Decline in Physical Restraint Use Following Implementation of Institutional Guidelines.

OBJECTIVE: To investigate the strategies implemented at our institution to reduce medical restraint use. BACKGROUND: Restraints have been utilized to prevent agitation, self-extubations, and falls, although they are often associated with negative repercussions for nurses and patients. METHODS: The restraint data at our institution were compared with the National Database of Nursing Quality Indicators (NDNQI) benchmark. We also described the measures taken to improve restraint documentation. RESULTS: The number of patients in medical restraints, medical restraint hours, medical restraints/patient-days, and deaths in restraints at our institution all significantly decreased (P < 0.00001). There were 27 self-extubations of restrained patients compared with 11 self-extubations of nonrestrained patients. The percentage of inpatients with restraints in critical care and step-down areas declined and remained below the NDNQI benchmark. CONCLUSIONS: This study reports the processes implemented to reduce restraint use through enhanced communication and increased documentation. Further exploration into factors that may attain a restraint-free environment is warranted.

A novel rabbit fixator made of a thermoplastic mask for awake imaging experiments.

This study aimed to develop and validate a novel rabbit fixator made from a thermoplastic mask for awake imaging experiments. When heated in a hot-water bath at 65-70 °C for 2-5 min, the thermoplastic mask became soft and could be molded to fit over the entire body of an anesthetized rabbit (4 ml of 3% pentobarbital sodium solution by intramuscular injection). Twenty rabbits were randomly divided into fixator (n = 10) and anesthesia (n = 10) groups. The animals' vital signs, stress hormones (cortisol and adrenaline), and subjective image quality scores for the computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) scanning were measured and compared. Phantom CT, MRI and PET studies were performed to assess the performance with and without the thermoplastic mask by using image agents at different concentrations or with different radioactivity. The respiration rate (RR), systolic blood pressure (SBP), diastolic blood pressure (DBP), peripheral capillary oxygen saturation (SpO2) and body temperature (T) decreased after anesthesia (all P < 0.05) but did not significantly decrease after fixation (all P > 0.05). The heart rate (HR), cortisol and adrenaline did not significantly decrease after either anesthesia or fixation (all P > 0.05). The subjective image quality scores for the CT and MRI images of the head, thorax, liver, kidney, intestines and pelvis and the subjective image quality scores for the PET images did not significantly differ between the two groups (all P > 0.05). For all examined organs except the muscle, 18F-FDG metabolism was lower after fixation than after anesthesia, and was almost identical of liver between two groups. The phantom study showed that the CT values, standard uptake values and MR T2 signal values did not differ significantly with or without the mask (all P > 0.05). A novel rabbit fixator created using a thermoplastic mask could be used to obtain high-quality images for different imaging modalities in an awake and near-physiological state.

Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture utilizing the Istanbul Protocol.

Despite being a common form of abuse, there is a paucity of literature describing shackling and wrist restraint injuries among survivors of torture. Forensic evaluation of alleged wrist restraint/handcuff injuries in survivors of torture presents challenges to the evaluator, especially if the injuries are remote and do not leave lasting marks nor neurologic deficits. Thorough history-taking and physical examination are critical to effective forensic documentation. Guidance is provided in The Manual on Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Istanbul Protocol), the gold standard for the medicolegal documentation of torture. This guidance relies primarily on physical findings, with less direction provided on how to interpret historical evidence or when historical evidence provided by the patient can be interpreted as highly consistent with alleged injury in the absence of current physical findings. Through a case-based review, we present diagnostic strategies for the evaluation of alleged abuse involving wrist restraints/handcuffs, focusing on skin, neurologic, and osseous injuries. We highlight key findings from both the history and physical examination that will allow the evaluator to improve the accuracy of their expert medical opinion on the degree to which medical findings correlate with the patient's allegations of wrist restraint injuries.

A Rat Model of Frozen Shoulder Demonstrating the Effect of Transcatheter Arterial Embolization on Angiography, Histopathology, and Physical Activity.

PURPOSE: To assess the angiographic findings and the effects of transcatheter arterial embolization on physical activity and histopathology using a frozen shoulder rat model. MATERIALS AND METHODS: First, the angiographic and histopathologic findings of rats in which the shoulder was immobilized with molding plaster for 6 weeks (n = 4) were compared to control rats with normal non-immobilized shoulders (n = 4). Next, a total of 16 frozen shoulder rats were divided into 2 groups. In the transcatheter arterial embolization group (n = 8), imipenem/cilastatin was injected into the left thoracoacromial artery. The changes of physical activity before and after procedures were evaluated and compared with a saline-injected control group (n = 8). Histopathologic findings were also compared between the 2 groups. RESULTS: Angiography revealed abnormal shoulder staining in all of the rats with a frozen shoulder. On histopathology, the numbers of microvessels and mononuclear inflammatory cells in the synovial membrane of the joint capsule were significantly higher compared with the control rats (both P = .03). In the transcatheter arterial embolization group, the running distance and speed were improved (P = .03 and P = .01, respectively), whereas there were no significant differences in the control group. The number of microvessels and mononuclear inflammatory cells in the transcatheter arterial embolization group were significantly lower than the control group (P = .002 and P = .001, respectively). CONCLUSIONS: The rat frozen shoulder model revealed the development of neovascularization. Transcatheter arterial embolization decreased the number of blood vessels and inflammatory changes in the frozen shoulder and increased the moving distance and speed of the rats.

A new hand-held holder optimizes the parameters of the laser-induced choroidal neovascularization model in mice.

BACKGROUND: The laser-induced choroidal neovascularization (CNV) mouse model, as the most classic animal model of age-related macular degeneration (AMD), has been widely used. We designed a hand-held mouse holder to optimize mouse fixation in the laser-induced CNV modelling process, which was inconvenient until now. This study aimed to evaluate the effectiveness of our in-house hand-held mouse holder design in the laser-induced CNV mouse modelling process. METHODS: Six ophthalmic residents were invited to perform laser-induced CNV mouse modelling by hand or using the holder. We compared the learning time of residents and their physical and mental fatigue with the two methods. In addition, we compared the parameters of CNV modelling with two methods by a skilled operator, including the time of photocoagulation, induction rate and uniformity of CNV lesions. RESULTS: In the learning phase, the average learning time to master the modelling method was significantly shortened by utilizing the holder. The fatigue in the operation process was quantified to a level from 0 to 4, and the physical fatigue by using holder (0.8 ± 0.3) was lower than by hand (2.6 ± 0.4), and the mental fatigue was relieved from 2.3 ± 0.5 to 0.4 ± 0.3. On the other hand, the skilled operator can significantly shorten the time of laser photocoagulation from 146.7 ± 36.0 s to 63.6 + 5.7 s and improve the success rate of modelling from 50.0% ± 8.3%-87.5% ± 6.7% by using a holder compared to hand. In addition, the standard error of the mean (SEM) of the distance between the CNV lesion and the optic nerve (ON) and the distance between each lesion was reduced. CONCLUSION: This hand-held mouse holder could optimize the setting and conditions of laser-induced CNV mouse modelling by improving the learning curve, reducing fatigue, shortening the time for photocoagulation, improving the success rate and consistency of laser-induced lesions.

Protocol for Recording from Ventral Tegmental Area Dopamine Neurons in Mice while Measuring Force during Head-Fixation.

Many studies in systems neuroscience use head-fixation preparations for in vivo experimentation. While head-fixation confers several advantages, one major limitation is the lack of behavioral measures that quantify whole-body movements. Here, we detail a step-by-step protocol for using a novel head-fixation device that measures the forces exerted by head-fixed mice in multiple dimensions. We further detail how this system can be used in conjunction with in vivo electrophysiology and optogenetics to study dopamine neurons in the ventral tegmental area. For complete details on the use and execution of this protocol, please refer to Hughes et al. (2020a, 2020b).

Automated task training and longitudinal monitoring of mouse mesoscale cortical circuits using home cages.

We report improved automated open-source methodology for head-fixed mesoscale cortical imaging and/or behavioral training of home cage mice using Raspberry Pi-based hardware. Staged partial and probabilistic restraint allows mice to adjust to self-initiated headfixation over 3 weeks' time with ~50% participation rate. We support a cue-based behavioral licking task monitored by a capacitive touch-sensor water spout. While automatically head-fixed, we acquire spontaneous, movement-triggered, or licking task-evoked GCaMP6 cortical signals. An analysis pipeline marked both behavioral events, as well as analyzed brain fluorescence signals as they relate to spontaneous and/or task-evoked behavioral activity. Mice were trained to suppress licking and wait for cues that marked the delivery of water. Correct rewarded go-trials were associated with widespread activation of midline and lateral barrel cortex areas following a vibration cue and delayed frontal and lateral motor cortex activation. Cortical GCaMP signals predicted trial success and correlated strongly with trial-outcome dependent body movements.

Canine collars: an investigation of collar type and the forces applied to a simulated neck model.

BACKGROUND: Dog collars have the potential to cause harm when the dog pulls on the lead. This study aimed to determine the effects of collar type and force applied using the lead on the pressure on a simulated neck model. METHODS: Seven collars and a slip lead were tested on a canine neck model. This consisted of a plastic cylinder 'neck', with a pressure sensor beneath the collar. A range of forces were applied to the lead representing different interactions: firm pull (40 N), strong pull (70 N) and jerk (mean force 141 N). Contact area of the collar and pressure on the neck were recorded. RESULTS: Collars exerted a pressure of between 83 kPa and 832 kPa on the model neck. There was a significant effect of collar type (F(7)=25.69, P<0.001) and force applied (F(2)=42.60, P<0.001) on the pressure exerted on the neck. Collar type (χ(7)=64.94, P<0.001), but not force applied (χ(2)=3.20, P=0.202), affected the contact area that the pressure was exerted over. CONCLUSION: Variation in the pressures exerted on the neck may have implications on comfort and the potential to cause injury. No single collar tested provided a pressure considered low enough to mitigate the risk of injury when pulling on the lead.

Getting a grip: cats respond negatively to scruffing and clips.

Use of scruffing and scruffing tools (eg, clipnosis clips) to immobilise cats is contentious, and cat handling guidelines vary in recommendations regarding these techniques. The current study examined whether cats show negative responses to the following restraint methods: (1) scruff (n=17), (2) clip application to the dorsal neck skin (n=16) and (3) full body (a known negative; n=19). Each cat was also handled with passive restraint (control) for comparison. During handling, cats were examined for behavioural (side/back ear positions, vocalisations, lip licking) and physiological (pupil dilation ratio, respiratory rate) responses. Full-body restrained cats showed more negative responses than passively restrained cats (respiratory rate: p=0.006, F3,37=4.31, p=0.01; ear p=0.002, F3,49=6.70, p=0.0007; pupil: p=0.007, F3,95=14.24, p=0.004; vocalisations: p=0.009, F3,49=4.85, p=0.005) and scruff-restrained cats (pupil: p=0.009; vocalisations: p=0.04). Clip restraint resulted in more negative responses than passive (pupil: p=0.01; vocalisations: p=0.007, ear p=0.02) and scruff restraint (pupil p=0.01; vocalisations: p=0.02). No differences were detected between full-body restraint, known to be aversive, and clip restraint. Full-body restraint and clip restraint resulted in the greatest number of negative responses, scruffing resulted in fewer negative responses and passive restraint showed the least number of responses. We therefore recommend against the use of full-body and clip restraint, and suggest that scruff restraint should be avoided when possible.

Exploring head and neck cancer patients' experiences with radiation therapy immobilisation masks: A qualitative study.

OBJECTIVE: Head and neck cancer (HNC) patients commonly undergo radiation therapy requiring immobilisation by a mask. Some find the mask distressing, and this can disrupt treatment sessions. This study aimed to explore the patient experience of immobilisation masks in the Australian and New Zealand (ANZ) context, to guide possible intervention. METHODS: Semi-structured interviews were conducted with HNC patients who had completed radiation therapy, recruited via hospitals and social media. Interviews continued until data saturation; then, three further interviews were conducted for member-checking purposes. Qualitative methodology with thematic analysis was used to identify themes in the data. RESULTS: Twenty HNC survivors participated in interviews, and seven themes were identified: information received by participants, potential predictors of mask anxiety, participant reactions to the mask, trajectories of mask anxiety, supportive behaviour and communication of health professionals, coping with the mask, and thoughts and feelings about the mask. CONCLUSIONS: Participant experiences of the immobilisation mask were diverse. The findings fit with Lazarus and Folkman's (Stress, appraisal, and coping. New York, NY: Springer Pub. Co) transactional model of stress and coping, as participants appeared to make cognitive appraisals of the mask and their coping abilities throughout treatment, resulting in varied levels of mask-related distress. Complex intervention is recommended to reduce mask anxiety in HNC patients across ANZ.

BET 1: cervical spine immobilisation in the management of drowning victims.

A short cut review was carried out to establish whether patients presenting to the emergency department after a near drowning should have cervical spine immobilisation. A search of the literature found only three studies directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that cervical spine injuries are rare in drowning and near drowning unless there is a history of diving or a fall or signs of trauma. Cervical spine immobilisation should be reserved for cases where there is a reasonable suspicion of a spinal injury.

Contenção mecânica de idosos na atenção domiciliar: revisão de literatura / Mechanical restriction of older adults in domiciliary attention: literature review

Objetivos: Identificar na literatura publicações que abordem o uso de contenção mecânica na atenção domiciliar. Métodos: Revisão integrativa da literatura realizadas nas bases de dados MEDLINE, LILACS, CINAHL e SCOPUS, no período de 2008 a 2018. Resultados: As prevalências de contenção física variavam entre 20% a 40%, a alta variação ser refere as distintas metodologias e legislações vigentes quanto à pratica de contenção física. A grade lateral é a contenção mais comum e as razões mais citadas para conter foram segurança do paciente, para evitar quedas e pedido dos familiares. Identificou- -se que 16,7% dos profissionais afirmaram ter aconselhado aos cuidadores o uso de restrições e, que 93% destes não souberam identificar alternativas para esta prática. Conclusão: Recomenda-se orientações específicas ao cuidado domiciliar centradas nas famílias, evitando a transposição inadequada do meio hospitalar para o âmbito domiciliar, e disseminar intervenções alternativas à contenção. (AU)

Objectives: To identify in the literature publications that address the use of mechanical restriction in home care. Methods: Integrative literature review carried out in the MEDLINE, LILACS, CINAHL and SCOPUS data bases from 2008 to 2018. Results: The prevalence of physical restraint ranged from 20% to 40%, the high variability refers to the different methodologies and legislation regarding the practice of physical restraint. The lateral grid is the most common containment and the most cited reasons to contain were patients afety, to avoid falls and family members' request. It was identified that 16.7% of the professionals stated that they advised caregivers to use restrictions, and that 93% of them did not know how to identify alternatives for this practice. Conclusion: Specific guidelines for household-centered care are recommended, avoiding the inadequate transposition of the hospital environment into the home, and disseminating alternative interventions to containment. (AU)

Rescue-like Behaviour in Mice is Mediated by Their Interest in the Restraint Tool.

Acting without the expectation of compensation is called prosocial behaviour. Since prosocial behaviour requires high cognitive and social abilities, it has been thought to be only shown by primates. Although prosocial behaviour has been recently reported in rats, there are still questions regarding this finding. We demonstrated rescue-like behaviour in mice in a previous report. In this study, we investigated the motives underlying rescue-like behaviour for constrained cage-mates among mice. We prepared either a tube containing a ball of yarn or an opaque tube and assessed whether mice displayed the same rescue-like behaviour shown in the case of tube-restrained cage-mates. Mice did not open the lid of the tube containing the ball of yarn but opened the opaque tube lid. Mice showed a high interest in the tube in which the cage-mate had been restrained and prioritized staying in this tube rather than rescuing additional cage-mates. Oxytocin, which increases empathy, had no effect on the lid-opening behaviour. Thus, the rescue-like behaviour of mice is not based on empathy but is related to social interest in the cage-mate and the tube itself. These results suggest that rodent lid-opening behaviour may not conclusively prove the presence of prosocial behaviour.

Refinements of Equipment and Methodology to Reduce Risk during Pole-guided Chair Transfer of Nonhuman Primates.

Neurophysiologic studies of NHP commonly involve their transfer from a housing enclosure to a laboratory by using a mobile chair. This transfer should be performed in a manner that is safe and minimizes stress for both animal and handler. The risk of harm associated with attempting to transfer these animals is increased when they are mature and naïve. We have modified previous chair designs and transfer methodologies to reduce this risk by maintaining a constant barrier between NHP and handler while providing control to the handler to facilitate chairing. Chair modifications were built inhouse, and a commercial, hydraulic lift table was used to dock the primate chair to home cages of different heights. The docking chair method was used with 8 adult, male rhesus macaques. A graduate student transferred the animals without complications. These modifications did not compromise existing features of the chair, they did not require training time in addition to that for the standard chairing method in our facility, and they improved safety. These refinements to a commonly used chair and transfer methodology support rapid habituation, safe transfer and reduced stress for both animal and handler. The refinements we describe mitigate the potential risk of harm during NHP transfers and thus advance animal welfare.

Implications of head and neck restraint test repeatability for specification improvement.

Objective: Since 2005, National Association for Stock Car Auto Racing, Incorporated (NASCAR) drivers have been required to use a head and neck restraint system (HNR) that complies with SFI Foundation, Inc. (SFI) 38.1. The primary purpose of the HNR is to control and limit injurious neck loads and head kinematics during frontal and frontal oblique impacts. The SFI 38.1 performance specification was implemented to establish a uniform test procedure and minimum standard for the evaluation of HNRs using dynamic sled testing. The purpose of this study was to evaluate the repeatability of the current SFI 38.1 test setup and explore the effects of a polyester seat belt restraint system. Method: Eight sled tests were conducted using the SFI 38.1 sled test protocol with additional test setup constraints. Four 0° frontal tests and 4 30° right frontal (RF) oblique tests were conducted. The first 3 tests of each principal direction of force (PDOF) used nylon SFI 16.1 seat belt restraint assemblies. The fourth test of each PDOF used polyester SFI 16.6 seat belt restraint assemblies. A secondary data set (Lab B Data) was also supplied by the HNR manufacturer for further comparisons. The International Organization for Standardization (ISO) 18571 objective comparison method was used to quantify the repeatability of the anthropomorphic test device (ATD) resultant head, chest, and pelvis acceleration and upper neck axial force and flexion extension bending moment time histories across multiple tests. Results: Two data sets generated using the SFI 38.1 test protocol exhibited large variations in mean ISO scores of ATD channels. The 8 tests conducted with additional setup constraints had significantly lower mean ISO score coefficients of variation (CVs). The Lab B tests conducted within the current specification but without the additional test setup constraints had larger mean ISO score standard deviation and CV for all comparisons. Specifically, tests with the additional setup constraints had average CVs of 3.3 and 2.9% for the 0° and 30° RF orientations, respectively. Lab B tests had average CVs of 22.9 and 24.5%, respectively. Polyester seat belt comparisons had CVs of 5.3 and 6.2% for the 0° and 30° RF orientations, respectively. Conclusion: With the addition of common test setup constraints, which do not violate the specification, the SFI 38.1 test protocol produced a repeatable test process for determining performance capabilities of HNRs within a single sled lab. A limited study using polyester webbing seat belt assemblies versus the nylon material called for in SFI 38.1 indicates that the material likely has less effects on ATD upper neck axial force and flexion extension bending moment time histories than the test setup freedom currently available within the specification. The additional test setup constraints are discussed and were shown to improve ATD response repeatability for a given HNR.

Seating configuration and position preferences in fully automated vehicles.

Objective: This study aimed to understand seating configuration and position preferences in a fully automated vehicle (FAV) across 7 hypothetical traveling scenarios.Methods: Participants completed an online survey in which they were asked to imagine traveling in an FAV across 7 hypothetical traveling scenarios and asked to select 1 of 5 seating configurations and 1 of 4 seating positions for themselves and for any additional occupants. Furthermore, participants were asked to indicate any activities that they and any additional occupants would engage in and whether they would be willing to wear a different seat belt in an FAV while seated in a non-forward-facing mode or while reclined.Results: Five hundred and fifty-two participants (male = 50.5%; mean = 36.6 years, SD = 14.0 years) completed the online survey. Most participants resided in Australia (40.9%), Spain (16.5%), Sweden (15.6%), or Lebanon (19.4%). Most participants drove on a daily basis (60.0%), had driven between 5,000 and 15,000 km in the previous year (33.2%), and reported that they always or almost always wear a seat belt while traveling in a motor vehicle (98.2%). Across all scenarios, participants were most likely to prefer a conventional seating configuration (i.e., all seats facing forward; between 40.0 and 76.3%). In terms of seating position preferences, participants preferred seating position A (i.e., the conventional driver's seat; between 54.6 and 68.3%), regardless of with whom they were traveling. The most common activity while traveling alone was reading (25.0%). However, when traveling with other occupants, talking was the most common activity (41.0-63.0%), even with someone they did not know (31.0%). Most participants predicted that they would always or almost always wear a seat belt when traveling in an FAV (95.9%). Most participants also reported that they would be very willing or willing to wear a different seat belt configuration in an FAV while seated in a non-forward-facing mode or while reclined (73.8 and 80.7%, respectively).Conclusions: This study has provided valuable insight regarding seating configuration and position preferences in an FAV, as well as predicted activities and restraint use. Future research will use this information to simulate likely injury outcomes of these preferences in the event of a motor vehicle crash and provide a basis for the design of occupant protection systems for FAVs.

Frame versus Frameless Leksell Stereotactic Radiosurgery.

For more than 65 years localization of brain targets suitable for stereotactic radiosurgery has been performed after application of an intracranial guiding device to the cranial vault. After imaging and dose planning the same frame is used to secure the target at the focus of the intersection of the ionizing radiation beams that create the radiobiological effect. Non-invasive immobilization systems first proposed for linear accelerator or proton radiation technologies have now been developed for the Leksell Gamma Knife ICON radiosurgical system. The ICON technology adds a cone-beam computed tomography (CBCT) scan to the original Perfexion radiosurgical device in order to define the brain stereotactic space. Marketed since 2015, the ICON can be used for standard radiosurgical procedures, most of which remain frame based, but also coupled with a non-invasive thermoplastic mask for carefully selected patients who undergo standard single-session radiosurgical procedures, as well as multisession procedures using repeat mask fixation. Both at UPMC as well as worldwide, mask immobilization has to date been used for approximately 10% of patients with specific characteristics: relatively simple dose plans, short radiation delivery times, and non-anxious patients, most of whom have metastatic or primary brain cancers. In certain cases, multisession radiosurgery is also performed using the mask. The workflow of frame versus frameless procedures is often altered, and is reliant on high-definition imaging, mostly MRI, done prior to dose planning. Since each CBCT takes 10-12 min to set up and acquire, co-register, and review with the treatment plan, and two CBCT scans are necessary to initiate the treatment plan, this workflow must be added to the beam on time. Although frame-based immobilization remains the predominant method to secure target fixation for problems suitable for single-session radiosurgery, the advent of a mask immobilization technique has proven valuable for a select group of patients. It also provides a non-invasive method to perform multisession or fractionated radiation in patients for whom traditional single-session radiosurgery is not feasible.

Restraint devices for repetitive transcranial magnetic stimulation in mice and rats.

INTRODUCTION: Repetitive transcranial magnetic stimulation has been widely used for the treatment of neurological and psychiatric diseases. Rodent animals including mice and rats are often used to investigate the potential cellular and molecular mechanisms for the therapeutic effects of repetitive transcranial magnetic stimulation. So far there is no report about an easy-to-use device to restrain rodent animals for repetitive transcranial magnetic stimulation. METHODS AND RESULTS: We introduced the design and use of the restraint device for mice or rats. In the mouse device, western blot and real-time PCR analysis showed that，in stimulated mouse frontal cortex, 10 Hz high frequency stimulation for 10 sessions resulted in enhanced expression of NR2B-containing N-methyl-D-aspartic acid receptors and reduced α1 subunit of inhibitory GABAA receptors, whereas 0.5 Hz low frequency stimulation for 10 sessions caused decreased expression of NR2B subunit and increased α1 subunit of GABAA receptors. In the rat device, measures of motor evoke potentials indicated that 10 Hz stimulation for 10 sessions increased the excitability of stimulated cortex, whereas 0.5 Hz for 10 sessions reduced it. CONCLUSIONS: These results suggested the effectiveness of the devices. Thus, the two devices are practical and easy-to-use to investigate the mechanisms of repetitive transcranial magnetic stimulation.

Open reduction through a posterior incision in the surgical treatment of shoulder posterior dislocation associated with proximal humeral fractures.

BACKGROUND: We explored the surgical technique of reducing the humeral head and repairing the fractures through a combined approach in the treatment of this complex injury. METHODS: Six patients with posterior shoulder dislocations associated with proximal humerus fractures were enrolled in this study. The posteriorly dislocated head was first reduced through a shoulder posterior incision and the ruptured posterior capsular tissues were repaired simultaneously using a suture anchor. The fractures were then reduced and fixed with a PHILOS through a deltopectoral approach. The affected shoulders were immobilized in a neutral position for 6 weeks postoperatively with a customized orthosis and then permitted active shoulder exercises after removal of the orthosis. At the last visit, union of the fractures was evaluated. Degrees of anterior forward of the affected shoulder were recorded. Outcomes were evaluated according to UCLA and Constant criteria. RESULTS: Six patients were followed up for an average of 24.5 ± 7.4 (range 13-35) months. At the last visit, the mean degree of anterior forward was 171.7 ± 7.5 (range 160-180) degrees. An average of 32.9 ± 1.2 (range 31-34) points was obtained according to UCLA criteria, demonstrating excellent and good results in two and four cases, respectively. The mean Constant score was 87.3 ± 4.1 (range 83-92) points. CONCLUSIONS: The dislocated humeral head can be reduced through a posterior approach, while fractures can be reduced and fixed through a deltopectoral approach. This technique has the advantages of simplicity and its minimally invasive approach for reducing the dislocation.