Open MR imaging of the unstable shoulder in the apprehension test position: description and evaluation of an alternative MR examination position.

The aim of this study was to describe and evaluate an alternative MR assessment procedure for analysis of unstable shoulders. Twelve patients with unilateral recurrent anterior shoulder dislocation had both shoulders examined. Magnetic resonance imaging was performed with an open-MR system in the apprehension position with the shoulder in 90 degrees of abduction and maximum tolerable external rotation. Contrast enhancement was achieved with intravenous gadolinium. Correlations were made to the findings at operation. In 10 of 12 unstable shoulders the inferior glenohumeral ligament labral complex (IGHLLC) was detached from the glenoid as seen on MR and later verified during surgery. In one shoulder MR was unable to show a capsulolabral detachment that was verified at surgery, whereas in one shoulder both MR and surgical assessment revealed no soft tissue detachment (accuracy 92 %). A Hill-Sachs lesion was visualized and verified in all unstable shoulders, whereas the stable controls revealed normal IGHLLC and no Hill-Sachs lesion. Open-MRI evaluation of the shoulder in the apprehension test position may become a useful tool for the evaluation of anterior shoulder instability.

Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients.

The purpose of this retrospective study was to assess the clinical and radiographical results of non-operative treatment of displaced multifragmental fractures of the proximal humerus with a minimum follow-up of 10 years. Fifteen patients (one man, 14 women) with 17 injured shoulders were examined. The Neer classification system was used to classify the fractures, and the functional outcome was assessed using the Constant score. At the 10 year review, the mean Constant score for the patients in the three-part fracture group was 59, and 47 in the four-part fracture group. The range of motion was satisfactory with a mean flexion and abduction over 90 degrees. Only four patients reported pain and it was graded as mild. In spite of low functional scoring and poor fracture reduction in many shoulders, the patient's contentment with their injured shoulder after 10 years with high. Radiographical examination revealed severe osteoarthrosis in one shoulder, and humeral head osteonecrosis in two shoulders. Results from this study suggests that non-operative treatment of displaced three-part fractures of the proximal humerus should be considered.

Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus.

We reviewed 27 patients who had sustained displaced three- or four-part fractures of the proximal humerus and who were treated with a humeral hemiarthroplasty. Seventeen patients had a three-part fracture, and 10 had a four-part fracture. The mean follow-up period was 39 months (12 to 94 months). All fractures were classified according to Neer's classification. The Constant score was used for their follow-up evaluation. The median Constant score at follow-up was 51 for the three-part fractures and 46 for the four-part fractures. The median range of movement for all the patients in flexion was 70 degrees, abduction 70 degrees, internal rotation 50 degrees, and external rotation 45 degrees. Nine patients still had moderate or severe pain. Eight patients had moderate or severe disability. Our results were disappointing, and further studies on open reduction and fixation are therefore justified.

Joint fluid enhancement at MRI of the glenohumeral joint with intravenous injection of gadodiamide in standard and triple dose: a prospective comparative study of stable and unstable shoulders.

OBJECTIVE: To investigate the joint fluid enhancement at MRI of unstable and stable glenohumeral joints after intravenous administration of different doses of gadodiamide. DESIGN AND PATIENTS: Fourteen patients with unilateral anterior shoulder instability and six healthy controls had both shoulders examined on two occasions using either a standard dose (0.1 mmol/kg) or a triple dose (0.3 mmol/kg) of gadodiamide in an open MRI magnet (0.2 T). RESULTS AND CONCLUSIONS: The joint fluid enhancement in the unstable shoulders was on average 134% following the lower dose and 182% for the triple dose, whereas corresponding values in the stable shoulder in the same individuals were 69% and 142%, and (65% and 159%) in the healthy controls. Enhancement of the joint fluid was higher after the triple dose than after the standard dose in both the unstable shoulders (P < 0.0001) and the controls (P < 0.0005). Compared with the stable controls enhancement in the unstable shoulders was higher for the lower dose (P < 0.0001) while there was no significant difference between the groups following the higher dose. The improved enhancement following the higher dose was especially evident in stable shoulders, while the lower dose was found satisfactory for unstable shoulders.

Treatment of displaced proximal humeral fractures in elderly patients.

We randomised 40 elderly patients of mean age 74 years with displaced three- or four-part fractures of the humerus to either conservative treatment or tension-band osteosynthesis. At one year and after three to five years, clinical follow-up showed no functional differences between the two groups of patients, with optimal function achieved within one year. There were major complications only in the surgically-treated group. Radiological review showed that surgery had improved the position of the fractured humeral head, but this was not reflected in improved function. Semi-rigid fixation with tension-band wiring of displaced multifragment fractures of the proximal humerus in the elderly did not improve the functional outcome when compared with conservative treatment.

Shoulder function after displaced fractures of the proximal humerus.

It is difficult to predict the outcome of comminuted fractures of the proximal humerus and give guidelines for optimal treatment. Different treatment modalities are available, and there are various scoring systems for postoperative evaluation. The aim of this study was to assess the functional outcome after three- and four-part fractures of the humeral head in 38 patients, with a 3-year follow-up. Twenty-eight patients were treated conservatively, seven were operated on with open reduction and internal fixation, and three received a hemiarthroplasty. All patients were examined clinically and radiographically. Neer and Constant scoring systems were used. The functional outcome after three-part fractures was generally good. Twenty-five of 26 patients with a three-part fracture could accept their shoulder situation. Range of motion was significantly lower in the four-part fracture group. Mean flexion was 89 degrees compared with 120 degrees in the three-part fracture group. Necrosis of the humeral head was found in 2 cases, both four-part fractures. Osteoarthrosis developed in 13 cases (6 with a three-part fracture, 7 with a four-part fracture). No disability was found in 16 of 24 patients with three-part fractures, and in 4 of 11 patients with four-part fractures. There was strong agreement between the Constant score and the patients' opinions.

Nail versus screw fixation of femoral neck fractures. A 2-year radiological and clinical prospective study.

137 recent femoral neck fractures were randomly allocated in a prospective study to internal fixation with either Nyström nails or Scand screws. A radiological and clinical follow-up was conducted of all survivors one and two years postoperatively. Reduction was unsatisfactory in 15 of 87 patients included in the two-year follow-up study. 13 of them developed complications. The 44 Nyström-nailed fractures included in the two-year follow-up showed sliding of the nail in 22 cases, redisplacement/nonunion in 14, and late segmental collapse in 5. The results of clinical examination were excellent or good in 30 patients and fair or poor in 14. Among the 43 Scand-screwed fractures sliding of the screw occurred in 1 case, redisplacement/nonunion in 14, and late segmental collapse in 4. In 35 patients the result was graded as excellent or good and in 8 as fair or poor. No statistical difference between the groups was found with respect to the incidence of redisplacement, nonunion and late segmental collapse, nor with respect to the results of the clinical assessment at the one-year and two-year follow-up. There was a considerably higher incidence of extrusion of the internal fixation device among the nailed fractures than those treated with screws. The results indicate that Scand screws are a better alternative to Nyström nails in the treatment of femoral neck fractures. If an adequate reduction cannot be achieved, primary hip replacement is recommended.