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What is the preferred method of the anterior shoulder dislocation among European Orthopaedic Surgeons?
132 Conclusion: Mortality can be improved with reduction in early morbidity and better care in community. Operation within 24 h of admission leads to less morbidity and mortality as well as early discharge. Keywords: Neck of femur; Mortality; Community care doi:10.1016/j.injury.2006.12.092 SESSION: UPPER LIMB
Abstracts Keywords: Shoulder instability; Bone loss doi:10.1016/j.injury.2006.12.093 O69 What is the preferred method of the anterior shoulder dislocation among European Orthopaedic Surgeons? Is there a need to change the practice? S.M.Y. Ahmed a,∗ , R. Mansingh a , P. Laxmanan b , M.F. Nicol a a Macclesfield
O68 The management of traumatic shoulder instability associated with glenoid bone loss Z. Sivardeen ∗ , S. Massoud, J. Paniker, D. Learmonth Royal Orthopaedic Hospital, UK Introduction: Traumatic dislocation of the shoulder can be associated with significant glenoid bone loss. If the Bone Loss is not addressed this group of patients often suffer from recurrent instability. The Aim of this study was to review the results of a new technique using autogenous iliac crest tricortical grafts on patients who had instability of the shoulder associated with significant bone loss. Methods: Ten consecutive patients were reviewed. All had significant loss of anterior glenoid bone stock as assessed by CT. All were treated by use of tricortical bone graft harvested from the iliac crest and fashioned to reconstitute the shape of the glenoid defect. The graft was fixed with cannulated screws. The antero-inferior capsule was then repaired to the glenoid rim. All patients had a standard rehabilitation regime. All patients had an assessment of the Oxford Shoulder Instability Score (OIS) and the American Shoulder and Elbow Surgeons Score (ASES), before and after the operation. Results: At an average follow-up of 26 months, the mean OIS had improved from 38.3 to 22.3, and the mean ASES had improved from 40.5 to 86.6. None had had a recurrent dislocation. Discussion: The use of autogenous iliac crest bone graft to treat shoulder instability associated with significant glenoid bone loss is an effective treatment for this difficult condition. This is the first study looking at a group of patients who have had the graft inserted in an intra-articular, but extra-capsular location. We believe this technique minimizes the risk of secondary osteoarthritic changes and produces excellent functional results.
b Freeman
District General Hospital, UK Hospital, UK
Shoulder dislocation is a common presentation to the emergency department. Traditionally the methods used for reduction require sedation or opioids with all their associated complications. Recently there has been interest in other methods of reduction which do not primarily require sedation and have high success rates. The objective of this study was to compare the practice of shoulder dislocation reduction across Europe and note the methods of reduction and the analgesia/sedation used. We distributed questionnaires to orthopaedic surgeons from different countries at the 7th European trauma congress in Ljubljana in Slovenia. The questionnaire identified the surgeon’s country of practice, the professional grade, the preferred method of shoulder reduction and the analgesia/sedation used if any. 94 questionnaires were returned from 21 countries out of these 93.7% were from European countries. 54.74% were residents and 45.26% were consultants. Methods of reduction employed: Kochers 60%, Gravitational traction 13.68%, Hippocratic 10.53%, Chair method 5.26%, Scapular manipulation 2.1%, Others 9.46%. 45.21% used benzodiazepines alone or with an analgesic, 27.32% opioids, 7.36% GA, 7.36% propofol or ketamine and only 29.47 used no sedation out of which 9.47% used intra-articular local anaesthetic. Traditional methods of shoulder reduction suffer from both procedural complications and complications of sedation. Kocher’s method is associated with fractures of humeral head, neck or shaft, avulsion of rotator cuff, axillary vessel and brachial plexus damage. Hippocratic method can damage axillary vessels and brachial plexus. In addition the use of sedation can cause respiratory depression; increased times spent in emergency department or require admission due excess sedation.
Abstracts We found that in the study 70.53% doctors used the above two methods and sedation/GA was used by 59.93% doctors. There are other methods like Scapular manipulation, modified Kochers method, external rotation and the Milch technique which are both safe and can be used without sedation in the first attempt. This study questions the current use of sedation in shoulder dislocation reduction and also the manipulation method of choice in anterior shoulder dislocations. Keywords: Shoulder dislocation; Sedation; Reduction doi:10.1016/j.injury.2006.12.094 O70 Four part proximal humeral fractures: Diagnosis with the sunset sign on anteroposterior radiograph
133 Results: Thirty out of 79 patients displayed ‘sunset’ sign in their preoperative radiograph. Of these 28 had confirmed four-part fractures operatively. The positive predictive value of ‘sunset’ sign in diagnosis the four-part fracture was 93%. The specificity and sensitivity were 95% and 78%, respectively. The sensitivity was affected by 8 patients with four part fractures with displaced articular head fragment which had dropped either medially or posteriorly. Conclusion: Our results suggest that in patients with proximal humeral fractures, the presence of ‘sunset’ sign in the anteroposterior radiograph is a reliable indicator of four-part fracture. Keywords: Radiology; Trauma; Proximal humerus fracture doi:10.1016/j.injury.2006.12.095
C. Kachramanoglou ∗ , R. Chidambaram, D. Mok
O71 Arthroscopic ‘‘tightrope’’ stabilisation of neer type 2 clavicular fractures
Epsom General Hospital, UK
F. Qureshi ∗ , A. Hinsche, D. Potter
Aim: To evaluate the radiographs of proximal humeral fractures in an attempt to define a diagnostic sign as a predictor of four-part fracture. Diagnostic sign: The normal humeral head articular surface points towards the glenoid. We describe our ‘sunset’ sign as ‘articular surface of humeral head pointing away from the glenoid and tilted upwards, in the presence of a displaced greater tuberosity fracture’. We postulate that a patient with proximal humerus fracture showing this sign has four-part fracture until proved otherwise. Materials and methods: Between 2002 and 2006, 80 consecutive patients underwent open reduction and internal fixation of their proximal humeral fractures in our Shoulder unit. We reviewed their preoperative radiographs and operative notes retrospectively. Seventy-nine patients were included in the study. One patient’s preoperative radiograph was not available. The AP radiograph was evaluated independently by three observers who were blinded to the identity of patients and operative diagnosis. The presence of ‘sunset’ sign was recorded. There was 90% inter-observer agreement. In the remaining 10%, a consensus review was performed as to the presence of sign for evaluation purpose. The findings were then correlated with the operative findings to confirm whether they were four-part fractures or not. With 95% confidence interval we calculated the sensitivity, specificity, positive and negative predictive values for our diagnostic sign.
Northern General Hospital, UK Fractures of the clavicle are one of the most common adult fractures. Distal clavicle fractures account for approximately one quarter of all clavicular fractures but are responsible for half of the non-unions. Neer classified this injury into three groups. The increased risk of non-union is well documented, especially when the fracture is displaced. The type II fractures are unstable injuries due to significant displacing forces. Most authors propose primary fixation of this fracture type due to the high incidence of delayed union and non-union. Over the years several methods of fixation have been described yet the most reliable method remains elusive. Treatments include K-wire or screw fixation, hook plates, coraco-clavicular screw fixation, Dacron slings. All these established procedures have recognised complications. These include implant failure, infection and non-union. We report the use of acute arthroscopic tightrope stabilisation as a new safe, minimally invasive option for the treatment of type II distal clavicular fractures in three patients. All three patients had united clinically and radiologically by 6 weeks with a full range of movement with no surgical complications. The mean shoulder scores for Oxford = 24, Constant = 97, DASH = 8.6, DASH (optional sport) = 0 and DASH (optional work) = 8.3. There were no clinical deformities present and the patients had returned to their pre-morbid work and recreational abilities.
Abstracts Keywords: Shoulder instability; Bone loss doi:10.1016/j.injury.2006.12.093 O69 What is the preferred method of the anterior shoulder dislocation among European Orthopaedic Surgeons? Is there a need to change the practice? S.M.Y. Ahmed a,∗ , R. Mansingh a , P. Laxmanan b , M.F. Nicol a a Macclesfield
O68 The management of traumatic shoulder instability associated with glenoid bone loss Z. Sivardeen ∗ , S. Massoud, J. Paniker, D. Learmonth Royal Orthopaedic Hospital, UK Introduction: Traumatic dislocation of the shoulder can be associated with significant glenoid bone loss. If the Bone Loss is not addressed this group of patients often suffer from recurrent instability. The Aim of this study was to review the results of a new technique using autogenous iliac crest tricortical grafts on patients who had instability of the shoulder associated with significant bone loss. Methods: Ten consecutive patients were reviewed. All had significant loss of anterior glenoid bone stock as assessed by CT. All were treated by use of tricortical bone graft harvested from the iliac crest and fashioned to reconstitute the shape of the glenoid defect. The graft was fixed with cannulated screws. The antero-inferior capsule was then repaired to the glenoid rim. All patients had a standard rehabilitation regime. All patients had an assessment of the Oxford Shoulder Instability Score (OIS) and the American Shoulder and Elbow Surgeons Score (ASES), before and after the operation. Results: At an average follow-up of 26 months, the mean OIS had improved from 38.3 to 22.3, and the mean ASES had improved from 40.5 to 86.6. None had had a recurrent dislocation. Discussion: The use of autogenous iliac crest bone graft to treat shoulder instability associated with significant glenoid bone loss is an effective treatment for this difficult condition. This is the first study looking at a group of patients who have had the graft inserted in an intra-articular, but extra-capsular location. We believe this technique minimizes the risk of secondary osteoarthritic changes and produces excellent functional results.
b Freeman
District General Hospital, UK Hospital, UK
Shoulder dislocation is a common presentation to the emergency department. Traditionally the methods used for reduction require sedation or opioids with all their associated complications. Recently there has been interest in other methods of reduction which do not primarily require sedation and have high success rates. The objective of this study was to compare the practice of shoulder dislocation reduction across Europe and note the methods of reduction and the analgesia/sedation used. We distributed questionnaires to orthopaedic surgeons from different countries at the 7th European trauma congress in Ljubljana in Slovenia. The questionnaire identified the surgeon’s country of practice, the professional grade, the preferred method of shoulder reduction and the analgesia/sedation used if any. 94 questionnaires were returned from 21 countries out of these 93.7% were from European countries. 54.74% were residents and 45.26% were consultants. Methods of reduction employed: Kochers 60%, Gravitational traction 13.68%, Hippocratic 10.53%, Chair method 5.26%, Scapular manipulation 2.1%, Others 9.46%. 45.21% used benzodiazepines alone or with an analgesic, 27.32% opioids, 7.36% GA, 7.36% propofol or ketamine and only 29.47 used no sedation out of which 9.47% used intra-articular local anaesthetic. Traditional methods of shoulder reduction suffer from both procedural complications and complications of sedation. Kocher’s method is associated with fractures of humeral head, neck or shaft, avulsion of rotator cuff, axillary vessel and brachial plexus damage. Hippocratic method can damage axillary vessels and brachial plexus. In addition the use of sedation can cause respiratory depression; increased times spent in emergency department or require admission due excess sedation.
Abstracts We found that in the study 70.53% doctors used the above two methods and sedation/GA was used by 59.93% doctors. There are other methods like Scapular manipulation, modified Kochers method, external rotation and the Milch technique which are both safe and can be used without sedation in the first attempt. This study questions the current use of sedation in shoulder dislocation reduction and also the manipulation method of choice in anterior shoulder dislocations. Keywords: Shoulder dislocation; Sedation; Reduction doi:10.1016/j.injury.2006.12.094 O70 Four part proximal humeral fractures: Diagnosis with the sunset sign on anteroposterior radiograph
133 Results: Thirty out of 79 patients displayed ‘sunset’ sign in their preoperative radiograph. Of these 28 had confirmed four-part fractures operatively. The positive predictive value of ‘sunset’ sign in diagnosis the four-part fracture was 93%. The specificity and sensitivity were 95% and 78%, respectively. The sensitivity was affected by 8 patients with four part fractures with displaced articular head fragment which had dropped either medially or posteriorly. Conclusion: Our results suggest that in patients with proximal humeral fractures, the presence of ‘sunset’ sign in the anteroposterior radiograph is a reliable indicator of four-part fracture. Keywords: Radiology; Trauma; Proximal humerus fracture doi:10.1016/j.injury.2006.12.095
C. Kachramanoglou ∗ , R. Chidambaram, D. Mok
O71 Arthroscopic ‘‘tightrope’’ stabilisation of neer type 2 clavicular fractures
Epsom General Hospital, UK
F. Qureshi ∗ , A. Hinsche, D. Potter
Aim: To evaluate the radiographs of proximal humeral fractures in an attempt to define a diagnostic sign as a predictor of four-part fracture. Diagnostic sign: The normal humeral head articular surface points towards the glenoid. We describe our ‘sunset’ sign as ‘articular surface of humeral head pointing away from the glenoid and tilted upwards, in the presence of a displaced greater tuberosity fracture’. We postulate that a patient with proximal humerus fracture showing this sign has four-part fracture until proved otherwise. Materials and methods: Between 2002 and 2006, 80 consecutive patients underwent open reduction and internal fixation of their proximal humeral fractures in our Shoulder unit. We reviewed their preoperative radiographs and operative notes retrospectively. Seventy-nine patients were included in the study. One patient’s preoperative radiograph was not available. The AP radiograph was evaluated independently by three observers who were blinded to the identity of patients and operative diagnosis. The presence of ‘sunset’ sign was recorded. There was 90% inter-observer agreement. In the remaining 10%, a consensus review was performed as to the presence of sign for evaluation purpose. The findings were then correlated with the operative findings to confirm whether they were four-part fractures or not. With 95% confidence interval we calculated the sensitivity, specificity, positive and negative predictive values for our diagnostic sign.
Northern General Hospital, UK Fractures of the clavicle are one of the most common adult fractures. Distal clavicle fractures account for approximately one quarter of all clavicular fractures but are responsible for half of the non-unions. Neer classified this injury into three groups. The increased risk of non-union is well documented, especially when the fracture is displaced. The type II fractures are unstable injuries due to significant displacing forces. Most authors propose primary fixation of this fracture type due to the high incidence of delayed union and non-union. Over the years several methods of fixation have been described yet the most reliable method remains elusive. Treatments include K-wire or screw fixation, hook plates, coraco-clavicular screw fixation, Dacron slings. All these established procedures have recognised complications. These include implant failure, infection and non-union. We report the use of acute arthroscopic tightrope stabilisation as a new safe, minimally invasive option for the treatment of type II distal clavicular fractures in three patients. All three patients had united clinically and radiologically by 6 weeks with a full range of movement with no surgical complications. The mean shoulder scores for Oxford = 24, Constant = 97, DASH = 8.6, DASH (optional sport) = 0 and DASH (optional work) = 8.3. There were no clinical deformities present and the patients had returned to their pre-morbid work and recreational abilities.