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We report 3 cases of successful vascularized ulnar nerve graft for reconstructing a large median or radial nerve defect after severe trauma of the upper extremity.
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A retrospective comparison of twelve patients with radial nerve transection treated by nerce repair, and thirteen similar patients treated by tendon transfer only, showed an average time to recovery of 7.5 months after nerve repair, and eight weeks after transfer. In view of this, a policy of early tendon transfer instead of radial nerve suture is advised. Results are reported in nine patients who had tendon transfers at an average of thirteen days after nerve injury.
Surgery for humeral shaft fractures. A series of 78 operative treated humeral shaft fractures was studied retrospectively. Sixteen times we found a radial nerve palsy, preoperatively. In this group we evaluated the type of fracture, the operation indication, the time of treatment and the postoperative recovery of the radial nerve palsy. Fourteen times we did an early exploration. The indication to operate was 9 times the conducting polytrauma, 5 times the radial nerve palsy itself and 2 times a pseudarthrosis. In 13 of the 16 patients nerve function recovered either clinically and/or electromyographically. This study confirms that radial nerve palsy is found especially in fractures located at the junction of the middle and the lower third of the humeral shaft. Because we found nearly always a macroscopically lesion of the nerve in this type of fracture, we recommend an early exploration in spiroid fractures at that junction. For the same reason we advise an early exploration in cases of secondary radial nerve palsy. If no other indication to operate occurs, we accept a conservative treatment of the humeral fracture with radial palsy.
An 18-year-old man presented with a spontaneously occurring radial nerve palsy that spared the triceps muscle. At surgery, the portion of the radial nerve located at the midarm level had an hourglass-like appearance. Under magnification, an external-internal neurolysis of the narrowed portion of the hourglass-shaped portion revealed nerve torsion. Straightening of the twisted nerve and fixation accomplished using epiperineurium-fascia stitches to avoid a new torsion resulted in complete functional recovery of the radial nerve.
By the presentation of the clinical material a series of 14 cases of the radial nerve microsurgical reparation has been analyzed with the reference to the modern achievements in this field and the possibilities of its quicker and better rehabilitation have been quoted. In our material we used the intraneural microsurgical technique with the direct funiculoraphy (3), the interfascicular nerve transplantation (8) and the external and internal microneurolysis (3). Twelve reconstructed radial nerves were evaluated by these methods. The successful motoric function (M3 and more), with the performance of will-power in the proximal and distal muscles, which spontaneously act on the resistance, and with the independent finger movements, have been detected in 84% of the cases in the period from 8 to 24 months after the reconstruction of this extensor nerve. The state of the contemporary micro-surgery prefers the timely and the exact neurological status, as well as the information on the extensiveness of the radial nerve lesion, on which bases the method for its functional restoration and anatomic rehabilitation should be determined.
Lateral elbow pain syndrome is probably a fairly common condition and known to be resistant to conservative treatments. It is suggested that this syndrome is caused by entrapment of the radial nerve. Thirty patients with lateral elbow pain syndrome, in which entrapment of the radial nerve was diagnosed, have been operated upon to release the radial nerve at the elbow. There were 9 men and 21 women. Their age ranged from 17 to 64 with an average of 42.5. Twenty one of thirty nerves were entraped by the arcade of Frohse or other soft tissues. Nine nerves were adherent to the tissues overlying the radial head. Follow-up has been from six months to two years and eight months. Postoperative results were excellent in 16 patients, good in 11, fair in two and poor in one. These results would indicate that entrapment of the radial nerve at the elbow is considered as a cause of lateral elbow pain syndrome.
Complete injuries to the sensory branch of the radial nerve may lead to the development of an area of dysesthesia in the dorsoradial aspect of the hand. However, lesions of the radial nerve proximal to the elbow level, affecting both the sensory branch and the posterior interosseous nerve, will never develop an area of distal dysesthesia. Therefore, it seems likely that the dysesthesia observed in isolated injuries of the sensory branch of the radial nerve is transmitted to the cortical receptors through the intact posterior interosseous nerve. On the basis of the above clinical observations, we have successfully treated 43 patients with radial dysesthesia by division of the distal posterior interosseous nerve. There have been no complications or functional deficits related to this procedure.
Three healthy men were engaged in continuous repetitive arm exercise when a sudden forceful contraction and stretch of the arm muscles led to a delayed upper arm radial nerve palsy. Radial nerve "entrapment" at the lateral head of the triceps muscles is a recognizable occupational nerve injury.
Orthodromic conduction of the radial nerve digital branches to the third digit from the anatomic snuffbox has rarely been described. This paper describes a technique for measuring conduction of the lateral and medial digital branches of the radial nerve to the third digit at a distance of 10cm from the base of the digit to the anatomic snuffbox. An evoked response from the lateral digital branch was recorded in each of the 56 nerves tested. Responses had an average latency of 2.10 +/- .18msec. Responses from the medial digital branches of the nerve were obtained in only 55% of the 49 nerves tested. Responses had an average latency of 2.11 +/- .21msec. When no appreciable response was recorded at the anatomic snuffbox from the medial digital branch, a response was recorded from the ulnar nerve at the volar wrist at 14cm.
This paper reports the results of treatment of 17 patients with fractures of the shaft of the humerus accompanied by paralysis of the radial nerve in a series of 111 patients with fractures of the shaft of the humerus. In early operative explorations in 14 cases the radial nerve appeared undamaged in 13 cases. In cases where spontaneous recovery of the function of the radial nerve failed to occur, no evidence has been found that the delay in exploration influenced eventual motor recovery. The high incidence of undamaged nerves at exploration suggests that a conservative approach by collar and cuff or Sarmiento bracing is justified in such cases of fractures of the shaft of the humerus. Paralysis of the radial nerve associated with fractures of the shaft of the humerus is, in our opinion, not an indication for early operative treatment.
The sensitive branch of radial nerve is superficial at the inferior third of forearm. This explain frequency of their operative lesions. The purpose of our work is to study his anatomy for choosing surgical approach who protect the nerve. The sensitive radial nerve was dissected is 20 cadaver forearms and wrists. The ride of the nerve and his terminal branches was constant at the lateral side of the radius may be the origins of the terminal branches was variable with 40% of specimens innervating the radial 2 1/2 digits. This is the common terminal distribution of the nerve. The authors do not recommended lateral approach advise anterior surgical approach for the inferior third of the radius to prevent nervous lesions, disagreeable in post-operative period.
For displaced fractures of the radius, the use of Kirschner wires (K Wires) is accepted practice either alone or to supplement external fixation. Complications related to K wires include infection, migration and damage to tendons and nerves. We set out to investigate to incidence of superficial radial nerve damage due to radial styloid K wires. Injury to the sensory branch of the superficial radial nerve was seen in eight (20%) out of the 40 patients. K wiring is a popular technique to help maintain anatomic reduction of distal radial fractures. It has the advantage of being a semi-closed procedure, which is simple to perform. However, the morbidity of nerve damage is often underestimated and can be avoided.
The ulnar and radial nerves to the hands of 12-31-d-old marmoset monkeys were transected and ligated, and the monkeys were subsequently reared for periods of 1.4-1.6 years with only median nerve innervation to the hand. Features of organization in the cortical area 3b hand map were then assessed with neurophysiological mapping procedures, and compared to features in monkeys that had undergone either a normal postnatal development with three intact hand nerves, or an abnormal development with two intact nerves due to postnatal injury of the median nerve. A systematic comparison of cortical organization in these monkeys led to three main findings. First, some features of organization show little or no change when monkeys are reared with one, two, or three hand nerves. These features include receptive field size and the overall size of the hand map. Second, other features are, in contrast, clearly altered in an injury-dependent manner. These features include cortical neuronal thresholds to light tactile stimuli, and the spatial location, size, shape, continuity, and somatotopic interfacing of representations of the parts of the hand. Finally, estimates of the peripheral innervation territories of the hand nerves, and of the corresponding distributions of cortical neurons activated by inputs from these territories, indicate that the normal hand map contains bandlike aggregates of neurons that are dominantly activated by inputs from each nerve. Postnatal nerve injuries alter the size of these nerve dominance aggregates.
Thirty-three cadaveric dissections were performed to identify radial nerve branching patterns to the triceps brachii. Radial innervation of the long head of the triceps originated in the axilla in 88% of the cases and the brachio-axillary angle in 12%. Innervation of the medial head of the triceps originated in the spiral groove in 52% of the cases, the brachio-axillary angle in 39%, and the axilla in 9%. The lateral head was innervated by branches arising in the spiral groove in 70% of the cases, the brachio-axillary angle in 24%, and the axilla in 6%. On average, the radial nerve crossed the midline in the proximal 45% of the arm, 3 cm superior to the level of the deltoid insertion. An intramuscular tendon was present in the medial head of the triceps. The tendon, located medial to the midline of the arm, was seen in all specimens. This tendon serves as an interneural plane with nerve branches descending on either side, but never crossing from one side to the other. Due to the complexity of radial nerve branching, this tendon may be used as a reference plane for longitudinal splitting of the medial head minimizing the risk of nerve damage.
Orthodromic sensory nerve conduction was studied in the distal segment of the superficial radial nerve in 50 cases of carpal tunnel syndrome in 41 patients. In patients aged 50 years or less, the mean conduction velocity was 48.6 m/s (SD +/- 4.8), and the mean amplitude of the sensory action potential was 9.7 microV (SD +/- 4.0). For patients aged over 50 years, the corresponding values were 46.4 m/s (SD +/- 5.5) and 7.5 microV (SD + 3.5). It is important to demonstrate normal radial nerve conduction in patients with carpal tunnel syndrome in order to exclude peripheral neuropathy or cervical radiculopathy. Spread of activity from the radial nerve may be mistaken for a median nerve potential.
This report reviews a case of radial nerve palsy associated with a supracondylar fracture of the right humerus. The patient was a four-year-old boy. Radiographs of the injury showed simple extension and a slightly angulated fracture. Complete radial nerve palsy was observed at the first consultation. After three months of conservative treatment without any obvious improvement, an operative exploration of the right radial nerve was conducted. Intraoperatively, the nerve was found to be transected, with both ends of the ruptured nerve buried in scar tissue at the fracture site. Five months after the nerve suture operation, the palsy was cured completely. This case shows that even a minimal displacement fracture can be associated with severe nerve injury that requires surgical treatment.
PURPOSE: To define the anatomy of the lateral antebrachial cutaneous nerve (LACN) and the superficial radial nerve (SRN) in relation to easily identifiable landmarks in the dorsoradial forearm to minimize the risk to both nerves during surgical approaches to the dorsal radius. METHODS: In this study 37 cadaveric forearms and 20 patients having distal radius external fixation were dissected to identify these nerves in relation to various anatomic landmarks. RESULTS: Based on these dissections the anatomy was divided into 2 zones that can be identified by easily visible and palpable landmarks. Zone 1 extends from the elbow to the cross-over of the abductor pollicis longus with the extensor carpi radialis brevis and longus. Zone 2 is distal to the cross-over. In zone 1 the 2 nerves can be differentiated through limited incisions based on their depth and anatomic location. Within this zone the SRN is deep to the brachioradialis until 1.8 cm proximal to zone 2 (9 cm proximal to the radial styloid), where it becomes superficial and pierces the fascia of the mobile wad and then remains deep to the subcutaneous fat. In contrast the LACN pierces the fascia between the brachialis and biceps muscles at the level of the elbow. In all specimens the LACN ran parallel to the cephalic vein within the subcutaneous fat. In 31 specimens it ran volar to the vein and in 5 specimens the nerve crossed under the cephalic vein at the elbow and ran dorsal to the vein in the forearm. One specimen had 2 branches with 1 on either side of the vein. Differentiation of these nerves was found to be possible through limited incisions in zone 1 during placement of external fixation pins for distal radius fractures. The LACN always was located in the superficial fat running with the cephalic vein, whereas the SRN was deeper to this nerve either covered by the brachioradialis or closely adherent to it within the investing fascia of the mobile wad. In zone 2 the nerves arborized and ran in the same tissue plane, making differentiation through limited incisions difficult. CONCLUSIONS: Dividing forearm anatomy into zones aids in understanding the complex 3-dimensional anatomy. Recognition of the consistent location of both the LACN and SRN facilitates surgical exposure. This allows localization through limited incisions during nerve repair and hardware placement, thereby enhancing uncomplicated and favorable outcomes.