A fracture of the tuberosity is associated with 16% of anterior glenohumeral dislocations. Manipulation of these injuries in the emergency department is safe with less than 1% risk of fracture propagation. However, there is a risk of associated neurological injury, recurrent instability and displacement of the greater tuberosity fragment. The risks and outcomes of these complications have not previously been reported. The purpose of this study was to establish the incidence and outcome of complications associated with this pattern of injury. We reviewed 339 consecutive glenohumeral dislocations with associated greater tuberosity fractures from a prospective trauma database. Documentation and radiographs were studied and the incidence of neurovascular compromise, greater tuberosity fragment migration and intervention and recurrent instability recorded. The mean age was 61 years (range, 18–96) with a female preponderance (140:199 male:female). At presentation 24% (n=78) patients had a nerve injury, with axillary nerve being most common (n=43, 55%). Of those patients with nerve injuries 15 (19%) did not resolve. Greater tuberosity displacement >5mm was observed in 36% (n=123) of patients with 40 undergoing acute surgery, the remainder did not due to comorbidities or patient choice. Persistent displacement after reduction accounted for 60 cases, later displacement within 6 weeks occurred in 63 patients. Recurrent instability occurred in 4 (1%) patients. Patient reported outcomes were poor with average EQ5D being 0.73, QDASH score of 16 and Oxford Shoulder Score of 41. Anterior glenohumeral dislocation with associated greater tuberosity fracture is common with poor long term patient reported outcomes. Our results demonstrate there is a high rate of neurological deficits at presentation with the majority resolving spontaneously. Recurrent instability is rare. Late tuberosity fragment displacement occurs in 18% of patients and regular follow-up for 6 weeks is recommended to detect this

Introduction: The Spaso technique for reduction of glenohumeral dislocation (GHD) has been recently introduced. It is considered to be a simple and successful method. However there are very few series. This study assesses the results obtained after the introduction of this technique in the Emergency Department. Materials and methods: A prospective observational study was carried out in the Emergency Department in the Hospital Clínic of Barcelona from 15 January to 25 of March 2007, when the Spaso technique began to be used. There were 27 glenohumeral dislocations reported in 26 patients. Two cases that had more than one day’s evolution were excluded. The mean age of the patients was 51 years (range 22–80); and there were 14 men and 10 women. In most cases (18 of the 25) analgesic-sedative treatment was administered previously. Success or failure of reduction was recorded as well as all associated complications. Results: The technique was effective in 19 of the 25 cases (76% rate of success). In relapses of gleno humeral dislocation, reduction was achieved in 8 out of 9 cases. The success rate was similar for residents and specialists. No complications were seen. Conclusions: The results achieved allow us to consider the Spaso technique as the safest and most effective method for reduction of anterior glenohumeral dislocation, with success rates similar to those previously described. We consider that it is simple to learn and that it is one more technique to add to the resources available to the trauma specialist in the Emergency Department

Glenohumeral dislocation is complicated with a greater tuberosity fracture in 16% of cases. Debate regarding the safety of closed reduction in the emergency department exists, with concerns over fracture propagation during the reduction manoeuvre. The study aim was to report the results of closed reduction, identify complications and define outcome for these injuries. 188 consecutive glenohumeral dislocations with a tuberosity fracture were identified from a prospective database from 2014–2017. 182 had an attempted closed reduction under appropriate sedation using standard techniques, five were manipulated in theatre due to contra-indications to sedation. Clinical, radiographic and patient reported outcomes, in the form of the QuickDASH and Oxford Shoulder Score (OSS), were collected. A closed reduction in the emergency department was successful in 162 (86%) patients. Two iatrogenic fractures of the proximal humerus occurred, one in the emergency department and one in theatre, representing a 1% risk. 35 (19%) of patients presented with a nerve lesion due to dislocation. Surgery was performed in 19 (10%) cases for persistent or early displacement (< 2 weeks) of the greater tuberosity fragment. Surgery resulted in QuickDASH and OSS scores comparable to those patients in whom the tuberosity healed spontaneously in an anatomical position (p=0.13). 18 patients developed adhesive capsulitis (10%). Glenohumeral dislocation with greater tuberosity fracture can be safely treated by closed reduction within the emergency department with a low risk of humeral neck fracture. Persistent or early displacement of the tuberosity fragment will occur in 10% of cases and is an indication for surgery

The patterns of nerve and associated skeletal injury were reviewed in 84 patients referred to the brachial plexus service who had damage predominantly to the infraclavicular brachial plexus and its branches. Patients fell into four categories: 1. Anterior glenohumeral dislocation (46 cases); 2. ‘Occult’ shoulder dislocation or scapular fracture (17 cases); 3. Humeral neck fracture (11 cases); 4. Arm hyperextension (9 cases). The axillary (38/46) and ulnar (36/46) nerves were most commonly injured as a result of glenohumeral dislocation. The axillary nerve was ruptured in only 2 patients who had suffered high energy trauma. Ulnar nerve recovery was often incomplete. ‘Occult’ dislocation refers to patients who had no recorded shoulder dislocation but the history was suggestive that dislocation had occurred with spontaneous reduction. These patients and those with scapular fractures had a similar pattern of nerve involvement to those with known dislocation, but the axillary nerve was ruptured in 11 of 17 cases. In cases of humeral neck fracture, nerve injury resulted from medial displacement of the humeral shaft. Surgery was performed in 7 cases to reduce and fix the fracture. Arm hyperextension cases were characterised by injury to the musculocutaneous nerve, with the nerve being ruptured in 8 of 9. Five had humeral shaft fracture or elbow dislocation. There was variable involvement of the median and radial nerves, with the ulnar nerve being least affected. Most cases of infraclavicular brachial plexus injury associated with shoulder dislocation can be managed without operation. Early nerve exploration and repair should be considered for:. Axillary nerve palsy without recorded shoulder dislocation or in association with fracture of the scapula. Musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is necessary for nerve injury resulting from fracture of the humeral neck to relieve ongoing pressure on the nerves

The aim of the study was to prospectively review the incidence of shoulder injuries in a group of professional rugby union players and to identify any relationship between the injury and the causes, position of play, treatment and time to return to playing. An electronic database system was developed specifically to identify the objectives listed above with a view of reducing injury incidence and recurrence through identification of trends. The system was implemented in both Cardiff(2000–2003) and Llanelli(2005–2007) Rugby Football clubs. Extensive prospective data was collected by the team physiotherapists including: Type of injury(Orchard Coding), playing position, session, mechanism of injury and days lost per injury. Shoulder injuries represented 14% of all injuries sustained. Soft tissue injuries account for about 50% of the injuries and result in an average loss of five playing days. AC joint injuries ( 26%) with a recovery period of 5 days were all treated conservatively. Glenohumeral dislocations caused an average loss of 150 days and all required surgery. Fractures around the shoulder were rare with an incidence of 4%. The most common mechanism for shoulder injury was the tackle (43%). Collisions accounted for 15% of injuries whereas weight training was responsible for 31%. Contact situation training was as risky as real game situations. Back row players were more likely to sustain AC joint injuries. Surgical intervention was needed in only 11% of all shoulder injuries. Our data has shown that most shoulder injuries were from contact related areas. Physiotherapy played a key role in the rehabilitation of these players with surgery only indicated in glenohumeral dislocations and fractures. Careful planning of training sessions with emphasis on tackling and weight lifting techniques may reduce the incidence of such injuries

PURPOSE. To validate the efficacy and accuracy of a novel patient specific guide (PSG) and instrumentation system that enables minimally invasive (MI) short stemmed total shoulder arthroplasty (TSA). MATERIALS AND METHODS. Using Amirthanayagam et al.'s (2017) MI posterior approach reduces incision size and eliminates subscapular transection; however, it precludes glenohumeral dislocation and the use of traditional PSGs and instruments. Therefore, we developed a PSG that guides trans-glenohumeral drilling which simultaneously creates a humeral guide tunnel/working channel and glenoid guide hole by locking the bones together in a pre-operatively planned pose and drilling using a c-shaped drill guide (Figure 1). To implant an Affinis Short TSA system (Mathys GmbH), novel MI instruments were developed (Figure 2) for: humeral head resection, glenoid reaming, glenoid peg hole drilling, impaction of cruciform shaped humeral bone compactors, and impaction of a short humeral stem and ceramic head. The full MI procedure and instrument system was evaluated in six cadaveric shoulders with osteoarthritis. Accuracy was assessed throughout the procedure: 1) PSG physical registration accuracy, 2) guide hole accuracy, 3) implant placement accuracy. These conditions were assessed using an Optotrak Certus tracking camera (NDI, Waterloo, CA) with comparisons made to the pre-operative plan using a registration process (Besl and McKay, 1992). RESULTS. 3D translational accuracy of PSG physical registration was: humeral PSG- 2.2 ± 1.1 mm and scapula PSG- 2.5 ± 0.7 mm. The humeral and scapular guide holes had angular accuracies of 6.4 ± 3.2° and 8.1 ± 5.1°, respectively; while the guide hole positional accuracies on the articular surfaces (which will control bone preparation translational accuracy) were 2.9 ± 1.2 mm and 2.8 ± 1.3 mm. Final implantation accuracy in translation was 2.9 ± 3.0 mm and 5.7–6.8 ± 2.2–4.0° across the implants’ three rotations for the humerus and in translation was 2.8 ± 1.5 mm and 2.3–4.3 ± 2.2–4.4° across the implants’ three rotations for the scapula (Figure 3). DISCUSSION. The overall implantation accuracy was similar to results of previously reported open, unassisted TSA (3.4 mm & 7–12°, Hendel et al., 2012, Nguyen et al., 2009). Analysis of the positional PSG registration accuracy very closely mirrors the final implantation accuracy (humerus:2.2 mm vs 2.9 mm, and scapula:2.2 mm vs 2.8mm), thus, this is likely the primary predictor of implantation accuracy. Furthermore, the greatest component of PSG registration error was mediolateral translation (i.e. along the guiding axis) and thus should not affect guide hole drilling accuracy. The drilled guide hole positional and angular error was low for the humerus (2.9 mm and 6.4°) but somewhat higher in rotation (8.1°) for the glenoid which may indicate a slight shift in the PSG prior to guide hole drilling due to the weight of the arm applied when the PSGs are locked together. In conclusion, this work has detailed the step-by-step surgical errors associated with the developed system and demonstrated that it achieves similar accuracy to open, unassisted TSA, while avoiding complications related to muscular transection and dislocation. Therefore, we believe this technique is worthy of clinical investigation

The natural history of primary anterior glenohumeral dislocation in adolescent patients remains unclear and no consensus exists for management of these patients. The study objectives were to report the natural history following primary anterior glenohumeral joint dislocation in adolescent patients and to identify risk factors for repeat dislocation. We reviewed prospectively-collected clinical and radiological data of 133 adolescent patients (mean age 16.3 years (range 13–18); 115 male patients (86.5%)) diagnosed with primary anterior glenohumeral joint dislocation and managed nonoperatively from 1996 to 2008 at our institution (mean follow-up 95.2 months (range 1–215)). During follow-up, 102 (absolute incidence of 76.7%) patients experienced repeat dislocation. Median time interval between primary and repeat dislocation was 10 months (CI: 7.4 – 12.6). On survival analysis, 59% (CI: 51.2 – 66.8%) of patients remained stable one year following initial injury, 38% (CI: 30.2 – 45.8%) after two years, 21% (CI: 13.2- 28.8%) after five years, and 7% (CI: 1.1–12.9%) after 10 years. Neither age nor gender significantly predicted repeat dislocation during follow-up. In conclusion, adolescent patients with primary anterior glenohumeral joint dislocations have a high rate of repeat dislocation, which usually occurs within two years of initial injury, and these patients should be considered early for operative stabilisation

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Purpose of the study: The purpose of this presentation was to focus on the situation where rotator cuff tears are associated with nerve injury and to clarify the clinical nosology of the shoulder triad (glenohumeral dislocation, acute cuff tear, and circumflex nerve injury) and of the «dead shoulder syndrome» (chronic massive cuff tear, acute glenohumeral dislocation, and circumflex nerve injury). Material and methods: This series included seven patients with the shoulder triad and five patients with dead shoulder syndrome who were treated in our department between 1996 and 2002. There were nine men and three women, aged 50–74 years (mean 58 years). Follow-up was two years or more. The Neer and Cofield classification was used to assess functional outcome and the simple shoulder test (SST) was recorded. Results: For the patients with the shoulder triad, outcome was excellent to satisfactory in all, with frontal and vertical elevation greater than 90°, nearly normal rotations, and acceptable force and range of motion for daily, occupational and sports activities. The patients with dead shoulder syndrome were a more heterogeneous population. Clinical outcome was less satisfactory although there was a real improvement in range of motion. Occasional pain was reported and some of the patients were satisfied. Conclusion: Combined lesions of the shoulder create a difficult diagnostic and therapeutic situation. As when occurring alone, it is important to recognize injury early in order to adapt treatment to achieve functional improvement

The axillary nerve injuries most commonly are observed after trauma such as contusion-stretch, gunshot wound, laceration and iatrogenic injuries. Two of the most commons causes seem to be the glenohumeral dislocation and the proximal humerus fractures. The axillary nerve may sustain a simple contusion, or its terminal elements may be avulsed from the deltoid muscle. Compressive neuropathy in the quadrilateral space also has been reported (quadrilateral space syndrome, Calhill and Palmer, 1983). The axillary nerve injuries incidence represents less than 1% of all nerve injuries. Aim: The purpose of this study was to analyze outcome in patients, who presented with injuries to the axillary nerve. Material and methods: We report a series of 15 cases of axillary nerve lesions, which were operated between 1995 and 2002. These injuries resulted from shoulder injury either with or without fracture and or dislocation. Patients were operated between 3 to 6 months after trauma and an anterior deltopectoral approach was usually followed during surgery. The follow up period ranged from 1 to 8 years. Results: The results were considered as satisfactory in 11 out of 15 axillary nerve lesions. According to clinical examination, of the function of the shoulder and the muscle strength the results were classified as excellent in 5 cases, good in 6 cases and poor in 4 cases. Conclusions: If indicated, nerve repair can lead to useful function in carefully selected patients

Background. Acute anterior dislocation of the glenohumeral joint may be complicated by injury to neighboring structures. These injuries are best considered a spectrum of injury ranging from an isolated dislocation (unifocal injury), through injuries associated with either nerve or osteoligamentous injury (bifocal injury), to injuries where there is evidence of both nerve and osteoligamentous injury. The latter combination has previously been described as the “terrible triad,” although we prefer the term “trifocal,” recognizing that this is the more severe end of an injury spectrum and avoiding confusion with the terrible triad of the elbow. We evaluated the prevalence and risk factors for nerve and osteoligamentous injuries associated with an acute anterior glenohumeral dislocation in a large consecutive series of patients treated in our Unit. Materials and Methods. 3626 consecutive adults (mean age 48yrs) with primary traumatic anterior shoulder dislocation treated at our unit were included. All patients were interviewed and examined by an orthopaedic trauma surgeon and underwent radiological assessment within a week of injury. Where rotator cuff injury or radiologically-occult greater tuberosity fracture was suspected, urgent ultrasonography was used. Deficits in neurovascular function were assessed clinically, with electrophysiological testing reserved for equivocal cases. Results. Unifocal injuries occurred in 2228 (61.4%) of patients. There was a bimodal distribution in the prevalence of these injuries, with peaks in the 20–29 age cohort (34.4% patients) and after the age of 60 years (23.0% patients). Of the 1120 (30.9%) patients with bifocal dislocations, 920 (82.1%) patients had an associated osteotendinous injury and 200 (17.9%) patients had an associated nerve injury. Trifocal injuries occurred in 278 (7.7%) of cases. In bifocal and trifocal injuries, rotator cuff tears and fractures of the greater tuberosity or glenoid were the most frequent osteotendinous injuries. The axillary nerve was most frequently injured neurological structure. We were unable to elicit any significant statistical differences between bifocal and trifocal injuries with regards to patient demographics. However, when compared with unifocal injuries, bifocal or trifocal injuries were more likely to occur in older, female patients resulting from low energy falls (p<0.05). Conclusions. We present the largest series reporting the epidemiology of injury patterns related to traumatic anterior shoulder dislocation. Increased understanding and awareness of these injuries among clinicians will improve diagnosis and facilitate appropriate treatment