Acute anterior dislocation of the glenohumeral joint may be complicated by injury to neighboring structures. These injuries are best considered a spectrum of injury ranging from an isolated dislocation (unifocal injury), through injuries associated with either nerve or osteoligamentous injury (bifocal injury), to injuries where there is evidence of both nerve and osteoligamentous injury. The latter combination has previously been described as the “terrible triad,” although we prefer the term “trifocal,” recognizing that this is the more severe end of an injury spectrum and avoiding confusion with the terrible triad of the elbow. We evaluated the prevalence and risk factors for nerve and osteoligamentous injuries associated with an acute anterior glenohumeral dislocation in a large consecutive series of patients treated in our Unit. 3626 consecutive adults (mean age 48yrs) with primary traumatic anterior shoulder dislocation treated at our unit were included. All patients were interviewed and examined by an orthopaedic trauma surgeon and underwent radiological assessment within a week of injury. Where rotator cuff injury or radiologically-occult greater tuberosity fracture was suspected, urgent ultrasonography was used. Deficits in neurovascular function were assessed clinically, with electrophysiological testing reserved for equivocal cases.Background
Materials and Methods
Displaced fractures of the lateral end of the clavicle in young patients have a high incidence of nonunion and a poor functional outcome after conservative management. Operative treatment is therefore usually recommended. However, current techniques may be associated with complications which require removal of the fixation device. We have evaluated the functional and radiological outcomes using a novel technique of open reduction and internal fixation. A series of 16 patients under 60 years of age with displaced fractures of the lateral end were treated by open reduction and fixation using a twin coracoclavicular endobutton technique. They were followed up for the first year after their injury. At one year the mean Constant score was 87.1 and the median Disabilities of the Arm, Shoulder and Hand score was 3.3. All fractures had united, except in one patient who developed an asymptomatic fibrous union. One patient had post-traumatic stiffness of the shoulder, which resolved with physiotherapy. None required re-operation. This technique produces good functional and radiological outcomes with a low prevalence of complications and routine implant removal is not necessary.
We treated 47 patients with a mean age of 57 years (22 to 88) who had a proximal humeral fracture in which there was a severe varus deformity, using a standard operative protocol of anatomical reduction, fixation with a locking plate and supplementation by structural allografts in unstable fractures. The functional and radiological outcomes were reviewed. At two years after operation the median Constant score was 86 points and the median Disabilities of the Arm, Shoulder and Hand score 17 points. Seven of the patients underwent further surgery, two for failure of fixation, three for dysfunction of the rotator cuff, and two for shoulder stiffness. The two cases of failure of fixation were attributable to violation of the operative protocol. In the 46 patients who retained their humeral head, all the fractures healed within the first year, with no sign of collapse or narrowing of the joint space. Longer follow-up will be required to confirm whether these initially satisfactory results are maintained.
