Wrist Level Research Articles

Cold Pressor Test Induces Significant Changes in Internal Jugular Vein Flow Dynamics in Healthy Young Adults.

BACKGROUND The cold pressor test (CPT), which has long been used to test autonomic functions by causing sympathetic excitation, increases systolic and diastolic blood pressure and heart rate and causes coronary vasodilation within physiological limits in healthy individuals. This study aimed to evaluate internal jugular vein (IJV) flow parameters using the CPT with systolic and diastolic blood pressure and heart rate in 40 healthy volunteers aged 18-40 years. MATERIAL AND METHODS The volunteers' IJV diameter, blood flow peak velocity, and volumetric flow values were recorded. Then, their right hands were immersed in a bucket of cold water maintained at 1°C up to the wrist level. At the end of the first minute (CPT-1), systolic and diastolic blood pressure, heart rhythm, IJV diameter, peak velocity, and volumetric flow measurements were performed again. RESULTS Systolic and diastolic blood pressure values were significantly higher at CPT-1 compared to baseline values (P<0.001, P<0.001). Heart rate and peak velocity values also showed a significant increase at CPT-1 compared to baseline values (P<0.001, P=0.001). While diameter values showed a significant decrease compared to baseline, volumetric flow rate values showed a significant increase at CPT-1 (P=0.003, P<0.001). CONCLUSIONS Sympathetic nervous system activation triggered by CPT increases IJV volumetric flow and flow velocity in healthy young individuals, and sympathetic nervous system activation causes a venoconstrictive effect in the IJV.

Progressive Ulnar Neuropathy Following a Presumed Catfish Sting.

Catfish are a highly diverse group of fish comprising more than 3500 species found in both freshwater and marine ecosystems. Upon handling, they can inflict a sting, with certain species capable of inducing significant pain and injury to the affected extremity. The prevalence of aquatic activities, such as fishing by line or manual capture ("noodling"), increases the likelihood of catfish stings, making prompt identification and treatment an important aspect of managing such encounters. A case of a presumed catfish spine injury during noodling in Tallahassee, Florida, is presented. The pectoral fin penetrated the volar aspect of the patient's right hand resulting in immediate pain and numbness. Over the course of 2 weeks, the patient developed distal ulnar neuropathy with conduction block at the wrist level. Surgical exploration revealed the ulnar nerve to be grossly intact, but the area surrounding the terminal division point of the ulnar nerve in the hand displayed infiltration by fibrous tissue that entrapped the nerve and its branches. Following surgical release of the ulnar nerve and its terminal branches from the fibrous tissue, complete resolution of distal ulnar neuropathy was achieved. In this patient's case, the absence of foreign bodies and the lack of visible nerve damage suggest that the injury to the patient's hand was largely attributable to toxin-mediated proinflammatory response and fibrosis.

Dropping Objects in Carpal Tunnel Syndrome: Clinical and Electrophysiological Features.

Background Dysfunction in both afferent sensory and efferent motor components of the median nerve may contribute to the manifestation of the symptom of dropping objects (DO) in carpal tunnel syndrome (CTS). The objective of this study was to compare the clinical and electrophysiological characteristics of CTS patients with dropping objects (wDO) and those without dropping objects (w/oDO). The study evaluated the correlation between DO symptoms and median partial conduction block, as well as the reduction in median motor conduction velocity at the wrist. Methodology An examination for CTSand the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) were performed. Median and ulnar sensory and motor nerve conduction studies were conducted in both upper extremities, and the percentage decrease in the median compound motor action potential amplitude at the wrist level was calculated. Results The study included 201 female participants aged between 22 and 88 years, comprising 57 patients withCTSwDO, 78 patients with CTSw/oDO, and 66 healthy controls. In the CTSwDO group, compared to the CTSw/oDO group, BCTQscores were significantly higher, the prevalence of sensory deficits was more pronounced, and a larger number of hands, both dominant and non-dominant, were classified as stage 3 or higher in the clinical CTS classification. However, no correlation was found between the presence of DO symptoms and any neurophysiological findings. Conclusions DO may be a symptom of clinical severity in CTS, as previously reported.No neurophysiological parameter that could be associated with DO was identified.

Functional Restoration of Bilateral Wrist Level Hand Amputee with Six-Toe Transfers and Three Free Flaps: An Alternative to Hand Allotransplantation or Prosthesis

Abstract Introduction Hand amputation at the wrist level is severely disabling, especially when bilateral. It is paramount to restore the hand function to the best possible level for the patient's daily living activities, as well as optimal social and occupational rehabilitation. There are various options for restoration of function after amputation at wrist and distal forearm levels including Krukenberg's operation, variations of toe transfers, hand allotransplantation, and prosthesis. Krukenberg's procedure and the reconstruction using toe transfer like Vilkki's procedure or two-toe transfers, restore only the pinch. Hand allotransplantation, although it gives excellent function, has limitations due to the complications of immunosuppression. Functional hand prosthesis, though superior in cosmetic appearance, have again limitations in function, and the cost is prohibitive for most patients in our country. Materials and Methods We present the unique case of a bilateral hand amputation at the wrist level reconstructed with three toes and free anterolateral thigh (ALT) flap in a single-stage surgery for each hand. In two stages, the patient had six toes transferred to both hands. Result All transferred toes and all three free (two ALT and one thoracodorsal artery perforator) flaps survived completely. Three-finger grip (tripod pinch) was thus restored in each hand. The hook grip was also restored well by the reconstructed two fingers. Within 3 months after surgery, the patient could perform all activities of daily living. He resumed his original job with some modification of his work within 6 months postinjury. Conclusion Hand reconstruction using three toes and a free flap is an excellent option for functional restoration for amputation at the wrist and distal forearm level. It allows an early return to function and good social and professional integration of the patient. This procedure is a potential alternative to expensive prosthesis and allotransplantation for a bilateral hand amputation.

Supercharged end-to-side anterior interosseous nerve transfer to restore intrinsic function in high ulnar nerve injury: a prospective cohort study

BackgroundHigh ulnar nerve injuries is known to have unfavorable motor outcomes compared to other peripheral nerve injuries in the upper extremity. Functional muscle recovery after peripheral nerve injury depends on the time to motor end plate reinnervation and the number of motor axons that successfully reach the target muscle. The purpose of this study is to assess the functional recovery, and complications following performing supercharge end-to-side (SETS) anastomosis for proximal ulnar nerve injuries. Our study focuses on the role of SETS in the recovery process of high ulnar nerve injury.Patient and methodsThis study is a prospective, single-arm, open-label, case series. The original proximal nerve pathology was dealt with according to the cause of injury, then SETS was performed distally. The follow-up period was 18 months. We compared the neurological findings before and after the procedure. A new test was used to show the effect of SETS on recovery by performing a Lidocaine proximal ulnar nerve block test.ResultsRecovery of the motor function of the ulnar nerve was evident in 33 (86.8%) patients. The mean time to intrinsic muscle recovery was 6.85 months ± 1.3, only 11.14% of patients restored protective sensation to the palm and finger and 86.8% showed sensory level at the wrist level at the end of the follow-up period. Lidocaine block test was performed on 35 recovered patients and showed no change in intrinsic hand function in 31 patients.ConclusionSETS exhibit a remarkable role in the treatment of high ulnar nerve damage. SETS transfer can act as a nerve transfer that can supply intrinsic muscles by its fibers and allows for proximal nerve regeneration. We believe that this technique improves recovery of hand motor function and allows recovery of sensory fibers when combined with treating the proximal lesion.Trial registrationApproved by Research Ethics Committee of Faculty of Medicine- Cairo University on 01/09/2021 with code number: MD-215–2021.

Further characterisation of late somatosensory evoked potentials using electroencephalogram and magnetoencephalogram source imaging.

Beside the well-documented involvement of secondary somatosensory area, the cortical network underlying late somatosensory evoked potentials (P60/N60 and P100/N100) is still unknown. Electroencephalogram and magnetoencephalogram source imaging were performed to further investigate the origin of the brain cortical areas involved in late somatosensory evoked potentials, using sensory inputs of different strengths and by testing the correlation between cortical sources. Simultaneous high-density electroencephalograms and magnetoencephalograms were performed in 19 participants, and electrical stimulation was applied to the median nerve (wrist level) at intensity between 1.5 and 9 times the perceptual threshold. Source imaging was undertaken to map the stimulus-induced brain cortical activity according to each individual brain magnetic resonance imaging, during three windows of analysis covering early and late somatosensory evoked potentials. Results for P60/N60 and P100/N100 were compared with those for P20/N20 (early response). According to literature, maximal activity during P20/N20 was found in central sulcus contralateral to stimulation site. During P60/N60 and P100/N100, activity was observed in contralateral primary sensorimotor area, secondary somatosensory area (on both hemispheres) and premotor and multisensory associative cortices. Late responses exhibited similar characteristics but different from P20/N20, and no significant correlation was found between early and late generated activities. Specific clusters of cortical activities were activated with specific input/output relationships underlying early and late somatosensory evoked potentials. Cortical networks, partly common to and distinct from early somatosensory responses, contribute to late responses, all participating in the complex somatosensory brain processing.

Neglected very large ancient schwannoma of the distal wrist: a case report and literature review

Ancient schwannoma is a variant of schwannoma characterized by slow progression, degenerative changes, and a higher incidence in older adults. There have been two prior reported cases of ancient schwannoma arising from the distal ulnar nerve at the wrist level, but neither were longstanding or very large. Herein, we report an ancient schwannoma found in the ulnar nerve of the distal forearm that was found to be clinically meaningful in size. A 61-year-old man presented with complaints of tingling sensation of the fourth and fifth fingers and bulging of the ulnar side of the wrist. The patient reported that the mass in his wrist had grown very slowly, starting about 10 years ago, and that he had started experiencing a tingling sensation in his fourth and fifth fingers about 3 years prior, which had become worse in the past year. Based on the results of the preoperative examination, a benign nerve sheath tumor was suspected. As it was thought that the possibility of malignancy was not high, we elected to perform a marginal excision. Pathological examination confirmed ancient schwannoma. At his most recent visit, 3 years after surgery, he reported no recurrence and that he felt better than before surgery, but some tingling sensations remained. As with small ancient schwannoma in the distal wrist, most cases of large ancient schwannoma can be treated without special complications based on an accurate preoperative diagnosis.

Nerve Magnified Regeneration by Distal Nerve Transfer in High Ulnar Nerve Injury

The concept of nerve-magnified regeneration, part of which is end-to-side nerve transfer, provides a theoretical basis for the treatment of high ulnar nerve injuries. High injury to the ulnar nerve causes severe consequences, such as loss of sensation, loss of movement and “claw hand” deformity, affecting the fine motor skills of the hand. A method of nerve-magnified regeneration – distal nerve transfer – interosseous anterior (median nerve) to the deep ulnar nerve at the wrist level is presented, used in 20 patients (2 to 66 years of age) with an average follow-up period of 3 years (10 months to 5 years). This is a microsurgical method for rapid re-innervation of the most distal hand muscles in proximal neurotmesis of ulnar nerve.

Intraneural ganglion of the media nerve at the wrist level: a rare clinical case report

Extraneural ganglia are the most common lesions in the wrist and hand. In contrast, intraneural ganglia on the upper extremity, particularly the wrist and hand, are extremely rare. The paper presents a clinical case of successful treatment of a patient with intraneural ganglion of a rare anatomical location – the median nerve at the level of the wrist.

Effect of Laser Therapy, Neurodynamic Stabilization and Strengthening Exercises on Hand Function in Patients of Carpal Tunnel Syndrome with Rheumatoid Arthritis- A Narrative Review

Background: Carpal tunnel syndrome (CTS) is an entrapment neuropathy in which median nerve is compressed or squeezed at the wrist level in the carpal tunnel. Carpal tunnel syndrome is the most prevalent neurological complication in the rheumatoid arthritis patients. The prevalence of CTS in RA ranged from 3.5% to 22.8 %. Tenosynovitis, inflammation of the synovial tissue of the flexor tendons, can cause increased pressure in the carpal tunnel and result in CTS. Hand function is usually affected in carpel tunnel syndrome which affects the daily living performance by affecting both gross motor activities like grasping, carrying, holding and fine motor activities like writing, gripping and buttoning the shirts. Laser therapy, also called as photo biomodulation, can reduce pain, inflammation, swelling and synovitis. The dexterity and functionality of the hands improved through hand and wrist stretching and strengthening exercises.&#x0D; Objective: To find out the effect of laser therapy, neurodynamic mobilization exercises and strengthening exercises on hand function in patients of carpal tunnel syndrome with rheumatoid arthritis.&#x0D; Study selection: This narrative review is conducted on databases from Pubmed, Google scholar, scopus, web of knowledge, Virtual Health Library, Research Gate and Cochrane library in Nov 2023.

Exploration of sensations evoked during electrical stimulation of the median nerve at the wrist level

Objective. Nerve rehabilitation following nerve injury or surgery at the wrist level is a lengthy process during which not only peripheral nerves regrow towards receptors and muscles, but also the brain undergoes plastic changes. As a result, at the time when nerves reach their targets, the brain might have already allocated some of the areas within the somatosensory cortex that originally processed hand signals to some other regions of the body. The aim of this study is to show that it is possible to evoke a variety of somatotopic sensations related to the hand while stimulating proximally to the injury, therefore, providing the brain with the relevant inputs from the hand regions affected by the nerve damage. Approach. This study included electrical stimulation of 28 able-bodied participants where an electrode that acted as a cathode was placed above the Median nerve at the wrist level. The parameters of electrical stimulation, amplitude, frequency, and pulse shape, were modulated within predefined ranges to evaluate their influence on the evoked sensations. Main results. Using this methodology, the participants reported a wide variety of somatotopic sensations from the hand regions distal to the stimulation electrode. Significance. Furthermore, to propose an accelerated stimulation tuning procedure that could be implemented in a clinical protocol and/or standalone device for providing meaningful sensations to the somatosensory cortex during nerve regeneration, we trained machine-learning techniques using the gathered data to predict the location/area, naturalness, and sensation type of the evoked sensations following different stimulation patterns.

Median and Ulnar Nerve Repair Using Sural Nerve Graft: A Case Report

Abstract: Most peripheral nerve injuries (PNI) are caused by trauma. Upper extrimities are most likely to get injured, and the radial nerve is the most common part in upper extrimites to be affected. There are different surgical options available to repair PNI. We reported a 48-years-old male consulted to the Neurosurgery Department for right upper limb weakness and numbness. He had history of laceration due to iron sheeting in the right arm. There was an irregular scar, weakness on right lower arm with hypesthesia, but no neurovascular distal (NVD) abnormalities were found. Further examination showed claw hand. EMG examination revealed total lesion of the right median and ulnar nerve, partial lesion of the right radial nerve with the lesion at wrist level, possibly neurotmesis according to Seddon Classification. Initial debridement, suturing, and repairing of radial artery and flexor carpi ulnar tendon were performed. The patient was then diagnosed as total lesion of the right median and ulnar nerve, partial lesion of the right radial nerve, post repair right ulnar and radial artery and flexor carpi ulnar tendon repair with the planning of nerve graft with no complication under monitoring. The patient was scheduled for sural nerve graft procedure. Early nerve repair or reconstruction is needed even though it only results in incomplete recovery for months to years. The sural nerve is great either in diameter or length which can be a huge source for the grafting of nerve and revealed good outcomes. Recent study showed incomplete recovery especially seen when the patient could not fully clench his hand and his thumb did not move properly during the movement. In conclusion, sural nerve graft is an appropriate choice for peripheral nerve injuries with more benefits included. Prognosis depends on how early the treatment performed and how severe the lesion is. Keywords: median nerve; sural nerve; peripheral nerve injury; nerve repair; nerve grafting

Outcomes of radiocarpal pinning to facilitate nerve repair in wrist level ulnar nerve injuries with defect.

The ideal scenario for ulnar nerve repair is primary end-to-end neurorrhaphy in a tension-free environment. However, this could be complicated by soft tissue loss, scarring and neuroma formation in a delayed injury, creating a nerve defect. With a wrist level nerve defect, a flexion position can help shorten the nerve gap. However, maintaining the position can be challenging intraoperatively and postoperatively. We proposed our method previously of using a 1.6mm K wire for radio-lunate-capitate pinning of the wrist in flexion to minimize the nerve gap, thereby facilitating neuroma excision and end-to-end neurorrhaphy in delayed ulnar nerve injury. In this study, we elaborate our method and present our case series. From October 2018 to July 2020, 5 patients (mean age: 48.2 years; mean delay from injury to surgery: 84.6 days; mean follow-up: 17.5 months) were retrospectively reviewed. The mean flexion fixation angle was 52 degrees and the K wire was removed at an average of 5.1 weeks postoperatively. All patients were followed-up for a minimum of 12 months. All patients achieved M4 and S3 or S3+ neurologically (according to the criteria of the Nerve Injuries Committee of the British Medical Research Council). The mean Disabilities Arm Hand and Shoulder score was 14.1. The mean grasp and pinch strengths were, respectively, 76.8% and 63.6% of the contralateral hand. All wrist range-of-motion returned to normal within 12 weeks. No complications were noted intraoperatively or postoperatively. Our study showed that radiocarpal pinning of the wrist in flexion was safe and convenient to minimize the nerve gap and to facilitate end-to-end neurorrhaphy in limited-sized wrist-level ulnar nerve defects.

Diabetic neuropathy results in vasomotor dysfunction of medium sized peripheral arteries.

The effect of the sympathetic nervous system on peripheral arteries causes vasoconstriction when smooth muscle cells in the walls of blood vessels contract, which leads to narrowing of arteries and reduction of the blood flow. To compare sympathetic vasomotor activation of the brachial arteries in healthy subjects and patients with painful diabetic neuropathy; and therefore, to assess whether there is significant vasomotor dysfunction of medium sized arteries in diabetic neuropathy. The study included 41 diabetic neuropathy patients and 41 healthy controls. Baseline diameter and flow rate of the brachial arteries were measured. Then, using a bipolar stimulus electrode, a 10 mA, 1 Hz electrical stimulus was administered to the median nerve at the wrist level for 5 s. The brachial artery diameter and blood flow rate were re-measured after stimulation. In the control group, the median flow rate was 70.0 mL/min prior to stimulation and 35.0 mL/min after stimulation, with a statistically significant decrease (P < 0.001), which is consistent with sympathetic nervous system functioning (vasoconstriction). In the diabetic neuropathy group, median flow rate before the stimulation was 35.0 mL/min. After stimulation, the median flow rate was 77.0 mL/min; thus, no significant decrease in the flow rate was detected. In the control group, the median brachial artery diameter, which was 3.6 mm prior to stimulation, decreased to 3.4 mm after stimulation, and this decrease was also statistically significant (P = 0.046). In the diabetic neuropathy group, the median brachial artery diameter increased from 3.4 mm to 3.6 mm following nerve stimulation. Once again, no narrowing was observed. Our research suggests that diabetic neuropathy results in significant vasomotor dysfunction of medium sized peripheral arteries. Physiological vasoconstriction in response to sympathetic activation is impaired in diabetic neuropathy.

Can the change of vasomotor activity in irritable bowel syndrome patients be detected via color Doppler ultrasound?

Irritable bowel syndrome (IBS) is one of the most frequently referred conditions to the gastrointestinal outpatient clinic. The pathophysiology of IBS has not been determined with certainty. Visceral hypersensitivity is indicated as one of the pathophysiologies. The sympathetic nervous system is primarily in charge of controlling the arteries, and its effect is vasospasm in the medium and large arteries, resulting in decreased blood flow. To demonstrate, using Doppler evaluation of the brachial artery, that sympathetic activity impairs vasomotor performance due to autonomic neuropathy, which we believe is associated with IBS. There were 58 participants in the study. The control group consisted of 29 healthy patients, while the remaining 29 patients had been diagnosed with IBS. Patients who met the Rome IV criteria and had IBS were included in the study. People with known polyneuropathy or non-IBS chronic conditions that can progress were excluded from the trial, as were those with essential hypertension, diabetes mellitus, cardiovascular disease, or peripheral arterial disease, and patients diagnosed with anxiety or depression. Those with moderate to severe carpal tunnel syndrome or a median nerve lesion due to trauma were also excluded from the trial. A Doppler probe was used to measure the baseline diameter and flow rates of the brachial artery from 2 cm superior to the antecubital fossa. The Doppler probe remained stationary throughout the experiment, allowing for continuous measurements. Then, to activate the sympathetic fibers, an electrical stimulus for 5 s with an intensity of 10 mA and a frequency of 1 Hz was applied to the median nerve at the wrist level via the bipolar stimulus electrode. The artery diameter and flow rates were measured again immediately following the fifth stimulus. In healthy persons with no history of chronic illness, there was a statistically significant decrease in flow rate after stimulation (P < 0.001). In addition, stimulation resulted in a statistically significant reduction in the diameter of the brachial artery (P < 0.001). Patients diagnosed with IBS had statistically significant vasodilation and an increase in flow rate. Sympathetic stimulation causes a reduction in vascular diameter and blood flow, whereas it has the reverse effect on IBS patients. In investigating the involvement of autonomic neuropathy in the development of IBS, significant changes in brachial artery Doppler parameters were observed before and after stimulation of the median nerve with low-current sensory stimulation. This method is thought to be more user-friendly and comfortable than other methods described in the literature.

Arteriovenous fistula, pulmonary hypertension, and tricuspid dysfunction in renal transplant recipients. A possible solution

Introduction: Cardiovascular dysfunction is the first cause of death in patients with chronic kidney disease. Methods: Observational, longitudinal and prospective study, which included 58 patients with functioning renal transplant who were studied different echocardiographic variables, before and six months after the closure of the arteriovenous fistula. Results: The average age was 46.62 years and the most frequent was male 30 (51.72%). The flow of angioaccesses at the wrist level was demonstrated in 28 patients (45.9%) with evidence of regression of mean pulmonary artery pressure from 25.56 to 19.58 mmHg (p=0.002), more connoted for those of intermediate flow; 14. Also, the area of tricuspid insufficiency was greater for that group; from 3.15 to 1.96 cm2 (p=0.001). The pattern of mild dysfunction was observed in 38 patients (62.3%) prior to closure. Subsequent to this 27; (51.9%), exhibited minimal valvular insufficiency and 9 individuals (14.9%) did not show any degree of valvular dysfunction. Conclusions: Closure of the arteriovenous fistula in patients with functioning renal transplantation contributed to decrease the risk of pulmonary hypertension and progression of tricuspid valve dysfunction.

EVALUATION OF THE EFFECT OF HAND DOMINANCE ON MEDIAN NERVE CROSS-SECTIONAL AREA AMONG HEALTHY ADULT SUBJECTS: A CROSS-SECTIONAL STUDY

Background:This study was designed considering the existing controversies on the normal range of median nerve cross-sectional area (MNCSA) and its association with hand dominance. Methods:In this cross-sectional descriptive study, the upper limbs of 100 healthy subjects (46 men and 54 women) were assessed bilaterally by sonography. MNCSA was measured at the level of the carpal tunnel inlet. Results:Calculated MNCSA values were 9.29 mm2 and 9.54 mm2 for the right and left sides, respectively. No significant difference was observed between the right and left hands. No significant correlation was observed between hand dominance and MNCSA in right-handed or left-handed subjects. Conclusion:Hand dominance does not significantly affect MNCSA at the wrist level, and thus does not affect the diagnosis of carpal tunnel syndrome.

Dynamic Ultrasound Examination for Extensor Pollicis Longus Tendon Rupture after Palpation-Guided Corticosteroid Injection.

This report aimed to present a case of wrist-tendon rupture and to discuss a rare complication after corticosteroid injection. A 67-year-old woman had difficulty extending her left-thumb interphalangeal joint several weeks after a palpation-guided local corticosteroid injection. Passive motions remained intact without sensory abnormalities. Ultrasound examination showed hyperechoic tissues at the site of the extensor pollicis longus (EPL) tendon at the wrist level and an atrophic EPL muscle stump at the forearm level. Dynamic imaging demonstrated no motion in the EPL muscle during passive thumb flexion/extension. The diagnosis of complete EPL rupture, possibly due to inadvertent intratendinous corticosteroid injection, was therefore confirmed.

8. Learning Curve of Wrist Level Tendon Repairs using a Novel Tendon Stapler Device vs. Traditional Suture Methods

Background: Tendon repairs in spaghetti wrists, wrist level replantation, or vascularized composite hand allotransplantations are time-consuming. Experience and skill greatly influence overall time in the operating room. A novel tendon stapler device (TSD) has the potential to mitigate these discrepancies among surgeons of varying levels of experience by enhancing the speed and consistency of primary tendon repairs. Methods: Participants of varying levels of surgical experience (novice, intermediate, expert) performed tendon repairs via suture method or TSD. Comparisons were performed on wrist level flexors and extensors from human cadaver arms. Suture repairs were performed using 3.0 braided polyester modified Kessler with horizontal mattress for a 4-strand repair. On matched, contralateral donor arms, TSD repairs were completed with a single simple 5.0 polypropylene stitch to approximate the tendon ends prior to device deployment. All repairs were timed by a non-participating data recorder. Learning curves were compared across repair types and surgeons with scatterplots fitted with Loess curves. Statistical analyses utilized one-way ANOVA, Tukey pairwise comparisons, two-sided independent samples t-test, and Fisher’s exact test. Results: A total of 228 tendon repairs from 12 donor arms were analyzed. Mean suture repair times were 3.25, 4.08, and 4.46 minutes for expert, intermediate, and novice, respectively with the expert being faster than the other two groups (p≤0.001). Mean TSD repair times were 1.32, 1.31, 1.28 minutes for expert, intermediate, and novice respectively, with no difference between groups. TSD repairs were significantly faster than suture repair (p<0.01). Suture repairs decreased to stable or “learned” level around repair #30, and then demonstrated small increases at the end of the session, suggesting user fatigue. TSD repairs showed faster, less variable time that stabilized around repair #23, consistent with a more efficient learning curve. Educational time required for both novice and intermediate groups to achieve competency was higher for the suture technique (106 and 54 minutes) than for the TSD (60 and 38 minutes). Conclusion: The TSD demonstrates tremendous potential for complex multi-tendon traumas by drastically reducing the learning curve, operative and warm ischemia times, overall cost, and surgeon variability based on experience and repair strength.

Anatomical and Histomorphometric Study of the Ulnar Nerve at the Wrist

The ulnar nerve (UN) is the main nerve responsible for innervation of the intrinsic musculature of the hand. It is of great importance to have a deep anatomical knowledge of the UN. The aim of this study is to enrich the knowledge of the UN anatomy at the wrist and provide useful reference information for clinical and surgical applications. In this descriptive cross-sectional study, 44 upper limbs of fresh cadavers were evaluated. The UN, the superficial branch of the ulnar nerve (SBUN), and the deep branch of the ulnar nerve (DBUN) were evaluated. Morphometric variables were measured using a digital caliper, and samples of nervous tissue were taken to evaluate the histomorphometry. Before entering the Guyon's canal, the UN had a diameter of 3.2 ± 0.4 mm. In 36 samples (82 %) the UN presented a bifurcation pattern and in the remaining 8 samples (18 %) a trifurcation was shown. The diameter of the DBUN was 1.9 ± 0.33 mm and that of the SBUN was 1.29 ± 0.22 mm. In the bifurcation patterns, the SBUN had a trunk of 5.71 ± 1.53 mm before bifurcating into the common digital nerve (fourth and fifth fingers) and an ulnar digital collateral nerve (fifth finger). The DBUN had an area of 2.84 ± 0.7 mm2 and was made up of 8 ± 1.4 fascicles and 3595 ± 465 axons. The SBUN area was 1.31 ± 0.27 mm2, it was made up of 6 ± 1.1 fascicles and 2856 ± 362 axons. The reported findings allow the hand surgeon to improve his understanding of the clinical signs of patients with UN pathologies at the wrist level and thus achieve greater precision while planning and performing surgical approaches and dissections.