We test the clinical validity and financial implications of the proposed Choosing Wisely statement: “Using ultrasound as a screening test for shoulder instability is inappropriate in people under 30 years of age, unless there is clinical suspicion of a rotator cuff tear.”

A retrospective chart review from a specialist shoulder surgeon's practice over a two-year period recorded 124 patients under the age of 30 referred with shoulder instability. Of these, forty-one had already had ultrasound scans performed prior to specialist review. The scan results and patient files were reviewed to determine the reported findings on the scans and whether these findings were clinically relevant to diagnosis and decision-making. Comparison was made with subsequent MRI scan results. The data, obtained from the Accident Compensation Corporation (ACC), recorded the number of cases and costs incurred for ultrasound scans of the shoulder in patients under 30 years old over a 10-year period.

There were no cases where the ultrasound scan was considered useful in decision-making. No patient had a full thickness rotator cuff tear. Thirty-nine of the 41 patients subsequently had MRI scans. The cost to the ACC for funding ultrasound scans in patients under 30 has increased over the last decade and exceeded one million dollars in the 2020/2021 financial year. In addition, patients pay a surcharge for this test.

The proposed Choosing Wisely statement is valid. This evidence supports that ultrasound is an unnecessary investigation for patients with shoulder instability unless there is clinical suspicion of a rotator cuff tear. Ultrasound also incurs costs to the insurer (ACC) and the patient. We recommend x-rays and, if further imaging is indicated, High Tech Imaging with MRI and sometimes CT scans in these patients

We document intra-articular pathology in collision athletes with shoulder instability and describe the ‘collision shoulder’ – a direct impact without dislocation, with unusual labral injury, significant intra-articular pathology and neurology. 183 collision athletes were treated for labral injuries in 3 centres. Details of injury mechanism and intra-articular pathology at surgery were recorded. Premier league and International (Elite) comprised 72 players. A tackle was implicated in 52% of injuries and 65% had a dislocation. The mechanism of injury was ABduction External Rotation (ABER) in 45%, direct impact 36%, abduction only 8% and axial load 6%. Dislocation occurred in 51% of shoulders with ABER mechanism. A Bankart lesion was found in 79% of these shoulders; Hill-Sachs in 58% and Bony Bankart in 26%. Inferoposterior labral tears were present in only 11%, Superior Labral Antero-Posterior (SLAP) lesions in 32% and partial injury to the rotator cuff in 32%. In those sustaining a direct impact to the shoulder, 61% did not document dislocation, had a high incidence of inferoposterior labral involvement (50%), neurological symptoms (32%), but a low incidence of Bankart (33%), Hill-Sachs (22%) and Bony Bankart (11%) lesions. The mechanism did not affect incidence of superior labral/SLAP tears (18%), or capsular tears (including Humeral Avulsion of Glenohumeral Ligaments – HAGL) – 15%. Elite athletes had less dislocations (43% vs 74%) irrespective of mechanism, but were 40% more likely to have neurology, posteroinferior labral, cartilaginous or capsular injuries. They had twice the incidence of Bony Bankart and rotator cuff lesions and 5 times more SLAP/superior labral tears. Collision athletes with shoulder instability have a wide spectrum of pathoanatomy of the labrum and frequent associated intra-articular lesions. Significant injury often occurs in the Elite athlete and those sustaining a direct hit without dislocation (the ‘Collision Shoulder’).

The spectrum of pathoanatomy in collision athletes with shoulder instability is wide, with a high incidence of extended labral lesions and associated intra-articular injuries. The ‘collision shoulder’ describes an injury sustained by direct impact to the shoulder without dislocation, but with extensive labral damage and a high incidence of other intra-articular pathology and neurological symptoms.

One hundred and eighty-three collision athletes (rugby and rugby league) were treated for labral injuries related to their sport in three different centres. Details of the mechanism of injury and findings at surgery were recorded. Only 60% of athletes in the series presented following a documented dislocation or subluxation episode of the shoulder. An additional pattern of injury was recognised in the remaining athletes involving a direct impact injury to the shoulder. In these athletes the clinical symptoms and signs were less specific but there was a high incidence of ‘dead arm’ at the time of injury (72%).

The spectrum of pathology in this series was wide with a high incidence of associated intra-articular lesions. In those athletes with an impact type of injury without dislocation there was more extensive labral pathology with a high incidence of posterior labral tears (50%). The incidence of associated chondral lesions was similarly very high but significant bony pathology was less common than in the dislocation group (11 % versus 26%). Elite athletes had less frank dislocations but were more likely to sustain neurological injury, posterior labral tears, SLAP lesions and cartilaginous and capsular injuries.

The incidence of all lesions in this series of collision athletes is higher than those previously published. These lesions often occurred in the absence of a frank dislocation (the ‘collision shoulder). It is important to anticipate additional pathology when planning definitive management in these patients, with surgery tailored to the specific lesions found. The athlete with an impact type of injury without dislocation can do well following surgery, with a high rate of return to contact sport, either at the same or a higher level.

The aim was to define the operative and MRI arthrogram findings in recurrent post stabilization instability, to establish the accuracy of MRI findings compared to surgical findings, and to define the role of MRI in evaluation and planning for these patients.

The operative findings in 25 consecutive patients undergoing revision shoulder stabilization procedures were reviewed. 18 of these patients had MRI arthrograms prior to their revision procedure. All revision procedures were performed by the same surgeon, and all MRI scans reviewed by 2 musculoskeletal radiologists.

Primary and contributing factors for instability were identified for each patient. Primary factors for failure included; new injury at a different site to the index repair (6 patients), laxity of the inferior glenohumeral ligament (5 patients), failure of the index repair (7 patients) and failure to address the pathology at the index procedure (7 patients).

MRI arthrography had 85% sensitivity, 100% specificity and 89% accuracy.

MRI arthrography is accurate in assessment of the labrum in recurrent post stabilization instability. Recurrent instability is complex and multifactorial, but a primary factor can often be identified. In some cases new trauma results in injury at a different site to the initial repair. MRI arthrogram may assist in surgical planning. If a labral injury is present without laxity or a glenoid bony defect, arthroscopic revision may be undertaken. If significant capsular laxity or bone deficiency is present, then an open procedure with capsular shift and rotator interval closure may be appropriate.

Aim: To determine the accuracy of the posterior-to-anterior (PA) 15 degrees caudad view of the clavicle to assess amount of shortening of clavicular fractures. Method: The first stage of the study involved taking x-rays of an adult skeleton, centred on the clavicle. The projections included the standard anterior-to-posterior (AP) 15 degrees cephalad view, and the PA 15 degrees caudad view. Additional images were taken in the 15 degrees caudad view with a series of oblique rotational views, and oblique images in the vertical plane. Metal markers were placed on the clavicle at 10mm intervals. The clavicular length and the interval between markers were measured on the x rays.The second stage of the study involved obtaining the PA 15 degrees caudad x-ray on 50 patients with clavicular fractures. The non injured clavicle was also x-rayed. The lengths of the non injured clavicle and the lengths of the fragments of the fractured clavicle were recorded.

Results: The length of the clavicle of the skeleton in the AP standard image was 149mm. The length in the PA 15 degrees caudad image was 130mm, with a maximum of 4mm variation on the oblique views up to 30 degrees. The true length was 124mm.Forty-five fractures were diaphyseal, and five were outer third fractures. There was less than 5mm measured difference in the length of injured and non injured clavicle in 38 out of 45 patients with diaphyseal fractures (84%).

Conclusions: The PA 15 degrees caudad clavicular x-ray provided a more accurate assessment of clavicular shortening than the standard AP view, and was well tolerated by the patients.

Aim: To describe accurately the contributions of glenohumeral (GH) and scapulothoracic (ST) joints in shoulder movements in normal male adult subjects, aged 20–30 years.

Methods: We recorded data with a Polhemus magnetic tracking device (Kaiser Aerospace and Electronics Co., Vermont). Receivers were taped on landmarks, over the sternum, scapula and humerus. The movements that were studied were elevation in the sagittal plane, abduction in the scapular plane and lowering the arm from these positions. We collected data from 26 male subjects (52 shoulders), aged 20–30 years, with no history of shoulder problems. Repeatability data were obtained in 16 subjects.

The data can be expressed in a number of ways, including plotting the ratio of GH/ST movement versus overall shoulder movement. Polynomial equations to fit these curves describe movement patterns. We have developed software to calculate cumulative averaging of data.

Results: Both GH and ST movements contribute to shoulder movement throughout the ranges studied. Although the shapes of the movement curves were fairly consistent, there were some non-conforming curves and variations. As the arm is abducted the mean ratio of GH/ST movement increases to approximately 3/1. Adduction produces curves that nearly mirror image the abduction curves. Flexion and extension curves tend to be flatter with a mean GH/ST ratio of 2–3/1, throughout the range. The reproducibility data shows satisfactory fits to initial curves.

Conclusions: We have developed a method to describe shoulder movement that provides new information regarding normal shoulder movements. This method can be applied to study patients with shoulder disorders.

Introduction: The patterns of forearm and hand paralysis in traumatic tetraplegia are recognised and classified by an international classification system. Although weakness and wasting are common around the shoulder in tetraplegia, it is harder to discern individual muscle function.

Aim: To determine the activity of shoulder girdle muscles in patients with traumatic tetraplegia and to relate these results to the subjects’ international forearm classifications.

Methods: Twenty-five male tetraplegic subjects (50 upper limbs) were examined. Forearm muscle strengths were recorded according to the international classification system. The strengths of nine shoulder movements were recorded according to the Medical Research Council (MRC) grading system. The presence of wasting and the electromyographic (EMG) activity of nine shoulder muscle regions were noted. Using surface electromyography we noted whether voluntary EMG patterns were present or absent and whether lower motor denervation signs were present or absent.

Results: Absence of voluntary EMG activity was only seen in latissimus dorsi, and only in patients with very high-level lesions (either no MRC grade IV forearm muscles, or brachioradialis only, i.e. international forearm grade I or less). Lower motor neuron signs were observed in latissimus dorsi in most patients without ipsilateral MRC grade IV finger extension (international forearm grade VI or less). Lower motor neuron signs were observed in infraspinatus in most patients without MRC grade IV forearm pronation (international forearm grade IV or less).

Conclusions: Only patients with very high level lesions showed paralysis of any shoulder girdle muscles and, then, only latissimus dorsi. In most cases of traumatic tetraplegia shoulder girdle muscles have the capacity to be strengthened by use and rehabilitation.

We reviewed the results of reconstruction of 97 upper limbs in a consecutive series of 57 tetraplegic patients, treated from 1982 to 1990. Of these, 49 had functional and eight had cosmetic reconstructions. The principal functional objectives were to provide active elbow extension, hook grip, and key pinch. Elbow extension was provided in 34 limbs, using deltoid-to-triceps transfer. Hook grip was provided in 58 limbs, mostly using extensor carpi radialis longus to flexor pollicis longus transfer, and key pinch in 68, mostly using brachioradialis to flexor pollicis longus transfer. Many other procedures were employed. At an average follow-up of 37 months, 70% had good or excellent subjective results, and objective measurements of function compared favourably with other series. Revisions were required for 11 active transfers and three tenodeses, while complications included rupture of anastomoses and problems with thumb interphalangeal joint stabilisation and wound healing. We report a reliable clinical method for differentiating between the activity of extensor carpi radialis longus and brevis and describe a successful new split flexor pollicis longus tenodesis for stabilising the thumb interphalangeal joint. Bilateral simultaneous surgery gave generally better results than did unilateral surgery.