Brachial plexus injury after shoulder dislocation: a literature review.

Brachial plexus injuries are among the rarest but at the same time the most severe complications of shoulder dislocation. The symptoms range from transient weakening or tingling sensation of the upper limb to total permanent paralysis of the limb associated with chronic pain and disability. Conflicting opinions exist as to whether these injuries should be treated operatively and if so when surgery should be performed. In this review, available literature dedicated to neurological complications of shoulder dislocation has been analysed and management algorithm has been proposed. Neurological complications were found in 5.4-55% of all dislocations, with the two most commonly affected patient groups being elderly women sustaining dislocation as a result of a simple fall and young men after high-energy injuries, often multitrauma victims. Infraclavicular part of the brachial plexus was most often affected. Neurapraxia or axonotmesis predominated, and complete nerve disruption was observed in less than 3% of the patients. Shoulder dislocation caused injury to multiple nerves more often than mononeuropathies. The axillary nerve was most commonly affected, both as a single nerve and in combination with other nerves. Older patient age, higher energy of the initial trauma and longer period from dislocation to its reduction have been postulated as risk factors. Brachial plexus injury resolved spontaneously in the majority of the patients. Operative treatment was required in 13-18% of the patients in different studies. Patients with suspected neurological complications require systematic control. Surgery should be performed within 3-6 months from the injury when no signs of recovery are present.

Use of collision tests to identify physiological differences between the median and ulnar nerves.

INTRODUCTION: Median and ulnar nerves are used in comparative electrophysiological studies. We analyzed the conduction values in these hand nerves in healthy volunteers to find any physiological differences between them. METHODS: We performed standard conduction studies and conduction velocity distribution (CVD) tests with estimation of 3 quartiles in 31 healthy right-handed volunteers (17 women, 14 men) with a mean age of 44.8 ± 15.5 years. RESULTS: The conduction velocities in all quartiles of CVD tests were statistically faster in the ulnar nerve (P < 0.00001), with no differences in the spread of conduction values and no differences between sides. In the ulnar nerve, CVD velocities in all quartiles were faster in the female group (P < 0.05). DISCUSSION: The ulnar nerve has more fibers conducting with high velocities than does the median nerve. Electrophysiological comparisons between hand nerves must be performed carefully. Muscle Nerve 59:470-474, 2019.

Volar retinacular ganglions (flexor tendon sheath ganglions) The results of surgical treatment.

Volar retinacular ganglions are the third most common group of all ganglions located in the hand and wrist region. The purpose of this work is to present our experience in management and the results of operative treatment of volar retinacular ganglions. One-hundred-and-seven patients were operated-on for volar retinacular ganglions between 2000 and 2014. One-hundred-and-eight ganglions were resected. Complications which were observed in five patients postoperatively (digital nerve irritation, restricted range of motion of digital joints) resolved within several weeks. At final follow-up, no ganglion recurrence, impairment of finger mobility, innervation or blood supply were observed in any of the patients.

Position of Immobilization After First-Time Traumatic Anterior Glenohumeral Dislocation: A Literature Review.

Anterior glenohumeral dislocation affects about 2% of the general population during the lifetime. The incidence of traumatic glenohumeral dislocation ranges from 8.2 to 26.69 per 100 000 population per year. The most common complication is recurrent dislocation occurring in 17-96% of the patients. The majority of patients are treated conservatively by closed reduction and immobilization in internal rotation for 2-3 weeks. However, no clear conservative treatment protocol exists. Immobilization in external rotation can be considered an alternative. A range of external rotation braces are commercially available. The purpose of this work was to review the current literature on conservative management of glenohumeral dislocation and to compare the results of immobilization in internal and external rotation. A comprehensive literature search and review was performed using the keywords "glenohumeral dislocation", "shoulder dislocation", "immobilization", "external rotation", and "recurrent dislocation" in PubMed, MEDLINE, Cochrane Library, Scopus, and Google Scholar databases from their inceptions to May 2016. Three cadaveric studies, 6 imaging studies, 10 clinical studies, and 4 meta-analyses were identified. The total number of 734 patients were included in the clinical studies. Literature analysis revealed better coaptation of the labrum on the glenoid rim in external rotation in cadaveric and imaging studies. However, this tendency was not confirmed by lower redislocation rates or better quality of life in clinical studies. On the basis of the available literature, we cannot confirm the superiority of immobilization in external rotation after glenohumeral dislocation when compared to internal rotation. A yet-to-be-determined group of patients with specific labroligamentous injury pattern may benefit from immobilization in external rotation. Further studies are needed to identify these patients.

Chitosan and its composites: Properties for use in bone substitution.

For many years, research has been carried out on finding an ideal bone substitute. Chitosan (CTS) is a naturally occurring polysaccharide, obtained mainly from, inter alia, the shells of crustaceans. It is characterized by its high level of biocompatibility, biodegradability and antimicrobial properties as well as its support in the healing of wounds. Chitosan, due to its ability to form porous structures, can be used in the production of scaffolds used in the treatment of bone defects. There are numerous studies on the use of CTS in combination with other substances which aim to improve its biological and mechanical properties. The combination of chitosan with the calcium phosphate hydroxyapatite (HAp) has been extensively tested. The objective of the current studies is to verify the properties of scaffolds consisting of chitosan and other substances like polybutylene succinate, human bone marrow mesenchymal stem cells (hBMSCs), collagen, alginate, transforming growth factor - ß (TGF-ß), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF) or bone morphogenetic proteins (BMP). The aim of the current research is to develop a scaffold with sufficiently good mechanical properties. Trials are underway with many of the biological and synthetic components affecting the biological properties of chitosan. This will allow for the creation of a substitute that fully meets the conditions for an ideal artificial bone.

The role of chitin and chitosan in peripheral nerve reconstruction.

Chitin is a natural polysaccharide commonly found in nature and chitosan is its partially deacetylated derivative. The properties of both biopolymers allow their wide use in medicine and various industries. This paper presents the possibilities offered by chitin and chitosan for the creation of neurotubes utilized in peripheral nerve repair procedures. In the initial part of this manuscript, experimental studies on both polysaccharides carried out by numerous authors have been presented and their results have been discussed. Further, basic information on Reaxon® Nerve Guide, being the first chitosan tube approved for clinical use, is provided. Finally, existing limitations in the optimal use of chitosan tubes in peripheral nerve reconstruction have been pointed out. It is expected that modification of the properties of chitosan itself as well as enriching neurotubes with components of extracellular matrix, cells, growth factors and filaments will further improve the results of nerve regeneration obtained with chitosan-based nerve conduits.

Effect of Collateral Sprouting on Donor Nerve Function After Nerve Coaptation: A Study of the Brachial Plexus.

BACKGROUND The aim of the present study was to evaluate the donor nerve from the C7 spinal nerve of the rabbit brachial plexus after a coaptation procedure. Assessment was performed of avulsion of the C5 and C6 spinal nerves treated by coaptation of these nerves to the C7 spinal nerve. MATERIAL AND METHODS After nerve injury, fourteen rabbits were treated by end-to-side coaptation (ETS), and fourteen animals were treated by side-to-side coaptation (STS) on the right brachial plexus. Electrophysiological and histomorphometric analyses and the skin pinch test were used to evaluate the outcomes. RESULTS There was no statistically significant difference in the G-ratio proximal and distal to the coaptation in the ETS group, but the differences in the axon, myelin sheath and fiber diameters were statistically significant. The comparison of the ETS and STS groups distal to the coaptation with the controls demonstrated statistically significant differences in the fiber, axon, and myelin sheath diameters. With respect to the G-ratio, the ETS group exhibited no significant differences relative to the control, whereas the G-ratio in the STS group and the controls differed significantly. In the electrophysiological study, the ETS and STS groups exhibited major changes in the biceps and subscapularis muscles. CONCLUSIONS The coaptation procedure affects the histological structure of the nerve donor, but it does not translate into changes in nerve conduction or the sensory function of the limb. The donor nerve lesion in the ETS group is transient and has minimal clinical relevance.

Causes of Secondary Radial Nerve Palsy and Results of Treatment.

BACKGROUND The aim of this study was to analyze the causes that lead to secondary damage of the radial nerve and to discuss the results of reconstructive treatment. MATERIAL AND METHODS The study group consisted of 33 patients treated for radial nerve palsy after humeral fractures. Patients were diagnosed based on clinical examinations, ultrasonography, electromyography, or nerve conduction velocity. During each operation, the location and type of nerve damage were analyzed. During the reconstructive treatment, neurolysis, direct neurorrhaphy, or reconstruction with a sural nerve graft was used. The outcomes were evaluated using the Medical Research Council (MRC) scales and the quick DASH score. RESULTS Secondary radial nerve palsy occurs after open reduction and internal fixation (ORIF) by plate, as well as by closed reduction and internal fixation (CRIF) by nail. In the case of ORIF, it most often occurs when the lateral approach is used, as in the case of CRIF with an insertion interlocking screws. The results of the surgical treatment were statistically significant and depended on the time between nerve injury and revision (reconstruction) surgery, type of damage to the radial nerve, surgery treatment, and type of fixation. Treatment results were not statistically significant, depending on the type of fracture or location of the nerve injury. CONCLUSIONS The potential risk of radial nerve neurotmesis justifies an operative intervention to treat neurological complications after a humeral fracture. Adequate surgical treatment in many of these cases allows for functional recovery of the radial nerve.

Chemical Substances Used in the Treatment of Ganglions Located in the Hand and Wrist.

The aim of this work was to compare different chemical substances used in the treatment of ganglions located in the hand and wrist region. Their basic properties and mechanisms of action have been described. Moreover, the risks associated with the use of particular substances have been highlighted and potential complications connected with their administration have been discussed. On the basis of the available literature, the results of ganglion aspiration treatment followed by an injection of a chemical substance into the cyst cavity have been assessed. In the authors' opinion, due to the existing risk of complications associated with this treatment, as well as the relatively high rate of ganglion recurrence, this procedure should only be performed by qualified medical personnel. The authors recommend observation in cases of asymptomatic ganglions of the hand and wrist, and operative treatment in cases in which pain, restriction of limb mobility and weakening of handgrip strength are observed.

Peripheral nerve tumours: 30-year experience in the surgical treatment.

Peripheral nerve tumours are relatively rare type of soft tissue tumours. The aim of this work is to present our experience with surgical treatment of this type of lesions. Clinical material consists of 94 patients (56 females, 38 males), in whom 101 tumours deriving from peripheral nervous system were removed. The patients underwent surgical treatment between 1983 and 2012. Tumours occurred mainly in the upper extremity (72 tumours), less often in the lower extremity (25 tumours). Lesions developed in major peripheral nerves (51 tumours) and small nerve branches (50 tumours). The most common symptoms reported before surgery included presence of tumour mass (100 %), positive Hoffmann-Tinel sign (95.6 %) and paraesthesia (93.4 %). Less often sensory deficit (89.1 %) and pain (71.7 %) were observed. Motor deficit was the least common manifestation (41.3 %). Benign tumours prevailed in presented material (94 tumours). In 7 cases, malignant peripheral nerve sheath tumour (MPNST) was identified. As a result of surgical treatment in the group of tumours deriving from major peripheral nerves, in 87.8 % of the patients, pain relief was achieved; in 84 %, Hoffmann-Tinel sign was negative; and in 79 %, paraesthesia resolved. Sensory function improvement was observed in 51.2 % of the patients while motor function improved in 26.3 % of the patients. None of the patients experienced tumour relapse. In the group of tumours deriving from small nerve branches, 47 patients had no signs of tumour recurrence. One female patient diagnosed with MPNST suffered a relapse. Obtaining satisfactory results of peripheral nerve tumour treatment requires both careful differential diagnosis and well thought-out strategy at every stage of therapeutic management.

Benign nerve tumours of the hand (excluding wrist).

INTRODUCTION: Hand tumours of neural origin are rare in clinical practice. The aim of this work is to present our experience in operative treatment of benign nerve tumours located in the hand. Special emphasis has been put on determining the occurrence rates of particular tumour types characterized by their unique histopathological patterns and describing detailed location of the lesions. The obtained results of treatment were assessed. MATERIALS AND METHODS: The study comprised of 26 patients, both female (19) and male (7). The mean age and age range of the female and male patients were 44.8 years (range, 21-73 years) and 39.6 years (range, 21-74 years), respectively. The patients underwent operative treatment for tumours of neurogenic origin located in the hand between the years 1990 and 2013. In total, 31 tumours in 26 patients were removed. The most common site of tumour origin was small cutaneous branches and only exceptionally the tumours arose from common digital nerves (2 patients). No patient was lost to postoperative follow-up. The shortest period of postoperative follow-up covered 1 year. RESULTS: No tumour recurrence was detected during postoperative follow-up examinations. The patients reported neither pain nor presence of paraesthesias. Neurofibromas (17 tumours) predominated in the gathered clinical material, while the second most common group of tumours were schwannomas (12 tumours). CONCLUSIONS: (1) Benign nerve tumours of the hand are rare. Neurofibromas and schwannomas predominate among them. Tumours having other histopathological patterns are extremely uncommon. (2) The prognosis after resection of benign nerve tumours located in the hand is good and the risk of postoperative complications and recurrence is low.

Results of surgical treatment of tarsal tunnel syndrome.

BACKGROUND: The aim of our study is to evaluate retrospectively the prognostic factors affecting the final outcome of surgical treatment of tarsal tunnel syndrome. MATERIAL AND METHODS: Surgical decompression were performed on 31 patients. All patients had EMG and anesthetic test confirmation. The results were evaluated according to VAS scale and modified AOFAS score. Follow-up was after 12 months. RESULTS: 22 patients received very good or good (71%), 7 satisfactory (22%), 2 poor (7%) results in the subjective and objective patient's assessment. The outcomes decreased from 5.19 (SD 1.01) points to 1.19 (SD 0.83) points according to VAS scale, and modified AOFAS increased from 31.77 (SD 9.08) points to 57.58 (SD 9.90). Patients with diagnosed cause, short period of time between onset of disease till surgery, and positive Tinel's sign achieved the best results. CONCLUSION: Etiology of the tarsal tunnel syndrome has influence on the results. Immediate diagnosis and short period between occurrences of symptoms in surgical treatment improves the outcomes. Tinel's sign may be used as a prognostic factor.

The effect of perinatal brachial plexus lesion on upper limb development.

BACKGROUND: Deficiency in upper limb development is a sequel of the perinatal brachial plexus palsy. The purpose of this study was to evaluate the effect of brachial plexus birth lesion on upper limb development. METHODS: Forty-four patients with unilateral obstetric brachial plexus palsy underwent measurements of both upper extremities. The average age at the time of evaluation was 6.8 years. Active motion was assessed using Gilbert-Raimondi, the modified MRC, and Al-Qattan scales. Paired t test was used for statistical analysis. Correlation between limb length / circumference discrepancy and age / time of surgery was assessed using Pearson correlation coefficient. RESULTS: A decrease in the circumference and length was observed in all limbs with brachial plexus lesion. We found a statistically significant difference between degree of hand length and width decrease and its useful and useless function. We observed a statistically significant difference in measurement: forearm length, hand length and width dependent on the type of surgical procedure (neurolysis, reconstruction). We observed no correlation between age and limb length / circumference discrepancy. We also observed no correlation between time of surgery and limb length / circumference discrepancy. CONCLUSIONS: The decrease in dimensions of the affected limbs occurred predominantly during the period of early childhood. Disparities in dimensions are observed in both cases of deficiency of useful function of upper limb and cases in which functional efficiency appears.

[The possibilities of using a chitin and chitosan in wounds treatment]. / Mozliwosci wykorzystania chityny i chitozanu w leczeniu ran.

Chitin and chitosan are natural polysaccharides. In this study, we presented the possibilities of using chitin and chitosan in medical practice and experimental studies. Chitin and chitosan, based wound dressings available as commercial products, were presented. The directions of future progress in employment chitin and chitosan in treatment of many kinds of wounds were also described. In this study, the main properties of these polymers were established. The usefulness of the chitin and chitosan as hemostatic products, wound dressing and skin substitutes was emphasized.

Selective demyelination of a sciatic nerve allograft after SARS-CoV-2 infection - Case report.

Peripheral neurological complications are seen after SARS-CoV-2 infections. These are mostly immune-mediated such as Guillaine-Barré syndrome or chronic inflammatory demyelinating polyneuropathy. We present a 39-year-old man treated with a right sciatic nerve allotransplantation with subsequent clinical and electrophysiological improvement within 30 months of observation. After SARS-CoV-2 infection, he developed clinical deterioration with selective sciatic nerve demyelination in a nerve conduction study. Nerve conduction velocity returned to previous values within six months of treatment. Intravenous immunoglobulins were used at standard dosage. The inflammatory immune process seemed to be a cause of peripheral demyelination isolated to a nerve allograft with good reaction for intravenous immunoglobulin treatment.

Expression of MMP-2, TIMP-2, TGF-ß1, and decorin in Dupuytren's contracture.

To investigate the mechanisms underlying matrix deposition in Dupuytren's disease, the expression of gelatinase A (MMP-2), the tissue inhibitor of metalloproteinase-2 (TIMP-2), transforming growth factor beta 1 (TGF-ß1), decorin (DCN), and periostin was studied. The level of relative MMP-2 activation was investigated using zymography. The mRNA expression of MMP-2, TIMP-2, TGF-ß1, and DCN was detected using reverse transcription polymerase chain reaction (RT-PCR), while the presence of protein was detected using immunohistochemical (IHC) and Western blot techniques. The level of MMP-2 activation was significantly elevated in tissues with Dupuytren's contracture. RT-PCR demonstrated significantly higher expression of MMP-2, TIMP-2, TGF-ß1, and DCN mRNA in the pathological tissues; and the IHC and immunoblotting studies revealed elevated expression of TGF-ß1, DCN, and periostin. The balance between MMP-2 and TIMP-2 was disrupted in patients with Dupuytren's disease. TGF-ß1, DCN, and periostin are involved in extracellular matrix (ECM) homeostasis in Dupuytren's contracture.

[Skin substitutes--the present and the future]. / Materialy zastepcze skóry--terazniejszosc i przyszlosc.

Full-thickness skin deficits are indications to autologic skin graft. In extensive skin injuries an employment of skin substitutes is sometimes necessary. In this study we presented the classification of skin substitutes (permanent, temporary, biological, synthetic). The different kinds of skin substitutes approved to commercial production were described (epidermal substitutes, dermal substitutes, composite dermo-epidermal substitutes). The possibilities of clinical applications of skin equivalents and results obtained by many authors after employment of artificial skin were also presented. Still existing limitations in possibilities of recovery of all skin functions were emphasized and the directions of future development of the studies were presented.

The Relevance of Collision Tests and Quantitative Sensory Testing in Diagnostics and Postoperative Outcome Prediction in Carpal Tunnel Syndrome.

Background: The gold standards for the diagnosis and treatment of carpal tunnel syndrome (CTS) and its outcome are undecided. Using clinical and electrophysiological methods, we tried to establish which fibers achieved full postoperative recovery, and the possibility of using non-standard electrophysiological tests as outcome predictors. Methods: The study group consisted of 35 patients and controls. The Historical-Objective Scale, standard neurography, conduction velocity distribution tests (CVD), and quantitative sensory testing (QST) were performed before and after CTS surgery. Results: Clinical improvement was observed on average in 54.3% of the patients, higher in less advanced CTS. All parameters improved significantly after surgery, except for CVD; most remained worse than in the controls. Only QST parameters fully returned to normal limits. Patient age and CTS severity were important in the estimation of the risk of no improvement. Conclusions: The efficiency of minimally invasive CTS surgery is higher in younger patients with less advanced CTS. Complete recovery was present only in small fibers; larger fibers could most likely be responsible for residual signs. We did not notice any benefits in CTS diagnosis using methods of small fiber assessment. QST seemed to be useful in the diagnosis of residual signs, and in deciding upon possible reoperation.

Preganglionic injuries in perinatal brachial plexus palsies - results of surgical treatment.

BACKGROUND AND PURPOSE: The authors report their experience in surgical treatment of preganglionic injuries in perinatal brachial plexus palsies. MATERIAL AND METHODS: Clinical material consisted of 16 children, of both sexes, aged from 2.5 to 33 months (mean 6.2 months), treated surgically between 1994 and 2006. The clinical view of the injury and location of preganglionic lesions was analysed and the description of the performed microsurgical techniques is provided. Control clinical examinations included a group of 14 children. The shortest postoperative observation period was 3 years. The currently accepted scales of evaluation of function of particular joints of the upper limb were used. RESULTS: The following outcome was noted after surgical treatment of perinatal brachial plexus palsies with signs of pre- and postganglionic injuries: good shoulder function in 6 cases, and average in 2 others; good elbow function in 4 cases, and average in 7 patients; functional position of the forearm in 9 cases, and good range of pronation and supination in 1 patient; useful function of wrist (flexion/extension) in 4 cases; good motor hand function in 3 cases, and fair in 6 patients. CONCLUSIONS: In preganglionic perinatal brachial plexus injuries located in the upper-middle part, spinal nerve C7 roots avulsion is the most frequently observed, and in the lower part of the brachial plexus, spinal nerve C8 roots avulsion is the most frequently observed. In preganglionic injuries of the brachial plexus, the number of avulsed spinal nerves has an influence on technical possibilities of performing reconstruction procedures, and then the results of the surgical treatment.

The Use of Quantitative Sensation Testing to Identify the Physiological Differences Between the Median and Ulnar Nerves.

INTRODUCTION: Similarities in morphology, physiological function, and neurophysiological findings between median and ulnar nerves are not unequivocal. Our previous study confirmed differences in motor fiber parameters between these nerves in healthy persons. We made an attempt to assess and compare the physiological parameters of different sensation modalities (temperature, pain, and vibration) in median and ulnar nerves. METHODS: The study was performed in 31 healthy, right-handed volunteers: 17 women, 14 men, mean age 44.8 ± 15.5 years. Standard sensory conduction tests in the median and ulnar nerves were performed together with the estimation of vibratory, temperature, and warm- and cold-induced pain thresholds in the C7 and C8 dermatomes on the palm, using quantitative sensory testing. RESULTS: There were no statistically significant differences in the standard sensory conduction test in the median and ulnar nerves across the whole group: between right and left hands, and between women and men. We revealed differences in the temperature and pain thresholds between these nerves, mainly in low temperature perception. There were no differences in estimated thresholds between sides or in female and male groups. The vibratory limits did not differ significantly between nerves, and subgroups. CONCLUSION: The study confirmed the differences in the physiological sensory perception between the median and ulnar nerves. The median nerve is more sensitive to temperature stimulation than the ulnar nerve, but simultaneously less sensitive to pain-inducing temperature stimuli. These findings should be considered during the examination of hand nerve pathology.