Intermuscular Septum Research Articles

Revision surgery for recurrent ulnar nerve compression following failed subcutaneous transposition.

Recurrent ulnar nerve compression after primary anterior subcutaneous transposition is relatively rare, and revision surgery is challenging. This study retrospectively evaluated the clinical outcomes of revision anterior subcutaneous transposition for recurrent ulnar nerve compression. Eight patients who underwent revision anterior subcutaneous transposition for recurrent ulnar nerve compression were enrolled in this study. The outcomes were based on preoperative and postoperative symptoms, physical examination findings, and electromyographic evaluation. Ulnar nerve enlargement was preoperatively found in all patients with a mean cross sectional area of 0.15 cm2 (range, 0.14-0.18 cm2). Intraoperative findings showed that recurrent compression occurred in three areas, including the medial intermuscular septum (n = 5), the medial epicondyle (n = 6) and nerve entrance to forearm fascia (n = 1). Post-operation, significant improvements were observed in ring/little finger numbness (from severe to mild, p = 0.031), grip strength (from 48.00% to 80.38% of the intact side, p < 0.001) and McGowan grade (from Grade III to Grade I, p = 0.049). Postoperative electromyography test also showed significant improvement in motor nerve conduction at elbow (velocity, 23.30 ± 9.598 vs. 35.30 ± 9.367, p = 0.012; amplitude, 3.40 ± 3.703 vs. 5.65 ± 2.056, p = 0.007) and sensory nerve conduction at wrist (velocity, 27.04 ± 22.450 vs. 36.45 ± 18.099, p = 0.139; amplitude, 1.44 ± 1.600 vs. 4.00 ± 2.642, p = 0.011). Seven of the eight patients reported satisfaction with the postoperative results. Revision anterior subcutaneous transposition was an effective treatment for recurrent ulnar nerve compression from prior failed procedures.

Double-Flap Elevation From the Ipsilateral Lower Extremity: The Anterior Approach to Fibula Osteo-Cutaneous Flap Elevation.

The free fibular flap has been elevated by a "lateral approach" from the posterior edge of the peroneal muscle for more than 40 years. However, in this approach, the surgical view is limited because flap elevation in mandibular reconstruction is performed simultaneously with tumor resection in the supine position, even when using positioning pillows. We herein propose an "anterior approach" as a new surgical method. We retrospectively investigated free fibular flap surgeries performed using the anterior approach, which consists of three anterior approaches, over a seven-year period. First, to avoid the course of the superficial peroneal nerve, the crural fascia was incised 1-2 cm posterior to the anterior edge of the peroneal muscle. The anterior edge of the peroneus muscle is detached from the anterior intermuscular septum. After performing osteotomies distal and proximal to the fibula, the interosseous membrane was incised from the anterior view. Pulling out the fibula to the anterior space between the anterior intermuscular septum and the peroneal muscle made the surgical field shallow. No postoperative superficial or deep peroneal nerve palsies were found in the 55 patients. Only one tourniquet was used in 31 of the 55 cases (56.4%), with an average of 95 min. Twenty-four patients (43.6%) required a second tourniquet 38 min after an interval. Only one tourniquet was used in 25 of the 30 (83.3%) cases in the last 3 years. Moreover, double flaps were used in 21 cases (38.2%), all of which involved ipsilateral ALT flaps. In 18 cases, double-flap elevation and prefabrication were successfully finished before the completion of tumor resection by otorhinolaryngologists.

Exploratory Anterior Cruciate Ligament Graft Stress during Medial Knee Rotation with and without Iliotibial Band–Intermuscular Septum Lateral Extra-Articular Tenodesis for Transtibial and Anteromedial Femoral Tunnels

Exploratory Anterior Cruciate Ligament Graft Stress during Medial Knee Rotation with and without Iliotibial Band–Intermuscular Septum Lateral Extra-Articular Tenodesis for Transtibial and Anteromedial Femoral Tunnels

Anatomical study of the safety corridor for bridge plating positioned on the lateral border of the humerus.

This study shows the danger zone and the safety corridor in the lateral approach with bridge plating by measuring the distance between the lateral side of the plate positioned on the lateral aspect of the humerus and the radial nerve after it pierces the lateral intermuscular septum, in the different forearm positions. Forty arms of 20 human cadavers were used, the radial nerve was identified and marked on the lateral surface the radial nerve at the exit of the lateral intermuscular septum and anteriorisation of the nerve in relation to the humeral shaft and the lateral epicondyle was also marked. The distances were measured with a digital caliper. A submuscular extraperiosteal corridor was created, proximally between the biceps brachialis and deltoid muscle and distally between the triceps and brachioradialis muscle, followed by the positioning of the low contact large fragments contoured plate with 14 combined holes (fixed and cortical angle), inserted from distal to proximal. Measurements were performed in four positions (elbow flexion with forearm pronation, elbow flexion with forearm supination, elbow extension with forearm pronation and elbow extension with forearm supination). Significant statistical differences occurred with the different positions, and the elbow flexion with forearm supination was shown to be the position that provides the safest submuscular extraperiosteal corridor in a lateral approach of the humerus. The danger zone of radial nerve is an area that extends from 15cm to 5cm proximal to the lateral epicondyle and the safest way to create a submuscular and extraperiosteal corridor in the lateral region of the humerus is with the elbow in flexion and the forearm in supination.

A Cadaveric Study on Radial Nerve Risk Zone in the Distal Part of the Arm

Introduction: Injury to the radial nerve in the arm is very frequent following fractures of the shaft of the humerus and may also occur during surgery on the arm. These iatrogenic injuries can be prevented by predicting the point at which the nerve penetrates the lateral intermuscular septum during its course from the posterior-to-anterior compartment of the arm. Aims and Objectives: Our study aims to find out the point of penetration of the radial nerve in the lateral intermuscular septum (radial nerve risk zone [RNRZ]). Materials and Methods: The study was conducted on 30 upper limbs of adult formalin-embalmed cadavers during MBBS undergraduate dissection at the department of anatomy. The posterior aspect of the arm was dissected to expose the radial nerve, and measurements of parameters were recorded. Results: The mean humeral length was 29.91 ± 2.66 cm. The mean distance from the lateral epicondyle of the humerus to the point on the lateral intermuscular septum where radial nerve pierces during its course from posterior-to-anterior compartment was 11.42 ± 1.042 cm, r = 0.368, and P &lt; 0.05 which was statistically significant. The mean (standard deviation) humeral length of both left and right side difference was statistically significant with P = 0.009 (P &lt; 0.05). Conclusion: We believe that our study will help orthopedic surgeons to estimate the point of penetration of radial nerve into the lateral intermuscular septum which is the RNRZ. This minimizes the risk of radial nerve damage during the fixation of the fractured shaft of the humerus.

Growing stylohyoideus muscle insertion to the hyoid bone with special reference to its topographical relation to the intermediate tendon of digastricus muscle: A histological study using human fetuses

BackgroundIn adults, the intermediate tendon of digastricus muscle usually runs along the medial or lateral side of the stylohyoideus muscle insertion. To provide a better understanding of the variations, we examined the topographical anatomy of the muscle and tendon in fetuses. MethodsWe examined histological sections from six early-term, 26 mid-term and six near-term fetuses (approximately 8–9, 12–18 weeks and 25–33 weeks). ResultsAt early-term, an initial sheath of intermediate tendon of digastricus muscle received the stylohyoideus muscle at the superior aspect. The muscle and tendon was distant from the hyoid. At mid-term, near the insertion to the hyoid greater horn, the stylohyoideus muscle consistently surrounded more than 2/3 of the intermediate tendon circumference. In contrast, we found no near-term specimen in which the stylohyoideus muscle surrounded the intermediate tendon. The multilayered tendon sheath was fully developed until near-term and connected to the body of hyoid by an intermuscular septum between the thyrohyoideus muscle and one or two of suprahyoid muscles. Therefore, the hyoid insertion of the styloglossus muscle was a transient morphology at mid-term. ConclusionThe stylohyoideus muscle insertion was appeared to move from the tendon sheath to the hyoid greater horn and, until near-term, return to the tendon sheath. A fascia connecting the tendon sheath to the body of hyoid was strengthened by the suprahyoid and infrahyoid muscles. The latter muscles seemed to regulate fixation/relaxation of the intermediate tendon to the hyoid. The stylohyoideus muscle slips sandwiching the intermediate tendon might be a rare morphology.

Anconeus Muscle Transfer to Correct or Prevent Wrist Radial Deviation in Radial and Posterior Interosseous Nerve Injuries

Wrist radial deviation is a possible complication of tendon transfer for restoration of wrist extension in cases of radial nerve paralysis. In posterior interosseous nerve (PIN) injury, this is because of the imbalance caused by the intact extensor carpi radialis longus and paralysis of the extensor carpi ulnaris (ECU). This deformity may also occur following transfer of the pronator teres (PT) to the extensor carpi radialis brevis (ECRB) for radial nerve palsy. To address wrist radial deviation, we propose transferring the anconeus muscle, extended by the intermuscular septum between the ECU and the flexor carpi ulnaris (FCU), to the ECU tendon. Through an incision over the ulna, the intermuscular septum between the ECU and FCU is harvested at the level of the periosteum and left attached to the anconeus proximally. The anconeus muscle is then released from the ulna, and the intramuscular septum extension is sutured to the ECU tendon under maximal tension. Anconeus muscle transfer was performed on two patients to correct chronic wrist radial deviation following PT to ECRB tendon transfer for radial nerve injury, as well as on two patients with PIN paralysis. In four patients, transfer was performed in addition to standard tendon transfers for radial nerve paralysis to prevent radial wrist deviation deformity. Wrist radial deviation was corrected or prevented in all but one patient at an average follow-up of 10 months. Patients with PIN lesions and those who had anconeus transfer concomitantly with radial nerve tendon transfers were capable of active ulnar deviation. No patient experienced elbow extension weakness, pain, or instability. Anconeus muscle transfer extended by intermuscular septum presents a viable alternative for addressing radial deviation of the wrist in cases of PIN nerve lesions or following PT to ECRB tendon transfer in radial nerve paralysis. Therapeutic V.

Ulnar Nerve Decompression With Subcutaneous Transposition

Background: Medial-sided elbow injuries are becoming increasingly common among throwing athletes due to overuse and increased specialization at early ages. High valgus stress and repetitive elbow flexion/extension during throwing not only affects the ligaments and dynamic support of the elbow, but commonly affects the ulnar nerve. Indications: Management of cubital tunnel syndrome is initially rest, therapy, and functional training; however, if conservative measures do not appropriately address the ulnar neuropathy, surgical decompression with subcutaneous transposition is a reliable treatment option. Technique Description: An incision is created over the medial epicondyle. The medial antebrachial cutaneous nerve is identified and protected. The ulnar nerve is identified and tagged with a vessel loop to allow for appropriate handling of the nerve. Decompression of the ulnar nerve begins proximally by spreading the tissues superficial to the ulnar nerve and splitting the fascia overlying it. Then, dissection deep to the nerve is performed. A small strip of the medial intermuscular septum will be used as a sling to hold the nerve securely in the transposed position. This is released proximally and the distal attachment to the medial epicondyle is left in place. Decompression is then continued distally by releasing the superficial fascia over the flexor carpi ulnaris (FCU) and a portion of the deep FCU muscle belly and fascia. The nerve is decompressed circumferentially, while preserving penetrating branches to the FCU as able. Ultimately, the ulnar nerve is decompressed 10 cm proximal and 10 cm distal to the medial epicondyle. The intermuscular septum is then pulled over the nerve, checked for appropriate length, and sutured in place both posterior and anterior to the ulnar nerve. Results: Symptom improvement after decompression and transposition is high (&gt;90%); however, performance outcomes in overhead and throwing athletes is variable, and return to previous or higher level of play ranges from 60% to 90%. Discussion/Conclusion: Ulnar nerve decompression and transposition can reliably address underlying symptoms, but results are mixed for return to sport outcomes in overhead and throwing athletes. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

3D printing for an anterolateral thigh phalloplasty

BackgroundPhalloplasty procedures are performed to create a phallus, typically as a gender-affirming surgery for treating gender dysphoria. Due to the controversial nature of this specific procedure, more innovation is needed to directly assist surgical teams in this field. As a result, surgeons are left to improvise and adapt tools created for other procedures to improve surgical outcomes. This study developed a patient-specific 3D printed model from segmented computed tomography (CT) scans to accurately represent the relevant vasculature necessary for anterolateral thigh (ALT) flap phalloplasty. The surgical procedure seeks to maintain intact vessels that derive from the descending branch of the lateral circumflex femoral artery, typically found traveling within the intermuscular septum between the rectus femoris and vastus lateralis.MethodsIn this study, we created and printed 3D models of the leg and vasculature using two techniques: (1) a standard segmentation technique with the addition of a reference grid and (2) a bitmap method in which the total CT volume is colorized and printed.ResultsThe results gathered included the physician’s view on the model’s accuracy and visualization of relevant anatomy. Bitmap-printed models resulted in a high amount of detail, eliciting surgeons’ undesirable reactions due to the excess of information. The hybrid method produced favorable results, indicating positive feasibility.ConclusionsThis study tested the ability to accurately print a patient-specific 3D model that could represent the vasculature necessary for ALT flap procedures and potentially be used in surgical reference and planning in the future. A surgeon performing phalloplasty procedures discussed their approval of both models and their preference for grid creation and application.

Anterior transposition of the radial nerve to achieve primary suture for its reconstruction: Anatomical feasibility study

IntroductionRadial nerve palsy after humeral shaft fractures is often associated with formation of a neuroma in continuity. The current standard of treatment is neuroma resection and nerve grafting with contentious results. Anterior transposition of the radial nerve may reduce the length of its path, allowing reconstruction by primary suture. The aim of this study was to determine the maximum length of radial nerve defect that can be treated by the anterior transposition to allow primary suture to be performed. MethodsWe use 10 arms from five fresh cadavers. The radial nerve was dissected in the lateral inter-muscular septum and along the anterior aspect of the forearm. The radial nerve was transected at the level of the spiral groove and both stumps were than transposed anterior to the medial inter-muscular septum. The length of tension-free overlap that could be achieved was measured. ResultsThe average length of the overlap at zero degrees of elbow flexion was 10.00 ± 1.84 mm. Theoretically, this will allow a defect of 20 ± 3.69 mm SD to be treated by primary suture. ConclusionOur results suggest that anterior transposition can be used for radial nerve defects up to 2 cm; however, dissection of both stumps proved to be challenging.

Perforator flap for burn reconstruction

BackgroundMajority of burn patients in Bangladesh are treated at home and tend to develop scar and scar contracture. Other than physical limitations there are also stigmatization, loss of marriageability or divorce particularly for women. Skin grafts are prone to contraction and need prolonged splintage and physiotherapy. Flaps are often too bulky. Local flaps have the advantage of increased positional comfort as compared to distant flaps like the abdominal or the groin flaps. Free flaps are technically demanding and facilities are not universally available. Advances in knowledge of blood supply of the skin have increased the potentials for perforator based skin flaps. MethodologyA total of 72 patients who could complete a minimum one year follow up were included in the study. All flaps were rotated around the axis of the perforator ranging from 90 degrees to 180 degrees. Skin pedicles were kept when possible, complete island flaps were designed when rotation was maximum. ResultsAmong the 72 cases 54 cases were electric burn wounds and18 were post burn scar contracture, 59 were male and 13 were female. 44 cases were done on leg. Smallest flap was 5 cm in length and the largest was 16 cm. Immediate complications include total flap loss, tip loss, margin loss, wound infection and hematoma under the flap was noted. In one case emergency exploration was required to control hemorrhage. Contour defect, dependent edema in legs, sensorineural deficit, limitation of joint movement was also observed. ConclusionA single perforator may safely supply its proper angiosome and up to the half of vascular territory of the adjacent perforator. This possibility is favored by vascular adoption directed toward the periphery that occurs by means of increased vascular pressure in the perforator artery after ligature of collateral subcutaneous and intramuscular arterial branches. The authors percept is, usually perforation is along the intermuscular septum, the portion of the flap that crosses beyond the adjacent intermuscular septum are at risk. Not required to go that far as residual wounds can be grafted with split thickness skin.

A Soft-Tissue Landmark to Assess Humeral Component Rotation in Total Elbow Arthroplasty.

Assessing the rotational alignment of the humeral component during total elbow arthroplasty is dependent upon bony landmarks that can be absent or altered in cases of distal humerus fractures, revision arthroplasty, severe bone loss, or deformity. We hypothesize that the intermuscular septum can be used as a reliable soft-tissue landmark to set the rotation of the humeral component intra-operatively when previously described bony landmarks are not reliable or present. Forty-eight unpaired cadaveric human subjects (mean age and standard deviation 63 ± 12 years; 24 males, 24 females) underwent computed tomography (CT) scans. The geometric centers of the trochlea and capitellum were assessed, and the line through these two points was set as the flexion-extension axis (FEA) of the elbow. The intermuscular septum axis (IMSA) was drawn proximal to the olecranon fossa and at least 4 cm proximal to the most distal point of the articular surface, where the posterior humeral cortex was flat. The angles between the FEA and IMSA were calculated and compared using a two-tailed t-test. Regression analysis was used to assess the inter- and intra-observer reliability of the IMSA. The IMSA was externally rotated 10.3° ± 2.8 compared to the FEA (p < 0.001 and confidence interval (CI) of 2.8 with α set to 0.01). The inter- and intra-observer reliability of the IMSA was high, with an R-value of 0.91 and 0.97, respectively. The intermuscular septum can be used as a soft-tissue landmark to set humeral component rotation and is 10.3° externally rotated with respect to the FEA of the ulnohumeral joint.

Evaluation of a New Method of Sciatic Nerve Block: A Prospective Pilot Study.

The location of the sciatic nerve deep within the thigh tissue makes it challenging to locate while the patient is in a supine position. The posterior intermuscular septum of the thigh, which encircles the posterior surface of the adductor magnus muscle (AMM), is where the sciatic nerve is located. Our hypothesis was that administering local anesthetic injections into this area could block the sciatic nerve. Therefore, our aim was to evaluate the effectiveness of sciatic nerve block achieved by injecting local anesthetic into the posterior intermuscular septum of the thigh, named the AMM approach. Twenty-six patients undergoing total knee arthroplasty were included in the study. We performed an ultrasound-guided sciatic nerve block by injecting 20 mL of 0.25% ropivacaine into the posterior surface of the adductor magnus muscle, using the AMM approach. Additionally, we administered a femoral nerve block with 20 mL of 0.4% ropivacaine. We assessed the sensory and motor effects of the blockade in the operated lower limb and recorded postoperative pain scores at 0, 4, 8, 12, 24, and 48 hours after the operation. The AMM approach successfully block the sciatic nerve in all 26 patients. The onset of the sensory and motor blockades was achieved within 5.4 ± 1.9 min and 8.7 ± 3.5 min, respectively. We achieved a satisfactory position with the first puncture in 19 of 26 patients (73.1%). The muscle strength of the tibialis anterior immediately after surgery was 4 (ranging from 2 to 5). Additional rescue analgesics were required in 5 of the 26 patients (19.2%) during the first 24 hours postoperatively. The AMM approach is an innovative and effective method for sciatic nerve block. When combined with simultaneous femoral nerve block in patients undergoing total knee arthroplasty, it provides a useful analgesic treatment option.

Anatomic consideration of the radial nerve in relation to humeral length for unilateral external fixation: a retrospective study using magnetic resonance imaging findings in korean

BackgroundThis study aimed to present a safe zone for distal pin insertion for external fixation using magnetic resonance imaging (MRI) images.MethodsAll patients who took at least one upper arm MRI from June 2003 to July 2021 were searched via a clinical data warehouse. For measuring the humerus length, proximal and distal landmarks were set as the highest protruding point of the humeral head and lowermost margin of ossified bone of the lateral condyle, respectively. For children or adolescents with incomplete ossification, the uppermost and lowermost ossified margin of the ossification centers were set as proximal and distal landmarks respectively. The anterior exit point (AEP) was defined as the location of the radial nerve exiting the lateral intermuscular septum to the anterior humerus and distance between the distal margin of the humerus and AEP was measured. The proportions between the AEP and full humeral length were calculated.ResultsA total of 132 patients were enrolled for final analysis. The mean humerus length was 29.4 cm (range 12.9–34.6 cm). The mean distance between the ossified lateral condyle and AEP was 6.6 cm (range 3.0–10.6 cm). The mean ratio of the anterior exit point and humeral length was 22.5% (range 15.1–30.8%). The minimum ratio was 15.1%.ConclusionA percutaneous distal pin insertion for humeral lengthening with an external fixator may be safely done within 15% length of the distal humerus. If pin insertion is required more proximal than distal 15% of the humeral shaft, an open procedure or preoperative radiographic assessment is advised to prevent iatrogenic radial nerve injury.

Intramuscular Stress Transmission Between the Muscles of the Ball of the Thumb, and the Latissimus Dorsi Muscle After Tensegrity Massage Application a Pilot study

Introduction: The phenomenon of tensegrity in the muscular system still remains theoretical. Research has been mostly performed in vitro. Unfortunately, analyses of this type are focused on this part of the phenomenon. They do not consider, e.g. the presence of body fluids.Study objective: The aim of the study was in vivo verification regarding the occurrence of tensegrity in a model consisting of the latissimus dorsi muscle (LAT), the medial intermuscular septum, muscles of the anterior forearm and muscles of thenar eminence.Material and methods: The study group was divided into an experimental (n =10) and control group (n=10). The experimental group took part in 1 massage session of the thenar eminence muscles for 5 minutes. The control group spent 5 minutes on a couch in the same position as in the experimental group, receiving no intervention. In both groups, at the beginning and end of the session, LAT was tested with a tensiomyograph and algometer.Results: Statistically significant differences between the groups occurred in pressure pain threshold (p=0.02), contraction time (p=0.01), relaxation time (p=0.01) and LAT sustaining duration (p=0.046). The level of statistical significance was p&lt;0.05.Conclusions: In the tested model, the change in the tension of the distal end of the model influenced the displacement of the muscle at the proximal end of the model in accordance with the tensegrity model.

Possible Points of Ulnar Nerve Entrapment in the Arm and Forearm: An Ultrasound, Anatomical, and Histological Study.

Ulnar nerve entrapment is one of the most common entrapment neuropathies, usually occurring in the cubital tunnel of the elbow and in Guyon's canal of the wrist. However, it can also occur at other anatomical locations. Our aim was to review other possible locations of ulnar nerve entrapment in an ultrasound and anatomical study. Eleven upper limbs from eight adult corpses were ultrasonographically examined and subsequently dissected in a dissection laboratory. Four specific anatomical points were analysed, and any anatomical variations were documented. Moreover, six samples of the nerve were taken for histological analysis. Distinct anatomical relationships were observed during ultrasound and dissection between the ulnar nerve and the medial intermuscular septum, the triceps aponeurosis, Osborne's fascia at the elbow, the arcuate ligament of Osborne and the intermuscular aponeurosis between the flexor carpi ulnaris and the flexor digitorum superficialis muscles. A statistical study showed that these locations are potential areas for ulnar nerve compression. In addition, a fourth head of the triceps brachii muscle was found in some specimens. Results demonstrate that ultrasound is a good tool to investigate ulnar nerve entrapment neuropathy and to identify other anatomical points where the nerve can remain compressed.

Minimally Invasive Plate Osteosynthesis (MIPO) Through the Posterior Approach for the Humerus: A Cadaveric Study.

Background Minimally invasive plate osteosynthesis (MIPO) has been effectively used in femur and tibia fractures. MIPO in the humerus is conducted by anterior (most commonly used), lateral, and posterior approaches. However, in the anterior approach, in distal humeral diaphyseal fractures, there is a lack of adequate room for screw placement in the distal fragment for good stability. In such cases, the posterior approach for MIPO may be a propitious treatment method. However, the literatureon MIPO using the posterior approach for humeral diaphyseal fractures is limited. This study aimed to evaluate the feasibility of MIPOthrough the posterior approachand study the association of radial nerve injury with MIPOthrough the posterior approach for the humerus. Methodology This experimental study was conducted in the Department of Orthopedics, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India, and 20 cadaveric arms (10 right and 10 left) of 11 embalmed (formalin) cadavers were included (seven males and four females). Cadavers were placed prone on the dissection table. The posterolateral tip of the acromion and lateral epicondyle of the humerus were used as bony landmarks that were marked under C-Arm (Ziehm Imaging, Orlando, FL, USA) using K wires (Kirschner wires, Surgical Holdings, Essex, UK). Two incisions on theposterior part of the arm were made, and the radial nerve was identified at the proximal incision. After creating a submuscular tunnel, a 3.5 mm extraarticular distal humerallocking compression plate (LCP) was introduced over the posterior surface of the humerus and fixed to the humerus distally with one screw and then adjusted proximally and fixed to the humerus with another screw in the proximal window, followed by placement of couple more screws under C-Arm. After plate fixation, the dissection was completed to meticulously explore the radial nerve. The radial nerve was examined thoroughly for any injury sustained after completion of dissection, from the triangular interval to the lateral intermuscular septum where the nerve enters the anteriorchamber. The position of the radial nerve with respect to plate holes was noted.The distance from the posterolateral tip of the acromion to the lateral epicondyle was measured as humeral length.The medial and lateral points where radial nerve passed over the posterior surface of the humerus were measured from the posterolateral tip of the acromion and compared with the humeral length. Results In this study, the radial nerve was lying over the posterior surface of the humerus for a mean distance of 52.161 ± 5.16 mm. The mean distance at which the radial nerve crossed the medial and lateral borders of the posterior surface of the humerus, measured from the posterolateral tip of the acromion, was 118.34 ± 10.86 mm (40.07% of humeral length) and 170 ± 12.30 mm (57.57% of humeral length), respectively, and the mean humeral length in this study was 295.27 ± 17.94 mm. The radial nerve and its branches were found to be intact in all cases. The radial nerve was related to the fifth, sixth, and seventh holes, with the nerve lying most commonly over the sixth hole (3.5 mm extraarticular distal humerus locking plate). Conclusions The posterior approach of MIPO in humeral fractures is a safe and reliable treatment modality with minimal risk of radial nerve injury. The radial nerve can be safely identified at the spiral groove using the bony landmarks described in our study.

Quantification of Comfort for the Development of Binding Parts in a Standing Rehabilitation Robot.

Human-machine interfaces (HMI) refer to the physical interaction between a user and rehabilitation robots. A persisting excessive load leads to soft tissue damage, such as pressure ulcers. Therefore, it is necessary to define a comfortable binding part for a rehabilitation robot with the subject in a standing posture. The purpose of this study was to quantify the comfort at the binding parts of the standing rehabilitation robot. In Experiment 1, cuff pressures of 10-40 kPa were applied to the thigh, shank, and knee of standing subjects, and the interface pressure and pain scale were obtained. In Experiment 2, cuff pressures of 10-20 kPa were applied to the thigh, and the tissue oxygen saturation and the skin temperature were measured. Questionnaire responses regarding comfort during compression were obtained from the subjects using the visual analog scale and the Likert scale. The greatest pain was perceived in the thigh. The musculoskeletal configuration affected the pressure distribution. The interface pressure distribution by the binding part showed higher pressure at the intermuscular septum. Tissue oxygen saturation (StO2) increased to 111.9 ± 6.7% when a cuff pressure of 10 kPa was applied and decreased to 92.2 ± 16.9% for a cuff pressure of 20 kPa. A skin temperature variation greater than 0.2 °C occurred in the compressed leg. These findings would help evaluate and improve the comfort of rehabilitation robots.

Subconjunctival Fat Prolapse

Subconjunctival fat prolapse is an extremely rare condition. Confirmation of the fatty nature of this lesion and demonstration of the focal tenon capsule defect makes Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) of orbit the investigations of choice. This manuscript report a 69-year-old female who presented with complaints of swelling in lateral aspect of both orbit, since two years. On clinical examination, there was yellowish colored swelling in the superolateral quadrant of bilateral orbit. CT scan show herniation of intraconal fat content through the defect at the tenon capsule, intermuscular septum and thus confirmed the nature of lesion and the diagnosis. The patient was not willing for surgical correction and preferred regular follow-ups.

A cadaveric study of anatomical variations of the radial nerve and their clinical significance

Background/Aim. The radial nerve (RN) is the largest terminal branch of the posterior cord of the brachial plexus. Upon leaving the axilla, the RN moves to the posterior compartment of the arm, where it makes close contact with the humerus. By penetrating the lateral intermuscular septum, RN enters the anterior compartment and, in the very proximity of the lateral epicondyle, divides into two terminal branches. The anatomy of this nerve is characterized by remarkable variability, the knowledge of which is of utmost importance in the fields of orthopedics and traumatology. The aim of the study was to examine the anatomy of the RN, including two parameters: the location and the way the RN divides into terminal branches, with a particular emphasis on the clinical implications of this data. Methods. The research was conducted on 27 cadavers, 15 female and 12 male, with a total of 54 upper extremities. After careful dissection, variations in the location and way of termination of the RN were observed on both the right and left hands. Collected data were then analyzed using Microsoft Office Excel. A classification where the division of the RN into terminal branches above the biepicondylar line (BEL) is defined as type A, while the division of RN below BEL is defined as type B was used. Results. According to the proposed classification, we observed a higher incidence of type A (66.7%) compared to type B (33.3%) in the total sample of 54 extremities. In addition, a higher prevalence of type A was observed in the female population, while a higher prevalence of type B was observed in the male population. There were differences in the distribution of types A and B between the left and right arms, but there were no variations in the way of termination of the RN. Conclusion. The present study showed an important complexity in the domain of RN anatomy with significant clinical implications. With that in mind, it is crucial for every patient that the limits of safe zones be defined while performing surgical procedures in the elbow to protect the RN and its branches from iatro-genic injuries.