The Isolated Motor Branch of the Ulnar Nerve Injury During Open Carpal Tunnel Release.

A 76-year-old woman underwent open carpal tunnel release (OCTR). She had sudden sharp shooting pain in her hand, in the mid-palmar area, during the operation. She was then unable to abduct or adduct her thumb and fingers after surgery. She had no sensation impairment of the ulnar digit. The nerve conduction study confirmed a complete transection of the motor branch of the ulnar nerve (MUN). The MUN was repaired, and the patient recovered her intrinsic hand muscle function two years after the operation. The mechanism of injury, related anatomy and potentially dangerous area, clinical findings, management, and prevention are discussed.

Anatomic Study of the Motor Branch of the Ulnar Nerve Regarding Carpal Tunnel Surgery: A Cadaveric Study.

Background: Motor branch of the ulnar nerve (MUN) injury during carpal tunnel surgery is rare and it should never be injured during carpal tunnel release (CTR). However, an iatrogenic injury of the MUN can cause catastrophic physical and mental suffering. The aim of our study is to understand the anatomy of the MUN in relation to carpal tunnel in order to prevent iatrogenic injury during CTR. Methods: We dissected 34 fresh cadaver hands and located the MUN in relation to the anatomical axis used for carpal tunnel surgery. Possible mechanisms of injury and the vulnerable area of the MUN were determined along the dissection. Results: The MUN turned towards the thumb distal to hook of hamate. It then travelled on the floor of the carpal tunnel which was formed by intrinsic hand muscles under flexor tendons. The nerve located at 29.39 ± 7.41, 35.01 ± 3.14 and 38.79 ± 4.03 mm (Mean ± SD) in the central axis of ring finger, the vertical axis of the third web-space and the central axis of middle finger respectively. The nerve's turning point, 10.9 ± 2.63 mm distal to the centre of hook of hamate where it lies just below the level of the transverse carpal ligament. Conclusions: Surgeons should be aware of the nerve's location. Surgical dissection or passing of any surgical instruments around the hook of hamate should be done with care. Level of Evidence: Level IV (Therapeutic).

A Surgical Framework for the Management of Incomplete Axillary Nerve Injuries.

BACKGROUND: Axillary nerve injury is the most common nerve injury affecting shoulder function. Nerve repair, grafting, and/or end-to-end nerve transfers are used to reconstruct complete neurotmetic axillary nerve injuries. While many incomplete axillary nerve injuries self-resolve, axonotmetic injuries are unpredictable, and incomplete recovery occurs. Similarly, recovery may be further inhibited by superimposed compression neuropathy at the quadrangular space. The current framework for managing incomplete axillary injuries typically does not include surgery. METHODS: This study is a retrospective analysis of 23 consecutive patients with incomplete axillary nerve palsy who underwent quadrangular space decompression with additional selective medial triceps to axillary end-to-side nerve transfers in 7 patients between 2015 and 2019. Primary outcome variables included the proportion of patients with shoulder abduction M3 or greater as measured on the Medical Research Council (MRC) scale, and shoulder pain measured on a Visual Analogue Scale (VAS). Secondary outcome variables included pre- and postoperative Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores. RESULTS: A total of 23 patients met the inclusion criteria and underwent nerve surgery a mean 10.7 months after injury. Nineteen (83%) patients achieved MRC grade 3 shoulder abduction or greater after intervention, compared with only 4 (17%) patients preoperatively (p = 0.001). There was a significant decrease in VAS shoulder pain scores of 4.2 ± 2.5 preoperatively to 1.9 ± 2.4 postoperatively (p < 0.001). The DASH scores also decreased significantly from 48.8 ± 19.0 preoperatively to 30.7 ± 20.4 postoperatively (p < 0.001). Total follow-up was 17.3 ± 4.3 months. CONCLUSION: A surgical framework is presented for the appropriate diagnosis and surgical management of incomplete axillary nerve injury. Quadrangular space decompression with or without selective medial triceps to axillary end-to-side nerve transfers is associated with improvement in shoulder abduction strength, pain, and DASH scores in patients with incomplete axillary nerve palsy.

Beyond the Cubital Tunnel: Use of Adjunctive Procedures in the Management of Cubital Tunnel Syndrome.

BACKGROUND: Our management of cubital tunnel syndrome has expanded to involve multiple adjunctive procedures, including supercharged end-to-side anterior interosseous to ulnar nerve transfer, cross-palm nerve grafts from the median to ulnar nerve, and profundus tenodesis. We also perform intraoperative brief electrical stimulation in patients with severe disease. The aims of this study were to evaluate the impact of adjunctive procedures and electrical stimulation on patient outcomes. METHODS: We performed a retrospective review of 136 patients with cubital tunnel syndrome who underwent operative management from 2013 to 2018. A total of 38 patients underwent adjunctive procedure(s), and 33 received electrical stimulation. A historical cohort of patients who underwent cubital tunnel surgery from 2009 to 2011 (n = 87) was used to evaluate the impact of adjunctive procedures. Study outcomes were postoperative improvements in Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores, pinch strength, and patient-reported pain and quality of life. RESULTS: In propensity score-matched samples, patients who underwent adjunctive procedures had an 11.3-point greater improvement in DASH scores than their matched controls (P = .0342). In addition, patients who received electrical stimulation had significantly improved DASH scores relative to baseline (11.7-point improvement, P < .0001), whereas their control group did not. However, when compared between treatment arms, there were no significant differences for any study outcome. CONCLUSIONS: Patients who underwent adjunctive procedures experienced greater improvement in postoperative DASH scores than their matched pairs. Additional studies are needed to evaluate the effects of brief electrical stimulation in compression neuropathy.

Comparison of the effect of ketorolac versus triamcinolone acetonide injections for the treatment of de Quervain's tenosynovitis: a double-blind randomized controlled trial.

BACKGROUND: De Quervain's disease is tenosynovitis of the first dorsal compartment causing severely painful radial-side wrist pain and impaired function. Steroids are effective in treating this condition due to their anti-inflammatory properties. However, this drug causes problems such as hypopigmentation, and is contradicted in diabetes mellitus patients. Non-steroidal anti-inflammatory drug (NSAID) which are efficacious in shoulder pathology and not contraindicated in diabetics and can be used to avoid the local effects of steroids could be beneficial for some patients. The present study was a randomized controlled trial to examine the differences in pain scores and functional response to local injections of a corticosteroid and the NSAID ketorolac. METHODS: Sixty-four patients with radial styloid tenosynovitis were randomized using a computer-generated random number table into two groups receiving either a ketorolac injection or a triamcinolone injection. We evaluated post-injection pain intensity using a verbal numerical rating scale (VNRS), functional outcomes using the Thai Disabilities of the Arm, Shoulder and Hand (DASH) scale, and evaluated grip and pinch strengths, recorded at baseline and 6 weeks after the injection. RESULTS: Thirty-one participants in the ketorolac group and 29 participants in the triamcinolone group completed the study and were included in the analysis. There were no significant differences in the assessments at baseline. At the 6-week conclusion of the study, patients in the triamcinolone group had a statistically lower average pain score than in the ketorolac group (0.7 ± 2.0 vs 5.3 ± 3.2, P < 0.001), higher DASH functional score (4.4 ± 6.5 vs 34.1 ± 20.2, P < 0.001), higher right grip strength (60.8 ± 16.8 vs 49.2 ± 18.6, P < 0.015), and higher left grip strength (59.8 ± 18.1 vs 50.3 ± 18.0, P < 0.04). However, there was no difference in pinch strength. CONCLUSIONS: Our study found that ketorolac injections resulted in inferior pain reduction, functional score and grip improvement than triamcinolone injection in patients with radial styloid tenosynovitis. Future studies are required to examine the effects of ketorolac in larger group and with longer follow-up periods to further elucidate the findings of this study. TRIAL REGISTRATION: The study was registered at Clinicaltrials.in.th (TCTR20200909006).

Multiple carpometacarpal joint fracture-dislocation from the second to fifth: A case report.

Introduction: and importance: Herein we present a rare case of multiple second to fifth carpometacarpal joint fracture-dislocations. It is important in such cases to be aware of a high-velocity impact etiology of the fractures, which will ensure proper imaging, diagnosis and treatment. Case presentation: A 34-year-old male presented with severe pain in his left hand following a motorcycle accident. He was diagnosed as multiple second to fifth carpometacarpal joint fracture-dislocations. He was successfully treated with closed reduction with multiple Kirshner wires fixation under general anesthesia. A one-year follow up confirmed excellent clinical results. Clinical discussion: There are various surgical options including casting, closed reduction and percutaneous pinning (CRPP), and open reduction internal fixation, however, the optimal treatment is still controversial. The closed reduction is recommended in all CMC joint dislocations. Adding a K-wire fixation can create a secure fixation and achieve an excellent outcome. Conclusion: Multiple carpometacarpal joint fracture-dislocations is a very rare injury. Careful clinical examination is important for an accurate diagnosis and plain radiographic studies are necessary. Standard fracture dislocation treatment can be used. Simple closed reduction with the K-wires fixation technique is easy to perform and in our case achieved successful treatment in terms of clinical and radiographic outcomes.

Using a point reduction clamp with a rubber stopper from a sterile bottle for reduction of a distal radius fracture.

INTRODUCTION: There are many choices of surgical treatment for a distal radius fracture. The goal of treatment in these injuries is stable anatomical reduction of the articular surface. In a coronal split fracture, the dorsal fragment tends to dorsal displacement during drilling or when applying the distal locking screws of the plate. CASE PRESENTATION: We present an illustrative case from a larger series of a 65-year-old Thai woman with an intraarticular distal radius fracture with a dorsal fragment from a coronal-split configuration reduced and stabilized with a volar locking plate utilizing a large point reduction clamp held in place with a rubber stopper from a sterile glass bottle to counter the displacement effect of the drilling. DISCUSSION: Using a large point reduction clamp with a rubber stopper from a sterile glass bottle enables this type of difficult fracture to be both reduced and stabilized with the locking screw easily inserted to stabilize the dorsal fragment without any further displacement. The rubber stopper acts to distribute the compressive force from the large point reduction clamp over a larger area allowing a more stable fracture stabilization, while at the same time reducing skin and soft tissue trauma at the dorsal aspect of the wrist. CONCLUSION: This workaround allows improved stability in reduction and stabilization of a coronal split intraarticular distal radius fracture. The advantage of this workaround is that it uses small things readily available in every operating room setting, and it does not require any special experience or skills.