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Background: Nerve transfers to reinnervate ulnar intrinsic musculature can restore function in severe ulnar neuropathy, and supercharged end-to-side (SETS) nerve transfers have garnered early adoption. Given the relative expendability of the abductor digiti minimi (ADM), redirecting its axons to more critical components of the ulnar motor nerve (UMN) in a turbocharged end-to-side (TETS) nerve transfer with concomitant anterior interosseous SETS nerve transfer (AIN) as a super-turbocharged end-to-side (STETS) or twin-charged double nerve transfer may improve functional recovery., Methods: A retrospective study of patients undergoing the STETS AIN/ADM to UMN double nerve transfer or TETS ADM to UMN nerve transfer for severe ulnar neuropathy between 2020 and 2022 was performed. Primary outcomes were improvement in first dorsal interosseous (FDI) strength and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Dichotomous and continuous variables were compared with χ 2 and t tests, respectively., Results: Fifty patients with severe ulnar nerve injuries were identified with at least 1-year surgical follow-up. Preoperative symptom duration was an average of 11.3 months. The STETS cohort (n = 42) reported significantly decreased DASH scores from 58 to 28 ( P < .001) and improved FDI Medical Research Council (MRC) score from 0.7 to 3.3 ( P < .001). The TETS cohort (n = 8) reported significantly decreased DASH scores from 54 to 23 ( P = .016) and improved FDI MRC score from 2.0 to 3.6 ( P = .008)., Conclusions: Distal transfer of the ADM nerve to the ulnar deep motor branch in a turbocharged fashion is reported. The findings suggest that the STETS double nerve transfer may improve patient outcomes and warrants further investigation with prospective cohort studies., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The arcade of Struthers was first proposed by Kane et al in 1973. Clinical investigations of this structure have been limited to small case series, focusing on the arcade as an isolated cause of compressive ulnar neuropathy. The purpose of our study was to investigate the incidence of this structure in patients undergoing ulnar nerve transposition., Methods: A retrospective chart review of prospectively maintained data in a single surgeon's practice was performed. Records of patients undergoing surgery for compressive ulnar neuropathy at the cubital tunnel were evaluated for documentation of a compressive arcade of Struthers. In addition, a scoping review of the literature was undertaken to better characterize current understanding of this structure and its recognition in clinical practice., Results: A total of 197 patients underwent ulnar nerve transposition. The overall incidence of a compressive arcade of Struthers was noted to be 67 out of 197 (34%). All patients with a compressive arcade were noted to have an internal brachial ligament running below the nerve. Patients undergoing revision surgery were found to have a compressive arcade 51% of the time (20/39), whereas 30% of patients undergoing primary surgery were found to have a compressive arcade (47/158). Only 12 clinical studies examining the arcade of Struthers have been published in the last 20 years, the majority being single case reports., Conclusions: Compression of the ulnar nerve by the arcade of Struthers is a common finding and can contribute to compressive ulnar neuropathy at the elbow both in primary and revision cases., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Traumatic peripheral nerve injuries cause chronic pain, disability, and long-term reductions in quality of life. However, their incidence after extremity trauma remains poorly understood., Methods: The IBM® MarketScan® Commercial Database from 2010 to 2015 was used to identify patients aged 18 to 64 who presented to emergency departments for upper and/or lower extremity traumas. Cumulative incidences were calculated for nerve injuries diagnosed within 2 years of trauma. Cox regression models were developed to evaluate the associations between upper extremity nerve injury and chronic pain, disability, and use of physical therapy or occupational therapy., Results: The final cohort consisted of 1 230 362 patients with employer-sponsored health plans. Nerve injuries were diagnosed in 2.6% of upper extremity trauma patients and 1.2% of lower extremity trauma patients. Only 9% and 38% of nerve injuries were diagnosed by the time of emergency department and hospital discharge, respectively. Patients with nerve injuries were more likely to be diagnosed with chronic pain (hazard ratio [HR]: 5.9, 95% confidence interval [CI], 4.3-8.2), use physical therapy services (HR: 10.7, 95% CI, 8.8-13.1), and use occupational therapy services (HR: 19.2, 95% CI, 15.4-24.0) more than 90 days after injury., Conclusions: The incidence of nerve injury in this national cohort was higher than previously reported. A minority of injuries were diagnosed by emergency department or hospital discharge. These findings may improve practitioner awareness and inform public health interventions for injury prevention.

Background: Ulnar nerve transposition (UNT) surgery is performed for the treatment of cubital tunnel syndrome. Improperly performed UNT can create iatrogenic pain and neuropathy. The aim of this study is to identify anatomical structures distal to the medial epicondyle that should be recognized by all surgeons performing UNT to prevent postoperative neuropathy. Methods : Ten cadaveric specimens were dissected with attention to the ulnar nerve. Intramuscular UNT surgery was simulated in each. Distal to the medial epicondyle, any anatomical structure prohibiting transposition of the ulnar nerve to a straight-line course across the flexor-pronator mass was noted and its distance from the medial epicondyle was measured. Results : Seven structures were found distal to the medial epicondyle whose recognition is critical to ensuring a successful anterior transposition of the ulnar nerve: (1) Branches of the medial antebrachial cutaneous (MABC) nerve; (2) Osborne's fascia; (3) branches from the ulnar nerve to the flexor carpi ulnaris (FCU); (4) crossing vascular branches from the ulnar artery to the FCU; (5) the distal medial intermuscular septum between the FCU and flexor digitorum superficialis (FDS); (6) the combined muscular origins of the flexor-pronator muscles; and (7) the investing fascia of the FDS. Measurements are given for each structure. Conclusions : Poor outcomes and unnecessary revision surgeries for cubital tunnel syndrome can be avoided with intraoperative attention to 7 structures distal to the medial epicondyle. Surgeons should expect to dissect up to 12 cm distal to the medial epicondyle to adequately address these and prevent kinking of the nerve in transposition.