Ulnar Paresthesia Research Articles

Clinical outcomes of triceps reflecting anconeus pedicle and olecranon osteotomy approach for distal humerus intercondylar fractures.

The preferred treatment for distal humeral intercondylar fractures is open reduction and internal fixation. While there is consensus about the posterior approach, several posterior approaches have been developed. It is debatable as to which approach is best. To compare triceps reflecting anconeus pedicle (TRAP) and olecranon osteotomy approaches for internal fixation of distal humeral intercondylar fracture. In total, 40 cases of Arbeitsgemeinschaft für Osteosynthesefragen/Association of the Study of Internal Fixation type C, closed, and Gustilo type I intercondylar humeral fractures were included. Patients ranged in age from 18 years to 70 years. The patients were randomized into two groups: TRAP group and olecranon osteotomy group, with 20 cases in each. All were followed up at 6 wk, 3 months, 6 months, and 12 months. Functional outcomes were measured in terms of flexion-extension arc, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score. The mean age was 43.2 years in the TRAP group and 37.5 years in the olecranon osteotomy group. The mean operative time and mean duration of hospital stay in the TRAP group were significantly higher than in the olecranon osteotomy group (119.5 vs 111.5 min and 9.85 vs 5.45 d, respectively). The mean arc of flexion-extension, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score were comparable without any significant difference in the groups at the 12-month follow-up (107.0 vs 106.2, 18.3 vs 15.7, and 84.2 vs 86.2, respectively). Ulnar paresthesia and superficial infections were comparable in both groups (2 cases vs 3 cases and 3 cases vs 2 cases, respectively). Hardware prominence was significantly higher in the olecranon osteotomy group, mostly due to tension band wiring. Both approaches were equivalent, but there is a need for further study including higher numbers of subjects and longer study duration to prove the benefits of one approach over the other.

Snapping Wrist From Bowstringing of the Digital Flexors After Carpal Tunnel Release: A Case Report.

Symptomatic bowstringing of digital flexor tendons is a rare complication of carpal tunnel release (CTR). Two weeks after open CTR, a 47-year-old man with severe carpal tunnel syndrome had relief of his preoperative median paresthesia but complained of new-onset painful snapping of the wrist and transient ulnar paresthesia occurring with wrist dorsiflexion and concomitant digital flexion. Physical examination localized the audible snapping to the hook of hamate (HOH) where manual pressure eliminated the wrist motion-induced snapping and the associated ulnar paresthesia. Wrist radiographs showed stage III scapholunate advanced collapse (SLAC) with marked palmar subluxation of the lunate. Wrist magnetic resonance imaging revealed palmar and ulnar subluxation of the digital flexors over the HOH due to the mass effect of the palmarly displaced lunate and the chronic carpal malalignment. The snapping wrist and accompanying ulnar paresthesia resolved after HOH excision, and no additional treatment for the asymptomatic SLAC wrist deformity was required. Satisfactory clinical outcome was observed at 5-year follow-up.

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.

Tuberosity healing in reverse shoulder arthroplasty in traumatology: Use of an offset modular system with bone graft

IntroductionReverse shoulder arthroplasty (RSA) has become a common treatment in displaced proximal humeral fracture (PHF) in elderly patients due to inconstant results with osteosynthesis or hemiarthroplasty. RSA allows a good anterior elevation but rotational results are more random and depend on tuberosity healing. HypothesisUse of an offset modular system (OMS) on the prothesis improve tuberosity healing and functional results. Material and methodsThis retrospective cohort analysed radiological and clinical outcomes at least one year after the use of RSA Humelock II Reversed (Fx Solutions) after a displaced PHF Neer 3 or 4 in patients over 70 years. The first criterion was tuberosity healing with or without the use of the OMS device on radiographs. The second criterion was a clinical analysis of active range of motion (ROM), anterior elevation (AAE), external and internal rotations (ER, IR), Constant, DASH, SSV, VAS scores according to tuberosity healing. We also analysed radiological and clinical complications. ResultsWe analysed from November 2013 to May 2018 thirty-four RSA. Mean age was 78±5,7 years, mean follow up was 18±7,2 months and the mean tuberosity healing rate was 79%. Mean ROM were: 117±24 (AAE), 18̊±18 (ER) and L2 (IR). On the first analysis, healing tuberosity with cage was present on 24 (92%) patients versus 3 (37,5%) without (p<0,005). The second analysis showed a non-significant improvement on ER, IR, Constant, DASH and SSV. Complications found were three removal of prothesis after infection, one axillary nerve lesion, one ulnar paraesthesia and one humeral loosening. ConclusionThe use of the OMS cage allows a better consolidation of tuberosities in a significant way but no significant clinical effects was highlighted due to a small patient number in the study. Level of evidencelevel III, retrospective cohort.

Outcomes of ulnar nerve anterior transmuscular transposition and significance of ulnar nerve instability in cubital tunnel syndrome

We investigated the experience of a single surgeon with ulnar nerve anterior transmuscular transposition with the patient in the lateral decubitus position for cubital tunnel syndrome. The medical records of all patients who underwent primary or revision ulnar nerve anterior transmuscular transposition were screened to define a cohort of 156 patients (162 limbs) for further study of demographic and disease-specific data and retrospective assessment of short-term outcomes. Ulnar neuropathy severity was stratified by McGowan grade. A prospective cohort composed of 49 patients (51 limbs) with a minimum 2-year follow-up volunteered to complete patient outcome surveys, and some presented for an ulnar nerve-focused examination to assess long-term outcomes. The overall patient satisfaction rate was 92%, with statistically significant improvements in ulnar sensation and intrinsic strength at short- and long-term follow-up. Outcomes were better for lower McGowan grades than for higher grades and better in primary cases than in revision cases. Ulnar nerve instability was observed in 69 of 162 cases (43%) in this series. A major complication occurred in 7 cases (4.3%), but all were mitigated by contributory patient-related factors. Reoperation for recurrent ulnar paresthesia was required in 4 cases (2.5%). No operations or outcomes were compromised by the lateral decubitus position. Ulnar nerve anterior transmuscular transposition in the lateral decubitus position is a good surgical option for primary or recurrent cubital tunnel syndrome and remains our preferred procedure. The high prevalence of ulnar nerve instability observed in this study is a factor worthy of consideration by surgeons and patients weighing the surgical options for ulnar neuropathy at the elbow.

Outpatient total elbow arthroplasty: 90-day outcomes

Interest in outpatient arthroplasty has grown in response to increasing emphasis on the efficient delivery of safe, high-quality medical care. This study evaluated 90-day episode-of-care complications after outpatient total elbow arthroplasty (TEA). We retrospectively evaluated 28 patients discharged the same day after primary TEA for 90-day episode-of-care complications, reoperations, and readmissions. Postoperative complications and elbow range of motion measurements were recorded and evaluated at the latest follow-up. All patients were contacted and given a satisfaction survey to assess their outpatient experience. Univariate logistic regression was performed for each risk factor to evaluate the risk for major and minor complications. Statistical significance was set as P < .05. Final follow-up data were available for 28 patients at an average of 14 months. Major complications within 90 days of surgery occurred in 7.1% of patients, ulnar nerve paresthesias occurred in 42.8% of patients, and minor wound problems occurred in 39.2% of patients. Five reoperations occurred after the 90-day postoperative period. All ulnar paresthesias and minor wound complications had resolved by the latest follow-up. Univariate regression analysis revealed a significant correlation between smoking and minor wound complications (P = .038). The satisfaction survey had an 85.7% response rate, with 91.7% of patients stating they were happy they went home the same day, and 95.8% feeling more confident and in control of their lives. The risk profile of carefully selected patients undergoing same-day discharge after TEA is acceptable when combined with close follow-up.

The Impact of Carpal Tunnel Syndrome on Ulnar Nerve: An Electro-Clinical Study

Introduction: The paresthesias’ spread to whole hand in carpal tunnel syndrome (CTS) raises the hypothesis of ulnar nerve involvement. We performed this study to verify this hypothesis. Methods: We analyzed electro-clinical data of 304 patients with suspected idiopathic CTS to investigate correlations between nerve conduction study (NCS) parameters (amplitude of sensory potential (ASP), sensory conduction velocity (SCV) and motor distal latency (MDL)) of ulnar (u) and median (m) nerves, and between ulnar parameters and paresthesias’ topography. Results: A positive correlation between ASPu and ASPm (r= 0.13, p<0.05), and significant difference of ulnar parameters averages between affected and healthy hands were highlighted. Ulnar parameters averages were different according to paresthesias’ topography (median territory versus whole hand), but not statistically significant. Discussion: Our results support the hypothesis of CTS impact on ulnar nerve at the wrist, which has major implications not only to understand physiopathology and symptoms, but also for therapeutic management.

A Simple Accommodation for Ulnar Nerve Paraesthesia Following Body Impacts from Mechanical Energies

Acquired painful or distracting paraesthesia of the lateral two fingers subsequent to a strong mechanical impact to the body can also be elicited clinically by point stimulation around the ipsilateral periscapular region. This neurological (ulnar) demonstration offers an alternative attribution of the etiology for the patient. A simple mechanical procedure that can be self-administered by the patient over several weeks minimizes the symptom and can facilitate sense of control of the unwanted experiences.

Short- and Medium-Term Results of Total Elbow Arthroplasty after Trauma

Treatment of distal humerus fractures by open reduction and internal fixation, especially in elderly patients, does not always result in satisfactory outcomes. Previous studies show good outcomes in total joint replacement of these fractures. The objective of this study is to present our experience with primary and secondary implantation of a semiconstrained elbow prosthesis after trauma. In two study centers, between 2003 and 2009, a total of 44 patients (34 women and 10 men) with an average age of 65 years were treated primarily (n = 19) or secondarily (n = 25) by semiconstrained total elbow replacement after distal humerus fractures. Primary treatment referred exclusively to 13C2 and 13C3 fractures according to the AO/ASIF-classification, except for two cases. Indications for secondary elbow arthroplasty were post-traumatic arthrosis (n = 10), non-union of the bone (n = 6), failed osteosynthesis (n = 5), post-traumatic chronic luxation (n = 2) and severe bony defect situation after chronic osteitis (n = 2). In two cases a prostheses exchange for a periprosthetic fracture after fall was performed. Clinical outcome was radiologically controlled and measured by the use of the Mayo Elbow Performance Score (MEPS) and DASH score after a mean follow-up of 38 (13 to 96) months. 33 Patients (75 %) had a follow-up examination clinically and radiologically. Mayo Elbow Performance Score was excellent or good in 27 (82 %) cases with a mean of 87 points (primary group 87 vs. secondary group 86). The average DASH score was 28 points (primary group 24 vs. secondary group 32). The flexion was on average 131° (110 to 145°), the extension deficit 30° (0 to 80°) to neutral position and the range of motion was 100° (40 to 145°) (primary group 102° vs. secondary group 97°). The mean operation time was 141 (100 to 250) minutes (primary group 138 vs. secondary group 144 min.). The length of stay in hospital was on average 15 days. Complications occurred due to ulnar paresthesia (n = 4), deep infection (n = 6), periprosthetic ulna fracture (n = 1), heterotopic ossifications requiring intervention (n = 1), elbow stiffness (n = 1), triceps insufficiency (n = 5) and triceps avulsion (n = 2). Primary elbow joint replacement seems to be a promising alternative for distal humerus fractures without a sufficient reconstruction opportunity, showing encouraging short- and medium-term results in the elderly. Secondary replacement can achieve satisfying results in failed osteosynthesis, non-union of the bone or post-traumatic arthrosis as well. The rate of complications and revisions is high.

Steindler flexorplasty to restore elbow flexion in C5-C6-C7 brachial plexus palsy type

BackgroundLoss of elbow flexion due to traumatic palsy of the brachial plexus represents a major functional handicap.Then, the first goal in the treatment of the flail arm is to restore the elbow flexion by primary direct nerve surgery or secondary reconstructive surgery.There are various methods to restore elbow flexion which are well documented in the medical literature but the most known and used is Steindler flexorplasty.This review is intended to detail the author's experience with Steindler flexorplasty to restore elbow flexion in patients with brachial plexus palsy C5-C6-C7 where wrist extensors are paralyzed or weakened.MethodsWe conducted a retrospective follow-up study of 12 patients with absent or extremely weak elbow flexion (motor grade 2 or less), wrist/finger extensor and triceps palsy associated; who had undergone surgical reconstruction of the flail upper limb by tendon transfer (Steindler flexorplasty) and wrist arthrodesis to restore elbow flexion. The aetiology of elbow weakness was in all patients brachial plexus palsy (C5-C6-C7 deficit). Data were collected from medical records and from the information obtained during follow-up visits.Age, sex, preoperative strength (rated on a 0 to 5 scale for the flexors of the elbow, wrist flexors, pronator and triceps), previous surgery, length of follow-up, other associated operative procedures, results and complications were recorded.ResultsThe results are the follows: Eleven patients were found to have very good or good function of the transferred muscles. One patient had mild active flexion of the elbow despite the reconstructive procedure.There were no major intraoperative complications. Two patients experienced transient, intermittent nocturnal ulnar paresthesias postoperatively. In both patients these symptoms subsided without further surgery.ConclusionOur study suggests that in patients with C5-C6-C7 palsy where the wrist and finger extensors are paralyzed or weaked, the flexor-pronators muscles of the forearm are strong but the triceps is not available for transfer; Steindler flexorplasty to restore elbow flexion should be complemented with wrist arthrodesis.

Combination of Arthrolysis by Lateral and Medial Approaches and Hinged External Fixation in the Treatment of Stiff Elbow

Various methods are available to treat the stiff elbow. However, there is no consensus on which one is most useful. This study involves the effects of combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow. We treated 12 patients with stiff elbows using a combination of arthrolysis by lateral and medial approaches and hinged external fixation. The arthrolysis was applied to the elbow for complete soft-tissue release, and the hinged external fixation mainly for rehabilitation and stability of the elbow after arthrolysis. With the help of the hinged external fixation, nonsurgical treatment including exercises was effectively performed to maintain the stability and the results of arthrolysis. Before surgery, the mean extension was -35 degrees and the mean flexion 70 degrees. One patient had a loss of 70 degrees in pronation. Satisfactory follow-up was given to 11 patients with the mean length of 15 month. The mean postoperative extension was -8 degrees whereas flexion 122 degrees. Two of 11 patients had a transient ulnar paresthesia and returned to normal after 8-month follow-up. The loss of pronation in one patient reduced to 30 degrees afterward. There were no complicating infections. All patients reported satisfactory effect. The combination of arthrolysis by lateral and medial approaches and hinged external fixation in the treatment of stiff elbow is safe and effective.

The outcome of examination (manipulation) under anesthesia on the stiff elbow after surgical contracture release

We have used a technique of elbow examination under anesthesia in select patients after surgical release to assess the smoothness of the articulation, evaluate stability, and to stretch the flexion and rotation arcs. The study comprised 51 consecutive patients who underwent an examination under anesthesia between January of 1996 and December of 2001. The examination occurred a mean of 40 days after surgery. Forty-four patients with a minimum of 12 months follow-up revealed a mean pre-examination arc of 33 degrees , which improved to 73 degrees at the final assessment. Three patients had no appreciable change (<10 degrees ) in the total arc, and 1 patient lost motion. Four patients underwent a second examination under anesthesia at a mean of 119 days after the first examination. The average pre-examination arc of 40 degrees increased to 78 degrees at the final assessment (mean improvement, 38 degrees ). The only complication was worsening of ulnar paresthesias in 3; with 2 resolving spontaneously, and 1 patient requiring anterior ulnar nerve transposition. Examination (manipulation) under anesthesia can be a valuable adjunctive procedure to help regain the motion obtained at the time of surgical release. Because this was not a controlled series, additional studies might be conducted to refine those not benefiting from this procedure. In our series no permanent complications were noted.

Bilateral Ulnar Decubitus as a Complication of Macular Hole Surgery

Bilateral ulnar decubitus is described in a 69-year-old patient maintaining prone positioning after vitrectomy, membrane peeling, and perfluoropropane gas injection for the treatment of a macular hole. Patients should be warned to report any skin breakdown or ulnar paresthesias resulting from positioning and to change position frequently to allow weight bearing on other parts of the body. Patients with certain personality traits may be more likely to maintain correct positioning despite pain or injury to ensure surgical success.

Backpacking-Induced Paresthesias

To evaluate the presence of numbness and paresthesias among long-distance backpackers on the Appalachian Trail. Backpackers who hiked a minimum of 7 days were interviewed while hiking. Following their hike, a written questionnaire was mailed to the participants that explored the incidence of injuries and illnesses among hikers. Paresthesias were defined as either numbness or "phantom, burning, or shooting pains." A case-control analysis of risk factors for paresthesias was performed. Paresthesias were reported by 34% (96 of 280) of the backpackers completing the study. They included ulnar paresthesias (n = 4), meralgia paresthetica (n = 10), tarsal tunnel syndrome (n = 6), digitalgia paresthetica (n = 21), and nonspecific paresthesias (n = 61). The most common symptom was numbness: 81% (78 of 96). Significant risk factors included a distance of >2000 miles (relative risk [RR] = 1.3; 95% CI, 1.1-1.6; P = .01) and the duration of hiking (RR = 2.0; 95% CI, 1.2-3.2; P = .004) for the longest quartile. Nonsignificant factors included backpack weight, initial body weight, percentage of weight loss, running shoe usage, and multivitamin usage. Ninety-eight percent of the paresthesias (94 of 96) had resolved by the time of follow-up (median = 30 days). Paresthesias were a surprisingly common complaint among long-distance backpackers. Although they were distressing during backpacking, these neuropathies were self-limited and resolved after completion of hiking.

Progressive surgical release of a posttraumatic stiff elbow. Technique and outcome after 2-18 years in 46 patients.

We treated 46 consecutive patients (47 elbows) suffering from posttraumatic contracture of the elbow joint with operative release. A lateral approach was used to perform a capsulectomy after release of the extensor muscles in 23 elbows. An additional medial approach was used to excise ulnar adhesions and perform a more extensive capsulectomy and an ulnar nerve neurolysis in 24 elbows. Postoperative rehabilitation consisted of immediate passive range-of-motion exercises. The results were assessed after average 10 (2-18) years. Before surgery, the mean active arc of motion was 45 (SD 36) degrees, which improved to 99 (SD 34) degrees after release. 7 patients had transient ulnar paresthesia, 4 recurrent stiffness, which did not become worse after surgery, 1 was reoperated on and 2 developed a postoperative infection, which responded to antibiotic treatment after a few months. No patient suffered from joint instability, or an increase in pain. 44 patients were satisfied with the result at the latest follow-up. We found similar improvement in both treatment groups.

The Column Procedure

Thirty-eight elbows (thirty-seven patients) with an extrinsic contracture were treated operatively with a limited lateral approach to the anterior and posterior aspects of the capsule. Because the procedure elevates muscles from the anterior and posterior aspects of the lateral supracondylar osseous ridge, we called it the column procedure. The mean preoperative arc of flexion was 49 degrees (from 52 to 101 degrees). At a mean of forty-three months (range, twenty-four to seventy-four months) postoperatively, the mean arc of flexion was 94 degrees (from 27 to 121 degrees). The mean total gain in the arc of flexion-extension was 45 degrees; thirty-four elbows (89 percent) had an improved range of motion at the latest follow-up examination. Overall, thirty-one elbows (82 percent) had a satisfactory result. Greater improvement was obtained in elbows that had had severe stiffness (a total arc of 31 to 60 degrees) or very severe stiffness (a total arc of 30 degrees or less) or that had had a combined flexion and extension contracture. A complication occurred in four elbows (11 percent). A hematoma developed in two elbows and impaired the final outcome in one of them. Two elbows had transient ulnar paresthesia, which resolved spontaneously. The arc of flexion obtained at the time of the operation was lost in ten elbows (26 percent) after an initial period of improvement; at the latest follow-up evaluation, four of these elbows had a mean decrease in the arc of flexion of 24 degrees compared with preoperatively. The column procedure is associated with a low rate of complications and is safe and effective for the treatment of a limitation in flexion or extension resulting from an extrinsic contracture of the elbow.

Symptomatic Macromastia: A Quality of Life Evaluation after Reduction Mammaplasty

Abstract: The aim of this retrospective study is to present the severity of symptoms and clinical signs attributed to macromastia and the extent to which reduction mammaplasty relieves them. We studied, both by specially designed questionnaires and review of their clinical records, 92 patients, aged 18–64 years, who underwent bilateral reduction mammaplasty for symptomatic macromastia. The most common symptoms were breast pain and discomfort, shoulder grooving and pain, back and neck pain, intertrigo, and in one case, ulnar paraesthesia. The mean weight of removed tissue from each breast was 720 g. The complication rate was 11%, the most frequent being postoperative infection. The mean follow-up period was 27 months. Postoperatively 88 patients presented with significant improvement of symptoms, whereas in 3 patients the breast discomfort persisted apparently due to residual fibrocystic elements. The majority of patients would recommend the operation to friends and relatives with macromastia. The significant degree of symptom recess supports the reconstructive value of reduction mammaplasty.

Elbow flexorplasty. An analysis of long-term results.

We analyzed the long-term functional results in twenty-five consecutive patients who underwent Steindler elbow flexorplasty between 1952 and 1976. In eighteen patients, the elbow flexorplasty was augmented by a glenohumeral arthrodesis. The mean length of the follow-up was 9.3 years. The mean arc of active flexion following floxorplasty was 95 degrees. The postoperative loss of elbow extension averaged 36 degrees. The mean postoperative active pronation was 79 degrees and supination, 51 degrees. In two patients mild transient ulnar paresthesias developed following flexorplasty. At final evaluation, fourteen patients were judged to have excellent; six, good; four, fair; and one, poor function. All but one patient noted subjective improvement after the procedure.

Prevention of Postsurgical Ulnar Neuropathy

<h3>To the Editor.—</h3> Ulnar paresthesia involving one or both hands or forearms, can be a rare but distressing and troublesome complication of major surgical procedures performed under general anesthesia on parts of the body other than the arms. Operations undertaken when the patient is in the face-down position (eg, lumbar laminectomy) are a particular source of this complication, but we have seen ulnar paresthesia of lengthy persistence following appendectomy, removal of a knee cartilage, repair of dislocation of the shoulder, and cholecystectomy. The causative factor appears to be compression of the ulnar groove of the elbow on the edge of an armboard or on an outrigging bar that runs along the edge of the operating table and is used for attachment of lateral supports such as those employed in operations upon the kidney. The arm is often held in place alongside the body by the lifting sheet used to transport