Shoulder & Elbow

Controversy exists regarding the best methods for the operative management of proximal humerus fractures. We hypothesized that trauma surgeons perform the majority of these procedures and that there is variability in the type of fixation used at our institutions based on the type of fellowship training.

A retrospective review of 177 consecutive operative closed proximal humerus fractures was conducted. All images were classified based on the Neer system, including: simple (two-part surgical neck or isolated tuberosity) or complex (three- or four-part). Choice of fixation was determined based on surgeon subspecialty.

One-hundred and nine procedures were performed by trauma, 45 by shoulder, and 17 by hand. Thirty-eight percent (67/177) were simple and 62% (110/177) were complex. A significant difference was only found in blade plating of two-part surgical neck fractures (p < 0.05) and the management of tuberosity fractures (p < 0.05). Analysis of complex fractures showed a significant difference in the rate of arthroplasty (p < 0.05).

Trauma surgeons perform the majority of procedures on proximal humerus fractures, although at a similar rate to shoulder surgeons. A significant difference in management was found with regard to the utilization of blade plating, arthroplasty and the management of tuberosity fractures.

High re-tear rates and the cost of anchor repair have led some arthroscopic surgeons to consider going ‘back to the future’ and using Neer type transosseous sutures arthroscopically.

We examined the strength of suture repair in the laboratory using a Monsanto tensiometer (Monsanto, Swindon, UK) using a single pull to failure loading programme.

This shows that, in transosseous repair, the bone tunnels can fail at between 16 N and 115 N compared to anchors that fail at 168 N to 712 N.

This cautionary tale means that going back to ‘the good old days’ might not be such a good idea.

Cystic changes in the greater tuberosity of the humerus are common, and are often reported to be associated with rotator cuff tear or ageing. The present study aimed to assess whether cysts on plain radiograph of the shoulder are indicative of rotator cuff tears.

One hundred and five consecutive patients with painful shoulders who underwent arthroscopic procedures were recruited prospectively. The observed radiographic cysts in the tuberosity were correlated with arthroscopic findings of their rotator cuff, as well as with other pathologies.

Cysts appeared more often in shoulders with rotator cuff tears than in those without tears (p < 0.001). The overall positive predictive value for a patient with a painful shoulder in the presence humeral cysts was 68%. This rises to 85% if the patient is aged 60 years or older. Cysts occurred with similar probability in shoulders with or without superior labral tears, calcific tendinitis, impingement and frozen shoulder.

Cystic changes in the greater tuberosity were closely associated with rotator cuff tears and age. When humeral cysts are detected on plain radiographs in a patient with a painful shoulder, the index of suspicion for rotator cuff tear should be high, particularly for those patients aged over 60 years.

Magnetic resonance arthrography(MRA) is a routine diagnostic investigation for glenohumeral lesions; however, diagnostic arthroscopy remains the gold standard. The present study aimed tto investigate the diagnostic accuracy of glenohumeral MRA compared to arthroscopy, with particular interest in previously unreported aspects, such as posterior labral lesions and the locality of the reporting radiologists.

Ninety-five consecutive patients with pre-operative MRA and subsequent arthroscopy were included. Patients were grouped into MRA reported by specialist radiologists within the specialist shoulder unit (n = 58) or reported by nonlocal musculoskeletal radiologists (n = 37).

In the local radiologist group, the sensitivity/specificity for Hill – Sachs lesions was 0.71/0.85, anterior labral tears 0.75/0.73, posterior labral tears 0.50/0.92, superior labral tear from anterior to posterior (SLAP) lesions 0.71/0/91 and rotator cuff tears (RCTs) 0.40/0.81. In the nonlocal radiologist group, the sensitivity/specificity for Hill – Sachs lesions was 0.64/0.88, anterior labral tears 0.70/0.79, posterior labral tears 0.40/0.81, SLAP lesions 0.66/0/82 and RCT 0.40/0.81. A nonsignificant trend of lower sensitivity/specificity for lesions reviewed by the nonlocal radiologists was found.

MRA is not 100% sensitive or specific and does not negate arthroscopy. There is a lower diagnostic accuracy of posterior compared to anterior labral lesions and improved accuracy of glenohumeral MRA diagnosis may be achieved with the increased experience of radiologists within specialist units and regular surgical feedback of cases.

Fractures of the proximal humerus contribute a large number of admissions to our unit each year both for operative and conservative treatment. They can be a cause of great morbidity in many of these patients. Open reduction and internal fixation of fractures is performed in those patients who have displaced fractures and who are significantly independent to warrant surgical management.

This is a retrospective study evaluating the early experiences of a new type of plate fixation, the S3 plate (DePuy, Warsaw, IN, USA), in patients with displaced three- and four-part fractures. The case notes of those patients with more than 1 year of follow-up following fixation of their humeral fracture with a S3 plate were retrospectively reviewed. Each patient was also sent an Oxford Shoulder Score in the post for completion. Fifty-three patients were identified for inclusion in the study from 2007 onwards. Patients with a two-part fracture (n = 10) were excluded from the study because it was felt that these patients represented a group in whom conservative management was often the more commonly used treatment modality.

Mean age was 54.1 years (range 21 years to 76 years); the male to female ratio was 1 : 2.4; and there were 25 three-part fractures and 17 four-part fractures. Time to discharge ranged from 4 months to 16 months, with a mean of 6.7 months. There were no intra-operative complications, one superficial wound infection and only one patient required further surgery. At 1 year, we have seen a low complication rate with good return to activity.

The implant has a very low revision rate and union was seen in most fractures by 6 months. The present study was limited by documented union time, numbers and differing discharge protocols. This new plating technique appears to offer a decreased complication rate compared to other plating systems without compromising patient outcomes.

Symptoms of shoulder impingement are very common in clinical practice; however, diagnosis of the exact cause of the impingement remains a challenge. Evidence-based guidelines published for physiotherapists state that night pain is particularly associated with rotator cuff tears. This retrospective study aimed to determine whether patients diagnosed with impingement of the shoulder are more likely to report night pain if a tear of the rotator cuff is present.

The findings at surgery of 873 patients following open or arthroscopic decompression of the shoulder were studied to determine whether a tear of the rotator cuff had been identified. The pre-operative response for each of these patients regarding sleep disturbance as a result of their shoulder pain was cross-matched with the surgical findings.

There was no significant difference between those patients who were found to have a cuff tear and those with an intact rotator cuff and their complaint of night pain.

Night pain is a common complaint of patients presenting with impingement of the shoulder. It cannot be used in isolation as a diagnostic predictor for the presence of a rotator cuff tear.

Reliable measurements of shoulder strength are important in assessing rotator cuff integrity.

To determine whether a fixed strength assessment device is more reliable than a handheld dynamometer (HHD) when measuring the strength of five shoulder movements (internal rotation, external rotation, abduction, lift-off and adduction).

We tested 12 asymptomatic and 11 symptomatic shoulders in the intra-rater reliability assessment. For each shoulder tested, the strength of five shoulder movements were recorded three times using HHD and three times using the fixed device by the same examiner. We tested 11 asymptomatic shoulders and 10 symptomatic shoulders in the inter-rater reliability assessment. Each of three examiners tested the shoulder strength of each subjectl once using HHD and once using the fixed device. Intra-class correlation coefficients (ICCs) were calculated to assess reliability of measurements.

Both HHD and the fixed device showed excellent (ICC > 0.80) intra-rater and inter-rater reliability for all movements. The inter-rater reliability of HHD began to decrease as the subject strength increased when testing abduction in the plane of the scapula.

HHD is a reliable method of measuring shoulder strength in the clinical setting. However, when several examiners are testing strength of stronger subjects in abduction of the scapular plane, stabilizing the dynamometer provides more reliable results.