Visualization of Median Nerve Entrapment After Reduction of an Elbow Fracture Dislocation Using 3-Dimensional Magnetic Resonance Imaging: A Case Report.

CASE: A 10-year-old girl presented after closed reduction of an elbow fracture dislocation. She demonstrated intact vascularity but a dense median nerve palsy. Preoperative magnetic resonance neurography (MRN) precisely mapped the median nerve entrapped within the medial epicondylar fracture. Intraoperatively, the median nerve was freed preceding reduction and fracture fixation. Postoperatively, neurological symptoms completely resolved, and she regained full elbow function. CONCLUSION: Median nerve injury can present without associated vascular injury. In this case, MRN was helpful in preoperatively illustrating the spatial relationship between the median nerve and the medial epicondyle.

Entrapment of Median Nerve After Pediatric Elbow Dislocation with a Brief Review of Literature: A Case Study.

CASE: We present a case of type II (intraosseous) entrapment of the median nerve in a patient who was diagnosed based on clinical examination and magnetic resonance imaging and who was treated with medial epicondyle osteotomy, neurolysis, and transposition of the nerve to its anatomical position within a month of injury. Our patient made a complete motor and sensory recovery at 5 months with complete functionality and grip strength. CONCLUSION: Median nerve entrapment after posterolateral elbow dislocation is a rare complication with roughly 40 cases reported in the literature. This case illustrates the importance of prompt diagnosis and treatment.

Anemia to Median Nerve Palsy.

Mesenteric angina has a high mortality rate. Occlusion of the superior mesenteric artery is the most common cause. Increasingly, it is managed endovascularly instead of by open revascularization. Despite the lower risk of complications in minimally invasive procedures, it is important to be mindful of long-term sequelae of minor complications. Patient education regarding risks and complications is paramount for better clinical outcomes. The risks of transbrachial angiography procedures are low. Postprocedural vigilance for interventionists and written educational advice to patients are paramount in all minimally invasive endovascular procedures, especially because most of these patients with a complication require urgent operative correction.

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.

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.

High Median Nerve Entrapment by Fracture Callus in Surgically Treated Pediatric Supracondylar Humeral Fracture: A Case Report.

CASE: We describe a patient with incomplete high median nerve palsy after surgical treatment of pediatric supracondylar humeral fracture (SCHF). Preoperative images after 11 months after the surgical treatment of the SCHF showed rotational deformity and an isolated median nerve entrapped between the proximal humerus anteriorly and callus posteriorly in the bony tunnel of the distal humerus. Two years after neurolysis, he showed clinical recovery. Four cases similar to our case were reported previously. CONCLUSION: Common pediatric fractures may cause unusual neuropathy. Rotational deformity of fracture might be an important factor for isolated median nerve entrapment after SCHF.

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.

A Rare Case of Median Nerve Entrapment within the Bone After Surgical Treatment of a Pediatric Supracondylar Humerus Fracture: A Case Report.

CASE: We present the rare event of median nerve bony entrapment after a supracondylar distal humerus fracture in a child. The median nerve was both clinically and electrically still, partially intact at 2 years after the injury. The nerve was surgically extracted from the bone. Follow-up evaluation a year later showed motor and sensory improvement. We found only 2 similar reports in the literature and one similar postmortem example. CONCLUSION: We hope that this case brings awareness of an unusual complication after a commonly encountered injury.

Surgical Excision of a Thrombosed Persistent Median Artery Causing Carpal Tunnel-Like Symptoms: A Case Report.

CASE: A 51-year-old man presented with pain and paresthesias in the median nerve distribution and a subjective loss of grip strength. Imaging revealed a thrombosed persistent median artery in the carpal tunnel abutting the median nerve. The thrombosed portion of the artery was surgically excised, and the patient experienced resolution of symptoms. CONCLUSION: Persistent median artery thrombosis is rare and can cause carpal tunnel syndrome. Ultrasound is a useful tool for diagnosis and appropriate surgical planning. Although treatment with systemic anticoagulation is an option, surgical excision resulted in resolution of symptoms and an excellent short-term outcome.

Distal radius fractures: an evidence-based approach to assessment and management.

Distal radius fractures account for one in five bony injuries in both primary and secondary care. These are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. Owing to the heterogeneous injury patterns and patient profiles, the preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results, especially in older adults. Immobilisation with or without reduction forms the mainstay of non-operative treatment. Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation. Patients should be encouraged to mobilise as soon as it is safe to do so, to prevent stiffness. Median nerve compression is the most common complication followed by tendon rupture, arthrosis and malunion. This article outlines the British Orthopaedic Association Standards for Trauma and Orthopaedics for the management of distal radius fractures.

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.

Short-term cane use in subacute stroke patients affects the nonparetic upper extremity nerves.

Overuse of the nonparetic upper extremity can lead to entrapment neuropathies in chronic stroke patients. However, little is known about the effects of cane use in subacute stage of stroke. The aim of this study was to investigate the short-term effects of cane use on the upper extremity nerves in subacute stroke patients recovering from a bedridden state. Thirty subacute hemiparetic stroke patients who were initially bedridden participated when they were able to walk with a cane. Symptoms and signs related to the median or ulnar nerves were checked, and nerve conduction studies were performed. The largest cross-sectional area (CSA) of these nerves from the wrist to elbow was measured with ultrasound. After 3 weeks of cane use, electrophysiologic and ultrasonographic reevaluation was performed. Nerve conduction studies and CSA of the nerves at the nonparetic upper extremity showed significant changes, whereas those of the hemiparetic upper extremity did not. Walking with a cane for a short period can induce the enlargement of the median and ulnar nerves at the nonparetic extremity of subacute hemiparetic stroke patients. Attention should be placed on correct cane usage from the beginning of rehabilitation.

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.