Pain Relief after Surgical Decompression of the Distal Brachial Plexus.

Background Brachial plexopathy causes pain and loss of function in the affected extremity. Entrapment of the brachial plexus terminal branches within the surrounding connective tissue, or medial brachial fascial compartment, may manifest in debilitating symptoms. Open fasciotomy and external neurolysis of the neurovascular bundle in the medial brachial fascial compartment were performed as a surgical treatment for pain and functional decline in the upper extremity. The aim of this study was to evaluate pain outcomes after surgery in patients diagnosed with brachial plexopathy. Methods We identified 21 patients who met inclusion criteria. Documents dated between 2005 and 2019 were reviewed from electronic medical records. Chart review was conducted to collect data on visual analog scale (VAS) for pain, Semmes-Weinstein monofilament test (SWMT), and Medical Research Council (MRC) scale for muscle strength. Pre- and postoperative data was obtained. A paired sample t -test was used to determine statistical significance of pain outcomes. Results Pain severity in the affected arm was significantly reduced after surgery (pre: 6.4 ± 2.5; post: 2.0 ± 2.5; p < 0.01). Additionally, there was an increased response to SWMT after the procedure. More patients achieved an MRC rating score ≥3 and ≥4 in elbow flexion after surgery. This may be indicative of improved sensory and motor function. Conclusion Open fasciotomy and external neurolysis at the medial brachial fascial compartment is an effective treatment for pain when nerve continuity is preserved. These benefits were evident in patients with a prolonged duration elapsed since injury onset.

Surgical Intervention for Spastic Upper Extremity Improves Lower Extremity Kinematics in Spastic Adults: A Collection of Case Studies.

BACKGROUND: Spasticity of the upper extremity often occurs after injury to the upper motor neurons (UMN). This condition can greatly interfere with the hand positioning in space and the functional use of the arm, affecting many daily living activities including walking. As gait and balance involve the coordination of all segments of the body, the control of upper limbs movement is necessary for smooth motion and stability. The purpose of this study was to assess the effects of surgical interventions on upper extremity spasticity to gait patterns in three spastic patients, as a way to assess the effect on patient's mobility. METHODS: Three patients with an anoxic brain injury, upper extremity spasticity, and an altered gait participated in this study. A specific treatment plan based on the patient was tailored by the orthopedic hand surgeon to help release the contractures and spastic muscles. Three-dimensional gait analysis was performed before surgery, 3, 6, and 12 months postoperatively. During each experimental session, the patient walked at a self-selected pace in a straight line across four force plates embedded into the floor (Kistler®). Motion data were acquired using Vicon® Motion Capturing System. Spatiotemporal measurements as well as bilateral kinematics of the hip, knee and ankle were studied. The results from matched non-disabled controls were included as reference. RESULTS: Overtime, clinical assessment displayed recovery in hand functions and restored sensation in the fingers. Gait analysis results demonstrated overall improvements in spatiotemporal parameters, specifically in cadence and walking speed. Improvements in kinematics of the lower limbs were also evident. CONCLUSION: The results of this study indicated that, within a timeframe of one year, gait patterns improved in all patients. These observations suggest that, over time, upper limb surgery has the potential to improve the biomechanics of gait in spastic patients.

Acute pediatric upper extremity compartment syndrome in the absence of fracture.

BACKGROUND: To determine the etiologies and outcomes associated with acute pediatric upper extremity compartment syndrome in the absence of fracture. METHODS: A retrospective review was performed looking at children treated for acute upper extremity compartment syndrome in the absence of fracture at a major teaching hospital. Reason for admission, age, etiology, sensorium, time to fasciotomy, involved compartments, secondary procedures, and functional outcome were recorded. RESULTS: A total of 14 extremities in 13 children with acute compartment syndrome in the absence of fracture were identified over a 22-year period at this single institution. There were 8 boys and 5 girls, with an average age of 7.2 years. Average follow-up was 22 months. Ten patients were being managed in the intensive care unit and had an obtunded sensorium. The cause was iatrogenic in 8 patients, and 2 of these resulted in loss of the involved limb. Six patients required 9 secondary procedures, including 4 amputations, 3 contracture releases, and 2 skin grafts. Of the 3 patients who required a total of 4 amputations, 2 of the patients were in the intensive care unit, and all were younger than 3 years. Only 7 patients had normal hand function. Upon comparing patients with a normal outcome versus those with an abnormal outcome, there was a statistically significant difference if surgery was performed in shorter than 6 hours (P = 0.033). CONCLUSIONS: This problem is often iatrogenic in etiology and can be diagnosed late in this population. An increased level of vigilance should be adopted for this entity because the final outcome can be catastrophic for both the patient and the hospital and early fasciotomy is associated with improved results. LEVEL OF EVIDENCE: Level IV Case Series.

Extensor retinaculum capsulorrhaphy for ulnocarpal and distal radioulnar instability: the Herbert sling.

Wrist pain and instability are challenging problems that may be the result of pathology at the distal radioulnar (DRUJ) or ulnocarpal joints or both. Instability of the wrist can often be attributed to a compromise of the integrity of the triangular fibrocartilage complex (TFCC), a key soft tissue stabilizer of the DRUJ and ulnocarpal articulations. Subsequently, when surgical reconstruction is indicated, techniques should strive to restore the biarthrodial function of the TFCC. Although anatomic reconstruction of the DRUJ ligaments provides successful stabilization of the radioulnar articulation, those patients who present with concomitant ulnocarpal instability require an alternative technique that addresses both the DRUJ- and ulnocarpal-stabilizing functions of the TFCC. The Herbert sling, which is an extensor retinaculum capsulorrhaphy, is an effective method of creating a strong tether among the distal radius, ulna, and ulnar carpus. Preliminary biomechanical and clinical results have been encouraging.

The use of tricorticocancellous bone graft in severely comminuted intra-articular fractures of the distal radius.

PURPOSE: We report the results of a retrospective study of the use of tricorticocancellous iliac crest bone graft in 12 patients with acute AO type C3.2 or type C3.3 fractures of the distal radius who were followed up for at least 1 year. METHODS: Twelve of 17 patients treated with the protocol were available for follow-up evaluation. All fractures were treated with open reduction and combined internal and external fixation. Five fractures were plated dorsally, 1 volarly, and 5 volarly and dorsally. RESULTS: Five patients had AO type C3.2 fractures and 7 had AO type C3.3 fractures. Nine of 10 radiographic parameters that were restored to near-normal values during the surgery were maintained at near-normal levels at the final follow-up evaluation at a mean of 28 months after surgery. Nine fractures had less than 2 mm of articular step-off of the distal radius and 8 had less than 3 mm of total articular incongruity (gap plus step-off). In 10 patients the radial length was restored to at least 10 mm. The mean arc of flexion-extension was 67% and the mean grip strength was 57% of that of the uninjured side. According to the Gartland and Werley demerit-point system 5 of the patients had good or excellent results. According to the modified Green and O'Brien clinical rating system 2 patients had good or excellent results. Poor results for 2 patients according to the demerit-point system and for 6 patients according to the Green and O'Brien clinical rating system were associated with severe ipsilateral soft-tissue and osseous injuries of the wrist, forearm, and arm. The total articular incongruity had a moderately strong correlation with the outcome as assessed by the demerit-point system. CONCLUSIONS: Tricorticocancellous bone grafting in conjunction with combined internal and external fixation is a satisfactory treatment that can lead to a high rate of return to work and sports, a high level of patient satisfaction, and a low rate of complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

The role of soft tissues in plate fixation of proximal phalanx fractures.

The tension band effect of plate fixation and the contribution of soft tissues to that effect was examined biomechanically in human proximal phalanges. Forty-six proximal phalanges in whole cadaver hands with all soft tissues in place (intact) and 43 proximal phalanges stripped of soft tissues (denuded) were tested. After midshaft osteotomy, each proximal phalanx was fixed internally with a dorsal minicondylar plate, a lateral minicondylar plate, a dorsal straight plate, or a lateral straight plate. Specimens were tested in three-point apex dorsal bending to clinical failure, defined as 30 degrees angulation. Ultimate moment (stability) at this angulation was similar among the four fixation methods in the specimens with all soft tissues intact. Stability also was similar among these methods in the denuded specimens. There were no significant differences in stability between minicondylar and straight plates or between dorsal and lateral plates in the specimens with soft tissues, nor were there significant differences between these groups in the denuded specimens. The stability of the four fixation methods was significantly greater in the specimens with soft tissues than in the denuded specimens. Soft tissues increased the stability of lateral minicondylar plates by 163%, lateral straight plates by 157%, dorsal minicondylar plates by 126%, and dorsal straight plates by 104%, providing a dorsal tension band effect that counteracted the buttress (compression) of the volar fracture surfaces of the phalanx. The results suggest that in the clinical setting a laterally placed straight or minicondylar plate may provide as much stability to a phalanx with a midshaft fracture as does the traditional, more invasive dorsally placed minicondylar or straight plate. These findings must be evaluated with caution, however, because all specimens were from embalmed cadavers, and the formalin fixation may have augmented the stability and stiffness of the soft tissues in the intact specimens. A subsequent pilot study comparing intact proximal phalangeal specimens that were formalin-fixed with those that were fresh-frozen showed a significant increase in stability and stiffness of formalin-fixed specimens.

Role of soft tissues in metacarpal fracture fixation.

The contribution of soft tissues in stabilizing fracture fixation in metacarpals is appreciated clinically, but no quantitative biomechanical study of their role has been done. All previous studies of fracture fixation in vitro have been done on metacarpals denuded of soft tissues. To quantify the role of soft tissues in metacarpal fracture fixation, the biomechanical effectiveness of four fixation devices was examined in human cadaver metacarpals with and without soft tissues. Values were compared for three nonrigid methods (expandable intramedullary fixation devices, crossed Kirschner wires, and single half-pin frames) and one rigid method (dorsal plates) in 45 disarticulated metacarpals stripped of soft tissues (denuded) and in 46 metacarpals in whole hands with all soft tissues remaining (intact). Mechanical testing to complete failure in three-point apex dorsal bending was done in all specimens. Ultimate moment (strength) of each of the four fixation methods was significantly greater in intact specimens than in denuded specimens. Crossed Kirschner wires were most stable in intact specimens, and dorsal plates were more stable in denuded specimens. The results show that soft tissues contribute to the strength of fracture fixation. Clinically, surgeons may be able to use a less invasive fixation method than plating without compromising the strength of metacarpal fixation in patients whose soft tissues are not severely disrupted and the fracture configuration allows. Plating may offer optimum stability in patients whose soft tissues are damaged severely and provide less strengthening of the fracture construct.