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Cubital tunnel syndrome is the second most commonly encountered compression neuropathy of the upper limb. Multiple techniques for surgical management have been proposed but no universally accepted algorithm for management exists. Six cadaveric upper limbs underwent ulnar nerve decompression and anterior transposition into subcutaneous and then submuscular positions. After marking nerves with tungsten, radiological examination of nerve motion was performed and nerve angulations were measured in the region of the flexor carpi ulnaris (FCU) origin. Comparison of ulnar nerves in each position revealed statistically significant greater angulation after subcutaneous transposition than after submuscular transposition with the elbow held in full flexion. This point of angulation may act as a secondary point of compression or as a focus for neuritis and scar formation. This finding can contribute to the understanding of why differing outcomes may be observed after different forms of anterior transposition.

The author reports an unusual case of neural fibrolipoma (lipofibromatous hamartoma) of the ulnar nerve in the hand. A 20-year-old man presented with a fusiform soft tissue mass in his right hand. Neurological examination was normal except to minimal pain on palpation. Surgical exploration revealed that ulnar nerve and its digital branches were infiltrated by fibrofatty tissues. Fibrofatty tissues were dissected and removed from the nerve by microsurgical technique. Histological examination confirmed the diagnosis as a lipofibromatous hamartoma of the nerve. The result of surgical debulking was satisfactory.

Cubital tunnel syndrome is one of the most common entrapment neuropathies in adults. It is mainly caused by the depression of ulnar nerve from normal structures at the elbow area. Despite the fact that several pathgological entities can be potential mechanisms of the syndrome, the pathogenesis due to benign or malignant neoplasms is extremely rare. In the present report we describe the first case of cubital tunnel syndrome due to giant cell tumour of the tendon sheaths.

Diffusion-weighted images based on magnetic resonance reveal the microstructure of tissues by monitoring the random movement of water molecules. In this study, we investigated whether this new technique could visualize pathologic lesions on ulnar nerve in cubital tunnel. Six elbows in six healthy males without any symptoms and eleven elbows in ten patients with cubital tunnel syndrome underwent on diffusion-weighted MRI. No signal from the ulnar nerve was detected in normal subjects. Diffusion-weighted MRI revealed positive signals from the ulnar nerve in all of the eleven elbows with cubital tunnel syndrome. In contrast, conventional T2W-MRI revealed high signal intensity in eight elbows and low signal intensity in three elbows. Three elbows with low signal MRI showed normal nerve conduction velocity of the ulnar nerve. Diffusion-weighted MRI appears to be an attractive technique for diagnosis of cubital tunnel syndrome in its early stages which show normal electrophysiological and conventional MRI studies.

There are significant variations in the anatomy of the dorsal cutaneous branch of the ulnar nerve. The dorsal cutaneous branch is at a risk of injury during a therapy for the ulnar side of the wrist. The purpose of this study is to measure the variations of the dorsal cutaneous branch. We studied 30 embalmed cadaver specimens. In its course, two division patterns of the dorsal cutaneous branch were identified, namely proximal and distal types. The proximal type went around the ulna proximal to the ulnar styloid process, and directed toward the ulnodorsal aspect. The distal type went around to the ulnodorsal aspect, distal to the styloid process. The proximal type was found in 21 of 30 cadavers, and the distal type was found in nine of 30 cadavers.

Cubital tunnel syndrome is the second most common nerve entrapment neuropathy. When non-operative treatments fail, surgical intervention is indicated. Although there remains no consensus between simple decompression and anterior transposition, there is a growing recognition of improved clinical outcomes in the latter. Few details of ulnar nerve branches around the elbow are available however and their sacrifice may be necessary to facilitate anterior transposition. Therefore, ten cadaveric upper extremities were dissected to delineate the course and branching pattern of the ulnar nerve around the elbow joint; anterior transposition was also performed in the cadaveric specimens. Digital photographs of the dissection study were analyzed using the Image J package. Results show that distal ulnar nerve branches are distributed more laterally towards the olecranon and may potentially restrict transposition more than has been recognized; proximal branches may also overlap incision lines of such transposition procedures.

Anterior dislocation of the ulnar nerve is occasionally encountered after simple decompression of the nerve for treatment of cubital tunnel syndrome. The purpose of this study was to determine whether the incidence of dislocation of the nerve following simple decompression of the nerve is correlated with the patient's preoperative characteristics and/or elbow morphology. We studied 51 patients with cubital tunnel syndrome who underwent surgery at our institution. Intraoperatively, we simulated dislocation of the nerve after simple decompression by flexing the elbow after releasing the nerve in each patient. Univariate and multiple logistic regression analysis showed that young age and a small ulnar nerve groove angle are positively correlated with dislocation of the nerve. Our results suggest that patients who are young and/or have a sharply angled ulnar nerve groove identified radiographically have a high probability of experiencing anterior dislocation of the ulnar nerve after simple decompression.

Ulnar nerve neuropathy is a rare complication following the carpal tunnel release. Above all, compression neuropathy is much rare. We report an acute ulnar nerve neuropathy following open carpal tunnel release due to the volar and ulnar displacement of the flexor tendons from the carpal tunnel and review the literature.

Epidermal cyst is a dermal or subcutaneous epithelial cyst that contains keratin and is lined by true epidermis. Although extremely rare, it can cause pathology including nerve compression syndrome. We report a rare case of ulnar nerve compression in the elbow that was caused by olecranon bursitis and concomitant epidermal cyst in a 67-year-old man. The ulnar nerve was immediately adjacent to the olecranon bursa and was significantly compressed. There was no connection between the tumor and the ulnar nerve. Pain, numbness, and weakness in his ring and little fingers disappeared after resection of the cyst and bursa.

Lipofibromatous hamartoma (LFH) is a rare condition of the peripheral nerves that typically affects the median nerve. To the best of our knowledge, this is the first report of LFH of both, the median and ulnar nerves, at the wrist of a 63-year-old female patient. The patient presented to our hospital with a 40-year history of pain, numbness, and dysesthesia affecting all fingers of her left hand. Atrophy of the thenar muscles and the first dorsal interosseous was observed upon physical examination. Imaging studies and a surgery revealed that the patient's median and ulnar nerves were significantly enlarged, confirming the LFH diagnosis. The patient's dysesthesia and numbness improved after Carpal tunnel and Guyon canal release, and her pinch ability improved after opponensplasty. LFH has been known to be solitary, typically affecting median nerve, but it must be noted that the tumor may affect multiple nerves like in our case.

A 43-year-old female is presented who underwent a two-stage tendon reconstruction and developed a low ulnar nerve palsy postoperatively. Exploration found that the tendon graft was passing through Guyon’s canal and that the ulnar nerve was divided. This is a previously unreported complication. The reconstruction is discussed, the literature reviewed and a guide is given on how to identify the correct tissue plane when passing a tendon rod.

Background: Brachial plexus injury is very commonly associated with road traffic accidents, and frequently affects young adults, causing significant disability and impact on quality of life. The successful treatment of upper plexus injury with the Oberlin technique to restore elbow flexion with good functional results.

Methods: We retrieved the records of all patients with upper plexus injury who underwent Oberlin transfer operation between March 2007 and July 2012. Outcomes were assessed using the Medical Research Council (MRC) power grading system for biceps muscle, Disabilities of the Arm, Shoulder and Hand score (DASH) for patient functional outcomes and the Visual Analogue Scale for daily disability (VAS where 0- no restrictions; 10- significant limitations) for overall patient satisfaction. Follow-up was performed for at least 12 months post-operatively.

Results: The average follow up period was 43.6 months. Six cases gained effective elbow flexion, improving to MRC grade 5/5 and four cases improved to MRC grade 4/5 for biceps function. The average DASH score was 27.25. One patient had serious disability with no changes after Oberlin’s transfer operation. No permanent impairment of ulnar nerve function was observed. Seven out of 10 patients had begun daily work, with no discomfort and no functional impact on activities of daily living.

Conclusions: We found The Oberlin transfer is a useful salvage procedure and most effective results are for young patients with short interval between injury and operation.

Background: Cubital tunnel syndrome (CuTS) is generally treated successfully by surgery and recurrent cases are rare. This study retrospectively investigated the clinical characteristics of recurrent CuTS caused by ganglion.

Methods: We evaluated nine patients who were surgically treated for recurrent CuTS caused by ganglion. Age distribution at recurrence ranged from 43 to 79 years. The initial surgery for CuTS had been performed using various methods. The asymptomatic period from initial surgery to recurrence ranged from 22 to 252 months. Clinical, diagnostic imaging, and operative findings during the second surgery were analyzed. All patients were treated by anterior subcutaneous ulnar nerve transposition with ganglion resection and later examined directly within a mean of 71 months after the second surgery.

Results: The interval from recurrence to consultation was shorter than two months for eight cases. Chief complaints included numbness with or without pain in the ring and little fingers in all patients and resting pain in the medial elbow in five patients. Elbow osteoarthritis was present in all cases. Although four of 10 ganglia were palpable, ultrasonography and magnetic resonance imaging could identify all ganglia preoperatively. The ulnar nerve typically had become entrapped by the ganglion posteriorly and by fascia, scar tissue, and/or muscle anteriorly. Chief complaints and ulnar nerve function were improved in all patients following revision surgery.

Conclusions: The acute onset of numbness with or without intolerable pain in the ring and little fingers after a long-term remission period following initial surgery for CuTS in patients with elbow osteoarthritis appears to be the characteristic clinical profile of recurrent CuTS caused by ganglion. As ganglia are often not palpable, ultrasonography and magnetic resonance imaging are recommended for accurate diagnosis.

Background: In combined high median and ulnar nerve injury, transfer of the posterior interosseous nerve branches to the motor branch of the ulnar nerve (MUN) is previously described in order to restore intrinsic hand function. In this operation a segment of sural nerve graft is required to close the gap between the donor and recipient nerves. However the thenar muscles are not innervated by this nerve transfer. The aim of the present study was to evaluate whether the superficial radial nerve (SRN) can be used as an “in situ vascular nerve graft” to connect the donor nerves to the MUN and the motor branch of median nerve (MMN) at the same time in order to address all denervated intrinsic and thenar muscles.

Methods: Twenty fresh male cadavers were dissected in order to evaluate the feasibility of this modification of technique. The size of nerve branches, the number of axons and the tension at repair site were evaluated.

Results: This nerve transfer was technically feasible in all specimens. There was no significant size mismatch between the donor and recipient nerves

Conclusions: The possible advantages of this modification include innervation of both median and ulnar nerve innervated intrinsic muscles, preservation of vascularity of the nerve graft which might accelerate the nerve regeneration, avoidance of leg incision and therefore the possibility of performing surgery under regional instead of general anesthesia. Briefly, this novel technique is a viable option which can be used instead of conventional nerve graft in some brachial plexus or combined high median and ulnar nerve injuries when restoration of intrinsic hand function by transfer of posterior interosseous nerve branches is attempted.

A 20-year-old male has presented with mild numbness and tingling sensation at 4, 5^th finger of his left hand. Simple radiograph and MRI images revealed bony mass at medial joint space of ulno-humeral joint. After surgical exploration, we found that there were two cause of ulnar nerve irritation symptom. Fixed ulnar nerve position at anterior aspect to medial condyle with deficiency of nerve gliding was one cause, and friction irritation around bony mass was another. It is rarely reported that ulnar nerve always travels to the anterior side of the medial condyle of the elbow, and there are no cases involving skeletal variation. In this case, the ulnar nerve may be penetrated while forming an anterior medial portal around elbow joint. It is important to know the path of the ulnar nerves very carefully through imaging and physical examination when there is a bony variant in the elbow joint.

Background: Shoulder and elbow motions can affect ulnar nerve strain. However, there is no evidence that links this kind of strain to specific activities. The purpose of this study was to examine ulnar nerve strain at the elbow resulting from normal daily activities.

Methods: This study was conducted using thirty fresh frozen cadaveric elbows from subjects who had no deformities or history of previous upper extremity surgery. Strain was calculated based on nerve elongation. Ulnar nerve strain at the elbow from motion related to common daily activities was measured in both normal nerves and nerves in which gliding motion was restricted. The results of these measurement were then compared.

Results: Activities related to extreme elbow and shoulder motions, such as cellular phone use, yielded an average strain of 6.3%. In addition, we found that nerve strain increased significantly in conditions in which gliding motion was restricted. Nerve strain due to motion associated with cellular phone use, for example, rose by 69.1%.

Conclusions: Elbow flexion and shoulder abduction in daily activities are associated with increases in ulnar nerve strain, but this may not cause permanent damage to the nerve. After nerve gliding motion had been restricted, nerves that normally exhibited less strain often had even increased higher levels of strain than those nerves that normally exhibited high strain.

Background: This study investigated the functional outcomes of intramuscular ulnar nerve transposition (IMUNT) in young adults with cubital tunnel syndrome (CuTS).

Methods: This retrospective study enrolled 37 military soldiers on active duty diagnosed with and treated for CuTS to determine the compression sites, complication rate, and postoperative results. Patient outcomes were analyzed using the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and the Bishop–Kleinman rating scales.

Results: Patient outcomes were analyzed after a mean follow-up duration of 26.1 (22–29) months for 37 extremities. DASH scores improved from 38.7 (range, 13–63 points) preoperatively to 5.8 (range, 0–18 points) postoperatively. Patient improvement was statistically significant (p < 0.05). Based on the 12-point Bishop–Kleinman rating system, 30 (82.1%) patients were graded as excellent; five (13.5%) as good, and two (5.4%) as failed outcomes. Statistically significant improvements in both key pinch and grip strength were noted. Complications included one case of transient neuroparaxias of the medial antebrachial cutaneous nerve and one case of hematoma formation.

Conclusions: We consider intramuscular ulnar nerve transposition to be a satisfactory procedure for CuTS. The procedure enhances upper limb function, thus allowing the patients to resume their physically demanding work with minimal complications.

Background: The aim of this study is to determine the prevalence of Martin-Gruber Anastomosis (MGA) in healthy Egyptian subjects, and to discuss the available literature regarding MGA subtypes and their clinical implications.

Methods: An electrophysiological study was conducted in both forearms of 140 healthy subjects. This included the ulnar and median nerves. Compound muscle action potentials were recorded from abductor pollicis brevis, abductor digiti minimi, and first dorsal interosseous muscles. Other measurements included the compound motor action potential amplitude and its innervation ratio.

Results: MGA was found in 56 of the 280 forearms. This included 20 men and 36 women. Type II MGA subtype was the most frequent in both genders. The MGA was bilateral in 6 subjects and more frequent on the right side. The highest mean amplitude and innervation ratio were recorded at first dorsal interosseus muscle.

Conclusions: The prevalence of MGA in the studied sample of the Egyptian population is 20%. It is important for Hand, Orthopaedic and Neurosurgeons to be aware of this anatomic variation in order to explain paradoxical motor and sensory loss in patients.

Schwannomas of the ulnar nerve in the hand are uncommon and those arising from the deep motor branch of the ulnar nerve (DMBUN) are rare. We were able to find only five reports of a schwannoma of the DMBUN. We report a schwannoma arising from DMBUN beyond the Guyon canal and summarise the literature on schwannomas involving the DMBUN.

Level of Evidence: Level V (Therapeutic)

Lymphoma is a malignant tumour of the lymphatic system. Neurolymphomatosis occurs when lymphoma cells invade the peripheral nervous system (PNS). Neurolymphomatosis has been reported involving the sciatic nerve, nerve roots and within the axilla and the upper arm. It can cause nerve dysfunction depending on the involved nerve. Neurolymphomatosis involving the ulnar nerve is rare. We report a patient with neurolymphomatosis of the ulnar nerve around the elbow that presented with features of cubital tunnel syndrome. A high index of suspicion is necessary in patients with cubital tunnel syndrome that present with uncommon symptoms such as sudden onset, rapid progression and/or severe pain.

Level of Evidence: Level V (Therapeutic)