Posterior fracture-dislocation of the shoulder. A superior subacromial approach for open reduction.

We describe 11 cases of posterior fracture-dislocation of the shoulder that required open reduction and fixation. Difficulties with access through anterior approaches led us to use the superior subacromial approach. This is an extension of the approach often used to expose the rotator cuff; the joint is opened by splitting the supraspinatus tendon 5 mm behind the cuff interval. The glenoid, proximal humerus and any fracture fragments can be seen from above, allowing reduction of the dislocation and osteosynthesis to be performed with minimal risk of damage to the humeral head and its blood supply. The proximity of the axillary nerve limits the exposure of the proximal humeral shaft. The superior subacromial approach is ideal for posterior dislocation with fracture of the articular segment, but is not suitable when there is a fracture of the proximal humeral shaft.

A classification of acute acromioclavicular dislocation: a clinical, radiological and anatomical study.

Forty-eight patients with acute acromioclavicular dislocation were assessed clinically and radiologically before random allocation to non-operative management (28) or open reduction and coracoclavicular screw fixation (20) and followed for a minimum of 4 years. In 6 patients, late salvage surgery was required, the results of which were inferior to early operative intervention. Early surgery also gave better results than non-operative treatment in severe disruptions which could be identified in the acute stage. Three types of acromioclavicular dislocation which have predictable clinical outcomes could be distinguished on radiographs. When treated non-operatively, type A dislocations (19 per cent) may develop painful subluxation, type B (68 per cent) remain dislocated but retain sufficient muscle attachment to avoid fatigue on activity, and type C (12 per cent) leave a weak and unsightly shoulder. In type C dislocations, the clavicle is displaced 2 cm or more from the acromion on plain anteroposterior radiographs and the attached origin of the anterior deltoid is avulsed. Type C dislocations may benefit from early operative reconstruction.

The management of acute acromioclavicular dislocation. A randomised prospective controlled trial.

In a prospective study, 60 patients with acute acromioclavicular dislocation were randomly allocated to treatment with a broad arm sling or to reduction and fixation with a coracoclavicular screw. Of these 54 were followed for four years. Conservatively-treated patients regained movement significantly more quickly and fully, returned to work and sport earlier and had fewer unsatisfactory results than those having early operation. For severe dislocations, with acromioclavicular displacement of 2 cm or more, early surgery produced better results. Conservative management is best for most acute dislocations, but younger patients with severe displacement may benefit from early reduction and stabilisation.

Supplement feeds and nitrogen and calorie balance following femoral neck fracture.

A 10 day study of nitrogen and calorie balance has been undertaken in 61 women patients aged 65-96 years (mean age 81 years) with femoral neck fractures. All underwent fracture surgery with an inhalation anaesthetic lasting from 45 min to 2 h. Intake of ward food varied widely but was always low with a mean of 127 mg N kg-1 and 17 kcal kg-1 daily. Daily nitrogen production was 85-250 mg N kg-1 (mean 158 mg N kg-1) and calorie expenditure was 17-48 kcal kg-1 (mean 32 kcal kg-1). These were greatest in trochanteric fracture patients. Of the 61 patients, 90 per cent were in negative nitrogen balance with a mean 8 day deficit of 411 mg N kg-1 and all in negative calorie balance, mean 141 kcal kg-1. The deficits were greatest in trochanteric fracture patients. Sip feeding with supplementary enriched drinks raised protein and calorie intake substantially. Both nitrogen and calorie balance were significantly improved, but large calorie deficits remained; intolerance of the supplements proved to be a handicap in correcting the deficits in many patients.

Four-part fractures of the neck of the humerus.

Four-part fractures of the upper end of the humerus are uncommon injuries and there is still dispute about the best form of management. A retrospective study of 32 patients with these injuries has shown that non-operative management is frequently followed by persistent pain, stiffness and dysfunction of the shoulder. A prospective study of 49 patients with this injury presenting at the Bristol Royal Infirmary has shown that reconstruction of the upper end of the humerus with insertion of a Neer prosthesis will usually restore comfort and function. Whichever regimen is employed, disability is prolonged and dedicated physiotherapy is essential in their management.

Injuries of the proximal interphalangeal joint of the fingers.

A consecutive group of ninety-three patients with ninety-six affected joints, have been reviewed retrospectively to provide information regarding the incidence and longer term effects of injuries to the proximal interphalangeal joint of the fingers. The patients have been grouped according to the severity of the injury, judged clinically and radiologically. From this review it would appear that these injuries are somewhat less common than is suggested in the literature. The severity of the trauma would seem to influence the result in that some thirty per cent with dislocation or fracture-dislocation did badly and of these forty-three per cent had open injuries. Some experimental work on fresh cadavers, to investigate the damage to the ligaments in the more common dorsal dislocation, has been included. From our findings, suggestions have been made regarding the treatment of these injuries.

Mefenamic acid and dextropropoxyphene with paracetamol as analgesics in the accident department.

A double-blind study was carried out in 48 patients with soft-tissue injuries to compare the effectiveness of mefenamic acid and dextropropoxyphene plus paracetamol in relieving acute post-injury pain. Patients received capsules containing either 250 mg mefenamic acid or 32.5 mg dextropropoxyphene hydochloride plus 325 mg paracetamol and were instructed to take up to 6 capsules daily as necessary. By the third post-injury day both preparations had controlled pain adequately and lessened local tenderness in most cases. There was no significant difference in response between the two patient groups. Two patients in each group stopped treatment because of gastro-intestinal intolerance, and a further 4 patients in each group reported troublesome side-effects.

Inpatients in an accident unit.

A one-year prospective study was undertaken in the 79-bed accident unit of the Bristol Royal Infirmary to define reasons for continuing inpatient care. This showed that, of a consecutive series of 466 patients staying in hospital for over two weeks, 35% lengthened their stay beyond that needed for acute nursing or continued medical care. A combination of factors usually led to total social dependence, the major problem being the absence of a caring relative. Other factors included pre-existing locomotor disorder or mental infirmity, unmanageable incontinence of urine after catheterisation, and institutional disorientation. If the pattern of management of elderly patients after injury is not changed and beds are to be kept available for the newly injured the unit will need about 50 new long-stay beds each year.