Pronator Teres Research Articles

Unilateral accessory brachialis muscle and its functional significance: a case report of rare variation.

Variations of the brachialis muscle are uncommon in the literature. During regular cadaveric dissection, we observed the unilateral presence of an accessory muscle in the front of the right arm of a female cadaver, taking its origin from the medial aspect of the brachialis and the adjacent intermuscular septum. The muscle belly descended downwards, crossed the neurovascular bundle in the cubital fossa and merged with the fibres of the pronator teres. There is no doubt regarding its significance in the etiogenesis of numerous compression syndromes due to its close topographical relationship with the neurovascular bundle. In our report, we consider the potential developmental processand therapeutic implications of this variation, which can aid surgeons in their strategy and management.

Turnover Tendon Lengthening Does Not Alter Biomechanical Strength of Pronator Teres-to-Extensor Carpi Radialis Brevis Tendon Transfer.

The pronator teres (PT) to extensor carpi radialis brevis (ECRB) tendon transfer reestablishes wrist extension. Occasionally, the PT periosteal extension is of suboptimal quality to support a strong transfer. In these instances, turnover lengthening techniques can increase usable tendon length. This study characterized the optimal length of tendon turnover and the effect of lengthening on transfer strength. Twenty-seven cadaveric extensor tendons were lengthened using the turnover lengthening technique with 1 to 3 cm of tendon overlap. PT-to-ECRB tendon transfers were performed with native or lengthened ECRB tendons. Tensile testing was used to evaluate stress relaxation and load to failure. The median maximum load to failure increased with increasing overlap length, measuring 35.6 N (quartile 1, 30.2 N; quartile 3, 38.6 N) for 1 cm, 66.0 N (quartile 1, 59.1 N; quartile 3, 74.7 N) for 2 cm, and 96.6 N (quartile 1, 85.9; quartile 3, 114.9 N) for 3 cm of overlap ( P < 0.05). Failure occurred most frequently at the junction of the central overlap and native tendon. Tendons lengthened with 2 and 3 cm of overlap displayed greater stiffness than those with 1 cm ( P < 0.05). Lengthening the ECRB tendon with 2 or 3 cm of overlap did not disrupt the strength or stiffness of subsequent PT-to-ECRB tendon transfers. Turnover tendon lengthening does not detrimentally affect PT-to-ECRB tendon transfer. Greater overlap lengthening distance confers greater stiffness and resistance to rupture. When the periosteal extension of the PT tendon avulses or is of poor quality, the ECRB tendon can be lengthened using the turnover tendon lengthening technique to facilitate a robust transfer.

Pronator teres nerve branch transfer to the extensor carpi radialis brevis nerve branch for wrist extension reconstruction in proximal radial nerve injury following humeral shaft fractures

BackgroundTendon and nerve transfers are used for functional reconstruction in cases of proximal radial nerve injury complicated by humeral fractures in patients who do not show functional recovery after primary nerve repair. The effectiveness of pronator teres (PT) nerve branch transfer to the extensor carpi radialis brevis (ERCB) nerve branch for wrist extension reconstruction was investigated and compared to the results of tendon transfer.MethodsThis study included 10 patients with proximal radial nerve injury, who did not show functional recovery after primary nerve repair at our hospital between April 2016 and May 2019. The nerve transfer procedure included PT nerve branch transfer to the ECRB nerve branch to restore wrist extension and the flexor carpi radialis (FCR) nerve branch to the posterior interosseous nerve (PIN) to restore thumb and finger extension. Tendon transfer procedures included PT transfer to the ECRB for wrist extension, FCR transfer to the extensor digitorum communis (EDC) for finger extension and palmaris longus (PL) transfer to the extensor pollicis longus (EPL) for thumb extension.ResultsFive patients recovered Medical Research Council grade M4 muscle strength in the ECRB and EPL in both tendon and nerve groups. Two patients recovered grade M3 strength and three patients recovered grade M4 strength in the EDC in the tendon transfer group, and all five patients recovered grade M4 strength in the EDC in the nerve transfer group. Limited wrist flexion was observed only in one patient in the tendon transfer group.ConclusionPT nerve branch transfer to the ECRB nerve branch combined with FCR nerve branch transfer to PIN is a useful strategy for wrist and fingers extension reconstruction in patients with proximal radial nerve injuries.

Atypical Fracture of Radial Diaphysis After Sauvé-Kapandji Procedure: A Retrospective Radiographic Evaluation of Fracture Progression.

The Sauvé-Kapandji procedure (SK), which combines distal radioulnar joint arthrodesis with creation of an ulnar pseudarthrosis, achieves good outcomes with few complications for patients with distal radioulnar joint instability or arthritis. The authors describe a case of atypical fracture of the radial diaphysis that occurred in a 79-year-old woman with rheumatoid arthritis who had undergone SK 18 years earlier. The patient had taken alendronate for osteoporosis for 13 years but had discontinued treatment 2 years before onset of symptoms. Retrospective review of serial radiographs revealed focal cortical thickening at the fracture site beginning 18 months before the onset of prodromal pain and becoming more evident over time. The patient underwent surgical repair of the fracture, which had occurred at the attachment of the pronator teres. Histopathological examination of bone excised from the fracture site and from the iliac graft used for fracture repair revealed markedly fewer trabecular osteoblasts than normal and no osteoclasts, indicating severe suppression of bone turnover. It is important to evaluate the radial diaphysis on radiographs taken after SK for early signs of atypical fracture, especially in patients with rheumatoid arthritis and a history of bisphosphonate use. Given the patient's history of bisphosphonate use and the similar radiographic appearance to atypical femoral fractures, the authors applied the term atypical radial fracture to this case. [Orthopedics. 2023;46(5):e317-e320.].

A Young Man With Acute-Onset Bilateral Arm Weakness After Traumatic Sciatic Neuropathy: A Clinical Vignette.

A Young Man With Acute-Onset Bilateral Arm Weakness After Traumatic Sciatic Neuropathy: A Clinical Vignette.

Effects of myofascial release with tennis ball on spasticity and motor functions of upper limb in patients with chronic stroke: A randomized controlled trial.

Background:Impaired motor function and upper extremity spasticity are common concerns in patients after stroke. It is essential to plan therapeutic techniques to recover from the stroke. The objective of this study was to investigate the effects of myofascial release with the tennis ball on spasticity and motor functions of the upper extremity in patients with chronic stroke.Methods:Twenty-two chronic stroke patients (male-16, female-6) were selected to conduct this study. Two groups were formed: the control group (n=11) which included conventional physiotherapy only and the experimental group (n=11) which included conventional physiotherapy along with tennis ball myofascial release – in both groups interventions were performed for 6 sessions (35 minutes/session) per week for a total of 4 weeks. The conventional physiotherapy program consisted of active and passive ROM exercises, positional stretch exercises, resistance strength training, postural control exercises, and exercises to improve lower limb functions. All patients were evaluated with a modified Ashworth scale for spasticity of upper limb muscles (biceps brachii, pronator teres, and the long finger flexors) and a Fugl-Meyer assessment scale for upper limb motor functions before and after 4 weeks. Nonparametric (Mann–Whitney U test and Wilcoxon signed-rank test) tests were used to analyze data statistically. This study has been registered on clinicaltrial.gov (ID: NCT05242679).Results:A significant improvement (P < .05) was observed in the spasticity of all 3 muscles in both groups. For upper limb motor functions, significant improvement (P < .05) was observed in the experimental group only. When both groups were compared, greater improvement (P < .05) was observed in the experimental group in comparison to the control group for both spasticity of muscles and upper limb motor functions.Conclusion:Myofascial release performed with a tennis ball in conjunction with conventional physiotherapy has more beneficial effects on spasticity and motor functions of the upper extremity in patients with chronic stroke compared to conventional therapy alone.

Morphologic observation for anomalous patterns of the flexor carpi radialis muscle and atypical insertions: a proposal for a new classification.

In the present study, four types of variations of the flexor carpi radialis with accessory muscular bundles were classified depending on the origin of the accessory muscular bundle and relationships with the bicipital aponeurosis, biceps brachii, pronator teres, and coracobrachialis. Six types of insertions of the tendon of the flexor carpi radialis were also divided according to their inserted positions on the carpal and metacarpal bones. An accessory muscular bundle of the flexor carpi radialis was found in 4 (1 female and 3 males) of 68 cadavers (5.88%), with five examples in 136 arms (3.68%). It was bilateral in one cadaver and unilateral (two on the right and one on the left) in three. The insertion of the flexor carpi radialis tendon was not only on the proximal surface of the base of the second metacarpal bone but also on the third metacarpal bone, the tubercle of the trapezium, and the scaphoid. These findings and classifications are important in anatomical education, and have important significances in clinical diagnosis and therapies.

Características anatómicas del nervio mediano en el codo y antebrazo proximal

IntroductionKnowledge of anatomy of the median nerve in its course through the elbow allows understanding the origin of several pathologies; in addition, identifying the distribution and anatomical variants of the nerve branches is useful for defining surgical approaches for this nerve. Materials and methodsDissection of cadaveric specimens, convenience sample, with prior approval of the ethics committee and following a dissection protocol identifying the median nerve and its ramifications in the elbow and its relationship with vascular and myotendinous structures. ResultsTwenty elbows with an average age of 60.8 years were dissected, exploring the median nerve, its ramifications and adjacent anatomical structures in the antecubital fossa. No Struthers ligament was found, the distance to the pronator teres (PT) arcade from the interepichondyle line was 51.3mm and 74.1mm to the flexor digitorum superficialis (FDS) arch. The most frequent pattern was a trunk for PT, a proximal transverse branch with divisions for FDS, flexor carpi radialis (FCR) and palmaris longus (PL). The innervation of the FCR originated mostly from the trunk of the PT. DiscussionGreat variability of origin and distribution of the branches originated from the median nerve in the elbow was observed, the distances and morphological characteristics in the known compression sites were quantified. The FCR branch is put at risk in the exploration of the tendon arches of the PT and the FDS.

Poster 185: Flexor Pronator Mass Contribution to Elbow Valgus Stability: A Biomechanical Project

Objectives:Identify the main muscle in the flexor pronator mass (the pronator teres (PT), flexor carpi radialis (FCR), flexor digitorum superficialis (FDS), and flexor carpi ulnaris (FCU)) that contributes most to valgus stability at a greater range of elbow motion (60-150 degrees) than in previous studies.Methods:8 cadaveric elbows in an in vitro biomechanical study were investigated. The specimens were mounted on a custom apparatus from the distal humerus to the fingers. Each muscle group of the flexor pronator mass was relatively loaded based on physiologic cross-sectional area. There were 6 loaded conditions: all loaded, unloaded PT, unloaded FCR, unloaded FDS, unloaded FCU, and all unloaded. A 2 N-m valgus torque was applied at a rate of 1 mm/sec. Valgus angle was measured for each loaded condition, especially between all loaded and one unloaded muscle. This allowed an increase in valgus angle for one unloaded muscle. The higher increase in valgus angle indicated the higher the contribution of that released muscle to valgus stability. This was performed at 60, 90, 120, and 150 degrees of elbow flexion to cover the range at which the UCL tears during the late cocking and early acceleration phases of throwing. The measurements were made in two conditions: first with the UCL intact and second with the UCL resected at the anterior bundle.Results: There was a statistical significance in the mean change in valgus angle at all flexion angles and load conditions when the UCL was intact vs when it was resected (3.76 ± 2.78 SD vs 4.82 ± 2.99 SD degrees).The valgus angle was statistically mostly increased in the “all unloaded” condition when compared to all the other loaded conditions at all flexion angles involving both when the UCL was intact and resected.Unloading one individual flexor pronator muscle did not significantly affect the valgus stability of the elbow.There was a trend towards FDS as being the primary flexor pronator stabilizer when the elbow was taken from an all-loaded condition to one muscle that was unloaded (P value = 0.169).At 150 degrees, the elbow was statistically significantly most stable compared to all the other flexion angles.At 90 degrees, the elbow was most unstable with an increase in valgus angle of 1.2 degrees between intact and resected UCL conditions.At 60 degrees with the UCL resected, there was not a statistical significant difference in valgus angle between all unloaded and unloaded FDS conditions signifying that the FDS contributed most to valgus stability. Conclusions: Physical examination of the UCL is best performed with the elbow at 90 degrees with the forearm in neutral (most unstable out of the flexion angles we tested).At 150 degrees, the elbow is most stable to valgus stress.When the UCL is injured, the FDS appeared to contribute most to valgus stability at 60 degrees out of the four flexor pronator muscles.There was a trend towards FDS as being the primary flexor pronator stabilizer.Rehabilitation of the flexor-pronator mass should focus on the FDS. Figure 1.Figure 2.Table 1.Two-group comparisons of mean valgu angle under different loading conditionsTable 2.Two-group comparisons between all unloaded condition and other loaded conditions at 60˚ elbow flexion with resected UCL.

Double-Incision Technique for the Treatment of Distal Biceps Tendon Rupture.

A longitudinal antecubital incision of 3 to 4 cm allows dissection to identify and isolate the lateral antebrachial cutaneous nerve (LABCN). Supination of the forearm protects the posterior interosseus nerve, which often cannot be visualized. The distal portion of the distal biceps should be carefully identified and exposed. A high-resistance nonresorbable suture is sewn with use of a Krackow technique to whipstitch the distal 4 cm of the tendon. Alternatively, 2 sutures (4 strands) can be utilized. A curved forceps is placed in the interosseous space to identify the location for the second 4-cm incision, on the dorsal proximal forearm over the tip of the forceps with the forearm pronated. The radial tuberosity is exposed by bluntly separating the common extensor tendons, followed by transection of the supinator fibers. Two drill holes are made 5 mm apart from one another for suture passage. The tendon is passed across a loop of wire, from the anterior to the posterior incision. With the elbow at 90° of flexion and full pronation, the tendon is docked into the trough and the sutures are tied. Alternatively, the surgical repair of the distal biceps tendon rupture can be performed through a single anterior approach4. The exposure starts with a curved longitudinal antecubital incision, exploiting the interval between the brachioradialis and pronator teres with radial (lateral) retraction of the brachioradialis and medial retraction of the pronator teres. A single anterior incision allows repair through the use of various types of fixation devices, such as suture anchors, cortical buttons, and interference screws, but seems to carry an increased risk of neurological complications, especially in terms of paresthesias in the distribution of the LABCN. Nonoperative treatment might be acceptable for elderly patients with poor functional demands. The double-incision technique with bone-tunnel fixation provides good fixation strength with an expected low rate of neurological complications1. This approach offers a useful treatment option for young and active patients with physically demanding lifestyles. The double-incision technique is an effective and safe procedure to restore elbow functionality in patients with distal biceps tendon rupture. A meta-analysis1,4-16 revealed no significant differences in postoperative functional scores following procedures performed via the single-incision compared with double-incision approach. Although the differences were smaller than the minimal clinically important difference17, the single-incision technique yielded significantly greater flexion (mean ± standard deviation, 136° ± 13°) and pronation range of motion (79° ± 10°) compared with the double-incision technique (133° ± 13° and 75° ± 14°, respectively) at 2 years postoperatively. No differences in extension and supination were observed. Rates of heterotopic ossification ranged from 0.5% to 11% for the single-incision approach and from 1% to 21.4% for the double-incision approach, with significant differences favoring the single-incision technique, although in the majority of cases the heterotopic ossification was an incidental finding. Neurological complications were found in 24.5% and 13.4% cases for the single- and double-incision techniques, respectively, with a significant difference favoring the double-incision technique. When damage to specific nerves was evaluated, the double-incision technique was associated with significantly less risk of LABCN damage. One or 2 high-resistance nonresorbable sutures are sewn with use of a Krackow technique to whipstitch the distal 4 cm of the biceps tendon.A curved forceps is placed in the interosseous space to identify the location for the second incision, on the dorsal proximal forearm over the tip of the forceps.Pronation of the forearm protects the posterior interosseus nerve, which often cannot be visualized during volar dissection and bone fixation.Positioning the tendon more posteriorly on the radial tuberosity allows for optimal biomechanical function. ROM = range of motionCR = conventional radiologyMRI = magnetic resonance imagingUS = ultrasoundLABC = lateral antebrachial cutaneousPIN = posterior interosseous nerveHO = heterotopic ossificationCI = confidence intervalSI = single incisionDI = double incision.

Supracondylar Process of Humerus – Report of Two Cases

Supracondylar process of the humerus is a congenital bone projection seen on the distal humerus on the anteromedial surface. A fibrous band called ligament of Struthers’ connects the supracondylar process of humerus with medial epicondyle. It is mainly asymptomatic but rarely can present as supracondylar process syndrome due to neurovascular compression. Although isolated median nerve injuries are most common they can also present with fractures and vascular complications. The ulnar nerve is rarely involved. The median nerve can be trapped at several sites proximal to the carpal tunnel. Potential sites where the median nerve can be trapped are bicipital aponeurosis, two heads of pronator teres, flexor digitorum superficialis, aponeurotic arch and Gantzer muscle.[1]&#x0D; Supracondylar process of the humerus is a hook-like bony process seen about 5 cm proximal to the medial epicondyle and has a pointed apex. It is curved downwards and forwards and is commonly seen in climbing mammals. Vinilla et al. published a comparison of measurements of the supracondylar process of the humerus in different studies. The length of the process varied from 0.3 cm to 1.6 cm, breadth 1cm to 1.5 cm and distance from the medial epicondyle varied from 4.4 cm to 6.5 cm. They concluded that the supracondylar process had to be differentiated from osteochondroma and myositis ossificans.[2]

Outcomes of Rerouting the Palmaris Longus to Extensor Pollicis Longus Tendon Transfer through the Second Extensor Compartment for Radial Nerve Palsy.

Background: A palmaris longus (PL) to extensor pollicis longus (EPL) is a standard tendon transfer used to restore thumb extension in patients with radial nerve palsy. This transfer is done by withdrawing the EPL from the third compartment and passing it subcutaneously to reach the PL. We modified this transfer by rerouting the EPL through the second extensor compartment to improve the retropulsion of the thumb. The aim of this study is to report the outcomes of this modified transfer. Methods: Four patients with traumatic radial nerve palsy underwent the modified PL to EPL transfer. They also underwent transfer of the pronator teres (PT) to extensor carpi radialis brevis (ECRB) and flexor carpi radialis (FCR) to extensor digitorum communis (EDC). Patients were followed up for at least 1 year after surgery. The data with regard to age, gender, cause of radial nerve palsy, duration between injury and surgery, and duration of follow-up was recorded. At final follow-up, the arc of motion at the interphalangeal joint (IPJ), metacarpophalangeal joint (MCPJ), palmar and radial abduction and retropulsion were measured for the reconstructed thumb and contralateral normal thumb. Results: All patients were male, with a mean age of 34.3 (range, 19-46) years. The mean duration between the injury and surgery was 15.9 (7-27) months, and the mean post-operative follow-up period was 16.8 (12-25) months. All patients recovered good thumb function. The mean arc of motion of the affected and contralateral thumb were IPJ flexion: 52°/80°; IPJ extension: 21°/14°; MCPJ flexion: 30°/33°; MCPJ extension:24°/31°; radial abduction: 70°/74°; palmar abduction: 68°/75° and retropulsion: 4.8cm/5.0cm. Conclusion: Rerouting the PL to EPL tendon transfer through the second extensor compartment in radial nerve palsy can restore good thumb function especially retropulsion. Level of Evidence: Level IV (Therapeutic).

Brachial plexus injury following blunt trauma; an anatomical variation in electrodiagnostic findings

Damage to the brachial plexus branches is one of the most important events during traumatic events, which may cause various disabilities. Electrodiagnostic testing is the preferred method to evaluate the extent of damage to the brachial plexus following trauma. The case presented in this paper, is a 26-year-old man who had near normal function of pronator teres and flexor carpi radialis muscles on electrodiagnostic testing following a right upper limb severe blunt injury at the level of his arm. After surgical investigation, we found a rare variation in the proximal part of the median nerve. In this case, branches to the pronator teres muscle and flexor carpi radialis had emerged from the proximal section of the median nerve in the arm region. This new variation holds important clinical implications especially in trauma patients presenting with weakness in forearm flexion.

Radiologic evaluation and clinical effect of calcification in medial epicondylitis.

Although most radiologic findings of medial epicondylitis (ME) are normal, up to 25% show calcification, and little is known about the clinical relevance of soft-tissue calcification in ME. The purposes of this study were to reveal the characteristics of calcification in ME and to identify their clinical relevance. This study included 187 patients (222 elbows) with a diagnosis of ME. We classified calcification according to its anatomic location and further evaluated its distribution. Logistic regression analysis was performed to calculate the odds ratios and 95% confidence intervals for possible factors that may affect calcification in ME: age, sex, laterality, hand dominance, visual analog scale (VAS) pain score, Mayo Elbow Performance Score, symptom duration, history of steroid injection, number of steroid injections, concomitant ulnar neuropathy, and treatment method in terms of conservative treatment or surgery. Of a total of 222 elbows, 53% (118 of 222 elbows) showed calcification in radiologic findings. The VAS pain score, the number of steroid injections, and concomitant ulnar neuropathy were significantly associated with calcification in ME. Calcification was most commonly identified at the anatomic insertion site of the common flexor tendon (33%), followed by the pronator teres (18%) and the medial collateral ligament (10%). Of the total cases of calcification, 45% were distributed at multiple sites, and age was strongly associated with multiple-site distribution. Calcification in ME was more commonly identified than previously reported and was distributed over a relatively broad area. Calcification was associated with a higher VAS pain score, a history of steroid injection, and combined ulnar neuropathy. The anatomic insertion site of the common flexor tendon most commonly showed calcification, and age was a strong indicator of a broad distribution of calcification.

Median Nerve Passing below the Ulnar Head of Pronator Teres in Cadavers of a Medical College in Western Nepal: A Descriptive Cross-sectional Study.

Median nerve passes between two heads of pronator teres muscle while passing through the elbow. Detailed knowledge of these variations in the course of Median Nerve in relation to pronator teres and its neighboring structure is required for diagnosis of pronator syndrome. The aim of the study is to find out the proportion of Median Nerve passing below the ulnar head of pronator teres in cadavers of a medical college in Western Nepal. A descriptive cross-sectional study was carried out at the Department of Anatomy in a medical college of Nepal from 20th July 2021 to 2nd September 2021 after ethical clearance from the same institution (Reference number: UCMS/IRC/079/21). Variations in the course of the median nerve while passing through pronator teres were observed, recorded and photographed. Convenience sampling method was used. Data were analyzed using Microsoft Excel 2016. Point estimate at 95% Confidence Interval was calculated along with frequency and percentage. Out of 54 prosected specimens of upper limbs, 4 (7.40%) (0.418-14.38 at 95% Confidence Interval) Median Nerve passed below the ulnar head of pronator teres muscle and in 50 (92.60%) specimens Median Nerve passed between two heads of pronator teres. Our study shows that the median nerve passed below the ulnar head of pronator teres muscle is higher as compared to other studies done in similar settings. Thus, knowledge of variations in the course of Median Nerve in elbow has immense importance in the academic and clinical arena.

Unusual additional distal aponeurotic slips of biceps brachii: A rare variation

Biceps brachii muscle is basically a powerful supinator. Although there is ample literature on variant origin of biceps brachii, variant insertion pattern was minimally reported. Here, we report a case, in which apart from usual insertion of biceps brachii, three distal accessory aponeurotic slips were found on the right arm of 55-year-old embalmed male cadaver. Two slips were arising from the lateral most part of bicipital aponeurosis traversing across the cubital fossa superficial to the brachial artery and median nerve and get attached to deep fascia covering the brachioradialis and pronator teres. Third accessory aponeurotic slip arises from the lateral side of biceps brachii muscle belly, traversing superficial to the musculocutaneous nerve and get attached to deep fascia covering the lateral border of brachioradialis and extensor carpi radialis longus. These extra slips may affect the kinematics of biceps brachii muscle and adds to the differential diagnosis of variety of clinical symptoms of neurovascular syndrome.

Dose selection of Incobotulinumtoxin A for the treatment of spasticity and sialorrhea in cerebral palsy: results of a retrospective multicenter study

Introduction. In patients with infantile cerebral palsy (CP), botulinum therapy is used to treat both muscle tone disorders and sialorrhea. Therefore, it is logical to use one preparation of botulinum toxin type A to treat spasticity and sialorrhea in one injection procedure. The aim of the work is to conduct a retrospective analysis of data from 15 centres that treat patients with cerebral palsy and use the botulinum therapy method to determine the optimal doses of IncobotulinumtoxinA (IBTA) for the treatment of spasticity and chronic sialorrhea in real clinical practice. Materials and methods. The treatment results of 389 children with cerebral palsy (including 211 (54.2%) boys) with IBTA were analyzed. The majority were children with bilateral forms of cerebral palsy - 312 (80.2%). The average age of the patients was 5.27 ± 3.71 years, the average weight of the patients was 18.8 ± 10.9 kg. Results. The total dose of IBTA in the group of 389 patients with cerebral palsy for the treatment of spasticity was 163.74 ± 80.65 U (25-550; 95% CI 155.7-171.7) and 10.4 ± 5.4 U/kg body weight (1,25-29.7; 95% CI 9.8-10.9). The total dose of IBTA in the group of patients with cerebral palsy with simultaneous treatment of spasticity and chronic sialorrhea (n = 16) was significantly higher: 267.18 ± 124.57 U (115-570; 95% CI 200.8-333.6) and 13, 0 ± 7.1 U/kg (5.8-24.6; 95% CI 9.2-16.8). In the lower extremities, the most frequent target muscles were the gastrocnemius (55.0% of cases; 95% CI 49.9-60.0) and semitendinosus / semimembranous muscle (46.3% of cases; 95% CI 41.2-51.4 ), and in the upper limbs - pronator teres (48.6% of cases; 95% CI 43.5-53.7) and biceps brachii (28.8% of cases; 95% CI 24.3-33.6). Limitations of the study. The limitations of our work are the use of an open retrospective study format, a relatively small sample of patients with chronic sialorrhea, the absence of long-term follow-up of patients and the results of repeated IBTA injections. Conclusion. If it is necessary to use botulinum therapy for the treatment of spasticity and sialorrhea in a child with CP, it is optimal to use the product IncobotulinumtoxinA, which will allow correction of two pathological manifestations in one procedure and can shorten the intervals between repeated injection cycles.

Outcome of Surgical Treated Isolated Pronator Teres Syndromes-A Retrospective Cohort Study and Complete Review of the Literature.

Purpose: This study aims to elucidate the occurrence of postoperative carpal tunnel syndrome (CTS), the functional outcome of patients with primary pronator teres syndrome (PTS), and review complete literature regarding this topic. Material and Methods: A retrospective chart review was conducted in patients with PTS at a single center. In all patients, a numeric Visual Analog Scale (VAS) score, Pinch-Test, Jamar hand dynamometer test (JAMAR), and the Disabilities of the Arm Shoulder and Hand (DASH) score were analyzed preoperatively and at final follow-up to assess outcome. Additionally, a complete review of the literature was performed, including all data dealing with pronator teres syndrome. Results: Ten female and two male patients were included with a mean age of 49 years. Significant improvement in DASH and numeric VAS was detected at latest postoperative follow-up. In three patients, clinical signs of CTS pathology were detected during the follow-up period. One patient needed to be treated surgically, and in the other two patients, a conservative management was possible. In one patient (8%), a PTS recurrence was detected. All patients presented satisfied at latest follow-up. Conclusion: In one-fourth of our patients, a CTS occurred during the follow-up period. Therefore, focusing on double-crush syndrome in unclear or mixed symptoms is necessary to avoid multiple operations. Furthermore, it seems that assessment with NCV is not enough for diagnosing PTS; therefore, further research is needed to clarify this problem.

Establishing the Role of Elbow Muscles by Evaluating Muscle Activation and Co-contraction Levels at Maximal External Rotation in Fastball Pitching.

Background: Baseball pitching is associated with a high prevalence of ulnar collateral ligament injuries, potentially due to the high external valgus load on the medial side of the elbow at the instant of maximal shoulder external rotation (MER). In-vitro studies show that external valgus torque is resisted by the ulnar collateral ligament but could also be compensated by elbow muscles. As the potential active contribution of these muscles in counteracting external valgus load during baseball pitching is unknown, the aim of this study is to determine whether and to what extent the elbow muscles are active at and around MER during a fastball pitch in baseball.Methods: Eleven uninjured pitchers threw 15 fastball pitches. Surface electromyography of six muscles crossing the elbow were measured at 2000 Hz. Electromyography signals were normalized to maximal activity values. Co-contraction index (CCI) was calculated between two pairs of the flexor and extensor elbow muscles. Confidence intervals were calculated at the instant of MER. Four ranges of muscle activity were considered; 0–20% was considered low; 21–40% moderate; 41–60% high and over 60% as very high. To determine MER, the pitching motion was captured with a highspeed camera at 240 Hz.Results: The flexor pronator mass, pronator teres, triceps brachii, biceps brachii, extensor supinator mass and anconeus show moderate activity at MER. Considerable variation between participants was found in all muscles. The CCI revealed co-contraction of the two flexor-extensor muscle pairs at MER.Interpretation: The muscle activation of the flexor and pronator muscles at MER indicates a direct contribution of forearm muscles crossing the medial side of the elbow in counteracting the external valgus load during fastball pitching. The activation of both flexor and extensor muscles indicates an in-direct contributory effect as the combined activity of these muscles counteract opening of the humeroulnar joint space. We believe that active muscular contributions counteracting the elbow valgus torque can be presumed to relieve the ulnar collateral ligament from maximal stress and are thus of importance in injury risk assessment in fastball pitching in baseball.

Patterns of median nerve branching in the cubital fossa: implications for nerve transfers to restore motor function in a paralyzed upper limb.

The purpose of this study was to describe the anatomy of donor and recipient median nerve motor branches for nerve transfer surgery within the cubital fossa. Bilateral upper limbs of 10 fresh cadavers were dissected after dyed latex was injected into the axillary artery. In the cubital fossa, the first branch was always the proximal branch of the pronator teres (PPT), whereas the last one was the anterior interosseous nerve (AIN) and the distal motor branch of the flexor digitorum superficialis (DFDS) on a consistent basis. The PT muscle was also innervated by a distal branch (DPT), which emerged from the anterior side of the median nerve and provided innervation to its deep head. The palmaris longus (PL) motor branch was always the second branch after the PPT, emerging as a single branch together with the flexor carpi radialis (FCR) or the proximal branch of the flexor digitorum superficialis. The FCR motor branch was prone to variations. It originated proximally with the PL branch (35%) or distally with the AIN (35%), and less frequently from the DPT. In 40% of dissections, the FDS was innervated by a single branch (i.e., the DFDS) originating close to the AIN. In 60% of cases, a proximal branch originated together with the PL or FCR. The AIN emerged from the posterior side of the median nerve and had a diameter of 2.3 mm, twice that of other branches. When dissections were performed between the PT and FCR muscles at the FDS arcade, we observed the AIN lying lateral and the DFDS medial to the median nerve. After crossing the FDS arcade, the AIN divided into: 1) a lateral branch to the flexor pollicis longus (FPL), which bifurcated to reach the anterior and posterior surfaces of the FPL; 2) a medial branch, which bifurcated to reach the flexor digitorum profundus (FDP); and 3) a long middle branch to the pronator quadratus. The average numbers of myelinated fibers within each median nerve branch were as follows (values expressed as the mean ± SD): PPT 646 ± 249; DPT 599 ± 150; PL 259 ± 105; FCR 541 ± 199; proximal FDS 435 ± 158; DFDS 376 ± 150; FPL 480 ± 309; first branch to the FDP 397 ± 12; and second branch to the FDP 369 ± 33. The median nerve's branching pattern in the cubital fossa is predictable. The most important variation involves the FCR motor branch. These anatomical findings aid during nerve transfer surgery to restore function when paralysis results from injury to the radial or median nerves, brachial plexus, or spinal cord.