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Introduction In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but there is not much information about long-term functional outcomes. In addition, there is still some concern that respiratory complications might become manifest with aging. The aim of this study was to report the outcome of phrenic nerve transfer after a minimum follow-up of 5 years. Patients and methods Twenty-six patients were reviewed and evaluated clinically. Age at surgery averaged 25.2 years and follow-up averaged 9.15 years. Results Shoulder abduction and external rotation achieved by transfer of phrenic to axillary nerve (or posterior division of upper trunk), combined with spinal accessory to suprascapular nerve transfer, were better than that achieved by transfer of phrenic to suprascapular nerve, combined with grafting the posterior division of upper trunk from C5, 52.3 and 45.5 degrees versus 47.5 and 39.4 degrees, respectively. There was no difference in abduction when the phrenic nerve was transferred directly to the posterior division of upper trunk or to the axillary nerve using nerve graft. Elbow flexion (≥M3 MRC) was achieved in 5 (83.3%) of 6 cases. Elbow extension M4 MRC or greater was achieved in 4 (66.6%) of 6 cases. All patients, including those who exceeded the age of 45 years and those who had concomitant intercostal nerve transfer, continued to have no respiratory symptoms. Conclusions The long-term follow-up confirms the safety and effectiveness and of phrenic nerve transfer for functional restoration of shoulder and elbow functions in brachial plexus avulsion injuries.

Background Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk. Methods We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment. Results Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement. Conclusions In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background In late presentation of brachial plexus trauma, it is unclear whether donor nerves should be devoted to nerve reconstruction or reserved for free functional muscle transfer. The authors systematically reviewed recovery of elbow flexion after nerve reconstruction versus free functional muscle transfer for late, traumatic brachial plexus palsy. Methods A systematic review was performed using the PubMed, Embase, and Cochrane databases to identify all cases of traumatic brachial plexus palsy in patients aged 18 years or older. Patients who underwent late (≥12 months) nerve reconstruction or free functional muscle transfer for elbow flexion were included. Age, time to operation, and level of brachial plexus injury were recorded. British Medical Research Council grade for strength and range of motion were evaluated for elbow flexion. Results Thirty-three studies met criteria, for a total of 103 patients (nerve reconstruction, n = 53; free functional muscle transfer, n = 50). There were no differences across groups regarding surgical age (time from injury) and preoperative elbow flexion. For upper trunk injuries, 53 percent of reconstruction patients versus 100 percent of muscle transfer patients achieved grade M3 or greater strength, and 43 percent of reconstruction patients versus 70 percent of muscle transfer patients achieved grade M4 or greater strength. Of the total brachial plexus injuries, 37 percent of reconstruction patients versus 78 percent of muscle transfer patients achieved grade M3 or greater strength, and 16 percent of reconstruction patients versus 46 percent of muscle transfer patients achieved grades M4 or greater strength. Conclusion In late presentation of traumatic brachial plexus injuries, donor nerves should be reserved for free functional muscle transfer to restore elbow flexion. Clinical question/level of evidence Therapeutic, IV.

Bullock, GS, Schmitt, AC, Chasse, PM, Little, BA, Diehl, LH, and Butler, RJ. The relationship between trunk rotation, upper quarter dynamic stability, and pitch velocity. J Strength Cond Res 32(1): 261-266, 2018-Understanding the relationship between upper quarter mobility, dynamic stability, and pitching velocity may be beneficial in elucidating underlying factors that affect pitching performance. The purpose of this study was to investigate upper trunk rotation mobility and upper quarter dynamic stability and their correlation to pitch velocity in NCAA Division I collegiate pitchers. We hypothesized that collegiate pitchers with greater upper trunk rotation mobility and upper extremity dynamic stability would exhibit higher pitching velocity. Trunk rotation and the Upper Quarter Y-Balance Test (YBT-UQ) were measured using standardized protocols. Collegiate pitchers (N = 30) then proceeded to complete their team prescribed dynamic and throwing warm-up followed by a pitching session from regulation distance at 100% effort. Each pitch was recorded for velocity and pitch type, only fastballs were used in analysis. The relationships between trunk rotation and fastball velocity, and YBT-UQ scores and fastball velocity were assessed using a series of 2-tail Pearson's correlations (p < 0.05). Throwing and nonthrowing sides (69.6 ± 9.5°, 70.7 ± 9.4°) had similar trunk rotation mobility. No statistically significant correlation between upper trunk rotation mobility and pitch velocity was found (throwing arm: r = 0.131; p < 0.491; nonthrowing arm: r = 0.135; p < 0.478). There was also no correlation between the YBT-UQ and fastball velocity. In this study of Division I baseball pitchers, we found no relationship between trunk rotational mobility, upper quarter dynamic stability, and pitching velocity. This suggests that increased upper extremity stability and trunk mobility are not directly related to fastball velocity. Understanding factors that associate to velocity may be helpful in predicting pitching performance.

During a period of 1 month, 3 episodes of probable or actual venous air embolism occurred during hysteroscopic surgery. All patients developed the same symptoms of ventilatory and hemodynamic decompensation, beginning with a reduction in end-tidal carbon dioxide, arterial desaturation, and cyanosis on the upper trunk, and rapidly progressed to hypotension and 2 cardiac arrests. While entrainment of some air is common during hysteroscopy, life-threatening embolism is a rare but serious complication for which an anesthetist needs to be vigilant and prepared. If even a small drop in end-tidal carbon dioxide occurs, venous air embolism should be suspected and the operation should be discontinued.

STUDY DESIGN Prospective observational study. OBJECTIVE To study axial plane deformation of the shoulder in adolescent idiopathic scoliosis (AIS) and try to correlate it with curve type and surgical correction. SUMMARY OF BACKGROUND DATA It is established that AIS is a 3-dimensional deformity. The rib hump is the most common manifestation of axial plane deformations; the least common manifestation seems to be upper trunk and shoulder rotation, which has been hitherto undescribed. METHODS Fourteen consecutive, operated cases of AIS were analyzed prospectively. Preoperative and postoperative x-rays of the spine and clinical photographs were studied. Clinical photographs (top view) were taken with patients in the sitting position, to show shoulder level in relation to the axis of the head and pelvis. Chest computed tomography scans were also studied to determine the direction of apical vertebra and trunk torsion. RESULTS All 14 patients in this series had their right shoulders anteriorly rotated preoperatively (anticlockwise). The direction of rotation seemed unrelated to the curve type and shoulder elevation, although most had rib humps on the right. This shoulder rotation was corrected postoperatively by routine maneuvers done for scoliosis correction. Minor residual rotation was seen in 6 patients who also had minimal persisting rib hump. In 1 case the axial plane rotation worsened, although the shoulder level and trunk symmetry improved significantly. The apical vertebral rotation on computed tomography had little bearing on the direction of shoulder rotation. CONCLUSIONS Axial plane rotation of the shoulder is a hitherto un-described dimension of AIS deformity complex. Much of it corrects spontaneously with correction of the thoracic spinal deformity.

Brachial plexus is complex network of nerves, formed by joining and splitting of ventral rami of spinal nerves C5, C6, C7, C8, and T1 forming trunks, divisions, and cords. The nerves emerging from trunks and cords innervate the upper limb and to some extent pectoral region. Scanty literature describes the variations in the formation of cords and nerves emanating from them. Moreover, the variations of cords of brachial plexus and nerves emanating from them have iatrogenic implications in the upper limb and pectoral region. Hence study has been carried out. Twenty-eight upper limbs and posterior triangles from 14 cadavers fixed in formalin were dissected and rare and new variations of cords were observed. Most common variation consisted of formation of posterior cord by fusion of posterior division of upper and middle trunk and lower trunk continued as medial cord followed by originating of 2 pectoral nerves from anterior divisions of upper and middle trunk. Other variations include anterior division of upper trunk continued as lateral cord and pierced the coracobrachialis, upper and middle trunk fused to form common cord which divided into lateral and posterior cords, upper trunk gave suprascapular nerve and abnormal lateral pectoral nerve and formation of median nerve by 3 roots. These variations were analyzed for diagnostic and clinical significance making the study relevant for surgeons, radiologists in arresting failure patients and anatomists academically in medical education.

Background Intraoperative ultrasound (US) has been used as a guide during surgery to better identify deep neuroanatomical structures. Objective To correlate histologic cross-sections from nerve samples taken at the time of surgery with axial, high-resolution US images at similar locations and validate this important tool for intraoperative guidance in nerve surgery. Methods Three subjects undergoing nerve repair procedures after traumatic nerve injuries were enrolled prospectively. US images captured at the time of surgery were later matched with gross anatomic cross-sections and fascicular anatomy compared across modalities. Results In cases 1 and 3, neuromatous tissue spanned the entire cross-section of the common peroneal and upper trunk of the brachial plexus, respectively. In case 2, only a portion of the sciatic nerve was involved with neuroma. Intraoperative US aided in differentiating normal peripheral nerve from neuroma in all 3 cases and helped minimize the disruption of healthy peripheral nerve tissue. Conclusion Intraoperative US correlates well with anatomic sections removed at the time of surgery. The ability to noninvasively image the peripheral nerve along with compound nerve action potentials can greatly assist in determining the extent of neurolysis, resection, and grafting and is a useful adjunct for intraoperative decision-making. This report serves to highlight the role of US and validate its use in peripheral nerve surgery for trauma.

Few studies have examined the efficacy of trunk orthoses that support the upper trunk and a paretic limb in stroke patients. To improve stability and alignment of the trunk and pelvis in hemiparetic patients, we developed a newly designed trunk orthosis that provides resistive force through spring joints.This study aimed to determine the newly designed trunk orthosis's biomechanical effects during level walking.Before-after trials must be better.Measurements were taken for nine chronic-phase (2 years post-onset) stroke patients using a three-dimensional motion capture system and force plates under three experimental conditions: self-selected gait speed without the newly designed trunk orthosis, with the newly designed trunk orthosis, and after newly designed trunk orthosis removal. We analyzed and compared spatiotemporal and kinetic parameters of the paretic and non-paretic limbs and kinematic parameters of the trunk and bilateral limbs.Several pre-swing gait parameters (e.g. hip joint flexion moment and ankle joint plantar flexion angle) after newly designed trunk orthosis removal were significantly increased compared to those without newly designed trunk orthosis. Step length of the paretic limb tended to increase after newly designed trunk orthosis removal.The newly designed trunk orthosis effectively modified trunk alignment, but larger improvements in kinetic and kinematic parameters were observed in the bilateral limbs after newly designed trunk orthosis removal than with the newly designed trunk orthosis.Stroke patients improved only trunk malalignment while wearing the newly designed trunk orthosis. Gait after newly designed trunk orthosis removal was better than with the newly designed trunk orthosis. Positive changes after removal were mostly observed in pre-swing of the hemiparetic limb. The newly designed trunk orthosis might be effective for gait training in stroke patients.

Background: Brachial plexus exploration is performed in infants when addressing birth palsies and in children and adults following trauma. The upper trunk is most often injured. Traditional drawings of the brachial plexus depict the suprascapular nerve as a branch of the midportion of the upper trunk, with the more lateral branch of the upper trunk as the anterior division. We have not found this orientation to be accurate in clinical practice. The purpose of this study was to determine the branching patterns of the upper trunk and to delineate nerve orientations at the level of the divisions. Methods: Bilateral brachial plexus dissections were performed on eight adult cadavers. The length of the upper trunk and distance of the takeoff of the suprascapular nerve from the anterior and posterior divisions was measured. The native positions of the divisions and of the suprascapular nerve from lateral to medial were recorded across all trunks. Results: In six (38%) of the sixteen specimens, a trifurcation was found at the level of the upper trunk. The suprascapular nerve was the most lateral structure at the clavicular level in all specimens, followed by the posterior division and then the anterior division. The mean distance of the takeoff of the suprascapular nerve was 4 mm proximal to the branch point of the divisions; however, in two specimens, the nerve was found to take off from the posterior division proper. Conclusions: These findings differ from the standard illustrations and descriptions of the brachial plexus. A thorough understanding of the course of the upper trunk and its branches, such as the suprascapular nerve, is vital to performing nerve transfer surgery or neuroma excision and grafting.

In lower brachial plexus injury, finger flexion after brachialis motor branch transfer is relatively weak. We sought to screen potential branches of the median nerve from the upper trunk for strengthening finger flexion in addition to the brachialis motor branch. However, the spinal origin of the muscular branches of the median nerve based on electrophysiological study was unclear.To determine the spinal origin of the muscular branches of the median nerve.An intraoperative electrophysiological study was carried out in 18 patients who underwent contralateral C7 nerve transfer. After exposure of the brachial plexus nerve roots on the healthy side, the amplitude of the compound muscle action potential of each median nerve-innervated muscle was recorded while the different nerve roots were stimulated.The pronator teres received fibers from C5, C6, and C7. It had more contribution from C5 and C6 than from C7 (P.05). The flexor carpi radialis was innervated mainly by C6 and C7. The nerve branches of the palmaris longus and flexor digitorum superficialis stemmed primarily from C7 and the lower trunk, and no significant difference was found between them (P.05). The flexor digitorum profundus, flexor pollicis longus, pronator quadratus, and abductor pollicis brevis were innervated predominantly by the lower trunk (P.05).This electrophysiological study indicates that the pronator teres branch might be the most feasible alternative donor nerve to supplement the brachialis motor branch and strengthen finger flexion after lower brachial plexus injury.

Introduction: Orthopaedic surgeons are in a position to assist in identifying intimate partner violence (IPV) patients. It was the purpose of this study to analyze the demographics and fracture patterns of IPV patients in the United States. Methods: Data from the National Electronic Injury Surveillance System All Injury Program from 2005 through 2013 were used. Injuries due to domestic violence were identified, and statistical analyses accounted for the weighted, stratified nature of the data. Results: There were 1.65 million emergency department visits over nine years for IPV. The median age was 29.8 years, 83.3% were women, and 55.3% occurred at home. The major diagnoses were contusion/abrasions (43.4%), lacerations (16.9%), strain/sprains (15.6%), internal organ injuries (14.4%), and fractures (9.7%). The most common fracture involved the face (48.3%), followed by the finger (9.9%), upper trunk (9.8%), and hand (6.4%). The highest proportion of lower extremity fractures occurred in men, and upper extremity fractures increased with increasing age. The odds of fracture in an IPV patient were greatest in those sustaining an upper extremity injury (odds ratio [OR] = 6.62), lower extremity injury (OR = 6.51), upper trunk injury (4.28), and head/neck injury (OR = 3.08) compared with a lower trunk injury (referent), and women (OR = 1.80) compared with men (referent). Older patients sustaining IPV had higher odds of a fracture (the few patients 10-14 and >65 years old were excluded from this analysis). Conclusions: As this study encompasses the entire United States, these results are germane to all US orthopaedic surgeons. Knowing typical fracture patterns/locations is helpful in identifying IPV patients, although the victim may not fully divulge the history and details of the event. Identification is important for the physical and mental health of the victim, and abuse often continues if intervention does not occur. The odds of a fracture in an IPV patient are greatest when the injury involved the extremities and increased with increasing age of the patient.

Multiple symmetric lipomatosis (MSL) is a rare disease of unknown etiology, characterized by the presence of multiple, symmetrical, noncapsulated lipomas, mostly in the neck and upper trunk. To date, there is no effective medical treatment of MSL. Surgical treatment is based on 2 options, namely, lipectomy and/or liposuction. In this retrospective study, we compare traditional lipectomy with ultrasound-assisted liposuction. Our initial experience demonstrates that the ultrasound-assisted liposuction procedure can be applied to patients with MSL, allowing simultaneous treatment of multiple areas in a single session and the removal of a substantial amount of fat, thus improving aesthetic results. If lipomas are circumscribed and isolated, traditional lipectomy is probably to be preferred.

BackgroundHIV infection has been associated with dyslipidemia, insulin resistance, and changes in body composition, including loss of subcutaneous fat and skeletal muscle, with relative sparing of upper trunk and visceral fat. Because of its resemblance to Cushing's syndrome, caused by glucocorticoid excess, we hypothesized that variations in the glucocorticoid receptor (GR) gene, associated with changes in sensitivity to glucocorticoids, may be associated with such abnormalities in HIV-infected patients.DesignThis was a cross-sectional genetic association study.Materials and methodsGR polymorphisms were determined in HIV-infected participants from the study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM). We created haplotypes in 754 participants and assessed the associations with fasting metabolic parameters and body composition by MRI.ResultsAfter stratification for ethnicity, we found no consistent pattern of associations between the described GR haplotypes and body composition or metabolic parameters in HIV-infected patients. However, we found a new haplotype comprising the Tth111I polymorphism in African-Americans. Heterozygous carriers of this haplotype (n=24) had significantly higher levels of high-density lipoprotein cholesterol compared with age-matched and sex-matched noncarriers (n=96) (median 55 vs. 44 mg/dl, P=0.026) and a tendency toward lower glucose (-5 mg/dl) and triglyceride (-21 mg/dl) levels and lower visceral adipose tissue mass (-0.22 l). CD4 count as well as skeletal muscle mass were also lower in carriers of this haplotype (-154 cells/l and -1.6 l, respectively).ConclusionAlthough our cohort included only a small number of carriers of the new Tth111I haplotype, these results are suggestive that this GR haplotype may be associated with a healthier metabolic profile in African-Americans with HIV infection.

Background The goal of this study was to clarify the anatomical origins of the suprascapular and lateral pectoral nerves from the brachial plexus as an aid to surgical exploration. Methods Both nerves were studied in 100 adult cadaver specimens. Topographic points of origin were described as distance from the bifurcation of the upper trunk or distance from the formation point of the lateral cord, using visual anatomical models. Results The suprascapular nerve originated from (1) the posterior division of the upper trunk distal to the bifurcation of the upper trunk (61 specimens); (2) the point of upper trunk bifurcation (29 cases); (3) the upper trunk proximal to the bifurcation point (six cases); and (4) directly from the C5 root (four cases). The lateral pectoral nerve originated from (1) the anterior division of the upper trunk proximal to the point of lateral cord formation (88 cases); (2) the point of lateral cord formation (five cases); (3) the lateral cord distal to the lateral cord formation point (four cases); and (4) the anterior division of the middle trunk (three cases). Eighty-two cases had origins from both the anterior upper trunk and the anterior middle trunk. Conclusions The suprascapular nerve most frequently originates from the posterior division of the upper trunk, and the lateral pectoral nerve from the anterior divisions of the upper and middle trunks. This information can be used to guide the surgeon in identifying the key landmarks of the supraclavicular brachial plexus at surgical exploration.

Current surgical management of obstetrical brachial plexus injury is primary reconstruction with sural nerve grafts. Recently, the nerve-to-nerve transfer technique has been used to treat brachial plexus injury in adults, affording the benefit of distal coaptations that minimize regenerative distance. The purpose of this study was to test the hypothesis that nerve transfers are effective in reconstructing isolated upper trunk obstetrical brachial plexus injuries.Ten patients aged 10 to 18 months were treated with three nerve transfers: spinal accessory nerve to the suprascapular nerve for shoulder abduction and external rotation; a radial to axillary nerve for shoulder abduction; and ulnar or median nerve transfer to the musculocutaneous nerve for elbow flexion. Patients were assessed preoperatively and postoperatively using the Active Movement Scale. All patients were followed regularly for up to 2 years.Improvement in elbow and shoulder function was observed between 6 and 24 months. By 6 months, all patients passed the cookie test. At 24 months, shoulder abduction improved from 3.7 ± 0.6 to 5.0 ± 0.5, shoulder external rotation from 1.8 ± 0.4 to 4.3 ± 0.6, shoulder flexion from 3.7 ± 0.5 to 5.4 ± 0.5, elbow flexion from 3.7 ± 0.6 to 6.3 ± 0.2, and forearm supination from 2.1 ± 0.4 to 5.9 ± 0.2. There was no clinically appreciable donor-site morbidity.Nerve transfers reduced operative times compared with traditional nerve grafting procedures. Those patients showed significant gains in Active Movement Scale score by 24 months postoperatively, comparable to results achieved by nerve grafting. These findings support nerve transfers as a potential alternative treatment option for upper trunk obstetrical brachial plexus injuries.Therapeutic, IV.

To establish a model for nerve grafts and determine the anatomic characteristics of the brachial plexus in rhesus monkeys. Ten specimens of the brachial plexus were obtained from five rhesus monkey cadavers. Anatomic dissection of the brachial plexus was systemically performed. The length of each root, trunk, and each division was measured using a Vernier caliper proximodistally. The anatomic distributions of the suprascapular, axillary, and musculocutaneous nerve were documented. The brachial plexus of rhesus monkeys included the spinal nerves or roots of C5, C6, C7, C8, and T1 (80%, 8/10), with a small contribution from the C4 root (20%, 2/10) occasionally. The upper trunk was not measurable because of their irregular structures. The lower trunk had a mean length of 1.62 (range, 0.96-2.1 mm) and a mean diameter of 2.29 (range, 1.9-2.94 mm). For the upper trunk, the C5 and C6 roots either divided into two very short divisions or sent out very long divisions before they joined together. For the middle trunk, the C7 root had a straight course after leaving the foramen and blended imperceptibly into the middle trunk before dividing into the anterior and posterior divisions. The lower trunk was noted in almost all the specimens (80%, 8/10), which was formed by C8 and T1. The brachial plexus in rhesus monkeys varies from that of humans, and defects can be made at the level of C5 and C6 roots and the C7 root should also be cut off and ligated.

Trunk endurance tests are generally performed in sagittal or frontal plane. However, trunk field tests that measure the endurance of the rotator muscles are lacking. In view of this situation, we developed a flexion-rotation trunk test (FRT test) to assess the oblique abdominal muscle endurance. This new field test consists mainly in performing the maximum number of upper trunk flexion and rotation movements (reps) possible in 90 seconds. The objectives of this study were to analyze the FRT test reliability and to examine the effect of both the repetition and sex on test results. Fifty-one recreationally trained men (n = 35) and women (n = 16) completed 4 trials of the FRT test (T1, T2, T3, and T4), separated by 7 days each. The scores increased significantly between T1 and T3 (p < 0.001), showing a clear learning effect, but the increase between T3 and T4 was only 4.25% (p = 0.108). The intraclass correlation coefficients (ICCs) between trials were ≥0.83 and the standard errors of measurement (SEMs) ≤7.54 reps. The ICCs between trials increased, and SEMs decreased with test repetition, reaching an ICC of 0.94 and an SEM of 6.46 reps between T3 and T4. The comparison between sexes showed a higher abdominal endurance in men when compared with that in women (p = 0.003), and also a higher learning effect in men, especially at the beginning of the study. These findings suggest that, the FRT test is a reliable field protocol that differentiates between the abdominal endurance of men and women. However, it is necessary to perform an extensive familiarization period before testing (at least 3 trials of practice) to make learning effect negligible.

Background Ipsilateral whole C7 root transfer has been reported in treating C5-C6 avulsion. To minimize donor deficits, partial ipsilateral C7 (PIC7) transfer was developed. Objective To investigate the long-term results of PIC7 transfer to the upper trunk in treating C5-C6 avulsion of the brachial plexus. Methods We prospectively studied 8 young adults with C5-C6 avulsion. Five patients (group A) who also had spinal accessory nerve (SAN) injury underwent PIC7 transfer to the upper trunk. The other 3 patients (group B) without SAN injury underwent a combination of PIC7 to the upper trunk and the SAN to the suprascapular nerve (SSN). Postsurgical evaluations including donor deficits, functional recovery, and co-contraction of the muscles were performed 1 week later and then at intervals of 3 months. Results After a mean period of 39.2 months, all subjects were found to have gained elbow flexion of 110 to 150° with muscle strength of M4-5. The patients in group B achieved external rotation of 60 to 70° at M3-4, and 2 achieved shoulder abductions approaching 180° at M4. The patients in group A showed no active external rotation and shoulder abduction of 25 to 50° at M2-3. The temporary deficits caused by PIC7 transfer disappeared in all subjects within the first 3 months. Co-contraction of the latissimus dorsi against the deltoid was recorded in group A but not in group B. Conclusion PIC7 transfer, when combined with SAN transfer to SSN as a novel approach, is a safe, easy, and efficacious surgical procedure for patients with simple C5-C6 avulsion.

Genetic studies may help explain abnormalities of fat distribution in HIV-infected patients treated with antiretroviral therapy (ARV).Subcutaneous adipose tissue (SAT) volume measured by MRI in the leg, the lower trunk, the upper trunk, and the arm was examined in 192 HIV-infected White men, ARV-treated from the Fat Redistribution and Metabolic Change in HIV infection study. Single-nucleotide polymorphisms were assayed using the Illumina Human CNV370-quad beadchip. Multivariate and univariate genome-wide association analyses of the four SAT depots were implemented in PLINK software adjusted for age and ARV duration. Functional annotation analysis using Ingenuity Systems Pathway Analysis tool was carried out for markers with P lower than 10(-3) near known genes identified by multivariate analysis.Loci (rs10504906, rs13267998, rs921231) in or near the anion exchanger solute carrier family 26, member 7 isoform a (SLC26A7) were strongly associated with the upper trunk and the arm SAT (9.8×10(-7) ≤P7.8×10(-6)). Loci (rs193139, rs7523050, rs1761621) in and near a gene-rich region including G-protein-signaling modulator 2 (GPSM2) and syntaxin-binding protein 3 (STXBP3) were significantly associated with the lower body SAT depots (9.9×10(-7) ≤P9.5×10(-6)). GPSM2 is associated with cell division and cancer whereas STXBP3 is associated with glucose metabolism in adipoctyes. Ingenuity Systems Pathway Analysis identified atherosclerosis, mitochondrial function, and T-cell-mediated apoptosis as processes related to SAT volume in HIV-infected individuals (P5×10(-3)).Our results are limited by the small sample size and replication is needed; however, this genomic scan uncovered new genes associated with metabolism and inflammatory pathways that may affect SAT volume in ARV-treated HIV-infected patients.

Background: In treating patients with brachial plexus injury, there are no comparative data on the outcomes of nerve grafts or nerve transfers for isolated upper trunk or C5-C6-C7 root injuries. The purpose of our study was to compare, with systematic review, the outcomes for modern intraplexal nerve transfers for shoulder and elbow function with autogenous nerve grafting for upper brachial plexus traumatic injuries. Methods: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies in which patients had surgery for traumatic upper brachial plexus palsy within one year of injury and with a minimum follow-up of twelve months. Strength and shoulder and elbow motion were assessed as outcome measures. The Fisher exact test and Mann-Whitney U test were used to compare outcomes, with an alpha level of 0.05. Results: Thirty-one studies met the inclusion criteria. Two hundred and forty-seven (83%) and 286 (96%) of 299 patients with nerve transfers achieved elbow flexion strength of grade M4 or greater and M3 or greater, respectively, compared with thirty-two (56%) and forty-seven (82%) of fifty-seven patients with nerve grafts (p < 0.05). Forty (74%) of fifty-four patients with dual nerve transfers for shoulder function had shoulder abduction strength of grade M4 or greater compared with twenty (35%) of fifty-seven patients with nerve transfer to a single nerve and thirteen (46%) of twenty-eight patients with nerve grafts (p < 0.05). The average shoulder abduction and external rotation was 122° (range, 45° to 170°) and 108° (range, 60° to 140°) after dual nerve transfers and 50° (range, 0° to 100°) and 45° (range, 0° to 140°) in patients with nerve transfers to a single nerve. Conclusions: In patients with demonstrated complete traumatic upper brachial plexus injuries of C5-C6, the pooled international data strongly favors dual nerve transfer over traditional nerve grafting for restoration of improved shoulder and elbow function. These data may be helpful to surgeons considering intraoperative options, particularly in cases in which the native nerve root or trunk may appear less than optimal, or when long nerve grafts are contemplated. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Restoration of elbow flexion is commonly achieved with nerve transfer to the musculocutaneous nerve branches after upper trunk brachial plexus injury. It is unknown if double nerve transfer to the biceps and brachialis nerve branches results in greater strength than single nerve transfer to the biceps branch alone.A retrospective review was performed of all patients receiving nerve transfer to restore elbow flexion. Single and double nerve transfers were compared in regard to severity of injury, elbow flexion, supination, grip strengths, and Disabilities of the Arm, Shoulder, and Hand scores. Elbow flexion and supination torque strength were measured quantitatively.Fifty-five patients underwent nerve transfer to restore elbow flexion (23 single, 32 double). At similar follow-up periods, British Medical Research Council grade improved to 4 or better in 14 of 21 single and 24 of 30 double nerve transfer patients. Supination strength was similar between groups (p = 0.148). Grip strength was greater in the double nerve transfer patients (p = 0.028). Preoperative Disabilities of the Arm, Shoulder, and Hand scores were significantly greater in single versus double nerve transfer patients (p = 0.018). Although single nerve transfer patients had a greater improvement in scores, the final mean scores were similar in the two groups. The severity of injury was different between the two groups, with 19 of 23 single nerve transfer patients having injury beyond the C5-6 level and only 16 of 32 of double nerve transfer patients with greater than C5-6 injury (p = 0.020).Outcomes are similar between the two groups for elbow flexion and supination strength. Postoperative Disabilities of the Arm, Shoulder, and Hand scores are similar in single and double nerve transfer patients.

OBJECTIVE: Previously, we reported bypass coaptation of the C3 and C4 anterior rami to the upper trunk of the brachial plexus for restoration of the muscles denervated as a result of C5 and C6 nerve root avulsion. This procedure is thought to be superior to the transfer of individual peripheral nerve fibers to the brachial plexus branches. Therefore, the benefits of the bypass coaptation procedures in the treatment of various root avulsions are presented. METHODS: Twenty-six patients were selected as suitable candidates for bypass coaptation procedures. They were divided into 3 groups: 1) Erb-Duchenne palsy due to C5 and C6 root avulsion, 2) Klumpke palsy due to C8 andT1 root avulsion, and 3) the flail arm (or flail upper limb) due to C5 through T1 root avulsion. The surgical techniques are described in detail. RESULTS: The coaptation procedures for the first group resulted in excellent recovery of all the denervated muscles. The patients in the second group showed reinnervation of the finger muscles and finger sensory distributions in infants within the first year after surgery. The flail arm group regained satisfactory proximal muscle function but only mild distal muscle function. One exception was a child who showed significant recovery in proximal and distal motor and sensory function. CONCLUSION: We recommend the bypass coaptation as a useful procedure for the following categories: Erb-Duchenne palsy due to C5 and C6 root avulsion in all ages, Klumpke palsy due to the C8 and T1 avulsion, and the flail arm due to C5 through T1 avulsion in young children. However, bypass procedures for the flail limb in adults require additional innovative methods to facilitate the growth rate of regenerating nerves.

Background Operative treatment of traction lesions in obstetric brachial plexus palsy is still controversial. The authors analyzed the histopathology of neuroma-in-continuity of the upper trunk by study of the resected neuroma. Methods The neuroma-in-continuity of the upper trunk was studied histopathologically in 28 children with Erb palsy who had undergone resection of the neuroma and nerve reconstruction of the plexus at the age of 3 to 11 months. The authors recorded the distribution of myelinated motor nerve fibers and the proportions of collagen and regenerating nerve fibers traveling the neuroma, analyzed the relationship between the percentage of nerve fibers across the neuroma and findings of intraoperative neurophysiologic investigations and the patient's age at surgery, and compared the number of nerve fibers in C5 and C6 proximal to the neuroma with that in their normal counterparts. Results In the central segment of the neuroma, the structure of the upper trunk was replaced by copious collagen and sporadic nerve fibers wrapped by an undeveloped myelin sheath, and the percentage of collagen was statistically greater than that of the normal upper trunk. The mean percentage of regenerating nerve fibers across the neuroma was 41.83 percent (95 percent confidence interval, 38.69 to 44.69 percent) and this was not statistically correlated with the outcome of intraoperative neurophysiologic investigations or the patient's age at surgery. The number of nerve fibers was statistically less in C5 and C6 proximal to the neuroma than in their normal counterparts. Conclusions The nerve structure of the neuroma-in-continuity is substantially damaged in obstetric brachial plexus palsy. Its resection followed by nerve reconstruction of the plexus is favored.

The lymphatic drainage of cutaneous melanomas located on the upper trunk is often complex and sometimes follows an unexpected pattern. Occasionally, even direct drainage to cervical lymph nodes is seen. In this case series, 3 patients with lymphatic drainage to the neck derived from melanomas located over the manubrium sterni are described. There appears to be a restricted area that involves the manubrium sterni from which lymphatic drainage to different cervical node basins appears more frequent. SPECT/CT was helpful in visualizing these patterns and for the localization of the sentinel nodes.

OBJECTIVE In multiple avulsions of the brachial plexus, the search for extraplexal donor nerves in the hope of achieving motor neurotization is a major goal. We explored the possibility of using the hypoglossal nerve as a transfer point to reanimate muscles in the upper limb. METHODS The hypoglossal nerve was used as a donor nerve for neurotization in seven patients with avulsive injuries of the brachial plexus. The surgical technique—an end-to-side microsuture using approximately half of the nerve fascicles—is basically the same as that used in the hypoglossal nerve-facial nerve jump graft, which is a well-known technique in facial nerve reanimation. The recipient nerves were the suprascapular (two patients), the musculocutaneous (one patient), the posterior division of the upper trunk (two patients), and the medial contribution to the median nerve (two patients). RESULTS In spite of a connection documented by electromyography and selective activation in three of seven patients, the functional results in our patients were extremely disappointing: no patient had an outcome better than M1 in the reinnervated muscles. CONCLUSION This technique was of no help to the patients and thus has been abandoned at our institution.

A 20-yr-old active duty soldier complained of right lateral forearm numbness that began shortly after carrying 100 lbs of equipment (20-lb load-bearing equipment, 20-lb individual body armor, and 60-lb rucksack) while deployed during Operation Iraqi Freedom. Physical examination revealed normal strength but decreased sensation over the right lateral forearm, thumb, and index finger. Imaging studies were normal. Electrodiagnostic studies revealed an absent right lateral antebrachial cutaneous nerve conduction study with abnormal electromyography findings in the right deltoid and biceps brachii. He was diagnosed with an upper trunk brachial plexopathy. The patient's symptoms gradually resolved with conservative treatment. Although rucksack palsies have been previously reported, this relatively rare cause of brachial plexus injury has been generally declining with the reengineering of more ergonomically favorable rucksacks. It is possible that the additional body armor may have contributed.

Background: Adult atopic dermatitis (AD) with severe and refractory eruptions on the face, neck, and upper trunk, although quite rare in western countries, has increased in Japan. Objective: We have tried to clarify the possible causative factors for this particular type of AD, predominantly seen in Japan. Methods: Eighty-seven AD patients (37 men and 50 women) who had severe and refractory facial and neck lesions were patch tested with topical medicaments, cosmetics, and skin-management products. Results: Thirty-seven (42.5%) patients showed positive reactions to more than one of those products: 14 patients to shampoo, rinse, or soap; 11 to topical nonsteroidal anti-inflammatory agents (NSAIDs); 7 to cosmetics; and 6 to corticosteroids. Conclusion: We believe that topical NSAIDs, (which are often prescribed for the treatment of AD in Japan and rarely used for the treatment of eczamatous skin disorders in western countries), as well as common detergents, play important roles in the increased prevalence of AD patients with severe and refractory lesions on the face, neck, and upper trunk in Japan.

In the past, patients with cervical spinal nerve root avulsions were resigned to accept a natural crippling from upper extremity neurological deficits. Recently, bypass coaptation procedures have resulted in functional return of denervated muscles after such avulsions, much to the appreciation of patients. Presented are 12 patients with avulsion of cervical spinal nerve roots that form either the brachial plexus upper trunk (n = 7), lower trunk (n = 1), or all three trunks (n = 4). The patients underwent the new bypass coaptation procedures with complete or partial return of motor and sensory function, which otherwise would be totally nonfunctional. The most dramatic results were noted in those patients who underwent operations within 6 weeks of injury. The results of these procedures offer patients a valid therapeutic modality for an enhanced quality of life after cervical nerve root avulsion.

Summary: Upper extremity reconstruction is most often encountered in trauma patients. Although the rate of complications from elective orthopedic procedures remains relatively low, these complications are oftentimes in the form of open joints or joint infections that can be devastating. Classically, wounds of the shoulder girdle have been treated with large muscles such as the pectoralis major, pectoralis minor, and latissimus dorsi. Flaps more local to the area including the deltoid muscle flap have been overlooked due to their small size. Despite its size, the anterior deltoid can be used for shoulder girdle reconstruction with minimal functional deficit and allows for reconstruction of the glenohumeral joint without sacrifice of the larger muscles of the upper trunk. This study reports a case of a chronic shoulder girdle wound and successful management with the use of an anterior deltoid muscle flap.

Magnetic stimulation of cervical nerve roots is a promising new technique, limited in part by uncertainty about the site of nerve depolarization. We used a modified "butterfly" stimulus coil with an easily defined excitation field to activate the C-8/T-1 nerve roots, recording over abductor digiti minimi. Locating both the lowest threshold for stimulation and the points of maximum stimulation, we determined the optimum rostral-caudal position and orientation for the stimulus coil over the posterior neck and upper trunk. The most favorable positions corresponded to the C-8/T-1 neural foramina, and the most favorable orientations to the roots within them. Additional measurements of depth and electric field suggested that the stimuli used should have been insufficient to activate nervous tissue in a homogeneous medium. A simple model indicates that the induced current is intensified where it passes through a bony foramen and explains preferential excitation of the nerve root at this site.

Objective and importance The sural nerve is the donor nerve most commonly used for peripheral nerve reconstruction. The objective of this paper is to present an endoscopic technique for harvesting these sural nerve grafts, using the Guidant VasoView Uniport Plus device (Guidant Corp., Indianapolis, IN), originally designed to obtain the saphenous vein. The importance of this technique is its use of a small, 12-mm incision for removing the entire sural nerve, which is an improvement over the two, three, or one 3-cm incisions(s) for sural nerve harvesting described in other publications. Endoscopic techniques, in general, replace the former open technique requiring a longitudinal incision along the entire posterior lower leg, which is a distinct advantage. Clinical presentation Two cases of patients with lesions requiring sural nerve grafts are presented. Nerve action potential recordings showed no transmission in each case and nerve grafts were required for repair of these lesions after their resection to healthy-appearing tissue. Intervention The first patient had a stretch contusion injury extending from the right C5 and C6 roots to the upper trunk (UT) and UT outflow to the suprascapular nerve (SSN). This patient required a sural nerve graft 20 cm in length, which was harvested by the described endoscopic technique within 20 minutes. The second patient had in continuity lesions involving the C5 and C6 roots to the UT including the SSN and the C7-middle trunk to posterior spinal cord. These lesions required a 31-cm sural nerve graft harvested via the endoscopic technique in 25 minutes. Conclusion When compared with the open techniques, the endoscopic method using the Guidant VasoView Uniport Plus device has the advantages of being fast, less traumatic, safer, and resulting in a more aesthetic technique.

STUDY DESIGN A cross-sectional study in patients with recurrent/chronic low back trouble and healthy control subjects. OBJECTIVE To evaluate the effect of paraspinal muscle fatigue on the ability to sense a change in lumbar position. SUMMARY OF BACKGROUND DATA Protection against spinal injury requires proper anticipation of events, appropriate sensation of body position, and reasonable muscular responses. Lumbar fatigue is known to delay lumbar muscle responses to sudden loads. It is not known whether the delay is because of failure in the sensation of position, output of the response, or both. METHODS Altogether, 106 subjects (57 patients with low back trouble [27 men and 30 women] and 49 healthy control subjects [28 men and 21 women]) participated in the study. Their ability to sense a change in lumbar position while seated on a special trunk rotation unit was assessed. A motor rotated the seat with an angular velocity of 1 degree per second. The task in the test involved reacting to the perception of lumbar movement (rotation) by releasing a button with a finger movement. The test was performed twice, before and immediately after a fatiguing procedure. During the endurance task, the participants performed upper trunk repetitive extensions against a resistance, with a movement amplitude adjusted between 25 degrees flexion and 5 degrees extension, until exhaustion. RESULTS Patients with chronic low back trouble had significantly poorer ability than control subjects on the average to sense a change in lumbar position (P = 0.007), which was noticed before and after the fatiguing procedure. Lumbar fatigue induced significant impairment in the sensation of position change (P < 0.000001). CONCLUSIONS Lumbar fatigue impairs the ability to sense a change in lumbar position. This feature was found in patients and control subjects, but patients with low back trouble had poorer ability to sense a change in lumbar position than control subjects even when they were not fatigued. There seems to be a period after a fatiguing task during which the available information on lumbar position and its changes is inaccurate.

This study compares the areas of analgesia obtained with the lateral and posterior approaches to the interscalene space after injection of equal volumes of anaesthetic solution (40 ml of a mixture of 0.5% bupivacaine with adrenaline 1:200,000 and 2% lignocaine in equal parts). There was a significant difference in the distribution of the areas of analgesia between the two approaches. With the posterior approach, the region supplied by the radial, medial and ulnar nerves and the post-axial border of the upper limb were more frequently involved, whilst with the lateral approach the area of analgesia was usually confined to the regions supplied by the most caudal roots of the cervical plexus and the upper trunk of the brachial plexus (pre-axial border of the upper limb). On these grounds it appears that two different types of interscalene block are possible.

Two patients with leiomyosarcomas are described, both men with lesions located in the upper trunk. Both lesions were present for more than 10 years. The diagnosis was established after excisional biopsy. The diagnostic criteria are a tumor size greater than 2.5 cm in diameter; a mitotic rate of 1 or more per 5 high-power fields in cellular areas; and electron microscopic verification of smooth muscle cells. The literature is reviewed and the clinical presentation of the 2 patients is discussed. Wide excision is the treatment of choice after histological diagnosis.

1. This preliminary report suggests the effectiveness of the technique of progressive-resistance exercise in the after-care of knee injuries and low-back strains and in the development of the muscles of the upper trunk and arms of adolescents. 2. The desirability of utilizing a therapeutic-exercise method which will not only restore muscle power, but which will also produce a considerable increase over the strength existing prior to injury, is urged. 3. Further clinical trial of progressive-resistance exercise is suggested in conditions which require that muscle power be increased.

Experience with 17 patients with delayed onset of compression neuropraxia due to hemorrhage following nonoperative treatment of penetrating arterial injuries is presented. Fifteen cases involved the arteries of the neck shoulder girdle and upper extremity and two the gluteal vessels. This resulted in dysfunction of components of the brachial plexus, median ulnar, and sciatic nerves. Follow-up extended from 3 to 18 months. Of 10 brachial plexus lesions two recovered fully, five partially, and three not at all. Of seven peripheral nerve injuries, full recovery occurred in two patients and none in five. Adverse prognostic factors for neurological recovery are sepsis, involvement of intrinsic hand innervation and the sciatic nerve. An improved prognosis may be expected for upper trunk lesions of the brachial plexus and radial nerve lesions. The complication is essentially avoidable and a careful appraisal of the circulatory status must be made in all patients with penetrating trauma in the neck and shoulder girdle and buttock.

In order to assess the predictive value of pain drawings of sciatic pain, 81 patients admitted because of symptoms and signs of lumbar disc herniation were asked to chart their pain on a schematic body drawing prior to myelography. There were no differences in sexes, ages, or pain duration between the group of 37 patients with a herniated lumbar disc compared to the 44 patients with a normal myelogram. From the features of the pain drawing alone, it was possible to predict the presence or absence of a herniated disc with a high statistical significance (p less than 0.001). Patients with a disc herniation rarely had pain in the upper trunk or arms (three of 37) compared with the normal group (23 of 44). Only one of nine patients with pain in the groin had disc herniation, and the same was true concerning pain in the iliac crest. Three patients without pain below the knee had no prolapsed disc. The Ransford score was significantly higher in patients with nondiscogenic sciatica, but there was no difference between the groups in the number of types of pain sensation.

✓ The suprascapular nerve, formed from the upper trunk of the brachial plexus, can be entrapped at the suprascapular notch and result in significant patient morbidity. Seven patients with suprascapular nerve palsy are presented, and their evaluation, treatment, and outcome over a mean follow-up period of 24 months are described. Six of these patients were treated surgically and one medically; all experienced good results. In a review of the relevant literature, this entity is distinguished from other causes of shoulder pain, the typical presenting signs and symptoms are outlined, and the appropriate management of these patients is addressed.

The purpose of this study was to evaluate isokinetic strength measurement in ankle joint. The study was divided into three parts. A comparison of dorsal and plantar flexion with and without consideration to the biomechanical circumstances was done. The series comprised 15 men and 10 women. A comparison of strength measurements of dorsal flexion with and without fixation of the upper trunk. The series consisted of 10 men. A reference series for dorsal and plantar flexion comprising 15 men (mean age = 34 +/- 9 yr) was used for comparison. Strength was tested at 0 degree, 15 degrees, 30 degrees, 60 degrees, 120 degrees, 180, and 240 degrees/s. The readings made without biomechanical adjustment were significantly higher than connected readings. Mean difference at 30 degrees/s was 8.4 +/- 7.1 Nm for dorsal flexion and 18 +/- 3.1 Nm for plantar flexion. The torque values were significantly higher when the upper trunk was not immobilized, and higher standard deviations were obtained. The left (viz. dominant) leg produced significantly higher muscle torque at all velocities for plantar flexors and at all but 180 degrees and 240 degrees/s for dorsal flexors. The regression coefficient was used as a measure of peak torque velocity relation, the coefficient was -0.50 +/- 0.16 for plantar flexion and -0.22 +/- 0.06 for dorsal flexion.