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Short report letters ultrasonography. Our case suggested that fascicular constrictions in AIN palsy can potentially be diagnosed pre-operatively using ultrasound. Theoretically, the early identification of patients who are unlikely to experience functional recovery with conservative management, or for whom early surgery would facilitate recovery and shorten the period of disability, could substantially influence treatment preferences. As demonstrated by this report, the potential for preoperative diagnosis of fascicular constrictions raises the possibility of further research into the natural history of these lesions and whether they benefit from early surgery. Conflict of interests None declared.
References Lundborg G. Commentary: hourglass-like fascicular nerve compressions. J Hand Surg Am. 2003, 28: 212–4. Nakamichi K, Tachibana S. Ultrasonographic findings in isolated neuritis of the posterior interosseous nerve: comparison with normal findings. J Ultrasound Med. 2007, 26: 683–7. Nagano A. Spontaneous anterior interosseous nerve palsy. J Bone Joint Surg Br. 2003, 85: 313–8. Rossey-Marec D, Simonet J, Beccari R et al. Ultrasonographic appearance of idiopathic radial nerve constriction proximal to the elbow. J Ultrasound Med. 2004, 23: 1003–7.
A. Kodama, T. Sunagawa and M. Ochi Department of Orthopaedic Surgery, Hiroshima University Hospital, Hiroshima, Japan. Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413518692 available online at http://jhs.sagepub.com
Reconstruction of the median and musculocutaneous nerves with a nerve graft combined with endto-side neurorrhaphy: A case report Dear Sir, We present a patient with traumatic deficits of the median and musculocutaneous nerves in the upper arm repaired with a combined method of nerve grafting for the median nerve and end-to-side
anastomosis of the musculocutaneous nerve to the median nerve. A 19-year-old man sustained a deep wound in his left proximal arm and axilla after a serious traffic accident. He presented to our department 6 months after the injury with high median, radial, ulnar, and musculocutaneous nerve palsies in his left extremity. He had no active movement in his hand, wrist, and elbow, and no sensation distal to the elbow. Nerve conduction studies revealed denervation within the distribution of the median and radial nerves, and severe dysfunction of the ulnar nerve. The patient complained of moderate-to-severe spontaneous pain (visual analogue scale [VAS] 6–8) in his affected extremity. We planned to perform one-stage combined median and musculocutaneous nerve reconstruction consisting of a conventional nerve grafting and end-to-side and side-to-side nerve anastomoses. We did not intend to repair the radial nerve defect. Intra-operatively, we found defects of 15 cm in the median and radial nerves, respectively, and a 10 cm defect in the musculocutaneous nerve. The ulnar nerve was compressed by a scar but was found intact after decompression. We repaired the median nerve with three bundles of 17 cm long grafts of sural nerves harvested from both calves. Next, we anastomosed the distal stump of the musculocutaneous nerve to the proximal part of the median nerve using an endto-side repair (Figure 1a). An additional incision was made in the wrist where the median and ulnar nerves were exposed and bridged side-to-side with two bundles of sural nerve grafts (Figure 1b). After the operation, the elbow and wrist were immobilized in a dorsal plaster splint for 4 weeks. The post-operative course was uneventful. The patient was followed-up for 15 months. No recovery was found at 3 months. At 8 months, the ulnar nerve recovered completely. Thumb opposition was Kapandji 2-3 (suggesting innervation via the ulnar-to-median via bridging), but there was no active wrist or finger flexion. There was slight elbow flexion suggesting partial re-innervation of the bicep muscles. At 15 months, pain had subsided to VAS 4–5. Some motor function recovered well: there was 120° active elbow flexion (M3), 60° wrist flexion (M4 to M5), full finger and thumb flexion (M4), and only a 10° extension deficit in the interphalangeal joints. There was no elbow, wrist, or metacarpophalangeal joint active extension. Grip strength was of 12 kgF (32% of the other side), and the Disabilities of the Arm, Shoulder and Hand (DASH) score was 52. The Kapandji test for the thumb opposition was 5. The filament test showed good sensation (blue filament) in the ring and little fingers, and reduced sensation in the index and
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The Journal of Hand Surgery (Eur) 40(6)
Figure 1a. Schematic diagram of the injury before reconstruction. (1) Irreparable deficit of the musculocutaneous nerve. (2) Deficit of the median nerve. (3) Damage zone of the ulnar nerve, but in continuity.
middle fingers (purple filament) and thumb (red filament). The patient had excellent ulnar nerve recovery that was not divided, but presented with serious dysfunction, very good median nerve recovery (substantial deficit restored by conventional grafting), and good musculocutaneous nerve recovery, which was result of side-to-end repair from the intact part of the median nerve. The collateral sprouting of axons after end-to-side neurorrhaphy has been shown in several animal studies, mostly of motor nerves. Several past reports documented a good recovery of sensation (filament test, green and blue) in fingers supplied by the repaired digital nerves in several patients by an end-to-side repair (Landwehrs and Bruser, 2008; Voche and Quattara, 2005). Mennen (2003) reported more patients with satisfactory outcomes after end-to-side neurorrhaphy in mixed nerves in the upper limb. Here we present a patient with combined nerve repair
Figure 1b. Post-reconstruction. (1a) End-to-side neurorrhaphy of the musculocutaneous to the median nerve. (2a) Sural nerve graft for the median nerve. (3a) Spontaneous recovery of the ulnar nerve. (4a) Distal side-to-side neurorrhaphy of the ulnar-to-median nerves with the sural nerve graft.
methods, including nerve graft, end-to-side repair, and side-to-side repair. This patient’s results support the role of end-to-side neurorrhaphy as a part of complex nerve reconstruction. In this patient, we presume that the recovery of ulnar nerve function is the result of ulnar nerve release from its surrounding scar. The side-to-side repair of ulnar nerve to the median nerve at distal forearm at least favours a quicker recovery of function of the median nerve. Conflict of interests None declared.
References Landwehrs GM, Bruser P. Clinical results of terminolateral neurorrhaphy in digital nerves. Handchir Mikrochir Plast Chir. 2008, 40: 318–21. Mennen U. End-to-side nerve suture in clinical practice. Hand Surg. 2003, 8: 33–42.
Downloaded from jhs.sagepub.com by guest on November 15, 2015
645
Short report letters Voche P, Quattara D. End-to-side neurorrhaphy for defects of palmar sensory digital nerves. Br J Plast Surg. 2005, 58: 239–44.
Ireneusz Walaszek and Andrzej Żyluk
Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland Email: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413518881 available online at http://jhs.sagepub.com
Median nerve neuropathy associated with cubital heterotopic ossification Dear Sir, A 13-year-old boy fell from a basketball hoop in a school playground and injured his left arm. Fractures of the left radial neck and distal radius were seen on radiographs. Through a lateral incision the radial neck fracture was fixed with a mini-screw. A rupture of the lateral collateral ligament of the elbow was found at operation and repaired using an anchor suture (Mitek®, DePuy Mitek, Raynham, MA, USA). Reduction of the distal radial fracture was maintained by two Kirschner wires, which were removed 5 weeks after surgery. Thirteen weeks after the operation, he complained of pain in the cubital area and heterotopic ossification was found on plain radiographs. The heterotopic ossification enlarged and matured over time (Figure 1). The range of motion of the left elbow was preserved, but he developed a neuropathy affecting the median nerve distribution to the hand, and there was a positive Tinel sign in the left cubital area. Surgical exploration was carried out through a curvilinear incision in the cubital area. There was fibrosis in the distal part of the brachialis muscle over the trochlea. The heterotopic ossification protruded out about 5 mm from the scarred area and was located just posteromedial to the median nerve. The nerve, which ran over the scarred muscle, was adherent to the protruding heterotopic ossification and slightly displaced anterolaterally (Figure 2). The protruding bone and adjacent scar tissue were excised and a neurolysis of the median nerve was done. The patient remains symptom-free, without recurrence, after 5-years follow-up. Although heterotopic ossification is a common complication of elbow injuries, it rarely causes compressive neuropathy. Specifically, we have not found any previous reports of median nerve neuropathy
Figure 1. A plain radiograph showing cubital heterotopic ossification distant from the elbow joint.
Figure 2. The heterotopic ossification was observed just posteromedial to the median nerve over the trochlea. Inset: explanatory diagram.
with heterotopic ossification around the elbow. Ulnar nerve neuropathy, with heterotopic ossification in the cubital tunnel, has been reported after head injury (Fikry et al., 2004). Some cases of median nerve neuropathy with heterotopic ossification in the carpal tunnel have also been reported (Yuen and Thomson, 2011). The present case of median nerve neuropathy is somewhat different as the heterotopic ossification occurred outside the capsule or ligaments. A partial tear of the brachialis over the elbow joint could have triggered heterotopic ossification, leading to the median nerve neuropathy in the cubital area. Conflict of interests None declared.
Downloaded from jhs.sagepub.com by guest on November 15, 2015
Short report letters ultrasonography. Our case suggested that fascicular constrictions in AIN palsy can potentially be diagnosed pre-operatively using ultrasound. Theoretically, the early identification of patients who are unlikely to experience functional recovery with conservative management, or for whom early surgery would facilitate recovery and shorten the period of disability, could substantially influence treatment preferences. As demonstrated by this report, the potential for preoperative diagnosis of fascicular constrictions raises the possibility of further research into the natural history of these lesions and whether they benefit from early surgery. Conflict of interests None declared.
References Lundborg G. Commentary: hourglass-like fascicular nerve compressions. J Hand Surg Am. 2003, 28: 212–4. Nakamichi K, Tachibana S. Ultrasonographic findings in isolated neuritis of the posterior interosseous nerve: comparison with normal findings. J Ultrasound Med. 2007, 26: 683–7. Nagano A. Spontaneous anterior interosseous nerve palsy. J Bone Joint Surg Br. 2003, 85: 313–8. Rossey-Marec D, Simonet J, Beccari R et al. Ultrasonographic appearance of idiopathic radial nerve constriction proximal to the elbow. J Ultrasound Med. 2004, 23: 1003–7.
A. Kodama, T. Sunagawa and M. Ochi Department of Orthopaedic Surgery, Hiroshima University Hospital, Hiroshima, Japan. Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413518692 available online at http://jhs.sagepub.com
Reconstruction of the median and musculocutaneous nerves with a nerve graft combined with endto-side neurorrhaphy: A case report Dear Sir, We present a patient with traumatic deficits of the median and musculocutaneous nerves in the upper arm repaired with a combined method of nerve grafting for the median nerve and end-to-side
anastomosis of the musculocutaneous nerve to the median nerve. A 19-year-old man sustained a deep wound in his left proximal arm and axilla after a serious traffic accident. He presented to our department 6 months after the injury with high median, radial, ulnar, and musculocutaneous nerve palsies in his left extremity. He had no active movement in his hand, wrist, and elbow, and no sensation distal to the elbow. Nerve conduction studies revealed denervation within the distribution of the median and radial nerves, and severe dysfunction of the ulnar nerve. The patient complained of moderate-to-severe spontaneous pain (visual analogue scale [VAS] 6–8) in his affected extremity. We planned to perform one-stage combined median and musculocutaneous nerve reconstruction consisting of a conventional nerve grafting and end-to-side and side-to-side nerve anastomoses. We did not intend to repair the radial nerve defect. Intra-operatively, we found defects of 15 cm in the median and radial nerves, respectively, and a 10 cm defect in the musculocutaneous nerve. The ulnar nerve was compressed by a scar but was found intact after decompression. We repaired the median nerve with three bundles of 17 cm long grafts of sural nerves harvested from both calves. Next, we anastomosed the distal stump of the musculocutaneous nerve to the proximal part of the median nerve using an endto-side repair (Figure 1a). An additional incision was made in the wrist where the median and ulnar nerves were exposed and bridged side-to-side with two bundles of sural nerve grafts (Figure 1b). After the operation, the elbow and wrist were immobilized in a dorsal plaster splint for 4 weeks. The post-operative course was uneventful. The patient was followed-up for 15 months. No recovery was found at 3 months. At 8 months, the ulnar nerve recovered completely. Thumb opposition was Kapandji 2-3 (suggesting innervation via the ulnar-to-median via bridging), but there was no active wrist or finger flexion. There was slight elbow flexion suggesting partial re-innervation of the bicep muscles. At 15 months, pain had subsided to VAS 4–5. Some motor function recovered well: there was 120° active elbow flexion (M3), 60° wrist flexion (M4 to M5), full finger and thumb flexion (M4), and only a 10° extension deficit in the interphalangeal joints. There was no elbow, wrist, or metacarpophalangeal joint active extension. Grip strength was of 12 kgF (32% of the other side), and the Disabilities of the Arm, Shoulder and Hand (DASH) score was 52. The Kapandji test for the thumb opposition was 5. The filament test showed good sensation (blue filament) in the ring and little fingers, and reduced sensation in the index and
Downloaded from jhs.sagepub.com by guest on November 15, 2015
644
The Journal of Hand Surgery (Eur) 40(6)
Figure 1a. Schematic diagram of the injury before reconstruction. (1) Irreparable deficit of the musculocutaneous nerve. (2) Deficit of the median nerve. (3) Damage zone of the ulnar nerve, but in continuity.
middle fingers (purple filament) and thumb (red filament). The patient had excellent ulnar nerve recovery that was not divided, but presented with serious dysfunction, very good median nerve recovery (substantial deficit restored by conventional grafting), and good musculocutaneous nerve recovery, which was result of side-to-end repair from the intact part of the median nerve. The collateral sprouting of axons after end-to-side neurorrhaphy has been shown in several animal studies, mostly of motor nerves. Several past reports documented a good recovery of sensation (filament test, green and blue) in fingers supplied by the repaired digital nerves in several patients by an end-to-side repair (Landwehrs and Bruser, 2008; Voche and Quattara, 2005). Mennen (2003) reported more patients with satisfactory outcomes after end-to-side neurorrhaphy in mixed nerves in the upper limb. Here we present a patient with combined nerve repair
Figure 1b. Post-reconstruction. (1a) End-to-side neurorrhaphy of the musculocutaneous to the median nerve. (2a) Sural nerve graft for the median nerve. (3a) Spontaneous recovery of the ulnar nerve. (4a) Distal side-to-side neurorrhaphy of the ulnar-to-median nerves with the sural nerve graft.
methods, including nerve graft, end-to-side repair, and side-to-side repair. This patient’s results support the role of end-to-side neurorrhaphy as a part of complex nerve reconstruction. In this patient, we presume that the recovery of ulnar nerve function is the result of ulnar nerve release from its surrounding scar. The side-to-side repair of ulnar nerve to the median nerve at distal forearm at least favours a quicker recovery of function of the median nerve. Conflict of interests None declared.
References Landwehrs GM, Bruser P. Clinical results of terminolateral neurorrhaphy in digital nerves. Handchir Mikrochir Plast Chir. 2008, 40: 318–21. Mennen U. End-to-side nerve suture in clinical practice. Hand Surg. 2003, 8: 33–42.
Downloaded from jhs.sagepub.com by guest on November 15, 2015
645
Short report letters Voche P, Quattara D. End-to-side neurorrhaphy for defects of palmar sensory digital nerves. Br J Plast Surg. 2005, 58: 239–44.
Ireneusz Walaszek and Andrzej Żyluk
Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland Email: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413518881 available online at http://jhs.sagepub.com
Median nerve neuropathy associated with cubital heterotopic ossification Dear Sir, A 13-year-old boy fell from a basketball hoop in a school playground and injured his left arm. Fractures of the left radial neck and distal radius were seen on radiographs. Through a lateral incision the radial neck fracture was fixed with a mini-screw. A rupture of the lateral collateral ligament of the elbow was found at operation and repaired using an anchor suture (Mitek®, DePuy Mitek, Raynham, MA, USA). Reduction of the distal radial fracture was maintained by two Kirschner wires, which were removed 5 weeks after surgery. Thirteen weeks after the operation, he complained of pain in the cubital area and heterotopic ossification was found on plain radiographs. The heterotopic ossification enlarged and matured over time (Figure 1). The range of motion of the left elbow was preserved, but he developed a neuropathy affecting the median nerve distribution to the hand, and there was a positive Tinel sign in the left cubital area. Surgical exploration was carried out through a curvilinear incision in the cubital area. There was fibrosis in the distal part of the brachialis muscle over the trochlea. The heterotopic ossification protruded out about 5 mm from the scarred area and was located just posteromedial to the median nerve. The nerve, which ran over the scarred muscle, was adherent to the protruding heterotopic ossification and slightly displaced anterolaterally (Figure 2). The protruding bone and adjacent scar tissue were excised and a neurolysis of the median nerve was done. The patient remains symptom-free, without recurrence, after 5-years follow-up. Although heterotopic ossification is a common complication of elbow injuries, it rarely causes compressive neuropathy. Specifically, we have not found any previous reports of median nerve neuropathy
Figure 1. A plain radiograph showing cubital heterotopic ossification distant from the elbow joint.
Figure 2. The heterotopic ossification was observed just posteromedial to the median nerve over the trochlea. Inset: explanatory diagram.
with heterotopic ossification around the elbow. Ulnar nerve neuropathy, with heterotopic ossification in the cubital tunnel, has been reported after head injury (Fikry et al., 2004). Some cases of median nerve neuropathy with heterotopic ossification in the carpal tunnel have also been reported (Yuen and Thomson, 2011). The present case of median nerve neuropathy is somewhat different as the heterotopic ossification occurred outside the capsule or ligaments. A partial tear of the brachialis over the elbow joint could have triggered heterotopic ossification, leading to the median nerve neuropathy in the cubital area. Conflict of interests None declared.
Downloaded from jhs.sagepub.com by guest on November 15, 2015
