Ulnar Distribution Research Articles

Ulnar Distribution Pattern May Be Predominant in Upper Extremity Lymphatic Malformations

The locoregional distribution patterns of lymphatic malformations (LM) in the upper extremity have not been described in the scientific literature. Twelve patients were diagnosed with a LM in their upper extremities between 1998 and 2021 at our center. In all cases, these were isolated malformations. Nine patients (75%) presented an ulnar distribution pattern of the LM, two (16.7%) presented a radial distribution pattern, and one (8.3%) presented involvement of both territories. We found no statistically significant differences in any sociodemographic or clinical variable between patients with ulnar or radial LM distribution patterns. In this work, we found that the ulnar distribution pattern was more frequent than the radial distribution pattern in upper extremity LM. Furthermore, we observed that LM in the radial territory appeared as lesions limited to the distal segment of the upper limb (thumb and distal radius). This is a small retrospective case series and therefore, these findings should be interpreted with caution. Larger sample size studies are necessary to validate and characterize this finding.

Cervical intradural traumatic neuroma without history of trauma: illustrative case.

Traumatic neuroma typically refers to a reactive process in the injured peripheral nerve, characterized by an excessive growth of axons, Schwann cells, and fibroblasts at the proximal end of the nerve after its interruption. The authors report a case of a traumatic neuroma in the cervical nerve root in a patient with no history of trauma. The patient presented with sensation loss in the right-hand ulnar distribution, right flank around the T4-11 region, and right small toe along with motor power weakness over the right upper and lower extremity. Magnetic resonance imaging revealed an intradural extramedullary mass lesion with extension along the C7 nerve root. Histological examination showed traumatic neuroma. A total resection of the lesion along with the resolution of sensory and motor deficits was achieved directly after surgery. Traumatic neuroma should always be kept in the armamentarium for diagnosis of an intradural nerve sheath tumor.

Outcomes following use of VersaWrap nerve protector in treatment of patients with recurrent compressive neuropathies.

Epineural scarring following previous carpal or cubital tunnel release can lead to pain and permanent dysfunction. To prevent this cascade, nerve wraps are an option. The purpose of this study was to evaluate outcomes following use of VersaWrap nerve protector during surgical decompression and neurolysis in patients with recurrent compressive neuropathies in the upper extremity. Twenty patients comprised the patient cohort, with a mean postoperative follow-up time of 139 days (range: 42-356 days). There were 13 females and 7 males, with a mean age of 43.4 years. Fourteen surgeries were performed for revision cubital tunnel, 5 for revision carpal tunnel, and 1 for revision radial tunnel syndrome. Average duration of symptoms prior to revision surgery with VersaWrap was 2 years (range 9 months to 6 years). Postoperatively, the mean DASH score was 57.7 and VAS 3.1. Mean s2PD median distribution was 7.3, s2PD ulnar distribution 8.9, m2PD median distribution 6.9 and m2PD ulnar distribution 7.3. All patients had subjective improvement of symptoms and were satisfied with their result. No patients in our cohort required further revisional surgery. In conclusion, the use of VersaWrap as a nerve protector following revision surgery for recurrent compressive neuropathies in the upper extremity was safe and effective. Level of Evidence: IV; retrospective case series.

Allograft nerve repair to prevent sensorimotor loss after nerve sheath tumor resection

Acellularized nerve allografts (ANAs) have been developed as substitutes for nerve autograft to promote nerve regeneration after surgical repair. In this video, the authors demonstrate operative techniques for using ANAs to repair potentially functional nerve fascicles during tumor resection. A 67-year-old female with schwannomatosis requested resection of a painful enlarging mass of the left ulnar nerve proximal to the elbow. During surgery, neuromonitoring suggested that fascicles entering the tumor could be functional. Therefore, nerve allograft was used to repair the transected fascicles. The patient recovered with full strength and sensation in the ulnar distribution, with resolution of her preoperative symptoms. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22101.

Treatment of Ulnar Neuropathic Pain with Peripheral Nerve Stimulation: Two Case Reports.

Ulnar neuropathy is a condition that manifests with symptoms of neuropathic pain, numbness, tingling, and even possible motor deficits in the ulnar distribution of the arm. This debilitating painful condition may be refractory to conservative, pharmacologic, and surgical interventions. Peripheral nerve stimulation (PNS) technology has advanced significantly in recent years allowing for conditions such as ulnar neuropathy to be treated in a minimally invasive manner. Here we report the first case reports in the literature (to our knowledge) of two patients with intractable ulnar neuropathy who underwent minimally invasive PNS Bioventus implants. Both patients experienced at least 75% pain relief based on NRS scores at 6 months after ulnar nerve PNS implantation. The patients also experienced significant improvement in functional outcomes, including return to employment, ability to perform activities of daily living without any impairment, and improved quality of life measures. While the results presented in our two case reports are promising, we only provide observational data over a 6 to 15-month period post-implantation. Future well-powered, large-scale, and long-term randomized controlled trials are warranted to determine efficacy and long-term pain and functional outcomes from PNS therapy for treatment of ulnar neuropathy.

A Dorsal Epidural Herniated Disc Fragment Initially Presenting as Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that presents with neurological symptoms that can mimic other conditions. This mimicry can hide other important neurological diagnoses. Here, we present a rare case of thoracic myelopathy secondary to a sequestered dorsal epidural herniated disc fragment that initially presented with the classic findings of GBS.A 58-year-old female presented with progressing bilateral lower extremity weakness, paresthesias, and absent bilateral lower extremity deep tendon reflexes. Lumbar magnetic resonance imaging (MRI) findings were disproportionate to presentation, and lumbar puncture fluid analysis revealed clear, colorless fluid with albuminocytological dissociation. The patient was diagnosed with GBS and treated with a short course of intravenous steroids followed by intravenous immunoglobulin. The patient later developed new-onset ulnar distribution paresthesias, lower extremity spasticity, constipation, and urinary retention that caused a decline in functional progress. Further investigation prompted evaluation with cervical and thoracic MRIs, which revealed a left dorsal epidural lesion at the T9-T10 level causing severe cord compression. The patient was definitively treated with a T9-T10 laminectomy and excision of the offending lesion. Pathology revealed collagenous tissue with fibroblastic proliferation, consistent with a sequestered fragment of the herniated intervertebral disc. The patient was further treated with both acute and subacute rehabilitation. She was eventually discharged home and was able to ambulate independently with a walker.Dependency on positive albuminocytological dissociation in cases of potential GBS can lead to errors in diagnostic accuracy and delay appropriate treatment. Clinicians should remain mindful that GBS is a diagnosis of exclusion and MRI of the entire spine should be considered when the diagnosis of GBS is uncertain.

P-PN021. A case series of cryoglobulinemia with different clinical presentations and different nerve conduction studies (NCS) findings

Introduction . Neuropathy in cryoglobulinemia can be due to hyperviscosity (type I) or non obstructive immune complex mediated inflammatory vasculitis (type II and III). Methods . Case series: Our first patient was a 72-year-old gentleman with 5-month duration of severe asymmetrical neuropathic pain and rapidly progressive weakness in right peroneal and bilateral ulnar distribution associated with significant weight loss and pain, but no sphincter and autonomic dysfunction. He denied fever, arthritis, Raynaud’s phenomenon, rash and edema. His NCS revealed bilateral ulnar and right peroneal neuropathy. Left sural nerve biopsy revealed vasculitis, and cryoglobulin was found to be positive. Myeloma panel was suggestive of Kappa monoclonal gammopathy with normal flow cytometry and bone marrow. We concluded it as cryoglobulinemic vasculitis with Kappa light chain MGUS presenting with mononeuritis multiplex. Second patient was a 56-year-old man, HCV treated one year ago with undetectable viral load currently, and had generalized Myasthenia Gravis, presented with burning sensation of bilateral feet and erythematous macules, blanching papules on ankles, arms with normal power and reflexes. Nerve conduction study was normal and supported the clinical diagnosis of small fiber neuropathy due to cryoglobulinemia with treated HCV. Third case, a 70-year-old lady, presented with tingling sensation of both lower limbs with impaired sensation of up to ankles, distal toes weakness (3/5) and absent ankle reflexes for 2 months. Her NCS showed distal sensorimotor axonal polyneuropathy. She was found to be anti-HCV positive and cryoglobulinemia with viral load of 1 × 10 6 IU/ml. All our patients had no history of exposure to heavy metals, metabolic, infection screening and ENA, ANCA, anti-CCP were negative and cryoglobulin was positive. Conclusion . Nerve conduction study can add to the clinical for diagnosis of various types of polyneuropathy (mononeuritis multiplex, large fiber peripheral neuropathy, small fiber neuropathy) as depicted in our cases.

Chronic Ischemic Monomelic Neuropathy after Arteriovenous Fistula Creation: A Unique Presentation of Vascular Steal

We discuss a case of a 58 year old male who presented for left upper extremity steal syndrome including ischemic monomelic neuropathy (IMN) 1.5 months after arteriovenous fistula creation. He presented after three surgical attempts to salvage his fistula with rest pain, complete loss of function with contracture of the 4th and 5th digits, and loss of sensation in the ulnar distribution for more than three weeks. At our institution, he underwent surgical ligation of the distal fistula and creation of a new fistula proximally, resulting in complete resolution of his vascular steal symptoms almost immediately despite the chronicity prior to surgical presentation. Our patient provides a unique perspective regarding dialysis access salvage versus patient quality of life. The patients’ functional status and pain levels should take precedence over salvage of an arteriovenous access site, and early ligation of the access should be completed prior to chronic IMN development. However, if a patient presents late along the IMN course, we recommend strong consideration of access ligation in order to attempt to regain the full neurovascular function of the extremity as we experienced in our patient.

Left Elbow Pain In An Elite Basketball Player

HISTORY: A 32 year old, right handed, female professional basketball player presented two weeks following injury to the left elbow. Her history is significant for various lower extremity musculoskeletal injuries but no previous elbow or shoulder complaints. She presented two weeks following an in-game injury, in which she was “tied up” with another player and felt a hyperextension and valgus movement at the elbow. She felt immediate pain at the medial elbow. Initially there were paresthesias in the ulnar distribution but these resolved shortly. She continued playing through the discomfort for two weeks. PHYSICAL EXAMINATION: On inspection, there was a trace effusion about the left elbow. There was tenderness to palpation over the flexor pronator mass, medial epicondyle, and sublime tubercle. Extension lacked 5 degrees of range of motion. Flexion was normal at 130 degrees. Strength testing was normal, although there was pain with resisted wrist flexion and pronation. There was no pain with wrist or finger extension or elbow supination. A moving valgus stress test reproduced pain. There was no obvious laxity. Tinel’s test over the ulnar nerve was negative. DIFFERENTIAL DIAGNOSIS: 1. Medial epicondylosis 2. Ulnar collateral ligament sprain or tear 3. Ulnar neuropathy 4. Valgus extension overload syndrome TEST AND RESULTS: Left elbow X-ray: Unremarkable; Left elbow ultrasound: Full-thickness proximal UCL tear with significant (2.7mm) humeroulnar joint space opening with valgus stress test; Left elbow MRI: Full-thickness tear of the UCL at its humeral attachment with associated edema and inflammation extending into the adjacent flexor digitorum superficialis muscle and partially encasing the ulnar nerve within the cubital tunnel FINAL WORKING DIAGNOSIS: Left ulnar collateral ligament full thickness tear TREATMENT AND OUTCOMES: 1. The patient underwent PRP to the UCL tear 2. Post injection rehabilitation started with 6 weeks of rest, protection and range of motion. Pain resolved. 3. Follow up ultrasound at 6 weeks demonstrated interval healing of the full-thickness proximal UCL tear with no significant humeroulnar joint opening on valgus stress testing (0.7mm). 4. Continued PT through 16 weeks post injection and remained pain free with a normal elbow examination throughout the following season without limitation.

Right Arm Numbness In An Adolescent

HISTORY: A 14-year-old high school student presented to Orthopedics Urgent Care for right arm numbness and discoloration. Four days prior had noticed that her right arm would turn a dusky purple or blue color from the shoulder to her fingers with associated numbness and tingling in the entire arm. Episodes lasted only a few seconds to a minute. She would have multiple episodes a day. No specific pattern or time of day, however she thinks it may occur more frequently while wearing a backpack or if her arm is in an elevated position. Episodes resolve on their own. ROS otherwise negative. PHYSICAL EXAMINATION: Right upper extremity without dusky appearance, appears similar to left upper extremity. Full ROM and strength at the shoulder, elbow, wrist, and fingers. Decreased sensation in the ulnar distribution of the right hand compared to the left. Strong radial pulse when right hand is lowered. Positive Adson for loss of radial pulse, positive Roos for numbness and tingling. DIFFERENTIAL DIAGNOSIS: 1. Right upper extremity DVT 2. Thoracic outlet syndrome 3. Pancoast tumor TEST AND RESULTS: Right upper extremity venous ultrasound normal. Right upper extremity arterial ultrasound with normal triphasic arterial waveforms with arm at patient’s side and at 90 degrees abducted in the subclavian, axial, brachial, radial, and ulnar arteries. With arm raised above patient’s head, abnormal monophasic waveform in the right subclavian artery. FINAL WORKING DIAGNOSIS: Arterial thoracic outlet syndrome. TREATMENT AND OUTCOMES: 1. Referred to pediatric vascular surgery. 2. Was referred to physical therapy, will follow up in 6 months.

Mononeuritis multiplex with multiple skin ulcers

A heterogeneous group of diseases lead to mononeuritis multiplex and multiple skin ulcers. A 45-year-old man presented with multiple painful subcutaneous nodules with ulcerations, distal predominant weakness of both upper and lower limbs, reduced sensations over ulnar distribution of the right hand and high-grade intermittent fever for 2 months. The patient was diagnosed to have cutaneous polyarteritis nodosa based on clinical and histopathological evidence after ruling out other conditions. The patient was treated with prednisolone 1 mg/kg, which was tapered over months and azathioprine was added. When reviewed after 6 months he was afebrile, skin lesions were healed, and the power was improving. Mononeuritis multiplex and multiple skin ulcers have various etiologies. A detailed workup is essential to rule out other systemic diseases before making a diagnosis of cutaneous polyarteritis nodosa which is a benign disorder with a favorable outcome.

Frequency of neurological deficits in Sudanese lepromatic patients

Leprosy has been a major burden on humanity over thousands of years. To study the pattern of neurological manifestations among adult Sudanese leprosy patients seen in Khartoum Dermatology Hospital in the period from Feb 2018 to Jul 2018. This is a prospective cross-sectional hospital-based study. Seventy adult Sudanese leprosy patients were studied using simple, direct, standardized questionnaire including history and neurological examination. Numbness was the most common neurological symptom seen in 77.14%.Each of visual disturbance, headache and bilateral ulnar sensory impairment was detected in 7.14%. Half of the patients had upper limbs sensory nerve dysfunction while 42.86% exhibited sensory nerve dysfunction in the lower limbs. ";“Gloves and stoking";” sensory impairment was the most common finding (30%) while bilateral lateral popliteal sensory impairment was seen with the same percentage. Bilateral median and unilateral posterior tibial sensory impairment were found in 1.43% each. Unilateral radial cutaneous sensory impairment was seen in 2.86%. Approximately half (48.57%) of the patients had upper limbs motor dysfunction. Bilateral ulnar distribution motor affection was seen in 40%. A significant number (41.43%) had upper limbs muscle wasting. Impaired olfaction was the most common cranial nerve sign seen in 12.86%. Leprosy reactions were detected in 21.43%; type 2 reaction in 14.29% while type 1 reaction in 7.14%. Numbness and limbs weakness were the most common neurological symptoms in leprosy patients. “Gloves and stokes";” peripheral sensory neuropathy being the most common sensory disturbance. Ulnar and median nerves motor affection was the most common motor dysfunctions.

Cross-Palm Nerve Grafts to Enhance Sensory Recovery in Severe Ulnar Neuropathy.

Background: Intrinsic atrophy and debilitating sensory loss are prominent features of severe ulnar neuropathy with limited surgical options to reliably improve recovery. Restoration of sensation is important to provide protection for the vulnerable ulnar border of the hand. Here, we report our experience with side-to-side sensory nerve grafting from the median to ulnar nerve in the palm to enhance ulnar sensory recovery. Methods: A retrospective chart review identified patients with severe ulnar neuropathy who underwent cross-palm nerve grafting. Included patients had objective loss of protective sensation in the ulnar distribution with 2-point discrimination >8 mm, Semmes-Weinstein monofilament testing (SWMT) >4.56, or no sensory response on nerve conduction testing. Cross-palm side-to-side tension-free grafting from median to ulnar sensory components was performed using short-segment allograft or autografts. Analysis included patient etiology, procedures, nerve conduction studies, objective sensory testing, and Disabilities of the Arm, Shoulder, and Hand Disability score. Results: Forty-eight patients with severe ulnar neuropathy underwent cross-palm nerve grafting between 2014 and 2017. Twenty-four patients had adequate follow-up for inclusion. Of the 24 patients, 21 (87%) had return of protective sensation, 16 (66.7%) had return of diminished light touch sensation, and 6 (25%) had return to normal range sensation within 1 year as assessed by SWMT and/or 2-point discrimination. Patients treated with autograft demonstrated referred sensation to the median nerve distribution. Conclusions: Cross-palm nerve grafting may be a useful adjunct to enhance sensory recovery in severe ulnar neuropathy. Further study to quantify differences in sensory recovery between traditional operative techniques and cross-palm nerve grafting is required.

Vascular Analysis of Radial Artery Perforator Flaps.

Background:Radial forearm free flap with all its present day modifications is the workhorse of soft tissue reconstruction in head & neck. Although there are several advantages, it requires the sacrifice of a major artery of forearm. There are several modifications of harvesting a forearm flap based on perforator principles. A clear understanding of vascular anatomy of individual perforators relative to its vascular territory & flow characteristics is essential for both flap harvest & design. The purpose of this cadaveric observational anatomical study was to determine the location, size & vascular territory of the radial artery cutaneous perforators.Materials and Methods:12 fresh human cadavers & 24 cadaveric forearms were dissected to determine the total number, location, size & vascular territory of radial artery adipo-fascio cutaneous perforator. The cutaneous territory of distally dominant perforators was analyzed using methylene blue injections & three-dimensional computed tomographic angiogram.Results:In the 12 fresh human cadavers & 24 forearm specimens, a total of 222 perforators were dissected for an average of 18.5 radial artery perforators per forearm. Of the total 222 perforators dissected 118 were smaller than 0.5mm in diameter (53.15%) these were not clinically significant. 104 perforators were greater than 0.5mm in diameter (46.84%) these were clinically significant. Of the 222 radial artery perforators dissected, 127 perforators (57.20%) were radially distributed & 95 perforators (42.79%) had ulnar distribution. A total of 90 perforators (40.54%) were identified on distal side (Radial styloid) & 132 perforators (59.45%) were identified on proximal side (Lateral epicondyle). Mean number of perforators on radial side was 10.6 & 7.9 on ulnar side, a comparison of both using student t paired test gives a P value of 0.006, which was statistically significant. Comparison of mean number of perforators on the distal side was 7.5 & proximal side was 11.0, Student Paired t test gives a P value of 0.003, which was statistically significant. Comparison of mean Diameter of perforators between the Distal side (1.11) & Proximal side (0.86) using Student Paired t test gives a P value of 0.01 which was statistically significant. A chi square test was done to compare mean diameter of perforators on distal side, which were more than 1mm (80%) & less than 1mm (20%) & on proximal side more than 1mm (35.6%) & less than 1mm (64.4%). Chi square value of 42.406 was obtained, degree of freedom value was 1& P value of <0.001 was achieved which was found to be highly significant. Methylene blue injections into the proximal part of radial artery demonstrated clusters both in proximal & distal forearm & also cutaneous territory of flap. Three- dimensional computed tomographic angiography reveals a network of linking vessels found to communicate between adjacent perforators & running parallel to radial artery. Large network of linking vessels could be found between fascia & dermis, which also explains the ability to harvest forearm flap at the supra-fascial level.Conclusion:Increase in knowledge of vascular territory of radial artery perforators with regards to numbers, size, location, and cutaneous territory can lead to expanded use of radial forearm flap based on either distal or proximal perforator alone, without sacrificing the radial artery.

Adipo Fascio Cutaneous Perforator Based, Shape Modified Radial Forearm Flap: Vascular Analysis of Perforators &amp;amp; Its Clinical Applications in Head &amp;amp; Neck Reconstruction

Resume of the study & Background: Radial forearm free flap with all its present day modifications is the workhorse of soft tissue reconstruction. Although there are several advantages, it requires sacrifice of a major artery of forearm. Several modifications are described in harvesting a forearm flap. In order to achieve a reliable, safe flap harvest & design one must have a very clear understanding of radial artery perforators, relative to its distribution, territory & flow. The purpose of this study is to determine the location, size & vascular territory of the radial artery cutaneous perforators & to demonstrate application of shape modification of radial forearm free flap based on its distal & proximal perforators in various head & neck defects. Materials & Methods: Anatomical Study: 12 fresh human cadavers & 24 cadaveric forearms were dissected to determine the number, location, size & vascular territory of radial artery perforator. The cutaneous territory of distally dominant perforators was analyzed using methylene blue injections & three-dimensional computed tomographic angiogram to determine the vascular network. Clinical Study: 15 patients with various head neck defects following oncological resections were reconstructed with shape modified adipo-fascio cutaneous free forearm flap. All these patients were prospectively followed for donor site healing, motor & sensory nerve deficit, function & quality of life questioner for donor site assessment. Results: 12 fresh human cadavers & 24 cadaveric forearms were dissected, and a total of 222 perforators were dissected for an average of 18.5 perforators per forearm. 118 were smaller than 0.5 mm in diameter (53.15%) & were not clinically significant. 104 perforators were greater than 0.5 mm in diameter (46.84%) & were clinically significant. 127 perforators (57.20%) were radially distributed & 95 perforators (42.79%) had ulnar distribution. 90 perforators (40.54%) were identified on distal side (Radial styloid) & 132 perforators (59.45%) were identified on proximal side (Lateral epicondyle). Mean number of perforators, on radial side was 10.6 & 7.9 on ulnar side; comparison of both using student t paired test gives a P value of 0.006, which is significant. Comparison of mean number of perforators on the distal side was 7.5 & proximal side was 11.0; Student Paired t test gives a P value of 0.003, which was statistically significant. Comparison of mean diameter of perforators on Distal side (1.11) & Proximal side (0.86), side using Student Paired t test gives a P value of 0.01 which was statistically significant. A chi square test was done to compare mean diameter of perforators on distal side, which was more than 1 mm (80%) & less than 1 mm (20%) & on proximal side more than 1 mm (35.6%) & less than 1 mm (64.4%). Chi square value of 42.406 was obtained, degree of freedom value was 1 & P value of <0.001 was achieved which was found to be highly significant. Methylene blue injections demonstrated clusters both in proximal & distal forearm & also marked the cutaneous territory of flap. Three-dimensional computed tomographic angiography reveals a network of linking vessels found to communicate between adjacent perforators & running parallel to radial artery. A total of 15 patients were reconstructed with shape modified radial forearm flap following oncologic resections. Wound healing in all 15 patients was good, with scar assessment faring better than traditional radial forearm flap. There was no sensory or motor nerve deficit. Although pedicle length was comparatively shorter in shape-modified flap, there was no problem in anastomosing to neck vessels. Conclusion: Increase in knowledge of vascular territory of radial artery perforators with regards to numbers, size, location, & cutaneous territory can lead to expanded use of radial forearm flap based on either distal or proximal perforator alone. Shape modified technique for harvesting radial forearm flap allows primary closure of donor site. Donor site is better healed and shows a predicted pattern, which is functionally and aesthetically good.

Analyses of Dermatoglyphic Patterns in Ntamante, Boki Local Government Area (LGA) of Cross River State, Nigeria

Analysis of the dermatoglyphics pattern in Ntamante Boki LGA of Cross River State, South-South, Nigeria is a research work carried out with the sole aim of analysing the dermatoglyphics pattern of the Ntamante people of Boki LGA in Cross river. Two hundred persons were randomly selected for the research comprising male and females. The collection of the finger prints was done using the ink procedure described by Cummins and Midlo analysis of data that was done using SPSS. The result obtained was thus: for females, the mean standard deviation was least in the radial loop (1 ± 1.6), followed by the Arches (4.9 ± 3.8), the Whorls (6.4 ± 4.4) and highest on the Ulnar loop (9.1 ± 9.7). Variables measured differed significantly (p = 0.05) with a Chi-square (X2) value of 17.41. Pr > Chisq = 0.053. For males, the mean standard deviation was highest in the Ulnar Loop pattern (12.6 ± 9.2), followed by the arch pattern (4.7 ± 2.8), then the whorls (3.3 ± 3) and then the radial loops (0.1 ± 0.4). This index study shows a higher frequency distribution of patterns of the Ulnar Loop, followed by the arches, then the whorls and finally the radial loop in the male samples which is different from the usual trend of Ulnar loop > Whorls > Arches > Radial loop obtained in other ethnic groups in Nigeria following the work of Jaja et al. among the Ijaws, Ekanem et al. amongst the Annangs, Ujaddughe et al. amongst the Esan of Edo state. Sexual dimorphism was evident in this research work with males showing a higher Ulnar loop distribution (12.6 ± 9.2), while the female percentage frequency distribution was (9.1 ± 9.7). In conclusion, this study shows the percentage frequencies of patterns among the Ntamante with the Ulnar Loop >Arch > Whorls> Radial loop amongst the males. Amongst the females, this was the distribution of pattern: Ulnar Loop > Whorls > Arches > Radial Loop. This is in line with what was obtained in different ethnic groups in Nigeria with regards to the percentage frequency distribution in the females, while amongst the males, the distribution shows the distribution pattern in Asia and Europe.

Ulnar Nerve Neuropathy Secondary to “Snapping Triceps Syndrome”

Cubital tunnel syndrome is the second most common compression neuropathy of the upper extremity and the most common point of compression for the ulnar nerve. We present a case of ulnar nerve compression neuropathy at the elbow secondary to an abnormal subluxating medial head of triceps. A 37-year-old right hand dominant male presented with a history of bilateral medial elbow pain and ulnar distribution hand numbness. During his left cubital tunnel release surgery, the abnormal anatomy was noted. Initial subfascial anterior transposition was insufficient and had to be revised to a subcutaneous transposition intraoperatively. Failure to recognize the contribution of triceps abnormalities can lead to incomplete resolution following surgery. Surgeons should be wary of uncommon findings and adjust their approach appropriately.

Neurogenic Thoracic Outlet Syndrome Presenting as Chronic Elbow Pain After Obstacle Course

HISTORY: A 20-year-old female US Naval Academy freshman sustained a left elbow injury after repetitive shoulder abduction movements while completing a required obstacle course. She denied specific trauma, including a fall. There was no numbness, tingling, or radiation of pain. Five days later, she reported her left elbow pain to her physician. Originally diagnosed with an elbow contusion versus epicondylosis, the patient’s progressive left elbow pain lasted for more than 6 months when she developed ulnar dysesthesias in her hand. PHYSICAL EXAMINATION: Examination revealed diffuse elbow tenderness with swelling. Normal neurovascular examination was demonstrated. Elbow strength and range of motion were normal. Neck and shoulder exams demonstrated no abnormalities. Swelling resolved in one week. Exam remained unchanged for several months before she developed ulnar distribution pain. Then, an Allen test reproduced and worsened her elbow pain and neurologic symptoms. DIFFERENTIAL DIAGNOSIS: 1. Elbow Contusion 2. Chronic Regional Pain Syndrome 3. Intraarticular Body, Elbow Fracture 4. Brachial Plexopathy 5. Thoracic Outlet Syndrome TEST AND RESULTS: Left elbow anterior-posterior, lateral radiographs: — no acute osseous abnormality Left elbow MRI: — likely resolving bony contusion of radial head without evidence of fracture CT Left Elbow: —normal evaluation of the left elbow EMG left upper extremity: —normal electrodiagnostic study Left brachial plexus MRI: —normal left brachial plexus Chest MRI, with contrast: —findings consistent with thoracic outlet syndrome localized to costoclavicular space Left upper extremity venogram: —no evidence of venous occlusion or compression FINAL/WORKING DIAGNOSIS: Neurogenic Thoracic Outlet Syndrome TREATMENT AND OUTCOMES: 1. Relative rest, ice, compression and NSAIDs for 4 weeks without improvement. 2. Activity modification and trial of acupuncture demonstrated minimal improvement in presenting elbow pain. 3. Left scalene block with complete relief of symptoms, indicating neurogenic thoracic outlet syndrome. 4. Partial left first rib resection with resolution of chronic left elbow pain and ulnar nerve dysesthesias. 5. Range of motion, shoulder, and neck strengthening exercises started gradually 6 weeks post-surgery.

Prospective cohort study of symptom resolution outside of the ulnar nerve distribution following cubital tunnel release.

Resolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after release of the ulnar nerve at the elbow. Twenty patients with isolated cubital tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones, and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected. The same data were collected at 6-week follow-up. Paired t tests or non-parametric Wilcoxon Signed-Rank tests were used where appropriate to examine for significant (p ≤ 0.05) changes between pre- and post-operative scores. Probability of resolution was greater outside of the ulnar nerve distribution than within at early follow-up. There was a decrease in pain, numbness, and tingling symptoms both within and outside the ulnar distribution after cubital tunnel release. There was a decrease in pain as measured by several validated questionnaires. This study documents resolution of symptoms in an extra-ulnar distribution after cubital tunnel release. Improvement in pain and function after cubital tunnel release may be associated with an improvement in symptoms both within and outside theulnar nerve distribution. Future studies could be directed at correlating pre-operative disease severity with probability of extra-territorial symptom resolution using a larger sample population.

Superior sulcus (Pancoast) tumors: current evidence on diagnosis and radical treatment.

Pancoast tumors account for less than 5% of all bronchogenic carcinomas. These tumors are located in the apex of the lung and involve through tissue contiguity the apical chest wall and/or the structures of the thoracic inlet. The tumors become clinically evident with the characteristic symptoms of the "Pancoast-Tobias syndrome" which includes Claude-Bernard-Horner syndrome, severe pain in the shoulder radiating toward the axilla and/or scapula and along the ulnar distribution of the upper arm, atrophy of hand and arm muscles and obstruction of the subclavian vein resulting in edema of the upper arm. The diagnosis will be made by the combination of the characteristic clinical symptoms with the radiographic findings of a mass or opacity in the apex of the lung infiltrating the 1(st) and/or 2(nd) ribs. A tissue diagnosis of the tumor via CT-guided FNA/B should always be available before the initiation of treatment. Bronchoscopy, thoracoscopy and biopsy of palpable supraclavicular nodes are alternative ways to obtain a tissue diagnosis. Adenocarcinomas account for 2/3 of all Pancoast tumors, while the rest of the tumors are squamous cell and large cell carcinomas. Magnetic resonance imaging of the thoracic inlet is always recommended to define the exact extent of tumor invasion within the thoracic inlet before surgical intervention. Pancoast tumors are by definition T3 or T4 tumors. Induction chemo-radiotherapy is the standard of care for any potentially resectable Pancoast tumor followed by an attempt to achieve a complete tumor resection. Resection can be made through a variety of anterior and posterior approaches to the thoracic inlet. The choice of the approach depends on the location of the tumor (posterior - middle - anterior compartment of the thoracic inlet) and the depth/extent of invasion. Prognosis depends mainly on T stage of tumor, response to preoperative chemo-radiotherapy and completeness of resection. Resection of the invaded strictures of the thoracic inlet should me made en bloc with pulmonary parenchyma resection, preferably an upper lobectomy. Invasion of the vertebral column is not a contraindication for surgery which, however, should be performed in oncologic centers with experience in spinal surgery. Surgery for Pancoast tumors is associated with 5% mortality rate and the complication rate varies from 7-38%. The overall 2-year survival rate after induction chemo-radiotherapy and resection varies from 55% to 70%, while the 5-year survival for R0 resections is quite good (54-77%). The main pattern of recurrence is that of distant metastases, especially in the brain.