Shin, Alexander Y.

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.

Case: A right-hand dominant, 38-year-old man presented to clinic with atraumatic left wrist pain of 1 year duration in the setting of bilateral bipartite lunate. Both wrists ultimately became symptomatic and were treated with proximal row carpectomy. The patient had durable pain relief in both wrists after proximal row carpectomy. Conclusion: Bipartite lunate is a rare developmental anomaly that is usually asymptomatic. Operative intervention directed at treating involved osteoarthritic joints is warranted in the rare symptomatic patient. Clinicians should be aware of the pathology given its high rate of misdiagnosis.

Case: We present 3 cases of brachial plexus injuries (BPI) secondary to compressive hematomas during extracorporeal membrane oxygenation (ECMO), with follow-up ranging from 18 months to 12 years. Patients exhibited profound upper extremity deficits and underwent variable interventions, including surgical decompression. All demonstrated meaningful neurologic recovery. Conclusion: BPI is a rare but serious complication of ECMO. These cases highlight the importance of early recognition and hematoma evacuation, emphasizing the need for clinical vigilance to optimize neurologic outcomes following hematoma-induced nerve injury.

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.

This study presents the first in vivo intraoperative measurement of the kinetic properties of spastic human muscle. Despite slower relaxation in spastic biceps, the force-frequency relationship was similar to that of the healthy gracilis muscle. This suggests that spasticity does not substantially alter frequency-dependent force summation, possibly due to similar fiber-type compositions and limited changes in calcium handling or myosin isoforms in human spastic muscle.

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.