Reappraisal of Clinical Deficits Following High Median Nerve Injuries

Abstract

Purpose: To describe clinically apparent motor and sensory deficits in a cohort of 11 patients with isolated injury of the median nerve above the elbow and compare them against similar cases reported in the literature.

Method: Eleven patients of mean age 30 years (SD ± 14 years; 6 males, 5 females) were examined a mean of 21 weeks (SD ± 16 weeks) after an isolated high median nerve injury. Pronation, wrist flexion, and finger flexion range of motion and strength (British Medical Research Council scale) were evaluated. Grasp and lateral pinch strength were assessed bilaterally using a dynamometer. Thumb opposition was evaluated using the Kapandji score. Sensory impairment was considered significant when there was no perception of a 2.0-g Semmes-Weinstein filament.

Results: Pronation was largely preserved in all patients to a mean range of motion of 52° (SD ± 13°), and pronation strength was M4 in 10 of 11 patients. Wrist flexion scored M5 in all patients. Thumb and index distal interphalangeal joint flexion were absent in all patients. In all patients, middle, ring, and little finger flexion was complete and scored M5. Thumb function scored above 5 in all patients, averaging 7.5 (SD ± 1.2) on the Kapandji scale. Grasp and pinch strength were 43% (SD ± 12%) and 36% (SD ± 11%) of the contralateral (normal) limb, respectively. Impaired sensation of a 2.0-g monofilament was found only in the palmar region over the middle and distal phalanges of the index and middle fingers and the distal phalanx of the thumb.

Conclusions: Noteworthy discrepancies were identified between the clinical motor and sensory deficits described in the literature and those observed in our patients.

Clinical relevance: In most patients with a high median nerve injury, only thumb and index flexion and palmar sensation warrant surgical reconstruction. Decreased grasp and pinch strength was a major finding that should also be addressed by surgery.

Type of study/level of evidence: Prognostic IV.

Keywords: Median nerve; above-elbow median nerve injury; median nerve palsy; nerve transfer; proximal median nerve injury.