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Recovery of brachial plexus injury after shoulder dislocation
Injury, Int. J. Care Injured 40 (2009) 1327–1329
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Recovery of brachial plexus injury after shoulder dislocation Arkaphat Kosiyatrakul *, Surasak Jitprapaikulsarn, Sebastein Durand, Christophe Oberlin Department of Orthopedic Surgery, Hospital Bichat-Claude Bernard, 46 rue Henri Huchard, 75877 Paris Cedex 18, France
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 15 May 2009
Brachial plexus injury is an underestimated complication from anterior dislocation of the shoulder. To our knowledge, there is limited information available about the factors that influence neurological recovery of this injury. We reviewed 15 upper extremities in 14 patients with brachial plexus injuries caused by anterior shoulder dislocation. Two-thirds of the cases had total brachial plexus palsy. With the conservative treatment, the motor recoveries of all cases are full or nearly full within 20 months except intrinsic muscle of the hand. Intrinsic muscle recovery may be better in a younger age group (less than 50 years). Nerve exploration is usually unnecessary. However, reconstructive surgery for the residual neurological deficit can provide improvement of hand function. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: Recovery Brachial plexus injury Shoulder dislocation
Shoulder dislocation is a very common shoulder injury that may result from a fall, sports or trauma. Multiple complications have been reported as a result of shoulder dislocation. These include most commonly recurrent dislocation, in addition to rotator cuff tear – especially in the older patients – and axillary nerve injury and cartilage and bony defects.10,12,18,22,24–26 Most reviews on the neurological complications of shoulder dislocation focus on isolated nerve injuries.12,24,26 However, the incidence of brachial plexus injury and the factors that influence its recovery after shoulder dislocation are seldom reported in the literature.12,13,18,25,26 The purpose of this article is to report the natural history, pattern of recovery and management of a group of patients who were referred to our centre with brachial plexus injury after shoulder dislocation. Materials and methods Review of our database revealed 14 patients (15 shoulders), who presented to our centre between 2001 and 2007 for a history of brachial plexus injury after shoulder dislocation. All patients were treated by the senior author (CO). The reviews included gender, age, affected side, cause of injury, type of brachial plexus injury, associated injury, duration and progression of recovery, residual deficit and individual surgical treatments. The patients with follow-up period of 2 years or more were analysed in the study. Causes of injury were reviewed and determined according to the force of injury. The type of brachial plexus injury, which was determined by physical examination and electrodiagnostic study,
* Corresponding author. Tel.: +33 1 40 25 74 02; fax: +33 1 40 25 74 02. E-mail address: [email protected] (A. Kosiyatrakul). 0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.05.015
was recorded as total brachial plexus palsy (entire roots involvement) or partial plexus palsy (upper or lower roots involvement).1 Strength of muscle in the first and each followup examination was recorded according to guidelines of the Medical Research Council (MRC).16 As the pattern of recovery was random, with some cases recovering individual muscles and others recovering group of muscles (flexors, extensors, intrinsics, etc.), the authors recorded the strength of individual muscles as well as group of muscles. The recorded muscles included the supraspinatus, deltoid, elbow flexors, elbow extensors, wrist extensors, flexor carpi radialis (FCR), flexor carpi ulnaris (FCU), finger extensor, finger flexors, interosseous muscles of the hand and thenar muscles. The radiographic examinations were done in each case to determine the type of dislocation and associated injury. The duration of recovery was determined by the interval between initial injury to the last follow-up or before operation. The chosen treatment depended on the progression of recovery of brachial plexus and severity of residual neurological deficit. Results Fifteen upper extremities in 14 cases (nine men and five women) were included in the study. The mean age of the patients was 47.8 years (range: 27–83 years). Seven right upper extremities, six left and one bilateral were involved. The causes of injuries were: simple fall in five cases, car accident in three cases, motorcycle accident in three cases, ski accident in one case, lifting heavy object in one case, and fall from a height in one case. Nine upper extremities had total brachial plexus palsy, four had incomplete injuries, and one had pre-existing cubital syndrome with worsening of ulnar nerve symptom after shoulder dislocation. Six patients had associated fractures of greater tuberosity. The demographic data are show in Table 1.
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A. Kosiyatrakul et al. / Injury, Int. J. Care Injured 40 (2009) 1327–1329
Table 1 Demographic data of patients who had shoulder dislocation complicated with brachial plexus injury. Mean age in years (range) Gender Male Female
Table 2 Recovery of intrinsic muscle according to different kinds of factors. Recovery of interosseous and thenar muscle grade 0–II (number of upper extremities)
Recovery of interosseous and thenar muscle grade III–V (number of upper extremities)
Associated injury Fracture greater tuberosity No associated injury
2 5
2 3
Energy of injury High-energy trauma Low-energy trauma
5 2
3 2
Type of brachial plexus injury Total palsy Partial palsy
5 2
4 1
Age of patient (years) <50 >50
2 4
6 0
47.8 (27–83)
9 5
Affected side Right Left Bilateral
7 6 1
Mechanism of injury High energy Low energy
8 6
Sub-classification of anterior dislocation Subcoracoid
15
Type of brachial plexus injury Total palsy Partial palsy
10 5
The duration of recovery of these muscles is analysed except for three cases. The first patient had worsening of cubital tunnel symptom. The second patient lost follow-up at 3 months after injury. The last patient is waiting for the follow-up. The recovery of supraspinatus, deltoid, elbow flexors, elbow extensors, wrist extensors and finger extensors were complete or nearly complete (grade M4 to 5) in average 5.9, 7.1, 8.6, 8.9, 10.2 and 10.8 months, respectively (range: 1–20 months), in all upper extremities. The recovery of FCR and FCU was complete or nearly complete in average 11.7 and 12.5 months, respectively (range: 2– 20 months) in 11 upper extremities. One had grade M3 in both muscles within 20 months. The recovery of long finger flexors of three radial and two ulnar digits in 10 upper extremities were complete or nearly complete in average 12.8 and 12.5 months, respectively (range: 2–20 months). Two had grade M3 in these muscles at 20 and 23 months, respectively. The pattern of recovery of the interosseous and thenar muscles was different from the other muscles. The recovery was complete in one hand only within 6 months; however, six hands did not recover fully their interossei (grade M3 in five hands and M2 in one hand) and five patients had no signs of any recovery of the interossei after 2 years of follow-up.
The conclusion of the duration and number of shoulders with full or nearly full recovery of individual or group of the muscles is shown in Fig. 1. Surgical reconstructions were indicated in patients with functional disability from residual neurological deficit (established claw hand deformity or loss of thumb opposition), or developing of finger stiffness. Three patients were included in these criteria. Tendon transfer was performed on two patients to correct the claw deformity (FCR transfer with fascia lata graft)5 and paralysis of the thenar muscles (extensor indicis proprius (EIP) transfer).2 One patient was performed tendon transfer for opponenplasty (EIP transfer).2 All of them gained satisfactory hand function after the operations. Another two patients with severe intrinsic weakness did not have surgery. One patient was deemed to be too old for surgery. One patient could adapt to use the hand for the activity of daily living and denied the surgical treatment. In relation to recovery of the intrinsic muscles of the hand, the relation of recovery and associated injuries, energy of injuries, type of brachial plexus injury and age of the patients are shown in Table 2. When considering the age of the patients, two of eight upper extremities in the patients aged less than 50 years had no or inadequate interosseous and thenar muscle recovery, while all upper extremities in the patients aged more than 50 years had no or inadequate interosseous and thenar muscle recovery. Discussion
Fig. 1. Conclusion of duration and number of the upper extremities with full or nearly full recovery of individual or group of the muscles. & = average time, ( ) = number of the upper extremities, FCR = flexor carpi radialis, FCU = flexor carpi ulnaris, LFF of 3R = long finger flexor of three radial digits, LFF of 2U = long finger flexor of two ulnar digit.
Brachial plexus injury after shoulder dislocations is relatively less common than that of isolated axillary nerve. Only a few case series13,18,25 or case reports3,4,6–8,11,14,15,17,20–22,27 have been published. For this reason, it was not possible to determine the true incidence of brachial plexus injury associated with shoulder dislocation. Most of the reported neurological lesions of the brachial plexus were infraclavicular postganglionic and infraclavicular type.12,13,18,21,23 Several studies reported the associated suprascapular nerve involvement in shoulder dislocation.10,12,22,25 In our study, two-thirds of the cases were major brachial plexus injuries as we are the tertiary referral centre. Three of our cases had suprascapular nerve involvement. In this series, we found the prognosis of spontaneous recovery in brachial plexus injury following the anterior dislocation of the shoulder was favourable, corresponding to the previous reports.3,4,6,7,12,14,17,19,20,22,25,27 Most cases treated conservatively had nearly completed renervation of brachial plexus within 20
A. Kosiyatrakul et al. / Injury, Int. J. Care Injured 40 (2009) 1327–1329
months. However, the recovery of the intrinsic muscles is uncommon. Only one of our cases had full restoration of the intrinsic function. Very few reports mentioned about residual hand function after the injury.6,25 Three of our cases, who had undergone the tendon transfers for intrinsic reconstruction, reported the satisfactory outcomes after the surgery. We prefer the FCR tendon transfer to restore intrinsic function5 since the FCR always recovers earlier and more frequently than that of the long finger flexors. Furthermore, transfer using the flexor digitorum superficialis resulted in substantial weakness of grasp.9 Our study found that 50% of patients under 50 years of age had recovery of intrinsic muscle to at least grade M3, while all patients over 50 years of age had recovery less than grade M3. Similar to our findings, Pasila et al.19 reported 44 cases of nerve injuries (25 plexus lesions and 19 axillary nerve lesions) after shoulder dislocations; they concluded that the younger patients (<51 years) had more complete recovery than older patients. The most common mechanism of brachial plexus injury in shoulder dislocation is traction. The brachial plexus is stretched over the dislocated humeral head when the humeral head passes over the anterior rim of the glenoid.25 Other possible mechanisms are compression by haematoma and/or direct trauma by the head of the humerus.3,8 Low-energy trauma such as simple fall is relatively more common.8,11,12,14,18,21,25,26 However, some reported cases occur after high-energy trauma.3,6,7,15,17,20 In our series, the number of high-energy trauma patients was slightly higher. There are two main drawbacks in this study. First, the patient group is not large enough to determine a statistical significance of the factors influential in recovery. The other is that several patients had already had some neurological improvement before the first visit to our clinic. For this reason, we are unable to identify the findings on the initial physical examination and the exact interval between the injury and renervation. Conclusions In this study, most of the cases are massive plexus injuries and have good prognosis for recovery except intrinsic muscles of the hand. Intrinsic recovery may be better in a younger age group (less than 50 years). Nerve exploration is usually unnecessary. However, reconstructive surgery such as tendon transfer can provide improvement of hand function in the patient with residual neurological deficit. Conflict of interest The authors have no conflict of interest.
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References 1. Alnot JY. Traumatic brachial plexus lesions in the adult. Indications and results. Hand Clin 1995;11:623–31. 2. Chouhy-Aguirre S, Caplan S. Sobre secuelas de lesion alta e irreparable de nervio mediano y cubital, y su tratamiento. Prensa Med Argent 1956;43:2341–6. 3. Dhar D. Anterior dislocation of shoulder with brachial plexus injury. J Coll Physicians Surg Pak 2007;17:110–1. 4. Duchenne GB. Deuxie`me, editor. L’E´lectrisation Localise´e. Paris: J-B Baillie`re et Fils; 1861, p. 179–88. 5. Giraudeau P, Carayon A. Traitement palliatif des paralysies des muscles intrinse`ques des doigts par le grand palmaire prolonge´ par quatre bandelettes de fascia lata. A propos de 23 observations. Rev Chir Orthop 1971;57:145–50. 6. Gonzalez D, Lopez R. Concurrent rotator-cuff tear and brachial plexus palsy associated with anterior dislocation of the shoulder. A report of two cases. J Bone Joint Surg (Am) 1991;73:620–1. 7. Goubier JN, Duranthon LD, Vandenbussche E, Kakkar R, Augereau B. Anterior dislocation of the shoulder with rotator cuff injury and brachial plexus palsy: a case report. J Shoulder Elbow Surg 2004;13:362–3. 8. Helm AT, Watson JS. Compression of the brachial plexus in a patient with false aneurysm of the axillary artery as a result of anterior shoulder dislocation. J Shoulder Elbow Surg 2002;11:278–9. 9. Hastings II H, Davidson S. Tendon transfers for ulnar nerve palsy. Evaluation of results and practical treatment considerations. Hand Clin 1998;4:167–79. 10. Johnson JR, Bayley JI. Early complications of acute anterior dislocation of the shoulder in the middle-aged and elderly patient. Injury 1982;13:431–4. 11. Koulali-Idrissi K, Sennoune B, Hachimi K, et al. Complete brachial plexus paralysis in anterior shoulder dislocation: a case report. Chir Main 2003;22:109–11. 12. de Laat EA, Visser CP, Coene LN, et al. Nerve lesions in primary shoulder dislocations and humeral neck fractures. A prospective clinical EMG study. J Bone Joint Surg (Br) 1994;76:381–3. 13. Leffert RD, Seddon H. Infraclavicular brachial plexus injuries. J Bone Joint Surg (Br) 1965;47:9–22. 14. McManus F. Brachial plexus lesions complicating anterior fracture-dislocation of the shoulder joint. Injury 1976;8:63–6. 15. Mehta MP, Kottamasu S. Anterior dislocation of the shoulders with bilateral brachial plexus injury. Ann Emerg Med 1989;18:589–91. 16. MRC. Peripheral nerve injuries. Medical Research Council special report series no. 282. London: Her Majesty’s Stationary Office; 1954. 17. Paley D, Love R, Malcolm W. Bilateral anterior fracture dislocation of the shoulder with brachial plexus and axillary artery injury. Orthop Rev 1986;15:443–6. 18. Pasila M, Jaroma H, Kiviluoto O, Sundholm. Early complications of primary shoulder dislocations. Acta Orthop Scand 1978;49:260–3. 19. Pasila M, Kiviluoto O, Jaroma H, Sundholm A. Recovery from primary shoulder dislocation and its complications. Acta Orthop Scand 1980;51:257–62. 20. Saab M. Brachial plexus lesion following an anterior dislocation of the shoulder. Eur J Emerg Med 2004;11:168–9. 21. Shears E, Sunderamoorthy D, Ali SA. Brachial plexus injury after anterior shoulder dislocation: a case report. Acta Orthop Belg 2005;71:489–90. 22. Simonich SD, Wright TW. Terrible triad of the shoulder. J Shoulder Elbow Surg 2003;12:566–8. 23. Stayner LR, Cummings J, Andersen J, Jobe CM. Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231–9. 24. Toolanen G, Hildingsson C, Hedlund T, et al. Early complications after anterior dislocation of the shoulder in patients over 40 years. An ultrasonographic and electromyographic study. Acta Orthop Scand 1993;64:549–52. 25. Travlos J, Goldberg I, Boome RS. Brachial plexus lesions associated with dislocated shoulders. J Bone Joint Surg (Br) 1990;72:68–71. 26. Visser CP, Coene LN, Brand R, Tavy DLJ. The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg (Br) 1999;81:679–85. 27. Volpin G, Langer R, Stein H. Complete infraclavicular brachial plexus palsy with occlusion of axillary vessels following anterior dislocation of the shoulder joint. J Orthop Trauma 1990;4:121–3.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Recovery of brachial plexus injury after shoulder dislocation Arkaphat Kosiyatrakul *, Surasak Jitprapaikulsarn, Sebastein Durand, Christophe Oberlin Department of Orthopedic Surgery, Hospital Bichat-Claude Bernard, 46 rue Henri Huchard, 75877 Paris Cedex 18, France
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 15 May 2009
Brachial plexus injury is an underestimated complication from anterior dislocation of the shoulder. To our knowledge, there is limited information available about the factors that influence neurological recovery of this injury. We reviewed 15 upper extremities in 14 patients with brachial plexus injuries caused by anterior shoulder dislocation. Two-thirds of the cases had total brachial plexus palsy. With the conservative treatment, the motor recoveries of all cases are full or nearly full within 20 months except intrinsic muscle of the hand. Intrinsic muscle recovery may be better in a younger age group (less than 50 years). Nerve exploration is usually unnecessary. However, reconstructive surgery for the residual neurological deficit can provide improvement of hand function. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: Recovery Brachial plexus injury Shoulder dislocation
Shoulder dislocation is a very common shoulder injury that may result from a fall, sports or trauma. Multiple complications have been reported as a result of shoulder dislocation. These include most commonly recurrent dislocation, in addition to rotator cuff tear – especially in the older patients – and axillary nerve injury and cartilage and bony defects.10,12,18,22,24–26 Most reviews on the neurological complications of shoulder dislocation focus on isolated nerve injuries.12,24,26 However, the incidence of brachial plexus injury and the factors that influence its recovery after shoulder dislocation are seldom reported in the literature.12,13,18,25,26 The purpose of this article is to report the natural history, pattern of recovery and management of a group of patients who were referred to our centre with brachial plexus injury after shoulder dislocation. Materials and methods Review of our database revealed 14 patients (15 shoulders), who presented to our centre between 2001 and 2007 for a history of brachial plexus injury after shoulder dislocation. All patients were treated by the senior author (CO). The reviews included gender, age, affected side, cause of injury, type of brachial plexus injury, associated injury, duration and progression of recovery, residual deficit and individual surgical treatments. The patients with follow-up period of 2 years or more were analysed in the study. Causes of injury were reviewed and determined according to the force of injury. The type of brachial plexus injury, which was determined by physical examination and electrodiagnostic study,
* Corresponding author. Tel.: +33 1 40 25 74 02; fax: +33 1 40 25 74 02. E-mail address: [email protected] (A. Kosiyatrakul). 0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.05.015
was recorded as total brachial plexus palsy (entire roots involvement) or partial plexus palsy (upper or lower roots involvement).1 Strength of muscle in the first and each followup examination was recorded according to guidelines of the Medical Research Council (MRC).16 As the pattern of recovery was random, with some cases recovering individual muscles and others recovering group of muscles (flexors, extensors, intrinsics, etc.), the authors recorded the strength of individual muscles as well as group of muscles. The recorded muscles included the supraspinatus, deltoid, elbow flexors, elbow extensors, wrist extensors, flexor carpi radialis (FCR), flexor carpi ulnaris (FCU), finger extensor, finger flexors, interosseous muscles of the hand and thenar muscles. The radiographic examinations were done in each case to determine the type of dislocation and associated injury. The duration of recovery was determined by the interval between initial injury to the last follow-up or before operation. The chosen treatment depended on the progression of recovery of brachial plexus and severity of residual neurological deficit. Results Fifteen upper extremities in 14 cases (nine men and five women) were included in the study. The mean age of the patients was 47.8 years (range: 27–83 years). Seven right upper extremities, six left and one bilateral were involved. The causes of injuries were: simple fall in five cases, car accident in three cases, motorcycle accident in three cases, ski accident in one case, lifting heavy object in one case, and fall from a height in one case. Nine upper extremities had total brachial plexus palsy, four had incomplete injuries, and one had pre-existing cubital syndrome with worsening of ulnar nerve symptom after shoulder dislocation. Six patients had associated fractures of greater tuberosity. The demographic data are show in Table 1.
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A. Kosiyatrakul et al. / Injury, Int. J. Care Injured 40 (2009) 1327–1329
Table 1 Demographic data of patients who had shoulder dislocation complicated with brachial plexus injury. Mean age in years (range) Gender Male Female
Table 2 Recovery of intrinsic muscle according to different kinds of factors. Recovery of interosseous and thenar muscle grade 0–II (number of upper extremities)
Recovery of interosseous and thenar muscle grade III–V (number of upper extremities)
Associated injury Fracture greater tuberosity No associated injury
2 5
2 3
Energy of injury High-energy trauma Low-energy trauma
5 2
3 2
Type of brachial plexus injury Total palsy Partial palsy
5 2
4 1
Age of patient (years) <50 >50
2 4
6 0
47.8 (27–83)
9 5
Affected side Right Left Bilateral
7 6 1
Mechanism of injury High energy Low energy
8 6
Sub-classification of anterior dislocation Subcoracoid
15
Type of brachial plexus injury Total palsy Partial palsy
10 5
The duration of recovery of these muscles is analysed except for three cases. The first patient had worsening of cubital tunnel symptom. The second patient lost follow-up at 3 months after injury. The last patient is waiting for the follow-up. The recovery of supraspinatus, deltoid, elbow flexors, elbow extensors, wrist extensors and finger extensors were complete or nearly complete (grade M4 to 5) in average 5.9, 7.1, 8.6, 8.9, 10.2 and 10.8 months, respectively (range: 1–20 months), in all upper extremities. The recovery of FCR and FCU was complete or nearly complete in average 11.7 and 12.5 months, respectively (range: 2– 20 months) in 11 upper extremities. One had grade M3 in both muscles within 20 months. The recovery of long finger flexors of three radial and two ulnar digits in 10 upper extremities were complete or nearly complete in average 12.8 and 12.5 months, respectively (range: 2–20 months). Two had grade M3 in these muscles at 20 and 23 months, respectively. The pattern of recovery of the interosseous and thenar muscles was different from the other muscles. The recovery was complete in one hand only within 6 months; however, six hands did not recover fully their interossei (grade M3 in five hands and M2 in one hand) and five patients had no signs of any recovery of the interossei after 2 years of follow-up.
The conclusion of the duration and number of shoulders with full or nearly full recovery of individual or group of the muscles is shown in Fig. 1. Surgical reconstructions were indicated in patients with functional disability from residual neurological deficit (established claw hand deformity or loss of thumb opposition), or developing of finger stiffness. Three patients were included in these criteria. Tendon transfer was performed on two patients to correct the claw deformity (FCR transfer with fascia lata graft)5 and paralysis of the thenar muscles (extensor indicis proprius (EIP) transfer).2 One patient was performed tendon transfer for opponenplasty (EIP transfer).2 All of them gained satisfactory hand function after the operations. Another two patients with severe intrinsic weakness did not have surgery. One patient was deemed to be too old for surgery. One patient could adapt to use the hand for the activity of daily living and denied the surgical treatment. In relation to recovery of the intrinsic muscles of the hand, the relation of recovery and associated injuries, energy of injuries, type of brachial plexus injury and age of the patients are shown in Table 2. When considering the age of the patients, two of eight upper extremities in the patients aged less than 50 years had no or inadequate interosseous and thenar muscle recovery, while all upper extremities in the patients aged more than 50 years had no or inadequate interosseous and thenar muscle recovery. Discussion
Fig. 1. Conclusion of duration and number of the upper extremities with full or nearly full recovery of individual or group of the muscles. & = average time, ( ) = number of the upper extremities, FCR = flexor carpi radialis, FCU = flexor carpi ulnaris, LFF of 3R = long finger flexor of three radial digits, LFF of 2U = long finger flexor of two ulnar digit.
Brachial plexus injury after shoulder dislocations is relatively less common than that of isolated axillary nerve. Only a few case series13,18,25 or case reports3,4,6–8,11,14,15,17,20–22,27 have been published. For this reason, it was not possible to determine the true incidence of brachial plexus injury associated with shoulder dislocation. Most of the reported neurological lesions of the brachial plexus were infraclavicular postganglionic and infraclavicular type.12,13,18,21,23 Several studies reported the associated suprascapular nerve involvement in shoulder dislocation.10,12,22,25 In our study, two-thirds of the cases were major brachial plexus injuries as we are the tertiary referral centre. Three of our cases had suprascapular nerve involvement. In this series, we found the prognosis of spontaneous recovery in brachial plexus injury following the anterior dislocation of the shoulder was favourable, corresponding to the previous reports.3,4,6,7,12,14,17,19,20,22,25,27 Most cases treated conservatively had nearly completed renervation of brachial plexus within 20
A. Kosiyatrakul et al. / Injury, Int. J. Care Injured 40 (2009) 1327–1329
months. However, the recovery of the intrinsic muscles is uncommon. Only one of our cases had full restoration of the intrinsic function. Very few reports mentioned about residual hand function after the injury.6,25 Three of our cases, who had undergone the tendon transfers for intrinsic reconstruction, reported the satisfactory outcomes after the surgery. We prefer the FCR tendon transfer to restore intrinsic function5 since the FCR always recovers earlier and more frequently than that of the long finger flexors. Furthermore, transfer using the flexor digitorum superficialis resulted in substantial weakness of grasp.9 Our study found that 50% of patients under 50 years of age had recovery of intrinsic muscle to at least grade M3, while all patients over 50 years of age had recovery less than grade M3. Similar to our findings, Pasila et al.19 reported 44 cases of nerve injuries (25 plexus lesions and 19 axillary nerve lesions) after shoulder dislocations; they concluded that the younger patients (<51 years) had more complete recovery than older patients. The most common mechanism of brachial plexus injury in shoulder dislocation is traction. The brachial plexus is stretched over the dislocated humeral head when the humeral head passes over the anterior rim of the glenoid.25 Other possible mechanisms are compression by haematoma and/or direct trauma by the head of the humerus.3,8 Low-energy trauma such as simple fall is relatively more common.8,11,12,14,18,21,25,26 However, some reported cases occur after high-energy trauma.3,6,7,15,17,20 In our series, the number of high-energy trauma patients was slightly higher. There are two main drawbacks in this study. First, the patient group is not large enough to determine a statistical significance of the factors influential in recovery. The other is that several patients had already had some neurological improvement before the first visit to our clinic. For this reason, we are unable to identify the findings on the initial physical examination and the exact interval between the injury and renervation. Conclusions In this study, most of the cases are massive plexus injuries and have good prognosis for recovery except intrinsic muscles of the hand. Intrinsic recovery may be better in a younger age group (less than 50 years). Nerve exploration is usually unnecessary. However, reconstructive surgery such as tendon transfer can provide improvement of hand function in the patient with residual neurological deficit. Conflict of interest The authors have no conflict of interest.
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References 1. Alnot JY. Traumatic brachial plexus lesions in the adult. Indications and results. Hand Clin 1995;11:623–31. 2. Chouhy-Aguirre S, Caplan S. Sobre secuelas de lesion alta e irreparable de nervio mediano y cubital, y su tratamiento. Prensa Med Argent 1956;43:2341–6. 3. Dhar D. Anterior dislocation of shoulder with brachial plexus injury. J Coll Physicians Surg Pak 2007;17:110–1. 4. Duchenne GB. Deuxie`me, editor. L’E´lectrisation Localise´e. Paris: J-B Baillie`re et Fils; 1861, p. 179–88. 5. Giraudeau P, Carayon A. Traitement palliatif des paralysies des muscles intrinse`ques des doigts par le grand palmaire prolonge´ par quatre bandelettes de fascia lata. A propos de 23 observations. Rev Chir Orthop 1971;57:145–50. 6. Gonzalez D, Lopez R. Concurrent rotator-cuff tear and brachial plexus palsy associated with anterior dislocation of the shoulder. A report of two cases. J Bone Joint Surg (Am) 1991;73:620–1. 7. Goubier JN, Duranthon LD, Vandenbussche E, Kakkar R, Augereau B. Anterior dislocation of the shoulder with rotator cuff injury and brachial plexus palsy: a case report. J Shoulder Elbow Surg 2004;13:362–3. 8. Helm AT, Watson JS. Compression of the brachial plexus in a patient with false aneurysm of the axillary artery as a result of anterior shoulder dislocation. J Shoulder Elbow Surg 2002;11:278–9. 9. Hastings II H, Davidson S. Tendon transfers for ulnar nerve palsy. Evaluation of results and practical treatment considerations. Hand Clin 1998;4:167–79. 10. Johnson JR, Bayley JI. Early complications of acute anterior dislocation of the shoulder in the middle-aged and elderly patient. Injury 1982;13:431–4. 11. Koulali-Idrissi K, Sennoune B, Hachimi K, et al. Complete brachial plexus paralysis in anterior shoulder dislocation: a case report. Chir Main 2003;22:109–11. 12. de Laat EA, Visser CP, Coene LN, et al. Nerve lesions in primary shoulder dislocations and humeral neck fractures. A prospective clinical EMG study. J Bone Joint Surg (Br) 1994;76:381–3. 13. Leffert RD, Seddon H. Infraclavicular brachial plexus injuries. J Bone Joint Surg (Br) 1965;47:9–22. 14. McManus F. Brachial plexus lesions complicating anterior fracture-dislocation of the shoulder joint. Injury 1976;8:63–6. 15. Mehta MP, Kottamasu S. Anterior dislocation of the shoulders with bilateral brachial plexus injury. Ann Emerg Med 1989;18:589–91. 16. MRC. Peripheral nerve injuries. Medical Research Council special report series no. 282. London: Her Majesty’s Stationary Office; 1954. 17. Paley D, Love R, Malcolm W. Bilateral anterior fracture dislocation of the shoulder with brachial plexus and axillary artery injury. Orthop Rev 1986;15:443–6. 18. Pasila M, Jaroma H, Kiviluoto O, Sundholm. Early complications of primary shoulder dislocations. Acta Orthop Scand 1978;49:260–3. 19. Pasila M, Kiviluoto O, Jaroma H, Sundholm A. Recovery from primary shoulder dislocation and its complications. Acta Orthop Scand 1980;51:257–62. 20. Saab M. Brachial plexus lesion following an anterior dislocation of the shoulder. Eur J Emerg Med 2004;11:168–9. 21. Shears E, Sunderamoorthy D, Ali SA. Brachial plexus injury after anterior shoulder dislocation: a case report. Acta Orthop Belg 2005;71:489–90. 22. Simonich SD, Wright TW. Terrible triad of the shoulder. J Shoulder Elbow Surg 2003;12:566–8. 23. Stayner LR, Cummings J, Andersen J, Jobe CM. Shoulder dislocations in patients older than 40 years of age. Orthop Clin North Am 2000;31:231–9. 24. Toolanen G, Hildingsson C, Hedlund T, et al. Early complications after anterior dislocation of the shoulder in patients over 40 years. An ultrasonographic and electromyographic study. Acta Orthop Scand 1993;64:549–52. 25. Travlos J, Goldberg I, Boome RS. Brachial plexus lesions associated with dislocated shoulders. J Bone Joint Surg (Br) 1990;72:68–71. 26. Visser CP, Coene LN, Brand R, Tavy DLJ. The incidence of nerve injury in anterior dislocation of the shoulder and its influence on functional recovery. A prospective clinical and EMG study. J Bone Joint Surg (Br) 1999;81:679–85. 27. Volpin G, Langer R, Stein H. Complete infraclavicular brachial plexus palsy with occlusion of axillary vessels following anterior dislocation of the shoulder joint. J Orthop Trauma 1990;4:121–3.