We report ten cases of rupture of the distal part of the tendon of biceps brachii in patients aged from 27 to 58 years. MRI allowed assessment of the degree of retraction of the tendon which was related to the integrity of the bicipital expansion. When the retraction exceeded 8 cm the expansion was always ruptured. When there was doubt, or in longstanding injury, MRI allowed the lesions to be defined. Surgical repair was by reinsertion on the radial tuberosity at one or two fixation points in eight patients and reinsertion on the anterior brachial muscle in one. The other patient refused surgery. The MRI findings were confirmed at operation. Use of fixation points allowed minimal intervention, thereby reducing the risk of damaging the radial nerve. One year after operation, dynamometric evaluation of the strength of flexion and supination confirmed that the best results were obtained by reinsertion to the radial tuberosity

The use of volar locking compression plates for the treatment of fractures of the distal radius is becoming increasingly popular because of the stable biomechanical construct, less soft-tissue disturbance and early mobilisation of the wrist. A few studies have reported complications such as rupture of flexor tendons. We describe three cases of rupture of extensor tendons after the use of volar locking compression plates. We recommend extreme care when drilling and placing the distal radial screws to prevent damaging the extensor tendons

We reviewed 80 shoulders (77 patients) at a mean follow-up of 44 months after insertion of a Grammont inverted shoulder prosthesis. Three implants had failed and had been revised. The mean Constant score had increased from 22.6 points pre-operatively to 65.6 points at review. In 96% of these shoulders there was no or only minimal pain. The mean active forward elevation increased from 73° to 138°. The integrity of teres minor is essential for the recovery of external rotation and significantly influenced the Constant score. Five cases of aseptic loosening of the glenoid and seven of dissociation of the glenoid component were noted.

This study confirms the promising early results obtained with the inverted prosthesis in the treatment of a cuff-tear arthropathy. It should be considered in the treatment of osteoarthritis with a massive tear of the cuff but should be reserved for elderly patients.

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

We reviewed 101 patients with injuries of the terminal branches of the infraclavicular brachial plexus sustained between 1997 and 2009. Four patterns of injury were identified: 1) anterior glenohumeral dislocation (n = 55), in which the axillary and ulnar nerves were most commonly injured, but the axillary nerve was ruptured in only two patients (3.6%); 2) axillary nerve injury, with or without injury to other nerves, in the absence of dislocation of the shoulder (n = 20): these had a similar pattern of nerve involvement to those with a known dislocation, but the axillary nerve was ruptured in 14 patients (70%); 3) displaced proximal humeral fracture (n = 15), in which nerve injury resulted from medial displacement of the humeral shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension of the arm (n = 11): these were characterised by disruption of the musculocutaneous nerve. There was variable involvement of the median and radial nerves with the ulnar nerve being least affected. Surgical intervention is not needed in most cases of infraclavicular injury associated with dislocation of the shoulder. Early exploration of the nerves should be considered in patients with an axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is needed in cases of nerve injury resulting from fracture of the humeral neck to relieve pressure on nerves

Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis. At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively. Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of p?ctoralis major, particularly if there is pre-operative anterior subluxation of the humeral head

In a prospective randomised study we compared the results of arthroscopic subacromial bursectomy alone with debridement of the subacromial bursa followed by acromioplasty. A total of 57 patients with a mean age of 47 years (31 to 60) suffering from primary subacromial impingement without a rupture of the rotator cuff who had failed previous conservative treatment were entered into the trial. The type of acromion was classified according to Bigliani. Patients were assessed at follow-up using the Constant score, the simple shoulder test and visual analogue scores for pain and functional impairment. One patient was lost to follow-up. At a mean follow-up of 2.5 years (1 to 5) both bursectomy and acromioplasty gave good clinical results. No statistically significant differences were found between the two treatments. The type of acromion and severity of symptoms had a greater influence on the clinical outcome than the type of treatment. As a result, we believe that primary subacromial impingement syndrome is largely an intrinsic degenerative condition rather than an extrinsic mechanical disorder

Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control. There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one a complete rupture of the supraspinatus tendon, four inflammatory changes in the acromioclavicular joint and one a fracture of the coracoid process. These injuries may contribute to pain and dysfunction of the shoulder following treatment, and their presence indicates that antegrade nailing is only partly, if at all, responsible for these symptoms

We treated surgically 16 shoulders with an isolated traumatic rupture of the subscapularis tendon over a six-year period. Nine patients had a total and seven a partial tear of the subscapularis tendon. Repair was undertaken through a small deltopectoral groove approach. The mean Constant score improved in total tears from 38.7 to 89.3 points (p = 0.003) and in partial tears from 50.7 to 87.9 points (p = 0.008). The total tears were significantly more improved by surgery than the partial tears (p = 0.001). The delay between trauma and surgery was inversely proportional to the improvement in the Constant score suggesting that early diagnosis and surgical repair improves outcome

We describe a new surgical technique for the treatment of lacerations of the extensor tendon in zone I, which involves a tenodesis using a length of palmaris longus tendon one-quarter of its width. After exposing the dorsal aspect of the distal interphalangeal joint and harvesting the tendon, a 1.5 mm drill bit is passed through the insertion of the extensor tendon into the distal phalanx where it penetrates through the skin of the pulp of the digit. The palmaris longus tendon is threaded through the drill hole from dorsal to ventral and the ventral end is tied in a simple knot and trimmed. The palmaris longus tendon is then sutured to the extensor tendon close to its insertion, and also at the middle of the middle phalanx. The operation was undertaken on 67 patients: 27 with an acute injury and 40 patients with a chronic mallet deformity. One finger (or the thumb) was involved in each patient. At a mean follow-up of 12 months (6 to 18), 66 patients (98.5%) received excellent or good results according to both the American Society for Surgery of the Hand (ASSH) classification and Miller’s classification. Tenodesis using palmaris longus tendon after complete division of an extensor tendon in zone 1 is a reliable form of treatment for isolated acute or chronic ruptures

We describe the clinical outcome of a technique of surgical augmentation of chronic massive tears of the rotator cuff using a polyester ligament (Dacron) in 21 symptomatic patients (14 men, seven women) with a mean age of 66.5 years (55.0 to 85.0). All patients had MRI and arthroscopic evidence of chronic massive tears. The clinical outcome was assessed using the Constant and Murley and patient satisfaction scores at a mean follow-up of 36 months (30 to 46). The polyester ligament (500 mm × 10 mm) was passed into the joint via the portal of Neviaser, medial to the tear through healthy cuff. The two ends of the ligament holding the cuff were passed through tunnels made in the proximal humerus at the footprint of the insertion of the cuff. The ligament was tied with a triple knot over the humeral cortex. All the patients remained free from pain (p < 0.001) with improvement in function (p < 0.001) and range of movement (p < 0.001). The mean pre-operative and post-operative Constant scores were 46.7 (39.0 to 61.0) and 85.4 (52.0 to 96.0), respectively (p < 0.001). The mean patient satisfaction score was 90%. There were two failures, one due to a ruptured ligament after one year and the other due to deep-seated infection. The MR scan at the final follow-up confirmed intact and thickened bands in 15 of 17 patients. This technique of augmentation gives consistent relief from pain with improved shoulder movement in patients with symptomatic massive tears of the rotator cuff

Lesions of the anterior interosseous nerve in the forearm are rare and often misdiagnosed as tendon injuries. A consecutive series of 13 patients with this condition referred for electrodiagnosis is reviewed. Only three had originally a correct clinical diagnosis and three were initially considered to have tendon ruptures. Five cases were of mechanical origin and seven due to ‘neuritis’. All showed electrophysiological abnormalities, most commonly involving the pronator quadratus. Late spontaneous recovery was common, and only one case had surgical exploration

Arthrodesis of the wrist is a standard operation which is indicated for severe rheumatoid arthritis in which destruction is too advanced for more conservative procedures, or after failure of previous surgery. We have developed an L-shaped plate designed for this purpose. It provides rigid internal fixation with the wrist in the neutral position and utilises bone grafts obtained from the distal ulna and the carpal bones. We have carried out 29 successful fusions between 1992 and 1995. In all 29 patients synovectomy and resection of the head of the ulna were performed; 11 also had reconstruction of ruptured extensor tendons. All the patients obtained bony union, pain relief and improved function

In 28 patients with a solitary diagnosis of instability of the trapeziometacarpal joint because of a rupture of the anterior oblique ligament, reconstruction was carried out using a slip of the tendon of flexor carpi radialis. We were able to review 26 patients. The results after a follow-up of four years seven months showed that most (87%) had significant relief from pain and symptoms. Seventeen were graded as good to excellent. The mean grip strength recovered to 86% of the contralateral side. Most patients (81%) felt that they had subjective improvement and would have undergone the operation again. A lesser functional result was seen in those who developed a flexion deformity because of overtightening of the reconstruction. Increased awareness of this lesion can lead to an early and clear diagnosis so that the patient may be advised adequately. We describe a specific, diagnostic, clinical test which we have used consistently and successfully

Operative release for entrapment of the suprascapular nerve was carried out in 35 patients. They were assessed at an average of 30 months (12 to 98) after operation using the functional shoulder score devised by Constant and Murley. The average age at the time of surgery was 40 years (17 to 67). Entrapment was due to injury in ten patients and no cause was found in three; 34 had diffuse posterolateral shoulder pain. The strength of abduction was reduced in all the patients. The average Constant score, unadjusted for age or gender, before operative release was 47% (28 to 53). In 25 of the patients both the supraspinatus and infraspinatus muscles were atrophied and seven had isolated atrophy of the infraspinatus muscle. The average conduction time from Erb’s point to the supraspinatus muscle and to the infraspinatus muscle was 5.7 ms (2.8 to 12.8) and 7.4 ms (3.4 to 13.4), respectively. In two patients MRI revealed a ganglion in the infraspinatus fossa and, in another, a complete rupture of the rotator cuff. The average time from the onset of symptoms to operation was ten months (3 to 36). A posterior approach was advocated. The average Constant score, after operative release, unadjusted for age or gender was 77% (35 to 91). The overall result was excellent in ten of the patients, very good in seven, good in 14, fair in two, and poor in two. The symptomatic and functional outcome in our series confirmed the usefulness and safety of operative decompression for entrapment of the suprascapular nerve

We present a review of claims made to the NHS Litigation Authority (NHSLA) by patients with conditions affecting the shoulder and elbow, and identify areas of dissatisfaction and potential improvement. Between 1995 and 2012, the NHSLA recorded 811 claims related to the shoulder and elbow, 581 of which were settled. This comprised 364 shoulder (64%), and 217 elbow (36%) claims. A total of £18.2 million was paid out in settled claims. Overall diagnosis, mismanagement and intra-operative nerve injury were the most common reasons for litigation. The highest cost paid out resulted from claims dealing with incorrect, missed or delayed diagnosis, with just under £6 million paid out overall. Fractures and dislocations around the shoulder and elbow were common injuries in this category. All 11 claims following wrong-site surgery that were settled led to successful payouts.

This study highlights the diagnoses and procedures that need to be treated with particular vigilance. Having an awareness of the areas that lead to litigation in shoulder and elbow surgery will help to reduce inadvertent risks to patients and prevent dissatisfaction and possible litigation.

Cite this article: Bone Joint J 2014; 96-B:574–9.

Reverse total shoulder replacement (RTSR) depends on adequate deltoid function for a successful outcome. However, the anterior deltoid and/or axillary nerve may be damaged due to prior procedures or injury. The purpose of this study was to determine the compensatory muscle forces required for scapular plane elevation following RTSR when the anterior deltoid is deficient. The soft tissues were removed from six cadaver shoulders, except for tendon attachments. After implantation of the RTSR, the shoulders were mounted on a custom-made shoulder simulator to determine the mean force in each muscle required to achieve 30° and 60° of scapular plane elevation. Two conditions were tested: 1) Control with an absent supraspinatus and infraspinatus; and 2) Control with anterior deltoid deficiency. Anterior deltoid deficiency resulted in a mean increase of 195% in subscapularis force at 30° when compared with the control (p = 0.02). At 60°, the subscapularis force increased a mean of 82% (p < 0.001) and the middle deltoid force increased a mean of 26% (p = 0.04).

Scapular plane elevation may still be possible following an RTSR in the setting of anterior deltoid deficiency. When the anterior deltoid is deficient, there is a compensatory increase in the force required by the subscapularis and middle deltoid. Attempts to preserve the subscapularis, if present, might maximise post-operative function.

The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ.

Instability of the SCJ is rare and can be difficult to distinguish from medial clavicular physeal or metaphyseal fracture-separation: cross-sectional imaging is often required. The distinction is important because the treatment options and outcomes of treatment are dissimilar, whereas the treatment and outcomes of ACJ separation and fracture of the lateral clavicle can be similar. Proper recognition and treatment of traumatic instability is vital as these injuries may be life-threatening. Instability of the SCJ does not always require surgical intervention. An accurate diagnosis is required before surgery can be considered, and we recommend the use of the Stanmore instability triangle. Most poor outcomes result from a failure to recognise the underlying pathology.

There is a natural reluctance for orthopaedic surgeons to operate in this area owing to unfamiliarity with, and the close proximity of, the related vascular structures, but the interposed sternohyoid and sternothyroid muscles are rarely injured and provide a clear boundary to the medial retroclavicular space, as well as an anatomical barrier to unsafe intervention.

This review presents current concepts of instability of the SCJ, describes the relevant surgical anatomy, provides a framework for diagnosis and management, including physiotherapy, and discusses the technical challenges of operative intervention.

Cite this article: Bone Joint J 2013;95-B:721–31.

This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations.

Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired.

The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer.

Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert score and 1.6 on the Mallett score. Pre-operative electrodiagnosis is a reliable indicator of the depth of the lesion and of the outcome after repair. Intra-operative somatosensory evoked potentials were helpful in the detection of occult intradural (pre-ganglionic) injury.

Injectable collagenase is an alternative to surgical treatment for Dupuytren’s disease. Previous studies have reported on the effectiveness of collagenase in finger contractures. This prospective study reports on the short-term safety and efficacy of collagenase treatment in five thumb and first web space Dupuytren’s contractures. The thumb and first web space contractures were treated with injectable collagenase in four consecutive patients (five hands) with experience of previous surgical digital fasciectomy. The thumb contracture was measured by angle and span in two planes of thumb extension and abduction before injection and after manipulation. Collagenase treatment resulted in release of the contracture with a mean increase in thumb to index angle from 23° (10° to 35°) to 56° (45° to 60°) in extension and from 30° (10° to 50°) to 58° (50° to 65°) in abduction and a mean increase in span from 1.9 cm (1 to 3.5) to 3.9 cm (3 to 5) in extension and from 2.4 cm (1.5 to 3.5) to 3.9 cm (3 to 4.5) in abduction. All patients reported an increased range of movement and function and described collagenase therapy as preferable to surgery. In the short-term collagenase is an effective, well-tolerated and safe alternative to surgery for Dupuytren’s disease of the thumb.