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Medial epicondyle fracture associated with incarcerated intra‐articular fragment and ulnar nerve palsy is uncommon and frequently missed. We report a case of 13‐year‐old boy with incarcerated medial epicondyle fracture fragment in ulnohumeral joint and ulnar nerve palsy, which was managed successfully by open reduction internal fixation and ulnar nerve transposition.

Background: Injury to the ulnar collateral ligament (UCL) leading to medial elbow instability and possible ulnar neuritis is common in overhead-throwing athletes. Treatment may require UCL reconstruction (UCLR) and concomitant ulnar nerve transposition (UNT) for those with preoperative ulnar neuritis. Purpose: To evaluate the return-to-play (RTP) rates, clinical outcomes, and rates of persistent ulnar neuritis after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuritis. Study Design: Case series; Level of evidence, 4. Methods: Eligible patients were those who underwent concomitant UCLR and UNT at a single institution between January 2008 and June 2018 and who had a minimum of 2 years of follow-up. Additional inclusion criteria were athletes who identified as baseball players and who had a confirmed history of ulnar neuritis. Patients were contacted at a minimum of 2 years from surgery and assessed with the Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow Score, Andrew-Timmerman (A-T) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score, and a custom RTP questionnaire. Results: Included were 22 male baseball players with a mean age of 18.9 ± 2.1 years (range, 16-25 years). The mean follow-up was 6.1 ± 2.4 years (range, 2.5-11.7 years). Preoperatively, all 22 patients reported ulnar nerve sensory symptoms, while 4 (18.2%) patients reported ulnar nerve motor symptoms. At the final follow-up, 7 (31.8%) patients reported persistent ulnar nerve sensory symptoms, while none of the patients reported persistent ulnar nerve motor symptoms. Overall, 16 (72.7%) players were able to return to competitive play at an average of 11.2 months. The mean postoperative patient-reported outcome scores for the KJOC Shoulder and Elbow Score, MEPS, A-T Elbow Score, and SANE score were 77.9 ± 20.9 (range, 14-100), 92.7 ± 12.7 (range, 45-100), 86.1 ± 17.1 (range, 30-100), and 85.5 ± 14.8 (range, 50-100), respectively. Conclusion: This study demonstrated that after concomitant UCLR and UNT for UCL insufficiency and associated ulnar neuritis, baseball players can expect reasonably high RTP rates and subjective outcomes; however, rates of persistent sensory ulnar neuritis can be as high as 30%.

BACKGROUND: Open excision remains the gold standard of treatment for posttraumatic heterotopic ossification (HO) of the elbow. The purpose of this study is to evaluate the functional outcome of early surgical excision done by adhering to a proposed surgical protocol with exclusive posttraumatic HO of the elbow. METHODS: A retrospective study was conducted with 31 patients (25 males and 6 females) with a mean follow-up of 40.5 ± 27.44 months. Excision was done according to our surgical protocol based on the location of HO, associated fractures, stability, need for ulnar nerve transposition, previous operative scar. Improvement in elbow function, Mayo elbow performance score (MEPS) preoperatively and at final follow-up was compared, and statistical analysis was done. RESULTS: Mean flexion–extension arc, supination-pronation arc and MEPS improved by 74.68° ± 29.32°, 26.13° ± 32.93°, 30.48 ± 11.57, respectively. Flexion arc deteriorated by 10.81° ± 10.42° from intraoperative to final follow-up. Improvement at final follow-up was significant in all the cases (P

The medial epicondyle may act as a fulcrum causing deformation of the ulnar nerve during elbow flexion. Furthermore, ulnar neuropathy can be potentiated by dynamic instability of the ulnar nerve around and over the medial epicondyle. Anterior transposition techniques were designed to eliminate traction on the nerve from the medial epicondyle or mechanical irritation in the presence of dynamic instability. Subcutaneous anterior transposition has been advocated as a less morbid alternative to deeper transposition techniques (i.e. intramuscular or submuscular) as it requires less dissection. Multiple techniques have been reported to maintain the nerve in its subcutaneous position after transposition, utilizing a fasciodermal sling from the flexor-pronator mass, an adipose flap, the medial intermuscular septum, or even Osborne’s ligament. Care must be taken with anterior transposition to avoid creation of new sites of compression, particularly at the medial intermuscular septum and the flexor carpi ulnaris fascia. Subcutaneous ulnar nerve transposition has been found to be comparable to in situ decompression as well as submuscular and intramuscular transposition techniques in several randomized trials and large outcomes series.

Objectives: Injury to the ulnar collateral ligament (UCL)—leading to medial elbow instability and concomitant ulnar neuropathy symptoms—is common in the overhead throwing athlete secondary to the repetitive stress that these individuals place on the elbow during the throwing motion. Treatment customarily involves UCL reconstruction (UCLR) and for those with preoperative ulnar neuropathy symptoms, concomitant ulnar nerve transposition (UNT) may also be warranted. The purpose of this study was to evaluate the return to play rates, clinical outcomes and more specifically rates of persistent ulnar nerve symptoms after concomitant UCLR and UNT in a cohort of baseball players with confirmed preoperative ulnar neuropathy symptoms. Methods: Patients who underwent concomitant UCLR and UNT from January 2008 to June 2018 were identified at one institution with a minimum of 2 years of follow-up. Additional inclusion criteria included athletes who identified as baseball players with a confirmed history of ulnar neuropathy symptoms. Exclusion criteria included patients who had any other concomitant open procedures at the time of surgery. After identifying the cohort, patients were contacted via phone to complete a Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow Score (KJOC), Andrews-Timmerman (AT) Elbow Score, Mayo Elbow Performance Score (MEPS), Single Assessment Numeric Evaluation (SANE) score and a custom return to play questionnaire. Evidence for preoperative and postoperative ulnar nerve symptoms was elicited within the custom survey and corroborated with the provider’s clinical notes. Sensory ulnar nerve symptoms were defined as having numbness and/or tingling sensations in the 5th and ulnar half of the 4th fingers. Motor ulnar nerve symptoms were defined as either exhibiting 1st dorsal interosseous muscle weakness by inability to maintain finger abduction resistance, ulnar-sided hand grip weakness of inability to control precise movement of the 5th digit. Results: During this time period, a total of 22 male baseball players underwent concomitant UCLR and UNT at a mean age of 18.9+/-2.1 years (range, 16-25). The mean follow-up was 6.1+/-2.4 years (range, 2.5-11.7 years). The cohort consisted of 15 pitchers and 7 position players. In total, 7 players competed in high school and 15 competed in college. Preoperatively, all 22 patients reported ulnar nerve sensory symptoms while only 4 (18.2%) patients reported ulnar nerve motor symptoms. Overall, 16 (72.3%) players were able to return to competitive play at an average of 11.2 months. Of the 6 that failed to return to play after surgery, 3 reported that persistent elbow symptoms were the reason for not returning to play while the other 3 reported losing the desire to return to play. At final follow-up, 7 (31.8%) patients reported of persistent sensory ulnar nerve sensory symptoms while 1 (4.5%) of these patients additionally reported persistent ulnar nerve motor symptoms. The mean postoperative patient reported outcome scores were as follows: KJOC: 77.9+/-20.9 (range, 14-100); MEPS: 92.7+/-12.7 (range, 45-100); AT Elbow Score: 86.1+/-17.1 (range, 30-100); SANE score: 85.5+/-14.8 (range, 50-100). Conclusions: While patient-reported outcome scores and return to play rates are reasonably high, this study demonstrates that following concomitant UCL reconstruction and ulnar nerve transposition for UCL insufficiency and associated ulnar neuropathy, rates of persistent ulnar neuropathy symptoms are persistently present in over 30% of patients. Currently, handling of the ulnar nerve in the setting of UCL insufficiency is debated and thus further investigation is warranted to optimize outcomes for this group of patients.

Background: Elite-level women's fastpitch softball players place substantial biomechanical strains on the elbow that can result in medial elbow pain and ulnar neuropathic symptoms. There is scant literature reporting the expected outcomes of the treatment of these injuries. This study examined the results of treatment in a series of these patients. Methods: We identified 6 female softball pitchers (4 high school and 2 collegiate) with medial elbow pain and ulnar neuropathic symptoms. Trials of conservative care failed in all 6, and they underwent surgical treatment with subcutaneous ulnar nerve transposition. These patients were subsequently monitored postoperatively to determine outcome. Results: All 6 female pitchers had early resolution of elbow pain and neuropathic symptoms after surgical treatment. Long-term follow-up demonstrated that 1 patient quit playing softball because of other injuries but no longer reported elbow pain or paresthesias. One player was able to return to pitching at the high school level but had recurrent forearm pain and neuritis 1 year later while playing a different sport and subsequently stopped playing competitive sports. Four patients continued to play at the collegiate level without further symptoms. Conclusions: Medial elbow pain in women's softball pitchers caused by ulnar neuropathy can be treated effectively with subcutaneous ulnar nerve transposition if nonsurgical options fail. Further study is necessary to examine the role of overuse, proper training techniques, and whether pitching limits may be necessary to avoid these injuries.

Intra articular fractures of the distal humerus cause considerable morbidity to the patients. There are several controversies regarding the approach and fixation of the fracture. AO advocated 90-90 plating of both columns while recent biomechanical studies demonstrated superior mechanical strength with parallel plating. But parallel plating is associated with many complications. We performed bicolumnar perpendicular plating in 15 intraarticular AO type C fractures through transolecranon approach. Ulnar nerve was isolated and carefully protected, but ulnar nerve transposition was not done. We achieved union in all cases with functional range of movement in 13 patients. We had no case of post-operatively developed ulnar nerve neuropathy or heterotopic ossification. The average Mayo Elbow Performance Score was 85 points. We infer that 90-90 plating is effective in intercondylar fractures of distal humerus with minimal complications.

Ulnar nerve is often trapped in cubital tunnel at elbow level, this being the second most common place of entrapment of the peripheral nerves in the upper limb.3 The most commonly associated etiology is the anatomic alteration of the cubital tunnel.12 There are three mechanisms described: compression, traction, and friction. The symptoms exhibited are hypoesthesia, pain, and weakness, which increase with the bending of the elbow at an angle greater than 90°, and according to nerve involvement we can classify the clinical status using the modified McGowan score.13 In this article, an unusual extrinsic compression mechanism to cubital tunnel is shown, caused by free intra-articular body, and its surgical management.

Introduction Cubital tunnel syndrome (CTS) is responsible for one of the types of ulnar nerve neuropathy and is the second cause of compressive neuropathy of the upper limb, only surpassed by carpal tunnel syndrome. Objective To describe the epidemiological data of the ulnar nerve transposition surgical code in the treatment of CTS by the United Health System (SUS) from 2005 to 2015. Methodology This is a descriptive epidemiological study, in which data were obtained through consultation of the DATASUS database. Results/Discussion During this period, 774 procedures were performed and, despite the addition of 20.3 million people to the Brazilian population, the incidence was 0.33/1,000,000. National and international epidemiology point to a slightly higher prevalence of the procedure between men, in the fourth and fifth decades of life. Low permanence rate, as well as the absence of hospital deaths related to the procedure, infer that the procedure is safe, with low morbidity and mortality rates. Conclusion The annual incidence of the cubital syndrome submitted to surgical treatment at SUS in the Brazilian population was 1/7,670,833 in 2005 and ½,174,468 in 2015. The cost of each surgical procedure during the same period ranged from R$ 318.88 to R$ 539.74. The mean hospitalization time for CTS surgery was 1.85 days.

Forearm muscle herniation is a rare but known cause of symptomatic pain in the upper extremity caused by compression or strangulation of the muscle belly through a defect in the overlying fascia. Because of the rarity of this condition, optimal treatment is still widely unknown and debated. To date, there are various treatment methods published, including rest, physiotherapy, primary repair, fasciotomy, fascia lata inlay, onlay or wrap-around, mesh graft, and acellular porcine collagen matrix. In this study, a 61-year old man underwent an ulnar nerve transposition to correct cubital tunnel syndrome, resulting in subsequent symptoms of muscle herniation on the volar aspect of the forearm. Prominent muscle herniation was visible a few weeks after the onset of symptoms and surgical correction of the fascial defect was performed using a local fascial flap. Postoperatively, the patient's herniation symptoms resolved without signs of ulnar nerve entrapment. The rationale for this treatment option is discussed.

Ulnar collateral ligament (UCL) reconstruction is now being performed more commonly and on younger patients than in prior decades. As a result, radiologists will increasingly be asked to evaluate elbow imaging of patients presenting with pain who have had UCL reconstruction. It is essential for radiologists to understand the normal and abnormal imaging appearances after UCL reconstruction and ulnar nerve transposition, which is also commonly performed in overhead-throwing athletes. Doing so will allow radiologists to provide accurate interpretations that appropriately guide patient management.

Critical review of surgical outcomes is vital to optimizing patient care. Multiple studies have ventured to address outcomes after cubital tunnel surgery. Due to variation in surgical technique, limited objective data, and inconsistency in measured outcome variables between studies, obtaining any generalized conclusions on anticipated postoperative outcomes remains somewhat challenging. This chapter reviews the available literature on outcomes after cubital tunnel release.

Background We designed a survey to ascertain the current perspectives of hand surgeons on the evaluation and management of ulnar nerve instability at the elbow. The secondary aim was to assess the concordance of hand surgeons on definitions of the terms “subluxated” and “dislocated” for classification of ulnar nerve instability. Methods A questionnaire, including demographic practice variables, cubital tunnel practice patterns, preoperative imaging and electrodiagnostic evaluation, and a series of standardized intraoperative photographs of ulnar nerve instability at the elbow were developed and distributed to the current American Society for Surgery of the Hand (ASSH) membership. Results A total of 690 (26.8%) members completed the survey; 84.2% of respondents indicated that they evaluate for ulnar nerve instability preoperatively with clinical examination, whereas only 6.1% indicated they routinely obtained dynamic ultrasound. Respondents indicated that the factors most strongly influencing their decision to proceed with anterior transposition of the ulnar nerve were subluxation on physical examination (89.6%), history consistent with ulnar nerve subluxation (85.8%), and muscle atrophy (43.2%). On review of clinical photographs, respondents demonstrated varying degrees of agreement on the terms “subluxated” or “dislocated” and recommendations for ulnar nerve transposition at intermediate degrees of ulnar nerve instability. Conclusion ASSH members routinely evaluate for ulnar nerve instability with history and clinical examination without uniform use of preoperative ultrasound, and nearly half of the time the decision to transpose the ulnar nerve is made intraoperatively. Definitions for the degree of ulnar nerve instability at the elbow are not uniformly agreed upon, and further development of a classification system may be warranted to standardize treatment.

Background: While ulnar collateral ligament reconstruction (UCLR) of the elbow is an increasingly commonly performed procedure with excellent results reported in the published literature, less attention has been paid to specifically on the characterization of postoperative ulnar nerve complications, and it is unclear what operative strategies may influence the likelihood of these complications. Purpose: The purpose of this study is to examine the prevalence and type of ulnar nerve complications after UCLR of the elbow based on the entirety of previously published outcomes in the English literature. In addition, this study examined how the rate of ulnar nerve complications varied as a function of surgical exposures, graft fixation techniques, and ulnar nerve management strategies. Study Design: Systematic review and meta-analysis. Methods: A systematic review of the literature was completed using the MEDLINE, PubMed, and Ovid databases. UCLR case series that contained complications data were included. Ulnar neuropathy was defined as any symptoms or objective sensory and/or motor deficit(s) after surgery, including resolved transient symptoms. Meta-analysis of the pooled data was completed. Results: Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. The mean prevalence of postoperative ulnar neuropathy was 12.0% overall after any UCLR procedure at a mean follow-up of 3.3 years, and 0.8% of cases required reoperation to address ulnar neuropathy. There were no cases of intraoperative ulnar nerve injury reported. The surgical approach associated with the highest rate of neuropathy was detachment of flexor pronator mass (FPM) (21.9%) versus muscle retraction (15.9%) and muscle splitting (3.9%). The fixation technique associated with the highest rate of neuropathy was the modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%), interference screw (5.0%), docking technique (3.3%), hybrid suture anchor-bone tunnel (2.9%), and modified docking (2.5%). Concomitant ulnar nerve transposition was associated with a higher neuropathy rate (16.1%) compared with no handling of the ulnar nerve (3.9%). Among cases with concomitant transposition performed, submuscular transposition resulted in a higher rate of reoperation for ulnar neuropathy (12.7%) compared with subcutaneous transposition (0.0%). Conclusion: Despite a perception that UCLR has minimal morbidity, a review of all published literature revealed that 12.0% of UCLR surgeries result in postoperative ulnar nerve complications. UCLR techniques associated with the highest rates of neuropathy were detachment of the FPM, modified Jobe fixation, and concomitant ulnar nerve transposition, although it remains unclear whether there is a causal relationship between these factors and subsequent development of postoperative ulnar neuropathy due to limitations in the current body of published literature.

The most common site of ulnar nerve compression is within the cubital tunnel. Surgery has historically involved an open cubital tunnel release with or without transposition of the nerve. A comparative study has demonstrated that endoscopic decompression is as effective as open decompression and has the advantages of being less invasive, utilizing a smaller incision, producing less local symptoms, causing less vascular insult to the nerve, and resulting in faster recovery for the patient. Ulnar nerve transposition is indicated with symptomatic ulnar nerve instability or if the ulnar nerve is located in a "hostile bed" (eg, osteophytes, scarring, ganglions, etc.). Transposition has previously been performed as an open procedure. The authors describe a technique of endoscopic ulnar nerve release and transposition. Extra portals are used to allow retractors to be inserted, the medial intermuscular septum to be excised, cautery to be used, and a tape to control the position of the nerve. In our experience this minimally invasive technique provides good early outcomes. This report details the indications, contraindications, surgical technique, and rehabilitation of the endoscopic ulnar nerve release and transposition.

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 The purpose of this study was to contrast the rate and types of complications and secondary surgeries for in situ cubital tunnel release and ulnar nerve transposition. Methods A retrospective cohort study was performed by query of hospital billing records for all patients who underwent cubital tunnel surgery from August 2008 to July 2013, yielding 421 patients. Exclusion criteria were acute trauma, revision surgery, neoplasm, age younger than 18 years, incomplete records, and postoperative follow-up less than 3 months. Of the remaining 234 patients, 147 patients underwent 157 in situ cubital tunnel releases and 87 patients underwent 90 ulnar nerve transpositions. Results In 157 in situ cubital tunnel releases, there were 6 complications (3.8%), including 3 cases (1.9%) of ulnar nerve instability, 2 cases (1.3%) of postoperative infection, and 1 case (0.6%) of a postoperative seroma. In 90 ulnar nerve transpositions, there were 2 complications (2.2%), including 1 case (1.1%) of postoperative infection and 1 case (1.1%) of medial antebrachial cutaneous nerve injury. The secondary surgery rate was 5.7% overall, 2.5% for in situ cubital tunnel release, and 11.1% for ulnar nerve transposition. Chronic kidney disease was associated with complication after cubital tunnel surgery. Prior trauma to the elbow and ulnar nerve transposition were associated with secondary surgery. Conclusions The short-term complication rates of cubital tunnel surgery are low (3.2%), but higher for patients with chronic kidney disease. The secondary surgery rate after cubital tunnel surgery was 5.7% overall, but higher for patients with prior elbow trauma and for patients undergoing ulnar nerve transposition. Type of study/level of evidence Therapeutic IV.

This study compared the therapeutic effects of two techniques for surgical decompression treatment for ulnar nerve entrapment at the elbow: subcutaneous transposition and modified submuscular transposition with Z-lengthening of the pronator teres origin. A total of 278 patients with ulnar nerve entrapment (McGowan grades I-III) were randomly assigned to undergo one of these techniques. All patients were followed-up for 2 years. The effects were assessed by preoperative and postoperative cross-sectional area, motor conduction velocity, sensory conduction velocity and nerve action potential. All of these parameters improved after surgery in both groups. For patients with grade I disease, there were no significant differences between the two techniques. For patients with grade II and III disease, modified submuscular transposition was associated with significantly greater improvements compared with subcutaneous transposition. In conclusion, subcutaneous ulnar nerve transposition is recommended for grade I patients and modified submuscular ulnar nerve transposition for grade II and III patients.

Background:The surgical treatment of Cubital tunnel syndrome (CubTS) is still a matter of debate. No consensus exists about the necessity of anterior transposition of the ulnar nerve after decompression. However, this technique is fairly common in clinical practice.Material and Methodology:In the present study we compared the operative technique (incision length, operative time), postoperative care (postoperative pain and complications) and the outcome between subcutaneous transposition and submuscular transposition of the ulnar nerve as two surgical modalities in treating moderate CubTS.Between March 2004 and March 2007, twenty six patients with moderate CubTS (according to Dellon’s grading system) were stratified according to age and gender into these two surgical techniques. The two groups were prospectively followed up 2 weeks, 6 months and 12 months postoperatively by the same observer and the operation outcome was assessed using the Bishop rating system.Results:We found that the subcutaneous transposition of the ulnar nerve was associated with shorter incision, shorter operative time, less postoperative pain, less postoperative complication and better outcome compared with the submuscular transposition.Conclusion:The authors recommend the subcutaneous technique when considering anterior transposition of the ulnar nerve in treating moderate CubTS.

OBJECT Surgical transposition of the ulnar nerve to alleviate entrapment may cause otherwise normal structures to become new sources of nerve compression. Recurrent or persistent neuropathy after anterior transposition is commonly attributable to a new distal compression. The authors sought to clarify the anatomical relationship of the ulnar nerve to the common aponeurosis of the humeral head of the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS) muscles following anterior transposition of the nerve. METHODS The intermuscular septa of the proximal forearm were explored in 26 fresh cadaveric specimens. The fibrous septa and common aponeurotic insertions of the flexor-pronator muscle mass were evaluated in relation to the ulnar nerve, with particular attention to the effect of transposition upon the nerve in this region. RESULTS An intermuscular aponeurosis associated with the FCU and FDS muscles was present in all specimens. Transposition consistently resulted in angulation of the nerve during elbow flexion when this fascial septum was not released. The proximal site at which the nerve began to traverse this fascial structure was found to be an average of 3.9 cm (SD 0.7 cm) from the medial epicondyle. CONCLUSIONS The common aponeurosis encountered between the FDS and FCU muscles represents a potential site of posttransposition entrapment, which may account for a subset of failed anterior transpositions. Exploration of this region with release of this structure is recommended to provide an unconstrained distal course for a transposed ulnar nerve.

BACKGROUND Ulnar nerve decompression at the elbow traditionally requires regional or general anesthesia. We wished to assess the feasibility of performing ulnar nerve decompression and transposition at the elbow under local anesthesia. METHODS We examined retrospectively the charts of 50 consecutive patients having undergone ulnar nerve entrapment surgery either under general or local anesthesia. Patients were asked to estimate pain on postoperative days 1 and 7 and satisfaction was assessed at 1 year. RESULTS On day 1, pain was comparable among all groups. On day 7, pain scores were twice as high when transposition was performed under general anesthesia when compared with local anesthesia. Patient satisfaction was slightly increased in the local anesthesia group. These patients were significantly more willing to repeat the surgery. CONCLUSION Ulnar nerve decompression and transposition at the elbow can be performed under local anesthesia without added morbidity when compared with general anesthesia.

Prior to Jobe’s description of a reconstruction technique for ulnar collateral ligament (UCL) insufficiency, the injury was career ending. Despite successful results in about 70 % of cases, concerns with elevation of the flexor-pronator mass, ulnar nerve complications and relatively large bone tunnels in the medial epicondyle of the humerus led to modifications to Jobe’s technique. One of the most novel modifications was the “docking technique.” Differences included: (1) arthroscopic evaluation and management, when indicated, of concomitant intra-articular pathology, (2) maintenance of the ulnar nerve in situ unless symptoms specifically indicate transposition, (3) use of a muscle splitting approach through the flexor mass, and (4) “docking” of the graft into a humeral socket. Ulnar preparation remained the same as originally described Jobe. These modifications facilitated improved graft tensioning while minimizing the number of large tunnels drilled in the relatively small medial epicondyle. Intraoperative morbidity was minimized by the muscle-splitting approach and the reservation of ulnar nerve transposition only when indicated based on preoperative exam. Clinical results have been excellent using this technique, and it is our preferred technique for UCL reconstruction.

Purpose: To evaluate the clinical results of anterior subcutaneous ulnar nerve transposition operation and the factors that influence the results for cubital tunnel syndrome. Materials and Methods: Seventeen cases of cubital tunnel syndrome were treated by anterior subcutaneous transposition between March 2001 and December 2003. The mean age was 56 years and mean follow up period was 20.4 months. All patients were reviewed retrospectively. The preoperative evaluation was done by Dellon`s classification and the clinical results were evaluated by Messina’s classification. We analyzed the effect of the operation and the relations between the results and the preoperative factors, for example, duration of symptom, age, cause of illness, present of association with diabetes mellitus or preoperative flexion contracture of the elbow were analyzed. Results: The results according to Messina`s classification were 4 cases of excellent, 9 cases of good, 3 cases of fair, and 1 case of poor. The preoperative factors like duration of symptom, age, cause of illness and flexion contracture of the elbow didn`t show any statistical difference in the result of operation, but the cases which have diabetes mellitus were unsatisfactory with statistical difference (p

Purpose To report the safety of using the proximal anteromedial portal, using a simplified ulnar nerve management strategy derived from an earlier study, in a series of patients with previously transposed ulnar nerves. Methods A retrospective review of all elbow arthroscopies performed by a single surgeon from 2009 to 2014 was performed. The following techniques were used if, by palpation, localization of the ulnar nerve was considered to be certain (group 1) or uncertain (group 2): In group 1 (certain) the proximal anteromedial portal was established in the normal antegrade fashion. In group 2 (uncertain) a 1- to 3-cm incision was made at the planned proximal anteromedial portal site, and blunt dissection down to the capsule was performed without identification of the nerve. The nerve was not visualized but sometimes was palpated through the wound to confirm its location anteriorly or posteriorly. If there was a disparity between the prior operative records and the physical examination findings, the nerve was explored through a 3- to 4-cm incision. Results We reviewed 394 elbow arthroscopy cases, 22 of which had a prior transposed ulnar nerve (21 subcutaneous and 1 submuscular) that required anterior-compartment arthroscopic surgery. Group 1 (certain location) consisted of 9 elbows (41%), whereas group 2 (uncertain location) consisted of 13 (59%). In 2 cases in group 2, the ulnar nerve was explored because of the disparity between the previous medical records and the physical examination findings. There were no operative ulnar nerve injuries related to the use of the proximal anteromedial portal. Conclusions The proximal anteromedial portal was able to be used safely in patients with prior transposition of the ulnar nerve. This was achieved by using an algorithm based on the degree of certainty with which the nerve can be localized in the region of the planned portal by clinical palpation. Level of Evidence Level IV, therapeutic case series.

The patient was identified and the affected extremity was marked before transfer to the operating room. A regional block was administered by the anesthesiologist. IV antibiotics were given. A well-padded tourniquet was placed on the right/left proximal arm. The right/left upper extremity was then prepped and draped in the usual sterile fashion. The extremity was exsanguinated with an Esmarch and the tourniquet was inflated to 250 mmHg.

Posteromedial varus rotatory subluxation and subsequent instability of the elbow has only recently been described, with few reports in the literature. Ring and Doornberg recently reported a series of posteromedial varus rotatory elbow injuries, concluding that adequate fixation of the anteromedial facet of the coronoid was necessary to restore optimal elbow function. Left untreated, there is a predilection for early posttraumatic ulnohumeral arthritis manifested by narrowing of the medial ulnohumeral articulation. Further characterization of this injury pattern will improve recognition and treatment of this uncommon but important variant of elbow fracture-dislocation. This case report describes a 35-year-old man with a posteromedial varus rotatory elbow dislocation with an associated traumatic, irreducible ulnar nerve transposition. Recurrent subluxation of the ulnar nerve has been described in 16.2% of normal subjects, although elbow extension reduced the nerve into the cubital tunnel in every case. Posteromedial varus rotatory subluxation of the elbow can result in an irreducible ulnar nerve transposition, increasing the risk of injury to the nerve during surgical exposure of the coronoid process.

We carried out a prospective randomised study comparing medial epicondylectomy with anterior transposition for the treatment of ulnar neuropathy at the elbow. The mean follow-up period was 4.5 years and we assessed the patients neurologically and orthopaedically. Neither procedure appeared to have a significant effect on elbow function. Our study showed better results after medial epicondylectomy; in particular patient satisfaction was higher than after ulnar nerve transposition. There were no significant differences in motor power or nerve-conduction rates and sensory fibres appeared to be more vulnerable to devascularisation.

Object. Failed surgical treatment for ulnar neuropathy or neuritis due to dislocation of the ulnar nerve presents diagnostic and therapeutic challenges. The authors of this paper will establish unrecognized dislocation (snapping) of the medial portion of the triceps as a preventable cause of failed ulnar nerve transposition.Methods. Fifteen patients had persistent, painful snapping at the medial elbow after ulnar nerve transposition, which had been performed for documented ulnar nerve dislocation with or without ulnar neuropathy. The snapping was caused by a previously unrecognized dislocation of the medial portion of triceps over the medial epicondyle. Seven of the 15 patients also had persistent ulnar nerve symptoms. The correct diagnosis of snapping triceps was delayed for an average of 22 months after the initial ulnar nerve transposition. An additional surgical procedure was performed in nine of the 15 cases and, in part, consisted of lateral transposition or excision of the offending snapping medial portion of the triceps. Of the four patients in this group who had persistent neurological symptoms, submuscular transposition was performed in the two with more severe symptoms and treatment of the triceps alone was performed in the two with milder neurological symptoms. Excellent results were achieved in all surgically treated patients. Six patients declined additional surgery and experienced persistent snapping and/or ulnar nerve symptoms.Conclusions. Failure to recognize that dislocation of both the medial portion of the triceps and the ulnar nerve can exist concurrently may result in persistent snapping, elbow pain, and even ulnar nerve symptoms after a technically successful ulnar nerve transposition.

Controversy surrounds the reliability of methods of treating ulnar nerve compression at the elbow. The effectiveness of submuscular anterior nerve transposition was evaluated in 33 limbs of 31 patients. The flexor-pronator Z-lengthening technique, without internal neurolysis, was used. Results were determined by patient chart reviews. Severity of preoperative nerve compression was measured using Dellon's classification. Of the 33 limbs, 6 had mild preoperative nerve compression; 7, moderate; and 20, severe. Overall outcome was evaluated using a modification of the Bishop rating system. At a mean follow-up period of 49 months, 12 limbs (36%) had excellent results, 20 limbs (61%) had good results, and 1 limb (3%) had a poor result. These findings indicate that submuscular ulnar nerve transposition using the flexor-pronator Z-lengthening technique without internal neurolysis is a reliable method of treating ulnar nerve compression at the elbow.

Reports of subluxation of the medial head of the triceps tendon over the medial epicondyle are rare. This may be associated with symptomatic ulnar nerve compression at the elbow. We report a case of bilateral snapping triceps tendon after bilateral ulnar nerve release at the elbow with anterior submuscular transposition. Careful inspection of the triceps tendon in flexion and extension at the time of the ulnar nerve submuscular transposition may prevent this potential complication.

Ten patients who had persistent or recurrent paresthesias, muscular weakness, or sensory loss following transposition of the ulnar nerve at the elbow were explored. Operative findings included compression of the nerve at the intermuscular septum or at the entrance to the cubital tunnel, dense scarring after intramuscular transposition, and constriction by fascial slings. The average interval from the previous operation to re-exploration was 13 months. All patients were improved following neurolysis and submuscular transposition. Recovery was incomplete in nine patients. The average follow-up was 14.5 months.

An improved method of operative positioning of a patient for ulnar nerve transposition is described. It lends itself admirably in any procedure requiring approach to the mesial aspect of the elbow.

To the Editor.— The letter by John F. Aita, MD, concerning ulnar neuropathy occurring after cardiac surgery (1981;245:2295) attracted our attention. We have also recently noticed two cases of ulnar neuropathy at the elbow occurring after coronary bypass surgery. One of these patients underwent ulnar nerve transposition and has shown remarkable improvement, both in sensation and in strength of the abductor digiti quinti muscle. We must take issue, however, with the suggestion that this neuropathy is exclusively compressive in nature. At our institution, we have scrupulously padded the elbow in patients undergoing surgery of any sort in the supine position. Furthermore, we are careful not to tape the arm on an arm board in such a fashion as to produce pressure in the cubital tunnel, either from the edge of the arm board or from adjacent tubing. Despite these precautions, we have noted the occurrence of postcardiotomy ulnar nerve palsy.