Anatomic considerations of the peripheral nerve in compressive neuropathies of the upper extremity.
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The role of the orthopedic surgeon in the management of Paget's disease is in: evaluation and treatment of the cause of a patient's pain; evaluation of any deformities; treatment of fractures and tumors in affected bones. Pain due to active disease must be differentiated from nerve compression syndromes and arthritic pain because effective medical treatment is now available for pagetic bones. Spinal stenosis and sciatica are frequent in patients with Paget's desease because of vertebral body remodeling and collpase. Femoral and pelvic osseus pain may improve with treatment while an arthritic hip will remain symptomatic and require hip joint replacement. On one hand, bowed femora with inactive disease appear to be subject to an aching type of pain that does not respond well to antipagetic agents. On the other hand, for some unknown reason, tibial symptoms may respond dramatically to the same treatment. Biopsy is necessary only to exclude neoplastic transformation. Bone scans are useful to screen for distribution of the disease. The serum alkaline phosphatase and 24 hour urinary hydroxyproline determinations are the main indicators of the response of the disease to treatment.
Stress fractures of the axial and appendicular skeleton typically present as localized pain that develops without a history of specific acute injury. The differential diagnosis includes primary or metastatic neoplasms, infections, musculoskeletal soft tissue injuries, nerve compression syndromes and joint diseases. Plain radiographs may demonstrate changes consistent with fracture, including a fracture line or fracture callus. In many cases, however, initial radiographs are normal or nondiagnostic. This occurs most frequently in three situations: (1) when radiographs are obtained soon after the onset of symptoms, before the appearance of a fracture line or new bone formation; (2) in patients with osteopenia, in whom detection of a fracture line and new bone formation is difficult, and (3) when the fracture involves areas of the skeleton that are difficult to study with plain films (including the spine and pelvis). When the plain films are normal, other tests such as bone scans, computed tomography or magnetic resonance imaging usually demonstrate the fracture.
Clinicians elicit a Tinel's sign by tapping over a nerve site with their fingertips. No standard force has been established, and overzealous tapping can produce a false-positive "Tinel's sign" that is actually a positive percussion test. The purpose of our study was to determine a threshold force that produces a positive percussion test in each of seven nerve locations in the upper extremities of subjects with no known nerve injuries and in subjects with nerve injuries. These data suggest limits for the amount of force necessary to elicit a Tinel's sign. If these limits are adhered to, the incidence of false-positive responses may be kept low.
A retrospective analysis of 26 consecutive cases of traumatic common peroneal nerve palsy seen during a four-year period in the Department of Rehabilitation Medicine at New York Medical College was carried out. Fifteen were complete lesions, nine were incomplete lesions, and there were two cases of neurapraxia. Among the factors studied were etiology, age, sex, associated injuries, electrodiagnostic findings, and prognosis for recovery. The ultimate functional status of the patients was evaluated up to three years following injury. Of the patients, 19.2% recovered fully, and 26.9% showed partial recovery. The maximum time of recovery was achieved in 15.5 months in complete lesions and 9.5 months in incomplete lesions. The relationship of peronneal nerve injury to fractures of the femur is emphasized. The indications for medical, surgical and rehabilitative management are discussed.
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The early ultrastructural changes which arise in nerve fibres following axonotmesis are described. The study was conducted experimentally by means of silk ligature of the tibial nerve in rabbits. The findings on electron microscopy of samples of nerve taken at two and twenty four hours respectively after operation are reported.
Compression neuropathies may occur at several points along the course of a nerve. Electrodiagnostic studies are helpful in the evaluation of nerve compression. Nerve conduction studies are the most useful of these techniques in determining the site of compression. Compression neuropathies of the upper extremities are common, and a well planned study is important to localize the site of involvement and the severity of the nerve damage.
The authors studied contractile properties of the skeletal muscle in 54 patients with compression-neural and myodystrophic syndromes of lumbar osteochondrosis aged 18-59 with the disease duration from one to six months, as well as in 200 experimental animals which had been subjected to application of colchicine to the root nerve L5 and reflex action on the axoplasmatic transport. Similarity of contractile parameters examined in experiment and in patients with myodystrophic manifestations has been established. At early periods of reinnervation one can observe a decrease in the force and rate of a single contraction and in a tetanic index, and at later periods--their decrease.
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Compression neuropathies are common in clinical practice. This article is a review of the clinical features of the common entrapment neuropathies affecting the upper extremity. The frequently found entrapment syndromes are discussed in detail. Uncommon syndromes are also briefly discussed.
Anterior interosseous nerve syndrome is a rare occurrence. One particular case, in terms of its etiopathogenesis, and its clinical findings that involved isolated lesion of the long flexor muscle of the thumb is reported. Healing occurred after approximately 10 months. Medical and physiotherapeutic treatment were carried out.
Compressive neuropathies of the radial nerve at the elbow can lead to one of 2 clinical entities. Posterior interosseous syndrome is primarily a motor deficiency of the posterior interosseous nerve, and radial tunnel syndrome presents as pain along the radial tunnel and extensor muscle mass. The radial nerve can be compressed at a number of sites around the elbow. In addition, numerous mass lesions reported in the literature can cause compressive neuropathy of the radial nerve at the elbow. Standard surgical management for persistent radial tunnel syndrome that is refractory to nonsurgical treatment is open decompression of the radial nerve. Cysts occurring in other joints are commonly treated arthroscopically. Supraglenoid cysts of the shoulder, meniscal cysts in the knee, and dorsal wrist ganglia are routinely treated with arthroscopic decompression or excision with management of the underlying etiology of the cyst. We present a case of radial tunnel syndrome caused by a ganglion cyst of the proximal radioulnar joint that was treated using arthroscopic excision of the cyst and decompression of the radial nerve.
The blood serum lactate dehydrogenase (LDH), creatine kinase (CK), and LDH isoforms activities have been measured in 103 patients with the compression neural and myodystrophic syndromes of lumbar osteochondrosis. The studies have revealed a relationship between the myodystrophic process severity and the intensity of LDH and CK ejection from the muscle into the blood, particularly in the trigger stage. The shift of LDH activity towards the predominance of slowly migrating isoforms augments and the total blood serum LDH and CK activities grow as the muscular syndrome progresses. These data permit a differentiation between the compression neural and the myodystrophic syndromes, as well as between the algic and the trigger stages of muscle involvement. Such a differentiation does not involve biopsy in many cases.
Standard electromyographic investigations: detection and stimulodetection; segmental motor nerve conduction rate, distal motor latencies (interphalangeal V and I short abductor muscles), and distal sensory (antidromic) conduction time, were used to explore seven cases of distal paralysis of the ulnar nerve. Results enabled differentiation of elective lesions of the deep motor branch from those of the ulnar nerve in Guyon's canal. These two types of lesion correspond to precise anatomical features: the channel between the pisiform and unciform bones on the one hand and Guyon's canal on the other. The electroclinical syndrome of the deep branch should be considered as a separate true canalicular syndrome. Treatment is by surgery in most cases.
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