We review the pertinent literature and survey 31 collegiate women's volleyball programme athletic trainers estimating the prevalence of shoulder pain among participants, particularly the ‘hitters’. We also survey experienced coaches for their estimate of the number of overhead arm swings performed by these athletes (during matches, practices and pre-game warm-ups) confirming these estimates by actual counts where available. A brief review of the results leads us to conclude that adoption of a ‘swing count', analogous to the baseball ‘pitch count', might ameliorate the substantial shoulder issues reported to us.
]]>Background With this case series, we report the management of patients who present with non-union after no treatment or intentional non-operative management of a displaced olecranon fracture. We hypothesized that the majority of these patients would be satisfied with their symptoms and function.
Methods Ten patients (six women and four men) with a mean age of 59 years (range 21 years to 94 years) presented to one of seven surgeons with non-union of a displaced fracture of the olecranon a mean of 17 months (range 3 months to 7 years) after injury.
Results The mean flexion-extension arc at presentation was 117° (range 100° to 135°) with a mean flexion of 137° (range 120° to 150°) and a mean extension of 21° (range 10° to 40°). Forearm rotational arc was a mean of 172° (range 150° to 180°) with a mean pronation of 86° (range 75° to 90°) and a mean supination of 86° (range 75° to 90°). Two patients who had difficulty participating in daily activities because of pain or loss of function requested operative treatment. Eight patients declined operative treatment.
Conclusions Patients who present with a non-union after a displaced olecranon fracture managed non-operatively have reasonable elbow function and uncommonly request operative treatment.
Background Disassembly of the Coonrad-Morrey total elbow replacement with the pin in pin locking mechanism has previously been reported. We present the largest series documented to date with failure of this mechanism.
Methods A retrospective review of patients treated at the shoulder and elbow unit of the Northern General Hospital Sheffield UK.
Results There were five men and one woman with a mean age at pin failure of 56 years (range 39 years to 79 years). One patient had failure of bilateral replacements and two patients had failure on two separate occasions. Three patients had undergone surgery for distal humeral fractures, two for non-inflammatory arthritis and one for rheumatoid arthritis. All patients required revision surgery. A mechanism of pin failure is proposed and the risk factors are identified.
Conclusion Despite the redesign of the locking mechanism of the Coonrad–Morrey total elbow arthroplasty, there remains a risk of pin failure. This would appear to be greatest in younger male patients undergoing a total elbow replacement for a distal humeral fracture or post-traumatic arthritis.
A 51-year-old female underwent an uncomplicated resection of a sigmoid adenocarcinoma. Postoperatively, 12 cycles of the FOLFOX chemotherapy regime were completed, consisting of a combination of folinic acid, 5-fluorouracil and oxaliplatin over a 24 week period. Following chemotherapy, the patient developed simultaneous adhesive capsulitis in both shoulder joints, as radiologically confirmed by magnetic resonance imaging. Bilateral adhesive capsulitis is rare and usually associated with a systemic cause. This case highlights a possible previously unreported association between the widely used FOLFOX chemotherapy regime and bilateral adhesive capsulitis. Oncologists and orthopaedic surgeons should be aware of such presentations in FOLFOX patients to facilitate prompt investigation and management.
]]>The most common causal organism in septic bursitis and pyomyositis is Staphylococcus aureus. Primary subacromial and subdeltoid abscess caused by viridans Streptococcus infection has never been reported and, to our knowledge, nor has diffuse pyomyositis of the rotator cuff associated with subacromial abscess. We describe the clinical presentation, radiological investigations and strategies for the management of a 56-year-old female who presented with purulent subacromial/subdeltoid bursitis and abscess formation in the rotator cuff muscles as a result of viridans Streptococcus infection. Because of its deep anatomic location, primary subacromial/subdeltoid septic bursitis and pyomyositis of rotator cuff muscles are rarely reported. The immunocompromise caused by diabetes mellitus presented a risk factor for the unusual infection observed in this patient. Magnetic resonance imaging aided the diagnosis. Treatment consisted of surgical debridement and drainage, with antibiotic administration, which resolved the infection without sequelae.
]]>Background The accuracy of retrospective recall of shoulder symptoms has not been well documented. This prospective study assesses the ability of patients to recall their preoperative shoulder function one year after a surgical intervention, using the Oxford Shoulder Score (OSS).
Methods 35 patients completed an OSS before undergoing shoulder surgery. One year later, patients were asked to recall their symptoms prior to their surgery. The recalled OSS of the patients as a group was compared to their preoperative score. The recall bias of each test pair was assessed with a Bland – Altman plot.
Results On recall after a mean of 12.6 months, the mean OSS from the index assessment increased from 36.25 to 38.25 points. The mean difference of 2 points for the patients as a group was not significant (p = 0.14). The statistical limits of agreement of the Bland – Altman plot were set at +/−2 SD = 14.079 points. The plotted points showed fair correlation between each individual test pair.
Conclusion The recall of symptoms of a large group of patients at 1 year after the index intervention appears to have a moderate correlation with the preoperative scoring. Although statistically acceptable, this limit of agreement is much larger than the 4.5-point difference, established to be clinically relevant in prior studies. The variation seen within the scores at the individual level suggests that these data cannot be used as a retrospective tool.
Bilateral scapula fractures are rare and are most often associated with high energy trauma and electrocution. We present a case of an elderly man who sustained this unusual fracture pattern following a syncopal event. We highlight the importance of appropriate clinical examination and investigations in low energy mechanisms of injury to avoid a delay in diagnosing this potentially serious shoulder injury.
]]>Background Cuff tear arthropathy (CTA)-specific hemiarthroplasty was designed to allow for smoother articulation. Results following standard hemiarthroplasty for CTA have been unpredictable. Recent work emphasized the importance of closely evaluating cuff-deficient shoulders with histories, exams, and radiographs in an attempt to provide better treatment algorithms for these shoulders. We hypothesized that CTA-specific hemiarthroplasty for cuff-deficient shoulders without prior surgical intervention would improve shoulder comfort and function.
Methods From November 2006 to January 2009, we performed 22 CTA-specific hemiarthroplasties in 21 patients with previously unoperated shoulders. All were assessed with radiographs and scored according to Seebauer. Constant and Simple Shoulder Test scores were obtained pre-operatively and at a minimum two-year follow-up.
Results 15 of the original 22 shoulders were available for evaluation by an orthopaedist other than the operative surgeon. One was lost to follow-up. 3 were in patients that had died. Mean absolute Constant score improved from 37 pre-op to 62 post-op; mean Simple Shoulder Test score improved from 4 to 9. Of the 15, there were 2 IA's, 0 IB's, 13 IIA's, and 0 IIB's according to Seebauer's classification. 4 out of 22 (18%) shoulders were either converted to reverse arthroplasties (2) or were in patients that were dissatisfied with their results and refused follow-up (1) or lost to follow-up (1).
Conclusions CTA-specific hemiarthroplasty for rotator cuff-deficient shoulders with arthritis and without escape or previous surgery improves comfort and function in most shoulders. However, the risk of conversion to reverse, dissatisfaction, or presumed dissatisfaction in this small series was 18% in short term follow-up.
Background Few studies have examined muscular activation levels during commonly prescribed range of motion (ROM) exercises in a post-surgical superior labral tear anterior to posterior (SLAP) repair patient group. The present cross-sectional study compared shoulder musculature activation levels between postoperative SLAP repair patients with those of a healthy control cohort performing commonly prescribed postoperative shoulder exercises. The maximal ROM (MAX ROM) achieved during exercises was also studied.
Methods Ten healthy volunteers and nine postoperative patients (post-SLAP) performed 10 rehabilitative exercises during the recording of electromyogram (EMG) activity from six shoulder muscles. Root mean squared amplitudes normalized to a submaximal reference voluntary contraction (RVC) were analyzed to compare exercises. A two-dimensional video of humeral-trunk angle captured the shoulder ROM for each exercise.
Results One significant difference was found between groups; the anterior deltoid mean activity across all exercises was found to be higher in the post-SLAP group 53% RVC [95% confidence interval (CI) = 48% to 57% RVC] compared to the healthy group 46% RVC (95% CI = 42% to 50% RVC) (p = 0.02). Post-SLAP patients generated the least MAX ROM performing the Pendulum exercise 97°(95% CI = 88° to 107°) and the greatest during Forward Bow 131° (95% CI = 121° to 142°), (p = 0.002).
Conclusions The present study identifies the shoulder muscle EMG and MAX ROM obtained during rehabilitation exercise in patients' after SLAP repair. Knowledge of these parameters will help clinicians match the appropriate exercise to meet the desired objective for the particular rehabilitation goal.
We present a case of extreme glenohumeral dysmorphism with pain and arthropathy which benefited from a Computer-Aided Design and Computer-Aided Manufacture (CADCAM) ‘Piggy-Back’ reverse total shoulder arthroplasty.
]]>The elbow joint is susceptible to osteochondral injuries related to complex fracture-dislocations, as well as to conditions such as osteochondritis dissecans. In many instances, the repair of fragments or fibrocartilage-stimulating techniques are sufficient to treat the defects but, in some patients, this is either not feasible or has failed. In these situations, osteochondral autografts provide reconstructive options. The present review discusses reconstructive options for the coronoid, radial head and capitellum using autografts.
]]>Background Lateral epicondylitis has been studied mainly in work related and occupational groups, however little is known about the incidence or demographic associations in the general population. We have undertaken a large study using The Health Improvement Network (THIN) database to examine the epidemiology of lateral epicondylitis in the UK general population.
Methods Diagnoses of lateral epicondylitis between 1987 and 2006 were used to calculate the incidence stratified by age, gender, deprivation score, UK health authority, and year. The age standardised rates for lateral epicondylitis in the UK were calculated with reference to the European Standard Population.
Results The incidence rate of lateral epicondylitis was 2.45 per 1000 person-years. This was more common in males than females (males 2.63, females 2.55 per 1000 person-years, p < 0.001). After direct standardization, the age adjusted rates were 2.38 for males and 2.43 for females.
The highest incidence rate of 7.35 per 1000 person-years was found in the age group 45–50 years. Regional distribution of the incidence rates showed a fairly even spread across 13 UK Health Authorities with the exception of London where incidence rates were significantly lower (1.75 per 1000 person-years, p < 0.001). Social deprivation was assessed using the Townsend score. The least deprived areas of the population had the highest incidence rates (2.86 per 1000 person years).
Conclusions Our study represents the largest general population study of lateral epicondylitis reported to date. The results obtained provide the clinician with a better understanding of the epidemiology of lateral epicondylitis in the community.
Treatment of avascular necrosis of the humeral head is a challenging clinical problem because patients often present at a young age with established destruction of bony tissue. Reccommended surgical treatment at this stage of the disease is joint replacement surgery using a metal implant, although this has potential complications. The present case report describes the novel use of a synthetic bone-graft substitute (TruFit plug; Smith & Nephew, Andover, MA, USA) that was successfully used to restore full range of movement and completely alleviate pain in a patient with stage II avascular necrosis of the right humeral head.
]]>Glenohumeral joint posterior capsule contracture may cause shoulder pain by altering normal joint mechanics. Contracture is commonly noted in throwing athletes but can also be present in nonthrowers. The cause of contracture in throwing athletes is assumed to be a response to the high amount of repetitive tensile force placed on the tissue, whereas the mechanism of contracture in nonthrowers is unknown. It is likely that mechanical and cellular processes interact to increase the stiffness and decrease the compliance of the capsule, although the exact processes that cause a contracture have not been confirmed. Cadaver models have been used to study the effect of posterior capsule contracture on joint mechanics and demonstrate alterations in range of motion and in humeral head kinematics. Imaging has been used to assess posterior capsule contracture, although standard techniques and quantification methods are lacking. Clinically, contracture manifests as a reduction in glenohumeral internal rotation and/or cross body adduction range of motion. Stretching and manual techniques are used to improve range of motion and often decrease symptoms in painful shoulders.
]]>Background Stiffness after arthroscopic shoulder surgery is of significant concern to the patient, surgeon and therapist. The present study aimed to investigate the natural history of stiffness after shoulder arthroscopic procedures.
Methods Postoperative recovery of range of motion (ROM) in patients who underwent 234 consecutive arthroscopic procedures over a 1-year period was reviewed. The time needed to regain full ROM was recorded for every patient. Stiffness was graded from 0 to 3 depending on the loss of movements as compared to the opposite side.
Results Postoperative ROM returned to normal in 63% of patients within 3 months, 94% of patients within 6 months, 96% of patients within 9 months and 97% of patients within 1 year after surgery. Stiffness was graded as a loss of ROM compared to the contralateral shoulder, with less than a third loss as grade 1, one third to two-thirds loss as grade 2 and more than two thirds loss as grade 3. Some 85% patients with Grade 1 stiffness recovered complete ROM at 6 months, whereas only 43% of grade 2/3 stiffness returned to normal at 6 months. Only four patients required further active intervention for recovery from stiffness. Risk of developing stiffness was related to the pre-operative diagnosis.
Conclusions Although, minor (grade 1) stiffness after shoulder surgery occurs commonly despite early mobilization rehabilitation protocols; it resolves rapidly without further surgical intervention in a majority of the patients.
Background The present study comprised a retrospective review aiming to identify the differences between patients with a posterior Monteggia injury with and without concomitant dislocation of the elbow.
Methods Forty-nine consecutive adult patients with 50 posterior Monteggia fractures were identified that had operative treatment. Demographics and injury characteristics were recorded for the entire cohort (13 with and 36 without ulnohumeral dislocation) and final motion was recorded in 29 patients (10 with and 19 without dislocation) that had more than 10 months of follow-up.
Results Fractures with concomitant elbow dislocation occur in younger patients (45 years versus 56 years; p = 0.046); are associated with higher-energy injuries (54% versus 21%, p = 0.037); are more likely to have a Regan–Morrey type 2 (85% versus 26%, p = 0.003)/Mayo type 1 coronoid fractures (85% versus 21%; p < 0.001); and are more likely to have a Mason type 2 radial head fracture (61% versus 30%; p = 0.046).
Conclusions Patients with a posterior Monteggia fracture and concomitant elbow dislocation have smaller coronoid fractures and worse ultimate ulnohumeral motion than patients without an elbow dislocation.
Sleep is a complex physiological process essential to sustain life. Very little is known about why we sleep, although evidence of the harmful effects of sleep disturbance to our health is rapidly emerging. Sleep disturbance is a distinct and debilitating symptom of shoulder pathology. The important relationship between sleep and pain is only beginning to be appreciated, and the physiological process underlying this feature in shoulder pain remains elusive. A number of theories have been explored; however, there is still no adequate solution to address this important symptom in painful conditions of the shoulder.
]]>Background Previous studies have demonstrated that the glenoid fossa can be anteverted or retroverted with respect to the scapular spine and that this may affect the propensity to dislocate, although clinical studies have provided conflicting evidence.
Methods We have used a highly accurate, noncontact laser morphometric method of analysis to determine the precise shape of 59 glenoid fossae from shoulders, with no evidence of instability, arthritis or rotator cuff disease.
Results We have shown that, at the mid-glenoid level, most fossae are retroverted, although some are anteverted. Furthermore, below this level, the glenoid can either twist into greater anteversion or retroversion. This forms the basis of a classification system that describes how much static restraint to dislocation is provided by the bony glenoid, and we have repeated the work to identify any contribution from variations in the thickness of overlying articular cartilage. Of 59 fossae, five were of type 1A, comprising an anteverted glenoid that becomes increasingly anteverted below its equator and provides least bony restraint to anterior dislocation.
Conclusions We propose that this classification system is used to study the effect of glenoid shape on shoulder stability and options for reconstruction.
Background Application of extracorporeal shockwave therapy (ESWT) induces an improvement in tissue healing associated with augmented tissue perfusion. The present study aimed to investigate the responses of human rotator cuff tissue to the application of ESWT.
Methods Thirty-one consecutive patients with symptomatic rotator cuff tendinopathy with complete tears were approached and enrolled in the present study. Before surgical resolution, a single treatment of focused ESWT was offered to all patients. Ten patients accepted such treatment and 21 refused ESWT. Tendon tissue biopsies were collected for evaluation using haematoxylin and eosin and characterized according to the Riley Classification. Vascular volume area (VVA) was determined semi-quantitatively and immunohistochemical (IHC) analysis included CD14, CD34, PCNA, Tenascin-C and D2-40 markers.
Results Distribution of grade according to the Riley Classification with respect to study group was: Group A: Grade III (n = 9), Grade IV (n = 1); Group B: Grade III (n = 13), Grade IV (n = 8). Mean group-specific VVA analysis was 18.47% and 7.03% for Group A and Group B, respectively. IHC Grade III protein staining was significantly more prevalent in Group A compared to Group B for CD34, PCNA, Tenascin-C and D2-40 (p < 0.05 for all comparisons).
Conclusions ESWT is associated with increased neovascularization and neolymphangiogenesis in rotator cuff tendinopathy. IHC analysis suggests an improvement in healing response in the ESWT-treated tendon.
We present a review of the literature with respect to the anatomy, biomechanics, classification, diagnosis and rationale for contemporary management of both acute and chronic acromioclavicular joint dislocations. Both conservative and surgical management are discussed.
]]>Background Frozen shoulder is considered to be associated with diabetes, thyroid disease, heart disease, high cholesterol and Dupuytren's disease. However, these associations have been made without arthroscopic confirmation of frozen shoulder or comparison with a control group. The present study aimed to compare the incidence of co-morbidities in a group of arthroscopically proven frozen shoulder patients and an age- and sex-matched control group.
Methods One hundred and one patients with clinical and arthroscopically proven primary frozen shoulder and no other intra-articular pathology were identified. One hundred and one patients were recruited from a fracture clinic as an age- and sex-matched control group. Each patient was sent a questionnaire to document co-morbidities and frozen shoulder in siblings.
Results Only diabetes (p = 0.002) and a sibling with frozen shoulder (p < 0.02) were found to be risk factors for frozen shoulder.
Discussion This is the first large study to use a precise diagnosis and a well-matched control group to quantify the associations of frozen shoulder. It confirms the link of frozen shoulder with diabetes and adds to the argument for a genetic link in patients requiring an arthroscopic capsular release. It questions the association of heart disease, high cholesterol and thyroid disease with frozen shoulder.
Background A well-defined, reproducible small animal model that allows quantitative assessment of musculotendinous changes would be desirable for investigations concerning rotator cuff pathology.
Methods The supraspinatus tendon was released by osteotomy of the greater tuberosity in seven New Zealand rabbits. The musculotendinous unit was then allowed to retract during 6 weeks. Retraction was monitored with computed tomography (CT). At sacrifice, CT measurements of retraction were validated by measurement of the total length of the musculotendinous unit after sacrifice and by correlation with functional and structural properties of the musculotendinous unit at tendon release and at sacrifice.
Results Mean (SD) retraction of the musculotendinous unit was 1.8 (0.2) cm on CT, precisely, and negatively correlated with the total length of the retracted musculotendinous unit at sacrifice (r = −0.87, p = 0.011) but not significantly correlated with CT measurements of atrophy (r = 0.20, p = 0.699) or fatty infiltration (r = 0.13, p = 0.78). Mean (SD) muscle work decreased from 1.6 (0.23) Nm to 1.2 (1) Nm (p = 0.056). Mean (SD) muscle fibre diameter decreased from 65 (10) µm to 48 (16) µm (p = 0.063). This decrease was significantly correlated with the amount of fatty infiltration (r = 0.79, p = 0.033).
Discussion Tendon release using osteotomy of the rabbit greater tuberosity allows precise measurement of musculotendinous retraction and offers the possibility for functional muscular testing. Changes in the rabbit supraspinatus muscle caused by myotendinous retraction correspond to those observed in established sheep models.
Background We performed a prospective randomised trial recruiting patients with adhesive capsulitis of the shoulder, to undergo either manipulation under anaesthesia (MUA) or capsular distension.
Methods Between 2006 and 2010, 28 patients (30 shoulders) were recruited. The mean age was 53 years (44–69). Randomisation was done using a sealed envelope.
Results Preoperatively, the MUA group had significantly less mean abduction than the distension group (58.2 ± 5.2° vs. 75.7 ± 5.4°; p = 0.03). At 6 months, the MUA group achieved greater mean abduction (163.0 ± 2.4° vs. 130.7 ± 10.3°; p = 0.02). Preoperatively, the MUA group had significantly less external rotation compared to the distension group (11.0 ± 2.8° vs. 24.0 ± 4.1°; p = 0.03). At 6 months, the external rotation was not statistically different between the groups (40.3 ± 4.0° vs. 40.3 ± 4.6°; p = 0.75). Preoperatively, both groups had similar pain visual analogue score (VAS) (5.7 ± 0.6 vs. 4.7 ± 0.6; p = 0.30) and Disabilities of the Arm, Shoulder and Hand (DASH) scores (49.4 ± 4.7 vs. 53.8 ± 1.6; p = 0.26). However there was no statistically significant difference noted between the groups for VAS (1.5 ± 0.4 vs. 2.9 ± 0.8; p = 0.39) or DASH (12.4 ± 4.3 vs. 25.1 ± 6.4; p = 0.21) at 6-month review.
Discussion MUA resulted in better shoulder abduction than capsular distension at 6 months following the procedure. However, there was no significant difference between the two groups in external rotation or pain relief achieved.
Background Partial tears of the rotator cuff tendons of the shoulder are a common cause of significant pain and disability, yet are difficult to diagnose clinically. Handheld dynamometry has demonstrated good sensitivity and specificity in the diagnosis of full-thickness rotator cuff tears. The present study aimed to determine whether handheld dynamometer measurements could predict the presence of a partial-thickness rotator cuff tear among patients with shoulder pain.
Methods Handheld dynamometer measurements and signs of impingement were collected before surgical evaluation in 450 patients with a partial-thickness rotator cuff tear (n = 150), full-thickness rotator cuff tear (n = 150) or nonrotator cuff pathology (n = 150).
Results Patients with partial-thickness tears did not have significantly different strength compared to patients without rotator cuff tears. Patients with full-thickness tears had a decrease in abduction and external rotation strength (p < 0.001). Patients with any rotator cuff tear were more likely to have signs of impingement during internal rotation (p < 0.001) and impingement during external rotation (p = 0.004).
Conclusions Handheld dynamometer measurements were unable to reliably distinguish patients with partial-thickness rotator cuff tears from patients with other causes of shoulder pain. The abduction and external rotation muscle strength tests demonstrated their usefulness when distinguishing partial-thickness rotator cuff tears from full-thickness rotator cuff tears.
Background Shoulder arthrodesis is a unique procedure, which has shifted from a well-established procedure for osteoarthritis to a salvage procedure. In the present retrospective study, functional outcome and morbidity in shoulder arthrodesis using combined plate/screw fixation versus screw fixation alone were evaluated.
Materials and methods Shoulder arthrodesis was performed on 28 shoulders: 16 cases with only cancellous screws and 12 cases with combined plate/screw fixation. At a mean follow-up of 6.8 years (range 1 years to 20.4 years), patients were invited for clinical follow-up, with evaluations of visual analogue scale for pain, function and satisfaction, Constant–Murley scores, and recorded complications.
Results All patients had severe limitations in the use of their shoulder, although they had little pain and were satisfied. The overall Constant–Murley score increased significantly from 33.4 to 52.2. In eight cases with combined plate/screw arthrodesis and nine with screw arthrodesis, there was persistent pain, which resolved after removal of osteosynthesis material. Non-union was only found in five patients with screw arthrodesis.
Conclusions Although the risk of a second operation for removal of osteosynthesis material in combined plate/screw arthrodesis is equal to screw fixation alone, for complete glenohumeral fusion, a combined plate/screw fixation appears to be superior to screw fixation alone.
Background Management of degenerate rotator cuff tears associated with subacromial impingement is debatable.
Methods We performed a prospective, randomised controlled trial to assess the efficacy of arthroscopic subacromial decompression (ASD) with or without repair of the rotator cuff using a mini-open technique.
Results 42 patients (29 males and 13 females) with a mean age of 64 years (range 54–77 years) were recruited. 25 patients underwent ASD and cuff repair using mini-open technique whereas 17 patients had only ASD alone. All the patients were followed for a minimal of 1 year post-operatively.
At final follow-up the mean Constant scores and patient satisfaction scores were not different between the groups (p value 0.06 and 0.44 respectively). The mean DASH scores were marginally significant (p value 0.05) and mean ASES scores were significant (p value 0.03). A 38% cuff rerupture rate was noted in the cuff repair group.
Conclusions Our study demonstrates that in short-term the results of ASD with or without rotator cuff repair are not significantly different, however positive trends were noted in the cuff repair group. Although a significant rerupture rate was noted (38%) this had little effect on the outcome.
The coracoid process of the scapula is a vital landmark in shoulder surgery and has become increasingly popular as a basis for acromioclavicular joint (ACJ) stabilizations and bone transfer in the treatment of shoulder instability (Bristow–Latarjet procedure). As such, it is important that the anatomy and anatomical aberrations are well understood. We describe an aberrant structure noted during routine ACJ stabilization of a 24-year-old man using a coracoclavicular sling technique.
]]>Longitudinal instability of the forearm (the Essex-Lopresti injury, radioulnar dissociation) is uncommon and is often missed in the initial assessment of a patient with a radial head fracture. The present review outlines the anatomy and biomechanics of the forearm unit, as well as the current means of diagnosis and the range of treatment options avaailable for this challenging problem.
]]>Background This prospective cohort study tested the hypothesis that agreement with the idea that ‘stretching of the elbow beyond the point where it becomes painful is important in recovery’ leads to greater elbow range of motion, 1 month after injury.
Methods Seventy-one patients with an isolated partial articular radial head fracture seen within 14 days after injury completed measures of depression and catastrophic thinking and rated their agreement with a statement regarding pain and recovery from their injury on a five-point Likert scale. One month later, patients completed the Disabilities of the Arm, Shoulder, and Hand questionnaire and elbow and forearm motion were measured.
Results Nine patients (12.6%) disagreed with the role of pain in recovery, six (8%) were neutral and 56 (78.9%) agreed. Patients that disagreed with the role of stretch pain in recovery were older (p = 0.031), had more depressive symptoms (Center for the Epidemiological Study of Depression Instrument;p = 0.047), and achieved less elbow extension (p = 0.050) and forearm rotation (p = 0.017) 1 month after injury.
Conclusions A protective attitude towards stretch pain during recovery from fracture of the radial head is associated with less elbow motion 1 month after injury.
Level of evidence Prognostic study, Level 1 (prospectively).
Background To assess intra- and inter-tester reliability of measuring shoulder strength using a new hand-held dynamometer.
Methods On two occasions, two examiners (blinded to output) measured seven separate tests of shoulder strength. Twenty-three participants with no shoulder symptoms were tested bilaterally. Each test was performed three times as a ‘make test' using a hand-held digital dynamometer.
Results Intraclass correlation coefficients (2,1) and (2,3), 95% confidence intervals and standard errors of measurements (SEM) demonstrated good intra- and inter-tester reliability of all tests [ICC(2,3) >0.87], with the exception of inter-tester reliability of right abduction [ICC(2,3) = 0.77]. Greater reliability of all tests was demonstrated when the mean of three trials was used compared to the first measurement. Intra-tester reliability of all tests using ICC(2,1) ranged from 0.74 to 0.98; ICC(2,3) ranged from 0.89 to 0.98. Inter-tester reliability using ICC(2,1) ranged from 0.52 to 0.94; ICC(2,3) ranged from 0.77 to 0.96. The smallest detectable difference (SDD), used to measure precision, ranged from 5.9 to 12.5 Newtons.
Discussion The findings obtained in the present study suggest that using the methods employed in the population investigated demonstrated good to excellent intra- and inter-tester reliability for the measurement of shoulder strength. The SEM and SDD findings provide guidance for values that may be considered as a real change in strength.
Background Twenty percent of cases seen by primary care clinicians (general practitioners; GPs) are musculoskeletal in nature, and approximately one-quarter of these are shoulder complaints. GPs are increasingly overloaded with clinical information and unfamiliarity with current research can easily lead to misdiagnosis and, in turn, to unnecessary test requests or onward specialist referrals. Well-designed diagnostic clinical decision support systems (CDSS) have been shown to facilitate clinical decision-making and reduce diagnostic errors. However, no CDSS have been developed or tested for musculoskeletal disorders.
Methods We have developed a prototype knowledge-based diagnostic CDSS for musculoskeletal shoulder conditions. The CDSS uses Bayesian reasoning to diagnose six common musculoskeletal shoulder pathologies, based on current evidence and expert opinion. The CDSS was tested by comparing its diagnostic outcome against 50 case studies with known diagnosis by radiological imaging.
Results The CDSS diagnostic validity and reliability was shown to be 88% with a Kappa value of 0.85 to a confidence level of 99% compared to known diagnosis by radiological imaging.
Conclusions The results suggest that a Bayesian network-based CDSS is a promising instrument in the diagnosis of musculoskeletal shoulder conditions, having been shown to be valid and reliable for 50 case studies.