The patterns of nerve and associated skeletal injury were reviewed in 84 patients referred to the brachial plexus service who had damage predominantly to the infraclavicular brachial plexus and its branches. Patients fell into four categories: 1. Anterior glenohumeral dislocation (46 cases); 2. ‘Occult’ shoulder dislocation or scapular fracture (17 cases); 3. Humeral neck fracture (11 cases); 4. Arm hyperextension (9 cases). The axillary (38/46) and ulnar (36/46) nerves were most commonly injured as a result of glenohumeral dislocation. The axillary nerve was ruptured in only 2 patients who had suffered high energy trauma. Ulnar nerve recovery was often incomplete. ‘Occult’ dislocation refers to patients who had no recorded shoulder dislocation but the history was suggestive that dislocation had occurred with spontaneous reduction. These patients and those with scapular fractures had a similar pattern of nerve involvement to those with known dislocation, but the axillary nerve was ruptured in 11 of 17 cases. In cases of humeral neck fracture, nerve injury resulted from medial displacement of the humeral shaft. Surgery was performed in 7 cases to reduce and fix the fracture. Arm hyperextension cases were characterised by injury to the musculocutaneous nerve, with the nerve being ruptured in 8 of 9. Five had humeral shaft fracture or elbow dislocation. There was variable involvement of the median and radial nerves, with the ulnar nerve being least affected. Most cases of infraclavicular brachial plexus injury associated with shoulder dislocation can be managed without operation. Early nerve exploration and repair should be considered for:. Axillary nerve palsy without recorded shoulder dislocation or in association with fracture of the scapula. Musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is necessary for nerve injury resulting from fracture of the humeral neck to relieve ongoing pressure on the nerves

Compared with general anaesthesia, brachial plexus (BP) anaesthesia improves patient satisfaction and accelerates hospital discharge after ambulatory hand surgery; however, variable success rates and typical onset times up to 30 minutes have limited its widespread use. Increasing availability of high-resolution portable ultrasound has renewed interest in more proximal approaches to the BP, previously thought to carry unacceptable risk. The aim of this study was to compare the onset times of ultrasound guided supraclavicular and infraclavicular BP block in patients undergoing ambulatory hand surgery. With ethics committee approval, patients presenting for hand surgery were prospectively randomised to either supraclavicular (trunks/divisions) or infraclavicular (cords) BP block. A single experienced operator (MF) placed all blocks using ultrasound only guidance. A blinded observer (AP, SY) assessed pinprick sensory and motor block on 3-point scale (normal=2, reduced=1, absent=0) in the median, ulnar, radial and musculocutaneous nerve territories every five minutes, or until blocks were complete. A single general anaesthesia without influence from the unblended anaesthetist. Of the first 27 patients recruited, block placement details and Intraoperative data are presented in There was a trend to faster onset times and higher success in group infraclavicular, however, this did not reach statistical significance. Interim results are so far inconclusive for the superiority of one approach. Both techniques were well tolerated and had a high success rate for surgical anaesthesia

Introduction: Clavicle fractures represent 5% of fractures in adults and almost 44% of shoulder injuries and are usually treated none operatively with good results. However significantly displaced fractures can be associated with high non-union rate and there is a lack of consensus on when surgical treatment is indicated for such fractures. The aim of this study was to identify guidelines for surgical intervention, safer surgical approach and outcome of surgical intervention. Method: A retrospective audit of all clavicle fractures managed surgically over past 5 years (March 2004 to 2009) in a district general hospital. Case notes were reviewed to study the surgical indication, surgical approach, patient satisfaction and oxford should score and need for metal work removal. In all 35 patients (29 male) underwent surgery for significant fracture displacement with shortening, manual workers and keen sportsmen at the time of injury. The infraclavicular approach was used in 21 patients and 14 patients had direct incision approach. Radiological union was achieved in all patients after an average of 13.26(8–24) weeks. Six patients required plate removal at 6 months following surgery, infraclavicular (2 patients) & direct approach (4 patients). All patients returned to their original occupation at average 2.55 months. The Oxford Shoulder Score at 3 months after surgery was average 15 (range12–20) and all patients, except one, scored excellent on subjective scoring. Conclusion: Our study showed excellent surgical outcome for displaced clavicle fractures in young and active patients and is supported by the high union rate, good oxford shoulder score, early return to work and high patient satisfaction scores. The infraclaviculr approach is a betterthan direct approach based on the low complication rate and less need for metal work removal

Clavicle fracture account for about 44% of all adult fracture around the shoulder, although non-operative care results in high union rates for most, surgery is indicated in particular if displacement and/or shortening greater than 15–20 mm, lack of cortical apposition in young, healthy, active individual to yield the best clinical results in terms of alignment, union and early mobilisation. We did a retrospective audit to define the guidelines for admission, safer surgical approach and functional outcome using oxford score for the period Jan2002–Jan2007. This included 35pts, with Female: male ratio 1:2.5, Right: left side of 12:23, just over 50%were manual labours. Most common indication for surgery was displacement/shortening (16pts). 28 pts were operated within 4 weeks as acute admission. Direct incision was used in 14pts and infraclavicular incision in 21pts. Radiological union were seen in all pts on average 13.26 weeks (8 – 24wks). 10 patients had minor complications, 28% with direct incision and 19% with infraclavicular approach 29 patients went back to original work by 2.55 month, 5 excluded as 3 were at school, 2 unemployed and 1 did not mention. All patients had an oxford score of 12–20, showing satisfactory joint function. Metal work were removed in 6 patients, 2 (9.5%) in infraclavicular and 4 (28%) in direct incision. Conclusion: Our study included 35 patients, union were achieved in all with good functional results. 34 patients express to recommend surgical fixation to others. Infraclavicular approach was associated with less complication and less metal work removal

The standard approach is through the deltopectoral interval. Among patients with prior incisions, one makes every effort to either utilise the old incision or to incorporate it into a longer incision that will allow one to approach the deltopectoral interval and retract the deltoid laterally. The deltopectoral interval is most easily developed just distal to the clavicle, where there is a natural infraclavicular triangle of fat that separates the deltoid and pectoralis major muscles even in very scarred or stiff shoulders. Typically, the deltoid is retracted laterally leaving the cephalic vein on the medial aspect of the exposure. The anterior border of the deltoid is mobilised from the clavicle to its insertion on the humerus. The anterior portion of the deltoid insertion together with the more distal periosteum of the humerus may be elevated slightly. The next step is to identify the plane between the conjoined tendon group and the subscapularis muscle. Dissection in this area must be done very carefully due to the close proximity of the neurovascular group, the axillary nerve, and the musculocutaneous nerve. Scar is then released from around the base of the coracoid. The subacromial space is freed of scar and the shoulder is examined for range of motion. Particularly among patients with prior rotator cuff surgery, there may be severe scarring in the subacromial space. Internal rotation of the arm with dissection between the remaining rotator cuff and deltoid is critical to develop this plane. If external rotation is less than 30 degrees, one can consider incising the subscapularis off bone rather than through its tendinous substance. For every 1 cm that the subscapularis is advanced medially, one gains approximately 20 to 30 degrees of external rotation. The rotator interval between the subscapularis and supraspinatus is then incised. This release is then continued inferiorly to incise the inferior shoulder capsule from the neck of the humerus. This is performed by proceeding from anterior to posterior with progressive external rotation of the humerus staying directly on the bone with electrocautery and great care to protect the axillary nerve. The key for glenoid exposure as well as improvement in motion is deltoid mobilization, a large inferior capsular release, aggressive humeral head cut and osteophyte removal

The surgical approach to compressive syndromes of the thoracic outlet of vascular or nervous origin represents, for anatomical and historical reasons, an important issue for orthopaedic surgeons. Today’s angiographic techniques give an easy and unequivocal insight of the vascular and non-vascular (indirect) nature of the disease and, consequently, give more solid indications for surgery than before. A series of 35 cases, 21 women and 14 men with an average age of 39 years, of thoracic outlet syndrome (TOS) of vascular origin is presented here. The causes of compression were cervical rib (n=24), soft tissue anomalies (n=10) and scar tissue after clavicular fracture (n=1). During surgery, two subclavian artery aneurysms containing intraluminal thrombus and one subclavian artery occlusion were found. Presenting features of cases with arterial TOS included: hand ischaemia (n=32), transient ischaemic attack (n=3) and claudicatio or vasomotor phenomena during the arm in hyperabduction (n=3). Two patients with venous TOS developed hand oedema during arm hyperabduction, and another patient had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approachs were performed. Decompression were achieved by cervical rib excision (n=24), combined cervical and first rib excision (n=10) and first rib excision (n=1). In all cases, division of all tissue elements was also accomplished. Associated vascular procedures included resection and replacement of two subclavian aneurysms. The mean follow-up period was 3 years and 2 months (range 1–6). Complete resolution of symptoms with a return to full activity was achieved in all cases. The medium-term clinical results suggest that the surgical indication for TOS, if supported by digital angiography, is justified and effective

Aim: To study the functional outcome ofmusculocutaneous nerve neurotization in brachial plexus palsy patients. Methods: From 1998 to 2001, 51 adult patients (mean age 24,6 years) with posttraumatic brachial plexus palsy were operated. Exploration of the brachial plexus was performed in 39 patients with a mean denervation time of 6 months (1 to 14 months). Seven patients had an extended infraclavicular lesion, while from the 32 supraclavicular lesions, 21 had the element of avulsion (4 global, 10 four-root and 7 three-roots avulsions). Neurotization of the musculocutaneous was performed in 25 via nerve grafts from intraplexus donors (C5, C6, C7)and from extraplexus donors in 14. In 7 patients, the phrenic was used alone or with intraplexus donor (5), in 3 cases the accessory nerve, in one patient the accessory and cervical plexus motor branches and þnally in 3 patients 3 intercostal nerves were used. Results: All intraplexus neurotizations of the musculocutaneous nerve, but two, regained useful biceps function (M3+ to M4+). From the extraplexus neurotizations the phrenic n. as a conjunctant donor gave functional result, when used alone gave M3 and M3−; the accessory n. gave M3+ in combination with cervical motors and M3− when used alone. The intercostal neurotizations gave M2+ and M3−. Conclusions: In brachial plexus paralysis, when avulsion is present the reconstruction often is based in extraplexus donors. The return of biceps function is greater and faster when intraplexus donors are used. Extraplexus neurotizations yield satisfactory results used in combinations Vertebral osteoporosis and fracture

Many surgical approaches at decompression have been attempted for the thoracic outlet syndrome (TOS), but only the transaxillary and supraclavicular routes carry the best outcomes. More recently, a selective and tailored approach via the supraclavicular route has been favoured. We performed a retrospective review between 1978 and 1998, and report the outcome of the ‘’two surgeon approach’’ for TOS via the supraclavicular method. An orthopaedic and vascular surgeon jointly conducted 30 operations for disabling symptoms relating to TOS in 27 patients (21F, 6M), mean age of 29 yrs (range 18–63 yrs), having performed the preoperative assessment in conjunction with a neurologist. In all cases, it was essential that patient selection for surgery was determined on clinical grounds rather than the presence of a cervical rib. Anterior scalenectomy was performed via the supraclavicular route except in one case where the infraclavicular route was utilised. Additional surgical procedures were carried out according to the underlying abnormalities, i.e. excision of cervical rib or band or medial scalenectomy. The first rib was always spared. At mean follow-up of 37 mths (range 3-228 mths), 26/30 sides (87%) had excellent or good results. The results were fair or poor in three cases where scalenec-tomy alone was performed. There were no major complications and no patients required a re-operation. 24 patients (89%) returned to their previous lifestyle or occupation. Our results suggest that, with a multidisciplinary assessment and two-surgeon team, good to excellent surgical outcomes can be achieved via the supraclavicular route without resection of the first rib. Instead of the current practise of routine transaxillary first rib resection, we recommend decompression via this approach with further procedures tailored to the abnormality identified

Aims

Brachial plexus injury (BPI) is an often devastating injury that affects patients physically and emotionally. The vast majority of the published literature is based on surgeon-graded assessment of motor outcomes, but the patient experience after BPI is not well understood. Our aim was to better understand overall life satisfaction after BPI, with the goal of identifying areas that can be addressed in future delivery of care.

The December 2014 Shoulder & Elbow Roundup³⁶⁰ looks at: cuff tears and plexus injury;

corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?