Introduction. The flexor carpi radialis (FCR) approach is widely used for volar plate fixation of distal radius fractures. However, patients sometimes complain of postoperative numbness at the thenar eminence. We propose this is derived from injury to the palmar cutaneous branch of the median nerve (PCBm). Materials and methods. From March 2010 to March 2012, we performed 10 operations of volar plate fixation for distal radius fractures using the FCR approach. We detected the PCBm intraoperatively and investigated the anatomy. Results. On average, the PCBm arises from the median nerve 44 mm proximal to the distal wrist crease. It arose from the radial side of the median nerve in nine cases and the ulnar side in one case. In all cases, it ran between the FCR and the palmaris longus tendon under the antebrachial fascia. Nerve supply to the FCR sheath was not observed in the field of operation. Discussion. Numerous studies report the necessity to preserve the PCBm during carpal tunnel release surgery, but the relationship between the FCR approach and the PCBm has not been emphasized. Our results generally agree with past reports on PCBm anatomy. In our experience, the FCR tendon should be retracted to the ulnar side to prevent PCBm injury. If the FCR tendon is retracted radially, the PCBm should be detected and retracted gently. Some studies report that the PCBm joins the FCR sheath at the level of the distal wrist crease. Thus, the distal sheath incision should not be extended blindly

Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome

The median nerve compression in the carpal tunnel is the most common compression syndrome of the upper limb. In most cases it is idiopathic but may also occur from anatomical, traumatic, endocrine, rheumatic or tumoral causes. Chow's endoscopic technique was initially used to treat this disease and then modified to a mini-open approach through a single palmar incision. This incision is similar to the one used in endoscopic release by Agee. After exposing the proximal part of the transverse carpal ligament a meniscus knife is advanced until there is a complete section of the ligament, without endoscopic equipment. Between 2004 and 2006, 200 hands in 179 patients with a diagnosis based on clinical and electromyographic criteria were operated by this mini-open technique. The mean follow-up was 49 months (minimum of 34 months and a maximum of 70 months). 50 randomly selected patients were submitted to the self-administered Boston questionnaire. 50 patients treated by the minimal-incision decompression during the same period were also given the questionnaire. The aesthetic satisfaction was registered as well as if they would have surgery on the other hand or would recommend the procedure. This mini-open technique is another technique available to the surgeon that allows very similar functional results to endoscopic surgery, without use of specific material and with a shorter surgical time

Introduction. Carpal tunnel syndrome is a common neuropathy of the median nerve. Occupation has been widely examined as a risk factor for the development of carpal tunnel syndrome. The aim of this study was to examine the validity of the United Kingdom (UK) NS-SEC (National Statistics Socioeconomic Classification) in the assessment of correlation between occupation and CTS. Methods. A prospective audit database was collected of patients diagnosed with CTS over a 6 year period. Occupation was assessed using the NS-SEC self coded method, where occupation is classified depending on the type of job and the size of the employer. UK Census data from 2001 was used to compare the occupation profile of the cohort with the regional population. Results. There were 1564 patients diagnosed with CTS over a 6 year period. There were fewer patients with CTS in managerial and professional occupations (OR 0.77 95% CI 0.66 to 0.9), lower supervisory and technical occupations (OR 0.33, 0.23 to 0.45), and semi-routine and routine occupations (OR 0.68, 95% CI 0.58 to 0.79). There was a higher proportion of patients who were self-employed (OR 4.60, 3.93 to 5.30). Discussion. The NS-SeC is superficially attractive to assess occupational differences between a general population and a study group due to the availability of census data. This study has shown a higher proportion of patients having CTS in the self-employed category than in the general population. Such occupational classifications that are based on economic inidicators may not be useful in assessing exposure to risk factors for musculoskeletal disorders. Caution should be exercised in their use and more accurate scores developed that address physical intensity of an occupation

Introduction. Nerve conduction studies are considered to be the investigation of choice for the diagnosis of Carpal Tunnel Syndrome. However they are expensive and can be painful. We scored patients based on a ten point scoring system; four symptoms (Katz Hand Diagram – Classic and Probable pattern for tingling and numbness, nocturnal paresthesia, bilateral symptoms), four signs (weak thumb abduction test, Tinel sign, Phalen sign, Hypoalgesia in median nerve territory) and two risk factors (age more than 40 years and female sex). This was done in an effort to predict the severity of carpal tunnel syndrome and to correlate it with nerve conduction studies. Method. A prospective study of 59 patients was performed between May 2009 and March 2010. For every patient in the study we completed a scoring system based on ten points and correlated it with the severity (normal, mild, moderate and severe) result from the nerve conduction studies. Results. There were 61 completed data sets (59 patients, two patients had bilateral carpal tunnel release). The mean age of patients was 60 years (range: 37–91 years). The mean duration of symptoms was 17 months. The female to male ratio was 2.3:1. All scores greater than seven matched with nerve conduction study of moderate to severe intensity apart from three scores which were greater than seven that matched with a normal result. Conclusion. Based on this study, we believe that patients who score less than eight may require nerve conduction studies to confirm the diagnosis of carpal tunnel syndrome. However patients who score more than seven have a 93% chance of having moderate to severe carpal tunnel syndrome on nerve conduction studies

Introduction. Flexor tendon injuries are quite common injuries. They can result in persisting functional deficit if not repaired and appropriately rehabilitated. We look at flexor tendon injuries over a period of 1 year and re-audited three years later. Method. We audited all flexor tendon injuries that were treated at our institution and repeated the same audit three years after. We looked at various aspects of the injuries including the site injured, the zone of injury, other structures injured, the type of repair and material used as well as the rehabilitation regime. Results. The initial audit had 43 patients, 83% male, 55% unemployed with 85 tendon injuries. There were 35% zone 5 injuries with 34% repaired in <24hrs with modified Kessler core 3.0 prolene sutures and 6.0 prolene peripheral sutures. The rupture rate was 3% and the infection rate was 1%. A re-audited was done 3 years later, over the same time period, there were 69 patients, 83% male, 1% unemployed with 102 tendon injuries. There were 40% zone 2 injuries with 43% repaired with modified Kessler core 3.0 prolene sutures and 6.0 prolene peripheral sutures. Rupture rate was 9% and infection rate was 1% and 10% median nerve injury. All injuries were rehabilitated using the Belfast regime. Discussion and Conclusion. Flexor tendon injuries are frequently occurring injuries and require a careful and meticulous attention to detail, relative to repair, to achieve the most effective recovery. We found that over a three year period that the zone of injury in the cohort of patients in our region had changed, as well as the unemployment rate. Other parameters were generally similar. We conclude that treatment of flexor tendon injuries should undergo the audit cycle to ensure that best practice is achieved and maintained

We investigated the response of chronic neck and shoulder pain to decompression of the carpal tunnel in 38 patients with whiplash injury. We also determined the plasma levels of substance P (SP) and calcitonin gene-related peptide (CGRP), which are inflammatory peptides that sensitise nociceptors. Compared with normal control subjects, the mean concentrations of SP (220 v 28 ng/l; p < 0.0001) and CGRP (400 v 85 ng/l; p < 0.0005) were high in patients with chronic shoulder and neck pain before surgery. After operation their levels fell to normal. There was resolution of neurological symptoms with improvement of pain in 90% of patients. Only two of the 30 with chronic neck and shoulder pain who had been treated conservatively showed improvement when followed up at two years. In spite of having neuropathic pain arising from the median nerve, all these patients had normal electromyographic and nerve-conduction studies. Chronic pain in whiplash injury may be caused by ‘atypical’ carpal tunnel syndrome and responds favourably to surgery which is indicated in patients with neck, shoulder and arm pain but not in those with mild symptoms in the hand. Previously, the presence of persistent neurological symptoms has been accepted as a sign of a poor outcome after a whiplash injury, but our study suggests that it may be possible to treat chronic pain by carpal tunnel decompression

Aims

To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years.

Aims

We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus.

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort’s cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers.

Cite this article: Bone Joint J 2014;96-B:254–8.

The outcomes of 261 nerve injuries in 100 patients were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in 18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)). The initial grades for the 42 sutures and graft were 11 good, 14 fair and 17 poor. After subsequent revision repairs in seven, neurolyses in 11 and free vascularised fasciocutaneous flaps in 11, the final grades were 15 good, 18 fair and nine poor. Pain was relieved in 30 of 36 patients by nerve repair, revision of repair or neurolysis, and flaps when indicated. The difference in outcome between penetrating missile wounds and those caused by explosions was not statistically significant; in the latter group the onset of recovery from focal conduction block was delayed (mean 4.7 months (2.5 to 10.2) vs 3.8 months (0.6 to 6); p = 0.0001). A total of 42 patients (47 lower limbs) presented with an insensate foot. By final review (mean 27.4 months (20 to 36)) plantar sensation was good in 26 limbs (55%), fair in 16 (34%) and poor in five (11%). Nine patients returned to full military duties, 18 to restricted duties, 30 to sedentary work, and 43 were discharged from military service. Effective rehabilitation must be early, integrated and vigorous. The responsible surgeons must be firmly embedded in the process, at times exerting leadership.

A series of 26 children was referred to our specialist unit with a ‘pink pulseless hand’ following a supracondylar fracture of the distal humerus after a mean period of three months (4 days to 12 months) except for one referred after almost three years. They were followed up for a mean of 15.5 years (4 to 26). The neurovascular injuries and resulting impairment in function and salvage procedures were recorded. The mean age at presentation was 8.6 years (2 to 12). There were eight girls and 18 boys.

Only four of the 26 patients had undergone immediate surgical exploration before referral and three of these four had a satisfactory outcome. In one child the brachial artery had been explored unsuccessfully at 48 hours. As a result 23 of the 26 children presented with established ischaemic contracture of the forearm and hand. Two responded to conservative stretching. In the remaining 21 the antecubital fossa was explored. The aim of surgery was to try to improve the function of the hand and forearm, to assess nerve, vessel and muscle damage, to relieve entrapment and to minimise future disturbance of growth.

Based on our results we recommend urgent exploration of the vessels and nerves in a child with a ‘pink pulseless hand’, not relieved by reduction of a supracondylar fracture of the distal humerus and presenting with persistent and increasing pain suggestive of a deepening nerve lesion and critical ischaemia.

We describe 261 peripheral nerve injuries sustained in war by 100 consecutive service men and women injured in Iraq and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the median interval between injury and first review was 4.2 months (mean 8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months (mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly focal prolonged conduction block/neurapraxia in 116 (45%), axonotmesis in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed between the upper and the lower limbs. Explosions accounted for 164 (63%): 213 (82%) nerve injuries were associated with open wounds. Two or more main nerves were injured in 70 patients. The ulnar, common peroneal and tibial nerves were most commonly injured. In 69 patients there was a vascular injury, fracture, or both at the level of the nerve lesion. Major tissue loss was present in 50 patients: amputation of at least one limb was needed in 18. A total of 36 patients continued in severe neuropathic pain.

This paper outlines the methods used in the assessment of these injuries and provides information about the depth and distribution of the nerve lesions, their associated injuries and neuropathic pain syndromes.

A total of 118 consecutive patients with a fracture of the distal radius were treated with a volar locking plate; 50 patients had no ulnar styloid fracture, 41 had a basal ulnar styloid fracture, and 27 had a fracture of the tip of the ulnar styloid. There were no significant differences in radiological and clinical results among the three groups. The outcome was good and was independent of the presence of a fracture of the ulnar styloid. A total of five patients (4.2%) had persistent ulnar-sided wrist pain at final follow-up. Nonunion of the ulnar styloid fracture did not necessarily lead to ulnar wrist pain. Patients with persistent ulnar pain had a higher mean initial ulnar variance and increased post-operative loss of ulnar variance.

The presence of an associated ulnar styloid fracture of the ulnar styloid does not adversely affect the outcome in patients with a fracture of the distal radius treated by volar plating.

Recent reports have suggested that a delay in the management of type-III supracondylar fractures of the humerus does not affect the outcome. In this retrospective study we examined whether the timing of surgery affected peri-operative complications, or the need for open reduction. There were 171 children with a closed type-III supracondylar fracture of the humerus and no vascular compromise in our study. They were divided into two groups: those treated less than eight hours from presentation to the Accident and Emergency Department (126 children), and those treated more than eight hours from presentation (45 children). There were no differences in the rate of complications between the groups, but children waiting more than eight hours for reduction were more likely to undergo an open reduction (33.3% vs 11.2%, p < 0.05) and there was a weak correlation (p = 0.062) between delay in surgery and length of operating time. Consequently, we would still recommend treating these injuries at the earliest opportunity.

We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58).

The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly.

A total of 11 patients with combined traumatic injuries of the brachial plexus and spinal cord were reviewed retrospectively. Brachial plexus paralysis in such dual injuries tends to be diagnosed and treated late and the prognosis is usually poor. The associated injuries, which were all on the same side as the plexus lesion, were to the head (nine cases), shoulder girdle (five), thorax (nine) and upper limb (seven). These other injuries were responsible for the delayed diagnosis of brachial plexus paralysis and the poor prognosis was probably because of the delay in starting treatment and the severity of the associated injuries. When such injuries are detected in patients with spinal cord trauma, it is important to consider the possibility of involvement of the brachial plexus.