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A case of successful treatment of pronation contracture of the forearm due to iatrogenic scar formation in the distal membranous part of the interosseous membrane of the forearm is presented and the management of this problem is discussed.
Pain patterns of the myofascial trigger points (TrP) for most muscles of the forearm have been documented. However, there are no published reports on the referred pain patterns for the pronator quadratus (PQ) muscle. The purpose of this study was to determine the referred pain pattern of the TrP in the PQ. Thirty-five arms of 35 healthy adult volunteers with no history of neck pain, arm pain or paresthesia were studied. Following skin sterilization, a Teflon-coated syringe needle was inserted into the PQ of the non-dominant forearm under electromyographic guidance, and 0.3mL of 6% hypertonic saline was injected. Subjects drew in their pain areas on a pain diagram, and this drawing was transferred into the Pain Chart System for analysis. Two main pain patterns were observed. The most common pattern involved pain spreading both distally and proximally from the injection site, along the medial aspect of the forearm (57%). In half of these cases, the pain area extended to the medial epicondyle proximally and the fifth digit distally. The second main pattern revealed pain spreading distally to the third and/or fourth finger (29%). The pain patterns originating from the PQ resemble the C8-T1 dermatomes, and ulnar and median nerve sensory distributions. Thus, myofascial pain of the PQ should be considered as a possible cause of pain in the medial forearm and hand, especially when no other neurological abnormalities are present.
The authors describe a palmar abduction-pronation osteotomy of the first metacarpal bone combined with a tendon transfer for treatment of palsy of the lateral thenar muscles. The results of fourteen cases are reported.
Thumb dysplasia imposes a proportionately greater functional deficit than does dysplasia of any other digit. To simulate an opposable unit, the child with but four normal fingers naturally will turn to the next most radial (index) digit and by abducting and pronating will widen his first cleft. When the thumb is absent bilaterally, formal neurovascular pollicization of at least one index digit is the logical choice. The inherent deficiencies in formal pollicization, however, may detract from its use in certain instances, for example, unilateral thumb aplasia or thumb aplasia associated with radial club hand. A simpler procedure performed at age 3 or 4 years avoids many of these deficiencies while still creating a more functional pinch and grasp. Through a small web incision, the index metacarpal is separated from the adjacent metacarpal. The base of the index metacarpal is sectioned and shortened 1.5 cm. The digit is recessed, rotated and abducted radially and palmarly, then immobilized by a K-wire fixation to its base. Since 1960, 17 procedures have been performed with good functional results and acceptable appearance.
Traumatic injuries to the distal forearm present a challenging problem for soft tissue coverage. There is a need for a local flap to provide a vascularized soft tissue bed. This article demonstrates the anatomic basis that enables the pronator quadratus muscle potentially to fulfill these needs.
The tendency for the index finger to pronate after implant arthroplasty of the metacarpophalangeal joint is often a problem for the surgeon and hand therapist. The three splinting methods described correct this problem and yet allow the patient to participate in the full postoperative protocol during the early encapsulation phase. The method of choice, microfoam tape, moleskin, or Velcro, depends on the patient's ability to manage the material.
Ulnar head resection for treatment of painful traumatic and arthritic conditions of the distal radioulnar joint has been performed for over 100 years. Although this is a time-honored procedure, several negative sequelae of the operation have been described. Most of these problems have been due to the instability of the ulna remnant with respect to surrounding structures, including the radius and extensor tendons. This report describes an operative technique to prevent and treat this problem. The pronator quadratus origin is transferred to the dorsum of the ulna, placing the muscle belly between the radius and the ulna remnant. Theoretically, this may provide a soft tissue cushion to prevent ulnoradial impingement. We have been performing this operation since 1985 and report here the results on 16 wrists in 15 patients who underwent surgery between 1985 and 1989. Patients included in this study had pain in the distal radioulnar joint due to osteoarthritis, post-traumatic arthritis, or incongruity. No patients with rheumatoid or other autoimmune arthritis were included. The average follow-up period was 8 years, with a range of 5-9 years. Two groups of patients were studied, including seven who had failure of prior ulna head resection and eight who underwent this procedure (one on both wrists) concomitantly with ulnar head resection.
Diagnosis of tears of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb is often made by dynamic radiography. In contrary to the usual technic, the best position is forced pronation of the hand. The metacarpal and the first phalanx are horizontal on the X ray plate. The patient is encouraged to push the tip of his thumb against an object thus obtaining a forced abduction. The two hands can be held in place with a tight bandage. This yields a simultaneous and symmetrical image of the two thumbs on the same film.
The wrist plays an essential in role the transmission of pronosupination movements. The four main muscles responsible for these movements are situated above the radiocarpal joint. This anatomic configuration allows a passive movement: Radio Metacarpal Rotation or RMR which is analysed here. Radio Metacarpal Rotation varies according to grip and the couple which is applied distally. An apparatus has been designed to simultaneously measure the angle, the force of grip and the couple. Radio Metacarpal Rotation is firstly measured with the wrist relaxed (grip strength < 5 N) and a distally applied rotation couple of 0.2 N.m in the supination direction and 0.5 N.m in the pronation direction. Secondly, the patient is asked to maintain a grip strength between 80 N and 100 N, and a couple of 1 N.m is applied distally in each direction. One hundred wrists were evaluated. We have looked for the rotation centers of active pronosupination and Radio Metacarpal Rotation. A three dimensional motion analysis device was used (ELITE system). Thirty normal wrists were evaluated. An anatomic study of the radiocarpal ligaments stretched by Radio Metacarpal Rotation was carried out on ten cadaver wrists. When the wrist is relaxed: there is an average Radio Metacarpal Rotation of 42 degrees. This Radio Metacarpal Rotation is reduced when grip is tightened. We have defined a locking test based on these two parameters. This clinical test is represented by two curves on a graph. The active pronosupination center and the radio metacarpal center do not coincide. The center of active pronosupination is situated near the center of the ulnar head and the center of radio-metacarpal rotation is always more lateral. On the anatomical preparations, we found a helicoidal configuration of the radiocarpal ligaments: a ligamentous double helix pronosupination. Radio Metacarpal Rotation interferes with transmission of pronosupination movements. When the wrist is not well locked there is a large lateral sweeping between radius and scaphoid. This sliding at the level of the cartilage can head to development of osteoarthritis of the wrist with a horizontal scaphoid and the good cartilage results after proximal row carpectomy. Radio Metacarpal Rotation must be taken into account when a prothesis designing. We propose a wrist locking test. The results of this test are directly related to the capacity of the joint surfaces to transmit pronosupination movements. Radio Metacarpal Rotation shows the importance of the horizontal plane in the wrist and its essential role in the transmission of pronosupination movements.
The medical collateral ligament is a common site of injury in baseball pitchers, causing substantial morbidity and loss of pitching time. Twenty-six skilled baseball pitchers with medial collateral ligament insufficiency were studied before surgery with high-speed cinematography and fine-wire electromyography of eight muscles around the elbow. Data from the pitchers with injured elbows were compared with data obtained from uninjured pitchers. The flexor carpi radialis muscle in the pitchers with medial collateral ligament deficiencies revealed significantly decreased firing during the acceleration and deceleration phase of the fastball when compared with that of the pitchers with normal elbows, and the flexor carpi radialis muscle was significantly depressed during the early cocking and deceleration phases. The extensor muscles revealed slightly increased activity in the injured elbows; however, this was not statistically significant. Although the muscles of the flexor pronator group (especially the flexor carpi ulnaris muscle and the flexor digitorum superficialis muscles) are anatomically positioned to provide dynamic stability of the elbow, they did not demonstrate increased electrical activity in pitchers with medial collateral ligament deficiencies. This finding suggests that the muscles on the medial side of the elbow do not supplant the role of the medial collateral ligament during the fastball pitch.
Treatment of painful neuromas in continuity of the median nerve at the wrist level is a challenging problem. Nine median nerve neuromas were covered with the pronator quadratus muscle preelevated as an island flap. Patients were followed for 10 to 60 months after surgery. Results showed a marked improvement in terms of symptoms in all patients. In particular, 6 patients had complete pain relief and 3 patients complained of mild intermittent pain.
We have recently treated two patients with closed pronation-external rotation bimalleolar ankle fractures. During the surgical explorations, an avulsion type rupture of the posterior tibial tendon was observed. Open reduction and internal fixation of the fracture in conjunction with primary tendon repair has produced excellent clinical results. We wish to report these two cases of this uncommon injury. More important, we wish to point out the association of the tendon rupture in conjunction with a particular type of fracture pattern.
A pronator teres (PT) tendon transfer is used to treat patients with multiple pathologies, including radial nerve palsy, cerebral palsy, and tetraplegia. Identification of the tendon at time of surgery may involve a random search for its insertion site along the radius. Efficient location of the PT is essential to expedite the procedure and limit unnecessary tissue dissection. This paper describes a succinct method of identifying the tendon using a systematic and anatomic approach. The radial sensory nerve is identified at its exit point from beneath the brachioradialis (BR) muscle. The fascia surrounding the BR muscle and tendon is incised, and the radial artery is visualized. The radial sensory nerve is traced in a proximal direction under the BR muscle. The BR is retracted medially and the ECRL laterally. The PT tendon and insertion site are found just proximal to the emergence site of the radial sensory nerve from the BR. This method of identification of the PT insertion saves tourniquet time and avoids unnecessary dissection.
Full-thickness skin loss in the distal volar forearm presents a challenge to the burn surgeon. Two cases are presented in which a pronator quadratus muscle flap with split-thickness skin was used to cover the underlying tendons and nerves. The unique vascular perfusion makes this a useful and predictable transfer.
A case of pronator teres syndrome associated with mononeuritis multiplex in polyarteritis nodosa is reported. External neurolysis of the median nerve at the proximal forearm and prednisolone were effective for treatment of the disease.
The author has observed inward turning of the foot of 2 parkinsonian patients following thalamotomy on the contralateral side. In one instance, the surgery was unilateral and in the other bilateral. The anatomical position of the involved lesions was in the region of the complex of the ventrocaudal nuclei (ventralis posterolateralis). It appears that three elements are present whenever such pronation of the foot occurs, namely, paresis, hypertonicity, and impairment of sensory modalities such as localization, two-point discrimination and vibration.
Compartment syndrome is caused by an increase in intracompartmental pressure above the capillary level, preventing capillary flow. The acute onset of symptoms occurs after events such as fracture, soft tissue trauma, and revascularization and usually necessitates prompt fasciotomy to avoid loss of function or even necrosis of the enclosed muscle. Compartment syndromes in athletes are of a recurrent nature and are usually referred to as chronic. Nonoperative treatment is often successful. Although compartment syndromes can occur in several anatomic regions, the most commonly seen in athletes involve the leg. Chronic compartment syndromes of the upper extremity are rare, and only a few cases have been reported in the literature. The intracompartmental pressures causing chronic symptoms in these cases ranged between 22 mm Hg at rest and 40 mm Hg after 30 minutes of exercise. Under maximal contraction, a pressure of 58 mm Hg has been recorded. The object of this paper is to report a case of a tennis player where much higher flexor-pronator muscle intracompartmental pressures than those noted above were recorded. We compared the intracompartmental pressure data of this patient with intracompartmental pressures measured in six symptom-free volunteers.
We have considered the indications for and results of transplanting pronator teres to extensor carpi radialis brevis in cerebral palsy. The operation has some virtue but a very limited application. We achieved satisfactory functional results in six of nine patients and some improvement in one. Two operations failed because of poor selection. In all patients the appearance of the limb was improved.