Abstract
Ulnar neuropathy at the elbow (UNE) is commonly encountered in clinical practice. It results from either static or dynamic compression of the ulnar nerve. While the retroepicondylar groove and its surrounding structures are quite superficial, the use of ultrasound (US) imaging is associated with the following advantages: (1) an excellent spatial resolution allows a detailed morphological assessment of the ulnar nerve and adjacent structures, (2) dynamic imaging represents the gold standard for assessing the ulnar nerve stability in the retroepicondylar groove during flexion/extension, and (3) US guidance bears the capability of increasing the accuracy and safety of injections. This review aims to illustrate the ulnar nerve's detailed anatomy at the elbow using cadaveric images to understand better both static and dynamic imaging of the ulnar nerve around the elbow. Pathologies covering ulnar nerve instability, idiopathic cubital tunnel syndrome, space-occupying lesions (e.g., ganglion, heterotopic ossification, aberrant veins, and anconeus epitrochlearis muscle) are presented. Additionally, the authors also exemplify the scientific evidence from the literature supporting the proposition that US guidance is beneficial in injection therapy of UNE. The non-surgical management description covers activity modifications, splinting, neuromobilization/gliding exercise, and physical agents. In the operative treatment description, an emphasis is put on two commonly used approaches—in situ decompression and anterior transpositions.
Highlights
Ulnar neuropathy at the elbow (UNE) represents the second most common entrapment neuropathy in the upper extremity encountered in clinical practice
Wade et al., [98] in 2020, performed a comprehensive review and meta-analysis of all possible open or endoscopic methods for treating cubital tunnel syndrome. They found that open in situ decompression appears to be the safest and most effective method for primary cubital tunnel syndrome patients. It was associated with the greatest response to treatment and the lowest risk of complications, reoperation, and recurrence
Open in situ decompression should be considered a first choice in treating patients with primary cubital tunnel syndrome
Summary
Ulnar neuropathy at the elbow (UNE) represents the second most common entrapment neuropathy in the upper extremity encountered in clinical practice. VanVeen et al [90] in their study used visualization in the long axis, which, FIGURE 10 | (A) Prone position for the ultrasound-guided ulnar nerve in-plane injection with the elbow flexed and hanging over the examination bed. Another feasibility study was conducted by Choi et al, [88] who assessed the in-plane approach of US-guided steroid injection for cubital tunnel syndrome in 10 patients Their results showed a statistically significant decrease in the severity of the symptoms as evaluated by the VAS and CSA decrease in the first and fourth week of follow-up. Its theoretical advantages are the patient’s faster recovery, decreased invasiveness, minimal adverse events, and less scar discomfort It should be applied only in selected cases without evidence of nerve subluxation, traumatic etiology of cubital tunnel syndrome, or significant structural pathology [106]. Another disadvantage is that it is necessary to have an assistant holding the arm in place and changing the flexion degree as needed [99]
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