Surgical outcomes of 654 ulnar nerve lesions

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Object. In this article the authors present a retrospective analysis of 654 surgical outcomes in patients with ulnar nerve entrapments, injuries, and tumors during a 30-year period.

Methods. Data were gathered between 1968 and 1998 at Louisiana State University Health Sciences Center. Mechanisms of injuries or lesions included 460 entrapments at the elbow level (70%), 76 lacerations (12%), 52 stretches/contusions (8%), 34 fractures/dislocations (5%), 12 gunshot wounds (2%), two injection-induced injuries (0.3%), and 13 nerve sheath tumors (2%).

In cases of entrapment, direct operative recordings uniformly demonstrated a slowing of conduction at the elbow, even in cases in which preoperative noninvasive studies had been nondiagnostic. Intraoperative electrical “inching” studies also demonstrated significant conduction abnormalities that lie just proximal to and through the olecranon notch rather than distal, beneath the flexor carpi ulnaris muscle. There were only eight exceptions to this. Lesions not in continuity due to the injury required primary or secondary end-to-end sutures or graft repair. Aided by intraoperative nerve action potential recording, lesions in continuity received either external or internal neurolysis and split repair or resection followed by end-to-end suture or graft repair. Functional recoveries of Grade 3 or better were seen in 81 (92%) of 88 patients who underwent neurolysis, 42 (72%) of 58 patients who received suture repair, and 24 (67%) of 36 patients who received graft repair. Nevertheless, fewer Grade 4 or 5 recoveries were reached than those seen in patients with radial or median nerve injuries. Nerve sheath tumors were resected with preservation of preoperative function in five of seven patients.

Conclusions. Although difficult to obtain, useful functional recovery can be achieved with proper surgical management of ulnar nerve entrapments and injuries.

Article Information

Address reprint requests to: Daniel H. Kim, M.D., Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, California 94305–5327. email: neurokim@stanford.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photographs obtained in patients with ulnar nerve injuries. A: Clawlike appearance of ring and little fingers. B: Severe first dorsal interosseous wasting.

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    Two representative cases in which positive intraoperative NAP recordings were detected across the ulnar nerve lesion in continuity at the elbow level. Stimulating (S1) and recording (R1, R2, R3) electrodes are placed on the nerve proximal and distal to the lesion to assess the NAP. A decrease in the amplitudes of the NAP and in nerve conduction velocities can be observed when recordings are made across the lesion site. C.V. = conduction velocity; dist = distance; nrma = neuroma; r = right.

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    Intraoperative photographs. A: The ulnar nerve is exposed and displaced by a Penrose drain after thorough neurolysis. B: The ulnar nerve has been transposed deep to the transected PTM and the FCUM. C: The PTM and the FCUM have been sewn back together after submuscular ulnar nerve transposition.

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    Intraoperative photographs showing submuscular transposition of the ulnar nerve at the elbow level to decrease the length of the graft after blunt laceration.

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    Modified algorithm for the surgical management of an ulnar nerve injury.+/− = with or without. Reprinted from Neurol Clin 10, Dubuisson A, Kline DG: Indications for peripheral nerve and brachial plexus surgery, 935–951, copyright 1992, with permission from Elsevier.

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    Imaging studies demonstrating an ulnar nerve sheath tumor at the arm level.

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