Decision Making and Operative Tactics for Ulnar Nerve

Techniques in Shoulder and Elbow Surgery 7(1):52–60, 2006
Ó 2006 Lippincott Williams & Wilkins, Philadelphia
R E V I E W
m
m
Decision Making and Operative Tactics for
Ulnar Nerve Compression at the Elbow
Steven Z. Glickel, MD, Salil Gupta, MD, and Louis W. Catalano III, MD
St Luke’sYRoosevelt Hospital Hand Service
Department of Orthopaedic Surgery
New York, NY
m
ABSTRACT
Cubital tunnel syndrome is the second most common
compressive neuropathy of the upper limb, exceeded in
prevalence only by carpal tunnel syndrome. It often
responds to nonoperative treatment, but for those cases
which do not, there are several good surgical options.
This article will discuss the principles of these surgical
techniques and focus on the rationale and operative
technique of anterior transposition of the ulnar nerve
using a noncompressing fasciodermal sling. The postoperative protocol will be outlined as will recent results
of treatment and complications.
Keywords: cubital tunnel syndrome, anterior transposition, ulnar nerve decompression, fasciodermal sling,
compressive neuropathy, subcutaneous transposition
m
HISTORICAL PERSPECTIVE
Cubital tunnel syndrome is the second most common
compressive neuropathy of the upper limb, exceeded in
prevalence only by carpal tunnel syndrome. It often
responds to nonoperative treatment.1 For cases that
persist despite flexion block splinting, nonsteroidal antiinflammatory medications, and avoidance of pressure
on the nerve, a variety of surgical options are available.
Although the list of surgical options includes decompression in situ and medial epicondylectomy, the most
frequently used procedures that have predictably good
results are those that transpose the nerve anteriorly and
stabilize it in some manner.2
There are a number of sites around the elbow where
the ulnar nerve may be compressed. The most proximal
potential site of compression is the arcade of Struthers,
which lies approximately 8 cm proximal to the medial
epicondyle. The arcade of Struthers is a musculofascial
band composed of the deep investing fascia of the arm,
superficial fibers of the medial head of the triceps, and
the internal brachial ligament.3 Recently, Von Schroeder
Address correspondence and reprint requests to Steven Z. Glickel,
MD, C.V. Starr Hand Surgery Center, 1000 10th Avenue, 3rd Floor,
New York 10019, NY. E-mail: sglickel@msn.com.
52
and Scheker4 described the arcade as more of a canal with
an average length of 6 cm, with the proximal extent
located 9.6 cm from the medial epicondyle. The ulnar
nerve may also be compressed as it passes over the thick
medial intermuscular septum. The septum is usually not
problematic before transposition unless the nerve subluxes anteriorly across it.5 In bodybuilders, a hypertrophied medial head of the triceps may compress the
nerve or snap over the medial epicondyle and cause a
friction neuritis.6 Valgus deformity of the distal humerus, resulting from an old epiphyseal injury to the lateral
condyle or a malunited supracondylar fracture, may
cause the nerve to be more susceptible to compressive
forces.6
After passing posterior to the medial epicondyle, the
ulnar nerve enters the cubital tunnel. The cubital tunnel
is a fibro-osseous ring formed by the medial epicondyle
and the proximal ulna. The roof of the cubital tunnel is
formed by the deep forearm investing fascia of the
flexor carpi ulnaris (FCU) and the cubital tunnel
retinaculum,7 which is also called the arcuate or
Osborne ligament.8,9 The cubital tunnel retinaculum is
4 mm wide and extends from the medial epicondyle to
the tip of the olecranon.7 Dynamic forces of traction and
compression occurring with elbow flexion may affect
the nerve within the cubital tunnel. As the elbow flexes,
the aponeurotic origin of the FCU stretches 5 mm for
each 45 degrees of flexion, which decreases the volume
of the cubital tunnel and may potentially compress the
ulnar nerve.10 In addition to these dynamic forces, the
nerve may be physically compressed within the cubital
tunnel by space-occupying lesions, including anomalous
muscles such as the anconeus epitrochlearis and ganglia,
and by synovitis and arthritis that may alter the floor of
the tunnel.11
The ulnar nerve passes between the ulnar and
humeral heads of the FCU as it exits the cubital tunnel
and then is located between the FCU and the flexor
digitorum profundus muscle bellies. Five centimeters
distal to the medial epicondyle, the nerve penetrates the
deep flexor-pronator aponeurosis to lie between the
Techniques in Shoulder and Elbow Surgery
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ulnar Nerve Compression at the Elbow
flexor digitorum superficialis and profundus. The nerve
may be compressed by either the 2 heads of the FCU or
by the deep flexor-pronator aponeurosis.12 In addition,
the common aponeurosis of the FDS to the ring finger
and the humeral head of the FCU has an independent
attachment to the proximal ulna distinct from the main
flexor-pronator aponeurosis. This aponeurosis may
cause kinking and tethering of the nerve during anterior
transposition if not released.13
Decompression in situ is the least complicated of the
operative alternatives for decompressing the ulnar
nerve. The technique involves release of the ulnar nerve
from all of the aforementioned potential sites of
compression of the nerve. Proponents of the procedure
point to the complexity, complications, and potential for
devascularization of the ulnar nerve that may occur with
anterior transposition as the rationale for performing an
isolated decompression.14 Among the potential problems with in situ decompression is that it does not
prevent fixation of the ulnar nerve to the periosteum or
to the medial collateral ligament.5 There is also a risk of
anterior subluxation of the nerve.5 If the neurolysed
ulnar nerve is left in situ, it remains susceptible to the
effects of traction and compression with progressive
elbow flexion.15 Decompression in situ is contraindicated in posttraumatic cases resulting in perineural
scarring, in cases with a space-occupying lesion in the
epitrochlear groove, and when there is subluxation or
dislocation of the nerve.16
In 1950, King17 described medial epicondylectomy
as a modification of decompression in situ. This
procedure involves more dissection about the flexorpronator origin and periosteal stripping than in situ
decompression and may theoretically result in increased
scarring and fixation of the nerve.5 O’Driscoll et al7
demonstrated that resection of greater than 20% of the
medial epicondyle results in violation of the anterior
band of the medial collateral ligament, the major
restraint to valgus stress of the elbow. Excessive
resection of the medial epicondyle, therefore, may
destabilize the joint.5,18
Among the advantages of transposing the ulnar nerve
anteriorly is that it allows the nerve to be positioned in a
less scarred tissue bed. In addition, moving the nerve into
the anterior compartment functionally lengthens it by 3
to 4 cm, which results in less tension on the nerve with
elbow flexion. Therefore, anterior transposition of the
ulnar nerve is indicated in patients with positive elbow
flexion tests. Anterior transposition of the nerve can be
useful for eliminating tension on the ulnar nerve in cases
of ulnar nerve repair about the elbow.5,16
Submuscular transposition places the nerve deep to
the flexor-pronator mass. Intramuscular transposition
places the nerve through a superficial channel created
within the flexor-pronator muscle mass. Subcutaneous
transposition stabilizes the nerve anteriorly by the
creation of a fasciodermal sling. The decision about
whether to transpose the nerve subcutaneously, intramuscularly, or submuscularly is based largely on surgeon’s
preference and theoretical concerns. Dellon’s review19 of
these techniques showed that outcomes criteria have been
variably reported and that grading systems have not been
consistent. Recent reports in the literature describe a
number of new techniques for anterior transposition,
including the use of a V-sling from the intermuscular
septum20 and musculofascial lengthening,21 which are
modifications on the themes of anterior transposition
with a fasciodermal sling and intramuscular transposition.
In 1942, Learmonth22 described submuscular transposition of the ulnar nerve. The technique involves
detachment of the flexor-pronator origin from the
humerus, placement of the mobilized ulnar nerve
beneath the muscle mass, and reattachment of the origin
to the medial epicondyle. The nerve is decompressed,
mobilized anteriorly into an unscarred bed, and protectively padded by the overlying muscle mass. Two to 3
weeks of immobilization in no more than 45 degrees of
elbow flexion16 is required to permit muscle healing.
Time to return to activity is longer with submuscular
transposition than for subcutaneous transposition because of the need for muscle healing and restoration of
elbow motion and power.5,16 Some authors have also
expressed concern for the longitudinal blood supply of
the ulnar nerve with submuscular transpositions.23
Intramuscular transposition of the ulnar nerve in an
anterior position was first described by Adson in 1918.24
The technique involves placement of the mobilized
nerve into a 5-mm trough created within the flexorpronator muscle mass.25 The superficial fascia is then
closed over the nerve. Proponents of the procedure
believe that it is preferable to subcutaneous transposition because the nerve is straighter in the transposed
position and is protected by the surrounding muscle and
fascia.25,26 The theoretical advantage of intramuscular
transposition is that it requires less extensive dissection
than does submuscular transposition.25 A potential
disadvantage of intramuscular transposition is that
persistent compression may occur if the fascia is closed
too tightly or if muscle swelling develops.5 In addition,
scarring within the muscle postoperatively may result in
further compression27 or fibrosis of the nerve.28
Curtis29 described subcutaneous transposition of the
ulnar nerve in 1858. Various techniques for stabilizing
the nerve anteriorly have been described. Eaton et al,30
in 1980, described the creation of a fasciodermal sling
that functions as a new medial septum posterior to the
transposed nerve. The technique does not secure the sling,
composed of a flap of 1.5 2-cm flap of antebrachial
Volume 7, Issue 1
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
53
Glickel et al
fascia, to any fixed structure.2,5 Only normal fat is placed
superficial to the nerve. Because the muscles have not
been detached, the most recent iteration of the protocol is
to begin immediate range of motion diminishing the
potential for nerve fixation or entrapment.2,5 Critics argue
that the disadvantage of subcutaneous transposition is
that the nerve remains vulnerable to repeated trauma,
particularly in thin active individuals.16
m
INDICATIONS/
CONTRAINDICATIONS
The diagnosis of cubital tunnel is a clinical one. Sensory
symptoms begin as intermittent numbness and tingling
involving the ring and small fingers, which may become
continuous. Numbness may progress to anesthesia of these
digits. Sensory loss may include the dorsum of the hand,
and patients may have dysesthesias involving the ulnar
hand and digits. Relevant history should include when,
during the day, symptoms occur and what provocative
activities cause or exacerbate the symptoms. Motor
symptoms may include weakness, loss of grip and pinch
strength, clumsiness, loss of dexterity, and clawing. Some
patients notice a loss of muscle bulk in the involved hand.
Physical examination should begin at the neck with
careful examination of the cervical spine for signs of
cervical radiculopathy or arthrosis. Percussion over the
brachial plexus might elicit a Tinel sign suggestive of a
plexopathy. Adson maneuver, Wright maneuver, and
Roos test should be performed to screen for thoracic
outlet syndrome.
The elbow should be inspected for angulatory
deformity. The carrying angle and range of motion of
the elbow should be measured and compared with the
contralateral side. Palpation, especially along the course
of the nerve, may identify inflammation, masses, sites of
tenderness, and subluxation of the ulnar nerve with elbow
flexion. Percussion of the ulnar nerve may elicit a Tinel
sign. Tinel sign over the nerve is positive in up to 24%
of normal patients.31 The most diagnostic test for cubital
tunnel syndrome is the elbow flexion test.11 The elbow
is maximally flexed with the forearm in supination and
the wrist in extension. Symptoms of paresthesias in the
ulnar nerve distribution within 1 minute are considered
a positive test, although some authors consider the test
positive if symptoms occur within 3 minutes.6,9,11
Rayan et al31 reported a positive elbow flexion test in
up to 24% of a normal population. Percussion of the
ulnar nerve over Guyon canal should also be performed.
Sensory examination may demonstrate hypesthesia
in the ulnar compared with the median nerve distribution. Diminished sensibility on the ulnodorsal aspect of
the hand may help localize the pathology to proximal to
Guyon canal. Initial changes in the nerve resulting from
54
compression affect threshold before innervation density.6,9 Therefore, light touch with Semmes-Weinstein
monofilaments is affected sooner than 2-point discrimination. Two-point discrimination on the involved side
should be compared with the uninvolved side.
Sensory symptoms generally precede motor weakness. The hand should be inspected for atrophy of the
intrinsic muscles, which is most readily discernable over
the first dorsal interosseous muscle. The presence of clawing or the inability to adduct the small finger (Wartenberg
sign) suggests advanced compression. The intrinsic muscles of the hand should be evaluated for function and
strength. Motor weakness of the third palmar interosseous
is one of the earliest signs of ulnar innervated muscle
weakness.5 Thumb interphalangeal joint flexion and
metacarpophalangeal joint hyperextension with key
pinch (Froment sign) may be present in more advanced
nerve compression with weakness of the adductor
pollicis and flexor pollicis brevis. Weakness of the
FCU and flexor digitorum profundus of the ring and
small fingers is usually not present with cubital tunnel
syndrome.11
Conservative treatment of cubital tunnel syndrome
begins with rest and avoidance of external pressure on
the elbow, particularly when it is flexed beyond 90
degrees. Patient education and activity modification,
including avoiding resting on the elbow and activities
that require prolonged or repetitive elbow flexion, are
mainstays of treatment. People often sleep with their
elbows flexed, and this commonly exacerbates their
symptoms. This is treated by a variety of techniques to
avoid elbow flexion during sleep, including a towel or
pillow wrapped around the elbow, a reversed elbow pad,
or a rigid thermoplastic extension splint worn during
sleep. Nonsteroidal anti-inflammatory medications may
occasionally be helpful. Steroid injection directly into
the cubital tunnel should be avoided.
In 1950, McGowan32 introduced a classification
system for cubital tunnel syndrome. Grade I lesions, or
minimal lesions, are those with paresthesias and
numbness but without weakness. Grade II lesions are
intermediate and consist of numbness with intrinsic
weakness and wasting. Severe lesions, grade III, have
ulnar intrinsic paralysis with hypesthesia or anesthesia
in the ulnar nerve distribution. Patients with grade II or
III disease are unlikely to improve with conservative
treatment and are candidates for surgical decompression. Most patients with McGowan I cubital tunnel
syndrome should be treated nonoperatively initially. If
they fail to respond to conservative treatment and
remain persistently symptomatic, they should be considered for ulnar nerve decompression.
Relative contraindications to anterior subcutaneous
transposition of the ulnar nerve using a fasciodermal
Techniques in Shoulder and Elbow Surgery
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ulnar Nerve Compression at the Elbow
sling include very thin individuals with scant subcutaneous tissue, athletes participating in contact sports, and
cases of revision cubital tunnel surgery where the index
operation had been a subcutaneous transposition.
m
PREOPERATIVE PLANNING
Standard anteroposterior, lateral, and oblique radiographs may be useful, particularly with a history of
trauma, arthritis, abnormal carrying angle, or limited
range of motion on physical examination.
Electrodiagnostic studies should be obtained routinely before surgery, particularly if localization of
pathology is not well defined, if a double-crush lesion
may be present, or if the diagnosis of cubital tunnel
syndrome is not clear-cut. The classic electrodiagnostic
finding is slowing of conduction in the ulnar nerve
segment that crosses the elbow.9 The lower limit of
normal motor conduction velocity of the elbow segment
is 49 m/s with the elbow flexed 135 degrees, and the
elbow segment normally has a conduction velocity of
within 11 m/s of the forearm segment.33 False-negative
electrodiagnostic studies are not uncommon. Surgical
intervention will often provide relief of dysesthesias in
patients with negative studies.5,34
m
TECHNIQUE
The extremity is prepared with povidone-iodine (Betadine) scrub and alcohol solution and draped with a
stockingette and an impervious extremity drape. The
skin incision is outlined with a skin scribe with the
elbow in a semiflexed position. A slightly curvilinear,
longitudinal incision is marked over the interval
FIGURE 1. Anterior transposition on the ulnar nerve with
a fasciodermal sling. A longitudinal skin incision is
outlined over the course of the ulnar nerve in the interval
between the medial epicondyle and olecranon. A mark is
made in the skin 1 to 1.5 cm anterior to the medial
epicondyle, which is the planned point of attachment for
the fasciodermal sling.
FIGURE 2. The fascia is incised to the level of the arcade
of Struthers, 8 cm proximal to the medial epicondyle.
between the medial epicondyle and the olecranon along
the course of the ulnar nerve in and proximal to the
cubital tunnel. The medial epicondyle is outlined as a
point of reference. A point 1 to 1.5 cm anterior to the
medial epicondyle is also marked (Fig. 1). This will be
the point of attachment of the fasciodermal sling at the
end of the procedure. The extremity is exsanguinated
with an Esmarch bandage, and the tourniquet is inflated
to 100 mm Hg above the patient’s systolic blood
pressure.
Flaps are elevated anteriorly and posteriorly (Fig. 2).
Branches of the medial brachial cutaneous and medial
antecubital cutaneous nerves are identified and gently
retracted. The medial brachial cutaneous nerve usually
courses relatively longitudinally and then posteriorly in
the distal brachium. The branches of the medial
antebrachial cutaneous nerve are transversely oriented,
perpendicular to the course of the ulnar nerve (Fig. 3).
They are 1 to 2 mm in diameter and can be easily
FIGURE 3. Branches of the medial antebrachial cutaneous nerve are generally perpendicular to the longitudinal
axis of the ulnar nerve and lie in the areolar tissue
overlying the fascia. These branches must be dissected
and protected to avoid painful neuromata.
Volume 7, Issue 1
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
55
Glickel et al
FIGURE 4. The ulnar nerve is identified within the cubital
tunnel.
FIGURE 6. The medial intermuscular septum is excised.
missed if not specifically looked for. There can be from
1 to 6 branches. They must be retracted very gently to
avoid traction injury to the nerves.
The ulnar nerve is identified proximal to the cubital
tunnel. To facilitate finding the nerve, the cubital tunnel
is located posterior to the medial epicondyle, and the
dissection is carried proximally. The fascia over the
nerve is incised, and the nerve is exposed (Fig. 4). The
fascial dissection is continued proximally to the arcade of
Struthers, which is approximately 8 cm proximal to the
medial epicondyle. The surgeon can assess the completeness of the proximal release manually by passing his
(her) index finger along the ulnar nerve proximally. The
nerve is mobilized from the adjacent tissue to assure that
it is fully decompressed. The medial intermuscular
septum is identified, and its anterior and posterior
surfaces are exposed (Fig. 5). The septum is excised to
the level of the medial epicondyle (Fig. 6). There is a
plexus of vessels posterior to the intermuscular septum
just proximal to the medial epicondyle that should be
avoided (Fig. 7). If injured, these vessels can bleed
briskly and be somewhat difficult to control.
Attention is then directed to decompression of the
cubital tunnel. The cubital tunnel retinaculum (Osborne
fascia/ligament) is carefully incised from proximal to
distal over the nerve using a relatively blunt-tipped
(Littler) scissor (Fig. 8). The branches of the medial
antebrachial cutaneous nerve are in jeopardy during this
part of the dissection and need to be protected. They
must be retracted very gingerly. The fascial roof of the
cubital tunnel is incised over the nerve. It is not
uncommon for there to be a discrete area beneath the
cubital tunnel retinaculum where the nerve is visibly
compressed, has prominent vascular markings, or is
hyperemic.
At the distal end of the tunnel, the first motor branch
of the ulnar nerve to the FCU muscle takes off; it should
be identified and protected. The nerve then runs beneath
the 2 heads of the FCU muscle. The fascia over this
interval is incised along the course of the underlying
nerve (Fig. 9).
Once the fascia is released, the nerve has to be
adequately mobilized to allow transposition. There are
FIGURE 5. The medial intermuscular septum is exposed.
56
FIGURE 7. There is a plexus of veins deep to the
intermuscular septum just proximal to the medial epicondyle. This should be avoided during the excision of the
septum or fairly active bleeding can result if it is injured.
Techniques in Shoulder and Elbow Surgery
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ulnar Nerve Compression at the Elbow
FIGURE 8. The cubital tunnel retinaculum (Osborne
fascia) is incised exposing the ulnar nerve within the
cubital tunnel.
longitudinal vessels, venae comitantes, that course
adjacent and parallel to the nerve and contribute to its
blood supply. Ideally, these branches should be mobilized with the nerve as it is prepared for transposition. If
they cannot be mobilized, at a minimum, they should be
preserved. To facilitate the dissection of the nerve, a
medium Penrose drain can be placed around it for gentle
traction. It is advisable to manipulate the Penrose by
hand rather than clamping the ends with a hemostat, the
weight of which might cause a traction injury to the
nerve. When the nerve is fully mobilized, it should be
transposed anterior to the medial epicondyle to assure
that it is fully free.
A fascial sling is created from the fascia of the
flexor-pronator origin. It is based proximally and
measures approximately 2 cm long by 1.5 cm wide
(Fig. 10). It is oriented along the longitudinal axis of the
flexor-pronator origin. It is carefully elevated from the
FIGURE 9. The fascia overlying the interval between the
heads of the FCU muscle is incised, completing the
decompression of the ulnar nerve and allowing it to be
transposed. During this part of the dissection, the branch
of the ulnar nerve to the FCU muscle needs to be
identified and protected.
FIGURE 10. The fascial sling is outlined with a marking
pen. It is approximately 2 cm long and 1.5 cm wide and is
based on the fascial origin on the medial epicondyle
which is left intact.
underlying muscle (Fig. 11). The nerve is transposed
anteriorly with the fascial sling posterior to it (Fig. 12).
The point of attachment of the sling to the subcutaneous
tissue had been previously marked with the marking
pen. A simple technique has been used to identify that
point in the subcutaneous tissue. The subcutaneous layer
on the edge of the anterior skin flap is grasped with an
Allis clamp. The blunt end of an instrument such as a
dental probe is placed on the mark on the skin. The flap
is everted, and the probe is pushed against the mark,
delivering it into the wound. Before suturing the fascial
sling, the area of planned attachment is inspected. There
are frequently superficial sensory nerves within the
subcutaneous tissue (Fig. 13). If present, they need to be
avoided by the sutures. The fascial sling is spread as
broadly as possible and sutured to the subcutaneous
tissue with 3 interrupted figure-of-8, 3-0 PDS sutures
(Fig. 14). The elbow is taken through an arc of motion
from full extension to full flexion while observing the
transposed nerve. It is important that there be no areas
of kinking or acute angulation of the nerve.
FIGURE 11. The fascial flap is elevated off of the
underlying flexor-pronator muscle from distal to proximal.
Volume 7, Issue 1
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
57
Glickel et al
FIGURE 12. The ulnar nerve is transposed anteriorly,
deep to the fascial sling.
The skin is reapproximated with interrupted subcutaneous sutures of 3-0 absorbable suture such as
polyglactin 910 (VICRYL). The skin is closed with a
running subcuticular suture of 3-0 or 4-0 polypropylene
surgical mesh (Prolene), one throw of which is brought
superficial to the skin in the middle of the incision for
ease of removal (Fig. 15). The wound edges are painted
with a dermal adhesive such as dromostanolone propionate (Mastisol) or benzoin, and the suture is reinforced
with Steri-Strips. The wound is dressed with Xeroform,
a single layer of moist gauze, 4 8-in gauze sponges,
and an ABD pad which is secured with kling and an
elastic mesh dressing such as Surgifix (Fig. 16). The
elbow is supported with a sling; there is no splint or cast
used postoperatively.
m
RESULTS
Black et al 2 recently published the results of a
retrospective review of 47 patients who underwent a
FIGURE 13. There are frequently sensory nerves in the
subcutaneous tissue at or near the planned point of
attachment of the fasciodermal sling. These sensory
nerves should be identified and protected.
58
FIGURE 14. The fasciodermal sling is sutured to the
subcutaneous tissue at the predetermined point of
attachment with 3 interrupted sutures of 3-0 size of
long-lasting absorbable suture such as PDS.
total of 51 stabilized anterior subcutaneous transpositions from 1973 to 1995 with a minimum of 2 years’
follow-up comparing the results of immediate range of
motion with postoperative immobilization. The surgical
technique detailed herein, originally described by Eaton
et al,30 was used in all patients. Reported results
included decreased time to return to work with a
postoperative protocol of immediate range of motion
when compared with 2 to 3 weeks of postoperative
immobilization. Thirty-eight of the 46 patients with
preoperative paresthesias had complete resolution of the
paresthesias postoperatively. Postoperative grip strength
increased an average 14%, and pinch strength increased
an average of 20% for the immobilized group and 27%
for the immediate motion group (not statistically
significant). Forty-nine of 51 elbows achieved full range
of motion, with no change between preoperative and
FIGURE 15. The skin is reapproximated with a subcutaneous suture of 3-0 rapidly absorbing suture such as
VICRYL and a running subcuticular suture of 3-0 Prolene,
which is brought superficial to the skin in the middle of the
incision for ease of removal.
Techniques in Shoulder and Elbow Surgery
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ulnar Nerve Compression at the Elbow
becomes necessary to do so) results in neither ischemia
to the nerve segment nor functional compromise to the
nerveIknowledge of the extrinsic and intrinsic microcirculation of peripheral nerves, however, as well as a
half century of successful surgical experience worldwide, assures us that the technique, if performed
properly, is safe and effective.’’
m
FIGURE 16. The wound is dressed with sterile gauze
dressing secured with elastic mesh gauze that allows
range of motion.
final follow-up values. Patients were satisfied with the
results in 47 of the 51 affected limbs. The authors
concluded that ‘‘subcutaneous ulnar nerve transposition
stabilized with a fasciodermal sling engendered reliable
results and high patient satisfaction after follow-up of at
least 2 years.’’2
m
POSTOPERATIVE MANAGEMENT
A soft dressing is applied to the elbow, and patients are
encouraged to move the joint through an unrestricted arc
of motion beginning on the day of the operation.
Progressive nonstrenuous use of the involved extremity
is encouraged and includes active motion and gentle
activities of daily living, including playing light musical
instruments. The patient returns approximately 2 weeks
postoperatively for suture removal and to begin formal
hand therapy to optimize elbow range of motion and,
after 6 weeks, strength. It is critically important that, for
6 weeks, the patient avoid strenuous use of the involved
limb, including manual labor, heavy lifting, strengthening exercises, and sports involving use of the involved
arm.2
COMPLICATIONS
Stabilized subcutaneous transposition of the ulnar nerve
rarely leads to complications.5 Preoperative symptoms
may recur or persist if adequate decompression of the
ulnar nerve is not performed.27,28,35,36 Neuroma of the
posterior branch of the medial antebrachial cutaneous
nerve or numbness in its sensory distribution can occur
if this nerve is transected during surgery.37 Neuromas of
this nerve may be painful. Perineural fibrosis of the
transposed nerve12 and compression of the nerve at the
site of the sling may occur.27 The subcutaneous position
of the nerve may expose it to blunt trauma. During the
course of 20 years of surgical experience, the authors
witnessed only 3 ruptures of the fasciodermal sling.
These failures of the fasciodermal sling to keep the
nerve anterior have been in situations where the patients
were noncompliant with instructions to avoid strenuous
use or have had the elbow traumatized in the immediate
postoperative period.
Yamaguchi et al38 reported that the inferior ulnar
collateral artery provides the only direct blood supply
to the ulnar nerve. This branch is occasionally
sacrificed during anterior transposition. Critics of
anterior transposition cite the potential for vascular
compromise of the ulnar nerve with transposition. This
argument has been challenged by Kleinman15 who
states that ‘‘as a half century of published clinical
experience has shown, sacrifice of the inferior ulnar
collateral artery during anterior transposition (if it
m
REFERENCES
1. Eisen A, Dannon J. The mild cubital tunnel syndrome. Its
natural history and indications for surgical intervention.
Neurology. 1974;24:608Y613.
2. Black BT, Barron OA, Townsend PF, et al. Stabilized
subcutaneous ulnar nerve transposition with immediate
range of motion. Long-term follow-up. J Bone Joint Surg
Am. November 2000;82-A(11):1544Y1551.
3. Spinner M, Kaplan EB. The relationship of the ulnar
nerve to the medial intermuscular septum in the arm and
its clinical significance. Hand. October 1976;8(3):
239Y242.
4. Von Schroeder HP, Scheker LR. Redefining the ‘‘arcade
of Struthers’’. J Hand Surg. 2003;28A:1018Y1021.
5. Gelberman RH, Eaton RG, Urbaniak JR. Peripheral nerve
compression. Instr Course Lect. 1994;43:31Y53.
6. Posner MA. Compressive ulnar neuropathies at the elbow:
I. Etiology and diagnosis. J Am Acad Orthop Surg.
SeptemberYOctober 1998;6(5):282Y288.
7. O’Driscoll SW, Horii E, Carmichael SW, et al. The
cubital tunnel and ulnar neuropathy. J Bone Joint Surg Br.
July 1991;73(4):613Y617.
8. Botte MJ. Nerve anatomy. In: Doyle JR, Botte MJ, eds.
Surgical Anatomy of the Hand and Upper Extremity.
Philadelphia, PA: Lippincott Williams & Wilkins, 2003:
185Y236.
Volume 7, Issue 1
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
59
Glickel et al
9. Szabo RM. Entrapment and compression syndrome. In:
Green DP, Hotchkiss RN, Pederson WC, eds. Green’s
Operative Hand Surgery, 4th ed. Philadelphia, PA:
Churchill Livingstone, 1999:1404Y1447.
10. Vanderpool DW, Chalmers J, Lamb DW, et al. Peripheral
compression lesions of the ulnar nerve. J Bone Joint Surg
Br. November 1968;50(4):792Y803.
11. Idler RS. General principles of patient evaluation and
nonoperative management of cubital syndrome. Hand
Clin. May 1996;12(2):397Y403.
12. Amadio PC, Beckenbaugh RD. Entrapment of the ulnar
nerve by the deep flexor-pronator aponeurosis. J Hand
Surg Am. January 1986;11(1):83Y87.
13. Inserra S, Spinner M. An anatomic factor significant in
transposition of the ulnar nerve. J Hand Surg Am. January
1986;11(1):80Y82.
14. Heithoff SJ. Cubital tunnel syndrome does not require
transposition of the ulnar nerve. J Hand Surg Am.
September 1999;24(5):898Y905.
15. Kleinman WB. Cubital tunnel syndrome: anterior transposition as a logical approach to complete nerve decompression. J Hand Surg Am. September 1999;24(5):886Y897.
16. Posner MA. Compressive ulnar neuropathies at the elbow:
II. Treatment. J Am Acad Orthop Surg. SeptemberY
October 1998;6(5):289Y297.
17. King T. The treatment of traumatic ulnar neuritis.
Mobilization of the ulnar nerve at the elbow by removal
of the medial epicondyle and adjacent bone. Aust N Z J
Surg. August 1950;20(1):33Y42.
18. Froimson AI ,Anouchi YS, Seitz WH Jr, et al. Ulnar nerve
decompression with medial epicondylectomy for neuropathy at the elbow. Clin Orthop Relat Res. April 1991;
265:200Y206.
19. Dellon AL. Review of treatment results for ulnar nerve
entrapment at the elbow. J Hand Surg Am. July 1989;
14(4):688Y700.
20. Tan V, Pope J, Daluiski A, et al. The V-sling: a modified
medial intermuscular septal sling for anterior transposition
of the ulnar nerve. J Hand Surg Am. March 2004;29(2):
325Y327.
21. Dellon AL, Coert JH. Results of the musculofascial
lengthening technique for submuscular transposition of
the ulnar nerve at the elbow. J Bone Joint Surg Am.
September 2004;86-A suppl 1(pt 2):169Y179.
24. Adson AW. Surgical treatment of progressive ulnar
paralysis. Minn Med. 1918;1:455Y460.
25. Kleinman WB, Bishop AT. Anterior intramuscular transposition of the ulnar nerve. J Hand Surg Am. November
1989;14(6):972Y979.
26. Plancher KD, McGuillicuddy JO, Kleinman WB. Anterior
intramuscular transposition of the ulnar nerve. Hand Clin.
May 1996;12(2):435Y444.
27. Broudy AS, Leffert RD, Smith RJ. Technical problems
with ulnar nerve transposition at the elbow: findings and
results of reoperation. J Hand Surg Am. January 1978;
3(1):85Y89.
28. Leffert RD. Anterior submuscular transposition of the
ulnar nerves by the Learmonth technique. J Hand Surg
Am. March 1982;7(2):147Y155.
29. Curtis BF. Traumatic ulnar neuritis. Transplantation of the
nerve. J Nerv Ment Dis. 1898;25:480Y481.
30. Eaton RG, Crowe JF, Parkes JC 3rd. Anterior transposition
of the ulnar nerve using a non-compressing fasciodermal
sling. J Bone Joint Surg Am. July 1980;62(5):820Y825.
31. Rayan GM, Jensen C, Duke J. Elbow flexion test in the
normal population. J Hand Surg Am. January 1992;17(1):
86Y89.
32. McGowan AJ. The results of transposition of the ulnar
nerve for traumatic ulnar neuritis. J Bone Joint Surg Br.
August 1950;32-B(3):293Y301.
33. Hilburn JW. General principles and use of electrodiagnostic studies in carpal and cubital tunnel syndromes.
With special, attention to pitfalls and interpretation. Hand
Clin. May 1996;12(2):205Y221.
34. Tomaino MM, Brach PJ, Vansickle DP. The rationale for
and efficacy of surgical intervention for electrodiagnosticnegative cubital tunnel syndrome. J Hand Surg Am.
November 2001;26(6):1077Y1081.
35. Gabel GT, Amadio PC. Reoperation for failed decompression of the ulnar nerve in the region of the elbow.
J Bone Joint Surg Am. February 1990;72(2):213Y219.
36. Amadio PC, Gabel GT. Treatment and complications
of failed decompression of the ulnar nerve at the elbow.
In: Gelberman RH, ed. Operative Nerve Repair and
Reconstruction. Volume II. Philadelphia, PA: J. B.
Lippincott Co, 1991:1107Y1119.
22. Learmonth JR. A technique for transplanting ulnar nerve.
Surg Gynecol Obstet. 1942;75:792Y793.
37. Dellon AL, Chiu DTW. Cubital tunnel and radial tunnel
syndromes. In: Trumble TE, ed. Hand Surgery Update 3.
Rosemont, IL: American Society for Surgery of the Hand,
2003:313Y324.
23. Mackinnon SE, Novak CB. Compressive neuropathies.
In: Green DP, Hotchkiss RN, Pederson WC, et al eds.
Green’s Operative Hand Surgery, 5th ed. Philadelphia,
PA: Elsevier Inc, 2005:999Y1046.
38. Yamaguchi K, Sweet FA, Bindra R, et al. The extraneural
and intraneural arterial anatomy of the ulnar nerve at the
elbow. J Shoulder Elbow Surg. JanuaryYFebruary 1999;
8(1):17Y21.
60
Techniques in Shoulder and Elbow Surgery
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.