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Becciolini M, Pivec C, Raspanti A, Riegler G. Ultrasound of the Ulnar Nerve: A Pictorial Review: Part 1: Normal Ultrasound Findings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:171-188. [PMID: 37815434 DOI: 10.1002/jum.16350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/19/2023] [Accepted: 09/24/2023] [Indexed: 10/11/2023]
Abstract
This is the first of a two-part article in which we focus on the ultrasound (US) appearance of the normal ulnar nerve (UN) and its main branches. The detailed US anatomy of the UN course is presented with high-resolution US images obtained with the latest-generation US machines and transducers.
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Affiliation(s)
- Marco Becciolini
- Department of Ultrasound, Misericordia di Pistoia, Pistoia, Italy
- Scuola Siumb di Ecografia Muscolo-Scheletrica, Pisa, Italy
| | - Christopher Pivec
- Department of Ultrasound, PUC-Private Ultrasound Center Vienna, Vienna, Austria
| | - Andrea Raspanti
- SOC Ortopedia e Traumatologia, Ospedale Santa Maria Annunziata, Azienda USL Toscana Centro, Firenze, Italy
| | - Georg Riegler
- Department of Ultrasound, PUC-Private Ultrasound Center Graz, Lassnitzhoehe, Austria
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
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Ferre-Martinez A, Miguel-Pérez M, Möller I, Ortiz-Miguel S, Pérez-Bellmunt A, Ruiz N, Sanjuan X, Agullo J, Ortiz-Sagristà J, Martinoli C. Possible Points of Ulnar Nerve Entrapment in the Arm and Forearm: An Ultrasound, Anatomical, and Histological Study. Diagnostics (Basel) 2023; 13:diagnostics13071332. [PMID: 37046548 PMCID: PMC10093241 DOI: 10.3390/diagnostics13071332] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023] Open
Abstract
Background: Ulnar nerve entrapment is one of the most common entrapment neuropathies, usually occurring in the cubital tunnel of the elbow and in Guyon’s canal of the wrist. However, it can also occur at other anatomical locations. Purpose: Our aim was to review other possible locations of ulnar nerve entrapment in an ultrasound and anatomical study. Material and Methods: Eleven upper limbs from eight adult corpses were ultrasonographically examined and subsequently dissected in a dissection laboratory. Four specific anatomical points were analysed, and any anatomical variations were documented. Moreover, six samples of the nerve were taken for histological analysis. Results: Distinct anatomical relationships were observed during ultrasound and dissection between the ulnar nerve and the medial intermuscular septum, the triceps aponeurosis, Osborne’s fascia at the elbow, the arcuate ligament of Osborne and the intermuscular aponeurosis between the flexor carpi ulnaris and the flexor digitorum superficialis muscles. A statistical study showed that these locations are potential areas for ulnar nerve compression. In addition, a fourth head of the triceps brachii muscle was found in some specimens. Conclusion: Results demonstrate that ultrasound is a good tool to investigate ulnar nerve entrapment neuropathy and to identify other anatomical points where the nerve can remain compressed.
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Affiliation(s)
- Andrea Ferre-Martinez
- Unit of Human Anatomy and Embryology, Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences (Bellvitge Campus), University of Barcelona, 08907 Barcelona, Spain
| | - Maribel Miguel-Pérez
- Unit of Human Anatomy and Embryology, Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences (Bellvitge Campus), University of Barcelona, 08907 Barcelona, Spain
| | - Ingrid Möller
- Unit of Human Anatomy and Embryology, Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences (Bellvitge Campus), University of Barcelona, 08907 Barcelona, Spain
| | - Sara Ortiz-Miguel
- Unit of Human Anatomy and Embryology, Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences (Bellvitge Campus), University of Barcelona, 08907 Barcelona, Spain
- Basic Sciences Department, Universitat Internacional de Catalunya, 08017 Barcelona, Spain
| | - Albert Pérez-Bellmunt
- Basic Sciences Department, Universitat Internacional de Catalunya, 08017 Barcelona, Spain
| | - Núria Ruiz
- Unit of Human Anatomy and Embryology, Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences (Bellvitge Campus), University of Barcelona, 08907 Barcelona, Spain
- Department of Pathology, University Hospital of Bellvitge, 08907 Barcelona, Spain
| | - Xavier Sanjuan
- Department of Pathology, University Hospital of Bellvitge, 08907 Barcelona, Spain
- Unit of Pathological Anatomy, Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences (Bellvitge Campus), University of Barcelona, 08907 Barcelona, Spain
| | - Jose Agullo
- Unit of Human Anatomy and Embryology, Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences (Bellvitge Campus), University of Barcelona, 08907 Barcelona, Spain
| | | | - Carlo Martinoli
- Cattedra di Radiologia “R”-DICMI, Universita di Genova, 16126 Genoa, Italy
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Jung HS, Jang YH, Lee HI, Lee JS. Clinical comparison of the over-the-top and flexor carpi ulnaris split approaches for the treatment of anteromedial facet fracture of the coronoid process. J Shoulder Elbow Surg 2021; 30:1750-1758. [PMID: 33675975 DOI: 10.1016/j.jse.2021.01.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/14/2021] [Accepted: 01/31/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The flexor carpi ulnaris (FCU)-split approach and the over-the-top approach have been used frequently for the fixation of anteromedial facet (AMF) fractures of the coronoid process. Clinical studies have not compared functional recovery and complication rates associated with these approaches. This study aimed to compare the clinical effectiveness of the over-the-top and FCU-split approaches for the treatment of AMF fractures of the coronoid process. METHODS Thirty-two patients who underwent surgery for AMF fractures between January 2013 and August 2019 were divided into the FCU-split and over-the-top groups. The FCU-split approach was used from January 2013 to March 2016, and the over-the-top approach was used from April 2016 to August 2019. Bony union, radiographic signs of osteoarthritis (Broberg and Morrey classification), and development of heterotopic ossification were evaluated. Postoperative pain score (visual analog scale at 2 days after the operation), surgical time (minutes), range of motion of the elbow, elbow function (Mayo Elbow Performance Score [MEPS]), and the presence of postoperative ulnar neuropathy were also compared between the 2 groups. RESULTS The FCU-split and over-the-top approaches were performed in 15 and 17 patients, respectively. The mean age was 46 ± 13 years (range, 22-67 years), and the mean follow-up duration was 19± 6.7 months (range, 13-38 months). All coronoid fractures had a solid osseous union during the follow-up, and no subluxation or dislocation was observed in the 2 groups. The occurrence of heterotopic ossification and the grade of post-traumatic arthritis did not differ significantly between the groups (all P > .05). There were also no significant differences between the groups in terms of postoperative pain score, range of motion, and MEPS (all P > .05). However, the surgical time was shorter for the over-the-top approach than that for the FCU-split approach (79± 23 vs. 101 ± 14, P = .008), and the surgical time was significantly associated with the fracture classification and surgical approach (P = .001 and .003, respectively). In addition, postoperative ulnar neuropathy occurred less with the over-the-top approach than with the FCU-spilt approach (5.9% vs. 46%, P = .013). CONCLUSION Both the FCU-split and over-the-top approaches were appropriate for performing the buttress plate fixation for AMF fractures of the coronoid process and for restoring the elbow stability. The fixation of AMF fractures through the over-the-top approach was technically easier and had less incidence of postoperative ulnar neuropathy.
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Affiliation(s)
- Hyoung-Seok Jung
- Department of Orthropaedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea
| | - Ye-Hoon Jang
- Department of Orthropaedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea
| | - Hyun Il Lee
- Department of Orthopaedic Surgery, Ilsan-Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Jae-Sung Lee
- Department of Orthropaedic Surgery, Hospital of Chung-Ang University of Medicine, Seoul, Republic of Korea.
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Mezian K, Jačisko J, Kaiser R, Machač S, Steyerová P, Sobotová K, Angerová Y, Naňka O. Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment. Front Neurol 2021; 12:661441. [PMID: 34054704 PMCID: PMC8160369 DOI: 10.3389/fneur.2021.661441] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/23/2021] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Jakub Jačisko
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czechia
| | - Stanislav Machač
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Petra Steyerová
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Karolína Sobotová
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Yvona Angerová
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Ondřej Naňka
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czechia
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Ortiz-Miguel S, Miguel-Pérez M, Navarro J, Möller I, Pérez-Bellmunt A, Agullo JL, Ortiz-Sagristà J, Blasi J, Martinoli C. Compartments of the antebrachial fascia of the forearm: clinically relevant ultrasound, anatomical and histological findings. Surg Radiol Anat 2021; 43:1569-1579. [PMID: 33818623 DOI: 10.1007/s00276-021-02736-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 03/10/2021] [Indexed: 01/14/2023]
Abstract
PURPOSE Acute compartment syndrome is defined as a limb-threatening condition caused by bleeding or oedema in a closed muscle compartment surrounded by fascia or bone. It is most commonly encountered in the forearm, which has three compartments: posterior, anterior and lateral. These are surrounded and closed in by the antebrachial fascia, formed by dense connective tissue that facilities their study on ultrasound and is key to fasciotomy treatment. The purpose of this study was to broaden existing ultrasound, anatomical and histological knowledge of the fascia of the forearm to facilitate their identification on ultrasound, with possible clinical and therapeutic applications. METHODS The study was performed in 50 cryopreserved upper limbs from adult cadavers from the dissection room of the Faculty of Medicine and Health Sciences. They were examined on ultrasound and subsequent anatomical dissection and microscopy to study the fascia and its relationship with different muscles of the forearm compartments. RESULTS Distinct anatomical relationships were observed on ultrasound and dissection between the fascia and the extensor carpi ulnaris, extensor digiti minimi, and anconeus muscle in the posterior compartment, and the flexor carpi radialis and flexor carpi ulnaris in the anterior compartment. They were isolated by the antebrachial fascia and had distinct relationships with the neurovascular structures. CONCLUSION These results demonstrate that high-definition ultrasound enables us to locate the antebrachial fascia and particular muscles with a distinct relationship with neurovascular structures. This helps better identify these structures, facilitating diagnosis of any pathology in the area, with potential therapeutic and clinical applications.
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Affiliation(s)
- S Ortiz-Miguel
- Unit of Human Anatomy and Embryology, University of Barcelona, C/Feixa Llarga s/n 08907, L'Hospitalet de Llobregat, Barcelona, Spain.,Basic Sciences Department, Universitat Internacional de Catalunya, Barcelona, Spain
| | - M Miguel-Pérez
- Unit of Human Anatomy and Embryology, University of Barcelona, C/Feixa Llarga s/n 08907, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - J Navarro
- Unit of Human Anatomy and Embryology, University of Barcelona, C/Feixa Llarga s/n 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - I Möller
- Unit of Human Anatomy and Embryology, University of Barcelona, C/Feixa Llarga s/n 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | - A Pérez-Bellmunt
- Basic Sciences Department, Universitat Internacional de Catalunya, Barcelona, Spain
| | - J L Agullo
- Unit of Human Anatomy and Embryology, University of Barcelona, C/Feixa Llarga s/n 08907, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - J Blasi
- Unity of Histology, Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences (Bellvitge Campus), University of Barcelona, Barcelona, Spain
| | - C Martinoli
- Cattedra di Radiologia "R"-DICMI, Universita di Genova, Genoa, Italy
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Draghi F, Bortolotto C, Ballerini D, Preda L. Ultrasonography of the ulnar nerve in the elbow: video article. J Ultrasound 2020; 23:335-336. [PMID: 32222947 DOI: 10.1007/s40477-020-00451-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022] Open
Abstract
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.
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Affiliation(s)
- Ferdinando Draghi
- Radiology Department, Istituto Di Radiologia, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
| | - Chandra Bortolotto
- Radiology Department, Istituto Di Radiologia, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy.
| | - Daniela Ballerini
- Radiology Department, Istituto Di Radiologia, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
| | - Lorenzo Preda
- Radiology Department, Istituto Di Radiologia, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi 2, 27100, Pavia, Italy
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Choi PJ, Nwaogbe C, Iwanaga J, Georgiev GP, Oskouian RJ, Tubbs RS. The Deep Fascia of the Forearm and the Ulnar Nerve: An Anatomical Study. Cureus 2018; 10:e2842. [PMID: 30131934 PMCID: PMC6101443 DOI: 10.7759/cureus.2842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction A reoperation for a cubital tunnel syndrome is not uncommon. Patients often complain of sensorimotor symptoms in the ulnar nerve distribution after their primary surgery. The documented etiologies for such a phenomenon include a “new” kinking of the distal ulnar nerve and a “new” compression of the ulnar nerve by the fascial septum in between or tendinous bands over the muscles of the forearm. The deep fascial plane along which the ulnar nerve travels in the forearm has had scant attention. We present an anatomical study to provide a better understanding of such etiologies to aid physicians in performing successful primary ulnar nerve release that does not lead to risky reoperations and ultimately yields improved patient satisfaction. Materials and methods The forearms of 12 fresh frozen cadavers (24 arms) underwent dissection, during which the fascial relationships between the ulnar nerve and muscles of the anterior compartment were explored with a blunt technique. The relationship between the fascial planes and the ulnar nerve was quantitatively and qualitatively documented. The ranges of motion of the elbow were also observed for any potential compression points on the nerve during the movement. Results In all specimens (n = 24), the ulnar nerve entered the forearm between the humeral and ulnar heads of the flexor carpi ulnaris, after which it routed deep to a deep fascia between the anterior surface of the flexor carpi ulnaris and the posterior surface of the flexor digitorum superficialis. Ulnar nerve branches to the flexor carpi ulnaris pierced this fascial septum while en route to the posterior surface of the muscle. Medially, the branches to the flexor digitorum profundus also pierced this fascial plane. In most arms, the fascia became thinner near the junction between the proximal two-thirds and distal one-third of the forearm. On no side was the ulnar nerve found to be grossly compressed by this deep fascia. However, with the extension of the elbow, a degree of angulation of the proximal ulnar nerve was observed due to its compact connection with the deep fascia. Conclusion Our study revealed that there is an intimate relationship between the ulnar nerve and the deep fascia of the forearm. Since the ulnar branches to the overlying flexor carpi ulnaris pierce this deep structure, a care should be given to its anatomical course during surgery in this region to prevent denervation of the muscle.
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Affiliation(s)
- Paul J Choi
- Surgery, Seattle Science Foundation, Seattle, USA
| | - Chidinma Nwaogbe
- Molecular, Cellular & Biomedical Sciences, CUNY School of Medicine, New York, USA
| | | | - Georgi P Georgiev
- Orthopaedics and Traumatology, University Hospital Queen Giovanna, Sofia, BGR
| | - Rod J Oskouian
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - R Shane Tubbs
- Neurosurgery, Seattle Science Foundation, Seattle, USA
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