Case report of a primary ectopic extradural and extraspinal meningioma of the brachial plexus.

Primary ectopic extradural and extraspinal meningiomas are rare. We present a unique case of this type of meningioma in the brachial plexus. A 25-year-old man consulted us because of neuropathic supraclavicular pain and the appearance of a supraclavicular mass whose volume had increased. Clinical examination found paresis of the deltoid, biceps brachii and brachialis muscles rated as M4 (MRC) and a strong Tinel sign at the supraclavicular fossa, over the palpable mass. There was no sign pointing towards central nervous system involvement or altered general condition. MRI revealed a mass measuring 53 × 24 mm invading the C5-C6 plexus roots and the primary upper trunk, but not the bone or spinal area. This lesion was hyperintense on DWI/ADC, hyperintense on T2 with hypointense spots, and hypointense on T1 with intense heterogeneous gadolinium enhancement. Excisional biopsy was done 6 months after symptoms started. The tumor had developed at the C5 root, which was fibrous and at the C6 root, which was grossly normal. Anatomical pathology confirmed the WHO grade 1 meningioma, meningothelial and psammomatous histological subtypes. At 6 months, a follow-up MRI found no postoperative tumor remnants or recurrence. During the postoperative course, persistent paralysis of the deltoid muscle at 5 months justified a nerve transfer. This is a rare case of ectopic extraspinal and extradural meningioma of the brachial plexus. The diagnosis of an ectopic meningioma must be considered when a patient presents with a brachial plexus tumor causing neurological deficits. The extradural nature is not sufficient to rule out this diagnosis.

Tendon transfers for C8-T1 palsy of the brachial plexus in adults.

Brachial plexus palsy after C8-T1 nerve root injury is rare, but causes a loss of finger flexion and extension, which greatly limits the patient's grip function. It can benefit from nerve transfers if the diagnosis is made early. Otherwise, tendon transfers may be proposed. Transfers of the extensor carpi radialis longus and brachioradialis to the flexor digitorum profundus and the flexor pollicis longus, respectively, restores finger flexion and thumb flexion. Tenodesis of the extensor digitorum communis allows passive extension of the fingers during active wrist flexion. Translocation of the flexor pollicis longus and the creation of a "lasso equivalent" on the flexor digitorum superficialis provides some recovery of the intrinsic function of the fingers and thumb. Finally, a nerve transfer of the lateral cutaneous nerve of forearm on the superficial branch of the ulnar nerve can improve sensitivity on the ulnar edge of the hand to limit the risk of cutaneous lesions, which frequently occur in this type of paralysis.

Transfer of the rhomboid nerve for restoration of shoulder external rotation in partial brachial plexus palsy.

Restoration of shoulder external rotation in partial brachial plexus palsies is a real challenge. The transfer of the spinal accessory nerve to the suprascapular nerve remains the gold standard. This transfer, however, cannot be always performed. Therefore, in these cases, we previously proposed the transfer of the rhomboid nerve to the suprascapular nerve through a posterior approach. The goal of the present study is to assess this technique through a short series. Eight male patients had a partial plexus palsy. Five patients had C5, C6 root injuries, two patients had C5, C6, C7 root injuries, and one patient had C5 to C8 root injuries. No patients had C5 or C6 root avulsions. In one patient, the spinal accessory nerve was injured and in seven patients, the proximal suprascapular nerve was not available. All patients underwent a transfer from the rhomboid nerve to the suprascapular nerve. Concerning shoulder elevation, transfers from the branch of the long head of the triceps or ulnar nerve fascicle were transferred to the axillary nerve. For elbow flexion, fascicles from the ulnar nerve, median nerve, or both were used. For elbow extension, three intercostal nerves in one patient and one fascicle from the ulnar nerve in two patients were transferred to the branch of the long head of the triceps. For wrist and finger extension, palliative surgery was proposed. All patients recovered external shoulder rotation (from 70-110º) and shoulder elevation (range, 80-140º). Active elbow flexion was coded M4 in seven patients and M3 in one patient. All patients recovered active elbow extension. The transfer of the rhomboid nerve to the suprascapular nerve is an efficient procedure for shoulder external rotation in partial brachial plexus palsies without C5 root avulsion. The results in terms of range-of-motion are, however, poorer than with the spinal accessory nerve. Therefore, this technique is appropriate if the spinal accessory nerve is injured or if the suprascapular nerve is not available in the cervical area. This technique must be associated with another transfer to the axillary nerve for shoulder elevation. The study of more patients will be necessary to confirm these results.

The value of preoperative examination and MRI for the diagnosis of graftable roots in total brachial plexus palsy.

The objective of our study was to evaluate the reliability of clinical examination paired with MRI to determine whether one or both of the superior C5 and C6 roots are graftable in cases of complete brachial plexus palsy. We conducted a retrospective study from 2013 to 2018. Twenty-seven patients who had total brachial plexus palsy and were more than 18 years of age were included. The Horner and the Tinel signs, potential phrenic nerve injury and anterior serratus muscle function were investigated. MRI with STIR 3D sequence was performed in each patient. Surgical exploration of the C5 and C6 roots confirmed if they were avulsed and, if found to be ruptured, assessed the possibility of grafting them. Serratus anterior testing had a specificity and a positive predictive value of 100% and diagnostic accuracy of 78%. The presence of the Tinel sign had a sensitivity and a negative predictive value of 100% and diagnostic accuracy of 93%. MRI had a sensitivity, specificity and diagnostic accuracy of 89%. A decision tree to determine whether or not C5 and/or C6 can be grafted has been developed. Its sensitivity and negative predictive value were 100%. This study provides initial validation of this diagnostic method for the diagnosis of graftable C5 and/or C6 roots. It could help prevent needless cervical exploration.

The first case of hourglass-like constriction neuropathy of a digital nerve.

Neuropathies of digital nerves are an infrequent phenomenon and their causes are most often mechanical. A rare cause of acute neuropathy is hourglass-like fascicular constriction of a nerve due to torsion. Although several cases of hourglass-like constriction have been described in the literature, none to our knowledge involved digital nerves. In this report, we present the first case of hourglass-like constriction of a digital nerve.

Rhomboid nerve transfer to the suprascapular nerve for shoulder reanimation in brachial plexus palsy: A clinical report.

Recovery of shoulder function is a real challenge in cases of partial brachial plexus palsy. Currently, in C5-C6 root injuries, transfer of the long head of the triceps brachii branch is done to revive the deltoid muscle. Spinal accessory nerve transfer is typically used for reanimation of the suprascapular nerve. We propose an alternative technique in which the nerve of the rhomboid muscles is transferred to the suprascapular nerve. A 33-year-old male patient with a C5-C6 brachial plexus injury with shoulder and elbow flexion palsy underwent surgery 7 months after the injury. The rhomboid nerve was transferred to the suprascapular nerve and the long head of the triceps brachii branch to the axillary nerve for shoulder reanimation. A double transfer of fascicles was performed, from the ulnar and median nerves to the biceps brachii branch and brachialis branch, respectively, for elbow flexion. At 14 months' follow-up, elbow flexion was rated M4. Shoulder elevation was 85 degrees and rated M4, and external rotation was 80 degrees and rated M4. After performing a cadaver study showing that transfer of the rhomboid nerve to the suprascapular nerve is technically possible, here we report and discuss the clinical outcomes of this new transfer technique.

Transfer of the rhomboid nerve to the suprascapular nerve: An anatomical feasibility study.

Paralysis of the suprascapular nerve, in partial injuries of the brachial plexus, most often warrants a nerve transfer. Transfer of the spinal accessory nerve to the suprascapular nerve is performed most often. We propose to directly transfer the nerve of the rhomboid muscles (branch of the dorsal scapular nerve) to the suprascapular nerve in the supraspinatus fossa. This anatomical study included 10 shoulders. Dissection of the suprascapular nerve and the branch of dorsal scapular nerve to rhomboid muscles (rhomboid nerve) was performed through a posterior approach. Once the nerves were freed, the possibility of suturing the two nerves together was evaluated. Tensionless suture of the rhomboid nerve to the suprascapular nerve was possible in all shoulders in this study. In addition, the diameter of the two nerves was macroscopically compatible: the average diameter of the rhomboid and suprascapular nerve was 2.9 and 3mm, respectively. The diameter of the rhomboid nerve is more suitable than that of the spinal accessory nerve for a transfer to the suprascapular nerve. Moreover, the spinal accessory nerve is preserved in this technique, thereby preserving the function of the trapezius muscle, which could be used for muscle transfer if the nerve surgery fails. In addition, use of the rhomboid nerve allows the suture to be performed downstream to the suprascapular notch and avoids poor results linked to multilevel injuries of this nerve. Finally, if the posterior approach is extended laterally, associated transfer of the nerve to the long head of the triceps brachii to the axillary nerve is also possible. Rhomboid nerve transfer to the suprascapular nerve is anatomically possible. A clinical study will now be necessary to confirm this hypothesis and set out preliminary results.

Adult post-traumatic radioulnar synostosis.

Post-traumatic radioulnar synostosis is a rare complication of forearm fracture. Resulting in loss of forearm axial rotation, it is functionally very disabling. The surgical indication, timing of operation, surgical technique, interest and type of adjuvant treatment are all issues with which physicians managing radioulnar synostosis must deal. No therapeutic consensus yet exists, but a wide variety of surgical techniques and adjuvant treatments are suggested. A literature review sought to identify risk factors for synostosis, with a view to prevention and determining a suitable therapeutic attitude in the light of existing data.

[Scaphotriquetral capsulodesis for scapholunate instability]. / Traitement de l'instabilité scapholunaire par capsulodèse au ligament scaphotriquétral selon Berger.

OBJECTIVES: Scapholunate ligament injuries may lead to scapholunate instability and wrist osteoarthritis. Many surgical techniques have been described to repair these injuries. The goal of our study is to assess the clinical results after capsulodesis with the scaphotriquetral ligament for scapholunate instabilities. METHODS: Twenty-eight patients, 22 men and six women, were operated for scapholunate instability between January 2006 and December 2008. The average age was 37.8 years, and the average time between trauma and surgery was 9.9 months. The scaphoid shift test was present in 26 patients. All patients underwent static and dynamic X-rays of the wrist and scan. A capsulodesis with scaphotriquetral ligament was performed in all patients. RESULTS: At 24 months follow-up, a 13° significant decreased of wrist range-of-motion was noted. The strength was significantly improved after surgery. The wrist stability was improved in 26 patients. Concerning pain, a significant reduction was noted with Analogical Visual Scale after surgery (p<0.005). Twenty-one patients returned to their previous work. Complications were reflex dystrophy in one patient and wrist infection in one patient. CONCLUSION: Many techniques were described for treatment of scapholunate injuries, from the simple scapholunate ligament suture to partial wrist arthrodesis. Capsulodesis with scaphotriquetral ligament improves grip strength, decreases wrist instability and pain with a slight lost of range-of-motion.

In vivo kinematics of the first carpometacarpal joint after trapezectomy.

UNLABELLED: First carpometacarpal osteoarthitis is frequent and surgery may be necessary if medical treatment is not efficient. Trapeziometacarpal arthroplasty, trapeziometacarpal arthrodesis and trapezectomy may be proposed. These surgical solutions may modify the carpometacarpal kinematics of the thumb. However, no clinical tools are currently available to assess these modifications. The goal of our study is to assess the TM kinematics, with an optoelectronic system, in patients after trapezectomy. Ten women, average age 53 (range 45 to 67) underwent trapezectomy with ligamentoplasty for trapeziometacarpal osteoarthritis. An optoelectronic device (Polaris(®)) was used to analyse postoperative range-of-motion of the thumb. Splints were used in order to isolate the trapeziometacarpal joint and retroreflective markers were placed both on the splints and on the thumb. Mean flexion-extension, abduction-adduction, axial rotation and circumduction were calculated. RESULTS: The mean range-of-motion of trapeziometacarpal joint was 50 degrees for flexion-extension, 47 degrees for abduction-adduction and 11 degrees for axial rotation. The mean angle between rotation axes was 90 degrees and the mean distance d between the axes was 3 millimeters. Comparisons between patients and healthy subjects showed no significant differences in flexion-extension, abduction-adduction and axial rotation. Circumduction in patients was reduced compared to healthy subjects. No significant differences were noted between the operated side and the contralateral side. DISCUSSION AND CONCLUSION: Our study showed that this protocol can be used in the postoperative follow-up of patients after trapezectomy. We did not find any significant differences compared to the contralateral side. However, circumduction after trapezectomy was reduced compared to healthy subjects.

The importance of a double team in brachial plexus surgery.

AIM: Brachial plexus surgery constitutes a long and complex procedure. The aim of our study is to assess the interest of having a double operating team throughout the duration of this surgery. PATIENTS AND METHODS: Seventeen patients with brachial plexus palsy underwent surgery operated by a double team. The operating time corresponding to each step of the procedure and the total operating time were measured for each patient. The separate values were added so as to obtain a simulation of the total duration value for a single surgeon. The operative time of this virtual group of patients (Group I) was compared to that of the real group operated by the double team (Group II). Both values were compared to assess any statistical significance. RESULTS: The mean operating time was 259 min with surgery operated by a double team and 371 min in the group I, a difference found to be statistically significant (p<0.05). Exploration and preparation of the cervical region lasted 70 min in average with the double team versus 132 min in the group I (p<0.05). No perioperative complications were noted. DISCUSSION AND CONCLUSION: Brachial plexus surgery performed by a double team allows the reduction of the operating time and thus minimizes the drawbacks associated with lengthy surgery such as perioperative bleeding and infection. Microsurgical suturing which is the crucial part of the surgery is easier when performed at the end of a shortened intervention and shared by two senior surgeons with, subsequently, less fatigue. This new organization that improves the operating conditions guarantees best results.

Normal range-of-motion of trapeziometacarpal joint.

PURPOSE: The range-of-motion of the trapeziometacarpal joint is difficult to assess clinically. The purpose of our study was to constitute a range-of-motion database from normal active trapeziometacarpal joints. MATERIAL AND METHODS: Two hundred hands from 101 healthy subjects (50 female and 51 male) with a mean age of 23.1 years (range: 22 to 35 years) have been evaluated. An optoelectronic device (Polaris) was used to analyse the thumbs range-of-motion. Splints were fitted so as to isolate the trapeziometacarpal joint and retroreflective markers were placed both on the splints and on the thumb. After active flexion-extension, abduction-adduction, axial rotation and circumduction, the different range-of-motion parameters were calculated. RESULTS: The mean range-of-motion of the trapeziometacarpal joint was 41 degrees for flexion-extension, 51 degrees for abduction-adduction and 21 degrees for axial rotation. Comparisons between female and male subjects showed significant differences concerning flexion-extension, abduction-adduction axial rotation and circumduction. No significant differences were noted between right and left hands except for the abduction-adduction movement. DISCUSSION AND CONCLUSION: One hundred and one healthy subjects were analysed for the development of a database of normal active range-of-motion parameters of the trapeziometacarpal joint, with an in vivo protocol. This database should allow comparing the range-of-motion of patients with osteoarthritic trapeziometacarpal joint and assessing surgical outcome.

[Radio-scapho-lunate arthrodesis with distal scaphoid excision]. / Arthrodèse radioscapholunaire avec excision du scaphoïde.

Painful dysfunction of the radio-scapho-lunate joint may occur secondary to a number of post-traumatic, inflammatory and non-inflammatory conditions. When symptomatic, this problem may necessitate fusing the radio-scapho-lunate joint. The goal of this study is to describe precisely the technical steps of radio-scapho-lunate fusion with distal scaphoidectomy and to present the results in a clinical series. Sixteen patients presented with degeneration of the radio-scapho-lunate joint combined with a normal midcarpal joint. Radio-scapho-lunate fusion with distal scaphoidectomy was performed in all patients. At an average follow-up of 37 months, complete relief of pain was obtained in 10 patients, three had slight pain with strenuous loading, and three had occasional pain with regular activities. The average range of passive motion at follow-up was 32 degrees of flexion and 35 degrees of extension. The average postoperative grip strength was 76%. In all cases a solid fusion was obtained. In two patients who had originally suffered a perilunate dislocation, midcarpal degenerative arthritis was noted. We suggest that in cases of radio-scapho-lunate osteoarthritis without degenerative change in the midcarpal joint, radio-scapho-lunate fusion is a possible solution. However, it is necessary to perform distal scaphoidectomy in order to avoid scapho-trapezo-trapezoid impingement. Provided all the technical principles are respected, complications such as ulnocarpal impingement or nonunion, are rare.

[Scapho-trapezio-trapezoidal arthrodesis for scapho-trapezio-trapezoidal osteoarthritis]. / Traitement de l'arthrose scaphotrapézotrapézoidienne isolée par arthrodèse scaphotrapézotrapézoidienne: une série de 13 cas.

Scapho-trapezio-trapezoid arthrodesis was originally performed for the treatment of scapho-lunate instability. However, only a few publications have described this technique for treatment of osteoarthritis of the scapho-trapezio-trapezoid (STT) joint. The purpose of this paper is to analyze the results of triscaphoid arthrodesis for STT osteoarthritis with a long-term follow-up. Thirteen cases of osteoarthritis of the STT joint in twelve patients, all treated by STT arthrodesis, were reviewed with an average follow-up of 60 months. Pain was classified according to Alnot's classification: eight patients were classified as grade III, two as grade IV and two as grade II. The average preoperative range of motion of the wrist was 51 degrees for flexion, 39 degrees for extension, 9 degrees for radial deviation and 28 degrees for ulnar deviation. Grip strength was compared to the contralateral side. Radiographic changes were classified according to Crosby's classification, including sublevels for carpal instability. Four wrists were classified 2a and nine wrists were classified 2b. The average radio-lunate and scapho-lunate angles were 14 and 45 degrees respectively. Pain was improved in all patients (P = 0.05) all of whom were subjectively satisfied. Strength and range-of-motion did not statistically decrease after STT arthrodesis except for wrist extension (P = 0.03). Radio-lunate and scapho-lunate angles were unchanged in five patients and improved in five patients. There were four non-unions of whom two patients without pain were not re-operated. The other two were re-operated with the same technique leading to fusion. Scapho-trapezio-trapezoid arthrodesis is an efficient procedure for STT osteoarthritis with regard to pain reduction. Strength and global range-of-motion are not modified by this procedure. Moreover, as it limits carpal instability, this procedure is preferable in active patients.

[Patient information in carpal tunnel release]. / Syndrome du canal carpien: information et consentement eclairé.

Patients must be informed of the benefits and risks before any surgical procedure. This information must be clear, honest, specific and complete in order that the patient can give his or her informed consent. This information has to be given face to face, however paper may be used to emphasize certain points and aid retention of information. We studied information sheets for carpal tunnel release given out in ten different hand surgery centres. Different points were identified to analyse each form. From this analysis, a literature review and recent law texts, we propose a new information sheet for carpal tunnel release.

[A new cause for iatrogenic lesion of the ulnar nerve at the arm: contraceptive hormonal implant. Report of two cases]. / Une nouvelle cause iatrogène d'atteinte du nerf ulnaire au bras: l'implant hormonal contraceptif. A propos de deux cas.

The authors describe two cases of iatrogenic lesions of the ulnar nerve at the arm level after insertion of contraceptive hormonal implants. The presence of only a thin subcutaneous fat layer on the medial side of the arm in slim women, exposes the ulnar nerve to danger during the insertion or withdrawal of the implant. We therefore advise the insertion of such implants on the medial side of the thigh in slim women. We equally recommend that withdrawal of non-tangible devices implanted on the medial side of the arm or in case of neurologic symptoms, even transitory, be done by a trained microsurgeon.

[Neonatal Volkmann's compartment syndrome. A report of two cases]. / Le syndrome de Volkmann néonatal. A propos de deux cas.

Neonatal Volkmann's compartment syndrome is a rare entity. This diagnosis may be suspected when a case presents cutaneous damage associated with poor hand and wrist function after delivery. We present two such cases of neonatal Volkmann compartment syndrome with long term clinical and x-ray follow-up. In our patients, a hand surgeon was not consulted in the perinatal period and early fasciotomy was not performed. No particular aetiology or associated cerebrovascular accident was found. A series of operations was necessary in order to improve function of the hand. Neonatal Volkmann compartment syndrome must be recognised early in order to enable further investigation of any underlying condition and to perform early surgical decompression. Long term clinical and x-ray follow-up is necessary to prevent and treat wrist deformation and finger contractures.

Three-dimensional rotations of human three-joint fingers: an optoelectronic measurement. Preliminary results.

Longitudinal axial rotations of phalanges during flexion motions of digits have scarcely been analyzed with current anatomical or radiological methods. Recent optoelectronic systems were developed for three-dimensional (3D) kinematic analysis of human motion. These systems have the advantages of being non-invasive and non-irradiating. The current study was based on the VICON optoelectronic system. A validation of the protocol was made among a sample of volunteers for further direct clinical applications. An experimental protocol was set up with adaptations to the requirements of finger analyses (multiple infrared markers inside small-sized capture volumes). The set-up and the protocol details are described. Kinematic studies consisted in recording the movements of the right hand of six volunteers (free from any visible pathology). Results were displayed for the joints of each three-joint finger with calculation of 3D rotations. Metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) flexion angles ranged from 78 degrees to 118 degrees, 72 degrees to 119 degrees and 9 degrees to 66 degrees respectively. Lateral angles ranged from 5 degrees to 39 degrees (MCP), 4 degrees to 39 degrees (PIP) and 4 degrees to 30 degrees (DIP). Mean longitudinal axial rotations of MCP, PIP and DIP joints ranged from 11 degrees pronation to 26 degrees supination. The index finger was in a global pronation position (five of the six specimens). The fourth and fifth fingers were in a global supination position in every case. The third finger was in a more variable global rotation (pronation in four of the six specimens). An experimental protocol using an optoelectronic system (VICON) has been developed for a kinematic analysis of three-joint finger. A global measure study should be initiated among a wider sample of adults. A database should be created with direct clinical applications. Patients' kinematic deficits could be graded either for standard movements (flexion/extension and abduction/adduction) or for longitudinal axial rotations.

Rotations of three-joint fingers: a radiological study.

The aim of the current study was to test a protocol of quantification of phalangeal three-dimensional (3D) rotations during flexion of three-joint digits. Three-dimensional-specific software was developed to analyze CT reconstruction images. A protocol was carried out with six fresh-frozen upper limbs from human cadavers free from any visible pathology (three females, three males). CT millimetric slices were done for reconstruction of hand bone units. Orthonormal coordinate systems of inertia were calculated for each unit. Three-dimensional phalangeal rotations were estimated between two static positions (fingers in extension and in a fist position). Results were displayed for the joints of each three-joint finger with calculation of 3D rotations. Mean longitudinal axial rotations of metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints ranged from 14 degrees pronation to 19 degrees supination. The index finger was in a global pronation position (4/6 specimens). The fourth and fifth fingers were in a global supination position in every case. The third finger was in a more variable global rotation (pronation in 2/6 specimens). MCP, PIP and DIP flexion angles ranged respectively from 71 degrees to 89 degrees, 65 degrees to 87 degrees, and 41degrees to 77 degrees. Lateral angles ranged from 19 degrees (ulnar angulation) to 23 degrees (radial angulation). The study of phalangeal rotations was possible in spite of a heavy protocol. This protocol could be partially automatated to speed up the analyses. Longitudinal axial rotations could be analyzed, in addition to flexion/extension or abduction/adduction rotations. CT scan reconstructions would be helpful for investigating pathological fingers. Abnormal rotations of digits could be quantified more precisely than during a current clinical examination of the hand.