程序化操作在尺神经皮下前置术中的应用

目的 探讨程序化手术操作在尺神经皮下前置术中的应用效果.方法 我院自2017年1月至2019年12月采用尺神经松解皮下前置术治疗肘管综合征病人34例.所有病人均采用程序化操作处理前臂内侧皮神经、Struthers弓、内侧肌间隔、Osborne韧带、尺侧腕屈肌两头、指浅屈肌筋膜、尺神经伴行血管、尺侧屈腕肌肌支及关节支、屈...     

Tardy ulnar nerve palsy after fracture non-union medial epicondyle of humerus – An unusual case

Tardy ulnar nerve palsy is a chronic clinical condition characterised by delayed onset ulnar neuropathy. Typically tardy ulnar nerve palsy occurs as a consequence of non-union of lateral condyle in child resulting in cubitus valgus deformity which ultimately is the cause of ulnar nerve palsy. However very few literature are available for tardy ulnar nerve palsy as a result of old fracture of medial epicondyle without cubitus varus or valgus deformity. We report a rare case of tardy ulnar nerve in an adult male with fracture non-union of medial epicondyle of humerus.     

儿童肱骨内上髁骨折术后迟发性尺神经炎的预防

目的探讨骨折切开复位内固定并一期行尺神经前移术对肱骨内上髁骨折术后发生迟发性尺神经炎的预防作用。方法将57例眩骨内上髁骨折患者分为骨折切开复位内固定并一期行尺神经前移（32例）和单纯骨折切开复位内固定（25例）两组,对两组迟发性尺神经炎的发生率进行比较．结果骨折切开复位内固定并一期行尺神经前移组的迟发性尺神经炎发生率为6．25％,而单纯骨折切开复位内固定组为36％．两组差异有显著性（P〈0．05）。结论 肱骨内上髁骨折切开复位内同定并一期行尺神经前移能较好地预防术后迟发性尺神经炎的发生。     

Anterior Transposition of the Ulnar Nerve

Twenty-four patients with 26 ulnar neuropathies in the elbow region were treated by anterior transposition of the ulnar nerve. the dominant arm was involved in 14 of these patients.

Improvement of paresthesia was found in 17 out of 21 (75 per cent) in this series of patients; 10 out of 18 (55 per cent) had improvement of sensation; 7 out of 14 (50 per cent) had less pain; 10 out of 14 (71 per cent) showed an increase in motor power, but only 2 out of 12 patients (16 per cent) with long—standing muscle atrophy showed any improvement in their condition.

Electromyographic studies (EMG) were carried out before and after operation. the postoperative studies revealed increased motor conduction velocity within the elbow segment of the ulnar nerve in 15 patients. Slowing in ulnar nerve conduction velocity was found in 3 patients, and in 8 the EMG remained unchanged.

Our EMG series indicated that patients with a conduction velocity of less than 40 m/s will certainly benefit more from anterior transposition of the ulnar nerve than will patients whose measurements are within the normal range.     

Evaluation of Tension at Median and Ulnar Nerve Repairs at the Wrist in a Cadaveric Model

Background: Median and ulnar nerve lacerations at the wrist are often combined with zone 5 tendon injury. The inability to provide early range of motion leads to increased adhesions. Current therapy protocols recommend the wrist be held in 30° of flexion post operatively to protect the nerve repair. However, if tension and elongation across the nerve repair stay under a critical level in less wrist flexion, postoperative splinting in more extension could allow for better tendon excursion and less adhesions. Methods: Six cadaveric specimens were used. After appropriate dissection, the median and ulnar nerves were transected and repaired with a single 10-0 nylon suture. The wrist was ranged from 30° flexion to 45° extension to see if the repair would fail. Next, an epineural repair was accomplished with 9-0 nylon suture. The percent elongation along the nerve repair was measured at set increments from 30° flexion to 45° extension. Results: In all 6 specimens, median and ulnar nerve repairs with a single 10-0 nylon suture did not fail with wrist range of motion from 30° flexion to 45° extension. Mean percent elongation stayed under critical levels in up to 30° of extension. Conclusions: Both median and ulnar nerve repairs stayed under critical levels of tension and elongation in up to 30° of wrist extension. We believe it is possible to be more aggressive with wrist positioning in wrist level median and ulnar nerve repairs.     

Alternatives to sural nerve grafts in the upper extremity

Background

The sural nerve is the most common nerve graft donor despite requiring a second operative limb and causing numbness of the lateral foot. The purposes of this study were to review our experience using nerve autografts in upper extremity nerve reconstruction and develop recommendations for donor selection.

Methods

A retrospective case series study was performed of all consecutive patients undergoing nerve grafting procedures for upper extremity nerve injuries over an 11-year period (2001–2012).

Results

Eighty-six patients received 109 nerve grafts over the study period. Mean patient age was 42.9 ± 18.3 years; 57 % were male. There were 51 median (59 %), 26 ulnar (30 %), 14 digital (13 %), 13 radial (16 %), and 3 musculocutaneous (4 %) nerve injuries repaired with 99 nerve autografts (71 from upper extremity, 28 from lower extremity). Multiple upper extremity nerve autograft donors were utilized, including the medial antebrachial cutaneous nerve (MABC), third webspace branch of median, lateral antebrachial cutaneous nerve (LABC), palmar cutaneous, and dorsal cutaneous branch of ulnar nerve. By using an upper-extremity donor, a second operative limb was avoided in 58 patients (67 %), and a second incision was avoided in 26 patients (30 %). The frequency of sural graft use declined from 40 % (n = 17/43) to 11 % (n = 7/64).

Conclusions

Our algorithm for selecting nerve graft material has evolved with our growing understanding of nerve internal topography and the drive to minimize additional incisions, maximize ease of harvest, and limit donor morbidity. This has led us away from using the sural nerve when possible and allowed us to avoid a second operative limb in two thirds of the cases.     

Feasibility of a fascial flap to avoid anterior transposition of unstable Ulnar nerve: A cadaver study

BackgroundCompression of the ulnar nerve at the elbow is the second most frequent site of nerve compression in the upper limb. Upon release, anteposition of the nerve may be necessary to avoid dislocation of the latter when unstable. Numerous techniques are described in the literature (subcutaneous transposition, intramuscular transposition, subfascial transposition, medial epicondylectomy …), none of which is without complications. Based on Han's work, the authors propose a technique of covering the ulnar nerve with epicondylar fascial flap, avoiding transposition, but ensuring good stability of the ulnar nerve.MethodsAs part of the SICM (Italian Society of Hand Surgery) cadaver dissection course (ICLO, Verona, Italy) the authors dissected 36 elbows, of which 20 presented subluxation of the ulnar nerve after its decompression. The fascial flap was therefore made on these 20 elbows, coming from 14 different donors (9 men, 5 women) with an average age of 78 years. The diameter of the ulnar nerve was then measured (at the level of the passage in the cubital canal), the diameter of the newly formed canal, the difference between the two previous measurements (residual space in the flexed elbow canal), and it was verified whether the ulnar nerve was unstable once covered by the flap.ResultsThe mean diameter of the ulnar nerve was 5.1 mm (range 4–6), while the mean diameter of the neo-canal was 10.1 mm (range 8–11) in elbow extension and 8.9 mm (range 7–10) in elbow flexion. The remaining space in the flexed elbow canal was 3.8 mm (range 3–5).In none of the 20 cases the ulnar nerve was dislocated after having made the fascial flap.ConlusionsIn light of the results obtained, the authors think that the use of the epicondylar fascial flap may be a solution to keep in mind to avoid dislocation of the ulnar nerve when it becomes unstable following its decompression. This work obviously needs clinical confirmation on living patients.Level of evidenceV.     

A comparative study of two percutaneous pinning techniques (lateral vs medial–lateral) for Gartland type III pediatric supracondylar fracture of the humerus

BackgroundThe management of displaced supracondylar fracture of the humerus with closed reduction and percutaneous pin fixation is the most widely accepted method of treatment, but controversy continues regarding the pin fixation techniques. A prospective randomized controlled study was undertaken to compare the stability, functional outcome and iatrogenic ulnar nerve injury between lateral pin fixation and medial–lateral pin fixation.ResultsThere were two (6.5 %) iatrogenic ulnar nerve injury cases in the medial–lateral entry group and two (6.5 %) cases with mild loss of reduction in the lateral entry group. No major loss of reduction was observed in either of the groups. There was no statistically significant difference in change of Baumann angle, metaphyseal–diaphyseal angle, Flynn grade, carrying angle, and the total elbow range of motion (P < 0.05) between the two groups.ConclusionsLateral pin fixation offers similar functional and radiological outcome and almost equal mechanical stability compared with medial–lateral pinning without the risk of iatrogenic ulnar nerve injury.

Level of evidence [OCEBM 2011]

Level 2.     

肘部单切口下二氧化碳灌注内窥镜辅助下尺神经松解及前置术

目的 介绍一种在单个小切口下利用二氧化碳(CO2)气泵于肘部尺神经行经处创造气腔,在内窥镜辅助下彻底松解尺神经并前置的方法.方法 2005年至2008年,对12例临床确诊为肘管综合征的患者在肘内侧做单个纵行小切口,利用气腹机在肘部皮下与前臂或臂部深筋膜之间产生的CO2气腔内,采用℃角内窥镜下行尺神经松解及屈肌筋膜下前置术.采用Dellon及改良Bishop评分系统进行手术前后评估.结果 术前根据Dellon评分,12例肘管综合征中轻度5例、中度5例、重度2例.肘部手术切口长(15±3)mm,CO2气腔均成功建立,尺神经松解长度为(18±2)cm,内窥镜下的神经松解及筋膜下前置手术均顺利,整个手术持续时间为(30±5)min.术后所有患者的尺神经症状均较术前有改善,无并发症发生.随访时间为12～18个月,按改良Bishop 评分:优10例(占83.3％),良2例(占16.7％).结论 肘部单个小切口下,CO2灌注产生的皮下气腔可以更好地暴露尺神经,结合内窥镜肘部尺神经松解及前置术减少了对神经分支及血供的损伤.该方法简单安全,创伤小,恢复快.     

Usability and Reliability of the Edinburgh Visual Gait Score in Children with Spastic Cerebral Palsy Using Smartphone Slow-Motion Video Technology and a Motion Analysis Application: A Pilot Study

BackgroundThe Edinburgh Visual Gait Score (EVGS) is a comprehensive measure of gait abnormalities in children with cerebral palsy (CP) and has good psychometric properties. However, it is cumbersome to administer and requires multiple devices to record and measure its various components. We conducted this study to determine if a smartphone video protocol could be used to improve the usability and reliability of the EVGS for daily use in a clinic setting.MethodsWe used a handheld smartphone camera with slow-motion video technology and a motion analysis application to record and measure the EVGS of 30 ambulatory children with spastic CP. We tested the inter- and intra-rater reliability of various components of the EVGS between two observers.ResultsAverage age was 7 years 3 months (range 4–14 years). The mean (range) EVGS scores for the trunk, pelvis, hip, knee, ankle, and foot were 1.18 (0–3), 0.68 (0–3), 1.1 (0–4), 3.95 (1.5–7.5), 1.87 (0–4) and 4.13 (2–6.5) respectively. Total score was 12.92 (7–21.5). The mean (SD) scores for Gross Motor Function Classification System (GMFCS) levels II and III were 10.73 (3.86) and 14.96 (4.2) (p < 0.001). The intra-observer and inter-observer reliability using percentage of complete agreement was 65–98.3% and 61.7–92.5% respectively, with kappa values ranging from 0.15 to 0.87. Reliability was more for distal limb segments as compared to proximal segments.ConclusionWe have described a simple and reliable method for quantitative OGA of children with CP, using smartphone video technology and motion analysis application, which can be performed by every clinician in an office setting.Level of EvidenceLevel III.     

肘部尺神经滑脱──流行病学调查及病理解剖观察

通过流行病学调查和病理解剖观察，提示尺神经滑脱可能与组织结构发育缺陷有关，如肱骨内上髁较小，肘管三角韧带及尺神经系膜松弛等。男女之间尺神经滑脱发生率有显著性差异。肘部尺神经滑脱并非少见，鉴于尺神经滑脱者发生肘部尺神经损害的危险性较一般人群高，一旦尺神经损害其所支配的已挛缩的手内在肌很难恢复，尺神经滑脱者是值得人们注意的肘部尺神经损害的易感人群。因尺神经滑脱者除上述结构缺陷外，更重要的是尺神经滑脱过程为重复累积性损伤，故尺神经前移以免尺神经在肱骨内上髁反复摩擦损伤为首选的治疗方法。     

肘部尺神经卡压与尺神经半脱位的诊疗进展

肘部尺神经卡压也称为肘管综合征,可造成手部一系列功能障碍,是最常见的上肢神经卡压症之一。尺神经脱位及半脱位为尺神经卡压的影响因素。尺神经卡压按McGowan分级分为Ⅰ、Ⅱ、Ⅲ级。Ⅰ级首选保守治疗 Ⅱ、Ⅲ级保守治疗效果欠佳,多需要手术治疗。手术方式主要有尺神经原位松解术（包括肱骨内髁切除术）、粘膜下尺神经前置术、肌下尺神经前置术及肌内尺神经前置术等,其中原位松解手术操作相对简单,但对于尺神经卡压伴有尺神经脱位者多属禁忌,应首选尺神经前置术。     

Management of Iatrogenic Ulnar Nerve Transection

A case of iatrogenic ulnar nerve laceration at the elbow is presented. Five subsequent surgeries over the course of the ensuing 20 months were performed to address this complication. The article examines the scientific basis for the various decisions needed to formulate a strategy that effectively addresses the problem. Emphasis is placed on the microsurgery of nerve topics: direct nerve repair, autogenous cable nerve grafting, biodegradable conduits, decellularized nerve allograft, and transfer of the anterior interosseous nerve to the ulnar motor branch. The discussion covers the relationship between choices made at the level of the original injury at the cubital tunnel to the timing and selection of distal reconstructive efforts, with specific attention to the distinction between end-to-end anterior interosseous to ulnar motor branch transfer as opposed to the supercharged end-to-side variation of this procedure.     

Ultrasound‐Assisted Precise In Situ Decompression for Cubital Tunnel Syndrome

ObjectiveTo explore the effect of locating the ulnar nerve compression sites and guiding the small incision so as to decompress the ulnar nerve in situ on the elbow by high‐frequency ultrasound before operation.MethodsA retrospective analysis was conducted on 56 patients who underwent ultrasound‐assisted in situ decompression for cubital tunnel syndrome from May 2018 to August 2019. The patients'' average age was 51.13 ± 7.35 years, mean duration of symptoms was 6.51 ± 1.96 months, and mean postoperative follow‐up was 6.07 ± 0.82 months. Nine patients had Dellon''s stage mild, 39 had stage moderate, and eight had stage severe. Ultrasound and electromyography were completed in all patients before operation. The presence of ulnar nerve compressive lesion, the specific location, and the reason and extent of compression were determined by ultrasound. A small incision in situ surgery was given to decompress the ulnar nerve according to the pre‐defined compressive sites.ResultsAll patients underwent in situ decompression. The compression sites around the elbow were as follows: two in the arcade of Struthers, one in the medial intermuscular septum, four in the anconeus epitrochlearis muscle, five beside the cyst of the proximal flexor carpi ulnaris (FCU), and the remaining 44 cases were all from the compression between Osborne''s ligament to the two heads of the FCU. The compression localizations diagnosed by ultrasound were confirmed by operations. Preoperative ultrasound confirmed no ulnar nerve subluxation in all cases. The postoperative outcomes were satisfactory. There was no recurrence or aggravation of symptoms in this group of patients according to the modified Bishop scoring system; results showed that 43 cases were excellent, 10 were good, and three were fair.ConclusionsHigh‐frequency ultrasound can accurately and comprehensively evaluate the ulnar nerve compression and the surrounding tissues, thus providing significant guidance for the precise minimally invasive treatment of ulnar nerve compression.     

Factors Predicting the Oculomotor Nerve Palsy following Surgical Clipping of Distal Vertebrobasilar Aneurysms: A Single-Institution Experience

Background The aim of our study was to identify various clinical and radiologic factors that correlate with the oculomotor nerve palsy following clipping of distal vertebrobasilar aneurysms. Methods A total of 48 patients with 51 aneurysms were included in this retrospective study . Patient''s age, gender, size, location, and projection of the aneurysm, preoperative Hunt and Hess (H&H) grade, presence of subarachnoid hemorrhage (SAH), temporary clipping, preoperative third nerve palsy, and Glasgow Outcome Scale were included in the model for analysis. Results A total of 15 patients (31.25%) developed oculomotor nerve palsy following clipping of basilar apex aneurysms. 38 patients (79.2%) presented with SAH and 35 patients (72.9%) had poor H&H grades at presentation. The size of the aneurysm (p = 0.03), preoperative H&H grade (p = 0.04), preoperative oculomotor nerve dysfunction (p = 0.007), and projection of an aneurysm (p = 0.004) had shown a significant correlation with the oculomotor nerve palsy. The size of the aneurysm (p = 0.030, odds ratio: 0.381; 95% confidence interval, 0.175–0.827] was an independent predictor of postoperative nerve dysfunction. Conclusion The size of the aneurysm, clinical grade at presentation, and projection of the aneurysm correlated with the oculomotor nerve dysfunction following clipping. These clinical and radiologic parameters can be used to predict the oculomotor nerve outcome.     

Setting expectations following endoscopic cubital tunnel release

Background

The objective was to evaluate recovery characteristics of patients undergoing endoscopic cubital tunnel release (ECuTR) by determining the following: (1) return to work (RTW) times following ECuTR compared with RTW times of patients that underwent anterior transposition of the ulnar nerve (ATUN), (2) satisfaction rates and factors affecting satisfaction, (3) resolution rates of common preoperative complaints and findings, and (4) effect of preoperative ulnar nerve subluxation on postoperative outcomes.

Methods

A total of 172 cases in 148 patients undergoing ECuTR were prospectively enrolled including 56 women and 92 men. Kaplan-Meier analyses were performed to determine RTW time for ECuTR patients and for a cohort of 15 patients that underwent ATUN. Patients were evaluated for subjective and objective complaints preoperatively and postoperatively. Cases were grouped by Dellon’s classification preoperatively and modified by Bishop’s postoperatively.

Results

Half of ECuTR patients returned to normal work within 8 days postoperatively versus 71 days following ATUN. Variables significantly negatively affecting RTW were male sex, manual labor, and worker’s compensation status. Dellon’s was the best predictor of postoperative satisfaction. Complete resolution of symptoms occurred in 86 % of patients for weakness, 81 % for pain, 79 % for numbness and tingling (N/T), 78 % for atrophy, 76 % for abnormal two-point discrimination, and 65 % for Wartenberg’s. Preoperative ulnar nerve subluxation had no effect on outcome.

Conclusions

Improved RTW time following ECuTR versus ATUN indicates potential and substantial cost-saving implications with respect to reduced worker productivity loss. Patients with more severe preoperative Dellon’s classification can expect less optimal results regarding postoperative satisfaction and resolution rates of N/T and pain.     

Tardy ulnar nerve palsy caused by cubitus varus deformity

Clinical features and X-rays of thirty-four cases with cubitus varus deformity were analysed in order to explain the occurrence of tardy ulnar nerve palsy caused by cubitus varus deformity. Cubitus varus cases with tardy ulnar nerve palsy, compared to cases without it, were older at the first visit to the clinic for cubitus varus deformity. There were no other differences between the two groups in clinical features. Computed tomography showed that the olecranon moved to the ulnar side against the olecranon fossa. Operative findings showed that the medial head of triceps brachii shifted medially and covered the ulnar nerve. Both from computed tomography and operative findings we conjectured the possibility that tardy ulnar nerve palsy was caused because the ulnar nerve was compressed by the forward medial movement of the medial head of the triceps brachii caused by cubitus varus deformity.     

The prognostic value of the head-shaft angle on hip displacement in children with cerebral palsy

BackgroundHip displacement is the second most common deformity in cerebral palsy (CP). The risk for hip displacement is related to the Gross Motor Function Classification System (GMFCS). Recently, the head-shaft angle (HSA) has been identified as a predictor for hip displacement and the aim of this study is to assess the predictive value of the HSA for hip displacement in CP.MethodsIn this retrospective cohort, we performed radiological measurements in 50 children on both hips. In children with GMFCS level II (30 hips), III (30 hips), IV (20 hips) and V (20 hips), we measured the HSA and migration percentage (MP) in three age intervals: age two years (T1), age four years (T2) and age seven years (T3).ResultsAt T1, the HSA was larger (more valgus) in hips that will displace than in hips that will not displace (174° vs. 166°; p = 0.001) and was also larger in higher GMFCS levels (IV–V vs. II–III) (172° vs. 165°; p < 0.001). At T1, GMFCS [odds ratio (OR) 14.7; p = 0.001] and HSA (OR 1.102; p = 0.043) were predictors for hip displacement at T3, but at T2, MP (OR 1.071; p = 0.010) was the only predictor for hip displacement at T3.ConclusionsThe HSA at two years is larger in hips that will displace and larger in children with higher GMFCS levels (IV–V). At age two years, GMFCS and HSA are valuable predictors for hip displacement, but at the age of four years, only MP should be used in the prediction of hip displacement.

Level of evidence

Prognostic study, level II.