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PubMed2003

Arthroscopic treatment of gunshot wounds to the shoulder.

Two cases are presented that demonstrate the utility of arthroscopic intervention for the management of gunshot wounds to the shoulder. The first report involves a 24-year-old man with a retained bullet in his glenohumeral joint after a drive-by shooting The intra-articular bullet was retrieved arthroscopically avoiding chondral injury from the mechanical effects of a loose body as well as the potential local and systemic effects of lead toxicity. Irrigation and debridement was performed to evacuate joint debris, which could have served as a nidus for infection or inflammation. The other case describes a 19-year-old man who sustained a gunshot wound to the lateral portion of his upper arm resulting in a proximal humerus fracture along with a retained bullet in his subacromial space. The bullet was successfully removed arthroscopically avoiding a traditional exposure, which would have complicated his fracture care.

Adult↗
PubMed2004

The impacted varus (A2.2) proximal humeral fracture: prediction of outcome and results of nonoperative treatment in 99 patients.

UNLABELLED: BACKGROUND AND PATIENTS: The outcome of the impacted varus proximal humeral fracture has not been described. We present the results of a prospective analysis of 99 such fractures. RESULTS: This fracture was relatively common in the elderly population and non-operative treatment sometimes resulted in increased varus angulation. Decreased shoulder function was associated with increasing age but not with increasing varus angulation. After nonoperative management the outcome was good, regardless of the degree of varus, 1 year after fracture. Age was the main predictor of outcome. Physiotherapy did not improve outcome.

Adolescent↗
PubMed1989

Shoulder joint: arthrographic CT and long-term follow-up, with surgical correlation.

One hundred two computed tomographic (CT) arthrograms of the shoulder were retrospectively reviewed and compared with conventional double-contrast arthrograms from 101 patients (24 females and 77 males aged 9-70 years). One- to 4-year follow-up was obtained in 84 patients, 40 of whom underwent open-shoulder surgery or arthroscopy. Morphology of the normal portions of each labrum was categorized according to length, width, and tip shape. Correlation between morphology and age was weak, but abnormal labra were more common in younger patients. Conventional radiography was more accurate for detecting bony glenoid margin fractures, but CT was more accurate for detecting Hill-Sach fractures. CT was also more reliable than conventional arthrography in the detection of rotator cuff tears. Hence, few if any conventional radiographs are necessary between contrast material injection and CT imaging. A reduction in the number of images obtained will result in decreased radiation dose, less cost, and shorter examination time without loss of diagnostic accuracy.

Adolescent↗
PubMed2006

Double line sign: a helpful sonographic sign to detect occult fractures of the proximal humerus.

The aim of this study was to describe a new sonographic sign of bone fracture and to determine if it can be helpful in decreasing the number of missed fractures of the proximal humerus. Ultrasound (US) of the shoulder was performed in 57 consecutive patients with shoulder pain and/or disability following trauma. All cases were prospectively reviewed for the presence of a humeral fracture. Sonographic signs of fractures, with special emphasis on what was termed the 'double line sign' (DLS), were assessed. Plain radiography was considered the standard of reference and in equivocal cases magnetic resonance imaging (MRI). Twenty-eight patients had a tuberosity complex fracture, which were all detected at US examination. Sonographic features of a fracture were periosteal elevation, corticol bone discontinuity, step-off deformity or a combination of these findings. This study showed that in 26 (93%) patients an additional sonographic feature, a DLS, could be demonstrated. The DLS is a helpful and probably reliable sonographic sign to indicate a humeral fracture. High-spatial-resolution US substantially increases the detection of fractures of the proximal humerus and should be considered as an alternative diagnostic tool prior to computed tomography (CT), MRI and arthroscopy in patients with persisting shoulder pain and/or disability following trauma.

Adult↗
PubMed2004

Anatomical considerations for percutaneous proximal humeral fracture fixation.

PURPOSE: To investigate the hypothesis that percutaneous wire fixation of proximal humeral fractures is prone to regional neurovascular injury. MATERIALS AND METHODS: 40 cadaveric shoulders had percutaneous wires inserted from anterior and lateral humeral shaft entry points into the humeral head. The shoulders were then dissected to identify the neurovascular structures in this area. RESULTS: The axillary nerve trunk and posterior circumflex humeral artery were found to be within the field of dissection. The axillary nerve was damaged on three occasions by the lateral wires, two of which were direct nerve penetrations. The anterior wires caused a single perineural injury of a terminal branch. The main neurovascular leash was 57 mm (range 35-70 mm) from the acromion tip laterally and 51 mm (range 35-85 mm) anteriorly, with a width of 6 mm (range 4-13 mm) laterally, and 12 mm (range 7-15 mm) anteriorly. CONCLUSIONS: Percutaneous wire stabilisation is an attractive fixation option but this study highlights the close proximity of the important neurovasculature. Such fixation should be performed utilising a limited open approach, with dissection to bone under direct vision, with the subsequent use of a drill-sleeve for soft-tissue protection.

Aged↗
PubMed1992

[Sonographic diagnosis of the injured acromioclavicular joint. A standardized examination procedure].

The possibility of using ultrasound leads to an improvement and extension of the methods conventionally used for diagnostic examination of the injured acromio-clavicular (AC) joint. Periarticular soft tissues can be assessed, as well as the osseous parts making up the joint. Coraco-clavicular ligaments in particular can be visualized well, and the coraco-clavicular distance can be measured precisely. Evaluation of the ultrasound findings makes classification of the grade of severity of injury according to Tossy much easier. We examined 35 injured AC joints of all grades of severity. With two standard planes of examination--a frontal and a sagittal plane--it was possible to obtain information about the grade severity of the injury in every case. Instability of the joint is diagnosed by measuring the coraco-clavicular distance with and without weights pulling on each arm. Standard X-rays of the shoulder remain mandatory to exclude fractures. When ultrasound examination is possible, however, X-ray examination of the shoulder with weights pulling on the arms is unnecessary.

Acromioclavicular Joint↗
PubMed1997

The extremities and spine.

A variety of pearls, pitfalls, and updates related to the extremities and spine are discussed. Tricks of the trade regarding shoulder dislocations, easily missed fractures, radial head subluxation, and the approach to deep lacerations are discussed. In the pitfall section, potential difficulties in the evaluation of suspected nonaccidental trauma, compartment syndromes, partial cord syndromes, and hip pain in children are discussed. Finally, new information regarding cost-effective evaluation of knee and ankle injuries, as well as advances in ultrasound evaluation of shoulder and extremity injuries, is presented in the clinical updates section.

Adult↗
PubMedDate not supplied

Stability of tuberosity reattachment in proximal humeral hemiarthroplasty.

Hemiarthroplasty can be an effective treatment for 4-part fractures of the proximal humerus; however, results are often unpredictable. Proper surgical technique is critical for success. Reconstruction of the displaced tuberosities should attempt to impart maximal interfragmentary stability. To our knowledge, a comparison of different tuberosity reconstruction methods has not been reported. We evaluated 5 techniques of tuberosity reattachment on 8 humeri. Four-part fractures were simulated by an oscillating saw in fresh-frozen cadaveric shoulders. In the control construct, the greater and lesser tuberosities were attached to the humeral shaft with nylon strap ties (2.4 x l mm) applied at 9.1 N with closure of the rotator interval. Five anatomic reconstructions were then performed:(1) the control tuberosities were attached to each other with strap ties, and (2) the control tuberosities were attached to each other with strap ties, incorporating the anterior fin of the prosthesis. To each of these 3 constructs, a circumferential cerclage (4.8 x 1.25-mm strap tie) applied at 39.2 N was placed around the tuberosities and incorporated into the medial hole of the prosthesis (techniques 3, 4, and 5). Through use of a robot articulator at a rate of 10 degrees /s, passive external rotation from 0 degrees to 60 degrees was performed on the control and the 5 test constructs of each specimen. Interfragmentary displacement of the bony fragments was measured with mercury strain gauges and strain calculated. This strain was minimal and statistically less (P <.05) in those constructs in which a cerclage was used. Incorporation of the nylon strap into the fin of the prosthesis did not enhance stability. In those constructs in which a cerclage was used, maximal displacement was 0.14 +/- 0.7 mm (38% +/- 19% strain), as compared with 0.72 +/- 0.5 mm (204% +/- 133% strain) without it. Reconstruction of 4-part proximal humerus fractures with hemiarthroplasty should incorporate a circumferential medial cerclage. This will decrease interfragmentary motion and strain, maximize fracture stability, and facilitate postoperative rehabilitation.

Adult↗
PubMed1992

[MR tomography versus CT arthrography in glenohumeral instabilities].

In a prospective study the diagnostic value of MRI compared to CT arthrography (CT-A) was evaluated in 26 patients with 27 instable shoulder joints. Surgical and/or arthroscopic correlation was available in all cases. Both methods showed a high accuracy (96% CT-A, 94% MRI) in the evaluation of the glenoid labrum. CT-A was significantly superior to MRI in the detection of capsular lesions (sensitivity 96% vs. 44%, accuracy 96% vs. 72%, negative predictive value 96% vs. 67%). CT-A and MRI results regarding humeral head fractures were similar; fractures of the glenoid rim were better detected by CT-A, the difference, however, was statistically not significant. Overall, CT-A proved to be superior to MRI, as lesions of the joint capsule were shown with greater certainty.

Adolescent↗
PubMed2004

Arthroscopic treatment for greater tuberosity fractures: rationale and surgical technique.

A description of a new technique for arthroscopic treatment of minimally displaced greater tuberosity fractures of the humerus and associated soft tissue lesions is presented. This kind of fracture is usually treated nonsurgically. However, recent evidence suggests that even a small amount of superior displacement may produce shoulder dysfunction and require a perfect surgical reduction and fixation. Moreover, any displaced fracture of the greater tuberosity presents a high rate of associated and largely undetected soft tissue lesions. To avoid underestimating accompanying soft tissue pathology, arthroscopic assessment before open treatment of greater tuberosity fractures has been suggested. In 2 earlier case reports, we described the use of an arthroscope not only to diagnose and treat a rotator cuff tear and a Bankart lesion associated with a minimally displaced greater tuberosity fracture but also to arthroscopically reduce and treat the fracture. With advancements in arthroscopy and equipment, we refined and systematized the original arthroscopic technique that we have routinely used since 1997. This article presents the new technique.

Arthroscopy↗
PubMed1998

Inferior dislocation of the glenohumeral joint combined with the compartment syndrome of the upper arm: case report.

Compartment syndromes occurring in the forearm and leg are not infrequent. However, reports of compartment syndrome of the upper arm are conspicuously rare. Inferior dislocation of the shoulder combined with compartment syndrome has rarely been reported in the literature. We report our experience with a patient with inferior dislocation of the glenohumeral joint combined with compartment syndrome of the upper arm. A 29-year-old man had traumatic inferior dislocation of the glenohumeral joint combined with severe swelling of the shoulder and upper arm. After close reduction, the shoulder and upper arm were still tensely swollen. Compartment pressure of the upper arm was measured using a digital manometer (Quick Pressure Monitor 295-1, Stryker) and remained very high, thus, fasciotomy was performed. After debridement and skin graft, the arm healed without sequelae. When a patient has a fracture dislocation of the shoulder joint associated with a swollen arm, compartment syndrome of the upper arm should be included as a differential diagnosis. Detecting the compartment pressure can confirm the diagnosis of compartment syndrome objectively.

Adult↗
PubMed2000

Posttraumatic arthritis.

The surgical management of posttraumatic arthritis is one of the most difficult problems encountered in shoulder surgery. Bone and soft tissue abnormalities resulting from the initial injury and from any subsequent surgery must be addressed to achieve the best outcome possible. A review of the literature reveals distinctly inferior results and a higher rate of complications following surgical treatment of posttraumatic sequelae compared with the surgical treatment of acute proximal humeral fractures. The authors present helpful hints for dealing with the complex problems encountered in the posttraumatic setting.

Adult↗
PubMed2001

Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid.

BACKGROUND: The marked loss of glenoid bone volume or alteration of glenoid version can affect glenoid component fixation in patients undergoing total shoulder arthroplasty. The purpose of this study was to evaluate the long-term results associated with the use of bone-grafting for restoration of glenoid volume and version at the time of total shoulder arthroplasty. METHODS: Twenty-one shoulders received an internally fixed, corticocancellous bone graft for the restoration of peripheral glenoid bone stock at the time of total shoulder arthroplasty between 1980 and 1989. Grafting was indicated when glenoid bone stock was insufficient to maintain adequate version or fixation of the prosthesis. Seventeen shoulders were available for follow-up; the average duration of follow-up for the thirteen shoulders that did not have prosthetic failure within the first two years was seventy months. Total shoulder arthroplasty was performed because of osteoarthritis in five shoulders, chronic anterior fracture-dislocation in five, capsulorrhaphy arthropathy in three, inflammatory arthritis in two, recurrent dislocation in one, and failure of a previous arthroplasty in one. All patients had some form of anterior or posterior instability preoperatively. There were five anterior and twelve posterior glenoid defects. Bone from the resected humeral head was used for grafting in fifteen shoulders, and bicortical iliac-crest bone was used in two. RESULTS: The average glenoid version after grafting was 4 degrees of retroversion, with an average correction of 33 degrees. The graft failed to maintain the original correction in three shoulders due to nonunion, dissolution, or shift. Five total shoulder replacements failed, necessitating glenoid revision at two to ninety-one months postoperatively. The failures were associated with recurrent massive cuff tears (one shoulder), persistent instability (two shoulders), improper component placement (one shoulder), and loss of graft fixation (one shoulder). There were no humeral component failures. According to the criteria of Neer et al., the functional result was rated as excellent in three shoulders, satisfactory in six, and unsatisfactory in eight. CONCLUSIONS: Despite the finding that eight shoulders had an unsatisfactory functional result at the time of longterm follow-up, corticocancellous grafting of the glenoid successfully restored glenoid version and volume in fourteen of the seventeen shoulders in the present study. Patients with glenoid deficiency often have associated glenohumeral instability, which may affect the results of total shoulder arthroplasty. Bone-grafting of the glenoid is a technically demanding procedure that can restore bone stock in patients with structural defects.

Adult↗
PubMed1991

Shoulder dystocia.

Shoulder entrapment during delivery is a true obstetric emergency that can result in significant maternal and infant trauma. Fetal macrosomia, maternal obesity, maternal diabetes and prolonged second stage of labor are associated risk factors. Infant complications of shoulder dystocia include traumatic brachial plexus injury, humeral fracture, clavicular fracture and severe birth asphyxia. With fetal shoulder entrapment, the mother may have significant hemorrhage, fourth-degree perineal lacerations and endometritis. Maneuvers to release the shoulder include closed-fist suprapubic pressure, downward pressure on the posterior shoulder, rotation of the anterior shoulder to the oblique position, rotation of the posterior shoulder beneath the pubic symphysis, release of the posterior arm and anterior rotation of the fetal body.

Delivery, Obstetric↗
PubMed1987

Total shoulder arthroplasty.

A prospective study was done of fifty total shoulder replacements in forty-four patients who were followed for an average of 3.5 years (range, 2.0 to 7.5 years). The preoperative diagnosis was osteoarthritis in thirty-three shoulders, rheumatoid arthritis in eleven, and a previous fracture of the humeral head in six shoulders. Nine of the shoulders had a tear of the rotator cuff. The Neer-II system of total shoulder replacement with a non-metal-backed component was used in all fifty shoulders. At follow-up, forty-four shoulders (88 per cent) had no significant pain. Of the six painful shoulders, four had loosening of the glenoid component and one had malposition of both components. Three of the six shoulders had no significant pain after revision. The average range of active forward elevation in all of the shoulders improved from 71 to 100 degrees, and both external and internal rotation improved as well. Five specific activities of daily living were evaluated, and the patients' ability to perform them improved from 14 to 78 per cent. Thirty-five shoulders (68 per cent) were rated by the patients as much better; thirteen shoulders (26 per cent), as better; and three (6 per cent), as no better. An incomplete lucent line was noted around five (10 per cent) of the cemented humeral stems and around thirty-seven (74 per cent) of the glenoid prostheses. Four arthroplasties (8 per cent) required revision: three for loosening of the glenoid component and one for malposition of both components.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗
PubMed2002

Allograft reconstruction after resection of malignant tumors of the scapula.

The oncologic and functional outcomes of six patients who had scapular allograft reconstruction after scapulectomy for malignant tumors were reviewed. Five patients had Stage IIB and one patient had Stage IB tumors. Total scapulectomy was done in five patients, and partial scapulectomy (glenoid and neck) was done in one patient. Frozen glycerolized scapular allografts were implanted and fixed with plates and screws. The scapular muscles were reattached to the allograft. Tendon reconstruction to replace the excised muscles was done in two patients. The patients were followed up for an average of 3.8 years (range, 2-6 years). Cosmesis, elbow, and hand function were good in all patients. There were no infections, nonunions, or shoulder dislocations. One patient fractured the body of the allograft after a fall. One patient had local recurrence and had scapulectomy 5 years postoperatively. Two patients died 3 and 5 years postoperatively with lung metastases but with functioning grafts. The mean functional result using the Musculoskeletal Tumor Society functional score was 82 (range, 77-87). In this series, scapular allograft reconstruction restored cosmesis, shoulder stability, and function. Preservation or reconstruction of rotator cuff muscles is recommended.

Adult↗
PubMed2006

Upper extremity fracture patterns following motor vehicle crashes differ for drivers and passengers.

PURPOSE: Injury patterns of occupants in motor vehicle crashes are changing, with upper extremity injury becoming more common in patients treated at trauma centres. Although not life threatening, upper extremity injuries may result in long-term disability, including chronic deformity, neurovascular compromise and degenerative arthritis. The purpose of this study was to compare upper extremity injury in drivers and passengers using the Crash Injury Research Engineering Network (CIREN) database. METHODS: CIREN data were used to compare upper extremity skeletal injury patterns and sources for drivers and passengers in frontal and side impacts. Occupant variables (age, gender, co-morbidity, avoidance maneuvers and restraint use) and crash variables (direction of impact, delta V and vehicle crush) were considered in the analysis. RESULTS: Only 24.8% of all occupants in the CIREN database had upper extremity injuries. One-half of upper extremity injuries to drivers were forearm fractures compared to one-third for passengers. Occupants in side impacts were more likely (OR=5.05) to have clavicle fractures, even while controlling for driver versus passenger status and safety belt use. Air bags were more likely to be a source of forearm fracture (OR=2.31) when controlling for driver versus passenger status, direction of force, sex and age compared to other sources. Only 10% of driver fractures with air bag deployment in frontal impacts were associated with air bag fling. CONCLUSIONS: This study found that drivers and passengers have different upper extremity injury patterns but the direction of impact also plays an important role.

Abbreviated Injury Scale↗