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.

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.

Factors Affecting the Occurrence of Late Median Nerve Neuropathy After Open Reduction and Volar Locking Plate Fixation of Distal Radius Fracture.

It is well-known that late median nerve neuropathy can occur after open reduction and internal fixation (ORIF) of distal radius fracture (DRF). The current study investigated the predictive factors of late median nerve neuropathy after ORIF with a volar locking plate for DRF. The authors retrospectively reviewed 712 patients who underwent ORIF using a volar locking plate after DRF at 3 medical institutions between 2006 and 2017. Thirty-seven (5.2%) patients developed late median nerve neuropathy at a mean of 8.25±3.47 months (range, 3-19 months) after surgery. The radiographic data of 37 patients (group A) who had late median nerve neuropathy were compared with those of 148 patients (group B) who did not. Group A had a significantly higher proportion of type C3 fracture and Soong grade 2 than group B. Postoperative dorsal tilt in group A was greater than that in group B. On multivariable logistic regression analysis, the following predictive factors were associated with late median nerve neuropathy: increased postoperative dorsal tilt and Soong grade 2. The development of late median nerve neuropathy after ORIF using a volar locking plate for DRF was associated with increased postoperative dorsal tilt and the plate being placed distal to the volar rim. Physicians should consider the possibility of late median nerve neuropathy in patients with these factors during follow-up. [Orthopedics. 2021;44(3):e367-e372.].

Median nerve entrapment syndrome in the elbow and proximal forearm. Anatomic causes and results for a 55-case surgical series at a mean 7years' follow-up.

BACKGROUND: Proximal median nerve (MN) neuropathy represents 1% of upper-limb compressive neuropathies. The literature reports two clinical presentations, depending on the location of the entrapment: pronator teres (PT), and anterior interosseous nerve (AIN) syndrome. HYPOTHESIS: There is no correlation between symptoms and location of proximal compressive structures on the MN trunk or AIN. PATIENTS AND METHODS: Clinical and paraclinical data from 55 surgical MN releases around the elbow and proximal forearm were analyzed retrospectively. Mean age at diagnosis was 56±15years. Preoperative sensory and motor deficit signs were present in 89% of cases. Reduced MN conduction velocity and/or neurogenic anomalies in the MN territory were present in 94% of cases. Intraoperative details of compressive structures were collected. Patients were followed up in consultation to assess progression of symptoms and deficits. RESULTS: Mean follow-up was 84±70months. Objective motor deficit signs persisted in 18 of the 35 patients (18 cases), and objective sensory signs in 19 cases. A compressive anatomical structure was systematically found. There were at least two MN entrapment sites in 13 cases (24%). No isolated AIN entrapment was found. There was a significant correlation between symptom duration and persistence of objective sensory signs (p=0.002). DISCUSSION: There was no correlation between entrapment site and clinical signs on examination. Surgery requires exploring all potential entrapment sites. Improvement may be incomplete in case of late treatment. LEVEL OF EVIDENCE: IV; retrospective study.

An accessory abductor digiti minimi as possible risk factor of the median and ulnar nerves compression / Músculo abductor digiti minimi accesorio como posible factor de riesgo de la compresión de los nervios mediano y ulnar

SUMMARY: During routine dissection of a left upper limb of a 68-year-old male human cadaver, an unusual muscle was observed originating from the radius and flexor retinaculum, and continued in the hypothenar region with the muscle belly of the abductor digiti minimi. We checked that it was an accessory abductor digiti minimi (ADM). Its muscular belly was in close relation to the median and ulnar nerves. We review the literature regarding such muscle variations and discuss the potential for compression of the median and ulnar nerves. Although the accessory ADM is usually asymptomatic and only rarely results in nerve compression, it should be taken into account by surgeons when establishing a differential diagnosis in the compression neuropathies of the median and ulnar nerves. An ultrasound scanning can help establish the differential diagnosis.

RESUMEN: Durante la disección de rutina de un miembro superior izquierdo de un cadáver humano masculino de 68 años, se observó un músculo inusual que se originaba en el radio y el retináculo flexor del carpo, y continuuaba en la región hipotenar con el vientre muscular del abductor digiti minimi manus. Verificamos que se trataba del músculo abductor digiti minimi accessorius (ADMA). Su vientre muscular se encontraba en estrecha relación con los nervios mediano y ulnar. Revisamos la literatura sobre variaciones musculares y discutimos la potencial compresión de los nervios mediano y ulnar. Aunque el ADMA suele ser asintomático y rara vez produce compresión nerviosa, los cirujanos deben tenerlo en cuenta al establecer un diagnóstico diferencial en las neuropatías de compresión de los nervios mediano y ulnar. Una ecografía puede ayudar a establecer el diagnóstico diferencial.

Entrapment of the Median Nerve after Elastic Intramedullary Nailing of a Pediatric Forearm Fracture.

Closed reduction and fixation with elastic intramedullary nails is a popular technique to treat displaced pediatric forearm fractures and has yielded good functional results. Postoperative neurological symptoms can be due to neuropraxia and expectative treatment has been advised for 3 months until further investigation is necessary. We present a case of an 11-year-old boy that presented with median nerve palsy 2 months after a displaced forearm fracture treated with elastic intramedullary nails. Ultrasound and nerve conduction study confirmed the presence of a median nerve entrapped in the callus of the radial fracture. Surgical exploration demonstrated that the nerve was twisted around the intramedullary device. After neurolysis and surgical repair the patient finally recovered 2 years after the operation. This case highlights the possibility of median nerve entrapment after reduction with elastic intramedullary nails. Symptoms should be recognized early, and urgent surgical exploration is needed to prevent irreversible damage.

Acute Upper Limb Ischemia Due to Delayed Presentation of a Brachial Artery Pseudoaneurysm Post-Venipuncture.

Brachial artery pseudoaneurysms (BAPs) are rare but could lead to complications of high morbidity. We report a case of a BAP presenting with hand ischemia and median nerve neuropathy nearly a decade after the inciting iatrogenic trauma, successfully treated with excision and direct repair. This report highlights that untreated pseudoaneurysms can be indolent and present late with both symptoms of embolization and local compression.

Assessment of Distal Radius Fracture Complications Among Adults 60 Years or Older: A Secondary Analysis of the WRIST Randomized Clinical Trial.

Importance: Complications affect treatment outcomes and quality of life in addition to increasing treatment costs. Objectives: To evaluate complication rates after the treatment of a distal radius fracture, to determine whether the rate or complication type is associated with treatment method, and to determine predictors of complications. Design, Setting, and Participants: The multicenter Wrist and Radius Injury Surgical Trial (WRIST), a randomized clinical trial, enrolled participants from April 10, 2012, to December 31, 2016. The study included 304 adults 60 years or older with isolated unstable distal radius fractures; 187 were randomized and 117 opted for casting. The study was conducted at 24 health systems in the United States, Canada, and Singapore. Data for this secondary analysis were collected from April 24, 2012, to February 28, 2018. Interventions: Participants opting for surgery were randomized to receive the volar locking plate system (n = 65), percutaneous pinning (n = 58), or bridging external fixation with or without supplemental pinning (n = 64). Patients who chose not to have surgery (n = 117) were not randomized and were enrolled for casting. Main Outcomes and Measures: Complication rate. Results: The WRIST enrolled a total of 304 participants, of whom 8 casting group participants were later found to be ineligible and were excluded from the analysis, leaving 296 participants. Randomized participants' mean (SD) age was 68 (7.2) years, 163 (87%) were female, and 165 (88%) were white. Casting participants' mean (SD) age was 75.6 (9.6) years, 93 (84%) were female, and 85 (85%) were white. The most common type of complications varied by treatment. Twelve of 65 participants (18.5%) in the internal fixation group reported a median nerve compression, while 16 of 26 participants (25.8%) who received external fixation and 13 of 56 participants (23.2%) who received pinning sustained pin site infections. Compared with the internal fixation group, complication rate for any severity complication was higher in participants who initially received casting (adjusted rate ratio, 1.88; 95% CI, 1.22-2.88), whereas the rate for moderate complications was higher in the external fixation group (adjusted rate ratio, 2.52; 95% CI, 1.25-5.09). Conclusions and Relevance: The distal radius fracture treatment decision-making process for older patients should incorporate a complication profile for each treatment type. For example, external fixation and pinning could be used for patients after apprising them of pin site infection risk. Internal fixation can be done in patients with high functional demands who are willing to receive surgery. Internal fixation use should be substantiated owing to the time and cost involved. Trial Registration: ClinicalTrials.gov Identifier: NCT01589692.

Association between the Rosén and Lundborg Score and the Screening Activity Limitation and Safety Awareness scale in hand functional evaluation of patients with leprosy diagnosis.

PURPOSE: To evaluate the association of results from the Rosén and Lundborg Score and the screening activity limitation and Safety Awareness scale for the assessment of hand in patients diagnosed with leprosy. METHOD: An association between the Rosén and Lundborg Score and the Screening Activity Limitation and Safety Awareness scale for hand was evaluated in a cross-section study with 25 people of a mean age of 51 years old (SD 14), undergoing drug treatment for leprosy. RESULTS: The mean quantitative score in the Screening Activity Limitation and Safety Awareness scale was 27.9 (SD 10.5). Rosén and Lundborg Score for the median nerve were 2.43 (SD 0.38) on the right hand and 2.41 (SD 0.54) on the left hand whilst for the ulnar nerve, the scores observed were 2.33 (SD 0.42) for the right hand and 2.31 (SD 0.61) for the left hand. Significant correlations between the two instruments in assessment of the median and ulnar nerves on both hands were found. CONCLUSIONS: Due to the association found between the scales, the Rosén and Lundborg Score may be used in assessment of the hand in patients diagnosed with leprosy, as a tool to assist the result evaluation after the drug treatment, surgical treatment, rehabilitation and follow-up in the hand dysfunction in leprosy. Implications for Rehabilitation The leprosy inflammatory neuropathy may cause limitations and disabilities related to hand functions of patients. Instruments with quantitative scores provide a reliable basis for therapeutic intervention prognosis. New evaluation methods promote a better monitoring of treatment and hand function evolution of people with leprosy.

Distally Based Pedicled Flexor Carpi Ulnaris Muscle Flap: An Anatomical Study and Clinical Application.

BACKGROUND: Proximally based, pedicled flexor carpi ulnaris (FCU) muscle flap has been described previously for soft tissue coverage of the proximal forearm and elbow. No studies have been done on the distal muscular perforators and its use as a distally based flap. METHODS: Ten fresh-frozen cadaveric dissections were done. Specimens were injected with latex to facilitate identification of the perforators. Distal muscular perforators were dissected and distances of the pedicles from the distal wrist crease and ulnar styloid were measured and recorded. A clinical case is also presented where a distally based FCU muscle flap was used for coverage in a patient with median nerve neuroma. RESULTS: A distal muscular perforator and a second more proximal perforator were identified in all specimens. The average distance from the most distal muscular perforator to the ulnar styloid was 3.0 cm. The average distance to the wrist crease was 4.6 cm. The more proximal perforators had an average distance to the ulnar styloid and wrist crease of 7.3 cm and 8.8 cm, respectively. At 7 months post-op, the patient who underwent median nerve neurolysis and coverage with pedicled FCU flap had much improved sensation, with complete resolution of pain and tingling, and without any functional deficits. CONCLUSIONS: The use of a distally based FCU muscle flap is a good option for soft tissue coverage of the distal forearm, wrist, and hand. The distal muscular perforators from the ulnar artery exhibit a relatively consistent anatomy.

Pulseless Supracondylar Humerus Fracture With Anterior Interosseous Nerve or Median Nerve Injury-An Absolute Indication for Open Reduction?

BACKGROUND: Optimal management for a pulseless supracondylar humerus fracture associated with anterior interosseous nerve (AIN) or median nerve injury is unclear. The purpose of this study was to determine the incidence of pulseless supracondylar humerus fractures associated with AIN or median nerve injury, to assess open versus closed surgical management, to determine factors associated with the need for neurovascular intervention, and to report the outcome. METHODS: A retrospective review was performed at 4 pediatric trauma hospitals on all patients who sustained a Gartland III or IV supracondylar humerus fracture with the combination of absent distal palpable pulses and AIN or median nerve injury between 2000 and 2014. Choice of treatment, details regarding preoperative and postoperative exam findings, follow-up course, and outcome were recorded. RESULTS: A total of 71 patients met inclusion criteria; 52 patients (73%) underwent closed reduction (CR); 19 patients (27%) underwent open reduction (OR) and early antecubital fossa exploration. The index procedure of CR plus percutaneous pinning was sufficient treatment in 50 (of 52, 96%) patients with only 2 requiring reoperation. One patient developed compartment syndrome approximately 9 hours after CRPP (13.5 h after time of injury) and underwent emergent fasciotomies. Of the 19 patients who underwent OR and early exploration, 6 needed vascular procedures, 5 required detethering of entrapped surrounding fibrous tissues. Forty patients were diagnosed with median nerve palsy versus 31 diagnosed with AIN palsy. There was no significant difference between patients presenting with median nerve versus AIN palsy, with similar rates of need for OR (10/40; 25% vs. 9/31; 29%), rate of compartment syndrome (3/40; 7.5% vs. 3/31; 9.7%), need for reoperation (4/40; 10% vs. 6.5%), and ultimate resolution of nerve palsy (4/36; 20.1% vs. 3/30; 10%). Compartment syndrome developed in 6 (of 71, 8.5%) patients and was associated with poor perfusion status on presentation and delayed time from injury to surgery. In patients with at least 3-month neurological follow-up, 59 (of 61, 97%) patients had complete resolution of nerve palsy. CONCLUSIONS: Although previous authors have suggested a pulseless SCH fx with an associated AIN or median nerve injury should be treated with exploration and OR, 70% (50/71) of the patients in this series were treated with a CR. In this series, both AIN and median nerve palsies among patients presenting with pulseless extremity and Gartland III or IV SCH fracture, offer similar rates of OR, risk of compartment syndrome, and resolution of nerve palsy. LEVEL OF EVIDENCE: Level IV.

Combined median and ulnar nerve palsy complicating distal radius fractures.

BACKGROUND: Fractures of the distal radius only rarely give rise to complications in the immediate postoperative period. Combined median and ulnar nerve palsy is a complication that can be missed by the surgeon. MATERIALS AND METHODS: Three cases diagnosed early after surgery are reported here. The patients were 15, 16, and 30 years of age, respectively. None had preoperative neurological deficits. The youngest patient was injured during sports and the other 2 patients during traffic accidents. All 3 patients had a displaced fracture of the distal radius combined with a fracture of the distal fourth of the ulna or ulnar styloid process and were treated by anterior plate fixation. Operative times were 47, 62, and 120minutes, respectively. Compartment syndrome was ruled out based on low pain intensity and absence of forearm tightness to palpation. RESULTS: The electrophysiological study performed 1 month post-injury in all 3 patients showed severe impairments of both median and ulnar nerve function. Median and ulnar nerve release surgery was performed in the 15-year-old 6 weeks post-injury. No nerve damage or fibrosis was seen during the procedure. All patients recovered fully within 3 months and had normal findings from follow-up electrophysiology testing after 6 months. DISCUSSION: Combined median and ulnar nerve palsy has rarely been reported and is among the rare complications of distal radial fractures that can develop in the event of a high-energy trauma and/or major displacement. Both previously published data and our experience indicate that surgical nerve release is unnecessary. Clinical recovery within 3 months is the rule. LEVEL OF EVIDENCE: IV, case-reports.

Resonancia magnética en el atrapamiento del nervio supraescapular por quiste supraglenoideo / Magnetic resonance in nerve entrapment suprascapular supraglenoid cyst

El síndrome de atrapamiento del nervio supraescapular es una causa infrecuente de dolor en el hombro y de difícil diagnóstico clínico. Puede ser consecuencia de traumatismo, infección, compresión extrínseca o estiramiento secundario a movimientos repetitivos. Los quistes supraglenoideos deben considerarse en el diagnóstico diferencial pues son una causa frecuente de compresión del nervio supraescapular que ocurre casi exclusivamente en hombres. Se evaluaron con resonancia magnética (RM) y en forma retrospectiva siete pacientes con diagnóstico de atrapamiento del nervio supraescapular por quiste supraglenoideo. La RM mostró la causa y localización de la compresión nerviosa así como la distribución del edema muscular en todos los casos. Puede evaluar el grado de severidad de la enfermedad y realizar el diagnóstico diferencial con otras causas que provocarían atrapamiento del nervio supraescapular. (AU)

Suprascapular nerve entrapment has been regarded as a relatively uncommon condition that is easily overlooked in the differential diagnosis of shoulder discomfort. The common feature is nerve damage, caused either by trauma, extrinsic compression or by stretching secondary to repeated movements. Ganglion cysts account for the majority of the masses causing entrapment and seem to occur exclusively in men. Seven cases of suprascapular nerve entrapment caused by supraglenoid cyst compression were reviewed with MRI. MRI showed the cause and location of nerve compression as well as the distribution of muscular edema in all cases. MR imaging also allows an evaluation of the severity of the disease. It is also very efficient in excluding several differential diagnoses. (AU)

Treatment of Hand Allodynia Resulting from Wrist Cutting with Radial and Ulnar Artery Perforator Adipofascial Flaps.

In this article, we report two cases in which recurrent adhesive hand neuropathy with allodynia were successfully treated with radial and ulnar artery adipofascial perforator flap coverage. Treatment of recurrent neuropathy, such as recurrent carpal tunnel syndrome and re-adhesion after neurolysis using free and pedicle flaps to cover the nerves, has been reported to show good results. However, for severe painful nerve disorders, such as complex regional pain syndrome, the efficacy of this treatment was unclear. We present two cases diagnosed with recurrent adhesive hand neuropathy with allodynia, resulting from wrist cutting; these cases were treated with neurolysis and flap coverage with good results and no recurrence. This suggests that neurolysis and flap coverage are effective methods for treating complex regional pain syndrome.

Comparison of Different Sequences of Magnetic Resonance Imaging and Ultrasonography with Nerve Conduction Studies in Peripheral Neuropathies.

BACKGROUND: Peripheral neuropathies refer to a group of disorders in which there is damage to the nerves of the peripheral nervous system. Electrophysiologic studies are the main stay for the diagnosis of peripheral neuropathies. However, direct visualization of the nerves is possible with exact localization of site of disease with high-resolution ultrasonography (USG) and 3-Tesla magnetic resonance imaging (MRI) scanner, and newer magnetic resonance (MR) sequences. METHODS: We performed a cross-sectional study including 55 patients and 64 nerves with upper limb peripheral neuropathies. All patients included underwent high-resolution focused USG of the nerves and MR neurography. A nerve conduction velocity study was performed for reference. RESULTS: The diagnostic confidence of the turbo spin echo T2-weighted (T2W) MR sequence was seen to be highest, with a sensitivity of 95.31%, whereas it was 81.25% for USG. Continuity of the nerve in patients with traumatic neuropathy was seen in 65.7% and 62.86% (22/35) nerves on MRI and USG, respectively. T1-weighted and T2W MR sequences were seen to be equally effective in establishing the continuity of the nerve. Increase in the caliber/thickening was seen in 77% of cases on MRI and 73.8% of cases on USG. Neuroma formation was seen equally on both MR and USG in 60.66%. We consistently found low fractional anisotropy (FA) values at the site of disease. CONCLUSIONS: USG is a sensitive technique to diagnose peripheral neuropathies and it should be used as a screening modality for focused MR to be performed later. Turbo spin echo T2W fast spin has the highest sensitivity to identify nerve disease and is comparable with nerve conduction studies. Among the newer sequences, diffusion tensor imaging should be performed to increase diagnostic confidence.

Low Median Nerve Palsy as Initial Manifestation of Churg-Strauss Syndrome.

Anterior interosseous nerve (AIN) syndrome is typically characterized by forearm pain and partial or complete dysfunction of the AIN-innervated muscles. Although the exact etiology and pathophysiology of the disorder remain unclear, AIN syndrome is increasingly thought to be an inflammatory condition of the nerve rather than a compressive neuropathy because the symptoms often resolve spontaneously following prolonged observation. However, peripheral neuropathy can be 1 of the first symptoms of systemic vasculitis that needs early systemic immunotherapy to prevent extensive nerve damage. Churg-Strauss syndrome (CSS; eosinophilic granulomatosis with polyangiitis) is 1 type of primary systemic vasculitis that frequently damages the peripheral nervous system. CSS-associated neuropathy usually involves nerves of the lower limb, and few studies have reported on the involvement of the upper limb alone. We report on a rare case of low median nerve palsy as the initial manifestation of CSS. The patient recovered well with early steroid treatment for primary systemic vasculitis.