We report on six men and two women (mean age 42.5 years) who had sustained posterior dislocation of the shoulder in motor vehicle accidents (three), falls (two), equestrian accidents (two), cycling accidents (one) and in a fainting spell (one). In four patients, the dislocation was the only injury, but two had humeral shaft fractures, one a humeral neck fracture and the fourth a glenoid and humeral shaft fracture. The mean delay to diagnosis was 14 weeks (2 to 21). In three patients a medical officer, a general practitioner and a radiologist missed the dislocations, but in five orthopaedic surgeons missed them. Four patients had only anteroposterior radiographs of their shoulder taken, one had anteroposterior and lateral scapular views, and three had anteroposterior and lateral radiographs of the humerus. Four patients underwent hemi-arthroplasties and the other four open reduction and McLaughlin procedures. Though rare, posterior dislocations are often missed. Careful examination, especially in the absence of external rotation, can eliminate this. In the presence of a fracture, a dislocation or injury to the joint above and below must be excluded. Anteroposterior and lateral scapular views alone are inadequate in trauma cases and an axillary or modified axillary view should be done. If there is any doubt, CT should be performed.
We retrospectively reviewed 10 children treated for tuberculosis of the elbow over a 21-year period from 1979 to 1999. The mean age at diagnosis was 5.5 years (1 to 11). The median duration of symptoms was 10 weeks (l week to 18 months). The patients presented mainly with swelling of the elbow joint due to synovitis. Radiological appearances of the elbow at presentation were assessed according to Kerri and Martini’s classification. One elbow was stage I (osteopoenia), eight were stage II (osteopoenia and erosions) and one stage III (joint space narrowing). Open biopsy was performed on all patients. There was positive histology (caseating granuloma) and/or positive culture in eight patients. Of the two patients with non-specific histology and negative culture, one was found on chest radiograph to have tuberculosis involvement and the other healed on anti-tuberculosis therapy. All patients were treated with rifampicin, isoniazide and pyrazinamide for nine months. No synovectomy was done. Postoperatively all patients were immobilised in a backslab and then actively mobilised. At a mean follow-up of three years (1 to 10), patients were assessed according to a modification of Kerri and Martini’s classification. Seven of the eight stage-I or stage-II patients had an excellent result (full range of movement) or good result (loss of less than 30% of range of movement). One stage-II patient had a fair result (loss of range of movement of 30% to 50%). The stage-III patient had a poor result (loss of more than 50% of range of movement). We concluded that elbows with stage-I and stage-II disease (synovitis) have a good outcome. Anti-tuberculosis chemotherapy is effective in the treatment of stage-I and stage II disease. Synovectomy is unnecessary.
Of 44 patients (55 hips) with slipped upper femoral epiphysis treated from 1963 to 1989, 13 (14 hips) developed chondrolysis. Eight hips had chondrolysis at the time of presentation, all in female patients who were either coloured or black and who had moderate or severe slips. The other six hips had persistent pin penetration of the joint; in five of these the pin penetrated the anterosuperior quadrant of the head. Removal of penetrating pins resulted in improvement in pain in all six hips and in the range of movement in four. Chondrolysis did not develop in any of 11 hips with transient intraoperative pin penetration. In hips with chondrolysis maximum joint-space narrowing developed within the first year; improvement in joint space and range of movement continued for up to three years after maximal involvement. At an average follow-up of 13.3 years no patient had pain but five hips were stiff.
