Shoulder injury related to vaccine administration (SIRVA) is a prolonged episode of shoulder dysfunction that commences within 24 to 48 hours of a vaccination. Symptoms include a combination of shoulder pain, stiffness, and weakness. There has been a recent rapid increase in reported cases of SIRVA within the literature, particularly in adults, and is likely related to the mass vaccination programmes associated with COVID-19 and influenza. The pathophysiology is not certain, but placement of the vaccination in the subdeltoid bursa or other pericapsular tissue has been suggested to result in an inflammatory capsular process. It has been hypothesized that this is associated with a vaccine injection site that is “too high” and predisposes to the development of SIRVA. Nerve conduction studies are routinely normal, but further imaging can reveal deep-deltoid collections, rotator cuff tendinopathy and tears, or subacromial subdeltoid bursitis. However, all of these are common findings within a general asymptomatic population. Medicolegal claims in the UK, based on an incorrect injection site, are unlikely to meet the legal threshold to determine liability. Cite this article: Bone Joint J 2023;105-B(8):839–842

The conservative management if isolated humeral shaft fractures is a long, drawn out, painful process for the patient. For the clinician, it involves multiple clinic attendances and repeated radiographic assessment and brace alteration.

The primary reason for conservative management is the excellent results, but a very definite secondary consideration is the high incidence of shoulder pathology after I.M. nailing. This is thought to be due to rotator cuff pathology at the time of surgery. We question the validity of this second argument.

Ten consecutive humeral shaft fractures attending our unit had an MRI of both shoulders carried out during the initial stages of their injury. Two of the ten had retrograde nailing and the remainder was managed conservatively. While there was no patient with an occult coracoid fracture in association with the shaft fracture. We found eight out of ten to have significant signal changes in the subacromial space on the side of the fracture only.

We conclude that there is a significant occult injury to the shoulder at the time of humeral shaft fracture and this may in fact represent a cause for the high incidence of shoulder pain post fracture.

The August 2023 Shoulder & Elbow Roundup360 looks at: Motor control or strengthening exercises for rotator cuff-related shoulder pain? A multi-arm randomized controlled trial; Does the choice of antibiotic prophylaxis influence reoperation rate in primary shoulder arthroplasty?; Common shoulder injuries in sport: grading the evidence; The use of medial support screw was associated with axillary nerve injury after plate fixation of proximal humeral fracture using a minimally invasive deltoid-splitting approach; MRI predicts outcomes of conservative treatment in patients with lateral epicondylitis; Association between surgeon volume and patient outcomes after elective shoulder arthroplasty; Arthroscopic decompression of calcific tendinitis without cuff repair; Functional outcome after nonoperative management of minimally displaced greater tuberosity fractures and predictors of poorer patient experience

Introduction. Virtual fracture clinics (VFC's) aim to reduce the number of outpatient appointments while improving the clinical effectiveness and patients experience through standardisation of treatment pathways. With 4.6% of ED admissions due to trauma the VFC prevents unnecessary face to face appointments providing a cost savings benefit to the NHS. Methods. This project demonstrates the importance of efficient VFC process in reducing the burden on the fracture clinics. We completed preformed a retrospective cross-sectional study, analysing two cycles in May (n=305) and September (n=332) 2021. We reviewed all VFC referrals during this time assessing the quality of the referral, if they went on to require a face to face follow up and who the referring health care professional was. Following the cycle in May we provided ongoing education to A&E staff before re-auditing in September. Results. Between the two cycles there was an average 19% improvement in quality of the referrals, significant reduction in number of inappropriate referrals for soft tissue knee and shoulder injuries from 15.1% (n=50) to 4.5% (n=15) following our intervention. There was an 8% increase in number of fracture clinic appointments to 74.4% (n=247), primarily due to an increase number of referrals from nurse practitioners. Radial head fractures were targeted as one group that were able to be successfully managed in VFC, despite this 64% (n=27) of patients were still seen in the outpatient department following VFC referral. Conclusion. Despite the decrease in the number of inappropriate referrals, and the increase in quality of referrals following our intervention. The percentage of VFC referrals in CAVUHB is still higher than other centres in with established VFCs in England. This possibly highlights the need for further education to emergency staff around describing what injuries are appropriate for referral, specifically soft tissue injuries and radial head fractures. In order to optimise the VFC process and provide further cost savings benefits while reducing the strain on fracture clinics

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

Although the epidemiology and pathomechanics of shoulder injuries in throwing athletes has been wellstudied, less is known about shoulder injuries in other sports where significant loads are carried by the upper limb. We evaluated 90 professional gymnasts who participated in a regular performance schedule during the millennium celebrations in the calendar year 2000. The gymnasts were divided into Group I (n=60) who were selected and trained for 18 months, and Group II (n=30) who were ‘fast-tracked’ through recruitment and training in the final six months before performance. At the conclusion of the performance year, athletes were assessed using a subjective questionnaire, the SF-12 general health instrument, the Oxford instability questionnaire and the Constant score. They also underwent clinical examination, hypermobility scoring and fatigue testing. Of those surveyed, 46% complained of pain in one or both shoulders, and the majority of these received nonoperative physical therapy during the year and were able to continue performing. Five patients (6%) had refractory pain, demonstrated signs of hypermobility, abnormal joint translation and positive relocation tests, often in the absence of symptomatic instability. All were in Group II, presented in the final six months of performance and required arthroscopic treatment for complex tears involving the anterior and superior labrum, including the biceps anchor. These results indicate that the incidence of shoulder injury is very high among professional aerial gymnasts. The underlying cause is likely to be multifactorial in these hypermobile athletes, but the findings are consistent with the concept of cumulative microtrauma to the capsulolabral complex. Acute-on-chronic injury appears to be associated with complex labral pathology which presents with pain rather than with overt instability. Our observations suggest that training and performance schedules should be carefully monitored, incorporating extended preparation and recovery, in order to reduce the risk of shoulder injury. Further work on kinematics of the shoulder during dynamic loading of the weightbearing upper limb is required

The expansion of arthroscopic treatment to serious and catastrophic injuries to the weightlifters of the Hellenic National Weightlifting Team. The evaluation of the results of this specific arthroscopic treatment. 45 athletes (36 male, 9 female) with shoulder injuries 2000–2009. 15 yrs – 35 yrs, average: 27 yrs. One 3-times Golden Olympic. One Bronze medalist, Two Silver Olympic, Three Olympic winners, Five World championsetc. Clinical examination and musculoskeletal ultrasound. Plain X-rays. E.M.G, M.R.I.-arthrography, 3DC/T when that was required. Strength measurement with Nottingham McMecin Myometer for ipsi-contro lateral shoulder. Full ROM was necessary for the operated shoulder before starting exercise for a competition. All 48 underwent arthroscopic treatment (3 mini-open). Arthroscopic stabilization using absorbable or non anchors. 45 athletes, 48 shoulders operated,(3 bilat-erally).36 RC tears, 6 bony-bankart, 2 posterior and 28 anterior labrum detachment, 3 avulsion osteochondral fractures, 2 AMBRII, 4 deranged LH of biceps, 4 underwent SSN release. All patient returned at same sport level except one with AMBRII and cervical spine pathology. Rehabilitation time for basic weightlifting exercise was 3.5 months and for competition level was 4,5 -6 months. The shoulder demands during the snatch, clean and jerk of the weightlifters provoke often shoulder injuries. The arthroscopic surgery gives thorough and broad knowledge of their shoulder injuries. The minimal detachment, less postoperative joint stiffness and decreased shoulder pain are encouraging factors for the arthroscopic treatment. Additionally, the returning time for training and competition combining with a proper rehabilitation seems to be less than open surgery

This study was carried out to determine the incidence of shoulder injuries in the ipsilateral shoulder of patients who attended our unit with fractures of the humeral diaphysis. This was a prospective study. 22 patients with fractures of the humeral diaphysis had an early (within 10 days of injury) MRI scan of the shoulder. The contralateral shoulder was also scanned as an internal control. There were 10 male and 12 female patients. The average age was 45 years. 20 were treated non-operatively, and 2 had retrograde intra-medullary nailing of the humerus. 6 patients in our study had a symmetrical MRI scan. The remaining 16 patients had some acute abnormality evident in the ipsilateral shoulder. 11 patients had a significant subacromial bursitis. 2 of these patients had a tear of the supraspinatus tendon. 1 patient had an undisplaced fracture of the coracoid process. The remaining 4 patients had significant AC joint inflammation, 3 being acute, the 4th being acute-on-chronic. This study shows a high incidence of asymmetrical MRI scans, indicating a definite shoulder injury sustained at the time of the fracture of the humeral diaphysis. We therefore surmise that shoulder pain and dysfunction post antegrade intra-medullary nailing of the humerus may not be due to iatrogenic causes, but may in fact result from concomitant ipsilateral shoulder injury. To our knowledge, this is the first study demonstrating such an association

Purpose of the study:. To describe the incidence, nature, and risk factors associated with upper limb injuries in athletes participating in the London 2012 Paralympic Games. Materials and methods:. This study formed a component of the large prospective cohort study conducted over the 14-day period of the London 2012 Paralympic Games, coordinated through the IPC Medical Committee. Daily injury data were collected by team physicians in 3 329 athletes (46 606 athlete days) participating in the study, and 258 upper limb injuries were recorded. The incidence proportion (IP=number of injuries per 100 athletes), and incidence (number of injuries per 1000 athlete days) of upper limb injuries was calculated. Results:. The overall IP (with 95% CI) of upper limb injuries was 7,2 (6,4–8,1), with an incidence of 5,2 (4,6–5,8). Shoulder injuries were encountered most frequently with an overall incidence of 2,2 (1,85–2,7) and caused the greatest amount of time lost from sport. The incidence of shoulder injuries by sport was 8,8 (5,4–13,5) in powerlifting, 5,0 (2,1–9,8) in Judo, 2,8 (1,2–5,6) in wheelchair basketball, and 2,7 (1,6–4,2) in swimming. The incidence of injuries of the wrist and hand was 3,9 (1,4–8,5) in goal ball, 3,2 (1,5–6,0) in wheelchair basketball, and 2,8 (1,3–5,4) in table tennis. The majority of upper limb injuries occurred in athletes with spinal cord injuries (38,3%) and athletes with amputation or limb deficiency (28,4%). Rotator cuff impingement syndrome and chronic rotator cuff injury were the most frequent specific diagnoses in the upper limb injuries. Conclusion:. To date, this is the largest study evaluating upper limb injuries at the Paralympic Games. The shoulder is the anatomical region most frequently injured and caused the greatest time lost from sport. Type of sport, older age group, and athlete disability category were identified as risk factors for upper limb injuries

We reviewed 67 consecutive patients with fractures of the coracoid process, classifying them by the relationship between the fracture site and the coracoclavicular ligament. The 53 type-I fractures were behind the attachment of this ligament, and the 11 type-II fractures were anterior to it. The relationship of three fractures was uncertain. Type-I fractures were associated with a wide variety of shoulder injuries and consequent dissociation between the scapula and the clavicle. Treatment was usually by open reduction and fixation for type-I fractures and conservative methods for type-II. At follow-up of the 45 available patients, 87% had excellent results, with no significant differences between the operative and non-operative groups or between the type-I and type-II fractures. We consider that operative treatment should be reserved for patients with multiple shoulder injuries with severe disruption of the scapuloclavicular connection

The early diagnosis of the suprascapular nerve (SSN) entrapment in overhead athletes with simultaneous shoulder injuries and its arthroscopic release plays an important role for their appropriate treatment and recovery. SSN release at suprascapular and spinoglenoid notches, seems very helpful for increasing their performance. 21 Elite overhead athletes were treated from Jan 2005–May 2009. From 16 to 34 years old, mean 26 years, 4 Javelin throwers (Olympic and National level thrower), 4 Weightlifters (International level), 8 Volleyball Players, 3 Kick Boxer, 2 Water Polo Players. Extreme ROM of arm creates large torques about the shoulder cycle of repetitive microtrauma to the SSN, Direct trauma: fracture, dislocation, blunt trauma traction injury, Sling effect with hyper-abduction injury at the SS Notch, Correlation ROM with SSN entrapment in volley ball players, Eccentric contraction of the ISP (spinoglenoid notch), Internal impingement, Rotator cuff tears, Biceps lesions, Instability, SLAP lesion, Bankart lesion, Mainly infraspinatus muscle atrophy. X-rays, Nerve conduction studies, EMG studies, MRI. All of them had complete pain relief, especially at the posterior shoulder, regained full ROM of the operated shoulder, 19 fully recovered at the pre-injury level, 2 at the postoperative phase, Muscle atrophy improved. Advanced SSN entrapment provoke significant muscle wasting, often irreversible. This underscores the importance of a quick and accurate diagnosis to appropriate intervention. The overhead athletes with increased ROM of their shoulder predispose in SSN entrapment and shoulder injuries and vice-versa. An arthroscopic shoulder procedure for repairing the glenohumeral pathology with a simultaneous arthroscopic SSN release seems to be the appropriate treatment regarding to our resu

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

Gunshot injuries to the shoulder are rare and difficult to manage. We present a case series of seven patients who sustained a severe shoulder injury to the non-dominant side as a result of a self-inflicted gunshot wound. We describe the injury as ‘suicide shoulder’ caused by upward and outward movement of the gun barrel as the trigger is pulled. All patients were male, with a mean age of 32 years (21 to 48). All were treated at the time of injury with initial repeated debridement, and within four weeks either by hemiarthroplasty (four patients) or arthrodesis (three patients). The hemiarthroplasty failed in one patient after 20 years due to infection and an arthrodesis was attempted, which also failed due to infection. Overall follow-up was for a mean of 26 months (12 to 44). All four hemiarthroplasty implants were removed with no feasible reconstruction ultimately possible, resulting in a poor functional outcome and no return to work. In contrast, all three primary arthrodeses eventually united, with two patients requiring revision plating and grafting. These patients returned to work with a good functional outcome. We recommend arthrodesis rather than replacement as the treatment of choice for this challenging injury. Cite this article: Bone Joint J 2013;95-B:820–4

1. Two cases of arterial damage complicating shoulder injuries are reported. 2. The treatment is described and the importance of early diagnosis is stressed. 3. Operation was indicated in both cases by developing ischaemia in spite of conservative measures

Aims

This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA).

There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases ligamentous laxity. Oestrogen decreases the synthesis of collagen and progesterone does the opposite. Insufficient diet and intensive training can lead to menstrual irregularities, which are common in female athletes and result in injury, whereas oral contraception may have a protective effect against certain injuries. It is important for coaches, physiotherapists, nutritionists, doctors, and athletes to be aware of these issues and to implement preventive measures. This annotation explores the relationship between the menstrual cycle and orthopaedic sports injuries in pre-menopausal females, and proposes recommendations to mitigate the risk of sustaining these injuries.

Cite this article: Bone Joint J 2023;105-B(7):723–728.

The February 2024 Shoulder & Elbow Roundup³⁶⁰ looks at: Does indomethacin prevent heterotopic ossification following elbow fracture fixation?; Arthroscopic capsular shift in atraumatic shoulder joint instability; Ultrasound-guided lavage with corticosteroid injection versus sham; Combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis; Are vascularized fibula autografts a long-lasting reconstruction after intercalary resection of the humerus for primary bone tumours?; Anatomical versus reverse total shoulder arthroplasty with limited forward elevation; Tension band or plate fixation for simple displaced olecranon fractures?; Is long-term follow-up and monitoring in shoulder and elbow arthroplasty needed?

Telehealth has the potential to change the way we approach patient care. From virtual consenting to reducing carbon emissions, costs, and waiting times, it is a powerful tool in our clinical armamentarium. There is mounting evidence that remote diagnostic evaluation and decision-making have reached an acceptable level of accuracy and can safely be adopted in orthopaedic surgery. Furthermore, patients’ and surgeons’ satisfaction with virtual appointments are comparable to in-person consultations. Challenges to the widespread use of telehealth should, however, be acknowledged and include the cost of installation, training, maintenance, and accessibility. It is also vital that clinicians are conscious of the medicolegal and ethical considerations surrounding the medium and adhere strictly to the relevant data protection legislation and storage framework. It remains to be seen how organizations harness the full spectrum of the technology to facilitate effective patient care.

Cite this article: Bone Joint J 2023;105-B(8):843–849.

Aims

Orthopaedic surgery requires grafts with sufficient mechanical strength. For this purpose, decellularized tissue is an available option that lacks the complications of autologous tissue. However, it is not widely used in orthopaedic surgeries. This study investigated clinical trials of the use of decellularized tissue grafts in orthopaedic surgery.

Our purpose was to study the functional outcome and electrophysiologically to assess the axially nerve function in patients who have undergone surgery using a deltoid-splitting approach to treat complex proximal humeral fractures. This was a prospective observational study and was carried out in the Shoulder injury clinic at a university teaching hospital. Over a one-year period we treated fourteen locally-resident patients (median age 59 years) who presented with a three- or four-part proximal humeral fracture. All patients were treated using the extended deltoid-splitting approach, with open reduction, bone grafting and plate osteosynthesis. All patients were prospectively reviewed and underwent functional testing using the DASH, Constant and SF-36 scores as well as spring balance testing of deltoid power, and dynamic muscle function testing. At one year after surgery, all patients underwent EMG and nerve latency studies to assess axillary nerve function. Thirteen of the fourteen patients united their fractures without complications, and had DASH and Constant score that were good, with comparatively minor residual deficits on assessment of muscle power. Of these thirteen patients, only one had evidence of slight neurogenic change in the anterior deltoid. This patient had no evidence of anterior deltoid paralysis and her functional scores, spring balance and dynamic muscle function test results were indistinguishable from the patients with normal electrophysiological findings. One of the fourteen patients developed osteonecrosis of the humeral head nine months after surgery and had poor functional scores, without evidence of nerve injury on electrophysiological testing. Reconstruction through an extended deltoid-splitting approach provides a useful alternative in the treatment of complex proximal humeral fractures. The approach provides good access for reduction and implant placement and does not appear to be associated with clinically-significant adverse effects