Efficacy of shortwave diathermy in ulnar nerve entrapment at the elbow: a double-blind randomized controlled clinical trial.

OBJECTIVE: To investigate the efficacy of shortwave diathermy in treatment of ulnar nerve entrapment at the elbow. DESIGN: The study was a double blind, randomized controlled clinical trial. SETTING, PARTICIPANTS: A total of 76 adult patients diagnosed with ulnar nerve entrapment at the elbow clinically and electrophysiologically, were randomly assigned into two groups. Patients were evaluated at baseline, after completing treatment and 1 and 3 months after treatment. Physical examination, quick-DASH (disabilities of arm, shoulder, hand) and SF-36 (short form) questionnaires for daily life activities, dynamometer for grip strength, and visual analog scale for pain were used. INTERVENTION: A total of 10 sessions of shortwave diathermy were applied to patients in treatment group as five sessions/week, 2 weeks. Control group was given placebo shortwave diathermy. Both groups were given elbow splints and informed to avoid symptom provoking activities. MAIN OUTCOME MEASURES: Visual analog scale, grip strength, SF-36, and quick-DASH results. RESULTS: Out of 76 patients, 61 of them completed the study where n = 31 for treatment group and n = 30 for control group. Mean age was 46.18 ± 13.45 years. There were 32 (52.5%) women and 29 (47.5%) men. The p values between groups 3 months after intervention for visual analog scale, quick-DASH, SF-36 questionnaire, and dynamometer were 0.669, 0.277, 0.604, and 0.126, respectively (p > 0.05). CONCLUSION: Application of shortwave diathermy to patients with ulnar nerve neuropathy at the elbow was not associated with any difference in outcome.

Compressive Neuropathy of the Ulnar Nerve in the Hypothenar Region by Lipoma: Case Report

Lipomas are well-defined tumors of the adipose tissue that often occur in the torso or the extremities of adult patients. These tumors usually develop painlessly and insidiously, but theymay compress adjacent structures. The objective of the present study is to describe the case of a 68-year-old female patient with a giant lipoma located at the hypothenar region, with manifestation of compression of the common palmar digital nerves, the ulnar nerve, andthe abductormuscle of theVfinger. Regarding the symptoms, the patient feltmoderate pain in the hypothenar region, with no Tinel sign, and no changes in the motor function or sensibility of the digits innervated by the ulnar nerve. Lipomasmay present a varied range of histological characteristics, and malignant tumors may be a differential diagnosis. An imaging exammay aid in the diagnosis, which is confirmed by a histopathological study. For the present case, as recommended in the literature, a surgical procedure was performed for the resection of the tumor, which resulted in the control of the symptoms.

Tardy Ulnar Nerve Palsy.

Tardy ulnar nerve palsy is a chronic clinical condition characterized by a delayed onset ulnar neuropathy after an injury to the elbow. Typically, tardy ulnar nerve palsy occurs as a consequence of nonunion of pediatric lateral condyle fractures at the elbow, which eventually lead to a cubitus valgus deformity. While the child grows, the deformity worsens and the ulnar nerve is gradually stretched until classic symptoms of ulnar nerve neuropathy appear. Other childhood elbow trauma has also been associated with tardy ulnar nerve palsy, including supracondylar fractures resulting in cubitus varus, fractures of the medial condyle and of the olecranon, as well as radial head or Monteggia fractures/dislocation, with or without deformity. The clinical assessment includes obtaining a complete history, physical examination, nerve conduction tests, and elbow imaging studies. Treatment consists of ulnar nerve decompression, with or without corrective osteotomy, with overall successful results usually achieved.

Treatment for ulnar neuropathy at the elbow.

BACKGROUND: Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy after carpal tunnel syndrome. Treatment may be conservative or surgical, but optimal management remains controversial. This is an update of a review first published in 2010 and previously updated in 2012. OBJECTIVES: To determine the effectiveness and safety of conservative and surgical treatment in ulnar neuropathy at the elbow (UNE). We intended to test whether:- surgical treatment is effective in reducing symptoms and signs and in increasing nerve function;- conservative treatment is effective in reducing symptoms and signs and in increasing nerve function;- it is possible to identify the best treatment on the basis of clinical, neurophysiological, or nerve imaging assessment. SEARCH METHODS: On 31 May 2016 we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, AMED, CINAHL Plus, and LILACS. We also searched PEDro (14 October 2016), and the papers cited in relevant reviews. On 4 July 2016 we searched trials registries for ongoing or unpublished trials. SELECTION CRITERIA: The review included only randomised controlled clinical trials (RCTs) or quasi-RCTs evaluating people with clinical symptoms suggesting the presence of UNE. We included trials evaluating all forms of surgical and conservative treatments. We considered studies regarding therapy of UNE with or without neurophysiological evidence of entrapment. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed titles and abstracts of references retrieved from the searches and selected all potentially relevant studies. The review authors independently extracted data from included trials and assessed trial quality. We contacted trial investigators for any missing information. MAIN RESULTS: We identified nine RCTs (587 participants) for inclusion in the review, of which three studies were found at this update. The sequence generation was inadequate in one study and not described in three studies. We performed two meta-analyses to evaluate the clinical (3 trials, 261 participants) and neurophysiological (2 trials, 101 participants) outcomes of simple decompression versus decompression with submuscular or subcutaneous transposition; four trials in total examined this comparison.We found no difference between simple decompression and transposition of the ulnar nerve for both clinical improvement (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08; moderate-quality evidence) and neurophysiological improvement (mean difference (in m/s) 1.47, 95% CI -0.94 to 3.87). The number of participants to clinically improve was 91 out of 131 in the simple decompression group and 97 out of 130 in the transposition group. Transposition showed a higher number of wound infections (RR 0.32, 95% CI 0.12 to 0.85; moderate-quality evidence).In one trial (47 participants), the authors compared medial epicondylectomy with anterior transposition and found no difference in clinical and neurophysiological outcomes.In one trial (48 participants), the investigators compared subcutaneous transposition with submuscular transposition and found no difference in clinical outcomes.In one trial (54 participants for 56 nerves treated), the authors found no difference between endoscopic and open decompression in improving clinical function.One trial (51 participants) assessed conservative treatment in clinically mild or moderate UNE. Based on low-quality evidence, the trial authors found that information on avoiding prolonged movements or positions was effective in improving subjective discomfort. Night splinting and nerve gliding exercises in addition to information provision did not result in further improvement.One trial (55 participants) assessed the effectiveness of corticosteroid injection and found no difference versus placebo in improving symptoms at three months' follow-up. AUTHORS' CONCLUSIONS: We found only two studies of treatment of ulnar neuropathy using conservative treatment as the comparator. The available comparative treatment evidence is not sufficient to support a multiple treatment meta-analysis to identify the best treatment for idiopathic UNE on the basis of clinical, neurophysiological, and imaging characteristics. We do not know when to treat a person with this condition conservatively or surgically. Moderate-quality evidence indicates that simple decompression and decompression with transposition are equally effective in idiopathic UNE, including when the nerve impairment is severe. Decompression with transposition is associated with more deep and superficial wound infections than simple decompression, also based on moderate-quality evidence. People undergoing endoscopic surgery were more likely to have a haematoma. Evidence from one small RCT of conservative treatment showed that in mild cases, information on movements or positions to avoid may reduce subjective discomfort.

Syndrome of canal of Guyon - definition, diagnosis, treatment and complication.

Syndrome of canal of Guyon is the second after carpal tunnel syndrome, compression syndrome in the wrist. Opposite to median nerve compression, ulnar nerve compression is not very popular. However it impairs functioning of the hand even more than median nerve lesion. Authors deal with definition, possible diagnostic methods, treatment and most frequent complication.

Compresión nervio cubital en el canal de Guyón: estudio retrospectivo de 12 casos / Compression of the ulnar nerve in Guyon’s canal: retrospective study of 12 cases

Objetivo: valorar causas y zonas de compresión del nervio cubital en el canal de Guyon. Material y método: se realizó un estudio retrospectivo de 12 pacientes intervenidos de síndrome del túnel cubital con un seguimiento medio de 9 meses. A todos se les practicó un estudio electrofisiológico y se observó si existe relación con la presencia de síndrome de túnel del carpo. Resultados: En solo 3 casos encontramos una etiología clara de la compresión nerviosa. Existe mayor presencia de síndrome de túnel del carpo en aquellos con compresión cubital idiopática pero sin significación estadística. Conclusiones: La mayoría de las compresiones cubitales en la muñeca, bajo nuestra experiencia, son de origen idiopático. Con la cirugía existe mejoría clínica de la sintomatología

Objective: To assess causes and areas of ulnar nerve compression in Guyon's canal Methods: A retrospective study of 12 patients undergoing cubital tunnel syndrome with a mean of 9 months was performed. All we performed an electrophysiological study and found the correlation with the presence of carpal tunnel syndrome. Results: In only 3 cases we found a clear etiology of nerve compression. There is an increased presence of carpal tunnel syndrome in those with idiopathic ulnar compression but without statistical significance. Conclusions: Most of the ulnar compression at the wrist, in our experience, are idiopathic. With surgery there is clinical improvement of symptoms

Ulnar nerve entrapment at the wrist.

Presentation of ulnar nerve entrapment at the wrist varies based on differential anatomy and the site or sites of compression. Therefore, an understanding of the anatomy of the Guyon canal is essential for diagnosis in patients presenting with motor and/or sensory deficits in the hand. The etiologies of ulnar nerve compression include soft-tissue tumors; repetitive or acute trauma; the presence of anomalous muscles and fibrous bands; arthritic, synovial, endocrine, and metabolic conditions; and iatrogenic injury. In addition to a thorough history and physical examination, which includes motor, sensory, and vascular assessments, imaging and electrodiagnostic studies facilitate the diagnosis of ulnar nerve lesions at the wrist. Nonsurgical management is appropriate for a distal compression lesion caused by repetitive activity, but surgical decompression is indicated if symptoms persist or worsen over 2 to 4 months.

Ulnar tunnel syndrome.

Ulnar neuropathy at or distal to the wrist, the so-called ulnar tunnel syndrome, is an uncommon but well-described condition. However, diagnosis of ulnar tunnel syndrome can be difficult. Paresthesias may be nonspecific or related to coexisting pathologies, such as carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, C8-T1 radiculopathy, or peripheral neuropathy, which makes accurate diagnosis challenging. The advances in electrodiagnosis, ultrasonography, computed tomography, and magnetic resonance imaging have improved the diagnostic accuracy. This article offers an updated view of ulnar tunnel syndrome as well as its etiologies, diagnoses, and treatments.

How to treat Guyon's canal syndrome? Results from the European HANDGUIDE study: a multidisciplinary treatment guideline.

BACKGROUND: Although Guyon's canal syndrome is not highly prevalent, a considerable knowledge of anatomy is needed to localise and treat the pathology. Data on the effectiveness of interventions for this disorder are lacking. OBJECTIVE: To achieve consensus on a multidisciplinary treatment guideline for this disorder based on experts' opinions. METHODS: A European Delphi consensus strategy was initiated. In total, 35 experts (hand surgeons/hand therapists selected by the national member associations of their European federations and Physical Medicine and Rehabilitation physicians) participated in the Delphi consensus strategy. Each Delphi round consisted of a questionnaire, an analysis and a feedback report. RESULTS: After three Delphi rounds, consensus was achieved on the description, symptoms and diagnosis of Guyon's canal syndrome. The experts agreed that patients with this disorder should always receive instructions and that these instructions should be combined with another form of treatment. Instructions combined with splinting or with surgery were considered as suitable treatment options. Details on the use of instructions, splinting and surgery were described. Main factors for selecting one of the aforementioned treatment options were identified: severity and duration of the syndrome and previous treatments given. A relation between the severity/duration and choice of therapy was indicated by the experts and reported in the guideline. CONCLUSIONS: Although this disorder is less prevalent and not easy to diagnose, this guideline may contribute to better insight into and treatment of Guyon's canal syndrome.

Ulnar tunnel syndrome.

Ulnar tunnel syndrome could be broadly defined as a compressive neuropathy of the ulnar nerve at the level of the wrist. The ulnar tunnel, or Guyon's canal, has a complex and variable anatomy. Various factors may precipitate the onset of ulnar tunnel syndrome. Patient presentation depends on the anatomic zone of ulnar nerve compression: zone I compression, motor and sensory signs and symptoms; zone II compression, isolated motor deficits; and zone III compression; purely sensory deficits. Conservative treatment such as activity modification may be helpful, but often, surgical exploration of the ulnar tunnel with subsequent ulnar nerve decompression is indicated.

Treatment for ulnar neuropathy at the elbow.

BACKGROUND: Ulnar neuropathy at the elbow is the second most common entrapment neuropathy after carpal tunnel syndrome. Treatment may be conservative or surgical but optimal management remains controversial. This is an update of a review first published in 2010. OBJECTIVES: To determine the effectiveness and safety of conservative and surgical treatments in ulnar neuropathy at the elbow. SEARCH METHODS: We searched the Cochrane Neuromuscular Disease Group Specialized Register (20 February 2012), CENTRAL (2012, Issue 2), MEDLINE (January 1966 to February 2012), EMBASE (January 1980 to February 2012), AMED (January 1985 to February 2012), CINAHL Plus (January 1937 to February 2012), LILACS (January 1982 to Feburary 2012), PEDro (January 1980 to February 2012), and the papers cited in relevant reviews. SELECTION CRITERIA: The review included only randomised controlled clinical trials (RCTs) or quasi-RCTs evaluating people with clinical symptoms suggesting the presence of ulnar neuropathy at the elbow. We included trials evaluating all forms of surgical and conservative treatments. We considered studies regarding therapy of ulnar neuropathy at the elbow with or without neurophysiological evidence of entrapment. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed titles and abstracts of references retrieved from the searches and selected all potentially relevant studies. The authors extracted data from included trials and assessed trial quality independently. They contacted trial investigators for missing information. MAIN RESULTS: We identified six RCTs (430 participants), with moderate quality evidence, for inclusion in the review. When the searches were updated in 2012 we found no further studies. The sequence generation was not adequate in one study and not described in two studies. We performed two meta-analyses to evaluate the clinical (three trials, 261 participants included) and neurophysiological (two trials, 101 participants included) outcomes of simple decompression versus decompression with submuscular or subcutaneous transposition.We found no difference between simple decompression and transposition of the ulnar nerve for both clinical improvement (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.80 to 1.08) and neurophysiological improvement (mean difference (in m/s) 1.47, 95% CI -0.94 to 3.87). In the simple decompression group 91 out 131 patients clinically improved; in the transposition group 97 out 130 patients improved. Transposition showed a higher number of wound infections (RR 0.32, 95% CI 0.12 to 0.85).In one trial (47 participants) the authors compared medial epicondylectomy with anterior transposition and found no difference in the clinical and neurophysiological outcomes.One trial (51 participants) assessed conservative treatment in clinically mild or moderate ulnar neuropathy at the elbow. The authors found that information on avoiding prolonged movements or positions was effective in improving subjective discomfort. Night splinting and nerve gliding exercises in addition to the information did not produce further improvement. AUTHORS' CONCLUSIONS: The available evidence is not sufficient to identify the best treatment for idiopathic ulnar neuropathy at the elbow on the basis of clinical, neurophysiological and imaging characteristics. We do not know when to treat a patient conservatively or surgically. However, the results of our meta-analysis suggest that simple decompression and decompression with transposition are equally effective in idiopathic ulnar neuropathy at the elbow, including when the nerve impairment is severe. In mild cases, evidence from one small RCT of conservative treatment showed that information on movements or positions to avoid may reduce subjective discomfort.

Conservative management of ulnar tunnel syndrome: secondary to excessive healing tissue; a rare complication after flexor tendon injury--a case report.

The ulnar tunnel syndrome occurs usually from ganglions, lipoma, cysts, chronic repetitive trauma, bicycling, and the activities that require either prolonged wrist hyper extension or continued pressure on the hypothenar eminence. The ulnar tunnel syndrome after flexor tendon repair is a rare complication. We report on a 24-year-old man with ulnar tunnel syndrome after a flexor tendon repair secondary to girder cut injury. The patient was managed conservatively for his hypertrophic scar for 9 weeks. After 9 weeks, the patient presented with no clawing and complete closure of the hand.

Morphology of the cubital tunnel: an anatomical and biomechanical study with implications for treatment of ulnar nerve compression.

PURPOSE: The purpose of this study is to provide a thorough understanding of the anatomy of the cubital tunnel and to outline specific anatomical parameters of the cubital tunnel retinaculum (CuTR) that might aid in the management of ulnar nerve problems. The hypotheses of this study are (1) that the nerve elongates with elbow flexion and (2) that the cross-sectional area of the cubital tunnel is inversely proportional to the degree of elbow flexion. METHODS: Eleven fresh-frozen cadaver arms were dissected at the medial elbow. The CuTR was identified, and its thickness was measured. After excising the CuTR, we measured the elongation of the anterior and posterior aspects of the ulnar nerve, as well as the length of the CuTR origin/insertion, at increasing intervals of elbow flexion (15°, 30°, 45°, 90°, 120°, and 135°). Using 3-dimensional digitization technology, the surface of the cubital tunnel was recorded at 4 positions of elbow flexion (15°, 45°, 90°, and 135°) and analyzed to define the tunnel geometry. RESULTS: The CuTR origin-to-insertion length and the ulnar nerve length both increased significantly with increasing flexion angle. Both lengths at 90°, 120°, and 135° of elbow flexion were greater than at 15° or 30°. The cubital tunnel area was significantly less at 135° compared to either 45° or 90° of flexion. There was a linear relationship between the cubital tunnel area of the different arms with the corresponding nerve cross-sectional area when measured at the level of the epicondyle and when the arm was at 90° of elbow flexion. CONCLUSIONS: The CuTR begins to stretch at 60° of flexion and continues to stretch with increasing flexion. Similarly, the ulnar nerve is more taut in flexion. The area within the cubital tunnel decreases beyond 90° of elbow flexion. CLINICAL RELEVANCE: Understanding the dynamic anatomical relationships of the cubital tunnel might help in the safe treatment of cubital tunnel syndrome when using minimally invasive techniques and instrumentation.

Treatment for ulnar neuropathy at the elbow.

BACKGROUND: Ulnar neuropathy at the elbow is the second most common entrapment neuropathy after carpal tunnel syndrome. Treatment may be conservative or surgical but optimal management remains controversial. OBJECTIVES: The objectives of this systematic review were to determine the effectiveness and safety of conservative and surgical treatments in ulnar neuropathy at the elbow. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Specialized Register (16 February 2010), Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 1), MEDLINE (January 1966 to February 2010), EMBASE (January 1980 to February 2010), AMED (January 1985 to February 2010), CINAHL Plus (January 1937 to February 2010), LILACS (January 1982 to Feburary 2010), PEDro (January 1980 to February 2010), and the papers cited in relevant reviews. SELECTION CRITERIA: The review included only randomised controlled clinical trials. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed titles and abstracts of references retrieved from the searches and selected all potentially relevant studies. The authors extracted data from included trials and assessed trial quality independently. They contacted trial investigators for missing information. MAIN RESULTS: We identified 1461 papers and selected six randomised controlled clinical trials with moderate quality evidence. The sequence generation was not adequate in one study and not described in two studies. We performed two meta-analyses to evaluate the clinical and neurophysiological outcomes of simple decompression versus decompression with submuscular or subcutaneous transposition.We found no difference between simple decompression and transposition of the ulnar nerve for both clinical improvement (risk ratio (RR) 0.93, 95% CI 0.80 to 1.08) and neurophysiological improvement (RR 1.47, 95% CI -0.94 to 3.87). Transposition showed a higher number of wound infections (RR 3.10, 95% CI 1.18 to 8.15).In one trial the authors compared medial epicondylectomy with anterior transposition and found no difference in the clinical and neurophysiological outcomes.One trial assessed conservative treatment in clinically mild or moderate ulnar neuropathy at the elbow. The authors found that information on avoiding prolonged movements or positions was effective in improving subjective discomfort. Night splinting and nerve gliding exercises in addition to the information did not produce further improvement. AUTHORS' CONCLUSIONS: The available evidence is not sufficient to identify the best treatment for idiopathic ulnar neuropathy at the elbow on the basis of clinical, neurophysiological and imaging characteristics. We do not know when to treat a patient conservatively or surgically. However, the results of our meta-analysis suggest that simple decompression and decompression with transposition are equally effective in idiopathic ulnar neuropathy at the elbow, including when the nerve impairment is severe. In mild cases, evidence from one small randomised controlled trial of conservative treatment showed that information on movements or positions to avoid may reduce subjective discomfort.

[Ulnar entrapment neuropathy].

Ulnar nerve entrapment is one of the most common entrapment neuropathies in the upper limb. The most frequent location of this syndrome is behind the elbow. The clinical picture is associated with the localization of the entrapment but usually consists of an altered sensation at the fourth and fifth digits and a weakness of the intrinsic muscles of the palm. The most constructive tool in making the diagnosis and in assessing the treatment's efficacy is the physical examination. Treatment alternatives depend on entrapment location. Conservative treatment options such as rest, a change in the work environment and patterns as well as splints are all accepted modalities. A lack of improvement following conservative treatment or a deteriorating nerve function is an indication for surgical intervention. This includes procedures comprised of decompression of the ulnar nerve alone or those which combine its transposition.

Ulnar tunnel syndrome.

As our understanding of the anatomy of the ulnar tunnel has increased, so too has our ability to clinically predict the specific sites of compression in ulnar tunnel syndrome. Anatomic studies have described in detail the course of the ulnar nerve as it passes through the ulnar tunnel and have helped correlate symptoms with anatomic location. Although the most common cause of compression is from a ganglion, other space-occupying lesions, such as tumors, anomalous muscles, or a thrombosed ulnar artery, are important to consider in the initial evaluation of the patient. While conservative management can sometimes be successful, the mainstay of treatment of this condition remains meticulous surgical exploration and decompression.

Compression neuropathies of the upper extremity.

Nerve compression syndromes of the upper extremity occur at predicable locations. The diagnosis of nerve compression or nerve entrapment is based on the neurologic and electrodiagnostic examinations. The anatomy, neurophysiology, and electrodiagnosis of nerve compression are discussed. Common and uncommon compression and entrapment syndromes of the upper extremity are described. Errors in diagnosis occur when the neurologic or electrodiagnostic examinations are incomplete or inaccurate.

[Entrapment neuropathies of the arm]. / Kompressionssyndrome der Armnerven.

Compression-induced damage to the peripheral nerves can cause persistent, mostly exercise-related intensified pain syndromes. In the presence of brachialgia, compression neuropathies must always be considered when rendering the differential diagnosis, whether in the scapular region (e.g. suprascapular syndrome) in the elbow (e.g. supinator syndrome) or the hand (carpal tunnel syndrome, distal ulnar tunnel syndrome). Knowledge of neuroanatomy, detailed history of pain and provocative movements and a targeted examination technique including the findings of provocative testing will usually lead to an accurate diagnosis. Focal neural damage, its exact localization and degree of severity can all be confirmed by the targeted use of electroneurography and needle myography. These procedures will also allow a prognostic estimation and provide information about whether surgical therapeutic procedures are indicated.

Nerve entrapments of the wrist: early treatment preserves function.

Nerve entrapment syndromes may affect as many as one in four office workers. Prompt diagnosis is critical to the selection of an appropriate and effective treatment.