Ultrasound-Based Multi-Planar Bilateral Comparisons as a Diagnostic and Treatment-Definition Method for Unilateral Peripheral Nerve Entrapment.

OBJECTIVE: The primary goal was to determine the performance of the cross-section area swelling rate (CSASR) for diagnostic and therapeutic purposes based on the reference standard of electrodiagnosis examination (EDX) in this diagnostic test study. METHODS: First, patients with symptoms like unilateral carpal tunnel syndrome (CTS), cubital tunnel syndrome (CuTS), and radial nerve compression (RNC) underwent EDX and ultrasound examination. Second, patients with positive ultrasound were calculated for the CSASR of diseased nerve. Based on previously established CSASR criteria, each patient was categorized as having or not having peripheral nerve entrapment, and for those meeting diagnostic criteria, non-surgical or surgical treatment was recommended. Then, the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rate (ACC) of ultrasound diagnosis and therapeutic decision-making were calculated based on the reference standard of EDX that had been historically used in the practice. RESULTS: The total sensitivity, specificity, PPV, NPV, and ACC of ultrasound diagnosis are respectively 93.4, 85.2, 94.7, 82.1, and 91.3%. Which of therapeutic decision-making by ultrasound are, respectively, 83.3, 52.2, 78.4, 60.0, and 73.2%. CONCLUSION: The sensitivity and Youden's index of CSASR diagnostic threshold for CuTS is higher than other ultrasound methods. The CSASR diagnostic threshold for CuTS has a potential diagnostic role, but the current date is still not enough to support the potential diagnostic role for CTS or RNS. There is insufficient evidence to suggest that CSASR for CuTS can be used in isolation for diagnosis. Additional research is needed to confirm the diagnostic role of CSASR. The current results suggest that this ultrasound examination method is not suitable for therapeutic decision-making.

The Use of Physiotherapy in the Conservative Treatment of Cubital Tunnel Syndrome: A Critical Review of the Literature.

BACKGROUND: The lack of a clear answer regarding the efficacy of physiotherapy in the treatment of cubital tunnel syndrome (CuTS) has led to attempts to critically assess the scientific studies conducted to date. MATERIALS AND METHODS: Two databases (MEDLINE via PubMed and PEDro) and Google Scholar were used to search for papers. The inclusion criteria were randomized controlled trials, case series, and case reports that evaluate the effects of physiotherapy in the treatment of patients with CuTS. RESULTS: A total of 18 studies met the eligibility criteria, capturing a total of 425 participants. Seven papers were randomized controlled trials, three more described prospective studies without a control group, and eight papers contained case reports. An analysis of the literature evaluating the effectiveness of various forms of broadly defined physiotherapy indicates that their use can have a beneficial effect in reducing many subjective and objective symptoms and improving function. In the majority of papers included in this review, their authors indicated positive therapeutic effects. Only one randomized controlled trial reported no change following therapy. It can therefore be stated that the results of the research conducted so far are optimistic. However, only 7 of the 18 papers were randomized controlled trials, while 3 were prospective studies, and 8 papers were case studies, in which 23 people with CuTS were studied. CONCLUSIONS: The small number of randomized clinical trials and their considerable heterogeneity do not allow firm conclusions to be drawn about the effectiveness of physiotherapy in the conservative treatment of CuTS.

Double entrapment neuropathy of the ulnar nerve at the elbow and the wrist : double crush syndrome?

BACKGROUND: Double crush syndrome refers to a nerve in the proximal region being compressed, affecting its proximal segment. Instances of this syndrome involving ulnar and cubital canals during ulnar neuropathy are rare. Diagnosis solely through clinical examination is challenging. Although electromyography (EMG) and nerve conduction studies (NCS) can confirm neuropathy, they do not incorporate inching tests at the wrist, hindering diagnosis confirmation. We recently encountered eight cases of suspected double compression of ulnar nerve, reporting these cases along with a literature review. METHODS: The study included 5 males and 2 females, averaging 45.6 years old. Among them, 4 had trauma history, and preoperative McGowan stages varied. Ulnar neuropathy was confirmed in 7 cases at both cubital and ulnar canal locations. Surgery was performed for 4 cases, while conservative treatment continued for 3 cases. RESULTS: In 4 cases with wrist involvement, 2 showed ulnar nerve compression by a fibrous band, and 1 had nodular hyperplasia. Another case displayed ulnar nerve swelling with muscle covering. Among the 4 surgery cases, 2 improved from preoperative McGowan stage IIB to postoperative stage 0, with significant improvement in subjective satisfaction. The remaining 2 cases improved from stage IIB to IIA, respectively, with moderate improvement in subjective satisfaction. In the 3 cases receiving conservative treatment, satisfaction was significant in 1 case and moderate in 2 cases. Overall, there was improvement in hand function across all 7 cases. CONCLUSION: Typical outpatient examinations make it difficult to clearly differentiate the two sites, and EMG tests may not confirm diagnosis. Therefore, if a surgeon lacks suspicion of this condition, diagnosis becomes even more challenging. In cases with less than expected postoperative improvement in clinical symptoms of cubital tunnel syndrome, consideration of double crush syndrome is warranted. Additional tests and detailed EMG tests, including inching tests at the wrist, may be necessary. We aim to raise awareness double crush syndrome with ulnar nerve, reporting a total of 7 cases to support this concept.

Ultrasound Measurements of the Ulnar Nerve at the Medial Epicondyle Correlate With Electrodiagnostic Studies.

BACKGROUND: Cubital tunnel syndrome is the second most common compressive neuropathy in the upper extremity and is commonly evaluated with electrodiagnostic studies (EDS). Ultrasound (US) has emerged as a potentially more efficient alternative to EDS. The purpose of this study is to evaluate whether measurements of the cross-sectional area (CSA) of the ulnar nerve at the elbow correlate with EDS results. METHODS: This study was a prospective analysis of patients who presented with signs and symptoms consistent of cubital tunnel syndrome, who received USs of the ulnar nerve at the elbow and nerve conduction tests. Pearson correlation coefficients were used to evaluate the correlation between ulnar nerve CSA and electrodiagnostic data. t Tests were used to evaluate statistical differences between the mean ulnar nerve CSA of patients with positive or negative nerve conduction study results. Youden Index was used to calculate the optimal cut-off point for US CSA based on maximal sensitivity and specificity. Statistical significance was based on a two-sided P less than .05. RESULTS: The association between increasing US CSA at the medial epicondyle with slowing of the conduction velocity of the ulnar motor nerve across the elbow was statistically significant (r = -0.35, P = .02). Patients with positive EDS tests had significantly larger nerve size than those with negative tests (all Ps < .03). A cut-off point of greater than or equal to 11 mm2 had a sensitivity of 70.83% and specificity of 66.67%. CONCLUSIONS: Larger ulnar nerve CSAs correlate with slowing of the conduction velocity on EDSs, and those with positive EDSs have larger nerve sizes than those with negative tests.

The relationship between diffusion tensor imaging and the clinical classification of cubital tunnel syndrome.

The purpose of the study was to investigate the relationship between diffusion tensor imaging (DTI) and the clinical classification of cubital tunnel syndrome (CuTS). Ten patients with CuTS (7 men and 3 women; mean age: 52.7 years) and 5 patients without ulnar neuropathy (2 men and 3 women; mean age: 38.0 years) were enrolled in this retrospective study. Fifteen patients were clinically classified into three groups: "Normal", "1 and 2A", and "2B and 3" by an orthopedic surgeon using the modified McGowan stages. DTI was acquired using a 3.0-T MRI. Fractional anisotropy (FA) of the ulnar nerve was measured in slices covering 20 mm proximal to 20 mm distal to ulnar sulcus. Median FA values in each group were compared by Kruskal-Wallis and Steel-Dwass test (P < 0.05). Five patients with CuTS were classified as "1 and 2A" and five patients as "2B and 3". The FA values, proximal 12 mm to the ulnar sulcus were 0.486 ± 0.117, 0.425 ± 0.166 and 0.298 ± 0.0386 in the "Normal", "1 and 2A" and "2B and 3" groups, respectively. The FA values of patients classified as "Normal" were significantly higher than those classified as "2B and 3" (P = 0.0326 in Steel-Dwass test). FA proximal to the ulnar sulcus might be associated to the modified McGowan stages for the clinical classification of CuTS.

Surgical Decision Making for Mild-to-Moderate Cubital Tunnel Syndrome.

Purpose: The management of ulnar neuropathy remains unclear as there are neither consensus guidelines nor compelling data available to inform optimal treatment. Identifying patients in the mild-to-moderate group that would benefit most from surgery is challenging as their symptoms can be subtle and less debilitating. This study investigated predictors of surgical intervention among patients presenting with McGowan mild or moderate cubital tunnel syndrome (CuTS). Methods: This is an institutional review board-approved study. Patients evaluated from March 2016 to July 2022 were included if they were diagnosed with McGowan mild or moderate CuTS and underwent concurrent electrodiagnostic and ultrasound evaluations. Patient demographics, symptom presentation, and clinical and diagnostic test findings were analyzed. Variables were analyzed using Student t test, Mann-Whitney U test, or Pearson's chi-square test. Multivariable logistic regression was used to assess the association of covariates and surgery. Results: Seventy-three patients and 103 elbows were identified. The mean age and body mass index were 51 years and 26.9, respectively. Most patients were men, right-handed, and unilaterally symptomatic in the dominant hand. Twenty-six elbows were surgically treated. Bivariable analyses by surgical treatment showed that patients who underwent surgery more often had positive electrodiagnostic findings including motor nerve conduction velocity <50 m/s and a >10 m/s conduction velocity difference across the forearm compared with elbow. Fifty-nine cases were categorized as electrodiagnostically normal. Of the electrodiagnostically normal cases, 29 had positive findings of CuTS on ultrasound. Logistic regression model showed that electrodiagnostically severe cases had 3.7 times higher odds of being surgically treated than normal counterparts (adjusted odds ratio, 3.7; 95% CI, 1.11-12.6; P = .03). Conclusions: Not many differences in objective findings identify patients who should receive operative treatment. In addition to test results, more subjective findings from patients such as patient-reported level of impairment may be able to bridge this gap in surgical decision making. Clinical relevance: This study contributes to treatment decision making for mild and moderate CuTS.

A novel classification of intraoperative ulnar nerve instability to aid transposition surgery.

HYPOTHESIS: The purpose of this study was to compare inter- and intraobserver agreement of a novel intraoperative subluxation classification for patients undergoing ulnar nerve surgery at the elbow. We hypothesize there will be strong inter- and intraobserver agreement of the 4-category classification system, and reviewers will have substantial confidence while reviewing the classification system. METHODS: Four blinded fellowship-trained orthopedic hand surgeons reviewed 25 videos in total on 2 separate viewings, 21 days apart. Variables collected were ulnar subluxation classification (A, B, C, or D) and a confidence metric. Subsequent to primary data collection, classification grading was stratified into A/B or C/D subgroups for further analysis. Cohen κ scores were used to evaluate all variables collected in this study. The interpretation of κ scores included ≤0.0 as no agreement, 0.01-0.20 as none to slight, 0.21-0.40 as fair, 0.41-0.60 as moderate, 0.61-0.80 as substantial, and 0.81-1.0 as almost perfect agreement. RESULTS: Interobserver agreement of subluxation classification as a 4-category scale demonstrated a moderate agreement on first viewing, second viewing, and when both viewings were combined (κ = 0.51, 0.51, and 0.51 respectively). Seventy-five percent (3 of 4) of reviewers had moderate intraobserver agreement for ulnar nerve subluxation classification, whereas 1 reviewer had substantial intraobserver classification (κ = 0.72). Overall, there was high confidence in 65% of classification scores in the second round of viewing, which improved from 58% in the first viewing round. When ulnar subluxation classification selections were regrouped into classes A/B or C/D, 100% of reviewers had substantial interobserver (κ = 0.74-0.75) and substantial to almost perfect intraobserver (κ = 0.71-0.91) agreement. CONCLUSIONS: The 4-category classification was reproducible within and between reviewers. Agreement appeared to increase when simplifying the classification to 2 categories, which may provide guidance to surgical decision making. The validation of a reproducible classification scheme for intraoperative ulnar subluxation may aid with decision making and further postoperative outcomes research.

Ulnar Nerve Entrapment Among Cell Phone Users: Cell Phone Elbow (Cubital Tunnel Syndrome).

Introduction Cell phone usage has tremendously increased, and to make usage comfortable, accessories such as Bluetooth earphones are available. But still, most people use cell phones for a long period of time by flexing their elbows near their ears. When the users flex the elbow to hold the phone near the ear, this results in increased pressure over the ulnar nerve since the ulnar nerve runs superficially at the level of the elbow. The extensive pressure over the ulnar nerve may result in nerve compression, which results in cubital tunnel syndrome, recently called the cell phone elbow. Hence, this study was undertaken to assess the ulnar nerve function among cell phone users in relation to the duration of usage. Materials and methods Young healthy volunteers (n = 30) aged between 20 and 25 years were selected for the study in order to prevent age-related neuropathic changes. After getting a history of mobile phone usage, the subjects were asked about neural symptoms such as tingling, numbness, and pain while using cell phones. Ulnar nerve function was assessed by Froment's sign and Wartenberg's sign. An ulnar nerve conduction study was done. Results Seventy percent of the subjects (n = 21) out of the 30 subjects participating in the study reported tingling and numbness during mobile phone usage. But Froment's sign and Wartenberg's sign were negative for all the subjects. There was a significant positive correlation (r = 0.913 and r = 0.8253) between the duration of mobile phone use and latency and a negative correlation (r = -0.8439) with conduction velocity. Conclusion The malposition of the elbow during prolonged cell phone use results in ulnar nerve entrapment. The continuous usage of cell phones without rest by flexing the elbow causes nerve compression. This can be taken as a warning sign to prevent further damage.

Utilizing Diagnostic Musculoskeletal Ultrasound in the Evaluation of Cubital Tunnel Syndrome and Ulnar Nerve Pathology.

Cubital Tunnel Syndrome (CTS), is a frequently encountered condition in clinical settings, typically arising from static or dynamic compression of the ulnar nerve. CTS is characterized by the irritation of the ulnar nerve within the cubital tunnel and is a common neuropathic condition that can significantly impact functional abilities and quality of life. This article explores the utility of diagnostic musculoskeletal ultrasound (MSK-US) in the evaluation of the cubital tunnel and the ulnar nerve. The cubital tunnel syndrome, a common entrapment neuropathy of the ulnar nerve, often presents diagnostic challenges. Traditionally, nerve conduction studies and electromyography have been the primary diagnostic tools used to diagnose CTS. Given the superficial nature of the ulnar groove and its adjacent structures, MSK-US imaging known for its non-invasive nature and high-resolution imaging capabilities, has become an increasingly valuable tool in the assessment and management of various musculoskeletal conditions. This article reviews the technical aspects of MSK-US, its advantages in visualizing the ulnar nerve and related structures, and its implications in clinical practice for rehabilitation providers. By integrating MSK-US in the evaluation of CTS, rehabilitation professionals can enhance diagnostic accuracy, tailor interventions, and improve patient outcomes.

Volumetric assessment of ulnar nerves in cubital tunnel syndrome with 3D modeling of the MRI and its relationship with electrodiagnostic findings.

BACKGROUND: Thickened nerve cross-sectional areas (CSA) have been investigated in compressive neuropathy, but the longitudinal extent of nerve swelling has yet to be evaluated. We did a volumetric assessment of the ulnar nerve in cubital tunnel syndrome (CuTS) with three-dimensional (3D) magnetic resonance imaging (MRI) modeling and investigated this relationship with clinical and electrodiagnostic parameters. METHODS: We compared 40 CuTS patient elbow MRIs to 46 patient elbow MRIs with lateral elbow epicondylitis as controls. The ulnar nerve was modeled with Mimics software and was assessed qualitatively and quantitatively. The CSA and ulnar nerve volumes were recorded, and the area under the receiver operating characteristic (ROC) curve was calculated for diagnostic performance. We analyzed clinical and electrodiagnostic parameters to investigate their relationship with the 3D ulnar nerve parameters. RESULTS: For the diagnosis of CuTS, the area under the curve value was 0.915 for the largest CSA and 0.910 for the volume in the ROC curve. The optimal cut-off was 14.53 mm2 and 529 mm3 respectively. When electrodiagnostic parameters were investigated, the 3D ulnar nerve volume was significantly inversely associated with motor conduction velocity, although there was no association between the largest CSA and any of the electrodiagnostic parameters. CONCLUSIONS: The 3D ulnar nerve volume, which is an integration or multilevel measurement of CSAs, showed diagnostic usefulness similar to CSA, but it correlated better with conduction velocity, indicating demyelination or early-to-moderate nerve damage in CuTS.

The anatomical variations of the cubital tunnel in a South African body donor sample.

PURPOSE: The ulnar nerve (UN) courses through the cubital tunnel, which is a potential site of entrapment. Anatomical variations of the cubital tunnel may contribute towards cubital tunnel syndrome (CuTS), however, these are not well described. The aim was to compare the range of variations and dimensions of the cubital tunnel and the UN between sexes and sides of the body. METHODS: Sixty elbows from 30 embalmed bodies (17 males and 13 females) were dissected. The prevalence of the cubital tunnel retinaculum (CuTR) or anconeus epitrochlearis (AE) forming the roof of the tunnel was determined. The length, width, thickness, and diameter of the cubital tunnel and its roof were measured. The diameter of the UN was measured. RESULTS: The AE was present in 5%, whereas the CuTR was present in the remaining 95% of elbows. The tunnel was 32.1 ± 4.8 mm long, 23.4 ± 14.2 mm wide, 0.18 ± (0.22-0.14) mm thick, and the median diameter was 7.9 ± (9.0-7.1) mm, while the median diameter of the UN was 1.6 ± (1.8-1.3) mm. The AE was thicker than the CuTR (p < 0.001) and the UN was larger in elbows with the AE present (p = 0.002). The tunnel was longer in males (p < 0.001) and wider on the right (p = 0.014). CONCLUSION: The roof of the cubital tunnel was more frequently composed of the CuTR. The cubital tunnel varied in size between sexes and sides. Future research should investigate the effect of the variations in patients with CuTS.

Round table discussion: the management of idiopathic cubital tunnel syndrome.

Idiopathic cubital tunnel syndrome is the second most common neuropathy in the upper limb. Best evidence regarding the surgical management of this condition has evolved from anterior or submuscular transposition as the former reference standard, to in situ simple release. Differences of opinion remain regarding the timing of surgery, type of surgery and adjunctive surgery. Four surgeons with Level 5 expertise were asked to answer specific questions regarding this condition.

Effectiveness of chitosan phonophoresis on ulnar nerve conduction velocity, pain relief, and functional outcomes for mild to moderate cubital tunnel syndrome: A double-blind randomized controlled trial.

BACKGROUND: Cubital tunnel syndrome (CBTS) impairs hand function, with limited conservative options often leading to surgery. Chitosan neuroregenerative effects delivered via phonophoresis provide a rationale for testing this emerging treatment approach. PURPOSE: The primary goal of this research was to assess the impact of chitosan phonophoresis on the conductivity of the ulnar nerve, as well as its effects on pain levels and functional outcomes in individuals diagnosed with mild to moderate CBTS. STUDY DESIGN: Double-blind randomized controlled trial. METHODS: This was a prospective, double-blinded, randomized controlled study. The participants consisted of 54 individuals aged between 20-35 years who were randomly assigned using block randomization. The control group (n = 27) received standard hand therapy alone, while the experimental group (n = 27) received both standard hand therapy and chitosan phonophoresis. Both groups underwent three treatment sessions per week, each lasting for 60-72 minutes, over a period of five weeks. Pre- and post-intervention evaluations included assessments of ulnar nerve conduction velocity (NCV), pain assessment using the numerical pain rating scale (NPRS), as well as hand function evaluated using the Quick Disabilities of Arm Shoulder Hand (QuickDASH) questionnaire. RESULTS: After the intervention, the experimental group significantly improved in all outcome measures compared to the control group. Accordingly, ulnar NCV (MD = 2.233 m/sec; CI = 1.63:2.83; p < 0.001; η2p = 0.516), NPRS (MD = -1.11; CI = -1.71: -0.50; p < 0.001; η2p = 0.208) and QuickDASH (MD = -2.72; CI = -4.54:0.87; p < 0.007; η2p = 0.133). CONCLUSIONS: The study findings suggest that chitosan phonophoresis may have the potential as a supplementary treatment to hand therapy for individuals with mild to moderate CBTS. This approach demonstrated significant improvements in nerve conduction, pain reduction, and enhancement of hand function.

Surgical management of cubital tunnel syndrome: A systematic review and meta-analysis of randomised trials.

Background: Cubital tunnel syndrome (CUTS) is a common upper limb compression neuropathy with significant consequences when left untreated. Surgical decompression remains gold-standard treatment for moderate to severe disease, however the optimal operative technique remains unclear. This network meta-analysis (NMA) of Level I and II randomised prospective studies aims to discern superiority between open in-situ, endoscopic and anterior transposition (subcutaneous or submuscular techniques) with respect to the primary outcome of response-to-treatment and secondary outcomes which include complications, post-operative chronic pain VAS scale, return to work and re-operation. Methods: This NMA adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. PubMed, Web of Science, Cochrane Central, Science direct and Embase were searched. The MESH database was further searched with the terms 'cubital tunnel' to improve sensitivity of the search. Data pertaining to the primary and secondary outcomes were pooled for NMA. Results: Following abstract and full-text screening, 10 randomised prospective trials were included. There was no statistical difference in the response-to-treatment between the four studied techniques. Endoscopic decompression conferred a significantly higher complication rate compared to open decompression (Odds Ratio [OR], 4.21; 95% CI, 1.22-14.59). Endoscopic decompression had a statistically significant lower risk of post-operative chronic pain compared to open in-situ decompression (OR, 0.03, 95% CI, 0.00-0.32). There were no differences between techniques with respect to return to work or re-operation rates. Conclusion: Response-to-treatment was similar between the four operative techniques for CUTS. Endoscopic decompression was found to be more hazardous when compared to open-in situ decompression but conferred significantly less post-operative chronic pain. There was significant heterogeneity in reported outcomes between the included articles. The authors suggest conducting more high-quality research with standardised outcome reporting to facilitate comparison. Level of evidence ii: Systematic Review and Meta-analysis of Randomised Prospective Trials- Therapeutic study.

On the Physiology of the Sensory-Collapse Test.

The sensory-collapse test (formerly the scratch-collapse test) is a physical examination finding describing a momentary inhibition of external shoulder rotation following light stimulation of an injured nerve in the ipsilateral limb. Similar to other physical examination tests designed to interrogate nerve compression, such as the Phalen or Tinel tests, its test characteristics demonstrate variation. There remains speculation about the test's existence and anatomic basis. The literature of mammalian reflex physiology was reviewed with an emphasis on the sensory pathways from the upper extremity, the extrapyramidal system, and newly discovered pathways and concepts of nociception. A clear reflex pathway is described connecting the stimulus within an injured nerve through the afferent pathways in the fasciculus cuneatus in the spinal cord directly to the lateral reticulospinal tract, resulting in the inhibition of extensor muscles in the proximal limb (eg, shoulder) and activation of the limb flexors by acting upon alpha and gamma motor neurons. The sensory-collapse test represents a reflex pathway that teleologically provides a mechanism to protect an injured nerve by withdrawal toward the trunk and away from the noxious environment.

The Unpredictable Ulnar Nerve-Ulnar Nerve Entrapment from Anatomical, Pathophysiological, and Biopsychosocial Aspects.

Peripheral nerves consist of delicate structures, including a rich microvascular system, that protect and nourish axons and associated Schwann cells. Nerves are sensitive to internal and external trauma, such as compression and stretching. Ulnar nerve entrapment, the second most prevalent nerve entrapment disorder after carpal tunnel syndrome, appears frequently at the elbow. Although often idiopathic, known risk factors, including obesity, smoking, diabetes, and vibration exposure, occur. It exists in all adult ages (mean age 40-50 years), but seldom affects individuals in their adolescence or younger. The patient population is heterogeneous with great co-morbidity, including other nerve entrapment disorders. Typical early symptoms are paresthesia and numbness in the ulnar fingers, followed by decreased sensory function and muscle weakness. Pre- and postoperative neuropathic pain is relatively common, independent of other symptom severity, with a risk for serious consequences. A multimodal treatment strategy is necessary. Mild to moderate symptoms are usually treated conservatively, while surgery is an option when conservative treatment fails or in severe cases. The decision to perform surgery might be difficult, and the outcome is unpredictable with the risk of complications. There is no consensus on the choice of surgical method, but simple decompression is relatively effective with a lower complication rate than transposition.

Post-traumatic recurrent ulnar nerve dislocation at the elbow: a rare case report.

Introduction and importance: Several authors have also made reference to a less prevalent condition known in elbow as ulnar nerve subluxation. However, this particular condition tends to manifest primarily in young individuals who engage in professional sports or activities involving extensive use of the forearm. A more severe form of ulnar nerve subluxation, which is ulnar nerve dislocation, gives rise to a characteristic dislocation and relocation of the nerve at the elbow during flexion and extension of the forearm. Due to the rarity of this condition in clinical settings and its predominant occurrence as subluxation in younger patients, there are instances where traumatic ulnar nerve dislocation can be overlooked and misdiagnosed with two commonly encountered pathological conditions as ulnar nerve entrapment or medial epicondylitis. Case presentation: The authors present a 51-year-old male with chronic pain when moving his right forearm following a fall that caused a direct force injury to his elbow. The patient was misdiagnosed and treated as medial epicondylitis and early-stage ulnar nerve entrapment. However, the symptoms did not improve for a long time. The authors performed the ulnar nerve anterior transposition surgery using the subcutaneous transposition technique and the result is very good without any pain. Clinical discussion: The ulnar nerve can naturally be subluxed or dislocated if Osborne's ligament is loose or when there are anatomical variations in the medial epicondyle. In some case, this ligament can be ruptured by trauma. The symptoms of ulnar instability are caused by friction neuritis. Dynamic ultrasound of the ulnar nerve in two positions show clearly this condition. Conclusion: Post-traumatic ulnar nerve dislocation is a rare condition, and the recurrent characteristic of it leads to neuritis or neuropathy. The condition can be overlooked or misdiagnosed as medial epicondylitis or early-stage ulnar nerve entrapment. The nerve transposition surgery will give good result.

Risk Factors for Rescue Opioid Prescription After Cubital Tunnel Surgery.

BACKGROUND: Concerns regarding the ongoing opioid epidemic have led to heightened scrutiny of postoperative opioid prescribing patterns for common orthopedic surgical procedures. This study investigated patient- and procedure-specific risk factors for additional postoperative opioid rescue prescriptions following ambulatory cubital tunnel surgery. METHODS: A retrospective review was performed of patients who underwent cubital tunnel surgery at 2 academic medical centers between June 1, 2015 and March 1, 2020. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was postoperative rescue opioid prescription. Univariate and bivariate statistical analyses were performed. RESULTS: Two hundred seventy-four patients were included, of whom 171 (62%) underwent in situ ulnar nerve decompression and 103 (38%) underwent ulnar nerve decompression with anterior transposition. The median postoperative opioid prescription amount was 90 morphine equivalent units (MEU) for the total cohort, 77.5 MEU for in situ ulnar nerve decompression, and 112.5 MEU for ulnar nerve decompression with transposition. Twenty-two patients (8%) required additional rescue opioid prescriptions postoperatively. Female sex, fibromyalgia, chronic opioid use, chronic pain diagnosis, and recent opioid were associated with the need for additional postoperative rescue opioid prescriptions. CONCLUSIONS: While most patients do not require additional rescue opioid prescriptions after cubital tunnel surgery, chronic pain patients and patients with pain sensitivity syndromes are at risk for requiring additional rescue opioid prescriptions. For these high-risk patients, preoperative collaboration of a multidisciplinary team may be beneficial for developing a perioperative pain management plan that is both safe and effective.

Compression of the Ulnar Nerve by the Arcade of Struthers: Look and You Shall Find.

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.

Anterior transposition and positioning via helix sling method in cubital tunnel syndrome: An open-label, retrospective trial of maximum 5-year follow-up.

Background: Ulnar nerve transposition is used for cubital tunnel syndrome (CuTS) with nerve instability. The aim is to report a modified technique for ulnar nerve transposition using medial intermuscular septum and Osborne's ligament as a double-strand helix sling to recreate a sliding channel for the ulnar nerve and the functional outcomes at follow-ups. Methods: Twenty-five patients with persistent CuTS underwent nerve release and subcutaneous transposition from January 2017 to January 2022 in our institute. Among them, 9 patients were excluded due to incomplete medical records, lack of follow-up history, or bilateral limb numbness. The medial intermuscular septum with one end attached was excised to rebuild a tension-free double-strand helix sling by anchoring at the residue of Osborne's ligament. The modified Mc-Gowan classification was applied to evaluate the disease severity preoperatively. The quick disability of arm and shoulder and hand (quickDASH) questionnaire and visual analogue scale (VAS) scores were used to evaluate pre- and postoperative symptoms. Ultrasound imaging was utilized for nerve structure evaluation before surgery and at follow-ups. Results: Sixteen out of twenty-five patients received follow-ups postoperatively (ranging from 9 to 69 months, 36 months in average). No findings indicated subluxation of ulnar nerve or recompression by ultrasound imaging examination. According to quickDASH and VAS scores and physical examination, 14 out of 16 patients showed postoperative improvement in symptoms and function at final follow-ups. Interpretation: In this modified technique, the medial intermuscular septum and Osborne's ligament can create tension-free helix sling for stable and smooth sliding and preventing subluxation after nerve transposition, which is highly effective and safe for CuTS treatment.