Nomenclature of the radial nerve: distinguishing between the deep branch of the radial nerve and the posterior interosseous nerve.

To address an inconsistency in the nomenclature of the anatomy and compressive syndromes of the deep branch of the radial nerve, we advocate for a single compression syndrome that presents along a spectrum from pain to posterior interosseous nerve palsy.

Anatomical front and back reconstruction sustains radiographic alignment: a comparison to three-ligament tenodesis.

Multiple techniques exist to reconstruct the scapholunate interosseous ligament, though none have demonstrated superiority. This study compares 1-year radiographic outcomes of the three-ligament tenodesis and the anatomical front and back reconstruction. All patients who underwent reconstruction of their scapholunate interosseous ligament at one institution with either anatomical front and back reconstruction or three-ligament tenodesis between 2011 and 2020 were retrospectively reviewed. At 52-week follow-up, anatomical front and back reconstruction maintained a statistically significant improvement in scapholunate gap, corrected radiolunate angle and dorsal scaphoid translation, while three-ligament tenodesis demonstrated no sustained improvement in any parameter. The improvement in dorsal scaphoid translation was significantly greater for patients undergoing anatomical front and back reconstruction compared with three-ligament tenodesis at the 16-weeks postoperative timepoint (-1.0 mm, -0.3 mm). Anatomical front and back reconstruction demonstrates sustained improvement in radiographic outcomes at 1 year when compared with three-ligament tenodesis. By addressing both volar and dorsal critical ligament restraints, adoption of anatomical front and back reconstruction for advanced stage scapholunate interosseous ligament injuries should be considered.Level of evidence: IV.

Factors Influencing Surgical Decision Making in Trapeziometacarpal Osteoarthritis.

Purpose: With trapeziometacarpal osteoarthritis (TMC OA), the relationship between disease severity and pretreatment dysfunction, patient expectations, and preferred patient treatment and management remains unclear. This study aimed to assess the association between functional status, pretreatment expectations, and demographic and clinical characteristics of TMC OA patients who decide to undergo operative management. Methods: Patients diagnosed with TMC OA (n = 96) were administered the Thumb Arthritis Expectations Survey and the Brief Michigan Hand Questionnaire (bMHQ) during their initial office visit. Demographic data (sex, age, race, education level, marital status, comorbidities, and hand dominance) and clinical characteristics (prior injury, and therapeutic interventions including splinting, steroid injections, therapy, and anti-inflammatory medication) were collected. Multiple logistic regression was used to assess the association between surgical treatment and expectation scores. Results: Our logistic regression model found that lower bMHQ scores, high thumb arthritis expectation survey scores, and prior treatments for TMC OA were associated significantly with the surgical treatment of TMC OA. After controlling for all possible covariates, the odds of having surgery was 3.9 times higher among patients with high expectations (above median) compared to patients with low expectations (adjusted odds ratio [AOR], 3.9; 95% confidence interval [CI], 1.3-11.2). Patients with average function, as measured by bMHQ scores, were 74.5% less likely to elect for surgery than those with the lowest bMHQ (AOR, 0.3; 95% CI, 0.1-0.9). Patients treated previously with steroids were 13 times more likely to elect for surgery than those who were never treated for TMC arthritis (AOR,13.1; 95% CI, 2.2-77.0). Conclusions: Patients with TMC OA who elect to proceed with surgical management have lower bMHQ (greater perceived dysfunction) and higher expectations, and have had prior treatment. Age was not a significant predictor of surgical management of TMC OA. Type of study/level of evidence: Prognostic IV.

Development and Validation of a Survey to Measure Patients' Expectations of Wrist Arthritis Surgery.

Background The purpose of this study was to develop and test a patient-derived expectations survey for wrist arthritis surgery. We hypothesized that preoperative patient expectations are higher in people with greater functional impairment and that postoperative fulfilment of patient expectations correlates with functional improvement. Methods The study was conducted in four phases. Development (n = 22) Preoperatively, patients were asked open-ended questions regarding expectations of surgery. A draft survey was then assembled. Reliability (n = 35) The survey was administered twice preoperatively. Concordance was measured with weighted kappa values and intraclass correlations (ICC). Validity (n = 58) Validity was assessed by comparing responses from the Expectations Survey to the patient-rated wrist evaluation (PRWE). Responsiveness (n = 18) Responsiveness was calculated by comparing the proportion of expectations fulfilled to PRWE scores 1-year postoperatively. Results Development Twenty-two distinct items representing the most frequent responses were utilized from the draft survey items of 1,244 expectations volunteered. Reliability Patients had high preoperative expectations of surgery (mean = 76.8); 30% had scores ≥90. Test-retest reliability was high (Cronbach α coefficients = 0.91, 0.93, ICC = 0.86). Endorsement of items = 66 to 100%; and weighted kappa values = 0.39 to 0.96. Validity Patients with greater preoperative expectations (≥63) had more pain, worse function, and worse PRWE scores than those with lower expectations. Responsiveness The proportion of fulfilled expectations was high (mean 0.80, median 0.79), and greater fulfillment (proportion > 0.80, n = 8) was associated with better postoperative PRWE scores. Conclusion The patient-derived expectations survey is reliable, valid, responsive, and addresses a spectrum of expectations for patients undergoing surgery for wrist arthritis. Clinical relevance Understanding patient expectations can contribute to customized care given the range of surgical choices for the arthritic wrist.

Biomechanical analysis of three techniques of suspensionplasty after trapeziectomy: a cadaveric study.

The aim of the present cadaveric study was to assess resistance to first metacarpal subsidence of three techniques of suspensionplasty after trapeziectomy. In total, 18 forearms (mean age 60 years [range 20-89]) were used with six specimens per surgical technique: palmar oblique ligament reconstruction with tendon interposition (LRTI), abductor pollicis longus (APL) suspensionplasty, or suture suspensionplasty. There was no significant difference in mean trapezial space height after trapeziectomy and suspensionplasty compared to the preoperative trapezial height. However, after simulation of physiological lateral pinch, there was a significant (p < 0.05) difference in mean trapezial space height between the APL suspensionplasty and the suture suspensionplasty compared to the LRTI group. After axial loading, there was significantly greater metacarpal subsidence in the LRTI group compared to the APL and suture suspensionplasty groups but no statistically significant difference between the suture suspensionplasty and the APL suspensionplasty groups.Level of evidence: V.

The Influence of Psychosocial Factors on Disability and Expected Improvement Before Surgery for Adult Traumatic Brachial Plexus Injury.

PURPOSE: Psychosocial factors influence pain and recovery after extremity trauma and may be targets for early intervention. This may be of particular interest for patients with adult traumatic brachial plexus injury (BPI), given the broad and devastating impact of the injury. We hypothesized that there would be an association between depressive symptoms, anxiety, and pain interference with preoperative disability and expectations for improvement after BPI surgery. METHODS: We enrolled 34 patients into a prospective multicenter cohort study for those undergoing surgery for adult traumatic BPI. Before surgery, participants completed Patient-Reported Outcome Measurement Information System scales for pain interference, anxiety, and depressive symptoms, and a validated BPI-specific measure of disability and expected improvement. We performed Pearson correlation analysis between pain interference, anxiety symptoms, and depressive symptoms with (A) disability and (B) expected improvement. We created separate linear regression models for (A) disability and (B) expected improvement including adjustment for severity of plexus injury, age, sex, and race. RESULTS: Among 34 patients, there was a moderate, statistically significant, correlation between preoperative depressive symptoms and higher disability. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. There was no association between severity of plexus injury and disability. Depressive symptoms also were moderately, but significantly, correlated with higher expected improvement. This remained significant in a linear regression model adjusted for severity of plexus injury, age, sex, and race. CONCLUSIONS: Depressive symptoms are associated with greater disability and higher expected improvement before BPI surgery. Screening for depressive symptoms can help BPI teams identify patients who would benefit from early referral to mental health specialists and tailor appropriate expectations counseling for functional recovery. We did not find an association between severity of BPI and patient-reported disability, suggesting either that the scale may lack validity or that the sample is biased. LEVEL OF EVIDENCE: Prognostic II.

Referral Patterns Associated With Delayed Care for Traumatic Brachial Plexus Injuries.

PURPOSE: Traumatic brachial plexus injuries (BPI) are devastating, time-sensitive conditions that often require definitive treatment at academic tertiary care centers. Delays to presentation and surgery have been associated with inferior outcomes. In this study, we evaluate referral patterns associated with delayed presentation and late surgery in traumatic BPI patients. METHODS: Patients diagnosed with a traumatic BPI at our institution from 2000 to 2020 were identified. Medical charts were reviewed for demographic characteristics, prereferral work-up, and referring provider characteristics. Delayed presentation was defined as greater than 3 months from date of injury to initial evaluation by our brachial plexus specialists. Late surgery was defined as greater than 6 months from date of injury. Multivariable logistic regression was used to identify factors associated with delayed presentation or surgery. RESULTS: A total of 99 patients were included, 71 of whom underwent surgery. Sixty-two patients presented delayed (62.6%), with 26 receiving late surgery (36.6%). There were similar rates of delayed presentation or late surgery by referring provider specialty. Patients whose initial diagnostic EMG was ordered by the referring provider prior to initial presentation at our institution were more likely to have a delayed presentation (76.2% vs 31.3%) and undergo late surgery (44.9% vs 10.0%). CONCLUSIONS: Delayed presentation and late surgery in traumatic BPI patients were associated with initial diagnostic EMG ordered by the referring provider. CLINICAL RELEVANCE: Delayed presentation and surgery have been associated with inferior outcomes in traumatic BPI patients. We recommend that providers direct patients with clinical concern of traumatic BPI directly to a brachial plexus center without further work-up before referral and encourage referral centers to accept these patients.

Topographic Localization of the Extensor Retinaculum A Cadaveric Study.

PURPOSE: The extensor retinaculum of the wrist, a thickening of the deep forearm fascia, is often used as do- nor graft material for annular pulley reconstructions and bone-retinaculum-bone grafts for ligament reconstructions. The purpose of our study was to identify the relationships between the radial and ulnar styloids, readily recogniz- able topographic landmarks of the wrist, and the anatomic boundaries of the retinaculum. METHODS: The extensor retinacula of 12 preserved, right cadaver wrists (3 male and 9 female) were studied by gross dissection using 3.5-power loupe magnification. The proxi- mal and distal extents of the retinaculum were identified and marked with needles, and their distances from the radial and ulnar styloids measured to determine the lengths of the retinaculum on both sides. RESULTS: The extensor retinaculum on the radial side extended 23.9 ± 2.9 mm proximal to the radial styloid and 5.8 ± 2.6 mm distal to the styloid for a total length of 29.7 ± 3.8 mm. On the ulnar side, the retinaculum extended 2.4 ± 1.4 mm proximal to the ulnar styloid and 17.9 ± 2.6 mm distal to the styloid for a total length of 20.3 ± 2.9 mm. CONCLUSIONS: The extensor retinaculum has a consis- tent relationship with the readily recognized topographic landmarks of the radial and ulnar styloids. The use of the extensor retinaculum as donor material for pulley and liga- ment reconstruction make these findings useful for surgical planning.

Treatment of Painful Lower Extremity Neuromas with Processed Nerve Allograft.

BACKGROUND: Painful neuromas remain a challenge for both patients and surgeons. Despite numerous described treatments, they are often unreliable with variable outcomes. This study evaluated the use of processed nerve allografts for the treatment of painful lower extremity neuromas by either reconstruction or transposition into muscle. The null hypoth- esis was that both techniques for painful neuromas would not result in improved pain or functional outcomes. METHODS: Retrospective review was performed of 12 pa- tients treated by a single surgeon for painful lower extremity neuromas with the utilization of processed nerve allograft either with elongation of the residual nerve stump and trans- location into muscle (n = 7) or nerve reconstruction (n = 5). Patient demographics, surgical details, and outcomes data were evaluated comparing preoperative and postoperative PROMIS (Patient Reported Outcomes Measurement Infor- mation System) scores. Patients underwent preoperative workup with imaging (ultrasound and magnetic resonance imaging). Utilizing a processed nerve allograft, reconstruc- tion was performed if the proximal and distal nerve ends were identifiable, otherwise translocation to muscle was performed to preserve proximal nerve branches. RESULTS: Average follow-up was 15.2 months (SD: 11.4). Neuroma locations included intermetatarsal (n = 4), sural (n = 1), deep peroneal (n = 3), superficial peroneal (n = 4), and medial plantar (n = 1). Five patients failed a previous neuroma surgery, five patients had prior surgery in the zone of injury, one patient sustained a traumatic laceration, and one patient had a motor vehicle collision (MVC) requiring multiple previous surgeries. All but one patient had at least one prior surgery, with seven patients (five translocation, two reconstruction) having undergone a previous attempt to spe- cifically address neuroma pain. Preoperative injection when administered demonstrated improvement in pain and symp- toms in six of seven and two of two of the translocation and reconstruction groups, respectively. Preoperative ultrasound identified a neuroma in four of seven translocation and all four reconstruction patients. Pathology confirmed a neuroma in all 12 patients. Outcome data were available for 10 patients (six translocation, four reconstruction), which demonstrated a statistically significant improvement in PROMIS interference (p = 0.006), intensity (p = 0.011), pain behavior (p = 0.016), and NRS (p = 0.0004). Three patients underwent revision for recurrent neuroma: one translocation, two reconstruction. CONCLUSIONS: For patients with painful cutaneous neu- romas, translocation and reconstruction using processed nerve allografts improved pain in most patients, however, 25% required revision surgery. Three patients had neuroma occurrence requiring revision surgery, prompting caution when counseling patients about outcomes and recurrence.

Localization of Brachial Plexopathies Using a Novel Diagnostic Program.

Background: Assessing the extent and specific location of brachial plexus injuries can be difficult given the variety of mechanisms of injury and anatomic complexity of the plexus. We developed a program to accurately assess the location of a patient's neurologic injury based on electromyographic data. Purpose: We sought to test our hypothesis that the location of traumatic brachial plexopathies could be accurately assessed with a novel program that processed electromyogram (EMG) and mechanism of injury data. Methods: This retrospective diagnostic cohort study was carried out with a novel diagnostic algorithm developed with the Python programming language. The program accepts user input of muscles demonstrating decreased motor unit recruitment, positive sharp waves, or fibrillation potentials. The testing data set was derived from a registry of brachial plexus injuries treated at our center. The primary outcome was the percent concordance of the algorithm's diagnosis with the surgical diagnosis. Results: Ninety-five cases met the inclusion criteria. Median time from injury onset to EMG examination was 4 months; median time from EMG examination to surgery was 1.2 months. The program diagnosis matched the surgical diagnosis in 92 out of 95 (97%) of cases, including cases with multilevel injuries and additional peripheral nerve injuries. Conclusion: This program accurately localized brachial plexopathies in nearly all cases, including those involving polytrauma or complex patterns of injury. This algorithm may be valuable as an aid to complete electrodiagnostic examinations, a diagnostic adjunct when planning treatment of severe plexus palsies, or an educational tool.

High resolution ultrasound for the evaluation of radial nerve pathology adjacent to metallic hardware.

Accurate localization and characterization of peripheral nerve injuries adjacent to metallic hardware is difficult with magnetic resonance imaging (MRI) due to susceptibility artifact. This study sought to present the use of high-resolution ultrasound (US) in accurate characterization of radial nerve injury adjacent to metallic hardware, using findings at the time of operative exploration as confirmation of the US assessment. A retrospective chart review of cases with clinically identified radial nerve injuries evaluated by the high-resolution US was performed from January 2015 through December 2019. Preoperative clinical data, US reports, MRI reports, electrodiagnostic (EDx) reports, and operative reports were reviewed for each case. Preoperative US correctly characterized the affected nerve component, type, and location of injury in all 13 cases (100%), when correlated with intraoperative findings. Nerve injury was directly adjacent to metallic hardware in 12 cases (92%). Out of the seven cases evaluated by both US and MRI, US correctly accurately diagnosed radial nerve injuries in all cases, whereas MRI accurately diagnosed in four cases (57%). In 3/7 cases (43%) MRI was nondiagnostic due to susceptibility artifact. MRI evaluation of the nerve was limited to some degree by metallic artifact in 6/7 cases (85%).

Surgical Treatment of Iatrogenic Nerve Injury Following Arthroscopic Capsulolabral Repair.

PURPOSE: Case reports of nerve injuries following arthroscopic capsulolabral repair emphasize the proximity of major nerves to the glenoid. This study describes preoperative localization using nerve-sensitive magnetic resonance imaging in a small cohort of patients with iatrogenic nerve injuries following arthroscopic capsulolabral repair and the outcomes of nerve repair in these patients. METHODS: Cases of iatrogenic nerve injury following arthroscopic capsulolabral repair referred to 2 surgeons from January 2017 to December 2019 were identified. Clinical charts, electrodiagnostic testing, magnetic resonance imaging studies, and operative reports were reviewed. RESULTS: Four cases of iatrogenic nerve injury were identified. The time to presentation to our institution ranged from 2 weeks to 8 years. The axillary nerves in 3 cases were tethered by a suture at the inferior glenoid, whereas 1 case had a suture tied around the radial and median nerves inferior to the glenohumeral joint capsule. One case underwent excision and nerve transfer, 1 underwent excision and nerve repair, and 2 underwent suture removal and neurolysis. Open and arthroscopic approaches, including a recently described approach to the axillary nerve in the "blind zone," were used. Three cases demonstrated good recovery of all affected motor and sensory functions after surgery. At the 10-month follow-up, 1 case had persistent weakness, but there was evidence of axonal regeneration on electrodiagnostic testing. CONCLUSIONS: Arthroscopic capsulolabral repair places regional nerves, particularly the axillary nerve, at risk owing to their proximity to the joint capsule and inferior glenoid. Patients with neuropathic pain in the distribution of affected nerves with corresponding sensorimotor loss following arthroscopic capsulolabral surgery should undergo focused magnetic resonance imaging with nerve-sensitive sequences and electrodiagnostic testing to localize the injury. The use of multiple surgical windows to the axillary nerve in the "blind zone" enables full visualization for neurolysis, suture removal, and nerve repair or transfer. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Long-term radiographic outcomes and functional evaluation of ulnar shortening osteotomy in patients with ulnar impaction syndrome and reverse oblique sigmoid notch: a retrospective case series study.

BACKGROUND: Ulnar shortening osteotomy (USO) is an effective treatment for ulnar impaction syndrome. However, there have been reports of osteoarthritis (OA) at the distal radioulnar joint (DRUJ) when USO was performed on patients with a reverse oblique sigmoid notch. This study aimed to evaluate the radiographic and functional outcomes following USO in patients with a reverse oblique sigmoid notch. METHODS: We retrospectively reviewed patients having a reverse oblique sigmoid notch who underwent USO for ulnar impaction syndrome between 2002 and 2013. We evaluated radiographic changes of the DRUJ and functional outcomes of patients. RESULTS: We enrolled 22 patients (22 wrists) with an average age of 49.6 years and a mean follow-up of 93.2 (range, 36-179; standard deviation [SD], 38.2) months. We found that there were changes in the inclination angle of the sigmoid notch, from an average reverse oblique of 14.9o (range, 11o-23o; SD, 3.4o) preoperatively to a more parallel 5.1o (range, 0o-11o; SD, 3.2o) at the final follow-up. The functional results at the final follow-up were good, with a mean visual analogue scale for pain of 0.2 (range, 0-1; SD, 0.4) at rest and 1.3 (range, 0-3; SD, 0.9) during activity, QuickDASH of 15.1 (range, 2.3-34.1; SD, 8.8), and modified Mayo Wrist Score of 91.6 (range, 70-100; SD, 6.4). Seven wrists (31.8%) had changes compatible with OA, but the wrists did not exhibit a significantly worse function when compared to wrists without OA changes, except for supination motion and grip strength. CONCLUSIONS: For patients with a reverse oblique sigmoid inclination following USO, we observed that the inclination angle had a tendency to become parallel and some patients developed OA at the DRUJ. However, long-term functional outcomes could still be good. The reverse oblique sigmoid inclination does not seem to be an absolute contraindication for USO.

A Cadaveric Study on the Utility of the Levator Scapulae Motor Nerve as a Donor for Brachial Plexus Reconstruction.

PURPOSE: The purpose of the study was to evaluate the utility of the levator scapulae motor nerve (LSN) as a donor nerve for brachial plexus nerve transfer. We hypothesized that the LSN could be transferred to the suprascapular nerve (SSN) or long thoracic nerve (LTN) with a reliable tension-free coaptation and appropriate donor-to-recipient axon count ratio. METHODS: Twelve brachial plexus dissections were performed on 6 adult cadavers, bilaterally. We identified the LSN, spinal accessory nerve (SAN), SSN, and LTN. Each nerve was prepared for transfer and nerve redundancies were calculated. Cross-sections of each nerve were examined histologically, and axons counted. We transferred the LSN to target first the SSN and then the LTN, in a tension-free coaptation. For reference, we transferred the distal SAN to target the SSN and LTN and compared transfer parameters. RESULTS: Three cadavers demonstrated 2 LSN branches supplying the levator scapulae. The axon count ratio of donor-to-recipient nerve was 1:4.0 (LSN:SSN) and 1:2.1 (LSN:LTN) for a single LSN branch and 1:3.0 (LSN:SSN) and 1:1.6 (LSN:LTN) when 2 LSN branches were available. Comparatively, the axon count ratio of donor-to-recipient nerve was 1:2.5 and 1:1.3 for the SAN to the SSN and the LTN, respectively. The mean redundancy from the LSN to the SSN and the LTN was 1.7 cm (SD, 3.1 cm) and 2.9 cm (SD, 2.8 cm), and the redundancy from the SAN to the SSN and the LTN was 4.5 (SD, 0.7 cm) and 0.75 cm (SD, 1.0 cm). CONCLUSIONS: These data support the use of the LSN as a potential donor for direct nerve transfer to the SSN and LTN, given its adequate redundancy and size match. CLINICAL RELEVANCE: The LSN should be considered as an alternative nerve donor source for brachial plexus reconstruction, especially in 5-level injuries with scarce donor nerves. If used in lieu of the SAN during primary nerve reconstruction, trapezius tendon transfer for improved external rotation would be enabled.

Outcomes of Microneurolysis of Hourglass Constrictions in Chronic Neuralgic Amyotrophy.

PURPOSE: Wide variability in the recovery of patients affected by neuralgic amyotrophy (NA) is recognized, with up to 30% experiencing residual motor deficits. Using magnetic resonance imaging and ultrasound (US), we identified hourglass constrictions (HGCs) in all affected nerves of patients with chronic motor paralysis from NA. We hypothesized that chronic NA patients undergoing microsurgical epineurolysis and perineurolysis of constrictions would experience greater recovery compared with patients managed nonsurgically. METHODS: We treated 24 patients with chronic motor palsy from NA and HGCs identified on magnetic resonance imaging and US either with microsurgical epineurolysis and perineurolysis of HGCs (11 of 24) or nonsurgically (13 of 24). Muscle strength (both groups) and electrodiagnostic testing (EDX) (operative group) was performed before and after surgery. Preoperative EDX confirmed muscle denervation in the distribution of affected nerve(s). All patients met criteria for microneurolysis: 12 months without improvement since onset or failure of clinical and EDX improvement after 6 months documented by 3 successive examinations, each at least 6 weeks apart. RESULTS: Mean time from onset to surgery was 12.5 ± 4.0 months. Average time to most recent post-onset follow-up occurred at 27.3 months (range, 18-42 months; 15 nerves). Average time to latest follow-up among nonsurgical patients was 33.6 months (range, 18-108 months; 16 nerves). Constrictions involved individual fascicular groups (FCs) of the median nerve and the suprascapular, axillary and radial nerves proper (HGCs). Nine of 11 operative patients experienced clinical recovery compared with 3 of 13 nonsurgical patients. EMG revealed significant motor unit recovery from axonal regeneration in the operative group. CONCLUSIONS: Microsurgical epineurolysis and perineurolysis of FCs and HGCs was associated with significantly improved clinical and nerve regeneration at an average follow-up of 14.8 months compared with nonsurgical management. We recommend microneurolysis of HGCs and FCs as a treatment option for patients with chronic NA who have failed to improve with nonsurgical treatment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Role of high-resolution peripheral nerve magnetic resonance imaging in diagnosing median nerve tethering in a case of both-bone forearm fracture in a child.

Forearm fractures are common injuries in pediatric patients. We present a case of median nerve tethering as a complication of both-bone forearm fracture in a child, with an emphasis on MRI as an appropriate and important complement to clinical and electrodiagnostic examination. Early intervention is essential because delayed surgical management of median nerve tethering can result in poor clinical outcomes as a result of irreversible muscle denervation. In this case, we highlight the importance of MRI to facilitate management, including early surgical intervention when appropriate, in median neuropathy following forearm fractures.

Postoperative Pain Is Correlated with Scaphoid Dorsal Translation following Scapholunate Interosseous Ligament Reconstruction.

Background Dorsal scaphoid translation (DST) has been demonstrated to occur in patients with complete scapholunate interosseous ligament (SLIL) tears. Radiographs and magnetic resonance imaging (MRI) have demonstrated ability to detect DST in patients with documented complete scapholunate (SL) disruption, but the relevance of this parameter to outcomes of reconstruction has not been determined. Purpose The purpose of this article is to determine how radiographic parameters of SL dissociation correlate with postoperative pain and functional outcomes of SLIL reconstruction. Methods We performed a retrospective review of prospectively collected data on a cohort of 14 patients who underwent SLIL repair or reconstruction. Preoperative data included radiographic measurements of carpal posture and alignment (SL angle, radiolunate [RL] angle, SL gap, and DST), self-reported measure of average pain on a numerical rating scale (NRS) of 0 to 10, and the patient rated wrist evaluation (PRWE) survey. Postoperatively, the same data were collected at each follow-up visit. Radiographic parameters were statistically compared with postoperative NRS pain score and PRWE scores. Statistical correlations were calculated using Spearman's correlation coefficient, and mean NRS pain scores were compared using Wilcoxon's rank-sum tests, with an α value of p = 0.05. Results Mean NRS pain scores improved significantly after surgery. Mean DST improved significantly after surgery. The presence of postoperative dorsal scaphoid translation (DST) correlated strongly with postoperative pain. SL angle, RL angle, and SL gap showed no correlation with patient reported pain. There was no correlation with any radiographic parameter and PRWE. Conclusions Our study demonstrates that the presence of DST in postoperative radiographs has a strong correlation with patient reported pain following SLIL reconstruction. We conclude that correction of dorsal translation of the scaphoid is a more sensitive predictor of postoperative pain relief than SL gap, RL angle, or SL angle. Level of evidence This is a Level IV study.

Association of Claustrophobia and Anxiety with Cast Intolerance in Patients with Extremity Injuries.

BACKGROUND: Patients undergoing casting for upper or lower extremity injuries may present with recalcitrant pain without an identifiable physiologic etiology, which increases the likelihood of more frequent or unscheduled office visits, insomnia, decreased patient satisfaction, unnecessary investigative procedures or treatments, and-in some cases-cast intolerance. The exact causes of cast intolerance are not well studied, although claustrophobia and associated fears of suffocation and restriction may be underlying causes. QUESTIONS/PURPOSES: We sought to explore the association between claustrophobic tendencies and cast intolerance. We hypothesized that patients with claustrophobia or claustrophobic tendencies would have a higher rate of cast intolerance. METHODS: Patients requiring circumferential casting of an upper or lower extremity were prospectively enrolled at the time of cast application. Data were collected at each office visit until cast removal. Pre- and post-casting anxiety were quantified using the Beck Anxiety Inventory® (BAI®). Pain was assessed at each visit using the visual analog scale (VAS). Claustrophobic tendencies were evaluated after cast removal using the Claustrophobia Questionnaire (CLQ). At the completion of the study, patients were assigned to either the cast-tolerant or the cast-intolerance cohort according to predetermined criteria. CLQ, BAI, and VAS scores were compared between cohorts. RESULTS: Out of 199 patients enrolled, 4% (n = 8) met the criteria for cast intolerance. There was no difference in BAI (anxiety) scores between groups at casting, but cast-intolerant patients had significantly lower post-casting BAI scores than the cast-tolerant controls, indicating a decrease in anxiety after cast removal. Taken together, both groups demonstrated significant reduction in VAS scores from casting to cast removal. The tolerant group had a significant reduction in VAS scores, whereas the intolerant group did not. The intolerant group had a significant negative correlation between initial VAS scores and final BAI scores. The tolerant group had a significant positive correlation between initial VAS scores and final BAI scores, as well as between final VAS scores and final BAI scores. Interestingly, no difference in CLQ scores was seen between groups, although there were positive correlations between CLQ scores and pre- and post-casting anxiety scores and between CLQ and final VAS scores. CONCLUSIONS: Our hypothesis was not supported. Although we did not find a relationship between claustrophobia and cast intolerance, we did find significant correlations between anxiety and pain. The tolerant group's initial and final pain scores had significantly positive correlations to final anxiety, suggesting that pain is likely to cause or increase anxiety; indeed, as pain decreased, so did anxiety. The intolerant group, however, had a significant negative correlation between initial pain and final anxiety scores. It would not be expected that lower pain scores would increase anxiety. This may suggest that cast-intolerant patients experience or report their anxiety as pain. These findings may explain why some patients suffer from pain that cannot be explained by an underlying physiologic process and is resistant to traditional pain management. A multidisciplinary approach, including psychological and psychosocial assessments, may help identify nonphysiologic components to pain. An accurate diagnosis for the cause of pain may lead to nonpharmacological interventions and therefore reduce opioid use and overall costs and improve patient outcomes.

Ultrasound imaging of nerves in the neck: Correlation with MRI, EMG, and clinical findings.

OBJECTIVE: We evaluated the performance of ultrasound in the detection of neuropathy of the suprascapular nerve (SSN), long thoracic nerve (LTN), spinal accessory nerve (SAN), and phrenic nerve and compared this performance with MRI. METHODS: A retrospective review of 56 patients who had undergone ultrasound imaging of the SSN, LTN, SAN, and phrenic nerve was performed. Diagnoses made by ultrasound, MRI, EMG reports, and clinical and operative notes were recorded. RESULTS: Ultrasound was successful in visualizing nerves in the neck in the overwhelming majority of cases. Sonographic findings were typically in agreement with MRI and clinical findings. CONCLUSION: Ultrasound is effective in the visualization and diagnostic evaluation of the SSN, LTN, SAN, and phrenic nerve. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that ultrasound can effectively visualize and diagnose neuropathy of the SSN, LTN, SAN, and phrenic nerve in the neck.