m decision making and operative tactics for ulnar … making and operative tactics... · decision...

m R E V I E W m

Decision Making and Operative Tactics forUlnar Nerve Compression at the ElbowSteven Z. Glickel, MD, Salil Gupta, MD, and Louis W. Catalano III, MDSt Luke’sYRoosevelt Hospital Hand ServiceDepartment of Orthopaedic SurgeryNew York, NY

m ABSTRACTCubital tunnel syndrome is the second most common

compressive neuropathy of the upper limb, exceeded in

prevalence only by carpal tunnel syndrome. It often

responds to nonoperative treatment, but for those cases

which do not, there are several good surgical options.

This article will discuss the principles of these surgical

techniques and focus on the rationale and operative

technique of anterior transposition of the ulnar nerve

using a noncompressing fasciodermal sling. The post-

operative protocol will be outlined as will recent results

of treatment and complications.

Keywords: cubital tunnel syndrome, anterior transposi-

tion, ulnar nerve decompression, fasciodermal sling,

compressive neuropathy, subcutaneous transposition

m HISTORICAL PERSPECTIVE

Cubital tunnel syndrome is the second most common

compressive neuropathy of the upper limb, exceeded in

prevalence only by carpal tunnel syndrome. It often

responds to nonoperative treatment.1 For cases that

persist despite flexion block splinting, nonsteroidal anti-

inflammatory medications, and avoidance of pressure

on the nerve, a variety of surgical options are available.

Although the list of surgical options includes decom-

pression in situ and medial epicondylectomy, the most

frequently used procedures that have predictably good

results are those that transpose the nerve anteriorly and

stabilize it in some manner.2

There are a number of sites around the elbow where

the ulnar nerve may be compressed. The most proximal

potential site of compression is the arcade of Struthers,

which lies approximately 8 cm proximal to the medial

epicondyle. The arcade of Struthers is a musculofascial

band composed of the deep investing fascia of the arm,

superficial fibers of the medial head of the triceps, and

the internal brachial ligament.3 Recently, Von Schroeder

and Scheker4 described the arcade as more of a canal with

an average length of 6 cm, with the proximal extent

located 9.6 cm from the medial epicondyle. The ulnar

nerve may also be compressed as it passes over the thick

medial intermuscular septum. The septum is usually not

problematic before transposition unless the nerve sub-

luxes anteriorly across it.5 In bodybuilders, a hypertro-

phied medial head of the triceps may compress the

nerve or snap over the medial epicondyle and cause a

friction neuritis.6 Valgus deformity of the distal humer-

us, resulting from an old epiphyseal injury to the lateral

condyle or a malunited supracondylar fracture, may

cause the nerve to be more susceptible to compressive

forces.6

After passing posterior to the medial epicondyle, the

ulnar nerve enters the cubital tunnel. The cubital tunnel

is a fibro-osseous ring formed by the medial epicondyle

and the proximal ulna. The roof of the cubital tunnel is

formed by the deep forearm investing fascia of the

flexor carpi ulnaris (FCU) and the cubital tunnel

retinaculum,7 which is also called the arcuate or

Osborne ligament.8,9 The cubital tunnel retinaculum is

4 mm wide and extends from the medial epicondyle to

the tip of the olecranon.7 Dynamic forces of traction and

compression occurring with elbow flexion may affect

the nerve within the cubital tunnel. As the elbow flexes,

the aponeurotic origin of the FCU stretches 5 mm for

each 45 degrees of flexion, which decreases the volume

of the cubital tunnel and may potentially compress the

ulnar nerve.10 In addition to these dynamic forces, the

nerve may be physically compressed within the cubital

tunnel by space-occupying lesions, including anomalous

muscles such as the anconeus epitrochlearis and ganglia,

and by synovitis and arthritis that may alter the floor of

the tunnel.11

The ulnar nerve passes between the ulnar and

humeral heads of the FCU as it exits the cubital tunnel

and then is located between the FCU and the flexor

digitorum profundus muscle bellies. Five centimeters

distal to the medial epicondyle, the nerve penetrates the

deep flexor-pronator aponeurosis to lie between the

Techniques in Shoulder and Elbow Surgery 7(1):52–60, 2006 � 2006 Lippincott Williams & Wilkins, Philadelphia

Address correspondence and reprint requests to Steven Z. Glickel,MD, C.V. Starr Hand Surgery Center, 1000 10th Avenue, 3rd Floor,New York 10019, NY. E-mail: [email protected].

Techniques in Shoulder and Elbow Surgery52

Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

flexor digitorum superficialis and profundus. The nerve

may be compressed by either the 2 heads of the FCU or

by the deep flexor-pronator aponeurosis.12 In addition,

the common aponeurosis of the FDS to the ring finger

and the humeral head of the FCU has an independent

attachment to the proximal ulna distinct from the main

flexor-pronator aponeurosis. This aponeurosis may

cause kinking and tethering of the nerve during anterior

transposition if not released.13

Decompression in situ is the least complicated of the

operative alternatives for decompressing the ulnar

nerve. The technique involves release of the ulnar nerve

from all of the aforementioned potential sites of

compression of the nerve. Proponents of the procedure

point to the complexity, complications, and potential for

devascularization of the ulnar nerve that may occur with

anterior transposition as the rationale for performing an

isolated decompression.14 Among the potential prob-

lems with in situ decompression is that it does not

prevent fixation of the ulnar nerve to the periosteum or

to the medial collateral ligament.5 There is also a risk of

anterior subluxation of the nerve.5 If the neurolysed

ulnar nerve is left in situ, it remains susceptible to the

effects of traction and compression with progressive

elbow flexion.15 Decompression in situ is contraindi-

cated in posttraumatic cases resulting in perineural

scarring, in cases with a space-occupying lesion in the

epitrochlear groove, and when there is subluxation or

dislocation of the nerve.16

In 1950, King17 described medial epicondylectomy

as a modification of decompression in situ. This

procedure involves more dissection about the flexor-

pronator origin and periosteal stripping than in situ

decompression and may theoretically result in increased

scarring and fixation of the nerve.5 O’Driscoll et al7

demonstrated that resection of greater than 20% of the

medial epicondyle results in violation of the anterior

band of the medial collateral ligament, the major

restraint to valgus stress of the elbow. Excessive

resection of the medial epicondyle, therefore, may

destabilize the joint.5,18

Among the advantages of transposing the ulnar nerve

anteriorly is that it allows the nerve to be positioned in a

less scarred tissue bed. In addition, moving the nerve into

the anterior compartment functionally lengthens it by 3

to 4 cm, which results in less tension on the nerve with

elbow flexion. Therefore, anterior transposition of the

ulnar nerve is indicated in patients with positive elbow

flexion tests. Anterior transposition of the nerve can be

useful for eliminating tension on the ulnar nerve in cases

of ulnar nerve repair about the elbow.5,16

Submuscular transposition places the nerve deep to

the flexor-pronator mass. Intramuscular transposition

places the nerve through a superficial channel created

within the flexor-pronator muscle mass. Subcutaneous

transposition stabilizes the nerve anteriorly by the

creation of a fasciodermal sling. The decision about

whether to transpose the nerve subcutaneously, intramus-

cularly, or submuscularly is based largely on surgeon’s

preference and theoretical concerns. Dellon’s review19 of

these techniques showed that outcomes criteria have been

variably reported and that grading systems have not been

consistent. Recent reports in the literature describe a

number of new techniques for anterior transposition,

including the use of a V-sling from the intermuscular

septum20 and musculofascial lengthening,21 which are

modifications on the themes of anterior transposition

with a fasciodermal sling and intramuscular transposition.

In 1942, Learmonth22 described submuscular trans-

position of the ulnar nerve. The technique involves

detachment of the flexor-pronator origin from the

humerus, placement of the mobilized ulnar nerve

beneath the muscle mass, and reattachment of the origin

to the medial epicondyle. The nerve is decompressed,

mobilized anteriorly into an unscarred bed, and protec-

tively padded by the overlying muscle mass. Two to 3

weeks of immobilization in no more than 45 degrees of

elbow flexion16 is required to permit muscle healing.

Time to return to activity is longer with submuscular

transposition than for subcutaneous transposition be-

cause of the need for muscle healing and restoration of

elbow motion and power.5,16 Some authors have also

expressed concern for the longitudinal blood supply of

the ulnar nerve with submuscular transpositions.23

Intramuscular transposition of the ulnar nerve in an

anterior position was first described by Adson in 1918.24

The technique involves placement of the mobilized

nerve into a 5-mm trough created within the flexor-

pronator muscle mass.25 The superficial fascia is then

closed over the nerve. Proponents of the procedure

believe that it is preferable to subcutaneous transposi-

tion because the nerve is straighter in the transposed

position and is protected by the surrounding muscle and

fascia.25,26 The theoretical advantage of intramuscular

transposition is that it requires less extensive dissection

than does submuscular transposition.25 A potential

disadvantage of intramuscular transposition is that

persistent compression may occur if the fascia is closed

too tightly or if muscle swelling develops.5 In addition,

scarring within the muscle postoperatively may result in

further compression27 or fibrosis of the nerve.28

Curtis29 described subcutaneous transposition of the

ulnar nerve in 1858. Various techniques for stabilizing

the nerve anteriorly have been described. Eaton et al,30

in 1980, described the creation of a fasciodermal sling

that functions as a new medial septum posterior to the

transposed nerve. The technique does not secure the sling,

composed of a flap of 1.5 � 2-cm flap of antebrachial

Volume 7, Issue 1 53

Ulnar Nerve Compression at the Elbow


fascia, to any fixed structure.2,5 Only normal fat is placed

superficial to the nerve. Because the muscles have not

been detached, the most recent iteration of the protocol is

to begin immediate range of motion diminishing the

potential for nerve fixation or entrapment.2,5 Critics argue

that the disadvantage of subcutaneous transposition is

that the nerve remains vulnerable to repeated trauma,

particularly in thin active individuals.16

m INDICATIONS/CONTRAINDICATIONS

The diagnosis of cubital tunnel is a clinical one. Sensory

symptoms begin as intermittent numbness and tingling

involving the ring and small fingers, which may become

continuous. Numbness may progress to anesthesia of these

digits. Sensory loss may include the dorsum of the hand,

and patients may have dysesthesias involving the ulnar

hand and digits. Relevant history should include when,

during the day, symptoms occur and what provocative

activities cause or exacerbate the symptoms. Motor

symptoms may include weakness, loss of grip and pinch

strength, clumsiness, loss of dexterity, and clawing. Some

patients notice a loss of muscle bulk in the involved hand.

Physical examination should begin at the neck with

careful examination of the cervical spine for signs of

cervical radiculopathy or arthrosis. Percussion over the

brachial plexus might elicit a Tinel sign suggestive of a

plexopathy. Adson maneuver, Wright maneuver, and

Roos test should be performed to screen for thoracic

outlet syndrome.

The elbow should be inspected for angulatory

deformity. The carrying angle and range of motion of

the elbow should be measured and compared with the

contralateral side. Palpation, especially along the course

of the nerve, may identify inflammation, masses, sites of

tenderness, and subluxation of the ulnar nerve with elbow

flexion. Percussion of the ulnar nerve may elicit a Tinel

sign. Tinel sign over the nerve is positive in up to 24%

of normal patients.31 The most diagnostic test for cubital

tunnel syndrome is the elbow flexion test.11 The elbow

is maximally flexed with the forearm in supination and

the wrist in extension. Symptoms of paresthesias in the

ulnar nerve distribution within 1 minute are considered

a positive test, although some authors consider the test

positive if symptoms occur within 3 minutes.6,9,11

Rayan et al31 reported a positive elbow flexion test in

up to 24% of a normal population. Percussion of the

ulnar nerve over Guyon canal should also be performed.

Sensory examination may demonstrate hypesthesia

in the ulnar compared with the median nerve distribu-

tion. Diminished sensibility on the ulnodorsal aspect of

the hand may help localize the pathology to proximal to

Guyon canal. Initial changes in the nerve resulting from

compression affect threshold before innervation densi-

ty.6,9 Therefore, light touch with Semmes-Weinstein

monofilaments is affected sooner than 2-point discrim-

ination. Two-point discrimination on the involved side

should be compared with the uninvolved side.

Sensory symptoms generally precede motor weak-

ness. The hand should be inspected for atrophy of the

intrinsic muscles, which is most readily discernable over

the first dorsal interosseous muscle. The presence of claw-

ing or the inability to adduct the small finger (Wartenberg

sign) suggests advanced compression. The intrinsic mus-

cles of the hand should be evaluated for function and

strength. Motor weakness of the third palmar interosseous

is one of the earliest signs of ulnar innervated muscle

weakness.5 Thumb interphalangeal joint flexion and

metacarpophalangeal joint hyperextension with key

pinch (Froment sign) may be present in more advanced

nerve compression with weakness of the adductor

pollicis and flexor pollicis brevis. Weakness of the

FCU and flexor digitorum profundus of the ring and

small fingers is usually not present with cubital tunnel

syndrome.11

Conservative treatment of cubital tunnel syndrome

begins with rest and avoidance of external pressure on

the elbow, particularly when it is flexed beyond 90

degrees. Patient education and activity modification,

including avoiding resting on the elbow and activities

that require prolonged or repetitive elbow flexion, are

mainstays of treatment. People often sleep with their

elbows flexed, and this commonly exacerbates their

symptoms. This is treated by a variety of techniques to

avoid elbow flexion during sleep, including a towel or

pillow wrapped around the elbow, a reversed elbow pad,

or a rigid thermoplastic extension splint worn during

sleep. Nonsteroidal anti-inflammatory medications may

occasionally be helpful. Steroid injection directly into

the cubital tunnel should be avoided.

In 1950, McGowan32 introduced a classification

system for cubital tunnel syndrome. Grade I lesions, or

minimal lesions, are those with paresthesias and

numbness but without weakness. Grade II lesions are

intermediate and consist of numbness with intrinsic

weakness and wasting. Severe lesions, grade III, have

ulnar intrinsic paralysis with hypesthesia or anesthesia

in the ulnar nerve distribution. Patients with grade II or

III disease are unlikely to improve with conservative

treatment and are candidates for surgical decompres-

sion. Most patients with McGowan I cubital tunnel

syndrome should be treated nonoperatively initially. If

they fail to respond to conservative treatment and

remain persistently symptomatic, they should be con-

sidered for ulnar nerve decompression.

Relative contraindications to anterior subcutaneous

transposition of the ulnar nerve using a fasciodermal


Glickel et al


sling include very thin individuals with scant subcuta-

neous tissue, athletes participating in contact sports, and

cases of revision cubital tunnel surgery where the index

operation had been a subcutaneous transposition.

m PREOPERATIVE PLANNING

Standard anteroposterior, lateral, and oblique radio-

graphs may be useful, particularly with a history of

trauma, arthritis, abnormal carrying angle, or limited

range of motion on physical examination.

Electrodiagnostic studies should be obtained rou-

tinely before surgery, particularly if localization of

pathology is not well defined, if a double-crush lesion

may be present, or if the diagnosis of cubital tunnel

syndrome is not clear-cut. The classic electrodiagnostic

finding is slowing of conduction in the ulnar nerve

segment that crosses the elbow.9 The lower limit of

normal motor conduction velocity of the elbow segment

is 49 m/s with the elbow flexed 135 degrees, and the

elbow segment normally has a conduction velocity of

within 11 m/s of the forearm segment.33 False-negative

electrodiagnostic studies are not uncommon. Surgical

intervention will often provide relief of dysesthesias in

patients with negative studies.5,34

m TECHNIQUE

The extremity is prepared with povidone-iodine (Beta-

dine) scrub and alcohol solution and draped with a

stockingette and an impervious extremity drape. The

skin incision is outlined with a skin scribe with the

elbow in a semiflexed position. A slightly curvilinear,

longitudinal incision is marked over the interval

between the medial epicondyle and the olecranon along

the course of the ulnar nerve in and proximal to the

cubital tunnel. The medial epicondyle is outlined as a

point of reference. A point 1 to 1.5 cm anterior to the

medial epicondyle is also marked (Fig. 1). This will be

the point of attachment of the fasciodermal sling at the

end of the procedure. The extremity is exsanguinated

with an Esmarch bandage, and the tourniquet is inflated

to 100 mm Hg above the patient’s systolic blood

pressure.

Flaps are elevated anteriorly and posteriorly (Fig. 2).

Branches of the medial brachial cutaneous and medial

antecubital cutaneous nerves are identified and gently

retracted. The medial brachial cutaneous nerve usually

courses relatively longitudinally and then posteriorly in

the distal brachium. The branches of the medial

antebrachial cutaneous nerve are transversely oriented,

perpendicular to the course of the ulnar nerve (Fig. 3).

They are 1 to 2 mm in diameter and can be easily

FIGURE 1. Anterior transposition on the ulnar nerve witha fasciodermal sling. A longitudinal skin incision isoutlined over the course of the ulnar nerve in the intervalbetween the medial epicondyle and olecranon. A mark ismade in the skin 1 to 1.5 cm anterior to the medialepicondyle, which is the planned point of attachment forthe fasciodermal sling.

FIGURE 2. The fascia is incised to the level of the arcadeof Struthers, 8 cm proximal to the medial epicondyle.

FIGURE 3. Branches of the medial antebrachial cutane-ous nerve are generally perpendicular to the longitudinalaxis of the ulnar nerve and lie in the areolar tissueoverlying the fascia. These branches must be dissectedand protected to avoid painful neuromata.




missed if not specifically looked for. There can be from

1 to 6 branches. They must be retracted very gently to

avoid traction injury to the nerves.

The ulnar nerve is identified proximal to the cubital

tunnel. To facilitate finding the nerve, the cubital tunnel

is located posterior to the medial epicondyle, and the

dissection is carried proximally. The fascia over the

nerve is incised, and the nerve is exposed (Fig. 4). The

fascial dissection is continued proximally to the arcade of

Struthers, which is approximately 8 cm proximal to the

medial epicondyle. The surgeon can assess the complete-

ness of the proximal release manually by passing his

(her) index finger along the ulnar nerve proximally. The

nerve is mobilized from the adjacent tissue to assure that

it is fully decompressed. The medial intermuscular

septum is identified, and its anterior and posterior

surfaces are exposed (Fig. 5). The septum is excised to

the level of the medial epicondyle (Fig. 6). There is a

plexus of vessels posterior to the intermuscular septum

just proximal to the medial epicondyle that should be

avoided (Fig. 7). If injured, these vessels can bleed

briskly and be somewhat difficult to control.

Attention is then directed to decompression of the

cubital tunnel. The cubital tunnel retinaculum (Osborne

fascia/ligament) is carefully incised from proximal to

distal over the nerve using a relatively blunt-tipped

(Littler) scissor (Fig. 8). The branches of the medial

antebrachial cutaneous nerve are in jeopardy during this

part of the dissection and need to be protected. They

must be retracted very gingerly. The fascial roof of the

cubital tunnel is incised over the nerve. It is not

uncommon for there to be a discrete area beneath the

cubital tunnel retinaculum where the nerve is visibly

compressed, has prominent vascular markings, or is

hyperemic.

At the distal end of the tunnel, the first motor branch

of the ulnar nerve to the FCU muscle takes off; it should

be identified and protected. The nerve then runs beneath

the 2 heads of the FCU muscle. The fascia over this

interval is incised along the course of the underlying

nerve (Fig. 9).

Once the fascia is released, the nerve has to be

adequately mobilized to allow transposition. There are

FIGURE 4. The ulnar nerve is identified within the cubitaltunnel.

FIGURE 5. The medial intermuscular septum is exposed.

FIGURE 6. The medial intermuscular septum is excised.

FIGURE 7. There is a plexus of veins deep to theintermuscular septum just proximal to the medial epicon-dyle. This should be avoided during the excision of theseptum or fairly active bleeding can result if it is injured.


Glickel et al


longitudinal vessels, venae comitantes, that course

adjacent and parallel to the nerve and contribute to its

blood supply. Ideally, these branches should be mobi-

lized with the nerve as it is prepared for transposition. If

they cannot be mobilized, at a minimum, they should be

preserved. To facilitate the dissection of the nerve, a

medium Penrose drain can be placed around it for gentle

traction. It is advisable to manipulate the Penrose by

hand rather than clamping the ends with a hemostat, the

weight of which might cause a traction injury to the

nerve. When the nerve is fully mobilized, it should be

transposed anterior to the medial epicondyle to assure

that it is fully free.

A fascial sling is created from the fascia of the

flexor-pronator origin. It is based proximally and

measures approximately 2 cm long by 1.5 cm wide

(Fig. 10). It is oriented along the longitudinal axis of the

flexor-pronator origin. It is carefully elevated from the

underlying muscle (Fig. 11). The nerve is transposed

anteriorly with the fascial sling posterior to it (Fig. 12).

The point of attachment of the sling to the subcutaneous

tissue had been previously marked with the marking

pen. A simple technique has been used to identify that

point in the subcutaneous tissue. The subcutaneous layer

on the edge of the anterior skin flap is grasped with an

Allis clamp. The blunt end of an instrument such as a

dental probe is placed on the mark on the skin. The flap

is everted, and the probe is pushed against the mark,

delivering it into the wound. Before suturing the fascial

sling, the area of planned attachment is inspected. There

are frequently superficial sensory nerves within the

subcutaneous tissue (Fig. 13). If present, they need to be

avoided by the sutures. The fascial sling is spread as

broadly as possible and sutured to the subcutaneous

tissue with 3 interrupted figure-of-8, 3-0 PDS sutures

(Fig. 14). The elbow is taken through an arc of motion

from full extension to full flexion while observing the

transposed nerve. It is important that there be no areas

of kinking or acute angulation of the nerve.

FIGURE 9. The fascia overlying the interval between theheads of the FCU muscle is incised, completing thedecompression of the ulnar nerve and allowing it to betransposed. During this part of the dissection, the branchof the ulnar nerve to the FCU muscle needs to beidentified and protected.

FIGURE 10. The fascial sling is outlined with a markingpen. It is approximately 2 cm long and 1.5 cm wide and isbased on the fascial origin on the medial epicondylewhich is left intact.

FIGURE 11. The fascial flap is elevated off of theunderlying flexor-pronator muscle from distal to proximal.

FIGURE 8. The cubital tunnel retinaculum (Osbornefascia) is incised exposing the ulnar nerve within thecubital tunnel.




The skin is reapproximated with interrupted subcu-

taneous sutures of 3-0 absorbable suture such as

polyglactin 910 (VICRYL). The skin is closed with a

running subcuticular suture of 3-0 or 4-0 polypropylene

surgical mesh (Prolene), one throw of which is brought

superficial to the skin in the middle of the incision for

ease of removal (Fig. 15). The wound edges are painted

with a dermal adhesive such as dromostanolone propio-

nate (Mastisol) or benzoin, and the suture is reinforced

with Steri-Strips. The wound is dressed with Xeroform,

a single layer of moist gauze, 4 � 8-in gauze sponges,

and an ABD pad which is secured with kling and an

elastic mesh dressing such as Surgifix (Fig. 16). The

elbow is supported with a sling; there is no splint or cast

used postoperatively.

m RESULTS

Black et al2 recently published the results of a

retrospective review of 47 patients who underwent a

total of 51 stabilized anterior subcutaneous transposi-

tions from 1973 to 1995 with a minimum of 2 years’

follow-up comparing the results of immediate range of

motion with postoperative immobilization. The surgical

technique detailed herein, originally described by Eaton

et al,30 was used in all patients. Reported results

included decreased time to return to work with a

postoperative protocol of immediate range of motion

when compared with 2 to 3 weeks of postoperative

immobilization. Thirty-eight of the 46 patients with

preoperative paresthesias had complete resolution of the

paresthesias postoperatively. Postoperative grip strength

increased an average 14%, and pinch strength increased

an average of 20% for the immobilized group and 27%

for the immediate motion group (not statistically

significant). Forty-nine of 51 elbows achieved full range

of motion, with no change between preoperative and

FIGURE 13. There are frequently sensory nerves in thesubcutaneous tissue at or near the planned point ofattachment of the fasciodermal sling. These sensorynerves should be identified and protected.

FIGURE 14. The fasciodermal sling is sutured to thesubcutaneous tissue at the predetermined point ofattachment with 3 interrupted sutures of 3-0 size oflong-lasting absorbable suture such as PDS.

FIGURE 15. The skin is reapproximated with a subcuta-neous suture of 3-0 rapidly absorbing suture such asVICRYL and a running subcuticular suture of 3-0 Prolene,which is brought superficial to the skin in the middle of theincision for ease of removal.

FIGURE 12. The ulnar nerve is transposed anteriorly,deep to the fascial sling.


Glickel et al


final follow-up values. Patients were satisfied with the

results in 47 of the 51 affected limbs. The authors

concluded that ‘‘subcutaneous ulnar nerve transposition

stabilized with a fasciodermal sling engendered reliable

results and high patient satisfaction after follow-up of at

least 2 years.’’2

m COMPLICATIONS

Stabilized subcutaneous transposition of the ulnar nerve

rarely leads to complications.5 Preoperative symptoms

may recur or persist if adequate decompression of the

ulnar nerve is not performed.27,28,35,36 Neuroma of the

posterior branch of the medial antebrachial cutaneous

nerve or numbness in its sensory distribution can occur

if this nerve is transected during surgery.37 Neuromas of

this nerve may be painful. Perineural fibrosis of the

transposed nerve12 and compression of the nerve at the

site of the sling may occur.27 The subcutaneous position

of the nerve may expose it to blunt trauma. During the

course of 20 years of surgical experience, the authors

witnessed only 3 ruptures of the fasciodermal sling.

These failures of the fasciodermal sling to keep the

nerve anterior have been in situations where the patients

were noncompliant with instructions to avoid strenuous

use or have had the elbow traumatized in the immediate

postoperative period.

Yamaguchi et al38 reported that the inferior ulnar

collateral artery provides the only direct blood supply

to the ulnar nerve. This branch is occasionally

sacrificed during anterior transposition. Critics of

anterior transposition cite the potential for vascular

compromise of the ulnar nerve with transposition. This

argument has been challenged by Kleinman15 who

states that ‘‘as a half century of published clinical

experience has shown, sacrifice of the inferior ulnar

collateral artery during anterior transposition (if it

becomes necessary to do so) results in neither ischemia

to the nerve segment nor functional compromise to the

nerveIknowledge of the extrinsic and intrinsic micro-

circulation of peripheral nerves, however, as well as a

half century of successful surgical experience world-

wide, assures us that the technique, if performed

properly, is safe and effective.’’

m POSTOPERATIVE MANAGEMENT

A soft dressing is applied to the elbow, and patients are

encouraged to move the joint through an unrestricted arc

of motion beginning on the day of the operation.

Progressive nonstrenuous use of the involved extremity

is encouraged and includes active motion and gentle

activities of daily living, including playing light musical

instruments. The patient returns approximately 2 weeks

postoperatively for suture removal and to begin formal

hand therapy to optimize elbow range of motion and,

after 6 weeks, strength. It is critically important that, for

6 weeks, the patient avoid strenuous use of the involved

limb, including manual labor, heavy lifting, strengthen-

ing exercises, and sports involving use of the involved

arm.2

m REFERENCES

1. Eisen A, Dannon J. The mild cubital tunnel syndrome. Its

natural history and indications for surgical intervention.

Neurology. 1974;24:608Y613.

2. Black BT, Barron OA, Townsend PF, et al. Stabilized

subcutaneous ulnar nerve transposition with immediate

range of motion. Long-term follow-up. J Bone Joint SurgAm. November 2000;82-A(11):1544Y1551.

3. Spinner M, Kaplan EB. The relationship of the ulnar

nerve to the medial intermuscular septum in the arm and

its clinical significance. Hand. October 1976;8(3):

239Y242.

4. Von Schroeder HP, Scheker LR. Redefining the ‘‘arcade

of Struthers’’. J Hand Surg. 2003;28A:1018Y1021.

5. Gelberman RH, Eaton RG, Urbaniak JR. Peripheral nerve

compression. Instr Course Lect. 1994;43:31Y53.

6. Posner MA. Compressive ulnar neuropathies at the elbow:

I. Etiology and diagnosis. J Am Acad Orthop Surg.SeptemberYOctober 1998;6(5):282Y288.

7. O’Driscoll SW, Horii E, Carmichael SW, et al. The

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FIGURE 16. The wound is dressed with sterile gauzedressing secured with elastic mesh gauze that allowsrange of motion.




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