A prospective, observational cohort study of patients presenting to an emergency department with acute shoulder trauma: the Manchester emergency shoulder (MESH) project

Background Fracture and dislocation of the shoulder are usually identifiable through the use of plain radiographs in an emergency department. However, other significant soft tissue injuries can be missed at initial presentation. This study used contrast enhanced magnetic resonance arthrography (MRA) to determine the pattern of underlying soft tissue injuries in patients with traumatic shoulder injury, loss of active range of motion, and normal plain radiography. Methods A prospective, observational cohort study. Twenty-six patients with acute shoulder trauma and no identifiable radiograph abnormality were screened for inclusion. Those unable to actively abduction their affected arm to 90° at initial presentation and at two week’s clinical review were consented for MRA. Results Twenty patients (Mean age 44 years, 4 females) proceeded to MRA. One patient had no abnormality, three patients showed minimal pathology. Four patients had an isolated bony/labral injury. Eight patients had injuries isolated to the rotator cuff. Four patients had a combination of bony and rotator cuff injury. Four patients were referred to a specialist shoulder surgeon following MRA and underwent surgery. Conclusions Significant soft tissue pathology was common in our cohort of patients with acute shoulder trauma, despite the reassurance of normal plain radiography. These patients were unable to actively abduct to 90° both at initial presentation and at two week’s post injury review. A more aggressive management and diagnostic strategy may identify those in need of early operative intervention and provide robust rehabilitation programmes

An Unrecognised Case of a Scapula Fracture Sustained through an Unusual Indirect Mechanism

Scapula fractures following low-velocity injuries are extremely rare but can be a missed associated fracture of other upper limb injuries. We describe the case of a patient who sustained a fracture of the scapula through an unusual and hitherto unreported indirect mechanism. The injury was associated with a radial head fracture and initially missed on presentation. This case highlights the need for increased vigilance when diagnosing injuries with unusual mechanisms

Histological incorporation of acellular dermal matrix in the failed superior capsule reconstruction of the shoulder

Abstract Background Superior capsule reconstruction addresses massive rotator cuff tears using allografts and aims to restore the natural superior constraint of the shoulder and therefore shoulder biomechanics and function. There is no evidence relating to the histological incorporation of these grafts. Methods 27 superior capsule reconstructions were performed between June 2016 and November 2017. Follow-up was with clinical assessment and Magnetic Resonance Imaging, to identify graft failure. Reverse total shoulder replacement was offered for ruptured grafts and the graft was sent for histological analysis along with the footprint of graft attachment where possible. Results Five patients (18.5%) had evidence of graft failure, three of whom (11.1%) underwent revision procedures. Of the five ruptures, four failed at the glenoid insertion, and one was an intra-substance tear. Histological analysis showed extensive fibroblastic infiltration. The intra-substance tear showed some vascularity at the medial and lateral ends, and one of the glenoid pull-outs demonstrated micro-calcification and osteoid formation. There was no evidence of in-growth into the bone. Discussion An inflammatory response to the grafts was seen, with neo-vascularisation, and micro-calcification observed. These findings are from ruptured grafts, so may not represent the characteristics of those which have not ruptured. Further evidence from explanted intact grafts could be gained to improve our understanding of its incorporation. Level of evidence Level IV evidenc