Ulnar Neuropathy Research Articles

Ultrasonographic evaluation of ulnar nerve morphology in patients with ulnar nerve instability.

Ulnar nerve instability (UNI) in the retroepicondylar groove is described as nerve subluxation or dislocation. In this study, considering that instability may cause chronic ulnar nerve damage by increasing the friction risk, we aimed to examine the effects of UNI on nerve morphology ultrasonographically. Asymptomatic patients with clinical suspicion of UNI were referred for further clinical and ultrasonographic examination. Based on ulnar nerve mobility on ultrasound, the patients were first divided into two groups: stable and unstable. The unstable group was further divided into two subgroups: subluxation and dislocation. The cross-sectional area (CSA) of the nerve was measured in three regions relative to the medial epicondyle (ME). In the ultrasonographic evaluation, UNI was identified in 59.1% (52) of the 88 elbows. UNI was bilateral in 50% (22) of the 44 patients. Mean CSA was not significantly different between groups. A statistically significant difference in ulnar nerve mobility was found between the group with CSA of <10 versus ≥10 mm2 (p = .027). Nerve instability was found in 85.7% of elbows with an ulnar nerve CSA value of ≥10 mm2 at the ME level. The probability of developing neuropathy in patients with UNI may be higher than in those with normal nerve mobility. Further prospective studies are required to elucidate whether asymptomatic individuals with UNI and increased CSA may be at risk for developing symptomatic ulnar neuropathy at the elbow.

Core outcomes in nerve surgery: development of a core outcome set for ulnar neuropathy at the elbow.

Ulnar neuropathy at the elbow (UNE) is common, affecting 1%-6% of the population. Despite this, there remains a lack of consensus regarding optimal treatment. This is primarily due to the difficulty one encounters when trying to assess the literature. Outcomes are inconsistently reported, which makes comparing studies or developing meta-analyses difficult or even impossible. Thus, there is a need for a core outcome set (COS) for UNE (COS-UNE) to help address this problem. The objective of this study was to utilize a modified Delphi method to develop COS-UNE. A 5-stage approach was utilized to develop COS-UNE: stage 1, consortium development; 2, literature review to identify potential outcome measures; 3, Delphi survey to develop consensus on outcomes for inclusion; 4, Delphi survey to develop definitions; and 5, consensus meeting to finalize the COS and definitions. The study followed the Core Outcome Set-STAndards for Development (COS-STAD) recommendations. The Core Outcomes in Nerve Surgery (COINS) Consortium comprised 21 participants, all neurological surgeons representing 11 countries. The final COS-UNE consisted of 22 data points/outcomes covering the domains of demographic characteristics, diagnostics, patient-reported outcomes, motor/sensory outcomes, and complications. Appropriate instruments, methods of testing, and definitions were set. The consensus minimum duration of follow-up was 6 months, with the consensus optimal timepoints for assessment identified as preoperatively and 3, 6, and 12 months postoperatively. The authors identified consensus data points/outcomes and also provided definitions and specific scales to be utilized to help ensure that clinicians are consistent in their reporting across studies on UNE. This COS should serve as a minimum set of data to be collected in all future neurosurgical studies on UNE. The authors hope that clinicians evaluating ulnar neuropathy will incorporate this COS into routine practice and that future studies will consider this COS in the design phase.

The necessity of ulnar nerve exploration and translocation in open reduction of medial humeral epicondyle fractures in children.

Medial humeral epicondyle fractures (MHEFs) are common elbow fractures in children. Open reduction should be performed in patients with MHEF who have entrapped intra-articular fragments as well as displacement. However, following open reduction, transposition of the ulnar nerve is disputed. The aim of this study is to evaluate the need for ulnar nerve exploration and transposition. This was a retrospective cohort study. The clinical data of patients who underwent surgical treatment of MHEF in our hospital from January 2015 to January 2022 were collected. The patients were allocated to either transposition or non-transposition groups. Data for sex, age, cause of fracture, duration of follow-up, Papavasiliou and Crawford classification, injury-to-surgery time, preoperative ulnar nerve symptoms, intraoperative exploration of ulnar nerve injury, surgical incision length, intraoperative blood loss, postoperative ulnar nerve symptoms, complications, persistent ulnar neuropathy, and elbow joint function were analyzed. Binary logistic regression analysis was used for statistical analysis. A total of 124 patients were followed up, 50 in the ulnar nerve transposition group and 74 in the non-transposition group. There were significant differences in ulnar nerve injury (p = 0.009), incision length (p < 0.001), and blood loss (p = 0.003) between the two groups. Binary logistic regression analysis revealed that preoperative ulnar nerve symptoms (p = 0.012) were risk factors for postoperative ulnar nerve symptoms. In addition, ulnar nerve transposition did not affect the occurrence of postoperative ulnar nerve symptoms (p = 0.468). Ulnar nerve transposition did not improve clinical outcomes. It is recommended that the ulnar nerve should not be transposed when treating MHEF operatively.

Complications of operatively treated distal radial fractures.

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.

CUBITAL TUNNEL SYNDROME LITERATURE REVIEW

The article describes the symptoms, main methods of diagnosis and treatment of ulnar nerve neuropathy at the level of the cubital canal. Indications for surgical treatment have been determined. The most common operations indicated for this pathology are described.

Application of Kirschner wire placement guided technology in paediatric supracondylar humerus fractures

BackgroundTo analyze the clinical efficacy of K-wire placement guided technology in paediatric supracondylar humerus fractures.MethodsA retrospective study was conducted in 105 patients who underwent closed reduction and percutaneous pinning surgeries in our hospital from June 2019 to August 2022. 54 patients treated with a assisted reduction fixation device to assist in closed reduction and percutaneous K-wire cross-fixation were allocated into the Non-guided group, and 51 patients with K-wire placement guided technology to guide K-wire placement were assigned into the Guided group. The operation duration, number of disposable K-wire placement, intraoperative fluoroscopy frequency, Baumann angle, carrying angle, fracture healing time and Flynn score of elbow joint function at the final follow-up were compared between two groups. The postoperative complications of two groups were recorded.ResultsThere were significant differences between two groups in terms of operation duration, intraoperative fluoroscopy frequency, and disposable K-wire placement rate (p < 0. 05), while no significant differences of Baumann angle, carrying angle and the fracture healing time between two groups were observed (p > 0. 05). In the control group, ulnar nerve injury in 2 case, pin site infection in 4 cases, mild cubitus varus in 2 cases and loss of reduction in 4 cases were detected. In the study group, ulnar nerve injury in 1 case, pin site infection in 2 cases and loss of reduction in 1 case was observed. There was no significant difference in Flynn scores between two groups.ConclusionK-wire placement guided technology is simple and convenient. The application of K-wire placement guided technology could relatively improved disposable K-wire placement rate, shorten the intraoperative fluoroscopy frequencies and reduce complication rates.

P03 EB or not EB? A report of two neonates with congenital blisters

Abstract Neonatal compartment syndrome (NCS) is extremely rare, with less than 100 cases reported. The affected limb usually presents with significant swelling and sentinel skin changes such as desquamation, blisters and skin necrosis. Risk factors that predispose infants to a hypercoagulable state or trauma have been implicated, but the exact cause remains elusive. We report two neonates with no family history of note, except for oligohydramnios in patient 1, who presented with congenital bullae over the upper extremity which led to an open wound. They were both referred to our service with a provisional diagnosis of epidermolysis bullosa (EB). Patient 1 also presented with a reduction in spontaneous movements of the hand shortly after birth. The wound took weeks to heal with scaring and subcutaneous tissue and muscle loss resulting in significant ulnar deviation by age 9 weeks. This was managed with stretching exercises, splints and surgical intervention. Despite this there remained noticeable limb length discrepancy and functional limitations to date. Patient 2 had a lack range of motion and restricted passive motion on the affected limb by the age of 4 weeks. Subsequent neurophysiological studies showed evidence of a severe chronic median and ulnar neuropathy with distal axonal loss and a right radial neuropathy at the site of the scar. Clinically, both cases were in keeping with NCS. A skin biopsy and molecular analysis ruled out EB. NCS requires early recognition and intervention as it can lead to long-term sequelae including Volkmann contracture, limb length discrepancies and permanent nerve damage.

Chapter 6 - Ulnar neuropathy

Ulnar neuropathy at the elbow is the second most common compressive neuropathy. Less common, although similarly disabling, are ulnar neuropathies above the elbow, at the forearm, and the wrist, which can present with different combinations of intrinsic hand muscle weakness and sensory loss. Electrodiagnostic studies are moderately sensitive in diagnosing ulnar neuropathy, although their ability to localize the site of nerve injury is often limited. Nerve imaging with ultrasound can provide greater localization of ulnar injury and identification of specific anatomical pathology causing nerve entrapment. Specifically, imaging can now reliably distinguish ulnar nerve entrapment under the humero-ulnar arcade (cubital tunnel) from nerve injury at the retro-epicondylar groove. Both these pathologies have historically been diagnosed as either "ulnar neuropathy at the elbow," which is non-specific, or "cubital tunnel syndrome," which is often erroneous. Natural history studies are few and limited, although many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously. Conservative management, perineural steroid injections, and surgical release have all been studied in treating ulnar neuropathy at the elbow. Despite this, questions remain about the most appropriate management for many patients, which is reflected in the absence of management guidelines.

Ulnar Neuropathy Caused by Repeated Thrombophlebitis of the Slow-flow Venous Malformation in the Cubital Tunnel: A Case Report

Cubital tunnel syndrome is the most common entrapment neuropathy of the ulnar nerve at the elbow. Although there are many primary and secondary causes of cubital tunnel syndrome, ulnar neuropathy secondary to recurrent thrombophlebitis of the slow- flow Venous Malformation (VM) in the vicinity of the cubital tunnel has not been reported. Hereby, authors discuss a case of 22- year-old female with slow-flow VM in the vicinity of the cubital tunnel causing symptoms of transient ulnar neuropathy, progressing to ulnar neuritis resulting in persistent ulnar neuropathy. This was successfully treated by direct Stick Sclerotherapy of the VM, leading to complete relief of the symptoms. Follow-up Magnetic Resonance Imaging (MRI) revealed near-total resolution of the VM with complete resolution of the ulnar neuritis. This was an atypical presentation of ulnar neuropathy secondary to recurrent thrombophlebitis of a slow-flow VM in the cubital tunnel, which was successfully managed by treating the malformation.

Radiofrequency Ablation of Palmar Digital Branches of Ulnar Nerve in a Patient with Ulnar Neuropathy

Ulnar Tunnel Syndrome (UTS) is ulnar neuropathy at the wrist or hand typically caused by ganglion cysts, lipomas, wrist or hand compression, carpal bone fractures, carpal tunnel syndrome, or anything else that can impinge on the nerve. The symptoms of UTS can be uncomfortable and debilitating, with numbness and tingling of the 4th and 5th digits being the most common. Weakness of the ulnar portion of the hand can lead to decreased grip strength. UTS is typically managed with conservative treatment including anti-inflammatory oral medications, splinting, physical therapy, activity modification, acupuncture, and stretching. Second line treatment includes corticosteroid injections, although these have shown to have little efficacy. Surgery is also an option but may lead to iatrogenic ramifications. Radiofrequency ablation (RFA) is a treatment modality used for chronic pain, which utilizes heat to target nociceptive fibers. Traditionally, RFA is used in treating cervical and lumbar radiculopathy, but it is less studied in peripheral nerve areas. This case report examines a patient who had clinically significant pain relief after RFA to the palmar digital branches of the ulnar nerve. The patient was 63-year-old male who presented with left ulnar neuropathy that had been ongoing for 3 years. Despite conservative management, his symptoms of pain, paresthesia, and weakness persisted. The patient then elected to have a left cubital tunnel release at the elbow with anterior subcutaneous transposition. The surgery provided relief for three months but then led to worsening contractures and pain in the 4th and 5th digits of the left hand. Due to persistent symptoms after conservative management and surgical intervention, he was referred to interventional pain clinic. A decision was made to trial a digital nerve block of the left medial and lateral digital palmar nerves. Following the nerve block, the patient reported 100% improvement in pain and increased range of motion and function. Four weeks later, the patient returned for a radiofrequency ablation of the same nerves. In the week following the procedure, the patient reported that the pain in the little finger was entirely resolved. While radiofrequency ablation has become increasingly popular for the treatment of chronic back pain, its use in peripheral nerve pain has been limited to case reports and few randomized control trials. This case report highlights the successful use of radiofrequency ablation in the treatment of little finger pain and ulnar neuropathy by targeting the median and lateral branches of the palmar digital nerve.

SUPRACONDYLAR FRACTURES IN CHILDREN: A SYSTEMATIC REVIEW OF TREATMENT OPTIONS.

To compare the outcomes of surgical stabilization of pediatric supracondylar humeral fractures with the use of crossed Kirschner wires versus divergent lateral pinning wires. This is a systematic review with meta-analysis carried out by searching the MEDLINE/PubMed, Science Direct and Scielo databases. In these, the search for journals was carried out between January and August 2023, where 695 studies were found. To assess the quality of the studies, the Jadad and the MINORS scales were used.. The selection and reading of relevant articles were carried out by the researchers and 11 studies met the selection criteria. From the 11 selected studies, 963 patients who met the criteria for the surgical treatment of these fractures were grouped. After the statistical analysis, we found that the ulnar nerve injury had a higher incidence when the crossed-K wire technique was used; and the lateral fixation is safer for the ulnar nerve. Both fixation techniques determine good functional results. However, fixation with lateral Kirschner wires proves to be safer considering the risk of iatrogenic injury to the ulnar nerve. Crossed-K wire fixation is more effective in terms of stability and maintenance of fracture reduction. Level of Evidence II, Systematic Review of Level II or Level I Studies with discrepant results.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Ulnar neuropathy at the elbow-laterality, disability, and associated conditions

Ulnar neuropathy at the elbow-laterality, disability, and associated conditions

Chapter 7 - Radial neuropathy

Radial neuropathy is the third most common upper limb mononeuropathy after median and ulnar neuropathies. Muscle weakness, particularly wrist drop, is the main clinical feature of most cases of radial neuropathy, and an understanding of the radial nerve's anatomy generally makes localizing the lesion straightforward. Electrodiagnosis can help confirm a diagnosis of radial neuropathy and may help with more precise localization of the lesion. Nerve imaging with ultrasound or magnetic resonance neurography is increasingly used in diagnosis and is important in patients lacking a history of major arm or shoulder trauma. Radial neuropathy most often occurs in the setting of trauma, although many other uncommon causes have been described. With traumatic lesions, the prognosis for recovery is generally good, and for patients with persistent deficits, rehabilitation and surgical techniques may allow substantial functional improvement.

Chapter 2 - The role of imaging in focal neuropathies

Electrodiagnostic testing (EDX) has been the diagnostic tool of choice in peripheral nerve disease for many years, but in recent years, peripheral nerve imaging has been used ever more frequently in daily clinical practice. Nerve ultrasound and magnetic resonance (MR) neurography are able to visualize nerve structures reliably. These techniques can aid in localizing nerve pathology and can reveal significant anatomical abnormalities underlying nerve pathology that may have been otherwise undetected by EDX. As such, nerve ultrasound and MR neurography can significantly improve diagnostic accuracy and can have a significant effect on treatment strategy. In this chapter, the basic principles and recent developments of these techniques will be discussed, as well as their potential application in several types of peripheral nerve disease, such as carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow (UNE), radial neuropathy, brachial and lumbosacral plexopathy, neuralgic amyotrophy (NA), fibular, tibial, sciatic, femoral neuropathy, meralgia paresthetica, peripheral nerve trauma, tumors, and inflammatory neuropathies.

Bony encasement of the ulnar nerve secondary to heterotopic ossification of the elbow: an evaluation of long-term outcomes

BackgroundUlnar neuropathy at the elbow caused by heterotopic ossification (HO) is a rare condition. This retrospective study aims to report on 32 consecutive cases of ulnar nerve encasement caused by elbow HO and evaluate long-term outcomes of operative management and a standardized postoperative rehabilitation regimen. MethodsA retrospective case series was conducted on 32 elbows (27 patients) that underwent operative management of bony ulnar nerve encasement. All procedures were performed in the inpatient setting at an Academic Level 1 Trauma Center from September 1999 to July 2021 by one of three fellowship-trained shoulder and elbow. Postoperatively, all patients received formal physical therapy, heterotopic ossification prophylaxis (30 received indomethacin, 2 received radiation), and a structured continuous passive motion machine regimen. Patient demographics, age, gender, type of injury, history of tobacco use, and medical comorbidities were obtained to include in the analysis. Long-term follow-up examinations were performed to evaluate elbow flexion-extension arc of motion, Mayo Elbow Performance Scores (MEPS), and visual analog scale (VAS) pain scores. ResultsThirty-two elbows with complete bony ulnar nerve encasement secondary to HO were identified (14 from burns, 15 from trauma, 3 closed head injuries). Following surgery, the mean flexion-extension arc of motion improved significantly, increasing from 21° to 100° at long-term follow-up (average 8.7 years, range 2-17 years), with statistically significant improvements in preoperative versus long-term postoperative elbow extension (p < 0.001), flexion (p < 0.001), and total arc of motion (p < 0.001). There was a statistically significant improvement in pre- vs. post-procedure ulnar nerve function, as demonstrated by a decrease in average McGowan grade (1.2 to 0.7; p = 0.002). Additionally, 63% of patients with preoperative ulnar neuropathy symptoms (20/32) had either complete resolution or subjective improvement after surgery. The mean time from injury to surgery was 518 days (range 65-943 days). Age, gender, time to surgery, and medical co-morbidities were not associated with outcomes. The complication rate was 9% (3/32). Patients had an average flexion-extension arc of motion of 97 degrees and average MEPS of 80 (“good”) at long-term follow-up. ConclusionsThe combination of operative management, postoperative heterotopic ossification prophylaxis, and a regimented rehabilitation program has proven to be a durable solution for treating and ensuring good long-term functional outcomes for patients with elbow HO and bony ulnar nerve encasement. This treatment approach leads to superior range of motion, improved or resolved ulnar neuropathy, and good to excellent long-term functional outcomes.

Terrible Triad Injuries around the Elbow: It is Still a Puzzle? Prospective Study.

The "terrible triad" injury of the elbow, consisting of fractures of the coronoid process and radial head along with posterolateral elbow dislocation and refractory instability, has historically led to poor functional outcomes. Traditional treatment focused on bony injuries, but it is now recognized that soft-tissue injuries must also be addressed. Surgical management aims to restore bony and soft-tissue stabilizers, including fixation of the coronoid process and radial head, repair of ligament complexes, and reduction of elbow dislocation. Studies emphasize the importance of early reduction and tailored treatment. This study discusses means and methods of treating this complex injury, highlighting the significance of addressing both bony and soft-tissue injuries for better functional outcomes. This is a prospective study conducted at a single center and involved 27 consecutive patients diagnosed with terrible triad injuries around the elbow. The objective was to evaluate functional outcomes and complications associated with surgical treatment of terrible triad injuries around the elbow. From July 2017 to October 2018, 27 patients with terrible triad injuries around the elbow were operated on and evaluated for a minimum of 1 year in terms of functional results using the mean elbow performance score (MEPS) and VAS score. The surgical protocol included coronoid fixation or repair of the anterior capsule, radial head fixation or arthroplasty, and repair of the lateral collateral ligament (LCL) in a sequential manner. The medial collateral ligament was repaired if the elbow remained unstable.On follow-up, mean MEPS scores improved significantly. The final mean range of motion of the operated upper limb was as follows: 28.5° of extension deficit (standard deviation [SD] 9.07, range, 10°-40°), 117.5° of flexion (SD 13.18, range, 90°-130°), 70.9° of supination (SD 10.19, range, 40°-85°), and 65.5° of pronation (SD 9.54, range, 40°-80°) at the end of 1 year. A total of 12 patients had complications. Out of the 12 patients, three had elbow arthritis, two had heterotopic ossification, three had radial nerve neuropraxia, two patients had elbow stiffness, and two patients suffered from ulnar nerve neuropathy. Surgical intervention in terrible triad injuries around the elbow in the form of coronoid fixation, radial head fixation, or arthroplasty and soft-tissue repair around the elbow gives satisfactory results at the end of 1 year. Addressing each and every component of fracture in a sequential and step-wise manner is associated with good functional outcomes at the end of 1 year.

ОДНОЭТАПНАЯ КОРРЕКЦИЯ ПОСЛЕДСТВИЙ ПОВРЕЖДЕНИЯ ЛОКТЕВОГО НЕРВА

Objective: : To enhance the outcomes of surgical treatment for chronic ulnar nerve injuries by performing one-stage correction. Methods: From 2015 to 2023, 11 patients with chronic ulnar neurovascular bundle (NVB) injuries underwent one-stage reconstruction to restore hand function. The operations were performed on 8 men and 3 women aged 16 to 23. The duration of treatment for patients from the time of injury varied from 1.2 years to 5 years Results: In cases where there was a diastasis between the neural ends of no more than 3 cm in the upper third of the forearm due to nerve damage, restoration of the nerve with epineural suture was performed in 2 patients, while in two other cases with more significant gaps of 3.5 and 5 cm, epineural repair was carried out after anterior transposition of the nerve trunk. In one case of nerve damage in the middle third of the forearm, epineural sutures were applied to a 2.5 cm gap. Among 6 patients with damage to the ulnar NVB in the lower third of the forearm, 4 received epineural restoration of the ulnar nerve, and autologous neuroplasty was performed in gaps exceeding 3 cm in 2 patients. In cases of damage to the ulnar artery, 3 patients received autologous vein grafting, while in 3 other cases, there were no indications for vascular reconstruction. No infectious or inflammatory complications were observed in the immediate postoperative period, and there were no cases of thrombosis of autologous vein grafts of the ulnar artery. After evaluating all patients for 6 months to 2 years, it was found that 9 cases showed favorable and satisfactory long-term functional outcomes, while 2 cases exhibited unsatisfactory results. Conclusion: Restoring hand function after damage to the ulnar nerve is greatly influenced by the location, extent, and type of the damage, as well as the choice of an appropriate reconstruction method. Breaking the procedure into multiple stages can prolong patient recovery and negatively impact treatment outcomes. Conversely, performing the operation in a single stage within a relatively short timeframe can restore hand function and significantly reduce overall treatment and rehabilitation time Keywords: Ulnar nerve, neurovascular bundle, injury, tendon-muscular transfer, epineural suture

Functional outcomes following anterior interosseous nerve transfer in cases of ulnar nerve injury

Functional outcomes following anterior interosseous nerve transfer in cases of ulnar nerve injury

The Relationship between Entrapment Level of the Nerve and Upper Extremity Function and Sleep Quality in Ulnar Neuropathy Patients

The Relationship between Entrapment Level of the Nerve and Upper Extremity Function and Sleep Quality in Ulnar Neuropathy Patients