Transfer of the levator scapulae, rhomboid major, and rhomboid minor for paralysis of the trapezius.

Twenty-two patients who had paralysis of the trapezius muscle secondary to injury of the spinal accessory nerve had transfer of the levator scapulae and rhomboid major and minor muscles. In each patient, function of the trapezius had failed to improve with either physical therapy or an operative attempt at neurolysis or reconstruction of the spinal accessory nerve. The etiology of the injury was biopsy of a cervical node in thirteen patients, trauma in seven, and radical dissection in the neck in two. All patients had pain, visible deformity, and dysfunction of the shoulder girdle. Physical examination revealed asymmetry of the neckline, drooping of the shoulder girdle with lateral displacement of the scapula, and weakness of active elevation. Fourteen patients had had an incorrect clinical diagnosis, and twelve patients had had an inaccurate or incomplete electromyographic examination. A long thoracic nerve palsy developed in three patients. At an average of seven and a half years (range, two to fourteen years), the result of the operative procedure, as determined with the American Shoulder and Elbow Surgeons Shoulder Evaluation Form, was excellent for thirteen patients, satisfactory for six, and unsatisfactory for three. All but three patients had adequate relief of pain and demonstrable functional improvement.

Evaluation and treatment of the winged scapula.

Winging of the scapula is often associated with palsy of the serratus anterior muscle, but can be due to numerous pathologic processes. Often representing more than just a cosmetic deformity of the shoulder, it can lead to significant pain and functional impairment. Winging can be due to disease in the nerves, muscles, bones, and joints in the periscapular area and may be either a static or dynamic deformity. Treatment of the winged scapula depends on the severity of the patient's complaints, and the exact treatment required is determined by the underlying pathologic process. A systematic approach to the winged scapula is essential to ascertain the underlying cause and successfully manage this deformity of the shoulder girdle.

Neurologic Injuries in the Athlete's Shoulder.

OBJECTIVE: To review the presentation, evaluation, treatment, and prognosis of various nerve injuries about the shoulder in the athletic population. Included are injuries to the axillary, suprascapular, musculocutaneous, long thoracic, and spinal accessory nerves. DATA SOURCES: This article represents a review of the literature regarding incidence, presentation, and results of treatment of these various nerve injuries. The clinically pertinent anatomy is also presented to better relate mechanism of injury to the occurrence of nerve injury. I searched MEDLINE from 1966 through 1999 and the Journal of Shoulder and Elbow Surgery from 1992 through 1999 for the key words "nerve" and "shoulder." DATA SYNTHESIS: A historical review of treatment results is presented as well as a review of treatment options and the results of studies using modern techniques in the management of nerve injuries. CONCLUSIONS/RECOMMENDATIONS: Nerve injuries about the shoulder present as distinct clinical syndromes, although signs and symptoms can be subtle. The athletic trainer and team physician must be able to recognize the presentation of these injuries so that adequate evaluation and prompt treatment can be instituted to maximize the athlete's chance for early return to sport.

Troubleshooting the supraspinatus outlet view.

Radiographic evaluation of the acromion is integral to the management of subacromial impingement syndrome. The supraspinatus outlet view reveals acromial morphologic traits, acromial slope, subacromial excrescences, and inferior osteophytes at the acromioclavicular joint. The major disadvantage of the outlet view is reproducibility. The purpose of this article is to describe technical factors that allow for obtaining this view consistently. In this study 7 different outlet views were obtained of the shoulder of an asmptomatic, voluntary subject. One view was obtained correctly; the other 6 were taken by simulating common technical errors. Each radiograph was then evaluated to determine how each technical error affected the radiographic image. Guidelines were then formulated for obtaining a proper outlet view on no more than 2 attempts. Correction of a faulty supraspinatus outlet view should be guided by the shape of the scapular body, the position of the floor of the supraspinatus fossa, and the distance between the humeral head and acromion.

Isolated nerve injuries about the shoulder.

Infraclavicular nerve injuries are rare and potentially disabling problems. A retrospective study of 24 patients with 28 nerve injuries is presented, including 18 axillary, 7 suprascapular, and 3 musculocutaneous nerve injuries. Vague shoulder pain and weakness of the involved muscle groups were the main symptoms of nerve injury in these patients. All patients had atrophy of the specific muscles involved. Diagnosis of these nerve lesions can often be difficult because of this vague presentation. Followup from date of injury averaged 60 months and included evaluation by questionnaire, repeat physical examinations, and serial electromyograms. There were 21 complete or satisfactory nerve recoveries, while 7 patients had unsatisfactory results. The etiology of the injury appeared to be an important factor with respect to outcome. Eight of 10 nerve injuries secondary to blunt trauma went on to complete recovery, and 4 of 6 nerve injuries secondary to shoulder dislocation recovered completely. None of the 7 nerves injured during surgery recovered completely. No patient with spontaneous onset of nerve dysfunction had an unsatisfactory result. Poor results were noted in patients with initial total denervation as shown by electromyogram and in patients with intraoperative nerve damage.

The use of arthroscopy in the treatment of resistant frozen shoulder.

Arthroscopy serves as a useful adjunct to manipulation under anesthesia in the treatment of resistant frozen shoulder. In this technique the shoulder is manipulated under interscalene brachial plexus block anesthesia, followed by arthroscopic examination and debridement of the glenohumeral joint and the subacromial space. The addition of arthroscopy allows the identification and treatment of associated pathology, such as impingement lesions and secondary subacromial space inflammation, calcific deposits, and acromioclavicular arthritis. Range of motion can also be increased by arthroscopically guided sectioning of the coracohumeral ligament. This treatment regimen has yielded overall satisfactory results in 25 (83%) of 30 shoulders in this series. The subgroup with diabetes mellitus fared less well than the other groups, with only 64% satisfactory results. While most patients with frozen shoulder will respond to nonoperative treatment, the technique of manipulation under anesthesia followed by arthroscopy offers a safe and reliable treatment for the resistant frozen shoulder.

Anterior acromioplasty for subacromial impingement in patients younger than 40 years of age.

The indications and results of anterior acromioplasty in patients older than 40 years of age are well documented; however, little is reported concerning this procedure in younger patients because the majority are treated conservatively. Over the last seven years, 26 patients younger than 40 years of age were treated by anterior acromioplasty for subacromial impingement resistant to conservative therapy. The indication for surgery was failed conservative therapy in 17 patients. Six patients had impingement despite previous surgery, such as failed acromioplasty, biceps tenolysis, and biceps tenodesis. Two patients had impingement secondary to greater tuberosity malunion. The average duration of symptoms was 27 months and of conservative therapy, 17 months. All patients had a bursectomy and anterior acromioplasty. In addition, eight had a complete acromioclavicular arthroplasty for concurrent acromioclavicular arthritis, four had a modified acromioclavicular arthroplasty for impingement under the acromioclavicular joint, three had calcium excisions, and one had a rotator cuff repair. The greater tuberosity malunions were advanced in one patient and excised in one. The results were 81% (21) excellent and good, 15% (four) fair, and 4% (one) poor. The average follow-up period was 33 months. The majority of younger patients with subacromial impingement can be successfully treated conservatively. In those patients with persistent symptoms, open acromioplasty can reliably give good results with regard to pain and function.

Arthroscopic resection of the distal clavicle with a superior approach.

Forty-one patients (41 shoulders) with acromioclavicular joint disease refractory to conservative treatment underwent arthroscopic distal clavicle resection. Thirty-one men and 10 women with an average age of 32 years were studied. The dominant extremity was involved in 68% of the patients. At an average follow-up period of 31 months (range 24 to 49 months), 18 excellent, 16 good, and seven poor results were found. Twenty-seven (93%) of 29 shoulders with acromioclavicular arthritis or osteolysis of the distal clavicle went on to have satisfactory results compared with only seven (58%) of 12 shoulders with previous grade II acromioclavicular separations or acromioclavicular hypermobility. Total amount of bone removal did not correlate with success, if the resection was even. Five reoperations were done; one uneven resection was revised with arthroscopy, and four shoulders underwent acromioclavicular stabilization procedures. The high failure rate in patients with even subtle acromioclavicular instability (42%) suggests that in these cases formal stabilization with ligament reconstruction should be considered in addition to resection of the distal clavicle.

Operative treatment of nonunions of the surgical neck of the humerus.

Twenty patients underwent surgical reconstruction for nonunion of fractures of the surgical neck of the humerus. Average time from injury to surgery was 10 months (range 4 to 14 months). The operation consisted of bone grafting combined with humeral head replacement in 10 cases and open reduction and internal fixation in 10 cases. Results, at an average follow-up of 51 months (range 24 to 124 months), were excellent in five (25%), satisfactory in six (30%), and unsatisfactory in nine (45%). Twelve nonunions resulted from fractures initially treated with close reduction; repair of these nonunions achieved by 67% excellent or satisfactory results. Eight nonunions resulted from fractures initially treated with internal fixation; repair of these nonunions achieved only 38% excellent or satisfactory results. Fifteen complications, 11 of which necessitated reoperation, occurred. Surgical reconstruction for nonunions of the surgical neck of the humerus usually results in significant improvement in pain but much more modest improvement in active motion and function. Surgery should be reserved for patients with significant symptoms and disability.