We used magnetic resonance (MR) myelography in ten patients with injuries to the brachial plexus and compared the findings with those obtained by conventional myelography and postmyelographic CT (CTM). In the presence of complete nerve-root avulsion (seven cases), a post-traumatic meningocele was detected by MR myelography. In injuries to the upper roots (three cases) MR myelography showed abnormal findings with a high signal intensity in the nerve root, obliteration of the damaged nerve root, or enlargement and obliteration of the root sleeve. No pseudomeningoceles were detected in these upper-root injuries by MR myelography and CTM. The overall accuracy of detection of damaged nerve roots or root sleeves was better with MR myelography than with conventional myelography and was similar to that of CTM. MR myelography is non-invasive, relatively quick, requires no contrast medium, provides imaging in multiple projections, and is comparable in diagnostic ability to the more invasive, time-consuming techniques of conventional myelography and CTM

Restoration of hand function is rarely achieved after a complete closed traction lesion of the supraclavicular brachial plexus. We describe the injury, treatment, rehabilitation and long-term results of two patients who regained good function of the upper limb and useful function in the hand after such an injury. Successful repairs were performed within six days of injury. Tinel’s sign proved accurate in predicting the ruptures and the distribution of pain was accurate in predicting avulsion. The severe pain that began on the day of injury resolved with the onset of muscle function.

Recovery of muscle function preceded recovery of sensation. Recovery of the function of C and Aδ fibres was the slowest of all.

A suspected fracture of the scaphoid remains difficult to manage despite advances in knowledge and imaging methods. Immobilisation and restriction of activities in a young and active patient must be balanced against the risks of nonunion associated with an undiagnosed and undertreated fracture of the scaphoid.

The assessment of diagnostic tests for a suspected fracture of the scaphoid must take into account two important factors. First, the prevalence of true fractures among suspected fractures is low, which greatly reduces the probability that a positive test will correspond with a true fracture, as false positives are nearly as common as true positives. This situation is accounted for by Bayesian statistics. Secondly, there is no agreed reference standard for a true fracture, which necessitates the need for an alternative method of calculating diagnostic performance characteristics, based upon a statistical method which identifies clinical factors tending to associate (latent classes) in patients with a high probability of fracture.

The most successful diagnostic test to date is MRI, but in low-prevalence situations the positive predictive value of MRI is only 88%, and new data have documented the potential for false positive scans. The best strategy for improving the diagnosis of true fractures among suspected fractures of the scaphoid may well be to develop a clinical prediction rule incorporating a set of demographic and clinical factors which together increase the pre-test probability of a fracture of the scaphoid, in addition to developing increasingly sophisticated radiological tests.

We prospectively studied 26 consecutive patients with clinically documented sensory or motor deficiency of a peripheral nerve due to trauma or entrapment using ultrasound, and in 19 cases surgical exploration of the nerves was undertaken. The ultrasonographic diagnoses were correlated with neurological examination and the surgical findings. Reliable visualisation of injured nerves on ultrasonography was achieved in all patients. Axonal swelling and hypoechogenity of the nerve was diagnosed in 15 cases, loss of continuity of a nerve bundle in 17, the formation of a neuroma of a stump in six, and partial laceration of a nerve with loss of the normal fascicular pattern in five. The ultrasonographic findings were confirmed at operation in those who had surgery.

Ultrasound may be used for the evaluation of peripheral nerve injuries in the upper limb. High-resolution ultrasound can show the exact location, extent and type of lesion, yielding important information that might not be obtainable by other diagnostic aids.

We have examined the accuracy of 143 consecutive ultrasound scans of patients who subsequently underwent shoulder arthroscopy for rotator-cuff disease. All the scans and subsequent surgery were performed by an orthopaedic surgeon using a portable ultrasound scanner in a one-stop clinic. There were 78 full thickness tears which we confirmed by surgery or MRI. Three moderate-size tears were assessed as partial-thickness at ultrasound scan (false negative) giving a sensitivity of 96.2%. One partially torn and two intact cuffs were over-diagnosed as small full-thickness tears by ultrasound scan (false positive) giving a specificity of 95.4%. This gave a positive predictive value of 96.2% and a negative predictive value of 95.4%. Estimation of tear size was more accurate for large and massive tears at 96.5% than for moderate (88.8%) and small tears (91.6%). These results are equivalent to those obtained by several studies undertaken by experienced radiologists.

We conclude that ultrasound imaging of the shoulder performed by a sufficiently-trained orthopaedic surgeon is a reliable time-saving practice to identify rotator-cuff integrity.

The aim of this study was to define the microcirculation of the normal rotator cuff during arthroscopic surgery and investigate whether it is altered in diseased cuff tissue.

Blood flow was measured intra-operatively by laser Doppler flowmetry. We investigated six different zones of each rotator cuff during the arthroscopic examination of 56 consecutive patients undergoing investigation for impingement, cuff tears or instability; there were 336 measurements overall.

The mean laser Doppler flowmetry flux was significantly higher at the edges of the tear in torn cuffs (43.1, 95% confidence interval (CI) 37.8 to 48.4) compared with normal cuffs (32.8, 95% CI 27.4 to 38.1; p = 0.0089). It was significantly lower across all anatomical locations in cuffs with impingement (25.4, 95% CI 22.4 to 28.5) compared with normal cuffs (p = 0.0196), and significantly lower in cuffs with impingement compared with torn cuffs (p < 0.0001).

Laser Doppler flowmetry analysis of the rotator cuff blood supply indicated a significant difference between the vascularity of the normal and the pathological rotator cuff. We were unable to demonstrate a functional hypoperfusion area or so-called ‘critical zone’ in the normal cuff. The measured flux decreases with advancing impingement, but there is a substantial increase at the edges of rotator cuff tears. This might reflect an attempt at repair.

We performed a double-blind, randomised controlled trial to assess the effectiveness of a continuous-infusion brachial plexus block with levobupivacaine compared with that of a standard single injection for the management of post-operative pain after surgery on the shoulder.

Eight patients were randomised to receive a pre-operative brachial plexus block using 30 ml of levobupivacaine 0.5% with adrenaline 1:200 000 followed by insertion of a 20-gauge polyamide catheter. This was connected to a disposable elastometric pump, set immediately after surgery to administer a continuous flow of levobupivacaine 0.25% at a rate of 5 ml per hour. The other eight patients were randomised to receive only the initial injection of 30 ml. The study was double-blinded with the aid of sham catheters and clamped pumps.

All patients were given regular paracetamol and were prescribed morphine through a patient-controlled analgesia pump. Motor and sensory block assessments, visual analogue scale pain scores and consumption of morphine were recorded after the operation and then at 6, 12 and 24 hours after administration of the block.

Satisfactory motor and sensory block was achieved in all patients. The mean visual analogue scale pain score at 12 hours and consumption of morphine at 24 hours after injection were significantly lower (p < 0.05) in the continuous-infusion group. This group also took longer to request their first additional analgesia and reported a significantly higher overall level of satisfaction.

Our study has shown that continuous interscalene infusion of levobupivacaine is an effective method of post-operative analgesia after major surgery of the shoulder.

In a prospective randomised trial of calcifying tendinitis of the rotator cuff, we compared the efficacy of dual treatment sessions delivering 2500 extracorporeal shock waves at either high- or low-energy, via an electromagnetic generator under fluoroscopic guidance. Patients were eligible for the study if they had more than a three-month history of calcifying tendinitis of the rotator cuff, with calcification measuring 10 mm or more in maximum dimension. The primary outcome measure was the change in the Constant and Murley Score.

A total of 80 patients were enrolled (40 in each group), and were re-evaluated at a mean of 110 (41 to 255) days after treatment when the increase in Constant and Murley score was significantly greater (t-test, p = 0.026) in the high-energy treatment group than in the low-energy group. The improvement from the baseline level was significant in the high-energy group, with a mean gain of 12.5 (−20.7 to 47.5) points (p < 0.0001). The improvement was not significant in the low-energy group. Total or subtotal resorption of the calcification occurred in six patients (15%) in the high-energy group and in two patients (5%) in the low-energy group.

High-energy shock-wave therapy significantly improves symptoms in refractory calcifying tendinitis of the shoulder after three months of follow-up, but the calcific deposit remains unchanged in size in the majority of patients.