Neurovascular Compromise Research Articles

A 75-year-old with left ankle pain.

A 75-year-old female with a history of smoking presented with left foot pain after a fall. She was cleaning her pool when she lost her footing while walking down a step. On extremity examination of her left ankle, there was plantar flexion weakness, a palpable dell at the insertion of the Achilles tendon, and a bony mass proximal to the gap (Figure 1). Left ankle radiographs were remarkable for an acute fracture of the posterior proximal aspect of the left calcaneus (Figure 2). Before surgery, the skin had become ecchymotic and edematous. The patient underwent open reduction with internal fixation with podiatric surgery. As there was enough bone remaining, 2 cannulated screws were placed to fix the fracture along with the attached Achilles tendon. The patient was discharged with a recommendation of non-weight-bearing status for the left lower extremity, a cast, and orthopedic follow-up in 2 weeks. Calcaneal fractures account for 1%–2% of all fractures. Calcaneal avulsion fractures account for less than 3% of calcaneal fractures.1 The calcaneus is the largest tarsal bone; it supports axial load from the body. This report demonstrates a type 2 calcaneal avulsion fracture; a “beak fracture” where the tendon pulls on the tuberosity causing a horizontal fracture.2 It also demonstrates a rare tongue-type fracture where the tuberosity splits into a superior and an inferior fragment.3 Patients often present with pain, swelling, and ecchymosis near the posterior aspect of the calcaneus. Patients can have skin tenting that can lead to skin necrosis if not treated.3 This woman had ecchymosis before surgery but did not have skin necrosis. It is important to assess these patients for neurovascular compromise and signs of other injuries. A plain radiograph is usually sufficient for diagnosis. Treatment depends on the severity. Fractures with skin tenting, neurovascular injury, or significant displacement will likely require open reduction and internal fixation in the operating room.4 This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

The subscapularis muscle: A meta-analysis of its variations, prevalence, and anatomy.

The subscapularis (SSC) is the largest rotator cuff muscle and is involved in the medial rotation, abduction, adduction, and anterior stabilization of the shoulder. It is anatomically variable, as is the morphology and prevalence of the accessory SSC (aSSC), a rare muscle slip attached to the SSC. There is no current review investigating the prevalence and morphometrics of the SSC and aSSC. To investigate the prevalence of the morphological variants of the SSC and aSSC via meta-analysis and review the relevant literature involving cadaveric, magnetic resonance imaging, and ultrasonographic studies. Meta-analysis. Literature data reporting the prevalence rates and morphometrics of the SSC and aSSC and their variants were pooled. Literature searches and data analyses were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Anatomical Quality Assurance guidelines. Forty-six studies, totaling 2166 shoulders, were assessed. The SSC showed an overall length, thickness, cross-sectional area, and volume of 152.2 mm (95% confidence interval, CI, 103.8-200.5 mm), 5.6 mm (95% CI, 4.6-6.6 mm), 18.1 cm2 (95% CI, 14.2-22.0 cm2 ), and 126.9 cm3 (95% CI, 87.2-166.5 cm3 ), respectively. The SSC displayed substantial variations in its origin and insertion points and in the composition of its tendon. The aSSC had an overall pooled prevalence of 24.6% (95% CI, 0.0%-76.9%). The SSC and aSSC have been implicated in multiple shoulder pathologies, including muscle and tendon ruptures and neurovascular compromise. A better understanding of SSC and aSSC variants when diagnosing and treating their related pathologies will reduce patient morbidity and improve treatment regimens.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

Talar Arthroscopic Reduction and Internal Fixation (TARIF): A Novel All-Inside Soft-Tissue-Preserving Technique.

Jednoaktna procedura po Mutafu za urođene konstriktivne prstenove - bezbedna i efikasna

Introduction: Congenital constriction ring is a rare congenital malformation that especially affects the limbs. It is associated with fibrous bands that could encircle, strangle, or amputate some parts of the fetus. However, there are only a few techniques described for the correction of this anomaly. We aim to present a successful treatment of congenital constriction ring by means of the one-stage Mutaf technique. Patient Review: In our report, we presented two infants with congenital constriction rings. In the first case, we presented an infant with a constriction band on the right arm accompanied by deformity of the distal part and lymphoedema. In the second case, we presented an infant with multiple constriction bands on the distal part of the right leg with clubfeet and severe lymphoedema. They were both treated by the one-stage Mutaf technique using rectangular dermofat grafts to fill the groove. Using this technique we obtained a normal limb contour, with no oedema or neurovascular compromise. Filling the groove with the rectangular dermofat flaps parallel to the relaxed skin tension lines provides a better scar in comparison with multiple Zor W-plastics techniques. Additionally, advantages of the one-stage procedure are reduction of surgical and psychological trauma in patients and their parents, less time spent under general anesthesia and lower amount of anesthetic the patient receives, and lower treatment costs. Conclusion: We find the Mutaf technique to be an effective and safe technique for the treatment of congenital constriction rings.

Functional Outcome of Open Latarjet Procedure for Recurrent Anterior Shoulder Dislocation

OBJECTIVES To find the functional outcome of the open Latarjet method for recurrent anterior shoulder dislocation. METHODOLOGY The current retrospective study was conducted at the Orthopedic and Trauma Department of the Khyber Teaching Hospital in Peshawar from September 2020 to August 2021. A total of 31 patients were included in the study, of which 29 were males and 2 were females. A detailed medical history was obtained through physical examination, and all necessary laboratory tests were requested. AP and axillary views of plain X-ray radiographs were taken. We used a CT scan on all the patients to calculate the humeral and glenoid bone loss. We had all patients undergo an MRI to rule out soft tissue pathology. Six months after surgery, the outcome was graded using the Constant Murley Score on a good, good, fair, and poor scale. RESULTS In this study open Latarjet procedure was done in 31 patients with 29 males (93.4%) and two females (6.45%). The right-sided shoulder was involved in 24 (77.14 %) patients, while the left shoulder was involved in 7 patients (22.58%). A bipolar lesion in the shoulder with bone loss was seen on the glenoid side at 17.5% (range 10-25%), and the humeral side was 22.5%. Follow-up was done for six months in which 22 patients had a very good outcome (70.96%), six patients had a good outcome(19.35%), two patients had a fair outcome(6.45%), and one patient had a poor outcome(3.22%). There were no major complications seen like graft fractures, graft malposition, neurovascular compromise, and hardware breakage CONCLUSION Recurrent anterior shoulder instability can be effectively treated with open Latarjet with excellent functional outcomes and a very low complication rate and recurrence.

Keeping an eye on the diabetic foot: The connection between diabetic eye disease and wound healing in the lower extremity.

Diabetic eye disease is strongly associated with the development of diabetic foot ulcers (DFUs). DFUs are a common and significant complication of diabetes mellitus (DM) that arise from a combination of micro- and macrovascular compromise. Hyperglycemia and associated metabolic dysfunction in DM lead to impaired wound healing, immune dysregulation, peripheral vascular disease, and diabetic neuropathy that predisposes the lower extremities to repetitive injury and progressive tissue damage that may ultimately necessitate amputation. Diabetic retinopathy (DR) is caused by cumulative damage to the retinal mic-rovasculature from hyperglycemia and other diabetes-associated factors. The severity of DR is closely associated with the development of DFUs and the need for lower extremity revascularization procedures and/or amputation. Like the lower extremity, the eye may also suffer end-organ damage from macrovascular compromise in the form of cranial neuropathies that impair its motility, cause optic neuropathy, or result in partial or complete blindness. Additionally, poor perfusion of the eye can cause ischemic retinopathy leading to the development of proliferative diabetic retinopathy or neovascular glaucoma, both serious, vision-threatening conditions. Finally, diabetic corneal ulcers and DFUs share many aspects of impaired wound healing resulting from neurovascular, sensory, and immunologic compromise. Notably, alterations in serum biomarkers, such as hemoglobin A1c, ceruloplasmin, creatinine, low-density lipoprotein, and high-density lipoprotein, are associated with both DR and DFUs. Monitoring these parameters can aid in prognosticating long-term outcomes and shed light on shared pathogenic mechanisms that lead to end-organ damage. The frequent co-occurrence of diabetic eye and foot problems mandate that patients affected by either condition undergo reciprocal comprehensive eye and foot evaluations in addition to optimizing diabetes management.

Shoulder Erecta Dislocation

Dislocation of the shoulder is defined by a total loss of contact of the humeral head with the glenoid socket of the scapula. Inferior shoulder dislocation or luxatio erecta humeri is a rare type of glenohumeral dislocation that constitutes <1% of all shoulder dislocations, characterized by subglenoid displacement of the humeral head [1]. Irreducible abduction is pathognomonic attitude for shoulder erecta dislocation.It is a traumatological emergency, that should be early recognized and reduced to prevent neurovascular compromise with increased swelling [2].

Return to Full Function in Patient with Nonoperative Management of a Comminuted, Displaced Clavicle Fracture: A Case Report.

Clavicle fractures are common skeletal injuries that account for 2%-10% of adult fractures. Surgical indications include presence of an open fracture, severe angulation, comminution, displacement, skin tenting with a threat of skin perforation, neurovascular compromise, symptomatic nonunion, or fracture shortening >1.5-2cm. In this case, the patient had a comminuted, displaced fracture - thus meeting criteria for operative treatment. However, the patient opted for nonoperative management. After 3 months, the patient regained full strength and range-of-motion. This case highlights the current heterogenous mixture of studies in the literature surrounding the best management for midshaft clavicle fractures. The patient was informed that data concerning the case would be submitted for publication and provided consent.

All Arthroscopic Suprapectoral Biceps Tenodesis

Background: Biceps tendinopathy can have significant clinical manifestations in active patients. Failure to achieve resolution of symptoms through nonsurgical modalities oftentimes results in surgical intervention. The 2 most common surgical treatment options for tendinopathy of the long head of the biceps tendon (LHBT) are tenotomy and tenodesis. Both modalities have shown efficacy within the literature; however, tenodesis of the LHBT has many advantages to tenotomy. Indications: Subgroove tenodesis eliminates the potential pain generation within the bicipital groove. Despite recent proof of clinical equivalence in open versus arthroscopic tenodesis, there has been increasing interest in all-arthroscopic biceps tenodesis techniques in hopes of minimizing surgical exposure, decreasing the rate of potential neurovascular compromise, and decreasing the time to recovery. Technique: We present an all-arthroscopic technique for a subgroove biceps tenodesis using a unicortical tensionable button. The proximal biceps anchor is held in place at its insertion site with a spinal needle to prevent retraction. The lateral portal is redirected into the subdeltoid space. A novel suprapectoral biceps portal, called the Willingboro portal, is placed percutaneously 2 cm above the pectoralis tendon. Onlay fixation of the LHBT is performed proximal to the pectoralis major muscle insertion using a unicortical button. Postoperative protocol is similar to other fixation constructs. Results: Numerous arthroscopic biceps tenodesis techniques have been described with good success; however, an all-arthroscopic suprapectoral tenodesis is attractive to many reasons. The unicortical button construct shows similar load to failure strength as the bicortical button construct, both of which are greater than all other constructs described in the literature. Discussion/Conclusion: Arthroscopic subgroove biceps tenodesis using a unicortical button technique is a viable option that avoids the complications associated with an open axillary incision as well as persistent groove pain. Anchoring the biceps tendon prior to tenotomy allows for preservation of tendon length, limiting the complications associated with tendon retraction with anticipated improvement in patient-reported outcomes. The unicortical button is known to have a similar strength profile as the bicortical button technique, which is greater than other techniques described in the literature. Future studies should be aimed at assessing long-term patient-reported outcomes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Management of Displaced Midshaft Clavicle Fractures in Pediatrics and Adolescents: Operative vs Nonoperative Treatment.

The purpose of the current review is to describe the management of displaced midshaft clavicle fractures in pediatric and adolescent patients. Midshaft clavicle fractures are relatively common in pediatric and adolescent patients. They most commonly occur from direct trauma and are often related to sports participation in adolescents. Recent literature in the management of adult midshaft clavicle fractures has supported operative management due to improved functional outcomes, decreased time to union, leading to early return to activity. A similar trend of increasing frequency in operative management has been seen in pediatric and adolescent patients with no consensus in the literature on optimal management. Nonoperative treatment consists of with a brief period of sling immobilization followed by range of motion. Operative management may be considered for open fractures, fractures with significant neurovascular compromise and soft tissue complications. Studies have shown comparable mid- to long-term functional and patient-reported outcomes after operative and nonoperative management of midshaft clavicle fractures in pediatric patients.

Displaced paediatric distal radius fractures with volar skin tenting following manipulation and reduction: a report of two cases and literature review

Distal radius fractures are amongst the most common forearm fractures in children and can often be managed with closed reduction and casting for the majority of patients. While the thick periosteum sleeve can be used to guide reduction, it can also make the traction used in an adult patient counterproductive to closed reduction attempts. We report two unusual cases of distal radius fractures with displaced volar fragments in children that required urgent surgical intervention following manipulation and reduction due to concern for skin and neurovascular compromise. While one patient developed post-operative superficial skin necrosis managed conservatively, both children recovered well without long-term complications.

Proximal humerus fractures: anatomy, diagnosis and management.

Proximal humeral fractures are common with a bimodal distribution and sex discrepancy, affecting younger men and older women. The presentation of a proximal humeral fracture can vary greatly because of this bimodal distribution and the associated differences in mechanism of injury. Initial management should involve assessment of life- and limb-threatening injuries as outlined by the British Orthopaedic Association Standards for Trauma, with particular attention paid to axillary nerve function and vascular status. Initial imaging should involve orthogonal X-rays in three planes to determine fracture characteristics and exclude glenohumeral dislocation. Computed tomography imaging improves interobserver agreement and is the gold standard in determining fracture management. Management depends on fracture pattern, patient functionality and bone stock. Most patients with proximal humeral fractures achieve good functional outcomes via conservative methods (sling support and early, graded mobilisation), although there is a lack of evidence in certain populations, including younger patients. Surgery is required for open fractures and more complex fracture patterns where there is a risk of avascular necrosis of the humeral head, unacceptable impairment of functionality or neurovascular compromise. Surgical techniques can be head-sparing or involve replacement of the humeral head. There are several head-sparing techniques, each with different cost-benefit and complication profiles with no one technique superior to any other. However, improvements in plate technology may render open reduction internal fixation a more suitable technique, particularly in younger patients. Head replacement techniques (hemiarthroplasty and reverse shoulder arthroplasty) are indicated when the risk of avascular necrosis is too high or in older patients with osteoporotic bone. In these patients, reverse shoulder arthroplasty is preferred as it achieves better functional results than hemiarthroplasty. Complication rates vary depending on the fracture configuration and the course of management undertaken.

Accidental penetrating injury by wooden stick a case report

Penetrating trauma is an injury caused by a foreign object piercing the skin and damaging the underlying tissues and results in an open wound. The most common cause of such trauma are gun shots, explosive devices and stab wounds. These penetrating injuries if neglected can result in various complications like neurovascular compromise, flexor or extensor tendon injuries, ischemic changes, infection and it can even go for compartment syndrome. Here we report a case of accidental penetrating injury to forearm by wooden stick and the proper timely intervention in removing it and make limb salvageable. We have removed it by supraclavicular block with the tourniquet and proper lazy S incision and so that preserving the neurovascular structures which was just close to it along with repairing the flexor muscles of the forearm. We report here a case with accidental penetrating injury to forearm by wooden stick. A 35year-old male patient presented with history of pain and swelling in his right forearm occurs after an accident. There was an entry wound on radial side of forearm around 3×4 cm and an exit wound of 3×3 cm with wooden stick in situ. A detail history and careful examination is needed.

Asymptomatic isolated intramuscular cysticercosis in diabetic patient: a case report

Cysticercosis is an endemic disease in multiple areas of the world, caused by ingestion of embryonated eggs of Taenia solium. We reported a case of a 66-year old diabetic male presenting with decrease of consciousness and “rice grain” calcification in both hemithorax and neck soft tissue region, without findings of cysticercosis in computed tomography (CT) scan. Cysticercosis most commonly affects the central nervous system, causing neurocysticercosis (NCC), while solitary intramuscular cysticercosis without involvement of the central nervous system is rare. Treatment of cysticercosis is indicated for symptomatic patients, including NCC surgery is indicated in patients with neurovascular compromise caused by growth of cyst. Recognizing the signs and symptoms of cysticercosis is crucial for diagnosis and treatment in endemic areas where Taenia solium is prevalent.

Modified Double-Row and Double-Pulley Technique for the Treatment of Type Ia Scapular Glenoid Fractures.

ObjectiveTo evaluate the efficacy of the double‐row and double‐pulley technique in treating anterior shoulder glenoid fracture (Ideberg type Ia) using shoulder arthroscopy.MethodsThirty‐six patients with Ideberg type Ia admitted from March 1, 2017, to March 1, 2020, were retrospectively reviewed. Data of the patients' history included age, sex, side of the affected arm, the mean time from injury to surgery, the surgical duration, the average blood loss, and the average total duration of hospital stay. The double‐row and double‐pulley technique was used to repair the scapular glenoid fracture under arthroscopy. Computed tomography (CT) was used to evaluate fracture healing after surgery. The American Shoulder and Elbow Surgeons (ASES) score, the University of California at Los Angeles (UCLA) shoulder joint scoring system, and the Constant–Murley shoulder function score were used to assess the function of the affected shoulder.ResultsThe surgical duration was 90–150 min, with a mean of 127 min. The average blood loss was 90 mL (range, 60–120 mL), and the average total duration of hospital stay was 9.2 days (range, 3 to 14 days). At 9 months after surgery, the CT results showed that all fractures healed, and all patients returned to their previous levels of activity and regained an excellent range of motion. The visual analog scale (VAS) score was 7.55 ± 1.32 before surgery, and the VAS score significantly decreased to 1.24 ± 0.72 at 12 months after the operation (p < 0.05). The Constant, ASES, and UCLA shoulder function scores were 44.38 ± 2.16, 43.47 ± 12.76, and 21.80 ± 1.16 before the surgery, respectively, which improved to 93.52 ± 2.82, 91.34 ± 8.28, and 33.24 ± 1.64, respectively, in the following 12 months. One patient experienced fat liquefaction. However, no cases of deep venous thrombosis, iatrogenic neurovascular compromise, wound infection, or neurovascular injury were identified.ConclusionThe double‐row and double‐pulley technique for treating Ideberg type Ia under shoulder arthroscopy has minor surgical trauma, reliable fracture reduction and fixation, less postoperative pain, and fewer postoperative complications and significantly improves the patient's shoulder joint function.

Factors associated with conversion to open reduction of type 3 supracondylar humerus fractures in children

BackgroundThe US News and World report utilizes the number of supracondylar humerus fractures treated in an open procedure, excluding open fractures and vascular exploration, as a metric in assessing Pediatric Orthopedic trauma care. The purpose of this study was to identify factors that increase the likelihood of a patient needing open reduction for Gartland Type 3 SCH fractures. MethodsAll pediatric patients who underwent surgical management of closed, Type 3 SCH fractures at our Pediatric Level 1 Trauma Center between 2011 and 2017 were considered for inclusion. Patient age greater than 16 years, patients with closed physes and open fractures were excluded. Electronic medical records and radiographic imaging were reviewed. Student's t- and chi-squared tests were used, and logistic regression was performed comparing closed v open reduction. Results362 subjects were included in this study. 318/362 (87.8%) were treated with closed reduction. 44/362 (12.2%) required open reduction. There were no statistically significant differences in age, gender, BMI, concomitant ipsilateral extremity fractures, Type 4 unstable fracture or patients that underwent hospital transfer. The mechanisms of injury with the greatest percentage requiring open reduction were fall from furniture and trampoline. Of those patients that underwent open reduction, 65.9% had posterolateral displacement of the fracture. Those with displacement >4 mm had 3.14 higher odds of requiring an open reduction (p = 0.002). The anterior spike fracture pattern had the highest rate of failed closed reduction of 66.7%. Of those patients that had an open reduction, 13/44 (29.5%) had a neuropraxia and 5/44 (11.4%) had vascular compromise. Those with neuropraxia had 3.26 higher odds of requiring an open reduction (p = 0.005). Time to operating room was significantly shorter in patients that underwent open reduction (p < 0.001). ConclusionOur rate of open reduction for Type 3 SCH fractures, 12.2%, is consistent with previously described rates. Posterolateral displacement of fractures, displacement >4 mm, fractures with an anterior spike and fractures associated with neurovascular compromise are more likely to undergo open reduction. Transfer status, BMI and patient age were not associated with open reduction. Open reduction was associated with shorter time to the operating room, likely representing the urgent care of significantly displaced fractures associated with neurovascular compromise. Level of evidenceLevel III.

Knee dislocations and multi-ligament knee injuries: A review

Acute knee dislocations are a relatively rare type of injury that can lead to serious neurovascular compromise and ligament instability. These injuries can be potentially limb threatening if not properly identified and managed. The following review discusses the relevant anatomy of the knee joint and different classification systems of dislocations in order to highlight the complications that could occur. Timely evaluation and management, including reduction, is paramount to ensure stability and determine the need for additional imaging or urgent consultation. Knee dislocations are also associated with the unique presentation of a multi-ligament injury. This text provides an overview of multi-ligament knee injuries and the various surgical modalities currently being used. Finally, considerations are given on the role of the osteopathic approach in restoring function of the knee in the context of a dislocation.

Parona space collection: A serious complication of hand infections

A 61-year-old man presented with erythematous and painful swelling of his left hand, wrist, and distal forearm for five days. He denied any penetrating injury and had no known inflammatory arthropathy or thrombophilia. There was no fluctuance or neurovascular compromise. Investigations revealed elevated leucocyte counts (14.11 × 109/L) and C-reactive protein (228 mg/L).

Ankle Injuries.

Ankle Injuries.

Distal Radius Open Reduction and Internal Fixation

Fractures of the distal radius are common injuries, with an annual incidence of 27 per 10,000 per year. As many as two-thirds of these fractures are displaced, necessitating reduction to restore wrist function and avoid neurovascular compromise. When adequate reduction cannot be achieved by closed reduction alone, closed reduction and percutaneous pinning versus open reduction and internal fixation is considered. Here we present the case of a middle aged female presenting with a dorsally displaced and angulated fracture of the distal radius after a fall on the outstretched hand. The fracture was treated by open reduction and internal fixation with a volar locking plate. We outline the natural history, preoperative care, intraoperative technique, and postoperative considerations of distal radial fractures.