Brachial plexus injury after shoulder dislocation: a literature review.

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.

Volar retinacular ganglions (flexor tendon sheath ganglions) The results of surgical treatment.

Volar retinacular ganglions are the third most common group of all ganglions located in the hand and wrist region. The purpose of this work is to present our experience in management and the results of operative treatment of volar retinacular ganglions. One-hundred-and-seven patients were operated-on for volar retinacular ganglions between 2000 and 2014. One-hundred-and-eight ganglions were resected. Complications which were observed in five patients postoperatively (digital nerve irritation, restricted range of motion of digital joints) resolved within several weeks. At final follow-up, no ganglion recurrence, impairment of finger mobility, innervation or blood supply were observed in any of the patients.

Benign nerve tumours of the hand (excluding wrist).

INTRODUCTION: Hand tumours of neural origin are rare in clinical practice. The aim of this work is to present our experience in operative treatment of benign nerve tumours located in the hand. Special emphasis has been put on determining the occurrence rates of particular tumour types characterized by their unique histopathological patterns and describing detailed location of the lesions. The obtained results of treatment were assessed. MATERIALS AND METHODS: The study comprised of 26 patients, both female (19) and male (7). The mean age and age range of the female and male patients were 44.8 years (range, 21-73 years) and 39.6 years (range, 21-74 years), respectively. The patients underwent operative treatment for tumours of neurogenic origin located in the hand between the years 1990 and 2013. In total, 31 tumours in 26 patients were removed. The most common site of tumour origin was small cutaneous branches and only exceptionally the tumours arose from common digital nerves (2 patients). No patient was lost to postoperative follow-up. The shortest period of postoperative follow-up covered 1 year. RESULTS: No tumour recurrence was detected during postoperative follow-up examinations. The patients reported neither pain nor presence of paraesthesias. Neurofibromas (17 tumours) predominated in the gathered clinical material, while the second most common group of tumours were schwannomas (12 tumours). CONCLUSIONS: (1) Benign nerve tumours of the hand are rare. Neurofibromas and schwannomas predominate among them. Tumours having other histopathological patterns are extremely uncommon. (2) The prognosis after resection of benign nerve tumours located in the hand is good and the risk of postoperative complications and recurrence is low.

Multiple schwannomas of the digital nerves and superficial radial nerve: two unusual cases of segmental schwannomatosis.

Two cases of segmental sporadic schwannomatosis characterized by unusual location of multiple schwannomas in digital nerves (case 1) and the superficial radial nerve (case 2) are described in this paper. In the first of the described cases, 6 tumours located at the base of the middle finger and in its distal portion were excised from both digital nerves. In the second case, 3 tumours located in the proximal 1/3 and halfway down the forearm were removed from the superficial radial nerve. In both cases, symptoms such as palpable tumour mass, pain, paraesthesias, and positive Tinel-Hoffman sign resolved after operative treatment. Final diagnoses were made based on histopathological examination results. In the second of the described cases, the largest of the excised lesions had features enabling diagnosis of a rare tumour type - ancient schwannoma.

Results of surgical treatment of schwannomas arising from extremities.

Schwannomas are benign neoplasms derived from Schwann cells. In this work, we present our experience in operative management of schwannomas and analyse results of treatment. Clinical material consisted of 34 patients, in whom 44 schwannomas located in extremities were excised between 1985 and 2013. Thirty-five tumours originated from major peripheral nerves and 9 from small nerve branches. Postoperatively, in the first group of tumours, pain resolved in 100%, paresthesias in 83.3%, and Hoffmann-Tinel sign in 91.6% of the patients. Improvement in motor function was noted in 28.5% of the cases, in sensory function: complete in 70%, and partial in 15%. The most frequently affected major peripheral nerves were the ulnar (11 tumours) and median (5 tumours) nerves. Schwannomas originating from small nerve branches were removed without identification of the site of origin. After their resection, definitive healing was achieved. Conclusions. (1) Schwannomas located in extremities arise predominantly from major peripheral nerves, most commonly the ulnar and median nerves. (2) Gradual tumour growth causes exacerbation of compression neuropathy, creating an indication for surgery. (3) In most cases, improvement in peripheral nerve function after excision of schwannoma is achieved. (4) The risk of new permanent postoperative neurological deficits is low.

Treatment of camptodactyly using injection of botulinum neurotoxin.

BACKGROUND: Camptodactyly is usually painless, not caused by trauma, often appearing bilaterally, gradually progressive flexion contracture of the proximal interphalangeal joint mainly on the 5th fingers. OBJECTIVES: The aim of the study was to analyze the efficacy injecting botulinum neurotoxin in short muscles of the hand responsible for the contraction of the proximal interphalangeal joint. MATERIAL AND METHODS: The clinical material consisted of 12 patients (8 women, 4 men) treated with injections of botulinum neurotoxin in 2009-2012. Patients were monitored respectively for 2 weeks, 3 and 6 months and then every six months after the procedure. The observation period after injection of toxin ranged from 18 to 36 months. Our proposed method of treatment is inducing a temporary paralysis of muscles (lumbrical, interosseous) by means of botulinum neurotoxin (Botox). RESULTS: In the majority (10) of patients an improvement and stabilization was achieved just after one injection and there were no disease progression in subsequent controlled studies. These patients continued treatment with usage of redressing extensive splints. In case of the other two patients it was required to repeat the injections. CONCLUSIONS: The preliminary results obtained are promising. This method of treatment requires further studies and long-term follow-ups every six months until release of symptoms of the disease will be achieved. The operative treatment is reserved for severe deformities.

The effect of perinatal brachial plexus lesion on upper limb development.

BACKGROUND: Deficiency in upper limb development is a sequel of the perinatal brachial plexus palsy. The purpose of this study was to evaluate the effect of brachial plexus birth lesion on upper limb development. METHODS: Forty-four patients with unilateral obstetric brachial plexus palsy underwent measurements of both upper extremities. The average age at the time of evaluation was 6.8 years. Active motion was assessed using Gilbert-Raimondi, the modified MRC, and Al-Qattan scales. Paired t test was used for statistical analysis. Correlation between limb length / circumference discrepancy and age / time of surgery was assessed using Pearson correlation coefficient. RESULTS: A decrease in the circumference and length was observed in all limbs with brachial plexus lesion. We found a statistically significant difference between degree of hand length and width decrease and its useful and useless function. We observed a statistically significant difference in measurement: forearm length, hand length and width dependent on the type of surgical procedure (neurolysis, reconstruction). We observed no correlation between age and limb length / circumference discrepancy. We also observed no correlation between time of surgery and limb length / circumference discrepancy. CONCLUSIONS: The decrease in dimensions of the affected limbs occurred predominantly during the period of early childhood. Disparities in dimensions are observed in both cases of deficiency of useful function of upper limb and cases in which functional efficiency appears.

Our experience with surgical treatment of perinatal brachial plexus palsy--results in different types of lesions.

INTRODUCTION: Perinatal brachial plexus palsies can be divided into upper (C5-C6), upper-middle (C5-C6-C7) and total injuries (C5-Th1). The study aimed to evaluate the results of surgical repair in the different types of palsies. MATERIAL AND METHODS: The patient population comprised 80 children who underwent primary repair of the brachial plexus (external neurolysis, internal neurolysis, direct neurorrhaphy, nerve grafts, extraanatomical intraplexus reconstruction, extraanatomical extraplexus reconstruction). 31 patients were additionally subjected to 39 tenomioplasty procedures. Widely recognised assessment scales were used to evaluate the outcome of surgical treatment of different types of palsies in 70 patients. RESULTS: Good and very good post-operative function of the glenohumeral and elbow joints was demonstrated in all patients with upper palsy. In the group of upper-middle injuries, 61.5% of patients presented good and very good function of the shoulder joint and 76.9% had good function of the elbow. In subjects with total brachial plexus palsy, good function of the glenohumeral was demonstrated by 51.2%, good function of the elbow by 61% and 53.6% presented with a functionally useful hand. CONCLUSIONS: 1. While surgical repair may be indicated in brachial plexus injuries at all levels, it is usually inevitable in total and upper-middle palsies. 2. The surgical outcome depends on the extent of baseline damage to the brachial plexus, with the best prognosis in insolated upper palsies.

Neurolysis of the conducting neuroma-in-continuity in perinatal brachial plexus palsy - evaluation of the results of surgical treatment.

UNLABELLED: The aim of the study was to evaluate the surgical treatment results of cases of perinatal brachial plexus palsy with presence of neuroma-in-continuity. Clinical material included 21 children, aged from 3.5 to 36 months, treated surgically between 1996 and 2005. The control examination included 19 children. The shortest postoperative observation period was 4 years. After surgical treatment during clinical evaluation of function dependent on localization of neuroma-in-continuity we observed the following: in upper injury in 1 child good shoulder and elbow function; in upper-middle injuries with neuroma-in-continuity in upper trunk good elbow function in 66.6%, good shoulder function in 83.3% of cases; in upper-middle injuries with neuroma-in-continuity in upper and middle trunk in 1 examined child good function of elbow, shoulder, and wrist; in total injuries with neuroma-in-continuity in upper trunk good elbow function in 75%, and good shoulder function in 50% of cases; in total injuries with neuroma-in-continuity in upper and middle trunk good elbow function in 66.6%, good shoulder function in 33.3%, good wrist function in 66.6% of cases; in total injuries with neuroma-in-continuity in lower trunk grade 2 of motor hand function and return of sensibility to a level of S3+. CONCLUSIONS: The choice of microsurgical technique during surgical treatment of perinatal brachial plexus palsies with neuroma-in-continuity should be based on the whole clinical and intraoperative view. The best results after neurolysis should be expected when neuroma-in-continuity is localized in the upper trunk, the injury corresponds to third degree on Sunderland's scale, and during electric stimulation a normal motor response can be obtained.

Tenomyoplastic procedures to improve shoulder function in the treatment of perinatal brachial plexus palsy.

BACKGROUND: A contracture of the shoulder joint in the course of perinatal brachial plexus palsy significantly affects the function of the upper limb as a whole. The aim of this paper is to present the authors' experience in surgical procedures carried out to improve shoulder joint function impaired as a result of perinatal brachial plexus palsy and evaluate the treatment outcomes. MATERIAL AND METHODS: The study involved 36 patients who underwent 37 tenomyoplastic procedures (subscapular release, teres major transfer, transfer of a portion of the trapezius). Pre- and postoperative shoulder joint function was assessed with the Gilbert scale. RESULTS: Surgical release of the subscapular muscle improved shoulder function in all patients, usually by 1 degree in the Gilbert scale. Teres major transfer improved shoulder function in all 4 patients (grade IV - 3 children, grade V - 1 child). One patient benefited from tenomyoplasty involving the trapezius. CONCLUSIONS: 1. Indications for tenomyoplasty procedures in the region of the shoulder joint may be present both in children who had previously undergone microsurgery and in those in whom rehabilitation had led to a good outcome of perinatal brachial plexus palsy. 2. The fact that most patients improved following tenomyoplastic procedures justifies their advisability. A visible functional improvement of the upper limb can be achieved with a relatively low risk of complications.

Preganglionic injuries in perinatal brachial plexus palsies - results of surgical treatment.

BACKGROUND AND PURPOSE: The authors report their experience in surgical treatment of preganglionic injuries in perinatal brachial plexus palsies. MATERIAL AND METHODS: Clinical material consisted of 16 children, of both sexes, aged from 2.5 to 33 months (mean 6.2 months), treated surgically between 1994 and 2006. The clinical view of the injury and location of preganglionic lesions was analysed and the description of the performed microsurgical techniques is provided. Control clinical examinations included a group of 14 children. The shortest postoperative observation period was 3 years. The currently accepted scales of evaluation of function of particular joints of the upper limb were used. RESULTS: The following outcome was noted after surgical treatment of perinatal brachial plexus palsies with signs of pre- and postganglionic injuries: good shoulder function in 6 cases, and average in 2 others; good elbow function in 4 cases, and average in 7 patients; functional position of the forearm in 9 cases, and good range of pronation and supination in 1 patient; useful function of wrist (flexion/extension) in 4 cases; good motor hand function in 3 cases, and fair in 6 patients. CONCLUSIONS: In preganglionic perinatal brachial plexus injuries located in the upper-middle part, spinal nerve C7 roots avulsion is the most frequently observed, and in the lower part of the brachial plexus, spinal nerve C8 roots avulsion is the most frequently observed. In preganglionic injuries of the brachial plexus, the number of avulsed spinal nerves has an influence on technical possibilities of performing reconstruction procedures, and then the results of the surgical treatment.

[The employment of synthetic biodegradable polymers in reconstructions of the peripheral nerves]. / Zastosowanie syntetycznych polimerów ulegajqcych biodegradacji w rekonstrukcjach nerwów obwodowych.

In this study we presented the possibility of using a synthetic biodegradable polymers to production a conduits employ in reconstructions of the peripheral nerves in experimental studies and medical practice. The aliphatic polyesters are most common used to this purpose. The poly(phosphoesters) and polyurethanes are used rather rare. In study we presented experiences of many authors in employment of the following polymers in experimental conditions. The obtained results were also described. The cases of clinical using of artificial nerve conduits from PGA--polyglycolic acid and PLCL--poly(DL-lactide-epsilon-caprolactone) were also described. Only PGA and PLCL marked as GEM Neurotube and Neurolac were approved to commercial production. The basic aspects of operating technique during reconstructions with artificial nerve conduits and causes of potential failure in microsurgical reconstructions were described. Still existing limitations in employment of artificial nerve tubes were emphasized and the directions of future progress in studies were presented. The possibility of establish of molecular weight of polymers building a tube scaffold and porosity and degradability of the wall create a chance to production an optimal in clinical applications artificial nerve tube.

Comparison of the results of surgical treatment after direct neurorrhaphy and reconstruction with sural nerve grafts in perinatal brachial plexus lesions.

The neurotmesis of elements of the brachial plexus in perinatal lesions requires microsurgical reconstruction. In this study we present our own experiences in surgical treatment of postganglionic lesions in the fifth degree of injury in Sunderland's scale. The clinical material consisted of 14 children aged from 2.5 to 6 months treated surgically due to neurotmesis of the neural elements of the brachial plexus. In 8 cases direct neurorrhaphy and in 6 cases reconstruction with sural nerve grafts were performed. During the operations material from the proximal stumps of the brachial plexus trunks was collected for histopathological examination. The analysis of the material comprised: clinical type of injury, location of postganglionic lesion and type of surgical procedure. The results of surgical treatment were evaluated using generally accepted scales (Gilbert's, Raimondi's, Al-Qattan's and British Medical Research Council scales). Comparison of the results of treatment between the surgical methods was also performed. Better results of surgical treatment were observed after direct neurorrhaphy. In our opinion the indications for these two methods are different and both operative techniques are useful in surgical treatment of perinatal brachial plexus palsy.

[The evaluation of the properties of the silicone-rod and tissue reation after 5,5 years period of implantation]. / Ocena wlasciwosci preta silikonowego oraz odczynu tkanek po 5,5 letnim okresie implantacji.

In this study we presented a case of prolonged detention of the temporary flexor tendon prosthesis after implantation in the hand. The silicone-rod removed after more than 5 years was subject to an examination: scanning microscopy, measurement of hardness, scanning differential calorimetry, spectroscopy in infra-red and resistance examinations. The obtained results were compared with a findings after examinations of the new, not used silicone-rod. The greatest changes were observed in maximum value of tensile strength (sigmaB) of the material after test of uniaxial tensile tests, which was about 30% smaller for a silicone-rod after implantation. The other result of investigations didn't reveal an important differences between a new and a used rod. The comparison of the tissue reaction was performed by collection a part of sheath in described case and a part of sheath produced around a rod after 10 weeks period of implantation. The generation of a capsules consisted of fibrous connective tissue with concomitant inflammation process was observed in both cases in histopathological view. Silicone rubber is a material which preserve its most important properties even after prolonged period of implantation.

[Intraneural ganglion of the tibial nerve--a case report]. / Torbiel galaretowata nerwu piszczelowego--opis przypadku.

This paper describes a surgically treated case of gelatinous cyst of extremely rare location within the tibial nerve at the level of the popliteal fossa. The initial diagnosis was based on imaging exams (MRI, ultrasonography) and surgical exploration of the tumour. The intraneural ganglion was completely removed. Neurological motor and sensory deficits were observed neither in the preoperative nor in the postoperative period. The ultimate diagnosis was established based on the histopathological examination.

Entrapment of the suprascapular nerve: anatomy, etiology, diagnosis, treatment.

Entrapment of the suprascapular nerve is a rare peripheral neuropathy, which can be easily overlooked in the differential diagnosis of shoulder pain and dysfunction. Entrapment of the suprascapular nerve can occur at different locations along the pathway of the nerve. The primary symptoms are pain, weakness, and atrophy of the supraspinate and infraspinate muscles. Differential diagnosis should include brachial plexopathy, disorders of the cervical spine, cervical discopathy, glenohumeral pathology, tendonitis, and rotator cuff tear. Accurate diagnosis facilitates appropriate and timely treatment.

Brachial plexus injuries after radiotherapy - analysis of 6 cases.

Radiation-induced brachial plexus neuropathy is caused by compression of the nerve fibres by dense and inelastic fibrous connective tissue. In this study our own experience in treatment of lesions of the brachial plexus after radiotherapy is presented. The clinical material consisted of 6 patients aged from 40 to 64 years with injuries of the brachial plexus after radiotherapy. The analysis of the material comprised: basic disease, duration of radiotherapy, radiated fields, total dose of radiation, onset and character of symptoms, location and severity of injury. 5 women were qualified for surgical treatment. After neurolysis of the brachial plexus a significant improvement was obtained in 2 cases. In one patient remission of pain and sensory recovery was temporary. No improvement was observed in the remaining 2 patients. Lesions of the brachial plexus after radiotherapy are rare but difficult to prevent. The treatment depends on the grade of severity of injury. Surgical neurolysis is advised for grades 3 and 4 on the LENT-SOMA scale.

[Lower extremity nerves injuries in bone fractures and joint dislocations--etiopathogenesis, treatment]. / Uszkodzenia nerwów konczyn dolnych w zlamaniach kosci i zwichnieciach stawów--etiopatogeneza, leczenie.

Lower extremity nerve injuries accompanying bone fractures and joint dislocations lead to serious disturbances at the lower limbs and caused significant prolongation of the treatment time. Clinical material consisted of 73 patients treated surgically with lower extremity nerve injuries due to bone fractures and joint dislocation. Based on this material we analysed the most frequent localisations of the nerves lesions and the mechanism of injury. The indications to surgical treatment were also described.

[Iatrogenic lesions of the lower extremity nerves--causes, prevention and indications to the surgical treatment]. / Jatrogenne uszkodzenia nerwów koniczyn dolnyc--przyczyny, zapobieganie, wskazania do leczenia operacyjnego.

Iatrogenic lesions of the nerve might be of a deliberate or unintentional character. The clinical material consisted of 73 patients treated surgically with unintentional injuries of the lower limbs nerves. Based on this material we analysed the causes of iatrogenic lesions of the lower limbs nerves and the probably mechanism of injury. The methods of prevention of these complications and the indication to surgical treatment were also described.

[Self-mutilation as a consequence of the perinatal brachial plexus palsy]. / Samookaleczenie dloni jako nastepstwo okoloporodowego uszkodzenia splotu ramiennego.

In this study we presented 2 cases of the self-mutilation of the hand following obstetrical brachial plexus palsy. The mechanism of this behaviour was also discussed.