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Chen S, Portnoy A, Tabbaa A, Voyvodic L, Diamond K, Horn A, Razi AE, Choueka J. Trends and impact of comorbidities on Guyon's Canal release for the treatment of Guyon's Canal syndrome: A decade long nationwide analysis. J Orthop 2024; 57:127-132. [PMID: 39021588 PMCID: PMC11251089 DOI: 10.1016/j.jor.2024.06.020] [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] [Received: 06/10/2024] [Accepted: 06/16/2024] [Indexed: 07/20/2024] Open
Abstract
Background Guyon's Canal Syndrome (GCS) is a rare nerve entrapment condition with limited studies exploring the trends of GCS patients undergoing Guyon's Canal release. The aim of this study is to examine the trends associated with GCS: (1) Guyon's Canal release procedures performed; (2) surgically relevant comorbidities; (3) 90-day readmissions; and (4) same-day and 90-day reimbursement. Methods A retrospective query was performed on the PearlDiver Mariner Database from 2010 to 2020 by CPT code 64719 to identify patients who underwent Guyon's Canal release. A total of 33,3764 patients were identified. Linear regression models were used to analyze trends in procedures performed, comorbidities, readmission, and reimbursement over this period. A P-value less than 0.05 was considered statistically significant. Results Between 2010 and 2020, there was an overall significant decreasing trend in the number of Guyon's Canal release procedures performed (RC, -127.50; p < 0.001). There was an increase in number of GCS patients that had undergone Guyon's Canal release who drink alcohol (RC, 0.33; p < 0.001), are obese (RC, 0.81; p < 0.001), and use tobacco (RC, 0.56; p < 0.004), and decrease number of GCS patients with a history of diabetes (RC, -0.82; p < 0.001), hypothyroidism (RC, -0.56; p < 0.001), PVD (RC, -0.71; p < 0.001), and RA (RC, -0.33; p < 0.001). We also found an overall increasing trend in 90-day readmissions (RC, 0.09; p = 0.019) and increased same-day (RC, 68.09; p < 0.001) and 90-day average reimbursement (RC, 257.15; p < 0.001) from 2010 to 2020. Conclusion The study demonstrated a decreasing trend in Guyon's Canal release performed in GCS patients but increasing cost of care implicated by the increased 90-day readmissions and same day and 90-day reimbursement. This may be attributed to the comorbidities present in GCS patients undergoing Guyon's Canal release. Therefore, it is imperative when consulting GCS patients with surgically relevant comorbidities to weigh the risk and benefits of the procedure.
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Affiliation(s)
- Shirley Chen
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
- State University of New York (SUNY) Downstate, College of Medicine, Brooklyn, NY, USA
| | - Antoinette Portnoy
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Ameer Tabbaa
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Lucas Voyvodic
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Keith Diamond
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Andrew Horn
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Afshin E. Razi
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
| | - Jack Choueka
- Maimonides Medical Center, Department of Orthopaedic Surgery, Brooklyn, NY, USA
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Sim D, Kuo KT, Rodriguez-Silva W, Seal S, Filippi L, Tuffaha S, Elhelali A. Evaluation of Rehabilitation Techniques for Traumatic Ulnar Nerve Injuries After Surgical Repair: A Systematic Review. Ann Plast Surg 2024; 93:478-487. [PMID: 39331746 DOI: 10.1097/sap.0000000000004123] [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: 09/29/2024]
Abstract
BACKGROUND Traumatic ulnar nerve injuries often result in significant loss of motor and sensory function, negatively impacting patients' quality of life. Physical rehabilitation is crucial for recovery, but standardized treatment protocols are lacking. This study aims to systematically review rehabilitation techniques to identify future research direction and improve existing protocols for ulnar nerve injury patients. METHODS PubMed, Embase, CINAHL, Cochrane CENTRAL, Web of Science, and Scopus were queried from inception until July 31, 2023. Articles containing axonotmesis or neurotmesis injuries of the ulnar nerve were included. Reviews, opinions, editorials, technical reports without clinical outcomes, conference abstracts, non-English text, nonhuman studies, and studies without adult patients were excluded. Three independent reviewers performed screening and data extraction using Covidence, and risk of bias assessments utilizing Cochrane and JBI tools. Because of article heterogeneity, a narrative review was conducted. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database, registration number CRD42023442016. RESULTS This systematic review included one randomized controlled trial and four observational studies (103 patients), which exhibited differences in study quality. Overall, motor and sensory outcomes improved after rehabilitation. Rehabilitation techniques varied widely, and early sensory reeducation appeared to improve sensory function. Only two studies included patient-reported outcomes. CONCLUSIONS Diverse rehabilitation techniques are used to address ulnar nerve injuries. The low number of included studies, differences in study quality, and small sample size underscore the need for larger and more inclusive studies to improve functional recovery after ulnar nerve injuries. Future research should consider the impact of patient and injury characteristics to develop comprehensive treatment guidelines for these patients.
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Affiliation(s)
- Danielle Sim
- From the Department of Plastic and Reconstructive Surgery
| | - Keith T Kuo
- From the Department of Plastic and Reconstructive Surgery
| | | | | | - Lourdes Filippi
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Sami Tuffaha
- From the Department of Plastic and Reconstructive Surgery
| | - Ala Elhelali
- From the Department of Plastic and Reconstructive Surgery
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Tovar-Bazaga M, Cervera-Irimia J. Feasibility of a less invasive supercharged end-to-side anterior interosseous nerve to ulnar motor nerve transfer. J Hand Surg Eur Vol 2024:17531934241278885. [PMID: 39340262 DOI: 10.1177/17531934241278885] [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: 09/30/2024]
Abstract
The object of this study was to perform an anatomical dissection of Thiel-embalmed specimens in a step-by-step procedure, to establish a 'safe zone' in which to perform a less invasive supercharged end-to-side (SETS) anterior interosseous nerve to ulnar motor nerve transfer without tension and to demonstrate its feasibility. The sample size was calculated with a 5 mm error to reach a 95% confidence interval. Dissection was performed in 15 specimens and the 'safe zone' was established between 40 and 90 mm proximal to the pisiform. Several surgical tips are recommended to help complete the procedure. A reproducible 'safe zone' was found for performing a SETS anterior interosseous to ulnar motor nerve transfer with 95% certainty, reducing soft tissue damage and enhancing the original surgical technique.
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Affiliation(s)
- Miguel Tovar-Bazaga
- Department of Orthopaedic and Traumatology Surgery, Hand Surgery and Microsurgery Unit, IIS-Fundación Jiménez Díaz, Madrid, Spain
| | - Javier Cervera-Irimia
- Department of Orthopaedic and Traumatology Surgery, Hand Surgery and Microsurgery Unit, IIS-Fundación Jiménez Díaz, Madrid, Spain
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Bertelli JA. Reconstructing Pinch Strength after Ulnar Nerve Injury by Transferring the Opponens Pollicis Motor Branch. Plast Reconstr Surg 2024; 154:351-361. [PMID: 37585813 DOI: 10.1097/prs.0000000000010993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
BACKGROUND With ulnar nerve injuries, paralysis of the first dorsal interosseous and adductor pollicis muscle weakens the patient's pinch. In the palm, we transferred the opponens pollicis motor branch to the deep terminal division of the ulnar nerve for pinch reconstruction. METHODS Sixteen patients with ulnar nerve injuries around the elbow underwent reconstruction and were followed up postoperatively for a minimum of 14 months. Their mean age was 41 ± 16 years, and the mean interval between injury and surgery was 134 ± 126 days (range, 2 to 390 days). Preoperatively and postoperatively, grasp, key, and subterminal key pinch strength were measured using dynamometers. RESULTS Reinnervation of the first dorsal interosseous muscle was observed in 15 of the 16 patients. Mean grasp strength improved from 15.5 ± 8.5 kg preoperatively to 24 ± 10 kg postoperatively, achieving 57% ± 16% of contralateral hand strength. Preoperatively, terminal key pinch averaged 3 ± 1 kg, which improved postoperatively to 5.5 ± 2 kg, achieving 71 ± 24% of the strength measured contralaterally. Preoperatively to postoperatively, subterminal key pinch force increased from 0 to 2.4 ± 1.3 kg, achieving 61% ± 27% that of the unaffected side. Patients who underwent surgery within 6 months of their injury showed a mean subterminal key pinch strength recovery of 63% ± 27% of the normal side, whereas those who underwent surgery between 7 and 13 months after injury showed a mean subterminal key pinch strength recovery of 51% ± 29%. CONCLUSION Transferring the opponens pollicis motor branch to the deep terminal division of the ulnar nerve improved pinch and grasp strength without jeopardizing thumb function. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Jayme Augusto Bertelli
- From the Department of Traumatology and Orthopedics, Governador Celso Ramos Hospital; and Department of Surgery, Federal University of Santa Catarina
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Felici N, Alban A. Timing of surgery in peripheral nerve injury of the upper extremity. J Hand Surg Eur Vol 2024; 49:712-720. [PMID: 38641934 DOI: 10.1177/17531934241240867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Peripheral nerve injuries present a complex clinical challenge, requiring a nuanced approach in surgical management. The consequences of injury vary, with sometimes severe disability, and a risk of lifelong pain for the individual. For late management, the choice of surgical techniques available range from neurolysis and nerve grafting to tendon and nerve transfers. The choice of technique utilized demands an in-depth understanding of the anatomy, patient demographics and the time elapsed since injury for optimized outcomes. This paper focuses on injuries to the radial, median and ulnar nerves, outlining the authors' approach to these injuries.Level of evidence: IV.
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Affiliation(s)
- Nicola Felici
- Department of Limb Reconstructive Surgery & Plastic Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | - Alice Alban
- Department of Limb Reconstructive Surgery & Plastic Surgery, San Camillo Forlanini Hospital, Rome, Italy
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Lana JF, Navani A, Jeyaraman M, Santos N, Pires L, Santos GS, Rodrigues IJ, Santos D, Mosaner T, Azzini G, da Fonseca LF, de Macedo AP, Huber SC, de Moraes Ferreira Jorge D, Purita J. Sacral Bioneuromodulation: The Role of Bone Marrow Aspirate in Spinal Cord Injuries. Bioengineering (Basel) 2024; 11:461. [PMID: 38790327 PMCID: PMC11118755 DOI: 10.3390/bioengineering11050461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
Spinal cord injury (SCI) represents a severe trauma to the nervous system, leading to significant neurological damage, chronic inflammation, and persistent neuropathic pain. Current treatments, including pharmacotherapy, immobilization, physical therapy, and surgical interventions, often fall short in fully addressing the underlying pathophysiology and resultant disabilities. Emerging research in the field of regenerative medicine has introduced innovative approaches such as autologous orthobiologic therapies, with bone marrow aspirate (BMA) being particularly notable for its regenerative and anti-inflammatory properties. This review focuses on the potential of BMA to modulate inflammatory pathways, enhance tissue regeneration, and restore neurological function disrupted by SCI. We hypothesize that BMA's bioactive components may stimulate reparative processes at the cellular level, particularly when applied at strategic sites like the sacral hiatus to influence lumbar centers and higher neurological structures. By exploring the mechanisms through which BMA influences spinal repair, this review aims to establish a foundation for its application in clinical settings, potentially offering a transformative approach to SCI management that extends beyond symptomatic relief to promoting functional recovery.
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Affiliation(s)
- José Fábio Lana
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Clinical Research, Anna Vitória Lana Institute (IAVL), Indaiatuba 13334-170, SP, Brazil
- Medical School, Max Planck University Center (UniMAX), Indaiatuba 13343-060, SP, Brazil
| | - Annu Navani
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Medical School, Max Planck University Center (UniMAX), Indaiatuba 13343-060, SP, Brazil
- Comprehensive Spine & Sports Center, Campbell, CA 95008, USA
| | - Madhan Jeyaraman
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Department of Orthopaedics, ACS Medical College and Hospital, Chennai 600077, Tamil Nadu, India
| | - Napoliane Santos
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Luyddy Pires
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Gabriel Silva Santos
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Izair Jefthé Rodrigues
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Douglas Santos
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Tomas Mosaner
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Gabriel Azzini
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Lucas Furtado da Fonseca
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Medical School, Federal University of São Paulo (UNIFESP), São Paulo 04024-002, SP, Brazil
| | - Alex Pontes de Macedo
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Stephany Cares Huber
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Daniel de Moraes Ferreira Jorge
- Department of Orthopedics, Brazilian Institute of Regenerative Medicine (BIRM), Indaiatuba 13334-170, SP, Brazil; (J.F.L.); (N.S.); (L.P.); (I.J.R.); (D.S.); (T.M.); (G.A.); (L.F.d.F.); (A.P.d.M.); (S.C.H.); (D.d.M.F.J.)
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
| | - Joseph Purita
- Regenerative Medicine, Orthoregen International Course, Indaiatuba 13334-170, SP, Brazil; (A.N.); (J.P.)
- Medical School, Max Planck University Center (UniMAX), Indaiatuba 13343-060, SP, Brazil
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Li CW, Huang RW, Lin CH, Hsu CC, Lin YT, Chen HC, Tang YB, Chen SH. Supercharge end-to-side nerve transfer from anterior interosseous nerve to augment intrinsic recovery in high ulnar nerve injuries of varying magnitudes. Asian J Surg 2024:S1015-9584(24)00569-4. [PMID: 38599967 DOI: 10.1016/j.asjsur.2024.03.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/21/2024] [Accepted: 03/22/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND High ulnar nerve injuries result in intrinsic muscle weakness and are inconvenient for patients. Moreover, conventional surgical techniques often fail to achieve satisfactory motor recovery. A potential reconstructive solution in the form of the supercharge end-to-side (SETS) anterior interosseous nerve (AIN) transfer method has emerged. Therefore, this study aims to compare surgical outcomes of patients with transected and in-continuity high ulnar nerve lesions following SETS AIN transfer. METHODS Between June 2015 and May 2023, patients with high ulnar palsy in the form of transection injuries or lesion-in-continuity were recruited. The assessment encompassed several objective results, including grip strength, key pinch strength, compound muscle action potential, sensory nerve action potential, and two-point discrimination tests. The muscle power of finger abduction and adduction was also recorded. Additionally, subjective questionnaires were utilized to collect data on patient-reported outcomes. Overall, the patients were followed up for up to 2 years. RESULTS Patients with transected high ulnar nerve lesions exhibited worse baseline performance than those with lesion-in-continuity, including motor and sensory functions. However, they experienced greater motor improvement but less sensory recovery, resulting in comparable final motor outcomes in both groups. In contrast, the transection group showed worse sensory outcomes. CONCLUSIONS Our findings suggest that SETS AIN transfer benefits patients with high ulnar nerve palsy, regardless of the lesion type. Nonetheless, improvements may be more pronounced in patients with transected lesions.
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Affiliation(s)
- Chun-Wei Li
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University, College of Medicine, Keelung, Taiwan (No. 222, Maijin Rd, Anle District, Keelung City, 204, Taiwan
| | - Ren-Wen Huang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan
| | - Yu-Te Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan (No. 2, Yude Rd, North District, Taichung City, 404327, Taiwan
| | - Yueh-Bih Tang
- Department of Plastic Surgery, National Taiwan University Hospital, Taipei, Taiwan (No. 7, Chung Shan S. Rd, Zhongzheng District, Taipei City, 100225, Taiwan; Department of Cosmetic Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan (No. 21, Section 2, Nanya S. Rd, Banqiao District, New Taipei City, 220, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taoyuan, Taiwan (No. 5, Fuxing St, Guishan District, Taoyuan City, 333, Taiwan; Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan (No. 1, Section 1, Ren'ai Rd, Zhongzheng District, Taipei City, 100, Taiwan.
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Chaudhary RK, Karkala N, Nepal P, Gupta E, Kaur N, Batchala P, Sapire J, Alam SI. Multimodality imaging review of ulnar nerve pathologies. Neuroradiol J 2024; 37:137-151. [PMID: 36961518 PMCID: PMC10973834 DOI: 10.1177/19714009231166087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
The ulnar nerve is the second most commonly entrapped nerve after the median nerve. Although clinical evaluation and electrodiagnostic studies remain widely used for the evaluation of ulnar neuropathy, advancements in imaging have led to increased utilization of these newer / better imaging techniques in the overall management of ulnar neuropathy. Specifically, high-resolution ultrasonography of peripheral nerves as well as MRI has become quite useful in evaluating the ulnar nerve in order to better guide treatment. The caliber and fascicular pattern identified in the normal ulnar nerves are important distinguishing features from ulnar nerve pathology. The cubital tunnel within the elbow and Guyon's canal within the wrist are important sites to evaluate with respect to ulnar nerve compression. Both acute and chronic conditions resulting in deformity, trauma as well as inflammatory conditions may predispose certain patients to ulnar neuropathy. Granulomatous diseases as well as both neurogenic and non-neurogenic tumors can also potentially result in ulnar neuropathy. Tumors around the ulnar nerve can also lead to mass effect on the nerve, particularly in tight spaces like the aforementioned canals. Although high-resolution ultrasonography is a useful modality initially, particularly as it can be helpful for dynamic evaluation, MRI remains most reliable due to its higher resolution. Newer imaging techniques like sonoelastography and microneurography, as well as nerve-specific contrast agents, are currently being investigated for their usefulness and are not routinely being used currently.
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Affiliation(s)
| | - Nikitha Karkala
- Department of Radiology, Northwell North Shore University Hospital, Long Island Jewish Medical Center, Queens, NY, USA
| | - Pankaj Nepal
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Elina Gupta
- Department of Radiology, St. Vincent’s Medical Center, Bridgeport, CT, USA
| | - Neeraj Kaur
- Department of Radiology, University Hospital of Northern British Columbia, Prince George, BC, Canada
| | - Prem Batchala
- Department of Radiology, University of Virginia, Charlottesville, VA, USA
| | - Joshua Sapire
- Department of Radiology, St. Vincent’s Medical Center, Bridgeport, CT, USA
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Fulceri F, Marinelli C, Ghelarducci G, Nucci AM, Poggetti A, Ryskalin L, Gesi M. Early post-surgical rehabilitation and functional outcomes of a traumatic ulnar nerve injury: a pediatric case report. Front Neurol 2024; 15:1351407. [PMID: 38385043 PMCID: PMC10879349 DOI: 10.3389/fneur.2024.1351407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/24/2024] [Indexed: 02/23/2024] Open
Abstract
Background Peripheral nerve injuries (PNIs) of the upper limb are very common events within the pediatric population, especially following soft tissue trauma and bone fractures. Symptoms of brachial plexus nerve injuries can differ considerably depending on the site and severity of injury. Compared to median and radial nerves, the ulnar nerve (UN) is the most frequently and severely injured nerve of the upper extremity. Indeed, due to its peculiar anatomical path, the UN is known to be particularly vulnerable to traumatic injuries, which result in pain and substantial motor and sensory disabilities of the forearm and hand. Therefore, timely and appropriate postoperative management of UN lesions is crucial to avoid permanent sensorymotor deficits and claw hand deformities leading to lifelong impairments. Nevertheless, the literature regarding the rehabilitation following PNIs is limited and lacks clear evidence regarding a solid treatment algorithm for the management of UN lesions that ensures full functional recovery. Case presentation The patient is a 11-year-old child who experienced left-hand pain, stiffness, and disability secondary to a domestic accident. The traumatic UN lesion occurred about 8 cm proximal to Guyon's canal and it was surgically treated with termino-terminal (end-to-end) neurorrhaphy. One month after surgery, the patient underwent multimodal rehabilitative protocol and both subjective and functional measurements were recorded at baseline (T0) and at 3- (T1) and 5-month (T2) follow-up. At the end of the rehabilitation protocol, the patient achieved substantial reduction in pain and improvement in quality of life. Of considerable interest, the patient regained a complete functional recovery with satisfactory handgrip and pinch functions in addition with a decrease of disability in activities of daily living. Conclusion A timely and intensive rehabilitative intervention done by qualified hand therapist with previous training in the rehabilitation of upper limb neuromuscular disorders is pivotal to achieve a stable and optimal functional recovery of the hand, while preventing the onset of deformities, in patients with peripheral nerve injuries of the upper limb.
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Affiliation(s)
- Federica Fulceri
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Chiara Marinelli
- Center for Rehabilitative Medicine “Sport and Anatomy”, University of Pisa, Pisa, Italy
| | - Giulia Ghelarducci
- Center for Rehabilitative Medicine “Sport and Anatomy”, University of Pisa, Pisa, Italy
| | - Anna Maria Nucci
- Department of Pediatric Orthopedics and Traumatology, Azienda Ospedaliero Universitaria, Meyer Children Hospital, Florence, Italy
| | - Andrea Poggetti
- Hand and Reconstructive Microsurgery Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Larisa Ryskalin
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Center for Rehabilitative Medicine “Sport and Anatomy”, University of Pisa, Pisa, Italy
| | - Marco Gesi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
- Center for Rehabilitative Medicine “Sport and Anatomy”, University of Pisa, Pisa, Italy
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10
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Andreis FR, Metcalfe B, Janjua TAM, Fazan VPS, Jensen W, Meijs S, Nielsen TGNDS. Morphology and morphometry of the ulnar nerve in the forelimb of pigs. Anat Histol Embryol 2024; 53:e12972. [PMID: 37715494 DOI: 10.1111/ahe.12972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/24/2023] [Accepted: 09/09/2023] [Indexed: 09/17/2023]
Abstract
The knowledge of the morphology and morphometry of peripheral nerves is essential for developing neural interfaces and understanding nerve regeneration in basic and applied research. Currently, the most adopted animal model is the rat, even though recent studies have suggested that the neuroanatomy of large animal models is more comparable to humans. The present knowledge of the morphological structure of large animal models is limited; therefore, the present study aims to describe the morphological characteristics of the Ulnar Nerve (UN) in pigs. UN cross-sections were taken from seven Danish landrace pigs at three distinct locations: distal UN, proximal UN and at the dorsal cutaneous branch of the UN (DCBUN). The nerve diameter, fascicle diameter and number, number of fibres and fibre size were quantified. The UN diameter was larger in the proximal section compared to the distal segment and the DCBUN. The proximal branch also had a more significant number of fascicles (median: 15) than the distal (median: 10) and the DCBUN (median: 11) segments. Additionally, the mean fascicle diameter was smaller at the DCBUN (mean: 165 μm) than at the distal (mean: 197 μm) and proximal (mean: 199 μm) segments of the UN. Detailed knowledge of the microscopical structure of the UN in pigs is critical for further studies investigating neural interface designs and computational models of the peripheral nervous system.
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Affiliation(s)
- Felipe Rettore Andreis
- Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg, Denmark
| | - Benjamin Metcalfe
- Bath Institute for the Augmented Human, University of Bath, Bath, UK
| | - Taha Al Muhammadee Janjua
- Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg, Denmark
| | - Valéria Paula Sassoli Fazan
- Department of Surgery and Anatomy, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Winnie Jensen
- Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg, Denmark
| | - Suzan Meijs
- Department of Health Science and Technology, Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg, Denmark
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11
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Lo IN, Yin CY, Huang HK, Huang YC, Wang JP. Outcomes of radiocarpal pinning to facilitate nerve repair in wrist-level ulnar nerve injuries with defect. J Chin Med Assoc 2023; 86:981-984. [PMID: 37729606 DOI: 10.1097/jcma.0000000000001000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND The ideal scenario for ulnar nerve repair is primary end-to-end neurorrhaphy in a tension-free environment. However, this could be complicated by soft tissue loss, scarring, and neuroma formation in a delayed injury, creating a nerve defect. With a wrist-level nerve defect, a flexion position can help shorten the nerve gap; however, maintaining the position can be challenging intraoperatively and postoperatively. METHODS Previously, we proposed our method of using a 1.6-mm K wire for radius-lunate-capitate pinning of the wrist in flexion to minimize the nerve gap, thereby facilitating neuroma excision and end-to-end neurorrhaphy in delayed ulnar nerve injury. In this study, we elaborate our method and present our case series. RESULTS From October 2018 to July 2020, five patients (mean age: 48.2 years; mean delay from injury to surgery: 84.6 days; mean follow-up: 17.5 months) were retrospectively reviewed. The mean flexion fixation angle was 52°, and the K wire was removed at an average of 5.1 weeks postoperatively. All patients were followed up for a minimum of 12 months. All patients achieved M4 and S3 or S3+ neurologically (according to the criteria of the Nerve Injuries Committee of the British Medical Research Council). The mean disabilities arm, shoulder, and hand score was 14.1. The mean grasp and pinch strengths were, respectively, 76.8% and 63.6% of the contralateral hand. All wrist range of motion returned to normal within 12 weeks. No complications were noted intraoperatively or postoperatively. CONCLUSION Our study showed that radiocarpal pinning of the wrist in flexion was safe and convenient to minimize the nerve gap and to facilitate end-to-end neurorrhaphy in limited-sized wrist-level ulnar nerve defects.
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Affiliation(s)
- I-Ning Lo
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital Taitung Branch, Taitung, Taiwan, ROC
| | - Cheng-Yu Yin
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hui-Kuang Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Department of Orthopaedics, Chiayi Christian Hospital, Chiayi, Taiwan, ROC
- Chung Hwa University of Medical Technology, Tainan, Taiwan, ROC
| | - Yi-Chao Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Jung-Pan Wang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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12
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Gontre G, Polmear M, Carter JT, Castagno C, Herrera FA. Primary Repair versus Reverse End-to-Side Coaptation by Anterior Interosseous Nerve Transfer in Proximal Ulnar Nerve Injuries. Plast Reconstr Surg 2023; 152:384-393. [PMID: 36912900 DOI: 10.1097/prs.0000000000010395] [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: 03/14/2023]
Abstract
BACKGROUND Proximal ulnar nerve lacerations are challenging to treat because of the complex integration of sensory and motor function in the hand. The purpose of this study was to compare primary repair and primary repair plus anterior interosseous nerve (AIN) reverse end-to-side (RETS) coaptation in the setting of proximal ulnar nerve injuries. METHODS A prospective cohort study was performed of all patients at a single, academic, level I trauma center from 2014 to 2018 presenting with isolated complete ulnar nerve lacerations. Patients underwent either primary repair (PR) only or primary repair and AIN RETS (PR + RETS). Data collected included demographic information; quick Disabilities of the Arm, Shoulder and Hand questionnaire score; Medical Research Council score; grip and pinch strength; and visual analogue scale pain scores at 6 and 12 months postoperatively. RESULTS Sixty patients were included in the study: 28 in the PR group and 32 in the RETS + PR group. There was no difference in demographic variables or location of injury between the two groups. Average quick Disabilities of the Arm, Shoulder and Hand questionnaire scores for the PR and PR + RETS groups were 65 ± 6 and 36 ± 4 at 6 months and 46 ± 4 and 24 ± 3 at 12 months postoperatively, respectively, and were significantly lower in the PR + RETS group at both points. Average grip and pinch strength were significantly greater for the PR + RETS group at 6 and 12 months. CONCLUSION This study demonstrated that primary repair of proximal ulnar nerve injuries plus AIN RETS coaptation yielded superior strength and improved upper extremity function when compared with PR alone. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, II.
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Affiliation(s)
- Gil Gontre
- From the Department of Orthopaedics, Texas Tech University Health Science Center
| | - Michael Polmear
- From the Department of Orthopaedics, Texas Tech University Health Science Center
| | - Jordan T Carter
- From the Department of Orthopaedics, Texas Tech University Health Science Center
| | - Christopher Castagno
- From the Department of Orthopaedics, Texas Tech University Health Science Center
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13
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Henriques VM, Torrão FJL, Rosa LAN, Sanches GE, Guedes F. Surgery as an Effective Therapy for Ulnar Nerve Neuropathic Pain Caused by Gunshot Wounds: A Retrospective Case Series. World Neurosurg 2023; 173:e207-e217. [PMID: 36791879 DOI: 10.1016/j.wneu.2023.02.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Peripheral nerve injuries remain a major medical problem worldwide and are associated with multiple causes, including gunshot wounds (GSWs), which are the second most common cause of brachial plexus injuries in peacetime and the main, or only, cause reported in wartime studies. The ulnar nerve (UN) is one of the most affected nerves. Peripheral nerve trauma may cause intense neuropathic pain, which is very difficult to control. Particularly UN gunshot injuries may impact individual daily life, as injuries to this nerve result in both sensory and motor deficits within the hand. We evaluated the improvement of neuropathic pain after surgical treatment in a consecutive series of 20 patients with UN injury due to GSWs. METHODS This single-center, retrospective, consecutive case series included 20 patients with UN injuries due to GSWs, who presented with excruciating neuropathic pain and underwent surgical treatment between 2005 and 2017. RESULTS Of injuries, 13 occurred in the right upper limb (65%); 12 patients had a high UN injury (60%). Regarding associated injuries, 8 patients had bone injuries (40%), and 4 patients had arterial injuries (20%). A neuroma in continuity was detected in 8 cases (40%), and 4 patients (20%) had shrapnel lodged within the UN. All patients had severe neuropathic pain and functional deficit, with a mean visual analog scale score of 8.45 ± 1.4 and a mean reduction of 6.95 points 12 months after surgery; 10 patients (50%) had a British Medical Research Council score ≥M3. CONCLUSIONS Surgery is an effective treatment for neuropathic pain from GSWs. Early isolated external neurolysis is associated with better pain management and functional outcomes postoperatively.
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Affiliation(s)
- Vinícius M Henriques
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil.
| | - Francisco J L Torrão
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil
| | - Livia A N Rosa
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil
| | - Gabriel E Sanches
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil
| | - Fernando Guedes
- Division of Neurosurgery, Department of Surgery, Gaffrée and Guinle University Hospital, Federal University of the State of Rio de Janeiro (HUGG-Unirio/Ebserh), Rio de Janeiro, Brazil
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14
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Chambers SB, Wu KY, Smith C, Potra R, Ferreira LM, Gillis J. Interfascicular Anatomy of the Motor Branch of the Ulnar Nerve: A Cadaveric Study. J Hand Surg Am 2023; 48:309.e1-309.e6. [PMID: 34949481 DOI: 10.1016/j.jhsa.2021.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 08/03/2021] [Accepted: 10/06/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The motor branch of the ulnar nerve contains fascicles that innervate the intrinsic musculature of the hand. This cadaveric study aimed to describe the organization and consistency of the internal topography of the motor branch of the ulnar nerve. METHODS Five fresh-frozen cadaveric specimens with an average age of 74 years (range, 65-88 years) were dissected. The ulnar nerve was exposed and transfixed to the underlying tissues to maintain its orientation throughout the dissection. The dorsal cutaneous branch (DCB) and the volar sensory branch were identified and reflected to expose the motor branch. The fascicles to the first dorsal interosseus (FDI), flexor pollicis brevis, and abductor digiti minimi (ADM) were identified. Internal neurolysis was performed distal to proximal to identify the interfascicular arrangement of these fascicles within the motor branch. The organization of these fascicles was noted, and the branch points of the DCB, FDI, and ADM were measured relative to the pisiform using a handheld electronic caliper. RESULTS The internal topography of the motor branch was consistent among all specimens. Proximal to the pisiform, the arrangement from radial to ulnar was as follows: volar sensory branch, flexor pollicis brevis, FDI/intrinsic muscles, ADM, and DCB. The position of these branches remained consistent as the deep motor branch curved radially within the palm and traveled to the terminal musculature. The locations of the average branch points of the FDI, ADM, and DCB with respect to the pisiform were as follows: FDI, 4.6 cm distal (range, 4.1-4.9 cm), 4.5 cm radial (range, 4.1-4.9 cm); ADM, 0.65 cm distal (range, 0.3-1.1 cm), 0.7 cm radial (range, 0.3-1.1 cm), DCB, 7.7 cm proximal (range, 4.2-10.1 cm), and 0.4 cm ulnar (range, 0.3-0.8 cm). CONCLUSIONS The internal topography of the ulnar nerve motor branch was consistent among the specimens studied. The topography of the motor branches was maintained as the motor branch turns radially within the palm. CLINICAL RELEVANCE This study provides further understanding of the internal topography of the ulnar nerve motor branch at the wrist level.
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Affiliation(s)
- Spencer B Chambers
- Division of Plastic and Reconstructive Surgery, University of Western Ontario, Roth McFarlane Hand and Upper Limb Center, St. Joseph's Health Care, London, Ontario, Canada
| | - Kitty Yuechuan Wu
- Division of Plastic and Reconstructive Surgery, University of Western Ontario, Roth McFarlane Hand and Upper Limb Center, St. Joseph's Health Care, London, Ontario, Canada
| | - Corey Smith
- Surgical Mechatronics Research Laboratory, Roth McFarlane Hand and Upper Limb Center, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Robert Potra
- Surgical Mechatronics Research Laboratory, Roth McFarlane Hand and Upper Limb Center, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechatronics Systems Engineering, Western University, London, Ontario, Canada
| | - Louis M Ferreira
- Surgical Mechatronics Research Laboratory, Roth McFarlane Hand and Upper Limb Center, St. Joseph's Health Care, London, Ontario, Canada; Department of Mechatronics Systems Engineering, Western University, London, Ontario, Canada; School of Biomedical Engineering, Western University, London, Ontario, Canada
| | - Joshua Gillis
- Division of Plastic and Reconstructive Surgery, University of Western Ontario, Roth McFarlane Hand and Upper Limb Center, St. Joseph's Health Care, London, Ontario, Canada; Surgical Mechatronics Research Laboratory, Roth McFarlane Hand and Upper Limb Center, St. Joseph's Health Care, London, Ontario, Canada.
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15
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Lu CC, Huang HK, Wang JP. Direct End-to-End Neurorrhaphy for Wrist-Level Long Nerve Defect with Fixation of the Wrist in Flexion: Technique Note. J Wrist Surg 2022; 11:362-366. [PMID: 35971473 PMCID: PMC9375678 DOI: 10.1055/s-0041-1729635] [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] [Received: 10/25/2020] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
Background For a nerve gap, end-to-end neurorrhaphy would either be difficult or would include tension. The use of a nerve graft or conduit could be a solution, but it might compromise the reinnervation. We describe a method for wrist-level ulnar and/or median long nerve injury by fixing the wrist in the flexion position with K-wire (s) to make possible an end-to-end and tension-free neurorrhaphy. Patients and Methods Two patients had wrist-level ulnar nerve injury for 2 and 3 months and nerve gaps of 2.5 cm and 3.5 cm, respectively, after the neuroma excision. K-wires were used to transfix from the radius to carpal bones, in order to keep their wrists in flexion of 45 and 65 degrees, respectively, with which the tension-free end-to-end neurorrhaphy could be achieved. The K-wires were removed in 6 weeks after surgery, and their wrists were kept in the splint for a progressive extension program. Results Both patients were noted to have an improved claw hand deformity 4 months after the surgery. The ulnar nerve motor and sensory function could be recovered mostly in the 12-month follow-up. The wrist flexion and extension motion arc both achieved, at least, 150 degree in the 12-month follow-up. There were no complications related to the K-wire fixation. Conclusion With the wrist fixed in a flexed position, maintaining a longer nerve gap to achieve a direct end-to-end and tension-free neurorrhaphy would be more likely and safer. Without the use of nerve graft, innervation of the injured nerve would be faster.
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Affiliation(s)
- Chun-Ching Lu
- Department of Orthopaedics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hui-Kuang Huang
- Department of Orthopaedics, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan
| | - Jung-Pan Wang
- Department of Orthopaedics, Taipei Veterans General Hospital, Taipei, Taiwan
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16
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Moling S, Heitz A, Ruyer J. Reliability of deep branch of ulnar nerve identification in interosseous-to-ulnar motor nerve transfer: A cadaver study of 20 wrists. HAND SURGERY & REHABILITATION 2021; 41:103-106. [PMID: 34856362 DOI: 10.1016/j.hansur.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 11/19/2022]
Abstract
Reinnervation of the intrinsic hand muscles after proximal ulnar nerve repair is often unsatisfactory. Promising results have nevertheless been reported recently for supercharged end-to-side anterior interosseous to deep branch of the ulnar nerve (DBUN) transfer. The aim of this study was to determine whether the DBUN can be reliably identified without retrograde intraneural dissection from Guyon's canal. Twenty cadaveric wrists were dissected. In a first stage, nerve transfer was performed through a limited 4 cm incision without releasing Guyon's canal. In a second stage, correct identification of the DBUN was assessed by retrograde intraneural dissection from its point of exit from Guyon's canal. The DBUN was correctly identified in 18 of the 20 wrists (90%). Although anatomical landmarks provide valuable clues, identifying the DBUN by neurolysis is technically challenging. All the elements required for nerve transfer can be exposed through a 4 cm incision, but the DBUN was nevertheless incorrectly identified in 10% of cases. Guyon canal release seems advisable to guarantee correct DBUN identification.
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Affiliation(s)
- S Moling
- Faculté de Médecine Lyon Est (Université Claude Bernard Lyon 1), 8 Avenue Rockefeller, 69003 Lyon, France
| | - A Heitz
- Service de Chirurgie du Membre Supérieur - SOS Main, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003 Lyon, France.
| | - J Ruyer
- Centre de la Main, Clinique de la Sauvegarde (Lyon-Ortho-Clinic), 29b Avenue des Sources, 69009 Lyon, France
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Outcomes of anterior interosseous nerve transfer to restore intrinsic muscle function after high ulnar nerve injury. J Plast Reconstr Aesthet Surg 2021; 75:703-710. [PMID: 34789435 DOI: 10.1016/j.bjps.2021.09.072] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 06/19/2021] [Accepted: 09/27/2021] [Indexed: 11/20/2022]
Abstract
Traumatic high ulnar nerve injuries have historically resulted in long-term loss of hand function due to the long re-innervation distance to the intrinsic muscles. Transfer of the anterior interosseous nerve (AIN) to the deep motor branch of the ulnar nerve (MUN) is proving promising in these patients. The purpose of this study was to evaluate the outcomes and efficacy of this procedure in our series. Eligible high ulnar nerve injury patients who underwent AIN to MUN nerve transfer were evaluated with a mean follow-up of 17 months. Data including demographics, injury details, surgical procedures, and outcomes were collected. A review of the current literature was performed for comparison. Sixteen patients had AIN to MUN transfer, mean age of 39.4 years, and a median delay from injury to nerve transfer of 0.8 months. The injury site was above the elbow in 5 cases, at the elbow in 8 cases, and in the proximal forearm in 3 cases. The majority were sharp transection, with the remaining from blast injuries, traumatic traction, and one post-traumatic neuroma resection. Transfer was performed end-to-end in 7 cases, hemi end-to-end in 7 cases, and supercharged end-to-side in 2 cases. Five patients achieved intrinsic muscle recovery of MRC 4+ and thirteen gained MRC 3 or above. The AIN to MUN nerve transfer provides meaningful intrinsic recovery in the majority of traumatic high ulnar nerve injuries. This procedure should be routinely considered, however, warrants further research to validate the optimum technique.
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Węgiel A, Zielinska N, Tubbs RS, Olewnik Ł. Possible points of compression of the ulnar nerve: Tricks and traps that await clinicians from an anatomical point of view. Clin Anat 2021; 35:155-173. [PMID: 34610170 DOI: 10.1002/ca.23798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022]
Abstract
The ulnar nerve can be subject to numerous types of compression. The most common are cubital tunnel and ulnar tunnel syndromes, but there are many others with more uncommon etiologies. The existence of additional communicating branches, median nerve involvement, various types of injuries, and unusual anatomical variations can be a challenge for both diagnosis and treatment. This review presents a comprehensive depiction of ulnar nerve entrapment syndromes with particular reference to their anatomical background, risk factors, and clinical evaluation. Even common disorders can result from atypical morphological changes. It is important to be familiar with them as it is a key ability in daily medical practice.
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Affiliation(s)
- Andrzej Węgiel
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Łódź, Poland
| | - Nicol Zielinska
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Łódź, Poland
| | - Richard Shane Tubbs
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA.,Department of Anatomical Sciences, St. George's University, True Blue, Grenada
| | - Łukasz Olewnik
- Department of Anatomical Dissection and Donation, Medical University of Lodz, Łódź, Poland
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Siotos C, O'Neill ES, Lumpkin AH, Hasan JS, Grevious MA, Doscher ME. Acute Ulnar Neurapraxia and Carpal Tunnel Syndrome in the Context of a Distal Radius Fracture. EPLASTY 2021; 21:e6. [PMID: 35603016 PMCID: PMC9128657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Distal radius fractures, carpal tunnel syndrome, and ulnar nerve compression are common causes of symptoms that result in patients presenting for hand evaluation. This is a unique case of a distal radius fracture leading to both carpal tunnel syndrome and ulnar nerve compression requiring urgent operative management.
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Affiliation(s)
- Charalampos Siotos
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, USA
- Division of Plastic and Reconstructive Surgery, Cook County Health, Chicago, IL 60607, USA
| | - Elizabeth S. O'Neill
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, USA
- Division of Plastic and Reconstructive Surgery, Cook County Health, Chicago, IL 60607, USA
| | - Ada H. Lumpkin
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, USA
| | - Jafar S. Hasan
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, USA
| | - Mark A. Grevious
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, USA
| | - Matthew E. Doscher
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, USA
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Neuroplasticity following Nerve Transfer of the Anterior Interosseous Nerve for Proximal Ulnar Nerve Injuries. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3684. [PMID: 34277319 PMCID: PMC8277281 DOI: 10.1097/gox.0000000000003684] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/05/2021] [Indexed: 12/14/2022]
Abstract
Background: Injuries to the ulnar nerve at or above proximal forearm level result in poor recovery despite early microsurgical repair, especially concerning the intrinsic motor function of the hand. To augment the numbers of regenerating axons into the targeted muscles, a nerve transfer of the distal branch of the median nerve, the anterior interosseous nerve, to the ulnar motor branch has been described. Methods: Two patients with severe atrophy of the intrinsic hand muscles following an initial proximal ulnar nerve repair had surgery with an end-to-side transfer of the anterior interosseous nerve to the ulnar motor branch at the wrist level. Outcome and neuroplasticity were prospectively studied using questionnaires, clinical examinations, electroneurography, electromyography, somatosensory evoked potentials at pre nerve transfer and 3-, 12-, and 24-months post nerve transfer as well as navigated transcranial magnetic stimulation at pre nerve transfer and 3- and 12-months post nerve transfer. Results: Successively improved motor function was observed. Complete reinnervation of intrinsic hand muscles was demonstrated at 12- to 24-months follow-up by electroneurography and electromyography. At the cortical level, navigated transcranial magnetic stimulation detected a movement of the hot-spot for the abductor digiti mini muscle, originally innervated by the ulnar nerve and the size of the area from where responses could be elicited in this muscle changed over time, indicating central plastic processes. An almost complete reinnervation of the pronator quadratus muscle was also observed. Conclusion: Both central and peripheral plastic mechanisms are involved in muscle reinnervation after anterior interosseous nerve transfer for treatment of proximal ulnar nerve injuries.
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The Cutting Edge: Surface Texture Analysis following Resection of Nerve Stumps Using Various Instruments. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3566. [PMID: 33996348 PMCID: PMC8116000 DOI: 10.1097/gox.0000000000003566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/05/2021] [Indexed: 11/27/2022]
Abstract
Background: Preparation of nerve ends is an essential part of nerve repair surgery. Multiple instruments have been described for this purpose; however, no consensus exists regarding which is the least traumatic for tissue handling. We believe that various instruments used for nerve-end excision will lead to different surface roughness. Methods: Median and ulnar nerves from fresh frozen cadavers were dissected, and 1–2 cm lengths were excised using a No. 11 blade, a razor blade, or a pair of scissors. Using electron microscopy, 3-dimensional surface analysis of roughness (Sa) for each specimen was performed using ZeeScan optical hardware and GetPhase software (PhaseView, Buisson, France). An ANOVA or Kruskal-Wallis test compared roughness measures among cutting techniques. Results: Forty nerves were included. Of these, 13 (32.5%) were cut using scissors, 15 (37.5%) using a razor blade, and 12 (30%) using a No. 11 blade. An ANOVA test showed statistical differences in Sa among the cutting techniques (P = 0.002), with the lowest mean Sa noted in the scissors group (7.2 µM, 95% CI: 5.34–9.06), followed by No. 11 blade (7.29 µM, 95% CI: 5.22–9.35), and razor blade (11.03 µM, 95% CI: 9.43–12.62). Median Ra (surface profile roughness) was 4.58 (IQR: 2.62–5.46). A Kruskal-Wallis test demonstrated statistical difference in Ra among techniques (P = 0.003), with the lowest by No. 11 blade (3 µM, IQR: 1.87–4.38), followed by scissors (3.29 µM, IQR: 1.56–4.96), and razor (5.41 µM, IQR: 4.95–6.21). Conclusion: This novel technique of 3-dimensional surface analysis found razor blade use demonstrated poor roughness, whereas a No. 11 blade or nerve-specific scissors led to equivocally smooth nerve ends.
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Dunn JC, Gonzalez GA, Fernandez I, Orr JD, Polfer EM, Nesti LJ. Supercharge End-to-Side Nerve Transfer: Systematic Review. Hand (N Y) 2021; 16:151-156. [PMID: 30924361 PMCID: PMC8041420 DOI: 10.1177/1558944719836213] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background: To decrease the time to reinnervation of the intrinsic motor end plates after high ulnar nerve injuries, a supercharged end-to-side (SETS) anterior interosseous to ulnar motor nerve transfer has been proposed. The purpose of this study was to compile and review the indications, outcomes, and complications of SETS anterior interosseous to ulnar motor nerve transfer. Methods: A literature search was performed, identifying 73 papers; 4 of which met inclusion and exclusion criteria, including 78 patients. Papers included were those that contained the results of SETS between the years 2000 and 2018. Data were pooled and analyzed focusing on the primary outcomes: intrinsic muscle recovery and complications. Results: Four studies with 78 patients met inclusion and exclusion criteria. Most patients (33.3%) underwent SETS for an ulnar nerve lesion in continuity, the average age was 46.5 years, and the average follow-up was 10 months. The average duration of symptoms before surgery was 99 weeks, all patients had weakness and numbness, nearly all (96%) had atrophy, and half (53%) had pain. Grip and key pinch strength improved 202% and 179%, respectively, from the preoperative assessment. The vast majority (91.9%) recovered intrinsic function at an average of 3.7 months. Other than 8% of patients who did not recover intrinsic strength, no other complications were reported in any of the 78 patients. Conclusions: The SETS is a successful procedure with low morbidity, which may restore intrinsic function in patients with proximal nerve injuries.
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Affiliation(s)
- John C. Dunn
- William Beaumont Army Medical Center, El Paso, TX, USA
| | | | - Isaac Fernandez
- Texas Tech University Health Sciences Center El Paso, USA,Isaac Fernandez, Department of Orthopaedic Surgery & Rehabilitation, Texas Tech University Health Sciences Center El Paso, 4801 Alberta Avenue, El Paso, TX 79905, USA.
| | - Justin D. Orr
- William Beaumont Army Medical Center, El Paso, TX, USA
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Sharp E, Roberts M, Żurada‐Zielińska A, Zurada A, Gielecki J, Tubbs RS, Loukas M. The most commonly injured nerves at surgery: A comprehensive review. Clin Anat 2020; 34:244-262. [DOI: 10.1002/ca.23696] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/08/2020] [Accepted: 10/08/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Elizabeth Sharp
- Department of Internal Medicine Mount Sinai Health System New York New York USA
| | - Melissa Roberts
- Department of Anatomical Sciences, School of Medicine St George's University Grenada West Indies
| | | | - Anna Zurada
- Department of Anatomy Medical School Varmia and Mazuria Olsztyn Poland
- Department of Radiology, Collegium Medicum, School of Medicine University of Warmia and Mazury Olsztyn Poland
| | - Jerzy Gielecki
- Department of Anatomy Medical School Varmia and Mazuria Olsztyn Poland
- Department of Radiology, Collegium Medicum, School of Medicine University of Warmia and Mazury Olsztyn Poland
| | - Richard Shane Tubbs
- Department of Anatomical Sciences, School of Medicine St George's University Grenada West Indies
- Department of Neurosurgery and Ochsner Neuroscience Institute Ochsner Health System New Orleans Louisiana USA
- Department of Structural & Cellular Biology Tulane University School of Medicine New Orleans Louisiana USA
- Department of Neurosurgery Tulane University School of Medicine New Orleans Louisiana USA
| | - Marios Loukas
- Department of Anatomical Sciences, School of Medicine St George's University Grenada West Indies
- Department of Anatomy Medical School Varmia and Mazuria Olsztyn Poland
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Miclescu A, Straatmann A, Gkatziani P, Butler S, Karlsten R, Gordh T. Chronic neuropathic pain after traumatic peripheral nerve injuries in the upper extremity: prevalence, demographic and surgical determinants, impact on health and on pain medication. Scand J Pain 2020; 20:95-108. [PMID: 31536038 DOI: 10.1515/sjpain-2019-0111] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/23/2019] [Indexed: 01/10/2023]
Abstract
Background and aims Aside from the long term side effects of a nerve injury in the upper extremity with devastating consequences there is often the problem of chronic neuropathic pain. The studies concerning the prevalence of persistent pain of neuropathic origin after peripheral nerve injuries are sparse. The prevalence and risk factors associated with chronic neuropathic pain after nerve injuries in the upper extremity were assessed. Methods A standardized data collection template was employed prospectively and retrospectively for all patients with traumatic nerve injuries accepted at the Hand Surgery Department, Uppsala, Sweden between 2010 and 2018. The template included demographic data, pain diagnosis, type of injured nerve, level of injury, date of the lesion and repair, type of procedure, reoperation, time since the procedure, S-LANSS questionnaire (Self report-Leeds Assessment of Neuropathic Symptoms and Signs), RAND-36 (Item short form health survey), QuickDASH (Disability of Shoulder, Arm and Hand) and additional questionnaires concerned medication, pain intensity were sent to 1,051 patients with nerve injuries. Partial proportional odds models were used to investigate the association between persistent pain and potential predictors. Results More than half of the patients undergoing a surgical procedure developed persistent pain. Prevalence of neuropathic pain was 73% of the patients with pain (S-LANSS ≥ 12 or more). Multivariate analysis indicated that injury of a major nerve OR 1.6 (p = 0.013), years from surgery OR 0.91 (p = 0.01), younger age OR 0.7 (p < 0.001), were the main factors for predicting pain after surgery. The type of the nerve injured was the strongest predictor for chronic pain with major nerves associated with more pain (p = 0.019). Conclusions A high prevalence of chronic pain and neuropathic pain with a negative impact on quality of life and disability were found in patients after traumatic nerve injury. Major nerve injury, younger age and less time from surgery were predictors for chronic pain.
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Affiliation(s)
- Adriana Miclescu
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Antje Straatmann
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Stephen Butler
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Rolf Karlsten
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Torsten Gordh
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Barrett JE, Farooq H, Merrell GA. Reliability of focal identification of motor fascicles of the ulnar nerve proximal to the wrist: an anatomical study. J Hand Surg Eur Vol 2020; 45:237-241. [PMID: 32050859 DOI: 10.1177/1753193419889280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We investigated whether motor fascicles of the ulnar nerve can be reliably identified proximal to the wrist. In 17 cadaveric upper limbs, the anterior interosseous nerve was transected at its arborization in the pronator quadratus and transposed to the palmar aspect of the ulnar nerve. The motor fascicular bundle was identified at this level after distinguishing the intraneural epineural involution by microsurgical probing. The motor branch was identified in Guyon's canal and traced retrograde via intraneural dissection to assess accuracy of the original identification. The motor fascicular bundle was found to have been correctly identified in all specimens. We conclude that local anatomic landmarks allow for the motor fascicular group to be correctly identified. Therefore, retrograde, internal dissection of the ulnar nerve is not likely to be required for reliable transfer of anterior interosseous nerve to ulnar nerve motor fascicles.
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Hong GH, Liu JB, Liu YZ, Gao KM, Zhao X, Lao J. Modified contralateral C7 nerve transfer: the possibility of permitting ulnar nerve recovery is confirmed by 10 cases of autopsy. Neural Regen Res 2019; 14:1449-1454. [PMID: 30964072 PMCID: PMC6524498 DOI: 10.4103/1673-5374.253530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Contralateral C7 nerve transfer surgery is one of the most important surgical techniques for treating total brachial plexus nerve injury. In the traditional contralateral C7 nerve transfer surgery, the whole ulnar nerve on the paralyzed side is harvested for transfer, which completely sacrifices its potential of recovery. In the present, novel study, we report on the anatomical feasibility of a modified contralateral C7 nerve transfer surgery. Ten fresh cadavers (4 males and 6 females) provided by the Department of Anatomy, Histology, and Embryology at the Medical College of Fudan University, China were used in modified contralateral C7 nerve transfer surgery. In this surgical model, only the dorsal and superficial branches of the ulnar nerve and the medial antebrachial cutaneous nerve on the paralyzed side (left) were harvested for grafting the contralateral (right) C7 nerve and the recipient nerves. Both the median nerve and deep branch of the ulnar nerve on the paralyzed (left) side were recipient nerves. To verify the feasibility of this surgery, the distances between each pair of coaptating nerve ends were measured by a vernier caliper. The results validated that starting point of the deep branch of ulnar nerve and the starting point of the medial antebrachial cutaneous nerve at the elbow were close to each other and could be readily anastomosed. We investigated whether the fiber number of donor and recipient nerves matched one another. The axons were counted in sections of nerve segments distal and proximal to the coaptation sites after silver impregnation. Averaged axon number of the ulnar nerve at the upper arm level was approximately equal to the sum of the median nerve and proximal end of medial antebrachial cutaneous nerve (left: 0.94:1; right: 0.93:1). In conclusion, the contralateral C7 nerve could be transferred to the median nerve but also to the deep branch of the ulnar nerve via grafts of the ulnar nerve without deep branch and the medial antebrachial cutaneous nerve. The advantage over traditional surgery was that the recovery potential of the deep branch of ulnar nerve was preserved. The study was approved by the Ethics Committee of Fudan University (approval number: 2015-064) in July, 2015.
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Affiliation(s)
- Guang-Hui Hong
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jing-Bo Liu
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Yu-Zhou Liu
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Kai-Ming Gao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Xin Zhao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
| | - Jie Lao
- Department of Hand Surgery, Huashan Hospital, Fudan University; Key Laboratory of Hand Reconstruction, Ministry of Health; Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
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Mori T, Nomura O, Ihara T. Ultrasound-guided peripheral forearm nerve block for digit fractures in a pediatric emergency department. Am J Emerg Med 2019; 37:489-493. [DOI: 10.1016/j.ajem.2018.11.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 11/25/2022] Open
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Koszewicz M, Szydlo M, Gosk J, Wieczorek M, Budrewicz S. Use of collision tests to identify physiological differences between the median and ulnar nerves. Muscle Nerve 2019; 59:470-474. [PMID: 30681158 DOI: 10.1002/mus.26428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/11/2019] [Accepted: 01/20/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Median and ulnar nerves are used in comparative electrophysiological studies. We analyzed the conduction values in these hand nerves in healthy volunteers to find any physiological differences between them. METHODS We performed standard conduction studies and conduction velocity distribution (CVD) tests with estimation of 3 quartiles in 31 healthy right-handed volunteers (17 women, 14 men) with a mean age of 44.8 ± 15.5 years. RESULTS The conduction velocities in all quartiles of CVD tests were statistically faster in the ulnar nerve (P < 0.00001), with no differences in the spread of conduction values and no differences between sides. In the ulnar nerve, CVD velocities in all quartiles were faster in the female group (P < 0.05). DISCUSSION The ulnar nerve has more fibers conducting with high velocities than does the median nerve. Electrophysiological comparisons between hand nerves must be performed carefully. Muscle Nerve 59:470-474, 2019.
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Affiliation(s)
- Magdalena Koszewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
| | - Mariusz Szydlo
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
| | - Jerzy Gosk
- Department of Trauma and Hand Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Malgorzata Wieczorek
- Faculty of Earth Sciences and Environmental Management, University of Wrocław, Wroclaw, Poland
| | - Slawomir Budrewicz
- Department of Neurology, Wroclaw Medical University, Borowska 213, 50-556, Wroclaw, Poland
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Peripheral nerve injuries in the pediatric population: a review of the literature. Part I: traumatic nerve injuries. Childs Nerv Syst 2019; 35:29-35. [PMID: 30215119 DOI: 10.1007/s00381-018-3974-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/04/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE This article reviews the clinical results that can be obtained after repair of a traumatic peripheral nerve injury in the pediatric population. METHODS A systematic review of the published literature has been made. RESULTS Functional outcome after major nerve injuries is sometimes disappointing in adults. However, children have been reported to experience much better functional results after nerve repair than adults. Moreover, recovery generally is faster in children. The superior capacity of children's central nervous system to adapt to external or internal environmental changes (neural plasticity) and the shorter recovery distance from the axon repair site to the target muscle are claimed to be crucial determinants of their favorable outcomes. Moreover, even in the pediatric population, it has been demonstrated that functional results are better the younger the patient is, including better clinical results in those injured in early childhood (< 6 years old) than in those injured in adolescence. Other favorable prognostic factors include the type of nerve injury (with complete transections doing less well than crush injuries) and the timing of surgery (with better outcomes after early repairs). CONCLUSIONS All efforts should be done to repair in a timely and adequate fashion traumatic peripheral nerve injuries in children, as the results are good.
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Patel M, Iwanaga J, Oskouian RJ, Tubbs RS. Variant Distal Ulnar Nerve Loop: A Previously Undescribed Anatomical Finding. Cureus 2018; 10:e2604. [PMID: 30013868 PMCID: PMC6039214 DOI: 10.7759/cureus.2604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A previously undescribed variant ulnar nerve loop was discovered during the routine anatomic forearm and hand dissection of an adult female. The major finding was that of a large loop traveling around the distal tendon of the flexor carpi ulnaris. The variation presented here appears to be unique. The exact function of such derailed anatomy is not clear but, if found during surgery, might confound normal dissection methods or, when present, could result in varied clinical presentations regarding the sensory or motor examination of the hand.
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Affiliation(s)
- Mayank Patel
- Clinical Anatomy Research, Seattle Science Foundation, Seattle, USA
| | | | - Rod J Oskouian
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - R Shane Tubbs
- Neurosurgery, Seattle Science Foundation, Seattle, USA
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Kaneko A, Sugiyama Y, Nagura N, Goto K, Iwase Y, Obayashi O, Naito K, Kaneko K. Attrition rupture of ulnar nerve in a patient with rheumatoid elbow arthritis: A case report. Medicine (Baltimore) 2018; 97:e0535. [PMID: 29703029 PMCID: PMC5944549 DOI: 10.1097/md.0000000000010535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cubital tunnel syndrome has been recognized as a common pathology in rheumatoid arthritis (RA) of the elbow. We encountered a patient with RA of the elbow showing attrition rupture of the ulnar nerve. This pathology is extremely rare, and we discussed preventive measures for similar cases in the future based on our case. PATIENT CONCERNS A 53-year-old woman, received drug treatment for RA since 30 years earlier, had numbness in the left ulnar nerve territory, dorsal interossei muscle atrophy, and resulting claw hand. DIAGNOSES Plain x-ray examination showed bone destruction of the left elbow joint and marked osteophyte formation in the medial joint space. In nerve conduction velocity (NCV) tests, the Motor NCV was immeasurable in the ulnar nerve territory. Based on these findings, a diagnosis of left cubital tunnel syndrome was made, and anterior transposition of the ulnar nerve was planned. INTERVENTIONS When the ulnar nerve dissection was advanced, about 80% portion of the ulnar nerve was ruptured. After the ends of the divided nerve were freshened, end-to-end anastomosis was possible by anterior transposition of the ulnar nerve. OUTCOMES Two years after the operation, numbness and muscle atrophy also remained. There were no changes in the level of daily activities after the operation. However, motor NCV, showed improvement (22.8 m/s) after the operation. LESSONS In patients with RA showing ulnar neuropathy symptoms, marked osteophyte formation in the medial joint space or valgus deformity may indicate attrition nerve rupture. In the future, when such patients with RA are examined, active nerve exposure and dissection should be considered in terms of ulnar nerve protection.
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Affiliation(s)
- Ayaka Kaneko
- Department of Orthopaedics, Juntendo University School of Medicine
| | - Yoichi Sugiyama
- Department of Orthopaedics, Juntendo University School of Medicine
| | - Nana Nagura
- Department of Orthopaedics, Juntendo University School of Medicine
- Department of Orthopaedic surgery, Juntendo Tokyo Koto Geriatric Medical Center
| | - Kenji Goto
- Department of Orthopaedics, Juntendo University School of Medicine
| | - Yoshiyuki Iwase
- Department of Orthopaedic surgery, Juntendo Tokyo Koto Geriatric Medical Center
| | - Osamu Obayashi
- Department of Orthopaedic Surgery, Juntendo University Shizuoka Hospital, Japan
| | - Kiyohito Naito
- Department of Orthopaedics, Juntendo University School of Medicine
| | - Kazuo Kaneko
- Department of Orthopaedics, Juntendo University School of Medicine
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Atiyya AN, Nassar WAM. Ulnar Nerve Repair With Simultaneous Metacarpophalangeal Joint Capsulorrhaphy and Pulley Advancement. J Hand Surg Am 2015; 40:1818-23. [PMID: 26100986 DOI: 10.1016/j.jhsa.2015.04.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the validity of performing a static anti-claw procedure (metacarpophalangeal joint volar capsulorrhaphy and A1 and A2 pulley release) at the time of ulnar nerve repair for acute or chronic lacerations to prevent development of claw hand deformity and disability or to correct them. METHODS We present a case series of 14 patients for whom metacarpophalangeal joint capsulorrhaphy and pulley advancement were done at the time of ulnar nerve management. Direct nerve repair was performed in 10 patients, nerve grafting in 2, neurolysis in 1, and combined direct repair and anterior interosseous nerve transfer in 1. Outcome measurements included assessment of claw hand correction and sequence of phalangeal flexion according to modified evaluation criteria of Brand and motor recovery of ulnar nerve function using the British Medical Research Council (MRC) scale. RESULTS Average follow-up was 39 months. At 3 months, 12 patients had good and 2 had fair claw hand correction. At 6 months, 2 patients had excellent, 10 patients had good, and 2 patients had fair correction. At final follow-up, 13 patients had good to excellent correction and 1 had fair correction. Motor recovery of the intrinsic muscles was rated from 2 to 5 according to the MRC scale. CONCLUSIONS This technique is simple and effective. It acts as an internal orthosis during recovery of sufficient strength of the intrinsic muscles. In cases of incomplete recovery of the intrinsic muscles (up to MRC grade 2), it may eliminate the need for secondary surgery to correct a claw hand deformity. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ahmed Naeem Atiyya
- Orthopaedic Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Wael A M Nassar
- Orthopaedic Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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