Fracture of the humeral shaft associated with total replacement arthroplasty of the shoulder. A case report.
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Aged↗
Biomedical subjects
R J Hawkins
Publications and source records attributed to R J Hawkins.
Release of the subscapularis for internal rotation contracture and pain after anterior repair for recurrent anterior dislocation of the shoulder.
Ten patients who had an internal rotation contracture and pain after an anterior repair for recurrent dislocation of the shoulder were treated by release of the subscapularis muscle. For six of the patients, radiographs demonstrated severe osteoarthrotic changes in the shoulder as well. The release was done an average of eleven years after the original procedure, which, for most patients, had been a Putti-Platt repair. After release of the subscapularis, each patient had less pain in the shoulder and an average increase of 27 degrees of external rotation. Release of the subscapularis can offer relief of pain and of functional limitations associated with the symptoms caused by an internal rotation contracture after an anterior repair of the shoulder.
Adult↗
Current concepts and recent advances in the athlete's shoulder.
The demands placed on the shoulder girdle during athletics can often exceed its physiologic limits and result in significant injury. The goal of orthopedists, therapists, trainers, and ancillary personnel who care for athletes involved in sports which require extreme demands of the shoulder is to enhance athletic performance, extend their longevity, and prevent injury. With the new concepts available from basic science and clinical research, a clear understanding of normal architecture and biomechanical function of the shoulder girdle is better appreciated. A greater understanding of sporting activities and their physiologic demands on the shoulder are also more clear. The future of all this research seems to be pointing toward maintenance and restoration of normal anatomy and physiology about the shoulder girdle.
Athletic Injuries↗
Controversy in anterior shoulder instability.
The main areas of controversy in anterior shoulder instability are acute dislocation, recurrent instability, pain and instability in the "throwing athlete", and the role of arthroscopy. Treatment of the acute dislocation involves rest initially, followed by aggressive rehabilitation with protection of the shoulder until strength and motion have returned and pain and apprehension have resolved. Patients with recurrent instability may be seen with a variety of clinical scenarios. The surgical indications, pathology, and two methods of soft-tissue reconstruction are described along with an approach to postoperative rehabilitation. Return to sporting activity may be feasible by three months. The current thinking on the painful shoulder in the "throwing athlete" is outlined. Management must be based on an accurate diagnosis. Strengthening of the rotator cuff and scapular stabilizers is recommended with surgery to correct the pathology in those who fail this program. Arthroscopy is a valid tool in the diagnosis of anterior shoulder instability. The clinical significance of some intraarticular findings has not yet been clarified. Therapeutic use should be undertaken only in experienced hands, appreciating that failure of arthroscopic repair is higher than comparable open surgical techniques. The open approach to anterior stabilization is preferred.
Arthroscopy↗
Glenohumeral osteoarthrosis. A late complication of the Putti-Platt repair.
Osteoarthrosis of the glenohumeral joint is a potential late complication of anterior Putti-Platt capsulorrhaphy. In ten patients (eleven shoulders), disabling pain in the shoulder began an average of 13.2 years after a Putti-Platt repair that had been done for recurrent anterior unidirectional instability. In all of the patients, the osteoarthrosis of the glenohumeral joint resulted in substantial limitation of motion. Seven shoulders were successfully treated non-operatively, and a technique of anterior release was successful in four shoulders.
Adult↗
Cervical spine and shoulder pain.
The complex problem of combined neck and shoulder pain was investigated in 26 operations in 13 patients who had a shoulder procedure (subacromial decompressions or rotator cuff repairs) and an anterior cervical spine fusion. This select group of complex patients illustrates the diagnostic studies required to determine whether the pain comes primarily from the cervical spine, shoulder, or both. Good pain relief was accomplished after 24 of the 26 surgical procedures (average follow-up, 4.3 years). In the 13 patients, eight presented with nearly equal neck and shoulder pain as the chief complaint, whereas in the remaining five patients, the initial complaint was predominantly neck pain with only minor shoulder involvement. The shoulder pain became more significant after the anterior cervical fusion in these five patients. This study emphasizes the need for a careful evaluation of patients with combined neck-shoulder pain syndrome in a systematic approach allowing appropriate treatment.
Adult↗
Rotator cuff disorders.
Rotator cuff problems present with shoulder pain on repetitive overhead activity. Chronic irritation may develop into impingement tendonitis, with weakness of abduction and external rotation and night pain. Conservative management with rest, anti-inflammatory medicine and physiotherapy resolves the majority of symptoms. If these persist, surgical decompression affords good relief of pain.
Combined Modality Therapy↗
Posterior instability of the shoulder.
Posterior instability is a rare entity in which subluxation is much more common than dislocation. This problem should be assessed and treated by someone particularly interested in shoulder problems. Reconstruction produces fairly high recurrence and complication rates. Accurate preoperative patient selection and improved surgical procedures and techniques are required to maximize success.
Humans↗
Total shoulder arthroplasty.
Seventy Neer Series II total shoulder arthroplasties were performed in 65 patients. The average age was 69 years. The average follow-up period was 40 months. Rheumatoid arthritis or osteoarthritis was the diagnosis in 34 and 29 shoulders, respectively. Rotator cuff tears were identified in 18 patients. There were no infections, neurological injuries, or vascular injuries, or vascular injuries. Two glenoid fractures and two humeral shaft fractures were sustained intraoperatively. Uniformly, excellent pain relief was obtained regardless of the disease process. The resultant average increase in range of motion (ROM) was 60 degrees of active forward elevation and 18 degree of external rotation. Radiolucent lines were present in 17 humeral components; however, none was symptomatic or had progressed in thickness. Five glenoid components demonstrated progression of radiolucency, and two required revision. Both of these were in patients with rheumatoid arthritis. Although pain relief was uniformly good among all patient groups, a statistically significant degree of improvement in ROM was found in individuals with osteoarthritis. The etiology of the disease process and the status of the rotator cuff may determine the eventual outcome in individuals treated with total shoulder arthroplasty.
Adult↗
Failed anterior acromioplasty. A review of 51 cases.
This report is a retrospective review of 51 patients, each of whom had a failed acromioplasty that was performed after presumptive diagnoses of impingement tendinitis. The purpose of the review is to analyze the failures, define their causes, and make recommendations regarding further management. Average age at time of initial surgery was 40 years (range, 20-64 years), and the follow-up period averaged 5.5 years (range, three to nine years). Thirty-four patients were found to have symptoms and signs that corresponded to a recognized clinical diagnosis and were thought to be sufficient to be a major cause of their pain. Twenty-three had a diagnosis other than continuing impingement. Success of a second surgical procedure was significantly greater in nonworker's compensation (WC) patients than in WC patients. Repeat acromioplasties in WC patients have poor results and are not recommended. Seventeen patients had no clear cause for their continuing shoulder tendinitis; however, time and supportive therapy allowed five patients to improve over an average 18-month period. In all categories, WC patients fared poorly, so prognosis must be guarded in this group. Non-WC patients may be helped with repeat surgery following an appropriate diagnosis for the cause of failure.
Acromioclavicular Joint↗
Traumatic spondylolisthesis of the axis.
Hanging, a common method of execution, began in antiquity and continues to this date. Unfortunately, the exact cause of a victim's demise was not always obvious, and many victims died as the result of asphyxiation from the hangman's noose. In the latter part of the 19th century, scientific curiosity led to autopsy studies of the cervical spine; Paterson in 1890 first described the lethal lesion. Experimental work in 1913 demonstrated that when the hangman's knot was placed beneath the chin, death rapidly occurred because of a traumatic spondylolisthesis of the second cervical vertebra. This knot placement then became standard as the most efficient method of execution. It was not until the mid-20th century that the similarity between judicial and civilian injury was recognized. The reports were infrequent, and most of the pars interarticularis fractures resulted from automobile accidents in which the victim was thrown forward and struck his or her face against the windshield which caused sudden violent hyperextension. The similarity between civilian and vehicular injuries was recognized in 1965 by Schneider who, together with his associates, reported eight cases; it was this group who introduced the term "hangman's fracture". Garber presented his thoughts on this subject, noting that there was a difference between the forces generated by judicial hanging and those caused by motor vehicle accidents and other similar civilian injuries. The former results in axial loading and hyperextension, and, rarely, in flexion or axial loading. Since the lesion occurs at the pars interarticularis of C2, Garber suggested that a more appropriate term might be traumatic spondylolisthesis of the axis.
Axis, Cervical Vertebra↗
Acromioplasty for impingement with an intact rotator cuff.
This is a retrospective review of 108 patients who underwent decompressive anterior acromioplasty for chronic impingement in the absence of a full thickness rotator cuff tear. Before operation, all the patients had had shoulder pain for at least one year despite conservative treatment. At operation, the rotator cuff tendons were explored and were intact. Anterior acromioplasty, followed by rehabilitation was successful in 87% of patients. The operation was less successful in women, in those who had diminished movement before operation, who were involved in worker's compensation claims, and whose pain followed direct trauma. Appropriate selection of patients is considered the key to success.
Acromion↗
Posterior shoulder instability.
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Humans↗
Internal fixation techniques for proximal humeral fractures.
Operative treatment of proximal humeral fractures is performed with a variety of fixation techniques. Selection of the optimum device for fixation is dependent on anatomic considerations, fracture characteristics, surgical exposure, and biomechanical features of fixation devices. Fixation objectives are evaluated in light of Neer's four segment classification. An extended deltopectoral approach with release of anterior deltoid distal insertion as well as the proximal pectoralis major raphe provides a wide exposure. The approach heals rapidly and allows rapid rehabilitation. The shoulder fracture fragments are adaptable to tension band wiring. With loss of bone stock, tension band wiring becomes increasingly important because compression or shearing forces can be expended in the tendinous insertion of the fragments. Fixation principles are applied according to specific fracture patterns. Whatever the choice of fixation method, a protracted and vigorous rehabilitation program is essential to achieve maximal functional recovery.
Fracture Fixation, Internal↗
Advances in shoulder surgery.
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Fractures, Bone↗
Impingement syndrome in the absence of rotator cuff tear (stages 1 and 2).
Impingement syndrome affects a wide range of today's active population with various pathologies and presentations. Tendinitis can cause further subacromial loading, unless specific attention is directed at interrupting this disorder. Today's emphasis in high-risk populations, such as pitchers and swimmers, is on prophylaxis. Once symptoms occur, the majority can be successfully managed with nonoperative measures. Prolonged failure of conservative care prior to rotator cuff tear requires surgical decompression with predictable success in most. Results can be optimalized if strict attention is paid to patient selection, surgical technique, and a carefully supervised rehabilitation program following surgery.
Combined Modality Therapy↗
Displaced proximal humeral fractures. Selecting treatment, avoiding pitfalls.
This article, based on years of modified classification of displaced proximal humeral fractures, presents the treatment alternative for each type of injury and the problems to be avoided with each method. The authors recommend reduction and fixation in active patients with displaced proximal humeral fractures. Percutaneous pin fixation for two-part fractures, tension band fixation for three-part fractures, and hemiarthroplasty for four-part fractures are advocated.
Aged↗
A functional analysis of shoulder fusions.
Seventeen shoulder fusions with relatively normal musculature were analyzed with particular interest to the ability of the fused extremity to perform activities of daily living. Joints fused for paralysis were excluded. No patient was able to work overhead or with arms abducted as required for activities such as hammering, house painting, or climbing a ladder. Many patients had difficulty functioning at head level for hygienic purposes. Many were unable to perform functions behind the back, although waist-level function approached normal. The position of rotation was the most critical factor in approaching optimum function. Fusions in positions of internal rotation reduced the ability to comb hair, wash the face, or to otherwise use the hand at head level. Fusion in a position of excessive external rotation made it impossible for the patient to reach the opposite axilla or belt buckle. There was a range of acceptability of abduction of forward flexion that did not appear to compromise the eventual functional result. The recommended position is 25 degrees to 40 degrees abduction, 20 degrees to 30 degrees flexion, and 25 degrees to 30 degrees of internal rotation. Even at the ideal position, shoulder fusion produces significant limitations in function. For patients with painful, nonfunctional shoulders who need arthrodesis, these limitations should be clearly discussed, along with the pros and cons of surgical treatment in general.
Activities of Daily Living↗