Technical problems with ulnar nerve transposition at the elbow: Findings and results of reoperation Ten patients who had persistent or recurrent paresthesias, muscular weakness, or sensory loss following transposition of the ulnar nerve at the elbow were explored. Operative findings included compression of the nerve at the intermuscular septum or at the entrance to the cubital tunnel, dense scarring after intramuscular transposition, and constriction by fascial slings. The average interval from the previous operation to re-exploration was 13 months. All patients were improved following neurolysis and submuscular transposition. Recovery was incomplete in nine patients. The average follow-up was 14.5 months.
Arnold S. Broudy, M.D., Robert D. Leffert, M.D., and Richard J. Smith, M.D., Boston, Mass.
Anterior transposition is commonly recommended in the treatment of ulnar neuropathy at the elbow and is reported to have been successful in most cases.1· 16 Yet a number of patients are not benefited; symptoms even may be exacerbated. During the past 3 years, 10 patients have been re-explored for persistent or recurrent ulnar nerve symptoms following anterior transposition. The findings at reoperation indicate several technical pitfalls which should be avoided in performing this procedure. Analysis of cases The clinical manifestations and treatment of 10 patients who underwent re-exploration are shown in Table I. There were seven women and three men, whose ages ranged from 18 to 71 years (mean, 42 years). Nine patients had the initial anterior transposition of the nerve performed at other institutions and were referred for care when they failed to improve. One patient (case 6) had had two previous anterior transpositions without relief. Six patients had no relief of symptoms or recurrence within several weeks of the initial operation. Four patients had complete resolution after the first procedure with a symptom-free interval of 4 to 23 months. One From the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Received for publication DeC. 27, 1976. Revised for publication March 26, 1977. Reprint requests: Arnold S. Broudy, M.D., Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114.
Vol. 3, No.1, pp. 85-89
patient required re-exploration within 3 days (case 5). With the exception of this patient, the mean time interval from the previous operation to re-exploration was 13 months. The clinical manifestations which led to reoperation were typical of ulnar neuropathy: paresthesias in the ring and little fingers and ulnar border of the hand (all 10 patients), intrinsic atrophy (two patients), weakness of grip (eight patients), and variable degrees of ulnar sensory loss (1O patients). A positive Tinel' s sign at the elbow was present in eight patients. All patients had electrodiagnostic studies performed prior to the initial procedures. Repeat studies performed in six patients prior to re-exploration showed slowing of conduction of the ulnar nerve across the elbow. Operative findings at re-exploration Of the 10 patients, five had undergone subcutaneous anterior transposition of the ulnar nerve. In four the nerve was located in a channel cut into muscle which subsequently had become densely scarred. One patient who had a submuscular anterior transposition and resection of the medial intermuscular septum was reexplored at 3 days because of increased symptoms. The nerve was found to be compressed beneath the antebrachial fascia in the region of the lacertus fibrosus. When several fascial sutures were removed to open the antebrachial fascia, the compression was relieved. In nine patients the medial intermuscular septum was intact, and there was kinking or compression of the nerve in eight. In two patients there was a constriction in the region of a subcutaneous sling which had been conJanuary, 1978
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Table I. Status before re-exploration Case No.
Age (yr)
Sex
I
55 51 48 35 18 23 47 30 46 71
F M M F F F M M F F
2 3 4 5 6 7 8 9 10
Period of improvement after initial operation (mo)
Pain
None
+
Paresthesia dysesthesia
+ + + + + + + + + +
Y2 6 None None None 6 4 23
Weakness
+ + + + + +
Sensory loss
Tinel's sign
+ + + + + + + + + +
+
+ + + + + + + + +
+ + + + + + +
Interval to reoperation (mo) 18 9 12 15 3 days 7 5 8 21 24
Table II. Findings at re-exploration and postoperative status Postoperative status
Findings at re-exploration
Condition of nerve In ulnar groove with dense scar Embedded in muscle with dense scar Dense scar compressed by septum Compressed by fascial sling Compressed by antebrachial fascia Kinked at the septum Embedded in muscle, kinked at cubital tunnel with dense scar Compressed at cubital tunnel with dense scar Neuroma in continuity with dense scar Compressed by septum and fascial sling
I
Medial intermuscular septum
Follow-up (mo)
Improved Normal Unchanged Improved Unchanged Improved Normal
6 19 6 6 30 16
Improved
Improved
24
Improved
Improved
Improved
18
Normal
Normal
Normal
Paresthesia dysesthesia
Weakness
Intact Intact Intact Intact Previously resected Intact Intact
Improved Improved Improved Improved Improved Improved Improved
Improved Improved Unchanged Improved Improved Normal Improved
Improved Normal Improved Improved Unchanged Improved Normal
Intact
Normal
Improved
Intact
Improved
Intact
Normal
structed to hold the nerve anteriorly. In one patient (case I), the ulnar nerve was found to have slipped back into the groove behind the medial epicondyle. A localized constriction of the nerve with hyperemia or pseUdoneuroma formation was documented in eight patients. Treatment
In all 10 patients a neurolysis was performed under magnification; epineurectomy was done in eight. Once the nerve was exposed and retracted, the medial intermuscular septum was resected. The flexor pronator origin was detached from the medial epicondyle. The nerve then was transposed beneath the flexor pronator origin into an unscarred bed on the brachial is adjacent to the median nerve (Figs. 1 through 3). All of the sutures used to reapproximate the tendinous origin of the flexor pronator group were placed under direct vision to avoid injury to the nerve. The arm was immobilized
I
Sensory loss
Pain
II
9
with the elbow in 90° of flexion, the forearm fully pronated, and the wrist flexed 20 0. A long arm plaster dressing was applied on the third or fourth day after operation and maintained for 3 weeks. Results
All patients benfited from re-exploration (Table II). Of nine who had had a motor deficit, three regained normal power and six were improved. The severity of pain was reduced in nine of 10 patients. Two had complete relief. Less pain but mild-to-moderate discomfort persisted in seven. Occasional paresthesias or hypesthesia persisted in seven patients; of these, six reported improvement. Sensation was unchanged in two and was improved in five. Three patients had return of normal sensation. The average follow-up was 14.5 months (range, 6 to 30 months). In eight patients in whom the follow-up was less than 2 years, continued improvement can be anticipated.
Vol.3 No . 1 January , 1978
Fig. 1. The ulnar nerve being retracted by a Penrose drain as it enters a scarred area within the flexor carpi ulnaris.
Ulnar nerve transposition at the elbow
87
Fig. 2. The scissors indicates an intact medial intermuscular septum which must be removed to avoid Idnking the nerve as it is brought forward.
Case reports Case 4. A 35-year-old right-handed female bookkeeper who had developed numbness and pain in the right ring and little fingers and weakness of grasp during a 7 month interval was found to have tenderness in the ulnar groove, but there was no muscle atrophy or sensory loss. Nerve conduction studies were normal. When symptoms persisted for an additional 6 weeks, anterior subcutaneous transposition of the ulnar nerve was performed . Afascial sling was created from the ulnar side of the common flexor origin and sutured to the subcutaneous tissue. Her postoperative course was uneventful and symptoms subsided . Six months later, following vigorous snow shoveling, she developed painful paresthesias in the little finger and ulnar aspect of the ring finger. There was no response to treatment with indomethacin or immobilization in a long arm plaster. We first saw her 13 months after operation. The nerve was not palpable. A positive Tinel ' s sign was present on the medial aspect of the elbow. Grip strength on the right was 20 kg, as compared to 32 kg on the left. There was mild hypothenar atrophy but no interosseus atrophy. Slight weakness of the flexor cligitorum profundus to the little finger was noted . Froment 's sign was negative . Hyperesthesia to pinprick was present in the ring and little fingers. At re-exploration 2 months later, the nerve was found to be compressed and inflamed in the region of the fascial sling . A neurolysis and epineurectomy were performed . The intact medial intermuscular septum was excised . The ulnar nerve then was transposed deep to the flexor pronator muscles. The elbow was immobilized in flexion with the forearm pronated . Improved sensation and decreased paresthesias were noted during the first few days following operation . During the next 4 months, symptoms continued to resolve . Case 7. A 57-year-old man with progressive numbness in the ulnar nerve distribution of the right hand of 4 months' duration was treated by anterior transposition of the ulnar nerve, but an exacerbation of these symptoms with severe hand pain
Fig. 3. The flexor-pronator muscle mass has been elevated. The alignment of the transposed ulnar nerve is shown. followed. Four months after operation he was referred for evaluation . Mild atrophy of the first dorsal interosseus m.uscle and slight weakness of the adductor pollicis were noted. The little finger could not be adducted and the flexor digitorum profundus of the little finger was weak. Ulnar nerve conduction was delayed at the elbow. Five months after the initial procedure, the ulnar nerve was re-explored . It was found to be scarred in a channel which had been made through the flexor pronator mass . In addition , there was kinking of the nerve at the intact medial intermuscular septum. A submuscular transposition was performed and the septum was resected. Gradually the severe hand pain diminished to a dull ache. He regained strength in the fingers and muscle bulk in the hand returned to normal. Eighteen months after re-exploration, the patient had normal motion and sensation in the right hand and forearm, though he continued to complain of occasional paresthesias in the ring and little fingers.
88
Broudy, Leffert, and Smith
Case 10. A 69-year-old woman gave a a history of 6 months of painful paresthesias in the ulnar nerve distribution of the right hand. She denied previous trauma. There was a positive Tine!'s sign posterior to the medial epicondyle and decreased sensation to pinprick of the ring and little fingers. No motor weakness was evident. Nerve conduction studies revealed slowing of conduction of the ulnar nerve across the elbow . Subcutaneous anterior transposition of the ulnar nerve was performed with creation of a fascial sling . Gradually the patient experienced complete recovery. Twenty-three months after the transposition, without trauma , the symptoms recurred . Nerve conduction studies indicated ulnar neuropathy at the elbow. A positive Tinel's sign could be elicited 2 cm proximal and I cm anterior to the medial epicondyle. At reexploration the nerve was found to be compressed at the firm medial intermuscular septum. There was mild compression at the site of the fascial sling. The septum was resected completely . At follow-up 9 months later, she was asymptomatic and had no neurological deficit in the hand.
Discussion Curtis 19 is reported to have published the first case of anterior transposition of the ulnar nerve in 1898. Subsequently Murphy,20 in 1916, Adson ,21 in 1918, and Platt,2.3 in 1926 and 1928, advocated this technique. Three variations have been used. Placement of the nerve in the subcutaneous tissues superficial to the common flexor origin renders it more vulnerable to trauma, particularly in patients with scant subcutaneous tissue. Also, the nerve is liable to subluxate to its former position unless a fascial sling is created (case I). This sling, however, may become a site of compression (cases 4 and 10). Asecond alternative is to cut a channel or groove in the flexor pronator muscles to accommodate the nerve. This technique has been described as hazardous since it places the nerve directly in a potential bed of scar.16 Complications of this technique were encountered in cases 2, 7, and 9. The third approach, submuscular transposition , was reported by Learmonth22 in 1942. The flexor pronator group is divided at its origin, and the nerve is placed deep to this muscle plane adjacent to the median nerve . 13. 16 After operation the elbow is immobilized in flexion and pronation for 3 weeks to allow the tendinous origin to heal. This technique requires the most extensive mobilization of the nerve, with resection of the medial intermuscular septum and unroofing of the cubital tunnel to prevent compression in the transposed position. Gerl and Thorwirth 14 reported that 19 of 22 patients treated by submuscular transposition of the ulnar nerve had good functional results, whereas only 16 of 39 patients treated by the subcutaneous technique had satisfactory results.
The Journal of HAND SURGERY
Relatively little information is available concerning the operative findings at re-exploration for unsuccessful transposition of the ulnar nerve at the elbow. Gay and Love6 described a patient who had had three unsuccessful subcutaneous transplantations before neurolysis and intramuscular transposition relieved the symptoms. McGowan 7 described six cases that were re-explored because of persistence of symptoms. In one the nerve had slipped back into the ulnar groove. In five others inadequate mobilization of the nerve had caused sharp angulation and constriction 1.0 to 2.5 cm below the medial epicondyle. All were relieved by mobilizing the nerve and placing it deep to the flexor origin. Wilson and Krout23 reported a case in which two previous explorations had failed. At the third operation the nerve was found to be severely scarred and adherent to the adjacent tissues and sharply angulated over the medial epicondyle. The cubital tunnel was divided and the nerve was returned to its original bed . Relief of pain was obtained, although diminished sensation and weakness remained. Campbell, Post, and Morantz 17 treated nine patients with unsuccessful anterior transposition by external neurolysis and covering the reexplored nerve with strips of silicone. Detailed operative findings and descriptions of the original operations were not given. At follow-up five of the eight patients had complete elimination of pain and dysesthesia. Three of these had full return of motor function, while two had some improvement of strength . Three patients were classified as failures. L1uch 18 described a patient who developed ulnar paresthesias following open reduction of a distal humeral fracture and anterior transposition of the ulnar nerve. Progressive sensory and motor changes led to re-exploration 14 weeks later, which revealed kinking of the nerve at the site where a sling-type suture had been placed to maintain the nerve anteriorly. In this series IO patients were re-explored. One reexploration was performed at 3 days in a patient who developed progressive hypesthesia and weakness of ulnar innervated muscles with a positive Tinel's sign distal and anterior to the elbow after a sub muscular transposition. Relief was obtained by opening the antebrachial fascia which had been closed too tightly . In the remainder of cases, re-exploration was undertaken at intervals from 5 to 24 months. In five patients the initial procedure had failed to provide significant relief and the neuropathy continued insidiously. The operative findings suggested that a significant site of compression had not been relieved adequately or a secondary site of compression had been created. Four patients had had their symptoms relieved , only to suffer recurrence at periods from 3 to 23
Vol. 3 No.1 January, 1978
months. The operative findings at re-exploration demonstrated scar formation or compression by the medial intermuscular septum as the probable cause. The prognosis for recovery depends upon the degree of intraneural damage present prior to exploration. Harrison and Nurick l2 found that the chance of recovery from primary exploration was .decreased if symptoms were present for more than a year. Shelden l stated that subjective symptom of pain is more likely to be relieved than are the objective findings such as muscle wasting and weakness. With secondary transposition, Seddon l6 advised that a guarded prognosis always should be given because of the uncertain prospect of complete recovery. All 10 patients in this series were improved by reexploration, but only one is totally asymptomatic. Five have only mild or occasional paresthesias. Five still are trpubled by pain. Four have a persistent motor deficit with weakness of grasp. Whether or not to re-explore the nerve following anterior transposition depends upon the symptoms . Exacerbation of muscle weakness or an acute increase in pain is an indication for early re-exploration. Paresthesias, which frequently accompany nerve regeneration, are not necessarily a cause for concern if there is steady improvement in neurologic function and a diminuition in the pain. Conclusions
When ulnar neuropathy at the elbow is treated by anterior transposition, the nerve should be placed deep to the flexor-pronator origin, and the medial intermuscular septum should be completely resected. Epineurectomy under adequate magnification is recommended whenever the nerve appears to be constricted. With recurrence or persistence of ulnar nerve symptoms following anterior transposition, re-operation is indicated. Possible sites of compression include the medial . intermuscular septum, fascial slings, fibrous bands at the entrance to the cubital tunnel, and tight antebrachial fascia. Although re-exploration may result in significant improvement, the prognosis for complete recovery is guarded. We wish to thank Dr. Hannibal Hamlin of the Massachusetts General Hospital, Boston, Mass., for his pennission to include two of his patients in this study.
REFERENCES I . Shelden WD: Tardy paralysis of the ulnar nerve. Med Clin North Am 5:499, 1921
Ulnar nerve transposition at the elbow
89
2. Platt H: The pathogenesis and treatment of traumatic neuritis of the ulnar nerve in the post-condylar groove. BrJ Surg 13:409, 1926 3. Platt H: The operative treatment of traumatic ulnar neuritis at the elbow. Surg Gynecol Obstet 47:822, 1928 4. Davidson AJ, Horwitz MT: Late or tardy ulnar nerve paralysis. J Bone Joint Surg 17:844, 1935 5 . Richards RL: Traumatic ulnar neuritis, the results of anterior transposition of the ulnar nerve . Edinb Med J 52: 14, 1945 6 . Gay JR , Love JG: Diagnosis and treatment of tardy paralysis of the ulnar nerve; based on a study of 100 cases. J Bone Joint Surg 29: 1087, 1947 7 . McGowan AJ: The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg 32-B:293, 1950 8. Childress HM: Recurrent ulnar nerve dislocation at the elbow. J Bone Joint Surg 38-A:978, 1956 9. Jensen E: Ulnar perineuritis . Acta Psychiatr Neurol Scand 34:205, 1959 10. Sunderland S: Nerves and nerve injuries , Baltimore, 1968, The Williams & Wilkins Co. II. Ho, HC, Mannor L: Entrapment of the ulnar nerve at the elbow. Am J Surg 121 :355 , 1970 12. Harrison MJG, Nurick S: Results of anterior transposition of the ulnar nerve for ulnar neuritis. Br Med J 1:27, 1970 13. Levy DM, Apfelberg DB: Results of anterior transposition for ulnar transposition for ulnar neuropathy at the elbow. Am J Surg 123:304, 1972 14. Gerl A, Thorwirth V: Ergebnisse der ulnarisver-Iagering. Acta Neurochir 30:227, 1974 15. Childress HM: Recurrent ulnar nerve dislocation at the elbow. Clin Orthop 108: 168, 1975 16. Seddon H: Surgical disorders of the peripheral nerves, London, 1975, Churchill-Livingstone, Ltd 17. Campbell JB, Post KD, Morantz RA: A technique for relief of motor and sensory deficits occurring after anterior ulnar transposition. J Neurosurg 40:405, 1974 18. Lluch A: Ulnar nerve entrapment after anterior transposition at elbow. NY State J Med 75:75, 1975 19 . Curtis BF: Traumatic ulnar neuritis; transplantation of the nerve. J Nerv Ment Dis 25:480, 1898 20. Murphy JB: Cicatrical fixation of ulnar nerve from ancient cubitus valgus release and transference to new site. Clin. JB Murphy Mercy Hosp 5:661, 1916 21. Adson A W: The surgical treatment of progressive ulnar paralysis. Minn Med 1:455, 1918 22. Leannonth JR: A technique for transplanting the ulnar nerve. Surg Gynecol Obstet 75:792, 1942 23 . Wilson DH, Krout R: Surgery of ulnar neuropathy at the elbow: 16 cases treated by decompression without transposition . J Neurosurg 38:780, 1973
Arnold S. Broudy, M.D., Robert D. Leffert, M.D., and Richard J. Smith, M.D., Boston, Mass.
Anterior transposition is commonly recommended in the treatment of ulnar neuropathy at the elbow and is reported to have been successful in most cases.1· 16 Yet a number of patients are not benefited; symptoms even may be exacerbated. During the past 3 years, 10 patients have been re-explored for persistent or recurrent ulnar nerve symptoms following anterior transposition. The findings at reoperation indicate several technical pitfalls which should be avoided in performing this procedure. Analysis of cases The clinical manifestations and treatment of 10 patients who underwent re-exploration are shown in Table I. There were seven women and three men, whose ages ranged from 18 to 71 years (mean, 42 years). Nine patients had the initial anterior transposition of the nerve performed at other institutions and were referred for care when they failed to improve. One patient (case 6) had had two previous anterior transpositions without relief. Six patients had no relief of symptoms or recurrence within several weeks of the initial operation. Four patients had complete resolution after the first procedure with a symptom-free interval of 4 to 23 months. One From the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Received for publication DeC. 27, 1976. Revised for publication March 26, 1977. Reprint requests: Arnold S. Broudy, M.D., Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114.
Vol. 3, No.1, pp. 85-89
patient required re-exploration within 3 days (case 5). With the exception of this patient, the mean time interval from the previous operation to re-exploration was 13 months. The clinical manifestations which led to reoperation were typical of ulnar neuropathy: paresthesias in the ring and little fingers and ulnar border of the hand (all 10 patients), intrinsic atrophy (two patients), weakness of grip (eight patients), and variable degrees of ulnar sensory loss (1O patients). A positive Tinel' s sign at the elbow was present in eight patients. All patients had electrodiagnostic studies performed prior to the initial procedures. Repeat studies performed in six patients prior to re-exploration showed slowing of conduction of the ulnar nerve across the elbow. Operative findings at re-exploration Of the 10 patients, five had undergone subcutaneous anterior transposition of the ulnar nerve. In four the nerve was located in a channel cut into muscle which subsequently had become densely scarred. One patient who had a submuscular anterior transposition and resection of the medial intermuscular septum was reexplored at 3 days because of increased symptoms. The nerve was found to be compressed beneath the antebrachial fascia in the region of the lacertus fibrosus. When several fascial sutures were removed to open the antebrachial fascia, the compression was relieved. In nine patients the medial intermuscular septum was intact, and there was kinking or compression of the nerve in eight. In two patients there was a constriction in the region of a subcutaneous sling which had been conJanuary, 1978
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Table I. Status before re-exploration Case No.
Age (yr)
Sex
I
55 51 48 35 18 23 47 30 46 71
F M M F F F M M F F
2 3 4 5 6 7 8 9 10
Period of improvement after initial operation (mo)
Pain
None
+
Paresthesia dysesthesia
+ + + + + + + + + +
Y2 6 None None None 6 4 23
Weakness
+ + + + + +
Sensory loss
Tinel's sign
+ + + + + + + + + +
+
+ + + + + + + + +
+ + + + + + +
Interval to reoperation (mo) 18 9 12 15 3 days 7 5 8 21 24
Table II. Findings at re-exploration and postoperative status Postoperative status
Findings at re-exploration
Condition of nerve In ulnar groove with dense scar Embedded in muscle with dense scar Dense scar compressed by septum Compressed by fascial sling Compressed by antebrachial fascia Kinked at the septum Embedded in muscle, kinked at cubital tunnel with dense scar Compressed at cubital tunnel with dense scar Neuroma in continuity with dense scar Compressed by septum and fascial sling
I
Medial intermuscular septum
Follow-up (mo)
Improved Normal Unchanged Improved Unchanged Improved Normal
6 19 6 6 30 16
Improved
Improved
24
Improved
Improved
Improved
18
Normal
Normal
Normal
Paresthesia dysesthesia
Weakness
Intact Intact Intact Intact Previously resected Intact Intact
Improved Improved Improved Improved Improved Improved Improved
Improved Improved Unchanged Improved Improved Normal Improved
Improved Normal Improved Improved Unchanged Improved Normal
Intact
Normal
Improved
Intact
Improved
Intact
Normal
structed to hold the nerve anteriorly. In one patient (case I), the ulnar nerve was found to have slipped back into the groove behind the medial epicondyle. A localized constriction of the nerve with hyperemia or pseUdoneuroma formation was documented in eight patients. Treatment
In all 10 patients a neurolysis was performed under magnification; epineurectomy was done in eight. Once the nerve was exposed and retracted, the medial intermuscular septum was resected. The flexor pronator origin was detached from the medial epicondyle. The nerve then was transposed beneath the flexor pronator origin into an unscarred bed on the brachial is adjacent to the median nerve (Figs. 1 through 3). All of the sutures used to reapproximate the tendinous origin of the flexor pronator group were placed under direct vision to avoid injury to the nerve. The arm was immobilized
I
Sensory loss
Pain
II
9
with the elbow in 90° of flexion, the forearm fully pronated, and the wrist flexed 20 0. A long arm plaster dressing was applied on the third or fourth day after operation and maintained for 3 weeks. Results
All patients benfited from re-exploration (Table II). Of nine who had had a motor deficit, three regained normal power and six were improved. The severity of pain was reduced in nine of 10 patients. Two had complete relief. Less pain but mild-to-moderate discomfort persisted in seven. Occasional paresthesias or hypesthesia persisted in seven patients; of these, six reported improvement. Sensation was unchanged in two and was improved in five. Three patients had return of normal sensation. The average follow-up was 14.5 months (range, 6 to 30 months). In eight patients in whom the follow-up was less than 2 years, continued improvement can be anticipated.
Vol.3 No . 1 January , 1978
Fig. 1. The ulnar nerve being retracted by a Penrose drain as it enters a scarred area within the flexor carpi ulnaris.
Ulnar nerve transposition at the elbow
87
Fig. 2. The scissors indicates an intact medial intermuscular septum which must be removed to avoid Idnking the nerve as it is brought forward.
Case reports Case 4. A 35-year-old right-handed female bookkeeper who had developed numbness and pain in the right ring and little fingers and weakness of grasp during a 7 month interval was found to have tenderness in the ulnar groove, but there was no muscle atrophy or sensory loss. Nerve conduction studies were normal. When symptoms persisted for an additional 6 weeks, anterior subcutaneous transposition of the ulnar nerve was performed . Afascial sling was created from the ulnar side of the common flexor origin and sutured to the subcutaneous tissue. Her postoperative course was uneventful and symptoms subsided . Six months later, following vigorous snow shoveling, she developed painful paresthesias in the little finger and ulnar aspect of the ring finger. There was no response to treatment with indomethacin or immobilization in a long arm plaster. We first saw her 13 months after operation. The nerve was not palpable. A positive Tinel ' s sign was present on the medial aspect of the elbow. Grip strength on the right was 20 kg, as compared to 32 kg on the left. There was mild hypothenar atrophy but no interosseus atrophy. Slight weakness of the flexor cligitorum profundus to the little finger was noted . Froment 's sign was negative . Hyperesthesia to pinprick was present in the ring and little fingers. At re-exploration 2 months later, the nerve was found to be compressed and inflamed in the region of the fascial sling . A neurolysis and epineurectomy were performed . The intact medial intermuscular septum was excised . The ulnar nerve then was transposed deep to the flexor pronator muscles. The elbow was immobilized in flexion with the forearm pronated . Improved sensation and decreased paresthesias were noted during the first few days following operation . During the next 4 months, symptoms continued to resolve . Case 7. A 57-year-old man with progressive numbness in the ulnar nerve distribution of the right hand of 4 months' duration was treated by anterior transposition of the ulnar nerve, but an exacerbation of these symptoms with severe hand pain
Fig. 3. The flexor-pronator muscle mass has been elevated. The alignment of the transposed ulnar nerve is shown. followed. Four months after operation he was referred for evaluation . Mild atrophy of the first dorsal interosseus m.uscle and slight weakness of the adductor pollicis were noted. The little finger could not be adducted and the flexor digitorum profundus of the little finger was weak. Ulnar nerve conduction was delayed at the elbow. Five months after the initial procedure, the ulnar nerve was re-explored . It was found to be scarred in a channel which had been made through the flexor pronator mass . In addition , there was kinking of the nerve at the intact medial intermuscular septum. A submuscular transposition was performed and the septum was resected. Gradually the severe hand pain diminished to a dull ache. He regained strength in the fingers and muscle bulk in the hand returned to normal. Eighteen months after re-exploration, the patient had normal motion and sensation in the right hand and forearm, though he continued to complain of occasional paresthesias in the ring and little fingers.
88
Broudy, Leffert, and Smith
Case 10. A 69-year-old woman gave a a history of 6 months of painful paresthesias in the ulnar nerve distribution of the right hand. She denied previous trauma. There was a positive Tine!'s sign posterior to the medial epicondyle and decreased sensation to pinprick of the ring and little fingers. No motor weakness was evident. Nerve conduction studies revealed slowing of conduction of the ulnar nerve across the elbow . Subcutaneous anterior transposition of the ulnar nerve was performed with creation of a fascial sling . Gradually the patient experienced complete recovery. Twenty-three months after the transposition, without trauma , the symptoms recurred . Nerve conduction studies indicated ulnar neuropathy at the elbow. A positive Tinel's sign could be elicited 2 cm proximal and I cm anterior to the medial epicondyle. At reexploration the nerve was found to be compressed at the firm medial intermuscular septum. There was mild compression at the site of the fascial sling. The septum was resected completely . At follow-up 9 months later, she was asymptomatic and had no neurological deficit in the hand.
Discussion Curtis 19 is reported to have published the first case of anterior transposition of the ulnar nerve in 1898. Subsequently Murphy,20 in 1916, Adson ,21 in 1918, and Platt,2.3 in 1926 and 1928, advocated this technique. Three variations have been used. Placement of the nerve in the subcutaneous tissues superficial to the common flexor origin renders it more vulnerable to trauma, particularly in patients with scant subcutaneous tissue. Also, the nerve is liable to subluxate to its former position unless a fascial sling is created (case I). This sling, however, may become a site of compression (cases 4 and 10). Asecond alternative is to cut a channel or groove in the flexor pronator muscles to accommodate the nerve. This technique has been described as hazardous since it places the nerve directly in a potential bed of scar.16 Complications of this technique were encountered in cases 2, 7, and 9. The third approach, submuscular transposition , was reported by Learmonth22 in 1942. The flexor pronator group is divided at its origin, and the nerve is placed deep to this muscle plane adjacent to the median nerve . 13. 16 After operation the elbow is immobilized in flexion and pronation for 3 weeks to allow the tendinous origin to heal. This technique requires the most extensive mobilization of the nerve, with resection of the medial intermuscular septum and unroofing of the cubital tunnel to prevent compression in the transposed position. Gerl and Thorwirth 14 reported that 19 of 22 patients treated by submuscular transposition of the ulnar nerve had good functional results, whereas only 16 of 39 patients treated by the subcutaneous technique had satisfactory results.
The Journal of HAND SURGERY
Relatively little information is available concerning the operative findings at re-exploration for unsuccessful transposition of the ulnar nerve at the elbow. Gay and Love6 described a patient who had had three unsuccessful subcutaneous transplantations before neurolysis and intramuscular transposition relieved the symptoms. McGowan 7 described six cases that were re-explored because of persistence of symptoms. In one the nerve had slipped back into the ulnar groove. In five others inadequate mobilization of the nerve had caused sharp angulation and constriction 1.0 to 2.5 cm below the medial epicondyle. All were relieved by mobilizing the nerve and placing it deep to the flexor origin. Wilson and Krout23 reported a case in which two previous explorations had failed. At the third operation the nerve was found to be severely scarred and adherent to the adjacent tissues and sharply angulated over the medial epicondyle. The cubital tunnel was divided and the nerve was returned to its original bed . Relief of pain was obtained, although diminished sensation and weakness remained. Campbell, Post, and Morantz 17 treated nine patients with unsuccessful anterior transposition by external neurolysis and covering the reexplored nerve with strips of silicone. Detailed operative findings and descriptions of the original operations were not given. At follow-up five of the eight patients had complete elimination of pain and dysesthesia. Three of these had full return of motor function, while two had some improvement of strength . Three patients were classified as failures. L1uch 18 described a patient who developed ulnar paresthesias following open reduction of a distal humeral fracture and anterior transposition of the ulnar nerve. Progressive sensory and motor changes led to re-exploration 14 weeks later, which revealed kinking of the nerve at the site where a sling-type suture had been placed to maintain the nerve anteriorly. In this series IO patients were re-explored. One reexploration was performed at 3 days in a patient who developed progressive hypesthesia and weakness of ulnar innervated muscles with a positive Tinel's sign distal and anterior to the elbow after a sub muscular transposition. Relief was obtained by opening the antebrachial fascia which had been closed too tightly . In the remainder of cases, re-exploration was undertaken at intervals from 5 to 24 months. In five patients the initial procedure had failed to provide significant relief and the neuropathy continued insidiously. The operative findings suggested that a significant site of compression had not been relieved adequately or a secondary site of compression had been created. Four patients had had their symptoms relieved , only to suffer recurrence at periods from 3 to 23
Vol. 3 No.1 January, 1978
months. The operative findings at re-exploration demonstrated scar formation or compression by the medial intermuscular septum as the probable cause. The prognosis for recovery depends upon the degree of intraneural damage present prior to exploration. Harrison and Nurick l2 found that the chance of recovery from primary exploration was .decreased if symptoms were present for more than a year. Shelden l stated that subjective symptom of pain is more likely to be relieved than are the objective findings such as muscle wasting and weakness. With secondary transposition, Seddon l6 advised that a guarded prognosis always should be given because of the uncertain prospect of complete recovery. All 10 patients in this series were improved by reexploration, but only one is totally asymptomatic. Five have only mild or occasional paresthesias. Five still are trpubled by pain. Four have a persistent motor deficit with weakness of grasp. Whether or not to re-explore the nerve following anterior transposition depends upon the symptoms . Exacerbation of muscle weakness or an acute increase in pain is an indication for early re-exploration. Paresthesias, which frequently accompany nerve regeneration, are not necessarily a cause for concern if there is steady improvement in neurologic function and a diminuition in the pain. Conclusions
When ulnar neuropathy at the elbow is treated by anterior transposition, the nerve should be placed deep to the flexor-pronator origin, and the medial intermuscular septum should be completely resected. Epineurectomy under adequate magnification is recommended whenever the nerve appears to be constricted. With recurrence or persistence of ulnar nerve symptoms following anterior transposition, re-operation is indicated. Possible sites of compression include the medial . intermuscular septum, fascial slings, fibrous bands at the entrance to the cubital tunnel, and tight antebrachial fascia. Although re-exploration may result in significant improvement, the prognosis for complete recovery is guarded. We wish to thank Dr. Hannibal Hamlin of the Massachusetts General Hospital, Boston, Mass., for his pennission to include two of his patients in this study.
REFERENCES I . Shelden WD: Tardy paralysis of the ulnar nerve. Med Clin North Am 5:499, 1921
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2. Platt H: The pathogenesis and treatment of traumatic neuritis of the ulnar nerve in the post-condylar groove. BrJ Surg 13:409, 1926 3. Platt H: The operative treatment of traumatic ulnar neuritis at the elbow. Surg Gynecol Obstet 47:822, 1928 4. Davidson AJ, Horwitz MT: Late or tardy ulnar nerve paralysis. J Bone Joint Surg 17:844, 1935 5 . Richards RL: Traumatic ulnar neuritis, the results of anterior transposition of the ulnar nerve . Edinb Med J 52: 14, 1945 6 . Gay JR , Love JG: Diagnosis and treatment of tardy paralysis of the ulnar nerve; based on a study of 100 cases. J Bone Joint Surg 29: 1087, 1947 7 . McGowan AJ: The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg 32-B:293, 1950 8. Childress HM: Recurrent ulnar nerve dislocation at the elbow. J Bone Joint Surg 38-A:978, 1956 9. Jensen E: Ulnar perineuritis . Acta Psychiatr Neurol Scand 34:205, 1959 10. Sunderland S: Nerves and nerve injuries , Baltimore, 1968, The Williams & Wilkins Co. II. Ho, HC, Mannor L: Entrapment of the ulnar nerve at the elbow. Am J Surg 121 :355 , 1970 12. Harrison MJG, Nurick S: Results of anterior transposition of the ulnar nerve for ulnar neuritis. Br Med J 1:27, 1970 13. Levy DM, Apfelberg DB: Results of anterior transposition for ulnar transposition for ulnar neuropathy at the elbow. Am J Surg 123:304, 1972 14. Gerl A, Thorwirth V: Ergebnisse der ulnarisver-Iagering. Acta Neurochir 30:227, 1974 15. Childress HM: Recurrent ulnar nerve dislocation at the elbow. Clin Orthop 108: 168, 1975 16. Seddon H: Surgical disorders of the peripheral nerves, London, 1975, Churchill-Livingstone, Ltd 17. Campbell JB, Post KD, Morantz RA: A technique for relief of motor and sensory deficits occurring after anterior ulnar transposition. J Neurosurg 40:405, 1974 18. Lluch A: Ulnar nerve entrapment after anterior transposition at elbow. NY State J Med 75:75, 1975 19 . Curtis BF: Traumatic ulnar neuritis; transplantation of the nerve. J Nerv Ment Dis 25:480, 1898 20. Murphy JB: Cicatrical fixation of ulnar nerve from ancient cubitus valgus release and transference to new site. Clin. JB Murphy Mercy Hosp 5:661, 1916 21. Adson A W: The surgical treatment of progressive ulnar paralysis. Minn Med 1:455, 1918 22. Leannonth JR: A technique for transplanting the ulnar nerve. Surg Gynecol Obstet 75:792, 1942 23 . Wilson DH, Krout R: Surgery of ulnar neuropathy at the elbow: 16 cases treated by decompression without transposition . J Neurosurg 38:780, 1973
