Opinion varies as to the incidence of nerve lesions in anterior dislocation of the shoulder after low-velocity trauma. Most studies are retrospective or do not use EMG. We have investigated the incidence and the clinical consequences of nerve lesions in a prospective study by clinical and electrophysiological examination. Axonal loss was seen in 48% of 77 patients. The axillary nerve was most frequently involved (42%). Although recovery as judged by EMG and muscle strength was almost complete, function of the shoulder was significantly impaired in patients with lesions of the axillary and suprascapular nerves. Unfavourable prognostic factors are increasing age and the presence of a haematoma. It is not necessary to carry out EMG routinely; an adequate programme of physiotherapy is important. In patients with a severe paresis, EMG is essential after three weeks

Aims. The aim of this study was to compare the pain caused by the application of a tourniquet after exsanguination of the upper limb with that occurring after simple elevation. . Patients and Methods. We used 26 healthy volunteers (52 arms), each of whom acted as their own matched control. The primary outcome measure was the total pain experienced by each volunteer while the tourniquet was inflated for 20 minutes. This was calculated as the area under the pain curve for each individual subject. Secondary outcomes were pain at each time point; the total pain experienced during the recovery phase; the ability to tolerate the tourniquet and the time for full recovery after deflation of the tourniquet. . Results. There was a significant difference in the area under the pain curves in favour of exsanguination (mean difference 8.4; 95% confidence interval (CI) 3.0 to 13.7, p = 0.004). There was no difference between the dominant and non-dominant arms (mean difference -0.2; 95% CI -23.2 to 22.8, p = 0.99). The area under both recovery curves were similar (mean difference 0.7; 95% CI -6.0 to 4.6, p = 0.78). There was no statistical difference in recovery time, the actual mean difference being 30 seconds longer in the elevation group (p = 0.06). Conclusion. Many orthopaedic and plastic surgery procedures are done under local anaesthetic or regional block where a bloodless field and a motionless patient are essential. Optimising patient comfort during surgery with the tourniquet inflated is thus a priority. This study is useful in that it compares two common methods of preparation of the upper limb prior to tourniquet inflation and which have not previously been compared in this context. Following on the results of this study, we can confidently conclude that exsanguinating the upper limb before inflating a tourniquet is more comfortable than simply elevating the arm for patients undergoing a procedure under local or regional block, both during the procedure and in the recovery phase. . Take home message: Exsanguination rather than elevation is recommended in order to minimise patient discomfort and optimise the surgical field. Cite this article: Bone Joint J 2016;98-B:519–25

Aims

Rotator cuff (RC) injuries are characterized by tendon rupture, muscle atrophy, retraction, and fatty infiltration, which increase injury severity and jeopardize adequate tendon repair. Epigenetic drugs, such as histone deacetylase inhibitors (HDACis), possess the capacity to redefine the molecular signature of cells, and they may have the potential to inhibit the transformation of the fibro-adipogenic progenitors (FAPs) within the skeletal muscle into adipocyte-like cells, concurrently enhancing the myogenic potential of the satellite cells.

Objectives. The aim of this study was to determine whether there is any significant difference in temporal measurements of pain, function and rates of re-tear for arthroscopic rotator cuff repair (RCR) patients compared with those patients undergoing open RCR. Methods. This study compared questionnaire- and clinical examination-based outcomes over two years or longer for two series of patients who met the inclusion criteria: 200 open RCR and 200 arthroscopic RCR patients. All surgery was performed by a single surgeon. . Results. Most pain measurements were similar for both groups. However, the arthroscopic RCR group reported less night pain severity at six months, less extreme pain and greater satisfaction with their overall shoulder condition than the open RCR group. The arthroscopic RCR patients also had earlier recovery of strength and range of motion, achieving near maximal recovery by six months post-operatively whereas the open RCR patients took longer to reach the same recovery level. The median operative times were 40 minutes (20 to 90) for arthroscopic RCR and 60 minutes (35 to 120) for open RCR. Arthroscopic RCR had a 29% re-tear rate compared with 52% for the open RCR group (p < 0.001). . Conclusions. Arthroscopic RCR involved less extreme pain than open RCR, earlier functional recovery, a shorter operative time and better repair integrity

Aims

Rotator cuff tear (RCT) is the leading cause of shoulder pain, primarily associated with age-related tendon degeneration. This study aimed to elucidate the potential differential gene expressions in tendons across different age groups, and to investigate their roles in tendon degeneration.

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An objective technological solution for tracking adherence to at-home shoulder physiotherapy is important for improving patient engagement and rehabilitation outcomes, but remains a significant challenge. The aim of this research was to evaluate performance of machine-learning (ML) methodologies for detecting and classifying inertial data collected during in-clinic and at-home shoulder physiotherapy exercise.

Restoration of hand function is rarely achieved after a complete closed traction lesion of the supraclavicular brachial plexus. We describe the injury, treatment, rehabilitation and long-term results of two patients who regained good function of the upper limb and useful function in the hand after such an injury. Successful repairs were performed within six days of injury. Tinel’s sign proved accurate in predicting the ruptures and the distribution of pain was accurate in predicting avulsion. The severe pain that began on the day of injury resolved with the onset of muscle function. Recovery of muscle function preceded recovery of sensation. Recovery of the function of C and Aδ fibres was the slowest of all

We reviewed 42 consecutive children with a supination deformity of the forearm complicating severe birth lesions of the brachial plexus. The overall incidence over the study period was 6.9% (48 of 696). It was absent in those in Narakas group I (27.6) and occurred in 5.7% of group II (13 of 229), 9.6% of group III (11 of 114) and 23.4% of group IV (18 of 77). Concurrent deformities at the shoulder, elbow, wrist and hand were always present because of muscular imbalance from poor recovery of C5 and C7, inconsistent recovery of C8 and T1 and good recovery of C6. Early surgical correction improved the function of the upper limb and hand, but there was a tendency to recurrence. Pronation osteotomy placed the hand in a functional position, and increased the arc of rotation of the forearm. The supination deformity recurred in 40% (17 of 42) of those treated by pronation osteotomy alone, probably because of remodelling of the growing bone. Children should be followed up until skeletal maturity, and the parents counselled on the likelihood of multiple operations

The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed the published evidence and developed an algorithm to guide management. We searched web-based databases for studies published in the past 40 years and identified further pages through manual searches of the bibliography in papers identified electronically. Of 391 papers identified initially, encompassing a total of 1045 patients with radial nerve palsy, 35 papers met all our criteria for eligibility. Meticulous extraction of the data was carried out according to a preset protocol. The overall prevalence of radial nerve palsy after fracture of the shaft of the humerus in 21 papers was 11.8% (532 palsies in 4517 fractures). Fractures of the middle and middle-distal parts of the shaft had a significantly higher association with radial nerve palsy than those in other parts. Transverse and spiral fractures were more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture (p < 0.001). The overall rate of recovery was 88.1% (921 of 1045), with spontaneous recovery reaching 70.7% (411 of 581) in patients treated conservatively. There was no significant difference in the final results when comparing groups which were initially managed expectantly with those explored early, suggesting that the initial expectant treatment did not affect the extent of nerve recovery adversely and would avoid many unnecessary operations. A treatment algorithm for the management of radial nerve palsy associated with fracture of the shaft of the humerus is recommended by the authors

Ulnar neuropathy presents as a complication in 5% to 10% of total elbow replacements, but subsequent ulnar neurolysis is rarely performed. Little information is available on the surgical management of persistent ulnar neuropathy after elbow replacement. We describe our experience with the surgical management of this problem. Of 1607 total elbow replacements performed at our institution between January 1969 and December 2004, eight patients (0.5%) had a further operation for persistent or progressive ulnar neuropathy. At a mean follow-up of 9.2 years (3.1 to 21.7) six were clinically improved and satisfied with their outcome, although, only four had complete recovery. When transposition was performed on a previously untransposed nerve the rate of recovery was 75%, but this was reduced to 25% if the nerve had been transposed at the time of the replacement

Aims

To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound.

Aims

Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model.

The integrity of the spinal accessory nerve is fundamental to thoracoscapular function and essential for scapulohumeral rhythm. This nerve is vulnerable along its superficial course. This study assessed the delay in diagnosis and referral for management of damage to this nerve, clarified its anatomical course and function, and documented the results of repair. From examination of our records, 111 patients with lesions of the spinal accessory nerve were treated between 1984 and 2007. In 89 patients (80.2%) the damage was iatropathic. Recognition and referral were seldom made by the surgeon responsible for the injury, leading to a marked delay in instituting treatment. Most referrals were made for painful loss of shoulder function. The clinical diagnosis is straightforward. There is a characteristic downward and lateral displacement of the scapula, with narrowing of the inferior scapulohumeral angle and loss of function, with pain commonly present. In all, 80 nerves were explored and 65 were repaired. The course of the spinal accessory nerve in relation to the sternocleidomastoid muscle was constant, with branches from the cervical plexus rarely conveying motor fibres. Damage to the nerve was predominantly posterior to this muscle. Despite the delay, the results of repair were surprising, with early relief of pain, implying a neuropathic source, which preceded generally good recovery of muscle function

We investigated the effect of delay before nerve repair on neuropathic pain after injury to the brachial plexus. We studied 148 patients, 85 prospectively and 63 retrospectively. The mean number of avulsed spinal nerves was 3.2 (1 to 5). Pain was measured by a linear visual analogue scale and by the peripheral nerve injury scale. Early repair was more effective than delayed repair in the relief from pain and there was a strong correlation between functional recovery and relief from pain

We have reviewed 38 surgically treated cases of spontaneous posterior interosseous nerve palsy in 38 patients with a mean age of 43 years (13 to 68) in order to identify clinical factors associated with its prognosis. Interfascicular neurolysis was performed at a mean of 13 months (1 to 187) after the onset of symptoms. The mean follow-up was 21 months (5.5 to 221). Medical Research Council muscle power of more than grade 4 was considered to be a good result. A further 12 cases in ten patients were treated conservatively and assessed similarly. Of the 30 cases treated surgically with available outcome data, the result of interfascicular neurolysis was significantly better in patients < 50 years old (younger group (18 nerves); good: 13 nerves (72%), poor: five nerves (28%)) than in cases > 50 years old (older group (12 nerves); good: one nerve (8%), poor: 11 nerves (92%)) (p < 0.001). A pre-operative period of less than seven months was also associated with a good result in the younger group (p = 0.01). The older group had a poor result regardless of the pre-operative delay. Our recommended therapeutic approach therefore is to perform interfascicular neurolysis if the patient is < 50 years of age, and the pre-operative delay is < seven months. If the patient is > 50 years of age with no sign of recovery for seven months, or in the younger group with a pre-operative delay of more than a year, we advise interfascicular neurolysis together with tendon transfer as the primary surgical procedure

The transfer of part of the ulnar nerve to the musculocutaneous nerve, first described by Oberlin, can restore flexion of the elbow following brachial plexus injury. In this study we evaluated the additional benefits and effectiveness of quantitative electrodiagnosis to select a donor fascicle. Eight patients who had undergone transfer of a simple fascicle of the ulnar nerve to the motor branch of the musculocutaneous nerve were evaluated. In two early patients electrodiagnosis had not been used. In the remaining six patients, however, all fascicles of the ulnar nerve were separated and electrodiagnosis was performed after stimulation with a commercially available electromyographic system. In these procedures, recording electrodes were placed in flexor carpi ulnaris and the first dorsal interosseous. A single fascicle in the flexor carpi ulnaris in which a high amplitude had been recorded was selected as a donor and transferred to the musculocutaneous nerve. In the two patients who had not undergone electrodiagnosis, the recovery of biceps proved insufficient for normal use. Conversely, in the six patients in whom quantitative electrodiagnosis was used, elbow flexion recovered to an M4 level. Quantitative intra-operative electrodiagnosis is an effective method of selecting a favourable donor fascicle during the Oberlin procedure. Moreover, fascicles showing a high-amplitude in reading flexor carpi ulnaris are donor nerves that can restore normal elbow flexion without intrinsic loss

This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations. Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired. The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer. Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert score and 1.6 on the Mallett score. Pre-operative electrodiagnosis is a reliable indicator of the depth of the lesion and of the outcome after repair. Intra-operative somatosensory evoked potentials were helpful in the detection of occult intradural (pre-ganglionic) injury

We describe the results of surgical treatment in a prospective study of 183 consecutive cases of subluxation (101) and dislocation (82) of the shoulder secondary to obstetric brachial plexus palsy between 1995 and 2000. Neurological recovery was rated ‘good’ or ‘useful’ in all children, whose lesions fell into groups 1, 2 or 3 of the Narakas classification. The mean age at operation was 47 months (3 to 204). The mean follow-up was 40 months (24 to 124). The mean gain in function was 3.6 levels (9.4 to 13) using the Mallet score and 2 (2.1 to 4.1) on the Gilbert score. The mean active global range of shoulder movement was increased by 73°; the mean range of active lateral rotation by 58° and that of supination of the forearm by 51°. Active medial rotation was decreased by a mean of 10°. There were 20 failures. The functional outcome is related to the severity of the neurological lesion, the duration of the dislocation and onset of deformity

We describe 20 patients, aged between 43 and 88 years, with delayed nerve palsy or deepening of an initial palsy caused by arterial injury from low-energy injuries to the shoulder. The onset of palsy ranged from immediately after the injury to four months later. There was progression in all the patients with an initial partial nerve palsy. Pain was severe in 18 patients, in 16 of whom it presented as neurostenalgia and in two as causalgia. Dislocation of the shoulder or fracture of the proximal humerus occurred in 16 patients. There was soft-tissue crushing in two and prolonged unconsciousness from alcoholic intoxication in another two. Decompression of the plexus and repair of the arterial injury brought swift relief from pain in all the patients. Nerve recovery was generally good, but less so in neglected cases. The interval from injury to the repair of the vessels ranged from immediately afterwards to 120 days. Delayed onset of nerve palsy or deepening of a nerve lesion is caused by bleeding and/or impending critical ischaemia and is an overwhelming indication for urgent surgery. There is almost always severe neuropathic pain

We studied 21 patients with a spontaneous palsy of the anterior interosseous nerve. There were 11 men and 10 women with a mean age at onset of 39 years (17 to 65). Pain around the elbow or another region (forearm, shoulder, upper arm, systemic arthralgia) was present in 17 patients and typically lasted for two to three weeks. It had settled within six weeks in every case. In ten cases the palsy developed as the pain settled. A complete palsy of flexor pollicis longus and flexor digitorum profundus to the index finger was seen in 13 cases and an isolated palsy of flexor pollicis longus in five. All patients were treated without operation. The mean time to initial muscle contraction was nine months (2 to 18) in palsy of the flexor digitorum profundus to the index finger, and ten months (1 to 24) for a complete palsy of flexor pollicis longus. An improvement in muscle strength to British Medical Research Council grade 4 or better was seen in all 15 patients with a complete palsy of the flexor digitorum profundus and in 16 of 18 with a complete palsy of flexor pollicis longus. There was no significant correlation between the duration of pain and either the time to initial muscle contraction or final muscle strength. Prolonged pain was not always associated with a poor outcome but the age of the patient when the palsy developed was strongly correlated. Recovery occurred within 12 months in patients under the age of 40 years who achieved a final British Medical Research Council grade of 4 or better. Surgical decompression does not appear to be indicated for young patients with this condition