Wk 3, Case 3 - Review

Patient History
20 year-old-male with left shoulder pain and instability. History of four prior shoulder dislocations.

Findings
ROTATOR CUFF: Normal supraspinatus, infraspinatus, subscapularis, and teres minor.

SUBACROMIAL/SUBDELTOID BURSA: Mild subacromial-subdeltoid peritendinitis.

MUSCLES (ROTATOR CUFF/DELTOID, TRAPEZIUS, PECTORALIS): No muscle strain, atrophy, or tear.

BICEPS TENDON: Normal long head biceps tendon and anchor.

AC JOINT: Normal acromioclavicular joint without separation.

CORACOCLAVICULAR LIGAMENTS: Normal without sprain.

SUBACROMIAL ARCH/OUTLET: No subacromial arch stenosis.

SUBCORACOID ARCH: No subcoracoid arch stenosis.

GLENOHUMERAL JOINT: No bony Bankart. No glenoid bone loss. No cartilage defect. No loose body. No humeral avulsion of the glenohumeral ligaments.

GLENOID LABRUM: Soft Bankart labral and periosteal tear, nondisplaced or minimally displaced, 3 o’clock to 6 o’clock.

BONES: Hill-Sachs type microfracture and flattening of the humeral head, no displaced fracture fragment. Additional mild contusion of the greater tuberosity.

SUBCUTANEOUS SOFT TISSUES: Normal without soft tissue swelling or mass.

AXILLA: Normal without adenopathy or vascular abnormality.

Impressions
Large nondisplaced soft Bankart lesion involving the labrum and periosteum. Hill-Sachs equivalent with both subtle cortical irregular fractures and microtrabecular fractures with an ancillary anterolateral contusion.
Normal rotator cuff.
The humerus remains centered in the glenohumeral articulation.