Does median nerve translate pre- and postoperatively in carpal tunnel syndrome?

OBJECTIVES: This study aims to evaluate the distance between the median nerve and the hook of the hamate pre- and postoperatively in patients with carpal tunnel syndrome and to investigate the efficiency of magnetic resonance imaging in diagnosis and postoperative follow-up. PATIENTS AND METHODS: Median nerve decompression was performed by releasing the carpal tunnel in 15 patients (4 males, 11 females; mean age 51 years; range, 41 to 66 years) with carpal tunnel syndrome. The shortest distance between the median nerve and the hook of the hamate was measured with magnetic resonance imaging preoperatively and at three months after the operation and radial and ulnar translations were assessed. Findings were compared to those of a control group of 15 subjects (5 males, 10 females; mean age 52.2 years; range, 40 to 65 years). RESULTS: Median nerve shifted ulnarwards in patients with carpal tunnel syndrome. An intragroup evaluation of five patients with thenar atrophy revealed that as disease severity increased, the degree of the nerve's medial translation increased. Compared to preoperation, the median nerve significantly shifted to the radial side after decompression. CONCLUSION: In carpal tunnel syndrome patients, we observed significant ulnar translation of the median nerve and lateral translation after releasing the carpal tunnel. Magnetic resonance imaging may be used to establish a diagnosis and to assess operation success in advanced carpal tunnel syndrome patients who may recover slowly postoperatively.

Soft-Tissue Mallet Injuries: A Comparison of Early and Delayed Treatment.

PURPOSE: To compare the results of early and delayed extension orthosis fabrication in closed tendinous mallet injuries. METHODS: Between March 1992 and May 2011, 45 patients with isolated closed tendinous mallet finger injuries were treated with orthosis fabrication. The patients were classified into 2 different groups based on their date of presentation. Group 1 consisted of 28 patients who presented within 2 weeks of sustaining the trauma, and group 2 consisted of 17 patients who received treatment beginning between 2 and 4 weeks after sustaining the trauma. During the final assessments, the patients were assessed clinically using the Crawford classification scale and satisfaction ratings. RESULTS: The mean delay between initial injury and presentation to our center was 3 days (range, 1-14 d) in group 1 and 19 days (range, 15-30 d) in group 2. There were no significant differences between the groups regarding their ages, initial extension lag, and arc of flexion. According to the Crawford classification criteria, 72% of the patients in group 1 had excellent results, and 59% of the patients in group 2 had excellent results. There was no significant difference between the groups. CONCLUSIONS: The treatment results of patients with different presentation times have been reported for heterogeneous groups of osseous and nonosseous mallet finger injuries. Our results suggest that conservative management of tendinous mallet finger injuries that have been neglected for 2 to 4 weeks can be treated as well as those injuries in patients presenting within the first 2 weeks of injury with low long-term complication rates. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Comparison of two different measurement methods to determine glenoid bone defects: area or width?

BACKGROUND: This study compared two different techniques that have been used to measure the glenoids of patients with recurrent anterior shoulder dislocation. METHODS: We analyzed 36 patients who had received arthroscopic Bankart repair for anterior shoulder instability. Retrospectively, 3-dimensional computed tomography images of both shoulders were available for these patients. Two measurement methods were compared to determine the glenoid defects. One of these techniques is based on linear measurement, previously defined as the glenoid index. The other method is based on surface area measurement. Subsequently, 3 more diameters and the average values obtained from these diameters were compared with the surface measurement method. Pearson correlation coefficient (r) was assessed to determine the relationship. RESULTS: There was an almost perfect relationship between measurement methods when the defect area was less than 6% of the inferior glenoid circle (r, 0.915; P < .001). This relation decreased and the difference became more pronounced (r, 0.343; P = .657) when the bone loss exceeded 14% of the inferior glenoid circle. The highest correlations with the actual defects were the average values obtained from 4 different diameters (r, 0.964; P < .001) and the 4-o'clock position of the single diameter measurements (r, 0.860; P = .001). In addition, 11 patients had crescent-like defects, demonstrating a relatively low correlation between the measurement methods (r, 0.679; P = .021). CONCLUSION: Although the best correlation was achieved from average values obtained from different diameter positions, in practical use, we advise a linear measurement to estimate the glenoid bone loss at the 4-o'clock position to achieve a high correlation between the measurement techniques.

Forearm compartment syndrome of a newborn associated with extravasation of contrast agent.

Extravasation of contrast agents is a possible complication of imaging studies. Although extravasations typically cause minimal swelling or erythema, they can lead to compartment syndrome when the volume of extravasation is high. In this article, we will present an exceptional case where an insignificant amount of contrast agent extravasation led to a forearm compartment syndrome in a newborn, who was treated with an extended fasciotomy. We would like to emphasize the preventive techniques and treatment options of this iatrogenic complication in newborns. Close followup of the patient by the nurses, awareness of the parents and the personnel in the radiology department are the most important preventive measures in this extremity-threatening complication. Forearm compartment syndrome due to contrast agent extravasation may progress more rapidly in newborns even with smaller amounts of extravasation and prompt recognition of the pathology and immediate intervention are unevitable.

Recipient splenic artery utilization for arterial re-anastomosis in living donor liver transplantation: single-center experience.

Thrombosis of recipient hepatic artery is a life threatening complication for liver transplantation. The etiology of hepatic arterial thrombosis is multi-factorial and can be caused by intimal dissection, poor surgical technique and coagulopathies. The patency of hepatic arterial flow is very important for both graft survival and patient survival. Intraoperative diagnosis of inadequate hepatic arterial flow found with Doppler ultrasonography is essential in order to achieve good results after liver transplantation. Urgent re-anastomosis is necessary when the arterial blood flow is insufficient. We performed 317 living donor liver transplantations from July 2004 to July 2011. We used recipient splenic artery for hepatic artery reconstruction in six patients. These six patients were included in this study. Using the recipient splenic artery is a simple, safe and practical alternative for hepatic artery re-anastomosis in living donor liver transplantations.

Biomechanical assessment of suture techniques used for tendon repair.

OBJECTIVE: The aim of this study was to assess different tendon suture techniques from the perspectives of both tensile strength and early active mobilization. METHODS: In this study, we implemented repairs on 40 flexor digitorum profundus (FDP) tendons, acquired from fresh frozen cadavers. The tendons were divided into 5 groups of 8 tendons each. We applied the 2-strand modified Kessler suture technique in the first group, the 4-strand Strickland suture technique in the second group, the 4-strand modified Kessler (without epitenon suture) suture technique in the third group, and the 4-strand modified Kessler (with epitenon sutures) suture technique in the fourth group. The remaining 8 intact tendons were set aside as the control group. The strength of the different tendon suture techniques were measured using the Instron(®) device. RESULTS: The average tolerance strength of the first group was determined as 39.89 ± 9.65 Newtons (N), the average tolerance strength of the second group was 39.64 ± 9.14 N, the average tolerance strength of the third group was 50.29 ± 11.24 N, the average tolerance strength of the fourth group was 54.47 ± 6.83 N, and the average tolerance strength of the control group was 119 ± 17.59 N. The tensile strength of the fourth group was significantly higher (p<0.05) than the first group, and the tensile strength of the third group was also significantly higher (p<0.05) than the first group. No significant difference was observed between the tensile strengths of the second and first groups (p>0.05). CONCLUSION: According to our findings, the tensile strength of 4-strand sutures, with or without epitenon sutures, are significantly higher than the tensile strength of 2-strand sutures. All suture techniques applied had sufficient tensile strength to promote early mobilization.

Innervation pattern of the pronator teres muscle.

OBJECTIVE: To determine the innervation patterns of the pronator teres muscle (PTM), which is used as a donor in muscle transfer. METHODS: This study was conducted from 2001-2006 at the Anatomy Department of the Medical Faculty of Cerrahpasa, University of Istanbul. There were 34 upper extremities of 17 fixed adult cadavers dissected. RESULTS: The classical pattern of innervation by the superior and inferior branches of the median nerve was observed in 19 of the cases (55.9%). In 4 forearms (11.8%) one branch in 10 (29.4%), 3 branches (2 humeral, 1 ulnar) and in one (2.9%), 4 branches (3 humeral, 1 ulnar) were found to be innervating the muscles. CONCLUSION: In all cases, the humeral and ulnar head of the PTM was innervated separately. These variations are of great importance during transfer of PTM.

The muscular branching patterns of the ulnar nerve to the flexor carpi ulnaris and flexor digitorum profundus muscles.

The branching pattern of the ulnar nerve in the forearm is of great importance in anterior transposition of the ulnar nerve for decompression after neuropathy of cubital tunnel syndrom and malformations resulting from distal end fractures of the humerus. In this study, 37 formalin-fixed forearms were used to demonstrate the muscular branching patterns from the main ulnar nerve to the flexor carpi ulnaris muscle (FCU) and ulnar part of the flexor digitorum profundus muscle (FDP). Eight branching patterns were found and classified into four groups according to the number of the muscular branches leaving the main ulnar nerve. Two (Group I) and three (Group II) branches left the main ulnar nerve in 18 and 17 forearms respectively. The remaining two specimens had four (Group III) and five (Group IV) branches each. Usually one or two branches were associated with the innervation of the FCU. However, in 2 cases, three and in one, four branches to FCU were observed. The FDP received a single branch in all cases, except in four, all of which had two branches. In six forearms, a common trunk was observed arising from the ulnar nerve to supply the FCU and FDP. The distribution of the muscular branches to the revealed muscles was outlined in figures and the distance of the origin of these branches from the interepicondylar line was measured in millimeters. The first muscular branch leaving the main ulnar nerve was the FCU-branch in all specimens. The terminal muscular branch of the ulnar nerve to the forearm muscles arose at the proximal 1/3 of the forearm in all specimens. In 7 forearms, Martin-Gruber anastomosis in form of median to ulnar was observed.

Ramification pattern of the thenar branch of the median nerve entering the thenar fascia and the distribution of the terminal branches in the thenar musculature: Anatomic cadaver study in 144 hands.

Knowledge of the anatomy of the median nerve is important in surgery of the palmar aspect of the hand. The purpose of our study was to investigate the ramification pattern of the thenar branch before entering the thenar fascia and the distribution of the terminal branches in the thenar musculature. The observations were carried out on 144 hands of 74 dissecting room cadavers. According to the number of the thenar branches entering the thenar fascia we classified our specimens into four types. In 121 hands (84%, Group I) the thenar branch piercing the thenar fascia was a single trunk. In 19 hands (13.2%, Group II) two branches; in three (2.1%; Group III), three branches; and in one hand (0.7%; Group IV), four branches were identified entering the thenar fascia. Accessory thenar nerve was found in 8.3% of hands. The further division of each branch to its terminal branches was investigated in detail. Our results show that the more the number of thenar branches entering the thenar fascia, the less the terminal branching. Because more than one branch was seen in 16% of the specimens, meticulous dissection is required for preventing injury of the thenar branches before entering the thenar fascia.