Traumatic Anterior Shoulder Instability (TUBS)

Topic updated on 07/07/16 3:01pm
  • 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
  • Mechanism
    • mechanism is an anteriorly directed force on the arm when the shoulder is abducted and externally rotated  
  • 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
    • fractures & bone defects
      • 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
      • 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
      • 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
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
  • Glenohumeral anatomy  
  • Anterior static shoulder stability is provided by 
    • anterior band of IGHL
      • 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
  • 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
    • apprehension sign
      • patient supine with arm in 90/90 position
    • relocation sign
      • decrease in apprehension with anterior force applied on shoulder
    • sulcus sign
      • tested with patient's arm at side
  • 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 Indications
  • Nonoperative
    • acute reduction, immobilization, followed by therapy
      • indications
        • management of first time dislocators remains controversial
      • reduction
        • simple traction-countertraction is most commonly used
        • relaxation of patient with sedation or intraarticular lidocaine is essential
      • immobilization
        • 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
      • outcomes
        • results now equally efficacious as open repair with the advantage of less pain and greater motion preservation
    • open Bankart repair +/- capsular shift
      • indications
        • glenoid defects < 20%  q q q 
        • humeral avulsion of the glenohumeral ligament (HAGL)
          • can also be performed arthroscopically but is technically challenging
    • Bristow and Latarjet Procedure  
      • indications
        • bony deficiencies with >20-25% glenoid deficiency 
        • transfer of coracoid bone and conjoined tendon for sling effect
        • Latarjet procedure performed more commonly
    • Putti-Platt / Magnuson-Stack / Boyd-Sisk
      • indications
        • historic purposes only
        • led to over-constraint and arthrosis
    • Remplissage technique
      • indication
        • engaging large (>25%) Hill-Sachs defect q
      • technique
        • posterior capsule and infraspinatus tendon sutured into the Hill-Sachs lesion
        • may be performed with concomitant Bankart repair
    • Hill-Sachs bony reconstruction
      • indication
        • engaging Hill-Sachs lesions
      • technique
        • allograft reconstruction
        • arthroplasty
        • rotational osteotomy
Treatment Techniques
  • Arthroscopic Bankart repair +/- capsular plication  
    • approach
      • shoulder arthroscopic approach 
    • technique
      • drive through sign might be present prior to labral repair and capsulorraphy
  • Open Bankart repair +/- capsular shift
    • approach
      • shoulder anterior (deltopectoral) approach 
    • technique
      • subscapularis transverse split or tenotomy
      • open labral repair and capsulorraphy
  • 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
  • Bristow and Latarjet Procedure  
    • approach
      • shoulder anterior (deltopectoral) approach 
    • technique
      • coracoid transfer to anterior inferior glenoid bone defect
      • Latarjet: coracoid passed through a split in the proximal 1/3 subscapularis
    • complications
      • nonunion
      • hardware problems
      • musculocutaneous nerve injury
  • Putti-Platt & Magnuson-Stack
    • 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 value only
    • technique
      • transfer of biceps laterally and posteriorly
    • complications
      • high rate of recurrence


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Qbank (24 Questions)

(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? Topic Review Topic
FIGURES: A          

1. Superior labrum anterior to posterior (SLAP) repair
2. Open approach for bone grafting of humeral defect with allograft
3. Open repair of humeral avulsion of glenohumeral ligament (HAGL) lesion
4. Remplissage procedure
5. Arthroscopic Bankart repair and Remplissage procedure

(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. Topic Review Topic
FIGURES: A          

1. Humeral avulsion of the glenohumeral ligament (HAGL lesion) stabilization and EMG/NCV studies
2. Immobilization in sling with external rotation and EMG/NCV studies
3. Anterior labral periosteal sleeve avulsion (ALPSA) stabilization
4. Bony Bankart lesion stabilization
5. Transfer of the infraspinatus tendon and greater tuberosity to the humeral head

(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?
Topic Review Topic
FIGURES: A   B        

1. Partial articular sided thickness rotator cuff tear (PASTA)
2. Anterior labral periosteal sleeve avulsion (ALPSA)
3. Humeral avulsion of the glenohumeral ligament (HAGL)
4. Glenoid labral articular defect (GLAD)
5. Superior labral anterior posterior lesion (SLAP)

(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? Topic Review Topic

1. Supraspinatus tear
2. Humeral avulsion of the glenohumeral ligaments
3. Long head of the biceps tear
4. Superior labrum anterior to posterior tear
5. Anteroinferior labral tear

(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? Topic Review Topic
FIGURES: A   B        

1. Superior labrum anterior posterior (SLAP) tear
2. Supraspinatus partial articular sided tendon avulsion (PASTA)
3. Humeral avulsion of the glenohumeral ligament (HAGL)
4. Engaging (>25%) Hill Sachs defect
5. Anterior labral periosteal sleeve avulsion (ALPSA)

(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? Topic Review Topic
FIGURES: A   B   C      

1. Another course of physical therapy
2. Latarjet procedure
3. Lesser tuberosity transfer
4. Pectoralis major transfer
5. Latissimus dorsi transfer

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

1. 25-year-old with first time acute traumatic dislocation
2. 78-year-old with a rotator cuff tear arthropathy with superior escape
3. 24-year-old with chronic dislocation and large engaging Hill-Sachs lesion
4. 30-year-old with an acute bony Bankart fracture-dislocation
5. 27-year-old with a chronic anterior dislocation and inverted pear-shaped glenoid

(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? Topic Review Topic
FIGURES: A          

1. Adduction, internal rotation
2. Adduction, external rotation
3. Abduction, external rotation
4. Extension, internal rotation
5. Axial traction in adduction

(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? Topic Review Topic
FIGURES: A   B   C   D   E  

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

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

1. Suprascapular
2. Upper or lower subscapular
3. Musculocutaneous
4. Radial
5. Axillary

(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 reccommended. This is believed to improve stability through which of the following mechanism(s)? Topic Review Topic

1. Increasing the glenoid bony support and excursion distance prior to dislocation.
2. The conjoined tendon passing through the subscapularis becomes a supportive sling.
3. Answers 1, 2 and 5 are correct.
4. Both 1 and 2 are correct.
5. The remnant of the CA ligament can be used to aid in repair of the capsular tissues.

(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? Topic Review Topic
FIGURES: A   B        

1. Inferior glenohumeral
2. Middle glenohumeral
3. Superior glenohumeral
4. Coracohumeral
5. Coracoacromial

(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? Topic Review Topic
FIGURES: A   B        

1. Rotator cuff tear
2. SLAP tear
3. Bankart lesion
4. Glenoid fracture
5. Humeral avulsion of glenohumeral ligaments (HAGL)

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

1. Axillary
2. Median
3. Musculocutaneous
4. Radial
5. Suprascapular

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

1. History of contralateral shoulder dislocation
2. Young age (<25-years-old) at time of dislocation
3. Dislocation of the dominant shoulder
4. Family history of shoulder instability
5. History of patella instability

(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? Topic Review Topic

1. Glenolabral articular disruption (GLAD)
2. Humeral avulsion of the glenohumeral ligament (HAGL)
3. Superior labrum tear from anterior and posterior (SLAP)
4. Anterior labro-ligamentous periosteal sleeve avulsion (ALPSA)
5. Partial articular-sided supraspinatus tendon avulsion (PASTA)

(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? Topic Review Topic
FIGURES: A          

1. Anteroinferior labral nonunion
2. Unrecognized humeral avulsion of the glenohumeral ligament (HAGL)
3. Anteroinferior glenoid bone defect
4. Engaging Hill Sachs defect
5. Untreated SLAP lesion

(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? Topic Review Topic
FIGURES: A          

1. Bankart lesion
2. SLAP tear
3. Rotator cuff tear
4. ALPSA lesion
5. HAGL lesion

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

1. Anterosuperior labral tear
2. Anteroinferior labral tear
3. Posterosuperior labral tear
4. Posteroinferior labral tear
5. Hill Sachs lesion

(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? Topic Review Topic
FIGURES: A          

1. Rotator cuff tear
2. SLAP tear
3. Posterior labral tear
4. Hill-Sachs lesion
5. Buford complex

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