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Background: Conventionally, neural transfer of the spinal accessory nerve to the suprascapular nerve for shoulder abduction in traumatic brachial plexus injury is performed via the anterior approach. However, important advantages of the posterior approach have made it an alternative option, such as the proximity of neural coaptation to the muscle to be reinnervated and negating the effects of a second injury to the suprascapular nerve., Methods: Retrospective data was collected from 30 patients with brachial plexus injury who underwent spinal accessory nerve to suprascapular nerve transfer over 4 years. There were 15 patients in the anterior-approach group (group A) and 15 in the posterior-approach group (group B). Functional outcome at the shoulder was measured as muscle power and active range of motion at 18 months, and data on patients' satisfaction levels and surgeons' perceptions was also collected., Results: No statistical difference was found in the muscle strength achieved in the 2 groups (P = 0.34), but significant recovery was found in the external rotation achieved by group B (P = 0.02). Statistical difference was insignificant in the 2 groups' active range of motion during abduction and external rotation. The satisfaction index of patients was 86.7% in group B as compared to 68% in group A. Surgeons' perspective showed a faster speed of suprascapular nerve exploration in the posterior approach, with better visibility of supraspinatus muscle contraction, and overall surgeons preferred the posterior approach., Conclusions: External rotation at the shoulder is better via the posterior approach, but no difference in abduction was noted. Patients who underwent the posterior approach were more satisfied with the recovery, and surgeons preferred the posterior approach., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Shoulder surgeries, vital for diverse pathologies, pose a risk of iatrogenic nerve damage. Existing literature lacks diverse bone landmark-specific nerve position data. The purpose of this study is to address this gap by investigating such relationships., Method: This cadaveric study examines axillary, radial and suprascapular nerves' relation with acromion, coracoid and greater tuberosity of the humerus (GT). It also correlates this data with humeral lengths and explores nerve dynamics in relation to arm positions., Results: The mean distance from the axillary nerve to (i) GT was 4.38 cm (range 3.32-5.44, SD 0.53), (ii) acromion was 6.42 cm (range 5.03-7.8, SD 0.694) and (iii) coracoid process was 4.3 cm (range 2.76-5.84, SD 0.769). Abduction brought the nerve closer by 0.36 cm, 0.35 cm and 0.53 cm, respectively. The mean distance from radial nerve to (i) GT was 5.46 cm (range 3.78-7.14, SD 0.839), (ii) acromion was 7.82 cm (range 5.4-10.24, SD 1.21) and (iii) tip of the coracoid process was 6.09 cm (range 4.07-8.11 cm, SD 1.01). The mean distance from the suprascapular nerve to the acromion was 4.2 cm (range 3.1-5.4, SD 0.575). The mean humeral length was noted to be 27.83 cm (range 25.3-30.7, SD 1.13). There was no significant correlation between these distances and humeral lengths., Conclusion: It is essential to exercise caution to avoid axillary nerve damage during the abduction manoeuvre, as its distance from the greater tuberosity and tip of the coracoid process has shown a significant reduction. The safe margins, in relation to the length of the humerus and consequently the patient's stature, exhibit no significant variation. In situations where the greater tuberosity (GT) and the border of the acromion are inaccessible due to reasons such as trauma, the tip of the coracoid process can serve as a dependable bone landmark for establishing a secure surgical margin., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Background: In brachial plexus surgery, a key focus is restoring shoulder abduction through spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer using either the anterior or posterior approach. However, no published randomised control trials have directly compared their outcomes to date. Therefore, our study aims to assess motor outcomes for both approaches. Methods: This study comprises two groups of patients. Group A: anterior approach (29 patients), Group B: Posterior approach (29 patients). Patients were allocated to both groups using selective randomisation with the sealed envelope technique. Functional outcome was assessed by grading the muscle power of shoulder abductors using the British Medical Research Council (MRC) scale. Results: Five patients who were operated on by posterior approach had ossified superior transverse suprascapular ligament. In these cases, the approach was changed from posterior to anterior to avoid injury to SSN. Due to this reason, the treatment analysis was done considering the distribution as: Group A: 34, Group B: 24. The mean duration of appearance of first clinical sign of shoulder abduction was 8.16 months in Group A, whereas in Group B, it was 6.85 months, which was significantly earlier ( p < 0.05). At the 18-month follow-up, both intention-to-treat analysis and as-treated analysis were performed, and there was no statistical difference in the outcome of shoulder abduction between the approaches for SAN to SSN nerve transfer. Conclusions: Our study found no significant difference in the restoration of shoulder abduction power between both approaches; therefore, either approach can be used for patients presenting early for surgery. Since the appearance of first clinical sign of recovery is earlier in posterior approach, therefore, it can be preferred for cases presenting at a later stage. Also, the choice of approach is guided on a case to case basis depending on clavicular fractures and surgeon preference to the approach. Level of Evidence: Level II (Therapeutic).

Among high-speed sports, an increased number of high-speed injuries have been observed in alpine downhill racing. We report the case of a young professional ski racer who sustained a shoulder dislocation with an avulsion of the axillary nerve during a World Cup race. After initial treatment was provided for the shoulder dislocation, the patient was left with abduction weakness and a sensory deficit in the region of the deltoid muscle. She underwent electrophysiological and clinical examinations and visited our centre with delay. We immediately performed surgical treatment with a nerve transfer and nerve transplantation. After only 11 months following her fall, she was able to resume her training program. This case report shows the importance of early diagnostic investigation, a visit to a centre of plastic surgery and the good outcome after surgical treatment in patients with peripheral nerve injuries., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Dual nerve transfer of the spinal accessory nerve to the suprascapular nerve (SAN-SSN) and the radial nerve to the axillary nerve is considered to be the most feasible method of restoration of shoulder abduction in brachial plexus injuries. Supraspinatus muscle plays an important role in the initiation of abduction and its functional restoration is crucial for shoulder movements. There are two possible approaches for the SAN-SSN transfer: the more conventional anterior approach and the posterior approach in the area of scapular spine, which allows more distal neurotization. Although the dual nerve transfer is a widely used method, it is unclear which approach for the SAN-SSN transfer results in better outcomes. We conducted a search of English literature from January 2001 to December 2021 using the PRISMA guidelines. Twelve studies with a total 142 patients met our inclusion criteria. Patients were divided into two groups depending on the approach used: Group A included patients who underwent the anterior approach, and Group B included patients who underwent the posterior approach. Abduction strength using the Medical Research Scale (MRC) and range of motion (ROM) were assessed. The average MRC grade was 3.57 ± 1.08 in Group A and 4.0 ± 0.65 (p = 0.65) in Group B. The average ROM was 114.6 ± 36.7 degrees in Group A and 103.4 ± 37.2 degrees in Group B (p = 0.247). In conclusion, we did not find statistically significant differences between SAN-SSN transfers performed from the anterior or posterior approach in patients undergoing dual neurotization technique for restoration of shoulder abduction.

Background: Restoration of shoulder function in obstetrical brachial plexus injury is paramount. There remains debate as to the optimal method of upper trunk reconstruction. The purpose of this study was to test the hypothesis that spinal accessory nerve to suprascapular nerve transfer leads to improved shoulder external rotation relative to sural nerve grafting., Methods: A systematic review of Medline, EMBASE, EBSCO CINAHL, SCOPUS, Cochrane Library, and TRIP Pro from inception was conducted. Our primary outcome was shoulder external rotation., Results: Four studies were included. Nerve transfer was associated with greater shoulder external rotation relative to nerve grafting (mean difference: 0.82 AMS 95% confidence interval [CI]: 0.27-1.36, P < .005). Patients undergoing nerve grafting were more likely to undergo a secondary shoulder stabilizing procedure (odds ratio [OR]: 1.27, 95% CI: 0.8376-1.9268)., Conclusion: In obstetrical brachial plexus injury, nerve transfer is associated with improved shoulder external rotation and a lower rate of secondary shoulder surgery., Level of Evidence: Level III; Therapeutic.

Background: The purpose of this work was to evaluate the clinical outcomes of triceps motor branch to axillary nerve transfers and to identify prognostic factors which may influence these outcomes., Methods: A retrospective cohort included all patients who underwent a triceps motor branch to axillary nerve transfer (2010-2019) with at least 12 months of follow-up. The primary outcome measure was shoulder abduction strength assessed with British Medical Research Council (MRC) grade., Results: Ten patients were included with a mean follow-up of 19.1 (SD 5.9) months. Compared with preoperative MRC shoulder abduction strength (0.2 SD 0.4), patients significantly improved postoperatively (2.8 SD 1.6; P = .005). Increased body mass index (BMI) was significantly associated with worse postoperative MRC ( P = .014)., Conclusion: Triceps motor branch to axillary nerve transfer is a beneficial procedure for restoring shoulder function in patients presenting with either isolated axillary nerve or brachial plexus pathology. Patients with elevated BMI may not have as robust strength recovery and should be counseled carefully regarding prognosis.

Background: The external rotation and abduction of shoulder are considered one of the priorities of reconstruction in brachial plexus injury. The aim of this study was to evaluate the functional results and complications of shoulder arthrodesis in patients with brachial plexus injury to better comprehend the benefits of this procedure., Methods: Between 2015 and 2019, 15 shoulder arthrodesis were performed in patients with long-standing brachial plexus injury. The main indication for arthrodesis was absent or poor recovery of shoulder abduction and external rotation. Patients presented different levels of injury. Shoulder measurements of active abduction and external rotation were made based on image records of the patients. A long 4.5-mm reconstruction plate was fit along the scapular spine, acromion, and lateral proximal third of the humerus. Structured bone graft was fit into the subacromial space., Results: The mean preoperative abduction was 16°, and the mean postoperative abduction was 42°. The mean preoperative external rotation was -59°, and the mean postoperative external rotation was -13°. The mean increase in abduction and external rotation was 25° and 45°, respectively. Bone union was achieved in all cases at an average time of 5.23 months. We experienced humeral fractures in 26.66% of the cases, which were all successfully treated nonoperatively., Conclusions: Shoulder arthrodesis is a rewarding procedure for patients with brachial plexus injuries. A marked improvement in the upper limb positioning was observed in all patients. It should be considered as the main therapeutic option in cases where nerve reconstruction is no longer possible.

Background: Interscalene brachial plexus block is associated with phrenic nerve paralysis. The objective of this study was to evaluate an alternative approach to interscalene brachial plexus blocks in terms of efficacy, grade of motor and sensory blockade, and phrenic nerve blockade., Methods: The study was prospective and interventional. The ten living patients studied were 18 to 65 years old, ASA physical status I or II, and submitted to correction of rotator cuff injury. A superior trunk blockade was performed at the superior trunk below the omohyoid muscle, without blocking the phrenic nerve. The needle was advanced below the prevertebral layer until contacting the superior trunk. In order to guarantee the correct positioning of the needle tip, an intracluster pattern of the spread was visualized. The block was performed with 5.ßmL of 0.5% bupivacaine in ten patients. In the six cadavers, 5.ßmL of methylene blue was injected. Diaphragmatic excursion was assessed by ultrasonography of the ipsilateral hemidiaphragm. In three patients, pulmonary ventilation was evaluated with impedance tomography. Pain scores and analgesic consumption were assessed in the recovery room for 6.ßhours after the blockade., Results: In the six cadavers, methylene blue didn...t reach the phrenic nerve. Ten patients underwent arthroscopic surgery, and no clinically phrenic nerve paralysis was observed. No patient reported pain during the first 6.ßhours., Conclusions: This study suggests that this new superior trunk approach to block the superior trunk may be an alternative technique to promote analgesia for shoulder surgery in patients with impaired respiratory function., (Copyright © 2021 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.)

Purpose: We aimed to analyze changes in suprascapular nerve (SSN) position within the suprascapular notch during in vivo shoulder abduction., Materials and Methods: Three-dimensional models of the shoulder complex were constructed based on magnetic resonance imaging of the brachial plexus (BP-MR) in a patient diagnosed with SSN dysfunction but normal scapular movement. Using BP-MR in neutral position and computed tomography data on shoulder abduction, shoulder abduction was simulated as the transition between two positions of the shoulder complex with overlapping of a neutral and abducted scapula. SSN movement during abduction was evaluated using the finite element method. Contact stress on the SSN was measured in the presence and absence of the transverse scapular ligament (TSL)., Results: In the neutral position, the SSN ran almost parallel to the front of the TSL until entering the suprascapular notch and slightly contacted the anterior-inferior border of the TSL. As shoulder abduction progressed, contact stress decreased due to gradual loss of contact with the TSL. In the TSL-free scapula, there was no contact stress on the SSN in the neutral position. Towards the end of shoulder abduction, contact stress increased again as the SSN began to contact the base of the suprascapular notch in both TSL conditions., Conclusion: We identified changes in the position of the SSN path within the suprascapular notch during shoulder abduction. The SSN starts in contact with the TSL and moves toward the base of the suprascapular notch with secondary contact. These findings may provide rationale for TSL release in SSN entrapment., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2022.)

Background: Since 2007, the authors have performed the triceps-to-axillary nerve transfer using the medial triceps branch to reconstruct axillary nerve function in brachial plexus and isolated axillary nerve palsies., Methods: A retrospective chart review was undertaken of patients reconstructed with this transfer, recording patient and injury demographics and time to surgery. Preoperative and postoperative function was graded using the Medical Research Council scale and the Disabilities of the Arm, Shoulder, and Hand questionnaire., Results: Postoperatively, 31 patients (64.6 percent) reached Medical Research Council grade 3 or higher at final follow-up. The median Disabilities of the Arm, Shoulder, and Hand score was 59.9 (interquartile range, 38.8 to 70.5) preoperatively and 25.0 (interquartile range, 11.3 to 61.4) at final follow-up. Sixteen patients (33 percent) had isolated axillary nerve injury; the median Medical Research Council grade was 4.25 (interquartile range, 3 to 4.25), with 14 patients (87.6 percent) achieving grade 3 or higher. Thirty-two patients (77 percent) had brachial plexus-associated injury; median Medical Research Council grade was 3 (interquartile range, 2 to 3), with 17 patients (53.1 percent) achieving grade 3 or higher., Conclusion: Medial triceps nerve branch is a strong donor for triceps-to-axillary nerve transfer; however, injury factors may limit the motor recovery in this complex patient population, particularly in axillary nerve palsy associated with brachial plexus injury., Clinical Question/level of Evidence: Therapeutic, IV., Competing Interests: Disclosure:The authors have no conflicts of interest or financial disclosures to report., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Restoring shoulder abduction is one of the main priorities in the surgical treatment of brachial plexus injuries. Double nerve transfer to the axillary nerve and suprascapular nerve is widely used and considered the best option. The most common donor nerve for the suprascapular nerve is the spinal accessory nerve. However, donor nerves for axillary nerve reconstructions vary and it is still unclear which donor nerve has the best outcome. The aim of this study was to perform a systematic review on reconstructions of suprascapular and axillary nerves and to perform a meta-analysis investigating the outcomes of different donor nerves on axillary nerve reconstructions. We conducted a systematic search of English literature from March 2001 to December 2020 following PRISMA guidelines. Two outcomes were assessed, abduction strength using the Medical Research Council (MRC) scale and range of motion (ROM). Twenty-two studies describing the use of donor nerves met the inclusion criteria for the systematic review. Donor nerves investigated included the radial nerve, intercostal nerves, medial pectoral nerve, ulnar nerve fascicle, median nerve fascicle and the lower subscapular nerve. Fifteen studies that investigated the radial and intercostal nerves met the inclusion criteria for a meta-analysis. We found no statistically significant difference between either of these nerves in the abduction strength according to MRC score (radial nerve 3.66 ± 1.02 vs intercostal nerves 3.48 ± 0.64, p = 0.086). However, the difference in ROM was statistically significant (radial nerve 106.33 ± 39.01 vs. intercostal nerve 80.42 ± 24.9, p < 0.001). Our findings support using a branch of the radial nerve for the triceps muscle as a donor for axillary nerve reconstruction when possible. Intercostal nerves can be used in cases of total brachial plexus injury or involvement of the C7 root or posterior fascicle. Other promising methods need to be studied more thoroughly in order to validate and compare their results with the more commonly used methods., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Entrapment neuropathies of the shoulder most commonly involve the suprascapular or axillary nerves, and they primarily affect the younger, athletic patient population. The extremes of shoulder mobility required for competitive overhead athletes, particularly in the position of abduction and external rotation, place this cohort at particular risk. Anatomically, the suprascapular nerve is most prone to entrapment at the level of the suprascapular or spinoglenoid notch; the axillary nerve is most prone to entrapment as it traverses the confines of the quadrilateral space.Radiographs should be ordered as a primary imaging study to evaluate for obvious pathology occurring along the course of the nerves or for pathology predisposing the patient to nerve injury. Magnetic resonance imaging plays a role in not only identifying any mass-compressing lesion along the course of the nerve, but also in identifying muscle signal changes typical for denervation and/or fatty atrophy in the distribution of the involved nerve., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Shoulder abduction is crucial for daily activities, and its restoration is one of the surgical priorities. We evaluated the predictive factors of shoulder abduction functional outcome after spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer, with special emphasis on the effect of time from injury to the surgery, in the treatment of traumatic brachial plexus injuries., Method: This cohort included adult patients who underwent SAN-to-SSN transfer with a preoperative Medical Research Council strength grade 0 and a follow-up of minimum 18 months. The primary outcome was shoulder abduction function (bad, < 30°; good, 30°-60°; or excellent, > 60°). Demographics, trauma characteristics, time lapse between injury and surgery, concomitant axillary nerve reconstruction, and surgery duration were registered. Ordinal logistic regression was used to identify predictors of functional outcomes., Results: The records of 83 patients (86.7% men, mean age 28.8 ± 9.8 years) were analysed. Mean body mass index was 24.1 ± 3.7 kg/m 2 , and 43.1% were overweight/obese. Motorcycle crashes were the most common trauma mechanism (88.0%). Excellent, good, and bad outcomes were achieved by 20.4%, 38.6%, and 41.0%, respectively. Older patients tended to have worse outcomes (p = 0.074), as well as left-sided lesions (p = 0.015) or those contralateral to manual dominance (p = 0.057). The longer the interval between injury and surgery the worse the outcome: excellent, 5.5 (4.3-7.1); good, 6.9 (5.9-8.7); and bad, 8.2 (5.7-10.1) months (p = 0.018). After multivariable analysis, longer time interval predicted lower odds of better outcomes (OR 0.823, 95% CI 0.699-0.970, p = 0.020; 17.7% lower odds of good or excellent outcome for each additional month). The odd of good or excellent outcomes was also associated with axillary nerve reconstruction (OR 2.767, 95% CI 1.016-7.536, p = 0.046), but not with age or lesion laterality., Conclusions: Excellent or good functional outcomes for shoulder abduction were achieved by almost sixty percent of adults who underwent SAN-to-SSN transfer for reconstruction of traumatic brachial plexus injuries, associated or not with axillary nerve reconstruction strategies. Longer delays from injury to surgery predicted worse outcomes, and the best time frame seemed to be less than 6 months., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

The kinkajou (Potos flavus) is a carnivoran adapted for arboreal quadrupedal locomotion along with a prehensile tail. The thoracic limb bones and muscles of this species have been studied, but the knowledge about its nerves is still scarce. This knowledge is necessary to perform several veterinary procedures, and to review the differences among carnivoran species. Thus, the objective of this study was to describe the origin and distribution of the brachial plexus in Potos flavus. Thereby, both brachial plexuses of five specimens were dissected (10). Seven plexuses originated from C6-T2 (70%), whilst three plexuses originated from C5-T2 (30%). Additionally, C6 and C7 formed two cranial trunks, and C8, T1 and T2 formed two caudal trunks. All nerves from the brachial plexus that have been reported in carnivorans were successfully located. In addition, we found one nerve reaching the teres major muscle originating directly from the brachial plexus and not from the axillary nerve as reported in other carnivorans. The brachiocephalic nerve was found partially innervating the cleidobrachialis muscle (50%), but this muscle always was innervated by the axillary nerve. Moreover, one to three subscapular nerves were found, and the musculocutaneous nerve formed two communicating branches (proximal and distal) to the median nerve. However, the distal communicating branch of the musculocutaneous nerve was absent in two specimens (40%). In conclusion, the brachial plexus of P. flavus was differentiated mainly with other carnivorans by a higher contribution from T2, formations of trunks, and one independent nerve to the teres major muscle., (© 2022 Wiley-VCH GmbH.)

Background: The objective of this work was to perform a critical review of the 2-dimensional and 3-dimensional anatomy of the adult brachial plexus divisions and cords. Methods: Twelve adult brachial plexuses from fresh cadavers were dissected. All were male and aged between 30 and 50 years. Only corpses without brachial plexus injuries were selected. The purpose of the dissections was to identify the origin of the anterior and posterior divisions of the adult brachial plexus in their respective trunks, as well as the positioning of the posterior, lateral, and medial cords. Results: The posterior division of all trunks had a cranial and dorsal origin, while the anterior division of all trunks had a caudal and ventral origin. The posterior cord was the most cranial of all, the lateral cord was central, and the medial cord was the most caudal of all cords. The posterior division of the superior trunk was always between the suprascapular nerve and the anterior division. Conclusions: Brachial plexus diagrams in most textbooks and papers are different from what was found in our dissections. Contrary to the known diagram, the posterior divisions always had a cranial origin in the superior, middle, and inferior trunks.

Background: This cadaveric study investigated the innervations of the clavicle and clavicular joints (ie, sternoclavicular and acromioclavicular joints)., Methods: Twenty cadavers (40 clavicles) were dissected. A skin incision was made to permit exposure of the posterior cervical triangle and infraclavicular fossa. The platysma, sternocleidomastoid, and trapezius muscles were cleaned in order to identify the supraclavicular nerves. Subsequently, the suprascapular and subclavian nerves were localized after removal of the prevertebral layer of the deep cervical fascia. In the infraclavicular region, the pectoralis major and minor muscles were retracted laterally in order to visualize the lateral pectoral nerve. The contribution of all these nerves to the clavicular bone and joints were recorded., Results: Along their entire length, all clavicular specimens received contributions from the supraclavicular nerves. The latter innervated the cephalad and ventral aspects of the clavicular bone. The caudal and dorsal aspects of the clavicle were innervated by the subclavian nerve (middle and medial thirds). The lateral pectoral nerve supplied the caudad aspect of the clavicle (middle and lateral thirds). The sternoclavicular joint derived its innervation solely from the supraclavicular nerves whereas the acromioclavicular joint was supplied by the supraclavicular and lateral pectoral nerves., Conclusion: The clavicle and clavicular joints are innervated by the subclavian, lateral pectoral, and supraclavicular nerves. Clinical trials are required to determine the relative importance and functional contribution of each nerve., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The objective of our study is to determine the anatomical viability in cadavers of a novel doble nerve transfer technique for simultaneous reanimation of shoulder abduction and sensory recovery of the hand, in patients with brachial plexus injuries sustaining a C5-C6-C7 roots avulsion. These new transfers should be complemented in the clinical setting with other classic nerve transfers, i.e.: (1) a spinal accessory to suprascapular for shoulder abduction and stability, (2) ulnar nerve fascicles to the biceps branches of the musculocutaneous for elbow flexion, and (3) intercostal to triceps branches for elbow extension., Methods: The proposed surgical technique includes (1) transferring motor fascicles of the median nerve (MNF), as donors to the axillary nerve (AN), and (2) the whole medial antebrachial cutaneous nerve (MACN) to the lateral contribution (sensory) of the median nerve (LCMN), both without the use of interposed nerve grafts. These techniques were performed in eight cadaveric upper extremities. Analyzed variables were: donor and receptor nerves diameter, length and distance of donor and receptors nerves, and axonal count., Results: The mean distance between the MNF and its point of coaptation to the AN was 19 mm. The average length of each one of the MNF, after distal dissection, was 46.5 mm. The average diameter of each fascicle of the median nerve at its coaptation point with the axillary nerve was 0.8 mm, while the average diameter of the latter was 3.9 mm. The average distance between the MACN and its point of coaptation to the LCMN, was 16.5 mm. The average diameter of the MACN and the LCMN at their point of coaptation, were 2.7 mm and 3.5 mm, respectively., Conclusion: These nerve transfers are anatomically viable and could be a complement for other currently used techniques that can be employed in severely injured C567 brachial plexus patients., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Upper brachial plexus injury or isolated lesions of the axillary nerve (AN) compromise shoulder functionality significantly. Different surgical techniques have been described for selective reconstruction of the AN, with good results especially in association with repair of the suprascapular nerve. The objective of this study is to describe the transfer of motor fascicles of the median nerve to the AN by an axillary approach in cadavers and the clinical results in 2 patients. Dissections were performed on 5 cadavers, followed by identification and dissection of the AN and its divisions before entering the quadrangular space. We standardized the surgical technique in which the median nerve was first identified and then an intrafascicular dissection was performed. Then we harvested a fascicle and transferred it to the anterolateral branch of the AN. Two patients underwent an operation; at 2 years of follow-up, average abduction of 125 degrees and external rotation of 95 degrees were observed. In conclusion, the transfer of motor fascicles of the median nerve to the AN by an axillary approach could be an alternative technique for the deltoid reinnervation in upper brachial plexus injury. Some advantages are the proximity of the donor nerve to the receptor nerve and the low morbidity of the target muscles of the donor nerve. Studies with a larger number of patients are required to establish its effectiveness compared with other techniques already described., Competing Interests: Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Advanced imaging (ultrasound, computed tomography, MRI) is a key component in defining and localizing the underlying cause of forelimb lameness. Given the propensity of soft tissue injury/disease of the shoulder and brachial plexus, ultrasound and MRI are of particular utility in defining tendinous, muscular, and nerve lesions. An advanced knowledge of shoulder and brachial plexus anatomy is necessary for both image acquisition and interpretation. To determine clinical significance, interpretation of both normal anatomy and suspected pathology must be correlated with clinical signs and orthopedic examination findings., Competing Interests: Disclosure Nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The capuchin is a neotropical primate that presents easy reproduction in captivity and is used in scientific research. The objective of this work was to describe the structure and the branching pattern of the brachial plexus of the capuchin and to compare the results with data from the literature for humans, chimpanzees, baboons and Callithrix., Methods: Twelve specimens were used: eight males and four females. No animals were killed for the purpose of this study., Results: The brachial plexus of Sapajus sp was constituted mainly from the ventral roots of the last four cervical spinal nerves, from C5 to C8, mainly, and the first thoracic nerve (T1)., Conclusions: The pattern of formation of the brachial plexus of the capuchin monkey was more similar to that of Callithrix and baboons, perhaps because they are the only primates in this study to be essentially quadrupedal., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: The decision-making in neonatal brachial plexus palsy (NBPP) treatment continues to have many areas in need of clarification. Graft repair was the gold standard until the introduction of nerve transfer strategies. Currently, there is conflicting evidence regarding outcomes in patients with nerve grafts versus nerve transfers in relation to shoulder function. The objective of this study was to further define the outcomes for reconstruction strategies in NBPP with a specific focus on the shoulder., Methods: A cohort of patients with NBPP and surgical repairs from a single center were reviewed. Demographic and standard clinical data, including imaging and electrodiagnostics, were gathered from a clinical database. Clinical data from physical therapy evaluations, including active and passive range of motion, were examined. Statistical analysis was performed on the available data., Results: Forty-five patients met the inclusion criteria for this study, 19 with graft repair and 26 with nerve transfers. There were no significant differences in demographics between the two groups. Understandably, there were no patients in the nerve grafting group with preganglionic lesions, resulting in a difference in lesion type between the cohorts. There were no differences in preoperative shoulder function between the cohorts. Both groups reached statistically significant improvements in shoulder flexion and shoulder abduction. The nerve transfer group experienced a significant improvement in shoulder external rotation, from -78° to -28° (p = 0.0001), whereas a significant difference was not reached in the graft group. When compared between groups, there appeared to be a trend favoring nerve transfer in shoulder external rotation, with the graft patients improving by 17° and the transfer patients improving by 49° (p = 0.07)., Conclusions: In NBPP, patients with shoulder weakness experience statistically significant improvements in shoulder flexion and abduction after graft repair or nerve transfer, and patients with nerve transfers additionally experience significant improvement in external rotation. With regard to shoulder external rotation, there appear to be some data supporting the use of nerve transfers.

Background: The shoulder is the joint most prone to dislocating in the human body and accounts for 45% of all dislocations. In addition to ruptures of the soft tissue and bony injuries, lesions to vascular structures as well as the brachial plexus and its corresponding nerves might occur. With an incidence of up to 65%, nerve lesions are frequently reported after shoulder dislocations. The aim of this study is to obtain information on epidemiology, diagnostics, treatment and duration until remission or late sequelae after shoulder dislocation and concomitant nerve injury in a large patient cohort., Methods: The patient cohort consisted of 15,739 patients from three centres who had sustained a shoulder dislocation. All patient files were searched for concomitant injury of the brachial plexus or its corresponding nerves. For epidemiological data analysis, demographic data, clinical follow-ups, electromyography and nerve conduction velocity were evaluated., Results: In total, 60 patients (32 males, 28 females) with a mean age of 60 years (range 19-88 years) met the inclusion criteria. In the majority of patients (n = 51), the trauma mechanism was a trivial fall on the outstretched arm. The most frequent dislocation direction was anterior-caudal in 61.6%, followed by strictly caudal in 16.6%. The brachial plexus was injured in 46 patients (76.6%) and isolated nerve damage was documented in 14 patients (23.3%). Electroneurographic examinations were performed in less than half of the patients (38.3%)., Conclusion: A combination injury of shoulder dislocation and plexus lesion may occur at any age and sometimes has a poor outcome. Electroneurographic examinations should be implemented when managing these patients as a cost-effective and supportive examination., Level of Evidence: Level IV, retrospective study.

Background: Shoulder stability, abduction and external rotation are vital for the performance of usual daily tasks., Aims: To compare the functional outcomes in the shoulder following spinal accessory to suprascapular nerve transfer (SASNT)., Patients and Methods: Comparison of the outcome of adult patients with upper traumatic brachial plexus palsy undergoing SASNT with patients with complete palsy submitted to the same procedure., Statistical Analysis: Ranges of motion were compared via the Mann-Whitney U test. The percentages of patients with a favorable outcome were compared by the chi-square test. All tests were two-tailed and P values <0.05 were considered statistically significant., Results: SASNT was performed in 76 patients: 23 cases (30.2%) of upper-plexus injuries and 53 cases (69.7%) of complete brachial plexus palsy. Good shoulder abduction was achieved in 15 patients (65.2%) with upper plexus palsy and a good external rotation in 5 (21.7%). In those patients with a good recovery, the average range of motion (ROM) was 53° for shoulder abduction and 71.2° for external rotation. Thirty-six patients (67.9%) with complete palsy had a good shoulder abduction recovery with 30.7° of average ROM, but only 3 patients (5.6%) recovered a good shoulder external rotation with 68.3° of average ROM. There was no statistical difference for the abduction outcome, but the external rotation outcome was superior in the upper plexus palsy group., Conclusion: SASNT is a consistent procedure to achieve functional recovery of shoulder abduction after a partial or complete plexus injury, but the outcomes of external rotation were quite disappointing in both the groups., Competing Interests: None

The aim of this study was to estimate the incidence, identify the causes, and explore treatments of the injuries to the brachial plexus and peripheral nerves of the shoulder girdle and upper limb in the 1,220,000-inhabitant Italian region Friuli Venezia Giulia.We linked at the individual patient level various administrative databases using an anonymous stochastic key: list of residents, hospital discharge, emergency department, and outpatient care prescriptions database. We abstracted hospital discharge records with at least one discharge diagnosis code ICD-9-CM 953.4 (brachial plexus) or 955.0-955.9 (upper limb). For hospitalized patients, we investigated the prescriptions of ambulatory care during the following year. Emergency department visits in the month prior to hospital admission were also assessed.From 2000 to 2015, we observed 474 hospitalizations (annual average: 61); 48% of patients received at least one prescription of outpatient physical therapy and rehabilitation in the following year, accounting for more than 25,000 visits and interventions. According to emergency department data, falls were the most common mechanism among the elderly; cuts were common among the young.This is the first population study of peripheral nerve injuries to the brachial plexus and peripheral nerves of the shoulder girdle and upper limb in Italy.

Rationale: Malignant granular cell tumor is a kind of rare and highly aggressive malignant tumor that commonly occurs in lower extremity, trunk, and peritoneal cavity. Huge malignant granular cell tumor (MGCT) with suprascapular nerve and brachial plexus invasion was extremely rare., Patient Concerns: We present a special case of a 48-year-old orthopedist who suffered from MGCT. The orthopedist had regarded that he suffered from scapulohumeral periarthritis., Diagnoses: The disease was noticed until a painless mass on his right neck was discovered 9 months later. MRI result confirmed a large occupying in axillary fossa, supraclavicular and infraclavicular region., Interventions: During the operation, a tumor measuring 22 × 13 × 6 cm with suprascapular nerve and brachial plexus invasion was identified. The tumor was fractional resected carefully to maintain the integrity of nerves and vessels. Lymph nodes were simultaneously resected., Outcomes: The motor function and sensation of the upper extremity were same to that of preoperation. The postoperative histological diagnosis was MGCT. At a 12-month follow-up, there was no recurrence of the tumor showed by MRI., Lessons: This study presents a rare case of large MGCT with suprascapular nerve and brachial plexus invasion that was successfully managed by surgery.

Anatomical variations in the suprascapular nerve (SSN) and its depth in the suprascapular notch can make it difficult to target with ultrasonography (US). One alternative could be a proximal approach to the SSN, if US provides a reliable description of its origin (orSSN). The primary objective of this study was to demonstrate that US can reliably locate the orSSN. The secondary objective was to describe the features of the proximal SSN. Seventy brachial plexuses (BPs) from 30 healthy volunteers (60 BPs) and 5 cadavers (10 BPs) were included. There were two parts to this study: (1) description of the proximal SSN in healthy volunteers using US to determine the diameter, depth and location of the orSSN; (2) targeting of the orSSN with US in cadaver limbs to determine its distance from the needle, ink marking and locating the orSSN. In Part I, the diameter of the orSSN averaged 1.33 mm (1-9 mm) and its depth averaged 5.12 mm (2.7-10.6 mm). The orSSN was located in the upper trunk of the BP (53) or its posterior division (7). In Part II, the orSSN was successfully targeted in nine of the 10 specimens by US; the needle/orSSN distance averaged 3.8 mm (0-8 mm). The implanted needle was at the orSSN in two cases, proximal to it in seven and distal to it in one. US is a valid modality for describing and pinpointing the orSSN, irrespective of patient morphology. Clin. Anat. 30:747-752, 2017. © 2017Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

Brachial plexus is complex network of nerves, formed by joining and splitting of ventral rami of spinal nerves C5, C6, C7, C8, and T1 forming trunks, divisions, and cords. The nerves emerging from trunks and cords innervate the upper limb and to some extent pectoral region. Scanty literature describes the variations in the formation of cords and nerves emanating from them. Moreover, the variations of cords of brachial plexus and nerves emanating from them have iatrogenic implications in the upper limb and pectoral region. Hence study has been carried out. Twenty-eight upper limbs and posterior triangles from 14 cadavers fixed in formalin were dissected and rare and new variations of cords were observed. Most common variation consisted of formation of posterior cord by fusion of posterior division of upper and middle trunk and lower trunk continued as medial cord followed by originating of 2 pectoral nerves from anterior divisions of upper and middle trunk. Other variations include anterior division of upper trunk continued as lateral cord and pierced the coracobrachialis, upper and middle trunk fused to form common cord which divided into lateral and posterior cords, upper trunk gave suprascapular nerve and abnormal lateral pectoral nerve and formation of median nerve by 3 roots. These variations were analyzed for diagnostic and clinical significance making the study relevant for surgeons, radiologists in arresting failure patients and anatomists academically in medical education.

Purpose: The purpose of this study was to document the distribution of the articular branch of the lateral pectoral nerve (LPN) to the shoulder and to identify a suitable point for its blockade., Methods: This study involved the dissection of 43 shoulders of 22 unembalmed cadavers (6 male and 16 female) to identify the LPN and its articular branch to the shoulder. To identify the suitable anatomical point for blocking the articular branch of the LPN, several anatomical landmarks around the shoulder were measured., Results: The articular branch of the LPN to the shoulder was present in 29 of 43 cases (67.4 %). The appropriate point to block the articular branch of the LPN was identified at a mean distance of 1.5 cm below the clavicle, on the line connecting the closest points between the clavicle and the coracoid process, and at a mean depth of 1.0 cm from the skin., Conclusion: The articular branch of the LPN to the shoulder, as well as the muscular and cutaneous branches of the LPN, covers a portion of the shoulder joint with suprascapular and axillary nerves. Surgeons might consider a peripheral block of the suprascapular, axillary, and LPNs to provide maximum block coverage after shoulder joint surgery.

Background: The standard approach for the suprascapular nerve block is deep in the supraspinous fossa. However, with this approach, the suprascapular nerve is difficult to visualize by ultrasound. The aim of this study was to describe a new method to visualize and selectively block the suprascapular nerve in a more superficial and proximal location., Methods: Twelve healthy volunteers were included. We located the brachial plexus in transverse section with ultrasound, and by longitudinal slide, we identified the departure of the suprascapular nerve from the superior trunk. The suprascapular nerve was followed under ultrasound visualization into the subclavian triangle under the inferior belly of the omohyoid muscle. We performed in-plane ultrasound-guided selective suprascapular nerve block by injecting 1 ml of lidocaine, 20 mg/ml close to the nerve. Nerve identification was aided by nerve stimulation. We assessed sensory and motor block of the suprascapular, axillary, radial, median, and ulnar nerves before, 15 and 30 min after performing the block., Results: Eight volunteers demonstrated a selective suprascapular nerve block. Three had block failure and one volunteer did not receive the intervention., Conclusions: We describe a new ultrasound-guided low-volume local anaesthetic technique to selectively block the suprascapular nerve. The potential clinical role of this new approach remains to be determined., (© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: The aim of this study was to compare the results of ultrasonographically guided axillary nerve block (ANB) combined with suprascapular nerve block (SSNB) with those of SSNB alone on postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair., Methods: Forty-two patients with rotator cuff tears who had undergone arthroscopic rotator cuff repair were enrolled in this study. Among them, 21 patients were randomly allocated to group 1 and received both SSNB and ANB with 10 mL ropivacaine. The other 21 patients were allocated to group 2 and received SSNB with 10 mL 0.75% ropivacaine and ANB with 10 mL saline. Visual analog scale (VAS) pain score, patient satisfaction (SAT), and lateral pain index (LPI) was checked at 1, 3, 6, 12, 18, 24, 36, and 48 hours postoperatively., Results: Group 1 showed a significantly lower mean VAS score at postoperative 1, 3, 6, 12, 18, and 24 hours compared with group 2 (5.1 < 7.6, 4.4 < 6.3, 3.7 < 5.3, 3.2 < 4.5, 2.7 < 4.0, and 2.7 < 3.4, respectively). A significantly high mean SAT and low mean LPI was observed in group 1 at postoperative 1, 3, 6, 12, 18, 24, and 36 hours (4.9 > 2.4, 5.9 > 3.7, 6.3 > 5.0, 6.8 > 5.7, 7.3 > 6.2, 7.5 > 6.6, and 7.7 > 7.0, respectively), (1.1 < 3.0, 0.8 < 2.5, 0.7 < 2.0, 0.7 < 1.6, 0.6 < 1.3, 0.6 < 1.0, and 0.4 < 0.7, respectively). The frequency of rebound pain decreased in group 1 compared with group 2 (P = .032). In addition, rebound phenomenon showed a correlation with ANB on univariate logistic regression (P = .034; odds ratio, 0.246)., Conclusions: Ultrasonographically guided ANB combined with SSNB in arthroscopic rotator cuff repair showed an improved mean VAS in the first 24 hours after surgery compared with SSNB alone. The mean SAT and LPI of the combined blocks were better than those of the single block within the first 36 hours. Ultrasonographically guided ANB combined with SSNB also decreased the rebound phenomenon., Level of Evidence: Level I, randomized controlled trial., (Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the minimum volume of methylene blue (MB) to completely color the brachial plexus (BP) nerves, simulating an effective anesthetic block in cats., Methods: Fifteen adult male cat cadavers were injected through subscapular approach with volumes of 2, 3, 4, 5 and 6 ml in both forelimbs, for a total of 30 brachial plexus blocks (BPB). After infusions, the specimens were carefully dissected preserving each nervous branch. The measurement of the effective area was indicated by the impregnation of MB. Nerves were divided into four segments from the origin at the spinal level until the insertion into the thoracic limb muscles. The blocks were considered effective only when all the nerves were strongly or totally colored., Results: Volumes of 2, 3 and 4 ml were considered insufficient suggesting a failed block, however, volumes of 5 and 6 ml were associated with a successful block., Conclusions: The injection of methylene blue, in a volume of 6 ml, completely colored the brachial plexus. At volumes of 5 and 6 ml the brachial plexus blocks were considered a successful regional block, however, volumes of 2, 3 and 4 ml were considered a failed regional block.

The trend towards regional anesthesia began in the late 1800s when William Halsted and Richard Hall experimented with cocaine as a local anesthetic for upper and lower limb procedures. Regional anesthesia of the upper limb can be achieved by blocking the brachial plexus at varying stages along the course of the trunks, divisions, cords and terminal branches. The four most common techniques used in the clinical setting are the interscalene block, the supraclavicular block, the infraclavicular block, and the axillary block. Each approach has its own unique set of advantages and indications for use. The supraclavicular block is most effective for anesthesia of the mid-humerus and below. Infraclavicular blocks are useful for procedures requiring continuous anesthesia. Axillary blocks provide effective anesthesia distal to the elbow, and interscalene blocks are best suited for the shoulder and proximal upper limb. The two most common methods for localizing the appropriate nerves for brachial plexus blocks are nerve stimulation and ultrasound guidance. Recent literature on brachial plexus blocks has largely focused on these two techniques to determine which method has greater efficacy. Ultrasound guidance has allowed the operator to visualize the needle position within the musculature and has proven especially useful in patients with anatomical variations. The aim of this study is to provide a review of the literature on the different approaches to brachial plexus blocks, including the indications, techniques, and relevant anatomical variations associated with the nerves involved., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: The goal of this study was to clarify the anatomical origins of the suprascapular and lateral pectoral nerves from the brachial plexus as an aid to surgical exploration., Methods: Both nerves were studied in 100 adult cadaver specimens. Topographic points of origin were described as distance from the bifurcation of the upper trunk or distance from the formation point of the lateral cord, using visual anatomical models., Results: The suprascapular nerve originated from (1) the posterior division of the upper trunk distal to the bifurcation of the upper trunk (61 specimens); (2) the point of upper trunk bifurcation (29 cases); (3) the upper trunk proximal to the bifurcation point (six cases); and (4) directly from the C5 root (four cases). The lateral pectoral nerve originated from (1) the anterior division of the upper trunk proximal to the point of lateral cord formation (88 cases); (2) the point of lateral cord formation (five cases); (3) the lateral cord distal to the lateral cord formation point (four cases); and (4) the anterior division of the middle trunk (three cases). Eighty-two cases had origins from both the anterior upper trunk and the anterior middle trunk., Conclusions: The suprascapular nerve most frequently originates from the posterior division of the upper trunk, and the lateral pectoral nerve from the anterior divisions of the upper and middle trunks. This information can be used to guide the surgeon in identifying the key landmarks of the supraclavicular brachial plexus at surgical exploration.

The range of open and arthroscopic shoulder procedures continues to evolve and expand. Despite advances in instrumentation and technology, complications still exist and neurologic injury remains an inherent part of these procedures. Iatrogenic nerve injuries are among the more commonly cited complications associated with shoulder surgery. Various surgical procedures about the shoulder are known to place the brachial plexus and peripheral motor nerves at risk. Peripheral nerve monitoring has been helpful in identifying specific surgical steps and key anatomic regions that are susceptible to iatrogenic nerve injury.

Background: Although axillary nerve injury is a catastrophic surgical complication, there is little data for precise prediction of the location of that nerve's anterior branch. To address that, the authors searched for a useful correlation between the acromion-axillary nerve distance (AAND) and one or more physical factors., Methods: The heights, humeral lengths, AAND, and axillary nerve indexes (ANI: ratio between AAND and humeral length) of 25 male and 20 female cadavers were determined. Any gender differences in the mean measurements were determined. The correlations of each AAND with height, humeral length, and ANI were determined. The authors determined that using the ANI and the humeral length allowed the shortest prediction of the AAND., Results: The mean AAND, cadaver height, and humeral length were 6.5 ± 0.8, 164.9 ± 10.0, and 33.5 ± 2.7 cm, respectively. An independent t test revealed significant gender differences in the mean AAND (P = .003), height (P = .000), and humeral length (P = .000), but not in the mean ANI (P = .564). The Pearson coefficients for the associations of the AAND with height (r = .767), humeral length (r = .797) and ANI (r = .732) demonstrated strong correlations (P < .001), especially with humeral length. The use of the ANI with the humeral length yielded the shortest predictions of AAND, with a 97.8% probability of safety., Conclusion: There is a strong correlation between AAND and humeral length. In clinical practice, humeral length and ANI are useful for predicting the location of the anterior branch of the axillary nerve, when the arm is positioned at the side in neutral rotation., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Introduction: The current literature indicates that neurologic injuries during shoulder surgery occur infrequently and result in little if any morbidity. The purpose of this study was to review one institution's experience treating patients with iatrogenic nerve injuries after shoulder surgery., Methods: A retrospective review of the records of patients evaluated in a brachial plexus specialty clinic from 2000 to 2010 identified twenty-six patients with iatrogenic nerve injury secondary to shoulder surgery. The records were reviewed to determine the operative procedure, time to presentation, findings on physical examination, treatment, and outcome., Results: The average age was forty-three years (range, seventeen to seventy-two years), and the average delay prior to referral was 5.4 months (range, one to fifteen months). Seven nerve injuries resulted from open procedures done to treat instability; nine, from arthroscopic surgery; four, from total shoulder arthroplasty; and six, from a combined open and arthroscopic operation. The injury occurred at the level of the brachial plexus in thirteen patients and at a terminal nerve branch in thirteen. Fifteen patients (58%) did not recover nerve function after observation and required surgical management. A structural nerve injury (laceration or suture entrapment) occurred in nine patients (35%), including eight of the thirteen who presented with a terminal nerve branch injury and one of the thirteen who presented with an injury at the level of the brachial plexus., Conclusions: Nerve injuries occurring during shoulder surgery can produce severe morbidity and may require surgical management. Injuries at the level of a peripheral nerve are more likely to be surgically treatable than injuries of the brachial plexus. A high index of suspicion and early referral and evaluation should be considered when evaluating patients with iatrogenic neurologic deficits after shoulder surgery.

Brachial plexus lesions are among the most severe injuries of the upper extremity. Despite intensive conservative and surgical treatment efforts, patients frequently suffer from serious impairments in the quality of life. This contribution presents the results of a retrospective clinical survey on the quality of life after brachial plexus injuries. Out of 38 treated patients, 25 patients could be included in the study. The disability of arm, shoulder and hand was evaluated by the DASH score and the quality of life by the FLZm, a questionnaire on life satisfaction. In addition, demographic data, work situation and mechanism and type of injury were recorded. The examined patients were mainly young males who were injured in traffic, in particular motorcycle accidents. The DASH score analysis revealed that plexus injuries are among the most disabling injuries of the upper extremity. The associated restrictions in the different sections of the quality of life involve not only the health-related section but also partnership, family and leisure time activities. A strong relation between the possibility to return to work and the quality of life was found. We recommend the use of the DASH score and the FLZm questionnaire on life satisfaction as routine tools for the evaluation of the therapeutic outcome after brachial plexus injuries., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Children with obstetrical brachial plexus injury often develop an internal rotation and adduction contracture about the shoulder as a secondary deformity, resulting in an inability to externally rotate and abduct the shoulder. The Hoffer procedure is evaluated for its potential benefit in improving shoulder abduction and external rotation and its impact on activities of daily living., Methods: This is a retrospective review of patients treated in brachial plexus injury clinic who underwent tendon transfer procedures about the shoulder. Preoperative and postoperative active movement and active range of motion were measured and recorded using the Mallet scale and the Active Movement Scale., Results: Twenty patients were included in the study. Average age at time of surgery was 6.35 years. Thirteen patients had primary brachial plexus reconstructive surgery and four patients had concomitant wrist extension tendon transfer procedures. All patients had full passive range of motion preoperatively. The average follow-up period was 25.45 months. Average differences in pre-Hoffer and post-Hoffer Mallet scale scores are as follows: active abduction, 1.20; external rotation, 1.35; hand-to-neck, 1.25; hand-to-back, 0.75; hand-to-mouth, 0.65; and aggregate score, 5.20 (p<0.001 for all). Average differences in relevant pre-Hoffer and post-Hoffer Active Movement Scale scores are as follows: shoulder abduction, 2.10; shoulder external rotation, 4.25; and shoulder internal rotation, -0.80. All patients maintained full range of motion passively; thus, no functional loss was experienced. These results showed very high statistical significance (p<0.001 for all) and clinical significance. Younger patients (≤6 years) and those with better preoperative shoulder flexion and shoulder internal rotation yielded better postoperative results., Conclusions: The Hoffer procedure provides clinically and statistically significant improvement in external rotation and abduction while preserving functional internal rotation range in the child with obstetrical brachial plexus palsy and secondary shoulder deformity., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Residual muscle imbalance is a common problem affecting obstetrical brachial plexus palsy patients. The goal of this study was to examine the efficacy of botulinum toxin type A (Botox) in improving this muscle imbalance., Methods: The authors retrospectively reviewed obstetrical brachial plexus palsy patients treated with Botox for muscle imbalance as an isolated procedure. Outcomes were the change in Active Movement Scale scores from pre-Botox scores to scores at 1 month after Botox and 1 year after Botox., Results: Twenty-seven patients were included, 19 treated for shoulder imbalance and eight treated for elbow imbalance. Active Movement Scale scores (mean±SD) for shoulder external rotation improved from 0.6±1.0 before Botox to 2.6±2.14 (p<0.01) at 1 month after Botox, and declined to 1.3±1.2 (p<0.01) at 1 year after Botox. Scores for elbow flexion were 3.3±2.1 before Botox, unchanged at 4.4±1.8 (p=0.07) 1 month after Botox, and improved to 5.8±0.5 (p<0.01) at 1 year after Botox. Scores for elbow supination were 2.9±1.7 before Botox and 3.4±1.5 (p=0.2) at 1 month after Botox, and improved to 3.9±2.0 (p<0.01) at 1 year after Botox., Conclusions: Botox for shoulder movement imbalance produces improvement in external rotation that is not sufficiently sustained over time to be of clinical benefit. However, Botox for elbow movement imbalance produces a sustained and clinically useful improvement., Clinical Question/level of Evidence: Therapeutic, IV.

Introduction: In upper brachial plexus palsy patients, loss of shoulder function and elbow flexion is obvious as the result of paralysed muscles innervated by the suprascapular, axillary and musculocutaneus nerve. Shoulder stabilisation, restoration of abduction and external rotation are important as more distal functions will be affected by the shoulder situation., Patients and Methods: Between 2005 and 2011, eleven patients with upper type brachial plexus palsy were operated on with triceps nerve branch transfer to anterior axillary nerve branch and spinal accessory nerve transfer to the suprascapular nerve for shoulder abduction and external rotation restoration. Nine patients met the inclusion criteria for the study. All patients were men with ages ranged from 21 to 35 years (average, 27.4 years). The interval between injury and surgery ranged from 4 to 11 months (average, 7.2 months). Atrophy of the supraspinatus, infraspinatus and deltoid muscle and subluxation at the glenohumeral joint was obvious in all patients preoperatively. During the pre-op examination all patients had at least muscle grading 4 on the triceps muscle., Results: The mean post-operative value of shoulder abduction was 112.2° (range: 60-170°) while preoperatively none of the patients was able for abduction (p<0.001). The mean post-operative value of shoulder external rotation was 66° (range: 35-110°) while preoperatively none of them was able for external rotation (p<0.001). Postoperative values of shoulder abduction were significantly better that those of external rotation (p=0.0004). The postoperative average muscle grading for shoulder abduction according the MRC scale was 3.6±0.5 and for the shoulder external rotation was 3.2±0.4., Conclusions: Combined nerve transfer by using the spinal accessory nerve for suprascapular nerve neurotisation and one of the triceps nerve branches for axillary nerve and teres minor branch neurotisation is an excellent choice for shoulder abduction and external rotation restoration., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Many studies have attempted to define a safety zone for the axillary nerve in lateral approaches to the deltoid, but with varying results. The main objective of our study was to analyze the variations in the position of this nerve, especially in relation to the length of the humerus. Overall, 16 cadaveric shoulders were dissected. The distances between both the anterolateral edge of the acromin (anterior distance) and the lateral edge of the acromion (posterior distance) to the axillary nerve were measured; the length of the humerus was also measured. Correlation analysis was performed between each distance and the length of the humerus. The average anterior and posterior distance were 7.2 cm ± 0.84 cm and 7.9 cm ± 0.92 cm, respectively; the average length of the humerus was 30.7 cm ± 3.2 cm. A significantly high positive correlation was found between the length of the humerus and both anterior distance (P = .94), and posterior distance (P = .92). In shoulder surgery, prior measurement of the length of the humerus could predict the distance between the acromion and the axillary nerve, and determine its position.

Background: Ultrasound-guided supraclavicular brachial plexus block carries a risk for puncture of vascular structures. In this study, we determined the frequency with which the transverse cervical artery (TCA) and the dorsal scapular artery (DSA) are detected by ultrasound evaluation at 3 probe positions during supraclavicular block., Methods: Ultrasound examinations of the supraclavicular region were performed in 53 healthy adult volunteers. Ultrasound images of the supraclavicular region were acquired at 3 probe positions: position A (the brachial plexus and the subclavian artery both lying on the first rib); position B (the brachial plexus on the first rib; the artery on the pleura); and position C (the brachial plexus between the anterior and middle scalene muscles). The primary outcome variables were the frequencies with which TCA and DSA were detected by 2-dimensional and color Doppler imaging at 3 specified probe positions., Results: One hundred six supraclavicular regions were examined in 53 subjects. The subclavian artery was detected in all subjects. TCA was more often detected than DSA, 94 (88.7%, 95% confidence interval [CI] 80.7%-93.8%) and 36 (34%, 95% CI 25.3%-43.9%) of 106 scans, respectively (McNemar P value <0.001). TCA was detected in 2 (1.9%, 95% CI 0.3%-7.3%), 31 (29.2%, 95% CI 20.9%-38.9%), and 61 (57.5%, 95% CI 47.5%-66.9%) of scans at probe positions A, B, and C, respectively, whereas DSA was detected in 3 (2.8%, 95% CI 0.7%-8.6%), 23 (21.7%, 95% CI 14.5%-30.9%), and 10 (9.4%, 95% CI 4.8%-17.0%) of scans at probe positions A, B, and C, respectively. Thus, the TCA and DSA were less likely to be present with probe position A (all P < 0.001)., Conclusion: TCA was more often detected than DSA in the vicinity of the brachial plexus in the supraclavicular region. Both TCA and DSA were least likely to be present in probe position A. Color Doppler, particularly for probe position A, may help to reduce the risk for inadvertent vascular puncture during ultrasound-guided supraclavicular block.