Injuries associated with serious brachial plexus involvement in polytrauma among patients requiring surgical repair

Background

Brachial plexus injury occurs in up to 5% of polytrauma cases involving motorcycle crashes and in approximately 4% of severe winter sports injuries. One of the conditions for the success of operative therapy is early detection, ideally within three months of injury. The aim of this study was to evaluate associated injuries in patients with severe brachial plexus injury and determine whether there is a characteristic concomitant injury (or injuries), the presence of which, in the polytrauma, could act as a marker for nerve structures involvement and whether there are differences in severity of polytrauma accompanying specific types of brachial plexus injury.

Methods

We evaluated retrospectively 84 surgical patients from our department, from 2008 to 2011, that had undergone brachial plexus reconstruction. For all, an injury severity scale (ISS) score and all major associated injuries were determined.

Results

72% of patients had an upper, 26% had a complete and only 2% had a lower brachial plexus palsy. The main cause was motorcycle crashes (60%) followed by car crashes (15%). The average ISS was 35.2 (SD = 23.3), although, values were significantly higher in cases involving a coma (59.3, SD = 11.0). The lower and complete plexus injuries were significantly associated with coma and fractures of the shoulder girdle and injuries of lower limbs, thoracic organs and head. Upper plexus injuries were associated with somewhat less severe injuries of the upper and lower extremities and less severe injuries of the spine.

Conclusion

Serious brachial plexus injury is usually accompanied by other severe injuries. It occurs in high-energy trauma and it can be stated that patients involved in motorcycle and car crashes with multiple fractures of the shoulder girdle are at high risk of nerve trauma. This is especially true for patients in a primary coma. Lower and complete brachial plexus injuries are associated with higher injury severity scale.     

An epidemiological study of traumatic brachial plexus injury patients treated at an Indian centre

Background:

Epidemiological studies on traumatic brachial plexus injuries are few and these studies help us to improve the treatment, rehabilitation of these patients and to allocate the resources required in their management. Epidemiological factors can vary in different countries. We wanted to know the situation in an Indian centre.

Materials and Methods:

Data regarding age, sex, affected side, mode of injury, distribution of paralysis, associated injuries, pain at the time of presentation and the index procedure they underwent were collected from 304 patients. Additional data like the vehicle associated during the accident, speed of the vehicle during the accident, employment status and integration into the family were collected in 144 patients out of the 304 patients.

Results:

Road traffic accidents accounted for 94% of patients and of the road traffic accidents 90% involved two wheelers. Brachial plexus injury formed a part of multitrauma in 54% of this study group and 46% had isolated brachial plexus injury. Associated injuries like fractures, vascular injuries and head injuries are much less probably due to the lower velocity of the vehicles compared to the western world. The average time interval from the date of injury to exploration of the brachial plexus was 127 days and 124 (40.78%) patients presented to us within this duration. Fifty-seven per cent had joined back to work by an average of 8.6 months. It took an average of 6.8 months for the global brachial plexus-injured patients to write in their non-dominant hand.KEY WORDS: Epidemiological study, Indian centre, nerve injury, traumatic brachial plexus injury     

An unusual presentation of whiplash injury: long thoracic and spinal accessory nerve injury

Whiplash injuries from motor vehicle accidents are very common. The usual presentation and course of this condition normally results in resolution of symptoms within a few weeks. Brachial plexus traction injuries without any bone or joint lesion of the cervical spine have been reported before. We report a case where a gentleman was involved in a rear end vehicle collision, sustained a whiplash injury and was later found to have a long thoracic nerve palsy and spinal accessory nerve palsy. Although isolated injuries of both nerves following a whiplash injury have been reported, combined injury of the two nerves following a whiplash injury is very uncommon and is being reported for the first time.

     

Fracture of the shoulder girdle in multiply injured patients - an imperative for a high level of suspicion for associated neurovascular injuries

Background

The combination of a bony injury to the shoulder girdle and damage to the brachial plexus and the subclavian vessels is a rare finding. The cases of this combined injury pattern described in the literature are most notably reported in multiply-injured patients after high velocity trauma.

Findings

Three cases were admitted to our hospital after motorcycle accidents resulting in a combination of severe bony injuries to the shoulder girdle, to the subclavian artery and a lesion to the brachial plexus. Based on these three clinical cases the patterns of injury, as well as primary and secondary treatment approaches are presented.

Conclusion

The early detection of these injuries can be difficult in given acute, life threatening injuries addressed first in these multiply injured patients. A high level of suspicion, in conjunction with standardized ATLS based institutional protocols for secondary and tertiary survey, should increase the likelihood of a timely detection and early management of these rare but potentially devastating injuries.

     

Nerve transfers using collateral branches of the brachial plexus as donors in patients with upper palsy—thirty years’ experience

Background  

Nerve transfers in cases of directly irreparable or high-level extensive brachial plexus traction injuries have been done using a variety of donor nerves with various success, but an ideal method has not been established. The purpose of this study is to analyze the results of nerve transfers using the thoracodorsal and medial pectoral nerves as donors in patients with upper palsy.     

Prevalence of brachial plexus injuries in patients with scapular fractures: A National Trauma Data Bank review

BACKGROUND:

Studies investigating the prevalence of brachial plexus injuries associated with scapular fractures are sparse, and are frequently limited by small sample sizes and often restricted to single-centre experience.

OBJECTIVE:

To determine the prevalence of brachial plexus injuries associated with scapular fractures; to determine how the prevalence varies with the region of the scapula injured; and to assess which specific nerves of the brachial plexus were involved.

METHODS:

The present study was a retrospective review of data from the National Trauma Data Bank over a five-year period (2007 to 2011).

RESULTS:

Of 68,118 patients with scapular fractures, brachial plexus injury was present in 1173 (1.72%). In patients with multiple scapular fractures, the prevalence of brachial plexus injury was 3.12%, and ranged from 1.52% to 2.22% in patients with single scapular fractures depending on the specific anatomical location of the fracture. Of the 426 injuries with detailed information on nerve injury, 208 (49%) involved the radial nerve, 113 (26.5%) the ulnar nerve, 65 (15%) the median nerve, 36 (8.5%) the axillary nerve and four (1%) the musculocutaneous nerve.

CONCLUSION:

The prevalence of brachial plexus injuries in patients with scapular fractures was 1.72%. The prevalence was similar across anatomical regions for single scapular fracture and was higher with multiple fractures. The largest percentage of nerve injuries were to the radial nerve.     

Diagnosis and management of adult BPI: Results of first 50 cases

IntroductionCommonest cause of brachial plexus injury in adults is traction injury sustained in motorcycle accidents. This article reports the results of first 50 cases done in a tertiary referral center with a brief review of literature.Material and methodsFirst 50 patients (46 male; 4 female, age from 12 to 45 years) with post traumatic brachial plexus palsy were included. There were 30 upper plexus and 20 pan plexus injuries, 27 had preganglionic and 23 postganglionic injury. Neurolysis was done in 19 patients and various combination of nerve transfer in 31. Mean follow-up period was 13.98 months.Results– Over all shoulder abduction was good in 10 patients, fair in 32 and poor in 8. Elbow flexion was good in 19 patients, fair in 18 and poor in 13 patients.ConclusionThe upper plexus and partial injuries have a good outcome in a majority of cases, while the results in global palsy are far from satisfactory.     

Intraoperative brachial plexus injury during emergence following movement with arms restrained: a preventable complication?

Background  

Despite considerable analysis and preventive strategies, brachial plexus injuries remain fairly common in the perioperative setting. These injuries range from brief periods of numbness or discomfort in the immediate postoperative period to, in rare cases, profound, prolonged losses of sensation and function. We present a case of an orthopedic surgery patient who suffered a brachial plexus injury while under anesthesia after trying to sit upright with his arms restrained.     

Nerve reconstruction: A cohort study of 93 cases of global brachial plexus palsy

Introduction:

Brachial plexus injury leading to flail upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgeries may preclude reinnervation of the paralysed muscles. Currently for such injuries nerve transfers are the preferred procedures. We here present a series of 93 cases of global brachial plexus palsy treated with nerve transfers.

Materials and Methods:

Ninety-three cases of global palsies out of 384 cases of brachial plexus injury operated by the senior surgeon (AB) were selected. Age varied from 4 to 51 years with 63 patients in 20 to 40 age group and all patients having a minimum follow up of at least 1 year post surgery ranging up to 130 months. The delay before surgery ranged from 15 days to 16 months (mean 3.2 months). The aim of the surgery was to restore the elbow flexion, shoulder abduction, triceps function and wrist and finger flexion in that order of priority. The major nerve transfers used were spinal accessory to suprascapular nerve, intercostal to musculocutaneous nerve and pectoral nerves, contralateral C7 to median and radial nerves. Nerve stumps were used whenever available (30 patients).

Results:

Recovery of ≥ grade 3 power was noted in biceps in 73% (68/93) of patients, shoulder abduction in 89% (43/49), pectoralis major in 100% (8/8). Recovery of grade 2 triceps power was seen in 80% (12/16) patients with nerve transfer to radial nerve. Derotation osteotomies of humerus (n=13) and wrist fusion (n=14) were the most common secondary procedures performed to facilitate alignment and movements of the affected limb. Better results were noted in 59 cases where direct nerve transfers were done (without nerve graft).

Conclusion:

Acceptable function (restoration of biceps power ≥3) can be obtained in more than two thirds (73%) of these global brachial plexus injuries by using the principles of early exploration and nerve transfer with rehabilitation.     

Schutzmaßnahmen am Trampolin können schwere Verletzungen nicht vermeiden

Background

The number of injuries caused by accidents while springing on a trampoline has increased significantly. This study therefore focused on the incidence, morbidity and circumstances of the accidents in pediatric patients.

Methods

The children admitted to this hospital from 2002 to 2010 were re-examined and the children injured during trampolining were asked to fill out a questionnaire focusing on the mechanism of the injury and the circumstances.

Results

A total of 268 accidents were included in the study and 28% of the injuries were severe (e.g. fracture, luxation and rupture). If there were special safety measures (e.g. safety net, floor mats, surrounding water 63%) 28.4% of the injuries were severe and without safety measures 28.6% were severe. Safety measures did not influence the incidence of severe trauma (p=1). If a trampoline was equipped with a safety net (53%) 31% of the injuries were severe and without a safety net 25% were severe (p=0.473).

Conclusion

Pediatric accidents on a trampoline result in severe injuries in 28% of cases. There is no difference in the severity of the injury regarding trampolines with or without special safety measures. Safety nets do not reduce the risk of severe injury.     

Pelvic injuries in childhood and adolescence: Retrospective analysis of 5-year data from a national trauma centre

Background

Pelvic fractures are uncommon injuries in paediatric trauma patients because of specific anatomical features. Due to the low incidence there is no standardized therapeutic algorithm.

Material and methods

This retrospective review evaluates paediatric pelvic fractures of a Level I Trauma Centre over 5 years. In addition, we compared the data with adult pelvic fractures and reviewed the literature. A total of 37 pelvic fractures (??16 years) were documented, with an incidence of 9.9% in the child with multiple injuries. The most common injury mechanisms were traffic accidents, followed by falls from heights.

Results

Type A injuries occurred in 50% (type B: 16%, type C: 27%, acetabular injuries: 11%). Osteosynthesis was performed in nine cases. Therapeutic intervention was necessary in three cases of haemodynamically relevant bleeding; 97% of all children had associated injuries (mean ISS: 38).

Conclusion

Our data showed some differences to the literature. Pelvic fractures are predictors for high injury severity. Despite similar fracture pattern, in contrast to adults most injuries could be treated non-operatively. In unstable or dislocated fractures open reduction and stabilization must be performed.     

Comparative study of phrenic nerve transfers with and without nerve graft for elbow flexion after global brachial plexus injury

Background

Nerve transfer is a valuable surgical technique in peripheral nerve reconstruction, especially in brachial plexus injuries. Phrenic nerve transfer for elbow flexion was proved to be one of the optimal procedures in the treatment of brachial plexus injuries in the study of Gu et al.

Objective

The aim of this study was to compare phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury.

Methods

A retrospective review of 33 patients treated with phrenic nerve transfer for elbow flexion in posttraumatic global root avulsion brachial plexus injury was carried out. All the 33 patients were confirmed to have global root avulsion brachial plexus injury by preoperative and intraoperative electromyography (EMG), physical examination and especially by intraoperative exploration. There were two types of phrenic nerve transfers: type1 – the phrenic nerve to anterolateral bundle of anterior division of upper trunk (14 patients); type 2 – the phrenic nerve via nerve graft to anterolateral bundle of musculocutaneous nerve (19 patients). Motor function and EMG evaluation were performed at least 3 years after surgery.

Results

The efficiency of motor function in type 1 was 86%, while it was 84% in type 2. The two groups were not statistically different in terms of Medical Research Council (MRC) grade (p = 1.000) and EMG results (p = 1.000). There were seven patients with more than 4 month's delay of surgery, among whom only three patients regained biceps power to M3 strength or above (43%). A total of 26 patients had reconstruction done within 4 months, among whom 25 patients recovered to M3 strength or above (96%). There was a statistically significant difference of motor function between the delay of surgery within 4 months and more than 4 months (p = 0.008).

Conclusion

Phrenic nerve transfers with and without nerve graft for elbow flexion after brachial plexus injury had no significant difference for biceps reinnervation according to MRC grading and EMG. A delay of the surgery after the 4 months might imply a bad prognosis for the recovery of the function.     

High-velocity penetrating thoracic trauma with suspected cardiac involvement in a combat support hospital

Purpose  

The most common cardiac injuries in the United States are blunt trauma from motor vehicle accidents or low-velocity trauma from stabbings. During military conflict, high-velocity injuries, including gunshot wounds (GSW) and fragment injury from improvised explosive devices (IED), are relatively more common.     

广州市五所医院臂丛神经损伤流行病学回顾性研究

目的通过对广州市五所医院臂丛神经损伤患者的流行病学调查，了解臂丛损伤的构成及其发病学特点。方法回顾性调查广州市五所医院近十年收治的452例臂丛损伤的病例。根据性别、年龄、损伤部位等，分析该群体的流行病学特征。结果20～39岁年龄组占64．6％，男女性别比为6：1。工人、农民工占62．4％，无业人员占11．7％。摩托车伤占45．1％，机动车辆伤占20．4％。损伤类型：全臂丛损伤占33．6％，上中干损伤占17．3％，上干损伤占12．6％。臂丛损伤合并多发伤的占74．6％，其中头部外伤占多发伤的57．0％。结论臂丛损伤主要发生在青壮年男性，摩托车和机动车辆伤是臂丛损伤的主要原因；加强臂丛交通伤的预防医学，有助于减少臂丛损伤的发生率。     

Descriptive epidemiology of traumatic spinal injury in Japan

Background

Spine injury epidemiology in Japan has not been studied since the 1990s when its incidence was 39.4–40.2 per million and the major cause of injury was motor vehicle crashes. We elucidate the current epidemiological state of spinal injury and spinal injury patients in Japan for the clinicians and public health prevention programs.

A cross-sectional study of knife injuries at a London major trauma centre

INTRODUCTION

No national recording systems for knife injuries exist in the UK. Understanding the true size and nature of the problem of knife injuries is the first stage in reducing the burden of this injury. The aim of this study was to survey every knife injury seen in a single inner city emergency department (ED) over a one-year period.

METHODS

A cross-sectional observational study was performed of all patients attending with a knife injury to the ED of a London major trauma centre in 2011. Demographic characteristics, patterns of injury, morbidity and mortality data were collected.

RESULTS

A total of 938 knife injuries were identified from 127,191 attendances (0.77% of all visits) with a case fatality rate of 0.53%. A quarter (24%) of the major trauma team’s caseload was for knife injuries. Overall, 44% of injuries were selfreported as assaults, 49% as accidents and 8% as deliberate self-harm. The highest age specific incident rate occurred in the 16–24 year age category (263/100,000). Multiple injuries were seen in 19% of cases, of which only 81% were recorded as assaults. The mean length of stay for those admitted to hospital was 3.04 days. Intrathoracic injury was seen in 26% of cases of chest trauma and 24% of abdominal injuries had a second additional chest injury.

CONCLUSIONS

Violent intentional injuries are a significant contributory factor to the workload of the major trauma team at this centre. This paper contributes to a more comprehensive understanding of the nature of these injuries seen in the ED.     

Arthroscopic release of the subscapularis for shoulder contracture of obstetric palsy

Objective  

Retrospective study of one surgeon’s experience with arthroscopic release in obstetrical brachial plexus palsy.     

Spontaneous recovery of non-operated traumatic brachial plexus injury

Purpose

We investigated the spontaneous recovery of non-operated traumatic brachial plexus injury (BPI).

Methods

A total of 25 cases of non-operated traumatic BPI were analysed by retrospective review of medical records; in all cases, consecutive electrodiagnostic studies (ES) were conducted from 1 to 4 months and 18 to 24 months post-trauma. Injury severity was assessed using a modified version of Dumitru and Wilbourn’s scale (DWS) based on ES. Spontaneous recovery of brachial plexus components per subject was analysed using Wilcoxon’s signed-rank test. A two-tailed Fisher’s exact or Pearson’s Chi-square test was used to examine the associations between initial injury severity (DWS grade 2 vs. 3, complete vs. incomplete), accompanying injury type (open vs. closed), main lesion location (supraclavicular vs. infraclavicular lesion), and spontaneous recovery.

Results

The most common cause of BPI was traffic accident (TA) (15 cases, 60%), and the most common type of TA-induced BPI was a motorcycle TA (5 cases), accounting for 20% of all injuries. The second most common type of injury was an occupational injury (6 cases, 24%). Thirty-eight (69%) of 55 injured brachial components in 25 cases had DWS grade 3 and 17 brachial components (31%) had grade 2. The DWS grade of brachial plexus components per subject significantly differed between the first and follow-up ES (p = 0.000). However, initial injury severity, accompanying injury type, and main lesion location were not statistically associated with spontaneous recovery (p > 0.05).

Conclusions

Spontaneous recovery may be possible even in severe traumatic BPI. Multiple factors should be considered when predicting the clinical course of traumatic BPI.