Background:Diagnosis and assessment of functional deltoid recovery following axillary nerve injury is challenging due to numerous other muscular contributions to shoulder movement - particularly supraspinatus, rhomboids and long head of triceps. We present the deltoid abduction lag test (DALT) which offers four clear benefits: 1) it successfully isolates deltoid in the presence of a functioning supraspinatus with intact tendon and attachment; 2) it is safe to perform early following anterior shoulder dislocation (the most common cause of axillary nerve injury); 3) it allows assessment of early functional reinnervation of posterior deltoid to aid decision-making with respect to surgical intervention; 4) it is an objective measure which does not rely on patient compliance with initiation of active movement. Methods:A retrospective review of consecutive patients referred with axillary nerve injury to a national centre for Peripheral Nerve Injury between 2014 and 2024 was conducted. Inclusion criteria was isolated persistent axillary nerve injury confirmed on neurophysiological testing with intact rotator cuff, rhomboid and triceps function. Patients who had undergone prior nerve transfer to address axillary nerve injury were excluded. Patients were independently assessed by two orthopaedic surgeons and a Cohen's kappa (κ) value was calculated to assess inter-rater reliability. The DALT was performed with a goniometer used to measure degree of lag comparative to the coronal plane. Passive range of shoulder movement, rotator cuff / triceps / rhomboid power, upper lateral cutaneous nerve sensation, swallow-tail test, deltoid extension lag test, 'akimbo' test and Bertelli test were documented for both shoulders. Results:Six patients with a mean age of 36 (15-68) were included. The DALT was positive in all cases of ongoing axillary nerve palsy. There was no discrepancy between both surgeons' independent clinical interpretation of the DALT. Conclusion:The DALT successfully and reproducibly isolates deltoid function and identifies axillary nerve palsy. We specifically advocate using this test immediately following injury to confirm the presence of an axillary nerve lesion, at 3 months post-injury to identify patients who have experienced a neurapraxic injury and at 6 months to identify axonal lesions which may benefit from surgical intervention.

A 73-year-old woman was referred to a National Centre for Peripheral Nerve Injury with a post-operative left radial nerve degenerative lesion following open reduction and internal fixation of a proximal third humerus fracture using radiolucent Arthrex FiberTape® Cerclage as an adjunct to plating to improve stability. Intra-operative photographs illustrate compression of the radial nerve under the cerclage construct. Use of radiolucent cerclage for humerus fractures is increasing with modern systems capable of withstanding an ultimate load of 4300 N. We highlight the risk of debilitating neurological injury when not deployed safely and describe anatomical high-risk zones for injury. We emphasize the impact of delay in diagnosis and treatment.

CASE:A 22-year-old man underwent a posterior cruciate ligament reconstruction following a sporting injury. Postoperatively, he developed a new foot drop on the hamstring harvest side that was contralateral to the ligamentous injury. On surgical exploration, a lesion in the peroneal nerve fascicles of the sciatic nerve, 20 cm from the fibula head, was neurolyzed with improvement in the foot drop. CONCLUSIONS:Sciatic nerve injury is a rare complication when harvesting the hamstring. Care of orientation of the tendon stripper blade and direction of harvest is required to avoid injury to the sciatic nerve.

In modern orthopedic practice, some degree of subspecialist expertise is required and training programs must provide for this. Specialist training in university teaching hospitals provides opportunities beyond just exposure to the complex case mix of a tertiary center. Specialist orthopedic hospitals provide care and leadership with national and international expertise. Their role in orthopedic training is substantial. With legislative reductions in permissible working hours orthopedic training continues to adapt to provide surgeons with the opportunities to fully develop skills, with teaching hospitals well placed to facilitate this. This article discusses the role of specialist training and teaching hospitals in contemporary orthopedic surgery.