Compression du nerf ulnaire au coude et paraostéoarthropathie neurogène : à propos de cinq cas

Aim

Heterotopic ossification (HO) is common in head-injured patients. Ulnar nerve compression by HO at the elbow is rare. The purpose of this study was to establish a strategy for the management of ulnar nerve compression secondary to HO at the elbow.

Patients and methods

The authors report a retrospective study (2000-2008) of five cases of ulnar nerve compression at the elbow secondary to HO. All patients were male (mean age, 33 years). The HO was secondary to head injury (four cases) and severe burn (one case). According to the Dellon's classification, the ulnar nerve entrapment was severe in two cases and moderate in three. The elbow was ankylosed; the flexion deformity ranged from 60° to 120°. Only in one case was nerve decompression performed before HO maturation. In the other cases, elbow release and nerve decompression were done at the same time, when maturation of HO was achieved. Postoperative outcome assessment was based on the Kleiman and Bishop's score.

Results

At 4 years of follow-up, the neurolysis result was excellent in one case, good in three cases, and poor in one.

Conclusion

It seems that HO is not the direct cause of ulnar nerve compression, but its impairment may be increased by the nerve tension and elbow fixation that it causes. When HO is mature, neurolysis can be combined with elbow release. However, when HO maturation is not achieved early neurolysis associated with anterior transposition should be done without elbow release.     

Comparative outcomes of ulnar nerve transposition versus neurolysis in patients with entrapment neuropathy at the cubital tunnel: a 20-year analysis

Background

Entrapment neuropathy of the ulnar nerve at the level of the elbow is the shared domain of multiple surgical specialties. A wide variety of operative methods for its surgical management have been reported. Our hospital utilizes neurolysis (NL) and subcutaneous transposition (AST). The aim of this paper was to compare the clinical outcomes in patients treated by ulnar nerve transposition versus neurolysis over a 20-year period.

Methods

We included patients who underwent either neurolysis or an ulnar nerve transposition. A retrospective analysis was performed which included 480 patients at our institution between January 1992 and December 2012. In total, physical and electronic records for 480 patients were reviewed. Three-hundred and one underwent ulnar nerve transposition and 179 underwent ulnar nerve neurolysis .

Results

In the AST group 201/301 patients suffered from parasthesiae pre-operatively and 156/301 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 99/301 patients. At the 3-month follow-up appointment, 187/201 patients with parasthesiae and 113/156 patients with local pain had resolution of their symptoms. In the NL group 151/179 patients had parasthesiae pre-operatively and 126/179 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 56/179 patients. At the 3-month follow-up appointment, 141/151 patients with parasthesiae and 117/126 patients with local pain had resolution of their symptoms.

Conclusions

In cases of ulnar nerve compression at the cubital tunnel, both neurolysis and transposition are effective in improving clinical outcome. The only statistically significant advantage of neurolysis over transposition seems to be relief of localized elbow pain. We recommend neurolysis as the preferred procedure.     

Ultrasound-guided surgical treatment for ulnar nerve entrapment: A cadaver study

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

The effect of operative technique on ulnar nerve strain following surgery for cubital tunnel syndrome

Background

The aim of this study is to compare the amount of strain on the ulnar nerve based on elbow position after in situ release, subcutaneous transposition, submuscular transposition, and medial epicondylectomy.

Methods

Six matched cadaver upper extremity pairs underwent ulnar nerve decompression, transposition in a sequential fashion, while five elbows underwent medial epicondylectomy. A differential variable reluctance transducer (DVRT) was placed in the ulnar nerve. An in situ release, a subcutaneous transposition, and a submuscular transposition were performed sequentially with the strain being measured after each procedure in neutral, full elbow flexion, and extension positions. The strain was then averaged and compared for each procedure. Five cadavers underwent medial epicondylectomy and were similarly tested.

Results

After the in situ release, there was no statistically significant change in strain in either flexion or extension. After a subcutaneous transposition, there was a statistically significant decrease in strain in full elbow flexion but not in extension. Similarly after a submuscular transposition, there was a statistically significant decrease in strain in full flexion but not in extension. There was not a statistically significant change in strain with medial epicondylectomy.

Conclusion

An in situ release of the ulnar nerve at the elbow may relieve pressure on the nerve but does not address the problem of strain which may be the underlying pathology in many cases of ulnar neuropathy at the elbow (UNE). Transposition of the ulnar nerve anterior to the medial epicondyle addresses the problem of strain on the ulnar nerve. In addition, it does not create an increased strain on the ulnar nerve with elbow extension.     

重建钢板固定和尺神经前置治疗肱骨髁间骨折

目的评价AO重建钢板固定及常规尺神经前置治疗肱骨髁间骨折的疗效。方法1996年3月～2001年9月,手术治疗肱骨髁间骨折68例,随访资料完整43例,男28例,女15例;年龄18～65岁,平均41岁。开放性骨折7例,闭合性骨折36例。43例肱骨髁间骨折按AO/ASIF分型:C1型14例,C2型18例,C3型11例。行切开复位AO重建钢板内固定,并常规行尺神经前置。取肘后正中切口,经肱三头肌舌形瓣入路32例,经尺骨鹰嘴截骨入路6例,合并鹰嘴骨折经骨折端进入5例。术后早期行肘关节CPM功能锻炼。结果随访12～37个月,平均17.7个月。术后12～18周,骨折全部愈合。采用Aitken-Rorabeck评分系统进行疗效评定:优33例,良4例,可5例,差1例;优良率为86.1%。6例尺神经损伤均完全恢复,无一例发生迟发性神经麻痹。伤后4周出现异位骨化2例;肘内翻3°1例,但不影响肘关节的功能;切口感染3例。肘关节功能受限2例,其中1例伸屈为43°,另1例为62°。结论肱骨髁间骨折应及早解剖复位,尺神经前置能减少尺神经麻痹的发生,早期进行功能锻炼,有助于肘关节功能的恢复。     

肘部尺神经卡压症

目的 :探讨肘部尺神经卡压症的术式及并发症。方法 :8例采用单纯松解术 ,3 0例采用前置术 ,对所有病人从struths弓到屈指深肌腱膜进行探查松解 ,术中保护尺神经血供。结果 :尺神经在肘部多处可受到卡压 (平均 2 4处 )。随访平均 2 2个月 ,按 2 0 0 0年手外科学会周围神经功能评价标准评价 ,优良率 86 8%。神经卡压症状在1年内手术术后疗效好。结论 :手术对尺神经卡压的 5个部位都应进行探查、松解。根据不同的病例选择前置或单纯的松解术。     

Feasibility of a fascial flap to avoid anterior transposition of unstable Ulnar nerve: A cadaver study

BackgroundCompression of the ulnar nerve at the elbow is the second most frequent site of nerve compression in the upper limb. Upon release, anteposition of the nerve may be necessary to avoid dislocation of the latter when unstable. Numerous techniques are described in the literature (subcutaneous transposition, intramuscular transposition, subfascial transposition, medial epicondylectomy …), none of which is without complications. Based on Han's work, the authors propose a technique of covering the ulnar nerve with epicondylar fascial flap, avoiding transposition, but ensuring good stability of the ulnar nerve.MethodsAs part of the SICM (Italian Society of Hand Surgery) cadaver dissection course (ICLO, Verona, Italy) the authors dissected 36 elbows, of which 20 presented subluxation of the ulnar nerve after its decompression. The fascial flap was therefore made on these 20 elbows, coming from 14 different donors (9 men, 5 women) with an average age of 78 years. The diameter of the ulnar nerve was then measured (at the level of the passage in the cubital canal), the diameter of the newly formed canal, the difference between the two previous measurements (residual space in the flexed elbow canal), and it was verified whether the ulnar nerve was unstable once covered by the flap.ResultsThe mean diameter of the ulnar nerve was 5.1 mm (range 4–6), while the mean diameter of the neo-canal was 10.1 mm (range 8–11) in elbow extension and 8.9 mm (range 7–10) in elbow flexion. The remaining space in the flexed elbow canal was 3.8 mm (range 3–5).In none of the 20 cases the ulnar nerve was dislocated after having made the fascial flap.ConlusionsIn light of the results obtained, the authors think that the use of the epicondylar fascial flap may be a solution to keep in mind to avoid dislocation of the ulnar nerve when it becomes unstable following its decompression. This work obviously needs clinical confirmation on living patients.Level of evidenceV.     

Recurrent cubital tunnel syndrome. Etiology and treatment.

Controversy surrounds the treatment of recurrent cubital tunnel syndrome after previous surgery. Irrespective of the surgical technique, namely pure decompression in the ulnar groove and the cubital tunnel distal of the medial epicondyle, and the different methods of volar transposition (subcutaneous, intramuscular, and submuscular), the results of surgical therapy of cubital tunnel syndrome are often not favorable, especially in cases of long-standing symptoms and severe deficits. Twenty-two patients who had previously undergone surgical treatment for ulnar nerve entrapment at the elbow were evaluated because of persistent or recurrent pain, paresthesia, numbness, and motor weakness. Ten patients had undergone a nerve transposition, 5 patients underwent a simple decompression of the ulnar nerve, and 7 patients experienced two previous operations with different surgical techniques. Two patients underwent surgery at our hospital, whereas 20 patients underwent their primary surgery at other institutions. Various surgical techniques were used during the subsequent surgery, such as external neurolysis, subcutaneous anterior transposition, and subsequent transfer of the nerve back into the sulcus. The causes of continued or recurrent symptoms after initial surgery included dense perineural fibrosis of the nerve after subcutaneous transposition, adhesions of the nerve to the medial epicondyle and retention of the medial intermuscular septum. The average follow-up after the last procedure was 7 months (2 - 20 months). All 7 patients with subsequent transfer of the ulnar nerve back into the sulcus became pain-free, whereas only 11 of 15 patients who had external neurolysis or subcutaneous transposition became free of pain or experienced reduced pain. The recovery of motor function and return of sensibility were variable and unpredictable. In summary, reoperation after primary surgery of cubital tunnel syndrome gave satisfactory results in 18 of 22 cases. Subsequent transfer of the ulnar nerve back into the sulcus promises to be useful in cases in which subcutaneous transposition had not been successful.     

Failed surgery for ulnar nerve compression at the elbow

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

Surgical approaches for nonneurogenic elbow heterotopic ossification with ulnar neuropathy

BACKGROUND: Few reports are available concerning elbow heterotopic ossification (HO) and its optimal management in nonneurologic or nonburn patients after repetitive elbow manipulation. The unique anatomic relationship of the ulnar nerve at the elbow renders it rather vulnerable to injury when elbow HO occurs medially or posteromedially and extends into the vicinity of the cubital tunnel. METHODS: A total of 16 consecutive patients without neurologic injury were diagnosed with heterotopic ossification formation in the elbow and referred to the Upper Extremity Unit of Chang Gung Memorial Hospital. All 16 patients were diagnosed with ulnar palsy, and 14 were found to have sensory dysfunction and muscle wasting for an average of 5.2 months. RESULTS: Fourteen of 16 patients achieved functional range of motion or more after surgery. The final gain in range of motion averaged 80.3 degrees. All except one had complete neurologic recovery postoperatively. The patient who had ulnar palsy for 1 year presurgery did not achieve any neurologic recovery. CONCLUSION: Forceful and repetitive manipulation may add further damage to an already stiffened elbow and should be avoided in an elbow after immobilization or surgery. Early surgical resection of HO and ulnar nerve decompression followed by gentle and aggressive physical therapy terminate the vicious cycle and yield encouraging results.     

Compression neuropathy of the cubital nerve at the elbow]

Compression neuropathy of the ulnar nerve at the elbow has numerous known etiologies, and the anatomy of the ulnar nerve around the elbow leaves it vulnerable to compression at numerous sites. The compression may be extrinsic such as in occupational neuropathy or in cases of postanesthesia neuropathy. The so-called idiopathic compression may be favored by some anatomic variations. The cubital tunnel retinaculum may be loose, leading to ulnar nerve dislocation or subluxation or tight compression of the nerve during flexion of the elbow. Bulging of the synovium in the floor of the tunnel may be the cause of compression in rheumatoid arthritis, whereas osteophytes may be the cause in degenerative osteoarthritis. Cubitus valgus or instability due to a pseudarthrosis of the lateral epicondyle or to ligamentous injury may stretch the nerve. The choice of a surgical technique must be based on (i) the pathophysiology of chronic nerve compression at the elbow, (ii) an understanding of the etiology of the nerve compression in the particular patient's case, and (iii) the knowledge of the potential technical drawbacks of the various operative procedures. Simple decompression is the first choice in case of minimal compression without instability of the nerve. Decompression of the nerve with a medial epicondylectomy is indicated in case of instability of the nerve and is the first choice in case of pseudarthrosis or malunion of the medial epicondyle. Ulnar nerve transposition is technically the most demanding procedure. Inadequate surgical technique creates new sites of compression.(ABSTRACT TRUNCATED AT 250 WORDS)     

带尺侧下副动脉尺神经松解前置术治疗肘管综合征

目的 总结带尺侧下副动脉尺神经松解前置术治疗肘管综合征的手术方法及临床效果.方法 2005年9月-2006年5月,采用保留尺侧下副动脉在尺神经上的吻合支,行带血供尺神经松解前置术治疗25例肘管综合征.男19例,女6例:年龄20～72岁,平均60岁.发病至手术时间2个月～3年,平均6.7个月.发病原因:骨性关节炎23例,肘管内囊肿及尺神经滑脱各1例.术前按Pasque肘管综合征评分系统评定:可19例,差6例.电生理检查:肘关节周围尺神经运动神经传导速度<42 m/s.结果 术后切口均1期愈合,无手术并发症及复发患者.25例术后均获随访,随访时间1年～2年半,平均13.9个月.按Pasque肘管综合征评分系统评定:优15例,良9例,可1例,优良率96%;与术前评定结果比较,差异有统计学意义(P＜0.05).电生理检查;肘关节周围尺神经运动神经传导速度>42m/s.结论 带尺侧下副动脉尺神经松解前置术是治疗肘管综合征的安全有效方法之一.     

The management of complex distal humerus nonunion in the elderly by elbow capsulectomy, triple plating, and ulnar nerve neurolysis

Six elderly patients (average age, 68 years) were treated for a complex, low supracondylar nonunion of the humerus. Each nonunion had in common an associated ulnar neuropathy, extensive periarticular fibrosis, a low synovial nonunion, and osteopenic bone. The surgical approach included ulnar nerve neurolysis, complete elbow capsulectomy, three strategically placed plates, and autogenous iliac crest bone graft. All the nonunions healed and all six patients regained ulnar nerve function. The average arc of elbow motion was 102°, with an average flexion of 122° and a flexion contracture of 19°. Radiographic follow-up revealed only one case with a focal area of avascular necrosis involving a previously ununited intraarticular fracture of the trochlea.     

肘管综合征135例尺神经皮下前移术疗效分析

目的 随访肘管综合征135例尺神经皮下前移术治疗效果.方法 分析2002年2月一2005年12月,135例肘管综合征尺神经皮下前移患者的病情特点及效果.其中男109例,女26例,男女比例为4.2:1.41岁以上占68.1%.以手指活动笨拙就诊15例(占11%);电生理检测均有尺神经肘部段卡压征象.42例合并肘部骨折史.占病因的31%.135例均采用尺神经外膜松解,皮下前移术.结果 术后92例获得2-5年随访.平均2.5年;43例失访.按中华医学会手外科学会上肢功能评定标准,本组优72例,良12例,差8例,优良率为91.3%.结论 尺神经皮下前移术简单、有效,术中应保护前臂内侧皮神经、尺神经血供及分支,并确保尺神经无张力.应重视因肘部骨折和以手部活动笨拙为主要症状的早期诊治.     

Ulnar nerve entrapment due to heterotopic bone formation after a severe burn

Heterotopic bone formation occurs in approximately 2% of severe burns. It occurs most frequently about the elbow and is not related to the location of the burn. Although bony encasement of the ulnar nerve is frequently found, signs and symptoms of ulnar nerve compression due to heterotopic bone have not been previously reported. Early anterior transposition of the nerve is recommended to prevent progressive neurologic loss if compressive symptoms are found in the face of developing heterotopic bone.     

Ulnar nerve elongation and excursion in the cubital tunnel after decompression and anterior transposition

We studied the elongation and excursion of cadaveric ulnar nerves during elbow flexion in control conditions and after in situ decompression and anterior subcutaneous transposition. We found that the normal nerve had the greatest elongation (23%) and excursion (14 mm) in the epicondylar groove. Decompression did not alter the excursion, but significantly reduced the elongation in the groove (6%) and increased it proximally (19%). After anterior subcutaneous transposition, the nerve segment which was originally in the groove elongated with elbow extension to the same extent as occurred with the normal nerve during flexion.     

Subtotal medial epicondylectomy as a surgical option for treatment of cubital tunnel syndrome

Ulnar nerve compression at the elbow is commonly accepted as the second most frequent compressive peripheral neuropathy. The unique anatomic location of the ulnar nerve directly posterior to the medial epicondyle at the elbow places it at risk for injury. With normal motion of the elbow, the ulnar nerve is subjected to compression, traction, and frictional forces. Compression can occur at any of the 5 sites that begin proximally at the arcade of Struthers and end distally where the nerve exits the flexor carpi ulnaris in the forearm. Initial treatment of compressive neuropathy is nonoperative, usually consisting of rest, modification, and/or restriction of elbow or wrist movement. If symptoms persist, especially when accompanied by muscle weakness, surgery is usually indicated. Surgical options include decompression in situ, medial epicondylectomy, transposition of the ulnar nerve (subcutaneous, intramuscular, or submuscular), and/or a combination of these procedures. Careful decompression with a subtotal medial epicondylectomy is a valuable procedure that allows decompression at all levels with minimal risk of devascularizing the nerve or creating elbow instability.     

Technical problems with ulnar nerve transposition at the elbow: findings and results of reoperation

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.     

Cubital tunnel syndrome: anterior transposition as a logical approach to complete nerve decompression.

In it's native position, deep to Osborne's ligament, within the retrocondylar groove of the elbow, the ulnar nerve courses with a significant lever distance posterior to the elbow axis of rotation. In this position, flexion of the elbow places longitudinal traction and local compression forces on the nerve. This biomechanical consideration, as well as variations in anatomy, may potentially contribute to a decrease in the nerve's microcirculation and partial pressure of oxygen, leading to cubital tunnel syndrome. Anterior transposition of the ulnar nerve at the elbow for cubital tunnel syndrome will eliminate natural as well as pathological traction and compression forces; the procedure relieves the nerve of potential microcirculation compromise. Risks of mobilizing the nerve for transposition, however, include iatrogenic ischemia from segmental separation of the nerve from its mesentery-like extrinsic blood supply. Intrinsic interstitial "step-ladder" vessels within the substance of the ulnar nerve allow it to be separated from its extrinsic circulation safely, making anterior transposition a logical and reasonable choice for cubital tunnel syndrome requiring operative intervention.     

肘部尺神经的临床解剖学研究

目的：研究产生肘部尺神经卡压的解剖学基础。方法：观测５０侧成人尸体肘部尺神经的位置及被动屈肘时尺神经的伸长长度。临床调查并检测２００位正常人肘部尺神经的位置。结果：自肘部伸直位（０度）至完全屈肘位（１３５度），尺神经可拉长 ６．６％±０．３％（ｘ±ｓｘ自身对照，下同）；屈曲度大于 ９０度后，伸展性明显减少，为０．８％±０．１％。２００位正常人肘部尺神经半脱位发生率为９．５％（１９／２００）。结论：肘关节反复屈伸时尺神经不断被牵拉和压迫是造成肘部尺神经卡压的解剖学基础。