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Ulnar Neuropathy Treatment & Management

  • Author: Charles F Guardia, III, MD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE  more...
 
Updated: Jul 20, 2016
 

Approach Considerations

Nonsurgical therapy may be helpful in many cases of ulnar neuropathy. If conservative therapy fails, surgical treatment is warranted, typically involving one of the following procedures[137, 141, 142, 143, 144, 145, 146] :

  • Decompression in situ
  • Decompression with anterior transposition (subcutaneous, intramuscular, or submuscular)
  • Medial epicondylectomy

More specifically, indications for surgery for ulnar nerve entrapment include the following:

  • No improvement in presenting symptoms after 6-12 weeks of conservative treatment
  • Progressive palsy or paralysis
  • Clinical evidence of a long-standing lesion (eg, muscle wasting or clawing of the fourth and fifth digits)

If a fracture of the hook of the hamate is noted in the wrist, cast immobilization or splinting is required for 4-6 weeks. Surgery is indicated if symptoms progress during this time. On the other hand, as swelling subsides, pressure on the nerve may abate and symptoms may disappear. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also valuable for reducing swelling in the tunnel.

Depending upon etiology, symptoms, and signs, referral to a neurosurgeon, hand surgeon, pain specialist, internist, physiatrist, rheumatologist, occupational therapist, or alternative medicine specialist may be appropriate.

Follow-up after surgery for ulnar nerve entrapment should take place at 1 month, 3 months, 6 months, and 1 year.

With appropriate decompression performed in a timely manner, the result of surgery for ulnar nerve entrapment should be a return to normal function. If decompression in situ is performed appropriately, return to normal function is almost immediate. With transposition of the nerve following decompression, postoperative immobilization, and the rehabilitative process, 3-6 months may pass before the patient regains normal function.[147]

In chronic palsy (lasting >3-4 months) associated with pain, muscle weakness, or atrophy, surgical outcome is less certain. The duration of entrapment and the severity of numbness and muscle weakness are key factors influencing the prognosis. In these chronic cases, improvement may be limited or even absent after decompression and transposition, but further progression can be halted with proper decompression.

An important pitfall in treatment is to lead the patient to believe that full recovery can be expected in cases where recovery is actually uncertain. Of course, few doctors today promise perfection, and physicians often downplay the likelihood of complete recovery so as not to raise expectations unduly. Even so, many physicians, even neurologists and physiatrists, do not realize that an operation for ulnar entrapment has much less chance of a highly satisfactory result than an operation for carpal tunnel syndrome does. The reason for this is unclear.

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Nonsurgical Therapy

Medical and other nonsurgical treatments can provide significant help in cases of ulnar neuropathy. Conservative measures are most likely to be successful when paresthesias are transient and caused by malposition of the elbow or blunt trauma. Vasculitic and metabolic causes can be evaluated and diagnosed to facilitate treatment of the underlying condition.

The physician can address pain or other sensory symptoms by trying various pain medications, including the following:

  • NSAIDs
  • Tricyclic (and related) antidepressants
  • Anticonvulsants
  • Narcotics (generally considered to be a last resort)

Oral vitamin B-6 supplements may be helpful for mild symptoms. This treatment should be carried out for 6-12 weeks, depending on patient response.

Occupational therapy and work hardening programs are also beneficial. Therapists may use and design splints to restrict the range of joint motion and cushions to ameliorate the effects of pressure.[148] They may also use nerve gliding, sliding, or tensioning exercises aimed at promoting smoother movement of the nerve within the cubital tunnel and reducing adhesions and other causes of physical nerve compression.[149]

With nonoperative treatment, strengthening the elbow’s flexors and extensors both isometrically and isotonically within 0-45° of range of motion is helpful. To avoid ulnar nerve impingement in the cubital tunnel, the arc of elbow motion should be limited to an extended range.[150, 151] The patient should be advised to decrease repetitive activities that may exacerbate symptoms. The ulnar nerve should be protected from prolonged elbow flexion during sleep and protected during the day through avoidance of direct pressure or trauma.

For initial conservative treatment of cubital tunnel syndrome, use of an elbow pad or night splinting for a 3-month trial period is recommended.[152, 153] If symptoms do not improve with splinting, daytime immobilization for 3 weeks should be considered. Surgical release may be warranted if the symptoms do not improve with conservative treatment. If the symptoms do improve, conservative treatment should be continued for at least 6 weeks beyond symptom resolution to prevent recurrence.[154]

For mild cubital tunnel symptoms, a reversed elbow pad that covers the antecubital fossa, rather than the olecranon, helps remind the patient to maintain the elbow in an extended position and to avoid pressure on the nerve. At night, a pillow or folded towel may be placed in the antecubital fossa to keep the elbow in an extended position. Another option is to apply a commercial soft elbow splint, with a thermoplastic insert, for persistent symptoms.

For constant pain and paresthesia, one should consider using a rigid thermoplastic splint positioned in 45° of flexion to decrease pressure on the ulnar nerve. Initially, patients should wear this splint at all times; as symptoms subside, they can wear it only at night.

Patient education and insight are important. Resting on elbows at work, using elbows to lift the body from bed, and resting elbows on car windows while driving all are causes of paresthesia that can be corrected without surgical treatment. Patient education, anterior elbow extension splinting (if necessary), and correction of ergonomics at work should correct these transient palsies.

A randomized, controlled study of conservative methods to treat mild and moderate ulnar neuropathy at the elbow indicated that simply giving patients information about how to avoid injuring the ulnar nerve by avoiding or reducing movements or positions that compromise the nerve led to significant symptomatic improvement.[97, 155] It is noteworthy that in this study, adding splinting or nerve-gliding treatments to the program of providing information did not yield a significant further benefit.

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Options for Surgical Intervention

If nonsurgical methods fail and the patient has severe or progressive weakness or atrophy, specific surgical techniques (eg, decompression in situ, decompression with anterior transposition, and medial epicondylectomy) are often beneficial in cases of ulnar neuropathy at the elbow.[156, 157] Entrapments in the canal of Guyon are also amenable to surgical treatment.[1] Surgery is also valuable for correction or stabilization of traumatic injuries, resection of masses or cysts, and sectioning of fibrous bands.

Preoperatively, appropriate blood work, chest radiography (if indicated), and a careful clinical examination are required (see Presentation and Workup). The usual surgical preparation of the affected extremity from fingers to neck is indicated. This is followed by the application of a tourniquet, if necessary.

Indications for ulnar nerve decompression in situ at the elbow are as follows:

  • Mild ulnar nerve compression
  • Documented mild slowing on electromyography (EMG) as the ulnar nerve passes into and through the proximal flexor carpi ulnaris
  • Absence of pain around the medial epicondyle
  • Nerve that does not sublux with elbow flexion
  • Normal osseous anatomy and epicondylar (ulnar) groove at the elbow and findings at surgery that are consistent with compression under the fibrous arcade [158]

Indications for ulnar nerve decompression with anterior transposition include the following:

  • Unsuitable bed for the nerve secondary to the presence of osteophytes
  • Tumor
  • Ganglion
  • Accessory anconeus epitrochlearis
  • Heterotopic bone
  • Significant bursal tissue or other mass
  • Significant tension on the ulnar nerve as indicated by a positive elbow flexion test result or symptoms aggravated by activities requiring flexion
  • Subluxation of the ulnar nerve with elbow flexion
  • Deformity at the elbow secondary to a valgus elbow or a tardy ulnar palsy [159, 3]
  • Valgus instability at the elbow

Indications for medial epicondylectomy include the following[160, 161] :

  • Nonunion of an epicondyle fracture with ulnar nerve symptoms (best indication)
  • Poor bed for the ulnar nerve in the epicondylar groove
  • Ulnar nerve subluxation

Contraindications for the various operative procedures used to decompress the ulnar nerve are as follows:

  • Decompression in situ - This procedure should not be used in cases of severe posttraumatic neuropathy with scarring, chronic subluxation, or dislocation of the ulnar nerve from the epicondylar groove and soft-tissue masses in the epicondylar groove
  • Decompression with anterior subcutaneous transposition - This procedure does not release the ulnar nerve completely, leaving the distal course from the cubital tunnel as a possible site of compression; thus, it may not be the best choice for transposition in a thin person who lacks significant adipose tissue at the site of transposition, because of the possibility of repeated trauma to the nerve at the elbow [18]
  • Decompression with anterior intramuscular transposition - This is the most controversial of the procedures because of the claim of severe postoperative scarring
  • Decompression with anterior submuscular transposition - This procedure is contraindicated in the presence of scarring of the joint capsule or irregularity of the elbow joint due to malunited fracture, severe arthritis, or previous excisional arthroplasty
  • Medial epicondylectomy - This procedure is not used when double-crush syndrome with entrapment at the distal end of the cubital tunnel or soft-tissue masses in the epicondylar groove are suspected

A Cochrane review examined two meta-analyses of five randomized, controlled clinical trials of surgery for idiopathic ulnar neuropathy at the elbow,[97] four of which compared simple decompression with decompression plus transposition.[162, 163, 164, 165] These studies found no significant difference between simple decompression of the nerve and decompression with either submuscular or subcutaneous transposition.

The inability to detect a significant difference between simple decompression and decompression with transposition applied both to clinical outcomes and to neurophysiologic outcomes (ie, nerve conduction studies and EMG).[97] However, one difference between the two surgical approaches was that decompression with transposition produced more superficial and deep wound infections.

Two additional meta-analyses, using somewhat different methods, were also unable to find any significant differences between the outcomes of simple decompression and those of decompression plus transposition.[137, 166] However, one of these studies detected a trend in favor of decompression plus transposition, and the authors raised the possibility that a more highly powered study might be able to detect a difference.[137]

The aforementioned Cochrane review also examined one study that compared medial epicondylectomy with decompression plus anterior transposition and concluded that no significant differences could be found with respect to either clinical or neurophysiologic outcomes.[97] However, patient satisfaction was higher in patients treated with epicondylectomy.[92]

A more recent study of 480 patients reported in 2014 showed that for ulnar nerve compression at the cubital tunnel, both approaches were effective in improving clinical outcome.[167] However, the decompression (neurolysis) alone showed greater effectiveness in relieving pain at the elbow.

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Decompression in Situ

Decompression in situ is essentially a localized decompression of the nerve, accomplished by incising the Osborne ligament and opening the tunnel beneath the two heads of the flexor carpi ulnaris by incising the fascia holding them together. It is easy to perform, and the complication rate is low. In contrast to other methods, ulnar nerve decompression in situ avoids damage to the vascular supply of the nerve. It is less traumatic to the patient than other decompression procedures, and it has been shown to be equally successful.[168, 142, 169]

The main advantage of decompression in situ is the ability to release the ulnar nerve in areas of compression with minimal disturbance of the blood supply. This procedure avoids subluxation of the ulnar nerve, which may lead to a recurrence of symptoms secondary to repeated contusion of the nerve as it snaps over the medial epicondyle.

The disadvantages of simple decompression are the potentially higher recurrence rate and the risk of continued subluxation of the ulnar nerve over the medial epicondyle, if that was present preoperatively.

An incision about 6-10 cm in length is made along the course of the ulnar nerve, midway between the medial epicondyle and the tip of the olecranon. This posterior incision is recommended to avoid damage to the medial brachial and medial antebrachial cutaneous nerves,[170] which must be identified and protected if encountered.

Tourniquet control is employed to facilitate visualization of the nerve. The ulnar nerve is identified proximally. The medial intermuscular septum is released; in some cases, it may be advisable to excise part of the thickened distal medial intermuscular septum to prevent kinking.

The cubital tunnel retinaculum is sharply divided in a proximal-to-distal direction. The ulnar nerve is exposed as it passes between the two heads of the flexor carpi ulnaris. The fascia over the flexor carpi ulnaris is incised, and the nerve is exposed as it passes through the muscle. The deep flexor-pronator aponeurosis is released. Neurolysis is not necessary.

The elbow is taken through its range of motion (ROM), and the ulnar nerve is examined for subluxation; if subluxation is noted, medial epicondylectomy or decompression with anterior transposition should be considered. The tourniquet is dropped, and hemostasis is obtained. Subcutaneous and skin layers are closed. A simple soft compressive dressing is applied. Postoperatively, no or only minimal immobilization is needed, and early active use of the extremity is encouraged.

Some, out of concern over possible resultant subluxation and new compression, believe that the nerve should not be decompressed proximally.[171] The risk of these adverse outcomes can be greatly reduced by limiting the decompression distal to a line drawn from the medial epicondyle to the tip of the olecranon. Proximal decompression is recommended when compression is secondary to a hypertrophied medial head of the triceps or to a snapping of the medial head of the triceps with elbow flexion.

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Decompression With Anterior Transposition

Decompression with anterior transposition is usually the operation of choice for ulnar nerve compression at the elbow. Its main advantage is that it moves the ulnar nerve from an unsuitable bed to one that is less scarred. The nerve is effectively lengthened a few centimeters with transposition, and this decreases the tension placed on the nerve with elbow flexion.[37]

The primary disadvantage of an anterior transposition is that it is more technically demanding than a simple ulnar nerve decompression. The risk of complications is increased when the nerve is moved from its natural bed, and there is a potential for devascularization of the ulnar nerve.

There are three types of anterior transposition, as follows:

  • Subcutaneous
  • Intramuscular
  • Submuscular

Each type has its advocates, and specific indications, advantages, and disadvantages differ from one type to the next.

Subcutaneous transposition

Subcutaneous transposition is the most commonly used method of transposition. It may be the procedure of choice in athletes who throw and do not have muscular atrophy. These athletes may lose forearm strength from a submuscular transposition and a simple decompression may not provide adequate relief of symptoms.

The main advantage of a subcutaneous transposition is that it is easy to perform. It is a good procedure when subluxation and traction on the nerve are contributing to the patient’s symptoms.[172] The primary disadvantage is that the nerve may be hypersensitive after surgery because of its new superficial location. The potential exists for disruption of the ulnar nerve blood supply with the transposition.

A longitudinal incision approximately 15 cm in length is made over the course of the ulnar nerve. Once the nerve is visualized from about 8 cm proximal to the medial epicondyle to 6 cm distal to the epicondyle, the distal portion of the medial intermuscular septum, the fibroaponeurotic roof of the epicondylar groove, the Osborne ligament, and the flexor carpi ulnaris fascia are incised, freeing the nerve. About 3-4 cm of the medial intermuscular septum proximal to the medial epicondyle is excised to prevent postoperative kinking of the nerve.

Distally, the additional common aponeurosis between the flexor digitorum superficialis to the ring finger and the humeral head of the flexor carpi ulnaris is sought and, if present, excised to prevent kinking. Motor branches to the flexor carpi ulnaris and flexor digitorum profundus are identified, protected, and preserved. The first motor branch to the flexor carpi ulnaris from the ulnar nerve proper is dissected out if necessary to prevent kinking.

The nerve is transposed into the subcutaneous plane. A search is made for any remaining sites of constriction or tethering. Several different modifications are used to maintain the ulnar nerve in the transposed position. One is to hold the nerve to the muscle fascia with a few sutures through the epineurium. However, the more popular approach is to use some form of sling.[173, 174] .

A commonly used technique involves the creation of a fasciodermal sling. A 1- to 1.5-cm square flap of antebrachial fascia based on the apex of the medial epicondyle is raised and reflected medially. The nerve is transposed anterior to this flap, and the apex is then sutured to the dermal tissue approximately 1 cm anterior to the medial epicondyle.

Another technique is to use a subcutaneous-to-fascial sling. About 2 cm of the subcutaneous fascia of the anterior skin flap is sutured to the flexor-pronator fascia, just anterior to the epicondyle, to keep the nerve in the transposed position.

A third technique is to create a fascial sling by using the medial intermuscular septum. The intermuscular septum is divided 3-4 cm proximal to its insertion on the medial epicondyle, with the distal attachment kept intact. The nerve is transposed. The septum is then used as either a myofascial or a fasciodermal sling to prevent posterior subluxation of the nerve. Care must be taken to prevent kinking of the nerve at the sling. Finally, a simple soft compressive dressing is applied, and early active ROM is instituted.

Postoperatively, the elbow must be immobilized in 45° of flexion for 2 weeks. Active mobilization with muscle stretching and strengthening is then carried out for 2-3 months.

Intramuscular transposition

Intramuscular transposition is the least popular decompression method. It yields the lowest rate of excellent results and is associated with the most recurrences with severe ulnar nerve compression.

The main advantage of an intramuscular transposition is that it buries the nerve deeply while providing a tunnel through which the nerve can pass. It also allows the nerve to be entirely surrounded by vascularized muscle tissue. The primary disadvantage is that it is a complicated procedure, involving substantial soft-tissue dissection. The risk of perineural scarring is increased, and the procedure may expose the nerve to repeated muscular contractions.

A longitudinal incision 15-20 cm in length is made over the course of the ulnar nerve, and the nerve is decompressed in the same manner as for subcutaneous transposition. The proximal border of the pronator teres and the medial intermuscular septum are excised from the midhumerus to the elbow. The nerve is then temporarily transposed, and the position of the nerve on the flexor-pronator mass is noted.

The ulnar nerve is replaced in the epicondylar groove, and a 5 mm deep trough is made in line with the nerve in its transposed position on the flexor-pronator mass. The fibrous septum separating the flexor-pronator muscles is then excised to provide a soft vascularized muscle bed. The nerve is transposed. The flexor-pronator fascia is closed over the nerve with the forearm fully pronated and the elbow flexed 90°. Finally, a simple soft compressive dressing is applied.

Postoperative management involves 3 weeks of immobilization at 90° of elbow flexion with the forearm in full pronation. This is followed by gradual active ROM exercises, stretching, and muscle strengthening.

Submuscular transposition

A submuscular transposition offers the best results with the fewest recurrences with severe ulnar nerve compression.[175] It is the best salvage procedure when previous surgery has failed because it places the nerve in an unscarred bed. It also works well for patients who are very thin, in whom a subcutaneous transposition may result in an area of hypersensitivity over the transposed nerve. Many consider an anterior submuscular transposition the procedure of choice for symptomatic athletes who throw.

The disadvantage of a submuscular transposition is that it is a technically demanding procedure. Because of the extensive dissection involved, postoperative recovery is more difficult, and there is a 5-10% risk of elbow flexion contracture. Patients may also develop extensive scar formation from the procedure, and revision is difficult if the patient has a recurrence.

In a submuscular transposition, the origin of the flexor-pronator muscle group must be released. This can be accomplished in a number of ways, and the most important part of any of these releases is to be able to reattach the muscle origin securely. Once the nerve has been transposed to its new bed deep to the flexor-pronator muscle group and on the brachialis, the flexor carpi ulnaris fascia is closed, as is the roof of the epicondylar groove.

A longitudinal incision 15-20 cm in length is made over the course of the ulnar nerve, and the nerve is decompressed in the same manner as for subcutaneous transposition. The anterior skin flap is raised until the bicipital aponeurosis is visualized. The overlying fascia is incised, with care taken to identify and protect the median nerve. Because of the extensive venous system in this area, meticulous hemostasis is important.[176]

With the nerves protected, the margins of the flexor-pronator mass are delineated. A plane is developed with blunt dissection between the flexor-pronator mass and the flexor digitorum superficialis and the ulnar collateral ligament. A hemostat is passed in this plane, with care taken to protect the nerves. The flexor-pronator mass is incised in a Z-cut fashion 1-2 cm distal to the medial epicondyle, and then reflected distally. The ulnar collateral ligament must be protected.

The tourniquet is then released and hemostasis obtained. The ulnar nerve is transposed adjacent and parallel to the median nerve. The lengthened flexor-pronator mass is reattached with nonabsorbable sutures with the elbow flexed and the arm pronated.

Postoperatively, the elbow is immobilized in a post mold or cast in 45° of flexion, with slight pronation and the wrist in neutral position, for 3-4 weeks. Active ROM exercises, stretching, and strengthening are then carried out for 3-4 months.

Surgical outcomes

In a retrospective study by Charles et al, 49 patients who underwent ulnar nerve transposition were followed to assess clinical sensory and motor recovery in cubital tunnel syndrome and to determine whether recovery is influenced by such factors as preoperative McGowan stage, age, and symptom duration.[141] Submuscular transposition was used in 25 patients, and subcutaneous transposition was applied in 24 patients.

Obvious improvement was reported in 20 of the 25 patients in the submuscular group and in 17 of the 24 patients in the subcutaneous group.[141] Both groups showed significant improvement in sensory and motor function, with 17 patients in each group recovering sensory function and 19 in each group recovering motor function. Patients with symptoms lasting longer than 6 months had a poor prognosis, regardless of the surgical technique used.

Jaddue et al compared operative technique (incision length and operating time), postoperative care (postoperative pain and complications), and outcome between subcutaneous and submuscular surgical techniques for anterior transposition of the ulnar nerve after decompression in moderate cubital tunnel syndrome.[177] Subcutaneous transposition was found to be associated with a shorter incision, reduced operating time, less postoperative pain, fewer postoperative complications, and better outcome.

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Medial Epicondylectomy

Medial epicondylectomy is another technique for releasing pressure on the ulnar nerve at the elbow. Removal of the epicondyle removes a compressive area. Excision of the proper amount of bone is critical to the success of the procedure. If too much bone is excised, damage to the medial collateral ligament of the elbow with valgus instability may occur; if too little is removed, the procedure fails because the compressive area remains.

The main advantage of medial epicondylectomy is that it provides a more thorough decompression of the ulnar nerve than a simple release does. This results in a minitransposition of the ulnar nerve. Compared with decompression plus anterior transposition, medial epicondylectomy better preserves the blood supply to the nerve, causes less injury to the nerve, and preserves the small proximal nerve branches that might be sacrificed with an anterior transposition.[178]

The primary disadvantage is that it allows greater migration of the ulnar nerve with elbow flexion. There is a potential for elbow instability if the collateral ligaments are damaged. Bone pain and nerve vulnerability at the epicondylectomy site may occur. Compared with simple decompression, medial epicondylectomy is more likely to result in elbow stiffness or an elbow flexion contracture. In addition, it is often a poor choice for athletes who throw because of the significant stresses placed on the medial aspect of the elbow joint.

A longitudinal incision 10-15 cm in length is made over the course of the ulnar nerve, centered 1 cm anterior to the tip of the medial epicondyle.[179] The posterior branches of the medial brachial and antebrachial cutaneous nerves are identified and protected, and the nerve is decompressed as previously described.

A longitudinal incision is made over the medial epicondyle, which is then exposed by means of subperiosteal dissection. The flexor-pronator origin is detached from the epicondyle and reflected distally. With care taken to protect the nerve, the medial epicondyle, or a portion of it, is removed with an osteotome. It is important not to enter the elbow joint or cut the ulnar collateral ligament. Sharp edges of bone are smoothed with a rongeur or rasp.

The periosteum is then closed to prevent tethering of the nerve to the raw bone surface. The flexor-pronator origin is reattached with the elbow in extension to help prevent the development of a flexion contracture. The ulnar nerve is allowed to slide anteriorly.[180] Finally, a simple soft compressive dressing is applied.

No postoperative immobilization is necessary, and active ROM exercises are started as soon as the patient is able to tolerate them. Within 1-2 months, normal activities should be resumed.

Surgical outcomes

Seradge found flexion contractures after medial epicondylectomy in 5% of patients who started rehabilitation at an average of postoperative day 3 and in 52% of patients who started rehabilitation at an average of postoperative day 14.[89, 90] Patients in the early mobilization group returned to work twice as early as those in the late mobilization group did, and they experienced no adverse effects on their grip strength or other hand functions.

Weirich studied 36 patients who underwent subcutaneous transposition and found no differences in pain relief, weakness, patient satisfaction, grip strength, lateral pinch, or two-point discrimination between patients who were started on immediate active ROM exercises and those who started rehabilitation an average of 14 days postoperatively.[181] Patients in the immediate-mobilization group returned to work and performed activities of daily living earlier (median, 1 month) than those in the delayed-mobilization group (median, 2.75 months).

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Endoscopic Cubital Tunnel Release

Endoscopy of nonjoint cavities is widely performed, and endoscopic carpal tunnel release is a popular, though still debated, method of releasing the median nerve at the wrist.[38] With this experience in mind, some authors have attempted endoscopic cubital tunnel release. This technique allows local decompression while offering the ability to decompress the nerve at all potential sites of compression. The possible advantages of this technique include limited invasiveness, reduced complication rates, and quicker rehabilitation.[182, 183]

Tsu-Min Tsai et al, after performing an endoscopic cubital tunnel release on 85 elbows in 76 patients and monitoring them for an average of 32 months, found that 42% had excellent results, 45% had good results, 11% had fair results, and 2% had poor results.[184] These results are comparable to those achieved with the other decompressive techniques, for which the overall rate of good-to-excellent results is 85-90%.

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Complications of Surgical Intervention

The most serious complications of surgical decompression of the ulnar nerve are the following[185] :

  • Failure to decompress the nerve adequately, causing a new area of entrapment with the decompression
  • Injury to the nerve during decompression or transposition
  • Neuromata of the medial antebrachial cutaneous nerve
  • Failure to recognize a double-crush syndrome
  • Infection, failure to heal, thrombophlebitis, atelectasis, and failure of the operation due to an unknown cause

The creation of a new compressive site at the time of surgery can occur with any of the decompressive methods.[186, 187] Injury to the posterior branches of the medial antebrachial cutaneous nerves at dissection is common. This nerve laceration results in loss of sensibility in an area of skin posterior and distal to the incision. Some patients develop a resultant dysesthesia in the nerve distribution; others develop an amputation neuroma.

Recurrent ulnar nerve subluxation and elbow instability can result from damage to the elbow collateral ligaments.[188] A postoperative flexion contracture can occur, most commonly following a submuscular transposition; it is seen after 5-10% of submuscular transpositions. Medial epicondylitis can occur from detachment of the flexor-pronator mass or as a result of a medial epicondylectomy. In addition, the symptoms may recur after an incomplete anterior transposition. Infection can occur with any surgical procedure.

After decompression with anterior transposition, complications can include recurrent subluxation of the ulnar nerve. Incomplete release of fascial slings may result in new areas of compression. In one series of subcutaneous transpositions, 90% of the failures were secondary to incomplete release of the medial intermuscular septum. An ineffective sling may not maintain the position of the transposed nerve and prevent resubluxation.

In addition, scarring may occur in the new muscular channel for the nerve. Perineural fibrosis may result from an intraneural injury or from a nerve transfer to a hypovascular bed. Injury to the flexor carpi ulnaris motor branches during nerve mobilization may result in weakness. Ligation of the posterior ulnar recurrent artery during nerve mobilization may result in nerve devascularization. A postoperative elbow flexion contracture may occur.

After medial epicondylectomy, medial instability may occur. To prevent this complication, the flexor-pronator origin is carefully detached to preserve the fibers of the medial collateral ligament. According to O’Driscoll et al, excision of more than 20% (1-4 mm) of the width of the medial epicondyle in the coronal plane violates the important anterior band of the ligament.[12]

Removal of the optimal amount of medial epicondyle, without creating instability, also improves results. Heithoff and Millender found in their series that a complete osteotomy resulted in 81% good and excellent results.[87] A partial osteotomy yielded a 67% rate of good or excellent results, and a minimal osteotomy yielded a 50% rate of good or excellent results.

Tenderness at the operative site can occur after medial epicondylectomy, sometimes resulting in prolonged and persistent discomfort during bone healing. In addition, loss of the protection afforded by the medial epicondyle may render the ulnar nerve more susceptible to trauma. To prevent the nerve from adhering to the osteotomy site postoperatively, it is important to preserve and close the periosteum at the end of the procedure.

Detachment of the flexor-pronator origin can result in weakness. Patients may develop an elbow flexion contracture that is often attributed to reattachment of the flexor-pronator muscle origin while the elbow is flexed or to delayed or inadequate postoperative mobilization.

Finally, postoperative ulnar neuropathies frequently give rise to lawsuits. Although such neuropathies appear to be most common after cardiac procedures, a Mayo Clinic study cited a rate of 0.5% even after noncardiac procedures.[189] Often, the neuropathy does not appear immediately after the operation, which suggests that the nerve trauma may occur in the postoperative period. Careful attention to protecting the ulnar nerve both during and after the procedure may reduce both the injury rate and the number of ensuing legal claims.

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Contributor Information and Disclosures
Author

Charles F Guardia, III, MD Instructor in Neurology, Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth

Charles F Guardia, III, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, Radiological Society of North America, American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD, MHA, CPE Founding Editor-in-Chief, eMedicine Neurology; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, MHA, CPE is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American Academy of Neurology

Disclosure: Nothing to disclose.

Acknowledgements

Sandeep K Aggarwal, MD Clinical Assistant Professor of Neurology, Department of Neurology, Northwestern University Medical School

Disclosure: Nothing to disclose.

Christina J Azevedo MD Staff Physician, Department of Neurology, Dartmouth-Hitchcock Medical Center

Christina J Azevedo MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Paul E Barkhaus, MD Professor, Department of Neurology, Medical College of Wisconsin; Director of Neuromuscular Diseases, Milwaukee Veterans Affairs Medical Center

Paul E Barkhaus, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association

Disclosure: Nothing to disclose.

Neil A Busis, MD Chief, Division of Neurology, Department of Medicine, Head, Clinical Neurophysiology Laboratory, University of Pittsburgh Medical Center-Shadyside

Neil A Busis, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

Mark D Lazarus, MD Associate Professor of Orthopedic Surgery, Medical College of Pennsylvania-Hahnemann University, Chief of Shoulder and Elbow Service, Department of Orthopedic Surgery, Hahnemann University Hospital

Disclosure: Nothing to disclose.

Andrew K Palmer, MD Chair, Professor, Department of Orthopedics, State University of New York-Upstate Medical University

Andrew K Palmer, MD is a member of the following medical societies: American Osteopathic College of Physical Medicine and Rehabilitation

Disclosure: Del Palma Orthopedics Salary Board membership

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Orthopaedics Overseas

Disclosure: Nothing to disclose.

Scott P Steinmann, MD Assistant Professor of Orthopedics, Mayo Medical School; Consulting Staff, Department of Orthopedic Surgery, Mayo Clinic of Rochester

Scott P Steinmann, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Minnesota Medical Association

Disclosure: Nothing to disclose.

Mark Stern, MD Former Chief, Department of Orthopedic Surgery, Cedars-Sinai Medical Center

Mark Stern, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, California Medical Association, and Western Orthopaedic Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

James R Verheyden, MD Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades

James R Verheyden, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, and American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

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Schematic diagram of elbow region, with 5 main sites (as given by Posner) labeled 1-5; other sites and structures are also named. Main regions of interest are circled with pastel-colored arrows. Sites 2 and 3 are close together and cannot be distinguished by means of electromyography and nerve conduction studies. This location is referred to as ulnar (or epicondylar) groove.
Diagram shows ulnar nerve distal to elbow region. Dorsal ulnar cutaneous nerve (lavender) branches off main trunk (blue). Although course is not followed in detail after that, lavender region on sensory dermatome diagram shows where this sensory nerve innervates skin. Similarly, palmar cutaneous sensory nerve (yellow) branches off to innervate skin area depicted in yellow. Superficial terminal branch is mostly sensory (see green-colored skin on palmar surface), though it also gives off branch to palmaris brevis. Deep terminal branch has no corresponding skin area, because it is solely motor-innervating muscles shown, as well as others not explicitly depicted. Nerve could be pinched or injured anywhere, but sites labeled I-IV are more commonly involved.
Inching technique used to isolate conduction block in left ulnar nerve. Note significant amplitude drop at 305 mm, which correlates with position 2 cm above medial epicondyle. This is example of supracondylar block. Image courtesy of A S Lorenzo, MD.
Normal median and ulnar patterns are compared with those of 3 commonly recognized types of Martin-Gruber anomaly.
First 3 traces correspond to ulnar compound muscle action potential (CMAP) amplitude during recording at abductor digiti quinti (ADQ) and stimulating at wrist, below elbow, and above elbow, respectively. Fourth trace corresponds to stimulation of median nerve at elbow during recording at ADQ. Although CMAP amplitude is reduced markedly above elbow, this is compensated for by adding response seen after stimulation of median nerve; this represents Martin-Gruber anastomosis.
First 3 traces correspond to stimulation of ulnar nerve during recording at first dorsal interosseous (FDI) muscle at wrist, below elbow, and above elbow, respectively. Fourth trace corresponds to stimulation of median nerve at elbow during recording at FDI muscle; this represents Martin-Gruber anastomosis.
In those with Martin-Gruber anomaly who have no other significant neuropathy or nerve compression, stimulation of specific nerves at different sites yields differing results. With median nerve, stimulation at elbow yields larger compound muscle action potential (CMAP) at hypothenar muscles, first dorsal interosseous (FDI) muscle, or thenar muscles (or combination thereof) than does stimulation at wrist. With ulnar nerve, stimulation at wrist yields larger CMAP at hypothenar muscles, FDI muscle, or thenar muscles (or combination thereof) than does stimulation at elbow. In this context, "larger" and "smaller" generally refer to amplitude differences ≥1.0 mV.
Riche-Cannieu anastomosis is communication between recurrent branch of median nerve and deep branch of ulnar nerve in hand. Although it is present in 77% of hands, it yields highly variable degrees of detectable physiologic difference; in many hands, it contributes little and does not affect diagnostic findings at all. Most common effect is probably to give ulnar innervation to some muscles usually innervated by median nerve, median innervation to muscles usually innervated by ulnar nerve, or both. Most extreme version is so-called all-ulnar hand (very rare). Two examples of confusion this might cause are as follows. (1) Median lesion could cause denervation in typically ulnar muscle, such as adductor digiti minimi (adductor digiti quinti) or first dorsal interosseous muscle. (2) Ulnar lesion could cause denervation in typically median muscle, such as flexor pollicis brevis or abductor pollicis brevis.
Table. Types of Martin-Gruber Anastomosis
Type Anatomy Most Characteristic Finding Confirmation Additional Verification Potential Clinical Confusion
I Crossover fibers innervate hypothenar muscles Ulnar stimulation at wrist* produces larger hypothenar CMAP than stimulation at elbow Stimulation of median nerve at elbow† produces response at hypothenar muscles Hypothenar CMAP from ulnar stimulation at wrist is equal to hypothenar CMAP from ulnar stimulation at elbow plus hypothenar CMAP from median stimulation at elbow Smaller response from proximal stimulation could be mistaken for conduction block
II Crossover fibers innervate FDI muscle Ulnar stimulation at wrist produces larger FDI CMAP than stimulation at elbow Stimulation of median nerve at elbow produces response at FDI FDI CMAP from ulnar stimulation at wrist is equal to FDI CMAP from ulnar stimulation at elbow plus FDI CMAP from median stimulation at elbow Usually none, because FDI muscle is not usually recording site; if it is used, conduction block could be suspected, as in type I
III Crossover fibers innervate thenar muscles (typically ADP and FPB) Elbow stimulation of median nerve produces greater thenar response than wrist stimulation Ulnar stimulation produces thenar CMAP with initial positive deflection; it is higher with wrist stimulation than with elbow stimulation For thenar CMAP amplitudes, median elbow stimulation amp is equal to median wrist stimulation amplitude plus ulnar wrist stimulation amplitude minus ulnar elbow stimulation amplitude Can complicate median nerve studies, especially when carpal tunnel syndrome is involved
ADP—adductor pollicis; CMAP—compound motor (or muscle) action potential; FDI—first dorsal interosseous; FPB—flexor pollicis brevis.



*Ulnar stimulation at wrist yields larger CMAP at hypothenar muscles, FDI, or thenar muscles (or sometimes combination of these) than does stimulation at elbow.



†Median stimulation at the elbow yields larger CMAP at hypothenar muscles, FDI, or thenar muscles (or sometimes combination of these) than does stimulation at wrist.



Note: “Larger” and “smaller” generally mean amplitude difference ≥1.0 mV.



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