Purpose: Serratus anterior palsy is usually part of a Parsonnage and Turner syndrome. When occurring alone, it may be secondary to compression of the long thoracic nerve. The anatomic point of contact has been described at the level of the second rib. We report our experience with a musculofascial serratus anterior flap showing that the crossing point of the long thoracic nerve and the thoracic branch of the thoracodorsal artery, the serratus anterior fascia could also be a potential point of compression.

Material and method: We cared for two patients with complete and isolated palsy of the serratus anterior. In the first patient, the paralysis developed over one year and in the second had started three months before treatment. In both patients, the preoperative electromyogram showed an absence of serratus anterior activity. We therefore performed exoneurolysis of the long thoracic nerve in both cases. At surgery, the nerve was clearly compressed at the point where the long thoracic nerve crossed the thoracic branch of the thoracodorsal artery.

Results: The first patient recovered normal muscle activity one year after surgery. Complete recovery was achieved in the second patient at three months.

Discussion: These two cases would support the hypothesis that the long thoracic nerve can become compressed within the serratus anterior fascia. In all cases with serratus anterior palsy secondary to suspected mechanical compression, we propose exoneurolysis of the long thoracic nerve.

Introduction and purpose: The most frequent neurological complication of humeral fractures is radial nerve palsy. Most patients with humeral fractures and radial nerve palsy recover with conservative treatment. But a small percentage of patients require surgical treatment; these are patients who show no clinical improvement of their nerve lesion after 3 months of conservative treatment, those with an open fracture, an associated vascular lesion, secondary radial palsy or patients who require open fracture osteosynthesis. The aim of this study is to assess and analyze humeral fractures with radial palsy that have required surgical treatment. Materials and methods: A prospective pre and postoperative study with a protocol was carried out between 1999 and 2007 in which 28 patients with humeral fractures and radial palsy required surgical treatment. Of the patients studied 10 were women and 18 were men. Their ages varied from 18 to 74 years of age. As to the type of radial palsy, it was primary in 11 patients, secondary in 2 patients (included in the fracture callus) and postoperative in 15. Neurolysis was performed in 20 patients and fascicular grafts were used in 8. Results: Time to fracture healing was 14.2 + 5.6 weeks. The period of radial nerve recovery was 7.2 + 5.7 months. Neurolysis was performed in 20 patients and fascicular grafts in 8. There were 20 complete recoveries, 4 incomplete but useful, in 4 cases there was no recovery and palliative surgery was subsequently performed. Conclusions: Surgical treatment of humeral fractures with radial palsy is indicated in patients who show no clinical improvement of their nerve lesion after 3 months of conservative treatment, those with an open fracture, an associated vascular lesion, secondary radial paralysis or in patients who require an open fracture osteosynthesis. Functional recovery rates are high if surgery is carried out during the appropriate period of time. Treatment is neurolysis or fascicular grafts. Palliative surgery is reserved for cases in which complete recovery is not achieved

Purpose: Meralgia paraesthetica is usually caused by entrapment of the lateral femoral cutaneous nerve (LFCN) at the inguinal ligament. We present our experience with 114 patients who underwent surgical management for meralgia paraesthetica. Material: We reviewed 114 patients (48 men, 66 women, five bilateral cases) who underwent surgery for meralgia paraesthetica between 1987 and 1999; local anaesthesia was used for neurolysis in most cases. We identified five aetiologies: idiopathic (n=69, three bilateral), abdominal surgery (n=19), iliac graft harvesting (n=12, one bilateral), hip surgery (n=7), trauma (n=7, one bilateral). Methods: We analysed outcome at more than two years follow-up for the entire series and by aetiology using a standard 12-point evaluation scale accounting for residual pain, sensorial disorders, and patient satisfaction. Results: The overall results were good, mean score 9/12 (range 1–12). Ninety-two patients were very satisfied or satisfied. Among the 27 patients who were not satisfied, five developed recurrence. Mean time to full pain relief was 70 days (range 1 – 364 days). Recovery of thigh sensitivity was noted at 128 days (range 1 – 364). Discussion: The essential criteria of poor prognosis were duration of the meralgia before surgery and its aetiology. Neurolysis of an LFCN injured by trauma or iliac graft harvesting provided less satisfactory results (scores 7 and 6 respectively) than for idopathic meralgia paraesthetica or abdominal-surgery injury (scores 9 and 10 respectively). Eight of the neurolysis procedures in this series did not provide satisfactory results (score 5). Conclusion: Neurolysis appears to be the surgical treatment of choice for mearlgia paraesthetica. In skilled hands, neurolysis can be performed under local anaesthesia, although certain difficulties can be encountered: obesity, modified anatomy due to prior operations, nerve variability (frequent). Knowledge of these different elements is essential not only to achieve neurolysis but also prevent iatrogenic injury

The anatomical integrity of the epi- and para-nevrium is the most relevant factor for the correct gliding of the median nerve, and when they are surrounded by scar tissue, the result is a chronic neuropathy. This recurrent compressive neuropathy represents a very challenging clinical and surgical problem. Neurolysis can not always improve the recovery of nerve function, and the soft tissue coverage is necessary to prevent recurrent scar and to achieve a useful mobilization of the median nerve. The autogenous vein graft wrapping technique has shown great promise for the treatment of chronic compressive neuropathy after other procedures have failed. The author present their experience using the Basilic vein grafting as a valid alternative to the Saphenous one. All our patients presented symptoms in the median nerve distribution, including pain, swelling and numbness, and grip strength reduction. Four of these patients presented a CRPS and have been evaluated before treatment in a multidisciplinary dedicated equipe to plan the surgical procedure. The vein graft wrapping represents a simple technique without problem in donor area. In the authors’ casuistry it presented also as a very useful technique in the treatment of median neuropathy in CRPS

Hamstring muscle strain is a common sports related injury. It has been reported in a variety of sports, following acceleration or deceleration while running or jumping. Injury may vary from simple muscle strains to partial or complete rupture of the hamstring origin. Avulsion fracture of the ischial tuberosity has also been described. Simple hamstring muscle strains are treated conservatively. Surgical exploration and repair is currently advocated for partial or complete rupture of the hamstring origin. A few case series exists in literature suggesting the benefits of early intervention. We report a series of 8 athletes who presented between 2002 and 2006 with complete tear of their hamstring origin. Avulsion of the ischial tuberosity was excluded in these cases. After confirming the diagnosis, early surgical exploration and repair or reattachment was performed. The patients were braced for 8 weeks. This was followed by specialist physiotherapy and a supervised rehabilitation programme over 6 months. All patients were followed up to monitor return to normal activities and sports. The sciatic nerve was scarred to the avulsed tendon in three cases. Neurolysis led to a rapid relief of symptoms. Cases where the hamstring origin had retracted more than 3 cm required a figure 7 incision. There were no major complications including nerve palsies. An excellent functional outcome was noted by 12 months in all 8 patients. 7 of them returned to their previous level within 6-9 months of injury. One person despite a very good recovery, opted out of sports. No other complications were seen as a result of the surgical procedure. In conclusion, a tear of the origin of hamstring muscles is a significant injury. Early surgical repair and physiotherapy is associated with a good outcome and enables an early return to high level sports

Aim: To present and analysis the neurological complications after ORIF with plates of bicondylar fractures of the humerus. Material and Methods: For the period 1996 – 2003 77 bicondylar fractures were operated with plates. All of them were followed up. 36 Man and 41 women. Dominant hand was affected in 43 patients. The AO types were C1- 25, C2 – 28, C3 – 24. There were 18 open fractures (I–II degree). High-energy trauma caused 19 fractures. 14 were with associated ipsilateral fractures of the upper limb. All patients were operated by the standard AO technique. In all patients the ulnar nerve was identified. There was no case where the radial nerve was exposed. In 36 patients the nerve was transposed anteriorly subcutaneosly and for the rest it was not. Results: We observed 20 postoperative ulnar and radial nerve disfunctions (19 ulnar nerve and 1 radial nerve disfunctions). Electromiography was performed in all cases. 7 of 36 (with transposition) cases finished with temporary ulnar nerve palsy. 3 of 41 (without transposition) cases finished with permanent ulnar nerve palsy and the other 9 of 41 finished with temporary disfunction. The disfunction of the radial nerve was temporary. The temporary neurological disfunctions recovered completely for 3–7 months. Neurolysis and anterior transposition of the ulnar nerve was performed in the cases with permanent ulnar nerve palsy. Conclusions: We suggest that ulnar nerve transposition is a method of choice in operative treatment of bicondylar fractures of the humerus. Careful management of the ulnar nerve is mandatory. Meticulous soft-tissue dissection and hemostasis help to prevent perineural fibrosis

Purpose of the study: Surgical management of neurological injury encountered in patients with a ruptured pelvic girdle remains exceptional. In this work, we present our experience and compare our results with data in the literature. Material and methods: This retrospective analysis concerned four clinical css. Mean patient age was 20.2 years for two men and two women. All patients were victims of high-energy trauma and presented type C (Tile) pelvic girdle injury. All presented a paralysis of the lumbosacral plexus. One patient presented bilateral paralysis of the pudendal plexus. The work-up included: saccora-diculography, myeloscan, lumbar magnetic resonance imaging. One patient presented a pseudomeingocele. Results: Surgical exploration was performed within a mean delay of 3.75 months. Two types of exploration were used: for two patients the transperitoneal approach was used because of a suspected lesion of the lumbosacral trunk and for two others, the trans-sacral approach because of suspected intra-spinal rupture. Neurolysis was performed for three patients and an caudia equina nerve graft for one. Nervous injuries involved section or rupture of the roots. There were no cases of medullary avulsion. All patients presented signs of nerve regeneration at last follow-up (mean 5.5 years). Discussion: Even though injury to the lumbosacral plexus is exceptional, advances in surgical techniques offer therapeutic options adapted to each type of injury and nerve territory. One or more motor functions can be restored. Microsurgical nervous repair of the lumbo-sacral plexus is possible irrespective of the level of the injury. Nerve repair by grafting or neurotization can be achieved via a combination of trans-sacral and anterior retroperitoneal approaches or even a transabdominal approach

Purpose of the study: Neurolysis is required for the treatment of non-regressive posttraumatic or spontaneous palsy of the anterior interosseous nerve. This technique is difficult because of the anatomic variability of the nerve and the neighbouring structures. The purpose of this study was to determine the imperative elements for neurolysis by analysing the anatomic relations of the anterior interosseous nerve and identifying the potentially compressive musculo-aponeurotic and vascular structures. Material and methods: Twelve fresh anatomic specimens were dissected unilateral; the subjects (six male, six female) were aged 82.6 years on average at death. Emergences of the anterior interosseous nerve and its division branches were studied. The relations with the following structures and their anatomic variations were analysed: the lacertus fibrosus, the fibrous arcades of the pronator teres, and the flexor digitorum superficialis, the accessory head (if present) of the flexor pollicis longus (Gantzer muscle) and the vascular structures in close contact with the nerve. The topographic landmarks were noted in relation to the bi-epicondylar line. Results: Emergence of the anterior interosseous nerve was situated, on average 54.5 mm below the bi-epicondylar line, on the posterior (n=9) or ulnar (n=3) aspect of the median nerve. The relative situations of its division branches were variable. A fibrous arcade was found between the lacertus fibrosus and the pronator teres in two specimens. Nine specimens had two arcades at the pronator teres and the flexor digitalis superficialis, but three specimens only had one. The presence of an accessory head within the flexor digitalis superficialis was a configuration with risk of nerve compression. The Gantzer muscle was present in six specimens and crossed the nerve superficially. Two types of potentially compressive vascular arcades were found in eight specimens. Discussion: Sites of compression of the anterior interosseous nerve were found a various positions and in variable numbers in the different anatomic specimens. The presence of several sites of compression in the same individual could explain why the electromyogram fails to identify the level of the nerve compression in certain cases, leading to the standardised neurolysis technique recalled here. Conclusion: This study demonstrates that several sites of potential compression of the anterior interosseous nerve can coexist in the same patient. The surgeon should be perfectly aware of these “at risk” sites when performing neurolysis

Purpose: This retrospective analysis was designed to determine the contribution of arthroscopy in the management of moderately stiff elbows arising from degenerative disease or trauma. Material and methods: Between 1992 and 2001, we performed 31 arthroscopic examinations of the elbow in patients with moderately stiff elbows. Mean preoperative motion was 94.8°. Men age at surgery was 41.6 years; there were nine women and 22 men. The dominant side was involved in 70% of the cases. Twentyfive patients were available for clinical review at a mean 32 months follow-up (range 5 months to 9 years). The causal event was trauma in 13 cases. The stiff elbow was a consequence of degenerative disease in 13 cases with no notion of trauma. Three elbows had been exposed to repeated microtrauma. For the majority of the cases, the intervention consisted in an anterior time via two portals then a posterior time. In five cases, anterior capsulotomy was performed. The other interventions were limited to joint cleaning. For two elbows, we used the Kashiwagi Outerbridge technique. Neurolysis of the ulnar nerve was performed at the elbow level during the same operative time. Results: Elbow motion in flexion was significantly improved after arthroscopy (P=0.01) and the flexion of the stiff elbow was reduced significantly (P=0.0001). At last follow-up none of the patients felt arthroscopy had worsened the elbow condition. The gain in joint motion was 25°. This gain was significantly greater when we performed anterior capsulotomy at the end of the procedure (P< 0.001). In three cases, there was a postoperative loss of motion. We did not have any intra or postoperative complications. Eighty percent of the patients felt arthroscopy had improved their elbow. Discussion: Arthroscopy of the stiff elbow arising from variable causes remains a difficult intervention which in our series provided gain in motion comparable to that reported in other series in the literature. This could be an interesting less invasive alternative to open surgery in the case of moderately stiff elbow

Aims

Brachial plexus injury (BPI) is an often devastating injury that affects patients physically and emotionally. The vast majority of the published literature is based on surgeon-graded assessment of motor outcomes, but the patient experience after BPI is not well understood. Our aim was to better understand overall life satisfaction after BPI, with the goal of identifying areas that can be addressed in future delivery of care.