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BACKGROUND: Traumatic nerve injuries are associated with a high morbidity and long rehabilitation times. The extent of a nerve lesion and the related regeneration potential can often only be estimated during the course, whereby the time window for successful surgical interventions is limited. OBJECTIVE: The incidence and distribution of traumatic nerve lesions are reported. Algorithms for treatment decisions are presented. MATERIAL AND METHODS: Statistics from the German TraumaRegister DGU® as well as international registers were evaluated. The results of basic research and expert recommendations for diagnostics and treatment are discussed. RESULTS AND CONCLUSION: A strategic approach to conservative and surgical treatment of traumatic nerve injuries depending on the extent of injury and resulting regeneration potential is recommended. In conjunction with the clinical course, electrophysiology and imaging diagnostics, e.g. nerve sonography, can help to differentiate between neurapraxia, axonotmesis and neurotmesis.

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Otfrid Foerster (1873-1941) became a self-taught neurosurgeon during and after WW I, playing a critical role in the development of peripheral nerve reconstruction. Although best known for describing dermatomes, he published over 300 articles on the nervous system. Confronted by thousands of nerve injuries during WW I, as well as poor results and disinterest from his surgical colleagues, Foerster began performing neurolysis and tension-free nerve repairs himself under emergency conditions. He pioneered grafting motor nerve defects by expendable cutaneous nerves (e.g., sural) and performed intraplexal neurotizations and various nerve transfers, such as the pectoral, subscapular, long thoracic, and thoracodorsal nerves in brachial plexus injuries. Foerster championed rehabilitation, recognizing the potential of electrostimulation and physiotherapy to influence cortical reorganization (brain plasticity) and improve recovery after nerve injury. Foerster died from tuberculosis in 1941, leaving a rich reconstructive peripheral nerve legacy; his innovative and visionary spirit serves as a role model.

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Results after free flap reconstruction in the extremities are often impaired by missing color match of the transferred flap and the recipient site. But pre-existing color match is the precondition for satisfying aesthetic results. To obtain suitable free flap donor sites in terms of color for extremity reconstruction and to understand frequent color mismatch, we performed a colorimetric study including 60 healthy volunteers. Ten free flap donor sites were compared with ten recipient sites in the extremities. The results of our study showed that lower extremity sites are markedly lighter than upper extremity sites with the exception of the palmar forearm. We encountered an excellent color match of the radial forearm flap to the back of the hand (4.10 ± 1.91) and the palm of the hand (5.62 ± 2.21), and significantly relevant color match to the palmar aspect of the forearm (2.52 ± 1.23). Additionally, the lateral arm flap showed a remarkable color match to the dorsal aspect of the forearm (3.13 ± 2.06). Furthermore we encountered significantly relevant color match of the fibula flap to the anterior aspect of the lower leg (2.01 ± 1.08) and excellent color match of the anterolateral thigh flap (ALT) to the palmar aspect of the forearm (3.66 ± 2.10). No further significantly relevant color differences between the other donor sites and recipient regions were found. Colorimetric measurements are a helpful tool in reconstructive surgery to compare skin color of different anatomic sites.

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The anterolateral thigh (ALT) flap has become a workhorse in reconstructive surgery of the head and neck region and the extremities. However, its inconsistent vascular anatomy and frequent intramuscular course of perforators often cause difficulties during the dissection of this versatile flap. Hence, reliable preoperative perforator mapping and identification of vascular anomalies may render the raising of the flap easier and safer. The aim of this study was to evaluate the use of Color Duplex sonography and whether it allows the distinction between septocutaneous and musculocutaneous perforators. For this purpose, the thighs of 13 patients undergoing reconstruction with ALT flaps were examined preoperatively, and results were compared to intraoperative findings. A total of 30 perforators could be detected preoperatively, of which 29 were confirmed during flap dissection. Preoperative Color Duplex sonography correctly predicted the course of all perforators as either running through the vastus lateralis muscle or the intermuscular septum. In our investigations, Color Doppler sonography had a 96.7% positive predictive value and a 96.7% true positive rate in detecting perforators. Color Duplex sonography is a highly reliable tool in the preoperative assessment of ALT flaps. Localization and course of perforators can be determined accurately and vascular anomalies can be identified.

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OBJECTIVE: Reconstruction of active elbow flexion against gravity (strength grade > or =M(3)) by transfer of the latissimus dorsi muscle in order to improve the functionality of the upper extremity. INDICATIONS: Irreparable lesions of the musculocutaneous nerve (C(5)/6). Failure of regeneration after peripheral nerve reconstruction for the musculocutaneous nerve (neurolysis, suture, nerve grafting). Brachial plexus injury (lesions to the upper part, C(5)/6). Loss of biceps function due to trauma, ischemia, poliomyelitis or tumor. CONTRAINDICATIONS: Possible recovery of biceps function by reinnervation, spontaneously or after nerve reconstruction. Weakness of the latissimus dorsi muscle (strength grade < M(4)). Insufficient passive range of motion of the elbow joint (osteoarthritis, contracture). Lack of motivation, reliability, and cooperation of the patient in postoperative rehabilitation program. SURGICAL TECHNIQUE: The intact latissimus dorsi muscle is transferred with its origin and insertion ventrally and sutured with its thoracic aponeurosis into the insertion of the biceps tendon in order to act as an elbow flexor. POSTOPERATIVE MANAGEMENT: Following postoperative immobilization in an upper-arm Gilchrist bandage at 100 degrees flexion and supination (or neutral position, but not pronation) of the forearm for 6 weeks, passive motion exercises of the elbow are started. Active flexion and extension exercises begin at 8-10 weeks postoperatively. To prevent the deleterious effect of muscle and tendon elongation, an orthosis is used during the night to keep the elbow flexed at 90 degrees for 6 months. RESULTS: According to the authors' experience and the results reported in the literature, bipolar latissimus dorsi muscle transfer is a reliable method to restore functional elbow flexion regarding range of motion (> 90 degrees elbow flexion) and strength (at least antigravity strength, > or =M(3)) with acceptable donor morbidity and complication rate.

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BACKGROUND: We present a case of combined median nerve contusion with immediate loss of sensation after the strangulation with a wakeboarding rope and prolonged referral to our department 72 hours after the injury accompanied by an acute carpal tunnel syndrome with immediate relief of numbness of a significant proportion of the median nerve following surgical decompression. CASE PRESENTATION: The palmar branch of the median nerve was surrounded by a significant haematoma in addition to the strangulation damage caused by its more superficial location in contrast to the median nerve. CONCLUSION: In case of acute median neuropathy, urgent surgical intervention with exploration, decompression of both, the median nerve and the superficial branch of the median nerve, accompanied by compartment measurements of the forearm should be performed to regain or re-establish neurological integrity.

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Tendinopathy of the flexor carpi ulnaris tendon is a rare entity. We present a 35-year old tennis player suffering tremendous pain (visual analogue scale (VAS) rating of 9/10) at the flexor carpi ulnaris tendon with adjacent calcification in close proximity to the pisiform bone. Sclerosing therapy using polidocanol under power and laser Doppler guidance was initiated, with immediate decrease of capillary blood flow by 25% with resolution of the neovascularisation in power Doppler. Immediately following sclerosing, the patient's reported pain level on the VAS was reduced from 9/10 to 4/10. Following a short period of rest, eccentric training of the forearm muscle was initiated over 12 weeks with functional complete recovery and complete resolution of wrist pain.

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BACKGROUND: Radial artery forearm flaps are used for reconstruction of soft tissue defects. However, the functional consequences of removal of the radial artery for hand perfusion remain unclear at rest. We hypothesised that baseline microcirculation at rest is different following removal of the radial artery in a long-term perspective. METHODS: 114 atherosclerotic patients (100 males, 61.7+/-6.7 years) were included undergoing elective coronary revascularisation using the radial artery of the non-dominant forearm with non-pathological Allen's Test. Resting palmar microcirculatory mapping was applied at 25+/-5 months following removal of the radial artery regarding capillary flow, finger tip oxygenation as well as postcapillary venous filling pressures at both hands using combined non-invasive real-time laser Doppler flowmetry and spectrophotometry. RESULTS: 54/56 positions, more than 2 years following radial artery removal, did not reveal a difference beyond a 5% threshold at rest. No clinical signs of malperfusion were found following radial artery removal. No patient was impaired in his daily palmar motor activity or suffered exercise-related signs of malperfusion. Superficial and deep oxygen saturation decreased with age. In the non-donor hand, oxygen saturation declined in the first and second digits. Postcapillary venous filling pressure in both thenars increased with age. CONCLUSIONS: The hypothesis was rejected. Pedicled removal of the radial artery does not compromise superficial or deep palmar capillary blood flow, finger tip oxygenation or postcapillary venous filling pressures among atherosclerotic patients at rest in a clinically significant way.

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BACKGROUND: The relationship of non-invasive CW Doppler cardiac output (COUSCOM) and stroke volume (SVUSCOM) and calculated COSTRINGER and SVSTRINGER based on the Stringer calculations in healthy athletes is unknown. METHODS: 20 athletes (19.9+/-11 years) underwent a standardized stepwise treadmill test including breath-by-breath spirometry, and non-invasive SVUSCOM and COUSCOM. Stringer formula a-vDO2=5.721+(0.1047%VO2max) and CO=VO2/C(a-vDO2) (direct Fick method) were applied. RESULTS: Total values of COSTRINGER vs. COUSCOM and SVSTRINGER vs. SVUSCOM showed high correlation (r=0.879 and r=0.813, p<0.01). Mean differences between total measures of COSTRINGER vs. COUSCOM were 0.4+/-4.1 l/min and SVSTRINGER vs. SVUSCOM -9.9+/-19.9 cm3. Mean % errors were COSTRINGER vs. COUSCOM -31+/-66% and SVSTRINGER vs. SVUSCOM -39+/-58% respectively. Regression modelling determined COSTRINGER=1.58CO-4.02 l/min, and SVSTRINGER=1.45SV-35.60 cm3. SVSTRINGER vs. SVUSCOM correlated best at peak exercise (r=0.997), followed by r=0.668 at recovery3 min and 0.585 at recovery1 min. COSTRINGER vs. COUSCOM correlated best at recovery3 min (r=0.611), followed by recovery1 min (r=0.556) and moderately at peak exercise (r=0.447). At rest, both COSTRINGER and SVSTRINGER were not correlated with COUSCOM and SVUSCOM (r=0.276 and r=0.130, respectively). CONCLUSION: Calculated SVSTRINGER and COSTRINGER are applicable at peak exercise and during recovery compared to CW Doppler SVUSCOM and COUSCOM. However certain limitations are evident regarding calculated COSTRINGER at peak exercise and at rest in comparison to CW Doppler measurements.

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BACKGROUND: The effect of combined cryotherapy/compression versus cryotherapy alone on the Achilles tendon is undetermined. HYPOTHESIS: Standardized combined cryotherapy/compression changes in midportion Achilles tendon microcirculation are superior to those with cryotherapy during intermittent application. STUDY DESIGN: Controlled laboratory study. METHODS: Sixty volunteers were randomized for either combined cryotherapy/compression (Cryo/Cuff, DJO Inc, Vista, California: n = 30; 32 +/- 11 years) or cryotherapy alone (KoldBlue, TLP Industries, Kent, United Kingdom: n = 30; 33 +/- 12 years) with intermittent 3 x 10-minute application. Midportion Achilles tendon microcirculation was determined (O2C, LEA Medizintechnik, Giessen, Germany). RESULTS: Both Cryo/Cuff and KoldBlue significantly reduced superficial and deep capillary tendon blood flow within the first minute of application (43 +/- 46 arbitrary units [AU] vs 10 +/- 19 AU and 42 +/- 46 AU vs 12 +/- 10 AU; P = .0001) without a significant difference throughout all 3 applications. However, during recovery, superficial and deep capillary blood flow was reestablished significantly faster using Cryo/Cuff (P = .023). Tendon oxygen saturation was reduced in both groups significantly (3 minutes Cryo/Cuff: 36% +/- 20% vs 16% +/- 15%; KoldBlue: 42% +/- 19% vs 28% +/- 20%; P < .05) with significantly stronger effects using Cryo/Cuff (P = .014). Cryo/Cuff led to significantly higher tendon oxygenation (Cryo/Cuff: 62% +/- 28% vs baseline 36% +/- 20%; P = .0001) in superficial and deep tissue (Cryo/Cuff: 73% +/- 14% vs baseline 65% +/- 17%; P = .0001) compared with KoldBlue during all recoveries. Postcapillary venous filling pressures were significantly reduced in both groups during application; however, Cryo/Cuff led to significantly, but marginally, lower pressures (Cryo/Cuff: 41 +/- 7 AU vs baseline 51 +/- 13 AU; P = .0001 and KoldBlue: 46 +/- 7 AU vs baseline 56 +/- 11 AU; P = .026 for Cryo/Cuff vs KoldBlue). CONCLUSION: Increased tendon oxygenation is achieved as tendon preconditioning by combined cryotherapy and compression with significantly increased tendon oxygen saturation during recovery in contrast to cryotherapy alone. Both regimens lead to a significant amelioration of tendinous venous outflow. CLINICAL RELEVANCE: Combined cryotherapy and compression is superior to cryotherapy alone regarding the Achilles tendon microcirculation. Further studies in tendinopathy and tendon rehabilitation are warranted to elucidate its value regarding functional issues.

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