Arthroscopic removal of an intramedullary nail in the humerus

The most frequent criticism of antegrade humeral nailing is its potentially deleterious effect on shoulder function owing to the trauma to the rotator cuff at the insertion point. This problem may also occur when removing an intramedullary nail from the humerus. In an effort to decrease the trauma to the rotator cuff at the nail insertion site during removal of an intramedullary nail from the humerus and to allow recovery of shoulder function as soon as possible after removal, we performed arthroscopic removal of the intramedullary nail and arthroscopic rotator cuff repair. The advantages of this method include the fact that it is a less invasive approach, which causes minimal disruption of the rotator cuff, requires fewer days in hospital, and allows simultaneous arthroscopic correction of the accompanying lesion.     

The active abduction view: A new maneuvre in the diagnosis of rotator cuff tears

The plain film views of the shoulder in the case of a fresh rotator cuff tear are usually normal. Reduction of the space between the under surface of the acromion process of the scapula and the humeral head occurs only in late, neglected cases. A new projection is described, the active abduction view of the shoulder, where in many patients with a complete rotator cuff tear the humeral head is closely apposed to the acromion, obliterating the subacromial space. In such a situation, the medial portion of the torn rotator cuff retracts during active abduction, allowing approximation of the two bones.     

Ultrasound measurement of rotator cuff thickness and acromio-humeral distance in the diagnosis of subacromial impingement syndrome of the shoulder

The usefulness of ultrasound measurements in the diagnosis of the subacromial impingement syndrome of the shoulder was evaluated. Fifty-seven patients with unilateral symptoms of the impingement syndrome underwent ultrasound examination of both shoulder joints, which included assessment of rotator cuff integrity, measurement of rotator cuff thickness and the distance between the infero-lateral edge of acromion and the apex of the greater tuberosity of humerus (AGT distance) in the standard ultrasonographic positions. As a control group, 36 volunteers (72 shoulders) with no history of shoulder pain were examined sonographically. Ultrasonographic assessment of humeral head elevation, measured as the AGT distance, proved to be useful in establishing the diagnosis of the subacromial impingement syndrome of the shoulder. A difference in rotator cuff thickness of more than 1.1 mm and a difference in the AGT distance of more than 2.1 mm between both shoulder joints may reflect dysfunction of rotator cuff muscles.     

切开复位内固定Ⅰ期肩袖修补治疗肱骨近端骨折合并肩袖撕裂的长期疗效分析

目的 探讨切开复位内固定Ⅰ期肩袖修补治疗肱骨近端骨折合并肩袖撕裂的长期疗效.方法 采用回顾性病例系列研究分析2012年1月至2015年12月上海交通大学医学院附属瑞金医院收治的40例肱骨近端骨折合并肩袖撕裂患者的临床资料,其中男24例,女16例;年龄52 ～93岁[(72.5±10.2)岁].Neer分型:两部分肱骨近...     

Sonographic detection of rotator cuff tears

Thirty-nine consecutive patients referred for shoulder arthrography underwent shoulder sonography to determine the ability of sonography to detect rotator cuff tears. Fifteen patients had arthrographically proven rotator cuff tears. Of these, 14 were detected by sonography, for a sensitivity of 93%. The three sonographic criteria indicative of rotator cuff tear were (1) discontinuity in the normal homogeneous echogenicity of the rotator cuff; (2) replacement of the normal homogeneous echogenicity by a central echogenic band; and (3) nonvisualization of the cuff. Twenty patients had normal sonographic examinations, 19 of which were normal by arthrography. Therefore, the predictive value of a negative sonogram was 95%. On the basis of these findings, sonography can provide a noninvasive means of screening patients with suspected rotator cuff tears.     

MRI and sonography of the shoulder

We prospectively evaluated the diagnostic value of sonography and magnetic resonance imaging (MRI) in 24 shoulders in 23 patients with suspected rotator cuff tears using arthrography as gold standard. Sonography demonstrated 14 of 15, MRI 10 of 15 rotator cuff tears, respectively. Sonography diagnosed seven of nine intact rotator cuffs correctly, MRI eight of nine. In a retrospective study we reviewed the diagnostic value of sonography and MRI in other pathologies of the shoulder including intra-articular pathology, humeral head and acromioclavicular joint pathology, and calcification. We conclude that with regard to cost and patient compliance, sonography should be the first radiologic examination in suspected rotator cuff tears if performed by an experienced sonographer. MRI is superior in depicting additional pathology and is less operator dependent. It may thus become the method of choice for the evaluation of the rotator cuff and related pathology in the future.     

Complex fractures of the proximal humerus: role of CT in treatment

The authors reviewed the computed tomography (CT) scans, plain radiographs, and subsequent treatment of 17 patients with complex proximal humeral fractures. CT scans and radiographs were compared in the demonstration of fracture lines, displacement of fracture fragments, rotation of fragments relative to their normal positions, and status of the head and articular surface of the humerus. The impact of CT findings on the decision to treat with surgery versus closed reduction and on the choice of surgical procedure was assessed. Surgery was not performed in nine patients because CT scans showed no significant displacement of fragments previously judged displaced or "indeterminate" on radiographs. Surgery was performed in eight patients; CT demonstrated significant abnormalities not definitely shown with radiography. In six of these eight patients, CT scans demonstrated unsuspected abnormalities that directed the choice of surgical procedure. CT scans provide clinically useful information for the treatment of complex proximal humeral fractures when radiographs provide inadequate or indefinite information.     

Rotator cuff coactivation ratios in participants with subacromial impingement syndrome

Coactivation of the rotator cuff is vital to glenohumeral joint stability by centralising the humeral head within the glenoid fossa. Yet in individuals with subacromial impingement, it is hypothesised that rotator cuff coactivation abnormalities are present that could contribute to their shoulder pain. The purpose of this study was to determine if abnormal rotator cuff coactivation and deltoid activation patterns exist in participants with subacromial impingement. Rotator cuff (supraspinatus, infraspinatus, and subscapularis) coactivation and middle deltoid activation was assessed during an elevation task. ANOVA models were used to compare muscle activation patterns in 10 participants with subacromial impingement and 10 control participants. Participants with impingement exhibited decreased rotator cuff coactivation (subscapularis–infraspinatus and supraspinatus–infraspinatus) and increased middle deltoid activation at the initiation of elevation (0–30° of humeral elevation). The participants with impingement also had higher subscapularis–infraspinatus and supraspinatus–infraspinatus coactivation above the level of the shoulder where pain is typically present (90–120° of humeral elevation). The results indicate that individuals with subacromial impingement exhibit rotator cuff muscle coactivation and deltoid activation abnormalities during humeral elevation that might contribute to the encroachment of the subacromial structures associated with subacromial impingement.     

肱骨大结节囊性变发生率与肩袖撕裂的关系

目的:探讨肱骨大结节囊性变发生率与肩袖撕裂之间的关系。方法:回顾性总结了2006年至2008年于北京大学第三医院运动医学研究所接受肩关节镜治疗的肩袖撕裂患者74名和复发性脱位患者71名,分别为肩袖撕裂组和复发性脱位组。测量患者MRI及X线片上显示的囊性变的最大直径,并且使用X线片评估大结节及肩峰的硬化、增生情况及形态。结果:所有患者中,39.3%患者的MRI中发现有囊性变。肩袖撕裂组,60.8%患者的MRI显示有囊性变,44.6%患者的MRI及X线片同时显示有囊性变。复发性脱位组,16.9%患者的MRI显示有囊性变,8.5%患者的MRI及X线片同时可见囊性变。肩袖撕裂患者中,有囊性变的患者平均病史23个月(7天-20年),未发现囊性变的患者平均病史26.8个月(1-120个月)。X线片显示,肱骨大结节囊性变及局限性密度减低,同时伴有III型肩峰及大结节增生硬化的患者均为肩袖撕裂患者。结论:肩袖撕裂患者出现肱骨大结节囊性变的比例明显高于无肩袖损伤患者,囊性变发生率与病史无明显相关。     

Greater tuberosity notch: an important indicator of articular-side partial rotator cuff tears in the shoulders of throwing athletes.

We examined the location of rotator cuff tears, associated labral injuries, and notches on the greater tuberosity of the humeral head in shoulders of throwing athletes. Arthroscopic findings (rotator cuff tear, labral condition, and greater tuberosity notch) as well as other factors (duration of playing baseball, range of motion, and joint laxity) of 61 baseball players were retrospectively studied. The presence of a greater tuberosity notch was also evaluated for by plain radiographs. Forty patients had articular-side partial rotator cuff tears, most of which occurred in the interval between the supraspinatus and infraspinatus tendons. The existence of a rotator cuff tear was not related to the range of motion, joint laxity, the detachment of the superior glenoid labrum, or posterosuperior labral injury. Greater tuberosity notches were recognized in 38 shoulders by arthroscopy and most were detected on plain radiographs. The presence of a notch was significantly related to the existence of a rotator cuff tear, while the size of the notch was significantly related to the depth and width of the tear. The greater tuberosity notch seems to be one of the most important diagnostic indicators for a rotator cuff tear in throwing athletes.     

Rotator cuff lesions of the shoulder: evaluation by direct sagittal CT arthrography

Direct sagittal computed tomographic scanning (DSCT) of the shoulder was performed in 42 symptomatic patients, six healthy volunteers, and two cadaver shoulders. Axial CT scanning and double-contrast arthrography with plain radiographs were performed in 41 patients for comparison. DSCT enabled correct identification of 27 of 29 lesions in 24 patients. Seventeen patients had normal shoulders. Axial CT scanning and DSCT together enabled correct identification of all lesions and were markedly superior to plain-film arthrography. DSCT enabled diagnosis of all cases of complete rotator cuff tear plus three cases of incomplete tear and three of rotator cuff atrophy not identified by the other techniques. Axial CT scanning was better than DSCT for diagnosis of Bankart lesions.     

Pitfalls of rotator cuff sonography

Experience with rotator cuff sonography in 106 patients was analyzed to identify the causes of scan misinterpretation. Possible interpretive errors may be classified into four categories: those from failure to recognize normal anatomy, those caused by soft-tissue abnormalities, those caused by bony abnormalities, and those caused by technical limitations of the study. Errors in recognition of normal anatomy are easily overcome by experience and comparison to the normal, contralateral rotator cuff. Errors resulting from soft-tissue abnormalities were seen in two patients with calcific tendinitis simulating rotator cuff tears. Problems in interpretation resulting from fractures in two patients and inferior glenohumeral subluxation in two other patients could have been avoided by review of the plain films before performing sonography. The major technical limitation of the study arises from the inability to image the rotator cuff beneath the acromion. Fortunately, rotator cuff tears are rarely isolated in this location, and passive maneuvers often allow otherwise hidden parts of the cuff to be imaged.     

The shoulder impingement syndrome: prevalence of radiographic findings and correlation with response to therapy

The shoulder impingement syndrome is believed to be caused by compression of the rotator cuff tendons and subacromial bursa between the humeral head and structures that make up the coracoacromial arch. Plain film findings were tabulated for 36 patients, 22-81 years old, who had signs and symptoms of an acute impingement syndrome. The most common radiographic abnormalities were subacromial bony proliferation in 68%, degenerative changes in the greater tuberosity of the humerus in 66%, and degenerative joint disease in the acromioclavicular joint in 66%. There was evidence of calcium deposition in the rotator cuff in 37%, inferiorly oriented acromioclavicular osteophytes in 32%, and degenerative changes of the lesser humeral tuberosity in 29%. The acromiohumeral space was narrowed in only 21%. The radiographic findings were scored blindly and compared to the treatment outcome of 6 weeks of medical therapy. There was no statistically significant correlation between any of the radiographic findings and the response to medical therapy. The results suggest that radiographic findings are extremely common in patients with the acute impingement syndrome, but that they are not useful as prognostic indicators of the short-term response to medical treatment.     

Limited sensitivity of ultrasound for the detection of rotator cuff tears

Bilateral rotator cuff sonography was performed on 56 patients referred for shoulder arthrography to detect rotator cuff tears. Since one patient had bilateral arthrography there were 57 arthrograms. Twenty-seven shoulders had rotator cuff tears shown on arthrography, 15 of which were detected by sonography. Eleven were false negative by sonography, and one was indeterminate. Of the 30 shoulders with negative arthrograms, 28 had normal sonograms and two were false positive. Sensitivity was 58%, specificity was 93% and overall accuracy was 77%. The positive and negative predictive values were 88% and 72%. These results suggest that sonography has limited value in screening patients for rotator cuff tears and that a positive sonographic reading is more reliable than a negative one. Theories relating to the variable anatomic configuration of a tear are postulated to explain these results, which differ from those previously reported.     

Extaarticular manifestations of septic arthritis of the glenohumeral joint.

Five patients with septic arthritis involving the glenohumeral joint are described. Although initial plain films were normal in all six involved joints, abnormalities were frequent on subsequent examinations, including demineralization (five joints), joint space narrowing (three joints), superior subluxation of the humeral head (three joints), osseous erosion (two joints), and inferior subluxation of the humeral head (one joint). Arthrography was helpful in documenting intraarticular placement of the needle for aspiration, synovial abnormalities, and extraarticular extension of disease. Particularly noteworthy was the occurrence of rotator cuff tears in four of six shoulders, suggesting a possible relationship between joint infection and disruption of the rotator cuff.     

Ultrasonography of the rotator cuff. Normal and pathologic anatomy

Forty-eight patients with shoulder pain and 15 normal volunteers underwent rotator cuff imaging using high resolution real time ultrasound. The potential diagnostic value of sonography in detecting rotator cuff tears was evaluated by correlating ultrasound findings with surgical findings in 19 patients, 12 of whom also underwent preoperative arthrography. The preoperative ultrasound diagnosis was correct in 18 of the 19 patients undergoing surgery for possible rotator cuff tears. In the group of 12 surgical patients undergoing both preoperative arthrography and sonography, ultrasound correctly predicted the presence of a rotator cuff tear in 12 of 12 patients, while arthrography predicted cuff tears in only nine of 12. Good anatomic definition of the rotator cuff was obtained in both symptomatic and asymptomatic groups. The characteristic appearance of the normal and pathologic rotator cuff is described. Rotator cuff sonography promises to be a valuable new diagnostic tool for evaluating patients with suspected rotator cuff tears.     

MR arthrography of the shoulder: comparison with conventional MR imaging

Twenty-three patients underwent both conventional MR imaging of the shoulder and MR shoulder arthrography for clinically suspected labral or rotator cuff abnormalities. Images obtained before and after contrast administration were studied independently, and without knowledge of clinical findings, by two radiologists for the presence of abnormalities of the glenoid labrum or rotator cuff. Results were correlated with surgical findings in all patients. Nine patients had surgically proved labral tears. MR arthrography detected all nine labral abnormalities, while six of the nine were missed on conventional MR imaging. Fourteen patients had surgically proved rotator cuff tears. MR arthrography detected 11 of the 14 tears and missed three partial tears on the bursal surface. Conventional MR imaging detected nine cuff tears and missed five tears; two of these were complete rotator cuff tears and three were partial tears of the undersurface of the rotator cuff. Our results suggest that MR arthrography enhances the accuracy of MR in the evaluation of the glenoid labrum and rotator cuff tendon.     

Anterior oblique projection in radiography of the traumatized shoulder

A series of 132 consecutive shoulder radiographs of traumatized patients was analyzed prospectively. Each shoulder examination included anteroposterior projections with external and internal rotation of the humerus and an anterior oblique projection. Each view was evaluated for the abnormalities that were identifiable on it. There were 84 normal examinations and 48 abnormal examinations. There were 29 fractures, dislocations, or acromioclavicular separations identified. Two fractures of the greater tuberosity were seen only on the anteroposterior projection with external rotation. One humeral head fracture and three scapular fractures were visualized only on the anterior oblique projection.     

Shoulder arthroplasty

Shoulder prostheses are now commonly used. Clinical results and patient satisfaction are usually good. The most commonly used types are humeral hemiarthroplasty, unconstrained total shoulder arthroplasty, and semiconstrained inversed shoulder prosthesis. Complications of shoulder arthroplasty depend on the prosthesis type used. The most common complications are prosthetic loosening, glenohumeral instability, periprosthetic fracture, rotator cuff tears, nerve injury, infection, and deltoid muscle dysfunction. Standard radiographs are the basis of both pre- and postoperative imaging. Skeletal scintigraphy has a rather limited role because there is overlap between postoperative changes which may persist for up to 1 year and early loosening and infection. Sonography is most commonly used postoperatively in order to demonstrate complications (hematoma and abscess formation) but may also be useful for the demonstration of rotator cuff tears occurring during follow-up. CT is useful for the demonstration of bone details both pre- and postoperatively. MR imaging is mainly used preoperatively, for instance for demonstration of rotator cuff tears.     

Double line sign: a helpful sonographic sign to detect occult fractures of the proximal humerus

The aim of this study was to describe a new sonographic sign of bone fracture and to determine if it can be helpful in decreasing the number of missed fractures of the proximal humerus. Ultrasound (US) of the shoulder was performed in 57 consecutive patients with shoulder pain and/or disability following trauma. All cases were prospectively reviewed for the presence of a humeral fracture. Sonographic signs of fractures, with special emphasis on what was termed the ‘double line sign’ (DLS), were assessed. Plain radiography was considered the standard of reference and in equivocal cases magnetic resonance imaging (MRI). Twenty-eight patients had a tuberosity complex fracture, which were all detected at US examination. Sonographic features of a fracture were periosteal elevation, corticol bone discontinuity, step-off deformity or a combination of these findings. This study showed that in 26 (93%) patients an additional sonographic feature, a DLS, could be demonstrated. The DLS is a helpful and probably reliable sonographic sign to indicate a humeral fracture. High-spatial-resolution US substantially increases the detection of fractures of the proximal humerus and should be considered as an alternative diagnostic tool prior to computed tomography (CT), MRI and arthroscopy in patients with persisting shoulder pain and/or disability following trauma.