Examination of the adolescent shoulder seeks to evaluate similar issues to those present in adult shoulder instability. Careful examination of the unclothed shoulder bilaterally is critical, as scapular dyskinesia and multidirectional instability will be present to a greater degree than with adults. Range of motion should be checked and compared with the unaffected side, with careful attention to loss of internal rotation or GIRD syndrome. Profound loss of motion or significant strength deficits can indicate a need for a preoperative course of physical therapy. Again, asymptomatic laxity can be difficult to separate from pathologic instability, and careful check for anterior and posterior apprehension tests and load and shift test are critical. Pathologically increased shoulder motion or a large sulcus sign should prompt the examiner to consider multidirectional instability, and all patients should be asked about any voluntary instability, which may recommend pursuing a course of nonoperative treatment due to the inferior success rates with surgical repair of multidirectional instability [21] although recent experiences have been more successful [22]. Especially in the under 14 age group, voluntary instability can be otherwise asymptomatic and has been shown by Neer and others to often correct with time [23]. Significant hyperlaxity of the shoulder can also be the initial presentation of several hereditary musculoskeletal conditions such as Ehlers-Danlos or Marfan’s syndrome in this age group, with significantly poorer outcomes with surgical repair, and may require consideration of other associated disorders such as cardiac and ocular conditions.

Radiographs should include at least standard AP and axillary view; a Grashey view can also be helpful [24]. While large bone defects are less common in this age group, they are not unheard of, and significant bone defects such as large Hill-Sachs lesions or glenoid defects may require bone-block-type procedures [25]. Rotator cuff pathology in this group is distinctly uncommon and does not require special preoperative imaging, and so plain arthrograms are not normally indicated. While CT scanning can more reliably measure bone loss, the risks of the required radiation is not insignificant, especially as the field involves the breast and thyroid tissues [26]. For this reason, MRI scanning may be a more appropriate imaging study if bone loss is to be assessed in this age group.

The indication for an open Bankart repair in the adolescent is the presence of recurrent instability failing conservative management in an appropriate patient with significant limitations of activities. The presence of neurologic deficits, large bone defects, and profound stiffness or marked weakness contraindicates this procedure. While universal success of surgical treatment is not common, nonoperative treatment fails in a substantial number of patients [13], and primary open repair for the first-time dislocator has become a reasonable option. The presence of a significant component of multidirectional instability will at least require a change in technique to incorporate some component of capsular tightening, and marked voluntary instability with significant ligament laxity should give the surgeon pause.

The technique is much the same as for adult Bankart repair. Because of the risk of unrecognized associated intraarticular pathology, complete, thorough arthroscopic evaluation of the shoulder should be done prior to proceeding with the open repair, and any associated pathology, such as superior labral lesions, articular cartilage injuries, loose bodies, and rotator cuff injuries can be addressed arthroscopically prior to the open repair. This can be done in the beach chair position, with the advantage of easy conversion to the open repair, or in the lateral decubitus position and then re-prepping and redraping the patient.

With the arthroscopic examination completed, attention can be directed to the open repair. A low axillary incision has been shown to improve the cosmesis of the scar [10]. A standard deltopectoral approach with preservation of the cephalic vein is performed. Management of the subscapularis is controversial, with a subscapularis split felt by some [27] to improve overhead function and others [10] finding reasonable results with a negative postoperative lift off test with detachment. As these younger patients rarely get stiff, immobilization after repair is reasonable and may permit the greater exposure afforded by detachment of the subscapularis without causing postoperative weakness. Once exposed, the Bankart lesion can be prepared by abrading the glenoid. At least three suture anchors should be placed at roughly the one, three, and five o’clock position and used to reattach the labrum to the bone. A Heaney needle holder can be very helpful in placing these sutures anatomically. Traditionally, the rotator interval has been closed, although recently some surgeons have suggested that leaving this open might improve external rotation [10]. Meticulous hemostasis should be assured prior to skin closure, and a thorough check of the neurologic status should be performed in the recovery room prior to discharge, an advantage of general anesthesia over intrascalene block.

Open Bankart surgery can generally be performed outpatient without undue difficulty. Compliance with postoperative restrictions, as any parent knows, can be difficult in this patient population. Both the patient and parents need to be well aware that failure to comply with postoperative restrictions can negatively impact the results of the surgery. For this reason, it has seemed easier over the years to insist on continuous use of a sling for six weeks postoperatively, as this seems to create an easily understandable demarcation between appropriate and inappropriate activities. Driving should be avoided for six weeks as well and should be clearly understood preoperatively, as this is often a significant issue postoperatively. Hand, wrist, and elbow exercises can start immediately, with pendulum exercises starting at three weeks.