Development and Assessment of a Patient "Journey Guide" for Adult Traumatic Brachial Plexus Injury.

BACKGROUND: Patients with a traumatic brachial plexus injury (BPI) have previously identified the need for improved patient education tools, emphasizing the importance of communicating outcome expectations, providing attention to the emotional aspects of the injury and the treatment of pain, and acknowledging the needs of caregivers. We created a journey guide, a BPI-specific educational tool, to address these deficiencies. In this study, we determined the acceptability of the journey guide through surveys of and semistructured interviews with patients with a BPI. METHODS: The journey guide was created by a multidisciplinary team focusing on previously defined areas for the improvement of patient education and care delivery related to BPI. To assess the acceptability of the journey guide, we recruited 19 participants from the brachial plexus clinic of our institution and the United Brachial Plexus Network to complete a series of surveys and semistructured interviews. Participants completed surveys regarding their satisfaction with the journey guide, and we conducted semistructured interviews to assess patient BPI experiences and impressions of the journey guide and to seek feedback. Interview transcripts were qualitatively analyzed to determine common themes for improvement. RESULTS: A total of 19 participants with a mean age of 44.7 years were included. The cohort was predominantly male (13 participants) and White (16 participants). The mean time since BPI was 12.9 years, ranging from 2.0 to 39.7 years. On a visual analog scale, satisfaction with the journey guide was given a mean score of 8.4; expected usefulness when a patient is first injured, 8.7; potential for continued use, 7.3; and the fit for the BPI community, 8.8. Qualitative analysis demonstrated a primarily positive view of the guide and identified 4 major themes: (1) visuals and quotes improve clarity and engagement, (2) the journey guide would be most useful immediately following an injury, (3) the journey guide is an effective organizational tool, and (4) it is difficult to orient patients toward future hardships. CONCLUSIONS: The journey guide successfully filled a gap in the current care for BPI and was largely deemed acceptable by patients with a BPI. Specifically, participants found the journey guide to be a concise educational resource and an effective organizational tool. Participants also indicated that areas for improvement include the increased use of graphics and images and recognition of the greater BPI community with which patients can engage.

Toward peripheral nerve mechanical characterization using Brillouin imaging spectroscopy.

Significance: Peripheral nerves are viscoelastic tissues with unique elastic characteristics. Imaging of peripheral nerve elasticity is important in medicine, particularly in the context of nerve injury and repair. Elasticity imaging techniques provide information about the mechanical properties of peripheral nerves, which can be useful in identifying areas of nerve damage or compression, as well as assessing the success of nerve repair procedures. Aim: We aim to assess the feasibility of Brillouin microspectroscopy for peripheral nerve imaging of elasticity, with the ultimate goal of developing a new diagnostic tool for peripheral nerve injury in vivo. Approach: Viscoelastic properties of the peripheral nerve were evaluated with Brillouin imaging spectroscopy. Results: An external stress exerted on the fixed nerve resulted in a Brillouin shift. Quantification of the shift enabled correlation of the Brillouin parameters with nerve elastic properties. Conclusions: Brillouin microscopy provides sufficient sensitivity to assess viscoelastic properties of peripheral nerves.

Future Considerations in the Diagnosis and Treatment of Compressive Neuropathies of the Upper Extremity.

Compressive neuropathies of the upper extremity are among the most common conditions seen by hand surgeons. The diagnoses of carpal tunnel syndrome and cubital tunnel syndrome have traditionally been made by a combination of history, physical examination, and electrodiagnostic testing. However, findings can be nonspecific and electrodiagnostic testing is invasive for the patient. The diagnosis of compressive neuropathies continues to evolve as technology advances, and newer diagnostic modalities predominantly focus on preoperative diagnostic imaging with ultrasound and magnetic resonance imaging/neurography. With the advent of cheaper, faster, and less invasive imaging, the future may bring a paradigm shift away from electrophysiology as the gold standard for the preoperative diagnosis of compressive neuropathies. Intraoperative imaging of nerve health is an emerging concept that warrants further investigation, whereas postoperative imaging of nerve recovery with ultrasound and magnetic resonance imaging currently has a limited role because of nonspecific findings and potential for misinterpretation. Advances in surgical treatment of compressive neuropathies appear to center around the use of imaging for less invasive neurolysis techniques and other adjunctive treatments with nerve decompression. The management of failed peripheral nerve decompressions and recurrent compressive neuropathies remains challenging.

The Influence of Psychosocial Factors on Disability and Expected Improvement Before Surgery for Adult Traumatic Brachial Plexus Injury.

PURPOSE: Psychosocial factors influence pain and recovery after extremity trauma and may be targets for early intervention. This may be of particular interest for patients with adult traumatic brachial plexus injury (BPI), given the broad and devastating impact of the injury. We hypothesized that there would be an association between depressive symptoms, anxiety, and pain interference with preoperative disability and expectations for improvement after BPI surgery. METHODS: We enrolled 34 patients into a prospective multicenter cohort study for those undergoing surgery for adult traumatic BPI. Before surgery, participants completed Patient-Reported Outcome Measurement Information System scales for pain interference, anxiety, and depressive symptoms, and a validated BPI-specific measure of disability and expected improvement. We performed Pearson correlation analysis between pain interference, anxiety symptoms, and depressive symptoms with (A) disability and (B) expected improvement. We created separate linear regression models for (A) disability and (B) expected improvement including adjustment for severity of plexus injury, age, sex, and race. RESULTS: Among 34 patients, there was a moderate, statistically significant, correlation between preoperative depressive symptoms and higher disability. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. There was no association between severity of plexus injury and disability. Depressive symptoms also were moderately, but significantly, correlated with higher expected improvement. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. CONCLUSIONS: Depressive symptoms are associated with greater disability and higher expected improvement before BPI surgery. Screening for depressive symptoms can help BPI teams identify patients who would benefit from early referral to mental health specialists and tailor appropriate expectations counseling for functional recovery. We did not find an association between severity of BPI and patient-reported disability, suggesting either that the scale may lack validity or that the sample is biased. LEVEL OF EVIDENCE: Prognostic II.

Mechanomyography as a Surgical Adjunct for Treatment of Chronic Entrapment Neuropathy: A Case Series.

BACKGROUND: Chronic entrapment neuropathy results in a clinical syndrome ranging from mild pain to debilitating atrophy. There remains a lack of objective metrics that quantify nerve dysfunction and guide surgical decision-making. Mechanomyography (MMG) reflects mechanical motor activity after stimulation of neuromuscular tissue and may indicate underlying nerve dysfunction. OBJECTIVE: To evaluate the role of MMG as a surgical adjunct in treating chronic entrapment neuropathies. METHODS: Patients 18 years or older with cubital tunnel syndrome (n = 8) and common peroneal neuropathy (n = 15) were enrolled. Surgical decompression of entrapped nerves was performed with intraoperative MMG of the hypothenar and tibialis anterior muscles. MMG stimulus thresholds (MMG-st) were correlated with compound muscle action potential (CMAP), motor nerve conduction velocity, baseline functional status, and clinical outcomes. RESULTS: After nerve decompression, MMG-st significantly reduced, the mean reduction of 0.5 mA (95% CI: 0.3-0.7, P < .001). On bivariate analysis, MMG-st exhibited significant negative correlation with common peroneal nerve CMAP ( P < .05), but no association with ulnar nerve CMAP and motor nerve conduction velocity. On preoperative electrodiagnosis, 60% of nerves had axonal loss and 40% had conduction block. The MMG-st was higher in the nerves with axonal loss as compared with the nerves with conduction block. MMG-st was negatively correlated with preoperative hand strength (grip/pinch) and foot-dorsiflexion/toe-extension strength ( P < .05). At the final visit, MMG-st significantly correlated with pain, PROMIS-10 physical function, and Oswestry Disability Index ( P < .05). CONCLUSION: MMG-st may serve as a surgical adjunct indicating axonal integrity in chronic entrapment neuropathies which may aid in clinical decision-making and prognostication of functional outcomes.

Factors Influencing Patient Experience After Cubital Tunnel Syndrome Surgery.

PURPOSE: The purpose of this study was to use qualitative methodology to better understand patient experiences after cubital tunnel surgery, with the goal of identifying areas of improvement in delivery of care. METHODS: Patients who underwent surgery (in situ decompression or anterior transposition) for cubital tunnel syndrome within the last 12 months, which was performed by one of three fellowship-trained hand surgeons, were identified. Participants were invited to an interview regarding "their experiences with ulnar nerve surgery." An interview guide with semistructured, open-ended questions regarding the decision for surgery, treatment goals, and the recovery process was used. Interim data analyses were conducted to assess emerging themes, and interviews were continued until thematic saturation was achieved. RESULTS: Seventeen participants completed interviews; the mean age of study participants was 57 years, and 71% were women. The mean time between surgery and the interview was 6 months. Participants identified the following two key areas that could improve their surgical experience: (1) the need for detailed preoperative education about the surgery and recovery process, (2) and the importance of discussing treatment goals and expectations. Participants suggested providing both written and online resources to patients, including specific details about incision size and recovery process in education materials, and setting expectations for symptom resolution. CONCLUSIONS: Although the overall patient experience after cubital tunnel surgery was positive, participants noted that there is a need for providing improved educational resources and counseling before surgery. CLINICAL RELEVANCE: Addressing education and counseling needs before cubital tunnel surgery will help surgeons to improve delivery of care.

Expectant Management, Tendon Transfer, or Nerve Transfer Surgery for Radial Nerve Injury: A Qualitative Study Exploring Patient Expectations, Goals, and Treatment Experiences.

BACKGROUND: After a radial nerve injury, patients must weigh a complicated set of advantages and disadvantages to observation or surgery. We conducted semistructured interviews to characterize the decision-making process that these patients undertake. METHODS: We recruited participants who were treated with expectant management (nonoperatively), received only a tendon transfer, or received a nerve transfer. Participants completed a semistructured interview that was transcribed and coded to identify recurring themes, to describe the influence of qualitative findings on treatment decision-making. RESULTS: We interviewed 15 participants (5 expectant management, 5 tendon transfer only, and 5 nerve transfer). Participants' primary concerns were returning to work, hand appearance, regaining motion, resuming activities of daily living, and enjoying hobbies. Delayed diagnosis and/or insurance coverage led 3 participants to change treatment from nerve transfer to isolated tendon transfer. Interactions with providers early in diagnosis and treatment had strong effects on how members of the care team were perceived. The hand therapist was the primary person who shaped expectations, provided encouragement, and prompted referral to the treating surgeon. Participants valued debate among the care team members regarding treatment, provided that medical terminology was explained. CONCLUSIONS: This study highlights the importance of initial, collaborative care in setting expectations for patients with radial nerve injuries. Many participants named returning to work and hand appearance as primary concerns. Hand therapists were the primary source of support and information during recovery. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Catastrophic Health Care Expenditure Following Brachial Plexus Injury.

PURPOSE: Brachial plexus injuries (BPIs) are devastating to patients not only functionally but also financially. Like patients experiencing other traumatic injuries and unexpected medical events, patients with BPIs are at risk of catastrophic health expenditure (CHE) in which out-of-pocket health spending exceeds 40% of postsubsistence income (income remaining after food and housing expenses). The individual financial strain after BPIs has not been previously quantified. The purpose of this study was to assess the proportion of patients with BPIs who experience risk of CHE after reconstructive surgery. METHODS: Administrative databases were used from 8 states to identify patients who underwent surgery for BPIs. Demographics including age, sex, race, and insurance payer type were obtained. Inpatient billing records were used to determine the total surgical and inpatient facility costs within 90 days after the initial surgery. Due to data constraints, further analysis was only conducted for privately-insured patients. The proportion of patients with BPIs at risk of CHE was recorded. Predictors of CHE risk were determined from a multivariable regression analysis. RESULTS: Among 681 privately-insured patients undergoing surgery for BPIs, nearly one-third (216 [32%]) were at risk of CHE. Black race and patients aged between 25 and 39 years were significant risk factors associated with CHE. Sex and the number of comorbidities were not associated with risk of CHE. CONCLUSIONS: Nearly one-third of privately-insured patients met the threshold for being at risk of CHE after BPI surgery. CLINICAL RELEVANCE: Identifying those patients at risk of CHE can inform strategies to minimize long-term financial distress after BPIs, including detailed counseling regarding anticipated health care expenditures and efforts to optimize access to appropriate insurance policies for patients with BPIs.

Factors Associated with the Success and Timing of Orthopaedic Surgery Resident Research Thesis Project Publication.

Scholarship and research are important aspects of orthopaedic surgery training. Many orthopaedic surgery residency programs have developed dedicated research curricula, often culminating in a capstone thesis project with the intended goal of peer-reviewed publication. However, data on the success of these programs are scarce. The purpose of the current study was to determine the success rate and time to publication of resident research thesis projects at our own institution while evaluating factors associated with these outcomes. Methods: Resident research thesis projects performed over the past 15 years were aggregated and reviewed. Additional data regarding the projects and former trainees who performed them were collected using public resources which included measures of current academic aptitude (i.e., H-index and number of publications) as well as project and publication characteristics. Cox and linear regression analyses were conducted to assess the relation between numerous predictor variables and the success and time to publication. All analyses were conducted at the 95% confidence interval (CI) level. Results: Sixty-eight (n = 68; 83%) resident research thesis projects were published an average of 2,582.8 days, or roughly 7 years from the start of their residency training. Graduate adjusted H-index was associated with increased success and decreased time to publication (hazard ratio 1.183 [95% CI: 1.059-1.322], p = 0.003). A lower journal impact factor was associated with taking significantly shorter time to reach publication (F(1,66) = 7.839, p = 0.007; Β1 = 146.45, p = 0.007). Study type (clinical vs. laboratory), posttraining practice setting (academic vs. private), and whether the research topic was within the same area of the trainee's matched fellowship(s) did not predict publication success. Discussion/Conclusion: Over the past 15 years, 83% of orthopaedic resident research thesis projects at our institution were published. A higher adjusted H-index was associated with greater completion and faster timing to publication. A lower journal impact factor was also associated with quicker publication. These data highlight the publication metrics of a formalized resident research program and identify factors associated with success and timing of publication.

'Being a patient the rest of my life'- The influence of patient participation during recovery after brachial plexus injury.

BACKGROUND: Given the modest functional outcomes seen after surgical reconstruction and subsequent therapy, increasing attention is being directed to patient satisfaction and psychological aspects of recovery after brachial plexus injury (BPI). PURPOSE: To better understand the recovery course after surgical reconstruction for BPI, we used qualitative interviews and focused on common points of frustration for patients. STUDY DESIGN: Qualitative, interpretive description study METHODS: We conducted semi-structured interviews with BPI patients who were 6+ months post-surgical reconstruction. The interview focused on the patients' experience with BPI, focusing on emotional aspects of recovery. Interviews were transcribed and independently coded by 2 researchers. We used inductive and deductive analysis to organize codes into themes. Once thematic saturation was reached, no additional interviews were conducted. RESULTS: We interviewed 15 BPI patients at median 13 months after surgery (range: 6-43 months). Our analysis revealed: (1) BPI patients expressed variable degrees of participation during recovery, with the indeterminate state of function making it difficult to adjust to life after BPI. (2) The uncertainty while waiting for improved function is frustrating to BPI patients, with many patients expressing concern for activities and moments they are missing due to injury. (3) While many BPI patients feel left out of decision-making, those who felt engaged in the process expressed less frustration and more acceptance of their status. CONCLUSION: Traumatic BPI patients those who felt engaged in decision-making were more receptive to adjustment to their new state of function. When coordinating multidisciplinary care, measures to encourage patients to feel agency over their outcome and to develop self-management skills have the potential to improve patient satisfaction.

Trends in Brachial Plexus Surgery: Characterizing Contemporary Practices for Exploration of Supraclavicular Plexus.

BACKGROUND: There is variability in treatment strategies for patients with brachial plexus injury (BPI). We used qualitative research methods to better understand surgeons' rationale for treatment approaches. We hypothesized that distal nerve transfers would be preferred over exploration and nerve grafting of the brachial plexus. METHODS: We conducted semi-structured interviews with BPI surgeons to discuss 3 case vignettes: pan-plexus injury, upper trunk injury, and lower trunk injury. The interview guide included questions regarding overall treatment strategy, indications and utility of brachial plexus exploration, and the role of nerve grafting and/or nerve transfers. Interview transcripts were coded by 2 researchers. We performed inductive thematic analysis to collate these codes into themes, focusing on the role of brachial plexus exploration in the treatment of BPI. RESULTS: Most surgeons routinely explore the supraclavicular brachial plexus in situations of pan-plexus and upper trunk injuries. Reasons to explore included the importance of obtaining a definitive root level diagnosis, perceived availability of donor nerve roots, timing of anticipated recovery, plans for distal reconstruction, and the potential for neurolysis. Very few explore lower trunk injuries, citing concern with technical difficulty and unfavorable risk-benefit profile. CONCLUSIONS: Our analysis suggests that supraclavicular exploration remains a foundational component of surgical management of BPI, despite increasing utilization of distal nerve transfers. Availability of abundant donor axons and establishing an accurate diagnosis were cited as primary reasons in support of exploration. This analysis of surgeon interviews characterizes contemporary practices regarding the role of brachial plexus exploration in the treatment of BPI.

Gray-Scale and Power Doppler Ultrasound Findings Predictive of Cubital Tunnel Syndrome Severity.

BACKGROUND: The use of ultrasound in the diagnosis of cubital tunnel syndrome (CuTS) is an attractive alternative to electrodiagnostic (EDX) studies, but its utility is binary with poor severity correlation. We hypothesize that increasing ulnar nerve cross-sectional area (CSA) and power Doppler measurement of intraneural vascularity may predict the extent of disease. METHODS: We identified 20 elbows from patients with a history of CuTS and 20 elbows in 10 asymptomatic controls. Electrodiagnosis was performed for symptomatic patients. Gray-scale ultrasound and power Doppler ultrasound were performed to measure CSA and intraneural vascularity in all participants. Functional measures, Boston Carpal Tunnel Questionnaire (BCTQ), and Patient-Reported Outcomes Measurement Information System surveys were also completed. RESULTS: A strong positive correlation was found between CSA and motor nerve conduction velocity (MNCV) decrease between elbow and forearm, which increased when BCTQ >2 was used as a screening criterion. Increased CSA also demonstrated a high positive predictive value (PPV) in predicting MNCV changes, but poor ability to predict axonal loss. In contrast, power Doppler ultrasound demonstrated 100% PPV and 94% negative predictive value (NPV) in predicting severe CuTS (defined as compound motor action potential [CMAP] amplitude <6 mV and electromyography [EMG] findings). CONCLUSIONS: Cross-sectional area is a sensitive method for identifying changes in MNCV and amplitude but does not stratify disease severity, as defined by diminished CMAP amplitude and/or evidence of denervation on EMG. The presence of increased intraneural vascularity is relatively sensitive but highly specific for axonal loss. The combination of nerve CSA, BCTQ screening, and power Doppler ultrasound may provide an alternative means for CuTS assessment.

Early Expression of MMP-9 Predicts Recovery of Tibialis Anterior after Sciatic Nerve Crush Injury.

Background: The purpose of this study was to assess the expression of molecular markers and epineural blood flow after differing degrees of nerve injury to identify potential tools to predict nerve recovery in a rat sciatic nerve model. Methods: A total of 72 rats were divided into nine groups. Each group was subjected to one of three crush injuries, created by applying one of three vascular clamps for 30 seconds. Vascularity was assessed with laser Doppler flowmetry before and after crush, and at nonsurvival surgery. Nonsurvival surgeries were performed 6 hours, 2 weeks, or 6 weeks later with nerve conduction studies and muscle strength testing. Expression of matrix metalloproteinase 9 (MMP-9) and matrix metalloproteinase 2 (MMP-2) in each nerve was quantified using with enzyme linked immunosorbent analysis. Results: Persistent hyperemia was noted in the zone of injury compared with baseline at 2 weeks and 6 weeks in the groups that displayed incomplete recovery. Expression of MMP-9 at 6 hours increased with increasing severity of crush and was inversely related to tibialis anterior muscle force recovery. The ratio of MMP-9:MMP-2 expression correlated well with recovery of compound nerve action potential amplitude at 6 weeks. Conclusions: Resolution of nerve hyperemia may correlate with nerve recovery from trauma, but early measures of nerve blood flow after injury are not prognostic of recovery. Ratio of MMP-9:MMP-2 expression 6 hours after injury correlates with recovery of compound nerve action potential at 6 weeks, while MMP-9 expression alone predicts tibialis anterior recovery. These findings together suggest that increased MMP-9 expression is a potentially useful marker of more severe nerve injury.

Team Approach: Management of Brachial Plexus Injuries.

¼: Traumatic brachial plexus injuries are relatively rare but potentially devastating injuries with substantial functional, psychological, and economic consequences. ¼: Prompt referral (ideally within 6 weeks of injury) to a center with a team of experts experienced in the diagnosis and management of these injuries is helpful to achieving optimal outcomes. ¼: Preoperative and intraoperative decision-making to diagnose and plan reconstructive procedures is complex and must take into account a number of factors, including the time from injury, concomitant injuries, preservation of cervical nerve roots, and the availability of intraplexal and extraplexal donor nerves for nerve transfer. ¼: A team approach is essential to ensure accurate localization of the pathology before surgery and to maximize rehabilitation after surgery, necessitating close contact between the surgical team, physiatrists, radiologists, and therapists.

A system for automated acquisition of digital flexion using a 3-D camera and custom gantry.

Introduction: Automated measurement of digital range of motion (ROM) may improve the accuracy of reporting and increase clinical efficiency. We hypothesize that a 3-D camera on a custom gantry will produce ROM measurements similar to those obtained with a manual goniometer. Methods: A 3-D camera mounted on a custom gantry, was mechanized to rotate 200° around a platform. The video was processed to segment each digit and calculate joint angles in people with no history of any hand conditions or surgery to validate the system. A second-generation prototype was then assessed in people with different hand conditions. Metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint flexion were measured repeatedly with a goniometer and the automated system. The average difference between manual and automatic measurements was calculated along with intraclass correlation coefficients (ICC). Results: In the initial validation, 1,488 manual and 1,488 automated joint measurements were obtained and the measurement algorithm was refined. In people with hand conditions, 688 manual and 688 automated joint measurements were compared. Average acquisition time was 7 s per hand, with an additional 2-3 s required for data processing. ICC between manual and automated data in the clinical study ranged from 0.65 to 0.85 for the MCP joints, and 0.22 to 0.66 for PIP joints. Discussion: The automated system resulted in rapid data acquisition, with reliability varying by type of joint and location. It has the potential to improve efficiency in the collection of physical exam findings. Further developments of the system are needed to measure thumb and distal phalangeal motions.

Influences of Repair Site Tension and Conduit Splinting on Peripheral Nerve Reconstruction.

BACKGROUND: We investigated the use of a conduit splinting technique to mitigate tension at the coaptation site of a rodent nerve defect model to determine the optimal reconstruction method for segmental nerve defects. METHODS: A rat sciatic nerve segmental defect model was created by excising 5mm of the sciatic nerve unilaterally. Four groups of 10 rats were each reconstructed using 1 of 4 techniques: primary repair, repair with conduit splinting, reverse isograft with conduit splinting, and reverse isograft without splinting. Functional outcomes were assessed at 6 weeks by measurement of Sciatic Functional Index (SFI), and sciatic nerves were harvested at the nonsurvival surgery. Histomorphologic measurements were reported as a value normalized to the average measurements of the control side. The primary outcomes were assessment of nerve continuity and the proportion of nerve fibers in the regenerating nerve compared with the uninjured side. RESULTS: The number of repair site rupture rates was lower when a conduit splint was used-less than half of the primary repairs under tension remained intact at 6 weeks. No difference was seen in axon number, size, and density between primary repairs and those augmented by conduit splints, but worse functional outcomes and more debris were present compared with the intact primary repairs. CONCLUSIONS: Nerve conduit splinting reduced rupture rates, particularly for nerve repairs associated with a segmental defect. No significant difference was seen in the number of axons among techniques. Primary nerve repair under tension that did not rupture demonstrated superior SFI.

Systematic Review of the Use of Power Doppler Ultrasound in the Imaging of Peripheral Nerve Compression Neuropathy.

BACKGROUND: Power Doppler ultrasonography has been used as an adjunct in the diagnosis of peripheral nerve compression neuropathy. To better characterize its sensitivity and specificity, the authors performed a systematic review of its use in carpal and cubital tunnel syndrome diagnosis. METHODS: The authors systematically reviewed published literature on the use of power Doppler ultrasound to diagnose peripheral compression neuropathy using Ovid MEDLINE, Embase.com, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, NHS Economic Evaluation Database, World Health Organization International Clinical Trial Repository Platform, and Clinicaltrials.gov. No filters for language, date, or publication type were used. RESULTS: After reviewing 1538 identified studies, 27 publications were included involving 1751 participants with compression neuropathy (2048 median and 172 ulnar). All but three studies examined patients with carpal tunnel syndrome. Heterogeneity between study design and methodology was a noted limitation. Sensitivity and specificity of power Doppler ultrasound in the diagnosis of carpal tunnel syndrome ranged from 2.2 to 93.4 percent, and 89 to 100 percent, respectively, whereas sensitivity for cubital tunnel syndrome was 15.3 to 78.9 percent. There was variability in power Doppler signal detection based on location, with higher sensitivities at the carpal tunnel inlet and in areas of increased nerve swelling. CONCLUSIONS: Power Doppler ultrasound is unreliable as a screening test but appears to increase diagnostic accuracy of ultrasonography in compression neuropathies. It is most beneficial in moderate to severe disease and may be valuable in detecting early cases and in disease surveillance.

An Epidemic Amidst a Pandemic: Musculoskeletal Firearm Injuries During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has substantially impacted the delivery of health care, both through direct care associated with COVID-19 and through more pervasive effects. Our goal was to evaluate whether the number of orthopaedic consultations for firearm injuries differed during the early months of the COVID-19 pandemic compared with the same period in prior years. We hypothesized that the initial months of the COVID-19 pandemic, compared with the same period in prior years, would have a higher number of orthopaedic consultations for firearm injuries and a lower rate of outpatient follow-up after consultations. METHODS: A prospectively collected database of orthopaedic trauma consultations at a level-I trauma center was queried for firearm injuries. We compared the number of orthopaedic consultations for firearm injury during the initial months of the COVID-19 pandemic (March 23, 2020, to September 30, 2020, referred to as the pandemic group) with identical dates from 2017 to 2019 (referred to as the pre-pandemic group). Outpatient follow-up rates, ZIP codes (and associated Area Deprivation Index), and demographic data were compared between the pandemic group and the pre-pandemic group. RESULTS: During the entire study period, 552 orthopaedic consultations for firearm injuries were identified. There was a 63% increase in the daily mean number of firearm injury consultations in the pandemic group, to 1.01, compared with the pre-pandemic group, 0.62 (p < 0.001). There was no difference in the rate of outpatient follow-up: 66% for the pandemic group and 72% for the pre-pandemic group. There was no difference in the percentage of patients from the most socially deprived decile: 45.3% in the pandemic group and 49.5% in the pre-pandemic group. Patients presenting during the pandemic were more often uninsured (75.8%) relative to the pre-pandemic group (67.9%), with a lack of health insurance significantly decreasing the likelihood of outpatient follow-up (p < 0.01). CONCLUSIONS: Compared with the same period in prior years, there was a significant increase in the number of orthopaedic consultations for firearm injuries during the early months of the COVID-19 pandemic in our community. Patient race, socioeconomic status, and outpatient follow-up were similar between the pandemic group and the pre-pandemic group. There was a higher proportion of uninsured patients within the pandemic group and a lower rate of follow-up among those without insurance.

"This New Chapter of Life": Content Analysis of Facebook Posts After Traumatic Brachial Plexus Injury.

Background: After traumatic brachial plexus injuries (BPI), the sudden loss of physical function is often accompanied by psychological distress. Given the complex nature and relative infrequency of the injury, BPI patients will often use online resources for information about their injury as well as emotional support. Questions/Purpose: Recognizing the influence of social media, we sought to search a popular social media platform to identify challenges faced by BPI patients and strategies used to overcome these challenges. Methods: We searched "traumatic brachial plexus injury" on Facebook and selected the 2 most popular BPI support groups. We collected posts regarding traumatic BPI from November 1, 2018 through November 1, 2019. We performed inductive and deductive thematic analysis of the posts to identify recurring topics, knowledge gaps, and peer interaction dynamics. Results: We analyzed 7694 posts from the 2 Facebook support groups. The following themes emerged: (1) BPI patients express discontent regarding the inability to use their arm and the slow or stagnant pace of recovery; (2) BPI patients are frustrated over their inability to retain their preinjury livelihood; and (3) BPI patients emphasize that acceptance and moving on are key components of adjustment to their condition. Some patients described the role of limb amputation in achieving these goals. Conclusions: Our analysis demonstrates the areas in which BPI patients are in need of emotional support. Adjustment to BPI might be facilitated through multidisciplinary care that addresses emotional aspects of recovery and emphasizes self-management skills, in addition to the traditional focus on physical function.

Management of Adult Brachial Plexus Injuries.

Adult brachial plexus injuries result in profound functional deficits, debilitating pain, substantial mental health implications, and extensive economic impacts. Their initial evaluation includes a detailed physical examination, electrodiagnostic studies, advanced imaging, and patient counseling. A team-based approach, led by a peripheral nerve surgeon and including hand therapists, electrodiagnosticians, mental health experts, and pain-management specialists, is used to provide optimal longitudinal care during the lengthy recovery process. The options for the surgical management of brachial plexus injuries include exploration, neurolysis, nerve grafting, nerve transfer, free functional muscle transfer, tendon transfer, arthrodesis, and amputation. When treated within 6 months, the outcomes are favorable for the restoration of essential shoulder and elbow function. Free functional muscle transfer is a powerful tool to address elbow flexion and rudimentary grasp in both primary and delayed settings. The restoration of hand function remains a challenge for patients with complete brachial plexus injury. The purpose of this review is to summarize foundational concepts in diagnosis and management, discuss current trends and controversial topics, and address areas for future investigation.