Scapular neck fracture--the influence of permanent malalignment of the glenoid neck on clinical outcome

A scapular neck fracture is considered unstable if it is associated with an ipsilateral clavicular fracture or an acromioclavicular (AC) joint dislocation. Currently, it is recommended that stabilization of a disrupted shoulder girdle must be achieved through open reduction and internal fixation of the clavicular fracture or by reduction of the AC joint, without addressing the scapular neck. However, if the displaced glenoid neck is not simultaneously reduced, malalignment of the glenoid neck may persist. The purpose of this retrospective study was to analyze the effect of associated shoulder girdle injury on glenoid displacement and the influence of glenoid malalignment on clinical outcome. Nineteen patients with scapular neck fractures were reviewed clinically and radiologically at a mean of 8 years (range 2-21 years) after injury. None of them has developed nonunion of the scapular neck, and only one showed radiological signs of mild degenerative joint disease. The glenopolar angle (GPA), which assesses the rotational malalignment of the glenoid about an anteroposterior axis perpendicular to the scapular plane on plain X-rays was measured less than 20 degrees in six patients. Three of them had sustained an associated clavicular fracture or AC joint dislocation. The other 3 patients had permanent severe malalignment of the glenoid neck in the absence of an associated shoulder girdle injury. Five patients with GPA less than 20 degrees complained of moderate or severe pain, whereas of the 13 patients with mild or no glenoid rotational displacement or medial displacement alone, 11 patients had no or mild pain, and only 2 had moderate or severe pain (P = 0.0095). Five patients presented with reduced activities of daily living, 4 of them had severe glenoid rotational displacement (P = 0.0173). Loss of motion was found in only 2 patients, and both had a severely displaced glenoid neck (P = 0.088). In conclusion, severe displacement of the glenoid neck may occur with or without associated fracture of the clavicle or dislocation of the AC joint and can be identified as a GPA less than 20 degrees. Scapular neck fractures with such malalignment have a less favorable long-term outcome compared with otherwise comparable cases with absence of glenoid malalignment as measured with the glenopolar angle.

Arthroscopic findings in luxatio erecta of the glenohumeral joint: case report and review of the literature

PURPOSE

We report the case of an inferior glenohumeral dislocation of the shoulder in which arthroscopic assessment showed an extensive detachment of the labral-biceps tendon complex (Bankart and superior labrum anterior posterior [SLAP] lesions). We sought to review the literature to compare our findings with the reported lesions in this type of shoulder dislocation.

CASE SUMMARY

A young patient presented with an inferior dislocation of his right shoulder (erect dislocation) after having sustained a motorcycle accident. Conventional radiographs revealed the humeral shaft parallel to the scapular spine and an anteroinferior position of the humeral head with a large avulsion of the greater tuberosity. Preceding arthroscopy showed a complete detachment of the anterior labrum and ligament complex (SLAP lesion). After open reduction and internal fixation of the greater tuberosity, the capsulolabral complex was reduced and securely fixed with three bone anchors at the glenoidal rim. The patient recovered well reaching full shoulder function after 5 months and regaining the former sports activity level within 9 months after surgery.

DISCUSSION

Arthroscopy identified the location and extent of an important labral detachment that, in combination with the stability testing under anesthesia, proved the need for a labral refixation. The literature regarding reported pathology in inferior glenohumeral dislocation is reviewed, and the additional information on associated soft-tissue lesions by means of arthroscopy are discussed.

RELEVANCE

No prior case of arthroscopic assessment in inferior glenohumeral dislocation of the shoulder has been reported. Recognizing the extent and site of accompanying labral detachments contributing to the instability of the joint may enhance our knowledge of the full pathology in these dislocations and thus allow an adequate surgical treatment.

Discrete synchronous multifocal osteoid osteoma of the humerus

A 24-year-old patient is described who had a 4-year history of pain in the right upper arm, with distinct night pain, that responded to salicylates. From the findings on conventional radiography, bone scintigraphy and MRI a multifocal osteoid osteoma was suspected, with one focus in the cancellous region of the greater tuberosity and a second cortical focus at the proximal humeral diaphysis. The resection "en bloc" of both tumors and histological examination confirmed the diagnosis. The patient was painfree after the curative resection of the two osteoid osteomas. Osteoid osteoma is a frequently found benign bone tumor, accounting for approximately 11% of cases. In rare cases a multicentric occurrence has been described. A possible occurrence of more than one osteoid osteoma in a single bone, not verified histologically, has been reported only three times in the literature. In patients with scintigraphic and radiographic findings of two foci, discrete synchronous multifocal osteoid osteomas should be suspected.

Comminuted humeral head fractures: a multicenter analysis

Three centers' experience with 93 comminuted humeral head fractures were clinically (Constant score) and radiologically (Neer) analyzed. The results revealed fundamental differences between the various types of fractures depending on the number of fragments. For three-part fractures open reduction and internal fixation (mean Constant scores 83 and 91 points, respectively) or conservative treatment (78 points) seem to be indicated. The prognosis for four-part fractures is determined largely by the vascular supply of the head fragment with a high risk of humeral head osteonecrosis. For this reason primary prosthetic replacement (mean Constant score, 74 points compared with 54 points for conservative treatment and 52 points for open reduction) should be recommended for this type of fracture. In conclusion, we stress the importance of fracture type directing the therapeutic modality.

[Epiphysiolysis of the femoral head--can surgery prevent later arthritis?]

Slipped capital femoral epiphysis is one of the few orthopaedic emergencies. All orthopaedic surgeons agree that operation is the treatment of choice. In early stages, complete healing is possible. Fixation in situ is sufficient. If there is more severe dislocation of the head of the femur, the results become worse. More sophisticated and more difficult interventions aim at correction of the deformity, which may be a preliminary stage ['prearthrosis'] of osteoarthritis later in life. According to the extent of the slip, the surgeon may choose among different operations. The decision in a particular case is not easy. Complications are relatively frequent and sometimes severe. Long-term control show the late results and can thereby give guidelines for the surgeon's choice. Early diagnosis, however, is still decisive for a good prognosis in later life. As the disease is rather rare, the doctor who sees the patient first must be aware of it. Even at an early stage diagnosis can always be made on the basis of history, clinical findings and two X-rays.

Prevention of heterotopic ossification in hip arthroplasties by means of an early single-dose radiotherapy (6 Gy)

Radiotherapy has proven to be efficient in the prevention of heterotopic bone formation. Its importance is increasing in the treatment of uncemented implants in prosthetic hip surgery, where a localized irradiation field is applied to cover the bone-implant interface. In a prospective study the efficiency of two radiation concepts using two different doses to prevent heterotopic ossifications after total hip arthroplasties or revision arthroplasties was compared. In 7 patients after fractioned irradiation (5 x 2 Gy), two recurrences of periarticular ossification occurred, whilst in 17 patients after a single-shot irradiation of 6 Gy on the first postoperative day, no recurrences were seen. There were no side-effects from the radiation. Radiological signs of lucent cement-free implants or delayed wound-healing were absent. Thus, a single shot of 6 Gy applied within 24 h postoperatively reliably prevents heterotopic bone formation. It is safer than 5 x 2 Gy and facilitates the management of the patient.

[Functional results of Neer II type hemi-arthroplasty joint replacement of multi-fragment humerus head fractures]

Among the fractures of the proximal humerus--a typical kind of injury affecting elderly people, as well as gainfully employed patients, the comminuted and dislocated humeral head fractures have a specific position because of therapeutical reasons. By means of a retrospective analysis, a review is given of the results of 26 comminuted humeral head fractures type IV-VI according to Neer, treated with a Neer prosthesis type II at the surgical clinic of the Kantonsspital Lucerne between 1983 and 1989. Our interest is mainly concentrated on the functional results and on their correlation with biomechanical and perioperative factors. We use the fracture-classification and functional evaluation as described by Neer. For the results classified as "failures" (13 cases) the functional deficits of the glenohumeral joint mobility are essential. The scores reveal no significant correlation to the age of the patients, to the time interval between trauma and operation, as well to the duration of the postoperative physiotherapy. On the other hand the scores of patients with preoperative manipulation of the fractured joint (i.e. osteosynthesis, reduction attempts, physiotherapy) were significantly worse than those with primary prosthetic replacement. Furthermore, because of the insufficient restitution of the lever arm conditions, the implantation of the small-head component (15 mm) leads to significantly less favorable functional scores, with a corresponding radiological hyperpression in the cranial articular space. Our analysis leads to the following conclusions: 1. Under the condition of a conclusive preoperative diagnosis a primary prosthetic procedure is recommended depending on the type of fracture.(ABSTRACT TRUNCATED AT 250 WORDS)