Management of soft-tissue injuries in distal radius fractures

Distal radius fractures account for approximately 15% of all fractures in adults, and are the most common fractures seen in the emergency department. Soft-tissue injuries associated with distal radius fractures may influence strategies for the acute management of the fracture, but also may be a source of persisting pain and/or disability despite fracture healing. This article describes soft-tissue injuries and considerations for treatment associated with distal radius fractures, including injuries to the skin, tendon and muscle, ligaments, the triangular fibrocartilage complex, neurovascular structures, and related conditions such as compartment syndrome and complex regional pain syndrome.     

Quadrilateral space syndrome: diagnosis, pathology, and treatment

Quadrilateral space syndrome is an infrequent, recently established neurovascular compression syndrome affecting young active adults. With this syndrome, the neurovascular bundle, consisting of the posterior humeral circumflex artery (PHCA) and the axillary nerve, is compressed by fibrotic bands as it traverses the quadrilateral space. Symptoms result from compression of the axillary nerve, not from PHCA occlusion. Because of the vague, often nonspecific, clinical presentation of patients with quadrilateral space syndrome, diagnosis is challenging and requires a high index of suspicion from the orthopedist. Subclavian arteriography confirms the diagnosis. Treatment is usually conservative; operative management is reserved for selected patients. A posterior approach with detachment of the deltoid and teres minor muscles is recommended for surgical decompression and for lysis of fibrous tissue. We report two cases of persistent quadrilateral space syndrome in young adults, treated surgically, with 2-year follow-up. In the present report, diagnostic criteria, pathology, management, operative technique, and recent literature are also reviewed.     

Delayed presentation of acute compartment syndrome after contusion of the thigh

Acute compartment syndrome has been described as a result of thigh contusion in several contact sports, and emergent fasciotomy has routinely been recommended. However, recent data suggest that thigh contusions in athletes presenting with isolated elevation of compartment pressures in the absence of neurovascular deficits may be treated expectantly. We describe a case of anterior thigh contusion, which initially presented with isolated compartmental hypertension without neurovascular symptoms. Under nonoperative treatment the patient developed delayed acute compartment syndrome from persistent muscular hemorrhage ten days after the initial trauma, requiring operative treatment. This case demonstrates that expanding hematoma formation may result in delayed increase of intramuscular pressures and compromise of myoneural perfusion in patients with severe thigh contusions. Early evacuation of the hematoma may help to prevent late development of compartment syndrome and reduce the risk for long-term complications.     

Measurement of subclavicular pressure on the subclavian artery and brachial plexus in the costoclavicular space during provocative positioning for thoracic outlet syndrome

Background  

Thoracic outlet syndrome is thought to be caused by compression of the brachial plexus or subclavian artery in the interscalene, costoclavicular, or subcoracoid space. Some provocative tests are widely used for diagnosing thoracic outlet syndrome. However, whether provocative positions actually compress the neurovascular bundle in these spaces remains unclear. The purpose of this study was to investigate the possibility of neurovascular bundle compression in the costoclavicular space by measuring the pressure applied to the brachial plexus and subclavian artery in provocative positions.     

History of thoracic outlet syndrome

Thoracic outlet syndrome (TOS), a condition in which neurovascular structures in the thoracic outlet region are compressed, can be caused by anatomical abnormalities or acquired changes in the soft tissues and bony structures in the region. The brachial plexus is the most frequently affected structure. TOS is one of the most difficult neurovascular compressions in the upper extremity to manage because of the variability of complaints and the high risk associated with surgical treatment.     

Unexplained pain conditions of the upper extremity

Diagnosis can be very difficult in the case of painful conditions of the upper extremity, since this is a region where the site of the changes and pathologic conditions precipitating or causing the pain is not always identical with the area where the pain is felt. This is particularly so in the case of pain resulting from vascular disease and irritation of peripheral nerves and in the thoracic outlet and inlet syndrome. Recent observations and studies suggest that this is extremely important for the etiology and pathogenesis of epicondylar periostitis and tendovaginitis, carpal tunnel syndrome, and some trophic conditions affecting the hand. Stenosis of the subclavian vein can be responsible for post-traumatic and postoperative edema of the hand and for similar changes whose "cause is unclear", and also for certain difficulties with wound healing. Preliminary experience suggests that Sudeck's dystrophy may be the most severe form of the thoracic outlet and inlet syndrome. Accordingly, transaxillary decompression of the neurovascular cord with upper thoracic sympathectomy can be recommended as a last resort for refractory Sudeck's dystrophy. The problem of epicondylitis of the lateral humerus is discussed in some detail, as is the pathogenesis of pain resulting from neuroma.     

Traitement des vertiges selon leurs mécanismes

Vertigo is an illusion of rotatory or linear movement that demonstrates a functional or lesional disturbance of the vestibular system, from periphery to central connections. According to the ANAES report (1997), benign paroxysmal positional vertical vertigo, vestibular neuronitis and Ménière's disease account for 40-50% of all mixed vertigo etiologies. Central etiologies may account for 20-40% of causes and 10-40% remain more difficult to classify, and are usually classified under the term of “peripheral vestibulopathy.” These include vertigo due to neurovascular compression syndrome of the VIIIth nerve. Clinical manifestations, differential diagnosis, and treatment of the main etiologies of vertigo will be developed in this chapter. A specific section will discuss the subject of neurovascular compression syndrome of the VIIIth nerve. Even though some publications should be challenged, it appears that neurovascular compression syndrome of the VIIIth nerve might explain some cases of vertigo or chronic instability, with or without cochlear signs. The diagnosis is difficult and must be established on multiple clinical, electrophysiological and radiological arguments. A therapeutic test with antiepileptic drugs is helpful. The treatment includes these drugs as a first option but may require a neurosurgical approach if medical treatment fails.     

Neurovascular injuries to the athlete's shoulder: Part I

The neurovascular structures traversing the shoulder region can be compromised in a number of ways. Athletes are particularly at risk of neurovascular injury to the shoulder as the result of extreme force and stress on the shoulder girdle. Many such injuries have been described in the literature as cervical radiculitis, spinal accessory nerve injury, long thoracic nerve palsy, burner (stinger) syndrome, and brachial neuritis. A high index of diagnostic acumen and proper selection of clinical assessment and imaging techniques are needed to diagnose such injuries.     

Thoracic outlet and pectoralis minor syndromes

Compression of the neurovascular bundle to the upper extremity can occur above or below the clavicle; thoracic outlet syndrome (TOS) is above the clavicle and pectoralis minor syndrome is below. More than 90% of cases involve the brachial plexus, 5% involve venous obstruction, and 1% are associate with arterial obstruction. The clinical presentation, including symptoms, physical examination, pathology, etiology, and treatment differences among neurogenic, venous, and arterial TOS syndromes. This review details the diagnostic testing required to differentiate among the associated conditions and recommends appropriate medical or surgical treatment for each compression syndrome. The long-term outcomes of patients with TOS and pectoralis minor syndrome also vary and depend on duration of symptoms before initiation of physical therapy and surgical intervention. Overall, it can be expected that >80% of patients with these compression syndromes can experience functional improvement of their upper extremity; higher for arterial and venous TOS than for neurogenic compression.     

Neurovascular trauma in athletes

Injuries to neurovascular structures are not the most common injuries seen in athletes and for this reason may often be overlooked. Additionally, diagnosis and management may be more difficult because of inexperience with these injuries. The majority of acute sports-related neurovascular injuries are associated with contact sports such as rugby, wrestling, ice hockey, and especially football. These injuries most commonly occur about the shoulder girdle and brachial plexus, with "burners" syndrome being the most common. Less common injuries include thoracic outlet syndrome, effort-induced thrombosis, axillary artery occlusion, and peripheral nerve injuries, as well as compression syndromes involving the axillary, suprascapular, and long thoracic nerves.     

Thoracic outlet syndrome in a patient with SAPHO syndrome – A case report

Introduction and ImportanceThoracic outlet syndrome (TOS) includes disorders caused by compression of the neurovascular structures in the upper thoracic outlet (Roos and Owens, 1996 [1]; Bürger, 2014; Curuk, 2020 [3]). Depending on the compressed structure, it is categorized into neurological, arterial and venous TOS.SAPHO syndrome (synovitis–acne–pustulosis–hyperostosis–osteitis syndrome) is a rare chronic inflammatory disease of unknown etiology. With its typical involvement of sternoclavicular joint and clavicle, complication due to hyperostosis in this region, leading to thrombosis of the subclavian vein have been reported in some cases of SAPHO syndrome.Between 2015 and 2019 488 patients, suffering from neurological, vascular or combined TOS presented at our department. Depending on clinical and diagnostic results surgical therapy was performed in 175 cases via the transaxillary approach, including complete first rib and/or cervical rib resection, neurolysis of plexus brachialis, thoracic sympathectomy and vascular reconstruction if indicated (Curuk, 2020). During this period, only one single patient presented with SAPHO syndrome with thrombosis of the subclavian vein and neurovascular TOS.Case presentationWe present a 50-year-old female patient, in line with the SCARE 2020 criteria (Agha et al., 2020 [12]) suffering from extremely rare combination of neurovascular TOS and SAPHO syndrome with thrombosis of the left subclavian vein due to hyperostosis of the left clavicle.ConclusionProgressive bone changes associated with SAPHO syndrome can lead to narrowing of the thoracic outlet. Pharmacological therapies to avoid the progression of the hyperostosis of the costoclavicular joint and the clavicle do currently not exist. First rib resection is a therapeutic option to widen the space in the upper thoracic region. Surely, it is a rare condition and more long-term follow-up data are required.     

Extensive or partial microsurgical sympathectomy of the arm by supraclavicular route for primary or secondary Raynaud symptoms

Surgery was performed in patients with Raynaud's disease (primary Raynaud symptoms) or with Raynaud symptoms as part of the cervical rib/scalenus-anticus syndrome (secondary Raynaud symptoms). In 13 arms with primary, and six with secondary Raynaud symptoms with trophic changes, the aim was extensive sympathectomy. Good results, without Horner's syndrome, were obtained with extensive postganglionic sympathectomy. When the grey ramus T1 could not be identified, T2 ganglionectomy and extirpation of the grey rami C7 and C8 were performed with the same result. Extirpation of the grey ramus C6 was not mandatory for a good result. Extirpation of unidentified T1 rami resulted in permanent Horner's syndrome in two of four patients. Cases of secondary Raynaud symptoms without trophic changes were divided into two equal groups, each of 18 arms. Combined neurovascular decompression and partial sympathectomy were performed in one group, and neurovascular decompression only in the other. Partial sympathectomy seemed to improve the results.     

Thoracic Outlet Syndrome

The manifestations of thoracic outlet syndrome vary according to which of the neurovascular structures are affected. To provide optimal treatment, the pathogenesis must be understood in terms of both the anatomic variants and the dynamic factors. The diagnosis is primarily clinical, although ancillary diagnostic studies are useful in selected patients. Following a careful examination, the orthopaedic surgeon should be able to initiate a program of appropriate therapy depending on the nature and severity of the clinical manifestations. Initial treatment is oriented toward postural reeducation and periscapular muscle strengthening. Glenohumeral instabilities and painful upper-limb conditions that cause disuse atrophy must be addressed. Operative treatment is reserved for patients in whom a conservative program has failed and for those with significant neural or vascular deficits. The surgeon must be cognizant of the potential complications of the various procedures used to correct thoracic outlet syndrome. Proper selection of surgical candidates should produce significant improvement in most patients.     

Blunt lower-extremity trauma and popliteal artery injuries: revisiting the case for selective arteriography

HYPOTHESIS: Abandoning mandatory angiography in patients with blunt lower-extremity trauma and normal neurovascular examination results does not affect limb salvage. DESIGN: Retrospective, nonrandomized cohort study. Mean follow-up (31 of 52 patients) of 9.5 months (range, 0-96 months). SETTING: Single-institution, academic level I trauma center. PATIENTS: Medical records of patients presenting on an emergency basis with knee dislocation, distal femoral fractures, or proximal tibial fractures during a 20-year period were reviewed. Fifty-three injuries occurred in 52 patients. Patients were predominantly male (81%) and young (mean age, 32.7 years). Mechanisms and side of extremity injury, coincident injuries, and neurovascular status on admission were recorded. Hard signs of arterial insufficiency or compartment syndrome were identified. INTERVENTIONS: Angiographic findings and operative and nonoperative interventions were recorded to identify whether angiographic data would alter therapy dictated by clinical findings alone. MAIN OUTCOME MEASURES: Limb salvage rate and necessity for vascular surgical intervention based on angiographic data in patients with normal neurovascular examination results. RESULTS: Multiorgan trauma occurred in 11 patients. Pulses were normal in 35, absent in 16, and diminished or identified by Doppler signal in 2. Arterial insufficiency or compartment syndrome was present in 29%. Twenty-seven patients (28 limbs) underwent angiography at the discretion of the attending surgeon. Of 13 abnormal arteriograms, 2 occurred in patients with normal pulses and 11 in patients with abnormal examination results. Thirteen of 36 patients with normal pulses underwent angiography; none had clinically significant arterial injuries that necessitated intervention. No vascular interventions were necessary in 23 patients with normal pulses who did not undergo angiography (P<.001). Normal neurovascular status bore a 100% negative predictive value in determining the necessity of vascular intervention. CONCLUSIONS: Angiography is unnecessary in the routine evaluation of the patient with blunt lower-extremity trauma who presents with a normal neurovascular examination result and can be used selectively for patients with diminished pulses who lack associated indications for mandatory operative exploration.     

Intracranial aneurysm surgery in Ehlers-Danlos syndrome Type IV

OBJECTIVE: Ehlers-Danlos syndrome Type IV is a heritable connective tissue disorder with frequent neurovascular manifestations, such as intracranial aneurysms. Patients with this syndrome have notoriously fragile blood vessels, and the reported mortality rate for any type of vascular surgical procedure is 40%. This syndrome is rare, however, and the complication rate of aneurysm surgery may have been overestimated. METHODS: We reviewed our experience with aneurysm surgery in a group of patients with Ehlers-Danlos syndrome Type IV. RESULTS: The patient population consisted of three women and one man with a mean age of 44 years (age range, 20-57 yr). One patient, who had a ruptured anterior circulation aneurysm, died as a direct result of surgery because of marked vascular fragility. Three patients underwent successful surgery, consisting of a craniotomy and clipping of a ruptured anterior circulation aneurysm in two patients and a craniotomy and clip ligation of the parent artery in one patient with a ruptured dissecting vertebral artery aneurysm. Intraoperatively, mild vascular or connective tissue fragility was commonly observed. Postoperative complications (e.g., spontaneous pneumothorax and vertebral artery dissection) also were common but did not result in permanent morbidity. CONCLUSION: The risk of neurovascular surgery is high in patients with Ehlers-Danlos syndrome Type IV and intra- and postoperative complications are common. However, most patients tolerate the operation without permanent morbidity.     

Neurovascular neurosurgery

Neurovascular disorders including brain aneurysms, arteriovenous malformations and intracranial atherosclerotic disease with its associated morbidity and mortality have a significant health and economic toll on our population. They form a major part of the neurosurgical work load. Neurovascular or vascular neurosurgery covers a wide variety of conditions; intracerebral haemorrhage, subarachnoid haemorrhage, cerebral aneurysms, atherosclerotic and non-atherosclerotic cerebrovascular disease, vascular malformations, both cranial and spinal, but to name some. The aim of this article is to outline the more commonly encountered neurovascular conditions, their diagnosis and management, to better equip those looking after patients with neurovascular conditions.     

Computed tomography angiography to evaluate thoracic outlet neurovascular compression

The objective was to evaluate the efficacy of computed tomography angiography with upper extremity hyperabduction to diagnose thoracic outlet syndrome. Over 5 years, 21 patients were treated surgically for neurogenic symptoms of thoracic outlet syndrome. For patients whose diagnosis was unclear after history and physical examination, adjunctive tests (duplex, magnetic resonance angiography, or computed tomography angiography) were performed to help establish the diagnosis. Five of the 6 computed tomography angiograms were positive. The sixth computed tomography was deemed to be an incomplete study. With mean follow-up of 9.4 months, 95% (n = 19) of patients with a positive hyperabduction test on physical examination were free of symptoms postoperatively. All patients with a positive computed tomography angiogram, with their neurovascular compression localized to the thoracic outlet, had successful operative decompression. Computed tomography angiogram with abduction of the arm can be used as an adjunct to confirm the diagnosis of neurovascular compression and then predict successful operative decompression.     

Introduction to primary hemifacial spasm: A neurosurgical disease

Primary hemifacial spasm is a hyperactive cranial nerve syndrome. The cause is always a neurovascular compression, generally at the root exit zone from the brainstem. Its curative treatment is microvascular decompression, that may be performed as a first option, or secondarily when botulinum toxin injections fail.     

Radiodiagnosis of the thoracic outlet syndrome]

The results of roentgenological investigations in thoracic outlet syndrome are summarized. The method for defining the width of a costoclavicular cleft and its diagnostic importance in 72 patients operated on is described. A role of anomalies of the osteofibrous formations in the development of neurovascular compression is noted.     

Abdominal compartment syndrome during hip arthroscopy

Hip arthroscopy is recognised as a highly effective means of treating joint disorders. The majority of complications associated with hip arthroscopy involve neurovascular traction injury. We report a relatively unusual complication of hip arthroscopy, extravasation of irrigation fluid into the retroperitoneal and intraperitoneal cavities, resulting in abdominal compartment syndrome.