 45°

16%

(303/1923)

Anterior-superior labrum, HAGL lesion, internal rotation with shoulder abducted at 90°

6%

(110/1923)

Posterior-inferior labrum, GLAD lesion, internal rotation with shoulder abducted at 45°

2%

(34/1923)

Anterior-inferior labrum, Bankart lesion, external rotation with shoulder abducted at 90°

74%

(1423/1923)

Posterior-inferior labrum, ALPSA lesion, external rotation with shoulder abducted at 45°

2%

(32/1923)

L 3 A

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(OBQ18.108) A 20-year-old female presents with recurrent anterior shoulder instability. Imaging is obtained and demonstrates a bony Bankart lesion involving 40% of the glenoid. A Laterjet procedure is planned for the patient. Which of the nerves in Figure A is most at risk during the planned procedure?

QID: 213004
FIGURES:

A

24%

(480/2032)

B

1%

(25/2032)

C

2%

(37/2032)

D

3%

(58/2032)

E

69%

(1405/2032)

L 3 A

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(SBQ16SM.3) A collegiate waterpolo player presents to your office for a second opinion. He has had 2 anterior dislocations of his throwing shoulder, both of which were able to be reduced on the pool deck. However, he feels the shoulder is still unstable and cannot return to play at his desired level. Which of the below factors places him at greatest risk for recurrent dislocation following isolated arthroscopic labral repair?

QID: 211139

Instability of dominant arm

2%

(38/1779)

Overhead throwing athlete

12%

(219/1779)

Age under 25 years

39%

(692/1779)

Labral tear involving the biceps attachment

2%

(37/1779)

An inverted pear-shaped glenoid on arthroscopy

44%

(775/1779)

L 1 B

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(OBQ14.178) Figure A is a glenoid CT 3D reconstruction of a 26-year-old accountant who has recurrent shoulder instability. His first dislocation occurred after a fall while skiing. He has now sustained his third dislocation, which was reduced in the emergency department prior to being sent to your office. What is the most appropriate definitive treatment?

QID: 5588
FIGURES:

Immobilization in external rotation for 6 weeks

1%

(39/4688)

Arthroscopic bony Bankart repair

69%

(3227/4688)

Arthroscopic Remplissage procedure

4%

(165/4688)

Glenoid augmentation using coracoid transfer

22%

(1045/4688)

Glenoid augmentation using tricortical iliac crest graft

2%

(72/4688)

L 3 A

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(OBQ13.118) A 30-year-old man undergoes arthroscopic Bankart repair for recurrent anterior dislocation. He continues to experience instability postoperatively. Examination reveals a positive apprehension test. Radiographs of both shoulders are seen in Figure A. CT scan of his left shoulder is seen in Figure B. What is the best treatment option?

QID: 4753
FIGURES:

Bankart repair

13%

(518/4103)

Humeral head bone augmentation

2%

(67/4103)

Remplissage

6%

(251/4103)

Coracoid autograft

73%

(3015/4103)

Connolly procedure

3%

(118/4103)

L 3 B

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(OBQ12.9) A 38-year-old former professional football player complains of longstanding left shoulder pain. He admits to multiple previous shoulder dislocations in the past which were treated conservatively with physical therapy. He now complains of symptoms of repetitive instability and a "catching" feeling whenever he abducts and externally rotates his arm. On physical exam he has a positive apprehension test and crepitus in the 90/90 position. A current MRI image of his shoulder is seen in Figure A. Which of the following surgical treatments is most appropriate to address his symptoms?

QID: 4369
FIGURES:

Superior labrum anterior to posterior (SLAP) repair

5%

(312/6911)

Open approach for bone grafting of humeral defect with allograft

5%

(353/6911)

Open repair of humeral avulsion of glenohumeral ligament (HAGL) lesion

4%

(306/6911)

Remplissage procedure

3%

(223/6911)

Arthroscopic Bankart repair and Remplissage procedure

82%

(5643/6911)

L 2 B

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(OBQ11.19) A 22-year-old collegiate football player has immediate onset of left shoulder pain after a tackle. He reports a history of multiple subluxations in the past, but this is the first time he had to "pop" his shoulder back into place. On examination 3 days later, he has weakness in the deltoid. CT axial image is displayed in Figure A. Which of the following is the MOST appropriate next step in management.

QID: 3442
FIGURES:

Humeral avulsion of the glenohumeral ligament (HAGL lesion) stabilization and EMG/NCV studies

2%

(85/4207)

Immobilization in sling with external rotation and EMG/NCV studies

8%

(331/4207)

Anterior labral periosteal sleeve avulsion (ALPSA) stabilization

4%

(175/4207)

Bony Bankart lesion stabilization

85%

(3573/4207)

Transfer of the infraspinatus tendon and greater tuberosity to the humeral head

0%

(13/4207)

L 2 A

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(OBQ11.220) A 24-year-old male gymnast is scheduled for arthroscopic repair of the right shoulder. His preoperative MRI is seen in Figure A and the initial arthroscopic examination as viewed from an anterior portal in the lateral decubitus position is demonstrated in Figure B. Based on these images, which of the following diagnoses is correct?

QID: 3643
FIGURES:

Partial articular sided thickness rotator cuff tear (PASTA)

4%

(209/5177)

Anterior labral periosteal sleeve avulsion (ALPSA)

5%

(258/5177)

Humeral avulsion of the glenohumeral ligament (HAGL)

83%

(4278/5177)

Glenoid labral articular defect (GLAD)

3%

(132/5177)

Superior labral anterior posterior lesion (SLAP)

5%

(236/5177)

L 1 B

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(OBQ10.77) A 23-year-old man acutely dislocates his shoulder for the first time while kayaking. His shoulder MRI is shown in Figures A and B. He undergoes arthroscopic Bankart repair and re-dislocates his shoulder within 1 month after surgery. What other pathology, besides the Bankart lesion, is likely contributing to this patient's recurrent instability?

QID: 3165
FIGURES:

Superior labrum anterior posterior (SLAP) tear

4%

(89/2254)

Supraspinatus partial articular sided tendon avulsion (PASTA)

2%

(52/2254)

Humeral avulsion of the glenohumeral ligament (HAGL)

79%

(1789/2254)

Engaging (>25%) Hill Sachs defect

9%

(204/2254)

Anterior labral periosteal sleeve avulsion (ALPSA)

5%

(102/2254)

L 1 C

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(OBQ10.63) A 25-year-old basketball player sustains an anterior shoulder dislocation during a game that is subsequently reduced with traction. A MRI will most likely show which of the following?

QID: 3151

Supraspinatus tear

1%

(59/4908)

Humeral avulsion of the glenohumeral ligaments

6%

(311/4908)

Long head of the biceps tear

0%

(16/4908)

Superior labrum anterior to posterior tear

8%

(388/4908)

Anteroinferior labral tear

84%

(4101/4908)

L 1 B

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(OBQ09.133) Which patient would be ideal for an open shoulder reduction and glenoid bone augmentation?

QID: 2946

25-year-old with first time acute traumatic dislocation

1%

(11/2044)

78-year-old with a rotator cuff tear arthropathy with superior escape

1%

(12/2044)

24-year-old with chronic dislocation and large engaging Hill-Sachs lesion

10%

(201/2044)

30-year-old with an acute bony Bankart fracture-dislocation

10%

(204/2044)

27-year-old with a chronic anterior dislocation and inverted pear-shaped glenoid

79%

(1606/2044)

L 2 C

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(OBQ09.136) The pathology seen in Figure A is most likely to result from trauma that occurred with the shoulder in which of the following positions?

QID: 2949
FIGURES:

Adduction, internal rotation

4%

(101/2779)

Adduction, external rotation

9%

(253/2779)

Abduction, external rotation

85%

(2372/2779)

Extension, internal rotation

1%

(35/2779)

Axial traction in adduction

0%

(7/2779)

L 1 B

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(OBQ09.143) An 18-year-old football player sustains an anterior shoulder dislocation that is reduced on the field. When he presents to the office complaining of posterior pain, you suspect a Hill-Sachs defect. Which of the following is the best radiographic view for identifying a Hill-Sachs defect?

QID: 2956
FIGURES:

Figure A

3%

(100/3062)

Figure B

2%

(56/3062)

Figure C

65%

(1980/3062)

Figure D

2%

(62/3062)

Figure E

28%

(845/3062)

L 3 B

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(SAE08OS.8) What is the most common neurologic problem associated with a simple shoulder dislocation?

QID: 6370

A neurapraxic brachial plexus injury

1%

(6/665)

A neurapraxic axillary nerve injury

94%

(625/665)

A neurapraxic musculocutaneous nerve injury

2%

(16/665)

A neurotmetic axillary nerve injury

2%

(10/665)

An axonotmetic musculocutaneous nerve injury

0%

(3/665)

L 1 E

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(OBQ08.45) A patient sustains the injury seen on the radiograph in Figure A. Which nerve is most likely to be injured?

QID: 431
FIGURES:

Suprascapular

8%

(130/1669)

Upper or lower subscapular

4%

(65/1669)

Musculocutaneous

2%

(38/1669)

Radial

0%

(8/1669)

Axillary

85%

(1425/1669)

L 1 C

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(OBQ07.259) What factor has highest risk for recurrent instability following a traumatic anterior shoulder dislocation?

QID: 920

History of contralateral shoulder dislocation

7%

(70/1033)

Young age (<20-years-old) at time of dislocation

84%

(872/1033)

Dislocation of the dominant shoulder

4%

(42/1033)

Family history of shoulder instability

2%

(19/1033)

History of patella instability

2%

(22/1033)

L 2 C

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(OBQ07.80) An athlete has recurrent anterior shoulder instability despite non-operative treatment including PT and bracing. He is noted to have anterior glenoid bone loss and a coracoid transfer (Latarjet) procedure is recommended. This is believed to improve stability through which of the following mechanism(s)?

QID: 741

Increasing the glenoid bony support and excursion distance prior to dislocation.

6%

(122/1892)

The conjoined tendon passing through the subscapularis becomes a supportive sling.

1%

(23/1892)

Answers 1, 2 and 5 are correct.

60%

(1139/1892)

Both 1 and 2 are correct.

29%

(543/1892)

The remnant of the CA ligament can be used to aid in repair of the capsular tissues.

3%

(52/1892)

L 2 C

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(OBQ07.216) A 17-year-old football player sustained an injury to his shoulder. The MRI images are seen in Figures A and B. What is the most likely finding seen at the time of arthroscopy?

QID: 877
FIGURES:

Rotator cuff tear

3%

(60/2032)

SLAP tear

8%

(171/2032)

Bankart lesion

81%

(1648/2032)

Glenoid fracture

2%

(31/2032)

Humeral avulsion of glenohumeral ligaments (HAGL)

6%

(115/2032)

L 3 B

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(OBQ07.252) What nerve is the most frequently injured in the condition shown in the radiograph?

QID: 913
FIGURES:

Axillary

97%

(1024/1058)

Median

0%

(2/1058)

Musculocutaneous

1%

(15/1058)

Radial

0%

(5/1058)

Suprascapular

1%

(6/1058)

L 1 C

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(OBQ07.130) A 22-year-old basketball player has recurrent instability of the left shoulder. Magnetic resonance imaging is shown in Figures A and B. Which of the following ligaments is injured?

QID: 791
FIGURES:

Inferior glenohumeral

81%

(1528/1882)

Middle glenohumeral

12%

(224/1882)

Superior glenohumeral

4%

(67/1882)

Coracohumeral

3%

(54/1882)

Coracoacromial

0%

(1/1882)

L 1 B

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(OBQ06.256) What is the most common finding during surgery for traumatic anterior shoulder instability?

QID: 267

Anterosuperior labral tear

11%

(120/1118)

Anteroinferior labral tear

75%

(840/1118)

Posterosuperior labral tear

2%

(18/1118)

Posteroinferior labral tear

1%

(10/1118)

Hill Sachs lesion

11%

(124/1118)

L 2 B

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(OBQ06.49) A patient undergoes an MRI arthrogram for recurrent shoulder instability. Based on the imaging, the surgeon feels that arthroscopic treatment is contra-indicated and recommends open treatment. What is the most likely diagnosis?

QID: 160

Glenolabral articular disruption (GLAD)

14%

(145/1036)

Humeral avulsion of the glenohumeral ligament (HAGL)

61%

(630/1036)

Superior labrum tear from anterior and posterior (SLAP)

3%

(33/1036)

Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA)

18%

(184/1036)

Partial articular-sided supraspinatus tendon avulsion (PASTA)

3%

(36/1036)

L 3 D

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(OBQ06.59) A 23-year-old offensive lineman had an arthroscopic anteroinferior labral repair 1 year ago for shoulder instability. He has continued to have recurrent instability. Below is the preoperative MRI from 1 year ago. What is the most likely cause of the recurrent instability?

QID: 170
FIGURES: