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A systematic approach to the injured shoulder includes careful history taking and sequential examination of all anatomic components of the shoulder girdle in each and every patient. High quality radiographs, with two views at 90 degrees to one another, are essential. A specific diagnosis can and must be made on every patient with an injured shoulder to enable referral for proper care and follow-up.
The shoulder complex is particularly vulnerable to neurovascular injuries due to its intimate anatomical relationship with the brachial plexus and axillary vessels. Therapists, trainers, and physicians who cover athletic events witness the violence of injury to the neck and shoulder. Fortunately, permanent neurovascular deficits are rare, and many are subtle. However, tragically, some can be career-ending and even life-threatening. Neurovascular injuries may occur in association with musculoskeletal injury or as an isolated finding. Symptoms may present on an acute basis or in a chronic fashion. On the playing field or in the emergency room, focus is often placed on the obvious musculoskeletal injury, ie., dislocation or fracture. Medical personnel must always have a high index of suspicion of neurovascular injuries to the shoulder complex to avoid misdiagnosis. They must consider that failure to progress in rehabilitation for musculoskeletal injuries may be secondary to a previously unrecognized neurovascular lesion. The purpose of this review is to provide a basic reference for diagnosis and treatment of neurovascular injuries to the shoulder complex for therapists, trainers, and physicians. Also, we hope to raise the index of suspicion for neurovascular injuries during evaluation of patients with common shoulder injuries. The review is organized by location and association with specific musculoskeletal injuries.
The simplicity, safety, and physiologic nature of the forward elevation maneuver for reductions of anterior dislocations and fracture-dislocations of the shoulder, is illustrated in a report of 50 cases. The method is effective and free of complications. The maneuver requires very little, if any, sedation and is particularly useful in all well-muscled young athletes with anterior dislocations of the shoulder.
This article tries to identify the most frequent osseous lesions in the shoulder complex found in the all day routine of a trauma center or trauma unit. It discusses the clinical diagnosis, the most typical radiological findings and the current concepts of treatment. This report is designed mainly to help the general practitioner outside the hospital community.
We report a case of locked posterior dislocation of the shoulder successfully treated with arthroscopic removal of an intraarticular loose body and flattening of the impression fracture of the humeral head. A 2-year follow-up shows excellent clinical results and no redislocation. We also describe the arthroscopic findings of this pathological situation.
A new operative approach is presented for treatment of fractured distal end of clavicle associated with recurrent anterior shoulder subluxations. One case is presented in which open reduction of the fractured clavicle and stabilizing the anterior shoulder joint were accomplished by transfer of the coracoid process with its attached muscles under the subcapularis muscle onto the clavicle. The operation was followed by complete reduction of the fracture and a stable shoulder joint.
OBJECTIVE: The indication, surgical techniques and results had been discussed through clinical analysis of percutaneous pinning for the treatment of proximal humerus fractures. METHODS: Forty-nine patients with 49 shoulders treated with percutaneous pinning had been reviewed with a mean follow-up period of 16.9 months. All were acute fractures, with a mean age of 40.4 years. There were 39 2-part surgical neck fractures, 6 impacted 2-part greater tuberosity fractures and 4 valgus-impaction 4-part fractures. SST (Simple Shoulder Test) questionnaire, ASES (American Shoulder & Elbow Surgeon) score, Constant-Murley score and UCLA score had been adopted for final evaluation at the latest follow-up. RESULTS: The mean ASES score was 91.4, the mean VAS score was 1.7, the mean forward flexion was 146.7 degrees, external rotation 39.6 degrees, internal rotation at T(8)-T(9) level; the mean Constant-Murley score was 88.2; the mean UCLA score was 31.2; the mean number of questions for "yes" in SST questionnaire was 10.1. All fractures healed with a mean period of 8.8 weeks. No patient had been found for any evidence of humeral head necrosis at the latest follow-up The total satisfaction rate for pain relieve was 95.9% (47/49), and for functional recovery was 91.8% (45/49). CONCLUSIONS: Most 2-part surgical neck fractures, impacted 2-part greater tuberosity fractures and 4-part valgus-impaction fractures are good indications for percutaneous pinning. With appropriate and intense rehabilitation, satisfactory results can be expected in percutaneous pinning for the treatment of certain types of proximal humerus fractures.
A retrospective review of 21,632 live births from January 1982 to July 1987 was performed to determine the incidence and risk factors associated with fractures of the clavicle in the newborn. Fifty-eight fractures (57 patients) were identified, for an incidence of 2.7 clavicle fractures per 1000 live births. Fractures of the clavicle were associated with heavy neonates and shoulder dystocia. Three patients had concurrent clavicular fractures and Erb's palsy. These findings suggest that the incidence of clavicle fractures in the newborn may be reduced by identifying the macrosomic fetus and by minimizing shoulder dystocia. When clavicle fractures occur, a brachial plexus injury should be ruled out.
AIM: Shoulder arthrodesis following prosthesis explantation or resection of the acromion has not often been described in the literature. The presented article analyses the special features and problems of these preoperative circumstances in 4 cases and discusses them within the entire group. PATIENTS AND METHOD: Between 06/1987 and 02/2001, a total of 30 shoulder arthrodeses using plate fixation were performed in our clinic and then analysed after an average of 2.7 (0.5 - 8.7) years. Surgery was carried out on 5 (17 %) females and 25 (83 %) males with a mean age of 37 (17 - 82) years. Two patients underwent shoulder arthrodesis as a salvage operation following unsatisfactory arthroplasty, or after trapezius transfer with corresponding reduced bony conditions, respectively. RESULTS: The active extent of movement following arthrodesis was 56 degrees (20 degrees - 90 degrees ) abduction, and 60 degrees (20 degrees - 105 degrees ) anteversion. The most frequent complications following arthrodesis included pseudarthroses (3/10 %), infections (4/13 %), and fractures of the humerus (4/13 %). The rate of complications was especially high in the cases after explantation of a shoulder prosthesis and resection of the acromion. In two of the four patients, three or five revision operations, respectively, were necessary. Two of the three pseudarthroses of the entire group occurred in these two cases. CONCLUSION: Complications of shoulder arthrodesis after resection of the acromion or the proximal humerus are especially frequent. To avoid pseudarthrosis in such cases, primary spongioplasty is advantageous. A fixation with plates is superior to a simple screw arthrodesis. For postoperative immobilization a plaster cast instead of an orthotic device should be taken into consideration.
AIM: Sonography of the shoulder is an effective method for detecting tears of the rotator cuff and bone lesions. The purpose of this study was to evaluate prospectively the sonographic findings after shoulder dislocation. METHODS: Sonography was performed on 208 patients with 210 shoulder dislocations, which were all verified by radiography. RESULTS: We diagnosed 62 rotator cuff lesions (29.5%), which were all in the group with traumatic shoulder dislocation. The incidence of tears in patients with first traumatic dislocation (n = 134) was 36.5%. 12 tears (21.8%) of the rotator cuff were noted in recurrent dislocations (n = 55). 23 fractures or bony avulsions of the greater tuberosity of the humerus (11%) and 168 Hill-Sachs lesions (80%) were seen. CONCLUSION: Sonographic examination of the shoulder revealed a significant amount of information that would remain undetected without the aid of expensive and/or invasive diagnostic tools.
Twenty-four patients who sustained a fracture of the superior border of the scapula are reviewed. All were associated with a fracture of the coracoid process and other shoulder injuries. There were 19 long fracture lines and 5 short. The former and 3 of the latter were extensions of a coracoid fracture; in 2, there appeared to be an avulsion fracture by traction through the superior transverse scapular ligament resulting from the upward displacement of the coracoid.
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We studied 37 fractures lateral to the spinoglenoidal notch to evaluate the validity of collectively handling these fractures as an acromion fracture and to ascertain the mechanism of injury. We divided them into three groups according to the location of the fracture line. Fracture of the anatomic acromion or the extremely lateral scapular spine (groups I and II, 28 fractures) was frequently associated with fracture of the coracoid base, acromioclavicular joint injury, or both. The mechanism of injury in most cases was presumed to be indirect force brought to bear on the shoulder from the lateral direction. Fracture descending to the spinoglenoidal notch (group III, nine fractures) was seldom associated with other shoulder injuries, and surgery was rarely needed. The mechanism was assumed to be direct force brought to bear on the shoulder from the posterior direction. Therefore fractures of the anatomic acromion and the extremely lateral scapular spine may be managed collectively. However, fracture descending to the spinoglenoidal notch should be managed separately. We advocate that these fractures should be classified into two types in terms of clinical consideration: type I fractures, comprising those of the anatomic acromion and the extremely lateral scapular spine, and type II fractures, located in the more medial spine and descending to the spinoglenoidal notch.
OBJECTIVE: The purpose of this study was to determine whether there is a risk profile for predicting or preventing shoulder dystocia and whether any of the obstetric maneuvers to disimpact a shoulder reduce the likelihood of permanent injury. STUDY DESIGN: A retrospective analysis of 14,297 parturients with 12,532 vaginal deliveries and 1765 cesarean sections (12.4%) from January 1986 through June 1990 was performed. A total of 204 maternal and infant charts, related to shoulder dystocia or neonatal injury, were reviewed in depth for age, parity, episiotomy, type of delivery, hemorrhage, maternal obesity, diabetes, weight gain, fetal weight, sex, and Apgar scores. In addition, the type of maneuver or combination thereof used to relieve the dystocia, type of injury to the infant, and follow-up of the injury were reviewed. RESULTS: The 185 coded episodes of shoulder dystocia represent 1.4% of all vaginal deliveries (12,532). There were 42 injuries recorded: 14 fractured clavicles and 28 brachial plexus injuries. An additional 19 patients, not coded for shoulder dystocia, sustained 14 fractured clavicles and five brachial plexus injuries. All but one of the brachial plexus injuries resolved by 6 months. The occurrence of shoulder dystocia increased in direct relationship to the birth weight and becomes significant in newborns over 4000 gm (p < 0.01). The occurrence of a previous large infant was also a significant risk factor (p < 0.01). Diabetes and midforceps delivery become significant factors only in the presence of a large fetus. Obesity, multiparity, postdate pregnancy, use of oxytocin, low forceps delivery, episiotomy, and type of anesthesia were unrelated to shoulder dystocia. No delivery method was without injury. CONCLUSIONS: This study clearly indicates that most of the traditional risk factors for shoulder dystocia have no predictive value, shoulder dystocia itself is an unpredictable event, and infants at risk for permanent injury are virtually impossible to predict. In addition, no delivery method in shoulder dystocia was superior to another with respect to injury. Thus no protocol should serve to substitute for clinical judgment.
We report about two patients with posterior fracture-dislocation of the shoulder following convulsive seizures, one case unilateral, one case bilateral. The radiological findings are typical and similar to the cases described in literature: Impression or head splitting fracture of the ventro-medial part of the humeral head associated with posterior dislocation. The mechanism of injury, methods of treatment and late results are discussed.