[Ulnar nerve tunnel syndrome of the elbow and an occupational disorder. Analysis of socio-professional and physical parameters]

Ulnar neuropathy at the elbow

At the elbow, the ulnar nerve (UN) may be the site of a static compression (by the cubital tunnel retinaculum and Osborne's ligament between the two heads of the flexor carpi ulnaris), or a dynamic compression, especially when the nerve is unstable (subluxation/dislocation outside the ulnar groove). The clinical basis for the diagnosis of ulnar neuropathy involves looking for subjective and objective signs of sensory and/or motor deficit in the ulnar nerve's territory in the hand, a pseudo-Tinel's sign, and doing manipulations to provoke UN irritation. The diagnosis is confirmed by electromyography and ultrasonography. In the early stages, patient education and elimination of flexion postures or repeated elbow flexion motions can provide relief. If this fails or signs of sensory and/or motor deficit are present, surgical treatment is proposed. If the nerve is stable, in-situ nerve decompression is typically done as the first-line treatment. If the nerve is unstable, anterior nerve transposition - generally subcutaneous - or more rarely, a medial epicondylectomy can be done. If surgical treatment fails, the patient's history is reviewed, and diagnostic tests can be repeated. Except in cases of a fibrotic scar, the main causes of failure are neuroma of a branch of the medial cutaneous nerve of the forearm, instability of the nerve and persistence of a compression point. In the latter two cases, surgical revision is justified and anterior nerve transposition or epicondylectomy can be proposed.

Work Disabling Nerve Injury at Both Elbows Due to Laptop Use at Flexible Workplaces inside an Office: Case-Report of a Bilateral Ulnar Neuropathy

Background: This case report describes whether a female civil servant who developed bilateral ulnar neuropathy can be classified as having an occupational disease. Methods: The Dutch six-step protocol for the assessment and prevention of occupational diseases is used. Results: Based on the six-step protocol, we propose that pressure on the ulnar nerve in the elbow region precipitated the neuropathy for this employee while working prolonged periods in elbow flexion with a laptop. Conclusion: Despite the low incidence laptop use might be a risk factor for the occurrence of ulnar neuropathy due to prolonged pressure on the elbow. Employers and workers need to be educated about this disabling occupational injury due to laptop use and about protective work practices such as support for the upper arm and elbow. This seems especially relevant given the trend of more flexible workspaces inside and outside offices, and given the seemingly safe appearance of laptop use.

Relationship between Smoking and Outcomes after Cubital Tunnel Release

Purpose

Several studies have drawn a connection between cigarette smoking and cubital tunnel syndrome. One comparison article demonstrated worse outcomes in smokers treated with transmuscular transposition of the ulnar nerve. However, very little is known about the effect that smoking might have on patients who undergo ulnar nerve decompression at the elbow. The purpose of this study is to evaluate the effect of smoking preoperatively on outcomes in patients treated with ulnar nerve decompression.

Materials and Methods

This study used a survey developed from the comparison article with additional questions based on outcome measures from supportive literature. Postoperative improvement was probed, including sensation, strength, and pain scores. A thorough smoking history was obtained. The study spanned a 10-year period.

Results

A total of 1,366 surveys were mailed to former patients, and 247 surveys with adequate information were returned. No significant difference was seen in demographics or comorbidities. Patients who smoked preoperatively were found to more likely relate symptoms of pain. Postoperatively, nonsmoking patients generally reported more favorable improvement, though these findings were not statistically significant.

Conclusion

This study finds no statistically significant effect of smoking on outcomes after ulnar nerve decompression. Finally, among smokers, there were no differences in outcomes between simple decompression and transposition.

Can We Make Simple In Situ Decompression of the Ulnar Nerve at the Elbow Still Easier?

BACKGROUND

In situ decompression and transposition are equally effective in cubital tunnel syndrome treatment. Both are traditionally performed in the supine position.

OBJECTIVE

To validate our surgical technique for in situ decompression in the lateral decubitus position, comparing results with other techniques used in our institutions.

METHODS

A retrospective study was performed from January 2009 to February 2016, of 188 patients with cubital tunnel syndrome 115 males, 73 females; mean age, 53.44 ± 12.12 years standard deviation (range, 18-84 years) treated with in situ decompression in the lateral or supine positions or transposition (subcutaneous or submuscular). The lateral decubitus group received local anesthesia and the remainder received a brachial plexus block. Clinical and electrophysiologic results between these 4 groups were compared.

RESULTS

There were no statistically significant demographic differences between groups. Results were better in in situ decompression groups compared with transpositions. Mean follow-up was 1511.1 ± 770.57 days standard deviation (range, 310-4203 days). There were no recurrences or residual elbow pain/dysesthesia/anesthetic scar/hyperesthesia/neuroma in the lateral decubitus group. Complication and recurrence rates were in direct correlation to incision size. The worst results were seen in transpositions, particularly in the submuscular group. In situ decompression in the supine position had better results than transpositions but worse than those performed in lateral decubitus. Smaller surgical wound correlates with a reduction in operating time, costs, complication rates, and time out of work.

CONCLUSIONS

In situ decompression is equally as effective as ulnar nerve transpositions but with fewer complications and recurrences. In the lateral decubitus position, the retroepicondylar tunnel is more accessible, allowing smaller incisions and better results.

Overall health status in patients with mild to moderate carpal tunnel syndrome: A case-control study

STUDY DESIGN

A case-control study.

INTRODUCTION

There are no reports in the literature that evaluate the overall health status (OHS) of patients with mild to moderate forms of carpal tunnel syndrome (CTS) using 36-Item Short Form Health Survey (SF-36).

PURPOSE OF THE STUDY

To assess OHS in patients with mild to moderate CTS, in comparison with healthy subjects.

METHODS

The study involved 273 healthy people and 140 people diagnosed with CTS. The CTS diagnosis was made on the basis of clinical examinations and nerve conduction studies. OHS was assessed using the SF-36.

RESULTS

In the assessment of physical components of OHS, in the CTS group (compared with healthy subjects), the results show significantly lower values in physical functioning, role limitations because of physical health problems, bodily pain, and general health perceptions by 7.44, 23.2, 18.9, and 4.1, respectively. Mental components were lower (in CTS group) only in relation to vitality and social functioning by 4.1 and 5.5, respectively. In the assessment of physical component summary (PCS) and mental component summary (MCS), the results show significantly lower values of PCS (by 13 in CTS group) and no significant differences in the assessment of MCS between patients with CTS and healthy subjects.

DISCUSSION

The perception of the OHS in CTS patients is diminished. Hence, when evaluating the effects of the therapy, not only disease-specific scales should be used, but also the OHS. This will allow an assessment of the impact of CTS on OHS and the impact of applied therapy, not only in terms of a reduction in the main symptoms of the condition.

CONCLUSIONS

Mild and moderate forms of CTS significantly affected the PCS of the OHS and all its subcomponents (physical functioning, role limitations because of physical health problems, bodily pain, and general health perceptions) but did not affect the MCS of OHS evaluated as a whole. There were significant differences in the mental component in the evaluation of vitality and social functioning.

LEVEL OF EVIDENCE

3.

The relationship between the Patient-rated Ulnar Nerve Evaluation and the common impairment measures of grip strength, pinch strength, and sensation

STUDY DESIGN

Prospective cohort study.

INTRODUCTION

Grip strength, pinch strength, and sensory threshold are common evaluations used on a daily basis. Identifying how these variables relate to function for patients allows these assessments to be used for screening to identify who may benefit from surgical intervention, and provides valuable information about what impairments patients think are important with respect to functional use of their upper extremity. Therapists can use this information to focus rehabilitation programs on the most important impairments.

PURPOSE

To evaluate the relationship between the Patient-rated Ulnar Nerve Evaluation (PRUNE) and impairment measures of grip strength, pinch strength, and one-point sensory threshold.

METHODS

Data was prospectively collected from 77 patients before surgery and during regular time points for 2 years following surgery. Patients completed the PRUNE, grip and pinch strength measures, and a one-point sensory threshold evaluation. Correlations between these variables were calculated at baseline, 2 years after surgery, and for change scores during the 2-year follow up. A multiple regression analysis was used to determine the contribution of the impairment variables for determining functional change.

RESULTS

Grip strength showed moderate, statistically significant correlation with PRUNE scores at both baseline (r = -0.38) and at two years (r = -0.29). There was also a statistically significant correlation between one point sensory threshold for the small finger at two years (r = 0.36), but not at baseline. Change in grip strength (r = -0.28) and pinch strength (r = -0.30) both demonstrated significant correlations with PRUNE change scores. Overall, changes in grip strength, pinch strength, and sensation accounted for 20% of the variance in PRUNE changes.

CONCLUSION

Since grip strength was most highly correlated with PRUNE scores at baseline and at two years, rehabilitation programs that target grip strengthening is supported. While neither grip nor pinch strength were significant contributors to the regression when used together, each showed significant contributions to PRUNE variability when used in the model independently. Therefore, a combination of grip and pinch strengthening may be important during rehabilitation for improving functional results in patients that undergo surgical intervention for cubital tunnel syndrome.

LEVEL OF EVIDENCE

2b.

[Cubital tunnel syndrome: a retrospective review of 55 subcutaneous transpositions with minimum 3-year follow-up]

The surgical management of the cubital tunnel syndrome has no strict rules to follow. Surgical treatments are various, but none of them has been shown to be superior to the others. This retrospective study presents the clinical results in 73 patients who underwent an anterior subcutaneous transposition of the ulnar nerve, between January 2000 and January 2010, with a minimum 3-year follow-up. Fifty-five patients were assessed with an average follow-up of 65.7 months. McGowan grading system as modified by Goldberg was used to analyse clinical results, preoperatively and at follow-up. The DASH score was used to assess physical function. The average preoperative evolution of symptoms was 16.7 months, and mean period to resolution was 4.7 months. The grade in McGowan grading system as modified by Goldberg significatively improved at follow-up (P=0.0002). Only five patients kept paresthesia. The mean postoperative DASH score was 7.27/100. The satisfaction rate was 96%, and all the patients except one returned back to their occupation. There was neither infection nor complex regional pain syndrome. The anterior subcutaneous transposition leads to very good clinical results, satisfaction and physical function. It is an effective surgical method, without complication in our study, which gives long-term results.

[Idiopathic ulnar nerve entrapment at the elbow: report of 20 cases]

We report a retrospective study of 20 patients treated for idiopathic cubital tunnel syndrome in a period of 10 years (2002-2011). The average age was 46 years. A profession at risk was present in the majority of cases. The treatment was surgical in all the cases. The indication for surgery was related to the importance of sensory-motor deficit, the long duration of symptoms, and the failure of conservative treatment. Two surgical techniques were used in this work: isolated neurolysis and neurolysis with anterior transposition of the ulnar nerve. There were no complications or recurrence of symptoms. After a mean follow-up of 12 months, our results evaluated thanks to the classification of Bishop were considered as excellent or good in 85% of cases and fair in 15% of cases. Prognosis factors were advanced age (more than 60 years), severity of the disease, and duration of symptoms (more than one year). The management of this affection must go through a better knowledge of the disease, for early diagnosis and appropriate treatment, only guarantees for a good result.

Upper limb cumulative trauma disorders for the orthopaedic surgeon

Work-related musculoskeletal disorders (WRMSDs) of the upper limb have become a serious concern in many countries and have been steadily progressing for several decades. The cause of WRMSDs is assumed to be the direct consequence of repetitiveness, extreme postures, and intensive efforts in a problematic psychosocial environment. Therapy should therefore associate the occupational physician and the regulatory bodies. It may be necessary to modify the individual workstation and to reorganize the company. Such upper limb pathologies may be surgically treated but the results are often delayed and poorer when compared to the general population.

Surgical options for ulnar nerve entrapment: an example of individualized decision analysis

The decision-making process in the diagnosis and treatment of an ulnar nerve entrapment (UNE) at the elbow is presented from the viewpoint of the patient and from that of a physician who in this case, were the same individual. The problems of diagnosis and the selection of the appropriate therapy-conservative or surgical and the choice of a particular surgical approach are discussed in the light of recent evidence-based medicine (EMB) literature.

Carpal tunnel syndrome and ulnar neuropathy at the elbow in floor cleaners

OBJECTIVE

To determine the occurrence of carpal tunnel syndrome (CTS) and ulnar neuropathy at the elbow (UNE) in a cohort of floor cleaners and to check differences between workers with and without CTS.

METHODS

All female floor cleaners of three major hospitals in Tuscany (Italy) were contacted. Clinical and electrophysiological severity of CTS and UNE were evaluated with standardized scales and symptoms were assessed with the self-administered Boston Questionnaire (BQ); demographic and non-occupational factors and durations of current and previous occupations were recorded. Univariate analysis of risk factors was performed in workers with and without CTS. Logistic regression was used to evaluate the capacity of independent variables to predict CTS.

RESULTS

Out of a total of 179 cleaners, 145 (81%)-mean age 39.6 years (20-64 years)-were enrolled in the study; 70 (48%) had CTS (diagnosis based on clinical and electrophysiological findings). BQ symptom and hand function scores were anomalous in 108 (74%) and 84 (58%) subjects, respectively. UNE was detected in 7/103 women. Univariate analysis showed that cleaners with CTS were older, had greater BMI and longer exposure to cleaning with previous employers than those without CTS. In the logistic regression, the only predictor of CTS was cleaning with previous employers (O.R. 12.1, 95% CI 3-49.9).

CONCLUSIONS

These results indicate a high occurrence of CTS in floor cleaners; UNE is less frequent than CTS, presumably due to repetitive movements that stress wrists more than elbows. The only predictive factor of CTS was cleaning as an occupation with previous employers. Therefore, the actual risk factor for CTS could not be cleaning per se, but how this job is performed.

Incidence of ulnar neuropathy at the elbow in the province of Siena (Italy)

BACKGROUND

Although ulnar neuropathy at the elbow (UNE) is the second most frequent focal peripheral neuropathy of the upper limb after carpal tunnel syndrome (CTS), no figures on its prevalence or incidence in the general population have been reported.

OBJECTIVE

To determine the incidence of UNE in a general population.

METHODS

Retrospective study to identify newly diagnosed cases on the basis of clinical symptoms or signs and slowing of motor conduction velocity of the ulnar nerve across the elbow or surgical evidence of nerve compression in the elbow region. In the 5-year period from 1995 to 1999, cases among residents in Siena Province (Italy) were identified from medical records of electromyographic services of Local Health District no. 7 and from hospital medical records coded ICD 354.2, 04.49 and 04.6. Siena province has a population of 251,930.

RESULTS

In the 5-year period, 311 cases (112 women and 199 men, mean age 56 years, range 15-86) were identified. The mean annual crude incidence was 24.7 cases per 100,000 person-years, and the standardized incidence was 20.9. The sex-specific incidences were 32.7 for men and 17.2 for women. The mean annual crude and sex-specific incidences remained constant during the study period. The age-specific incidences of whole population and both genders showed an increasing trend with decade of age. The incidence of "possible", "probable" and "definite" UNE cases, classified according to level of motor conduction velocity anomalies and evidence of surgical compression of the ulnar nerve at the elbow, was 4.3, 10.6, and 9.8, respectively. The residents of a health subdistrict where manual work is dominant had a higher male-specific incidence (57.1) than other areas.

CONCLUSIONS

This is the first published study on the incidence of UNE. The incidence was higher in males than females and about one-thirteenth that reported for CTS in part of the present geographic area.

Intermediate and long-term outcomes following simple decompression of the ulnar nerve at the elbow

INTRODUCTION

There is currently little consensus regarding the appropriate surgical approach to treatment of cubital tunnel syndrome (CubTS), and few studies have reported long-term follow-up of patients who have received surgical treatment for ulnar nerve compression at the elbow.

METHOD

Seventy-four patients with a total of 102 cases of CubTS treated with simple decompression of the ulnar nerve were examined 1.0-12.4 years postoperatively. Ulnar nerve conduction studies (slowest conducting 5 cm segment of ulnar nerve motor fibers measured at the elbow) were performed both pre- and postoperatively. The primary clinical outcome was percentage relief of symptoms, divided into "excellent" outcome group or less (> or = 90% improvement or < 90% improvement).

RESULTS

Ulnar nerve conduction improved pre- to postoperatively, but clinical improvement was not related to changes in velocity. Women reported greater clinical improvement than men, and weight gain in men (but not women) predicted less improvement. Relief of cubital tunnel symptoms was greatest for those arms receiving carpal tunnel release surgery simultaneous or subsequent to cubital tunnel release.

DISCUSSION

Simple decompression may offer excellent intermediate and long-term relief of symptoms associated with CubTS. Although improvement in ulnar motor nerve conduction velocity occurs following treatment of CubTS, it may not be a consistent marker of perceived symptom relief. Finally, these findings suggest that less complete relief of symptoms following ulnar nerve decompression may be related to unrecognized carpal tunnel syndrome or weight gain.

Surgical Treatment for Ulnar Nerve Entrapment at the Elbow

The outcomes of 81 operations were assessed for the treatment of ulnar nerve entrapment at the elbow performed on 55 males (bilateral operations in one) and 25 females during the period from January 1995 to December 2000. Before operation, neurophysiological examination was performed in all patients. Simple ulnar nerve decompression or anterior transposition of the ulnar nerve (subcutaneous or intramuscular) was performed with or without the operating microscope. Nine patients were lost to follow up. The outcome was excellent or good in 63 of 72 cases, no change in eight cases, and poor in one case. The outcomes of procedures performed with the operating microscope tended to be superior.