The floating shoulder.

The floating shoulder is defined as ipsilateral fractures of the midshaft of the clavicle and the neck of the glenoid. This rare injury can be difficult to manage without a thorough understanding of the complex anatomy of the shoulder girdle. Surgical intervention needs to be considered for all of these injuries. While acceptable results can be expected with non-operative management of minimally-displaced fractures, displacement at one or both sites is best managed with surgical reduction and fixation.

Humeral bone density losses after shoulder surgery and immobilization.

This study evaluates disuse osteoporosis of the proximal humerus after shoulder surgery and immobilization. This was accomplished by quantifying bone mineral density changes in 22 patients' proximal humeri after 6 weeks of immobilization for soft-tissue shoulder surgery. The bone mineral density of the humeral head, neck, and proximal diaphyseal subregions was determined 1 to 2 weeks before surgery and at 3, 6, and 12 weeks after surgery with dual-energy x-ray absorptiometry. By the sixth postoperative week statistically significant bone mineral density decreases of 6% to 14% were observed in the humeral neck and head subregions, respectively. The changes in these three regions diminished slightly after 6 weeks of remobilization, but the differences were still statistically significant. No significant bone mineral density changes occurred in any subregion or during any time interval in the nonoperated humerus. Our study represents the first report with dual-energy x-ray absorptiometry to quantify bone loss of the proximal humerus of patients after shoulder immobilization. Further long-term study is warranted to determine the clinical significance of this bone loss and to determine whether these losses are partially or fully recoverable.

The scapula: coracoid, acromial, and avulsion fractures.

Fractures of the coracoid and acromial processes and avulsion fractures of the scapula are uncommon with the vast majority being managed quite successfully nonoperatively. On occasion, however, these injuries may be significantly displaced and of functional importance, thus making surgical management a consideration. Diagnosis is radiographic. Due to the complex anatomy in the area, CT scanning is often necessary to detect and accurately define these injuries. The various fracture patterns that occur as well as mechanisms of injury are described. Surgical indications are detailed as are the various fixation techniques that may be employed or required. The postoperative rehabilitation program is as important as the surgical procedure.

Fractures of the glenoid neck.

Glenoid neck fractures are uncommon and have received little attention in the literature. However, these injuries involve a major articulation and can cause considerable morbidity if significantly displaced. Consequently, a review of current diagnostic and therapeutic principles with respect to these potentially challenging fractures is justified. The vast majority of glenoid neck fractures are undisplaced or insignificantly displaced (Type I fractures) and are managed without surgery. Type II fractures, however, are significantly displaced, making surgical management a consideration. Significant displacement is defined as translational displacement greater than or equal to 1 cm or angulatory displacement greater than or equal to 40° (in either the coronol or transverse plane). The primary surgical approach is posterior; however, a superior extension is often necessary. Fixation devices include K-wires, 3.5 mm reconstruction plates, and 3.5 mm cannulated lag screws. Follow-up care and rehabilitation are absolutely critical to optimizing the final functional result.

Double disruptions of the superior shoulder suspensory complex.

The superior shoulder suspensory complex (S.S.S.C.), a bony/soft tissue structure, is important both for its role as an intact unit and for the individual components that make up this unit. Traumatic "double disruptions" of the S.S.S.C. frequently create an unstable anatomic situation with adverse long-term healing and functional consequences. This "double disruption" principle underlies, unites, and allows one to understand several well-described but difficult-to-treat shoulder injuries that have previously been described in isolation. Injuries to the S.S.S.C. require careful radiologic evaluation for the possible presence of a "double disruption." If displacement is unacceptable, surgical reduction and stabilization of one or more of the injury sites is necessary.

CT and MR evaluation of the labral capsular ligamentous complex of the shoulder.

Stability of the glenohumeral articulation is dependent on the integrity of the rotator cuff, labrum, glenohumeral ligaments, capsular elements, and bony glenoid. The importance of the soft-tissue elements in maintaining stability has been well documented in the surgical literature but has only recently been introduced into the radiologic literature. The purpose of this essay is to illustrate the normal labrum, capsular complex, and glenohumeral ligaments, including common congenital variations as depicted by CT arthrography and MR imaging, and to describe the pathologic findings leading to shoulder instability.

Works in progress #3. Recurrent symptomatic posterior glenohumeral subluxation.

This paper is a retrospective review of 12 patients (13 shoulders) who were treated surgically for recurrent symptomatic posterior glenohumeral subluxation. The surgical procedure was designed to "fix the pathology." Postoperatively, all patients were immobilized in a shoulder spica for six weeks with the arm in 30 degrees of abduction and 30 degrees of external rotation. This was followed by an intensive rehabilitation program. The patients were evaluated two to six years following surgery; all felt they were significantly improved. Surgical reconstruction for recurrent symptomatic posterior glenohumeral subluxation is a reliable procedure in properly selected patients (particularly those whose instability is trauma-related), provided the surgery is done carefully and the patient managed well postoperatively.

Anterior glenohumeral instability.

The understanding of and approach to anterior shoulder instability has changed and improved dramatically in recent years. It is now accepted that a shoulder can subluxate as well as dislocate and that chronic instability may or may not be caused by an initial traumatic event. An anteriorly unstable shoulder also can be unstable inferiorly and/or posteriorly (multi-directional instability). The author's diagnostic acumen has increased with the addition of glenohumeral axillary arthrotomography, glenohumeral CT arthrography, glenohumeral arthroscopy, and other studies. Surgical treatment has moved away from "repair of choice" to an "anatomic reconstruction." The current preferred treatment is to identify and repair only the pathology while preserving normal anatomy, hoping to restore shoulder stability, while preserving normal mobility and strength. Areas of controversy exist. 1) How long should acute dislocations be immobilized, if at all, and is physiotherapy helpful in preventing chronic instability? 2) How long should the surgically repaired shoulder be immobilized, if at all? 3) Is there a place for therapeutic arthroscopy in this area? Also controversial is the concept of "functional instability" or shoulder internal derangement. These patients are felt to have shoulder slipping and catching due to the intermittent interposition of a fragment of tissue (a torn labrum, a loose body, etc) between the articulating surfaces. Arthroscopic debridement of the pathology would be ideally suited for such a clinical entity. Undoubtedly, improvements and controversy will continue until orthopedists are able to accurately diagnose and correct shoulder instability, while preserving range of motion and strength at minimal inconvenience to the patient.

Proximal humeral fractures revisited.

Although 80% of proximal humeral fractures can be managed fairly easily, 20% are significantly displaced and difficult to analyze and treat. The four-segment classification of proximal humeral fractures allows the fracture to be understood and described intelligently, provides a guide to treatment, and helps the physician to make early prognostic judgments. Plain radiographs, tomography, and/or CT scanning allows an individual case to be fitted into the classification scheme. Treatment (non-operative or operative) depends on the degree of displacement of the four major segments, whether the humeral articular surface is involved, and whether the glenohumeral joint is dislocated. Follow-up care and rehabilitation are extremely important for an optimum final outcome.

Rotator cuff injuries.

The rotator cuff lends stability to the glenohumeral joint and provides active motion. The cuff is susceptible to attritional disease, and as a result, injuries tend to fall into an age-related spectrum. Symptoms and treatment vary with the severity of the injury. Full-thickness cuff tears are suspected clinically, diagnosed by arthrography, and treated surgically by decompressing the impingement interval and repairing the defect. Postoperative care includes six weeks of immobilization, followed by an intensive physiotherapy program designed to regain shoulder range of motion, strength, and functional use. First-time surgery is associated with 70% to 90% good to excellent results. Repeat surgery, however, is far less successful.

Axillary arthrotomography of the glenoid labrum.

In a study of 67 shoulders evaluated by axillary arthrotomography, tears of the glenoid labrum were accurately detected in all 26 surgically confirmed cases. One false-positive case was identified in the five patients without labral tears; there were no false-negative cases. Only 40% of the patients had clinical evidence of subluxation or dislocation. Axillary arthrotomography provides important information about the integrity of the labrum that may be helpful in planning surgery for patients with anatomic instability. Its greatest utility seems to be in those patients without clinical subluxation or dislocation but with pain, clicking, or vague shoulder discomfort secondary to labral pathology (functional instability). In these patients, the arthrotomogram forms the basis for surgical intervention.

Symptomatic shoulder instability due to lesions of the glenoid labrum.

Lesions of the glenoid labrum can be associated with and cause shoulder instability and symptomatology by (1) allowing the shoulder to dislocate recurrently (anatomical instability); (2) allowing the shoulder to subluxate (anatomical instability); and (3) allowing the shoulder to click, catch, and lock secondary to partially attached fragments becoming interposed between the articular surfaces (functional instability). The latter two clinical entities are usually associated with "lesser" labral damage and diagnosis can be difficult. Six illustrative cases are presented and salient diagnostic and therapeutic points are discussed. The glenohumeral axillary arthrotomogram is presented as a sensitive diagnostic test for detecting labral lesions.

Acute osteomyelitis: advantage of white cell scans in early detection.

Acute osteomyelitis was induced in 18 rabbits after direct injection of a solution of Staphylococcus aureus culture into a proximal tibial metaphysis. Serial plain radiographs and radionuclide studies with indium-111 oxide labeled while blood cells and technetium-99m methylene diphosphonate were performed over the next 4 weeks. Visual and quantitative analysis by measuring the isotope activity of 111In and 99mTc over the infected tibias as compared with the opposite bones revealed that the white blood cell scans were positive in 15 (83%) of the 18 rabbits during the first week after injection of the microorganism. During the same period, the 99mTc bone scans were positive in only 22% of the animals (p less than 0.005). In the animals that survived, both white blood cell and bone scans were positive during the second week, and thereafter, the bone scans revealed consistently higher activity than was observed with white blood cell scans. Computed tomography performed in six rabbits revealed an increased attenuation coefficient of the medullary cavities in the infected bones of four animals during the first week and of one more during the second week. Plain radiographs became positive after the 12th day. Results indicate that in patients with suspected acute osteomyelitis, white blood cell scans and probably computed tomography can detect the disease earlier than 99mTc bone scans and plain radiographs.

Late hematogenous infection of total joint replacement.

Late deep wound infection secondary to hematogenous spread of bacteria from a distant focus is an infrequent but devastating complication of total joint replacement. Nine patients (ten implants) with documented late hematogenous infection are reported, all of whom demonstrated several characteristic features. The initial operation was free of clinical evidence of infection and a long asymptomatic interval ensued, followed by a definite febrile illness and acute joint pain. The source of the infection often was not recognized until late and prophylactic antibiotics were not given when it was identified. Seven of the ten implants had to be removed. The primary responsibility for the prevention of this devastating complication lies with the surgeon, who must inform each patient of the risk of late hematogenous seeding from infection elsewhere in the body. It is also important to pay special attention to patients who are at particularly high risk, such as those with rheumatoid arthritis or other systemic diseases. A knowledge of the bacterial flora of the various areas of the human body is essential in choosing the appropriate prophylactic antibiotic.

The efficacy of low-dose heparin--warfarin anticoagulation prophylaxis after total hip replacement arthroplasty.

The prime therapeutic objective of prophylactic anticoagulation for patients undergoing total hip replacement is to reduce to a minimum fatalities from pulmonary embolism. Our low-dose heparin-warfarin prophylactic anticoagulation protocol affords significant protection in this regard (one fatal pulmonary embolism in 796 cases) without the use of venography or other objective tests to check for deep venous thrombosis and for all patients including those with venous disease or a history of prior thromboembolic disease. The 13.1% hematoma rate (5.0% late major) is a small, nonlethal, and acceptable price to pay for this protection.