Capitate Proximal Fragment Migration Compressing the Median Nerve in Scaphocapitate Fracture: A Case Report.

BACKGROUND Scaphocapitate syndrome is a rare clinical entity consisting of a combined scaphoid and capitate fracture along with a 90- or 180-degrees rotation of the proximal capitate fragment. The syndrome is scarcely described in the literature, with proximal migration of the capitate fragment being reported only by Mudgal et al in 1995. Concurrent compression of the median nerve is a highly unfortunate event, suggesting a unique case presented here. CASE REPORT We present a unique case of scaphocapitate fracture-dislocation in a 25-year-old man with volar dislocation of the capitate's fragment deep to the median nerve. X-rays and CT scan were performed and the patient was treated few hours after the injury by a hand specialist, in order to prevent median neuropathy and avascular necrosis of the fragment. Open reduction and internal fixation utilizing a Herbert screw for the scaphoid fracture and 3 additional K-wires was performed. Immediately post-operatively, the acute neurological symptoms had subsided and good reduction was acquired radiologically. One year post-operatively the patient had regained good hand and wrist functionality, with no extension or flexion ROM deficits. CONCLUSIONS Immediate intervention in a specialized center with reduction and fixation utilizing a Herbert screw and K-wires showed favorable 1-year results in our case of scaphocapitate syndrome. The impending complications of median neuropathy and capitate avascular necrosis were avoided despite the high-risk injury pattern.

[Rare nerve compression neuropathies] / Seltene Nervenkompressionssyndrome.

UNCOMMON NERVE COMPRESSION SYNDROMES: In regard to the complex anatomical relationship of peripheral nerves and muscles, tendons, fasciae as well as their long course within those anatomical structures and additional close contact to bony structures, they are prone to suffer from local compression syndromes. Hence creating a vast majority of entrapment syndromes - well described in literature for almost every single nerve. The purpose of this article is to give an overview of symptoms, signs, diagnostic studies and treatment options, addressing especially the less known syndromes. Compression syndromes of the upper arm and shoulder region include the suprascapular nerve syndrome the compression of the axillary nerve within the spatium quadrilaterale and the compression of the long thoracic nerve at the chest wall. The upper extremity offers a variety of infrequent entrapment syndromes, as the pronator teres syndrome and anterior interosseus syndrome, both resulting from pressure to the median nerve in the forearm. Compression neuropathy in the course of the radial nerve in the distal upper extremity is also known as supinator syndrome. Guyon's canal syndrome is the ulnar side equivalent to the well-known carpal tunnel syndrome. In the case of a Cheiralgia paresthetica, a compression of a sensory branch of the superficial radial nerve can be seen. In the lower extremities, a variety of nerves especially in the groin and thigh area can be compressed as they pass through the narrow spaces between the abdominal muscles or underneath the inguinal ligament. Compression of the lateral femoral cutaneous nerve is the most common syndrome. Compression syndromes of the femoral and obturator nerves are most often iatrogenic. Pain around the knee, especially the lateral part and following orthopedic procedures of the knee, can arise from a compression or a lesion of a small infrapatellar branch of the saphenous nerve. Another probably underdiagnosed syndrome is piriformis syndrome, resulting from an entrapment of the sciatic nerve as it passes through certain muscular structures. In the distal lower extremity, the peroneal and tibial nerves can be compressed at multple sites, clinically known as peroneal nerve paralysis resulting from nerve compression around the fibular head, the anterior and posterior tarsal tunnel syndrome, and Morton's metatarsalgia.

Provocative changes in nerve conductions: Fact or fiction?

At times electrodiagnostic medical consultants (EMCs) are asked to perform studies in both a neutral position, and then again after the patient is in a provocative position that exacerbates symptoms, to assess for measurable electrophysiologic changes. While this approach might seem initially appealing, particularly when standard studies are not effective at diagnosis, empiric studies in several conditions have been unimpressive. Studies in median neuropathy at the wrist, thoracic outlet syndrome, piriformis syndrome, and radial tunnel syndrome have failed to demonstrate reproducible changes in nerve conduction studies in positions that exacerbate symptoms. Furthermore, there is lack of a plausible pathophysiologic mechanism for producing both measurable and rapidly reversible electrophysiologic changes after just a few minutes, or less, of compression. Axon loss and demyelination would not be rapidly reversible, and positional changes of 2 min or less (the durations generally studied) would be insufficient to produce measurable nerve ischemia. Last, we have gained a greater appreciation for how much nerves move within limbs with changes in joint position; this movement can lead to misleading changes in nerve conduction studies. It is thus appropriate to conclude that testing nerve conduction in provocative or symptomatic positions adds no value to electrodiagnostic testing.

Effect of pronator teres muscle botulinum neurotoxin type-A injection on proximal median nerve entrapment.

PURPOSE: We aimed to evaluate the effect of botulinum neurotoxin type-A (Btx-A) injection into the pronator teres muscle in proximal median nerve entrapment (PMNE). METHODS: Intramuscular injection of 30 IU Btx-A into the pronator teres muscle was performed in 12 patients (14 extremities) diagnosed with PMNE. The injection was made under nerve stimulator control. One patient with thoracic outlet syndrome was excluded from the study and not included in the clinical evaluation. Grip and pinch strength, 2-point discrimination, Q-DASH score, and pain on VAS were evaluated and compared before and 6-8 months after injection. The patients were contacted again by phone after the first and fifth years and asked about PMNE symptomatology. RESULTS: None of the patients had complications. No significant difference in pinch strength was observed following Btx-A injection, but there was significant improvement in grip strength, 2-point discrimination, and Q-DASH and VAS pain scores. CONCLUSION: The outcomes of our study were promising: Btx-A injection improved symptoms in patients with PMNE. LEVEL OF EVIDENCE: Level IV.

Pronator syndrome and anterior interosseous nerve palsy due to neurolymphomatosis: a case report.

Pronator syndrome is a median nerve entrapment neuropathy that can be difficult to diagnose due to its variable presentation and objective findings. Neurolymphomatosis is an uncommon disease in which malignant lymphocytes infiltrate central or peripheral nerve endoneurium and is often missed for prolonged periods prior to diagnosis. We present a rare case of pronator syndrome and anterior interosseous nerve palsy due to neurolymphomatosis that was occult on initial MRI in spite of the presence of a median nerve mass discovered intra-operatively during neurolysis. This case demonstrates the value of ultrasound for the examination of peripheral nerve pathology and illustrates its utility as an adjunct to MRI, in part due to the ability to screen a large region.

Median nerve entrapment during closed reduction of antebrachium fracture in a child.

This is a case report of a four-year-old boy who suffered a forearm fracture managed with closed reduction and casting for six weeks. Postoperatively, the patient showed symptoms of median nerve affection which was misinterpreted as neuropraxia. Ultrasonography of the forearm revealed that the median nerve was trapped in the radius fracture site. The patient underwent a second operation with neurolysis and nerve grafting. This case report highlights the use of ultrasonography in the diagnostics of nerve entrapment neuropathy.

SARS-COV-2 INFECTION AND INVOLVEMENT OF PERIPHERAL NERVOUS SYSTEM: A CASE SERIES OF CARPAL TUNNEL SYNDROME AGGRAVATION OR NEW ONSET WITH COVID-19 DISEASE AND A REVIEW OF LITERATURE.

COVID-19 may be asymptomatic or have a typical presentation with fever, cough, anosmia, lymphocytopenia. In some cases, it occurs with a "chimeric" presentation, with more subtle and ambiguous symptoms which may be initially misdiagnosed and are referred to in long covid condition. A possible central and peripheral nervous system involvement has been recognized. We present our experience and review the literature about association between carpal tunnel syndrome (CTS) and hand's arthritis presenting a case series of patients who firmly state that their condition of CTS arised or got worse during a typical presentation of COVID-19. The outbreak of COVID-19 has resulted in significant global healthcare implications. While the respiratory manifestations of COVID-19 have been widely studied, there is emerging evidence suggesting potential associations between COVID-19 and various other health conditions. This review of the literature aims to investigate the potential relationship between COVID-19 and the development or exacerbation of CTS. By synthesizing the available literature on this topic, we aim to provide a comprehensive overview of the current knowledge and enhance our understanding of the potential implications of COVID-19 on CTS. Case series: In this article we report 13 cases of typical presentations of COVID-19 with fever, myalgia, and respiratory system involvement, with a simultaneous aggravation of the median nerve pre-existing neuralgia and some cases that developed a median nerve neuralgia during COVID-19, which came to the attention of the hand surgeon. Some cases had stable symptomatic CTS and were on waiting list for surgical carpal tunnel release, some cases were previously asymptomatic and developed a median nerve neuralgia during COVID-19. All patients referred to a rapid worsening of acral paraesthesia and neuralgic pain of the same quality of CTS and in the median nerve topography. Some patients developed typical COVID-19 symptoms and died; the others were surgically treated. CTS could be an atypical presentations of COVID-19 or a condition of long-covid disease and clinical and epidemiological significance needs to be fully studied. We presented cases of worsening of the median nerve neuralgia which presented among other symptoms of COVID infection. We conclude a causal relation may exist and needs to be further investigated.

Median nerve entrapments in the forearm - a case report of rare anterior interosseous nerve syndrome.

Nowadays, median nerve entrapment is a frequent issue. Many physicians are familiar with the most common median entrapment, which is the carpal tunnel syndrome (CTS). By contrast, less frequent entrapments, historically called "pronator syndrome" are still misdiagnosed as overuse syndrome, flexor tendinitis or other conditions. This article is meant to introduce proximal median nerve entrapments, followed by a case report of the rarest example - anterior interosseous nerve syndrome (AIN syndrome).

The prevalence of double- and multiple crush syndromes in patients surgically treated for peripheral nerve compression in the upper limb.

OBJECTIVE: The double crush syndrome describes a condition characterized by multifocal entrapment of a nerve. In the upper limb, the high prevalence of carpal tunnel syndrome makes it a common diagnosis of assumption in the setting of median neuropathy. More proximal compressions may tend to be overlooked, under-diagnosed and under-treated in the population. This study aims to map the prevalence of peripheral upper limb nerve compressions among patients undergoing peripheral nerve decompression. METHODS: A prospective case series was conducted on 183 patients undergoing peripheral nerve decompression in a private hand surgery clinic. Level(s) of nerve compression in the median, ulnar and radial nerves were determined by history and physical examination. The prevalence of each nerve compression syndrome or combination of syndromes was analyzed. RESULTS: A total of 320 upper limbs in 183 patients were analyzed. A double crush of the median nerve at the levels of the lacertus fibrosus and carpal tunnel was identified in 78% of upper limbs with median neuropathy, whereas isolated lacertus syndrome and carpal tunnel syndrome were present in only 5% and 17% of affected limbs respectively. Cubital tunnel syndrome affected 12.5% of upper limbs, and 80% of these had concomitant lacertus and carpal tunnel syndromes, compared to only 7.5% with isolated cubital tunnel syndrome. CONCLUSION: A high prevalence should prompt clinicians towards more routine assessment for double crush syndrome to avoid misdiagnosis, inadequate treatment, recurrence, and revision surgeries.

Pinch strength analyses in lacertus syndrome.

PURPOSE: Lacertus syndrome is defined as proximal median nerve entrapment at the lacertus fibrosus. We aimed to analyze change in pinch strengths in patients who underwent median nerve release at the lacertus fibrosus under WALANT (wide-awake local anesthesia, no tourniquet). METHODS: Pinch strength was measured with a pinch gauge. Subjective DASH score and pain, numbness in the operated extremity and satisfaction on visual analog scales were analyzed before and 6 weeks after surgery. RESULTS: There were 32 patients. Median nerve release under the lacertus fibrosus elicited statistically significant increases in tip-to-tip, lateral and tripod pinch strength at postoperative week 6. Improvements in DASH score, pain and paresthesia were also statistically significant. CONCLUSIONS: For lacertus syndrome treatment, mini-incision release of the lacertus fibrosus under WALANT was satisfactory and increased pinch strength significatively. LEVEL OF EVIDENCE: Therapeutic, Level IV - Case series.

Median Nerve Palsy in Pediatric Supracondylar Humerus Fractures Recovers Faster With Open Than Closed Reduction.

BACKGROUND: Management of supracondylar humerus fractures (SCHF) with coexisting median nerve injury is controversial. Although many nerve injuries improve with the reduction and stabilization of the fracture, the speed and completeness of recovery are unclear. This study investigates median nerve recovery time using the serial examination. METHODS: A prospectively maintained database of SCHF-related nerve injuries referred to a tertiary hand therapy unit between 2017 and 2021 was interrogated. Factors related to the injury (vascularity, Gartland grade, open vs. closed fracture) and treatment (fixation modality, adequacy, timing of reduction, vascular and nerve intervention, and secondary procedures) were assessed.Primary outcomes were the motor recovery of Medical Research Council (MRC) grade 4 or 5 in flexor pollicis longus or flexor digitorum profundus (index) and detection of the 2.83 Semmes Weinstein monofilament.A retrospective clinical note review of all SCHF presenting during the same period was also conducted. RESULTS: Of 1096 SCHF, 74 (7%) had an associated median nerve palsy. Twenty-one patients [mean age 7 years (SD 1.6)] with SCHF-related median nerve injuries underwent serial examination. Nineteen (90%) were modified Gartland III or IV, and 10 (48%) were pulseless on presentation. The mean follow-up was 324 days.The mean motor recovery time was 120 days (SD 71). Four (27%) and 2 (13%) patients had not achieved MRC grade 4 by 6 months and 2 years, respectively. Only 50% attained MRC grade 5 at 2 years.When compared with closed reduction, those who underwent open reduction recovered motor function 80 days faster (mean 71 vs. 151 d, P =0.03) and sensory function 110 days faster (52 vs. 162, P =0.02). Fewer patients recovered after closed reduction (8 of 10) than open (5 of 5).Modified Gartland grade, vascular status, adequacy of reduction, and secondary surgery were not associated with recovery time. CONCLUSIONS: Median nerve recovery seems to occur slower than previously thought, is often incomplete, and is affected by treatment decisions (open vs. closed reduction). Retrospective reporting methods may overestimate median nerve recovery. LEVEL OF EVIDENCE: Level III-therapeutic.

Radius palmar plate removal without carpal tunnel release: Correlation between plate position and median nerve symptoms.

We aimed to report the clinical results of volar plate removal without carpal tunnel release in patients with late-onset median neuropathy and to evaluate the relationship between plate position and median nerve symptoms. Part I. Twelve consecutive patients with late-onset median neuropathy treated with volar plate removal without carpal tunnel release were enrolled for analysis. Pre- and post-operative Tinel sign, Phalen and Ten test, subjective rating of tingling sensation, Mayo wrist score and Disabilities of the Arm, Shoulder and Hand (DASH) score were collected. Part II. 232 consecutive patients underwent volar plating for distal radius fracture. The relationships between median nerve symptoms and volar plate prominence on the Soong classification, fracture classification, gender and age were investigated. All cases except one showed complete symptom resolution at final follow-up, with negative Tinel sign and Ten test score of 10/10. Tingling was rated 0 at final follow-up. Mean Mayo wrist and DASH scores improved to 86.7 and 23.1, respectively. The incidence of the median nerve symptoms in our cohort was 5.6%. Even though the odds ratio in Soong grade 2 was 4.0957 (95% CI, 0.93-16.9) compared to the combination of grades 0 and 1, no statistically significant relationship was found between the median nerve symptoms and volar plate prominence (p > 0.05). Plate removal without carpal tunnel release adequately relieved symptoms of late-onset median neuropathy after volar plating in patients with distal radius fracture. LEVEL OF EVIDENCE: IV; Therapeutic.

Adductor Branch of Terminal Divisions of the Ulnar Nerve Transfer to the Thenar Motor Branch in a High Median Nerve Palsy: A Case Report.

CASE: The author reports a 4-month-old high median nerve palsy in a 19-year-old man with right forearm fractures, stabilized with dynamic compression plates and screws. Surgical exploration revealed a large median nerve neuroma in the midarm that was excised, and the gap was bridged with sural nerve cable grafts. The extensor carpi radialis nerve was transferred to the anterior interosseous nerve in the forearm. The adductor branch of terminal divisions of the ulnar nerve was transferred to the thenar branch of the median nerve in the hand. CONCLUSIONS: The adductor branch of ulnar nerve transfer to the thenar motor branch in high median nerve palsy efficiently restored thumb opposition in 10 months of follow-up. In addition, the patient's grasp and pinch improved, preserving thumb adduction.

Lacertus syndrome: a ten year analysis of two hundred and seventy five minimally invasive surgical decompressions of median nerve entrapment at the elbow.

PURPOSE: This study aims to assess the clinical presentation and surgical outcomes of lacertus syndrome (LS) and concomitant median nerve entrapments. METHODS: A retrospective study of prospectively collected data was conducted on patients undergoing lacertus release (LR) from June 2012 to June 2021. Available DASH (Disability of the Arm Shoulder Hand questionnaire) scores and post-operative Visual Analogue Scale (VAS) of pain, numbness, subjective satisfaction with surgical outcome, and intra-operative return of strength were analyzed. RESULTS: Two-hundred-seventy-five surgical cases were identified of which 205 cases (74.5%) underwent isolated LR, and 69 cases (25.1%) concomitant lacertus and carpal tunnel release. The three most common presenting symptoms in LS patients were loss of hand strength (95.6%), loss of hand endurance/fatigue (73.3%), and forearm pain (35.4%). Numbness in the median nerve territory of the hand was found in all patients with combined LS and carpal tunnel syndrome. Quick-DASH significantly improved (pre-operative 34.4 (range 2.3-84.1) to post-operative 12.4 (range 0-62.5), p < 0.0001) as did work and activity DASH (p < 0.0001). The postoperative VAS scores were pain VAS 1.9 and numbness VAS 1.8. Eighty-eight percent of patients reported good/excellent satisfaction with the surgical outcome. Intra-operative return of strength was verified in 99.2% of cases. CONCLUSION: LS is a common median nerve compression syndrome typically presenting with loss of hand strength and hand endurance/fatigue. Minimally invasive LR immediately restores hand strength, significantly improves DASH scores, and yields positive outcomes regarding VAS pain, numbness, and subjective satisfaction with surgery in patients with proximal median nerve entrapment at a minimum six month follow-up.

Transient Proximal Median Nerve Entrapment in a Tetraplegic Hand Cyclist Following a 24-Hour Endurance Race.

Median nerve entrapment is a frequent disorder encountered by all clinicians at some point of their career. Affecting the distal median nerve, entrapment occurs most frequently at the level of the wrist resulting in a carpal tunnel syndrome. Median nerve entrapment may also occur proximally giving rise to the much less frequent pronator teres syndrome and even less frequent anterior interosseous nerve syndrome, which owing to the paucity of cases may prove challenging to diagnose. An unusual case of anterior interosseous syndrome precipitated by extraordinary exertion in a tetraplegic endurance athlete is presented with ancillary dynamometric, electrodiagnostic, ultrasonographic, and biochemical findings.

Unusual Anatomic Location of the Median Nerve Within the Pronator Teres Muscle: A Case Report.

CASE: A 57-year-old man presented with pain and paresthesia in both hands and was diagnosed with pronator teres syndrome. Surgical decompression of the left elbow and forearm revealed the median nerve in an unusual anatomic location, specifically running within the pronator teres muscle. CONCLUSION: Anatomic anomalies of the pronator teres muscle and the path of the median nerve have been described. However, there are no reports of the median nerve entering and traveling within the pronator teres. Surgeons should be aware of this anomaly to avoid potential iatrogenic injury when performing an anterior surgical approach to the elbow and proximal forearm.

Median nerve entrapment in an adolescent medial epicondyle fracture of humerus: A case report.

A 14-year-old boy with a displaced medial epicondyle fracture without elbow dislocation was found to have an entrapped median nerve. Entrapment of the median nerve is a potential consequence of a displaced medial epicondyle fracture, even when there are no neu-rologic deficits on presentation. This provides additional support for the open reduction of these fractures rather than percutaneous treatment or non-operative management. The early identification and release of an interposed median nerve are imperative to prevent the catastrophic consequences of the upper extremity nerve palsy in children, as well as to optimize fracture healing and development.

Isolated Proximal Median Neuropathy after Aortic Dissection Repair: Case Report.

Surgery-related isolated proximal median neuropathy is a rare complication. Brachial plexus injury is a possible complication after major cardiac surgery; however, isolated mononeuropathy is less frequently documented. We present an unusual case of isolated proximal median neuropathy after aortic dissection repair surgery in a 39-year-old man. Electrodiagnostic study and ultrasound examinations helped in localizing the lesion to the axillary region. Serial follow-ups showed improvement in electrodiagnostic parameters, which were compatible with clinical symptoms. Partial recovery was achieved at the seventh month follow-up. This case report aimed to increase awareness of nerve stretching during open heart surgery and demonstrate the diagnosis and clinical follow-up by concomitant use of electrodiagnostic and nerve ultrasound studies.