INTRODUCTION: Median Nerve has small vessel on the volar aspect of the nerve which is filled with blood and results in so called ‘ BLUSHING’ of the nerve once it has been decompressed. It was thought that the nerve which didnot blush meant an inadequate decompression was carried out. PURPOSE: To evaluate whether ‘Blushing’ of the Median Nerve is correlated with adequate decompression and level of recovery in Carpal Tunnel Syndrome through Mini Palmar Incision. METHODS & MATERIALS: Retrospective analysis of a Single Surgeon practise where it was documented in operation notes whether the nerve was seen to ‘Blushed’ at the time of surgery.They were assessed postoperatively from notes for complete resolution of symptoms and whether there was any recurrence of symptoms. RESULTS: n=330 Carpal Tunnel Decompressions were reviewed. It was noted that those who had complete resolution of symptoms had ‘Blushing’ noted at the time of surgery compared to those who had partial or incomplete resolution of symptoms wher ‘No BUSHING’ was noticed. Average time of follow up = 6 weeks. Blushing Noted at the time of decompression 192, Recovery/ improvement of symptoms 189, Blushing not noted at the time of surgery 38, NO documentation about Blushing in 100. CONCLUSION: Blushing of Median Nerve intraoperatively is a reliable sign for complete decompression of the nerve and is correalted with good final outcome

The anatomical integrity of the epi- and para-nevrium is the most relevant factor for the correct gliding of the median nerve, and when they are surrounded by scar tissue, the result is a chronic neuropathy. This recurrent compressive neuropathy represents a very challenging clinical and surgical problem. Neurolysis can not always improve the recovery of nerve function, and the soft tissue coverage is necessary to prevent recurrent scar and to achieve a useful mobilization of the median nerve. The autogenous vein graft wrapping technique has shown great promise for the treatment of chronic compressive neuropathy after other procedures have failed. The author present their experience using the Basilic vein grafting as a valid alternative to the Saphenous one. All our patients presented symptoms in the median nerve distribution, including pain, swelling and numbness, and grip strength reduction. Four of these patients presented a CRPS and have been evaluated before treatment in a multidisciplinary dedicated equipe to plan the surgical procedure. The vein graft wrapping represents a simple technique without problem in donor area. In the authors’ casuistry it presented also as a very useful technique in the treatment of median neuropathy in CRPS

Purpose : We report two cases of bifid median nerve in the carpal tunnel because of the exceptional rarity of this event. This does not abolish the possibility of the existence of the second branch and the inspection of the carpal tunnel’s content should be done with special care. Materials and methods : 530 patients with carpal tunnel syndrome were operated in our clinic in the time period 1994 to 2002 with the open and endoscopic method. 351 of them were women and 179 men. Among these patients two had a bifid median nerve in the carpal tunnel. These two patients were married women whose children had dysplasia of different organs. Results : In both cases the patients were relieved from the symptoms of pressure after the release of the transverse carpal ligament and the epineurium. Conclusions : It is not known if the existence of a bifid median nerve is a reason of carpal tunnel syndrome. However it is an exceptional rare event and we must take special care to recognize the second branch so as to have the same handling as the first one. Finally, we must examine the children of these parents for the existence of organs dysplasia

Purpose: The aim of this study was to redefine the localization of the thenar motor branch (TMB) of the median nerve in relation to the surface landmarks which are in routine use. Methods: The study was performed in 37 hands of 34 patients who underwent carpal tunnel release. All of the patients were women and the mean age was 50 (35–67). A radiological marking technique was used to determine the localization of the TMB, the middle finger radial side line and the Kaplan’s cardinal line. For marking TMB a circumscribing soft radioopaque yarn was used while the surface landmark lines were demonstrated by taping one K-wire for each. An image intensifier print image was obtained for each case and the distances between the markers of the TMB and the wires were measured. Results: The TMB had a mean ulnar offset of 12.6 mm (4.0–19.7) from the middle finger radial side line and located 4.4 (0–9.5) mm proximal to the cardinal line. Conclusion: During the carpal tunnel release operations one must pay more attention to the localization of the TMB of the median nerve because it was found to be 12.6 mm ulnar than that was described in classic literature

The postoperative course of median nerve decompression in the carpal tunnel syndrome may sometimes be complicated by postoperative pain, paresthesias, and other unpleasant symptoms, or be characterized by a slow recovery of nerve function due to prolonged preoperative injury causing extensive nerve damage. The aim of this study is to explore any possible effects of alpha lipoic acid (ALA) in the postoperative period after surgical decompression of the median nerve at the wrist. Patients were enrolled with proven carpal tunnel syndrome and randomly assigned into one of two groups: Group A: surgical decompression of the median nerve followed by ALA for 40 days. Group P: surgical decompression followed by placebo. The primary endpoint of the study was nerve conduction velocity at 3 months post surgery, Other endpoints were static 2 point discrimination, the Boston score for hand function, pillar pain and use of pain killers beyond the second postoperative day. ALA did not show to significantly improve nerve conduction velocity or Boston score. However, a statistically significant reduction in the postoperative incidence of pillar pain was noted in Group A. In addition, static 2 point discrimination showed to be significantly improved by ALA. Administration of ALA following decompression of the median nerve for carpal tunnel release is effective on nerve recovery, although this is not detectable through nerve conduction studies but in terms of accelerated and improved static two-point discrimination. The use of ALA as a supplementation for nerve recovery after surgical decompression may be extended to all types of compression syndromes or conditions where a nerve is freed from a mechanical insult. Furthermore, ALA limits post-decompression pain, including late pericicatricial pain at the base of the palm, the so called pillar pain, which seems to be associated with a reversible damage to the superfical sensitive small nerve fibers. In conclusion postoperative administration of ALA for 40 days post-median nerve decompression was positively associated with nerve recovery, induced a lower incidence of postoperative pillar pain and was associated with a more rapid improvement of static two-point discrimination. This treatment is well tolerated and associated with high levels of satisfaction and compliance, supporting its value as a standard postoperative supplementation after carpal tunnel decompression

Purpose of the study: We report the results of a prospective series of 104 cases of carpal tunnel decompression using a minimally invasive technique performed by one operator. Material and methods: The 92 patients (28 men) were treated in an outpatient clinic between February 1999 and July 2002. Mean age was 50 years and 86% of the cases involved the dominant side. Twenty-one patients were manual laborers. There was a notion of repeated motion (occupational disease) in nine cases and eight patients were diabetics. Nocturnal paresthesia predominated the clinical presentation in all patients. Anesthesia of the median nerve territory was noted in five patients. There was no motor deficit. The technique consisted in decompression of the carpal tunnel under local anesthesia via an incision in the flexion fold of the wrist and introduction of a pre-moulded canulated probe into the carpal tunnel then section of the anterior retinacular ligament using a n°15 lancet guided by the probe. Patients were reviewed at 15 days, then one, three and six months. Results: Outcome was excellent or good in 97.2%. One patient was partially relieved: this diabetic patient retained decreased sensitivity in the median nerve territory but the nocturnal paresthesia resolved completely. Two patients underwent decompression on both sides (same technique) and continued to complain about pain on one side. There were no neurological, tendinous, or infectious complications and no conversion to open surgery was required. Mean duration of sick leave was 22.3 days and daily activities were resumed without pain at the base of the hand on average 15 days after surgery. Conclusion: The results obtained with this minimally invasive non-endoscopic technique are comparable with endoscopic techniques but at a lesser cost

To evaluate the functional outcome after complete median nerve transaction and repair, and sensory reeducation. We studied 40 patients, aged 20 to 32 years, with median nerve neurotmesis at the wrist. Primary epineural microsurgical repair using 8-0 single strand sutures was done in all patients, and a hand and wrist cast was applied for 4 weeks. After cast removal all patients went through physical therapy for 1 month to restore motion and reduce stiffness of the injured hand. After reinnervation was completed, the patients were randomly allocated into 2 equal groups: Group A patients were instructed to a sensory re-education program; Group B patients had no further treatment. Clinical evaluation was done at 18 months postoperatively including the localization test (locognosia), the static and the moving 2 point discrimination tests, the Moberg’s pick-up test (stereognosia), and the hand grip and the opposition strength tests. All patients were included in the postoperative evaluation. Hand grip and opposition strength, static and moving two point discrimination were not statistically significant between the two groups (p= 0.622, p= 0.112 and p= 0.340, respectively). The localization test was statistically significant in group A (p= 0.007), and a trend to statistical significance was observed regarding the Moberg’s pick up test in group A (90% statistical significance, p= 0.063). Sensory reeducation is essential for patients with median nerve neurotmesis and repair, as it significantly re-educates localization and stereognosia in the shortest time following peripheral nerve injury and repair

Whiplash remains a challenging condition because the pathology is undefined. The purpose of this study was to evaluate the response of chronic neck, shoulder and arm pain to decompression of the median nerve at the wrist and pronator teres level. In a prospective study of 150 cases following whiplash injury (108 carpal tunnel and 42 pronator teres syndrome) clinical symptoms were assessed by clinical, neurological, radiological and visual analogue scale. The pathophysiology of pain and effects of surgery have also been assessed by neuropeptide studies. Clinical and neurological examination revealed signs and symptoms of carpal tunnel and pronator teres syndrome along with severe neck, shoulder and arm pain. Local anesthetic infiltration around the median nerve at the wrist and forearm abolished the chronic neck and shoulder pain within 10mins of injection. This demonstrated the site of pathology and temporarily relieved upper limb symptoms and trapezius muscle spasm as well. Neurophysiological studies were always normal. Surgical intervention in successful cases cured chronic neck shoulder and arm pain with sensory and motor recovery. Also activities of daily life normalised permanently. The main neurotransmitter peptides Substance P and Calcitonin gene related peptide levels returned to control levels six weeks after surgery in successful cases (p< 0. 005 and p< 0. 05 respectively). This is the biochemical evidence of effect of surgery in relieving pain and neuroinflammatory process. Our study suggests that neck shoulder and arm pain following whiplash injury is caused by entrapment of the median nerve due to stretching. Surgical decompression of the carpal tunnel and pronator teres muscle yielded 93% and 80% good results respectively with the disappearance of chronic neck shoulder and arm pain. Consequently normalisation of daily activities were observed. Although mild hand symptoms caused by carpal tunnel syndrome have also been cured the primary aim of surgical intervention is to cure chronic neck shoulder and arm pain

Aims: The combination of microsurgical techniques with engineering of pseudo-nerves has recently seen an increased employment for the repair of peripheral nerve defects. Over the last ten years, we have investigated a particular type of bio-engineered nerve guide, the muscle-vein-combined tube, which is made by filling a vein with skeletal muscle. However, the basic mechanism underlying the effectiveness of this surgical technique are still unclear and yet an experimental study on its efficacy on functional recovery compared to traditional nerve autografts is still lacking in the literature. The aim of the present study was thus to fill this gap. Methods: In rats, 10-mm-long median nerve defects were repaired using either traditional autografts or fresh muscle-vein-combined bioengineered scaffolds. Posttraumatic nerve recovery was assessed by grasping test. The samples were collected at different times after surgery: 5, 15, 30 days and 6 months. Analysis was carried out by light and electron microscopy. In addition, reverse transcription polymerase chain reaction (RT-PCR) was used to investigate the expression of mRNAs coding for glial markers as well as glial growth factor (NRG1) and its receptors (erbB2 and erbB3). Results: Results showed that both types of nerve repair techniques led to successful axonal regeneration along the severed nerve trunk as well as to a partial recovery of the lost function as assessed by grasping test. Rats operated on by traditional nerve autografts performed better in the grasping test. Biomolecular analysis by RT-PCR demonstrated early overexpression during nerve regeneration of the gliotrophic factor NRG1 and two of its receptors: erbB2 and erbB3. Conclusions: Our results confirmed that use of muscle-vein-combined tissue-engineered conduits is a good approach for bridging peripheral nerve defects in selected cases when traditional autografts are not employable and disclosed one of the basic biological mechanism that support the effectiveness of this surgical technique. Our experience also suggested that the rat forelimb experimental model is particularly appropriate for the study of microsurgical reconstruction of major mixed nerve trunks. Furthermore, since the forelimb model is less compromising for the animal, it should be preferred to the hindlimb model for many research purposes

Introduction. The flexor carpi radialis (FCR) approach is widely used for volar plate fixation of distal radius fractures. However, patients sometimes complain of postoperative numbness at the thenar eminence. We propose this is derived from injury to the palmar cutaneous branch of the median nerve (PCBm). Materials and methods. From March 2010 to March 2012, we performed 10 operations of volar plate fixation for distal radius fractures using the FCR approach. We detected the PCBm intraoperatively and investigated the anatomy. Results. On average, the PCBm arises from the median nerve 44 mm proximal to the distal wrist crease. It arose from the radial side of the median nerve in nine cases and the ulnar side in one case. In all cases, it ran between the FCR and the palmaris longus tendon under the antebrachial fascia. Nerve supply to the FCR sheath was not observed in the field of operation. Discussion. Numerous studies report the necessity to preserve the PCBm during carpal tunnel release surgery, but the relationship between the FCR approach and the PCBm has not been emphasized. Our results generally agree with past reports on PCBm anatomy. In our experience, the FCR tendon should be retracted to the ulnar side to prevent PCBm injury. If the FCR tendon is retracted radially, the PCBm should be detected and retracted gently. Some studies report that the PCBm joins the FCR sheath at the level of the distal wrist crease. Thus, the distal sheath incision should not be extended blindly

Median nerve release is one of the most common procedures performed in hand surgery (classical incision or endoscopic methods), with a low complication rate, but not free of morbidity conditioning work reincorporation. We present a comparative study between the classical technique and double-incision approach of median nerve preserving the intereminencial space. Material and methods. A review of 155 hands in 133 patients (all operated by the same surgeon), divided in two separate groups:. – 72 hands (61 patients) operated by classical technique. – 83 hands (72 patients) operated by double-incision approach. Excluding criteria: patients under 30 years-old, antecedents or symptoms of associated local pathology, trophic troubles of thenar or hypothenar eminences and recurrent carpal tunnel syndrome. We reviewed: per-operatory neurovascular complications, difficulties in hand activity related to pillar pain at 10 and 21 days and 3 and 12 months after surgery, discomfort in the thenar-hypothenar areas (intereminencial pruritus), remaining discomfort in the area of the surgical scar at 3 and 12 months after surgery, and recurrences at 24 months. Results: Nerve compression symptoms disappeared in all 155 hands and neither complications nor recurrences were observed at 24 months. Pillar pain conditioning hand activity:. 21 days: A-group 32 cases (44 %) %, B-group 0%. 3 months: A-group 18 cases (25 %), B-group 0%. 12 months: A-group 5 cases (7 %), B-group 0%. Discomfort in the thenar-hypothenar areas (inter-eminencial pruritus):. 21 days: A-group 0%, B-group 15 cases (18 %). 3 months: A-group 0%, B-group 6 cases (7 %) Remaining discomfort in surgical scars areas:. 3 months: A-group 18 cases (25%) palm area, B-group 4 cases (5 %) wrist area. 12 months: A-group 5 cases (7 %) palm area, B-group 0%. Conclusion: Absence of pillar pain in double-incision approach and free hand activity 3-4 weeks post-operatively were obtained, only a discrete intereminencial pruritus was observed (unusual at 3 months). We therefore consider this technique as a first choice in suitable patients as it avoids discomfort or disability. Furthermore this technique is of low risk and low cost

Introduction: Conventional nerve conduction studies localize the lesion of a nerve and can disclose the degree of focal conduction block or pinpoint the region of focal slowing, giving complementary information about the character of the lesion. In a group of active population transient disturbances during physical efforts are commonly observed. Aim: To precise the evolution with time of EMG recordings of the median nerve in common sport-specific positions. Material and methods: 20 healthy volunteers and 12 symptomatic patients (persons with a conduction block were excluded from the study). Conventional EMG of median nerve was performed, than a “reversed Phalen” position kept for 30 min, and consequent measurements in 5 min periods were performed. Results: In 20% of asymptomatic patients a significant decrease of sensory nerve action potential was recorded after 20 min of observation, while 100% of symptomatic in daily living and negative in conventional EMG studies developed a severe decrease of conduction and blocks after 15 min. These symptoms recuperated after 5 min in functional wrist position. We proposed to these patients a neuromobilisation physiotherapy program, that clinically diminished their complaints. Conclusions: EMG shows a 97–100% diagnostic specificity and sensitivity. It might be a functional test helping to distinguish a group of risk of development of carpal tunnel syndrome with exercises. This method is useful among patients with functional disturbances due to joint instability or repetitive motions in sports

Aims. The sensitivity and specificity of electrodiagnostic parameters in diagnosing carpal tunnel syndrome (CTS) have been reported differently, and this study aims to address this gap. Methods. This case-control study was conducted on 57 cases with CTS and 58 controls without complaints, such as pain or paresthesia on the median nerve. The main assessed electrodiagnostic parameters were terminal latency index (TLI), residual latency (RL), median ulnar F-wave latency difference (FdifMU), and median sensory latency-ulnar motor latency difference (MSUMLD). Results. The mean age in cases and controls were 50.7 years (SD 9.9) and 47.9 years (SD 12.1), respectively. The CTS severity was mild in 20 patients (34.4%), moderate in 19 patients (32.8%), and severe in 19 patients (32.8%). The sensitivity and specificity of the electrodiagnostic parameters in diagnosing CTS were as follows: TLI 75.4% and 87.8%; RL 85.9% and 82.5%; FdifMU 87.9% and 82.9%; and MSUMLD 94.8% and 60.0%, respectively. Conclusion. Our findings indicated that electrodiagnostic parameters are significantly associated with the clinical manifestation of CTS, and are associated with high diagnostic accuracy in CTS diagnosis. However, further studies are required to highlight the role of electrodiagnostic parameters and their combination in CTS detection. Cite this article: Bone Jt Open 2024;5(10):898–903

Objective. Carpal tunnel release surgery is a commonly performed procedure for alleviating symptoms of median nerve compression and restoring hand function. With pressure on theatre time these procedures are now commonly performed in a step-down out-patient facility under local anaesthetic. The choice of suture for skin closure in this procedure can impact the quality of wound healing, patient outcomes and the follow-up required however the question of the best type of suture remains unanswered. The purpose of this study was to compare the outcomes of absorbable and non-absorbable sutures using a randomised control trial design. Methods. Eighty patients diagnosed with bilateral carpal tunnel syndrome were enrolled and underwent outpatient carpal tunnel release surgery under local anaesthetic in a staged fashion. Random number generation was used to assign each hand to receive interrupted nylon or Vicryl Rapide sutures. Pre-operative data collection included patient demographics, ASA, inflammatory conditions, smoking status as well as a Boston Carpal Tunnel Questionnaire (BCTQ) for each hand. Patients were followed up at 2 and 6 weeks after each operation and the BCTQ was repeated along with the Patient and Observer Scar Assessment Scale and the VAS score for wound discomfort. This study has approval from the DHB ethics committee, Local Iwi, HDC and ANZ Clinical Trials:ACTRN12623000100695. Results. Statistical analysis assessed patient preference and the scores between the groups. Multi-variate analysis was performed to assess the factors that may be contributing to patient choice. Conclusion. Insights into patient preference and clinical outcomes associated with absorbable sutures and non-absorbable sutures in the setting of out-patient surgery are discussed

Tourniquet is a commonly used tool in orthopaedic practice. Incidence of complications is low but if any develops, it is devastating. Transient nerve damage, ischemia or skin burns are the possible tourniquet related complications. There is big variation in practice regarding the limb occlusion pressure. 51 procedures in 50 patients were reviewed retrospectively in our district general hospital. We looked at quality of documentation guided by the BOAST standard (The Safe Use of Intraoperative Tourniquets, published in October 2021). Limb occlusion pressure and ischemic time were analysed. Intra-operative and post-operative notes were reviewed to assess quality of documentation and post-operative complications. Although limb occlusion pressure was above the recommended range in more than 75% of cases, there were no significant complications observed. Two cases only developed transient neuropraxia in common peroneal nerve and median nerve following tibial plateau ORIF and trapeziectomy simultaneously. Tibial ORIF fixation case had prolonged ischemic time (more than 120 minutes) and the limb occlusion pressure for the hand case was above the recommended range. Both have recovered within few days with no long-term consequences. Minimum documentation threshold was not met with regarding tourniquet site condition, method of skin isolation and padding, and exsanguination method. This relatively new standard with no previous similar guidance needs time until it is followed by the health care professionals especially when there is no high incidence of complications related to the use of the tourniquet. However, it is crucial to increase the theatre staff awareness of such standards. This will prevent devastating complications specifically in vulnerable patients. Adjustments to theatre checklist have been suggested to improved documentation. Additionally, local teaching sessions will be delivered to theatre personnel aiming at improving our compliance to this standard

Introduction: The surgical management for carpal tunnel syndrome is the release of pressure on the median nerve by dividing the transverse carpal ligament. There are different ways to release median nerve viz.extensive lazy ‘S’ incision from palm to forearm and the advanced arthroscopic release at wrist. We describe a simple, effective and minimally invasive surgery for C.T.S. to divide transverse carpal ligament. Material & method: We present 38cases of C.T.S. after clinical and Electro diagnosis confirmation underwent the minimal invasive surgery. A 1” transverse incision over the center of distal wrist crease placed exposing the palmeris longus (retracted/divided) and exposing transverse carpal ligament. These transverse fibers are cut in the line of skin incision and exposing the median nerve. With blunt curved scissors the transverse ligament is cut distally in the palm and proximally in the wrist separating from the median nerve thus relieving the compression. The wound is closed in layers over the drain and compression bandage applied. Post operatively hand elevated for 24hours, drain removed after 48hours and suture removed at 7th day. Results: In all the 38cases there was pain relief immediately after the surgery. There was progressive neurological recovery (sensory/motor) took place from 6months to 1year. One case developed a pulsatile swelling at the wrist (false A-V aneurysm). The false aneurysm was due to accidental nicking of superficial palmar branch of radial artery, which was ligated on second day. There was superficial marginal necrosis was observed in 6 cases, which healed in 12–16 days. Discussion: The technique is simple, short, safe, economic, effective and easily reproducible. The transverse incision gives better visualization of transverse carpal ligament; easy resection of the ligament and better exposion of median nerve at the wrist makes this procedure to have good results. This tiny incision is in the langhans line at wrist has early wound healing, a cosmetic scar and least morbidity

Introduction and Objective. Carpal tunnel syndrome (CTS) is a very common compressive neuropathy involving the median nerve. The typical symptoms are paraesthesia, dysesthesia and loss of strength; in severe case, this compression deteriorates the sensorimotor control of the hand and interferes with the adjustment of the forces at the level of the fingers, thus affecting the components that are the basis of dexterity and control of fine movements. For these reasons, the CTS has repercussions on various activities of daily life, including writing skills. Word processing via PC and mobile device (touch-typing) require a fine control of the hand-wrist movement and of the opposition of the thumb, while in handwriting, gripping and gripping movements are carried out in a protracted manner. In modern society, present skills play a role of fundamental importance from an educational, professional and social point of view. The aim of the study is to describe the effects of carpal tunnel release (CTR) on handwriting and digital writing performance. Materials and Methods. We recruited patients suffering from carpal tunnel syndrome (CTS) who were candidates for CTR surgery and collected clinical and demographic data, including age, occupation, duration of symptoms and electromyography outcomes. The first trial session was carried out before surgery and the subsequent ones at 1, 2, 3, 4, 8 and 12 weeks after the CTR. These trials involved copying a 500-character paragraph by handwriting, personal computer (PC) and mobile device, for which a dedicate Google Colab web page was computed. We used as parameters the speed, expressed in words per minute (wpm), and the accuracy of copying, which was measured in number of errors (en). Moreover in each session the patient filled in the QuickDASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire. We used the one-way anova to evaluate the change in the three performances and in the QuickDASH score in follow-up sessions. We used the two-way anova to detect a possible interactions between speed improvement and groups of variables, namely gender, writing frequency, schooling, diabetes, dysthyroidism and metabolic syndrome. Results. We recruited 20 patients of whom 7 dropped out for personal reasons and 13 had completed all trial sessions. The PC writing performance had an average speed and accuracy of 15.1 ± 6.8 wpm and 13.1 ± 8.2 en, respectively, while post-operatively it returned values of 17.6 ± 5.0 wpm and 9.9 ± 5.6 en. Regarding touch-typing, a pre-operative average of 16.9 ± 5.8 wpm and 14.3 ± 14.4 en was recorded, while post-operatively an average of 21.7 ± 6.5 wpm and 11.5 ± 14.7 en was reported. Handwriting performance initially had a mean of 20.5 ± 7.1 wpm and 0.1 ± 0.6 en and after three months returned a mean of 22.4 ± 4.0 wpm and 0 ± 0 n. The QuickDASH score had a pre-operative mean of 39.1 ± 9.1 and post-operative mean of 17 ± 6 points. The only statistically significant improvements were those related to touch-typing (P = 0.022) and QuickDASH score (P < 0.001). There was no significant interaction between gender, comorbidity, writing frequency, level of schooling and recovery of writing ability. Conclusions. The data collected showed, in agreement with previous studies, that CTS has a significant impact on the patient's writing ability, who benefits from the surgical treatment, especially in terms of touch-typing and general manual dexterity. In addition, the recovery of writing ability did not show significant correlation with other variables

Background: Median nerve motor branch compression in patients with Carpal Tunnel Syndrome is usually characterised by reduced finger grip and pinch strength, loss of thumb abduction and opposition strength and thenar atrophy. Surgical decompression is usually necessary in these patients but may result in poor outcomes due to irreversible intraneural changes. Hypothesis: The aim of this study was to investigate patient-reported symptoms which may enable a clinical diagnosis of median nerve motor branch compression to be made irrespective of the presence of advanced signs. Methods: One-hundred-and-twelve patients (166 hands) with a clinical diagnosis of Carpal Tunnel Syndrome were referred to the neurophysiology department and completed symptom severity questionnaires with subsequent neurophysiological testing. Results: An increasing frequency of pain experienced by patients was significantly associated with an increased severity of median nerve motor branch compression with prolonged motor latencies measured in patients that described pain as a predominant symptom. An increasing frequency of paraesthesia and numbness and weakness associated with dropping objects was significantly associated with both motor and sensory involvement but not able to distinguish between them. Conclusion: This study suggests that patients presenting with a clinical diagnosis of carpal tunnel syndrome with pain as a frequently experienced and predominant symptom require consideration for urgent investigation and surgical treatment to prevent chronic motor branch compression with permanent functional deficits. Level of evidence: Prognostic study level 2

Background. Patients with hand injuries frequently present to Emergency Departments. The ability of junior doctors to perform an accurate clinical assessment is crucial in initiating appropriate management. Objectives. To assess the adequacy of junior doctor hand examination skills and to establish whether further training and education is required. Methods. A double-centre study was conducted using an anonymous survey assessing hand examination completed by junior doctors (Foundation year 1 and Senior House Officer grades) working in Trauma & Orthopaedics or Emergency Departments. The survey covered all aspects of hand examination including assessment of: Flexor and Extensor tendons, Nerves (motor and sensory) and Vascular status. Surveys were marked against answers pre-agreed with a Consultant hand surgeon. Results. 32 doctors completed the survey. Tendons: 59% could accurately examine extensor digitorum, 41% extensor pollicis longus, 38% flexor digitorum profundus and 28% flexor digitorum superficialis. Nerves – Motor: 53% could accurately examine the radial nerve, 37% the ulnar nerve, 22% the median nerve and 9% the anterior interosseous nerve. Nerves – Sensory: 88% could accurately examine the radial nerve, 81% the ulnar nerve, 84% the median nerve and 18.8% digital nerves. Vascular: 93% could describe 3 methods of assessing vascularity. Conclusions. Tendon and neurological aspects of hand clinical examination were poorly executed at junior doctor level in this pragmatic survey. This highlights the need for targeted education and training to improve the accuracy of junior doctor hand injury assessment and subsequent improving patient treatment and safety. Recommendations include dedicated hand examination teaching early in Orthopaedic/A&E placements and introduction of an illustrated Hand Trauma Examination Proforma. Level of evidence. III - Evidence from case, correlation, and comparative studies

Purpose: We present a 12 year follow up of a patient who presented with a multiple plexiform schwannoma of the median nerve with multiple recurrences, where it was possible to salvage the limb. Patients and Methods: Multiple plexiform Schwannomas are rare nerve sheath tumours. In this case the tumour presented as a soft non-tender swelling in the palm of a child. On exploration the lesion was found to involve the median nerve from the digital nerves to the antecubital fossa. Histology confirmed a plexiform schwannoma. The tumour was locally very aggressive with multiple recurrences initially in the median nerve and ulnar nerves and later in the nerve grafts used following excision of the primary tumour. We present a pictorial review of the mode of presentation of the tumour; discuss different modalities used for limb salvage and the differential diagnosis of this rare tumour. Conclusion: There are very few reports of PS involving main nerve trunks and none describe the long term follow-up. We report a twelve year follow up of a PS involving the main nerve trunks of the upper limb with salvage despite multiple recurrences. The clinical course of the tumour is presented up to the age of sixteen where the growth tumour appears to have regressed