Posterior approach technique for accessory-suprascapular nerve transfer: a cadaveric study of the anatomical landmarks and number of myelinated axons.

Accessory-suprascapular nerve transfer by the anterior supraclavicular approach technique was suggested to ensure transferrance of the spinal accessory nerve to healthy recipients. However, a double crush lesion of the suprascapular nerve might not be sufficiently demonstrated. In that case, accessory-suprascapular nerve transfer by the posterior approach would probably solve the problem. The aim of this study was to evaluate the anatomical landmarks and histomorphometry of the spinal accessory and suprascapular nerve in the posterior approach. Dissection of fresh cadaveric shoulder in a prone position identified the spinal accessory and suprascapular nerve by the trapezius muscle splitting technique. After that, nerves were taken for histomorphometric evaluation. The spinal accessory nerve was located approximately halfway between the spinous process and conoid tubercle. The average distance from the conoid tubercle to the suprascapular nerve (medial edge of the suprascapular notch) is 3.3 cm. The mean number of myelinated axons of the spinal accessory and suprascapular nerve was 1,603 and 6,004 axons, respectively. The results of this study supported the brachial plexus reconstructive surgeons, who carry out accessory-suprascapular nerve transfer by using the posterior approach technique. This technique is an alternative for patients who have severe crushed injury of the shoulder or suspected double crush lesion of the suprascapular nerve.

Electromyographic comparison of various exercises to improve elbow flexion following intercostal nerve transfer.

We compared the quantitative electromyographic activity of the elbow flexors during four exercises (forced inspiration, forced expiration, trunk flexion and attempted elbow flexion), following intercostal nerve transfer to the musculocutaneous nerve in 32 patients who had sustained root avulsion brachial plexus injuries. Quantitative electromyographic evaluation of the mean and maximum amplitude was repeated three times for each exercise. We found that mean and maximum elbow flexor activity was highest during trunk flexion, followed by attempted elbow flexion, forced inspiration and finally forced expiration. The difference between each group was significant (p < 0.001), with the exception of the difference between trunk flexion and attempted elbow flexion. Consequently, we recommend trunk flexion exercises to aid rehabilitation following intercostal nerve transfer.

Pulmonary and biceps function after intercostal and phrenic nerve transfer for brachial plexus injuries.

This pseudo-randomized study was performed to compare the pulmonary function and biceps recovery after intercostal (19 cases) and phrenic (17 cases) nerve transfer to the musculocutaneous nerve for brachial plexus injury patients with nerve root avulsions. Pulmonary function was assessed pre-operatively and postoperatively by measuring the forced vital capacity, forced expiratory volume in 1 second, vital capacity, and tidal volume. Motor recovery of biceps was serially recorded. Our results revealed that pulmonary function in the phrenic nerve transfer group was still significantly reduced 1 year after surgery. In the intercostal nerve transfer group, pulmonary function was normal after 3 months. Motor recovery of biceps in the intercostal nerve group was significantly earlier than that in phrenic nerve group. We conclude that pulmonary and biceps functions are better after intercostal nerve transfer than after phrenic nerve transfer in the short term at least.

Digitotalar dysmorphism with craniofacial and other new associated abnormalities.

We report digitotalar dysmorphism in a grandfather, father, and a daughter. All the affected members had clasped thumbs. The father had a short stature, large zygomatic arch and a flat mandibular condyle. The newly recognized findings found in the affected girl were large maxillary deciduous central incisors, a short proximal phalanx of the second finger, and a large subcutaneous hemangioma of the back. Her paternal grandfather had only congenital clasped thumbs. Congenital clasped thumb is a very heterogeneous anomaly and related to many syndromes. The findings in the reported family which are consistent with digitotalar dysmorphism, include congenital clasped thumbs, ulnar deviation of fingers, and a congenital vertical tali.

Primary intraosseous glomus tumor: a case report.

We reported a rare case of a primary intraosseous glomus tumor in a 53-year-old woman who had a small lytic lesion in the distal phalanx of her left index finger. The radiologic appearance showed a well circumscribed osteolytic lesion without sclerotic rim. Histologic examination revealed solid nests or sheets of polygonal cells surrounding branching vasculatures consistent with a glomus tumor. Curettage resulted in complete removal of the tumor as well as pain alleviation. The patient was well without evidence of recurrent disease following an 18 month follow-up. Despite its rarity, intraosseous glomus tumor should be included in the differential diagnosis of bone lesions in which plain radiography showed a well circumscribed punch-out lesion without sclerotic rim especially those arising in the finger.

Are triphalangeal thumb-polysyndactyly syndrome (TPTPS) and tibial hemimelia-polysyndactyly-triphalangeal thumb syndrome (THPTTS) identical? A father with TPTPS and his daughter with THPTTS in a Thai family.

We report on a Thai man who had triphalangeal thumb-polysyndactyly syndrome (TPTPS, MIM *190605) and his daughter who had tibial hemimelia-polysyndactyly-triphalangeal thumb syndrome (THPTTS, MIM *188770). The father had polysyndactyly of triphalangeal thumbs, syndactyly of fingers, duplicated distal phalanx of the left great toe, brachymesophalangy of toes, and the absence of middle phalanges of some toes. He was diagnosed as having TPTPS. His daughter was more severely affected, having complete syndactyly of five-fingered hands in rosebud fashion (Haas-type syndactyly), hypoplastic tibiae, absent patellae, thick and displaced fibulae, preaxial polysyndactyly of triphalangeal toes, and cutaneous syndactyly of some toes, the manifestations being consistent with THPTTS. Having two different syndromes in the same family suggests that they are actually the same disorder. A literature survey showed that there have been several families where THPTTS occurred with TPTPS or Haas-type syndactyly (and/or preaxial polydactyly type 2, PPD2). In addition, all loci for TPTPS, THPTTS, and PPD2 (and/or PPD3) have been assigned to chromosome band 7q36. These findings support our conclusion that TPTPS, PPD2 (and/or PPD3), and Haas-type syndactyly are a single genetic en-tity (THPTTS). We propose to call the condition "tibial hemimelia-polysyndactyly-triphalangeal thumbs syndrome."

Endoscopic carpal tunnel release: an anatomic study of the two-incision method in human cadavers.

To determine the relationship of neurovascular structures to the sites of portal placement and transverse carpal ligament division during two-portal endoscopic carpal tunnel release, a study of 20 fresh cadaver specimens was carried out. Open dissection of the carpal tunnel after endoscopic surgery showed complete ligamentous release in 18 hands (90%). In 10 specimens, the procedure was performed as described by Chow. There was one partial transection of the superficial palmar arch (5%), and five specimens (50%) had complete divisions of the superficial palmar fascia with considerable pressure placed on the ulnar nerve at the wrist. A modified technique was used in 10 specimens in which the proximal incision was made in a more distal location and a distally based ligamentous flap was created. The superficial palmar arch and the distal edge of the transverse carpal ligament were visualized directly before passage of the trocar. No complications were noted with this method.