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The complex anatomy and functioning of the shoulder may challenge the radiologist. In this review the patterns of injury and radiographic findings for bony injuries of the shoulder are illustrated. The radiographic and cross-sectional imaging findings in fractures of the clavicle, scapula, and proximal humerus and in dislocations of the sternoclavicular, acromioclavicular, and glenohumeral articulations are discussed.
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A new biomodular prosthesis was used for the treatment of a displaced fracture of the proximal part of the humerus in twenty-two shoulders in twenty-two patients. The fractures were classified according to the Neer system; there were thirteen four-part, five three-part, and four head-splitting fractures. There were fifteen women and seven men, and the mean age was seventy years (range, forty-nine to eighty-seven years). The hemiarthroplasty was performed an average of eleven days (range, one to forty-five days) after the injury. The deltopectoral interval was used in all patients, and the prosthesis was implanted with cement in twenty of the shoulders. All of the patients participated in a supervised program of rehabilitation. The patients were followed for an average of thirty-six months (range, twenty-six to forty-nine months). Twenty of the twenty-two patients had a good or excellent result. The active forward elevation averaged 119 degrees; external rotation, 40 degrees; and internal rotation, to the twelfth thoracic vertebra. All of the patients except for the two who had a poor result had satisfactory relief of pain. The two patients who had a poor result had a successful revision with a modular prosthesis of the same design. The modular head could be removed, enabling the surgeon to gain access to the glenoid and to adjust the soft tissues. The over-all scores correlated inversely with the age of the patients and the interval from the injury to the operation.(ABSTRACT TRUNCATED AT 250 WORDS)
Sixty-eight shoulders in 63 athletic patients with anterior-inferior glenohumeral instability underwent an anterior-inferior capsular shift procedure. Shoulders with glenoid fractures, predominantly posterior instability, or routine, unidirectional anterior instability were not included in this study. There were 42 men and 21 women, with an average age of 23 years. Forty-two repairs were performed on the dominant arm. All 31 overhead throwing athletes had their dominant arms repaired. Forty-six shoulders had histories of recurrent anterior dislocations, while 22 shoulders had recurrent subluxation. All 68 shoulders had an anterior-inferior capsular shift, tailored to the degree of laxity found; in addition, 21 had repair of a Bankart lesion. Forty-two patients were rated excellent (67%), 17 good (27%), 2 fair (3%), and 1 poor (3%). Fifty-eight of 63 (92%) patients returned to their major sports, 47 (75%) at the same competitive levels. Only 5 of 10 elite throwing athletes returned to their prior competitive levels. Loss of external rotation averaged 7 degrees. Two patients (2.9%) re-dislocated postoperatively, after violent falls.
Any disabling injury of the elbow or wrist should be studied roentgenographically for evidence of fracture which may not be otherwise evident but which may cause permanent disability unless the joint is immobilized for healing."Tennis elbow" may be treated with physical therapy and analgesic injection but may require splinting or tendon stripping. Elbow sprain can occur in the growing epiphysis but is rare in adults. A jarring fall on the hand may cause fracture or dislocation at the elbow. Full extension of the joint should be restored gradually by active exercise rather than passive or forcible stretching. Fracture at the head of the radius may cause joint hemorrhage with severe pain which can be relieved by aspiration. A displacing fracture at the head of the radius requires removal of the head to prevent arthritic changes. Myositis ossificans contraindicates operation until after it has cleared. Healing of wrist fractures may be facilitated by exercise of the shoulder and elbow while the wrist is still in a cast. Fractures of the navicular bone are difficult to detect even roentgenographically and splinting may have to be done on clinical evidence alone.
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In patients with habitual dislocation of the shoulder and post-fracture malrotation the measurement of humeral torsion is important in preoperative diagnostics. An easy method of ultrasonic measurement of humeral torsion is proposed. The correlation with anthropometric, radiological and CT-measurement is good, what could be shown in 20 macerated humeri. In 111 patients with normal glenohumeral joints the average of humeral retrotorsion was 61 degrees. 86% had a torsion between 40 and 80 degrees.
Analysis of birth records of neonates a birth weight of 4,500 g or more (n = 83) has been made in order to compare the course of pregnancy and delivery to a normal birth weight of 3,000-3,500 (n = 100) among 14,193 newborns observed from 1983 to 1987 in Obstetric department of district hospital Berlin-Friedrichshain. On both groups mortality rate amounted to nil. Maternal morbidity is mainly caused by delivery injuries and postpartal atony. The perinatal morbidity which accounts for 7.2% is caused to increased acidosis rate (9.6%), complications of birth traumas such as shoulder dystocia (4.8%), fractures (2.4%) and paresis of nerve plexes (2.4%). The antenatal ultrasound assessment of fetal weight has been emphasized. Caesarean section is advised in cases of a fetal weight of 5,000 g, or more malpresentation and in a primipara with a history of previous caesarean section and with fetal weight more than 3,500-4,000 g. The problems of shoulder dystocia are being discussed.
In 1951 a shoulder prosthesis was developed for the treatment of complex humeral head fractures by Neer. The Neer-II-Prosthesis, which was developed further in 1973 represents the basis of modern shoulder implants. The unsatisfactory postoperative functional results for primary humeral head replacement required the development of new adaptable implants for the treatment of complex humeral fractures, which allow the reconstruction of humeral length, the reconstruction of center of rotation and humeral offset, the anatomic positioning, the reconstruction of retrotorsion and the secure refixation of the tuberosities. The development of third and fourth generation of humeral head prosthesis achieves a three-dimensional adaptability for the conditions of posttraumatic arthritis. Primary and secondary humeral head replacement in humeral head fractures as well as revision of prosthetic replacement are complex and technical demanding operations with high and different requirements on implants having to be realised on further development.
Fracture and dislocation of major joints may be caused by the forceful tonic muscular contractions of seizure activity. A 77-year-old man who was found dead in bed with no sign of external trauma had bilateral central fracture dislocations of the femoral head through the acetabular floor with fatal pelvic hemorrhage and extensive pulmonary fat and bone marrow embolism. He had epilepsy, but the last seizure was 6 years earlier, and he had long discontinued medication. The fractures were attributed to a new unwitnessed seizure. This is the twentieth case of central fracture dislocation of the hip since 1970, when better anesthesia eliminated convulsive therapy-induced fractures. The authors review these 20 cases. Seizures followed inflammation, infarction or neoplasia of the brain, eclampsia, metabolic or iatrogenic causes, or epilepsy (6 cases, 2 of which had no prior seizures for 5 years). There were 11 men (mean age, 64 years) and 9 women (mean age, 47 years). Fractures were unilateral in 13 and bilateral in 7. Additional fractures (in vertebrae, shoulders, or femur) were present in eight. Only eight had prior bone disease. Local symptoms led to diagnosis in most, but two were identified incidentally on imaging. The current patient was the only one to die suddenly, but six other patients presented with shock and three died (one of whom had injuries that led to a suspicion of manslaughter). Central fracture-dislocation of the hip is a rare and little known consequence of seizures, with strong potential for misdiagnosis and lethal complications.
INTRODUCTION: In a comparative study, mid-term findings after posttraumatic and degenerative hemi-prosthetic shoulder joint replacement were analyzed and compared with current reports in the literature. METHODS: The patient sample in the retrospective study consisted of 20 patients with proximal fractures of the humeral head (x = 64 years) and 6 patients (x = 61 years) with degenerative shoulder joint disease. In 14 patients the humeral head was replaced as a primary procedure at < 4 weeks after the trauma and in 6 patients as a secondary treatment at > 4 weeks. The follow-up period was 38-41 months on average. Evaluation was based on the Constant Score, subjective assessment by the patient, and conventional radiographs. RESULTS: After posttraumatic shoulder replacement, the patients achieved a Constant Score of 65 (+/- 19) and after degenerative replacement 74 (+/- 34) points. In the posttraumatic group, the Constant Score after primary implantation was better than after secondary implantation (68 +/- 16 versus 59 +/- 15 points). After posttraumatic replacement, the only improvement over time was in pain levels (p < 0.05). 92% of all patients were satisfied with the result and would accept the same treatment again. Radiologically, a clinical correlate could be found for the arrosions at the acromion and occasionally for the secondary upwards displacement of the humerus. The results correlated well with data from the literature. CONCLUSIONS: For posttraumatic conditions, hemiarthroplasty led to better results within four weeks and seemed to be a suitable alternative to other procedures, especially in older patients. Patients with primary osteoarthritis and idiopathic humeral head necrosis can expect good to excellent results after hemiarthroplasty. In both groups, the overall results depend mainly upon patient compliance and the state of the rotator cuff.
The authors describe their series of seven cases of complications and failures of shoulder hemiarthroplasty that were submitted to revision surgery involving an inverse prosthesis. This prosthesis has for some time now been indicated in elderly patients with arthropathy caused by rupture of the cuff. In our cases this prosthesis was implanted in patients who had undergone shoulder hemiarthroplasty for fracture and for arthrosis. The Constant score was used for pre- and postoperative evaluation. Results at mid-term, from 2 to 4 years, indicate evident improvement in Constant score that rose from a mean of 23.14 preoperatively to a mean of 49.14 postoperatively. Despite the limited follow-up the authors suggest the use of the inverse prosthesis as an effective alternative solution in shoulder arthroplasty revision surgery.
Up to 20% of all patients with pectoral symptoms have an underlying orthopedic problem. The most common orthopedic conditions that may mimic chest pain radiating into the left arm include slipped disc, cervicothoracic tension syndrome, blockage of intervertebral or rib joints, and intercostal neuralgia. Less common causes of such pain are arthrosis of the shoulder, spondylocystitis, osteoporotic fractures or tumors of the bone. Management is oriented to the underlying cause, and treatment extends from physiotherapeutic measures (rest, heat treatment) via medication (non-steroidal anti-inflammatory drugs, myotonolytic agents) to operative interventions.
The authors compared self-reports of non-spine fractures in a cohort of elderly white women with radiologic reports and medical records. Subjects (n = 9,704) were recruited between 1986 and 1988 in Baltimore, Pittsburgh, Minneapolis, and Portland, Oregon. Eleven percent (95% confidence interval 9-13%) of self-reports of fracture were false-positive (radiographs were negative) and a total of 20% (18-23%) could not be confirmed (radiographs were negative, uncertain, or not available). Report by proxy respondent was more accurate than self-report. There were no confirmed fractures in the medical records of a random sample of 283 participants who did not report a fracture. The percent of false-positives varied by the site of the injury and was low for self-reported fractures of the shoulder or upper arm (5%; 1-13%), wrist (8%; 4-11%), and hip (11%; 5-19%), but was high for hand or finger (20%; 12-30%), rib (23%; 15-32%), and face or skull (33%; 17-54%). Having a college education was associated with increased accuracy, while a history of falls and self-reported osteoporosis were associated with decreased accuracy. The authors conclude that elderly women overreport fractures, but that self-report is relatively accurate for several important osteoporotic fractures, including those of the hip, wrist, and humerus. Self-report of "any" fracture, rib, distal extremity, and head fracture, and fractures in women with a tendency to fall or with osteoporosis should be verified by a radiologic diagnosis.
OBJECTIVES: To compare the clinical and radiographic results for locked intramedullary (IM) nails and plates used in the treatment of humeral diaphyseal fractures. DESIGN: Prospective randomization by sealed-envelope technique of eighty-four patients into two study groups: those treated by intramedullary nailing (IMN group; n = 38) and those treated by compression plating (PLT group; n = 46). SETTING: Patients admitted consecutively to a university-affiliated Level I trauma center. PATIENT/PARTICIPANTS: All skeletally mature patients admitted to Harborview Medical Center with acute humeral shaft fractures requiring surgical stabilization. Fractures of the diaphysis were defined as being at least three centimeters distal to the surgical neck and at least five centimeters proximal to the olecranon fossa. INTERVENTION: Treatment with locking antegrade intramedullary humeral nails (Russell-Taylor design [Smith and Nephew Richards]) or with 4.5-millimeter dynamic compression and limited contact dynamic compression plates (AO design [Synthes]). MAIN OUTCOME MEASUREMENTS: Clinical outcome measurements included fracture healing, radial nerve recovery, infection, and elbow and shoulder discomfort. Radiographic measurements included fracture alignment, time to healing, delayed union, and nonunion. RESULTS: Follow-up averaged thirteen months. Forty-two fractures (93 percent) in the PLT group were healed by sixteen weeks versus thirty-three fractures (87 percent) in the IMN group (p = 0.70). Shoulder pain and a decrement in shoulder range of motion (ROM) were significant associations with IMN (p = 0.007 for both variables) but not with PLT. A decrement in elbow ROM was significantly associated with PLT (p = 0.03), especially for fractures of the distal third of the diaphysis, whereas elbow pain was not (p = 0.123). The sum of other complications demonstrated nearly equal prevalence for both treatment groups. CONCLUSIONS: For patients requiring surgical treatment of a humeral shaft fracture, intramedullary nailing and compression plating both provide predictable methods for achieving fracture stabilization and ultimate healing.
INTRODUCTION: We describe an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing, which preserves the articular surface and rotator cuff integrity. MATERIAL AND METHODS: Thirty-two patients with humeral shaft fractures underwent antegrade intramedullary nailing using a modified insertion point located 1 cm below the crest of the greater tuberosity, in a region outside the articular surface and rotator cuff area. RESULTS: In all cases, nailing was done successfully, without any perforation of the humeral inner cortex by the nail. Extension of the fracture line to the distal metaphysis happened intraoperatively in one case of a distal diaphysis fracture. In the remainder of the patients, postoperative reduction of the fracture was successful, with no sign of an iatrogenic incident of fracture comminution. Excellent active shoulder function and full early functional recovery of the shoulder joint (to 16th week postoperatively) were established in 98% of the patients. All fractures were united in a mean period of 14 weeks. CONCLUSION: We suggest an extra-articular, extra-rotator cuff entry point for antegrade humeral nailing as a possible and safe technique with beneficial results for the shoulder's postoperative function.
The authors summed up an 11-year experience of treatment of trans- and epicondylic fractures of the shoulder bone in 218 children by different methods. It was established that stable positive results of closed repositions were worse at remote terms as compared with the results of patients treated by the method of open reposition and skeletal stretching. Complications were observed in 9,5% and 4,09% of cases respectively.
Hemiarthroplasty of the shoulder is a treatment of choice for severe types of proximal humeral fractures. From 2001 to 2003, 8 hemiarthroplasties were performed at the University Clinic for Orthopaedic Surgery and Traumatology, Clinical Center Novi Sad. The aim of this study was to retrospectively assess functional outcomes of those patients. By determing the factors that affected the outcome, we would try to improve results of future patients.