Background and purpose of the study

Dropped Head Syndrome (DHS) is characterized by a chin on chest flexion neck deformity that is passively correctible. The condition is rare and literature on surgical and conservative management is focused on case studies and theoretical evidence.

Objective: To report a rare case of lymphomatous transformation in a Pagetic bone

Methods: A 61yr old lady with an 8yr history of monostotic Paget’s disease affecting her right proximal humerus presented with increasing right arm pain. Initial investigations including plain films, a radioisotope bone scan and MRI scan showed evidence of malignant transformation.

Results: The patient was admitted for an incision biopsy. Initial pathological examination suggested a high grade Paget’s sarcoma. However, further stains and immunohistochemical markers showed bone involvement by a malignant B-cell lymphoma.

Conclusion: Although sarcoma is by far the commonest malignant transformation of Pagetic bone, rare cases of lymphoma must also be considered, especially since the management and prognosis are radically different.

Aim: We investigated the accuracy of clinical signs for the diagnosis of rotator cuff disease.

Methods: Fifty patients with history of rotator cuff disease (subacromial impingement syndrome or rotator cuff tear) were examined by two observers to determine the accuracy of clinical tests for the condition. The observers were a consultant (cons.) with an established shoulder practice and a senior registrar (reg.) with an interest in shoulder surgery. The clinical signs evaluated include the painful arc, the drop arm test, Neer’s sign and Hawkins’ sign. For rotator cuff pathology we evaluated the strength of abduction initiation and at 90 degrees abduction for supraspinatus, Speed’s and Yergason’s tests for biceps, strength of shoulder external rotation for infraspinatus and the Gerber lift-off test for subscapularis. We compared our clinical accuracy against a positive subacromial injection test for impingement syndrome, and the findings of rotator cuff tears at arthroscopy.

Results: The consultant and the registrar did not differ significantly in their assessments (paired t-test, p> 0.05). The highly sensitive tests have poor specificity. The most sensitive tests for impingement syndrome were the Hawkins’ sign (cons: 100%, reg: 97%) and the Neer’s sign (cons: 94%, reg: 81%). The Hawkins’ sign also had high negative and positive predictive values. The painful arc and the drop arm tests both had low sensitivity and specificity. Testing the supraspinatus strength at 90 degrees abduction was more sensitive for full thickness cuff tear than testing strength of abduction initiation (cons: 100% vs 67%; reg: 90% vs 50%). These tests were poor at differentiating partial thickness tears from full thickness tears.

Conclusion: The Neer’s and Hawkins’ signs were the most sensitive for impingement syndrome. Testing the supraspinatus at 90 degrees abduction was more sensitive than abduction initiation for full thickness supraspinatus tear.