Axillary nerve injury associated with glenohumeral dislocation: A review and algorithm for management

Diagnosis and treatment approach of delayed presentation of anterior branch axillary nerve injury following shoulder dislocation: case report

In this case report, a unique instance of delayed isolated anterior branch axillary nerve injury following shoulder dislocation is highlighted. The patient, a 55-year-old manual laborer, presented with severe deltoid wasting and reduced power 18 months postdislocation, necessitating a specialized treatment approach. The use of axillary nerve neurolysis and an innovative upper trapezius to anterior deltoid transfer via a subacromial path posterior to the clavicle, facilitated by an autologous semitendinosus graft, resulted in significant improvement with 160 degrees of abduction and Grade 4+ power Medical Research Council grading (MRC) at the 5-year follow-up.

Neglected Superior Dislocation of the Shoulder Joint: A Case Report

The anterior subtype of shoulder dislocations constitutes the vast majority that either reduces instantly or is reduced at the point of care with no serious complexities. The posterior ones are infrequent and inferior and superior dislocations are even more rare. Rupture of the deltoid is considered to be linked with superior dislocation; regardless, very few articles are available pertaining to the mechanism of onset and the management of a superior shoulder dislocation. In the line of traumatic shoulder dislocations, we present a one-year-old neglected case of a 23-year-old male who sustained an open injury over the right outstretched upper arm, abducted at an angle of approximately 45° due to a fall from a height of approximately 18 feet. This unique report outlines the various surgical modalities available, given the patient's late presentation due to neglect.

Reverse Shoulder Arthroplasty for Irreparable Rotator Cuff Tear After Radial to Axillary End-to-Side Transfer: A Case Report

CASE

A 60-year-old man sustained a massive irreparable rotator cuff tear and axillary nerve palsy with deltoid dysfunction after an anterior shoulder dislocation. He underwent staged reverse end-to-side radial-to-axillary nerve transfer with return of deltoid function allowing for subsequent reverse shoulder arthroplasty. At 1 year postoperatively, he returned to full activity.

CONCLUSION

Irreparable rotator cuff tears complicated by axillary nerve palsy can be effectively treated with a staged approach of nerve transfer followed by reverse shoulder arthroplasty.

Prevalence and risk factors for nerve injury following shoulder dislocation

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.

Experience of endoscopic transcapsular axillary nerve decompression: series of clinical cases

Introduction. Posttraumatic axillary nerve neuropathy is a widely spread pathology, more often is seen after shoulder joint trauma. It can be also occurred as a complication after orthopaedic surgeries, for example, after Latarjet procedure for shoulder stabilization. Endoscopic surgical technique of decompression is an effective less traumatic alternative to open procedures. Goal. Improve the results of treatment of patients with axillary nerve neuropathy. Material and methods. The results of endoscopic transcapsular axillary nerve decompression in 5 patients, which were operated from 2018 to 2021 year, with the clinics of axillary nerve neuropathy. The mean age of the patients was 44.414.9. Patients were performed endoscopic axillary nerve decompression. Statistical analysis was made according to Mann-Whitney U test. Results. According to VAS-scale the severity of pain syndrome before the surgery was 64.6 points, 6 months after decreased to 1.4 0.5 points (p0.05). According to DASH scale the function of the of shoulder joint before the surgery was 77,6 6,9 points, 6 months after decreased to 12 5,2 points (p0.05). According to BMRC scale (M0-M5) strength of the deltoid muscle was 2 0,4 points, after increased to 4,4 0,5 points (p0.05). Range of motion in a shoulder was: flexion 107 45,6, extension 102 49, external rotation 22 13,6; 6 months after: flexion 154 25,6, extension 156 22,4, external rotation 50 8 (p0,05). The thickness of deltoid muscle according to US before the surgery was 7.21.04 mm., after 6 months - 11.81.44 mm (p0.05). Conclusion. The results characterize the method of endoscopic transcapsular axillary nerve decompression as a reproducible, minimally invasive and effective technique for pain relief, can treat neurological and intraarticular pathology, promotes early restoration of the function of upper limb.

Patterns of Nerve Injury and Recovery Rates of Infraclavicular Brachial Plexus Lesions Following Anterior Shoulder Dislocation

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.

Isolated axillary nerve palsy after liposuction, an exceptional complication

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.

A Systematic Review of Acute Irreducible Shoulder Dislocations in the 21st Century

Background

Rarely, closed reduction cannot be achieved in patients with acute shoulder dislocation, necessitating open management. A paucity of literature exists regarding these cases.

Purpose

To perform a systematic review on the mechanism, management, and outcome data of acute irreducible shoulder dislocations.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of the literature was performed using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE between 2000 and 2020. Inclusion criteria were as follows: human participants, acute irreducible shoulder dislocation requiring open management, English language, and publication within the past 20 years. We excluded basic science articles, technique articles, reviews, editorials, and studies of chronic shoulder dislocations or dislocations with ipsilateral humeral shaft fractures.

Results

Twelve articles fit the inclusion criteria and were considered for review. All studies were single case reports (level 4 evidence). Ten of the 12 studies were of male patients. The direction of dislocation included 7 anterior/anteroinferior, 2 posterior, 1 inferior, 1 bilateral inferior, and 1 superolateral. Most dislocations were irreducible owing to a mechanical block to reduction. The most common type of block was an incarcerated long head of the biceps tendon, followed by interposition of 1 of the rotator cuff tendons. The axillary and musculocutaneous nerves, displaced fracture fragments, and Hill-Sachs and bony Bankart lesions were other causes of blocks to reduction. Eleven patients were treated with open surgery, while 1 patient was treated arthroscopically. Procedures performed were dependent on concurrent pathology. Final follow-up ranged from 6 weeks to 2 years, with no repeat dislocation episodes reported. Complications after open reduction included 1 case of brachial plexopathy (posterior cord) and 1 case of musculocutaneous nerve palsy.

Conclusion

There is a paucity of literature on the management of irreducible acute shoulder dislocations. The most common irreducible dislocation found in this systematic review was anterior with a mechanical block attributed to interposition of the long head of the biceps tendon. When patients were treated with an open or arthroscopic procedure, recurrence was low, with none reporting recurrent dislocation in limited follow-up.

C6 and not C5 nerve fibers more commonly contribute most to deltoid muscle innervation: anatomical study with application to better diagnosing cervical nerve injuries

Most anatomical textbooks list both the C5 and C6 spinal nerves as contributing to the deltoid muscle's innervation via the axillary nerve. To our knowledge, no previous study has detailed the exact spinal nerve components of the axillary nerve terminating in the deltoid via cadaveric dissection. Twenty formalin-fixed cadavers (40 sides) underwent dissection of the brachial plexus. The fascicles making up the axillary nerve branch that specifically terminated in the deltoid muscle were traced proximally. The axillary nerve branch to the deltoid muscle was most commonly (70%) made up of three spinal nerve segments and less commonly (30%) by two spinal nerve segments. For all axillary nerve branches to the deltoid muscle, C4 spinal nerves contributed 0-5%, C5 spinal nerves contributed 1-80%, C6 spinal nerve contributed 15-99%, C7 spinal nerves contributed 0-30%, and C8 and T1 spinal nerves were not found to contribute any fibers to any deltoid muscle branches. The nerve to the deltoid muscle was contributed to equally by C5 and C6 nerve fibers on 10% of sides. On 16% of sides, C5 contributed the most nerve fibers to this muscle. On 35% of sides, C6 contributed the majority fibers found in the axillary nerve branches to the deltoid. Based on our anatomical study, C6 is more often than not the main level of innervation. C5 was never the sole component of the axillary nerve branches to the deltoid muscle. Such anatomical data will now need to be reconciled with clinical studies.

«Terrible triad» of the shoulder. Biomechanicalsemi-natural modeling andjustificationto rotator cuff restoration

The aim of this study: was determine the force of tension and deformation of axillary nerve in rupture rotator cuff and paresis of deltoid muscle of the shoulder joint. Material and methods: Semi-natural modelling based on the axial scans spiral computed tomography of the intact shoulder joint was performed to determine the degree of traction load on the axillary nerve with distal displacement shoulder head and tendon rupture which paresis of the deltoid muscle. Result: The values of deformations for axillary nerve being at the limit of tissue strength at distal displacement of humeral head of the model by 50 %, progressively increased with increasing distal displacement of humeral head to 100 % of its diameter, reaching values 1.7 times higher than the strength nervous tissue. Conclusion: The progressive changes occurring in the axillary nerve under the action of traction loads, and as a consequence of its ischemia, over time can lead not only to demyelination, but also to the defeat of the axons themselves atrophy of its fibers. In turn, deltoid muscle atrophy increases the traction load on the affected axillary nerve, which forms a vicious circle. The only possible option to "break" the vicious circle is restore the stabilizing structures damaged during the injury, among which one of the most important is the tendons of the rotator cuff of the shoulder. Surgical restoration of the integrity rotator cuff of the shoulder reduces the traction load acting on the axillary nerve, which in turn significantly improves the conditions for reinnervation of the deltoid muscle.

Functional deficits as a result of brachial plexus injury in anterior shoulder dislocation

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.

Iatrogenic peripheral nerve injury: a guide to management for the orthopaedic limb surgeon

Nerves may be inadvertently injured during trauma surgery due to distorted anatomy, traction applied to a limb, soft tissue retraction, by power tools, instrumentation and from compartment syndrome. Elective orthopaedic surgery has additional risks of joint dislocation for arthroplasty surgery, limb lengthening, thermal injury from cement and direct injury from peripheral nerve blocks.The true incidence is unknown, and many cases are diagnosed as neurapraxia with the expectation of a full and timely recovery without the need for intervention. The incorrect assignation of a neurapraxia diagnosis may delay treatment for a higher grade of injury and in addition fails to recognize that a diagnosis of neurapraxia should be made with caution and a commitment to regular clinical review. Untreated, a neurapraxia can deteriorate and result in axonopathy. The failure to promptly diagnose such a nerve injury and instigate treatment may result in further deterioration and expose the clinician to medicolegal challenge.The focus of this review is to raise awareness of iatrogenic peripheral nerve injuries in orthopaedic limb surgery, the importance of regular clinical examination, the role of investigations, timing and nature of interventions and also to provide a guide to when onward referral to a specialist peripheral nerve injury unit is recommended. Cite this article: EFORT Open Rev 2021;6:607-617. DOI: 10.1302/2058-5241.6.200123.

Isolated axillary nerve palsy after liposuction, an exceptional complication

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.

Suspension torture and its physical sequelae

Suspension torture is one of the most common and widespread methods of torture. The objective of the study is to conduct a systematic literature review and produce an overview of suspension torture and its health implications, thus improving the diagnosis of suspension torture victims and documentation of their injuries. The review includes the prevalence, geographical distribution and description of variations of suspension torture. Physical sequelae like nerve injuries, e.g. brachial plexus injuries, scars, joint dislocation and possible causes of death will be described in detail. The results of the review are discussed resulting in recommendations on torture identification and documentation practices and possible future research questions.

Quadrangular Space Syndrome: A Narrative Overview

OBJECTIVE

The purpose of this narrative review of the literature is to provide an overview of quadrangular space syndrome with special attention to its clinical presentation, differential diagnosis, and treatment.

METHODS

A narrative review of the English-language, peer-reviewed literature was performed using the key words "axillary nerve," "quadrangular space," "quadrilateral space," and "posterior humeral circumflex artery." Databases searched were Medline Complete, Cumulative Index to Nursing and Allied Health Literatures, and Index to Chiropractic Literature. The search period was from 1983 through January 2020.

RESULTS

There were 85 articles selected for this review. A summary and overview are provided.

CONCLUSION

Quadrangular space syndrome is an uncommon cause of shoulder pain. Clinicians should consider it as a diagnosis after ruling out more common shoulder conditions and examining other concurrent diseases.

Anatomy of the nerves to the teres minor and the long head of the triceps brachii for electromyography

BACKGROUND

We investigated the branching pattern and topographic anatomy of the nerves to the teres minor (Tm) and the long head of the triceps brachii (LHT) in relation to reference lines extending between surface landmarks, to identify the innervation patterns of, and the optimal needle placement points within, the Tm and the LHT.

METHODS

The anatomical courses of the nerves to the Tm and the LHT were investigated in 37 upper limbs of fresh-frozen cadavers. Distances from the acromion to nerve penetration points, and crossing points of reference lines with the Tm and LHT were measured in 27 cadaveric upper limbs.

RESULTS

The Tm was innervated by the axillary nerve in all specimens in three patterns, and the LHT was innervated exclusively by the radial nerve. Our dissection and measurements indicate that the midpoint of the reference line from the acromion to the inferior angle of the scapula is the optimal needle insertion point for the Tm. The target point for the LHT appears to be the one-third point of the reference line from the acromion to the medial epicondyle, or the two-thirds point of the reference line from the acromion to the axillary fold.

CONCLUSIONS

We investigated the branching pattern of the nerves to the Tm and the LHT and propose optimal needle placement points for electromyography of the Tm and LHT.

Isolated Radial Nerve Palsy as a Complication After Anterior Dislocation of the Glenohumeral Joint: A Case Report and Clinical Review

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.

Sequelae of bilateral luxatio erecta in the acute post-reduction period demonstrated by MRI: a case report and literature review

Luxatio erecta humeri (LEH), also known as inferior shoulder dislocation, is uncommon, comprising about 0.5% of all cases of shoulder dislocation. Synchronous bilateral LEH is exceedingly rare and, to our knowledge, there are no descriptions of axillary nerve injury on magnetic resonance imaging (MRI) following LEH. We present a case of traumatic bilateral LEH in a 59-year-old woman who fell from a fast-moving mobility scooter and sustained direct axial loading forces on the fully abducted shoulders. Both shoulders were successfully reduced using the traction-countertraction technique in the emergency department. In this article, we describe the characteristic features of LEH on plain radiography and the pattern of acute soft-tissue injuries on MRI. We emphasize the importance of reviewing the axillary neurovascular bundle, which by virtue of its location beneath the shoulder joint, is prone to injury in inferior shoulder dislocation and thus has a substantial impact on functional recovery. This important complication is unfortunately not routinely examined by radiologists, partly because of the paucity of literature highlighting its clinical significance.