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Postoperative function and muscular strength of the shoulder joint were studied in five patients who had undergone extirpation of the deltoid muscle because of a soft tissue tumor. No patient had significant functional impairment but all had a slightly limited range of active abduction and flexion. The strength reduction did not exceed 40 per cent in any position.
The authors report a case of septic arthritis of the shoulder-joint due to group B beta-hemolytic Streptococci (Streptococcus agalactiae) in a 63-year-old female patient. These germs are a major cause of meningitis and septicemia in newborns and pregnant women. In adults, men and nonpregnant women, they have been a rare cause of septic arthritis.
This study describes a congenital deformity of the shoulder joint in a 5-year-old female, associated with an undescended scapula and the presence of an omovertebral bone. Dissections on 16 cadavers were done to identify structures in danger of injure before operating on the patient. Surgeons need to take specific note of the dorsal scapular nerve.
The results of surgery in 74 cases of recurrent anterior dislocation of the shoulder are reported. The procedures used were Eden-Hybbinette (E-H) in 48 cases and Putti-Platt (P-P) in 26 cases. The recurrence rate in the 62 shoulder joints re-examined some 4 years postoperatively was 3/41 in E-H cases and 3/21 in P-P cases. The clinical results were excellent in 46 cases, satisfactory in 11, unsatisfactory in four and poor in one case without notable difference between the methods. A restriction of the outward rotation of more than 10 degrees could be observed in half the cases regardless of method. Radiographically, the Bankart lesion of the glenoid rim could be observed in two-thirds of the cases and osteoarthrosis of the glenohumeral joint was evident in one tenth. The transplanted bone block used in the E-H reconstruction was still in position in the majority but some degree of resorption could usually be observed. These observations did not correlate with the clinical results.
"Functional differentiation" within skeletal muscle refers to the ability of the Central Nervous System (CNS) to control, with a degree of independence, individual subunits of a muscle during a particular muscle contraction. Essentially, the concept of functional differentiation within skeletal muscle suggests an ability of the CNS to selectively activate those segments of a muscle which have the most appropriate line of action for the task as a means of ensuring the muscles efficient utilisation. The present study was undertaken to determine whether functional differentiation was present within the radiate muscle, Latissimus Dorsi, during a series of isometric muscle contractions. Six surface electrode pairs were placed along the origin of the muscle and electromyographic (EMG) potentials were recorded during isometric contractions in various planes and levels of contraction intensity. The EMG waveforms were integrated (IEMG) and then normalised. The normalised EMG waveforms (nIEMG) were then statistically compared to determine if muscle fibres within the detection area of each electrode pair had varied their contribution to the total activity of the muscle, from one isometric contraction to another. Alterations in the contribution of each site were taken to be indicative of functional differentiation. The results of this study indicated that functional differentiation did occur within Latissimus Dorsi. In essence, the most caudal fibres were utilised preferentially when subjects performed adduction from an abducted position of the shoulder joint. Conversely, activity was distributed over the entire muscle when subjects attempted adduction from the anatomical position. A similar situation was observed when subjects performed horizontal extension from either a flexed or abducted position.(ABSTRACT TRUNCATED AT 250 WORDS)
The painful shoulder in the paralysed stroke patient, is a great problem in the field of physical medicine. Certain pathological changes are taking place in the patients with extensive paralysis in the upper limb. These changes are: (1) lesions or rupture of the rotatorcuff, (2) displacement of caput humeri in a caudal direction, (3) neuropathy of plexus brachialis with peripheral paresis. Careless handling of the patients' arm and the passive pull of the heavy, paralytic arm are claimed to be the main cause for these lesions. Correct handling of the patient and support of the shoulder is necessary to prevent these injuries from taking place. The different arm-slings used for this purpose, are not good enough. The article describes an orthosis which supports the shoulder joint and reposition caput humeri (if this has been luxated). It also gives the patient a better balance by straightening the trunk and letting the arm hang extended and slightly abducted along the side of the body. The orthosis is only tested in a few patients. Further development and testing on several patients are now being planned.
CT of the soft tissues of the shoulder without intra-articular contrast injections is useful for demonstrating effusions and synovial proliferation in the shoulder joint, in the bursa and in the synovial coverings of the long head of the biceps. The authors describe, for the first time, an intracapsular collection of fat in the posterior aspect of the capsule. This can be demonstrated via CT in 80% of the population. This fat line is displaced by even a few ml. of fluid in the presence of an effusion.
Degenerative ossification is formed directly at the major tubercle. Like in any other gliding tendon, fibrocartilage cells lie on the articular side of the rotator tendon at the pivot of the humerus head. Typically, the calcific deposits of calcifying tendinitis are found between these two areas. At this site, hydroxyapatite is usually formed by fibrocartilage cells through an unknown stimulus. There is no ossification. This is a two-phase disease. During the chronic initial phase, a calcific deposit is formed in the tendon of the rotator cuff. In the X-ray, it is clearly circumscribed and has a dense appearance (type I). Pain is inconsistent and may exist for years. In the acute phase, the deposit undergoes spontaneous resolution. Now it takes on a translucent and cloudy appearance without clear circumscription (type III). Patients experience severe pain for 2-3 weeks. Finally, a normally functioning shoulder joint will result. The X-ray therefore allows a prognostic conclusion. In a study including 235 calcific deposits, it became clear that there are some cases where it is not possible to designate the specific X-ray morphology to a given deposit (type II). Irrespective of the phase of disease, the so-called calcific deposit is composed of poorly mineralized hydroxyapatite. For a diagnosis, we require: a typical history, clinical findings consistent with tendinitis of the rotator cuff, calcific deposits in the tendon associated with signs and symptoms of tendinitis. It is recommended that radiographs be taken at least in AP projections with the shoulder in internal and external rotation to demonstrate the deposits without super-imposition. Ultrasound shows concomitant bursitis and is useful for the differential diagnosis of rupture of the rotator cuff. Radiographic diagnosis is most difficult when there are small opacifications near the rotator attachment. In this case, allocation may become possible only later in the course of disease. Initial treatment should always be non-operative. Almost all therapeutic modalities are said to be quite successful. Needles under local anesthesia is recommended only for patients with marked pain who lack any signs of resolution in the X-ray. According to a prospective study, the success rates of needles depend on the roentgenologic findings: in type I deposits, resolution occurs in 33%, in typq II deposits in 71%. Freedom from pain is seen in about 50% of the patients. Type III deposits undergo resolution with and without therapy in about 2-3 weeks. Post-operative results are reported to lie between 77% and 96% irrespective of the method used.(ABSTRACT TRUNCATED AT 400 WORDS)
Isolated and painless infraspinatus atrophy and weakness are described in two top-level volleyball players. EMG revealed isolated denervation of the infraspinatus muscle. One athlete continued playing and his clinical features have not changed. The other recovered her muscle bulk and strength after stopping playing. These findings were attributed to intense activity of the shoulder joint, without any direct trauma. On clinical grounds, we did not consider these cases as true examples of entrapment neuropathy. Pathogenesis was related to traction of the distal branch of the suprascapular nerve during the act of reception of the ball ("Manchete").
Ultrasonographic changes around the shoulder joint were compared in ten symptomatic patients with dialysis related amyloid (DRA) and seventeen patients without symptoms. All patients had been on long-term (greater than 7 years) hemodialysis (HD). Three control groups were used: 8 predialysis patients, 10 continuous ambulatory peritoneal dialysis (CAPD) and 9 HD patients who had been on dialysis for less than two years. Dry bodyweight, sex, handedness, length of hemodialysis and fistula side were not significantly different between the study groups. Proven amyloid patients were significantly older than other groups (p less than 0.001). Parameters assessed included cross-sectional area of long head of biceps tendon (LHB), diameter of supraspinatus tendon (SS), and general features (bursae, deposits) around the joint. Results demonstrated significant differences in all parameters in patients with symptomatic amyloid compared with other long-term patients: [SS: 7.4 mm +/- 0.7, mean +/- SEM, vs 5.1 +/- 0.2 (right, R), p = 0.001; 6.7 +/- 0.7 vs 4.9 +/- 0.2 (left, L), p = 0.01. LHB: 140.0 mm2 +/- 11.1 vs 79.6 +/- 5.1 (R), p less than 0.001; 114.5 +/- 10.5 vs 80.8 +/- 5.4 (L), p = 0.004. Bursae: 5 vs 1 (patients), p = 0.006]. Compared with controls changes in the amyloid group were less marked though in most cases still significant. There was no significant difference between control groups nor between controls and asymptomatic long-term HD patients in any parameter. We conclude that shoulder ultrasound may have a role in identifying patients with dialysis related amyloid. Serial measurements may also help to elucidate the pathogenesis of the tendon changes.
In a cross sectional study 30 patients with craniomandibular disorders (CMD) and 30 controls were screened for general musculoskeletal complaints. A questionnaire was used to mark the sites of the body that were painful and assessments of pain intensities in the neck, shoulders and the jaws were registered. "Pain tolerance" was clinically measured with cutaneous electrical stimulation over the masseter areas. The CMD patients had a significantly higher number of painful sites on the body than the controls. They showed significantly increased "relative risks" of having musculoskeletal pain especially in the upper neck, the shoulder and lower neck region, the shoulder joint and the thoracic back. Discomfort and pain rating values for the neck and shoulders were significantly higher for CMD patients than for controls. The measurements of "pain tolerance" did not differ between groups. However, an individual variation was found among the CMD patients. Those who had pain in many different parts of the body were the least tolerant of experimentally induced pain.
We evaluated the results of treatment in twenty-three patients with twenty-four shoulder dislocations that had gone unreduced for at least three weeks. Fourteen dislocations were posterior, eight were anterior, and one each was superior and inferior. Seventy-nine per cent of the posterior dislocations had not been recognized by the initial treating physician. Fourteen shoulders (58 per cent) were operated on. Of seven that were treated by open reduction with preservation of the humeral head, the results in two were graded as excellent; in three, as good; and in two, as fair. A Neer total shoulder-replacement prosthesis was used in one patient with an excellent result, and a Neer humeral-head prosthesis was used in two patients with a good and a fair result. In four patients, the humeral head was removed and a Jones procedure was performed, with one good and three fair results. There were no poor results after surgical treatment and it was not necessary to arthrodese any shoulder. We did not find it necessary to transfix the shoulder joint by screws or pins, or to use plaster spica casts to maintain stability of the shoulder following open reduction. Supporting the arm at the side in a position posterior to the coronal plane for a posterior dislocation, and anterior to the coronal plane for an anterior dislocation, proved to be comfortable and effective. There were no postoperative dislocations using this simple method. These results show that the over-all prognosis for surgical treatment of the chronic unreduced dislocation shoulder is more favorable than has previously been reported. A rating system based on 100 units was used to evaluate our final results, and is recommended as a standard system for future comparative studies.
Surgical procedures in the region of the shoulder joint are among the most painful interventions in orthopedic practice. For this reason, in addition to intravenous pain therapy with opioids, blockade of the brachial plexus has become established as an effective method to provide analgesia.High-resolution ultrasound offers the possibility of performing nerve blockades under visual monitoring. Studies on interscalene blockade performed under sonographic control provide evidence for both the high efficacy and safety of the procedure. Clinically manifest signs of nerve damage have not appeared with use of this method. Smaller operations can usually be adequately managed with perioperative single-shot blockade. More extensive operations for which severe pain lasting for several days can be expected and surgical interventions involving preexistent shoulder stiffness necessitate catheterization for uninterrupted pain therapy. Successful rehabilitation after shoulder surgery requires diligent perioperative pain blockade, which can primarily be provided by interscalene plexus blockade.
A common method of treating PASTA (partial articular surface tendon avulsion) lesions involves completing the tear followed by arthroscopic repair. Frequently, the boundaries of the tear are difficult to determine from the bursal side with the use of a single marking stitch. Therefore, we describe a simple technique that allows the surgeon to reproducibly define the boundaries of the partial tear. Following a standard arthroscopic examination of the articular portion of the shoulder joint, the PASTA lesion is identified. A spinal needle is introduced and the most anterior and posterior aspects of the tear are marked by passing 2 sutures. Following a bursectomy, the 2 sutures that clearly define the boundaries of the tear are identified. The tear is then completed by "connecting the dots" outlined by the sutures and an arthroscopic repair is performed in the standard manner.
In order to clarify the factors that mainly influence arm morbidity following treatment of breast cancer with the full axillary dissection protocol, we evaluated, in a model of multiple regression analysis, parameters such as the type of breast surgery, adjuvant radiotherapy, time of irradiation, age, number of dissected nodes and axillary nodal status. A total of 104 women were studied. Late arm edema was observed in 17% of the patients and was more frequent when (1) irradiation was given immediately after the operation than if it was given 6 months later (p = 0.009) and (2) the number of removed nodes exceeded 40 (p = 0.037). Upper limb pain was reported by 16% of the patients and was reported more frequently from patients over 60 years of age (p = 0.036), as well as from patients who underwent modified radical mastectomy (p = 0.044) and those in whom 30-40 nodes were dissected (p = 0.025). Shoulder joint mobility was impaired in 17% of the patients, and it was not affected by any of the examined factors. It seems that conservative breast surgery or adjuvant breast radiotherapy 6 months after the operation might reduce independently the likelihood of arm morbidity by 25%.
This study evaluated the safety and effectiveness of an 8-week full-body resistance and aerobic exercise program for 27 survivors of breast cancer (age, 57.7 +/- 7.2 years; years posttreatment, 0.8- 21.0) with prior upper-body conditioning. Physical fitness and quality-of-life (QOL) measures were obtained before and after the training period. Lymphedema, evaluated via arm volume measurement at baseline, was self-monitored throughout the trial. Sum of skinfolds, waist girth, and hip girth were significantly reduced posttraining (p < 0.01), although body weight did not change. Significant improvements (p < 0.01) were observed in upper-body strength (35.6 +/- 16.4%) and endurance (167.4 +/- 55.4%), lower-body strength (50.7 +/- 32.3%) and endurance (273.1 +/- 120.7%), Vo(2peak), trunk flexibility, and flexibility of the ipsilateral (surgical) and contralateral shoulder joint. Psychological QOL and overall QOL, evaluated via the World Health Organization Quality of Life Assessment Scale-Abbreviated Version. Inventory also improved significantly (p < 0.01). No incidents of lymphedema or injury were reported. These findings suggest that survivors of breast cancer can safely benefit from engaging in a full-body exercise regimen.
Radiological investigation of the shoulder joint in articular instability syndromes often yields inadequate information. Computerised tomography, either with or without a contrast medium, can provide more precise information about the pathological anatomy of the bones and capsuloligamentous structures. The authors report their experience in 50 normal and 33 pathological shoulders.
The follow-up and the pathological findings of a previously described case of non-myelomatous monoclonal gammopathy with relapsing localized amyloid masses of the shoulder joints are reported. The peculiar "mesodermal" distribution of amyloid deposits, strictly limited to tissues lined by mesothelial or endothelial cells emphasizes the role of local factors in the pathogenesis of amyloidosis thus supporting the hypothesis that amyloid deposition can be related also to some differentiated tissues with peculiar local susceptibility. The morphological findings of the present case enable the Authors to suggest a pathogenic mechanism for amyloid deposition.