The Relationship Between Arm Abduction Position and the Risk of Iatrogenic Anterior Branch of the Axillary Nerve Injuries: A Cadaveric Study

Common sports-related nerve injuries seen by the electrodiagnostic medical consultant

The high physiologic demands of sports create dynamic stress on joints, soft tissues, and nerves which may lead to injuries in the athlete. Electrodiagnostic (EDx) assessment is essential to identify the correct diagnosis, localization, and prognosis, to guide management of sports-related neuropathies. A comprehensive review was performed to provide the EDx medical consultant with a practical approach to the common peripheral nerve disorders seen in athletes. Sports-related neuropathies reviewed include transient traumatic irritation of the brachial plexus and/or cervical nerve roots ("Burners and stingers,") suprascapular and axillary neuropathies, ulnar neuropathy at the elbow (UNE) in throwers, ulnar neuropathy at the hand/wrist in cyclists, multi-ligamentous knee injury, and foot/ankle neuropathies including tarsal tunnel syndrome. A thorough understanding of peripheral anatomy, possible entrapment sites, mechanisms of injury, and key physical examination findings is essential for correct diagnosis. EDx assessments beyond routine studies are generally required for sports-related neuropathy, which may not necessarily follow typical entrapment patterns. Adjunct diagnostic imaging, such as point-of-care ultrasound and magnetic resonance imaging, are helpful tools to identify associated musculoskeletal pathology such as compressive cysts or nerve entrapment, which may be amenable to interventional or surgical treatment. When no clear reversible structural pathology exists, management of sports-related neuropathy is athlete-specific and generally multi-modal, involving a combination of physical rehabilitation techniques to address muscle imbalances, load management, protective equipment, and interventional pain procedures.

Optimising safe margins in shoulder surgeries: a cadaveric study on brachial plexus nerves with anthropometric and movement correlation

PURPOSE

Shoulder surgeries, vital for diverse pathologies, pose a risk of iatrogenic nerve damage. Existing literature lacks diverse bone landmark-specific nerve position data. The purpose of this study is to address this gap by investigating such relationships.

METHOD

This cadaveric study examines axillary, radial and suprascapular nerves' relation with acromion, coracoid and greater tuberosity of the humerus (GT). It also correlates this data with humeral lengths and explores nerve dynamics in relation to arm positions.

RESULTS

The mean distance from the axillary nerve to (i) GT was 4.38 cm (range 3.32-5.44, SD 0.53), (ii) acromion was 6.42 cm (range 5.03-7.8, SD 0.694) and (iii) coracoid process was 4.3 cm (range 2.76-5.84, SD 0.769). Abduction brought the nerve closer by 0.36 cm, 0.35 cm and 0.53 cm, respectively. The mean distance from radial nerve to (i) GT was 5.46 cm (range 3.78-7.14, SD 0.839), (ii) acromion was 7.82 cm (range 5.4-10.24, SD 1.21) and (iii) tip of the coracoid process was 6.09 cm (range 4.07-8.11 cm, SD 1.01). The mean distance from the suprascapular nerve to the acromion was 4.2 cm (range 3.1-5.4, SD 0.575). The mean humeral length was noted to be 27.83 cm (range 25.3-30.7, SD 1.13). There was no significant correlation between these distances and humeral lengths.

CONCLUSION

It is essential to exercise caution to avoid axillary nerve damage during the abduction manoeuvre, as its distance from the greater tuberosity and tip of the coracoid process has shown a significant reduction. The safe margins, in relation to the length of the humerus and consequently the patient's stature, exhibit no significant variation. In situations where the greater tuberosity (GT) and the border of the acromion are inaccessible due to reasons such as trauma, the tip of the coracoid process can serve as a dependable bone landmark for establishing a secure surgical margin.

Appropriate intradeltoid muscle needle penetration depth in vaccine administration: an MRI study in Thailand

Objective

The objective of this study was to evaluate the appropriate vaccination needle penetration depth into the deltoid muscle to avoid injection-site complications from an inappropriate injection depth and/or injection site in the Thai population.

Methods

This was a retrospective study using axial proton density-weighted images of MRI shoulders at the level of 2 fingerbreadths below the acromion process to measure the combined thickness of the skin, subcutaneous fat pad and deltoid muscle to evaluate the percentage of injections into the deltoid muscle with various needle penetration depths.

Results

There were 509 MRI shoulder images of 222 males and 287 females (265 right shoulders and 244 left shoulders). The average body mass index and age were 24.54 ± 3.54 kg/m2 and 64.81 ± 10.20 years, respectively. Using a needle penetration depth of 12.7 mm (0.5 inches) achieved 100% of injections into the deltoid muscle.

Conclusion

We recommend advancing the entire length of a 0.5-inch needle perpendicular to the skin at 2 fingerbreadths below the acromion process for adult intradeltoid vaccinations. This approach ensures optimal vaccine delivery and minimizes the risk of injection-related injuries.

Septic arthritis of shoulder joint following a COVID-19 vaccination: A case report

Introduction

Septic arthritis of the shoulder joint is a serious condition which requires early diagnosis and treatment. This condition usually presents with shoulder pain, limited range of motion and/or fever, and is diagnosed by shoulder arthrocentesis with significant synovial fluid leukocytosis or positive synovial fluid gram stain or culture. There are some risk factors for septic arthritis, notably bacteremia, pre-existing joint pathology and an immunocompromised host such as poorly controlled type II diabetes mellitus.

Case presentation

A 45-year-old Thai female developed left shoulder septic arthritis after an Astra-Zeneca COVID-19 vaccine administration. The clinical symptoms were left shoulder pain, limited range of motion and fever. The probable risk factors were underlying diabetes mellitus type II and vaccine administration technique. The joint fluid culture showed Staphylococcus aureus. This patient was treated with combined arthroscopic debridement and an intravenous antibiotic for 1 week which was then switched to an oral antibiotic for 5 weeks. Her clinical symptoms gradually improved over the 2 weeks following the initiation of treatment.

Conclusion

Septic arthritis is a rare complication after a vaccination. Doctors should be especially careful with immunocompromised patients, and always use a correct injection technique.

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Septic arthritis of the shoulder should not be missed in the patient with shoulder pain after vaccination.

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Even through the type II diabetes mellitus was well-controlled, the type II diabetes mellitus still placed her at extra risk of septic arthritis.

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The other possible cause was the injection technique of the vaccination.

Shoulder Injury Related to COVID-19 Vaccine Administration: A Case Series

Background: A shoulder injury related to vaccine administration (SIRVA) is a vaccination complication that can affect daily life activities. To date, there have been no case series of patients diagnosed as SIRVA following a COVID-19 vaccination. We offer a series of seven SIRVA cases including clinical presentations, investigations and treatment outcomes. Methods: A retrospective chart review was performed for seven patients who developed SIRVA following a COVID-19 vaccination between April 2021 and October 2021. All patients had no prior shoulder pain before their vaccination and then developed shoulder pain within a few days following the vaccination, which did not spontaneously improve within 1 week. Results: Four of the seven patients were male, and the average age was 62.29 ± 7.76 years. The average body mass index was 25.1 ± 2.2 kg/m². In all cases, the cause of the SIRVA was from an incorrect COVID-19 vaccine administration technique. Two patients developed shoulder pain immediately following the injection, one patient about 3 h after the injection, and the other four patients within the next few days. Two of the seven patients visited the orthopedic clinic after the persistent shoulder pain for 3 and 4 days and the other five patients 1–9 weeks following their injections. One of the seven patients was treated with combined intravenous antibiotic and oral non-steroidal anti-inflammatory drug (NSAID) because septic arthritis of the shoulder could not initially be ruled out, and recovered within 2 weeks. The other six patients had shoulder pain without acute fever, and five of them were treated with only oral prednisolone 30 mg/day for 5–10 days, following which the pain improved and they all could return to normal activities within 14 days, with no side effects from the prednisolone such as stomachache, nausea, vomiting, headache, or dizziness. Discussion and conclusion: In our series, the most common cause of SIRVA was an incorrect vaccination technique. Most patients responded well to oral NSAIDs or oral prednisolone. Clinical relevance: All SIRVAs were from an incorrect injection technique and not actually the vaccination, so our series highlights the importance of ensuring all vaccinators understand the importance of taking proper care with the injection technique. Additionally, most of our patients with SIRVA from a COVID-19 injection responded well to oral prednisolone (30 mg/day). If there are no contraindications, we suggest this as the first line treatment for COVID-19-related SIRVA.

Combined subacromial-subdeltoid bursitis and supraspinatus tear following a COVID-19 vaccination: A case report

Introduction

After a vaccine administration, many people have localized symptoms such as pain, redness, warmth, swelling, itching and/or bruising, which usually improve in a few days. If the clinical symptoms do not improve in this period, a shoulder injury related to vaccine administration (SIRVA) should be ruled out. The most common cause of a SIRVA is an improper injection technique. Herein, we reported the first case of combined subacromial-subdeltoid bursitis and supraspinatus tendon tear which was apparently caused by an improper COVID-19 vaccination technique.

Case presentation

A 51-year-old Thai female began to experience severe right shoulder pain about 3 hours after receiving a COVID-19 vaccination. Ultrasonography showed combined subacromial-subdeltoid bursitis and supraspinatus tendon tear. Her clinical symptoms gradually improved after treatment with an oral non-steroidal anti-inflammatory drug. Our investigation found that an improper injection technique had been used, namely inserting the needle too deeply, and using an incorrect landmark.

Conclusion

We report a case of combined subacromial-subdeltoid bursitis and supraspinatus tendon tear following a second dose of the Oxford-AstraZeneca COVID-19 vaccine. This is a rare condition which is usually related to an incorrect injection technique. To reduce the chance of SIRVA, the healthcare worker giving the injection should pay careful attention to find the appropriate landmark, and ensuring the correct needle length and direction of the injection.

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If the clinical symptoms after vaccination do not improve in 2-3 days, a shoulder injury related to vaccine administration should be considered.

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There is a risk of SIRVA if the anatomical landmark of the needle was too high.

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Before diagnosis SIRVA, the serious condition such as septic arthritis of shoulder should be ruled out.

Shoulder injury related to Sinovac COVID-19 vaccine: A case report

Introduction

After a vaccination, patients frequently have clinical symptoms of pain and swelling over the injection area which usually resolve 2–3 days after the injection. If the symptoms do not improve, a shoulder injury related to vaccine administration (SIRVA) will be considered, perhaps related to an improper injection technique. Herein we report our first case of a SIRVA after a Sinovac COVID-19 vaccination which occurred due to deep penetration and direction of the needle. The clinical symptoms of the patient improved after treatment with combined oral non-steroidal anti-inflammatory drugs and a short course of intravenous antibiotic.

Case presentation

A 52-year-old Thai male without prior shoulder pain had a Sinovac COVID-19 vaccination at his right shoulder. The injection was given by a nurse using a 27-gauge needle, 1.5 inches in length. The injection landmark was 3 finger breadths below the midlateral edge of the acromial process. The direction of the needle was 45° to the skin cephalad. Three days after receiving the vaccine the patient began to have right shoulder pain with limited range of motion and acute fever. He was admitted for medical treatment which his clinical symptoms gradually improved.

Conclusion

We report a case of subacromial-subcoracoid-subdeltoid bursitis following a Sinovac COVID-19 vaccine injection. This condition is rare, and usually related to an incorrect vaccination technique. To avoid this complication, nurses should identify the correct landmark, use an appropriate needle length, and point the needle in the correct direction.

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After a vaccination, if the symptoms do not improve, SIRVA will be considered.

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There is a risk of SIRVA if the direction of the needle was pointed to the skin cephalad.

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Before diagnosis SIRVA, septic arthritis of shoulder should be ruled out.