High Yield Overview

GLENOID FRACTURES - ARTICULAR STABILITY

Rim vs Body | Bone Loss Assessment Critical | Fix If Unstable

20-25%Bone loss threshold for instability

10%Of shoulder fractures

85%Associated with dislocation

IdebergStandard classification system

MAIN FRACTURE TYPES

Rim Fracture

PatternBony Bankart, anteroinferior

TreatmentArthroscopic or open based on size

Ideberg Type I

PatternRim avulsion fracture

TreatmentFix if large, address instability

Ideberg Type II-V

PatternBody fractures various patterns

TreatmentORIF via posterior or anterior approach

Critical Must-Knows

Bone loss over 20-25% of glenoid width causes recurrent instability
Most glenoid fractures occur with anterior dislocation (bony Bankart)
Ideberg classification describes fracture patterns through glenoid body
CT with 3D essential for bone loss quantification and surgical planning
Off-track lesion assessment combines glenoid bone loss with Hill-Sachs

Examiner's Pearls

"
25% glenoid bone loss = inverted pear glenoid on en-face view
"
Glenoid track concept: On-track Hill-Sachs engages in ROM, off-track does not
"
Bony Bankart larger than 20-25% needs bone augmentation
"
Posterior glenoid fractures associated with posterior instability

Clinical Imaging

Imaging Gallery

Anteroposterior radiograph of the right shoulder showing a displaced Ideberg type III fracture of the gleniod, with some ipsilateral rib fracturesCredit: Bonczek SJ et al. via Int J Shoulder Surg via Open-i (NIH) (Open Access (CC BY))

Coronal computed tomography scan image of the right shoulder revealing a 5 mm intra-articular step in the gleniod surfaceCredit: Bonczek SJ et al. via Int J Shoulder Surg via Open-i (NIH) (Open Access (CC BY))

6-panel composite showing arthroscopic bony Bankart treatment with 3D CT, arthroscopy, and post-op X-rays — Arthroscopic Bony Bankart Repair. (A) 3D CT showing anteroinferior glenoid rim fracture (bony Bankart). (B) Arthroscopic view of bony fragment (arrow). (C) Suture anchor placement for fixation. (D) Hill-Sachs lesion visualization (arrow) - assess for glenoid track concept. (E-F) Post-operative AP and Y-views showing anchor placement and restored glenoid rim.Credit: PMC Open Access, CC BY 4.0

AP shoulder X-ray showing glenoid fracture with significant bone loss — Glenoid Fracture with Bone Loss. AP radiograph demonstrating anterior glenoid fracture with significant bone loss creating potential for recurrent instability. CT with 3D reconstruction is essential for accurate bone loss quantification (greater than 20-25% requires bone augmentation).Credit: PMC Open Access, CC BY 4.0

Critical Glenoid Fracture Exam Points

Bone Loss Threshold

20-25% glenoid bone loss is the critical threshold. Below this, soft tissue repair may suffice. Above this, bone augmentation (Latarjet, bone graft) is needed as soft tissue alone will fail.

CT is Essential

3D CT with subtraction of humeral head allows accurate measurement of glenoid bone loss. Use the best-fit circle method or measure against contralateral glenoid. AP X-ray underestimates bone loss.

Associated Injuries

85% occur with dislocation. Always assess for Hill-Sachs lesion (glenoid track concept), rotator cuff tear (especially older patients), and neurovascular injury (axillary nerve).

Instability is Key

The goal of treatment is to restore stability, not just anatomic reduction. A well-reduced but unstable glenoid will fail. Address bone loss and soft tissue deficiency together.

At a Glance - Management by Bone Loss

Bone Loss	Pattern	Treatment	Key Consideration
Under 15%	Small bony Bankart	Arthroscopic Bankart repair	May include fragment if reducible
15-20%	Moderate rim defect	Arthroscopic with anchors vs open Bankart	Consider bone block if contact sport
20-25%	Significant bone loss	Latarjet or bone graft (Eden-Hybinette)	Soft tissue alone will fail
Over 25%	Severe bone loss	Latarjet preferred	Inverted pear glenoid configuration
Ideberg II-V	Glenoid body fracture	ORIF (posterior approach usually)	Goal is articular congruity

Mnemonic

CIRCLEGlenoid Bone Loss Assessment

CT scan essential

3D CT with humeral head subtraction

Inverted pear at 25%

Over 25% bone loss appearance

Reference contralateral

Compare to uninjured side

Calculate percentage

Bone loss as % of inferior diameter

Look for Hill-Sachs

Glenoid track concept

Engage or not (on-track)

Determines surgical strategy

Memory Hook:Draw a CIRCLE on the glenoid to measure bone loss!

Mnemonic

IDEALSIdeberg Classification

Type I - rim avulsion

Anterior or posterior rim fracture

Type II - Down (transverse)

Exits through lateral scapula

Type III - Exit superior

Oblique through superior glenoid

Type IV - Across (horizontal)

Horizontal through body, medial exit

Type V - Combined (I+IV)

Combination pattern

Type VI - Severe comminution

Comminuted glenoid body

Memory Hook:IDEALS classification helps you describe glenoid body fractures!

Mnemonic

TRACKGlenoid Track Concept

Track measurement

0.83 x glenoid width - bone loss

Risk of engagement

Hill-Sachs may engage if larger than track

Address bipolar lesions

Both glenoid and humeral defects

Calculate HSI

Hill-Sachs Interval measurement

Key decision point

On-track vs Off-track guides surgery

Memory Hook:Keep the shoulder on TRACK to prevent re-dislocation!

Overview and Epidemiology

Glenoid fractures represent a spectrum from small rim avulsions (bony Bankart) to complex body fractures (Ideberg types). Understanding the distinction between rim fractures causing instability and body fractures affecting articular congruity is essential.

Two main categories:

Rim fractures (bony Bankart): Associated with anterior instability, bone loss is the critical factor
Body fractures (Ideberg): Articular fractures affecting joint congruity, require reduction and fixation

Mechanism of injury:

Anterior dislocation: most common mechanism for rim fractures
Direct trauma: high-energy impact to shoulder
FOOSH: fall with axial loading through shoulder
Sports injury: contact sports, rugby, American football

Bony Bankart vs Body Fracture

Bony Bankart is an avulsion of the anteroinferior glenoid rim with the labrum and capsule attached - the key issue is instability. Body fractures (Ideberg II-V) are articular fractures where joint congruity and stability both matter.

Anatomy and Biomechanics

Glenoid anatomy:

Shallow, pear-shaped articular surface
Inferior width: approximately 25mm
Superior-inferior height: approximately 35mm
Retroversion: 5-7° relative to scapular body
Inferior tilt: varies but affects stability

Pear-Shaped Glenoid

The normal glenoid is pear-shaped (wider inferiorly). Loss of anterior bone changes this to an inverted pear - a sign of significant bone loss causing instability.

Stability mechanisms:

Bony congruity: glenoid provides 50% of stability
Labrum: deepens socket by 50%
Capsule and ligaments: static restraints
Rotator cuff: dynamic stabilizers

Bone loss effects:

Effect of Glenoid Bone Loss

Bone Loss	Stability Effect	Surgical Implication
Under 15%	Minimal effect on stability	Soft tissue repair adequate
15-20%	Increased recurrence risk	Consider bone augmentation in athletes
Over 20-25%	High recurrence with soft tissue repair	Bone augmentation required

Glenoid track concept:

Glenoid track = 0.83 x inferior glenoid width - bone loss
Hill-Sachs interval = medial to lateral width of Hill-Sachs
If Hill-Sachs interval is greater than glenoid track, it is off-track (will engage)
Off-track lesions need to be addressed (remplissage, bone graft, arthroplasty)

Classification Systems

Ideberg Classification (1984) - Glenoid fossa fractures

Type	Description	Fracture Line
Ia	Anterior rim fracture	Avulsion anteroinferior
Ib	Posterior rim fracture	Avulsion posterior
II	Transverse through glenoid	Exits lateral scapula border
III	Oblique through superior glenoid	Exits suprascapular notch area
IV	Horizontal through body	Exits medial scapula border
V	Combination Type I + Type IV	Combined rim and body
VI	Comminuted (added later)	Severe comminution

Type I vs Others

Type I (rim fractures) are fundamentally about instability - treat based on bone loss. Types II-V are about articular congruity - treat based on displacement and joint surface.

Clinical Assessment

History

Mechanism: dislocation, direct trauma, sport
Number of prior dislocations
Hand dominance and sport level
Prior shoulder surgery
Occupation and functional demands

Examination

Inspection: contour, swelling, bruising
Palpation: bony landmarks
ROM: usually limited acutely
Instability tests: apprehension, load-and-shift
Neurovascular: axillary nerve

Axillary Nerve Assessment

The axillary nerve is at risk with anterior dislocations and glenoid fractures. Test:

Sensation: regimental badge area (lateral shoulder)
Motor: deltoid function (when pain allows) Document neurovascular status clearly before and after any manipulation.

Key examination findings:

Apprehension test positive with anterior instability
Load-and-shift test may demonstrate increased translation
Palpable bony defect sometimes possible
Associated rotator cuff weakness (especially over age 40)

Investigations

Imaging Protocol

InitialPlain Radiographs

AP in internal rotation: Hill-Sachs
Axillary view: glenoid rim, anterior bone loss
West Point view: anteroinferior glenoid
Stryker notch view: Hill-Sachs

EssentialCT Scan

3D reconstruction: gold standard for bone loss
En-face glenoid view: bone loss quantification
Humeral subtraction: removes overlap
Axial cuts: fracture pattern, displacement

Soft TissueMRI

Labral pathology: Bankart lesion
Rotator cuff: tears, especially older patients
Capsular damage: HAGL, ALPSA lesions
Bone marrow edema: confirms injury location

CT is Essential

Plain X-rays underestimate glenoid bone loss by up to 50%. Always obtain CT with 3D reconstruction and humeral head subtraction for accurate bone loss measurement. This determines whether soft tissue repair or bone augmentation is needed.

Management Algorithm

Management based on bone loss:

Algorithm by Bone Loss

Low RiskUnder 15% Bone Loss

Arthroscopic Bankart repair
May incorporate fragment with anchors
Good outcomes with soft tissue repair

Intermediate15-20% Bone Loss

Individualized decision
Young contact athlete: consider bone augmentation
Recreational: may try soft tissue repair first
Counsel on recurrence risk

High RiskOver 20-25% Bone Loss

Bone augmentation required
Latarjet (coracoid transfer)
Eden-Hybinette (iliac crest graft)
Soft tissue alone will fail

Why Latarjet Works

Latarjet provides triple benefit: bone block effect, sling effect (conjoint tendon), and capsular repair. It extends the glenoid track by the width of the coracoid (approximately 10mm), converting many off-track lesions to on-track.

Surgical Technique

Indications:

First-time dislocation with bony Bankart under 15% bone loss
Recurrent instability with minimal bone loss

Setup:

Beach chair or lateral decubitus
Standard posterior and anterior portals
May need accessory 5 o'clock portal

Steps:

Diagnostic arthroscopy - assess bone loss, labrum
Prepare glenoid rim (decorticate)
Place anchors at 5, 4, 3 o'clock positions
Pass sutures through labrum
Tie knots to restore labral bumper
May incorporate small bony fragment

Anchor Placement

Anchors should be placed on the glenoid face, not the neck. This restores the labral bumper effect. At least 3 anchors typically needed for adequate repair.

Complications

Complications by Treatment

Complication	Incidence	Risk Factors	Management
Recurrent instability	5-25%	Bone loss over 25%, soft tissue repair	Revision with bone augmentation
Glenoid arthritis	10-30%	Malreduction, excessive lateralization	Activity modification, arthroplasty
Stiffness	5-15%	Prolonged immobilization, capsular repair	Physiotherapy, manipulation, arthroscopy
Nerve injury (axillary/suprascapular)	Less than 5%	Surgical approach, retraction	Observation, exploration if no recovery
Graft/coracoid nonunion (Latarjet)	5-10%	Poor technique, smoking	Observation if stable, revision if unstable
Hardware failure	Less than 5%	Poor bone quality, early motion	Revision fixation

Recurrence Risk Factors

Factors increasing recurrence after instability surgery:

Bone loss over 25% not addressed
Off-track Hill-Sachs not addressed
Young age (under 20)
Contact sport athlete
Connective tissue disorder

Postoperative Care

Rehabilitation Protocol - Instability Surgery

0-3 weeksPhase 1: Protection

Sling immobilization
Pendulum exercises only
No external rotation beyond neutral
Elbow, wrist, hand ROM

3-6 weeksPhase 2: Early Motion

Passive to active-assisted ROM
Begin external rotation to 30°
Forward flexion to 120°
Wean from sling

6-12 weeksPhase 3: Strengthening

Full ROM goal
Isometric then isotonic strengthening
Rotator cuff program
Scapular stabilization

3-6 monthsPhase 4: Return to Sport

Sport-specific training
Plyometrics
Contact sports at 6 months
Full clearance after strength testing

ORIF-specific considerations:

Weight-bearing restrictions until union
ROM based on fixation stability
Earlier motion if stable fixation

Outcomes and Prognosis

Outcome by procedure:

Procedure Outcomes

Procedure	Recurrence	Return to Sport	Arthritis Risk
Arthroscopic Bankart	5-15% (higher with bone loss)	85-95%	Low
Open Bankart	5-10%	85-90%	Low
Latarjet	2-5%	90-95%	10-30% (long-term)
ORIF body fracture	N/A	80-90%	Depends on reduction

Evidence Base

Bone Loss Threshold for Recurrence

Level III

Shaha et al. • Am J Sports Med (2016)

Key Findings:

Systematic review of glenoid bone loss studies
20-25% bone loss critical threshold
Higher recurrence with bone loss over 20%
Soft tissue repair alone inadequate above threshold

Clinical Implication: Bone loss over 20-25% requires bone augmentation (Latarjet or graft) for successful stabilization.

Glenoid Track Concept

Level IV

Di Giacomo et al. • Arthroscopy (2014)

Key Findings:

Introduced glenoid track concept for bipolar lesions
On-track lesions less likely to engage
Off-track lesions need Hill-Sachs addressed
Helps guide surgical decision-making

Clinical Implication: Use glenoid track to determine if Hill-Sachs needs treatment (remplissage, bone graft, or increase track with Latarjet).

Latarjet vs Bankart Repair

Level III

Bliven et al. • J Shoulder Elbow Surg (2017)

Key Findings:

Meta-analysis of 25 studies
Latarjet lower recurrence (3% vs 11%)
Higher complication rate with Latarjet
Both achieve good functional outcomes

Clinical Implication: Latarjet has lower recurrence but higher complication rate. Reserve for significant bone loss or failed Bankart.

ORIF Outcomes for Glenoid Fractures

Level IV

Schandelmaier et al. • Clin Orthop (2002)

Key Findings:

22 patients with Ideberg II-V fractures
ORIF achieved anatomic reduction in 86%
Good to excellent outcomes in 77%
Malreduction associated with poor outcomes

Clinical Implication: ORIF for displaced glenoid body fractures. Anatomic reduction is key to good outcomes.

Arthroscopic Bone Block Procedures

Level IV

Lafosse et al. • Arthroscopy (2007)

Key Findings:

Arthroscopic Latarjet technique described
93% good/excellent results at 2 years
3% recurrence rate
Steep learning curve acknowledged

Clinical Implication: Arthroscopic Latarjet feasible with good outcomes but technically demanding. Requires significant experience.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Recurrent Instability with Bone Loss

EXAMINER

"A 24-year-old rugby player has had 5 anterior dislocations over 2 years. MRI shows Bankart lesion. CT shows 22% anteroinferior glenoid bone loss. How would you manage this patient?"

EXCEPTIONAL ANSWER

Thank you. This patient has recurrent anterior shoulder instability with significant glenoid bone loss. Let me approach this systematically. **Assessment:** The key factors here are: young age, contact sport athlete, 5 dislocations, and 22% glenoid bone loss. The CT finding of 22% bone loss is at the critical threshold where soft tissue repair alone is likely to fail. **Bone loss significance:** At 22% bone loss, we are approaching the "inverted pear" configuration. The literature shows that soft tissue Bankart repair alone has unacceptably high recurrence rates (up to 70%) when bone loss exceeds 20-25%. **Glenoid track assessment:** I would also assess the Hill-Sachs lesion to determine if this is an on-track or off-track lesion. With 22% glenoid bone loss, the glenoid track is reduced, making engagement more likely. **Management:** My recommendation would be bone augmentation via **Latarjet procedure**. This addresses the bone deficit directly, extends the glenoid track, and provides the sling effect of the conjoint tendon. In a contact sport athlete with this degree of bone loss, I would not attempt arthroscopic soft tissue repair. **Procedure overview:** I would use a deltopectoral approach, transfer the coracoid to the anterior glenoid flush with the articular surface, fix with two screws, and repair the capsule. Post-operatively, he would be in a sling for 3 weeks with return to rugby at 6 months. I would counsel him on the expected success rate of 95% and the small risk of complications including graft nonunion and long-term arthritis.

KEY POINTS TO SCORE

Recognize 20-25% as critical bone loss threshold

Soft tissue repair inadequate for significant bone loss

Latarjet addresses bone deficit and extends glenoid track

Contact athlete with bone loss needs bone augmentation

COMMON TRAPS

✗Attempting arthroscopic Bankart for significant bone loss

✗Not measuring bone loss on CT before planning surgery

✗Ignoring the Hill-Sachs lesion (glenoid track concept)

LIKELY FOLLOW-UPS

"How do you position the coracoid?"

"What are the complications of Latarjet?"

"What if he had 15% bone loss instead?"

VIVA SCENARIOChallenging

Scenario 2: Acute Glenoid Body Fracture

EXAMINER

"A 45-year-old woman presents after motor vehicle accident with severe shoulder pain. X-rays show a glenoid fracture. CT reveals an Ideberg Type III fracture with 5mm articular step. How would you manage this?"

EXCEPTIONAL ANSWER

Thank you. This patient has an acute Ideberg Type III glenoid body fracture with significant articular displacement. **Classification:** An Ideberg Type III fracture is an oblique fracture line that exits through the superior glenoid toward the suprascapular notch. With 5mm of articular step, this requires surgical intervention. **Assessment:** I would complete my assessment looking for: - Associated injuries (high-energy mechanism) - Neurovascular status (axillary, suprascapular nerves) - Associated scapula or clavicle fractures (floating shoulder pattern) - Rotator cuff status **Imaging:** The CT scan is essential and has shown the fracture pattern. I would review the 3D reconstruction to plan the surgical approach and fixation. **Management:** With 5mm articular step, operative management is indicated. The surgical threshold is generally 2-5mm displacement. Nonoperative treatment would result in articular incongruity and early arthritis. **Surgical approach:** For an Ideberg Type III, I would use a **posterior Judet approach**: - Lateral decubitus position - Incision along scapula spine extending to lateral border - Develop infraspinatus-teres minor interval - Protect the suprascapular nerve at the spinoglenoid notch - Direct visualization of the glenoid neck and body **Fixation:** I would achieve anatomic reduction of the articular surface, fix with lag screws through the fracture, and apply a neutralization plate along the lateral scapular border. **Post-operative:** She would be in a sling for 2-4 weeks with early passive motion, progressing to active motion as the fracture heals. I would expect union at 8-12 weeks.

KEY POINTS TO SCORE

Ideberg Type III is oblique through superior glenoid

5mm step exceeds threshold for surgical intervention

Posterior Judet approach for most body fractures

Anatomic reduction is critical for good outcome

COMMON TRAPS

✗Not recognizing the surgical threshold for displacement

✗Using anterior approach for posterior/superior fracture

✗Forgetting to protect suprascapular nerve posteriorly

LIKELY FOLLOW-UPS

"How would you protect the suprascapular nerve?"

"What if this was an Ideberg Type Ia instead?"

"What is the long-term prognosis?"

VIVA SCENARIOCritical

Scenario 3: Bipolar Bone Loss

EXAMINER

"A 28-year-old presents after first-time dislocation. CT shows 18% glenoid bone loss and a large Hill-Sachs lesion measuring 25mm (medial to lateral). How do you decide on treatment?"

EXCEPTIONAL ANSWER

Thank you. This is a bipolar bone loss situation requiring careful analysis using the glenoid track concept. **Glenoid track calculation:** First, I need to calculate the glenoid track. Assuming a normal inferior glenoid width of 25mm: - Glenoid track = 0.83 x 25mm - bone loss - Glenoid track = 20.75mm - (18% of 25mm) - Glenoid track = 20.75mm - 4.5mm = approximately 16mm **Hill-Sachs assessment:** The Hill-Sachs interval (medial to lateral width) is 25mm. **On-track vs Off-track:** Since the Hill-Sachs interval (25mm) is GREATER than the glenoid track (16mm), this is an **off-track** lesion. This means the Hill-Sachs will engage with the glenoid rim during external rotation, causing instability. **Treatment implications:** In an off-track situation, I cannot simply do an isolated soft tissue Bankart repair. I need to either: 1. Address the Hill-Sachs directly (remplissage, bone graft) 2. Increase the glenoid track (Latarjet adds approximately 10mm) 3. Or both **My recommendation:** Given 18% bone loss and an off-track lesion, I would recommend a **Latarjet procedure**. This will: - Add approximately 10mm bone to the glenoid (increased track to approximately 26mm) - Convert the off-track lesion to on-track - Provide the conjoint tendon sling effect - Be more reliable than isolated remplissage **Alternative:** If I were to attempt arthroscopic management, I would need to combine Bankart repair with remplissage (infraspinatus tenodesis into the Hill-Sachs). However, with 18% bone loss approaching threshold and an off-track lesion, Latarjet is more predictable. I would discuss both options with the patient, acknowledging Latarjet has slightly higher complication risk but lower recurrence.

KEY POINTS TO SCORE

Calculate glenoid track: 0.83 x width - bone loss

Compare to Hill-Sachs interval to determine on/off-track

Off-track lesions need Hill-Sachs addressed or track increased

Latarjet adds approximately 10mm to glenoid track

COMMON TRAPS

✗Ignoring the Hill-Sachs in decision-making

✗Not calculating glenoid track for bipolar lesions

✗Treating off-track lesion with isolated soft tissue repair

LIKELY FOLLOW-UPS

"What is remplissage and when would you use it?"

"What if this was an on-track lesion?"

"How does Latarjet increase the glenoid track?"

MCQ Practice Points

Q1: Bone Loss Threshold

Q: What percentage of glenoid bone loss is the threshold above which bone augmentation is recommended?

A) 10-15%
B) 20-25%
C) 30-35%
D) 40-45%

A: B - 20-25% bone loss is the critical threshold. Above this, soft tissue repair alone has unacceptably high recurrence rates.

Q2: Ideberg Classification

Q: An Ideberg Type III glenoid fracture is:

A) Anterior rim avulsion
B) Transverse fracture exiting lateral border
C) Oblique fracture exiting superiorly
D) Horizontal fracture exiting medially

A: C - Type III is an oblique fracture through the superior glenoid exiting near the suprascapular notch.

Q3: Glenoid Track

Q: The glenoid track is calculated as:

A) 0.5 x glenoid width + bone loss
B) 0.83 x glenoid width - bone loss
C) 1.0 x glenoid width - bone loss
D) 0.83 x glenoid width + Hill-Sachs interval

A: B - Glenoid track = 0.83 x inferior glenoid width - glenoid bone loss (d).

Q4: Latarjet Mechanism

Q: What does Latarjet provide stability through all EXCEPT?

A) Bone block effect
B) Sling effect of conjoint tendon
C) Capsular repair
D) Rotator cuff augmentation

A: D - Latarjet provides bone block, sling effect (conjoint tendon), and capsular repair. It does not augment the rotator cuff.

Inverted Pear Question

Q: What does an inverted pear glenoid indicate? A: Significant anterior-inferior bone loss (greater than 25%). Normal glenoid is pear-shaped with wider inferior portion. An inverted pear indicates loss of inferior width, causing recurrent instability.

CT Imaging Question

Q: Why is CT with 3D reconstruction essential for glenoid fractures? A: Plain X-rays underestimate bone loss by up to 50%. CT with humeral head subtraction and en-face glenoid view allows accurate quantification of bone loss for surgical planning.

Australian Context

Glenoid fractures and instability are common presentations in Australia, particularly in the context of contact sports such as rugby union, rugby league, and Australian rules football. The high participation rates in these sports result in significant numbers of young athletes with anterior shoulder instability and associated bone loss.

Australian orthopaedic practice generally follows international guidelines regarding bone loss thresholds. CT scanning is readily available for accurate bone loss quantification, and the glenoid track concept has been widely adopted for surgical planning.

The Latarjet procedure has become the preferred bone augmentation technique in Australia for significant glenoid bone loss. Both open and arthroscopic techniques are performed, with surgeon experience being the key determinant of approach selection.

Return to contact sport is typically permitted at 6 months post-operatively, with appropriate rehabilitation and strength testing. Documentation of neurovascular status and informed consent regarding recurrence risk and potential complications are important medicolegal considerations.

GLENOID FRACTURES

High-Yield Exam Summary

Classification

•Type I = rim avulsion (bony Bankart)
•Type II = transverse (exits laterally)
•Type III = oblique (exits superiorly)
•Type IV = horizontal (exits medially)
•Type V = combined I + IV
•Type VI = comminuted

Bone Loss Thresholds

•Under 15% = soft tissue repair adequate
•15-20% = individualize (consider bone block in athletes)
•Over 20-25% = bone augmentation required
•Over 25% = inverted pear glenoid appearance

Glenoid Track

•Track = 0.83 x glenoid width - bone loss
•Compare to Hill-Sachs interval (HSI)
•HSI greater than Track = off-track = will engage
•Off-track needs Hill-Sachs addressed or track increased
•Latarjet adds approximately 10mm to track

Surgical Options

•Arthroscopic Bankart: under 15% bone loss
•Latarjet: over 20-25% bone loss or off-track
•ORIF: displaced body fractures (Ideberg II-V)
•Remplissage: address Hill-Sachs arthroscopically

Complications

•Recurrence 5-15% (higher with bone loss)
•Arthritis 10-30% (especially post-Latarjet)
•Stiffness 5-15%
•Nerve injury under 5%

Bone Loss

Pattern

Treatment

Key Consideration

Under 15%

Small bony Bankart

Arthroscopic Bankart repair

May include fragment if reducible

15-20%

Moderate rim defect

Arthroscopic with anchors vs open Bankart

Consider bone block if contact sport

20-25%

Significant bone loss

Latarjet or bone graft (Eden-Hybinette)

Soft tissue alone will fail

Over 25%

Severe bone loss

Latarjet preferred

Inverted pear glenoid configuration

Ideberg II-V

Glenoid body fracture

ORIF (posterior approach usually)

Goal is articular congruity

Bone Loss

Stability Effect

Surgical Implication

Under 15%

Minimal effect on stability

Soft tissue repair adequate

15-20%

Increased recurrence risk

Consider bone augmentation in athletes

Over 20-25%

High recurrence with soft tissue repair

Bone augmentation required

Type

Description

Fracture Line

Anterior rim fracture

Avulsion anteroinferior

Posterior rim fracture

Avulsion posterior

Transverse through glenoid

Exits lateral scapula border

III

Oblique through superior glenoid

Exits suprascapular notch area

Horizontal through body

Exits medial scapula border

Combination Type I + Type IV

Combined rim and body

Comminuted (added later)

Severe comminution

Management based on bone loss:

Algorithm by Bone Loss

Low RiskUnder 15% Bone Loss

Arthroscopic Bankart repair
May incorporate fragment with anchors
Good outcomes with soft tissue repair

Intermediate15-20% Bone Loss

Individualized decision
Young contact athlete: consider bone augmentation
Recreational: may try soft tissue repair first
Counsel on recurrence risk

High RiskOver 20-25% Bone Loss

Bone augmentation required
Latarjet (coracoid transfer)
Eden-Hybinette (iliac crest graft)
Soft tissue alone will fail

Why Latarjet Works

Complication

Incidence

Risk Factors

Management

Recurrent instability

5-25%

Bone loss over 25%, soft tissue repair

Revision with bone augmentation

Glenoid arthritis

10-30%

Malreduction, excessive lateralization

Activity modification, arthroplasty

Stiffness

5-15%

Prolonged immobilization, capsular repair

Physiotherapy, manipulation, arthroscopy

Nerve injury (axillary/suprascapular)

Less than 5%

Surgical approach, retraction

Observation, exploration if no recovery

Graft/coracoid nonunion (Latarjet)

5-10%

Poor technique, smoking

Observation if stable, revision if unstable

Hardware failure

Less than 5%

Poor bone quality, early motion

Revision fixation

Procedure

Recurrence

Return to Sport

Arthritis Risk

Arthroscopic Bankart

5-15% (higher with bone loss)

85-95%

Low

Open Bankart

5-10%

85-90%

Low

Latarjet

2-5%

90-95%

10-30% (long-term)

ORIF body fracture

N/A

80-90%

Depends on reduction