In obstetrical brachial plexus paralysis, root avulsion of C5 and C6 with an inability to flex the elbow can be treated with success and no obvious morbidity by which nerve transfer?
10% of ulnar nerve to musculocutaneous. Upper brachial plexus avulsion injuries cause impairment of shoulder and elbow function which is very disabling for patients. Restoration of elbow flexion is the first goal to be achieved in order to restore arm function. In cases of nerve root rupture, the majority show successful results after repair, but in nerve root avulsions tendon and/or nerve transfers are the only option. Steindler flexorplasty is the most commonly used muscle transfer. Nerve transfers include spinal accessory nerve, intercostal nerves and contralateral C7 nerve root. Although not generally accepted, it seems that the overall results of nerve transfer are superior to tendon transfer. In 1994, Oberlin presented a new method for nerve transfer involving transfer of 10% of fascicles 1.
References: 1. Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg [Am] 1994; 19(2): 232-7.
In radial dysplasia:
Which is correct in relation to replantation of a digit?
Is generally not recommended for proximal Urbaniak Class III ring avulsion/amputation injuries. Urbaniak and colleagues classified ring avulsion injuries into Class I (circulation intact), II (compromised circulation requiring revascularisation; no fracture/dislocation) and III (total degloving; may be accompanied by fracture/dislocation); this has since been modified. Ring avulsions with digital amputation have a poor prognosis and are usually better managed by primary amputation, especially if proximal to the FDS tendon insertion. Surviving digital replants exist following 42 hours warm ischaemia and 94 hours cold ischaemia. Especially good outcomes can be achieved with amputations at the level of the DIP joint.
References: 1. Urbaniak JR, Evans JP, Bright DS. Microvascular management of ring avulsion injuries. J Hand Surg [Am] 1981; 6(1): 25-30.
In nerve transfer for brachial plexus injury:
The axillary nerve can be innervated by the nerves to triceps. The intercostal nerves are most commonly used to transfer to the musculocutaneous, thoracodorsal, serratus anterior, pectoral nerves or as donor axons for free muscle transfer. They are very rarely grafted to the median nerve. The phrenic nerve can be used for transfer, particularly if there is an accessory phrenic nerve. The phrenic nerve would not be used if there was a significant chest injury. Transfer of the spinal accessory nerve does not cause loss of function to the trapezius muscle. This is because it can be divided after it has innervated the upper fibres of the trapezius muscle and transferred up, usually to innervate the suprascapular nerve. The axillary nerve can be re-innervated by transferring the nerve to the long head of triceps, which can be sacrificed without undue donor morbidity. This is usually done in combination with an accessory to suprascapular nerve transfer for shoulder function. The contralateral C7 root transfer has been widely used in China and East Asia. This is usually performed in significant avulsion injuries of the contralateral limb. When performed it is usually performed in combination with a vascularised ulnar nerve graft. Complications may include sensory disturbances in the previously intact limb, usually in the index and thumb. Temporary motor deficit is sometimes found with respect to shoulder extension, elbow extension, forearm pronation and wrist extension but full functional recovery is usually documented within 6 months.
A 43-year-old woman has a pinpoint area of tenderness at the base of the nail of the left ring finger. The area is painful to touch and sensitive to cold. Physical examination of the finger shows a deformity of the nail plate. Which of the following is the most likely diagnosis?
Glomus tumour. While ganglion cysts and glomus tumours can both cause deformity of the nail plate, the presence of pain and cold sensitivity are highly specific for a glomus tumour. A glomus tumour arises from a glomus body, which functions to regulate peripheral blood flow in response to temperature change. Glomus tumours may involve the nailbed, sometimes causing ridging of the nail plate, and classically present with localised cold intolerance, pain and tenderness. Reproduction of the pain by placing the involved digit into ice-cold water for 1 minute is diagnostic.
References: 1. Shapiro PS, Seitz WH. Non-neoplastic tumors of the hand and upper extremity. Hand Clin 1995; 11(2): 133-60.
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