Digital Nerve Injury: Assessment and Treatment.

Undertreated digital nerve injuries may result in sensory deficits and pain. Early recognition and treatment will optimize outcomes, and providers should maintain a high index of suspicion when assessing patients with open wounds. Acute, sharp lacerations may be amenable to direct repair while avulsion injuries or delayed repairs require adequate resection and bridging with nerve autograft, processed nerve allograft, or conduits. Conduits are most appropriate for gaps less than 15 mm, and processed nerve allografts have demonstrated reliable outcomes across longer gaps.

Clinical and electrophysiological assessment of injury to infrapatellar branch(es) of saphenous nerve during anterior cruciate ligament reconstruction using oblique incision for hamstring graft harvest: A prospective study.

BACKGROUND: One of the complications of arthroscopic reconstruction of anterior cruciate ligament (ACL) using hamstring autograft is injury to the infrapatellar branch of the saphenous nerve (IPBSN) leading to loss of sensation around the knee. Its incidence varies according to the orientation of incision for hamstring graft harvest, with oblique incision having the lowest chance of this injury. Aim of this study was to assess clinically and electrophysiologically injury to IPBSN after ACL reconstruction using oblique incision for hamstring graft harvest. METHODS: Fifty patients that were scheduled to undergo arthroscopic ACL reconstruction were included. All the patients were evaluated both clinically and electrophysiologically preoperatively and at three weeks and six months postoperatively to determine injury to IPBSN. Patient satisfaction after surgery was also compared. RESULTS: IPBSN injury was found to be present in 12 out of 50 patients (24%). Both clinical and electrophysiological data correlated completely. The difference in the length of the skin incisions between IPBSN injured and IPBSN intact patients was found to be statistically significant (P = .0043). The difference in the satisfaction score between patients with injured and intact IPBSN was also found to be statistically significant (P = .02). CONCLUSIONS: Oblique incision for hamstring graft harvest results in lower incidence of IPBSN injury and subsequent sensory loss when compared with similar studies with different skin incisions carried out in the past. Patients undergoing ACL reconstruction should be counseled preoperatively regarding this potential complication, and if this complication occurs, improvement can be expected with time.

Neurologic Assessment and Management of the Multiple Ligament Injured Knee: A Review and Synthesis of Current Evidence.

Knee dislocations are rare but devastating injuries that can often be associated with concomitant nerve injury, most often of the common peroneal nerve. Prompt diagnosis, investigation, and appropriate treatment are important in this subset of patients. This article provides an overview of relevant injury demographics, anatomy, diagnosis, and prognosis, and suggests a treatment algorithm for nerve injury associated with multiligament knee injury.

The Epidemiology of Upper Extremity Nerve Injuries and Associated Cost in the US Emergency Departments.

BACKGROUND: The purpose of our study was to determine the incidence and average cost of nerve injuries in patients presenting with upper extremity trauma. METHODS: The Nationwide Emergency Department Sample database was queried using International Classification of Diseases, Ninth Revision codes specific to peripheral nerve injuries of the upper extremity. Data on the incidence, patient demographics, average number of associated diagnoses, Injury Severity Scale (ISS) score, mechanism of injury, and average cost of care were collected and analyzed. RESULTS: Of 1.58 million upper extremity traumatic injuries, there were 5244 nerve injuries, resulting in an annual incidence of 16.9 per 100,000 persons with an average age of 38.42 years. Ulnar nerve injuries were the most common (3.86 per 100,000) followed by digital nerve (2.96 per 100,000), radial nerve (2.90 per 100,000), and median nerve (2.01 per 100,000). Injuries to the brachial plexus had the highest average ISS score (9.79 ± 0.71) and number of presenting diagnoses (8.85 ± 0.61) while having a lower than average emergency department (ED) cost. Patients with digital nerve injuries had the highest average ED cost ($8931.01 ± $847.03), whereas their ISS score (2.82 ± 0.19) and number of presenting diagnoses (4.92 ± 0.22) were the lowest. The most commonly reported mechanism of injury in this study population was from a laceration (29.2%) followed by blunt injury, fall (14.8%), and being struck (7.20%). Males were 2.14 (2.01-2.28) times more likely to have an injury to an upper extremity nerve and 3.25 (2.79-3.79) times more likely to injure a digital nerve. CONCLUSIONS: While there was a low incidence of upper extremity nerve injuries associated with upper extremity trauma, the ulnar nerve was most frequently injured. Males were twice as likely to sustain a traumatic upper extremity nerve injury, with laceration being the most common mechanism of injury. The average ED cost associated with upper extremity nerve injuries in the United States was determined to be approximately $5779.

Indirect Cost of Traumatic Brachial Plexus Injuries in the United States.

BACKGROUND: Traumatic brachial plexus injuries (BPIs) disproportionately affect young, able-bodied individuals. Beyond direct costs associated with medical treatment, there are far-reaching indirect costs related to disability and lost productivity. Our objective was to estimate per-patient indirect cost associated with BPI. METHODS: We estimated indirect costs as the sum of (1) short-term wage loss, (2) long-term wage loss, and (3) disability payments. Short-term (6-month) wage loss was the product of missed work days and the average earnings per day. The probability of return to work was derived from a systematic review of the literature, and long-term wage loss and disability payments were estimated. Monte Carlo simulation was used to perform a sensitivity analysis of long-term wage loss by varying age, sex, and return to work simultaneously. Disability benefits were estimated from U.S. Social Security Administration data. All cost estimates are in 2018 U.S. dollars. RESULTS: A systematic review of the literature demonstrated that the patients with BPI had a mean age of 26.4 years, 90.5% were male, and manual labor was the most represented occupation. On the basis on these demographics, our base case was a 26-year-old American man working as a manual laborer prior to BPI, with an annual wage of $36,590. Monte Carlo simulation estimated a short-term wage loss of $22,740, a long-term wage loss of $737,551, and disability benefits of $353,671. The mean total indirect cost of traumatic BPI in the Monte Carlo simulations was $1,113,962 per patient over the post-injury lifetime (median: $801,723, interquartile range: $22,740 to $2,350,979). If the probability of the patient returning to work at a different, lower-paying job was doubled, the per-patient total indirect cost was $867,987. CONCLUSIONS: BPI can have a far-reaching economic impact on both individuals and society. If surgical reconstruction enables patients with a BPI to return to work, the indirect cost of this injury decreases. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Novel technique for intraoperative sciatic nerve assessment in complex primary total hip arthroplasty: a pilot study.

INTRODUCTION: Sciatic nerve injury (SNI) is a potentially devastating complication after total hip arthroplasty (THA). Intraoperative neural monitoring has been found in several studies to be useful in preventing SNI, but can be difficult to implement. In this study, we examine the results of using a handheld nerve stimulator for intraoperative sciatic nerve (SN) monitoring during complex THA requiring limb lengthening and/or significant manipulation of the SN. METHODS: A consecutive series of 11 cases (9 patients, 11 hips) with either severe developmental dysplasia of the hip (Crowe 3-4) or other underlying conditions requiring complex hip reconstruction involving significant leg lengthening and/or nerve manipulation. SN function was monitored intraoperatively by obtaining pre- and post-reduction thresholds during component trialing. The results of nerve stimulation were then used to influence intraoperative decision-making. RESULTS: No permanent postoperative SN complications occurred, with an average increase of 28.5 mm in limb length, range (6-51 mm). In 2 out of 11 cases, a change in nerve response was identified after trial reduction, which resulted in an alternate surgical plan (femoral shortening osteotomy and downsizing femoral head). In the remaining cases, the stimulator demonstrated a response consistent with the baseline assessment, assuring that the appropriate lengthening was achieved without SNI. 1 patient had a transient motor and sensory peroneal nerve palsy, which resolved within 2 weeks. CONCLUSIONS: The intraoperative use of a handheld nerve stimulator facilitates surgical decision-making and can potentially prevent SNI. The real-time assessment of nerve function allows immediate corrective action to be taken before nerve injury occurs.

Traumatic peripheral nerve injuries in children: epidemiology and socioeconomics.

OBJECT: Despite the negative effects of peripheral nerve injuries (PNIs) on long-term population health, their true prevalence among pediatric trauma patients is under debate. The authors investigated the prevalence of PNIs among children involved in trauma and investigated associations between PNIs and several patient characteristics. METHODS: The authors performed a retrospective cohort study of pediatric trauma patients who were registered in the National Trauma Data Bank from 2009 through 2011 and who fulfilled the study inclusion criteria. They used regression techniques to investigate the association of demographic and socioeconomic factors with the rate of PNIs among these patients. RESULTS: Of the 245,470 study patients, 50,211 were involved in motor vehicle crashes, 3380 in motorcycle crashes, 20,491 in bicycle crashes, 18,262 in pedestrian accidents, 26,294 in other crashes (mainly involving all-terrain vehicles and snowmobiles), and 126,832 in falls. The respective prevalence of PNIs was 0.66% for motor vehicle crashes, 1% for motorcycle crashes, 0.38% for bicycle crashes, 0.42% for pedestrian accidents, 0.79% for other crashes, and 0.52% for falls. Multivariate logistic regression analysis demonstrated that the following were associated with an increased incidence of PNIs: increased patient age (OR 1.10, 95% CI 1.01-1.20), higher Injury Severity Score (OR 1.10, 95% CI 1.01-1.20), elevated systolic blood pressure at arrival at the emergency room (OR 1.10, 95% CI 1.01-1.20), and increased number of trauma surgeons at the institution (OR 1.10, 95% CI 1.01-1.20). The following were associated with lower incidence of PNIs: female sex (OR 0.94, 95% CI 0.87-1.02), rural hospitals (OR 0.94, 95% CI 0.87-1.02), and urban nonteaching hospitals (OR 0.94, 95% CI 0.87-1.02). CONCLUSIONS: PNIs are more common than previously identified for the pediatric trauma population. These injuries are associated with older age and increased severity of the overall injury.

Documentation of neurovascular status in supracondylar fractures and the development of an assessment proforma.

BACKGROUND: Supracondylar fractures are associated with a high incidence of neurovascular complications. Comprehensive clinical evaluation is a necessity when children with these injuries present to the emergency department. Neurovascular assessment can be difficult due to pain, anxiety and the young age of these patients; however, it is crucial findings are well documented to identify patients requiring urgent surgical intervention, in addition to allowing the neurovascular status to be monitored over time. The aim of this study was to evaluate the preoperative neurovascular documentation in children presenting with displaced supracondylar fractures and devise an emergency department assessment proforma to facilitate comprehensive evaluation. METHODS: A retrospective case-note review was performed on patients with Gartland grades 2 and 3 supracondylar fractures observed in a 2-year period from July 2008 to July 2010. RESULTS: 137 patients were included; only 12 patients (8.8%) and 19 patients (13.9%), respectively, had a complete preoperative neurological or vascular assessment documented. Regarding the individual nerves, 59 (43.1%) patients had median nerve integrity documented, 55 (40.1%) ulnar nerve and 49 (35.8%) radial nerve integrity documented. Only 18 patients (13.1%) had their anterior interosseous nerve (AIN) function documented. CONCLUSIONS: Preoperative documentation of neurovascular status in children with displaced supracondylar fractures was poor. Documentation of AIN examination was particularly poor. The introduction of a proforma (Liverpool upper limb fracture assessment) is proposed to increase documentation of neurovascular assessment and optimise emergency department evaluation of children presenting with upper limb injuries.

Perioperative nerve injury after total shoulder arthroplasty: assessment of risk after regional anesthesia.

BACKGROUND AND OBJECTIVES: One of the most debilitating complications after total shoulder arthroplasty (TSA) is perioperative nerve injury (PNI). Interscalene blockade (ISB) improves clinical outcomes after TSA, but it may increase the risk for PNI. The objective of this large-scale, single-institution cohort study was to test the hypothesis that the use of ISB increases the risk for PNI after elective TSA. METHODS: All patients 18 years and older and undergoing primary elective TSA at Mayo Clinic Rochester between 1993 and 2007 were identified. The primary outcome was the presence of new PNI documented within 3 months of the procedural date. The frequency of PNI was summarized using point estimates, along with 95% confidence intervals (CIs) that were calculated using the Poisson approximation. Multivariable logistic regression was used to evaluate potential risk factors for PNI. RESULTS: A total of 1569 patients underwent elective TSA during the study period; 35 cases met criteria for PNI. The overall incidence of PNI was 2.2% (95% CI, 1.6%-3.1%). Use of ISB was associated with reduced odds for PNI (odds ratio [OR], 0.47; 95% CI, 0.24-0.93; P = 0.031). Sex (OR, 0.85; P = 0.645) and operative time (OR, 1.07 per 30-minute increase; P = 0.263) were not associated with PNI. Most patients with PNI (97%) experienced complete or partial neurologic recovery at last documentation. CONCLUSIONS: The incidence of PNI (2.2%) is consistent with previous estimates in patients undergoing TSA. The use of ISB did not increase the risk for PNI. Most patients with PNI had improvement of their neurologic symptoms. These results further support the use of ISB analgesia for patients undergoing TSA.