Ossification of the coracoacromial ligament: association with rotator cuff pathology of the shoulder

The objective of this study was to assess the association of ossification of the coracoacromial ligament (CAL) observed on conventional radiographs with the presence of rotator cuff pathology as demonstrated by magnetic resonance imaging (MRI), arthrography, and/or surgery. Conventional radiographs (internal and external rotation and outlet and axillary views) on eight patients showed ossification of the coracoacromial ligament. Rotator cuff integrity was assessed by physical examination in all 8 patients, by arthrography in 3 patients, and by MRI in 2 patients. Surgery was performed on four of the patients. Physical examination showed impingement findings and decreased rotator cuff strength suggestive of rotator cuff disease in all eight patients. The arthrograms and MRI examinations showed the presence of full-thickness rotator cuff tears. Four of these patients underwent surgery and the rotator cuff defects were confirmed and repaired. Identification of ossification of the CAL on conventional radiographs should be recognized as strongly suggestive of associated significant rotator cuff pathology.     

Activation of the rotator cuff in generating isometric shoulder rotation torque

This study compared and quantified electromyographic muscle activation of the rotator cuff with the isometric torque generated by performing shoulder rotation in various positions. Twenty healthy volunteers were tested in 29 shoulder positions. Using a Cybex II dynamometer synchronously with electromyography, surface electrodes were placed over the pectoralis major muscle and three parts of the deltoid muscle. Intramuscular wire electrodes were inserted into the four rotator cuff muscles. We found that the greatest external rotation isometric force is generated in the frontal and scapular planes in the neutral or full internal rotation positions. The sagittal, dependent, and the scapular plane with 45 degrees of elevation in rotational positions of either full or half external rotation generated the greatest torques for internal rotation isometric force. The rotator cuff muscles generated greatest electromyographic activity in neutral to midrotational positions. The scapular plane with 90 degrees of shoulder elevation in neutral rotation best isolated the subscapularis muscle. The infraspinatus-teres minor muscles were isolated in the sagittal plane with 90 degrees of shoulder elevation in a half externally rotated position. We were unable to isolate the supraspinatus muscle in any of these tested positions. These positions are recommended for manual muscle testing and for strengthening these muscles.     

Irreducible anterior shoulder dislocation with fracture of the greater tuberosity

The combination of an anterior shoulder dislocation and an avulsion fracture of the greater tuberosity can usually be reduced by closed methods. This report describes a patient requiring open reduction and division of the subscapularis tendon before reduction of the glenohumeral dislocation could be achieved.     

Vascular complications of anterior dislocation of the shoulder

Vascular complications are rare in cases of simple anterior dislocation of the shoulder but the axillary artery and its branches may be damaged. Four cases of axillary artery injury, including 2 cases of complete transection of the artery, are presented. Full upper limb function may return if the vascular damage is recognized and prompt surgical treatment undertaken.     

Open capsulorrhaphy with suture anchors for recurrent anterior dislocation of the shoulder

OBJECTIVE: The aim of this study was to index the frequency of occurrence of acute stress disorder following mild traumatic brain injury and to determine its utility in predicting posttraumatic stress disorder (PTSD). METHOD: Consecutive adult patients who sustained a mild traumatic brain injury following a motor vehicle accident (N = 79) were assessed for acute stress disorder within 1 month of their trauma with the Acute Stress Disorder Inventory, a structured clinical interview based on DSM-IV criteria. Patients were followed up 6 months after the trauma (N = 63) and were administered the PTSD module of the Composite International Diagnostic Interview. RESULTS: Acute stress disorder was diagnosed in 14% of patients, and at follow-up 24% satisfied criteria for PTSD. Six months after the trauma PTSD was diagnosed in 82% of patients who had been diagnosed with acute stress disorder and in 11% of those who had not been diagnosed with acute stress disorder. CONCLUSIONS: These findings point to the frequency of PTSD following mild traumatic brain injury. While the criteria for acute stress disorder are useful in identifying those individuals who are at risk of developing chronic PTSD, the findings suggest that current criteria require modification in order to optimally predict PTSD following mild traumatic brain injury.     

Shoulder kinematics with two-plane x-ray evaluation in patients with anterior instability or rotator cuff tearing

There is still a significant lack of treatment and rehabilitation facilities for chronic pain patients in Germany today. Most of all the treatment of low back pain and widespread pain syndromes or panalgesia is time consuming and complicated. The main problem of anaesthesiological pain clinics is the increase of these complex pain syndromes in the last years. The definition of chronic pain is a continuous noxious input modulated and compounded by the prolonged or recurrent nature of chronic state and further complicated by a multitude of economic and psychosocial factors. It is now clear that no one discipline or mode will suffice. Only a multidisciplinary and intensive approach will prevail, as discussed in this article. Unfortunately these multidisciplinary pain units are nearly not existing in Germany just as little as control of the effectiveness of pain treatment.     

Treatment of recurrent anterior dislocation of the shoulder with pectoralis minor muscle-bone flap]

We treated 10 patients with recurrent anterior dislocation of the shoulder by transplantation of pectoralis minor muscle-bone flap transplanted to the upper part of the humerus. All patients were followed-up for an average 31 months and no recurrent was found. We consider that the muscle beily exerts a protective effect like a barrier on the weak anterio inferior region of the shoulder and increases the force for extending the shoulder and lifting the arm. The operation is based on biomechanics. Meanwhile, suturing the laxative joint capsule and repairing the weak anteroinfeior region of the shoulder is more beneficial to prevent from redislocation of the humerus head.     

Partial-thickness tears of the rotator cuff: evaluation and management

The approach to management of a partial-thickness rotator cuff tear is best made with the understanding that this is not a singular condition. Rather, partial tears represent the common outcome of a variety of insults to the rotator cuff. Degenerative changes due to aging, anatomic impingement, and trauma may all be etiologic agents. Overhead athletes may develop tears due to repetitive microtrauma or internal impingement. Outlet radiographs and magnetic resonance imaging are recommended for routine preoperative evaluation. A nonoperative treatment program for rotator cuff strengthening and stretching is appropriate as initial treatment; modification of activities and anti-inflammatory medication are often used as well. Operative management may be considered when nonoperative treatment fails. Arthroscopic evaluation is required to determine the true extent of the cuff lesion. Arthroscopic subacromial decompression is recommended when outlet impingement is present. Rotator cuff debridement or formal cuff repair is dependent on the size of the cuff defect and the age and activity level of the patient. The importance of recognizing the different causes of partial-thickness rotator cuff tears is emphasized in this review of pathogenesis, clinical diagnosis, imaging, and treatment.     

Sonographic findings of rotator cuff tears: correlation with MR imaging

Sonography was performed in 41 patients with symptoms referable to the rotator cuff. Sonography was performed immediately after MR imaging, so that the information obtained by MR imaging could be applied to sonographic diagnosis. Twenty patients were diagnosed from T2-weighted images as having complete tears of the rotator cuff. Sonography showed full-thickness anechoic areas in 12 of the 20 patients, heterogeneous hyperechoic areas in seven, and no abnormal findings in the other one. Thirteen patients were diagnosed as having incomplete tears with MR imaging. Sonography showed heterogeneous hyperechoic areas in 12, but no abnormal findings in one of the 13. Hyperechoic areas in the rotator cuff were shown in four of eight patients who had been diagnosed from T2-weighted images as not having tears. We consider full-thickness anechoic areas to be specific findings of complete tears, although some patients with rotator cuff tears did not show this finding.     

Strength of fixation with transosseous sutures in rotator cuff repair

The effect of various configurations of placement of transosseous sutures on the immediate strength of fixation was studied in forty-five fresh-frozen humeri from cadavera of older individuals (mean age at the time of death, sixty-three years). The ultimate strength (the strength to failure) was significantly greater (p < 0.05) when the sutures were placed at sites more distal to the tip of the greater tuberosity or when the sutures were tied over a wider bone bridge. Cortical augmentation with use of a plastic button through which the transosseous sutures were tied increased the ultimate strength approximately 1.9-fold. The increase in the ultimate strength of the transosseous repair corresponded significantly with the increasing mean thickness of the cortical bone as the sutures were placed more distally along the lateral aspect of the humerus. We concluded that the strength of the fixation of a rotator cuff repair can be increased by placing the transosseous sutures at least ten millimeters distal to the tip of the greater tuberosity and by tying them over a bone bridge that is at least ten millimeters wide. When bone is very osteoporotic, cortical augmentation with a readily available plastic button strengthens the repair.     

Lag signs in the diagnosis of rotator cuff rupture

We assessed the relative value of lag signs for the evaluation of rotator cuff rupture in a prospective study of 100 consecutive painful shoulders with impingement syndrome, stages 1 to 3. Lag signs were compared with the Jobe and lift-off signs. Three tests were designed to assess the main components of the rotator cuff: the external rotation lag sign (ERLS) for the supraspinatus and the infraspinatus tendons, the drop sign for the infraspinatus, and the internal rotation lag sign (IRLS) for the subscapularis tendon. For assessment of the supraspinatus and infraspinatus the ERLS was less sensitive but more specific than the jobe sign. The drop sign was the least sensitive but was as specific as the ERLS. Partial ruptures of the supraspinatus remained concealed to the ERLS. For assessment of the subscapularis the IRLS was as specific but more sensitive than the lift-off sign. Partial ruptures of the subscapularis tendon could be missed by the lift-off sign but were detected by the IRLS. The magnitude of the lag correlated with the size of the rupture for both the ERLS and the IRLS. Clinical testing for lag signs was efficient, reproducible, and reliable. In patients with little or no restriction of motion it enhanced the accuracy of clinical diagnosis in rotator cuff lesions.     

The timing of congenital brachial plexus injury: a study of electromyography findings in the newborn piglet

OBJECTIVE: Permanent congenital brachial plexus palsy is a recognized serious complication associated with shoulder dystocia. The timing and etiology of this injury remains controversial. Previous authorities have used adult-derived, non-brachial plexus data to extrapolate the anticipated timing for electromyographic denervation changes to date such injuries in the newborn. With use of a domestic swine model, this investigation tests the hypothesis that electromyographic evidence of brachial plexus denervation in the newborn is temporally different than that in the adult. STUDY DESIGN: Five healthy 2-day-old and two adult pigs underwent unilateral sharp transection of the brachial plexus. Daily electromyographic studies were performed in brachial plexus innervated muscle groups on the involved and contralateral (control) front limbs. Postmortem measurements of the transected nerve segments were obtained in one piglet and one adult animal. Representative hard copy recordings of individual electromyographic studies were collected. RESULTS: Immediately after surgical transection of the brachial plexus, no electromyographic evidence of denervation was observed. Uniformly in the newborn piglets, at 24 hours after transection, denervation in the form of fibrillation potentials, positive sharp waves, and complex repetitive discharges was seen. Serial testing demonstrated proximal to distal gradients of denervation over the next 24 to 48 hours. A delay in electromyographic evidence of denervation was observed in the two adult pigs until days 5 and 8, respectively. Control limb studies remained normal throughout the study period. Nerve length measurements for individual muscle groups were as follows for the adult and newborn pigs, respectively: deltoid 11.4 cm, 2.5 cm; cleidobrachialis 16.0 cm, 4.0 cm; triceps 15.5 cm, 4.5 cm; forelimb flexors 26.0 cm, 6.5 cm; and extensor carpi radialis 31.0 cm, 9.0 cm. CONCLUSION: Electromyographic evidence of brachial plexus denervation after surgical transection differs between the newborn and the adult pig. Consistent with wallerian degeneration, a correlation exists between length of the distal nerve segment and timing for electromyographic signs of denervation. These findings suggest it would be inappropriate to extrapolate the anticipated timing for electromyographic changes in the newborn on the basis of previously established adult non-brachial plexus data.     

Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete

A case of impingement of the deep surface of the supraspinatus tendon on the posterior superior rim of the glenoid and mild anterior laxity has been presented. The partial-thickness tear of the undersurface rotator cuff tendon, degenerative tear of the posterior superior labrum, and osteochondral impression fracture of the humeral head have been documented. The purpose of this case report is to present the pathological findings associated with posterior superior glenoid rim impingement and emphasize its role as a cause of shoulder pain in the overhead athlete. In addition it is important to stress the fact that shoulder pain in the overhead athlete may be multifactorial.     

Magnetic nerve root stimulation in two types of brachial plexus injury: segmental demyelination and axonal degeneration

Magnetic cervical nerve root stimulation was performed in 9 patients with plexopathies secondary to suspension (SP) and in 12 cases with neurogenic thoracic outlet syndrome (NTOS). The findings were compared with those of the previously reported case groups: n-hexane polyneuropathy (HPNP), inflammatory demyelinating polyneuropathy (IDP), and motor neuron disease (MND). Muscle responses elicited by magnetic stimulation had very high rates of amplitude and area loss in the neck-axilla segments of the 6 SP patients. This, along with the other electrophysiological findings, suggested the presence of segmentally demyelinating plexus lesions. In NTOS patients, magnetic stimulation findings were not significantly different from those of the controls. Neck-axilla segment amplitude and are reduction rates in SP and IDP patients were significantly higher than those found in NTOS, HPNP, and MND groups, implying that magnetic nerve root stimulation may have a role in the demonstration of segmentally demyelinating lesions involving proximal nerve segments.     

Anatomy of the normal brachial plexus revealed by sonography and the role of sonographic guidance in anesthesia of the brachial plexus

The complete amino acid sequence of [2Fe-2S] ferredoxin from Physalis alkekengi var. francheti has been determined by automated Edman degradation of the entire Cm-protein and of the peptides obtained by trypsin and endoproteinase Asp-N digestions. This ferredoxin exhibited ten, ten, and nine differences respectively in the amino acid sequence, when compared with the ferredoxins of Datura stramonium, D. metel, and D. arborea, but 21-28 differences for other angiosperms, and 34-37 differences for fern and horsetails. These results are in harmony with the taxonomic position for these plants.     

Paresis of the brachial plexus: subcapital varus osteotomy, arthrodesis of shoulder joint and above-elbow amputation (author's transl)]

In brachial plexus paresis with partial sensory sparing in the upper arm and complete motor paralysis we amputate through the humerus at the distal limit of sensation. The remaining proximal humerus is fixed by an arthrodesis of the shoulder joint, combined with a varus-osteotomy below the head. This increases with axillary space, facilitates the fitting of a prosthesis and improves care of the skin in this critical area. It also improves the outline of the shoulder the muscles of which shrink.