Objective The utilization of the prone position to treat patients with COVID-19 pneumonia who are critically ill and mechanically ventilated is well documented. This case series reports the location, severity, and prevalence of focal peripheral nerve injuries involving the upper limb identified in an acute COVID-19 rehabilitation setting. The purpose of this study was to report observations and to explore the challenges in assessing these patients. Methods Participants were patients with suspected peripheral nerve injuries following discharge from COVID-19 critical care who were referred to the peripheral nerve injury multidisciplinary team. The patients studied had suspected peripheral nerve injuries following discharge from COVID-19 critical care and were referred to the peripheral nerve injury multidisciplinary team. Data were collected retrospectively on what peripheral neuropathies were observed, with reference to relevant investigation findings and proning history. Results During the first wave of the COVID-19 pandemic in the United Kingdom, 256 patients were admitted to COVID-19 critical care of Queen Elizabeth Hospital, Birmingham, United Kingdom. From March to June 2020, a total of 114 patients required prone ventilation. In this subgroup, a total of 15 patients were identified with clinical findings of peripheral nerve injuries within the upper limb. In total, 30 anatomical nerve injuries were recorded. The most commonly affected nerve was the ulnar nerve (12/30) followed by the cords of the brachial plexus (10/30). Neuropathic pain and muscle wasting were identified, signifying a high-grade nerve injury. Conclusion Peripheral nerve injuries may be associated with prone positioning on intensive care units, although other mechanisms, such as those of a neuroinflammatory nature, cannot be excluded. Impact Proning-related upper limb peripheral nerve injuries are not discussed widely in the literature and may be an area of further consideration when critical care units review their proning protocols. Physical therapists treating these patients play a key part in the management of this group of patients by optimizing the positioning of patients during proning, making early identification of peripheral nerve injuries, providing rehabilitation interventions, and referring to specialist services if necessary.

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Patients with poor grade aneurysmal subarachnoid haemorrhage (SAH) are associated with high mortality and morbidity, and hence are often treated conservatively. This study has set out to determine the outcome for all poor grade subarachnoid haemorrhage patients, and attempts to identify a subgroup with a more favourable prognosis. During a prospective audit of patients with aneurysmal SAH, patients of poor grade [World Federation of Neurological Surgeons (WFNS) IV (and not obeying commands) and V] were sedated, paralysed and ventilated for transfer to the Regional Neurosurgical Unit. Any intraventricular blood and/or hydrocephalus was treated by external ventricular drainage. Following a 24-h period for active blood gas, fluid and electrolyte resuscitation, patients were assessed after reversal of sedation. Selection for angiography and potential aneurysm surgery was restricted to those who showed a purposeful response to painful stimulation. Patients who could readily obey commands were not considered 'true' poor grade and were excluded from analysis. In 102 patients with 'true' poor grade SAH admitted between 1991 and 1997, the overall management outcome at 6 months was poor (favourable outcome 25%, mortality 67%). Following reversal of sedation, 55 patients demonstrated a purposeful response and proceeded to angiography, of whom 37 underwent clipping and three coiling of aneurysm. The outcome in this aneurysm treated subgroup was favourable in 53% (mortality 28%). If patients over the age of 65 years are excluded, the management outcome was favourable in 35% (mortality 58%), with those patients proceeding to clipping or coiling of aneurysms having a favourable outcome in 57% (mortality 27%). Patients over the age of 65 years with poor grade SAH had a favourable outcome in only 6% (mortality 85%). The mortality for poor grade SAH patients remains high. However, following resuscitation and correction of any acute hydrocephalus, a patient subgroup identified on simple clinical criteria can be identified who can expect a better outcome.

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Axillary nerve injury is a well-recognized complication of glenohumeral dislocation. It is often a low-grade injury which progresses to full recovery without intervention. There is, however, a small number of patients who have received a higher-grade injury and are less likely to achieve a functional recovery without surgical exploration and reconstruction.Following a review of the literature and consideration of local practice in a regional peripheral nerve injury unit, an algorithm has been developed to help identification of those patients with more severe nerve injuries.Early identification of patients with high-grade injuries allows rapid referral to peripheral nerve injury centres, allowing specialist observation or intervention at an early stage in their injury, thus aiming to maximize potential for recovery.Cite this article: EFORT Open Rev 2018;3:70-77. DOI:10.1302/2058-5241.3.170003.

BackgroundComplex regional pain syndrome (CRPS) is a heterogenous and poorly understood condition that can be provoked by quite minor injuries. The symptoms and signs of CRPS persist, long after the patient has recovered from the inciting event. In some cases, there is a clear association with a peripheral nerve injury. The degree of disability produced by CRPS is often out of proportion to the scale of the original insult and the condition is associated with protracted recovery times and frequent litigation.MethodsWe have performed a PubMed literature search, referenced landmark papers in the field and included a national expert in peripheral nerve injury and repair in our team of authors.Results and ConclusionsThe diagnostic criteria for CRPS have changed repeatedly over the last two centuries and much of the historical literature is difficult to compare with more recent research. In this review article, we consider how our understanding of the condition has evolved and discuss its pathogenesis, its apparent heterogenicity and the various investigations and treatments available to the clinician.

Nerves may be inadvertently injured during trauma surgery due to distorted anatomy, traction applied to a limb, soft tissue retraction, by power tools, instrumentation and from compartment syndrome. Elective orthopaedic surgery has additional risks of joint dislocation for arthroplasty surgery, limb lengthening, thermal injury from cement and direct injury from peripheral nerve blocks. The true incidence is unknown, and many cases are diagnosed as neurapraxia with the expectation of a full and timely recovery without the need for intervention. The incorrect assignation of a neurapraxia diagnosis may delay treatment for a higher grade of injury and in addition fails to recognize that a diagnosis of neurapraxia should be made with caution and a commitment to regular clinical review. Untreated, a neurapraxia can deteriorate and result in axonopathy. The failure to promptly diagnose such a nerve injury and instigate treatment may result in further deterioration and expose the clinician to medicolegal challenge. The focus of this review is to raise awareness of iatrogenic peripheral nerve injuries in orthopaedic limb surgery, the importance of regular clinical examination, the role of investigations, timing and nature of interventions and also to provide a guide to when onward referral to a specialist peripheral nerve injury unit is recommended. Cite this article: EFORT Open Rev 2021;6:607-617. DOI: 10.1302/2058-5241.6.200123

Traumatic knee dislocation is a complex ligamentous injury that may be associated with simultaneous vascular and neurological injury.Although orthopaedic surgeons may consider CPN exploration at the time of ligament reconstruction, there is no standardised approach to the management of this complex and debilitating complication.This review focusses on published evidence of the outcomes of common peroneal nerve (CPN) injuries associated with knee dislocation, and proposes an algorithm for the management.Cite this article: Deepak Samson, Chye Yew Ng, Dominic Power. An evidence-based algorithm for the management of common peroneal nerve injury associated with traumatic knee dislocation. EFORT Open Rev 2016;1:362-367. DOI: 10.1302/2058-5241.160012.