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Purpose: The objective of this study was to investigate whether the base of the third metacarpal can predict the location of the thenar branch (TB) of the median nerve and the accuracy of palpating the base of the third metacarpal., Methods: In 15 patients with ulnar nerve lesions around the elbow, we transferred the opponens motor branch to repair the deep terminal division of the ulnar nerve (DTDUN). Before surgery, we located the TB by palpating the base of the third metacarpal volarly. During surgery, we placed three needles at the following places: one at the entrance of the TB into the abductor pollicis brevis, another at the point where the TB contacted the thenar muscles, and third at the DTDUN's trajectory over the third metacarpal. We obtained fluoroscopic images and measured distances between the needles and structures with image software. We also examined the relationship between the TB, DTDUN, and the volar tubercle of the base of the third metacarpal in cadaver hands. Finally, we invited 22 surgeons to palpate the base of the third metacarpal on volunteer hands and verified their accuracy using fluoroscopy., Results: During surgery, after dissection and palpation of the TB, under fluoroscopy, we confirmed that the palpable bone prominence was the base of the third metacarpal. In cadaver dissections, we observed the TB crossing the volar tubercle of the base of the third metacarpal superficially from proximal to distal and from ulnar to radial. The DTDUN was, on average, 14 mm distal to the base of the third metacarpal distal limit. In total, 19 of the 22 surgeons correctly identified the base of the third metacarpal and consequently the trajectory of the TB., Conclusions: The palpable base of the third metacarpal can be used to determine the trajectory of both the TB and DTDUN., Type of Study/level of Evidence: Diagnostic II., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: Earlier research has explored carpal tunnel release (CTR) surgery outcomes using electrodiagnostic tests (EDX). However, evaluation of the median nerve before and after CTR by ultrasound (US) is understudied. This study aimed to establish the outcomes of CTR by EDX and US, and examine the correlation between the clinical improvement and US after CTR., Methods: The sample consisted of 172 wrists that underwent CTR. Pain was assessed using the visual analog scale (VAS). The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), including the symptom severity and function subscales, was applied before and 3 months after CTR. The proximal and distal cross-sectional areas (CSAs) of the median nerve were measured using US, and EDX was performed before and 3 months after CTR., Results: Patients had mean preoperative and postoperative VAS scores of 7.7 ± 1.2 and 1.7 ± 1.2, respectively. The mean preoperative and postoperative proximal CSA measurements were 16.4 ± 4.5 mm 2 and 12.1 ± 3.9 mm 2 , respectively. The mean preoperative and postoperative distal CSA measurements were 13.6 ± 3.7 mm 2 and 11.0 ± 3.1 mm 2 , respectively. A significant improvement was observed in VAS, BCTQ, and EDX 3 months after CTR. A weak, positive correlation was observed between the improvement in the BCTQ symptom severity and function subscales and CSAs following CTR., Conclusions: The results of this study demonstrate that preoperative median nerve CSA values may be used in evaluating CTR outcomes., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: Local steroid injection is an effective treatment modality for carpal tunnel syndrome. This study aimed to investigate the success rate of ultrasonography-guided local steroid injection and determine the prognostic value of the cross-sectional area (CSA) of the median nerve for steroid injection., Methods: We retrospectively evaluated 40 patients with carpal tunnel syndrome whose median nerve CSA was >15 mm 2 (large-CSA group; n = 16) or ≤15 mm 2 (small-CSA group; n = 24). The CSA was measured using ultrasonography, and all the patients were treated with ultrasonography-guided corticosteroid injection. Demographic characteristics, symptoms, initial QuickDASH score, Boston Carpal Tunnel Questionnaires, and results of the nerve conduction study were assessed at baseline. Treatment success was defined in this study as the absence of symptom recurrence within the entire follow-up period., Results: The treatment success rate was 45% (n = 18) after an average follow-up of 16 months. Overall, 11 patients (28%) underwent carpal tunnel release on an average of 11 months after steroid injection. The large-CSA group showed a significantly worse grade of electrodiagnostic testing at baseline than did the small-CSA group; however, there was no significant difference in final Boston Carpal Tunnel Questionnaires symptom score (1.7 vs 1.8, respectively) and the rate of continued treatment success at the last follow-up (42% vs 50%, respectively). The proportions of patients who required carpal tunnel decompression were 29% and 25% in the small-CSA and large-CSA groups, respectively., Conclusions: Local steroid injection for carpal tunnel syndrome has an overall success rate of 45% after a mean follow-up of 16 months. Preinjection CSA was not associated with whether the steroid injection was considered successful. This indicates that increased median nerve CSA does not preclude the possibility of symptomatic relief after a local steroid injection., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Pronator syndrome (PS) is a compressive neuropathy of the median nerve in the proximal forearm, with symptoms that often overlap with carpal tunnel syndrome (CTS). Because electrodiagnostic studies are often negative in PS, making the correct diagnosis can be challenging. All patients should be initially managed with nonsurgical treatment, but surgical intervention has been shown to result in satisfactory outcomes. Several surgical techniques have been described, with most outcomes data based on retrospective case series. It is essential for clinicians to have a thorough understanding of median nerve anatomy, possible sites of compression, and characteristic clinical findings of PS to provide a reliable diagnosis and treat their patients., (Copyright © 2020 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the ideal suture material to test strain at nerve repair sites. Based on nerve strain tolerance, we aimed to determine which suture reliably failed by an average of 5% and a maximum of 8% strain when loaded to failure., Methods: The median nerve of 19 cadavers was exposed in the distal forearm, transected proximally, and attached to a spring gauge. It was marked 5 cm on either side of its midpoint to measure strain. A laceration was created at its midpoint. We performed a tension-free end-to-end repair with a single epineural suture. Load to failure of the repair site was recorded. We recorded strain at failure and mode of failure (pullout vs breakage). Eight different sutures were tested: 6-0, 8-0, 9-0, and 10-0 nylon; and 6-0, 7-0, 8-0, and 10-0 polypropylene., Results: Average strain at failure of 9-0 nylon most closely approximated 5% (4.9%). Moreover, 8-0 polypropylene and 10-0 nylon and polypropylene failed with average strains less than 5% and a maximum strain of failure less than 8%. Regardless of type, 6-0 to 8-0 caliber suture failed primarily by pullout of the suture from the epineurium whereas 9-0 and 10-0 nylon and polypropylene failed by suture breakage. Decreased precision through increased variability was seen when testing sutures failing via pullout., Conclusions: Nylon suture size 8-0 has been advocated as the suggested intraoperative aid to test strain at nerve repair sites. Our study suggests that 9-0 nylon may be a more appropriate testing suture because of its more predictable failure via breakage and its failure by a threshold of 5% to 8% strain. Although 8-0 nylon and polypropylene may also represent reasonable testing sutures, 8-0 nylon failed on average above 5% strain, with strains exceeding 8%, and both failed via the mechanism of pullout., Clinical Relevance: This study's findings provide information for surgeons attempting to decide during surgery whether to perform direct nerve repair., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Carpal tunnel release is one of the most common hand operations in the United States and every year approximately 500,000 patients undergo surgical release. In this article, we examine the argument for endoscopic carpal tunnel release versus open carpal tunnel release, as well as some of the literature on anatomical variants in the median nerve at the wrist. We further describe the experience of several surgeons in a large academic practice. The goals of this article are to describe key anatomic findings and to present several cases that have persuaded us to favor offering patients open carpal tunnel release., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The aims of this study were (1) to assess the utility of the Quality of Life in Neurological Disorder (Neuro-QoL) questionnaire in patients with carpal tunnel syndrome by comparing the validated patient-reported outcome (PRO) measure Neuro-QoL to the validated Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) before and following carpal tunnel release, (2) to compare the measurements of the median nerve cross-sectional area (CSA) using high-resolution ultrasound (HRUS) before and after surgery, and (3) to determine a correlation between HRUS and PRO., Methods: Individuals diagnosed with carpal tunnel syndrome were evaluated using the CTSAQ, Neuro-QoL, and HRUS before surgery and at 3 months after surgery., Results: Twenty patients completed the study. Overwhelmingly, there was an improvement in symptoms and function assessed by patients on both the Neuro-QoL and the CTSAQ at 3 months after surgery. The Neuro-QoL Physical Function and Upper Extremity scores had strong correlation with the CTSAQ activity score but had low to moderate correlation with the CTSAQ symptoms score, before and after surgery. The HRUS measurements of the median nerve at the carpal tunnel inlet demonstrated a decrease in CSA whereas no noticeable changes were observed at mid tunnel and at the outlet (hook of hamate). The correlations between the ultrasound findings and PRO measures ranged from weak to strong., Conclusions: Patients had resolution of symptoms and higher physical function following carpal tunnel release measured by both the CTSAQ and the Neuro-QoL scores. The Neuro-QoL self-assessment questionnaire, a measurement of quality of life, correlated well with the CTSAQ. Therefore, it could be used as a self-assessment outcomes tool in patients undergoing carpal tunnel release. At 3 months after surgery, HRUS measurements of the median nerve CSA showed a noticeable decrease of CSA only at the inlet of carpal tunnel. This objective improvement correlated with the improvement in CTSAQ and Neuro-QoL scores., Type of Study/level of Evidence: Diagnosis II., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The postoperative course of median nerve decompression in carpal tunnel syndrome may be associated with complications. The aim of this study was to explore the possible effects of alpha-lipoic acid (ALA) in the postoperative period after surgical decompression of the median nerve at the wrist., Methods: We conducted a double-blind prospective, randomized, controlled trial. A total of 64 patients with proven carpal tunnel syndrome were enrolled and randomly assigned into 1 of 2 groups: group A (n = 32) patients had surgical decompression of the median nerve followed by ALA for 40 days, and group P (n = 32) patients had surgical decompression followed by placebo. The primary end point of the study was a comprehensive indicator of sensory and motor nerve conduction velocity (electrophysiology score) at 3 months after surgery, Other end points were static 2-point discrimination, Boston Carpal Tunnel score, presence or absence of pillar pain, and use of analgesics beyond the second postoperative day., Results: Alpha-lipoic acid did not improve nerve conduction velocity or Boston Carpal Tunnel score significantly. However, a statistically significant reduction in the postoperative incidence of pillar pain was noted in the ALA group. In addition, static 2-point discrimination improved in both groups., Conclusions: Postoperative administration of ALA for 40 days after median nerve decompression may result in a lower incidence of pillar pain. This treatment is relatively well tolerated, which may support its value as standard postoperative supplementation after carpal tunnel decompression if further studies on larger samples confirm these preliminary findings., Type of Study/level of Evidence: Therapeutic I., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Congenital radial head dislocations are rare, and presentation with late complications is even less common. We present a case of a patient who presented with symptoms and findings of proximal median nerve compression secondary to large osteophytes associated with untreated congenital radial head dislocations., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The thread carpal tunnel release (TCTR) technique has been improved and offers more precise control in dissecting thread placement. The purpose of this cadaveric study was to test the procedure operationally and verify the modified TCTR anatomically., Methods: Eleven unembalmed cadaver wrists underwent the transverse carpal ligament (TCL) release by using the modified TCTR technique. An experienced observer dissected each specimen and assessed for completeness of release under direct visual assessment. Injury to the superficial palmar aponeurosis (SupPA), the Berrettini and common digital nerve branches were also recorded as a secondary outcome., Results: Eleven out of 11 wrists (100%) underwent the modified TCTR with complete release of the TCL. All 11 wrists were released without damage to any vital neurovascular structure including the Berrettini branch and the common digital nerves. The SupPA remained intact in all 5 wrists performed with the preservation steps., Conclusions: The modified TCTR technique demonstrated complete division of the TCL while protecting the SupPA as well as the Berrettini and common digital nerve branches., Clinical Relevance: The modified TCTR has the potential to offer a clinically safe and effective minimally invasive procedure for complete carpal tunnel release., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

We present the case of an 11-year-old boy with intraneural nodular fasciitis of the median nerve at the distal part of the carpal tunnel. Complete excision of the involved median nerve and cable grafting using 4 fascicular segments of the sural nerve was performed for persistent pain and numbness after initial resection of the tumor in piecemeal fashion. Pain and numbness were completely resolved and there was no evidence of recurrence 24 months after the final surgery., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Volar plating of distal radius fractures using an approach through the flexor carpi radialis (FCR) sheath is commonplace. The palmar cutaneous branch of the median nerve (PCB) is considered to run in a position adjacent to, but outside, the ulnar FCR sheath. Anatomic studies have not identified anatomic abnormalities relevant to volar plating. The purpose of this study was to determine the frequency of anomalous PCB branches entering the FCR sheath during volar plating., Methods: This observational study involved 10 attending hand surgeons during a 7-month period (July 2015-January 2016). Surgeons assessed, documented, and reported any PCB anomalies that were encountered during volar plating through a trans-FCR approach., Results: There were 182 volar plates applied that made up the study group. There were 10 cases (5.5%) of anomalous PCBs entering the FCR sheath. In 4 cases, the PCB pierced the radial FCR sheath proximally, crossed beneath the tendon, and traveled distally on the ulnar side. In 4 other cases, the PCB entered the FCR sheath proximally on the ulnar or central aspect of the sheath and remained within the sheath, staying along the ulnar or dorsal side of the tendon. In 1 case, the PCB pierced the ulnar distal aspect of the sheath and split into 2 branches. In 1 case, the PCB ran within the sheath along the radial aspect of the FCR., Conclusions: Anomalies in the course of the PCB are more common than often considered. These variants are at risk during volar surgical approaches to the wrist that proceed through the FCR sheath., Clinical Relevance: Although dissecting along the radial side of the FCR sheath may protect the PCB in most cases, care must be taken to identify anomalous branches (if present) and protect them during surgery., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe clinically apparent motor and sensory deficits in a cohort of 11 patients with isolated injury of the median nerve above the elbow and compare them against similar cases reported in the literature., Method: Eleven patients of mean age 30 years (SD ± 14 years; 6 males, 5 females) were examined a mean of 21 weeks (SD ± 16 weeks) after an isolated high median nerve injury. Pronation, wrist flexion, and finger flexion range of motion and strength (British Medical Research Council scale) were evaluated. Grasp and lateral pinch strength were assessed bilaterally using a dynamometer. Thumb opposition was evaluated using the Kapandji score. Sensory impairment was considered significant when there was no perception of a 2.0-g Semmes-Weinstein filament., Results: Pronation was largely preserved in all patients to a mean range of motion of 52° (SD ± 13°), and pronation strength was M4 in 10 of 11 patients. Wrist flexion scored M5 in all patients. Thumb and index distal interphalangeal joint flexion were absent in all patients. In all patients, middle, ring, and little finger flexion was complete and scored M5. Thumb function scored above 5 in all patients, averaging 7.5 (SD ± 1.2) on the Kapandji scale. Grasp and pinch strength were 43% (SD ± 12%) and 36% (SD ± 11%) of the contralateral (normal) limb, respectively. Impaired sensation of a 2.0-g monofilament was found only in the palmar region over the middle and distal phalanges of the index and middle fingers and the distal phalanx of the thumb., Conclusions: Noteworthy discrepancies were identified between the clinical motor and sensory deficits described in the literature and those observed in our patients., Clinical Relevance: In most patients with a high median nerve injury, only thumb and index flexion and palmar sensation warrant surgical reconstruction. Decreased grasp and pinch strength was a major finding that should also be addressed by surgery., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the anatomic feasibility of a median-to-radial nerve transfer in cadaver limbs and to quantify the number of axons present in the cut ends of the involved donor and recipient nerves., Methods: Ten fresh frozen cadaveric upper limbs were dissected. We investigated whether the flexor carpi radialis (FCR) branch/flexor digitorum superficialis (FDS) branch (donor nerve) reached the posterior interosseous nerve (PIN)/extensor carpi radialis brevis (ECRB) branch (recipient nerve) without tension. We also investigated the length of the transected supinator fascia for FCR-posterior interosseous nerve transfer and the FDS-ECRB positional relationship using the epicondyle line and the midline of the forearm as axes. The findings were used for these 2 types of nerve transfer with evaluation closer to the target muscles. The distance between the point at which the FDS and ECRB branches met and the point at which the ECRB branch entered the muscle was measured. After nerve coaptation, the axon number was determined by histological evaluation., Results: In all limbs, the FCR and FDS branches reached the PIN and the ECRB branch without tension. The transected supinator fascia was 17 (3-25) mm long. The point at which the FDS branch reached the ECRB branch [corrected] was 48 (23-65) mm distal to the epicondyle line and approximately 23 (18-27) mm radial to the midline of the forearm. The distance between the point at which the FDS and ECRB branches met and the point at which the ECRB branch entered the muscle was 27 (17-40) mm. The mean axon numbers were FCR, 1501 (932-3022); PIN, 5162 (4325-7732); FDS, 885 (558-962); and ECRB, 548 (433-723)., Conclusions: The FCR branch could be transferred to the PIN [corrected] and the FDS to the ECRB branch in all limbs without tension., Clinical Relevance: We provide anatomical and histological information for median-to-radial nerve transfer., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the relative benefits of an extended flexor carpi radialis (FCR) (eFCR) approach with prophylactic carpal tunnel release at the time of volar plate osteosynthesis for distal radius fracture via a single incision into the traditional volar Henry (VH) approach., Methods: This was a prospective cohort comparison of preoperative and postoperative median nerve function of 27 patients (15 eFCR and 12 VH) with unilateral, isolated distal radius fractures requiring open reduction internal fixation without preoperative acute carpal tunnel syndrome. Patients were operated on via either the eFCR or VH approach. The validated Levine-Katz Carpal Tunnel Questionnaire (symptom and functional severity scores) was administered and Semmes-Weinstein monofilament and 2-point discrimination testing were conducted preoperatively and at 6 weeks and 3 months postoperatively. Grip and pinch strength were measured at 6 weeks and 3 months. The groups were comparable in terms of age, sex, and fracture type and displacement., Results: Comparing across groups, there were no statistically significant differences in any outcome measured preoperatively or postoperatively. The eFCR and VH groups demonstrated significant improvement in functional severity scores, symptom severity, and grip strength. The symptom severity score improved to statistical significance at 6 weeks in the eFCR group and at 3 months in the VH group., Conclusions: In this small comparative study, the eFCR approach was found to be safe and efficacious. There was no increased surgical morbidity, which suggests that this technique can be used safely for all patients undergoing volar plating and not just in cases of concurrent carpal tunnel syndrome. It allows easier retraction of carpal tunnel contents; therefore, it is our preferred approach., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

A distal median to ulnar nerve transfer for timely restoration of critical intrinsic muscle function is possible in isolated ulnar nerve injuries but not for combined ulnar and median nerve injuries. We used a distal nerve transfer to restore ulnar intrinsic function in the case of a proximal combined median and ulnar nerve injury. Transfer of the nonessential radial nerve branches to the abductor pollicis longus, extensor pollicis brevis, and extensor indicis proprius to the motor branch of the ulnar nerve was performed in a direct end-to-end fashion via an interosseous tunnel. This method safely and effectively restored intrinsic function before terminal muscle degeneration., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The supracondylar process is a congenital bone projection on the distal anteromedial humerus often associated with a ligament of Struthers, a fibrous connection between the process and medial epicondyle. It is largely asymptomatic and only on rare occasions presents with neurovascular compression resulting in a supracondylar process syndrome. This case report describes a 28-year-old woman with supracondylar process syndrome, and our management. The topic is further explored with a literature review of 43 reported cases. Analysis of the case reports indicates that isolated median nerve injuries are the most common. Other presentations such as fractures, vascular compromise, and ulnar nerve involvement are less frequent., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Median nerve injuries in the forearm are reasonably common and can lead to devastating functional sequelae for the hand if they are not managed in a timely and appropriate fashion. Most nerve lacerations should be repaired soon after injury, and current widespread application of microsurgical techniques should lead to reasonable results in most individuals. Despite these advances, many patients do not have ideal outcomes from injuries to the median nerve and are often left with permanent sequelae. This article will discuss current techniques in the management of median nerve injuries, with the goal of preventing or alleviating the potential negative sequelae of these injuries., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Radial nerve injury results in loss of wrist, finger, and thumb extension. Traditionally, radial nerve palsies that fail to recover spontaneously have been reconstructed with tendon transfers or nerve grafts. Nerve transfers are a novel approach to the surgical management of Sunderland grade IV and V radial nerve injuries. We describe our technique for median to radial nerve transfers. In this procedure, the flexor digitorum superficialis nerve is transferred to the extensor carpi radialis brevis nerve for wrist extension, and the flexor carpi radialis nerve is transferred to the posterior interosseous nerve for finger and thumb extension. Our experience with these nerve transfers has demonstrated excellent outcomes up to 10 months after injury. Indeed, unlike tendon transfers, median to radial nerve transfers have the potential to restore normal radial nerve function, including independent finger motion. Tension-free nerve coaptation and postoperative motor re-education are critical factors to achieving these successful outcomes., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate intraoperative findings and outcomes of revision carpal tunnel release (CTR) and to identify predictors of pain outcomes., Methods: We performed a retrospective cohort study of all adult patients undergoing revision CTR between 2001 and 2012. Patients were classified according to whether they presented with persistent, recurrent, or new symptoms. We compared study groups by baseline characteristics, intraoperative findings, and outcomes (strength and pain). Within each group, we analyzed changes in postoperative pinch strength, grip strength, and pain from baseline. Predictors of postoperative average pain were examined using both multivariable linear regression analyses and univariable logistic regression to calculate odds ratios of worsened or no change in pain., Results: We performed revision CTR in 97 extremities (87 patients). Symptoms were classified as persistent in 42 hands, recurrent in 19, and new in 36. The recurrent group demonstrated more diabetes and a longer interval from primary CTR, and was less likely to present with pain. Incomplete release of the flexor retinaculum and scarring of the median nerve were common intraoperative findings over all. Nerve injury was more common in the new group. Postoperative pinch strength, grip strength, and pain significantly improved from baseline in all groups, apart from strength measures in the recurrent group. Persistent symptoms and more than 1 prior CTR had higher odds of not changing or worsening postoperative pain. Higher preoperative pain, use of pain medication, and workers' compensation were significant predictors of higher postoperative average pain., Conclusions: Carpal tunnel release may not always be entirely successful. Most patients improve after revision CTR, but a methodical approach to diagnosis and adherence to safe surgical principles are likely to improve outcomes. Symptom classification, number of prior CTRs, baseline pain, pain medications, and workers' compensation status are important predictors of pain outcomes in this population., Type of Study/level of Evidence: Therapeutic III., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate patients with median nerve damage in the distal forearm treated with type 1 collagen nerve conduits., Methods: Nine patients with damage to the median nerve in the distal forearm underwent treatment with a type 1 collagen nerve conduit. The nerve gaps ranged between 1 and 2 cm. An independent observer reexamined patients after treatment at a minimal follow-up of 14 months and a mean follow-up of 21 months. Residual pain was evaluated using a visual analog scale. Functional outcome was quantified by assessing static 2-point discrimination, nerve conduction velocity relative to the uninjured limb, and Disabilities of the Arm, Shoulder, and Hand outcome measure scoring. We also recorded quality of life measures including patients' perceived satisfaction with the results and return to work latency., Results: We observed no implant-related complications. Of 9 patients, 7 were free of pain, and the mean visual analog scale was 0.6. The mean Disabilities of the Arm, Shoulder, and Hand score was 6. The static 2-point discrimination was less than 6 mm in 3 patients, between 6 and 10 mm in 4 patients, and over 10 mm in 2 patients. Six patients reached a status of M4 or higher. Eight patients were satisfied with the procedure and would undergo surgery again., Conclusions: This study indicates that purified type 1 bovine collagen conduits are a practical and efficacious method for the repair of median nerves in the distal forearm., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To perform contralateral C7 nerve transfer in a controlled, survival rat functional magnetic resonance imaging model, so as to understand the extent of cortical plasticity after brachial plexus injury and surgical manipulation with this procedure., Methods: A total of 24 rats divided into 3 groups underwent surgery followed by functional magnetic resonance imaging in this study. Group I rats served as sham controls. Group II injury rats underwent complete right brachial plexus root avulsion. Group III repair rats underwent complete right brachial plexus root avulsion and then contralateral C7 nerve transfer to the right median nerve. We assessed cortical response to median nerve stimulation at 0, 3, and 5 months after injury using functional magnetic resonance imaging at 9.4 T. We concurrently performed sensory and motor functional testing., Results: We noted a progression in cortical activation in the repair rats over 0, 3, and 5 months. Initially, right median nerve stimulation in the repair group showed complete loss of activation in the contralateral somatosensory cortex. Nerve stimulation at 3 months produced primarily ipsilateral cortical activation; at 5 months, 3 patterns of cortical activation emerged: ipsilateral, bilateral, and contralateral activation. After right median nerve stimulation, injury rats maintained a lack of cortical activation and control rats maintained exclusive contralateral activation throughout all time points. Functional testing revealed a degree of return of sensory and motor function over time in the repair group compared with the injured group., Conclusions: A high degree of transhemispheric cortical plasticity occurred after contralateral C7 nerve transfer. There appears to be a predilection for the rat brain to restore the preinjury somatotopic representation of the brain., Clinical Relevance: Understanding the cortical changes after nerve injury and repair may lead to specific pharmacologic or behavioral interventions that can improve functional outcomes., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine with magnetic resonance imaging (MRI) the morphologic changes in the carpal tunnel and median nerve 3 months after endoscopic carpal tunnel release (ECTR)., Methods: We enrolled patients who had complete resolution of numbness and pain by 6 weeks after ECTR. Patients who met these inclusion criteria received an MRI at 3 months after surgery. Images were analyzed to determine whether median nerve morphology changes and discrete gap or separation of the flexor retinaculum could be appreciated on MRI., Results: There were 17 patients screened and 15 met the inclusion criteria. Three-month MRI in all patients demonstrated changes in the flexor retinaculum over the median nerve. In all 15 patients, a distinct gap or separation in the fibers of the flexor retinaculum overlying the median nerve could not be appreciated. Median nerve width-to-height ratios at the level of the pisiform and at the hook of the hamate were 2.4 and 2.1, respectively. Median nerve cross-sectional area was 14.1 at the pisiform and 13.3 at the hook of the hamate., Conclusions: MRI of patients 3 months after successful ECTR does not demonstrate a discrete gap or separation in the flexor retinaculum overlying the median nerve but may be useful for evaluating median nerve morphology., Type of Study/level of Evidence: Diagnostic II., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

In infraclavicular lesions of brachial plexus, severe lesions of the posterior cord often occur when medial and lateral cord function is preserved to a greater or lesser extent. In these cases, shoulder function may be preserved by activity of the muscles innervated by the suprascapular nerve, but complete paralysis exists in the deltoid, triceps, and brachioradialis, and all wrist and finger extensors. Classical reconstruction procedures consist of nerve grafts, but their results in adults are disappointing. We report an approach transferring: (1) an ulnar nerve fascicle to the motor branch of the long portion of the triceps brachii muscle, (2) a median nerve branch from the pronator teres to the motor branch of the extensor carpi radialis longus, and (3) a median nerve branch from the flexor carpi radialis to the posterior interosseous nerve. We describe the procedure and report 2 clinical cases showing the effectiveness of this technique for restoring extension of the elbow, wrist, and fingers in the common infraclavicular lesions of the brachial plexus affecting the posterior cord., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: A targeted muscle reinnervation (TMR) model was created using a pedicled rabbit rectus abdominis (RA) flap to receive the input from previously amputated forelimb neuromas. We hypothesize that a segmental muscle flap can undergo TMR and that it is possible to differentiate the signal from 3 independent nerves. In addition, by virtue of the nerve coaptation, the morphology of the previous amputation neuroma would become more like that of an in-continuity neuroma., Methods: Five New Zealand white rabbits had a forelimb amputation. In a second-stage surgery, an RA flap was transposed onto the chest wall. After neuroma excision, 3 neurorrhaphies were made between the median nerve, radial nerve, and ulnar nerves, and 3 motor nerves of the RA. After 10 weeks, the electrophysiologic properties of the reinnervated flap were tested. Nerve specimens from the median, radial, and ulnar nerves were harvested before and after TMR to quantify the histomorphometric changes effected by TMR on the mixed nerve neuromas., Results: Of the 12 nerve coaptations performed in the 4 viable flaps, all 12 were grossly successful. Muscle surface EMG data demonstrated that the RA retained its segmental innervation pattern after TMR. Similarly, prolonged stimulation of 1 nerve reinnervating the RA resulted in the depletion of glycogen specific to the territory of the muscle stimulated by that nerve. TMR was found to favorably alter the histomorphometric characteristics of the neuroma by decreasing myelinated fiber counts and increasing fascicle diameter in the transferred nerves., Conclusions: This study demonstrates that 1 segmented muscle having TMR by multiple nerve ingrowth and in turn generate discrete EMG signals. During this process, the previous amputation neuroma undergoes favorable morphologic alteration., Clinical Relevance: Based on these preclinical results, this technique might be useful in upper extremity amputees to recruit target muscles to have reinnervation to drive myoelectric prostheses and to treat symptomatic neuromas., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Arthroscopic management of lateral epicondylitis is a commonly performed procedure that has a good track record of efficacy and safety based on the current literature. Here, we report 2 cases of nerve injuries resulting from this operation: 1 posterior interosseous nerve transection and 1 partial median nerve laceration., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Peripheral nerve injury of the upper extremity frequently causes changes in the thermoregulatory system of the hands and fingers and leads to reports of cold intolerance. In this study, we aimed to measure the influence of median or ulnar nerve injury on cold-induced vasodilatation (CIVD) during prolonged cooling at low temperatures., Methods: We tested 12 patients with a median (n = 6) or ulnar (n = 6) injury 4 to 76 months after nerve repair. The palmar sides of both hands were cooled continuously using a cold plate at 5°C. We measured the skin temperature of the fingers using videothermography and plotted graphs of the temperature changes of the nailbed. The presence of a CIVD reaction was defined as a minimum increase in temperature of 2.5°C starting at the distal phalanx. Furthermore, we measured self-reported symptoms of cold intolerance using the Cold Intolerance Severity Scale questionnaire., Results: A CIVD reaction was absent in the affected digits of 4 patients (follow-up, 6-37 mo), whereas the CIVD reaction in the uninjured hand was present. The CIVD was present in 6 patients after 50 months' follow-up (range, 24-76 mo). Two patients had no CIVD reaction in the injured or uninjured fingers. All patients with a CIVD response had at least diminished protective sensation. Presence of the CIVD reaction did not exclude self-reported symptoms of cold intolerance., Conclusions: After peripheral nerve injury, it is possible to recover the CIVD reaction. This might be an indication of nerve recovery. However, a positive CIVD reaction does not exclude subjective symptoms of posttraumatic cold intolerance., Type of Study/level of Evidence: Diagnostic III., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

In lower lesions of the brachial plexus (C8-T1) there is good function of the shoulder, elbow, and wrist, although that of the hand is impaired. Reconstruction of finger flexion is generally obtained by tendon transfer. We present a case report involving transfer of the motor nerve branch of the brachioradialis muscle to the anterior interosseous nerve to restore finger flexion in acute lower brachial plexus lesion., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the clinical outcomes in patients with radial nerve palsy who underwent nerve transfers using redundant fascicles of median nerve (innervating the flexor digitorum superficialis and flexor carpi radialis muscles) to the posterior interosseous nerve and the nerve to the extensor carpi radialis brevis., Methods: This was a retrospective review of the clinical records of 19 patients with radial nerve injuries who underwent nerve transfer procedures using the median nerve as a donor nerve. All patients were evaluated using the Medical Research Council (MRC) grading system. The mean age of patients was 41 years (range, 17-78 y). All patients received at least 12 months of follow-up (range, 20.3 ± 5.8 mo). Surgery was performed at a mean of 5.7 ± 1.9 months postinjury., Results: Postoperative functional evaluation was graded according to the following scale: grades MRC 0/5 to MRC 2/5 were considered poor outcomes, whereas an MRC grade of 3/5 was a fair result, 4/5 was a good result, and 4+/5 was an excellent outcome. Postoperatively, all patients except one had good to excellent recovery of wrist extension. A total of 12 patients recovered good to excellent finger and thumb extension, 2 had fair recovery, and 5 had poor recovery., Conclusions: The radial nerve is commonly injured, causing severe morbidity in affected patients. The median nerve provides a reliable source of donor nerve fascicles for radial nerve reinnervation. The important nuances of both surgical technique and motor reeducation critical for the success of this transfer have been identified and are discussed., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the results of end-to-side nerve transfer of the superficial radial nerve into the median nerve for restoration of sensation and pain relief at the dorsal radial aspect of the hand in C5 and C6 root avulsion., Methods: Eight patients with a mean age of 32 years, with paresthesia and pain at the dorsal radial aspect of the hand due to upper brachial plexus injuries, had end-to-side nerve transfer of the superficial radial nerve into the ulnovolar part of the median nerve. Five patients had S0 and 3 patients had S1 sensory evaluation at the dorsal radial aspect of the affected hand. We evaluated patients for pain using a visual analog scale. We assessed sensory recovery with the Semmes-Weinstein monofilament test and British Medical Research Score, respectively. The follow-up period ranged from 24 to 36 months (average, 28 mo)., Results: Six patients had S2 and 2 patients had S3. All patients perceived at least one number lower of the Semmes-Weinstein filament in the dorsal radial aspect of the affected hand compared with the preoperative status. The best result was perception of the 3.61 filament in 2 patients. No downgrading of the donor nerve was observed after surgery. All patients had relief of pain 2 weeks after surgery, and the pain decreased dramatically at the last follow-up., Conclusions: This method is a reliable, effective, and simple procedure. We recommend this sensory nerve transfer as an additional procedure to the combined motor nerve transfers to relieve pain and restore sensation in the dorsal radial aspect of the hand in patients who have C5 and C6 root avulsion., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: Previous anatomical and clinical studies classified the course of the thenar motor branch of the median nerve into 3 types: the extraligamentous, subligamentous, and transligamentous courses. The presence of a truly preligamentous course has been questioned. Furthermore, there has been recent interest in the presence of a hypertrophic muscle over the transverse carpal ligament (TCL). The current study has 2 aims: to determine the prevalence of the various types of thenar motor branch with particular attention to the existence of the preligamentous type, and to investigate whether the hypertrophic muscle is associated with certain thenar motor branch types., Methods: One hundred consecutive patients undergoing open carpal tunnel releases were studied prospectively. The following data were documented: type of thenar motor branch, presence of hypertrophic muscle over the TCL, and number of thenar branches., Results: In 100 consecutive patients undergoing open carpal tunnel releases, extraligamentous, subligamentous, transligamentous, and preligamentous types were seen in 56, 34, 9, and 1 patient, respectively. All transligamentous and preligamentous branches were associated with the presence of a hypertrophic muscle over the TCL. Twenty-six of the extraligamentous branches were also associated with the hypertrophic muscle., Conclusions: The extraligamentous type seems to be the most prevalent thenar motor branch type in most previous studies of various races, including our Middle Eastern population, whereas the preligamentous type is rare. Finally, it is important for the surgeon to know that transligamentous and preligamentous types are associated with the presence of hypertrophic muscle origin over the TCL and that the motor branch will be within this hypertrophic muscle. Incision of this muscle should be done carefully and on the ulnar side to avoid injury to the thenar motor branch., (Copyright © 2010. Published by Elsevier Inc.)

Purpose: To compare changes in the largest cross-sectional area (CSA) of the median nerve in wrists undergoing surgical decompression with changes in wrists undergoing non-surgical treatment of carpal tunnel syndrome (CTS)., Methods: This study was a prospective cohort study in 55 consecutive patients with 78 wrists with established CTS, including 60 wrists treated with surgical decompression and 18 wrists with non-surgical treatment. A sonographic examination was scheduled before and 4 months after initiation of treatment. We compared changes in CSA of the median nerve between wrists with surgical treatment and wrists with non-surgical treatment using linear regression models., Results: Decreases in CSA of the median nerve were more pronounced in wrists with CTS release than in wrists undergoing nonsurgical treatment (difference in means, 1.0 mm(2); 95% confidence interval, 0.3-1.8 mm(2)). Results were robust to the adjustment for age, gender, and neurological severity at baseline. Among wrists with CTS release, those with postoperative CSA of 10 mm(2) or less tended to have better clinical outcomes than those with postoperative CSA of greater than 10 mm(2) (p=.055). Postoperative sonographic workup in the 3 patients with unfavorable outcome or recurrence identified likely causes for treatment failure in 2 patients., Conclusions: In this observational study, surgical decompression was associated with a greater decrease in median nerve CSA than was nonsurgical treatment. Smaller postoperative CSAs may be associated with better clinical outcomes. Additional randomized trials are necessary to determine the optimal treatment strategy in different subgroups of patients with CTS., Type of Study/level of Evidence: Therapeutic III., (Copyright 2010. Published by Elsevier Inc.)

Purpose: The superficialis to profundus (STP) tendon transfer is an effective procedure to correct a spastic clenched fist deformity in a nonfunctional upper extremity. An intrinsic thumb-in-palm (TIP) deformity, caused by increased activity in the adductor pollicis and flexor pollicis brevis muscles, commonly becomes apparent after an STP procedure. The goal of this study was to investigate the efficacy of median nerve recurrent branch neurectomy, done at the time of STP and in concert with an ulnar motor nerve neurectomy and wrist arthrodesis, in the prevention of an intrinsic TIP deformity caused by spastic thenar muscles., Methods: We retrospectively evaluated a consecutive series of 23 patients with upper motor neuron syndrome who underwent an STP transfer performed by a single surgeon at our institution. Group 1 included 11 consecutive patients who underwent an STP, ulnar nerve motor branch neurectomy, and wrist arthrodesis. Group 2 included 12 consecutive patients who underwent the same procedures with the addition of a neurectomy of the recurrent median nerve. We examined outcomes including development of a postoperative intrinsic TIP deformity, resolution of hygiene issues, and the need for additional surgery to correct the remaining deformities., Results: Patients were observed for an average of 16.1 months. In group 1, 5 of 11 patients developed an intrinsic TIP deformity, compared with 2 of 12 in group 2. Hygiene-related issues resolved in 8 of 11 patients in group 1 and 10 of 12 patients in group 2. There were no wound infections. In the 7 patients with postoperative intrinsic TIP deformity (5 in group 1 and 2 in group 2), 5 elected to have additional surgery. Of the 7 patients, 2 declined additional surgery because their deformities were mild and their hygiene issues had resolved., Conclusions: Median nerve recurrent branch neurectomy appears to be a useful adjunct to STP with ulnar motor branch neurectomy and wrist arthrodesis in the prevention of an intrinsic TIP deformity in the nonfunctional hand., Type of Study/level of Evidence: Therapeutic III., (Copyright 2010 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Recovery of either the motor or sensory functions has not been consistently achieved in upper extremity end-to-side neurorrhaphy; this technique was only indicated when more conventional nerve repair was not possible. In most studies, the whole median or ulnar nerve was used for end-to-side neurotization. In this report, we present 4 cases of high-median or ulnar nerve laceration in which a nerve graft was placed end-to-side between the median and ulnar motor fascicles close to the wrist. At 4 months after surgery, 3 of 4 patients began to recover active movement of the affected small muscles of the hand. EMG and nerve conduction studies confirmed that nerve conduction was through the nerve grafts., (Copyright 2010 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The median nerve displays frequent anatomic variation. Here, we report an unusual anatomic variation consisting of a penetrated median nerve and the tendon of the flexor digitorum superficialis to the index finger passing through it approximately 4 cm proximal to the wrist crease., (Copyright 2010 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

We present findings of anomalous musculotendinous anatomy in a patient having exploration of an acute volar wrist laceration. Surgical dissection demonstrated supernumerary flexor carpi radialis brevis and flexor carpi ulnaris brevis muscle bellies crossing the radiocarpal and ulnocarpal joints, in addition to injuries to several normal tendons and nerves. Postoperative magnetic resonance imaging confirmed the presence of a bilateral supernumerary flexor carpi radialis brevis but contralateral absence of flexor carpi ulnaris brevis.

Purpose: To evaluate the feasibility of restoring wrist extension in patients with complete cervical root 5 (C5), 6, and 7 avulsion injuries by transferring the most proximal branch of the median nerve that innervates flexor digitorum superficialis (FDS) muscle (proximal FDS branch) to the branch of the radial nerve that innervates extensor carpi radialis brevis (ECRB) muscle (ECRB branch) in an anatomic study and 2 case reports., Methods: The study was performed on 10 fresh cadavers. The nerve branches of the median nerve and the radial nerve were measured for length, diameter, and sites of origin of their nerve branches. The nerve branches of the median nerve, the posterior interosseous nerve, and the ECRB branch of the radial nerve were processed for histomorphometric evaluation. Using image analysis software, we took all histomorphometric measurements of the nerve sections. Based on this anatomical study, the proximal FDS branch was transferred directly to the ECRB branch without nerve graft in 2 patients., Results: The average distance from the origin of nerve branches to the interepicondylar line was 3.5 and 2.3 cm, respectively, for the proximal FDS and ECRB branches. The average length of the proximal FDS branch and ECRB branch was 2.8 and 3.3 cm, respectively. The average number of myelinated nerve fibers of the proximal FDS branch and ECRB branch was 983 and 2,797, respectively. At 2 years' follow-up, preliminary clinical results demonstrated that wrist extension had gained strength against resistance (grade M4). The arc of motion for wrist extension was 30 degrees in the first patient and 70 degrees in the second one. Useful functional recovery was achieved and classified as good result in both cases., Conclusions: The anatomic study and 2 reported results supports our hypothesis that transfer of the proximal FDS branch of median nerve to the ECRB branch of radial nerve could be an alternative method for reconstructiing wrist extension in C5, 6, and 7 avulsion injuries.

We report a case of a median to ulnar end-to-side neurorrhaphy with epineurectomy but without fascicular donor nerve section. Surgery was performed for the curative treatment of an elbow synovial sarcoma at the level of the elbow that necessitated resection of 10 cm of the median nerve. The patient was followed up for 24 months. After 4 months, a recovery of protective sensation in the territory of the median nerve was noticed and had stabilized by 1 year.