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Background: After upper extremity nerve repair, there occurs impairment in hand functions which represents a major problem in activities of daily living (ADL) for the patient. Therefore, the patients after peripheral nerve repair needs rehabilitation to improve their functional status. This study was conducted to determine the efficacy of modified constraint-induced movement therapy in subjects after nerve repair in upper extremity. Methodology: 27 post-surgical subjects of ulnar and/or median nerve repair, aged 18-60 years, were included in the study as per the selection criteria. The subjects were randomly divided into two groups, Group A (n=14) and Group B (n=13) and were assessed for functional disability, integrated hand function, pain and muscle strength using DASH questionnaire, SHFT, VAS and BMRC muscle strengthening grading system respectively. Group A received Modified constraint-induced movement therapy along with conventional therapy. Group B received Conventional therapy alone. The subjects were given a total duration of intervention of 8 weeks, with 5 weekly sessions and were reassessed after 8 weeks. Conclusion: The results of this study conclude that modified constraint induced movement therapy combined with Conventional physiotherapy is more effective when compared to Conventional therapy alone in improving muscle strength and integrated hand function, reducing pain and disability in subjects with nerve repair in upper extremity. [ABSTRACT FROM AUTHOR]

Purpose: Several experimental studies have investigated the effects of hyperbaric oxygen therapy (HBOT) on peripheral nerve regeneration. However, to the best of our knowledge, clinical studies to evaluate the effects of HBOT on peripheral nerve recovery are seldom performed. The aim of our study was to investigate the efficacy of HBOT following primary nerve repair in patients with upper extremity nerve injuries. Methods: Patients admitted to our hospital between 2015 and 2019 with ulnar and median nerve injuries were included in the study. Patients were randomized based on their application dates and divided into two different groups. Patients who received HBOT following standard epineural nerve repair were included in group 1, while patients who only underwent epineural nerve repair were included in group 2. All patients were followed up at 3, 6, and 12 months post-treatment and evaluated through electroneuromyography analysis of the traumatized nerve, injured nerve-related muscle strength, and two-point discrimination test. Results: Impulse transmission of injured nerves to the end organ was faster in group 1. Further, ENMG parameters demonstrated that injured nerves of patients in group 1 recovered faster. Patients in group 1 also reached higher power score and had significantly more rapid motor recovery than patients in group 2. Conclusion: This prospective study of upper extremity injuries demonstrated the favorable effects of HBOT on nerve recovery both clinically and electrophysiologically following nerve repair. One HBOT session each day for 5 days after surgical treatment can decrease morbidity and facilitate recovery. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. A 53-year-old right-handed female weightlifter presented to our clinic for evaluation of left elbow pain and intermittent numbness in her first 3 digits. She reported an elbow injury while weight lifting and carrying heavy planters 6 months earlier. A magnetic resonance imaging obtained previously was interpreted as bicipital-radial bursitis, and she had previously undergone a comprehensive nonoperative management program for her pain and numbness. A diagnostic ultrasound performed in clinic revealed distal biceps tendinopathy, bicipital-radial bursitis, and "pseudotumor," which was dynamically compressed between the biceps tendon and radius with pronation and also caused a mass effect on the median nerve at the level of the pronator teres. Surgical excision of the mass resulted in near-complete resolution of her symptoms, and histology was consistent with scar tissue. This is the first case to the best of our knowledge to describe point-of-care ultrasound diagnosis of a biceps tendon "pseudotumor," as well as demonstrating dynamic impingement of this pseudotumor causing mass effect on the median nerve. [ABSTRACT FROM AUTHOR]

Precise nerve fascicle identification is important in certain peripheral nerve procedures. Although we believe bipolar nerve stimulation with intraoperative neuromonitoring is a superior method, many rely on clinical response evoked by handheld monopolar nerve stimulators. We present a modification in the use of the latter for a more precise fascicle stimulation. A 55-year-old man with a right high brachial plexus injury and a 47-year-old woman with a left median nerve schwannoma were scheduled for exploration and ulnar-to-musculocutaneous nerve transfer, and for surgical excision respectively. Intraoperatively, we used a disposable handheld monopolar nerve stimulator in an unorthodox way, placing the anode right next to the cathode (both touching the same nerve fascicle). In the first case, a fascicle that showed flexor carpi ulnaris (FCU) and intrinsic hand muscle contraction with standard stimulation (anode placed on patient's skin), showed only FCU activation with our modified method, and was chosen as donor. A BMC grade M4 elbow flexion was achieved 9 months after surgery. In the second case, safe schwannoma excision was performed after our modified stimulation technique caused thenar muscle activation in a single, unaffected fascicle, while standard monopolar stimulation showed activation in several fascicles. No unexpected motor/sensory deficits were noted during follow-up. This report shows an easy modification in the use of handheld nerve stimulators that improves selectiveness when looking for nerve fascicles., (© 2024 Wiley Periodicals LLC.)

Objective: Schwannomas are benign, slow-growing tumors originating from Schwann cells in peripheral nerves, commonly affecting the median and ulnar nerves in the forearm and wrist. Surgical excision is the gold standard treatment. This study presents our treatment strategies and outcomes for large-sized ulnar and median nerve schwannomas at the forearm and wrist level., Methods: From 2012 to 2023, we enrolled 15 patients with schwannomas over 2 cm in size in the median or ulnar nerve at the forearm and wrist. The study included 12 patients with median nerve schwannomas (mean age: 61 years) and 3 with ulnar nerve schwannomas (mean age: 68 years), with a mean follow-up of 26.9 months., Results: After surgery, all patients with median nerve schwannomas experienced mild, transient numbness affecting fewer than two digits, resolving within six months without motor deficits. Ulnar nerve schwannoma excision caused mild numbness in two patients, also resolving within six months, but all three developed ulnar claw hand deformity, which persisted but improved at the last follow-up. Despite this, patients were satisfied with the surgery due to relief from severe tingling pain., Conclusions: Schwannomas of the median, ulnar, and other peripheral nerves should be removed by carefully dissecting the connecting nerve fascicles to avoid injury to healthy ones. Sensory deficits may occur but are unlikely to significantly impact quality of life. However, in motor-dominant nerves like the ulnar nerve, there is a risk of significant motor deficits that could affect hand function, though not completely. Therefore, thorough preoperative discussion and consideration of interfascicular nerve grafting are essential., (© 2024. The Author(s).)

A 48-year-old right-handed male surgeon complained of finger numbness, pain, cramps and weakness of 2 years' progression, without improvement after 2 carpal tunnel corticosteroid injections and splinting. The patient was diagnosed with lacertus syndrome with Hagert's triad. Sensory collapse test was positive, but the sensations during the test were not consistent with the literature. Therefore, a sensory collapse test was performed in combination with electromyography; immediately following cutaneous stimulation, partial transient collapse in muscle tone was observed, without complete interruption. Following surgical release of the ipsilateral median nerve at the lacertus fibrosus, the symptoms were resolved, and combined sensory collapse test and electromyography revealed minimal to no collapse in muscle tone following cutaneous stimulation., (Copyright © 2024 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Upper extremity peripheral nerve injuries present functional deficits that are amenable to management by tendon or nerve transfers. The principles of tendon and nerve transfers are discussed, with technical descriptions of preferred tendon and nerve transfers for radial, median, and ulnar nerve injuries., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The aim of this study is to determine the maximum loss of median and ulnar nerve substances that can be treated by direct suture in elbow flexion and to quantify this elbow flexion. The other objective is to determine the participation of the wrist position in this direct suture in elbow flexion., Methods: We performed an experimental study on 6 ulnar nerve lesions and 6 median nerve lesions. For each defect, a direct tensionless suture was performed with elbow flexion and in three different positions of the wrist (wrist extension, neutral position, and wrist flexion)., Results: A 90° elbow flexion allowed direct suturing of defects up to 40 mm in the 3 positions of the wrist. A bowstringing effect (i.e., increase of the perpendicular distance of the nerve from the axis of rotation of the elbow) was noted starting from 25 mm of nerve defect. Wrist extension placed tension on the nerve suture for both nerves., Conclusions: The results of this first anatomical study clarified the conditions for direct suturing of ulnar and median nerve defects in the flexed elbow position and flexed wrist position. This is an approach to consider for limited nerve defects to the elbow or when allograft harvesting is to be avoided., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Unconscious bias of the clinician favors the diagnosis of carpal tunnel syndrome (CTS) in patients with median paresthesia. We hypothesized that more patients in this cohort would be diagnosed with proximal median nerve entrapment (PMNE) by strengthening our cognitive awareness of this alternative diagnosis. We also hypothesized that patients with PMNE may be successfully treated with surgical release of the lacertus fibrosus (LF)., Methods: In this retrospective study, cases of median nerve decompression at the carpal tunnel and in the proximal forearm for the 2-year periods before and after adopting strategies to mitigate cognitive bias for CTS were enumerated. Patients diagnosed with PMNE and treated by LF release under local anesthesia were evaluated to determine surgical outcome at minimum 2-year follow-up. Primary outcome measures were changes in preoperative median paresthesia and proximal median-innervated muscle strength., Results: There was a statistically significant increase in PMNE cases identified after our heightened surveillance was initiated ( z = 3.433, P < .001). In 10 of 12 cases, the patient had previous ipsilateral open carpal tunnel release (CTR) but experienced recurrent median paresthesia. In 8 cases evaluated an average of 5 years after LF release, there was improvement in median paresthesia and resolution of median-innervated muscle weakness., Conclusions: Owing to cognitive bias, some patients with PMNE may be misdiagnosed with CTS. All patients with median paresthesia, particularly those with persistent or recurrent symptoms after CTR, should be assessed for PMNE. Surgical release limited to the LF may be an effective treatment for PMNE., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Polyethylene glycol (PEG) can fuse severed closely apposed axolemmas and restore axonal continuity. The authors evaluated the effects of PEG fusion on functional recovery in a rodent forelimb model of peripheral nerve injury., Methods: The median nerves of male Lewis rats ( n = 5 per group) were transected and repaired with standard suture repair (SR), SR with PEG (PEG), or SR with PEG and 1% methylene blue (PEG+MB); a sham surgery group was also included. Proximal stimulation produced compound nerve and muscle action potentials recorded distally. The contralateral limb of each animal acted as an internal control for grip strength measurements., Results: Compound nerve and muscle action potentials immediately returned in all PEG and PEG+MB animals, but not in SR animals. The PEG and PEG+MB groups demonstrated earlier return of function by postoperative day (POD) 7 (62.6 ± 7.3% and 50.9 ± 6.7% of contralateral limb grip strength, respectively) compared with the SR group, in which minimal return of function was not measurable until POD 21. At POD 98, the PEG group grip strength recovered to 77.2 ± 2.8% and the PEG+MB grip strength recovered to 79.9 ± 4.4%, compared with 34.9 ± 1.8% recovery in the SR group ( P < 0.05). The PEG and PEG+MB groups reached 50% of the sham group grip strength on POD 3.8 and POD 6.3, respectively, whereas the SR group did not reach 50% grip strength recovery of the sham group throughout the study period., Conclusion: PEG fusion plus neurorrhaphy with or without MB reestablished axonal continuity, shortened recovery time, and augmented functional recovery compared with suture neurorrhaphy alone., Clinical Relevance Statement: PEG fusion with neurorrhaphy may bypass Wallerian degeneration, leading to augmented and shortened functional recovery., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Carpal tunnel syndrome being the most common entrapment neuropathy and can be managed with hydrodissection of the median nerve when conservative treatment options fail in mild-moderate disease cases. The principle behind hydrodissection is to free up the nerve from entrapment by separating the nerve from surrounding tissue. Fenestration of the flexor retinaculum can also help in the release of mechanical compression of the entrapped nerve, but poorly described in the literature and not routinely used. Here we present a case of a 72-year-old female patient with carpal tunnel syndrome managed with ultrasound-guided fenestration of the flexor retinaculum and hydrodissection of the median nerve with significant symptomatic and functional improvement over 2-month follow-up. [ABSTRACT FROM AUTHOR]

Background: The incidence of median nerve injuries in pediatric elbow dislocations is approximately 3% and avulsion of the open medial epicondylar epiphysis in the pediatric population is one predisposing factor that may explain this age predilection. These lesions can be difficult to diagnose in the acute phase because symptoms tend to be mild or delayed, consequently their management can be challenging and functional outcome poorer.Methods: We present the case of an unrecognized median nerve entrapment in a 16-year-old boy with posterior dislocation of the elbow and a medial epicondyle fracture, treated initially with close reduction and open stabilization with a cannulated screw. Assessment is supported by a review of similar reported cases available in literature.Results: We discuss the diagnostic approach and the surgical options that can be used for this type of injury.Conclusions: High clinical suspicion of entrapment is imperative in presence of signs of damage to the median nerve in the pediatric patient immediately after the reduction of an elbow dislocation. If diagnosis of entrapment is made the therapeutic choice between neurolysis and nerve graft depends on the lesion severity. In the presence of a Fourrier's type 4 lesion, neurolysis should be avoided, while nerve resection and grafting are recommended. [ABSTRACT FROM AUTHOR]

Introduction: Intercostal nerve transfer is a surgical technique used to restore function in patients with total brachial plexus injury. Stem cell and secretome therapy has been explored as a potential treatment for brachial plexus injuries. This study aimed to compare the functional and histologic outcome of intercostal nerve transfer to median nerve with local stem cells or secretome injection in total type brachial plexus injuries., Materials and Methods: This was a double-blinded, randomized controlled study (RCT). We included patients with neglected total type brachial plexus injury (BPI) who underwent nerve transfer and local injection of either umbilical cord-derived mesenchymal stem cells (UC-MSC) or secretome into median nerve-flexor digitorum superficialis (FDS) neuromuscular junction (NMJ). We measured preoperative and 8-month postoperative FDS muscle strength, SF-36, DASH score, and histologic assessment. We then analyzed the difference outcome between those two groups., Result: A total of 15 patients were included in this study. Our study found that after nerve transfer and implantation with either UC-MSC or secretome, significant postoperative improvements were observed in physical functioning, role limitations, energy/fatigue, emotional well-being, social functioning, pain, general health, and DASH scores, particularly in the overall cohort and the secretome group. When we compared the mean difference of clinical outcome from preoperative to postoperative between UC-MSC and secretome groups, the UC-MSC group showed better improvement of health change in SF-36 subgroup compared to secretome group. From the analysis, there was no significant difference in the histologic outcomes (inflammation, regeneration, and fibrosis) in overall cohort between preoperative and postoperative cohort. There was also no significant difference in mean change of the histologic outcomes (inflammation, regeneration, and fibrosis) preoperative and postoperatively between UC-MSC and secretome groups., Discussion and Conclusion: Implantation of either UC-MSC or secretome along with nerve transfer may provide clinical improvement, while to achieve histologic improvement, further conditioning should be performed., (© 2024. The Author(s).)

Case: A 10-year-old girl presented after closed reduction of an elbow fracture dislocation. She demonstrated intact vascularity but a dense median nerve palsy. Preoperative magnetic resonance neurography (MRN) precisely mapped the median nerve entrapped within the medial epicondylar fracture. Intraoperatively, the median nerve was freed preceding reduction and fracture fixation. Postoperatively, neurological symptoms completely resolved, and she regained full elbow function., Conclusion: Median nerve injury can present without associated vascular injury. In this case, MRN was helpful in preoperatively illustrating the spatial relationship between the median nerve and the medial epicondyle., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C416)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: Intraoperative mapping of the nervous system is used to identify "eloquent" cortical areas. In this technical report, we describe a novel way of mapping the somatosensory cortex so that injury to those critical pathways can be avoided., Methods: An 8-year-old female with drug resistant epilepsy presented for resection of a right posterior parietal focal cortical dysplasia. Left median nerve stimulation was used to record somatosensory evoked potentials (SEPs) directly from the somatosensory cortex with a strip electrode. A handheld monopolar electrode was also used to record both the median and tibial SEP. Total intravenous anesthesia with propofol and remifentanil was used., Results: SEP recordings were obtained from a 4-contact strip electrode placed across the central sulcus. A phase reversal was identified and the most likely post central gyrus was noted. With the strip electrode left in place, a monopolar handheld electrode was used to record the median nerve SEPs from different locations on the postcentral gyrus. The tibial nerve was also stimulated to record where the highest amplitude tibial nerve SEP was present. This map was used delineate functionally "eloquent" areas to avoid during surgery. During resection, the median nerve SEP was recorded from the strip electrode continuously. No significant change in the SEP was noted, and the patient awoke without any sensory deficits., Conclusions: Sensory mapping of the cortex is possible with a handheld monopolar electrode. This technique is easy to perform and can help reduce neurological morbidity., (Published by Elsevier Inc.)

Case: We present a case of type II (intraosseous) entrapment of the median nerve in a patient who was diagnosed based on clinical examination and magnetic resonance imaging and who was treated with medial epicondyle osteotomy, neurolysis, and transposition of the nerve to its anatomical position within a month of injury. Our patient made a complete motor and sensory recovery at 5 months with complete functionality and grip strength., Conclusion: Median nerve entrapment after posterolateral elbow dislocation is a rare complication with roughly 40 cases reported in the literature. This case illustrates the importance of prompt diagnosis and treatment., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C402)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Bennett fractures are traditionally fixed with percutaneous K-wires from dorsal to volar, or with a volar to dorsal screw via a volar open approach. While volar to dorsal screw fixation is biomechanically advantageous, an open approach requires extensive soft tissue dissection, thus increasing morbidity. This study aims to investigate the practicality and safety of Bennett fracture fixation using a percutaneous, volar to dorsal screw, particularly with regard to the median nerve and its motor branch during wire and screw insertion. Methods: Fifteen fresh frozen forearm and hand specimens were obtained from the University of Auckland human cadaver laboratory. A guidewire is placed under image intensifier from volar to dorsal with the thumb held in traction, abduction and pronation. The wire is passed through the skin volarly under image intensifier, then the median nerve is dissected from the carpal tunnel and the motor branch of the median nerve (MBMN) is dissected from its origin to where it supplies the thenar musculature. The distance between the K-wire to the MBMN is measured. Results: In 14 of 15 specimens, the wire was superficial and radial to the carpal tunnel. The mean distance to the origin of the MBMN is 6.2 mm (95% CI 4.1-8.3) with the closest specimen 1 mm away. The mean closest distance the wire gets to any part of the MBMN is 3.7 mm (95% CI 1.6-5.8); in two specimens, the wire was through the MBMN. Conclusions: Wire placement, although done under image intensifier, is subject to significant variation in exiting location. While research has shown the thenar portal in arthroscopic thumb surgery is safe, our guidewire needs to exit further ulnar to capture the Bennett fracture fragment, placing the MBMN at risk. This cadaveric study has demonstrated the proposed technique is unsafe for use.

Background: Targeted muscle re-innervation (TMR) is increasingly being used for treatment of postamputation pain and myoelectric prosthesis (MYP) control. Palmaris longus (PL) is a potential target following transradial amputation. The purpose of this study was to determine the branching pattern of the median nerve (MN) as it pertains to the PL motor branch entry point (MEP) and to present clinical results of patients who had PL used as a target., Methods: Eight cadaveric arms were dissected and branching patterns of the MN were documented. Additionally, we reviewed adult patients from a prospectively collected database who underwent TMR using PL. We recorded patient-reported outcomes and signal strength generated by the PL., Results: The average distance from the medial epicondyle to PL MEP was 53 mm. All palmaris motor branches passed through a chiasm within the flexor digitorum superficialis muscle belly, which was a mean of 18 mm away from the MN proper. Patients with long-term follow-up reported an average Pain visual analog scale of 3.3 and Disabilities of the Arm, Shoulder and Hand of 46.2. All but one patient were using an MYP, and all generated at least 10 mV of signal from the PL, which is ample signal for surface electrode detection and MYP control. There were no postoperative neuromas and only one patient-reported postoperative phantom limb pain., Conclusions: Palmaris longus is a suitable target for TMR. Our objective measurements and anatomic relationships may help surgeons consistently find the PL's motor branch. Our series of patients reveal sufficient signal strength and acceptable clinical outcomes following TMR using the PL., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: A.H. and M.D. declare that they have no relevant disclosures. E.M. has received consulting fees from Axogen and IP royalties from NewClip Technics. D.N.D. has consulting fees from Axogen and Exosmed. B.L. has received consulting fees from Hanger Clinic and is a paid speaker for Hanger Clinic, he is also a paid consultant and paid presenter or speaker for Checkpoint Surgical. G.G. has received royalties and consulting fees from Biomet, consulting fees from BME, Hanger Clinic, Integra, Restor3d, and Stryker; was a paid presenter or speaker for DePuy, Endo Pharmaceutical, Integra, and Zimmer; is a member of the American Association for Hand Surgery and American Society for Surgery of the Hand, is also on the editorial board of Journal of Hand Surgery.

Intraneural lipomas and lipofibromas (also called lipofibromatous hamartomas) are rare, benign tumours occurring in peripheral nerves in the forearm and wrist. They usually present as asymptomatic masses, but if they are large enough, they may cause symptoms of compression neuropathy. Intraneural lipomas and lipofibromas differ with regard to anatomy and clinical behaviour: the former tumour has a well-defined capsule and most commonly occurs within the median nerve in the forearm and wrist. It is diagnosed in the fourth and fifth decades of life and seen more frequently in women. The latter (lipofibroma) has no capsule, is infiltrative in nature, is composed of fatty and fibrous tissue and also most commonly seen in the median nerve. It occurs in a younger age group with no sexual predominance. Due to these differences, these lesions are managed differently 1 2., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Peripheral nerve injuries present a complex clinical challenge, requiring a nuanced approach in surgical management. The consequences of injury vary, with sometimes severe disability, and a risk of lifelong pain for the individual. For late management, the choice of surgical techniques available range from neurolysis and nerve grafting to tendon and nerve transfers. The choice of technique utilized demands an in-depth understanding of the anatomy, patient demographics and the time elapsed since injury for optimized outcomes. This paper focuses on injuries to the radial, median and ulnar nerves, outlining the authors' approach to these injuries. Level of evidence: IV., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The technique of radiofrequency neurotomy (RFN) of the facet joints has been used for decades to treat persistent low back pain to good effect in carefully selected patients. Traditionally, the target is the medial branches of the dorsal root supplying the facet joint. An alternative denervation target is the facet joint capsule. Capsule‐targeting techniques may spare the multifidus muscle, a possible unintended target of traditional RFN that is thought to be important in recovering from low back pain, and have shown promising results. Methods: A modified RFN technique that targets the capsule and spares the multifidus (multifidus‐sparing RFN) is described here, along with a brief report of its application in patients with symptomatic facet joint low back pain as compared to traditional medial branch RFN (MBRF). Results: Over a 2‐year period, a total of 401 initial multifidus‐sparing RFN and 94 initial MBRF procedures were performed on patients attending a multidisciplinary pain clinic. The proportion of repeat procedures was similar: 28.4% of multifidus‐sparing procedures and 23.4% of MBRF procedures. The median repeat interval was 12 months for both groups and interquartile range was 10 months (8–18 months) for multifidus‐sparing RFN and 4 months (11–15 months) for MBRF. Effectiveness and safety profiles appear to be similar, although limited, retrospective outcome information prevented robust analysis. Conclusion: Multifidus‐sparing RFN represents an intriguing technique to denervate the facet joint pain generator while maintaining normal multifidus function. Further study is warranted, particularly in order to identify the appropriate patient criteria and long‐term outcomes. [ABSTRACT FROM AUTHOR]

Posttraumatic acute carpal tunnel syndrome is a not a usual complication in traumatic hand injuries but requires more urgent and aggressive management. Compression of the median nerve should be systematically sought when there is a major and painful swelling of the hand, associated with one or several hand and wrist fractures. In rare case, a single metacarpal fracture or dislocation can be the only cause of median nerve compression and requires urgent diagnosis. If missed or neglected irreversible damage could occur to the median nerve. If surgery is perform in a timely manner outcomes are excellent, with complete recovery in most of the cases. We present the case of a 24-year-old man with an acute compression of the median nerve due to an intra-articular fracture of the 2nd metacarpal base. A bony fragment shifting from the base of 2nd metacarpal was found in the carpal tunnel participating, at least in part, in the compression of the median nerve. [ABSTRACT FROM AUTHOR]

Purpose: Regarding surgical indications for carpal tunnel syndrome (CTS), the hypothesis that the recovery processes of subjective symptoms differ among pain, sensory, and motor symptoms and correlate with recovery in objective nerve conduction studies was examined in the present study., Methods: The global symptom score (GSS) is a method used to assess clinical outcomes and covers subjective symptoms, including pain (pain and nocturnal awakening), sensory (numbness and paresthesia), and motor (weakness/clumsiness) symptoms. The relationships between long-term changes in GSS and recovery in nerve conduction studies were investigated., Results: Forty patients (40 hands) were included (mean age 65 years; 80% female; 68% with moderate CTS: sensory nerve conduction velocity < 45 m/s and motor nerve distal latency > 4.5 ms). Pain and nocturnal awakening rapidly subsided within 1 month after surgery and did not recur in the long term (median 5.6 years). Paresthesia significantly decreased 3 months after surgery and in the long term thereafter. Weakness/clumsiness significantly decreased at 1 year. Sensory nerve distal latency, conduction velocity, and amplitude significantly improved 3 months and 1 year after surgery, and correlated with nocturnal awakening in the short term (3 months) in moderate CTS cases. The patient satisfaction rate was 91%., Conclusion: Rapid recovery was observed in pain and nocturnal awakening, of which nocturnal awakening correlated with the recovery of sensory nerve conduction velocity. Patients with pain symptoms due to moderate CTS may benefit from surgical release., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Objective: High median nerve injuries can lead to poor distal recovery, especially poor functioning of median innervated thenar muscles involved in thumb opposition and palmar abduction. The palmaris brevis (PB) is a small subcutaneous muscle innervated by ulnar nerve. Innervation of the PB is in most of cases provided by the ulnar digital nerve to the little finger. The purpose of this study is to assess the feasibility of transferring the PB motor branch (PBMB) to the median nerve thenar motor branch (TMB), in order to allow for early restoration of thumb palmar abduction and opposition, through a preliminary cadaveric study., Methods: Twenty-five cadaver upper limbs were dissected under magnification. The length of the PBMB and TMB, and their origin were recorded. Nerve transfer from PBMB to TMB was conducted, and evaluated on 2 parameters: surgical feasibility, and distance from the coaptation site to the recipient nerve muscle entry point. The PBMB and TMB were harvested, fixated in formalin, then embedded in paraffin. They were sectioned transversely, and stained with a combination of hematoxylin-eosin and Luxol fast blue. Myelinated axons were counted in each specimen and the donor-to-recipient axon ratio was recorded., Results: The PBMB was constant and originated from the ulnar digital nerve of the little finger in all cases. The transfer from PBMB to TMB was feasible in all cases. Mean myelinated axon counts of PBMB and TMB were 253±142 and 356±198, respectively (p=0.06). The donor-to-recipient axon ratio was 1:1.41. The mean distance from coaptation of the PBMB to the recipient thenar muscles was 23.1±3.0mm., Conclusions: Based on our results, PBMB to TMB transfer is feasible. The PBMB has the advantage over other distal nerve transfer donors to be constant and superficial, allowing for an easier harvest. Moreover, this procedure does not sacrifice any intrinsic function of the hand, and the proximity of the PBMB with the carpal tunnel allows for a single incision procedure. Therefore, early restoration of the median innervated thenar muscles may be feasible by the PBMB to TMB transfer in cases of high median nerve lesions., Level of Evidence: IV., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Case: A 47-year-old orthopaedic surgeon presented with acute volar left wrist pain. He performed over 250 robot-assisted knee arthroplasties each year. Color Doppler evaluation revealed bilateral persistent median arteries and bifid median nerves, with focal occlusive thrombosis of the left median artery. He was advised rest and oral aspirin. He could return to his professional activities after 1 month. He had no recurrence of symptoms at 1 year of follow-up., Conclusion: Orthopaedic surgeons use vibrating hand tools on a daily basis. The possibility of hand-arm vibration syndrome must be considered in the differential diagnosis of wrist pain among orthopaedic surgeons., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C333)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Endoscopic carpal tunnel release (ECTR) techniques have been established as a successful treatment for carpal tunnel syndrome and have proven equally effective as traditional open carpal tunnel release (OCTR) techniques in relieving pain and numbness. However, patients who undergo OCTR are more likely to experience scar tenderness and pillar pain and take longer to return to work. We present here a method of metacarpal small incision for carpal tunnel release (MSICTR) as a safe, reliable, cost-effective alternative surgical decompression of the median nerve of the wrist. This technique utilizes a metacarpal small incision and direct visualization of the median nerve and carpal tunnel contents, reducing the risk of permanent injury and neurasthenia when compared to traditional OCTR. MSICTR is also suitable for the examination of the median nerve, surrounding tendon sheath, or space-occupying lesions. MSICTR is associated with shorter operation times, less postoperative pain, faster recovery, and improved cosmetic results when compared to traditional OCTR. Therefore, MSICTR is an effective surgical decompression of the median nerve for the treatment of carpal tunnel syndrome.

Background: We hypothesized that postoperative Boston Carpal Tunnel Questionnaire (BCTQ) scores and ultrasound (US) measurements of the median nerve cross-sectional area (CSA) at the distal wrist crease are significantly decreased at 2-week, 6-week, and ≥ 6 months follow-up appointments, compared with baseline values., Methods: This study was a retrospective chart review of patients who presented to a single hand clinic with evidence of carpal tunnel syndrome over a 6-year period (2014-2020). Patients received baseline US measurements of the median nerve CSA as well as completion of the BCTQ, and for the patients who underwent carpal tunnel release (CTR), postoperative US measurements and questionnaire scores were obtained at 2 weeks, 6 weeks, or ≥ 6 months postoperatively., Results: This study included 224 separate wrists. Median Nerve CSA measurements were 13.2 ± 4.5 mm 2 at baseline, 11.9 ± 3.6 mm 2 at 2 weeks postoperatively, 11.6 ± 4.5 mm 2 at 6 weeks postoperatively, and 11.7 ± 4.3 mm 2 at 6 months or more ( P = .002). The BCTQ Symptom Severity Scale scores were 3.14 ± 0.76 at baseline, 1.76 ± 0.63 at 2 weeks, 1.68 ± 0.70 at 6 weeks, and 1.41 ± 0.64 at 6 months or longer ( P < .001). The BCTQ Functional Status Scale scores were 2.56 ± 0.89 at baseline, 2.03 ± .1.0 at 2 weeks, 1.65 ± 0.77 at 6 weeks, and 1.36 ± 0.61 at 6 months or longer ( P < .001)., Conclusions: These findings demonstrated a sustained decrease in median nerve CSA and patient-reported outcomes following CTR at 2 weeks, 6 weeks, and between 6 and 12 months., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare that there are no conflicts of interest. J.R.F. is a member of the Integra Life Sciences Nerve Advisory Board; however, this relationship has no conflict with this manuscript.

Background: Median nerve (MN) variation in the carpal tunnel has been well documented by Lanz. Encountering rarely documented variants, that do not fit into existing classifications, increases the risk of iatrogenic injury.Methods: The random occurrence of two unclassifiable anatomical variants of the MN in the carpal tunnel gives motivation to search the literature for similar and identical cases.Case Reports: This article presents two cases of very rare anatomical variants of high division of the MN. First case is a pure high branching of the 3rd space common digital nerve (CDN). The second case is a high division of the MN to a thicker lateral component and a thinner medial component. The lateral component of the MN gives off the palmar cutaneous branch (PCB), the thenar motor branch (TMB), the 1st and 2nd space CDN's and contributes medially with a branch to the 3rd space CDN. The medial component of the MN bifurcates distally into a medial and lateral branch. The lateral branch from the medial component of the MN distally unites with the medial branch of the lateral component of the MN to form the 3rd space CDN. The medial branch from the medial component of the MN has a major contribution to the 4th space CDN from the ulnar nerve. In both cases, the medial component of the MN has a transmuscular course through the flexor digitorum superficialis (FDS) muscle.Discussion: Finding similar case reports from worldwide suggests the need to improve current classification of the MN variants in the carpal tunnel.Conclusions: One cannot rely entirely on the existing anatomical classifications of the MN in the carpal tunnel. There is an underappreciated risk of iatrogenic injury, especially in endoscopic carpal tunnel release, and a chance of missing out on repair of important anatomical structures in trauma cases. There is a possibility of augmenting group 3 of Lanz's classification by adding subgroup "3D High division of the MN with the medial component having a transmuscular course through the FDS muscle", stating the different distal branching patterns. [ABSTRACT FROM AUTHOR]

Background: Upper extremity injuries have a significant impact on social and professional life. They represent about 10% of visits to emergency departments. Nerve lacerations are one of the biggest problem because loss of innervation results in muscle atrophy, decreased sensibility, and therefore permanent dysfunction. Appropriate treatment is very important for patients to regain function.Materials and Methods: The study included 41 patients, 30 men and 11 women who underwent nerve repair surgery in the middle and distal forearm level in the years 2001-2017. The patients' age ranged from 9 to 73 years with an average of 37 years. They were divided into 3 groups with repaired median, ulnar and both nerves. We determined time from injury to nerve repair, assessed sensitivity in index and little finger with a two-point discriminator, and muscle strength by measuring adduction of the little finger and palmar abduction of the thumb.Results were rated based on Medical Research Council Scale (MRC). In addition, general hand disability was assessed according to the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH).Results: There was a statistically significant (p = 0.0197), positive correlation (r > 0) between the period from injury to surgery and the DASH score, and statistically significant difference (p = 0.0001) in return of muscular function between groups with median, ulnar and both nerves injury. Also correlation between patients age and score of DASH was statistically significant (p = 0.0140) with positive correlation (r > 0). There was no statistically significant difference in the return of sensitivity (p = 0.4337) and the DASH score (p = 0.3831) between these three groups.Conclusions: Patients with shorter time from injury to repair and at a younger age had better DASH results. The median nerve had the best motor function between the groups. There was no difference in sensitivity or DASH scores between groups. [ABSTRACT FROM AUTHOR]

The article reports on the use of dynamic ultrasound (US) to visualize and document the abnormal tethering of the MN to the ulnar head of the pronator teres (UHPT) was also well delineated. Topics include abnormal tethering is caused by abnormal adhesion or friction between the posterior surface; and physical examination of weakness or motor atrophy, and has abnormal electrodiagnostic studies.

Objective To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria. Design Comprehensive systematic review. Methods A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. Outcome Measures The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief. Results Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used. Conclusions Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief. [ABSTRACT FROM AUTHOR]

Background Cervical medial branch radiofrequency ablation (CMBRFA) is an effective treatment for facetogenic pain in patients selected by Spine Intervention Society (SIS) guidelines of 100% symptom improvement with dual medial branch blocks (MBBs) ± placebo block. Patient selection for CMBRFA using ≥80% symptom improvement after dual concordant MBBs is common; however, this has not been studied. Objective To evaluate the effectiveness of CMBRFA and compare outcomes in individuals selected by 80–99% vs 100% symptom improvement with dual concordant MBBs. Design Cross-sectional cohort study. Methods Medical records of 87 consecutive patients were reviewed; 50 met inclusion criteria. A standardized telephone survey was performed at six or more months post-CMBRFA to query numerical rating scale (NRS) pain and patient global impression of change (PGIC) scores. The primary outcomes were the proportion of patients reporting ≥50% reduction of index pain. Results At a mean follow-up time of 16.9 ± 12.7 months, 54% (95% confidence interval [CI] = 35–73%) and 54% (95% CI = 32–74%) of the 80–99% and 100% MBBs groups, respectively, reported ≥50% pain reduction. Between-group comparison showed a relative risk of 0.99 (95% CI = 0.59–1.66) for meeting the primary outcome. Seventy percent (95% CI = 56–81%) of patients reported a PGIC score consistent with "improved or very much improved" at follow-up. Conclusions CMBRFA is an effective treatment in patients who report ≥80% symptom relief with dual concordant MBBs. The present study demonstrated an overall ≥50% pain reduction rate of 54% and no significant difference between those selected by 80–99% vs 100% symptom relief with dual concordant MBBs. [ABSTRACT FROM AUTHOR]

Background: Compound muscle action potential (CMAP) scan and MScanFit have been used to understand the consequences of denervation and reinnervation. This study aimed to monitor these parameters during Wallerian degeneration (WD) after acute nerve transections (ANT).Methods: Beginning after urgent surgery, CMAP scans were recorded at 1-2 day intervals in 12 patients with ANT of the ulnar or median nerves, by stimulating the distal stump (DS). Stimulus intensities (SI), steps, returners, and MScanFit were calculated. Studies were grouped according to the examination time after ANT. Results were compared with those of 27 controls.Results: CMAP amplitudes and MScanFit progressively declined, revealing a positive correlation with one another. SIs were higher in WD groups than controls. Steps appeared or disappeared in follow-up scans. The late WD group had higher returner% than the early WD and control groups.Conclusions: MScanFit can monitor neuromuscular dysfunction during WD. SIs revealed excitability changes in DS. [ABSTRACT FROM AUTHOR]

Case: A 77-year-old woman who sustained a distal radius and ulna fracture underwent open reduction internal fixation through a standard flexor carpi radialis (FCR) approach. On dissection, a proximal division of the median nerve was identified, with an aberrant motor branch crossing radial to ulnar deep to FCR and superficial to flexor pollicis longus., Conclusion: Although many anatomic variants of the median nerve have been described, the current case demonstrates a particularly important median motor branch variant, imposing a substantial risk of iatrogenic injury during a standard FCR approach., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C214)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Lipofibromatous hamartoma (LFH) of the median nerve is a rare condition in the hand and often remains asymptomatic for a significant period. MRI imaging can reveal unique tumour characteristics; however, the definitive diagnosis is confirmed through a tissue biopsy. In this report, a 38-year-old male presented with a gradually growing mass on his right hand. Physical examination revealed a large soft tissue mass extending from the thenar area to the wrist, causing compression of the median nerve. MRI confirmed the presence of a distinct soft tissue mass on the volar side of the hand. The mass was excised along with a fascicle and confirmed by histological examination. One year after surgery, sensation has improved, but weakness remains and opponensplasty was offered to the patient. Although the treatment strategy of LFH of the median nerve remains controversial, delayed treatment can result in severe compressive neuropathy and irreversible nerve damage. Level of Evidence: Level V (Therapeutic).

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

Purpose: Carpal tunnel syndrome is the most common compressive neuropathy. There is limited evidence to support endoscopic compared to open carpal tunnel release according to the 2016 American Academy of Orthopaedic Surgeons Clinical Practice Guideline on carpal tunnel syndrome. The purpose of the present study was to assess differences between the two procedures by comparing 30- and 90-day complications and mean hospital costs in a large patient population., Methods: Using the national Mariner15 Database by PearlDiver Technologies, we retrospectively studied 27,192 carpal tunnel syndrome patients who received carpal tunnel release using an endoscopic or open surgical approach from 2010 to 2019. Patients who met the inclusion criteria were grouped and case-matched at a 1:1 ratio through the corresponding International Classification of Diseases codes (n = 13,596) and assessed for 30- and 90-day complications such as median nerve injury, superficial palmar arch injury, and revision carpal tunnel release surgery. Univariate analysis was used to compare outcomes and a multivariate regression was performed to identify risk factors associated with each outcome., Results: Endoscopic carpal tunnel release was associated with a higher rate of median nerve injury than open release at 30 days (0.3% vs. 0.1% odds ratio, 2.21; 95% confidence interval, 1.29-3.81; p < 0.05) and 90 days (0.4% vs. 0.3%; odds ratio, 1.77; 95% confidence interval, 1.16-2.70; p < 0.05). Endoscopic release was also associated with a higher rate of superficial palmar arch injury (0.1% vs. 0%; odds ratio, 25.02; 95% confidence interval, 1.48-423.0; p < 0.05)., Conclusions: In the present study, risk of median nerve injury and vascular injury was higher after endoscopic than open carpal tunnel release. At 90 days, all-cause revision rates were similar between techniques. Surgeons should understand these differences, to optimize surgical decision-making., Level of Evidence: Therapeutic, IIIa., (Copyright © 2023 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Introduction: Median nerve injuries occur in approximately 3% of pediatric elbow fracture dislocations. These rare injuries can be difficult to diagnose, and the results are poor in delay cases. Surgical timing is one of the most important prognostic factors. We aimed to present three patients with median nerve palsy who were referred to our clinic late, and according to these cases, we emphasized the expected time frame for exploration based on our anatomical cadaver study., Materials and Methods: Between 2008 and 2010, three patients were referred to our clinic because of median nerve paralysis after a treated elbow dislocation. The mean interval between injury and referral was 15 (min: 13-max: 18) months, and the mean age of the patients was 15 (13-18) years. Neurolysis was performed in two patients, and for the third patent, after neurolysis, axonal continuity was observed to be disrupted so sural nerve grafting was performed with four cables. Tendon transfers were performed in all patients. A total number of 20 upper extremities of 10 cadavers were dissected. Due to its proximal innervation and ease of assessment, the muscle innervation of the flexor pollicis longus (FPL) was planned to be evaluated. The distance from the medial epicondyle is calculated in the cadaver study where the nerve injury is found., Results: The mean length from the medial epicondyle to the motor innervation of FPL was calculated in each specimen and found to be 101.99 millimeters (mm) (range: 87.5-134.2). The mean longest innervation of FPL was 110.83 mm from (range 87.5-148.1) the medial epicondyle calculated by including each specimens longest nerve length. Knowing that the healing time of a nerve lesion is 1 mm per day, we calculated that the recovery of FPL would take approximately 4 months., Conclusion: When nerve healing is expected to be 1 mm a day in axonotmesis type injury, after the median nerve palsy following elbow dislocation, thumb flexion should be achieved in the following 4 months generally if the nerve was not entrapped in the joint. This cadaver-based study objectively defined how long to wait for the innervation of the FPL in median nerve injuries in elbow fracture dislocations.

Cases: We present 2 cases of median nerve reconstruction using distal nerve transfers after resection of unusual benign median nerve tumors. Critical sensation was restored in case 1 by transferring the fourth common digital nerve to first web digital nerves. Thumb opposition was regained by transferring the abductor digiti minimi ulnar motor nerve branch to the recurrent median motor nerve branch. Critical sensation was restored in case 2 by transferring the long finger ulnar digital nerve to the index finger radial digital nerve., Conclusion: Distal nerve transfers, even with short grafts, are reliable median nerve deficit treatments, sparing the need for larger autologous nerve grafts and late tendon opponensplasties., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C278)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Melanoma is a malignant neuroectodermal tumor arising from skin pigment cells (melanocytes). Distant metastases and damage to the nervous system occur mainly at the later stages of disease. However, primary tumor may not be verified despite distant metastases in some cases. We present a patient with metastatic melanoma to the left median nerve and brachial plexus without clear primary lesion. This case describes surgical treatment of melanoma metastasis followed by median neuropathy.

Objectives: The use of fascicle transfers in the reconstruction of traumatic brachial plexus injury is well established, but limited evidence is available regarding their use in atraumatic elbow flexion paralysis. This retrospective case review aimed to verify whether median and ulnar fascicle transfers are similarly effective in atraumatic versus traumatic elbow flexion paralysis when measured using the British Medical Research Council (MRC) scale, Brachial plexus Assessment Tool (BrAT) and Stanmore Percentage of Normal Elbow Assessment (SPONEA) scores at long-term follow-up., Methods: All median and ulnar fascicle transfer cases performed at the Queen Elizabeth Hospital Birmingham between August 2007 and November 2018 were reviewed to compare the outcomes of transfers performed for traumatic and atraumatic indications. Data on patient demographics, mechanism and nature of injury, date of injury or symptom onset, date of operation, and other nerve transfers performed were collected. Outcome measures collected included the British MRC scale and two patient-reported outcome measures (PROMs), BrAT and SPONEA., Results: In total, 34 patients with 45 median and ulnar fascicle transfers were identified. This included 27 traumatic and seven atraumatic brachial plexus insults. Thirty patients had sufficient follow-up to be included in MRC analysis and 17 patients had sufficient follow-up to be included in PROM analysis. No significant differences were found between traumatic and atraumatic subgroups for median MRC, BrAT, or SPONEA scores., Conclusions: This study suggests that nerve transfers might be considered effective reconstructive options in atraumatic pathology and provides validation for further research on the subject., Competing Interests: Declaration of Competing Interest No conflicts of interest are declared by the authors., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Fibrolipomatous hamartoma of the median nerve is an uncommon benign tumour of the childhood, which usually manifests in adolescents or adulthood with signs of compressive neuropathy at wrist. Symptomatic tumour is unusual in children below 5 years age and can be underdiagnosed. Magnetic resonance imaging provides pathognomonic features for the diagnosis, obviating the need for biopsy. Although standard ultrasonography is frequently the first-line imaging approach in the evaluation of soft-tissue masses, sonographic findings of this lesion are less frequently reported and have to be kept in mind by radiologist. We report the unusual case of carpal tunnel syndrome secondary to fibrolipomatous hamartoma of the median nerve in a 4-year-old child successfully treated with surgical carpal tunnel release., (© 2022. Società Italiana di Ultrasonologia in Medicina e Biologia (SIUMB).)

Background: Endoscopic carpal tunnel release (ECTR) is a less invasive procedure but has a higher risk of complications. We analysed ECTR cases dividing them into three periods according to a single surgeon's experience when the ECTR was performed: the initial, midterm and late period. Cases of iatrogenically induced median nerve injuries that occurred after ECTR were then noted and evaluated. Methods: We reviewed 195 ECTRs done with the 2-portal technique and divided the patients into three groups according to periods of when ECTR was done. The indications for ECTR surgery were limited to severe CTS cases. These groups of patients were similar in terms of age, duration of disease, electrophysiological study results and severity of the disease. The patients were evaluated for median neuropathy pre- and postoperatively using Semmes-Weinstein monofilament test (SWT), Disabilities of the arm, shoulder and hand (DASH) Score, Coin-flip test (CFT), postoperative paraesthesias and complications, such as pillar pain, and so on. Electrophysiological evaluation was performed only preoperatively. Results: Postoperative median nerve recovery was overall good. Normal recovery was noted in 181 cases (93%). SWT, DASH and CFT were all significantly improved upon follow-up in all three groups. In terms of iatrogenic neuropathy, median nerve palsy worsened (including those transiently worsened) after ECTR in 11 cases (5.6%), even in the later period. The sensory disturbance was equally worsening from the radial to the ulnar side. Conclusions: The fact that there were neurologically worsened cases even in the later period, when the operator is higher skilled in the technique, suggests that the surgical technique itself may be the one posing higher risk than the level of surgical skill. The most likely causes of aggravated nerve palsy were a direct injury by cannula insertion at the proximal portal, or additional median nerve compression during cannula insertion into the carpal tunnel. Level of Evidence: Level IV (Therapeutic).

Background: Reliable measurement of functional recovery is critical in translational peripheral nerve regeneration research. Behavioral functional assessments such as volitional grip strength testing (vGST) are limited by inherent behavioral variability. Isometric tetanic force testing (ITFT) is highly reliable but precludes serial measurements. Combining elements of vGST and ITFT, stimulated grip strength testing (sGST) involves percutaneous median nerve stimulation to elicit maximal tetanic contraction of digital flexors, thereby allowing for consistent measurement of maximal grip strength.Methods: We measured side-to-side equivalence of force using sGST, vGST, and ITFT to determine relative reliability and repeatability. We also performed weekly force measurements following median nerve repair.Results: sGST demonstrated greater reliability and inter-trial repeatability than vGST and similar reliability to ITFT, with the added benefit of serial measurements.Conclusions: sGST is a valid method for assessing functional recovery that addresses the limitations of the currently available modalities used in translational peripheral nerve regeneration research. [ABSTRACT FROM AUTHOR]

Prospective controlled study. Previous studies evaluated the effectiveness of sensory reeducation (SR) after peripheral nerve injury and repair. However, evidence for long-term clinical usefulness of SR is inconclusive. The purpose of this study is to compare the sensory results of patients with low-median nerve complete transection and microsurgical repair, with and without SR at long term. We prospectively studied 52 consecutive patients (mean age, 36 years; range, 20-47 years) with low-median nerve complete transection and microsurgical repair. When reinnervation was considered complete with perception of vibration with a 256-cycles per second tuning fork (mean, 3.5 months after nerve injury and repair), the patients were sequentially allocated (into 2 groups [group SR, 26 patients, SR; group R, 26 patients, reassured on recovery without SR). SR was conducted in a standardized fashion, in 2 stages, as an independent home-based program: the first stage was initiated when reinnervation was considered complete, and included instruction in home exercises to identify familiar objects and papers of different roughness, and localization of light touch (eyes open and closed); the second stage was initiated when the patients experienced normal static and moving 2-point discrimination (2PD) at the index fingertip of injured hand, and included instruction in home exercises for stereognosia, supplementary exercises for localization of light touch, and identification of small objects (eyes open and closed). Exercises were prescribed for 5-10 minutes, 4 times per day. At 1.5, 3, and 6 years after nerve injury and repair, we evaluated the static and moving 2PD, stereognosia with the Moberg's pick-up test, and locognosia with the modified Marsh test. Comparison between groups and time points was done with the nonparametric analysis of variance (Kruskal-Wallis analysis of variance). Static and moving 2PD and stereognosia were not significantly different between groups at any study period. Locognosia was significantly better at 1.5 and 3 years in group SR; locognosia was excellent in 17 patients of group SR vs 5 patients of group R at 1.5-year follow-up and in 14 patients of group SR vs 5 patients of group R at 3-year follow-up. Locognosia was not different between the study groups at 6-year follow-up. A 2-stage home program of SR improved locognosia at 1.5 and 3 years after low-median nerve complete transection and repair without significant differences in other modalities or the 6-year follow-up of a small subsample. [ABSTRACT FROM AUTHOR]

Introduction. The aim of this research was to test, in an animal model, the nerve regeneration technique with a hypoallergenic acellular dermal matrix used to wrap the microsurgical neural suture. Materials and Methods. Two groups of rats received the cut of limb right median nerves. The regeneration technique considers for both groups an end-to-end nerve suture. In the experimental group (A) was used also a wrapping protocol by a conduit of collagen matrix currently used in oral surgery. The animals underwent functional grasping tests (at 1, 3, 5, and 7 months) and a histological and quantitative analysis of distal nerve was performed at the end of experimental time. Result. After seven months, the grasping test reveals functional recovery in each tested animal; this improvement is more evident in Group A. The fibers appear well organized with restored myelin sheaths in both groups. Group A showed a great quantity of connective tissue surrounding the nerve. The quantitative morphology analysis in both groups shows a similar fibers density, fiber diameter, and myelin thickness. The differences between the groups in axon mean diameter are significant. In Group A M/d, D/d, and g-ratio is significantly higher compared to control group. Conclusions. Histological and functional assessments show a functional recovery of the injured nerve in the test groups, stressed by the results of the grasping tests and the meaningful increasing in fiber diameter and higher g-ratio. Moreover, a connective tissue cuff distinguishes the distal portion of the injured nerve. Considering the easy availability and handling of the material used in this study we can conclude that this experimental technique can be considered as a valid alternative to protect nerves in nerve wrap surgery. [ABSTRACT FROM AUTHOR]