Elsevier

World Neurosurgery

Volume 105, September 2017, Pages 623-631
World Neurosurgery

Original Article
Results of Operative Treatment of Brachial Plexus Injury Resulting from Shoulder Dislocation: A Study with A Long-Term Follow-Up

https://doi.org/10.1016/j.wneu.2017.06.059Get rights and content

Background

Injury to the infraclavicular brachial plexus is an uncommon but serious complication of shoulder dislocation. This work aims to determine the effectiveness of operative treatment in patients with this type of injury.

Methods

Thirty-three patients (26 men and 7 women; mean age, 45 years and 3 months) treated operatively for brachial plexus injury resulting from shoulder dislocation between the years 2000 and 2013 were included in this retrospective case series. Motor function of affected limbs was assessed pre- and postoperatively with the use of the British Medical Research Council (BMRC) scale. Sensory function in the areas innervated by ulnar and median nerves was evaluated with the BMRC scale modified by Omer and Dellon and in the remaining areas with the Highet classification. Follow-up lasted 2–10 years (mean, 5.1 years).

Results

Good postoperative recovery of nerve function was observed in 100% of musculocutaneous, 93.3% of radial, 66.7% of median, 64% of axillary, and 50% of ulnar nerve injuries. No recovery was observed in 5.6% of median, 6.7% of radial, 10% of ulnar, and 20% of axillary nerve injuries. Injury to a single nerve was associated with worse treatment outcome than multiple nerve injury.

Conclusions

Obtaining improvement in peripheral nerve function after injury resulting from shoulder dislocation may require operative intervention. The type of surgical procedure depends on intraoperative findings: sural nerve grafting in cases of neural elements' disruption, internal neurolysis when intraneural fibrosis is observed, and external neurolysis in the remaining cases. The outcomes of surgical treatment are good, and the risk of intra- and postoperative complications is low.

Introduction

Traumatic shoulder dislocation is one of the most common major joint dislocations.1, 2, 3 Accompanying injuries include glenoid labrum avulsion (Bankart lesion), glenoid rim fracture (bony Bankart), rotator cuff tear (RCT), greater tuberosity fracture of the humerus (GTF), osteochondral fracture of the humeral head (Hill-Sachs lesion), and rarer but more serious vascular and neural complications.1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Damage to the peripheral nervous system usually involves infraclavicular brachial plexus at the level of cords and nerves.1, 10, 13, 14, 15 This complication is observed in 5%–65% of cases.3, 7, 8, 16, 17, 18, 19 The axillary nerve is most commonly affected.1, 3, 10, 16, 18, 20 In contrast with a high number of publications about the results of surgical treatment in traction injuries of the supraclavicular part of the brachial plexus, literature dedicated to nerve injury resulting from shoulder dislocation is scarce and consists mainly of case reports and studies on small patient groups. This prompted us to publish our results. The purpose of this work is to determine whether operative treatment is indicated and effective in improving the function of the limb in patients with persistent and disabling brachial plexus injury after shoulder dislocation.

Section snippets

Materials and Methods

This study was designed as a retrospective case series. Based on a patient database search and clinical reports review, the patients operated on for persistent neurologic deficit resulting from shoulder dislocation, with a minimum of 2 years of postoperative follow-up, were included in the study. The details of patients' symptoms, mechanisms of trauma, types of accompanying injuries, pre- and postoperative examinations results, and details of operative procedures were extracted and analyzed.

Preoperative Examination Results

All patients in this study sustained anterior shoulder dislocation, and in 1 case the dislocation was open. The right side was affected in 22 patients (67%) and the left side in 11 patients (33%). Dislocations were caused by fall from a height (windowsill, ladder, stairs, or bicycle) in 12 patients (36.4%), fall from patient's own height in 10 patients (30.3%), motor vehicle accident in 7 patients (21.2%), and other causes in 4 patients (12.1%). Dislocations were isolated in 19 patients (57.6%)

Discussion

Injury to the nerves of the upper extremity after shoulder dislocation results from traction mechanism with compression component exerted by humeral head on individual nerves. Additional compression is caused by hematoma moving down the upper limb. Secondary compression results from hyperplasia of fibrous tissue after resolution of hematoma.13, 20, 24, 25 These mechanisms cause injury of varying severity, reflected by Millesi's fibrosis classification26 and Sunderland's classification.27

The

Conclusions

Obtaining improvement of peripheral nerve function after injury to infraclavicular brachial plexus resulting from shoulder dislocation, without significant recovery of limb function spontaneously or after rehabilitation within 3 months from dislocation, requires operative intervention. Because neurologic injuries resulting from this mechanism are usually neuropraxic or axonotmetic, neurolysis is sufficient and can produce satisfactory results in most cases. Injury to a single nerve carries

Acknowledgment

The authors would like to thank Bartosz Witkowski for technical support during the preparation of this manuscript.

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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