Incidence, Etiology, and Management of Long Thoracic and Accessory Nerve Injuries and Winging Scapula
Abstract
Background. Peripheral nerve injuries make up many upper extremity musculoskeletal disorders (UE-MSDs), as peripheral nerves in the upper extremities are susceptible to damage due to their superficial course and length. The health and economic burdens of peripheral nerve injuries are rising. Upper-limb peripheral nerve injuries caused by prone positioning in COVID-19 patients in intensive care have occurred during the current global pandemic. Understanding the incidence and causation of these injuries is essential, as these affect primarily young workers and athletes with skeletal immaturity and contribute to significant morbidity.
Methods and Patients. A total of 789 patients, 481 of whom were male and 308 female, with limited upper-extremity movements, scapular winging, and pain due to upper brachial plexus, long thoracic and accessory nerve injuries (459 right, 282 left, and 48 bilateral) were included in the study. Patient age at the onset of injury ranged between 11 months and 68 years.
Results. A total of 18 causes of peripheral nerve injury were identified among the 789 patients with UE-MSD. The most affected patients (12.7%) were involved in sports and related activities, with 20 different sports and related activities reported in this patient population. Weightlifting caused the most (10.9%) number of injuries in this group. Incidences in the least affected patients were due to massage and viral infection, at 0.6% and 0.6% respectively.
Conclusions. Sports and recreational-related physical activities are essential components of a healthy lifestyle, and may help decrease the incidence of obesity, diabetes, and cardiovascular diseases. Injury and fear of impairment, however, can be barriers in the participation of these activities. Surgery and other interventions can help maximize return to work and regular activities after UE-MSDs.
ePlasty 2021;21:e11 Epub 2021 November
Background
Upper extremity musculoskeletal disorders (UE-MSDs) with limited shoulder movement and scapular winging due to upper brachial plexus, long thoracic, and accessory nerve injuries can be devastating and if left untreated can cause lifelong disability with pain that negatively impacts patients' daily activities and quality of life.1,2 Peripheral nerve injuries make up a large portion of UE-MSDs. The health and economic burdens of peripheral nerve injuries are rising.3 Understanding the incidence and causation of these injuries is essential, as these primarily affect young workers and athletes with skeletal immaturity, causing significant morbidity.
Kaiser et al4 recently reviewed and reported data from 10 studies involving 3032 patients regarding the prevalence of specific types and causes of brachial plexus injuries (BPIs) in adults. These injuries typically affect the younger, working-age population and can have a severe socio-economic impact. Increases in sports participation and in the number of motor vehicle accidents have resulted in a global rise in the incidence of BPIs.5-14 Upper-limb peripheral nerve injuries due to prone positioning have also occurred in COVID-19 patients in intensive care. 15
Muscles begin to undergo atrophy if diagnosis and treatments of peripheral nerve injuries are delayed. Early diagnosis and a referral to a peripheral nerve surgeon are important in cases that may necessitate surgical intervention. The complexity of the injury, nature of the surgical reconstruction, and the prolonged time off from work have the potential to accumulate substantial direct (2018 median: $38816 per patient) and indirect costs (2018 median: $801723 per patient) to the individual and society, respectively.16,17 Recent data from the Monte Carlo simulation suggest that surgery and other interventions may maximize patients’ ability to return to work after traumatic brachial plexus and accessory nerve injuries, which may result in decreases in indirect costs.16
The diagnosis of peripheral nerve injury can be obtained using nerve conduction velocity (NCV) test, electromyography (EMG), and magnetic resonance (MR) neurography. Several treatment approaches are available including conservative treatments (physical therapy, orthotics, and pain control), early surgical intervention (neurolysis, nerve graft, and nerve transfer), and late surgical options (arthrodesis, tendon, and free muscle transfers). Early surgical intervention may provide the best means of obtaining a functional return. 13, 18-20 In this study 18 causes of UE-MSDs with limited shoulder movements and winging scapula were found in 789 of patients. Of these, 481 (61%) were male and 308 (39%) were female. (Table 1).
Methods and Patients
Type of examination and scales used for evaluation. Initial evaluation obtained for all patients included demographics (gender, age) and detailed medical history (cause, onset, and left/right or bilateral side of the injury. Physical and clinical examinations were performed by the lead author and the surgeon (RKN). Male patients were asked to remove their shirts, and females were asked to wear halter tank tops during the physical examination of the winging scapula/of the posterior thorax. The extent of scapular winging was assessed while the patient forward flexed his/her arms to the horizontal and pushed on a wall in a push-up motion. A 4-point numerical scale was used for determining the extent of scapula winging: 1 – severe; 2 – moderate; 3 – mild; and 4 – minimal/normal 17 (Figure 1 and Video 1, Video 2, Video 3, Video 4). NCV and EMG examination reports were obtained for the patients to assess the regional sensory or motor loss of the nerve injury.
Patients were asked to send a short video of the following movements by filming from behind without a shirt (male) or with a halter tank top (female) so that the shoulder blade is visible. A video was also taken of these patients performing the following movements before and after surgery.
Movement 1. Patients were asked to raise their arms straight in front at a right angle to their body, then raise them as high as possible, return them to resting position in the same way.
Movement 2. Patients were asked to raise their arms to the side through a "T" position then raise them as high as possible and return them to the resting position through the same "T" position.
Movement 3. Facing a wall, patients were asked to raise their arms to the front at a right angle to their body and continue to raise them as high as possible above their head (as in movement 1), and then take them down to the side through a "T" position (as in movement 2) without bringing their arms completely down and return them to the front. Then, they were asked to perform a press-up against a wall.
Stills were taken from the video of these patients performing these movements (0° being relaxed at the side and 180° being fully abducted above the head). They were evaluated for shoulder flexion in the sagittal plane and abduction in the frontal plane while videotaped from the posterior and superior views.
Related Videos: Measurement of the extent of scapular winging (ESW) and shoulder range of motion (ROM).
Video 1: A patient with severe scapular winging (ESW- 1) performing ROM - < 30ᵒ.
Video 2: A patient with moderate scapular winging (ESW- 2) performing ROM - 90ᵒ.
Video 3: A patient with mild scapular winging (ESW- 3) performing ROM - 120ᵒ.
Video 4: A patient with minimal scapular winging/normal (ESW- 4) performing ROM- 180ᵒ.
Results and Discussion
Eighteen causes of peripheral nerve injury were identified among the 789 patients with UE-MSDs. The most affected patients (12.7%) were involved in sports and related activities, with 20 different types of sports and related activities reported in this patient population. Weightlifting caused the most number of injuries (10.9%) in this group. Incidences in the least affected patients were due to massage and viral infection, at 0.6% and 0.6% respectively.
Comparatively, Kaiser et al3 recently reported data from 10 studies of 3032 patients with BPIs. The prevalence of closed BPIs was 93%, with lacerations accounting for 3% and a prevalence of male and female patients at 93% and 7%, respectively. The most common cause of BPI was motorcycle accidents with 67% occurrence, followed by car crashes at 14%.
Conclusion
Sports and recreational-related physical activities are essential components of a healthy lifestyle, and may help decrease the incidence of obesity, diabetes, and cardiovascular diseases. Injury and fear of impairment; however, can be barriers in the participation of these activities. Surgery and other interventions can help maximize return to work and regular activities after UE-MSDs.
Acknowledgments
Authors: Rahul K. Nath MD, Chandra Somasundaram PhD
Affiliations: Texas Nerve and Paralysis Institute, Houston, Texas, 77030
Correspondence: Rahul K. Nath MD, 6400 Fannnin St Ste 2420, Houston, Texas, 77030; drnath@drnathmedical.com
Disclosure: The authors disclose no financial or other conflicts of interest.
References
1. Estrella EP, Castillo-Carandang NT, Cordero CP, Juban NR. Quality of life of patients with traumatic brachial plexus injuries. Injury. 2021; S0020-1383(20):31054-8. doi 10.1016/j.injury.2020.11.074.
2. Cole T, Nicks R, Ferris S, Paul E, O'Brien L, Pritchard E. Outcomes after occupational therapy intervention for traumatic brachial plexus injury: A prospective longitudinal cohort study. J Hand Ther. 2020;33(4):528-539. doi: 10.1016/j.jht.2019.08.002.
3. Karsy M, Watkins R, Jensen MR, Guan J, Brock AA, Mahan MA. Trends and Cost Analysis of Upper Extremity Nerve Injury Using the National (Nationwide) Inpatient Sample. World Neurosurg. 2019 Mar;123:e488-e500. doi: 10.1016/j.wneu.2018.11.192.
4. Kaiser R, Waldauf P, Ullas G, Krajcová A. Epidemiology, etiology, and types of severe adult brachial plexus injuries requiring surgical repair: systematic review and meta-analysis. Neurosurg Rev. 2020;43(2):443-452. doi: 10.1007/s10143-018-1009-2.
5. Ahmed-Labib M, Golan JD, Jacques L. Functional outcome of brachial plexus reconstruction after trauma. Neurosurgery. 2007;61(5):1016–1022; discussion 1022-1013. doi: 10.1227/01.neu.0000303197.87672.31.
6. Dubuisson AS, Kline DG. Brachial plexus injury: a survey of 100 consecutive cases from a single service. Neurosurgery. 2002;51(3):673–682; discussion:682–683.
7. Krishnan KG, Martin KD, Schackert G. Traumatic lesions of the brachial plexus: an analysis of outcomes in primary brachial plexus reconstruction and secondary functional arm reanimation. Neurosurgery. 2008;62(4):873–885; discussion 885-876. doi: 10.1227/01.neu.0000318173.28461.32.
8. Jain DK, Bhardwaj P, Venkataramani H, Sabapathy SR. An epidemiological study of traumatic brachial plexus injury patients treated at an Indian Centre. Indian J Plast Surg. 2012;45(3):498–503. doi: 10.4103/0970-0358.105960.
9. Kaiser R, Waldauf P, Haninec P. Types and severity of operated supraclavicular brachial plexus injuries caused by traffic accidents. Acta Neurochir. 2012;154(7):1293–1297. doi: 10.1007/s00701-012-1291-7.
10. Midha R. Epidemiology of brachial plexus injuries in a multitrauma population. Neurosurgery. 1997;40(6):1182–1188 discussion 1188-1189. doi: 10.1097/00006123-199706000-00014.
11. Doi K, Muramatsu K, Hattori Y, et al. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results. J Bone Joint Surg Am. 2000;82(5):652–666.
12. Doi K, Kuwata N, Muramatsu K, Hottori Y, Kawai S. Double muscle transfer for upper extremity reconstruction following complete avulsion of the brachial plexus. Hand Clin. 1999;15(4):757–767.
13. Moran SL, Steinmann SP, Shin AY. Adult brachial plexus injuries: mechanism, patterns of injury, and physical diagnosis. Hand Clin. 2005;21(1):13-24. doi: 10.1016/j.hcl.2004.09.004.
14. Sakellariou VI, Badilas NK, Mazis GA, et al. P. Brachial plexus injuries in adults: evaluation and diagnostic approach. ISRN Orthop. 2014;2014:726103. doi: 10.1155/2014/726103.
15. Miller C, O'Sullivan J, Jeffrey J, Power D. Brachial Plexus Neuropathies During the COVID-19 Pandemic: A Retrospective Case Series of 15 Patients in Critical Care. Phys Ther. 2021;101(1):pzaa191. doi: 10.1093/ptj/pzaa191.
16. Dy CJ, Lingampalli N, Peacock K, et al. Direct cost of surgically treated adult traumatic brachial plexus injuries. J Hand Surg Glob Online. 2020;2(2):77-79. doi:10.1016/jhsg.2019.12.001.
17. Hong TS, Tian A, Sachar R, et al. Indirect Cost of Traumatic Brachial Plexus Injuries in the United States. J Bone Joint Surg Am. 2019;101(16):e80. doi: 10.2106/JBJS.18.00658.
18. Nath RK, Lyons AB, Bietz G. Microneurolysis and decompression of long thoracic nerve injury are effective in reversing scapular winging: long-term results in 50 cases. BMC Musculoskelet Disord. 2007;8:25. doi: 10.1186/1471-2474-8-25.
19. Nath RK, Somasundaram C. Meta-Analysis of Long Thoracic Nerve Decompression and Neurolysis Versus Muscle and Tendon Transfer Operative Treatments of Winging Scapula. Plast Reconstr Surg Glob Open. 2017;5(8): e1481. doi: 10.1097/GOX.0000000000001481.
20. Nath RK, Somasundaram C. Excellent Recovery of Shoulder Movements After Decompression and Neurolysis of Long Thoracic Nerve in Teen Patients with Winging Scapula. Eplasty. 2019;19: e15.
