Trauma

Terry Thomas Sign and Its Significance

Terry Thomas sign is an important sign on wrist x-rays that indicate a type of wrist injury.

It refers to an increase in the scapholunate space on an AP radiograph of the wrist or coronal CT scan.

The increased distance indicates scapholunate dissociation and often can be associated with rotary subluxation of the scaphoid.

The sign is named after well-known British comic Terry Thomas.

Terry Thomas (1911 – 1990) had a large gap between his two front teeth [frontal dental diastema] and this made his smile very peculiar.

Here is Terry Thomas with his typical smile.

And here is the increased space between lunate and scaphoid on wrist x-ray.

Terry Thomas Sign In Wrsit — Terry Thomas Sign In Wrist

Just to make things more clear, for comparison, here is a normal x-ray of the wrist. Note that there is a minimum gap between the two bones normally.

Scapholunate dissociation is a wrist injury that occurs due to falling on an outstretched hand or FOOSH injury.

The rupture of the scapholunate ligament leads to separation of the lunate and scaphoid bones. The injury also causes rotation of scaphoid bone.

How much Gap is Significant?

There is no consensus on this value. But most people agree that a gap of 3-4 mm is diagnostic in most cases. In fact, a gap of more than 3mm is pathognomonic for scapholunate dissociation by some authors.

or newer radiology students who do not know who Terry-Thomas was, this finding might also be known as the David Letterman sign.

David Letterman Sign or Madonna sign?

The sign also called as known as the David Letterman sign. Some people call it Madonna sign too.

This is because both of these persons, David Letterman and Madonna, also have dental frontal diastema.

But the gap is not as big and classic as Terry.

Normal Wrist X-ray

By Arun Pal Singh

Wrist x-rays are commonly done for wrist injuries and other wrist ailments.

Wrist x-rays are only able to tell about the status of

carpal bones
radiocarpal joint
Carpometacarpal joint
Distal radius
Ulna

In clinical practice, the common x-ray views of the wrist are posteroanterior and lateral.

Oblique radiographs are included to increase sensitivity to carpal, metacarpal, and phalangeal fractures.

PA, lateral and the semipronated oblique views are part of the three-view wrist series. It is most commonly done wrist series.

If we add semisupinated oblique, also called reverse oblique, it is called four-view series.

Apart from wrist series special views can also be done as needed

[Read more about the anatomy of wrist]

Wrist Series Views

PA and lateral views of wrist — PA and lateral Views of Wrist

Posteroanterior or PA View

This view is interchangeably referred to as AP view though it is performed PA. It is also called palmar dorsal view.

The patient sits alongside the table.

With the shoulder, elbow and wrist at the same height [makes radius and ulna parallel], the affected arm is flexed at 90 degrees at elbow and wrist is rested on the table with the palm facing down on the image receptor

This view demonstrates the carpal joint spaces more clearly.

A good PA view has only minor superimposition of the metacarpal bases and the distal radioulnar joint has no or little superimposition.

Oblique Views

There are two oblique views. one is in semipronated position and other is in semisupinated position.

The semipronated oblique is useful in identifying scaphoid fractures, triquetrum and hamate injuries.

The reverse oblique is quite useful for detecting fractures of the ulnar-sided carpal bones

Lateral View

This x-ray is done at a right angle to PA view and shows multiple carpal bones. It allows the assessment of the alignment of the radius, lunate, and capitate when a dislocation is suspected.

It can be done traditionally where the patient keeps the forearm in neutral rotation. This demands to move the forearm to the desired position. However in horizontal beam lateral wrist projection, the movement of the limb is not required and instead, the projection is made horizontal instead of vertical

Special Views

Ulnar and Radial Deviation Views

Changes in the width of the intercarpal joint spaces may occur because of increased intercarpal mobility and the findings are better demonstrated in these views. In short, these views can provide information on the integrity of the carpal ligament system.

Flexion and Extension Views

These views are taken in positions of flexion and extension of the wrist. These again are helpful in evaluating carpal instability.

Clenched Fist PA views

Useful additional view for evaluating suspected intercarpal ligament damage. Widening of the joint space (>2 mm) is considered significant.

it is especially useful in scapholunate dissociation.

Carpal Tunnel View

The carpal tunnel view is an axial projection to look for medial and lateral prominences and the concavity. It is especially helpful to look for injuries of the hook of hamate, pisiform, and trapezium.

The patient sits or stands with the back facing the table and palmar surface of hand is placed in contact with the cassette placed at the table margin.

The wrist is dorsiflexed approximately 135 degrees lifting the carpals and metacarpals away from the cassette. The best method to do this is to ask the patient to pull their fingers back with the other hand.

The resulting image provides a There should be a clear outline of the ventral aspect of the carpal bones.

Carpal Bridge View

The carpal bridge view is used to assess the dorsal aspect of the scaphoid, lunate and the triquetrum.

The patient sits along the table and dorsal aspect the wrist is placed on the cassette and wrist is flexed, as much as tolerable to the patient.

The x-ray provides, a clear outline of the dorsal aspect of the carpal bones with no superimposition.
This x-ray can be very helpful in imaging triquetrum fractures.

How to Visualize Wrist X-ray

For understanding the wrist x-ray, one needs to know how does a normal wrist x-ray look like.

Beginning proximally, the following structures are looked at as we move distally on x-ray.

Distal radius
Distal ulna
Carpal bones
Alignment
Metacarpals

Distal radius

AP view
- Distal radial articular surface should cup the carpals
- Radial styloid is the most distal portion of the articular surface
Lateral view
- Radial surface should be smooth
- Distal radial cortical irregularity or a lucent line [fracture]
- Look for an ulnar styloid avulsion or intra-articular extension.
  Check the ulna styloid
Look for structural integrity and presence of a fracture line
Note for any radiolucent lesion

Ulnar Styloid

However, trace the cortex of the ulna
Look for any avulsion

Carpals

There are eight carpal bones

These are scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate.

In the following x-ray, each carpal bone has been marked.

The carpus has eight bones in two rows

The proximal row consists of the scaphoid, the lunate, and the triquetrum.

The distal row consists of Trapezium, trapezoid, capitate, and hamate.

In the x-ray, the bones have been marked as follows.

S – Scaphoid
L- Lunate
T – Triquetrum
P – Pisiform
Tm – Trapezium
Td – Trapezoid
C – Capitate
H – Hamate

The most commonly injured carpal bone is the scaphoid. It is also important because of the risk of avascular necrosis.

Look at the cortex of the scaphoid on all views
Trace the cortices of the other carpal bones.

Alignment

On the lateral view, a line drawn through the distal radius, lunate and capitate should be smooth.

The lunate should sit within the cup of the distal radius.

The capitate should sit in the cup of the lunate

Any disruption of the line must raise suspicion of carpal dislocation

Carpal arcs [Gilula arcs]

Articular surfaces of the carpal rows form three smooth lines. Tracing these arcs in a normal x-ray, PA view, will reveal 1-2 mm joint space between the carpal bones.

A widening of the space between the scaphoid and lunate is seen in scapholunate dissociation.

Distally, the joint space between the distal carpal row and the metacarpals is visible all along. If there is an overlap it carpometacarpal dislocation.

Metacarpals

Trace the base of each metacarpal for continuity. Look for any lesion or fracture line. Small avulsion fracture need to be looked very carefully.

Brachial Plexopathy – Causes, Symtptoms and Treatment

By Arun Pal Singh

Brachial plexopathy is an affection of brachial plexus. Plexopathy refers to a disorder affecting nerves, blood or lymph vessels in the regions of the brachial or lumbosacral plexus, the two major plexus in the body.

The symptoms of plexopathy include pain, loss of motor control, and sensory deficits.

It should be kept in the mind that the clinical presentation of cervical radiculopathies could often be confused with brachial plexopathies. A detailed clinical examination, nerve conduction studies, and electromyography can help to differentiate.

Anatomy of Brachial Plexus

Brachial plexus is a complex interconnected network of nerves in the neck formed by contributions from C5 to T1 which divide reconnect and form peripheral nerves.

Suprascapular nerve arising from brachial plexus, Public domainimage — Suprascapular nerve arising from brachial plexus, Public domain image

The complex arrangement is shown below.

Brachial plexopathy can be caused by a variety of disorders affect the brachial plexus [neural, vascular, lymphatic]. Important causes of brachial plexopathy are discussed below

Idiopathic Brachial Neuritis or Parsonage-Turner syndrome

Idiopathic brachial neuritis is a disorder of unknown cause with asymmetric involvement of the brachial plexus. It commonly occurs between the third and seventh decade affecting men more than women.

Different events occurring days or weeks prior to the onset have been

Upper respiratory infection
Flu-like illness
Immunization
Surgery
Emotional stress

No triggers can be found in half of the cases.

The condition is commonly seen in athletes participating in such as wrestling, weight lifting, and gymnastics.

Parsonage-Turner syndrome is thought to be an immune-mediated disorder [ suggested by demonstration of antiganglioside antibodies in serum and multifocal mononuclear infiltrates in brachial plexus biopsies.]

The typical presentation is acute sharp, stabbing or throbbing intense pain in regions of the shoulder, trapezius ridge, scapular area, upper arm, forearm, or hand. Few patients do not go through the painful stage.

The pain lasts from a few hours to weeks. A minority of the patients do not experience the initial painful stage.

After the pain goes, there develops a weakness of shoulder girdle and arm and progresses over few days.

Deltoid, supra and infraspinatus, serratus anterior, and biceps are commonly affected muscles. The muscles get wasted rapidly. Often one or more muscles in the same root distribution are spared.

The sensory deficit is not as pronounced as the motor deficit.

Sometimes, the lesions involve individual peripheral nerves such as the axillary nerve, the suprascapular nerve, and the anterior interosseous nerve.

Diaphragmatic involvement is seen in few cases. [Phrenic neuropathy may also be a part of the brachial neuritis spectrum]

Bilateral affection is seen in about thirty percent.

Electrophysiological studies help in the confirmation of diagnosis, the extent of the lesion, and prognostication. MRI findings range from normal to mild thickening of the plexus.

Most of the patients recover well.

Patients often require analgesic drugs for relief of pain. The pain can be severe in some patients, requiring a combination of agents and, at times, requiring opioid derivatives.

Corticosteroids have been used regularly in the management enough evidence is not available. IV immunoglobulin has been tried but again, a significant evidence is lacking.

Immobilization followed by physical therapy and range of motion exercises are carried. Exercises include strengthening of the rotator cuff muscles and scapular stabilization.

Nerve grafting or tendon transfers may be considered to improve shoulder abduction when recovery is not present.

Recurrence is rare.

[Read more on Parsonage-Turner Syndrome]

Idiopathic Hypertrophic Brachial Neuritis

It is an uncommon disease that progressively affects brachial plexus over months to even years.

It is characterized by slowly progressive weakness and wasting of the segments affected by the disease. Motor disability is overwhelming and sensory findings, when present, are mild.

This condition is painless from the beginning.

Nerve conduction studies and electromyography shows show demyelinating features [ not seen in idiopathic brachial neuritis].

Enlargement of the brachial plexus may be seen on MRI.

Hereditary Neuralgic Amyotrophy

It is an autosomal-dominant disorder characterized by repeated episodes of severe pain followed by paralysis and sensory disturbances in an affected limb.

The onset of is at birth or later in childhood. The recovery generally occurs after an attack but repeated attacks may leave with neurological deficit.

The episodes are triggered by infections, immunizations, surgery, delivery of a child, and stress.

The frequency of the episodes tends to decrease with age.

The individuals accumulate residual problems, such as chronic pain and impaired movement, over the time.

In some hereditary lineage, there are characteristic dysmorphic facial features like hypotelorism, epicanthal folds, long narrow face, facial asymmetry, cleft palate etc along with neck and forearm skin folds or creases and syndactyly

Cranial nerves are frequently involved in hereditary neuralgic amyotrophy.

Electrophysiological studies show normal or mildly reduced motor nerve conduction velocities distal to the affected brachial plexus. Pathological studies have found mild focal axonal degeneration in nerves examined distal to the plexus abnormality.

Neurogenic Thoracic Outlet Syndrome

Thoracic outlet syndrome is characterized by pain, paresthesias, and weakness in the upper extremity.

Cervical rib, enlarged C7 transverse processes, fibrous bands are major causes of this.

Pain, paresthesias or weakness in the upper extremity are common symptoms. Paresthesias may affect the ring and small fingers. Symptom severity tends to increase after certain activities and worsens at the end of the day or during sleep.

There is a weakness of the hand, loss of dexterity of the fingers, and atrophy of the affected muscles.

Provocative tests are used to ascertain the diagnosis. These tests are

Adson Test

Extension of the neck with a rotation of the head toward the involved extremity, which is held in an extended position at the side.
Maneuver constricts the interscalene triangle.
Change in the radial pulse when the patient inhales deeply and holds his/her breath means positive

Wright test

The patient places the arm in full abduction and external rotation
Leads to constriction of the costoclavicular space.
Positive if typical symptoms are elicited along with detection of a change in pulse.

Elevated Arm Stress Test (Roos test)

The patient keeps the affected arm in full abduction and external rotation
The patient is asked to open and close fists slowly over 3 min
Causes constriction of the costoclavicular space.
Positive if typical symptoms are produced and the patient is unable to sustain the maneuver for the full 3 min

X-rays and MRI are helpful in diagnosis.

Electrodiagnostic tests show the absent or reduced amplitude of sensory and motor nerve action potential in ulnar or median nerves.

Needle electromyography which shows denervation in at least one muscle supplied by each of two different nerves from the lower trunk of the brachial plexus with normal cervical paraspinal muscles.

conservative treatment includes modification of activities, postural exercises, physical therapy [Strengthening and stretching exercises] and anti-inflammatory drug therapy.

If there is no response to conservative treatment within 6 weeks, or if time loss extends longer than 2 weeks, surgical treatment may be considered.

Metastatic Brachial Plexopathy

The condition is more common in the elderly patients. Lung and breast cancers most commonly metastasize to brachial plexus reaching by direct extension or through the lymphatics from the axilla. Lymphoma, sarcoma, and melanoma are less common but associated.

The characteristic feature of metastatic plexopathy is severe pain in the shoulder girdle radiating to the inner aspect of the upper limb.

The lower trunk is preferentially involved due to the proximity of draining lymph nodes.

MRI can identify the mass adjacent to the plexus and encroachment of epidural space.

Treatment is often difficult and palliative in form of radiotherapy and chemotherapy of the underlying tumor.

Radiation-Induced Brachial Plexopathy

Radiation therapy to the chest, neck or axillary region for the underlying tumor may result in brachial plexopathy. Radiation dose > 6000 cGy are more likely to develop.

Breast carcinoma is most commonly associated followed by lung carcinoma and lymphoma.

Limb paresthesia, swelling, and motor weakness are common presenting complaints though pain is an inconsistent feature. Radiation-induced brachial plexopathy has a predilection for the upper trunk and not for the lower trunk, probably secondary to the protective effect of the clavicle and relatively shorter course of the lower trunk through the radiation port.

MRI may show thickening and diffuse enlargement of the brachial plexus without the focal mass. Nerve conduction studies may show features of demyelinating conduction blocks. EMG show spontaneous activity in the form of myokymic discharges.

Prognosis is not good. Palliative care is offered. Lymphatic bypass surgery to relieve lymphedema may rarely be needed.

Traumatic Brachial Plexopathy

Traumatic brachial plexopathy usually result from a motor vehicle accident especially in motorcycles, fall from a significant height, penetrating injuries and gunshot wounds, and iatrogenic injury [nerve block administration].

Upper plexus injuries are commonly injured if the arm is at the side [because the first rib acts as a fulcrum to direct the traction forces preferentially in line with the upper plexus]. The lower plexus lesion predominates when the arm is abducted and raised overhead violently [ because the coracoid acts as a fulcrum in a similar fashion.]

MRI can differentiate between pre-ganglionic injuries [root avulsion], pseudomeningocele and post-ganglionic lesions [ enhancing nodular thickening (neuroma) and hematoma in the vicinity of the plexus]

In an acute situation, the patient is put on symptomatic treatment. Once the general condition of the patient is stabilized, reassessment of neurological deficit is carried out.

Primary nerve reconstruction, joint fusion and tendon transfers alone or in combinations are used in the recovery of functions in many patients.

[Read more on Traumatic Brachial Plexopathy]

References

Suarez GA, Giannini C, Bosch EP, Barohn RJ, Wodak J, Ebeling P, et al. Immune brachial plexus neuropathy: Suggestive evidence for an inflammatory-immune pathogenesis. Neurology. 1996;46:559–61.
van Eijk JJ, van Alfen N, Tio-Gillen AP, Maas M, Herbrink P, Portier RP, et al. Screening for antecedent Campylobacter jejuni infections and anti-ganglioside antibodies in idiopathic neuralgic amyotrophy. J Peripher Nerv Syst. 2011;16:153–6.
Martínez-Salio A, Porta-Etessam J, Berbel A, Alonso A, Gutiérrez-Rivas E, Trueba J. Amyotrophic neuralgia: Review of 37 cases. Rev Neurol. 1998;27:823–6.
McCarty EC, Tsairis P, Warren RF. Brachial neuritis. Clin Orthop Relat Res. 1999:37–43
Todd M, Shah GV, Mukherji SK. MR imaging of brachial plexus. Top Magn Reson Imaging. 2004;15:113–25.
Rovak JM, Tung TH. Traumatic brachial plexus injuries. Mo Med. 2006;103:632–6.
Rohde RS, Wolfe SW. Nerve transfers for adult traumatic brachial plexus palsy (brachial plexus nerve transfer) HSS J. 2007;3:77–82

Flail Chest Injury – Causes, Presentation and Treatment

By Arun Pal Singh

Flail chest is caused by severe blunt injury which causes multiple [3 or more] segmental [rib fractures at two points say anterior and posterior] rib fracture resulting in paradoxical movement of broken chest wall segment [that becomes devoid of any attachment and moves with changes in intrathoracic pressure.]

With a better understanding of injury pattern, the treatment of flail chest has greatly evolved from placing towel clips on broken segments to orotracheal intubation with positive pressure ventilation to pneumatically stent the ribcage to modern surgical fixation of the segments.

Flail chest variations include posterior flail segments, anterior flail segments, and flail including the sternum with ribs on both sides of the thoracic cage fractured.

Significant force is required to cause this injury. It requires a significant force diffused over a large area of the thorax for flail chest to occur by creating multiple anterior and posterior rib fractures.

In the case of osteoporotic ribs, lower forces may cause the injury.

In addition to the injury to the chest wall, the amount of injury to the underlying structures, specifically the lungs and heart are more important for the outcome of flail chest.

The exact incidence of flail chest is not precisely known. Bimodal distribution has been noted – adults and elderly.

Flail chest in a neonate/ child has been reported as a potential marker of child abuse.

Associated injuries are scapula fractures, clavicle fractures, and hemothorax and/or pneumothorax

Causes and Pathophysiology

Flail chest is caused by significant trauma to the chest. This may be due to

Motor vehicle accidents
Falls
Assaults in younger

Preexisting conditions like osteoporosis, total sternectomy, and multiple myeloma, as well as individuals with congenital absence of the sternum can have flail chest with lesser force.

Presentation

There is a history of chest injury and patient presents with severe chest pain and difficulty in breathing. Paradoxical or reverse motion of a chest wall segment while spontaneously breathing suggests flail chest.

The inherent structural stability of the chest wall due to the ribs and intercostal muscles usually does not show abnormal or paradoxical motion without 3 or more ribs involved. Therefore if a flail segment is noted on examination, it indicates 3 or more broken ribs.

However, the paradoxical movement is not noted after intubation with positive pressure ventilation, which may result in results in a delayed diagnosis.

The degree of respiratory insufficiency is typically related to the underlying lung injury, rather than the chest wall abnormality.

Diagnosis

Lab studies have a role in the management of flail chest and its fallouts but not physiologic abnormalities, but no t in the diagnosis of flail chest.

Arterial blood gas (ABG) measurements demonstrate the severity of the hypoventilation and are helpful at baseline to assess the requirement for mechanical ventilation

Chest x-rays though are able to show the fractures but may not show all fracture sites.

AP or PA chest x-ray is sufficient. Plain films can miss rib fractures and pneumothoraces but id flail chest is clinically observed, the injury pattern should be looked for intently.

Saggital and coronal reconstruction of thoracic CT scan can be used to identify the rib fractures and evaluation of other possible injuries as well.

Treatment of Flail Chest

Pain control and pulmonary care, including medical management of their pulmonary injury is the standard treatment. Mechanical ventilation is indicated in patients with persistent respiratory insufficiency or failure after good pain control or when the complications associted with drug use occur.

The various options for pain control are patient-controlled analgesia, oral pain medications, and indwelling epidural catheters

Surgical stabilization of the chest, though not routinely performed has found an increased role in recent times. It is worth assertion again that respiratory failure is more due to pulmonary injury than injury to the chest wall. Therefore fixation is not indicated routinely.

In general, operative fixation is most commonly performed in patients

Requiring a thoracotomy for other reasons or in cases of gross chest wall deformity.
Flail chest in presence of
- Multiple myeloma
- Sternal absence [Total sternectomy]
Open fractures

Surgical rib fixation has been found to decrease the number of ventilator days by as much four times.

Complications

Chest wall pain
Intercostal neuralgia
Periscapular muscle weakness
Pneumonia
Dyspnea on exertion or Restrictive type pulmonary function
Chest deformity

Prognosis

5-10% reported mortality has been reported in patients who reach the hospital alive. The patients who do not need ventilation do better statistically.

A higher injury severity score is associated with higher mortality.

References

Kilic D, Findikcioglu A, Akin S, Akay TH, Kupeli E, Aribogan A, et al. Factors affecting morbidity and mortality in flail chest: comparison of anterior and lateral location. Thorac Cardiovasc Surg. 2011 Feb. 59(1):45-8.
Gipson CL, Tobias JD. Flail chest in a neonate resulting from nonaccidental trauma. South Med J. 2006 May. 99(5):536-8
Tanaka H, Tajimi K, Endoh Y, Kobayashi K. Pneumatic stabilization for flail chest injury: an 11-year study. Surg Today. 2001. 31(1):12-7.
Pettiford BL, Luketich JD, Landreneau RJ. The management of flail chest. Thorac Surg Clin. 2007 Feb. 17(1):25-33
Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: indications, technique, and outcomes. J Bone Joint Surg Am. 2011 Jan 5. 93(1):97-110.

Rib Fractures – Causes, Presentation and Treatment

By Arun Pal Singh

Rib fractures are the most common injury sustained after blunt chest trauma. Rib fractures are more common in elderly and adults [older people are more prone than young adults] than children.

Elderly are more likely to have associated injuries and complications.

Rib fractures can be associated with injury to internal organs. This includes injury to lung parenchyma, hemothorax, pneumothorax etc. In first rib injury underlying vessels and spinal injuries.

Fracture of the lower ribs usually is associated with injury to abdominal organs [spleen, liver, kidney].

When there is an associated pelvic fracture with lower rib fractures, there is a higher incidence of solid organ injury.

Ribs 4 to 9 are the most commonly injured.

Patients with fractured ribs and vital capacity of less than 30% have been found to have a higher rate of pulmonary complications.

Pathophysiology of Rib Fracture

The chest wall protects underlying sensitive structures and is necessary for normal respiration. Rib fractures may compromise ventilation due to

Pain from rib fractures can cause respiratory splinting, resulting in atelectasis and pneumonia.
Multiple contiguous rib fractures interfere with normal costovertebral and diaphragmatic muscle excursion [flail chest] leading to ventilatory insufficiency.
Hemothorax or pneumothorax.

The posterior angle is the structurally weakest area of the rib. Ribs commonly fracture at the posterior angle or point of impact.

In the first rib, the thinnest and weakest portion of the first rib is at the groove for the subclavian artery. The fracture of the first rib is often caused by a violent contraction of the scalene muscles due to sudden forward movement of the head and neck.

First rib fractures have often been associated with serious head injury, cervical spine injury, delayed subclavian vessel thrombosis, aortic aneurysm, tracheobronchial fistula, thoracic outlet syndrome, and Horner syndrome

Causes of Rib Fracture

Blunt trauma
- Motor vehicle accidents [most common mechanism]
- Motorcycle injuries
- Assault
- Falls, especially down staircases

Coughing spells
Child abuse [non-accidental trauma in children]
Elderly abuse
Repetitive minor trauma
- In athletes
- Causes stress fractures

Clinical Presentation

The presentation is varied owing to the multiple methods of causation.

Conscious patients with rib fracture frequently complain of pain on inspiration and dyspnea.

Tenderness on palpation, crepitus, and chest wall deformity are common findings.

Paradoxical chest wall excursion with inspiration is seen with flail chest. A flail chest compromises respiratory function and may necessitate intubation and ventilatory support.

Signs of ventilatory insufficiency

Cyanosis
Tachypnea
Retractions and use of accessory muscles
Anxiety
Agitation.

In fracture of the lower ribs is look for abdominal tenderness and coastal margin tenderness which may indicate an injury to intra-abdominal organs.

Differential Diagnoses

Abdominal Trauma, Blunt
Acute Aortic Dissection
Clavicle fracture
Mechanical Back Pain
Sternal Fracture

Lab Studies

Laboratory studies are generally not useful for evaluation of isolated rib fractures.

Urinalysis in cases of lower rib fractures, as hematuria may indicate associated renal injury.

Arterial blood gas measurements) are used to determine if the lungs have been contused.

Imaging

Chest X-ray

Anteroposterior (AP) and lateral chest films are done for chest injuries.

The x-rays of the chest are not very sensitive [50%] for rib fracture [sensitivity as low as 50%]

Presence of a sternal fractureor scapular fractureshould increase suspicion for rib fractures.

Chest radiographs are useful in the diagnosis of underlying injuries, including hemothorax, pneumothorax, lung contusion, atelectasis, pneumonia etc.

The aortic injury is marked by a widening of the mediastinum.

A skeletal survey should be done in infants suspected of being abused. Presence of multiple rib fractures/other bone fractures in various stages of healing will be seen.

Ultrasonography

Ultrasound is useful in pediatric rib fractures. It tells about the fracture in unossified bone and diagnosis of other rib fractures that may be missed on plain radiographs.

It also detects costal cartilage fractures and costochondral junction fractures better.

CT scan

More sensitive than plain
Better fracture delineation
Useful in stress fractures

Abdominal CT in lower rib injuries should be considered in lower rib fractures with a suspected visceral injury.

Angiography

It can be done in first and second rib fractures as these are often associated with vascular injury.

Bone Scan

For diagnosis of stress fracture [see below]

MRI

MRI is able to provide a better spectrum of soft tissues injuries associated. It is also useful in the stress fracture.

Management of Rib Fractures

The approach to rib fracture would depend on the condition of the patient, associated injuries.

In an emergency setting, evaluation and stabilization of the trauma patient are priorities

Pain control is fundamental to the management of rib fractures to decrease chest wall splinting and alveolar collapse in order to clear pulmonary secretions.

Isolated rib fractures, without associated injuries, may be managed on an outpatient basis with oral analgesics, with NSAIDs or opioids or both.

Rib belts or binders control pain but are not recommended as they have been linked to hypoventilation, atelectasis, and pneumonia.

Patients with greater injuries [and risk of complications]need admission.

Consider admission and observation in the following situations

Isolated rib fractures but patient not able to cough and clear secretions adequately
Underlying lung disease or decreased pulmonary reserve.
Older persons with isolated rib fractures >65 years
- hypoventilation, hypercapnia, atelectasis, and pneumonia
Initial systolic blood pressure < 90 mm Hg
Hemothorax
Pneumothorax
3 or more unilateral rib fractures
Pulmonary contusion.

If required nerve blocks like a paravertebral block and an intercostal nerve block may be used for pain control. The incentive spirometer is used for prevention of splinting.

Admission also gives an opportunity to find occult visceral injuries.

All patients who had just been observed and have isolated rib fractures who are able to cough and clear secretions adequately can be discharged after 24 hours.

Other patients need to be managed as guided by the presence of other injuries and their progress.

Open reduction and internal fixation may be considered in flail chest, chest wall deformity and in >3rib fractures with severe symptoms.

The surgery used is open reduction and internal fixation. Surgical treatment lowers mortality, shortens the duration of mechanical ventilation and the need for tracheostomy.

Complications

Complications of rib fracture may include the following:

Respiratory failure
Hypoventilation
Hypercapnia
Hypoxia
Atelectasis
Pneumonia
Damage to underlying visceral organs
- Pneumothorax
- Hemothorax
- Aortic injury
- Pulmonary contusion
- Intra-abdominal organ injury

Stress Fractures of Ribs in Athletes

Stress fractures of ribs are not that common and occur in athletes.

First rib is the most common site where stress fractures occur anterolaterally. Stress fracture of the first rib is noted in baseball pitchers, basketball, weightlifters and ballet dancers.

Stress fractures are in middle ribs (4-9th) occur laterally and anterolaterally and increased incidence is noted in competitive rowers. Posteromedial stress fractures are noted in novice golfers

Risk factors

Extreme overuse
Repetitive use
Repetitive coughing paroxysms
Females
- amenorrhea
- osteopenia / osteoporosis

Pathophysiology of Stress Fracture

Repetitive contraction of attached muscle places stresses on the rib. More so during training, because muscles strengthen more rapidly than bone
Muscle fatigue during prolonged activity places a bone at risk for fracture by lessening the ability of a muscle to absorb and dissipate opposing forces
Anatomic sites of weakness make the bone prone. For example, first rib stress fracture occurs at the groove for the subclavian artery. The fracture is caused by superiorly directed forces from the scalene muscles and inferiorly directed forces from the serratus anterior and intercostal muscles

Clinical Presentation

The athlete would complaint of an insidious onset of pain worsened with coughing, deep inspiration, and overhead activities. Acute presentations are known where the patient might have heard the snap [complete fracture of fatigued bone] while performing the activity.

On examination, there would be focal tenderness directly over the affected rib. In chronic injuries, a palpable callus may develop

Imaging

X-rays are negative for a fracture in as many as 60% of patients with rib fracture of any etiology

The bone scan should be done when clinical suspicion remains in spite of negative x-ray. It would show increased activity.

CT scan shows clear delineation of the fracture pattern

MRI is done when x-rays are negative and clinical suspicion remains. It is used more commonly than bone scans in athletes. MRI shows marrow edema signifying stress response; the fracture line may or may not be seen.

Treatment

It is mostly nonoperative consisting of rest, analgesia, stopping of inciting activity and correction of training errors or faulty mechanics

Majority of rib fractures heal uneventfully

References

Ochi K, Furuya T, Ikari K, Taniguchi A, Yamanaka H, Momohara S. Sites, frequencies, and causes of self-reported fractures in 9,720 rheumatoid arthritis patients: a large prospective observational cohort study in Japan. Arch Osteoporos. 2013. 8(1-2):130.
Boele van Hensbroek P, Mulder S, Luitse JS, van Ooijen MR, Goslings JC. Staircase falls: high-risk groups and injury characteristics in 464 patients. Injury. 2009 Aug. 40(8):884-9.
Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000 Jun. 48(6):1040-6; discussion 1046-7.
Hassan AN, Ballester J, Slater N. Bilateral first rib fractures associated with Horner’s syndrome. Injury. 2000 May. 31(4):273-4.
Coris EE, Higgins HW 2nd. First rib stress fractures in throwing athletes. Am J Sports Med. 2005 Sep. 33(9):1400-4.
Ingalls NK, Horton ZA, Bettendorf M, Frye I, Rodriguez C. Randomized, double-blind, placebo-controlled trial using lidocaine patch 5% in traumatic rib fractures. J Am Coll Surg. 2010 Feb. 210(2):205-9.
Bansidhar BJ, Lagares-Garcia JA, Miller SL. Clinical rib fractures: are follow-up chest X-rays a waste of resources?. Am Surg. 2002.
Karmakar MK, Ho AM. Acute pain management of patients with multiple fractured ribs. J Trauma. 2003 Mar. 54(3):615-25.

Distal clavicle Osteolysis Symptoms, Diagnosis and Treatment

By Arun Pal Singh

Distal clavicle osteolysis refers to the process causing resorption of subchondral bone in the distal clavicle [lateral calvicle], often caused by repetitive strain injury and microfracture, and presenting as pain in the acromioclavicular joint.

Distal clavicle osteolysis was first described in 1936.

Distal clavicle osteolysis is believed to be an underreported and underdiagnosed condition. More than 100 cases have been reported in the literature.

Due to growing popularity of weightlifting, the condition is on the rise in total and in women too.

Pathophysiology of Distal Clavicle Osteolysis

The acromioclavicular joint is a diarthrodial joint between the distal clavicle and acromion process of the scapula. The clavicle is convex and acromion has a flat surface. Both the surfaces are covered by hyaline cartilage.

A fibrocartilage disc is present between the two surfaces.

The joint is stabilized by Its capsule reinforced by the superior and inferior acromioclavicular ligaments and the coracoclavicular ligaments.

Acromioclavicular joints provide horizontal stability and coracoclavicular ligaments provide vertical stability.

There is a fibrocartilaginous disc present between the convex distal clavicle and the flat acromion, both of which are covered by hyaline cartilage.

Distal clavicle osteolysis leads to disruption of articular cartilage, subchondral cyst formation, and increased osteoclastic activity.

There are different theories but repetitive microtrauma caused subchondral stress fractures and remodeling theory is currently the most widely accepted one

Clinical Presentation

Pain of over acromioclavicular joint area exacerbated by athletic or work activity.
Tenderness over the affected AC joint
Cross-chest maneuvers elicit pain
Range of motion of the glenohumeral joint is full

Imaging

X-rays

X-rays are often normal in the early stages. Anteroposterior view and 10-15° cephalic tilt view are done.

In later stages, the following are noted in distal clavicle

Loss of subchondral bone detail
Microcystic changes in the subchondral area,
Widening of the acromioclavicular joint may be seen

Distal Clavicle Osteolysis xray — Distal Clavicle Osteolysis, Image Credit: Orthobullets

Lytic changes are absent in acromion. Involvement of acromion on x-ray should raise the suspicion of acromioclavicular pathologies.

The differentiation is important acromioclavicular arthritis tends to do worse than distal clavicle osteolysis.

Bone scanning

If the plain x-ray is normal, technetium-labeled bone scanning may help to confirm the diagnosis of distal clavicle osteolysis.

Increased radiotracer uptake is noted in the distal clavicle.

MRI

MRI shows bone marrow edema and increases signal intensity in T2 weighted images. MRI is also useful to rule out other shoulder pathologies.

Local Injection

A local anesthetic with injection into the acromioclavicular joint may help achieve a more accurate diagnosis.

Treatment of Distal Clavicle Osteolysis

Non-operative Treatment

The condition is self-limiting and typically resolves within 1-2 years with activity modification. It is the first line of treatment.

Conservative management consists

Rest and avoidance of symptomatic activity.
Modification of activity
Avoiding aggravating weight-lifting exercises or modify the technique
Nonsteroidal anti-inflammatory drugs (NSAIDs
Corticosteroid injections
- Temporary relief
- Accuracy increases with ultrasound

Surgical Treatment

It is indicated in patients in whom conservative treatment fails or who refuse to limit their activities.

The only contraindications noted for surgical treatment is when the patient is not able to tolerate the surgery.

The surgical treatment involves Open or arthroscopic distal clavicle excision. It could be an open surgery or arthroscopic.

Arthroscopic resection has the advantage of allowing evaluation of the glenohumeral joint and early postoperative mobilization too leading to quicker recovery and returns to activity.

Open procedures require meticulous repair of deltoid-trapezial fascia and thus mobilization in postoperative period needs to be deferred.

About 4 mm of resection has been found effective and sufficient. Excessive bony resection should be avoided so as not to violate the posterior superior AC joint capsule, in that this can lead to horizontal instability of the AC joint.

After the surgery patient is put on a passive range of motion to prevent loss of shoulder motion. In this context arthroscopic treatment has an edge because the patient can be put on a range of motion exercises early.

Complications

Damage to the underlying neurovascular structures.
Infection
Frozen Shoulder
Horizontal instability of the clavicle [in the aggressive resection.]

Prognosis

Although the outcome of conservative treatment is good, many patients are unable to limit their activities.

Arthroscopic resection had a 90% success rate, with the direct approach resulting in quicker returns to work and sport.

References

Schwarzkopf R, Ishak C, Elman M, Gelber J, Strauss DN, Jazrawi LM. Distal clavicular osteolysis: a review of the literature. Bull NYU Hosp Jt Dis. 2008. 66(2):94-101.
Roedl JB, Nevalainen M, Gonzalez FM, Dodson CC, Morrison WB, Zoga AC. Frequency, imaging findings, risk factors, and long-term sequelae of distal clavicular osteolysis in young patients. Skeletal Radiol. 2015 May. 44 (5):659-66.
Kassarjian A, Llopis E, Palmer WE. Distal clavicular osteolysis: MR evidence for subchondral fracture. Skeletal Radiol. 2007 Jan. 36(1):17-22.
Auge WK, Fischer RA. Arthroscopic distal clavicle resection for isolated atraumatic osteolysis in weightlifters. Am J Sports Med. 1998 Mar-Apr. 26(2):189-92.

ACR Guidelines For Imaging of Rib Fracture

By Arun Pal Singh

Rib fracture is the most common thoracic injury. It is found in 10% of all traumatic injuries and 40% of cases of blunt trauma.

5th to 9th ribs are most commonly involved probably due to the protection offered by shoulder girdle to upper ribs and mobility of lower ribs.

Isolated rib fractures have relatively low morbidity. But rib fractures should be watched for complications especially in severe injuries. These may include pneumothorax, hemothorax, pulmonary contusion, atelectasis, flail chest and visceral injuries.

Imaging of rib fractures is important to diagnose the rib fracture and its severity. American college of radiology has come out with imaging guidelines termed as American College of Radiology (ACR) Appropriateness Criteria for rib fracture.

$ACR guidelines for imaging of rib fracture$

Summary of the guideline and practical inference is mentioned below. For complete document, the link at the bottom may be followed.

No Dedicated Radiography for Minor Trauma

It is usually not necessary to perform dedicated radiography in addition to chest radiography for the diagnosis of in adults after minor trauma. CT or bone scintigraphy form dedicated studies.

Consider Dedicated Studies in Multiple Rib Fractures in Special Situations Only

There is no evidence that performing dedicated studies like CT, or bone scintigraphy are beneficial even in multiple fractures of ribs.

However, they should be considered such evaluation is necessary for establishing further care or other investigations. For example in cases of elder abuse, legal documentation etc.

Use of CT skeletal scintigraphy, and ultrasound in Occult Fractures and CPR survivors

These modalities may be helpful in evaluating selected patients with occult fractures [sterss fractures] and in evaluating selected CPR survivors or in situations in which identifying a rib fracture is deemed to be clinically important.

Radiography

The standard posteroanterior (PA) chest radiograph is specific but not very sensitive for fractures. The supine anteroposterior [AP] radiograph is even less sensitive.

Clinical examination is sensitive but not specific.

Rib detail radiographs rarely add additional information to the PA film that would change treatment.

Dual-energy chest radiography with bone subtraction imaging has failed to show improved detection when compared with standard radiographs.

Multidetector CT

Multidetector CT provides an accurate assessment of fractures and associated internal injuries and is increasingly used as the method of choice for the radiologic evaluation of the trauma patient.

It also visualizes accurately cartilage fractures, which are typically missed on radiography.

However, CT is not usually performed only to evaluate for the presence of rib fractures.

Rather, it is used to evaluate for other associated complications of trauma.

Ultrasound (US) may also be used for depiction of rib fractures or associated costal cartilage injury in the emergency setting.

Bone Scans

Bone scans are sensitive but not specific for detection of rib fracture. These are most commonly used for detection of bony involvement in systemic processes like metastatic disease and may result in a false-positive diagnosis of malignancy in a patient with rib fractures.

However, both could be differentiated on basis of the tracer uptake.

References

ACR Guidelines

Humeral Avulsion of Glenohumeral ligament or HAGL

By Arun Pal Singh

Humeral avulsion of the glenohumeral ligament or HAGL refers to avulsion of the inferior glenohumeral ligament (IGHL) from its humeral insertion.

When it is associated with a bony avulsion fracture, it is called as bony humeral avulsion of the glenohumeral ligament (BHAGL lesion).

Humeral avulsion of the glenohumeral ligament is often seen in young men engaged in contact sports like rugby, football etc..

It can lead to traumatic anterior shoulder instability. Though Bankart lesion (detachment of the anteroinferior labrum) is a major cause of traumatic instability of the shoulder, humeral avulsion of the glenohumeral ligament is also an important reason in roughly 7-9% of cases of primary shoulder instability.

HAGL most often results from anterior shoulder dislocation due to forced hyperabduction and external rotation of the arm.

This lesion should be considered in the presence of a known following lesions along with the absence of any other demonstrable cause of chronic shoulder instability and pain.

Bankart lesion
Hill-Sachs defect
Rotator cuff pathology

Proper diagnosis and management of these lesions are critical to restore shoulder stability and function. Surgical repair is generally recommended.

Anatomy and Biomechanics

Inferior glenohumeral ligament is sometimes referred to as the inferior glenohumeral ligament complex. It runs from runs from the inferior two-thirds of the glenoid labrum and/or neck to the lateral humerus to attach on the anatomical neck of the humerus and is composed anterior band, posterior band and axillary pouch which is laxity between anterior and posterior bands

Inferior glenohumeral ligament is the most important of the three glenohumeral ligaments as it prevents dislocation at the extreme range of motion. It is the most important static stabilizer of the shoulder.

It can stretch or tear esp the anterior band, at the glenoid insertion with or without concomitant injury to the labrum and capsule. The disruption occurs at the humeral insertion or midsubstance are less common.

Inferior glenohumeral ligament is most stressed in abduction and external rotation.

There is an increased likelihood of a HAGL lesion with hyperabduction and external rotation,

The extent of the injury is often fully appreciated and diagnosed only at the time of shoulder arthroscopy.

In multiple injuries, the HAGL may go unrecognized and cause continued instability.

Clinical presentation of HAGL

Usually, there would be a history of shoulder dislocation. There would be a complaint of shoulder instability and anterior shoulder pain. Some patients may report locking of the shoulder in certain position.

Clinical examination of the shoulder may reveal shoulder instability. There is apprehension in the abduction and lateral rotation.

A crepitus may be noted on examination.

Imaging

X-rays are mostly without any specific findings. MRI is the modality of choice for assessment of HAGL.

The finding may be difficult to diagnose on arthroscopy. Typical findings include avulsion of the inferior glenohumeral ligament from the proximal humerus [ it must be stressed that the avulsion is more common at the glenoid (40%) or mid-substance (35%). Only 25% tearing occurs at the humerus

Retraction of the inferior glenohumeral ligament depicted by J sign. [The normal shape visible is U because the ligament droops down to give the appearance of a U] Disruption of this normality causes J sign.

As most of the HAGL lesions are associated with history of anterior shoulder dislocation, following signs are seen in 65% cases.

Bankart lesion and/or anterior labrum injuries
Subscapularis tear
Hill-Sachs lesion

Treatment of HAGL

HAGL lesions respond poorly to conservative management and surgery is associated with better functional outcomes.

Surgical treatment includes open or arthroscopic repair of the avulsion. Both produce good results and functional outcomes appear to be good for patients undergoing either open or arthroscopic management.

The majority of patients show resolution of instability and pain cessation with surgical treatment of HAGL lesions.

References

Bokor D, Conboy V, Olson C. Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament. J Bone Joint Surg Br. 1999;81:93–96.
Bhatia DN, DasGupta B. Surgical treatment of significant glenoid bone defects and associated humeral avulsions of glenohumeral ligament (HAGL) lesions in anterior shoulder instability. Knee Surg Sports Traumatol Arthrosc. 2013;21(7):1603–1609.
Bui-Mansfield LT, Banks KP, Taylor DC. Humeral avulsion of the glenohumeral ligaments the HAGL lesion. Am J Sports Med. 2007;35(11):1960–1966.
Gehrmann RM, DeLuca PF, Bartolozzi AR. Humeral avulsion of the glenohumeral ligament caused by microtrauma to the anterior capsule in an overhand throwing athlete: a case report. Am J Sports Med. 2003;31(4):617–619.
Oberlander MA, Morgan BE, Visotsky JL. The BHAGL lesion: a new variant of anterior shoulder instability. Arthroscopy. 1996;12(5):627–633.
Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy. 1995;11(5):600–607.

Axillary Nerve Injury – Causes, Effects and Treatment

By Arun Pal Singh

Axillary nerve injury can result either from compression of the axillary nerve or traumatic injury resulting from traction, direct trauma or from injections.

As deltoid is the muscle that is being supplied along with skin over the deltoid area, the axillary nerve injury causes deltoid muscle paralysis and numbness over the region.

Axillary nerve injury is reported to be 0.3% to 6% of the brachial plexus injuries.

The clinical presentation of axillary nerve dysfunction is variable. It can be missed due to the presence of concomitant injuries like dislocation or fracture. and can go undetected, as the concomitant dislocation or fracture may mask the symptoms. Nerve injury should be considered as part of the differential diagnosis process when a patient reports pain, weakness, or paresthesias.

Anatomy of Axillary Nerve

Axillary nerve originates from the posterior cord of brachial plexus and carried C5 and C6 fibers.

After its formation, it lies to anterior to the subscapularis muscle and posterior to the axillary artery.

It courses along anterior subscapularis to inferior end and then exits the axilla posteriorly via the quadrangular space. It is accompanied by the posterior circumflex humeral artery.

Quadrangular space is in the posterior scapular region, which is bounded by the superior margin of the teres major inferiorly, the inferior margin of the teres minor superiorly, the lateral margin of the long head of the triceps brachii medially and the surgical neck of the humerus laterally.

Here, the axillary nerve supplies a branch to the shoulder joint [articular branch] The posterior circumflex humeral artery and vein also run posterior to this nerve in this space.

The nerve divides into anterior and posterior terminal branches within the quadrangular space. The anterior

The anterior branch wraps around the surgical neck of the humerus, running in the deep deltoid fascia with the posterior circumflex humeral artery. Anterior branch has been shown to run 5-7 cm distal to the lateral edge of the acromion

It supplies the anterior deltoid muscle and terminates in small cutaneous branches supplying the anterior and anterolateral shoulder.

Axillary nerve injury would affect its supply as shown, image in PD — Axillary nerve anatomy

Posterior branch supplies the teres minor and posterior deltoid muscles. It is the most susceptible to injury during arthroscopy. It terminates at the superior lateral brachial cutaneous nerve supplying the lateral shoulder.

Causes of Axillary Nerve Injury

Anterior shoulder dislocation
Blunt trauma
Injection palsy
Injury during arthroscopy
Quadrangular space syndrome Compression of the axillary nerve within the quadrangular space in overhead athletes Muscle hypertrophy or paralabral cysts are the causes

Clinical Presentation

The usual presentation is not acute often masked by other injuries. A motor and sensory examination in the acute situation are not certain too as the presence of pain/deformity would affect movements and ability to judge sensory examination input.

The patient presents a duration after the injury, often when another injury has been taken care of, generally after 2-4 weeks.

There are complaints of generalized mild, dull, and ache which is deep or on the lateral shoulder. Occasionally, the pain could radiate to the proximal arm.

There would complain of numbness and paraesthesiae of the lateral arm and/or posterior aspect of the shoulder

There may be a feeling of the shoulder of instability and shoulder weakness.

Weakness is especially pronounced in flexion, abduction, and external rotation.

Not all persons are symptomatic though.

Some athletes may complain of weakness and early-onset fatigue with exercise only, especially with overhead activities and heavy lifting.

History of trauma may always be not available.

Though rare intramuscular injections in deltoid may injure the nerve and should be probed in absence of clear trauma.

On examination, there would be an area of hypoaesthesia on the lateral aspect of the upper arm, typically in the region where regimental badges used to be placed. Typically, the lower half of the deltoid.

Motor supply of axillary nerve is to teres minor and deltoid and depending on the level of injury there would be the weakness in both these muscles or only in the deltoid.

There would be visible muscle atrophy of the deltoid and teres minor.

A complete examination of the shoulder should be done.

The findings would vary with the extent of damage to the axillary nerve.

Clinical Tests

Lag sign test

The physician stands behind the patient and elevates the patient’s arm.

The patient is asked to hold this position without the doctor’s assistance. If the patient cannot hold this position on their own and an angular drop occurs, it indicates deltoid weakness.

Hornblower’s test

This test detects teres minor weakness. For this test place shoulder in 90° abduction and 90° external rotation. The test is considered positive if patient unable to maintain external rotation, arm falls into internal rotation

Investigations

Electromyography is the diagnostic test of choice to identify nerve conduction loss but the changes may not be identifiable until 2-3 weeks after injury. Electromyography is also able to distinguish between atrophy secondary to pain or nerve injury.

It can also be used to monitor the progression of the injury.

Treatment of Axillary Nerve Injury

The choice of treatment is determined by the type of injury

The prognosis worsens with the severity of the injury.

Conservative Treatment

Patients with grade I and II [neuropraxia and most of the patients with neuropraxia [grade 1 injury] recover with conservative management within 6 to 12 months.

Patients with axonotmesis (2^nd degree) nerve injury, the recovery rate is about 80%.

The patient should be put on conservative treatment and if there are no signs of functional return by 6 months, surgical exploration and possible nerve grafting are recommended.

Patients with neurotmesis (nerve transection) there is typically no recovery without surgical intervention.

Moreover, the prognosis is better if the surgery is performed within 6 months of the injury.

In acute closed injuries with axillary nerve injury, the treatment of the injury takes precedence.

In closed injuries, an immediate reduction would cause the nerve to relax and has better chances of responding to conservative treatment.

In open injuries, the exploration may be indicated depending on the severity of the wound.

Conservative treatment for nerve injury consists of maintaining joint range of motion while waiting for nerve recovery.

For local symptoms like pain, relevant drugs may be taken.

Surgical Treatment

Surgical treatment is considered at the outset for axonotmesis [complete transection].

It can be done immediately where a compression or injury is due to a structure that needs removal. For example, an osteophyte I quadrilateral space.

Indications for Surgery

Compression in the quadrilateral space
No clinical or EMG improvements seen after 3 to 6 months of injury/conservative treatment.

Choice of surgical procedures available

Neurolysis – When the nerve is intact but compressed by surrounding tissue
Nerve repair
Nerve grafting – To fill the gap between the nerve ends
Nerve transfer – Usually using triceps motor branch

After surgery, the shoulder should be immobilized for 4 to 6 weeks and followed by rehabilitation.

Dorsal Scapular Nerve Entrapment Syndrome

By Arun Pal Singh

The dorsal scapular nerve entrapment is a relatively less common nerve entrapment that causes shoulder and arm pain. It is vulnerable during brachial plexus injections as the nerve passes through the middle scalene muscle.

Dorsal scapular nerve entrapment is uncommon and therefore frequently underrecognized cause of pain in shoulder and neck area.

The symptoms are easily mistaken for other problems.

Relevant Anatomy

Anatomy of Dorsal Scapular Nerve

Understanding anatomy of nerve is crucial for diagnosis dorsal scapular nerve entrapment — Nerves to scapula, Image credit: Musculoskeletal Key

The dorsal scapular nerve arises from the brachial plexus, usually from the cervical nerve C5. After leaving C5, it commonly pierces the middle scalene muscle and continues beneath the undersurface of levator scapulae and the rhomboids.

It provides motor innervation to the rhomboid muscles, which pull the scapula towards the spine and levator scapulae muscle, which elevates the scapula.

The course of the nerve is accompanied by one of two arteries: either the dorsal scapular artery that arises from the third part of the subclavian artery or deep branch of the transverse cervical artery [when the other artery is absent].

It is a branch of the thyrocervical trunk which is a branch of the first part of the subclavian artery,

The dorsal scapular nerve supplies the levator scapulae muscles, the rhomboid major and minor muscles.

The rhomboids minor and major muscles connect the medial edge of the scapula to the spinal column. Both rhomboid muscles pull the scapula towards the midline (scapular adduction) and they also pull the scapula superiorly with downward rotation, function opposite to serratus anterior.

Anatomy of Rhomboids and Levator Scapulae

Rhomboids

There are two rhomboids are two muscles – rhomboid major & rhomboid minor.
Rhomboid major originates from spinous Processes T2-T5 and inserted on to medial border of scapula from level of the spine to inferior angle

Rhomboid Minor originates from nuchal ligament and spinous Processes C7 & T1. It inserts on a triangular area of the medial end of the medial end of the scapular spine
Both the rhomboids lie deep to trapezius and form parallel bands that pass inferolaterally from the vertebrae to the medial border of the scapula. The two are often separated by a small space between but in some cases, one single blended muscle may be present.

Levator Scapulae

It originates from the posterior tubercle of the first four transverse processes of cervical vertebrae and is inserted into medial border of the scapula extending from superior angle to junction of the spine and medial border of the scapula.

Causes of Dorsal Scapular Nerve Entrapment

Entrapment in scalenus medius muscle
Direct injury to the nerve
- Severe C5 root lesion or avulsion.[Brachial plexus injuries]
- Anterior shoulder dislocation
C5 radiculopathy has also been suggested as a causative factor.

[In overhead athletics, a muscle injury to rhomboids may cause rhomboids palsy leading to winging of the scapula and mimicking dorsal scapular nerve entrapement]

Clinical Presentation and Diagnosis

Injury/entrapment of dorsal scapular nerve causes weakness of the levator scapulae and the rhomboid muscles and results in a winging of the scapula.

[Scapular winging refers to the abnormal protrusion of scapula on patients back. It occurs because of paralysis of stabilizing muscles of the scapula. Serratus anterior and trapezius are common causes whereas rhomboids weakness is an uncommon cause.

The scapular winging in dorsal scapular nerve syndrome is not as severe as seen with serratus anterior muscle and trapezius.]

The usual complaint in dorsal scapular nerve entrapment is a history of the abnormal movement of the shoulder joint, and stiff joint. The patient may also complain of pain in the shoulder region.

On examination, as noted before, there could be scapular winging. The scapula may become laterally displaced with an upward motion.

When asked to bring the scapulae together [adduct], the patient is not able to do so or the affected side is less adducted. Palpation of the contracted rhomboideus muscles would confirm the weakness.

When the patient is asked to move the arm forward on elevation will result in the medial border of the scapula being lifted and pulling on the inferior angle of this bone.

An electromyogram would help in confirmation of diagnosis.

MRI scan helps to diagnose roots avulsions.

Treatment of Dorsal Scapular Nerve Entrapment

Treatment usually is conservative which includes

Cervical stabilization
- Cervical collar
- Cervical traction
Muscle relaxants
NSAIDs
Physical therapy
- Strengthening of the trapezius [middle trapezius provides compensation for loss of rhomboids]
Local steroid block for muscle

Surgery can be considered in severe cases that are unresponsive to conservative treatment.

The procedures are

Fascial sling operation
- Two fascia lata grafts are used to connect the lower medial border of the scapula to the spinal muscles and the inferior angle of the scapula to the latissimus dorsi.
- This anchors the scapula to the posterior thoracic wall, eliminating winging.
- Grafts may stretch or fail with time
Neurolysis or nerve decompression
- Suggested as last resort

References

Tubbs RS, Tyler-Kabara EC, Aikens AC, Martin JP, Weed LL, Salter EG, Oakes W. Surgical anatomy of the dorsal scapular nerve. J Neurosurg. 2005 May; 102(5):910-1.
Fisher MA, Gorelick PB. Entrapment neuropathies. Differential diagnosis and management. Postgrad Med. 1985 Jan; 77(1):160-74.
Jerosch J, Castro WH, Geske B, Damage of the long thoracic and dorsal scapular nerve after traumatic shoulder dislocation: case report and review of the literature.Acta Orthop Belg. 1990; 56(3-4):625-7.