Radial Nerve Distribution Research Articles

Permanent Peripheral Nerve Stimulator for Complex Regional Pain Syndrome of the Forearm and Hand

Summary: A 51-year-old woman with diabetes and depression was referred to the anesthesia pain clinic with a 15-year history of complex regional pain syndrome type I of the right forearm and hand in the radial sensory nerve distribution. There was no recognized antecedent trauma and she had failed both medical treatment and radial sensory nerve decompression surgery. An ultrasound-guided local anesthetic block of the radial nerve in the upper arm resulted in partial and temporary improvement in pain. She subsequently underwent trial of a peripheral nerve stimulator (PNS) followed by permanent PNS implant placement over the radial nerve proper proximal to the elbow. Within the first month of use, she endorsed substantially improved pain and strength in her right hand. These improvements were sustained for more than 1 year. Applications of PNS technology for treatment of extremity complex regional pain syndrome and neuropathic extremity pain in general are reviewed.

Buerger's Disease And Avascular Necrosis Of The Scaphoid

HISTORY: 58 year old right-hand dominant, who comes in today for evaluation of her right wrist. She awoke 1.5-2 years ago one morning with pain. Denies any trauma or falls. She saw her PCM for what was presumed to be carpal tunnel syndrome, and was supposed to be sent to a specialist; however, this did not happen. Not seen again until late July 2020 with another provider. She reports intermittent pain but predominantly stiffness and limited flexion of her wrist. Cannot lift objects heavier than a gallon of milk. Reports carpal tunnel surgery in the same wrist in 1985. Reports a 24 pack-year history and is actively trying to quit. PHYSICAL EXAMINATION: Examination revealed swelling overlying the distal radius. Flexion of the right wrist was limited to 10 degrees, and extension was limited to 45 degrees. She demonstrated normal function of the FDS/FDP/FHL tendons, along with all of her extensor tendons. Sensation to light touch was in-tact in the median, radial, and ulnar nerve distributions. DIFFERENTIAL DIAGNOSIS: 1. Avascular necrosis of the scaphoid 2. Severe osteoarthritis of the radioulnar joint 3. Scapholunate dissociation TEST AND RESULTS: XRay of the right wrist-Chronic scaphoid avascular necrosis. MRI of the right wrist without contrast 1. Fragmentation, flattening, and partial collapse of the sclerotic edematous scaphoid, with mild volar flexion, with possible chronic osteonecrosis. 2. Severe osteoarthritis at the radiocarpal joint with high-grade cartilage injury, synovitis, capsular sprain, and small volar ganglion cysts. 3. Chronic appearing scarring and degeneration of the scapholunate ligament and TFCC. 4. Mild tenosynovitis and mild tendinosis of the tendons within the first and second extensor compartments. FINAL/WORKING DIAGNOSIS: Avascular necrosis of the scaphoid as a result of Buerger's Disease TREATMENT AND OUTCOMES: 1. Smoking cessation 2. Celestone injection of the scaphoid by Ortho-Hand Surgery 3. Thumb spica splint 4. Follow-up as needed

This Month in Anesthesiology

This Month in Anesthesiology

Age-dependent Reliability of Semmes-Weinstein and 2-Point Discrimination Tests in Children.

Objective sensory testing is a critical component of the physical examination in children as they may be unable to communicate whether or not numbness is present. The purpose of this study was to determine at what age objective sensory tests could reliably be performed. Normal, uninjured participants aged 2 to 17 years were enrolled in the study. Monofilament and static/moving 2-point discrimination tests were performed bilaterally assessing the median, ulnar, and radial nerves. Performance scores were recorded using the monofilament size and 2-point discrimination distance. Statistical analysis was performed utilizing univariable linear regression, 1-way ANOVA, and Welch t test. A total of 396 hands were tested utilizing the Semmes-Weinstein monofilament and static/moving 2-point discrimination tests. For the monofilament test, 27% of 3-year-olds, 83% of 4-year-olds, and all participants 5 years of age and older were capable of performing the monofilament test. The average monofilament scores were 2.874, 2.868, and 3.043 for the ulnar, median, and radial nerves, respectively, with no correlation with advancing age present. The ulnar and median nerve distributions were more sensitive than the radial nerve distribution (P<0.001).For 2-point discrimination tests, 33% of 4-year-olds, 61% of 5-year-olds, 88% of 6-year-olds, 95% of 7- and 8-year-olds, and all participants 9 years and older were capable of performing the static/moving 2-point discrimination tests. The average static 2-point discrimination scores were 3.348, 2.806, and 9.637 mm for the ulnar, median, and radial nerves, respectively. The average moving 2-point discrimination scores were 2.977, 2.483, and 8.506 mm for the ulnar, median, and radial nerves, respectively. There was no correlation between advancing age and performance scores. Children are the most sensitive in the median, then ulnar, and then radial nerve distribution (P<0.001). Better discrimination is present between 2 moving points than static points (P<0.001). Objective threshold testing utilizing a monofilament can reliably be performed in the vast majority of children aged 4 years and above, whereas density testing utilizing 2-point discrimination can reliably be performed in the vast majority of children aged 6 years and above. Level II.

Single-point versus double-point injection technique of ultrasound-guided supraclavicular block: A randomized controlled study.

Background and Aims:This study aims to compare the single-point injection and double-point injection technique of ultrasound-guided supraclavicular block with regard to the success rate, time taken to perform the procedure, onset and duration of sensory and motor block, and complications.Material and Methods:A total of 60 American Society of Anesthesiologists physical status I and II patients between 20 and 50 years of age, with body mass index ≤30 kg/m2 posted for forearm surgeries, with anticipated surgical duration more than 1 h were randomly divided into two groups: group S (single-point injection) and group D (double-point injection technique). After locating the brachial plexus with ultrasound, needle was inserted from lateral to medial direction to reach the plexus. In group D, 20 ml of inj. bupivacaine 0.5% was deposited as 10 ml each in superior (in the cluster) and inferior pocket (corner pocket) between the plexus and subclavian artery with the help of hydrodissection while in group S the total 20 ml was deposited in the superior (in the cluster) pocket. The onset of sensory and motor block was assessed using pin prick method and modified Bromage scale. Adequacy of block was ensured by assessing the ulnar, radial, and median nerve distribution. Procedural time was defined from the point of scanning the plexus till the drug was injected completely. Total sensory, motor duration, and complications if any were noted.Results:Group D had higher success rate compared to group S (96.7 vs. 83.3%; P < 0.0001). The total procedural time was significantly more in group D compared to group S (14.6 ± 2.7 vs. 10.1 ± 1.7 min; P < 0.0001). The onset of sensory and motor block was faster and the duration of sensory and motor block was significantly longer in group D.Conclusion:The adequacy of block, sensory, and motor duration was significantly high in newer double-point injection technique. However, it requires longer procedural time compared to single-point injection technique.

Segmental Schwannomatosis of the Upper Extremity

Schwannomatosis is characterized by the development of multiple schwannomas without evidence of vestibular tumors. Segmental schwannomatosis is defined as being limited to 1 limb or 5 or fewer contiguous segments of the spine. We report a case of a 38-year-old male with multiple, painful masses of the right upper extremity with associated numbness and paresthesia in the ulnar and radial nerve distribution. An open, microsurgical approach provided definitive diagnosis and treatment. Twenty-one cases of segmental schwannomatosis of the upper extremity have been reported in the literature, making this case the 22nd. It is 1 of 5 cases of segmental schwannomatosis to have simultaneous tumors in the forearm and hand. We are the first to report multiple schwannomas of the ulnar and ulnar sensory nerve and the second to report multiple schwannomas of the radial sensory nerve. We additionally review the literature regarding pathogenesis, diagnosis, and treatment of this uncommon tumor.

Comparative study between bupivacaine-dexmedetomidine combination and bupivacaine (plain) in brachial plexus block using nerve stimulator

Introduction: Brachial plexus block has evolved into a valuable and safe alternative to general anaesthesia for the upper limb surgeries. It is a great tool in the anaesthetic armamentarium for relief of pain preoperatively, perioperatively and post operatively. It is possible and desirable for patient to remain ambulatory. Adjuvants with local anaesthetics in brachial plexus block are being used to achieve quick, dense and prolonged block. Dexmedetomidine added to local anesthetics prolongs the duration of block and postoperative analgesia in brachial plexus block. Methods and Methodology: It is a prospective, randomised, comparative study of 60 patients admitted in a tertiary hospital for upper limb surgery who were posted under regional anaesthesia during the period of October 2012 to December 2014. The patients taken in this study were allocated into two groups randomly. Group B (n=30) 20millilitres (ml) of 0.5%% bupivacaine +1ml saline and group D (n=30) 20ml of 0.5% bupivacaine +1microgram (mcg)/kilogram (kg) dexmedetomidine was given. Results: There were no clinical or statistically significant differences in the demographic profile of patients in either group. Onset of sensory block in radial, median and ulnar nerve distributions were significantly shorter in group B. Motor onset was also significantly shorter in group B. However rescue time was higher in group D. There were no adverse effects noted in both the groups. There was a significant percentage of GA conversion seen in case of group. B. Discussion: Onset of sensory block was faster in Group B than in Group D, onset of motor block was faster in Group B than in Group D, and the difference was statistically significant. There was significant increase in duration of analgesia in Group D (456.12±97.99 min) as compared with Group B (289.67±62.50 min). The difference was statistically significant No side-effects (nausea, vomiting, dry mouth) were reported during the first 24 h in the post-operative period in both the groups. From this study, we would like to suggest that dexmedetomidine can be safely used with local anaesthetic in peripheral nerve blocks; however, further trials to determine the exact dose and effect of neurotoxicity on the human nerve are required.

Radial nerve palsy in mid/distal humeral fractures: is early exploration effective?

Radial nerve palsies are a common complication with displaced distal humeral fractures. This case series examines the outcomes of early operative exploration and decompression of the nerve with fracture fixation with the view that this provides a solid construct for optimisation of nerve recovery. A total of 10 consecutive patients with a displaced distal humeral fracture and an acute radial nerve palsy were treated by the senior author by open reduction and internal fixation of the distal humerus and exploration and decompression of the radial nerve. Motor function and sensation of the radial nerve was assessed in the post-operative period every 2 months or until full recovery of the radial nerve function had occurred. All patients (100%) had recovery of motor and sensation function of their upper limb in the radial nerve distribution over a 12-month period. Recovery times ranged between 4 and 32 weeks, with the median time to recovery occurring at 26 weeks and the average time to full recovery being 22.9 weeks. Wrist extension recovered by an average of 3 months (range 2-26 weeks) and then finger extension started to recover 2-6 weeks after this. Disability of the arm, shoulder and hand scores ranged from 0 to 11.8 at greater than 1 year post-operatively. Our study demonstrated that early operative exploration of the radial nerve when performing an open stabilization of displaced distal humeral fractures resulted in a 100% recovery of the radial nerve.

Preoperative Computer Simulation and Patient-specific Guides are Safe and Effective to Correct Forearm Deformity in Children.

Posttraumatic and congenital forearm deformities in children can be difficult to appreciate in all planes. In cases of distal radioulnar joint instability and loss of forearm rotation, surgical correction is challenging. Advances in 3-dimensional printing allow creation of custom guides at a reasonable cost, enabling precise correction of the deformity in all planes. Nineteen children with deformity of the forearm had corrective osteotomies performed using preoperative 3-dimensional computer modeling and patient-specific surgical guides. Surgicase software was used for 3-dimensional planning of the corrective osteotomy, by superimposing a mirror image of the unaffected side as a template. Based upon this planning, patient-specific surgical guides were manufactured. Radiographic and clinical outcomes were assessed. Three patients had a diagnosis of multiple hereditary exostoses, and one of Madelung's deformity. The remaining 15 patients had a diagnosis of fracture malunion. Average preoperative angulation of both the radius and ulna was 23 degrees. For the patients with fracture malunions, the time from injury to surgery ranged from 6 months to 8 years. Twelve patients underwent osteotomies of both the radius and ulna, 5 had osteotomies of the radius alone, and 2 had a single osteotomy of the ulna only. All osteotomies went on to unite and no patient lost range of motion. Preoperative arc of forearm rotation averaged 101 degrees (range 0 to 180 degrees). Postoperatively, this improved to 133 degrees (range 85 to 180 degrees). Eight patients had distal radioulnar instability preoperatively, all of which normalized after surgery. There were 4 complications: 1 hypertrophic scar, 1 subject with extensor pollicis longus weakness, and 2 transient sensory losses in the superficial radial nerve distribution. This case series demonstrates that 3-dimensional computer modeling permits complex and multiple osteotomies to be done safely to achieve deformity correction in children. Limitations in forearm rotation and distal radioulnar malalignment can be reliably improved using this technique. Level IV-retrospective case series.

Intramedullary Cortical Button Fixation Of Distal Biceps Tendon Rupture: Long-term Patient Outcomes

Objectives:No consensus currently exists for optimal distal biceps rupture fixation. Dorsal cortical button (DCB) and dual incision transosseous (DITO) provide the greatest biomechanical load-to-failure, permitting earlier mobilization to prevent arthrofibrosis. Both methods have associated complications, restricted range of motion (ROM) from heterotopic ossification and proximal radioulnar synostosis for DITO while DCB has increased incidence of cutaneous and posterior interosseous nerve (PIN) injuries despite different techniques to reduce their frequency. The intramedullary cortical button (ICB) fixation technique aims to decrease PIN palsy risk, decrease implant costs and provide strong tendon-bone fixation allow for early ROM. We set out to determine the long-term efficacy of this technique and any difference in complication rates including re-rupture.Methods:31 patients underwent ICB fixation of chronic and acute distal biceps tendon ruptures without allograft with more than 1 year follow up. 21 patients completed a questionnaire and Disabilities of the Arm, Shoulder and Hand (DASH) survey. Elbow and forearm ROM, cosmesis, pain, strength, motor nerve neuropraxia, cutaneous sensory changes and other complications were obtained from the chart and questionnaire. The ICB technique utilizes a 4cm transverse anterior incision 2cm distal to the distal antecubital flexion crease. The tuberosity is prepared, creating a clean, bleeding bony surface. A #2 high-strength braided suture is passed through the toggle hole at both ends of a Smith and Nephew Endobutton. A needle passes one suture pair in the 4.7mm hole and out the 2mm hole drilled with mild convergence in the distal and proximal tuberosity footprint with a 1.5cm bony bridge. This suture pair shuttles the Endobutton into the intramedullary canal, both limbs of each suture exits their respective hole. One limb from each suture is whipstitched proximally and back distally. Tensioning the free suture limb exiting the 2mm hole and tying to its free suture pair compresses the biceps stump against the radial tuberosity and secures the Endobutton against the intramedullary cortex at the 2mm hole. Finally the free suture limb exiting the 4.7mm hole is tensioned and tied to its suture pair limb, distributing tendon compression over the entire tuberosity footprint.Results:At an average of 4 (1.3-7.4) years postoperatively, 81% were extremely and 10% very satisfied with their overall outcome. 81% reported no strength or ROM limitations, 76% had pain-free activity, 86% and 81% were extremely satisfied with postoperative elbow ROM and forearm ROM respectively. The mean DASH and sports DASH score were 3.52 and 2.5. Transient sensory changes were noted in the lateral antebrachial cutaneous nerve and superficial radial nerve distributions in 38% and 19% of patients respectively. Excluding workers compensation patients improved the percent of extremely satisfied patients to 93% and the average DASH score to 0.93. No biceps re-ruptures or PIN palsies were observed.Conclusion:The ICB technique provides secure distal biceps tendon fixation with excellent long-term patient satisfaction and comparable functional outcomes to existing fixation techniques with restoration of normative DASH scores. The ICB technique has a cutaneous nerve complication rate comparable to other single incision studies and no observed PIN palsies or wound complications were noted while decreasing the implant costs.

Motor-Sparing Surgical Nerve Blocks for Upper Extremity Surgery: Significantly Less Motor Paralysis Using 15 mL versus 30 mL of Mepivacaine 1.5% for Supraclavicular Block - A Prospective Randomized Double-Blinded Study

Background and objectives: We performed a prospective randomized double-blinded study evaluating if a reduced volume of local anesthetic would result in operative limb surgical anesthesia while decreasing motor paralysis during an ultrasound-guided supraclavicular nerve block. Current tendencies in clinical practice towards smaller injectate volumes during ultrasound-guided nerve block placement prompted our investigation on its impact regarding block quality. Methods: 43 patients were consented for this prospective, double-blinded randomized clinical trial. Each patient was randomly assigned. Group HIGH received the conventional injection dose of 30 mL of 1.5% Mepivacaine. Group LOW received the reduced volume dose of 15 mL. An ultrasound-guided supraclavicular nerve block was performed on each patient. Motor block and sensory perception to pin-prick were assessed in the nerve distributions for the ulnar, median, radial, and musculocutaneous branches at 5, 10, 15, 20, and 30 minutes post-injection. Results: Complete motor block in the radial, ulnar, musculocutaneous and median nerve distributions at 30 minutes, was present in 55% of patients in Group HIGH versus 10% in Group LOW and was statistically significant between both groups (p<0.01). The anatomic distribution of the observed motor-sparing was statistically significant in the median (p<0.01) and ulnar (p<0.05) nerve branches among those patients who received 15 mL LA boluses. Conclusions: Our study demonstrated that 15 mL vs. 30 mL injections of mepivacaine 1.5% at the supraclavicular approach provide equivalent surgical anesthesia, while reducing the incidence of motor block. These findings may have implications on early postoperative physical therapy for the subset of patients that present with Galeazzi-type fractures, carpal tunnel syndrome, and minimally-displaced distal radius fractures.

Safety, efficacy, and functional outcome of elastic stable intramedullary nailing in unstable fractures of both bones of forearm in children

Aims: To determine the clinical profile and clinical, functional, and radiological outcomes and complications in children who underwent elastic stable intramedullary nailing (ESIN) for unstable fractures of both bones of forearm. Materials and Methods: A retrospective observational study was conducted in the Paediatric Orthopaedic Unit of the institution. Children with forearm fractures, who underwent ESIN of both the bones with titanium nails from January 2004 to June 2010, were included in the study. Clinical evaluation for deformity, range of motion at wrist and elbow, Daruwalla’s grading for forearm fractures, and radiological evaluation for bony union, malalignment, and radial bow were done. Paediatric Outcomes Data Collection Instrument (PODCI) questionnaire was used to assess functional outcome. Results: Twenty-six patients were followed up for a mean of 2.14 years. These included one primary internal fixation for unstable injury in a 15-year old, 10 open fractures, and 15 with malalignment after closed reduction. Age ranged from 5 to 15 years (mean of 11.39). Average time to bony union was 6 weeks. Twelve children had excellent, 12 good, and two fair outcomes according to Daruwalla’s grade. Average PODCI score was 50.78 (standardized range is minimum of −140 to maximum of 53). There were no major complications related to ESIN. Three patients had paraesthesia over superficial radial nerve distribution, three patients had hypertrophied scars, and one patient had superficial wound infection. One child had distal radial physeal arrest following inadvertent physeal injury during implant removal. Conclusion: ESIN is safe and effective for internal fixation of unstable forearm fractures.

Nerve transfers for brachial neuralgia

Motor function, rather than sensory function, is the primary concern for most brachial plexus surgeons. After root avulsions from the spinal cord, numbness in the affected limb may be associated with extreme, almost unbearable, intractable pain. Deafferent pain is the result of avulsion of the root from the spinal cord. Pain from the brachial plexus avulsion probably arises from the disinhibition of neurons within the substantia gelatinosa that fire spontaneously. The convulsive pain of the brachial plexus injury may correlate with the burst pattern of firing in lamina V also observed in higher levels of the central nervous system including the thalamus. It has been postulated that the lack of sensory input into the spinal cord leads to spontaneous discharges of the neurons in the dorsal horn, therebycausing pain. In our experience, one-third of patients with C5 and C6 root avulsion presented with pain on the dorsal radial aspect of the hand correlated with the superficial radial nerve distribution. Nerve transfer may inhibit abnormal electrical activity in the dorsal horn or higher levels of the central nervous system such as the thalamus by restoring the input to the damaged limb. In 2011 we described the technique “End-to-Side Radial Sensory to Median Nerve Transfer to Restore Sensation and Relieve Pain in C5 and C6Nerve Root Avulsion” in 8 patients. Six patients had S2 and 2 patients had S3. All patients perceived at least one number lower of the Semmes-Weinstein filament in the dorsal radial aspect of the affected hand compared with the preoperative status. The best result was perception of the 3.61 filament in 2 patients. No downgrading of the donor nerve was observed after surgery. All patients had relief of pain 2 weeks after surgery, and the pain decreased dramatically at the last follow-up. An interesting finding in our patients is that we observed no cross-misperception between the injured nerve and donor nerve territories. One hypothesis is that the induced collateral axons are specifically aimed to their new target reconnecting with the spinal cord neurons; another explanation is that there is an unknown mechanism of brain plasticity. Recently, we performed end-to-side median nerve into contralateral C7 transfer to relieve pain at the median nerve distribution area of the hand in late total arm type brachial plexus injury in 7 patients. All patients perceived at least 2 number lower of the Visual Analog Scale (VAS) for pain at the median nerve distribution area of the affected hand and at least 20% decrease in the PSRS compared with the preoperative status. The mean VAS was decreased from 7.8 to 4.1 and the mean PSRS was decrease from 28.4 to 17.5 at last F/U. No downgrading of the donor nerve was observed after surgery. None of the patients experienced any major complication. This nerve transfer could be an alternative method to treat refractory deafferent pain in total arm type brachial plexus injury without major complications.

Shearing of a Continuous Interscalene Catheter with Lancinating Symptoms After an Interscalene Block: A Case Report.

Placement of a continuous indwelling nerve block catheter is generally safe and effective for pain control in the outpatient setting1. As reported in several large series in the literature, catheter-related complications are rare1-3; however, neurologic injury is possible. We present a patient who experienced a unique complication after placement of an interscalene nerve catheter and successful postoperative anesthesia. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A healthy fifty-seven-year-old right-hand dominant woman (considered class-2 status by the American Society of Anesthesiologists) presented to our orthopaedic clinic with right shoulder pain. Five years previously, she had fallen from a standing height and had sustained a fracture of the proximal third of the humeral shaft, which had developed into a chronic atrophic nonunion with gross motion at the fracture site. She also had experienced weakness in the radial nerve distribution, suggesting partial nerve injury from the fracture. An interscalene approach to the brachial plexus was used for catheter placement to deliver continuous interscalene analgesia. This catheter was utilized to provide a longer duration of postoperative pain control than a single-shot interscalene block. An 18-gauge 50-mm Tuohy needle was advanced with use of nerve stimulator localization. Stimulation of the nerve was begun at 1.5 mA, and the stimulation progressed until the biceps contraction disappeared at 0.5 mA in order to accurately place the needle in close proximity to the nerves of the brachial plexus. A 19-gauge StimuCath (Arrow International, Reading, Pennsylvania) catheter (Fig. 1) was advanced 3 cm beyond the tip of the needle, and aspiration was negative for blood. There was no evidence of damage to the catheter before placement. A 40-mL combination bolus solution (30 mL of bupivacaine 0.5% with epinephrine, and 10 mL of …

Type II complex regional pain syndrome of the hand resulting from repeated arterial punctures during transradial coronary intervention

Coronary catheterization using a transradial approach has become a common procedure, as the risks of local complications are low and this procedure affords relatively expeditious postprocedural patient mobilization. Access site complications--such as radial artery spasm, hematoma, and compartment syndrome--have been reported in the literature; however, cases of complex regional pain syndrome (CRPS) of the hand related to the procedure are extremely rare. We describe a case of type II CRPS affecting the hand after a transradial coronary intervention that was complicated by repeated periprocedural arterial punctures. In this case, a 55-year-old woman underwent a percutaneous coronary intervention for the treatment of unstable angina. After successful completion of the procedure, the patient complained of severe pain along the median and radial nerve distributions and resulting disability of the right hand. Although subsequent duplex sonography showed no abnormalities, a nerve conduction study uncovered injury to multiple nerves on the right. A diagnosis of type II CRPS was then made and the patient was treated with a nerve block as well as multiple medical modalities. This case demonstrates a very unusual complication resulting from the transradial approach to percutaneous coronary intervention.

Deltoid, triceps, or both responses improve the success rate of the interscalene catheter surgical block compared with the biceps response

The influence of the muscular response elicited by neurostimulation on the success rate of interscalene block using a catheter (ISC) is unknown. In this investigation, we compared the success rate of ISC placement as indicated by biceps or deltoid, triceps, or both twitches. Three hundred (ASA I-II) patients presenting for elective arthroscopic rotator cuff repair were prospectively randomized to assessment by biceps (Group B) or deltoid, triceps, or both twitches (Group DT). All ISCs were placed with the aid of neurostimulation. The tip of the stimulating needle was placed after disappearance of either biceps or deltoid, triceps, or both twitches at 0.3 mA. The catheter was advanced 2-3 cm past the tip of the needle and the block was performed using 40 ml ropivacaine 0.5%. Successful block was defined as sensory block of the supraclavicular nerve and sensory and motor block involving the axillary, radial, median, and musculocutaneous nerves within 30 min. Success rate was 98.6% in Group DT compared with 92.5% in Group B (95% confidence interval 0.01-0.11; P<0.02). Supplemental analgesics during handling of the posterior part of the shoulder capsule were needed in two patients in Group DT and seven patients in Group B. Three patients in Group B had an incomplete radial nerve distribution anaesthesia necessitating general anaesthesia. One patient in Group B had an incomplete posterior block extension of the supraclavicular nerve. No acute or late complications were observed. Eliciting deltoid, triceps, or both twitches was associated with a higher success rate compared with eliciting biceps twitches during continuous interscalene block.

Symptoms of Cumulative Trauma in Hand Therapy Professionals, A Descriptive Study

Sharon R. Flinn, Kimberly Couch, Amy Darragh, Division of Occupational Therapy, Ohio State University, Columbus, OH, USA; Hand Center Occupational Therapy Services, The Ohio State University, Columbus, OH, USA Purpose: Describe the physical and functional changes found in working hand therapists. Background: Several authors have identified hand therapists at risk for cumulative trauma symptoms. Harmon et al. (1997) found 73% of hand therapists had previously experienced CTD symptoms. Caragianis (2002) found 66% of hand therapists with pain were occupational injuries with the most common site of pain at MP/CMC joints of the thumb. CTS symptoms have been reported in 38-46% of hand therapists and 67-75% had engaged in protective/corrective measures (Bash & Farber, 1999; Sefcovic et al. 2000). Methods: This study was part of a larger study to document exposure to risk factors for work-related musculoskeletal symptoms among hand therapists. Quantitative measures were collected in this study on symptoms of cumulative trauma and limitations found in non-work activities. Physical functioning instruments included pain (VAS, diagrams), sensibility (SWM), motor function (composite ROM, tendon gliding), hand volume, grip, pinch strength. FDS findings of # 2cm and intrinsic tightness # .5 cm were considered normal. Average grip and pinch over three trials were calculated. Nonwork activity limitations were assessed using the Flinn Performance Screening Tool to identify valued life activities. Over 300 photographs were used to screen ADL/IADL. Results: Demographics. Twenty therapists from three hand therapy clinics were evaluated. The mean age was 47 years (SD 7.09). Total therapy experience was 23 years (SD 8.85) with hand therapy experience of 17 years (SD 7.83). All participants reported being right hand dominant. Pain. When rating least and worst pain levels, 55% reported no pain for least levels but 100% reported worst levels averaging 4.99/10. Of those reporting worst pain, 63% reported pain occurred at work, 26% at home, and 10% at work and home. The most common area of pain was dominant thumb (75%), upper back/posterior head (55%), the nondominant thumb (50%), and dominant anterior forearm (45%). A majority had pain/pulling with the Finkelstein’s maneuver on right (60%) and left (70%) thumbs. A small subgroup had positive grind test on the right (20%) and left (15%) thumbs. Sensibility. 35% reported hand paresthesias. The upper limb test was positive most often for the median nerve on right (60%) and left (40%) extremities. Over 50% had abnormal findings for the median nerve using 2.83 monofilament. 25% had decreased sensibility in radial nerve distribution and 20% in all peripheral nerves. Motor. Composite ROM was not problematic for extrinsic and intrinsic extensibility, FDS gliding, or thumb flexion-abduction. Large restrictions were found in Apply-Scratch Test on right (-6 cm) and left (-8 cm). Average strength dominant and non-dominant hands were 54/48#; lateral pinch 16/15#, and tip pinch 10/10#. Hand Volume. Hand volumes were not problematic with averages of 12ml difference between dominant/non-dominant and 1ml difference between pre-posttests. ADL Function. An average of 11 ADL limitations was reported with a range of 0-48 items. A majority of items required upper body strength or pinch. Conclusion: A majority of participants experienced specific cumulative trauma symptoms and non-work ADLs. Recommendations will be provided for improved surveillance.

Complex Regional Pain Syndrome Secondary to Leprosy

Leprosy is a chronic infectious disease caused by Mycobacterium leprae affecting the skin and the nerves. Complex regional pain syndrome (CRPS/Sudeck's dystrophy) is a painful and disabling condition--a triad of autonomic, sensory, and motor symptoms disproportionate to the inciting event (inflammatory, infective, or traumatic nerve damage). A 20-year-old male presented with continuous pain, aggravated by cold and emotions, loss of fine touch and temperature sensation, redness, swelling, along lateral aspect of left hand and forearm with weakness in the grip of 6 months' duration. There was a 5-year history of sensory loss only over left index finger that he ignored. Examination revealed abnormal sensory and autonomic functions along left radial and median nerve distribution that were confirmed by nerve conduction studies suggestive of mononeuritis multiplex. Radial cutaneous nerve biopsy was suggestive of leprosy. Magnetic resonance imaging and ultrasonography showed no compressive etiology; however, MRI showed involvement of brachial plexus. Antileprosy, anti-inflammatory drugs, and steroids were given in view of neuritis because of lepra reaction with supportive measures of physiotherapy, transcutaneous electrical nerve stimulation, to no avail. A surgical median nerve decompression also failed to relieve the pain. Temporary stellate ganglion block improved the pain scale. Thus, excluding all other causes, the final diagnosis was CRPS secondary to leprosy. There is only one reported case of CRPS with leprosy. Leprous neuropathy caused the nerve damage that lead to CRPS type 2. Very rarely leprosy can lead to CRPS. CRPS is a diagnosis of exclusion.

Salvage of Complete Degloved Digits With Reversed Vascularized Pedicled Forearm Flap: A New Technique

Complete ring avulsion injury necessitates a difficult choice between microvascular repair and revision amputation. Microvascular repair is technically difficult and amputation may leave an unsatisfactory result. We describe an alternative method whereby a reverse radial forearm flap is wrapped around the complete degloved digit. This provides good quality cover to the whole volar, dorsum, and both sides of the finger. We performed 26 pedicle radial forearm flaps for 26 patients in the Hand and Reconstructive Microsurgery Unit, Sohag University Hospital, from 2001 to 2009. Indications included soft tissue coverage of the thumb (n = 8), ring finger (n = 11), index finger (n = 4), middle finger (n = 2), and little finger (n = 1). Finger salvage was successful in 96% of patients. There was complete loss of 1 flap and partial flap loss of a second. Finger range of motion was excellent in 18 fingers, good in 7, and fair in 1. Two donor sites were closed primarily; the rest were closed with split-thickness skin grafts. There were no reports of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution.

Radial Forearm Free Flap Donor Site Morbidity&lt;subtitle&gt;Ulnar-Based Transposition Flap vs Split-Thickness Skin Graft&lt;/subtitle&gt;

To evaluate morbidity associated with the radial forearm free flap donor site and to compare functional and aesthetic outcomes of ulnar-based transposition flap (UBTF) vs split-thickness skin graft (STSG) closure of the donor site. Case-control study. Tertiary care institution. The inclusion criteria were flap size not exceeding 30 cm(2), patient availability for a single follow-up visit, and performance of surgery at least 6 months previously. Forty-four patients were included in the study and were reviewed. Twenty-two patients had UBTF closure, and 22 had STSG closure. Variables analyzed included wrist mobility, Michigan Hand Outcomes Questionnaire scores, pinch and grip strength (using a dynamometer), and hand sensitivity (using monofilament testing over the radial nerve distribution). In analyses of operated arms vs nonoperated arms, variables obtained only for the operated arms included Vancouver Scar Scale scores and visual analog scale scores for Aesthetics and Overall Arm Function. The mean (SD) wrist extension was significantly better in the UBTF group (56.0° [10.4°] for nonoperated arms and 62.0° [9.7°] for operated arms) than in the STSG group (59.0° [7.1°] for nonoperated arms and 58.4° [12.1°] for operated arms) (P = .02). The improvement in wrist range of motion for the UBTF group approached statistical significance (P = .07). All other variables (Michigan Hand Outcomes Questionnaire scores, pinch and grip strength, hand sensitivity, and visual analog scale scores) were significantly better for nonoperated arms vs operated arms, but no significant differences were observed between the UBTF and STSG groups. The radial forearm free flap donor site carries significant morbidity. Donor site UBTF closure was associated with improved wrist extension and represents an alternative method of closure for small donor site defects.