Case Report Radial, Median, and Ulnar Nerve Dysfunction Associated with a Congenital Constricting Band of the Arm Paul M. Weeks, M.D. Jas, Dysfunction of the motor component of a pe- ripheral nerve secondary toa congenital constrict- ing band has not been documented. Moses, Flatt, and Cooper’ reviewed 45 patients with congenital constriction bands. Neural deficits were noted in “23% of the patients.” ‘The “upper part of the arm” was involved in three patients, Nine pa- tients with constriction rings proximal to the wrist or ankle had deficits in sensation (pinprick, light touch). No patients had motion deficits or loss of proprioception. Simple removal of the constric- tion ring and closure of the wound using a Z- plasty was associated with an improved neuro- logic status. The object of this report is to call attention to the need for complete neurologic evaluation of the patient with a congenital band as well as the need for exploration of the involved nerves at the time of band release. Case Report A S.week-old white female, the product of a normal pregnancy and delivery, wan referred for evaluation of constricting band of the right arm. The child was the firs born of her 22-year-old parents. Physical examination re vealed a severe consricting band in the midarm level (Fig 1), Tissues beneath the band were firm aod resisted com pression. There was no edema in the extremity distal to the band, Motion about the shoulder was normal, and the child was able to extend and flex the elbow. ‘The Finger flexors hhad “tone,” and no activity was evident, ‘The wrist was slightly flexed and held in wlnar deviation. There was no evidence of finger or thumb extension, but the parents felated that chey had seen some movement (either real or imagined). Because of a distinctly positive response to pin prick in the little finger pulp, testing sensation in he median And radial nerves was precluded, The following possibilities were entertained to explain the neurologic Findings: (1) the nerves were intact but. com pressed by the band: (2) comprewion by the band had From the Dis a8 resulted in axonotmesis: (8) there was complete disruption lf nerve trunks: or (2) there were no nerves prevent distal 1 the site of the band, Previous reports on nerve dysfinet indicated that compression by the constricting hand was the culprit Surgery was directed toward removal of the constricting band and thereby decompression of the nerves. In September of 1978, an 8mm cuff of normal tissue on each side of the band was inchided in the specimen to eliminate infolding hy the skin partiipating in the band. Approximately 80 percent of the circumference of the band was removed, There was obvious compression of the muscle mass. I hes tated to explore the nerves because of concert fering with vascular and lymphatic eewurn from the hand. A single, large Z-planty was used (0 eloxe the wound The size and extent of the resection was certainly ade- quate 10 completely decompress the nerves. ‘The child's Postoperative course was unremarkable, and in November of 1078 (age 9 weeks). she underwent resection of the te maining 20 pereent of the band and closure with a singe Z- plasty [elected to wait 5 months to see how much improve rent there would be in the child's neurologic satus, There was none, In March of 1979, electromyographic studies, revealed severe searcity of units in the wrist extensors and Rexors. Nerve conduction studies are summarized in Table I [elected to wait an additional 6 months. In September of 1979, it was evident that no improvement had occurred. On Sepiember 26, 1979, the radial nerve was explored through the previous incision, The brachial muscle was reflected, as was the triceps, a the level of the band, This revealed severe compression of the radial nerve as it penetrated the lateral intermuscular septum. «large neuroma and larger glioma were separated by the septum (Fig. 2). Removal of the septum revealed a thin, cm filament of tissue extending from the neuroma to the glioma (Fig, 3). The involved nerve was resected and a hem sural nerve graft was obtained from the right foot, The sural nerve was ax large as the normal radial nerve. An epincural repair was accomplished using 9-0 suture with the aid of the aperating microscope (Fig. 4. Av result ofthese Findings, we were obligated to examine the median and ulnar nerves. Yet we were hesitant to do the entire disection at one siting of Plastic Surgery at the Washington University Schl of Medicine334 Fie. 1. Asevere eunstricting band 2 mo in width extends 1 the humerus, Note absence of distal swelling TABLE 1 Moor Nerve Conduction Velocity Study Uinar 2 ney ao forms HOH) ek) HH HD Radial Attempts eis adil semany espn wee nn acon In December of 197%, the median and wlbsar nerves were explored through the site of band excision, The median andl Ulhae nerves were identified proximal an! distal to the site fot and excision. Hoth nerve were af nar caliber pr ally andl listally. ‘There was severe compression of the nerves at the site \lexciien, This appeared to represent scar deep te the dermal searring associated! with the eongen ital hand. psevloneuroma of the median nerve was present proximal w the site of the compression, but the nerve was af hhormeal caliber distally (Fig. 5) A 2c seynient eas mark tally compressed When the median nerve ssas sinnslatel wither dorsal oF prosinsal to the site of campresion, most: tent was observed in the hand and seri. The ulnar nerve twas more severely compress a 2-em segment (Fig. 6) TThe most distal point of eompresion way sshere the nerve penetrated he medial intermusetar septam. When the Slnae nerve wis stimulated proximal and distal ta the cow sleet, there wat siguifcant eontraetion of the fingers a talnae deviation of the hand It was elected to leave the heres intact. Mer ensiing that the nerves were completely dlecumpesed, the wounds were clned April of 0, 4 months after decompression of the ane mice nerves, the chill coll fle the tha, st. The parents had observed slight extension a the tng and lise fingers Tn December of 1980, 12 months after decompression af the median and ulnar nerves and 1 months fier sal nerve graft the radial nerve. electromyography revealed many Abrillations ancl severe sareity of units in the wrist PLASTIC AND RECONSTRUCTIVE SURGERY, February 1982 Fs, 2 ‘The lateral interment septiny tered) is severely cutrieting the radial nerve. Note large qhinma (hick aor) sel necro i ar extensors, "There were few fibillations in the wrist flexors, The nerve conduction studies see summarized in Table Th The right upper extremity has failed to grone at the same rate as the normal left upper extremity, but its growing Discussion Barenberg and Greenberg’ reported a 10-day- old boy with multiple congenital bands involving the right lower extremity (multiple toes and the leg just above the ankle). At 18 months, the right foot was noted to be anesthetic. The ring was released by excision and direct closure. Perception, of pinprick was noted below the ring eonstrietion and a “small part of the dorsum of the foot.” Stevenson’ reported a 10-year-old boy with wwo contraction bands—one just below the knee and. the second just above the ankle. The anterior part of the foot was absent. He stated that there was an “absence of nerves or muscles passing through points of constriction.” Neither nerves nor mus: cles were visualized at the time of surgery. After surgical release, sensation was regained down to the ankle Blackfield and Hause" reported a 4-month-oldVol. 69, No. 2 / avian Pc. 3. The lateral intermusculae sepruny has been ex ised exposing a thin filament extending from the nevirant te the glioma Hic, 1 Radial nerve continuity has been seestablished ssid 9 sural nerve graf, white female with three constricting bands of the Fight leg with anesthesia of the leg distal to the second band located at the junetion of the upper and middle thirds of the leg. No follow-up re garding anesthesia is given Pers reported an infant with congenital ab- sence of skin involving most of the for MEDIAN, ASD CLNAR NERVE DYSFUNCTION: 335 Fie. 5. The median nerve was compres by a 2s band of sear. A penidonicurona is evident provintal to the site nf compression, naved to expan the severely comprewed ulnar nee TABLE It Motor Nerve Conduction Velocity Study Median 2 7 oz) oa ntl) Gy etm ha am Ulnar a on Cee (ronal Oy LM esaN oan Radia Alte to otc raise rater woe narrow bridge of skin on the volar surface of the forearm showed a groove. There was cither a radial nerve palsy or loss of the extensor mu associated with the congenital absence of skin. ‘The wound was skin-grafted and the wrist sup- ported to prevent wrist drop. No comment is made concerning the nerve. In Flats 45 cases, 12 had neurologic deficits as336 determined by pinprick and light touch. None had motor or proprioception loss. This case should alert one to the necessity for ‘examination of the major nerve trunks beneath a ring constriction in the extremity with a neuro- logic deficit. The relative contribution of the constriction band and the lateral intermuscular septum to radial nerve compression is not clear. It is clear that simple removal of the constrictin ring did not decompress the radial nerve, Re- ‘moval of the intermuscular septum was necessary for decompression of the radial nerve. In this case, the nerve was so severely compressed that resec- tion and grafting were necessary. The occurrence of a normal-sized nerve distal to the constriction band indicates that compression of the nerve ‘occurred after normal formation of the major nerve trunks. It can be assumed that if the nerve was never in continuity over the compression site, the distal segment would have been atrophic. Since the distal segment was of normal caliber, fone can assume that nerve compression was of recent origin. The occurrence of the band imme- diately over the site of perforation of the lateral intermuscular septum by the radial nerve may have accentuated compression of the nerve by failure of the septum to develop normally The compression of the ulnar nerve was most severe at the site of its penetration of the median intermuscular septum. Similar to the radial and median nerves a 2-cm segment of the ulnar nerve was compressed. The most narrow part of the nerve was at the level of the septum. A. broad band of scar compressed the median and ulnar nerves over the same area at the same level This case brings into focus several considera- tions when managing a child with a congenital band overlying major nerve trunks: (1) the phys- ical evaluation of nerve function must be as thor- ‘ough as possible, even in the infant; (2) if there is evidence of nerve dysfunction, then clectromy- ographic and nerve conduction studies should be obtained; (3) at surgery, the most severely involved nerve should be explored and man- agement should be determined by preoperative physical examination, intraoperative nerve stim- ulation, and findings at surgery; (4) if removal of the constriction band is to be accomplished in PLASTIC AND RECONSTRUCTIVE suRcERY, February 1982 tone stage, one might choose to explore the major nerve trunks beneath the band: (5) ifa two-stage removal of the band is planned, the second stage should be performed as soon as feasible: and (6) complete removal of the constriction band may not completely decompress the nerves—the nerves may be compressed by hypoplastic struc tures beneath the band or by deeper scar. ‘A word about one-stage removal of constricting bands. This infant had no edema of the upper limb, yet she had a severe constriction. We were concerned that interference with vascular or lym- phatic return by extensive dissection could create a problem that did not exist before surgery. We removed 80 percent of the band but left 20 per- cent undisturbed, The patient had no edema afier any of the procedures. I expect the same result would have been seen following single-stage SuMMany A Baweek-old infant is described with a severe congenital ring constriction of the arm associated with total radial nerve palsy and median and ulnar nerve dysfunction. Observations made dur- ing this patient’s management may be of benefit in similar cases Paul M. Weeks, M.D. Division of Plastic Surgery +4960 Audubon Avenue St. Louis, Mo. 63110 REFERE! 1. Stevenson, T. W, Release of cieular constricting sear bby Zflaps, Plas. Reconstr. Sug. 1: 38, 1946, 2, Barenberg, L. H.,and Greenberg, B. Intrauterine am- pputations and constriction bands. Report of a case With anesthesia below the constriction. Am J. Dis Child. 64: 87, 1942. 3. Blackfield, H. Mand Hause, D. P, Congenital eon- stvicting bands of the extremities. Plast. Recon, Sur. 8: 101, 1951 4, Plau, AE. Constrition Ring Syndrome. In The Care of Congenital Hand Anomalies. St. Louist Mosby, 1977, P. 213. 5. Moses, JM. Platt, AE. and Cooper, RR. Annular constricting bands. J. Bone Joint Surg. VA 39, 1946. 6. Pers, M.- Congenital absence of skin: Pathogenesis and ‘elation so ring-constrietion. Acta Chi, Scand. 126: 388, 1965; 2. Smith, E, Multiple excision and % plastics in surface reconstruction. Plast. Rect. Surg. 1: 170, 196.