This is not how the patient – a male in his late 20s – intended his day to go: He was competing in an off-road motorcycle race that involved catapulting over a series of jumps, one of which he failed to negotiate. The resultant crash-landing threw the patient’s body forward, over the handlebars. However, because the patient maintained his grip, he subjected his right shoulder to a force sufficient to dislocate it.
A physician onsite took steps to reduce the shoulder and control the pain at the time of the mishap. Since this patient made a living competing in such events, he continued to ride his motorcycle for several months afterward, despite the injury. Eventually, he sought formal medical attention. An orthopedic surgeon he consulted in Southern California recommended arthroscopic repair of the shoulder. The outcome was wholly unsatisfactory. Approximately one year later, another operation was arranged – this time to perform stabilization surgery using open technique. Alas, this attempt similarly ended in failure.
Case description
Familiar with Swift Orthopedics’ reputation for excellence, the patient two years after injury decided to come to us on self-referral.
During our physical examination, we observed pain and tenderness in the anterior aspect of the shoulder, patient apprehension in abduction and lateral rotation and decreased external rotation. The patient reported a tendency for the shoulder to shift out of joint whenever he participated in his sport.
An MRI we ordered revealed something previously unnoticed – a HAGL lesion (that is, a humeral avulsion of the glenohumeral ligament), which was found below the level of the subscapularis in the inferior pouch of the shoulder.
Treatment plan
It was decided to perform a repair of the HAGL lesion using classic open-surgery technique and in which the objective would be to tie the anterior capsule back to the humerus.
The 90-minute procedure required making a small incision to the front of the shoulder, followed by take-down of one of the rotator cuff’s muscles, in order to gain access to the capsule. After six weeks of immobilization, the patient began a course of physical therapy aimed initially at restoring range of motion and, later, at strengthening and conditioning.
Outcome
Soon after surgery, the patient reported a marked improvement in right shoulder comfort. We followed his case for six months postoperatively and noted progressively gained strength and functionality. The patient was advised to abstain from motorcycle riding for six months, but was able to return to it after only three. However, he waited the full half-year before getting back into competition and jumping.
Discussion
For this patient, successful treatment hinged on the right diagnosis. It is quite possible with a case like this to easily miss a HAGL lesion, even though incidence rates approach 40% in patients whose presentation of anterior instability is caused by trauma and the condition is almost exclusively a male phenomenon (prevalence is as high as 92% among men). Or, to restate it more correctly, it is quite possible to assume that what one is encountering in these cases is the much more commonplace Bankart lesion.
Indeed, that is precisely what the patient’s previous orthopedic surgery team believed it had on its hands, which is why the surgical strategy it chose resulted twice in failure.
Getting the most and best diagnostic information from an MRI requires a team effort – the expertise of a trusted consulting radiologist and the orthopedic surgeon’s eagle eye for spotting barely noticeable indicators.
