Inducing Ulnar Nerve Function while Eliminating Claw Hand and Reducing Chronic Neuropathic Pain.

Ulnar nerve injury induces chronic neuropathic pain and is frequently devastating due to loss of cupping the hand around objects (finger clawing) and diminished grip strength. There is little chance of restoring good function, eliminating finger clawing, or reducing the pain. A novel technique was tested for its efficacy in promoting ulnar nerve function and reducing finger clawing and chronic neuropathic pain. A 25-year-old subject presented 5.7 months after a wrist gunshot that created three nerve gaps proximal to the deep ulnar nerve branch. He sought restoration of function due to developing ulnar nerve injury-induced claw hand and increasingly severe chronic neuropathic pain. After resection of the scarred nerve tissue, each gap was 10 cm long. The gaps were bridged with two nonreversed sural nerve grafts within a PRP-filled NeuroMend collagen tube (Collagen Matrix, Oakland, N.J.). Some axons regenerated entirely across all three 10-cm-long repaired nerve gaps, restoring excellent topographically correct sensitivity of S4, including two-point discrimination of 4 mm, good M4 motor function, and full ROM. The ulnar nerve injury-induced finger clawing was eliminated, and the chronic neuropathic pain of 7 was reduced to 0 on a 0-10 validated scale and did not return over the following 3.75 years. Thus, this novel technique induces good sensory and motor function, despite repairing three 10-cm-long nerve gaps while eliminating ulnar nerve injury-induced hand clawing and chronic neuropathic pain. Further studies are required to determine whether the effects were due to PRP.

Prospects for Improving the Extent of Recovery following Peripheral Nerve Trauma: A Review.

Restoring function to damaged peripheral nerves with a gap remains challenging, with <50% of patients who undergo nerve repair surgery recovering function. Further, despite enormous efforts to improve existing techniques and develop new ones, the percentage of patients who recover function and their extent of recovery has not increased in almost 70 years. Thus, although sensory nerve grafts remain the clinical "gold standard" technique for attempting to restore function to nerves with a gap, they have significant limitations. They are effective in restoring good to excellent function only for gaps <3-5 cm, repairs performed <3-5 months post-trauma, and patients <20-25 years old. As the value of any of these variables increases, the extent of recovery decreases precipitously, and if the values of two or all three variables increase, there is little to no recovery. Therefore, novel techniques are required that increase the percentage of patients who recover function and the extent of their recovery. This review discusses the limitations of sensory nerve grafts and other techniques currently being used to repair nerves. It also discusses the use of autologous platelet-rich plasma (PRP), which appears to be the most promising technique for inducing sensory and motor recovery even when the values of all three variables are significantly greater than when sensory nerve grafts alone are not effective. Thus, there is finally the promise that patients who presently have limited to no chance of any recovery may recover good to excellent sensory and motor function.

Functional Recovery following Repair of Long Nerve Gaps in Senior Patient 2.6 Years Posttrauma.

Sensory nerve grafts are the clinical "gold standard" for repairing peripheral nerve gaps. However, reliable good-to-excellent recovery develops only for gaps less than 3-5 cm, repairs performed less than 3-5 months posttrauma, and patients aged less than 20-25 years. As the value of any variable increases, the extent of recovery decreases precipitously, and if the values of any two or all increase, there is little to no recovery. One 9-cm-long and two 11-cm-long nerve gaps in a 56-year-old patient were repaired 2.6 years posttrauma. They were bridged with two sensory nerve grafts within an autologous platelet-rich plasma-filled collagen tube. Both were connected to the proximal ulnar nerve stump, with one graft end to the distal motor and the other to the sensory nerve branches. Although presurgery the patient suffered chronic level 10 excruciating neuropathic pain, it was reduced to 6 within 2 months, and did not increase for more than 2 years. Motor axons regenerated across the 9-cm gap and innervated the appropriate two measured muscles, with limited muscle fiber recruitment. Sensory axons regenerated across both 11-cm gaps and restored normal topographically correct sensitivity to stimuli of all sensory modalities, including static two-point discrimination of 5 mm, and pressure of 2.83 g to all regions innervated by both sensory nerves. This novel technique induced a significant long-term reduction in chronic excruciating neuropathic pain while promoting muscle reinnervation and complete sensory recovery, despite the values of all three variables that reduce or prevent axon regeneration and recovery being simultaneously large.

Practice Variation Among Hispanic American Orthopedic Surgeons in the Management of Geriatric Distal Radius Fracture.

INTRODUCTION: There is a controversy in the management of distal radius fractures (DRF) and its criteria for surgical intervention on geriatric patients. The American Academy of Orthopedic Surgeons (AAOS) developed evidence-based guidelines for treatment of DRF. The aim of this study was to evaluate the current practice of Hispanic orthopedic surgeons in the management of geriatric DRF and examine their adherence to AAOS guidelines based on years of surgical experience. MATERIAL & METHODS: A survey was emailed to all orthopedic surgeons who live in Puerto Rico and treated DRF in their daily practice. Responses concerning demographic, management and clinical scenarios were evaluated. For each clinical scenario, treatment of choice was selected with the same fracture in a geriatric and young adult patient. Comparison between years of surgical experience and adherence to the AAOS guidelines was performed. RESULTS: A total of 65 surgeons responded the survey with 65% having >15 years in practice. A high consensus with AAOS guidelines for DRF was found. Use of preoperative radiographs was reported in all respondents, with an additional 12% routine use of preoperative computed tomography scans. Seventy-seven percent of respondents did not allow any range of motion (ROM) at immediate postoperative period, while 23% allowed active or passive ROM. Use of postoperative therapy was reported in 72.3%. Correlation between years of surgical experience showed a higher use of Vitamin C postoperatively for prophylaxis of Complex Regional Pain Syndrome among surgeons <15 years (P = 0.01). A general consensus trend toward operative fixation was noted among geriatric and young adult patients with the same fracture type in all clinical scenarios. DISCUSSION AND CONCLUSIONS: This survey demonstrates a practice variation toward surgical management of geriatric DRF among Hispanic orthopedic surgeons; despite their compliance with the AAOS AUC guidelines. The geriatric DRF management does not vary significantly among years of surgical experience.

Local Hematoma Block as Postoperative Analgesia in Pediatric Supracondylar Humerus Fractures.

Purpose: Supracondylar humerus fracture (SHF) is the most common type of fracture in children. The aim of this study was to evaluate the efficacy of local hematoma block with 0.25% bupivacaine as postoperative pain control in patients with pediatric SHF who underwent closed reduction pin fixation. Methods: We performed an institutional review board-approved, prospective cohort study of 65 patients with SHF treated with closed reduction percutaneous pin fixation. For 6 months, all patients were randomly divided into 2 groups. The treatment group (35 patients) received an intraoperative local hematoma block using 0.25% bupivacaine whereas the control group (30 patients) did not receive a local hematoma block as postoperative pain management adjuvant. After surgery, all patients were prescribed opioid pain medication. To evaluate the efficacy of the hematoma block, postoperative morphine equivalent consumption and the Faces Pain Scale-Revised (FPS-R) survey were blindly recorded during postoperative day 1. Demographic data, surgical details, clinical neurovascular examination during the hospital stay, and complications were also evaluated. Results: Comparison of the control group with the treatment group showed similar morphine equivalent consumption and Face Pain Scale-Revised Survey results. No hematoma block-associated complications were reported. Conclusions: The result of this study do not favor the use of local hematoma block to improve pain control and decrease the need for opioid use on postoperative day 1 in pediatric SHF after patients undergo closed reduction percutaneous pin fixation. These results can lay the foundation for future studies while suggesting new, novel opioid-free pain control strategies in patients with SHF. Type of study/level of evidence: Therapeutic II.