Introduction. Ulnar nerve entrapment is the second most common nerve entrapment syndrome of the upper extremity. Despite this, only a few studies have assessed the outcome of ulnar nerve decompression. The objectives of the study were to review the pre-operative symptoms, nerve conduction studies, the co-morbidities, operative procedures undertaken and the post-operative outcomes; and investigate and ascertain prognostic factors particularly in cases of persistence of symptoms after the surgery. Methods. We reviewed the case notes of ulnar nerve decompressions surgery performed over a period of six year period. A structured proforma was created to document the demographics, patient complaints, method of decompression, per-operative findings and symptom status at the last follow up. Outcome grading was recorded as completely relieved, improved, unchanged or worse. Analysis of data was carried out using the SPSS software (Version 16.0; Illinois). The significance level was set at 5%. Results. 136 ulnar nerve decompressions formed the study group. Minimum follow-up was three months. Numbness and paresthesia in ulnar distribution were the two most common presenting symptoms (96%). The cause of compression was identified as idiopathic in 58.2%; flexor carpi ulnaris aponeurosis in 36.7% and Arcade of Stuthers in 5.1% extremities. The outcome was satisfactory in 85.2% of patients. No obvious association was demonstrated between the outcome of surgery and duration of symptoms, presence of co-morbidities or the type of surgery performed. Interestingly out of 12 patients who got worse or had no improvement, nine (75%) had either normal nerve conduction studies or none done pre-operatively. Conclusion. This is the largest review of outcomes after ulnar nerve decompressions at elbow. The study showed that good results (85.2%) of ulnar nerve decompression at elbow in majority of patients regardless of level of surgeon's experience or procedure undertaken

Ulnar compression neuritis at the elbow level, known as the cubital syndrome, is one of the most common nerve entrapment syndromes. There are many treatment alternatives, such as conservative treatment, submuscular transposition, simple facial release, medial epicondylectomy and anterior subcutaneous transposition. The aim of the present study is to suggest the intramuscular transposition of the ulnar nerve for the cubital syndrome treatment. With the technique based on flaps creation by “Z” lengthening of the flexorpronator muscules, the ulnar nerve is transferred in a well vascularizated area. Between 1992 and 2001, 76 patients were treated by anterior intramuscular transposition of the ulnar nerve. It was possible to follow up 27 patients, 19 males and 8 females. During the re-examination, the rough and thin grasping, the improved objective and subjective sings, as well as the return to the previous vocation, were reported. We make comparison with the international bibliography and correlation of the results to the age of the patients. We recommend the anterior intramuscular transposition of the ulnar nerve for the cubital tunnel syndrome treatment, which is technically demanding, but provides a satisfactory functional outcome

Introduction Ulnar nerve entrapment is the second commonest upper limb nerve entrapment syndrome. The purpose of this study was to determine the safety and efficacy of the Agee endoscopic system in ulnar nerve decompression at the elbow. This is the first report of its use in the elbow. Methods Six preserved cadaveric elbow specimens were used. One surgeon performed the endoscopic releases via a three centimetre longitudinal incision between the medial epicondyle and olecranon. All six specimens were examined independently with loupe magnification. This was done by extending the original incision to 20 cm. The ulnar nerve was assessed with regard to adequate decompression. The branching of the ulnar nerve at the elbow, as well as the presevation of these branches after the endoscopic procedure, was also studied. Results In all six specimens, the arcade of Struthers, the cubital tunnel retinaculum, and the flexor carpiulnaris aponeurosis were completely divided. There were an average of three motor branches to flexor carpiulnaris at a mean position of 21 mm distal to the medial epicondyle. Most of these were on the radial side of the nerve. The ulnar nerve was also found to give one to two sensory branches, at a mean position of nine millimetres proximal to the medial epicondyle. All the motor and sensory branches were found to be intact after the endoscopic procedure. Conclusions This study shows that the Agee endoscopic system is both safe and effective. It is a relatively simple procedure but cadaveric practice is recommended to obtain familiarity with the technique and the endoscopic view of the anatomy

Purpose: The aim of this retrospective study was to assess the correlation between the occurance of iatrogenic ulnar nerve injury and frontal and saggital angular insertion of the medial pin in pediatric type 3 supracondylar humerus fractures treated with closed reduction and percutaneous fixation using a crossed-pin configuration. Method: Among 164 patients with type 3 supracondylar humerus fractures, treated with closed reduction and percutaneous fixation using a crossed-pin configuration while the elbow was in hyperflexion, between 1999 and 2003, ninety patients (54 male and 36 female, mean age 6.1 years) with complete clinical and radiological records and follow-up period of at least 6 months were included the study. Frontal humerus-pin angle (FHPA) was the angle between the long axis of humerus and the axis of the medial pin measured on an anteroposterior radiograph. Saggital humerus-pin angle (SHPA) was the angle between the long axis of humerus and the axis of the medial pin measured on a lateral radiograph and expressed as a positive value if the medial pin direction was anteroposterior and as a negative value if the direction was posteroanterior. All the mesurements were made by the same observer blinded to the clinical records of the patients. Results: Postoperative ulnar nerve injury was observed in 18 patients. The ulnar nerve injury group and control group were similar with respect to age and gender. Mean FHPA was 36.6 and 33.8 degrees in ulnar nerve injury and control groups respectively (p=0.270). Mean SHPA was 12.1 and 1.6 degrees in ulnar nerve injury and control groups respectively, and the difference was significant (p=0.001). All the patients with ulnar nerve injury had complete recovery within 3 months following surgery. Conclusion: There are several methods to avoid iatrogenic ulnar nerve injury in supracondylar fractures such as insertion of two or three lateral pins, insertion of the medial pin while the elbow is less than 90 degrees of flexion. The findings of this retrospective study revealed that there was a considerable correlation between the occurence of iatrogenic ulnar nerve injury and sagittal angular insertion of the medial pin. We suggest that if a crossed-pin figuration is desired, it is better to insert the medial pin neutral or posteroanterior direction in the sagittal plane if the elbow is in hyperflexion

Supracondylar humeral fractures are the most common elbow injury in children, usually sustained from a fall on the outstretched hand. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring. NNH is the number of cases needed to treat in order to have one adverse outcome. A systemic review was undertaken to calculate relative risks, risk difference and number needed to harm following management of supracon-dylar fractures with cross or lateral K wires. It was found that there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires. The aim of this study was to calculate the number of cross K wiring of supracondylar fractures of the humerus that would need to be performed for one iatrogenic ulnar nerve injury to occur. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring of supracondylar fractures of the humerus. To date there are no clinical trials showing the benefit of cross K wiring over lateral K wiring in the management of supracondylar fractures of the humerus in children. If it can be confirmed that lateral K wiring is as effective as crossed K wiring, iatrogenic ulnar nerve injury can be avoided. A systematic review of iatrogenic ulnar nerve injuries following management of supracondylar fractures was conducted. The databases MEDLINE 1966 – present, EMBASE 1980 – present, CINAHL 1982 – present, CDSR, and DARE were searched along with a meticulous search of the Journal of Paediatric Orthopaedics from 1998 to 2004. Of the two hundred and forty-eight papers identified, only thirty-six met the inclusion criteria. The papers where both lateral crossed K wires were used as treatment were identified for calculating relative rates, risk difference and number needed to harm. NNH was 7.69. When a sensitivity analysis removing two studies that had five subjects or fewer and a 100% ulnar nerve injury rate was peformed, the NNH was 27.7. In other words, there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires

The purpose of this study is to evaluate the long-term results of the surgical treatment of cubital tunnel syndrome by comparing the in-situ decompression and release of the ulnar nerve with or without partial medial epicondylectomy and the anterior transposition and release respectively. Material and Method: From 1991 since 2008, 119 patients, (81 men and 38 women) with an average age of 51(13–72 years) years were treated surgically for ulnar nerve compression at the elbow. The average duration of symptoms before surgery was 15 months (2–48 months). Preoperatively 2 patients were grade I, 52 patients were grade IIA, 31 patients were IIB and 34 were grade III according to the modified McGowan score. We performed in-situ decompression of the ulnar nerve in 35 patients, release with partial medial epicon-dylectomy in 44 patients and release with anterior transposition of the nerve in 40 patients. 17 patients were lost to follow-up. 108 patients were clinically assessed. Comparing the results among different surgical procedures, an improvement of at least one McGowan grade was obtained in 26 of 30 patients treated with simple decompression, in 29 of 35 patients treated with release and anterior transposition of the nerve and in 38 of 43 patients treated with release and medial epicondylectomy. The results of this study show that the possibility for complete recovery is inversely related to the initial neuropathy grade. Partial medial epicondylectomy is a valuable surgical procedure for treating grade I to IIB ulnar neuropathy because is an anatomic method with minimal nerve manipulation preserving regional blood supply

Aim: The purpose of the present retrospective study was to evaluate reasonable routine transposition of the ulnar nerve in bicondylar humeral fractures. Material and method: From 1996 to 2007 112 bicondylar fractures were operated. 88 pateints (47 women and 41 men) were followed up for average 56 months. Average age was 48 (14–80) years. Open fractures were 17. Fractures were distributed by the AO classification as follows: type C1.2 – 16, C1.3 – 10, C2.1 – 22, C2.2 – 7, C2.3 – 3, C3.1 – 17, C3.2 – 8 and C3.3 -5. All fractures were operated by the AO method with dorsal approach, osteotomy of the olecranon (83 fractures) and fixation with 2 plates. In 47 cases the ulnar nerve was routinely anteriorly transposed and for the rest 41 patients transposition was not done. Results: From 47 patients with routine anterior transposition 7 had Mc Gowan I dysfunction that was resolved in 3 months. From 41 patients without transposition 9 had a type Mc Gowan I dysfunction. There was no statistical significance between the two groups. (p> 0,05). However, 12 to 18 months later 3 patients from the group without transposition with type C1.3, C3.1 and C3.3 fractures returned with late postoperative nerve palsy Mc Gowan II and III. They were treated by neurolysis and transposition. Conclusion: Routine anterior transposition of the ulnar nerve is not reasonable in every type of bicondylar humeral fractures. The type of the bicondylar fracture defines whether the nerve transposition is reasonable or not. In low bycondilar humeral fractures and type C3 fractures the nerve transposition is obligatory

The purpose of this study was to identify aetiological that may determine prognosis in ulnar nerve lesions and to evaluate the role of non-operative treatment. 148 consecutive patients (100 male) with 170 electrophysiologically proven (by nerve conduction and electromyography) ulnar nerve lesions were identified from the departmental records. Patient details, symptoms, known aetiology and treatment profile were recorded. Each patient was then contacted by telephone and/or questionnaire 1–6 (median 3. 8) years following electrodiagnosis to determine clinical progress and outcome. In patients with sensory symptoms alone or non-progressive painless motor symptoms, non-operative treatment was commenced. This involved advice on activity modifications and protection with a tubipad bandage or night spin. 12. 9% and 8. 8% of lesions were due to injury and intra-operative pressure respectively. Other causes included deformity and/or synovitis from arthritis of the elbow, repeated pressure, medial epicondylitis and benign space occupying lesions. 58. 2% were idiopathic with no clinical aetiological factor. 22 patients had expected bilateral lesions whereas 15 had contralateral lesions that were not symptomatic. 89. 4% and 4. 7% of lesions occurred at the elbow and wrist respectively. 83% of patients received non-operative first line treatment. 21% of these required operative intervention following further clinical and electrophysiological assessment. Partial or complete recovery occurred in 80%, 67% and 52% of the intra-operative, idiopathic and injury cases respectively (P< 0. 05). We conclude lesions of the ulnar nerve predominate in males and can be treated non-operatively providing clinical and electrophysiological monitoring is possible. Bilaterality is not uncommon and should be excluded. Lesions due to injury have a worse prognosis than those caused by direct continuous or repeated pressure or where no aetiological factor exists

Introduction: Crossed K-wires provide a stable fixation for supracondylar fractures of the humerus in children but are associated with a risk of iatrogenic ulnar nerve injury (≈5%). There is reluctance by many surgeons to use the medial approach and crossed K-wires because of the liability of ulnar nerve injury. Aim: To assess the risk of iatrogenic ulnar nerve injury using the mini medial incision to reduce and stabilise displaced supracondylar fractures of the humerus in children with crossed K-wires. Methods: We performed a retrospective evaluation of 26 children with closed Wilkins type IIB and III supracondylar fractures of the humerus, without vascular deficit, between January 1999 and April 2007. Mean age was 5.5 years (2.5–11 years). All were treated with open reduction and crossed K-wire fixation using a mini medial incision (5cm). Our modification is that we do not expose the fracture site or the ulnar nerve. It is a ‘feel’ rather than ‘see’ approach. The medial K-wire is placed under direct vision. All patients had early and late (4 months) post-operative ulnar nerve assessment. Patient outcome was assessed clinically using Flynn’s classification and radiologically using the metaphyseal-diaphyseal and humerocapitellar angles. Mean length of follow-up was 5 months (4–8 months). Results: There was no post-operative ulnar nerve injury. Clinically and radiologically there were 23 excellent and 3 good results. Conclusions: The mini medial incision is simple. It provides an excellent view for correct medial pin entry; hence it reduces the risk of iatrogenic ulnar nerve injury. Crossed K-wires provide a stable and reliable fixation

Introduction. Antegrade K wiring of the fifth metacarpal for treatment of displaced metacarpal neck fractures is a well recognized surgical procedure. However it is not without complication and injury to the dorsal cutaneous branch of the ulnar nerve has been reported in up to 15% of cases. Methods. We performed a cadaver study to determine the proximity of this nerve to the K wire insertion point at the base of the fifth metacarpal. K wires were percutaneously inserted under image intensification in sixteen cadaver hands and advanced into the head of the metacarpal. Wires were then cut and bent outside the skin. This was then followed by meticulous dissection of the ulnar nerve from proximal to distal. A number of measurements were taken to identify the distance from the insertion point of the K wire to each branch of this nerve. Results. The distance from the insertion point at the base of the fifth metacarpal to the dorsal component of the nerve averaged 5.6 mm (range 1mm–12mm) and from the volar component was 6 mm (range 1mm–10mm). The heel of the wire was touching the nerve in five cases. Conclusion. Our findings highlight the importance of making a small incision and bluntly dissecting to bone at the base of the fifth metacarpal to protect the nerve. In addition, use of a tissue protector is vital when drilling the 2mm hole at the base of the fifth metacarpal. We have confirmed that the dorsal cutaneous branch of the ulnar nerve is vulnerable during insertion of an antegrade intramedullary K wire for treatment of neck of fifth metacarpal fractures

The purpose of this study was to identify aetiological factors that may determine prognosis in ulnar nerve lesions at the elbow and to evaluate the role of non-operative treatment. One hundred and thirty consecutive patients (92 male) with 152 electrophysiologically proven (by nerve conduction and electromyography) ulnar nerve lesions at the elbow were identified from the departmental records. Patient details, symptoms, known aetiology and treatment profile were recorded. Each patient was then contacted by telephone and / or questionnaire between one and six years after electrodiagnosis to determine clinical progress and outcome. In patients with sensory symptoms alone or non-progressive painless motor symptoms, non-operative treatment was commenced. This involved advice on activity modification and protection with a tubipad bandage or night splint with continued clinical and electrophysiological surveillance. Sixty-one percent of lesions were idiopathic with no clinical aetiological factor. Defined causes included deformity and/or synovitis from arthritis of the elbow (11.2%), injudicious intra-operative pressure (9.2%), injury/trauma (8.5%) repeated pressure (4.1%), medial epicondylitis (2.9%) and benign space occupying lesions (2.9%). Twenty-two patients had expected bilateral lesions whereas 15 had contralateral lesions that were not symptomatic. Eighty-three percent of patients received non-operative first line treatment. Twenty-one percent of these required operative intervention (simple decompression) following further clinical and electrophysiological assessment. Partial or complete recovery occurred in 88%, 80%, 67% and 52% of the arthritis, intra-operative, idiopathic and injury cases respectively (P< 0.05). We conclude lesions of the ulnar nerve at the elbow predominate in males and the majority can be treated non-operatively providing clinical and electrophysiological monitoring is possible. Bilaterality is not uncommon and should be excluded. Lesions due to injury have a worse prognosis than those caused by arthritis of the elbow, direct continuous or repeated pressure or where no aetiological factor exists

Aim: To assess the risk of iatrogenic ulnar nerve injury using the mini medial incision to reduce and stabilise displaced supracondylar fractures of the humerus in children with crossed K-wires. Methods: We performed a retrospective evaluation of 26 children with closed Wilkins type IIB and III supracondylar fractures of the humerus, without vascular deficit, between January 1999 and April 2007. Mean age was 5.5 years (2.5–11 years). All were treated with open reduction and crossed K-wire fixation using a mini medial incision (5cm). Our modification is that we do not expose the fracture site or the ulnar nerve. It is a “feel” rather than “see” approach. The medial K-wire is placed under direct vision. All patients had early and late (4 months) post-operative ulnar nerve assessment. Patient outcome was assessed clinically using Flynn’s classification and radiologically using the metaphyseal-diaphyseal and humerocapitellar angles. Mean length of follow-up was 5 months (4–8 months). Results: There was no post-operative ulnar nerve injury. Clinically and radiologically there were 23 excellent and 3 good results. Conclusions: The mini medial incision is simple. It provides an excellent view for correct medial pin entry; hence it reduces the risk of iatrogenic ulnar nerve injury. Crossed K-wires provide a stable and reliable fixation

The purpose of this study was to evaluate the results of subcutaneous ulnar nerve transposition in the treatment of Cubital Tunnel Syndrome (CTS) and the influence of prognostic factores such as preoperative McGowan stage, age and duration of symptoms. 36 patients (17 men and 19 women) with CTS who underwent subcutaneous ulnar nerve transposition between 2006 and 2009 were evaluated postoperatively, an average follow-up of 28 months. Sensory and motor recovery was evaluated clinically. The postoperative outcome was based on modified Bishop score, subjective assessment of function and on the degree of patient satisfaction. The dominant side was involved in 61% cases and the mean age was 51.2 years. There were 9 (25%) McGowan stage I, 18 (50%) stage II and 9 stage III patients. We used the Mann-Whitney and Kruskal-Wallis test to compare continuous variables and chi-square and Fisher Exact Test for categorical variables. There was a statistically significant improvement of sensory (p=0.02) and motor (p=0.02) deficits. We obtained 21 (58.3%) excellent results, seven (19.4%) fair, six (16.7%) satisfactory, and two bad ones (5.55%). There was a statistically significant improvement of function (p<0.001). There is controversy in the literature regarding the best surgical treatment for CTS. The duration and severity of symptoms and advanced age, more than the surgical technique, seem to influence prognosis. With the technique used, the satisfaction rate was 86% and 72% recovered their daily activities without limitations. 78% of patients with severe neuropathy improved after surgery. The rates of postoperative complications were comparable with those of other studies. The severity of neuropathy and duration of symptoms (>12months) pre-operatively, but not age, had a negative influence on the outcome. The results showed that the subcutaneous ulnar nerve transposition is safe and effective for postoperative clinical sensory and motor recovery for several degrees of severity in CTS. Given the major prognostic factors, surgical treatment should be advocated as soon as axonal loss has become clinically evident

Introduction: The presence of atypical muscle groups especially in sportsmen population is one of the causes of ulnar nerve entrapmnet. To treat this problem a close cooperation in between neurophysiologist, US-diagnost, surgeon and physiotherapist is mandatory. The inching (short segment study – SSS) of the peripheral nerves was introduced for testing the ulnar neuropathy at the elbow (UNE). The conventional fractionated ulnar nerve conduction studies localize the lesion only approximately to the elbow region, should be followed by inching of the ulnar nerve at the elbow. Dynamic, functional US also precise the character and localise the lesion and region of mechanical obstacles for the nerve. These methods can disclose the degree of focal conduction block or pinpoint the region of focal slowing, giving complementary information about the character of the lesion and help to choose a therapy by neuromobilisation or operative treatment. Aim: To compare results of SSS and US with intraoperative observations in a group of 24 patients operated due to peripheral neuropathy. Results: US and SSS shows a 97–100% diagnostic specificity and sensitivity These methods are also useful among patients with functional disturbances due to joint instability or presence of abnormal muscle groups like the anconeus epitrochlearis muscle, additional triceps aponeurosis or abnormality of the medial head of triceps brachii. Conclusions: Precise diagnosis helps to choose optimal therapy of UNE directed at the specific site of involvement. In our observations muscular pathology is responsible for UNE in about 40% of cases among sportsmen

The anatomic study of the connection between median and ulnar nerve in the forearm, were first described by the Swedish anatomist Martin, in 1763 and later by Gruber in 1840. This connection is now known as the Martin-Gruder anastomosis. Despite its long history, its nature remains unclear. We performed anatomical dissection in 60 fresh cadaveric forearms. Thirty-four of them were on the right forearm and 26 on the left forearm. We supplement the anatomic study with a histologic examination of the bundles in the connections. We found 5 cases with a linking branch (8.5%).The distance between the proximal end of the anastomosis from the medial condyle were about 6.5 cm (5.0 to 8,0). The length of the anastomotic branches was between 3.5 – 6.5 cm. All the linking branches were located in the proximal third of the forearms. No connections between ulnar – median nerve were found. In conclusion the Martin – Gruber anastomosis is clinically important. A lesion of the median nerve situated proximal of the anastomosis would affect the median thenar muscles, whereas a lesion distal of that level would not. The anastomosis has a clinical significance for understanding median nerve lesions and the carpal tunnel syndrome. A lesion of the ulnar nerve situated proximal of the anastomosis would affect the ulnar muscles of the hand, whereas a lesion distal of that level would not. By recognizing the existence of the linking branches mistakes in the diagnosis of the peripheral nerve lesions can be avoided

Purpose: We evaluated submuscular anterior transposition of the ulnar nerve at the elbow with lengthening of the medial epicondylars as described by Dellon in patients with ulnar nerf deficiency due to compression. Material and methods: A consecutive series of 30 submuscular tranpositions of the ulnar nerve in 28 patients were performed between 1994 and 1998. Four patients had had a prior procedure (two simple neurolyses, two subcutaneous transpositions). Mean age was 52 years. Preoperative EMB confirmed the diagnosis of ulnar compression at the elbow. All patients has sensorial and/or motor deficits. Postoperative immobilisation was maintained for 15 to 20 days. Results: The patients were reviewed at a mean follow-up of four years two months. There were no cases of paraesthesia. Improved sensorial function was observed in 71% of the cases (normalisation in 50%) with improvement in the Foment sign and grip in 81.5% (normalisation in 48%). Mean elbow extension was −5°, and flexion was 135°. There was not limitation on wrist amplitudes. The thumb finger force on the operated side was 78% to 94% that measured on the healthy side and was a function of the MacGowan grade. The palm-finger force was 80% to 95% of the healthy side. There has been no recurrence at last follow-up. Conclusion: Submuscular transposition using the Dellon technique in 30 cases of ulnar nerve compression at the elbow in patients with ulnar deficiency provided satisfactory sensorial and motor recovery. The usefulness of lengthening the medial epicondyls lies in removing the tension on the ulnar nerve and the little effect on elbow and wrist mobility. Submuscular transposition is the technique of choice for repeated neurolysis

Aim. To investigate the effectiveness of a decision-based protocol designed to minimise the use of medial incisions when performing crossed-wire fixation of supracondylar fractures of the distal humerus whilst minimising ulnar nerve injury. Method. We have employed a protocol for placing the medial wire during crossed k-wire fixation of supracondylar fractures dependent upon the medial epicondyle. When this is palpable, the wire is introduced percutaneously; when it is not, a mini-incision is made. All cases of closed reduction and crossed K-wiring of supracondylar fracture over a three year period (2008–2011) were identified from our department database. Cases with a neurological injury identified pre-operatively, and those in which the protocol had not been followed were excluded. Casenotes were reviewed to determine the incidence and outcomes of post-operative ulnar nerve deficit. Results. A total of 106 cases were identified, from which 36 cases were excluded, leaving 70 cases in the study. The mean age was 5 (range 1–11). 68 were extension-type injuries, of which 29 (41%) were type 2 and 39 (56%) type 3 according to the classification of Gartland. 2 were flexion-type. A mini-incision for placement of the medial K-wire was required in only 3 cases (4.3%), with percutaneous placement in all other cases. There was clinical evidence of partial ulnar nerve injury in 1 case (1.4%) which recovered spontaneously within 11 months. Conclusion. The results of this study demonstrate our protocol to be effective. Careful percutaneous placement of the medial wire can be performed in the majority of cases with little risk of significant or permanent injury to the ulnar nerve. Open placement of the medial wire is indicated in only a small proportion of cases. We suggest that the routine use of a medial mini-incision should be re-considered

Aim:. To investigate the incidence of post-operative ulna nerve symptoms in total elbow arthroplasty after full in-situ release. Methods:. A retrospective review was completed of the medical records of eighty-three consecutive primary total elbow arthroplasties (TEA) performed between 2003 and 2012. Data analysed included the presence of pre-operative ulnar nerve (UN) symptoms, history of prior UN transposition, intra-operative management of the UN and presence of post-operative symptoms. Results:. One patient had a prior UN transposition. The nerve was transposed at time of TEA in 4 of the 83 elbows (4.8%). The indication for transposition in all 4 cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. The remaining 78 TEA's all received a full in-situ release of the nerve. The incidence of post-operative UN symptoms in this group was 7.7% (6/78). Four neuropraxias resolved in the early post-operative period, whilst two patients (2.6%) continued to experience significant UN symptoms requiring subsequent transposition, at 6 weeks and 12 months post TEA. Conclusion:. A 2.6% incidence of significant post-operative UN symptoms compares favourably with systematic reviews in the literature (3–11% incidence of UN complications). We do not believe routine transposition, which adds to the handling of the nerve and increases total surgical time, is necessary, and should be reserved for cases where intra-operative assessment by the surgeon deems it necessary

The anatomic study of the connection between median and ulnar nerve in the forearm, were first described by the Swedish anatomist Martin, in 1763 and later by Gruber in 1840. This connection is now known as the Martin-Gruber anastomosis. Despite its long history, its nature remains unclear. We performed anatomical dissection in 90 fresh cadaveric forearms. 49 of them were on the right forearm and 41 on the left forearm. We supplement the anatomic study with a histologic examination of the bundles in the connections. We found 9 cases with a linking branch (10%). The distance between the proximal end of the anastomosis from the medial condyle were about 6.5 cm (5.0 to 8.0). The length of the anastomotic branches was between 3.5 – 6.5 cm. All the linking branches were located in the proximal third of the forearms. No connections between ulnar – median nerve were found. In conclusion the Martin – Gruber anastomosis is clinically important. A lesion of the median nerve situated proximal of the anastomosis would affect the median thenar muscles, whereas a lesion distal of that level would not. The anastomosis has a clinical significance for understanding median nerve lesions and the carpal tunnel syndrome. A lesion of the ulnar nerve situated proximal of the anastomosis would affect the ulnar muscles of the hand, whereas a lesion distal of that level would not. By recognizing the existence of the linking branches mistakes in the diagnosis of the peripheral nerve lesions can be avoided

Introduction: The standard treatment of displaced supracondylar fractures of the distal humerus in children is closed reduction and pin fixation, but the optimal pin configuration is controversial. Crossed-pin fixation of the humerus is mechanically more stable than any other kind of pin configuration, but this fixation may cause iatrogenic ulnar nerve injury. Many authors recommended fixation from the lateral side in order to eliminate this complication. Since 1999, we have been using a 3-pinfixation technique with insertion of the first two pins with the elbow in full flexion, followed by insertion of the third wire through the medial side with the elbow in full extension. We call this the “flexion-extension cross-pinning technique”. Method: This is a retrospective review of 64 displaced supracondylar fractures fixed by flexion-extension cross pinning. Results: Eleven children had Gartland type 2 fractures and 53 children had Gartland type 3 fractures. There was no iatrogenic ulnar neve palsy. Loss of reduction in two children was related to technical errors. One patient had superficial pin tract infection. Conclusion: We feel that this technique and pins configuration is safe and easy to learn. It has become the standard method of fixation of displaced supracondylar fractures in our institution