Protective Sensation Research Articles

“Danger in the Smallest Dose”: Richard Neutra's Design Theory

ABSTRACTOver forty years Richard Neutra elaborated a complex design theory to support his architectural practice. At the root of his concerns was the capacity of design elements to both advance and destroy human sensory life. This essay explores the shift that occurs from Neutra's early ideals—centered on notions of open planning, user interactivity and design plasticity—to his later commitment to a psychoanalytically informed architecture. Neutra's postwar structures aimed to recreate the protective sensation of the womb as well as the traumatic experience of birth. Despite a clear shift in aesthetic and rhetoric from interaction to therapy, his basic intentions never changed. Underlying both phases was an emphatic interest in shaping the life of those who inhabited his structures through the use of materials that produced effects independent of artistic agency.

Results of Microsurgical Replantation and Revascularization Surgery of the Hand and Wrist

Objective: The objective of this paper was to present the results of replantation and revascularization surgery of the hand or digit and to describe the factors associated with survival of the replanted and revascularized digit. Methods: From January 1, 2005 to July 31, 2010, a retrospective review of the Microsurgery Unit Database was done to determine the number of patients referred to the Unit for amputations of the upper extremity. The injuries were classified by mechanism of injury (guillotine, crush, avulsion, and gunshot/blast), level of injury, and whether or not a vein graft was used. A total of 8 patients with 8 hand parts had replantation surgery and seven patients with 10 revascularized parts were reviewed. Functional Outcome: Functional outcome was measured using the range of motion of the involved digit or body part using a finger or standard goniometer. Sensory recovery of the replanted or revascularized part was measured using the static 2-point discrimination test. Results: A total of 86 patients from January 2005 to July 2010 suffered amputation or near amputation injuries that were referred to the Microsurgery Unit. Of these patients, 8 patients with 8 hand parts had replantation surgeries while 7 patients with 10 hand parts had revascularization surgeries. In total, there were 15 patients (14 males and 1 female) with an average age of 26.2 years old (range, 4-68 years old). The overall viability rate was 72.2% (62.5% for replantation surgery and 80% for revascularization surgery). The average follow-up of the patients who had a successful replantation procedure was 19 months (range, 3-48 months). Those who had successful revascularization procedures after partial or near amputation of the hand or fingers had an average of 7.3 months follow-up (range, 3-14 months). Functional Outcome: Four of the 12 patients had no functional results because of no recovery yet was expected on recent follow-up. In all digital replantations, stiffness was present even after 6 months post replantation. Of the 5 patients who had successful replantation surgery, only 4 had functional results. The best results were from the through-wrist and through-palm amputations. Protective sensation was achieved in all tested patients. Conclusion: Successful replantation and revascularization surgery mainly depend on the mechanism of injury. Crush injuries tend to have poorer prognosis compared to guillotine type injuries. Replantation and revascularization surgeries require intensive post-operative rehabilitation to maximize the functional outcome. Key words: replantation, revascularization

Diabetic foot screening: study of a 3000 times cheaper instrument

Diabetic foot is considered to be one of the most serious complications for patients suffering from Diabetes Mellitus (DM). Approximately 20–25% of all diabetic patients will present with lower extremity ulceration at some time in their lives. Diabetic foot is the leading cause of non-traumatic lower limb amputations in the world, resulting in an amputation risk for diabetic patients that is approximately 40 times greater than that of the general population. Post-amputation mortality is extremely high, with a three-year survival rate of 65% and a five-year survival rate of 41%. It is a health issue affecting several countries and represents a significant socioeconomic problem.1-4 In Brazil, amputation, admission, ulceration, and cost data are similar to other Western countries.5-7 Recognition of individuals at risk for ulceration, followed by adequate intervention, may reduce the chance of unfavorable results up to 80%.8 Peripheral sensory-motor neuropathy, which is responsible for the progressive loss of protective and proprioceptive sensations, is considered the main agent of the clinical abnormalities found in diabetic foot patients. It is important to consider that in the final phases of the disease the patient may present with a completely insensitive foot.9,10 One of the first studies looking to improve touch sensitivity screening dates back to 1898 and used a horsehair attached to a thorn.11 This method was refined and currently a 10g nylon monofilament, developed by Semmes and Weinstein, is accepted as the gold standard for detecting ulcer risk.12 Its reproducibility and predictive value lead the World Health Organization (WHO) and the International Diabetes Federation (IDF) to recommend its use in clinical practice.1,2 In 2006, Bourcier et al. showed the effectiveness of the “house made” monofilament, constructed from a fishing line, for screening for diabetic foot. The main characteristic of this line is that it exerts a 10 g pressure when bent (4 cm length by 500 µm diameter N° M-1425, South Bend Inc. North Brook, EUA).13 In Brazil, the 10 g monofilament is produced locally, but is not always available for purchase. The objective of this study was to identify a similar nylon line and compare it to the commercially available one.

Distal anterior interosseous nerve transfer to the deep ulnar nerve and end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve for treatment of high ulnar nerve injuries: experience in five cases

To demonstrate the results of a double nerve transfer at the level of the hand for recovery of the motor and sensory function of the hand in cases of high ulnar nerve injuries. Five patients underwent a transfer of the distal branch of the anterior interosseous nerve to the deep ulnar nerve, and an end-to-side suture of the superficial ulnar nerve to the third common palmar digital nerve. Two patients recovered strength M3 and three cases were graded as M4; recovery of protective sensation (S3+ in three patients and S4 in two) was observed in the fourth and fifth fingers, and at the hypothenar region. The monofilament test showed values of 3.61 or less in all cases and the two-point discrimination test demonstrated values of 7 mm in three cases and 5 mm in two. This technique of double nerve transfer is effective for motor and sensory recovery of the distal ulnar-innervated side of the hand.

Posterior Interosseus Palsy with an Incidental Froment-Rauber Nerve Presenting as a Pseudoclaw Hand

IntroductionAnatomic variations of peripheral nerves are well recog-nized and reported in literature [4]. It is important tounderstand these variations because they can explainunusual clinical deficits or findings. The Froment–Raubernerve is a distal continuation of the motor branch of theposterior interosseous nerve, which innervates the firstdorsal interosseus muscle. This report discusses a case ofthis rare anomalous connection that initially confused thediagnosis of a posterior interosseus palsy.Case ReportA 17-year-old left-hand dominant baseball pitcher pre-sented with an 8-month history of progressive pain in hisleft proximal forearm and elbow. His symptoms proceededto subjective weakness of the small finger that progressedradially to include the ring and middle fingers withposturing in flexion at the metacarpal−phalangeal andinterphalangeal joints. He was given the presumptivediagnosis of an ulnar palsy. Prior to the onset of handweakness, there were previous episodes of elbow pain thatresolved without sequelae. He was referred to a handsurgeon. Initial physical examination was notable forclawing of the middle, ring, and small digits (Fig. 1) withfull passive mobility. Additionally, he had subtle weaknessof the wrist and extrinsic digit extensors as well as of theextensor pollicis longis and the abductor pollicis longus. Hedenied any sensory changes but slightly decreased protec-tive sensibility was noted in the ulnar nerve distribution bySemmes–Weinstein monofilament testing (3.61), includingthe dorsal ulnar cutaneous nerve. A mildly positive Tinel’ssign over the ulnar nerve at the elbow was detected.Nonoperative treatments of splinting and nonsteroidal anti-inflammatory agents had been attempted and had failed toimprove his symptoms.Electrodiagnostic studies (nerve conduction and electro-myography (EMG)) were consistent with a posteriorinterosseous nerve (PIN) neuropathy. These findings in-cluded denervation in the extensor carpi ulnaris and firstdorsal interosseus with complex repetitive discharges in thelatter. The number of motor units in all muscles innervatedby the posterior interosseus nerve as well as in the firstdorsal interosseus were decreased. Nerve conductionstudies of the median and ulnar nerves were normal,including the amplitude of the thenar and hypothenarcompound action potentials. The amplitude of the extensorindicis proprius compound muscle action potential wassignificantly decreased. Notable is that although no neuro-physiologic evidence of ulnar nerve pathology was found atthe elbow or wrist, evidence of denervation was noted inhis first dorsal interosseus muscle on EMG. A completeneurological evaluation including magnetic resonance im-aging of the brain, cervical spine, elbow, and forearm were

Treatment of the donor site after wound healing of semi-toe nail flap

Objective To explore the wound healing of semi-toe nail flap donor site after transplantation. Methods To repair small wounds,on 13 toes the first metatarsal dorsal flaps were applied,and on 7 toes the second toe digital flaps were applied.While,to repair large wounds,free flaps were applied,including foot inside flaps on 3 toes,peroneal artery perforator flaps on 5 toes,tarsal lateral artery flaps on 2 toes,and phil bowel artery inside branch flaps on 3 toes.Wounds remaining on semi-toe nail flaps of 7 toes were all covered with fibular island flaps of the first toes. Results Twenty cases were followed up,and the rang between 6 months to 5 years.The nail margin was exposed out of the lateral flaps in 2 cases.The first toes and the second toes appeared nearly normal in the other 18 cases.The flaps appeared smooth,flexible appearance with nice color and no ulceration.Seven cases applied with free flaps recovered protective sensibility with no complaint. Conclusion To cover wounds on semi-toe nail flaps of the first toes and the second toes with flaps is an ideal treatment method.The method of free flap transplantation is superior to vascular pedicle flap graft. Key words: Toe nail flap; Surgical flap; Transplantation; Microsurgical operation

Cold-Induced Vasodilatation Following Traumatic Median or Ulnar Nerve Injury

Peripheral nerve injury of the upper extremity frequently causes changes in the thermoregulatory system of the hands and fingers and leads to reports of cold intolerance. In this study, we aimed to measure the influence of median or ulnar nerve injury on cold-induced vasodilatation (CIVD) during prolonged cooling at low temperatures. We tested 12 patients with a median (n = 6) or ulnar (n = 6) injury 4 to 76 months after nerve repair. The palmar sides of both hands were cooled continuously using a cold plate at 5°C. We measured the skin temperature of the fingers using videothermography and plotted graphs of the temperature changes of the nailbed. The presence of a CIVD reaction was defined as a minimum increase in temperature of 2.5°C starting at the distal phalanx. Furthermore, we measured self-reported symptoms of cold intolerance using the Cold Intolerance Severity Scale questionnaire. A CIVD reaction was absent in the affected digits of 4 patients (follow-up, 6-37 mo), whereas the CIVD reaction in the uninjured hand was present. The CIVD was present in 6 patients after 50 months' follow-up (range, 24-76 mo). Two patients had no CIVD reaction in the injured or uninjured fingers. All patients with a CIVD response had at least diminished protective sensation. Presence of the CIVD reaction did not exclude self-reported symptoms of cold intolerance. After peripheral nerve injury, it is possible to recover the CIVD reaction. This might be an indication of nerve recovery. However, a positive CIVD reaction does not exclude subjective symptoms of posttraumatic cold intolerance. Diagnostic III.

Reliability and Responsiveness of an 18 Site, 10-g Monofilament Examination for Assessment of Protective Foot Sensation

Older persons including those with diabetes are at increased risk for loss of protective sensation in the feet. The 5.07 (10-g) monofilament is recognized as a valid instrument to test for the presence or absence of protective sensation in the foot. Few studies report reliability and no studies report responsiveness for a multisite examination using the 10-g monofilament. The purpose of this study was to determine the responsiveness and reliability for the 10-g monofilament in evaluating protective sensation in the feet. A convenience sample of 28 (20 women and 8 men) participants between the ages 50 and 78 years were recruited for the study. Sensory testing was performed on 18 different sites (9 per foot) by 3 testers for each participant using the 10-g monofilament. Participants were tested on 2 occasions with approximately 1 week between tests. Participants' eyes were closed for the duration of the examination to blind them to the tester. Testers were blinded to each other and previous test results. Intratester and intertester reliability were calculated using intraclass correlation coefficients (ICC). Intratester ICC (3, 1) and minimal detectable change at the 95% confidence level (MDC(95)) were calculated for each tester and then averaged yielding the following: ICC = 0.76 (95% CI: 0.68-0.84), MDC(95) = 2.83. Intertester ICC (2, 1) was 0.78 (95% CI: 0.64-0.88). MDC(95) was 2.81. This gives an MDC(95) for this test of 3 sites. The results of this study support the use of the 10-g monofilament as a reliable clinical tool to assess changes in protective sensation of the feet for our participant pool. An 18-site sensory examination using the 10-g monofilament must result in sensory change at 3 or more sites to indicate actual change in protective sensation.

Clinical application of inside‐out vein grafts for the treatment of sensory nerve segmental defect

The gold standard for the treatment of segmental nerve defect is an autogenous nerve graft. However, donor site morbidity is an inevitable complication. We substituted an autogenous nerve graft with an inside-out vein graft for the treatment of segmental sensory nerve defect and the clinical results were evaluated retrospectively. Eleven patients of sensory nerve defects have undertaken inside-out vein grafts for the recovery of sensation. The involved nerves were digital nerves in three cases, peroneal nerves in two cases, saphenous nerve in two cases, and superficial radial nerves in four cases. The average length of defects was 2.71 cm (1-6 cm). Donor veins were harvested 4 mm longer than nerve defects and everted to promote nerve regeneration. Patients' objective satisfactions and two-point discriminations were determined, the Semmes-Weinstein monofilament test was performed, and British Medical Council sensory functional scores were evaluated. Sensory functional scores recovered to over S3 in all cases. No donor site morbidity was caused by vein harvesting, and all patients achieved satisfactory results with protective sensation at involved sites. The inside-out vein graft offers a good surgical alternative to an autogenous nerve graft for the reconstruction of sensory nerve defects without donor site morbidity.

Very Distal Sensory Nerve Transfers in High Median Nerve Lesions

We report on the results of reconstruction of fingertip sensation by very distal nerve transfer in 8 patients with high median nerve lesions. Before surgery, patients underwent sensory testing of the hand using Semmes-Weinstein monofilaments. All patients had surgery within 1 year of trauma. For sensory reconstruction, branches of the radial nerve on the proximal phalanx of the index and thumb were sutured to the ulnar proper digital nerve of the thumb and radial proper digital nerve of the index finger. Patients were followed up for 12 months. After median nerve lesions, zones of lost protective sensation were confined to the middle and index finger and the thumb. Sensation on the palm of the hand and proximal phalanx was preserved. Radial nerve transfer to palmar nerves restored protective or better sensation to the fingertips in all patients. Better results were observed for the thumb. Locognosia was acquired in all thumbs, and in 4 of 8 index fingers. Good results were detected even in patients who had undergone surgery later than 6 months after injury. Fingertip sensation can be restored by very distal nerve transfer of radial nerve branches to palmar nerves at the level of the proximal phalanx. This method of reconstruction appears useful in high median nerve lesions. In chronic lesions of the median nerve at the wrist and lesions in older patients, very distal nerve transfers might be adjunct to nerve grafting.

Patient awareness of loss of protective sensation in the diabetic foot: an opportunity for risk reduction?

Background Peripheral sensory neuropathy is a common complication in diabetes. Neuropathy is the single most powerful risk factor for diabetic foot amputation. Often foot care efforts are thwarted by the phenomenon of inadvertent injury, from events which may appear to the clinician as chronic and ignorant self-neglect on the part of neuropathic clients. This study aimed to determine the proportion of a study populatio no f people with diabetes and peripheral neuropathy who were simultaneously unaware of this sensory loss. Method Thirty-two (32) people with symptoms of diabetic neuropathy were tested. Subjects aligned themselves with one of two groups. Group1 consisted of those who predicted that their protective sensation was intact, by indicating that they expected to be able to feel if a blister was forming on their foot, and Group 2 comprised those who expected not to be able to feel if a blister was occurring. The presence or absence of protective sensation was determined by testing with the 5.07 (10 gram) Semmes Weinstein monofilament. Results Seventy-eight percent (78%) of the study population (25 of 32 subjects) assumed that their protective sensation was intact, however only twenty-five percent (25%) of these (8 subjects) were correct in this assumption according to the test criteria. Fifty-three percent (53%) of the total study population (17 of 32 subjects) demonstrated a lack of protective sensation and a concomitant lack of awareness of this loss. Conclusion

Glyceryl trinitrate patch therapy is associated with healing of arterial ulceration and improvement in toe pressure measurements: a case study and discussion of aspects of this novel treatment modality

A case study of one frail elderly client with indolent arterial ulceration was conducted, with glyceryl trinitrate (GTN) patch therapy appearing to have a positive role in the healing outcome and improved vascular status as measured by photoplethysmography (PPG ) toe pressure measurements. The history and pharmacological action of this novel mode of therapy are briefly presented. The presentation of chilblains (erythema pernio) and arterial ulceration are discussed in the context of this case. Loss of sensitivity to cold perception, related to age, arterial insufficiency and other factors are considered. Current research using this medication for other applications suggests that GTN patch therapy should have a positive role in healing arterial ulceration associated with peripheral vascular disease (PVD). Positive outcomes with painful diabetic neuropathy have also been found with this therapy and its use warrants further investigation. A review of the literature on the use of GTN therapy for digits is briefly summarised. Important to clinical treatment of aged people with reduced vascular supply are decreased sensory functions of pain, protective sensation and temperature sensation. Further research on the effects of GTN therapy for wound healing should aim to control for seasonal climate and environmental temperature changes, as well as other factors that influence wound healing such as wound care, wound dressings and nutrition.

The results of reverse-flow island flaps in pulp reconstruction.

The aim of this study was to retrospectively review the results of homodigital reverseflow proximal or middle phalanx dorsal skin island flaps. We reviewed the overall results of 67 dorsal skin flap reconstructions performed on 61 proximal phalanxes and 6 middle phalanxes at our hospital during an 11 year period. The results were evaluated with static two point discrimination, Semmes-Weinstein monofilament test, occurrence of nail deformities, loss of interphalangeal joint motion, scar appearance of flap donor area, the incidence of vascular insufficiency in postoperative period, and subjective evaluation of patient satisfaction. The highest incidence of defect types were palmar oblique pulp defects in 18 patients (26.8%), transverse pulp defects in 16 patients (23.8%), and hemipulp oblique amputations in 11 patients (16.4%). Crush injuries were the cause of injury in 66% of patients. The average followup time was 40 months and long-term results were available in 21 patients. Total necrosis of flap in one patient (1.4%), superficial epidermolysis in 4 patients (5.9%), and nail deformity in 4 patients (5.9%) were seen. According to Semmes-Weinstein monofilament test results, protective sensation was achieved in 76% of patients. Static two point discrimination data showed variable distribution between 2 mm and 11 mm. The subjective patient satisfaction level was 95%. Homodigital reverse-flow proximal or middle phalanx dorsal skin island flaps give satisfactory cosmetic and sensorial results outside the pinch area, even if the dorsal branch of the digital nerve is not included.

Charcot osteoarthropathy in diabetes: A brief review with an emphasis on clinical practice

Charcot osteoarthropathy (COA) is a potentially limbthreatening condition that mainly affects diabetic patients with neuropathy. In everyday practice, it presents as a red, hot, swollen foot, usually painless, and is frequently triggered by trivial injury. Its etiology is traditionally attributed to impairment of either the autonomic nervous system, leading to increased blood flow and bone resorption, or of the peripheral nervous system, whereby loss of pain and protective sensation render the foot susceptible to repeated injury. More recently, excessive local inflammation is thought to play a decisive role. Diagnosis is based on clinical manifestation and imaging studies (plain X-rays, bone scan, Magnetic Resonance Imaging). The mainstay of management is immediate off-loading, while surgery is usually reserved for chronic cases with irreversible deformities and/or joint instability. The aim of this review is to provide an overview of COA in terms of pathogenesis, classification and clinical presentation, diagnosis and treatment, with an emphasis on the high suspicion required by clinicians for timely recognition to avoid further complications.

The International Registry on Hand and Composite Tissue Transplantation

The International Registry on Hand and Composite Tissue Transplantation was founded in May 2002, and the analysis of all cases with follow-up information up to July 2010 is presented here. From September 1998 to July 2010, 49 hands (17 unilateral and 16 bilateral hand transplantations, including 1 case of bilateral arm transplantation) have been reported, for a total of 33 patients. They were 31 men and 2 women (median age 32 years). Time since hand loss ranged from 2 months to 34 years, and in 46% of cases, the level of amputation was at wrist. Immunosuppressive therapy included tacrolimus, mycophenolate mofetil, sirolimus, and steroids; polyclonal or monoclonal antibodies were used for induction. Topical immunosuppression was also used in several cases. Follow-up ranges from 1 month to 11 years. One patient died on day 65. Three patients transplanted in the Western countries have lost their graft, whereas until September 2009, seven hand grafts were removed for noncompliance to the immunosuppressive therapy in China. Eighty-five percent of recipients experienced at least one episode of acute rejection within the first year, and they were reversible when promptly treated. Side effects included opportunistic infections, metabolic complications, and malignancies. All patients developed protective sensibility, 90% of them developed tactile sensibility, and 82.3% also developed a discriminative sensibility. Motor recovery enabled patients to perform most daily activities. Hand transplantation is a complex procedure, and its success is based on patient's compliance and his or her careful evaluation before and after transplantation.

Crossover replantation as a salvage procedure following bilateral transhumeral upper limb amputation: a case report

Cross-over replantation is a salvage option for cases with bilateral extremity amputations where the wound conditions do not enable an orthotopic replantation. Here, we present a 24-year-old patient who applied to our center with bilateral transhumeral amputations. Due to the wound conditions, a cross-over replantation was performed. 24 months after the initial operation, the patient exhibits good protective sensation at the distal levels and function to some degree, whereas the active range of motion is not as promising as previously expected. In this article, we present this case together with its immediate and long-term outcomes and the consequences of the cross-over replantation.

Multiuse 10-g Monofilament Contamination

Growing interest has been given to the contamination of commonly used instruments in the physical exam (1,2). We are unaware of such scrutiny being given to the 10-g monofilament. The 10-g monofilament is a common screening test used to identify patients with loss of protective sensation and is part of recommended practice for the comprehensive foot exam for patients with diabetes (3). The instrument is typically used on feet with no open lesions or other breaks in the integument. With the growing prevalence and concern associated with resistant organisms such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococci , many preventative measures are now being used by clinics and hospitals around the country, including normal screening for these bacteria. …

Covering the below‐knee amputation stump with the pedicled dorsalis pedis flap from the ipsilateral foot: A case report

It is important to preserve the length, appropriate durable skin, and sensation of the stump when performing below-knee amputation to achieve functional ambulation with a prosthesis. There are many reports of reconstruction procedures using microvascular surgery to preserve the optimum length of the amputation stump for prosthesis; however, free tissue reconstruction is necessary to accompany with the donor site morbidity. In this report, we describe our experience with a below-knee amputation and stump covering using the pedicled dorsalis pedis flap from the no longer usable foot in the case of a severe osteomyelitis of a lower extremity after highly contaminated Gustilo type IIIB fracture. We achieved a well-healed amputated stump with enough length for a prosthesis and for protective sensation. The pedicled dorsalis pedis flap is easily elevated without microvascular anastomosis and is one useful option for the reconstruction of the below-knee amputated stump in the specific case.

UPPER EXTREMITY COMPLICATIONS IN PATIENTS WITH CHRONIC RENAL FAILURE RECEIVING HAEMODIALYSIS

Limited data are available about disability associated with upper extremity complications in patients who receive haemodialysis for end-stage renal disease. In this study of 123 patients receiving haemodialysis, the mean Disabilities of the Arm, Shoulder and Hand (DASH) score was 31 ± 22 points, indicating markedly greater disability than in a normal population. Dupuytren's contracture was the most frequent deformity. Brachial, radial and ulnar pulses were present in most upper limbs, but 14 (14%) of 102 patients had poor arterial perfusion pressures. Diabetic patients had residual or complete loss of protective sensation more frequently than nondiabetic patients. Motor testing with the index finger abduction and fifth finger flexion tests showed a significantly greater frequency of weakness in diabetic than nondiabetic patients. In summary, upper extremity disability was noted in haemodialysis patients, including loss of protective sensation and motor strength, both in diabetic and nondiabetic subjects.

Sensory disturbances and pain complaints after brachial plexus root injury: A prospective study involving 150 adult patients

After injury of the brachial plexus, sensory disturbance in the affected limb varies according to the extent of root involvement. The goal of this study was to match sensory assessments and pain complaints with findings on CT myelo scans and surgical observations. One hundred fifty patients with supraclavicular stretch injury of the brachial plexus were operated upon within an average of 5.4 months of trauma. Preoperatively, upper limb sensation was evaluated using Semmes-Weinstein monofilaments. Pain complaints were recorded for each patient. With lesions affecting the upper roots of the brachial plexus, hand sensation was largerly preserved. Sensory disturbances were identified over a longitudinal bundle on the lateral arm and forearm. In C8-T1 root injuries, diminished protective sensation was observed on the ulnar aspect of the hand. If the C7 root also was injured, sensation in the long finger was impaired. Eighty-four percent of our 64 patients with total palsy reported pain, versus just 47% of our 72 patients with upper type palsies. This rate dropped to 29% in the 14 patients with a lower-type palsy. C8 and T1, when injured, always were avulsed from the cord; when avulsion of these roots was the only nerve injury, pain was absent. Hand sensation was largely preserved in patients with partial injuries of the brachial plexus, particularly on the radial side. Even when T1 was the only preserved root, hand sensation was mostly spared. This indicates that overlapping of the dermatomal zones seems much more widespread than previously reported.