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Intracranial hemorrhage is a primary concern for patients with blunt head trauma. Any patient who has been struck on the head with a baseball bat should undergo a CT scan.A return-to-play decision for an athlete who has sustained a skull fracture should be based on fracture type, symptoms, clinical examination results, and a follow-up CT scan.Neuropsychologic testing may be a useful adjunct for the determination of readiness for return to play after head injury. [ABSTRACT FROM AUTHOR]

Unlabelled: The "shrug sign" (inability to lift the arm to 90 degrees abduction without elevating the whole scapula or shoulder girdle) has been associated with a diagnosis of rotator cuff disease. Based on our clinical experience, we hypothesized the shrug sign is not a specific diagnostic sign for this condition, but rather is associated with various shoulder conditions and shoulder weakness and loss of range of motion. We retrospectively reviewed 982 consecutive patients who had been examined preoperatively for the shrug sign. A positive shrug sign was present in 51.3% of the patients, and the average distance lost from the horizontal was 20.5 degrees +/- 2.2 degrees (standard error of mean). Increasing age was associated with the presence of a shrug sign. The highest incidence was in patients with adhesive capsulitis (94.7%). The shrug sign was not sensitive for tendinosis, partial rotator cuff tears, or full-thickness or massive rotator cuff tears. The shrug sign was associated with weakness in abduction, night pain, and loss of range of motion, especially passive abduction. Although the shrug sign is useful as a general sign of shoulder abnormality, particularly when associated with stiffness, it was not specific or sensitive for rotator cuff problems.Level Of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

No consensus yet exists on how to handle incidental fnd-ings (IFs) in human subjects research. Yet empirical studies document IFs in a wide range of research studies, where IFs are fndings beyond the aims of the study that are of potential health or reproductive importance to the individual research participant. This paper reports recommendations of a two-year project group funded by NIH to study how to manage IFs in genetic and genomic research, as well as imaging research. We conclude that researchers have an obligation to address the possibility of discovering IFs in their protocol and communications with the IRB, and in their consent forms and communications with research participants. Researchers should establish a pathway for handling IFs and communicate that to the IRB and research participants. We recommend a pathway and categorize IFs into those that must be disclosed to research participants, those that may be disclosed, and those that should not be disclosed. [ABSTRACT FROM AUTHOR]

Isolated distal clavicle excision performed as an open procedure has been considered safe and, in the literature, has been considered the standard for comparison with arthroscopic distal clavicle excisions. However, we noticed isolated open distal clavicle excision was associated with a number of complications. We therefore raised two questions about the complication rate in a cohort of our patients who had undergone this procedure: (1) What was the complication rate and how did it compare to that in the existing literature on this subject? and (2) Were the complications in our cohort similar to those previously reported? We studied 42 patients who underwent an isolated distal clavicle excision between 1992 and 2003. There were 27 complications (64%), which was substantially higher than rates previously reported. Complications in our cohort not previously reported included continued acromioclavicular joint tenderness and scar hypertrophy. Our study suggests complications after open distal clavicle excisions may be more frequent than and may differ from previously reported rates and types. [ABSTRACT FROM AUTHOR]

Challenges in using MRI in shoulder evaluation include defining the indications for ordering a scan, interpreting the findings, and determining which abnormalities require treatment. Determination of the presence or absence of recent trauma is the most important part of the history. Radiography displays some features of the bony anatomy better than MRI. Several MRI findings increase with age and do not require attention unless they can be established as the source of pain. Acromioclavicular arthritis found on MRI often does not require treatment. Evaluation of the labrum with magnetic resonance arthrography may be more accurate than with MRI. Relating clinical history and physical examination findings with those of the MRI examination is particularly important for rotator cuff evaluation. [ABSTRACT FROM AUTHOR]

Laxity testing is an important part of the examination of any joint. In the shoulder, it presents unique challenges because of the complexity of the interactions of the glenohumeral and scapulothoracic joints. Many practitioners believe that laxity testing of the shoulder is difficult, and they are unclear about its role in evaluation of patients. The objectives of the various laxity and instability tests differ, but the clinical signs of such tests can provide helpful information about joint stability. This article summarizes the principles of shoulder laxity testing, reviews techniques for measuring shoulder laxity, and evaluates the clinical usefulness of the shoulder laxity tests. Shoulder laxity evaluation can be a valuable element of the shoulder examination in patients with shoulder pain and instability. [ABSTRACT FROM AUTHOR]

Background: Although traumatic anterior shoulder instability is common, the usefulness of various physical examination tests as tools for the diagnosis of this condition has been studied infrequently. We hypothesized that (1) such tests would be specific but not sensitive for this condition, (2) the usefulness of the anterior drawer test would be limited because of pain during the test, and (3) an anterior drawer test would be a useful adjunct for making the diagnosis if it reproduced the instability symptoms.Methods: Between 2000 and 2004, 363 patients underwent a physical examination followed by shoulder arthroscopy. Forty-six patients with traumatic anterior shoulder instability that had been noted arthroscopically or documented radiographically after the trauma were included in our study group, and the remaining patients served as controls. The clinical usefulness of three tests (anterior apprehension, relocation, and anterior drawer tests) performed during the physical examination to make a diagnosis of traumatic anterior instability then was evaluated with statistical methods to assess their sensitivity, specificity, and likelihood ratios.Results: If demonstration (or relief) of apprehension was used as the diagnostic criterion for a positive test, the sensitivity, specificity, and likelihood ratio were 72%, 96%, and 20.2, respectively, for the apprehension test and 81%, 92%, and 10.4, respectively, for the relocation test. If pain (or relief of pain) was used as the diagnostic criterion for a positive test, the values for the sensitivity, specificity, and likelihood ratio of both tests were lower. The anterior drawer test could be performed successfully in the physician's office for 87% of the patients. If reproduction of instability symptoms was used as the criterion for a positive anterior drawer test, the sensitivity, specificity, and likelihood ratio values of that test were 53%, 85%, and 3.6, respectively.Conclusions: The three physical examination tests for traumatic anterior shoulder instability are specific but not sensitive. Apprehension is a better criterion than pain for a positive apprehension or relocation test. The anterior drawer test (when pain does not prevent it from being performed) is helpful for diagnosing traumatic anterior instability.Level Of Evidence: Diagnostic Level I. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The shoulder is difficult to examine because the causes of pathology are poorly understood, access to the affected area is restricted, pain patterns can overlap, and many shoulder tests are not specific. Key factors in the evaluation are the timing of symptom onset and the nature of the patient's complaint (pain, weakness, or loss of motion). Compare the affected and unaffected shoulders, and conduct a neurologic evaluation, including a brief sensory examination of the whole upper extremity, range of motion assessment, and strength testing. The initial imaging studies should be plain radiographs. The most important tests in the examination of patients for rotator cuff problems are those of strength and motion. A subacromial injection may be used to distinguish the pain of a stiff shoulder from that of a rotator cuff disorder. [ABSTRACT FROM AUTHOR]

The shoulder is a complicated joint that is difficult to examine because the causes of pathology are poorly understood, access to the affected area is restricted, pain patterns can overlap, and many shoulder tests are not specific. Major factors in evaluation are the timing of symptom onset and the nature of the patient's complaint. Clinicians should compare the affected and unaffected shoulders, conduct a neurologic evaluation, and begin imaging studies with plain radiographs. The most important tests in the examination of patients for rotator cuff problems are those of strength and motion. A subacromial injection may be used to distinguish the pain of a stiff shoulder from that of a rotator cuff problem. [ABSTRACT FROM AUTHOR]

The development and successful clinical application of suture anchors and tacks have revolutionized the surgeon's ability to secure soft tissues to bone via open or arthroscopic surgical techniques. When used carefully and with proper technique, these devices provide viable options for the repair and reconstruction of many intra-articular and extra-articular abnormalities in the shoulder, including rotator cuff tears, shoulder instability, and biceps lesions that require labrum repair or biceps tendon tenodesis. Like many technologies, however, the successful application of these devices requires an understanding of the biology and biomechanics that affect their use in the shoulder as well as knowledge of the factors that can affect subsequent clinical outcomes, including complications. [ABSTRACT FROM AUTHOR]

Background: Several tests for making the diagnosis of rotator cuff disease have been described, but their utility for diagnosing bursitis alone, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears has not been studied. The hypothesis of this study was that the degree of severity of rotator cuff disease affects the diagnostic values of the commonly used clinical tests.Methods: Eight physical examination tests (the Neer impingement sign, Hawkins-Kennedy impingement sign, painful arc sign, supraspinatus muscle strength test, Speed test, cross-body adduction test, drop-arm sign, and infraspinatus muscle strength test) were evaluated to determine their diagnostic values, including likelihood ratios and post-test probabilities, for three degrees of severity in rotator cuff disease: bursitis, partial-thickness rotator cuff tears, and full-thickness rotator cuff tears. A forward stepwise logistic regression analysis was used to determine the best combination of clinical tests for predicting the various grades of impingement syndrome.Results: The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the eight tests varied considerably. The combination of the Hawkins-Kennedy impingement sign, the painful arc sign, and the infraspinatus muscle test yielded the best post-test probability (95%) for any degree of impingement syndrome. The combination of the painful arc sign, drop-arm sign, and infraspinatus muscle test produced the best post-test probability (91%) for full-thickness rotator cuff tears.Conclusions: The severity of the impingement syndrome affects the diagnostic values of the commonly used clinical tests. The variable accuracy of these tests should be taken into consideration when evaluating patients with symptoms of rotator cuff disease. [ABSTRACT FROM AUTHOR]

Tibial plateau fractures typically are associated with high-energy mechanisms in young patients, as in the case of this 35-year-old softball player, and with low-energy trauma in the older population. A detailed history, careful physical examination, and plain radiographs constitute the essential initial study; MRI and CT are indicated to refine the diagnosis. Concomitant injuries are common, including ligament tears, meniscal damage, and other soft-tissue compromise. Less common but more devastating injuries include vascular disruption, nerve injury, and compartment syndrome. Injury severity determines whether treatment will be nonoperative or operative, but the goal is to restore the patient's normal function. [ABSTRACT FROM AUTHOR]

Background: Previous studies have demonstrated that a high surgical volume for certain surgical procedures reduces morbidity and improves economic outcome; however, to our knowledge, no study has demonstrated a similar relationship between volume and outcome for total shoulder arthroplasty and hemiarthroplasty. The objective of this study was to determine whether increased surgeon experience was associated with improved clinical and economic outcomes for patients undergoing total shoulder arthroplasty or hemiarthroplasty.Methods: We analyzed discharge data on patients treated between 1994 and 2000 from the Maryland Health Services Cost Review Commission, which has a statewide hospital discharge database of all patients in the state of Maryland. The database included all patients undergoing total shoulder arthroplasty and hemiarthroplasty. We assessed the relationship between surgeon volume (low, medium, and high) and the risk of complications, length of stay, and total charges. The statistics were adjusted for procedure, age, gender, race, marital status, comorbidity, diagnosis, insurance type, income, and hospital volume.Results: For the 1868 discrete total shoulder arthroplasties and hemiarthroplasties done in the state of Maryland, the risk of at least one complication associated with the procedures done by the high-volume surgeon group was nearly half that associated with the procedures done by the low-volume surgeon group (adjusted odds ratio, 0.6; 95% confidence interval, 0.4 to 0.9). High-volume surgeons were three times more likely than were low-volume surgeons to have patients with a hospital stay of less than six days (odds ratio, 0.3; 95% confidence interval, 0.2 to 0.6). Although the average cost of hospitalization was $1000 less in the high-volume surgeon group compared with the low-volume surgeon group, this reduction did not reach significance after adjustment for multiple variables (odds ratio, 0.8; 95% confidence interval, 0.5 to 1.4).Conclusions: This study indicates that the patients of surgeons with higher average annual caseloads of total shoulder arthroplasties and hemiarthroplasties have decreased complication rates and hospital lengths of stay compared with the patients of surgeons who perform fewer of these procedures. These analyses of hospital discharge data are limited because of a lack of prospective data, operative details, and patient outcomes data. However, this study emphasizes the importance of continued education for orthopaedic surgeons who perform shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Background: There currently is a wide variation in the definition of multidirectional instability of the shoulder in the literature. The purpose of this study was to determine if these variations influence the distribution of the diagnoses in a cohort of patients with shoulder instability.Methods: A cohort of 168 patients who underwent shoulder surgery for instability of any type was studied. Statistical analysis was performed in two steps. First, the instability of the shoulder in each patient was classified with the use of four existing systems, and the number of patients classified as having multidirectional instability was compared among the classification systems. Second, the definition of multidirectional instability was modified so that the result of laxity testing was the criterion for making the diagnosis, and the changes in the distribution of patients with a diagnosis of multidirectional instability were analyzed.Results: Classification with the four existing systems resulted in significant differences in the number of patients diagnosed as having multidirectional instability, with two (1.2%), seven (4.2%), thirteen (7.7%), and fourteen patients (8.3%) so diagnosed (p < 0.05). Modification of the definition of multidirectional instability so that it was based on laxity testing resulted in a wide variation in the number of patients diagnosed as having multidirectional instability; these numbers ranged from fourteen (8.3%) to 139 (82.7%) (p < 0.05).Conclusions: This study demonstrated that variations in the criteria used for the diagnosis of multidirectional instability significantly affect the distribution of patients with that diagnosis. The use of laxity testing tends to result in an overestimation of the number of patients with this condition. This observation is important because the results of studies may vary if patients with traumatic instability are considered to have multidirectional instability on the basis of laxity testing. Investigators studying patients with multidirectional instability should carefully define the inclusion criteria that they used. [ABSTRACT FROM AUTHOR]

BACKGROUND: Prevalence and clinical significance of partial tears of the subscapularis tendon have not been widely studied. PURPOSE: To determine prevalence of and clinical factors associated with partial tears of the subscapularis tendon at arthroscopy. STUDY DESIGN: Case control study. METHODS: During arthroscopic procedures on 314 consecutive shoulders, the arthroscopically visible portion of the subscapularis tendon was probed. Patients with and without partial tears were compared for prospectively identified variables. RESULTS: Partial tears were found in 60 of the 314 patients (19%). Increasing age and dominant arm involvement were significant variables for partial tears. Significantly associated factors included supraspinatus tendon tears (54 of 60; 90%), rotator cuff disease (44 of 60, 73%), and posterosuperior labral fraying (34 of 47, 72%). Increasing age, dominant arm involvement, and coexisting infraspinatus tendon tears were strong independent risk factors for partial tears. CONCLUSION: Partial tears of the subscapularis tendon are not uncommon findings during shoulder arthroscopic procedures and are associated with extensive rotator cuff disease. They do not appear to be associated with glenohumeral instability, but a possible association with atypical forms of instability (subclinical or superior instability) cannot be excluded by this study. The absence of a significant association between the lesion and specific subjective symptoms or physical findings suggests that caution should be taken when attributing a specific symptom to this condition. [ABSTRACT FROM AUTHOR]

BACKGROUND: Previous authors have suggested that the axillary nerve should be explored or palpated during all anterior shoulder stabilization procedures. OBJECTIVE: The goal of this study was to document the axillary nerve injury rate in a cohort of patients who had undergone anterior shoulder stabilization without axillary nerve dissection. HYPOTHESIS: Use of a subscapularis muscle-splitting approach by using a retractor along the scapular neck does not result in significant risk of injury to the axillary nerve, and exploration of the axillary nerve is not necessary using this approach. STUDY DESIGN: Prospective cohort study. METHODS: One hundred and twenty-eight anterior stabilizations were performed with a subscapularis muscle-splitting approach that has been previously described. In all cases a retractor was placed along the inferior scapular neck to protect the axillary nerve. The axillary nerve was not exposed or palpated in any case. All patients were evaluated on the 1st postoperative day and again within 10 days for symptoms of axillary nerve palsy, including sensory loss and return of muscle function. One patient (0.8%) had paresthesia in an axillary nerve distribution; recovery occurred without the need for electromyography or other interventions. There were no clinically detected cases of axillary nerve motor dysfunction. CONCLUSIONS: Routine exposure of the axillary nerve is not necessary during anterior stabilization procedures using a subscapularis muscle-splitting approach if proper precautions are taken to protect the nerve. Other techniques of anterior stabilization may require exposure of the axillary nerve. [ABSTRACT FROM AUTHOR]

During the last 3 decades, arthroscopy has revolutionized the way knee surgery is performed. The indications and the applications of arthroscopic procedures in the knee joint have enormously increased with the improvement in surgical technique and advent of new arthroscopic equipment. The use of arthroscopic techniques has led to a significant decrease in morbidity for the patient with intraarticular abnormalities, in terms of both diagnosis and surgical correction. Even though knee arthroscopy is a minimally invasive procedure with relatively low morbidity, it is not without risk of complications, of which neurovascular complications are among the most serious and devastating. The reported incidence of neurovascular complication is low, but it may be underestimated. Many neurovascular complications that occur are preventable with a thorough understanding of neurovascular anatomy, good preoperative and intraoperative planning, and attention to the details of basic techniques and the equipment used for the procedure. It is imperative that the surgeon who is performing arthroscopy be aware of these neurovascular complications, recognize them as early as possible, and initiate further evaluation and treatment as expeditiously as possible. In this article, the causes, management, prevention, and medicolegal implications of neurovascular complications of knee arthroscopy are reviewed. [ABSTRACT FROM AUTHOR]

Iatrogenic brachial plexus injury is an uncommon but potentially severe complication of shoulder reconstruction for instability that involves dissection near the subscapularis muscle and potentially near the brachial plexus. We examined the relationship of the brachial plexus to the glenoid and the subscapularis muscle and evaluated the proximity of retractors used in anterior shoulder surgical procedures to the brachial plexus. Eight fresh-frozen cadaveric shoulders were exposed by a deltopectoral approach. The subscapularis muscle was split in the middle and dissected to reveal the capsule beneath it. The capsule was split at midline, and a Steinmann pin was placed in the equator of the glenoid rim under direct visualization. The distance from the glenoid rim to the brachial plexus was measured with calipers with the arm in 0 degrees, 60 degrees, and 90 degrees of abduction. The brachial plexus and axillary artery were within 2 cm of the glenoid rim, with the brachial plexus as close as 5 mm in some cases. There was no statistically significant change in the distance from the glenoid rim to the musculocutaneous nerve, axillary artery, medial cord, or posterior cord with the arm in various degrees of abduction. Retractors placed superficial to the subscapularis muscle or used along the scapular neck make contact with the brachial plexus in all positions tested. [ABSTRACT FROM AUTHOR]

Elbow and knee bursitis is common in both athletes and nonathletes and has three basic presentations: acute, chronic nonseptic, and chronic infected. Most acute swellings occur after trauma and can be treated with early aspiration, compression, and padding. Chronic, nonseptic bursitis can usually be treated with conservative therapy and, occasionally, aspiration or corticosteroid injection. Inflamed bursae should be aggressively evaluated and treated. Some may require aspiration and decompression, and oral or intravenous antibiotics should be started to prevent septicemia. Incision and drainage is rarely needed but may be indicated for injuries that do not respond. Surgical excision of the bursa is recommended only for recalcitrant cases. [ABSTRACT FROM AUTHOR]

One hundred twelve practicing members of the American Shoulder and Elbow Surgeons in the United States and Canada were surveyed regarding use of weighted views of the acromioclavicular joint. They were also asked about treatment for hypothetical patients seen in the emergency department or office with grade II or III acromioclavicular separations. One hundred five physicians (94%) responded to the survey. Eighty-five members (81 %) did not recommend obtaining weighted views in the emergency department. Sixty members (57%) did not use weighted views, and the majority commented that weighted views had no influence on their decision-making regarding treatment. Forty-five members (43%) used weighted views, but most did not use the results of this test to determine surgical intervention. Physicians recommending weighted views averaged 21 years of practice, compared with 16 years for those who did not obtain weighted views. Only nine physicians (9%) had changed treatment on the basis of weighted views. The patient's arm dominance, work, or athletic status did not influence most surgeons' decision to perform surgery when weighted views revealed a grade III separation. We found no correlation between obtaining weighted views and performing surgical reconstruction for patients with grade III acromioclavicular separations. [ABSTRACT FROM AUTHOR]

We evaluated the frequency of posterior subluxations on physical examination of athletes who had no symptoms of shoulder injuries and correlated the findings with other measures of joint laxity. During routine sports physical examinations, 356 shoulders in 178 athletes were examined for posterior subluxation and graded as either positive or negative for subluxation. Sulcus signs were performed and graded as I (<1.0 cm), II (1.0 to 1.5 cm), or III (>1.5 cm). Standard hyperlaxity tests of other joints were used to measure general ligamentous laxity. Statistical analysis included the Student's t-test and chi-square analysis (P < 0.05). Overall, 55% of the shoulders could be subluxated posteriorly. More female shoulders (65%) than male shoulders (51%) could be subluxated posteriorly. Ten percent of the athletes had asymmetrical posterior shoulder laxity. Men had statistically significant less inferior translation (sulcus signs of grade I, 49%; grade II, 46%; grade III, 3%) than women (grade I, 36%; grade II, 54%; grade III, 9%). Five percent of the shoulders had posterior subluxation and a grade III sulcus sign. Asymptomatic posterior subluxation present at physical examination may represent normal laxity and may not indicate pathologic instability. [ABSTRACT FROM AUTHOR]

This report of a 19-year-old pitcher with chest pain illustrates how an atypical presentation of pulmonary tuberculosis in an athlete can delay diagnosis. In addition to a history, physical examination, and chest radiographs, the tuberculin skin test is the key to diagnosis of this disease. Laboratory work includes blood tests, liver and renal function studies, analysis of aspirated fluids, and sputum cultures. Treatment generally consists of daily doses of isoniazid, rifampin, pyrazinamide, and ethambutol or streptomycin. Screening close contacts such as teammates is essential; prophylaxis using isoniazid must be initiated for those who test positive. [ABSTRACT FROM AUTHOR]

Athletes in sports such as baseball, gymnastics, weight lifting, javelin, and racket sports are susceptible to stress lesions in the bones of the upper extremities. Injuries range from periostitis to bone spurs to stress fractures. Injuries in adolescents typically involve the growth plates, while mid-shaft injuries at the area of muscle insertion are more common in adults. It's especially important to detect these injuries in adolescents because untreated stress lesions at growth plates can have serious consequences. Plain films demonstrate obvious fractures and physeal injuries, but triple-phase bone scans are often needed to define the extent of stress lesions. [ABSTRACT FROM AUTHOR]

The histologic characteristics of the deltoid muscle attachment to nine cadaveric acromia were studied using light microscopy. The deltoid muscle attaches to the anterior and lateral acromion primarily by direct tendinous attachment. The muscle attaches to the dorsal side of the acromion by periosteal fiber attachment. In the specimens studied, a hypothetical acromioplasty of 4 mm would release, on average, 41% of the direct fiber attachment, and a 6-mm acromioplasty would release 69% for all zones examined histologically. The functional and clinical effects of these findings are not known, but the deltoid muscle would be released by arthroscopic acromioplasty in areas where bone is removed. [ABSTRACT FROM AUTHOR]

Overhand throwing requires contributions from and interaction between all limb segments. Most previous investigations have concentrated on the throwing arm itself, yet poor mechanics at the arm may originate in the lower extremities. Multicomponent ground-reaction forces of both the push-off and landing limbs were measured in six collegiate and one high school level baseball pitchers. Full body kinematics were simultaneously recorded to correlate phases in the pitching cycle with the force data. Pitchers were found to generate shear forces of 0.35 body weight in the direction of the pitch with the push-off leg and to resist forces of 0.72 body weight with the landing leg. Wrist velocity was found to correlate highly with increased leg drive. This study validates the clinical impression that the lower extremity is an important contributor to the throwing motion. Based on this study, strengthening of the lower extremities could be inferred to be important both to enhance performance and to avoid injury. [ABSTRACT FROM AUTHOR]