1/21. Severe, traumatic soft-tissue loss in the antecubital fossa and proximal forearm associated with radial and/or median nerve palsy: nerve recovery after coverage with a pedicled latissimus dorsi muscle flap.A total of 6 patients with complex, traumatic wounds of the antecubital fossa and proximal forearm were included in this study. All patients presented with radial and/or median nerve palsies in addition to their soft-tissue defect. Except for 1 patient with a 15-cm defect of the radial nerve, all other traumatized nerves appeared in-continuity at the time of surgery. However, the nerve injury was severe enough to induce wallerian degeneration (i.e., axonotmesis in traumatized nerves in-continuity). Three patients required brachial artery reconstruction with a reverse saphenous vein graft. Wound coverage was accomplished using a pedicled latissimus dorsi muscle flap, which was covered with a split-thickness skin graft. Successful reconstruction was obtained in all patients. Follow-up ranged from 2 to 6 years. The range of motion at the elbow and forearm was considered excellent in 5 patients and good in the remaining patient who had an intra-articular fracture. Motor recovery of traumatized nerves in-continuity was observed in all but 1 patient who had persistent partial anterior interosseous nerve palsy. The grip strength of the injured hand measured 70% to 85% of the contralateral uninjured hand. median nerve sensory recovery was excellent in all patients. The versatility of the pedicled latissimus dorsi muscle flap for coverage of these complex wounds with traumatized neurovascular bundles around the elbow is discussed.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
2/21. Surgical treatment of a long thoracic nerve palsy.A 17-year-old patient presented with a long thoracic nerve palsy following an idiopathic onset of weakness to the serratus anterior muscle. With no evidence of recovery 3.5 months following onset of serratus anterior weakness, the patient underwent a thoracodorsal to long thoracic nerve transfer to reinnervate the serratus anterior muscle. Follow-up examination 6.5 years following the nerve transfer revealed no scapular winging, full range of motion of the shoulder and no reported functional shoulder restriction. We conclude that a thoracodorsal to long thoracic nerve transfer results in good functional recovery of the serratus anterior muscle.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
3/21. Motor sensory dysfunction of upper limb due to conversion syndrome.Seven patients had functional paralysis that occurred in the dominant limb together with joint contracture and sensory disturbances associated with emotional problems. In five of these patients, the syndrome was preceded by trauma to the affected upper limb and in one patient by a myocardial infarction. The treatment consisted of persuasion, suggestion, general rhythmic exercises and emotional support given by the physiatrist (not a psychiatrist). In five of the subjects treated, the symptoms disappeared and the patients soon returned to work. In two patients the treatment did not succeed since no satisfactory rapport could be established between the patient and the physician.- - - - - - - - - - ranking = 2keywords = motion (Clic here for more details about this article) |
4/21. Surgical fixation of intra-articular fractures of the distal humerus in adults.We reviewed 15 adult patients with intra-articular fractures of the distal humerus treated over a period of 2 years. All patients underwent primary open reduction and internal fixation, which included 11 double plating procedures. The fractures were classified according to the AO/ASIF system. Patient outcome was assessed subjectively by scoring the patients' residual symptom of pain and their overall satisfaction of the treatment received. Objective assessment was performed using the Mayo elbow Performance Index (range of motion, assessment of functional status, pain and stability of the joint). At a mean follow-up of 12.3 months, 7 patients were rated as excellent; 6, as good; one, as fair; and one, as poor. These cases had an average arc of flexion of 109.7 degrees. The sub-group of type C fractures without revision surgery had a mean flexion arc of 110.7 degrees (95-140 degrees ), with 100% Good to Excellent scores. Complications included two post-operative ulnar nerve neuropraxia, one wound infection, and one fracture fibrous non-union. Three patients required revision surgery which included a total elbow arthroplasty for implant failure, whilst four patients (including the patient with the subsequent arthroplasty) required joint mobilisation procedures for residual stiffness.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
5/21. Technical considerations in pectoralis major transfer for treatment of the paralytic elbow.Modification of pectoralis major transfer as originally described by Clark in 1946 have not addressed concerns such as diminished strength and excursion of the transfer, along with obligatory supination of the forearm. Postoperative scarring from the long oblique chest incision further compounds the psychological impairment that accompanies brachial plexopathy. One hundred forty-three brachial plexopathies were seen over a five-year period. Seven pectoralis major transfers were done to restore elbow flexion in patients with C5-6 and C5-6-7 cord injuries. Mean age and follow-up were 26 years and 25 months respectively. The modifications of this transfer we use improve strength and range of motion by preserving dual innervation of the muscle, by tubularization of the transfer, and by restoration of the transverse aponeurosis as a fascial pulley. By transfer of the pectoralis insertion to the acromion, further anterior shoulder stability may be obtained. Aesthetics can also be improved by use of selected midline and deltopectoral incisions, along with preservation of the remaining pectoralis major and minor.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
6/21. Spinal accessory nerve palsy: an unusual complication of coronary artery bypass.The neurologic complications of coronary artery bypass surgery have been well documented, with a reported incidence of 61% in one large study. Most injuries to the peripheral nervous system involve the brachial plexus. We report the first case of a spinal accessory nerve lesion after coronary bypass surgery. The patient presented with progressive right shoulder weakness. Electrodiagnostic studies revealed a partial lesion of the right spinal accessory nerve. Physical therapy, including strengthening, range of motion, and electric stimulation to the right shoulder, was prescribed to assist recovery of strength and function. Repeat electrodiagnostic studies confirmed nerve regeneration. Prompt recognition of spinal accessory nerve damage after coronary bypass surgery is essential. Early rehabilitation will improve the chances of a better functional outcome.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
7/21. Is the syndrome of pathological laughing and crying a manifestation of pseudobulbar palsy?A case of angiographically occult brainstem vascular malformation presenting solely with pathological laughing and crying is reported. Although this emotional syndrome has been seen in association with several different pathological entities, review of the literature failed to identify its occurrence as the only clinical expression of angiographically occult brainstem vascular malformation, or as a solitary symptom in any disease. Our data suggest that pathological laughing and crying can occur without any other manifestation of pseudobulbar palsy. An attempt is made to correlate this patient's clinical and radiological findings. This case was treated by stereotactic Bragg-peak proton beam therapy.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
8/21. Apparent weakness of median and ulnar motors in radial nerve palsy.Muscle testing of a patient with radial nerve palsy can incorrectly suggest median and ulnar weakness because of a decreased ability to stabilize the thumb and wrist. Ten adult volunteers had radial nerve blocks and their strengths were quantitatively evaluated before and after blocking for grip, key pinch, isolated thumb adduction (adduction pinch), thumb palmar abduction, finger flexion, and flexor pollicis longus (FPL) function. Data were analyzed by paired t test (p less than 0.05). All composite motions that required stabilization of the wrist or thumb showed marked weakness after the radial nerve block (grip decreased 77%, key pinch decreased 33%, and thumb palmar abduction strength decreased 53%). The strength of adduction pinch, finger flexion, and FPL showed no significant decreases after the radial nerve block. Since adduction pinch and isolated FPL function can be easily tested clinically, they should be examined to prevent confusion with median and ulnar problems.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
9/21. Trapezius transfer for paralysis of the deltoid.A case of selective paralysis of shoulder muscles with its reconstructive procedure, is presented. The deltoid, infra- and supraspinatus paralysed, leaving one of the steering group of muscles around the shoulder--the subscapularis--intact, made the transfer of the trapezius to deltoid feasible, utilizing a modification of Saha's technique. An excellent result with full range of motion of the paralysed shoulder has been achieved.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
10/21. Serratus anterior paralysis in the young athlete.Ten cases of isolated, complete paralysis of the serratus anterior muscle were diagnosed in young athletes during a three-year period. One patient had recurrent partial paralysis of the serratus anterior muscle, the first such case reported. From studies on cadavera and clinical observations, we concluded that paralysis of the serratus anterior muscle results from a traction injury to the long thoracic nerve of Bell. Since full recovery usually occurs in an average of nine months, surgical methods of treatment should be reserved for patients in whom function fails to return after a two-year period. Non-strenuous use of the involved extremity with avoidance of the precipitating activity, followed by exercises designed to maintain the range of motion of the shoulder and to increase the strength of associated muscles, is advocated for treatment of acute or repetitive injuries to the long thoracic nerve of Bell.- - - - - - - - - - ranking = 1keywords = motion (Clic here for more details about this article) |
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