Bankart Lesion

Other Names

• Bankart Lesion
• Bony Bankart Lesion
• Soft Bankart Lesion
• Fibrous Bankart Lesion
• Anteroinferior Glenoid Labrum Lesion
• Perthes Lesion

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Background

• This page refers to a so-called 'Bankart Lesion', a common complication that occurs following a shoulder dislocation

History

• Named after Arthur Sydney Blundell Bankart (1879-1951), a British orthopedic surgeon, who first described them

Epidemiology

• Soft tissue bankart lesions are more commony than bony bankart lesions
• Occur in up to 22% of first-time anterior shoulder dislocations
• The prevalence of bony Bankart lesions ranges from 7.9% to 50% in cases of traumatic shoulder instability (need citation)

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Introduction

Diagrammatic representation of Bankart lesion. The anteroinferior part of the labrum detached from the glenoid.

AP xray of the right shoulder in a 68 year old woman with a bony bankart lesion

Classification of Bankart and Bankart variant lesions. (a) Bankart lesion. (b) Bony Bankart lesion. (c) ALPSA (anterior labro‐ligamentous periosteal sleeve avulsion) lesion. (d) Perthes Lesion. (e) GLAD (glenolabral articular disruption) lesion. (f) HAGL (humeral avulsion of glenohumeral ligaments) lesion

Final bony Bankart bridge repair with reduced bony Bankart piece, repaired labrum, and shifted capsule and inferior glenohumeral ligament complex. (Reprinted with permission from Millett PJ, Braun S. The bony Bankart bridge procedure: a new arthroscopic technique for reduction and internal fixation of a bony Bankart lesion.

General

• Characterized injury to the anteroinferior glenoid labrum following a anterior shoulder dislocation
• Patients with bankart lesions are at high risk of subsequent or recurrent dislocatoins and shoulder instability
• Diagnosis is made with history and physical exam coupled with MRI
• Nonsurgical and surgical treatment options are available depending on the size of the lesion, with arthroscopic repair being the most common treatment method

Terminology

• Bankart Lesion: injury of the labrum and associated glenohumeral capsule/ligaments at the anterior inferior labrum
• Bony Bankart: fracture of the adjacent anteroinferior glenoid, an injury which also commonly occurs in the setting of anterior glenohumeral dislocation

Pathophysiology

• Occur aas a direct result of anterior dislocation of the humeral head
  • The humerus is compressed against the glenoid labrum
• Subsequently, there is deatchment of the anterior inferior labrum from the underlying glenoid
• Labral tear can extend further superiorly or posteriorly
• Impaction fracture of the anterior-inferior margin of the glenoid commonly occurs
• Most commonly located at the 3:30 position

Associated Conditions

• Hill Sachs Deformity
  • 11x more likely to occur together than as isolated injuries
• Glenoid Labrum Lesion

Variants

• Perthes Lesion of the Shoulder: chondrolabral detachment with periosteal stripping of the scapula with the labral fragment attached to the periosteum without significant displacement
• Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA): mobilized labrum remains attached to the glenoid periosteum
• Glenolabral Articular Disruption (GLAD): associated anteroinferior articular cartilage and labral injury

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Risk Factors

Sports/ Occupation

• Rugby
• Americal Football
• Military
• Tennis

Risk Factors for Bankart Lesions

• High-energy mechanism of injury
• Arm abduction and extension at the time of initial dislocation
• Participation in contact sports

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Differential Diagnosis

Differential Diagnosis Shoulder Pain

• Fractures
  • Proximal Humerus Fracture
  • Humeral Shaft Fracture
  • Clavicle Fracture
  • Scapula Fracture
  • First Rib Fracture (traumatic or atraumatic)
  • Floating Shoulder
• Dislocations & Separations
  • Acromioclavicular Joint Separation
  • Glenohumeral Dislocation (Acute)
  • Sternoclavicular Joint Dislocation
  • Chronic Glenohumeral Dislocation
  • Glenohumeral Instability (Chronic)
• Arthropathies
  • Glenohumeral Arthritis
  • Acromioclavicular Joint Arthritis
  • Sternoclavicular Arthritis
• Muscle & Tendon Injuries
  • Pectoralis Major Injuries
  • Pectoralis Minor Injuries
  • Proximal Biceps Tendon Injuries
  • Scapular Dyskinesis
• Rotator Cuff
  • Rotator Cuff Tear
  • Rotator Cuff Tendonitis
  • Calcific Tendinitis of the Rotator Cuff
  • Subcoracoid Impingement Syndrome
• Bursopathies
  • Subacromial Bursitis
  • Scapulothoracic Bursitis
• Ligament Injuries
  • Glenoid Labral Tears
• Neuropathies
  • Suprascapular Nerve Injury
  • Parsonage-Turner Syndrome
  • Quadrilateral Space Syndrome
  • Winged Scapula
• Other
  • Adhesive Capsulitis
  • Paget-Schroetter Syndrome
  • Shoulder Injury Related To Vaccine Administration
  • Distal Clavicle Osteolysis
• Pediatrics
  • Coracoid Avulsion Fracture
  • Humeral Head Epiphysiolysis (Little League Shoulder)

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Clinical Features

Clinical demonstration of the anterior apprehension test

History

• Patients should be able to describe their history of shoulder dislocation(s)
• Appropriate questions
  • What was the mechanism of, direction of force?
  • Is there any perception of instability
  • Is there a history of previous dislocations
  • Was manual reduction ever required
  • Is there any surgical history?
• The bankart lesion may present with recurrent dislocations
• Widespread shoulder discomfort
• They may experience locking, catching and popping

Physical Exam: Physical Exam Shoulder

• Important to perform visual inspection, palpation, passive and active range of motion
• Strength and neurovascular assessment should be performed

Special Tests

• Anterior Apprehension Test
• Load And Shift Test
  • Combined sensitivity of anterior apprehension and load and shift test is 94%
• Bony Apprehension Test
  • 100% sensitivity, 86% specific in detecting bony lesions of the anterior glenoid rim
• Beighton Score: should be obtained to assess for generalized hypermobility

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Evaluation

(A) Bony Bankart lesion with a large displaced fragment of the anterior inferior glenoid (arrowhead). (B) Quantification of the size of the bony defect on a sagittal view; the defect encompasses nearly 30% of the articular surface of the glenoid.

MRI findings showing the Bankart lesion (A) and the superior labrum anterior to posterior lesion (B).

Radiographs

• Standard Radiographs Shoulder
  • Often normal
• Bernageau View
  • Provides better evaluation of the anterior glenoid rim
• Bony bankart
  • Characterized by a bony cortical defect seen at the anterior inferior glenoid rim
• Hill Sachs Deformity
  • Compression deformity of the posterior humeral head
  • Often seen in combination with a bankart lesion

CT

• Glenoid labrum not reliably visualized
  • May see something if arthrography used
• Bony bankart will be seen if present
• Allows for excellent 3d reconstruction of the glenoid rim

MRI

• Imaging modality of choice
• Frank displacement/separation of the anterior glenoid labrum, with or without glenoid fracture fragment
• Linear high T2/PD intensity through the non-displaced anteroinferior labrum, indicating a tear
• Abnormally small or absent anterior labrum
• Double axillary pouch sign (coronal MR arthrogram): specific sign for an anteroinferior labral tear

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Classification

• Soft Tissue Bankart
• Bony Bankart

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Management

Treatment based on size of the bony bankart lesion

AP radiograph following arthroscopic repair of a bony bankart lesion using 2 cortical buttons

Illustrations of a Bankart lesion (a) and labral Bankart repair (b) and sagittal T1 MR image (c) following Bankart repair. The Bankart lesion is demonstrated by detachment of the anteroinferior labrum (arrow in a). Three drill holes with suture anchors are placed along the glenoid from 3–5 o'clock and suture material is woven through the labrum and attached to the suture anchors, tightening and fixating the labrum back to the glenoid (arrows in b,c). Normal MRI findings following Bankart repair include labral and/or osseous fragmentation which is reattached to the glenoid rim with thickening of the labrum and anterior joint capsule

Nonoperative

• Consider in
  • First time dislocation
  • Patients with low activity levels
  • Concentrically reduced bony Bankart lesions that span less than 5% of the glenoid rim
• Immobilizaton with Shoulder Immobilizer or Shoulder Sling
• Physical Therapy

Operative

• Indications
  • Vast majority of young active patients
  • Failure of conservative management
• Technique
  • Arthroscopic repair
  • Latarjet Procedure

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Rehab and Return to Play

Postoeprative Rehabilitation

• Arthroscopic Repair
  • Maintain in a sling for 4 weeks
  • Supervised rehabilitation with passive ROM
  • Gradually allow patient to use shoulder for ADL
  • Terminal stretching beings at 2 months
  • Return to overhead and contact sports at 5-9 months post operatively
• Open Repair
  • Sling for 3 weeks
  • Immediate range of motion of hand and wrist
  • Physical therapy of shoulder starts at week 3 or 4
  • External rotation limited to 30 degrees for 6 weeks
  • No participation in contact sports for a minimum of 6 months

Return to Play/ Work

• Needs to be updated

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Prognosis and Complications

Prognosis

• Conservative management
  • Spiegl et al: 12 patients treated conservatively, 58% (excellent outcomes), 25% (good), 17% (moderate)
  • In general, conservative management is associated with a high risk of recurrent anterior shoulder instability
• Arthroscopic Repair
  • Reduces recurrence, improves return to play rates compared to conservative management

Complications

• Recurrent anterior shoulder instability
• Glenoid bone loss can occur
• Decreased function

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See Also

• Shoulder Pain
• Shoulder Anatomy
• Physical Exam Shoulder

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