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Bertelli JA, Rosa ICN, Ghizoni MF. Retrograde peripheral nerve regeneration from sensory to motor pathways in rats: a new experimental concept in nerve repair. Neurol Res 2024; 46:125-131. [PMID: 37729085 DOI: 10.1080/01616412.2023.2258039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 09/03/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND The polarity of nerve grafts does not interfere with axon growth. Our goal was to investigate whether axons can regenerate in a retrograde fashion within sensory pathways and then extend into motor pathways, leading to muscle reinnervation. METHODS Fifty-four rats were randomized into four groups. In Group 1, the ulnar nerve was connected end-to-end to the superficial radial nerve after neurectomy of the radial nerve in the axilla. In Group 2, the ulnar nerve was connected end-to-end to the radial nerve distal to the humerus; the radial nerve then was divided in the axilla. In Group 3, the radial nerve was divided in the axilla, but no nerve reconstruction was performed. In Group 4, the radial nerve was crushed in the axilla. Over 6 months, we behaviorally assessed the recovery of toe spread in the right operated-upon forepaw by lifting the rat by its tail and lowering it onto a flat surface. Six months after surgery, rats underwent reoperation, nerve transfers were tested electrophysiologically, and the posterior interosseous nerve (PIN) was removed for histological evaluation. RESULTS Rats in the crush group recovered toe spread between 5 and 8 days after surgery. Rats with nerve transfers demonstrated electrophysiological and histological findings of nerve regeneration but no behavioral recovery. CONCLUSIONS Ulnar nerve axons regrew into the superficial radial nerve and then into the PIN to reinnervate the extensor digitorum communis. We were unable to demonstrate behavioral recovery because rats cannot readapt to cross-nerve transfer.
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Affiliation(s)
- Jayme A Bertelli
- Department of Surgery in lieu of Department of Surgical Techniques, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | - Isadora Carvalho Nunes Rosa
- Center of Biological and Health Sciences, University of the South of Santa Catarina (UNISUL), Tubarão, Santa Catarina, Brazil
| | - Marcos F Ghizoni
- Department of Neurosurgery, Center of Biological and Health Sciences, University of the South of Santa Catarina (UNISUL), Tubarão, Santa Catarina, Brazil
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Łukasz W, Ryszard T, Maria D. Radial Nerve Palsy Associated with Humeral Shaft Fractures in Children. BIOMED RESEARCH INTERNATIONAL 2023; 2023:3974604. [PMID: 38075371 PMCID: PMC10708953 DOI: 10.1155/2023/3974604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 01/02/2023] [Accepted: 01/20/2023] [Indexed: 12/18/2023]
Abstract
Background This is the first systematic review of the relationship between humeral shaft fractures and radial nerve palsy in children. The present comprehensive review is aimed at identifying important clinical findings between humeral diaphysis fractures and radial nerve injuries and assessing the effects of treatment. Methods We searched electronic bibliographic databases, including PubMed, the Cochrane Library, Scopus, and Web of Knowledge, until March 2022. This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the patients, interventions, comparisons, outcomes guidelines. Results We identified 23 original papers, of which 10 were eligible for further analysis. Cases of 32 young patients with radial nerve palsy were identified and analyzed. The prevalence of radial nerve palsy was 4.34% (eight cases out of 184 patients with humeral shaft fractures). The radial nerve was most often associated with a simple transverse fracture (12A3, 17 cases (65.4%)). Conclusions Radial nerve injury in humeral shaft fractures in children is rare, with a frequency of 4.34%. We highly recommend early surgical nerve exploration with transverse fractures in the distal third segment combined with primary radial palsy. Furthermore, we recommend making thoughtful decisions regarding early nerve exploration in the Holstein-Lewis fractures. In addition, consideration of early surgical nerve exploration in fractures resulting from high-energy trauma and open fractures despite their morphology is recommended.
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Affiliation(s)
- Wiktor Łukasz
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children's Health Centre, Katowice, Poland
- Department of Trauma and Orthopedic Surgery, ZSM Hospital, Chorzów, Poland
| | - Tomaszewski Ryszard
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children's Health Centre, Katowice, Poland
- Faculty of Science and Technology, Institute of Biomedical Engineering, University of Silesia in Katowice, Katowice, Poland
| | - Damps Maria
- Department of Anaesthesiology and Intensive Care, Upper Silesian Child Health Centre, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
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Graff C, Dounas GD, Todd MRLC, Sung J, Kumawat M. Management of Traumatic Nerve Palsies in Paediatric Supracondylar Humerus Fractures: A Systematic Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1862. [PMID: 38136064 PMCID: PMC10741981 DOI: 10.3390/children10121862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023]
Abstract
Purpose: Up to 12% of paediatric supracondylar humerus fractures (SCHFs) have an associated traumatic nerve injury. This review aims to summarize the evidence and guide clinicians regarding the timing of investigations and/or surgical interventions for traumatic nerve palsies after this injury. Methods: A formal systematic review was undertaken in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews and PRISMA guidelines. Manuscripts were reviewed by independent reviewers against the inclusion and exclusion criteria, and data extraction, synthesis, and assessment for methodological quality were undertaken. Results: A total of 51 manuscripts were included in the final evaluation, reporting on a total of 510 traumatic nerve palsies in paediatric SCHFs. In this study, 376 nerve palsies recovered without any investigation or intervention over an average time of 19.5 weeks. Comparatively, 37 went back to theatre for exploration beyond the initial treatment due to persistent deficits, at an average time of 4 months. The most common finding at the time of exploration was entrapment of the nerve requiring neurolysis. A total of 27 cases did not achieve full recovery regardless of management. Of the 15 reports of nerve laceration secondary to paediatric SCHFs, 13 were the radial nerve. Conclusions: Most paediatric patients who sustain a SCHF with associated traumatic nerve injury will have full recovery. Delayed or no recovery of the nerve palsy should be considered for exploration within four months of the injury; earlier exploration should be considered for radial nerve palsies.
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Affiliation(s)
- Christy Graff
- The Women’s and Children’s Hospital, North Adelaide, SA 5006, Australia (J.S.)
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia (M.K.)
- The Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - George Dennis Dounas
- The Women’s and Children’s Hospital, North Adelaide, SA 5006, Australia (J.S.)
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia (M.K.)
- The Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Maya Rani Louise Chandra Todd
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia (M.K.)
- The Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Jonghoo Sung
- The Women’s and Children’s Hospital, North Adelaide, SA 5006, Australia (J.S.)
| | - Medhir Kumawat
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA 5005, Australia (M.K.)
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Gadani A, Rabhi C, Forli A. Radial nerve lesion after medial epicondyle osteosynthesis in a pediatric patient: A rare complication of surgery. HAND SURGERY & REHABILITATION 2023; 42:451-454. [PMID: 37482276 DOI: 10.1016/j.hansur.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/08/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023]
Abstract
Fractures of the medial epicondyle are relatively common in children and may be associated with nerve lesion, especially in case of displacement. Incarceration of the ulnar nerve in the fracture site is feared in Watson-Jones stage II, rarely directly related to osteosynthesis. Depending on the degree of fracture displacement, various osteosynthesis techniques may be used; nerve injuries are a rare but known complication of these procedures. We report a case of radial nerve injury related to pinning osteosynthesis of a medial epicondyle fracture.
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Affiliation(s)
- Anaëlle Gadani
- Pediatric Orthopedic Department, Grenoble Alpes University, Grenoble Alpes University Hospital, 38043 Grenoble Cedex 09, France.
| | - Camille Rabhi
- Pediatric Orthopedic Department, Grenoble Alpes University, Grenoble Alpes University Hospital, 38043 Grenoble Cedex 09, France
| | - Alexandra Forli
- Plastic and Reconstructive Surgery, Hand Surgery Unit, Grenoble Alpes University Hospital, 38043 Grenoble Cedex 09, France
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Zhu S, Lei GW, Pang Z, Gao ZR, Shen YD, Xu WD. Outcomes and prognostic factors for nerve grafting following high radial nerve injury. J Hand Surg Eur Vol 2023; 48:747-754. [PMID: 36708214 DOI: 10.1177/17531934221147651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In this study, we examined the prognostic factors affecting outcomes following nerve grafting in high radial nerve injuries. Thirty-three patients with radial nerve injuries at a level distal to the first branch to the triceps and proximal to the posterior interosseous nerve were retrospectively studied. After a follow-up of at least 1 year, 24 patients (73%) obtained M3+ wrist extension, 16 (48%) obtained M3+ finger extension and only ten (30%) obtained M3+ thumb extension. Univariate, multivariate and receiver operating characteristic analyses showed that a delay in the repair of less than 6 months, a defect length of less than 5 cm or when grafted with three or more donor nerve cables achieved better recovery. Number of cables used was related to muscle strength recovery but not time to reinnervation. Nerve grafting for high radial nerve injury achieved relatively good wrist extension but poor thumb extension and is affected by certain prognostic factors. Level of evidence: IV.
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Affiliation(s)
- Shuai Zhu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Gao-Wei Lei
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhen Pang
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Zheng-Run Gao
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yun-Dong Shen
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Wen-Dong Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
- Department of Hand and Upper Extremity Surgery, Jing'an District Center Hospital, Shanghai, China
- NHC Key Laboratory of Hand Reconstruction, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, China
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Kim D, Baghi R, Koh K, Zhang LQ. MCP extensors respond faster than flexors in individuals with severe-to-moderate stroke-caused impairment: Evidence of uncoupled neural pathways. Front Neurol 2023; 14:1119761. [PMID: 37034096 PMCID: PMC10075324 DOI: 10.3389/fneur.2023.1119761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 02/28/2023] [Indexed: 04/11/2023] Open
Abstract
Damage in the corticospinal system following stroke produces imbalance between flexors and extensors in the upper extremity, eventually leading to flexion-favored postures. The substitution of alternative tracts for the damaged corticospinal tract is known to excessively activate flexors of the fingers while the fingers are voluntarily being extended. Here, we questioned whether the cortical source or/and neural pathways of the flexors and extensors of the fingers are coupled and what factor of impairment influences finger movement. In this study, a total of seven male participants with severe-to-moderate impairment by a hemiplegic stroke conducted flexion and extension at the metacarpophalangeal (MCP) joints in response to auditory tones. We measured activation and de-activation delays of the flexor and extensor of the MCP joints on the paretic side, and force generation. All participants generated greater torque in the direction of flexion (p = 0.017). Regarding co-contraction, coupled activation of the extensor is also made during flexion in the similar way to coupled activation of the flexor made during extension. As opposite to our expectation, we observed that during extension, the extensor showed marginally significantly faster activation (p = 0.66) while it showed faster de-activation (p = 0.038), in comparison to activation and de-activation of the flexor during flexion. But movement smoothness was not affected by those factors. Our results imply that the cortical source and neural pathway for the extensors of the MCP joints are not coupled with those for the flexors of the MCP joints.
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Affiliation(s)
- Dongwon Kim
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, United States
- Department of Bioengineering, School of Engineering, University of Maryland, College Park, MD, United States
| | - Raziyeh Baghi
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, United States
| | - Kyung Koh
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, United States
| | - Li-Qun Zhang
- Department of Physical Therapy and Rehabilitation Science, University of Maryland, Baltimore, MD, United States
- Department of Bioengineering, School of Engineering, University of Maryland, College Park, MD, United States
- Department of Orthopedics, University of Maryland, Baltimore, MD, United States
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Wiktor Ł, Tomaszewski R. Treatment of Radial Nerve Palsy in Paediatric Humeral Shaft Fractures. STROBE-Compliant Investigation. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1571. [PMID: 36363527 PMCID: PMC9697801 DOI: 10.3390/medicina58111571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/09/2022] [Accepted: 10/29/2022] [Indexed: 12/25/2023]
Abstract
Background and Objectives:Due to the rarity of radial nerve palsy in humeral shaft fractures in the paediatric population and the lack of data in the literature, the purpose of our study was to report the treatment results of six children who sustained a radial nerve injury following a humeral shaft fracture. Materials and Methods: We treated six paediatric patients with radial nerve palsy caused by a humeral shaft fracture in our department from January 2011 to June 2022. The study group consisted of four boys and one girl aged 8.6 to 17.2 (average 13.6). The mean follow-up was 18.4 months. To present our results, we have used the STROBE protocol designed for retrospective observational studies. Results:We diagnosed two open and four closed humeral shaft fractures. Two simple transverse AO 12A3c; one simple oblique AO 12A2c; two simple spiral AO 12A1b/AO 12A1c and one intact wedge AO 12B2c were recognized. The humeral shaft was affected in the distal third five times and in the middle third one time. In our study group, we found two cases of neurotmesis; two entrapped nerves within the fracture; one stretched nerve over the bone fragments and one case of neuropraxia. We found restitution of the motor function in all cases. For all patients, extensor muscle strength was assessed on the grade M4 according to the BMRC scale (except for a patient with neuropraxia-M5). The differences in patients concerned the incomplete extension at the radiocarpal and metacarpophalangeal (MCP) joints. Conclusions: In our small case series, humeral shaft fractures complicated with radial nerve palsy are always challenging medical issues. In paediatric patients, we highly recommend an US examination where it is possible to be carried out to improve the system of decision making. Expectant observation with no nerve exploration is reasonable only in close fractures caused by low-energy trauma. Early surgical nerve exploration related with fracture stabilisation is highly recommended in fractures after high-energy trauma, especially in open fractures and where symptoms of nerve palsy appear at any stage of conservative treatment.
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Affiliation(s)
- Łukasz Wiktor
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children’s Health Centre, 40-752 Katowice, Poland
- Department of Trauma and Orthopedic Surgery, ZSM Hospital, 41-500 Chorzów, Poland
| | - Ryszard Tomaszewski
- Department of Trauma and Orthopaedic Surgery, Upper Silesian Children’s Health Centre, 40-752 Katowice, Poland
- Institute of Biomedical Engineering, Faculty of Science and Technology, University of Silesia in Katowice, 40-007 Katowice, Poland
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8
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Sacco C, Olivi S, Visani J, Donati R, Veronesi V, Mencarani C, Capone C, Bizzocchi G, Kiekens C, De Bonis P, Scerrati A, Staffa G. Functional outcome after transfer of brachialis on anterior interosseous and supinator on posterior interosseous nerves: A preliminary report. Microsurgery 2022; 42:577-585. [PMID: 35484858 DOI: 10.1002/micr.30891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 02/13/2022] [Accepted: 04/14/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Traumatic spinal cord injury (SCI) resulting in tetraplegia is a leading cause of morbidity among young adults worldwide and its management remains challenging. Restoring hand function in these patients must be considered a top priority with great impact on their quality of life (QOL); although nerve and tendon transfer have been extensively described, type of procedure to be chosen is not standardized and few studies have determined the functional outcome of those procedure and their impact on QOL is still poorly assessed. We report a preliminary retrospective study regarding feasibility and functional outcomes of nerve transfer procedures including bilateral brachialis nerve on anterior interosseous nerve (AIN) and supinator branch on posterior interosseous nerve (PIN) for hand reanimation following SCI focusing on the impact of these procedures on QOL. METHODS We performed a retrospective study involving patient sustained SCI and underwent nerve transfer of brachialis branch from musculocutaneous nerve on AIN and supinator branch from the trunk of the radial nerve on the PIN. We included 11 patients (14 limbs) with traumatic SCI resulting in C4 level tetraplegia in five patients, C5 in four and C6 and C7 in one case each, with a median age of 31.5 years underwent surgery at a median of 10 months after injury; including both transfers in 10 cases and AIN reanimation only in one. Functional assessment including medical research council (MCR) grade, graded redefined assessment of strength sensation and prehension (GRASSP) and spinal cord independence measure (SCIM) were performed at least 12 months follow up. RESULTS Thirteen PIN innervated muscles achieved an MRC score ≥3/5 whereas AIN supplied muscles in 5 out of 15. GRASSP qualitative measure improved from a baseline value of 1 to 2, while quantitative measure passed from 1 to 3 after 12 months; the difference was statistically significant (p = .005 and p = .008, respectively). SCIM self-care sub-score also statistically significant improved from 3 to 4 at 12 months (p = .016). No complication or donor morbidity occurred. CONCLUSIONS Functional performance has been significantly improved by nerve transfer procedures 1 year after surgery. Nerve transfers may represent a valuable option for the restoration of the hand function in patients with tetraplegia with minor or no morbidity.
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Affiliation(s)
- Carlo Sacco
- Peripheral Nerve Surgery Unit, Ospedale per gli Infermi-Faenza, Faenza, Italy
| | - Silvia Olivi
- Spinal Unit, Montecatone Rehabilitation Institute, Imola, Italy
| | - Jacopo Visani
- Peripheral Nerve Surgery Unit, Ospedale per gli Infermi-Faenza, Faenza, Italy.,Department of Neurosurgery, Sant'Anna University Hospital-Ferrara, Cona, Italy
| | - Roberto Donati
- Peripheral Nerve Surgery Unit, Ospedale per gli Infermi-Faenza, Faenza, Italy
| | - Vanni Veronesi
- Peripheral Nerve Surgery Unit, Ospedale per gli Infermi-Faenza, Faenza, Italy
| | - Camilla Mencarani
- Peripheral Nerve Surgery Unit, Ospedale per gli Infermi-Faenza, Faenza, Italy
| | - Crescenzo Capone
- Peripheral Nerve Surgery Unit, Ospedale per gli Infermi-Faenza, Faenza, Italy
| | - Gianluca Bizzocchi
- Peripheral Nerve Surgery Unit, Ospedale per gli Infermi-Faenza, Faenza, Italy
| | | | - Pasquale De Bonis
- Department of Neurosurgery, Sant'Anna University Hospital-Ferrara, Cona, Italy
| | - Alba Scerrati
- Department of Neurosurgery, Sant'Anna University Hospital-Ferrara, Cona, Italy
| | - Guido Staffa
- Peripheral Nerve Surgery Unit, Ospedale per gli Infermi-Faenza, Faenza, Italy
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Choong J, Baldrighi C, Oestreitch K, Jester A. Successful Delayed Neurolysis of the Median Nerve in a Teenager 7 years After Supracondylar Fracture: A Case Report and Review of the Literature. Ann Plast Surg 2021; 87:e37-e39. [PMID: 34559714 DOI: 10.1097/sap.0000000000002916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Supracondylar humeral fractures are the commonest elbow fractures in childhood, associated with a high rate of neurological complications. We present the case of a 14-year-old adolescent girl with persisting daily pain, lack of sensation, and strength to her left hand after a displaced supracondylar fracture 7 years earlier. At the time of the fracture, she underwent closed reduction and percutaneous Kirschner wire fixation. During revision surgery, half of the median nerve was found embedded in bone at the level consistent with the healed fracture site. Neurolysis of the fascicles adherent to the bone was performed. Postoperatively, the patient had complete recovery of sensation, reduced pain, and a 2.5-fold improvement of grip strength. This case shows that there is a role for delayed neurolysis in children.
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Catena N, Gennaro GLD, Jester A, Martínez-Alvarez S, Pontén E, Soldado F, Steiger C, Choong J, Zarantonello P, Farr S. Current concepts in diagnosis and management of common upper limb nerve injuries in children. J Child Orthop 2021; 15:89-96. [PMID: 34040654 PMCID: PMC8138792 DOI: 10.1302/1863-2548.15.200203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Peripheral nerve injuries (PNI) of the upper limb are a common event in the paediatric population, following both fractures and soft tissues injuries. Open injuries should in theory be easier to identify and the repair of injured structures performed as soon as possible in order to obtain a satisfying outcome. Conversely, due to the reduced compliance of younger children during clinical assessment, the diagnosis of a closed nerve injury may sometimes be delayed. As the compliance of patients is influenced by pain, anxiety and stress, the execution of the clinical manoeuvres intended to identify a loss of motor function or sensibility, can be impaired. Although the majority of PNI are neuroapraxias resulting in spontaneous recovery, there are open questions regarding certain aspects of closed PNI, e.g. when to ask for electrophysiological exams, when and how long to wait for a spontaneous recovery and when a surgical approach becomes mandatory. The aim of the article is therefore to analyse the main aspects of the different closed PNI of the upper limb in order to provide recommendations for timely and correct management, and to determine differences in the PNI treatment between children and adults.
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Affiliation(s)
- Nunzio Catena
- Hand Surgery and Microsurgery Unit – Pediatric Orthopedic and Traumatology Unit – Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | - Andrea Jester
- Hand and Upper Limb Service, Department of Plastic Surgery – Birmingham Womes’s and Children’s Hospital, Birmingham, UK
| | | | - Eva Pontén
- Department of Pediatric Orthopedic Surgery – Karolinska University Hospital, Stockholm, Sweden
| | - Francisco Soldado
- International Pediatric Hand Surgery and Microsurgery Institute – Barcelona Childrens Hospital HM Nens – HM Hospitales, Barcelona, Spain
| | - Christina Steiger
- Pediatric Orthopedic Division – Geneva Children’s Hospital, Geneve, Switzerland
| | - Jiahui Choong
- Hand and Upper Limb Service, Department of Plastic Surgery – Birmingham Womes’s and Children’s Hospital, Birmingham, UK
| | - Paola Zarantonello
- Pediatric Orthopedic and Traumatology Unit – IRCCS Rizzoli, Bologna, Italy
| | - Sebastian Farr
- Orthopedic Hospital Speising, Department of Pediatric Orthopedics and Foot and Ankle Surgery, Vienna, Austria,Correspondence should be sent to Sebastian Farr (EPOS Upper Limb Group Chair), Orthopedic Hospital Speising, Department of Pediatric Orthopedics and Foot and Ankle Surgery, Vienna, Austria. E-mail:
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11
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Bertelli JA, Nehete S, Winkelmann Duarte EC, Ghizoni MF. Transfer of the Distal Anterior Interosseous Nerve for Thumb Motion Reconstruction in Radial Nerve Paralysis. J Hand Surg Am 2020; 45:877.e1-877.e10. [PMID: 32209268 DOI: 10.1016/j.jhsa.2020.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 12/30/2019] [Accepted: 02/11/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE With nerve or tendon surgery, the results of thumb reconstruction to treat radial nerve paralysis are suboptimal. The goals of this study were to describe the anatomy of the deep branch of the posterior interosseous nerve (PIN) to the thumb extensor muscles (DBPIN), and to report the clinical results of transferring the distal anterior interosseous nerve (DAIN) to the DBPIN. METHODS The PIN was dissected in 12 fresh upper limbs. Myelinated nerve fibers in the DBPIN and DAIN were counted. Five patients with radial nerve paralysis underwent transfer of the motor branch to the flexor carpi radialis to the PIN and a motor branch of the pronator teres to the extensor carpi radialis brevis. In addition, these patients had selective reconstruction of thumb motion by transferring the DAIN to the DBPIN, through either a combined volar and dorsal approach (n = 2) or a single dorsal approach (n = 3) with division of the interosseous membrane. RESULTS At the origin of the abductor pollicis longus, the DBPIN divided into a lateral branch that innervated the abductor pollicis longus and extensor pollicis brevis, and a medial branch that innervated the extensor pollicis longus and extensor index proprius. The number of myelinated nerve fibers in the DAIN corresponded to 65% of that of the DBPIN. In each of the 5 patients, full thumb motion at the trapeziometacarpal joint was restored with no, or minimal, extension lag at the metacarpophalangeal (MCP) joint. CONCLUSIONS The anatomy of the DBPIN is predictable. Transferring the DAIN to the DBPIN is feasible through a single dorsal approach, allowing full recovery of thumb motion. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Jayme Augusto Bertelli
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Santa Catarina, Brazil; Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil.
| | - Sushil Nehete
- Wockhardt Hospital, The Umrao IMSR, Thane, Maharashtra, India
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Bertelli JA. Nerve Versus Tendon Transfer for Radial Nerve Paralysis Reconstruction. J Hand Surg Am 2020; 45:418-426. [PMID: 32093993 DOI: 10.1016/j.jhsa.2019.12.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 10/23/2019] [Accepted: 12/17/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE With radial nerve lesions, the results of nerve transfers and how they objectively compare with the outcomes of tendon transfers remain unstudied. We compared the results after nerve transfer in patients with less than 12 months since radial nerve injury with the results after tendon transfer in patients not eligible for nerve surgery because of longstanding paralysis (minimum of 15 months). METHODS In 14 patients with radial nerve lesions incurred less than 12 months previously, we transferred the anterior interosseous nerve to the nerve of the extensor carpi radialis brevis (ECRB), while the nerve to the flexor carpi radialis was transferred to the posterior interosseous nerve. In 13 patients with lesions of longer duration, we transferred the pronator teres tendon to the ECRB, the flexor carpi ulnaris tendon to the extensor digitorum communis, and the palmaris longus to the rerouted extensor pollicis longus (EPL) tendon. At a final evaluation, we measured passive and active range of motion (ROM) of the wrist, finger, and thumb and grasp strength. RESULTS In a comparison of wrist flexion-extension ROM and grasp strength, we observed better recovery in the nerve transfer than in the tendon transfer group. In the tendon transfer group, we observed limitations in wrist flexion in 9 of the 13 patients and permanent radial deviation in 5. Half of the patients in the tendon transfer group needed to flex their wrist to fully extend their fingers, whereas finger extension was possible with the wrist either extended or at neutral in all patients following nerve transfer. After nerve transfer, extension at the first carpometacarpal joint was restored in 11 of the 14 patients, whereas this occurred in just 4 of the 13 patients following tendon transfer. In both groups, we observed a 30° lag in thumb metacarpophalangeal extension, which reflects poor recovery of EPL function. CONCLUSIONS Overall, we observed better outcomes in those who underwent nerve transfer versus tendon transfer procedures. However, room still remains for improved thumb motion with both procedures. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Jayme Augusto Bertelli
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão; Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, SC, Brazil.
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Peripheral nerve injuries in the pediatric population: a review of the literature. Part I: traumatic nerve injuries. Childs Nerv Syst 2019; 35:29-35. [PMID: 30215119 DOI: 10.1007/s00381-018-3974-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/04/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE This article reviews the clinical results that can be obtained after repair of a traumatic peripheral nerve injury in the pediatric population. METHODS A systematic review of the published literature has been made. RESULTS Functional outcome after major nerve injuries is sometimes disappointing in adults. However, children have been reported to experience much better functional results after nerve repair than adults. Moreover, recovery generally is faster in children. The superior capacity of children's central nervous system to adapt to external or internal environmental changes (neural plasticity) and the shorter recovery distance from the axon repair site to the target muscle are claimed to be crucial determinants of their favorable outcomes. Moreover, even in the pediatric population, it has been demonstrated that functional results are better the younger the patient is, including better clinical results in those injured in early childhood (< 6 years old) than in those injured in adolescence. Other favorable prognostic factors include the type of nerve injury (with complete transections doing less well than crush injuries) and the timing of surgery (with better outcomes after early repairs). CONCLUSIONS All efforts should be done to repair in a timely and adequate fashion traumatic peripheral nerve injuries in children, as the results are good.
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