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https://upload.orthobullets.com/topic/3050/images/17_moved.jpg
https://upload.orthobullets.com/topic/3050/images/hill sachs.jpg
https://upload.orthobullets.com/topic/3050/images/shoulder mri- anterior dislocation.jpg
https://upload.orthobullets.com/topic/3050/images/shoulder-arthoscopic labral repair.jpg
Introduction
  • TUBS (Traumatic Unilateral dislocations with a Bankart lesion requiring Surgery)
  • 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 q
      • up to 80-90% in teenagers (90% chance for recurrence in age <20)
  • Pathophysiology
    • mechanism
      • anteriorly directed force on the arm when the shoulder is abducted and externally rotated  
    • "on-track" versus "off-track" concept (instability as a bipolar concept)
      • Hill-Sach's defect is "off-track" and will "engage" on the glenoid if size HS defect > glenoid articular track
      • conversely, Hill-Sach's defect is "on track" and will NOT "engage" if HS defect < glenoid articular track 
      • GT=0.83D-d (GT = Glenoid Track, D = diameter of inferior glenoid, d = width of anterior glenoid bone loss) 
      • may have implications regarding surgical management 
  • Associated injuries  
    • labral & cartilage injuries
      • Bankart lesion q q q
        • 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)  q q 
        • occurs in patients slightly older than those with Bankart lesions
        • associated with a higher recurrence rate if not recognized and repaired q
        • an indication for possible open surgical repair q
      • Glenoid labral articular defect (GLAD)
        • is a sheared off portion of articular cartilage along with the labrum
      • 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 
    • 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)
          • require 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%
      • Hill Sachs defect  
        • is a chondral impaction injury in the posterosuperior humeral head secondary to contact with the glenoid rim.
        • is present in 80% of traumatic dislocations and 25% of traumatic subluxations q
        • is not clinically significant unless it engages the glenoid
      • Greater tuberosity fracture
        • is associated with anterior dislocation in patients > 50 years of age
      • Lesser tuberosity fracture
        • is associated with posterior dislocations 
    • nerve injuries
      • Axillary nerve injury
        • is most often a transient neurapraxia of the axillary nerve q 
        • 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
Anatomy
  • Glenohumeral anatomy  
  • Static (bony anatomy, capsule, labrum, glenoid) and dynamic (rotator cuff, long head of biceps tendon) constraints
    • labrum contributes 50% of additional glenoid depth 
  • 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° oabduction 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 with locking
 
Sulcus Test Grading Scheme
Grade 1  • Acromiohumeral interval <1cm
Grade 2  • Acromiohumeral interval 1-2cm
Grade 3  • Acromiohumeral interval >2cm
 
Instability Severity Score
Variable Parameter SCORE
AGE < 20 years 2
> 20 years 0
DEGREE OF SPORTS PARTICIPATION  Competitive 2
Recreational/none 0
TYPE OF SPORT PARTICIPATION  Contact/forced overhead 1
Other 0
SHOULDER HYPERLAXITY  Hyperlaxity (anterior/inferior) 1
Normal 0
HILL SACHS ON AP XRAY  Visible on external rotation 2
Not visible on external rotation 0
GLENOID  CONTOUR LOSS ON AP XRAY  Loss of contour 2
No lesion 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
  • 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 topic
    • load and shift
      • Grade I - increased translation, no subluxation
      • Grade II - subluxation of humeral head to, but not over, glenoid rim
      • Grade III - dislocation of humeral head over glenoid rim
    • apprehension sign
      • patient supine with arm in 90/90 position
      • 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
    • sulcus sign
      • tested with patient's arm at side
    • generalized ligamentous laxity
      • assess via Beighton's criteria
      • shoulder specific laxity defined as
        • hyperexternal rotation at side > 85 degress
        • hyperabduction > 120 degrees (Gagey's maneuver)
        • OR > 2+ load shift in 2 or more planes (anterior, posterior, inferior)
Imaging
  • Radiographs
    • see imaging of shoulder 
    • a complete trauma series needed for evaluation 
      • true AP
      • scapular Y
      • axillary
    • other helpful views
      • West Point view
        • shows glenoid bone loss
      • Stryker view
        • shows Hill-Sachs lesion
  • CT scan
    • helpful for evaluation of bony injuries
  • MRI  
    • best for visualization of labral tear
    • addition of intraarticular contrast 
      • increases sensitivity and specificity 
Treatment
  • Nonoperative
    • acute reduction, ± immobilization, followed by therapy
      • indications
        • management of first-time dislocators remains controversial
        • risk factors for re-dislocation are
          • age < 20 (highest risk)
          • male
          • contact sports
          • hyperlaxity
          • glenoid bone loss >20-25%
      • reduction
        • simple traction-countertraction is most commonly used
        • relaxation of patient with sedation or intraarticular lidocaine is essential
      • immobilization
        • some studies show immobilization in external rotation decreases recurrence rates
          • 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) 
  • Operative
    • Arthroscopic Bankart repair +/- capsular shift   
      • 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 
          • < 20-20% glenoid bone loss 
          • remplissage augmentation with arthroscopic Bankart may be considered if Hills-Sachs "off-track"
      • outcomes
        • results now equally efficacious as open repair with the advantage of less pain and greater motion preservation
    • Open Bankart repair +/- capsular shift
      • indications
        • Bankart lesion with glenoid bone loss < 20-25%  q q q 
        • revision stabilization following failed arthroscopic Bankart repair without glenoid bone loss >20%
        • humeral avulsion of the glenohumeral ligament (HAGL)
          • can also be performed arthroscopically but is technically challenging
    • Latarjet (coracoid transfer) and Bristow Procedures for glenoid bone loss  
      • indications
        • chronic bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid) 
        • 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)
    • Autograft (tricortical iliac crest) or allograft (iliac crest or distal tibia) for glenoid bone loss
      • indications
        • bony deficiencies with >20-25% glenoid deficiency (inverted pear deformity to glenoid) 
        • revision of failed latarjet
    • Remplissage technique for Hill Sachs defects
      • indication
        • engaging large (>25-40%) Hill-Sachs defect q
        • "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
    • Bone graft reconstruction for Hill Sachs defects
      • indication
        • engaging large (>40%) Hill-Sachs lesions
      • technique
        • allograft reconstruction
        • arthroplasty
        • rotational osteotomy
    • Historical procedures: Putti-Platt / Magnuson-Stack / Boyd-Sisk
      • all procedures some variation of tightening subscapularis (advancment, plication, etc)
        • led to over-constraint and arthrosis
        • 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 
Techniques
  • Arthroscopic Bankart repair +/- capsular plication  
    • approach
      • shoulder arthroscopic approach 
    • technique
      • drive through sign might be present prior to labral repair and capsulorraphy
      • studies support use of ≥ 3 anchors (< 3 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 
      • axillary nerve injury
      • chondrolysis (from use of thermal capsulorraphy which is no longer used)
  • Open Bankart repair +/- capsular shift
    • approach
      • shoulder anterior (deltopectoral) approach 
    • technique
      • subscapularis transverse split or tenotomy
      • open labral repair and capsulorraphy
    • complications
      • recurrence, most often due to unrecognized glenoid bone loss
      • stiffness, especially in external rotation
      • subscapularis injury or failed repair (if tenotomy performed for approach)
      • axillary nerve injury
  • Open Capsular shift
    • approach
      • shoulder anterior (deltopectoral) approach 
    • technique
      • inferior capsule is shifted superiorly
    • complications
      • subscapularis injury or failed repair
        • post-operative physical exam will show a positive lift off and excessive ER
      • 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)
      • late arthritis
        • usually wear of posterior glenoid
        • may have internal rotation contracture
        • seen with Putti-Platt and Magnuson-Stack procedures
  • Latarjet and Bristow Procedure  
    • 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
    • complications
      • generally higher than arthroscopic or open Bankart, some studies report up to 25% incidence 
      • nonunion
      • graft lysis
      • hardware problems
      • stiffness, particularly in external rotation 
      • glenohumeral osteoarthritis 
        • will rapidly occur with lateral overhang of graft into the joint space 
      • nerve injury
        • majority are traction or contusion neuropraxias and resolve spontaneously
          • treat with observation for 3-6 weeks; delayed EMG if deficits persist  
        • musculocutaneous and axillary nerves most common
  • Putti-Platt & Magnuson-Stack (historic)
    • approach
      • shoulder anterior (deltopectoral) 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)
    • complications
      • both lead to decreased external rotation and loading on posterior glenoid
        • which leads to degenerative joint disease (capsulorrhaphy arthropathy)
  • Boyd-Sisk (historic)
    • technique
      • transfer of biceps laterally and posteriorly
    • complications
      • high rate of recurrence
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, < 3 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 
  • Shoulder pain
  • Nerve injury
    • musculocutaneous
    • axillary
  • Stiffness
    • especially in external rotation (particularly with Latarjet and additional remplissage)
  • Infection
  • Graft lysis (Latarjet)
  • 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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Technique Guides (4)
Questions (41)
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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)? Review Topic

QID: 741
1

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

8%

(64/758)

2

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

2%

(13/758)

3

Answers 1, 2 and 5 are correct.

56%

(423/758)

4

Both 1 and 2 are correct.

30%

(231/758)

5

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

3%

(21/758)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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(OBQ07.259) What factor has highest risk for recurrent instability following a traumatic anterior shoulder dislocation? Review Topic

QID: 920
1

History of contralateral shoulder dislocation

9%

(30/329)

2

Young age (<25-years-old) at time of dislocation

84%

(277/329)

3

Dislocation of the dominant shoulder

3%

(9/329)

4

Family history of shoulder instability

1%

(2/329)

5

History of patella instability

2%

(8/329)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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

QID: 267
1

Anterosuperior labral tear

14%

(52/381)

2

Anteroinferior labral tear

70%

(266/381)

3

Posterosuperior labral tear

1%

(4/381)

4

Posteroinferior labral tear

1%

(4/381)

5

Hill Sachs lesion

14%

(52/381)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(OBQ10.264) Open anterior shoulder stabilization procedures have failed twice for an active 22-year-old patient. Most recently he had another episode of instability when reaching into the back seat while driving. He has weakness performing the physical exam maneuver shown in Figure A. Images from his MRI are shown in Figures B and C. What is the most appropriate next surgical treatment? Review Topic

QID: 3315
FIGURES:
1

Another course of physical therapy

1%

(23/2642)

2

Latarjet procedure

15%

(408/2642)

3

Lesser tuberosity transfer

7%

(180/2642)

4

Pectoralis major transfer

66%

(1735/2642)

5

Latissimus dorsi transfer

10%

(273/2642)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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? Review Topic

QID: 3165
FIGURES:
1

Superior labrum anterior posterior (SLAP) tear

3%

(53/1573)

2

Supraspinatus partial articular sided tendon avulsion (PASTA)

2%

(31/1573)

3

Humeral avulsion of the glenohumeral ligament (HAGL)

84%

(1320/1573)

4

Engaging (>25%) Hill Sachs defect

6%

(102/1573)

5

Anterior labral periosteal sleeve avulsion (ALPSA)

4%

(56/1573)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 4369
FIGURES:
1

Superior labrum anterior to posterior (SLAP) repair

5%

(252/5347)

2

Open approach for bone grafting of humeral defect with allograft

5%

(292/5347)

3

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

5%

(242/5347)

4

Remplissage procedure

3%

(159/5347)

5

Arthroscopic Bankart repair and Remplissage procedure

81%

(4338/5347)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 877
FIGURES:
1

Rotator cuff tear

4%

(29/803)

2

SLAP tear

8%

(66/803)

3

Bankart lesion

80%

(645/803)

4

Glenoid fracture

2%

(15/803)

5

Humeral avulsion of glenohumeral ligaments (HAGL)

6%

(45/803)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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

QID: 2946
1

25-year-old with first time acute traumatic dislocation

1%

(7/1364)

2

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

0%

(4/1364)

3

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

8%

(110/1364)

4

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

9%

(117/1364)

5

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

82%

(1122/1364)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 160
1

Glenolabral articular disruption (GLAD)

15%

(53/361)

2

Humeral avulsion of the glenohumeral ligament (HAGL)

61%

(220/361)

3

Superior labrum tear from anterior and posterior (SLAP)

2%

(7/361)

4

Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA)

18%

(66/361)

5

Partial articular-sided supraspinatus tendon avulsion (PASTA)

4%

(13/361)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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? Review Topic

QID: 170
FIGURES:
1

Anteroinferior labral nonunion

4%

(10/285)

2

Unrecognized humeral avulsion of the glenohumeral ligament (HAGL)

9%

(27/285)

3

Anteroinferior glenoid bone defect

82%

(234/285)

4

Engaging Hill Sachs defect

4%

(12/285)

5

Untreated SLAP lesion

0%

(1/285)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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

QID: 913
FIGURES:
1

Axillary

96%

(401/418)

2

Median

0%

(2/418)

3

Musculocutaneous

2%

(7/418)

4

Radial

1%

(4/418)

5

Suprascapular

0%

(2/418)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 2949
FIGURES:
1

Adduction, internal rotation

3%

(61/1949)

2

Adduction, external rotation

10%

(189/1949)

3

Abduction, external rotation

85%

(1661/1949)

4

Extension, internal rotation

1%

(26/1949)

5

Axial traction in adduction

0%

(5/1949)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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. Review Topic

QID: 3442
FIGURES:
1

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

2%

(57/2985)

2

Immobilization in sling with external rotation and EMG/NCV studies

9%

(260/2985)

3

Anterior labral periosteal sleeve avulsion (ALPSA) stabilization

5%

(138/2985)

4

Bony Bankart lesion stabilization

84%

(2494/2985)

5

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

0%

(10/2985)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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?
Review Topic

QID: 3643
FIGURES:
1

Partial articular sided thickness rotator cuff tear (PASTA)

4%

(124/3540)

2

Anterior labral periosteal sleeve avulsion (ALPSA)

5%

(178/3540)

3

Humeral avulsion of the glenohumeral ligament (HAGL)

84%

(2966/3540)

4

Glenoid labral articular defect (GLAD)

2%

(80/3540)

5

Superior labral anterior posterior lesion (SLAP)

4%

(149/3540)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ05.42) A 21-year-old rugby player has recurrent pain and instability of the right shoulder recalcitrant to conservative management. Figure A is an image taken during diagnostic arthroscopy in the lateral decubitus position viewing from the posterior portal with instrument through a rotator interval anterior portal. In addition to the pathology seen in Figure A, what other associated intra-articular condition is most likely present? Review Topic

QID: 78
FIGURES:
1

Rotator cuff tear

3%

(13/439)

2

SLAP tear

23%

(102/439)

3

Posterior labral tear

9%

(40/439)

4

Hill-Sachs lesion

61%

(266/439)

5

Buford complex

3%

(13/439)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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? Review Topic

QID: 2956
FIGURES:
1

Figure A

3%

(61/2215)

2

Figure B

2%

(36/2215)

3

Figure C

65%

(1433/2215)

4

Figure D

2%

(49/2215)

5

Figure E

28%

(624/2215)

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 791
FIGURES:
1

Inferior glenohumeral

84%

(974/1161)

2

Middle glenohumeral

10%

(114/1161)

3

Superior glenohumeral

3%

(31/1161)

4

Coracohumeral

3%

(38/1161)

5

Coracoacromial

0%

(0/1161)

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PREFERRED RESPONSE 1

(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? Review Topic

QID: 3151
1

Supraspinatus tear

1%

(34/3650)

2

Humeral avulsion of the glenohumeral ligaments

6%

(214/3650)

3

Long head of the biceps tear

0%

(10/3650)

4

Superior labrum anterior to posterior tear

7%

(255/3650)

5

Anteroinferior labral tear

85%

(3118/3650)

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PREFERRED RESPONSE 5

(OBQ06.128) A 19-year-old right hand dominant male high school wide receiver complains of recurrent right shoulder subluxation. Clinical examination is remarkable for a postive apprehension sign and a positive sulcus sign. A T2 coronal MRI is shown below in Figure A. What is the diagnosis? Review Topic

QID: 314
FIGURES:
1

Bankart lesion

5%

(37/684)

2

SLAP tear

5%

(35/684)

3

Rotator cuff tear

1%

(4/684)

4

ALPSA lesion

5%

(31/684)

5

HAGL lesion

84%

(574/684)

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PREFERRED RESPONSE 5

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

QID: 431
FIGURES:
1

Suprascapular

8%

(70/915)

2

Upper or lower subscapular

2%

(22/915)

3

Musculocutaneous

2%

(16/915)

4

Radial

1%

(5/915)

5

Axillary

87%

(800/915)

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PREFERRED RESPONSE 5
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