Proximal Radial Nerve Research Articles

Ultrasound-guided proximal radial, ulnar, median and musculocutaneous (RUMM) nerve block in rabbit (Oryctolagus cuniculus) cadavers: medial vs lateral approach

Ultrasound-guided proximal radial, ulnar, median and musculocutaneous (RUMM) nerve block in rabbit (Oryctolagus cuniculus) cadavers: medial vs lateral approach

455 Distal Nerve Transfers in Treatment of Peripheral Nerve Lesions

INTRODUCTION: Distal nerve transfers can be used in treating patients with irreparable high nerve lesions, aiming to regain hand function. The indications for these transfers include upper (C5-C6) and lower (C8-T1) brachial plexus palsy, isolated proximal extensive radial, median, or ulnar nerve lesion, or isolated axillary or musculocutaneous nerve lesion. METHODS: The selected cases (n = 5) included lower brachial plexus injury (n = 2), and isolated radial (n = 1), ulnar (n = 1), and median (n = 1) nerve injuries. The MRC grading was used to examine postoperative muscle strength. The DASH and PNSQoL questionnaires were used to assess the postoperative quality of life. RESULTS: The useful functional recovery (MRC = 4-5) was achieved in all presented cases. The DASH and PNSQoL scores indicated a satisfying quality of life in terms of the absence of postoperative disability. CONCLUSIONS: Distal nerve transfers are a valuable technique for treatment of the patients with irreparable proximal nerve lesions. This technique reduces the path necessary for the regenerative nerve fibers to pass, provides direct nerve coaptation without additional suture line, and facilitates faster and better recovery, with the final outcome as an increase in the patients’ quality of life.

Fentanyl sparing effect of ultrasound-guided proximal radial, ulnar, median, and musculocutaneous nerve (RUMM) block for radial and ulnar fracture repair in dogs: a retrospective case-control study.

This study retrospectively evaluated the fentanyl-sparing effect of ultrasound-guided proximal radial, ulnar, median, and musculocutaneous nerve (RUMM) block for radial and ulnar fracture repair in dogs. Fentanyl was prepared for intraoperative analgesia in dogs, although proximal RUMM block was performed using 0.5% or 0.25% bupivacaine before surgery in the block group. Dogs without a nerve block were assigned to the control group. The fentanyl dose in the block group [0.8 (0-1.9) μg/kg/hr] [median (interquartile range)] was significantly lower than in the control group [8.4 (7.2-10) μg/kg/hr]. Surgery was performed without fentanyl in >50% of the dogs (5/7), using 0.5% bupivacaine. Ultrasound-guided proximal RUMM block can be useful as an intraoperative analgesic for radial and ulnar fracture repair in dogs.

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.

Atraumatic proximal radial nerve entrapment. Illustrative cases and systematic review of literature.

The aims of the present study were to describe atraumatic proximal radial nerve entrapment (PRNE) and potential strategies for management. We performed a comprehensive search of 4 electronic databases for studies pertaining to patients with atraumatic PRNE. Studies published between 1930 and 2020 were included. Clinical presentation, nerve conduction studies, electromyography, and treatment methods were reviewed. In order to outline management strategies, 2 illustrative cases of acute PRNE were presented. We analyzed 12 studies involving 21 patients with 22 PRNE (15 acute and 7 progressive). Sudden or repetitive elbow extension with forceful muscle contraction (n = 16) was the primary mechanism of injury. The two main sites of entrapment were the fibrous arch (n = 7) and hiatus of the lateral intermuscular septum (n = 7). Conservative treatment was performed in 4 patients and allowed for complete clinical recovery in all cases. The remaining 18 patients underwent epineurolysis (n = 16) or resection/repair of hourglass-like constriction (n = 2) between 1.5- and 120-months following diagnosis. Twelve patients experience complete recovery, while partial or no clinical recovery was reported in 1 and 4 cases, respectively; the outcome was unknown in 1 case. Atraumatic PRNE is rare and remains challenging with respect to diagnosis and treatment. Current literature suggests that primary sites of entrapment are the fibrous arch and hiatus of the radial nerve at the time of forceful elbow extension. Case series (IV) & systematic review (I).

Topographical, anatomical and neurosurgical aspects of "end-to-side" nerve repair

The article presents the results of a comprehensive anatomical and experimental study of individual variability in the structure and topography of motor branches of peripheral nerves in relation to the justification of methods for selective reinnervation of tissues by the "end-to-side" neurorrhaphy. It was found that relatively longer branches of peripheral nerves with a small number of connecting inter-arm collaterals characteristic of narrow and long limbs create conditions for less traumatic mobilization of motor branches. In cases with relatively wide and short extremities mobilization of peripheral nerves is complicated by the presence of a large number of collateral branches and intra-trunk connections, which are often damaged when separate bundles that make up the mobilized branches of the donor or recipient nerve are isolated from the main nerve trunk. It has been shown that potential recipient nerves should be motor branches of peripheral nerves, the preservation of which is of fundamental importance for the function of the corresponding segment of the limb. To create conditions conducive to selective reinnervation of functionally significant muscle groups of the upper limb, we have developed, justified from anatomical positions, and tested in an experiment on anatomical material methods for connecting the distal motor branches of peripheral nerves by the "end-to-side" neurorrhaphy. The main idea of accelerated recovery of the thumb opposition in injuries of the median nerve is to reinnervate the muscles of the elevation of the I finger due to nerve fibers that are part of the deep branch of the ulnar nerve. For this purpose, surgical techniques have been developed for connecting the recurrent motor branch of the damaged median nerve mobilized at the level of the wrist with the edges of a surgically formed perineurium defect on the lateral surface of the bundles that make up the deep branch of the ulnar nerve. In another clinical situation, in patients with radial nerve injuries, for the muscle reinnervation, а method is proposed for neurotisation of the deep motor branch of the radial nerve by the end-to-side suture to the lateral surface of the median nerve. We assume that performing the "end-to-side" nerve suture at the level of the base of the hand in the cases of proximal damage to the median nerve will reduce the time of reinnervation of the muscles of the thumb elevation by 400450 days. Transposition of the deep branch of the damaged at the proximal level radial nerve with "end-to-side" neurorrhaphy to the median nerve by 250300 days (based on the total length of the shoulder and forearm, which is about 50 cm and the rate of regeneration of nerve fibers 1 mm per day). Accordingly, with higher injuries (brachial plexus), the gain in the time of reinnervation of the distal segments will be even greater. In our opinion, the results can be used as a basis for further clinical research on the development of methods for selective tissue reinnervation in cases with isolated injuries of the peripheral nerves.

Management of Radial Nerve Lesions after Trauma or Iatrogenic Nerve Injury: Autologous Grafts and Neurolysis.

Background: Proximal radial nerve lesions located between the brachial plexus and its division into the superficial and deep branches are rare but severe injuries. The majority of these lesions occur in association with humerus fractures, directly during trauma or later during osteosynthesis for fracture treatment. Diagnostics and surgical interventions are often delayed. The best type of surgical treatment and the outcome to be expected often is uncertain. Methods: Twelve patients with proximal radial nerve lesions due to trauma or prior surgery were included in this study and underwent neurolysis (n = 6) and sural nerve graft interposition (n = 6). Retrospective analysis of the collected patient data was performed and the postoperative course was systematically evaluated. The Disabilities of the Arm, Shoulder, and Hand (DASH) and the LSUHS (Louisiana State University Health Sciences) scores were used to determine regeneration after surgery. Comparison between the patients’ and calculated normative DASH scores was performed. Results: All patients had a traumatically or iatrogenically induced proximal radial nerve lesion and underwent secondary treatments. The average time from radial nerve lesion occurrence to surgical intervention was approximately four months (1.5–10 months). Eight patients (66.67%) had a humeral fracture. During follow up, no statistically significant difference between the calculated normative and the patients’ DASH scores was observed. The LSUHS scores were at least satisfactory. Conclusions: Neurolysis or sural nerve graft interposition performed within a specific period of time are the primary treatment options for radial nerve lesions. They should be performed depending on the lesion type. Regeneration to a satisfactory degree was observed in all patients, and the majority achieved full recovery of sensory and motor functions. This was the first study to highlight the efficiency of neurolysis and sural nerve graft interposition as secondary treatment interventions, especially for radial nerve lesions.

The proximal humeral attachment of the lateral head of the triceps brachii: a cadaveric study and potential site for radial nerve compression.

Knowledge of potential compression sites of peripheral nerves is important to the clinician and surgeon alike. One anatomical location for potential compression of the radial nerve, which is rarely mentioned in the literature, is at the proximal humeral attachment of the lateral head of the triceps brachii at the level of the proximal spiral groove. As no anatomical studies have been devoted to this band, the present study was conducted. Ten adult fresh-frozen cadavers were dissected and the lateral head's attachment onto the posterior humerus evaluated for a band. This anatomy and its relation to the radial nerve during range of motion of the elbow and forearm were evaluated. A band was found on 15 of 20 arms. On five sides, the band was comprised of grossly muscle fibers of the lateral head of the triceps brachii and was not tendinous. The bands were crescent-shaped, straight, and duplicated on nine, five, and one arm, respectively. The length of the bands ranged from 1.1 to 2.2cm (mean 1.54cm). The width of the bands ranged from 0.5 to 1.1cm (mean 0.8cm). With elbow extension and the forearm in neutral, all bands were lax. With elbow extension and the forearm supinated, the bands became tauter less the muscular bands. In elbow extension and with the forearm in supination, the bands became most taut less the muscular bands. The presence of a fibrous band extending from the lateral head of the triceps brachii is common and should be among the differential diagnoses of anatomical sites for potential proximal radial nerve compression when other more common locations are ruled out.

Development of a lateral ultrasound-guided approach for the proximal radial, ulnar, median and musculocutaneous (RUMM) nerve block in cats

ObjectiveTo describe a lateral ultrasound (US)-guided approach to the radial, ulnar, median and musculocutaneous (RUMM) nerves through a single proximal in-plane insertion in cats and to determine whether one or two injection points are required to successfully stain all the target nerves. Study designProspective study. AnimalsA total of eight client-owned healthy cats and 12 cat cadavers. MethodsIn live cats, the US anatomy of the brachium, the landmarks and the site for needle accesses were determined. Then, 12 thawed feline cadavers were used to assess the spread of dye solution and nerve staining following the US-guided proximal-lateral-humeral RUMM injection using one and two injection points. Each cadaver was injected with 0.15 mL kg–1 of a 0.25% new methylene blue solution in either a single injection aimed for the radial nerve of one limb (G1) or via two sites delivering 0.1 mL kg–1 and 0.05 mL kg–1 aimed for the radial and musculocutaneous nerves of the opposite limb, respectively (G2). Upon dissection, staining of the target nerves around their circumference for length of >1 cm was considered successful. ResultsSonoanatomy was consistent with anatomy upon dissection and target nerves were identified in all cadavers. Staining was 100% successful for the radial, median and ulnar nerves in both groups, and 41.7% and 100% for the musculocutaneous nerve in G1 and G2, respectively. Conclusions and clinical relevanceThis novel lateral US-guided approach for the proximal RUMM nerve block allowed a good identification of the nerves and related structures, and it provided a consistent muscular structure through which the needle could be easily guided. An injection performed in two aliquots (within the caudal and cranial compartments of the neurovascular sheath) appeared to be necessary to successfully stain all the target nerves.

Abstract 14: Large Gap Peripheral Nerve Repair in a Non-Human Primate Model: Improving Outcomes Utilizing Photochemical Tissue Bonding (PTB) with Acellular Nerve Allograft (ANA)

PURPOSE: Segmental peripheral nerve deficits are challenging injuries associated with poor outcomes. While these injuries afflict civilians (e.g. Boston Marathon Bombing), they have become increasingly prevalent in combat trauma since the advent of improvised explosive devices. Standard of care large-gap (>3cm) reconstruction requires nerve autograft. Alternatives are sought in clinical scenarios where donor limb is not available (e.g. multiple extremity trauma) or donor site morbidity (e.g. painful neuroma formation, loss of function) makes autograft use suboptimal. A variety of alternatives have been proposed including allografts and conduits. Photochemical tissue bonding (PTB) as an alternative to traditional suture neurorrhaphy has been extensively studied in the rodent sciatic nerve model. PTB carries several advantages: reduction of needle trauma, prevention of axonal escape, and a water-tight seal to contain neuroregenerative factors and exclude inflammatory invasion. We report a non-human primate study which recapitulates human anatomy, allows for objective quantitative functional outcomes testing, electrophysiology and histomorphometry. The purpose of this study is to evaluate whether PTB can elevate the performance of acellular nerve allograft (ANA) to that of standard of care autograft/suture. METHODS: Nineteen rhesus macaques underwent 4cm proximal radial nerve defect creation in the right upper extremity, the radial nerve transected proximally at the humeral spiral groove, distally prior to the branch to brachioradialis. The radial nerve was selected as it is responsible for an isolated function with no input from other nerves. Three repair techniques were evaluated: n=6 autograft/suture, n=6 ANA/suture, n=7 ANA photosealed in place with light-activated human amnion wraps (PTB). An objective functional outcome test was conceived using an apparatus that accurately measured the degree of wrist extension as a function of time after surgery. Electromyography (EMG) was performed at 0, 120, 240, and 365 days (euthanasia). Histomorphometry and muscle mass retention were analyzed at euthanasia. RESULTS: Average loss of wrist extension was 88.3 ± 8.2° after radial nerve defect creation. Autograft group animals recovered 82.0° of extension by 7 months. Wrist extension recovery was modestly slower, as expected, in the ANA groups, however, by 8 months the ANA/PTB group recovered 63.0° of extension with no difference in recovery of baseline EMG amplitude as compared to controls (Avance/PTB=75.81% vs. autograft/suture=65.06%). If recovery follows current trajectory, we expect ANA/PTB to demonstrate equivalent outcomes to the autograft/suture group at one year. CONCLUSION: This radial nerve defect model improves upon existing animal models by allowing for large nerve gap testing in a primate model more analogous to the clinical large nerve gap injury in humans. ANA/PTB group functional recovery lagged modestly behind autograft/suture (by as long as 8 weeks) but is approaching equivalence at 8 months. EMG recovery is similar at 8 months. This preliminary data confirms PTB as a promising technique to improve outcomes of large nerve gap reconstruction in combination with autograft (previously demonstrated) and with acellular nerve allograft.

To graft or not to graft? Median to radial nerve transfer in the forearm: an alternative approach to treat proximal radial nerve injuries

Background. Reconstruction of proximal radial nerve (RN) injuries via grafting technique brings good recovery of wrist extensors, wherein finger and thumb extensors recover to a lesser degree. The outcomes are strongly dependent on a gap length, timing of procedure, etc. An alternative approach — median (MN) to RN transfer — brings regenerating axons much closer to target muscles. Objective. To compare the recovery of wrist and finger extensors provided by grafting versus distal neurotization technique at proximal RN injury. Methods. Twenty-eight patients with proximal RN injuries underwent 21 reconstruction of RN continuity via grafting technique. Seven patients underwent transfer of MN branches of m. flexor carpi radialis (FCR) and m. palmaris longus (PL) to n. posterior interosseus (PIN) with simultaneous transfer of m. pronator teres (PT) to m. extensor carpi radialis brevis (ECRB). Results. RN grafting brought recovery of the entire complex of thumb, fingers and wrist extensors only in 10 out of 21 cases (47.6 %). Radial wrist extensor(s) recovered in 100 % of cases, thumb extensors — in 85.7 %, finger extensors recovered in 61.9 % patients, with only 47.6 % showed recovery of thumb abductors. Eight patients required additional tendon transfers to restore fingers extension, 3 persons required thumb extension, 11 patients required thumb abduction. All 7 patients (100 %) after MN to PIN transfer received powerful and independent finger and thumb extension, as well as thumb abduction in much earlier terms. PT to ECRB transfer provided powerful and early wrist extension. Conclusions . The outcomes of MN to RN transfer at proximal RN injuries are more predictable, cogent and time-saving compared to the outcomes received with grafting in terms of recovery of full-fledged function of fingers extensors and thumb abductors.

The First Experience of Triple Nerve Transfer in Proximal Radial Nerve Palsy.

Injury to distal portion of posterior cord of brachial plexus leads to palsy of radial and axillary nerves. Symptoms are usually motor deficits of the deltoid muscle; triceps brachii muscle; and extensor muscles of the wrist, thumb, and fingers. Tendon transfers, nerve grafts, and nerve transfers are options for surgical treatment of proximal radial nerve palsy to restore some motor functions. Tendon transfer is painful, requires a long immobilization, and decreases donor muscle strength; nevertheless, nerve transfer produces promising outcomes. We present a patient with proximal radial nerve palsy following a blunt injury undergoing triple nerve transfer. The patient was involved in a motorcycle accident with complete palsy of the radial and axillary nerves. After 6 months, on admission, he showed spontaneous recovery of axillary nerve palsy, but radial nerve palsy remained. We performed triple nerve transfer, fascicle of ulnar nerve to long head of the triceps branch of radial nerve, flexor digitorum superficialis branch of median nerve to extensor carpi radialis brevis branch of radial nerve, and flexor carpi radialis branch of median nerve to posterior interosseous nerve, for restoration of elbow, wrist, and finger extensions, respectively. Our experience confirmed functional elbow, wrist, and finger extensions in the patient. Triple nerve transfer restores functions of the upper limb in patients with debilitating radial nerve palsy after blunt injuries.

Posterior interosseous neuropathy: Supinator syndrome vs fascicular radial neuropathy.

Objective:To investigate the spatial pattern of lesion dispersion in posterior interosseous neuropathy syndrome (PINS) by high-resolution magnetic resonance neurography.Methods:This prospective study was approved by the local ethics committee and written informed consent was obtained from all patients. In 19 patients with PINS and 20 healthy controls, a standardized magnetic resonance neurography protocol at 3-tesla was performed with coverage of the upper arm and elbow (T2-weighted fat-saturated: echo time/repetition time 52/7,020 milliseconds, in-plane resolution 0.27 × 0.27 mm2). Lesion classification of the radial nerve trunk and its deep branch (which becomes the posterior interosseous nerve) was performed by visual rating and additional quantitative analysis of normalized T2 signal of radial nerve voxels.Results:Of 19 patients with PINS, only 3 (16%) had a focal neuropathy at the entry of the radial nerve deep branch into the supinator muscle at elbow/forearm level. The other 16 (84%) had proximal radial nerve lesions at the upper arm level with a predominant lesion focus 8.3 ± 4.6 cm proximal to the humeroradial joint. Most of these lesions (75%) followed a specific somatotopic pattern, involving only those fascicles that would form the posterior interosseous nerve more distally.Conclusions:PINS is not necessarily caused by focal compression at the supinator muscle but is instead frequently a consequence of partial fascicular lesions of the radial nerve trunk at the upper arm level. Neuroimaging should be considered as a complementary diagnostic method in PINS.

Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord.

OBJECT Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord. METHODS The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients' average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength). RESULTS After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6. CONCLUSIONS The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.

Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord.

OBJECTIVE Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord. METHODS The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients' average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength). RESULTS After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6. CONCLUSIONS The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.

Ultrasound in dual nerve impairment after proximal radial nerve lesion.

IntroductionSonography in classical nerve entrapment syndromes is an established and validated method. In contrast, few publications highlight lesions of the radial nerve, particularly of the posterior interosseus nerve (PIN).MethodFive patients with a radial nerve lesion were investigated by electromyography, nerve conduction velocity and ultrasound. Further normative values of 26 healthy subjects were evaluated.ResultsFour patients presented a clinical and electrophysiological proximal axonal radial nerve lesion and one patient showed a typical posterior interosseous nerve syndrome (PINS). The patient with PINS presented an enlargement of the PIN anterior to the supinator muscle. However four patients with proximal lesions showed an unexpected significant enlargement of the PIN within the supinator muscle.ConclusionHigh-resolution sonography is a feasible method to demonstrate the radial nerve including its distal branches. At least in axonal radial nerve lesions, sonography might reveal abnormalities far distant from a primary proximal lesion site clearly distinct from the appearance in classical PINS.

Endoscopically assisted proximal radial nerve decompression: Surgical technique

State of the artThe proximal radial nerve compression syndrome includes supinator syndrome and proximal radial nerve constrictions. This article presents a new endoscopic assisted radial nerve decompression surgical technique described for the first time by Leclère et al. in 2013. Surgical techniqueEndoscopic scissor decompression of the proximal radial nerve is always performed under plexus anaesthesia. It includes 8 key steps documented in this article. We review the indications and limitations of the surgical technique. ConclusionEarly clinical results after endoscopic assisted decompression of the radial nerve appear excellent. However, they still need to be compared with conventional techniques. Clinical studies are likely to widely develop because of the mini-invasive nature of this new surgical technique.

Motor replacement surgery via tendon transfer in radial nerve palsy

Restoration of active extension of wrist, thumb and digits by muscle-tendon transposition. Radial nerve palsy due to peripheral nerve injury. Peripheral nerve disease. Muscle or tendon injury. Restoration of wrist extension in high radial nerve palsy. Reversible distal radial nerve palsy, absence of suitable donor muscles, spasticity, limited range of motion of affected joints, extensive scarring and inappropriate soft tissue conditions, unjustifiable loss of function at donor site. Reinnervated donor muscles, progressive muscle disease, insufficient patient compliance. Dissection of the flexor carpi ulnaris, palmaris longus and pronator teres tendon insertion. Transposition of the tendons. Interweaving of tendons of the pronator teres and extensor carpi radialis brevis muscles, the extensor digitorum communis and flexor carpi ulnaris muscles, as well as the extensor pollicis longus and palmaris longus muscles using the Pulvertaft technique. 3Weeks immobilization in forearm splint. Additional immobilization for 2weeks at night. Subsequently, intensive physical and occupational therapy for another 4-6weeks is required, starting 3weeks postoperatively. The procedure was carried out in 12patients over the past 14years. We treated proximal radial nerve palsy in nine cases. In accordance with the current medical literature, we consider the described motor replacement surgery a reliable procedure.

Superficial radial nerve–lateral antebrachial cutaneous nerve anatomic variation

IntroductionThis study focuses on an anatomic variation in which the lateral antebrachial cutaneous nerve (LACN) innervates the radial border of the dorsum of the hand and thumb in addition to, or replacing, the superficial radial nerve (RSN). Here, we propose a technique of nerve conduction that identifies this variation.MethodsWe studied nerve conduction in 200 upper limbs of two series of 50 volunteers. We sought evidence of the aforementioned variation on the dorsum of the hand and in the thumb.ResultsWe found eight occurrences of this variation on the dorsum of the hand and 11 variants on the thumb within the two respective series of 100 upper limbs studied.DiscussionThe RSN–LACN anatomic variation can be studied using nerve conduction. The knowledge of this variation is particularly important for the evaluation of proximal radial nerve injury.

IRM fonctionnelle. Quels apports en chirurgie de la main ?

Functional MRI (fMRI) allowed considerable advances upon understanding of cerebral functioning. Cortical plasticity, which allows the voluntary command of a restored function by a transferred muscle remains to be investigated in its intimacy. The authors present here the round table held at the 48th annual meeting of the French Society for Surgery of the Hand on December 22nd, 2012. It tries to review the analysis of the phenomenon observed during multiple tendinous transfers for restoration of proximal radial nerve palsy. Were successively approached: 1) Methods of acquisition and analysis of the signals (C. D-M.); 2) Movement reorganization (O.M.); 3) Motor plasticity after hand allograft (A. S.); 4) The potential interest of the fMRI in hand rehabilitation (F. D.); 5) The analysis of cerebral plasticity in general (H. B.). A rather philosophical conclusion opens other fields to f MRI (A.M.).