Neurovascular compression in the thoracic outlet produces great variation of signs and symptoms. The clinical picture is often complex, being made up of the derangement of blood vessels, somatic nerves and autonomic nervous networks in varying degrees. Thirty-eight of the 150 patients (25%) treated in our clinic because of possible thoracic outlet syndrome (TOS), complained of general malaise such as headache, dizziness, sleeplessness, nausea, anorexia or general fatigue, in addition to their peculiar signs and symptoms due to brachial plexus involvement. In order to find out whether or not autonomic nerve dysfunction can be demonstrated in patients with TOS, a non-invasive and quantitative technique was developed for assessing the mean (M) and coefficient of variations (CV) of R-R intervals in ECG at resting position. Thirty patients (13-39; mean 29.5 y/o) were put into two groups of 15 patient s each. In the first group patients with autonomic nerve disorder had complaints of general discomfort, M was 803.72 ± 106.9 msec and CV was 3.214±0.717%. In the second group, those without general discomfort, M was 972.21 ± 120.64 msec and CV was 5.926±0.720%. The first group had a significantly shorter M (P < 0.001) and smaller CV (P < 0.001) compared to the second group. Furthermore, in two cases in the first group diagnosed by psychologists as having schizophrenia and anxiety neurosis, it was found that their M and CV were the nearly same as those in the second group. Decompressive ope r a tions were performed on five patients in the first group. Their complaints decreased or vanished after the operation and the M and CV progressed to near the normal rate. From these results, we belive that this method in useful in differentiating between autonomic nervous disorders and psychological disorders; and that in patients with TOS, a decompressive operation can help eliminate complaints of general discomfort due to autonomic nervous disorders.
Adhesive capsulitis is common among diseases of the shoulder joint. The scapulo-humeral rhythm in patients with this disease is disturbed. The purpose of this study is to evaluate this rhythm with the use of fluoroscopy and a computer.
We did this study in order to analyse shoulder movement. Instability was measured in the cases with abnormal instability (hypermobility) and in a normal group through Roentgenographic findings. Materials were one hundred and eighty eight cases: 31 cases of traumatic recurrent dislocation,70 cases of loose shoulder,48 cases of “rotator interval” lesion and 39 cases of complete cuff tear. All were treated surgically. Nine hundred and thirty four normal cases were also measured as a contrast.
Treatment of voluntary dislocation of the shoulder is generally difficult. We experienced a ten-year-old boy of voluntary dislocation of left shoulder with intra-articular abnormal band. He has had a painful shoulder from time to time since two years ago, and noticed his shoulder dimple. He was admitted to our university hospital in Feburary,1987. Physical examination revealed tenderness in left bicipital groove, limited elevation due to pain, and Yargason test was positive. In X-ray view inferior instability was 68%, even though it was not under general anesthesia. Arthroscopic examination was performed. Cartilage of humeral head and glenoid were clear. Three glenohumeral ligaments were intact. Abnormal band run like a bandle from the supraglenoidal region to superior intracapsule. In arthroscopic findings the band suspended biceps long head tendon by interior traction of arm. And so the band was resected by arthroscopic surgery. Two days after operation, he forgot to dislocate shoulder by his own will. The glenohumeral angle (θ) of postoperative X-ray was compared with that of preoperative one. That angle of postoperative X-ray increased. It was thought that the pathology in this case was an improvement of scapula abduction.
Arthroscopic surgery of the shoulder is a relatively new advancement in the field of arthroscopy. The establishment of its indication and technique are very important themes for shoulder surgery. The purpose of this report is to evaluate clinical and arthroscopical results of arthroscopic surgery of the shoulder.29 patients (minimal follow-up period: 6 months)were studied for clinical assessment, and 14 patients who underwent second-look arthroscopy were studied for the assessment of arthroscopic stapling. The overall clinical results of 29patients who had labrum tears, anterior instability, and impingement syndrome with a partial rotator cuff tear. were satisfactory in 76%. Arthroscopic stabilization with stapling was confirmed in 79%. In order to get more satisfactory results, an accurate assessment of intra or extra-articular pathology, as well as a refined surgical technique and indicative determination were found to be the most important factors.
Twenty-nine patients, who had throwing injuries of the shoulder, underwent arthroscopy of the shoulder in order to investigate the internal derangement of the shoulder. The average age was 20.5 years and the average duration of symptoms prior to arthroscopy was 8.8months. The throwing sports involved were baseball (21), volleyball (4), tennis (2), and others (2). All patients complained of pain in the shoulder during overhead activity and did not respond to conservative therapy. At arthroscopy, superior labrum separation was confirmed in 13 cases anterior labrum tear or disruption in seven, posterior labrum flap tear in one, and isolated rim rent of the supraspinatus in three. Thus,24 of 29 (83%), demonstrated internal derangement of the shoulder, especially at the superior or anterior labrum portion, which were clinically similar to impingement syndrome or anterior subluxation. Thus, it was difficult to demonstrate characteristic objective findings of such throwing shoulders. We believe that it is necessary to perform arthroscopic examination aggressively for throwing injuries to the shoulder in order to establish an accurate diagnosis and appropriate management.
Arthroscopic examinations of shoulder joints were performed on 11 recurrent anterior dislocations,4 traumatic subluxations,5 voluntary posterior dislocations,2 voluntary anterior dislocations and one initial anterior dislocation. In simple voluntary dislocations no damage of intraarticular structures were found. In trauamtic subluxations, wide and shallow posterior cartilaginous or osseous defects of the humeral heads and fibrillated or thinned glenoid labra and mild degree of attenuation of glenohumeral ligaments were characteristic findings. In recurrent anterior dislocations, two types of intraarticular injuries were observed as follows: 1) Compression fracture type; deep and narrow compression fractures of the posterior or superior humeral head with torn or disappeared anterior labrum.2) Cartilaginous defect type; shallow and wide cartilaginous or osseous defect of the posterior or posteromedical humeral head with fibrillated or thinned labrum. All examined glenohumeral ligaments were ruptured or attenuated. We consider that morphological types of intraarticular lesions might be related to the mechanism of initial traumas.
Fracture-dislocation of the shoulder is a relatively common injury, but, posterior fracture-dislocation of the shoulder is a very rave one. We will present two cases treated with open reduction and fixation of the joint and the fracture. Case 1; A 30-year-old male injured his right s houlder and was treated with electroshock therapy by psychiarists. This case was a 2-part fracture with posterior dislocation in which the lesser tuberosity of the humerus was displaced. An attempt at closed manipulation of the posterior dislocation under full relaxant general anaesthesia was successful, and the lesser tuberosity of the humerus was reduced and fixed with A-O screws. Case 2; A 22-year-old male injured his right shoulder in a traffic accident, and was examined in our hospital four months after injury. This case was a 2-part fracture with posterior dislocation in which both tuberosities of the humerun were displaced. After open reduction of the posterior dislocation, both tuberosities were reduced and fixed with A-Oscrews. In this case, both tuberosities were displaced in a body. We couldn't classify this fracture according to Neer's classification. Open reduction of these two cases were undertaken using the anterior approach. Their results were satisfactory. The most important point concerning posterior disl o cations is that the diagnosis is so often overlooked because of inadequate roentgenographic examination of the shoulder. The definite and unmistakable diagnosis of posterior dislocation of the shou l d er is made by obtaining both anteroposterior and axillary roentgenograms habitually. We examined 35 cases of posterior dislocation of the shoulder reported in Japan.
Retrosternal dislocation of the clavicle is a relatively rare condition and may be difficult to diagnose if it is not suspected. We have recently experienced two retrosternal dislocation cases with similar mechanisms. Case 1. A fifteen -year-old boy's posterolateral surface of his right shoulder was struck while playing Rugby and he felt pain in the region of the right sternoclavicular joint. When he visited us he was unable to move his left arm without severe pain. Swelling and tenderness were found over the right sternoclavicular joint. Plain X-rays were interpreted as normal. A computed tomography scan revealed a retrosternal dislocation of the right clavicle. Closed reduction under general anesthesia was attempted, but it was unsu c cessful. Open reduction was performed and two Kirschner wires were drilled obliquely to fix the right sternoclavicle joint. One month later, one of the Kirschner wires was found to be broken on X-rays and immediately they were removed. At final follow up, two years later, the patient had full range of motion without pain. Case 2. A fifteen-year-old boy was injured similarly to case 1 during a basketball game. He supported his upper left extremity with his right hand and was unable to move his left arm without severe pain when he came to our hospital. Diagnosis of the left retrosternal dislocation was made on the basis of clinical findings and confirmed by a computed tomography scan. Closed reduction under general anesthesia was unsuccessful. We performed open reduction without internal fixation. At the final follow-up, six months later, the patient had no complaints. Closed reduction must be attempted not only with standard methods, but also with Buckerfield's method as soon as a diagnosis is established. Open reduction is indicated when closed reduction has failed. Suturing for effective repair is preferable to the use of internal fixation devices to hold the reduction.
In 1941, Mumford reported 4 cases which had persistent pain and disability on the acromioclavicular joint after its subluxation. In 1984, Rockwood also described some instances following a type II sprain which had persistent pain in the acromiaoclavicular joint, then he noted this type of injury as internal derangement of the acromioclavicular joint. We have experienced three cases which had the same pathology described by Roc k wood. He explained the mechanism of its internal derangement as follows. Since fibers of the joint were initially disrupted, it is possible that shreds of the ligament or flakes of the articular cartilage are loose in the joint, causing symptoms. The meniscus may have been detached, and it will be noted, with motion, to pop and displace in and out of the joint like a torn meniscus in the knee. We also fou n d abnormal movements of the affected a-c joints in our three cases of internal derangement. Case 1 had an abnormal movement to the longitudinal axis of the clavicle. Case 2 had an abnormal movement to the longitudinal axis of the clavicle and also had superior subluxation. Case 3 exhibited marked abnormal movement to the longitudinal axis of the clavicle and also showed posterior instability. Taking these findings into consideration, w e think that the arthritic changes of the a-c joint caused by interposition of debris, torn meniscus and degenerated joint cartilage may be a cause of symptoms. We explain abnormal movement of the a-c joint to be an additional cause of symptoms.
Eighteen patients with complete acromioclavicular separation were treated with an artificial vascular prosthesis, supplemented with a temporary fixation of the acromioclavicular joint. Fourteen patients were re-examined over an average of 5.0 years after the operation.. The functional results were excellent in all patients, however, the roentgenographic evaluations revealed various changes of the clavicle and the coracoid process, including subluxation or dislocation of the acromioclavicular joint, bone atrophy of the distal end of the clavicle, and erosion of the clavicle, as well as the coracoid process by an artificial graft. We are concerned about the use of an artificial prosthesis for this injury.
it is intended to know the limits of the treating result in the application of the following coservative treatments to the various types of fractures of the glenoid. Materials and Methods. Fracture of the glenoid is classified into the following 2 types. 1. The fracture line can be seen at the glenoid alone but d oes not extend to the glenoid cavity. 2. The fracture line extends to the glenoid cavity. As a rule, all these fractures are reduced w ith ulna K-pin traction, thereby, making fixation and reduction of the fracture by continuous traction of the arm in the direction of zero-position. Results: All these fractures of the glenoid were treated with an ulna K-pin, and continuous traction was made in the direction of zero-position. All the cases showed favorable resuts. Accordingly, we believe continuou s traction with an ulna K-pin is a recommendable method for the treatment of fractures of the glenoid.
It is well known that the shoulder joint can restore its function without operative treatment even after a rotator cuff tear. This fact raises the question whether surgical treatment is effective on the functional recovery of a shoulder with a torn cuff. The purpose of this paper is to evaluate the effect of surgical intervention on recovery after a cuff repair and to determine whether it is influenced by the duration of symptoms. With this aim, the authors prepared 43 patients with a r thrographically verified fullthickness tears of the cuff, who were under the age of 70 or laborers over 70 and suffering from unsatisfactory shoulder function (fair or poor in Wolfgang's criteria). Among them,21underwent surgery (at the average age of 58), while the remaining 23 refused operation and were treated conservatively (ave.62 y. o. ). The difference between the outcome of surgery and that of conservative treatment constituted the effect of surgery. Patients were followed up for 1 y. to 5 y.9 m. with an average of 2 y.3 m. The functional results of both groups we r e compared on the basis of the duration of symptoms. In patients with symptoms lasting over 3 months, the shoulder function following surgery was found significantly better (p <0.5) than that of conservative treatment (satisfactory results: 91% vs 40%). In those with a symptomatic period shorter than 3 months, the difference was insignificant (satisfactory results: 90% vs 75%). The authors conclude that surgery on long-standing cu f f tears is apparently effective in restoring shoulder function, but that surgery should be limited on fresh cuff tears.
Spur formation is often found on the acromial undersurface in cases of rotator cuff tear. The spur formation is thought to contribute to the occurrence and progress of the rotator cuff tear. Our series consisted of 40 joints of 36 men and 15 joints of 15 women. The average age (range,30 to 82) at the time of operation was 58.8. There were 26 joints (47.2%) with a spur on the acromial undersurface (spur group), and 29 joints (52.8%) without a spur (non-spur group). The average age of the spur group and that of the non-spur group at the time of operation was 62.7 and 55.2, respectively. The difference in the average age of the two groups was significant. The location of the spur formation extended from the front to the outside of the acromion on the X-ray in most cases. Narrowness of the acromio-humeral interval and spur formation on the glenoid and humerus occurred much more frequently in the spur group than in the non-spur group. A Combination o f anterior acromioplasty and McLaughlin's method was performed in most cases (47 joints). At operation, wide rupture was found in 12 (46.2%) of 24 joints in the spur group, but only in 8 (27.6%) of 29 joints in the non-spur group. Postoperative results were examined in the 26 joints of the spur group and 24 in the non spur group. No difference was found between the two groups in postoperative results. Radiographically the spur resected at operation was formed in a segmental f a shion and the bone trabecular structure was irregular. Histologically the normal structure of four layers seen at the anterior undersurface of the acromion was disturbed.
Twelve cases with isolated tear of the subscapularis tendon were observed during 250reconstructive procedures on the rotator cuff. The patients' age was 51.6 years on average. All of the patients had a definite history of trauma to an affected shoulder and persistent pain in the anterior shoulder part, combined with the inability to evevate the extremity. Arthrography was performed on all, and revealed that the dye had extravasated into the subacromial bursa, however, the supraspinatus tendon was intact on the external rotation view. Operative findings revealed that an isolated rupture of the subscapularis tendon was confirmed in all. In 10 cases with rupture of the supero-medial part of the subscapularis tendon, medial dislocation of the bicipital long tendon was observed. Therefore, the authors conclude that the supero-medial part of the subscapularis tendon, including the medial bundle of the coracohumeral ligament, is the most important portion which keeps the bicipital long tendon aligned with the sulcus, and that during reconstructive procedures on the shoulder capsule, these changes should be carefully looked for and evaluated.
In order to clarify the function of the rotator cuff as the dynamic stabilizer, intraarticular lesions in rotator cuff tears were observed in 52 shoulder joints of 26 cadavers. The glenoid labrums in 33 shoulder joints without cuff tears consisted of circumferentially oriented fibrous structure. The angular values of the labrums were 23.9° ± 5.6 (average± SD)in the superior portion,11.2° ± 4.3 in the inferior portion,9.2° ± 2.8 in the anterior portion, and 10.8° ± 3.2 in the posterior portion. On the other hand, the pathological changes of the glenoid labrum and intra-articular portion of the bicipital long tendon were recognized in all of the shoulder joints with cuff tears (19 joints). In the incomplete tears (12 joints), progressive hypertrophy was observed in the anterosuperior portion of the labrum. In the small or moderate tears (3 joints), hypertrophy and fraying were recognized from the anterosuperior to the anteroinferior portion. In the massive tears (4 joints), these pathological changes were extended all over the labrum. The intra-articular portion of the bicipital long tendon was slightly thickened in the incomplete tears, very thickened and widened in the small and moderate tears, and frayed, dislocated and ruptured in the massive tears. As obvious intra-articular lesions were recognized, even in the inc o mplete and small cuff tears, we conclude that the rotator cuff plays a significant role of glenohumeral stabilizer associated with intra-articular elements, such as the glenoid labrum and the bicipital long tendon.
The mechanisms for preventing inferior subluxation of the normal glenohumeral joint are unknown. The purpose of this study is to clarify the roles of various muscles in preventing inferior subluxation of the glenohumeral joint when the arm is in the unloaded dependent position. Relation s between the distribution of paralyzed muscles and the degree of inferior subluxation were investigated in 37 patients with peripheral nerve lesions. Ten muscles in the region of the shoulder joint were examined, namely, the trapezius, deltoid, supraspinatus, infraspinatus, biceps brachii, triceps brachii, pectoralis major, lattisimus dorsi, serratus anterior, and rhomboid muscles. Severity of paralysis in each muscle was evaluated by means of both an electromyographical study and a manual muscle test. The degree of inferior subluxation was expressed as the ratio of the inferior displacement to the longitudinal diameter of the glenoid according to Endo's method on an anterior-posterior x-ray film taken with the arm in the unloaded dependent position. Inferior subluxation occurred in 28 of the 30 cases whose deltoid had been completely paralyzed, but did not occur in any of the other 7 cases whose deltoid had not been completely paralyzed. Moreover, inferior subluxation occurred in all of the 5 cases whose deltoid alone had been completely paralyzed. The degrees of inferior subluxation were significantly greater in the cases whose deltoid, supraspinatus, infraspinatus, biceps brachii and triceps brachii also had been completely paralyzed compared with those cases whose deltoid, supraspinatus and infraspinatus alone had been completely paralyzed. These results suggest that when the arm is in the unloaded dependent position, the vertically running muscles participate in preventing inferior subluxation of the glenohumeral joint and that inferior subluxation is prevented mainly by the tone of the deltoid muscle.
We have performed Bateman's trapezius transfer for the reconstruction of paralyzed shoulders in Tohoku University Hospital. In the last 14 years, we followed up 12 cases i. e.12 shoulders of 10 males and 2 females. The age at operation time ranged from 6 to 43 years, with an average of 23 years. The causative diseases were 11 traumatic brachial plexus palsies (2 total types,9 upper types including 3 birth palsies) and one axillary nerve palsy. The average follow-up period was 7 years. Improvement of the active abduction angle after operation was from 0° to 110°, with a mean improvement of 39.2°. But the value in each case varied greatly. On the other hand, passive elevations were preserved at 136.5° on the average. According to the postoperative course, many patients had maximum angles of abduction within a year of operation and then the angle gradually decreased in most of the cases. At follow-up, all the patients could carry light-weight materials or hold them under their axillae. But 4 of the 5 cases, whose dominant arms were involved, began to use their non-dominant arms mainly, except in the axillary nerve palsy case. X-rays showed instabilities in 4 cases. We evaluated several factors which might affect the results, such as the degree of paralysis, the position of the muscle transfer, the existance of C-C ligament and the postoperative treatment. The important factors were that in patients with preserved power of steering and depressor groups or in those with released C-C ligament, the results were good. However, in patients with anterolateral transfer, the results were poor.
Fifteen clinical cases were examined, consisting of axillary nerve injuries (4), suprascapular nerve injury (1), associated nerve injuries with axillary and suprascapular (6) and accessory nerve injuries (4). Surgical exploration were performed in 14 cases. The axillary nerve was lacerated at the medial edge of the surgical neck of the humerus in 6 out of 8 cases. In 4 of these cases an interpositional nerve graft was placed through two simultaneous approaches, anterior and posterior. The suprascapular nerves were injured at the infraclavicular fossa in 4 cases. Paralytic inferior subluxation was found in only one case with lacerations of both nerves. The preoperative range of shoulder abduction of the cases with axillary nerve laceration alone showed a tendency to increase, in spite of complete paralysis of the deltoid muscle as the time after nerve injury progressed. Preoperative range of motion of the shoulder in the accessory nerve injuries showed a constant range from 155 to 120degrees in flexion and from 80 to 60 in abduction. Dynamic X-ray analysis in these cases revealed that the scapular position deviated anteriorly and laterally and the range of scapular rotation during abduction, from 60 to 80 degrees, was large on the paralytic side compared with the sound side. Good functional recovery was obtained about one year after accessory nerve repair in three cases.
During the past 17 years, we have had 52 patients with schwannomas which were diagnosed clinically and pathologically. Nine of them involved the brachial plexus. We have investigated the clinical features of schwannomas of the brachial plexus. Five patients were men and 4 were women. Their ages when visiting our hospital ranged from 28 to 78 years old with an average of 43 years old. The interval between onset of the symptoms and their first visit to the hospital ranged from 2 months to 5 years. The initial symptom was the exisitence of a tumor mass in the supraclavicular region in all except one patient. Seven patients complained of paresthesia in the upper extremities. Examinations revealed neurological deficit in 5 patients. Sensory disturbance was found in 3 and motor disturbance in 2. Compression or tapping of the mass elicited radiating pain into the upper extrmeties in all patients. Operations we r e porformed on 8 patients. Tumors originated from the 6th cervical root in one patient, from the 7th cervical root in two, from the 8th cervical root in two, from the upper trunk in one, and from the lower trunk in one case. In one case, the origin could not be identified. Tumors were removed by enucleation in 2 cases. In the other 6, dissection between the nerve and the tumor was difficult. So the tumors were resected together with the involved funiculus in 3, and with the involved root in 3. Postoperative examination revealed that the operations resulted in neurological deficits in 6. In 4 of these, the deficit was transient, and they recovered within 3 months. No motor disturbance was found in 2 of the 3 patients on whom the nerve root had been resected.
Autopsies were performed in two cases after the implantation of endoprosthesis for malignant tumors of the proximal humerus or of both the humerus and the scapula. In the first case, a 59 year-old man with metastatic tumors of the right proximal humerus and the 9th rib, we replaced the upper humerus with Al2O3 ceramic prosthesis and transfered it to the rotator cuff of the short head tendon of the biceps brachii. We resected the metastatic rib tumor and removed the left kidney with primary cancer. Three years after the operation, he died due to cachexia and metastatic tumors of the spine and the pelvis. In the autopsy, the recurrence of the tumor was not found in the operated region, and the transfered tendon of the biceps brachii-short head defensed the dislocation of the humeral head. In the second case of invasive rhabdomyosarcoma of the right humerus and scapula, we replaced the scapula with bone cement, mesh plate and high density polyethylene glenoid prosthesis, and replaced of the upper humerus with Al2O3 ceramic prosthesis after intraarterial chemotherapy. Seven months after the operation, the patient died due to lung metastasis. In the autopsy, metastases of both lungs and the right lobe of the liver were found. The surface of the prosthesis of the scapula and the upper humerus were covered with fibrous membranous tissue. Cross sections were made for microscopic examination. There was and abundant osseous bridge and a little fibrous tissue between the Al2O3 ceramic implant and the cortical bone.
Myofascial pain syndrome, a term applied to a hyperirritable locus with muscle spasms or its associated fascia, is characterized by referred pain from a trigger point in a specific pattern, characteristic in each muscle. Among the patients, complaining of shoulder pain. We have found many patients with this syndrome. Since the pain is referred from most myofascial trigger points, patients with this syndrome are frequently overlooked and misdiagnosed. The pain is in a specific pattern, characteristic of each muscle and increases by stretching the affected muscle or when the muscle contracts against resistance. The patients complained of motion pain, but there was no contracture in most cases. Infiltration of local anesthetics in trigger point is a useful diagnosis. This disease must be differentiated without fail when in consultation with a patient who complains of shoulder pain. The purpose of this report is to discuss the symptoms, differential diagnosis and treatment of this syndrome which causes shoulder pain. Myofascial pain syndrome of the following muscles are discussed: M. infraspinalis, M. supraspinalis, M. teres major and minor, M. subscaularis. M. triceps (long head), M. biceps brachii and M. pectoralis major.
Post-traumatic osteolysis of the distal end of the clavicle is a rare condition. It was first described by Dupas in 1936, and so far the total number of recoded cases is about a hundred. This condition is characterized by erosion and progressive resorption of the distal end of the clavicle following trauma. The interval between physical insult and radiographical recognition is from several weeks to several months. No more than 3 cm of bone have been lost in any recorded case, and remnants of bone may remain between the acromion and the clavicle. The usual symptoms are pain and restricted range of motion of the shoulder. The etiology of the osteolytic process is uncertain. Osteoclastic resorption, nervous system dysfunction, vascular compromise, and arising from the synovium have all been hypothesized. Now we will report a case of this condition.
We have previously studied rheumatoid shoulders by plain radiography and arthrography. But we believe evaluating rheumatoid shoulders with limited abduction by such methods is insufficient. So this time, we used dynamic radiographies and evaluated 41 rheumatoid shoulders. Scapular plane radiographies were taken of the arm by the side to maximum elevation at thirty-degree-intervals analyze the motion, and were evaluated by the rhythm of the Gleno-Humeral (G-H) motion and the Scapulo-Thoratic (S-T) motion. We also compared the dynamic analysis to plain radiographie s to clarify the influence of joint destruction to abduction motion. There are two motion patterns in rheumatoid shoulders with limited abduction. One is the normal rhythm pattern which reserves normal rhythm and has a mild joint destruction, and the other is the S-T dominant pattern which dose not keep normal rhythm and has severe joint destructions.
We would like report on the predisposing factors in the occurrence of the symptoms, the methods of treatment and postoperative courses collectively, by studying the clinical images of suppurative in pyogenic arthritis of the glenohumeral joint which were diagnosed and treated in this department. Five cases with suppurative arthritis consulted this department; three males and two females with their five joints. The causes of infection were intraarticular injection of a steroid agent in three cases, hematogenous infection in one case, and postoperative infection in the lest. The period from the occurrence of the symptoms to the first medical examinations in this department was between about two months and three years. They had had a pain in their shoulder joints since before the occurrence of the symptoms, and the times of megalgia, which are thought to be the yardstick of the occurrence of the symptoms, were obtained definitely in only two cases. The causal bacteria of inflammation were verified in the bacteria cultures of joint fluid in two cases, and three cases were diagnosed as pyogenic arthritis of the glenohumeral joint based on previous history, clinical symptoms, and the character of the joint fluid. As to treatment, a curettage of the lesion was carried out in three cases, and an arthrocentesis drainage without incision in two cases. At present, on case has recurred. Good results were obtained in several attempts of artirocentesis drainage in addition to strong chemotherapy through the vein for these cases which could be diagnosed early and were not accompanied by rupture of the tendon. We also studied and will report on the function of the shoulder joint after treatment.
Fourteen patients with deltoid contracture, treated surgically between 1971 and 1986were evaluated after an average follow up of 8.9 years (range, two to sixteen years). Nine patients were afflicted on their left sides, four patients on the right, and one on both sides. Twlve patients were children who had received multiple intramuscular deltoid injections in infancy or childhood. The other two patients were adults. The average age at operation time of the child cases was 13.6 years (range, from eight to seventeen years). Seven the child patients complained of winging scapula. Two adult patients complained of pain in their shoulders. The average abduction contracture angle in all the shoulders was 23.7 degrees (range, from 10 to 45 degrees) Of the fifteen oper a tive procedures, six were transections of the fibrous portion, seven were resections of the fibrous portion and two were resections of the fibrous portion and advancements of the posterior deltoid muscle At follow up time the average abdu c tion contracture angle was 6.3 degrees (range, from 0 to 15 degrees). Winging scapula had vanished in all the cases and the recurrence of abduction contracture was not recognized in any patient The average abduction contracture angle in the transection group was 25.0 degrees at pre-operation and 9.5 degrees at follow up. The average angle in the resection group was 25.7degrees at pre-operation and 5.3 degrees at follow up 2/6 patients in the transection group and 5/7 patients in the resection group complained of pain in their shoulders at follow up The roentgenographic examinations showed, three humeral heads had been fla t tended slightly Nine patients complained of their surgical scars and four patients asked for plastic surgery Thirteen patients were satisfied with the results and only one patient was dissatisfied because of residual shoulder and back pain.