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Background: Radial nerve injuries cause profound disability, and a variety of reconstruction options exist. This study aimed to compare outcomes of tendon transfers versus nerve transfers for the management of isolated radial nerve injuries. Methods: A retrospective chart review of 30 patients with isolated radial nerve injuries treated with tendon transfers and 16 patients managed with nerve transfers was performed. Fifteen of the 16 patients treated with nerve transfer had concomitant pronator teres to extensor carpi radialis brevis tendon transfer for wrist extension. Preoperative and postoperative strength data, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and quality-of-life (QOL) scores were compared before and after surgery and compared between groups. Results: For the nerve transfer group, patients were significantly younger, time from injury to surgery was significantly shorter, and follow-up time was significantly longer. Both groups demonstrated significant improvements in grip and pinch strength after surgery. Postoperative grip strength was significantly higher in the nerve transfer group. Postoperative pinch strength did not differ between groups. Similarly, both groups showed an improvement in DASH and QOL scores after surgery with no significant differences between the 2 groups. Conclusions: The nerve transfer group demonstrated greater grip strength, but both groups had improved pain, function, and satisfaction postoperatively. Patients who present early and can tolerate longer time to functional recovery would be optimal candidates for nerve transfers. Both tendon transfers and nerve transfers are good options for patients with radial nerve palsy.

Background Although many studies have investigated iatrogenic radial nerve palsy (RNP) in humerus shaft fracture, there is inconsistent evidence on which approach leads to iatrogenic RNP. Moreover, no meta-analysis has directly compared the anterolateral and posterior approaches regarding iatrogenic RNP. Methods In this systematic review and meta-analysis, the MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before March 30, 2021. We included studies that (1) assessed the RNP in the surgical treatment of humerus shaft fracture and (2) directly compared the anterolateral and posterior approaches regarding the RNP. We performed synthetic analyses of the incidence of iatrogenic RNP and the recovery rate of iatrogenic RNP in humerus shaft fracture between the anterolateral and posterior approaches. Results Our study enrolled nine studies, representing 1303 patients who underwent surgery for humerus shaft fracture. After exclusion of traumatic RNP, iatrogenic RNP was reported in 35 out of 678 patients in the anterolateral approach and in 69 out of 497 patients in the posterior approach. Pooled analysis revealed that the incidence of iatrogenic RNP was significantly higher in the posterior approach than in the anterolateral approach (OR = 2.72; 95% confidence interval (CI), 1.70-4.35; P Conclusion In this meta-analysis, the posterior approach showed a higher incidence of iatrogenic RNP than the anterolateral approach in the surgical treatment of humerus shaft fracture. With limited studies, it is difficult to anticipate if any particular approach favors the recovery of iatrogenic RNP.

Background Most surgeons are unaware that idiopathic neuropathy, which occurs independently of mechanical injury, can present as postoperative peripheral neuropathy. The aim of this study was to reveal the presence of postoperative neuropathy considered to be induced by surgical stress and to make surgeons aware that idiopathic neuropathy can occur postoperatively. Methods We conducted a survey among orthopedic surgeons regarding patients with postoperative neuropathies of unknown cause. For each case, the type of neuropathy, preceding surgery and anesthesia, patient background, clinical findings, and clinical course were investigated. Results Seven patients were identified. The mean time from surgery to the onset of neuropathy was 9.3 days (range 1–15 days). Five of the patients fully recovered spontaneously within 1 year, while the remaining two underwent neurolysis. One patient presented with hourglass-like constrictions in the radial nerve. No inflammatory cells were found in the epineurium of the affected nerve. Conclusions Although it is rare, postoperative idiopathic neuropathy occurs in clinical practice, and it is crucial that surgeons recognize the existence of this neuropathy to elucidate its pathogenesis as well as to reduce the risk of litigation.

Publisher Summary This chapter discusses the epidemiology and classification of traumatic peripheral nerve injuries, the effects of these injuries on nerve and muscle, and how electrodiagnosis is used to help classify the injury. Traumatic injury to peripheral nerves results in considerable disability across the world. In peacetime, peripheral nerve injuries result commonly from motor vehicle accident trauma and less commonly from penetrating trauma, such as falls and industrial accidents. If plexus and root injuries are also included, the incidence is about 5%. In the upper limb, the nerve injured most commonly is the radial nerve, followed by the ulnar and median nerves. Lower limb peripheral nerve injuries are less common, and the sciatic nerve is injured most frequently, followed by the peroneal and rarely the tibial or femoral nerves. Peripheral nerve injuries may be seen in isolation, but they also often accompany central nervous system (CNS) trauma. Peripheral nerve injuries have significant impact, as they impede the recovery of function and return to work. There is also a risk of secondary disability from falls, fractures, or other injuries.

Neuropathies are a common problem encountered by neurologist in the hospitalized setting. Nerve injury may occur secondary to compression, stretch, and direct trauma, among other causes. Common focal neuropathies include the ulnar, median, and radial nerve in the upper extremities and sciatic, peroneal, and femoral nerve in the lower extremities. Surgical and obstetric risk factors are especially important considerations in evaluation of patients with focal neuropathies. Treatment is either conservative therapy or surgery depending on the mechanism of injury and extent of recovery.

Background Posterior interosseous nerve palsy (PINP) is a disorder caused by damage to the posterior interosseous nerve, resulting in weak extension of the wrist and fingers as well as radial deviation of the wrist. Methods: In this study, a new type of evaluation for PINP was analyzed in hopes of increasing ease of diagnosis and earlier detection of the disorder. The “Window Test” is performed by the examiner laying hands on the ulnar aspect of the patient’s pronated forearm while the latter is trying to extend the wrist. A positive test is observed when a gap (window) appears between the examiner’s forearm and the patient’s hand. Lay people, medical students, residents, and practicing providers were assessed prospectively on their ability to correctly diagnose PINP by observing one hand, both hands, and by using the Window Test. Results: The Window Test was consistently found to be the most effective method of evaluation as it increased the accuracy of diagnoses in all groups surveyed. Additionally, case studies were performed using the Window Test on patients, further demonstrating the efficacy of the test by confirming wrist radial deviation. Conclusion: The Window Test introduces a reference frame, making it easier to assess wrist radial deviation and offering a simple evaluation that can be administered by virtually anyone. These findings indicate that the implementation of the Window Test will increase the accuracy and effectiveness of PINP diagnosis, thus allowing early diagnosis and better management.

Imaging has become an essential tool in the study of the posttraumatic paralytic upper limb, in addition to the clinical examination and electroneuromyography. Upper extremity surgeons must be aware of how these different techniques contribute to the initial and preoperative assessment of nervous injuries. We review the appearance of traumatic nerve damage and muscle denervation during the initial injury assessment, focusing on the main aspects of brachial plexus injuries, paralysis after shoulder dislocation and traumatic damage to the radial nerve. Finally, we discuss the role of imaging for preoperative assessment of musculotendinous and osteoarticular palliative surgeries.

Palliative tendon transfer is an integral part of radial nerve palsy treatment. It can be considered in the first weeks when the possibility of nerve repair by direct suture or nerve grafting is not feasible or reasonable. Mostly, it is discussed secondarily when it is too late for nerve surgery and motor recovery cannot be expected, or after failure or incomplete recovery after nerve repair. The goal of tendon transfers is to restore wrist, finger and thumb extension. For wrist extension, the use of pronator teres is well accepted. The best tendon transfer for finger extension is debated. This can be restored doing a flexor carpi ulnaris (FCU), flexor carpi radialis or flexor digitorum superficialis (FDS) to extensor digitorum communis transfer. Regarding thumb extension and abduction, a palmaris longus (PL) or one FDS tendon to the rerouted extensor pollicis longus (EPL) transfer can be performed. If a transfer is done on the EPL without rerouting it, abduction can be restored by doing a tendon transfer to the abductor pollicis longus (APL) or an APL tenodesis. The different tendon transfer options are selected based on the surgeon’s preference, and most importantly, discussed with the patients to define the objectives together. The transfer is chosen based on the clinical examination (high or low radial nerve palsy, tendon available for transfer like PL, wrist mobility) and based on the patient’s needs and expectations (activities requiring the FCU, finger independence, independence of thumb extension or abduction). If the surgical rules and the postoperative instructions for rehabilitation are followed, tendon transfers for radial nerve palsy regularly produce very satisfactory results.

Background Radial nerve palsy is a common complication associated with humeral shaft fractures. The purposes of this study were 1) to evaluate the status of primary radial nerve palsy in patients with humeral shaft fracture according to injury mechanism, 2) to estimate the risk factors of primary RNP, and 3) to evaluate whether early exploration is helpful for radial nerve recovery. Methods This study analyzed 162 patients with humeral shaft fractures from January 2014 to December 2019. All patients were surgically treated in our hospital. Of these, 109 high-energy injuries were identified and compared with 53 low–energy injuries. The risk factors of radial nerve palsy were analyzed, and the prevalence of radial nerve palsy and status of radial nerve exploration according to injury mechanism were evaluated. Nerve recovery rate according to early nerve exploration was investigated. Results There were 31 cases of radial nerve palsy among 162 patients; 27 in the high-energy humeral shaft fracture group, and four in the low-energy humeral shaft fracture group. Logistic regression analysis for risk factors showed that the injury mechanism was significantly associated with primary radial nerve palsy. Among 31 radial nerve palsy patients, 21 radial nerves were explored and 19 radial nerves were recovered completely (80.6%). In the high-energy humeral shaft fracture group, 18 radial nerves were explored during surgery among 27 radial nerve palsy cases, and 16 cases were recovered (88.9%). The other nine radial nerves were not explored, and only five cases were recovered (55.6%) Conclusions This study confirmed that the incidence of radial nerve paralysis was higher in high-energy humeral shaft fractures than in low-energy fractures. The more common fracture patterns were oblique, transverse, wedge, and comminuted in HE-HSF. This study suggests that these patterns are not directly associated with radial nerve palsy, but that high-energy injury is associated with a specific fracture pattern. Early nerve exploration during surgical treatment in patients with radial nerve palsy associated with humeral shaft fracture was helpful especially after high-energy injury.

Background The posterior approach to the humeral shaft is commonly used for surgical procedures on the humeral shaft. We present our experiences using the modification of the surgical exposure described by Gerwin M. which we have found useful at the time of revision surgery. Methods Between 2014 and 2019, six patients who underwent a revision surgical procedure for a nonunion of the humeral shaft where a prior surgical procedure was performed through a posterior incision were included. The approach used a modification of the posterior approach described by Gerwin M. where the lower lateral cutaneous nerve branch of the radial nerve is used to identify trace, mobilize, retract, and protect the radial nerve to achieve adequate exposure of the humeral shaft. Results and Discussion None of the patients had a postoperative nerve deficit.Adequate exposure to aid hardware removal, osteosynthesis, and bone grafting was achieved in all patients. Conclusion The modification of the posterior approach described by Gerwin M. is useful at the time of revision or redo surgery on the humeral shaft where other bony and soft tissue landmarks are altered to prevent an iatrogenic injury to the radial nerve while providing adequate exposure to treat a nonunion.

Background Iatrogenic nerve injuries can result from surgical damage. Thus, physicians should be aware of the risk factors and procedures that need to be followed in such patients. The purpose of this study was to examine data pertaining to patients with known iatrogenic nerve injuries and to elucidate the detailed causes of these injuries, the affected nerves, and the type of surgical procedures for treatment. Methods This retrospective study included 232 consecutive patients who underwent surgical treatment for peripheral nerve palsy or nerve injury between 2006 and 2017 at our hospital. Among the 232 patients investigated, we identified 51 cases with iatrogenic nerve injuries (23 women and 28 men; mean age, 51.3 years). Among the 51 patients, 45 were referred from other hospitals, and the remaining were from our hospital. Data were summarized using descriptive statistics. Results Direct surgical damage occurred in 94% (48/51) of patients with iatrogenic nerve injuries. Such injuries mostly developed after surgery for bone fractures (33%), resection of soft tissue tumors (22%), and carpal tunnel release procedures (20%). The nerves most commonly affected in such procedures are the radial nerve (26%), median nerve (24%), and ulnar nerve (17%). The median interval of referral to our hospital after nerve injury was 5.1 months. The median interval of surgery to correct the injury was 7 months. Surgeries to correct iatrogenic nerve injuries performed at our hospital included neurolysis (55%), nerve grafts (29%), direct suture procedures (10%), and tendon transfers (6%). Conclusions We believe that wide dissemination of the results obtained in this study will reduce the incidence of iatrogenic peripheral nerve injuries and increase the speed of referrals to specialized centers.

Background Schwannoma is a benign, encapsulated and slowly growing tumor originating from Schwann cells and is rarely seen in the peripheral nerve system. Typical symptoms are soreness, radiating pain and sensory loss combined with a soft tissue mass. Aim To evaluate pre- and postoperative symptoms in patients operated for schwannomas in the extremities and investigate the rate of malignant transformation. Methods In this single center retrospective study design, all patients who had surgery for a benign schwannoma in the extremities from May 1997 to January 2018 were included. The location of the tumor in the extremities was divided into five groups; forearm, arm, shoulder, thigh and leg including foot. The locations of the tumor in the nerves were also categorized as either; proximal, distal, minor or major nerve. During the pre- and postoperative clinical evaluation, symptoms were classified as paresthesia, local pain, radiating pain, swelling, impairment of mobility/strength and asymptomatic tumors that were found incidentally (with magnetic resonance imaging). The patients were evaluated after surgery using the following categories: Asymptomatic or symptomatic patients (radiating and/or local pain) and those with complications. The follow up period was from the time of surgery until last examination of the particular physician. Multivariate logistic regression analysis was performed to identify independent prognostic factors for postoperative significant symptoms at follow-up. Results We identified 858 cases from the institutional pathology register. We excluded cases with duplicate diagnoses (n = 407), pathology not including schwannomas (n = 157), lesions involving the torso, spine and neck (n = 150) leaving 144 patients for further analysis. In this group 99 patients underwent surgery and there were five complications recorded: 2 infections (treated with antibiotics) and 3 nerve palsies (2 involving the radial nerve and one involving the median nerve) that recovered spontaneously. At the end of follow-up, 1.4 mo (range 0.5-76) postoperatively, we recorded a post-operative decrease in clinical symptoms: Local pain 76% (6/25), radiating pain 97% (2/45), swelling 20% (8/10). Symptoms of paresthesia increased by 2.8% (37/36) and there was no change in motor weakness before and after surgery 1% (1/1). Multivariate analysis showed that tumors located within minor nerves had a significantly higher prevalence of postoperative symptoms compared with tumors in major nerves (odds ratio: 2.63; confidence intervals: 1.22-6.42, P = 0.029). One patient with schwannoma diagnosed by needle biopsy was diagnosed to have malignant transformation diagnosed in the surgically removed tumor. No local recurrences were reported. Conclusion Surgery of schwannomas can be conducted with low risk of postoperative complications, acceptable decrease in clinical symptoms and risk of malignant transformation is low.

Introduction: The humerus diaphyseal fractures account for 3% all bone fractures. Humerus diaphyseal fractures occurs in young adults because of high velocity injuries like road traffic accidents, fall from height, assaults and heavy machinery injuries, humerus diaphyseal fractures occurs in old age patients because of simple falls due to osteoporotic bones. Methods: A retrospective review was conducted of patients with humerus diaphyseal fractures. In all 26 patients were enrolled in the study, of which 13(50%) were treated with anterolateral approaches and the 13(50%) with posterior approaches. In this study we treated diaphyseal humerus fractures with open reduction and internal fixation by two different approaches, anterolateral and posterior, and compared results and functional outcome. Results: Out of all the 26 patients with diaphyseal humerus fracture 13 patients were operated with open reduction and internal fixation by plate osteosynthesis by anterolateral approach 10(38.46%) patients had excellent result, 1(3.84%) patient had good result and 3(11.53%) patients had poor result. And Out of all the 26 patients with diaphyseal humerus fracture 13 patients operated with posterior approach 9(34.61%) patients had excellent result, 4(15.38%) patients had good result and none had poor result. Conclusion: in our study we conclude that both approaches are equally effective for diaphyseal humerus fractures treatment in terms of fracture union, functional outcome and complications. Posterior approach to shaft humerus fracture is beneficial because with mobilization of radial nerve 76% of humerus shaft is exposed. In preoperative radial nerve palsy with diaphyseal shaft fractures posterior approach is better choice for nerve exploration. And anterolateral approach is better option for upper third and middle third diaphyseal humerus fractures and posterior approach is better option for distal third diaphyseal humerus fractures

The aim of the study was to determine if the use of tendon allografts in combination with distal scaphoid resection for the treatment of isolated STT arthrosis is a save procedure. We reviewed the postoperative complications, re-operations, clinical and radiological results of this treatment modality. A retrospective cohort study was conducted. Investigated parameters include wrist mobility (wrist extension and -flexion), strength (grip- and pinch strength), patient-reported outcome scores : Visual Analogue Scale (VAS), Quick Disabilities of the Arm, Shoulder and Hand score (Q-DASH) and Patient Rated Wrist/Hand Evaluation score (PRWHE) and radiographic measurements : scapholunate (SL) angle, radiolunate (RL) angle and capitolunate (CL) angle. Ten wrists were included in nine patients. No revision surgery was performed. Two patients had transient neuropraxia of the radial nerve. Postoperative flexion-extension arc was 112°. Grip-strength was significantly increased after surgery (20 to 28kg). The average VAS score the past week was 1.75 (range 0-6.7), the average maximum VAS score was 3.0 (range 0-10). The mean PRWHE score was 16.6 (range 0- 69). The mean Q-DASH score was 17.95 (range 0-51). The current study indicates that distal scaphoid resection for isolated STT arthritis is a save procedure with minimal complications. It significantly improves grip strength. Mobility of the wrist was similar to contralateral wrist after surgery. Pain postoperatively was very limited (low VAS scores) and good functional scores (Q-DASH and PRWHE) were noted. Our findings support the prior findings that excisional arthroplasty might worsen carpal instability.

To evaluate the effectiveness of interlocked humerus nail through a keyhole incision for the management of humeral diaphyseal fractures in terms of radiological union, shoulder function, and complications. In this prospective study of sixty-two patients with humeral diaphyseal fractures in our institute (51 men, 11 women; mean age 42 years; range 20 to 73 years), fifty-nine fractures were closed and three were grade I open fractures. Three patients had a preoperative radial nerve palsy. Key hole surgery was performed by closed technique (n = 56) and limited open technique (n = 6) with reamed humerus interlocked nail through an antegrade nailing procedure. The cases were followed up prospectively for union and function. The mean follow-up was 12.3 months (range 12 months to 18 months). The outcome of the procedure was assessed according to American Shoulder and Elbow Surgeons (ASES) score, radiological union, complications, and secondary procedures required. Fifty-eight (93.33%) fractures united with an average consolidation time of 12.75 weeks. Two patients had delayed union. Two patients had nonunion which required plating and bone grafting. No cases of infection were encountered. Neuropraxia which was detected preoperatively recovered fully in all three cases between three and six weeks. The ASES scores were excellent-to-good in fifty-six (90.32%) patients, fairly functional outcome was noted in four patients(6.5%), and two patients (3.2%) continued to have poor function at the time of final follow-up. The results of keyhole interlocked humerus nail with proximal multi-locking options were excellent-to-good for humeral diaphyseal fractures in terms of union, shoulder function, and complications. It is a safe, easy, and reliable method for the treatment of humeral diaphyseal fractures.

Compressive neuropathies of the forearm are common and involve structures innervated by the median, ulnar, and radial nerves. A thorough patient history, occupational history, and physical examination can aid diagnosis. Electromyography, X-ray, and Magnetic Resonance Imaging may prove useful in select syndromes. Generally, first line therapy of all compressive neuropathies consists of activity modification, rest, splinting, and non-steroidal anti-inflammatory drugs. Many patients experience improvement with conservative measures. For those lacking adequate response, steroid injections may improve symptoms. Surgical release is the last line therapy and has varied outcomes depending on the compression. Carpal Tunnel syndrome (CTS) is the most common, followed by ulnar tunnel syndrome. Open and endoscopic CTS release appear to have similar outcomes. Endoscopic release appears to incur decreased cost baring a low rate of complications, although this is debated in the literature. Additional syndromes of median nerve compression include pronator syndrome (PS), anterior interosseous syndrome, and ligament of Struthers syndrome. Ulnar nerve compressive neuropathies include cubital tunnel syndrome and Guyon’s canal. Radial nerve compressive neuropathies include radial tunnel syndrome and Wartenberg’s syndrome. The goal of this review is to provide all clinicians with guidance on diagnosis and treatment of commonly encountered compressive neuropathies of the forearm.

A 29-year-old female presented to the emergency clinic with gradual visual disturbance in both eyes for 15 days duration, accompanied by bilateral tinnitus, and ocular pain that increased with ocular movements. One month prior to presentation, the patient had tested positive for severe acute respiratory syndrome coronavirus-2 but without complications. Visual acuity was 20/100 in the right eye and 20/300 in the left eye. Funduscopy demonstrated optic nerve swelling, radial nerve fiber striation disruption, and bilateral retinal folds. Optical coherence tomography showed serous (bacillary) retinal detachment and multifocal areas of hyper-reflective changes in the inner and outer plexiform layer with inner nuclear layer thickening and disruption of the interdigitation zone bilaterally. We present a case of incomplete Vogt-Koyanagi-Harada disease following COVID-19 infection.

INTRODUCTION AND OBJECTIVES Rupture of distal biceps has a frequency of 1.2 cases per 100,000 population. Conservative treatment presents a loss in supination of 40% and flexion of 30%, like transfers to the brachialis. Our goal is to review our experience with anatomical reattachment. MATERIAL AND METHODS Cohorts study. We analized an historic cohort, although recent, treated with double approach (Boyd-Anderson) compared to another prospective cohort (treated with single and double approach). Sample size of 80 patients. Mean age of 48.9 ± 5.9 years. We analyzed laterality, time to diagnosis, presurgery time, surgery time, approach, type of reintegration, rehabilitation time, Mayo Elbow Performance Score (MEPS), biomechanical study and complications. Follow up from 2 years to 7 years. RESULTS Time for diagnosis was about 4 days. Preoperative time: 12.2 ± 6.4 days. Surgical time: 61.9 ± 15.7 min. We used the two-way surgical approach (Boyd-Anderson-Morrey) in 78.8% of patients, and the anterior surgical approach (Henry) in 21.2% of cases. Transosseous reinsertion was made in 45% of cases, with screw anchor in 40% and with cortical button in 15%. Rehabilitation time: 91 ± 29.7 days. MEPS: 88 ± 11.7 points. There was loss of flexor strength of 28 ± 16.6%. COMPLICATIONS 1 case of proximal radioulnar synostosis, 2 radial transient paralysis and 5 cases with residual stiffness. Hypothesis contrast: We reached best results in MEPS with double surgical approach (P = .009), with fewer complications (P = .008). We observed increased pain with cortical buttons (P

Background: Traumatic neuromas are a result of abnormal neural regeneration after nerve injury. Neuropathic pain arising from neuroma can be debilitating. Methods: This was a retrospective review of a consecutive series of patients who presented with a painful cutaneous neuroma secondary to direct trauma or surgery. The diagnosis was made by the presence of neuropathic symptoms in the dermatome of a cutaneous nerve and a positive Tinel sign. Local anaesthetic injection was performed for confirmation of diagnosis. Each patient was offered optimisation of medical therapy and physiotherapy for desensitisation. Outpatient neuromodulation was offered as an alternative to neuroma surgery. The primary aim of treatment was symptom reduction such that neuroma surgery was no longer required. Results: This study included 50 patients with painful cutaneous neuromas. Surgery was the commonest cause. The most frequently injured nerves were superficial radial nerve, digital nerve and dorsal ulnar cutaneous nerve, together comprising over 60% of cases. After receiving neuromodulation, 18 (36%) patients experienced sufficient symptom relief and did not wish to pursue neuroma surgery. Conclusions: Surgery is the commonest cause of a painful cutaneous neuroma. Following optimisation of pharmacotherapy and physiotherapy, neuromodulation may offer symptom relief such that neuroma surgery may be avoided in approximately one third of cases.

Objective Current evidence suggests that carpal tunnel syndrome (CTS) involves widespread pressure pain sensitivity as a manifestion of central sensitization. This study aimed to quantify mechanisms driving widespread pressure pain hyperalgesia in CTS by using network analysis. Design Cross-sectional. Setting Urban hospital. Subjects Women with CTS (n=120) who participated in a previous randomized clinical trial. Methods Pain intensity, related function, symptom severity, depressive levels, and pressure pain threshold (PPTs) over the median, radial, and ulnar nerves, as well as the cervical spine, the carpal tunnel, and the tibialis anterior, were collected. Network analysis was used to quantify the adjusted correlations between the modeled variables and to determine the centrality indices of each variable (i.e., the degree of connection with other symptoms in the network). Results The estimated network showed several local associations between clinical variables and the psychophysical outcomes separately. The edges with the strongest weights were those between the PPT over the median nerve and the PPT over the radial nerve (P=0.34), between function and depressive levels (P=0.30), and between the PPT over the carpal tunnel and the PPT over the tibialis anterior (P=0.29 ). The most central variables were PPT over the tibialis anterior (the highest Strength centrality) and PPT over the carpal tunnel (the highest Closeness and Betweenness centrality). Conclusions This is the first study to apply network analysis to understand the multivariate mechanisms of individuals with CTS. Our findings support a model in which clinical symptoms, depression, and widespread pressure pain sensitivity are connected, albeit within separate clusters. The clinical implications of the present findings, such as the development of treatments targeting these mechanisms, are also discussed.

Background: Left untreated, scaphoid nonunion can progress to carpal collapse and a predictable pattern of radiocarpal arthrosis. The goals of surgery for scaphoid nonunion include uniting the fracture and restoring carpal alignment. Objective: To assess the effect of pronator quadratus vascularized muscle bone pedicle graft in scaphoid nonunion with fixation. Patients and Methods: The study was conducted on 20 patients with a history of scaphoid fracture since three months ago and no clinical or radiological signs of healing at Al-Azhar University Hospitals from January 2018 till February 2019. The patients underwent pronator quadratus vascularized muscle bone pedicle graft in scaphoid nonunion with fixation. Results: The mean age of the studied cases was 34.27 ± 11.74 years and male predominance with all of the studied patients noted no complications wither early or late and returned to their previous level of activity. All the cases achieved bony union (100%) in a mean of 12.5 weeks. There was improvement in mean radiolunate and scapholunate angles. Average range of motion and modified Mayo score. There were no early complications of surgical site infection or sensory disturbances in the area of the radial nerve. There were also none late septic complications. No radiographic progression of arthritis was noted in any patient within the available follow-up time. All patients returned to their previous level of activity and satisfied with the late clinical and functional results. Conclusion: Volar vascularized bone grafts is an easy method and provides excellent results while needing no special equipment. Bone grafting is the mainstay treatment for non-union scaphoid. Vascularized bone grafts using pronator quadratus osteomuscular flaps have proved to be more biological and more successful treatment option.

Objective Arm wrestling is common sport amongst amateur enthusiasts. Multiple injuries are described as a result of the sport. The authors present a narrative review of the common injuries associated with the sport. Design Systematic review with a critical appraisal of the literature and a narrative review of the injuries associated with arm wrestling. Data sources Seven electronic databases were systematically searched using medical subject headings (MeSH) terms as follows. Arm wrestling, Indian Wrestling, Fractures, Injury, Ligament Injury with Boolean search terms “AND”. An extensive review of orthopaedic textbooks was also performed. Eligibility criteria for selecting studies Inclusion criteria were publications which included patients who suffered bony or soft tissue injuries as a result of arm wrestling published in English language. Results A total of 152 patients was seen across all studies. Spiral fractures of the distal third of the humerus are by far the most common injury reported in the setting of arm wrestling. The humerus fails due torsional and bending stresses. 23% were complicated by medial butterfly fragment and the incidence of radial nerve palsy was 23%. Fracture patterns differ in the skeletally immature arm wrestler, who show an increased incidence of medial humeral epicondyle fractures. We also report on the atypical fracture and soft tissue injury patterns that present.

OBJECTIVE The aim of this study was to investigate the incidence of postoperative radial nerve palsy (PORNP) after the surgical treatment of humeral shaft fractures through a posterior triceps splitting approach by a single surgeon's experience in a consecutive case series from a single trauma center. METHODS In this retrospective study, a total of 118 patients (82male, 36 female;mean age = 48 years, age range = 16 - 80 years)who underwent open reduction and plate fixation through posterior triceps splitting approach due to humeral shaft fractures at a level I trauma center were included. Level of the fractures was categorized as the proximal third, middle third, and distal third of the diaphysis, and then all the fractures were classified according to the AO/OTA classification system. The trend of incidence of PORNP was investigated. All the operations were performed by a single surgeon. The recovery time of PORNP was also recorded. RESULTS There were 13 cases of proximal third, 67 cases of middle third, and 38 cases of distal third fracture. Based on AO/OTA classification, there were 29 cases of A1-type, 23 cases of A2-type, 42 cases of A3-type, 17 cases of B2-type, 3 cases of B3-type, and 4 cases of C2-type fracture. The overall incidence of PORNP was 11% (13 cases). All the PORNP cases fully recovered within 10.3 ± 10.4 weeks (range = 1 - 44) with conservative treatment. Incidence of PORNP significantly decreased with increase in surgical experience (P = 0.009). The incidence of radial nerve palsy was not significantly related to the level of the fracture (P = 0.199). The incidence of radial nerve palsy was not significantly related with the fracture pattern according to AO/OTA classification (P = 0.659). CONCLUSION Evidence from this study has shown that the incidence of PORNP following the posterior triceps splitting approach for the treatment of humeral shaft fractures is significantly associated with the surgeon's experience. LEVEL OF EVIDENCE Level IV, Therapeutic Study.

The purpose of this study is to determine if a standardized protocol for radial nerve handling during humeral shaft repair reduces the incidence of iatrogenic nerve palsy post operatively. Seventy-three patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. In each case, the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure. Fractures were classified according to AO/OTA guidelines and included 23 Type 12A, 11 Type 12B, and 3 Type 12C. Eight patients had periprosthetic fractures and 28 fractures could not be classified. All patients in the cohort were fixed with locking plates. Surgery was indicated for 36 patients with humeral nonunions and 37 patients with acute humeral shaft fractures. Of the 73 patients, 2 (2.7%) developed radial nerve palsy following surgery, one from the posterior approach and one from the anterolateral approach. Both patients exhibited complete recovery of radial nerve function by 6-month follow-up. No significant differences (p > 0.05) were found in any demographic or surgical details between those with and without radial nerve injury. Nerve exploration identification and protection leads to a low incidence of transient radial nerve palsy compared to the rate reported in the current literature (2.7% compared to 6–24%). Thus, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs. Level III.

The aims of the present study were to describe atraumatic proximal radial nerve entrapment (PRNE) and potential strategies for management. We performed a comprehensive search of 4 electronic databases for studies pertaining to patients with atraumatic PRNE. Studies published between 1930 and 2020 were included. Clinical presentation, nerve conduction studies, electromyography, and treatment methods were reviewed. In order to outline management strategies, 2 illustrative cases of acute PRNE were presented. We analyzed 12 studies involving 21 patients with 22 PRNE (15 acute and 7 progressive). Sudden or repetitive elbow extension with forceful muscle contraction (n = 16) was the primary mechanism of injury. The two main sites of entrapment were the fibrous arch (n = 7) and hiatus of the lateral intermuscular septum (n = 7). Conservative treatment was performed in 4 patients and allowed for complete clinical recovery in all cases. The remaining 18 patients underwent epineurolysis (n = 16) or resection/repair of hourglass-like constriction (n = 2) between 1.5- and 120-months following diagnosis. Twelve patients experience complete recovery, while partial or no clinical recovery was reported in 1 and 4 cases, respectively; the outcome was unknown in 1 case. Atraumatic PRNE is rare and remains challenging with respect to diagnosis and treatment. Current literature suggests that primary sites of entrapment are the fibrous arch and hiatus of the radial nerve at the time of forceful elbow extension. Case series (IV) & systematic review (I)

Objective Intraneural perineurioma is a rare tumor entity. It is a benign, very slow growing peripheral nerve sheath tumor that typically occurs in children and young adults. Motor deficits and muscle atrophy are classic presenting symptoms, while sensory deficits are rare at the onset of the disease. Recommended treatment strategies are lacking. We have evaluated the clinical follow-up and our experience with treatment of this rare entity. Methods A total of 30 patients with intraneural perineuriomas were assessed retrospectively. Demographic data, clinical symptoms, diagnostic examinations, therapy strategies, and clinical outcome were analyzed. Descriptive statistical methods were used for evaluation. Results The mean age was 22 years. Eleven women and 19 men were affected. The lesion occurred in the area of the upper extremity in 16 patients and in the area of the lower extremity in 14 patients. The most frequently affected nerve was the sciatic nerve, followed by the radial nerve. All patients showed a motor deficit to some extent. Seventy percent (n = 21) revealed atrophy, 43.3% (n = 13) had sensitive deficits, and 17% (n = 5) suffered of pain. Fascicle biopsies were performed in 26 patients (87%). In four patients (13%), the tumor was completely resected and then reconstructed via nerve grafts. Seventy percent of the patients (n = 21) received a magnetic resonance imaging (MRI) within 5 years postoperatively, in which no progress was shown. Conclusions To diagnose perineurioma, it is essential to take a biopsy of an enlarged, nonfunctional fascicle. Furthermore, a long-distance epineuriotomy to decompress the hypertrophic fascicle is reasonable. To preserve the nerves' residual function, a complete resection is not recommended. Results after grafting are poor. One reason for this might be residual tumor cells along the nerve that cannot be visualized. Malignant transformation is not yet reported and tumor growth is stable for years.

Spiral fractures in the distal third humerus shaft (Holstein-Lewis fracture pattern) have been associated with high risk of radial nerve palsy in adults and surgical treatment is recommended as the treatment of choice to remove the entrapped nerve from the fracture site. But this association and treatment approach has not been evaluated in pediatric humerus shaft fractures. In a retrospective study, 38 pediatric patients with Holstein-Lewis fracture configuration were identified after a review of radiographs of 1609 patients with humerus shaft fracture. Age at initial presentation, sex, mechanism of injury, side involved, presence of any associated injuries, neurovascular status, radial nerve status, fracture management, and any complications were noted. Thiry-three (86.8%) patients with mean age 10.1 ± 3.7 years were successfully treated by closed methods. Five patients (13.2%) with mean age 15.2 ± 2.6 years underwent surgical treatment. Contrary to adults, no children/adolescents had radial nerve palsy at presentation. Radiographic healing was acceptable in all cases at latest follow-up. Holstein-Lewis fracture behaves differently in children with no increased risk of radial nerve palsy. Majority can be treated conservatively. The thick periosteum in children may offer protection to the radial nerve and may be responsible for the success of closed treatment.

Iatrogenic nerve injuries can cause patients and surgeons a great deal of distress and anxiety. To help prevent such injuries, surgeons should remain mindful for potential distortion of anatomy due to scarring and adhesions. Peripheral nerves are vulnerable to thermal injury, as well as mechanical injury by laceration and traction. Revision arthroplasty may involve removal of the implant and cement mantle. During this removal process, breaches in cortical bone can occur, with resultant cement extrusion within the soft tissues. Screw holes left vacant following screw removal may also allow for cement leakage. Thermal energy is released during the exothermic polymerisation process of cement curing. As a result, this thermal energy can also lead to injury to neural tissue. In this article, we present three cases of radial nerve palsy associated with cement extrusion during revision arthroplasty, in order to highlight pitfalls and learning points in the management. In addition, we propose strategies to avoid such injuries. Surgeons are reminded to be vigilant for cortical breaches intraoperatively, and if recognised, steps should be taken to minimise the risk of nerve injury.

BackgroundTreatments for metastatic fracture of the humeral shaft continue to evolve as advances are made in both oncological and operative management. The purposes of this study were to critically evaluate the effectiveness of intercalary endoprostheses in treating metastatic humeral shaft fractures and to clarify the surgical indications for this technique.MethodsSixty-three patients treated surgically for 66 metastatic fractures of the humerus shaft were retrospectively reviewed. Intramedullary nailing (IMN) was performed in 16 lesions, plate fixation (PF) in 33 lesions, and prosthetic replacement in 17 lesions. The operative time, intraoperative blood loss, and postoperative complications were noted. The function of the upper extremities was assessed by the Musculoskeletal Tumor Society (MSTS) score and American Shoulder and Elbow Surgeons (ASES) score. All included patients were followed until reconstructive failure or death.ResultsThe operative time was relatively shorter in the prosthesis group than in either the IMN group (p= 0.169) or PF group (p= 0.002). Notably, intraoperative blood loss was significantly less in the prosthesis group than in either the IMN group (p= 0.03) or PF group (p= 0.012). The average follow-up time was 20.3 (range, 3–75) months, and the overall survival rate was 59.7% at 12 months and 46.7% at 24 months. One rotator cuff injury, 3 cases of iatrogenic radial nerve palsy, 5 cases of local tumor progression, and 1 mechanical failure occurred in the osteosynthesis group, whereas one case of aseptic loosening of the distal stem and one case of local relapse were observed in the prosthesis group. There were no significant differences in functional scores among the three groups.ConclusionsIntercalary prosthetic replacement of the humeral shaft may be a reliable solution for pathologic fractures patients; it is indicated for lesions with substantial bone loss, or accompanied soft tissue mass, or for those patients with better prognosis.

The aim of the present study is to describe in detail the morphology and innervation pattern of the anconeus muscle, bearing in mind clinical implications such as iatrogenic injuries during surgical elbow approaches. A cadaveric study was performed; 56 elbows from 28 formalin-fixed cadavers belonging to the Anatomy Department of Universidad Complutense of Madrid were dissected. The triceps–anconeus nerve was located and dissected. A second innervation to the anconeus muscle from a branch of the posterior interosseous nerve (PIN) was occasionally detected. Taking the lateral epicondyle as a landmark, the entry points of both nerves in the muscle were referenced, the triceps–anconeus nerve was referenced at 0°, 30°, 45°, 70° and 90° of elbow flexion, and the PIN branch at 0°. Anconeus muscle was present in all specimens. The triceps–anconeus nerve was present in all of the dissected elbows. A branch from PIN to the anconeus muscle was present in 38 of the 54 elbows (70.4%). There were statistically significant differences in all measurements regarding the specimens’ gender, being higher for men. There is evidence of a high frequency of a double innervation pattern for the anconeus muscle: the main branch of triceps–anconeus muscle depending on the radial nerve, which is liable to being damaged during posterior elbow approaches, and a secondary branch depending on the PIN. There are very few references to this finding in Anatomical literature and none with such a large sample size.

Introduction: Humeral shaft fractures represent 1–3% of all the fractures coming in our OPD. These fractures are mostly treated conservatively. Both the plate fixation and nailing techniques are being used but plate fixation has the advantage of lesser rates of malunion and non-union. Our study aimed to evaluate the results of plate fixation in our hospital that employs plate fixation as the golden standard. Materials and Methods: This was a retrospective cohort study of all patients treated for a humeral shaft fracture in our hospital (District Hospital Vidisha associated with ABV Medical College, Vidisha between July 2018 and June 2020 with a mean follow-up of 6 months. Results: Plate fixation was performed in 40 patients with a humeral shaft fracture. The mean age was 50 (SD 20) years with 60 % (n = 24) being male. There were 55 % (n = 22) fractures in the right and 45 % (n =18) fractures in the left. None of the patients develops superficial surgical site infection. Complications like Radial Nerve palsy, Deep surgical site infections and Non-union occurred in 2.5 % (n = 1), 2.5 % (n = 1) and 5 % (n = 2) of patients, respectively. The median duration of radiological fracture healing was 18 (range 10–42) weeks. Conclusion: Plate fixation for humeral shaft fractures has low risks of complications. The complications can be further minimized with greater surgical expertise.

Background: Robert Wartenberg, a European-American neurologist, was born in 1887 and died in 1956. His description of radial sensory nerve compression at the forearm is memorialized as Wartenberg’s syndrome. He recognized that involuntary abduction of the little finger could be caused by ulnar nerve palsy - a finding often called Wartenberg’s sign Syndrome and signs are reviewed, and a brief biography is presented. Objective: To review Wartenberg’s sign and Wartenberg’s syndrome. Discussion: Compression of the superficial branch of the radial nerve, often called Wartenberg’s syndrome, is characterized by pain, paresthesia, and dysesthesia along the dorsoradial distal forearm. Non-operative treatment can include activity restriction and anti-inflammatory medication. If symptoms persist, surgical decompression of the radial nerve is an option. The abducted posture of the little finger - Wartenberg’s sign - can result from a low ulnar nerve palsy. Tendon transfer can be performed to correct this deformity. Conclusion: Compression of the superficial branch of the radial nerve and abducted posture of the little finger were described by Robert Wartenberg and carry his name as eponymous syndrome and sign, respectively.

Introduction Spontaneous radial nerve palsy with the surgical revelation of an hourglass-like constriction is a complicated condition. In general, the surgical strategy is decided in accordance with the results of surgical exploration. This study aimed to investigate the efficacies of various choices of surgical methods in the treatment of hourglass-like radial nerve constrictions. Material and methods Ten patients with spontaneous radial nerve palsy undergoing surgical exploration with the revelation of hourglass-like constrictions between November 2010 and December 2018 were reviewed in our hospital. Preoperative physical, electrophysiological and ultrasound examinations were performed for all patients. Varying levels, degrees and numbers of radial nerve constrictions were shown by surgical exposure. Epineurectomy and interfascicular neurolysis were performed in 4 cases with incomplete constrictions; resection and primary suture repair in 2 radial nerves with neurotmesis; resection and autologous nerve grafting in 4 patients with nerve defect > 2 cm. Both motor and sensory evaluations were performed at a follow-up visit. Results Ten patients underwent different history before the onset of symptom. Nerve ultrasound demonstrated swelling as well as constrictions of the radial nerve. All patients who were followed up presented with good to excellent recovery of motor function. The effectiveness of suture and autograft repair tended to be better than that of simple neurolysis. Conclusion The etiology of hourglass-like fascicular constrictive neuropathy of radial nerve involve with torsional factors. Nerve ultrasound is an important and useful measurement in diagnosing the pathology of spontaneous radial nerve palsy and in helping determine surgical approach. The surgical intervention is beneficial for the patients who do not recover in 4 weeks after onset of symptoms and for severe hourglass-like constrictions that are confirmed by preoperative ultrasound imaging. We recommend that nerve grafting be a suitable method in confrontation of nerve defect > 2 cm.

Introduction The transfer of intraplexal and extraplexal nerves for restoration of function in children with traumatic and birth brachial plexus palsies has become well accepted. Little has been written about using the long thoracic nerve (LTN) as a donor in reanimation of the upper extremity. The authors present a case series of nerve transfers using the LTN as a donor in brachial plexus injury. Methods A retrospective chart review was performed over a 10-year period at a single institution. The primary outcome measure was the active movement scale. Results Fourteen patients were included in the study: 10 birth injury patients and 4 blunt trauma patients. Average follow-up time was 21.3 and 10.75 months, respectively. The best outcomes were seen when the LTN was used for reinnervation of the obturator nerve in free functioning muscle transfers. The next most successful recipients were the musculocutaneous and axillary nerves. Outcomes were poor in transfers to the posterior interosseous fascicles of the radial nerve and the radial nerve branches to the triceps. Discussion The LTN may be a potential nerve donor for musculocutaneous or axillary nerve reinnervation in patients with brachial plexus injuries when other donors are not available during a primary plexus reconstruction. However, the best use may be for delayed neurotization of a free functioning muscle transfer after the initial plexus reconstruction has failed and no other donors are available. Level of evidence Level IV-therapeutic study.

Background and purposeHumeral shaft fractures are often associated with radial nerve palsy (RNP) (8–16%). The primary aim of this systematic review was to assess the incidence of primary and secondary RNP in closed humeral shaft fractures. The secondary aim was to compare the recovery rate of primary RNP and the incidence of secondary RNP between operative and non-operative treatment.MethodsA systematic literature search was performed in ‘Trip Database’, ‘Embase’ and ‘PubMed’ to identify original studies reporting on RNP in closed humeral shaft fractures. The Coleman Methodology Score was used to grade the quality of the studies. The incidence and recovery of RNP, fracture characteristics and treatment characteristics were extracted. Chi-square and Fisher exact tests were used to compare operative versus non-operative treatment.ResultsForty studies reporting on 1758 patients with closed humeral shaft fractures were included. The incidence of primary RNP was 10%. There was no difference in the recovery rate of primary RNP when comparing operative treatment with radial nerve exploration (98%) versus non-operative treatment (91%) (p = 0.29). The incidence of secondary RNP after operative and non-operative treatment was 4% and 0.4%, respectively (p InterpretationOne-in-ten patients with a closed humeral shaft fracture has an associated primary RNP, of which > 90% recovers without the need of (re-)intervention. No beneficial effect of early exploration on the recovery of primary RNP could be demonstrated when comparing patients managed non-operatively with those explored early. Patients managed operatively for closed humeral shaft fractures have a higher risk of developing secondary RNP.Level of evidenceLevel IV; Systematic Review.

Isolated mononeuropathies are uncommon complications after shoulder dislocations. Of these, injuries to the radial nerve are the rarest. Here, we present a case of an isolated radial nerve palsy after a collegiate athlete was hit during a football game and sustained a glenohumeral dislocation. After reduction of the shoulder, he went on to full recovery of motor and sensory function of the radial nerve 1 year after the injury. This case report is further unique given the long-term follow-up in a young, active patient. We review the sparse literature behind the epidemiology and management of these complications.

The objective of this study is to evaluate the effect of absolute stability (AS) versus relative stability (RS) performed through a minimally invasive plate osteosynthesis (MIPO) in AO/OTA 12A1 and 12A2 fractures on healing and the time to radiographic union. This was a retrospective cohort study of all patients treated with plate fixation for AO/OTA type 12A1–A2 fractures at a single institution. Patients were grouped according to the type of stability used in their surgery. Time until radiographic union was estimated using the Kaplan–Meier method, which was compared by long-rank test between both types of surgical techniques. A total of 70 patients were included in this study with 35 patients in each group. The median follow-up was 9 (IQR 6–14) months. The median time to radiographic union was significantly lower in the AS group than in the RS group: 12 (interquartile range (IQR) 10–14) weeks versus 18 (IQR 16–19) weeks, respectively (p

Background: Detection of peripheral nerve thickening and nerve function impairment is crucial in the diagnosis and the management of leprosy. Aims and objectives: (1) To document the cross-sectional area, echotexture and blood flow of peripheral nerves in healthy controls and leprosy cases using high-resolution ultrasound, (2) to compare the sensitivities of clinical examination and high-resolution ultrasound in detecting peripheral nerve thickening in leprosy. Methods: Peripheral nerves of 30 leprosy patients and 30 age- and sex-matched controls were evaluated clinically and by high-resolution ultrasound. When the cross-sectional area of a peripheral nerve on high-resolution ultrasound in a leprosy patient was more than the calculated upper bound of the 95% confidence interval for mean for that specific nerve in controls, that particular peripheral nerve was considered to be enlarged. Results: Cross-sectional areas more than 7.1 mm2 for the radial nerve, 8.17 mm2 for ulnar, 10.17 mm2 for median, 9.50 mm2 for lateral popliteal and 11.21mm2 for the posterior tibial nerve were considered as nerve thickening on high-resolution ultrasound. High-resolution ultrasound detected 141/300 (47%) nerves enlarged in contrast to the 60 (20%) diagnosed clinically by palpation (P < 0.001). Clinical examination identified thickening in 31/70 (44.3%) nerves in cases with impairment of nerve function and 29/230 (12.6%) in the absence of nerve function impairment. High-resolution ultrasound detected thickening in 50/70 (71.4%) nerves with impairment of function and in 91/230 (39.6%) nerves without any impairment of function. Limitation: A single-centre study design was the major study limitation. Conclusion: High-resolution ultrasound showed greater sensitivity than clinical examination in detecting peripheral nerve thickening in leprosy cases. High-resolution ultrasound, may therefore improve the sensitivity of the diagnostic criterion of peripheral nerve enlargement in the diagnosis and classification of leprosy.

Urgent surgical intervention for amniotic band sequence (ABS) is currently indicated for concerns of vascular compromise and progressive lymphedema. Peripheral motor nerve palsies are rare, and reports of surgical intervention in these cases describe persistent motor dysfunction. We report band release and ulnar, median, and radial nerve decompression in a 1-week-old with a severe upper extremity constriction band and signs of ulnar nerve motor dysfunction. A literature review on nerve exploration and outcomes of patients with motor nerve palsy from ABS was performed. Early evidence of ulnar motor function was observed at 5.5-month follow-up. Previous reports of nerve decompression for upper extremity constriction bands with motor nerve palsy document poor recovery after interventions beginning at 3 months of age. In this case, band release and nerve decompression were undertaken at 7 days of age, and we observed early motor recovery. This finding suggests that very early surgical intervention in the neonate may facilitate nerve recovery in appropriate candidates.

The structure of the proximal margin of the superficial layer of the supinator muscle is of high interest to many researches. Its tendinous appearance, called the arcade of Frohse, may be clinically important because of its close relationship to the deep branch of the radial nerve passing beneath it and is considered to be the cause of several syndromes. Given the importance of this structure, we aimed to provide a comprehensive and evidence-based review with meta-analytic techniques. The meta-analysis was performed in adherence to the PRISMA guidelines. Three medical databases were searched in order to identify all potentially eligible articles. Included studies were assessed for quality and the extracted morphological and morphometric data from the relevant articles was analyzed with the use of random effects meta-analysis. A total of 20 studies were included into this meta-analysis. The pooled prevalence of the arcade of Frohse was calculated to be 66% within the adult population and 0% in the fetuses. Other variations regarding the arcade of Frohse were identified as very rare. Analysis of the morphometric parameters revealed the average proportions to be 23.22 mm for the length, 11.05 mm for the width and the mean thickness is 0.67 mm. The arcade of Frohse is a commonly found structure in adults and thoughtful knowledge of its texture and morphology is especially useful in neurology, neurosurgery, orthopedics, trauma surgery and hand surgery, because it is considered to be the most common source of compression for the deep branch of the radial nerve.

Introduction Ultrasound has been commonly employed for depicting the morphology of the lesions in patients with radial nerve neuropathy, including entrapment, tumor, trauma, and iatrogenic injury. However, few studies have evaluated the efficacy of ultrasound for visualizing radial nerve lesions with coexistent plate fixation of humeral shaft fractures. This study aimed to address this special clinical issue. Methods We retrospectively examined the efficacy of ultrasound for visualizing radial nerve lesions with coexistent plate fixation of humeral shaft fractures based on intraoperative findings in patients who were treated in our hospital from January 2007 to June 2019. Results Forty-six patients were included, and there was a 100% concordance between the ultrasound and intraoperative findings on radial nerve lesions. Ultrasonography revealed four types of lesions: radial nerve in continuity in thirty-one patients, neuroma in continuity in four patients, radial nerve stuck under the plate in three patients, and radial nerve transection in eight patients. The lesion radial nerve in continuity comprised two situations according to intraoperative electrodiagnostic test results, which could not be differentiated by ultrasonography, radial nerve in continuity treated with neurolysis in twenty-five patients and radial nerve in continuity treated with nerve graft in six patients. Conclusion Ultrasonography can accurately depict radial nerve lesions with coexistent plate fixation of humeral shaft fractures. It provides a basis for determining the extent of nerve damage in all patients except those with the lesion radial nerve in continuity, which is conducive to making treatment decisions as early as possible.

The hand grip is severely impaired following high radial nerve palsy due to loss of extension of the wrist, metacarpo- phalangeal joint of fingers and thumb. If radial nerve does not show neural recovery following conservative or surgical repair during the optimum time, tendon transfer is considered the standard treatment. To evaluate and compare the clinical outcome between flexor carpi radialis and flexor carpiulnaris tendon transfer for fingers’ extension in high radial nerve palsy. This randomized controlled trial study was carried out in the Department of Orthopedic Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka over a period of two years from January 2013 to December 2014. A total of 30 patients with high radial nerve palsy were recruited, 15 patients were gone through Flexor Carpi Radialis tendon transfer procedure (FCR group) and the rest 15 patients were gone through Flexor Carpi Ulnaris tendon transfer procedure(FCU group). The patients were followed up for 12 weeks after surgical intervention. Out of all patients, 86.7% male were encountered in each group. The mean age was found 31.07±9.14 years in FCR group and 33.60±10.79 years in FCU group. Humerus fracture was remained a major cause of radial nerve palsy in both FCR and FCU groups (26.7% vs. 33.3%). In final follow-up at 12th week, no extension deficit was observed at MCP joint (93.3% vs. 80.0%, p>0.05).The end result of surgical intervention was found satisfactory equally in both the groups (86.7%). In case of high radial nerve palsy, both FCR and FCU tendon transfer procedures are effective forfingers’ extension at MCP joint. Bangladesh Med J. 2019 Sep; 48 (3): 9-15

The primary aim of this study is to describe medium-term functional outcomes following first dorsal compartment decompression using a longitudinal incision in patients with de Quervain's syndrome. The secondary aims are to describe the improvement in health-related quality of life and patient satisfaction, and to determine the cost-effectiveness of this procedure. Pre- and postoperative QuickDASH, EQ-5D-5 L, and satisfaction scores were collected prospectively over five years. Paired data were available for 36 patients (90% at mean 32 months follow-up). The median QuickDASH score improved significantly from 50 to 9.1 (p 0.01). Median EQ-5D-5L index scores improved from 0.65 preoperatively to 0.73 (p = 0.03). The satisfaction rate was 97% and there were no cases of superficial radial nerve injury or neuroma. The cost per quality-adjusted life year gained was £356 (€398; $449). First dorsal compartment release using a longitudinal incision results in a significant improvement in function, with high levels of patient satisfaction, and low complication rates. In addition, health economic analysis revealed that this is a cost-effective procedure for the treatment of de Quervain's syndrome. LEVEL OF EVIDENCE: III (cohort study).

This article describes the first case of successful nerve grafting for posterior interosseous nerve (PIN) palsy secondary to radiocapitellar joint entrapment 2 years following closed reduction (CR) of a pediatric Monteggia fracture-dislocation (MFD). Patient notes were examined. The literature was reviewed to determine whether similar cases or techniques had been reported. A 5-year-old girl presented with a PIN palsy 2 years following CR of an MFD, demonstrating Medical Research Council (MRC) grade 4 wrist and MRC grade 2 finger and thumb extension. Nerve exploration at 27 months revealed a PIN crushed in the radiocapitellar joint with a proximal neuroma-in-continuity and no response to electrical stimulation. Neurolysis and lateral antebrachial cutaneous nerve cable grafting were performed. The decision to pursue nerve grafting was based on the intraoperative appearance of an atrophic PIN with no response to stimulation, but with minimal muscle atrophy, short distance to target muscles, and pediatric patient with extended reinnervation timeline. Full recovery (MRC grade 5 wrist extension and MRC grade 4+ finger and thumb extension) was achieved at 1-year follow-up. We present the first case of successful nerve grafting for PIN palsy secondary to radiocapitellar joint entrapment 2 years following CR of a type III MFD. Even with significant treatment delay, nerve reconstruction should be considered in the pediatric population.

Light touch of a stable reference reduces sway during standing. However, unexpected displacement of a light touch reference leads to short-latency reactions in ankle muscles consistent with a balance reaction, that are replaced by responses in arm muscles on subsequent trials. We anticipated that the excitability of sensorimotor pathways arising from finger cutaneous afferents would reflect these changes in behavior. We hypothesized that (1) interlimb cutaneous reflexes in muscles of the ipsilateral leg, derived from median nerve (MED) stimulation would be facilitated when touch was stable, but reduced when touch was unreliable, (2) intralimb MED reflexes in muscles of the homonymous arm would be facilitated when touch was unreliable and participants tracked the touch reference with arm movements, and (3) radial nerve (RAD) evoked reflexes would be unaffected, given that the RAD innervation territory is not involved in the light touch task. Cutaneous reflexes were evoked using a transcutaneous train of pulses (5 × 1.0 ms square-wave pulses; 300 Hz) and recorded using electromyography of muscles of the ipsilateral arm and leg. As hypothesized, interlimb MED reflexes recorded in soleus (SOL) were larger when touching the stable reference (mean ± SD % MVC; 4.78 ± 1.57) than when not touching a reference (1.00 ± 1.05) or when touching an unstable reference (1.07 ± 1.16). In addition, intralimb MED reflexes in anterior deltoid (AD) were larger when touching an unstable reference (4.50 ± 1.31), compared to touching a stable reference (1.34 ± 1.01) or not touching (1.50 ± 1.00). In contrast, interlimb RAD reflexes in SOL were larger when not touching (4.29 ± 4.34), compared with touching a stable (1.14 ± 1.84) or unstable reference (3.11 ± 4.15). These findings indicate that cutaneous reflexes from the hand are scaled with a rapid change in motor behavior when a touch reference becomes unstable, suggesting that spinal sensorimotor pathways are functionally reweighted based in part upon the reliability of tactile inputs.

Injury to nerve is a well known complication of shoulder subluxation. Radial nerve injury is most commonly seen during percutaneous nephrolithotomy in lateral decubitus region. If the posterior aspect of the humerus is positioned incorrectly leads to radial nerve compression. Lateral decubitus position in percutaneous nephrolithotomy is the main position for posterior and lateral approaches. After percutaneous nephrolithotomy in lateral decubitus position reported the case of radial nerve palsy. A man of 26 year old from left (contralateral) percutaneous nephrolithotomy with signs of right radial nerve palsy on postoperative day number one. The body mass index is 28 & underwent laterally attempted percutaneous nephrolithotomy on the left and he was located about 6 h and 30 min in the lateral decubitus position. Orthopedics, physiotherapy and electromyography were done to treat radial nerve palsy in the post-operative period. It demonstrates complication of the radial nerve palsy which may be related with percutaneous nephrolithotomy. Being aware of the complication can be used to stop pressure points at percutaneous nephrolithotomy in the lateral decubitus position.

Objetivos: Determinar la viabilidad anatómica del aumento del continente del primer compartimento dorsal y comunicar la experiencia clínica de esta nueva técnica comparada con la liberación clásica. Materiales y Métodos: Estudio anatómico de 12 muñecas cadavéricas para comprobar el aumento del continente del primer compartimento y su relación con la rama sensitiva radial. Estudio clínico retrospectivo que incluyó a pacientes >18 años, sin cirugías previas, con tenosinovitis de De Quervain sin respuesta al tratamiento ortopédico, operados entre enero de 2014 y enero de 2019, y con un seguimiento mínimo de 12 meses. Veintidós pacientes fueron divididos en: grupo A (aumento) y grupo B (liberación simple). La edad promedio era 47 (grupo A) y 50 años (grupo B). La evaluación subjetiva incluyó la escala analógica visual para dolor, el puntaje QuickDASH y el cuestionario de satisfacción PSQ-18; el examen objetivo consistió en evaluaciones goniométrica y dinamométrica. Resultados: El estudio anatómico demostró un aumento del continente del primer compartimento dorsal y una íntima relación con la rama sensitiva radial. El seguimiento promedio del estudio clínico fue 24 y 50 meses, en los grupos A y B, respectivamente. El puntaje promedio de la escala analógica visual para dolor fue 0,5/10 (grupo A) y 1/10 (grupo B). El índice de satisfacción fue del 97% en ambos grupos. El puntaje QuickDASH, las evaluaciones goniométrica y dinamométrica no arrojaron diferencias significativas. Conclusión: La nueva plástica de aumento del continente del primer compartimento dorsal para tratar la tenosinovitis de De Quervain en este estudio anatomoclínico resultó eficaz y reproducible. Palabras clave: Tenosinovitis de De Quervain; aumento; primer compartimento; rama sensitiva radial.Nivel de Evidencia: III

Highlights • Segmental neurofibromatosis with MPNST showing multiple recurrences has not been reported in literature. • Studies were not conducted regarding the survival rate of such patients due to its extreme low incidence. • Being considered as a highly aggressive sarcoma, our patient with MPNST survived for a long period without distant metastasis. • Maintenance of old records helped to carry out review workup effectively., Introduction We present a rare case of Malignant Peripheral Nerve Sheath Tumour (MPNST) of the upper limb, which was excised thirteen times in thirteen years and ultimately ended in above elbow amputation. Presenting complaint and investigations A 48 year old female presented initially with a localised swelling of 2 cms diameter in the front of the left elbow in 2007, which was excised. It recurred repeatedly and was excised. In the earlier presentations, the swellings were firm, mobile and not fixed to bone. In the last stage alone, bone fixity was identified. All the fourteen surgeries were performed by the primary author from 2007 to 2020, as the patient was particular. The main clinical diagnoses had been neurofibroma and fibrosarcoma. There was no evidence of distant metastasis all these years. She did not respond to radiation or chemotherapy. Initially it was single, but later multiple. She had no clinical features of Neurofibromatosis 1 (NF1) or any family history. As the history progressed, the swellings became muscle deep and later encircled the radial nerve. The radial nerve was salvaged on three occasions. On the last three occasions, the tumour had to be shaved off from the humerus. The final amputation specimen showed a single tumour infiltrating the humerus and x-ray revealed bone destruction and tumour calcification. Final diagnosis was aided by immunohistochemistry (IHC) and cytogenetic study (FISH). Conclusion The case is presented for the rarity of the presentation and the trust and dependence of the patient on her personal surgeon.