Full Shoulder Research Articles

Antegrade Intramedullary Nailing in Humeral Shaft Fractures

Purpose: To evaluate union time and functional recovery of the shoulder joint in humeral shaft fractures treated with intramedullary nailing. Material and Methods: During the period 1990-2001, 43 patients with humeral shaft fractures were treated with intramedullary nailing. 38 patients (21 males and 17 females, mean age 48 years) were available at the final follow-up evaluation after 21 months on average. In 25 patients the entry point was below the greater tuberosity to avoid rotator cuff injury and in the other 18 patients the entry point was intra-articular. Passive shoulder and elbow motion was allowed from the second postoperative day followed by active assisted exercises from the second postoperative week. Union progress was assessed radiologically at 2nd, 4th, 8th, and 16th postoperative week whereas final shoulder function was evaluated using the parameters of the Constant-Murley scoring system. Results: Solid callus formation was noted in all fractures, except one, between the 8th and 35th postoperative week. Patients with extra-articular application of the nail had full passive shoulder motion between the 2nd and the 4th postoperative week whereas patients with intra-articular application had delayed passive shoulder motion and final functional limitation. Seven patients had painful shoulder motion 3 months postoperatively. There were 4 patients with transient radial nerve palsy, who demonstrated full functional recovery after 3 to 6 months and 3 patients with proximally migration of the nail underwent reoperation. Conclusions: Intramedullary nailing in humeral shaft fractures seems to be a reliable method of treatment regarding union and functional recovery. Advantages are shorter operative time, minor blood loss, small incision with shorter soft tissue detachment and early mobilization of the shoulder, especially in the patients with extra-articular nail application without rotator cuff injury.

Patient outcome after surgical management of an accessory nerve injury.

This study assessed patient outcome following surgical reconstruction of the accessory nerve after an iatrogenic injury. A retrospective chart review of 8 patients was performed. There were 3 men and 5 women in the study, and the mean time between injury and nerve graft/repair surgery was 5 months. Four injuries were sustained during a lymph node biopsy. Electromyography revealed a complete accessory nerve injury in all cases. In 6 cases, a nerve graft was required (mean length, 3.6 cm), and in 2 cases, a direct nerve repair was possible. The trapezius muscle was successfully reinnervated in all cases. In total, full shoulder abduction was achieved in 6 cases; in the remaining 2 cases, the patients achieved shoulder abduction to 90 degrees. Functional deficit after accessory nerve injury is significant. Nerve graft/repair reconstruction reliably yields a satisfactory result, providing good scapular rotation and thus good shoulder function.

Split-thickness skin grafts and negative-pressure dressings in the treatment of axillary hidradenitis suppurativa

Although a number of different reconstructive techniques have been described for the treatment of axillary skin defects, split-thickness skin grafting continues to be the most common surgical modality. Here, we present our recent experience of using split-thickness skin grafts together with negative-pressure dressings for the management of defects following wide surgical excision of severe hidradenitis suppurativa. This technique ensures complete skin-graft take whilst allowing full shoulder mobility, thereby minimising the undesirable sequelae associated with split-thickness skin grafting alone.

Experiences of combined visual training and arm activation in the rehabilitation of unilateral visual neglect: A clinical study

This study reports a rehabilitation training for unilateral visual neglect combining a visual training programme and arm activation. Four cases of left visual neglect are presented with differing arm use. Neglect impairment was assessed using seven neuropsychological tests at weekly intervals for nine weeks: three weeks before, during and after the treatment period. In addition, one patient was followed over a longer time period. The treatment consisted of both a visual training programme and simultaneous arm activation. Considerable improvement in three of the four patients was observed in article reading. Moreover, all patients showed some improvement on three cancellation tests, whereas there was no improvement on other tests. In particular, the patients who had full hand or shoulder movement showed improvement in their performance. These results point out the usefulness of combined visual training and arm activation in the rehabilitation of visual neglect.

SHOULDER INJURY - TENNIS

HISTORY A 32-year-old healthy right-hand-dominant recreational tennis player developed sudden onset of pain in his right lateral shoulder after a serve. The pain spontaneously resolved after two days; however, one week later he developed recurrent, sharp, lancinating pain over the lateral portion of the right shoulder, which eventually spread to involve the superior aspect of the scapula. He was evaluated by a primary care sports physician. Radiographs were unremarkable and examination was consistent with supraspinatus tendonitis. Treatment with oxaprozin and physical therapy was prescribed and his pain resolved in two days; however, the therapist noticed some abnormal scapular motion and he was referred to our clinic for further evaluation. PHYSICAL EXAMINATION Inspection revealed a well-developed young adult male with slight shoulder protraction bilaterally. There was full, pain-free passive and active shoulder range of motion. No tenderness about the shoulder girdle or rotator cuff. Strength was normal throughout the upper extremity with the exception of significant superiomedial scapular winging, which was noted with a wall push-up maneuver indicating serratus anterior muscle weakness. Reflexes were physiologic and symmetric. Spurling's maneuver was negative. DIFFERENTIAL DIAGNOSIS Long thoracic neuropathy. Serratus anterior muscle strain or tear. Brachial plexopathy. Cervical radiculopathy. TEST AND RESULTS No evidence of fracture, dislocation, arthropathy or tendonopathy. Fibrillation potentials (3+) and absence of voluntary activation of the right serratus anterior consistent with an electrophysiologically severe, active, right long thoracic neuropathy. FINAL/WORKING DIAGNOSIS Traumatic right long thoracic neuropathy. TREATMENT Patient education on etiology of the injury, anticipated recovery time, and potential for incomplete recovery. Physical therapy for facilitation of serratus anterior muscle activation and a scapular stabilizer strengthening program. Maintenance rotator cuff strengthening program. Repeat electromyography at three months to assess reinnervation.

Endoscopic Axillary Lymphadenectomy Without Prior Liposuction in 100 Patients With Invasive Breast Cancer

The purpose of this study was to evaluate intra- and postoperative outcome after endoscopic axillary lymphadenectomy without liposuction. One hundred patients with early stage breast cancer were treated by breast conserving therapy and endoscopic technique. The median duration of operation was 75 minutes (30-130 minutes). Switching from endoscopy to an open technique was necessary for two patients. The median number of removed lymph nodes was 16. Postoperatively, seroma developed in four patients, temporal winged scapula developed in three patients, and a wound infection in one patient. On postoperative day 5, arm mobility was not restricted for 89 patients. After a median follow-up of 14 months, 14 patients reported persistent impairment of sensibility, and two patients did not have full shoulder mobility. Axillary recurrence has not developed in any patient. Endoscopic axillary lymphadenectomy can be performed safely without previous liposuction.

Endoscopic axillary lymphadenectomy without prior liposuction. Development of a technique and initial experience.

A new technique of endoscopic axillary lymphadenectomy without prior liposuction was developed by our group. A total of 33 patients with early stage breast cancer were treated by breast-conserving therapy and endoscopic axillary lymphadenectomy. The median duration of the operation was 74.9 min (range, 30-130). Operation time was significantly shorter for the last 17 patients (p < 0.05) than for the first 16 patients. There were no intraoperative complications. The median number of removed lymph nodes was 14.5 (range, 2-28). Postoperatively three patients developed a seroma, one of which required evacuation. At postoperative day 5, arm mobility was unrestricted in 26 patients (78.7%); nine patients (27.2%) reported a loss of sensation in the outer side of the upper arm related to dermatome C5. One patient developed a temporary alar scapula, and one patient developed an axillary abscess 9 weeks after axillary lymphadenectomy during radiation therapy. After a median follow-up of 4.6 months seven patients reported persistent impairment of sensation, but all patients had regained full shoulder mobility. Endoscopic axillary lymphadenectomy can be done safely without prior liposuction.

Antegrade Interlocking Nailing of Acute Humeral Shaft Fractures

Between 1992 and 1996, 73 acute humeral shaft fractures in 71 patients were treated with antegrade Russell-Taylor humeral nailing. Sixty (84%) patients sustained multiple trauma, and 26 (36%) fractures were open. Three patients had preoperative brachial artery injuries, and 12 had preoperative nerve palsies. Sixty-nine (94.5%) fractures united primarily, and two additional fractures united after bone grafting. There were no infections. Two (2.7%) iatrogenic radial nerve palsies occurred, and both were transient. Full shoulder function returned in 66 (90%) patients. Two (2.7%) patients had impingement from proximal locking screws, and one (1.4%) had impingement from a prominent nail. Normal elbow function was regained in 96% of patients. All patients without full return of elbow and shoulder function had concomitant injuries. Antegrade Russell-Taylor nailing is an acceptable alternative for the treatment of acute humeral shaft fractures in multiply injured patients.

Usefulness of full shoulder extension test

Usefulness of full shoulder extension test

Physical Therapy Management of Isolated Serratus Anterior Muscle Paralysis

This case report presents a patient who developed right shoulder pain following strenuous upper-extremity exercise. Approximately 6 weeks later his pain resolved, he noticed persistent right upper-extremity weakness. He was referred to physical therapy for evaluation and treatment. Physical therapy evaluation revealed isolated serratus anterior muscle paralysis. A long thoracic neuropathy was subsequently confirmed by electromyographic testing. The etiology, pathophysiology, and pathokinesiology of serratus anterior muscle paralysis are reviewed. A case is presented, illustrating how the clinical decision making is based on the pathokinesiology and pathophysiology. The patient was followed over the course of 17 months and has recovered full right shoulder active range of motion. His serratus anterior muscle strength has increased to Good minus, and he reports significantly improved functional use of the upper extremity.

Passive insufficiency of two-joint shoulder muscles

This preliminary study examined the effects of full elbow flexion and full elbow extension on the end-point of active range of motion of shoulder flexion and shoulder extension respectively. The end-points were measured from lateral photographs of the right upper limbs of 30 men after they flexed and extended their shoulders with their elbows held in full flexion and full extension. Angular measurements showed that full elbow flexion limited shoulder flexion range of motion and that full elbow extension limited shoulder extension range of motion. The results indicated that passive muscle insufficiency of active shoulder flexion and extension was probably brought about by lengthening the triceps brachii and the biceps brachii muscles respectively. Clinicians are encouraged to considerthis passive insufficiency when measuring range of motion of shoulderflexion and extension and when implementing therapeutic interventions.

A MADYMO Model of Near-Side Human Occupants in Side Impacts

The protection of automotive occupants against broadside collisions is of current interest due to the implementation of a new Federal standard on side impact. There is controversy as to the validity of the standard, the best criterion to assess injury to the thorax and the type and manner in which padding should be used. Although it has been shown in a series of 17 cadaveric tests that paper honeycomb can reduce thoracic injuries dramatically, there are still concerns regarding the loss of air space between the door and the occupant due to the presence of the padding and regarding the loss of protection for the thorax when there is no engagement of the shoulder with the intruding side structure of the car. This paper describes the development of a three-dimensional rigid body model to simulate cadaveric experiments carried out at Wayne State University. Model parameters were chosen to yield human-like responses at the level of the shoulder, thorax, abdomen and pelvis. The model was then used to study the effect of padding on injury parameters related to the nearside occupant when a relatively thick padding is used (up to 100 mm). It was also used to study the increase in force on the thorax when shoulder engagement is lost. Laboratory tests were conducted with full shoulder engagement but in the field most cars have a low beltline (window sill) which effectively eliminates shoulder contact if the arms are outstretched in a normal driving posture. If a sufficiently soft padding was used, the model did not predict an increase in thoracic force level or any of the injury parameters.(ABSTRACT TRUNCATED AT 250 WORDS)

Impingement and instability in the throwing athlete

Shoulder pain in the throwing athlete presents a difficult diagnostic and therapeutic problem.Frequently, the impingement symptoms mask the more subtle findings of anterior instability, resulting in a delay in the diagnosis and treatment. In the young throwing athlete with shoulder pain, it is essential to recognize that anterior subluxation or instability, not impingement, is the primary process. The instability in these athletes results from the repetitive high-energy forces and the inherent increased range-of-motion demands of the sport. Excessive stress generated during repetitive overhand throwing causes fatigue of the dynamic restraints (rotator cuff and scapular stabilizers) of the shoulder and results in progressive attenuation of the anterior static restraints (capsulolabral complex). This leads to occult anterior subluxation of the humerus. Fortunately, most athletes respond to an aggressive 3- to 6-month rehabilitation program addressing the rotator cuff and scapular stabilizers. For those patients who do not respond to conservative treatment, the Mitek modification of the anterior capsulolabral reconstruction (ACLR) is directed at correcting the instability. This surgical procedure is performed through a muscle-splitting technique that leaves the muscle attachments undisturbed and allows early return of full shoulder range of motion.The most recent Mitek modification of the ACLR, together with an aggressive postoperative rehabilitation program, has resulted in a significant improvement in the ability to correct shoulder instability and successfully return the throwing athlete to competition.

Alternative (muscle-sparing) incisions in thoracic surgery

The technique, advantages, and disadvantages of a vertical axillary thoracotomy are discussed. This is a total muscle-sparing incision that allows adequate exposure of all intrathoracic structures. Postoperatively, there is excellent cosmetic healing and full shoulder girdle movement. The postthoracotomy pain also appears to be less. I prefer this approach for most routine thoracotomies, although I do not use it when chest wall resections or extremely difficult hilar dissections are anticipated.

Titanium staple and screw fixation for recurrent dislocation of the shoulder

A small titanium staple with a locking screw was designed in 1979 to hold the anterior capsule of the shoulder firmly to the front of the scapula just medial to the glenoid. The posterior or inferior capsule can also be stabilized. Two indentations on the staple diminish capsular compression, while a central hole for a 4.5-mm titanium alloy cortical screw allows firm fixation of the staple. A small deltopectoral or axillary approach is used and the subscapularis and capsule are incised on the line of the muscle fibres. The operation is relatively simple and combines the advantages of a Bankart, bone block and capsular plication in a single small operative procedure. Full movement, including external rotation, can be started 3 days postoperatively, and most patients can return to manual labour or contact sport in 4 to 6 weeks. A total of 47 anterior dislocations and two posterior dislocations have been treated since 1981, including six failed Putti-Platt operations and one Helfet operation. Full shoulder movement is usually achieved within 3 weeks of operation.

The Diagnosis and Treatment of Anterior Instability in the Throwing Athlete

In the overhand or throwing athlete, the shoulder is extremely vulnerable to injury due to the repetitive, high-energy forces. When these stresses are applied at a rate that exceeds that of tissue repair, progressive damage to the shoulder's stabilizing structures can occur. With continued throwing, the static restraints become progressively attenuated, allowing anterior glenohumeral subluxation. Initially, the dynamic stabilizers can compensate for this mild instability with increased muscle activity. Prolonged activity, however, may lead to fatigue. Over time, these compensatory mechanisms can become overloaded. The humeral head then may subluxate anteriorly, where it contacts with the coracoacromial arch, ultimately leading to subacromial impingement. Posterosuperior glenoid impingement may also occur as anterior humeral translation allows the undersurface of the tendinous portions of the supraspinatus and infraspinatus to impinge along the posterosuperior border of the glenoid rim. Fortunately, conservative management is effective in most chronic overuse injuries and includes an initial period of relative rest (avoidance of throwing), oral nonsteroidal antiinflammatory medication, a physical therapy program structured to provide local modalities to reduce inflammation, and a strengthening program for the rotator cuff and scapular rotators. For those athletes with continued symptoms, surgical intervention may become necessary. The appropriate surgical treatment depends on the diagnosis. In the young throwing athlete with shoulder pain, it is essential to recognize that instability or occult subluxation, rather than impingement, is the primary underlying pathology. The anterior capsulolabral reconstruction addresses the problem of instability by correcting the capsular redundancy or labral damage or both. When performed in the manner described, muscle attachments and proprioceptive muscle fibers are not disturbed and full shoulder range of motion can quickly be achieved. This most recent surgical technique and postoperative rehabilitation program has resulted in a significant improvement in the ability to correct instability in those athletes who have failed a prolonged course of conservative care. Prevention of these injuries may be attained, it is hoped, through continued research into the basic biomechanics and the pathoanatomy associated with overhand sports.(ABSTRACT TRUNCATED AT 400 WORDS)

The ‘stove-in shoulder’: results of treatment by early mobilization

The ‘stove-in shoulder’ is an injury in which the scapula is fractured and the lateral fragments are displaced medially. Out of 10 patients, eight treated by early mobilization regained full shoulder function within 1 year.

A locking nail for fractures of the humerus

We reviewed 19 patients treated for upper arm fractures using Seidel's locking nail system, which allows for early function after operation. The overall results were good with no cases of pseudarthrosis, infection or radial nerve palsy. All the patients regained full shoulder movements with no evidence of rotator cuff lesions.

The Serratus Anterior Free-Muscle Flap

We report free serratus transplantation in 100 consecutive patients, 10 in combination with the latissimus muscle and 2 with rib. Transplantation was performed for extremity soft-tissue coverage, contour correction, and facial reanimation. Twenty-two patients received serratus transplantation as part of complex reconstruction requiring multiple microvascular transplants. Overall success was 99 percent, with a single flap failure. Four patients suffered partial flap loss. Emergent reexploration for suspected vascular occlusion was infrequent, required in six flaps (6.0 percent), with an 83 percent salvage rate. Significant complications occurred in 18 percent of recipient sites and 12 percent of donor sites, with eight patients developing seroma/hematoma. No scapular winging was noted, and all patients retained full shoulder range of motion. The serratus muscle flap is a highly reliable flap characterized by a consistently long pedicle, excellent malleability, and multipennate anatomy permitting coverage of complex three-dimensional wounds and consistent performance as a functional transplant. Underlying rib can be included as a myo-osseous flap to expand the versatility of this flap.

Ｈｏｍｅ Ｐｏｓｉｔｉｏｎ診療姿勢がフィニッシング形態，特にフルショルダー形成へ及ぼす影響について 上顎左側第２小臼歯

Abutment tooth of full shoulder with castable ceramic crown for the maxillar left second premolar (5) was prepared in Home Position (H.P.).The following results are obtained on the influence in H.P. on the finishing form, especially on the full shoulder preparation.1. Finishing Form 1) Angle of inclination of shoulder surface sloped in each part, especially on buccal.2) Width of shoulder was narrow in each part, except in medio-buccal and lingual.3) Surface of abutment tooth of lower part of axial wall and shoulder was rough in almost any part, except in central lingual.4) As for Rough Value, smooth of curve on finishing line was questionable, especially on each angles.2. Amount of Reduction1) Amount of reduction on the subgingival was small, especially on central-buccal and lingual.2) Taper of axil wall almost acceptable, excep cept central-buccal.3. Required Time for PreparationAbutment tooth preparation required about 18/20min. and the share of the stopping time of air turbine was about 35%. The preparation of medial and distal proximal surface and subgingival required longer time than any other part.This research clarified that taper of axial wall was almost acceptable in abutment tooth preparation of full shoulder in H.P., however, subgingival preparation of finishing form including finishing line was a subject to be solved.