The traditional treatment for a primary anterior shoulder dislocation has been immobilisation in a sling with the arm in adduction and internal rotation. The recurrence rates after the initial traumatic event range from 20% to 94%. However, recent results have suggested that recurrent instability after primary shoulder dislocation may be reduced with immobilisation in external rotation. Since then, controversy exists regarding the position of immobilisation following these injuries. The objective of the present study was to compare immobilisation in internal and external rotation after a primary anterior shoulder dislocation. Fifty patients presenting to our fracture clinic with a primary traumatic anterior dislocation of the shoulder were randomly assigned to treatment with immobilisation in either internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. In addition of a two-years clinical follow-up, patients underwent a magnetic resonance imaging (MRI) of the shoulder with intra-articular contrast within four days following the traumatic event, and then at three months of follow-up. The primary outcome was a recurrent dislocation within 24 months of follow-up. The secondary outcome was the healing rate of the labral lesion seen on MRI (if present) within each immobilisation group. The follow-up rate after two years was 92% (23 of 25) in the IR group and 96% (24 of 25) in the ER group. The recurrence rate in the IR group (11 of 23; 47.8%) was higher than that in the ER group (7 of 24; 29.2%) but the difference did not reach statistical significance (p=0.188). However, in the subgroup of patients aged 20–40 years, the recurrence rate was significantly lower in the ER group (3 of 17; 6.4%) than that in the IR group (9 of 18; 50%, p<0,01). In the subgroup of patients with a labral lesion present on the initial MRI, the healing rate of the lesion was 46.2% (6 of 13) in the IR group and 60% (6 of 10) in the ER group (p=0.680). Overall, the recurrence rate among those who showed healing of the labrum (regardless of the immobilisation group) was 8.3% (1 of 12), but patients who did not healed their labrum had a recurrence rate of 45.5% (5 of 11; p=0.069). This study suggests that immobilisation in ER reduces the risk of recurrence after a primary anterior shoulder dislocation in patients aged between 20 and 40 years. At two years follow-up, the recurrence rate is lower in patients who demonstrated a healed labrum at three months, regardless of the position of immobilisation. Future studies are required in order to identify factors that can improve healing of the damaged labrum following a traumatic dislocation of the shoulder

Aims. To discover how the management of traumatic anterior shoulder dislocation in the young patient (17-25) has changed, if at all, over the past six years. Methods. The same postal questionnaire was sent in 2002 and 2009 to 164 shoulder surgeons. Questions were asked about initial reduction, investigation undertaken, timing of surgery, preferred stabilisation procedure, period of immobilisation and rehabilitation programme instigated in first-time and recurrent traumatic dislocators. Summary of Results. Response rate - 92% (2009), 83% (2002). The most likely management of a young traumatic shoulder dislocation:. Reduction under sedation in A&E by A&E doctor (80%). Apart from X-ray, no investigations are performed (80%). Immobilisation for 3 weeks, followed by physiotherapy (82%). 68% would consider stabilisation surgery for first time dislocators (especially professional sportsmen) compared to 35% (2002). Of them, nearly 90% would perform an arthroscopic stabilisation vs. 57.5% (2002). For recurrent dislocators:. 75% would consider stabilisation after a second dislocation. 85% would investigate prior to surgery, choice of investigation being MR arthrogram (52%), compared to 50% (2002). 77% would perform arthroscopic stabilisation vs. 18% (2002), commonest procedure-arthroscopic Bankart repair using biodegradable bone anchors (62% 2009 vs. 27% in 2002). Immobilisation for 3 weeks, full range of motion 1-2 months and return to contact sports 6 - 12 months. Conclusion. There has been a remarkable change in practice compared to the previous survey. A significant proportion of Orthopaedic Surgeons would consider stabilisation in young first-time dislocators instead of conservative management. Arthroscopic stabilisation is now the preferred technique compared to open stabilisation whenever possible. Surgeons are using more investigations prior to listing the patient for surgery, namely the MR arthrogram. There is also an increased use of bio-degradable anchors as compared to metallic bone anchors in 2002

Hypothesis. Recurrent shoulder dislocation is associated with bony defect of the glenoid rim, commonly seen along with bankart tear - a soft tissue injury of glenoid labrum. This cadaveric study compares the bone block effect of coracoid transfer using using two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet. We hypothesized that the force needed to dislocate the shoulder would be greater in Congruent Arc technique than the Classical Latarjet, because of increased contact surface area as a result of greater linear dimensions. Material and methods. We dissected 14 cadaveric shoulders. A bony Bankart lesion was created in form of an inverted pear glenoid. The humeral head was attached to a pulley system that was sequentially loaded until the shoulder dislocated anteriorly. The force needed to dislocate was noted. This was repeated after coracoid transfer with two common techniques, Classical Latarjet technique and the Congruent-Arc Latarjet. Results. The mean force required to dislocate shoulder post-Classical Latarjet technique was 325.71N, compared to 123.57 N in uncorrected shoulder. Similarly, the mean force required to dislocate shoulder post Congruent-Arc Latarjet technique was 327.14 N compared to 123.57 N in uncorrected shoulder. The two-tailed P value in either case was less than 0.0001, thus statistically significant. Unpaired t-test was done to compare the force required to dislocate the shoulder post procedure. Mean force required to dislocate shoulder post-Classical Latarjet, was 325.7N compared to 327N in post-Congruent Arc. The two-tailed P value equals 0.9020 and the 95% confidence interval was from −25.05 to 22.19, thus the difference was not statistically significant. Conclusion. The results confirm that both (Classical and Congruent-Arc Latarjet) techniques are good for addressing the shoulder instability, however bone block effect provided by one is not superior to other

Reverse Total shoulder arthroplasty (RTSA) was initially introduced to treat rotator cuff arthropathy. With proven successful long-term outcomes, it has gained a noteworthy surge in popularity with its indications consequently being extended to treating various traumatic glenohumeral diseases. Several countries holding national registries remain a guide to the use the prosthesis, however a notable lack of epidemiological data still exists. More so in South Africa where the spectrum of joint disease related to communicable diseases such as HIV and tuberculosis may influence indications and patient demographics. By analysing the epidemiology of patients who underwent RTSA at our institution, we aimed to outline the local disease spectrum, the patients afflicted and indications for surgery. A retrospective review of all patients operated within the sports unit between 1 January 2019 and 31 December 2022 was conducted. An analysis of the epidemiological data pertaining to patient demographics, diagnosis, indications for surgery and complications were recorded. Included in the review were 58 patients who underwent primary RTSA over the 4-year period. There were 41 females and 17 male patients, age <55 years (n= 14) >55 years (n=44). The indications included 23 rotator cuff arthropathy (40%), 12 primary glenohumeral osteoarthritis (OA) (20%), 10 avascular necrosis (AVN) humeral head (17%), 7 inflammatory OA (12%), 4 chronic shoulder dislocation (7%) and 2 sequalae of proximal humerus fractures (4%). The study revealed RTSA being performed in patients older than 55 years of age, the main pathologies included rotator cuff arthropathy and primary OA, however AVN and shoulder dislocations secondary to trauma contributed significantly to the total tally of surgeries undertaken. This highlights the disease burden of developing countries contributing to patients presenting for RTSA

Acromial morphology has been implicated as a risk factor for unidirectional posterior shoulder instability. Studies utilising plain film radiographic landmarks have identified an increased risk of posterior shoulder dislocation in patients with higher acromion positioning. The aims of this study were to develop a reproducible method of measuring this relationship on cross sectional imaging and to evaluate acromial morphology in patients with and without unidirectional posterior shoulder instability. We analysed 24 patients with unidirectional posterior instability. These were sex and age matched with 61 patients with unidirectional anterior instability, as well as a control group of 76 patients with no instability. Sagittal T1 weighted MRI sequences were used to measure posterior acromial height relative to the scapular body axis (SBA) and long head of triceps insertion axis (LTI). Two observers measured each method for inter-observer reliability, and the intraclass correlation coefficient (ICC) calculated. LTI method showed good inter-observer reliability with an ICC of 0.79. The SBA method was not reproducible due suboptimal MRI sequences. Mean posterior acromial height was significantly greater in the posterior instability group (14.2mm) compared to the anterior instability group (7.7mm, p=0.0002) as well when compared with the control group (7.0mm, p<0.0001). A threshold of 7.5mm demonstrated a significant increase in the incidence of posterior shoulder instability (RR = 9.4). We conclude that increased posterior acromial height is significantly associated with posterior shoulder instability. This suggests that the acromion has a role as an osseous restraint to posterior shoulder instability

Traditionally, sports Injuries have been sub-optimally managed through Emergency Departments (ED) in the public health system due to a lack of adequate referral processes. Fractures are ruled out through plain radiographs followed by a reactive process involving patient initiated further follow up and investigation. Consequently, significant soft tissue and chondral injuries can go undiagnosed during periods in which early intervention can significantly affect natural progression. The purpose of this quality improvement project was to assess the efficacy of an innovative Sports Injury Pathway introduced to detect and treat significant soft tissue injuries. A Sports Injury Pathway was introduced at Fiona Stanley Hospital (WA, Australia) in April 2019 as a collaboration between the ED, Physiotherapy and Orthopaedic Departments. ED practitioners were advised to have a low threshold for referral, especially in the presence of a history of a twisting knee injury, shoulder dislocation or any suggestion of a hip tendon injury. All referrals were triaged by the Perth Sports Surgery Fellow with early follow-up in our Sports Trauma Clinics with additional investigations if required. A detailed database of all referrals was maintained, and relevant data was extracted for analysis over the first 3 years of this pathway. 570 patients were included in the final analysis. 54% of injuries occurred while playing sport, with AFL injuries constituting the most common contact-sports injury (13%). Advanced Scope Physiotherapists were the largest source of referrals (60%). A total of 460 MRI scans were eventually ordered comprising 81% of total referrals. Regarding Knee MRIs, 86% identified a significant structural injury with ACL injuries being the most common (33%) followed by isolated meniscal tears (16%) and multi-ligament knee injuries (11%). 95% of Shoulder MRI scans showed significant pathology. 39% of patients required surgical management, and of these 50% were performed within 3 months from injury. The Fiona Stanley Hospital Sports Injury Pathway has demonstrated its clear value in successfully diagnosing and treating an important cohort of patients who present to our Emergency Department. This low threshold/streamlined referral pathway has found that the vast majority of these patients suffer significant structural injuries that may have been otherwise missed, while providing referring practitioners and patients access to prompt imaging and high-quality Orthopaedic sports trauma services. We recommend the implementation of a similar Sports Injury Pathway at all secondary and tertiary Orthopaedic Centres

Background:. A shoulder dislocation is defined as chronic when it has been unreduced for more than one week. Chronic anterior shoulder dislocations are commonly encountered in Kwazulu-Natal for various reasons. Different surgical options exist to treat chronic anterior shoulder dislocations. However the outcome of surgically treated chronic shoulder dislocations has not been favourable in all studies. Methods:. We report on a combined case series of chronic anterior shoulder dislocations previously treated at Edendale Hospital (EDH), Pietermaritzburg and Inkosi Albert Luthuli Central Hospital (IALCH), Durban. Patients were identified retrospectively using departmental databases and their case files were retrieved. Patient demographics, duration of dislocation, mechanism of injury and reason for delayed treatment were recorded. When available, X-rays, CT scans and MRI scans were retrieved to identify associated bony and soft tissue pathology. Surgical outcome was assessed using range of movement (ROM), change in pain severity, patient satisfaction, as well as Oxford Shoulder Instability Score (OIS) and Rowe and Zarins score. Post-operative complications including redislocations were also identified. Results:. Twenty-six patients with chronic anterior shoulder dislocations were surgically treated. The average duration of dislocation was 9 months (range 2 weeks to 7 years). The most common reason for chronicity was delayed presentation to clinic or hospital (9 patients). A Hill Sachs lesion was present in 20 patients, and a pseudo-glenoid was often encountered in dislocations present for more than 4 weeks (14 of 23 patients). Three supraspinatus ruptures and 4 biceps tears were encountered while neurological injury was uncommon (2 patients). Surgical treatment included open reduction (1 patient), open reduction and Latarjet (15 patients), hemi-arthroplasty (2 patients), hemi-arthroplasty and Latarjet (3 patients) and reverse total shoulder arthroplasty (5 patients). Eighteen patients were available for follow-up. Most patients (16 out of 18 patients) were satisfied with their outcome. This was due to improvement in pain. Regardless of the type of surgery done, post-operative range of motion and surgical outcome scores were generally poor. Two patients were unsatisfied, due to redislocations. Conclusion:. Surgical treatment of chronic anterior shoulder dislocations resulted in satisfactory pain relief but marginal improvement in range of motion and overall shoulder function

This study was performed to assess the incidence of generalised ligament laxity in patients presented with recurrent shoulder dislocations. Prospective data was collected for 38 patients with recurrent shoulder dislocations and 43 patients with clavicle fractures as a control group between May 2007 and July 2009, including demographic details, mechanism of injury, number of dislocations and hyperlaxity. Clinical examination was used to assess the ligament laxity using the Beighton score. The mean age was 29 years with a range from 14-40 years. There were 36 males and 2 females. The left shoulder was involved in 21 patients; right in 13 patients and 4 patients had bilateral shoulder dislocations. The average number of dislocations was 3 with a range from 2-17, while the average number of subluxations was 4.5 with a range from 0-35. The average Beighton score for the patients with recurrent shoulder dislocations was 2.8 with a range from 0-8. 17 patients (45%) in this group had a Beighton score of 4 or more as compared to the control group that had only 12 patients (27%) There was a statistically significant difference between the 2 groups with a P value of < 0.05. 8 patients (21%) fulfilled the Brighton criteria for BJHS. The most common cause of recurrent shoulder dislocation was sports related injuries in 26 patients (68%). The most common sport was football in 14 patients (37%) followed by rugby in 10 (26%) patients. We looked at the incidence of generalised ligament laxity in patients with recurrent shoulder dislocations and found a statistically significant difference as compared with the control group. 21% of the patients fulfilled the Brighton criteria for BJHS but 45% had a Beighton score of 4 or more. Appropriate advice should be given to these patients with hyperlaxity and the timing of shoulder stabilisation should be carefully decided

Purpose. Shoulder dislocations account for 50 % of all dislocations, of which 98% are anterior dislocations. Different techniques have been described in literature with variable success, which depends upon type of dislocation, technique used and muscle relaxation. Method. A retrospective review of data of all shoulder dislocations presented to accident and emergency department over a one-year period was undertaken. Over a 1-year period total of 52 patients presented with mean age of 41 years. Closed reduction was attempted in all patients by accident and emergency department using various techniques and combination of analgesia. Unsuccessful reductions and those with associated fractures were referred to orthopaedics department. This group had closed reduction utilising Sahas zero position technique in accident and emergency department. Post reduction all patients had two views of radiograph to confirm reduction and poly-sling for 2–3 weeks. Results. We had 37 (71.1%) males and 15(28.8%) females with shoulder dislocations. In our patients 98% were anterior dislocations and 14 % were dislocations associated with fractures. Of 52 patients 33 (63%) were first time dislocations and 17(33%) had recurrent dislocations In cohort of 52 patients 7(13.4%) had neurological deficit prior to reduction, which was sensory hypoesthesia along the regimental badge area, and 1(2%) had a post reduction neurology using modified Milch technique. Most of our patients 38 (73%) were reduced using various techniques for reducing shoulder dislocation. In these 38 patients analgesia varied from Entonox to combination of Entonox with intravenous morphine with or without diazepam. Our department was referred 14(27%) patients. Seven patients were referred due to failure of reduction where several attempts with different techniques were made and 7 were directly referred due to association of fracture with the dislocations. 14(27 %) of our patients were reduced using zero position of shoulder in first attempt without the need for additional analgesia. Of these 14 patients 7 had complex shoulder dislocation associated with fractures. We had only one failure of reduction using Sahas zero position of shoulder. This patient had recurrent dislocation with large Hill Sachs defect. This was reduced under general anaesthesia using zero position of shoulder as described by Saha. Conclusion. This study demonstrates that zero position of shoulder described by Saha is safe, effective and easy method for reducing both anterior, posterior and fracture dislocations of the shoulder. Given the principles of reduction in zero position no additional analgesia and traction is required. The feedback from patients in regards to discomfort and pain was also positive. We conclude that this data suggests the routine use of Sahas technique in reducing both simple and complex shoulder dislocations

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

Recurrent anterior shoulder instability (RASI) is related to progressive bone loss on the glenoid and on the humeral head. Bone deficit magnitude is a well-recognized predictor of recurrence of instability after an arthroscopic Bankart surgery, but the best way to measure it is unknown. In this study, we want to determine which measurement method is the best predictor of recurrence of instability and function. For 10 years now, all patients undergoing surgery for RASI in 4 centers are included in a prospective study: the LUXE cohort. Patients with a pre-operative CT-scan and a minimum of 1-year follow-up were included. ISIS score was used to stratify patients. WOSI and Quick-Dash questionnaires were used to characterise function. Bone defects were assessed using the Clock method, the Glenoid Ratio, the Humeral Ratio, the Glenoid Track method and the angle of engagement in the axial plane. A total of 262 patients are now included in the LUXE study. One hundred and three patients met the inclusion criteria for analysis with a majority of male (79%) and a mean age is 28 years old. The median number of dislocations prior to surgery was 6. Seventy patients had an arthroscopic Bankart repair and 33 patients underwent an open Latarjet procedure. The ISIS score for these groups were of 2.7 and 4.8 respectively (p<0.001). The mean bone defect on the glenoid was of 1h51 with the Clock method (range: 0h-4h48; SD=1h46) and of 9% for the glenoid ratio (0–37%, 10%). On the humeral side, the bone defect was of 1h59 (0h-4h08; 0h49) for the Humeral clock method, 15% (0–36%; 6%) with the ratio method and 71 degrees of external rotation (SD=30 degrees) with the angle of engagement measurement. On the combined evaluations, 53 patients presented an off-track lesion, with mean combined hours of 3h53 (SD= 2h13). The greatest correlation obtained was between the glenoid ratio and the glenoid clock method (r=0.919, p<0.001). Eighteen patients had a recurrence of shoulder dislocation after the initial surgery, leading to a recurrence rate of 23% in arthroscopic surgery versus six percent after a Latarjet (OR= 4.6, p=0.034). No bone defect was correlated to Latarjet failure. For the arthroscopic group, the risk of recurrence was related to a smaller angle of engagement of the Hill-Sachs (p=0.05), a smaller Humeral clock measurement (p=0.034) and a longer follow-up (p=0.006). No glenoid or combined measurements were correlated with arthroscopic procedure failure. Recurrence of dislocation was associated to worst function according to the WOSI (1036 vs 573, p=0.002) and DASH (32 vs 15, p=0.03). Even with lower ISIS score, arthroscopic procedures are still leading to high risk of recurrence in this “all comer” consecutive cohort study AND it is related to humeral side parameters. Recurrence is also affecting daily function and creating higher anxiety related to the shoulder

The Royal Marines regularly deploy to Norway to conduct Cold Weather, Arctic and Mountain Warfare training. A total of 1200 personnel deployed to Norway in 2010 over a 14-week period. Patients, whose injuries prevented them from continuing training, were returned to the UK via AEROMED. The aim of this investigation was to describe the epidemiology of musculoskeletal injuries during cold weather training. All data on personnel returned to the UK was prospectively collected and basic epidemiology recorded. 53 patients (incidence 44/1,000 personnel) were returned to the UK via AEROMED. 20/53 (38%) of cases were musculoskeletal injuries (incidence 17/1000 personnel). 15/20 musculoskeletal injuries were sustained while conducting ski training (incidence 13/1,000): 4/20 were non-alcohol related injuries, 1/20 was related to alcohol consumption off duty. Injuries sustained whilst skiing: 5/15 sustained anterior shoulders dislocation, 5/15 Grade 1-3 MCL/LCL tears, 2/15 sustained ACJ injuries, 1/15 crush fracture T11/T12, 1/15 tibial plateau fracture and 1/15 significant ankle sprain. Non-Training injuries: 1 anterior shoulder dislocation, 1 distal radial fracture, 1 olecranon fracture, 1 Scaphoid Fracture and one 5th metatarsal fracture. 60% of injuries were upper limb injuries. The most common injury was anterior shoulder dislocation 6/20 (Incidence 5/1000). Our results suggest that cold weather warfare training has a high injury rate requiring evacuation: 4% of all people deployed will require AEROMED evacuation, and 2% have musculoskeletal injuries. Ski training causes the majority of injuries, possibly due to the rapid transition from non-skier to skiing with a bergen and weapon. Military Orthopaedic and rehabilitation units supporting the Royal Marines, should expect sudden increases in referrals when large scale cold weather warfare training is being conducted. Further research is required to see if musculoskeletal injury rates can be decreased in cold weather warfare training

Background. The purpose of this retrospective study was to examine the functional outcomes of patients treated for isolated fracture of the greater tuberosity (GT) and to determine how their outcomes were affected by fracture pattern, treatment choices, associated shoulder injuries, the post fixation displacement of GT fragment and the time delay between injury and fixation. Methods. Forty-eight (28 male and 20 female) patients (mean age 45 years) treated at our institution between 1999–2009 matched our inclusion criteria. Thirty-five patients were treated surgically and 13 conservatively. Functional outcome was assessed using Oxford scores (OS), University of California and Los Angeles (UCLA) rating scale and the shoulder index of the American Shoulder and Elbow surgeons (ASES). The outpatient follow up time required and the presence of other shoulder injuries, time delay to surgery and the time off work were also recorded. Results. Outcome scores for patients who sustained simple vs comminuted fractures were not significantly different (OS = 41.8 vs 41, ASES 23.8 vs 23.4, UCLA 26.6 vs 26.3). Time taken off work was less in those who had a comminuted vs a simple fracture (21 vs 30 weeks). Shoulder dislocation was present in 77% and patients had a significantly worse outcome than those with no dislocation (OS = 40.6 vs 44, ASES 22.9 vs 26). Rotator cuff repair was required in 21% of patients and was also associated with a worse outcome (OS 42.8 vs 36.8, ASES 24.5 vs 20.5). Post fixation displacement of the GT fracture of < 5 mm led to a significantly better outcome than displacement >5mm (OS = 43 vs 37, ASES = 25.6 vs 17.7, UCLA 28.2 vs 21.3). Conclusion. Isolated fractures of the greater tuberosity have a worse outcome if they are associated with shoulder dislocation, rotator cuff tear and post fixation displacement of >5mm

Objective. Shoulder instability is a common cause of morbidity amongst Professional Rugby Union players. This study explores whether the risk of shoulder dislocation is associated with innate shoulder laxity. Methods. A randomised controlled study was completed in which all the Premiership Rugby Clubs in England were visited in 2006. 169 professional rugby players (mean age 25.1 years) with no history of instability in either shoulder were assessed and 46 injured players with one shoulder with a history of Bankart lesion or dislocation (mean age 27.5 years) also took part in this study. Shoulder laxity was measured by dynamic ultrasound. Anterior, posterior and inferior translations were measured in both shoulders for healthy players and the uninjured shoulder only for injured players. Results. No significant difference between the non-dominant (anterior: mean 2.9±1.2mm; posterior: mean 5.1±1.8mm; inferior: mean 3.1±1.0mm) and dominant (anterior: mean 3.1±1.1mm; posterior: mean 4.9±1.6 mm; inferior: mean 2.9±1.0mm) shoulders in healthy players (P>0.05). The comparison between healthy shoulders (anterior: mean 3.0±1.2mm; posterior: mean 5.0±1.7mm; inferior: mean 3.0±1.0mm) from healthy players and the uninjured shoulder (anterior: mean 4.2±1.7mm; posterior: mean 6.2±3.0mm; inferior: mean 3.4±1.2mm) from injured players identified that players with unstable shoulders have a significantly higher shoulder translation in their normal shoulder than healthy players (P<0.05). Conclusion. This is the first study looking at laxity and the risk of shoulder dislocations in sportsmen involved in a high contact sport. These results support the hypothesis that rugby players with ‘lax’ shoulders are more likely to sustain a dislocation or subluxation injury to one of these lax shoulders in their sport even if no symptom is presented

Purpose. The presence of a Hill-Sachs lesion is a major contributor to failure of surgical intervention following anterior shoulder dislocation. The relationship between lesion size, measured on pre-operative MRI, and risk of recurrent instability after surgery has not previously been defined. Hypothesis: We hypothesized that the size of Hill-Sachs lesions on pre-op MRI would be greater among patients who failed soft tissue stabilization when compared to patients who did not fail. We also hypothesized that the existence of a glenoid lesion would lead to failure with smaller Hill-Sachs lesions. Method. Nested case-control analysis of 114 patients was performed to evaluate incidence of failure after soft tissue stabilization. Successful follow-up of at least 24 months was made with 91 patients (80%). Patients with recurrent instability after surgery were compared to randomly selected age and sex matched controls in a 1:1 ratio. Pre-operative sagittal and axial MRI series were analyzed for presence of Hill-Sachs lesions, and maximum edge-to-edge length and depth as well as location of the lesion related to the bicipital groove (axial) and humeral shaft (sagittal) were measured. Results. Of 91 patients included in analysis, 77 (84.6%) had identifiable Hill-Sachs lesions. 32 patients (35.2%) suffered from failure of soft tissue stabilization (redislocation 22.0%; subjective instability 13.2%). Ten of these patients (11.0%) underwent further surgery. When comparing the age and sex matched failure and control groups, statistically significant differences in unadjusted data were found for axial edge-to-edge length (p = 0.01), axial depth (p = 0.01), and sagittal edge-to-edge length (p = 0.04), with larger sized lesions found in the failure group (Figure 1). Differences trended towards significant for sagittal depth and angle from the bicipital groove. Conclusion. In this retrospective case-control study, humeral head defect size was positively correlated with recurrent instability after soft-tissue stabilization. Larger Hill-Sachs lesions, as measured on pre-op MRI, were found in patients who failure surgical intervention when compared to patients who did not fail. These data and future studies may help determine pre-operative clinical guidelines for the treatment of anterior shoulder dislocation

Isolated Greater Tuberosity (GT) fractures were described as separate entities from proximal humeral fractures more than 100 years ago. However, there is limited literature available about the functional outcome of the two different types of GT fractures: avulsed and comminuted. To compare functional outcomes of the 2 different types of Greater Tuberosity fractures; simple and comminuted and to determine how these outcomes were affected by associated injuries such as shoulder dislocation and rotator cuff tear. We also looked at the acceptable post fixation displacement of GT fracture and when to consider it mal-reduction (malunion due to over or under reduction) and the acceptable time frame to delay the fixation and still get satisfactory results. We looked at Greater Tuberosity fractures of the humerus in Waikato Hospital between 1999–2009. Radiographs were reviewed by senior Author to classify them into simple and comminuted. Measurements were done by senior Author for post fixation displacement. Operative notes checked by the authors, when in doubt, double-checked by senior author. Outcome scores used: UCLA, ASES and oxford scores to compare functional outcome. We also measured the time off work and time on ACC (Physiotherapy), as well as period of follow up. A total of 35 patients were included in the final analysis were treated operatively. Mean age of the patients was 51 years. M/F ratio was 3/2. Mechanism of injury was predominantly direct force applied to that shoulder. Shoulder dislocation was found in around 77% of patients. Methods of fixation included tension band wiring with or without screws, rotator cuff repair and one T-plate. Follow up time was shorter for simple comminuted fractures (22 v 44 weeks respectively). Outcome scores for patients who sustained simple fractures were slightly higher than those with comminuted fractures but the difference did not reach statistical significance. The groups with dislocation and rotator cuff tear did worse than the other groups in all aspects of the study. Post fixation displacement of GT of less than 5 mm led to a significantly better outcome than displacement of 5mm plus. Better results were obtained when the time between injury and operation was less than 2 weeks. The comminuted group had similar functional outcome to the other group but required much longer follow up. Worse outcome should be expected with dislocation and rotator cuff tear associated with GT fracture. Satisfactory results relate to degree of displacement post fixation of <5 mm. Delay of fracture fixation of >2 weeks results in a less favourable outcome