Interesting one. There has been some cadaver work that shows external
rotation reduces the Bankhart lesion). The paper by Itoi (who I think was
also involved in cadaver work) et al showing a reduction in dislocation rate
to zero was an interim analysis. There has been a later interim analysis
showing results not as good. The full study was intended to include 80
patients and has not been published yet as far as I am aware- I'd be wary of
changing practice based on a publication that looks at only part of the
study.
Overall, immobilisation in ER seems to make a certain amount of sense.
Splints cost quite a bit, though. Our own redislocation rate seems a lot
lower than in many of the series. I like to think that this is due to gentle
reduction (by Kocher's manoeuvre as described by Kocher, not using traction
and passive ER or by a modification of the Milch manoeuvre usually). This
might reduce the incidence of iatrogenic rotator cuff tears, but I can't see
it making much difference to the incidence of Bankhart lesion. It is
interesting that the conclusion one could draw from Itoi's paper is that
early conservative treatment of the Bankhart lesion results in a high
healing rate, whereas previously I'd thought that Bankhart lesions should be
treated surgically.
One might be able to argue for looking for Bankhart lesions and deciding
whether to immobilise in IR (which is a bit easier for the patient as well
as cheaper) or ER depending on results. Might also guide when to remove
splinting (my experience is that most young patients with dislocated
shoulders remove the sling within 24 hours). Trouble is that it's often
invisible on ultrasound, and we don't have enough MRI scanning (seems to be
a general reluctance to allocate radiology resources to "minor injuries". If
there was little or no healing of the lesion with conservative treatment
then there would be a case for early MRI scan in all (or selected) anterior
dislocations with repair if there was a Bankhart lesion and early
mobilisation if not. But Itoi seems to suggest that this is not necessary.
Matt Dunn
Warwick
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