Fibrin Glue Acutely Blocks Distal Muscle Contraction after Confirmed Polyethylene Glycol Nerve Fusion: An Animal Study.

Background: Polyethylene glycol (PEG) is a synthetic, biodegradable, and hyperosmotic material promising in the treatment of acute peripheral nerve injuries. Our team set out to investigate the impact of fibrin glue upon PEG fusion in a rat model. Methods: Eighteen rats underwent sciatic nerve transection and PEG fusion. Electrophysiologic testing was performed to measure nerve function and distal muscle twitch. Fibrin glue was applied and testing repeated. Due to preliminary findings, fibrin glue was applied to an uncut nerve in five rodents and testing was conducted before and after glue application. Mann-Whitney U tests were used to compare median values between outcome measures. A Shapiro-Wilk test was used to determine normality of data for each comparison, significance set at a P value less than 0.05. Results: PEG fusion was confirmed in 13 nerves with no significant change in amplitude (P = 0.054), latency (P = 0.114), or conduction velocity (P = 0.114). Stimulation of nerves following PEG fusion produced distal muscle contraction in 100% of nerves. Following application of fibrin glue, there was a significant reduction in latency (P = 0.023), amplitude (P < 0.001), and conduction velocity (P = 0.023). Stimulation of the nerve after application of fibrin glue did not produce distal muscle twitch. Five uncut nerves with fibrin glue application blocked distal muscle contraction following stimulation. Conclusions: Our data suggest that fibrin glue alters the nerve's function. The immediate confirmation of PEG fusion via distal muscle twitch is blocked with application fibrin glue in this experimental model. Survival and functional outcome studies are necessary to understand if this has implications on the long-term functional outcomes.

Acute Compartment Syndrome After Isolated Soleus Tear in an Elderly Recreational Athlete.

CASE: A 62-year-old man without significant medical history (no anticoagulation) presented to the emergency department with intense leg pain following a short track race, during which he felt a pop in his calf. His physical exam was highly concerning for acute compartment syndrome (ACS) despite the lack of a typical mechanism or fracture. Compartment pressures were measured and found to be significantly elevated. He underwent compartment releases revealing a medial soleus tear with 400-500 cc hematoma. CONCLUSION: The case presents a patient with ACS after a soleus muscle tear. Prompt recognition and fasciotomy led to a good clinical outcome. Physicians should recognize that not only gastrocnemius tears can lead to compartment syndrome.

At Home Photography-Based Method for Measuring Wrist Range of Motion.

Purpose To determine the reliability of wrist range of motion (WROM) measurements based on digital photographs taken by patients at home compared with traditional measurements done in the office with a goniometer. Methods Sixty-nine postoperative patients were enrolled in this study at least 3 months postoperatively. Active and passive wrist flexion/extension and radial/ulnar deviation were recorded by one of the two attending surgeons with a 1-degree resolution goniometer at the last postoperative office visit. Patients were provided an illustrated instruction sheet detailing how to take digital photographic images at home in six wrist positions (active and passive flexion/extension, and radial/ulnar deviation). Wrist position was measured from digital images by both the attending surgeons in a randomized, blinded fashion on two separate occasions greater than 2 weeks apart using the same goniometer. Reliability analysis was performed using the intraclass correlation coefficient to assess agreement between clinical and photography-based goniometry, as well as intra- and interobserver agreement. Results Out of 69 enrolled patients, 30 (43%) patients sent digital images. Of the 180 digital photographs, only 9 (5%) were missing or deemed inadequate for WROM measurements. Agreement between clinical and photography-based measurements was "almost perfect" for passive wrist flexion/extension and "substantial" for active wrist flexion/extension and radial/ulnar deviation. Inter- and intraobserver agreement for the attending surgeons was "almost perfect" for all measurements. Discussion This study validates a photography-based goniometry protocol allowing accurate and reliable WROM measurements without direct physician contact. Passive WROM was more accurately measured from photographs than active WROM. This study builds on previous photography-based goniometry literature by validating a protocol in which patients or their families take and submit their own photographs. Clinical Relevance Patient-performed photography-based goniometry represents an alternative to traditional clinical goniometry that could enable longer-term follow-up, overcome travel-related impediments to office visits, improve convenience, and reduce costs for patients.

Successful Nerve Transfers for Traumatic Brachial Plexus Palsy in a Septuagenarian: A Case Report.

Background: Conventional wisdom and the available literature demonstrate compromised outcomes following nerve reconstruction for traumatic brachial plexus palsy in the elderly. We present a 74-year-old male who was reconstructed with multiple nerve transfers for brachial plexus palsy after a ski accident. Methods: Triceps to axillary nerve transfer, spinal accessory to suprascapular nerve transfer, and ulnar to musculocutaneous nerve transfer were performed 16 weeks post injury. Results: At 11 years post-op, the patient could abduct to 65° and forward flex at M4 strength, limited only by painful glenohumeral arthritis. Elbow flexion was M5- at both the biceps and brachialis, and bulk and tone were nearly symmetrical with the opposite side. Eleven-year electrodiagnostic studies demonstrated reinnervation and improved motor unit recruitment all affected muscles. Conclusion: This case questions the widely held dogma that older patients who undergo brachial plexus reconstruction do poorly. Given the short reinnervation distance and optimal donor nerve health, nerve transfers may be an excellent option for healthy older patients with traumatic brachial plexus palsy.

Subclavius posticus: an anomalous muscle in association with suprascapular nerve compression in an athlete.

UNLABELLED: Subclavius posticus is a rare anomalous muscle that traverses from the costal cartilage of the first rib posterolaterally to the superior border of the scapula. We present an athlete who presented with incapacitating suprascapular nerve compression associated with a subclavius posticus diagnosed by MRI. Symptoms were relieved, and function was restored by decompression of the nerve and excision of the anomalous muscle. We present this case to bring awareness of the subclavius posticus as an anatomic variant and a potential additional source for compression in suprascapular neuropathy. We recommend high-resolution magnetic resonance imaging to evaluate cases of isolated suprascapular neuropathy. LEVEL OF EVIDENCE: V.

Soft tissue complications of dorsal versus volar plating for ulnar shortening osteotomy.

PURPOSE: To compare the results and complications of fixed-angle dorsal locking plate fixation for ulnar shortening osteotomy (USO) with the conventional technique of volar plating. METHODS: We performed a retrospective review of 32 patients undergoing USO on 34 wrists and compared the outcomes of 16 consecutive cases with dorsal 2.4/2.7-mm fixed-angle plating and 18 consecutive cases with volar 3.5-mm plating. A minimum of 12 months' follow-up was used to assess outcomes. Primary outcomes were painful hardware and removal of symptomatic implants. Secondary outcomes were pain, Patient-Rated Wrist Evaluation, range of motion, time to union, grip strength, and complications. RESULTS: There were no significant differences in Patient-Rated Wrist Evaluation, pain score, range of motion, or time to union. Relative grip strength compared with the contralateral upper extremity in the dorsal group was higher than the volar group. After adjusting for hand dominance, dorsal plating was significantly associated with higher relative grip strength. There were 2 complications in the dorsal group, including one case with painful hardware. This was significantly lower than in the volar group, which had 10 complications including 2 nonunions and 6 cases of hardware-related soft tissue irritation. CONCLUSIONS: Both volar and dorsal plating techniques for USO yielded good functional outcomes. There was a higher incidence of painful hardware requiring removal of implants in the volar group. Based on these findings, we advocate dorsal plate position using a smaller fixed-angle plate for USO in ulnar impaction syndrome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Long-nerve grafts and nerve transfers demonstrate comparable outcomes for axillary nerve injuries.

PURPOSE: To compare the functional and EMG outcomes of long-nerve grafts to nerve transfers for complete axillary nerve palsy. METHODS: Over a 10-year period at a single institution, 14 patients with axillary nerve palsy were treated with long-nerve grafts and 24 patients were treated with triceps-to-axillary nerve transfers by the same surgeon (S.W.W.). Data were collected prospectively at regular intervals, beginning before surgery and continuing up to 11 years after surgery. Prior to intervention, all patients demonstrated EMG evidence of complete denervation of the deltoid. Deltoid recovery (Medical Research Council [MRC] grade), shoulder abduction (°), improvement in shoulder abduction (°), and EMG evidence of deltoid reinnervation were compared between cohorts. RESULTS: There were no significant differences between the long-nerve graft cohort and the nerve transfer cohort with respect to postoperative range of motion, deltoid recovery, improvement in shoulder abduction, or EMG evidence of deltoid reinnervation. CONCLUSIONS: These data demonstrate that outcomes of long-nerve grafts for axillary nerve palsy are comparable with those of modern nerve transfers and question a widely held belief that long-nerve grafts do poorly. When healthy donor roots or trunks are available, long-nerve grafts should not be overlooked as an effective intervention for the treatment of axillary nerve injuries in adults with brachial plexus injuries. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.