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

Radial nerve entrapment is an uncommon diagnosis. The entrapment can occur at any location within the course of the nerve distribution, but the most frequent location of entrapment occurs around the elbow and involves the posterior interosseous nerve. Several potential sites of radial nerve entrapment around the elbow are identified: the capsular tissue of the radiocapitellar joint; hypertrophic crossing branches of leash of henry; the leading proximal tendinous and medial edge of extensor carpi radialis brevis; the arcade of Frohse and distal border of the supinator between its two heads. The arcade of Frohse is the most common site of compression. The aim of this manuscript is to describe the common surgical methods to approach the radial nerve entrapments around the elbow and define the preferred surgical approach based on the site of compression., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction/aims: Ulnar nerve instability (UNI) in the retroepicondylar groove is described as nerve subluxation or dislocation. In this study, considering that instability may cause chronic ulnar nerve damage by increasing the friction risk, we aimed to examine the effects of UNI on nerve morphology ultrasonographically., Methods: Asymptomatic patients with clinical suspicion of UNI were referred for further clinical and ultrasonographic examination. Based on ulnar nerve mobility on ultrasound, the patients were first divided into two groups: stable and unstable. The unstable group was further divided into two subgroups: subluxation and dislocation. The cross-sectional area (CSA) of the nerve was measured in three regions relative to the medial epicondyle (ME)., Results: In the ultrasonographic evaluation, UNI was identified in 59.1% (52) of the 88 elbows. UNI was bilateral in 50% (22) of the 44 patients. Mean CSA was not significantly different between groups. A statistically significant difference in ulnar nerve mobility was found between the group with CSA of <10 versus ≥10 mm 2 (p = .027). Nerve instability was found in 85.7% of elbows with an ulnar nerve CSA value of ≥10 mm 2 at the ME level., Discussion: The probability of developing neuropathy in patients with UNI may be higher than in those with normal nerve mobility. Further prospective studies are required to elucidate whether asymptomatic individuals with UNI and increased CSA may be at risk for developing symptomatic ulnar neuropathy at the elbow., (© 2024 Wiley Periodicals LLC.)

Aim: To investigate co-contraction in reinnervated elbow flexor muscles following a nerve transfer. Materials & methods: 12 brachial plexus injury patients who received a nerve transfer to reanimate elbow flexion were included in this study. Surface electromyography (EMG) recordings were used to quantify co-contraction during sustained and repeated isometric contractions of reinnervated and contralateral uninjured elbow flexor muscles. Reuslts: For the first time, this study reveals reinnervated muscles demonstrated a trend toward higher co-contraction ratios when compared with uninjured muscle and this is correlated with an earlier onset of muscle fatigability. Conclusion: Measurements of co-contraction should be considered within muscular function assessments to help drive improvements in motor recovery therapies.

Objective: This pooled analysis evaluates the association between the number of nerves transferred and postoperative outcomes after intercostal nerve (ICN) nerve transfer for elbow flexion., Methods: A systematic and pooled analysis of studies reporting individual patient demographics and outcomes after ICN-musculocutaneous nerve (MCN) transfer for traumatic brachial plexus injury was conducted. The primary outcome was the ability to attain an elbow flexion Medical Research Council (MRC) score of ≥4 at the final postoperative follow-up visit., Results: Ten studies were included for a total of 128 patients. There were 43 patients who underwent two ICNT, 77 patients who underwent three ICNT, and 8 patients who underwent four ICNT. The three groups did not differ in ability to achieve MRC ≥ 4 (2ICNT 48.8%, 3ICNT 42.9%, 4ICNT 50.0%, p  = 0.789). The number of ICNs transferred was not associated with MRC scores ≥4 on the multivariable analysis (OR: 0.55, p  = 0.126)., Conclusions: These results indicate that two ICN transfers may be as effective as three ICN and four ICN transfers and highlight the potential for nonsurgical factors to influence postoperative outcomes. Taken together, this pooled analysis leads us to question the utility of transferring >2 ICNs for MCN neurotization.

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

Objective: Ulnar and/or median nerve fascicle to musculocutaneous nerve (MCN) transfers are used to restore elbow flexion following severe neonatal and nonneonatal brachial plexus injuries (BPIs). Restoring volitional control requires plastic changes in the brain. To date, whether the potential for plasticity is influenced by a patient's age remains unknown., Methods: Patients who had presented with a traumatic upper (C5-6 or C5-7) BPI were divided into two groups: neonatal brachial plexus palsies (NBPPs) and nonneonatal traumatic BPIs (NNBPIs). Both groups underwent ulnar or median nerve transfers to the MCN for elbow flexion restoration between January 2002 and July 2020. Only those who attained a British Medical Research Council strength rating of 4 were reviewed. The primary comparison between the two groups was the plasticity grading scale (PGS) score to determine the level of independence of elbow flexion (target) from forearm motor muscle movement (donors). The authors also assessed patient compliance with rehabilitation using a 4-point Rehabilitation Quality Scale. Bivariable and multivariable analyses were used to identify intergroup differences., Results: In total, 66 patients were analyzed: 22 with NBPP (mean age at surgery 10 months) and 44 with NNBPI (age range at surgery 3-67 years, mean 30.2 years; mean time to surgery 7 months, p < 0.001). All NBPP patients obtained a PGS grade of 4 at the final follow-up versus just 47.7% of NNBPI patients (mean 3.27, p < 0.001). On ordinal regression analysis, after nature of the injury was excluded because of excessive collinearity with age, age was the only significant predictor of plasticity (β = -0.063, p = 0.003). Median rehabilitation compliance scores were not statistically different between the two groups., Conclusions: The extent of plastic changes that occur for patients to regain volitional control over elbow flexion after upper arm distal nerve transfers following BPI is influenced by patient age, with complete plastic rewiring more likely in younger patients and virtually ubiquitous in infants. Older patients should be informed that elbow flexion after an ulnar or median nerve fascicle transfer to the MCN might require simultaneous wrist flexion.

Background: Elbow fractures are common in children. While Kirschner wire (K-wire) is the most commonly used fixation material in children, medial entry pins may be needed for fracture stability. This study aimed to assess ulnar nerve instability by ultrasonography in children., Methods: We enrolled 466 children aged 2 months to 14 years between January 2019 and January 2020. There were at least 30 patients in each age group. Ulnar nerves were observed under the ultrasound equipment with the elbow fully extended and flexed. If ulnar nerves were subluxated or dislocated, they were considered to have ulnar nerve instability. The children's clinical data, including sex, age, and elbow sides, were analyzed., Results: Of 466 enrolled children, 59 had ulnar nerve instability. Ulnar nerve instability rate was 12.7% (59/466). Instability was prevalent in children aged 0-2 years (P = .001). Among 59 children with ulnar nerve instability, 52.5% (31/59) had bilateral ulnar nerve instability, 16.9% (10/59) had right ulnar nerve instability, and 30.5% (18/59) had left ulnar nerve instability. Logistic analysis of the risk factors of ulnar nerve instability showed no significant difference in terms of sex and left or right ulnar nerve instability., Conclusions: Ulnar nerve instability correlated with age in children. Children aged <3 years had a low risk of ulnar nerve instability., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objectives: To explore the changes of elbow flexor muscle strength after musculocutaneous nerve injury and its correlation with needle electromyography (nEMG) parameters., Methods: Thirty cases of elbow flexor weakness caused by unilateral brachial plexus injury (involving musculocutaneous nerve) were collected. The elbow flexor muscle strength was evaluated by manual muscle test (MMT) based on Lovett Scale. All subjects were divided into Group A (grade 1 and grade 2, 16 cases) and Group B (grade 3 and grade 4, 14 cases) according to their elbow flexor muscle strength of injured side. The biceps brachii of the injured side and the healthy side were examined by nEMG. The latency and amplitude of the compound muscle action potential (CMAP) were recorded. The type of recruitment response, the mean number of turns and the mean amplitude of recruitment potential were recorded when the subjects performed maximal voluntary contraction. The quantitative elbow flexor muscle strength was measured by portable microFET 2 Manual Muscle Tester. The percentage of residual elbow flexor muscle strength (the ratio of quantitative muscle strength of the injured side to the healthy side) was calculated. The differences of nEMG parameters, quantitative muscle strength and residual elbow flexor muscle strength between the two groups and between the injured side and the healthy side were compared. The correlation between elbow flexor manual muscle strength classification, quantitative muscle strength and nEMG parameters was analyzed., Results: After musculocutaneous nerve injury, the percentage of residual elbow flexor muscle strength in Group B was 23.43% and that in Group A was 4.13%. Elbow flexor manual muscle strength classification was significantly correlated with the type of recruitment response, and the correlation coefficient was 0.886 ( P <0.05). The quantitative elbow flexor muscle strength was correlated with the latency and amplitude of CMAP, the mean number of turns and the mean amplitude of recruitment potential, and the correlation coefficients were -0.528, 0.588, 0.465 and 0.426 ( P <0.05), respectively., Conclusions: The percentage of residual elbow flexor muscle strength can be used as the basis of muscle strength classification, and the comprehensive application of nEMG parameters can be used to infer quantitative elbow flexor muscle strength.

Brachial plexus injury is not uncommon in our country like Bangladesh and it causes functional damage and physical disability of the upper limbs. Most of the cases were caused by motor vehicle accident. We have conducted a prospective study for the operative treatment of 105 adult traumatic brachial plexus injury cases in Hand unit in the department of Orthopaedics, Bangabandhu Sheikh Mujib Medial University (BSMMU) during January 2012 to July 2019. The main surgical options for brachial plexus injury include primary reconstructive surgery such as neurolysis, direct repair, nerve graft, nerve transfer (neurotization) and possibly free functioning (gracilis) muscle transfer and secondary reconstructive procedure such as tendon transfer, arthrodesis, FFMT and bony procedure. Each of these procedures is used either alone or in combination for particular clinical scenarios. Aims and objectives of this study was to restoration of shoulder abduction and external rotation, elbow flexion and hand function are goal of treatment of adult traumatic brachial plexus injury. Age range was from 14 years to 55 years (mean age 26 years). Male were 95 and female were 10 cases. Time from trauma to surgery was valid 3 months to 9 months. Motor cycle accident was most common mechanism of injury. Upper plexus (C5, C6) injury was 52 cases, extended upper plexus (C5, C6 & C7) injury was 19 cases and global brachial plexus injury was 34 cases. When there is high suspicion of root avulsions, early exploration and reconstruction is indicated. Operate these patients 2-3 months after their injury. In other patients without high suspicion of root avulsion, we routinely perform exploration between 3 to 6 months after injury when no adequate sign of recovery are present. Common reconstructive options are any injury with neuroma in continuity with conductive nerve action potential (NAP): only neurolysis or any injury with nerve rupture or postganglionic neuroma not conducting nerve Action potential (NAP) and good proximal nerve: Direct repair or repair with nerve graft or nerve transfer if possible. Follow up period from 6 months to 6 years. The best results were obtained in C5, C6 and C5, C6 & C7 brachial plexus injury cases. SAN to SSN, Oberlin II and long head triceps motor branch to anterior division of axillary nerve transfer for C5 & C6 injury or upper plexus injury and in addition intercostals nerve to anterior division of axillary nerve and AIN branch of median nerve to ECRB for C5, C6 & C7 (extended upper plexus injury). Extra-plexus and intra-plexus neurotization was done in global brachial plexus injury cases and 5 cases by contra-lateral C7 to median nerve by vascularised ulnar nerve graft and only 2 cases contra-lateral C7 to lower trunk through pre spinal or pre tracheal route were done and only one case by FFMT. Few cases gain shoulder abduction and elbow flexion but no improvement of hand function and most cases even by FFMT still in follow up. Results of surgical treatment of upper and extended upper brachial plexus injury cases were satisfactory on the other hand recovery of shoulder abduction and elbow flexion was acceptable and comparable to other study in global brachial plexus injury and recovery of hand function were poor.

Objective: The spinal accessory nerve (SAN) is commonly used as a donor nerve for reinnervation of elbow flexors in brachial plexus injury (BPI) reconstruction. However, no study has compared the postoperative outcomes between SAN-to-musculocutaneous nerve (MCN) transfer and SAN-to-nerve to biceps (NTB) transfer. Thus, this study aimed to compare the postoperative time to recovery of elbow flexors between the two groups., Methods: A total of 748 patients who underwent surgical treatment for BPI between 1999 and 2017 were retrospectively reviewed. Among them, 233 patients were treated with nerve transfer for elbow flexion. Two techniques were used to harvest the recipient nerve: the standard dissection technique and the proximal dissection technique. The postoperative motor power of elbow flexion was assessed every month for 24 months using the Medical Research Council (MRC) grading system. Survival and Cox regression analyses were used to compare the time to recovery (MRC grade ≥ 3) between the two groups., Results: Of the 233 patients who underwent nerve transfer surgery, there were 162 patients in the MCN group and 71 patients in the NTB group. At 24 months after surgery, the MCN group had a success rate of 74.1%, and the NTB group had a success rate of 81.7% (p = 0.208). When compared with the MCN group, the NTB group had a significantly shorter median time to recovery (19 months vs 21 months, p = 0.013). Only 11.1% of patients in the MCN group regained MRC grade 4 or 5 motor power 24 months after nerve transfer surgery compared with 39.4% patients in the NTB group (p < 0.001). Cox regression analysis showed that the SAN-to-NTB transfer in combination with the proximal dissection technique was the only significant factor affecting time to recovery (HR 2.33, 95% CI 1.46-3.72; p < 0.001)., Conclusions: SAN-to-NTB transfer in combination with the proximal dissection technique is the preferred nerve transfer option for restoration of elbow flexion in traumatic pan-plexus palsy.

Background: To clarify the real risk of nerve injury during elbow arthroscopy, the distances of the radial and median nerves to the elbow joint were investigated using ultrasonography in patients who underwent surgery., Methods: A total of 35 patients who underwent arthroscopic surgery of the elbow were investigated. The distances of the nerves to the capsule and bony landmarks were measured using ultrasonography. The radial nerve distances were measured at the capitellum, joint space, radial head, and radial neck levels. The median nerve distances were measured at the trochlear, joint space, and coronoid process levels. The patients were divided into 2 groups: nine patients in the hydrarthrosis (HA) group and 26 patients in the non-hydrarthrosis (non-HA) group. HA was defined as the intra-articular effusion on magnetic resonance imaging scans., Results: The radial nerve ran closer to the capsule at the radial neck level in the HA group than in the non-HA group (2.0 mm vs. 5.9 mm, P < .01). In the non-HA group, the radial nerve ran closer to the radial head than in the HA group (6.3 mm vs. 8.5 mm, P = .01). The median nerve ran closer to the capsule at the trochlear level in the HA group than in the non-HA group (5.2 mm vs. 8.8 mm, P < .01). Nerves at a distance of ≤2 mm from the capsule were found in 7 patients at the radial neck of the radial nerve and in 2 patients at the trochlear region of the median nerve in the HA group. In the non-HA group, they were found in 3 patients at the radial head and in 1 patient at the joint space of the radial nerve., Conclusions: The dangerous locations for nerve injury during elbow arthroscopy vary according to hydrarthrosis, and this risk should be recognized during arthroscopic surgery., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

The radial nerve is the biggest branch of the posterior cord of the brachial plexus and one of its five terminal branches. Entrapment of the radial nerve at the elbow is the third most common compressive neuropathy of the upper limb after carpal tunnel and cubital tunnel syndromes. Because the incidence is relatively low and many agents can compress it along its whole course, entrapment of the radial nerve or its branches can pose a considerable clinical challenge. Several of these agents are related to normal or variant anatomy. The most common of the compressive neuropathies related to the radial nerve is the posterior interosseus nerve syndrome. Appropriate treatment requires familiarity with the anatomical traits influencing the presenting symptoms and the related prognoses. The aim of this study is to describe the compressive neuropathies of the radial nerve, emphasizing the anatomical perspective and highlighting the traps awaiting physicians evaluating these entrapments., (© 2023. The Author(s).)

Purpose: Elbow flexion is one of the most important functions to restore following brachial plexus damage. The authors sought to systematically review available evidence to summarize outcomes of free gracilis and non-free muscle transfers in restoring elbow flexion., Methods: MEDLINE, EMBASE, and Cochrane were searched to identify articles reporting on elbow flexion reanimation in terms of transfer failure rates, strengths, range of motion (ROM), and/or Disabilities of the Arm, Shoulder and Hand (DASH) scores. A systematic review was chosen to select studies and reported according to PRISMA guidelines., Results: Forty-six studies met the inclusion criteria for this study. A total of 432 cases were gracilis free-flap muscle transfers (FFMT), and 982 cases were non-free muscle transfers. FFMT were shown to have higher Medical Research Council (MRC) strength scores than non-free muscle transfer groups. However, 42 studies, totaling 1,266 cases, were useful in evaluating graft failure, showing failure (MRC<3) in 77/419 (∼18.4%) of gracilis free-flap transfers and 215/847 (∼25.4%) of non-free muscle transfers. Sixteen articles, 285 cases, were useful to evaluate ROMs (total range: 0-140°), and eight articles, 215 cases, provided DASH scores (total range: 8-90.8)., Conclusions: Of patients who underwent gracilis FFMT procedures, higher mean strength scores and lower failure rates were observed when compared with non-free muscle transfers. Articles reporting non-free muscle transfer procedures (pectoralis, pedicled, Steindler, vascularized ulnar nerve grafts, Oberlin, single/double nerve transfers) provided comprehensive insight into outcomes and indicated that they may result in pooerer poorer DASH scores and ROM., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest directly or indirectly related to the work presented herein. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction/aims: Hypertrophic triceps brachii contributes to ulnar nerve movement, but the location of the mass effect of the triceps brachii muscle is not known. In this study we aimed to determine the mass effect of the distal medial head of the triceps brachii (DMTB) muscle on ulnar nerve movement., Methods: In 48 arms, movement of the ulnar nerve at the medial epicondyle and muscle thickness (medial and long head of the triceps brachii [MLTB], medial head of the triceps brachii [MTB], DMTB, and biceps brachii [BB]) were measured using ultrasonography., Results: Ulnar nerve movement at the elbow was consistently correlated with the DMTB muscle thickness (horizontal ulnar nerve movement at the elbow [HM] / vertical ulnar nerve movement at the elbow [VM] with 90° elbow flexion: r = 0.668 / r = 0.313, HM/VM with full elbow flexion: r = 0.481 / r = 0.391). With multiple linear regression, the DMTB was the most important muscle with regard to contribution of thickness to ulnar nerve movement. Individuals with partial and complete dislocation showed a thicker DMTB than those without dislocation., Discussion: Our data suggest that the mass effect of the triceps brachii muscle is exerted primarily by its distal portion. When ulnar nerve dislocation is observed, thickness and anatomical variation of DMTB in the retrocondylar area during elbow flexion should be assessed., (© 2022 Wiley Periodicals LLC.)

Elbow flexion paralysis is one of most significant deficiencies in the upper limb. When secondary to brachial plexus palsy or nerve trunk lesions, restoration of elbow flexion by means of early nerve surgery or palliative transfers should be part of a comprehensive treatment plan. Tendon transfers are indicated in long-standing palsies, in those who are poor candidates for nerve surgery or when the results of nerve surgery are inadequate. A regional pedicled muscle transfer is performed if available. In this case, a "strong" donor is preferred (pectoralis major with pectoralis minor transfer, triceps brachii to biceps brachii transfer, or bipolar latissimus dorsi transfer). A "weak" transfer is indicated in patients who have incomplete recovery of elbow flexion (MRC 2 strength): isolated pectoralis minor transfer, medial epicondylar muscle transfer according to Steindler technique, or advancement of biceps brachii tendon on forearm. When no donor muscle is available, a free reinnervated muscle transfer may be indicated if age and nerve regeneration conditions are favorable., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Elbow extension palsy is generally well tolerated, because when standing up, it is alleviated by gravity. In the case of trunk paralysis or brachial plexus palsy, standing is possible, thus the restoration of active elbow extension improves the hand's positioning above the shoulder, and allows the elbow to be locked in extension, which is necessary during certain activities such as cycling. In these palsy cases, the triceps brachii will be reinnervated by nerve transfers if surgery is performed early enough before irreversible atrophy of the effector muscle sets in. In these situations, secondary tendon transfers are rarely indicated. Few available muscles can be harvested without deleterious consequences on the donor site. Finally, in patients with a very deficient upper limb but with a healthy contralateral limb, when nerve transfers are no longer possible, elbow extension will not be restored. In the tetraplegics using a wheelchair, elbow extension becomes essential for positioning the hand in space and for potentiating the transferable muscles to activate the hand. As nerve transfers have rare indications and are currently being validated in this population, palliative tendon transfers are the reference technique. They must be integrated into an overall upper limb reconstructive surgery program that takes into consideration the potentially usable muscles and the presence of elbow flexion contracture and supination deformity of the forearm. Elbow extension restoration techniques are based on the transfer of two muscles, the posterior deltoid and the biceps brachii. The first is very effective and has very specific requirements, notably good anterior stabilization of the shoulder by the pectoralis major, while the second has broader indications, notably in the case of elbow contracture and inability to stabilize the shoulder anteriorly., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Purpose: Total elbow arthroplasty for the treatment of patients with severe elbow osteoarthritis is associated with postoperative activity limitations and risk of midterm complications. Elbow denervation could be an attractive therapeutic option for young, active patients. The aim of our study was to assess the feasibility of selective total elbow denervation via 2 anteriorly based approaches., Methods: Selective total elbow denervation was performed in 14 cadaver elbows by 2 fellowship-trained elbow surgeons. Lateral and medial approaches to the elbow were used. The length of skin incisions and the minimum distance between them were noted. The number of articular branches identified and their respective distances from the lateral or medial epicondyle of the humerus were recorded., Results: The anterolateral and anteromedial approaches allowed for the identification of all mixed and sensory nerves in all 14 cases. The mean number of resultant articular branches per cadaver was 1 for the musculocutaneous nerve, 2 (range, 1-3) for the radial nerve, 1 (range, 1-3) for the posterior cutaneous nerve of the forearm, 2 (range, 1-3) for the ulnar nerve, and 2 (range, 1-3) for the medial antebrachial cutaneous nerve; the collateral ulnar nerve was connected directly to the capsule. The length of the medial and lateral incisions was 15 cm (range, 12-18 cm) and 12 cm (range, 10-16 cm), respectively. The mean minimum distance between the incisions was 7.5 cm (range, 6.7-8.5 cm)., Conclusions: The findings suggest that selective elbow denervation via 2 approaches is feasible., Clinical Relevance: Selective elbow denervation via 2 approaches is feasible. Surgeons should target the articular branches of the musculocutaneous, radial, ulnar, and collateral ulnar nerves, posterior cutaneous nerve of the forearm, as well as medial antebrachial cutaneous nerves when carrying out this procedure., (Copyright © 2022 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Traumatic brachial plexus injuries (BPIs) often lead to devastating upper extremity deficits. Treatment frequently prioritizes restoring elbow flexion through transfer of various donor nerves; however, no consensus identifies optimal donor nerve sources., Objective: To complete a meta-analysis to assess donor nerves for restoring elbow flexion after partial and total BPI (TBPI)., Methods: Original English language articles on nerve transfers to restore elbow flexion after BPI were included. Using a random-effects model, we calculated pooled, weighted effect size of the patients achieving a composite motor score of ≥M3, with subgroup analyses for patients achieving M4 strength and with TBPI. Meta-regression was performed to assess comparative efficacy of each donor nerve for these outcomes., Results: Comparison of the overall effect size of the 61 included articles demonstrated that intercostal nerves and phrenic nerves were statistically superior to contralateral C7 (cC7; P = .025, <.001, respectively) in achieving ≥M3 strength. After stratification by TBPI, the phrenic nerve was still superior to cC7 in achieving ≥M3 strength (P = .009). There were no statistical differences among ulnar, double fascicle, or medial pectoral nerves in achieving ≥M3 strength. Regarding M4 strength, the phrenic nerve was superior to cC7 (P = .01) in patients with TBPI and the ulnar nerve was superior to the medial pectoral nerve (P = .036) for partial BPI., Conclusion: Neurotization of partial BPI or TBPI through the intercostal nerve or phrenic nerve may result in functional advantage over cC7. In patients with upper trunk injuries, neurotization using ulnar, median, or double fascicle nerve transfers has similarly excellent functional recovery., (Copyright © Congress of Neurological Surgeons 2021. All rights reserved.)

Joint torque feedback is a new and promising means of kinesthetic feedback imposed by a wearable device. The torque feedback provides the wearer temporal and spatial information during a motion task. Nevertheless, little research has been conducted on quantifying the psychophysical parameters of how well humans can perceive external torques under various joint conditions. This study aims to investigate the just noticeable difference (JND) perceptual ability of the elbow joint to joint torques. The paper focuses on the ability of two primary joint proprioceptors, the Golgi-tendon organ (GTO) and muscle spindle (MS), to detect elbow torques, since touch and pressure sensors were masked. We studied 14 subjects while the arm was isometrically contracted (static condition) and was moving at a constant speed (dynamic condition). In total there were 10 joint conditions investigated, which varied the direction of the arm's movement and the preload direction as well as torque direction. The JND torques under static conditions ranged from 0.097 Nm with no preload to 0.197 Nm with a preload of 1.28 Nm. The maximum dynamic JND torques were 0.799 Nm and 0.428 Nm, when the arm was flexing and extending at 213 degrees per second, respectively., (© 2021. The Author(s).)

The development of outcome measures that can track the recovery of reinnervated muscle would benefit the clinical investigation of new therapies which hope to enhance peripheral nerve repair. The primary objective of this study was to assess the validity of volumetric Magnetic Resonance Imaging (MRI) as an outcome measure of muscle reinnervation by testing its reproducibility, responsiveness and relationship with clinical indices of muscular function. Over a 3-year period 25 patients who underwent nerve transfer to reinnervate elbow flexor muscles were assessed using intramuscular electromyography (EMG) and MRI (median post-operative assessment time of 258 days, ranging from 86 days pre-operatively to 1698 days post- operatively). Muscle power (Medical Research Council (MRC) grade) and Stanmore Percentage of Normal Elbow Assessment (SPONEA) assessment was also recorded for all patients. Sub-analysis of peak volitional force (PVF), muscular fatigue and co-contraction was performed in those patients with MRC > 3. The responsiveness of each parameter was compared using Pearson or Spearman correlation. A Hierarchical Gaussian Process (HGP) was implemented to determine the ability of volumetric MRI measurements to predict the recovery of muscular function. Reinnervated muscle volume per unit Body Mass Index (BMI) demonstrated good responsiveness (R 2  = 0.73, p < 0.001). Using the temporal and muscle volume per unit BMI data, a HGP model was able to predict MRC grade and SPONEA with a mean absolute error (MAE) of 0.73 and 1.7 respectively. Muscle volume per unit BMI demonstrated moderate to good positive correlations with patient reported impairments of reinnervated muscle; co- contraction (R 2  = 0.63, p = 0.02) and muscle fatigue (R 2  = 0.64, p = 0.04). In summary, volumetric MRI analysis of reinnervated muscle is highly reproducible, responsive to post-operative time and demonstrates correlation with clinical indices of muscle function. This encourages the view that volumetric MRI is a promising outcome measure for muscle reinnervation which will drive advancements in motor recovery therapy., (© 2021. The Author(s).)

Objective: To systematically review the association between ulnar nerve hypermobility (UNH) at the elbow and ulnar neuropathy (UNE)., Data Sources: Cumulative Index to Nursing and Allied Health, MEDLINE, and Embase databases were searched for English language studies published up to July 4, 2020., Study Selection: We included case-control, cohort, and randomized controlled studies that established the presence or absence of UNH and UNE. Twenty out of 654 studies identified met the inclusion criteria., Data Extraction: Two reviewers independently extracted data for analysis. Risk of bias and applicability were assessed with the QUADAS-2 tool., Data Synthesis: We compared rates of UNH between patients diagnosed with and without UNE and found no significant difference. The meta-analysis pooled rate of UNH was 0.37 (95% confidence interval, 0.20-0.57) for those without UNE and 0.33 (95% confidence interval, 0.23-0.45) for those with UNE., Conclusions: The clinical finding of UNH is unhelpful when assessing for UNE, as the presence of UNH does not make the diagnosis of UNE more likely., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of the present study is to describe in detail the morphology and innervation pattern of the anconeus muscle, bearing in mind clinical implications such as iatrogenic injuries during surgical elbow approaches., Methods: A cadaveric study was performed; 56 elbows from 28 formalin-fixed cadavers belonging to the Anatomy Department of Universidad Complutense of Madrid were dissected. The triceps-anconeus nerve was located and dissected. A second innervation to the anconeus muscle from a branch of the posterior interosseous nerve (PIN) was occasionally detected. Taking the lateral epicondyle as a landmark, the entry points of both nerves in the muscle were referenced, the triceps-anconeus nerve was referenced at 0°, 30°, 45°, 70° and 90° of elbow flexion, and the PIN branch at 0°., Results: Anconeus muscle was present in all specimens. The triceps-anconeus nerve was present in all of the dissected elbows. A branch from PIN to the anconeus muscle was present in 38 of the 54 elbows (70.4%). There were statistically significant differences in all measurements regarding the specimens' gender, being higher for men., Conclusions: There is evidence of a high frequency of a double innervation pattern for the anconeus muscle: the main branch of triceps-anconeus muscle depending on the radial nerve, which is liable to being damaged during posterior elbow approaches, and a secondary branch depending on the PIN. There are very few references to this finding in Anatomical literature and none with such a large sample size., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk., Methods: We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment., Results: Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement., Conclusions: In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G405)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

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.

The pathogenesis of ulnar nerve subluxation and dislocation is widely debated. Upon elbow flexion, the ulnar nerve slips out of the groove for the ulnar nerve, relocates medial or anterior to the medial epicondyle, and returns to its correct anatomical position upon extension. This chronic condition can cause neuritis or neuropathy; however, it has also been suggested that it protects against neuropathy by reducing tension along the nerve. This article reviews the extant literature with the aim of bringing knowledge of the topic into perspective and standardizing terminology.

Based on the currently available literature, total denervation of the elbow joint is considered impossible. However, consensus with respect to the anatomic location of sensory branches is lacking. The aim of this literature review was to establish consensus with respect to the anatomic features of the articular branches innervating the elbow joint, as well as the distribution of sensory receptors about its capsule. Four electronic databases were queried, between January 1945 and June 2019. Twenty-one original articles providing a detailed description of the distribution of sensory receptors about the elbow joint capsule (5) and its articular branches (16) were reviewed. The posterior capsule was found to be primarily innervated by the ulnar and radial nerves via combined articular branches and sensory branches of the medial antebrachial cutaneous nerve. The anterior capsule was found to be primarily innervated by a plexus of articular ramifications from muscular branches of mixed nerves (ulnar, musculocutaneous, radial, and median nerves). A higher density of nociceptors and mechano-receptors was identified within the posterior and anterior capsules, respectively. Thorough denervation, via the technique proposed herein, is likely to be sufficient in eliminating pain from degenerative conditions of the elbow joint., (© 2019 Wiley Periodicals, Inc.)

Purpose: The aim of this study was to investigate the superficial head of supinator muscle (SM) and deep branch of the radial nerve (DBRN) course in SM to see whether the texture characteristics of the superficial head of SM might have a potential compressive effect on the nerve., Materials and Methods: Elbow and proximal forearm region of 20 preserved cadavers (n 40, 12 M, 8 F) were dissected in order to measure total and part of DBRN lengths between some reference points. The texture characteristics of both the proximal (where DBRN enters SM) and distal arcade (where DBRN exits SM) of the superficial head of SM were evaluated based on its structure's being muscular, musculotendinous, tendinous, or membranous., Results: The total length of DBRN between sexes without taking side (L/R) into consideration (P = 0.030) and left radiocapitellar joint (RCJ)-arcade of Frohse (AF) length between sexes (P = 0.050) were statistically significant. There was a gradual increase in caliber getting more flattened in every consecutive level which was statistically significant when every two consecutive levels were compared. When compared according to the texture type, there were also significant differences., Conclusions: Flattening of DBRN in the supinator canal suggests a chronic compression on the nerve. Differences in the texture of the superficial head of the supinator might facilitate this compression. An understanding of the anatomy and nerve topography is of utmost importance in the accurate diagnosis and effective management of peripheral nerve compression.

External fixation is a common, efficient technique used for humeral shaft stabilization and elbow fractures. There are reports of radial nerve injuries associated with this procedure. In this study, we investigated the course and variability of the radial nerve along the lateral humerus in relation to the elbow joint to determine a relatively safe zone for lateral pin placement in external fixation. Twenty upper extremities from 10 cadavers were studied. The nerve branches and course of the radial nerve along the lateral humerus were carefully dissected. Straight lines (a, b, and c) were made connecting three landmarks (the acromion, coracoid process, and anterior wall of the axilla) in the proximal upper extremity to the lateral condyle (LC) of the humerus; their intersections with the radial nerve (A, B, and C) were marked. We analyzed whether the intersection positions were correlated with the connecting line lengths. The mean lengths of the connecting lines were (a) 27.24 ± 2.57, (b) 26.18 ± 2.79, and (c) 20.95 ± 1.44 cm; the distance between the intersection points and the LC of the humerus were (Aa) 7.56 ± 1.31, (Bb) 6.90 ± 2.27, and (Cc) 5.01 ± 0.83 cm; and the measured intersection points of the radial nerve in the lateral aspect of the humerus were (A) 18.48%-34.82%, (B) 13.48%-40.00%, and (C) 19.27%-28.05% of the lengths of lines a, b, and c, respectively. Our data provide a more reliable reference to predict the course of the radial nerve on the lateral humerus and define a safe zone for pin placement. Clin. Anat., 33:637-642, 2020. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

Introduction: In individuals with tetraplegia, elbow extension is critical for overhead activities, weight shifting, independent transfers, and to perform self-care tasks such as eating. At present, restoration of elbow extension in tetraplegic patients can be performed using either tendon or nerve transfers. Each procedure presents several advantages and limitations that must be discussed with the potential surgical candidate, based on remaining muscular functions and functional goals., Case Presentation: We propose a novel combined technique of both tendon and nerve transfer to restore active elbow extension by transferring the posterior deltoid tendon to the triceps tendon and the branch of teres minor nerve to the long head of the triceps nerve. Techniques were performed from the same shoulder posterior surgical approach., Discussion: This surgical technique can add the benefits of each tendon and nerve transfer, leading to a reduction of failure rates, with more predictable outcomes.

Introduction: In this study we tested the hypothesis that fascicular constrictions (FCs) of the median nerve proximal to the elbow joint characterize anterior interosseous nerve syndrome (AINS)., Methods: Magnetic resonance neurography (MRN) and ultrasound (US) examinations were evaluated in 45 patients with clinically suspected AINS. All 22 patients at site 1 underwent MRN and 8 underwent US; all 23 patients at site 2 underwent US., Results: Median nerve FCs were identified in all MRN cases; FCs and/or fascicular enlargements were identified in 88% of US cases. Most FCs were in the mediannerve posterior/posteromedial region and were proximal to the elbow joint line (mean distance: MRN, 5.4 cm; US, 7.5 cm), with the exception of a single FC (located 1 cm distal). No extrinsic compression of median or anterior interosseous nerves was identified in the arm or forearm., Discussion: AINS is a noncompressive neuropathy characterized by median nerve FCs in the arm., (© 2019 Wiley Periodicals, Inc.)

Free functional gracilis transfer is a well-established technique for restoring active elbow flexion in brachial plexus injuries following delayed presentation or failed nerve reconstruction procedures. In cases of delayed presentation or failed nerve reconstruction following upper trunk injuries, the lower trunk intraplexal median and ulnar nerves are spared, thereby making them available to reinnervate the transferred gracilis. Therefore, we have inverted the conventional free functional gracilis orientation so as to orient the flap's recipient nerve in closer proximity to donor median or ulnar nerve fascicles to enable a short, tension-free coaptation in the middle to distal arm. Herein is our descriptive surgical technique for performing an inverted free functional gracilis muscle transfer in order to restore elbow flexion in the setting of an upper trunk injury.

Background: Various pathological elbow lesions are often complicated with ulnar neuropathy at the elbow (UNE), although the precise pathology, incidence, and clinical and neurological features of these lesions have not been identified. We therefore investigated elbow pathology and neurological severity in Japanese patients with UNE., Methods: The medical records of 457 Japanese UNE patients who were surgically treated among 6 hospitals were retrospectively examined. Eligible patients had UNE diagnosed by physical findings and nerve conduction studies according to the criteria of the American Association of Electrodiagnostic Medicine. The elbows were analyzed with regard to age, gender, occupation, pathology at the elbow, and severity of nerve palsy., Results: A total of 398 patients with 413 UNE elbows of a mean age of 63 years (range: 15-87) met the inclusion criteria. UNE elbows were predominantly in male patients (69.0%). Overall, 310 elbows (75.1%) had 1 or more elbow lesions: 238 elbows (76.8%) had a single lesion and 72 elbows (23.3%) had 2 or more lesions. The most common lesion was primary elbow osteoarthritis (EOA) occurring in 54.5% of elbows, followed next by medial elbow ganglion in 8.5% and cubitus valgus in 6.5%. Most elbows with medial elbow ganglion or cubitus valgus were associated with EOA. Entrapment sites were at the cubital tunnel in 84.5%-91.3% of UNE elbows, regardless of an association with elbow lesion. The incidence of McGowan grade III lesion was 50.8% in elbows with primary EOA, which was higher than the 35.0% in elbows with no lesion., Conclusions: This study revealed that UNE had various isolated or combined elbow lesions. In Japanese UNE, primary or secondary EOA was found in 62.2% of cases and severe motor weakness was noted in 47.2%. The incidences of EOA and severe ulnar nerve palsy in the Japanese UNE are higher than those in Caucasians., Level of Evidence: Level IV; Prognostic-Investigating the effect of a patient characteristic on the outcome of a disease; Case series., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Ulnar neuropathy is a common reason for referral to hand surgeons, and 10 to 30% of cubital tunnel syndrome (CuTS) is idiopathic. We hypothesized that the cause of idiopathic CuTS is in the bony structure., Methods: We analyzed 79 elbows (39 idiopathic CuTS and 40 without CuTS symptom) using computed tomography and Materialize Mimics software to compare the differences between the two groups. We proposed a new bony cubital tunnel with a new boundary that could play a role in ulnar nerve compression symptom., Results: The mean cubital tunnel volume was 1245.6 mm 3 in all patients, 1180.6 mm 3 in CuTS patients, and 1282.3 mm 3 in the control group. A significant difference (p = 0.015) between two groups was found. Bony cubital tunnel cross-sectional area, cubital tunnel depth, and cubital tunnel angle also showed significant differences., Conclusion: The shape of the bony cubital tunnel is an important cause of CuTS, and the normal variation of the volume and cross-sectional area of the cubital tunnel and cubital tunnel angle could influence the occurrence of idiopathic CuTS.

Background: The aim of the study was to investigate the anatomy of the anterior nerve and artery of the elbow joint to provide reference on the relevant surgical approach to the elbow joint, and determine a simple better surgical approach for the treatment of part of the fractures of the elbow joint., Materials and Methods: The upper extremities of 10 adult cadavers fixed by formaldehyde and perfused with red latex in the artery were observed to investigate the anatomic structure of the anterior approach to the elbow joint. From the clearance of the brachioradialis and pronator teres muscle to the approach of the neurovascular interval, we observed the states of the median nerve, the brachial, radial and ulnar arteries, and its branches through anatomical layers and measurement methods., Results: Through the anterior neurovascular interval approach to the elbow, nerve and artery can be protected, and the anterior structures of the elbow, such as the ulna coronoid process, humeroulnar joint and trochlea of the humerus, can be exposed., Conclusions: This study demonstrates that the anterior anatomical structure of the elbow joint including the trochlea of the humerus, coronoid process of the ulna and the front capsule of the elbow can be exposed through the anterior neurovascular approach to the elbow.

Elbow flexion is the first goal in upper partial brachial plexus palsy treatment. However, elbow extension is essential for daily living activities. To recover this function, one fascicle of ulnar nerve can be transferred to the branch of the long head of the triceps, but this procedure has been previously published in only two patients. The goal of our study is to assess a larger series of transfers of one fascicle of ulnar nerve to the branch of the long head of the triceps to help patients recover elbow extension. Ten male patients with C5, C6 and C7 brachial plexus injuries underwent operation. For shoulder recovery, we transferred the spinal accessory nerve and rhomboid nerve. For elbow flexion, one fascicle of median nerve was transferred to the nerve of the biceps. For elbow extension, we transferred one fascicle of ulnar nerve to the branch of the long head of the triceps. Tendon transfers were performed for wrist and finger extension. Nine patients recovered M4 elbow flexion and extension. One patient had M3 elbow extension and flexion. Average active shoulder elevation was 85° and average active shoulder external rotation was 65° All patients recovered finger and wrist extension. The classical techniques of grafts or phrenic or intercostal nerve transfers to recover elbow extension are not always reliable, according to the literature. Because the harvested ulnar nerve motor fascicle is close to the branch of the long head of the triceps, the recovery time for this procedure is shorter than that of other described nerve transfers. The isolated recovery of the reinnervated long head of the triceps muscle excludes spontaneous recovery occasionally noted in upper root plexus injuries. The transfer of one fascicle of ulnar nerve to the branch of the long head of the triceps is reliable for active elbow extension recovery in C5, C6 and C7 brachial plexus palsies., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Loss of elbow flexion commonly occurs following acute brachial plexus injury. The double fascicular transfer is often used in acute C5-C6 and C5-C7 root injuries, but is rarely applied in cases involving concomitant C8 or T1 root injury. The authors designed a rat model using varying severities of lower trunk injury to determine whether partial injury to the lower trunk affects nerve transfers for elbow flexion., Methods: There were four different rat groups in which 0, 25, 75, or 100 percent of the donor lower trunk remained intact. One-fourth of the cross-sectional area of the ulnar nerve was then transferred to the musculocutaneous nerve immediately. The authors assessed outcomes using a grooming test, muscle mass, retrograde labeling of sensory/motor neurons that regenerated axons, and immunohistochemical stain of regenerated axons., Results: Five months after nerve transfer, rats that underwent partial injury of the lower trunk fared significantly worse than the rats in whom the donor lower trunk remained 100 percent intact, but significantly better than the rats with 0 percent intact lower trunk. Rats with 25 or 75 percent of the lower trunk intact recovered equivalent function, at both the donor and recipient sites., Conclusions: Although relatively weak compared with the 100 percent intact donor lower trunk group, the partially injured donor nerve was still functional; even though the nerve sustained a partial injury, the residual axons reinnervated the target muscles. The power of the muscles following either 25 percent or 75 percent injuries was equal after the recovery. Resorting to this approach may be useful in cases in which no alternatives are available.

Study Design: Randomised, controlled, crossover study., Objectives: Paired corticospinal-motoneuronal stimulation (PCMS) involves repeatedly pairing stimuli to corticospinal neurones and motoneurones to induce changes in corticospinal transmission. Here, we examined whether PCMS could enhance maximal voluntary elbow flexion in people with cervical spinal cord injury., Setting: Neuroscience Research Australia, Sydney, Australia., Methods: PCMS comprised 100 pairs of transcranial magnetic and electrical peripheral nerve stimulation (0.1 Hz), timed so corticospinal potentials arrived at corticospinal-motoneuronal synapses 1.5 ms before antidromic motoneuronal potentials. On two separate days, sets of five maximal elbow flexions were performed by 11 individuals with weak elbow flexors post C4 or C5 spinal cord injury before and after PCMS or control (100 peripheral nerve stimuli) conditioning. During contractions, supramaximal biceps brachii stimulation elicited superimposed twitches, which were expressed as a proportion of resting twitches to give maximal voluntary activation. Maximal torque and electromyographic activity were also assessed., Results: Baseline median (range) maximal torque was 11 Nm (6-41 Nm) and voluntary activation was 92% (62-99%). Linear mixed modelling revealed no significant differences between PCMS and control protocols after conditioning (maximal torque: p = 0.87, superimposed twitch: p = 0.87, resting twitch: p = 0.44, voluntary activation: p = 0.36, biceps EMG: p = 0.25, brachioradialis EMG: 0.67)., Conclusions: Possible explanations for the lack of effect include a potential ceiling effect for voluntary activation, or that PCMS may be less effective for elbow flexors than distal muscles. Despite results, previous studies suggest that PCMS is worthy of further investigation.

Purpose: To systematically review available literature comparing location and safety of 2 common anteromedial portals with nearby neurovascular structures in cadaveric models and to determine the correct positioning and preparation of the joint before elbow arthroscopy., Methods: The review was devised in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inclusion criteria consisted of original, cadaveric studies performed by experienced surgeons on male or female elbows evaluating anteromedial portal placement with regard to proximity of the arthroscope to neurovascular structures. Exclusion criteria consisted of case reports, clinical series, non-English language studies, and noncadaveric studies. Statistical analysis was done to measure reviewer reliability after scoring of each study., Results: During screening, 2,596 studies were identified, and 10 studies met final inclusion as original, cadaveric investigations of anteromedial portal proximity to neurovascular structures. The difference in distance between proximal and distal portals was <1 mm for the brachial artery and <1.5 mm for the medial antebrachial cutaneous nerve, whereas the ulnar nerve was 4.17 mm further from the distal portal and the median nerve was 5.07 mm further from the proximal portal. Joint distension increased the distances of neurovascular structures to portal sites, with the exception of the ulnar nerve in distal portals. Elbow flexion to 90° increased distances of all neurovascular structures to portal sites., Conclusion: The results show that the proximal anteromedial portal puts fewer structures at risk compared with the distal portal. Elbows in 90° flexion with joint distension carry a lower risk for neurovascular injury during portal placement. These findings suggest the proximal anteromedial portal to be the safer technique in anteromedial arthroscopy of the elbow., Clinical Relevance: Discrepancies in placement of portals have existed in the literature, indicating differing safety margins regarding surrounding neurovascular anatomy. The present study aims to link together the literature-based evidence to describe the safest anteromedial portal variation., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Infants with brachial plexus birth injury who do not recover motor function spontaneously in a timely manner are candidates for brachial plexus reconstruction with nerve autograft. Outcomes of this intervention are incompletely understood. The authors present the long-term outcomes of brachial plexus reconstruction with sural nerve autograft in infants with brachial plexus birth injury., Methods: The authors retrospectively reviewed all infants with brachial plexus birth injury who underwent brachial plexus reconstruction with sural nerve autograft between 1992 and 2014 with a minimum 2-year follow-up. The authors used Active Movement Scale scores to determine the presence and timing of shoulder, elbow, and wrist recovery. They assessed recovery of hand function in infants with global brachial plexus birth injury with the Raimondi scale. The number and type of secondary reconstructive procedures were identified., Results: Forty-three infants who underwent brachial plexus reconstruction at age 7 ± 2 months old were followed for 7 ± 5 years. Most infants recovered antigravity elbow flexion (91 percent) and shoulder abduction (67 percent), but fewer recovered antigravity shoulder external rotation (19 percent) and wrist extension (37 percent). Mean postoperative times until observed antigravity motor strength (Active Movement Scale score >5) at the shoulder, elbow, and wrist were all greater than 12 months; evidence of initial motor recovery (Active Movement Scale score >2) was observed earlier. The mean Raimondi score in infants with global brachial plexus birth injury was 2.2 (range, 0 to 5) at final follow-up. Thirty-three children underwent 2 ± 1.2 secondary reconstructive procedures., Conclusions: Brachial plexus reconstruction with sural nerve autograft reliably results in recovery of shoulder abduction and elbow flexion, but recovery of shoulder external rotation and wrist extension is less predictable, and recovery often takes more than 1 year. Secondary procedures are often performed to optimize function., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Recent anatomic studies have failed to demonstrate a single utilitarian approach to intraoperative identification and surgical release of all 5 potential sites of posterior interosseous nerve (PIN) compression in the radial tunnel. This study examines if a single incision brachioradialis-splitting approach without the use of additional anatomic windows is capable of adequately exposing the entire length of the radial tunnel, including all 5 sites of PIN compression to allow for adequate release., Methods: Ten fresh frozen cadaver forearms (6 female, 4 male) were dissected utilizing a curvilinear 7 cm incision over the brachioradialis. The muscle belly was split via simple blunt retraction, exposing the radial tunnel. The PIN was identified and mobilized at 5 compression sites: radiocapitellar joint (RCJ), radial recurrent vessels (Leash of Henry), fibrous medioproximal edge of extensor carpe radialis brevis, arcade of Frohse, and distal edge of supinator., Results: The PIN was identified and effectively released in all specimens without difficulty from this single approach. All 5 sites of compression were visible and accessible through the brachioradialis-split approach. Specifically, there was no difficulty in identifying and releasing the PIN at the distal edge of supinator., Conclusions: Radial tunnel syndrome is defined as PIN compression within the radial tunnel spanning from the fibrous RCJ to the distal edge of the supinator. A single brachioradialis-splitting approach is adequate for complete visualization and release of all compression sites of the radial tunnel. Utilizing this technique allows for surgical access and ease as well as minimizing necessity for additional windows or multiple incisions.

Background: Isolated ulnar nerve decompression/transposition is an uncommon surgical procedure among professional baseball players., Purpose/hypothesis: To determine performance and rate of return to sport (RTS) among professional baseball players after isolated ulnar nerve decompression/transposition, including those who required decompression/transposition after ulnar collateral ligament reconstruction (UCLR), and to compare outcomes between cases and matched controls. The authors hypothesized a high rate of RTS among professional baseball players undergoing isolated ulnar nerve decompression/transposition with no difference in RTS rate or performance between cases and controls as related to earned run average, WHIP ([walks + hits]/innings pitched), wins above replacement, and on base + slugging percentage., Study Design: Cohort study; Level of evidence, 3., Methods: Utilizing the injury database of Major League Baseball, we identified all professional baseball players who underwent isolated ulnar nerve decompression/transposition between 2010 and 2016. De-identified demographic and performance data (before and after surgery) for each player were recorded from Major League Baseball records. Performance metrics were then compared between cases and matched controls., Results: The study included 52 players; 83% were pitchers; and 14 underwent prior UCLR. Most surgical procedures (92%) were anterior subcutaneous transpositions. Overall, 62% of players were able to successfully RTS, and 56% returned to the same or higher level. There was no significant difference between cases and controls in the majority of pre- and postoperative performance metrics-specifically, earned run average, WHIP, wins above replacement, and on base + slugging percentage. When players who had UCLR before ulnar nerve decompression/transposition were compared with controls with a history of UCLR but no subsequent ulnar nerve decompression/transposition, the only performance difference of all the recorded metrics was that cases allowed more walks per 9 innings (4.4 vs 2.8, P = .011)., Conclusion: Anterior subcutaneous transposition is the most common surgical procedure among professional baseball players to address ulnar neuropathy at the elbow. Players have a 62% rate of RTS, which is lower than expected for this nonreconstruction or repair procedure. For players who successfully RTS, performance metrics versus matched controls remained the same except for allowing significantly more walks per 9 innings. Postoperatively, pitchers with UCLR before ulnar nerve decompression/transposition who had a successful RTS performed the same as matched controls with prior UCLR without subsequent ulnar nerve decompression/transposition.

Study Design: Retrospective cohort study., Introduction: A new method of accurately assessing the compromised elbow's proprioception was developed for this postsurgical population using information from previous neurophysiologic proprioception studies of healthy elbows., Hypothesis: This retrospective cohort study investigated the patterns and the degree of proprioceptive impairment and recovery following arthroscopic surgery for chronic lateral epicondylitis., Material and Methods: Participants had undergone arthroscopic elbow surgery two years prior to this study (n=15). Healthy, non-injured volunteers with similar demographics (n=15) served as controls. Both groups were evaluated using quantitative measures of joint position sense for proprioceptive functioning. In order to obtain the most accurate proprioceptive measurements, interindividual interaction and visual input biases were eliminated. Retrospective chart reviews were performed to compare qualitative self-reported measures of proprioceptive function in arthroscopic surgery patients before surgery and two years post-surgery., Results: Active and passive joint repositioning outcome measurements were similar between groups (p>0.05). No significant differences were found among any angles except one: passive joint position sense at 120° of flexion (p<0.05). At this angle, the arthroscopy group showed greater deviation from target angles than the control group. The novel proprioceptive testing method we developed was found to be accurate and reliable., Discussion: Outcomes of arthroscopic treatment of chronic lateral epicondylitis with no decortication yielded outcomes measure similar to those of healthy controls. The sole significant difference was at 120° flexion passive joint repositioning, with a higher negative angular deviation from the target point. We propose that our study results and specific proprioception method may have implications for improving accuracy of future elbow arthroscopy and proprioceptive recovery in this population., Level of Evidence: II, low-powered prospective randomized trial., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

The axillary nerve is the most commonly injured nerve around the arm. In the deltopectoral approach, classical teaching states that lateral rotation of the humerus increases the distance between the subscapularis and the axillary nerve. This is the first anatomical study to quantify the distance change between the axillary nerve and subscapularis produced by arm rotation. Eight arms were placed in the supine position and a classical deltopectoral approach was performed. With digital calipers, measurements were made from the closest identifiable margin of the nerve to the inferior extent of the tenotomy. All measurements were made with the arm in 0° abduction and elbow in 90° of flexion, and repeated with the arm in 45° of medial rotation, 0° lateral rotation and 45° of lateral rotation. The mean d Axillary Nerve to subscapularis was recorded as 30.9 mm (95% CI:25.3-36.3), 39.4 mm(95% CI:34.1-44.8), and 46.1 mm (95% CI:41.1-51.2) for 45° MR, 0°, and 45° LR, respectively. Using paired-samples T-testing, the mean change in distance when moving from 45° MR to 0° was +8.5 mm (P < 0.0001), and from 0° to LR 45°, +6.7 mm (P < 0.0001). There is a significant difference in the distance between the subscapularis tenotomy and the axillary nerve with medial and lateral rotation. Laterally rotating the arm increased the distance by 6.7 mm, reaffirming that positioning the glenohumeral joint in a position of LR during subscapular tenotomy is protective against iatrogenic injury of the axillary nerve. Clin. Anat. 32:268-271, 2019. © 2018 Wiley Periodicals, Inc., (© 2018 Wiley Periodicals, Inc.)

Objective: To determine if the perceived pain intensity during the application of shock waves (SWs) is a determinant mechanism in producing hypoalgesic changes in pressure pain thresholds (PPTs) in asymptomatic individuals., Design: A randomised, single-blind controlled trial [NCT03455933]., Setting: University., Participants: Sixty-three asymptomatic individuals., Interventions: Participants were randomised into three groups: 1-SWs causing mild pain (SW-DP); 2-SWs generating moderate pain (SW-MP); and 3-cold pressor test (CPT)., Main Outcome Measurements: Before and after the intervention, the PPT was evaluated bilaterally at the following points: lateral epicondyle, median nerve in the flexure of the elbow, and tibia., Results: The results showed differences between various groups over time for all PPTs assessments, due to the existence of statistically significant differences in the interaction group x times (dominant arm lateral epicondyle [P < 0.001; η 2 p = 0.255]; dominant arm median nerve [P = 0.001; η 2 p = 0.212]; nondominant arm lateral epicondyle [P < 0.001; η 2 p = 0.275]; nondominant arm median nerve [P < 0.001; η 2 p = 0.268]; tibia [P = 0.012, η 2 p = 0.138]). The SW-MP group obtained a significant increase in all the PPT evaluations compared with the SW-DP group (d > 0.80). The CPT group only showed significantly higher results, and of high magnitude (d > 0.80), regarding the SW-DP group for the PPT evaluation in the dominant member. The SW-MP group showed differences compared with the CPT only for the PPT obtained in the nondominant arm., Conclusions: The findings show that SW treatment generates a hypoalgesic effect on the application point, with moderate pain. Further studies are necessary in order to link these hypoalgesic changes to the activation of the descending inhibitory systems., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: To evaluate sensitivity, specificity and predictive values of sensory findings in ulnar neuropathy at the elbow (UNE), differences according to UNE localization and pathophysiology, and relation between the sites of sensory symptoms, abnormal evaluation of sensation and neurographic findings of ulnar sensory nerve., Methods: Hand diagram and Semmes-Weinstein monofilaments were used for clinical evaluation in four ulnar hand territories. Sensory neurography was measured in the fourth and fifth digits-wrist segments (U5) and in the dorsal ulnar cutaneous nerve., Results: We enrolled 75 idiopathic UNE cases and 180 controls. Symptoms in the fifth digit, reduction of touch sensation and U5 sensory nerve action potential amplitude (SNAPa) had the highest sensitivity, specificity and predictivity in UNE diagnosis. The normal/abnormal sensory clinical findings of the fifth digit matched with normal/abnormal U5 SNAP more than the matching of sensory parameters in the other ulnar hand sites. Sensory anomalies were more frequent in predominantly axonal than demyelinating UNE. There were no differences according to UNE location., Conclusion: Sensory anomalies of the fifth digit are constant findings in UNE more than anomalies of the other ulnar nerve hand regions., Significance: Probably the fascicles from fifth digit are the most liable to damage at elbow., (Copyright © 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: In situ decompression, subcutaneous transposition, and submuscular transposition for cubital tunnel syndrome have historically yielded similar outcomes. The authors' null hypothesis is that no differences exist in surgical encounter total direct costs for in situ decompression, subcutaneous transposition, and submuscular transposition., Methods: Adult patients treated surgically for cubital tunnel syndrome by four fellowship-trained hand surgeons between August of 2011 and December of 2016 were identified by CPT code (64718) at their tertiary academic institution. Patients with prior elbow surgery or fracture/dislocation and those undergoing revision or additional simultaneous procedures were excluded. Using their institution's information technology value tools, the authors extracted prospectively collected surgical encounter total direct costs data for each surgical encounter. Costs were compared between groups and modeled using univariate and multivariable gamma regression., Results: In situ decompression, subcutaneous transposition, and submuscular transposition were performed on 45, 62, and 14 unique surgical encounters, respectively, with mean surgical times of 28.0, 46.5, and 50.0 minutes, respectively. Costs differed significantly between surgical methods. Surgical method and provider significantly affected surgical encounter total direct costs in the univariate model. Multivariable modeling demonstrated that subcutaneous transposition was 1.18-fold more costly than in situ decompression and submuscular transposition was 1.55-fold more costly than in situ decompression while controlling for age, sex, and provider., Conclusions: Surgical costs differed significantly between in situ decompression, subcutaneous transposition, and submuscular transposition. Given historically similar outcomes reported for these techniques, cost differences should be considered in addition to clinical factors to inform surgical decision-making for cubital tunnel syndrome patients.

Background and Importance: The use of nerve transfers to restore nerve function following traumatic avulsion injuries has been described, though there is still a paucity in the literature documenting technique and long-term outcomes for these procedures. The double Oberlin nerve transfer involves transferring fascicles from the median and ulnar nerves to the musculocutaneous nerve to restore elbow flexion in patients with a C5-C6 avulsion injury. The purpose of this case report is to present our indications and technique for a double Oberlin transfer in addition to exhibiting video footage at follow-up time points documenting the incremental improvement in elbow flexion following the injury., Clinical Presentation: The patient is a 25-yr old, left-hand dominant male who presented 5 mo following a motor vehicle accident. He had 0/5 biceps muscle strength on the left with a computed tomography myelogram that demonstrated pseudomeningoceles from C2-C3 to C7-T1 with root avulsions of C5 and C6. He was subsequently indicated for a double Oberlin nerve transfer to restore elbow flexion., Conclusion: In this case report, we present our technique and outcomes for a double Oberlin transfer with restoration of elbow flexion at 1-yr follow-up for a patient with traumatic brachial plexus injury. We believe that the double Oberlin transfer serves as a safe and effective method to restore elbow flexion in this patient population.

Ganglion of the anterolateral elbow is rare and may be associated with compression neuropathy of the radial nerve or its branches. Open ganglionectomy implies extensive soft tissue dissection. We present a case of anterolateral elbow ganglion without any compression neuropathy. This was successfully treated with endoscopic ganglionectomy.