Introduction

In patients with shoulder pain one of the important initial determinations is to assess the integrity of the rotator cuff. Clinical examination is often inconclusive. Compared with MRI and arthrography, ultrasound allows dynamic evaluation, is non-invasive, less expensive, less time-consuming and more acceptable to patients. The aim of the present study was to evaluate the accuracy of high resolution shoulder ultrasonography compared with arthroscopy in a series of consecutive patients with clinically suspected rotator cuff disease.

Neer type 2 fractures of the distal third of the clavicle have a non union rate of 22-35% after conservative treatment. Open reduction and internal fixation has been recommended by most authors but there is no consensus about the best method of internal fixation. We retrospectively assessed the union and shoulder function following Hook plate fixation in 18 patients with Neer type 2 fractures of lateral end clavicle with more then a six month follow up after surgery.

There were 14 males with a mean follow-up of 25.89 months (6-48 months) and the average age was 40.33 years (22-62 range). Fifteen had acute fractures and the rest were non unions. Complications included two non unions, one following a deep infection. There were no iatrogenic fractures. Acromial osteolysis was seen in five patients who had their plates in situ. The average pain score at rest was 1 (0-4) and the average pain score on abduction was 2.2 (0-5). The average Constant score was 88.5 (63-100). Patients were asked to rate their shoulder function; three said their shoulder was normal, eleven said it was nearly normal and one rated it as not normal.

Hook plate fixation appears to be a valuable method of stabilising Neer type 2 fractures of the clavicle resulting in high union rates and good shoulder function. These plates need to be removed after union to prevent acromial osteolysis.

Background

Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the two to see which is better.

Subacromial corticosteroid injection has been shown to be effective in treating impingement syndrome. The exact mechanism of action is not clear but it may be due to its anti-inflammatory properties. However, there are potential side effects of steroid injection including tendon weakening, dermal atrophy and infection. NSAIDs may offer similar anti-inflammatory properties but without the side effects of corticosteroids. Tenoxicam is a long-acting water soluble NSAID and is available without irritant preservatives. Studies have shown that peri-articular Tenocixam injection was useful in treating painful shoulders and local tolerability was good.

The aim of this study is to carry out a blinded ran-domised controlled study comparing subacromial Tenoxicam injection (NSAID) against methylprednisolone (steroid) injection in patients with clinical subacromial impingement syndrome.

The study protocol was approved by local research ethics committee. Patients over 18 with a clinical diagnosis of subacromial impingement syndrome were considered eligible to this study. Patients with other known causes of shoulder pain, contraindication or sensitivity to NSAID and pregnant patients were excluded.

Three functional outcome measures were used – Constant-Murley Shoulder Score, DASH and the Oxford Shoulder Score. The patients completed all three outcome measures before and 2, 4 and 6 weeks after the subacromial injection. Simple randomisation method was used and blinded to both researcher and the patient.

58 patients randomised into two groups were reviewed at the end of six weeks. Patients treated with subacromial steroid injection had a much better outcome compared to patients treated with subacromial tenoxicam injection and this difference was highly significant (p< .003)

In conclusion, patients with subacromial impingement syndrome have a better clinical outcome when treated with subacromial steroid injection than NSAID injection.

The use of high resolution ultrasonography for the detection of rotator cuff tears has achieved only limited acceptance by orthopaedic surgeons. Uncertainty about the accuracy of ultrasonography may be a contributing factor. The purpose of this study was to evaluate the accuracy of high-resolution ultrasonography compared to shoulder arthroscopy in the detection of rotator cuff tears. 100 consecutive patients with shoulder pain in whom arthroscopic surgery was planned underwent standardized preoperative ultrasonography. The ultrasound examinations were done by a single experienced musculoskeletal radiologist using a standard protocol. The findings at ultrasound were classified into intact cuff, tendinopathy, partial-thickness tear, and full-thickness rotator cuff tears. The size of the tear was measured in centimetres. The location was designated as subscapularis, supraspinatus, infraspinatus, or a combination. All of the subsequent shoulder arthroscopies were done by a single surgeon. The presence or absence of a rotator cuff tear and the size and extent of the tear when present were recorded. We then compared the ultrasonographic findings with the definitive operative findings. For the detection of rotator cuff tears, ultrasound had a sensitivity of 95% and a specificity of 94%; accuracy 95%. There was 100% sensitivity for full thickness tears (specificity 91% and accuracy 95%), while for partial-thickness tears there was a sensitivity of 80%, (specificity 98% and accuracy 95%). In experienced hands, ultrasound is a highly accurate diagnostic method for detecting rotator cuff tears. The results of this study compare favourably with the published results of magnetic resonance imaging for the investigation of this condition. Furthermore, dynamic imaging and comparison with the opposite shoulder is possible with ultrasonography.

Aims: The re-dislocation rates in adults (< 30 years) in the initial 12 months after FAT (first,anterior,traumatic) shoulder dislocations treated non-operatively vary from 25% to 95%. Some surgeons advocate early arthroscopic surgery following such dislocations as this appears to reduce recurrent instability. The purpose of this study was to establish if arthroscopic surgery reduces the incidence of recurrent instability after such dislocations when compared to non-operative treatment.

Material and Methods: Specific search terms were used to retrieve relevant studies from MEDLINE, EMBASE, and CINAHL extending from 1966 to October 2003. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed. Adults under 30 years of age, with clinical and radiological confirmation of anterior dislocation following trauma with a minimum follow-up of 12 months were included. Patients with previous shoulder problems, generalised joint laxity, neurological injury, impingement and a history of substance abuse were excluded.

Results: 13 studies involving 433 shoulders were reviewed.

Group A included 84 shoulders treated by arthroscopic lavage without stabilisation. There were no subluxations. The re-dislocation rate was 14.3% (12/84).

Group B had 179 shoulders treated by arthroscopic stabilisation. The incidence of subluxation was 5.02% (9/179) and dislocation was 6.14% (11/179).

Recurrent instability (subluxation /dislocation) following arthroscopic lavage (12/84 – 14.3%) was significantly higher than after arthroscopic stabilisation (20/179 – 11.2%). [p= 0.04, Relative risk = 2.32, 95% CI: 1.07 to 5.05]

Group C involved 170 shoulders treated non-operatively. The incidence of subluxation was 8% (12/150) and dislocation was 62% (93/150). The overall incidence of recurrent instability was 70% (119/170).

Recurrent instability following arthroscopic intervention (32/263 – 12.2%) was significantly lower than following non-operative treatment (119/170 – 70%) [p< 0.0001, Relative risk = 0.17, 95% CI: 0.12 to 0.24].

Conclusion: Early arthroscopic surgery reduces recurrent instability during the initial 12 months after FAT shoulder dislocation in young adults (< 30 years) when compared to non-operative treatment. Arthroscopic treatment should be offered to young, athletic patients especially those involved in contact sports or defence personnel, who are at a high risk of recurrent instability after initial shoulder dislocation. Further randomised control trials reporting on a larger number of patients with a minimum follow-up of 5 years are required before one can draw firm conclusions on the ability of arthroscopic intervention to influence the natural history of FAT shoulder dislocation.

Aim: The re-dislocation rates in adults (< 30 years) in the initial 12 months after first, anterior, traumatic (FAT) shoulder dislocations treated non-operatively vary from 25% to 95%. The purpose of this study was to establish if arthroscopic surgery reduces the incidence of recurrent instability (failure) after such dislocations when compared to non-operative treatment.

Material and Methods: Specific search terms were used to retrieve relevant studies from various databases extending from 1966 to May 2004. Guidelines for reporting of meta-analysis, adapted from QUOROM statement were followed.

Results: 13 studies involving 433 shoulders were reviewed. Group A included 84 shoulders treated by arthroscopic lavage without stabilisation. There were no subluxations. The re-dislocation rate was 14.3% (12/84). Group B had 179 shoulders treated by arthroscopic stabilisation. The incidence of subluxation was 5.02% (9/179) and dislocation was 6.14% (11/179). Failure following arthroscopic lavage (12/84 – 14.3%) was significantly higher than after arthroscopic stabilisation (20/179 – 11.2%). [p= 0.04, Relative risk = 2.32, 95% CI: 1.07 to 5.05]. Group C involved 170 shoulders treated non-operatively. The incidence of subluxation was 8% (12/150) and dislocation was 62% (93/150). The overall incidence of failure was 70% (119/170). Failure following arthroscopic intervention (32/263 – 12.2%) was significantly lower than following non-operative treatment (119/170 – 70%) [p< 0.0001, Relative risk = 0.17, 95% CI: 0.12 to 0.24].

Conclusion: Early arthroscopic surgery appears to reduce recurrent instability during the initial 12 months after FAT shoulder dislocation in young adults (< 30 years) when compared to non-operative treatment. Arthroscopic stabilisation may be considered for young, athletic patients and those involved in contact sports or defence personnel, who are at a high risk of recurrent instability after FAT shoulder dislocation. RCTs reporting on a larger number of patients with a minimum follow-up of 5 years are required before one can draw firm conclusions on the ability of arthroscopic intervention to influence the natural history of traumatic anterior shoulder dislocation.

We describe 20 patients, aged between 43 and 88 years, with delayed nerve palsy or deepening of an initial palsy caused by arterial injury from low-energy injuries to the shoulder. The onset of palsy ranged from immediately after the injury to four months later. There was progression in all the patients with an initial partial nerve palsy. Pain was severe in 18 patients, in 16 of whom it presented as neurostenalgia and in two as causalgia. Dislocation of the shoulder or fracture of the proximal humerus occurred in 16 patients. There was soft-tissue crushing in two and prolonged unconsciousness from alcoholic intoxication in another two.

Decompression of the plexus and repair of the arterial injury brought swift relief from pain in all the patients. Nerve recovery was generally good, but less so in neglected cases. The interval from injury to the repair of the vessels ranged from immediately afterwards to 120 days.

Delayed onset of nerve palsy or deepening of a nerve lesion is caused by bleeding and/or impending critical ischaemia and is an overwhelming indication for urgent surgery. There is almost always severe neuropathic pain.