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Rai A, Sharath HV, Raghuveer R, Qureshi MI. The Physiotherapy Management of Postoperative Mid-shaft Clavicular Fracture With Brachial Plexus Injury: A Case Report. Cureus 2024; 16:e66461. [PMID: 39246957 PMCID: PMC11380546 DOI: 10.7759/cureus.66461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 08/08/2024] [Indexed: 09/10/2024] Open
Abstract
Traumatic brachial plexus injury (BPI) is a debilitating condition predominantly affecting young males, often resulting from traction or direct injuries. Due to the complicated neuronal network, the damage is often classified as preganglionic or postganglionic injuries. It includes upper-limb mobility impairments as well as reduced muscular strength and sensitivity. We discuss a case of a 30-year-old female who suffered a displaced mid-shaft clavicular fracture and BPI after a road traffic collision. The patient experienced significant pain, restricted movement, and sensory and motor loss in her left arm. Imaging studies revealed additional complications, including epidural collection and pseudomeningoceles. She underwent open reduction and internal fixation of the clavicle, followed by a structured rehabilitation program focusing on pain management, muscle re-education, and functional recovery. This case highlights the complexity of managing clavicular fractures with concurrent BPI, requiring a multidisciplinary approach involving imaging, surgical intervention, and comprehensive physiotherapy for optimal recovery and functional restoration. Rehabilitation strategies were employed to address the diverse symptoms, including multi-sensory strategies, sensory re-education, graded motor imagery rehabilitation, and gradual restoration of upper extremity (UE) range, strength, and endurance and to develop neuromuscular control. Effective management of clavicular fractures with BPI requires early diagnosis, surgical intervention, and structured rehabilitation to improve functional outcomes and quality of life.
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Affiliation(s)
- Anjali Rai
- Department of Neuro-Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - H V Sharath
- Department of Neuro-Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Raghumahanti Raghuveer
- Department of Neuro-Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Moh'd Irshad Qureshi
- Department of Neuro-Physiotherapy, Ravi Nair Physiotherapy College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Hanna AS, Hellenbrand DJ, Schomberg DT, Salamat SM, Loh M, Wheeler L, Hanna B, Ozaydin B, Meudt J, Shanmuganayagam D. Brachial plexus anatomy in the miniature swine as compared to human. J Anat 2022; 240:172-181. [PMID: 34355792 PMCID: PMC8655215 DOI: 10.1111/joa.13525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 07/09/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022] Open
Abstract
Brachial plexus injury (BPI) occurs when the brachial plexus is compressed, stretched, or avulsed. Although rodents are commonly used to study BPI, these models poorly mimic human BPI due to the discrepancy in size. The objective of this study was to compare the brachial plexus between human and Wisconsin Miniature SwineTM (WMSTM ), which are approximately the weight of an average human (68-91 kg), to determine if swine would be a suitable model for studying BPI mechanisms and treatments. To analyze the gross anatomy, WMS brachial plexuses were dissected both anteriorly and posteriorly. For histological analysis, sections from various nerves of human and WMS brachial plexuses were fixed in 2.5% glutaraldehyde, and postfixed with 2% osmium tetroxide. Subsequently paraffin sections were counter-stained with Masson's Trichrome. Gross anatomy revealed that the separation into three trunks and three cords is significantly less developed in the swine than in human. In swine, it takes the form of upper, middle, and lower systems with ventral and dorsal components. Histological evaluation of selected nerves revealed differences in nerve trunk diameters and the number of myelinated axons in the two species. The WMS had significantly fewer myelinated axons than humans in median (p = 0.0049), ulnar (p = 0.0002), and musculocutaneous nerves (p = 0.0454). The higher number of myelinated axons in these nerves for humans is expected because there is a high demand of fine motor and sensory functions in the human hand. Due to the stronger shoulder girdle muscles in WMS, the WMS suprascapular and axillary nerves were larger than in human. Overall, the WMS brachial plexus is similar in size and origin to human making them a very good model to study BPI. Future studies analyzing the effects of BPI in WMS should be conducted.
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Affiliation(s)
- Amgad S. Hanna
- Department of Neurological SurgeryUniversity of Wisconsin School of Medicine and Public Health (UWSMPH) – MadisonMadisonWisconsinUSA
| | - Daniel J. Hellenbrand
- Department of Neurological SurgeryUniversity of Wisconsin School of Medicine and Public Health (UWSMPH) – MadisonMadisonWisconsinUSA
| | - Dominic T. Schomberg
- Department of Animal and Dairy SciencesUniversity of Wisconsin – MadisonMadisonWisconsinUSA
| | - Shahriar M. Salamat
- Department of Neurological SurgeryUniversity of Wisconsin School of Medicine and Public Health (UWSMPH) – MadisonMadisonWisconsinUSA
- Department of Pathology and Laboratory MedicineUniversity of Wisconsin School of Medicine and Public Health (UWSMPH)MadisonWisconsinUSA
| | - Megan Loh
- Department of Neurological SurgeryUniversity of Wisconsin School of Medicine and Public Health (UWSMPH) – MadisonMadisonWisconsinUSA
| | - Lea Wheeler
- Department of Neurological SurgeryUniversity of Wisconsin School of Medicine and Public Health (UWSMPH) – MadisonMadisonWisconsinUSA
| | - Barbara Hanna
- University of Wisconsin – MadisonMadisonWisconsinUSA
| | - Burak Ozaydin
- Department of Neurological SurgeryUniversity of Wisconsin School of Medicine and Public Health (UWSMPH) – MadisonMadisonWisconsinUSA
| | - Jennifer Meudt
- Biomedical & Genomic Research GroupUniversity of Wisconsin – MadisonMadisonWisconsinUSA
| | - Dhanansayan Shanmuganayagam
- Department of Animal and Dairy SciencesUniversity of Wisconsin – MadisonMadisonWisconsinUSA
- Department of SurgeryUniversity of Wisconsin School of Medicine and Public Health (UWSMPH) – MadisonMadisonWisconsinUSA
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Nath RK, Somasundaram C. Incidence, Etiology, and Management of Long Thoracic and Accessory Nerve Injuries and Winging Scapula. EPLASTY 2021; 21:e11. [PMID: 35603020 PMCID: PMC9128739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Peripheral nerve injuries make up many upper extremity musculoskeletal disorders (UE-MSDs), as peripheral nerves in the upper extremities are susceptible to damage due to their superficial course and length. The health and economic burdens of peripheral nerve injuries are rising. Upper-limb peripheral nerve injuries caused by prone positioning in COVID-19 patients in intensive care have occurred during the current global pandemic. Understanding the incidence and causation of these injuries is essential, as these affect primarily young workers and athletes with skeletal immaturity and contribute to significant morbidity. METHODS AND PATIENTS A total of 789 patients, 481 of whom were male and 308 female, with limited upper-extremity movements, scapular winging, and pain due to upper brachial plexus, long thoracic and accessory nerve injuries (459 right, 282 left, and 48 bilateral) were included in the study. Patient age at the onset of injury ranged between 11 months and 68 years. RESULTS A total of 18 causes of peripheral nerve injury were identified among the 789 patients with UE-MSD. The most affected patients (12.7%) were involved in sports and related activities, with 20 different sports and related activities reported in this patient population. Weightlifting caused the most (10.9%) number of injuries in this group. Incidences in the least affected patients were due to massage and viral infection, at 0.6% and 0.6% respectively. CONCLUSIONS Sports and recreational-related physical activities are essential components of a healthy lifestyle, and may help decrease the incidence of obesity, diabetes, and cardiovascular diseases. Injury and fear of impairment, however, can be barriers in the participation of these activities. Surgery and other interventions can help maximize return to work and regular activities after UE-MSDs.
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Affiliation(s)
- Rahul K. Nath
- Texas Nerve and Paralysis Institute, Houston, Texas, 77030
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Kaiser R, Waldauf P, Ullas G, Krajcová A. Epidemiology, etiology, and types of severe adult brachial plexus injuries requiring surgical repair: systematic review and meta-analysis. Neurosurg Rev 2020; 43:443-452. [PMID: 30014280 DOI: 10.1007/s10143-018-1009-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
Abstract
The literature describing epidemiology, etiology, and types of serious brachial plexus injuries (BPIs) is sparse. The aim of this review was to investigate the epidemiological and etiopathogenetical data of serious BPIs undergoing surgical reconstruction. A systematic search was conducted from January 1985 to December 2017. All studies that reported data about prevalence of specific types and causes of BPIs in adults treated surgically were included and cumulatively analyzed. Ten studies including 3032 patients were identified. The pooled prevalence of closed BPIs was 93% (95% CI: 87-97%), lacerations accounted for 3% (95% CI: 1-6%), and gunshot wounds (GSWs) for 3% (95% CI: 0-7%). The prevalence of male patients was 93% (95% CI: 90-96%) and female cases 7% (95% CI: 4-10%). The most common cause of closed BPI was motorcycle accidents with 67% (95% CI: 49-82%) prevalence followed by car crashes with 14% (95% CI: 8-20%). Other causes were rare. Ninety percent (95% CI: 78-98%) of patients suffered from a supraclavicular or combined supra-/infraclavicular trauma, while 10% (95% CI: 2-22%) from isolated infraclavicular injury. The prevalence of complete lesions was 53% (95% CI: 47-58%) followed by upper plexus lesion with 39% (95% CI: 31-48%) and lower plexus injury with 6% (95% CI: 1-12%). This meta-analysis demonstrates that the typical patient suffering from severe BPI is a male after motorcycle accident with closed supraclavicular injury causing complete or slightly less commonly upper plexus palsy. Lacerations and GSWs of brachial plexus are rare.
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Affiliation(s)
- Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czech Republic.
| | - Petr Waldauf
- Department of Anesthesiology and Critical Care Medicine, Third Faculty of Medicine, Charles University and Hospital Královské Vinohrady, Prague, Czech Republic
| | - Gautham Ullas
- Department of ENT, Cumberland Infirmary, North Cumbria University Hospitals NHS Trust, Carlisle, UK
| | - Aneta Krajcová
- Department of Plastic Surgery, First Faculty of Medicine, Charles University and Hospital Na Bulovce, Prague, Czech Republic
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Yang JT, Fang JT, Li L, Chen G, Qin BG, Gu LQ. Contralateral C7 transfer combined with acellular nerve allografts seeded with differentiated adipose stem cells for repairing upper brachial plexus injury in rats. Neural Regen Res 2019; 14:1932-1940. [PMID: 31290451 PMCID: PMC6676869 DOI: 10.4103/1673-5374.259626] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Nerve grafting has always been necessary when the contralateral C7 nerve root is transferred to treat brachial plexus injury. Acellular nerve allograft is a promising alternative for the treatment of nerve defects, and results were improved by grafts laden with differentiated adipose stem cells. However, use of these tissue-engineered nerve grafts has not been reported for the treatment of brachial plexus injury. The aim of the present study was to evaluate the outcome of acellular nerve allografts seeded with differentiated adipose stem cells to improve nerve regeneration in a rat model in which the contralateral C7 nerve was transferred to repair an upper brachial plexus injury. Differentiated adipose stem cells were obtained from Sprague-Dawley rats and transdifferentiated into a Schwann cell-like phenotype. Acellular nerve allografts were prepared from 15-mm bilateral sections of rat sciatic nerves. Rats were randomly divided into three groups: acellular nerve allograft, acellular nerve allograft + differentiated adipose stem cells, and autograft. The upper brachial plexus injury model was established by traction applied away from the intervertebral foramen with micro-hemostat forceps. Acellular nerve allografts with or without seeded cells were used to bridge the gap between the contralateral C7 nerve root and C5–6 nerve. Histological staining, electrophysiology, and neurological function tests were used to evaluate the effect of nerve repair 16 weeks after surgery. Results showed that the onset of discernible functional recovery occurred earlier in the autograft group first, followed by the acellular nerve allograft + differentiated adipose stem cells group, and then the acellular nerve allograft group; moreover, there was a significant difference between autograft and acellular nerve allograft groups. Compared with the acellular nerve allograft group, compound muscle action potential, motor conduction velocity, positivity for neurofilament and S100, diameter of regenerating axons, myelin sheath thickness, and density of myelinated fibers were remarkably increased in autograft and acellular nerve allograft + differentiated adipose stem cells groups. These findings confirm that acellular nerve allografts seeded with differentiated adipose stem cells effectively promoted nerve repair after brachial plexus injuries, and the effect was better than that of acellular nerve repair alone. This study was approved by the Animal Ethics Committee of the First Affiliated Hospital of Sun Yat-sen University of China (approval No. 2016-150) in June 2016.
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Affiliation(s)
- Jian-Tao Yang
- Department of Microsurgery & Orthopedic Trauma, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jin-Tao Fang
- Department of Microsurgery & Orthopedic Trauma, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Liang Li
- Department of Microsurgery & Orthopedic Trauma, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Gang Chen
- Department of Microsurgery & Orthopedic Trauma, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ben-Gang Qin
- Department of Microsurgery & Orthopedic Trauma, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Li-Qiang Gu
- Department of Microsurgery & Orthopedic Trauma, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
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Karsy M, Watkins R, Jensen MR, Guan J, Brock AA, Mahan MA. Trends and Cost Analysis of Upper Extremity Nerve Injury Using the National (Nationwide) Inpatient Sample. World Neurosurg 2018; 123:e488-e500. [PMID: 30502477 DOI: 10.1016/j.wneu.2018.11.192] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Epidemiology in upper extremity peripheral nerve injury (PNI) has not been comprehensively evaluated. The aim of this study was to calculate updated incidence of upper extremity PNIs in the United States and examine clinical trends and costs using a national database. METHODS The National (Nationwide) Inpatient Sample was used to evaluate patients with upper extremity PNI (International Classification of Diseases, Ninth Revision, Clinical Modification 9534, 9550-9559) in 2001-2013. RESULTS A weighted total of 170,579 patients experienced upper extremity PNI, representing a mean incidence of 43.8/1 million people annually. Mean (± SEM) age of patients was 38.1 ± 0.05 years, 74.3% of patients were male, and 49.0% were Caucasian. PNIs occurred to the ulnar (17.8%), radial (15.1%), digital (18.0%), median (13.0%), multiple (11.5%), and other (10.1%) nerves and brachial plexus (14.5%). The number of upper extremity PNIs decreased overall. Average care charge was $47,004 ± $185, with an average increase of $4623/year and compound annual growth rate of 9.59%. Although surgical nerve repair and home disposition were common with isolated PNIs, patients with brachial plexus PNIs did not have nerve surgery and were more likely to be discharged to skilled nursing facilities. Multivariate analysis showed that length of stay (β = 0.677, P = 0.0001) and number of procedures (β = 0.188, P = 0.0001) most affected total patient charges. CONCLUSIONS These results suggest an overall decrease in number of PNIs, suggesting lower incidence or frequency of detection; however, the cost of care has increased. Despite advances in nerve repair techniques, nerve surgery rates have not increased, especially for brachial plexus injuries, which may be undertreated.
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Affiliation(s)
- Michael Karsy
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Ryan Watkins
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael R Jensen
- Department of Neurosurgery, Stanford Neuroscience Health Center, Stanford, Palo Alto, California, USA
| | - Jian Guan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Andrea A Brock
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Mark A Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Fang J, Yang J, Yang Y, Li L, Qin B, He W, Yan L, Chen G, Tu Z, Liu X, Gu L. A novel rat model of brachial plexus injury with nerve root stumps. J Neurosci Methods 2018; 295:1-9. [DOI: 10.1016/j.jneumeth.2017.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/01/2017] [Accepted: 11/03/2017] [Indexed: 02/08/2023]
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Dengler NF, Antoniadis G, Grolik B, Wirtz CR, König R, Pedro MT. Mechanisms, Treatment, and Patient Outcome of Iatrogenic Injury to the Brachial Plexus-A Retrospective Single-Center Study. World Neurosurg 2017; 107:868-876. [PMID: 28847555 DOI: 10.1016/j.wneu.2017.08.119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Injury to the brachial plexus is a devastating condition, with severe impairment of upper extremity function resulting in distinct disability. There are no systematic reports on epidemiology, causative mechanisms, treatment strategies. or outcomes of iatrogenic brachial plexus injury (iBPI). METHODS We screened all cases of iatrogenic nerve injuries recorded between 2007 and 2017 at a single specialized institution. Mechanism of iBPI, type of previous causative intervention, location and type of the lesion as well as the type of revision surgery and functional patient outcome were analyzed. RESULTS We identified 14 cases of iBPI, which all presented with significant impairment of upper extremity motor function (at least 1 muscle Medical Research Council grade 0). Neuropathic pain was present in most patients (11/14). Orthopedic shoulder procedures such as rotator cuff fixation, arthroplasty, and repositioning of a clavicle fracture accounted for iBPI in 7 of 14 patients. Other reasons for iBPI were resection or biopsy of a peripheral nerve sheath tumor in 3 patients or lymph node situated at the cervicomediastinal area in 2 patients. Mechanisms also included transaxillary rib resection in one and sternotomy in another patient. The treatment of iBPI was conducted according to each individual's needs and included neurolysis in 4, nerve grafting in 9, and nerve transfers in 1 patient. We found improved symptoms after treatment in most patients (11/14). CONCLUSIONS Most common causes for iBPI were shoulder surgery and resection or biopsy of peripheral nerve sheath tumor and lymph nodes. Early referral to specialized peripheral nerve centers may help to improve functional patient outcome.
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Affiliation(s)
| | - Gregor Antoniadis
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Brigitta Grolik
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Christian Rainer Wirtz
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Ralph König
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Maria Teresa Pedro
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, Universitätsklinik Ulm am Bezirkskrankenhaus Günzburg, Günzburg, Germany
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A population-based study of injuries to the brachial plexus and to the peripheral nerves of the shoulder girdle and upper limb in the Italian region Friuli Venezia Giulia. Neurosurg Rev 2017; 41:519-523. [PMID: 28717892 DOI: 10.1007/s10143-017-0881-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/13/2017] [Accepted: 07/06/2017] [Indexed: 10/19/2022]
Abstract
The aim of this study was to estimate the incidence, identify the causes, and explore treatments of the injuries to the brachial plexus and peripheral nerves of the shoulder girdle and upper limb in the 1,220,000-inhabitant Italian region Friuli Venezia Giulia.We linked at the individual patient level various administrative databases using an anonymous stochastic key: list of residents, hospital discharge, emergency department, and outpatient care prescriptions database. We abstracted hospital discharge records with at least one discharge diagnosis code ICD-9-CM 953.4 (brachial plexus) or 955.0-955.9 (upper limb). For hospitalized patients, we investigated the prescriptions of ambulatory care during the following year. Emergency department visits in the month prior to hospital admission were also assessed.From 2000 to 2015, we observed 474 hospitalizations (annual average: 61); 48% of patients received at least one prescription of outpatient physical therapy and rehabilitation in the following year, accounting for more than 25,000 visits and interventions. According to emergency department data, falls were the most common mechanism among the elderly; cuts were common among the young.This is the first population study of peripheral nerve injuries to the brachial plexus and peripheral nerves of the shoulder girdle and upper limb in Italy.
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Duijnisveld BJ, Henseler JF, Reijnierse M, Fiocco M, Kan HE, Nelissen RGHH. Quantitative Dixon MRI sequences to relate muscle atrophy and fatty degeneration with range of motion and muscle force in brachial plexus injury. Magn Reson Imaging 2016; 36:98-104. [PMID: 27989913 DOI: 10.1016/j.mri.2016.10.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/14/2016] [Accepted: 10/26/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Assessment of muscle atrophy and fatty degeneration in brachial plexus injury (BPI) could yield valuable insight into pathophysiology and could be used to predict clinical outcome. The objective of this study was to quantify and relate fat percentage and cross-sectional area (CSA) of the biceps to range of motion and muscle force of traumatic brachial plexus injury (BPI) patients. METHODS T1-weighted TSE sequence and three-point Dixon images of the affected and non-affected biceps brachii were acquired on a 3 Tesla magnetic resonance scanner to determine the fat percentage, total and contractile CSA of 20 adult BPI patients. Regions of interest were drawn by two independent investigators to determine the inter-observer reliability. Paired Students' t-test and multivariate analysis were used to relate fat percentage, total and contractile CSA to active flexion and biceps muscle force. RESULTS The mean fat percentage 12±5.1% of affected biceps was higher than 6±1.0% of the non-affected biceps (p<0.001). The mean contractile CSA 8.1±5.1cm2 of the affected biceps was lower than 19.4±4.9cm2 of the non-affected biceps (p<0.001). The inter-observer reliability was excellent (ICC 0.82 to 0.96). The contractile CSA contributed most to the reduction in active flexion and muscle force. CONCLUSION Quantitative measurement of fat percentage, total and contractile CSA using three-point Dixon sequences provides an excellent reliability and relates with active flexion and muscle force in BPI.
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Affiliation(s)
- Bouke J Duijnisveld
- Department of Orthopaedics, Leiden University Medical Center, The Netherlands.
| | | | - Monique Reijnierse
- Department of Radiology, Leiden University Medical Center, The Netherlands
| | - Marta Fiocco
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, The Netherlands; Mathematica institute Leiden University, Leiden University Medical Center, The Netherlands
| | - Hermien E Kan
- C.J. Gorter Center for High Field MRI, Department of Radiology, Leiden University Medical Center, The Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, The Netherlands
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Nouraei MH, Hosseini A, Salek S, Nouraei F, Bina R. Median and ulnar nerve injuries; what causes different repair outcomes? Adv Biomed Res 2015; 4:215. [PMID: 26605244 PMCID: PMC4627180 DOI: 10.4103/2277-9175.166162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 03/18/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Peripheral nerve injuries have significant effects on patients' life quality. To make patients' therapeutic expectations more realistic, prediction of repair outcome has significant importance. MATERIALS AND METHODS Totally, 74 patients with 94 nerve injuries (44 median and 50 ulnar nerves) were evaluated and followed up for 5 years between 2008 and 2013 in two main university hospitals of Isfahan. Patients' age was 6-64 years. 24 nerves were excluded from the study and among the remaining; 53 nerves were repaired primarily and 17 nerves secondarily. 42 nerves were injured at a low-level, 17 nerves at intermediate and 11 at a high one. Medical Research Council Scale used for sensory and motor assessment. S3+ and S4 scores for sensory recovery and M4 and M5 scores for motor recovery were considered as favorable results. The follow-up time was between 8 and 24 months. RESULTS There was no significant difference between favorable sensory outcomes of median and ulnar nerves. The difference between favorable motor outcomes of the median nerve was higher than ulnar nerve (P = 0.03, odds ratio = 2.9). More favorable results were seen in high-level injuries repair than low ones (P = 0.035), and also cases followed more than 18 months compared to less than 12 months (P = 0.041), respectively. The favorable outcomes for patients younger than 16 were more than 40 and older, however, their difference was not significant (P = 0.059). The difference between primary and secondary repair favorable outcomes was not significant (P = 0.37). CONCLUSION In patients older than 40 or injured at a high-level, there is a high possibility of repetitive operations and reconstructive measures. The necessity for long-term follow-up and careful attentions during a postoperative period should be pointed to all patients.
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Affiliation(s)
- Mohammad Hadi Nouraei
- Department of Orthopedic Surgery, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Hosseini
- Department of Orthopedic Surgery, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shadi Salek
- Department of Pediatrics, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farhad Nouraei
- Students' Research Committee, International Islamic Azad University of Khorasgan, Isfahan, Iran
| | - Roya Bina
- Department of Internal Medicine, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
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Yu W, Wang J, Xu M, Qin H, Cui S. Brain-derived neurotrophic factor expression in dorsal root ganglion neurons in response to reanastomosis of the distal stoma after nerve grafting. Neural Regen Res 2015; 7:2012-7. [PMID: 25624832 PMCID: PMC4296420 DOI: 10.3969/j.issn.1673-5374.2012.26.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 07/24/2012] [Indexed: 01/09/2023] Open
Abstract
Studies have shown that retreatment of the distal stoma after nerve grafting can stimulate nerve regeneration. The present study attempted to verify the effects of reanastomosis of the distal stoma, after nerve grafting, on nerve regeneration by assessing brain-derived neurotrophic factor expression in 2-month-old rats. Results showed that brain-derived neurotrophic factor expression in L2-4 dorsal root ganglia began to increase 3 days after autologous nerve grafting post sciatic nerve injury, peaked at 14 days, decreased at 28 days, and reached similar levels to the sham-surgery group at 56 days. Brain-derived neurotrophic factor expression in L2-4 dorsal root ganglia began to increase 3 days after reanastomosis of the distal stoma, 59 days after autologous nerve grafting post sciatic nerve injury, significantly increased at 63 days, peaked at 70 days, and gradually decreased thereafter, but remained higher compared with the sham-surgery group up to 112 days. The results of this study indicate that reanastomosis of the distal stoma after orthotopic nerve grafting stimulated brain-derived neurotrophic factor expression in L2-4 dorsal root ganglia.
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Affiliation(s)
- Wei Yu
- Department of Hand Surgery, China Japan Union Hospital, Jilin University, Changchun 130033, Jilin Province, China
| | - Jian Wang
- Department of Orthopedics, First Affiliated Hospital, Wenzhou Medical College, Wenzhou 325000, Zhejiang Province, China
| | - Mingzhu Xu
- Department of Nephrology, China Japan Union Hospital, Jilin University, Changchun 130033, Jilin Province, China
| | - Hanjiao Qin
- Norman Bethune Medical College, Jilin University, Changchun 130021, Jilin Province, China
| | - Shusen Cui
- Department of Hand Surgery, China Japan Union Hospital, Jilin University, Changchun 130033, Jilin Province, China
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Tsai YJ, Su FC, Hsiao CK, Tu YK. Comparison of objective muscle strength in C5-C6 and C5-C7 brachial plexus injury patients after double nerve transfer. Microsurgery 2014; 35:107-14. [PMID: 24934721 DOI: 10.1002/micr.22283] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 11/07/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the quantitative muscle strength to distinguish the outcomes of different injury levels in upper arm type brachial plexus injury (BPI) patients with double nerve transfer. METHODS Nine patients with C5-C6 lesions (age = 32.2 ± 13.9 year old) and nine patients with C5-C7 lesions (age = 32.4 ± 7.9 year old) received neurotization of the spinal accessory nerve to the suprascapular nerve combined with the Oberlin procedure (fascicles of ulnar nerve transfer to the musculocutaneous nerve) were recruited. The average time interval between operation and evaluation were 27.3 ± 21.0 and 26.9 ± 20.6 months for C5-C6 and C5-C7, respectively. British Medical Research Council (BMRC) scores and the objective strength measured by a handheld dynamometer were evaluated in multiple muscles to compare outcomes between C5-C6 and C5-C7 injuries. RESULTS There were no significant differences in BMRC scores between the groups. C5-C6 BPI patients had greater quantitative strength in shoulder flexor (P = 0.02), shoulder extensor (P < 0.01), elbow flexor (P = 0.04), elbow extensor (P = 0.04), wrist extensor (P = 0.04), and hand grip (P = 0.04) than C5-C7 BPI patients. CONCLUSIONS Upper arm type BPI patients have a good motor recovery after double nerve transfer. The different outcomes between C5-C6 and C5-C7 BPI patients appeared in muscles responding to hand grip, wrist extension, and sagittal movements in shoulder and elbow joints.
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Affiliation(s)
- Yi-Jung Tsai
- Department of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan, Republic of China
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Hogendoorn S, Duijnisveld BJ, van Duinen SG, Stoel BC, van Dijk JG, Fibbe WE, Nelissen RGHH. Local injection of autologous bone marrow cells to regenerate muscle in patients with traumatic brachial plexus injury: a pilot study. Bone Joint Res 2014; 3:38-47. [PMID: 24565688 PMCID: PMC3942869 DOI: 10.1302/2046-3758.32.2000229] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objectives Traumatic brachial plexus injury causes severe functional impairment
of the arm. Elbow flexion is often affected. Nerve surgery or tendon
transfers provide the only means to obtain improved elbow flexion.
Unfortunately, the functionality of the arm often remains insufficient.
Stem cell therapy could potentially improve muscle strength and
avoid muscle-tendon transfer. This pilot study assesses the safety
and regenerative potential of autologous bone marrow-derived mononuclear
cell injection in partially denervated biceps. Methods Nine brachial plexus patients with insufficient elbow flexion
(i.e., partial denervation) received intramuscular escalating doses
of autologous bone marrow-derived mononuclear cells, combined with
tendon transfers. Effect parameters included biceps biopsies, motor
unit analysis on needle electromyography and computerised muscle tomography,
before and after cell therapy. Results No adverse effects in vital signs, bone marrow aspiration sites,
injection sites, or surgical wound were seen. After cell therapy
there was a 52% decrease in muscle fibrosis (p = 0.01), an 80% increase
in myofibre diameter (p = 0.007), a 50% increase in satellite cells
(p = 0.045) and an 83% increase in capillary-to-myofibre ratio (p
< 0.001) was shown. CT analysis demonstrated a 48% decrease in
mean muscle density (p = 0.009). Motor unit analysis showed a mean
increase of 36% in motor unit amplitude (p = 0.045), 22% increase
in duration (p = 0.005) and 29% increase in number of phases (p
= 0.002). Conclusions Mononuclear cell injection in partly denervated muscle of brachial
plexus patients is safe. The results suggest enhanced muscle reinnervation
and regeneration. Cite this article: Bone Joint Res 2014;3:38–47.
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Affiliation(s)
- S Hogendoorn
- Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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15
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Abstract
Congenital pseudoarthrosis of clavicle is a rare clinical entity. It usually presents as a swelling in the clavicular region at birth or soon after birth. Fitzwilliam's original description of 60 subtypes of congenital pseudoarthrosis of clavicle have addressed several anatomical variants, e.g. association with cervical rib and abnormally vertical and elevated upper ribs. However, congenital pseudoarthrosis of clavicle associated with bifurcation is an atypical anatomic variant. To the best of our knowledge, this variant has never been mentioned in the literature. In the present report, we have described this subtype of symptomatic congenital pseudoarthrosis of the clavicle with bifurcation and its possible management.
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Affiliation(s)
- Narender Kumar Magu
- Department of Orthopedics, Paraplegia, Physical Medicine and Rehabilitation, Rohtak, Haryana, India
| | - Rohit Singla
- Department of Orthopedics, Pt. BDS PGIMS, Rohtak, Haryana, India,Address for correspondence: Dr. Rohit Singla, Pt. BDS PGIMS, 319/19, Medicos Agencies, Opp. Civil Hospital, Rohtak - 124 001, Haryana, India. E-mail:
| | - Ashish Devgan
- Department of Orthopedics, Paraplegia, Physical Medicine and Rehabilitation, Rohtak, Haryana, India
| | - Paritosh Gogna
- Department of Orthopedics, Paraplegia, Physical Medicine and Rehabilitation, Rohtak, Haryana, India
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Injuries associated with serious brachial plexus involvement in polytrauma among patients requiring surgical repair. Injury 2014; 45:223-6. [PMID: 22658417 DOI: 10.1016/j.injury.2012.05.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 05/09/2012] [Accepted: 05/10/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Brachial plexus injury occurs in up to 5% of polytrauma cases involving motorcycle crashes and in approximately 4% of severe winter sports injuries. One of the conditions for the success of operative therapy is early detection, ideally within three months of injury. The aim of this study was to evaluate associated injuries in patients with severe brachial plexus injury and determine whether there is a characteristic concomitant injury (or injuries), the presence of which, in the polytrauma, could act as a marker for nerve structures involvement and whether there are differences in severity of polytrauma accompanying specific types of brachial plexus injury. METHODS We evaluated retrospectively 84 surgical patients from our department, from 2008 to 2011, that had undergone brachial plexus reconstruction. For all, an injury severity scale (ISS) score and all major associated injuries were determined. RESULTS 72% of patients had an upper, 26% had a complete and only 2% had a lower brachial plexus palsy. The main cause was motorcycle crashes (60%) followed by car crashes (15%). The average ISS was 35.2 (SD=23.3), although, values were significantly higher in cases involving a coma (59.3, SD=11.0). The lower and complete plexus injuries were significantly associated with coma and fractures of the shoulder girdle and injuries of lower limbs, thoracic organs and head. Upper plexus injuries were associated with somewhat less severe injuries of the upper and lower extremities and less severe injuries of the spine. CONCLUSION Serious brachial plexus injury is usually accompanied by other severe injuries. It occurs in high-energy trauma and it can be stated that patients involved in motorcycle and car crashes with multiple fractures of the shoulder girdle are at high risk of nerve trauma. This is especially true for patients in a primary coma. Lower and complete brachial plexus injuries are associated with higher injury severity scale.
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Prasad L, Sinha S, Kale SS, Nehra A, Mahapatra AK, Sharma BS. Traumatic brachial plexopathies – Analysis of postsurgical functional and psychosocial outcome. INDIAN JOURNAL OF NEUROTRAUMA 2013. [DOI: 10.1016/j.ijnt.2013.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Dimou S, Biggs M, Tonkin M, Hickie IB, Lagopoulos J. Motor cortex neuroplasticity following brachial plexus transfer. Front Hum Neurosci 2013; 7:500. [PMID: 23966938 PMCID: PMC3746454 DOI: 10.3389/fnhum.2013.00500] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 08/06/2013] [Indexed: 12/03/2022] Open
Abstract
In the past decade, research has demonstrated that cortical plasticity, once thought only to exist in the early stages of life, does indeed continue on into adulthood. Brain plasticity is now acknowledged as a core principle of brain function and describes the ability of the central nervous system to adapt and modify its structural organization and function as an adaptive response to functional demand. In this clinical case study we describe how we used neuroimaging techniques to observe the functional topographical expansion of a patch of cortex along the sensorimotor cortex of a 27-year-old woman following brachial plexus transfer surgery to re-innervate her left arm. We found bilateral activations present in the thalamus, caudate, insula as well as across the sensorimotor cortex during an elbow flex motor task. In contrast we found less activity in the sensorimotor cortex for a finger tap motor task in addition to activations lateralized to the left inferior frontal gyrus and thalamus and bilaterally for the insula. From a pain perspective the patient who had experienced extensive phantom limb pain (PLP) before surgery found these sensations were markedly reduced following transfer of the right brachial plexus to the intact left arm. Within the context of this clinical case the results suggest that functional improvements in limb mobility are associated with increased activation in the sensorimotor cortex as well as reduced PLP.
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Affiliation(s)
- Stefan Dimou
- Sydney Medical School, The University of Sydney , Sydney, NSW , Australia
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19
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Crouch DL, Plate JF, Li Z, Saul KR. Biomechanical contributions of posterior deltoid and teres minor in the context of axillary nerve injury: a computational study. J Hand Surg Am 2013; 38:241-9. [PMID: 23294649 PMCID: PMC3607282 DOI: 10.1016/j.jhsa.2012.11.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 11/02/2012] [Accepted: 11/25/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether transfer to only the anterior branch of the axillary nerve will restore useful function after axillary nerve injury with persistent posterior deltoid and teres minor paralysis. METHODS We used a computational musculoskeletal model of the upper limb to determine the relative contributions of posterior deltoid and teres minor to maximum joint moment generated during a simulated static strength assessment and to joint moments during 3 submaximal shoulder movements. Movement simulations were performed with and without simulated posterior deltoid and teres minor paralysis to identify muscles that may compensate for their paralysis. RESULTS In the unimpaired limb model, teres minor and posterior deltoid accounted for 16% and 14% of the total isometric shoulder extension and external rotation joint moments, respectively. During the 3 movement simulations, posterior deltoid produced as much as 20% of the mean shoulder extension moment, whereas teres minor accounted for less than 5% of the mean joint moment in all directions of movement. When we paralyzed posterior deltoid and teres minor, the mean extension moments generated by the supraspinatus, long head of triceps, latissimus dorsi, and middle deltoid increased to compensate. Compensatory muscles were not fully activated during movement simulations when posterior deltoid and teres minor were paralyzed. CONCLUSIONS Reconstruction of the anterior branch of the axillary nerve only is an appropriate technique for restoring shoulder abduction strength after isolated axillary nerve injury. When shoulder extension strength is compromised by extensive neuromuscular shoulder injury, reconstruction of both the anterior and posterior branches of the axillary nerve should be considered. CLINICAL RELEVANCE By quantifying the biomechanical role of muscles during submaximal movement, in addition to quantifying muscle contributions to maximal shoulder strength, we can inform preoperative planning and permit more accurate predictions of functional outcomes.
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Affiliation(s)
- Dustin L. Crouch
- Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Winston-Salem, NC, 27157,Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, NC, 27157
| | - Johannes F. Plate
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157,Neuroscience Program, Wake Forest School of Medicine, Winston-Salem, NC, 27157
| | - Zhongyu Li
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, 27157
| | - Katherine R. Saul
- Virginia Tech-Wake Forest School of Biomedical Engineering and Sciences, Winston-Salem, NC, 27157,Department of Biomedical Engineering, Wake Forest School of Medicine, Winston-Salem, NC, 27157
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20
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Kaiser R, Haninec P. The influence of seatbelts on the types of operated brachial plexus lesions caused by car accidents. J Hand Surg Am 2012; 37:1657-9. [PMID: 22763056 DOI: 10.1016/j.jhsa.2012.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Revised: 05/03/2012] [Accepted: 05/03/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine whether there is a relationship between seatbelt use and type of brachial plexus injury seen in automobile accidents. Knowledge of such a relationship may help guide the surgical management of these patients. METHODS We retrospectively evaluated 43 surgical patients with brachial plexus palsy caused by car accidents. We recorded sex, age, and type of injury for each case. We also obtained data regarding the patients' position in the car at the time of the accident and whether they were wearing a seatbelt. RESULTS We obtained data on 39 men and 4 women. Of the seatbelted patients, 24 (100%) had upper plexus palsy on the side where the seatbelt crossed the shoulder. Of those who were not wearing seatbelts, 17 (86%) had complete plexus injuries. We also found 1 upper and 1 lower plexus injury in the unbelted group. CONCLUSIONS We found a relationship between the type of brachial plexus injury sustained by the accident victim and the use and position of the seatbelt. Complete plexus injuries were more common in those who were not wearing seatbelts. We saw upper plexus injuries for those wearing seatbelts. Information about seatbelt use may be useful in clinical practice. When treating an unbelted car accident victim with a brachial plexus injury, it is reasonable to anticipate a more serious form of the injury. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Radek Kaiser
- Department of Neurosurgery, 3rd Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
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21
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Kaiser R, Waldauf P, Haninec P. Types and severity of operated supraclavicular brachial plexus injuries caused by traffic accidents. Acta Neurochir (Wien) 2012; 154:1293-7. [PMID: 22302237 DOI: 10.1007/s00701-012-1291-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 01/20/2012] [Indexed: 10/14/2022]
Abstract
BACKGROUND Brachial plexus injuries occur in up to 5% of polytrauma cases involving motorcycle accidents and in approximately 4% of severe winter sports injuries. One of the criteria for a successful operative therapy is the type of lesion. Upper plexus palsy has the best prognosis, whereas lower plexus palsy is surgically untreatable. The aim of this study was to evaluate a group of patients with brachial plexus injury caused by traffic accidents, categorize the injuries according to type of accident, and look for correlations between type of palsy (injury) and specific accidents. METHODS A total of 441 brachial plexus reconstruction patients from our department were evaluated retrospectively(1993 to 2011). Sex, age, neurological status, and the type and cause of injury were recorded for each case. Patients with BPI caused by a traffic accident were assessed in detail. RESULTS Traffic accidents were the cause of brachial plexus injury in most cases (80.7%). The most common type of injury was avulsion of upper root(s) (45.7%) followed by rupture (28.2%), complete avulsion (16.9%) and avulsion of lower root(s) (9.2%). Of the patients, 73.9% had an upper,22.7% had a complete and only 3.4% had a lower brachial plexus palsy. The main cause was motorcycle accidents(63.2%) followed by car accidents (23.5%), bicycle accidents(10.7%) and pedestrian collisions (3.1%) (p<0.001).Patients involved in car accidents had a higher percentage of lower avulsion (22.7%) and a lower percentage of upper avulsion (29.3%), whereas cyclists had a higher percentage of upper avulsion (68.6%) based on the data from the entire group of patients (p<0.001). Lower plexus palsy was significantly increased in patients after car accidents (9.3%,p<0.05). In the two main groups (car and motorcycle accidents),significantly more upper and fewer lower palsies were present. In the bicycle accident group, upper palsy was the most common (89%). CONCLUSION Study results indicate that the most common injury was an upper plexus palsy. It was characteristic of bicycle accidents, and significantly more common in car and motorcycle accidents. The results also indicate that it is important to consider the potential of a brachial plexus injury after serious traffic accidents and to examine both upper extremities in detail even if some motor function is preserved.
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Crouch DL, Li Z, Barnwell JC, Plate JF, Daly M, Saul KR. Computer simulation of nerve transfer strategies for restoring shoulder function after adult C5 and C6 root avulsion injuries. J Hand Surg Am 2011; 36:1644-51. [PMID: 21903345 PMCID: PMC3197221 DOI: 10.1016/j.jhsa.2011.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Revised: 07/21/2011] [Accepted: 07/22/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE Functional ability after nerve transfer for upper brachial plexus injuries relies on both the function and magnitude of force recovery of targeted muscles. Following nerve transfers targeting either the axillary nerve, suprascapular nerve, or both, it is unclear whether functional ability is restored in the face of limited muscle force recovery. METHODS We used a computer model to simulate flexing the elbow while maintaining a functional shoulder posture for 3 nerve transfer scenarios. We assessed the minimum restored force capacity necessary to perform the task, the associated compensations by neighboring muscles, and the effect of altered muscle coordination on movement effort. RESULTS The minimum force restored by the axillary, suprascapular, and combined nerve transfers that was required for the model to simulate the desired movement was 25%, 40%, and 15% of the unimpaired muscle force capacity, respectively. When the deltoid was paralyzed, the infraspinatus and subscapularis muscles generated higher shoulder abduction moments to compensate for deltoid weakness. For all scenarios, movement effort increased as restored force capacity decreased. CONCLUSIONS Combined axillary and suprascapular nerve transfer required the least restored force capacity to perform the desired elbow flexion task, whereas single suprascapular nerve transfer required the most restored force capacity to perform the same task. Although compensation mechanisms allowed all scenarios to perform the desired movement despite weakened shoulder muscles, compensation increased movement effort. Dynamic simulations allowed independent evaluation of the effect of restored force capacity on functional outcome in a way that is not possible experimentally. CLINICAL RELEVANCE Simultaneous nerve transfer to suprascapular and axillary nerves yields the best simulated biomechanical outcome for lower magnitudes of muscle force recovery in this computer model. Axillary nerve transfer performs nearly as well as the combined transfer, whereas suprascapular nerve transfer is more sensitive to the magnitude of reinnervation and is therefore avoided.
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Affiliation(s)
- Dustin L Crouch
- Biomedical Engineering, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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24
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Garg R, Merrell GA, Hillstrom HJ, Wolfe SW. Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy: a systematic review and analysis. J Bone Joint Surg Am 2011; 93:819-29. [PMID: 21543672 DOI: 10.2106/jbjs.i.01602] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In treating patients with brachial plexus injury, there are no comparative data on the outcomes of nerve grafts or nerve transfers for isolated upper trunk or C5-C6-C7 root injuries. The purpose of our study was to compare, with systematic review, the outcomes for modern intraplexal nerve transfers for shoulder and elbow function with autogenous nerve grafting for upper brachial plexus traumatic injuries. METHODS PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies in which patients had surgery for traumatic upper brachial plexus palsy within one year of injury and with a minimum follow-up of twelve months. Strength and shoulder and elbow motion were assessed as outcome measures. The Fisher exact test and Mann-Whitney U test were used to compare outcomes, with an alpha level of 0.05. RESULTS Thirty-one studies met the inclusion criteria. Two hundred and forty-seven (83%) and 286 (96%) of 299 patients with nerve transfers achieved elbow flexion strength of grade M4 or greater and M3 or greater, respectively, compared with thirty-two (56%) and forty-seven (82%) of fifty-seven patients with nerve grafts (p < 0.05). Forty (74%) of fifty-four patients with dual nerve transfers for shoulder function had shoulder abduction strength of grade M4 or greater compared with twenty (35%) of fifty-seven patients with nerve transfer to a single nerve and thirteen (46%) of twenty-eight patients with nerve grafts (p < 0.05). The average shoulder abduction and external rotation was 122° (range, 45° to 170°) and 108° (range, 60° to 140°) after dual nerve transfers and 50° (range, 0° to 100°) and 45° (range, 0° to 140°) in patients with nerve transfers to a single nerve. CONCLUSIONS In patients with demonstrated complete traumatic upper brachial plexus injuries of C5-C6, the pooled international data strongly favors dual nerve transfer over traditional nerve grafting for restoration of improved shoulder and elbow function. These data may be helpful to surgeons considering intraoperative options, particularly in cases in which the native nerve root or trunk may appear less than optimal, or when long nerve grafts are contemplated.
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Affiliation(s)
- Rohit Garg
- Hospital for Special Surgery, 523 East 72nd Street, New York, NY 10021, USA.
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Abstract
INTRODUCTION Brachial plexus injury leading to flail upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgeries may preclude reinnervation of the paralysed muscles. Currently for such injuries nerve transfers are the preferred procedures. We here present a series of 93 cases of global brachial plexus palsy treated with nerve transfers. MATERIALS AND METHODS Ninety-three cases of global palsies out of 384 cases of brachial plexus injury operated by the senior surgeon (AB) were selected. Age varied from 4 to 51 years with 63 patients in 20 to 40 age group and all patients having a minimum follow up of at least 1 year post surgery ranging up to 130 months. The delay before surgery ranged from 15 days to 16 months (mean 3.2 months). The aim of the surgery was to restore the elbow flexion, shoulder abduction, triceps function and wrist and finger flexion in that order of priority. The major nerve transfers used were spinal accessory to suprascapular nerve, intercostal to musculocutaneous nerve and pectoral nerves, contralateral C7 to median and radial nerves. Nerve stumps were used whenever available (30 patients). RESULTS Recovery of ≥ grade 3 power was noted in biceps in 73% (68/93) of patients, shoulder abduction in 89% (43/49), pectoralis major in 100% (8/8). Recovery of grade 2 triceps power was seen in 80% (12/16) patients with nerve transfer to radial nerve. Derotation osteotomies of humerus (n=13) and wrist fusion (n=14) were the most common secondary procedures performed to facilitate alignment and movements of the affected limb. Better results were noted in 59 cases where direct nerve transfers were done (without nerve graft). CONCLUSION Acceptable function (restoration of biceps power ≥3) can be obtained in more than two thirds (73%) of these global brachial plexus injuries by using the principles of early exploration and nerve transfer with rehabilitation.
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Affiliation(s)
- Anil Bhatia
- Joshi Hospital and Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra
| | - Ashok K Shyam
- Indian Orthopedic Research Group, Thane, Maharashtra, India,Address for correspondence: Dr. A K Shyam, Indian Orthopaedic Research Group, Mumbai Maharastra India. E-mail:
| | - Piyush Doshi
- Indian Orthopedic Research Group, Baroda, Gujarat, India
| | - Vitrag Shah
- Indian Orthopedic Research Group, Surat, Gujarat, India
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Lad SP, Nathan JK, Schubert RD, Boakye M. Trends in median, ulnar, radial, and brachioplexus nerve injuries in the United States. Neurosurgery 2010; 66:953-60. [PMID: 20414978 DOI: 10.1227/01.neu.0000368545.83463.91] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
UNLABELLED significant constraints on an individual's quality of life. OBJECTIVE To promote efforts to reduce exposure to injury risk factors and to utilize effective therapies when damage does occur, it is important to understand historical trends in both the demographics of peripheral nerve injury (PNI) patients and their treatment. We sought to examine some of these trends. METHODS We searched the Nationwide Inpatient Sample for discharges classified with International Classification of Diseases, Ninth Revision diagnosis codes of median, ulnar, radial, or brachioplexus nerve injury between 1993 and 2006. We analyzed these data to obtain trend information for the number of discharges, hospital charges, treatment course, patient demographics, and other measures. RESULTS Although aggregate discharges involving these injuries decreased slightly between 1993 and 2006, mean nominal hospital charges for their treatment increased significantly, in particular, for brachial plexus injuries. In 2006 30 to 40% of median, ulnar, and radial nerve injuries required acute repair by direct nerve suture. PNI patients in 2006 were more likely to be male, between the ages of 18 and 44 years, and from regions where the median income level is greater than $36 000. Approximately 75% of PNIs were treated in academic hospitals and 95% in metropolitan areas. CONCLUSION PNIs are complex injuries that primarily affect males in key years of adulthood, frequently requiring high-cost acute surgical repair. Although there has been a slight decline in their incidence in the past decade, treatment cost has increased.
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Affiliation(s)
- Shivanand P Lad
- Outcomes Research Lab, VA/Palo Alto Health Care System, and Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94304, USA
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Urgent endovascular stent-graft placement for traumatic penetrating subclavian artery injuries. J Neurol Sci 2008; 272:151-7. [PMID: 18649895 DOI: 10.1016/j.jns.2008.05.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 05/16/2008] [Accepted: 05/21/2008] [Indexed: 11/20/2022]
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