Ulnar Claw Research Articles

Excision of large median and ulnar nerve schwannomas: a case series

ObjectiveSchwannomas are benign, slow-growing tumors originating from Schwann cells in peripheral nerves, commonly affecting the median and ulnar nerves in the forearm and wrist. Surgical excision is the gold standard treatment. This study presents our treatment strategies and outcomes for large-sized ulnar and median nerve schwannomas at the forearm and wrist level.MethodsFrom 2012 to 2023, we enrolled 15 patients with schwannomas over 2 cm in size in the median or ulnar nerve at the forearm and wrist. The study included 12 patients with median nerve schwannomas (mean age: 61 years) and 3 with ulnar nerve schwannomas (mean age: 68 years), with a mean follow-up of 26.9 months.ResultsAfter surgery, all patients with median nerve schwannomas experienced mild, transient numbness affecting fewer than two digits, resolving within six months without motor deficits. Ulnar nerve schwannoma excision caused mild numbness in two patients, also resolving within six months, but all three developed ulnar claw hand deformity, which persisted but improved at the last follow-up. Despite this, patients were satisfied with the surgery due to relief from severe tingling pain.ConclusionsSchwannomas of the median, ulnar, and other peripheral nerves should be removed by carefully dissecting the connecting nerve fascicles to avoid injury to healthy ones. Sensory deficits may occur but are unlikely to significantly impact quality of life. However, in motor-dominant nerves like the ulnar nerve, there is a risk of significant motor deficits that could affect hand function, though not completely. Therefore, thorough preoperative discussion and consideration of interfascicular nerve grafting are essential.

Modification of the Zancolli Lasso Procedure for Simultaneous Correction of Wartenberg's Sign.

Ulnar nerve injury initiates an imbalance between the intrinsic muscles and extrinsic extensors of the ring and small fingers, which leads to the characteristic hyperextension of the metacarpophalangeal (MP) joints and flexion of the proximal interphalangeal joints of these 2 digits-commonly referred to as the ulnar claw hand. In addition to these changes in the static posture of the hand, ulnar nerve palsy severely impairs grasp due to deficient active MP joint flexion. In most cases, motor balance can be restored by preventing MP joint hyperextension and augmenting MP joint flexion using the Zancolli lasso procedure (ZLP). Ulnar neuropathy can cause a second motor imbalance between the ulnar intrinsics and the extensor digit minimi leading to an abduction deformity of the small finger known as Wartenberg's sign. The inability to adduct the small finger can be a great source of frustration to patients. Using a cadaveric biomechanical model, we have developed a simple modification of the Zancolli lasso procedure that simultaneously corrects claw deformity and Wartenberg's sign and we report its efficacy in 2 clinical cases.

Cobb Syndrome, A Rare Disease – Case Report

Cobb syndrome is a rare genetic disorder characterized by dermatomal pattern, with corresponding muscular, osseous, paraspinal, and/or spinal vascular lesions occurring at the same body somite (metamere). It is also known as spinal arteriovenous metameric syndrome (SAMS) and cutaneous meningospinal angiomatosis. We present a case of a 36 years old male presented to OPD with Complain of progressive weakness of Right upper limb for 5 years. On examination, Patient had large cutaneous port wine stain on the right side of the chest, nape of neck, and along the whole right upper limb in a dermatomal distribution with ulnar claw hand wasting of thenar muscles on right side. MRI cervical spine with contrast showed aggressive vertebral hemangioma involving anterior and posterior arch of C1 vertebra, vertebral body of C2 to C5, right half of vertebral body of C2 and C6 and right pedicle of C2 to C5 vertebra. Abnormal thickened and T2WI /STIR hyperintense skin and subcutaneous tissue involving right half of scalp and right half of neck which showing post contrast enhancement, possibility of subcutaneous hemangioma. Cobb syndrome was diagnosed based on the dermatomal distribution of the cutaneous vascular lesions and the corresponding vertebral, epidural, and paraspinal vascular lesions occurring at the same metamere. Treatment decision is guided by the patient’s symptoms and imaging features.

Presence of accessory abductor digiti minimi muscle in two cadavers.

During routine cadaveric dissection, accessory hypothenar muscles were incidentally discovered in two cadavers, both males, aged 86 and 92. Both muscles originated from the palmaris longus tendon in the distal portion of the forearm and were identified as accessory abductor digiti minimi (AADM) muscles, based on their association with abductor digiti minimi. While AADM is a common variant in the antebrachium, it is less typical for them to originate from the palmaris longus tendon. The presence of such an AADM could complicate surgical procedures requiring resection of the palmaris longus tendon. Moreover, the surrounding neurovasculature - namely the ulnar nerve as it passes through the ulnar canal between the pisiform and hook of the hamate - could be compressed by contractions of an AADM with such a proximal origin. This can manifest as ulnar neuropathies resulting in pain, weakness, or protracted flexion of the fourth and fifth digits (ulnar claw). Our description of these muscles adds to previous accounts of variation of the palmaris longus and abductor digiti minimi muscles while considering potential clinical implications.

A cross-sectional study on burden of disability among leprosy patients in a tertiary care center of West Bengal, India

Background: Leprosy, an infectious disease caused by Mycobacterium leprae, mainly affects skin, peripheral nerves, mucosa of the upper respiratory tract, and eyes. New goal of the WHO is to decrease the rate of disabilities in new cases among 10 lakhs population 35% with compare to base line 2010. Burden of disabilities continues to rise in society and they are in need of prevention and/or rehabilitation services. Prevention of disability consists of early detection and treatment of reactions and nerve damage. Aims and Objectives: The objectives of the study were to find out the proportion of disability among leprosy cases and the factors associated with disability. Materials and Methods: This observational, cross-sectional, and descriptive study was conducted at Dermatology, Venerology, and Leprosy Department of a tertiary hospital from May 2015 to January 2016. Data were collected from all the study population by interviewing the study subjects and clinical examination of patients with pre-designed and pre-tested schedule and disability assessment form available from National leprosy eradication program (NLEP). Skin examination was done as per NLEP guideline and palpation of all the nerve and function of the nerve by voluntary muscle testing (VMT) done as stated national guideline. Data were analyzed using R Studio. Results: Among the study population, 87.9% of patients had disability and 61.7% of patients had Grade 2 disability. EHF score of most of the patients (59.8%) was ranged between 4 and 6. Among participants 33.6% had foot ulcer, 28% had ulnar claw hand, and 15.6% had lagophthalmos. Proportions of the upper limb digit loss, median claw hand, wrist drop, foot drop, and lower limb digit loss were 5.6%, 13.1%, 3.7%, 9.3%, and 12.1%, respectively. Conclusion: The present study reflected that a large number of cases with leprosy have presented with complication and disability. There was significant association of disability with multibacillary cases, number of nerve thickening, and number of functionally impaired nerve as assessed by VMT, lepra reaction, presence of nodular skin lesion and patch in skin and delayed initiation of treatment since the onset of symptoms.

Reconstructive Surgery of Ulnar Claw Hand in Leprosy Patients by Lasso Procedure

Leprosy, Hansen's disease caused by mycobacterium leprae, is widely known. Though there has been a substantial achievement in recent years given eliminating the disease, the deformity caused by the disease needs to be managed by reconstructive surgery. The ulnar nerve being superficial, is the most common nerve affected. When affected, the muscles innervated by the nerve begin to weaken, leading to a disparity between the strong extrinsic muscles and the weakened intrinsic muscles and is characterized clinically by metacarpophalangeal joint hyperextension and flexion of the proximal and distal interphalangeal joint. Doing reconstructive surgery on these patients will help them carry out day-to-day activities and reduce social awkwardness. Corrective surgeries like modified Stiles-Bunnell transfer, extensor carpi radialis graft, Zancolli lasso procedure, and palmaris longus tail graft are known to us. Out of all, the Zancolli lasso procedure was chosen for operating on all our cases because all other surgeries need high precision with proper training and proper post-operative physiotherapy. The study aims to evaluate the functional outcome of patients with leprotic ulnar claw hand operated with the Zancolli lasso procedure. Objectives assessed were deformity correction, grip strength, and range of motion. During the last two years, ten patients with ulnar claw hands came to Sree Balaji Medical College and Hospital, Chennai. They were operated on with the Zancolli Lasso procedure with adequate results. The zancolli procedure is easy to do and can be done in small centers, which restores finger flexion and doesn’t harm other superficialis tendons, thus preventing swan neck deformity of the fingers.

Anti-Claw Procedure with Modified Dynamic Flexor Digitorum Superficialis Transfer for Ulnar Nerve Palsy: Our Experience.

The ulnar nerve palsy is a distressing injury, resulting in clawing of hand. The cause of clawing is due to paralysis of the interosseous muscles in the presence of functioning long extensor and long flexors of fingers. Various methods have been proposed to correct this deformity which include both static and dynamic procedures. In this study, we share our experience with flexor digitorum superficialis tendon transfer using Zancolli's modification for anti-claw correction. It was a retrospective case series study. A record of 53 patients was included in the study, during a period between June 2013 to July 2017 with ulnar nerve palsy. The procedure done was flexor digitorum superficialis tendon transfer as dynamic anti-claw procedure. The follow-up period was three months. The outcomes assessed were grip strength by using sphygmomanometer and active range of motion of fingers assessed by fingers tips touching the palm. Fifty-three patients were included out of them, there were fifty males and three females. The mean age was 28±10 years. All patients underwent flexor digitorum superficialis transfer for ulnar claw hand. A total of 84.9% patients have good grip strength and 83% showed good active range of motion. Flexor digitorum superficialis tendon transfer is found to be effective, reliable and reproducible technique in ulnar nerve palsy where patient need grip strength, good range of motion and acceptable hand function for daily routine work.

Correction of ulnar claw hand – A comparative study of extensor carpi radialis longus (ECRL) and flexor digitorum superficialis (FDS) as the motor unit of choice

Leprosy is a chronic infectious disease caused by M. leprae, with peripheral neuropathy as its most common manifestation. Deformity of the hand is particularly debilitating and the ulnar claw hand is the most common presentation. There are various surgical options available for correcting clawing in Hansen’s disease. In the present study we have tried to identify patient-related factors favouring either Extensor Carpi Radialis Longus (ECRL) or Flexor Digitorum Superficialis (FDS) as the motor unit of choice. Method A comparative study of ECRL (Brand Procedure) and FDS (Stiles–Bunnel) motor tendon transfer in the ulnar claw of hand was carried out. Correction of clawing of fingers was done in 60 ulnar claw hands using transfer of motor units ECRL and FDS. The Z deformity was corrected by 1∕2 FPL to EPL transfer. 12 cases were lost to follow up over the course of 5 years, so 48 cases were followed for up to 2 years, for various activities of daily life and routine work. Conclusion Both the transfers gave equivalent results. No morbid deformity was seen in ECRL transfer except the scar on the donor thigh. FDS transfer is the best reconstructive tendon transfer procedure for correction of ulnar claw hand in manual labourers. For white-collar workers, ECRL transfer should be the choice.

Dynamic correction of ulnar claw hand deformity with a simple insertion into the lumbrical muscle

Numerous methods of tendon transfers are available to correct claw hand deformity. In this article, we describe a simple insertion of the transferred flexor digitorum superficialis tendon, into the lumbrical muscle and proximal tendon. Sixty patients underwent surgery for claw hand correction. These were equally divided into three groups undergoing; modified Stiles Bunnell procedure; 'lasso' insertion into A1 pulley and the lumbrical insertion procedure. Evaluation was done with proximal interphalangeal joint angle measurements, grip strength and using the Brand's criteria, 1 year after surgery. The improvements were comparable among the three groups. Insertion into the lateral bands has been a standard method of claw correction. In addition to correcting the hyperextension of the metacarpophalangeal joint, it transmits force for interphalangeal joint extension and restores the sequence of flexion of fingers, thus making the grasp effective. Insertion into the lumbrical muscle belly and proximal tendon shows similar results. It can be performed via a single incision in the palm, reducing operative time.

Correction of ulnar claw hand and Wartenberg’s sign

Ulnar claw hand usually occurs when the ulnar nerve is damaged distally. Claw hand deformity is characterized by metacarpophalangeal hyperextension and interphalangeal flexion, making it impossible to oppose the fingers and thumb. Bouvier’s test is used to guide the procedure. Palliative surgery requires prior preparation of paralytic hands. In case of a positive Bouvier’s test, Zancolli’s lasso technique is preferred because of its effectiveness. Capsuloplasty with anteroposterior transosseous fixation is used if the bone is strong enough and when flexor digitorum profondus muscle is inactive and does not allow flexor digitorum superficialis tendon transfer. In case of a negative Bouvier’s test with interphalangeal extension deficit of 45° of less, direct interossei muscle restoration techniques by active transfers are performed. If the interphalangeal extension deficit is more than 45°, proximal interphalangeal arthrodesis is indicated.Wartenberg first described actively irreducible abduction of the little finger. Wartenberg’s sign is seen when ulnar paralysis occurs, and during ulnar nerve regeneration. Treatment of isolated Wartenberg's sign consists of re-routing the extensor digiti minimi. Among the other techniques, Belmahi’s “tie lasso” is preferred when flexible claw hand is associated with Wartenberg’s sign.

Visible disability as a presenting feature of leprosy: a rare but real concern in post-elimination phase in India

<p class="abstract">Leprosy (Hansen's disease) is a chronic infectious disease caused by <em>Mycobacterium leprae</em>, affecting mainly peripheral nerves and skin. Delayed diagnosis contributes to sensory-motor impairment leading to deformity and disability, thereby imposing a major impact on the physical, social, economic and psychological domains of the quality of life of affected individuals. Deformities and disabilities are largely preventable complications associated with tremendous social stigma and discrimination, assuming public health significance. India declared elimination of leprosy more than a decade and half ago in 2005. Hence, grade 2 disability is expected to be a rare manifestation in the post-elimination era. However, to the contrary, the proportion of new leprosy patients with visible disability recorded in India exceeds the global rate. Herein we report a middle-aged female presenting with saddle nose, bilateral fixed ulnar and mobile median claw hands (grade 2 disability) with multiple trophic ulcers. This case emphasizes that clinical suspicion after careful examination of skin and neural manifestations is of utmost importance for the early diagnosis of leprosy. Timely self-reporting and management with WHO-multi drug therapy (MDT) remains the key to minimize the risk of deformity and disability. Above all, it is essential to create awareness amongst the community regarding prompt recognition of symptoms and easy access to appropriate care along with intensified efforts to address the associated stigma.</p>

Anterior elbow fracture dislocation with ulnar nerve palsy in a six-year-old child

Background. Anterior elbow fracture dislocation is rare, especially in paediatric age group. Of the reported cases to date, three-quarter were posterior dislocation of the elbow. Anterior elbow dislocation is rarely reported, with incidence of only 2%.
 Clinical case. A 6-year-old girl presented to casualty with left elbow deformity and pain after she tripped and fell in the toilet. Ulnar clawing was present with reduced sensation over ulnar nerve distribution. No wound was found, distal pulses and circulation were good. The X-rays showed anterior dislocation of the left elbow with olecranon fracture. Closed manual reduction was attempted but failed. Open reduction and percutaneous K-wire insertion under general anaesthesia was performed. Medial approach of the elbow was done. Intra-operatively ulnar nerve was found impinged by the distal ulnar fragment but was in continuity. The transverse olecranon fracture was fixed with two K-wires and the radial head was reduced. Ulnar nerve was mobilised until tension-free. Ulnar collateral ligament was repaired. The elbow was immobilised with a splint. Ulnar claw was resolved at 2 weeks. The fracture heals and the K-wires were removed at 6 weeks. At 8 weeks, range of movement of the elbow was full. The elbow was stable in varus and valgus.
 Discussion. Anterior elbow dislocation is a high energy trauma and one should be cautious of neurovascular injury. There was no clear recommendation in the literature regarding surgical approach. We chose medial approach of the elbow for ulnar nerve exploration and olecranon fixation.
 Conclusion. This rare injury should be treated with high index of suspicious. Surgical approach should be tailored individually according to the instability of the elbow joint and neurovascular status, as in this case was the posteromedial instability associated with ulnar nerve palsy.

Evaluation of Different Modalities of Tendon Transfer in Ulnar Nerve Palsy

Background: Tendon transfer surgery is a type of hand surgery that is performed in order to improve lost hand function. A functioning tendon is shifted from its original attachment to a new one to restore the action that has been lost. Aim of the study: the present study was performed to evaluate the different modalities of tendon transfer in management of clawing of little and ring fingers in ulnar nerve palsy. Patients and Methods: Correction of clawing of ring and little fingers was done in 20 patients (with ulnar palsy whether high or low; age range: 5-60 years). Different techniques of tendon transfer were used including Zancolli-lasso procedure using flexor digitorum superficialis (FDS), Stiles Bunnel procedure using FDS and Brand procedure Results: Anti-claw procedures were performed in 20 cases, 10 patients showed excellent results, 6 patients showed good results, 3 patients showed fair results, while 1 patient showed poor result according to MRC grading system. Conclusion: It could be concluded that among many techniques of tendon transfer procedures prescribed for treatment of claw hand in ulnar nerve palsy, FDS transfer is the best reconstructive tendon transfer procedure for correction of ulnar claw hand especially in low ulnar palsy. In case of high ulnar palsy when FDS isn’t available ECRL transfer is the next choice.

Total elbow arthroplasty in patients with tumor-like lesions of elbow, preliminary results of a single-center experience

Objective The purpose of this study was to investigate the preliminary clinical outcomes of total elbow arthroplasty (TEA) in the treatment of elbow deformity caused by tumor-like lesions. Methods Between September 2009 and June 2017, the technique of triceps facial tongue exposure was adopted for all 11 patients who underwent total elbow arthroplasty. There were 5 females and 6 males with the mean age of 56.7±14.7 years. There were 6patients with synovial chondromatosis and 5 with pathologic hypertrophy of synovium. Seven of 11 patients were performed by posterior approach only, while the other 4by combined posterior-anterior approach. A semi-constrained Coonrad-Morrey prosthesis which provides 7° varus/valgus laxity was used in 7 patients, and custom-made total constrained prosthesis which only allow flexion and extension on a single plane was used in 4 cases. Preoperative average flexion range of elbow was 50.5°±14.0° (range, 20°-70°). The ulnar nerve compression and claw hand deformity was identified in 2patients preoperatively and the nerve was transposed during operation. According to Mayo elbow function score (MEPS score), the average preoperative MEPS score was 42.1±12.7 points (range, 15-60). Results Perioperative complications were not found. None of patients lost in thefollow-up and all the patients were alive. There was no pain in the joints, no triceps fracture or weakening of muscle strength, and no recurrence of the lesions. All 11 patients were followed up for 7 to 63 months with an average of 36.3±19.5 months. The mean MEPS score was improved to 89±7.2 point after surgery (t=-11.993, P= 0.000). The average flextion-extension arc improved from preoperative 50.5° to 105.9° postoperatively (t=-8.697, P=0.000). The average pronation-supination arc improvement from preoperative 105°-123.2° postoperatively (t=-6.901, P=0.000). For the two patients with ulnar nerve deficit before surgery, one patient recovered 6 months after operation, however, the other patient did not 2 years later. One Coonrad-Morrey prosthesis with deep infection was treated by removing the implant. Three of 4 custom-made total constrained prostheses experienced implant failure due to loosening or periprosthetic fracture. The incidence of complications of semi-constrained prosthesis was lower than that of total constrained prosthesis (14% vs. 75%), however, it did not reach a significant difference. Conclusion This study reveals an acceptable outcome with triceps facial tongue exposure for TEA in the treatment of tumor-like lesions of elbow. TEA is a viable good alternative treatment for selected patients with large mass around the elbow or with severe deformation. However, the failure rate of fully constrained prosthesis tends to be higher than semi-constrained one, possible due to its design flaw. Key words: Arthroplasty, replacement, elbow; Paraneoplastic syndromes; Surgical procedures, electiv

Functional evaluation of the hand after ulnar claw correction in patients with leprosy

Purpose: To evaluate hand function in leprosy patients after reconstructive surgery for claw hand. Methods: Patients who had completed multidrug therapy (MDT) and who had undergone tendon transfer surgery for ulnar claw correction at either of two reference centres for leprosy in Brazil between 2010 and 2014, were included. Clinical evaluations, Screening of Activity Limitation and Safety Awareness (SALSA) Scale, Disabilities of the Arm, Shoulder, and Hand Score (DASH) Questionnaire and the Jebsen Taylor Test (JTT) were used to measure arm/hand function recovery after surgery. Data were analyzed with the one sample t-test (p < 0.05). Results: Twenty-three patients participated in the study, with 13 males (57%), a mean age of 49.5 years and an average of 6.3 years post-surgery. On the SALSA Scale total score, 59% of the individuals had mild or no limitation of activity. On the specific score for the hand domain, 91% had mild or no limitation. The mean score of the DASH Questionnaire was 24.45. On the JTT, when comparing individuals who had surgery on the right hand with normative values for the dominant hand, matched for mean age and gender, there was a significant difference for all six tasks. When comparing individuals who had surgery on the left hand with normative values for the non-dominant hand, there was greater proximity between the means, although still significantly different. Conclusions: The SALSA, DASH and JTT were easily applicable and useful to measure the functional limitation of the leprosy hand. The data demonstrated that the patients had a good impression of their hand’s improved functionality after surgery. Patients exhibited mild to no disability. These results reinforce the importance of early diagnosis of neuritis and immediate therapeutic interventions to prevent physical disability. Level of evidence: Therapeutic study - Level III

Disseminated Mycobacterium hemophilum Presenting as Leprosy-like Cutaneous Lesions in an Immunocompromised Host

Background Mycobacterium hemophilumis a slow growing non-tuberculous mycobacterium that has predilection for lower temperatures and extremities. It presents commonly as a cutaneous infection but can have a variety of clinical presentations in immunocompromised patients.MethodsWe present a patient found to have disseminated Mycobacterium hemophiluminfection with a presentation similar to lepromatous leprosy.ResultsA 60 year-old man with a history of psoariatiform dermatitis and end stage renal disease. He received a deceased donor renal transplant in 2005 from China, complicated by chronic allograft dysfunction. He previously worked as an architect and apart from travel to China in 2005 did not travel to other leprosy endemic regions nor have contact with patients known to have leprosy. Despite medical therapy, he was reinitiated on dialysis 11 years after transplantation via a permanent catheter. He was on prednisolone, ciclosporin and MMF that ceased at time of reinitation of dialysis.He presented 4 months later with bilateral foot gangrene and an erythematous macular rash over his face and right upper limb. This was deemed to be drug related initially and he was treated with topical agents. His rash worsened with new nodular lesions over his chest, torso and lower limbs with facial and ear lobe involvement. He was also noted to have flattening of his nasal bridge that appeared saddle like. He was also noted to have wasting of bilateral intrinsic muscles of his hands with a right ulnar claw. This was thought to be in keeping with lepromatous leprosy. He underwent a skin biopsy that showed numerous acid fast bacilli with no formed granulomas. This grew Mycobacterium hemophilum and PCR for Mycobacterium leprae was negative. Nasal swabs and blood cultures also grew Mycobacterium hemophilum. Tissue cultures from his foot gangrene also grew Mycobacterium hemophilum. He was started on rifampicin, ciprofloxacin and clarithromycin. Despite medical therapy, he demised a month later from hospital acquired pneumonia.Conclusion Mycobacterium hemophilum can present with cutaneous lesions and neurological signs that can resemble lepromatous leprosy. High index of suspicion, good travel and exposure history, as well as obtaining specimens for culture would be essential in suspicion and diagnosis.Disclosures All authors: No reported disclosures.

Modificación simplificada de la técnica de Zancolli para la corrección de la garra cubital

ObjectivesThe objective of this paper is to study the results obtained with the Chevallard technique (simplified version of the Zancolli technique), to correct claw hand deformity, secondary to ulnar nerve palsy. Materials and methodRetrospective study conducted on 16 patients (16 hands) who underwent claw hand correction (January 2006-December 2013), and were evaluated at the 6 weeks, 3 months, 6 months and one year. ResultsAt one year later, an objective assessment (Brand criteria) showed excellent results in 18.75% (3 patients), good in 75% (12 patients), and poor in 6.25% (1 patient). The latter required a new intervention to solve the recurrence of the claw. ConclusionThe simplified of Zancolli technique or technique of Chevallard allows to easily correct the ulnar claw hand deformity, not ruling out a further intervention in the case of recurrence.

Reversal of Complex Regional Pain Syndrome Type 2 and the Subsequent Management of Complex Regional Pain Syndrome Type 1 Occurring after Corrective Surgery for Residual Ulnar Claw

Dear Editor, Complex regional pain syndrome type 1 (CRPS-1) that has previously resolved can recur after repeat surgery at the same anatomic site [1]. No existing treatment reverses CRPS-2 or a recurrent CRPS-1 [2–7]. We report the reversal of initial CRPS-2 as well as the subsequent CRPS-1 after surgery for residual ulnar claw with a multi-modality treatment regimen (MMTR) developed by us [8]. A lady of 39 years presented with 3 months of CRPS-2 following surgery for humerus fracture. Electromyography confirmed radial and ulnar nerve involvement. The Disability of Arm, Shoulder and Hand (DASH) score was 90.2 [9]. Ultrasonography (USG) showed hyperechogenicity in CRPS-2-affected muscles (Figure ⇓). She was treated with MMTR comprising medications (daily nortriptyline 35 mg, pregabalin 150 mg, tramadol 100 mg, and diclofenac as needed), continuous brachial plexus block (CBPB) for 4–5 weeks, dry needling (DN) of muscles of CRPS extremity, and physical therapy (PT). Figure 1 (A) Muscles of the normal left upper extremity showing a well-defined distinction between hypoechoic muscle fascicles enveloped by hyperechoic fascia characteristic of a normal muscle. (B) Muscles of CRPS-2-affected right limb flexor carpi radialis (FCR), flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP) show reduction in size and hyperechogenicity indicating fibrosis, whereas pronator teres (PT) is showing normal echogenecity; extensor digitorum (ED), supinator (S), biceps, and brachialis show hyperechogenecity, loss of outline, and reduction in size. (C) FCR, FDS, and FDP showing increase in size and appearance of new muscle fibers replacing fibrosis; ED showing new muscle fibers replacing fibrosis; biceps and brachialis showing new muscle fibers, appearance of outline, and increase in size. A-A, B-B, C-C, D-D are calipers put to measure the thickness of muscles; BI = biceps; BR = brachialis; CRPS = complex regional pain syndrome; EXT or E = extensors; …

Reconstructive surgery in children to correct ulnar claw hand deformity due to leprosy

To study the impact of tendon transfer surgery for ulnar claw hand correction in children with leprosy. All the children who underwent reconstructive surgery for ulnar nerve paralysis during the period 2007 to 2012 were included in the study. Unassisted angle, grasp contact, pinch contact and functional assessment were the main outcome measures. All the surgical procedures were performed by the same surgeon and pre- and post-operative therapy protocol was same for all the patients. A common surgical audit form was used to record assessments for all the patients. In this case series, 82 hands of 79 patients with ulnar paralysis were included. All the children had lasso surgery. In 83% of hands, flexor digitorum superficialis of middle or ringer finger was used, while in the remaining patients palmaris longus or extensor carpi radialis longus with fascia lata graft was used as the motor tendon. The unassisted angle decreased in all the patients, indicating correction of claw fingers. Hand function improved after surgery and it showed steady progress during follow-up. The deformity due to leprosy in the hands of children is a tragedy as it hampers the use of hands in daily routine activities, school work and other social interactions. Tendon transfer surgery should be done on children to correct established clawed fingers as it yields good results and helps in facilitating hand function to complete daily activities and lead a normal life.

Cubitus valgus and tardy ulnar nerve palsy due to an intracapsular ulnar nerve.

We describe a patient with tardy ulnar neuropathy and cubitus valgus deformity found to have an intracapsular ulnar nerve. An 89-year-old woman presented with severe neuropathic pain in the ulnar digits of the hand, advanced degenerative arthritis of the elbow, and tardy ulnar nerve palsy. Her pain was exacerbated with elbow movement, particularly flexion. She had paralysis of ulnar nerve innervated muscles, hypersensitivity with absence of two-point discrimination in her ulnar 1-1/2 digits, and a fixed ulnar claw deformity. She also had a grossly unstable elbow. Plain films revealed a cubitus valgus deformity (38°), an absent radial head, a dislocated proximal radioulnar joint and advanced arthritic changes. Ultrasonography revealed an indistinct ulnar nerve within the cubital tunnel which penetrated the joint. Electrophysiological studies revealed evidence of a severe ulnar neuropathy at the level of the elbow. Intraoperatively, an attenuated 2cm length of the retrocondylar ulnar nerve was observed to be incorporated into the joint capsule tethered by a fibrous/synovial band which was released. A large effusion was drained. The ulnar nerve was transposed subcutaneously. The capsular rent was repaired in layers. She noted immediate and sustained (2year follow-up) pain relief and regained moderate function in her interossei. We believe that the chronic cubitus valgus deformity and secondary degenerative elbow joint changes led to an altered course of the nerve and attenuation of the medial joint capsule such that the ulnar nerve spontaneously buttonholed itself intra-articularly.