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The teenage terrible triad: a case report.

Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon, although perhaps under-recognized, finding associated with anterior dislocation of the shoulder. Capsuloligamentous restraints play a primary role in shoulder stability, as labral deficiency alone does not appear to lead to significant glenohumeral instability. (1,2) Over half of those patients with HAGL lesions have other associated injuries, (3) which may include labral pathology, rotator cuff tears, or nerve injury. (4-6)

Anterior glenohumeral joint dislocation with associated rotator cuff tears or other injury can be seen in all ages (7) but is considered especially common in patients over 40 years of age. A thorough, systematic clinical and radiographic evaluation is needed in order to appropriately identify all pathology associated with a shoulder dislocation, including nerve, rotator cuff, labral, and capsular injuries. This case report involves the unusual triad of a HAGL lesion, rotator cuff tear, and axillary nerve palsy in a teenage male who sustained a traumatic, anterior shoulder dislocation.

Case Report

A 16-year-old, right-hand-dominant male high school football player presented for orthopaedic evaluation 1 day following a first-time right shoulder injury. He was attempting to recover a fumble and jumped onto the ball with outstretched arms. An opposing player jumped on top of him, forcing his right shoulder into a position of extreme abduction and external rotation. He was taken by ambulance to a local emergency room where plain radiographs demonstrated an anterior shoulder dislocation, and a closed reduction under intravenous sedation was performed.

Physical examination directed towards the right shoulder revealed no obvious swelling or deformity. There was tenderness to palpation about the glenohumeral joint. Active range of motion in a sitting position consisted of 30[degrees] of forward flexion, 20[degrees] of abduction, internal rotation to L4-L5, and 30[degrees] of external rotation with the shoulder in adduction. Manual muscle strength testing revealed 2/5 shoulder abduction strength, with no observable deltoid contraction (Fig. 1A). External rotation strength was graded as 5/5. Sensation to light touch was preserved throughout the shoulder girdle and was symmetrical to the contralateral extremity. There was a positive belly press and lift-off test.

Pre-reduction and post-reduction radiographs demonstrated an anterior glenohumeral dislocation followed by concentric reduction of the joint. MRI demonstrated an avulsion of the muscle attachment of the subscapularis onto the humeral neck along with the underlying anterior band of the inferior glenohumeral ligament, and an intact, normal appearing anterior-inferior labrum (Fig. 2B). Electrophysiologic studies were obtained and revealed findings compatible with complete axillary nerve palsy.

Surgery was performed at 10 days following the injury. The procedure was performed under general anesthesia with the patient in a semi-sitting, modified beach-chair position with the head elevated 30[degrees]. An anterior axillary incision was made and a standard deltopectoral approach was utilized. The conjoined tendon was retracted medially, and the clavipectoral fascia was dissected away from the underlying subscapularis. A small hematoma was evacuated, and the site of injury was readily identified. The lower 1/3 of the subscapularis along with the underlying capsule were found to be avulsed from the medial humeral neck. The axillary nerve was carefully exposed and protected at this location but not formally explored. The plane between the injured portions of the subscapularis and capsule was developed. The footprint attachment site on the medial humeral neck was prepared with a curette and motorized burr to create a bed to stimulate healing. Two double-loaded 4.5 mm screw-in suture anchors were then placed, and the inferior glenohumeral ligament and overlying subscapularis were repaired using modified Mason-Allen stitches (Fig. 3).

The patient's arm was maintained in a sling for 6 weeks. Physical therapy was initiated at 4 weeks following surgery. At this point in time, the axillary nerve showed signs of recovery with all three portions of the deltoid demonstrating visible signs of contraction. By 3 months following surgery, the axillary nerve appeared completely recovered with 5/5 abduction strength on manual muscle testing. At 9 months, the patient had pain-free active range of motion consisting of 175[degrees] of forward flexion, internal rotation to T10, and 55[degrees] and 110[degrees] of external rotation in adduction and abduction, respectively. An anterior apprehension sign was absent and belly press and lift-off tests were both negative. There was normal abduction and internal rotation strength that was symmetrical with the contralateral side (Fig. 1B). He was cleared to return to football and went on to complete the season free of further injury.


This case describes a rare triad in a teenager consisting of a HAGL lesion, rotator cuff tear, and axillary nerve palsy that resulted from an anterior shoulder dislocation. Although HAGL lesions may be treated via an arthroscopic or open technique, (4,8-11) a mini-open approach was employed in this case in order to best address both the capsular injury and inferior subscapularis tear.

HAGL lesions are often times missed on standard imaging studies, and they are frequently associated with other types of shoulder pathology. (12) A high clinical suspicion for a HAGL lesion is warranted, especially in the case of a traumatic anterior shoulder dislocation in which the anterior-inferior labrum is intact. While MRI can be an excellent tool to characterize pathology associated with anterior shoulder dislocation, there have been reports of poor sensitivity for identifying subscapularis tears, (13) as well as concerns of false-positive diagnosis of HAGL lesions. (14) MRI in this case was not only valuable in identifying both the HAGL lesion and subscapularis tear but also confirmed the absence of a Bankart lesion, which would typically be present following a traumatic anterior shoulder dislocation.

Given the extent of this patient's injuries, as well as a high risk for recurrent instability, early surgical management was deemed to be the most appropriate course of treatment. Optimal outcomes have been described with concomitant treatment of both the rotator cuff tear and capsulolabral injury in younger patients. (15,16) A higher incidence of recurrent shoulder instability may be expected when capsuloligamentous lesions occur in the setting of rotator cuff tears. (17,18) An important goal in this case was to reduce the risk of further, more extensive soft-tissue and potentially osseous injury by reducing the likelihood of recurrent instability. (19)

While outcomes of rotator cuff repair are less successful when associated nerve injury is present, (20) it is not necessary to wait for neurologic recovery to treat such patients with operative stabilization and rotator cuff repair, particularly when neuropraxia and eventual neurologic recovery is anticipated. (21) Delaying surgical intervention in this case would have potentially resulted in a less optimal repair of the subscapularis and capsule due to retraction and scarring. There is some anatomic variation with respect to the axillary nerve. The bifurcation of the axillary nerve into anterior and posterior branches may occur within the quadrilateral space or within the deltoid muscle. The deltoid muscle receives innervation from both the anterior and posterior branches, to varying extents. (22-24) The EMG and nerve conduction analysis suggested the axillary nerve injury occurred proximal to the bifurcation in this patient, affecting deltoid motor function in its entirety. The majority of patients with electrophysiological evidence of axillary nerve injury associated with shoulder dislocation can expect good recovery from motor loss. (25-27) Nerve exploration and neurolysis has not been shown to improve outcomes in athletes with isolated axillary nerve injury. (28) In this case, excellent functional outcome, with full recovery of nerve function, was achieved.

Anatomic descriptions of the subscapularis footprint on the lesser tuberosity detail a broad proximal footprint that narrows distally to a more muscular insertion at the inferior third. (29-31) In this patient, the subscapularis tear that resulted from anterior dislocation occurred at the inferior aspect, with no loss of integrity of the broad proximal tendinous insertion.


Cases of anterior shoulder dislocation involving capsuloligamentous injury, rotator cuff tear, and clinically significant axillary nerve palsy are rare. Addressing the humeral avulsion of the glenohumeral ligament and subscapularis tear with early surgical repair, and anticipating eventual nerve recovery, allowed this teenage patient to regain normal function and to return to playing football within a year following injury.

Graeme P. Whyte, M.D., M.Sc., F.R.C.S.C., and Andrew Rokito, M.D., Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York. Correspondence: Graeme P Whyte, M.Sc., F.R.C.S.C., NYU Hospital for Joint Diseases, 301 East 17th Street, New York, New York, 10003;

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.


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Caption: Figure 1 A, Preoperative clinical evaluation demonstrating severe right shoulder abduction weakness. B, Postoperative clinical evaluation demonstrating restoration of right shoulder abduction strength and return of axillary nerve function.

Caption: Figure 2 Axial, T2 weighted, MRI of the right shoulder. A, Complete avulsion of the subscapularis insertional fibers at the medial aspect of the humerus and complete avulsion of the anterior band of the inferior glenohumeral ligament (arrow). B, Intact anterior-inferior labrum (arrow).

Caption: Figure 3 Intraoperative image of inferior glenohumeral ligament repair to the medial humerus using two double-loaded 4.5 mm suture anchors (black arrow). Inferior subscapularis is tagged prior to closure (white arrow). To view this figure in color, see www.


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Title Annotation:traumatic anterior shoulder dislocation resulting from humeral avulsion of the glenohumeral ligament, rotator cuff tear, and axillary nerve palsy
Author:Whyte, Graeme P.; Rokito, Andrew
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Clinical report
Date:Apr 1, 2016
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