Transferencias tendíneas alrededor del hombro para paciente con secuelas de lesiones de plexo braquial / Tendon transfers around the shoulder for patient with brachial plexus injury sequels

Resumen: Las lesiones de plexo braquial pueden afectar de forma muy significativa la función de los pacientes. El tipo de manejo va a depender de la severidad de la lesión como también de la localización anatómica de ésta. Las transferencias tendíneas alrededor del hombro han surgido como una alternativa efectiva de tratamiento y por lo tanto, debemos considerarlas cuando nos vemos enfrentados a pacientes que la podrían requerir. Existen diversas técnicas de transferencia, las que se utilizan con más frecuencia son las transferencias de trapecio superior, de dorsal ancho y de trapecio inferior, cada una con sus indicaciones y objetivos específicos según el tipo de paciente. Estas cirugías tienen como propósito disminuir el dolor producto de la hipotonía y subluxación glenohumeral como también mejorar el rango de movimiento del hombro, logrando que el paciente lleve su mano al plano que requiera para realizar sus actividades de la vida diaria. Presentaremos algunas de las técnicas de transferencia tendínea de hombro más utilizadas asociadas a una revisión bibliográfica y una descripción de nuestra experiencia con estas cirugías.

Abstract: Brachial plexus lesions can significantly affect patient function. The type of management will depend on the severity of the injury as well as the anatomical location. Tendon transfers around the shoulder have emerged as an effective treatment alternative, and therefore we should consider them when faced with patients who might require it. There are various transfer techniques, within which the most frequently used are upper trapezium, latissimus dorsi and lower trapezium transfers, each with its specific indications and objectives depending on the type of patient. These surgeries aim to decrease the pain resulting from the hypotonia and glenohumeral subluxation as well as improve the range of movement of the shoulder, getting the patient to take his hand to the plane that requires to perform his daily life activities. We will provide a description of some of the most commonly used shoulder tendon transfer techniques associated with a bibliographic review and a description of our experience with these surgeries.

Síndrome de Parsonage-Turner en paciente sometido a cirugía de revascularización miocárdica. caso clínico / Parsonage-Turner syndrome: report of one case

We report a 59-year-old male who, three weeks after a coronary revascularization surgery, reported a sudden intense burning pain in his left upper limb. Two weeks later, he reports a paresis with difficulty to extend his left wrist and fingers. The electromyography showed a severe axonal damage of the radial nerve with distal denervation signs. This clinical picture probably corresponds to a neuralgic amyotrophy, an inflammatory disorder of the brachial plexus known by a number of terms, including Parsonage-Turner syndrome.

Lesiones del nervio torácico largo de Bell. Revisión de conceptos terapéuticos / Long thoracic nerve of Bell. Review of therapeutic management

Las lesiones del nervio torácico producen parálisis del serrato anterior y originan una deformidad característica (escápula alata), que genera debilidad y alteraciones importantes en la movilidad del hombro. En esta revisión, se analizan conceptos sobre anatomía, etiología, presentación clínica y alternativas terapéuticas.

The long thoracic nerve injuries are manifested by a characteristic deformity called scapula alata, causing weakness, and impaired shoulder mobility. In this review current concepts of the anatomy, etiology, clinical presentation and therapeutic management are analyzed.

Bilateral wrist drop complicating axillary crutches mobilization in a young adult / Mano péndula bilateral que complica la movilización con muletas axilares en un adulto joven

OBJECTIVE: Axillary crutches are simple rehabilitative devices that are globally used temporarily or permanently to assist in ambulation of patients and rarely present with complication. This report is about bilateral wrist drop incidentally noticed in a young adult patient mobilized on axillary crutches after internal fixation of a simple right tibia fracture. METHODS: The fracture was fixed by intramedullary nailing and the patient was mobilized on axillary crutches. At six weeks, patient fearfully refused to be commenced on partial weight bearing and at 12 weeks after surgery he was noticed to be totally weightbearing on the bars of the appropriately long axillary crutches and had developed bilateral wrist drop. There was radiological evidence of healing at the fracture sites. Treatment included mobilization on one elbow crutch on the left, physical therapy and nerve stimulation. RESULTS: At six weeks of physiotherapy, the power of the dorsiflexors of the wrists had recovered completely. CONCLUSION: Bilateral posterior cord palsy of brachial plexus could occur even in young healthy patients but total recovery could occur if the diagnosis and treatment are prompt. Patients should be told in unequivocal terms not to weight bear directly on axillary bars.

OBJETIVO: Las muletas axilares son simples dispositivos de rehabilitación que se utilizan en todo el mundo de manera temporal o permanentemente para ayudar a caminar a los pacientes, y raramente presentan complicación. Este trabajo trata de la mano péndula o mano caída, observada incidentalmente en un paciente adulto joven movilizado en muletas axilares, después de la fijación interna de una fractura simple de la tibia derecha. MÉTODOS: La fractura fue fijada mediante clavo intramedular, y el paciente fue movilizado con muletas axilares. A las seis semanas, el paciente se negó temeroso a la iniciación para sostener parcialmente todo su peso con ayuda de muletas, y a las 12 semanas después de la cirugía, se le vio sostener todo su peso sobre las barras de las muletas axilares de longitud adecuada, y había desarrollado mano péndula bilateral. Había evidencia radiológica de curación en los sitios de fractura. El tratamiento incluyó la movilización con una muleta de codo a la izquierda, terapia física, y estimulación nerviosa. RESULTADOS: A las seis semanas de fisioterapia, la capacidad de los dorsiflexores de las muñecas se había recuperado completamente. CONCLUSIÓN: La parálisis del fascículo posterior bilateral del plexo braquial podría ocurrir incluso en pacientes jóvenes sanos, pero la recuperación total podría ocurrir si el diagnóstico y el tratamiento se hacen a tiempo. A los pacientes se les debe decir en términos inequívocos que no deben soportar todo su peso directamente en las barras axilares.

A Five-year retrospective review of infants with Erb-Duchenne's palsy at a teaching Hospital in North Trinidad / Revisión retrospectiva quinquenal de infantes con la parálisis de Erb Duchenne en un Hospital docente en el Norte De Trinidad

Birth injuries are devastating to parents and carers alike. They carry the possibility of residual loss of function to the infant and thus the potential for litigation. The aim of this study was to determine the incidence of Erb-Duchenne's palsy and the identification of any contributing factors. A retrospective review over a five-year period, 2005-2009, was performed and an incidence of 0.94 per 1000 live births was noted. An association between both macrosomia and shoulder dystocia and the development of Erb-Duchenne palsy in the newborn was noted. The authors recommended the use of partograms and improved note documentation in the management of labour.

Las lesiones de nacimiento resultan devastadoras tanto para los padres como para los cuidadores. Ellos conllevan la posibilidad de pérdida residual de función para el infante y por ende la potencialidad de litigios. El objetivo de este estudio fue determinar la incidencia de la parálisis de Erb Duchenne y la identificación de cualquiera de los factores contribuyentes. Se llevó a cabo una revisión retrospectiva por un periodo de cinco años, 2005-2009, y se observó una incidencia de 0.94 por 1000 nacimientos vivos. Se observó una asociación entre macrosomía y distocia del hombro, por una parte, y el desarrollo de la parálisis de Erb Duchenne, por otra parte, en el recién nacido. Los autores recomendaron usar partogramas y mejorar la documentación de las notas clínicas durante el trabajo de parto.

Surgical treatment of adult traumatic brachial plexus injuries: an overview / Tratamento cirúrgico das lesões traumáticas do plexo braquial em adultos: uma visão geral

Traumatic injuries to the brachial plexus in adults are severely debilitating. They generally affect young individuals. A thorough understanding of the anatomy, clinical evaluation, imaging and electrodiagnostic assessments, treatment options and proper timing of surgical interventions will enable nerve surgeons to offer optimal care to patients. Advances in microsurgical technique have improved the outcome for many of these patients. The treatment options offer patients with brachial plexus injuries the possibility of achieving elbow flexion, shoulder stability with limited abduction and the hope of limited but potentially useful hand function.

As lesões traumáticas do plexo braquial em adultos são severamente debilitantes e, em geral, afetam indivíduos jovens. Uma ampla compreensão da anatomia, da avaliação clínica, dos estudos eletrodiagnósticos e por imagem, das opções de tratamento e do momento apropriado para o tratamento cirúrgico irá permitir que o cirurgião de nervos ofereça o tratamento ideal ao paciente. Os avanços na técnica microcirúrgica melhoraram os resultados para muitos desses pacientes. As opções de tratamento oferecem aos pacientes com lesões do plexo braquial a possibilidade de obter flexão do cotovelo, estabilidade do ombro com abdução limitada e a esperança de função limitada mas potencialmente útil da mão.

Sonographic diagnosis of catheter malposition in a patient with postoperative plexus lesion after right internal jugular vein catheterization

Postoperative brachial plexus lesion has been reported only rarely after catheterization of the right internal jugular vein [RIJV], and then is usually considered to be the result of puncture hematoma. We here present the case of plexus brachialis injury after catheterization of the RIJV with ultrasonography showing direct compression of the plexus brachialis by a central venous catheter without evidence of puncture hematoma. Every case of plexus brachialis injury after catheterization of the RIJV should be followed up by an emergency sonogram to rule out hematoma or catheter malposition

[Surveying limb shortening in obstetrical brachial plexus palsy]

Prior investigators have demonstrated the effectiveness of brachial plexus reconstructive surgery in neonates with obstetrical brachial plexus palsy. In the present study, we compared limb growth in a group of neonates underwent surgery with those who were subjected for surgery but refused. Totally, 55 neonates received treatment during a 10-year period were selected. They were assigned in 2 groups: 25 who could not achieve biceps flexion during the first 3 months and underwent reconstructive surgery [case group], and 30 neonates who had been subjected for reconstructive surgery but refused [control]. Finally, the intact and the injured limb were measured from acromion to the third finger. C5, C6, and C7 were the most common affected sites, while, nerve graft was the most common microscopic surgical approach. Limb shortening was 0-3 cm in operated as compared to 3-25 cm in nonoperated neonates [p<0.05]. Neonates who could not achieve biceps flexion during the first 3 months should be scheduled for reconstructive surgery, mainly with nerve grafting

Estudo epidemiológico das lesões traumáticas de plexo braquial em adultos / Epidemiological study of the traumatic brachial plexus injuries in adults

OBJETIVO: Determinar informações epidemiológicas sobre as variáveis relacionadas ao trauma de plexo braquial em adultos. MÉTODO: Foram analisados 35 pacientes, de maneira prospectiva, atendidos consecutivamente no período de um ano. RESULTADOS: A maioria das lesões apresentou localização supraclavicular (62 por cento), sendo 21 lesões por mecanismo de tração (60 por cento), nove por projétil de arma de fogo (25 por cento), três por compressão (8,5 por cento) e dois ferimentos cortantes (5,7 por cento). Acidentes motociclísticos responderam por 54 por cento das causas do trauma. A TC-mielografia identificou avulsão radicular em 16 casos (76 por cento). Melhora neurológica parcial espontânea foi observada em 43 por cento dos pacientes. Dor neuropática foi observada em 25 casos (71 por cento) sendo que em 16 (64 por cento) pôde ser controlada com medicações orais. CONCLUSÃO: Os traumas de plexo braquial são mais freqüentemente associados aos mecanismos de tração, sendo comum identificação de avulsão radicular. Em geral produzem dor no membro afetado e estão associados a lesões em outros órgãos. Na presente série, a incidência calculada para a população de abrangência foi 1,75/100000/ano.

Canadian frame and bilateral brachial plexus neurapraxia.

A reported case of postoperative bilateral brachial plexus neurapraxia associated with the use of a Canadian frame in a patient who had thoracolumbar spinal surgery under general anesthesia. Symmetrical misposition of the upper pads of the Canadian frame underneath both shoulder heads during prolonged surgery led to direct compression on or stretching of the bilateral brachial plexus. This complication should be prevented by carefully placing the patient on this sort of frame.

Botulinum toxin for treatment of cocontractions related to obstetrical brachial plexopathy

A toxina botulínica do tipo A foi introduzida recentemente para o tratamento das co-contrações entre os músculos biceps e triceps, que comprometem a função do cotovelo nas crianças com plexopatia braquial obstétrica. Apresentamos nossa experiência preliminar com esta abordagem. Oito crianças foram tratadas com 2 - 3 U/kg de toxina botulínica injetada nos músculos triceps (4 pacientes) e biceps (4 pacientes), divididas em 2 ou 3 sítios. Todos os pacientes submetidos a injeções no triceps apresentaram melhora persistente da flexão do cotovelo e nenhum precisou de novas aplicações após seguimento de 3 a 18 meses. Três pacientes submetidos a aplicações no biceps apresentaram melhora na extensão do cotovelo, mas nenhum adquiriu força antigravitacional e o efeito durou apenas 3 a 5 meses. Um paciente não respondeu às injeções. Nossos dados sugerem que a toxina botulínica pode ser útil no tratamento de algumas crianças com seqüelas de plexopatia braquial obstétrica.

Evaluación mediante resonancia magnética (RM) de las lesiones obstétricas del plexo braquial / Obstetrical brachial plexus injuries: a MRI diagnostic approach

Propósito. Demostrar la utilidad de la resonancia magnética (RM) en la evaluación de las lesiones obstétricas del plexo braquial. Material y métodos. Fueron evaluados mediante RM de campo alto (1,5 Tesla) 23 pacientes con semiología correspondiente a parálisis del plexo braquial. Se estudió con bobina de cerebro en los planos axial, coronal oblicuo y sagital en secuencias ponderadas para T1, T2 y STIR. Resultados. En cuatro pacientes (17 por ciento) el examen fue considerado como normal. En 19 pacientes (83 por ciento) se obtuvieron hallazgos patológicos (pseudomeningoceles, neuromas, tumor y quiste aracnoideo). Conclusión. La RM es un método no invasivo que logra determinar el sitio y grado de compromiso del plexo braquial, permitiendo de esta manera programar en forma precisa la terapéutica a instituir

Obstetric brachial plexus palsy: a clinical and electrophysiologic evaluation.

BACKGROUND: Obstetrical brachial plexus palsy (OBPP) occurs as sequelae of birth-related trauma, antenatal and parturition related complications. It is associated with varying degrees of functional disability. Electrodiagnostic studies (EDS) are an adjunctive tool and help to localise and prognosticate the outcome of OBPP. METHODS: Fourteen children, presenting with OBPP to the Clinical Neurophysiology Lab, were analyzed. Details of birth history were obtained, and EDS were performed to characterize the lesion. RESULTS: The age ranged from one month to one year. Ten had unilateral and four bilateral brachial palsy. On EDS, five had pan-plexus, six predominantly upper plexus and three lower plexus involvement. A poor re-innervation pattern on EMG correlated with inadequate recovery. CONCLUSION: OBPP, a condition associated with considerable disability, needs to be prevented. Electrodiagnostic studies are a useful adjunctive tool for characterizing the site of injury and prognostication.