Fracture of the body of the hamate bone associated with compartment syndrome and dorsal decompression of the carpal tunnel

Fracture of the body of the hamate is rare. A case is reported where a crushing injury produced disruption of the carpus and a compartment syndrome of wrist and forearm. The median nerve escaped compression by the dorsal decompression produced by the injury. The fracture was fixed with wires and a good recovery followed.     

Acute carpal tunnel syndrome secondary to iatrogenic hemorrhage. A case report

Carpal tunnel syndrome is a common compression neuropathy of the median nerve. Acute carpal tunnel syndrome (aCTS) is rare, associated with a variety of conditions. In this case report we present a patient who developed aCTS and volar forearm compartment syndrome after a radial artery line placement, while receiving intravenous heparin. The patient underwent immediate forearm fasciotomy and surgical release for restoration of nerve function, which resulted in improved hand function and mild residual median nerve neuropathy. There is controversy whether to discontinue or not anticoagulation in a patient with aCTS. In our patient, heparin therapy was restarted on the second postoperative day.     

Chronic exertional compartment syndrome of the forearm: a case report

A 40-year-old man sustained a circumferential crush injury to his right forearm. Four months after injury, he experienced the onset of numbness and tingling in the distribution of the median nerve after exercise. Elevated compartment pressures of the palmar forearm and slowing of median nerve conduction after exercise suggested chronic exertional compartment syndrome. A flexor fasciotomy led to complete relief of symptoms, which allowed the patient unrestricted activity.     

Clinical and neurophysiologic characteristics of the pronator syndrome

Nine patients were clinically diagnosed as having a pronator syndrome, i.e., high median nerve compression. The main symptom was pain at the proximal volar aspect of the forearm increasing for several hours after exercise. All patients showed local tenderness over the median nerve 4-5 cm distal to the elbow and pain on active forearm pronation against resistance. Two patients had been previously operated upon for carpal tunnel syndrome. Preoperative routine neurographic-electromyographic studies were normal. In the differential diagnosis, the exclusion of carpal tunnel syndrome and anterior interosseous nerve entrapment is most important. On active isometric forearm pronation, interference with median nerve motor conduction occurred in three patients preoperation. This phenomenon had disappeared following median nerve decompression at the level of the pronator muscle. Fibrous bands from the pronator muscle, encircling the nerve, seemed to be an etiological factor. Eight of nine patients were either improved or recovered completely by surgical treatment.     

Unusual cause of carpal tunnel syndrome: a case report.

An unusual case of compression of median nerve at the wrist is described due to a foreign body. In unusual presentation of carpal tunnel syndrome, ultrasonography of the wrist is recommended to rule out a foreign body in the region.     

Concomitant compression of median and ulnar nerves in a hemophiliac patient: a case report

A 15-year-old boy, with a diagnosis of hemophilia A, suffered bleeding into his left forearm 5 months before being admitted to our medical center. His neurological examination revealed a pronounced median neuropathy and a minor ulnar neuropathy on the left side. There was marked muscle atrophy on the thenar side and, to a lesser degree, on the hypothenar side and in the forearm. Electromyographic findings demonstrated an evident, nearly complete, sensorimotor axonal loss in the median nerve. Magnetic resonance imaging studies showed atrophy in muscles of the left forearm and median nerve. The patient was diagnosed as having median nerve axonotmesis and ulnar nerve neuropraxia due to compartment syndrome. In hemophiliac patients, frequent single nerve compressions (often involving the femoral nerve) can be seen. However, concomitant median and ulnar nerve injuries with differing severity are rare.     

Median nerve decompression in ischemic contracture of the forearm]

Ischemic contracture of the forearm known as Volkmann contracture develops from untreated (or treated to late) compartment syndrome within the forearm. Surgery is needed if function of the extremity is to be restored after fully developed Volkmann contracture. The uniform management is accepted in our Department since 1982. Multi-stage surgical treatment is indicated, the first stage consisting of median nerve neurolysis and removal of necrotic tissues to restore physiological excursion of the nerve. A series of 48 patients (16 females, 32 males aged 5-42 years) treated between 1982 and 1995 was included in the study. Complete neurolysis of the median nerve (microsurgical within proximal 1/3 of the forearm) was done in all patients. Long-term assessment of the median nerve function was done at half year to 3 years follow-up. Symptoms of nerve entrapment indicated reoperation. The study confirmed usefulness of an early median nerve decompression for prevention of neurological complications and improvement of the extremity function.     

Proximal median nerve compression.

Compression neuropathies of the median nerve in the proximal forearm are unusual lesions. Many patients have vague symptoms for many months or even years prior to confirming the diagnosis of either pronator syndrome or anterior interosseous syndrome of the forearm. Serial examinations clinically and electrodiagnostically may be necessary at intervals of 6 to 8 weeks as required for the evaluation of the patient's symptoms. As with other compression neuropathies, the diagnosis is solely dependent on the diagnosis of neuropathy of the median nerve using whatever parameter satisfies the surgeon's diagnostic criteria and then having made that diagnosis, localizing the site of that neuropathy by physical examination or electrodiagnosis with the support of radiographic techniques as appropriate. Surgical exploration of proximal median nerve compression is normally followed by prompt and predictable recovery from the median neuropathy and clinical symptoms between 8 and 12 weeks after surgical exploration. Prolonged symptom complexes after surgical exploration of the proximal median nerve are, in my experience, due to either (1) extremely severe median nerve injury secondary to pronator syndrome with prolonged recovery and distal nerve axomnetic recovery into the hand, or (2) sensory nerve dysesthesis of the small sensory nerves on the proximal volar surface of the forearm. The symptoms of either of these postoperative findings normally improve with time.     

Ballistic diaphyseal forearm fractures result in high incidence of neurovascular injury and compartment syndrome but have low rates of early infection: A single level I trauma center experience

IntroductionBallistic injuries to the upper extremity represent a small subset of injuries, and there is little data to provide guidance on management and outcomes. The purpose of this study is to assess the incidence of neurovascular injuries, compartment syndrome, and early postoperative infection, as well as patient and injury factors predictive of neurovascular injury following ballistic fractures of the forearm.Patients and methodsA retrospective review of operatively treated ballistic forearm fractures at a single level I trauma center between 2010 and 2022 was performed. Thirty-three patients with 36 forearm fractures were identified. Only diaphyseal injuries in patients greater than 18 years old were included. Medical and radiographic records were reviewed to identify pre-injury patient-specific factors, including age, sex, smoking status, and history of diabetes. Injury characteristics, including the type of firearm used, forearm fracture location, and any associated neurologic or vascular injury, as well as compartment syndrome, were collected and analyzed. Short-term outcomes such as post-operative infection and recovery of neurologic function were also collected and analyzed.ResultsThe median age was 27 years (range: 18–62), with a majority of male patients (78.8%, n = 26). 4 patients (12.1%) sustained high-energy injuries. 4 patients (12.1%) were found to have compartment syndrome pre-operatively or intra-operatively. 11 patients (33.3%) had nerve palsies postoperatively with 8 patients (24.2%) continuing to have nerve palsies at their final follow-up (mean follow-up= 149.9 +/- 187.2 days). The median length of stay was 4 days. There were no patients with infection at follow-up.ConclusionBallistic forearm fractures are complex injuries and can result in severe complications such as neurovascular injury and compartment syndrome. As such, a comprehensive evaluation and appropriate management of ballistic forearm fractures are essential to minimize the risk of severe complications and optimize patient outcomes. In our experience, when treated operatively, these injuries have a low rate of infection.     

New Mini-invasive Decompression for Pronator Teres Syndrome

The pronator teres syndrome is a set of signs and symptoms that result from compression of the median nerve in the upper forearm. It is a dynamic syndrome that is frequently associated with compression of the same nerve at the carpal tunnel. The literature describes different anatomic structures that can cause this syndrome. Experience showed us that the deep fascia of the superficial head of the pronator teres is the only anatomic structure that causes compression of the median nerve in the upper forearm. If the flexor digitorum test is negative, selective release of the deep fascia of the superficial head of the pronator teres ends the symptoms. Our surgical technique uses a mini-invasive approach that takes into account the anatomic knowledge of this region. A 3.5-cm oblique skin incision is done 6 cm distal to the medial epicondyle, over the flexor/pronator muscle mass. The medial cutaneous nerve is atraumatically retracted. The superficial fascia of the flexor/pronator muscles is opened transversely. With the section of the septum between the pronator teres and the flexor carpi radialis, access to the deep fascia of the superficial head of the pronator teres is obtained. This structure is released. The median nerve is now easily visualized, and other types of possible compression causes are excluded. The same surgeon treated 44 cases with this technique. Two assistants were always needed for this mini-invasive approach. Pronator teres symptoms disappeared in 93% of cases.     

An unusual cause of carpal tunnel syndrome. Case report.

A 38 year old woman with carpal tunnel syndrome of the right hand was treated with operative decompression, initially successfully. Subsequently, she developed a compartment syndrome after an injury. On re-exploration, an accessory palmaris longus muscle was encasing the median nerve at the distal forearm and passing through the flexor sheath, underneath the flexor retinaculum, inserted into the deep palmar fascia.     

Acute compartment syndrome in forearm fractures

Sixteen patients were reexamined 2 to 5 years after surgical treatment of acute compartment syndrome in forearm fractures. High-energy trauma was the casual factor in 11 cases, in 5 of which there was an open fracture with skin defect. Fracture stabilization and fasciotomy of forearm and carpal compartments were performed as emergency procedures. The time for fracture healing averaged 8 weeks. Median nerve function was impaired in all the patients, and the ulnar nerve function in 8. The median nerve recovered completely in 15 patients, but ulnar nerve function was still impaired in 2 patients, 1 of whom had a nerve tissue defect. Eight patients could resume their occupation within a year.     

Acute compartment syndrome in forearm fractures

Sixteen patients were reexamined 2 to 5 years after surgical treatment of acute compartment syndrome in forearm fractures. High-energy trauma was the casual factor in 11 cases, in 5 of which there was an open fracture with skin defect. Fracture stabilization and fasciotomy of forearm and carpal compartments were performed as emergency procedures. The time for fracture healing averaged 8 weeks. Median nerve function was impaired in all the patients, and the ulnar nerve function in 8. The median nerve recovered completely in 15 patients, but ulnar nerve function was still impaired in 2 patients, 1 of whom had a nerve tissue defect. Eight patients could resume their occupation within a year.     

108例腕管综合征正中神经传导测定结果分析

分析１０８例腕管综合征正中神经传导测定结果，以求最敏感的电诊断指标。比较１０８例正中神经复合肌肉动作电位，肘至腕的运动传导速度测定及指至腕部的感觉神经动作电位三项。指标异常检测率，表明拇指至腕段的感觉传导速度减慢是最敏感的电诊断参量。１０８例中伴有前臂段运动传导速度减慢的占１０．５％。同组病例无症状上肢出现电生理异常者为２０％，指示有亚临床的腕管部神经卡压存在的可能。     

Longitudinal sliding of the median nerve in patients with carpal tunnel syndrome

In nerve compression syndromes restricted nerve sliding may lead to increased strain, possibly contributing to symptoms. Ultrasound was used to examine longitudinal median nerve sliding in 17 carpal tunnel syndrome patients and 19 controls during metacarpophalangeal joint movement. Longitudinal movement in the forearm averaged 2.62 mm in controls and was not significantly reduced in carpal tunnel syndrome (CTS) patients (mean=2.20 mm). In contrast, CTS patients had a 40% reduction in transverse nerve movement at the wrist on the most, compared to least, affected side and nerve areas were enlarged by 34%. Normal longitudinal sliding in the patients indicates that nerve strain is not increased and will not contribute to symptoms.     

显微外科技术治疗骨间后神经卡压综合征17例

目的探讨显微外科技术治疗骨间后神经卡压综合征的疗效.方法对17例骨间后神经卡压征患者采用显微外科技术进行神经减压松解术.结果术后平均随访8个月,前臂伸肌肌力及肌电图检查均恢复正常.结论显微外科技术是治疗骨间后神经卡压综合征的有效方法.     

前臂间隔区综合征与缺血性肌挛缩的手术治疗

总结１９８９年至１９９４年间收治的３８例前臂间隔区综合征及缺血性肌挛缩的治疗体会，从治疗观点将其分成３期：（１）减压期，即间隔区综合征期（４８小时内）；（２）缺血性肌挛缩期（４８小时至１年以内）；（３）功能重建期（１年以上）。本组１３例间隔区综合征，及时行切开减压后，无１例发生缺血性肌挛缩。而２５例在４８小时内未及时有效治疗者，均出现不同程度的缺血性肌挛缩，经神经肌肉松解后，功能部分或完全恢复。故     

Compartment syndrome after low-velocity gunshot wounds to the forearm

Between 1980 and 1988, 127 patients with 131 low-velocity gunshot wounds to the forearm were treated. In 71 extremities there was no bony injury; 60 extremities sustained fractures. The diagnosis of a compartment syndrome was based on tissue pressure measurements and/or clinical examination. A univariate analysis followed by a multivariate stepwise logistic regression was used to evaluate potential risk factors including fracture location, displacement, comminution, and the quantity of radiographically determined metallic foreign bodies in the wound. A compartment syndrome was diagnosed in 13 of the extremities (10%). Fracture location was the only significant risk factor for the development of a compartment syndrome. Low-velocity gunshot injuries to the forearm are at definite risk for the occurrence of a compartment syndrome. A high index of suspicion is necessary to prevent untoward sequelae. Patients with this injury, especially those with a proximal one-third fracture who constitute an extremely high-risk group, should be monitored closely.     

Supracondylar humeral fractures in children

Operative fixation is indicated for most type-II and III supracondylar humeral fractures in order to prevent malunion. Medial comminution is a subtle finding that, if treated nonoperatively, is likely to lead to unacceptable varus malunion. Angiography is not indicated for a pulseless limb, as it delays fracture reduction, which usually corrects the vascular problem. A high index of suspicion is necessary to avoid missing an impending compartment syndrome, especially when there is a concomitant forearm fracture or when there is a median nerve injury, which may mask symptoms of compartment syndrome. Lateral entry pins have been shown, in biomechanical and clinical studies, to be as stable as cross pinning if they are well spaced at the fracture line, and they are not associated with the risk of iatrogenic ulnar nerve injury.