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Warwick CE, Hems T. Traumatic brachial plexus injuries: a national review of epidemiology in the Scottish population over a 10-year period. J Hand Surg Eur Vol 2024; 49:905-911. [PMID: 37882677 DOI: 10.1177/17531934231209661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
LEVEL OF EVIDENCE III.
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Affiliation(s)
- Catherine E Warwick
- Department of Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Tim Hems
- Department of Orthopaedic Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Scottish National Brachial Plexus Injury Service, Glasgow, UK
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2
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Pena Larrea L, López-Anglada Fernández E, Pena Vázquez J, Pérez Morala AB, Braña Vigil AF. [Translated article] Electromyographic axillary nerve injury in fractures of the proximal humerus: Prospective, observational study, analysing the fracture pattern. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T91-T96. [PMID: 38000540 DOI: 10.1016/j.recot.2023.11.020] [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: 09/12/2022] [Accepted: 03/04/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE Description and analysis of the relation between the proximal humerus fracture patterns and the traumatic injury of the axillary nerve. MATERIAL AND METHOD Prospective, observational study of a consecutive case series that analysed proximal humerus fractures. Radiographic evaluation was performed, and AO (Arbeitsgemeinshaft für Osteosynsthesefragen) system was used to classify the fractures. Electromyography was used to diagnose the axillary nerve injury. RESULTS Thirty-one patients on 105 who had a proximal humerus fracture met inclusion criteria. Eighty-six percent of the patients included were women and 14% men. The mean age was 71.8 years (30-96 years). Of the patients included in the study, 58% had normal or mild axonotmesis EMG, 23% had axillary nerve neuropathy without muscle denervation and 19% had injury with axillary nerve denervation. Patients who suffered complex fractures of the proximal humerus (AO11B and AO11C) had a higher risk of presenting axillary neuropathy type lesions with muscle denervation in the EMG, this relationship being statistically significant (p<0.001). CONCLUSION Patients who have more risk on presenting axillary nerve neuropathy with muscle denervation in electromyography are those who present complex proximal humerus fractures AO11B and AO11C (p<0.001).
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Affiliation(s)
- L Pena Larrea
- Departamento de Traumatología y Cirugía Ortopédica del Hospital Universitario San Agustín, Avilés, Spain.
| | - E López-Anglada Fernández
- Departamento de Traumatología y Cirugía Ortopédica del Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J Pena Vázquez
- Departamento de Traumatología y Cirugía Ortopédica del Hospital Universitario Central de Asturias, Oviedo, Spain
| | - A B Pérez Morala
- Departamento de Neurofisiología del Hospital Universitario Central de Asturias, Oviedo, Spain
| | - A F Braña Vigil
- Departamento de Traumatología y Cirugía Ortopédica del Hospital Universitario Central de Asturias, Oviedo, Spain
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3
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Pena Larrea L, López-Anglada Fernández E, Pena Vázquez J, Pérez Morala AB, Braña Vigil AF. Electromyographic axillary nerve injury in fractures of the proximal humerus: Prospective, observational study, analysing the fracture pattern. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:91-96. [PMID: 36898431 DOI: 10.1016/j.recot.2023.03.003] [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: 09/12/2022] [Revised: 02/17/2023] [Accepted: 03/04/2023] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE Description and analysis of the relation between the proximal humerus fracture patterns and the traumatic injury of the axillary nerve. MATERIAL AND METHOD Prospective, observational study of a consecutive case series that analyzed proximal humerus fractures. Radiographic evaluation was performed, and AO (Arbeitsgemeinshaft für Osteosynsthesefragen) system was used to classify the fractures. Electromyography was used to diagnose the axillary nerve injury. RESULTS Thirty-one patients on 105 who had a proximal humerus fracture met inclusion criteria. Eighty-six percent of the patients included were women and 14% men. The mean age was 71.8 years (30-96 years). Of the patients included in the study, 58% had normal or mild axonotmesis EMG, 23% had axillary nerve neuropathy without muscle denervation and 19% had injury with axillary nerve denervation. Patients who suffered complex fractures of the proximal humerus (AO11B and AO11C) had a higher risk of presenting axillary neuropathy type lesions with muscle denervation in the EMG, this relationship being statistically significant (p<0.001). CONCLUSION Patients who have more risk on presenting axillary nerve neuropathy with muscle denervation in electromyography are those who present complex proximal humerus fractures AO11B and AO11C (p<0.001).
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Affiliation(s)
- L Pena Larrea
- Departamento de Traumatología y Cirugía Ortopédica del Hospital Universitario San Agustín, Avilés, España.
| | - E López-Anglada Fernández
- Departamento de Traumatología y Cirugía Ortopédica del Hospital Universitario Central de Asturias, Oviedo, España
| | - J Pena Vázquez
- Departamento de Traumatología y Cirugía Ortopédica del Hospital Universitario Central de Asturias, Oviedo, España
| | - A B Pérez Morala
- Departamento de Neurofisiología del Hospital Universitario Central de Asturias, Oviedo, España
| | - A F Braña Vigil
- Departamento de Traumatología y Cirugía Ortopédica del Hospital Universitario Central de Asturias, Oviedo, España
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4
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Hems T. Re: Shah HR, Cavalli E, Bertelli JA. Triceps paralysis with intact distal radial nerve function in partial brachial plexus injury: a unique presentation. J Hand Surg Eur. 2023, 48: 277-9. J Hand Surg Eur Vol 2024; 49:112-113. [PMID: 37882703 DOI: 10.1177/17531934231200182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
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5
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Beecher G, Dyck PJB, Zochodne DW. Axillary and musculocutaneous neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:135-148. [PMID: 38697736 DOI: 10.1016/b978-0-323-90108-6.00004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
This chapter covers axillary and musculocutaneous neuropathies, with a focus on clinically relevant anatomy, electrodiagnostic approaches, etiologic considerations, and management principles. Disorders of the lateral antebrachial cutaneous nerve, a derivative of the musculocutaneous nerve, are also reviewed. We emphasize the importance of objective findings, including the physical examination and electrodiagnostic evaluation in confirming the isolated involvement of each nerve which, along with the clinical history, informs etiologic considerations. Axillary and musculocutaneous neuropathies are both rare in isolation and most frequently occur in the setting of trauma. Less commonly encountered etiologies include external compression or entrapment, neoplastic involvement, or immune-mediated disorders including neuralgic amyotrophy, postsurgical inflammatory neuropathy, multifocal motor neuropathy, vasculitic neuropathy, and multifocal chronic inflammatory demyelinating polyradiculoneuropathy.
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Affiliation(s)
- Grayson Beecher
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, MN, United States; Neuroscience and Mental Health Institute and Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - P James B Dyck
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, MN, United States; Peripheral Neuropathy Research Laboratory, Mayo Clinic, Rochester, MN, United States
| | - Douglas W Zochodne
- Neuroscience and Mental Health Institute and Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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6
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Faur CI, Nitu R, Abu-Awwad SA, Tudoran C, Abu-Awwad A. The Arterial Axis Lesions in Proximal Humeral Fractures-Case Report and Literature Review. J Pers Med 2023; 13:1712. [PMID: 38138939 PMCID: PMC10744402 DOI: 10.3390/jpm13121712] [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: 11/25/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND This comprehensive review delves into the nuanced domain of arterial axis lesions associated with proximal humeral fractures, elucidating the intricate interplay between fracture patterns and vascular compromise. Proximal humeral fractures, a common orthopedic occurrence, often present challenges beyond the skeletal realm, necessitating a profound understanding of the vascular implications. METHODS The study synthesizes the existing literature, presenting a collective analysis of documented cases and their respective clinical outcomes. The spectrum of arterial axis lesions, from subtle vascular compromise to overt ischemic events, is systematically examined, highlighting the varied clinical manifestations encountered in proximal humeral fractures. Diagnostic modalities, including advanced imaging techniques such as angiography and Doppler ultrasound, are scrutinized for their efficacy in identifying arterial axis lesions promptly. The review emphasizes the critical role of early and accurate diagnosis in mitigating the potential sequelae associated with vascular compromise, thereby underscoring the importance of a vigilant clinical approach. RESULTS Therapeutic strategies, ranging from conservative management to surgical interventions, are critically evaluated in the context of existing evidence. The evolving landscape of endovascular interventions and their applicability in addressing arterial axis lesions specific to proximal humeral fractures is explored, providing valuable insights for clinicians navigating the therapeutic decision-making process. Furthermore, the review addresses gaps in current knowledge and proposes avenues for future research, emphasizing the need for tailored, evidence-based guidelines in the management of arterial axis lesions in proximal humeral fractures. By consolidating current understanding and pointing towards areas warranting further exploration, this review contributes to the ongoing discourse surrounding the intricacies of vascular complications in orthopedic trauma. CONCLUSIONS this comprehensive review provides a synthesized overview of arterial axis lesions in proximal humeral fractures, offering a valuable resource for clinicians, researchers, and educators alike. The findings underscore the multifaceted nature of these lesions and advocate for a holistic, patient-centered approach to their management.
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Affiliation(s)
- Cosmin Ioan Faur
- Department XV—Discipline of Orthopedics—Traumatology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (C.I.F.); (A.A.-A.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Research Center University Professor Doctor Teodor Șora, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Razvan Nitu
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Department XII—Discipline of Obstetrics and Gynecology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Simona-Alina Abu-Awwad
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Department XII—Discipline of Obstetrics and Gynecology, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
| | - Cristina Tudoran
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Department VII, Internal Medicine II, Discipline of Cardiology, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- Center of Molecular Research in Nephrology and Vascular Disease, Faculty of the University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
| | - Ahmed Abu-Awwad
- Department XV—Discipline of Orthopedics—Traumatology, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania; (C.I.F.); (A.A.-A.)
- “Pius Brinzeu” Emergency Clinical County Hospital, Bld Liviu Rebreanu, No. 156, 300723 Timisoara, Romania; (S.-A.A.-A.); (C.T.)
- Research Center University Professor Doctor Teodor Șora, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Square, No. 2, 300041 Timisoara, Romania
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7
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Kokkalis Z, Giannatos V, Papagiannis S, Kouzelis A, Panagopoulos A. Terrible Triad of the Shoulder: A Case Series and Literature Review. Cureus 2023; 15:e47699. [PMID: 38022223 PMCID: PMC10674095 DOI: 10.7759/cureus.47699] [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] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
INTRODUCTION The shoulder terrible triad is an underdiagnosed injury pattern consisting of anterior shoulder dislocation, rotator cuff tear, and nerve injury from the brachial plexus in its original description. The purpose of this study is to raise awareness of the condition, suggest treatment strategies, and emphasize the difficulties in treating this condition. METHODS This case series of seven patients from the same institution. All patients underwent x-rays before and after the reduction of the dislocation, MRI to assess the musculoskeletal injuries, and EMG and clinical examination to assess the nerve lesions. Early arthroscopic repair was opted for the rotator cuff tears. A conservative approach was chosen for the nerve lesions. Active forward flexion and external rotation, Constant score, and Visual to Analogue Scale (VAS) were recorded pre- and post-operatively. RESULTS All the patients showed an improvement in function postoperatively. However, four of the seven patients did not recover fully. The mean Constant and VAS scores were improved from 15.2 +/- 2.8 (12 to 19) to 67 +/- 16.6 (44 to 86) and from 7.5 +/- 1 (6 to 9) to 2.3 +/- 0.8 (1 to 3), respectively. The patients were followed up for a mean time of 28.2 +/- 10.1 months (18 to 43 months). Time-to-surgery shorter than four weeks showed better results, but not statistically significant. CONCLUSIONS The diagnosis of the shoulder terrible triad requires a high level of suspicion. Early arthroscopic repair for the rotator cuff tears and waiting for the nerve recovery is suggested. Delayed time from injury to surgery might be related to worse outcomes, but higher-level research is needed in this direction.
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Affiliation(s)
- Zinon Kokkalis
- Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
| | - Vasileios Giannatos
- Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
| | - Spyridon Papagiannis
- Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
| | - Antonis Kouzelis
- Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
| | - Andreas Panagopoulos
- Orthopedics and Traumatology, University General Hospital of Patras, Patras, GRC
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8
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Hardie CM, Jordan R, Forker O, Fort-Schaale A, Wade RG, Jones J, Bourke G. Prevalence and risk factors for nerve injury following shoulder dislocation. Musculoskelet Surg 2023; 107:345-350. [PMID: 36445531 PMCID: PMC10432320 DOI: 10.1007/s12306-022-00769-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 11/04/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The glenohumeral joint dislocation can be associated with major nerve injury. The reported prevalence and risk factors for major nerve injury are variable and this injury can have a severe and life-long impact on the patient. The objectives of this study were to analyse the prevalence of major nerve injury following shoulder dislocation and examine risk factors. Management and outcomes of nerve injury were explored. METHODS A 1 year retrospective cohort study of 243 consecutive adults who presented with a shoulder dislocation was performed. Data were collected on patient demographics, timings of investigations, treatment, follow-up, and nerve injury prevalence and management. The primary outcome measure was prevalence of nerve injury. Risk factors for this were analysed using appropriate tests with Stata SE15.1. RESULTS Of 243 patients with shoulder dislocation, 14 (6%) had neurological deficit. Primary dislocation (p = 0.004) and older age (p = 0.02) were significantly associated with major nerve injury. Sex, time to successful reduction and force of injury were not associated with major nerve injury in this cohort. Patients with nerve injury made functional recovery to varying degrees. Recurrent shoulder dislocation was common accounting for 133/243 (55%) attendances. CONCLUSIONS Shoulder dislocation requires careful assessment and timely management in the ED. A 6% rate of nerve injury following shoulder dislocation was at the lower border of reported rates (5-55%), and primary dislocation and older age were identified as risk factors for nerve injury. We emphasise the importance of referring patients with suspected major nerve injury to specialist services.
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Affiliation(s)
- C M Hardie
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK.
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Clarendon Wing, Leeds General Infimrary, Great George Street, Leeds, LS1 3EX, UK.
| | - R Jordan
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
| | - O Forker
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
| | - A Fort-Schaale
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Clarendon Wing, Leeds General Infimrary, Great George Street, Leeds, LS1 3EX, UK
| | - R G Wade
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Clarendon Wing, Leeds General Infimrary, Great George Street, Leeds, LS1 3EX, UK
| | - J Jones
- Department of Emergency Medicine, Leeds Teaching Hospitals Trust, Leeds, UK
| | - G Bourke
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Clarendon Wing, Leeds General Infimrary, Great George Street, Leeds, LS1 3EX, UK
- Department of Integrative Medical Biology, University of Umea, Umeå, Sweden
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9
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Apostolakos JM, Brusalis CM, Uppstrom T, R Thacher R, Kew M, Taylor SA. Management of Common Football-Related Injuries About the Shoulder. HSS J 2023; 19:339-350. [PMID: 37435133 PMCID: PMC10331269 DOI: 10.1177/15563316231172107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 07/13/2023]
Affiliation(s)
- John M Apostolakos
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | | | - Tyler Uppstrom
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Ryan R Thacher
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Michelle Kew
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
| | - Samuel A Taylor
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY, USA
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10
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Patterns of Nerve Injury and Recovery Rates of Infraclavicular Brachial Plexus Lesions Following Anterior Shoulder Dislocation. J Hand Surg Am 2022; 47:1227.e1-1227.e7. [PMID: 34774345 DOI: 10.1016/j.jhsa.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 07/04/2021] [Accepted: 09/01/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE We reviewed our cases of infraclavicular brachial plexus injuries associated with anterior shoulder dislocation to determine patterns of injury, recovery rates, and factors associated with a poor motor outcome. METHODS This was a retrospective review of patients who had sustained a concomitant nerve injury following dislocation of the glenohumeral joint treated with closed manipulation. The data collected included patient demographics, injury factors, and patterns of neurological deficits. The Medical Research Council (MRC) grade for motor power was the primary outcome measure, where a grade of 4 or 5 was regarded as achieving good motor recovery. Univariate and multivariable analyses were used to identify factors associated with persistent motor weakness (MRC grades 0-3) at the final follow-up. RESULTS Between 2015 and 2019, 61 patients were assessed. There were 36 males and 25 females, with a median age of 64 years (interquartile range [IQR], 53-73 years). Four patterns of injury were identified: (1) isolated axillary nerve lesions; (2) single cord lesions; (3) combined lesions involving the medial and posterior cords; and (4) diffuse lesions affecting all 3 cords. Of 28 patients with isolated axillary nerve injuries, 22 recovered. All lateral cord injuries (11/11) and 20 of 24 posterior cord injuries recovered spontaneously. Recovery of hand intrinsic function from medial cord injuries had the worst outcome, with 14 of 27 patients not recovering beyond MRC grades 0 to 3. The median duration of dislocation before reduction was 6 hours (IQR, 3-12 hours). A multivariate analysis showed an association between the duration of shoulder dislocation and the likelihood of persistent motor weakness. CONCLUSIONS Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently. Persistent motor weakness may be associated with a prolonged duration of dislocation prior to glenohumeral relocation. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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11
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Martínez Núñez P, Pérez González M, Juárez Cordero Á. Isolated axillary nerve palsy after liposuction, an exceptional complication. NEUROCIRUGIA (ENGLISH EDITION) 2022; 33:258-260. [PMID: 35241408 DOI: 10.1016/j.neucie.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 06/14/2023]
Abstract
Isolated injury to the axillary nerve associated with the patient's surgical position is a very rare complication, and in most cases it is associated with the prone during spinal surgery. The presentation of this pathology in relation to surgeries of another nature is exceptional, with only a few cases in the scientific literature. We present the case of a patient who developed symptoms of isolated left axillary nerve palsy after undergoing lipoabdominoplasty and breast reduction, in which the prone and supine positions were alternated. The use of an infiltration solution with lidocaine and epinephrine could have contributed to the appearance of the lesion in this unique case. Finally, the clinical picture was fully resolved thanks to conservative treatment.
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Affiliation(s)
- Pablo Martínez Núñez
- Servicio de Cirugía Plástica, Estética y Reparadora, Hospital Universitario La Zarzuela, Madrid, Comunidad de Madrid, Spain.
| | - Mónica Pérez González
- Servicio de Radiodiagnóstico, Hospital Universitario Infanta Cristina, Parla, Comunidad de Madrid, Spain
| | - Ángel Juárez Cordero
- Servicio de Cirugía Plástica, Estética y Reparadora, Hospital Universitario La Zarzuela, Madrid, Comunidad de Madrid, Spain
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12
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Wiman K, Hulkkonen S, Miettunen J, Auvinen J, Karppinen J, Ryhänen J. Total, gender- and age-specific incidence rates of upper extremity nerve injuries in Finland. J Hand Surg Eur Vol 2022; 47:639-643. [PMID: 35172640 DOI: 10.1177/17531934221079230] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The aim of this study was to describe the epidemiology of nerve injuries of the upper extremity in the whole population of Finland (1998-2016). Data based on diagnosis codes were obtained from the Care Register for Health Care, including cases of median, radial, ulnar, musculocutaneous, axillary and digital nerves. Age- and gender-specific incidence rates, both crude and standardized (for the European normal population in 2011), were calculated. Our study included 13,440 patients with upper extremity nerve injury. The mean standardized annual incidence rate of any upper extremity nerve injury was 18.18 among men and 8.15 among women per 100,000 person-years over the study period. The incidence peaked among men at working age. Nerve injuries occurred most commonly in the fingers and thumb, with 5532 cases and mean standardized incidence rates per 100,000 person-years of 7.84 among men and 2.95 among women. The annual incidence did not change significantly over the study period.Level of evidence: III.
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Affiliation(s)
- Kirsi Wiman
- Department of Surgery, Lapland Central Hospital, Rovaniemi, Finland.,Department of Hand Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sina Hulkkonen
- Department of Hand Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jouko Miettunen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Juha Auvinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Finnish Institute of Occupational Health, Oulu, Finland
| | - Jorma Ryhänen
- Department of Hand Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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13
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Jordan R, Wade RG, McCauley G, Oxley S, Bains R, Bourke G. Functional deficits as a result of brachial plexus injury in anterior shoulder dislocation. J Hand Surg Eur Vol 2021; 46:725-730. [PMID: 33611983 DOI: 10.1177/1753193421993088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The incidence of brachial plexus injuries in anterior shoulder dislocation remains relatively uncommon. A retrospective study was conducted to observe the natural neurological recovery of patients following these injuries over a 2-year period. Muscle power according to the Medical Research Council scale and sensation were measured from presentation to discharge. In 28 patients, the power grade of proximal muscles supplied by nine injured nerves failed to improve over a median follow-up of 5 months. There was no statistically significant improvement in sensation over a median follow-up of 6 months. Poorer recovery in muscle power score was related to advancing age, whereby every decade increased the risk by approximately 30%. Anterior shoulder dislocation with a plexus injury carries a risk of permanent nerve injury. Patients should be referred for specialist nerve assessment leading to rehabilitation and timely early nerve reconstruction, if indicated.Level of evidence: IV.
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Affiliation(s)
- Rupert Jordan
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK
| | - Ryckie G Wade
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK.,Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Gordon McCauley
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK.,Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Suzanne Oxley
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Robert Bains
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Gráinne Bourke
- Faculty of Medicine and Health Sciences, University of Leeds, Leeds, UK.,Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK.,Department of Integrative Medical Biology, University of Umea, Umea, Sweden
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Martínez Núñez P, Pérez González M, Juárez Cordero Á. Isolated axillary nerve palsy after liposuction, an exceptional complication. Neurocirugia (Astur) 2021; 33:S1130-1473(21)00055-5. [PMID: 34154908 DOI: 10.1016/j.neucir.2021.04.006] [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: 03/10/2021] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
Isolated injury to the axillary nerve associated with the patient́s surgical position is a very rare complication, and in most cases it is associated with the prone during spinal surgery. The presentation of this pathology in relation to surgeries of another nature is exceptional, with only a few cases in the scientific literature. We present the case of a patient who developed symptoms of isolated left axillary nerve palsy after undergoing lipoabdominoplasty and breast reduction, in which the prone and supine positions were alternated. The use of an infiltration solution with lidocaine and epinephrine could have contributed to the appearance of the lesion in this unique case. Finally, the clinical picture was fully resolved thanks to conservative treatment.
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Affiliation(s)
- Pablo Martínez Núñez
- Servicio de Cirugía Plástica, Estética y Reparadora, Hospital Universitario La Zarzuela, Madrid, Comunidad de Madrid, España.
| | - Mónica Pérez González
- Servicio de Radiodiagnóstico, Hospital Universitario Infanta Cristina, Parla, Comunidad de Madrid, España
| | - Ángel Juárez Cordero
- Servicio de Cirugía Plástica, Estética y Reparadora, Hospital Universitario La Zarzuela, Madrid, Comunidad de Madrid, España
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15
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Abdelwahab A, Ahuja N, Iyengar KP, Jain VK, Bakti N, Singh B. Traumatic rotator cuff tears - Current concepts in diagnosis and management. J Clin Orthop Trauma 2021; 18:51-55. [PMID: 33996448 PMCID: PMC8093455 DOI: 10.1016/j.jcot.2021.04.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 12/26/2022] Open
Abstract
Rotator cuff tears represent one of common shoulder pathologies presenting over a wide spectrum of age groups and varying presentation. Typically, rotator cuff tears occur more frequently in elderly than in younger patients, following a chronic or acute-on-chronic course and usually secondary to due to tendon degeneration. Though there has been a considerable debate in the literature of the terms "acute" and "traumatic" used in the classification of rotator cuff tears, there appears to be consensus about the need for early diagnosis to facilitate prompt surgical treatment and the improve patient outcome. Significant differences in rotator cuff tears between those occurring in younger and older patients could be due to mechanism of injury, presentation, severity of the tear, biological healing potential and rehabilitation. Acute traumatic rotator cuff tears especially in younger age group represent a distinct entity from other patterns of rotator cuff tears. Consequently, a high index of suspicion, focused clinical examination, complementary imaging is a pre-requisite for an early diagnosis and effective management. We analyze the biomechanical consequences of acute rotator cuff tears along with characteristic mechanism of injury and spectrum of tendon involvement. The evolving concepts in the diagnosis and management of these distinct injuries are discussed with review of current literature.
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Affiliation(s)
| | - Neeraj Ahuja
- Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK
| | | | - Vijay Kumar Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi 110001, India
| | - Nik Bakti
- East Kent Hospitals University Foundation Trust, William Harvey Hospital, TN24 0LZ, UK
| | - Bijayendra Singh
- Canterbury Christ Church University, Medway NHS Foundation Trust, Kent, ME7 5NY, UK
- Corresponding author.
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Couch BK, Maher PL, Fourman MS, Moloney GB, Siska PA, Tarkin IS. Increased Medial Displacement of the Humeral Shaft of at Least 40% Correlates With an Increased Incidence of Nerve Injury in Proximal Humerus Fractures. THE IOWA ORTHOPAEDIC JOURNAL 2021; 41:163-166. [PMID: 34552419 PMCID: PMC8259169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Peripheral nerve and infraclavicular brachial plexus injury following proximal humerus fractures are commonplace, but diagnosing a concomitant nerve injury in the acute setting is challenging. Fracture displacement has been identified as a qualitative risk factor for nerve injury, and additional attention should be paid to the neurologic exams of patients with proximal humerus fractures with significant medial shaft displacement. However, a quantitative relationship between the risk of nerve injury and medialization of the humeral shaft has not been shown, and additional risk factors for this complication have not been assessed. The aim of this study was to identify the risk factors for a neurologic deficit following a proximal humerus fracture, with particular interest in the utility of the magnitude of medial shaft displacement as a predictor of neurologic dysfunction. METHODS A retrospective chart review was performed on all proximal humerus fractures in a 3-year period (2012-2015) at a level one trauma center. Isolated greater tuberosity fractures (OTA 11-A1) were excluded. Fracture displacement was measured on initial injury AP shoulder radiograph and expressed as a percentage of humeral diaphyseal width. All orthopedic inpatient documentation was assessed to identify clinical neurologic deficits. RESULTS We identified 139 patients for inclusion. There were 22 patients (16%) with new neurologic deficits at presentation (8 axillary nerve, 2 radial nerve, 12 infraclavicular brachial plexus or multiple nerve injuries). The average shaft medial displacement in patients with neurologic injuries was 59% vs. 21% without nerve deficits (p=0.03). Using a 40% medial displacement threshold, the odds ratio for a nerve injury was 5.24 (95% CI 1.54 - 17.77, p=.008). CONCLUSION Increased medial displacement of the humeral shaft following proximal humerus fracture is associated with an increased incidence of nerve injury at the time of initial presentation. This finding is not meant to be a surrogate for a high-quality neurologic exam in all patients with proximal humerus fractures. However, improved knowledge of the specific risk factors for an occult neurologic injury will improve the clinician's ability to accurately diagnose and properly treat proximal humerus fractures and their sequelae.Level of Evidence: III.
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Affiliation(s)
- Brandon K. Couch
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick L. Maher
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mitchell S. Fourman
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gele B. Moloney
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter A. Siska
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ivan S. Tarkin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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17
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Endoscopic brachial plexus neurolysis in the management of infraclavicular nerve injuries due to glenohumeral dislocation. Injury 2020; 51:2592-2600. [PMID: 32778326 DOI: 10.1016/j.injury.2020.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/30/2020] [Accepted: 08/02/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Infraclavicular brachial plexus (BP) injury secondary to glenohumeral joint (GHJ) dislocation is a rather common complication, which may be accountable for long-lasting deficits. The purpose of this study was to assess the potential benefits of BP neurolysis in such presentation, using an endoscopic approach. MATERIALS AND METHODS All patients who underwent endoscopic BP neurolysis in the setting of infraclavicular BP palsy due to GHJ dislocation were included. Preoperative physical examination was conducted to classify the observed motor and sensitive deficits into nerves and/or cord lesions. Six weeks after the trauma, examination was repeated and endoscopic BP neurolysis was elected if no significant improvements were observed. If nerve ruptures and/or severe damages were identified during surgery, nerve reconstructions were conducted within a month; in other cases, follow-up examinations were conducted at 6 weeks, 3 and 6 months to assess the course of postoperative recovery. RESULTS Eleven patients were included, including 6 men and 5 women, with a mean age of 43 ± 23 years (16;73). Six patients had at least one cord involved, four patients had isolated axillary nerve palsy, and one patient had a complete BP palsy. In 7 patients with cord lesions and/or isolated axillary nerve palsy, at least grade-3 strength, according to the British Medical Research Council grading system, was noted in all affected muscles within 6 weeks following the neurolysis; after 3 months of follow-up, grade-4 strength was observed in all muscles, and all but patients but one had fully recovered within 6 months. In 3 patients with isolated axillary nerve palsy, complete nerve ruptures (n=2) and severe damages (n=1) were identified under scopic magnification; secondary nerve transfers were conducted to reanimate the axillary nerve, and all patients fully recovered within a year. In one patient with complete BP palsy, improvements started after 6 months of follow-up, and full recovery was yielded after 2 years. No intra- and/or postoperative complications were noted. CONCLUSIONS At the cost of minimal additional morbidity, endoscopic BP neurolysis appears to be a safe and reliable procedure to shorten recovery delays in most patients presenting with BP palsy due to GHJ dislocation.
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Distribution of Peripheral Nerve Injuries in Patients with a History of Shoulder Trauma Referred to a Tertiary Care Electrodiagnostic Laboratory. Diagnostics (Basel) 2020; 10:diagnostics10110887. [PMID: 33143188 PMCID: PMC7693958 DOI: 10.3390/diagnostics10110887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 10/29/2020] [Accepted: 10/29/2020] [Indexed: 11/17/2022] Open
Abstract
Peripheral nerve injury after shoulder trauma is an underestimated complication. The distribution of the affected nerves has been reported to be heterogeneous in previous studies. This study aimed to describe the distribution of peripheral nerve injuries in patients with a history of shoulder trauma who were referred to a tertiary care electrodiagnostic laboratory. A retrospective chart review was performed for all cases referred to a tertiary care electrodiagnostic laboratory between March 2012 and February 2020. The inclusion criteria were a history of shoulder trauma and electrodiagnostic evidence of nerve injury. Data on patient demographics, mechanism of injury, degree of weakness, clinical outcomes at the final follow-up, and electrodiagnostic results were retrieved from medical records. Fifty-six patients had peripheral nerve injuries after shoulder trauma. Overall, isolated axillary nerve injury was the most common. A brachial plexus lesion affecting the supraclavicular branches (pan-brachial plexus and upper trunk brachial plexus lesions) was the second most common injury. In cases of shoulder dislocation and proximal humerus fracture, isolated axillary nerve injury was the most common. Among acromioclavicular joint injuries and clavicular fractures, lower trunk brachial plexus injuries and ulnar neuropathy were more common than axillary nerve or upper trunk brachial plexus injuries. Patients with isolated axillary nerve lesions showed a relatively good recovery; those with pan-brachial plexus injuries showed a poor recovery. Our study demonstrated the distribution of peripheral nerve injuries remote from displaced bony structures. Mechanisms other than direct compression by displaced bony structures might be involved in nerve injuries associated with shoulder trauma. Electrodiagnostic tests are useful for determining the extent of nerve damage after shoulder trauma.
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Kawano K, Hara Y, Hoshikawa S, Tajiri Y, Matsuura H. Isolated Axillary Nerve Rupture due to Closed Nondislocating Injury of the Shoulder in Contact Sports: A Report of 2 Cases. JBJS Case Connect 2020; 10:e1900501. [PMID: 32773705 DOI: 10.2106/jbjs.cc.19.00501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE Axillary nerve rupture without shoulder joint fracture or dislocation in contact sports is very rare. To date, there has been no detailed report on such cases. We present 2 rare cases of axillary nerve rupture in contact sports who were successfully treated with free nerve grafting. CONCLUSION In contact sports, the deltoid muscle is sometimes paralyzed temporarily after a collision. However, similar to our cases, the axillary nerve can be lacerated without fracture or dislocation. It is necessary to watch the course of paralysis carefully and consider nerve reconstruction if it does not recover.
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Affiliation(s)
- Kenichi Kawano
- 1Department of Orthopaedic Surgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
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20
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Gutkowska O, Martynkiewicz J, Urban M, Gosk J. Brachial plexus injury after shoulder dislocation: a literature review. Neurosurg Rev 2020; 43:407-423. [PMID: 29961154 PMCID: PMC7186242 DOI: 10.1007/s10143-018-1001-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/17/2018] [Accepted: 06/21/2018] [Indexed: 12/01/2022]
Abstract
Brachial plexus injuries are among the rarest but at the same time the most severe complications of shoulder dislocation. The symptoms range from transient weakening or tingling sensation of the upper limb to total permanent paralysis of the limb associated with chronic pain and disability. Conflicting opinions exist as to whether these injuries should be treated operatively and if so when surgery should be performed. In this review, available literature dedicated to neurological complications of shoulder dislocation has been analysed and management algorithm has been proposed. Neurological complications were found in 5.4-55% of all dislocations, with the two most commonly affected patient groups being elderly women sustaining dislocation as a result of a simple fall and young men after high-energy injuries, often multitrauma victims. Infraclavicular part of the brachial plexus was most often affected. Neurapraxia or axonotmesis predominated, and complete nerve disruption was observed in less than 3% of the patients. Shoulder dislocation caused injury to multiple nerves more often than mononeuropathies. The axillary nerve was most commonly affected, both as a single nerve and in combination with other nerves. Older patient age, higher energy of the initial trauma and longer period from dislocation to its reduction have been postulated as risk factors. Brachial plexus injury resolved spontaneously in the majority of the patients. Operative treatment was required in 13-18% of the patients in different studies. Patients with suspected neurological complications require systematic control. Surgery should be performed within 3-6 months from the injury when no signs of recovery are present.
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Affiliation(s)
- Olga Gutkowska
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, ul. Borowska 213, 50-556 Wroclaw, Poland
| | - Jacek Martynkiewicz
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, ul. Borowska 213, 50-556 Wroclaw, Poland
| | - Maciej Urban
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, ul. Borowska 213, 50-556 Wroclaw, Poland
| | - Jerzy Gosk
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, ul. Borowska 213, 50-556 Wroclaw, Poland
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Abstract
INTRODUCTION The shoulder terrible triad (STT) is a traumatic anterior shoulder dislocation, associated with rotator cuff (RC) tear and nerve injury from the brachial plexus. This study aimed to describe the functional results and prognostic factors of surgery in patients with STT. METHODS Thirty consecutive patients with acute STT were included at the same institution. All patients were examined with x-rays, MRI, and electromyography. Surgical treatment in the acute setting was indicated to address an RC injury or a displaced greater tuberosity fracture. Variables registered on the day of surgery were preoperative Constant and Western Ontario Rotator Cuff (WORC) scores and injury pattern. At final discharge, Constant, American Shoulder and Elbow Surgeons (ASES), WORC, and subjective shoulder value scores were recorded by an independent evaluator. RESULTS Twenty-seven patients underwent a complete follow-up. The dominant arm was affected in 50% of cases. The mean follow-up was 27 (12 to 43) months. The mean WORC and Constant scores improved from 1,543 to 1,093 (P = 0.015) and 31 to 54 (P = 0.003), respectively. The ASES and subjective shoulder value scores at the end of the follow-up were 60 and 56 points, respectively. RC tears and nerve injuries that did not involve the axillary or suprascapular nerves were associated to better results than greater tuberosity fractures and injuries to the axillary or suprascapular nerves, respectively, in WORC (P = 0.028), Constant (P = 0.024), and ASES scores (P = 0.035). Preoperative WORC and Constant scores were independent prognostic factors. CONCLUSIONS The most frequent patterns include complete RC tears, anterior capsular injuries, and an axillary nerve injury. Patients had improved functional scores at the end of follow-up after surgery. Better functional results were correlated to RC tears, injuries to nerves with innervation distal to the shoulder, and higher preoperative Constant and WORC scores.
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Probst DT, Mackinnon SE, Prather H. Isolated Axillary Nerve Injury in an Elite High School American Football Player: A Case Report. Sports Health 2019; 11:550-553. [PMID: 31484001 DOI: 10.1177/1941738119868478] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
An elite high school American football athlete sustained a traumatic, isolated, axillary nerve injury. Axillary nerve injuries are uncommon, but serious injuries in American football. With the advent of nerve transfers and grafts, these injuries, if diagnosed in a timely manner, are treatable. This case report discusses the multidisciplinary approach necessary for the diagnosis and treatment of an elite high school American football player who presented with marked deltoid atrophy. The athlete's injury was diagnosed via electrodiagnostic testing and he underwent a medial triceps nerve to axillary nerve transfer. After appropriate postsurgical therapy, the athlete was able to return to American football the subsequent season and continue performing at an elite level. This case report reviews the evaluation and modern treatment for axillary nerve injuries in the athlete, including nerve transfers, nerve grafts, and return to play.
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Affiliation(s)
- Daniel T Probst
- Division of Neurorehabilitation, Department of Neurology, Washington University School of Medicine, St Louis, Missouri
| | - Susan E Mackinnon
- Department of Plastic and Reconstructive Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Heidi Prather
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedic Surgery, Washington University School of Medicine, St Louis, Missouri
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Gasbarro G, Crasto JA, Rocha J, Henry S, Kano D, Tarkin IS. Reverse Total Shoulder Arthroplasty for Geriatric Proximal Humerus Fracture Dislocation With Concomitant Nerve Injury. Geriatr Orthop Surg Rehabil 2019; 10:2151459319855318. [PMID: 31218093 PMCID: PMC6558531 DOI: 10.1177/2151459319855318] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 05/07/2019] [Accepted: 05/10/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction Preoperative axillary nerve palsy is a contraindication to reverse total shoulder arthroplasty (rTSA) due to the theoretical risk of higher dislocation rates and poor functional outcomes. Treatment of fracture-dislocations of the proximal humerus with rTSA is particularly challenging, as these injuries commonly present with concomitant neurologic and soft tissue injury. The aim of the current study was to determine the efficacy of rTSA for this fracture pattern in geriatric patients presenting with occult or profound neurologic injury. Methods A retrospective case series of all shoulder arthroplasty procedures for proximal humerus fractures from February 2006 to February 2018 was performed. Inclusion criteria were patients aged greater than 65 years at the time of surgery, fracture-dislocations of the proximal humerus, and treatment with rTSA. Patients with preoperative nerve injuries were compared to patients without overt neurologic dysfunction. Forward elevation, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Visual Analog Scale (VAS), and Subjective Shoulder Value (SSV) were obtained at final follow-up. Results Forty-six rTSA for acute fracture were performed during the study period, 16 patients met the inclusion criteria and 5 (31%) presented with overt preoperative nerve injuries. At mean 3.1 years follow up, there were no postoperative complications including dislocations and final forward elevation was similar between study groups. Patients with overt nerve palsy had higher QuickDASH and VAS scores with lower SSV and self-rated satisfaction. Discussion In the majority of patients with or without overt nerve injury, rTSA reliably restored overhead function and led to good or excellent patient-rated treatment outcomes. Overt nerve palsy did not lead to higher complication rates, including dislocation. Despite greater disability and less satisfaction, complete or partial nerve recovery can be expected in the majority of patients. Conclusion Nerve injury following proximal humeral fracture dislocation may not be an absolute contraindication to rTSA.
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Affiliation(s)
- Gregory Gasbarro
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jared A Crasto
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jorge Rocha
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sarah Henry
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daiji Kano
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ivan S Tarkin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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24
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Kastanis G, Kapsetakis P, Velivasakis G, Spyrantis M, Pantouvaki A. Isolated Radial Nerve Palsy as a Complication After Anterior Dislocation of the Glenohumeral Joint: A Case Report and Clinical Review. J Investig Med High Impact Case Rep 2019; 7:2324709619844289. [PMID: 31088181 PMCID: PMC6537276 DOI: 10.1177/2324709619844289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Shoulder dislocation is the most common feature in emergencies, while the
anterior dislocation of the glenohumeral joint is the most frequent and requires
reduction. Accompanied nerve injury is common with an incidence of 21%, while
radial nerve palsy is very rare. We describe the case of a 56-year-old man who
presented with an anterior dislocation of the left shoulder due to a fall on an
outstretched hand with wrist drop 8 hours after injury. Neurological examination
revealed loss of sensation along the radial border of the forearm. Closed
reduction with Kocher procedure was performed. Magnetic resonance image
demonstrated a rotator cuff tear, and 3 weeks after the injury electromyography
showed complete radial nerve palsy. A physiotherapy program was applied to the
wrist and fingers with the goal of maintaining a full passive range of motion in
all joints affected while shoulder rehabilitation started 6 weeks after his
fall. Isolated radial nerve palsy associated with an anterior dislocation of the
shoulder is very rare but not impossible to occur. Correct diagnosis of the
nerve injury associated with the anterior dislocation is very important because
it has serious implications on the management and activity morbidity.
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Duke JM, Randall SM, Fear MW, Boyd JH, Rea S, Wood FM. Burn induced nervous system morbidity among burn and non-burn trauma patients compared with non-injured people. Burns 2019; 45:1041-1050. [PMID: 31056206 DOI: 10.1016/j.burns.2018.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/12/2018] [Accepted: 06/16/2018] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Burns cause acute damage to the peripheral nervous system with published reports identifying that neurological changes after injury remain for a prolonged period. To shed some light on potential mechanisms, we assessed injury etiology and patterns of nervous system morbidity after injury by comparing long-term hospital admissions data of burns patients and other non-burn trauma patients with uninjured people. METHODS Linked hospital and death data of a burn patient cohort (n=30,997) in Western Australia during the period 1980-2012 were analysed along with two age and gender frequency matched comparison cohorts: non-burn trauma patients (n=28,647) and; non-injured people (n=123,399). The number of annual NS disease admissions and length of stay (LOS) were used as outcome measures. Multivariable negative binomial regression modelling was used to derive adjusted incidence rate ratios and 95% confidence intervals (IRR, 95% CI) and adjusted Cox regression models and hazard ratios (HR) were used to examine time to first nervous system admission after burn and incident admission rates. RESULTS The most common peripheral nervous system condition identified in each cohort (burn, non-burn trauma, uninjured) were episodic and paroxysmal disorders followed by nerve root and plexus disorders and polyneuropathies/peripheral NS conditions. Significantly elevated admission rates for NS conditions (IRR, 95% CI) were found for the burn (2.20, 1.86-2.61) and non-burn trauma (1.85, 1.51-2.27), compared to uninjured. Peripheral nervous system admission rates after injury (IRR, 95% CI) were significantly higher regardless of age at time of injury for the burn (<15years: 1.97, 1.49-2.61; 15-45: 2.70, 2.016-3.55; ≥45year: 1.62, 1.33-1.97) and non-burn trauma cohorts (<15years: 1.91, 1.55-2.35; 15-45: 1.94, 1.51-2.49; ≥45year: 1.42, 1.18-1.72), when compared to the uninjured. Significantly higher rates of incident NS hospitalisations were found for the burn cohort vs. uninjured cohort for a period of 15-years after discharge (0-5 years: HR, 95% CI: 1.97, 1.75-2.22; 5-15 years; HR, 95% CI: 1.44, 1.28-1.63). The non-burn trauma cohort had significantly higher incident nervous system admissions for 10 years after discharge (0-30 days: HR, 95% CI: 4.75, 2.44-9.23; 30days to 1-year HR, 95% CI: 2.95, 2.34-3.74; 1-5 years; HR, 95% CI: 1.47, 1.26-1.70; 5-10 years; HR, 95% CI: 1.34, 1.13-1.58). CONCLUSIONS Results suggest that injury patients are at increased risk of peripheral nervous system morbidity after discharge for a prolonged period of time. The time patterns associated with incident nervous system conditions suggest possible differences in underlying pathology and long-term patient care needs. Further research is needed to elucidate the underlying neuropathology.
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Affiliation(s)
- Janine M Duke
- Burn Injury Research Unit, University of Western Australia, Western Australia, Australia.
| | - Sean M Randall
- Centre for Data Linkage, Curtin University, Western Australia, Australia
| | - Mark W Fear
- Burn Injury Research Unit, University of Western Australia, Western Australia, Australia
| | - James H Boyd
- Centre for Data Linkage, Curtin University, Western Australia, Australia
| | - Suzanne Rea
- Burn Injury Research Unit, University of Western Australia, Western Australia, Australia; Burns Service of Western Australia, Fiona Stanley Hospital and Princess Margaret Hospital, Western Australia, Australia
| | - Fiona M Wood
- Burn Injury Research Unit, University of Western Australia, Western Australia, Australia; Burns Service of Western Australia, Fiona Stanley Hospital and Princess Margaret Hospital, Western Australia, Australia
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Yoon JS, Park JH, Levin J, Roh EY, Park HJ, Won SJ. Ultrasonographic measurement of the cross-sectional area of the axillary nerve. Muscle Nerve 2019; 60:95-99. [PMID: 30927449 DOI: 10.1002/mus.26480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 03/24/2019] [Accepted: 03/26/2019] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The objectives of this study were to determine normal reference values for ultrasonographic measurement of the cross-sectional area (CSA) of the axillary nerve and to standardize the measurement methods. METHODS Sixty healthy volunteers were evaluated. Ultrasonography was performed with the shoulder positioned in 100°-120° abduction and 90° external rotation. The CSA of the axillary nerve was measured bilaterally. RESULTS The normal CSA of the right axillary nerve was 2.9 ± 1.1 mm2 . The side-to-side discrepancy was 22.8% ± 17.8%. DISCUSSION These reference values may be helpful for investigating pathologies involving the axillary nerve.
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Affiliation(s)
- Joon Shik Yoon
- Department of Rehabilitation Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Jung Hyun Park
- Department of Rehabilitation Medicine, Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Joshua Levin
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California, USA.,Department of Neurosurgery, Stanford University, Palo Alto, California, USA
| | - Eugene Y Roh
- Department of Orthopaedic Surgery, Division of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California, USA
| | - Hye Jung Park
- Department of Rehabilitation Medicine, Yeouido St Mary's Hospital, 10, 63-ro, Yeongdeungpo-gu, College of Medicine, The Catholic University of Korea, Seoul, 07345, South Korea
| | - Sun Jae Won
- Department of Rehabilitation Medicine, Yeouido St Mary's Hospital, 10, 63-ro, Yeongdeungpo-gu, College of Medicine, The Catholic University of Korea, Seoul, 07345, South Korea
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Payne RA, Sieg EP, Patrick N, Darowish M, Rizk E, Langan S, Harbaugh K. Fracture related ulnar and sciatic nerve transections: a report of two cases and literature review. Childs Nerv Syst 2018; 34:2187-2194. [PMID: 30187183 DOI: 10.1007/s00381-018-3961-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 08/20/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Case reports, case series, and case control studies have looked at the incidence of complete nerve transection in the setting of fracture and the need for surgical exploration dating back to the 1920s. We present two cases of nerve laceration accompanying traumatic fracture with a thorough review of the literature. METHODS We used the following search terms: "ulnar nerve" OR "sciatic nerve" AND "laceration" OR "transection" AND "fracture." Results were reviewed and included for discussion if they specifically reported ulnar or sciatic nerve laceration accompanying traumatic fracture. RESULTS Our search yielded 15 papers reporting a total of 10 ulnar nerve lacerations and nine sciatic nerve lacerations. We present two additional cases. The first is a patient with a humerus fracture and complete ulnar nerve transection. The second case is a patient who suffered a femur fracture and complete transection of the sciatic nerve. CONCLUSION Nerve laceration accompanying traumatic fracture is rare. We review the reported cases of nerve laceration and present two cases treated at our institution. Though uncommon, nerve laceration should be considered in the setting of traumatic fracture with neurological injury, particularly open fractures.
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Affiliation(s)
- Russell A Payne
- Department of Neurosurgery, Penn State Milton S Hershey Medical Center, 30 Hope Drive; EC 110, Hershey, PA, 17033, USA.
| | - Emily P Sieg
- Department of Neurosurgery, Penn State Milton S Hershey Medical Center, 30 Hope Drive; EC 110, Hershey, PA, 17033, USA
| | - Nathan Patrick
- Department of Orthopedic Surgery, Penn State Milton S Hershey Medical Center, Hershey, PA, USA
| | - Michael Darowish
- Department of Orthopedic Surgery, Penn State Milton S Hershey Medical Center, Hershey, PA, USA
| | - Elias Rizk
- Department of Neurosurgery, Penn State Milton S Hershey Medical Center, 30 Hope Drive; EC 110, Hershey, PA, 17033, USA
| | - Sara Langan
- Department of Neurosurgery, Penn State Milton S Hershey Medical Center, 30 Hope Drive; EC 110, Hershey, PA, 17033, USA
| | - Kimberly Harbaugh
- Department of Neurosurgery, Penn State Milton S Hershey Medical Center, 30 Hope Drive; EC 110, Hershey, PA, 17033, USA
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Karita Y, Kimura Y, Sasaki S, Nitobe T, Tsuda E, Ishibashi Y. Axillary artery and brachial plexus injury secondary to proximal humeral fractures: A report of 2 cases. Int J Surg Case Rep 2018; 50:106-110. [PMID: 30098526 PMCID: PMC6089080 DOI: 10.1016/j.ijscr.2018.04.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/30/2018] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Axillary artery and brachial plexus injuries have been reported to be associated with proximal humeral fractures. In this report, we present two cases of axillary artery and brachial plexus injury secondary to proximal humeral fracture. PRESENTATION OF CASES Case 1: An 88-year-old woman with cognitive impairment slipped and fell at home. The diagnosis was left proximal humeral fracture. The second day, paralysis of left upper arm due to left axillary artery occlusion appeared. Axillary-brachial artery bypass surgery was performed. After that, a radial artery pulse was palpable. Ten months have passed since the operation, but the neurologic deficit has not been restored. Case 2: A 74-year-old woman fell from a ladder. She was diagnosed with a right proximal humeral fracture and right axillary artery occlusion. Emergency axillary-brachial bypass surgery and osteosynthesis were performed. After reestablishing the blood flow, there have been no signs of blood flow disorders but paralysis has remained. DISCUSSION In neither of the two cases, were obvious findings of brachial plexus injury detected during surgery. The delayed onset of motor palsy implied that an ischemic factor was implicated in case 1. The acute onset of motor palsy might have been caused by a mechanical factor such as the dislocated of humeral head in case 2. CONCLUSION Axillary artery and brachial plexus injury secondary to proximal humeral fracture is rare but it can develop severe sequels. By identifying the high-risk patients, diagnosis and management of this vascular and plexus injury might lead to improvement.
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Affiliation(s)
- Yukiko Karita
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
| | - Yuka Kimura
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shizuka Sasaki
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Taisuke Nitobe
- Department of Orthopaedic Surgery, Tsugaru General Hospital, Goshogawara, Japan
| | - Eiichi Tsuda
- Department of Rehabilitation Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Abstract
Axillary nerve injury is a well-recognized complication of glenohumeral dislocation. It is often a low-grade injury which progresses to full recovery without intervention. There is, however, a small number of patients who have received a higher-grade injury and are less likely to achieve a functional recovery without surgical exploration and reconstruction. Following a review of the literature and consideration of local practice in a regional peripheral nerve injury unit, an algorithm has been developed to help identification of those patients with more severe nerve injuries. Early identification of patients with high-grade injuries allows rapid referral to peripheral nerve injury centres, allowing specialist observation or intervention at an early stage in their injury, thus aiming to maximize potential for recovery.
Cite this article: EFORT Open Rev 2018;3:70-77. DOI:10.1302/2058-5241.3.170003.
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Analysis of Patient-Dependent and Trauma-Dependent Risk Factors for Persistent Brachial Plexus Injury after Shoulder Dislocation. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4512137. [PMID: 29546059 PMCID: PMC5818932 DOI: 10.1155/2018/4512137] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/19/2017] [Accepted: 12/03/2017] [Indexed: 11/22/2022]
Abstract
Brachial plexus injuries (BPIs) caused by shoulder dislocation usually have a transient character and tend to resolve spontaneously. However, in some patients the symptoms can persist and require operative intervention. This work aims to determine the risk factors for persistent BPIs resulting from shoulder dislocation. The study comprised 73 patients (58 men, 15 women; mean age: 50 years) treated operatively between the years 2000 and 2016 for persistent BPIs resulting from shoulder dislocation. Patient age, gender, type of initial trauma, number of affected nerves, presence of accompanying injuries, and time interval from dislocation to its reduction were analysed. Elderly patients more often sustained multiple-nerve injuries, while single nerve injuries were more often observed in younger patients. Injury to a single nerve was diagnosed in 30% of the patients. Axillary nerve was most commonly affected. Fracture of the greater tuberosity of humerus coincided with total BPI in 50% of the cases. Longer unreduced period caused injury to multiple nerves. Analysis of our patient group against relevant literature revealed that persistent BPI after shoulder dislocation is more common in older patients. Injuries to ulnar and median nerves more often require operative intervention due to low potential for spontaneous recovery of these nerves.
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Theeuwes HP, van der Ende B, Potters JW, Kerver AJ, Bessems JHJM, Kleinrensink GJ. The course of the radial nerve in the distal humerus: A novel, anatomy based, radiographic assessment. PLoS One 2017; 12:e0186890. [PMID: 29073240 PMCID: PMC5658097 DOI: 10.1371/journal.pone.0186890] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 10/09/2017] [Indexed: 11/22/2022] Open
Abstract
Iatrogenic nerve injury during fracture surgery of the upper arm is a well-known complication. Prevention of this type of injuries would be of great value. The literature describes several methods to reduce this type of injury, but no perfect solution is at hand. In this study we introduce a new radiographic evaluation of the course and variation of the radial nerve in the distal part of the humerus in relation to bony landmarks as observed on a plain (trauma) radiographs. Aim of this new approach is to reduce the chance of iatrogenic nerve injury by defining of a danger zone in the distal upper arm regarding the radial nerve and hence give an advise for future implant fabrication.
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Affiliation(s)
- H. P. Theeuwes
- Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Surgery, VieCuri Medical Center, Tegelseweg BL Venlo, The Netherlands
- * E-mail:
| | - B. van der Ende
- Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Orthopedic Surgery, Reinier de Graaf Gasthuis, Reinier de Graafweg AD Delft, The Netherlands
| | - J. W. Potters
- Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - A. J. Kerver
- Department of Surgery, Franciscus Gasthuis & Vlietland, Kleiweg PM, Rotterdam, The Netherlands
| | - J. H. J. M. Bessems
- Department of Orthopedic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - G-J. Kleinrensink
- Department of Neuroscience-Anatomy and Erasmus MC Anatomy Research Project (EARP), Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Mitchell JJ, Chen C, Liechti DJ, Heare A, Chahla J, Bravman JT. Axillary Nerve Palsy and Deltoid Muscle Atony. JBJS Rev 2017; 5:e1. [DOI: 10.2106/jbjs.rvw.16.00061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Gutkowska O, Martynkiewicz J, Mizia S, Bąk M, Gosk J. Results of Operative Treatment of Brachial Plexus Injury Resulting from Shoulder Dislocation: A Study with A Long-Term Follow-Up. World Neurosurg 2017. [PMID: 28624567 DOI: 10.1016/j.wneu.2017.06.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Injury to the infraclavicular brachial plexus is an uncommon but serious complication of shoulder dislocation. This work aims to determine the effectiveness of operative treatment in patients with this type of injury. METHODS Thirty-three patients (26 men and 7 women; mean age, 45 years and 3 months) treated operatively for brachial plexus injury resulting from shoulder dislocation between the years 2000 and 2013 were included in this retrospective case series. Motor function of affected limbs was assessed pre- and postoperatively with the use of the British Medical Research Council (BMRC) scale. Sensory function in the areas innervated by ulnar and median nerves was evaluated with the BMRC scale modified by Omer and Dellon and in the remaining areas with the Highet classification. Follow-up lasted 2-10 years (mean, 5.1 years). RESULTS Good postoperative recovery of nerve function was observed in 100% of musculocutaneous, 93.3% of radial, 66.7% of median, 64% of axillary, and 50% of ulnar nerve injuries. No recovery was observed in 5.6% of median, 6.7% of radial, 10% of ulnar, and 20% of axillary nerve injuries. Injury to a single nerve was associated with worse treatment outcome than multiple nerve injury. CONCLUSIONS Obtaining improvement in peripheral nerve function after injury resulting from shoulder dislocation may require operative intervention. The type of surgical procedure depends on intraoperative findings: sural nerve grafting in cases of neural elements' disruption, internal neurolysis when intraneural fibrosis is observed, and external neurolysis in the remaining cases. The outcomes of surgical treatment are good, and the risk of intra- and postoperative complications is low.
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Affiliation(s)
- Olga Gutkowska
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, Wroclaw, Poland.
| | - Jacek Martynkiewicz
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Sylwia Mizia
- Department of Public Health, Department of Organisation and Management, Faculty of Health Science, Wroclaw Medical University, Wroclaw, Poland
| | - Michał Bąk
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Jerzy Gosk
- Department of Traumatology, Clinical Department of Traumatology and Hand Surgery, Wroclaw Medical University, Wroclaw, Poland
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Westphal T, Woischnik S, Adolf D, Feistner H, Piatek S. Axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures through an extended lateral deltoid-split approach: electrophysiological findings. J Shoulder Elbow Surg 2017; 26:464-471. [PMID: 27727054 DOI: 10.1016/j.jse.2016.07.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 07/03/2016] [Accepted: 07/19/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Axillary nerve injuries after shoulder surgery are rare. In most studies, the frequency of injury is usually determined using clinical examinations, but results from intraoperative neuromonitoring studies have revealed higher than expected rates. Few studies have investigated this topic. Our aim was to determine the frequency of axillary nerve lesions after open reduction and internal fixation of proximal humeral fractures by using electrophysiological assessments and to provide a review of the relevant literature. METHODS This was a retrospective cohort study of 76 consecutive patients who received open reduction and internal fixation of a proximal humeral fracture using a locking plate through a deltoid-splitting approach. We performed a clinical and electrophysiological examination at a minimum follow-up time of 12 months. Functional results were assessed according to the Constant-Murley and Disabilities of the Arm, Shoulder and Hand scores. Electrophysiological examinations comprised electromyography, electroneurography, and motor and somatosensory evoked potentials. The main outcome was the frequency of axillary nerve lesions. RESULTS Forty patients were monitored for an average of 28 months. The mean raw Constant-Murley score was 61 points, the age- and gender-adjusted score was 71%, and the mean Disabilities of the Arm, Shoulder and Hand score was 33 points. Neurapraxia occurred in 1 patient, axonotmesis with incomplete reinnervation occurred in 3, and complete reinnervation occurred in 3. The latter group was classified as having a temporary axillary nerve lesion. CONCLUSIONS The 10% rate of permanent axillary nerve lesions in our cohort is higher than expected based on the clinical examination. Electrophysiological assessment is therefore more appropriate to detect axillary nerve injuries.
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Affiliation(s)
- Thomas Westphal
- Department of Trauma Surgery, Orthopedics, and Hand Surgery, Klinikum Südstadt Rostock, Rostock, Germany.
| | | | - Daniela Adolf
- Gesellschaft für klinische und Versorgungsforschung mbH, Magdeburg, Germany
| | - Helmut Feistner
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Stefan Piatek
- Department of Trauma Surgery, Otto-von-Guericke University, Magdeburg, Germany
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Lam WL, Fufa D, Chang NJ, Chuang DCC. Management of infraclavicular (Chuang Level IV) brachial plexus injuries: A single surgeon experience with 75 cases. J Hand Surg Eur Vol 2015; 40:573-82. [PMID: 25294737 DOI: 10.1177/1753193414553753] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 09/01/2014] [Indexed: 02/03/2023]
Abstract
UNLABELLED Infraclavicular brachial plexus injuries (Level IV in Chuang's classification) have special characteristics, including high incidences of associated scapular fractures, glenohumeral dislocations, and vascular injuries. In addition, there are specific difficulties in surgical dissection and nerve repairs, especially if surgery is delayed (>3 months). A total of 153 patients with Level IV brachial plexus injuries underwent surgery between 1987 and 2008 with 75 patients (average age 29 years) available for a minimum of 4 years follow-up. Accompanying fractures/dislocations were suffered by 48 (64%) patients, and 17 (23%) had associated vascular injuries. The most common nerves to be injured were the axillary and musculocutaneous nerves. Nerve grafts to the axillary, musculocutaneous, and radial nerves achieved impressive results, but less reliable outcomes were achieved with the median and ulnar nerves. Decompression and/or external neurolysis were also beneficial for nerve recovery. Some surgical tips are presented, and the use of the C-loop vascularized ulnar nerve graft and functioning muscle transfers are discussed. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- W L Lam
- Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan
| | - D Fufa
- Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan
| | - N-J Chang
- Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan
| | - D C-C Chuang
- Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Chang Gung University, Tao-Yuan, Taiwan
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