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Objectives Laser speckle contrast imaging (LSCI) has seen limited use in the study of perfusion dynamics such as vasomotion. The aim of this study was to investigate the effects of a prolonged seated position on perfusion dynamics in the nail bed using LSCI. Methods Perfusion was recorded in digits II to IV bilaterally for 20 min during two separate sessions in ten healthy volunteers. The acclimatization period was 5 min for the 1st session and 20 min for the 2nd. Perfusion variability and the presence of recurring perfusion dips were analyzed. A digital nerve block was done to verify suspected nervous origin of phenomenon. Results Synchronized phases of vasoconstriction were observed in all subjects with perfusion dips in all digits bilaterally and simultaneously. Application of a digital nerve block abolished perfusion dips. The frequency of this phenomenon increased by 25.0% (95% CI: 1.6 to 49.2%) in the left-hand digits after a prolonged seated position. Perfusion variability increased by 11.6% (95% CI: 2.6 to 20.3%) in the digits of the left hand. Perfusion changes in right-hand digits did not significantly increase. During the 1st session, temperature increased by 2.7 °C (1.1 to 4.2) while it decreased by 1.3 °C (0.2 to 2.4) during the 2nd session. Conclusion The observed perfusion dips are of a centrally mediated nervous origin but are also affected by local factors. They are affected by seating duration and differ between left and right hands, likely because of local micro perfusion dips. This phenomenon seems related to digital thermoregulation.

Soft tissue injuries comprise a significant amount of hand trauma injuries. Knowledge of commonly injured structures and how best to manage them is crucial.

To determine whether ultrasound allows precise assessment of the course and relations of the medial plantar proper digital nerve (MPPDN). This work was initially undertaken in six cadaveric specimens and followed by a high-resolution ultrasound study in 17 healthy adult volunteers (34 nerves) by two musculoskeletal radiologists in consensus. Location and course of the MPPDN and its relationship to adjacent anatomical structures were analysed. The MPPDN was consistently identified by ultrasound along its entire course. Mean cross-sectional area of the nerve was 0.8 mm2 (range 0.4–1.4). The MPPDN after it branches from the medial plantar nerve was located a mean of 22 mm (range 19–27) lateral to the medial border of the medial cuneiform. More distally, at the level of the first metatarsophalangeal joint, mean direct distances between the nerve and the first metatarsal head and the medial hallux sesamoid were respectively 3 mm (range 1–8) and 4 mm (range 2–9). The MPPDN can be depicted by ultrasonography. Useful bony landmarks for its detection could be defined. Precise mapping of its anatomical course may have important clinical applications. • The medial plantar proper digital nerve (MPPDN) rises from the medial plantar nerve to the medial side of the hallux. • Because of its particularly long course and superficial position, the MPPDN may be subject to trauma, resulting in a condition known as Joplin’s neuroma. • The MPPDN can be clearly depicted by ultrasound along its entire course. Precise mapping of its anatomical course may have important clinical applications.

RESUMO Convencionalmente, a associação de anestésicos locais com vasoconstritores é evitada em extremidades pelo risco de isquemia. Entretanto, estudos recentes sugerem haver segurança no uso de vasoconstritor em extremidades. Procuramos, assim, avaliar a efetividade e segurança do uso de vasoconstritores combinados com anestésicos locais no bloqueio de nervos digitais em comparação ao uso de anestésicos plenos, através de uma revisão sistemática com metanálise de ensaios clínicos randomizados. Pesquisamos, até maio de 2019, nas bases de dados MEDLINE, LILACS, SciELO, ScienceDirect, Scopus, ClinicalTrials.gov e literatura cinzenta, sem restrições de data ou idioma, os descritores: bloqueio digital, vasoconstritor e isquemia. Foram incluídos ensaios clínicos randomizados nos quais houve a utilização de anestésicos locais associados ou não a vasoconstritores em bloqueios digitais. Nas variáveis primárias foram analisadas a ocorrência de complicações isquêmicas e a duração da anestesia, e nas variáveis secundárias foram observadas necessidade de reaplicação anestésica, de controle de sangramento e latência. Dez estudos foram incluídos nesta revisão. Não foi observada a ocorrência de isquemia, independente do uso ou não de vasoconstritores. O uso de vasoconstritores na concentração de 1:100.000 ou menor esteve associado a maior duração da anestesia (P

WOS: 000462822700006 Background: We aimed to evaluate the correlation of patients' satisfaction with sensorial evaluation results after primary repair of digital nerves and flexor tendons. Materials and Methods: In total, 31 fingers of 25 patients that underwent primary repair for clear-cut digital nerve and flexor tendon injuries were included in this retrospective study. The mean age of the patients was 34.8 +/- 9.4 years. Patients' gender, age at admission, trauma date, and injured finger were obtained from patients' folders. We called the patients for the last follow-up and used two-point discrimination (2PD) and Semmes-Weinstein monofilament (SWM) tests to evaluate sensorial recovery. Patients were interviewed for hand dominance, cold intolerance, and if they were satisfied. Visual analog scale (VAS) was used to evaluate the satisfaction of patients related to the injured finger. We analyzed correlations between VAS score and age, follow-up period, 2PD score, SWM score, cold intolerance score, gender, hand dominance, and the injured finger. Results: Patients' satisfaction was significantly correlated only with cold intolerance score. There was no significant correlation between patients' satisfaction and age, follow-up period, gender, hand dominance, injured finger, 2PD score, and SWM score. Conclusion: Our study revealed that patients' satisfaction was not only correlated with sensorial recovery scores but also significantly negatively correlated only with cold intolerance, and novel modalities to treat this phenomenon are required. Moreover, patients' satisfaction was not related to age, gender, hand dominance, and the injured finger; hence, surgeons should focus on meticulous repair of digital nerves in any age, for any gender, and any finger of patients.

Peripheral nerve injuries are difficult to treat, and the clinical outcome after surgical repair and reconstruction is still insufficient, particularly concerning recovery of sensory function. To improve the clinical treatment strategies, experimental models are used to systematically examine the mechanisms behind nerve regeneration and assess the improvement of nerve regeneration by introduction of new surgical nerve repair and reconstruction methods (e.g., novel devices made by bioartificial materials). Rat models, where the sciatic nerve has essentially a similar size as a human digital nerve, are widely used to evaluate nerve regeneration with the inherent advantages and disadvantages of the experimental models. Estimations revealing that a large number of diabetic patients will eventually suffer from peripheral nerve injury have motivated development of suitable experimental diabetes models for studying the nerve regeneration process and novel treatment approaches. We have successfully used the Goto-Kakizaki rat model, which shows moderately increased blood sugar closely resembling type 2 diabetes, for assessing the surgical peripheral nerve regeneration potential with and without artificial scaffolds. In order to improve outcome after repair and reconstruction of nerve injuries, one has to have a clear concept concerning how to evaluate novel repair and reconstruction techniques in experimental models before clinical studies can be initiated in an accurate way. (Less)

We will study the influence of low intensity and frequency surface peripheral electrical stimulation (PES) on nerve regeneration of digital nerve injuries of the hand after its surgical repair in humans. Participants will be patients with acute traumatic peripheral nerve injury referred to the Hand Surgery Service of the General Hospital of the State of Bahia, a reference service in the state. These patients will undergo surgery followed by PES in the immediate postoperative period. After hospital discharge, they will be followed up on an outpatient basis by researchers, who will remotely supervise a physiotherapy program. Our hypothesis is that PES will positively influence the recovery of sensory function in patients undergoing neurorrhaphy of digital nerves of the hand. ReBEC registration: U1111-1259-1998 (12/18/2020)

Desmopathy of the collateral sesamoidean ligament (CSL) is an unusual disorder in draft horses. This study records the magnetic resonance imaging (MRI) features of chronic CSL desmopathy in eight draft horses and confirms these features by histopathology. The recorded chronic CSL desmopathy has usually affected the forelimbs (100%) and commonly bilateral (62.5%). All horses showed positive proximal digital nerve block, positive front digital flexion test, and negative interphalangeal extension test. Radiography revealed no osseous abnormalities in all feet. MRI features of chronic CSL desmopathy included thickening of the ligament with increased moderate intensity in fast low-angle shot, T1 turbo spin echo, and proton density images in the affected part of the ligament. Chronic CSL desmopathy was concomitant with deep digital flexor tendon injury and distal sesamoidean impar desmitis. In most chronic cases of CSL desmopathy, heterogeneous signal intensities were seen with multiple foci of low signal intensities interlaced with increased moderate signal intensities of thickened CSL. Histopathology confirmed the MRI findings and revealed separated bundles and fascicles by septa of less organized and loose connective tissues containing fibroblasts and loose collagen fibers. Multifocal islands of cartilaginous metaplasia, mineralized areas, and dystrophic calcification were observed in the injured ligament. In conclusion, chronic CSL desmopathy may progress to cartilaginous metaplasia and dystrophic calcification. MRI is a beneficial diagnostic and prognostic tool for chronic CSL desmopathy, and histopathology is a gold standard to document the MRI findings associated with CSL dysmopathy in draft horses.

Objective: The aim of our study is to retrospectively evaluate the patients who had digital nerve defective injuries of the hand which was reconstructed with the terminal branch of posterior interosseous nerve (PIN) for treatment. Methods: Twenty-three patients with digital nerve defective injuries, who applied late and were treated with PIN terminal branch grafting were included in the study. The mean age of the patients was 36.4 ± 8.1 years and the mean follow-up duration was 17.3 ± 3.2 months. The mean interval between the injury and the surgery was 5 (2-8) months, and the average gap in defective site was 19.7 ± 3.8 mm. Clinical assessment of the nerve healing was made with Semmes Weinstein Monofilament (SWM) test and Static 2 Point Discrimination (S2PD) test and, the results were classified according to the British Medical Research Council (BMRC) scoring system. Results: The mean SMW test result was determined as 2.8 (2.8-20) grams, and the mean S2PD test result as 6 (4-20) mm at the sensory area of reconstructed nerve. Accordingly, BMRC scoring system revealed that sensory improvement was S4 level in 15 (65.2%) patients, S3 + in 4 (17.4%), S3 in 3 (13%) patients, and S2 level in 1 (4.3%) patient. Neuroma was not detected at any of the patients within the donor site. Scar formation was detected at 6 (26.1%) patients. Conclusion: PIN terminal branch is an appropriate substitute for digital nerve reconstruction with minimum morbidity and acceptable efficiency. [Hand Microsurg 2021; 10(2.000): 152-159]

We examined the hypothesis that the palmar digital nerves (PDNs), but not the dorsal branches (DBs) of the digital nerves, innervate the sensitive dorsal laminae of the equine foot by evaluating the effects of perineural anaesthesia of the PDNs and DBs separately on pain sensation evoked via mechanical stimulation of the dorsal laminae and other regions of the equine foot. Six clinically normal mares were used in a crossover design. A portable dynamometer was used to evaluate mechanical nociceptive thresholds at different points on the dorsal laminae, bulbs of the heel, coronary band and sole before and after the horses underwent perineural injection of PDNs or DBs with a local anaesthetic solution (treated group) or an isotonic saline solution (control group). Cornified tissue was removed from the sole and the dorsal aspect of the hoof wall before evaluations of mechanical nociceptive thresholds. Anaesthetising PDNs distal to the DBs increased mechanical nociceptive thresholds compared to baseline values (P

Joplin's neuroma is a rare perineurial fibrosis of the medial plantar digital proper nerve arising from various etiologies but most commonly after bunion surgery. Treatment for this painful great toe problem remains controversial. It is our purpose to describe our experience with this chronic pain problem, considering it to be a neuroma requiring resection. A retrospective medical record review of 8 patients with medial hallux pain related to the digital nerve was performed. Each patient had failed to respond to >6 months of nonoperative therapy. At surgery, the medial digital nerve to the hallux was identified distally, the neuroma was resected distally, and the proximal end of the nerve was implanted into the arch of the foot in 7 (87.5%) of the 8 patients. At a mean follow-up of 25 (range 13 to 43) months, 6 results (75%) were excellent, 1 (12.5%) was good, and 1 (12.5%) was fair. The 1 fair result was in the only patient in whom the distal end of the divided nerve was not implanted proximally, according to the patient's request. In conclusion, surgical resection of the medial plantar nerve to the hallux with implantation of the proximal end of the nerve into the arch of the foot, can be expected to result in good to excellent relief of pain in 80% of the patients.

Background: Current repair options for peripheral nerve injuries where tension-free gap closure is not possible include allograft, processed nerve allograft, and hollow tube conduit. Here we report on the outcomes from a multicenter prospective, randomized, patient- and evaluator-blinded, pilot study comparing processed nerve allograft and hollow conduit for digital nerve reconstructions in the hand. Methods: Across 4 centers, consented participants meeting inclusion criteria while not meeting exclusion criteria were randomized intraoperatively to either processed nerve allograft or hollow conduit. Standard sensory and safety assessments were conducted at baseline, 1, 3, 6, 9, and 12 months after reconstruction. The primary outcome was static 2-point discrimination (s2PD) testing. Participants and assessors were blinded to treatment. The contralateral digit served as the control. Results: We randomized 23 participants with 31 digital nerve injuries. Sixteen participants with 20 repairs had at least 6 months of follow-up while 12-month follow-up was available for 15 repairs. There were no significant differences in participant and baseline characteristics between treatment groups. The predominant nerve injury was laceration/sharp transection. The mean ± SD length of the nerve gap prior to repair was 12 ± 4 mm (5-20 mm) for both groups. The average s2PD for processed allograft was 5 ± 1 mm (n = 6) compared with 8 ± 5 mm (n = 9) for hollow conduits. The average moving 2PD for processed allograft was 5 ± 1 mm compared with 7 ± 5 mm for hollow conduits. All injuries randomized to processed nerve allograft returned some degree of s2PD as compared with 75% of the repairs in the conduit group. Two hollow conduits and one allograft were lost due to infection during the study. Conclusions: In this pilot study, patients whose digital nerve reconstructions were performed with processed nerve allografts had significantly improved and more consistent functional sensory outcomes compared with hollow conduits.

Digital nerve injuries are the mostly detected nerve injury in the upper extremity. However, since the clinical phenomenon of crossover innervation at some degree from uninjured digital nerve to the injured side occurs after digital nerve injuries is sustained, one could argue that this concept might even result in the overestimation of the outcome of the digital nerve repair. With this knowledge in mind, this study aimed to present novel, pure, focused and valuable clinical data by comparing the outcomes of bilateral and unilateral digital nerve repair. A retrospective review of 28 fingers with unilateral or bilateral digital nerve repair using end-to-end technique in 19 patients within 2 years was performed. Weber′s two-point discrimination, sharp/dull discrimination, warm/cold sensation and Visual Analog Scale scoring were measured at final 12-month follow ups in all patients. There was no significant difference in recovery of sensibility after unilateral and bilateral digital nerve repairs. Though there is crossover innervation microscopically, it is not important in the clinical evaluation period. According to clinical findings from this study, crossover innervations appear to be negligible in the estimation of outcomes of digital neurorrhaphy.

The influence of duration of immobilization and postoperative sensory re-education on the final outcome after reconstruction of digital nerves with direct suture or muscle-in-vein conduits was investigated. The final sensory outcome of 35 patients with 41 digital nerve injuries, who either underwent a direct suture (DS) or a nerve reconstruction with muscle-in-vein conduits (MVC), was assessed the earliest 12 months postoperatively using static and moving two-point discrimination as well as Semmes-Weinstein monofilaments. There was no significant difference in sensory recovery in cases with an immobilization of 3-7 days versus 10 days in the DS or MVC group. Moreover, no statistically significant difference in sensory recovery was found in cases receiving postoperative sensory re-education versus those not receiving in the DS or MVC group. An early mobilization does not seem to have a negative impact on the final outcome after digital nerve reconstruction. The effect of sensory re-education after digital nerve reconstruction should be reconsidered.

Background Digital nerve blocks are commonly performed in emergency departments. Health care practitioners are often taught to avoid performing blocks with epinephrine due to a risk of digital necrosis. Objective To review the literature on the safety of epinephrine 1:100,000–200,000 (5–10 μg/mL) with local anesthetics in digital nerve blocks in healthy patients and in patients with risk for poor peripheral circulation. Methods PubMed, Web of Science, and the Cochrane Library were searched in June 2014 using the query “digital block AND epinephrine OR digital block AND adrenaline”. The searches were performed without any limits. Results Sixty-three articles were identified, and 39 of these were found to be relevant. These include nine reviews, 12 randomized control trials, and 18 other articles. Most studies excluded patients with risk for poor peripheral circulation. Two studies described using epinephrine on patients with vascular comorbidities. No study reported digital necrosis or gangrene attributable to epinephrine, either in healthy patients or in patients with risk for poor peripheral circulation. In total, at least 2797 digital nerve blocks with epinephrine have been performed without any complications. Conclusions Epinephrine 1:100,000–200,000 (5–10 μg/mL) is safe to use in digital nerve blocks in healthy patients. Physiological studies show epinephrine-induced vasoconstriction to be transient. There are no reported cases of epinephrine-induced harm to patients with risk for poor peripheral circulation despite a theoretical risk of harmful epinephrine-induced vasoconstriction. A lack of reported complications suggests that the risk of epinephrine-induced vasoconstriction to digits may be overstated.

Introduction Proximal interphalangeal joint (PIP) is one of the joints exposed to upper limb injury. The dorsal fracture-dislocations of the PIP is a common injury. Treatment of cases with small avulsed bone fragments is challenging. Stable fixation with rapid recovery is important in these patients. Hypothesis Volar buttress plating a new technique in treatment of the dorsal proximal interphalangeal joint fracture dislocations but the results of it is unknown. Methods In this case series, 21 patients with dorsal fracture-dislocations of the proximal interphalangeal were studied. We used a volar hook plate buttressing technique so that fixation was done by low-profile 2-mm stainless steel hook plate with a 1.5-mm screw. Range of motion movements, power and grip strength were measured after 3 months. At end of follow-up period, functional outcome was determined by the visual analogue scale, Quick Disabilities of the Arm, Shoulder, and Hand. Results After three-month follow-up a union of fractures occurred in all of the patients. There were no complications, such as infection, digital nerve injuries or flexor tendon rupture. The joints range of motion were stable and had no restrictions. Postoperative range of motion outcome in 19 (90.5 %) patients was 85.7 ± 13.2 degree which was not significantly different from opposite side on other hand (p = 0.1). In two patients range of motion was 65.5 ± 5.4 degree and painful. Postoperative pain in 19 patients was 2.5 ± 0.8 so that there was no pain in 17(76.2 %) patients, three (14.1 %) patients had mild pain and two (9.5 %) patients had moderate pain (5.4 ± 1.2). Two patients complained of plate irritation of especially at end of proximal interphalangeal flexion. Conclusion Clinical application of hook plate buttressing technique induced stable fixation and rapid recovery. Because of maintaining articular congruity and restoring anatomically, this technique associated with good outcomes. Level of evidence IV, Therapeutic study.

Digital nerve lacerations are a common type of hand injury and one of the main causes of sensory impairment. The purpose of this study is to investigate the results of surgical treatment of traumatic digital nerve lesions in patients hands. We evaluated 65 patients with digital nerve injury that occurred after digital trauma between 2015 and 2018. The participants hypoesthesia scores on the numerical rating scale were greater than 5/10. Additionally, they felt hypoesthesia distally above the hand injury in their preliminary examinations at the emergency department. We analyzed the injuries of 65 patients (41 males, 24 females; mean age: 36 ± 2 years; age range: 1956 years). Group 1 consisted of 26 patients who did not undergo surgery, whereas Group 2 consisted of 39 patients who underwent surgery. We conducted the SemmesWeinstein monofilament test in Group 1. In total, 9 patients had normal sensations, 12 patients had light touch sensations; and 5 patients had protective sensations. We conducted nerve exploration surgery in Group 2. In total, the 12 patients who underwent this surgery were found to have no pathology in the digital nerve and identified to have neuropraxia. In the other 11 patients, the peripheral nerve was partially lacerated and it was repaired primarily, after performing the nerve exploration surgery on the remaining 16 patients. There wasnt statistically significant difference between the patients who underwent surgery and who did not undergo surgery in terms of hypoesthesia resulting from nerve laceration. [Med-Science 2020; 9(4.000): 926-8]

Surgical treatment of peripheral nerve injuries is still a major challenge in human clinic. Up to now, none of the well-developed microsurgical treatment options is able to guarantee a complete restoration of nerve function. This restriction is also effective for novel clinically approved artificial nerve guides. In this review, we compare surgical repair techniques primarily for digital nerve injuries reported with relatively high prevalence to be valuable attempts in clinical digital nerve repair and point out their advantages and shortcomings. We furthermore discuss the use of artificial nerve grafts with a focus on chitosan-based nerve guides, for which our own studies contributed to their approval for clinical use. In the second part of this review, very recent future perspectives for the enhancement of tubular (commonly hollow) nerve guides are discussed in terms of their clinical translatability and ability to form three-dimensional constructs that biomimick the natural nerve structure. This includes materials that have already shown their beneficial potential in in vivo studies like fibrous intraluminal guidance structures, hydrogels, growth factors, and approaches of cell transplantation. Additionally, we highlight upcoming future perspectives comprising co-application of stem cell secretome. From our overview, we conclude that already simple attempts are highly effective to increase the regeneration supporting properties of nerve guides in experimental studies. But for bringing nerve repair with bioartificial nerve grafts to the next level, e.g. repair of defects > 3 cm in human patients, more complex intraluminal guidance structures such as innovatively manufactured hydrogels and likely supplementation of stem cells or their secretome for therapeutic purposes may represent promising future perspectives.

Purpose We report the efficacy of a modified heterodigital neurovascular island flap innervated by the dorsal branch of the proper digital nerve and the proper digital nerve, for repairing either pulp or volar defects in the fingers. Method We repaired 14 digits of 14 patients who had a complex defect involving soft tissue and digital nerve in the pulp or volar surface of the digit using the modified heterodigital neurovascular island flap. Cases were divided into 2 groups: a pulp defect group including 5 thumbs and 1 little finger; and a volar defect group with a digital nerve defect, involving one thumb, 3 index and 3 middle fingers, and one ring finger. At the recipient site, nerve stumps of the PDNs in the pulp defect group were coapted with the proximal ends of the dorsal branch of the PDN and the proper digital nerve in the flap. The distal and proximal ends of the PDN in the flap were intercalated into the defect of the PDN in volar defect group, and the proximal end of dorsal branch of PDN in the flap was also coapted to the proximal end of the proper digital nerve of the recipient finger. At the donor site, the defect of the proper digital nerve was repaired with nerve graft harvested from the proximal portion of the dorsal branch of the same proper digital nerve, and a full-thickness skin graft covered the donor site. Results All flaps and the skin grafts of the donor site survived completely. At the final follow-up, 9 of 14 flaps had a static 2-point discrimination result below the normal threshold ( Conclusions The modified heterodigital neurovascular island flap is a useful and reliable treatment option for a digital pulp or volar defect, especially when the digital nerve defect requires repair. Type of study/level of evidence Therapeutic IV.

Malignant granular cell tumors are an extremely rare, high-grade sarcoma with a schwannian phenotype and are composed of malignant granular cells with cytoplasmic lysosomal inclusion. To date, 157 cases of malignant granular cell tumors have been reported. We report the first case of a malignant granular cell tumor arising from the digital nerve to the median nerve in the palm, and we review the 157 previously reported cases and summarize the clinical profile, treatment, and outcome of this tumor. The median age, tumor size, and follow-up periods were 51 years, 6 cm, and 24 months respectively. With respect to the oncological result, 53 patients (33.8%) had no evidence for disease, 31 (19.7%) were alive with the disease, and 51 (32.5%) died because of the disease. Our case report indicates that rare malignant tumors can arise from the digital nerve to the median nerve in the palm, an anatomical site that is usually affected by benign lesions. Exhaustive discussions between surgeons and pathologists are necessary for the treatment of this rare malignant tumor.

(1) Background: Afferent inhibition is the attenuation of the muscle response evoked from transcranial magnetic stimulation (TMS) by a prior conditioning electrical stimulus to a peripheral nerve. It is unclear whether the magnitude of afferent inhibition relates to sensation and movement; (2) Methods: 24 healthy, young adults were tested. Short-latency afferent inhibition (SAI) and long-latency afferent inhibition (LAI) were obtained following median and digital nerve stimulation. Temporal tactile acuity was assessed with a temporal order judgement (TOJ) task, spatial tactile acuity was assessed using a grating orientation task (GOT), and fine manual dexterity was assessed with the Pegboard task; (3) Results: Correlation analyses revealed no association between the magnitude of SAI or LAI with performance on the TOJ, GOT, or Pegboard tasks; (4) Conclusion: The magnitude of SAI and LAI does not relate to performance on the sensory and motor tasks tested. Future studies are needed to better understand whether the afferent inhibition phenomenon relates to human behavior.

We evaluated the strength of conduit-assisted primary digital nerve repairs, with varying suture location and number, in 56 digital nerves from cadavers. Maximum load to failure was tested for the following seven repairs, designated by the number of epineurial sutures followed by the number of sutures at each end of the conduit: 4 (epineurial sutures)/0 (sutures at each end of conduit), 4/4, 4/2, 2/2, 0/4, 0/2, 0/1. The 4/4 repair (3.0 N) was significantly stronger than 4/0 (1.5 N), 2/2 (1.6 N), 0/4 (2.0 N), 0/2 (1.4 N) and 0/1 (1.1 N). Considering all repair types, there was a significant correlation between suture number and failure load, with the strongest repair having a total of 12 sutures, which is impractical. Reasonable repair options, which have two sutures at each end of the conduit and either two or no epineurial sutures, are as strong as a four-suture epineurial repair but have less sutures at the coaptation site.

Purpose To describe the innervation of the proximal interphalangeal (PIP) joint of the fingers as well as the anatomical relations of the articular branches. Methods In this anatomical study, 52 fresh-frozen index, long, ring, and little fingers of 6 male and 4 female cadavers were dissected after injection of a colored latex composite. The anatomical dissections were performed under ×3.5 and ×6.0 magnifications. The numbers of articular nerve branches that penetrated the PIP joint on both sides of the fingers were quantified and patterns of innervation were established. We also measured the origin of the branches regarding the PIP articular line, the angle of emergence, and the diameter of the nerves. Results The PIP joint was innervated by one articular branch of the proper palmar digital nerve at each side of the finger (pattern 1). Less frequently, an additional distal branch from the same proper palmar digital nerve was found (pattern 2). Dorsal articular branches were identified innervating only the little finger. Conclusions The findings suggest that PIP joints of the fingers have a consistent articular nerve anatomy predominantly provided at the palmar aspect of the joint. These findings provide an anatomical basis for procedures to denervate the PIP joint. Clinical relevance An accurate understanding of peripheral nerve anatomy of the PIP joint is essential to improve outcomes in denervation techniques.

Background The purpose of this study is to describe a simple and reproducible method to localize the neurological structures at risk and to describe a safe zone for hallux minimally invasive surgery (MIS) procedures. Methods Ten fresh-frozen cadaveric feet were dissected to identify the dorsomedial digital nerve (DMDN) and the dorsolateral digital nerve (DLDN) of the first toe. Axial sections were performed at the sites of metatarsal osteotomies. We documented the position of the nerves with respect to the extensor hallucis longus (EHL) tendon using a clock method superimposed on the axial section Results The DMDN was found at an average of 26.2° medial to the medial border of the EHL tendon. (SD 11.26, range 14.5–45.5), whereas the average distance of the DLDN was 32.3° lateral to the medial border of the EHL tendon. (SD 6.29, range 13.5–40). Conclusions Using the clock method the DMDN and DLDN were found consistently between 10 o'clock and 2 o'clock in either right and left feet. The clock method may facilitate avoiding the area where these nerves are located serving as a valuable tool in minimally invasive foot surgery.

BACKGROUND Studies have shown proximal diffusion of injected drugs in perineural blocks; such diffusion may affect specificity of the nerve block. OBJECTIVES To investigate the effect of a compression bandage applied to the pastern region on proximal diffusion of contrast medium injected over the palmar digital nerves. STUDY DESIGN Experimental study, randomised cross-over design. METHODS Radiodense contrast medium was injected over the lateral and medial palmar digital nerves of the left front limb of nine mature horses. Each horse was injected on two separate occasions, once with a 5 cm wide compression bandage applied proximal to the injection site and once without. The order of the two treatments was randomised with a wash-out period between treatments of at least 7 days. Radiographs were obtained at 5, 10, 20 and 30 min and distribution of the contrast column assessed. RESULTS Proximal distribution of the contrast medium was significantly reduced (P

Rotation avulsion of fingers is usually caused by a fast rotating machine with a roller and occurs in the left thumb. In most patients, it is characterized by the following: (a) The skin is stripped with the subcutaneous tissue, which is like a flap or avulsion injury. (b) The extensor and flexor tendons are usually pulled out. (c) The digital veins are usually broken near the edge of the skin. (d) The digital nerves are usually pulled out with uneven ends because they are relatively strong. (e) The toughness of the arteries is stronger than that of the veins, but they are weaker than the nerves; thus, they are broken earlier than nerves and later than veins, which is easily understood.

This article contains the raw data from the article entitled: “The presence of synchronized perfusion dips in the microcirculation of the resting nail bed” Mirdell et al. (in press). A laser speckle contrast imager (LSCI) was used to make a total of 21 recordings of the perfusion in the resting nail bed of 10 healthy test subjects. The first 10 recordings were acquired after 5 min of acclimatization. An additional 10 recordings were acquired in the same test subjects, after 20 min of acclimatization. In the last recording, a digital nerve block was applied to the left dig III. The data show the presence of highly irregular perfusion variations, a phenomenon we like to call perfusion dips. The data also show how the perfusion dips can be abolished through a digital nerve block. An algorithm for the quantification of the perfusion dips is included in the data. Keywords: laser speckle contrast imaging, nail bed, microcirculation, perfusion

Summary Diffusion of local anaesthetic solution after a mid-pastern ring block has not previously been investigated. The aim of this study was to demonstrate potential distribution of local anaesthetic solution following injection of radiodense contrast medium as performed for a mid-pastern ring block. Twelve mature horses were used and 1.5 ml radiodense contrast medium injected over the medial or lateral palmar digital nerve at the level of the proximal aspect of the ungular cartilages. A dorsal ring block was performed on the ipsilateral side, 1.5 cm proximal to the palpable palmar aspect of the proximal eminence of the middle phalanx, using 2 or 5 ml contrast medium. Both forelimbs were injected on 2 days (48 injections). Four standard radiographic views of the pastern were obtained immediately, 10 and 20 min after injections. Images were analysed subjectively and objectively. After dorsal injections, the contrast medium was distributed in a diffuse patch over the ipsilateral half of the proximal phalanx (P1), extending proximally over the half of the length of P1 in all limbs (greatest proximal extension: 89.0% of the length of P1 [from distal] after 2 ml, 94.2% after 5 ml). There was significant proximal diffusion in the first 10 min after injection and significant dorsal diffusion between all time points (P

Restoration of tactile sensation after reconstruction of a thumb pulp defect is import for hand function. We describe our clinical experience using a modified first dorsal metacarpal artery island flap innervated by the radial dorsal branch of the proper digital nerve and the terminal branch of the superficial radial nerve in 20 consecutive cases. The results were compared with 25 patients treated by the conventional Foucher’s first dorsal metacarpal artery flap without nerve repair. At the final follow-up, flap sensation was assessed using static two-point discrimination and Semmes–Weinstein monofilament testing. All flaps survived uneventfully in both groups. At the final follow-up, the mean values for static two-point discrimination and Semmes–Weinstein monofilament testing in the study group were significantly different from the values in the control group. The modified first dorsal metacarpal artery island flap provides a reliable and simple option for sensory reconstruction of thumb pulp defects. Level of evidence: Therapeutic, level III

This evidence-based article discusses the current management options of Dupuytren disease and strategies to avoid and manage any potential complications. Treatment options include fasciectomy, needle fasciotomy/aponeurotomy, and collagenase injection. Complications include digital nerve and artery injury, flexor tendon injury, skin fissures and wound healing complications, hematoma, infection, flare reaction/complex regional pain syndrome, and recurrence. Complication rates, prevention, and management differ with each treatment modality. A detailed understanding of each of these options allows hand surgeons to select the most appropriate treatment for each patient.

Background Short-gap digital nerve injuries are a common surgical problem, but the optimal treatment modality is unknown. A multicenter database was queried and analyzed to determine the outcomes of nerve gap reconstructions between 5 and 15 mm with processed nerve allograft. Methods The current RANGER registry is designed to continuously monitor and compile injury, repair, safety, and outcomes data. Centers followed their own standard of care for treatment and follow-up. The database was queried for digital nerve injuries with a gap between 5 and 15 mm reporting sufficient follow-up data to complete outcomes analysis. Available quantitative outcome measures were reviewed and reported. Meaningful recovery was defined by the Medical Research Council Classification (MRCC) scale at S3-S4 for sensory function. Results Sufficient follow-up data were available for 24 subjects (37 repairs) in the prescribed gap range. Mean age was 43 years (range, 23–81). Mean gap was 11 ± 3 (5–15) mm. Time to repair was 13 ± 42 (0–215) days. There were 25 lacerations, 8 avulsion/amputations, 2 gunshots, 1 crush injury, and 1 injury of unknown mechanism. Meaningful recovery, defined as S3-S4 on the MRCC scales, was reported in 92% of repairs. Sensory recovery of S3+ or S4 was observed in 84% of repairs. Static 2PD was 7.1 ± 2.9 mm ( n = 19). Return to light touch was observed in 23 out of 32 repairs reporting Semmes-Weinstein monofilament outcomes (SWMF). There were no reported nerve adverse events. Conclusion Sensory outcomes for processed nerve allografts were equivalent to historical controls for nerve autograft and exceed those of conduit. Processed nerve allografts provide an effective solution for short-gap digital nerve reconstructions.

This study evaluates the long-term clinical outcome and complication rate after digital nerve repair in adults and aims to identify possible prognostic factors of sensory recovery. End-to-end epineural coaptation was performed under magnification. A total of 93 coapted digital nerves were clinically evaluated with a mean follow-up of 3.5 years (range 1–6 years). The mean two-point discrimination was 10.6 mm (versus 4.4 mm for the contralateral side). Cutaneous pressure threshold tested with Semmes–Weinstein monofilaments showed a mean value of 2.7 (versus 2.2 for the contralateral side). Only 2% of our patients developed painful neuromas. None of our patients recovered normal functional sensibility, however, recovery of protective sensation contributed to a high reported level of satisfaction. No correlation was observed between the sensory outcome and age, smoking, mechanism of injury, lesion to or anastomosis of a digital artery, or time of immobilization. The only identified predictor of the result was the surgeon’s level of experience. This highlights the importance of adequate training and practice in the surgical repair of smaller peripheral nerves. Level of evidence: IV

Muscle-in-vein conduits are used alternatively to nerve grafts for bridging nerve defects. The purpose of this study was to examine short- and long-term regeneration results after digital nerve reconstruction with muscle-in-vein conduits. Static and moving two-point discriminations and Semmes-Weinstein Monofilaments were used to evaluate sensory recovery 6-12 months and 14-35 months after repair of digital nerves with muscle-in-vein in 7 cases. Both follow-ups were performed after clinical signs of progressing regeneration disappeared. In 4 of 7 cases, a further recovery of both two-point discriminations and in another case of only the static two-point discrimination of 1-3 mm could be found between the short-term and long-term follow-up examination. Moreover, a late recovery of both two-point discriminations was demonstrated in another case. Four of 7 cases showed a sensory improvement by one Semmes-Weinstein Monofilaments. This pilot study suggests that sensory recovery still takes place even when clinical signs of progressing regeneration disappear.

In the era of perforator flaps, lower-abdominal/inguinal perforator flaps such as superficial circumflex iliac artery perforator (SCIP) flap and superficial inferior epigastric artery (SIEA) perforator flap are becoming popular with its longer vascular pedicle and usefulness in various reconstructions. SIEA flap's region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far. In this report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect. A 55-year-old male suffering from the volar skin necrosis of the right ring finger underwent the volar soft tissue reconstruction using a free sensate SIEA flap because of hypoplastic SCIA. The SIEA flap included the IHN anterior branch, and neuroraphy was performed between the IHN and the third common digital nerve in an end-to-side manner after vascular anastomoses. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes-Weinstein test and moving 2-point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. The IHN may be included in a SIEA flap, and a sensate SIEA flap may be a useful option when a SCIP flap is not available. Further anatomical and clinical studies are required to clarify anatomy and clinical usefulness of the IHN.

The aim of this study was to assess the resistance of microsurgically repaired proper palmar digital nerves (PPDN) to mobilization. Thirty-nine PPDN from fresh forearms cadavers were transected and then sutured using 10/0 nylon. After skin closure, each finger was forcefully flexed and extended 10 times. Out of the 39 repaired nerves, two were elongated and four were ruptured; this amounts to a 15.38% complication rate. We recommend immobilization of nerve repairs, although this contradicts most recent studies.

Introduction Composite injuries of the volar surfaces of fingers are frequently associated with digital vessel and nerve damage. Flow-through glabrous flaps can provide esthetic tissue coverage as well as revascularization, and using a neurovascular flap, allows primary reconstruction of the digital nerve. Methods Between June 2010 and August 2014, we prospectively studied the use of Microsurgical flow-through glabrous flaps to achieve simultaneously digital revascularization and soft tissue coverage in 13 fingers of 12 patients who experienced volar injuries, comprising 6 great toe fibular flaps, 3 medial plantar flaps, 1 pedis medialis flap, and 3 hypothenar flaps. The nerve passing through the great toe fibular flap or medial plantar flap was used to repair digital nerve defects. Results All flaps survived completely. During a mean follow-up period of 13.6 months, the majority recovered excellent appearance and function. The flaps had the characteristics of normal finger volar skin: hairless, with similar texture and color. The mean static 2-point discrimination and Semmes-Weinstein monofilament scores of finger pulp were 4.8 and 3.03 mmin the great toe fibular flap group, 7.3 and 3.89 mm in the medial plantar flap group, and 7.5 and 3.84 mm in the sural nerve group. Conclusions Glabrous flow-through flaps provide excellent reconstruction for fingers with volar injuries associated with digital vessel damage. The great toe fibular flap and the medial plantar flap are reliable and useful options for complicated finger injuries associated with digital vessel and nerve injuries.

The presented study aimed to assess objectively the response of distal interphalangeal joint (DIJ), navicular bursa (NB) and deep digital flexor tendon sheath (DDFTS) anesthesia in horses with forelimb hoof lameness; and evaluate if the presence of radiographic abnormalities on navicular bone could interfere on blocks’ results. Fifteen horses with lameness improvement above 70% after palmar digital nerve (PDN) block were selected for this study. Blocks were assessed separately on five consecutive trials at seven different time-points. The fifth trial was performed to evaluate the influence of exercise on preexisting lameness. Most of horses (73.33%) presented pain related to the podotrochlear apparatus based on clinical and lameness exam and blocks’ responses. NB and DIJ anesthesia differed on the frequency of horses with lameness improvement above 70% only at 10min (p=0.03), and both differed from DDFTS block until 30’(p0.05). The NB and DIJ blocks had similar responses and both were superior to DDFTS anesthesia, coincident with a major prevalence of podotroclear apparatus abnormalities in this equine population. RESUMO O presente estudo avaliou, de forma objetiva, as respostas do bloqueio da articulação interfalangeana distal (AID), da bursa do navicular (BN) e da bainha do tendão flexor digital profundo (BTFDP) em equinos com claudicação ligada ao casco nos membros torácicos; além de analisar a influência das alterações radiográficas do osso navicular no resultado dos bloqueios. Quinze cavalos, que apresentaram uma melhora da claudicação acima de 70% após o bloqueio do nervo digital palmar, foram selecionados para este estudo. Os bloqueios foram avaliados separadamente em cinco turnos consecutivos e em sete tempos diferentes. O quinto turno foi utilizado para analisar a influência do exercício sobre a claudicação preexistente. A maioria dos cavalos (73,33%) apresentou dor relacionada à porção palmar do casco, com base nos achados do exame clínico em movimento e nas respostas dos bloqueios. As anestesias da BN e da AID apresentaram diferença quanto à frequência de cavalos com melhora da claudicação acima de 70% apenas aos 10min (p=0.03), e ambos diferiram do bloqueio da BTFDP até os 30min (p0,05). Os bloqueios da BN e da AID apresentaram respostas semelhantes, e ambos foram superiores ao bloqueio da BTFDP, coincidindo com uma marcada prevalência de doença do aparato podotroclear nesta população de equinos.

Neuropathies of digital nerves are an infrequent phenomenon and their causes are most often mechanical. A rare cause of acute neuropathy is hourglass-like fascicular constriction of a nerve due to torsion. Although several cases of hourglass-like constriction have been described in the literature, none to our knowledge involved digital nerves. In this report, we present the first case of hourglass-like constriction of a digital nerve.

Morton's neuroma is a compressive neuropathy resulting in perineural fibrosis rather than a neuroma of the plantar digital nerve. Surgical treatment is indicated for patients with a clear diagnosis of Morton's neuroma and no improvement with nonsurgical treatment. The surgical options include isolated intermetatarsal ligament division, isolated interdigital nerve excision, and interdigital nerve excision with intermetatarsal ligament division, with or without submuscular transposition. This can be performed via dorsal or plantar approach. The open approaches require long incisions and extensive soft-tissue dissection. The purpose of this Technical Note is to describe the surgical details of endoscopic interdigital neurectomy. This is an endoscopic approach involving interdigital nerve excision with intermetatarsal ligament division and submuscular transposition.

Objective: The main objective of this study is to evaluate the availability of lateral antebrachial cutaneous nerve (LACN) autograft for acute or delayed repair of segmented digital nerve injuries. Patients and Methods: 13 digital nerve defects of 11 patients; treated with interposition of LACN graft that harvested from ipsilateral extremity were included in the study. Mean follow up period was 35, 7 months. The mean time from injury to grafting is 53, 3 days. The results of the mean 2PDT and SWMT values of injured /uninjured finger at the end of follow up period were evaluated with Paired T test. The correlation between the defect length and the difference of 2PDT, SWMT values between the uninjured and injured finger at the end of follow up period; were evaluated with Pearson - correlation analysis. Results: The mean value of our 2PDT and SWMT results are ~5,923, ~3, 52, respectively in which can be interpreted between the normal and diminished light touch. The defect length and difference percentage of SWMT values is positively and significantly correlated statistically. Mean length of interposed nerve grafts was 18.5 mm. The age of the patient and the mean values of 2PDT and SWMT with the difference % of 2PDT and % of SWMT are not statistically correlated. Conclusion: Based on results regarding sensory regaining at recipient side and negligible sensory deficit at harvesting side, we suggest that lateral antebrachial cutaneous nerve might be a valuable graft option for digital nerve defects.

In this chapter, anatomic variations and anomalies of the median nerve in or adjacent to the carpal tunnel are described. Cadaveric and clinical studies are reviewed that delineate the variable patterns, courses, and anastomoses of the median nerve and its branches in this region. Specific attention is given to the palmar cutaneous branch, thenar motor branch, and common digital nerve branches of the median nerve. Understanding these anatomic variations and anomalies is essential to minimizing risk during open or endoscopic carpal tunnel release.