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Pronator syndrome may be caused by a persistent median artery that passes completely through the proximal median nerve and then gives origin to a vascular leash to the flexor muscles that compresses the nerve. A "double crush" compression of the median nerve caused by persistent median artery producing first a carpal tunnel syndrome and then a pronator syndrome is described.
A case of functional replacement for traumatic thenar muscle loss using an innervated pronator quadratus free flap is reported. The pronator quadratus matched the damaged thenar muscle in size and excursion and provided satisfactory thumb opposition in long-term follow-up.
Functional instability, i.e., recurrent sprains or a feeling of "giving way" of the ankle, is common after ankle sprains. These patients have been supposed to have peroneal muscle weakness based on manual methods for measuring muscle strength. We have confirmed this theory by an isokinetic method for testing pronator muscle strength. Pronator muscle weakness on the affected side was found among patients with unilateral functional instability of the ankle joint. Impaired postural control was demonstrated by stabilometry with the patient standing on either foot.
Twenty-three adult patients with Morton's neuroma of one foot were randomized to receive in-shoe orthoses made from a hard, compressed, felt material that would either pronate or supinate both feet. The response of the neuroma pain was measured using subjective visual analogue scales, an objective examination, and the MACTAR patient-specific measure of maximal function. The development of any other lower limb symptoms was also recorded. The pain associated with Morton's neuroma was not significantly altered by changing the position of the foot with the compressed felt orthosis. Forcibly pronating the foot did not produce a significant incidence of lower limb symptoms in the short term.
We have performed a form of lunate replacement arthroplasty, which included excision of the lunate and insertion of a vascularised radial bone flap wrapped in pronator quadratus, for stage IIIB or stage IV Kienböck's disease, in 41 patients who have been followed up for more than three years. All patients reported an improvement in their symptoms, and 20 of the 41 became free of pain after the operation. Extension and flexion of the wrist were increased by a mean of 9 degrees and 6 degrees , respectively (p < 0.05). The radioscaphoid angle and the carpal height ratio were not significantly changed and only minimal deterioration was observed due to degenerative change. The size, density or location of the inserted bone did not change with time. A vascularised radial bone flap wrapped in pronator quadratus can be a reliable treatment option for advanced Kienböck's disease, when the pedicled bone and muscle envelope acts as a stable spacer for the excised lunate.
A 29-year-old pregnant dentist developed acute right forearm pain and associated weakness in her hand. A diagnosis of pronator syndrome was made. A review of the anatomy, pathophysiology, and treatment of pronator syndrome is given. We present this case to alert dentists, both male and female, of an uncommon but definite occupational hazard.
A case of congenital radio-ulnar synostosis with functional disability due to fixation of the forearm in maximal pronation was operated on with a rotational osteotomy in the proximal third of the forearm. Within four days postoperatively a total paralysis of the median nerve gradually developed. The median nerve was therefore explored and found to be strongly compressed by the stretched pronator teres and the superficialis bridge which were sectioned. Full motor and sensory recovery gradually occurred.
Thirty-three cases of infantile spastic hemiplegia have been treated surgically for wrist deformity in flexion, pronation and ulnar deviation. The authors used Green's technique in most of the cases (transplantation of flexor carpi ulnaris to the extensores carpi) either in isolation or in association with lengthening of the pronator teres. The indications for surgery are given and the details of surgical technique and postoperative care are described. The complications are described and the factors affecting prognosis are analysed. Half of the cases had good or excellent results; five were failures.
Functional outcome after V-Y musculofascial lengthening of the flexor-pronator musculotendinous origin was assessed in conjunction with submuscular transposition of the ulnar nerve for cubital tunnel syndrome. We retrospectively evaluated 38 submuscular transpositions with V-Y lengthening in 35 patients. A functional score was calculated on a 100-point scale both preoperatively and at latest follow-up, and pain and numbness scores were assessed using visual analog scales. Mean length of follow-up was 4.9 years (range, 2.5-7.9 years). Mean functional score improved from 33.5 preoperatively to 62.7 at latest follow-up (P<.001), pain improved from 7.4 to 3.5 (P<.001), and numbness improved from 7.0 to 4.1 (P<.001). V-Y lengthening of the flexor-pronator origin is an effective alternative to musculofascial lengthening in combination with submuscular transposition for treatment of cubital tunnel syndrome.
The "pronation worm", a method of early functional active conservative treatment for sprained ankle, is presented. In our department 75 patients were treated with this method with great success. Recent lateral tears in the ankle were confirmed by stress X-ray examinations, and according to these the patients were divided into two groups: group 1, containing patients with opening of the joint gap to 10-14 degrees (one-ligament injuries); and group 2, containing those with opening to 15 degrees or more (more-ligament injuries). The patients were required to wear ankle boots with a "pronation worm" for 6 weeks though they could take them off to get bathed, clean the boots and at bedtime. They were also asked to perform muscle training exercises for the peroneus muscles three times a day. The clinical-radiological evaluation showed complete healing in 97.3% after 6 weeks and after 6 months, and the stress X-ray photographs confirmed that there was no pathological opening of the joint gap (this applies to all patients in group 1 and 46 in group 2). In two patients in group 2 (2.7%) the X-ray pictures revealed pathologic opening of the joint-gap, but these patients had no subjective symptoms. These preliminary results suggest that recent tears of the lateral ligament ankle should be treated with this early functional active conservative method, i.e. without a surgical operation.
Based on statistical analysis of 97 chronic low back patients, a pelvic list model has been proposed explaining the correlation between leg length discrepancies (LLD) and sciatica. This model suggests that asymmetrical pronation patterns (one pedal arch dropping more than the contralateral pedal arch) initiates a forward downward rotation within the sacroiliac joint. Entrapment of the sciatic nerve between the piriformis muscle and sacrospinous ligament occurs. Clinically, paresis is observed: numbness, weakness and eventually paralysis of the affected limb. Based on this work, the authors have comprised a classification dividing LLD into two main categories: functional and anatomical. Functional LLD have been subdivided into two types of lists: static and dynamic. Treatment based on a combination of chiropractic and podiatric therapy is presented with a 6-month follow-up. Analysis of the success in this tandem approach is very promising. Concurrently, a chondromalacia model is proposed explaining the pathomechanical events associated with oblique tracking patellar syndrome. The authors suggest that excessive pronation is the causative factor directing asynchronous rotation between the shank and femur. This forces the patella out of its normal tracking groove, which, in turn, generates erosion between the inferior margin of the patella and femoral epicondyles.
Six surgically verified cases of pronator teres syndrome are reported. The anatomy of the median nerve at the upper third of the forearm, the relationships between the nerve and the pronator teres muscle and the serial innervation of the muscles of the forearm supplied by the n. medians are described. Clinical and electrophysiological features are reported in detail and their contribution in diagnosing the lesion is discussed.
A supination contracture of the forearm is a severe handicap in paraplegics as well as in brachial plexus pareses, e.g. in operating wheelchairs, supporting the upper part of the body and other daily tasks. For restoration of the pronation of the forearm, Zancolli et al. have suggested transfer of the biceps tendon. Since 1976, we have carried out this operation on 16 patients. These cases involved plexus pareses due to birth trauma, high transverse lesions of the cord with paraplegia. In two patients, there was spastic hemiparesis. The results are presented and discussed. Full active pronation can only rarely be achieved, since this is not possible for biomechanical reasons. However, the function of the arm can be improved in all patients by this operation. In children, this procedure should be carried out at an early stage before buckling of the forearm bones has occurred.
The pronator syndrome is caused by a compression of the median nerve at the level of the elbow. In the case presented bizonal compression of the nerve was seen, first by the lacertus fibrosus, second by an isolated abnormal tendon of the brachialis muscle. The treatment, therefore, includes the early and extensive operative exploration of the nerve, the resection of all compressive structures and sometimes interfascicular neurolysis and transposition of the nerve anterior to the pronator teres, when the nerve is in a badly scarred bed.
The authors report the results of their management of 14 forearm pronator teres contractures resulting from cerebral palsy. In almost every case, treatment was started with orthopedic splints and physiotherapy followed by the Gosset-Scaglietti technique and, one year later, Stoffel surgery, as proposed by Bastos-Mora in order to denervate the hypertonic pronator teres, was performed. The results were good in 80% of cases, fair in 16% and poor in 4%.
Based upon the findings of dissections and of histological investigations, the m. pronator quadratus was found to be composed of 2 heads. In the majority of the cases an oblique superficial head entirely covered a deep head, whose fasciculi were oblique from the ulnar origin to the distal volar surface of the radius. The fibers of both heads were arranged obliquely to the axis of rotation. From this both heads by contraction will develop a rotatory and a shunt force, the shunt components acting antagonistically. The superficial head is the rotator for pronation, whereas the deep head is well located for maintenance of transverse forces at the distal radioulnar joint. Moreover, the two heads insert into the capsule of the articulatio radioulnaris distalis.
Extremely painful paresthesias and mild motor weakness of the hand were relieved by sectioning the deep head of the pronator teres muscle and the fibrous arch of the flexor digitorum superficialis, thereby freeing the median nerve and its anterior interosseous branch. The characteristic pinch deformity of the thumb and index fingers usually described in anterior interosseous-nerve syndrome was not present. A Tinel sign at the level of the pronator teres was present.
Within a period of 14 years in 27 cases operative correction of a traumatic lesion of the distal radioulnar joint has been performed at the University Clinic of Giessen. The follow-up of our results is to be confined to the last ten cases; all efforts to evaluate the outcome of 17 joints having been operated on previously unfortunately have proved to be unfeasible. Different types of corrective operative procedures have been accomplished. Improvement of wrist function, particularly of pronation and supination, was obtained in almost every case.