Typical brachial neuritis (Parsonage-Turner syndrome) with hourglass-like constrictions in the affected nerves.

PURPOSE: To report on 5 patients who had acute brachial neuritis (Parsonage-Turner syndrome) with hourglass-like constriction in the affected nerves. METHODS: We retrospectively reviewed 5 patients who were treated in our department from December 2003 to December 2008. Acute, intense pain around the shoulder girdle and upper arm was the first symptom and was followed by muscle weakness and atrophy. Clinical and EMG examinations showed involvement of 2 or more nerves in the affected extremity. Those severely affected nerves that had no response to conservative treatment were explored, and an hourglass-like constriction was identified. Neurolysis was performed at the sites of constrictions in 2 radial nerves and 1 median nerve. The constricted portion was resected, and direct coaptation was performed in 1 radial nerve and 1 musculocutaneous nerve. The constricted portion was resected, and nerve graft was performed in 2 radial nerves and 1 median nerve. RESULTS: All patients were followed up for 24 to 84 months after surgery. Of 3 nerves treated with external neurolysis, all attained full recovery. Of 2 nerves treated with resection and neurorrhaphy, 1 attained full recovery, and the other had an incomplete recovery. Of 3 nerves treated with resection and nerve graft, 1 (4-cm nerve graft) attained full recovery, and 2 (4-cm and 13-cm nerve graft, respectively) had incomplete recovery. CONCLUSIONS: The site of nerve lesion of brachial neuritis was not necessarily within the brachial plexus. Our finding of hourglass-like constrictions in individual peripheral nerves suggest that multifocal involvement of terminal branch lesions may underlie the complex patterns of paralysis often encountered clinically. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Donor foot morbidity following modified wraparound flap for thumb reconstruction: a follow-up of 69 cases.

PURPOSE: To evaluate donor foot morbidity after thumb reconstruction using a modified wraparound flap. METHODS: We observed patients who accepted thumb reconstruction with the modified wraparound flap between January 2001 and December 2009. We examined and evaluated the reconstructed thumb and donor foot. Donor morbidity was assessed on both a subjective and an objective basis using the Foot Function Index-verbal rating scales (FFI-5pt), the American Orthopaedic Foot and Ankle Society for Hallux Metatarsophalangeal-Interphalangeal (MTP-IP) scale, and gait analysis and dynamic pedodynographic measurements. RESULTS: We reviewed 69 patients; the follow-up period ranged from 6 months to 5 years, with an average of 26 months. The reconstructed thumbs had good aesthetic appearance, and static 2-point discrimination averaged 9.4 ± 2.7 mm. Full length or most of the length of the donor toes was preserved in 67 patients. The retained plantar strip was significantly enlarged from an average of 14.5 ± 1.4 mm measured at surgery to 27.8 ± 4.7 mm measured at last follow-up (p < .05), and its 2-point discrimination was 9.1 ± 2.3 mm. A total of 34 patients were available for FFI-5pt and Hallux MTP-IP scale evaluation. The FFI-5pt total score was 3.1 ± 2.7 and the total Hallux MTP-IP score was 87.9 ± 7.1. Gait analysis and dynamic pedodynographic measurements were available in 20 patients. All 5 biomechanical parameters (timing, trajectory, symmetry, average peak force, and peak pressure between donor foot and the contralateral foot) had no significant difference. CONCLUSIONS: The function of the donor foot after a modified wraparound flap for thumb reconstruction was well preserved, the degree of pain and disability in the donor foot was mild, and foot function in gait was not disturbed. Although a certain degree of restriction in interphalangeal joint motion occurred, this was nearly negligible and did not deter return to normal daily living activity, work, and recreation.

[Biomechanical research of antegrade intramedullary fixation for the metacarpal fractures].

OBJECTIVE: To study the biomechanical characteristics of antegrade intramedullary fixation for metacarpal fractures. METHODS: From March to May 2008, both the 4th and 5th metacarpals from 25 formalin embalmed cadaver hands had three-point bending test after transverse osteotomy followed by randomly fixation with one of the following three methods: plate and screw, antegrade intramedullary K-wire, crossed K-wire. While, both the 2nd and 3rd metacarpals had torsional loading test after the same management as the 4th and 5th metacarpal had undergone. RESULTS: In the three-point bending test, both the maximum bending moment (M(max)) and bending rigidity (EI) of the antegrade intramedullary K-wire were comparable with those of the plate and screw, and were significantly larger than those of the crossed K-wire. In the torsional loading test, the antegrade intramedullary K-wire had a statistically smaller maximum torque (T(max)) than the plate and screw, and had a comparable T(max) with the crossed K-wire; while, the torsional rigidity (GJ) of the intramedullary K-wire was statistically weaker than that of both the plate and screw and the crossed wire. CONCLUSIONS: One single antegrade intramedullary K-wire can provide a satisfactory M(max) and EI for metacarpal fixation and shows relatively weak in the torsional loading test. The injured finger should be well protected to avoid torsional deformity in clinical practice.

[A method of measuring the displacement of the distal radioulnar joint on the three-dimensional CT imaging].

OBJECTIVES: To establish a clinical method for measuring the displacement of the distal radioulnar joint (DRUJ) precisely irrespective of ulnar variance, and to derive normal population translation references with palmar and dorsal stress. METHODS: Thirty-seven normal distal forearms were scanned with computed tomography using an apparatus designed by Pirela-Cruz. Each extremity was scanned in two positions: maximal ulnar palmar and dorsal stress. The digital imaging and communications in medicine (DICOM) CT images were then imported into Mimics 10.0 for three-dimensional reconstruction. On the DRUJs 3D images, choose the most prominent point of the palmar and dorsal margins of the sigmoid notch and the excavate ulna fovea as the reference points A, B and C. A perpendicular line was then drawn from the point C to a line connecting points A and B with the intersection D. Calculate the ratio of AD/AB and DB/AB. Two observers measured all the DRUJs independently and one repeated the measurements one month later to determine the interobserver and intraobserver reliability. RESULTS: The mean ratio values of palmar (AD/AB) and dorsal (DB/AB) translation were 0.39 ± 0.07 and 0.37 ± 0.07, and the normal references (x(-) ± 2 s) were from 0.25 to 0.50 and from 0.23 to 0.50, respectively. No significant differences were observed in terms of positions, genders and dominant hands. The intraclass correlation coefficient (ICC) values for interobserver and intraobserver reliability (DB/AB, AD/AB) were 0.84, 0.80, 0.93 and 0.92, respectively. CONCLUSIONS: This new method could accurately measure the displacement of DRUJs with acceptable reliability, even with ulna positive or negative variance. Instability of DRUJ may be indicated when AD/AB is less than 0.25 or BD/AB is less than 0.23.

[Malignant giant cell tumor of the tendon sheaths in the hand].

OBJECTIVES: To retrospectively study on malignant giant cell tumor of tendon sheath (MGCTTS) in the hand, and to evaluate its clinical, histologic, immunohistochemical features and biologic evolution. METHODS: Between January 1991 and December 2001, 10 patients with histologically proven MGCTTS were treated. The clinical material, radiographs and hematoxylin and eosin-stained sections were reviewed. Immunohistochemical studies and nuclear suspensions for flow cytometry were done on paraffin embedded tissue. All patients were followed up. RESULTS: Three of 10 patients in which the diagnosis of MGCTTS was originally considered were excluded after the slides reviewed and immunohistochemical examination performed. In the other 7 patients, one showed malignant and aggressive nature: the lesion recurred several times and the patient eventually died with pulmonary metastases. The immunohistochemical profile of the patient was similar to that reported in benign GCTTS, and the flow cytometry DNA analysis detected aneuploidy. Six cases presented histologic features of malignancy, 4 of them undertook the immunohistochemical examination and their profiles were similar to that reported in benign GCTTS. An aneuploidy DNA pattern was detected in one case on flow cytometry evaluation, diploidy DNA pattern was detected in 3 cases, and their S-phase fraction was 4.5%, 11.6% and 2.6% respectively. All of them had a benign clinical features, they were alive and without evidence of disease from 1.5 to 7.5 years (averagely, 4.5 years) after complete surgical excision or resections with wide surgical margins. None of them had received chemotherapy or radiation therapy. CONCLUSIONS: Malignant giant cell tumor of tendon sheath is an extremely rare malignant tumor, some cases have a poor outcome, the others, despite the histologically malignant features, have a good prognosis if wide surgical excision ablates the tumor completely.

[Clinical analysis of 73 cases of macrodactyly].

OBJECTIVE: To analyze the clinical characteristics of 73 cases of macrodactyly. METHODS: Review the incidence, distribution, characteristic, X-rays, pathogenesis and treatment of involved digits on the base of the clinical documents of 73 macrodactyly which were treated from 1965 to 2006. Twenty-eight cases had been followed-up. RESULTS: Unilateral involved 71 cases, bilateral involved 2 cases. In upper deformities, the most involved digit was the index finger, followed by thumb and middle finger enlargement. In lower deformities, the second toes were affected more. There were 12 cases of static macrodactyly, which were all presented at or soon after birth. Sixty-one cases were progressive macrodactyly: 39 cases presented at birth; 17 cases occurred at about 2 years old; 5 cases were found after age 2. Thirty-seven cases of progressive type presented digital deviation; 3 cases associated with syndactyly; 16 cases complicated with thenar eminence hypertrophy; 8 cases of multiple-digit involved combined with palm and forearm hyperplasia. CONCLUSIONS: Macrodactyly in hand has a preference for the median nerve territory, mainly involving index, thumb and middle finger. Pedal macrodactyly prefers medial plantar nerve territory, the second toe is the most commonly affected. The progressive macrodactyly is more common than static. It may present at birth and combine with syndactyly, digital deviation, thenar eminence hypertrophy, palm and forearm hyperplasia.

The Safety of the Thenar Portal: An Anatomical Study of the Thumb Carpometacarpal Arthroscopy.

Purpose To define the localization of the distal course of the motor branches of median nerve (MBMN) and its arborization and its quantitative relationships to the thenar portal of the carpometacarpal (CMC) joint in the hope of evaluating the safety of this portal. Method In 16 embalmed cadaveric upper extremities, the localization of the course of the MBMN and its arborization were defined. In 14 fresh-frozen cadaver upper extremities, the CMC arthroscopic portals, 1-U, 1-R, and a thenar portal, were established, after which the limbs were dissected. Measurements were taken from the portals to the superficial radial nerve, radial artery, and the MBMN. Results The distal course of the MBMN and its terminal branches were all located in the proximal third of the thenar muscles, where the thenar portal was introduced. The mean distances between vital structures and each traditional portal (1-R or 1-U) were consistent with the previously published studies. Both the superficial and the profound branches of MBMN were very close to the thenar portal, and the distance between these two main terminal branches and the thenar portal was 1.2 mm (range: 0-6.2; standard deviation [SD] = 2) and 2.2 mm (range: 0-7; SD = 2.1), respectively. Five (35.7%) of the 14 fresh-frozen specimens indicated the superficial branch lay directly over the portal. One hand (7.1%) had the profound branch crossed over the thenar portal. Four hands (28.5%) indicated both the superficial and profound branches directly overlay the thenar portal. The superficial palmar branch of the radial artery was found in six hands, and in four of them, it crossed over the thenar portal. Conclusion The distal course of the MBMN and its terminal branches were all located in the proximal third of the thenar muscles, where the thenar portal was introduced. Clinical Relevance The thenar portal could improve the view of the CMC joint of the thumb and provide better performance of procedures in this joint. We should bear in mind that the arborization of the MBMN was mostly located in the proximal third of the thenar muscle, and any operation in this area should be performed with great caution.

The mechanism of Naringin-enhanced remyelination after spinal cord injury.

Our previous study revealed that intragastric administration of naringin improved remyelination in rats with spinal cord injury and promoted the recovery of neurological function of the injured spinal cord. This study sought to reveal the mechanisms by which naringin improves oligodendrocyte precursor cell differentiation and maturation, and promotes remyelination. Spinal cord injury was induced in rats by the weight-drop method. Naringin was intragastrically administered daily (20, 40 mg/kg) for 4 weeks after spinal cord injury induction. Behavioral assessment, histopathological staining, immunofluorescence spectroscopy, ultrastructural analysis and biochemical assays were employed. Naringin treatment remarkably mitigated demyelination in the white matter, increased the quality of myelinated nerve fibers and myelin sheath thickness, promoted oligodendrocyte precursor cell differentiation by upregulating the expression of NKx2.2 and 2'3'-cyclic nucleotide 3'-phosphodiesterase, and inhibited ß-catenin expression and glycogen synthase kinase-3ß (GSK-3ß) phosphorylation. These findings indicate that naringin treatment regulates oligodendrocyte precursor cell differentiation and promotes remyelination after spinal cord injury through the ß-catenin/GSK-3ß signaling pathway.

[Antegrade intramedullary fixation of the neck and subcapital fractures of the fifth metacarpal].

OBJECTIVE: To investigate the treatment of the displaced neck and subcapital fractures of the fifth metacarpal. METHODS: Thirty-one patients with the neck and subcapital fractures of the fifth metacarpal had been operated on with antegrade intramedullary fixation between January and August 2005. There was 11 subcapital fractures (group A), and 20 neck fractures (group B). Following closed reduction of the fracture, a blunt 2.0 mm diameter K-wire, which was pre-bent into 20 degrees at the distal end, was inserted into the medullary canal of the fifth metacarpal and fixed the fractures. Postoperatively, patients in group A were immobilized in a short arm plaster splint for 4 weeks, and the ones in group B were treated with unrestricted mobilization. RESULTS: Operative time was 18 min averagely (range 5 to 30 min). Twenty-nine of 31 patients obtained anatomic reduction, and 2 patients had 2/3 apposition of bone end and no rotational deformity. Follow-up was available for all patients. The average follow-up interval was 4 months, with a range of 3 - 6 months. The head/shaft angle of the fifth metacarpal in group A was 63.4 degrees +/- 14.5 degrees preoperatively, and 15.0 degrees +/- 2.5 degrees postoperatively, and 15.4 degrees +/- 2.6 degrees in 3 months postoperatively. The difference between preoperative and postoperative angles was highly significant. The range of motion of the metacarpal joint was 89.5 degrees +/- 4.3 degrees postoperatively, which was not significantly different compared with that of uninjured side. The head/shaft angle in group B was 59.1 degrees +/- 10.0 degrees preoperatively, and 15.9 degrees +/- 2.5 degrees postoperatively, and 15.5 degrees +/- 2.8 degrees in 3 months postoperatively. The difference between preoperative and postoperative angles was highly significant. The range of motion of the metacarpal joint was 88.6 degrees +/- 3.6 degrees postoperatively, which was not significantly different compared with that of uninjured side. CONCLUSIONS: The technique is technically easy to perform, minimally invasive, low-cost, allowing early hand mobilization, with good functional results and low morbidity, and it has been proved to be an ideal method.

[The vola stress change of patients after operation of wrop-around flap for thumb reconstruction].

OBJECTIVE: To analyse the vola stress change after operation of wrop-around flap for thumb reconstruction,to know the influence of vola pressure change after operation of wrop-around flap. METHODS: From 1996 to 2004, 23 patients after the operation of wrop-around flap for thumb reconstruction were measured the entire footprint, the vola stress of single foot and double feet on static state and walking status. There were 16 males and 7 females,with a mean age of 23.7 years (17 to 42 years). The time from operation to measuring was 1.6 to 6 years (meana 3.8 years). The results of measuring were analyzed. RESULTS: Whether static footprint analysis or dynamic mechanical analysis, the plantar pressure distribution of donated foot were obviously different with those of the opposite site. The weight bearing of heel and the fourth and fifth metatarsal heads were nearly consistent with normal foot. But the former feet were obviously different. The weight bearing of the first metatarsal head was obviously lower than normal foot. And the weight bearing of the second and third metatarsal heads were obviously higher than normal foot. CONCLUSION: The operation of wrop-around flap for thumb reconstruction has advantage of the cosmesis and function of the reconstructed thumbs nearly consistent with normal thumbs. But the operation influences the postoperative foot pressure.

[Repair of postburn hand using scarred skin and an abdominal flap in patients with severe burns].

OBJECTIVE: To introduce a method for repairing and restoring hand function of the patients suffering from large surface area burn with scarce normal skin for reconstruction. METHODS: Seven patients (ten hands) were treated in our department from April 1994 to February 2001. The TBSA involved with second- or third-degree burns was 85%-96%. All the hands had severe scar contracture on the dorsum and lost most of their function. A scarred skin flap, based on the ulnar border of the hand was elevated integrally on the dorsum. A random-pattern abdominal flap at a less-scarred area was designed and elevated to cover the defect of the hand while the scarred skin flap of the hand was transferred to the donor site of the abdominal flap. RESULTS: All patients were followed for 0.5 to 4 years postoperatively. The range of motion of the metacarpophalangeal joint and the space capacity of the first web were greatly improved. All patients regained self-care ability. CONCLUSIONS: This method is simple and has satisfactory results. Under the circumstances where normal skin was not available for reconstruction, the function of the burned hand could be greatly improved by this method.