Incidence, diagnostics and treatment algorithm of nerve lesions after traumatic shoulder dislocations: a retrospective multicenter study

Scoping Review of the Published Guidelines for the Management of Traumatic Brachial Plexus Injuries

A traumatic brachial plexus injury (TBPI) is a rare yet debilitating condition with a typical incidence of 0.6-3.9 per 100000 annually, predominantly affecting young, economically active males following motorcycle accidents. Delayed diagnosis and treatment are associated with poorer functional outcomes, significant individual disability, and societal burdens, including loss of vocational potential and increased care costs. Individuals in resource-limited settings are particularly vulnerable to receiving suboptimal care. This study aimed to identify and evaluate existing published guidelines for the management of TBPI. A systematic review of literature from nine medical databases, using standardized search methods with results screened for relevance and analyzed using modified Appraisal of Guidelines for Research and Evaluation II-global rating scale (AGREE II-GRS) guidelines to determine quality. The search identified 1163 papers, of which eight met the inclusion criteria: six original research articles, one national guideline, and one departmental guideline. Six studies included treatment algorithms; however, only two categorized nerve transfers by pathology (upper (C5-6 ± C7), lower (C8-T1), or pan-plexus). None provided a sequenced or ordered approach to surgical management. Outcome reporting was inconsistent across studies. A modified AGREE II-GRS analysis indicated that the guidelines were appropriately targeted to relevant professional and patient groups. At present, there are no TBPI guidelines with structured, consensus-based recommendations for managing this condition within acute or secondary care settings in low- and middle-income countries (LMICs). Our study identified eight published and accessible guidelines with treatment algorithms, but none provided a comprehensive management regimen covering all aspects of TBPI care. Developing such a guideline for LMICs is challenging due to the rarity, variability, and complexity of this pathology. Any guideline designed for this context must account for the health economics, resource availability, logistical barriers, and personnel constraints required to ensure a fit-for-purpose management plan for a TBPI service.

[Relevance of Early Structured Diagnosis to Successful Nerve Reconstruction: A Case Report of an Alpine Professional Skier with an Axillary Nerve Injury]

Among high-speed sports, an increased number of high-speed injuries have been observed in alpine downhill racing. We report the case of a young professional ski racer who sustained a shoulder dislocation with an avulsion of the axillary nerve during a World Cup race. After initial treatment was provided for the shoulder dislocation, the patient was left with abduction weakness and a sensory deficit in the region of the deltoid muscle. She underwent electrophysiological and clinical examinations and visited our centre with delay. We immediately performed surgical treatment with a nerve transfer and nerve transplantation. After only 11 months following her fall, she was able to resume her training program. This case report shows the importance of early diagnostic investigation, a visit to a centre of plastic surgery and the good outcome after surgical treatment in patients with peripheral nerve injuries.

High-Resolution Ultrasound Imaging of Axillary Nerve and Relevant Injury

OBJECTIVE

To evaluate the feasibility of axillary nerve (AN) visualization in healthy volunteers and the diagnostic value of AN injury via high-resolution ultrasonography (HRUS).

METHODS

AN was examined by HRUS on both sides of 48 healthy volunteers and oriented the transducer according to three anatomical landmarks: quadrilateral space, anterior to subscapular muscle, and posterior to axillary artery. The maximum short-axis diameter (SD) and cross-sectional area (CSA) of AN were measured at different levels, and AN visibility was graded by using a five-point scale. The patients suspected of having AN injury were assessed by HRUS, and the HRUS features of AN injury were observed.

RESULTS

AN can be visualized on both sides in all volunteers. There was no significant difference in SD and CSA of AN at the three levels between the left and right sides or in SD between males and females. However, the CSA of males at different levels was slightly larger than those of females (P < .05). In most volunteers, AN visibility at different levels was excellent or good, and AN was best displayed anterior to subscapular muscle. Rank correlation analysis revealed that the degree of AN visibility had correlation with height, weight, and BMI. A total of 15 patients diagnosed with AN injury, 12 patients showed diffuse swelling or focal thickening in AN, and 3 patients showed AN discontinuity.

CONCLUSION

HRUS is able to reliably visualize AN, and it could be considered as the first choice for diagnosing AN injury.

The clinical diagnosis and treatment of the shoulder terrible tetrad: a case report and literature review

Traumatic anterior dislocation of the shoulder is often associated with anterior glenoid fracture or bankart injury. It can also be associated with rotator cuff injury, humeral greater tuberosity fracture, or brachial plexus injury. However, there are few clinical reports of all the above-mentioned injuries at the same time. We report a case of the left "Shoulder terrible tetrad." After closed reduction of the left shoulder dislocation, we performed one-stage arthroscopic massive rotator cuff repair (Chinese-Way technique) and anchor repair of the bony bankart injury. After 2 years follow-up, the left shoulder function recovered well and the range of motion was satisfactory. A detailed physical examination and electromyography (EMG) examination should be performed in time to avoid misdiagnosis and missed diagnosis, when the clinical manifestation of brachial plexus nerve injury appears after shoulder dislocation. The repairable rotator cuffs tears and bankart injuries can be repaired under shoulder arthroscopy in one stage.

Nerve Injuries after Glenohumeral Dislocation, a Systematic Review of Incidence and Risk Factors

Glenohumeral dislocation is a common shoulder injury that can result in nerve injury. However, the full impact of these injuries on patient function and recovery remains unclear. This systematic review aimed to determine (1) the incidence, (2) risk factors, and (3) functional outcomes following nerve injuries after glenohumeral dislocation. The study followed PRISMA guidelines and used the PICO strategy. PubMed, EMBASE, Scopus, and Cochrane Collaboration Library databases were searched for studies. Two reviewers independently assessed the study eligibility, and data extraction was conducted by two authors. The quality of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. Thirteen studies comprising 17,087 patients were included. The incidence of nerve injury ranged from 0.4% to 65.5%, with the axillary nerve being most commonly affected. The time to reduction did not significantly affect the incidence of nerve injury. The mechanism of injury, the affected side, associated injuries, and recovery time were found to be potential risk factors for nerve injury. Motor recovery was incomplete in many patients, and sensory recovery was less complete. By synthesizing the available evidence, this systematic review underscores the importance of considering nerve injury in the management of patients with glenohumeral dislocations. Future research can build on these findings to develop targeted prevention and treatment approaches that optimize patient outcomes.

[Post-traumatic pain mononeuropathies]

Neuropathic pain syndrome (NPS) caused by peripheral nerve (PN) injury is a serious clinical problem due to its prevalence, complexity of pathogenesis, significant impact on the quality of life of patients. The issues of epidemiology, pathogenesis and treatment of patients with NBS with PN injury are considered. Modern possibilities of invasive treatment of such patients are discussed.

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.

Luxatio erecta of the humerus: the spectrum of injury of inferior shoulder dislocation and analysis of injury mechanisms

Erecta dislocation/inferior dislocation of the shoulder is considered an uncommon injury and the present knowledge stems from case reports or compilation of cases. We believe that there are reasons to believe that the injury is much more prevalent than previously stated. In this review, we discuss the mechanism of injury and based on the number of patients with unusual injury patterns at our hospitals and in the literature, the anatomical features of different variants of inferior dislocation are described. Only a few patients present with their arm still locked in abduction, and most patients with initial inferior dislocation are diagnosed with other types of dislocation or injury. Irreducible dislocation, with tissue blocking the glenoid appears to be a consequence typical of an initial inferior dislocation. Nerve and vascular injuries are overrepresented, as are humeral avulsion glenohumeral ligaments-injuries. The description of shoulder dislocations should ideally include the dislocation path and not only the final position of the humeral head.

Risk Factors, Management, and Prognosis of Brachial Plexopathy Following Reverse Total Shoulder Arthroplasty

Brachial plexus injuries can have a significant impact on patient outcomes following RTSA by slowing the overall recovery and return of function. Risk factors for brachial plexopathy include traction injury related to arm positioning and exposure during the procedure, direct nerve injury from surgical dissection, and compression injury from retractor placement. Risk of nerve injury can be minimized by limiting the time spent with the arm extended and externally rotated and avoiding excessive traction on the arm during humeral preparation and implant insertion. Prompt identification of postoperative brachial plexopathy is important to optimize the recovery of function.

Distribution of Peripheral Nerve Injuries in Patients with a History of Shoulder Trauma Referred to a Tertiary Care Electrodiagnostic Laboratory

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.