Median Nerve Injury Research Articles

The Efficacy of Schwann-Like Differentiated Muscle-Derived Stem Cells in Treating Rodent Upper Extremity Peripheral Nerve Injury.

There is a pressing need to identify alternative mesenchymal stem cell sources for Schwann cell cellular replacement therapy, to improve peripheral nerve regeneration. This study assessed the efficacy of Schwann cell-like cells (induced muscle-derived stem cells) differentiated from muscle-derived stem cells (MDSCs) in augmenting nerve regeneration and improving muscle function after nerve trauma. The Schwann cell-like nature of induced MDSCs was characterized in vitro using immunofluorescence, flow cytometry, microarray, and reverse-transcription polymerase chain reaction. In vivo, four groups (n = 5 per group) of rats with median nerve injuries were examined: group 1 animals were treated with intraneural phosphate-buffered saline after cold and crush axonotmesis (negative control); group 2 animals were no-injury controls; group 3 animals were treated with intraneural green fluorescent protein-positive MDSCs; and group 4 animals were treated with green fluorescent protein-positive induced MDSCs. All animals underwent weekly upper extremity functional testing. Rats were euthanized 5 weeks after treatment. The median nerve and extrinsic finger flexors were harvested for nerve histomorphometry, myelination, muscle weight, and atrophy analyses. In vitro, induced MDSCs recapitulated native Schwann cell gene expression patterns and up-regulated pathways involved in neuronal growth/signaling. In vivo, green fluorescent protein-positive induced MDSCs remained stably transformed 5 weeks after injection. Induced MDSC therapy decreased muscle atrophy after median nerve injury (p = 0.0143). Induced MDSC- and MDSC-treated animals demonstrated greater functional muscle recovery when compared to untreated controls (hand grip after induced MDSC treatment: group 1, 0.91 N; group 4, 3.38 N); p < 0.0001) at 5 weeks after treatment. This may demonstrate the potential beneficial effects of MDSC therapy, regardless of differentiation stage. Both MDSCs and induced MDSCs decrease denervation muscle atrophy and improve subsequent functional outcomes after upper extremity nerve trauma in rodents.

Operative Management and Outcomes of Peripheral Vascular Trauma in Pediatric and Adolescent Population

Introduction: Unique characteristics of vascular injuries in children such as pronounced vascular spasm and lack of tissue support over small, thin-walled vessel make vascular repair challenging. This retrospective study was done to evaluate the management and outcome of pediatric and adolescent peripheral vascular trauma. Methodology: Fifteen patients with peripheral vascular trauma who met the inclusion criteria during the study period (August 2019-July 2020) were included. Data were analyzed retrospectively. Results: Majority, 12(80%) of patients suffered blunt trauma. Primary repair in 13(86.66%) patients was the most common surgical technique employed. All the patients had associated long bone fracture dealt with internal fixation. Four (26.66%) cases had median nerve injury which was amenable to direct repair. Associated venous injury in 5 (33.33%) was also repaired. No mortality, re-operations, or amputation was noted. Conclusion: Excellent limb salvage rate was achieved. Initial revascularization without delay should be the norm. Associated neurological involvement determines postoperative functional outcome. Clinical evaluation with Doppler assessment saves time and crucial in vascular injuries prone to spasm.

3: IGF-1 Hydrogel-based Nanofiber Drug Delivery System to Improve Nerve Regeneration and Functional Recovery After Peripheral Nerve Repair

Purpose:Insulin-like growth factor 1 (IGF-1) is a potent mitogen with the potential to enhance axonal regeneration and minimize muscle atrophy and Schwann cell senescence following prolonged denervation after peripheral nerve injury. IGF-1 is a small protein with a half-life of 5 min, making local delivery a challenge. Our group has demonstrated over 6 weeks of sustained release of bioactive IGF-1 encapsulated within biodegradable nanoparticles (NP) and subsequently developed a nanofiber fiber hydrogel composite (NHC) carrier to retain IGF-1 NPs at target tissue locally for the duration of drug release. The aim of this study was to further characterize and refine the IGF-1 NP-NHC drug delivery and then investigate its efficacy in both rodent and non-human primate (NHP) median nerve injury models.Methods:IGF-1 was encapsulated in biodegradable PCL NPs and then embedded within the NHC composed of hyaluronic acid and PCL nanofibers. Release kinetics and biocompatibility were evaluated and optimized both in vitro and in vivo. The drug delivery system was assessed using a chronic denervation median nerve injury rat model and an acute median nerve repair NHP model. IGF-1NP/NHC was injected along the median nerve and within denervated muscle. In rodents, a range of IGF-1 doses (300, 900 and 1500 μg/mL) were investigated to evaluate dose-response relationships. Axonal regeneration, muscle atrophy, neuromuscular junction reinnervation and recovery of grip strength were assessed.Results:The refined NP-NHC delivery system provided sustained release of bioactive IGF-1, in vivo, for at least 42 days by serial ELISA. IGF-1 treated rodents demonstrated a 35% increase in functional recovery (stimulated grip strength) compared to untreated rodents, with no differences observed between the different concentrations of IGF-1 that were evaluated. Median nerve histomorphometry demonstrated a significantly greater total number of axons at each concentration of IGF-1 compared to untreated rodents (p<0.0001). IGF-1 treated rodents also demonstrated a greater percentage of reinnervation of neuromuscular junctions by 17% (from 14% to 31%). In addition, the IGF-1 treated non-human primate demonstrated a 31% increase in functional recovery compared to the untreated animal (N=1 per group).Conclusion:The IGF-1 NP/NHC delivery system provided sustained delivery for over 42 days in rodents and NHP. IGF-1 improves motor functional recovery by enhancing axonal regeneration and neuromuscular junction reinnervation while limiting denervation-induced muscle and Schwann cell atrophy in rodents. Our NHP pilot study has established a used pre-clinical model with robust functional analysis that will serve as a platform for a formal NHP study prior to clinical testing. The components of the NP-NHC delivery system are already used in FDA approved formulations, which will facilitate clinical translation.

Ultrasonography Assessment of Repaired Median Nerve

Background: Traumatic peripheral nerve injuries (PNIs) caused by penetrating and lacerated trauma are among the most prevalent microsurgical injuries. Post-treatment follow-up and prognosis of patients undergoing repair are often based on clinical examinations and electrodiagnostic findings. Therefore, a reliable, inexpensive, useful, and rapidly accessible diagnostic method is necessary during the patient's follow-up.Objectives: This study aimed to assess the relationship between ultrasound imaging and treatment outcomes in patients with median peripheral nerve injury.Methods: In this cohort study, 21 eligible patients with symptoms of acute median nerve injury (MNI) caused by penetrating trauma in microsurgery were studied from June 2018 to June 2019. The patients underwent ultrasonography three months after repair and were followed up for at least nine months. The outcomes of the treatment were compared with those obtained six months after ultrasonography.Results: In all studied patients, mean thicknesses of the repaired nerve on the distal and the proximal sides were 2.58±0.51 and 2.51±0.61 mm2, respectively; 12 cases (57.1%) recovered very well nine months after surgery and in nine cases (42.9%) no nerve recovery was observed based on clinical electromyography (EMG) examinations and nerve conduction velocity (NCV). The amount of neuroma formed at the repair site was lower in well-recovered patients (1.5±0.4 mm3) than those with no recovery (4.9±1.5 mm3). No re-rupture was observed at the repair site. Each group underwent two-four repairs of flexor tendons.Conclusion: Ultrasound can be used as an effective and non-invasive method for assessment of PNI and follow-up of reconstructive surgery.

Immediate Tendon Transfer with Nerve Repair in Low Combined Ulnar and Median Nerve Injury.

Background:Combined median-ulnar nerve injury at the level of distal forearm (below the musculotendinous junction) causes a detrimental effect on hand functions, which have a great impact on patients’ hands as well as a financial burden. Many previous authors advocated early or immediate tendon transfer in solitary median or ulnar nerve injuries.Methods:This study included 20 patients with combined distal ulnar-median nerve injury, who were divided into 2 groups. Group I (control) included 10 patients who underwent primary (group fascicular) repair of both nerves only. Group II (study) included 10 patients underwent primary (group fascicular) repair with immediate tendon transfer simultaneously: opponenplasty using extensor indicies and adductoplasty extensor carpi radialis brevis with appropriate splinting, postoperative rehabilitation, and biofeedback facilities.Results:Twenty patients (age: 18–38 years) were affected. The response of median and ulnar nerves showed invariable results in both groups, whilst the hand grip, hand pinch, and opposition showed marked improvements in group II. Moreover, inter-phalangeal and metacarpophalangeal joints of thumb showed no deformities in group II in comparison with high level of deformities in group I, owing to early regain of thumb movements.Conclusions:Immediate (during neurorrhaphy) tendon transfer may offer additional merits over nerve repair only for distal combined ulnar and median injury, as it offers scarless field, no adhesion, and no joint edema, leading to very early return to normal hand functions with a consequent decrease of thumb deformities, better hand grip, and key pinch.

Direct End-to-End Neurorrhaphy for Wrist-Level Long Nerve Defect with Fixation of the Wrist in Flexion: Technique Note.

Background For a nerve gap, end-to-end neurorrhaphy would either be difficult or would include tension. The use of a nerve graft or conduit could be a solution, but it might compromise the reinnervation. We describe a method for wrist-level ulnar and/or median long nerve injury by fixing the wrist in the flexion position with K-wire (s) to make possible an end-to-end and tension-free neurorrhaphy. Patients and Methods Two patients had wrist-level ulnar nerve injury for 2 and 3 months and nerve gaps of 2.5 cm and 3.5 cm, respectively, after the neuroma excision. K-wires were used to transfix from the radius to carpal bones, in order to keep their wrists in flexion of 45 and 65 degrees, respectively, with which the tension-free end-to-end neurorrhaphy could be achieved. The K-wires were removed in 6 weeks after surgery, and their wrists were kept in the splint for a progressive extension program. Results Both patients were noted to have an improved claw hand deformity 4 months after the surgery. The ulnar nerve motor and sensory function could be recovered mostly in the 12-month follow-up. The wrist flexion and extension motion arc both achieved, at least, 150 degree in the 12-month follow-up. There were no complications related to the K-wire fixation. Conclusion With the wrist fixed in a flexed position, maintaining a longer nerve gap to achieve a direct end-to-end and tension-free neurorrhaphy would be more likely and safer. Without the use of nerve graft, innervation of the injured nerve would be faster.

Post-traumatic entrapment of the median nerve in the ulno-humeral joint: Diagnosis, treatment and literature review

BackgroundThe incidence of median nerve injuries in pediatric elbow dislocations is approximately 3% and avulsion of the open medial epicondylar epiphysis in the pediatric population is one predisposing factor that may explain this age predilection. These lesions can be difficult to diagnose in the acute phase because symptoms tend to be mild or delayed, consequently their management can be challenging and functional outcome poorer. MethodsWe present the case of an unrecognized median nerve entrapment in a 16-year-old boy with posterior dislocation of the elbow and a medial epicondyle fracture, treated initially with close reduction and open stabilization with a cannulated screw. Assessment is supported by a review of similar reported cases available in literature. ResultsWe discuss the diagnostic approach and the surgical options that can be used for this type of injury. ConclusionsHigh clinical suspicion of entrapment is imperative in presence of signs of damage to the median nerve in the pediatric patient immediately after the reduction of an elbow dislocation. If diagnosis of entrapment is made the therapeutic choice between neurolysis and nerve graft depends on the lesion severity. In the presence of a Fourrier's type 4 lesion, neurolysis should be avoided, while nerve resection and grafting are recommended.

Spaghetti wrist: Transverse injury, axial incision, layered microsurgical reconstruction

IntroductionAmong various patterns of complex injuries of the wrist and forearm, “spaghetti wrist” refers to an extensive volar forearm laceration, in which several of the 12 tendons, 2 major nerves and 2 major arteries are transected, leading to lifelong disability and psychological, social and economic consequences. The aim of the study is to emphasize the keynote principles for the management of these injuries through retrospective review of a large group of patients treated by a team of experienced hand surgeons. Material-MethodsData were retrospectively obtained for 61 patients (49 males and 12 females with average age of 34.7 years) treated for spaghetti wrist lacerations and followed for a minimum period of two years, in two accredited Orthopaedic / Hand-Upper Extremity Surgery and Microsurgery Departments in Greece. All patients were treated within 16 hours of injury and underwent primary, layered reconstruction of all injured structures through an axial forearm exposure. ResultsThe most frequent mechanism of injury was glass-related lacerations. Overall, 541 structures were reconstructed, of which 417 were tendons, 76 nerves, and 48 arteries. An average of 8.86 structures were injured per patient, including 6.83 tendons, 1.24 nerves, and 0.79 arteries. The majority of the patients (28/61) had ≥10 structures injured (45.9%), while 32.7% (20/61) and 21.3% (13/61) of patients had 6-9 and 3-5 injured structures respectively. Almost 80% (49/61) of patients had excellent/good grading in all six tests used for the functional assessment post-operatively. DiscussionSpaghetti wrist injuries usually occur in a transverse wound pattern and necessitate timely and definitive operative reconstruction of all injured structures in layers, through an axial approach, by experienced hand surgeons to maximize outcome and to avoid complications. The most important prognostic factor of functional recovery is not the number of transected tendons, but the involvement of ulnar and/or median nerve injury.

Prospective observational study of pediatric supracondylar humerus fractures operated with closed reduction and k wire fixation

Aim: To evaluate the cases of pediatric supracondylar humerus fractures operated with closed reduction and k wire fixation.Methods: A prospective study was conducted in the Department of Orthopaedics, Netaji Subhas Medical College and Hospital, Patna, Bihar, India, June 2018 to July 2019. Total 32 children’s with displaced supracondylar fracture of Humerus in aged between 2-14yrs. Type II and III fractures were included in this study. These patients were treated by closed reduction of fracture and percutaneous fixation with K-wire under C-arm guidance. The outcome was assessed clinically by Flynn’s criteria and radiologically by Skaggs’s criteria.Result: among 32 patients, 24 were male and 8 were female. The fracture was extension type in all 32 patients. Left side was involved in 23 patients and right side in 9 cases. The average age was 9.1 yrs. 23 patients presented within 24 hrs and 9 patients between 2 to 5 days. Based on Gartland classification 7 patients had type-II and 25 patients had type III pattern. The mode of violence was fall during play in the ground 28 patients and fall from height or bicycle in 4 patients. Complications were noted in 5 patients, 3 with radial nerve injury, 2 with median nerve injury. As per Flynn Criteria 23 were excellent, 6 Good, 2 were fair and 1 remained poor. 2 Patients developed myositis ossificans and both had restriction of elbow flexion and extension and graded fair. 5 patients reported pin tract infection. Conclusion: Closed reduction and percutaneous K-wire fixation is an effective treatment for displaced supracondylar fractures of Humerus in pediatric age group.

Opponensplasty in Cases with Low Median Nerve Injury

Thumb resistance is a basic activity of thumb. Middle nerve paralysis meddles with an enormous number of customary exercises like resistance. This investigation planned to survey the result of ligament move for reclamation of resistance in instances of low middle nerve injury in regards to hand grasp and scope of movement and useful result. Thirty patients, 19 guys and 11 females with a mean time of was 29 years, with a standard deviation of 11 years were remembered for this examination. The interim between wounds to a medical procedure was 17 months, with a standard deviation of 3 months. All patients experienced segregated low middle nerve injury with lost resistance were incorporated for and flexor digitorum superficialis (FDS) opponensplasty. Evaluation of resistance by Kapandji score and appraisal of level of agony by VAS and hand grasp by QuickDASH score. Every one of the patients will have nerve conduction and electromyogram, clinically assessment following fourteen days and evacuation of the skin stitch then at about a month expulsion of the piece and consider controlled scope of movement, and at 3, 4 months postoperatively FDS opponensplasty give better outcomes in low middle nerve paralysis. The volar slanted cut offers clear perception while isolating the FDS ligament, diminishing the frequency of flexion distortion of the ring finger.

Effectiveness of electrophysical modalities in the sensorimotor rehabilitation of radial, ulnar, and median neuropathies: A meta-analysis.

People with ulnar, radial or median nerve injuries can present significant impairment of their sensory and motor functions. The prescribed treatment for these conditions often includes electrophysical therapies, whose effectiveness in improving symptoms and function is a source of debate. Therefore, this systematic review aims to provide an integrative overview of the efficacy of these modalities in sensorimotor rehabilitation compared to placebo, manual therapy, or between them. We conducted a systematic review according to PRISMA guidelines. We perform a literature review in the following databases: Biomed Central, Ebscohost, Lilacs, Ovid, PEDro, Sage, Scopus, Science Direct, Semantic Scholar, Taylor & Francis, and Web of Science, for the period 1980-2020. We include studies that discussed the sensorimotor rehabilitation of people with non-degenerative ulnar, radial, or median nerve injury. We assessed the quality of the included studies using the Risk of Bias Tool described in the Cochrane Handbook of Systematic Reviews of Interventions and the risk of bias across studies with the GRADE approach described in the GRADE Handbook. Thirty-eight studies were included in the systematic review and 34 in the meta-analysis. The overall quality of evidence was rated as low or very low according to GRADE criteria. Low-level laser therapy and ultrasound showed favourable results in improving symptom severity and functional status compared to manual therapy. In addition, the low level laser showed improvements in pinch strength compared to placebo and pain (VAS) compared to manual therapy. Splints showed superior results to electrophysical modalities. The clinical significance of the results was assessed by effect size estimation and comparison with the minimum clinically important difference (MCID). We found favourable results in pain relief, improvement of symptoms, functional status, and neurophysiological parameters for some electrophysical modalities, mainly when applied with a splint. Our results coincide with those obtained in some meta-analyses. However, none of these can be considered clinically significant. PROSPERO registration number CRD42020168792; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=168792.

Evaluation of Functional Recovery in Rats After Median Nerve Resection and Autograft Repair Using Computerized Gait Analysis

Computerized gait analysis is a common evaluation method in rat models of hind limb nerve injuries, but its use remains unpublished in models of segmental nerve injury of the forelimb. It was the aim of this work to investigate if computerized gait analysis is a feasible evaluation method in a rat model of segmental median nerve injury and autograft repair. Ten male Lewis rats underwent 7-mm resection of the right median nerve with immediate autograft repair. The left median nerve was resected without repair and served as an internal control. Animals were assessed for 12 weeks after surgery via CatWalk (CW) gait analysis every 2 weeks. Evaluation of motor recovery by means of the grasping test was performed weekly while electrophysiological measurements were performed at the end of the observation period. CW data were correlated with grasping strength at each post-operative time point. CW data were also correlated with electrophysiology using linear regression analysis. Principal component analysis was performed to identify clusters of outcome metrics. Recovery of motor function was observable 4 weeks after surgery, but grasping strength was significantly reduced (p < 0.01) compared to baseline values until post-operative week 6. In terms of sensory recovery, the pain-related parameter Duty Cycle showed significant (p < 0.05) recovery starting from post-operative week 8. The Print Area of the right paw was significantly (p < 0.05) increased compared to the left side starting from post-operative week 10. Various parameters of gait correlated significantly (p < 0.05) with mean and maximum grasping strength. However, only Stand Index showed a significant correlation with compound muscle action potential (CMAP) amplitude (p < 0.05). With this work, we prove that computerized gait analysis is a valid and feasible method to evaluate functional recovery after autograft repair of the rat median nerve. We were able to identify parameters such as Print Area, Duty Cycle, and Stand Index, which allow assessment of nerve regeneration. The course of these parameters following nerve resection without repair was also assessed. Additionally, external paw rotation was identified as a valid parameter to evaluate motor reinnervation. In summary, computerized gait analysis is a valuable additional tool to study nerve regeneration in rats with median nerve injury.

Pseudoaneurysm with Median Nerve Injury Caused by Right Radial Artery Puncture: A Case Report

Background: Pseudoaneurysm with median nerve injury is a serious complication of radial artery puncture. It is very important to summarize the prevention and treatment experience of this complication through case discussion. Case report: A 66-year-old woman was admitted to the hospital because of “paroxysmal chest tightness and suffocation for 5 days.” Coronary angiography was performed. During insertion of the arterial sheath, the patient experienced severe pain in the right forearm, which radiated to the palm. The puncture sheath did not return blood after the sheath core was withdrawn. The sheath was removed and local compression was used to stop bleeding. There was no obvious bleeding at the puncture point, and the compression was removed 6 hours after the procedure. Local swelling and increased tension were seen in the right forearm. At the 1-week follow-up she exhibited swelling, high local tension, small blisters, and bluish-purple skin of the right forearm, with an acceptable right radial artery pulsation. She had severe pain in the affected limb, which radiated to the thumb, index finger, and middle finger. Case discussion: We discuss the causes of and treatment measures for pseudoaneurysm with median nerve injury caused by radial artery puncture.

A Case of Iatrogenic High Median Nerve Injury That Occurred during Elbow Arthroscopy and Was Treated by Nerve Grafting and Nerve Transfer

A Case of Iatrogenic High Median Nerve Injury That Occurred during Elbow Arthroscopy and Was Treated by Nerve Grafting and Nerve Transfer

Relationship between ultrasonographic hand muscle thickness measurements and muscle strength following median or ulnar nerve reconstruction.

The aim of this study was to assess the relationship between ultrasonographic hand muscle thickness measurements and hand muscle strength in patients who underwent median or ulnar nerve reconstruction. In this prospective, cross-sectional study, intrinsic hand muscle thicknesses were measured using ultrasound with a 4- to 13-MHz linear-array probe. Measurements of hand strength were performed using a dynamometer and a pinchmeter. In the median nerve group (n = 11), a moderate correlation (r = 0.694; P = .018) was observed between lateral pinch strength and transverse thenar thickness. In the ulnar nerve group (n = 11), longitudinal thenar thickness below the flexor pollicis longus tendon was moderate to highly correlated with pinch and handgrip strengths (r = 0.726-0.893; P < .05); whole transverse thenar thickness was moderate to highly correlated with pinch strengths (r = 0.724-0.836; P < .05). Sonographic measurements of intrinsic hand muscle thickness may be a useful tool for the assessment and follow-up of patients with median or ulnar nerve injury.

Median nerve injuries associated with humerus shaft fractures in children

Abstract Purpose and background Humeral shaft fractures associated with median nerve palsy in children are not commonly seen and reported in the literature. The purpose of this retrospective study is to discuss the injury pattern, treatment options, nerve recovery, and functional outcome in these injuries. Methods We treated twelve children with median nerve palsy between 2012 and 2015. We analyzed the clinical presentations, radiological features, fracture type, displacement, treatment modality, nerve recovery pattern, time to bone union, functional outcome, 2-point discrimination (PD), range of movements, DASH score, and complications interpreted. Results The mean follow-up was 67.3 (range 59–80 months). 7/12 patients with median nerve injury recovered with hanging U slab/Shoulder immobilizer/Functional brace. Three patients who had median nerve entrapped at the fracture site required microsurgical nerve repair, and two patients required neurolysis alone. 11/12 patients (92%) had an excellent motor and sensory recovery (M5/S4) with a full range of movement. All patients achieved an excellent radiological union. The mean time to bone union was 13.5 weeks (range 11–18 weeks). The mean time for complete median nerve motor recovery in 11 patients was 25.4 weeks (range 22–26 weeks), and sensory recovery was 30.4 weeks (24–42weeks). The mean 2PD was 5.4 mm (range 5–7 mm). THE mean DASH score was 5.2 (range 2.3–18.2). One patient had M2/S3 recovery because of a treatment delay of >180 days. Conclusions We can treat acute humeral shaft fractures associated with median nerve injuries with hanging U slab/Shoulder immobilizer/Functional brace to achieve a complete nerve recovery, good radiological union, and excellent functional results. In cases of delayed humeral shaft fractures with nerve entrapment and poor nerve recovery, neuroma excision and microsurgical nerve repair give excellent results. Level of evidence IV.

The Pulseless Supracondylar Elbow Fracture: A Rational Approach.

Supracondylar humerus fractures are the most common type of pediatric elbow fracture, accounting for 60-70% of all elbow fractures in children. Initial trauma and subsequent fracture displacement may damage surrounding neurovascular structures, leading to reports of associated neurovascular injury at rates as high as 49%, with vascular compromise reported in 3-19% of cases. This may be attributable to complete transection, kinking of the artery with reduced flow, thrombosis, intimal tear, arterial contusion or spasm, entrapment of the vessel within the fracture site or traumatic aneurysm of the brachial artery with subsequent thrombus formation. While there is general agreement that a child presenting with a pulseless white (dysvascular) hand associated with a displaced supracondylar humerus fracture requires emergent operative management, whether or not surgical exploration of the brachial artery is warranted in a patient with a pulseless pink hand is debatable. Given the lack of consensus, an individualized approach based on clinical findings at initial presentation, including quality of distal perfusion including doppler signal, associated median nerve injury, availability of a surgeon with microvascular skill-set, and access to vigilant post-operative monitoring, combined with an open discussion of the pros and cons of various treatment options with the family is prudent. Herein we outline our management principles, developed with careful consideration of the available literature and informed by practical experience. We recommend emergent management of pulseless supracondylar fractures, especially those that present with a pulseless white hand or with a dense median nerve palsy, with operative fracture reduction and fixation. In all children presenting with a pulseless supracondylar humerus fracture, the vascular status should be reassessed after adequate fracture reduction and fixation, and in patients with continued signs of abnormal distal perfusion, such as weak or absent Doppler signals or sluggish capillary refill, surgical exploration of the brachial artery with reestablishment of adequate distal flow should be conducted immediately. Much of the existing evidence surrounding the supracondylar humerus fracture associated with a pink, pulseless hand is of low quality. This shortcoming should serve as an impetus for establishment of an international registry of all dysvascular pediatric supracondylar fractures, with adequate documentation of the vascular exam before and after reduction, intra-operative and post-operative management and long term follow-up, to provide optimal management guidelines based on robust evidence.

Outcomes of K-wire pinning in supracondylar fractures of humerus in pediatric age group: A comprehensive study

Supracondylar fractures, one of the most common elbow injury in children, involves the lower end of the humerus, usually affecting the thin portion of humerus through olecranon fossa or just above the fossa through the metaphysis. Considering the high frequency and the complications that can occur, great diligence is required to secure an excellent result and to avoid or minimize any complications. Objectives: The present study was done to assess the result of the surgery concerning the restoration of function, deformity and about prevention of complications of the fracture.Methodology: The prospective study, conducted on 40 cases of supracondylar fractures (Type II and Type III), who underwent open/closed reduction with K-wire fixation b/w August 2019 to August 2020, at NDMC medical college and Hindu Rao hospital, Delhi, India. It included 30 males and 10 females and the average age of presentation was 7.3 years. 30 patients had left-sided and 10 of them had right-sided fractures. Type 3 fracture was seen in 28 (24 posteromedial and 4 posterolateral) and Type 2 in 12 patients. Two patients had radial nerve injury, 2 had median nerve injury and 1 had distal end radius fracture. All the 12 cases with type II underwent closed reduction, while of the type III cases, 10 of them underwent closed and 18 of them underwent open reduction. 16 patients underwent 2 cross-wired pinning, 2 of them underwent lateral pinning and 22 of them underwent 3 wire pinning. Post-operatively, 1 patient developed pin tract infection and 1 had cubitus varus. All the patients were reviewed at 3, 6 and 12 weeks postoperatively and assessed for range of movements and deformity. Results: Based on Flynn’s criteria, of the 40 cases, 34 patients obtained excellent results, 4 of them had good results and 2 of them had fair results. Conclusion: This study shows that anatomical reduction and K-wire pinning in the management of supracondylar fracture provides good results and minimal loss in the range of movement with relatively fewer complications. Thus, we conclude that percutaneous pinning with either lateral entry K-wires or cross k-wires or a combination of lateral wires with medial wire is an appropriate treatment of choice for displaced supracondylar fracture of the humerus in children either by closed reduction or open reduction.

Optical Analysis of Acute Changes after Peripheral Nerve Injury in Spatio-Temporal Pattern of Neural Response to Forelimb Stimulation in Rat Somatosensory Cortex

Peripheral nerve injury induces functional reorganization of the central nervous system. The mechanisms underlying this reorganization have been widely studied. Our previous study involving multiple-site optical recording reported that a neural excitatory wave induced by somatic stimulation begins in a small area and propagates in the cortex. In the present study, to examine the possible role of this propagation wave in cortical reorganization, we analyzed the early changes in the spatio-temporal pattern of the sensory-evoked wave immediately, and 30 min, after nerve injury. The response to hypothenar stimulation, innervated by the ulnar nerve and adjoining the median nerve area, persisted after injury to either the ulnar or median nerve. Initially, we assessed changes in the response pattern at the focus. The latency increased after ulnar nerve injury, whereas no change was observed after median nerve injury. Similarly, no change was noted in the duration of the response signal with either nerve injury. Second, changes in the propagation wave pattern were analyzed. Ulnar nerve injury decreased the propagation velocity in the medial direction but the median nerve injury induced no changes. These results indicated that the propagation wave pattern is readily altered, even immediately after nerve injury, and suggest that this immediate change in the spatio-temporal pattern is one of the factors contributing to the cortical reorganization.

SPP1 promotes Schwann cell proliferation and survival through PKC\u03b1 by binding with CD44 and \u03b1v\u03b23 after peripheral nerve injury

BackgroundSchwann cells (SCs) play a crucial role in Wallerian degeneration after peripheral nerve injury. The expression of genes in SCs undergo a series of changes, which greatly affect the proliferation and apoptosis of SCs as well as the fate of peripheral nerve regeneration. However, how do these genes regulate the proliferation and apoptosis of SCs remains unclear.ResultsSPP1 and PKCα were found upregulated after human median peripheral nerve injury, which promoted SCs proliferation and survival. The promoted proliferation and inhibited apoptosis by SPP1 were blocked after the treatment of PKCα antagonist Gö6976. Whereas, the inhibited proliferation and enhanced apoptosis induced by silence of SPP1 could be rescued by the activation of PKCα, which suggested that SPP1 functioned through PKCα. Moreover, both CD44 and αvβ3 were found expressed in SCs and increased after peripheral nerve injury. Silence of CD44 or β3 alleviated the increased proliferation and inhibited apoptosis induced by recombinant osteopontin, suggesting the function of SPP1 on SCs were dependent on CD44 and β3.ConclusionThese results suggested that SPP1 promoted proliferation and inhibited apoptosis of SCs through PKCα signaling pathway by binding with CD44 and αvβ3. This study provides a potential therapeutic target for improving peripheral nerve recovery.