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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]

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: 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.

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]

Penetrating lacerations to the hand are a common cause of nerve injury and can lead to debilitating pain and numbness in the distribution of the nerve affected. Owing to an overlap in the cutaneous innervation from different sensory nerves, clinically identifying the injured nerve can be difficult. We present a novel case of isolated injury to the palmar cutaneous nerve from a penetrating knife injury which was detected using 'comparison waveform' nerve conduction studies. Using this technique, we can isolate injuries to the palmar cutaneous branch of the median nerve (PCBmdn) from the median nerve, dorsal radial sensory nerve, and lateral antebrachial cutaneous nerve. In addition, sensory nerve testing identified conduction block as the mechanism of injury, which resolved after surgery at 8 weeks postoperatively. Preoperative nerve conduction study can discern the level of nerve injury to PCBmdn only, thus eliminating the need for median and radial nerve exploration at the forearm, unnecessary incisions, pain, and scarring. The objective of this case report is to illustrate the value of preoperative comparison waveform nerve conduction study, particularly the PCBmdn, in patients presenting with neurologic deficits who have sustained penetrating lacerations to the hand., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

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]

While the success or failure of carpal tunnel release ultimately depends on the interplay of a wide array of factors, a broad understanding of the normal anatomy of the carpal tunnel accompanied by awareness of the possible variations of the individual structures that make up its contents is crucial to optimizing surgical outcomes. While anatomic variants such as extension of the flexor digitorum muscle bellies have been described as a cause of primary carpal tunnel syndrome (CTS), there have been no reports depicting its association with recurrent CTS following initially successful carpal tunnel release, a finding with potentially significant prognostic implications that can aid in operative planning. In such cases where muscle extension is identified preoperatively, careful debulking of the muscle belly may be beneficial in improving long-term surgical outcomes. [ABSTRACT FROM AUTHOR]

Hereditary neuropathy with liability to pressure palsy (HNPP) often manifests via peripheral nerve entrapment including median nerve compression at the carpal tunnel. However, there are few reports on surgical interventions for focal compression of the median nerve at the wrist in patients with HNPP. We report a case of a patient with HNPP who improved clinically, electrophysiologically, and ultrasonographically after carpal tunnel release (CTR). A 56-year-old woman presented with an 18-month history of pain in both thumbs. Nerve conduction study (NCS) revealed bilateral median neuropathy at the wrist. Ultrasonography demonstrated a markedly increased cross-sectional area (CSA) of both median nerves. Gene analysis revealed a deletion of the PMP22 gene. She received bilateral CTR. Follow-up NCS at one year demonstrated the improvement of motor and sensory conduction; follow-up ultrasonography revealed significantly reduced CSA. Our case suggests that surgical decompression can be applicable to well-selected patients with HNPP. [ABSTRACT FROM AUTHOR]

Background: The contralateral seventh cervical (cC7) nerve root transfer represents a cornerstone technique in treating total brachial plexus avulsion injury. Traditional cC7 procedures employ the entire ulnar nerve as a graft, which inevitably compromises its restorative capacity., Objective: Our cadaveric study seeks to assess this innovative approach aimed at preserving the motor branch of the ulnar nerve (MBUN). This new method aims to enable future repair stages, using the superficial radial nerve (SRN) as a bridge connecting cC7 and MBUN., Methods: We undertook a comprehensive dissection of ten adult cadavers, generously provided by the Department of Anatomy, Histology, and Embryology at Fudan University, China. It allowed us to evaluate the feasibility of our proposed technique. For this study, we harvested only the dorsal and superficial branches of the ulnar nerve, as well as the SRN, to establish connections between the cC7 nerve and recipient nerves (both the median nerve and MBUN). We meticulously dissected the SRN and the motor and sensory branches of the ulnar nerve. Measurements were made from the reverse point of the SRN to the wrist flexion crease and the coaptation point of the SRN and MBUN. Additionally, we traced the MBUN from distal to proximal ends, recording its maximum length. We also measured the diameters of the nerve branches and tallied the number of axons., Results: Our modified approach proved technically viable in all examined limbs. The distances from the reverse point of the SRN to the wrist flexion crease were 8.24 ± 1.80 cm and to the coaptation point were 6.60 ± 1.75 cm. The maximum length of the MBUN was 7.62 ± 1.03 cm. The average axon diameters in the MBUN and the anterior and posterior branches of the SRN were 1.88 ± 0.42 mm、1.56 ± 0.38 mm、2.02 ± 0.41 mm,respectively. The corresponding mean numbers of axons were 1426.60 ± 331.39 and 721.50 ± 138.22, and 741.90 ± 171.34, respectively., Conclusion: The SRN demonstrated the potential to be transferred to the MBUN without necessitating a nerve graft. A potential advantage of this modification is preserving the MBUN's recovery potential., (© 2023. The Author(s).)

Objective: Remarkable progress has been made in the surgical treatment of capral tunnel syndrome recently. Popularity of endoscopic and minimally invasive techniques has been increased in particular. The aim of this study was to present the short-term outcomes of patients undertaken median nerve decompression surgery with palmar mini-incision using carpal tunnel knife with light (Blade-X®, Mavera Medical Devices, Ankara, Turkey). Material and Method: A total of 50 patients who were operated by using carpal tunnel knife, were retrospectively evaluated. Among those, 40 were female and 10 were male. Five patients had bilateral capral tunnel syndrome. Mean age was 59.75 (33-81 y). Mean duration of follow-up was 11,2 months (6-18 m). Preoperative clinical diagnosis was confirmed via electroneuromyography in all patients. Surgery was performed under local anesthesia without tourniquet with minimal palmar incision. Simple bandage was performed postoperatively and no immobilization was performed. Results: Mean duration of operation was 13 minutes (10-17 min). No complication was observed in any of the patients. Patients were able to use their hands for self-care after a mean of 7 days (5-13 d). Mean time to get back to work was 25 days (18-35 d) for those who are employed. All patients were satisfied except two patients experiencing scar pain. Conclusion: The most remarkable outcome of this minimally invasive method was rapid usage of the hands postoperatively and the functional recovery observed in the short-term. [ABSTRACT FROM AUTHOR]

The median nerve is the most important nerve in the upper extremity, as it is responsible for most of the sensation of the hand, the fine motor functions of the thumb, and finger grasping. Median neuropathies most commonly occur as compressive neuropathy or entrapment neuropathy, but sometimes as neuritis without any compressive lesion. Carpal tunnel syndrome (CTS), anterior interosseous nerve syndrome, and pronator teres syndrome are the subtypes of median nerve neuropathies, of which CTS is the most common. Median neuropathies can be diagnosed clinically by careful history-taking and a physical examination. Typical symptoms of CTS include night pain (crying), a tingling sensation of the radial digits, numbness or paresthesia, clumsiness, and atrophy of the thenar muscles. Electrophysiologic testing can be used for confirmation of the diagnosis and for documentation before surgical treatment. Imaging modalities including ultrasonography or magnetic resonance imaging can be used to ensure diagnostic accuracy and to detect unusual causes of compression. Conservative treatments include rest, bracing, nerve stretching, non-steroidal anti-inflammatory drugs, and steroid injections. If nonsurgical approaches are unsatisfactory or the nerve damage is severe, surgical treatment should be considered. Carpal tunnel release for CTS is a relatively simple procedure that involves division of the transverse carpal ligament and decompression of the median nerve. Early diagnosis and proper management are important, as muscle atrophy and sensory loss may persist when surgical release is delayed in patients with advanced disease. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the prognostic value of B-mode and Power Doppler (PD) ultrasound of the median nerve for the short- and long-term clinical outcomes of patients with carpal tunnel syndrome (CTS). Methods: Prospective study of 135 patients with suspected CTS seen 3 times: at baseline, then at short-term (3 months) and long-term (15–36 months) follow-up. At baseline, the cross-sectional area (CSA) of the median nerve was measured with ultrasound at 4 levels on the forearm and wrist. PD signals were graded semi-quantitatively (0–3). Clinical outcomes were evaluated at each visit with the Boston Questionnaire (BQ) and the DASH Questionnaire, as well as visual analogue scales for the patient’s assessment of pain (painVAS) and physician’s global assessment (physVAS). The predictive values of baseline CSA and PD for clinical outcomes were determined with multivariate logistic regression models. Results: Short-term and long-term follow-up data were available for 111 (82.2%) and 105 (77.8%) patients, respectively. There was a final diagnosis of CTS in 84 patients (125 wrists). Regression analysis revealed that the CSA, measured at the carpal tunnel inlet, predicted short-term clinical improvement according to BQ in CTS patients undergoing carpal tunnel surgery (OR 1.8, p = 0.05), but not in patients treated conservatively. Neither CSA nor PD assessments predicted short-term improvement of painVAS, physVAS or DASH, nor was any of the ultrasound parameters useful for the prediction of long-term clinical outcomes. Conclusions: Ultrasound assessment of the median nerve at the carpal tunnel inlet may predict short-term clinical improvement in CTS patients undergoing carpal tunnel release, but long-term outcomes are unrelated to ultrasound findings. [ABSTRACT FROM AUTHOR]

Background: Digital infrared thermal imaging (DITI), which detects infrared rays emitted from body surface to create a body heat map, has been utilized at various musculocutaneous conditions. Notably, DITI can demonstrate autonomic vasomotor activity in the nerve-innervated area, and thus may be of use in carpal tunnel syndrome (CTS). In this study, we compared DITI findings before and after carpal tunnel release (CTR) surgery in patients with unilateral CTS to investigate the corresponding neurophysiological changes., Methods: In this retrospective cohort study, DITI parameters such as the temperature differences between the median and ulnar nerve territories and median nerve-innervated digital anisometry were measured. Subjective symptom duration, pain scale, and ultrasonographic findings were also compared before and after CTR. Patients were evaluated before and 6 weeks after CTR, respectively., Results: A total of 27 patients aged 59.0 ± 11.2 years were finally included. After CTR, median nerve-innervated thermal anisometry was improved (2.55 ± 0.96 °C to 1.64 ± 1.34 °C; p = 0.003). The temperature differences between the median and ulnar nerve territories were not significantly changed. Subjective pain, the Simovic Weinberg Clinical Scale, and palmar bowing of the flexor retinaculum were also significantly improved (p <  0.001 for all comparisons)., Conclusions: Our results demonstrated that DITI findings could reflect an improvement in autonomic function after CTR. Therefore, DITI can be an objective method to assess pre- and post-operative neurophysiologic changes in CTS., (© 2023. The Author(s).)

Background: The purpose of this study was to evaluate the relationship between cross sectional area (CSA) of the median nerve on ultrasound (US) with pre- and postoperative Boston Carpal Tunnel Questionnaire (BCTQ) scores. We hypothesize that there is a positive correlation between CSA and the ΔBCTQ after carpal tunnel release (CTR)., Methods: This was a single center study. During a 6-year period (2014-2020), CSA of the median nerve on US and BCTQ scores were collected prospectively for patients presenting with the chief complaint of numbness and tingling in the upper extremity. Patients who underwent CTR and presented for their 6-week follow-up had repeat measurements of the CSA and BCTQ. These patients were included in this study. Patients were then divided into ultrasound positive (CSA ≥ 10) and ultrasound negative (CSA < 10) groups. These groups were compared on the basis of demographics, preoperative BCTQ scores, postoperative BCTQ scores, and 6-week ΔBCTQ score., Results: US-positive and-negative groups did not differ significantly in their preoperative BCTQ, postoperative BCTQ, or ΔBCTQ scores. Both groups did, however, experience significant improvement when comparing preoperative to postoperative BCTQ scores within their respective US group., Conclusion: Regardless of the preoperative CSA of the median nerve, patients who underwent CTR experienced a significant improvement in their BCTQ results. US-positive patients experienced no greater improvement than US-negative patients. These results would suggest that US is not a good predictor of subjective surgical outcome measures such as the BCTQ.

Background: Our purpose was to describe structural and morphological features of the median nerve and carpal tunnel on magnetic resonance imaging (MRI) studies obtained before, immediately after, 6 weeks after, and 6 years after endoscopic carpal tunnel release (ECTR)., Methods: In this prospective cohort study, 9 patients with a diagnosis of carpal tunnel syndrome (CTS) underwent ECTR. Standardized MRI studies were obtained before ECTR, immediately after ECTR, and 6 weeks and 6 years after surgery. Structural and morphological features of the median nerve and carpal tunnel were measured and assessed for each study with comparisons made between each time point., Results: All 9 patients had complete symptom resolution postoperatively. On the immediate postoperative MRI, there was a discrete gap in the transverse carpal ligament in all patients. There was retinacular regrowth noted at 6 weeks in all cases. The median nerve cross-sectional area and the anterior-posterior dimension of the carpal tunnel at the level of the hamate increased immediately after surgery and these changes were maintained at 6 years., Conclusions: We defined structural and morphological changes on MRI for the median nerve and carpal tunnel in patients with continued symptom resolution 6 years after ECTR. Changes in median nerve and carpal tunnel morphology that occur immediately after surgery remain unchanged at mid-term follow-up in asymptomatic patients. Established imaging criteria for CTS may not apply to postoperative patients. Magnetic resonance imaging appears to be of limited clinical utility in the workup of persistent or recurrent CTS.

Background: This study focused on the anatomical characteristics and variations of intercostobrachial (ICBN) nerve and median nerve to investigate the possible use of ICBN in restoration of sensory damage of hand after traumatic median nerve injury and to evaluate the feasibility of ICBN neurotization to median nerve., Methods: Variations of ICBN were noted in 16 axillary region dissections of eight cadavers. Measurements for ICBN's suitability in terms of neurotization to brachial plexus were done with millimetric devices. The distance of ICBN to the distal end of the lateral (LCMN) and medial (MCMN) contributions of the median nerve and the diameters of ICBN, LCMN, and MCMN were measured., Results: Fifteen axillary dissections exhibited ICBN, whereas it was absent on the left side of one of the cadavers. The mean diameter of ICBN at its origin was 2.0±0.7 mm and the mean diameter of ICBN at its coaptation point was 3.1±0.9 mm. The mean diameter of the LCMN was 3.9±2.0 mm, the mean diameter of MCMN was 3.5±0.9 mm. The length of ICBN was found to be adequate at both 45 and 90° of shoulder abduction to be extended to both LCMN and MCMN. The diameters of LCMN and MCMN were not significantly correlated with the diameter of ICBN both at origin and at coaptation point (LCMN: p=0.55-0.63 and MCMN: p=0.89-0.85). There is no significant difference between the diameter of LCMN and the diameter of ICBN at its coaptation point (p=0.168) and also between the diameter of MCMN and the diameter of ICBN at its coaptation point (p=0.232)., Conclusion: All ICBNs dissected showed adequate length to reach the lateral and medial contribution of the median nerve directly. The ICBN could be a feasible candidate since its diameter was close to LCMN and MCMN according to the descriptive and inferential statistics.

HISTORY: A 20 year old left handed male motorcyclist sustained a 3cm left volar wrist laceration closing a mirrored cabinet that shattered. He presented to the ED, where the laceration was irrigated and sutured, and he was given antibiotics. No imaging was done. Three days later, he went to UC for left palm numbness, swelling of fingers, and impaired wrist rotation. Patient was prescribed steroids and referred to Sports Medicine for follow up. Three days later at the Sports Medicine visit he reported constant numbness and tingling along the volar side of the left index, second finger, and thumb, inability to flex digits, and weakness and severe pain with specific movements of the left hand. He felt "something moving" inside his wrist when trying to move his thumb. PHYSICAL EXAMINATION: Inspection: Swelling along left digits 1-3, most noticeable along volar aspect, with stitches intact on volar wrist.Palpation: No tenderness or palpable foreign body. ROM: PROM intact. AROM revealed inability to make a closed fist, reduced flexion at first 3 digits, and intact flexion at 4th/5th digits. Strength: 3/5 flexor strength at left thumb and digits 1-3 and inability to maintain pincer grasp. Neurovascular: Decreased sensation along median nerve distribution and 2+ left radial pulse. DIFFERENTIAL DIAGNOSIS: Left median nerve injury Left flexor tendon injuryRetained foreign body TEST AND RESULTS: Left wrist xray:Density projecting volar to the thumb CMC joint, possibly reflecting a retained foreign body.MRI left wrist: Foreign body within the volar tissues of the wrist corresponding to anomaly seen on xrays. This extends through the transverse carpal ligament and lies immediately adjacent to the flexor pollicus longus tendon, the flexor digitorum superficialis tendon to the index finger, and the median nerve. There is abnormal signal within the median nerve concerning for nerve injury. FINAL WORKING DIAGNOSIS: Left median nerve laceration with retained foreign body. TREATMENT AND OUTCOMES:Left wrist removal of foreign body, left carpal tunnel release, left wrist median nerve repair. Wrist splint with three weeks of immobilization followed by slow advancement of activity. At 5 month follow-up he was exercising and riding a motorcycle without restriction. He had persistent mild sensory changes over left median nerve distribution. [ABSTRACT FROM AUTHOR]

Theoretical framework: Carpal Tunnel Syndrome (CTS) is a musculoskeletal disorder affecting the functionality of the upper limbs. Objective: To assess symptom severity and functional status, using the Boston Carpal Tunnel Questionnaire (BCTQ), and quality of life, using the SF-36 v2, in the preoperative period and two months after surgery. Methodology: Prospective study of 50 patients (60.7±11.7 years) who underwent decompression surgery. Participants were mostly women (52 %), with 62 % of them being post-menopausal women. Diabetes (8%), overweight (48%), and class I (26%) and class II obesity (4%) were found to be risk factors for CTS. Results: In the preoperative period, the affected hand had significantly less grip and pinch strength than the contralateral hand. The follow-up results suggest a decrease in symptom severity and an increase in functional status. Conclusion: Significant changes towards improving health-related quality of life were observed in the SF-36 v2 subscales: physical functioning, bodily pain, mental health, role-emotional, social functioning and vitality. [ABSTRACT FROM AUTHOR]

BACKGROUND Cubital tunnel syndrome results from pressure or stretching of the ulnar nerve, and carpal tunnel syndrome involves the median nerve. Elastofibroma is a rare, benign, slow-growing soft-tissue tumor that commonly occurs as a bilateral infrascapular tumor in elderly women. This report is of a 60-year-old woman who presented with combined carpal tunnel syndrome and cubital tunnel syndrome due to an elastofibroma causing compression of the median and ulnar nerves. CASE REPORT We report the case of a 66-year-old woman with left-hand numbness, tingling along the fingers, sleep disturbance, and weakness in pinching or holding objects for an extended period. The clinical examination and nerve conduction studies established the diagnosis of combined carpal tunnel syndrome (CTS) and cubital tunnel syndrome (CuTs) complicated by intrinsic muscle wasting. The patient underwent left carpal and cubital tunnels release surgery and end-to-side anterior interosseous nerve transfer to the motor component of the ulnar nerve. Pathologic evaluation of the entire specimen showed collagen bundles alternating with refractive cylinders stained with Verfoeff-van Gieson elastic stain. CONCLUSIONS This report is of a rare case of a histologically-confirmed single, peripheral, benign elastofibroma involving compression of the ulnar and median nerves. This case highlights the importance of histopathology in diagnosing rare soft-tissue tumors arising at an uncommon site and presenting with rare symptoms.

Background: High-resolution ultrasound (HRU) has demonstrated utility in the diagnosis and treatment of carpal tunnel syndrome (CTS) by measuring the cross-sectional area (CSA) of the median nerve. We investigated whether HRU could be helpful in evaluating outcomes of carpal tunnel release in patients with severe CTS., Methods: Patients greater than 18 years of age with severe CTS on electrodiagnostic (EDX) studies and scheduled to have carpal tunnel release were enrolled. At baseline visit within 6 weeks preoperatively, HRU was used to measure median nerve CSA at the carpal tunnel inlet and forearm, and the wrist/forearm ratio (WFR) was calculated. Patients also completed the Boston Carpal Tunnel Questionnaire (BCTQ). Ultrasound and BCTQ were repeated at 6 weeks and 6 months postoperatively., Results: Twelve patients completed the study (average age, 69 years; range, 52-80 years). The WFR improved significantly at 6 weeks and reached normal levels at 6 months. The CSA at the wrist also improved at 6 months, although this did not reach statistical significance ( P = .059). Boston Carpal Tunnel Questionnaire symptoms and function scores improved significantly at 6 weeks and 6 months., Conclusions: High-resolution ultrasound provides an objective assessment of surgical outcomes in cases of severe CTS, demonstrating normalization of WFR in our series of successful cases. Future study of poor outcomes may help determine whether improvement in WFR and CSA can provide reassurance and support for observation rather than reoperation. Ultrasound also provides anatomical evaluation and may be helpful in cases with medicolegal or psychosocial issues while potentially being less costly and better tolerated than EDX or magnetic resonance imaging.

Objective: The aim of this study was to compare the therapeutic effects of the mini-open incision and conventional open surgery for carpal tunnel syndrome (CTS)., Methods: The clinical data of 52 patients with CTS treated at the First Affiliated Hospital of the University of Science and Technology of China from October 2020 to February 2022 were retrospectively analyzed. The patients were divided into the conventional open surgery group (28 cases) and the mini-open incision group (24 cases) according to different surgical incisions applied. The incision length, operation time, time until postoperative return to work, and complications were observed in the two groups. The Visual Analog Scale (VAS) for pain at one day, one month, and three months after surgery and the Boston Carpal Tunnel Questionnaire scores before, at one month, and at three months after surgery were compared between the two groups., Results: The incision length, operation time, and time until return to work in the mini-open incision group were all shorter than those in the conventional open surgery group (2.58 ± 0.35 vs. 7.32 ± 0.61 cm, 18.67 ± 2.62 vs. 29.46 ± 3.42 min, and 5.33 ± 1.40 vs. 13.86 ± 2.70 d, respectively), and differences were statistically significant ( P  < 0.05 in all). The VAS scores in the mini-open incision group were lower than those in the conventional open surgery group at one day and one month after surgery, while the difference in the VAS scores at three months after surgery was not statistically significant between the two groups. There was no statistically significant difference in neurological recovery between the two groups at postoperative follow-ups ( P  > 0.05). The incidences of postoperative scar hyperplasia and scar pain were higher in the conventional open surgery group than those in the mini-open incision group, and differences were statistically significant ( P  < 0.05 in both)., Conclusion: Mini-open incision surgery for CTS was a safe and reliable procedure with a precise therapeutic effect, minimal surgical trauma, and high postoperative comfort for patients and could achieve enhanced recovery. Trial Registration . This trial is registered with ChiCTR2200064631., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Feng Hu et al.)

Isolated compression of the recurrent motor branch of the median nerve is an uncommon condition encontered in the daily life of the hand surgeon. Its early identification and correction can optimize functional outcomes. Among the few causes described, there are only 2 case reports of compression by fascial bands. We present a case of isolated compression of the recurrent motor branch of the median nerve secondary to anomalous fascial bands in a 34-year-old male patient, with significant atrophy of the thenar musculature of the right hand. Electroneuromyography showed isolated involvement of abductor pollicis brevis, with no sensory changes. The patient underwent exploration and decompression, recovering opposition and thumb function in 6 months.

Carpal tunnel syndrome (CTS), compression of the median nerve lying deep under the flexor retinaculum, is the most common entrapment neuropathy of the upper limb. After a failure of conservative treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs) and splinting, interventional techniques are required. Hydrodissection is an injection technique that separates the nerve from the surrounding tissue. Although this technique is gaining ground in modern medicine, the state-of-the-art literature is lacking a clear protocol or approach for hydrodissection for CTS. In this article, we describe a safe, minimally invasive, effective, and easy-to-use ultrasound-guided hydrodissection technique for CTS., (© 2021. The Author(s).)

Background: Carpal tunnel syndrome is a common condition in which the median nerve passes through the carpal tunnel is compressed. Then, gradual paralysis occurs. This study aimed to compare patient outcomes after surgery for carpal tunnel syndrome in both groups with and without splint.. Methods: This study was conducted in Isfahan University of Medical Sciences, Iran, in Kashani hospital during 2011. 64 patients underwent surgery for carpal tunnel syndrome were selected and randomly divided into two groups of 32. For the first group, splints were considered after the surgery and for the second group, as the control group, splint was not given. Patients within 3, 6 and 12 weeks after surgery were followed and healing in the sense of motion and pain based on the visual analogue scale (VAS) measures were examined. Findings: Sensory conflict scores at the 3rd and 6th weeks in the group with splint were higher than the group without it; but, 12 weeks after the treatment, the results were identical. In any cases, motor involvement was not seen. At the 3rd week after the treatment, the mean pain score in the group without splint was higher than with splint group. The results of the 6th week after the treatment in both groups were almost identical; but, at the 12th week after the treatment, changes in pain intensity was not significantly different between the two groups (P = 0.97). Conclusion: Splinting after the surgical release of the median nerve probably causes a delay in the recovery of sensory, motor and pain; but due to the effect of material of used splint, the result is still uncertain and further broader interventions needs to be done in this regard. [ABSTRACT FROM AUTHOR]

Aims: To investigate self-reported cold sensitivity and functional disability after a repaired major nerve trunk injury in the upper extremity., Methods: We identified 735 individuals with a major nerve trunk injury in the upper extremity, surgically treated with direct nerve repair or reconstructed with nerve autografts, in the Swedish national quality registry for hand surgery (HAKIR). Patient-reported symptoms, including cold sensitivity, and perceived disability were collected using two questionnaires (HQ-8 and QuickDASH) preoperatively, and at three and 12 months postoperatively., Results: We included 281 individuals, who had responded the questionnaires, where 197 (70%) were men (median age 34 [interquartile range 25-52] years) and 84 (30%) were women (median age 41 [25-55]). Cold sensitivity (scored 0-100) was the most prominent symptom 12 months postoperatively after an injured and repaired/reconstructed median (p<0.001) or ulnar (p<0.001) nerve, while individuals with a radial nerve injury showed milder symptoms. Concomitant injuries did not affect cold sensitivity scores. Individuals with ulnar nerve injuries scored higher in stiffness (p = 0.019), weakness (p<0.001) and ability to perform daily activities (p = 0.003) at 12 months postoperatively than median nerve injuries. Individuals with a median, ulnar or radial nerve injury with severe (>70) cold sensitivity had 25, 37 and 30 points higher QuickDASH scores, respectively (p<0.001), at 12 months postoperatively than individuals with mild (<30) cold sensitivity. There were no differences in QuickDASH score or cold sensitivity score at 12 months postoperatively between direct nerve repair or nerve reconstruction with nerve autografts. Neither age, nor sex, affected QuickDASH score at 12 months postoperatively., Conclusion: Cold sensitivity after surgery for a major nerve trunk injury in the upper extremity can be substantial with impaired ability to perform daily activities, where an ulnar nerve injury may have a worse outcome., Competing Interests: The authors have declared that no competing interests exist.

Epithelioid sarcoma of the peripheral nerves is extremely rare. We present a case concerning the median nerve of the right hand in a 35-year-old woman who was treated with radical resection, reconstructive surgery, and chemotherapy. After 2 years of follow-up, there is no evidence of local recurrence or metastatic dissemination.

The article discusses the study of "True" Lateral Imaging for Cervical Medial Branch Radiofrequency Neurotomy. Topics discussed include the effective use of radiofrequency thermal energy for the palliative relief of cervical facet pain has been known for decades; and the radiofrequency cannula is ideally placed in an exact manner both parallel to and as close as possible to the targeted cervical medial branch nerve before lesioning.

Background: The aims of this study were 2-fold: (1) to assess the morphological change of the median nerve in patients with carpal tunnel syndrome (CTS) preoperatively and at 6 and 12 months postoperatively; and (2) to analyze correlation between the changes in ultrasonographic findings and the changes in clinical findings after surgical decompression. Methods: Of the 28 patients with CTS, 34 wrists were treated with open carpal tunnel release. We evaluated them using the Boston questionnaire, Japanese Society for Surgery of the Hand Version of the Quick Disability of the Arm, Shoulder, and Hand questionnaire, nerve conduction study (NCS), and ultrasound preoperatively and at 6 and 12 months postoperatively. We measured the cross-sectional area (CSA) of the median nerve at the level of the proximal inlet of the carpal tunnel (CSAc) and more proximally at the level of the distal radioulnar joint (CSAd). Paired t tests and repeated measures analysis of variance of ranks were used to identify changes over time. The Spearman correlation coefficient by rank test was used for the analysis of the relation between the amount of change of CSA and the patient-rated questionnaire score and NCS findings. Results: Findings for CSAc, CSAd, and NCS and patient-rated outcomes at 6 and 12 months postoperatively were significantly lower than their preoperative values. However, no significant correlation was found between the postoperative changes in CSAc, CSAd, and clinical variables obtained preoperatively and postoperatively. Conclusions: Evaluation of sonographic imaging might not be helpful for assessing clinical conditions in patients with CTS after surgical decompression.

The most common procedure for the treatment of painful median nerve neuroma is coverage with vascularized soft tissue following external neurolysis. However, the ideal treatment should include reconnecting the proximal and distal stumps of the damaged nerve to allow the growth of regenerating axons to their proper targets for a functional recovery. We developed a useful technique employing radial artery perforator adipofascial flap including the lateral antebrachial cutaneous nerve (LABCN) to repair the median nerve by vascularized nerve grafting and to achieve coverage of the nerve with vascularized soft tissue. In an anatomical study of 10 fresh-frozen cadaver upper extremities, LABCN was constantly bifurcated into two branches at the proximal forearm (mean: 8.2 cm distal to the elbow) and two branches that run in a parallel manner toward the wrist. The mean length of the LABCN branches between the bifurcating point and the wrist was 18.2 cm, which enabled inclusion of adequate length of the LABCN branches into the radial artery perforator adipofascial flap. The diameters of the LABCN branches (mean: 1.7 mm) were considered suitable to bridge the funiculus of the median nerve defect after microsurgical internal neurolysis. In all cadaver upper extremities, the 3-cm median nerve defect at the wrist level could be repaired using the LABCN branches and covered with the radial artery perforator adipofascial flap. On the basis of this anatomical study, the median nerve neuroma was successfully treated with radial artery perforator adipofascial flap including vascularized LABCN branches.

There have been 8 synovial sarcomas of the median nerve reported. We report a case of a 15-year-old male with synovial sarcoma of the right-hand median nerve. Patient presented with a 2-month history of enlarging mass at the base of the right thenar eminence associated with numbness in the median nerve distribution. Physical examination revealed a soft mass over the thenar eminence and paresthesia in the median nerve distribution. He underwent excision of the tumor, which revealed a well-encapsulated lesion encompassing the median nerve, involving the first, second, and radial aspect of the third web space as well as recurrent branches of the median nerve. Following excision of the tumor, a thorough metastatic workup was negative for metastatic disease. He was staged as III, T2b, N0, M0-poorly differentiated monophasic synovial sarcoma of the right median nerve. Postoperatively the patient was started on chemotherapy and radiation. Intraneural synovial sarcoma is extremely rare. Our case is the youngest with the longest follow-up. He is currently at a status of 3 years posttreatment with no signs of recurrence and excellent use of his right hand. This case is of particular interest due to the rarity of the disease along with this being the best outcome reported in the literature to-date.

Background: Ultrasound has been well established as a diagnostic modality for carpal tunnel syndrome, but its prognostic utility has not been deeply investigated. Few studies, showing contradictory results, exist investigating ultrasound results as a predictor of patient outcomes. Methods: Patients with ultrasound measurement of the cross-sectional area (CSA) of the median nerve who completed the Boston Carpal Tunnel Questionnaire (BCTQ) and followed up after surgery were included in the study. A total of 199 wrists from 172 patients met the inclusion criteria. Preoperative CSA of the median nerve at the wrist was compared with change in BCTQ at various follow-up times postoperatively. Results: The BCTQ score was found on average to decrease for patients after surgery at all 3 follow-up times. There was a larger decrease in the preoperative BCTQ with each progressive follow-up time, with the largest change of 1.43 points coming at 6+ months. The average change in BCTQ at each follow-up time was found to be greater than the minimal clinically important difference. The greatest R 2 for preoperative CSA compared with change in BCTQ was 0.0552 for the 6+ month visits. No specific CSA value or range above or below which patients have better postoperative outcomes was found. Conclusions: Higher preoperative CSA, signifying worse carpal tunnel severity, showed almost no correlation with better outcomes after carpal tunnel release surgery as measured by improvement in patient-reported outcome scores.

This case study report demonstrates the use of motion analysis with a modification of the Box and Blocks test. The goal was to quantify observed improvements in compensatory movements and simultaneous control in a subject using different prostheses before and after targeted muscle reinnervation (TMR) surgery. This is a single case study with data collection using a body-powered prosthesis pre-TMR surgery and 6 mo postfitting with a TMR myoelectric prosthesis. The Box and Blocks test was modified for cyclical motion within a motion capture laboratory. With the TMR myoelectric prosthesis, the subject was able to simultaneously activate the hand and elbow. Task performance was slower, but there was improved elbow flexion and less trunk compensatory motion than with the body-powered prosthesis. There are several limitations to the case study because there is no direct comparison of myoelectric performance before and after TMR surgery; however, the current report presents a potential method to quantify quality of motion and compensatory movements of prosthetic users. With further study, this test procedure has the potential to be a useful outcome measure for future standardized assessments of upper-limb prosthetic function. [ABSTRACT FROM AUTHOR]

The article describes the approach practiced by the author from 1995. Mainly Hansen's patients and lower forearm injuries formed the bulk of these. In Opponen's transfer ECU was used only when others were not available as the wrist developed a tendency to radial deviation even when FCU was acting. PL with palmar aponeurosis as extension was used again in limited cases. The main stay was FDS and EIP. The Guyan's canal and lower end of ulna were the common pulleys. APB and EPL two slip inserts yielded good results. The approach describes the procedure under three distinct headings of choosing motor, Pulley and insert. Varying combinations of these can be used as per requirement. [ABSTRACT FROM AUTHOR]

Objective: The objective was to assess the outcome of selective motor fasciculotomy in relieving upper limb harmful resistant spasticity and thereby to improve motor functions in persons with cerebral palsy. Materials and Methods: Twenty people having cerebral palsy (12 females and 8 males) with age ranging from 5 to 35 (mean 12.85) years with upper limb resistant spasticity due to spastic hemiplegia (n=7), triplegia (n=6), and quadriplegia (n=7) were assessed using Modified Ashworth Scale, Selective Voluntary Control Grade, Wee FIM Scale and hand function evaluation. Selective motor fasciculotomy was performed on the musculocutaneous nerve (n=13) for elbow flexors spasticity, median nerve (n=24) for pronators and radial wrist flexors spasticity and ulnar nerve (n=3) for ulnar wrist flexors spasticity. Pre- and post-op therapeutic exercises were performed. Results: Statistical analysis using the Wilcoxon Signed Ranks test showed significant reduction in spasticity and improvement in selective voluntary control, hand functions (grasp to hold a 2 inch rod), and Wee FIM (self-care domain in particular). There was no recurrence in spasticity and complications following surgery. Conclusions: The selective motor fasciculotomy of musculocutaneous, median, and ulnar nerves significantly reduces spasticity in the affected muscle groups and thereby improves the self-care (motor) functions in selected people with cerebral palsy who have harmful resistant spasticity without any organic shortening of the muscles. The procedure is safe and the spasticity does not recur. [ABSTRACT FROM AUTHOR]

Background: Carpal tunnel syndrome is a common disorder in hand surgery practice. Both surgical and conservative interventions are utilized for the carpal tunnel syndrome. Although certain indications would specifically indicate the need for surgery, there is a spectrum of patients for whom either treatment option might be selected. The purpose of this systematic review was to compare the efficacy of surgical treatment of carpal tunnel syndrome with conservative treatment Methods: We included all controlled trials written in English, attempting to compare any surgical interventions with any conservative therapies. We searched Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2010), MEDLINE (1980 to June 2010), EMBASE (1980 to June 2010), PEDro (searched in June 2010), international guidelines, computer searches based on key words and reference lists of articles. Two reviewers performed study selection, assessment of methodological quality and data extraction independently of each other. Weighted mean differences and 95% confidence intervals for patient self-reported functional and symptom questionnaires were calculated. Relative risk (RR) and 95% confidence intervals for electrophysiological studies and complication were also calculated. Results: We assessed seven studies in this review including 5 RCTs and 2 controlled trials. The methodological quality of the trials ranged from moderate to high. The weighted mean difference demonstrated a larger treatment benefit for surgical intervention compared to non surgical intervention at six months for functional status 0.35( 95% CI 0.22, 0.47) and symptom severity 0.43 (95% CI 0.29, 0.57). There were no statistically significant difference between the intervention options at 3 months but there was a benefit in favor of surgery in terms of function and symptom relief at 12 months ( 0.35, 95% CI 0.15, 0.55 and 0.37, 95% CI 0.19 to 0.56). The RR for secondary outcomes of normal nerve conduction studies was 2.3 (95% CI 1.2, 4.4), while RR was 2.03 (95% CI 1.28 to 3.22) for complication, both favoring surgery. Conclusion: Both surgical and conservative interventions had treatment benefit in carpal tunnel syndrome. Surgical treatment has a superior benefit, in symptoms and function, at six and twelve months. Patient underwent surgical release were two times more likely to have normal nerve conduction studies but also had complication and side effects as well. Given the treatment differential and potential for adverse effects and that conservative interventions benefitted a substantial proportion of patients, current practice of a trial of conservative management with surgical release for severe or persistent symptoms is supported by evidence. [ABSTRACT FROM AUTHOR]

We report an extremely rare case of proximal entrapment neuropathy of the median nerve above the elbow in a 44-year-old man who presented with paresthesia with median nerve distribution. Tinel's sign was located in the upper arm medial to the biceps and 5 cm proximal to the elbow. The patient underwent microsurgery under local anesthesia. The fascia covering the brachial- and the biceps brachii muscle entrapped median nerve. After operation, he reported symptom improvement. Lesions above the elbow should be considered as possible causative factors of entrapment neuropathy of the median nerve. [ABSTRACT FROM AUTHOR]

Introduction: Carpal tunnel syndrome is the most common nerve entrapment peripheral neuropathy, caused by the compression of the median nerve in the wrist. Conservative treatment has a success rate of 75%. There are three surgical approaches: open, endoscopic and minimally invasive, all of which are highly effective. Trying to determine which is the most beneficial method is a controversial subject. Objective: To determine the advantages, drawbacks, and complications of the approaches using validated scales. Results: 48 patients with EMG-confirmed carpal tunnel syndrome were treated surgically with: a) Open release, b) Endoscopic release (Agee technique). Intraoperative findings with the endoscopic approach were a decreased carpal space and abundant fibroadipose tissue. Patients were followed-up and the results were assessed considering: CSTC, DASH, pain, Tinel sign, Phalen sign, sensitivity, muscle strength, wrist mobility. Conclusions: Both procedures are safe, no complications were reported. The patients treated with endoscopic release did significantly better during the immediate postoperative period, p = 0.001, up to 3 months postop p = 0.0001. They continued to improve up to 6 months, but the differences were not significant anymore. At one year postop, no significant difference was seen between the results of the patients from both groups. No differences were found in the CSTC. The DASH showed a very significant difference; p = 0.004 in favor of the endoscopic release. [ABSTRACT FROM AUTHOR]

&lt;b&gt;Introduction:&lt;/b&gt; Schwannoma is a nerve tumor originating from Schwann-cells of the nerve sheath. It is found in all body regions, the most frequent in the head, neck and in the extremities. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Aim:&lt;/b&gt; The objective of this study was analysis of outcomes of surgery for these lesions in the authors' institution. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Materials and methods:&lt;/b&gt; Results of the treatment of 12 patients, 7 women and 5 men, aged a mean of 40 years with shwannomas localized in the upper limb are presented. The follow-up assessment was performed in a form of telephone interview at a mean of 4.2 years post-operatively. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Results:&lt;/b&gt; The tumors were located in the hand in 5 patients, in the forearm in other 5 and in the wrist in 2. In 3 patients the tumors originated form the median, in 2 from the ulnar and in 2 from the radial nerves; in 5 cases it grew from small nerve branches. All lesions of the median, ulnar and radial nerves were encapsulated without damage of the nerve fascicles, while in the hand they were resected in total. At a mean of 4.2 years of follow-up, two recurrences (17%) occurred, both following resection of the tumor located in the hand. Complications were noted in 5 patients: two felt parasthesiae in the operated finger, two were disappointed due to unaesthetic scar and one patient following tumor resection from posterior interosseous nerve had incomplete finger extension. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusion:&lt;/b&gt; Outcomes of surgery for these rare tumors are generally good, but functional deficits should be considered in cases of lesions involving motoric nerves.

Background: Nerve conduction study (NCS) is the only useful test for objective assessment of carpal tunnel syndrome (CTS). However, the relationship between pre- and postoperative NCS and clinical outcomes was unclear. This study aimed to determine whether pre- and postoperative (6 months) NCS could predict patient-oriented and motor outcomes (6 and 12 months postoperatively) in patients with CTS., Method: Of the 85 patients with CTS, 107 hands were analyzed from March 2011 to March 2020. All patients underwent open carpal tunnel release and were examined using the disabilities of the arm, shoulder and hand (DASH) questionnaire and grip strength (GS) preoperatively and 6 and 12 months postoperatively. Moreover, NCS was examined preoperatively and 6 months postoperatively. Distal motor latency (DML) and sensory conduction velocity (SCV) were the parameters used for NCS. The correlation coefficient between NCS and DASH or GS was calculated. A receiver operating characteristic curve was utilized to determine the NCS threshold value to predict DASH and GS improvement., Results: The average scores of GS preoperatively and 6 and 12 months postoperatively were 21.3, 22.3, and 22.8, respectively. On the other hand, the average scores of DASH preoperatively and 6 and 12 months postoperatively were 28.8, 18.3, and 12.2, respectively. The average NCS scores (DML and SCV) preoperatively/6 months postoperatively were 7.3/5.4 and 27.8/36.7, respectively. Preoperative NCS did not correlate with DASH and GS. Postoperative SCV correlated with the change in grip strength (6-12 months, r = 0.67; 0-12 months, r = 0.60) and DASH (0-12 months, r = 0.77). Moreover, postoperative DML correlated with the change in DASH (6-12 months, r = - 0.33; 0-12 months, r = - 0.59). The prediction for the improvement of GS/DASH achieved a sensitivity of 50.0%/66.7% and a specificity of 100%/100%, at an SCV cutoff score of 38.5/45.0 or above. The prediction for improvement of GS/DASH achieved a sensitivity of 83.3%/66.7% and a specificity of 100%/66.7% at a DML cutoff score of 4.4/4.4 or below., Conclusion: NCS at 6 months postoperatively can be used to predict the improvement of clinical outcome after 6 months postoperatively in patients with CTS., (© 2021. The Author(s).)

Background: Mucopolysaccharidosis consists of a group of diseases caused by the deficiency of lysosomal enzymes, which may lead to the compression of the median nerve in the carpal tunnel due to the accumulation of glycosaminoglycan, resulting in the hand disability. The study purpose is to present functional results of carpal tunnel release in mucopolysaccharidosis patients. Patients were selected from an enzyme replacement group in the Department of Pediatric Neurology. The legal guardians of the patients were informed about the likely functional change of the hands induced by compression of the median nerve. Clinical evaluation was performed in those patients who received their legal guardians' consent to participate and was included inspection, assessment of functional level, wrinkle test and the digital pinch function to manipulate small and large objects. Ultrasound and electromyography were performed to confirm the clinical median nerve compression. Bilateral extended opening technique was performed to access the carpal tunnel and analyze the anatomic findings of the median nerve and the flexed tendons of the fingers. After the surgical release of the carpal tunnel, the clinical evaluation was repeated. Subjective observations of the legal guardians were also considered., Results: Seven patients underwent bilateral surgical opening of the carpal tunnel; six boys, mean age of 9.5 (5 to 13), five of them presenting Type II mucopolysaccharidosis, 1 Type I and 1 Type VI. The average follow-up was 12 months (10-13 months). The functional results observed included the improvement in the handling of small and large objects in all children who underwent decompression of the median nerve. The comparison between the pre-operative and post-operative functional levels revealed that 2 patients evolved from Level II to IV, 3 from Level III to IV, 1 from Level IV to V and 1 patient remained in Level III. Tenosynovitis around the flexor tendons and severe compression of the median nerve in the fourteen carpal tunnels were observed during the surgical procedure. In 6 wrists, partial tenosynovitis was performed., Conclusions: Despite the improvement in the overall function of the children' hands, we cannot conclude that only surgery was responsible for the benefit. Better designed studies are required., (© 2021. The Author(s).)

Background: Median nerve entrapment in the forearm (MNEF) without motor paralysis is a challenging diagnosis. This retrospective study evaluated the clinical presentation, diagnostic studies, and outcomes following surgical decompression of MNEF. Methods: The study reviewed 147 patient medical charts following MNEF surgical decompression. With exclusion of patients with combined nerve entrapments (radial and ulnar), polyneuropathy, neurotmetic nerve injury, or median nerve motor palsy, the study sample included 27 patients. Data collected include: clinical presentation and pain, strength, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 27 patients (mean follow-up = 7 months), and 13 patients had previous carpal tunnel release (CTR). Clinical presentation included pain (n = 27) (forearm, n = 22; median nerve innervated digits, n = 21; and palm, n = 21) and positive clinical tests (forearm scratch collapse test, n = 27; pain with compression over the flexor digitorum superficialis arch/pronator, n = 24; Tinel sign, n = 11). Positive electrodiagnostic studies were found for MNEF (n = 2) and carpal tunnel syndrome (n = 11). Primary CTR was performed in 10 patients and revision CTR in 7 patients. Postoperatively, there were significant ( P < .05) improvements in strength, pain, quality of life, and DASH scores. Conclusions: The MNEF without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent forearm pain and median nerve symptoms (especially after CTR) should be evaluated for MNEF. Surgical decompression provides satisfactory outcomes.

Carpal tunnel release is a routinely performed operation to relieve pressure caused by compression on the median nerve. In the majority of cases, the causation of the compression will be idiopathic. Among the secondary causes of median nerve compression is the palmaris profundus, a rare anatomical variant separate to the palmaris longus tendon. It has been suggested that it may cause carpal tunnel syndrome as it courses underneath the flexor retinaculum with the contents of the carpal tunnel reducing the space available to the median nerve. Several cases have found it intimately associated with the median nerve within the carpal tunnel. Raising awareness of this anatomical variant is therefore important for those undertaking carpal tunnel decompression in order to avoid unintended damage., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: This study is to compare the efficacy of short-axis hydrodissection with long-axis hydrodissection for patients with mild-to-moderate carpal tunnel syndrome (CTS). Methods: Forty-seven patients with mild-to-moderate CTS were enrolled in a prospective, randomized, single-blinded, controlled trial (6 months follow-up). With ultrasound guidance, patients in both groups (short-axis or long-axis groups) were injected with normal saline (5 mL per session). Assessments were performed before and 2 weeks after the injection, as well as at 1, 3, and 6 months post-intervention. The primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) score and secondary outcomes included the cross-sectional area of the median nerve and electrophysiological studies. Results: Forty-four patients (21 wrists in the short-axis group and 23 wrists in the long-axis group) completed the study. Compared with the baseline, both groups showed improved BCTQ and cross-sectional area at all follow-up assessments (p<0.05). The short-axis group was not more effective except significant improvements in BCTQ-severity and BCTQ-function 1 month post-injection compared to the long-axis group (p = 0.031 and p = 0.023, respectively). Conclusions: Both short- and long-axis hydrodissection were effective for patients with mild-to-moderate CTS and the short-axis approach was not more effective than long-axis injection. Further studies with larger sample sizes, multiple injections, and larger injection volume are encouraged in the future., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Objective: To investigate changes in the median nerve, retinaculum, and carpal tunnel on ultrasound after successful endoscopic carpal tunnel release (ECTR)., Materials and Methods: This prospective study involved 37 wrists in 35 patients (5 male, 30 female; mean age ± standard deviation [SD], 56.9 ± 6.7 years) with primary carpal tunnel syndrome (CTS). An in-house developed scoring system (0-3) was used to gauge the clinical improvement after ECTR. Ultrasound was performed before ECTR, and at 1, 3, and 12 months post-ECTR. Changes in the median nerve, flexor retinaculum, and carpal tunnel morphology on ultrasound after ECTR were analyzed. Ultrasound parameters for different clinical improvement groups were compared., Results: All patients improved clinically after ECTR. The average clinical improvement score ± SD at 12 months post-ECTR was 2.2 ± 0.7. The median nerve cross-sectional area proximal and distal to the tunnel decreased at all time intervals post-ECTR but remained swollen compared to normal values. Serial changes in the median nerve caliber and retinacular bowing after ECTR were more pronounced at the tunnel outlet than at the tunnel inlet. The flexor retinaculum had reformed in 25 (68%) of 37 wrists after 12 months., Conclusion: Postoperative changes in median nerve and retinaculum parameters were most pronounced at the tunnel outlet. Even in patients with clinical improvement after ECTR, nearly all ultrasound parameters remain abnormal at one year post-ECTR. These ultrasound parameters should not necessarily be relied upon to diagnose persistent CTS after ECTR., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2021 The Korean Society of Radiology.)

We, herein, presented a rare case of bilateral brachial artery infiltration by tumoral calcinosis located on both elbows. A 58-yearold man presented with a history of painless, palpable solid mass restricting the range of motion of both elbows. These masses were located on the anterior aspect of the elbows and gradually enlarged. After clinical, laboratory and radiological examinations, tumoral calcinosis was suspected, and excisional biopsy was planned for a definite diagnosis. Surgery was first performed on the left elbow. The median nerve was found to be compressed but not infiltrated by the mass. Interestingly, the brachial artery was totally infiltrated throughout the entire mass. Occlusion was observed in the brachial artery located within the mass. The tumor on the left elbow, 8.5 × 5.5 × 2.5 cm in size, was totally excised with approximately 12-cm brachial artery segment. The artery was resected until the healthy tissue was reached. The defect was reconstructed with saphenous vein graft obtained from the ipsilateral lower extremity. The same surgical procedure was performed on the right elbow after 3 months. The tumor size on the right elbow was 7 × 3.5 × 1.7 cm. Approximately 15-cm brachial artery segment was excised, and the defect was reconstructed with saphenous vein graft. Tumoral calcinosis is a rare benign condition that can be located in close relationship with neurovascular structures. In such cases, detailed neurologic and vascular examination, including imaging modalities, for arterial flow is essential to establish a more accurate surgical plan and avoid any unexpected situation during surgery.

Background: The aim of this study is to assess the outcomes of carpal tunnel release (CTR) in a cohort of patients with preoperatively unrecordable median nerve sensory and motor potentials in comparison with historical controls at minimum 5-year follow-up. Methods: We retrospectively identified 1297 patients who underwent CTR at a tertiary care referral center from July 2008 to June 2013. After exclusion criteria and review of available preoperative nerve conduction studies, 24 patients who underwent CTR with preoperative unrecordable sensory and motor nerve potentials were identified. Fifteen living, mentally capable patients were contacted by telephone for follow-up. Our primary outcome measure was the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ). Secondary outcome measures included Disabilities of the Arm, Shoulder, and Hand (DASH) score, pain on a 0 to 10 Likert scale, and satisfaction on a 0 to 10 Likert scale. Results: Our response rate was 80% (12 out of 15) of eligible patients. Mean follow-up was 6.9 years in our study (range, 5.4-9.5 years). The mean BCTQ symptom score was 1.4, and the mean BCTQ functional score was 1.8. Mean DASH score was 15.2. On average, patient-reported pain was 0.3 and satisfaction was 8.3. No difference was found in outcomes of CTR in patients with end-stage carpal tunnel syndrome compared with historical means. Conclusions: Patients with end-stage carpal tunnel syndrome do not have worse long-term patient-reported outcomes after CTR compared with the general population. Unrecordable nerve potentials are not a contraindication for CTR.

Introduction: Several structures liable to compress the median nerve have been described around the elbow and proximal forearm. Signs of deficit justify surgical exploration and decompression by exoneurolysis. Better knowledge of the locations of these structures would ensure reliable and effective exploration., Hypothesis: The study hypothesis was that compressive structures show precise topography, with few variations in distance along the median nerve course., Material and Methods: The study was performed on 36 upper-limb cadaver specimens. The measurement reference level was the humeral bi-epicondylar line. Proximal-to-distal dissection located: (1) Struthers' ligament, (2) the pronator teres bellies (PT) with their anatomic particularities of structure and insertion, (3) the lacertus fibrosus, (4) the fibrous arcade of the flexor digitorum superficialis (FDS), (5) the accessory muscles, (6) the origin of the anterior interosseous nerve (AIN), (7) and the vascular arches., Results: Struthers' ligament was not located, but 1 case of medial bicipital fibrous arcade was found. The lacertus fibrosus crossed the median nerve at +1.5±0.6cm. PT insertion was high in 19 cases (53%). The humeral PT belly was thin in 21 cases (58%), crossing the median nerve more distally (+1.8±0.8cm) than the thicker muscles (+1±1.1cm) (p=0.016). The ulnar PT belly was fibrous in 14 cases (39%). A fibrous arcade was found between the 2 PT bellies in 23 cases (64%). The FDS arcade was located at 4.5-7cm from the bi-epicondylar line. An accessory flexor pollicis longus belly was found in 11% of cases. The AIN origin was at +4±1.6cm from the reference. A vascular pedicle crossed the median nerve in 3 cases., Discussion: The present study inventoried and mapped 6 potentially compressive structures neighboring or crossing the median nerve. Except for the FDS arcade, they showed very precise proximal-to-distal location, with variations of 0.5 to 1.5cm., Level of Evidence: IV; case series., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Proximal median nerve (MN) neuropathy represents 1% of upper-limb compressive neuropathies. The literature reports two clinical presentations, depending on the location of the entrapment: pronator teres (PT), and anterior interosseous nerve (AIN) syndrome., Hypothesis: There is no correlation between symptoms and location of proximal compressive structures on the MN trunk or AIN., Patients and Methods: Clinical and paraclinical data from 55 surgical MN releases around the elbow and proximal forearm were analyzed retrospectively. Mean age at diagnosis was 56±15years. Preoperative sensory and motor deficit signs were present in 89% of cases. Reduced MN conduction velocity and/or neurogenic anomalies in the MN territory were present in 94% of cases. Intraoperative details of compressive structures were collected. Patients were followed up in consultation to assess progression of symptoms and deficits., Results: Mean follow-up was 84±70months. Objective motor deficit signs persisted in 18 of the 35 patients (18 cases), and objective sensory signs in 19 cases. A compressive anatomical structure was systematically found. There were at least two MN entrapment sites in 13 cases (24%). No isolated AIN entrapment was found. There was a significant correlation between symptom duration and persistence of objective sensory signs (p=0.002)., Discussion: There was no correlation between entrapment site and clinical signs on examination. Surgery requires exploring all potential entrapment sites. Improvement may be incomplete in case of late treatment., Level of Evidence: IV; retrospective study., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)