Little finger abduction and adduction testing in ulnar nerve lesions.

We aimed to evaluate the abduction and adduction of the little finger based on a new clinical test in the context of ulnar nerve lesions. We tested little finger abduction and adduction in 34 patients with an isolated ulnar nerve injury and 20 patients with cubital tunnel syndrome. With their forearms supinated, patients were asked to fully abduct their little finger. Then, the examiner held the patients' index, middle, and ring fingers in extension and maximal radial deviation, and then asked the patients to touch their little finger to their radially deviated ring finger. In patients with ulnar nerve injuries, either above or below the elbow, little finger abduction and adduction were impossible. In the patients with cubital tunnel syndrome, 19 had partial paralysis of little finger adduction and one patient had complete paralysis. Abduction and adduction of the little finger is not possible when the ulnar nerve is transected. In cubital tunnel syndrome, this little finger adduction test was able to identify decreased range of motion, possibly indicating muscle weakness.

Shoulder function in patients with deltoid paralysis and intact rotator cuff.

INTRODUCTION/HYPOTHESIS: The purpose of this study is to determine the mid/long term shoulder function in patients with complete deltoid paralysis and intact rotator cuff. 27 patients with at least 2-years FU were included. MATERIALS AND METHODS: Outcome measures included pain, range of motion (including the swallowtail test STT), deltoid extension lag test DELT and Bertelli test), subjective fatigability using the injured shoulder and postoperative modified Neer ratings. RESULTS: At an average 68 months FU, mean shoulder abduction was 131°, flexion 153°, external rotation with the arm at the side 58° and 58° with the arm abducted. All patients reported quick fatiguability with repetitive use of the injured arm which did not change over time. Average pain score was 2. Eighteen patients had positive STT and DELT tests and all patients had positive Bertelli test. DISCUSSION: This study demonstrates that patients with deltoid paralysis and intact rotator cuff do maintain most of their shoulder function and this is sustained over time. LEVEL OF EVIDENCE: Level IV; prognostic Study: case series.

Transfer of the musculocutaneous nerve branch to the brachialis muscle to the triceps for elbow extension: anatomical study and report of five cases.

We report the study of the anatomical feasibility of transferring the nerve to the brachialis muscle to the upper medial head motor branch that innervate the triceps, and outcomes of such transfers in restoring elbow extension in five patients with posterior cord lesion of the brachial plexus. The length of the branches to the brachialis muscle measured 7.6 cm and the triceps upper medial head motor branch was 5 cm in 10 adult cadavers. Five male patients were treated with this transfer 5 months after the injury (range 4 to 6 months) after posterior cord injury of the brachial plexus with a mean follow-up of 31 months (range 28 to 36 months). Elbow extension scored M4 in all cases. No complications occurred. These preliminary results suggest that transferring the nerve to the brachialis muscle is an effective technique for the reconstruction of elbow extension after posterior cord brachial plexus injuries. LEVEL OF EVIDENCE: IV.

[Non-Hodgkin's lymphoma primary in breast. Literature review in relation to a case report]. / Linfoma no Hodgkin primario en la mama: reporte de un caso.

BACKGROUND: Extranodal lymphoma are rare, in particular, breast non-Hodgkin's lymphoma has an impact of lower 0.5%. It is difficult to diagnose during the pre-operative period, since it can be confused with breast carcinoma. CASE REPORT: A 52 years old female patient was sent due to a lump in her left breast identified in a mammogram. A study was conducted with supplementary tests, being eventually diagnosed as low-grade B-cell follicular lymphoma. She was subjected to a mammary and axillary radioguided occult lesion localisation (ROLL). After, radiation therapy was delivered. CONCLUSIONS: It is a very rare pathology, therefore, there is not relevant research to show effective treatment or diagnosis.

Tendon palpation during agonist contraction and antagonist co-contraction to assess wrist flexor and extensor muscle function.

The aim of this study was to validate direct tendon palpation during agonist contraction and antagonist co-contraction as a method to assess wrist flexor and extensor muscle function in cases of upper limb paralysis. On one occasion, five doctors examined 17 patients with partial paralysis of the upper limb resulting from brachial plexus or cervical spinal cord injury. We asked examiners to determine if the extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor carpi ulnaris (ECU), flexor carpi radialis (FCR), flexor carpi ulnaris (FCU) and palmaris longus (PL) were paralyzed, weak or strong in each patient. Examiners tested flexion - extension and radial - ulnar deviation against resistance and palpated wrist motor tendons. While palpating tendons, co-contractions were encouraged by soliciting finger extension to evaluate the FCU, thumb extension to evaluate the ECU, and finger flexion to evaluate the ECRB. Kappa values were 0.8 for the ECRL, 0.7 for the ECRB, 0.5 for the ECU, 0.8 for the FCR, 0.6 for the PL, and 0.8 for the FCU, indicating moderate to almost perfect agreement between examiners. Tendon palpation during muscle examination was adequate to identify complete paralysis, as well as weak and strong muscle contractions. This assessment helps to identify muscles that could be used during nerve or tendon transfer for reconstruction of extensive upper limb paralysis.

Stretch-induced nerve injury: a proposed technique for the study of nerve regeneration and evaluation of the influence of gabapentin on this model.

The rat models currently employed for studies of nerve regeneration present distinct disadvantages. We propose a new technique of stretch-induced nerve injury, used here to evaluate the influence of gabapentin (GBP) on nerve regeneration. Male Wistar rats (300 g; n=36) underwent surgery and exposure of the median nerve in the right forelimbs, either with or without nerve injury. The technique was performed using distal and proximal clamps separated by a distance of 2 cm and a sliding distance of 3 mm. The nerve was compressed and stretched for 5 s until the bands of Fontana disappeared. The animals were evaluated in relation to functional, biochemical and histological parameters. Stretching of the median nerve led to complete loss of motor function up to 12 days after the lesion (P<0.001), compared to non-injured nerves, as assessed in the grasping test. Grasping force in the nerve-injured animals did not return to control values up to 30 days after surgery (P<0.05). Nerve injury also caused an increase in the time of sensory recovery, as well as in the electrical and mechanical stimulation tests. Treatment of the animals with GBP promoted an improvement in the morphometric analysis of median nerve cross-sections compared with the operated vehicle group, as observed in the area of myelinated fibers or connective tissue (P<0.001), in the density of myelinated fibers/mm2 (P<0.05) and in the degeneration fragments (P<0.01). Stretch-induced nerve injury seems to be a simple and relevant model for evaluating nerve regeneration.

Stretch-induced nerve injury: a proposed technique for the study of nerve regeneration and evaluation of the influence of gabapentin on this model

The rat models currently employed for studies of nerve regeneration present distinct disadvantages. We propose a new technique of stretch-induced nerve injury, used here to evaluate the influence of gabapentin (GBP) on nerve regeneration. Male Wistar rats (300 g; n=36) underwent surgery and exposure of the median nerve in the right forelimbs, either with or without nerve injury. The technique was performed using distal and proximal clamps separated by a distance of 2 cm and a sliding distance of 3 mm. The nerve was compressed and stretched for 5 s until the bands of Fontana disappeared. The animals were evaluated in relation to functional, biochemical and histological parameters. Stretching of the median nerve led to complete loss of motor function up to 12 days after the lesion (P<0.001), compared to non-injured nerves, as assessed in the grasping test. Grasping force in the nerve-injured animals did not return to control values up to 30 days after surgery (P<0.05). Nerve injury also caused an increase in the time of sensory recovery, as well as in the electrical and mechanical stimulation tests. Treatment of the animals with GBP promoted an improvement in the morphometric analysis of median nerve cross-sections compared with the operated vehicle group, as observed in the area of myelinated fibers or connective tissue (P<0.001), in the density of myelinated fibers/mm2 (P<0.05) and in the degeneration fragments (P<0.01). Stretch-induced nerve injury seems to be a simple and relevant model for evaluating nerve regeneration.

Clinical findings in C5-C6 and C5-C7 root palsies with brachial plexus traction lesions.

Stretch injuries of the C5-C7 roots of the brachial plexus traditionally have been associated with palsies of shoulder abduction/external rotation, elbow flexion/extension, and wrist, thumb, and finger extension. Based on current myotome maps we hypothesized that, as far as motion is concerned, palsies involving C5-C6 and C5-C7 root injuries should be similar. In 38 patients with upper-type palsies of the brachial plexus, we examined for correlations between clinical findings and root injury level, as documented by CT tomomyeloscan. Contrary to commonly held beliefs, C5-C7 root injuries were not associated with loss of extension of the elbow, wrist, thumb, or fingers, but residual hand strength was much lower with C5-C7 vs C5-C6 lesions.

Transfer of the supinator muscle to the extensor pollicis brevis for thumb extension reconstruction in C7-T1 brachial plexus palsy.

With C7-T1 brachial plexus injuries, finger motion is absent while shoulder, elbow and wrist function are largely preserved. Previously, we have reconstructed finger flexion by transferring the brachialis muscle to the flexor digitorum profundus and flexor pollicis longus; and we have restored extension of thumb and finger by transferring the motor nerve to the supinator to the posterior interosseous nerve, which is only feasible in fresh injuries. We describe the transfer of the supinator muscle to the extensor pollicis brevis to reanimate thumb extension in patients with long standing C7-T1 brachial plexus palsy.

Lengthening of subscapularis and transfer of the lower trapezius in the correction of recurrent internal rotation contracture following obstetric brachial plexus palsy.

An internal rotation contracture is a common complication of obstetric brachial plexus palsy. We describe the operative treatment of seven children with a recurrent internal rotation contracture of the shoulder following earlier corrective surgery which included subscapularis slide and latissimus dorsi transfer. We performed z-lengthening of the tendon of the subscapularis muscle and transferred the lower trapezius muscle to the infraspinatus tendon. Two years postoperatively the mean gain in active external rotation was 47.1 degrees, which increased to 54.3 degrees at four years. Lengthening of the tendon of subcapularis and lower trapezius transfer to infraspinatus improved the range of active external rotation in patients who had previously had surgery for an internal rotation contracture.

Lower trapezius muscle transfer for reconstruction of elbow extension in brachial plexus injuries.

Elbow extension is a prerequisite for adequate hand position. Muscle transfers are often employed in partial injuries of the brachial plexus, when neurological surgery is unlikely to achieve desired results. The posterior deltoid and latissimus dorsi are the two muscles most commonly used for transfer but there are few alternatives when these two muscles are paralysed. We now report on the successful transfer of the lower trapezius muscle to reconstruct triceps function in three patients with longstanding lesions of the brachial plexus that had not been previously treated surgically.

Treatment of scaphoid non-unions by a palmar approach with vascularised bone graft harvested from the thumb.

Ten patients with scaphoid non-unions which had been present for longer than 2 years were treated using a vascularised bone graft harvested from the thumb and pedicled on the first dorsal metacarpal artery. Bone harvesting and grafting were performed by a single palmar approach. Concomitant cancellous bone graft was not used. Bone healing was confirmed by CT scans in nine of the ten patients. Persistence of the non-union was observed in one patient who was the oldest in this series, had the longest standing non-union and was a heavy smoker. Twelve months after surgery, nine of the ten patients had significant pain relief with an improved range of motion and grip strength.

Brachialis muscle transfer to the forearm muscles in obstetric brachial plexus palsy.

Tendon transfers are frequently needed to improve hand function in obstetric brachial plexus injuries. The reconstruction cannot always be achieved using local donor transfers in the forearm as these are not always available. In such cases, we propose the use of the brachialis muscle as a useful donor for transfer. Five adolescents with obstetric brachial plexus palsy were operated on to reconstruct wrist extension and/or pronation using the brachialis muscle transfer to the pronator teres (n=1), extensor carpi radialis brevis (n=1) and extensor carpi radialis longus (n=3). Twelve months after surgery, average active motion recovery was 20 degrees for wrist extension and 14 degrees for pronation. Active and passive range of motion was similar.

Variation in nerve autograft length increases fibre misdirection and decreases pruning effectiveness: an experimental study in the rat median nerve.

OBJECTIVES: In the clinical set, autologus nerve grafts are the current option for reconstruction of nerve tissue losses. The length of the nerve graft has been suggested to affect outcomes. Experiments were performed in the rat in order to test this assumption and to detect a possible mechanism to explain differences in recovery. METHODS: The rat median nerve was repaired by ulnar nerve grafts of different lengths. Rats were evaluated for 12 months by behavioural assessment and histological studies, including ATPase myofibrillary histochemistry and retrograde neuronal labelling. RESULTS: It was demonstrated that graft length interferes in behavioural functional recovery that here correlates to muscle weight recovery. Short nerve grafts recovered faster and better. Reinnervation was not specific either at the trunk level or in the muscle itself. The normal mosaic pattern of Type I muscle fibres was never restored and their number remained largely augmented. An increment in the number of motor fibres was observed after the nerve grafting in a predominantly sensory branch in all groups. This increment was more pronounced in the long graft group. In the postoperative period, about a 20% reduction in the number of misdirected motor fibres occurred in the short nerve graft group only. CONCLUSION: Variation in the length of nerve grafts interferes in behavioural recovery and increases motor fibres misdirection. Early recovery onset was related to a better outcome, which occurs in the short graft group.

Adaptive Spectrogram for Surface EEnG Analysis.

Electroenterogram (EEnG) is the myoelectrical signal of the small bowel. It is the result of a permanent slow wave (low frequency component) and series of spike bursts (high frequency component) that are only present when a bowel contraction occurs. This means spectral content of EEnG changes throughout time. The definition of a t-f distribution that adapts to changes in EEnG spectrum could be very helpful to study this signal. Nine recording sessions of surface EEnG were carried out in three Beagle dogs in fast state. It was proposed an algorithm that selects the window length of spectrogram depending on the maximum frequency of interest of signal in previous window. The proposed adaptive spectrogram was applied to surface EEnG. When only slow waves are present, the adaptive spectrogram enlarges window length in order to present good frequency resolution to characterize the low frequency component of the EEnG. When spike bursts appear, windows of analysis are shorter reducing time resolution to identify individual units of slow waves accompanied by SB. The proposed adaptive spectrogram can be a helpful tool to identify surface EEnG activity in time and frequency domain. It is also likely to be adapted to study other multicomponent signals.

The towel test: a useful technique for the clinical and electromyographic evaluation of obstetric brachial plexus palsy.

The towel test consists of covering an infant's face with a towel and seeing if he/she can remove it with either arm. In this study it has been used to aid the clinical and electromyographic assessment of 21 infants with obstetric brachial plexus palsy. At 2 to 3 months, none of the 21 infants succeeded in removing the towel, either with their normal or affected arm. At 6 months, all the infants succeeded in removing the towel with their normal arm, but 11 could not with their affected arm, and the same was observed at a further assessment at 9 months. The towel test is a reliable technique for evaluating children with obstetric brachial plexus injuries.

Hemidigital resection with collateral ligament transplantation in the treatment of macrodactyly: a case report.

Macrodactyly is a rare congenital anomaly of the hand that is difficult to treat. We describe a new technique consisting of hemidigital, longitudinal, and transverse en bloc resection with collateral ligament transplantation to the proximal interphalangeal joint that we used in a case of macrodactyly. Four years after the procedure the digit's appearance was largely improved with preservation of complete motion at the proximal interphalangeal joint. Transplantation of the collateral ligament ensured a stable joint. Fingertip sensibility was maintained.