Radial Nerve Palsy in the Setting of Humeral Shaft Fracture.

The upper limb has a complex anatomy comprised of many nerve and vascular structures, making humeral shaft fractures extremely important. Injury to the humeral shaft commonly occurs due to trauma and affects younger male or older female patients. The radial nerve travels along the spiral groove of the humerus, placing it at an increased risk of damage in humeral shaft fractures. If injured, there are a variety of classifications of radial nerve injury, different indications for exploration, and treatment methods that orthopedic surgeons have available in treating these injuries. This review aims to discuss the etiology of humeral shaft fracture-associated radial nerve palsy, tools for diagnosis, and treatment.

Brachial Plexus Injury Secondary to Spontaneous Upper Limb Haematoma.

Spontaneous upper limb muscle haematomas are rare clinical phenomenons, which often go under- or misdiagnosed. They can present management challenges in the context of anticoagulant therapy, especially in the presence of other medical conditions. We present the case of a 52-year-old male with an initially missed presentation of a spontaneous muscle haematoma that progressed and re-presented to the emergency department (ED) with signs of mixed upper limb neuropathy requiring surgical evacuation and an emergency fasciotomy. This case highlights the importance of prompt diagnosis and intervention. While brachial plexus injuries from haematoma compression are uncommon, in our case, we discuss the need for surgical intervention to relieve pressure and optimise patient outcomes when clinically concerned about compartment syndrome or progressive neuropathy.

Shedding Light on Perioperative Nerve Injury: An Investigation Using the SHED (Symptoms Categorization-History Taking-Examination-Diagnostic Evaluations) Approach.

Peripheral nerve blocks (PNBs) provide analgesia and anesthesia in diverse surgical procedures. Despite their recognized benefits, the occurrence of complications, particularly peripheral nerve injuries (PNIs), is a noteworthy concern. Prompt identification and intervention for perioperative nerve injuries are crucial to prevent permanent neurological impairment. A meticulous, systematic evaluation centered on the onset and progression of symptoms becomes imperative. The SHED (symptoms categorization-history taking-examination-diagnostic evaluations) approach serves as a valuable tool for diagnosing causative factors, determining the type of nerve injury, and formulating an effective treatment plan to mitigate further harm. This case report employs the SHED approach to elucidate a perplexing instance of PNIs. The patient, experiencing neurological symptoms post-forearm surgery under a PNB, serves as a focal point. The report underscores the significance of a systematic, stepwise approach in managing patients with suspected PNIs. Vigilant patient monitoring, collaborative teamwork, shared responsibilities, and consideration of potential contributing factors beyond the nerve block are highlighted for an accurate diagnosis and effective treatment of PNIs. The aim is to guide healthcare professionals in navigating similar clinical scenarios, ultimately ensuring patient safety and optimizing outcomes.

Peripheral neuropathies after shoulder arthroscopy: a systematic review.

Purpose: Peripheral neuropathies after shoulder arthroscopy are rare, though likely under-reported. Many resolve spontaneously, but some patients are left with permanent neurological deficits. The purpose of this study was to review the literature to better characterize this patient population, diagnostic tests performed, the timing and type of surgical intervention, and report clinical outcomes. Methods: A systematic literature review was performed. Articles in English were identified from PubMed, EMBASE, and CINAHL in August 2021. Article titles and abstracts were screened for relevance by two authors and discordant abstracts were resolved by the senior author. Data were subsequently extracted from the included articles. Results: Seventeen articles were identified yielding a total of 91 patients. The average age was 53 ± 12 years, and most patients were male (72%). Rotator cuff repair (62%) was the most common procedure performed. A peripheral neuropathy was identified an average of 80 ± 81 days from the index procedure (range, 0-240 days). Most commonly, peripheral nerve injury presented as a mononeuropathy, with the median nerve (39%) and ulnar nerve (17%) affected predominantly. Seventeen percent of patients underwent a secondary surgery at an average of 232 ± 157 days after the index procedure. At the final follow-up, 55% of neuropathies had resolved, 14% partially improved, and 22% showed no clinical improvement. The most proposed etiologies were postoperative immobilization (29%) and intraoperative positioning (20%), but several possible etiologies have been suggested. Conclusions: Peripheral neuropathies after arthroscopic shoulder procedures are rare. While most spontaneously resolve, up to 1 in 5 patients may have persistent neuropathic symptoms. A high index of suspicion should be maintained throughout the postoperative period. When neurologic deficits are identified, patients should undergo a thorough diagnostic workup and be referred to a subspecialist in a timely manner.

Steroid Infiltrations Can Alleviate Refractive Superficial Peroneal Nerve Neuropraxia after Ankle Sprain: A Case Series.

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Brachial Neuritis After a COVID-19 Booster Vaccination: A Case Report and Literature Review.

Idiopathic brachial neuritis also known as Parsonage-Turner syndrome is a rare neurological disorder characterised by pain and paraesthesia involving the shoulder girdle and upper limb, followed by weakness of the affected area. The cause is not very well understood and is often misdiagnosed leading to delayed treatment and long-term disability. There are many risk factors for the condition, with immunisations being accountable for as many as 15% of cases. In response to the coronavirus disease 2019 (COVID-19) pandemic, many companies have been producing and distributing COVID-19 vaccinations. To our knowledge, there have been 42 cases of brachial neuritis reported following COVID-19 vaccination to date. Here, we report a case of brachial neuritis following a patient's fourth COVID-19 vaccination and present a review of the literature.

Ulnar Nerve Translocation Following a Routine Distal Radius Fracture.

A 35-year-old right hand dominant male sustained a high energy closed right distal radius fracture with associated generalized paresthesias. Following closed reduction, the patient was found to have an atypical low ulnar nerve palsy upon outpatient follow-up. After continued symptoms and an equivocal wrist MRI the patient underwent surgical exploration. Intraoperatively, the ulnar nerve as well as the ring and small finger flexor digitorum superficialis tendons were found to be translocated around the ulnar head. The nerve and tendons were reduced, the median nerve was decompressed, and the fracture was addressed with volar plating. Post-operatively, the patient continued to have sensory deficits and stiffness of the ring and small fingers. After one year, he reported substantial improvements as demonstrated by full sensation (4.0 mm two-point discrimination) and fixed flexion contractures at the proximal and distal interphalangeal joints of the small finger. The patient returned to work without functional limitations. This case highlights a unique case of ulnar nerve and flexor tendon entrapment following a distal radius fracture. History, physical examination, and a high index of clinical suspicion is essential for proper management of this rare injury. Level of Evidence: V.

Type III Monteggia Fracture-dislocation with Radial Nerve Injury in Adults - A Case Report of two Cases.

Introduction: Uncommon complication of Monteggia fracture is associated PIN palsy. The PIN palsy following Monteggia fracture-dislocation is neuropraxias and will recover spontaneously. Case Report: Two cases who were diagnosed as Monteggia fracture-dislocation with PIN palsy and associated superficial branch of radial nerve injury - Power 0/5 and sensations 0/2 were taken up for surgery (open reduction internal fixation of fracture of ulna + closed reduction of radial head). By the end of 7 weeks, both sensory and motor power were fully recovered spontaneously in both the cases. Discussion: Most of the PIN injuries following Monteggia fracture-dislocation are neuropraxias and will recover spontaneously after closed reduction of radial head without any intervention to the nerve. The nerve needs to be intervened if there are no signs of recovery by 3 months. The time frame for the nerve to be intervened remains controversial. Conclusion: In both of our cases, the injury is probably proximal to the terminal division of radial nerve and the injuries were neuropraxias and have recovered spontaneously. Hence, we suggest not exploring the nerve in all cases with Monteggia fracture-dislocation immediately even when there is associated sensory deficit.

Intraoperative Conversion From Endoscopic to Open Carpal Tunnel Release: A Systematic Review and Case Series.

PURPOSE: The purpose of this study was to assess the incidence, outcomes, and complications associated with conversion from endoscopic carpal tunnel release (ECTR) to open carpal tunnel release (OCTR). METHODS: A retrospective case review of all patients who underwent ECTR over 4 years by 2 fellowship-trained hand surgeons at a single academic center was performed. We recorded outcomes and the reason for conversion in patients who underwent conversion to an OCTR. Baseline demographics and surgical complications were compared between the 2 groups. A systematic review was performed to define the incidence and reasons for conversion from ECTR to OCTR. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included clinical studies of ECTR from 2000 to 2021. RESULTS: In the retrospective series, 9 of 892 (1.02%) ECTR cases underwent conversion to an OCTR at the time of the index procedure. One of 9 converted cases had transient neurapraxia involving the recurrent motor branch after surgery compared with 0 cases in the group that underwent ECTR without conversion. Improvements in the visual analog scale for pain and QuickDASH were noted at a mean of 46 weeks after surgery in the group that underwent conversion to OCTR. The systematic review identified an incidence of conversion of 0.62%. The most common reasons for conversion to OCTR in the case series and systematic review were poor visualization due to hypertrophic tenosynovium and aberrant nerve anatomy. CONCLUSIONS: The overall incidence of intraoperative conversion from ECTR to OCTR during the index procedure was 1.02%, with the most common reasons for conversion being poor visualization due to hypertrophic tenosynovium and aberrant nerve anatomy. Patients who undergo conversion from ECTR to OCTR demonstrate improvements in pain and disability, similar to patients who undergo ECTR without conversion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Early Postoperative Iatrogenic Neuropraxia After Lumbar Disc Herniation Surgery: Analysis of 87 Cases.

BACKGROUND: Postoperative early neuropraxia after lumbar disc herniation surgery is common. The emergence of new paresthesia findings with increased sensory and motor deficits in the postoperative period suggests iatrogenic neuropraxia. This study aimed to discuss the causes and prognosis of iatrogenic neuropraxia detected in the early postoperative period in patients who have been operated on for lumbar disc herniation. METHODS: Cases with postoperative iatrogenic neuropraxia were determined retrospectively. Deficits were evaluated at intervals of 0-2 hours, 2-12 hours, 12-24 hours, and 24-48 hours. The cases were evaluated in 2 groups as those who underwent aggressive discectomy and simple discectomy. In addition, the treatment results were compared between the 2 groups as the cases that were treated and not treated with methylprednisolone. RESULTS: The iatrogenic neuropraxia rate was significantly higher in patients who underwent aggressive discectomy. Although it was observed that paresthesia findings improved more rapidly in cases treated with methylprednisolone, no difference was found between the 2 groups in terms of its effects on the motor deficit. CONCLUSIONS: Iatrogenic neuropraxia is a finding whose cause cannot be determined by quantitative criteria. It is common in patients who underwent aggressive discectomy. Methylprednisolone treatment is effective in recovering the paresthesia finding faster and may show that the radicular injury is in the neuropraxia stage in the early period.

How common is nerve injury after reverse shoulder arthroplasty? A systematic review.

BACKGROUND: Nerve injury following reverse shoulder arthroplasty (RSA) is a known risk factor with wide ranging incidences reported. This systematic review evaluates the overall incidence of nerve injury following primary and revision RSA and summarizes the characteristics of the nerve injuries reported in the current literature. METHODS: A systematic review was performed using separate database searches (Pubmed, Embase, Web of Science, Cochrane) following the PRISMA guidelines. Search criteria included the title terms "reverse shoulder," "reverse total shoulder," "inverted shoulder," and "inverted total shoulder" with publication dates ranging from 01/01/2010 to 01/01/2022. Studies that reported neurological injuries and complications were included and evaluated for primary RSA, revision RSA, number of nerve injuries, and which nerves were affected. RESULTS: After exclusion, our systematic review consisted of 188 articles. A total of 40,146 patients were included, with 65% female. The weighted mean age was 70.3 years. The weighted mean follow-up was 35.4 months. The rate of nerve injury after RSA was 1.3% (510 of 40,146 RSAs). The rate of injury was greater in revision RSA compared to primary RSA (2.4% vs. 1.3%). Nerve injury was most common in RSAs done for a primary diagnosis of acute proximal humerus fracture (4.0%), followed by cuff tear arthropathy (3.0%), DJD (2.6%), and inflammatory arthritis (1.7%). Massive rotator cuff tears and post-traumatic arthritis cases had the lowest nerve injury rates (1.0% and 1.4%, respectively). The axillary nerve was the most commonly reported nerve that was injured in both primary and revision RSA (0.6%), followed by the ulnar nerve (0.26%) and median nerve (0.23%). Brachial plexus injury was reported in 0.19% of overall RSA cases. CONCLUSION: Based on current English literature, nerve injuries occur at a rate of 1.3% after primary RSA compared with 2.4% after revision RSA. The most common nerve injury was to the axillary nerve (0.64%), with the most common operative diagnosis associated with nerve injury after RSA being acute proximal humerus fracture (4.0%). Surgeons should carefully counsel patients prior to surgery regarding the risk of nerve injury.

Cocaine-Induced Kidney, Liver, Lung, and Muscle Injury (C-KLM), Presenting With Foot Drop: A Case Report.

Cocaine-associated organ injury is a well-known phenomenon that may lead to multi-organ failure. Cocaine-induced kidney, liver, lung, and muscle (C-KLM) involvement is an entity with alarmingly high creatinine phosphokinase (CPK) levels exceeding 100,000 U/L. This may have fatal outcomes. Rhabdomyolysis is one of the many mechanisms of kidney injury induced by cocaine intoxication. Sympathomimetic effects of cocaine contribute to muscle Injury in addition to vasoconstriction resulting in muscle ischemia, as well as liver ischemia (shock liver). Furthermore, increased muscular activity from hyperpyrexia, seizures, and agitation due to cocaine use disorder may contribute to muscle breakdown and worsening nephrotoxicity.  The authors detail a case of a 34-year-old male intravenous drug user who presented with an inability to bear weight or move his left lower extremity due to pain, associated with severe edema of his lower extremities of acute onset. He was subsequently noted with foot drop, oliguria, and high blood pressure following cocaine intoxication. The patient began crashing rather quickly and the intensive care unit was recommended. Labs were noted with overwhelming CPK levels over 100,000 U/L and rising for which urgent hemodialysis was initiated. We detail a catastrophic cocaine-induced multi-organ failure with a positive outcome following a multidisciplinary approach.

Management of Tourniquet-Related Nerve Injury (TRNI): A Systematic Review.

Tourniquet-related nerve injuries (TRNIs) are a rare but feared complication of operative tourniquet use. While the literature contains multiple discussions regarding tourniquet use as well as reported cases of its complications, there does not exist a consensus guideline for a safe tourniquet pressure, application time, or management of TRNI. This paper conducts a comprehensive review of the available literature for cases of TRNI with a specific focus on analyzing the management of cases of TRNI and their functional recovery. One hundred nine articles were retrieved in a search of medical literature (PubMed) using the keywords: tourniquet, nerve injury, paralysis, and palsy. The initial search was further narrowed down to seven case series and 10 case reports totaling 203 reported cases of TRNI. Of the 203 cases, 64 cases involved upper extremity tourniquet use, and 139 cases involved lower extremity tourniquet use. Most patients (89.75%) experienced a complete recovery. TRNI may occur over a wide range of tourniquet application times and tourniquet pressures; hence, it is a necessity for surgeons to consider it as a potential complication and understand the methodology for diagnosis and long-term management.

Incidence and risk factors for pseudosubluxation of the humeral head following proximal humerus fracture.

Background: Humeral head pseudosubluxation (HHPS) in relation to the glenohumeral joint is a common finding following fractures of the proximal humerus. The temporary inferior subluxation of the humeral head may be secondary to a transient axillary nerve neuropraxia, pain inhibition of the deltoid, or hemarthrosis or capsular disruption that alters the physiologically negative pressure in the glenohumeral joint. Despite the frequency of this finding, it is not well described in the literature. This study sought to describe the incidence, risk factors, and rate of resolution of HHPS following proximal humerus fracture. Methods: The practice of two fellowship-trained shoulder and elbow surgeons was queried for proximal humerus fractures. Patient radiographs were reviewed at the time of injury and all subsequent follow-ups through one year after injury. Data collection included the presence of HHPS, type of fracture based on the Neer classification, operative vs. nonoperative management, and resolution of HHPS. Exclusion criteria included skeletally immature patients, fracture-dislocations, patients treated with reverse shoulder arthroplasty, inadequate follow-up, or those patients with incorrect International Classification of Diseases coding. Results: The incidence of HHPS was 20.0% (103 out of 515 patients) overall. Patients who required surgical intervention were more likely to develop pseudosubluxation than those who were treated conservatively (P < .001). There was an increasing incidence of pseudosubluxation based on the Neer classification, with 0-part fractures demonstrating a 2.56% (2/78) rate, whereas 4-part fractures were found to have HHPS in 35.1% (20/57) of cases (P < .001). All patients were found to have resolution of their HHPS at the final follow-up or one year after injury. None of age, sex, obesity, or injury to the dominant arm was associated with the occurrence of HHPS. There was, however, a statistically significant difference in the body mass index of those who developed HHPS (28.4, ± 5.77) vs. those who did not (26.2, ± 5.32, P < .01). Conclusion: This retrospective radiographic study is the largest to date investigating the incidence of HHPS following proximal humerus fracture and first to correlate with Neer classification and operative intervention. We found that HHPS occurs in one-fifth of acute proximal humerus fractures and resolves regardless of intervention. More complex fractures, including those with increasing Neer parts or requiring operative intervention, developed HHPS at higher rates than simpler fracture patterns. This study will help both general orthopedists as well as shoulder surgeons understand the epidemiology of HHPS and provide reassurance to patients that PS is a benign finding with expected spontaneous resolution by one year.

A Rare Case of Brachial Plexus Neuropraxia After COVID-19 Vaccination.

The brachial plexus injury is a rare complication after vaccination like that of the Influenza virus. Though a well-known and reported complication, there is still a dearth of literature mentioning its pathophysiology, the trend of involvement, symptoms, and treatment. This has also been reported after the coronavirus disease 2019 (COVID-19) vaccination. To the best of our knowledge, to date, only four cases have been reported so far. Every case needs to be reported to better understand the complication and formulate a line of management for better outcomes. We report a case of brachial plexus involvement after Covishield vaccination with complete recovery after treatment.

Femoral head to lower lumbar neural foramen distance as a novel radiographic parameter to predict postoperative stretch neuropraxia.

OBJECTIVE: Lumbosacral fractional curves in adult spinal deformity (ASD) patients often have sharp coronal curves resulting in significant pain and imbalance. Postoperative stretch neuropraxia after fractional curve correction can lead to discomfort and unsatisfactory outcomes. The goal of this study was to use radiographic measures to increase understanding of the relationship between postoperative stretch neuropraxia and fractional curve correction. METHODS: In 62 ASD patients treated from 2015 to 2018, radiographic review was performed, including measurement of the distance between the lower lumbar neural foramen (L4 and L5) in the concavity and convexity of the lumbosacral fractional curve and the ipsilateral femoral heads (FHs; L4-FH and L5-FH) in pre- and postoperative anteroposterior spine radiographs. The largest absolute preoperative to postoperative change in distance between the lower lumbar neural foramen and the ipsilateral FH (ΔL4/L5-FH) was used for analysis. Chi-square analyses, independent and paired t-tests, and logistic regression were performed to study the relationship between L4/L5-FH and stretch neuropraxia for categorical and continuous variables, respectively. RESULTS: Of the 62 patients, 13 (21.0%) had postoperative stretch neuropraxia. Patients without postoperative stretch neuropraxia had an average ΔL4-FH distance of 16.2 mm compared to patients with stretch neuropraxia, who had an average ΔL4-FH distance of 31.5 mm (p < 0.01). Patients without postoperative neuropraxia had an average ΔL5-FH distance of 11.1 mm compared to those with stretch neuropraxia, who had an average ΔL5-FH distance of 23.0 mm (p < 0.01). Chi-square analysis showed that patients had a 4.78-fold risk of developing stretch neuropraxia with ΔL4-FH > 20 mm (95% CI 1.3-17.3) and a 5.17-fold risk of developing stretch neuropraxia with ΔL5-FH > 15 mm (95% CI 1.4-18.7). Logistic regression analysis indicated that the odds of developing stretch neuropraxia were 15:1 with a ΔL4-FH > 20 mm (95% CI 3-78) and 21:1 with a ΔL5-FH > 15 mm (95% CI 4-113). CONCLUSIONS: The novel ΔL4/L5-FH distances are strongly associated with postoperative stretch neuropraxia in ASD patients. A ΔL4-FH > 20 mm and ΔL5-FH > 15 mm significantly increase the odds for patients to develop postoperative stretch neuropraxia.

Neurologic complications in primary anatomic and reverse total shoulder arthroplasty: A review.

Neurologic injury during shoulder replacement is one of the less common complications of the procedure, however the clinical implications can be significant. The purpose of this paper is to review the current literature on neurologic complications in various types of shoulder replacement and provide recommendations regarding avoidance, evaluation, and management of these complications.

Transient Quadriparesis and Cervical Neuropraxia in Elite Athletes.

Elite athletes are often faced with difficult decisions when faced with a cervical spinal disorder. There are many aspects to consider such as the risk of further injury, short- and long-term effects on an athlete's life both during and after his/her career, and the options for treatment. Although there have been some recent contributions to this topic, the evidence-based literature is generally devoid of high-level clinical studies to help guide the decision-making process. This article reviews the pertinent available data/criteria and offer an algorithm for return-to-play considerations.

Inferior alveolar nerve damage secondary to orthodontic treatment: A systematic scoping review.

BACKGROUND: Neurosensory impairment is a common complication following inferior alveolar nerve (IAN) damage. OBJECTIVE: To document and report the various causes, diagnosis, and management of IAN damage secondary to orthodontic treatment. METHODS: An electronic search for studies that reported IAN damage in patients undergoing orthodontic treatment was performed up to July 15, 2020 using MEDLINE, Embase, and PubMed databases. Descriptive analyses and linear regression model were performed. RESULTS: A total of 15 case reports were identified including 16 patients with an overall mean age of 23.3. All the included studies reported temporary sensory alterations which manifested as anesthesia (19%, n = 3), paresthesia (75%, n = 12), or combined (6%, n = 1). The majority of cases managed by stopping the orthodontic force (75%, n = 12), followed by appliance adjustments (19%, n = 3), providing a bite plate (13%, n = 2), and/or providing pharmacological management (38%, n = 6). Full recovery median duration reported in all cases following the aforementioned managements was 17.5 days. CONCLUSIONS: IAN damage secondary to orthodontic treatment is emerging in the literature in recent years. Identifying high risk patients with close proximity to the IAN canal is a must to formulate a proper treatment plan to avoid such complications.

Asymptomatic Spinal Cord Compression: Is Surgery Necessary to Return to Play.

Advising athletes with asymptomatic cervical canal stenosis on their return to active play is a topic of considerable debate, with no definitive guidelines in place. Once cervical canal stenosis is identified, often through imaging following other injuries, it is difficult to predict the risk of future injury upon return to play in both contact and collision sports. Consequently, the decision can be a complicated one for the athlete, family, and physician alike. In this article, we identify radiographical and magnetic resonance imaging (MRI)-based criteria that may distinguish athletes "at-risk" for more severe consequences due to asymptomatic cervical canal stenosis from those who are safe to return to play. Using a Torg-Pavlov ratio <0.7 and MRI metrics, namely a minimal disc-level canal diameter <8 mm, a cord-to-canal area ratio >0.8, or space available for the cord <1.2 mm, can help when making these difficult decisions. Counseling can be a critical asset to patients with cervical stenosis who have had a previous episode of cervical cord neuropraxia, especially when they are involved in high-risk sports such as American football and rugby. We believe that while this remains an area of continued concern and controversy, improved MRI criteria will be a useful springboard for further studies, especially in the elite athlete population.