Tardy ulnar nerve palsy after fracture non-union medial epicondyle of humerus – An unusual case

Tardy ulnar nerve palsy is a chronic clinical condition characterised by delayed onset ulnar neuropathy. Typically tardy ulnar nerve palsy occurs as a consequence of non-union of lateral condyle in child resulting in cubitus valgus deformity which ultimately is the cause of ulnar nerve palsy. However very few literature are available for tardy ulnar nerve palsy as a result of old fracture of medial epicondyle without cubitus varus or valgus deformity. We report a rare case of tardy ulnar nerve in an adult male with fracture non-union of medial epicondyle of humerus.     

Management of lateral humeral condylar fracture in children

Lateral condylar fractures constitute 12% to 20% of all pediatric distal humerus fractures. These fractures are easily missed and when not managed appropriately can displace. Missed fracture is a common cause of nonunion and deformity; thus, a high index of suspicion and adequate clinical and radiographic evaluation are required. Displaced fractures are associated with a high rate of nonunion. Nondisplaced fractures or those displaced ≤2 mm are managed with cast immobilization and frequent radiographic follow-up. Fractures displaced >2 mm are managed with surgical fixation. Successful outcomes have been reported with closed reduction, open reduction, and arthroscopically assisted techniques. Complications associated with pediatric lateral condylar fracture include cubitus varus, cubitus valgus, fishtail deformity, and tardy ulnar nerve palsy.     

Long-standing nonunion of fractures of the lateral humeral condyle

BACKGROUND: Patients with nonunion of a fracture of the lateral humeral condyle often have pain, instability, or progressive cubitus valgus deformity with tardy ulnar nerve palsy. However, some patients have minimal or no symptoms or disabilities. We evaluated patients with long-standing established nonunion of the lateral humeral condyle to correlate the clinical long-term outcome of this condition with the original fracture type. METHODS: Nineteen elbows in eighteen patients who were at least twenty years of age were evaluated. Fourteen patients were male, and four were female. The average age at presentation was 42.5 years. The average interval from the injury to the presentation of the symptoms of the nonunion was thirty-seven years. Patients were divided into two groups on the basis of the size of the fragment and the location of the fracture line. Group 1 included nine elbows with nonunion resulting from a Milch Type-I injury, and Group 2 included ten elbows with a nonunion resulting from a Milch Type-II injury. Evaluations were performed with use of radiographic examination, clinical assessment, and calculation of the Broberg and Morrey score. RESULTS: Symptoms were seen more frequently in Group 1 than in Group 2. The range of flexion in Group 1 (range, 60 degrees to 145 degrees; average, 99 degrees) was more restricted than that in Group 2 (range, 100 degrees to 150 degrees; average, 129 degrees) (p = 0.0078). The functional score in Group 2 was significantly higher than that in Group 1 (p = 0.03). CONCLUSION: Disabling symptoms only rarely developed in Group-2 patients. Occasionally, however, these patients do present with clinically detectable dysfunction of the ulnar nerve. In contrast, pain, instability, and loss of range of motion as well as ulnar nerve dysfunction developed in Group 1. For this reason we think that a nonunion of a Milch Type-I fracture should be treated as soon as possible after injury, preferably before the patient reaches skeletal maturity.     

Tardy ulnar nerve palsy caused by cubitus varus deformity

Clinical features and X-rays of thirty-four cases with cubitus varus deformity were analysed in order to explain the occurrence of tardy ulnar nerve palsy caused by cubitus varus deformity. Cubitus varus cases with tardy ulnar nerve palsy, compared to cases without it, were older at the first visit to the clinic for cubitus varus deformity. There were no other differences between the two groups in clinical features. Computed tomography showed that the olecranon moved to the ulnar side against the olecranon fossa. Operative findings showed that the medial head of triceps brachii shifted medially and covered the ulnar nerve. Both from computed tomography and operative findings we conjectured the possibility that tardy ulnar nerve palsy was caused because the ulnar nerve was compressed by the forward medial movement of the medial head of the triceps brachii caused by cubitus varus deformity.     

Ununited fracture of the lateral condyle of the humerus. A 50 year follow-up

This is a case report of a 74-year-old man with an ununited fracture of the lateral condyle of the humerus of 50 years duration. There was minimal loss of motion, a moderate cubitis valgus deformity, and a definite ulnar nerve palsy. Despite the deformity and ulnar palsy, he was able to provide for himself and to perform satisfactorily as a laborer.     

Nonunion of the lateral humeral condyle--operative treatment, case report]

The nonunion of the lateral humeral condyle is the most important complication in course of the treatment of the fractures lateral humeral condyle. The cause of the occurrence is the articular liquid penetration to the fracture site, minor blood supply of the fractured fragment based only on the vessels penetrating from the metaphysis, insufficient immobilization period and fragment relocation. The operative treatment of a condyle nonunion previously was performed cautiously because of the high risk of the condyle necrosis and the mild nature of the deformity. The elbow with nonunion condyle is usefull and satisfactory even after bringing increasing valgus deformity and a high risk of the ulnar nerve neuropathy into consideration. A 7-YEAR-old boy with a condyle nonunion was treated operationaly. Operative procedure shouldn,t be prolonged for more than a year after the trauma because of the increased deformity and condyle remodelling. A Tahdjian technique was used. The operation focused on an intraarticular approach with an olecranon ostotomy for the avoidance of the vessels penetrating from the condyle metaphysis. After debridgement and cortical grafts filling of the nonunion site a Kirschner fixation combined with olecranon wire loop fixation were performed. Satisfactory results were achieved in a form of fragments union within six weeks of the surgery and the total range of motion of the elbow joint within 6 months of the operation. During the treatment no signs of the neurovascular complications were observed.     

儿童肱骨外髁骨折骨不连的治疗

目的 探讨儿童肱骨外髁骨折骨不连的治疗方法.方法 对13例肱骨外髁骨折骨不连进行诊治.患几年龄平均10.5岁(6～14岁),受伤至就诊时间平均6.7年(0.9～10年).其中Milch Ⅰ型3例(X线片表现为肱骨外髁骨块较小、桡骨小头呈圆形、肱骨小头凹陷),Milch Ⅱ型10例(X线片表现为肱骨外髁骨块较大、肱桡关节结构近似正常).13例中行单纯骨折切开复位内固定术1例,游离髂骨植骨内固定术3例,游离髂骨植骨内固定+尺神经松解前置术1例,游离髂骨植骨内固定+肱骨髁上楔形截骨术5例,游离髂骨植骨内固定+肱骨髁上楔形截骨+尺神经松解前置术3例.结果 术后随访时间平均为5.6年(2.2～12年).除2例患者骨延迟愈合外,其余患者均达到骨愈合.术前疼痛症状及肘关节不稳消失.患手握力恢复至健侧的87%(84%～100%).3例肘关节屈伸活动度得到明显改善.平均改善47.7°(30°～58°);2例肘关节屈伸活动度无明显改善;8例肘关节屈伸活动度与术前相比有所下降,平均下降16°(8°～30°).13例中除2例肘外翻角度增加和2例继发肘内翻外,其余9例提携角平均下降14.2°.按Broberg肘关节功能评分系统评定:优7例,良6例;优良率为100%.结论 儿童肱骨外髁骨折骨不连可行外科手术治疗,骨折切开复位、植骨内固定术是确实且有效的治疗方法.     

Cubitus valgus and tardy ulnar nerve palsy due to an intracapsular ulnar nerve

Background

We describe a patient with tardy ulnar neuropathy and cubitus valgus deformity found to have an intracapsular ulnar nerve.

Methods

An 89-year-old woman presented with severe neuropathic pain in the ulnar digits of the hand, advanced degenerative arthritis of the elbow, and tardy ulnar nerve palsy. Her pain was exacerbated with elbow movement, particularly flexion. She had paralysis of ulnar nerve innervated muscles, hypersensitivity with absence of two-point discrimination in her ulnar 1–1/2 digits, and a fixed ulnar claw deformity. She also had a grossly unstable elbow.

Results

Plain films revealed a cubitus valgus deformity (38°), an absent radial head, a dislocated proximal radioulnar joint and advanced arthritic changes. Ultrasonography revealed an indistinct ulnar nerve within the cubital tunnel which penetrated the joint. Electrophysiological studies revealed evidence of a severe ulnar neuropathy at the level of the elbow. Intraoperatively, an attenuated 2 cm length of the retrocondylar ulnar nerve was observed to be incorporated into the joint capsule tethered by a fibrous/synovial band which was released. A large effusion was drained. The ulnar nerve was transposed subcutaneously. The capsular rent was repaired in layers. She noted immediate and sustained (2 year follow-up) pain relief and regained moderate function in her interossei.

Conclusions

We believe that the chronic cubitus valgus deformity and secondary degenerative elbow joint changes led to an altered course of the nerve and attenuation of the medial joint capsule such that the ulnar nerve spontaneously buttonholed itself intra-articularly.     

Failure of active extension after traumatic cubitus varus. A case report

In children cubitus varus is common after malunion of a supracondylar fracture of the humerus. Later problems such as tardy ulnar nerve palsy, snapping of the lateral triceps tendon or ulnar nerve and posterolateral rotatory instability are well documented. We present a case of anteromedial dislocation of the entire triceps tendon with loss of extensor power and describe the method of treatment.     

Three-dimensional corrective osteotomy for cubitus varus in adults

In 23 adult patients, cubitus varus deformity was corrected by 3-dimensional osteotomy. During surgery, not only varus but internal rotation, flexion-extension deformity of the elbow, and lateral protrusion of the distal fragment were simultaneously addressed. The mean age of the patients was 26 years. Three showed tardy ulnar nerve palsy. The follow-up period after osteotomy averaged 1 year 10 months. The humeral-elbow-wrist angle improved from a mean 26 degrees of varus preoperatively to a mean of 3 degrees of valgus postoperatively. The mean internal rotation angle improved from 25 degrees to 5 degrees. As there was no recurrence of the deformity, this method of 3-dimensional corrective osteotomy for the treatment of cubitus varus in skeletally mature adults is recommended.     

Tardy ulnar nerve palsy in cubitus varus deformity associated with ulnar nerve dislocation in adults

Seven patients with tardy ulnar nerve palsy from a posttraumatic cubitus varus deformity were reviewed retrospectively. The severity of symptoms was grade I in 3 patients and grade II in 4 patients according to McGowan's classification. The mean internal rotation angle was 30.7 degrees (range, 25 degrees -45 degrees ). The most prominent feature was dislocation of the nerve anterior to the medial epicondyle and entrapment of the nerve by the fibrous band of the flexor carpi ulnaris muscle. Of these 7 patients, 4 were treated by 3-dimensional osteotomy with ulnar nerve transposition, and 3 were treated by anterior transposition of the ulnar nerve. All patients improved clinically, and there was no significant difference between anterior transposition of the nerve in the group with osteotomy and the group without osteotomy. Ulnar nerve instability due to internal rotation deformity and distal entrapment was considered to be the main cause of neuropathy.     

Electrophysiological diagnosis in ulnar nerve entrapment at elbow

Using "inching technique" we recorded antidromic sensory nerve action potentials from the little finger and compound muscle action potentials from the abductor digiti minimi, first dorsal interosseous and flexor carpi ulnaris muscles in 30 entrapped ulnar nerves. In cubital tunnel syndrome, localized conduction delay occurred most commonly at a point 2 to 4 cm distal to the medial epicondyle. In other ulnar neuropathies, with the exception of cubitus valgus deformity, conduction block or delay was noted at a site just distal to the medial epicondyle. These conduction abnormalities were most commonly observed in the abductor digiti minimi and first dorsal interosseous. In contrast, conduction abnormality in tardy palsy secondary to the valgus deformity reflected mainly in the flexor carpi ulnaris. This method provides useful information in diagnosing the early involvement and precise localization of nerve entrapment, and differentiation of cubital tunnel syndrome from other ulnar nerve entrapment.     

Endoscopic Anterior Transposition of Ulnar Nerve (EATUN) for Treatment of Tardy Ulnar Nerve Palsy

BackgroundTardy ulnar nerve palsy is the development of late onset ulnar nerve dysfunction and is usually treated by open anterior transposition of ulnar nerve. Open technique is done using a longitudinal incision about 6–8 inch. in length with chances of development of medial antebrachial cutaneous nerve neuromas.PurposeIn this study, we describe the technique of Endoscopic Anterior Transposition of Ulnar Nerve (EATUN procedure) to treat tardy ulnar nerve palsy and analyze the results.MethodsSeven patients diagnosed to have tardy ulnar nerve palsy was treated by EATUN. The humerus-elbow-wrist angle (HEW), pre- and post-operative intrinsic muscle power and sensory assessment, Dellon scores, and the Q-DASH was analyzed.ResultsThe minimum follow-up was 12 months (Mean 27.4 months, Range 12–36 months). Improvement in Dellon and Q-DASH scores following EATUN procedure was statistically significant. There was objective improvement of intrinsic muscle power and sensation on follow-up, though not statistically significant. No instance of neuroma of the medial cutaneous nerve of forearm was noted.ConclusionsThe endoscopic anterior transposition of the ulnar nerve is a good option in surgical management of tardy ulnar nerve palsy.Level of evidenceTherapeutic Level IV.Supplementary InformationThe online version contains supplementary material available at 10.1007/s43465-021-00366-w.     

Management of cubitus varus and valgus

BACKGROUND: Many types of osteotomy have been proposed for the treatment of cubitus varus and valgus, but they have limitations, such as poor internal fixation, residual protrusion of the lateral or medial condyle, technical difficulty, the need for long-term immobilization, a risk of neurovascular injury, and patient discomfort. We reviewed the results of a simple step-cut translation osteotomy that overcomes these limitations. METHODS: Between 1993 and 2002, we treated nineteen cases of cubitus varus and thirteen cases of cubitus valgus with use of a simple step-cut translation osteotomy and fixation with a Y-shaped humeral plate. After surgery, the patients were observed closely for more than one year. We compared preoperative and postoperative humerus-elbow-wrist angles, ranges of motion, and lateral or medial prominence indices for all patients. The results were evaluated according to the modified criteria of Oppenheim et al. The presence of tardy ulnar nerve palsy and its duration, and postoperative lazy-s deformity or unsightly scarring, were also noted. RESULTS: There were twenty-six excellent and six good results. In the nineteen patients with cubitus varus, the average amount of correction of the humerus-elbow-wrist angle was 26.0 degrees , to a mean postoperative angle of 8.6 degrees , and the average increase in the lateral prominence index was 8.2%. In the thirteen patients with cubitus valgus, the average correction in the humerus-elbow-wrist angle was 27.6 degrees , resulting in a final angle of 9.1 degrees , and the average increase in the medial prominence index was 11.9%. In all patients, the desired range of motion, good alignment, and complete union of the bone were achieved. CONCLUSIONS: Step-cut translation osteotomy, with a wedge-shaped osteotomized surface, fixed with a Y-shaped humeral plate is a relatively simple procedure resulting in very firm fixation that allows early movement of the joint with good clinical results.     

Ulnar nerve palsy after supracondylar humerus fracture

Six patients with cubitus varus deformity after a supracondylar fracture of the humerus had ulnar nerve palsy 7 (3-14) years following the fracture. All the patients showed anterior dislocation of the ulnar nerve during elbow flexion. In cubitus varus deformity, medial shifting of the triceps muscle occurs, which pushes the ulnar nerve anteriorly and frequently causes ulnar-nerve dislocation. Five of the 6 patients under-went surgery with subsequent improvement.     

Ulnar nerve palsy after supracondylar humerus fracture

Six patients with cubitus varus deformity after a supracondylar fracture of the humerus had ulnar nerve palsy 7 (3-14) years following the fracture. All the patients showed anterior dislocation of the ulnar nerve during elbow flexion. In cubitus varus deformity, medial shifting of the triceps muscle occurs, which pushes the ulnar nerve anteriorly and frequently causes ulnar-nerve dislocation. Five of the 6 patients underwent surgery with subsequent improvement.     

A systematic review of medial and lateral entry pinning versus lateral entry pinning for supracondylar fractures of the humerus

The supracondylar fracture of the distal humerus is the most common pediatric fracture in the elbow. This systematic review summarizes the existing data about the effect of medial and lateral (medial/lateral) entry pins versus only lateral entry pin fixation on the risk of iatrogenic nerve injury and deformity or loss of reduction. A literature search identified clinical trials and observational studies presenting the probability of nerve injury and/or deformity or loss of reduction associated with closed reduction and either medial/lateral entry or lateral entry pinning of supracondylar fractures in pediatric patients. Data from 2054 children were identified from 35 studies; 2 randomized trials, 6 cohort studies, and 25 case series. For operative fixation with medial/lateral entry pins, the probability of ulnar nerve injury is 5.04 times higher than with lateral entry pins. When all documented operative nerve injuries are included, the probability of iatrogenic nerve injury is 1.84 times higher with medial/lateral entry pins than with isolated lateral pins. Medial/lateral pin entry provides a more stable configuration, and the probability of deformity or loss of reduction is 0.58 times lower than with isolated lateral pin entry. When the prospective studies alone were analyzed, there were no significant difference in the probability of iatrogenic nerve injury or deformity and displacement, although the confidence intervals were wide. This systematic review indicates that medial/lateral entry pinning, of pediatric supracondylar fractures, remains the most stable configuration and that care needs to be taken regardless of technique to avoid iatrogenic nerve injury and loss of reduction.     

Conservative Treatment with Active Exercises in Osteoarthritis of the Hip

Six patients with cubitus varus deformity after a supracondylar fracture of the humerus had ulnar nerve palsy 7 (3–14) years following the fracture. All the patients showed anterior dislocation of the ulnar nerve during elbow flexion. In cubitus varus deformity, medial shifting of the triceps muscle occurs, which pushes the ulnar nerve anteriorly and frequently causes ulnar-nerve dislocation. Five of the 6 patients under-went surgery with subsequent improvement.     

Medial approach for corrective osteotomy of cubitus varus: a cosmetic incision

Osteotomies described previously to correct cubitus varus had been associated with unsatisfactory results such as a prominent lateral scar and condyle and injury to the triceps. The authors evaluated the results of a medial approach for the corrective osteotomy of 14 consecutive children (mean age 8.4 years) with cubitus varus. The incision was made medially and the ulnar nerve was identified and protected. An image intensifier was used to identify the wedge. Lateral closing wedge osteotomy was performed and secured with cross K-wires, and the distal fragment was translated medially to reduce the lateral prominence. Both hyperextension and internal rotation deformity could be corrected with the osteotomy. The mean carrying angle and hyperextension of the elbow of 19.3 degrees varus and 22.2 degrees were corrected to 2.4 degrees valgus and 8.8 degrees respectively. Radiographically, the Baumann's angle and the flexion angle were improved from 90.1 degrees to 77.3 degrees and 24.2 degrees to 37.2 degrees respectively. No patient had a prominent lateral condyle, and the operative scars were well concealed along the medial aspect of the elbow. There was one case of transient ulnar nerve paresis with residual varus.