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.

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.

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.

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.

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.

Brachial plexus dorsal rhizotomy in the treatment of upper-limb spasticity.

OBJECT: This study was conducted to evaluate the effects of dorsal rhizotomy on upper-limb spasticity, functional improvement, coordination, and hand sensibility. METHODS: Fifteen spastic upper limbs in 13 patients were selected and prospectively studied. Brachial plexus dorsal rhizotomy was performed in which two, three, or four dorsal roots were completely sectioned. Patients were followed up for at least 12 months after surgery; the mean follow-up period was 15.6 months and the maximum period was 30 months. A remarkable relief of spasticity was observed in all cases. Recurrence was observed in only one patient and was caused by insufficient dorsal root section. Functional improvement was observed in all cases, and functional improvement in the hand was found to be related to the presence of active finger extension in the preoperative period. Even when extended dorsal root section was performed, no hand anesthesia, either total or partial, was observed. No patient lost movement ability in the postoperative period, and no ataxic limbs were observed. CONCLUSIONS: Brachial plexus dorsal rhizotomy is very effective as a treatment for upper-limb spasticity and results in functional improvement without loss of sensation in the hand.

Sensitive areolar reconstruction in using a neurocutaneous island flap based on the medial antebrachial cutaneous nerve.

Sensory reconstruction has recently been stressed in breast reconstruction. However, there are no reports concerning the reconstruction of a sensitive areola. The bilateral reconstruction of a sensitive areola using a neurocutaneous flap based on the medial antebrachial cutaneous nerve is reported. The flap was harvested from the distal third of the forearm as an island flap and tunneled to reach the apex of the new breast, which was previously reconstructed using a 135-cc, gel-filled, silicone prosthesis covered by a latissimus dorsi myocutaneous flap. Six months later, fine sensibility in the reconstructed areola was demonstrated. The patient could perceive light touch, pain, and 14 mm two-point discrimination. At 2 months after surgery, 50 percent of cutaneous faulty stimulus location was observed. However, at 4 and 6 months after surgery, faulty location disappeared. Six months after harvesting the medial antebrachial cutaneous nerve, the sensory deficit was minimal; it included a hypoesthesic zone of 4 to 7 cm and an anesthesic zone of 2.5 to 5 cm on the middle third of the forearm. Fifteen months after the procedure, no hypoesthesic zone was observed; only a 2 to 3 cm anesthesic zone on the proximal medial side of the forearm existed. This sensory deficit passed unnoticed by the patient. The technique developed here is a refinement in breast reconstruction, and we think it should be used in selected patients.

Selective motor hyperreinnervation by using contralateral C-7 motor rootlets in the reconstruction of an avulsion injury of the brachial plexus. Case report.

Brachial plexus avulsion injuries are a clinical challenge. In recent experimental studies the authors have demonstrated the high degree of muscle reinnervation attained when a C-4 motor rootlet was directly connected to the musculocutaneous nerve. This degree of reinnervation was attributed to the good chance that a muscle fiber can be reinnervated by a motor fiber when the number of regenerating motor neurons is increased and when competitive sensory fibers are excluded from the process. The authors present the first clinical case in which this phenomenon has been observed. This 26-year-old man, who was involved in an automobile accident, presented with an upper brachial plexus avulsion, for which he underwent operation 4 months later. The axillary and suprascapular nerves were directly surgically connected to the motor rootlets of the C-7 contralateral root by using two cables of sural nerve graft. Two years postsurgery, the patient was able to perform shoulder abduction of 120 degrees and hold an 800-g weight at 90 degrees. These results are encouraging, and in selected patients motor rootlet transfer might prove to be a useful surgical strategy.

Cross-chest radial nerve transfer in brachial plexus injuries. Experimental and anatomical basis.

Brachial plexus avulsion injuries are devastating injuries to the upper limb, and nerve transfer remains the only option in reconstruction. Despite the encouraging results concerning recovery of shoulder and elbow function, no option is available for treatment of the paralytic hand. In rats, we sectioned the radial nerve in the elbow region and transferred it across the chest to reinnervate the lesioned contralateral medial cord of the brachial plexus. Rats were then evaluated for motor and sensory recovery, electrophysiologically, behaviorally and morphologically. Forepaw functional recovery was estimated to be 90%. In cadavers, the radial nerve and profunda brachii artery were dissected. It was observed that the radial nerve vascularized by the profunda brachii artery was able to reach the contralateral brachial plexus distal to the shoulder region without nerve grafts. After sectioning the radial nerve, sensory loss is minimal and motor palsy can be easily restored by tendon transfers. The results of tendon transfer for radial nerve palsy are better than for any other nerve. Cross-chest radial nerve transfer might be of clinical interest in the reconstruction of hand function in entire injury to the brachial plexus.