Evaluation of results of various tendon transfers in high and low radial nerve palsy

BACKGROUND

Various combinations of tendon transfers are available for radial nerve palsy. However, the choice of which set of transfer to be performed in a patient remains an issue of varied opinions among surgeons. The study attempts to evaluate the results of various tendon transfers for radial nerve palsy quantitatively and subjectively. It also identifies which set of transfer is suitable for particular groups of patients.

MATERIALS AND METHODS

The study was conducted between 2005 and 2007. A total of 15 tendon transfers were performed using various combinations and evaluated according to Bincaz's criteria, Kapandji scale and effect of tendon transfers on activities of daily living.

RESULTS

13 patients had excellent to fair outcome according to Bincaz's criteria. 2 patients had poor outcome. There was no hindrance in the activities of daily life in all patients. 93.4% of patients were satisfied with the results.

CONCLUSION

Every combination of tendon transfers has its own set of merits and demerits. Selection of donor tendons as per occupational need of patients is utmost important. Patients in our series were satisfied with set of transfers using Pronator teres(PT) for wrist extension, Flexor carpi radialis (FCR) for finger extension and rerouted Palmaris longus (PL) for extension of thumb. Flexor carpi ulnaris (FCU) is important for power grip.

Retrospective Analysis of Giant Cell Tumor Lower End Radius Treated with En bloc Excision and Translocation of Ulna

BACKGROUND

Distal end of radius is third most common site for GCT of long bones and 1% of these metastasize mostly to lungs. Reconstruction methods commonly used are fibula (vascularized and nonvascularized), centralization of ulna, translocation of ulna, and endoprosthetic replacement. We report the outcome of series of twenty cases where we did en bloc excision of tumor with translocation of ulna.

MATERIALS AND METHODS

Twenty cases of giant cell tumor (GCT) of lower end of radius were included in this retrospective study. The mean age of patients was 33.15 years (range 21-55 years). We had 14 of Campanacci Grade III and 6 of Grade II. Preoperative radiographs and magnetic resonance imaging of the involved wrist and forearm were done.

RESULTS

Of all twenty patients, 14 were males and 6 were females. Mean followup duration was 3.9 years (range 1.5-17 years). Mean grip strength of involved side as a percentage of normal side was 71% (range 42%-86%) and the actual mean value for operated side was 29 kg as compared to 40 kg for normal side. The average range of forearm movement was supination 80.25° (60°-90°) and pronation 77.5° (70°-90°). No patient was dissatisfied as far as cosmesis was concerned.

DISCUSSION

In our opinion considering the propensity to recur with more aggressiveness after recurrence, en bloc excision with translocation of ulna has become a standard treatment option for GCT of lower end of radius, with advantages of better functional outcomes, retained vascularity, and elimination of risk of donor site morbidity.

Radial nerve entrapement in osseous tunnel without clinical symptoms

Entrapment of a nerve in the callus of a healing fracture is not a common entity, but it does exist. The entrapment usually presents without neurological deficit. It is difficult to suspect the radial nerve injury if we need to operate on the same site. We present a case of entrapment of radial nerve in the callus of a supracondylar humerus fracture with cubitus varus deformity. The surgery for correction of the deformity led to the damage of the nerve. In retrospect a careful assessment of the x-rays showed two 3-4 mm diameter holes. Awareness of this finding would have given us sufficient indication of nerve entrapment to prevent this mishap.

Outcome of early active mobilization after flexor tendons repair in zones II-V in hand

BACKGROUND

The functional outcome of a flexor tendon injury after repair depends on multiple factors. The postoperative management of tendon injuries has paved a sea through many mobilization protocols. The improved understanding of splinting techniques has promoted the understanding and implication of these mobilization protocols. We conducted a study to observe and record the results of early active mobilization of repaired flexor tendons in zones II-V.

MATERIALS AND METHODS

25 cases with 75 digits involving 129 flexor tendons including 8 flexor pollicis longus (FPL) tendons in zones II-V of thumb were subjected to the early active mobilization protocol. Eighteen (72%) patients were below 30 years of age. Twenty-four cases (96%) sustained injury by sharp instrument either accidentally or by assault. Ring and little finger were involved in 50% instances. In all digits, either a primary repair (n=26) or a delayed primary repair (n=49) was done. The repair was done with the modified Kessler core suture technique with locking epitendinous sutures with a knot inside the repair site, using polypropylene 3-0/4-0 sutures. An end-to-end repair of the cut nerves was done under loupe magnification using a 6-0/8-0 polyamide suture. The rehabilitation program adopted was a modification of Kleinert's regimen, and Silfverskiold regimen. The final assessment was done at 14 weeks post repair using the Louisville system of Lister et al.

RESULTS

Eighteen of excellent results were attributed to ring and little fingers where there was a flexion lag of < 1 cm and an extension lag of < 15 degrees . FPL showed 75% (n=6) excellent flexion. 63% (n=47) digits showed excellent results whereas good results were seen in 19% (n=14) digits. Nine percent (n=7) digits showed fair and the same number showed poor results. The cases where the median (n=4) or ulnar nerve (n=6) or both (n=3) were involved led to some deformity (clawing/ape thumb) at 6 months postoperatively. The cases with digital or common digital nerve involvement (n=7 with 17 digits) showed five excellent, two good, four fair, and six poor results. Complications included tendon ruptures in 2 (3%) cases (one thumb and one ring finger) and contracture in 2 (3%) cases whereas superficial infection and flap necrosis was seen in 1 case each.

CONCLUSION

The early active mobilization of cut flexor tendons in zones II-V using the modified mobilization protocol has given good results, with minimal complications.

Management of radial clubhand with gradual distraction followed by centralization

BACKGROUND

Treatment of radial clubhand has progressed over the years from no treatment to aggressive surgical correction. Various surgical methods of correction have been described; Centralization of the carpus over the distal end of the ulna has become the method of choice. Corrective casting prior to centralization is an easy and effective method of obtaining soft tissue stretching before any definitive procedure is undertaken. Moreover, it helps put the limb in a correct position. The outcome of deformity correction by serial casting / JESS distractor followed by centralization is discussed.

MATERIALS AND METHODS

In a prospective study, of 17 cases with 18 radial clubhands of Heikel's Grade III and IV (with average age 11 months (range 20 days - 24 months) with M:F of 2.6:1, were treated by gradual soft tissue stretching using corrective cast (14 cases) and JESS distraction (4 cases), followed by centralization (16 cases) or radialization (2 cases) and tendon transfers.

RESULTS

The average correction attained during the study was 71 degrees of radial deviation and 31 degrees of volar flexion. The average third metacarpal to distal ulna angle in anteroposterior and lateral view at final follow-up was 7 degrees in both views. Angle of movement at elbow showed a small increase from 99 degrees to 101 degrees during the follow-up period. However, the range of movement at fingers showed increase in stiffness during the follow-up. No injury occurred to the distal ulnar epiphysis during the operative intervention. The results at the final follow-up, at the end of 2 years were graded on the basis of the criteria of F.W. Bora, and of Bayne and Klug. Considering the criteria of F.W. Bora, satisfactory result was shown by nine of the 18 hands (50%) while 16 out of 18 hands (89%) showed good or satisfactory result based on deformity criteria of Bayne and Klug.

CONCLUSION

The management of radial clubhand by gradual corrective cast or JESS distractor followed by centralization and tendon transfers in children is an acceptable method of treatment with consistently satisfactory results, both functional and cosmetic.

Outcome of early active mobilization after extensor tendon repair

BACKGROUND

Traditionally the repaired extensor tendons have been treated postoperatively in static splints for several weeks, leading to formation of adhesions and prolonged rehabilitation. Early mobilization using dynamic splints is common, but associated with many shortcomings. We attempted to study the results of early active mobilization, using a simple static splint, and easy-to-follow rehabilitation plan.

MATERIALS AND METHODS

In a prospective study 26 cases of cut extensor tendons in Zone V to VIII were treated with primary or delayed primary repair. Following this, early active mobilization was undertaken, using an easy-to-follow rehabilitation plan. The results were assessed according to the criteria of Dargan at six weeks and one year.

RESULTS

All the 26 patients were followed up for one year. 20 out of 26 patients were below 30 years of age, involving the dominant hand more commonly (16 patients, 62%). Agriculture instruments were the most common mode of injury (13 patients, 50%). The common site for injury was extensor zone VI (42%, n = 11).

CONCLUSION

Rehabilitation done for repaired extensor tendon injuries by active mobilization plan using a simple static splint has shown good results.

Acute carpal tunnel syndrome due to a hemangioma of the median nerve

Hemangioma of the median nerve presenting as acute carpal tunnel syndrome is unusual A-18- year old male presented with severe incapacitating pain of sudden onset of left forearm and hand after manual field work. There was swelling on volar aspect of forearm, with hyperalgesia in the median nerve distribution. The fingers and wrist were inmarked flexion and the patient did not allow wrist and finger extension. X-rays were within normal limits. An emergency volar carpal ligament release revealed, haematoma about 100 ml with numerous vessels encircling the median nerve. Histopathology of lesion turned out to be a cavernous hemangioma. Post operatively patient had full recovery.

Sectional neuroanatomy of the lower limb II: leg and foot

The authors have produced a pair of articles that can be used to rapidly identify back, hip, and lower limb muscles and their innervation(s). This article presents the motor and sensory innervation of the lower limb by color-coding structures to match their peripheral nerves. It provides a companion summary table that allows prediction of unique patterns of denervation from 12 lesions sites.

Sectional neuroanatomy of the lower limb I: lower back and hip

This series of two articles is structured to provide anatomically accurate functional schematics of the motor and sensory innervation of the lower back, hip, and lower limb. This first paper provides radiographically oriented schematic axial sections of the lower back and hip in which the muscles are appropriately color-coded to match the peripheral nerves. A companion color-coded summary table allows prediction of unique patterns of denervation from 25 lesion sites. These are divided into three categories (roots T12 to S4, four plexal quadrants, and 11 sectional levels). Correlation between an imaging abnormality at one of these lesion sites and the predicted denervation pattern ensures the lesion is, in fact, clinically significant. The next article will continue this color-coded approach into the lower limb.