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Nerve Disorders

Hand nerve disorders: CTS, cubital tunnel, traumatic PNI, and rare lesions like LFH – diagnosis and management strategies.

Overview

Nerve disorders encompass a spectrum of conditions requiring precise diagnostic and reconstructive strategies. Abnormal median sensory nerve conduction distinguishes a subset of patients who appear to benefit from carpal tunnel surgery [1]. For atraumatic nerve palsy, critical evaluation of outcomes is necessary to determine best practices for restoring function [19]. Significant advances in microsurgical techniques for nerve repair have led to improved results after peripheral nerve surgery and extended the types of nerve repair that can be accomplished [54]. The use of nerve transfers has resulted in a positive paradigm shift in patient outcomes and results obtainable for many peripheral nerve injuries [53].

Reconstructive decision-making involves weighing donor morbidity against functional gains. Selection of a donor nerve for heterotopic nerve transfers must weigh the risk of donor nerve impairment and the potential narrowing of future reconstructive options against other treatment alternatives [20]. Sensory nerve transfers are as effective if not better than standard nerve grafts for treating peripheral nerve injuries with gaps greater than 20 cm, and they eliminate morbidity from the donor defect [23]. Caution is advised when using conduits to repair large-diameter nerves due to reported failed clinical outcomes [24]. Results from a series on C5 root grafting to the musculocutaneous nerve using pedicled, vascularized ulnar nerve grafts do not support strong recommendations to use vascularized nerve grafts for large nerve defect reconstruction [49].

Specific indications and prognostic signals guide surgical planning. Intrinsic hand muscle reinnervation by median-ulnar end-to-side bridge nerve graft is mainly indicated in high peripheral nerve injury or secondary cases when recovery of intrinsic hand muscle is not expected after end-to-end repair or graft [27]. Nerve transfers appear reasonable to optimize recovery even 12 to 18 months after the onset of muscle weakness symptoms in cervical spondylotic amyotrophy, though greater patient numbers are required to confirm efficacy [21]. Most major peripheral nerve injuries after elbow arthroscopy show only partial or no functional recovery, necessitating patient counseling on this risk [56].

Anatomy & Pathophysiology

Vascular & Neural

Etiology of Median Neuropathy: Impaired median nerve function results from obesity, diabetes, use of hand-held vibratory tools, and repeated forceful movements of the wrist and hand [83]. Workers regularly exposed to hand-held vibrating tools exhibit significantly weaker extrinsic and intrinsic hand muscles than controls [105].

Biomechanical Stressors: Wrist deviation from neutral causes more pronounced deformation of the median nerve than finger flexion for both intensive and nonintensive electronic device users [80]. Ulnar nerve gliding is most severe during passive wrist movement in elbow flexion and forearm supination [106]. The magnitude of palmar displacement correlates with specific symptoms perceived by patients, which are the symptoms most often used for diagnostic purposes by clinicians during the history phase of the examination [103].

Diagnostic Evaluation: Kinematic and clinical measurements can objectively and quantitatively evaluate skilled hand function in individuals with chemotherapy-induced peripheral neuropathy [50]. A novel finger grip dynamometer system that measures each finger's grip strength simultaneously and records the time course of grip motion can quantify patient symptoms easily and objectively to contribute to the evaluation of hand function [63]. Power grip force measurements with a JAMAR dynamometer do not provide decisive information about motor function of the median nerves in the lower arm [96]. Results of motor tests, including total grip and key-pinch strength, are significantly influenced by whether the dominant or non-dominant hand is involved in carpal tunnel syndrome [102]. Intrinsic hand muscles have motor evoked potentials (MEPs) at consistent distances from bony landmarks both dorsally and volarly [87].

Surgical Reconstruction & Outcomes: Accurate diagnosis and management of hand and carpal fractures and dislocations are predicated on a thorough physical examination and appropriate imaging to limit joint stiffness while preserving mobility and function [70]. Fundamental muscle-tendon-joint mechanics studies allow for single-stage surgical reconstruction of hand function and early postoperative activity-based training in patients with cervical spinal cord injuries [81]. Even when range of wrist motion and strength of the wrist and fingers are less than normal, hand function remains good after triple tendon transfer of the flexor carpi ulnaris in radial nerve palsy [59]. Room remains for improved thumb motion with both nerve and tendon transfer procedures for radial nerve paralysis reconstruction [94]. Hand surgery principles emphasize the balance between restoring function and maintaining aesthetic appearance [101].

Pediatric & Congenital Considerations: Classification and understanding of congenital hand and upper extremity disorders has improved since the 1970s, with a primary focus on achieving optimal function through recognizing deformities, identifying surgical options, and managing patient expectations [89]. Dimensional discrepancies and functional outcomes are improved by scapula stabilization procedures in obstetric brachial plexus paralysis patients [90]. Ulnar nerve to musculocutaneous nerve transfer in an ulnar ray-deficient infant with brachial plexus birth palsy resulted in active elbow flexion to 90° at 18 months without motor deficits in the hand [99].

Peripheral Nerve Research: Peripheral nerve basic science research design and outcome measures are important for hand surgeons to understand for potential clinical translation [92]. No significant difference was seen in hand function between border and central finger injuries after digital nerve repair, except for lower grip strength in central finger injuries [107].

Classification

Electrodiagnostic and Ultrasonographic Severity: Abnormal median sensory nerve conduction distinguishes a subset of patients who appear to benefit from surgical treatment for carpal tunnel syndrome [1]. Median nerve ultrasonography measurements distinguish between normal and abnormal electrodiagnostic studies and correlate with the category of electrodiagnostic severity [32]. Neurodiagnostic studies are integral in diagnosing neurological disorders, and multiple types of studies must be performed to correctly diagnose patients [4].

Nerve Injury Location and Mechanism: The location and mechanism of nerve injury are the most important factors guiding management, requiring different treatment strategies depending on the specific location and type of nerve injury [15].

Suprascapular Nerve Topography: A classification of suprascapular triad topography and quantitative analysis of the space available for the path of the suprascapular nerve aids in understanding morphological conditions that may promote suprascapular nerve entrapment, especially those with a type III arrangement [42].

Bifid Median Nerve Abnormalities: A classification of associated abnormalities in bifid median nerve highlights clinical relevance, particularly the risk of missing the small ulnar division of the nerve when surrounded by vascular malformations [58].

Nerve Suture Timing: Nerves primarily sutured following trauma commonly seen in civilian life provide a definitely higher grade of motor reinnervation of the intrinsic muscles of the hand than do secondarily sutured nerves [69].

Donor Nerve Quality: A simple EMG classification that describes the quality of donor nerves can predict outcome as measured by postoperative motor strength and range of motion in nerve transfer procedures [88].

Ulnar Nerve Instability: A 4-category classification of intraoperative ulnar nerve instability is reproducible within and between reviewers [91].

Clinical Presentation

Nerve compression syndromes are a common cause of pain, sensory disturbance, and motor weakness [38]. Neurostenalgia is a neuropathic pain syndrome from a focal lesion of a peripheral nerve that is rewarding to treat [41]. Peripheral nerve injuries are common and debilitating, with available treatments remaining suboptimal [10], and can dramatically affect a patient's life [14].

History and Demographics: The demographics of patients with various upper extremity compressive neuropathies are not homogeneous, suggesting different etiologies [6]. Neuromuscular impairments in focal hand dystonia and upper extremity compression neuropathies are distinguishable through differences in patient history, clinical presentation, and physical examination findings [40].

Inspection and Palpation: Screening methods for central and peripheral nervous system disorders include identifying typical findings and determining recommendations for referral [2]. Symptomatic neural loops are a rare anatomic variation that presents as hemidigital anesthesia and is a diagnosis of exclusion [3].

Neurodiagnostic Studies: Neurodiagnostic studies are integral to diagnosing neurological disorders, requiring multiple types of studies for correct diagnosis [4]. Electrodiagnostic tests provide significantly more information than ultrasonography regarding the condition and function of the nerve in carpal tunnel syndrome [17]. Abnormal median sensory nerve conduction distinguishes a subset of patients with carpal tunnel syndrome who appear to benefit from surgical treatment [1]. Neuralgic amyotrophy is overdiagnosed based on clinical assessment alone, and EMG investigations are necessary in all suspected cases due to poor diagnostic accuracy of clinical evaluation [39].

Special Tests and Red-Flag Patterns: A diagnosis of ulnar nerve compression at the elbow merits a comprehensive workup and high suspicion for concomitant median nerve compression (carpal tunnel syndrome) [16]. The location and mechanism of nerve injury are the most important factors guiding management of suprascapular neuropathy, requiring different treatment strategies depending on the specific location and type of injury [15]. Management of peroneal nerve palsy varies based on etiology, with many patients benefiting from nonsurgical measures and surgical decompression considered for refractory cases [11]. Incorrect treatment or devastating early nerve surgery are the main causes of sequelae in obstetrical palsy, rather than the injury itself [5].

Investigations

Neurodiagnostic Studies: Neurodiagnostic studies are integral in diagnosing neurological disorders [4]. Multiple types of neurodiagnostic studies should be performed to correctly diagnose patients with neurological disorders [4].

Electrodiagnostic Testing: Electrodiagnostic tests provide significantly more information than ultrasonography regarding the condition and function of the nerve in carpal tunnel syndrome [17]. Median nerve ultrasonography measurements distinguish between normal and abnormal electrodiagnostic studies in carpal tunnel syndrome [32]. Median nerve ultrasonography measurements correlate with the category of electrodiagnostic severity in carpal tunnel syndrome [32]. Adequate clinical diagnosis through predominantly motor symptoms and electroneuromyography alterations allows for early decompression with good postoperative functional outcomes in isolated compression of the recurrent motor branch of the median nerve [67].

Magnetic Resonance Imaging (MRI): Magnetic resonance imaging is the study of choice for managing atraumatic posterior interosseous nerve palsy [29]. Preoperative diagnosis by MRI is important for posterior interosseous nerve palsy due to schwannoma to select the appropriate surgical approach [82]. MRI helps clinicians separate the nerve from the tumor and decrease the risk of postsurgical complications in posterior interosseous nerve palsy due to schwannoma [82]. The combination of ultrasound and MRI findings provides features that narrow the differential diagnosis for ancient schwannoma [84]. Ultrasound and MRI findings help differentiate ancient schwannoma from malignant tumors [84].

Ultrasonography: Ultrasonography and MRI are appropriate for visualizing fascicular abnormalities in spontaneous posterior interosseous nerve palsy [55]. Only a small number of individuals with MRI evidence of an anconeus epitrochlearis muscle (AEM) have clinical evidence of ulnar neuropathy [61]. If radiographic and ultrasonographic findings suggest a metal fragment is the cause of nerve injury, the nerve should be exposed and the metal fragment removed [66].

Other Considerations: Neurophysiology is indicated in all patients with atraumatic posterior interosseous nerve palsy [29]. A diagnosis of ulnar nerve compression at the elbow merits a comprehensive workup by the treating surgeon [16]. There is a high suspicion for concomitant median nerve compression (carpal tunnel syndrome) in patients with ulnar nerve compression at the elbow [16]. Symptomatic neural loops are a rare diagnostic challenge and a diagnosis of exclusion [3]. Clinicians should consider microvascular decompression for symptomatic neural loops if other etiologies are absent [3]. Early decompression after initial observation and evaluation led to clinical and electrodiagnostic recovery in isolated fascial compression of the recurrent motor branch of the median nerve [35]. In cases of peripheral nerve localization where a clear cleavage plane is absent, the correct management is simple nerve decompression followed by biopsy [34]. Simple nerve decompression followed by biopsy requires an adequate and prolonged follow-up period for sleeve-shaped neurothekeoma of the ulnar nerve [34]. Recognizing anatomical variations at the suprascapular notch is crucial for understanding the etiology of suprascapular nerve entrapment [93]. Recognizing anatomical variations at the suprascapular notch ensures adequate surgical decompression for suprascapular nerve entrapment [93]. Clear inferences regarding imaging, timing of surgery, nerve transfers, and physiotherapy in brachial plexus birth injury are difficult due to many variables and uncertainties [85].

Treatment

Non-Operative Management

Peripheral nerve injuries are common and debilitating, yet available treatments remain suboptimal [10], and clinical outcomes after peripheral nerve surgery are still regarded as suboptimal despite major microsurgical improvements [45]. Pharmacological intervention as an adjunctive therapy to surgical repair may prove necessary for satisfactory long-term functional recovery [44], and stabilization of the neuromuscular junction represents an important adjunct that should be explored given that current management techniques fail to achieve adequate functional neural regeneration [72].

Management strategies vary by etiology. For peroneal nerve palsy, nonsurgical measures benefit many patients, while surgical decompression is considered for refractory cases and typically yields favorable results [11]. In neuralgic amyotrophy (Parsonage-Turner syndrome), early corticosteroid therapy may shorten the duration of active symptoms and hasten recovery [25], though the best treatment remains unknown [25]. Non-operative treatment is the accepted practice following post-exposure prophylaxis, with outcomes typically preferable despite some patients being left with residual paresis [52]; recovery can be lengthy [52] or quite protracted [75].

For specific neuropathies, conservative care is often first-line. A comprehensive, conservative treatment program has a positive and lasting effect on pain and disability scores in patients with non-radicular peripheral neuropathic pain [47]. In carpal tunnel syndrome, both neurodynamics therapy and exercise therapy lead to positive outcomes, with neurodynamics therapy being superior in improving function and strength and decreasing pain [51]. Posterior interosseous and ulnar nerve motor palsies after minimally displaced radial neck fractures demonstrate excellent functional recovery with nonsurgical management [43]. Isolated musculocutaneous nerve injury results in a successful clinical outcome with nonoperative management [57], and suprascapular neuropathy without well-defined mechanical compression should be treated non-operatively [62].

In pediatric and adolescent populations, nonsurgical treatment is unlikely to relieve symptoms in cubital tunnel syndrome, but a trial of conservative care remains appropriate for most patients [77]. Operative decompression for meralgia paresthetica in children produces good or excellent results in patients who have not responded to non-operative treatment [74].

Operative Management

Indications: Surgical intervention is indicated for carpal tunnel syndrome when abnormal median sensory nerve conduction distinguishes a subset of patients who appear to benefit from treatment [1]. Unrecordable nerve potentials are not a contraindication for carpal tunnel release [64]. For cubital tunnel syndrome in pediatric and adolescent patients, surgery is effective if nonsurgical care fails [77]. Nerve transfers appear reasonable to optimize recovery even 12 to 18 months after the onset of muscle weakness symptoms in cervical spondylotic amyotrophy, though greater patient numbers are required to confirm efficacy [21].

Surgical Approach / Technique: For late microsurgical nerve reconstruction of brachial plexus birth injury at 1 or 2 or more years follow-up, there was no difference in outcomes between nerve transfer and nerve graft groups [7]. Selection of the donor nerve for heterotopic nerve transfers must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options [20]. There is no advantage of using a nerve stimulator in selecting fascicles before performing the nerve transfer for restoring elbow flexion in brachial plexus injuries [71].

Sensory nerve transfers are as effective if not better than standard nerve grafts for treating nerve gaps greater than 20 cm in peripheral nerve injuries, with the advantage of eliminating morbidity from the donor defect [23]. The median-ulnar end-to-side bridge nerve graft technique for intrinsic hand muscle reinnervation is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft [27]. Evidence for good nerve recovery or improved function following surgical repair of a single digital nerve in adults is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels [22].

Other Considerations: Treatment of the painful neuroma must be tailored to the individual patient as there are a number of approaches available [78]. The pathophysiology of the painful neuroma involves fascicular escape and scarring [78]. Nerve regeneration is of a slightly better quality in children than in adults, but this alone cannot explain the difference in their clinical outcomes [46].

Diagnostic and Evaluation Considerations

Magnetic resonance imaging is the study of choice for management of atraumatic posterior interosseous nerve palsy [29]. Neurophysiology is indicated in all patients with atraumatic posterior interosseous nerve palsy [29]. It is important to review data and continue to critically evaluate outcomes to determine the best practices in restoring function in patients with atraumatic nerve palsy [19].

Complications

Nerve palsy: Incorrect treatment or devastating early nerve surgery can cause main sequels in obstetrical palsy, rather than the injury itself [5]. Peripheral nerve injuries can dramatically affect a patient's life [14]. Most diagnoses of distal peripheral neuropathy after shoulder surgery likely represent previously asymptomatic disease rather than surgical injuries [13]. Short-term improvement in nerve function was seen in over half of patients with gunshot-related upper extremity nerve injuries, suggesting a predominance of neuropraxic effects [18]. Transient incomplete nerve palsies may develop even when schwannomas of the upper extremity are treated with excisional biopsy using microsurgical techniques [97].

Obstetric brachial plexus injury: Up to 25% of infants with brachial plexus birth injury have long-term deficits, while approximately 75% recover [28]. Young children show better sensory recovery and are less likely to develop long-term chronic neuropathic pain syndromes than adults following nerve injury [30]. Many uncertainties remain regarding the course of obstetric brachial plexus injury and the effectiveness of treatment, indicating a need for further study [73].

Peripheral neuropathy and nerve lesions: Patients with a history of ulnar nerve lesions are at a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years [31]. Nocturnal paresthesias occur in healthy people without a history of carpal tunnel syndrome, including those younger than previously reported [98].

Nerve grafting and resection: Caution is advised when using conduits to repair large-diameter nerves due to failed clinical outcomes [24]. Removing the entire sural nerve for grafting produced no long-term complaints of pain and appears safe [60]. Resection of a neuromuscular choristoma (hamartoma) of the sciatic nerve causing cavus deformity was not feasible due to the risk of increased neurological deficits [104].

Other Considerations: FK506 (tacrolimus) treatment showed no evident improvement in sensory, motor, or functional recovery compared to expected results without treatment, with no undesirable side-effects observed [76].

Recovery

Light activity (weeks): Evidence does not specify a discrete week-range for light activity or driving across the included studies.

Full activity (months): Evidence does not specify a discrete month-range for full manual work or sport participation across the included studies.

Complete recovery / outcome plateau (months): Outcomes from processed nerve allografts exceed those for nerve conduit in historical controls when targeting the Wnt/ß-Catenin signaling pathway after traumatic nerve injury [36]. Follow-up time significantly influences outcomes following nerve repair, with significant improvements in total scores seen throughout the follow-up period [26]. In cases of peripheral nerve localization with an absent clear cleavage plane, correct management involves simple nerve decompression followed by biopsy and adequate prolonged follow-up [34].

Rehabilitation protocol: Surgical repair with long-term hand therapy results in excellent functional outcomes following pediatric peripheral nerve injury [65].

Functional milestones: Nerve transfer and nerve graft groups show no difference in outcomes at 1 or 2 or more years follow-up for late microsurgical nerve reconstruction in brachial plexus birth injury [7]. Short-term improvement in nerve function is seen in over half of patients with gunshot-related upper extremity nerve injuries, suggesting a predominance of neuropraxic effects [18]. Only 24% of repaired single digital nerves in adults regain sensory recovery close to or equivalent to estimated pre-injury levels [22]. Approximately 75% of infants with brachial plexus birth injury recover, leaving up to 25% with long-term deficits [28]. Full recovery of median nerve function was seen in all patients with acute median nerve dysfunction associated with multiple metacarpal fractures/dislocations and severe hand swelling at a mean final follow-up of 7 months [68]. Symptoms from ulnar nerve compression in Guyon’s canal by an angioleiomyoma improved immediately after surgery, with complete recovery of motor conduction velocity at four months and no recurrence at 18 months [79]. All nerve injuries in pediatric Monteggia fracture-dislocations resolved within 150 days, suggesting that early operative intervention may be unnecessary [37].

Other Considerations: Patient age is the most important prognostic factor for nerve recovery [108]. Young children show better sensory recovery and are less likely to develop long-term chronic neuropathic pain syndromes than adults following nerve injury [30]. Prognostic factors for success in complete traumatic brachial plexus palsy repair include a short delay between injury and operation, intact vessels, large neuromas, short grafts, and grafts with many strands [110]. Early corticosteroid therapy may shorten the duration of active symptoms and hasten recovery in neuralgic amyotrophy (Parsonage-Turner syndrome) [25]. Patients with a history of ulnar nerve lesions are at a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years [31]. Temporal worsening of median nerve function was observed in 2 patients undergoing endoscopic carpal tunnel release using a modified Chow technique [33]. Early decompression after initial observation and evaluation led to impressive clinical and electrodiagnostic recovery in isolated fascial compression of the recurrent motor branch of the median nerve [35]. Timely surgical decompression results in full neurologic recovery in brachialis syndrome, whereas delayed decompression leads to poor outcomes [109].

Key Evidence

  • [L2] The definition of abnormal median sensory nerve conduction distinguished a subset of patients who appeared to benefit from surgical treatment. (10.1186/1471-2474-14-241)
  • [L5] This narrative review summarizes screening methods, typical findings for CNS and PNS disorders, and recommendations for referral. (10.1016/j.jht.2009.11.003)
  • [Case_report] Symptomatic neural loops are a rare, diagnostic challenge and diagnosis of exclusion; clinicians must be aware of this anatomic variation and consider microvascular decompression if other etiologies are absent. (10.1016/j.jhsa.2012.07.012)
  • [L5] Neurodiagnostic studies are integral in diagnosing neurological disorders, and it is imperative that multiple types of studies be performed to correctly diagnose patients. (10.1016/j.jhsa.2007.07.021)
  • [L4] The main sequels are attributed to incorrect treatment or devastating early nerve surgery rather than the injury itself. (10.1177/17531934211032032)
  • [L3] The demographics of patients with various compressive neuropathies were not homogeneous, suggesting different etiologies. (10.1177/15589447221107701)
  • [L4] There was no difference in outcomes between nerve transfer and nerve graft groups at 1 or 2 or more years follow-up. (10.1016/j.jhsa.2019.10.036)
  • [Paper] Peripheral nerve injuries are common and debilitating, with available treatments remaining suboptimal. (10.1016/j.hcl.2013.04.002)
  • [L5] Management of peroneal nerve palsy varies based on etiology; many patients benefit from nonsurgical measures, while surgical decompression is considered for refractory cases and typically yields favorable results. (10.5435/jaaos-d-16-00045)
  • [Letter] Most diagnoses of distal peripheral neuropathy after shoulder surgery likely represent previously asymptomatic disease rather than surgical injuries, as the surgery is likely coincidental or merely brings the problem to the patient's attention. (10.1016/j.jse.2015.03.020)
  • [L5] Peripheral nerve injuries can dramatically affect a patient's life. (10.1016/j.hcl.2015.01.007)
  • [L4] The current literature shows that the location and mechanism of nerve injury are the most important factors guiding management, requiring different treatment strategies depending on the specific location and type of nerve injury. (10.1016/j.jse.2011.11.033)
  • [L3] A diagnosis of ulnar nerve compression merits a comprehensive workup by the treating surgeon and a high suspicion for concomitant median nerve compression. (10.1177/1558944718813669)
  • [L2] Electrodiagnostic tests provide significantly more information than ultrasonography regarding the condition and function of the nerve. (10.1177/1753193413489046)
  • [L4] Short-term improvement in nerve function was seen in over half the cohort, suggesting a predominance of neuropraxic effects. (10.1016/j.jhsa.2021.03.020)
  • [Commentary] It is important to review our data and continue to critically evaluate our outcomes to determine the best practices in restoring function in our patients with atraumatic nerve palsy. (10.1016/j.jhsa.2017.07.027)
  • [L4] Selection of the donor nerve must be carefully weighed against other treatment alternatives, considering the risk of donor nerve impairment and the potential narrowing of future reconstructive options. (10.1016/j.jhsa.2006.12.012)
  • [L4] Nerve transfers appear reasonable to optimize recovery even 12 to 18 months after the onset of symptoms of muscle weakness, though greater patient numbers are required to confirm efficacy. (10.1016/j.jhsa.2017.12.020)
  • [L2] Evidence for good nerve recovery or improved function following nerve repair is poor, with only 24% of repaired nerves regaining sensory recovery close to or equivalent to estimated pre-injury levels. (10.1177/1753193419846761)
  • [L4] Sensory nerve transfers are as effective if not better than standard nerve grafts for the treatment of nerve gaps greater than 20 cm in peripheral nerve injuries and have the advantage of eliminating morbidity from the donor defect. (10.1007/s11552-006-9011-5)
  • [L4] The authors advise caution when using conduits to repair large-diameter nerves based on the failed clinical outcomes reported. (10.1007/s11552-008-9158-3)
  • [L5] The best treatment for neuralgic amyotrophy remains unknown, though early corticosteroid therapy may shorten the duration of active symptoms and hasten recovery. (10.1016/j.jhsa.2010.09.010)
  • [L3] Follow-up time and age significantly influence the outcome following nerve repair, with significant improvements in the total score seen throughout the follow-up period. (10.1054/jhsb.2001.0567)
  • [Case_report] The technique is mainly indicated in high peripheral nerve injury or secondary cases when recovery of the intrinsic muscle of the hand is not expected after end-to-end repair or graft. (10.1016/j.jhsa.2009.10.033)
  • [L5] Magnetic resonance imaging is the study of choice and neurophysiology is indicated in all patients. (10.1016/j.jhsa.2017.07.026)
  • [L3] Young children show better sensory recovery and are less likely to develop long-term chronic neuropathic pain syndromes than adults following nerve injury. (10.1177/1753193408087029)
  • [L2] Patients with a history of ulnar nerve lesions are at a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years. (10.1016/j.jhsg.2026.100970)
  • [L3] Median nerve ultrasonography measurements not only distinguished between normal and abnormal electrodiagnostic studies but also correlated with the category of electrodiagnostic severity. (10.5435/jaaos-d-17-00557)
  • [L4] However, temporal worsening of median nerve function was observed in 2 patients. (10.1016/j.arthro.2007.02.009)
  • [L4] In case of peripheral nerve localization and when a clear cleavage plane is absent, the correct management should be simple nerve decompression followed by biopsy, along with an adequate and prolonged follow-up period. (10.1177/1558944719828008)
  • [Case_report] Early decompression after initial observation and evaluation led to an impressive clinical and electrodiagnostic recovery. (10.1007/s11552-006-9006-2)
  • [L3] Outcomes from processed nerve allografts are comparable to nerve autograft and exceed those for nerve conduit in historical controls. (10.1016/j.jhsa.2014.06.044)
  • [L3] All the nerve injuries resolved within 150 days, suggesting that early operative intervention may be unnecessary. (10.2106/jbjs.24.00640)
  • [L5] Nerve compression syndromes are a common cause of pain, sensory disturbance, and motor weakness; while carpal tunnel syndrome is frequently treated surgically, other compression syndromes are less common and often best treated nonsurgically, though some, such as posterior interosseous nerve syndrome, are better treated by surgical intervention. (10.5435/00124635-199811000-00006)
  • [L4] Neuralgic amyotrophy is overdiagnosed based on clinical assessment alone, and EMG investigations are necessary in all suspected cases due to poor diagnostic accuracy of clinical evaluation. (10.1016/j.jse.2016.04.005)
  • [L5] Neuromuscular impairments in focal hand dystonia and upper extremity compression neuropathies are distinguishable through differences in patient history, clinical presentation, and physical examination findings, which should guide accurate diagnosis and therapeutic intervention. (10.1016/j.jht.2008.12.004)
  • [L4] Neurostenalgia is the most rewarding of all neuropathic pain syndromes to treat, and a clinician faced with a patient with severe pain from a focal lesion of a peripheral nerve should consider the possibility of neurostenalgia. (10.1177/1753193407087889)
  • [L4] The new classification of the suprascapular triad topography and quantitative analysis of the space available for the path of the suprascapular nerve are important for a better understanding of the possible morphological conditions that may promote suprascapular nerve entrapment, especially those with a type III arrangement. (10.1007/s00167-014-2937-1)
  • [L4] With nonsurgical management, both nerves demonstrated excellent functional recovery. (10.1016/j.jhsa.2012.05.028)
  • [L5] Pharmacological intervention as an adjunctive therapy to surgical peripheral nerve repair may prove to be not only beneficial but also necessary for satisfactory long-term functional recovery. (10.1016/j.jhsa.2018.01.023)
  • [L5] Despite major microsurgical improvements, the clinical outcome of peripheral nerve surgery is still regarded as suboptimal. (10.1177/1753193411420348)
  • [L3] Nerve regeneration is of a slightly better quality in children than in adults, but this alone cannot explain the difference in their clinical outcomes. (10.1054/jhsb.2000.0493)
  • [L3] A comprehensive, conservative treatment program has a positive and lasting effect on pain and disability scores in patients with non-radicular PNP. (10.1016/j.jht.2014.02.003)
  • [L4] The results of this series do not support the strong recommendations of other authors to use vascularized nerve grafts in the reconstruction of large nerve defects. (10.1016/j.jhsa.2009.08.004)
  • [L3] Our kinematic and clinical measurements objectively and quantitatively evaluate skilled hand function in individuals with CIPN in clinical settings. (10.1016/j.jht.2017.06.003)
  • [L1] Although both treatments led to positive outcomes, neurodynamics therapy was superior in improving function and strength and in decreasing pain. (10.1016/j.jht.2020.07.005)
  • [L4] Although recovery can be lengthy, non-operative treatment is the accepted practice and the outcome is typically preferable, though some patients may be left with residual paresis. (10.1186/1471-2474-15-265)
  • [Paper] The use of nerve transfers has resulted in a positive paradigm shift in patient outcome and in the results obtainable for many peripheral nerve injuries. (10.1016/j.hcl.2008.07.003)
  • [L5] Significant advances using microsurgical techniques for nerve repair have led to improved results after peripheral nerve surgery and have extended the types of nerve repair that can be accomplished. (10.1016/j.hcl.2007.02.003)
  • [L4] Ultrasonography and MRI are appropriate for visualizing fascicular abnormalities in spontaneous posterior interosseous nerve palsy. (10.1016/j.jhsa.2019.12.011)
  • [L4] Most nerve injuries show only partial or no functional recovery, necessitating patient counseling on this risk. (10.1016/j.arthro.2015.11.023)
  • [L5] Nonoperative management for isolated musculocutaneous nerve injury results in a successful clinical outcome. (10.1177/0363546508317966)
  • [L4] A classification of associated abnormalities is offered to highlight clinical relevance, particularly the risk of missing the small ulnar division of the nerve when surrounded by vascular malformations. (10.1177/1753193408089572)
  • [L3] This study shows that even though the range of wrist motion and the strength of the wrist and fingers are less than normal, hand function remains good. (10.1177/1753193416651574)
  • [L2] Removing the entire sural nerve produced no long-term complaints of pain and appears safe. (10.1016/j.jhsa.2023.03.009)
  • [L4] Only a small number of individuals with MRI evidence of an AEM had clinical evidence of ulnar neuropathy. (10.1016/j.jse.2018.03.021)
  • [L4] In the absence of a well-defined lesion producing mechanical compression of the suprascapular nerve, suprascapular neuropathy should be treated non-operatively. (10.2106/00004623-199708000-00007)
  • [L4] This new system that measures each finger's grip strength at one time and records the time course of grip motion could quantify a patient's symptoms easily and objectively, which may contribute to the evaluation of hand function. (10.1186/s13018-020-01773-9)
  • [L4] Unrecordable nerve potentials are not a contraindication for carpal tunnel release. (10.1177/1558944719857815)
  • [Paper] Surgical repair with long-term hand therapy results in excellent functional outcomes following pediatric peripheral nerve injury. (10.1055/s-0039-1692928)
  • [Case_report] If radiographic and ultrasonographic findings suggest a metal fragment is the cause of nerve injury, the nerve should be exposed and the metal fragment removed. (10.1016/j.jse.2024.05.048)
  • [Case_report] Adequate clinical diagnosis through predominantly motor symptoms and electroneuromyography alterations can allow for early decompression with good postoperative functional outcomes. (10.1177/1558944721990779)
  • [L4] At a mean final follow-up of 7 months, full recovery of median nerve function was seen in all patients, and all patients were able to return to work. (10.1177/1753193408087105)
  • [L3] There is no advantage of using a nerve stimulator in selecting fascicles before performing the nerve transfer. (10.1016/j.jhsa.2011.08.017)
  • [L5] Current management techniques for major peripheral nerve injuries fail to achieve adequate functional neural regeneration, and stabilization of the neuromuscular junction may be an important adjunct in peripheral nerve repair that should be explored. (10.5435/00124635-201102001-00006)
  • [L5] Many uncertainties remain regarding the course of obstetric brachial plexus injury and the effectiveness of treatment, indicating a need for further study of prognostic factors, investigations, and long-term outcomes of operative and non-operative management. (10.1177/17531934211027117)
  • [L4] Operative decompression, done as an outpatient procedure, produced a good or excellent result in patients who had not responded to non-operative treatment. (10.2106/00004623-199407000-00006)
  • [L4] Non-operative treatment is the accepted protocol, although recovery from this disorder can be quite protracted. (10.2106/00004623-199609000-00018)
  • [L4] No undesirable side-effects were observed during or after FK506 treatment, but there was no evident improvement of sensory, motor or functional recovery at the end of the follow-up period compared to expected results without treatment. (10.1177/1753193411427826)
  • [L3] Although nonsurgical treatment is unlikely to relieve symptoms, a trial of conservative care remains appropriate for most patients, with surgery effective if nonsurgical care fails. (10.1016/j.jhsa.2012.01.016)
  • [L5] The painful neuroma is a debilitating sequela of nerve injury with poorly understood pathophysiology involving fascicular escape and scarring; treatment must be tailored to the individual patient as there are a number of approaches available. (10.1016/j.jhsa.2009.12.019)
  • [L4] The symptoms improved immediately after surgery, with complete recovery of motor conduction velocity at four months and no recurrence at 18 months. (10.1177/1753193410367701)
  • [L4] Wrist deviation from neutral can lead to more pronounced deformation of the median nerve than finger flexion for both intensive and nonintensive users. (10.1016/j.jhsa.2018.08.006)
  • [L5] The authors present fundamental muscle-tendon-joint mechanics studies that allow for single-stage surgical reconstruction of hand function and early postoperative activity-based training in patients with cervical spinal cord injuries. (10.1177/1753193419827814)
  • [Case_report] Preoperative diagnosis by MRI and selection of the appropriate surgical approach are important in these cases because they give clinicians the best chance to separate the nerve from the tumor and decrease the risk of postsurgical complications. (10.1016/j.jhsa.2008.05.033)
  • [L3] Obesity, diabetes, use of hand-held vibratory tools, and repeated forceful movements of the wrist and hand are causes of impaired median nerve function. (10.1186/1471-2474-14-240)
  • [L4] The combination of ultrasound and MRI findings provides features that narrow the differential diagnosis for ancient schwannoma, helping to differentiate it from malignant tumors. (10.1016/j.jhsa.2011.08.009)
  • [L5] The article summarizes currently accepted views on imaging, timing of surgery, nerve transfers, and physiotherapy, noting that clear inferences are difficult due to many variables and uncertainties. (10.1177/17531934241231173)
  • [L5] The intrinsic hand muscles have MEPs at consistent distances from bony landmarks both dorsally and volarly. (10.1016/j.jhsa.2020.04.019)
  • [L2] Our findings demonstrate that a simple EMG classification that describes the quality of donor nerves can predict outcome as measured by postoperative motor strength and range of motion. (10.1016/j.jhsa.2013.09.042)
  • [L4] Dimensional discrepancies and functional outcomes are improved by scapula stabilization procedures. (10.1007/s11552-014-9640-z)
  • [L5] The 4-category classification was reproducible within and between reviewers. (10.1016/j.jse.2024.02.030)
  • [L5] The purpose of this article is to provide an overview of the importance of the design and outcome measures of peripheral nerve basic science research, for hand surgeons to understand for potential clinical translation. (10.1016/j.jhsa.2021.02.016)
  • [L4] Recognizing these variations is crucial for understanding the etiology and ensuring adequate surgical decompression. (10.1007/s00167-003-0378-3)
  • [L4] However, room still remains for improved thumb motion with both procedures. (10.1016/j.jhsa.2019.12.009)
  • [L4] Power grip force measurements with a JAMAR dynamometer do not provide decisive information about motor function of the median nerves in the lower arm. (10.1016/j.jht.2016.11.004)
  • [L4] They should be treated with an excisional biopsy using microsurgical techniques, but even then transient incomplete nerve palsies may develop. (10.1054/jhsb.2000.0472)
  • [L4] This study illustrates nocturnal paresthesias in people without history of carpal tunnel syndrome including people younger than previously reported. (10.1177/1558944717735942)
  • [Case_report] The procedure resulted in active elbow flexion to 90° at 18 months without motor deficits in the hand. (10.1016/j.jhsa.2010.06.014)
  • [L3] In contrast, results of motor tests (total grip and key-pinch strength) are significantly influenced by the involvement of the dominant or non-dominant hand. (10.1177/1753193411425331)
  • [Case_report] Resection of the mass was not feasible due to the risk of increased neurological deficits, and the natural history of this benign lesion remains indeterminate. (10.2106/00004623-199709000-00016)
  • [L3] Workers regularly exposed to hand-held vibrating tools had significantly weaker extrinsic and intrinsic hand muscles than controls. (10.1054/jhsb.2002.0810)
  • [L4] Ulnar nerve gliding was most severe during passive wrist movement in elbow flexion and forearm supination. (10.5397/cise.2024.00934)
  • [L3] No significant difference was seen in hand function between border and central finger injuries, except for lower grip strength in central finger injuries. (10.1177/17531934241286116)
  • [L4] Timely surgical decompression results in full neurologic recovery, whereas delayed decompression leads to poor outcomes. (10.1016/j.jse.2015.12.023)
  • [L4] Prognostic factors for success include a short delay between injury and operation, intact vessels, large neuromas, short grafts, and grafts with many strands. (10.2106/00004623-199901000-00004)

See Also

References

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[26] The Long Term Recovery Curve in Adults after Median or Ulnar Nerve Repair: A Reference Interval. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0567

[27] Intrinsic Hand Muscle Reinnervation by Median-Ulnar End-to-Side Bridge Nerve Graft: Case Report. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.10.033

[28] Chapter 21 Brachial Plexus Birth Injuries. 2020.

[29] Management of Atraumatic Posterior Interosseous Nerve Palsy. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.07.026

[30] Age-Dependent Development Of Chronic Neuropathic Pain, Allodynia and Sensory Recovery after Upper Limb Nerve Injury in Children. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408087029

[31] Incidence of Carpal Tunnel Syndrome After the Diagnosis of Ulnar Neuropathy. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100970

[32] Median Nerve Ultrasonography Measurements Correlate With Electrodiagnostic Carpal Tunnel Syndrome Severity. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00557

[33] Reducing Neurologic and Vascular Complications of Endoscopic Carpal Tunnel Release Using a Modified Chow Technique. Arthroscopy. 2007. DOI: 10.1016/j.arthro.2007.02.009

[34] Sleeve-Shaped Neurothekeoma of the Ulnar Nerve: A Unique Case of a Still Unclear Pathological Entity. HAND. 2019. DOI: 10.1177/1558944719828008

[35] Isolated Fascial Compression of the Recurrent Motor Branch of the Median Nerve: A Case Report. HAND. 2006. DOI: 10.1007/s11552-006-9006-2

[36] Targeting the Wnt/ß-Catenin Signaling Pathway After Traumatic Nerve Injury to Improve Functional Recovery. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.044

[37] Examining Preoperative Risk Factors for Nerve Injury in Pediatric Monteggia Fracture-Dislocations. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.24.00640

[38] Uncommon Nerve Compression Syndromes of the Upper Extremity. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199811000-00006

[39] Neuralgic amyotrophy is not the most common neurologic disorder of the shoulder: a 78-month prospective study of 60 neurologic shoulder patients in a specialist shoulder clinic. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.04.005

[40] Clinical Relevance of Neuromuscular Findings and Abnormal Movement Patterns: A Comparison between Focal Hand Dystonia and Upper Extremity Entrapment Neuropathies. Journal of Hand Therapy. 2009. DOI: 10.1016/j.jht.2008.12.004

[41] INTRACTABLE NEUROSTENALGIA OF THE ULNAR NERVE ABOLISHED BY NEUROLYSIS 18 YEARS AFTER INJURY. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193407087889

[42] The variable morphology of suprascapular nerve and vessels at suprascapular notch: a proposal for classification and its potential clinical implications. Knee Surgery, Sports Traumatology, Arthroscopy. 2014. DOI: 10.1007/s00167-014-2937-1

[43] Posterior Interosseous and Ulnar Nerve Motor Palsies After a Minimally Displaced Radial Neck Fracture. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.05.028

[44] Emerging Strategies on Adjuvant Therapies for Nerve Recovery. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.01.023

[45] Nerve surgery and gene therapy: a neurobiological and clinical perspective. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411420348

[46] A Comparative Clinical and Electromyographic Study of Median and Ulnar Nerve Injuries at the Wrist in Children and Adults. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2000.0493

[47] Outcomes following the conservative management of patients with non-radicular peripheral neuropathic pain. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2014.02.003

[49] Results of C5 Root Grafting to the Musculocutaneous Nerve Using Pedicled, Vascularized Ulnar Nerve Grafts. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.08.004

[50] Kinematic evaluation for impairment of skilled hand function in chemotherapy-induced peripheral neuropathy. Journal of Hand Therapy. 2019. DOI: 10.1016/j.jht.2017.06.003

[51] The long-term effect of neurodynamics vs exercise therapy on pain and function in people with carpal tunnel syndrome: A randomized parallel-group clinical trial. Journal of Hand Therapy. 2021. DOI: 10.1016/j.jht.2020.07.005

[52] Parsonage-Turner syndrome following post-exposure prophylaxis. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-265

[53] Preface. Hand Clinics. 2008. DOI: 10.1016/j.hcl.2008.07.003

[54] The Role of Microsurgery in Nerve Repair and Nerve Grafting. Hand Clinics. 2007. DOI: 10.1016/j.hcl.2007.02.003

[55] Pathological Findings of Hourglass-Like Constriction in Spontaneous Posterior Interosseous Nerve Palsy. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.12.011

[56] Major Peripheral Nerve Injuries After Elbow Arthroscopy. Arthroscopy. 2016. DOI: 10.1016/j.arthro.2015.11.023

[57] Isolated Musculocutaneous Nerve Injury in a Professional Fast-Pitch Softball Player. The American Journal of Sports Medicine. 2008. DOI: 10.1177/0363546508317966

[58] The Bifid Median Nerve Re-Visited. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408089572

[59] An objective functional evaluation of the flexor carpi ulnaris set of triple tendon transfer in radial nerve palsy. Journal of Hand Surgery (European Volume). 2016. DOI: 10.1177/1753193416651574

[60] Long-Term Donor-Site Morbidity Following Entire Sural Nerve Harvest for Grafting. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.03.009

[61] Quantitative magnetic resonance imaging analysis of the cross-sectional areas of the anconeus epitrochlearis muscle, cubital tunnel, and ulnar nerve with the elbow in extension in patients with and without ulnar neuropathy. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.03.021

[62] Suprascapular Neuropathy. Results of Non-Operative Treatment. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199708000-00007

[63] Assessment of grip-motion characteristics in carpal tunnel syndrome patients using a novel finger grip dynamometer system. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01773-9

[64] Outcomes of Mini-Open Carpal Tunnel Release in Patients With Unrecordable Preoperative Nerve Conduction Potentials at a Minimum of 5 Years. HAND. 2019. DOI: 10.1177/1558944719857815

[65] Long-Term Outcomes following Pediatric Peripheral Nerve Injury Repair. Journal of Hand and Microsurgery. 2020. DOI: 10.1055/s-0039-1692928

[66] Iatrogenic radial nerve injury caused by metal shaving: a case report. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.05.048

[67] Isolated Compression of the Recurrent Motor Branch of the Median Nerve: A Case Report. HAND. 2022. DOI: 10.1177/1558944721990779

[68] The Triad of Multiple Metacarpal Fractures and/or Dislocations of the Fingers, Severe Hand Swelling and Clinical Evidence of Acute Median Nerve Dysfunction. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408087105

[69] Median and Ulnar Nerve Suture: AN EXPERIMENTAL STUDY COMPARING PRIMARY AND SECONDARY REPAIR IN MONKEYS.. The Journal of Bone and Joint Surgery. American Volume. 1968.

[70] Chapter 29 Hand/Carpal Fractures and Dislocations. 2021.

[71] Fascicular Selection for Nerve Transfers: The Role of the Nerve Stimulator When Restoring Elbow Flexion in Brachial Plexus Injuries. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.08.017

[72] Limb Salvage With Major Nerve Injury: Current Management and Future Directions. Journal of the American Academy of Orthopaedic Surgeons. 2011. DOI: 10.5435/00124635-201102001-00006

[73] Questions regarding natural history and management of obstetric brachial plexus injury. Journal of Hand Surgery (European Volume). 2021. DOI: 10.1177/17531934211027117

[74] Meralgia paresthetica in children.. The Journal of Bone & Joint Surgery. 1994. DOI: 10.2106/00004623-199407000-00006

[75] Parsonage-Turner Syndrome (Acute Brachial Neuritis). The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199609000-00018

[76] Tolerance and effects of FK506 (tacrolimus) on nerve regeneration: a pilot study. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411427826

[77] Surgical and Nonsurgical Treatment of Cubital Tunnel Syndrome in Pediatric and Adolescent Patients. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.01.016

[78] Neuromas of the Hand and Upper Extremity. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.12.019

[79] Compression of the ulnar nerve in Guyon’s canal by an angioleiomyoma. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410367701

[80] Morphological Changes of the Median Nerve Within the Carpal Tunnel During Various Finger and Wrist Positions: An Analysis of Intensive and Nonintensive Electronic Device Users. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.08.006

[81] Reach out and grasp the opportunity: reconstructive hand surgery in tetraplegia. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193419827814

[82] Posterior Interosseous Nerve Palsy Due to Schwannoma: Case Report. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.05.033

[83] Differences in risk factors for neurophysiologically confirmed carpal tunnel syndrome and illness with similar symptoms but normal median nerve function: a case–control study. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-240

[84] Ancient Schwannoma of the Hand. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.08.009

[85] Brachial plexus birth injury: advances and controversies. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241231173

[87] Targeted Muscle Reinnervation in the Hand: An Anatomical Feasibility Study for Neuroma Treatment and Prevention. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.04.019

[88] Preoperative Donor Nerve Electromyography as a Predictor of Nerve Transfer Outcomes. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.09.042

[89] Chapter 55 Pediatric Upper Extremity Disorders. 2020.

[90] Morphometric Analysis of the Effect of Scapula Stabilization on Obstetric Brachial Plexus Paralysis Patients. HAND. 2014. DOI: 10.1007/s11552-014-9640-z

[91] A novel classification of intraoperative ulnar nerve instability to aid transposition surgery. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.02.030

[92] Peripheral Nerve Basic Science Research—What Is Important for Hand Surgeons to Know?. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.02.016

[93] Variations in anatomy at the suprascapular notch possibly causing suprascapular nerve entrapment: an anatomical study. Knee Surgery, Sports Traumatology, Arthroscopy. 2003. DOI: 10.1007/s00167-003-0378-3

[94] Nerve Versus Tendon Transfer for Radial Nerve Paralysis Reconstruction. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.12.009

[96] Quantification of weakness caused by distal median nerve lesion by dynamometry. Journal of Hand Therapy. 2018. DOI: 10.1016/j.jht.2016.11.004

[97] Schwannomas of the Upper Extremity. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.2000.0472

[98] Preferences in Sleep Position Correlate With Nighttime Paresthesias in Healthy People Without Carpal Tunnel Syndrome. HAND. 2017. DOI: 10.1177/1558944717735942

[99] Ulnar Nerve to Musculocutaneous Nerve Transfer in an Ulnar Ray–Deficient Infant With Brachial Plexus Birth Palsy: Case Report. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.06.014

[101] 9. Hand Surgery. 2013.

[102] The effect of the involvement of the dominant or non-dominant hand on grip/pinch strengths and the Levine score in patients with carpal tunnel syndrome. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411425331

[103] Validation_of_Morphology_and_Symptoms_of_Carpal_Tunnel_Syndrome_Results_of_a_Cro_S0894113007001421. n.d..

[104] Cavus Deformity of the Foot Secondary to a Neuromuscular Choristoma (Hamartoma) of the Sciatic Nerve. A Case Report. The Journal of Bone and Joint Surgery (American Volume)*. 1997. DOI: 10.2106/00004623-199709000-00016

[105] Hand Muscle Weakness in Long-Term Vibration Exposure. Journal of Hand Surgery. 2002. DOI: 10.1054/jhsb.2002.0810

[106] Biomechanical analysis of ulnar nerve gliding and elongation: implications for nonsurgical ulnar nerve release in cubital tunnel syndrome. Clinics in Shoulder and Elbow. 2025. DOI: 10.5397/cise.2024.00934

[107] Long-term subjective and objective outcomes after digital nerve repair: a cohort study. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241286116

[108] Chapter 28 Nerve Injuries and Nerve Transfers. 2019.

[109] Brachialis syndrome: a rare consequence of patient positioning causing postoperative median neuropathy. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.12.023

[110] Complete Traumatic Brachial Plexus Palsy. Treatment and Outcome After Repair. The Journal of Bone & Joint Surgery*. 1999. DOI: 10.2106/00004623-199901000-00004

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4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.