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Ahmed KS, Rajput BU, Siddiqui MAI, Nadeem A, Rahman MF. Median to Radial Nerve Transfer: An 8-Year Experience From a Lower-Middle Income Country. J Surg Res 2023; 291:231-236. [PMID: 37473628 DOI: 10.1016/j.jss.2023.04.013] [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] [Received: 03/06/2022] [Revised: 03/20/2023] [Accepted: 04/15/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION With an incidence of 2-16%, radial nerve palsy is one of the common forms of nerve injuries globally. Radial nerve palsy causes debilitating effects including loss of elbow extension, wrist drop and loss of finger extension. Reparative surgical pathways range from primary repair and neurolysis, to nerve grafting, nerve transfers, and tendon transfers. Due to ease of performance and acceptability and reproducibility of outcomes, tendon transfers are considered the gold standard of radial nerve palsy repair. However, independent finger function cannot be achieved and as such may not give truly desirable results. In lower-middle income countries, the question of nerve transfer versus tendon transfer for patients who are keen to get back to work is key. While tendon transfer recovery is faster, the functional loss is often considered devastating for fine hand function due to loss of grip secondary to lack of wrist and finger extension. In this study, we present our experience of performing median nerve transfers for radial nerve palsy in Pakistan. METHODS We performed a retrospective case-series of patients undergoing median to radial nerve transfer for radial nerve palsy over a period of 6 y, from 2012 to 2019. Patients with radial nerve palsy were diagnosed via electromyography and nerve conduction studies. The procedure involved coapting the branches of the flexor carpi radialis and flexor digitorum superficialis (long and ring finger) nerves to the posterior interosseous nerve and extensor carpi radialis brevis, respectively. Patients were assessed using the Medical Research Council scale for muscle strength of wrist, finger and thumb extension separately at 1 y time. Our results were then compared to results from similar nerve transfer studies. RESULTS We operated on 10 right-hand dominant patients, eight males and two females with a median age of 33 y (6-63 y). four sustained injury to the right hand and six to the left. Causes of the injuries included road traffic accident (n = 3), firearm injury (n = 4), shrapnel (n = 1), iatrogenic injury (injection in deltoid region (n = 1) and fall (n = 1). Types of fracture included mid humerus fracture, fracture of the surgical neck of the humerus, and supracondylar fracture of the humerus. Median time to surgery since injury was 4 mo (1-8 mo). Independent wrist extension was M4+ in all patients and independent finger extension was M4+ in seven and M4-in two patients. However, a patient who presented late at 8 mo had poorer finger outcomes with extension at M2-. All patients had independent movement of fingers. CONCLUSIONS Nerve transfer is a reliable method of post traumatic nerve repair and reinnervation, particularly in lower-middle income countries, even in cases where the nerve damage is severe and extensive and up to 6 mo may have elapsed between injury and presentation. Timely median to radial nerve transfer is a highly recommended option for radial nerve palsy, with regular follow-ups and physical therapy added to ensure positive outcomes.
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Affiliation(s)
- Kaleem S Ahmed
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan; Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Batool U Rajput
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan
| | | | - Afifa Nadeem
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan
| | - Mohammad Fazlur Rahman
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Aga Khan University, Karachi, Pakistan.
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Gu F, Fan J, Wang Z, Liu X, Yang J, Zhu Q. Automatic range of motion measurement via smartphone images for telemedicine examination of the hand. Sci Prog 2023; 106:368504231152740. [PMID: 36721870 PMCID: PMC10450288 DOI: 10.1177/00368504231152740] [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: 02/02/2023]
Abstract
BACKGROUND Telemedicine support virtual consultations and evaluations in hand surgery for patients in remote areas during the COVID-19 era. However, traditional physical examination is challenging in telemedicine and it is inconvenient to manually measure the hand range of motion (ROM) from images or videos. Here, we propose an automatic method using the hand pose estimation technique, aiming to measure the hand ROM from smartphone images. METHODS Twenty-eight healthy volunteers participated in the study. An eight-hand gestures measurement protocol and the Google MediaPipe Hands were used to analyze images and calculate the ROM automatically. Manual goniometry was also performed according to the guideline of the American Medical Association. The correlation between the automatic and manual methods was analyzed by the intraclass correlation coefficient and Pearson correlation coefficient. The clinical acceptance was testified using Bland-Altman plots. RESULTS A total of 32 parameters of each hand were measured by both methods, and 1792 measurement results were compared. The mean difference between automatic and manual methods is -2.21 ± 9.29° in the angle measurement and 0.48 ± 0.48 cm in the distance measurement. The intraclass correlation coefficient of 75% of parameters was higher than 0.75, the Pearson correlation coefficient of 84% of parameters was over 0.6, and 40.6% of parameters reached well-accepted clinical agreements. CONCLUSIONS The proposed method provides a helpful protocol for automatic hand ROM measurement based on smartphone images and the MediaPipe Hands pose estimation technique. The automatic measurement is acceptable and comparable with existing methods, showing a possible application in the telemedicine examination of hand surgery.
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Affiliation(s)
- Fanbin Gu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingyuan Fan
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhaoyang Wang
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaolin Liu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Engineering Laboratory for Soft Tissue Biofabrication, Guangzhou, China
- Guangdong Provincial Key Laboratory for Orthopaedics and Traumatology, Guangzhou, China
| | - Jiantao Yang
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Engineering Laboratory for Soft Tissue Biofabrication, Guangzhou, China
- Guangdong Provincial Key Laboratory for Orthopaedics and Traumatology, Guangzhou, China
| | - Qingtang Zhu
- Department of Microsurgery, Orthopaedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Engineering Laboratory for Soft Tissue Biofabrication, Guangzhou, China
- Guangdong Provincial Key Laboratory for Orthopaedics and Traumatology, Guangzhou, China
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Gu F, Fan J, Cai C, Wang Z, Liu X, Yang J, Zhu Q. Automatic detection of abnormal hand gestures in patients with radial, ulnar, or median nerve injury using hand pose estimation. Front Neurol 2022; 13:1052505. [PMID: 36570469 PMCID: PMC9767954 DOI: 10.3389/fneur.2022.1052505] [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: 09/24/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022] Open
Abstract
Background Radial, ulnar, or median nerve injuries are common peripheral nerve injuries. They usually present specific abnormal signs on the hands as evidence for hand surgeons to diagnose. However, without specialized knowledge, it is difficult for primary healthcare providers to recognize the clinical meaning and the potential nerve injuries through the abnormalities, often leading to misdiagnosis. Developing technologies for automatically detecting abnormal hand gestures would assist general medical service practitioners with an early diagnosis and treatment. Methods Based on expert experience, we selected three hand gestures with predetermined features and rules as three independent binary classification tasks for abnormal gesture detection. Images from patients with unilateral radial, ulnar, or median nerve injuries and healthy volunteers were obtained using a smartphone. The landmark coordinates were extracted using Google MediaPipe Hands to calculate the features. The receiver operating characteristic curve was employed for feature selection. We compared the performance of rule-based models with logistic regression, support vector machine and of random forest machine learning models by evaluating the accuracy, sensitivity, and specificity. Results The study included 1,344 images, twenty-two patients, and thirty-four volunteers. In rule-based models, eight features were finally selected. The accuracy, sensitivity, and specificity were (1) 98.2, 91.7, and 99.0% for radial nerve injury detection; (2) 97.3, 83.3, and 99.0% for ulnar nerve injury detection; and (3) 96.4, 87.5, and 97.1% for median nerve injury detection, respectively. All machine learning models had accuracy above 95% and sensitivity ranging from 37.5 to 100%. Conclusion Our study provides a helpful tool for detecting abnormal gestures in radial, ulnar, or median nerve injuries with satisfying accuracy, sensitivity, and specificity. It confirms that hand pose estimation could automatically analyze and detect the abnormalities from images of these patients. It has the potential to be a simple and convenient screening method for primary healthcare and telemedicine application.
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Affiliation(s)
- Fanbin Gu
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingyuan Fan
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chengfeng Cai
- Department of Hand and Foot Rehabilitation, Guangdong Provincial Work Injury Rehabilitation Hospital, Guangzhou, China
| | - Zhaoyang Wang
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaolin Liu
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Guangdong Provincial Engineering Laboratory for Soft Tissue Biofabrication, Guangzhou, China,Guangdong Provincial Key Laboratory for Orthopedics and Traumatology, Guangzhou, China
| | - Jiantao Yang
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Guangdong Provincial Engineering Laboratory for Soft Tissue Biofabrication, Guangzhou, China,Guangdong Provincial Key Laboratory for Orthopedics and Traumatology, Guangzhou, China,*Correspondence: Jiantao Yang
| | - Qingtang Zhu
- Department of Microsurgery, Orthopedic Trauma and Hand Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Guangdong Provincial Engineering Laboratory for Soft Tissue Biofabrication, Guangzhou, China,Guangdong Provincial Key Laboratory for Orthopedics and Traumatology, Guangzhou, China,Qingtang Zhu
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Charlotte J, Nathalie B, Caroline L. Nerve transfers in the forearm: potential use in spastic conditions. SURGICAL AND RADIOLOGIC ANATOMY : SRA 2022; 44:1091-1099. [PMID: 35906417 DOI: 10.1007/s00276-022-02990-z] [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: 12/28/2021] [Accepted: 06/24/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Deformities of the spastic upper limb result frequently from the association of spasticity, muscle contracture and muscle imbalance between strong spastic muscles and weak non-spastic muscles. This study was designed to evaluate the feasibility of combining selective neurectomy of the usual spastic and strong muscles together with transfer of their motor nerves to the usual weak muscles, to improve wrist and fingers motion while decreasing spasticity. METHODS Twenty upper limbs from fresh frozen human cadavers were dissected. All motor branches of the radial and median nerve for the forearm muscles were identified. We attempted all possible end-to-end nerve transfers between the usually strong "donor" motor branches, namely FCR and PT, and the usually weak "recipient" motor branches (ERCL, ECRB, PIN, AIN). RESULTS The PT had two nerve branches in 80%, thus allowing selective neurectomy. The proximal PT branch could be anastomosed end-to-end in 45% (AIN) to 85% (ECRL) of cases with the potential recipient branches. The distal PT branch could be anastomosed end to end to all potential recipient nerves. The FCR had a single branch in all cases. End-to-end anastomosis was possible in 90% for the ECRL and in 100% for all other recipient branches, but sacrificed all FCR innervation, ruling out hyperselective neurectomy. CONCLUSION Selective neurectomies can be associated with distal nerve transfers at the forearm level in selected cases. The motor nerve to the PT is the best donor for nerve transfer combined with selective neurectomy, transferred to the ECRL, ECRB, PIN or AIN.
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Affiliation(s)
- Jaloux Charlotte
- Marseille University Hospital APHM, Institut de Neurophysiopathologie UMR 7051, Marseille, France
| | | | - Leclercq Caroline
- Institut de La Main, Clinique Bizet, 21 rue Georges Bizet, Paris, France.
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Hagemann C, Harhaus L. [Combined distal nerve and tendon transfer in drop wrist for treatment of high injuries of the radial nerve]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2021; 33:399-404. [PMID: 34477889 DOI: 10.1007/s00064-021-00732-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/20/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of direct distal selective nerve transfer close to the end organ with high radial nerve injury is restoration of the paretic function before irreversible atrophy of the target muscle. Simultaneous tendon transfer enables direct functional correction of wrist drop. INDICATIONS Selective nerve and tendon transfer of the lower arm is indicated if a) the primary nerve lesion is located proximally distant and reinnervation by direct nerve repair would take too long to reach a paretic muscle because of the long distance involved, b) direct repair of the nerve lesion is impossible or c) there has been a substantial delay after the primary injury. A viable donor nerve must be available. CONTRAINDICATIONS A) After final denervation of a muscle, which occurs approximately 1.5 years after a nerve injury, the atrophy is irreversible and a nerve transfer can no longer restore the paretic muscle. Only younger patients under 30 years old might benefit from delayed nerve transfer. B) When no sufficient donor nerve is available only tendon transfer is possible. SURGICAL TECHNIQUE Direct nerve transfer from the median nerve to the radial nerve as well as direct functional correction of wrist drop by tendon transfer of the pronator teres muscle. POSTOPERATIVE MANAGEMENT Immobilization of the arm for 3 days, wrist orthosis for 6 weeks for protection of the tendon transfer, ergotherapy and physiotherapy preferably by a hand therapist. RESULTS Active wrist and finger extension 2 years after transfer, with individualized extension of the thumb and index finger is possible, wrist drop reversed.
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Affiliation(s)
- Christian Hagemann
- Abteilung Kinderneurochirurgie, Altonaer Kinderkrankenhaus gGmbH, Bleickenallee 38, 22763, Hamburg, Deutschland.
| | - Leila Harhaus
- Klinik für Hand‑, Plastische- und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Hand- und Plastische Chirurgie der Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
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Bertelli JA, Patel N, Soldado F, Duarte ECW. Patterns of median nerve branching in the cubital fossa: implications for nerve transfers to restore motor function in a paralyzed upper limb. J Neurosurg 2021; 135:1524-1533. [PMID: 33740763 DOI: 10.3171/2020.9.jns202742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the anatomy of donor and recipient median nerve motor branches for nerve transfer surgery within the cubital fossa. METHODS Bilateral upper limbs of 10 fresh cadavers were dissected after dyed latex was injected into the axillary artery. RESULTS In the cubital fossa, the first branch was always the proximal branch of the pronator teres (PPT), whereas the last one was the anterior interosseous nerve (AIN) and the distal motor branch of the flexor digitorum superficialis (DFDS) on a consistent basis. The PT muscle was also innervated by a distal branch (DPT), which emerged from the anterior side of the median nerve and provided innervation to its deep head. The palmaris longus (PL) motor branch was always the second branch after the PPT, emerging as a single branch together with the flexor carpi radialis (FCR) or the proximal branch of the flexor digitorum superficialis. The FCR motor branch was prone to variations. It originated proximally with the PL branch (35%) or distally with the AIN (35%), and less frequently from the DPT. In 40% of dissections, the FDS was innervated by a single branch (i.e., the DFDS) originating close to the AIN. In 60% of cases, a proximal branch originated together with the PL or FCR. The AIN emerged from the posterior side of the median nerve and had a diameter of 2.3 mm, twice that of other branches. When dissections were performed between the PT and FCR muscles at the FDS arcade, we observed the AIN lying lateral and the DFDS medial to the median nerve. After crossing the FDS arcade, the AIN divided into: 1) a lateral branch to the flexor pollicis longus (FPL), which bifurcated to reach the anterior and posterior surfaces of the FPL; 2) a medial branch, which bifurcated to reach the flexor digitorum profundus (FDP); and 3) a long middle branch to the pronator quadratus. The average numbers of myelinated fibers within each median nerve branch were as follows (values expressed as the mean ± SD): PPT 646 ± 249; DPT 599 ± 150; PL 259 ± 105; FCR 541 ± 199; proximal FDS 435 ± 158; DFDS 376 ± 150; FPL 480 ± 309; first branch to the FDP 397 ± 12; and second branch to the FDP 369 ± 33. CONCLUSIONS The median nerve's branching pattern in the cubital fossa is predictable. The most important variation involves the FCR motor branch. These anatomical findings aid during nerve transfer surgery to restore function when paralysis results from injury to the radial or median nerves, brachial plexus, or spinal cord.
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Affiliation(s)
- Jayme A Bertelli
- 1Department of Neurosurgery, Center of Biological and Health Sciences, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil
- 2Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Neehar Patel
- 3Department of Plastic Surgery, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Francisco Soldado
- 4Pediatric Hand Surgery and Microsurgery Unit, Barcelona University Children's Hospital HM Nens, HM Hospitales, Barcelona, Spain
- 5Pediatric Hand Surgery and Microsurgery Unit, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; and
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Nerve and Tendon Transfers After Spinal Cord Injuries in the Pediatric Population. Phys Med Rehabil Clin N Am 2020; 31:455-469. [DOI: 10.1016/j.pmr.2020.04.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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