Purpose: Scapulohumeral arthrodesis is principally indicated for plexus brachial paralysis. It is a controversial indication with limited use for non-neurological conditions. We report a series of shoulder arthrodeses performed for non-neurological conditions searching for the appropriate indications for this procedure.

Material and methods: The series included nine patients, six men and three women, mean age 48 years (23–89). The dominant side was fused in three and the non-dominant in six. Seven patients had had at least one operation prior to arthrodesis. The procedure was performed in one patient to remove a foreign body in a prosthetic cuff tendon, in three for off-centred joint degeneration with massive cuff tears and in two for degenerative disease with multidirectional instability. In all patients except one, the posterior approach was used for internal screw fixation associated with external fixation (left in place for 2.5 months on average).

Results: Subjectively, all patients except one were satisfied with the result (mainly because of pain relief). Objectively, active motion was 65° flexion, 65° abduction, 50° internal rotation (mean fusion position 20° flexion, 25° abduction, and 30° internal rotation). Two groups were identified for assessment with the absolute Constant score. The score improved 16 points (24 to 40) in the group without instability (pain score improved from 3 to 13) and decreased 14 points (66 to 52) in patients with instability (attributed to lesser motion, mean motion scores decreasing from 38 to 14). Complications included one case each of radial palsy, non-union, and gravity oedema of the upper limb.

Discussion: Pain relief and stability are not the sole objectives of shoulder arthrodesis. The procedure can also provide useful improvement in function (hand mouth, hand perineum, thoracobrachial clamp. It can be useful if prosthetic arthroplasty cannot be used (infectious arthritis, advanced osteoarthritis in young subjects and failed stabilisation of multidirectional instability). It is a predictable procedure in terms of outcome. We continue to use scapulohumeral arthrodesis for rare indications.

Purpose: Blast injury of the hand generally occurs during manipulations of unstable explosives. The explosion greatly damages the first commissure. The aim of this study was to define a classification system useful for establishing therapeutic strategy.

Material and methods: From 1988 to 2002, we treated eight patients (nine hands, five dominant) with blast injury of the hand. Mean age was 24 years. Five hands were injured during manipulation of firecrackers and four during manipulation of munitions. The thumb was amputated on five hands, including three cases of index or medius amputation. Thumb revascularisation was successful in only one case. Two proximal thumb amputations were treated by twisted toe transfer. For one of these patients, the transfer was prepared by translocation of M2 on M1 using an inguinal flap. Two patients required a composite osteocutaneous reconstruction of M1 using the index as the bone source. In one final patient, lesions were limited to soft tissues.

Discussion: Blast injured hands present several types of lesions: extensive soft tissue damage, diffuse vessel damage making revascularisation difficult or impossible, combined thenar and joint lesions leading to secondary closure of the first commissure. We distinguished three stages. Stage 1 involves only muscle and skin damage. After opening the first commissure with M1-M2 pinning, cover is achieved with a posterior interosseous flap or a skin graft. Stage 2 involves osteoarticular damage. Bone loss of M1 and P1 is often associated with dislocation. Bone reconstruction is often achieved using the distally amputated or greatly damaged thumb. Stage 3 involves amputation or devascularisation of the thumb. Reconstruction of the thumb is particularly difficult in these cases. If the amputation is distal beyond MP, M1 lengthening or classical toe transfer can be used. If the amputation is proximal, prior M1 reconstruction is required with a skin envelope using M2 fashioned with an interosseous or inguinal flap, followed by twisted toe transfer of the second toe. Stage 3 translocations are difficult because of the often damaged index and scar formation.