Processus Supracondyloidea Humeri with Concomitant Compression of the Median Nerve and the Ulnar Nerve

Compression of the median nerve and the ulnar nerve due to the anatomical anomaly processus supracondyloidea humeri is a rare condition. a case of combined median and ulnar nerve compression is described. Diagnostics and treatment are discussed in the light of the present case history and those described in the literature. The conclusion is that the treatment should be subperiosteal resection of the process together with the origin of the pronator teres muscle.     

Intraneural lipoma of the posterior interosseous nerve

Lipomas arising in the peripheral nerves are rare tumors, with most arising in the forearm and wrist, and most have occurred within the median nerve. This report describes a case with large lipoma arising in the posterior interosseous nerve.     

Median Nerve Mistaken for Palmaris Longus Tendon: Restoration of Function with Sensory Nerve Transfers

Intraoperative iatrogenic nerve injuries occur despite vigilance in the operating room. Most of these injuries occur as a result of patient positioning, traction or pressure injury, hematoma, or technical error. The median nerve is especially susceptible to injury during carpal tunnel release. A rare but devastating injury of the median nerve is complete transection. The number of devastating injuries is not well known, as few of the injuries are documented or publicized. We report a case where the median nerve was harvested instead of the palmaris longus tendon. We present a review of the literature and suggest an alternative treatment to median nerve grafting using sensory nerve transfers in the hand.     

Ulnar to median nerve anastomosis in the palm (Riches-Cannieu anastomosis)

This report describes an unusual case of pure bilateral ulnar innervation of the thenar and hypothenar muscles of the hands. The patient was a healthy 36-year-old woman who presented with neck pain. Examination and routine laboratory investigation findings were normal, but on electroneuromyography ulnar to median nerve anastomosis of the motor fibers in the palm was detected bilaterally. However, there was no anastomosis between the sensory fibers. On investigation of focal neuropathy the anomaly known as Riches-Cannieu anastomosis may surprise the electroneuromyographer and change the clinical signs and symptoms. It should be suspected when the hand muscles are clinically intact in the presence of a severe median nerve lesion in the forearm. In this case, a complete lesion of the median nerve at the forearm might erroneously be interpreted as a partial lesion of the median nerve. In every surgical intervention to the hand, this anomaly should be kept in mind and should be investigated electrophysiologically. Received: 25 June 1998 / Accepted: 19 August 1998     

异位支配对正中神经尺神经损伤诊断影响的研究

目的 了解正中神经和尺神经之间交通支的存在对前臂这两条神经损伤诊断的影响,前臂正中神经至尺神经的交通支(Martin-Gruber anastomosis,MGA)、前臂尺神经至正中神经的交通支(reversed Martin-Gruber anastomosis,RMGA)和手部尺神经至正中神经的交通支(Riche-Cannieu anastomosis,RCA).方法 将160例正中神经或尺神经损伤合并存在异常交通支的患者分为三组:尺神经损伤并MGA组65例;正中神经损伤并RMGA组8例;正中神经损伤并RCA组87例.就其解剖基础、临床表现、电生理表现以及诊断进行讨论.结果 正中神经或尺神经损伤时,受损神经所支配肌肉的功能由于异常交通支的存在而得以代偿,导致其临床表现与神经损伤情况及其电生理表现不符.结论 充分了解正中神经和尺神经之间三种异常交通支的特点,对正中神经或尺神经损伤的临床诊断和治疗有重要意义,同时也可以避免错误地解释相关神经电生理检测的结果.     

Intraneural lipomatous tumor of the median nerve: Three case reports with a review of literature

INTRODUCTIONIntraneural lipoma and fibrolipomatous hamartoma of the nerve are rare soft tissue tumors that most commonly occur in the forearm and the wrist, and particularly within the median nerve. When the lesions are large enough, they may cause progressive compression neuropathy. They are distinct entities each other with different clinical and radiological findings and thereby need different surgical treatments.PRESENTATION OF CASEWe report here 3 cases of intraneural lipomatous tumors of the median nerve (1 case of intraneural lipoma and 2 cases of fibrolipomatous hamartoma).DISCUSSIONAll patients were surgically treated successfully with complete excision for intraneural lipoma and with carpal tunnel releases for the both fibrolipomatous hamartomas.CONCLUSIONA careful preoperative planning is necessary for the optimal treatment by distinguishing whether it is a resectable or non-resectable tumor based on the clinical and radiological findings, because they have characteristic findings each other.     

Lipofibromatous hamartoma of the median nerve with macrodactyly of middle finger

Lipofibromatous Hamartoma (LFH) is a rare tumour affecting the peripheral nerves, mostly the median nerve. It is benign and slowly growing. Less than 100 cases have been reported in the literature, about one quarter of them are associated with macrodactyly in the field of the affected nerve.We reported a case of a 13 years old female with LFH of the median nerve at the level of the wrist associated Macrodactyly of the ipsilateral middle finger treated surgically by decompression only.     

Meaningful power grip recovery after salvage reconstruction of a median nerve avulsion injury with a pedicled vascularized ulnar nerve

In cases of median nerve injury alongside an unsalvageable ulnar nerve, a vascularized ulnar nerve graft to reconstruct the median nerve is a viable option. While restoration of median nerve sensation is consistently reported, recovery of significant motor function is less frequently observed. The authors report a case involving a previously healthy man who sustained upper arm segmental median and ulnar nerve injuries and, after failure of sural nerve grafts, was treated with a pedicled vascularized ulnar nerve graft to restore median nerve function. Long-term follow-up showed near full fist, with 12 kg of grip strength, key pinch with 1.5 kg of strength and protective sensation in the median nerve distribution. The present case demonstrates that pedicled ulnar vascularized nerve grafts can provide significant improvements to median nerve sensory and motor function in a heavily scarred environment.     

Hourglass-like constriction of the musculocutaneous nerve: case report

Hourglass-like constriction has been previously associated with the main trunk of the radial nerve, with its branch of the posterior interosseous nerve, as well as the anterior interosseous nerve, a branch of the median and axillary nerve. Here, we report a case of hourglass-like constriction of the musculocutaneous nerve lesion that showed no recognizable compressive structure.     

Axillary nerve injury in young adults—An overlooked diagnosis? Early results of nerve reconstruction and nerve transfers

Abstract

An injury to the axillary nerve from a shoulder trauma can easily be overlooked. Spontaneous functional recovery may occur, but occasionally reconstructive surgery is required. The time frame for nerve reconstruction procedures is from a neurobiological view crucial for a good functional outcome. This study presents a group of operatively and non-operatively treated young adults with axillary nerve injuries caused by motorcycle accidents, where the diagnosis was set late. Ten young men (median age at trauma 13 years, range 9–24) with an axillary nerve injury were diagnosed by examination of shoulder function and electromyography (EMG). The patients had either a nerve reconstruction procedure or were treated conservatively and their recovery was monitored. The axillary nerve was explored and reconstructed at a median of 8 months (range 1–22 months) after trauma in 8/10 patients. Two patients were treated non-operatively. In 4/8 cases, a reconstruction with sural nerve graft was performed and in 1/8 case only exploration of the nerve was made (minor neuroma). In 3/8 cases a radial nerve branch transfer to the axillary nerve was chosen as the procedure. The shoulder was mobilised after 3 weeks with physiotherapy and the patients were monitored regularly. Functional recovery was observed in 9/10 cases (median follow up 11 months, range 7–64) with EMG signs of reinnervation in seven patients. Axillary nerve function should not be overlooked in young patients with a minor shoulder trauma. Nerve reconstruction can successfully recreate function.     

Ulnar nerve palsy after open carpal tunnel decompression: Case report and review of the literature

Open carpal tunnel release is the commonest surgical treatment of median nerve compression at the wrist. Although successful in most cases, there are well described complications. We report a case of laceration of the deep motor branch of the ulnar nerve at the level of the hook of hamate following a complicated carpal tunnel decompression. Good surgical technique and knowledge of wrist anatomy are essential for performing this apparently simple procedure safely.     

Carpal tunnel syndrome due to fibrolipomatous hamartoma of the median nerve

Nervous lipofibromatous hamartoma is a rare tumor-like condition involving the peripheral nerves, whereby the epineurium and perineurium are enlarged and distorted by excess of fatty and fibrous tissues that infiltrate between and around nerve boundaries. The median nerve is much more likely to develop a hamartoma than other nerves with a predilection for the carpal tunnel. We present a case of carpal tunnel syndrome in an adult caused by fibrolipomatous hamartoma of the median nerve, successfully removed by excision of the fibrolipomatous tissue and decompression.     

Acute median nerve compression neuropathy from a foreign body in the forearm

Acute compression of the median nerve in the forearm usually occurs from compartment syndrome. A case of acute compression neuropathy of the median nerve from a foreign body, where there was no evidence of compartment syndrome, is reported. The diagnosis was made from the patient’s symptoms and radiographs. Early recognition and decompression of the forearm with removal of the foreign body led to full recovery.     

Carpal tunnel syndrome caused by cysticercosis

We present a case of carpal tunnel syndrome (CTS) due to compression of the median nerve within the carpal tunnel, caused by cysticercosis. Nerve conduction studies revealed severe CTS. Magnetic resonance imaging suggested an inflammatory mass compressing the median nerve in carpal tunnel. The histological diagnosis was consistent with cysticercosis. The case resolved with conservative treatment. Such solitary presentation of entrapment median neuropathy as CTS caused by cysticercosis is extremely rare. To our knowledge, this is the only case of its kind reported in literature till date.     

Motor Nerve Transfers to Restore Extrinsic Median Nerve Function: Case Report

Active pronation is important for many activities of daily living. Loss of median nerve function including pronation is a rare sequela of humerus fracture. Tendon transfers to restore pronation are reserved for the obstetrical brachial plexus palsy patient. Transfer of expendable motor nerves is a treatment modality that can be used to restore active pronation. Nerve transfers are advantageous in that they do not require prolonged immobilization postoperatively, avoid operating within the zone of injury, reinnervate muscles in their native location prior to degeneration of the motor end plates, and result in minimal donor deficit. We report a case of lost median nerve function after a humerus fracture. Pronation was restored with transfer of the extensor carpi radialis brevis branch of the radial nerve to the pronator teres branch of the median nerve. Anterior interosseous nerve function was restored with transfer of the supinator branch to the anterior interosseous nerve. Clinically evident motor function was seen at 4 months postoperatively and continued to improve for the following 18 months. The patient has 4+/5 pronator teres, 4+/5 flexor pollicis longus, and 4−/5 index finger flexor digitorum profundus function. The transfer of the extensor carpi radialis brevis branch of the radial nerve to the pronator teres and supinator branch of the radial nerve to the anterior interosseous nerve is a novel, previously unreported method to restore extrinsic median nerve function.     

全长膈神经移位重建屈指功能的临床报告

目的 探讨在胸腔镜视下切取全长膈神经直接移位至正中神经内侧头重建全臂丛撕脱伤后屈指功能的可行性,为全臂丛根性撕脱伤后屈指功能的恢复提供新思路.方法 对3例全臂丛根性撕脱伤的患者,采用胸腔镜视下游离胸腔内的全长膈神经,于入膈肌处切断膈神经,将全长膈神经直接移位于正中神经内侧头,术后每3个月随访肺功能和临床功能恢复情况.结果 3例患者随访时间均超过3年,拇长屈肌及2～5指指浅屈肌肌力均恢复至3～4级,掌长肌肌力2例为2级,1例为1级;桡侧腕屈肌、旋前圆肌、鱼际肌肌力为0级.肺功能显示患者在术后6个月内有不同程度的肺功能降低,但在1年内都恢复到术前水平.结论 胸腔镜视下切取全长膈神经直接移位至正中神经内侧头重建全臂丛撕脱伤后的屈指功能是一种可行的新术式.     

Long-term results of transplantations to repair median, ulnar, and radial nerve lesions by a microsurgical interfascicular autogenous cable graft technique

A comprehensive analysis of 187 patients (78 median, 86 ulnar, and 23 radial nerve lesions) treated by an interfascicular autogenous nerve grafting technique is presented. After a follow-up of at least 18 months good motor recovery was achieved in 72% of median nerve lesions, 77% of ulnar nerve lesions, and 57% of radial nerve lesions. Good functional sensory recovery was found in 36% of median, 45% of ulnar, and 48% of radial nerve lesions. It appears by multivariate analysis that the results obtained generally were better in younger patients, in patients with a shorter preoperative delay, and in cases with a shorter transplant.     

健侧颈7神经根移位同时修复两条神经的初步临床疗效

目的探讨用健侧颈，神经根移位同时修复2条上肢神经的临床效果。方法设计2种移位修复的方法。(1)合干法：健侧颈，前后股→尺神经→尺神经近端分2股分别和正中神经、桡神经(或肌皮神经)缝合，共5例。(2)分干法：健侧颈前后股→尺神经、腓肠神经→正中神经、桡神经(或肌皮神经)，共3例。结果合干法4例术后随访12～19个月，1例尚在随访中。正中神经运动：2例已恢复屈腕、屈指，肌力M3。2例屈腕肌力为M1。正中神经感觉：3例为S2，1例为S0。桡神经运动：2例伸腕、伸指肌力为M2。1例伸肘肌力为M2，1例伸腕肌力为M1。桡神经感觉：1例为S2，1例为S1，2例为S0。分干法1例术后随访15个月，已恢复屈腕、屈指，肌力为M3。正中神经感觉为是。肌皮神经：屈肘肌力为M3。另2例术后时间短尚在随访中。结论健侧颈，神经根移位同时修复上肢2条主要神经的新术式，初步应用结果证实是可行的、有效的。     

正中神经与肌皮神经的交通支及其临床意义

目的观察正中神经与肌皮神经之间的交通支，探讨其临床意义。方法对72侧防腐固定尸体解剖，对正中神经、肌皮神经之间的交通支进行测量与观察，并对不同类型交通支的结果进行比较。结果13人，16侧肢体存在18支交通支，出现率22．2％，男性与女性相比出现率高且差异显著，左右肢体的出现率无显著差异。其中肌皮神经从正中神经低位发出的有2支，正中神经-肌皮神经的交通支（Ⅰ型）与肌皮神经-正中神经的交通支（Ⅱ型）相比起、止点低，交通支较长，但直径细（Ⅰ型14．2～23．0cm，止点为11．0～21．5cm，长度为2．5～10．7cm，直径为0．55～2．15mm；Ⅱ型起点为0～17．ocm，止点为12．0～24．0cm，长度为1．9～8．4cm，直径为0．76～2．60mm）但两者差异无统计学意义（P〉0．05）。结论正中神经与肌皮神经之间存在着交通支，并起着一定的功能，手术时应注意加以保护，避免损伤。     

大鼠正中神经修复后不同时段的电生理变化与神经再生的相关性分析

目的 探讨大鼠正中神经切断缝合后的不同时段,其复合神经动作电位(CNAP)与形态学方面的特点及其相关性分析.方法 在大鼠上臂正中神经中段切断缝合后的不同时间点(2、3、4、6、8和12周)进行CNAP检测,随后取正中神经组织进行形态学检查.结果 术后第2周可以记录到CNAP.术后再生神经记录的CNAP幅度比对照组显著减低(P<0.01),波幅下面积(Area)也显著低于对照组(P<0.01),传导速度(CV)显著慢于对照组(P<0.01).术后2～6周的潜伏期(Lat)均比对照组明显延长(P<0.05);术后2～8周刺激强度,即阈强度(THI)和超大刺激强度(SSI)显著低于对照组.CNAP的第一峰波幅(FPA)、峰-峰波幅(PPA)、Area、CV变化趋势为随时间增加而逐渐增高,而其参数Lat、THI、SSI随时间增加而逐渐降低.神经修复后2周缝合口远端已有少量的新生轴突,随着再生时间延长,越来越多的再生轴突延伸至远端.远端记录的CNAP波幅与其有髓神经纤维计数之间有强的正相关(相关系数为0.953).线性回归分析表明,存在线性关系.术后8周髓鞘趋向于成熟.结论 CNAP是早期诊断和评价损伤神经再生程度的良好指标.正常正中神经的CNAP波幅可能与有髓神经纤维的计数呈线性关系.术后第8周,CNAP参数趋向于稳定,神经髓鞘渐趋向于成熟.

Abstract：

Objective To explore the characteristics of compound nerve action potential (CNAP) after rat median nerve transection and repair,and their correlation with neuromorphometry at various time points. Methods The median nerve was transected and sutured at mid-arm level. At various time points from 2 to 12 weeks postoperatively,CNAP recording was performed and the median nerve was harvested for morphological examination. Results CNAP could be recorded at 2 weeks after nerve repair. The CNAP amplitude,the area below the curve (Area) and conduction velocity (CV) of regenerated nerve were significantly lower than those of control group (P＜0.01). From 2 weeks to 6 weeks postoperatively,CNAP latency (Lat) was obviously longer than normal (P＜0.05). From 2 weeks to 8 weeks postoperatively,CNAP stimulus intensity (threshold intensity and the supramaximal stimulation intensity,THI and SSI) was significantly lower than that of the control group (P＜0.01). First peak amplitude (FPA),peak-peak amplitude (PPA),Area and CV of CNAP increased with time,while parameters such as Lat,THI and SSI decreased over time in regenerated median nerve. Regenerated axons could be seen at 2 weeks after nerve transection and repair. More and more regenerated axons were seen with the lapse of time. There was a strong positive correlation between CNAP amplitude and the number of myelinated nerve fibers,with a 0.953 correlation coefficient. Linear regression analysis revealed the existence of a linear relationship. The maturity of regenerated nerve at 8 weeks reflected by myelin sheath thickness was close to that of a normal median nerve. Conclusion CNAP recording is a valuable tool to evaluate the extent of early nerve regeneration after nerve suture repair. There might exist a linear relationship between CNAP amplitude of normal median nerve and the number of myelinated nerve fibers. CNAP parameters are inclined to stabilize and nerve myelin sheath maturation is close to normal 8 weeks postoperatively.