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Domingue GA, McLaury C, Pham A, Ullah R, Chenoweth B. Entrapment of Median Nerve After Pediatric Elbow Dislocation with a Brief Review of Literature: A Case Study. JBJS Case Connect 2024; 14:01709767-202409000-00018. [PMID: 39058797 DOI: 10.2106/jbjs.cc.24.00021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
CASE We present a case of type II (intraosseous) entrapment of the median nerve in a patient who was diagnosed based on clinical examination and magnetic resonance imaging and who was treated with medial epicondyle osteotomy, neurolysis, and transposition of the nerve to its anatomical position within a month of injury. Our patient made a complete motor and sensory recovery at 5 months with complete functionality and grip strength. CONCLUSION Median nerve entrapment after posterolateral elbow dislocation is a rare complication with roughly 40 cases reported in the literature. This case illustrates the importance of prompt diagnosis and treatment.
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Teodonno F, Maffeis J, Latini F, Chevrier B, Teboul F. Intraosseous Nontraumatic Median Nerve Entrapment at the Elbow: A Case Report. Hand (N Y) 2024:15589447231222319. [PMID: 38265033 DOI: 10.1177/15589447231222319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Intraosseous median nerve entrapment at the level of the elbow can occur after a traumatic event such as fracture and/or dislocation of the elbow. It is considered a rare and severe entity. We present a rare case of nontraumatic median nerve entrapment inside the distal humerus. No article about atraumatic intraosseous entrapment was encountered in literature.
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Affiliation(s)
| | - Jacopo Maffeis
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Frédéric Teboul
- Centre International de Chirurgie de la Main, Paris, France
- Hppe Sos Mains, Champigny-sur-Marne, France
- Institut de la Main, Clinique Bizet, Paris, France
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Yoğun Y, Bezirgan U, Şen Esmer T, Bilgin SS, Armangil M. Entrapment of median nerve after elbow fracture dislocations: expected surgical time frame based on cadaver study. J Plast Surg Hand Surg 2024; 59:14-17. [PMID: 38235969 DOI: 10.2340/jphs.v59.15323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/21/2023] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Median nerve injuries occur in approximately 3% of pediatric elbow fracture dislocations. These rare injuries can be difficult to diagnose, and the results are poor in delay cases. Surgical timing is one of the most important prognostic factors. We aimed to present three patients with median nerve palsy who were referred to our clinic late, and according to these cases, we emphasized the expected time frame for exploration based on our anatomical cadaver study. MATERIALS AND METHODS Between 2008 and 2010, three patients were referred to our clinic because of median nerve paralysis after a treated elbow dislocation. The mean interval between injury and referral was 15 (min: 13-max: 18) months, and the mean age of the patients was 15 (13-18) years. Neurolysis was performed in two patients, and for the third patent, after neurolysis, axonal continuity was observed to be disrupted so sural nerve grafting was performed with four cables. Tendon transfers were performed in all patients. A total number of 20 upper extremities of 10 cadavers were dissected. Due to its proximal innervation and ease of assessment, the muscle innervation of the flexor pollicis longus (FPL) was planned to be evaluated. The distance from the medial epicondyle is calculated in the cadaver study where the nerve injury is found. RESULTS The mean length from the medial epicondyle to the motor innervation of FPL was calculated in each specimen and found to be 101.99 millimeters (mm) (range: 87.5-134.2). The mean longest innervation of FPL was 110.83 mm from (range 87.5-148.1) the medial epicondyle calculated by including each specimens longest nerve length. Knowing that the healing time of a nerve lesion is 1 mm per day, we calculated that the recovery of FPL would take approximately 4 months. CONCLUSION When nerve healing is expected to be 1 mm a day in axonotmesis type injury, after the median nerve palsy following elbow dislocation, thumb flexion should be achieved in the following 4 months generally if the nerve was not entrapped in the joint. This cadaver-based study objectively defined how long to wait for the innervation of the FPL in median nerve injuries in elbow fracture dislocations.
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Affiliation(s)
- Yener Yoğun
- Hand Surgery Unit, Orthopedics and Traumatology Department, Ankara University Faculty of Medicine, Ankara, Turkey.
| | - Uğur Bezirgan
- Hand Surgery Unit, Orthopedics and Traumatology Department, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Tülin Şen Esmer
- Anatomy Department, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Mehmet Armangil
- Hand Surgery Unit, Orthopedics and Traumatology Department, Ankara University Faculty of Medicine, Ankara, Turkey
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Montanari S, Sartore R, Spina V, Adani R. Post-traumatic entrapment of the median nerve in the ulno-humeral joint: Diagnosis, treatment and literature review. J Orthop Sci 2022; 27:627-634. [PMID: 33863636 DOI: 10.1016/j.jos.2021.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 01/10/2021] [Accepted: 02/03/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND The incidence of median nerve injuries in pediatric elbow dislocations is approximately 3% and avulsion of the open medial epicondylar epiphysis in the pediatric population is one predisposing factor that may explain this age predilection. These lesions can be difficult to diagnose in the acute phase because symptoms tend to be mild or delayed, consequently their management can be challenging and functional outcome poorer. METHODS We present the case of an unrecognized median nerve entrapment in a 16-year-old boy with posterior dislocation of the elbow and a medial epicondyle fracture, treated initially with close reduction and open stabilization with a cannulated screw. Assessment is supported by a review of similar reported cases available in literature. RESULTS We discuss the diagnostic approach and the surgical options that can be used for this type of injury. CONCLUSIONS High clinical suspicion of entrapment is imperative in presence of signs of damage to the median nerve in the pediatric patient immediately after the reduction of an elbow dislocation. If diagnosis of entrapment is made the therapeutic choice between neurolysis and nerve graft depends on the lesion severity. In the presence of a Fourrier's type 4 lesion, neurolysis should be avoided, while nerve resection and grafting are recommended.
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Affiliation(s)
- Sara Montanari
- Department of Hand Surgery and Microsurgery, Azienda Ospedaliero Universitaria Modena, Largo Del Pozzo, 71, 41125 Modena, Italy.
| | - Roberta Sartore
- Department of Hand Surgery, Azienda Ospedaliero Universitaria Verona, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Vincenzo Spina
- Department of General and Emergency Radiology, Azienda Ospedaliero Universitaria Modena, Via Pietro Giardini 1355, 41126 Baggiovara-Modena, Italy
| | - Roberto Adani
- Department of Hand Surgery and Microsurgery, Azienda Ospedaliero Universitaria Modena, Largo Del Pozzo, 71, 41125 Modena, Italy
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O'Brien AC, Teh Z, Rinaldi M, Lee E, Hughes R, Aktselis I, McKean D. Intraosseous Type 2 Median Nerve Entrapment After Posterior Elbow Dislocation Diagnosed on Ultrasound With MRI and Surgical Correlation. Cureus 2021; 13:e18606. [PMID: 34659922 PMCID: PMC8500458 DOI: 10.7759/cureus.18606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/23/2022] Open
Abstract
Median nerve entrapment is a rare complication of posterior elbow dislocation and medial epicondyle fracture. In the event of delayed diagnosis, this injury pattern may result in significant and sometimes irreversible nerve damage. As such, a high degree of clinical suspicion and early imaging is indicated in patients with persistent nerve deficits following reduction of elbow dislocation. Here, a case of intraosseous type 2 median nerve entrapment that was diagnosed on ultrasound in an eight-year-old patient following ulnohumeral dislocation is discussed. This article reviews the key imaging findings of median nerve entrapment and discusses the subsequent MRI and surgical findings of this rare condition.
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Affiliation(s)
- Amy C O'Brien
- Radiology Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, GBR
| | - Zoe Teh
- School of Medicine, Cardiff University, Cardiff, GBR
| | - Marta Rinaldi
- National Spinal Injuries Centre, Buckinghamshire Healthcare NHS Trust, Aylesbury, GBR
| | - Elsa Lee
- Radiology, King's College London, London, GBR
| | - Richard Hughes
- Radiology Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, GBR
| | - Ioannis Aktselis
- Orthopaedic Surgery Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, GBR
| | - David McKean
- Radiology Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, GBR
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McCarthy CF, Kyriakedes JC, Mistovich RJ. Type-V Median Nerve Entrapment in a Pediatric Medial Condyle Fracture: A Case Report. JBJS Case Connect 2019; 8:e108. [PMID: 30601278 DOI: 10.2106/jbjs.cc.18.00168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
CASE A 30-month-old boy with a displaced medial condyle fracture and no history of an elbow dislocation was found to have an entrapped median nerve. CONCLUSION Entrapment of the median nerve is a potential consequence of a displaced medial condyle fracture, even when there are no neurologic deficits on presentation. This provides additional support for open reduction of these fractures rather than percutaneous treatment or nonoperative management. Prompt identification and extraction of an interposed ulnar or median nerve is imperative to prevent the catastrophic consequences of an upper-extremity nerve palsy in children, as well as to optimize fracture-healing and elbow growth and development.
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Affiliation(s)
- Conor F McCarthy
- Case Western Reserve University School of Medicine, Cleveland, Ohio.,Division of Pediatric Orthopaedic Surgery, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, Ohio
| | - James C Kyriakedes
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - R Justin Mistovich
- Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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O'Callaghan PK, Freeman K, Davis LC, Murphy RF. A rare case of type 2 entrapment of the median nerve after posterior elbow dislocation with MRI and ultrasound correlation. Skeletal Radiol 2019; 48:1629-1636. [PMID: 30868233 DOI: 10.1007/s00256-019-03201-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 02/02/2023]
Abstract
A 9-year-old boy sustained an ulnohumeral dislocation with a medial epicondyle fracture and experienced incomplete post-traumatic median nerve palsy in addition to post-traumatic stiffness following closed reduction and cast immobilization. When his motor palsy and stiffness did not improve, MRI and ultrasound were obtained, which demonstrated entrapment of the median nerve in an osseous tunnel at the fracture site, compatible with type 2 median nerve entrapment. Subsequently, the patient underwent surgery to mobilize the medial epicondyle and free the median nerve, resulting in improved range of motion, near complete restoration of motor function, and complete restoration of sensory function in the median nerve distribution within 6 months of surgery. Median nerve entrapment, particularly intraosseous, is a rare complication of posterior elbow dislocation and medial epicondyle fracture that may result in significant, sometimes irreversible, nerve damage if there is a delay in diagnosis and treatment. A high degree of clinical suspicion with early imaging is indicated in patients with persistent stiffness or nerve deficits following reduction of an elbow dislocation. Intra-articular entrapment diagnosed on ultrasound has been reported and intraosseous entrapment diagnosed clinically and on MR neurography have been reported; however, to our knowledge, this is the first reported case of intraosseous (type 2) median nerve entrapment clearly visualized and diagnosed on traditional MRI and ultrasound. The use of ultrasound for diagnosing median nerve entrapment is an accurate, accessible, and non-invasive imaging option for patients presenting with suspected nerve entrapment following elbow dislocation.
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Affiliation(s)
- Patrick K O'Callaghan
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC, USA
| | - Kyle Freeman
- Department of Radiology and Radiological Sciences, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC 383, Ste 210 CSB, Charleston, SC, 29425, USA
| | - Leah C Davis
- Department of Radiology and Radiological Sciences, Medical University of South Carolina, 96 Jonathan Lucas Street, MSC 383, Ste 210 CSB, Charleston, SC, 29425, USA.
| | - Robert F Murphy
- Department of Orthopedics, Medical University of South Carolina, Charleston, SC, USA
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Aggarwal A, Jana M, Kumar V, Srivastava DN, Garg K. MR neurography in intraosseous median nerve entrapment. World J Radiol 2017; 9:400-404. [PMID: 29104742 PMCID: PMC5661168 DOI: 10.4329/wjr.v9.i10.400] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/08/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023] Open
Abstract
Intraosseous entrapment of the median nerve is an uncommon complication of elbow dislocation and fractures. The condition is seen to occur in adolescent age group with a remote history of trauma. We report two rare cases of type 2 intraosseous median nerve entrapment. Though the diagnosis of median neuropathy is made with clinical tests and neurophysiological studies, however exact site of entrapment and presurgical mapping of nerve is done accurately with MR neurography. Imaging thus plays a pivotal role in management of this condition.
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Affiliation(s)
- Ankita Aggarwal
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Vijay Kumar
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Deep Narayan Srivastava
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi 110029, India
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Korus L, Morhart M, Jarman A, Olson J. Median nerve reconstruction after entrapment in the elbow. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2011; 17:130-2. [PMID: 21119844 DOI: 10.1177/229255030901700408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Median nerve entrapment in the elbow is a known but rare complication of pediatric elbow dislocations. It is classified on the anatomical basis of entrapment. Due to a variety of factors, it is often diagnosed late. Because of this, substantial injury occurs to the nerve, requiring some form of restorative surgery in addition to release from the joint. Such nerve injury has been treated in a variety of ways including neurolysis, end-to-end anastomosis and nerve grafting. To date, there has been no conclusive evidence in the literature that one method should be preferred over another. A case of median nerve entrapment that was treated with sural nerve grafting is presented. In a review of the literature, previous treatment of such cases is discussed and compared.
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Affiliation(s)
- Lisa Korus
- Plastic and Reconstructive and Pediatric Surgery
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Intra-articular median nerve incarceration after spontaneous reduction of a pediatric elbow dislocation: case report and review of the literature. J Pediatr Orthop 2010; 30:125-9. [PMID: 20179558 DOI: 10.1097/bpo.0b013e3181cf3bfd] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
UNLABELLED Intra-articular incarceration of the median nerve after closed reduction of an elbow dislocation is a rare and potentially devastating complication. We report the case of a 4-year-old boy who had an entrapment of the median nerve after spontaneous reduction of a posterior dislocation. All the cases previously reported in the literature are reviewed. The diagnostic algorithm and treatment options are discussed. This is the only case in the literature in which spontaneous reduction of the dislocation occurred before medical evaluation. This scenario can occur in children as young as 4 years of age. Although incarceration of the median nerve after an elbow dislocation is an uncommon complication, it must be recognized early and explored to prevent permanent disability. LEVEL OF EVIDENCE Level IV.
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Kamath AF, Baldwin K, Horneff J, Hosalkar HS. Operative versus non-operative management of pediatric medial epicondyle fractures: a systematic review. J Child Orthop 2009; 3:345-57. [PMID: 19685254 PMCID: PMC2758175 DOI: 10.1007/s11832-009-0192-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Accepted: 07/08/2009] [Indexed: 02/03/2023] Open
Abstract
PURPOSE There is ongoing debate about the management of medial epicondyle fractures in the pediatric population. This systematic review evaluated non-operative versus operative treatment of medial epicondyle fractures in pediatric and adolescent patients over the last six decades. METHODS A systematic review of the available literature was performed. Frequency-weighted mean union times were used to compare union rates for closed versus open treatments. Moreover, functional outcomes and range-of-motion variables were correlated with varying treatment modalities. Any complications, including ulnar nerve symptoms, pain, instability, infection, and residual deformity, were cataloged. RESULTS Fourteen studies, encompassing 498 patients, met the inclusion/exclusion criteria. There were 261 males and 132 female patients; the frequency-weighted average age was 11.93 years. The follow-up range was 6-216 months. Under the cumulative random effects model, the odds of union with operative fixation was 9.33 times the odds of union with non-operative treatment (P < 0.0001). There was no significant difference between operative and non-operative treatments in terms of pain at final follow-up (P = 0.73) or ulnar nerve symptoms (P = 0.412). CONCLUSIONS Operative treatment affords a significantly higher union rate over the non-operative management of medial epicondyle fractures. There was no difference in pain at final follow-up between operative and non-operative treatments. As surgical indications evolve, and the functional demands of pediatric patients increase, surgical fixation should be strongly considered to achieve stable fixation and bony union.
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Affiliation(s)
- Atul F. Kamath
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2nd Floor, Silverstein Building, Philadelphia, PA 19104 USA
| | - Keith Baldwin
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2nd Floor, Silverstein Building, Philadelphia, PA 19104 USA
| | - John Horneff
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2nd Floor, Silverstein Building, Philadelphia, PA 19104 USA
| | - Harish S. Hosalkar
- Rady Children’s Hospital, UCSD, 3030 Children’s way, Suite 410, San Diego, 92123 CA, USA
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Coulibaly N, Tiemdjo H, Sané AD, Kinkpé C, Diémé C, Dansokho AV, Ndiaye A, Seye S. Incarcération du nerf médian après luxation négligée du coude : à propos d’un cas. ACTA ACUST UNITED AC 2009; 28:171-4. [DOI: 10.1016/j.main.2009.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Revised: 03/10/2009] [Accepted: 03/10/2009] [Indexed: 11/15/2022]
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Sciatic nerve entrapment in associated both-column acetabular fractures: a report of 2 cases and review of the literature. J Orthop Trauma 2009; 23:80-3. [PMID: 19104309 DOI: 10.1097/bot.0b013e318190cfa0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Sciatic nerve injury associated with acetabular fractures has been reported in most series. Typically, sciatic neuropraxia occurs from traumatic impaction or compression due to posterior hip fracture-dislocation. We report 2 patients with sciatic nerve entrapment within the posterior column components of their associated both-column acetabular fractures. Following neuroplasty through a Kocher-Langenbeck surgical approach, both patients' neurologic function improved. This unlikely cause of neurologic compromise should be considered in all patients with symptoms of sciatic nerve injury or irritation and particularly in the presence of a mechanical block during posterior column reduction through an ilioinguinal approach.
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Hamdi M, Baccari S, Aloui I, Benjdidia G, Ghedira A, Tarhouni L. Incarcération du nerf médian après une fracture luxation du coude : à propos de deux cas. ACTA ACUST UNITED AC 2008; 27:235-9. [DOI: 10.1016/j.main.2008.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 07/09/2008] [Accepted: 08/06/2008] [Indexed: 11/26/2022]
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