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. 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).Aims
Methods
Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.Abstract
The pathogenesis of intraneural ganglion cysts is controversial.
Recent reports in the literature described medial plantar intraneural
ganglion cysts (mIGC) with articular branches to subtalar joints.
The aim of the current study was to provide further support for
the principles underlying the articular theory, and to explain the
successes and failures of treatment of mICGs. Between 2006 and 2017, five patients with five mICGs were retrospectively
reviewed. There were five men with a mean age of 50.2 years (33
to 68) and a mean follow-up of 3.8 years (0.8 to 6). Case history,
physical examination, imaging, and intraoperative findings were
reviewed. The outcomes of interest were ultrasound and/or MRI features
of mICG, as well as the clinical outcomes.Aims
Patients and Methods
The aim of this study was to compare the efficacy of a corticosteroid injection for the
treatment of carpal tunnel syndrome (CTS) in patients with and without Raynaud’s
phenomenon. In a prospective study, 139 patients with CTS were treated with a corticosteroid
injection (10 mg triamcinolone acetonide); 34 had Raynaud’s phenomenon and 105
did not (control group). Grip strength, perception of touch with a Semmes-Weinstein
monofilament and the Boston Carpal Tunnel Questionnaires (BCTQ) were assessed at
baseline and at six, 12 and 24 weeks after the injection. The Cold Intolerance Severity
Score (CISS) questionnaire was also assessed at baseline and 24 weeks after the
injection.Aims
Patients and Methods
The last decade has seen a considerable increase
in the use of in total ankle arthroplasty (TAA) to treat patients
with end-stage arthritis of the ankle. However, the longevity of
the implants is still far from that of total knee and hip arthroplasties. The aim of this review is to outline a diagnostic and treatment
algorithm for the painful TAA to be used when considering revision
surgery. Cite this article:
Aims. We aimed to identify the pattern of nerve injury associated with
paediatric supracondylar fractures of the humerus. Patients and Methods. Over a 17 year period, between 1996 and 2012, 166 children were
referred to our specialist peripheral nerve injury unit. From examination
of the medical records and radiographs were recorded the nature
of the fracture, associated vascular and neurological injury, treatment
provided and clinical course. Results. Of the 166 patients (111 male, 55 female; mean age at time of
injury was seven years (standard deviation 2.2)), 26 (15.7%) had
neurological dysfunction in two or more nerves. The injury pattern
in the 196 affected nerves showed that the most commonly affected
nerve was the ulnar nerve (43.4%), followed by the median (36.7%)
and radial (19.9%) nerves. A non-degenerative injury was seen in
27.5%, whilst 67.9% were degenerative in nature. Surgical exploration
of the nerves was undertaken in 94 (56.6%) children. The mean follow-up
time was 12.8 months and 156 (94%) patients had an excellent or
good clinical outcome according to the grading of Birch, Bonney
and Parry. Conclusion. Following paediatric supracondylar fractures we recommend prompt
referral to a specialist unit in the presence of complete nerve
palsy, a positive
We report our experience of performing an elbow
hemiarthroplasty in the treatment of comminuted distal humeral fractures
in the elderly patients. A cohort of 42 patients (three men and 39 women, mean age 72;
56 to 84) were reviewed at a mean of 34.3 months (24 to 61) after
surgery. Functional outcome was measured with the Mayo Elbow Performance
Score (MEPS) and range of movement. The disabilities of the arm,
shoulder and hand questionnaire (DASH) was used as a patient rated
evaluation. Complications and ulnar nerve function were recorded.
Plain radiographs were obtained to assess prosthetic loosening,
olecranon wear and heterotopic bone formation. The mean extension deficit was 23.5° (0° to 60°) and mean flexion
was 126.8° (90° to 145°) giving a mean arc of 105.5° (60° to 145°).
The mean MEPS was 90 (50 to 100) and a mean DASH score of 20 (0
to 63). Four patients had additional surgery for limited range of
movement and one for partial instability. One elbow was revised
due to loosening, two patients had sensory ulnar nerve symptoms,
and radiographic signs of mild olecranon wear was noted in five
patients. Elbow hemiarthroplasty for comminuted intra-articular distal
humeral fractures produces reliable medium-term results with functional
outcome and complication rates, comparable with open reduction and
internal fixation and total elbow arthroplasty. Cite this article:
There is conflicting evidence about the functional
outcome and rate of satisfaction of super-elderly patients (≥ 80 years
of age) after carpal tunnel decompression. We compiled outcome data for 756 patients who underwent a carpal
tunnel decompression over an eight-year study period, 97 of whom
were super-elderly, and 659 patients who formed a younger control
group (<
80 years old). There was no significant difference between
the super-elderly patients and the younger control group in terms
of functional outcome according to the mean (0 to 100) QuickDASH
score (adjusted mean difference at one year 1.8; 95% confidence
interval (CI) -3.4 to 7.0) and satisfaction rate (odds ratio (OR)
0.78; 95% CI 0.34 to 1.58). Super-elderly patients were, however,
more likely to have thenar muscle atrophy at presentation (OR 9.2,
95% CI 5.8 to 14.6). When nerve conduction studies were obtained,
super-elderly patients were more likely to have a severe conduction deficit
(OR 12.4, 95% CI 3.0 to 51.3). Super-elderly patients report functional outcome and satisfaction
rates equal to those of their younger counterparts. They are more
likely to have thenar muscle atrophy and a severe nerve conduction
deficit at presentation, and may therefore warrant earlier decompression. Cite this article:
We present our experience of managing patients
with iatropathic brachial plexus injury after delayed fixation of
a fracture of the clavicle. It is a retrospective cohort study of
patients treated at our peripheral nerve injury unit and a single
illustrative case report. We identified 21 patients in whom a brachial
plexus injury occurred as a direct consequence of fixation of a
fracture of the clavicle between September 2000 and September 2011. The predominant injury involved the C5/C6 nerves, upper trunk,
lateral cord and the suprascapular nerve. In all patients, the injured
nerve was found to be tethered to the under surface of the clavicle
by scar tissue at the site of the fracture and was usually associated
with pathognomonic neuropathic pain and paralysis. Delayed fixation of a fracture of the clavicle, especially between
two and four weeks after injury, can result in iatropathic brachial
plexus injury. The risk can be reduced by thorough release of the
tissues from the inferior surface of the clavicle before mobilisation
of the fracture fragments. If features of nerve damage appear post-operatively
urgent specialist referral is recommended. Cite this article:
We present the electromyographic (EMG) results
ten years after open decompression of the median nerve at the wrist
and compare them with the clinical and functional outcomes as judged
by Levine’s Questionnaire. This retrospective study evaluated 115
patients who had undergone carpal tunnel decompression at a mean
of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis
was found in 77 patients (67%), including those who were asymptomatic
at ten years. It is necessary to include both clinical and functional results
as well as electromyographic testing in the long-term evaluation
of patients who have undergone carpal tunnel decompression particularly
in those in whom revision surgery is being considered. In doubtful
cases or when there are differing outcomes, self-administered scales
such as Levine’s Questionnaire should prevail over EMG results when
deciding on the need for revision surgery.
The outcomes of 261 nerve injuries in 100 patients
were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in
18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)).
The initial grades for the 42 sutures and graft were 11 good, 14
fair and 17 poor. After subsequent revision repairs in seven, neurolyses
in 11 and free vascularised fasciocutaneous flaps in 11, the final
grades were 15 good, 18 fair and nine poor. Pain was relieved in
30 of 36 patients by nerve repair, revision of repair or neurolysis,
and flaps when indicated. The difference in outcome between penetrating
missile wounds and those caused by explosions was not statistically
significant; in the latter group the onset of recovery from focal
conduction block was delayed (mean 4.7 months (2.5 to 10.2)
We describe 261 peripheral nerve injuries sustained
in war by 100 consecutive service men and women injured in Iraq
and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the
median interval between injury and first review was 4.2 months (mean
8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months
(mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly
focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis
in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed
between the upper and the lower limbs. Explosions accounted for
164 (63%): 213 (82%) nerve injuries were associated with open wounds.
Two or more main nerves were injured in 70 patients. The ulnar,
common peroneal and tibial nerves were most commonly injured. In
69 patients there was a vascular injury, fracture, or both at the
level of the nerve lesion. Major tissue loss was present in 50 patients:
amputation of at least one limb was needed in 18. A total of 36 patients
continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these
injuries and provides information about the depth and distribution
of the nerve lesions, their associated injuries and neuropathic
pain syndromes.
A 60-year-old man developed severe neuropathic pain and foot-drop in his left leg following resurfacing arthroplasty of the left hip. The pain was refractory to all analgesics for 16 months. At exploration, a PDS suture was found passing through the sciatic nerve at several points over 6 cm and terminating in a large knot. After release of the suture and neurolysis there was dramatic and rapid improvement of the neuropathic pain and of motor function. This case represents the human equivalent of previously described nerve ligation in an animal model of neuropathic pain. It emphasises that when neuropathic pain is present after an operation, the nerve related to the symptoms must be inspected, and that removal of a suture or irritant may lead to relief of pain, even after many months.
The outcome of surgery in patients with medial epicondylitis of the elbow is less favourable in those with co-existent symptoms from the ulnar nerve. We wanted to know whether we could successfully treat such patients by using musculofascial lengthening of the flexor-pronator origin with simultaneous deep transposition of the ulnar nerve. We retrospectively reviewed 19 patients who were treated in this way. Seven had grade I and 12 had grade IIa ulnar neuropathy. At a mean follow-up of 38 months (24 to 48), the mean visual analogue scale pain scores improved from 3.7 to 0.3 at rest, from 6.6 to 2.1 with activities of daily living, and from 7.9 to 2.3 at work or sports, and the mean disabilities of the arm, shoulder and hand scores improved from 42.2 to 23.5. These results suggest that this technique can be effective in treating patients with medial epicondylitis and coexistent ulnar nerve symptoms.
Restoration of hand function is rarely achieved after a complete closed traction lesion of the supraclavicular brachial plexus. We describe the injury, treatment, rehabilitation and long-term results of two patients who regained good function of the upper limb and useful function in the hand after such an injury. Successful repairs were performed within six days of injury.
We evaluated 56 patients for neurological deficit after enucleation of a histopathologically confirmed schwannoma of the upper limb. Immediately after the operation, 41 patients (73.2%) had developed a new neurological deficit: ten of these had a major deficit such as severe motor or sensory loss, or intolerable neuropathic pain. The mean tumour size had been significantly larger in patients with a major neurological deficit than in those with a minor or no deficit. After a mean 25.4 months (12 to 85), 39 patients (70%) had no residual neurological deficit, and the other 17 (30%) had only hypoaesthesia, paraesthesiae or mild motor weakness. This study suggests that a schwannoma in the upper limb can be removed with an acceptable risk of injury to the nerve, although a transient neurological deficit occurs regularly after the operation. Biopsy is not advised. Patients should be informed pre-operatively about the possibility of damage to the nerve: meticulous dissection is required to minimise this.
A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3° ( We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome.
