Pulos, Nicholas

Abstract Background Ultrasound (US)‐guided hydrodissection is a minimally invasive treatment for cubital tunnel syndrome (CuTS) with promising early results. However, data on patient‐perceived outcomes, durability of relief, and impact on surgical need remain limited. Objective To assess the effectiveness of US‐guided cubital tunnel hydrodissection in improving CuTS symptoms via patient‐centered outcomes. Design Retrospective chart review with cross‐sectional telephone follow‐up. Setting Quaternary medical center multidisciplinary outpatient hand clinic. Participants Seventeen patients (19 arms) with clinical CuTS who received US‐guided hydrodissection from one physician. Interventions Patients were contacted by telephone for cross‐sectional outcome assessment. Main Outcome Measures Patient‐reported improvements in weakness, paresthesias, and/or pain, percent pain relief, symptom improvement duration, adverse events, and Patient Global Impression of Change (PGIC) scores. Results At mean 7 ± 5 month follow‐up, improvement in weakness, paresthesia, and pain was reported in 12 (63%) extremities (95% confidence interval [CI] 41%–85%; p < .001) . Pain relief ≥50% occurred in 12 (63%) and ≥75% in 8 (42%) extremities, with mean duration 4 months. PGIC scores showed 14 (74%; 95% CI 54%–94%; p < .001) at least “minimally improved” and 8 (42%) (95% CI 20%–64%; p < .001) “much improved.” No adverse events occurred. Two patients without improvement underwent surgical decompression with anterior transposition at 1 and 3 months after hydrodissection, achieving 90%–100% pain relief and “much or very much improved” PGIC scores. Of 19 extremities, 7 (37%) were McGowan Grade I and 12 (63%) Grade II; none were Grade III. Grade II extremities showed significantly greater overall symptom relief ( p = .004) and pain relief ≥50% ( p = .004). PGIC scores did not differ significantly between grades (both p > .062). Conclusion US‐guided cubital tunnel hydrodissection was associated with meaningful symptom improvement and no adverse events. Limitations include small sample size, no control group, single operator, and potentially time‐limited relief. The procedure appears safe and a potential nonoperative treatment option.

Patients with traumatic brachial plexus injuries (TBPI) undergo clinical examination and electromyography (EMG) to characterize injury severity and localization. However, precise localization with EMG alone can be difficult when multiple injury sites are possible. Brachial plexus ultrasound (BPUS) allows direct visualization of the brachial plexus, a needed adjunct to EMG to reveal multiple sites of injury in TBPI. We summarize three cases of EMG-confirmed upper trunk TBPI which were clarified using BPUS to additionally involve electrically hidden injuries to the extraforaminal C5 and C6 nerve roots. BPUS demonstrated extensive scarring and focal enlargement of the upper trunk in each patient (all cross-sectional area [CSA] ≥24 mm 2 ). However, all patients also had C5 and C6 extraforaminal nerve root enlargement (all CSA ≥9 mm 2 and 12 mm 2 , respectively), revealing further neural involvement proximal to the upper trunk into the EMG “gray zone”– postganglionic, extraforaminal cervical nerve root injury which is clinically and electrodiagnostically indistinguishable from the plexus but anatomically and radiographically distinguishable on BPUS. Some EMG-identified upper trunk TBPI may have more proximal involvement of the contributing extraforaminal C5-6 nerve roots, an area electrically indistinguishable from an upper trunk TBPI without the assistance of advanced imaging.

ABSTRACT Scapular winging (SW) describes abnormal scapular mechanics from weak stabilizing muscles or altered neural innervation. While electromyography (EMG) helps differentiate between myo‐ or neuropathic SW etiologies and determine the extent of muscle involvement, pediatric EMG may be limited due to the high risk of surrounding structures, small body habitus, and pain tolerance. Herein is a case of pediatric SW following anterior neck lymphadenopathy resection in which EMG was limited. Neuromuscular ultrasound (NMUS) showed asymmetric trapezius thinning and hyperechogenicity, revealing more expansive involvement than was previously known. NMUS is a painless, validated tool to augment the diagnostic capability of EMG and clarify the extent of neuromuscular involvement in SW from both a prognostic and rehabilitation point of view.

Background: Distal radius fractures involving the physis are among the most common upper extremity injuries in children and adolescents. Unlike transitional fractures of the distal tibia, known as Tillaux and triplane fractures, transitional fractures of the distal radius have not been well characterized. This study aims to evaluate Salter-Harris III and IV fractures of the distal radius in the pediatric transitional age population to determine if a characteristic fracture pattern exists analogous to the distal tibia. We hypothesized that pediatric transitional fractures of the distal radius would follow a pattern that would ultimately dictate treatment and predict outcomes. Methods: A retrospective chart review of pediatric patients with transitional fractures of the distal radius at a single institution was performed. Salter-Harris III and IV fractures of the distal radius with CT imaging were included. Two independent reviewers determined the metaphyseal fracture plane and the major intra-articular epiphyseal fracture fragments. Descriptive statistical analysis was performed. Results: Thirty patients who met inclusion criteria made the study cohort. There were 5 Salter-Harris III fractures and 25 Salter-Harris IV fractures. Mean age at the time of injury was 15±1.5 years. The metaphyseal fracture demonstrated a coronal fracture plane in all cases, and 20% had a sagittal plane component. The major epiphyseal fracture fragments were identified as dorsal ulnar corner in 70%, radial column in 43%, volar rim in 30%, and dorsal wall in 17%. Patients were treated with open reduction and internal fixation (N=12, 40%), closed reduction and percutaneous pinning (N=4, 13%), or cast immobilization (N=14, 47%). Most patients (N=24, 80%) did not demonstrate a growth disturbance after treatment. Angular deformity, however, was significantly higher in patients with a primary dorsal ulnar corner epiphyseal fragment (N=4, 19% vs. N=0%, P =0.03). Conclusion: Transitional fractures of the distal radius occurred on average at age 15. The injuries demonstrated a consistent pattern, with a coronal fracture plane in the metaphysis and a dorsal ulnar corner fragment in most epiphyses. The dorsal physis may be the strongest portion of the distal radius at the time of injury, though mechanism of injury may impact patterns as well. Level of Evidence: Level III.

OBJECTIVE The role of amputation and myoelectric prosthetic fitting for hand function in traumatic pan–brachial plexus injury (pBPI) continues to evolve. This study evaluated the function and activity performance of patients with traumatic pBPI who underwent amputation and prosthetic fitting with a myoelectric prosthesis (MEP) for hand function. METHODS A retrospective analysis of adult patients who underwent elective amputation after sustaining a pBPI followed by MEP for hand function was performed. Demographics, mechanisms of injury, amputation details, and outcomes were collected from medical records. The Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure was used to evaluate the impact of impairment, the visual analog scale (VAS) to assess pain, and the Activities Measure for Upper Limb Amputees (AM-ULA) to determine functional activity performance pre- and post-MEP usage. Follow-up time, prosthesis usage, satisfaction, and site of electrical signal used were recorded. Paired t-tests were used to compare outcomes. RESULTS Twenty-one adult patients with pBPI (90% male, mean age 32 years at the time of BPI) underwent amputations and were fitted with MEPs for hand function controlled by nonintuitive signals. Fifteen patients underwent a trans-radial amputation and 6 underwent a trans-humeral amputation. While all patients sought improved terminal grasp function, 3 patients subsequently declined prosthetic fitting after amputation. Of the 18 patients who underwent myoelectric prosthetic hand fittings, linear transducers activated by the contralateral shoulder protraction were used in 66% of patients, and traditional electrode signals from ipsilateral nonintuitive muscle were used in 33% to control MEP grasp function. Disability (DASH) and pain (VAS) scores significantly improved after amputation (p = 0.04 and p < 0.01, respectively). AM-ULA scores showed a significant improvement in activity performance after application of the MEP, with an average increase of 23 points from 0 points on a 40-point scale before amputation and prosthetic fitting (p < 0.0001). Daily users of the MEP averaged 6 hours per day and reported the prosthesis was useful during daily activities with great satisfaction at an average of 22 months of follow-up. CONCLUSIONS Amputation followed by MEP fitting in adult traumatic pBPI significantly improved function, reduced pain, and had a high prosthetic usage. The AM-ULA, a tool for quantitatively evaluating activity performance, was applied to measure the bimanual functional activity performance of patients before and after using MEPs, which revealed a significant improvement. Patients reported using their prosthetics daily with a high satisfaction rate with functional terminal grasp and release.

Background: Flexor pollicis longus (FPL) palsy following both-bone forearm fracture (BBFF) is a rare complication. Methods: A retrospective review of acute BBFF treated with open reduction internal fixation by a single surgeon from 2005 to 2023 was performed. Injury and surgical characteristics of patients with documented FPL palsy were reviewed. In addition, 10 cadaveric dissections were performed to evaluate the anatomy of the anterior interosseous nerve (AIN) and its branches. The distance of these branches from palpable elbow landmarks and variability in branching pattern were evaluated. Results: Twenty-nine patients underwent surgery for acute BBFF. Of these, 5 (17%) had evidence of an FPL palsy either at the time of injury presentation (n = 2) or immediately following surgery (n = 3). All patients with FPL palsy sustained fractures in the middle one-third of the radius. All palsies resolved after an average of 33 days of observation. In cadaveric dissections, the average distance from the lateral epicondyle to the AIN takeoff and branch to the FPL was 5.5 and 7.6 cm, respectively. The AIN takeoff and branch to the FPL were never less than 4 and 7 cm from the lateral epicondyle, respectively. Conclusion: Flexor pollicis longus palsy following BBFF can occur at the time of injury or following surgery. All FPL palsies involved midshaft radial fractures and were likely neurapraxia. The etiology of FPL palsy remains unclear, but cadaveric dissection suggests the FPL motor branch may be at risk from mid-to-proximal radius fracture fragments or excessive traction during surgery.

ABSTRACT Iatrogenic spinal accessory nerve (SAN) injuries can occur as complications of posterior triangle of the neck surgery, resulting in lateral scapular winging and a shoulder droop. Rarely has this complication been described after a cosmetic rhytidectomy (face‐lift procedure). Here, we present two cases of iatrogenic SAN injuries that occurred after cosmetic rhytidectomies. The use of electrodiagnostic and ultrasound examinations provides invaluable information to assess peripheral nerve injuries. Electrodiagnostic testing can confirm the presence and severity of the injury, while ultrasound can provide additional anatomical information and direct visualization to confirm the continuity of the nerve and assess muscle denervation changes.

Background: Secondary shoulder deformities are the most frequent sequelae of upper trunk-type brachial plexus birth injury (BPBI). Coracoid process dysplasia was recently described as being associated with glenoid retroversion and was recognized to block successful humeral head relocation. There are little to no reports on coracoid process deformity causing anterior shoulder pain. Our hypothesis is that coracoid process impingement causes anterior shoulder pain in BPBI, which is relieved by coracoid excision. This study presents the short-term results of this new technique in BPBI patients. Methods: A retrospective review identified BPBI patients who underwent coracoid excision from 2000 to 2022. Indications for this procedure include BPBI patients with anterior shoulder pain limiting the range of motion, localized tenderness over a prominent coracoid process, a dysplastic coracoid process seen on imaging, and persistent pain despite activity modification, medication, and therapy. Patient characteristics, preoperative shoulder pain score, range of motion, degree of glenohumeral subluxation, patient-reported outcomes measurement information system (PROMIS) scores for pain interference, and physical and upper extremity function were collected from chart review. Postoperative pain scores, range of motion, and PROMIS scores were collected at an average of 1 year after excision. Results: Five upper trunk BPBI patients, ages 10 to 25 years old, with anterior shoulder pain underwent coracoid excision. All had statistically significant pain relief from 6.5–8.5/10 before to 0–3/10 after the procedure. Forward flexion and external rotation improved by an average of 18 degrees. The pain interference score decreased by 25%. There was a 33% improvement in physical function scores and a 31% increase in upper extremity function scores. No complications or recurrence were observed at 7.5 months to 1 year and 7 months after surgery. Conclusions: Coracoid excision is a simple procedure that can relieve localized shoulder pain caused by coracoid impingement in adolescent/adult BPBI. Continued follow-up of all patients will be undertaken to determine long-term recurrence rates and complications. Level of Evidence: Level IV.