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PubMed2005

Management of midshaft clavicle fractures in adults.

Fractures of the clavicle are common injuries. The usual mechanism of clavicle fracture is a direct fall on the shoulder. There are 3 types of clavicle fractures, but type II or midshaft fractures make up the vast majority. Most clavicle fractures can be effectively treated nonoperatively. Rates of nonunion and poor functional outcome, however, may be higher than previously thought. Risk factors for nonunion include initial fracture displacement, comminution, shortening, and older age. The 2 main methods of operative management are plate-and-screws and intramedullary fixation. Study results for both methods have been good. Indications for operative management, however, remain controversial.

Adult↗
PubMed2000

Management of surgical neck nonunions.

A surgical neck nonunion is a seriously debilitating complication of a proximal humerus fracture. Patients have virtually no functional use of their shoulders and experience pain. Successful treatment is reliable in relief of pain and potentially can restore function. The diagnosis is not difficult, however, a CT scan may be necessary to identify tuberosity or head-splitting fractures. Successful treatment for these nonunions is difficult but gratifying because the percent improvement is immense.

Aged↗
PubMed1993

[Vertebral compression in epilepsy. Analysis of 8 cases].

Epileptic seizures can produce dislocations or fractures of the limbs and vertebral compression fractures. We tried to determine the clinical and radiological features of the latter in 8 patients: 6 men and 2 women including one aged only 41 years. The often multiple compression fractures involved the first thoracic (n = 3) and the intermediate thoracic (n = 3) or lower lumbar (n = 2) vertebrae but, contrary to common osteoporosis, never the thoracolumbar hinge. In 2 cases, the appearance of the fracture and the neurological signs led to surgery. Posterior dislocation of the shoulder was associated with the fractures in 2 cases. Chronic alcoholism (4 cases), anti-epileptic drugs (1 case) or corticosteroids (1 case) might have facilitated a demineralization which was however not obvious on X-ray films. The seizure was a first ever event in 6 cases. In the absence of controls the fracture was considered to be spontaneous. These particularities explain why a metastatic compression fracture was initially suspected in 3 cases, leading to explorations which sometimes were aggressive. In the presence of a suspicious vertebral compression fracture the clinician must consider the possibility of an epileptic seizure, a trauma which is sufficient to explain the fracture, as shown by the complications of electro-convulsive therapy.

Adult↗
PubMed1995

[Post-traumatic shoulder arthrodeses--indications, technique, results].

Shoulder arthrodesis definitely results in a restricted range of motion. However, in patients with a painful restricted motion after glenohumeral empyema or arthritis reduction of pain and an improved range of motion in the thoracoscapular joint are achieved with arthrodesis. Glenohumeral arthrodesis is also indicated for the management of paralysis of the rotator cuff if multidirectional stability is present. From 1978 to 1991 shoulder fusion was performed in ten patients in our institute. The mean age of the seven male and three female patients was 49 years. In six cases arthrodesis was necessary because of shoulder infections after internal fixation of humeral head fractures; three were performed because of posttraumatic arthritis and two, because of complete plexus lesions. The followup an average of just over 3 years after arthrodesis revealed acceptable function according to the Neer and Hawkins score. All patients but one reported a significant improvement of function and pain relief after arthrodesis.

Adult↗
PubMed2002

Fetal shoulder dystocia.

Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%. An increase in the incidence of shoulder dystocia has been recorded over the last 20 years, probably just because it has now been regularly registered at maternity wards as an obstetric complication. The risk factors for shoulder dystocia include fetal macrosomia, fetal malformations and tumors, maternal adiposity, excessive weight gain during pregnancy, diabetes mellitus, pathologic pelvis, multiparity, short maternal stature, advanced maternal age, postterm pregnancy, so-called midforceps delivery or vacuum extraction, prolonged delivery stage II, oxytocin labor induction, premature fetal expression according to Kristeller, and previous shoulder dystocia in macrosomatic children. The sequels of shoulder dystocia and obstetric maneuvers for incarcerated shoulder release include clavicular fracture, brachial plexus lesions, sternocleidomastoid muscle distension with or without hematoma, diaphragmatic paralysis, Horner's syndrome, peripartal asphyxia and consequential cerebral lesions (cerebral palsy), and peripartal death. Maternal complications due to shoulder dystocia are postpartal hemorrhage, cervical and vaginal lacerations, frequent infections during the puerperium, symphysiolysis and rupture of the uterus, and secondary cesarean section with related complications due to unsuccessful obstetric procedures or as continuation of Zavanelli's maneuver. McRoberts' maneuver (or Gaskin maneuver) is recommended as the initial procedure for shoulder release in case of shoulder dystocia. If it fails, other obstetric procedures such as Resnik's suprapubic pressure and Woods' grip with posteriorly placed arm release should be used, always with gross lateral episiotomy. The performance of all these obstetric procedures requires skilfull and highly experienced obstetrician and obstetric team as a whole.

Delivery, Obstetric↗
PubMed1987

External fixation of proximal humerus fracture. Clinical and cadaver study of pinning technique.

The risk of injuring important anatomic structures or interfering with motion of the glenohumeral joint by transcutaneous pinning of the proximal end of the humerus was investigated in 12 cadaver shoulders and in 23 patients with displaced fractures of the proximal humerus. In the cadavers, pinning of the proximal humeral shaft from laterally more than 20 mm below the surgical neck did not injure the neurovascular structures in any case. Pin insertions into the humeral head medial to the intertubercular groove endangered the cephalic vein and interfered with shoulder function by transfixing the subacromial bursa and by restricting internal rotation. Lateral pinning did not carry such risk. In the patients closed reduction and external fixation confirmed the low risk of neurovascular injuries. Lateral pinning of the humeral head resulted in an unrestricted passive mobility of the glenohumeral joint of the anesthetized patient, whereas anterior pinning carried the risk of mechanical restriction of the internal rotation.

Adult↗
PubMed1984

Survey of orthopaedic surgical research in a university center (Linköping).

Since 1969, seven orthopedic dissertations on the following subjects were submitted from the author's hospital. Postoperative use of special elastic bandages and oxyphenbutazone significantly decreased the frequency of thrombosis. Use of a randomized single-blind technique significantly improved chronic cases of lumbago by a new traction treatment called auto-traction. Two control groups were treated by bed rest and analgesics or routine physiotherapy measures. With a new mechanical device for tibial osteotomy, the precision of the angular change was significantly increased. In intracapsular hip fractures treated by Deyerle's technique, only 18% had necrosis of the femoral head after two years. By use of a new radiologic method for determining the stability of tibial fractures it was possible to determine a stability quotient; the quotient established the point at which the fracture could be mobilized without risk of delayed union or pseudarthrosis. In shoulder joint dislocations, three to four weeks of immobilization resulted in a recurrence rate equal to that of ordinary treatment in a sling. In a randomly selected group of people in Sweden, the incidence of shoulder dislocations was 2%. Forty percent of these patients had never seen a doctor. In Colles' fracture, the uptake of radioactive Tc-MDP was significantly increased by treating the fracture with electromagnetic fields. Arthroscopic percutaneous meniscectomies reduced the operation time normally required for an arthrotomy by an average of 30 minutes.

Arthroscopy↗
PubMedDate not supplied

Bicipital groove orientation: considerations for the retroversion of a prosthesis in fractures of the proximal humerus.

The bicipital groove anatomy is well documented, and this groove is used as a landmark to guide retroversion during implantation of a shoulder prosthesis. Whereas the proximal part of the groove is used in osteoarthritis, the distal part is used in fractures. If used in 4-part fracture cases, we must assume that the bicipital groove orientation is constant from proximal to distal. We measured the groove orientation in 40 cadaveric humeri using 3 superimposed computed tomography sections. The reference axis was the transepicondylar axis at the elbow level. The measured angle of the bicipital groove was 55.8 degrees +/- 4.5 degrees at the anatomic neck and 65.1 degrees +/- 3.5 degrees at the surgical neck. This difference (mean of 9.3 degrees, with extremes of -3 degrees and 22.5 degrees) was statistically significant. We confirmed a wide range of variation from 22 degrees to 89 degrees in the orientation of the groove. Because the values listed in the literature for lateral fin placement of a prosthesis have not been measured at the surgical neck level and because of the great variation in groove orientation, we caution surgeons about the use of the bicipital groove as a reliable landmark in shoulder replacement for fractures. Considering the risk of over- or under-retroversion of the prosthesis, we recommend the use of a fracture jig with retroversion set to 20 degrees.

Arthroplasty, Replacement↗
PubMedDate not supplied

Long-term functional results after manipulation of the frozen shoulder.

The use of shoulder manipulation in the treatment of frozen shoulder syndrome remains controversial. Opponents cite the risk of dislocation, fracture, nerve palsy, and rotator cuff tearing as limiting the usefulness of manipulation. A retrospective study of 38 shoulder manipulations in 32 patients was performed. These patients were followed for an average time of 58 months. The patients were examined in follow up for combined shoulder range of motion, external and internal rotation strength, and status of the long head of the biceps. Manipulation was performed in all patients by the senior author and supervised physical therapy was begun within 24 hours of the manipulation. The average recovery time was 13 weeks. In this series, 97% of patients had relief of pain and recovery of near complete range of motion, although 8% required a second manipulation to obtain a successful result. Mild weakness to manual muscle testing was present in 5.3% of patients in external rotation and 10.5% of patients in internal rotation. There was no deterioration of shoulder function with time. In fact, most patients improved with passage of time, even more. There was no evidence of biceps tendon rupture or rotator cuff insufficiency at the time of follow up in any of the patients. No fractures, dislocations or nerve palsies were observed, although one patient who had no premanipulation arthrogram was found to have a rotator cuff tear a few months after failed manipulation. Manipulation of the shoulder can therefore be offered to reduce the pain and period of disability in patients who fail conservative treatment of frozen shoulder syndrome.

Adult↗
PubMed1992

[Intramedullary nailing osteosynthesis with epiphyseal fixation of fractures of the proximal humerus in adults. 1 to 3-year follow-up].

The authors used a medullary pinning with epiphyseal fixation in the treatment of superior metaphyseal fractures of the humerus for 41 patients aged 22 to 82 years. There were 28 cases with epiphyseal fractures and 12 with metaphyseal fractures. The follow-up was 1 to 3 years. The pins were introduced through the triceps brachii after perforation of the diaphysis, 1 cm above the ulnar fossa. Results were very good. Strength returned within 8.5 weeks. There was only one case of nonunion of a proximal diaphyseal fracture due to a technical fault (diastasis between fragments). Rehabilitation began immediately, resulting in good elbow motion in 35 cases. The shoulder motion was the same as the healthy side in 36 cases, and inferior to 90 degrees of abduction in only two complex epiphyseal fracture. The proximal humerus was never perforated by the pins. The authors find this new instrumentation to be very effective.

Adult↗
PubMed2006

[Grammont reversed prosthesis for acute complex fracture of the proximal humerus in an elderly population with 5 to 12 years follow-up].

PURPOSE OF THE STUDY: Aim of this retrospective study was to analyze outcome in 23 cases of Delta III reverse ball-and-socket total shoulder prosthesis for acute complex fractures of the proximal humerus in an elderly population with poor bone quality. In such a population, this procedure could escape the difficulties of a reliable and efficient refixation of the tubercles. MATERIAL AND METHODS: From 1993 to 2000, 23 Delta III prostheses were implanted by a single operator for acute injury: 18 three-part and four-part fractures and 5 fracture-dislocations. The study population included two men and 21 women, mean age 75 years, 10 dominant sides. Surgery was performed under general anesthesia in the semi-sitting position via the anterolateral approach without osteotomy of the acromion, with 10-20 degrees retroversion of the humeral stem (except in one shoulder) and cement fixation in two. For five shoulders, the tubercles could be re-fixed. Postoperative physiotherapy was not possible in all patients. Outcome was assessed with the Constant score and with ap and lateral Lamy radiographs. RESULTS: Seven patients died so the series included sixteen cases for analysis. Complications were: reflex sympathetic dystrophy (n=2), postoperative Acinetobacter infection (n=1) requiring revision to clean and drain allowing preservation of the prosthesis, and early postoperative anterior dislocation (n=1) (10 degrees stem anteversion) with surgical revision to re-orient the stem. At mean follow-up of 86 months, the Constant score was 60 points (contralateral shoulder 83 points). Outcome, influenced in case of re-fixation of the tubercles, was good for pain (14.1), activity (13.3), strength (16.1), anterior elevation (6.5), and abduction (6.5), but very poor for external (1.1) and internal (2.4) rotations. The radiographs showed: aseptic glenoid loosening (n=1) at 12 years with surgical revision in 2005 with Constant score at 6 months follow-up of 48 points, inferior scapular notching (n=11) according the the Nérot classification (six stage 1, four stage 2, one stage 3, at 2, 4.3 and 5 years follow-up), inferior spurs (n=9) appearing at mean 2.5 years follow-up (stable after emergence without clinical impact), proximal humeral resorption (n=4) (medially for three at mean 8 year follow-up and one laterally at 10 years), and a humeral radiolucent line (n=1) at 5 years follow-up. DISCUSSION: For acute complex fractures of the proximal humerus in elderly subjects with poor bone quality, when an efficient and reliable re-fixation of the tubercles is difficult or impossible, reverse ball-and-socket shoulder prosthesis is a possible alternative providing good functional outcome except for rotations but with the risk of inferior scapular notching. Although not problematic in the mid term, these notches may contribute to glenoid loosening with bone loss in the long-term. Nevertheless, this procedure seems to improve the status of patients with such fractures.

Aged↗
PubMed1991

[The mechanism of fatigue fracture of the ribs].

To elucidate the mechanism of fatigue-rib-fracture, 8 rib-fractured cases were investigated. In assuming the M. serratus anterior (MSA) as the major cause from the anatomical muscle route, EMG was taken, and three-dimensional resultant forces from the muscles around the shoulder of a fresh cadaver were estimated. Most fractures were found in the sixth or seventh ribs, with a tendency to occur along the posterolateral segment. Biomechanical analysis revealed 12 and 62 kg forces applied on the scapulo-thoracic joint and gleno-humeral joint respectively by adding 90 degrees-anterior-elevation under no load. The maximum muscle-force of MSA occurring at 90 degrees-anterior-elevation was 1.2 kg in the sixth serratus in our study. These data were supported by the results with EMG. The stress on the ribs were calculated by two-dimensional finite element method, using the data. The maximum compressive stress on one rib was 4.75 kg/mm2 when 13.0 kg of MSA-force was added. In considering the limit of fatigue endurance of bones, these results suggest that muscle-force which causes fatigue fracture of ribs arises from lifting an object weighing more than 20 kg.

Adolescent↗
PubMed1997

Acute hemiarthroplasty after proximal humerus fracture in old patients. A retrospective evaluation of 18 patients followed for 2-7 years.

We evaluated the outcome of acute shoulder hemiarthroplasty in 18 patients following displaced three- and four-part fractures of the proximal humerus. The mean age of the patients was 82 (70-92) years and the average follow-up time was 3.5 (2-7) years. No revision due to loosening was performed. All patients were evaluated concerning activities of daily living, degree of pain (VAS-scale, 0-100 mm) and range of motion. The patients had a low functional level, but were able to sleep on the operated side and keep up their hobby. 11 patients were painfree and the worst pain recorded was 28 mm. Range of motion for all movements, except extension, was statistically significant lower than for the non-operated side. We conclude that in elderly patients acute hemiarthroplasty following three- or four-part fractures of the proximal humerus results in good pain relief, but a more limited range of motion than that reported for younger patients.

Activities of Daily Living↗