肘部尺神经滑脱

通过流行学调查和病理解剖观察，提示尺神经滑脱可能与组织结构发育缺陷有关，如肱骨内上踝较小，肘管三角韧带及尺神经系膜松驰等。男女之间尺神经滑脱发生率有显著性差异。肘部尺神经滑脱并非少见，临于尺神经滑脱者发生肘部尺神经损害的危险性较一般人群高，一旦尺神经损害其所支配的已挛缩的手内在肌很难恢复，尺神经滑脱者值得人们注意 肘部尺神经损害的易感人群，因尺神经滑脱者除上述结构缺陷外，更重要的是尺神经滑脱过程为     

迟发性尺神经炎

迟发性尺神经炎Ｐａｎａｓ１８７８年首先报导。尺神经的应用解剖包括神经走行、肘管结构、神经内结构及内压、肘部动态解剖学，均与发病有关。手术发现亦相符。临床表现发病缓慢、病程长，出现尺神经受损症状与体征。治疗以早期手术为妥。手术包括髁上截骨短正肘部畸形，加深尺神经沟、神经松解、前移、内上髁切除等。尺神经前移优于松解术，而肱骨内上髁切除，神经无再受压之虞，效果更优越。     

外伤性肘关节外翻畸形

１９６３～１９９５年我所共收治外伤性肘关节外翻畸形３０例。肘部损伤时年龄２～２１岁，平均８．１岁，其中儿童２８例，占９３．３％。肘部损伤为肱骨外髁骨折１９例，肱骨髁上骨折８例，肱骨内髁骨折１例，桡骨头脱位２例。肘关节提携角２０°～４５°，平均２８．７°。合并创伤性尺神经炎２２例，肘关节创伤性关节炎１１例。２２例创伤性尺神经炎均做了神经松解前移术，其中２０例平均随访６年４个月，优良率为８５％。７例做肱骨髁上截骨术，平均随访７年１１月，肘关节外观及功能满意。作者认为，肘部损伤（尤其是儿童肘部损伤）的延误诊治、复位固定不良和骨骺损伤是发生肘外翻的原因。早期诊断、及时准确复位和确切固定是减少肘外翻发生的重要措施。严重肘外翻畸形可做肱骨髁上截骨矫正，合并创伤性尺神经炎应早期做尺神经松解前移术。     

肘管综合征临床治疗进展

尺神经在肘部通过尺神经沟时受到腱膜、异常的肌肉或骨性改变的压迫而产生的症候群称肘管综合征。它是第二位常见的上肢神经卡压症，仅次于腕管综合征，发病率相当于腕管综合征的1/2。1958年Feindel和Stratford首先使用了肘管综合征这个术语。Bozentka[1]认为肘管前界是肱骨内上髁，外侧界为肘关节内侧的尺肱韧带，后侧界为尺侧腕屈肌两个头之间形成的纤维弓，管顶由尺骨鹰嘴延伸到肱骨内上髁的纤维束组成。１致病因素由于尺神经在肘部独特的解剖特点，即位置表浅、相对固定、位于肘关节屈伸轴的后方，因此极易受到损伤。它周围的组织如St…     

儿童肱骨髁上骨折经皮克氏针内固定后致尺神经麻痹14例分析

肱骨髁上骨折占儿童肘部损伤的６０％。HolmbergⅣ型肱骨髁上骨折复位后常不稳定，需要经皮克氏针交叉内固定。尺神经麻痹是肱骨髁上骨折复位后经皮克氏针内固定的一种并发症。目前国外文献仅有几组报告，在治疗上存在争论犤１－３犦。我们１９８４～１９９９年间共收治儿童肱骨髁上骨折４２７例，其中３８６例复位后行经皮克氏针内固定，１４例术后发生尺神经麻痹。临床资料本组１４例，男８例，女６例；年龄４～１１岁，平均７岁。患肘软组织损伤程度按Tscherne方法分度，Ⅰ度２例，Ⅱ度１２例。骨折按照Holmberg方法分型，Ⅲ型３例，Ⅳ…     

肱骨髁上骨折并发肘内翻畸形病理形态学分析

目的 :探讨肘内翻发生的病理形态学的改变特点。方法 :对 5 0例肘内翻进行X线片及术中所见病理形态学分析。结果 :大多数病例肱骨外髁膨大 ,内髁变小 ,滑车萎缩 ,尺骨鹰嘴窝变浅变形 ,肱骨远端尺偏、尺嵌及旋转 ,关节发育不均衡 ,尚有部分尺骨近端向肱骨尺神经沟方向滑脱。结论 :肘内翻是肱骨髁上骨折后由于肱骨远折端尺偏、尺嵌及内旋所引起 ,与骨骺损伤无关。内翻严重且日久者可造成肘关节的不稳定 ,关节面的不平衡从而出现肘外侧压痛等症状。宜早期发现 ,及早手术矫正。     

内窥镜下尺神经松解联合内上髁微小切除治疗伴尺神经滑脱的肘管综合征

目的探讨内窥镜下尺神经松解联合内上髁微小切除治疗伴尺神经滑脱的肘管综合征效果。方法 2004年6月-2009年6月,对11例伴尺神经滑脱的肘管综合征患者行内窥镜下尺神经松解联合内上髁微小切除术。男7例,女4例;年龄18～47岁,平均36岁。均有患侧小指及环指尺侧半刺痛感减退。第1骨间背侧肌伴小鱼际肌萎缩(++～+++)9例,肌萎缩不明显2例。术前肌电图检查示尺神经于肘部传导速度为(27.0±7.5)m/s。病程3～18个月,平均7个月。结果术后切口均Ⅰ期愈合,无相关并发症发生。患者均获随访,随访时间6～37个月,平均19个月。术后1个月11例感觉基本恢复正常。术后3个月7例肌力恢复至4级以上,4例为3～4级。术后3个月复查肌电图,尺神经于肘部传导速度为(43.5±9.5)m/s,与术前比较,差异有统计学意义(P0.05)。按Amadio肘部尺神经损害疗效评价标准,获优7例,良4例。结论内窥镜下尺神经松解联合内上髁微小切除治疗伴尺神经滑脱的肘管综合征安全、简便、有效,创伤小,术后恢复快。     

儿童肘外翻畸形

目的：探讨儿童肘外翻畸形的发生机制、预防和治疗方法。方法：8例儿童肝外翻畸形，1例非手术治疗，2例尺神经炎行神经松解前移术，5例创伤性关节炎行肱骨髁上截骨术。结果：所有手术病例均进行随访1.5-5年，平均随访3.4年，2例神经松解前移术后症状消失，5例肱骨髁上截骨术后获满意外观及功能。结论：儿童肘外翻畸形有先天性及后天性因素，先天性畸形多与性染色体异常有关，而后天性畸形大多为肘部损伤后未能及时治疗或治疗不当所致。肘部损伤早期准确复位、确切固定是预防肘外翻畸形的重要措施。严重肘外翻畸形可行肱骨髁上截骨术，合并尺神经炎应早期行尺神经松解前移术；出于外观考虑，截骨术适应证亦可相对放宽。     

带伴行血管尺神经前置术的解剖学研究

目的观察肘部尺神经的血液供应,设计带伴行血管尺神经前置的手术方法。方法取20侧防腐成人上肢标本,观测肘部尺神经血供来源和血管起始处外径、血管起始处至肱骨内上髁距离、血管起始处至尺神经垂直距离及尺神经伴行长度。另采用3侧防腐成人上肢标本模拟临床手术,设计带伴行血管尺神经前置术。结果肘部尺神经血供有3个来源,分别是尺侧上副动脉、尺侧下副动脉和尺侧返动脉后支。3条动脉从起始处至肱骨内上髁的距离分别是14.2±0.9、4.2±0.6和4.8±1.1cm;尺神经伴行长度分别是15.0±1.3、5.1±0.3和5.6±0.9cm;血管起始处外径分别是1.5±0.5、1.2±0.3和1.4±0.5mm;血管起始处至尺神经垂直距离分别是1.2±0.5、2.7±0.9和1.3±0.5cm。结论带伴行血管尺神经前置术治疗肘管综合征是可行的,且最大程度保留了肘部尺神经血供。     

改良钢丝张力带治疗肱骨髁上骨折

<正> 肱骨髁上骨折是小儿常见的骨折,占小儿肘部骨折的30％～40％。保守治疗效果不佳,易出现肘内翻畸形。传统的经内外上髁克氏针交叉固定治疗,存在钢针损伤尺神经、桡神经的情况,易造成不良后果。我院自1996～2001年采用改良钢丝张力带治疗26例小儿肱骨髁上骨折,取得了满意效果,现报告如下。     

肘部尺神经半脱位的解剖学和流行病学研究

目的：研究肘部尺神经半脱位的发生原因及其临床意义。方法：对１００侧成人尸体肘部的尺神经位置进行解剖观察；在人群中随机调查了８５４位正常人肘部尺神经的位置。结果：肘管深度为７．１±０．１４ｍｍ（χ±ｓχ）。解剖观察发现，６侧肢体的尺神经在屈肘时发生半脱位，肘管深度平均为４．８ｍｍ。８５４位正常人肘部尺神经半脱位发生率为８．９％（７６／８５４）。结论：绝大多数的肘部尺神经半脱位是先天性的。肘部尺神经半脱位不一定是肘部尺神经卡压的发病原因。     

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。     

Musculotendinous variations about the medial humeral epicondyle

Anatomical variations in the musculofascial structures about the region of the medial humeral epicondyle were evaluated in 104 extremities in sixty-four cadavers. This study demonstrated presence of an Osborne's band in 77%, of some degree of ulnar subluxation in 25%, of an epitrochlearis anconeus muscle in 11%, the ulnar nerve beneath the medial head of the triceps in 24%, the medial head of the triceps within the floor of the cubital tunnel in 28%, the presence of a rudimentary supracondylar process in 1.5%, and a high origin of the pronator teres in 17% of the cadavers. There was a significant association between the presence of an epitrochlearis anconeus muscle and the ulnar nerve being completely covered by the medial head of the triceps muscle (p less than .001). There was a significant relationship between the presence of the medial head of the triceps in the cubital tunnel and ulnar nerve subluxation (p.001). The high origin of the pronator teres may provide a proximal site for "double crush" syndromes of the median nerve.     

Ulnar bursa distention following volar subluxation of the distal radioulnar joint after distal radial fracture: a rare cause of carpal tunnel syndrome

This report describes an eighty-four-year-old woman with persistent carpal tunnel syndrome attributable to an ulnar bursa distention associated with the subluxation of the distal radioulnar joint after distal radial fracture. During surgery, when the forearm was placed in supination, the ulna head with a sharp osteophyte was found to be displaced into the carpal tunnel through a defect of the ruptured capsule of the wrist joint. This volar subluxation of the ulnar head had caused distention of the ulnar bursa, causing compression of the median nerve, which resulted in carpal tunnel syndrome. In addition to reduce displaced fractured segment to obtain anatomic articular surface, original radial length and tilt, the anatomic restoration of the distal radioulnar joint is essential to maintain better long-term function after fracture of the distal radius.     

Minimal medial epicondylectomy and decompression for cubital tunnel syndrome.

Sixty-four patients (66 elbows) treated for refractory cubital tunnel syndrome had minimal medial epicondylectomy and in situ decompression to minimize the potential disadvantages of classic medial epicondylectomy. After a mean followup of 27 months results were excellent in 27 patients (44%), good in 23 patients (35%), fair in 10 patients (15%), and poor in four patients (6%). No ulnar nerve palsy, ulnar nerve subluxation, or medial elbow instability were seen. The main complaint of patients regarding the procedure was tenderness at the osteotomy site. The results show that minimal medial epicondylectomy and in situ decompression of the ulnar nerve is a safe and effective method to treat patients with cubital tunnel syndrome. This procedure minimizes the disadvantage of medial instability and recurrent symptoms attributable to nerve trauma after a classic medial epicondylectomy.     

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.     

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)     

Postoperative Ulnar Neuropathy is not Necessarily Iatrogenic: a Prospective Study on Dynamic Ulnar Nerve Dislocation at the Elbow

Background

Patients who undergo surgery may develop ulnar neuropathy. Although the mechanism of ulnar neuropathy is still not clear, ulnar neuropathies are common causes of successful lawsuits against surgeons. Recently, the concept developed that endogenous patient factors can lead to postoperative peripheral neuropathies. We hypothesize that dynamic ulnar nerve dislocation at the elbow (DUNDE) may be a predisposing factor for ulnar irritation (i.e. neuropathy) in normal subjects.

Methods

In a prospective investigation, patients aged 20 years and older presenting in our emergency department were asked to participate. Three physicians examined both elbows of subjects included in our study for evidence of DUNDE (through clinical and sonographic examination) and for clinical symptoms related to ulnar neuropathy.

Results

Dynamic ulnar nerve dislocation was observed in 29.3 % of examined subjects. No significant difference in its occurrence was observed in relation to gender or dominant side. Physical examination with provocation tests demonstrated significantly more positive Tinel tests and spontaneous signs of neuropathy in patients with dynamic dislocating ulnar nerves (14.7 vs. 1.1 %).

Conclusion

Dynamic ulnar nerve dislocation may be linked to ulnar nerve irritability (i.e. ulnar neuropathy) in normal subjects without history of trauma, surgical procedure, or anesthesia. Considering the high incidence of this variant in the general population, our study supports previous investigations suggesting that many postoperative ulnar nerve deficits are traceable to chronic patient conditions. Our study suggests that dynamic ulnar nerve dislocation is a predisposing factor in the development of ulnar neuropathy in the postoperative period.

Notes

(1) neuropathy should be viewed as a broad definition as signs of nerve irritation/inflammation, and independently of the pathophysiology and etiology; (2) because no specific term exists in the international anatomic nomenclature (Nomina Anatomica) to designate this variant, several synonyms have been used in the literature, leading to confusion and misleading conclusions concerning its traumatic etiologies and their consequences: (a) recurrent or habitual ulnar nerve luxation (or subluxation) [1–3]; (b) recurrent or habitual ulnar nerve dislocation [4–7]; (c) ulnar nerve instability [8]; (d) laxity of the ulnar nerve [9]; and (e) ulnar nerve hypermobility [10].     

Ulnar deviation after volar subluxation of the proximal interphalangeal joint

A rare case of irreducible and progressive ulnar deviation after volar subluxation of the proximal interphalangeal joint is presented. An immobilized proximal interphalangeal joint with remaining volar subluxation after improper reduction showed ulnar deviation at 3 weeks after injury. During surgery, the radial collateral ligament was found to be ruptured at its origin, with formation of concomitant scar tissues. There were no apparent lesions at the central slip, lateral band, and volar plate. Interposition of the ruptured ligament and infiltration of the surrounding scar tissues into the proximal interphalangeal joint were identified. Surgical incision of the capsule along the dorsal margin of the radial collateral ligament readily produced successful reduction. The irreducible and progressive ulnar deviation of the proximal interphalangeal joint seemed to result from gradual infiltration of the scar tissues, subsequent to remaining volar subluxation because of interposition of the ruptured collateral ligament.     

Ulnar subluxation of the median nerve following carpal tunnel release: a case report

Complications of carpal tunnel release, while infrequent, include incomplete release resulting in persistent symptoms or recurrence due to postoperative scarring, as well as iatrogenic damage to nerves and vessels. We present the case of a patient who underwent carpal tunnel release with resolution of symptoms in the immediate postoperative period. At one and a half years post release he started to experience numbness and tingling in a median nerve distribution triggered by repetitive ulnar to radial deviation of the wrist, with no symptoms at rest. Dynamic ultrasound showed a subluxation of the median nerve from one side of the palmaris longus tendon to the other. The patient's symptoms were triggered as the median nerve squeezed in between the palmaris longus and flexor digitorum superficialis tendons.