SHOULDER INJURY LACROSSE

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HISTORY A twelve-year-old male presented for surgical correction of instability of his right, dominant shoulder. His first instability episode occurred at the age of 11 years of age when he sustained a hyperabduction injury to his right arm while wrestling. He had recurrent dislocations after that with sports, including lacrosse, football, and diving. His most recent dislocation occurred throwing a frisbee. All of his dislocations required reduction in the emergency room. He thought that the shoulder was dislocating anteriorly He had no history of instability in any of his other joints and was in good health. He had no family history of Ehlers-Danlos syndrome, Marfan's syndrome or other connective tissue disorders. He had no parasthesias, weakness or history of neck pain. PHYSICAL EXAMINATION He was a normal appearing adolescent male with no secondary sex characteristics indicating that he had entered puberty. He had full range of motion of both shoulders and was neurologically intact for light touch, strength testing and reflexes of both upper extremities. He had a positive anterior apprehension test but a negative posterior apprehension test. He had a grade II sulcus sign but that did not reproduce his symptoms. He could be subluxed over the rim when performing laxity testing of his shoulder, and that reproduced his symptoms, only he said his instability episodes were worse. He had some signs of generalized joint laxity but was within normal limits. DIFFERENTIAL DIAGNOSIS Traumatic anterior dislocations. Multi-directional instability. Voluntary instability with possible psychological component. Connective tissue disorder. TESTS AND RESULTS Plain radiographs (AP and axillary of shoulder): Normal with no Hill-Sachs lesion or bony Bankart lesion. MRI of the shoulder: normal. Plain radiographs from emergency room: anterior dislocation shoulder. Diagnostic arthroscopy: avulsion of glenohumeral ligaments from humeral side (HAGL lesion). FINAL/WORKING DIAGNOSIS Traumatic anterior dislocation due to HAGL lesion. TREATMENT AND OUTCOMES At time of arthroscopy open repair of HAGL lesion with subscapularis splitting approach and suture anchors placed in proximal humerus. At six weeks postoperatively stiffer than expected: radiographs suggest humeral head avascular necrosis. MRI show AVN process humeral head. Protected range of motion with no strengthening, MRI's every three months. AVN repaired and resolved at nine months and returned to sports with no limitations.