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McEachan JE, Dahlin LB, Ng CY, Ring D, Ruettermann M. Round table discussion: the management of idiopathic cubital tunnel syndrome. J Hand Surg Eur Vol 2024; 49:926-932. [PMID: 38534139 DOI: 10.1177/17531934241238942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
Idiopathic cubital tunnel syndrome is the second most common neuropathy in the upper limb. Best evidence regarding the surgical management of this condition has evolved from anterior or submuscular transposition as the former reference standard, to in situ simple release. Differences of opinion remain regarding the timing of surgery, type of surgery and adjunctive surgery. Four surgeons with Level 5 expertise were asked to answer specific questions regarding this condition.
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Affiliation(s)
- Jane E McEachan
- Fife Hand Clinic, Department of Orthopaedic Surgery, NHS Fife, UK
| | - Lars B Dahlin
- Department of Translational Medicine-Hand Surgery, Lund University, Malmö, Sweden
- Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Chye Yew Ng
- Upper Limb Unit, Wrightington Hospital, Wigan, UK
| | - David Ring
- University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Mike Ruettermann
- Department of Plastic Surgery, University of Groningen, Groningen, The Netherlands
- Institute for Hand and Plastic Surgery, Oldenburg, Germany
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2
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Ahmadli N, Akgun K, Terlemez R, Misirlioglu TO, Palamar D. Ultrasonographic evaluation of ulnar nerve morphology in patients with ulnar nerve instability. Muscle Nerve 2024; 69:543-547. [PMID: 38356457 DOI: 10.1002/mus.28058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/16/2024]
Abstract
INTRODUCTION/AIMS Ulnar nerve instability (UNI) in the retroepicondylar groove is described as nerve subluxation or dislocation. In this study, considering that instability may cause chronic ulnar nerve damage by increasing the friction risk, we aimed to examine the effects of UNI on nerve morphology ultrasonographically. METHODS Asymptomatic patients with clinical suspicion of UNI were referred for further clinical and ultrasonographic examination. Based on ulnar nerve mobility on ultrasound, the patients were first divided into two groups: stable and unstable. The unstable group was further divided into two subgroups: subluxation and dislocation. The cross-sectional area (CSA) of the nerve was measured in three regions relative to the medial epicondyle (ME). RESULTS In the ultrasonographic evaluation, UNI was identified in 59.1% (52) of the 88 elbows. UNI was bilateral in 50% (22) of the 44 patients. Mean CSA was not significantly different between groups. A statistically significant difference in ulnar nerve mobility was found between the group with CSA of <10 versus ≥10 mm2 (p = .027). Nerve instability was found in 85.7% of elbows with an ulnar nerve CSA value of ≥10 mm2 at the ME level. DISCUSSION The probability of developing neuropathy in patients with UNI may be higher than in those with normal nerve mobility. Further prospective studies are required to elucidate whether asymptomatic individuals with UNI and increased CSA may be at risk for developing symptomatic ulnar neuropathy at the elbow.
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Affiliation(s)
- Narmin Ahmadli
- Department of Physical Medicine and Rehabilitation, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Kenan Akgun
- Department of Physical Medicine and Rehabilitation, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Rana Terlemez
- Department of Physical Medicine and Rehabilitation, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Tugce Ozekli Misirlioglu
- Department of Physical Medicine and Rehabilitation, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Deniz Palamar
- Department of Physical Medicine and Rehabilitation, İstanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
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Przyklenk A, Hackl M, Leschinger T, Ott N, Harbrecht A, Müller LP, Wegmann K. Comprehensive analysis and classification of retrocondylar ulnar groove morphology using CT imaging in an average population of adults. Surg Radiol Anat 2024; 46:473-482. [PMID: 38329521 PMCID: PMC10995007 DOI: 10.1007/s00276-024-03297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/03/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE Anatomical variations of the concave shaped retrocondylar ulnar groove (RUG) can contribute to ulnar nerve instability. However, there are currently limited available standardized data describing the anatomy of the RUG based on radiologic imaging, such as computed tomography (CT). This study aims to provide a comprehensive description and classification of RUG anatomy based on RUG angle measurements. METHODS 400 CT scans of the elbows of adults showing no signs of osseous damage were evaluated. RUG angles were measured in four anatomically defined axial planes that spanned from the proximal to the distal end of the RUG. Furthermore, distance measurements at the medial epicondyle were conducted. A classification system for the RUG is proposed based on the acquired RUG angles, aiming to categorize the individual angles according to the 25th and 75th percentiles. RESULTS RUG angles were significantly larger in males compared to females (p < 0.001) accompanied by larger distances including the off-set and height of the medial epicondyle (p < 0.001). RUG angles decreased from proximal to distal locations (p < 0.05). CONCLUSION This study revealed that men exhibited larger RUG angles compared to women, indicating a less-concave shape of the RUG in men. Introducing an objective RUG classification system can improve our understanding of anatomical variations and potentially find application in diagnostics and preoperative planning.
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Affiliation(s)
- Axel Przyklenk
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - Michael Hackl
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Tim Leschinger
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Nadine Ott
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Andreas Harbrecht
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Lars Peter Müller
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Kilian Wegmann
- Department of Orthopedic and Trauma Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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Hannaford A, Simon NG. Ulnar neuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:103-126. [PMID: 38697734 DOI: 10.1016/b978-0-323-90108-6.00006-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Ulnar neuropathy at the elbow is the second most common compressive neuropathy. Less common, although similarly disabling, are ulnar neuropathies above the elbow, at the forearm, and the wrist, which can present with different combinations of intrinsic hand muscle weakness and sensory loss. Electrodiagnostic studies are moderately sensitive in diagnosing ulnar neuropathy, although their ability to localize the site of nerve injury is often limited. Nerve imaging with ultrasound can provide greater localization of ulnar injury and identification of specific anatomical pathology causing nerve entrapment. Specifically, imaging can now reliably distinguish ulnar nerve entrapment under the humero-ulnar arcade (cubital tunnel) from nerve injury at the retro-epicondylar groove. Both these pathologies have historically been diagnosed as either "ulnar neuropathy at the elbow," which is non-specific, or "cubital tunnel syndrome," which is often erroneous. Natural history studies are few and limited, although many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously. Conservative management, perineural steroid injections, and surgical release have all been studied in treating ulnar neuropathy at the elbow. Despite this, questions remain about the most appropriate management for many patients, which is reflected in the absence of management guidelines.
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Affiliation(s)
- Andrew Hannaford
- Westmead Clinical School, Westmead Hospital, University of Sydney, Westmead, NSW, Australia
| | - Neil G Simon
- Northern Beaches Clinical School, Macquarie University, Sydney, NSW, Australia.
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Ruettermann M, Broekstra DC, Groen GJ, Elting JW. Ultra-high-definition (22 MHz) ultrasound of the ulnar nerve: additional value and normative data. J Hand Surg Eur Vol 2023; 48:1036-1041. [PMID: 37125764 DOI: 10.1177/17531934231167751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
We studied 30 healthy volunteers (60 arms), categorized into three age groups with equal numbers to verify if a 22 MHz compared with a 15 MHz ultrasound transducer has additional value for studying the intraneural architecture of the ulnar nerve throughout its course. At six sites, there were no differences in cross-sectional area measurements between the two transducers. With both, the cross-sectional area was significantly larger at the medial epicondyle compared with the other sites and smaller at the mid-forearm and Guyon's canal compared with the mid-upper arm. With higher age the cross-sectional area significantly increased. Significantly more fascicles were visible distal to the medial epicondyle compared with more proximal sites, as well as in men compared with women. Finally, higher body weight was related to a significantly smaller number of fascicles being seen. A 22 MHz transducer depicts more details of the intraneural architecture than a 15 MHz transducer. Our data can be used as normative data or reference values in analysing ulnar nerve pathology.Level of evidence: II.
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Affiliation(s)
- Mike Ruettermann
- Department of Plastic Surgery, University Medical Centre Groningen, University of Groningen, The Netherlands
- Institute for Hand and Plastic Surgery Oldenburg, Oldenburg, Germany
| | - Dieuwke C Broekstra
- Department of Plastic Surgery, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Gerbrand J Groen
- Paincentre Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Jan Willem Elting
- Clinical Neurophysiology, Department of Neurology, University Medical Centre Groningen, University of Groningen, The Netherlands
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Pirri C, Pirri N, Stecco C, Macchi V, Porzionato A, De Caro R, Özçakar L. Hearing and Seeing Nerve/Tendon Snapping: A Systematic Review on Dynamic Ultrasound Examination. SENSORS (BASEL, SWITZERLAND) 2023; 23:6732. [PMID: 37571516 PMCID: PMC10422582 DOI: 10.3390/s23156732] [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: 06/25/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023]
Abstract
Nerve/tendon snapping can occur due to their sudden displacement during the movement of an adjacent joint, and the clinical condition can really be painful. It can actually be challenging to determine the specific anatomic structure causing the snapping in various body regions. In this sense, ultrasound examination, with all its advantages (especially providing dynamic imaging), appears to be quite promising. To date, there are no comprehensive reviews reporting on the use of dynamic ultrasound examination in the diagnosis of nerve/tendon snapping. Accordingly, this article aims to provide a substantial discussion as to how US examination would contribute to 'seeing' and 'hearing' these pathologies' different maneuvers/movements.
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Affiliation(s)
- Carmelo Pirri
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy; (C.S.); (V.M.); (A.P.); (R.D.C.)
| | - Nina Pirri
- Department of Medicine—DIMED, School of Radiology, Radiology Institute, University of Padua, 35122 Padova, Italy;
| | - Carla Stecco
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy; (C.S.); (V.M.); (A.P.); (R.D.C.)
| | - Veronica Macchi
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy; (C.S.); (V.M.); (A.P.); (R.D.C.)
| | - Andrea Porzionato
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy; (C.S.); (V.M.); (A.P.); (R.D.C.)
| | - Raffaele De Caro
- Department of Neurosciences, Institute of Human Anatomy, University of Padova, 35121 Padova, Italy; (C.S.); (V.M.); (A.P.); (R.D.C.)
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, 06100 Ankara, Turkey;
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Ooi MWX, Tham JL, Al-Ani Z. Role of dynamic ultrasound in assessment of the snapping elbow and distal biceps tendon injury. ULTRASOUND (LEEDS, ENGLAND) 2022; 30:315-321. [PMID: 36969535 PMCID: PMC10034657 DOI: 10.1177/1742271x211057204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022]
Abstract
Introduction Ultrasound is useful in assessing patients with snapping syndromes around the elbow joint. The dynamic nature of the examination allows for direct visualisation of the underlying causative factor.Topic description: We discuss the role of dynamic ultrasound in assessing various snapping syndromes around the elbow, such as ulnar nerve instability, snapping triceps and less commonly, snapping brachialis. Ultrasound is also useful in evaluating the distal biceps tendon, particularly in differentiating partial from complete tendon injury. Discussion Ulnar nerve instability and snapping triceps can be assessed via a medial approach with the transducer placed transversely between the medial epicondyle and the olecranon. In ulnar nerve instability, the nerve can be seen crossing over the medial epicondyle on elbow flexion. In snapping triceps syndrome, both the ulnar nerve and the distal triceps can be seen dislocating over the medial epicondyle. Dynamic assessment of the distal biceps tendon using a lateral approach minimises anisotropy artefact often seen on the anterior approach. Passive pronation and supination of the forearm will reveal little or no movement in a completely torn tendon whereas moving tendon fibres will be appreciated in partial tears. In a snapping brachialis, the medial portion of brachialis will be seen abnormally translocating anterolateral to the medial border of the trochlea during elbow flexion and snapping back into its normal position on elbow extension. Conclusion Dynamic ultrasound of the elbow is valuable in diagnosing patients with snapping sensations around the joint and in evaluating the integrity of the distal biceps tendon.
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Affiliation(s)
| | - Jun-Li Tham
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan,
UK
| | - Zeid Al-Ani
- Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan,
UK
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Jorgensen SP, Cartwright MS, Norbury J. Neuromuscular Ultrasound: Indications in the Electrodiagnostic Laboratory. Am J Phys Med Rehabil 2022; 101:78-88. [PMID: 33990480 DOI: 10.1097/phm.0000000000001790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Accurate assessment of neuromuscular disorders is critical to facilitate timely treatment and achieve the best outcomes. Historically, electrodiagnostic studies have filled this role, but recently, neuromuscular ultrasound is being used in the electrodiagnostic laboratory. This review discusses the uses of neuromuscular ultrasound in the electrodiagnostic laboratory that have strong evidence, emphasizing those that could be adopted in a typical electrodiagnostic laboratory with a reasonable level of equipment and training. The evidence currently supports using neuromuscular ultrasound to diagnose carpal tunnel syndrome and ulnar neuropathies at the elbow and as a supplementary test when electrodiagnostic studies are suspected to be falsely negative or in axonal nonlocalizing lesions. Neuromuscular ultrasound can identify the causes of focal mononeuropathies, which can change treatment in specific cases. It is sensitive at identifying fasciculations and providing complementary evidence of autoimmune demyelinating polyneuropathies. It is particularly helpful in assessing nerves after trauma. Neuromuscular ultrasound is likely to prove even more useful in the electrodiagnostic laboratory as the technology continues to advance.
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Affiliation(s)
- Shawn P Jorgensen
- From the Department of Physical Medicine and Rehabilitation, Albany Medical College, Albany, New York (SPJ); Department of Family Medicine, Larner Medical College at the University of Vermont, Burlington, Vermont (SPJ); Adirondack Rehabilitation Medicine, PLLC, Queensbury, New York (SPJ); Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, North Carolina (MSC); and Division of Physical Medicine and Rehabilitation, Department of Neurology, Texas Tech University Health Sciences Center, Lubbock, Texas (JN)
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Limbekar NS, Soong MC, Vytopil MM, Blanchet DT, Paci GM, Ho DT. High-Resolution Ultrasound in the Diagnosis and Surgical Management of Ulnar Neuropathy at the Elbow. Orthopedics 2021; 44:285-288. [PMID: 34590945 DOI: 10.3928/01477447-20210819-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
High-resolution ultrasound (HRU) has recently demonstrated the potential to facilitate diagnosis and treatment of upper extremity compression neuropathy. The authors hypothesized that HRU can improve preoperative evaluation of ulnar neuropathy at the elbow (UNE) and that changes in ulnar nerve cross-sectional area (CSA) after cubital tunnel release may correlate with outcomes. Nineteen adult patients diagnosed with UNE who were scheduled for surgical decompression by a single hand surgeon were enrolled. Electrodiagnostic (EDX) testing, HRU of the ulnar nerve, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and McGowan grade were obtained pre- and postoperatively. Fourteen patients completed the study. Statistically significant improvements were found in CSA measurements and QuickDASH scores. High-resolution ultra-sound was found to confirm UNE in all 7 patients with positive results on EDX, and additionally detected UNE in 3 of 6 patients with negative results on EDX and in 1 patient with equivocal (nonlocalized) EDX testing. All 4 of these additional HRU-detected cases improved clinically and by CSA measurements after surgery. In this series, HRU was superior to EDX testing in the diagnosis of UNE and demonstrated objective improvement in ulnar nerve CSA after successful cubital tunnel release. This modality, which is better tolerated, less costly, and less time-consuming than EDX testing or magnetic resonance imaging, should therefore be considered in the diagnosis and surgical management of UNE, particularly in cases with negative or equivocal results on EDX testing, or when outcomes are suboptimal. [Orthopedics. 2021;44(5):285-288.].
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The ultrasonographic assessment of the morphologic changes in the ulnar nerve at the cubital tunnel in Japanese volunteers: relationship between dynamic ulnar nerve instability and clinical symptoms. JSES Int 2021; 5:942-947. [PMID: 34505110 PMCID: PMC8411065 DOI: 10.1016/j.jseint.2021.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background We investigated the differences in the prevalence of ulnar nerve instability (UNI) by hand dominance and evaluated the relationship between UNI and morphologic changes in the ulnar nerve and the clinical findings and upper limb function. Methods This study examined 153 healthy participants (n = 306 elbows; 44 men, 112 women; mean age 65.4 years) who underwent ultrasonography to assess the ulnar nerve cross-sectional area (UNCSA) at three points of the bilateral cubital tunnel at 30° of elbow flexion. Participants were divided into three groups based on the ultrasonography findings of UNI: no instability (type N), subluxation (type S), and dislocation (type D). For the dominant and nondominant sides, we assessed the relationship between the UNCSA and clinical factors, including the age, gender, height, weight, body mass index, fat mass, grip strength, key pinch strength, UNCSA, and Patient-Rated Elbow Evaluation score. Results We identified 75 cases without instability in both elbows and 78 cases with some instability. The prevalence of UNI was 51%. No significant difference was found between hand dominance and the prevalence of UNI. The UNCSA at 1 cm proximal to the medial epicondyle on the bilateral sides in type S was the most increased among three types. Conclusion UNI was identified in almost half of the participants, with no marked difference found in the hand dominance. The UNCSA at 1 cm proximal to the medial epicondyle was significantly increased the most in type S. UNI does not appear to be associated with elbow symptoms in the general population.
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Ulnar Nerve Dislocation and Subluxation from the Cubital Tunnel Are Common in College Athletes. J Clin Med 2021; 10:jcm10143131. [PMID: 34300295 PMCID: PMC8304120 DOI: 10.3390/jcm10143131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Hypermobility of the ulnar nerve from the cubital tunnel reportedly occurs in healthy people without symptoms of ulnar neuropathy. However, the occurrence rate in athletes is unknown. We examined the occurrence rate of ulnar nerve hypermobility using ultrasonography, symptoms, and physical findings in athletes and compared the results of four types of sports. Methods: Medical charts of college athletes competing in baseball, rugby, soccer, and long-distance running between March and November 2018 were retrospectively examined. Dynamic evaluation of the ulnar nerve was performed using ultrasonography and categorized as Types N, S, and D respectively, indicating normal position, subluxation, and dislocation. Subjective and objective findings were evaluated. Results: The present study included 246 male athletes (mean age, 19.7 years; 492 elbows) including 46% Type D, 29.8% Type S, and 24.2% Type N. Subjective findings showed pain and dysesthesia in 9% and 4.5% of participants, respectively, whereas objective findings showed Tinel sign in 6%, nerve tension test in 1.3%, Froment’s sign in 0.5%, and weakness of strength of opponens digiti minimi muscle in 8% of patients with Types D and S. Conclusions: There was a high-frequency hypermobility of the ulnar nerve from the cubital tunnel with or without subjective and objective findings in college athletes.
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Frost G, Varey P, Haldane C, Lee T, Finlayson H. Is There an Association Between Ulnar Nerve Hypermobility and Neuropathy at the Elbow? Arch Phys Med Rehabil 2021; 102:2231-2238. [PMID: 33716114 DOI: 10.1016/j.apmr.2021.02.021] [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: 11/05/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To systematically review the association between ulnar nerve hypermobility (UNH) at the elbow and ulnar neuropathy (UNE). DATA SOURCES Cumulative Index to Nursing and Allied Health, MEDLINE, and Embase databases were searched for English language studies published up to July 4, 2020. STUDY SELECTION We included case-control, cohort, and randomized controlled studies that established the presence or absence of UNH and UNE. Twenty out of 654 studies identified met the inclusion criteria. DATA EXTRACTION Two reviewers independently extracted data for analysis. Risk of bias and applicability were assessed with the QUADAS-2 tool. DATA SYNTHESIS We compared rates of UNH between patients diagnosed with and without UNE and found no significant difference. The meta-analysis pooled rate of UNH was 0.37 (95% confidence interval, 0.20-0.57) for those without UNE and 0.33 (95% confidence interval, 0.23-0.45) for those with UNE. CONCLUSIONS The clinical finding of UNH is unhelpful when assessing for UNE, as the presence of UNH does not make the diagnosis of UNE more likely.
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Affiliation(s)
- Geoffrey Frost
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Peter Varey
- Division of Physical Medicine and Rehabilitation, Department of Medicine, McMaster University, Hamilton, Ontario
| | - Chloe Haldane
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia
| | - Heather Finlayson
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia; GF Strong Rehabilitation Centre, Vancouver, British Columbia, Canada.
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Ulnar nerve subluxation and dislocation: a review of the literature. Neurosurg Rev 2020; 44:793-798. [PMID: 32338326 DOI: 10.1007/s10143-020-01286-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/22/2020] [Accepted: 03/09/2020] [Indexed: 12/12/2022]
Abstract
The pathogenesis of ulnar nerve subluxation and dislocation is widely debated. Upon elbow flexion, the ulnar nerve slips out of the groove for the ulnar nerve, relocates medial or anterior to the medial epicondyle, and returns to its correct anatomical position upon extension. This chronic condition can cause neuritis or neuropathy; however, it has also been suggested that it protects against neuropathy by reducing tension along the nerve. This article reviews the extant literature with the aim of bringing knowledge of the topic into perspective and standardizing terminology.
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Role of dynamic sonography in ulnar nerve entrapment at elbow. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0063-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Aird C, Thoirs K, Maranna S, Massy-Westropp N. Ultrasound Measurements and Assessments of the Ulnar Nerve at the Elbow and Cubital Tunnel: A Scoping Review. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2019. [DOI: 10.1177/8756479319870467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Ulnar neuropathy at the elbow (UNE) is the second most frequent peripheral nerve entrapment neuropathy in the upper extremity. The diagnosis is determined through a combination of history, physical examination, and electrodiagnostic testing. However, the use of high-resolution sonography is increasing, with sonographic measurements of ulnar nerve dimension established as a reliable diagnostic criterion for UNE. Sonographic imaging can describe anatomical features beyond ulnar nerve size, and therefore additional observations could potentially be used in UNE diagnosis and treatment follow-up. This review was a scoping of the literature on different sonographic measurements and assessments that have been reported to evaluate the ulnar nerve and cubital tunnel. This should provide a guide to scanning protocols for sonographers.
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Affiliation(s)
- Courtney Aird
- The University of South Australia, Adelaide, South Australia, Australia
| | - Kerry Thoirs
- International Centre for Allied Health Evidence (iCAHE), University of South Australia, Adelaide, South Australia, Australia
| | - Sandhya Maranna
- Cancer Research Institute, University of South Australia, Adelaide, South Australia, Australia
| | - Nicola Massy-Westropp
- International Centre for Allied Health Evidence (iCAHE), University of South Australia, Adelaide, South Australia, Australia
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Walker FO, Cartwright MS, Alter KE, Visser LH, Hobson-Webb LD, Padua L, Strakowski JA, Preston DC, Boon AJ, Axer H, van Alfen N, Tawfik EA, Wilder-Smith E, Yoon JS, Kim BJ, Breiner A, Bland JDP, Grimm A, Zaidman CM. Indications for neuromuscular ultrasound: Expert opinion and review of the literature. Clin Neurophysiol 2018; 129:2658-2679. [PMID: 30309740 DOI: 10.1016/j.clinph.2018.09.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/10/2018] [Accepted: 09/02/2018] [Indexed: 12/11/2022]
Abstract
Over the last two decades, dozens of applications have emerged for ultrasonography in neuromuscular disorders. We wanted to measure its impact on practice in laboratories where the technique is in frequent use. After identifying experts in neuromuscular ultrasound and electrodiagnosis, we assessed their use of ultrasonography for different indications and their expectations for its future evolution. We then identified the earliest papers to provide convincing evidence of the utility of ultrasound for particular indications and analyzed the relationship of their date of publication with expert usage. We found that experts use ultrasonography often for inflammatory, hereditary, traumatic, compressive and neoplastic neuropathies, and somewhat less often for neuronopathies and myopathies. Usage significantly correlated with the timing of key publications in the field. We review these findings and the extensive evidence supporting the value of neuromuscular ultrasound. Advancement of the field of clinical neurophysiology depends on widespread translation of these findings.
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Affiliation(s)
- Francis O Walker
- Department of Neurology at Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, USA.
| | - Michael S Cartwright
- Department of Neurology at Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, USA.
| | - Katharine E Alter
- Department of Rehabilitation Medicine, National INeurolnstitutes of Health, Bethesda, MD 20892, USA.
| | - Leo H Visser
- Departments of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
| | - Lisa D Hobson-Webb
- Department of Neurology, Neuromuscular Division, Duke University School of Medicine, Durham, NC, USA.
| | - Luca Padua
- Don Carlo Gnocchi ONLUS Foundation, Piazzale Rodolfo Morandi, 6, 20121 Milan, Italy; Department of Geriatrics, Neurosciences and Orthopaedics, Universita Cattolica del Sacro Cuore, Rome, Italy.
| | - Jeffery A Strakowski
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, OH, USA; Department of Physical Medicine and Rehabilitation, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA; OhioHealth McConnell Spine, Sport and Joint Center, Columbus, OH, USA.
| | - David C Preston
- Neurological Institute, University Hospitals, Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Andrea J Boon
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA.
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena 07747, Germany.
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Eman A Tawfik
- Department of Physical Medicine & Rehabilitation, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Einar Wilder-Smith
- Department of Neurology, Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Neurology, Kantonsspital Lucerne, Switzerland; Department of Neurology, Inselspital Berne, Switzerland.
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Republic of Korea.
| | - Byung-Jo Kim
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Ari Breiner
- Division of Neurology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Canada.
| | - Jeremy D P Bland
- Deparment of Clinical Neurophysiology, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK.
| | - Alexander Grimm
- Department of Neurology, University Hospital Tuebingen, Tuebingen, Germany.
| | - Craig M Zaidman
- Division of Neuromuscular Medicine, Department of Neurology, Washington University in St. Louis, 660 S. Euclid Ave, Box 8111, St. Louis, MO 63110, USA.
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Chang KV, Wu WT, Han DS, Özçakar L. Ulnar Nerve Cross-Sectional Area for the Diagnosis of Cubital Tunnel Syndrome: A Meta-Analysis of Ultrasonographic Measurements. Arch Phys Med Rehabil 2017; 99:743-757. [PMID: 28888384 DOI: 10.1016/j.apmr.2017.08.467] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/02/2017] [Accepted: 08/02/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To examine the performance of sonographic cross-sectional area (CSA) measurements in the diagnosis of cubital tunnel syndrome (CuTS). DATA SOURCES Electronic databases, comprising PubMed and EMBASE, were searched for the pertinent literature before July 1, 2017. STUDY SELECTION Fourteen trials comparing the ulnar nerve CSA measurements between participants with and without CuTS were included. DATA EXTRACTION Study design, participants' demographic characteristics, diagnostic reference of CuTS, and methods of CSA measurement. DATA SYNTHESIS Among different elbow levels, the between-group difference in CSA was the largest at the medial epicondyle (6.0mm2; 95% confidence interval [CI], 4.5-7.4mm2). The pooled mean CSA in participants without CuTS was 5.5mm2 (95% CI, 4.4-6.6mm2) at the arm level, 7.4mm2 (95% CI, 6.7-8.1mm2) at the cubital tunnel inlet, 6.6mm2 (95% CI, 5.9-7.2mm2) at the medial epicondyle, 7.3mm2 (95% CI, 5.6-9.0mm2) at the cubital tunnel outlet, and 5.5mm2 (95% CI, 4.7-6.3mm2) at the forearm level. The sensitivities, specificities, and diagnostic odds ratios pooled from 5 studies, using 10mm2 as the cutoff point, were .85 (95% CI, .78-.90), .91 (95% CI, .86-.94), and 53.96 (95% CI, 14.84-196.14), respectively. CONCLUSIONS The ulnar nerve CSA measured by ultrasound imaging is useful for the diagnosis of CuTS and is most significantly different between patients and participants without CuTS at the medial epicondyle. Because the ulnar nerve CSA in healthy participants, at various locations, rarely exceeds 10mm2, this value can be considered as a cutoff point for diagnosing ulnar nerve entrapment at the elbow region.
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Affiliation(s)
- Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; Department of Physical and Rehabilitation Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan
| | - Der-Sheng Han
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; Department of Physical and Rehabilitation Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
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Pisapia JM, Ali ZS, Hudgins ED, Khoury V, Heuer GG, Zager EL. Ultrasonography Detects Ulnar Nerve Dislocation Despite Normal Electrophysiology and Magnetic Resonance Imaging. World Neurosurg 2017; 99:809.e1-809.e5. [PMID: 28089807 DOI: 10.1016/j.wneu.2017.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/01/2017] [Accepted: 01/03/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Dislocation of the ulnar nerve (UN) occurs in a subset of patients with ulnar neuropathy. Electrodiagnostic and magnetic resonance imaging (MRI) studies are performed to support the clinical diagnosis. We report the case of a patient with ulnar neuropathy with normal electrodiagnostic and MRI studies but with ultrasonography (US) showing UN dislocation, which prompted successful treatment by UN submuscular transposition. CASE DESCRIPTION A healthy 15-year-old female softball player presented with right medial elbow pain and paresthesias of the fourth and fifth digits. She had 4+/5 strength in the right hand intrinsic muscles and a Tinel sign at the right elbow. A snap was palpated at the elbow upon flexion. MRI showed mild common flexor tendonitis, and electrodiagnostic studies showed normal motor responses and no conduction block at the elbow. High-resolution US showed dislocation of the UN over the medial epicondyle. UN dislocation was confirmed intraoperatively, and, after UN submuscular transposition, the patient reported complete resolution of her preoperative symptoms at 6-week follow-up and continued resolution at 1 year. CONCLUSIONS Normal findings on electrodiagnostic or MRI studies should not immediately dissuade surgeons from operating on a symptomatic patient with a clinical examination supporting ulnar neuropathy and with US evidence of UN dislocation, because such a patient may experience postoperative symptom relief. Furthermore, the dynamic capability of US imaging complements data obtained from electrodiagnostic and MRI studies, especially when these tests are normal, and it should be considered by clinicians when evaluating patients with medial elbow pain or signs of ulnar neuropathy.
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Affiliation(s)
- Jared M Pisapia
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Zarina S Ali
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric D Hudgins
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Viviane Khoury
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory G Heuer
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Division of Neurosurgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric L Zager
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kim JG, Kim D, Seok HY, Kim Y, Yang KS, Rhyu IJ, Kim BJ. A Method of Radial Nerve Length Measurement Based on Cadaveric Investigation. Arch Phys Med Rehabil 2016; 98:596-599. [PMID: 27612940 DOI: 10.1016/j.apmr.2016.08.464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 08/17/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the most reliable method to measure the length of the radial nerve during a nerve conduction study (NCS). DESIGN Cadaveric investigation. SETTING A practical anatomy research laboratory in a university. PARTICIPANTS Fresh cadavers (N=10), with 1 cadaver for study design and 9 for data. INTERVENTIONS Design of measurement methods using cadaver dissection and comparison of the measured values to the true length in 18 arms of 9 cadavers. MAIN OUTCOME MEASURES Four points (A, B, C, D) were determined: (A) proximal stimulation point in NCS; (B) point at the elbow crease; (C) point in the midforearm; and (D) distal stimulation point 5cm above the extensor indicis. The true length of the radial nerve between the stimulus points (points A and D) in NCS was compared with the measured values by summation of the straight line segments between those points with various combinations. The difference in root mean square error (RMSE) of the distance measured by each method compared with the true length was calculated to determine the best measurement method. RESULTS The closest distance to the true length (28.7±2.8cm) in the cadaveric investigation was obtained using the summation of straight line segments between points A, B, and D (A-B-D, RMSE=.72cm), followed by the A-B-C-D distance (RMSE=.87cm) and the A-D distance (RMSE=1.38cm) methods, in sequence. The former 2 distance measurements were relatively closer to the true length than the latter measurement method. CONCLUSIONS Multiple segmentation measurement methods reflected the course of the radial nerve better than a single linear measurement method. We suggest that the distance measured using a stopover point near the lateral epicondyle between 2 stimulus points (A-B-D distance) is closer to the true length of the nerve.
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Affiliation(s)
- Jae-Gyum Kim
- Department of Neurology, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Dasom Kim
- Practical Anatomy Research Institute, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Hung Youl Seok
- Department of Neurology, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Yoohwan Kim
- Department of Neurology, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Kyung-Sook Yang
- Department of Biostatistics, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Im Joo Rhyu
- Practical Anatomy Research Institute, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea
| | - Byung-Jo Kim
- Department of Neurology, Korea University College of Medicine, Korea University Medical Center, Seoul, Korea.
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Thoirs K, Williams MA, Phillips M. Systematic Review of Sonographic Measurements of the Ulnar Nerve at the Elbow. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2016. [DOI: 10.1177/8756479307306110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A systematic review was performed to identify studies reporting summary data (mean, standard deviation) of sonographic cross-sectional measurements of the ulnar nerve at the elbow. Comparisons of measurements were performed to determine whether statistical differences existed between groups of individuals symptomatic and asymptomatic of ulnar nerve entrapment at the elbow (UNE). Across the four studies meeting the selection criteria of the search, five sample groups were identified and compared: three asymptomatic of UNE and two symptomatic of UNE. There were significant differences between measurements of people with and without UNE ( P < .0001—.041). Significant differences also existed between the two symptomatic populations ( P < .0001—.0062) and between the three asymptomatic populations ( P < .0001—.41). This systematic review demonstrates that significant differences exist between sonographic measurements of ulnar nerve dimension between people with and without UNE, confirming that these measurements are potential discriminators of UNE. The demonstration of significant differences between measurements of ulnar nerve size within sample populations with similar symptomatic status suggests that further studies are required to confirm the effect of ulnar nerve pathologies, measurement protocols, and anthropometric factors.
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Affiliation(s)
- Kerry Thoirs
- School of Health Sciences (City East Campus), University of South Australia, Adelaide, South Australia,
| | - Marie A. Williams
- School of Health Sciences (City East Campus), University of South Australia, Adelaide, South Australia
| | - Maureen Phillips
- School of Health Sciences (City East Campus), University of South Australia, Adelaide, South Australia
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21
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Liu Z, Jia ZR, Wang TT, Shi X, Liang W. Effect of Elbow Position on Short-segment Nerve Conduction Study in Cubital Tunnel Syndrome. Chin Med J (Engl) 2016; 129:1028-35. [PMID: 27098786 PMCID: PMC4852668 DOI: 10.4103/0366-6999.180515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Methods: Results: Conclusions:
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22
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Henn CM, Patel A, Wall LB, Goldfarb CA. Outcomes Following Cubital Tunnel Surgery in Young Patients: The Importance of Nerve Mobility. J Hand Surg Am 2016; 41:e1-7. [PMID: 26906941 DOI: 10.1016/j.jhsa.2016.01.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/14/2016] [Accepted: 01/20/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE To investigate the outcomes following surgical management of unstable and stable ulnar nerves at the elbow in young patients. METHODS We retrospectively reviewed the charts of 67 patients who were 30 years old or younger when they underwent primary cubital tunnel surgery at our institution over a 10-year period. In 34 (45%) of these patients, the ulnar nerve either subluxated or perched on the medial epicondyle with elbow flexion and made up the "unstable" cohort. The remaining 42 patients made up the "stable" cohort. Preoperative, intraoperative, and postoperative data were obtained from the patients' charts. Thirty-nine patients completed the following outcome measures: Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), visual analog scale (VAS) for pain and treatment satisfaction, return to sport or full activities, and the presence of persistent symptoms. RESULTS At an average of 5.6 years following surgery, the unstable cohort had a significantly lower QuickDASH score (6.4 vs 18.6) and a significantly higher VAS for treatment satisfaction (8.7 vs 5.9) compared with the stable cohort. The unstable cohort was also significantly less likely to experience residual symptoms (43% vs 94%), persistent numbness (39% vs 44%), or persistent tingling (22% vs 56%) compared with the stable cohort. Within the stable cohort, patients who underwent simultaneous carpal tunnel release exhibited improved VAS and QuickDASH scores compared with patients who did not. There were no differences in time to return to sports or full activities or pain VAS between the two groups. CONCLUSIONS Surgical management of young patients with symptomatic, unstable ulnar nerves results in superior subjective outcomes compared with surgery in young patients with stable ulnar nerves. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.
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Affiliation(s)
- Curtis M Henn
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Aalok Patel
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Lindley B Wall
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Charles A Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO.
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23
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Kawahara Y, Yamaguchi T, Honda Y, Tomita Y, Uetani M. The Ulnar Nerve at Elbow Extension and Flexion: Assessment of Position and Signal Intensity on MR Images. Radiology 2016; 280:483-92. [PMID: 26894443 DOI: 10.1148/radiol.2016150173] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To assess the position and signal intensity of the ulnar nerve at elbow extension and flexion by using magnetic resonance imaging. Materials and Methods Institutional review board approval and written informed consent were obtained. Transverse T2-weighted images were obtained perpendicular to the upper arm in 100 healthy elbows of 50 volunteers (23 men, 27 women; age range, 21-57 years) and nine elbows with ulnar neuropathy (five men, four women; age range, 24-59 years) with extension and 130° of flexion. Ulnar nerve position was classified into three types: no dislocation, subluxation, or dislocation. One-way analysis of variance, paired t tests, Student t tests, and multiple regression analysis were used to analyze correlations between ulnar nerve movement angle during flexion and age, sex, presence of the anconeus epitrochlearis muscle, and ulnar neuropathy and to compare the contrast-to-noise ratio of nerve to muscle between extension and flexion. Results Nerve positions in healthy elbows were as follows: All had no dislocation at extension, and at flexion, 51 of 100 elbows (51.0%) had no dislocation, 30 of 100 elbows (30.0%) had subluxation, and 19 of 100 elbows (19.0%) had dislocation. Nerve movement angle was smaller in elbows with the anconeus epitrochlearis muscle than in those without the muscle (P = .045, .015). Presence of the muscle was the only significant factor associated with nerve movement angle (P = .047, .013). Only dominant elbows with nerve movement angle of less than 15° and nondominant elbows with nerve movement angle of less than 10° showed contrast-to-noise ratio increase at flexion (P = .021-.030). Conclusion Ulnar nerve movement during flexion was apparent in approximately half of healthy elbows and was similar between healthy elbows and elbows with ulnar neuropathy. Nerve signal intensity increased during flexion only in elbows without apparent nerve movement. (©) RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Yasuhiro Kawahara
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
| | - Tetsuji Yamaguchi
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
| | - Yuzo Honda
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
| | - Yumiko Tomita
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
| | - Masataka Uetani
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
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Wang LH, Lo KC, Jou IM, Kuo LC, Tai TW, Su FC. The effects of forearm fatigue on baseball fastball pitching, with implications about elbow injury. J Sports Sci 2015; 34:1182-9. [DOI: 10.1080/02640414.2015.1101481] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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25
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Omejec G, Podnar S. Does ulnar nerve dislocation at the elbow cause neuropathy? Muscle Nerve 2015; 53:255-9. [DOI: 10.1002/mus.24786] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Gregor Omejec
- Institute of Clinical Neurophysiology, Division of Neurology; University Medical Center; SI-1525 Ljubljana Slovenia
| | - Simon Podnar
- Institute of Clinical Neurophysiology, Division of Neurology; University Medical Center; SI-1525 Ljubljana Slovenia
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26
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Cesmebasi A, O'driscoll SW, Smith J, Skinner JA, Spinner RJ. The snapping medial antebrachial cutaneous nerve. Clin Anat 2015. [PMID: 26212210 DOI: 10.1002/ca.22601] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Snapping elbow is a well-known condition where elbow flexion and extension elicits a painful, popping sensation. The most frequent etiology is anterior dislocation of the ulnar nerve over the medial epicondyle. Four patients (3 females and 1 male) presented with complaints of a popping sensation in the elbow, pain over the medial aspect of the forearm, and ulnar neuritis. All patients underwent preoperative dynamic ultrasound and surgical exploration of the medial elbow. Intraoperatively, snapping of the MABC over the medial epicondyle was discovered in all four patients. In three patients, there was abnormal displacement of the medial triceps and ulnar nerve: in two of these, both structures dislocated over the medial epicondyle and in one patient both structures subluxated. In each case, the MABC was decompressed (n = 1) and transposed (n = 3), and in three cases, the medial triceps and ulnar nerve were addressed as well. Symptomatic improvement was achieved in all cases. Retrospective review of the ultrasound revealed the snapping MABC, though it was less effective prospectively in the cases when snapping MABC was not suspected. In conclusion, snapping of the MABC broadens the spectrum of disorders that results in snapping elbow. To our knowledge, we are unaware of prior reports of this entity.
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Affiliation(s)
- Alper Cesmebasi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Division of Urology, Saint Elizabeth's Medical Center, Tufts University School of Medicine, Brighton, Massachusetts.,Department of Anatomical Sciences, St George's University, Grenada, West Indies
| | | | - Jay Smith
- Department of Radiology, Mayo Clinic, Rochester, Minnesota.,Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
| | - John A Skinner
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Orthopedics, Mayo Clinic, Rochester, Minnesota
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27
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Seok HY, Jang JH, Won SJ, Yoon JS, Park KS, Kim BJ. Cross-sectional area reference values of nerves in the lower extremities using ultrasonography. Muscle Nerve 2014; 50:564-70. [PMID: 24639103 DOI: 10.1002/mus.24209] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 01/31/2014] [Accepted: 02/10/2014] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Cross-sectional area (CSA) reference values of lower extremity nerves using ultrasonography have only been reported in a few studies and have been limited to white populations. METHODS For this study, 94 healthy Korean volunteers were recruited for measurement of the CSA at 7 sites of lower extremity nerves. The side-to-side difference in CSA was calculated for each nerve, and reference ranges were derived. External validity evaluation for the reference values was performed with 10 newly recruited volunteers at a different institution. RESULTS Nerve CSA was correlated significantly with body mass index, weight, and height; however, the absolute value of the side-to-side difference had no significant correlation with demographic factors. The external validity was adequate for all sites, ranging from 80% to 100%. CONCLUSIONS The lower extremity nerve CSA values obtained in this study may provide normal reference values for the Asian population.
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Affiliation(s)
- Hung Youl Seok
- Department of Neurology, Korea University College of Medicine, Seoul, #73, Inchon-ro, Seongbuk-gu, Seoul, 136-705, South Korea
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28
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Nakano K, Murata K, Omokawa S, Nakanishi Y, Shimizu T, Kira T, Onishi T, Tanaka Y. Dynamic analysis of the ulnar nerve in the cubital tunnel using ultrasonography. J Shoulder Elbow Surg 2014; 23:933-7. [PMID: 24751533 DOI: 10.1016/j.jse.2014.01.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/14/2014] [Accepted: 01/27/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND We investigated the dynamics of the ulnar nerve during elbow flexion and the relationships between these dynamics and the morphology of the ulnar nerve groove in healthy individuals. MATERIALS AND METHODS Twenty healthy volunteers (40 elbows) underwent ultrasonographic examination of the ulnar nerve at the elbow. We measured the breadth and depth of the ulnar nerve groove at 90° of elbow flexion and calculated the depth-to-breadth ratio. We recorded the distance from the trochlea of the humerus to the nerve and the short-axis diameter of the nerve at 30°, 60°, 90°, and 120° of elbow flexion. We calculated the medial shift and flattening of the ulnar nerve at each angle relative to 30° of flexion, compared the values among the different angles, and compared the depth-to-breadth ratio with the location, medial shift, and flattening ratio of the ulnar nerve. RESULTS The medial shift was significantly greater at 120° than at other angles (P < .001). Flattening increased with increasing elbow flexion and was significantly different at 60°, 90°, and 120° (all P < .001). The flattening ratios were significantly correlated with the depth-to-breadth ratio at 120° (r = -0.43, P = .005). CONCLUSIONS The ulnar nerve moves medially and is flattened with the elbow flexed between 90° and 120°. When the ulnar nerve groove is shallow, high degrees of elbow flexion result in flattening of the ulnar nerve in the groove.
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Affiliation(s)
- Kenichi Nakano
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Keiichi Murata
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Shohei Omokawa
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan.
| | - Yasuaki Nakanishi
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Takamasa Shimizu
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Tsutomu Kira
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Tadanobu Onishi
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara, Japan
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Tai TW, Kuo LC, Chen WC, Wang LH, Chao SY, Huang CNH, Jou IM. Anterior translation and morphologic changes of the ulnar nerve at the elbow in adolescent baseball players. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:45-52. [PMID: 24139913 DOI: 10.1016/j.ultrasmedbio.2013.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 07/28/2013] [Accepted: 07/29/2013] [Indexed: 06/02/2023]
Abstract
The effect of repetitive throwing on the ulnar nerve is not clear. There are no published imaging studies regarding this issue in adolescent baseball players. The purpose of this cross-sectional ultrasonographic study was to use 5- to 10-MHz frequency ultrasonography to define the anterior translation and flattening of the ulnar nerve in different elbow positions. We divided 39 adolescent baseball players into two groups, 19 pitchers and 20 fielders, according to the amount of throwing. Twenty-four non-athlete junior high school students were also included as controls. We ultrasonographically examined each participant's ulnar nerve in the cubital tunnel with the elbow extended and at 45°, 90° and 120° of flexion. Anterior translation and flattening of the ulnar nerve occurred in all groups. Pitchers had larger-scale anterior translation than did controls. In pitchers, the ulnar nerve exhibited more anterior movement on the dominant side than on the non-dominant side. The anterior subluxation of the ulnar nerve occurred in players without ulnar nerve palsy and was not correlated with elbow pain. In addition to the known musculoskeletal adaptations of pitchers' elbows, ultrasonography revealed new changes in the ulnar nerve, anterior translation and subluxation, after repetitive throwing. These changes might also be physiologic adaptations of throwing elbows.
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Affiliation(s)
- Ta-Wei Tai
- Department of Orthopaedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopaedics, Tainan Hospital Sinhua Branch, Tainan, Taiwan
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Yang SN, Yoon JS, Kim SJ, Kang HJ, Kim SH. Movement of the ulnar nerve at the elbow: a sonographic study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1747-1752. [PMID: 24065255 DOI: 10.7863/ultra.32.10.1747] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES The aim of this study was to measure the degree of movement of the ulnar nerve in the cubital tunnel using sonography in patients with ulnar neuropathy at the elbow compared to a healthy control group. METHODS We examined the ulnar nerve in the cubital tunnel using sonography with the elbow extended and then flexed in 26 patients with ulnar neuropathy and 13 control participants. The distance from the ulnar nerve to the skin, medial epicondyle, and tip of olecranon at the inlet of the cubital tunnel and the distance from the ulnar nerve to the skin and olecranon recess at the outlet of the cubital tunnel were measured when the elbow was extended and flexed, respectively. Displacement of the ulnar nerve during elbow extension and flexion between patients with ulnar neuropathy and controls was compared. RESULTS There was significantly greater displacement of the ulnar nerve to the medial epicondyle at the inlet of the cubital tunnel in the patients with ulnar neuropathy (mean ± SD, 4.22 ± 3.79 mm) compared to the controls (1.76 ± 1.51 mm) during elbow extension and flexion (P = .008). CONCLUSIONS A significantly greater degree of movement of the ulnar nerve occurs in patients with ulnar neuropathy at the elbow compared to healthy people, as determined by sonography.
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Affiliation(s)
- Seung Nam Yang
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, 80 Guro-gu, Guro-dong, Seoul 152-703, Korea.
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Cartwright MS, Walker FO. Neuromuscular ultrasound in common entrapment neuropathies. Muscle Nerve 2013; 48:696-704. [PMID: 23681885 DOI: 10.1002/mus.23900] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2013] [Indexed: 12/12/2022]
Abstract
Neuromuscular ultrasound involves the use of high-resolution ultrasound to image the peripheral nervous system of patients with suspected neuromuscular diseases. It complements electrodiagnostic studies well by providing anatomic information regarding nerves, muscles, vessels, tendons, ligaments, bones, and other structures that cannot be obtained with nerve conduction studies and electromyography. Neuromuscular ultrasound has been studied extensively over the past 10 years and has been used most often in the assessment of entrapment neuropathies. This review focuses on the use of neuromuscular ultrasound in 4 of the most common entrapment neuropathies: carpal tunnel syndrome, ulnar neuropathy at the elbow and wrist, and fibular neuropathy at the knee.
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Affiliation(s)
- Michael S Cartwright
- Department of Neurology, Wake Forest University School of Medicine, Main Floor Reynolds Tower, Winston-Salem, North Carolina, 27157, USA
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Van Den Berg PJ, Pompe SM, Beekman R, Visser LH. Sonographic incidence of ulnar nerve (sub)luxation and its associated clinical and electrodiagnostic characteristics. Muscle Nerve 2013; 47:849-55. [PMID: 23625811 DOI: 10.1002/mus.23715] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2012] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The aim of this study was to assess the presence of (sub)luxation of the ulnar nerve in patients with ulnar neuropathy at the elbow (UNE) compared with healthy controls (HC). We assessed its clinical patterns, electrodiagnostic, and sonographic characteristics. METHODS Using high-resolution sonography, we studied the incidence of (sub)luxation in a cohort of 342 patients and 70 HC. RESULTS Subluxation occurred in 14% and luxation in 6.7% of the UNE patients versus 5.7% and 5.7%, respectively, in HC (no significant differences). Pain at the elbow occurred more often in patients with (sub)luxation (P = 0.007). Electrodiagnostic and sonographic findings did not differ between patients with or without (sub)luxation. CONCLUSIONS The incidence of ulnar nerve (sub)luxation between patients with UNE and HC does not differ. UNE patients with (sub)luxation do not have specific clinical or electrodiagnostic findings, apart from experiencing pain at the elbow more often.
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Hobson-Webb LD, Padua L, Martinoli C. Ultrasonography in the diagnosis of peripheral nerve disease. ACTA ACUST UNITED AC 2012; 6:457-71. [PMID: 23480810 DOI: 10.1517/17530059.2012.692904] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION High-resolution ultrasound (US) of the peripheral nerves is now a standard means of assessing neuromuscular disorders in many centers. Currently used in conjunction with electrodiagnostic (EDX) studies, nerve US is especially effective in the diagnosis of entrapment neuropathies. AREAS COVERED This article reviews the basic physics of peripheral nerve US, guidelines for its current use and future directions. Advantages of using nerve US alongside EDX studies are outlined along with current limitations of testing. The role of US in the diagnosis of entrapment neuropathy is emphasized, particularly in carpal tunnel syndrome (CTS). US assisted diagnosis of peripheral nerve tumors, hereditary neuropathy and dysimmune neuropathy and traumatic injuries is also described. EXPERT OPINION US is a powerful tool in the assessment of peripheral nerve disease. Nerve US is an evolving, young discipline. There is still much to learn, but current evidence supports US imaging of all patients presenting for evaluation of possible mononeuropathy. With improvements in resolution, the introduction of US contrast agents and objective measures of nerve echogenicity, there is promise for further expanding its role in the diagnosis of all peripheral neuropathies.
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Affiliation(s)
- Lisa D Hobson-Webb
- Duke University Medical Center, Department of Neurology , Durham, NC 27710 , USA +1 919 668 2277 ; +1 919 660 3853 ;
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Koo YS, Cho CS, Kim BJ. Pitfalls in using electrophysiological studies to diagnose neuromuscular disorders. J Clin Neurol 2012; 8:1-14. [PMID: 22523508 PMCID: PMC3325427 DOI: 10.3988/jcn.2012.8.1.1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Revised: 06/01/2011] [Accepted: 06/01/2011] [Indexed: 12/02/2022] Open
Abstract
Electrodiagnostic testing is used widely for the full characterization of neuromuscular disorders and for providing unique information on the processes underlying the pathology of peripheral nerves and muscles. However, such testing should be considered as an extension of anamnesis and physical examination, not as pathognomonic of a specific disease entity. There are many pitfalls that could lead to erroneous interpretation of electrophysiological study results when the studies are not performed properly or if they are performed in the presence of anatomical aberrations. The diagnostic reliability of electrodiagnostic studies can be improved and the associated pitfalls overcome if the physician is familiar with all of those possible pitfalls. In this article we discuss the most common and important pitfalls associated with electrodiagnostic medicine.
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Affiliation(s)
- Yong Seo Koo
- Department of Neurology, Korea University College of Medicine, Seoul, Korea
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Korkmaz M, On AY, Çaliş FA. Reference data for ulnar nerve short segment conduction studies at the elbow. Muscle Nerve 2011; 44:783-8. [DOI: 10.1002/mus.22193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2011] [Indexed: 11/08/2022]
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Won SJ, Yoon JS, Kim JY, Kim SJ, Jeong JS. Avoiding false-negative nerve conduction study in ulnar neuropathy at the elbow. Muscle Nerve 2011; 44:583-6. [DOI: 10.1002/mus.22131] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Calfee RP, Manske PR, Gelberman RH, Van Steyn MO, Steffen J, Goldfarb CA. Clinical assessment of the ulnar nerve at the elbow: reliability of instability testing and the association of hypermobility with clinical symptoms. J Bone Joint Surg Am 2010; 92:2801-8. [PMID: 21123610 PMCID: PMC2991068 DOI: 10.2106/jbjs.j.00097] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Ulnar nerve hypermobility has been reported to be present in 2% to 47% of asymptomatic individuals. To our knowledge, the physical examination technique for diagnosing ulnar nerve hypermobility has not been standardized. This study was designed to quantify the interobserver reliability of the physical examination for ulnar nerve hypermobility and to determine whether ulnar nerve hypermobility is associated with clinical symptoms. METHODS Four hundred elbows in 200 volunteer participants were examined. Each participant was queried regarding symptoms attributable to the ulnar nerve. Three examiners, unaware of reported symptoms, independently performed a standardized examination of both elbows to assess ulnar nerve hypermobility. Ulnar nerves were categorized as stable or as hypermobile, which was further subclassified as perchable, perching, or dislocating. Provocative maneuvers, consisting of the Tinel test and flexion compression testing, were performed, and structural measurements were recorded. Kappa values quantified the examination's interobserver reliability. Unpaired t tests, chi-square tests, Wilcoxon tests, and Fisher exact tests were utilized to compare data between those with hypermobile nerves and those with stable nerves. RESULTS Ulnar nerve hypermobility was identified in 37% (148) of the 400 elbows. Hypermobility was bilateral in 30% (fifty-nine) of the 200 subjects. For the three examiners, weighted kappa values on the right and left sides were 0.70 and 0.74, respectively. Elbows with nerve hypermobility did not experience a higher prevalence of subjective symptoms (snapping, pain, and tingling) than did elbows with stable nerves. Provocative physical examination testing for ulnar nerve irritability, however, showed consistent trends toward heightened irritability in hypermobile nerves (p = 0.04 to 0.16). Demographic data and anatomic measurements were similar between the subjects with stable nerves and those with hypermobile nerves. CONCLUSIONS Ulnar nerve hypermobility occurs in over one-third of the adult population. Utilizing a standardized physical examination, a diagnosis of ulnar nerve hypermobility can be established with substantial interobserver reliability. In the general population, ulnar nerve hypermobility does not appear to be associated with an increased symptomatology attributable to the ulnar nerve.
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Affiliation(s)
- Ryan P. Calfee
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail address for R.P. Calfee:
| | - Paul R. Manske
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail address for R.P. Calfee:
| | - Richard H. Gelberman
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail address for R.P. Calfee:
| | - Marlo O. Van Steyn
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail address for R.P. Calfee:
| | - Jennifer Steffen
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail address for R.P. Calfee:
| | - Charles A. Goldfarb
- Department of Orthopaedic Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, 660 South Euclid Avenue, St. Louis, MO 63110. E-mail address for R.P. Calfee:
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Yoon JS, Walker FO, Cartwright MS. Ulnar neuropathy with normal electrodiagnosis and abnormal nerve ultrasound. Arch Phys Med Rehabil 2010; 91:318-20. [PMID: 20159139 DOI: 10.1016/j.apmr.2009.10.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 09/28/2009] [Accepted: 10/07/2009] [Indexed: 11/25/2022]
Abstract
Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy. It is diagnosed with electrodiagnostic studies, but they can yield false-negative results. Ultrasound was used to examine 4 patients with UNE and negative electrodiagnostic findings, and it showed ulnar nerve enlargement near the elbow in all cases, with a mean cross-sectional area of 20.1 mm. This indicates that ultrasound may be a useful tool for assessing those with UNE symptoms and normal electrodiagnostic findings.
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Affiliation(s)
- Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University College of Medicine, Seoul, South Korea.
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A musculoskeletal ultrasound course for physical medicine and rehabilitation residents. Am J Phys Med Rehabil 2010; 89:56-69. [PMID: 19884807 DOI: 10.1097/phm.0b013e3181c1ee69] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Musculoskeletal ultrasound is an imaging modality that can be used to evaluate nerve, tendon, muscle, ligament, and joint disorders and to guide therapeutic procedures. A growing proportion of physiatrists are interested in musculoskeletal ultrasound as demonstrated by the increasing number of musculoskeletal ultrasound articles published in physical medicine and rehabilitation journals and quantity of musculoskeletal ultrasound courses and workshops at physical medicine and rehabilitation conferences. The Mayo Clinic (Rochester, MN) Physical Medicine and Rehabilitation residency program developed a musculoskeletal ultrasound course for their physical medicine and rehabilitation residents, which was implemented in 2008. A detailed description of the course is provided in this article. In addition, results from a premusculoskeletal ultrasound course and postmusculoskeletal ultrasound course practical and written test are presented, and the results of a postmusculoskeletal ultrasound course resident survey are discussed. This information can be used by other physical medicine and rehabilitation residency programs to assist in the creation of their own musculoskeletal ultrasound course.
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Smith J, Finnoff JT. Diagnostic and Interventional Musculoskeletal Ultrasound: Part 2. Clinical Applications. PM R 2009; 1:162-77. [DOI: 10.1016/j.pmrj.2008.09.002] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 09/30/2008] [Indexed: 10/21/2022]
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Koenig RW, Pedro MT, Heinen CPG, Schmidt T, Richter HP, Antoniadis G, Kretschmer T. High-resolution ultrasonography in evaluating peripheral nerve entrapment and trauma. Neurosurg Focus 2009; 26:E13. [DOI: 10.3171/foc.2009.26.2.e13] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
High-resolution ultrasonography is a noninvasive, readily applicable imaging modality, capable of depicting real-time static and dynamic morphological information concerning the peripheral nerves and their surrounding tissues. Continuous progress in ultrasonographic technology results in highly improved spatial and contrast resolution. Therefore, nerve imaging is possible to a fascicular level, and most peripheral nerves can now be depicted along their entire anatomical course. An increasing number of publications have evaluated the role of high-resolution ultrasonography in peripheral nerve diseases, especially in peripheral nerve entrapment.
Ultrasonography has been shown to be a precious complementary tool for assessing peripheral nerve lesions with respect to their exact location, course, continuity, and extent in traumatic nerve lesions, and for assessing nerve entrapment and tumors. In this article, the authors discuss the basic technical considerations for using ultrasoniography in peripheral nerve assessment, and some of the clinical applications are illustrated.
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Ozturk E, Sonmez G, Colak A, Sildiroglu HO, Mutlu H, Senol MG, Basekim CC, Kizilkaya E. Sonographic appearances of the normal ulnar nerve in the cubital tunnel. JOURNAL OF CLINICAL ULTRASOUND : JCU 2008; 36:325-329. [PMID: 18446864 DOI: 10.1002/jcu.20486] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
PURPOSE To investigate the sonographic characteristics of the normal ulnar nerve in the cubital tunnel, as well as any differences related to age, sex, and dominant arm. METHOD Two hundred twelve elbows in healthy volunteers were evaluated sonographically. The cross-sectional area (CSA) of the ulnar nerve within the cubital tunnel was measured with the elbow in extension and in flexion. The presence and number of fascicles was determined. The displacement of the ulnar nerve out of the cubital tunnel in full elbow flexion was also investigated. RESULTS The mean +/- SD CSA of the ulnar nerve was 6.6 +/- 1.7 mm(2) (6.7 +/- 1.8 mm(2) in men and 6.5 +/- 1.7 mm(2) in women). The mean CSA of the ulnar nerve was highest for subjects aged 50-59 years, and lowest for subjects aged 30-39 years. Forty-two of 212 (19.8%) ulnar nerves had 2 fascicles, and 5 (2.4%) had 3 fascicles. The remaining 165 (77.8%) nerves had 1 fascicle. During elbow flexion, 49 of 212 (23.1%) ulnar nerves showed subluxation, and 18 (8.5%) were dislocated. CONCLUSION There were differences in the CSA of the ulnar nerve between some age groups, but there was no variation with sex or handedness. Sonography can evaluate the morphologic changes of the nerve during flexion of the elbow.
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Affiliation(s)
- Ersin Ozturk
- Department of Radiology, GATA Haydarpasa Teaching Hospital, Radyoloji Servisi, Uskudar, Istanbul 34668, Turkey
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Thoirs K, Williams MA, Phillips M. Ultrasonographic measurements of the ulnar nerve at the elbow: role of confounders. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2008; 27:737-743. [PMID: 18424649 DOI: 10.7863/jum.2008.27.5.737] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The purpose of this study was to identify factors confounding high-resolution ultrasonographic measurements of the ulnar nerve to test their influence when discriminating between limbs affected and unaffected by ulnar nerve entrapment (UNE) at the elbow. METHODS High-resolution ultrasonographic measurements of ulnar nerve dimensions at the elbow were compared between 2 groups of subjects: symptomatic and asymptomatic for UNE. Rank analysis of covariance regression tests were performed to determine whether significant differences existed between the 2 groups. The changing coefficient method (using rank analysis of covariance tests) was used to test for potential confounding effects of age, weight, height, body mass index, sex, limb sidedness, limb handedness, and nerve mobility. These tests were repeated for each measurement while controlling for the identified confounders. Exact 2-tailed Wilcoxon signed rank tests were performed to test for significant differences between measurements of the diameter of the ulnar nerve with the elbow in full extension and full flexion. RESULTS Age, weight, body mass index, sex, and elbow position were shown to have confounding influences on high-resolution ultrasonographic measurements of the ulnar nerve. No confounding effect was apparent for limb sidedness or dominance. Cross-sectional area and long-axis diameter measurements demonstrated significant differences between nerves with and without UNE after controlling for confounders. CONCLUSIONS Two cross-sectional measurements (area and maximum cross-sectional diameter) of the ulnar nerve, made at the level of the medial epicondyle, were found to be robust discriminators between nerves with and without UNE. In the absence of normative reference values of the ulnar nerve, the contralateral limb may be used as the comparative control.
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Affiliation(s)
- Kerry Thoirs
- School of Health Sciences, University of South Australia, Adelaide SA 5000, Australia.
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Shen PC, Chern TC, Wu KC, Tai TW, Jou IM. The assessment of the ulnar nerve at the elbow by ultrasonography in children. ACTA ACUST UNITED AC 2008; 90:657-61. [DOI: 10.1302/0301-620x.90b5.19820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We evaluated the morphological changes to the ulnar nerve of both elbows in the cubital tunnel by sonography in a total of 237 children, of whom 117 were aged between six and seven years, 66 between eight and nine years, and 54 between ten and 11 years. We first scanned longitudinally in the extended elbow and then transversely at the medial epicondyle with the elbow extended to 0°. We repeated the scans with the elbow flexed at 45°, 90°, and 120°. There were no significant differences in the area of the ulnar nerve, but the diameter increased as the elbow moved from extension to flexion in all groups. More importantly, the ulnar nerve was subluxated anteriorly on to the medial epicondyle by 1.5% to 1.9% in extended elbows, by 5.9% to 7.9% in those flexed to 45°, by 40.0% to 44% in those flexed to 90°, and by 57.4% to 58.1% in those flexed to 120°, depending on the age group. Sonography clearly and accurately showed the ulnar nerve and was useful for localising the nerve before placing a medial pin. Because the ulnar nerve may translate anteriorly onto the medial epicondyle when the elbow is flexed to 90° or more, it should never be overlooked during percutaneous medial pinning.
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Affiliation(s)
- P.-C. Shen
- Department of Orthopaedic Surgery, Tainan Hospital, Department of Health, Executive Yuan, No. 125, Jhongshan Road, Tainin City, 700 Taiwan
| | - T.-C. Chern
- Chern Tai-Chung’s, Orthopaedics Clinic, No. 370, Boai Road, Ping-Tong City, 900 Taiwan
| | - K.-C. Wu
- Department of Orthopedics, Kuo’s General Hospital, No. 22, Sec. 2, Minsheng Road, Tainin City, 700 Taiwan
| | - T.-W. Tai
- Department of Orthopedics, National Cheng Kung University, College of Medicine, No. 138 Sheng Li Road, Tainin City, 704 Taiwan
| | - I.-M. Jou
- Department of Orthopedics, National Cheng Kung University, College of Medicine, No. 138 Sheng Li Road, Tainin City, 704 Taiwan
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Cartwright MS, Shin HW, Passmore LV, Walker FO. Ultrasonographic Findings of the Normal Ulnar Nerve in Adults. Arch Phys Med Rehabil 2007; 88:394-6. [PMID: 17321837 DOI: 10.1016/j.apmr.2006.12.020] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To provide a detailed description of the ultrasonographic findings along the entire length of the normative ulnar nerve. DESIGN Volunteers were recruited to undergo ultrasonography of both upper extremities. Age, sex, height, weight, body mass index, arm length, and hand length were recorded, and cross-sectional measurements of the ulnar nerve were obtained at 7 predetermined sites. SETTING The diagnostic neurology laboratory of a referral medical center. PARTICIPANTS Thirty volunteers (60 arms) were recruited. Volunteers were screened by history and physical examination, and those with evidence of peripheral nervous system disease were excluded. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The average cross-sectional area (CSA) of the ulnar nerve at 7 predetermined sites along the entire course of the nerve. RESULTS The following average ulnar nerve CSAs were obtained: distal wrist crease, 5.9 mm2; arterial split, 6.3 mm2; 2 cm distal to tip of the medial epicondyle, 6.4 mm2; tip of the medial epicondyle, 6.5 mm2; 2cm proximal to tip of the medial epicondyle, 6.7 mm2; mid-humerus, 6.1 mm2; and axilla, 6.2 mm2. There was no statistical difference in nerve size when dominant and nondominant arms were compared, but women did have smaller nerves than men. Of all the variables measured, nerve size correlated most closely with weight, with a correlation coefficient of .59. CONCLUSIONS The ulnar nerve was easily visualized and measured along its entire course, and the CSA of the nerve was consistent at multiple sites. The reference values obtained in this study will facilitate the analysis of abnormal nerve conditions, and the information on side-to-side variation and sex-specific differences should be particularly helpful.
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Affiliation(s)
- Michael S Cartwright
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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Yoon JS, Kim BJ, Kim SJ, Kim JM, Sim KH, Hong SJ, Walker FO, Cartwright MS. Ultrasonographic measurements in cubital tunnel syndrome. Muscle Nerve 2007; 36:853-5. [PMID: 17879384 DOI: 10.1002/mus.20864] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The cubital tunnel is the most common site of ulnar nerve entrapment. Previous ultrasound studies have demonstrated enlargement of the ulnar nerve in cubital tunnel syndrome but did not report on the cubital tunnel itself. Twenty-two individuals with cubital tunnel syndrome were evaluated with nerve conduction studies and ultrasound. The ultrasound measurement that most strongly correlated with conduction velocity was the ratio of ulnar nerve to cubital tunnel cross-sectional area with the elbow flexed. Measurement of this ratio may improve the diagnostic accuracy of ultrasound in cubital tunnel syndrome, although further investigation is needed.
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Affiliation(s)
- Joon Shik Yoon
- Department of Rehabilitation Medicine, Korea University College of Medicine, Seoul, South Korea
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