Ann R Coll Surg Engl 2009; 91: 2-7 2The glenohumeral joint of the shoulder is the most commonly dislocated joint in the human body. Acute dislocation is a surgical emergency and demands urgent relocation. Failure to reduce a dislocated shoulder successfully within the first 24 hours carries the risk that it will be impossible to achieve a stable closed reduction. 1Broadly speaking, anterior shoulder dislocation shows a bimodal age distribution (Fig. 1) Anterior dislocation of the shoulder is commonly seen in accident and emergency (A&E) and trauma clinics. In this article, we review the existing literature on the injury and the recent trends in management. MATERIALS AND METHODS We have discussed this condition with our colleagues and performed a Medline search ('anterior shoulder dislocation') of the relevant papers. We also describe key historical publications and recent developments regarding immobilisation of the joint. RESULTS Management decisions regarding this condition continue to vary between units, especially for recurrent and posterior dislocation. This paper lays some emphasis on the choice of analgesic agent when attempting shoulder reduction in the A&E setting. A summary of the data from our own department has provided a graphical representation of the classical age and sex distribution for this condition. CONCLUSIONS Shoulder dislocation is a common injury. Delays in diagnosis remain the single biggest obstacle to optimum results in this group of patients. A significant proportion will require eventual surgery and up to a third of these patients will go on to develop long-term shoulder arthritis. Even patients who have experienced a single episode of dislocation may go on to develop long-term sequelae.

Background The present study aimed to assess the accuracy of high‐resolution ultrasonography in the detection of articular‐sided partial thickness rotator cuff tears. Methods Two‐hundred and forty‐six shoulders of 245 patients underwent ultrasonography and subsequent shoulder arthroscopy. All scans were performed by an experienced specialist musculoskeletal radiologist and arthroscopies were carried out by a single surgeon. Results Fifty‐eight partial thickness tears (of which 56 were articular‐sided) were found at arthroscopy. Of the remaining shoulders, 90 had full thickness tears and 98 had intact rotator cuffs. Ultrasonography correctly identified 21 of 56 articular‐sided tears as partial thickness tears. It had a sensitivity of 7%, a specificity of 98% and an accuracy of 74% for the diagnosis of articular‐sided partial thickness tears. If a full thickness tear was considered as a true positive, the sensitivity increased to 89%, specificity to 98% and accuracy to 96%. Discussion Ultrasonography is not sufficiently accurate to diagnose articular‐sided partial thickness tears. A higher accuracy can be achieved if a full thickness tear is considered a positive finding. Ultrasonography should not be considered a first line investigation for a clinically suspected partial thickness rotator cuff tear. An articular‐sided partial thickness rotator cuff tear should be considered in all patients undergoing an arthroscopic rotator cuff procedure.

BackgroundClavicle fractures account for around 4% of all fractures and up to 44% of fractures of the shoulder girdle. Fractures of the middle third (or mid-shaft) account for approximately 80% of all clavicle fractures. Management of this group of fractures is often challenging and the outcome can be unsatisfactory. In particular it is not clear whether surgery produces better outcomes than non-surgical management. Currently there is much variation in the use of surgery and a lack of good quality evidence to inform our decision.Methods/DesignWe aim to undertake a multicentre randomised controlled trial evaluating the effectiveness and safety of conservative management versus open reduction and internal fixation for displaced mid-shaft clavicle fractures in adults. Surgical treatment will be performed using the Acumed clavicle fixation system. Conservative management will consist of immobilisation in a sling at the side in internal rotation for 6 weeks or until clinical or radiological union. We aim to recruit 300 patients. These patients will be followed-up for at least 9 months. The primary endpoint will be the rate of non-union at 3 months following treatment. Secondary endpoints will be limb function measured using the Constant-Murley Score and the Disabilities of the Arm, Shoulder and Hand (DASH) Score at 3 and 9 months post-operatively.DiscussionThis article presents the protocol for a multicentre randomised controlled trial. It gives extensive details of, and the basis for, the chosen methods, and describes the key measures taken to avoid bias and to ensure validity.Trial RegistrationUnited Kingdom Clinical Research Network ID: 8665. The date of registration of the trial is 07/09/2006. The date the first patient was recruited is 18/12/2007.

Background:Rupture of the distal biceps and triceps tendons are relatively uncommon injuries typically occurring in middle-aged males as a result of eccentric loading of the tendon.Methods:A literature search was performed and the authors’ personal experiences reported.Results:This review discusses the diagnosis, indications and guidelines for management of these injuries and provides a description of the authors’ preferred operative techniques.Conclusion:Whilst non-operative treatment may be appropriate for patients with low functional demands, surgical management is the preferred option for the majority of patients. We have described a cortical button technique and osseous tunnel technique utilised at our institution for distal biceps and triceps tendon fixation respectively. For biceps or triceps tendon injuries, those receiving an early diagnosis and undergoing surgical intervention, an excellent functional outcome can be expected.

The association of fractures and neurological injuries is well recognized, especially with certain upper limb fractures. Typically, the nerve injury occurs at the time of initial fracture displacement. A case is reported of an unusual combination of fracture and nerve injury in a child, with the extremely rare occurrence of a slowly evolving nerve injury. The potential for delayed nerve injury following a fracture needs to be appreciated to prevent delays in diagnosis and treatment.

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