Functional deficits as a result of brachial plexus injury in anterior shoulder dislocation.

The incidence of brachial plexus injuries in anterior shoulder dislocation remains relatively uncommon. A retrospective study was conducted to observe the natural neurological recovery of patients following these injuries over a 2-year period. Muscle power according to the Medical Research Council scale and sensation were measured from presentation to discharge. In 28 patients, the power grade of proximal muscles supplied by nine injured nerves failed to improve over a median follow-up of 5 months. There was no statistically significant improvement in sensation over a median follow-up of 6 months. Poorer recovery in muscle power score was related to advancing age, whereby every decade increased the risk by approximately 30%. Anterior shoulder dislocation with a plexus injury carries a risk of permanent nerve injury. Patients should be referred for specialist nerve assessment leading to rehabilitation and timely early nerve reconstruction, if indicated.Level of evidence: IV.

Incidental findings associated with magnetic resonance imaging of the brachial plexus.

OBJECTIVE: The identification and management of incidental findings is becoming increasingly problematic, particularly in relation to brachial plexus imaging because the prevalence is unknown. Therefore, we aimed to estimate the prevalence of incidental findings in symptomatic patients undergoing MRI of the brachial plexus. METHODS: This retrospective cohort study included all children and adults who underwent MRI over a 12-year period, in a tertiary care centre in the UK. An incidental finding was any abnormality which was not a direct injury to or disease-process of the brachial plexus. An "incidentaloma" was defined by the need for further investigation or treatment. Multivariable logistic regression was used to estimate the odds ratio (OR) of an "incidentaloma". To estimate which factors were associated with the incident rate ratio (IRR) of incidental findings, multivariable Poisson regression was used. RESULTS: Overall, 502 scans (72%) reported incidental anomalies. Although the number of MRIs performed per annum increased by 23%, the prevalence of "incidentalomas" remained static (p = 0.766). Musculoskeletal incidental findings were the most prevalent (63%) and when identified, there were a median of 3 incidental anomalies per patient. Overall, 125 (18%) anomalies were "incidentalomas" which required further investigation or treatment. The odds of having further investigation or treatment was strongly related to the frequency of incidental findings [adjusted OR 1.16 (95% CI 1.08, 1.24)] and when a tumour was identified [adjusted OR 2.86 (95% CI 1.81, 4.53)]. The number of incidental findings recorded per scan increased when trainees co-reported with consultants [adjusted IRR 0.36 (95% CI 0.05, 0.67)] and in the presence of a tumour [adjusted IRR 0.39 (95% CI 0.28, 0.49)]. CONCLUSIONS: The prevalence of clinically important incidental findings on brachial plexus MRI is lower than organ-specific imaging, but still 18% of scans identified an 'incidentaloma' which required further investigation or treatment. ADVANCES IN KNOWLEDGE: This cohort study shows that approximately 1 in 5 symptomatic patients undergoing a brachial plexus MRI had a clinically important incidental findings, which required further investigation or treatment. This information can be used to inform patients consenting to clinical or research imaging.

The Comparative Efficacy of Chlorhexidine Gluconate and Povidone-iodine Antiseptics for the Prevention of Infection in Clean Surgery: A Systematic Review and Network Meta-analysis.

OBJECTIVE: There is uncertainty around preoperative skin antisepsis in clean surgery. Network meta-analysis provides more precise estimates than standard pairwise meta-analysis and can rank interventions by efficacy, to better inform clinical decisions. BACKGROUND: Infection is the most common and costly complication of surgery. The relative efficacy of CHG and PVI based skin antiseptics in clean surgery remains unclear. METHODS: We searched for randomized or nonrandomized studies comparing the effect of different preparations of CHG and PVI on the dichotomous outcome of surgical site infection. We included studies of adults undergoing clean surgery. We excluded studies concerning indwelling vascular catheters, blood sampling, combination antiseptics or sequential applications of different antiseptics. We performed a network meta-analysis to estimate the relative efficacy of interventions using relative risks (RR). RESULTS: We included 17 studies comparing 5 antiseptics in 14,593 individuals. The overall rate of surgical site infection was 3%. Alcoholic CHG 4%-5% was ranked as the most effective antiseptic as it halved the risk of surgical site infection when compared to aqueous PVI [RR 0.49 (95% confidence interval 0.24, 1.02)] and also to alcoholic PVI, although uncertainty was larger [RR 0.51 (95% confidence interval 0.21, 1.27)]. Adverse events related to antiseptic application were only observed with patients exposed to PVI. CONCLUSIONS: Alcoholic formulations of 4%-5% CHG seem to be safe and twice as effective as PVI (alcoholic or aqueous solutions) in preventing infection after clean surgery in adults. Our findings concur with the literature on contaminated and clean-contaminated surgery, and endorse guidelines worldwide which advocate the use of alcoholic CHG for preoperative skin antisepsis. REGISTRATION: PROSPERO ID CRD42018113001.