Modified simple decompression in the treatment of cubital tunnel syndrome: avoiding ulnar nerve subluxation.

OBJECTIVE: In this study, we propose a modification to the simple decompression technique that contains the ulnar nerve in the cubital fossa, thus preventing subluxation during forearm flexion movements. METHODS: Five consecutive patients with leprosy-associated cubital tunnel syndrome underwent surgery with the modified technique between July 2011 and October 2012. RESULTS: The most common symptoms were neuropathic pain and sensory changes (both 60%). On the McGowan scale, three patients maintained their preoperative score and two patients improved by two points, while on the Louisiana State University Health Sciences Center scale, two patients maintained the same scores, two improved by two points, and one improved by one point. Four patients were able to discontinue corticosteroid use. The mean follow-up time was 25.6 months (range 2-48 months). There were no recurrences or subluxations in the long-term. CONCLUSION: This alternative technique resulted in excellent functional results, as well as successful withdrawal from corticosteroids. Furthermore, it resulted in no ulnar nerve subluxations.

Modified simple decompression in the treatment of cubital tunnel syndrome: avoiding ulnar nerve subluxation / Descompressão simples modificada no tratamento da síndrome do túnel cubital: evitando subluxação do nervo ulnar

ABSTRACT Objective In this study, we propose a modification to the simple decompression technique that contains the ulnar nerve in the cubital fossa, thus preventing subluxation during forearm flexion movements. Methods Five consecutive patients with leprosy-associated cubital tunnel syndrome underwent surgery with the modified technique between July 2011 and October 2012. Results The most common symptoms were neuropathic pain and sensory changes (both 60%). On the McGowan scale, three patients maintained their preoperative score and two patients improved by two points, while on the Louisiana State University Health Sciences Center scale, two patients maintained the same scores, two improved by two points, and one improved by one point. Four patients were able to discontinue corticosteroid use. The mean follow-up time was 25.6 months (range 2-48 months). There were no recurrences or subluxations in the long-term. Conclusion This alternative technique resulted in excellent functional results, as well as successful withdrawal from corticosteroids. Furthermore, it resulted in no ulnar nerve subluxations.

RESUMO Objetivo Neste manuscrito apresentamos uma modificação da técnica de descompressão simples do nervo ulnar no túnel cubital que impede a subluxação do nervo em movimentos de flexão do antebraço. Métodos Foram incluídos cinco pacientes consecutivos acometidos por síndrome do túnel cubital (Hanseníase) submetidos à cirurgia entre 2011 e 2012. Resultados Os sintomas mais comuns foram dor neuropática e alterações sensitivas (60%). No pós-operatório, três pacientes mantiveram o mesmo escore e dois melhoraram dois pontos na escala de McGowan, enquanto na escala Louisiana State University Health Sciences Center, dois pacientes mantiveram o mesmo escore, dois melhoraram dois pontos e um melhorou um ponto. Os corticosteróides foram descontinuados em quatro pacientes. O tempo médio de seguimento foi 25,6 meses (variação 2-48 meses). Não foram observadas recorrência ou subluxação no longo prazo. Conclusões A técnica alternativa apresentou excelentes resultados funcionais e foi bem sucedida na retirada dos corticosteróides. Ademais, subluxações do nervo ulnar não foram observadas.

Desempenho funcional de pacientes com deformidades visíveis na hanseníase / Functional performance of patients with visible deformities in leprosy

Esse estudo tem por objetivo avaliar a capacidade funcional da mão das pessoas atingidas pela hanseníase na realização das atividades básicas e instrumentais da vida diária. A amostra foi constituída por 50 pacientes, maiores de 18 anos, que estavam sendo acompanhados no ambulatório do Instituto Lauro de Souza Lima. Para avaliação das características sociodemográficas e clínicas foi elaborado um questionário próprio. As dificuldades manuais para realizar atividades nas áreas de vestuário, alimentação, higiene pessoal, cuidados com a casa, escrita e outros foram avaliados por meio da Avaliação Funcional das Mãos em Hanseníase. Os resultados demonstram que em todas as atividades houve algum grau de dificuldade, porém, a maioria dos pacientes as realiza com independência. As atividades consideradas mais difíceis de serem executadas pelos pacientes com garra ulnar foram: pegar objetos pequenos em superfície plana, abrir/fechar fecho de corrente e cortar unhas. Na população de pacientes com garra ulnar/mediano foram: pegar objetos pequenos em superfície plana, abotoar/desabotoar, dar laço/ amarrar cadarço e abrir/fechar fecho de corrente. As atividades são realizadas com algum grau de dificuldade, porém, com independência pela maioria dos indivíduos que tem ou tiveram hanseníase e apresentam deformidades visíveis. Muitas dessas dificuldades podem ser minimizadas por meio de transferências tendinosas ou pela indicação, confecção e uso de tecnologia assistiva(AU).

This study aims to assess the functional capacity of the hand of people affected by leprosy in carrying out basic and instrumental activities of daily living. The sample consisted of 50 patients, aged over 18, who were being followed up at the outpatient clinic of the Instituto Lauro de Souza Lima. A questionnaire was developed to assess sociodemographic and clinical characteristics. Manual difficulties in carrying out activities in the areas of clothing, food, personal hygiene, home care, writing and others were assessed through the Functional Hand Assessment in Leprosy. The results show that in all activities there was some degree of difficulty, however, most patients perform them independently. The activities considered most difficult to be performed by patients with an ulnar claw were: picking up small objects on a flat surface, opening / closing the chain clasp and cutting nails. In the population of patients with an ulnar / median claw were: picking up small objects on a flat surface, buttoning / unbuttoning, looping / tying shoelaces and opening / closing chain fastening. The activities are performed with some degree of difficulty, however, independently by the majority of individuals who have or have had leprosy and have visible deformities. Many of these difficulties can be minimized by means of tendon transfers or by the indication, preparation and use of assistive technology(AU).

Zancolli lasso procedure for correction of paralytic claw hands.

PURPOSE: To evaluate the outcome of 20 claw hands corrected with the Zancolli lasso procedure. METHODS: 20 patients aged 7 to 48 (mean, 28) years with claw hand deformity for a mean of 33.3 months secondary to leprosy (n=17), traumatic ulnar nerve injury (n=2), or tardy ulnar nerve palsy (n=1) underwent the Zancolli lasso procedure, in which the flexor digitorum superficialis (FDS) of the middle finger was divided in to 4 slips (one for each finger) and reattached to itself after passing through the proximal pulley. Deformity, power, movement, and function of the hands were evaluated before and after surgery. RESULTS: The mean duration of surgery was 58.4 (range, 50-107) minutes. The mean duration of follow-up was 18 (range, 12-24) months. Deformity correction was good in 15 patients, fair in 3, and poor in 2. The mean angle improvement was maximum in the little finger, followed by the ring, index, and middle fingers. The transverse metacarpal arch (compared with the normal hand) was increased/reversed in 7 patients and decreased in 13 patients. The grip and pinch strength increased in 13 patients, remained unchanged in 6, and decreased in one. Motion and function of the hand was good in 12 patients, fair in 6, and poor in 2. One patient developed swan neck deformity in the little finger owing to suture tension of the transferred slip, and another had paraesthesia over the index finger. They underwent reoperation using the FDS of the ring finger; no sensory or motor recovery was achieved. CONCLUSION: The Zancolli lasso procedure is easy to perform and does not require extensive postoperative training. It restores synchronous finger flexion and spares other superficialis tendons, thus avoiding swan neck deformity of the fingers.

Questionário para avaliação funcional da mão em lesão de nervos / Questionnaire to evaluate hand function in nerve lesions

OBJETIVO: elaborar um questionário de avaliação funcional para analisar as dificuldades manuais encontradas na realização de atividades cotidianas de indivíduos ocidentais adultos com lesão dos nervos ulnar, mediano ou radial.MÉTODO: foi realizada entrevista com 50 pessoas, idade entre 21 e 65 anos, portadoras de lesão nos nervos ulnar, mediano ou radial para identificar as dificuldades manuais ao realizar as tarefas cotidianas. Em seguida, seis cirurgiões de mão e nove terapeutas de mão, analisaram as tarefas listadas pelos entrevistados e as classificaram em níveis de importância para uma avaliação funcional das mãos. Posteriormente, o questionário foi elaborado baseado nessa classificação.RESULTADOS: o "Questionário de avaliação da mão com lesão de nervo" é constituído por 30 questões objetivas divididas em domínios de tarefas (vestuário, alimentação, higiene pessoal, tarefas domésticas, escrita, uso de computador e atividades diversas). As respostas são atribuídas de acordo com o grau de dificuldade na realização das tarefas listadas no instrumento. O questionário foi respondido por 32 pessoas com idade entre 18 e 65 anos apresentando sequela de hanseníase. O cálculo do alfa de Cronbach foi utilizado para avaliar a confiabilidade do instrumento. Após a remoção de duas questões relacionadas ao uso de computador, o resultado do alfa de Cronbach aumentou para 0,90.CONCLUSÃO: o "Questionário de avaliação da mão com lesão de nervo" apresenta alta consistência interna. Além disso, é conciso, de fácil preenchimento não necessitando a presença de profissional especializado para sua aplicação e permite a verificação do nível de independência do indivíduo com lesão de nervo periférico na mão na realização de suas tarefas habituais.

OBJECTIVE: to develop a functional evaluation questionnaire to limitations in hand function by western adults individuals with lesions of the ulnar, median or radial nerves in their routine tasks.DESIGN: an interview was conducted with 50 patients of 21-65 years of age with ulnar, median and radial nerve lesions to identify any manual difficulties in their performance of routine daily tasks. Six hand surgeons and nine hand therapists then analyzed the tasks listed by the patients and graded them in levels of importance for the evaluation of hand function, after which a questionnaire based on this classification was drawn up.RESULTS: the instrument Evaluation of Hand with Nerve Damage Questionnaire, consists of 30 objective questions divided into task domains (dressing, feeding, personal hygiene, housework, writing, use of computers and "others"), answers being classified according to degree of difficulty. The questionnaire was completed by 32 patients of 18-65 years of age with sequelae of Hansen's disease. Cronbach's coefficient alpha was used to assess the reliability of the instrument. Following removal of two questions regarding computer use, Cronbach's coefficient alpha increased to 0.90.CONCLUSION: the Evaluation of Hand with Nerve Damage Questionnaire shows a high internal consistency. In addition it is concise, easy to fill instrument not requiring specialized professional to apply and allows evaluation of the degree of independence of the individual with peripheral nerve lesion in the hand in performing routine daily tasks.

Voluntary muscle testing and dynamometry in diagnosis of motor impairment in leprosy: a comparative study within the INFIR Cohort Study.

AIM: To evaluate hand muscle weakness detected through dynamometry as an indicator for change in motor nerve function detected by Voluntary Muscle Testing (VMT) of ulnar and median nerves. DESIGN: The research was carried out as part of the INFIR Cohort Study among 303 subjects newly diagnosed with MB leprosy in two centres in UP state, northern India. METHODS: To assess grip strength, key pinch and pulp-to-pulp pinch we adapted the cuffs of adult and neonatal sphygmomanometers. The testing was carried out at diagnosis and at each visit during a 2-year follow-up. RESULTS: 303 subjects with newly diagnosed MB leprosy were included in the study. We found statistically significant differences in grip strength, key pinch and pulp-to-pulp pinch between groups defined by ulnar VMT grades at time of diagnosis. There was also a statistically significant difference in hand grip between groups defined by median VMT at diagnosis. In each case, strength tended to reduce with increasing motor involvement. We explored reduction in grip strength, key pinch or pulp-to-pulp pinch as indicators of change in ulnar VMT during follow-up. A 25% reduction over two visits was the most effective indicator. Changes were also associated with marginal changes in motor and sensory nerve function, most commonly associated with Type I reactions. CONCLUSION: Dynamometry is recommended as an additional method that may be used to monitor changes in nerve function in leprosy, particularly in subjects with early motor impairment of the ulnar nerve.

Restoration of sensibility in irreparable ulnar and median nerve lesions with use of sensory nerve transfer: long-term follow-up of 20 cases.

A prospective study was conducted to evaluate patient outcomes following sensory nerve transfer. Twenty patients with irreparable ulnar or median nerve lesions underwent the procedure. Nerve involvement was bilateral in 5 cases. The mean age of the patients at the time of surgery was 29 years. The mean paralysis time and the average length of follow-up were 59 and 78 months, respectively. Eighteen of 20 patients attended a sensory re-education program after surgery. Outcome was assessed objectively by functional sensory recovery testing and by the British Medical Research Council standards. Subjective outcome was assessed by a questionnaire. Two-point discrimination of less than 10 mm was achieved in 15 of 25 hands. The mean functional sensory recovery score was 83. Eighteen of 20 patients reported that the function of their hands improved after the procedure. Good or excellent results were associated with immediate transfer of the nerve, young age, and patients' attendance to the sensory re-education program after surgery. No differences were found between the recovery of ulnar and median nerves. Based on these results we suggest that sensory nerve transfer is a simple and reliable way of restoring sensibility to the hand with favorably comparable results over conventional nerve grafting in selected cases.

A cirurgia de Smith na perda do movimento de aduçäo do polegar / Smith's surgery in the loss of the thumb adduction movement

Os autores analisam os resultados obtidos pela técnica cirúrgica descrita por Smith, que consiste na transferência do tendäo extensor radial curto do carpo para o tendäo do músculo adutor do polegar em sete pacientes com incapacidade da realizaçäo do movimento de aduçäo do polegar, devido à lesäo traumática do nervo ulnal (qatro casos) e neuropatia ulnal (três casos) causada pelo mal de Hansen.

Manifestaciones neurológicas de la lepra / Neurologic manifestation of the leprosy

La lepra es siempre una enfermedad cutánea y nerviosa periférica. Existen formas clínicas bien definidas localizadas en los troncos nerviosos: cara, cuello, miembros, dando la clásica mononeuritis múltiple. El primer lugar le corresponde al cubital, seguido por el ciático poplíteo externo. Según cifras estadísticas y nuestra propia experiencia hay predominancia para el cubital en la gotera oleacraneana respecto de la palma y en la cabeza del peroné para el ciático poplíteo externo respecto del hueco poplíteo. El engrosamiento nervioso es facilmente palpable y aún visible. Se hace la descripción anatómica y funcional siguiendo a Guy Lazorthes y la interpretación de la biomecánica en base a los estudios y aportes de Manzi, R.O y colaboradores, con las consecuencias ulcerotróficas del disbalance muscular. El panadizo analgésico y el mal perforante plantar son dos cuadros habituales en la lepra. No así el absceso del nervio y el síndrome hombro-mano-dedos. Se citan referencias en nuestro país. Nuestro material es recopilado del Hospital Perrando y servicio de Dermatología de Resistencia. Se observó predominancia de formas múltiples además de formas lepromatosas. En la fisiopatogenia se hace referencia al estado de hibernación en que vive el bacilo en la vaina de Schwann, ya que éste vive años a cambio del histiocito que no vive más de una semana. Como resultado de un conflicto local donde intervienen fenómenos tisulares, inmunológicos y circulatorios, se producen, de acuerdo a la capacidad del huésped, las distintas formas de lepra: tuberculoide, lepromatosa, dimorfa e incaracterística. Se describe otra forma que es la neuritis autoinmune secundaria de Languillon y Carayon como expresión de pérdida de alergia tisular. La isquemia del nervio es la condicionante de la lesión neural que lleva a la esclerosis. La liberación del tronco del canal por sección de fibras de inserción muscular y la neurolisis con epineurotomía son propuestas como los medios más útiles para la cirugía, cuando se han agotado los recursos médicos conservadores

Tratamiento quirúrgico de neuritis hansenianas / Surgical treatment of hansenian neuritis

Los autores analizan los problemas del tratamiento quirúrgico de las neuritis hansenianas. Se establecen los criterios que deben ser utilizados. Ubican la cirugía en el contexto terapéutico. Presentan ejemplos de su casuística. Se sugiere uniformar los criterios a fin de tornar comparativos los resultados

Manifestaciones neurológicas de la lepra / Neurologic manifestation of the leprosy

La lepra es siempre una enfermedad cutánea y nerviosa periférica. Existen formas clínicas bien definidas localizadas en los troncos nerviosos: cara, cuello, miembros, dando la clásica mononeuritis múltiple. El primer lugar le corresponde al cubital, seguido por el ciático poplíteo externo. Según cifras estadísticas y nuestra propia experiencia hay predominancia para el cubital en la gotera oleacraneana respecto de la palma y en la cabeza del peroné para el ciático poplíteo externo respecto del hueco poplíteo. El engrosamiento nervioso es facilmente palpable y aún visible. Se hace la descripción anatómica y funcional siguiendo a Guy Lazorthes y la interpretación de la biomecánica en base a los estudios y aportes de Manzi, R.O y colaboradores, con las consecuencias ulcerotróficas del disbalance muscular. El panadizo analgésico y el mal perforante plantar son dos cuadros habituales en la lepra. No así el absceso del nervio y el síndrome hombro-mano-dedos. Se citan referencias en nuestro país. Nuestro material es recopilado del Hospital Perrando y servicio de Dermatología de Resistencia. Se observó predominancia de formas múltiples además de formas lepromatosas. En la fisiopatogenia se hace referencia al estado de hibernación en que vive el bacilo en la vaina de Schwann, ya que éste vive años a cambio del histiocito que no vive más de una semana. Como resultado de un conflicto local donde intervienen fenómenos tisulares, inmunológicos y circulatorios, se producen, de acuerdo a la capacidad del huésped, las distintas formas de lepra: tuberculoide, lepromatosa, dimorfa e incaracterística. Se describe otra forma que es la neuritis autoinmune secundaria de Languillon y Carayon como expresión de pérdida de alergia tisular. La isquemia del nervio es la condicionante de la lesión neural que lleva a la esclerosis. La liberación del tronco del canal por sección de fibras de inserción muscular y la neurolisis con epineurotomía son propuestas como los medios más útiles para la cirugía, cuando se han agotado los recursos médicos conservadores

Tratamiento quirúrgico de neuritis hansenianas / Surgical treatment of hansenian neuritis

Los autores analizan los problemas del tratamiento quirúrgico de las neuritis hansenianas. Se establecen los criterios que deben ser utilizados. Ubican la cirugía en el contexto terapéutico. Presentan ejemplos de su casuística. Se sugiere uniformar los criterios a fin de tornar comparativos los resultados

[Cubital nerve injuries in shoe-stitching workers: medico-social approach]. / Lesões do nervo cubital em costureiras de calçados: abordagem médico-social.

An unexampled nosologic entity in the literature is described. Nineteen patients with atrophies in the hands are studied. The occupation is shoe stitching. The etiology of disease is due to microtraumatisms of the ulnar nerve at the elbow, during the work. Research for Hansen disease in patients was negative. Electromiographic-tests in 11 patients showed lesion on the periferic motor neron. Nervous conduction speed was diminished in all cases. The treatment consisted of analgesics, B complex vitamin, prednizone, surgery with transposition of the ulnar nerve at the elbow level. Preventive measures are analysed.

The protective value of a neurovascular island pedicle transfer in hands partially anesthetic due to ulnar denervation in leprosy.

Neurovascular skin island transfers were performed with the prime objective of protecting vulnerable anesthetic areas on the hands of patients with leprosy. After an average follow-up of eight years on sixteen patients, all had long-lasting protective benefits without further loss of tissue consequent to injury. At follow-up, two-point discrimination was less than ten millimeters in only one patient, more than twenty millimeters in ten, and indeterminate in five. Sensory misreference persisted in fourteen patients. Axon sprouting was evident in six but only over short distances (four to eight millimeters beyond the island). Compared with the intact side of the donor finger, nine of the sixteen transfers had lost some sensitivity but sensation was rated normal in one, nearly normal in six, and protective only in nine. The loss of sensation in the donor finger was less than expected and was not a problem. Scar contracture occurred in two donor and five recipient fingers, but this could be attributed to placement of the incision too far anteriorly, and hence was an unavoidable complication. Restoration of protective sensation to the ulnar border of the hand, whatever the cause of anesthesia, is considered extremely worth while.