Kiyohisa Ogawa

FRACTURES OF THE CORACOID PROCESS

We reviewed 67 consecutive patients with fractures of the coracoid process, classifying them by the relationship between the fracture site and the coracoclavicular ligament. The 53 type-I fractures were behind the attachment of this ligament, and the 11 type-II fractures were anterior to it. The relationship of three fractures was uncertain. Type-I fractures were associated with a wide variety of shoulder injuries and consequent dissociation between the scapula and the clavicle. Treatment was usually by open reduction and fixation for type-I fractures and conservative methods for type-II. At follow-up of the 45 available patients, 87% had excellent results, with no significant differences between the operative and non-operative groups or between the type-I and type-II fractures. We consider that operative treatment should be reserved for patients with multiple shoulder injuries with severe disruption of the scapuloclavicular connection.

Classification of Fractures of the Talus: Clear Differentiation Between Neck and Body Fractures

The treatment and prognosis of neck fractures (extra-articular) and body fractures (intra-articular) of the talus are different. Ratios between neck fractures and body fractures reported by different investigators vary widely (from 6:1 to 1:1), because it is difficult to differentiate fractures crossing the anteromedial aspect of the trochlea. We examined 215 fractures of the talus. By examining the inferior surface fracture line, we found that the 61 fractures crossing the anteromedial aspect of the trochlea could be differentiated into 28 neck fractures and 33 body fractures. We suggest classifying fractures of the talus based on the inferior, not superior, surface fracture line.

Throwing fracture of the humeral shaft. An analysis of 90 patients.

Ninety patients with humeral shaft fractures sustained during throwing were analyzed to determine what caused their injuries. All patients were recreational baseball players: 89 were men and 1 was a woman. The average age was 25 years (range, 12 to 43). The throwing style, type of pitch, fielding position, and type of ball used varied; however, the patients sustained their fractures while performing a hard throw in 87 (97%) of the occurrences. The actual courses of the balls thrown ranged from sideways to straight forward. All fractures were external rotation spiral fractures; 25 patients (28%) had a medial butterfly fragment, and 14 patients (16%) had radial nerve palsy. Fractures were most likely to have occurred in the distal half of the humerus, although they occurred frequently in the proximal half in patients in their early teens. We conclude that 1) the fracture can occur at any time during the acceleration phase before ball release, 2) this type of fracture can occur in any recreational baseball player attempting to perform a hard throw, and 3) the cause of this fracture is the throwing action itself.

Long-term outcome of isolated lesser tuberosity fractures of the humerus.

Ten cases of an isolated fracture of the lesser tuberosity and their long-term outcome are described. The patient ages at the time of injury ranged from 11 to 68 years, averaging 30 years. In six cases, the injury was acute; in four cases, it had occurred more than 6 months previously. Of the six acute cases: three were treated conservatively, and the result was satisfactory for all of them; surgery was carried out in the other three cases, of which, two outcomes were judged to be excellent, and one outcome was satisfactory. Regarding the four chronic cases, muscle-strengthening exercises were given in two cases, whereas an operation was performed after exercise failed in the remaining two cases. The results of all four cases were graded as excellent. The combination of open reduction and internal fixation is the method most often recommended for acute cases. In chronic cases, conservative treatment is usually the most appropriate. However, when conservative treatment proves to be ineffective, then open reduction and internal fixation should be considered.

Long-term follow up of talus fractures

Eighty-six patients who had experienced a fracture of the talus more than 10 years previously were assessed. The fracture had occurred in the neck of the talus in 52 feet and in the body of the talus in 27 feet. The fracture was complicated by dislocation in 47 feet, and aseptic necrosis had developed in 33 feet. The outcome was rated as excellent in 20 feet, good in 43, fair in 18, and poor in 7. The cause of poor outcome in the late stage was posttraumatic osteoarthritis secondary to avascular necrosis and incongruity of the joint surface. Early active exercise without weight bearing is recommended to prevent contracture and bone atrophy due to disuse, which may promote osteoarthrosis. Arthrodesis is recommended in patients with pain because the outcome is greatly improved by arthrodesis, even when performed more than 10 years after the injury.

Fractures of the acromion and the lateral scapular spine

We studied 37 fractures lateral to the spinoglenoidal notch to evaluate the validity of collectively handling these fractures as an acromion fracture and to ascertain the mechanism of injury. We divided them into three groups according to the location of the fracture line. Fracture of the anatomic acromion or the extremely lateral scapular spine (groups I and II, 28 fractures) was frequently associated with fracture of the coracoid base, acromioclavicular joint injury, or both. The mechanism of injury in most cases was presumed to be indirect force brought to bear on the shoulder from the lateral direction. Fracture descending to the spinoglenoidal notch (group III, nine fractures) was seldom associated with other shoulder injuries, and surgery was rarely needed. The mechanism was assumed to be direct force brought to bear on the shoulder from the posterior direction. Therefore fractures of the anatomic acromion and the extremely lateral scapular spine may be managed collectively. However, fracture descending to the spinoglenoidal notch should be managed separately. We advocate that these fractures should be classified into two types in terms of clinical consideration: type I fractures, comprising those of the anatomic acromion and the extremely lateral scapular spine, and type II fractures, located in the more medial spine and descending to the spinoglenoidal notch.

Magnetic resonance imaging of suprascapular nerve palsy

In magnetic resonance imaging of peripheral nerve palsy, changes of signal intensity are often found in paralyzed muscles. The purpose of this report is to clarify the relation between magnetic resonance imaging findings and clinical examination in suprascapular nerve palsy. The subjects were 12 patients with suprascapular nerve palsy who underwent magnetic resonance imaging examinations. In 9 of 12 cases ganglion cysts were found at the spinoglenoid notches. On T1-weighted images the signal intensity of infraspinatus muscle was high in four cases but normal in the supraspinatus muscle in all cases. On T2-weighted images the signal intensity of infraspinatus muscle was high in six cases, and that for supraspinatus muscle was high in one case. In two cases the high intensity of palsied muscles became normal after the palsy recovered. Magnetic resonance imaging is a useful examination of peripheral nerve palsy not only for the detection of ganglion cysts but also for assessing the stage of paralysis.

Isolated fractures of the greater tuberosity of the humerus: solutions to recognizing a frequently overlooked fracture.

BACKGROUND Although isolated fracture of the greater tuberosity of the humerus had been regarded as an easily overlooked fracture, recent literature focusing on its diagnosis is scarce. The purpose of this study was to elucidate the rate of missed diagnosis of isolated humeral greater tuberosity fracture and pitfalls in diagnosis and to ascertain the most effective method for preventing missed diagnosis. METHODS One hundred sixty-three shoulders, of which diagnosis was made by radiography for all and by proving a localized tenderness on the lateral wall of the greater tuberosity for the acute cases, were retrospectively reviewed. The diagnoses made at the previously visited clinic were analyzed, as was the relationship between missed diagnosis and other pertinent factors such as the extent of fracture and the amount of displacement of the fractured fragment. RESULTS Fractures were overlooked in 58 of the 99 shoulders (59%) that had been initially examined at other clinics. The rate (64%) of missed diagnosis in one-part fractures was significantly higher than that (27%) in two-part fractures (p < 0.01). Twenty-five (76%) of 33 isolated supraspinatus (SSP) (facet for the SSP), 26 (57%) of 46 SSP + infraspinatus (ISP) (facet for the infraspinatus ISP), and 6 (33%) of 18 SSP + ISP + teres minor (facet for the teres minor) fractures were overlooked at previous clinics. The smaller the fragment, the higher the rate of missed diagnosis (p < 0.05). CONCLUSION Isolated fracture of the greater tuberosity remains an easily overlooked injury. The likelihood of this missed diagnosis increases with the fracture being limited to the SSP facet and decreases as the fracture extends posteriorly. Confirming the presence of tenderness on the lateral wall of the greater tuberosity is a clinically effective method for preventing missed diagnosis.

Morphologic features of humeral head and glenoid version in the normal glenohumeral joint

BACKGROUND The morphologic features and clinical significance of version of the humeral head and glenoid remain unclear. The purpose of this study was to evaluate the normal values of humeral head version and glenoid version on computed tomography scans and to clarify their features in the normal glenohumeral joint. METHODS Images for analysis were computed tomography scans of 410 normal shoulders from healthy volunteers. Values of humeral head and glenoid version were measured. In glenoid version measurement, 3-dimensionally corrected slices were reconstructed to eliminate scapular inclination. Differences in humeral head version and glenoid version were assessed between dominant and nondominant shoulders and between men and women. Correlation analyses were also performed in the values of version between dominant and nondominant shoulders and between humeral head version and glenoid version. RESULTS The values of humeral head retroversion were widely distributed from -2° to 60°, with an average of 26° ± 11°. Average glenoid retroversion was 1° ± 3°, ranging from -9° to 13°. Both humeral head retroversion and glenoid retroversion were significantly higher on the dominant side than on the nondominant side and significantly higher in men than in women. Humeral head version and glenoid version values were well correlated with those of the contralateral shoulder. No correlation was found between humeral head version and glenoid version. CONCLUSIONS This study found differences in humeral head version and glenoid version by sex and shoulder dominance in a large sample. Both the humeral head and glenoid are thought to be more retroverted in high-demand shoulders.

Posterior shoulder dislocation associated with fracture of the humeral anatomic neck: treatment guidelines and long-term outcome.

OBJECTIVE We describe here 10 cases of posterior shoulder dislocation associated with fracture of the humeral anatomic neck. METHODS Patients were treated according to our uniform treatment guidelines, in which only the dislocated humeral head (closed, if possible) was reduced, without any concomitant repositioning or internal fixation for fractures. RESULTS Reduction resulted in an acceptable repositioning of the fractured fragments in all but one case. Anatomic neck fractures were impacted by applying longitudinal pressure for stabilization. Although early physiotherapy was initiated, redisplacement of the bone fragments did not occur. Of nine patients who were followed for more than 2 years, complete recovery of function was achieved in all but two patients. The completely detached humeral head became avascular necrotic accompanied by subchondral collapse in one case, and in the other case the displaced lesser tuberosity caused a decreased range of movement. CONCLUSION We recommend initially treating such patients by either open or closed reduction of the dislocated humeral head and impaction of the fracture, with neither repositioning nor internal fixation of any of the fractured fragments. A completely detached humeral head or bone fragments displaced more than 10 mm after reduction of the dislocated humeral head contraindicate the use of this method.