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

The case is reported of a fracture-dislocation of the shoulder, treated by an operation based upon a principle advanced by Moore in 1948. An excellent radiological and functional result was observed five and a half years after the injury

The stabilising effects on the glenohumeral joint of each of the rotator-cuff muscles and of the biceps were studied with the arm in abduction and external rotation in 13 cadaver shoulders. The muscles were loaded one at a time with forces proportional to their cross-sectional areas. We recorded the positions of the humeral head before and after the application to the humerus of an anterior force of 1.5 kg. When the capsule was intact, the anterior displacement with the subscapularis loaded was significantly larger than with the other muscles loaded (p = 0.0009). With the capsule vented, the displacement with the biceps loaded was significantly smaller than that with the subscapularis loaded (p = 0.0052). After creating an imitation Bankart lesion, the displacement with the biceps loaded was significantly less than with any of the rotator-cuff muscles loaded (p = 0.0132). We conclude that in the intact shoulder, the subscapularis is the least important anterior stabiliser, and that the biceps becomes more important than the rotator-cuff muscles as stability from the capsuloligamentous structure decreases. Strengthening of the biceps as well as the rotator-cuff muscles should be part of the rehabilitation programme for anterior shoulder instability

We performed a prospective study using MRI in 16 consecutive infants with a mean age of 5.2 months (2.7 to 8.7) who had shown inadequate recovery from an obstetric lesion of the brachial plexus in the first three months of life, in order to identify early secondary deformities of the shoulder. Shoulders were analysed according to a standardised MRI protocol. Measurements were made of the appearance of the glenoid, glenoid version and the position of the humeral head. The appearance of the glenoid on the affected side was normal in only seven shoulders. In the remainder it was convex in seven and bioconcave in three. The degree of subluxation of the humeral head was significantly greater (p = 0.01) in the affected shoulders than in normal shoulders (157° v 170°). The presence of an abnormal appearance of the glenoid, retroversion of the glenoid and subluxation of the humeral head increased with age. There was a statistical difference (p = 0.05) between infants younger than five months and those who were older

Reversed shoulder prostheses are increasingly being used for the treatment of glenohumeral arthropathy associated with a deficient rotator cuff. These non-anatomical implants attempt to balance the joint forces by means of a semi-constrained articular surface and a medialised centre of rotation. A finite element model was used to compare a reversed prosthesis with an anatomical implant. Active abduction was simulated from 0° to 150° of elevation. With the anatomical prosthesis, the joint force almost reached the equivalence of body weight. The joint force was half this for the reversed prosthesis. The direction of force was much more vertically aligned for the reverse prosthesis, in the first 90° of abduction. With the reversed prosthesis, abduction was possible without rotator cuff muscles and required 20% less deltoid force to achieve it. This force analysis confirms the potential mechanical advantage of reversed prostheses when rotator cuff muscles are deficient

We studied the contributions of the long and short heads of the biceps (LHB, SHB) to anterior stability in 13 cadaver shoulders. The LHB and SHB were replaced by spring devices and translation tests at 90 degrees abduction of the arm were performed by applying a 1.5 kg anterior force. The position of the humeral head was monitored by an electromagnetic tracking device with or without an anterior translational force; with 0 kg, 1.5 kg or 3 kg loads applied on either LHB or SHB tendons in 60 degrees, 90 degrees or 120 degrees of external rotation; and with the capsule intact, vented, or damaged by a Bankart lesion. The anterior displacement of the humeral head under 1.5 kg force was significantly decreased by both the LHB and SHB loading in all capsular conditions when the arm was in 60 degrees or 90 degrees of external rotation. At 120 degrees of external rotation, anterior displacement was significantly decreased by LHB and SHB loading only when there was a Bankart lesion. We conclude that LHB and SHB have similar functions as anterior stabilizers of the glenohumeral joint with the arm in abduction and external rotation, and that their role increases as shoulder stability decreases. Both heads of the biceps have been shown to have a stabilising function in resisting anterior head displacement, and consideration should therefore be given to strengthening the biceps during rehabilitation programmes for chronic anterior instability of the shoulder

The aim of this retrospective study was to review a series of patients with ipsilateral fractures of the neck of the scapula and of the clavicle. Between 1991 and 1996 a total of 79 general and orthopaedic surgeons treated 46 patients with a floating shoulder in The Netherlands. The records and radiographs of these patients were studied. Of the 35 patients available for follow-up, 31 had initially been treated conservatively and four by operation; three underwent secondary reconstructive surgery. The mean Constant score for the 28 patients treated conservatively was 76 and for the seven treated operatively it was 71 at a mean follow-up of 35 months. In six of the 28 patients treated conservatively the glenoid was dislocated caudally at the end of treatment; they had a score of 42. In the 22 patients without this dislocation the score was 85. We conclude that this rare injury is not inherently unstable and, in the absence of caudal dislocation of the glenoid, conservative treatment gives a good functional outcome

In children with obstetric brachial plexus palsy (OBPP) who develop an internal rotation deformity of the shoulder, release of subscapularis improves the range of external rotation of the shoulder and the strength of supination of the forearm. We studied the strength of supination in 35 healthy adult volunteers at 45° of both internal and external rotation. The mean and maximum torques were greater in external than internal rotation by 8.7% and 7.5%, respectively. This was highly significant (p < 0.0001). The increased strength of supination in external rotation is probably because the maximum power of biceps, particularly the long head, may be exerted in this position. In children the difference may be even greater due to anatomical differences causing the dramatic increases in the strength of supination after surgery for OBPP. In adults our findings suggest that the supination exercises which are undertaken after injury or surgery to the forearm or wrist should be performed in external rotation

A case of posterior fracture-dislocation of the shoulder is reported, and the method of closed reduction is described

We evaluated results at one year after surgical correction of internal rotation deformities in the shoulders of 270 patients with obstetric brachial plexus palsy. The mean age at surgery was 6.2 years (0.6 to 35). Two techniques were used: open subscapularis elongation and latissimus dorsi to infraspinatus transfer. In addition, open relocation was performed or attempted in all patients with subluxed or dislocated joints. A mixed effects model approach was used to evaluate the effects of surgery on internal and external rotation, abduction, flexion and Mallet score. Independent factors included operative status (pre- or post-operative), gender, age, the condition of the joint, and whether or not transfer was performed. The overall mean improvement in external rotation following surgery was 84.6° (95% confidence interval (CI) 80.2 to 89.1) and the mean Mallet score improved by 4.0 (95% CI 3.7 to 4.2). There was a mean decrease in internal rotation of between 27.6° and 34.4° in the relocated joint groups and 8.6° (95% CI 5.2 to 12.0) in the normal joint group. Abduction and flexion were unchanged following surgery. Adding a latissimus dorsi transfer did not result in greater improvement in the mean external rotation compared with elongation of the subscapularis alone. Cite this article: Bone Joint J 2013;95-B:1432–8

We describe the early results of glenoplasty as part of the technique of operative reduction of posterior dislocation of the shoulder in 29 children with obstetric brachial plexus palsy. The mean age at operation was five years (1 to 18) and they were followed up for a mean of 34 months (12 to 67). The mean Mallet score increased from 8 (5 to 13) to 12 (8 to 15) at final follow-up (p < 0.001). The mean passive forward flexion was increased by 18° (p = 0.017) and the mean passive abduction by 24° (p = 0.001). The mean passive lateral rotation also increased by 54° (p < 0.001), but passive medial rotation was reduced by a mean of only 7°. One patient required two further operations. Glenohumeral stability was achieved in all cases

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5). A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity. Cite this article: Bone Joint J 2013;95-B:660–3

1. The history of the genesis of the Putti-Platt operation for habitual dislocation of the shoulder is outlined so far as it is known. 2. The operation is described and briefly commented upon. 3. Since there is both gleno-labrial detachment and defect in the humeral head successful treatment depends upon: i) a block to the exit of the humeral head in front and ii) limitation of external rotation movement

It is difficult to establish the diagnosis of an injured shoulder if only one radiographic projection is used. We have compared two lateral projections, the Neer trans-scapular and the apical oblique in 80 patients; the radiographs were presented randomly to 10 casualty officers and nine radiologists. The apical oblique view was found to permit more accurate diagnosis of fractures and of dislocation by both groups

1. The pathogenesis of recurrent anterior dislocation of the shoulder has been studied at operation and by experiments on cadavers. 2. Lesions of the subscapularis muscle leading to lengthening and laxity have been demonstrated. 3. This lengthening is the prime factor in producing instability of the shoulder; capsular and bony defects are no more than subsidiary causes. 4. Good results have been obtained by a procedure based on this theory of etiology

A study of the attachment of the joint capsule to the scapula, and of the shape of the humeral head, has been carried out in 52 fetal and embryonic shoulders. In 77% of cases the anterior capsule was attached to the labrum or close to it; in the remaining 23% it was inserted into the neck of the scapula, so creating a pouch. In all 52 specimens the humeral head was spherical. It was concluded that the pouched and redundant anterior capsule sometimes seen during surgery for recurrent dislocation of the shoulder, may not be traumatic in origin, but could be a developmental variant