The management of skeletal metastases can be challenging for the orthopaedic surgeon. They represent a significant source of pain and disability for cancer patients, adding to the morbidity of their condition. Treatment is directed at the alleviation of symptoms and the restoration of function. Metastatic involvement of the proximal humerus can be especially debilitating, having the potential to cause severe pain which leads to loss of function, and may also be complicated by pathological fracture and hence attenuate upper limb function. We present a report of four cases where the use of reverse geometry proximal shoulder prostheses has provided excellent symptomatic relief and a pain free functional range of movement in metastatic proximal humerus disease.

To demonstrate a novel, effective surgical strategy for the management of proximal humeral metastatic disease in elderly patients with concomitant poor rotator cuff function, a review of the medical records and radiographic imaging who underwent reverse geometry shoulder replacement for metastatic disease of the proximal humerus was performed. Two cases were secondary to breast cancer, the other two of unknown primary. All four patients were referred with severe shoulder pain significantly limiting range of movement, in one case pathological fracture was demonstrated.

In all cases significant symptomatic relief was achieved in the post operative phase, signified by a marked reduction in analgesic requirements. Two patients were completely pain-free at follow up, whilst the remaining two used only minimal oral analgesia. Upper limb function was preserved in all cases, with demonstration of a satisfactory range of motion adequate for activities of daily living in all patients. No surgical complications were noted.

The use of reverse geometry shoulder prostheses in proximal humeral metastases (either with or without an associated proximal humeral fracture) demonstrates a reliable and effective method of pain relief with excellent restoration of upper limb function. The unique implant geometry allows the patient to achieve a functional range of motion without reliance on the rotator cuff musculature, which is often defunct in elderly patient groups.

In previously published work, MR arthrogram (MRA) has sensitivities and specificities of 88–100% and 89–93% respectively in detection of glenoid labrum tears. Our practice suggested higher frequency of falsely negative reports. We aimed to assess accuracy of this costly modality in practice.

We retrospectively reviewed MRA reports of 90 consecutive patients with clinical shoulder instability who had undergone arthroscopy. All had history of traumatic anterior dislocation and had positive anterior apprehension tests. All underwent stabilisation during the same procedure. We compared the findings, using arthoscopy as gold standard in identification of glenoid labral tears.

83/90 patients had glenoid labrum tears at arthroscopy. Only 54 were correctly identified at MRA. All normal labra were identified. This gave sensitivity of 65% and specificity of 100% in identification of all types of glenoid labrum tear. The majority had anterior glenoid labral tears, which were detected at an even lower rate of sensitivity (58%).

Sensitivity of MRA in this series is significantly lower than previously published. This study highlights the importance of an accurate history and clinical examination by specialist shoulder surgeons in the management of glenohumeral instability. The need for this costly investigation may not be as high as is currently the case.

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty.

It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable.