Jean-Bart Jaquet

Median and ulnar nerve injuries: A meta-analysis of predictors of motor and sensory recovery after modern microsurgical nerve repair

Background: The aim of this study was to quantify variables that influence outcome after median and ulnar nerve transection injuries. The authors present a meta-analysis based on individual patient data on motor and sensory recovery after microsurgical nerve repair. Methods: From 130 studies found after literature review, 23 articles were ultimately included, giving individual data for 623 median or ulnar nerve injuries. The variables age, sex, nerve, site of injury, type of repair, use of grafts, delay between injury and repair, follow-up period, and outcome were extracted. Satisfactory motor recovery was defined as British Medical Research Council motor scale grade 4 and 5, and satisfactory sensory recovery was defined as British Medical Research Council grade 3+ and 4. For motor and sensory recovery, complete data were available for 281 and 380 nerve injuries, respectively. Results: Motor and sensory recovery were significantly associated (Spearman r = 0.62, p < 0.001). Multivariate logistic regression analysis showed that age (<16 years versus >40 years: odds ratio, 4.3; 95 percent confidence interval, 1.6 to 11.2), site (proximal versus distal: odds ratio, 0.46; 95 percent confidence interval, 0.20 to 1.10), and delay (per month: odds ratio, 0.94; 95 percent confidence interval, 0.90 to 0.98) were significant predictors of successful motor recovery. In ulnar nerve injuries, the chance of motor recovery was 71 percent lower than in median nerve injuries (odds ratio, 0.29; 95 percent confidence interval, 0.15 to 0.55). For sensory recovery, age (odds ratio, 27.0; 95 percent confidence interval, 9.4 to 77.6) and delay (per month: odds ratio, 0.92; 95 percent confidence interval, 0.87 to 0.98) were found to be significant predictors. Conclusions: In this individual patient data meta-analysis, age, site, injured nerve, and delay significantly influenced prognosis after microsurgical repair of median and ulnar nerve injuries.

Median, ulnar, and combined median-ulnar nerve injuries: functional outcome and return to productivity.

BACKGROUND Forearm and wrist injuries are a common cause of morbidity and are often associated with suboptimal recovery of hand function. This study describes and compares outcome after median, ulnar, or combined median-ulnar nerve injuries. METHODS Three hundred thirteen wrist and forearm nerve injuries operated on between 1980 and 1997 in a large university hospital were reviewed in relation to complications, return to work, and sensor and motor recovery. Of these 313 patients, 220 (age range, 5-73 years) met the inclusion criteria. RESULTS Motor recovery, progress of sensory reinnervation, and number of severed structures were related to the type of injury (p < 0.05). Multiple linear regression analysis revealed a relation between the appearance of sensory reinnervation and motor recovery (beta = 0.02; 95% confidence interval, 0.01-0.04; p = 0.01). A probability of 24% of work loss, after a mean follow-up of 17.7 months, was found. Poor sensory and motor recovery were associated with work disability (odds ratio [OR], 2.9; p = 0.002; and OR, 2.9; p = 0.007, respectively). No relationship was found between type of injury and return to work (p = 0.47). Level of injury (OR, 2.6; p = 0.01), type of work (OR, 3.1; p = 0.002), number of complications (p < 0.001), and hand-therapy (OR, 0.24; p = 0.001) were found to influence return to work. CONCLUSION It may be concluded that peripheral nerve injuries at the forearm level can result in substantial functional loss and have major social consequences. This study identified factors influencing return to work that can be used to optimize postoperative treatment strategy.

Early psychological stress after forearm nerve injuries: a predictor for long-term functional outcome and return to productivity.

Forearm and wrist injuries can result in a nonfunctional hand caused by loss of motor and sensory functions. Psychological stress is known to accompany traumatic hand injuries and may therefore affect functional outcome. The authors conducted a retrospective study of 107 patients diagnosed with a median, ulnar, or combined median-ulnar nerve injury (79% response rate) who completed a questionnaire package consisting of the Impact of Event Scale (IES); Disabilities of Arm, Shoulder, and Hand; and a questionnaire concerning return to work and time off work. In an outpatient setting, motor and sensory recovery were examined. Ninety-four percent of those studied experienced early psychological stress. Thirty-six percent of patients reported sufficient symptoms 1 month postoperatively to be classified as in need for psychological treatment (IES score > 30 points). Combined median-ulnar nerve injuries (mean, 35.0 ± 20.3 points [standard deviation]) were accompanied by a higher psychological stress compared with single nerve injuries (median injuries: mean, 24.2 ± 20.6 points; ulnar injuries: mean, 22.6 ± 19.5 points;p = 0.049 and p = 0.021 respectively). Multiple linear regression adjusting for age, gender, and severity of the trauma revealed an association between the IES score and the functional symptom score (&bgr; = 0.51; 95% confidence interval [CI], 0.35–0.65), mean time off work (&bgr; = 0.44; 95% CI, 0.25–0.75), and motor recovery (grip: &bgr; = 0.37; 95% CI, 0.09–0.65; tip-pinch: &bgr; = 0.46; 95% CI, 0.13–0.80). Patients with higher scores on the IES were found to be at increased risk for incapacity for work (odds ratio, 3.32; 95% CI, 1.60–6.91). Higher education was found to be a protecting variable for posttraumatic psychopathology (&bgr; = −0.23; 95% CI, −6.05–−0.246). This study demonstrated a high level of early posttraumatic psychological stress after forearm and wrist nerve injuries. These data provide evidence that functional outcome and work resumption are influenced negatively by early psychological stress, independent from severity of the somatic trauma. This indicates that outcome after upper extremity nerve injuries may be influenced positively by psychological intervention.

Long-term outcome of muscle strength in ulnar and median nerve injury: comparing manual muscle strength testing, grip and pinch strength dynamometers and a new intrinsic muscle strength dynamometer.

OBJECTIVE To compare the outcome of muscle strength with manual muscle strength testing grip and pinch strength measurements and a dynamometer which allows for measurements of the intrinsic muscles of the hand in isolation (the Rotterdam Intrinsic Hand Myometer, RIHM). METHODS Thirty-four patients more than 2 years after ulnar and/or median nerve injury. Muscle strength was evaluated using manual muscle strength testing (MMST), grip, pinch and intrinsic muscle strength measurements. RESULTS Manual muscle strength testing showed that most muscles recover to grade 3 or 4. Average grip strength recovery, as percentage of the uninjured hand, was 83%. Pinch strength recovery was 75%, 58% and 39% in patients with ulnar, median and combined nerve injuries, respectively. The RIHM measurements revealed a poor recovery of the ulnar nerve innervated muscles in particular (26-37%). No significant correlation (Pearson) was found between the measurements of the RIHM and grip strength. Pinch strength was significantly correlated with strength of the abduction of thumb and opposition of the thumb strength (r 0.55 and 0.72, p = 0.026, 0.002) as measured with the RIHM. CONCLUSION While manual muscle strength testing and grip strength measurements show a reasonable to good recovery, measurements of the intrinsic muscles by means of the RIHM showed poor recovery of intrinsic muscle strength after peripheral nerve injury. No correlation was found between the recovery of intrinsic muscle strength and grip strength measurements.

Application of infrared thermography for the analysis of rewarming in patients with cold intolerance

Cold intolerance is a serious long-term problem after injury to the ulnar and median nerves, and its pathophysiology is unclear. We investigated the use of infrared thermography for the analysis of thermoregulation after injury to peripheral nerves. Four patients with injuries to the ulnar nerve and four with injuries to the median nerve (4–12 years after injury) immersed their hands in water at 15°C for 5 minutes, after which infrared pictures were taken at intervals of 2–4 minutes. The areas supplied by the injured nerves could be identified easily in the patients with symptoms of cold intolerance. At baseline temperature distribution of the hand was symmetrical, but after testing the injured side warmed up much slower. We concluded that the infrared profile of the temperature of the hand after immersion in cold water is helpful to assess thermoregulation after injury to peripheral nerves.

Prognostic factors for outcome after median, ulnar, and combined median–ulnar nerve injuries: A prospective study

BACKGROUND A major problem in the surgical treatment of peripheral nerve injuries of the upper extremities is the unpredictable final outcome. More insight and understanding of the prognostic factors is necessary to improve functional outcome after repair of the peripheral nerves. The objective of this study was to identify prognostic factors for the functional recovery of peripheral nerve injury of the forearm and their independent contribution in the outcome in the first year after reconstruction. METHODS A multicentered prospective study in the Netherlands resulted in the inclusion of 61 patients with a median, ulnar, or combined median-ulnar nerve injury. The age, level of injury, type of nerve injury, number of damaged structures, number of damaged arteries, education, smoking, and posttraumatic stress were analyzed as prognostic factors for functional outcome after repair of the peripheral nerves. The outcome parameters were sensory recovery (Semmes-Weinstein monofilament test) and motor recovery (Medical Research Council (MRC) score, power grip, and pinch grip) and the ability to perform daily activities. RESULTS Gender, age, level of education, number of injured arteries and structures, damaged nerve, location of the injury, type of the nerve injury, and posttraumatic stress at 1 and 3 months after repair of the peripheral nerve injury were found to be predictors of functional recovery. CONCLUSIONS Our prospective analysis of prognostic factors shows several factors to be predictive for the functional recovery after peripheral nerve injuries of the median and/or ulnar nerve of the forearm. Sensibility of the hand, power grip, and DASH score (DASH, Disabilities of Arm, Shoulder and Hand) have proven to be the three best prognostic factors in this study. Of these prognostic factors, only posttraumatic stress can be influenced to optimize functional outcome.

Clinical Value of Electrodiagnostic Testing Following Repair of Peripheral Nerve Lesions: A Prospective Study

This study prospectively assessed the level of correlation between functional and electrophysiological recovery after median and ulnar nerve lacerations. Motor and sensory recovery were recorded clinically and electrophysiologically every 3 months in 24 patients with 29 complete median or ulnar nerve lacerations. The strength of agreement between the clinical motor score and the electrophysiological score was “fair”, but in 41% a discrepancy was identified (kappa factor 0.39). Regeneration was not detected earlier by electrophysiology than by a thoroughly performed clinical evaluation. This suggests that electrophysiologic testing is of value as an adjunct to clinical assessment for evaluating cases in which there is clinical doubt as to the progress of regeneration and secondary surgery is contemplated.