Treatment for ulnar neuropathy at the elbow

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.

Ulnar neuropathy at the elbow: associations of pre-operative DTI parameters with clinical outcomes after cubital tunnel decompression

OBJECTIVES

To evaluate whether DTI parameters of the ulnar nerve at the elbow are associated with clinical outcomes in patients receiving cubital tunnel decompression (CTD) surgery for ulnar neuropathy.

METHODS

This retrospective study included 21 patients with cubital tunnel syndrome who received CTD surgery between January 2019 and November 2020. All patients underwent pre-operative elbow MRI, including DTI. Region-of-interest analysis was performed on the ulnar nerve at three levels around the elbow: above (level 1), cubital tunnel (level 2), and below (level 3). Fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity (AD) were calculated on three sections at each level. Clinical data on symptom improvement in respect to pain and tingling sensation after CTD were recorded. Logistic regression analysis was used to compare DTI parameters of the nerve at three levels and the entire nerve course between patients with and without symptom improvement after CTD.

RESULTS

After CTD, 16 patients showed improvement in symptoms, but five did not. ROC analysis of DTI parameters showed that AUCs of FA, AD, and MD were higher at level 1 than at levels 2 and 3, with FA showing the highest AUC (level 1: FA, 0.7104 [95% CI, 0.5206-0.9002] vs AD, 0.6521 [95% CI, 0.4900-0.8142] vs MD, 0.6153 [95% CI, 0.4187-0.8119]).

CONCLUSION

In patients who underwent CTD surgery for ulnar neuropathy at the elbow, the DTI parameters of FA, AD, and MD above the cubital tunnel level were associated with clinical outcomes, with FA showing the strongest associations.

KEY POINTS

• After CTD surgery for ulnar neuropathy at the elbow, persistent symptoms may be observed, depending on symptom severity. • DTI parameters of the ulnar nerve at the elbow showed differences in their capacity for discriminating between patients with and without symptom improvement following CTD surgery, with this capacity depending on the nerve level at the elbow. • FA, AD, and MD measured above the cubital tunnel on pre-operative DTI may be associated with surgical outcomes, with FA showing the strongest association (AUC at level 1, 0.7104 [95% CI, 0.5206-0.9002]).

Cost of surgical treatment for ulnar nerve entrapment in Finland, 2011-2015: a registry-based cost description study

OBJECTIVES

The aim of this study was to evaluate the cost of surgical treatment for primary ulnar nerve entrapment (UNE) borne by the public sector in Finland.

DESIGN

Registry-based cost description study.

SETTING

Primary and secondary care throughout Finland.

PARTICIPANTS

We identified all the patients diagnosed with primary UNE in the whole population of Finland from 2011 to 2015 from the Care Register for Health Care. From these patients, we identified those who had undergone ulnar nerve release during the year they were diagnosed or the following year.

INTERVENTIONS

Open ulnar nerve release.

OUTCOME MEASURES

The primary outcome measure was cost borne by the public sector in 2015 euros. The cost of surgery was based on the diagnosis-related group prices. We calculated the cost of a single visit to a primary care physician, an electroneuromyography examination, a preoperative visit to a hand surgeon and a follow-up appointment by telephone in specialised care for each patient. These unit costs were provided by the Finnish Institute for Health and Welfare and the same costs were used for each patient. We obtained the number of reimbursed sick days and the total amount reimbursed to each patient in euros within the 2 years after diagnosis from the Social Insurance Institution of Finland.

RESULTS

During our study period, approximately 1786 primary UNE diagnoses were made yearly, and on average, 876 (49%) of patients received surgical treatment annually. The surgery-related cost per patient averaged at EUR 1341 (43%) and reimbursed sick leaves at EUR 952 (30%) during this period. The annual cost of surgical treatment for UNE borne by the public sector in Finland varied between EUR 3082 and EUR 3213 per patient.

CONCLUSIONS

The average cost of surgical treatment for UNE in Finland was EUR 3140 per patient between 2011 and 2015.

YouTube as a Source of Patient Information for Cubital Tunnel Syndrome: An Analysis of Video Reliability, Quality, and Content

BACKGROUND

This study seeks to examine the reliability, quality, and content of YouTube videos on cubital tunnel syndrome, on which there is presently a paucity of information.

METHODS

The top 50 unique YouTube videos by relevance resulting from the Boolean search term "cubital tunnel + cubital tunnel syndrome" were identified, with video properties for analysis including source, upload date, duration, views, and comments. Content was assessed using the Journal of American Medical Association (JAMA) criteria, the Global Quality Score (GQS), and a "Cubital Tunnel-Specific Score" (CTSS).

RESULTS

The average video saw 72 108 ± 199 362 views, with videos produced by allied (nonphysician) health professionals demonstrating the highest mean views (111 789 ± 294 471 views). Videos demonstrated low mean JAMA scores (2.4/4 ± 0.7), GQS (2.8/5 ± 1.3), and CTSS (7.5/21 ± 4.3), with academic and nonacademic physician videos demonstrating significantly greater mean GQS and CTSS scores when compared with videos by allied health professionals. Positive independent predictors for GQS included academic sources (β = 1.871), nonacademic physician sources (β = 1.651), and video duration (β = 0.102), which were likewise positive predictors for CTSS (β = 4.553, 4.639, 0.374). Content relating to surgical techniques or approaches for cubital tunnel decompression had the greatest CTSS scores (11.2 [4.2]).

CONCLUSIONS

YouTube is a source of highly accessible information on cubital tunnel syndrome, although the average video presents generally poor and inadequate information. Directing patients toward higher quality video resources can be a meaningful component of patient education.

A Comprehensive Review of Cubital Tunnel Syndrome

Cubital Tunnel Syndrome (CuTS) is the compression of the ulnar nerve as it courses through the cubital tunnel near the elbow at the location colloquially referred to as the "funny bone". CuTS is the most commonly diagnosed mononeuropathy after carpal tunnel syndrome. Cubital tunnel syndrome can manifest as numbness, tingling, or pain in the ring/small fingers and dorsoulnar hand. Repetitive pressure, stretching, flexion, or trauma of the elbow joint are known causes of CuTS. Chronic ulnar nerve compression and CuTS, when left untreated, can lead to atrophy of the first dorsal interosseus muscle and affect one's quality of life to the point that they are no longer able to participate in daily activities involving fine motor function. It is estimated that up to 5.9% of the general population have had symptoms of CuTS. CuTS is underdiagnosed due to lack of seeking of treatment for symptoms. Compression or damage to the ulnar nerve is the main cause of symptoms experienced by an individual with CuTS. Repetitive elbow pressure or a history or elbow joint trauma or injury are additional known causes that can lead to CuTS. Common presentations of CuTS include paresthesia, clumsiness of the hand, hand atrophy and weakness. The earliest sign of CuTS is most commonly numbness and tingling of the ring and 5th finger. Older patients tend to present with motor symptoms of chronic onset; younger patients tend to have more acute symptoms. Pain and point tenderness at the medial elbow may also be seen. CuTS lacks universally agreed upon diagnostic and treatment algorithms. CuTS can be diagnosed by physical exam using Tinel's sign, flexion-compression tests, palpating the ulnar nerve for thickening presence of local tenderness along the nerve. Ultrasound and nerve conduction studies may be used in combination with physical exam for diagnosis. Conservative treatment for CuTS is almost always pursued before surgical treatment and includes elbow splints, braces, and night-gliding exercises. Surgical treatment may be pursued in severe CuTS refractory to conservative treatment. Surgical options include open and endoscopic in-situ decompression, medial epicondylectomy, and anterior transposition of the ulnar nerve. CuTS is a prevalent disease that, if left untreated, can significantly alter an individual's quality of life. Therefore, an accurate diagnosis and appropriate treatment is paramount in reducing further damage and preventing worsening or future symptoms.

Carpal Tunnel Syndrome and Diabetes—A Comprehensive Review

Carpal tunnel syndrome (CTS) is the most common compression neuropathy in the general population and is frequently encountered among individuals with type 1 and 2 diabetes. The reason(s) why a peripheral nerve trunk in individuals with diabetes is more susceptible to nerve compression is still not completely clarified, but both biochemical and structural changes in the peripheral nerve are probably implicated. In particular, individuals with neuropathy, irrespective of aetiology, have a higher risk of peripheral nerve compression disorders, as reflected among individuals with diabetic neuropathy. Diagnosis of CTS in individuals with diabetes should be carefully evaluated; detailed case history, thorough clinical examination, and electrophysiological examination is recommended. Individuals with diabetes and CTS benefit from surgery to the same extent as otherwise healthy individuals with CTS. In the present review, we describe pathophysiological aspects of the nerve compression disorder CTS in relation to diabetes, current data contributing to the explanation of the increased risk for CTS in individuals with diabetes, as well as diagnostic methods, treatment options, and prognosis of CTS in diabetes.

A retrospective study of electrodiagnostically evaluated ulnar neuropathies with special guidelines for ulnar neuropathies at elbow

Background

The diagnosis of type, severity of ulnar neuropathy based on symptoms and clinical tests are unsatisfactory. This study aimed to retrospectively analyze ulnar neuropathies at different sites evaluated through electrodiagnostic studies (EDx), especially for ulnar neuropathy at elbow (UNE).

Results

Total 270 ulnar neuropathy patients’ data were recruited from laboratory record over a five-year period (2016–2021).Their demographic data, clinical history and EDx parameters were analyzed focusing on etiology, nerve lesion types, 5th-digit sensory, dorsal ulnar cutaneous nerve (DUCN) conduction, motor nerve conduction velocity (NCV) across elbow along with EMG of ADM, FDI, FCU, FDP muscles. The patients grouped into traumatic injuries—27.8% (T) and 72.2% non-traumatic (NT) had varied sensory-motor symptoms: pain—10%, altered sensation—28.1%, pain-paresthesia—14.8%, atrophy—25.2% and clawing—8.9%. UNE was the most prevalent (82.75%-NT, 66.67% -T) with < 50 m/s motor and sensory NCV across elbow. Compound muscle action potential (CMAP) amplitude > 50% drop across elbow was seen in 55.17%-NT and 54.16%-T groups. Abnormal DUCN and short-segment inching NCV were less frequently noted. In EMG, ADM (T-83.33% and NT-65.51%) and FDI (T-70.83% and NT-68.96%) muscles were evaluated the most and FDP the least.

Conclusion

UNE was the most common followed by forearm and wrist. NCV and CMAP across elbow are stronger EDx parameters for UNE. Neuropathy was irrespective of gender and prevalent at early of middle age. The EDx could be considered as one of the most valuable tests in confirming the localization, severity and type of ulnar nerve lesion, which favors management and prognosis of patient.

The management of failed cubital tunnel decompression

Cubital tunnel decompression is a commonly performed operation with a much higher failure rate than carpal tunnel release.

Failed cubital tunnel release generally occurs due to an inadequate decompression in the primary procedure, new symptoms due to an iatrogenic cause, or development of new areas of nerve irritation.

Our preferred technique for failed release is revision circumferential neurolysis with medial epicondylectomy, as this eliminates strain, removes the risk of subluxation, and avoids the creation of secondary compression points.

Adjuvant techniques including supercharging end-to-side nerve transfer and nerve wrapping show promise in improving the results of revision surgery.

Limited quality research exists in this subject, compounded by the lack of consensus on diagnostic criteria, classification, and outcome assessment.

Cite this article: EFORT Open Rev 2021;6:735-742. DOI: 10.1302/2058-5241.6.200135

Post-Operative Assessment of Ulnar Nerve Tension Using Shear-Wave Elastography

BACKGROUND

Ulnar nerve compression at the elbow level is the second-most common entrapment neuropathy. The aim of this study was to use shear-wave elastography for the quantification of ulnar nerve elasticity in patients after ulnar nerve decompression with anterior transposition and in the contralateral non-operative side.

METHOD

Eleven patients with confirmed diagnosis and ulnar nerve decompression with anterior transposition were included and examinations were performed on an Aixplorer^TM ultrasound system (Supersonic Imagine, Aix-en-Provence, France).

RESULTS

We observed significant differences at 0-degree (p < 0.001), 45-degree (p < 0.05), 90-degree (p < 0.01) and 120-degree (p < 0.001) elbow flexion in the shear elastic modulus of the ulnar nerve in the operative and non-operative sides. There were no statistically significant differences between the elasticity values of the ulnar nerve after transposition at 0-degree elbow flexion and in the non-operative side at 120-degree elbow flexion (p = 0.39), or in the ulnar nerve after transposition at 120-degree elbow flexion and in the non-operative side at 0-degree elbow flexion (p = 0.09).

CONCLUSION

Shear-wave elastography has the potential to be used postoperatively as a method for assessing nerve tension noninvasively by the estimation of mechanical properties, such as the shear elastic modulus.

Compression Neuropathies of the Upper Extremity: A Review

Compressive neuropathies of the forearm are common and involve structures innervated by the median, ulnar, and radial nerves. A thorough patient history, occupational history, and physical examination can aid diagnosis. Electromyography, X-ray, and Magnetic Resonance Imaging may prove useful in select syndromes. Generally, first line therapy of all compressive neuropathies consists of activity modification, rest, splinting, and non-steroidal anti-inflammatory drugs. Many patients experience improvement with conservative measures. For those lacking adequate response, steroid injections may improve symptoms. Surgical release is the last line therapy and has varied outcomes depending on the compression. Carpal Tunnel syndrome (CTS) is the most common, followed by ulnar tunnel syndrome. Open and endoscopic CTS release appear to have similar outcomes. Endoscopic release appears to incur decreased cost baring a low rate of complications, although this is debated in the literature. Additional syndromes of median nerve compression include pronator syndrome (PS), anterior interosseous syndrome, and ligament of Struthers syndrome. Ulnar nerve compressive neuropathies include cubital tunnel syndrome and Guyon’s canal. Radial nerve compressive neuropathies include radial tunnel syndrome and Wartenberg’s syndrome. The goal of this review is to provide all clinicians with guidance on diagnosis and treatment of commonly encountered compressive neuropathies of the forearm.

Cubital tunnel syndrome

Cubital tunnel syndrome (CuTS) is the second most common compression neuropathy of the upper limb, presenting with disturbance of ulnar nerve sensory and motor function.The ulnar nerve may be dynamically compressed during movement, statically compressed due to reduction in tunnel volume or compliance, and tension forces may cause ischaemia or render the nerve susceptible to subluxation, further causing local swelling, compression inflammation and fibrosis.Superiority of one surgical technique for the management of CuTS has not been demonstrated. Different techniques are selected for different clinical situations with simple decompression being the most common procedure due to its efficacy and low complication rate.Adjunctive distal nerve transfer for denervated muscles using an expendable motor nerve to restore the axon population in the distal nerve is in its infancy but may provide a solution for severe intrinsic weakness or paralysis. Cite this article: EFORT Open Rev 2021;6:743-750. DOI: 10.1302/2058-5241.6.200129.

Nerve entrapment around elbow

Entrapment neuropathy around elbow is a common cause of disability across all age groups. The major nerves that traverse the elbow are ulnar, median and radial nerves and their branches. Cubital tunnel syndrome leading to ulnar nerve compression can often present with significant pain, paresthesia or weakness. Median and Radial nerve compression around the elbow, albeit less frequent, can also lead to significant morbidity and must be kept in the differential diagnosis when dealing with patients complaining of persistent pain around the elbow and weakness of forearm/hand muscles. Electrodiagnostic studies can be a useful adjunct to clinical examination, to help localize the site and quantify the grade of compression. Management should involve a trial of conservative treatment and failing that, surgical treatment should be considered. We hereby provide an overview of nerve entrapments around the elbow including their applied anatomy, etiology, clinical assessment and overview of the current concepts in surgical treatment.

Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment

Ulnar neuropathy at the elbow (UNE) is commonly encountered in clinical practice. It results from either static or dynamic compression of the ulnar nerve. While the retroepicondylar groove and its surrounding structures are quite superficial, the use of ultrasound (US) imaging is associated with the following advantages: (1) an excellent spatial resolution allows a detailed morphological assessment of the ulnar nerve and adjacent structures, (2) dynamic imaging represents the gold standard for assessing the ulnar nerve stability in the retroepicondylar groove during flexion/extension, and (3) US guidance bears the capability of increasing the accuracy and safety of injections. This review aims to illustrate the ulnar nerve's detailed anatomy at the elbow using cadaveric images to understand better both static and dynamic imaging of the ulnar nerve around the elbow. Pathologies covering ulnar nerve instability, idiopathic cubital tunnel syndrome, space-occupying lesions (e.g., ganglion, heterotopic ossification, aberrant veins, and anconeus epitrochlearis muscle) are presented. Additionally, the authors also exemplify the scientific evidence from the literature supporting the proposition that US guidance is beneficial in injection therapy of UNE. The non-surgical management description covers activity modifications, splinting, neuromobilization/gliding exercise, and physical agents. In the operative treatment description, an emphasis is put on two commonly used approaches-in situ decompression and anterior transpositions.

Work-related risk factors for ulnar nerve entrapment in the Northern Finland Birth Cohort of 1966

Ulnar nerve entrapment (UNE) is the second most common entrapment neuropathy in the upper extremity. The aetiology of UNE is multifactorial and is still not fully understood. The aim of the study was to identify occupational risk factors for UNE and to determine whether smoking modifies the effects of work-related factors on UNE. The study population consisted of the Northern Finland Birth Cohort of 1966 (NFBC1966). In total, 6325 individuals active in working life participated at baseline in 1997. Occupational risk factors were evaluated by a questionnaire at baseline. The data on hospitalizations due to UNE were obtained from the Care Register for Health Care between 1997 and 2018. The incidence rate of hospitalization due to UNE was 47.6 cases per 100,000 person-years. After adjusting for confounders, entrepreneurs (Hazard ratio (HR) = 3.68, 95% CI 1.20–11.27), smokers (HR = 2.51, 95% CI 1.43–4.41), workers exposed to temperature changes (HR = 1.72, 95% CI 1.00–2.93), workers with physically demanding jobs (HR = 3.02, 95% CI 1.39–6.58), and workers exposed to hand vibration (HR = 1.94, 95% CI 1.00–3.77) were at an increased risk of hospitalization for UNE. Exposure to work requiring arm elevation increased the risk of hospitalization due to UNE among smokers (HR = 2.62, 95% CI 1.13–6.07), but not among non-smokers. Work-related exposure to vibration and temperature changes, and physically demanding work increase the risk of hospitalization for UNE. Smoking may potentiate the adverse effects of work-related factors on UNE.

Enrollment in Treatment at a Specialized Pain Management Clinic at a Tertiary Referral Center after Surgery for Ulnar Nerve Compression: Patient Characteristics and Outcome

Purpose

To study patients who enroll in treatment at a specialized pain management clinic at a tertiary referral center following ulnar nerve decompression.

Methods

Data from medical charts and postoperative questionnaires were collected for all patients after surgery for ulnar nerve compression at the elbow from 2011 to 2014 (n = 173) at a tertiary referral center. Differences in characteristics between patients who enrolled in treatment at the pain management clinic (study group, n = 26) and the rest of the patients (reference group, n = 147) were analyzed. The study group was further evaluated using questionnaires from the Swedish Quality Registry for Pain Rehabilitation (SQRP) and regarding outcome of pain treatment.

Results

The study group was characterized by prior pain conditions, earlier contact with a pain management clinic, and high degrees of kinesiophobia, depression/anxiety, low quality of life, and low life satisfaction. These patients had significantly higher postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) scores, were significantly younger, and had bilateral surgery significantly more often than the reference group. For patients with unilateral surgery, simple decompression was significantly more common in the reference group. The most common treatments at the clinic were antidepressants and anticonvulsants for neurogenic pain. In 5 of 26 patients, pain relief, or pain reduction was the documented reason for discharge.

Conclusions

Pain is a relevant outcome measure for ulnar nerve decompression among complicated cases at a referral center. Severe postoperative pain is connected to higher disability, reduced life satisfaction, and overall low health status. This study maps out characteristics of patients who postoperatively enroll in treatment at a specialized pain management clinic following ulnar nerve decompression. Further studies are needed to define predictive factors for such pain.

Type of study/level of evidence

Prognostic III.

Ultrasound-Assisted Precise In Situ Decompression for Cubital Tunnel Syndrome

Objective

To explore the effect of locating the ulnar nerve compression sites and guiding the small incision so as to decompress the ulnar nerve in situ on the elbow by high‐frequency ultrasound before operation.

Methods

A retrospective analysis was conducted on 56 patients who underwent ultrasound‐assisted in situ decompression for cubital tunnel syndrome from May 2018 to August 2019. The patients' average age was 51.13 ± 7.35 years, mean duration of symptoms was 6.51 ± 1.96 months, and mean postoperative follow‐up was 6.07 ± 0.82 months. Nine patients had Dellon's stage mild, 39 had stage moderate, and eight had stage severe. Ultrasound and electromyography were completed in all patients before operation. The presence of ulnar nerve compressive lesion, the specific location, and the reason and extent of compression were determined by ultrasound. A small incision in situ surgery was given to decompress the ulnar nerve according to the pre‐defined compressive sites.

Results

All patients underwent in situ decompression. The compression sites around the elbow were as follows: two in the arcade of Struthers, one in the medial intermuscular septum, four in the anconeus epitrochlearis muscle, five beside the cyst of the proximal flexor carpi ulnaris (FCU), and the remaining 44 cases were all from the compression between Osborne's ligament to the two heads of the FCU. The compression localizations diagnosed by ultrasound were confirmed by operations. Preoperative ultrasound confirmed no ulnar nerve subluxation in all cases. The postoperative outcomes were satisfactory. There was no recurrence or aggravation of symptoms in this group of patients according to the modified Bishop scoring system; results showed that 43 cases were excellent, 10 were good, and three were fair.

Conclusions

High‐frequency ultrasound can accurately and comprehensively evaluate the ulnar nerve compression and the surrounding tissues, thus providing significant guidance for the precise minimally invasive treatment of ulnar nerve compression.

Effectiveness of electrophysical modalities in the sensorimotor rehabilitation of radial, ulnar, and median neuropathies: A meta-analysis

INTRODUCTION

People with ulnar, radial or median nerve injuries can present significant impairment of their sensory and motor functions. The prescribed treatment for these conditions often includes electrophysical therapies, whose effectiveness in improving symptoms and function is a source of debate. Therefore, this systematic review aims to provide an integrative overview of the efficacy of these modalities in sensorimotor rehabilitation compared to placebo, manual therapy, or between them.

METHODS

We conducted a systematic review according to PRISMA guidelines. We perform a literature review in the following databases: Biomed Central, Ebscohost, Lilacs, Ovid, PEDro, Sage, Scopus, Science Direct, Semantic Scholar, Taylor & Francis, and Web of Science, for the period 1980-2020. We include studies that discussed the sensorimotor rehabilitation of people with non-degenerative ulnar, radial, or median nerve injury. We assessed the quality of the included studies using the Risk of Bias Tool described in the Cochrane Handbook of Systematic Reviews of Interventions and the risk of bias across studies with the GRADE approach described in the GRADE Handbook.

RESULTS

Thirty-eight studies were included in the systematic review and 34 in the meta-analysis. The overall quality of evidence was rated as low or very low according to GRADE criteria. Low-level laser therapy and ultrasound showed favourable results in improving symptom severity and functional status compared to manual therapy. In addition, the low level laser showed improvements in pinch strength compared to placebo and pain (VAS) compared to manual therapy. Splints showed superior results to electrophysical modalities. The clinical significance of the results was assessed by effect size estimation and comparison with the minimum clinically important difference (MCID).

CONCLUSIONS

We found favourable results in pain relief, improvement of symptoms, functional status, and neurophysiological parameters for some electrophysical modalities, mainly when applied with a splint. Our results coincide with those obtained in some meta-analyses. However, none of these can be considered clinically significant.

TRIAL REGISTRATION

PROSPERO registration number CRD42020168792; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=168792.

Peripheral Neuropathies Seen by Ultrasound: A Literature Analysis through Lexical Evaluation, Geographical Assessment and Graph Theory

(1) Background: Ultrasound is a well-known tool used for the diagnosis and management of many diseases, including peripheral neuropathies. The main aim of this study was the lexical analysis of the literature on this topic considering the most cited words and the relationship between the words and the papers. Furthermore, a geographical analysis was performed to evaluate the worldwide prevalence. (2) Methods: We performed a literature search on PubMed, and we calculated the occurrence of the words indicating nerves and the body parts. Furthermore, we calculated the number of papers for each country, considering the affiliation of the first author. Finally, to describe the relationships between the words and the papers, we used the 30 most cited words, and we built a matrix describing in which papers a word was cited. This matrix was used to create a network based on the graph theory using Gephi 0.9.2 software. (3) Results: The most cited nerves were median and ulnar ones, and the most cited body parts were hand, wrist and elbow. The United States of America was the most productive country, with 80 papers. The graph of the network showed the importance of ultrasound as support for therapy. (4) Conclusions: The study represents a lexical analysis of the literature and shows information about subjects, authors and relationships of the papers. This may be helpful for better understanding and evaluation of the situation of the current literature.

Osseous morphology of the medial epicondyle: an anatomoradiological study with potential clinical implications

PURPOSE

The cubital tunnel is limited anteriorly by the medial epicondyle (ME), laterally by the medial collateral ligament, and superiorly by Osborne's fascia and the cubital tunnel retinaculum. Previous studies were mostly dedicated to the roof of the cubital tunnel, in the way that the study of the groove for ulnar nerve and ME anatomy is relatively scarce in the literature. We sought to describe the radiological anatomy of the groove for ulnar nerve and ME in healthy volunteers with multiplanar computed tomography (CT).

METHODS

We analyzed 3D CT images of 30 healthy volunteers (mean age 39 years, range 18-66 years). Nine variables were measured from the right elbow, including sizes, areas and angles in two different planes (coronal and axial).

RESULTS

Mean ME width and length were 17.3 ± 3.5 mm and 31.7 ± 4.5 mm, respectively. According to categorical correlation studies, ME width (X) was deemed the most representative morphological characteristic because of the positive correlation to five other different anatomical measurements. A three-tiered anatomical classification was proposed based on data distribution.

CONCLUSION

Large individual variation is found in the shape of ME, both in coronal and axial planes. The knowledge of individual osseous morphology is of great value potentially contributing to the surgical decision-making in patients affected by cubital tunnel syndrome.

Socioeconomic Factors in Patients with Ulnar Nerve Compression at the Elbow: A National Registry-Based Study

AIMS

To investigate demographics and socioeconomic status in patients with ulnar nerve compression and the influence of socioeconomic factors on patient-reported outcome measurements (PROM) as evaluated by QuickDASH (short version of Disabilities of Arm, Shoulder and Hand) after surgery for ulnar nerve compression at the elbow.

METHODS

Patients operated for primary ulnar nerve compression from 2010 to 2016 were identified in the National Quality Registry for Hand Surgery Procedures (HAKIR). Patients filled out questionnaires before and at three and 12 months after surgery. A total of 1346 surgically treated cases were included. Data from HAKIR were linked to data from Statistics Sweden (SCB) on socioeconomic status (i.e., education level, earnings, social assistance, immigrant status, sick leave, unemployment, and marital status).

RESULTS

Patients surgically treated for ulnar nerve compression at the elbow differed from the general population with lower levels of education, higher social assistance dependence, a high proportion of unemployment, and lower earnings. However, the results were not clear concerning the influence of socioeconomic factors on the outcome of surgery, except for long-term sick leave.

CONCLUSION

Patients surgically treated for ulnar nerve compression at the elbow are socioeconomically deprived, but only a history of long-term sick leave influences the outcome of surgery. This information is crucial in the diagnosis and treatment of these patients.

Patterns and parameters describing nerve thickening in compression and entrapment ulnar neuropathies at the elbow

OBJECTIVE

To compare pattern and parameters describing nerve thickening in ulnar neuropathy at the elbow (UNE) due to external compression in the retrocondylar groove (RTC), and entrapment under the humeroulnar aponeurosis (HUA).

METHODS

In a group of our previously reported UNE patients we ultrasonographically (US) measured ulnar nerve cross-sectional areas (CSA) on 6-8 standard locations in the elbow segment. We compared CSA patterns in both groups, and determined diagnostic utility of selected CSA based parameters.

RESULTS

We studied 79 patients (81 arms) with UNE due to external compression, and 53 patients (55 arms) due to entrapment. Maximal ulnar nerve CSA (>16 mm²), maximal CSA change (>7 mm²/1-2 cm) and maximal/minimal CSA ratio (>2.6) were significantly larger in UNE due to entrapment. They also differentiated these arms from arms with compression with sensitivities of 78%, 87% and 80%, and specificities of 90%, 94%, and 85%, respectively.

CONCLUSION

Maximal difference in CSA between points separated by 1-2 cm (>7 mm²/1-2 cm) very efficiently differentiated between UNE due to external compression and entrapment.

SIGNIFICANCE

The proposed parameter will hopefully complement precise localization in determining underlying mechanism of UNE. This may help physicians to determine the most appropriate treatment for UNE and possibly other focal neuropathies of unknown cause; i.e., conservative treatment for external compression and surgery for entrapment.

Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis

IMPORTANCE

Cubital tunnel syndrome is the second most common compressive neuropathy, affecting 6% of the population. Numerous different operations are performed globally to treat it; however, prior conventional (pairwise) meta-analyses have been unable to determine which procedure is associated with the best outcomes and fewest complications.

OBJECTIVE

To evaluate which operation for cubital tunnel syndrome is associated with the greatest likelihood of symptomatic cure.

DATA SOURCES

PubMed, EMBASE, and CENTRAL were searched from database inception to March 2, 2019, with no restrictions on the setting or design of studies.

STUDY SELECTION

Experimental and observational studies directly comparing the outcomes of at least 2 surgical treatments for adults with primary cubital tunnel syndrome were included. Case reports were excluded, and when comparative studies had subgroups with 1 participant, the single-participant subgroup was excluded. The treatments had to be in situ decompression with or without medial epicondylectomy or an anterior subcutaneous, subfascial, intramuscular, or submuscular transposition. The access could be open, minimally invasive, or endoscopic. The comparator could be sham surgery or any operation mentioned earlier.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by 2 independent reviewers, following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline and the PRISMA Network Meta-analysis extension statement. Network meta-analysis was used to estimate the relative efficacy and safety associated with interventions using relative risks. Surgical techniques were ranked by their probability of being the best (P score) and interpreted in terms of their clinical impact.

MAIN OUTCOMES AND MEASURES

The primary outcome was response to treatment (ie, symptomatic improvement). The secondary outcomes were perioperative complications, reoperation, and recurrence.

RESULTS

A total of 30 studies of 2894 limbs undergoing 8 different operations were included. Across the studies, 56% of participants were men, the mean (SD) age was 48 (8) years, and patients had symptoms for a mean (SD) of 15 (7) months. Overall, 87% (95% CI, 92%-91%) of patients improved with surgery; all forms of in situ decompression were more effective than any type of transposition procedure; for example, open in situ decompression with epicondylectomy was associated with higher success rates than subcutaneous transposition (relative risk, 1.13; 95% CI, 1.01-1.25). Postoperatively, 3% (95% CI, 2%-4%) of patients developed complications, and in situ decompressions were ranked as the least risky, although there was considerable uncertainty in this outcome. Overall, 2% (95% CI, 1%-3%) of patients required reoperation; open in situ decompression was associated with the fewest reoperations; in comparison, submuscular transposition was associated with 5 times the risk of reoperation (relative risk, 5.08; 95% CI, 2.06-12.52). During surveillance, 3% (95% CI, 1%-4%) of patients developed recurrence, and open in situ decompression with epicondylectomy was ranked as the safest operation, although there was uncertainty in the estimates.

CONCLUSIONS AND RELEVANCE

In this network meta-analysis, open in situ decompression (with or without medial epicondylectomy) appeared to be the safest operation and also was associated with the best outcomes for patients with primary cubital tunnel syndrome. Future research should focus on better defining this disorder and developing core outcome measures.

Ulnar Nerve Entrapment in Diabetes: Patient-reported Outcome after Surgery in National Quality Registries

BACKGROUND

Ulnar nerve entrapment at the elbow (UNE) is overrepresented in patients with diabetes, but the outcome of surgery is unknown. We aimed to evaluate patient-reported outcome in patients with and without diabetes, and to assess potential sex differences and compare surgical treatment methods.

METHODS

Data on patients operated for UNE (2010-2016, n = 1354) from the Swedish National Registry for Hand Surgery were linked to the Swedish National Diabetes Register. Symptoms were assessed preoperatively (n = 389), and 3 (n = 283), and at 12 months postoperatively (n = 267) by QuickDASH and HQ-8 (specific hand surgery questionnaire-8 questions). Only simple decompressions were included when comparing groups.

RESULTS

Men with diabetes reported higher postoperative QuickDASH scores than men without diabetes. Women scored their disability higher than men on all time-points in QuickDASH, but showed larger improvement between preoperative and 12 months postoperative values. Patients operated with transposition scored 10.8 points higher on QuickDASH than patients who had simple decompression at 12 months (95% confidence interval 1.98-19.6).

CONCLUSIONS

Women with diabetes benefit from simple decompression for UNE to the same extent as women without diabetes. Men with diabetes risk not to benefit from simple decompression as much as women do. Ulnar nerve transposition had a higher risk of residual symptoms compared to simple decompression.

Ultrasonography of the ulnar nerve in the elbow: video article

Disorders affecting the ulnar nerve in the elbow are common in clinical practice. The diagnosis is based on clinical evaluation and electrodiagnostic tests, but imaging examinations are frequently necessary, particularly for the identification of the structures associated with nerve compression. The purpose of this video article is to review the anatomy, the pathology, scanning techniques, and sonographic appearance of the ulnar nerve in the elbow.

Patient Characteristics in Ulnar Nerve Compression at the Elbow at a Tertiary Referral Hospital and Predictive Factors for Outcomes of Simple Decompression versus Subcutaneous Transposition of the Ulnar Nerve

Patient characteristics and predictive factors for outcomes were analysed in 202 cases undergoing simple decompression, primary subcutaneous transposition, or secondary subcutaneous transposition for ulnar nerve compression at the elbow at a tertiary referral hospital. Data from medical charts and a survey were evaluated. The mean patient age was 49 years with revision surgery cases being significantly younger. Sixty-one percent of cases were female, and 31% were smokers. The comorbidity was extensive, including other nerve compression lesions as well as neck and shoulder problems. Overall, 53% reported being pleased with the result of surgery and 57% of the cases rated function as better or completely recovered after surgery. The median postoperative DASH (Disabilities of the Arm, Shoulder and Hand) score was 26 (IQR 11–49), which is in accordance with unpublished national data. No significant differences in DASH scores were found between surgical groups, but a higher preoperative McGowan grade was significantly associated with a poorer postoperative DASH score. Women scored greater disability postoperatively than men. There was a significantly increased risk of complications, which was doubled for smokers, following primary and secondary transposition compared to simple decompression. Surgical cases with ulnar nerve compression treated at a tertiary referral hospital constitute a heterogeneous group with great comorbidity and frequent concomitant nerve compression lesions. We suggest simple decompression as the procedure of first choice. Transposition can be used in selected cases or when simple decompression fails. All patients should be strongly recommended to stop smoking considering the remarkably increased risk for complications among smokers.

Smoking is associated with ulnar nerve entrapment: a birth cohort study

Ulnar nerve entrapment is the second most common compression neuropathy of the upper extremity. It has been associated with smoking in cross-sectional studies. Our aim was to study whether smoking is associated with ulnar nerve entrapment. The study population consisted of the Northern Finland Birth Cohort 1966 participants, who attended the 31-year follow-up in 1997 (N = 8,716). Information on smoking, body mass index (BMI), long-term illnesses, and socio-economic status were recorded at baseline in 1997. Data on hospitalizations due to ulnar nerve entrapment neuropathies was obtained from the Care Register for Health Care, 1997-2016. Hazard ratios (HR) with 95% confidence intervals (CI) and population attributable risk (PAR) were calculated adjusted for gender, BMI and socio-economic status. 66 patients were diagnosed with ulnar nerve entrapment in the follow-up 1997-2016. Before the age of 31 years, smoking ≤10 pack years associated with more than doubled (HR = 2.57, 95% CI = 1.29-5.15) and smoking >10 pack years with more than five-folded (HR = 5.61, 95% CI = 2.80-11.23) risk for ulnar nerve entrapment compared to non-smokers in the adjusted analyses. Adjusted PAR for smoking (reference of no smoking) was 53.6%. In our study, smoking associated with increased risk for ulnar nerve entrapment, accounting for considerable proportion of increased risk.

Comparison of Surgical Encounter Direct Costs for Three Methods of Cubital Tunnel Decompression

BACKGROUND

In situ decompression, subcutaneous transposition, and submuscular transposition for cubital tunnel syndrome have historically yielded similar outcomes. The authors' null hypothesis is that no differences exist in surgical encounter total direct costs for in situ decompression, subcutaneous transposition, and submuscular transposition.

METHODS

Adult patients treated surgically for cubital tunnel syndrome by four fellowship-trained hand surgeons between August of 2011 and December of 2016 were identified by CPT code (64718) at their tertiary academic institution. Patients with prior elbow surgery or fracture/dislocation and those undergoing revision or additional simultaneous procedures were excluded. Using their institution's information technology value tools, the authors extracted prospectively collected surgical encounter total direct costs data for each surgical encounter. Costs were compared between groups and modeled using univariate and multivariable gamma regression.

RESULTS

In situ decompression, subcutaneous transposition, and submuscular transposition were performed on 45, 62, and 14 unique surgical encounters, respectively, with mean surgical times of 28.0, 46.5, and 50.0 minutes, respectively. Costs differed significantly between surgical methods. Surgical method and provider significantly affected surgical encounter total direct costs in the univariate model. Multivariable modeling demonstrated that subcutaneous transposition was 1.18-fold more costly than in situ decompression and submuscular transposition was 1.55-fold more costly than in situ decompression while controlling for age, sex, and provider.

CONCLUSIONS

Surgical costs differed significantly between in situ decompression, subcutaneous transposition, and submuscular transposition. Given historically similar outcomes reported for these techniques, cost differences should be considered in addition to clinical factors to inform surgical decision-making for cubital tunnel syndrome patients.

Ulnar Nerve In Situ Decompression versus Transposition for Idiopathic Cubital Tunnel Syndrome: An Updated Meta-Analysis

Purpose Evidence for the superiority of in situ simple decompression (SD) versus ulnar nerve transposition (UNT) for cubital tunnel syndrome remains controversial. The purpose of this study was to compare the clinical improvement, complication rate, and revision rate of SD versus UNT using the available evidence. Materials and Methods We performed a literature search of relevant publications using PubMed, SCOPUS, Cochrane Library, and Springer Link. Inclusion criteria included (1) adult patients >18 years of age, (2) idiopathic cubital tunnel syndrome, (3) primary comparison studies including both SD versus UNT with discrete data for each procedure, (4) average follow-up of at least 2 months, and (5) a full English language manuscript available. Odds ratios of improvement, complications, and revision surgery after SD compared with UNT were calculated. Data were analyzed using both fixed and random effects models, and studies were assessed for publication bias and heterogeneity. Results A total of 1,511 articles from 1970 to 2017 were identified before inclusion, and exclusion criteria were applied. Ultimately 17 studies met the inclusion criteria and included 2,154 procedures. Of these, 1,040 were SD, and 1,114 were UNT procedures. Study heterogeneity was low. Odds ratios of clinical improvement and revision surgery with SD versus UNT were not significantly different. The odds ratio of complications with SD versus UNT was 0.449 (95% confidence interval [CI] of 0.290-0.695) and 0.469 (95% CI of 0.297-0.738) for fixed and random effect models, respectively. The difference in complications between SD versus UNT was significant ( P < 0.001). Conclusion There is no statistically significant difference in clinical outcomes or rate of revision surgery between SD versus UNT. However, there were significantly more complications with UNT. The current body of evidence regarding cubital tunnel syndrome lacks prospective, randomized, controlled trials, uniform reporting of indications, and standardized outcome scoring.

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

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

Patient-Related Risk Factors for Infection Following Ulnar Nerve Release at the Cubital Tunnel: An Analysis of 15,188 Cases

BACKGROUND

Although cubital tunnel release is a commonly performed orthopaedic procedure, the overall incidence of and independent risk factors for infection largely remain undefined in the current literature.

PURPOSE

To establish the rate of postoperative infection after isolated cubital tunnel release and define relevant patient-related risk factors.

STUDY DESIGN

Case-control study; Level 3.

METHODS

All Medicare-insured patients undergoing ulnar nerve decompression at the cubital tunnel from 2010 through 2012 were identified. A multivariate binomial logistic regression analysis was utilized to evaluate the impact of patient-related risk factors for postoperative infection.

RESULTS

A total of 330 (2.17%) postoperative infections were identified in 15,188 cases. The majority (87%) were managed nonoperatively, while 13% required surgical debridement. The most significant risk factors for infection included hemodialysis use (odds ratio [OR], 2.47), chronic anemia (OR, 2.24), age <65 years (OR, 2.08), tobacco use (OR, 1.65), morbid obesity (OR, 1.53), inflammatory arthritis (OR, 1.43), depression (OR, 1.36), hyperlipidemia (OR, 1.33), male sex (OR, 1.32), and chronic lung disease (OR, 1.29).

CONCLUSION

The present study was adequately powered to determine numerous patient-related risk factors for infection following cubital tunnel release.

Ulnar nerve entrapment complicating radial head excision

•

The cubital tunnel syndrome can be caused by iatrogenic elbow valgus after radial head excision.

•

The radial head excision is a good procedure when indicated but must be followed by radial head replacement.

•

A neurological examination should be systematically controlled for severe trauma to the elbow.

Introduction

Several mechanisms are involved in ischemia or mechanical compression of ulnar nerve at the elbow.

Presentation of case

We hereby present the case of a road accident victim, who received a radial head excision for an isolated fracture of the radial head and complicated by onset of cubital tunnel syndrome. This outcome could be the consequence of an iatrogenic valgus of the elbow due to excision of the radial head. Hitherto the surgical treatment of choice it is gradually been abandoned due to development of radial head implant arthroplasty. However, this management option is still being performed in some rural centers with low resources.

Discussion

The radial head plays an important role in the stability of the elbow and his iatrogenic deformity can be complicated by cubital tunnel syndrome.

Conclusion

An ulnar nerve release was performed with favorable outcome.

Anterior Subcutaneous Transposition of the Ulnar Nerve Affects Elbow Range of Motion: A Mean 13.5 Years of Follow-up

BACKGROUND

Surgical decompression of the ulnar nerve is effective for cubital tunnel syndrome. However, deep approaches may result in iatrogenic elbow stiffness. This long-term study was to evaluate the range of motion (ROM) of the elbow and functional outcomes after anterior subcutaneous transposition.

METHODS

A total of 115 patients (78 male and 37 female; mean age: 46.6 years) who underwent anterior subcutaneous transposition of the ulnar nerve between 2001 and 2005 were evaluated retrospectively; mean follow-up was 13.5 years. Elbow ROM was measured as flexion arc, flexion, and extension preoperatively and at the final follow-up, and compared via a mixed analysis of variance adjusting for age. Neuropathy was assessed preoperatively using a modified McGowan neuropathy grade and postoperatively using modified Wilson-Krout criteria. An ordinal logistic regression analysis used postoperative modified Wilson-Krout criteria as the outcome and preoperative factors as predictors.

RESULTS

Preoperative McGowan grades were Grade 1 in 14 patients (12.2%), Grade 2A in 28 (24.3%), Grade 2B in 53 (46.1%), and Grade 3 in 20 (17.4%) patients. Postoperatively, 66 patients (57.4%) had excellent results, 26 (22.6%) had good results, 16 (13.9%) had fair results, and 7 (6.1%) had poor results at the final follow-up, as per the Wilson-Krout criteria. There were no complications. Pre- and postoperative elbow ROM was significantly decreased in patients with previous trauma or surgery of the elbow compared with those without (P < 0.05). Anterior subcutaneous transposition of the ulnar nerve did not significantly affect elbow ROM regardless of previous trauma or surgical history nor preoperative ROM (P > 0.05), after adjusting for age. Patients with prolonged symptoms prior to surgery and worse neuropathy tended to have less satisfactory functional outcomes (P < 0.05), after adjusting for covariates.

CONCLUSIONS

Anterior subcutaneous transposition of the ulnar nerve is an effective and reliable treatment of cubital tunnel syndrome with satisfactory outcomes and minimal effect on elbow ROM.