Reconstructing Pinch Strength after Ulnar Nerve Injury by Transferring the Opponens Pollicis Motor Branch.

BACKGROUND: With ulnar nerve injuries, paralysis of the first dorsal interosseous(FDI) and adductor pollicis muscle weakens the patient's pinch. In the palm, we transferred the opponens pollicis motor branch (Opp) to the deep terminal division of the ulnar nerve (DTDUN) for pinch reconstruction. METHODS: Sixteen patients with ulnar nerve injuries around the elbow underwent reconstruction and were followed post-operatively for a minimum of 14 months. Their mean age was 41 years (SD ± 15), and the mean interval between injury and surgery was 134 days (SD ±126, range: 2-390). Pre- and postoperatively grasp, key and subterminal key-pinch strength were measured using dynamometers. RESULTS: Reinnervation of the FDI was observed in 15 of the 16 patients. Mean grasp strength improved from 15.5kg (SD ± 8.5kg) pre-operatively to 24kg (SD ± 10kg) postoperatively, achieving 57% (SD ± 16%) contralateral hand strength. Preoperatively, terminal key pinch averaged 3kg (±1kg), which improved postoperatively to 5.5kg (SD ± 2kg), achieving 71% (±24%) the strength measured contralaterally. Pre- to post-operatively, subterminal key-pinch force increased from zero to 2.4kg (SD ± 1.3kg) achieving 61% (SD ± 27%) that of the unaffected side. Patients who underwent surgery within six months of their injury showed a mean subterminal key pinch strength recovery of 63% (SD ± 27) of the normal side, while those who underwent surgery between seven and 13 months after injury showed a mean subterminal key pinch strength recovery of 51% (SD ± 29). CONCLUSIONS: Transferring the Opp to the DTDUN improved pinch and grasp strength without jeopardizing thumb function.

Spinal Cord Injury: Epidemiology, Spontaneous Recovery, and Hand Therapy for the Reconstructive Hand Surgeon.

People with spinal cord injury (SCI) prioritize hand function above all else as a reconstructive goal, yet remain a markedly undertreated population by hand surgeons. This review article provides an overview of the epidemiology of SCI and the unmet clinical need of these patients. Further, this article outlines the natural history of SCI, including the expected spontaneous recovery over time and the expectations of hand function when treated with hand therapy alone. This review aims to equip reconstructive hand surgeons with a sound understanding of the basic principles of SCI and recovery and provide a rationale for when to intervene with surgery. In the last decade, this field has changed dramatically with the advent of reliable nerve transfers, making referral and surgical intervention time-sensitive. Therefore this review aims to highlight the expectations from hand therapy alone in this group, the urgent need for early referral to allow nerve transfer options to be viable, and the strategies for overcoming the barriers to these referrals. This offers the opportunity for surgeons to expand their tetraplegia practices while maximizing the considerable contributions to the hand function and quality of life of these patients.

A cut throat: a case of C5-C8 brachial plexus root transection providing evidence of T1 innervation of thumb and finger extensors.

The T1 nerve root is not routinely thought of as innervating the extensors of the thumb and fingers. Work by Bertelli and Ghizoni proposed that the pattern of brachial plexus paralysis with intact hand function and thumb and finger extensors traditionally attributed to C5/6/7 root injury is in fact a C5/6/7/8 injury, with only T1 remaining intact - a 'T1 hand'. This case presents a 19-year-old male who was stabbed in the neck; exploratory surgery determined complete transection of the brachial plexus, with only the T1 nerve root remaining intact. Clinical examination demonstrated grade M4 pronation (with pronator quadratus), wrist extension (with extensor carpi ulnaris), thumb and finger extension (with extensor policis longus and brevis, extensor digitorum communis and extensor index proprius), wrist flexion (with palmaris longus), finger flexion (with flexor digitorum superficialis and profundus), thumb flexion (with flexor policis longus), and thenar and hypothenar muscles. Extensor carpi radialis longus and brevis, flexor carpi radialis and flexor carpi ulnaris were paralyzed. Triceps scored M2. This case provides unequivocal evidence that the T1 root provides significant innervation to the extrinsic thumb and finger extensors.

Selective transfer of nerve to supinator to restore digital extension in central cord syndrome: An anatomical study and a case report.

BACKGROUND: Nerve transfers are increasingly used to restore upper extremity function in patients with spinal cord injury. However, the role of nerve transfers for central cord syndrome is still being established. The purpose of this study is to report the anatomical feasibility and clinical use of nerve transfer of supinator motor branches (NS) to restore finger extension in a central cord syndrome patient. MATERIALS AND METHODS: The posterior interosseous nerve (PIN), its superficial division, and branches were dissected in 14 fresh cadavers, with a mean age of 65 (58-79). Measurements included number and length of branches of donor and recipient, diameters, regeneration distance from coaptation site to motor entry point and axonal counts. A NS transfer to extensor carpi ulnaris (ECU), extensor digiti quinti (EDQ) and extensor digitorum communis (EDC) was performed in a 28-year-old patient, with central cord syndrome after a motorcycle accident, who did not recover active finger extension at 10 months post injury. RESULTS: The PIN consistently divided into a deep and superficial branch between 1.5 cm proximal to, and 2 cm distal to the distal boundary of the supinator. The superficial branch provided a first common branch to the ECU and EDQ. In 12/14 dissections, the EDC was innervated by a 4 cm long branch that entered the muscle on its radial deep surface. In all cases, the superficial branch of the PIN could be separated in a retrograde fashion from the PIN and coapted with NS. The mean myelinated fiber count in nerve to EDC was 401 ± 190 compared to 398 ± 75 in the NS. At 48 months after surgery, with the wrist at neutral, the patient recovered full metacarpophalangeal extension scoring M4. Supination was preserved with the elbow extended or flexed. CONCLUSIONS: Restoration of finger extension in central cord syndrome is possible with a selective transfer of the NS to EDC, and is anatomically feasible with a short regeneration distance and favorable axonal count ratio.

Two clinical tests assessing long thoracic nerve function to determine C5 and C6 root graft eligibility in patients with brachial plexus injury.

OBJECTIVE: Identifying roots available for grafting is of paramount importance prior to reconstructing complex injuries involving the brachial plexus. This is traditionally achieved by combining input from both clinical examinations and imaging studies. In this paper, the authors describe and evaluate two new clinical tests to study long thoracic nerve function and, consequently, to predict the status of the C5 and C6 roots after global brachial plexus injuries. METHODS: From March 2020 to December 2020, in 41 patients undergoing brachial plexus repair, preoperative clinical assessments were performed using modified C5 and C6 protraction tests, C5 and C6 Tinel's signs, and MRI findings to predict whether graft-eligible C5 and C6 roots would be identified intraoperatively. Findings from these three assessments were then combined in a logistic regression model to predict graft eligibility, with overall predictive accuracies calculated as areas under receiver operating characteristic curves. RESULTS: In the 41 patients, the pretest probability of C5 root availability for grafting was 85% but increased to 92% with a positive C5 protraction test and to 100% when that finding was combined with a positive C5 Tinel's sign and favorable MRI findings. The pretest probability of C6 root availability was 40%, which increased to 84% after a positive C6 protraction test and to 93% when the protraction test result concurred with Tinel's test and MRI findings. CONCLUSIONS: Combining observations of the protraction tests with Tinel's sign and MRI findings accurately predicts C5 and C6 root graft eligibility.

Studying nerve transfers: Searching for a consensus in nerve axons count.

Axonal count is the base for efficient nerve transfer; despite its capital importance, few studies have been published on human material, most research approaches being performed on experimental animal models of nerve injury. Thus, standard analysis methods are still lacking. Quantitative data obtained have to be reproducible and comparable with published data by other research groups. To share results with the scientific community, the standardization of quantitative analysis is a fundamental step. For this purpose, the experiences of the Italian, Austrian, German, Greek, and Iberian-Latin American groups have been compared with each other and with the existing literature to reach a consensus in the fiber count and draw up a protocol that can make future studies from different centers comparable. The search for a standardization of the methodology was aimed to reduce all the factors that are associated with an increase in the variability of the results. All the preferential methods to be used have been suggested. On the other hand, alternative methods and different methods have been identified to achieve the same goal, which in our experience are completely comparable; therefore, they can be used indifferently by the different centers according to their experience and availability.

Effectiveness of Distal Nerve Transfers for Claw Correction With Proximal Ulnar Nerve Lesions.

PURPOSE: To evaluate claw deformity correction following anterior interosseous nerve (AIN) end-to-end transfer to the deep motor branch of the ulnar nerve (DMBUN) in high ulnar nerve injuries. METHODS: Eleven patients were retrospectively evaluated for metacarpophalangeal joint hyperextension and proximal interphalangeal joint extension lag in the fourth and fifth digits following ulnar nerve injury adjacent or proximal to the elbow, who underwent AIN end-to-end transfer to the DMBUN. RESULTS: Patients underwent surgery an average of 5 months following injury (range, 2-9 months) and were followed for an average of 19 months after surgery (range, 12-30 months). At the last follow-up, clawing was observed in all patients, with proximal interphalangeal joint extension lag averaging 46.8° (SD, ±20°) in the fourth digit and 57.7° (SD, ±12°) in the little finger. CONCLUSIONS: None of our patients experienced claw correction after AIN end-to-end transfer to the DMBUN. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Subterminal key pinch dynamometry: a new method to quantify strength deficit in ulnar nerve paralysis.

Precise pre- and postoperative assessments are fundamental to recording the quality of recovery after ulnar nerve repair. Because of its imprecision, manual muscle testing is being replaced by dynamometry to measure grasping and key-pinch strengths. However, both grasping and key pinch are dependent not only on the ulnar nerve but also the median and radial nerves. We propose to measure strength using a new sort of pinch, called the 'subterminal key pinch'. Strength was measured using a commercially available pinch meter. Patients applied pressure on the dynamometer with the interphalangeal joint of the thumb, maintaining the joint in extension to avoid enhancement of strength by the flexor pollicis longus. We examined 17 patients before ulnar nerve repair. Preoperatively, grasping strength was 46% of normal, while key pinch was 58%, pinch-to-zoom strength was 26% and subterminal key pinch only 7%. Subterminal key pinch was the most affected pinch with a strength deficit of over 90%.Level of evidence: IV.

Transfer of the Distal Anterior Interosseous Nerve for Thumb Motion Reconstruction in Radial Nerve Paralysis.

PURPOSE: With nerve or tendon surgery, the results of thumb reconstruction to treat radial nerve paralysis are suboptimal. The goals of this study were to describe the anatomy of the deep branch of the posterior interosseous nerve (PIN) to the thumb extensor muscles (DBPIN), and to report the clinical results of transferring the distal anterior interosseous nerve (DAIN) to the DBPIN. METHODS: The PIN was dissected in 12 fresh upper limbs. Myelinated nerve fibers in the DBPIN and DAIN were counted. Five patients with radial nerve paralysis underwent transfer of the motor branch to the flexor carpi radialis to the PIN and a motor branch of the pronator teres to the extensor carpi radialis brevis. In addition, these patients had selective reconstruction of thumb motion by transferring the DAIN to the DBPIN, through either a combined volar and dorsal approach (n = 2) or a single dorsal approach (n = 3) with division of the interosseous membrane. RESULTS: At the origin of the abductor pollicis longus, the DBPIN divided into a lateral branch that innervated the abductor pollicis longus and extensor pollicis brevis, and a medial branch that innervated the extensor pollicis longus and extensor index proprius. The number of myelinated nerve fibers in the DAIN corresponded to 65% of that of the DBPIN. In each of the 5 patients, full thumb motion at the trapeziometacarpal joint was restored with no, or minimal, extension lag at the metacarpophalangeal (MCP) joint. CONCLUSIONS: The anatomy of the DBPIN is predictable. Transferring the DAIN to the DBPIN is feasible through a single dorsal approach, allowing full recovery of thumb motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Nerve Versus Tendon Transfer for Radial Nerve Paralysis Reconstruction.

PURPOSE: With radial nerve lesions, the results of nerve transfers and how they objectively compare with the outcomes of tendon transfers remain unstudied. We compared the results after nerve transfer in patients with less than 12 months since radial nerve injury with the results after tendon transfer in patients not eligible for nerve surgery because of longstanding paralysis (minimum of 15 months). METHODS: In 14 patients with radial nerve lesions incurred less than 12 months previously, we transferred the anterior interosseous nerve to the nerve of the extensor carpi radialis brevis (ECRB), while the nerve to the flexor carpi radialis was transferred to the posterior interosseous nerve. In 13 patients with lesions of longer duration, we transferred the pronator teres tendon to the ECRB, the flexor carpi ulnaris tendon to the extensor digitorum communis, and the palmaris longus to the rerouted extensor pollicis longus (EPL) tendon. At a final evaluation, we measured passive and active range of motion (ROM) of the wrist, finger, and thumb and grasp strength. RESULTS: In a comparison of wrist flexion-extension ROM and grasp strength, we observed better recovery in the nerve transfer than in the tendon transfer group. In the tendon transfer group, we observed limitations in wrist flexion in 9 of the 13 patients and permanent radial deviation in 5. Half of the patients in the tendon transfer group needed to flex their wrist to fully extend their fingers, whereas finger extension was possible with the wrist either extended or at neutral in all patients following nerve transfer. After nerve transfer, extension at the first carpometacarpal joint was restored in 11 of the 14 patients, whereas this occurred in just 4 of the 13 patients following tendon transfer. In both groups, we observed a 30° lag in thumb metacarpophalangeal extension, which reflects poor recovery of EPL function. CONCLUSIONS: Overall, we observed better outcomes in those who underwent nerve transfer versus tendon transfer procedures. However, room still remains for improved thumb motion with both procedures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Distal pronator teres motor branch transfer for wrist extension restoration in radial nerve paralysis.

OBJECTIVE: The authors describe the anatomy of the motor branches of the pronator teres (PT) as it relates to transferring the nerve of the extensor carpi radialis brevis (ECRB) to restore wrist extension in patients with radial nerve paralysis. They describe their anatomical cadaveric findings and report the results of their nerve transfer technique in several patients followed for at least 24 months postoperatively. METHODS: The authors dissected both upper limbs of 16 fresh cadavers. In 6 patients undergoing nerve surgery on the elbow, they dissected the branches of the median nerve and confirmed their identity by electrical stimulation. Of these 6 patients, 5 had had a radial nerve injury lasting 7-12 months, underwent transfer of the distal PT motor branch to the ECRB, and were followed for at least 24 months. RESULTS: The PT was innervated by two branches: a proximal branch, arising at a distance between 0 and 40 mm distal to the medial epicondyle, responsible for PT superficial head innervation, and a distal motor branch, emerging from the anterior side of the median nerve at a distance between 25 and 60 mm distal to the medial epicondyle. The distal motor branch of the PT traveled approximately 30 mm along the anterior side of the median nerve; just before the median nerve passed between the PT heads, it bifurcated to innervate the deep head and distal part of the superficial head of the PT. In 30% of the cadaver limbs, the proximal and distal PT branches converged into a single trunk distal to the medial epicondyle, while they converged into a single branch proximal to it in 70% of the limbs. The proximal and distal motor branches of the PT and the nerve to the ECRB had an average of 646, 599, and 457 myelinated fibers, respectively.All patients recovered full range of wrist flexion-extension, grade M4 strength on the British Medical Research Council scale. Grasp strength recovery achieved almost 50% of the strength of the contralateral side. All patients could maintain their wrist in extension while performing grasp measurements. CONCLUSIONS: The distal PT motor branch is suitable for reinnervation of the ECRB in radial nerve paralysis, for as long as 7-12 months postinjury.

Prior to Repair Functional Deficits in Above- and Below-Elbow Ulnar Nerve Injury.

PURPOSE: Clinical deficits might vary, depending on whether an ulnar nerve lesion is above or below the elbow. Lack of strength and clawing are common manifestations of ulnar nerve paralysis. However, the magnitude of strength deficit relating to different pinch patterns and the rate and range of proximal interphalangeal extension deficits are poorly described. METHODS: I prospectively evaluated 14 patients with above-elbow and 16 with below-elbow unrepaired ulnar nerve injuries. The completeness of flexion of the ring and little fingers was tested at the metacarpophalangeal and distal interphalangeal joints. Proximal interphalangeal joint extension lag of the ring and little fingers was assessed by goniometry, and adduction and abduction of the little finger. With dynamometers, I bilaterally evaluated grasp, key pinch, and pinch-to-zoom strength. Hand sensibility was evaluated with monofilaments. RESULTS: Metacarpophalangeal flexion in the ulnar fingers was absent in all patients, whereas distal interphalangeal joint flexion was preserved in 29 of 30 patients. In above-elbow ulnar nerve injuries, there was no paralysis of the flexor digitorum profundus. One-third of patients exhibited no clawing. There were minimal differences between the rate of clawing and proximal interphalangeal extension lag in above- and below-elbow ulnar nerve lesions, or its occurrence in the ring or little finger. In relation to the normal hand, grasping, key pinch, and pinch-to-zoom decreased by 62%, 51%, and 75% compared with 59%, 61%, and 76% in below- and above-elbow injuries groups, respectively. In both groups, sensory deficits were predominantly over the little finger and ulnar side of the hand. CONCLUSIONS: Minimal differences were observed in clinical deficits after above- and below-elbow ulnar nerve injuries. Hand weakness was the most frequent problem, whereas pinch-to-zoom strength was highly affected. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Lower Trapezius Muscle Transfer for Elbow Extension Reconstruction After Failed Nerve Transfer for Tetraplegia.

Reconstruction of elbow extension is a first priority in the surgical management of patients with tetraplegia. Traditionally, posterior deltoid and biceps to triceps muscle transfers were used, but in recent years, nerve transfers have become the preferred choice of a few surgeons. However, nerve transfer reconstruction failures exist, often related to poor donor nerves, prolonged intervals between the injury and surgery, and advanced patient age. As a valid surgical alternative in such cases, we propose transferring the lower trapezius muscle to reconstruct elbow extension, because this procedure is already being performed successfully in patients with brachial plexus injury. We report 2 patients in whom a lower trapezius transfer was employed as a successful salvage procedure after failed nerve transfer surgery.

Vascularized thumb metacarpal periosteal pedicled flap for scaphoid nonunion: An anatomical study and pediatric case report.

PURPOSE: Through an anatomical review, the primary aim of this study was to delineate the dorsal thumb metacarpal (TM) periosteal branches of the radial artery (RA). In addition, we report here the clinical utility of a vascularized TM periosteal pedicled flap (VTMPF), supplied by the first dorsal metacarpal artery (FDMA), in a complex case of scaphoid nonunion. METHODS: Ten latex-colored upper limbs from fresh human cadavers were used. Branches of the RA were dissected under 3x loupe magnification, noting the periosteal branches arising from the FDMA. The VTMPF was measured for both length (cm) and width (cm). RESULTS: The FDMA provided a mean 12 periosteal branches (range 9 to 15), with a mean distance between branches of 0.5 cm (range 0.2-1.1), allowing for the design of a VTMPF which measured a mean 4 cm in length and 1.2 cm in width. We used a VTMPF to treat recalcitrant scaphoid nonunion, with a volar defect of 0.7 cm, in a 16-year-old boy. No bone graft was used. The patient experienced no postoperative complications. Successful consolidation was achieved three months after surgery, confirming the flap's survival. At 14-months of postoperative follow-up, the patient's VAS pain rating was 0 out of 100, and his DASH questionnaire score was 5. The patient had painless range that was 95% that of the contralateral limb. The patient's pinch and grip strengths were 6.5 kg and 28 kg, respectively (95% of unaffected side). CONCLUSIONS: VTMPF may be considered a valuable and reliable surgical option for scaphoid nonunion in complex clinical scenarios.

Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus.

PURPOSE: To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis. METHODS: Twenty-four male patients were reoperated upon an average of 45 months (SD, ± 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle belly was sutured to the biceps distal tendon. Vascular repair was performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus. RESULTS: Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110° (95% confidence interval [95% CI], 100°-120°) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94° (95% CI, 86°-102°). There was, on average, a 10° (95% CI, 4.4°-15.6°). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in 12. CONCLUSIONS: In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Vascularized Thumb Metacarpal Periosteal Flap for Scaphoid Nonunion in Adolescents: A Prospective Cohort Study of 12 Patients.

PURPOSE: To evaluate clinical and radiological outcomes after surgical treatment of scaphoid nonunion in adolescents with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). METHODS: Twelve patients younger than 18 years with scaphoid nonunion, who underwent a VTMPF procedure without bone grafting, were included for this prospective cohort study, at a mean follow-up of 10.2 months. Patients were operated on by 3 different hand surgeons at 3 hand surgery institutions. All patients received a VTMPF, but with different scaphoid internal fixation modalities, in 10 cases using 1 or 2 retrograde 2-mm headless compression screws and in 2 cases without internal fixation. RESULTS: In 11 boys and 1 girl, the mean age was 15.6 years. There were 1 type D1 nonunions (Herbert classification), 6 type D2, 2 type D3, and 2 type D4. Six patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The mean anterior bone defect was 3.5 mm in length. The patients experienced no postoperative complications. Successful consolidation was achieved in all cases, with 79% cross-sectional trabecular bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS) results. Overall, 34% and 40% gains in strength and wrist motion, relative to the contralateral normal side, were observed. CONCLUSIONS: In this study, the use of VTMPF for scaphoid nonunion in children and adolescents is associated with generally good outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Transferring the Motor Branch of the Opponens Pollicis to the Terminal Division of the Deep Branch of the Ulnar Nerve for Pinch Reconstruction.

PURPOSE: With ulnar nerve injuries, paralysis of the first dorsal interosseous (FDI) and the adductor pollicis (ADP) muscles weakens pinch. The likelihood that these muscles will be reinnervated following ulnar nerve repair around the elbow is very low. To overcome this obstacle, we propose a more distal repair: transferring the opponens pollicis motor branch (OPB) to the terminal division of the deep branch of the ulnar nerve (TDDBUN). METHODS: We dissected 10 embalmed hands to study the anatomy of the thenar branches of the median nerve and TDDBUN. We also operated on 3 patients with recent ulnar nerve injuries around the elbow, suturing the ulnar nerve and transferring the OPB to the TDDBUN. Before and after surgery, we measured grasp, key pinch, and pinch-to-zoom strength using dynamometers. Pinch-to-zoom gesture consists of moving the index finger and thumb pulp toward each other for zooming out of an image on screen. Patients were followed for at least 15 months. RESULTS: The thenar branch of the median nerve innervated the abductor pollicis brevis and opponens pollicis in all specimens, but only half the superficial head of the flexor pollicis brevis. The TDDBUN gave off a single motor branch to the transverse head of the ADP, 1 or 2 branches to the oblique head, and a final branch to the FDI. The ratio of myelinated fibers between the OPB and the TDDBUN was 3:5. Relative to the normal side, pinch-to-zoom strength was mostly affected by the ulnar nerve lesion, with strength decreased by 80% to 90%. After surgery, we observed reinnervation of the FDI and an 80% to 90% improvement in pinch-to-zoom strength. CONCLUSIONS: Transferring the OPB to the TDDBUN provided reinnervation of the FDI and ADP, thereby contributing to pinch strength improvement. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Lunate Grafting Into the Radius for Lunate Fossa Reconstruction in Madelung Deformity.

A 40-year-old woman presented with Madelung deformity and severe arthritic changes at both the radiocarpal and the distal radioulnar joints. She was treated by using her lunate as an osteochondral graft into the radius allowing reconstruction of the lunate fossa. The scaphoid and triquetrum were removed concomitantly and a Sauve-Kapandji procedure was performed. Complete bone healing was achieved. Ten years later, an excellent functional result was maintained, with a pain-free wrist, an acceptable wrist joint range of motion, as well as a favorable aesthetic appearance. This procedure may be indicated for patients with severe Madelung deformity with painful radiocarpal and distal radioulnar joints associated with severe arthritis changes.

Transfer of the Motor Branch of the Abductor Digiti Quinti for Thenar Muscle Reinnervation in High Median Nerve Injuries.

PURPOSE: In high median nerve repairs, thenar muscle reinnervation is impossible because of the long distances over which axons must regenerate. To overcome this obstacle, we propose transferring the abductor digiti quinti motor branch (ADQMB) to the thenar branch of the median nerve (TBMN). METHODS: We used 10 embalmed hands for anatomical and histological studies. Thereafter, 5 patients with a high median nerve injury underwent surgical reconstruction within 8 months of their accident and were followed for at least 10 months after surgery (mean, 13.2 months). We transferred the ADQMB to the TBMN. The median nerve was grafted in 4 patients and the motor branch of the extensor carpi radialis brevis was transferred to the anterior interosseous nerve in 3. Patients had pre- and postoperative evaluations of thumb range of motion and strength. RESULTS: In cadaveric hands, the ADQMB was the first branch of the ulnar nerve to arise near the pisiform bone. The TBMN arose from the anterior surface of the median nerve, underneath the flexor retinaculum. Retrograde dissection of the TBMN allowed tension-free coaptation with the ADQMB. Both branches contained approximately 650 myelinated fibers. After surgery, all our patients improved thumb pronation, thenar eminence bulk, and abductor pollicis brevis British Medical Research Council score. They recovered approximately 75% of their normal-side grasp and pinch strength. No patient lost little finger abduction. CONCLUSIONS: Transfer of the ADQMB to the TBMN reinnervated the thenar muscles, which improved thumb range of motion and strength. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Sensory deficits after a radial nerve injury.

BACKGROUND: The aim of our study was to objectively test sensibility on the dorsal side of the hand in patients with radial nerve injury, to document deficits and to detect if surgery for sensory reconstruction is needed. METHODS: Nineteen patients of mean age 31 ± 10 years were examined at a mean of 26.4 ± 27.8 months post radial nerve injury. Sensory mechanical thresholds on the dorsal surface of the hand were evaluated using Semmes-Weinstein monofilaments. Sensation was considered significantly impaired when there was no perception of a 2.0 gr. Semmes-Weinstein filament. Nociception was evaluated using Adson forceps. RESULTS: Five patients had normal 2.0 monofilament perception. Two of these five also had normal perception of the lighter 0.05 monofilament. In nine patients, zones of impaired sensibility were restricted to the first web space. In combined radial and musculocutaneous nerve lesions, the zone of impaired sensibility extended to the dorsum of the third metacarpus and occasionally to the dorsal aspect of the thumb. This zone averaged being five times the size as in isolated radial nerve injuries. On average, the zone of decreased 0.05 monofilament perception was six times the size detected for the 2.0 monofilament. No patient had complete anesthesia over the dorsum of the hand. No patient complained about pain or numbness. Only one patient among four with a combined radial and musculocutaneous nerve injury required sensory reconstruction. CONCLUSIONS: Minimal sensory abnormalities should be expected after a radial nerve injury. Patients likely neither warrant nor request sensory reconstruction.