The prevalence of traumatic brachial plexus injury in. Prevalence of Rotator Cuff Tears in Adults with TraumaticBrachialPlexusInjuries

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1 e139(1) COPYRIGHT Ó 2014 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Prevalence of Rotator Cuff Tears in Aults with TraumaticBrachialPlexusInjuries Davi M. Brogan, MD, Braley C. Carofino, MD, Michelle F. Kircher, RN, Robert J. Spinner, MD, Bassem T. Elhassan, MD, Allen T. Bishop, MD, an Alexaner Y. Shin, MD Investigation performe at the Department of Orthopeic Surgery, Mayo Clinic, Rochester, Minnesota Backgroun: Restoration of shouler function is a primary goal when treating patients with traumatic brachial plexus injury. A concomitant rotator cuff tear may alter the treatment approach an prognosis for these iniviuals. The purpose of this stuy was to efine the prevalence of rotator cuff tears in patients with traumatic brachial plexus injuries. Methos: This is a retrospective review of 280 ault patients with traumatic brachial plexus injury treate at a single institution over a twelve-year perio. An upper-extremity magnetic resonance imaging (MRI) scan was acquire for all patients as part of the initial evaluation for posttraumatic brachial plexus injury. The raiographic an clinical ata on these patients were reviewe to ocument partial or full-thickness rotator cuff tears, mechanism an location of the brachial plexus injury, an age. Results: Twenty-three patients (8.2%) ha a full-thickness rotator cuff tear: one patient ha tears involving three tenons, eight patients ha tears involving two tenons, twelve patients ha a single-tenon tear, one patient ha a single-tenon tear in each shouler, an one patient ha a single-tenon tear in one shouler an a two-tenon tear in the other. Twentyone tears involve the supraspinatus, eight involve the infraspinatus, an seven involve the subscapularis. Thirteen patients unerwent surgical repair of the rotator cuff. The average age of the patients in this cohort was 33.4 years, an oler age was associate with an increase risk of full-thickness rotator cuff tears (os ratio [OR], 1.06 per year). Patients with infraclavicular brachial plexus injury ha a significantly higher rate of full-thickness rotator cuff tears. Conclusions: Concomitant rotator cuff tears are present in approximately one in ten patients with traumatic brachial plexus injury. These injuries may contribute to shouler ysfunction; therefore, evaluation of the rotator cuff with imaging stuies is appropriate when formulating treatment strategies. Level of Evience: Prognostic Level IV. See Instructions for Authors for a complete escription of levels of evience. Peer Review: This article was reviewe by the Eitor-in-Chief an one Deputy Eitor, an it unerwent bline review by two or more outsie experts. It was also reviewe byan expert in methoologyan statistics. The Deputy Eitor reviewe each revision of the article, an it unerwent a final reviewbythe Eitor-in-Chief prior to publication. Final corrections an clarifications occurreuring one or more exchanges between the author(s) an copyeitors. The prevalence of traumatic brachial plexus injury in polytrauma patients seen at a level-i trauma center has been previously reporte to be 1.2%, with the injuries mostly seen in young males 1. These brachial plexus injuries result in a spectrum of ysfunction ranging from temporary neurologic eficits to complete loss of limb function, an they can have evastating lifelong consequences. Shouler ysfunction may be cause by neurologic an/or musculoskeletal impairment. As a result of their high-energy nature, traumatic brachial plexus injuries are often associate with osseous an soft-tissue injuries aroun the shouler girle, yet the prevalence of concomitant rotator cuff tears in the setting of brachial plexus injuries has not been previously efine, to our knowlege. There have been case reports escribing rotator cuff tears with associate brachial plexus injuries. These cases have most commonly involve an anterior shouler islocation, an injury pattern that has been escribe as Disclosure: None of the authors receive payments or services, either irectly or inirectly (i.e., via his or her institution), from a thir party in support of any aspect of this work. One or more of the authors, or his or her institution, has ha a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomeical arena that coul be perceive to influence or have the potential to influence what is written in this work. No author has ha any other relationships, or has engage in any other activities, that coul be perceive to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitte by authors are always provie with the online version of the article. J Bone Joint Surg Am. 2014;96:e139(1-6)

2 e139(2) the terrible tria of the shouler 2,3. Isolate injuries of the brachial plexus along with a rotator cuff tear have also been reporte 4. Detection of such injuries by clinical examination is extremely challenging because brachial plexus injuries often prouce shouler girle weakness that overshaows or mimics the rotator cuff tear. Detecting an treating rotator cuff tears in patients with brachial plexus injury are important for two reasons. First, many brachial plexus surgeons consier shouler stability an motor function a priority of treatment 5. The rotator cuff muscles are critical as they contribute to shouler strength, motion, an stability 6-8. Secon, in patients with nerve injuries that inclue the suprascapular nerve, proceures for reinnervation of the supraspinatus an infraspinatus muscles are consiere if shouler function oes not show evience of recovery 5. These proceures inclue nerve transfers to the suprascapular nerve or a nerve graft repair. Before embarking on such an operation it woul be valuable to know if the target rotator cuff muscles are torn, as it has been shown that asymptomatic patients in the general population who have a large or massive rotator cuff tear have ecrease abuction strength when compare with the strength on the contralateral sie 9. The above finings suggest that optimal restoration of function in a patient with a brachial plexus injury epens on an intact rotator cuff. In aition, nerve transfers or grafting to the suprascapular nerve have ha variable success, with several stuies emonstrating overall isappointing results The cause of these variable results is unknown, but brachial plexus surgeons may seek to optimize outcomes in any way possible, incluing repair of rotator cuff tears when present. The appropriate screening criteria for associate soft-tissue injury aroun the shouler in a patient with a brachial plexus injury has not been establishe, perhaps in part because the prevalence of concomitant rotator cuff tears is unknown. Therefore, we reviewe shouler magnetic resonance imaging (MRI) scans in a series of patients with traumatic brachial plexus injury to efine the prevalence of concomitant rotator cuff tears. Materials an Methos After institutional review boar approval was obtaine, we performe a retrospective review of the charts of all patients who ha presente to a tertiary multiisciplinary brachial plexus clinic from 1998 to Any ault patient with a traumatic brachial plexus injury an a eicate MRI of the shouler was eligible for inclusion. During this time interval, MRI of the shouler was routinely performe as part of the stanar protocol for evaluation of all patients with brachial plexus injury presenting to our institution, regarless of whether a concomitant shouler injury was suspecte. Patients presenting with an MRI of the brachial plexus who i not also unergo a eicate shouler MRI were exclue. Aitionally, any patient with noniagnostic MRI seconary to poor quality or artifact were exclue, as were patients whose MRI was not available in the electronic meical recor for review. A total of 307 patients were evaluate in the brachial plexus clinic uring this time perio, an 280 of them met the inclusion criteria. Electronic recors of these patients were examine for emographic ata an finings from physical an electrophysiologic examinations, imaging stuies, an operative notes. As part of the global evaluation at the brachial plexus clinic, all patients were routinely aske about relevant meical history, incluing prior injury or surgical proceures in the upper extremity or shouler (see Appenix). The following ata were recore for Fig. 1 Status of the rotator cuff stratifie by injury mechanism. FT = full-thickness. ATV = all-terrain vehicle accient, MVA = automobile accient, an Pes VS MVA = peestrian-automobile accient.

3 e139(3) Fig. 2 Rotator cuff (RTC) tears stratifie by patient age. each patient: (1) age, (2) interval between the injury an presentation at the brachial plexus clinic, (3) mechanism of injury, (4) location of nerve lesion, (5) extent of rotator cuff injury (if present) base on MRI, an (6) operative treatment for the brachial plexus lesion an/or rotator cuff tear (if performe). MRI interpretations by fellowship-traine musculoskeletal raiologists were utilize to etermine which rotator cuff tenons (supraspinatus, infraspinatus, subscapularis, an/or teres minor) were involve. Aitionally, the tears were efine as either full-thickness or partial-thickness as etermine by the musculoskeletal raiologists at our institution. The location of the brachial plexus injury was etermine on the basis of serial physical examinations by a minimum of two of the three brachial plexus surgeons (A.Y.S., A.T.B., an R.J.S.), compute tomography (CT) myelography an electrophysiologic testing, an operative finings. The location of the brachial plexus injury was broaly categorize as either supraclavicular or infraclavicular. Supraclavicular lesions were efine as those involving the nerve root, trunk, or ivision, whereasthoseinvolvingcorsorterminalnervebrancheswereclassifieasinfraclavicular. The mechanism of injury was categorize into one of eight common groups for purposes of analysis (Fig. 1). Statistical Methos The clinical ata were recore in a spreasheet, an statistical analysis software was use. The average age an average interval between injury an presentation were calculate for all patients as well as for the subset of those with a fullthickness tear. A one-taile t test was use to evaluate for a significant ifference in age between the populations with an without a full-thickness tear as well as between the infraclavicular an supraclavicular injury populations. A logistic regression analysis was performe to examine the effects of increasing age on the probability of having a full-thickness rotator cuff tear. A binary outcome reflecting the presence of a full-thickness tear was compare with a continuous variable reflecting age. The association between full-thickness tears an the location of the nerve injury was examine with use of a one-taile Fisher exact test. Significance was set at an alpha value of MRIs were consiere noniagnostic seconary to metal artifact in the shouler, an another twenty patients presente with MRIs of the brachial plexus or the biceps, or magnetic resonance angiograms of the chest, without eicate shouler MRIs. Therefore, 280 patients forme our cohort; 242 were men an thirty-eight were women with an average of 33.4 years. Twenty-three patients (8.2%) ha a full-thickness rotator cuff tear. One patient ha tears involving three tenons, eight patients ha tears involving two tenons, twelve patients ha a single-tenon tear, one patient ha a single-tenon tear in each shouler, an one patient ha a single-tenon tear in one shouler an a two-tenon tear in the other. Twenty-one tears involve the supraspinatus, eight involve the infraspinatus, an seven involve the subscapularis. Seventy-seven patients (28.0%) ha a partial-thickness rotator cuff tear. Aitional etails regaring the patients with a full-thickness tear are presente Source of Funing There was no outsie source of funing for this stuy. Results Atotal of 307 ault patients were evaluate for a traumatic brachial plexus injury. Twenty-seven patients were exclue because of inaequate MRI. Of these, one patient ha an MRI performe at an outsie facility that was not available for review electronically. An aitional six were exclue because their Fig. 3 Logistic regression plot emonstrating an increasing prevalence of fullthickness (FT) rotator cuff tears with avancing age.

4 e139(4) Fig. 4 Full-thickness (FT) rotator cuff tears stratifie by location of neurologic injury. in the Appenix. The total number of patients who ha either a full or partial-thickness tear was 100 (35.7%). Association Between Age an Injury, an Rotator Cuff Tears The average age was 46.1 years for the patients with a fullthickness rotator cuff tear an 32.1 years for those without a full-thickness tear (p < 0.05). Thirty percent of the patients with a full-thickness tear were uner the age of forty, an 83% were less than sixty years ol (Fig. 2). A logistic regression analysis emonstrate an os ratio of 1.06 (95% confience interval, 1.03 to 1.09) for the likelihoo of having a full-thickness cuff tear with each increasing year of age (Fig. 3).The average age was 36.6 years for patients with a supraclavicular injury an 32.4 years for those with an infraclavicular injury. The meian ages of these groups were twenty-nine an thirty-two years, respectively. Association Between Location of Brachial Plexus Injury an Rotator Cuff Tears The brachial plexus injury was at the infraclavicular level in sixty-two patients (22%) an at the supraclavicular level in 218 (78%). A full-thickness rotator cuff tear was present in 19% (twelve) of the sixty-two patients with an infraclavicular injury an only 5% (eleven) of the 218 with a supraclavicular injury (Fig. 4) (p < 0.05). Discussion Restoration of shouler function is one of the primary goals of the treatment of brachial plexus injuries. For this reason, attention shoul be given to iagnosing an treating rotator cuff tears in these patients. To our knowlege, the prevalence of rotator cuff tears in the setting of traumatic brachial plexus injuries has not been efine. In our series, 8% of patients with brachial plexus injury also ha a full-thickness rotator cuff tear. Given the young age of our patient population, it is even more critical to recognize an repair tears as early as possible. Young age has been shown to be a positive preictor of healing after rotator cuff repair, an progression of fatty atrophy of rotator cuff tenons has been halte in patients with an intact repair 13. We also foun an association between full-thickness rotator cuff injuries an infraclavicular nerve injuries. The reason for this association is unclear. It may be ue to the age istributions in these groups, as those with infraclavicular injury were slightly oler, with a four-year ifference in the average ages. However, given the relatively young age of both groups, it seems more likely that the association between full-thickness rotator cuff injuries an infraclavicular nerve injuries is a consequence of the mechanism of injury. Forces that cause wiening of the shouler-neck angle prouce supraclavicular injuries while those that increase the scapulohumeral angle usually result in infraclavicular injuries 14. It is possible that the latter prouces a greater egree of rotator cuff amage. In many stuies, a fall onto an outstretche han or forceful external rotation of an aucte 15 or abucte 16 arm was the most common mechanism of injury for traumatic rotator cuff tears 17, particularly those involving the subscapularis. Severe, suen abuction of the arm woul be more likely to result in an infraclavicular injury. Although infraclavicular injuries were relatively rare in our series, they were isproportionately foun in patients with a rotator cuff tear. This fining is similar to that in a series from Louisiana State University, in which 28% of 509 stretch injuries were infraclavicular 18. In that patient population, Kim et al. foun the prevalence of shouler islocation, fracture, an vascular injury

5 e139(5) to be higher in patients with infraclavicular injury than in those with supraclavicular injury 18. As note previously, twenty-seven of the 307 patients evaluate in our clinic were exclue because of a lack of appropriate shouler imaging. Therefore, it may be helpful to consier how the exclue patients may have biase our results. If all twenty-seven of them ha a full-thickness rotator cuff injury, theprevalenceoffull-thicknesstearswoulbe16%.ifnoneha a full-thickness cuff tear, the prevalence woul be 7.5%. Both of these extremes seem unlikely, but it shoul be note that six of the patients were exclue because metal artifact (suture anchors, plates, an screws) renere their MRI unreaable. It seems highly probable that those patients ha an increase prevalence of rotator cuff tears compare with our clinic population. If all six of those patients ha a full-thickness rotator cuff tear, our prevalence woul increase from 8.2% to 10.1%. This stuy has limitations inherent to retrospective stuies of a population that is heterogeneous with respect to injury, mechanism, anisability. Perhaps more importantly, we are unable to etermine with absolute certainty whether the rotator cuff tears were traumatic injuries or preexisting egenerative tears. Screening MRI stuies have emonstrate a 28% prevalence of asymptomatic rotator cuff tears in patients over sixty years ol an none in patients between nineteen an thirtynine years ol 19. Tempelhof et al. examine the age-relate prevalence of asymptomatic rotator cuff tears an foun an increasing prevalence of full-thickness tears with increasing age 20. Patients in the sixth ecae of life ha a 13% prevalence of rotator cuff tears, an this number increase with each ecae 20.Inourpopulation, 30% of those with a full-thickness tear were below the age of forty years an 83% were uner the age of sixty years. In general, our patients were on the younger en of the spectrum of iniviuals with possible atraumatic tears; therefore, a preexisting egenerative tear is possible but less likely. Yamamoto et al. examine the prevalence of rotator cuff tears in the general population of a mountain village in Japan an foun that 20.7% of participants ha a full-thickness rotator cuff tear, with the risk for a rotator cuff tear increasing with a history of trauma or avancing age 21. No patient in their twenties an only 2.5% of patients in their thirties ha a rotator cuff tear 21. Braune et al. foun that the average age of patients with a traumatic tear was significantly younger than that of patients with an atraumatic tear (34.2 compare with 54.1 years) 22. Their criterion for iagnosis of a traumatic tear was no preexisting shouler pain or ysfunction with a suen loss of function accompanie by an aequate traumatic mechanism. In that stuy, an age of fifty years was use as the cutoff to exclue patients from their group with a traumatic tear. The average age of the patients with a rotator cuff tear in our stuy population was forty-six years. However, the authors of a recent meta-analysis incluing 511 traumatic rotator cuff tears from nine stuies reporte a weighte average age of 54.7 years 17.Ifa threshol of fifty years was applie to our patient population, seven patients woul be exclue from the group with a rotator cuff tear an sixteen woul remain, for a prevalence of rotator cuff tears of 5.7%. If a threshol of more than fifty-five years were applie instea, eighteen patients woul remain, for a prevalence of 6.4%. Therefore, while we cannot say with certainty whether or not the tears were preexisting, we believe it is highly improbable in the younger population. The exact etiology of the tear is seconary to the fact that full-thickness tears exist an may present a hinrance to postoperative recovery after a major shouler reconstruction. Perhaps more important than MRI finings, is preexisting pain or ysfunction of the shouler prior to the injury. The patient s history, along with his or her age, can be invaluable in elineating acute from chronic tears anetermining the likelihoo of future isability from such tears. As shown in the Appenix, only one patient ha a history of ifficulty with shouler abuction >90. In that patient, it is possible that the rotator cuff tear precee the trauma; however, only two of the remaining affecte patients ha any notable shouler history. The absence of a history of shouler problems, combine with the overall youth of those affecte, strongly suggests that the majority of the full-thickness tears resulte from the traumatic injury. The association of avancing age with increasing risk of rotator cuff tears in the regression moel suggests that oler patients may be preispose to sustaining a full-thickness rotator cuff tear with a traumatic injury. This association is likely ue to one of two factors: oler patients ha preexisting asymptomatic tears that were etecte by our screening protocol or oler patients ha rotator cuffs that were at greater risk as a result of preexisting egenerative changes. We were unable to control for these confouning factors with our current ata. Previous publications also have emonstrate that oler patients are more likely to sustain both traumatic anegenerative rotator cuff tears. Neviaser et al. 23 reporte on thirty-one patients with a traumatic rotator cuff tear following anterior shouler islocation, an all were oler than thirty five. Our stuy was not sufficiently powere to establish an absolute age below which a rotator cuff tear will not be present. The youngest patient in our series with such an injury was nineteen years ol. This stuy has emonstrate that the prevalence of fullthickness rotator cuff tears in patients with a traumatic brachial plexus injury is approximately 10%, an the risk of such an injury increases with age. We believe that this prevalence is high enough to warrant a preoperative shouler MRI to assess the status of the rotator cuff as part of the global evaluation of a patient presenting with a traumatic brachial plexus injury. Appenix A table summarizing the ata on the patients with a fullthickness rotator cuff tear is available with the online version of this article as a ata supplement at jbjs.org. n Davi M. Brogan, MD Braley C. Carofino, MD Michelle F. Kircher, RN Robert J. Spinner, MD

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