There are limited data available on the outcome of patients following isolated fractures of the greater tuberosity of the humerus. In this retrospective study, we looked at how differences with respect to the injury and subsequent management affected patient outcomes.
Forty-eight (28 men and 20 women) patients (mean age 45 years) who were treated at our institution between1999 and 2009 matched our inclusion criteria. Thirty-five patients were treated surgically and 13 were managed conservatively. Functional outcome was assessed after a mean follow-up of 5.5 years using the Oxford Shoulder Score (OSS), the University of California and Los Angeles (UCLA) rating scale and the shoulder index of the American Shoulder and Elbow Surgeons (ASES).
Post-fixation displacement of the greater tuberosity fragment of < 5 mm led to a significantly better outcome than displacement > 5 mm (OSS = 43 versus 37; ASES = 25.6 versus 17.7; UCLA 28.2 versus 21.3). Patients who had surgery > 2 weeks after the initial injury had a significantly worse outcome than those who had surgery in < 2 weeks (OSS = 37.4 versus 44.7; ASES = 18.9 versus 27.2). Patients with shoulder dislocation had worse outcome than those with no dislocation (OSS = 40.6 versus 44; ASES 22.9 versus 26) and rotator cuff tears were also associated with worse outcome scores than those without (OSS 42.8 versus 36.8; ASES 24.5 versus 20.5), although neither of these variables proved statistically significant.
Isolated fractures of the greater tuberosity have a worse outcome if there is a delay in surgical fixation of > 2 weeks and post-fixation displacement of > 5 mm.
In the second part of this review article the management of medial elbow tendinopathy, distal biceps and distal triceps tendinopathy will be discussed. There is a scarcity of publications concerning any of these tendinopathies. This review will summarise the current best available evidence in their management.
Medial elbow tendinopathy, also known as Golfer's elbow, is up to 6 times less common than lateral elbow tendinopathy. The tendinopathy occurs in the insertion of pronator teres and flexor carpi radialis. Diagnosis is usually apparent through a detailed history and examination but care must be made to exclude other conditions affecting the ulnar nerve or less commonly the ulnar collateral ligament complex. If doubt exists then MRI/US and electrophysiology can be used. Treatment follows a similar pattern to that of lateral elbow tendinopathy. Acute management is with activity modification and topical NSAIDs. Injection therapy and surgical excision are utilised for recalcitrant cases.
Distal biceps and triceps tendinopathies are very rare and there is limited evidence published. Sequelae of tendinopathy include tendon rupture and so it is vital to manage these tendinopathies appropriately in order to minimise this significant complication. Their management and that of partial tears will be considered.
Obstetric brachial plexus injuries are common, with an incidence of 0.42 per 1000 live births in the UK, and with 25% of patients being left with permanent disability without intervention. The shoulder is the most commonly affected joint and, as a result of the subsequent imbalance of musculature, the abnormal deforming forces cause dysplasia of the glenohumeral joint. In the growing child, this presents with changing pattern of pathology, which requires a multidisciplinary approach and a broad range of treatment modalities to optimize function.
]]>Bone loss involving the articular surfaces of the shoulder joint is challenging to manage. We review the reconstructive options for the glenoid and humeral head using structural autografts.
]]>Rotator cuff tendinopathy is common and a wide range of conservative interventions are currently used to treat this problem. The purpose of this review is to systematically review the systematic reviews that evaluate the effectiveness of conservative interventions for rotator cuff tendinopathy.
An electronic search of PEDro, MEDLINE and the Cochrane Library was undertaken and supplemented by hand and citation searching. The AMSTAR checklist was adopted for quality appraisal and a narrative synthesis was undertaken.
Twenty-six systematic reviews were retrieved. Methodological quality was variable. Exercise and multimodal physiotherapy appear to confer superior outcomes over no treatment or placebo, although the clinical significance of these results remains unclear. Surgery does not confer an additional benefit over exercise alone or multimodal physiotherapy. Combining manual therapy with exercise is not currently supported, neither is the use of corticosteroid injections or acupuncture. Other commonly prescribed interventions lack evidence of effectiveness.
Exercise and multimodal physiotherapy might be effective interventions for rotator cuff tendinopathy, although the clinical significance of this effect is unclear. This interpretation is drawn from systematic reviews comprising mainly small randomized controlled trials that frequently measure outcome in a heterogeneous manner, limiting the strength of any conclusions.
Coracoid pain is not a common presenting symptom in the shoulder clinic, however a small minority of patients do present complaining of pain well localised to the coracoid. To aid clinicians we present the findings of a review of the literature on coracoid pain. We divide the causes of pain into soft tissue and bony causes. We review and discuss the literature and present the evidence on diagnostic investigations and treatments.
Background Blockade of the suprascapular nerve (SSN) is used frequently in shoulder surgery and in chronic shoulder pain. Anatomical landmarks may be used to locate the nerve before infiltration with local anaesthetic, with ultrasound comprising a popular method for locating the nerve.
Methods Twelve cadaveric shoulders from six specimens were injected with dye using both the landmark and the ultrasound technique. The shoulders were scanned by computed tomography (CT) and then dissected to determine the accuracy of each technique.
Results Using the CT scan results, we found the ultrasound group to be more accurate with respect to placing the anaesthetic needle close to the suprascapular notch (and therefore nerve), with this being statistically significant (p = 0.021).
Conclusions The findings of the present study demonstrate that ultrasound-guided block is significantly more accurate than the landmark technique, therefore suggesting that ultrasound guidance be used for blockade of the SSN.
In severely osteoporotic proximal humerus fractures, the biomechanics of fixed-angle fracture fixation with locked smooth pegs may be improved by using polymethyl methacrylate (PMMA) augmentation. Commercially available smooth pegs were modified (added a central cannula and two distal side ports) to accommodate bone cement injection around the pegs. The failure strength and stiffness of proximal humerus fracture fixation with modified pegs and PMMA augmentation was evaluated.
Nineteen fresh-frozen cadaveric humeri were fixated with a locked plate using: (i) smooth pegs (seven specimens), (ii) threaded pegs (six specimens) or (iii) modified smooth pegs with PMMA augmentation (six specimens). The osteotomized humeri constructs were subjected to an axial compressive load to failure at loading rate of 5 mm/minute. The maximum failure load and slope for each specimen was calculated.
There was no difference (p > 0.31) between the failure strength of constructs containing smooth or threaded pegs. However, the mean failure strength and stiffness of modified smooth pegs with PMMA augmentation was higher than the constructs containing either the smooth or threaded pegs.
The results obtained in the present study show that the use of PMMA augmentation along with smooth pegs may benefit humerus fracture patients with severe osteoporosis.
Diabetes mellitus is a systemic disease that affects peripheral nerves. The use of regional anaesthesia in diabetic patients undergoing surgery can be unpredictable. We investigated the efficacy of brachial plexus block (BPB) in diabetic patients compared to nondiabetic individuals.
Four hundred and six patients were included. Forty-six patients were diabetic: 20 with type 1, 22 with type 2 and four with diet-controlled diabetes. A mixture of 0.5% bupivacaine and 1% prilocaine was used. Postoperative proximal and distal, motor and sensory functions were assessed. Motor function was assessed using the Medical Research Council grading system. Sensory function was assessed using a graded scale.
In diabetic patients, the BPB was as efficient for proximal motor (p = 0.25) and sensory (p = 0.33) blocks as it was in nondiabetic patients. There was a significant difference in the efficacy of the block distally between diabetic and nondiabetic patients in both motor (p = 0.007) and sensory function (p = 0.001). The efficacy of the BPB was poorer in diabetic patients.
A BPB can be used efficiently for shoulder surgery in diabetic patients. For distal surgery, surgeons and anaesthetists should be prepared to reinforce the block or use general anaesthesia.
The management of irreparable rotator cuff tears in younger patients remains challenging. The results achieved using arthroscopic debridement, tendon allograft and muscle transfers have been unpredictable.
We report a prospective study of 61 patients with irreparable rotator cuff tears who were treated with open cuff reconstruction using the GraftJacket (i.e. acellular human dermal matrix) (Wright Medical Technology, Inc., Arlington, TN, USA) to bridge the defect. The average age at the time of surgery was 62.6 years (range 47 years to 72 years). All patients were evaluated using the Oxford Shoulder Score pre- and postoperatively. The mean follow-up period was 3.6 years (range 1 year to 6 years).
There was a significant improvement in the Oxford Shoulder Score from 26.4 to 44.6 (p < 0.01) after surgery, with a similar improvement in pain score from 7 pre-operatively to less than 1 at follow-up. Significant improvements were also seen in the strength and range of movement. This improvement in function was seen even if pre-operative magnetic resonance imaging (MRI) scans showed > 50% fatty changes. Postoperative MRI scans showed the graft to be in continuity with the tendon.
The results obtained in the present study suggest that the GraftJacket allograft regenerative tissue matrix provides a very good option for bridging irreparable rotator cuff tears in the short to medium term.
Metallosis with an associated cutaneous pigmentation as a result of metal dispersion has not been reported in the literature. A case is described in a patient who developed an extensive metallosis that presented with cutaneous pigmentation 8 years after a reverse shoulder replacement.
Ganglion cyst of the subcoracoid location around the shoulder is uncommon. Most cysts of the shoulder are described in the adult population. No previous English literature has reported symptomatic cyst of this location in children. Ganglion of the shoulder can produce various symptoms from mechanical compression such as pain, limited motion and neuropathic weakness.
A thirteen-year-old patient presented with chronic pain of his coracoid process and limited shoulder motion in forward flexion and rotation. Ultrasound scan demonstrated a cystic mass at the base of the coracoid process. MRI suggested this mass consistent with ganglion cyst on T2-weighted images. No labral pathology was found on MRI and diagnostic arthroscopy.
The patient underwent arthroscopic exploration and open excisional biopsy. No associated intra-articular pathology was found. Through a deltopectoral approach, a cystic mass was directly identified and excised at the base of the coracoid process and subsequently. Histology confirmed the diagnosis of a ganglion cyst. Postoperatively the symptoms have resolved with improved function.
A rare case of ganglion cyst of the subcoracoid location in this young age group was reported. Chronic shoulder pain with impingement can be from mechanical compression of a ganglion cyst. Complete surgical excision is important to prevent recurrence.
A 39-year-old man developed a radial nerve palsy following repair of a left segmental humerus fracture with a rigid interlocking intramedullary nail and screws. His palsy manifested as a wrist and finger drop, associated with numbness in the distribution of the radial nerve. This was managed conservatively with a wrist brace and passive extension exercises. The fracture repair was surgically explored again 9 months later because of a lack of recovery of the radial nerve palsy and fracture non-union leading to localized pressure and pain. During this period, there was no recordable recovery of the nerve; objective clinical assessments were regularly made and the findings were confirmed by neurophysiological studies. During the operation, it was found that the two distal locking screws were impinging on the radial nerve, trapping the epineurium and part of the perineurium. Careful neurolysis was performed and the screws were removed. The fracture was then reduced and fixed without further incident. Immediately following the operation, the patient almost immediately regained complete function in his left wrist and hand. The sensation was restored to normal and the power of his wrist and finger extension returned to Medical Research Council grade 4. As a result of the rapid rate of recovery, we have concluded that impingement by the screws on the patient's radial nerve had resulted in axonamonosis, an uncommon nerve lesion in which pressure on a nerve results in mechanical demyelinization of a length of nerve with interruption of conduction. On release of the pressure, early recovery follows the return of the myelin insulation.
The trabecular architecture of the olecranon and proximal ulna has not been studied in detail. We undertook a primarily cadaveric study aiming to link with the theory of biomechanics.
Eight pairs of ulnae were obtained from cadavers. Half of the ulnae were sliced longitudinally, each slice 2 mm to 3 mm thick (Group I), and the remaining half were sliced vertically (Group II) and radiographed to study the trabecular orientation of the olecranon and proximal ulna. Computerized tomography (CT) scans of eight patients (Group III) were studied to determine the real-life trabecular pattern.
In Group I, two main sets of trabeculae were observed. The first set of trabeculae consists of three bundles, which arise from the anterior cortex. Anterior and middle bundles support the subarticular subchondral area. The posterior bundle curves and spreads to posterior cortex. The second set arises from posterior cortex and terminates under subchondral area. In Group II, trabeculae subtend a 90° angle to the articular surface. CT (Group III) confirmed the cadaveric observations.
Trabeculae of the olecranon and proximal ulna comprise a cluster that resists compressive loading and a further cluster that resists tensile stresses, which should be taken into consideration in the prosthetic design of elbow replacement to facilitate stress absorption.
We report a case of isolated rupture of the separate insertion of the short head of biceps on the radial tuberosity. This case occurred in a 52-year-old male fitness instructor who lifted a heavy weight. The patient presented with pain, bruising of the anterior elbow and weakness of elbow flexion. There was no bunching of the distal biceps and the hook test was normal. The rupture and location of the tendon ends was identified by several transverse and longitudinal ultrasound images and then definitively confirmed by magnetic resonance imaging. The rupture was surgically repaired, resulting in good functional ability. Early detection is vitally important for optimal management, especially when functional disability is present.