Evidence of the existence of multiple modules for the stroke-caused flexion synergy from Fugl-Meyer assessment scores.

Stroke-caused synergies may result from the preferential use of the reticulospinal tract (RST) due to damage to the corticospinal tract. The RST branches multiple motoneuron pools across the arm together resulting in gross motor control or abnormal synergies, and accordingly, the controllability of individual muscles decreases. However, it is not clear whether muscles involuntarily activated by abnormal synergy vary depending on the muscles voluntarily activated when motor commands descend through the RST. Studies showed that abnormal synergies may originate from the merging and reweighting of synergies in individuals without neurological deficits. This leads to a hypothesis that those abnormal synergies are still selectively excited depending on the context. In this study, we test this hypothesis, leveraging the Fugl-Meyer assessment that could characterize the neuroanatomical architecture in individuals with a wide range of impairments. We examine the ability to perform an out-of-synergy movement with the flexion synergy caused by either shoulder or elbow loading. The results reveal that about 14% [8/57, 95% confidence interval (5.0%, 23.1%)] of the participants with severe impairment (total Fugl-Meyer score <29) in the chronic phase (6 months after stroke) are able to keep the elbow extended during shoulder loading and keep the shoulder at neutral during elbow loading. Those participants underwent a different course of neural reorganization, which enhanced abnormal synergies in comparison with individuals with mild impairment (P < 0.05). These results provide evidence that separate routes and synergy modules to motoneuron pools across the arm might exist even if the motor command is mediated possibly via the RST.NEW & NOTEWORTHY We demonstrate that abnormal synergies are still selectively excited depending on the context.

Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury.

OBJECTIVE: To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment. STUDY DESIGN: Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data. RESULTS: There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%. CONCLUSIONS: In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.

Does the articularis cubiti muscle really exist? Anatomical, histological, and magnetic resonance imaging study with a narrative review of literature.

Although the term articularis cubiti muscle is incorporated in the official anatomical nomenclature, only sparse data about its appearance are available. It is usually described as few fibres originating from the medial head of the triceps brachii muscle and inserting to the capsule of the elbow joint. However, the most recent observations regarding the morphological relations in the posterior elbow region point towards the absence of a well-defined muscle. Therefore, this study was designed to verify the existence of the articularis cubiti muscle in question and to compile more data on the topographical features of the subtricipital area near the posterior aspect of the elbow. To address these questions, 20 embalmed upper limbs were dissected, and seven samples were collected for histological analysis. The laboratory findings were then correlated with 20 magnetic resonance imaging (MRI) scans of the elbow. Consequently, a narrative review of literature was performed to gain more information on the discussed muscle in a historical context. Upon the anatomical dissection, muscular fibres running from the posterior aspect of the shaft of the humerus to the elbow joint capsule and olecranon were identified in 100% of cases. Histologically, the connection with the joint capsule was provided via winding bands of connective tissue. On MRIs, the muscular fibres resembled a well-demarcated thin muscle located underneath the medial head of the triceps brachii muscle. Combined with the review of literature, we concluded that the constant articularis cubiti muscle originates from the posterior shaft of the humerus and attaches indirectly to the posterior aspect of the elbow joint capsule and directly to the superior portion of the olecranon. The obtained results slightly differ from the modern description, but are in agreement with the original publication, which has become misinterpreted throughout time. Presumably, the misused description has led to questioning the existence of an independent muscle. Moreover, our findings attribute to the articularis cubiti muscle, a function in pulling on the posterior aspect of the elbow joint capsule to prevent its entrapment, and possibly also a minor role in extension of the forearm. The presented results should be taken into consideration when intervening with the posterior aspect of the elbow joint because the articularis cubiti muscle poses a consistently appearing landmark.

Changes in brain functional connectivity and muscle strength independent of elbow flexor atrophy following upper limb immobilization in young females.

Muscle disuse induces a decline in muscle strength that exceeds the rate and magnitude of muscle atrophy, suggesting that factors beyond the muscle contribute to strength loss. The purpose of this study was to characterize changes in the brain and neuromuscular system in addition to muscle size following upper limb immobilization in young females. Using a within-participant, unilateral design, 12 females (age: 20.6 ± 2.1 years) underwent 14 days of upper arm immobilization using an elbow brace and sling. Bilateral measures of muscle strength (isometric and isokinetic dynamometry), muscle size (magnetic resonance imaging), voluntary muscle activation capacity, corticospinal excitability, cortical thickness and resting-state functional connectivity were collected before and after immobilization. Immobilization induced a significant decline in isometric elbow flexion (-21.3 ± 19.2%, interaction: P = 0.0440) and extension (-19.9 ± 15.7%, interaction: P = 0.0317) strength in the immobilized arm only. There was no significant effect of immobilization on elbow flexor cross-sectional area (CSA) (-1.2 ± 2.4%, interaction: P = 0.466), whereas elbow extensor CSA decreased (-2.9 ± 2.9%, interaction: P = 0.0177) in the immobilized arm. Immobilization did not differentially alter voluntary activation capacity, corticospinal excitability, or cortical thickness (P > 0.05); however, there were significant changes in the functional connectivity of brain regions related to movement planning and error detection (P < 0.05). This study reveals that elbow flexor strength loss can occur in the absence of significant elbow flexor muscle atrophy, and that the brain represents a site of functional adaptation in response to upper limb immobilization in young females.

Comparison of electrodiagnostic findings in acute traumatic versus chronic non-traumatic ulnar neuropathy at the elbow.

INTRODUCTION/AIMS: A common concept is that traumatic nerve injuries are more likely axonal, and that compressive neuropathies are more likely demyelinating. The purpose of this study was to compare traumatic versus non-traumatic ulnar neuropathy at the elbow (UNE) to look for electrodiagnostic differences between the two groups. METHODS: A retrospective 3 year review of UNE patients at two academic health science centers was conducted. Patients were grouped into acute traumatic UNE versus chronic non-traumatic UNE based on clinical history. Electrodiagnostic measurements were compared between the two groups. RESULTS: There were 50 subjects with acute traumatic UNE and 41 with chronic non-traumatic UNE. Mean age and sex distribution were similar but those with traumatic UNE had a 7 month duration of symptoms, while those with chronic UNE had 29 month duration (p < .001). All electrodiagnostic measurements were similar between the two groups including compound muscle action potential amplitudes, motor conduction velocities, frequency of conduction block, sensory nerve studies, and needle electromyography. DISCUSSION: We did not find a difference between the two groups. One should not make inferences regarding acuity or etiology based on electrodiagnostic features alone.

Diagnostic efficiency of conventional ultrasound, shear wave elastography, and superb microvascular imaging in evaluating ulnar neuropathy at the elbow.

INTRODUCTION/AIMS: The current diagnosis of ulnar neuropathy at the elbow (UNE) relies mainly on the clinical presentation and nerve electrodiagnostic (EDX) testing, which can be uncomfortable and yield false negatives. The aim of this study was to investigate the diagnostic value of conventional ultrasound, shear wave elastography (SWE), and superb microvascular imaging (SMI) in diagnosing UNE. METHODS: We enrolled 40 patients (48 elbows) with UNE and 48 healthy volunteers (48 elbows). The patients were categorized as having mild, moderate or severe UNE based on the findings of EDX testing. The cross-sectional area (CSA) was measured using conventional ultrasound. Ulnar nerve (UN) shear wave velocity (SWV) and SMI were performed in a longitudinal plane. RESULTS: Based on the EDX findings, UNE severity was graded as mild in 4, moderate in 10, and severe in 34. The patient group showed increased ulnar nerve CSA and stiffness at the site of maximal enlargement (CSA mean at the site of max enlargement [CSAmax] and SWV mean at the site of max enlargement [SWVmax]), ulnar nerve CSA ratio, and stiffness ratio (elbow-to-upper arm), compared with the control group (p < .001). Furthermore, the severe UNE group showed higher ulnar nerve CSAmax and SWVmax compared with the mild and moderate UNE groups (p < .001). The cutoff values for diagnosis of UNE were 9.5 mm2 for CSAmax, 3.06 m/s for SWVmax, 2.00 for CSA ratio, 1.36 for stiffness ratio, and grade 1 for SMI. DISCUSSION: Our findings suggest that SWE and SMI are valuable diagnostic tools for the diagnosis and assessment of severity of UNE.

Ultrasonographic evaluation of ulnar nerve morphology in patients with ulnar nerve instability.

INTRODUCTION/AIMS: Ulnar nerve instability (UNI) in the retroepicondylar groove is described as nerve subluxation or dislocation. In this study, considering that instability may cause chronic ulnar nerve damage by increasing the friction risk, we aimed to examine the effects of UNI on nerve morphology ultrasonographically. METHODS: Asymptomatic patients with clinical suspicion of UNI were referred for further clinical and ultrasonographic examination. Based on ulnar nerve mobility on ultrasound, the patients were first divided into two groups: stable and unstable. The unstable group was further divided into two subgroups: subluxation and dislocation. The cross-sectional area (CSA) of the nerve was measured in three regions relative to the medial epicondyle (ME). RESULTS: In the ultrasonographic evaluation, UNI was identified in 59.1% (52) of the 88 elbows. UNI was bilateral in 50% (22) of the 44 patients. Mean CSA was not significantly different between groups. A statistically significant difference in ulnar nerve mobility was found between the group with CSA of <10 versus ≥10 mm2 (p = .027). Nerve instability was found in 85.7% of elbows with an ulnar nerve CSA value of ≥10 mm2 at the ME level. DISCUSSION: The probability of developing neuropathy in patients with UNI may be higher than in those with normal nerve mobility. Further prospective studies are required to elucidate whether asymptomatic individuals with UNI and increased CSA may be at risk for developing symptomatic ulnar neuropathy at the elbow.

Semiquantitative index of symptomatic minor instability of the lateral elbow at CT arthrography (SMILE index): clinical applicability and reproducibility study.

OBJECTIVE: To assess the applicability of a semiquantitative index for symptomatic minor instability of the lateral elbow (SMILE). MATERIALS AND METHODS: CT arthrograms of consecutive patients with lateral elbow pain who underwent ultrasound-guided CT arthrography at our orthopedic center between April 2019 and May 2022 were included. Images were acquired at 100 kVp and 80 mAs. An expert radiologist (R1) and a radiology resident (R2) retrospectively performed an independent, blinded evaluation of the arthrograms to assess the presence of imaging findings suggestive of elbow instability. The SMILE index (0-8) was obtained adding (I) radial head chondromalacia (0 - 1); (II) humeral capitellum chondromalacia (0 - 1); (III) humeral trochlear ridge chondromalacia (0 - 1); (IV) annular ligament laxity (0 - 2); (V) synovial thickening (0 - 1); (VI) humeroradial joint asymmetry (0 - 1); and (VII) capsular tear (0 - 1). R1 repeated the assessment after 14 days. Cohen's weighted κ statistic and raw concordance were used to appraise reproducibility. RESULTS: Eighty patients (median age 49 years, interquartile range 40-53 years, 49, 61% males) underwent CT arthrography at our center, and 10 (12%) of them underwent bilateral elbow examination, leading to 90 included CT arthrograms. Median SMILE index was 4 (IQR: 2-5) for R1, 4 (IQR: 2-5) for R2, and 4 (IQR: 2-5) for the second assessment by R1. Intra-reader agreement was excellent (κ = 0.94, concordance 87%), while inter-reader agreement was substantial (κ = 0.75, concordance 67%). CONCLUSION: The proposed SMILE index showed good reproducibility; further studies are warranted to correlate our index with clinical and surgical data. CLINICAL RELEVANCE STATEMENT: Our scoring system allows a standardized evaluation of patients with lateral elbow pain and instability suitable for application into clinical practice, complementing the orthopedic surgeon's clinical diagnosis with imaging findings that may aid treatment choices. KEY POINTS: • Lateral elbow pain is often interpreted clinically as lateral epicondylitis, but it can also encompass intra-articular pathology. • The proposed arthrographic index allows comprehensive quantification of lateral elbow pathology with good reproducibility and application times. • Our index provides the orthopedic surgeon with information regarding intra-articular findings, aiding treatment choices.

Olecranon bone age assessment in puberty using a lateral elbow radiograph and a deep-learning model.

OBJECTIVES: To improve pubertal bone age (BA) evaluation by developing a precise and practical elbow BA classification using the olecranon, and a deep-learning AI model. MATERIALS AND METHODS: Lateral elbow radiographs taken for BA evaluation in children under 18 years were collected from January 2020 to June 2022, retrospectively. A novel classification and the olecranon BA were established based on the morphological changes in the olecranon ossification process during puberty. The olecranon BA was compared with other elbow and hand BA methods, using intraclass correlation coefficients (ICCs), and a deep-learning AI model was developed. RESULTS: A total of 3508 lateral elbow radiographs (mean age 9.8 ± 1.8 years) were collected. The olecranon BA showed the highest applicability (100%) and interobserver agreement (ICC 0.993) among elbow BA methods. It showed excellent reliability with Sauvegrain (0.967 in girls, 0.969 in boys) and Dimeglio (0.978 in girls, 0.978 in boys) elbow BA methods, as well as Korean standard (KS) hand BA in boys (0.917), and good reliability with KS in girls (0.896) and Greulich-Pyle (GP)/Tanner-Whitehouse (TW)3 (0.835 in girls, 0.895 in boys) hand BA methods. The AI model for olecranon BA showed an accuracy of 0.96 and a specificity of 0.98 with EfficientDet-b4. External validation showed an accuracy of 0.86 and a specificity of 0.91. CONCLUSION: The olecranon BA evaluation for puberty, requiring only a lateral elbow radiograph, showed the highest applicability and interobserver agreement, and excellent reliability with other BA evaluation methods, along with a high performance of the AI model. CLINICAL RELEVANCE STATEMENT: This AI model uses a single lateral elbow radiograph to determine bone age for puberty from the olecranon ossification center and can improve pubertal bone age assessment with the highest applicability and excellent reliability compared to previous methods. KEY POINTS: Elbow bone age is valuable for pubertal bone age assessment, but conventional methods have limitations. Olecranon bone age and its AI model showed high performances for pubertal bone age assessment. Olecranon bone age system is practical and accurate while requiring only a single lateral elbow radiograph.

Flexed elbow, abducted shoulder, forearm supinated (FABS) reconstruction from three-dimensional elbow MRI: diagnostic performance assessment in biceps head anatomy and pathology.

AIM: To determine inter-reader analysis and diagnostic performance on digitally reconstructed virtual flexed, abducted, supinated (FABS) imaging from three-dimensional (3D) isotropic elbow magnetic resonance imaging (MRI). MATERIALS AND METHODS: Six musculoskeletal radiologists independently evaluated elbow MRI images with virtual FABS reconstructions, blinded to clinical findings and final diagnoses. Each radiologist recorded a binary result as to whether the tendon was intact and if both heads were visible, along with a categorical value to the type of tear and extent of retraction in centimetres where applicable. Kappa and interclass correlation (ICC) were reported with 95% confidence intervals. Areas under the receiver operating curve (AUC) were reported. RESULTS: FABS reconstructions were obtained successfully in all 48 cases. With respect to tendon intactness, visibility of both heads, and type of tear, the Kappa values were 0.66 (0.53-0.78), 0.24 (0.12-0.37), and 0.55 (0.43-0.66), respectively. For the extent of retraction, the ICC was 0.85 (0.79-0.91) when including the tendons with and without retraction and 0.78 (0.61-0.91) when only including tendons with retraction. For tear versus no tear, AUC values were 0.82 (0.74-0.89) to 0.96 (0.91-1.01). CONCLUSION: Digital reconstruction of FABS positioning is feasible and allows good assessment of individual tendon head tears and retraction with high diagnostic performance.

Minimum Intensity of Daily Six Eccentric Contractions to Increase Muscle Strength and Size.

Our previous study showed that daily six maximal eccentric contractions that were performed 5 days a week for 4 weeks increased maximal voluntary isometric (MVC-ISO), concentric (MVC-CON), and eccentric contraction (MVC-ECC) strength of the elbow flexors and muscle thickness of biceps brachii and brachialis (MT) by 8.3 ± 4.9%, 11.1 ± 7.4%, 13.5 ± 11.5%, and 10.6 ± 5.1%, respectively. In the present study, we tested the hypothesis that the muscle strength and MT would still increase when the training intensity was reduced to 2/3 or 1/3 of the peak MVC-ECC torque. Thirty-six healthy young (19-24 years) adults who had not performed resistance training were placed to three groups (n = 12/group): 2/3MVC or 1/3MVC that performed six eccentric contractions with 2/3 or 1/3 MVC-ECC load using a dumbbell 5 days a week for 4 weeks or control group that did not perform any training. Changes in the MVC-ISO, MVC-CON, MVC-ECC torque, and MT before and after the 4-week period were compared among the groups and with the group of the previous study in which six maximal eccentric contractions were performed 5 days a week for 4 weeks (MVC group; n = 12). The control and 1/3MVC groups showed no significant changes in any measures. Significant (p < 0.05) increases in MVC-ISO (10.3 ± 11.4%), MVC-CON (10.9 ± 9.5%), and MVC-ECC (9.3 ± 8.8%) torque and MT (10.1 ± 9.2%) were observed for the 2/3MVC group. These changes were not significantly different from those of the MVC group. These results suggest that the 2/3-intensity eccentric contractions with a dumbbell are as effective as maximal-intensity isokinetic eccentric contractions to induce muscle adaptations.

The Effects of the StartReact on Reaction Time, Rate of Force Development, and Muscle Activity in Biceps Brachii.

The StartReact test, increasingly popular for assessing cortico-reticular functioning, is a valid method to influence the firing of reticulospinal tract neurons noninvasively. However, there remains limited evidence on how different stimuli employed in the StartReact test impact motor output in humans. The present study tested elbow flexor responses of 33 adults (aged 26-48 years) to visual stimuli only (LED light), audio-visual (80 dB) stimuli, and startle-inducing audio-visual (120 dB) stimuli sitting with the arm supinated in an electromechanical dynamometer. Surface electromyogram (EMG) recorded muscle activity from the right biceps brachii muscle. Participants were presented with 20 stimuli for each of the three conditions in pseudorandom order with interstimulus intervals of ~8 s. Reaction times were calculated from the stimulus trigger to the initial rise in the EMG signal above 7 × SD from baseline. Rate of torque development (RTD) and EMG signals were recorded throughout and analyzed over their initial 50 ms and 100 ms time-windows. Reaction times were reduced from visual (169 ± 23) to audio-visual (140 ± 23) and further reduced to startle-inducing audio-visual stimuli (108 ± 19, p < 0.001). While RTD and EMG were consistently greatest following startle-inducing stimuli (p < 0.001), they were also enhanced following all audio-visual stimuli over 100 ms (p < 0.05). It appears that startle-inducing audio-visual stimuli result in shorter reaction times, increased RTD, and enhanced muscle activity within the initial 50 ms, likely from subcortical upregulation. However, the 100 ms time-window suggests cortical upregulation following all audio-visual stimuli considering the longer transmission times.

The initiation factor 3 (IF3) residues interacting with initiator tRNA elbow modulate the fidelity of translation initiation and growth fitness in Escherichia coli.

Initiation factor 3 (IF3) regulates the fidelity of bacterial translation initiation by debarring the use of non-canonical start codons or non-initiator tRNAs and prevents premature docking of the 50S ribosomal subunit to the 30S pre-initiation complex (PIC). The C-terminal domain (CTD) of IF3 can carry out most of the known functions of IF3 and sustain Escherichia coli growth. However, the roles of the N-terminal domain (NTD) have remained unclear. We hypothesized that the interaction between NTD and initiator tRNAfMet (i-tRNA) is essential to coordinate the movement of the two domains during the initiation pathway to ensure fidelity of the process. Here, using atomistic molecular dynamics (MD) simulation, we show that R25A/Q33A/R66A mutations do not impact NTD structure but disrupt its interaction with i-tRNA. These NTD residues modulate the fidelity of translation initiation and are crucial for bacterial growth. Our observations also implicate the role of these interactions in the subunit dissociation activity of CTD of IF3. Overall, the study shows that the interactions between NTD of IF3 and i-tRNA are crucial for coupling the movements of NTD and CTD of IF3 during the initiation pathway and in imparting growth fitness to E. coli.

Weekly minimum frequency of one maximal eccentric contraction to increase muscle strength of the elbow flexors.

PURPOSE: Our previous study showed that one 3-s maximal eccentric contraction a day performed 5 days a week for 4 weeks (5DW) increased maximal voluntary contraction (MVC) strength of the elbow flexors more than 10%. The present study examined whether muscle strength would still increase when the frequency was reduced to 2 days or 3 days per week. METHODS: Twenty-six healthy young adults were recruited in the present study and placed to two groups (n = 13/group) based on the weekly frequency of the one 3-s maximal eccentric contraction for two (2DW) or three days per week (3DW) for 4 weeks. Changes in MVC-isometric, MVC-concentric, MVC-eccentric torque of the elbow flexors, and muscle thickness of biceps brachii and brachialis (MT) before and after the 4-week training were compared between 2DW and 3DW groups, and also compared to the 5DW group in the previous study. RESULTS: The 2DW group showed no significant changes in MVC torque. Significant (P < 0.05) increases in MVC-concentric (2.5 ± 10.4%) and MVC-eccentric (3.9 ± 4.9%) torque were observed for the 3DW group, but the magnitude of the increase was smaller (P < 0.05) than that presented by the 5DW group (12.8 ± 9.6%, 12.2 ± 7.8%). No significant changes in MT were evident for any of the groups. CONCLUSION: These results suggest that at least three days a week are necessary for the one 3-s maximal eccentric contraction to be effective for increasing muscle strength, and more frequent sessions in a week (e.g., 5 days) appear to induce greater increases in muscle strength.

Blood flow restriction increases necessary muscle excitation of the elbow flexors during a single high-load contraction.

PURPOSE: To investigate the effects of blood flow restriction (BFR) on electromyographic amplitude (EMGRMS)-force relationships of the biceps brachii (BB) during a single high-load muscle action. METHODS: Twelve recreationally active males and eleven recreationally active females performed maximal voluntary contractions (MVCs), followed by an isometric trapezoidal muscle action of the elbow flexors at 70% MVC. Surface EMG was recorded from the BB during BFR and control (CON) visits. For BFR, cuff pressure was 60% of the pressure required to completely occlude blood at rest. Individual b (slope) and a terms (gain) were calculated from the log-transformed EMGRMS-force relationships during the linearly increasing and decreasing segments of the trapezoid. EMGRMS during the steady force segment was normalized to MVC EMGRMS. RESULTS: For BFR, the b terms were greater during the linearly increasing segment than the linearly decreasing segment (p < 0.001), and compared to the linearly increasing segment for CON (p < 0.001). The a terms for BFR were greater during the linearly decreasing than linearly increasing segment (p = 0.028). Steady force N-EMGRMS was greater for BFR than CON collapsed across sex (p = 0.041). CONCLUSION: BFR likely elicited additional recruitment of higher threshold motor units during the linearly increasing- and steady force-segment. The differences between activation and deactivation strategies were only observed with BFR, such as the b terms decreased and the a terms increased for the linearly decreasing segment in comparison to the increasing segment. However, EMGRMS-force relationships during the linearly increasing- and decreasing-segments were not different between sexes during BFR and CON.

Double entrapment neuropathy of the ulnar nerve at the elbow and the wrist : double crush syndrome?

BACKGROUND: Double crush syndrome refers to a nerve in the proximal region being compressed, affecting its proximal segment. Instances of this syndrome involving ulnar and cubital canals during ulnar neuropathy are rare. Diagnosis solely through clinical examination is challenging. Although electromyography (EMG) and nerve conduction studies (NCS) can confirm neuropathy, they do not incorporate inching tests at the wrist, hindering diagnosis confirmation. We recently encountered eight cases of suspected double compression of ulnar nerve, reporting these cases along with a literature review. METHODS: The study included 5 males and 2 females, averaging 45.6 years old. Among them, 4 had trauma history, and preoperative McGowan stages varied. Ulnar neuropathy was confirmed in 7 cases at both cubital and ulnar canal locations. Surgery was performed for 4 cases, while conservative treatment continued for 3 cases. RESULTS: In 4 cases with wrist involvement, 2 showed ulnar nerve compression by a fibrous band, and 1 had nodular hyperplasia. Another case displayed ulnar nerve swelling with muscle covering. Among the 4 surgery cases, 2 improved from preoperative McGowan stage IIB to postoperative stage 0, with significant improvement in subjective satisfaction. The remaining 2 cases improved from stage IIB to IIA, respectively, with moderate improvement in subjective satisfaction. In the 3 cases receiving conservative treatment, satisfaction was significant in 1 case and moderate in 2 cases. Overall, there was improvement in hand function across all 7 cases. CONCLUSION: Typical outpatient examinations make it difficult to clearly differentiate the two sites, and EMG tests may not confirm diagnosis. Therefore, if a surgeon lacks suspicion of this condition, diagnosis becomes even more challenging. In cases with less than expected postoperative improvement in clinical symptoms of cubital tunnel syndrome, consideration of double crush syndrome is warranted. Additional tests and detailed EMG tests, including inching tests at the wrist, may be necessary. We aim to raise awareness double crush syndrome with ulnar nerve, reporting a total of 7 cases to support this concept.

Pediatric thrower's elbow: maturation-dependent MRI findings in symptomatic baseball players.

BACKGROUND: Elbow pain is common among youth baseball players and elbow MRI is increasingly utilized to complement the clinical assessment. OBJECTIVE: To characterize, according to skeletal maturity, findings on elbow MRI from symptomatic youth baseball players. MATERIALS AND METHODS: This IRB-approved, HIPAA-compliant retrospective study included pediatric (<18 years of age) baseball players with elbow pain who underwent MRI examinations between 2010 and 2021. Two radiologists, blinded to the outcome, independently reviewed examinations to categorize skeletal maturity and to identify osseous and soft tissue findings with consensus used to resolve discrepancies. Findings were compared between skeletally immature and mature patients and logistic regression models identified predictors of surgery. RESULTS: This study included 130 children (115 boys, 15 girls): 85 skeletally immature and 45 mature (12.8±2.3 and 16.2±1.0 years, respectively, p<0.01). Kappa coefficient for interobserver agreement on MRI findings ranged from 0.64 to 0.96. Skeletally immature children, when compared to mature children, were more likely to have elbow effusion (27%, 23/85 vs 9%, 4/45; p=0.03), medial epicondyle marrow edema (53%, 45/85 vs 16%, 7/45; p<0.01), avulsion fracture (19%, 16/85 vs 2%, 1/45; p=0.02), and juvenile osteochondritis dissecans (OCD, 22%, 19/85 vs 7%, 3/45; p=0.04), whereas skeletally mature children were more likely to have sublime tubercle marrow edema (49%, 22/45 vs 11%, 9/85; p<0.01) and triceps tendinosis (40%, 18/45 vs 20%, 17/85; p=0.03). Intra-articular body (OR=4.2, 95% CI 1.5-47.8, p=0.02) and osteochondritis dissecans (OR=3.7, 95% CI 1.1-11.9, p=0.03) were independent predictors for surgery. CONCLUSION: Differential patterns of elbow MRI findings were observed among symptomatic pediatric baseball players based on regional skeletal maturity. Intra-articular body and osteochondritis dissecans were independent predictors of surgery.

Ankle, knee, and elbow arthrography: 2022 survey of Society of Skeletal Radiology members.

OBJECTIVE: To determine the preferred ankle, knee, and elbow arthrography injection techniques for Society of Skeletal Radiology (SSR) members and whether more recently described techniques are gaining acceptance. We also sought to determine whether the concept of knowledge translation might explain differences between the preferred technique, year of fellowship graduation, and year the newer technique was described. MATERIALS AND METHODS: A 29-question survey was created in Qualtrics and submitted to current SSR members to determine if they perform knee, elbow, and ankle arthrography, and if so, the year of fellowship completion and preferred approaches. Survey respondents indicated the starting and ending needle tip positions for three knee, two elbow, and three ankle arthrography approaches using grids placed over provided frontal and lateral radiographs. RESULTS: Two hundred seventy-four SSR members (mean post-fellowship 13 years; range 0-38) completed the survey and performed fluoroscopic-guided knee (93%), elbow (95%), and ankle (75%) arthrography. Preferred approaches included the following: knee lateral subpatellar (43%), anterior (40%); elbow radiocapitellar (74%); ankle anterior/peritendon (70%), lateral mortise (24%). Preference of newer technique was related to fellowship graduation year and publication year for the ankle mortise (26% before, 42% after; p = 0.03) and posterior trans-triceps elbow articles (19% before, 33% after; p < 0.01). The anterior knee approach preference increased from 11% in 2008 to 40% (p ≤ 0.001). CONCLUSION: Nearly twice as many SSR members who graduated after the posterior trans-triceps and ankle mortise techniques were published prefer them for performing arthrography, possibly due to knowledge translation. The preference of the anterior knee arthrography approach has increased nearly fourfold since 2008.

Editorial Commentary: At Least 2 out of 3 Adolescent Athletes Can Return to Preinjury Sports After Marrow Stimulation for Osteochondritis Dissecans of the Elbow.

Osteochondritis dissecans (OCD) of the capitellum is a common cause of elbow pain in young throwers and gymnasts, symptoms of which can rob these young athletes of valuable time participating in sporting activities. The optimal treatment of adolescent capitellar OCD lesions is dependent on a variety of patient- and lesion-specific factors, including, but not limited to, lesion size, lesion location, physeal status, and lesion chronicity. Promisingly, marrow stimulation with or without debridement appears to confer high return-to-sport rates coupled with a low complication rate for young athletes suffering from this condition. Furthermore, these outcomes appear to remain consistent across the spectrum of OCD lesions typically encountered. There is concern, however, with the inconsistent reporting of patient- and lesion-specific factors across the literature, which greatly interferes with our ability to synthesize knowledge from multiple published studies and may lead surgeons astray when deciding on the optimal treatment for their patients. It is clear that no two OCD lesions are the same, and each patient requires a thorough history and physical exam, a complete radiographic workup, and a surgeon comfortable with a variety of surgical interventions if outcomes are to be maximized.

One- and 2-Year American Shoulder and Elbow Surgeons Scores Do Not Vary Significantly After Arthroscopic Rotator Cuff Repair: A Prospective Multicenter Analysis of 1,567 Patients.

PURPOSE: To evaluate whether there are clinically significant changes in patient-reported outcomes between 1 and 2 years' postoperatively after arthroscopic rotator cuff repair (RCR). METHODS: A retrospective analysis of prospective, multicenter registry was queried for all patients who underwent RCR. Patients with preoperative, 6-month, 1-year, and 2-year postoperative American Shoulder and Elbow Surgeons (ASES) scores were included. We evaluated mean postoperative ASES scores, Δ (change from preoperative) ASES, and the %MOI (% maximum outcome improvement). We also evaluated achievement of clinically significant outcomes (CSOs) for the ASES score, including the minimal clinically important difference (MCID), substantial clinical benefit, and patient-acceptable symptom state. RESULTS: There were 1,567 patients with complete data through 2-year follow-up. There were small differences in achievement of CSOs from 1 to 2 years: 88% to 91% for MCID, 81% to 83% for substantial clinical benefit, and 65% to 71% for patient-acceptable symptom state. There were statistically significant differences from 1 to 2 years in mean ASES (87 to 88, P < .001), Δ ASES (37 to 39, P < .001), and %MOI (72% to 76%, P < .001); however, these changes were well below the MCID of 11.1. From 1 to 2 years, the mean ASES improved only 1.7 points (P < .001). At 1 year, patients achieved, on average, 97% of their 2-year ASES. CONCLUSIONS: Both patient-reported outcomes and achievement of CSOs show small differences at 1 and 2 years after RCR. Given the large sample size, there were statistical differences, but these are unlikely to be clinically relevant. LEVEL OF EVIDENCE: Level IV, case series.