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Brachial plexus injuries (BPIs) caused by shoulder dislocation usually have a transient character and tend to resolve spontaneously. However, in some patients the symptoms can persist and require operative intervention. This work aims to determine the risk factors for persistent BPIs resulting from shoulder dislocation. The study comprised 73 patients (58 men, 15 women; mean age: 50 years) treated operatively between the years 2000 and 2016 for persistent BPIs resulting from shoulder dislocation. Patient age, gender, type of initial trauma, number of affected nerves, presence of accompanying injuries, and time interval from dislocation to its reduction were analysed. Elderly patients more often sustained multiple-nerve injuries, while single nerve injuries were more often observed in younger patients. Injury to a single nerve was diagnosed in 30% of the patients. Axillary nerve was most commonly affected. Fracture of the greater tuberosity of humerus coincided with total BPI in 50% of the cases. Longer unreduced period caused injury to multiple nerves. Analysis of our patient group against relevant literature revealed that persistent BPI after shoulder dislocation is more common in older patients. Injuries to ulnar and median nerves more often require operative intervention due to low potential for spontaneous recovery of these nerves.

Purpose: In high median nerve repairs, thenar muscle reinnervation is impossible because of the long distances over which axons must regenerate. To overcome this obstacle, we propose transferring the abductor digiti quinti motor branch (ADQMB) to the thenar branch of the median nerve (TBMN)., Methods: We used 10 embalmed hands for anatomical and histological studies. Thereafter, 5 patients with a high median nerve injury underwent surgical reconstruction within 8 months of their accident and were followed for at least 10 months after surgery (mean, 13.2 months). We transferred the ADQMB to the TBMN. The median nerve was grafted in 4 patients and the motor branch of the extensor carpi radialis brevis was transferred to the anterior interosseous nerve in 3. Patients had pre- and postoperative evaluations of thumb range of motion and strength., Results: In cadaveric hands, the ADQMB was the first branch of the ulnar nerve to arise near the pisiform bone. The TBMN arose from the anterior surface of the median nerve, underneath the flexor retinaculum. Retrograde dissection of the TBMN allowed tension-free coaptation with the ADQMB. Both branches contained approximately 650 myelinated fibers. After surgery, all our patients improved thumb pronation, thenar eminence bulk, and abductor pollicis brevis British Medical Research Council score. They recovered approximately 75% of their normal-side grasp and pinch strength. No patient lost little finger abduction., Conclusions: Transfer of the ADQMB to the TBMN reinnervated the thenar muscles, which improved thumb range of motion and strength., Type of Study/level of Evidence: Therapeutic V., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Presents a case report of carpal tunnel syndrome with associated wrist triggering caused by an intramuscular lipoma in anomalous muscle belly of the middle finger lumbrical. Information on the case of a 43-year-old man presented with triggering of the left wrist related to the use of the flexor tendons of that hand of several months' duration; Discussion of the case.

A rare case of acute carpal tunnel syndrome is described. This is the first report of an acute tear within a lumbrical muscle causing carpal tunnel syndrome. A review of related cases in the literature is also presented. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about tarsal tunnel syndrome caused by synovial sarcoma.

An anomaly of the median nerve in which there is a division into two branches at the level of the distal third of the forearm is reported. This case was unique in that the ulnar branch of the median nerve passed through a separate compartment within the transverse carpal ligament. It was necessary to decompress both branches of the nerve when releasing the carpal canal. [ABSTRACT FROM AUTHOR]

A case of isolated thenar wasting caused by a large superficial palmar branch of the radial artery is reported. [ABSTRACT FROM AUTHOR]

Provides information on carpal tunnel syndrome (CTS). Characterization of the illness; Clinicopathological correlations and pathophysiology of CTS.

This is a case report of carpal tunnel syndrome caused by an idiopathic calcareous lesion within the carpal canal. The median nerve was trapped between the transverse carpal ligament and the calcified mass. The mass was predominantly composed of calcium phosphate. Surgical release of the transverse carpal ligament and removal of the calcareous mass relieved the symptoms. [ABSTRACT FROM AUTHOR]

The article presents a study which examined the efficacy of a corticosteroid injection just proximal the carpal tunnel for carpal tunnel syndrome (CTS). This syndrome is caused by compression of the median nerve at the wrist that results in hand numbness, loss of dexterity, muscle wasting and decreased functional ability at work. Injection with methylprednisolone proximal to the carpal tunnel is effective in stopping the symptoms of CTS. It can also cause prolonged relief in half of treated patients for at least 1 year.

Background: Little attention has been given to neurologic complications after shoulder joint replacement (SJR). Previously thought to occur infrequently, it is likely that many are not clinically recognized, and they can result in postoperative morbidity and impair the patient's recovery. The purpose of this study was to document the prevalence of nerve complications after SJR, to identify the nerves involved, and to define patient outcomes., Methods: This was a retrospective review of 211 SJRs in 202 patients during a 5-year period were included, with 89 male and 122 female patients at an average age of 70 years. All patients underwent a comprehensive analysis of any postoperative nerve complication, including onset, duration, investigation, treatment, and symptom resolution., Results: Of the 211 SJR procedures, 44 were identified as having sustained a nerve complication (20.9%), with 36 female (81.8%) and 8 male patients (18.2%). Reverse SJR was associated with the highest number of nerve complications. The median nerve (25 patients) and musculocutaneous nerve (8 patients) were most commonly involved. Most nerve complications were transient and resolved within 6 months. Permanent sequelae and injuries that required secondary surgical intervention were rare., Conclusion: The occurrence of nerve complications after SJR is common, but almost all will fully recover. Most are transient neurapraxias involving the lateral cord of the brachial plexus. Women are more likely to be affected, as are patients who have undergone prior surgery to the affected shoulder. Most are likely to be the result of excessive traction or direct injury to the nerves during glenoid exposure., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: Peripheral nerve injuries (PNI) are among the leading causes of physical disability in the United States. The majority of injuries occur in the upper extremities, and functional recovery is often limited. Robust animal models are critical first steps for developing effective therapies to restore function after PNI., Methods: We developed an automated behavioral assay that provides quantitative measurements of volitional forelimb strength in rats. Multiple forelimb PNI models involving the median and ulnar nerves were used to assess forelimb function for up to 13 weeks postinjury., Results: Despite multiple weeks of task-oriented training following injury, rats exhibit significant reductions in multiple quantitative parameters of forelimb function, including maximal pull force and speed of force generation., Discussion: This study demonstrates that the isometric pull task is an effective method of evaluating forelimb function following PNI and may aid in development of therapeutic interventions to restore function. Muscle Nerve 56: 1149-1154, 2017., (© 2017 Wiley Periodicals, Inc.)

Background: Our aims were to identify iatrogenous injuries to the palmar branch of the median nerve sustained during volar plate fixation of the distal radius, make the clinician aware of this relatively uncommon complication of distal radius fixation, to emphasise common threads in symptomatology and to propose an algorithm for evaluation and management., Methods: Retrospectively interrogating our database over a 5 year period, the case records, neurophysiology records, operative records, therapy records were reviewed. The data was analysed with regard to the grade of surgeon performing the procedure, the site of injury, complexity of the fracture, delay to surgery, implant choice and outcome of the treatment. Variations in nerve anatomy were documented during revision surgery and common themes in symptomatology and clinical presentation were identified., Results: Seven patients with an iatrogenic injury involving the palmar branch of the median nerve associated with volar plate fixation of the distal radius were assessed. The male: female ratio was 1:6 and the mean age of patients was 47.8 years (33-74 years). The initial operative fixation was undertaken by a consultant orthopaedic surgeon at a mean of 7.8 (1-17) days from injury. The mean time from fracture fixation surgery to referral to the peripheral nerve injury service was 8.9 (2-36) months. Six patients presented with pain on attempted wrist extension. Five patients had parasthesia, hyperaesthesia or dysaesthesia in the distribution of the PCBMN. Anaesthesia or hypoaesthesia was present in three patients. Two patients presented with symptoms of complex regional pain syndrome (CRPS) Type 2., Conclusions: Revising relevant anatomy and possible variations as well as careful placements of retractors in the region of the median nerve could bring down these injuries. We propose an algorithm for their management.

Background: The objective of this clinical study was to evaluate sensory and motor functions in the later period following primary repair of combined injuries of the ulnar and median nerves in the forearm at proximal, middle, and distal levels., Methods: Later period sensory evaluation of ulnar and median combined cuts was performed using two-point discrimination and monofilament tests. On the other hand, motor evaluation was performed by determining dorsal palmar interosseus strength for the ulnar nerve and abductor pollicis brevis muscle strength for the median nerve. Cold intolerance, object recognition, and weight discrimination were also reviewed., Results: In total, 26 patients with ulnar-median combined cut and aged between 5 and 59 years were included in this study. Although no deficiency was observed in the sensory functions of any of the patients, a decrease in tactile sensation was detected in the median sensory region in 12 (46%) patients and in the ulnar sensory region in 7 (26%) patients. The most significant loss in terms of motor functions was detected in the opposition pinch strength. Two patients developed claw hand and two showed joint contracture., Conclusion: Ideal treatment for peripheral nerve injuries should be primary repair. Restoration of the motor function in the median nerve is relatively easier than that in the ulnar nerve. No significant difference was observed in terms of sensory function. An alternative is needed for primary repair because of lack of motor function in proximal ulnar incisions. There is no standardization of tests performed for peripheral nerve repair.

Background: Iatrogenic nerve injuries are nerve injuries caused by medical interventions or inflicted accidentally by a treating physician., Methods: We describe and analyze iatrogenic nerve injuries in a total of 122 consecutive patients who received surgical treatment at our Institution during a period of 10 years, from January 1, 2003, to December 31, 2013. The final outcome evaluation was performed 2 years after surgical treatment., Results: The most common causes of iatrogenic nerve injuries among patients in the study were the operations of bone fractures (23.9%), lymph node biopsy (19.7%), and carpal tunnel release (18%). The most affected nerves were median nerve (21.3%), accessory nerve (18%), radial nerve (15.6%), and peroneal nerve (11.5%). In 74 (60.7%) patients, surgery was performed 6 months after the injury, and in 48 (39.3%) surgery was performed within 6 months after the injury. In 80 (65.6%) patients, we found lesion in discontinuity, and in 42 (34.4%) patients lesion in continuity. The distribution of surgical procedures performed was as follows: autotransplantation (51.6%), neurolysis (23.8%), nerve transfer (13.9%), direct suture (8.2%), and resection of neuroma (2.5%). In total, we achieved satisfactory recovery in 91 (74.6%), whereas the result was dissatisfactory in 31 (25.4%) patients., Conclusions: Patients with iatrogenic nerve injuries should be examined as soon as possible by experts with experience in traumatic nerve injuries, so that the correct diagnosis can be reached and the appropriate therapy planned. The timing of reconstructive surgery and the technique used are the crucial factors for functional recovery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The pucker sign, also called skin tenting, indicates significant displacement of the supracondylar fracture and can be a cause for alarm. The purpose of this study is to compare a cohort of patients with type III supracondylar fractures presenting with a pucker sign to a group without a pucker sign by evaluating neurovascular injury at presentation, need for open reduction, persistent neurovascular injury, range of motion, and carrying angle at final follow-up., Methods: A retrospective review was performed for Gartland type III extension type supracondylar fractures. Those with a pucker sign were identified and evaluated. Type III supracondylar fractures with a pucker sign were compared with a similar cohort without a pucker sign., Results: In total, 12 patients with a pucker sign at an average age of 5.2 years were evaluated. A total of 11 patients (92%) had diminished or absent pulses, and 2 (17%) had weakness in the median nerve distribution. Nine (75%) patients in this group were transferred to the university hospital. Average time to surgery was 8.9 hours with an average operating time of 25.1 minutes. Open reduction was not needed in any case. At an average follow-up of 4.7 months no patients had persistent neurovascular compromise. Two patients lacked <5 degrees of extension and 1 lacked 10 degrees of extension. One patient lacked 10 degrees of flexion. No patients had a change in carrying angle difference compared with the contralateral side. No statistical differences were observed between the 2 groups., Conclusions: Pucker sign, in the context of a supracondylar fracture of the humerus, is a soft tissue defect with potential entrapment of median nerve and brachial artery. At a maximum time of 16 hours from injury to surgery we report excellent outcomes and no long-term complications. Using the techniques of gradual traction, and milking the soft tissue, the pucker sign can be eliminated. Closed reduction and percutaneous pinning were performed in all the cases., Level of Evidence: Level III-retrospective comparative study.

Background: Neuropathic symptoms after median nerve repair at the wrist or secondary to refractory carpal tunnel syndrome may become debilitating. These symptoms develop because of perineural adhesions, intraneural fibrosis, and fixation of the nerve to the transverse carpal ligament after surgery, and often require neurolysis. Interposition of vascularized soft tissue over the median nerve at the time of neurolysis prevents recurrence of such adhesions. The synovial flap, fashioned from the synovial lining of the flexor tendon sheath, is an ideal tissue for this purpose. Previous authors have described the surgical technique of the synovial flap, but the anatomical basis and design of the flap have not been previously discussed., Methods: Twenty fresh cadaver upper extremities were injected with Microfil to analyze the arterial anatomy, flap dimensions, and arc of rotation of the flexor tendon synovium mobilized as a flap suitable for coverage of the median nerve at the wrist. The authors determined that both radial and ulnar-based flaps are clinically useful for providing coverage in the wrist and distal forearm. This flap was used in 18 patients with complicated median nerve lesions in this region., Results: All patients had an uncomplicated postoperative course. Of 13 patients treated for posttraumatic median nerve neuromas, all but two had significant resolution of symptoms., Conclusions: When used as a vascularized flap, the flexor tendon synovium provides adequate protection of the median nerve. Flap dimensions and vascularity of this tissue make it an ideal local flap option when performing reoperative surgery on the median nerve.

Background: In cases of high ulnar nerve palsy, result of nerve repair in term of intrinsic muscle recovery is unsatisfactory. Distal nerve transfer can diminish the regeneration time and improve the results. But, there was no perfect distal nerve transfer for restoring intrinsic hand function in combined proximal median and ulnar nerve injuries. This cadaveric study aims to evaluate the possibility and feasibility of supinator nerve transfer to motor branch of ulnar nerve (MUN)., Methods: Ten cadaveric upper limbs dissected to identify the location of the supinator branch, anterior interosseous nerve (AIN), and MUN. The AIN was cut from its origin and transferred to the supinator branches. Also, the AIN was distally cut and transferred to the MUN. After nerve coaptation, surface area, fascicle count, and axon number were determined by histologic methods., Results: In all limbs, the proximal and distal stumps of AIN reached the supinator branch and the MUN without tension, respectively. The mean of axon number in the supinator, proximal stump of AIN, distal stump of AIN and MUN branches were 32,426, 45,542, 25,288, and 35,426, respectively., Conclusions: This study showed that transfer of the supinator branches to the MUN is possible via the in situ AIN bridge. The axon count data showed a favorable match between the supinator branches, AIN, and MUN. Therefore, it is suggested that this technique can be useful for patients with combined high median and ulnar nerve injuries., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Magnetic resonance scans on patients with non-specific arm pain (repetitive strain injury) show reduced median-nerve movement in the carpal tunnel, suggesting that this common condition may involve nerve entrapment. [ABSTRACT FROM AUTHOR]

Presents an abstract of the article `Prevalence of Carpal Tunnel Syndrome in a General Population,' by I. Atroshi, C. Gummesson, et al. published in the 1999 issue of the `Journal of American Medical Association.'

Editorial. Highlights some of the flaws in the study by Atroshi et al in the July 14, 1999 'Journal of the American Medical Association'. Questions regarding the nature of Carpal Tunnel Syndrome (CTS); Statistics relating to diagnosis and testing for CTS.

OBJECTIVE A thorough understanding of anatomy is critical for successful carpal tunnel release. Several texts depict the median nerve (MN) as taking a course parallel to the long axis of the forearm (LAF). The authors report on their attempt to formally assess the course of the MN as it travels to the carpal tunnel in the distal wrist and discuss its potential clinical significance. METHODS The width of the wrist, the distance from the radial wrist to the MN, and the distance from the distal volar wrist crease to the point where the MN emerges between the flexor carpi radialis (FCR) tendon and the flexor digitorum superficialis (FDS) tendons were recorded during cadaveric dissection of 76 wrist specimens. The presence or absence of palmaris longus was documented. Finally, the angles between the MN and FCR tendon and between the MN and the LAF were measured using ImageJ. RESULTS The relative position of the MN at the distal wrist crease, as determined by the ratio of the distance from the MN to the radial wrist divided by wrist width, revealed a mean value of 0.48, indicating that the nerve was usually located just radial to midline. The mean distance between the distal wrist crease and the MN's emergence was 34.6 mm. The mean angle between the MN and the FCR tendon was 14.1°. The angle between the MN and the LAF had a mean value of 8.8° (range 0.0°-32.2°). The nerve was parallel to the LAF in only 10.7% of the studied wrists. Palmaris longus was absent in 14 (18.4%) of the 76 wrists. CONCLUSIONS The MN takes an angular approach to the carpal tunnel in the distal wrist in the vast majority of cases. This newly described finding will be useful to both clinicians and anatomists.

A systematic review of the literature was performed to compare complications of endoscopic and open carpal tunnel release. Techniques were further subdivided into traditional open, limited open, single-portal endoscopic, and two-portal endoscopic. This study also compared incidence of complications in each group based on chronological periods of data collection. The study found that endoscopic release has a higher incidence of transient nerve injury. There was also an increased incidence of superficial palmar arch injuries in the endoscopic group in the 1960-1990 time period as compared with the 1991-2000 and 2001-2012 periods. No difference was found in scar complications between open and endoscopic groups. While vascular injuries have decreased over time, the rate of nerve injuries has not changed since the introduction of endoscopic release. This higher incidence of transient nerve injury and lack of increased skin complications should be weighed when deciding between open and endoscopic techniques.

Presents an abstract of a paper entitled `Influence of Wrist Dimensions on Sensory Nerve Conduction Studies,' by J.J. Dagostino, C.A. Lavayen et al, presented at the Physical Therapy `97: Scientific Meeting and Exposition of the American Physical Therapy Association.

Focuses on the study `The valve of special motor and sensory tests for the diagnosis of benign and minor median nerve lesion at the wrist,' by P Seror. Comparison of the median and ulnar nerve conductions at the wrist; Recording of the compound motor unit action potentials (CMAP) from the abductor pollicis brevis muscle and ulnar thenar muscles.

Purpose . Analysis of early vascular and nerve complications of supracondylar humerus fractures in children. Material and Methods . 220 children hospitalized in the Pediatric Trauma-Orthopedic Department in the years 2004-2014. The group consisted of 143 males and 77 females. Results . Acute neurovascular complications occurred in 16.81% of patients with displaced supracondylar fracture (37 children). Nerve damage was found in 10% of patients with displaced fracture (22 children). The most injured nerve was median nerve; this complication occurred in 15 patients (68.18%). The total nerve function returned after average of 122 days (0-220 days after surgery). Symptoms of vascular injury occurred in 7.7% children with displaced fracture (17 children). Conclusions . (1) In children with supracondylar fracture the most often injured nerve is median nerve. (2) The incidence of vascular and nerve complications positively correlates with the progression of fracture according to Gartland classification., Competing Interests: No conflicts of interest were declared by the authors.

Background: A rare and disastrous complication of harvesting a tendon graft is the misidentification of the median nerve for the palmaris longus. Methods: The authors report a referred case in which the median nerve was harvested as a free tendon graft. Results: Few reports of this complication are found in the literature despite the frequency of palmaris longus tendon grafting and the proximity of the palmaris tendon to the median nerve. Given the obvious medicolegal implications, the true incidence of this complication is difficult to assess. Discussion: Safe harvesting of the palmaris longus mandates a thorough understanding of the relevant anatomy, in particular the proper differentiation between nerve and tendon and recognition of when the palmaris longus tendon is absent. Techniques to facilitate proper identification of the palmaris longus are outlined., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: A retrospective cohort study., Introduction: Some patients after median or ulnar nerve injury report a diminished sensibility in the fingers that are supplied by the uninjured nerve., Purpose of the Study: The purpose of this study was to evaluate the function of the uninjured nerve in patients after peripheral nerve injury to assess the presence and degree of its functional impairment., Methods: There were 28 patients with median and 29 patients with ulnar nerve injury examined for sensory disturbances in the injured and uninjured nerves, using several tests assessing touch, temperature, and vibration sensibility., Results: In 16 patients after ulnar and 13 patients after median nerve injury, some disturbances in the uninjured nerve were found, mostly in individual tests. Only 8 patients had 3 or more different tests abnormal., Discussion: The injured nerve function in patients with functional disturbances in the uninjured nerve was worse than in patients with normal test results., Conclusion: Posttraumatic changes in central nervous system are the possible reasons., Level of Evidence: Level III study., (Copyright © 2016 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.)

Background: Mechanisms underlying neuropathic pain relief by the neurosteroid allopregnanolone remain uncertain. We investigated if allopregnanolone attenuates glial extracellular signal-regulated kinase (ERK) activation in the cuneate nucleus (CN) concomitant with neuropathic pain relief in median nerve chronic constriction injury (CCI) model rats., Methods: We examined the time course and cellular localization of phosphorylated ERK (p-ERK) in CN after CCI. We subsequently employed microinjection of a mitogen-activated protein kinase kinase (ERK kinase) inhibitor, PD98059, to clarify the role of ERK phosphorylation in neuropathic pain development. Furthermore, we explored the effects of allopregnanolone (by mouth), intra-CN microinjection of γ-aminobutyric acid type A receptor antagonist (bicuculline) or γ-aminobutyric acid type B receptor antagonist (phaclofen) plus allopregnanolone, and allopregnanolone synthesis inhibitor (medroxyprogesterone; subcutaneous) on ERK activation and CCI-induced behavioral hypersensitivity., Results: At 7 days post-CCI, p-ERK levels in ipsilateral CN were significantly increased and reached a peak. PD98059 microinjection into the CN 1 day after CCI dose-dependently attenuated injury-induced behavioral hypersensitivity (withdrawal threshold [mean ± SD], 7.4 ± 1.1, 8.7 ± 1.0, and 10.3 ± 0.8 g for 2.0, 2.5, and 3.0 mM PD98059, respectively, at 7 days post-CCI; n = 6 for each dose). Double immunofluorescence showed that p-ERK was localized to both astrocytes and microglia. Allopregnanolone significantly diminished CN p-ERK levels, glial activation, proinflammatory cytokines, and behavioral hypersensitivity after CCI. Bicuculline, but not phaclofen, blocked all effects of allopregnanolone. Medroxyprogesterone treatment reduced endogenous CN allopregnanolone and exacerbated nerve injury-induced neuropathic pain., Conclusions: Median nerve injury-induced CN glial ERK activation modulated the development of behavioral hypersensitivity. Allopregnanolone attenuated glial ERK activation and neuropathic pain via γ-aminobutyric acid type A receptors. Reduced endogenous CN allopregnanolone after medroxyprogesterone administration rendered rats more susceptible to CCI-induced neuropathy.

Nerve damage is a common complication of distal radius fractures. It may be a result of the injury event or be iatrogenic. It is the source of disability and potential handicap. There is little published data on this topic and no study has validated the strategies needed to prevent or manage these nerve-related complications. There is no consensus on treatment. Prevention requires a good knowledge of the various surgical approaches and rigorous fracture fixation technique. The objective of this article is to take stock of recent data from the scientific literature., (Copyright © 2016 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Background: Nerve transfers have resulted in increased interest in the microanatomy of peripheral nerves. Herein, we expand our understanding of the internal anatomy of the digital nerve to the ulnar index and long fingers, the radial long and ring fingers, and the nerves to the second and third web spaces. Methods: The median nerve was dissected from the digital nerves to the antecubital fossa in 14 fresh upper extremities. The distance of proximal internal neurolysis of the fascicles to the second and third web space and proper digital nerves was measured relative to the radial styloid. Plexi encountered during proximal lysis were noted. Results: Digital nerves to the ulnar index and radial long fingers were lysed 2.4 ± 0.5 cm (mean ± SD), and digital nerves to the ulnar long and the radial ring fingers were lysed 3.0 ± 0.6 cm distal to the radial styloid. Fascicles to the third web space were lysed to the takeoff of the anterior interosseous nerve, 21.1 ± 1.4 cm. Plexus groupings were encountered at 4.5 ± 1.6 cm, 8.3 ± 1.2, cm and 16.1 ± 1.9 cm proximal to radial styloid. The fascicles to the second web space were lysed to 5.0 ± 1.2 cm proximal to radial styloid where a plexus grouping was encountered. Another plexus group was found at 3.3 ± 1.3 cm. Conclusions: We demonstrate that extended internal neurolysis of second web space, along with the digital nerves, is technically and clinically feasible. This technique can be used to treat mixed median nerve injury in the hand and wrist., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

To examine the complications of brachial and axillary artery punctures and the precautionary measures taken to lower their incidences. Retrospective analysis of 266 cases of brachial and axillary artery punctures was performed for angiography or angioplasty between January 2009 and December 2013 at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University. Complications and their causes were assessed. Among all brachial artery punctures (n = 140), there were complications in 3.6 per cent of cases, including local hematoma in 1.4 per cent, pseudoaneurysm in 0.7 per cent, acute arterial thrombosis in 0.7 per cent, and median nerve injury in 0.7 per cent. Among all axillary artery punctures (n = 126), there were complications in 10.3 per cent of cases, including local hematoma in 4.8 per cent, pseudoaneurysm in 0.8 per cent, acute arterial thrombosis in 0.8 per cent, acute venous thrombosis in 0.8 per cent, and nerve injury in 3.2 per cent. The incidence of complications was significantly lower in brachial axillary artery puncture compared with axillary artery puncture (P < 0.05). The main factors associated with complications might be patient's vascular condition, perioperative medication, anatomical features of the artery, puncture site, successful rate of first-attempt puncture, and bandage strength. Incidence of complications of brachial and axillary artery punctures could be lowered by strengthening the choice of indications, improving the perioperative managements, being fully aware of the anatomical characteristics of the brachial and axillary arteries, and applying the standardized techniques of puncture and compression hemostasis.

Luxatio erecta humeri (LEH) is a rare type of shoulder dislocation in which the humeral head becomes trapped beneath the glenoid. Patients present with the arm in a fixed hyperabducted position. LEH is estimated to occur in 0.5% of all shoulder dislocations, most often caused by trauma and has a significant association with local bone, ligament and less frequently neurovascular injury. We present a case with initial neurovascular compromise and sustained neurological impairment at long-term follow-up. Urgent closed reduction is advocated and subsequent treatment is dependent on associated injuries., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

Peripheral nerve injuries result in reorganization within the contralateral hemisphere. Furthermore, recent animal and human studies have suggested that the plastic changes in response to peripheral nerve injury also include several areas of the ipsilateral hemisphere. The objective of this study was to map the inter-hemispheric plasticity in response to median nerve injury, to investigate normal differences in contra- and ipsilateral activation, and to study the impact of event-related or blocked functional magnetic resonance imaging (fMRI) design on ipsilateral activation. Four patients with median nerve injury at the wrist (injured and epineurally sutured >2 years earlier) and ten healthy volunteers were included. 3T fMRI was used to map the hemodynamic response to brain activity during tactile stimulation of the fingers, and a laterality index (LI) was calculated. Stimulation of Digits II-III of the injured hand resulted in a reduction in contralateral activation in the somatosensory area SI. Patients had a lower LI (0.21±0.15) compared to healthy controls (0.60±0.26) indicating greater ipsilateral activation of the primary somatosensory cortex. The spatial dispersion of the coordinates for areas SI and SII was larger in the ipsilateral than in the contralateral hemisphere in the healthy controls, and was increased in the contralateral hemisphere of the patients compared to the healthy controls. There was no difference in LI between the event-related and blocked paradigms. In conclusion, patients with median nerve injury have increased ipsilateral SI area activation, and spatially more dispersed contralateral SI activation during tactile stimulation of their injured hand. In normal subjects ipsilateral activation has larger spatial distribution than the contralateral. Previous findings in patients performed with the blocked fMRI paradigm were confirmed. The increase in ipsilateral SI activation may be due to an interhemispheric disinhibition associated with changes in the afferent signal inflow to the contralateral primary somatosensory cortex., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To measure distances from anatomical landmarks to the median nerve, and estimate the length of the flexor-pronator/flexor carpi ulnaris (FCU) detachment necessary to expose the anteromedial facet of the ulnar coronoid process (UCP) using the Hotchkiss over-the-top approach., Methods: Dissections were made of 20 fresh-frozen cadaveric upper limbs. Measurements were made of the shortest distance from the medial epicondyle to the median nerve, the distance from the medial epicondyle to the median nerve in line with the flexor-pronator/FCU interval, the shortest distance from the apex of the UCP to the median nerve, and the length of the flexor-pronator/FCU detachment necessary to expose the anteromedial facet of the UCP. Measurements were also made of the length of the ulnar insertion of the brachialis muscle and the shortest distances from the proximal and distal insertions of the brachialis muscle to the median nerve., Results: The distances and lengths were as follows: medial epicondyle to median nerve, 31 ± 3 mm; in line with the flexor-pronator/FCU interval, 43 ± 5 mm; from the apex of the UCP to the median nerve, 7 ± 2 mm; the detachment necessary to expose the UCP, 47 ± 6 mm; the ulnar insertion of the brachialis muscle, 27 ± 4 mm; and the proximal and distal insertions of the brachialis muscle to the median nerve, 14 ± 2 mm and 5 ± 1 mm, respectively., Conclusions: The length of the flexor-pronator/FCU detachment necessary to expose the anteromedial facet of the UCP was similar to the distance from the medial epicondyle to the median nerve in line with the flexor-pronator/FCU interval. The distance from the distal insertion of the brachialis muscle to the median nerve was 5 mm., Clinical Relevance: The results of our study provide information on important points for surgeons to consider when performing distal exposure using the Hotchkiss over-the-top approach., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The median nerve serves a crucial role in extrinsic and intrinsic motor and sensory function to the radial half of the hand. High median nerve injuries, defined as injuries proximal to the anterior interosseous nerve origin, therefore typically result in significant functional loss prompting aggressive surgical management. Even with appropriate recognition and contemporary nerve reconstruction, however, motor and sensory recovery may be inadequate. With isolated persistent high median nerve palsies, a variety of available tendon transfers can improve key motor functions and salvage acceptable use of the hand., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To increase awareness of peripherally inserted central catheter (PICC) fracture and necessary nursing assessment to identify development of nerve injury after removal of the PICC fracture., Methods: This is a case review of a cancer patient with fractured PICC and the postoperative symptoms leading to nerve injury., Results: The reason for PICC fracture is the fragility of silicon. Secondary surgical intervention of a PICC fragment resulted in nerve damage from a hematoma placing pressure on the median nerve in the arm., Conclusions: It is necessary to use power injectable polyurethane PICCs. It is vital to have a clear understanding of signs and symptoms of nerve impingement in the arm when monitoring a post-operative patient. Assessment of neurological status, circulation, swelling and patient complaints of pain are all necessary functions of the nurse in caring for this type of patient.

This article describes the clinically significant motor and sensory deficits that follow high median nerve injuries and addresses the indications, limitations, and outcomes of nerve transfers, when striving to overcome the deficits these patients' experiences. Preferred surgical reconstructive strategy using motor and sensory nerve transfers, and surgical techniques used to perform these transfers, are described., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Describes a patient who complained of numbness in the right hand. Surgical procedure done to correct the patient's carpal tunnel syndrome; Patient's complaint of lethargy and hoarseness following the procedure.