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Case: We describe a 13-year-old adolescent girl experiencing persistent pain and reduced grip strength following nonoperative treatment of a medial epicondyle fracture-dislocation with closed reduction over 5 years before her referral to our clinic. Neurological examination and magnetic resonance imaging of the elbow revealed damage to the median nerve due to an entrapment within the elbow. Surgical release of the nerve resulted in complete pain relief and improved neurological function with normalized nerve conduction., Conclusion: Persistent neurologic deficits should be investigated following pediatric elbow trauma. Promising results can be achieved with surgical treatment even after long-term entrapment of the median nerve., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C533)., (Copyright © 2025 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: A supracondylar process is a bony spur on the distal anteromedial surface of the humerus, and it is considered an anatomical variant with a prevalence of 0.4-2.7% according to anatomical studies. In almost all cases, it is associated with a fibrous, sometimes ossified ligament, which extends from the supracondylar process to the medial epicondyle. This ligament is known in the literature as the ligament of Struthers, named after the Scottish anatomist who first described it in detail in 1854. In rare cases, the supracondylar process can be a clinically relevant finding as a cause of nerve compression syndrome. The median and ulnar nerve can be trapped by the ring-shaped structure formed by the ligament of Struthers and the supracondylar process., Case Report: A 59-year-old patient with symptoms of a cubital tunnel syndrome and additional ipsilateral sensory deficits in his thumb was referred to our clinic. Electroneurography showed no signs of an additional carpal tunnel syndrome. Preoperative x-ray and CT scans of the upper arm revealed a supracondylar process, which led us to suspect an associated entrapment of the median nerve. An MRI scan of the upper arm showed a ligament of Struthers and signs of a related median nerve compression as we initially assumed. We performed a surgical decompression of the median nerve in the distal upper arm and of the ulnar nerve in the cubital tunnel. Intraoperatively, there was evidence of compression of the median nerve due to the supracondylar process and the ligament of Struthers. The latter was cleaved and then resected along with the supracondylar process. Three months after surgery, the patient had no motor or sensory deficits., Summary: The ring-shaped structure formed by the supracondylar process and ligament of Struthers represents a rare cause of compression syndrome of the median and ulnar nerve. Its incidence remains unknown so far. This anatomical variant should be considered a differential diagnosis in case of possibly related nerve entrapment symptoms after ruling out other, more frequent nerve compression causes. Moreover, the supracondylar process should be completely resected including the periosteum during surgery to minimise the risk of recurrence., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Proximal median nerve (MN) neuropathy represents 1% of upper-limb compressive neuropathies. The literature reports two clinical presentations, depending on the location of the entrapment: pronator teres (PT), and anterior interosseous nerve (AIN) syndrome., Hypothesis: There is no correlation between symptoms and location of proximal compressive structures on the MN trunk or AIN., Patients and Methods: Clinical and paraclinical data from 55 surgical MN releases around the elbow and proximal forearm were analyzed retrospectively. Mean age at diagnosis was 56±15years. Preoperative sensory and motor deficit signs were present in 89% of cases. Reduced MN conduction velocity and/or neurogenic anomalies in the MN territory were present in 94% of cases. Intraoperative details of compressive structures were collected. Patients were followed up in consultation to assess progression of symptoms and deficits., Results: Mean follow-up was 84±70months. Objective motor deficit signs persisted in 18 of the 35 patients (18 cases), and objective sensory signs in 19 cases. A compressive anatomical structure was systematically found. There were at least two MN entrapment sites in 13 cases (24%). No isolated AIN entrapment was found. There was a significant correlation between symptom duration and persistence of objective sensory signs (p=0.002)., Discussion: There was no correlation between entrapment site and clinical signs on examination. Surgery requires exploring all potential entrapment sites. Improvement may be incomplete in case of late treatment., Level of Evidence: IV; retrospective study., (Copyright © 2021 Elsevier Masson SAS. 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.)

A 9-year-old boy sustained an ulnohumeral dislocation with a medial epicondyle fracture and experienced incomplete post-traumatic median nerve palsy in addition to post-traumatic stiffness following closed reduction and cast immobilization. When his motor palsy and stiffness did not improve, MRI and ultrasound were obtained, which demonstrated entrapment of the median nerve in an osseous tunnel at the fracture site, compatible with type 2 median nerve entrapment. Subsequently, the patient underwent surgery to mobilize the medial epicondyle and free the median nerve, resulting in improved range of motion, near complete restoration of motor function, and complete restoration of sensory function in the median nerve distribution within 6 months of surgery. Median nerve entrapment, particularly intraosseous, is a rare complication of posterior elbow dislocation and medial epicondyle fracture that may result in significant, sometimes irreversible, nerve damage if there is a delay in diagnosis and treatment. A high degree of clinical suspicion with early imaging is indicated in patients with persistent stiffness or nerve deficits following reduction of an elbow dislocation. Intra-articular entrapment diagnosed on ultrasound has been reported and intraosseous entrapment diagnosed clinically and on MR neurography have been reported; however, to our knowledge, this is the first reported case of intraosseous (type 2) median nerve entrapment clearly visualized and diagnosed on traditional MRI and ultrasound. The use of ultrasound for diagnosing median nerve entrapment is an accurate, accessible, and non-invasive imaging option for patients presenting with suspected nerve entrapment following elbow dislocation.

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.)

We report an extremely rare case of proximal entrapment neuropathy of the median nerve above the elbow in a 44-year-old man who presented with paresthesia with median nerve distribution. Tinel's sign was located in the upper arm medial to the biceps and 5 cm proximal to the elbow. The patient underwent microsurgery under local anesthesia. The fascia covering the brachial- and the biceps brachii muscle entrapped median nerve. After operation, he reported symptom improvement. Lesions above the elbow should be considered as possible causative factors of entrapment neuropathy of the median nerve.

Besides carpal tunnel and cubital tunnel syndrome, other nerve compression or constriction syndromes exist at the upper extremity. Using the technique of endoscopically assisted decompression such rare nerve compression syndromes of the upper extremity can be treated. The technique of endoscopical decompression is presented in six patients with rare compression or hour-glass-like constriction syndromes at the upper extremity. According to the classification of Roles and Maudsley in 5 of 6 cases excellent results were recorded. All but one patient considered the results excellent. The poorest responder developed a CRPS II and refused postoperative physiotherapy. Endoscopically assisted decompression in rare compression syndrome of the upper extremity is highly appreciated by patients and provides excellent functional results.

This review discusses key diagnostic points and treatment guidelines for compression neuropathies of the wrist, forearm, and elbow. Recent treatment progress is reviewed, controversies are highlighted, and consensus is summarized. Limited or mini-open releases and endoscopic carpal tunnel releases are considered equally safe and efficient. Both methods are currently mainstays of surgical treatment., (Copyright © 2014 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.)

Background: Recurrent or persistent compression neuropathies of the upper extremity, including carpal and cubital tunnel syndrome, present a difficult treatment challenge to the hand or peripheral nerve surgeon. Collagen conduits have been used successfully for decades in nerve injury repair, but have not been studied in the treatment of compression neuropathy., Methods: Patients with recurrent or persistent compression neuropathies treated with a repeat decompression and collagen wrap from a 5-year period were retrieved from the Computerized Patient Record System database and 15 patient records were identified. A systematic review was performed for all articles from 1946 to 2012 on secondary carpal and cubital tunnel syndrome., Results: The mean age of the 15 patients treated was 63.3 years and ranged from 35 to 86 years. The patients with revision carpal tunnel decompression had an 89% subjective response rate, whereas those with revision cubital tunnel decompression had an 83% resolution or improvement of symptoms. Visual analog scale decreased from a preoperative mean 2.47 to 0.47 postoperatively and the mean number of opiate medications decreased from 0.67 to 0.40. We identified 32 papers using various treatment strategies for recurrent carpal tunnel syndrome with success rates ranging from 53% to 100%. We identified 18 papers on recurrent cubital tunnel syndrome, with success rates ranging from 33% to 100%, with a weighted success of 78.1% overall but 71.7% in the submuscular transposition group., Conclusions: Here we report on the novel technique of using a collagen matrix wrap in recurrent compression neuropathies with good success. The collagen wrap allows nerve gliding, protection from perineural scar formation, and a favorable microenvironment. Submuscular transposition seems to be no better than other methods of decompression for recurrent cubital tunnel syndrome in contrary to traditional teaching.

The aetiology of anterior interosseous nerve (AIN) syndrome and an optimal treatment strategy remain controversial. Eleven patients with spontaneous AIN syndrome, who were treated by surgical exploration, were reviewed at a mean of 32.5 months after the operation. Eight men and three women were included in the study. None of the patients had a history of trauma and there was no evidence of a neuropathy other than AIN syndrome. Six patients showed complete paralysis of the flexor pollicis longus (FPL) and the flexor digitorum profundus of the index finger (FDS1). Five patients had incomplete paralysis, with isolated lesions of the FPL in two and the FDP1 in three. Surgery was performed 7.8 months after the onset of paralysis. The most common structure of nerve compression was a fibrous band of the flexor digitorum sublimis muscle. However, no definitive compression site or anatomic abnormality could be found in four patients. Ten of the 11 patients had recovered muscle strength above grade 4 within 12 months of the operation. Good results were obtained in 10 patients and fair in only one at final assessment. Four patients (one man and three women) raised cosmetic concerns due to excessive scar formation on the upper forearm. Surgical exploration is recommended only in cases where AIN syndrome is apparent, no other neuronal lesions are apparent, and where there was no recovery after 6 months of conservative treatment. Careful preoperative examination is essential to avoid misdiagnosis and inappropriate operation, particularly in cases of incomplete AIN syndrome.

Nerve compression syndromes of the upper extremity, including carpal tunnel syndrome, cubital tunnel syndrome, posterior interosseous syndrome and radial tunnel syndrome, are common in the general population. Diagnosis is made based on patient complaint and history as well as specific exam and study findings. Treatment options include various operative and nonoperative modalities, both of which include aspects of hand therapy and rehabilitation.

Background: Besides carpal tunnel and cubital tunnel syndrome, other nerve compression or constriction syndromes exist at the upper extremity. This study was performed to evaluate and summarize our initial experience with endoscopically assisted decompression., Materials and Methods: Between January 2011 and March 2012, six patients were endoscopically operated for rare compression or hour-glass-like constriction syndrome. This included eight decompressions: four proximal radial nerve decompressions, and two combined proximal median nerve and anterior interosseus nerve decompressions. Surgical technique and functional outcomes are presented., Results: There were no intraoperative complications in the series. Endoscopy allowed both identifying and removing all the compressive structures. In one case, the proximal radial neuropathy developed for 10 years without therapy and a massive hour-glass nerve constriction was observed intraoperatively which led us to perform a concurrent complementary tendon transfer to improve fingers and thumb extension. Excellent results were achieved according to the modified Roles and Maudsley classification in five out of six cases. All but one patient considered the results excellent. The poorest responder developed a CRPS II and refused post-operative physiotherapy., Conclusion: Endoscopically assisted decompression in rare compression syndrome of the upper extremity is highly appreciated by patients and provides excellent functional results. This minimally invasive surgical technique will likely be further described in future clinical studies.

Intra-articular entrapment of the median nerve following reduction of a pediatric posterior elbow dislocation is a rare complication but has been reported in the literature.This article describes a case of a 7-year-old girl who sustained a posterior elbow dislocation associated with a medial epicondyle fracture and the subsequent intraosseous entrapment of her median nerve. The entrapment is believed to have resulted from new bone formation over the nerve that went unrecognized for nearly 2 years following injury. Routine imaging studies failed to detect the entrapment prior to exploratory surgery. Intra-articular entrapment of the median nerve must be suspected following pediatric elbow dislocation when concentric reduction fails, postreduction images demonstrate joint widening, or the patient has persistent clinical symptoms. This case demonstrates the potential for delay in diagnosis of the cause for neurological impairment following a relatively common injury in the pediatric population.Objective intraoperative findings and intraoperative micropathology aided in limiting the amount of nerve resected to nonviable portions. Our case demonstrates the potential use of a cable nerve graft to bridge segmental defects in peripheral nerves., (Copyright 2012, SLACK Incorporated.)

The palmaris profundus is a rare, but known anatomic variation which may lead to compression of the median nerve and/or its branches. Two patients with carpal tunnel syndrome are presented in whom a palmaris profundus was discovered at operation. In these cases, median nerve compression at the wrist was attributed to the course of the extra tendon and its local mass effect on the nerve (i.e., the palmaris profundus and median nerve shared a common sheath); more commonly, the resultant decreased available space for the median nerve within the carpal tunnel due to the presence of an accessory (10th) flexor tendon is thought to be responsible. Postoperative 3 Tesla magnetic resonance imaging (MRI) was performed to demonstrate the full course of the variant muscle; despite variations in the size and longitudinal extent of the accessory musculotendinous unit, an important similarity was noted: the intimate relationship of the median nerve and the palmaris profundus. These two cases and our review of the literature highlight the fact that one name (i.e. palmaris profundus) reflects several anatomic subtypes. However, the close relationship of the palmaris profundus with the median nerve in the forearm and the palm is a common theme which emphasizes the potential pathoanatomic consequences of this relationship: nerve compression.

Nerve compressions in the extremities are very common. This article will present relevant pathophysiology of peripheral nerve compression, discuss appropriate patient evaluation techniques, and present current standard methods of treatment for the more common nerve compressions of the upper extremity.

A 42-year-old woman was surgically treated for carpal tunnel syndrome, revealing schwannoma of the median nerve. A year later, she developed a tarsal tunnel syndrome. At time of this diagnosis, hereditary neuropathy with liability to pressure palsies (HNPP) was diagnosed genetically and a schwannoma of the medial plantar nerve was treated surgically. The occurrence of HNPP and schwannomas in the same patient might be purely coincidental, but it is tempting to speculate that they share a common genetic basis.

Unlabelled: CASE STUDIED: Median nerve entrapment is a rare, serious complication of elbow dislocation. We report a Type 4 median nerve entrapment after elbow dislocation in a 10-year-old boy. Radiologically Matev's sign and a new radiological finding-a sclerotic tunnel at the lateral side of the olecranon-were seen., Treatment: The patient was treated by excising the damaged segment and reanastomosing the nerve 13 months after the injury.

Electrophysiological functions of ulnar and median nerves in paucibacillary leprosy patients were studied. Patients who showed deterioration of sensory motor functions in spite of steroid therapy were offered nerve decompression together with oral steroids. On periodic follow-up of those who opted for surgery, it was observed, in general, that NCV and amplitude remained reduced even though clinical recovery occurred. Only 80% recovery of electrophysiological functions was seen (as compared to control levels), even in cases that showed good results. Motor function recovered better than sensory function. Complete electrophysiological recovery, if it occurs at all, takes much longer than clinical recovery.

Loss of pronation affects most activities of daily living. We report 2 cases of traumatic loss of pronator teres function and successful reconstruction by transfer of a redundant motor branch to the flexor digitorum superficialis to the pronator teres branch(es). Follow-up period was 2 years and pronation strength was restored to +4/5 and 5/5 in the 2 patients. The anatomy of the median nerve in the proximal forearm was examined by dissecting 31 cadaver specimens. A branching scheme was formulated. The histomorphometric properties of the individual muscular branches were studied in 15 fresh specimens to evaluate their suitability and size match for nerve transfer.

Two hundred twenty-seven successive cases of carpal tunnel syndrome confirmed by abnormal electrodiagnostic studies were reviewed. All cases underwent open carpal tunnel release by a single surgeon over a 3-year period. Thirty-two hands (14% of all cases) in 29 patients demonstrated an hourglass deformity at the time of surgery. Electrodiagnostic tests revealed no evidence of any other type of peripheral neuropathy in any patient. Postoperative electrodiagnostic studies were obtained in all cases on completion of therapy. The length of the follow-up period averaged 11 months (range, 3-35 months). The duration of preoperative symptoms ranged from 2 years to more than 10 years. Twenty-eight of the 32 hands (88%) with hourglass deformities demonstrated subjective clinical improvement or complete resolution of symptoms. Chronicity of symptoms and electrophysiologic severity did not correlate with the presence of the hourglass deformity. Presence of hourglass compression of the median nerve in carpal tunnel syndrome is therefore not a negative prognostic indicator.

Distal median neuropathy is the most common entrapment neuropathy affecting the upper extremity. Although most often idiopathic, there are a large number of associated medical disorders. Electrophysiologic testing plays a central role in the diagnosis of distal median neuropathy in establishing localization; assessing severity; and excluding disorders of the proximal median nerve, plexus, and nerve roots which can mimic the clinical symptoms of distal median neuropathy. Treatment is usually successful, especially when diagnosis is established early in the course before any significant axonal loss has occurred.

Proximal median neuropathies are uncommon. They are usually caused by overuse of the forearm, anatomic variations, or both. Forearm pain, weakness of muscles supplied by the affected nerves, and sensory loss, including the thenar eminence, are common clinical findings. Nerve conduction studies and needle electromyography are helpful in the diagnosis of these syndromes. Treatment is avoidance of overuse and release of mechanical compression. Prognosis is generally good.

The surgeon's perspective of nerve entrapment lesions in the upper extremity is discussed in this article. The focus is on the most common lesions of the median, ulnar, and radial nerves. An understanding of the anatomy and the potential pathologies provide the basis for surgical treatment. Current treatment protocols are discussed with the authors' recommendations that are based upon experience and literature review.

Objective: To study the compression factor and clinical manifestation of the compression of the palmar cutaneous branch of the median nerve., Methods: Anatomic study was done on both sides of 2 cadavers and 6 cases of hand injury in the debridement, the origin, course, branch of the palmar cutaneous branch of the median nerve were observed. From 1995 to 1998, 12 patients of compression of the palmar cutaneous branch were treated by local blockade injection. Among them, there were 8 males and 4 females, aged from 23 to 65 years and the course of disease ranged 3 to 12 months., Results: The palmar cutaneous branch of the median nerve was (1.3 +/- 0.1) mm in diameter, it could be pulled when the wrist dorsi-extension. All cases showed good recovery of hand function and no recurrence after 4 to 12 months follow-up., Conclusion: The palmar cutaneous branch compression syndrome is closely related to the local anatomy. The diagnosis is definite according to the clinical symptoms and signs, and local blocking is effective on the most patients.

In a patient with severe, recurrent bilateral carpal tunnel syndrome secondary to mucolipidosis, the 'turnover' palmaris brevis flap was used in conjunction with internal neurolysis. The procedure was effective in alleviating symptoms of recurrent carpal tunnel compression in both hands.

Proteus syndrome is a multi-organ disorder, a prime feature of which is localized gigantism, usually clinically obvious. Symptoms secondary to hypertrophy of nerves has not been previously recognized as a part of the syndrome.

Entrapment of the median nerve in the proximal forearm, the so-called pronator syndrome, is considered a rather rare condition but it is four times more common in women than in men. In this study, 23 of 30 female machine milkers with symptoms in the forearm and hand were clinically diagnosed as having the pronator syndrome. The diagnosis of median nerve involvement was based on the clinical history and on physical examination by a hand surgeon. All 23 milkers complained of aching in the volar part of the forearm and had a sensation of numbness, tingling, and decreased muscle strength in their hands, mostly in the hands which usually were statically loaded with heavy equipment. Objectively, all had an experience of tenderness over the pronator teres muscle. Furthermore, they showed reduced muscle strength, especially in the following muscles: pronator teres (PT), flexor carpi radialis (FCR), flexor pollicis longus (FPL), and flexor digitorum profundus II (FDP II). To validate the manual muscle testing, Mannerfeldt's intrinsicmeter was used to quantify the clinically observed weakness. Eight of the 23 milkers with pronator syndrome were surgically released from neuropathy and were almost symptom-free at follow-up after six months. One patient had a slight sensation of numbness and had to be given surgical carpal tunnel release later on. The external exposure of the arm during the application of the milking cluster probably causes muscle and fascial tensions that induce compression of the nerve. Further studies are needed to establish the level of the internal exposure.

Proteus syndrome is a rare congenital disorder comprised of subcutaneous and internal hamartomas, pigmented skin nevi, skull exostoses, hemihypertrophy, and macrodactyly of the hands and feet. A 5-year-old girl diagnosed with Proteus syndrome presented with distal median compression neuropathy with the primary complaint of severe pain involving the left hand. Surgical exploration of the hand revealed a lipofibromatous hamartoma of the median nerve. The transverse carpal ligament was released and epineurectomy of the median nerve was performed. The patient remains symptom free at the 9-month follow-up. This report is the first description of a hamartoma directly involving a peripheral nerve in Proteus syndrome. Decompression of the nerve with the removal of the fibrofatty neural sheath resulted in the resolution of the symptoms in this patient. The surgeon should consider this approach as a potential first line of treatment before a more radical resection of the nerve is contemplated.

Supracondylar process syndrome of the humerus has received little attention in the orthopaedic literature. This case report presents a patient with this condition.

We report a case of an eight-year-old girl with bilateral supracondylar process of the humerus and compression of the median nerve on the left side. A typical ligament of Struthers was found. After resection of bone and ligament, complete recovery was achieved.

The interosseus anterior syndrome is a rare nerve compression syndrome that concerns only the motor branch of the median nerve. It is evidenced by paralysis of the M. flexor pollicis longus and M. flexor digitorum profundus II with weakness of flexion of the terminal joint of the thumb and index finger but without sensory loss. From the surgical point of view this complication has special importance because of pediatric fractures of the distal humerus. In this paper we discuss the differential diagnosis, therapy and prognosis of this nerve injury by presenting an illustrative case of a 7-year-old boy suffering a supracondylar fracture of the humerus with a post-traumatic anterior interosseus nerve syndrome.

An anomalous course of the palmar cutaneous branch of the median nerve was noted in a patient with symptoms of compression of the median nerve and its palmar cutaneous branch at the wrist level. The palmar cutaneous branch of the nerve pierced the tendon of a normal palmaris longus muscle near its insertion. Decompression of the median nerve and its palmar cutaneous branch was performed, with complete relief of symptoms.

The incidence of secondary tumors in the hand is set slightly over 0.1%, the primary tumor localized in the lung, followed by the breast and the kidney. The authors describe a case of a renal carcinoma metastatic to the soft tissue of the palm of the hand in a patient who had undergone nephrectomy for carcinoma of the right kidney eleven years previously. The sixty-one year old female patient developed a swelling of the palm of the left hand and showed symptoms of median and ulnar nerve compression. The patient had neurosurgery because of a solitary metastatic brain tumor of the right hemisphere three months earlier and did not approve to an additional surgical intervention in the hand at that time. The decision was made to treat the tumor with a local radiation therapy. Five months later, the treatment showed no effect and the patient decided to have the operation done. Histologic examination established the diagnosis of a metastatic renal cell carcinoma. The healing was prolonged. An ulceration developed in the distal part of the wound area and healing took seven weeks. Seven months after the operation the patient was alive and well without evidence of disease. The hand showed a good function with little impairment and the symptoms of nerve compression had completely disappeared.

Thirty-nine limbs in 36 patients underwent surgical decompression of the median nerve in the proximal forearm. Seventeen patients with 19 limbs had prior ipsilateral carpal tunnel releases, and 24 had workers' compensation claims related to heavy labor or repetitive tasks. The most common presenting complaints were paresthesias/numbness in the distribution of the median nerve and pain in the forearm or hand. The most common physical finding was a positive pronator compression test, followed by median nerve hypesthesia. Elbow to wrist nerve conduction tests were obtained in 37 of 39 limbs and were abnormal in 12. Intraoperatively, the nerve was compressed at the flexor digitorum superficialis tendon in 22 limbs, pronator teres in 13 limbs, and both in 4 limbs. Postoperatively, 30 limbs had complete or partial relief of symptoms; in a sub-group of 19 limbs that had a prior failed carpal tunnel release, 14 had complete or partial relief. Although there was a trend toward better results in patients with normal preoperative nerve conduction tests and intraoperative compression at the flexor digitorum superficialis, the difference was not significant.

A rare case of median nerve compression syndrome outside the carpal tunnel in the distal forearm is reported. A 21-year-old man suffered while working from symptoms of temporary median nerve compression in both forearms; this was caused by hypertrophy of reversed palmaris longus muscles. Resection of the abnormal muscle bellies relieved the symptoms immediately. Only ten similar cases have been reported in the literature, and this is the first case with bilateral symptoms.

This review of the literature reveals pathology responsible for the occurrence of entrapment neuropathies at the elbow associated with rheumatoid arthritis. Clinical symptoms and surgical treatment of ulnar, radial, and median nerve palsies are described.

A follow-up examination of 21 cases of anterior interosseous nerve syndrome in 20 patients is presented. In 15 patients the anterior interosseous nerve was explored, with objective signs of compression in nine. 11 of these patients showed satisfactory function and three had a tendon transfer. Five cases were not operated on. Two recovered and three had continuous paralysis after more than four years. One patient had a primary tendon transfer. We conclude that exploration of the anterior interosseous nerve is the treatment of choice, and that expectant treatment can be reserved for patients with slight disability or poor general health. As recovery may take over a year, tendon transfer should be postponed until after this period in patients who do not show satisfactory recovery.

Compression neuropathies of the median nerve in the proximal forearm are unusual lesions. Many patients have vague symptoms for many months or even years prior to confirming the diagnosis of either pronator syndrome or anterior interosseous syndrome of the forearm. Serial examinations clinically and electrodiagnostically may be necessary at intervals of 6 to 8 weeks as required for the evaluation of the patient's symptoms. As with other compression neuropathies, the diagnosis is solely dependent on the diagnosis of neuropathy of the median nerve using whatever parameter satisfies the surgeon's diagnostic criteria and then having made that diagnosis, localizing the site of that neuropathy by physical examination or electrodiagnosis with the support of radiographic techniques as appropriate. Surgical exploration of proximal median nerve compression is normally followed by prompt and predictable recovery from the median neuropathy and clinical symptoms between 8 and 12 weeks after surgical exploration. Prolonged symptom complexes after surgical exploration of the proximal median nerve are, in my experience, due to either (1) extremely severe median nerve injury secondary to pronator syndrome with prolonged recovery and distal nerve axomnetic recovery into the hand, or (2) sensory nerve dysesthesis of the small sensory nerves on the proximal volar surface of the forearm. The symptoms of either of these postoperative findings normally improve with time.

The evaluation and treatment of five patients with upper extremity neuropathies secondary to Charcot-Marie-Tooth disease were reviewed with emphasis on age at onset of Charcot-Marie-Tooth disease and upper extremity deformities, clinical findings, signs of associated nerve compression, and outcome of surgical treatment. The onset of the disease generally occurred in the first or second decade of life. The onset of upper extremity symptoms lagged behind by an average of 8 years. All patients had intrinsic minus hands with decreased sensibility. Three of five patients had clinical or electrophysiologic evidence of associated nerve compression syndromes. Treatment with standard tendon transfers, nerve compression releases, soft tissue releases, and joint fusions resulted in subjectively improved function in three of four patients undergoing reconstruction. Release of six compression neuropathies in one patient provided excellent pain relief, but the underlying neuropathy progressed. Pessimism regarding reconstructive surgery in the patient with upper extremity neuropathies secondary to Charcot-Marie-Tooth disease is unwarranted.

In the case of combination of osteopoikilosis with dermal alterations we wanted to know if the hereby discussed general mesenchymal lesions are the cause of the additional entrapment syndromes of peripheral nerves present in our case. For this purpose we recorded the pressure at the distal median and ulnar nerves within and out of the entrapment location. The results of the pressure recording of not point to a primary nerve lesion by a elevated pressure susceptibility or a pressure elevation at the peripheral nerve out of a defined entrapment location e.g. by an increase of connective tissue. Because of a hypertrophic scar formation in this case it should be paid attention to the wound healing of all patients with osteopoikilosis. The histologically verified nevoid mesenchymal alterations of the connective tissue found in this case, are to be delineated from the disseminated lenticular dermatofibrosis of the Buschke-Ollendorff syndrome.

Hemorrhagic events in patients undergoing fibrinolytic therapy for acute myocardial infarction are well known. We report a case of acute compression of the median nerve caused by a hematoma in the carpal tunnel following infusion of streptokinase in a 71 year-old man with acute myocardial infarction. Operative decompression was carried out. The postoperative course was uneventful, with complete recovery from symptoms of median nerve entrapment.