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Vital L, Vidinha V, Neves N, Negrão P. Supracondylar Apophysis of the Humerus: Rare Cause of High Compression of the Median Nerve. Rev Bras Ortop 2023; 58:e659-e661. [PMID: 37663176 PMCID: PMC10468235 DOI: 10.1055/s-0040-1718509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022] Open
Abstract
Supracondylar apophysis (SA) is a bony prominence that originates from the anteromedial aspect of the distal humerus with a lower projection and which, although usually asymptomatic, due to the relationship with adjacent structures can cause symptoms. We describe the case of a 42-year-old woman with pain complaints radiating from her elbow to her hand, with 6 months of evolution. On objective examination, the patient had a sensory deficit in the median nerve territory and decreased grip strength. Radiographs of the distal humerus were performed, in which a bone spike was visible, and magnetic resonance imaging showed thickening of the median nerve epineurium. Electromyography showed severe axonal demyelination of the median nerve proximal to the elbow. A median nerve compression caused by a SA was diagnosed. The patient underwent surgery and, 1 year after the operation, she had a complete clinical recovery. Supracondylar apophysis is a rare, but possible and treatable cause of high median nerve compression.
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Affiliation(s)
- Luísa Vital
- Médicos Ortopedistas, Departamento de Ortopedia e Traumatologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Vitor Vidinha
- Médicos Ortopedistas, Departamento de Ortopedia e Traumatologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Nuno Neves
- Médicos Ortopedistas, Departamento de Ortopedia e Traumatologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Pedro Negrão
- Médicos Ortopedistas, Departamento de Ortopedia e Traumatologia, Centro Hospitalar Universitário de São João, Porto, Portugal
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Dharmshaktu G, Dharmshaktu I, Agarwal N. Incidental finding of asymptomatic supracondylar process of the humerus: A case series. MATRIX SCIENCE MEDICA 2023. [DOI: 10.4103/mtsm.mtsm_9_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Löppönen P, Hulkkonen S, Ryhänen J. Proximal Median Nerve Compression in the Differential Diagnosis of Carpal Tunnel Syndrome. J Clin Med 2022; 11:3988. [PMID: 35887752 PMCID: PMC9317082 DOI: 10.3390/jcm11143988] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022] Open
Abstract
Carpal tunnel syndrome (CTS) is the most common median nerve compression neuropathy. Its symptoms and clinical presentation are well known. However, symptoms at median nerve distribution can also be caused by a proximal problem. Pronator syndrome (PS) and anterior interosseous nerve syndrome (AINS) with their typical characteristics have been thought to explain proximal median nerve problems. Still, the literature on proximal median nerve compressions (PMNCs) is conflicting, making this classic split too simple. This review clarifies that PMNCs should be understood as a spectrum of mild to severe nerve lesions along a branching median nerve, thus causing variable symptoms. Clear objective findings are not always present, and therefore, diagnosis should be based on a more thorough understanding of anatomy and clinical testing. Treatment should be planned according to each patient's individual situation. To emphasize the complexity of causes and symptoms, PMNC should be named proximal median nerve syndrome.
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Affiliation(s)
- Pekka Löppönen
- Department of Orthopedics and Traumatology, Seinäjoki Central Hospital, FI-60220 Seinäjoki, Finland
| | - Sina Hulkkonen
- Department of Hand Surgery, Helsinki University Hospital, University of Helsinki, FI-00029 Helsinki, Finland; (S.H.); (J.R.)
| | - Jorma Ryhänen
- Department of Hand Surgery, Helsinki University Hospital, University of Helsinki, FI-00029 Helsinki, Finland; (S.H.); (J.R.)
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Husain R, Reddy A, Dayan E, Huang M, Corcuera-Solano I. MRI Evaluation of Various Elbow, Forearm, and Wrist Neuropathies: A Pictorial Review. Semin Musculoskelet Radiol 2021; 25:617-627. [PMID: 34706391 DOI: 10.1055/s-0041-1729961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Upper extremity entrapment neuropathies are common and can cause pain, sensory loss, and muscle weakness leading to functional disability. We conducted a retrospective review from January 2007 until March 2020 of the magnetic resonance imaging (MRI) features of intrinsic and extrinsic causes of wrist, forearm, and elbow neuropathies of 637 patients who received a diagnosis of neuropathy by means of clinical and electrodiagnostic testing. We discuss cases with varying intrinsic and extrinsic nerve pathologies, including postoperative examples, affecting the median, radial, and ulnar nerve.Our collection of cases demonstrates a diversity of intrinsic and extrinsic causative factors. Intrinsic pathologies include neuritis as well as tumors arising from the nerve. Extrinsic causes resulting in nerve entrapment include masses, acute and chronic posttraumatic cases, anatomical variants, inflammatory and crystal deposition, calcium pyrophosphate deposition disease, and dialysis-related amyloidosis. Finally, we review postsurgical cases, such as carpal tunnel release and ulnar nerve transposition.Although upper extremity neuropathies tend to have a typical clinical presentation, imaging, particularly MRI, plays a vital role in evaluating the etiology and severity of each neuropathy and ultimately helps guide clinical management.
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Affiliation(s)
- Rola Husain
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Arthi Reddy
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Etan Dayan
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Mingqian Huang
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Idoia Corcuera-Solano
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
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Antil N, Stevens KJ, Lutz AM. Elbow Imaging: Variants and Asymptomatic Findings. Semin Musculoskelet Radiol 2021; 25:546-557. [PMID: 34706384 DOI: 10.1055/s-0041-1729960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
One of the key principles in the interpretation of radiology images is the ability to differentiate between normal and abnormal findings. This article provides a comprehensive overview of normal structures and anatomical variants occurring around the elbow including potential diagnostic pitfalls. We discuss frequently observed anatomical variants found in routine clinical practice associated with osseous, ligamentous, musculotendinous, and neurovascular structures at the elbow that may simulate pathology or predispose to symptoms under specific circumstances.
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Affiliation(s)
- Neha Antil
- Division of Musculoskeletal Imaging, Department of Radiology, Stanford University, School of Medicine, Stanford, California
| | - Kathryn J Stevens
- Division of Musculoskeletal Imaging, Department of Radiology, Stanford University, School of Medicine, Stanford, California
| | - Amelie M Lutz
- Division of Musculoskeletal Imaging, Department of Radiology, Stanford University, School of Medicine, Stanford, California
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Abstract
Compressive neuropathies of the forearm are common and involve structures innervated by the median, ulnar, and radial nerves. A thorough patient history, occupational history, and physical examination can aid diagnosis. Electromyography, X-ray, and Magnetic Resonance Imaging may prove useful in select syndromes. Generally, first line therapy of all compressive neuropathies consists of activity modification, rest, splinting, and non-steroidal anti-inflammatory drugs. Many patients experience improvement with conservative measures. For those lacking adequate response, steroid injections may improve symptoms. Surgical release is the last line therapy and has varied outcomes depending on the compression. Carpal Tunnel syndrome (CTS) is the most common, followed by ulnar tunnel syndrome. Open and endoscopic CTS release appear to have similar outcomes. Endoscopic release appears to incur decreased cost baring a low rate of complications, although this is debated in the literature. Additional syndromes of median nerve compression include pronator syndrome (PS), anterior interosseous syndrome, and ligament of Struthers syndrome. Ulnar nerve compressive neuropathies include cubital tunnel syndrome and Guyon’s canal. Radial nerve compressive neuropathies include radial tunnel syndrome and Wartenberg’s syndrome. The goal of this review is to provide all clinicians with guidance on diagnosis and treatment of commonly encountered compressive neuropathies of the forearm.
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El-Haj M, Ding W, Sharma K, Novak C, Mackinnon SE, Patterson JMM. Median Nerve Compression in the Forearm: A Clinical Diagnosis. Hand (N Y) 2021; 16:586-591. [PMID: 31540555 PMCID: PMC8461194 DOI: 10.1177/1558944719874137] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Median nerve entrapment in the forearm (MNEF) without motor paralysis is a challenging diagnosis. This retrospective study evaluated the clinical presentation, diagnostic studies, and outcomes following surgical decompression of MNEF. Methods: The study reviewed 147 patient medical charts following MNEF surgical decompression. With exclusion of patients with combined nerve entrapments (radial and ulnar), polyneuropathy, neurotmetic nerve injury, or median nerve motor palsy, the study sample included 27 patients. Data collected include: clinical presentation and pain, strength, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 27 patients (mean follow-up = 7 months), and 13 patients had previous carpal tunnel release (CTR). Clinical presentation included pain (n = 27) (forearm, n = 22; median nerve innervated digits, n = 21; and palm, n = 21) and positive clinical tests (forearm scratch collapse test, n = 27; pain with compression over the flexor digitorum superficialis arch/pronator, n = 24; Tinel sign, n = 11). Positive electrodiagnostic studies were found for MNEF (n = 2) and carpal tunnel syndrome (n = 11). Primary CTR was performed in 10 patients and revision CTR in 7 patients. Postoperatively, there were significant (P < .05) improvements in strength, pain, quality of life, and DASH scores. Conclusions: The MNEF without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent forearm pain and median nerve symptoms (especially after CTR) should be evaluated for MNEF. Surgical decompression provides satisfactory outcomes.
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Affiliation(s)
- Madi El-Haj
- Washington University School of Medicine, St. Louis, MO, USA
| | - Wei Ding
- Shanghai Ninth People’s Hospital, China
| | - Ketan Sharma
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - J. Megan M. Patterson
- University of North Carolina School of Medicine, Chapel Hill, USA
- J. Megan M. Patterson, Department of Orthopaedics, University of North Carolina School of Medicine, 3135 Bioinformatics Building, Campus Box 7055, Chapel Hill, NC 27599-7055, USA.
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Elmgreen SB. Transient Proximal Median Nerve Entrapment in a Tetraplegic Hand Cyclist Following a 24-Hour Endurance Race. Mil Med 2021; 188:e1327-e1329. [PMID: 34114011 DOI: 10.1093/milmed/usab226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 11/13/2022] Open
Abstract
Median nerve entrapment is a frequent disorder encountered by all clinicians at some point of their career. Affecting the distal median nerve, entrapment occurs most frequently at the level of the wrist resulting in a carpal tunnel syndrome. Median nerve entrapment may also occur proximally giving rise to the much less frequent pronator teres syndrome and even less frequent anterior interosseous nerve syndrome, which owing to the paucity of cases may prove challenging to diagnose. An unusual case of anterior interosseous syndrome precipitated by extraordinary exertion in a tetraplegic endurance athlete is presented with ancillary dynamometric, electrodiagnostic, ultrasonographic, and biochemical findings.
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Affiliation(s)
- Søren Bruno Elmgreen
- Military Medical Research and Development, Danish Defence Medical Command, Brabrand, DK 8220, Denmark
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Abstract
The supracondylar process is a rare but commonly reported anatomical variant of the humerus. Though it is usually asymptomatic, it can lead to serious symptoms. In this report, a lateral supracondylar process of the humerus was found. This is much rarer than a medial supracondylar process, and to our knowledge, it has not been reported previously. Surgeons and radiologists must account for supracondylar process variations to diagnose neurovascular pathology in the forearm accurately and quickly to optimize surgical outcomes. Here, we describe the origin and clinical importance of the supracondylar process variant.
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Affiliation(s)
- Somya Bhatnagar
- Neurosurgery, Tulane University School of Medicine, New Orleans, USA
| | - Joe Iwanaga
- Neurosurgery, Tulane University School of Medicine, New Orleans, USA
| | - Aaron S Dumont
- Neurosurgery, Tulane University School of Medicine, New Orleans, USA
| | - R Shane Tubbs
- Neurosurgery and Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, USA
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Codd CM, Abzug JM. Upper Extremity Compressive Neuropathies in the Pediatric and Adolescent Populations. Curr Rev Musculoskelet Med 2020; 13:696-707. [PMID: 32720100 PMCID: PMC7661676 DOI: 10.1007/s12178-020-09666-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Although somewhat rare, upper extremity compressive neuropathies can occur in the pediatric and adolescent populations due to various etiologies. Some of the most common conditions seen include thoracic outlet syndrome, supracondylar process syndrome, cubital tunnel syndrome with subluxation of the ulnar nerve, and carpal tunnel syndrome. This review will focus on these diagnoses and how to address them in the pediatric and adolescent populations. RECENT FINDINGS Due to the rarity of upper extremity compressive neuropathies in the pediatric and adolescent populations, substantial advancement in the literature does not routinely occur. However, recent literature has found a difference in the rate of various subtypes of thoracic outlet syndrome in children versus adults. Additionally, cubital tunnel syndrome associated with ulnar nerve subluxation/instability has recently been found to have better outcomes following surgical decompression of the ulnar nerve and transposition than those with stable ulnar nerves. In summary, this review provides the most recent knowledge surrounding upper extremity compressive and entrapment neuropathies in the pediatric and adolescent populations.
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Affiliation(s)
- Casey M. Codd
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD USA
| | - Joshua M. Abzug
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD USA
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Chun SW, Lim SK. The utility of electrodiagnostic inching study and conservative treatment in supracondylar process syndrome: A case report. Medicine (Baltimore) 2020; 99:e20506. [PMID: 32481471 DOI: 10.1097/md.0000000000020506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Supracondylar process is a rare bony anomaly that can cause neurovascular symptoms. Previous reports on supracondylar process syndrome mostly suspect the condition by physical examination and simple radiograph with little assistance of electrodiagnostic methods and report efficiency of surgical treatment. PATIENTS CONCERNS A 45-year-old woman working at an assembly line packing boxes presented with tingling pain at her middle and ring fingers that started 2 months ago. She had positive Tinel sign at the medial side of the distal arm. DIAGNOSIS Electrodiagnostic inching study on median nerve was conducted and the conduction velocity at the segment between 3 cm to 5 cm proximal to the elbow crease was decreased to 27m/s. Following imaging studies revealed supracondylar process at 4.2 cm proximal to the medial epicondyle. She was successfully treated with conservative treatment. INTERVENTIONS Oral medications including Non-steroidal anti-inflammatory drug and pregabalin were prescribed along with superficial and deep heat modalities. The extent of manual labor was modified. Additionally, self-massage and stretching/nerve-gliding exercises were delivered. OUTCOMES The symptoms substantially improved and she could sleep without trouble, however, complete resolution was not achieved. After a year, she was nearly symptom-free after changing occupations with only occasional tingling after manual labor of unusual intensity. LESSONS This case report enlightens the versatility of electrodiagnostic inching study in localizing median neuropathy at the distal arm and the effectiveness of conservative treatment in supracondylar process syndrome.
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Affiliation(s)
- Se-Woong Chun
- Department of Rehabilitation Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
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Narayanan S, Adikesavan PN. Coexistence of variant pronator teres muscle and variant course of the neurovascular structures in the arm: clinical significance. Surg Radiol Anat 2020; 42:249-252. [DOI: 10.1007/s00276-019-02413-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/30/2019] [Indexed: 11/28/2022]
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