Sensory innervation of the human shoulder joints in healthy and in chronic pain shoulder syndromes.

BACKGROUND: Afferent innervation of shoulder joints plays a fundamental role in nociception and mechanoception and its alteration result in shoulder´s disease that course with pain and functional disability. METHODS: Joints shoulder from healthy subjects (n = 20) and with chronic pain shoulder syndromes (n = 17) were analyzed using immunohistochemistry for S100 protein to identify nerve structures (nerve fibers and sensory corpuscles), coupled with a quantification of the sensory formations. Sensory nerve formations were quantified in 13 distinct areas in healthy joint shoulder and in the available equivalent areas in the pathological joints. Statistical analyses were conducted to assess differences between healthy shoulder and pathological shoulder joint (p< 0.05). RESULTS: All analyzed structures, i.e., glenohumeral capsule, acromioclavicular capsule, the extraarticular structures (subcoracoid region and subacromio-subdeltoid bursa) and intraarticular structures (biceps brachii tendon and labrum articulare) are variably innervated except the extrinsic coracoacromial ligament, which was aneural. The afferent innervation of healthy human shoulder joints consists of free nerve endings, simple lamellar corpuscles and Ruffini's corpuscles. Occasionally, Golgi-Mazzoni's and Pacinian corpuscles were found. However, the relative density of each one varied among joints and/or the different zones within the same joint. As a rule, the upper half and anterior half of healthy glenohumeral capsules have a higher innervation compared to the lower and posterior respectably. On the other hand, in joints from subjects suffering chronic shoulder pain, a reduced innervation was found, involving more the corpuscles than free nerve endings. CONCLUSIONS: Our findings report a global innervation map of the human shoulder joints, especially the glenohumeral one, and this knowledge might be of interest for arthroscopic surgeons allowing to develop more selective and unhurt treatments, controlling the pain, and avoiding the loss of afferent innervation after surgical procedures. To the light of our results the postero-inferior glenohumeral capsular region seems to be the more adequate to be a surgical portal (surgical access area) to prevent nerve lesions.

Tratamiento del dolor persistente de hombro con inyección subacromial de ácido hialurónico / Treatment of persistent shoulder pain with subracromial sodium hyaluronate injection

Introducción y objetivo: El dolor de hombro es un motivo frecuente de consulta y se relaciona con perdida de función articular y periodos de invalidez significativa. El objetivo de este trabajo es evaluar el efecto de la infiltración subacromial con ácido hialurónico, mediante una única dosis, en el tratamiento del dolor de hombro, comparandolo con la infiltración subacromial de corticoides. Material y método: Este es un estudio aleatorizado, doble-ciego, controlado con el tratamiento con corticoides. Los pacientes que se incluyeron en el estudio fueron aleatorizados en dos grupos, uno donde se infiltró una solución de corticoides (1cc triamcinolona acetonido+2cc mepivacaína), y otro que se trató con una única infiltración de 3cc ácido hialurónico (20mg/cc).Los pacientes se evaluaron en el momento de la infiltración y luego en los meses 1, 3 y 6. Los resultados se valoraron en términos de disminución del dolor (registrado mediante la Escala Visual Analógica: EVA) y mejoría de la función articular (mediante la escala de Constant).Resultados: Se formaron dos grupos de 9 pacientes comparables en edad, valor de la EVA (media 6.29±1.54) y del Constant (media 66.17±17.9). En el momento del la última valoración (mes 6), ambos grupos mostraron una reducción significativa del dolor y una incremento de los valores del Constant. No existían diferencias significativas entre los dos grupos. Conclusiones: Los resultados muestran que la infiltración subacromial de ácido hialurónico disminuye el dolor y mejora la función articular del mismo modo que los corticoesteroides. Los corticoesteroides hacen mejorar a los pacientes más rápido, mientras que con el ácido hialurónico la mejoría es progresiva, presentando los mismos resultados a los 6 meses (AU)

Purpose: Persistent shoulder pain is a highly prevalent problem that is frequently associated with limited range of motion and decreased function. The purpose of this study is to evaluate the effect of subacromial injections of sodium hyaluronate inpatients with pain shoulder, clinical subacromial impingement, and no rotator cuff tear. Material: This was a randomized, double-blind (blinded observer),corticoid controlled study. It was designed to evaluate the efficacy of subacromial sodium hyaluronate injection in patients with persistent shoulder pain. They were randomized into two treatment groups receiving both a single subacromial injection, either corticoid solution (1cc triamcinolone acetonide + 1cc mepivacaine),or sodium hyaluronate (2cc). Patients were evaluated at baseline and at 1, 3 and 6 months. Demographic data were registered before stating the study. Entity of pain was evaluated with the use of the Visual Analogue Scale (VAS). Functional assessment was performed according to the Constant Score. Results: Nine patients were allocated in each group. The demographic characteristics were similar in the two treatment groups. At baseline mean EVA was 6.29 (SD 1.54) and mean Constant score was 66.17 (SD 17.9). Both groups showed significant reduction from baseline in the VAS and an increase in his functional score whith in the first month. No significant changes were seen between first month and neither 3 nor 6 month assessment. Conclusions: These results show that Sodium Hyaluronate subacromial injections are an effective treatment option in patients with persistent shoulder pain and no rotator cuff tear. Compare to corticoid injection have shown same results at medium term follow-up. However, sodium hyaluronate injections can prevent the occurrence of corticoids-related complication, such as local degradation of tissues, tendon tearing, or arthropathy. Most of the improvent in functional score and pain relief is seen in the first 4weeks, after that no significant changes are shown (AU)

Intrathoracic fracture-dislocation of the humeral head: a case report.

Fracture-dislocation of the humeral head into the thoracic cavity is a rare injury. We present one such case in a 70-year-old woman. She presented with a 4-part fracture-dislocation of the proximal humerus, with displacement of the humeral head into the thoracic cavity. She had no signs of acute distress or hemodynamic instability. She underwent hemiarthroplasty of the right shoulder, but the humeral head fragment could not be removed. At 27-month follow-up, the patient had limited mobility of her right shoulder due to axillary nerve palsy but no pain or intrathoracic complications. In the absence of intrathoracic complications, the removal of the humeral head may not be necessary.

Nonreferral of possible soft tissue sarcomas in adults: a dangerous omission in policy.

Introduction. The aim of this study is to compare outcomes in three groups of STS patients treated in our specialist centre: patients referred immediately after an inadequate initial treatment, patients referred after a local recurrence, and patients referred directly, prior to any treatment. Patients and methods. We reviewed all our nonmetastatic extremity-STS patients with a minimum follow-up of 2 years. We compared three patient groups: those referred directly to our centre (group A), those referred after an inadequate initial excision (group B), and patients with local recurrence (group C). Results. The study included 174 patients. Disease-free survival was 73%, 76%, and 28% in groups A, B, and C, respectively (P < .001). Depth, size, and histologic grade influenced the outcome in groups A and B, but not in C. Conclusion. Initial wide surgical treatment is the main factor that determines local control, being even more important than the known intrinsic prognostic factors of tumour size, depth, and histologic grade. The influence on outcome of initial wide local excision (WLE), which is made possible by referral to a specialist centre, is paramount.