Injury: the British Joumal of Accident Surgery (1992) Vol. 23/No.
418
femoral head fragment is reduced anatomically, one can anticipate a good result from a stable closed reduction. Hougaard and Thomsen (1987b) recommended closed reduction, but if the hip cannot be reduced or if there is a poor reduction of the femoral head, they advise an open reduction. According to Hougaard and Thomsen (1988) the prognosis for patients who have a type I or type II Pipkin injury is the same as for those who have a simple dislocation. In a found the time interval previous report, those authors between injury and reduction (preferably less than 6 h), the severity of the initial injury, and the development of avascular necrosis of the femoral head to be the most important factors regarding the long-term prognosis (Hougaard and Thomsen, 1987b). Although radiographs at I year show the fracture to be united with anatomical reduction maintained, and no evidence of avascular necrosis, we believe that the follow-up period is insufficient to draw conclusions regarding the prognosis of the hip joints.
6
Epstein H. C., Wiss D. A. and Cozen
L. (1985) Posterior fracture-dislocation of the hip with fractures of the femoral head. Clin. Orfhop. 20x,9. Hougaard K., Lindequist S. and Nielsen L. B. (1987a) Computerised tomography after posterior dislocation of the hip. J. &me Joint Surg. 69B, 556. Hougaard K. and Thomsen B. (1987b) Coxarthrosis following traumatic posterior dislocation of the hip.]. BoneJoint Stcrg.69A, 679. Hougaard K. and Thomsen B. (1988) Traumatic posterior fracturedislocation of the hip with fracture of the femoral head or neck, or both. ]. Bone Joint Surg. 7OA, 233. Ordway C. B. and Xeller C. F. (1984) Transverse computerized axial tomography of patients with posterior dislocation of the hip. J Trauma 24, 76.
Paper accepted 4 November
1991.
References Butler J. E. (1981) Pipkin type-11 fractures of the femoral head. 1. he]oinf Su?g 63A, 1292.
Reqmfs for reprink shoukd be aaIled to: Dr JesGs Guiral, Department of Orthopaedics, General Hospital, 40002 Segovia, Spain.
Fixation of fractures of the glenoid rim J. Sinha and A. J. Miller Department
of Orthopaedics,
Mayday
University
Hospital, Croydon,
Introduction The reported incidence of fractures of the glenoid rim associated with acute anterior dislocation of the shoulder is rare. The mechanism for anterior dislocation is said to be abduction and external rotation. There may also be a fracture of the anterior glenoid rim when dislocation occurs with the arm adducted (Aston and Gregory, 1973). A fracture of the glenoid without dislocation is extremely rare (Varriale and Adler, 1983). A case may be made for open reduction and internal fixation of the fragments, as chronic dislocation is said to occur without fixation (Kummel, 1970). We describe two cases in fit young men, one associated with dislocation and the other case without dislocation.
UK
fracture of the antero-inferior
portion of the glenoid rim (Figure I).
It was decided to fix the fragment internally. The shoulder was explored through an anterior approach, and the humeral head was found to be unstable, dislocating forwards, with a fracture involving approximately one-half of the anterior
Case reports cuse1 A d4-year-old male injured his right shoulder when he slipped on a wet surface and the shoulder hit the ground. Following this, the patient complained that his shoulder dislocated several times. He was able to reduce it, but it felt unstable when externally rotated. Examination revealed a normal range of movements and no instability was demonstrated. However, radiographs showed a 0 1992 Butterworth-Heinemann Ltd 0020-1383/92/04042&02
Figure 1. Fracture of the ant~inferior nm.
portion
of the glenoid
Case reports
glenoid rim. The fragment was reduced and fixed with a 26mm A0 cancellous screw (Figure2). The subscapularis was plicated and the joint was subsequently stable. The arm was bandaged to the side for 4 weeks, and then mobilized. He has since regained an excellent range of movement. Case 2 A 25year-old male sustained an injury to his right shoulder while skiing and presented a few days later. He denied that the shoulder had dislocated. Examination of the shoulder was essentially normal, but radiographs revealed a fracture of the anterior glenoid rim. The right shoulder was explored and the jolnt was found to be stable. A large fragment of the anterior part of the glenoid rim was found to be displaced and was secured with an A0 cancellous screw. The subscapularis was plicated. He was discharged home with his arm immobilized in a sling for 4 weeks, and was then referred for mobilization in the physiotherapy department. His shoulder remained stiff and at 6 weeks manipulation under anaesthetic was performed. Excellent movements were obtained, which have been maintained subsequently.
Discussion Fractures of the anterior glenoid rim are rare in association with acute anterior dislocation, but have a definite incidence in association with recurrent dislocation. The reported rate is variable, being described as ‘unusual’ (Adams, 1948) to II per cent (De Palma, 1973) and as high as 44 per cent (Rowe et al., 1978). A fracture of the glenoid without dislocation is extremely rare and we could find only one other case reported in the literature (Varriale and Adler, 1983). Previously reported cases in association with acute dislocation suggest that open reduction and internal fixation of the fracture fragment should be sufficient to stabilize the joint to avoid dislocation (Aston and Gregory, 1973). Our two cases were found to be stable on open reduction and internal fixation of the fracture fragment with a single screw. Capsular repair has also been advocated in addition to fixing the fragment (De Palma, 1973) and we performed a subscapularis plication to increase stability. However, we now feel that plication of the subscapularis should not be undertaken unless there is obvious instability as in one of our cases the shoulder was stiff postoperatively, requiring further manipulation. These fractures must not be ignored because of the risk of chronic dislocation (Kummel, IWO).
Monteggia equivalent
injury
Figure 2. Fixation of the frachm tiagment.
References Adams, J. C. (1948) Recurrent dislocation of the shoulder. J, k ]oinf Surg.3OB, 26. Aston J. W. Jr. and Gregory C. F. (1973) Dislocation of the shoulder with significant fracture of the glenoid. J Bone Joint Surg.55A, 1531. De Palma, A. F. (1973) Surgeryoffhe Shouhr, 2nd Ed. Philadelphia: Lippincott. Kummel B. M. (1970) Fractures of the glenoid causing chronic dislocation of the shoulder. Clin. Orfhop. 69, 189. Rowe C. R., Pate1 D. and Southmayd W. W. (1978) The Bankart JointSurg. procedure - a long-term end result study. J. ti 6OA, 1. Varriale P. L. and Adler M. L. (1983) Occult fracture of the glenoid without dislocation. J BoneJoint Surg.65A, 688. Paper accepted 4 November
1991
Reqtcestsfor reprints shouM be addressed to: Mr A. J. Miller, Department of Orthopaedics, Mayday University Hospital, Mayday Road, Thornton Heath, Surrey CR7 7YE, UK.
in a very young patient
Th. Karachaliosl, E. J. Smith2 and M. F. Pearse’ lBristo1 Royal Infirmary and zBristol Royal Hospital for Sick Children, Bristol, UK
Introduction
Case report
Monteggia fractures classically occur in adults. However, the incidence of this fracture in childhood is higher than is often appreciated, presenting as a so-called Monteggia equivalent (Wiley and Galey, 1985). We report an isolated Monteggia equivalent injury in a 16-month-old child. To our knowledge this is the youngest patient reported to date. The difficulties of diagnosing this injury in the very young and the differential diagnosis are discussed.
S.A., a 16-month-old girl, was admitted to the hospital with a history of a fall, landing on the right forearm. She was subsequently unable to use her right arm. Clinical examination revealed a mild deformity of the right forearm and a full range of painful movement of the right elbow. Radiographs confirmed the presence of a fracture of the right midshaft ulna and a dislocated radial head (Qure I). A Monteggia equivalent injury (type I) was diagnosed. After reduction, the arm was splinted in an aboveelbow cast in supination with 90” of elbow flexion for 4 weeks. On
@ 1992 Butterworth-Heinemann 0020-1383/92/060421-02
Ltd
418
femoral head fragment is reduced anatomically, one can anticipate a good result from a stable closed reduction. Hougaard and Thomsen (1987b) recommended closed reduction, but if the hip cannot be reduced or if there is a poor reduction of the femoral head, they advise an open reduction. According to Hougaard and Thomsen (1988) the prognosis for patients who have a type I or type II Pipkin injury is the same as for those who have a simple dislocation. In a found the time interval previous report, those authors between injury and reduction (preferably less than 6 h), the severity of the initial injury, and the development of avascular necrosis of the femoral head to be the most important factors regarding the long-term prognosis (Hougaard and Thomsen, 1987b). Although radiographs at I year show the fracture to be united with anatomical reduction maintained, and no evidence of avascular necrosis, we believe that the follow-up period is insufficient to draw conclusions regarding the prognosis of the hip joints.
6
Epstein H. C., Wiss D. A. and Cozen
L. (1985) Posterior fracture-dislocation of the hip with fractures of the femoral head. Clin. Orfhop. 20x,9. Hougaard K., Lindequist S. and Nielsen L. B. (1987a) Computerised tomography after posterior dislocation of the hip. J. &me Joint Surg. 69B, 556. Hougaard K. and Thomsen B. (1987b) Coxarthrosis following traumatic posterior dislocation of the hip.]. BoneJoint Stcrg.69A, 679. Hougaard K. and Thomsen B. (1988) Traumatic posterior fracturedislocation of the hip with fracture of the femoral head or neck, or both. ]. Bone Joint Surg. 7OA, 233. Ordway C. B. and Xeller C. F. (1984) Transverse computerized axial tomography of patients with posterior dislocation of the hip. J Trauma 24, 76.
Paper accepted 4 November
1991.
References Butler J. E. (1981) Pipkin type-11 fractures of the femoral head. 1. he]oinf Su?g 63A, 1292.
Reqmfs for reprink shoukd be aaIled to: Dr JesGs Guiral, Department of Orthopaedics, General Hospital, 40002 Segovia, Spain.
Fixation of fractures of the glenoid rim J. Sinha and A. J. Miller Department
of Orthopaedics,
Mayday
University
Hospital, Croydon,
Introduction The reported incidence of fractures of the glenoid rim associated with acute anterior dislocation of the shoulder is rare. The mechanism for anterior dislocation is said to be abduction and external rotation. There may also be a fracture of the anterior glenoid rim when dislocation occurs with the arm adducted (Aston and Gregory, 1973). A fracture of the glenoid without dislocation is extremely rare (Varriale and Adler, 1983). A case may be made for open reduction and internal fixation of the fragments, as chronic dislocation is said to occur without fixation (Kummel, 1970). We describe two cases in fit young men, one associated with dislocation and the other case without dislocation.
UK
fracture of the antero-inferior
portion of the glenoid rim (Figure I).
It was decided to fix the fragment internally. The shoulder was explored through an anterior approach, and the humeral head was found to be unstable, dislocating forwards, with a fracture involving approximately one-half of the anterior
Case reports cuse1 A d4-year-old male injured his right shoulder when he slipped on a wet surface and the shoulder hit the ground. Following this, the patient complained that his shoulder dislocated several times. He was able to reduce it, but it felt unstable when externally rotated. Examination revealed a normal range of movements and no instability was demonstrated. However, radiographs showed a 0 1992 Butterworth-Heinemann Ltd 0020-1383/92/04042&02
Figure 1. Fracture of the ant~inferior nm.
portion
of the glenoid
Case reports
glenoid rim. The fragment was reduced and fixed with a 26mm A0 cancellous screw (Figure2). The subscapularis was plicated and the joint was subsequently stable. The arm was bandaged to the side for 4 weeks, and then mobilized. He has since regained an excellent range of movement. Case 2 A 25year-old male sustained an injury to his right shoulder while skiing and presented a few days later. He denied that the shoulder had dislocated. Examination of the shoulder was essentially normal, but radiographs revealed a fracture of the anterior glenoid rim. The right shoulder was explored and the jolnt was found to be stable. A large fragment of the anterior part of the glenoid rim was found to be displaced and was secured with an A0 cancellous screw. The subscapularis was plicated. He was discharged home with his arm immobilized in a sling for 4 weeks, and was then referred for mobilization in the physiotherapy department. His shoulder remained stiff and at 6 weeks manipulation under anaesthetic was performed. Excellent movements were obtained, which have been maintained subsequently.
Discussion Fractures of the anterior glenoid rim are rare in association with acute anterior dislocation, but have a definite incidence in association with recurrent dislocation. The reported rate is variable, being described as ‘unusual’ (Adams, 1948) to II per cent (De Palma, 1973) and as high as 44 per cent (Rowe et al., 1978). A fracture of the glenoid without dislocation is extremely rare and we could find only one other case reported in the literature (Varriale and Adler, 1983). Previously reported cases in association with acute dislocation suggest that open reduction and internal fixation of the fracture fragment should be sufficient to stabilize the joint to avoid dislocation (Aston and Gregory, 1973). Our two cases were found to be stable on open reduction and internal fixation of the fracture fragment with a single screw. Capsular repair has also been advocated in addition to fixing the fragment (De Palma, 1973) and we performed a subscapularis plication to increase stability. However, we now feel that plication of the subscapularis should not be undertaken unless there is obvious instability as in one of our cases the shoulder was stiff postoperatively, requiring further manipulation. These fractures must not be ignored because of the risk of chronic dislocation (Kummel, IWO).
Monteggia equivalent
injury
Figure 2. Fixation of the frachm tiagment.
References Adams, J. C. (1948) Recurrent dislocation of the shoulder. J, k ]oinf Surg.3OB, 26. Aston J. W. Jr. and Gregory C. F. (1973) Dislocation of the shoulder with significant fracture of the glenoid. J Bone Joint Surg.55A, 1531. De Palma, A. F. (1973) Surgeryoffhe Shouhr, 2nd Ed. Philadelphia: Lippincott. Kummel B. M. (1970) Fractures of the glenoid causing chronic dislocation of the shoulder. Clin. Orfhop. 69, 189. Rowe C. R., Pate1 D. and Southmayd W. W. (1978) The Bankart JointSurg. procedure - a long-term end result study. J. ti 6OA, 1. Varriale P. L. and Adler M. L. (1983) Occult fracture of the glenoid without dislocation. J BoneJoint Surg.65A, 688. Paper accepted 4 November
1991
Reqtcestsfor reprints shouM be addressed to: Mr A. J. Miller, Department of Orthopaedics, Mayday University Hospital, Mayday Road, Thornton Heath, Surrey CR7 7YE, UK.
in a very young patient
Th. Karachaliosl, E. J. Smith2 and M. F. Pearse’ lBristo1 Royal Infirmary and zBristol Royal Hospital for Sick Children, Bristol, UK
Introduction
Case report
Monteggia fractures classically occur in adults. However, the incidence of this fracture in childhood is higher than is often appreciated, presenting as a so-called Monteggia equivalent (Wiley and Galey, 1985). We report an isolated Monteggia equivalent injury in a 16-month-old child. To our knowledge this is the youngest patient reported to date. The difficulties of diagnosing this injury in the very young and the differential diagnosis are discussed.
S.A., a 16-month-old girl, was admitted to the hospital with a history of a fall, landing on the right forearm. She was subsequently unable to use her right arm. Clinical examination revealed a mild deformity of the right forearm and a full range of painful movement of the right elbow. Radiographs confirmed the presence of a fracture of the right midshaft ulna and a dislocated radial head (Qure I). A Monteggia equivalent injury (type I) was diagnosed. After reduction, the arm was splinted in an aboveelbow cast in supination with 90” of elbow flexion for 4 weeks. On
@ 1992 Butterworth-Heinemann 0020-1383/92/060421-02
Ltd
