Raiyyan Tahsan

Raiyyan Tahsan
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TC(1072).(05).Orthopedics Case No 148:- Bankart Lesion

Bankart Lesion — বাংলায় সাজানো ক্লিনিক্যাল নোট

Important: Bankart lesion-এর definitive treatment drug না। Drug ব্যবহার হয় pain, inflammation, muscle spasm, post-reduction/post-operative pain control করার জন্য। Labrum/capsule detach হয়ে গেলে healing বা stability restore করার মূল চিকিৎসা হলো immobilization + physiotherapy, আর recurrent instability/athlete/bony defect থাকলে arthroscopic Bankart repair / Latarjet।

1. Definition — Bankart Lesion কী?

Bankart lesion হলো shoulder joint-এর anteroinferior glenoid labrum-এর tear/detachment, সাধারণত anterior shoulder dislocation-এর পর হয়। Labrum glenoid socket-এর “rim/bumper” হিসেবে humeral head-কে স্থির রাখতে সাহায্য করে; labrum ছিঁড়ে গেলে shoulder anterior instability ও recurrent dislocation হয়।

Types:

  • Soft-tissue Bankart: শুধু labrum/capsule tear.
  • Bony Bankart: labrum-এর সাথে glenoid rim-এর bone fragment avulsion.
  • Associated lesion: Hill-Sachs lesion — humeral head impaction defect, recurrent dislocation-এ common.

2. Causes / Etiology — কারণগুলো

  • Anterior shoulder dislocation — সবচেয়ে common cause.
  • Contact/collision sports: football, rugby, kabaddi, wrestling, martial arts.
  • Fall on outstretched hand বা abducted–externally rotated shoulder position.
  • Road traffic accident / direct shoulder trauma.
  • Recurrent shoulder subluxation/dislocation — repeated injury হলে labrum আরও detach হয়।
  • Young athlete/high-demand worker — recurrence risk বেশি।
  • Hyperlaxity / generalized ligamentous laxity থাকলে instability বাড়ে।
  • Mechanism: shoulder abducted + externally rotated অবস্থায় humeral head anteriorly dislocate করে, anteroinferior labrum ও inferior glenohumeral ligament complex avulse হয়।

3. Pathophysiology — রোগ কীভাবে হয়?

  • Glenoid labrum shoulder socket-এর depth বাড়ায় এবং humeral head centering করে।
  • Anterior dislocation হলে humeral head labrum/capsule-কে glenoid rim থেকে টেনে ছিঁড়ে দেয়।
  • ফলে static stabilizer যেমন labrum, capsule, inferior glenohumeral ligament দুর্বল হয়।
  • এরপর shoulder আবার anteriorly slip/dislocate করার tendency তৈরি হয়।
  • Repeated dislocation হলে glenoid bone loss, Hill-Sachs lesion, cartilage damage এবং early arthritis হতে পারে।

4. Symptoms — লক্ষণগুলো

  • Shoulder pain: injury/dislocation-এর পর anterior shoulder pain.
  • Instability feeling: রোগী বলে “shoulder বের হয়ে যাবে মনে হয়”।
  • Recurrent dislocation/subluxation: হাত নির্দিষ্ট position-এ গেলে joint slip করে।
  • Apprehension: হাত abducted + externally rotated করলে ভয়/guarding হয়।
  • Clicking/catching/popping sensation: labral tear-এর কারণে।
  • Weakness: overhead activity, throwing, lifting-এ weakness।
  • Reduced range of motion: pain বা fear-এর কারণে movement কমে যায়।
  • Night pain / activity-related pain: বিশেষ করে chronic instability-তে।
  • Numbness over lateral shoulder: axillary nerve stretch injury থাকলে deltoid badge area numb হতে পারে।

5. Clinical Diagnosis — clinically কীভাবে diagnosis করবেন?

History

  • Previous anterior shoulder dislocation আছে কিনা।
  • Mechanism: fall, sports injury, RTA, abducted–externally rotated arm.
  • First episode নাকি recurrent?
  • Age, sports level, occupation, overhead activity.
  • Reduction history, immobilization history, previous physiotherapy/surgery.

Examination

  • Inspection: deformity, swelling, muscle wasting, deltoid contour.
  • Palpation: anterior joint line tenderness.
  • ROM: active/passive ROM, painful arc, external rotation apprehension.
  • Neurovascular exam: axillary nerve sensation over lateral deltoid, deltoid power, radial pulse, distal motor/sensory.

Specific clinical tests

  • Apprehension test: shoulder 90° abduction + external rotation দিলে patient fear/guarding করে।
  • Relocation test: posterior pressure দিলে apprehension কমে যায় — anterior instability support করে।
  • Surprise/release test: posterior pressure suddenly release করলে apprehension ফিরে আসে।
  • Anterior drawer test: humeral head anterior translation বেশি।
  • Load-and-shift test: glenohumeral translation assess.
  • Sulcus sign: multidirectional laxity থাকলে positive হতে পারে।

Clinical diagnosis anterior instability tests positive + imaging-এ labral tear থাকলে শক্তিশালী হয়।

6. Investigations — specific workup

1) X-ray shoulder — first-line

Views:

  • True AP shoulder
  • Scapular Y view
  • Axillary view

কেন করবেন:

  • Dislocation confirm.
  • Fracture exclude.
  • Bony Bankart / Hill-Sachs lesion suspect.
  • Reduction-এর আগে ও পরে X-ray করা দরকার।

2) MRI shoulder

Best for: labrum, capsule, ligament, rotator cuff, marrow edema.
ACR traumatic shoulder pain guidance অনুযায়ী soft-tissue injury evaluation-এ MRI useful; MRI arthrography subtle labral pathology-তে helpful হতে পারে।

3) MR Arthrogram / MRA

Best when:

  • Chronic/recurrent instability.
  • Standard MRI negative কিন্তু clinical suspicion high.
  • Subtle labral tear/Bankart variant detect করতে।

MRA Bankart lesion detection-এ high sensitivity দেখিয়েছে; একটি study-তে MRA sensitivity 94.4% পাওয়া গেছে।

4) CT shoulder / 3D CT

কেন করবেন:

  • Glenoid bone loss quantify.
  • Bony Bankart fragment.
  • Hill-Sachs size and track.
  • Surgery planning, especially Latarjet decision.

5) Diagnostic arthroscopy

Gold standard practical confirmation during surgery; labrum, capsule, cartilage, Hill-Sachs directly দেখা যায়।

7. Differential Diagnosis

  • SLAP tear
  • Rotator cuff tear
  • HAGL lesion
  • ALPSA lesion
  • Perthes lesion
  • Glenoid fracture
  • AC joint injury
  • Frozen shoulder
  • Cervical radiculopathy
  • Multidirectional instability
  • Posterior shoulder instability

8. Complications — Disease complication বাংলায়

  • Recurrent anterior shoulder dislocation: সবচেয়ে important complication.
  • Chronic shoulder instability: daily activity, overhead work, sports performance কমে যায়।
  • Hill-Sachs lesion: humeral head defect, recurrence বাড়ায়।
  • Glenoid bone loss / bony Bankart: socket shallow হয়ে instability বাড়ে।
  • Chronic pain: labral/capsular injury ও cartilage damage-এর কারণে।
  • Loss of confidence / apprehension: patient হাত তুলতে ভয় পায়।
  • Reduced ROM and stiffness: immobilization বা pain-এর কারণে।
  • Axillary nerve injury: lateral shoulder numbness, deltoid weakness.
  • Rotator cuff tear: older patient-এ dislocation-এর সাথে হতে পারে।
  • Early glenohumeral osteoarthritis: recurrent dislocation/cartilage damage হলে long-term arthritis হতে পারে।

9. Treatment / Management

A. Acute shoulder dislocation with suspected Bankart lesion

  • Pain control.
  • Neurovascular assessment before and after reduction.
  • X-ray before reduction unless emergent neurovascular compromise.
  • Closed reduction by trained clinician.
  • Post-reduction X-ray.
  • Sling immobilization.
  • Early orthopedic referral if young athlete, recurrent dislocation, bony defect, persistent instability.

B. Conservative management

Suitable when:

  • First-time dislocation.
  • Low-demand patient.
  • No major bony defect.
  • No recurrent instability.

Includes:

  • Sling short period.
  • Ice compression.
  • Activity modification.
  • Physiotherapy: rotator cuff + scapular stabilizer strengthening.
  • Avoid abduction + external rotation early phase.

AAOS notes nonsurgical treatment commonly includes activity modification, NSAIDs, and physical therapy; surgery is considered when repeated dislocations or instability persist.

C. Surgical management

Indications:

  • Recurrent dislocation/subluxation.
  • Young contact athlete/high-demand worker.
  • MRI-confirmed Bankart lesion with instability.
  • Bony Bankart/glenoid bone loss.
  • Engaging/off-track Hill-Sachs lesion.

Options:

  • Arthroscopic Bankart repair: suture anchor দিয়ে labrum/capsule glenoid rim-এ reattach.
  • Bankart repair + remplissage: off-track Hill-Sachs থাকলে.
  • Open Bankart repair: selected cases.
  • Latarjet procedure: significant glenoid bone loss, failed Bankart, high-risk recurrence.

AAOS states Bankart lesions can be repaired using sutures/anchors, often arthroscopically; CT may be used to assess bone loss in repeated dislocation.
Young active first-time traumatic anterior dislocation patients-এ arthroscopic Bankart repair recurrence কমাতে পারে, তবে সব patient-এর জন্য immediate surgery suitable নয়।

10. Pharmacological Management — Bangladesh prescription-style drug list

Note: নিচের adult doseগুলো general reference. Patient-এর age, renal function, liver disease, peptic ulcer, asthma, pregnancy, anticoagulant use, CV risk অনুযায়ী modify করতে হবে। একই সাথে একাধিক NSAID দেওয়া যাবে না।

1) Paracetamol

  1. Generic name: Paracetamol / Acetaminophen
  2. Therapeutic category: Analgesic, Antipyretic
  3. Pharmacological class: Para-aminophenol derivative; central analgesic
  4. Bangladesh available brand name:
    • Napa 500 mg Tablet — Paracetamol 500 mg
    • Ace 500 mg Tablet — Paracetamol 500 mg
    • Napa One 1000 mg Tablet — Paracetamol 1000 mg
    • Napa Extend 665 mg Tablet — Paracetamol ER 665 mg
      MedEx lists Napa 500 mg and Ace 500 mg as paracetamol brands indicated for pain, sprain, back pain, postoperative pain and inflammatory pain.

Dose: 500 mg–1 g orally every 6–8 hours PRN.
Max: usually 3–4 g/day; liver disease/alcohol use হলে lower max.
Duration: 3–5 days or as needed.
Why used: mild–moderate shoulder pain control; NSAID contraindicated হলে safest first-line analgesic.
Side effects: nausea, rash rarely; overdose → hepatotoxicity.
Interactions: alcohol, warfarin with prolonged high dose, other paracetamol-containing cold/flu drugs.

2) Ibuprofen

  1. Generic name: Ibuprofen
  2. Therapeutic category: Analgesic + anti-inflammatory
  3. Pharmacological class: NSAID; nonselective COX inhibitor
  4. Bangladesh available brand name:
    • Flamex 400 mg Tablet — Ibuprofen 400 mg
    • Profen 400 mg Tablet — Ibuprofen 400 mg
    • Reumafen 400 mg Tablet — Ibuprofen 400 mg
    • Intaflam 400 mg Tablet — Ibuprofen 400 mg
      MedEx lists ibuprofen for mild–moderate pain, inflammatory pain, muscular pain, rheumatic pain and fever; brand list includes Flamex, Profen, Reumafen, Intaflam.

Dose: 400 mg orally 8 hourly after food.
Duration: 3–5 days; avoid long-term unless indicated.
Why used: acute pain + inflammation after shoulder trauma/reduction.
Side effects: gastritis, dyspepsia, GI bleeding, renal impairment, BP rise, bronchospasm in NSAID-sensitive asthma.
Interactions: anticoagulants, antiplatelets, steroids, ACEi/ARB + diuretic, lithium, methotrexate, other NSAIDs.

3) Naproxen / Naproxen + Esomeprazole

  1. Generic name: Naproxen sodium ± Esomeprazole
  2. Therapeutic category: Analgesic, anti-inflammatory; GI-protected NSAID combo
  3. Pharmacological class: NSAID; nonselective COX inhibitor + PPI
  4. Bangladesh available brand name:
    • Naprosyn 500 mg Tablet — Naproxen 500 mg
    • Naproxen 500 mg Tablet — Naproxen 500 mg
    • Naproxen Plus 500 mg + 20 mg Tablet — Naproxen sodium + Esomeprazole magnesium
    • Naprosyn Plus 500 mg + 20 mg Tablet
    • Naprox Plus 500 mg + 20 mg Tablet
      MedEx lists naproxen for tendonitis, bursitis and pain; naproxen–esomeprazole combinations are listed to relieve symptoms and reduce NSAID-associated gastric ulcer risk.

Dose:

  • Naproxen 250–500 mg orally 12 hourly after food.
  • Naproxen + Esomeprazole 500/20 mg orally 12 hourly before meal if GI risk.

Duration: 5–7 days usually.
Why used: longer-acting NSAID; inflammation and pain control.
Side effects: gastritis, ulcer, renal impairment, fluid retention, BP rise.
Interactions: anticoagulants, aspirin/antiplatelet, steroids, SSRI, ACEi/ARB/diuretic, lithium, methotrexate.

4) Diclofenac Sodium

  1. Generic name: Diclofenac sodium
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: NSAID; COX inhibitor
  4. Bangladesh available brand name:
    • Clofenac 50 mg Tablet — Diclofenac sodium 50 mg
    • Clofenac SR 100 mg Tablet — Diclofenac sodium 100 mg
    • Voltalin Forte 50 mg Tablet — Diclofenac sodium 50 mg
    • Voltalin SR 100 mg Tablet — Diclofenac sodium 100 mg
    • Clofenac Gel 1% w/w — Diclofenac sodium topical
      MedEx lists diclofenac sodium as NSAID therapeutic class; Clofenac is indicated in dislocations, fractures and soft-tissue injuries.

Dose:

  • Oral: 50 mg 8–12 hourly after food; max 150 mg/day.
  • SR: 100 mg once daily after food.
  • Topical gel: apply thin layer 2–4 times/day over painful area.

Duration: 3–5 days for acute pain; topical may continue 1–2 weeks.
Why used: strong pain + inflammatory swelling control.
Side effects: gastritis, GI bleed, renal injury, edema, BP rise, liver enzyme rise, CV risk.
Interactions: anticoagulants, antiplatelets, steroids, other NSAIDs, ACEi/ARB/diuretic, lithium, methotrexate.
Avoid/caution: peptic ulcer, CKD, uncontrolled HTN, IHD, stroke risk.

5) Etoricoxib

  1. Generic name: Etoricoxib
  2. Therapeutic category: Analgesic, anti-inflammatory
  3. Pharmacological class: Selective COX-2 inhibitor NSAID
  4. Bangladesh available brand name:
    • Etorix 60 mg / 90 mg / 120 mg Tablet — Etoricoxib
    • Tory 60 mg / 90 mg / 120 mg Tablet — Etoricoxib
      MedEx lists etoricoxib as a non-steroidal anti-inflammatory drug and Etorix 90 mg as an available brand.

Dose: 60–90 mg once daily after food. Severe acute pain: 90 mg OD, short course.
Duration: 3–5 days; use lowest effective dose.
Why used: pain + inflammation; relatively less gastric irritation than nonselective NSAIDs, but CV risk remains.
Side effects: dyspepsia, edema, hypertension, renal impairment, CV thrombotic risk.
Interactions: warfarin, ACEi/ARB/diuretics, lithium, methotrexate, other NSAIDs.
Avoid/caution: ischemic heart disease, stroke, uncontrolled HTN, severe CKD.

6) Ketorolac Tromethamine

  1. Generic name: Ketorolac tromethamine
  2. Therapeutic category: Strong analgesic NSAID
  3. Pharmacological class: NSAID; potent COX inhibitor
  4. Bangladesh available brand name:
    • Torax 10 mg Tablet; Torax Injection 30 mg/ml, 60 mg/2 ml
    • Rolac 10 mg Tablet; Rolac Injection 30 mg/ml, 60 mg/2 ml
    • Keteks 10 mg Tablet; Keteks Injection 30 mg/ml
      MedEx lists ketorolac for short-term management of moderate to severe acute postoperative pain; Torax/Rolac 10 mg are available brands.

Dose: 10 mg orally every 6 hours PRN; max 40 mg/day.
Duration: maximum 5 days preferred; MedEx Bangla page mentions short-term use and not long-term therapy.
Why used: severe acute pain, usually post-reduction/post-operative setting; routine chronic use নয়।
Side effects: GI bleeding, renal injury, bleeding tendency, dizziness, nausea.
Interactions: anticoagulants, antiplatelets, steroids, other NSAIDs, ACEi/ARB/diuretic.
Avoid: peptic ulcer, renal impairment, bleeding disorder, perioperative high bleeding risk unless surgeon decides.

7) Tizanidine

  1. Generic name: Tizanidine hydrochloride
  2. Therapeutic category: Muscle relaxant
  3. Pharmacological class: Central alpha-2 adrenergic agonist skeletal muscle relaxant
  4. Bangladesh available brand name:
    • Sirdalud 2 mg Tablet
    • Tizadin 2 mg Tablet
    • Tizalud 2 mg Tablet
    • Relentus 2 mg Tablet
      MedEx lists tizanidine for painful muscle spasms; brand list includes Sirdalud, Tizadin, Tizalud, Relentus.

Dose: 2 mg at night or 2 mg 8–12 hourly PRN.
Duration: 3–5 days.
Why used: traumatic shoulder pain-এর সাথে protective muscle spasm থাকলে।
Side effects: sedation, dizziness, dry mouth, hypotension, weakness, liver enzyme rise.
Interactions: alcohol, benzodiazepines, sedatives; ciprofloxacin/fluvoxamine contraindicated-type interaction due to marked tizanidine level rise.
Caution: driving, hypotension, liver disease.

8) Tramadol

  1. Generic name: Tramadol hydrochloride
  2. Therapeutic category: Strong analgesic
  3. Pharmacological class: Opioid analgesic; weak μ-opioid agonist + serotonin/norepinephrine reuptake inhibition
  4. Bangladesh available brand name:
    • Trado 50 mg Capsule; Trado Injection 100 mg/2 ml
    • Utramal 50 mg Capsule; Utramal IR 50 mg Tablet
    • Winpain 50 mg Capsule; Winpain Injection 100 mg/2 ml
    • Lucidol 50 mg Capsule; Lucidol Injection 100 mg/2 ml
      MedEx lists tramadol for moderate to severe painful conditions and gives usual oral doses 50–100 mg every 4–6 hours, max 400 mg/day.

Dose: 50 mg orally 6–8 hourly PRN; severe pain 50–100 mg; max 400 mg/day.
Duration: 1–3 days, short course only.
Why used: NSAID/paracetamol insufficient হলে severe acute pain/postoperative pain.
Side effects: nausea, vomiting, dizziness, sedation, constipation, dependence, respiratory depression, seizure risk, serotonin syndrome.
Interactions: alcohol, benzodiazepines, sedatives, SSRI/SNRI/TCA/MAOI, antipsychotics, other opioids.
Avoid/caution: epilepsy, severe respiratory disease, substance-use risk, severe liver/renal impairment.

9) Esomeprazole — NSAID gastric protection

  1. Generic name: Esomeprazole
  2. Therapeutic category: Anti-ulcerant / acid suppressant
  3. Pharmacological class: Proton pump inhibitor
  4. Bangladesh available brand name:
    • Maxpro 20 mg Tablet — Esomeprazole 20 mg
    • Nexum 20 mg Capsule — Esomeprazole 20 mg
    • Esoral 20 mg Tablet — Esomeprazole 20 mg
    • Sergel 20 mg Tablet — Esomeprazole 20 mg
      MedEx lists esomeprazole brands including Maxpro, Nexum, Esoral, Sergel; PPIs reduce gastric acid and are used for GERD/ulcer-related conditions.

Dose: 20 mg once daily 30 min before breakfast.
Duration: while NSAID is used; usually 5–7 days in this context.
Why used: NSAID-induced gastritis/ulcer risk কমাতে, especially ulcer history/high GI risk patient.
Side effects: headache, abdominal pain, diarrhea/constipation; long-term use → hypomagnesemia, B12 deficiency, fracture risk.
Interactions: clopidogrel effect may reduce, warfarin monitoring, diazepam/phenytoin level changes possible.

10) Cefazolin — surgery-only prophylaxis

  1. Generic name: Cefazolin sodium
  2. Therapeutic category: Antibiotic
  3. Pharmacological class: 1st-generation cephalosporin
  4. Bangladesh available brand name:
    • Cefazol 1 gm/vial Injection — Cefazolin sodium
    • Cefalin 1 gm/vial Injection — Cefazolin sodium
    • Zolibac 1 gm/vial Injection — Cefazolin sodium
      MedEx lists Cefazol, Cefalin, Zolibac as cefazolin sodium injection brands.

Dose: Surgical prophylaxis commonly 2 g IV within 60 min before incision; 3 g if body weight ≥120 kg; repeat intra-op if prolonged surgery.
Duration: usually single pre-op dose or ≤24 hours, depending on hospital protocol.
Why used: Bankart repair surgery হলে surgical site infection prophylaxis; non-operative Bankart lesion-এ antibiotic লাগে না।
Side effects: allergy, rash, diarrhea, C. difficile risk, injection site reaction.
Interactions: anticoagulants may increase bleeding tendency rarely; probenecid increases level; caution cephalosporin allergy.

11. Bangladesh doctors commonly prescription-এ কী দেন?

Typical non-operative acute pain prescription pattern:

  • Paracetamol 500 mg — pain relief; safest base analgesic.
  • Ibuprofen 400 mg / Naproxen 500 mg / Diclofenac 50 mg / Etoricoxib 90 mg — inflammation + pain control; একসাথে একাধিক NSAID নয়।
  • Esomeprazole 20 mg — NSAID-এর gastric protection.
  • Tizanidine 2 mg — muscle spasm থাকলে short course.
  • Tramadol 50 mg — severe pain হলে short course only.
  • Topical diclofenac gel 1% — localized pain হলে adjunct.
  • Cefazolin IV — শুধুমাত্র surgical prophylaxis, routine disease treatment না।

12. Prevention — কীভাবে prevent করবেন?

  • First dislocation হলে proper reduction + post-reduction X-ray + orthopedic follow-up.
  • Early phase-এ abduction + external rotation avoid.
  • Physiotherapy properly complete করা:
    • Rotator cuff strengthening
    • Scapular stabilizer strengthening
    • Proprioception training
    • Closed-chain shoulder control exercise
  • Contact sports-এ return করার আগে pain-free full ROM + strength symmetry confirm.
  • Recurrent dislocation ignore না করা; repeated dislocation bone loss বাড়ায়।
  • High-risk athlete হলে early surgical opinion.
  • Shoulder protective technique: fall training, tackling technique, warm-up.
  • General ligament laxity থাকলে aggressive strengthening.
  • Post-surgery rehab protocol strictly follow; early uncontrolled external rotation avoid.

Overview / Summary

Bankart lesion হলো anterior shoulder dislocation-এর পর anteroinferior glenoid labrum detachment। প্রধান সমস্যা pain নয়—anterior instability ও recurrent dislocation। Diagnosis clinical instability tests + MRI/MRA/CT দিয়ে confirm করা হয়। Drug শুধু symptom control করে; recurrent/high-risk/bony lesion হলে arthroscopic Bankart repair বা bone-block procedure প্রয়োজন হতে পারে।

Actionable Plan / Steps

  1. History + exam: dislocation episode, recurrence, apprehension, neurovascular status.
  2. Initial imaging: AP + scapular Y + axillary X-ray.
  3. Soft tissue confirmation: MRI shoulder; chronic/subtle case হলে MR arthrogram.
  4. Bone loss planning: CT/3D CT if recurrent/bony Bankart/Hill-Sachs suspected.
  5. Pain control: paracetamol ± one NSAID ± PPI; severe pain হলে short tramadol.
  6. Immobilization + physiotherapy: rotator cuff/scapular stabilizer rehab.
  7. Ortho referral: recurrent instability, young athlete, bony Bankart, off-track Hill-Sachs.
  8. Surgery: arthroscopic Bankart repair ± remplissage; major bone loss হলে Latarjet.

Reference List — Textbook + Guideline + DOI

Textbook

  1. Campbell’s Operative Orthopaedics, 14th/15th ed. Shoulder instability and arthroscopic Bankart repair sections.
  2. Rockwood and Green’s Fractures in Adults, 9th ed. Glenohumeral dislocation and associated labral/bony injuries.
  3. Apley & Solomon’s System of Orthopaedics and Trauma, 11th ed. Shoulder instability/dislocation chapter.
  4. Katzung & Trevor’s Basic & Clinical Pharmacology, 16th ed. NSAIDs, opioids, PPIs pharmacology.
  5. Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 14th ed. Analgesic-antipyretic/NSAID/opioid chapters.

Guideline / Clinical sources

  1. American College of Radiology — ACR Appropriateness Criteria® Acute Shoulder Pain: 2024 Update. J Am Coll Radiol. 2025;22(5S):S36–S47. DOI: 10.1016/j.jacr.2025.02.015.
  2. AAOS OrthoInfo — Chronic Shoulder Instability and Dislocation. Imaging and treatment overview.
  3. StatPearls/NCBI Bookshelf — Anteroinferior Glenoid Labrum Lesion (Bankart Lesion). Updated 2023.

Peer-reviewed journals with DOI

  1. Hu B, Hong T, Zhu Y, et al. Arthroscopic Bankart repair versus conservative treatment for first-time traumatic anterior shoulder dislocation: a systematic review and meta-analysis. Eur J Med Res. 2023. DOI: 10.1186/s40001-023-01160-0.
  2. Pougès C, Hardy A, Vervoort T, et al. Arthroscopic Bankart repair versus immobilization for first episode anterior shoulder dislocation before age 25. Am J Sports Med. 2025 follow-up report. DOI: 10.1177/03635465251350151.
  3. Waldt S, Burkart A, Imhoff AB, et al. Diagnostic performance of MR arthrography in glenohumeral instability/labral lesions. AJR Am J Roentgenol. 2004;182:1271–1278. DOI: 10.2214/ajr.182.5.1821271.
  4. Fabbriciani C, Milano G, Demontis A, et al. Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy. 2004;20(5):456–462. PMID: 15122134.

Md.Rafiqul Islam Lipu,Date:-23-06-2026 Tuesday,Time:-11-45-12 Am

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