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In a prospective study we evaluated the ap-translation of the humeral head in the glenoid socket during active joint movements. In 150 healthy volunteers we documented normative data for four different joint positions. We compared these results with the data of 36 patients with traumatic anterior shoulder instability. The normal joint in adducted position shows a dorsal overhang of the humeral head in relation to the dorsal brim of the glenoid of 8.9 mm (+/- 3.0) on the dominant and of 9.1 mm (+/- 3.1) on the non dominant side. In the 90 degrees flexion position the dorsal overhang was 7.6 mm (+/- 3.5) on the dominant and 8.0 mm (+/- 2.3) on the non dominant side. In neutral as well as in the flexion position we found no differences between men and women nor between the dominant and non dominant extremity. In 90 degrees abduction and neutral rotation, the dorsal overhang was 1.5 mm (+/- 3.5) on the dominant side and 1.9 mm (+/- 3.4) on the non dominant side in the volunteer group. However, in patients with shoulder instability we found a statistically highly significant difference with a ventral overhang of 3.0 mm (+/- 4.0) on the dominant side. On the non dominant side a dorsal overhang of 0.3 mm (+/- 3.7) still remained in the above mentioned position. The differences between both sides were statistically highly significant. In abduction and external rotation we found a similar relation with a highly significant larger anterior translation of the humeral head in patients with unstable shoulder joints.

Twenty athletes who had recurrent posterior subluxation of the shoulder, eight of whom also had associated anterior instability, were treated with capsulorraphy with a posterior staple. Nine patients had an unsatisfactory result: six had recurrence of the posterior instability and three still had moderate or severe pain. Five of six patients who had lax ligaments had a recurrence. Complications developed in five patients: pain from a staple in one, postoperative adhesions in two, and ectopic bone in two. Only one patient was able to throw as well as he had before the injury. Staple capsulorrhaphy is not acceptable treatment for posterior subluxation of the shoulder because it is associated with a high rate of failure and complications.

The authors analysed the results obtained in 94 recurrent dislocations of the shoulder submitted to surgery between 1979 and 1988 according to the Latarjet method. After considering the reasons for selecting this method, they discuss some aspects of the physiopathology of recurrent dislocation and instability of the shoulder. the principles of the Latarjet method are described and the Patte modification, used by the authors since 1986, is briefly illustrated. The long-term results were evaluated according to the walch and Duplay evaluation scheme. Sixty-nine patients with a follow-up ranging from a minimum of 1 year to a maximum of 9 were reviewed. The results were excellent or good in 93% of the cases.

Thirty-three anterior staple capsulorrhaphies of the shoulder were reviewed at an average 49.7 months postoperatively (range 12 to 127 months); one postoperative dislocation occurred. The patients' quality of athletic participation improved with surgical therapy in 50%, remained the same in 38%, and was lowered in 12%. Average loss of external rotation was 11.4 degrees with the arm adducted and 13.9 degrees with the arm abducted 90 degrees. A positive apprehension sign persisted in 50%. Shoulder function was good or excellent in 84%. Mild pain was admitted by 55%, moderate pain by 6%, and severe pain by 3%. Staple malpositioning or loosening was identified in 12 shoulders; six of these patients had attributable clinical problems. Biomechanical studies in porcine bone were used to demonstrate that predrilling facilitates proper staple positioning without compromising staple fixation strength and, in a synthetic trabecular model, that a 5 degrees variance in the alignment of the staple holder during staple insertion weakens the fixation strength by 51% (P less than .001). The operation usually prevents recurrent dislocation, permits recovery of normal (or near normal) shoulder motion, and allows satisfactory return to competitive athletics. If staple malpositioning and loosening occur, they may cause clinical problems, including degenerative arthritis. Though most patients (92%) stated they would again have the operation, when practical, we recommend other methods of repair of capsule and labral detachment.

Arthroscopic evaluation of patients with an acute anterior shoulder dislocation was done to identify and classify the intraarticular lesions that might predict recurrent dislocations. Forty-five shoulders fit the following criteria for inclusion in our study: initial dislocation with no prior history of shoulder problems; confirmation of the dislocation radiographically or reduction by a physician; and arthroscopy within 10 days. The 42 men and 3 women had an average age of 21.2 years (range, 14 to 28 years). Mechanism of injury was a twisting of the arm into forced abduction and external rotation, a fall on the outstretched arm, or a direct blow to the shoulder. Based on this preliminary study of 45 shoulders, we present a classification of the lesions found in the acute shoulder dislocation. Group 1 (six shoulders) had capsular tears with no labral lesions: these shoulders were stable under anesthesia and had no or minimal hemarthrosis. Group 2 (11 shoulders) had capsular tears and partial labral detachments: these shoulders were mildly unstable and had mild to moderate hemarthrosis. Group 3 (28 shoulders) had capsular tears with labral detachments: these shoulders were grossly unstable and had large hemarthrosis. They had complete capsular/labral detachments. In the past, redislocation rates have been primarily related to age at the time of initial dislocation and, to a lesser degree, the period of immobilization. We have identified the intraarticular lesions in 45 patients with an initial anterior glenohumeral dislocation and classified these shoulders into three groups based on the lesions found. By doing so, we can develop a more accurate method of determining which shoulders are prone to recurrent dislocation.(ABSTRACT TRUNCATED AT 250 WORDS)

In human cadavers we were able to show that the glenohumeral joint is comparable to the model of a physical piston. The labrum glenoidale functions like a valve against atmospheric pressure. It is possible to characterize the behavior of intraarticular negative pressure by the equation (formula; see text). The calculations of the force F of atmospheric pressure tending to resist distraction of the joint surfaces leads to a 95% confidence interval from 6.9 to 22.9 kp. Under a general anesthetic, distraction of the healthy glenohumeral joint also produces negative intraarticular pressure in the area of the fossa glenoidalis in vivo. Joints with a labral tear (Bankart defect) and a chronic instability are not characterized by this phenomenon. A change in intraarticular pressure might stimulate intraarticular pressure receptors. This could be important in functioning as a neuromuscular protection reflex for the joint.

This study compares the axillary and the scapular "Y" view in 75 consecutive patients with suspected shoulder dislocation who were evaluated according to a prospective protocol. In each patient, an AP, axillary, and scapular "Y" view was obtained. Evaluation was by the following criteria: accuracy of diagnosis; patient preference; ease of technique; and diagnosis of associated pathology. In 69 cases (92%), the scapular "Y" view and axillary view resulted in the same diagnosis. However, in six cases (8%), the axillary view failed to give the correct diagnosis when compared to the scapular "Y" view. Sixty-one patients (81%) preferred the scapular "Y" view to the axillary view because of less pain. Once the technician was adept with the scapular "Y" view, it was preferred and was considered easier to obtain than the axillary view. With the exception of the Hill-Sachs lesion, the axillary view and scapular "Y" view visualized associated pathology equally well. A new method to obtain the scapular "Y" view is described. The technique is easy to use, and routinely results in an accurate diagnosis with minimal patient discomfort.

Anterior shoulder dislocation can be willfully produced by a subject through abnormal unbalanced muscle contraction at the shoulder joint. It may be associated with pathologic lesions at the shoulder. Treatment consists of vigorous shoulder strengthening exercises and/or surgery to increase anterior stability at the joint. For any treatment approach to be successful the subject must avoid dislocation of the shoulder. A psychologic component frequently associated with this condition is its use as a mechanism for attention, sympathy or defense--a factor that has a significant negative effect on response to treatment.

Six mechanisms which may produce fracture-separation of the proximal humeral epiphysis are proposed. Four of them are illustrated by case reports. It is suggested that they may be differentiated by examination of the patient and study of the radiographs. In unstable fractures manipulation is indicated and, if performed with an understanding of the mechanism of injury, will produce a stable reduction.

A review of fifty-one cases of the modified Bristow procedure for recurrent anterior shoulder instability is presented. The results were favorable. The redislocation rate was 2% with few complications. The average limitation of motion was 11 degrees of external rotation. Athletic individuals with involvement of the dominant shoulder were not capable of returning to high performance levels of overhead sports activity (particularly throwing) after the operation.

We used arthrotomography to study the glenoid labrum in 114 patients. Sixty-nine of the patients had anatomic instability of the shoulder (including recurrent dislocation and subluxation of the shoulder), and 45 patients had functional instability of the shoulder (denoted by chronic pain, clicking of the joint, and the sensation that an unstable condition exists without the objective signs of it). Labral tears were revealed arthrotomographically in 86% of the patients with anatomic instability, while only 40% of the patients with functional instability had labral abnormalities, and these were primarily of minor severity. Fifty-six patients (44 of whom had anatomic instability; 12, functional instability) required surgery. The surgical findings were correlated with the arthrotomographic findings, and no false-positive results were revealed. However, arthrotomography demonstrated only part of the pathologic condition of two patients. These results confirm that there is a strong correlation between labral pathologic conditions and anatomic instability of the shoulder. Arthrotomographic studies have a great impact on the selection of therapy in cases of both anatomic and functional instability of the shoulder.

Rotational subcapital osteotomy of the humerus for recurrent anterior dislocation of the shoulder associated with a large Hill-Sachs lesion was performed first by us in 1964 as a trial. From 1967 through 1981, 207 rotational humeral osteotomies were performed. Follow-up was possible on 180 of these shoulders. The over-all redislocation rate was 5.7 per cent and the rate of non-traumatic redislocation, 1.1 per cent. Limitation of motion of more than 10 degrees was present in only 3.9 per cent, the maximum limitation of external rotation being 15 degrees in one patient. The average loss of external rotation was less than 5 degrees, without noticeable diminution of power or function in most patients. The results as graded by a standard rating scale were good to excellent in 90 per cent, fair in 3 per cent, and poor in 7 per cent of the patients. The fair and poor results were due to redislocation, delayed union or non-union, post-traumatic arthritis, and over-rotation at the osteotomy site. Reoperation was necessary in two patients with a non-traumatic recurrence, in six patients with delayed union or non-union, and in one patient with excessive rotation at the osteotomy site. Plate removal was performed one to two years postoperatively in 107 of the 180 shoulders. Of the 321 recurrent dislocations seen over the fourteen-year period, 65 per cent were associated with a moderate to severe posterior-superior impression fracture of the humeral head (Hill-Sachs lesion).(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior glenohumeral instability is an important cause of shoulder disability in athletes. Recurrent glenohumeral instability can seriously impair the athlete's performance. Since the surgical repair of recurrent instability may result in a loss of flexibility, particularly in the thrower and gymnast, the physician must optimize both joint stability and joint flexibility.

Glenohumeral instability is an important cause of shoulder pain and disability in an active population. An awareness of the prevalence of recurrent instability, either in the form of dislocation or subluxation, is particularly useful in the assessment of the young athlete presenting with shoulder pain. Young adults presenting with rotator cuff tendinitis may have an underlying instability as the primary cause of their problem. A careful clinical examination should determine whether the instability is voluntary or involuntary, of traumatic or atraumatic onset, and the primary direction of the instability, as these factors have important implications with regard to treatment. Anterior glenohumeral instability is most common and the incidence of recurrent instability following on from an initial dislocation is high in the young active patient. An intensive rehabilitation programme is indicated for all initial dislocations or subluxations but surgery may become necessary after failure of conservative treatment. Care must be taken to determine accurately those patients with voluntary or multi-directional instability and a longer trial of conservative treatment is indicated here, as results of operative treatment in those cases are less favourable. Conservative treatment should be directed at strengthening the dynamic stabilizers of the shoulder joint, notably the rotator cuff muscles. Additional X-ray views are needed to demonstrate all the radiological changes associated with recurrent instability and further evaluation with examination under anaesthesia and arthroscopy is beneficial in the assessment of these patients. Arthroscopic surgery also has a role in the treatment of patients with symptomatic labral pathology and is now being used to perform stabilization procedures in selected cases. Many operative procedures have been described for stabilization of the shoulder and these should be directed at correcting the pathology present. Restoration of the patient's flexibility and strength postoperatively is essential, especially in the athlete in order to allow a full return to sporting activity.

The X-ray examination of an injured part of a skeleton requires, to obtain a 3-D effect, two vertical levels to one another. The explanation of this radiographic minimum demand is seen especially in the posterior dislocation of the shoulder as the a-p-view with the discrete indirect signs of luxation; this is often misinterpreted as being normal by inexperienced people. Indirect X-ray signs are: fixed internal rotation of the Humerus, "Trough-line", positive "Rim-sign", flattening of the medial aspect of the humeral head and "loss of the normal half-moon shadow" caused by the overlap of the humeral head on the posterior part of the glenoid cavity. The position of the second dimension is brought out with more success using the transscapular or the Velpeau axillary view radiogram without in being painful for the patient.

Subglenoid dislocation of the shoulder is uncommon. The clinical picture is striking and the radiographic appearances are characteristic, with the head of the humerus lying inferior to the glenoid and the shaft directed upwards and internally rotated. Complications such as associated fractures and injury to the brachial plexus or acillary vessels may occur. Fracture of the greater tuberosity or rupture of the rotator cuff is always seen. Post-traumatic frozen shoulder is common and leads to a poor functional result. The authors describe ten cases and review the literature. The mechanism of the injury is discussed and experimental evidence which supports the current concepts of shoulder instability is reviewed.

Erect (luxatio erecta) and superior glenohumeral dislocations are extremely uncommon. In luxatio erecta, the humeral head is subglenoid or subcoracoid just as in the more common anterior dislocation, but the shaft of the humerus is parallel to the spine of the scapula, not parallel to the chest wall as seen in the anterior type. Superior dislocations have the humeral head overlying the acromion or the clavicle on the anteroposterior radiograph. Radiographic findings in seven cases are presented and some of the associated complications are discussed.

The costo-clavicular ligament is always ruptured in dislocation at the sterno-clavicular joint. Anterior, superior or posterior displacement of the medial end of the clavicle may occur. Acute dislocation usually responds to conservative treatment and operation is seldom required. Chronic, or recurrent, dislocation may cause pain and disability on strenuous activity and necessitate surgical treatment. The operation of tenodesis of the subclavius tendon with capsulorrhaphy described by Burrows (1951) has been adopted. The intraarticular meniscus is often damaged and displaced, and may block reduction; its removal is then necessary. In addition, a threaded Stinmann pin transfixing the joint has been found useful to maintain the stability of reduction. The operation has been performed on five patients, four of whom had excellent results. The fifth patient disrupted the repair in a drinking bout shortly after the operation.

The role of atmospheric pressure in providing static stability of the shoulder was studied experimentally in 24 cadaveric shoulders. Atmospheric air was allowed to enter the joint after puncturing the capsule. Three types of experiment were performed: in the first, the capsule was punctured after sequential division of the muscles; in the second, atmospheric air was let in by percutaneous puncture of of the capsule without dividing the muscles; and in the third, air was first let into the joint by percutaneous puncture of the capsule and then the muscles of the shoulder were divided. It was found that the intact shoulder subluxated after percutaneous puncture even without division of the overlying muscles or the capsule. Our findings suggest that negative pressure and muscle tone are the main static stabilisers of the shoulder, rather than the joint capsule.

Using fresh cadaveric arms, extraneural pressures were recorded along the path of the ulnar nerve at the elbow using a fine silastic cannula. Significant pressure increases occurred when the elbow was flexed beyond a right angle, and concomitant shoulder abduction further raised the pressures recorded at the cubital tunnel and post-condylar groove. Surgical release of the cubital tunnel decreased pressures in the post-condylar groove by approximately 50 per cent when the elbow was fully flexed, whereas clamping the flexor carpi aponeurotic arch significantly increased extraneural pressures in the groove, presumably by preventing accommodative changes in neural relationships.

The results of latissimus dorsi transfer for recurrent anterior dislocation of the shoulder performed during the past three decades were subjected to a failure analysis. Twenty patients operated on in the light of this had no episodes of dislocation and obtained full function. The mode of action of the latissimus dorsi transfer explains the apparent paradox of an operation that produces external rotation resulting in the prevention of anterior dislocation. The action of the transfer in pulling the humeral head posteriorly is the most important feature. If the transfer is not located correctly, this force will be less than that produced in external rotation and dislocation will recur.

Study of 55 cases of recurrent dislocation of the shoulder treated by the operation of Bankart and Putti-Platt during 10 years. A new dislocation after the operation was present in one single case. The authors opinion is that the most important point of the technique is the correct reinsertion of the anteroinferior part of the capsule. If the glenoidal labrum is detached from the rim, the Bankart technique must be combined with the Putti-Platt. A comprehensive review of the results demonstrates that the patients are rarely disturbed by the limitation of external rotation of the operated shoulder.

Literature on anterior shoulder instability deals most often with elimination of recurrence following reconstruction. We analyzed the subjective function, loss of motion and shoulder strength of three operative procedures: Magnuson-Stack, Bristow, and Putti-Platt. A retrospective review of 27 patients, 9 in each surgical group, with no postoperative dislocations or on-going pain was performed. All patients were male, right hand dominant with the right shoulder affected. Average time of followup was 6.75 years (range, 4.2 to 10.3 years). All patients completed a questionnaire and had their range of motion measured by a hand-held goniometer and their shoulder strength tested on the Cybex II Dynomometer. Peak torque as a percent of body weight and side-to-side differences were calculated for six arm positions and compared to nine right hand dominant controls of similar age and recreational activity. Sixty percent returned to throwing sport. One Magnuson-Stack and Bristow patient felt full functional return to preinjury level. Three patients in each of these two groups returned to unmodified throwing sport whereas no Putti-Platt patient attained this level. Deficit of external rotation at shoulder neutral measured 4.7 degrees, Magnuson-Stack; 12.2 degrees, Bristow; and 21.8 degrees, Putti-Platt. At 90 degrees shoulder abduction, similar deficits in external rotation measured 6.4 degrees, 11.6 degrees, and 28.8 degrees respectively. These values were statistically significant employing analysis of variance. We compared the operative groups as a whole to the controls and compared the operative groups to each other.(ABSTRACT TRUNCATED AT 250 WORDS)

The Putti-Platt procedure and its mode of action were investigated clinically and by work on anatomic specimens. The clinical work comprised 72 cases (Group A) of recurrent traumatic anterior dislocation of the shoulder operated on by the classic Putti-Platt technique from 1961 to 1985 and 92 cases (Group B) treated by the simplified operation from 1966 to 1979. Sixty-five patients from Group A and 83 (85 shoulders) from Group B were reexamined. There were two recurrences in Group A and three in Group B. In Group A, lateral rotation of the arm was restored in 19 of the 65 patients; it was increased in 44 patients by 60 degrees to 70 degrees compared with immediate postoperative rotation, which was 20 degrees to 30 degrees from the neutral position. On anatomic specimens in which the classic Putti-Platt technique was used, lateral rotation could not reach neutral without disruption of the lateral stump from the labrum. Since the lateral stump of the subscapularis is tendinous and inelastic, the postoperative increase in lateral rotation among Group A patients could be explained if the lateral stump had become gradually detached from the labrum. Therefore, it seems that this difficult part of the classic Putti-Platt procedure may be omitted, rendering the operation simpler and shorter than the original technique but just as successful.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective review of the cases of fifteen patients with a three-part fracture of the proximal part of the humerus is presented. Fourteen of the fractures were treated with tension-band wiring and one, with an AO buttress plate. The patients were evaluated for pain, range of motion, strength, and function of the involved shoulder and the radiographic result at an average of fifty-four months after the injury. At follow-up, the shoulders had an average of 126 degrees of active elevation, 29 degrees of active external rotation, 81 degrees of active abduction, and internal rotation to the second lumbar vertebra. The only early complication was failure of fixation in the patient who had been treated with a buttress plate. In two patients, radiographic evidence of avascular necrosis of the humeral head later developed, and one of them required revision to a hemiarthroplasty. In conclusion, we recommend operative treatment for the healthy, active individual who has a three-part fracture of the proximal part of the humerus. We found that the best results with these difficult fractures are obtained using tension-band wiring.

Transfer of the subscapularis tendon using a slightly modified Magnuson-Stack procedure was done in 154 shoulders with recurrent anterior dislocation. A follow-up to two to twenty-two years (average, 7.6 years) revealed only three recurrences of the dislocation and no serious complications.

In two cases of bilateral spontaneous posterior dislocation of the shoulder, the authors have detected an anomaly of orientation of the glenoid cavity. A technique of radiological examination which allows a study of the position of the joint surface relative to the acromion and the coracoid process is described. Osteotomy of the glenoid was completed by a posterior graft taken from the end of the acromion with satisfactory results in the two cases.

Shoulder subluxation is an extremely common problem confronting the sports medicine physician and may present in a variety of ways, with the patient complaining of pain of a sense of instability. In throwing spots, tendinitis secondary to impingement is common, but it may also be secondary to instability as a result of traction or compression of the rotator cuff. In addition, subluxation may develop initially, then progress to dislocation, or the converse may occur. However, some patients may have subluxation over an extended period of time. The physician must consider the entity and take a careful history, followed by an examination that notes subtle losses of motion and strength and the presence of apprehension. The x-ray films may be helpful when the standard views are supplemented by the West Point and Stryker notch views. Examination under anesthesia and arthroscopy have played an increasingly significant role in the recognition and evaluation of these patients. At times, arthroscopy is helpful in the treatment of shoulder subluxation in patients who have partial labral detachment. This is mainly in throwers or tennis players in whom open surgery is likely to result in significant loss of athletic ability. Stretching and strengthening exercises are frequently helpful in managing subluxations and tendinitis associated with the microtrauma of repetitive use in contrast to traumatic subluxation. Operative procedures are indicated after the failure of conservative treatment. It is important to explore the joint to find loose bodies and to note any labral damage or detachment. Great care must be taken to avoid excessively tightening the capsule, which will limit athletic activity and may increase the instability in the opposite direction. Postoperatively, a well-directed exercise program to restore the patient's flexibility and strength is indicated prior to the resumption of any sporting activity.

A 24-year-old man sustained a rare form of anterior dislocation of the shoulder known as luxatio erecta. As in this case, the presentation of these patients is nearly pathognomonic. Successful reduction was accomplished, and the patient suffered no sequelae.

Much strain is placed on the shoulder joint in all sports. Sports injuries may be caused by a single, violent incident. Fractures of the clavicle, acromioclavicular and sternoclavicular traumas, isolated fractures of the greater tuberosity and shoulder dislocations are frequent clinical pictures which today can be managed by well established procedures. Other sports injuries, however, involve over-use of the shoulder which, through repetitive harmful movements, can bring about microtraumatic lesions of the rotator cuff, glenoid labrum, acromioclavicular joint and certain peripheral nerves around the suprascapularis. In all cases, a programmed, comparative, clinical examination and complementary, sequential examinations will indicate suitable curative and preventive treatment.

Although posterior dislocation of the shoulder is a rare injury in athletes, failure to recognize and properly manage acute dislocation may have serious consequences. The article discusses the incidence, mechanism of injury, classification, pathologic findings, clinical and radiologic diagnosis, and management.

The purpose of this study was to examine kinesthesia in normal (uninjured) shoulders and in shoulders with a history of glenohumeral joint dislocations. Both shoulders of 10 healthy subjects and 8 subjects with a history of unilateral anterior dislocation were tested for accuracy of angular reproduction, threshold to sensation of movement, and end-range reproduction using a motor-driven shoulder-wheel apparatus. An analysis of variance revealed significant differences (p less than .001) between the injured and uninjured shoulders for all three tests. Post hoc analysis showed significant differences (p less than .02) between the involved shoulders and all uninvolved shoulders. No significant difference was found among the uninvolved shoulders. The results of this study indicate that kinesthetic deficits occur after glenohumeral dislocation and may result in abnormal neuromuscular coordination and subsequent reinjury of the shoulder. Clinicians should consider rehabilitation of shoulder kinesthesia using therapeutic activation of the shoulder joint and muscle receptors when treating patients with previous dislocations.

EMG activity from eight shoulder muscles in parallel was recorded from 4 patients with generalized joint laxity. During external rotation of the humerus in 45 degrees abduction, humeroscapular dislocation occurred in 2 patients and subluxation in the 2 others. The activity level in the subscapularis was low, and the activation speed was slow. The low muscle activity and delay in activation of the subscapularis muscle may contribute to the instability.

In 3 cases of simultaneous bilateral anterior dislocation of the shoulders, considering the forces which predispose to anterior dislocations, it is postulated that in each case forced abduction and external rotation or abduction with hyperextension causes these injuries to occur.