645
Short report letters Voche P, Quattara D. End-to-side neurorrhaphy for defects of palmar sensory digital nerves. Br J Plast Surg. 2005, 58: 239–44.
Ireneusz Walaszek and Andrzej Żyluk
Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland Email: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413518881 available online at http://jhs.sagepub.com
Median nerve neuropathy associated with cubital heterotopic ossification Dear Sir, A 13-year-old boy fell from a basketball hoop in a school playground and injured his left arm. Fractures of the left radial neck and distal radius were seen on radiographs. Through a lateral incision the radial neck fracture was fixed with a mini-screw. A rupture of the lateral collateral ligament of the elbow was found at operation and repaired using an anchor suture (Mitek®, DePuy Mitek, Raynham, MA, USA). Reduction of the distal radial fracture was maintained by two Kirschner wires, which were removed 5 weeks after surgery. Thirteen weeks after the operation, he complained of pain in the cubital area and heterotopic ossification was found on plain radiographs. The heterotopic ossification enlarged and matured over time (Figure 1). The range of motion of the left elbow was preserved, but he developed a neuropathy affecting the median nerve distribution to the hand, and there was a positive Tinel sign in the left cubital area. Surgical exploration was carried out through a curvilinear incision in the cubital area. There was fibrosis in the distal part of the brachialis muscle over the trochlea. The heterotopic ossification protruded out about 5 mm from the scarred area and was located just posteromedial to the median nerve. The nerve, which ran over the scarred muscle, was adherent to the protruding heterotopic ossification and slightly displaced anterolaterally (Figure 2). The protruding bone and adjacent scar tissue were excised and a neurolysis of the median nerve was done. The patient remains symptom-free, without recurrence, after 5-years follow-up. Although heterotopic ossification is a common complication of elbow injuries, it rarely causes compressive neuropathy. Specifically, we have not found any previous reports of median nerve neuropathy
Figure 1. A plain radiograph showing cubital heterotopic ossification distant from the elbow joint.
Figure 2. The heterotopic ossification was observed just posteromedial to the median nerve over the trochlea. Inset: explanatory diagram.
with heterotopic ossification around the elbow. Ulnar nerve neuropathy, with heterotopic ossification in the cubital tunnel, has been reported after head injury (Fikry et al., 2004). Some cases of median nerve neuropathy with heterotopic ossification in the carpal tunnel have also been reported (Yuen and Thomson, 2011). The present case of median nerve neuropathy is somewhat different as the heterotopic ossification occurred outside the capsule or ligaments. A partial tear of the brachialis over the elbow joint could have triggered heterotopic ossification, leading to the median nerve neuropathy in the cubital area. Conflict of interests None declared.
Downloaded from jhs.sagepub.com at Stockholm University Library on November 15, 2015
646
The Journal of Hand Surgery (Eur) 40(6)
References Fikry T, Saidi H, Madhar M, Latifi M, Essadki B. Cubital tunnel syndrome and heterotopic ossification. Eight case reports. Chir Main. 2004, 23: 109–13. Yuen A, Thomson S. Carpal tunnel syndrome caused by heterotopic ossification. J Hand Surg Eur. 2011, 36: 425–6.
K. J. Han, J. H. Lee and H. D. Lee Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Korea Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413519936 available online at http://jhs.sagepub.com
Surgical treatment of spontaneous posterior interosseous nerve palsy with hourglass-like constriction Dear Sir, Spontaneous posterior interosseous nerve (PIN) palsy with hourglass-like fascicular constrictions is uncommon. When conservative treatment fails, surgery including interfascicular neurolysis (Ochi et al., 2011), resection of constriction and even repair by neurorrhaphy or autografting have been performed (Yongwei et al., 2003), but it is controversial (Nagano et al., 1996). We analysed 20 patients (11 male, nine female) retrospectively, with a mean age of 35 years (range 21– 60) treated from 2001–2011. There was a mean duration of symptoms of 4.6 months (range 3–13). All patients had complete palsy of their extensor pollicis longus (EPL), extensor digitorum communis (EDC) and extensor carpi ulnaris muscles without sensory disturbance. A total of 14 patients complained of pain. Pre-operative ultrasonagraphy and electromyography were undertaken for each patient. On electromyography there were only denervation potentials and no voluntary motor unit potentials in the completely paralysed muscles. We defined fascicle thinning of ≥75% on ultrasonography as severe constriction and 75%). Similarly, Ochi et al. found that eight of 25 patients with ≥75% constrictions had poor recovery after interfascicular neurolysis (Ochi et al., 2011). Poor results of interfascicular neurolysis have also been reported elsewhere (Umehara et al., 2003). The mechanism(s) leading to nerve constriction remained largely unknown. Our histology of the PIN constriction showed concentrations of small
Downloaded from jhs.sagepub.com at Stockholm University Library on November 15, 2015
Short report letters Voche P, Quattara D. End-to-side neurorrhaphy for defects of palmar sensory digital nerves. Br J Plast Surg. 2005, 58: 239–44.
Ireneusz Walaszek and Andrzej Żyluk
Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Szczecin, Poland Email: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413518881 available online at http://jhs.sagepub.com
Median nerve neuropathy associated with cubital heterotopic ossification Dear Sir, A 13-year-old boy fell from a basketball hoop in a school playground and injured his left arm. Fractures of the left radial neck and distal radius were seen on radiographs. Through a lateral incision the radial neck fracture was fixed with a mini-screw. A rupture of the lateral collateral ligament of the elbow was found at operation and repaired using an anchor suture (Mitek®, DePuy Mitek, Raynham, MA, USA). Reduction of the distal radial fracture was maintained by two Kirschner wires, which were removed 5 weeks after surgery. Thirteen weeks after the operation, he complained of pain in the cubital area and heterotopic ossification was found on plain radiographs. The heterotopic ossification enlarged and matured over time (Figure 1). The range of motion of the left elbow was preserved, but he developed a neuropathy affecting the median nerve distribution to the hand, and there was a positive Tinel sign in the left cubital area. Surgical exploration was carried out through a curvilinear incision in the cubital area. There was fibrosis in the distal part of the brachialis muscle over the trochlea. The heterotopic ossification protruded out about 5 mm from the scarred area and was located just posteromedial to the median nerve. The nerve, which ran over the scarred muscle, was adherent to the protruding heterotopic ossification and slightly displaced anterolaterally (Figure 2). The protruding bone and adjacent scar tissue were excised and a neurolysis of the median nerve was done. The patient remains symptom-free, without recurrence, after 5-years follow-up. Although heterotopic ossification is a common complication of elbow injuries, it rarely causes compressive neuropathy. Specifically, we have not found any previous reports of median nerve neuropathy
Figure 1. A plain radiograph showing cubital heterotopic ossification distant from the elbow joint.
Figure 2. The heterotopic ossification was observed just posteromedial to the median nerve over the trochlea. Inset: explanatory diagram.
with heterotopic ossification around the elbow. Ulnar nerve neuropathy, with heterotopic ossification in the cubital tunnel, has been reported after head injury (Fikry et al., 2004). Some cases of median nerve neuropathy with heterotopic ossification in the carpal tunnel have also been reported (Yuen and Thomson, 2011). The present case of median nerve neuropathy is somewhat different as the heterotopic ossification occurred outside the capsule or ligaments. A partial tear of the brachialis over the elbow joint could have triggered heterotopic ossification, leading to the median nerve neuropathy in the cubital area. Conflict of interests None declared.
Downloaded from jhs.sagepub.com at Stockholm University Library on November 15, 2015
646
The Journal of Hand Surgery (Eur) 40(6)
References Fikry T, Saidi H, Madhar M, Latifi M, Essadki B. Cubital tunnel syndrome and heterotopic ossification. Eight case reports. Chir Main. 2004, 23: 109–13. Yuen A, Thomson S. Carpal tunnel syndrome caused by heterotopic ossification. J Hand Surg Eur. 2011, 36: 425–6.
K. J. Han, J. H. Lee and H. D. Lee Department of Orthopaedic Surgery, Ajou University School of Medicine, Suwon, Korea Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193413519936 available online at http://jhs.sagepub.com
Surgical treatment of spontaneous posterior interosseous nerve palsy with hourglass-like constriction Dear Sir, Spontaneous posterior interosseous nerve (PIN) palsy with hourglass-like fascicular constrictions is uncommon. When conservative treatment fails, surgery including interfascicular neurolysis (Ochi et al., 2011), resection of constriction and even repair by neurorrhaphy or autografting have been performed (Yongwei et al., 2003), but it is controversial (Nagano et al., 1996). We analysed 20 patients (11 male, nine female) retrospectively, with a mean age of 35 years (range 21– 60) treated from 2001–2011. There was a mean duration of symptoms of 4.6 months (range 3–13). All patients had complete palsy of their extensor pollicis longus (EPL), extensor digitorum communis (EDC) and extensor carpi ulnaris muscles without sensory disturbance. A total of 14 patients complained of pain. Pre-operative ultrasonagraphy and electromyography were undertaken for each patient. On electromyography there were only denervation potentials and no voluntary motor unit potentials in the completely paralysed muscles. We defined fascicle thinning of ≥75% on ultrasonography as severe constriction and 75%). Similarly, Ochi et al. found that eight of 25 patients with ≥75% constrictions had poor recovery after interfascicular neurolysis (Ochi et al., 2011). Poor results of interfascicular neurolysis have also been reported elsewhere (Umehara et al., 2003). The mechanism(s) leading to nerve constriction remained largely unknown. Our histology of the PIN constriction showed concentrations of small
Downloaded from jhs.sagepub.com at Stockholm University Library on November 15, 2015
