Prevalence of brachial plexus injuries in patients with scapular fractures: a national trauma data Bank review

S capular fractures comprise 3% to 5% of all shoulder girdle fractures, while accounting for <1% of all fractures (1). Fracture of the scapula usually occurs after high-energy trauma; thus, approximately 90% of patients have concomitant injuries (2,3). In a previous study investigating scapular fractures, McGahan et al (4) found that at four weeks follow-up after injury, complaints pertaining to the shoulder, such as decreased range of motion and pain, were limited to the subset of patients who experienced neurological deficits in addition to their scapular fracture. That article emphasized the importance of early recognition and treatment of brachial plexus injuries to improving patient outcomes. The purpose of the present investigation was to study a large number of patients with different types of scapular fractures to determine the prevalence of concurrent brachial plexus injuries; to determine how prevalence varies in different regions of the scapula injured; and to assess which specific nerves of the brachial plexus were injured. This information may help to guide clinical suspicion and increase awareness of this often devastating injury. The National Trauma Data Bank (NTDB), currently the largest trauma registry in the United States (US), containing data on >5 million cases from >900 registered US trauma centres, was used to gather the data (5). METHODS The present study was a retrospective review of the NTDB data set from 2007 through 2011. The NTDB is an incident-centred database that uses International Classification of Diseases, Ninth Revision (ICD-9) codes to code for specific diagnoses. Because no patient identifiers exist in the database, patient incidents are represented with unique incident identifier keys. All incidents involving scapular fracture, as assessed according to ICD-9 diagnosis code, were extracted from the database. Specifically, scapular fractures were divided into six anatomical regions according to ICD-9 code: acromial process, coracoid process, body or spine grouped together, glenoid cavity or neck grouped together, multiple region fractures and unspecified region fractures. The scapular fracture data were accompanied by a list of other injuries associated with the given incident. Among these, injuries to the brachial plexus were of interest. Brachial plexus injuries were divided according to ICD-9 codes into injuries to specific nerves: axillary nerve, median nerve, musculocutaneous nerve, radial nerve, ulnar nerve, cutaneous sensory nerve of the upper limb, cervical root injury, other specified nerve injury, multiple nerve injury and unspecified nerve injury. BACKgROUND: Studies investigating the prevalence of brachial plexus injuries associated with scapular fractures are sparse, and are frequently limited by small sample sizes and often restricted to single-centre experience. OBJECTIVE: To determine the prevalence of brachial plexus injuries associated with scapular fractures; to determine how the prevalence varies with the region of the scapula injured; and to assess which specific nerves of the brachial plexus were involved. METHODS: The present study was a retrospective review of data from the National Trauma Data Bank over a five-year period (2007 to 2011). RESULTS: Of 68,118 patients with scapular fractures, brachial plexus injury was present in 1173 (1.72%). In patients with multiple scapular fractures, the prevalence of brachial plexus injury was 3.12%, and ranged from 1.52% to 2.22% in patients with single scapular fractures depending on the specific anatomical location of the fracture. Of the 426 injuries with detailed information on nerve injury, 208 (49%) involved the radial nerve, 113 (26.5%) the ulnar nerve, 65 (15%) the median nerve, 36 (8.5%) the axillary nerve and four (1%) the musculocutaneous nerve. CONCLUSION: The prevalence of brachial plexus injuries in patients with scapular fractures was 1.72%. The prevalence was similar across anatomical regions for single scapular fracture and was higher with multiple fractures. The largest percentage of nerve injuries were to the radial nerve

Locally applied Ketorolac and Bupivicaine with epinephrine for the control of postoperative pain in breast augmentation patients

One of the difficulties that continues to challenge reconstructive and aesthetic surgeons is postoperative pain control. Developments in anaesthesia have increased the understanding of pain and it is now accepted that there is a role for pre-empting it. Research with systemic non-steroidal anti-inflammatory drugs and local anaesthetics has been encouraging. The use of locally applied non-steroidal anti-inflammatory drugs in combination with local anaesthetics has not been studied. The objective of this study was to test the effectiveness of locally administered, intraoperative Ketorolac and Bupivicaine with epinephrine at reducing pain in the first two-hours of the postoperative period. Ethical approval was obtained from the Ethics Review Board of the Okanagan / Similkameen Health Region through the Kelowna General Hospital and the Medical Director of the Okanagan Plastic Surgery Center. The study was designed as a prospective, randomized, triple-blind, clinical trial. One hundred consecutive breast augmentation patients were enrolled and informed consent was obtained from each patient. A standard anaesthetic protocol and surgical procedure were followed. The intervention was divided into four groups of twenty-five patients that received either normal saline, Ketorolac only, Bupivicaine only or Ketorolac and Bupivicaine. The primary outcome was pain as measured by the Visual Analog Pain Scale. The secondary outcome was time spent in the recovery room. Other variables were considered for their effect on postoperative pain. All patients completed the study. The power of this study was 0.90 and confidence intervals of 95% were used to determine significance. The findings of this study allow rejection of the null hypothesis and support the alternate hypothesis that in women undergoing primary augmentation mammaplasty, intraoperative irrigation of Ketorolac combined with Bupivicaine with epinephrine into the surgical wound reduced pain in the postoperative period. It did not appear that anaesthesiologist, anaesthesia time, surgeon, OR time, difficulty of dissection or implant size had a significant impact on postoperative pain. Time in the recovery room was not different between the current standard of care and the Ketorolac and Bupivicaine patients. However, there was a trend that Ketorolac and Bupivicaine patients did spend less time in the recovery room than the Bupivicaine only patients.Surgery, Department ofMedicine, Faculty ofGraduat

Stabilization of the Chest Wall: Autologous and Alloplastic Reconstructions

The goals of chest wall stabilization include maintenance of a rigid airtight cavity, protection of the thoracic and abdominal contents, optimization of respiration, and, whenever possible, an aesthetic reconstruction. Evidence suggests that bony fixation results in reduced ventilator dependence, a shorter overall hospital stay, and improved upper extremity function. We prefer to accomplish this with autologous tissue alone (such as the pectoralis major, latissimus dorsi, or rectus abdominus muscle flaps) for small to moderate defects. En bloc resection of defects larger than 5 cm or containing four or more ribs will likely benefit from chest wall stabilization. For patients previously treated with radiation, even larger defects may be tolerated owing to fibrosis. For these larger defects, methyl methacrylate composite meshes are used and covered with vascularized tissue. Contaminated wounds are generally reconstructed with bioprosthetic mesh rather than synthetic mesh. Using these principles, the reconstructive plastic surgeon can devise a comprehensive and safe plan to repair tremendous defects of the chest wall