Biomedical subjects
Publications and source records attributed to R D Leffert.
The shoulder is the most mobile joint in the body. Because it serves as a way station for the nerves supplying the upper limb, it creates a potential for nerve lesions that may be caused or significantly influenced by the complex dynamics of the shoulder girdle. This article presents the most commonly encountered lesions as well as an algorithm for their diagnosis and treatment.
BACKGROUND: Paralysis of the serratus anterior muscle can be functionally disabling. As a result of the scapular winging associated with such paralysis, the scapula does not remain apposed to the thorax when the upper extremity is elevated forward at the shoulder. This produces functional disability associated with pain and loss of a stable base for movement of the upper extremity. METHODS: We reviewed the results of transfer of the pectoralis major tendon with the addition of a fascial graft in sixteen patients who had paralysis of the serratus anterior. The average age of the patients at the time of the operation was thirty-three years (range, twenty to fifty-five years). Electrodiagnostic studies confirmed the presence of an isolated injury of the long thoracic nerve. The index operation was performed sixteen months to eleven years after the onset of pain and weakness. The etiology of the paralysis was idiopathic in two patients, traumatic in seven, and secondary to operative intervention in seven. All patients had pain in the shoulder on the side of the paralysis. RESULTS: The result was excellent for eight patients, good for five, and fair for one at an average of four years and three months (range, two years and one month to nine years) postoperatively. There were two failures, both of which occurred after a traumatic event. Of the fourteen patients in whom the procedure did not fail, eight were asymptomatic and had normal function, five had intermittent mild discomfort, and one had frequent mild pain without any winging of the scapula. The average Constant and Murley score for the fourteen patients in whom the procedure did not fail increased from 36 points preoperatively to 92 points postoperatively. CONCLUSIONS: The index procedure successfully alleviated the functional disability caused by paralysis of the serratus anterior muscle.
Thoracic outlet syndrome may follow trauma but also may be seen as a result of postural abnormalities of the shoulder girdle. Cervical ribs and other anatomic variations are not prerequisites for the diagnosis, although they may be more common in patients with thoracic outlet syndrome. The diagnosis is made by history and physical examination. There is no reliable laboratory diagnostic test to confirm or exclude the diagnosis. Proper selection of candidates for surgery can produce excellent and good results in a high percentage of cases. The transaxillary approach to first rib resection is tolerated well, and serious complications should be unusual when the procedure is performed by an experienced surgeon. Postoperative attention to shoulder girdle mechanics is important in the prevention of recurrence of symptoms and treating them should they occur.
TOS may arise in a variety of circumstances including trauma, but it may also be seen as a result of postural abnormalities that may be induced by different factors. Cervical ribs and other congenital anomalies are not necessary prerequisites for either the causation or diagnosis of TOS, although they are more common in the TOS population. More important than diagnostic tests are the history and physical examination of the patient. Double crush syndrome can complicate the diagnosis and treatment; however, proper selection of candidates for surgery can produce excellent and good results in a high percentage of cases. Perioperative complications can be significant, so that surgery should be restricted to only those patients who find their symptoms intolerable.
Explore the source record for details and available documents.
A system for evaluation of patients with brachial plexus injury is based on careful observation, including the patient's history and a physical examination, a radiographic assessment, and electrodiagnosis. The clinical history and physical examination remain the cornerstone of this evaluation and their documentation is vital. Traction injuries, wherein there is a possibility of root avulsion, were examined myelographically and electromyographically at one month. Although they must be considered, the limitations of these methods of evaluation do not vitiate their usefulness. Modification of the evaluation procedures should be made according to the requirements imposed by specific causal agents and circumstances.
Brachial plexus injuries result in severe functional deficits in the upper limb. The authors review a group of 74 patients with brachial plexus injuries who underwent 160 tendon transfer operations, as well as 94 additional procedures, in an attempt to augment lost function. Following evaluation of functional recovery, 58 percent of the patients were rated Good, 34 percent Improved, and 8 percent Unimproved. The authors conclude that significant benefit can be obtained by peripheral reconstruction and tendon transfers in patients with brachial plexus injuries.
Tendon transfer and bulk reduction procedures are an alternative to amputation of the elephantoid enlarged limb with neurofibromatosis and paralysis. A patient with this progressive disease has been followed-up for 10 years and retains sufficient function to work as a computer operator.
The rehabilitation of patients with brachial plexus injury is a complex process that is dependent upon the understanding by the physician, and others involved in providing care, of the nature of the nerve injury, its natural history, and what measures are available to lessen the disability of such patients. In addition, the patients themselves must understand these same facts so that they can maximize the treatment they receive.
Twenty-three patients who had a clavicular non-union were treated operatively at the Massachusetts General Hospital from 1974 to 1985. Twenty-one non-unions were the result of fracture and two, secondary to osteotomy. Twenty non-unions were located in the middle third of the clavicle, while three were in the lateral third. Radiographically, eighteen non-unions were atrophic and three, hypertrophic. Two non-unions resembled pseudarthrosis. Of the etiological factors that were reviewed the extent of displacement of the original fracture was the most significant. Associated complications of the non-union included limited mobility of the shoulder in fourteen, neurological symptoms in eight, thoracic outlet syndrome in four, and arterial ischemia in one. Of the nineteen patients who were treated to obtain union, seventeen had a successful result at an average length of follow-up of 23.8 months. In sixteen (93.7 per cent) of the seventeen patients union was achieved by fixation with a plate; one patient required two procedures. Ancillary bone graft was used in eighteen patients, with three requiring a sculptured bicortical graft from the iliac crest to span a defect. Of the four other patients three were treated with a partial clavicular resection and one, with complete clavicectomy.
A relationship exists between anterior shoulder subluxation and thoracic outlet syndrome that is responsible for the more florid symptoms of dead arm syndrome (DAS) in some patients. This relationship was demonstrated in eight of 27 patients (30%) in a consecutive series of Bankart operations for treatment of subluxation. The mechanism is associated with a disturbance in the kinesiology of the shoulder-joint complex that alters the position of the scapula relative to the rib cage and neurovascular supply to the upper limb. Therapy is directed toward restoration of the stability of the glenohumeral joint so that normal biomechanics can be reestablished. In advanced stages of thoracic outlet syndrome, however, DAS may initially require surgical decompression of the nerves and vessels. Careful attention to postural mechanics is essential for rational diagnosis and treatment of DAS.
The clinical entity of frozen shoulder has been the subject of considerable controversy concerning pathogenesis and treatment. This is a review and interpretation of the literature against the background of my personal experience and a formulation of a treatment algorithm based on a practical synthesis of these sources. The separate stages of the disease are clearly definable and must be considered in prescribing treatment for the purpose of compressing the natural history and morbidity of this self-limited though disabling condition.
We describe our experience with 100 musicians in whom occupation-related difficulties developed. The majority, pianists, experienced hand difficulties in midcareer (average age, 31 years). These were described as "pain, tightening, or weakness" of the right hand or arm or drooping of the fourth or fifth fingers. These difficulties led to loss of control (34%) or diminished facility (18%), endurance (18%), or speed (18%) while playing trills, arpeggios, or octaves requiring fast, forte finger movements. Most commonly found were inflammatory disorders of tendon or joint (45%) or disorders of motor control (24%). Less likely were entrapment of peripheral nerves and noninflammatory tendon or joint disorders.
Explore the source record for details and available documents.
Thoracic outlet syndrome may be the cause of symptoms wrongly attributed to shoulder pathology, or it may accompany or result from shoulder injury. If misdiagnosed, it may leave the physician wondering why relevant shoulder therapy fails to result in a return to full potential, but if correctly diagnosed, it can be cured or ameliorated.
Thirty-eight patients with progressive posttraumatic ulnar neuropathy at the elbow underwent anterior submuscular transposition of their nerves. Multiple mechanical causes of neuropathy were identified. Fourteen patients had undergone previous surgery for ulnar neuropathy, while 24 had not. Postsurgical follow-up averaged 23.1 months. The operative technique is described and illustrated in detail. Complications attributable to surgery were minimal. No absolute prognostic factors could be identified, and even those patients with significant muscular atrophy or time delay before operation were generally benefited. If prior surgery had induced significant scarring and neural damage, the prognosis for recovery was considerably worse, as it also was for patients who had severe preoperative dysesthesia or pain. Four patients thought to represent examples of double crush or compression syndrome were identified.
Explore the source record for details and available documents.
Nine patients seen in civilian practice with severe open injuries of the hand, including loss of portions of some or all of the metacarpals, were treated by primary restoration of metacarpal length and alignment by distraction-fixation with the use of transverse intermetacarpal Kirschner wires. An external fixation device was added in two of the nine patients. Severe associated soft tissue injuries were present in all but one patient. Two injuries were caused by firearms, and the other seven by heavy machinery. Contractures of the joints were prevented by the use of a second set of wires to position the metacarpophalangeal joints in 70 degrees of flexion and the first metacarpal in abduction and pronation. Staged closure of wounds by local or distant flaps and secondary reconstructions by bone, nerve, and tendon grafts or transfers were necessary in all and required an average of almost 2 years until treatment was completed. All except the one child and the one most recently injured patient have returned to employment or vocational retraining. Follow-up was 24 to 78 months from injury.