Trends in Epidemiology and Reimbursement for Nerve Exploration and Reconstruction After Brachial Plexus Injury in the United States From 2009 to 2019.

Shoulder dislocations are common in emergency settings; however, associated vascular injuries are rare, occurring in approximately 1–2% of cases. Among these, axillary and subclavian artery damage is particularly serious, with high morbidity and potential limb loss if not promptly recognized. We report the case of a 79-year-old male, hypertensive and dyslipidemic, who sustained a ground-level fall with right glenohumeral dislocation. Following an attempted closed reduction without sedation, he developed ischemic signs and an expanding hematoma. Initial workup with non-contrast tomography and bedside ultrasound suggested subclavian artery thrombosis. During brachial artery embolectomy, a complete subclavian artery rupture with a 7 cm gap was identified, requiring open repair with a 6 mm Dacron® graft. Postoperatively, the patient developed significant motor deficits of the right upper limb, confirmed by MRI and electromyography as brachial plexus injury. He was discharged on anticoagulation and remains under follow-up with partial functional recovery. This case highlights the importance of systematic neurovascular examination in shoulder dislocation, especially in elderly patients with comorbidities, as collateral circulation may mask early ischemia. Early use of contrast imaging and standardized emergency protocols are critical to improving outcomes. Although rare, subclavian artery injury during shoulder reduction must always be considered, requiring immediate diagnosis and intervention to preserve limb viability and function.

Nontraumatic neuropathies of the shoulder and brachium result from Pancoast tumors, brachial plexus neuritis, thoracic outlet syndrome, proximal compression of the radial nerve, and supracondylar compression of the median nerve. Although these pathologies often require multidisciplinary intervention, patients with these conditions often first present for orthopaedic evaluation. The surgeon should take care to elicit a history of trauma in their workup because this too can be an important cause of neuropathy. A practical description of the presentation, diagnosis, treatment, and prognosis of these pathologies is important for the orthopaedic surgeon.

Current Concepts in Microsurgical Reconstruction of the Upper Limb.

Reconstruction of Thumb and Index Flexion in High Median Nerve Paralysis Using a Single Radial Wrist Extensor Tendon Transfer.

Discussion: Spinal Accessory Nerve Injury in Patients with Brachial Plexus Injury: Prevalence, Predisposing Factors, and Spontaneous Recovery.

Radiation-induced brachial plexopathy in a patient with ATM mutation following radiochemotherapy for grade 2 invasive ductal breast carcinoma

ObjectivesStellate ganglion block (SGB) is a unique anesthetic procedure distinguished by rapid onset, precise effects, and repeatability. The advent of ultrasound guidance has markedly increased the accuracy and safety of this technique, providing a novel approach for nerve blockade in model animals. This study aimed to evaluate the efficacy and safety of ultrasound-guided SGB in C57BL/6 mice, a strain commonly used in biomedical research because of its stable genetic characteristics and well-documented immune responses.MethodsA total of 8–10-week-old C57BL/6 mice were used in this study and were divided into three groups: the control group, the SGB-R group (right side), and the SGB-L group (left side). The SGB-R and SGB-L groups received an injection of 0.25% ropivacaine solution in a volume of 0.08 mL, whereas the control group was administered an equivalent volume of saline. To evaluate the efficacy of the procedure, we monitored the incidence of Horner’s syndrome, heart rate fluctuations, changes in carotid artery flow velocity and diameter, and temperature variations in the affected upper limb. Additionally, we used 3D CT imaging to precisely identify the needle tip position and the diffusion range of the local anesthetic. Simultaneously, we documented the associated complications, including brachial plexus block, hematoma, respiratory distress and mortality, to assess the safety of the procedure.ResultsAmong the SGB-treated mice, 100% presented with Horner’s syndrome. Compared with preintervention levels, the SGB-R and SGB-L groups presented significant decreases in heart rate, increases in carotid artery diameter, increased blood flow velocity, and elevated limb temperature on the blocked side after SGB intervention. Compared with the Con group, the SGB-R and SGB-L groups presented significantly greater carotid artery diameter and blood flow velocity, as well as notable increases in limb temperature. Importantly, no major postsurgical complications, such as brachial plexus injury, hematoma, respiratory distress, or mortality, occurred in any of the groups.ConclusionThis study presents a methodological blueprint for the implementation of ultrasound-guided SGB in C57BL/6 mice, demonstrating its potential effectiveness and safety. The newly established SGB model significantly enhances stability and minimizes potential complications. Compared with traditional techniques, this method offers superior applicability for SGB-related research.

Brachial plexus injury (BPI) is one of the major complications associated with shoulder dystocia. This study aimed to identify risk factors for shoulder dystocia-related BPI (SD BPI) in the Finnish population. The study included all deliveries in the Hospital District of Helsinki and Uusimaa between 2006 and 2015 (n = 181 352). Singleton deliveries complicated by shoulder dystocia, BPI, and clavicle fracture were identified using ICD-10 codes O66.0, P13.4, P14.0, and P14.1 (n = 1708). Following a thorough review of medical records, 374 cases of BPI were identified, 259 of which were related to shoulder dystocia. The background-matched control group (n = 566) consisted of singleton deliveries without BPI. The incidences of both BPI with and without shoulder dystocia declined significantly during the study period, from 0.16% to 0.05% and from 0.09% to 0.03%, respectively. Multivariate analysis identified the following independent risk factors for SD BPI: birthweight ≥4000 g (adjusted odds ratio, aOR 15.3), maternal diabetes (aOR 4.0), vacuum extraction (aOR 3.7), and maternal height ≤160 cm (aOR 2.7). A predictive model based on these four risk factors demonstrated a positive predictive value of 48.2% and a negative predictive value of 92.9% for SD BPI cases. The odds of permanent BPI were 2.5-fold for cases associated with shoulder dystocia compared to those without. Antepartum and intrapartum variables were not predictive of permanent SD BPI. Among all BPI cases, 69.3% were associated with shoulder dystocia and 64.2% with birthweight ≥4000 g. Birthweight ≥4000 g, maternal diabetes, height ≤160 cm, and vacuum extraction independently increased the risk of SD BPI. Notably, 14.7% of all BPI cases occurred in the absence of both shoulder dystocia and birthweight ≥4000 g.

There is much debate about the best mode of delivery for the macrosomic fetus. This study compares maternal and neonatal outcomes of macrosomic in prelabor cesareans (PLC) vs. in trials of labor (TOL). Retrospective cohort including neonates with birthweight of 4,000 g or more delivered in a public teaching hospital between October 2019 and December 2024. Exclusions: preterm, non cephalic, multiples, fetal death and malformed. Created three composite outcomes: "any serious adverse neonatal outcome", "any adverse maternal outcome", "neonatal respiratory morbidity". Considered significant a value of p<0.05. Included 611 births. There was no maternal death and, in the group of TOL, one neonatal death; 37.7 % had vaginal births and 62.3 % had cesareans. Were conducted 341 (56 %) TOL's; from these, 32.8 % failed. Among 231 vaginal births, we had 61 (26.4 %) cases of shoulder dystocia, among which 9 neonates were discharged with brachial plexus injury (3.9 % of vaginal births; 1/25). We found a greater frequency of "any neonatal adverse outcome" in TOL, adjusted Odss Ratio (aOR) 6.68; p=0.037. No significant difference in "respiratory morbidity". In TOL, the frequency of "any maternal adverse outcome" was higher: aOR 3.53; p=0.009. A sensivity analysis excluding birthweights of 4,500 g or more had basically the same results. We had a high frequency of infants discharged with brachial plexus injury. Higher maternal morbidity in TOL could be because of the high rate of failed TOL. Not accessed in this work, there is still some difficulty in correctly identifiying the macrosomic antenatally.

Nerve transfers, which are increasingly applied not only for traumatic peripheral nerve injuries but also in oncologic reconstructions, spinal cord injuries, and a wide range of neurological disorders, rely heavily on the capacity of the central nervous system to reorganize and reassign motor control pathways. Among the multiple factors influencing postoperative recovery, age-dependent brain plasticity appears to play a critical role in determining the degree to which patients can regain functional control after reinnervation. This study aims to characterize this correlation in depth and to identify clinically meaningful age-related thresholds that may guide treatment planning and optimize surgical outcomes. We examined two patient groups who underwent a nerve transfer: (1) neonatal brachial plexus palsy (NBPP) and (2) non-neonatal brachial plexus injury (NNBPI). The Plasticity Grading Scale (PGS) was utilized to assess the degree of volitional control achieved, with scores ranging from 1 (indicating poor brain plasticity) to a maximum of 4 (indicating complete independence of movements, a sign of excellent brain plasticity). Additionally, we analyzed the relationship between age, selected nerve transfer, and PGS outcomes. A total of 168 patients underwent nerve transfers, including 34 with NBPP and 134 with NNBPI. The median PGS scores were 4 and 3 respectively. Age was significantly associated with PGS scores in NNBPI patients receiving extra-plexual nerve transfers (p < 0.001). Optimal scores were observed in patients under 5years of age, regardless of the donor type. In NNBPIs, intra-plexual transfers demonstrated early and sustained plasticity across all ages, whereas extra-plexual donors showed superior outcomes in patients aged 14-20, followed by a plateau after age 21. Age significantly impacts neural plasticity after nerve transfer. This effect is further modulated by the properties of the donor nerve and the target muscle.

Brachial plexus injuries are common; however, pure posterior cord injuries are rare and present with exclusive clinical manifestations that require specialized surgical approaches to achieve acceptable outcomes. Here, we present our experience with these unique cases. Four patients with lacerated pure posterior cord injuries were included in the study. All cases underwent brachial plexus exploration, and nerve grafts were used for reconstruction. After completing physiotherapy, demographic, medical, and surgical data were collected and evaluated. All four patients were referred due to brachial plexus injury. One patient had sustained a gunshot wound and had undergone arterial reconstruction with a vein graft one week prior. The remaining patients had penetrating injuries. Surgical exploration confirmed pure posterior cord injury in all cases. Sural nerve grafts were used to repair the nerve injuries and bridge the gaps. Patients participated in intensive physiotherapy programs for approximately 12 months, followed by motor and sensory evaluations. Three patients achieved excellent outcomes, while the patient with the gunshot wound had a poor result. There are numerous approaches to managing brachial plexus injuries, including non-surgical treatments, nerve repair, nerve grafting, nerve transfer, and muscle neurotization, depending on the condition and surgeon preference. In cases with clearly defined proximal and distal nerve ends, nerve grafting is preferred. Posterior cord injuries have recognizable clinical manifestations, and appropriate surgical techniques may yield good to excellent outcomes. Although pure posterior cord injuries are rare, meticulous exploration and effective nerve grafting can improve final results.

Patterns of Brachial Plexus Injuries: An Ethiopian Experience

Abstract Acute and overuse shoulder injuries in pediatric sports have become more prevalent (seen in almost 40% of baseball pitchers) due to multiple factors such as increased participation in athletic events and games played, less recovery time, and sport specialization (i.e., intense year-round focus on a single sport). The differential is broad when approaching a pediatric athlete with shoulder pain. To complicate things, pediatric athletes are prone to conditions that are not typical in adults, such as proximal humeral epiphysiolysis or Little League shoulder (LLS). It is important to include brachial plexopathy and thoracic outlet syndrome in this differential due to different management strategies. Overall, this age group has a predilection for fractures and sprains as opposed to ligamentous or tendinous damage when insults to the shoulder occur owing to skeletal immaturity. The search was conducted on PubMed (from January 2010 to July 2025) and Scopus (from January 2023 to September 2025) producing a total of 178 reference (82 were included in this review); additional relevant references published before 2010 were also included. Although each shoulder injury presenting in an athlete may be distinct, this narrative review will demonstrate how these pathologies are closely related, how to approach diagnosis, and discuss the evidence and expectations for return to play.

Brachial plexus injuries (BPI) can result in irreversible functional loss of shoulder girdle musculature leading to humeral head subluxation and instability. The resultant mechanical pain can be debilitating and unresponsive to neuropathic pain medications. Surgical intervention, in the form of shoulder arthrodesis (SA), stabilizes the joint and can help to relieve this mechanical pain. Outcomes after SA have been variable in the general population, with high reported rates of nonunion. This is of particular concern in patients with BPI as they often have disuse osteopenia. Here, we describe the use of the Reamer-Irrigator-Aspirator system (RIA, DePuy Synthes, Raynham, MA) for harvesting of autologous bone graft that is used in conjunction with plate and screw fixation for SA in patients with BPI. This study details the operative technique as well as the early outcomes in the first 4 patients.

Mild hypothermia regulates neuronal inflammation and oxidative stress through HSP70 to alleviate brachial plexus injury.

A systematic review of outcomes following transhumeral amputation for brachial plexus injury.

Neurogenic Thoracic Outlet Syndrome (nTOS), the most prevalent type of thoracic outlet syndrome, results from compression of the compression of the brachial plexus as it traverses the scalene triangle and rectopectoralis minor space. It typically presents with upper extremity pain, hand weakness, paresthesia, and muscle atrophy that is often exacerbated by arm elevation or overhead activity. Etiology commonly includes congenital anatomical variants, trauma, and repetitive overhead activity. Diagnosis remains challenging as a result of significant symptom overlap with cervical radiculopathy, brachial plexopathies, and entrapment neuropathies. Work up involves a combination of thorough history and physical with electrophysiologic testing, diagnostic injections and imaging such as MRI or duplex ultrasonography. Initial therapy indicates physical therapy with a focus on decompression and postural correction. In patients with persistent symptoms, motor deficits or failed conservative management, surgical decompression using transaxillary, supraclavicular or minimally invasive techniques is indicated. Rib-sparing surgical decompression is increasingly favored given lower complication rates. Postoperative rehabilitation focuses on restoring range of motion and shoulder girdle strength. This review serves to outline clinical presentation, diagnostic strategies and operative options for nTOS while emphasizing an individualized, stepwise approach to optimize outcomes and minimize risk.

The intramuscular neurovascular branching pattern of the latissimus dorsi muscle provides 2 parts with independent neurovascular supply. The medial and lateral branches arising from the thoracodorsal pedicle run parallel to the muscle fibers and, therefore, 2 independent motor flaps can be harvested. We propose a modification to the latissimus dorsi tendon transfer for external rotation based on these 2 muscular parts. The medial (transverse) part is transferred to the rotator cuff insertion to dynamically enhance external rotation, and the lateral part acts as a stabilizer of the humeral head during rotation. A retrospective review of the patients who underwent this procedure was performed, and active and passive ranges of motion for external rotation and Mallet scores were analyzed, with special attention to complications and limitations to internal rotation. The average shoulder abduction aROM after the procedure was 140 degrees (range: 90 to 180 degrees). The external rotation aROM showed a significant postoperative increase both in abduction (from a mean value of 3 to 78 degrees) and in adduction (from a mean value of 1 to 37 degrees). A significant improvement of the Mallet scores for global abduction, global external rotation, hand to neck and hand to mouth motions was registered, with no significant change in hand on spine score. The proposed technique proved to be a good option to optimize the reconstruction of external rotation without limiting internal rotation. It takes advantage of the anatomy of the latissimus dorsi to perform a double transfer with one donor muscle, limiting morbidity. Level of Evidence: Therapeutic IV.

Evaluation of nerve transfer techniques for shoulder function recovery in traumatic brachial plexus injuries: A Systematic review and individual patient data meta-analysis.