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Ulnar tunnel syndrome (UTS) is relatively uncommon compared to the carpal tunnel or cubital tunnel syndromes. Few reports dedicated to the functional outcomes after surgical intervention of the UTS exist. Herein we compare the outcomes of patients with UTS of different etiologies.Patients diagnosed with UTS between 2016 and 2020 were recruited. Ulnar tunnel release was performed in all patients, along with other necessary osteosynthesis or reconstructive procedures in the traumatic group. Patients were followed-up every six months post-operatively. Outcomes measured include: objective evaluations, subjective questionnaires, records of clinical signs, and grading of the British Medical Research Council scale for intrinsic muscle strength.21 patients were recruited, and favorable results were noted in all of them after surgery. Traumatic UTS patients had a worse initial presentation than the non-traumatic cases, but had a greater improvement after surgery and yielded outcomes comparable with those of the patients without trauma. Patients with aberrant muscles in their wrists had better outcomes in some objective measurements than those without aberrant muscles.Ulnar tunnel release improves the outcome of patients regardless of the etiology, especially in patients with trauma-induced UTS. Thus, a proper diagnosis of the UTS should be alerted in all patients encountering paresthesia in the ulnar digits, ulnar-sided pain, weakness of grip strength, or intrinsic weakness to ensure good outcomes.

Guyon canal (GC) syndrome is a rare peripheral neuropathy involving the distal part of the ulnar nerve. Several causes are associated with GC syndrome, including anatomic variations, space-occupying tumors, and trauma. Because of disease rarity, the only reported studies of GC syndrome are case series with small sample size. We conducted a multicenter study to identify the basic characteristics of patients with surgically treated GC syndrome and the risk factors for the disease. This retrospective multicenter study was conducted between January 2001 and December 2020. We screened 70 patients who underwent GC release surgery by seven hand surgeons at six institutes. A total of 56 patients were included in this study, including 38 patients (67.9%) who underwent isolated GC decompression and 18 (32.1%) who underwent combined peripheral nerve decompression. The mean patient age was 48.4 years (range: 20-89 years), and 40 patients (71.4%) were male. The average preoperative symptom duration was 18.5 months, and most patients were office workers. Ultrasound was positive for GC syndrome in 7/10 patients evaluated, CT in 2/5, MRI in 17/23, and electrodiagnostic studies in 35/44. The most common cause of GC syndrome was tumor (n = 23), followed by idiopathic (n = 17), trauma (n = 12), anatomic variants (n = 3), and inflammation (n = 3). In conclusion, most patients with GC syndrome in this study were male and had symptoms in one wrist. The most common cause of GC syndrome in this study was a tumor, including a ganglion cyst. Level of Evidence: Level IV case series.

Summary Ulnar nerve (UN) entrapment is a common peripheral neuropathy and can lead to dysfunction of both sensory and motor function of the hand. Surgical release is the mainstay of treatment, but post-operative rehabilitation of UN innervated intrinsic muscles is lacking evidence. This cohort study utilized surface electromyography (EMG) and assessed the activation of UN innervated intrinsic and extrinsic hand muscles during four exercises in healthy participants. Exercises included rotating baoding balls, squeezing a stress ball or grip device every second, and repetitive finger abduction against a rubber band. Normalized percent activation of each muscle was calculated for each exercise. It was demonstrated that rubber band resistance (RBR) finger abduction showed significantly increased activation in both intrinsic muscles tested, while minimizing activation of the one tested UN innervated extrinsic muscle. Thus, to best target the intrinsic hand muscles without fatiguing extrinsic muscles, the inexpensive and practical RBR exercise is beneficial in post-UN release rehabilitation.

Repetitive vibratory trauma in cyclists is one of the most common causes of ulnar nerve compression at the wrist. This study describes five cases of clinically suspected compression syndrome of the deep terminal branch of the ulnar nerve (DBUN) defined by high-resolution ultrasound (HRUS) with a 18-MHz linear transducer. Reliable HRUS visualization of the DBUN was feasible in all patients. The affected nerves had focally swollen and hypo-echoic changed segments. HRUS is a good imaging tool for the evaluation of a suspicious DBUN neuropathy if no electrodiagnostic testing is available or in patients with mild to moderate clinical symptoms with inconclusive electrodiagnostic results.

Submuscular transposition (SMT) for treatment of ulnar nerve entrapment is commonly performed, however published comparisons of surgical techniques exclude a high proportion of the at-risk population encountered in real world practice. To examine the influence of risk factors on the clinical outcome following SMT we performed a retrospective review of all patients who underwent SMT, including patient self-reported outcome and Louisiana State University Medical Centre ulnar nerve grading scale. A total of 403 ulnar nerves were operated, with follow-up data available for 385 cases (359 patients). Risk factors (including smoking, diabetes, previous elbow trauma/pathology, subluxation, workers’ compensation) were reported in 266 of 385 surgeries (69.09%). SMT was the primary procedure in 339 nerves (88.05%), revision procedure in 46 nerves (11.95%). At last follow up 91.05% reported symptomatic improvement. Nerve grade improvement in 71.09% of primary and 67.39% revision surgery (p = 0.605). No significant difference in improvement was identified between demographic and risk categories, except for patient reported improvement in those without peripheral neuropathy (90.59% vs 73.33%, p = 0.027), and those not improved were on average older than those improved (62.94 vs. 55.68 years, p = 0.012). Superficial infection occurred in 2.6% and there were no deep infections. Application of published exclusion criteria would have resulted in exclusion of ½–⅔ of our cohort. SMT in patients with a history of elbow trauma, diabetes, workers compensation, smoking history, nerve subluxation or revision surgery have similar outcomes compared to those without these factors, whilst improved results were observed in younger patients and those without peripheral neuropathy.

Background Previous studies demonstrated that soft tissues, such as retinaculum, fibrous band, and anconeus, cause ulnar nerve compression, whereas other studies showed that the bony structures strain the ulnar nerve that runs directly behind the medial epicondyle constituting the boundary of the cubital tunnel during elbow flexion. However, no studies have reported the association of the shape of the bony structure with cubital tunnel syndrome symptoms. Are computed tomography (CT) and magnetic resonance imaging (MRI)-measured parameters of the bony cubital tunnel related to idiopathic cubital tunnel syndrome symptoms? Hypothesis We hypothesized that CT and MRI-measured parameters of the bony cubital tunnel were related to idiopathic cubital tunnel syndrome symptoms. We aimed to investigate the relationship between the radiographic parameters based on CT and MRI and idiopathic cubital tunnel syndrome symptoms. Patients and methods We analyzed 224 elbows (77 affected elbows of patients with idiopathic cubital tunnel syndrome, 77 unaffected elbows of patients with cubital tunnel syndrome, 70 elbows of patients without cubital tunnel syndrome symptoms) using CT and MRI. Cubital tunnel cross-sectional area, cubital tunnel volume, and ulnar nerve cross-sectional area were measured in the three groups at flexion and extension. A new cubital tunnel center with a new boundary was proposed that could play a role in ulnar nerve compression symptoms. Results The cross-sectional areas and volumes of the cubital tunnel measured in the elbow flexion state were the smallest among the group with the affected elbows in patients. There was no difference between unaffected elbows and the non-patient group. The cross-sectional area of the ulnar nerve highly correlated with cubital tunnel symptoms in the flexion state. Discussion The shape of the cubital tunnel is an important factor in cubital tunnel syndrome, and normal variations in the volume and cross-sectional area of the cubital tunnel and ulnar nerve could influence the occurrence of idiopathic cubital tunnel syndrome. Level of evidence III, Therapeutic study.

Background Ulnar nerve entrapment at the elbow is the second most common nerve entrapment syndrome at the upper limp, after carpal tunnel syndrome. Many surgeons feel that ulnar nerve instability contra-indicates endoscopic nerve release. Published studies, however, found no evidence that pre-operative or intra-operative ulnar nerve instability adversely affected clinical outcomes. The objective of this prospective study was to define the indications and describe the outcomes of endoscopic ulnar nerve release at the elbow. Hypothesis Endoscopic ulnar nerve release at the elbow is a valid option even in patients with ulnar nerve instability and regardless of the severity of the compression. Material and methods We conducted a prospective single-centre study of patients scheduled for surgery based on clinical and electromyographic manifestations of ulnar nerve entrapment at the elbow. Ulnar nerve instability (incomplete dislocation, i.e., Childress A) before or during surgery was not a contra-indication to the procedure. The patients were re-evaluated 12 months after surgery. Results Seventeen patients were included in the statistical analysis. The modified Bishop's score indicated excellent or good outcomes in 15 (88%) patients (excellent in 4 and good in 11) and a fair outcome in 2 patients. Functional outcomes were not associated with the presence of ulnar nerve instability before surgery. Discussion We elected to include patients with Childress A ulnar nerve instability. Clinical outcomes in these patients were similar to those in patients without ulnar nerve instability. Level of evidence IV, open prospective study of treatment outcomes.

Ulnar nerve entrapment is the second most common compressive neuropathy after carpal tunnel syndrome. The accessory anconeus epitrochlearis muscle - present in 4% to 34% of the general population - is a known, but rare cause of ulnar nerve entrapment at the elbow. The aim of this article was to expand our knowledge about this condition based on six cases that we encountered at our hospital between 2011 and 2015. Every patient had a typical clinical presentation: hypoesthesia or sensory deficit in the fourth and fifth fingers; potential intrinsics atrophy of the fourth intermetacarpal space; loss of strength and difficulty with fifth finger abduction. Although it can be useful to have the patient undergo ultrasonography or MRI to aid in the diagnosis, only electromyography (EMG) was performed in our patients. EMG revealed clear compression in the ulnar groove, with conduction block and a large drop in nerve conduction velocity. Treatment typically consists of conservative treatment first (splint, analgesics). Surgical treatment should be considered when conservative treatment has failed or the patient presents severe neurological deficits. In all of our patients, the ulnar nerve was surgically released but not transposed. Five of the six patients had completely recovered after 0.5 to 4years follow-up. Ulnar nerve entrapment at the elbow by the anconeus epitrochlearis muscle is not common, but it must not be ignored. Only ultrasonography, MRI or, preferably, surgical exploration can establish the diagnosis. EMG findings such as reduced motor nerve conduction velocity in a short segment of the ulnar nerve provides evidence of anconeus epitrochlearis-induced neuropathy.

The ulnar nerve is more frequently injured than the median or radial nerves after elbow dislocation [1]. Ulnar nerve palsy can be due to the injury itself or to manipulation or surgical treatment. Entrapment of the ulnar nerve at the elbow in association with elbow dislocation and medial epicondyle fracture has been reported in the literature [2]. However, there is no case of intra-articular ulnar nerve entrapment in elbow dislocation that has been reported in the English literature. We present a unique case of intraarticular ulnar nerve entrapment after an elbow dislocation with clinical presentation of a painful flexion contracture.

Primary synovial chondromatosis is a rare, benign, proliferative disease of hyaline cartilaginous bodies within the synovium of joints. We report a rare case of primary synovial chondromatosis diffusely affecting the ulnohumeral joint causing pain and motion limitations with extrusion into the cubital tunnel and compressing the ulnar nerve but without any preoperative signs or symptoms of ulnar nerve compression. The patient was successfully treated with an open synovectomy to limit disease progression and improve motion. This case highlights that synovial conditions of the elbow may involve the ulnar nerve even when a patient is asymptomatic. Preoperative use of magnetic resonance imaging of the elbow should be considered in patients undergoing either an open or arthroscopic synovectomy.

Several open and endoscopic techniques for the surgical treatment of ulnar nerve entrapment at the elbow (cubital tunnel syndrome) have been described that provide decompression with or without anterior transposition. Based on our experience with US-guided decompression for carpal tunnel syndrome in our department, we developed a similar surgical technique for the decompression of the ulnar nerve at the elbow. Using sixteen cadaver upper limbs, we performed decompression of all the structures possibly responsible for ulnar nerve compression at the elbow. The structures involved were Struthers' arcade, the cubital tunnel retinaculum, Osborne's fascia and Amadio-Beckenbaugh's arcade. The procedure was followed by anatomical dissection to confirm complete sectioning of the compressive structures, absence of iatrogenic vascular or nervous injuries and absence of nerve dislocation or instability. There were no remaining compressive structures after the release procedure. There was no iatrogenic damage to the nerves and no nerve dislocation was observed during elbow flexion or extension. In 3.4% cases, a thin superficial layer of one or more of the identified structures remained but these did not appear to compress the nerve based on US imaging. Using ultrasonographic visualization of the nerve and compressive structures is easy. Each procedure can be tailored according to the nerve compression sites. Our cadaveric study shows the feasibility of an US-guided percutaneous surgical release for ulnar nerve entrapment.

Summary Nerve compression syndromes caused by non-neural tumours or tumour-like lesions are rare. We retrospectively reviewed 541 consecutive patients operated on by the same surgeon to study nerve compression syndromes in the forearm and hand. There were 414 due to nerve compression and 127 caused by tumours. Twenty-two patients showed compression neuropathy associated with 17 tumours and six tumour-like lesions, with 13 different pathological types. The most common types were fatty and vascular tumours. Twenty-one tumours were extraneural and one was intraneural. The median nerve was affected in nine cases, the ulnar nerve or the dorsal sensory branch of the ulnar nerve in five cases, the posterior interosseous nerve or the superficial radial branch in four cases and the common digital nerves in two cases. There was a concomitant involvement of the median and ulnar nerves in two other patients. Clinically, there were eight different compression neuropathies, of which the most frequent was the carpal tunnel syndrome. The postoperative histology was consistent with preoperative magnetic resonance imaging findings in the vascular and fatty tumours. Pain disappeared completely in 15 out of 16 patients with preoperative pain. All patients had preoperative paraesthesia, which persisted after tumour excision in three patients: attenuated in two patients and unchanged in one. In three patients, we did not observe any change in paresis or amyotrophy. The mean postoperative follow-up was 31 months, without tumour recurrence. The quick Disabilities of the Arm, Shoulder and Hand (DASH) score went from 49.9 points preoperatively to 10.2 points after surgery.

Ulnar nerve anterior transmuscular transposition is a well-accepted surgical technique for the treatment of ulnar nerve entrapment or subluxation at the elbow. The procedure, which addresses both compression and traction forces on the nerve, may be performed with the patient in the lateral decubitus position, allowing direct access to and excellent visualization of the ulnar nerve through an incision on the posteromedial aspect of the elbow. This report reviews the surgical indications and contraindications, pertinent anatomy, patient positioning rationale and method, surgical technique, postoperative management, and potential complications for this ulnar nerve transposition procedure. Discussion of the technique and an illustrative case are also provided.

Purpose Establishing minimally clinically important difference (MCID) for patient-reported outcomes questionnaires is an important component of outcomes research to understand treatment effectiveness from the patient's perspective. For patients with ulnar neuropathy at the elbow (UNE), these assessments are vital to examine how much change in the questionnaire scores equate to patient satisfaction. Methods We calculated the change in scores of Michigan Hand Outcomes Questionnaire (MHQ), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and Carpal Tunnel Questionnaire (CTQ) from preoperative to 3, 6, and 12 months after ulnar nerve simple decompression procedure. We used the anchor-based approach of receiver operating characteristic curves to determine the MCID. Results On average, MCID of 10, 12, and 7 points were identified for pain, function, and activities of daily living domains of the MHQ. Similarly, DASH, CTQ-symptom severity scale, and CTQ-function severity scale had an average MCID of 7, 0.7, and 0.3, points respectively. At the 3, 6, and 12 months' time points, an MCID of 9, 8, and 13 points for pain; 12, 12, and 12 points for function; and 6, 8, and 6 points for activities of daily living domains of the MHQ were identified; similarly an MCID of 8, 7, and 7 points for DASH; 0.4, 0.7, and 0.7 points for CTQ-symptom severity scale; and 0.3, 0.3, and 0.4 points for CTQ-function severity scale were established. Conclusions The smaller MCIDs of MHQ, DASH, and even smaller MCIDs of CTQ found in our study indicate that a small change in the scores identified satisfied patients. Simple decompression surgery for UNE produced patient satisfaction with only a small change in their questionnaire scores. The implications of this finding are that simple decompression surgery for UNE is a highly effective procedure and that the outcomes questionnaires used are highly responsive, which minimizes sample size requirements for future research studies relating to UNE. Type of study/level of evidence Therapeutic II.

Ulnar neuropathy in the region of the wrist (UNW) is a rare conition that is sometimes confused with ulnar neuropathy at the lbow and thus can be a challenging diagnosis for physicians [1]. NW can be caused by various etiologies [1]. Recently, occupaional trauma was reported to be the most common cause of deep almar branch lesion of the ulnar nerve [2]. There are several classications of UNW, which was most recently classified into five types ccording to clinico-anatomical lesion location [3]. Electrodiagnosic tests have been developed to differentiate UNW from proximal lnar neuropathy, medial cord or lower trunk lesions of the brachial lexus, and C8 and T1 radiculopathy, as well as to localize UNW nto subtypes according to lesion location. In this case report, we escribe a patient with a deep palmar branch lesion of the ulnar erve in the palm, associated with a ganglion and precipitated by eightlifting. This case report demonstrates the usefulness of short egmental nerve conduction studies of the ulnar nerve around the rist for localizing the lesion [4] as well as the utility of diagnostic ltrasound for detecting a space-occupying lesion.

In this review, we delineate clinical, electrodiagnostic, and radiographic features of ulnar mononeuropathies. Ulnar neuropathy at the elbow (UNE) is most commonly due to lesions at the level of the retroepicondylar groove (RTC), with approximately 25% at the humeroulnar arcade (HUA). The term 'cubital tunnel syndrome' should be reserved for the latter. The diagnostic accuracy of nerve conduction studies is limited by biological (e.g. low elbow temperature) and technical factors. Across-elbow distance measurements greater than 10 cm improve diagnostic specificity at the expense of decreased sensitivity. Short-segment incremental studies can differentiate lesions at the HUA from those at the RTC.

Ulnar tunnel syndrome could be broadly defined as a compressive neuropathy of the ulnar nerve at the level of the wrist. The ulnar tunnel, or Guyon's canal, has a complex and variable anatomy. Various factors may precipitate the onset of ulnar tunnel syndrome. Patient presentation depends on the anatomic zone of ulnar nerve compression: zone I compression, motor and sensory signs and symptoms; zone II compression, isolated motor deficits; and zone III compression; purely sensory deficits. Conservative treatment such as activity modification may be helpful, but often, surgical exploration of the ulnar tunnel with subsequent ulnar nerve decompression is indicated.

We describe the case of an original insertion and course of the abductor digiti minimi muscle on the medial part of the palmaris longus tendon. The anomalous muscle was only present on the left side. Various studies have reported the frequency of anomalous muscles in approximately 22 to 35% of hands and it was in majority an anomalous abductor digiti minimi muscle. The knowledge of this original insertion is important because it can sometimes be correlated with ulnar nerve compression at Guyon's canal. But Guyon's canal syndrome is less common than carpal tunnel syndrome, and the incidence of ulnar nerve compression in relation with anomalous muscle is approximately 2.9% of cases. It is possible to diagnose the anomalous muscle through ultrasound or MRI. This variation should be taken into consideration by surgeons during surgical procedures for ulnar nerve decompression at Guyon's canal and when performing anteromedial approach to the wrist between flexors tendons and ulnar bundle.

Purpose The purpose of this study is to provide a thorough understanding of the anatomy of the cubital tunnel and to outline specific anatomical parameters of the cubital tunnel retinaculum (CuTR) that might aid in the management of ulnar nerve problems. The hypotheses of this study are (1) that the nerve elongates with elbow flexion and (2) that the cross-sectional area of the cubital tunnel is inversely proportional to the degree of elbow flexion. Methods Eleven fresh-frozen cadaver arms were dissected at the medial elbow. The CuTR was identified, and its thickness was measured. After excising the CuTR, we measured the elongation of the anterior and posterior aspects of the ulnar nerve, as well as the length of the CuTR origin/insertion, at increasing intervals of elbow flexion (15°, 30°, 45°, 90°, 120°, and 135°). Using 3-dimensional digitization technology, the surface of the cubital tunnel was recorded at 4 positions of elbow flexion (15°, 45°, 90°, and 135°) and analyzed to define the tunnel geometry. Results The CuTR origin-to-insertion length and the ulnar nerve length both increased significantly with increasing flexion angle. Both lengths at 90°, 120°, and 135° of elbow flexion were greater than at 15° or 30°. The cubital tunnel area was significantly less at 135° compared to either 45° or 90° of flexion. There was a linear relationship between the cubital tunnel area of the different arms with the corresponding nerve cross-sectional area when measured at the level of the epicondyle and when the arm was at 90° of elbow flexion. Conclusions The CuTR begins to stretch at 60° of flexion and continues to stretch with increasing flexion. Similarly, the ulnar nerve is more taut in flexion. The area within the cubital tunnel decreases beyond 90° of elbow flexion. Clinical relevance Understanding the dynamic anatomical relationships of the cubital tunnel might help in the safe treatment of cubital tunnel syndrome when using minimally invasive techniques and instrumentation.

We present a case of Guyon's canal syndrome caused by a synovial cyst within the left wrist of a 48-year-old female patient. The patient presented pain and paresthesia in the region of the ulnar nerve, with loss of muscle strength and left-hand deformity. Electroneuromyography showed a compression of the ulnar nerve at the wrist level. Surgical decompression of the nerve at Guyon's canal with resection of the cyst was performed. After the surgery, the patient presented an improvement in the pain and paresthesia, as well as an increase in muscle trophism and correction of the deformity.

Purpose To examine the anatomy of the ulnar tunnel, with emphasis on the pisohamate arcade and pisohamate hiatus, and study the influence of wrist kinematics on the morphology of these structures. Methods Ten fresh-frozen cadaveric hands were dissected. The dimensions and relationships of the ulnar tunnel, pisohamate arcade, and pisohamate hiatus were recorded. The effect of 4 wrist positions on these dimensions and relationships was investigated. Results The ulnar tunnel has 3 compartments—proximal, middle, and distal relative to the pisiform—with variable morphologies, dimensions, and boundaries. In wrist neutral position, the length of the ulnar tunnel was 45 mm (range, 42 to 51 mm). The middle compartment was found to be the narrowest; the proximal, the widest, averaging 5.0 mm; and the pisohamate hiatus that separates the middle and distal compartments, highly dynamic. The length of the pisohamate arcade was 21.5 mm (range, 18.0 to 26.0 mm), and the length and width of the pisohamate hiatus were 11.0 mm (range, 9.8–11.5 mm) and 6.0 mm (range, 5.3 to 7.2 mm), respectively. During wrist extension, the ulnar nerve was under tension. Wrist flexion was the position that caused the most change in ulnar tunnel and pisohamate arcade and hiatus anatomy, causing the width of the proximal compartment to increase from 5.0 to 10.0 mm. During this motion, the shape of the pisohamate arcade changed from a C shape to linear, and the length increased to 24.5 mm (range, 19.3 to 28.5 mm). The pisohamate hiatus narrowed, its width decreased to 1.5 mm, and the deep branch of the ulnar nerve was somewhat compressed. Conclusions The ulnar tunnel is a dynamic space with dimensions and relationships that are influenced by wrist motion. During ulnar tunnel surgery, all 3 compartments of the ulnar tunnel should be explored and decompressed, including the pisohamate hiatus, by releasing the pisohamate arcade.

Objective To describe morphologic and functional modifications of the ulnar nerve at the wrist in carpal tunnel syndrome (CTS) after carpal tunnel release (CTR). Methods Ultrasonography was used to study the cross sectional area (CSA) of the ulnar nerve at Guyon’s canal, before and 1 and 6 months after CTR, in 18 CTS patients. A parallel electrophysiological and clinical analysis was also conducted. Results CSA of the ulnar nerve significantly increased 6 months after CTR. Ten (55%) cases showed abnormal CSA values compared to a control group before surgery and five (28%) at 6 month follow-up. In addition, there were improvements in the motor and sensory ulnar axon recruitment properties and the conduction values in sensory ulnar fibres. Patients with extra-median distribution of paresthesia (4 subjects) were free from symptoms. Conclusions CTR has a significant effect not only on the anatomical geometry of Guyon’s canal, but also on the morphology and function of the ulnar nerve. Significance In CTS, high pressure in the carpal tunnel may result in anatomical changes of ulnar nerve, thus causing functional impairment to the ulnar fibres. CTR appears to reverse some of this damage.

Surgical procedures for the treatment of ulnar nerve compression at the elbow are well described. Studies have reported clinical outcomes after decompression of the nerve without transposition and decompression with transposition. Numerous preoperative, intraoperative, and postoperative factors contribute to failure of the surgical procedures. Although the techniques available for revision decompression of the ulnar nerve at the elbow are similar to those used in the primary setting, the results after repeat surgical intervention are less predictable.

t b A s p a F o a ubital tunnel syndrome is a well-described clinical roblem associated with the anatomic relationship of the lnar nerve as it passes through the cubital tunnel renering it susceptible to injury and compressive neuropthy. Cases of ulnar tunnel syndrome due to compresion of the ulnar nerve by lesions such as ganglia, alcific neuritis, calcium pyrophosphate dihydrate crysals, synovial cysts, vascular abnormalities, ligamenous attachments, and anomalous musculature ave also been reported. We describe the case and maging studies of a patient in whom a previous bony nd/or ligamentous injury precipitated ulnar nerve comression after blunt trauma.

Sports-related injuries to the wrist range from minor sprains to severe soft tissue disruption that can pose a risk to the normal function of the upper extremity. It is important to identify the specific nature of such injuries so as to establish an accurate diagnosis and deliver appropriate treatment. MRI of the wrist has greatly benefited from the use of dedicated surface coils, which allow fine depiction of soft tissue and cartilaginous structures. A review of the normal anatomy, MR interpretation pitfalls, and most common abnormalities of the tendons, ligaments, triangular fibrocartilage complex, and nerves of the wrist are presented.

Most regard ganglion, giant cell tumor of tendon sheath and epidermal inclusion cysts as tumor-like conditions as opposed to true neoplasms. Ganglion cysts are the most common lesion of the hand and wrist, accounting for 50% to 70% of all masses identified. The majority of ganglion cysts can be treated nonoperatively but when surgery is performed a low recurrence rate can be anticipated. Giant cell tumor of the tendon sheath hand epidermoid cysts are also common hand lesions that require surgical excision in most instances. Of the three, giant cell tumor of tendon sheath have the most notable recurrence rates. This article reviews the clinical presentations of these lesions as well as their proposed pathophysiology.

Objective : To evaluate the occurrence of nerve entrapment syndrome in chronic inflammatory demyelinating polyneuropathy (CIDP). Methods : We retrospectively evaluated neurophysiologic results of 41 (25 male and 16 female, mean age 49.8, range 11–87) patients with CIDP. We evaluated the frequency of focal neurophysiologic lesion at entrapment site distinguishing two kinds of lesion: (a) true entrapment; and (b) false entrapment on the basis of nerve conduction results. Results : Occurrence of focal aggression within the entrapment site is similar to that out of the entrapment site in all examined nerves. Conclusions : The entrapment sites are not an elective zone of focal autoimmune aggression in CIDP. Therefore, in CIDP patients a true entrapment, neurophysiologically demonstrated, could be a concomitant pathology and if a severe and persistent entrapment worsens functional deficit and symptoms, a surgical decompression could be useful.

Nerve compression is a common entity that can result in considerable disability. Early diagnosis is important to institute prompt treatment and to minimize potential injury. Although the appropriate diagnosis is often determined by clinical examination, the diagnosis may be more difficult when the presentation is atypical, or when anatomic and technical limitations intervene. In these instances, imaging can have an important role in helping to define the site and etiology of nerve compression or in establishing an alternative diagnosis. MR imaging and ultrasound provide direct visualization of the nerve and surrounding abnormalities. For both modalities, the use of high-resolution techniques is important. Bony abnormalities contributing to nerve compression are best assessed by radiographs or CT. For the radiologist, knowledge of the anatomy of the fibro-osseous tunnels, familiarity with the causes of nerve compression, and an understanding of specialized imaging techniques are important for successful diagnosis of nerve compression.

Purpose: The purposes of this study were to determine the distribution of causes and sites of nerve compression in the ulnar tunnel (Guyon's canal), and investigate the relationship between ulnar tunnel syndrome (UTS) and other conditions associated with it. Methods: We performed a retrospective review of 31 patients diagnosed with and treated for UTS to determine the most common cause of compression and the sites of compression, systemic illnesses associated with UTS, and postoperative results. Results: The cause of ulnar nerve compression was idiopathic in 14, trauma in 8, a thrombosis in 2, proliferation of synovium in 2, a prominent hook of the hamate in 1, a schwannoma in 1, postoperative swelling in 1, an aberrant fibrous band in 1, and a ganglion in 1. The sites of compression were classified into 3 zones. Twenty-eight cases had compression in zone 1, 6 in zone 2, and 19 in zone 3. Seventeen cases (55%) had compression in more than 1 zone. Twenty-two cases (71%) were associated with carpal tunnel syndrome (CTS). Twelve (86%) of the 14 idiopathic UTS cases were associated with CTS. The relationship between idiopathic UTS and CTS was not statistically significant. Six cases were associated with diabetes mellitus. Conclusions: The most common cause of UTS in our series was idiopathic. Most idiopathic UTS cases were associated with CTS. The clinical symptoms of UTS improved after surgery in all cases. Therefore because of the presence of multiple compression sites of the ulnar nerve in the hand, for UTS patients we believe that the release of Guyon's canal and/or the pisohamate tunnel is an effective way not only to relieve symptoms but also to determine the real cause of compression.

A rare cause of ulnar nerve compression at the elbow is presented in this report. A 42 year old right-handed mechanic developed subacute, progressive numbness, tingling and weakness in his right hand. Electrophysiologic studies demonstrated a severe conduction block affecting the ulnar nerve in the retrotrochlear groove but without any sign of major axonal loss. His hand functions were carefully studied prior to surgery. While fine motor tasks were not affected, the hand strength was markedly diminished. At surgery, a 1-cm diameter intraneural ganglion at the site of the conduction block was found and excised. The patient made a dramatic recovery within 6 weeks post-surgery. The conduction block completely resolved and the hand functions also returned to normal. This and other reported cases point to the importance of early diagnosis and intervention.

Intraneural ganglions of the hand are rare and remain poorly understood. We report a case of an intraneural ganglion arising from the pisotriquetral joint that penetrated the ulnar nerve at Guyon's canal. Although rare, these ganglions should be considered in the differential diagnosis of any neoplasms causing compression neuropathy.

Paternostro-Sluga T, Ciovika R, Turkof E, Zauner-Dungl A, Posch M, Fialka-Moser V. Short segment stimulation of the anterior transposed ulnar nerve at the elbow. Arch Phys Med Rehabil 2001;82:1171-5. Objective: To determine whether short segment stimulation after anterior subcutaneous transposition of the ulnar nerve reaches normal values and correlates with postoperative clinical findings. Design: Comparative cross-sectional study. Setting: Outpatient clinic of a university department of physical medicine and rehabilitation. Patients: Nineteen patients (15 men, 4 women) with 21 surgically treated ulnar neuropathies at the elbow; and 19 healthy controls (11 men, 8 women) with 24 measured nerves. Interventions: Assessed motor function of ulnar innervated muscles and staged into 4 categories; used questionnaire to assess clinical course of the nerve lesion and graded into 5 categories; took electrophysiologic recordings to measure motor conduction velocity and compound muscle action potentials; and studied short segment stimulation across elbow and lower arm. Main Outcome Measures: Mean ± standard deviation of ulnar short segment conduction time across the elbow, amplitude and motor conduction velocity; grading of ulnar nerve lesions; grading of the course of disease after surgery; and logistic regression and correlation (Spearman's correlation coefficient) for electrophysiologic and clinical parameters. Results: Sixteen nerves showed focal conduction slowing in patients. No significant correlation between the course of disease and electrophysiologic parameters was seen. For stepwise logistic regression, there was a significant effect between grade of nerve lesion and amplitude, but no significant effect between the course of disease and electrophysiologic parameters. Conclusion: A focal conduction slowing across the elbow after anterior subcutaneous transposition does not correlate with postoperative clinical findings. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Secondary ulnar nerve palsy, an unusual condition in which the onset of ulnar nerve dysfunction occurs 1 to 3 months after elbow trauma, can be the cause of sudden deterioration of elbow function. Initially recognized in 1899, this condition has not been reported often. We describe 2 patients who had no subjective or objective evidence of ulnar nerve dysfunction after elbow trauma but had a sudden loss of motion, pain, and clinical and electrophysiologic evidence of ulnar nerve compression at the elbow 4 to 5 weeks after trauma. Marked improvement occurred after ulnar nerve subcutaneous transposition and contracture release.

Purpose: To assess measurement properties and construct validity of health status measures. Method: Forty-three patients with surgically managed ulnocarpal impingement completed a self-report mail survey, including regional (Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire), disease-specific (Brigham Functional Scale), and generic (Short Form 36 [SF-36] Acute Health Survey) health status measures and questions on condition severity and work status. Statistical analysis: Scores were transformed and frequency distributions constructed to compare the distribution of responses to the measures. Correlation analysis and analysis of variance were applied to assess construct validity. Results: The DASH and Brigham questionnaires had similar distributions of scores, with a slightly greater spread of responses and no ceiling effect on the DASH. Patients appeared slightly less healthy on the basis of the SF-36 scores, which reflected in part the effect of comorbidities. Both the DASH and the Brigham discriminated across levels of severity and work status; the DASH also discriminated on the basis of type of surgery. The SF-36 was able to discriminate some constructs but not as well as the regional and disease-specific measures. Conclusion: This study provides evidence of construct validity for the DASH and Brigham questionnaires in patients with ulnar wrist problems in the late post-operative period.

Localised hypertrophic mononeuropathy is the progressive enlargement of a large peripheral nerve, which can lead to profound loss of function. In this case report, we describe the postoperative occurrence of this phenomenon and possible ways to monitor for this condition.

We describe the acute development of ulnar nerve compression following carpal tunnel release in a patient with an accessory palmaris longus muscle. Although anomalous muscles in the wrist are relatively common and may produce ulnar nerve compression, this particular occurrence following carpal tunnel release has not been previously described in the literature. We theorize that the compression of the ulnar nerve proximal to Guyon's canal was caused by increased tension along the long axis of the anomalous accessory palmaris longus muscle as a consequence of transverse carpal ligament division.

This report is the first account of Guyon's syndrome after the bilateral use of forearm crutches. Crutch palsy is usually neuropraxic in nature and associated with clinical and electrophysiologic recovery of nerve function, especially if patients are instructed to not bear excessive weight on the wrist. The present case history follows this pattern. In establishing the diagnosis of a focal compression neuropathy, a combination of clinical assessment and neurophysiologic studies are typically used. This report describes the additional application of ultrasound imaging to verify the diagnosis and to track changes in the appearance of the nerve during follow-up.

Objectives: To determine whether electrodiagnostic testing changes diagnostic certainty compared with a detailed history and physical examination, and whether interactions between medical information, the extent of testing, and diagnostic certainty imply a need for advanced medical knowledge on the part of the tester. Design: Prospective observation. Setting: University orthopedic department and small community hospital electrodiagnostic laboratories. Patients: Two hundred fifty-five consecutive referrals for upper extremity nerve complaints. Outcome Measures: Diagnosis, diagnostic confidence, and severity of neurologic lesion were coded after standardized history and physical and after electrodiagnostic testing. Results: Electrodiagnostic testing substantially altered 42% of diagnoses, confirmed 37%, and did not clarify 21%. The extent of testing correlated with the size of the differential diagnosis, the number of previous hospitalizations, and the number of other medical problems. Confidence in final diagnoses correlated positively with severity of the lesion, but negatively with the size of the differential diagnosis and the number of painful body areas. Hospitalizations and medical problems also tended towards negative correlations. Conclusions: This study, in which all electrodiagnostics, histories, and physical examinations were performed by a single physician, suggests that electrodiagnosis substantially alters clinical impressions in a large percentage of patients. The complex relationship between clinical information, the extent of testing, and final diagnostic certainty suggests that specialized medical knowledge is required for accurate electrodiagnosis.

P erip heral nerve repair has been a source of considerable controversy almost since the beginning of recorded history. In approximately 1300 AD, Galen postulated that there was no benefit in repairing peripheral nerves. For this reason and because of the significant incidence of gangrene following surgery, peripheral nerve repair was not widely practiced. Subsequently, Guy de Chaulic proposed that both tendons and nerves were amenable to suture. In the 1800s, Muller reported that nerve axons could regenerate across a site of nerve transection. Using silver stain, Cajal showed the presence of regenerating axons across the site of nerve repair. Also in the 1800s, Vulpius reported the first basic science studies of nerve grafts and their outcomes. The clinical foundations for peripheral nerve surgery have been traced to the observations of Silas Weir Mitchell during his work as a Civil-Warera physician. In his treatise Injuries of Nerves and Their Consequences, Mitchell describes causalgia as a syndrome characterized by burning pain and trophic limb changes often caused by ballistic nerve injury. During World War II, Barnes Woodall and Sir Herbert Seddon performed pioneering work in the care of casualties with peripheral nerve injury. They critically examined the methods of primary nerve repair, secondary nerve repair, and nerve grafting. In the 1960s Jacobsen and others developed the operating microscope which, combined with new methods of producing ultrafine suture and precision needles, allowed surgeons to more precisely coapt transected nerves. Sunderland and colleagues performed extensive anatomic work on the internal architecture of peripheral nerves, providing surgeons with an accurate road map for repair. Ten years ago clinicians caring for peripheral nerve injuries had access to sophisticated internal road maps of peripheral nerves and high-quality

We evaluated the results of cubital tunnel release with endoscopic assistance. The study included 76 patients (85 elbows); 47 women and 29 men. Nine patients had bilateral procedures. Patients were excluded if they had less than 1 year of follow-up, associated pathology at the elbow to account for the nerve compression, or recurrent cubital tunnel syndrome. Before surgery, cases were categorized by stage of cubital tunnel syndrome according to Dellon's classification: 33 (39%) elbows were classified as mild, 35 (41%) moderate, and 17 (20%) severe. Surgical results were assessed according to a modified Bishop rating system. The mean follow-up period was 32 months (range, 12-52 months). Results were excellent in 42% of the elbows, good in 45%, fair in 11%, and poor in 2%. Recurrence occurred in 3 elbows. There were no serious complications. The results of this study support our recommendation of cubital tunnel release with endoscopic assistance as a safe and reliable technique for the treatment of cubital tunnel syndrome, especially in patients with mild to moderate symptoms.

A new technique using the released medial intramuscular septum as a fascial or fasciodermal sling to prevent posterior subluxation of the ulnar nerve following subcutaneous transposition is described. The technique is simple and prevents subluxation, yet it still allows free excursion of the ulnar nerve and postoperative rehabilitation is begun immediately.

The purpose of this study was to modify the classical longitudinal skin incision to avoid injury to the cutaneous nerve branches on the medial side of the elbow when a surgical release of the ulnar nerve was performed. Injury to the medial antebrachial cutaneous nerve is not a rare complication after release of the ulnar nerve at the elbow. This will leave an area of hyposthesia on the posteromedial aspect of the proximal forearm, to which the patient will usually get accustomed. Some patients may have an area of skin dysesthesia and a painful amputation neuroma requiring surgical treatment. To avoid these complications and yet to obtain adequate exposure for ulnar nerve release, we have used a transverse incision in 20 patients without any sequelae of hyposthesia or amputation neuromas and have attained a far superior esthetic result. (J Shoulder Elbow Surg 1998;7:38-42.)

The effects of early versus late range of motion (ROM) following cubital tunnel decompression and medial epicondylectomy were evaluated in a randomized prospective study. Forty-five consecutive procedures were divided into 2 groups. The early mobilization group started rehabilitation at an average of 3 days after surgery and the late mobilization group started rehabilitation at an average of 14 days after surgery. Flexion contracture of more than 5 degrees degrees was observed in 5% of the early mobilization group, compared to 52% of the late mobilization group (p.001). On average, patients in the early mobilization group returned to work twice as early as those in the late mobilization group and did not experience any adverse effects on their grip strength or other hand functions. Institution of ROM exercises immediately after surgery was found to be more effective in preventing elbow flexion contractures, obtaining a quicker recovery, and allowing return to work with no ill effects.

Variations in the medial triceps in conjunction with bilateral ulnar neuropathy have been identified in three generations of one family also possessing the phenotype of Waardenburg syndrome (a rare autosomal-dominant disorder with clinical features including cochlear deafness, dystopia canthorum, and pigmentation problems). To our knowledge, no other inherited condition with triceps anomalies has been reported. Study of this family provided insight into the relationship between dislocating medial triceps and ulnar neuropathy and demonstrated that a broad spectrum of clinical presentations exists-from being completely asymptomatic to producing symptomatic snapping and ulnar neuropathy.

Nine patients (11 elbows) presented with cubital tunnel syndrome that was complicated by calcium pyrophosphate dihydrate (CPPD) crystal deposition disease. Their age ranged from 63 to 86 years, and 8 of the 9 patients were more than 70 years old. X-ray film examination demonstrated the presence of CPPD crystal deposition not only in the elbow but also in the knee, wrist, or spine in all patients. Medial epicondylectomy was performed in 8 patients (9 elbows), while 1 patient with both elbows affected was treated conservatively at his request. Thickening of the ulnar collateral ligament and synovium due to CPPD crystal deposition and degenerative joint changes induced protrusion of the floor of the cubital tunnel, resulting in ulnar neuropathy in these patients. The ulnar nerve was compressed between the protruded floor and fibrous band. Though various causes of cubital tunnel syndrome have been reported, findings of this study indicate that CPPD crystal deposition disease should also be considered a cause of this syndrome.

Compression neuropathies are common in clinical practice. This article is a review of the clinical features of the common entrapment neuropathies affecting the upper extremity. The frequently found entrapment syndromes are discussed in detail. Uncommon syndromes are also briefly discussed.

Compression of the ulnar nerve can be understood in terms of the anatomic and dynamic factors. Although the ulnar nerve may be compressed at any point along its course, it is particularly susceptible at the elbow and the wrist. Clinically relevant anatomy will be reviewed in an attempt to provide the reader with a logical framework for successfully diagnosing and managing typical and atypical ulnar nerve compression lesions.

A concise review of the internal anatomy of the peripheral nerve and the inter-nervous planes is presented to help a practicing upper extremity surgeon better understand and operate on the nerves of the upper extremity.

Fifty cadaver hands were dissected to better delineate the extensor tendon anatomy to the little finger. The extensor digitorum communis was present in 35. Of 15 hands without an extensor digitorum communis, 12 had a junctura present. Three hands lacked both extensor digitorum communis and juncturae. Transfer of the extensor digiti minimi tendon in these hands could cause loss of extension to the little finger. Ten hands had a direct attachment of the extensor digiti minimi tendon on the abductor tubercle. Twenty-two hands had either an attachment of the extensor digiti minimi on the abductor tubercle, an unbalanced ulnar slip of the extensor digiti minimi, or both, anatomic factors that could--in the event of ulnar nerve compression or laceration--cause Wartenberg's sign. Twenty-eight hands did not have an anatomic variant of the extensor that could cause ulnar deviation of the little finger.