Ulnar neuropathy.

Ulnar neuropathy at the elbow is the second most common compressive neuropathy. Less common, although similarly disabling, are ulnar neuropathies above the elbow, at the forearm, and the wrist, which can present with different combinations of intrinsic hand muscle weakness and sensory loss. Electrodiagnostic studies are moderately sensitive in diagnosing ulnar neuropathy, although their ability to localize the site of nerve injury is often limited. Nerve imaging with ultrasound can provide greater localization of ulnar injury and identification of specific anatomical pathology causing nerve entrapment. Specifically, imaging can now reliably distinguish ulnar nerve entrapment under the humero-ulnar arcade (cubital tunnel) from nerve injury at the retro-epicondylar groove. Both these pathologies have historically been diagnosed as either "ulnar neuropathy at the elbow," which is non-specific, or "cubital tunnel syndrome," which is often erroneous. Natural history studies are few and limited, although many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously. Conservative management, perineural steroid injections, and surgical release have all been studied in treating ulnar neuropathy at the elbow. Despite this, questions remain about the most appropriate management for many patients, which is reflected in the absence of management guidelines.

Treatment related fluctuation and response to intravenous immunoglobulin therapy in post COVID-19 Guillain-Barre syndrome.

Treatment related fluctuation (TRF) poses a special challenge in the treatment of Guillain-Barre syndrome (GBS). Many cases of GBS following COVID-19 infection have been reported in literature till date, but treatment related fluctuation (TRF) in post COVID-19 GBS has not been reported till date. We report a 35-year-old male patient who developed GBS following COVID-19 infection and had TRF after intravenous immunoglobulin (IV-IG) therapy. He required ventilator support but repeat IV-IG therapy led to complete recovery. Significant proximal muscle involvement, cranial nerve palsy, no antecedent diarrhea and absence of anti-GM1 antibodies are important predictors of TRF in GBS and need to be recognized early in the course of this illness. Early recognition of TRF and differentiating it from other forms of immune mediated neuropathy such as acute onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP) are important for prognostication and management.

In situ decompression vs conservative treatment for mild ulnar neuropathy at the elbow.

INTRODUCTION: The best treatment strategy for mild ulnar neuropathy at the elbow (UNE) is not known, due to lack of trials comparing surgery vs conservative treatment. METHODS: We recruited patients with clinical symptoms and signs of mild UNE and an electrophysiologically or sonographically confirmed diagnosis. Patients were randomly allocated to either in situ decompression or conservative treatment. The primary outcome was the proportion of patients with subjective symptom improvement at short-term (3 months) and long-term (6-12 months) follow-up. RESULTS: One hundred seventeen patients were included: 56 and 61 patients were allocated to surgery and conservative treatment, respectively. A larger proportion of surgically treated patients showed improvement at short-term follow-up (85% vs 50%; odds ratio, 5.6; P < .001), but no differences were observed at long-term follow-up. DISCUSSION: In situ decompression for mild UNE may result in faster relief of symptoms when compared with conservative treatment, but at long-term follow-up no differences were observed.

The functional effect of 3D-printing individualized orthosis for patients with peripheral nerve injuries: Three case reports.

RATIONALE: In the medical field, the use of 3-dimensional (3D) printing is increasing explosively and it is especially widespread in the clinical application of fabricating orthosis. Advantages of 3D-printed orthosis compared to conventional ones include its lower cost, easier modification, and faster fabrication. The 3D-printing technique makes it possible for physicians to easily create individual-tailored products. Recently, many kinds of orthosis through 3D printing have been studied and used. The knee orthosis, ankle-foot orthosis, wrist orthosis, hand orthosis, and foot orthotics are examples used in the rehabilitation fields of orthotics. We reported 3 cases of 3D-printed orthoses in patients with peripheral nerve injuries. PATIENTS CONCERNS: In spite of the rapid development of the clinical use of 3D printing, to our knowledge, its application to patients with peripheral nerve injuries has not yet been reported. Two patients suffered from upper limb problems and 1 patient had a foot drop associated with peripheral nerve injury. DIAGNOSIS: Three patients diagnosed with median neuropathy, ulnar neuropathy, and right lower lumbar radiculopathy, respectively, by electromyography. INTERVENTIONS: Herein we present 3 case reports of patients with peripheral nerve injuries whose orthotic needs were fulfilled with the application of 3D-printed wrist orthosis and ankle-foot orthosis. OUTCOMES: For hand function evaluation, we assessed the Jebsen-Taylor hand function test. Grasp and pinch powers were assessed by a hand dynamometer before and after orthosis application. For lower limb functional evaluation, we used a 6-minute walking test and modified Emory Functional Ambulation Profile for ambulatory function. LESSONS: The 3D-printed orthosis could help functional improvement in patients with peripheral nerve injuries.

Tardy Ulnar Nerve Palsy.

Tardy ulnar nerve palsy is a chronic clinical condition characterized by a delayed onset ulnar neuropathy after an injury to the elbow. Typically, tardy ulnar nerve palsy occurs as a consequence of nonunion of pediatric lateral condyle fractures at the elbow, which eventually lead to a cubitus valgus deformity. While the child grows, the deformity worsens and the ulnar nerve is gradually stretched until classic symptoms of ulnar nerve neuropathy appear. Other childhood elbow trauma has also been associated with tardy ulnar nerve palsy, including supracondylar fractures resulting in cubitus varus, fractures of the medial condyle and of the olecranon, as well as radial head or Monteggia fractures/dislocation, with or without deformity. The clinical assessment includes obtaining a complete history, physical examination, nerve conduction tests, and elbow imaging studies. Treatment consists of ulnar nerve decompression, with or without corrective osteotomy, with overall successful results usually achieved.

Long-term outcomes in patients with ulnar neuropathy at the elbow treated according to the presumed aetiology.

OBJECTIVES: Ulnar neuropathy at the elbow (UNE) consists mainly of two conditions: entrapment under the humeroulnar aponeurosis (HUA) and extrinsic compression in the retrocondylar (RTC) groove. These in our opinion need different treatment: surgical HUA release and avoidance of inappropriate arm positioning, respectively. We treated our UNE patients accordingly, and studied their long-term outcomes. METHODS: We invited our cohort of UNE patients to a follow-up examination consisting of history, neurological, electrodiagnostic (EDx) and ultrasonographic (US) examinations performed by four blinded investigators. RESULTS: At a mean follow-up time of 881 days, we performed a complete evaluation in 117 of 165 (65%) patients, with 96 (90%; 35 HUA and 61 RTC) treated according to our recommendations. An improvement was reported by 83% of HUA and 84% of RTC patients. In both groups the ulnar nerve mean compound muscle action potential (CMAP) amplitude, and the minimal motor nerve conduction velocity increased, while the maximal ulnar nerve cross-sectional area (CSA) decreased. CONCLUSION: After 2.5 years similar proportions of HUA and RTC patients reported clinical improvement that was supported by improvement in EDx and US findings. SIGNIFICANCE: These results suggest that patients with UNE improve following both surgical decompression and non-operative treatment. A clinical trial comparing treatment approaches in neuropathy localised to the HUA and RTC will be needed to possibly confirm our opinion that the therapeutic approach should be tailored according to the presumed aetiology of UNE.

Ulnar neuropathy at wrist: entrapment at a very "congested" site.

Ulnar tunnel syndrome indicates ulnar neuropathy at different sites within the wrist. Several classifications of ulnar tunnel syndrome are present in literature, based upon typical nerve anatomy. However, anatomical variations are not uncommon and can complicate assessment. The etiology is also complex, due to the numerous potential causes of entrapment. Clinical examination, neurophysiological testing, and imaging are all used to support the diagnosis. At present, many therapeutic approaches are available, ranging from observation to surgical management. Although ulnar neuropathy at the wrist has undergone extensive prior study, unresolved questions on diagnosis and treatment remain. In the current paper, we review relevant literature and present the current knowledge on ulnar tunnel syndrome.

Bilateral position-related ulnar neuropathy at elbow in pediatric population and review of the literature.

Perioperative ulnar neuropathies attributed to inappropriate arm positioning and padding during surgical procedures are commonly found in adults. However, their extremely rare incidence in the pediatric population may cause absent awareness of the risk of nerve injury in anesthetized pediatric patients. Furthermore, young patients respond to conservative treatment of neuropathy less favorably than adults and their response also depends on the pathomechanism of the ulnar nerve injury. A surgeon's or anesthetist's failure to recognize all of these specifics in children may result in substantial morbidity of young patients leading to lawsuits. Fortunately, with an adequate knowledge of surgical anatomy and types of procedures and positions in which the ulnar nerve is particularly vulnerable, and familiarity with measures to minimize the potential for neuropathy, this serious complication can be prevented. The aims of this review are to highlight personal experience and current knowledge of the rare position-related ulnar neuropathy, both from a clinical and anatomical-pathophysiological perspective, and to raise awareness about this rare but serious complication in the pediatric population.

Treatment for Ulnar Neuritis Around the Elbow in Adolescent Baseball Players: Factors Associated With Poor Outcome.

BACKGROUND: Ulnar neuritis around the elbow is one of the injuries seen in throwing athletes. Outcomes of nonsurgical treatment and factors associated with failure outcomes have not been reported. PURPOSE: To investigate the outcomes of treatments for ulnar neuritis in adolescent baseball players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We assessed 40 male baseball players with a mean age of 15.0 years (range, 13-17 years) who presented with ulnar neuritis. There were 19 pitchers and 21 fielders whose throwing side was affected. All patients had elbow pain, and 13 patients had hand numbness on the ulnar side. The mean Kerlan-Jobe Orthopaedic Clinic (KJOC) overhead athlete shoulder and elbow score was 52.5 at the first follow-up visit (n = 36 patients). Thirteen patients were identified with ulnar nerve subluxation, and 23 patients had concomitant elbow ulnar collateral ligament (UCL) injury. All patients underwent nonsurgical treatment, which included rehabilitation exercises and prohibition of throwing. If the nonsurgical treatment failed, we recommended surgical treatment. We investigated the outcomes of the nonsurgical and surgical treatments. Return to sports was evaluated, combined with factors associated with return to sports in nonsurgical treatment by univariate and multivariate statistical analysis. RESULTS: The mean follow-up period was 23.6 months (range, 6-39 months). After nonsurgical treatment, 24 patients (60%) returned to the previous competition level after a mean of 2.4 months. Two patients returned to a recreational level. One patient gave up playing baseball at 2 months. The remaining 13 patients underwent surgery and returned to sports after a mean of 2.0 months postoperatively, and 12 had no limitation of sports activities. Multivariate logistical regression analysis demonstrated that hand numbness, ulnar nerve subluxation, and UCL injury were associated with failure of nonsurgical treatment ( P < .05). In addition, KJOC score of <45 at the first follow-up tended to be associated with poor outcomes of nonsurgical treatment ( P = .06). CONCLUSION: Hand numbness on the ulnar side, ulnar nerve subluxation, and UCL injury are strong predictors of poor outcomes after nonsurgical treatment for ulnar neuritis, and surgery provides excellent results.

Ulnar Neuropathy in Cyclists.

The form and function of the cyclist exposes the ulnar nerve to both traction and compressive forces at both the elbow and wrist. Prevention of ulnar neuropathy and treatment of early symptoms include bike fitting, avoidance of excessive or prolonged weight-bearing through the hands, and the use of padded gloves. For persisting or progressive symptoms, a thorough history and physical examination is essential to confirm the diagnosis and to rule out other sites of nerve compression. The majority of compression neuropathies in cyclists resolve after appropriate rest and conservative treatment; however, should symptoms persist, nerve decompression may be indicated.

A randomized trial of diagnostic ultrasound to improve outcomes in focal neuropathies.

INTRODUCTION: Neuromuscular ultrasound is valid, reliable, and accurate, but it is not known whether combining it with electrodiagnostic studies leads to better outcomes in individuals with focal neuropathies. METHODS: One hundred twenty individuals with focal neuropathy, based on history, examination, and electrodiagnosis, were enrolled in this study. All patients underwent neuromuscular ultrasound and were randomized to either have their ultrasound results sent to the referring physician or not have them sent. Outcomes were assessed at 6 months by evaluators blinded to group assignment. RESULTS: The Overall Disability Sum Score and 7 of 8 domains of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) showed more improvement in the "report sent" group, although only the general health perception domain was significant (P = 0.005). CONCLUSIONS: Most 6-month outcomes did not reach statistical significance between the 2 groups. However, the "report sent" group had trends toward better outcomes, with significance being reached in the general health perception domain of the SF-36.

Diagnosis and Treatment of Work-Related Ulnar Neuropathy at the Elbow.

Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy after carpal tunnel syndrome and occurs most commonly at the elbow due to mechanical forces that produce traction or ischemia to the nerve. The primary symptom associated with UNE is diminished sensation or dysesthesias in the fourth or fifth digits, often coupled with pain in the proximal medial aspect of the elbow. Treatment may be conservative or surgical, but optimal management remains controversial. Surgery should include exploration of the ulnar nerve throughout its course around the elbow and release of all compressive structures.

Ulnar Neuropathy After Extracorporeal Shockwave Therapy: A Case Report.

Currently, extracorporeal shockwave therapy (ESWT) is widely used for treatment of various musculoskeletal disorders. We report a case of ulnar neuropathy secondary to the application of ESWT. A 48-year-old man was diagnosed with medial epicondylitis and underwent 2 sessions of ESWT. Immediately after the second session, he experienced paresthesia and weakness in the right hand. On physical examination, atrophy of the first dorsal interosseus and weakness of the abductor digiti minimi were observed. Electrophysiologic study demonstrated ulnar neuropathy at the elbow with severe partial axonotmesis. Our case report demonstrates that ESWT might cause or contribute to peripheral nerve injury at the site of application.

Elbow injuries in the throwing athlete.

High valgus and extension loads imparted to the athlete's elbow during repetitive overhead throwing can lead to acute and chronic pathology. Over time, normal soft tissue and bony stabilizing structures of the elbow undergo progressive structural changes and can succumb to injury. Modern diagnostic modalities, including plain radiographs, computed tomography, and magnetic resonance imaging, in addition to arthroscopy, can aid in diagnosis. Although nonoperative management is often successful, surgical intervention may be necessary before allowing return to play.

ACOEM practice guidelines: elbow disorders.

OBJECTIVE: The American College of Occupational and Environmental Medicine has updated the treatment guidelines in its Elbow Disorders chapter through revision processes begun in 2006. This abbreviated version of that chapter highlights some of the evidence and recommendations developed. METHODS: Comprehensive systematic literature reviews were accomplished with article abstraction, critiquing, grading, evidence table compilation, and guideline finalization by a multidisciplinary expert panel and extensive peer-review to develop evidence-based guidance. Consensus recommendations were formulated when evidence was lacking and often relied on analogy to other disorders for which evidence exists. A total of 108 high- or moderate-quality trials were identified for elbow disorders. RESULTS: Guidance has been developed for 13 major diagnoses and includes 270 specific recommendations. CONCLUSION: Quality evidence is now available to guide treatment for elbow disorders, particularly for lateral epicondylalgia.

Bilateral ulnar neuropathy at the elbow secondary to neuropathic arthropathy associated with syringomyelia.

Neuropathic arthropathy (NA), also known as Charcot joint, refers to a chronic progressive degenerative arthritis that is associated with an underlying central or peripheral neurologic disorder. The elbow is rarely reported to be involved in NA, but when affected, it is commonly a result of a cervical syrinx or tabes dorsalis. Few reports in the literature describe ulnar neuropathy at the elbow (UNE) associated with NA of the elbow, and none describe bilateral UNE in association with a cervicothoracic syrinx. We present a unique case of bilateral UNE resulting from NA of the elbow associated with a cervicothoracic syrinx.

Peripheral nerve stimulation in intractable neuropathic pain.

Peripheral nerve stimulation (PNS) is a neurostimulation analgesic technique. PNS is utilized to treat peripheral neuropathic pain. It is highly sophisticated and a specialized technique used where other forms of treatment have failed. This paper describes the PNS procedure, its therapeutic principles, indications, and the comprehensive care for patients after the PNS implant. First, we summarize our experience using this type of invasive treatment. In the second part, a case of intractable neuropathic pain following repeated surgery to the ulnar nerve is reported. Prior to PNS, the patient underwent multiple types of antineuralgic treatment with no significant result. Only after the PNS application, was a significant analgesic effect achieved.