Jeffrey N. Lawton

An outcome study for ulnar neuropathy at the elbow: A multicenter study by the surgery for ulnar nerve (SUN) study group

BACKGROUND Many instruments have been developed to measure upper extremity disability, but few have been applied to ulnar neuropathy at the elbow (UNE). OBJECTIVE We measured patient outcomes following ulnar nerve decompression to (1) identify the most appropriate outcomes tools for UNE and (2) to describe outcomes following ulnar nerve decompression. METHODS Thirty-nine patients from 5 centers were followed prospectively after nerve decompression. Outcomes were measured preoperatively and at 6 weeks, 3 months, 6 months, and 12 months postoperatively. Each patient completed the Michigan Hand Questionnaire (MHQ), Carpal Tunnel Questionnaire (CTQ), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Grip, key-pinch strength, Semmes-Weinstein monofilament, and 2-point discrimination were measured. Construct validity was calculated by using Spearman correlation coefficients between questionnaire scores and physical and sensory measures. Responsiveness was assessed by standardized response means. RESULTS Key-pinch (P = .008) and Semmes-Weinstein monofilament testing of the ulnar ring (P < .001) and small finger (radial: P = .004; ulnar: P < .001) improved following decompression. Two-point discrimination improved significantly across the radial (P = .009) and ulnar (P = .007) small finger. Improved symptoms and function were noted by the CTQ (preoperative CTQ symptom score 2.73 vs 1.90 postoperatively, P < .001), DASH (P < .001), and MHQ: function (P < .001), activities of daily living (P = .003), work (P = .006), pain (P < .001), and satisfaction (P < .001). All surveys demonstrated strong construct validity, defined by correlation with functional outcomes, but MHQ and CTQ symptom instruments demonstrated the highest responsiveness. CONCLUSION Patient-reported outcomes improve following ulnar nerve decompression, including pain, function, and satisfaction. The MHQ and CTQ are more responsive than the DASH for isolated UNE treated with decompression.

Trend of recovery after simple decompression for treatment of ulnar neuropathy at the elbow.

Background: Although numerous studies have investigated long-term outcomes after surgical treatment of ulnar neuropathy at the elbow with simple decompression, no study has evaluated the trend of postoperative recovery. The authors assessed timing of recovery after simple decompression for ulnar neuropathy at the elbow. Methods: The five-center Surgery of the Ulnar Nerve Study Group prospectively recruited 58 consecutive subjects with ulnar neuropathy at the elbow and treated them with simple decompression. Patients were evaluated preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patient-rated outcomes questionnaires included the Michigan Hand Questionnaire; the Disabilities of the Arm, Shoulder and Hand questionnaire; and the Carpal Tunnel Questionnaire. Functional tests used were grip strength, key pinch strength, two-point discrimination, and Semmes-Weinstein monofilament testing. Postoperative improvement was assessed at each time point to establish the trend of recovery in reaching a plateau. Results: Significant patient-reported symptomatic and functional recovery occurred over the first 6 weeks postoperatively as represented by improvements in questionnaire scores. Symptomatic recovery occurred earlier than functional recovery as measured by sensory and strength testing and the work domain of the Michigan Hand Questionnaire. Improvement in patient-reported outcomes continued and reached a plateau at 3 months, whereas measured strength and sensory recovery continued over 12 months. Conclusion: The greatest clinical improvement after simple decompression for ulnar neuropathy at the elbow, according to questionnaire scores, occurs in the first 6 weeks postoperatively and reaches a plateau by 3 months. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Radial collateral ligament of the elbow: sonographic characterization with cadaveric dissection correlation and magnetic resonance arthrography.

An abnormality of the radial collateral ligament (RCL) in the setting of lateral epicondylitis can indicate a poor clinical outcome; therefore, accurate assessment is important. The purpose of this study was to characterize the proximal RCL attachment, or footprint, as seen on sonography using cadaveric dissection correlation and magnetic resonance arthrography.

Coronal Shear Fractures of the Distal Humerus

Management of coronal shear fractures of the distal humerus has evolved considerably over the past 3 decades, with an increased appreciation of the complexity of these fractures, improvements in internal fixation techniques, and the use of more extensile exposures. Nearly all of these fractures are displaced, given the paucity of soft tissue attachments and correspondingly, nonsurgical management is fraught with complications including chronic pain, mechanical symptoms, and instability and is not recommended. Good to excellent outcomes can be achieved in the majority of patients with open reduction internal fixation, particularly when the fracture is limited to the radiocapitellar joint. Outcomes are worst for those with considerable medial extension or comminution. Computed tomography is highly recommended to guide surgical planning. The presence of posterior comminution or extension to the medial column might require more extensile exposures and supplemental fixation for adequate stability. Arthroscopic reduction and fixation techniques have been described for the simple fracture. Those not amenable to fixation might do better with total elbow arthroplasty in a select population. Long-term data demonstrate the durability of these elbows following open reduction internal fixation. Complications other than stiffness are rare. Radiographic avascular necrosis does not appear to affect outcome. Radiographic mild to moderate arthritis was observed in half of patients at 17-year follow-up.

Sonography of the Lateral Antebrachial Cutaneous Nerve With Magnetic Resonance Imaging and Anatomic Correlation

Abnormalities of the lateral antebrachial cutaneous nerve (LABCN) are associated with antecubital elbow conditions, such as distal biceps brachii tendon tears and traumatic cephalic vein phlebotomy. These can lead to lateral forearm, elbow, and wrist symptoms that can mimic other disease processes. The purpose of this study was to characterize the sonographic appearance of the LABCN using cadaveric dissection and retrospective analysis of sonographic examinations of symptomatic patients with magnetic resonance imaging correlation.

Predictors of functional outcomes after simple decompression for ulnar neuropathy at the elbow: a multicenter study by the SUN study group.

OBJECTIVE To identify predictors of surgical outcome for ulnar neuropathy at the elbow (UNE). DESIGN Prospective cohort followed for 1 year. SETTING Clinics. PARTICIPANTS Patients diagnosed with UNE (N=55). INTERVENTION All subjects had simple decompression surgery. MAIN OUTCOME MEASURES The primary outcome measure was patient-reported outcomes, such as overall hand function through the Michigan Hand Outcomes Questionnaire (MHQ). Predictors included age, duration of symptoms, disease severity, and motor conduction velocity across the elbow. RESULTS Multiple regression models with change in the overall MHQ score as the dependent variable showed that at 3 months postoperative time, patients with <3 months duration of symptoms showed 12 points (95% confidence interval [CI], 0.9-23.5) greater improvement in MHQ scores than those with ≥3 months symptom duration. Less than 3 months of symptoms was again associated with 13 points (95% CI, 2.9-24) greater improvement in MHQ scores at 6 months postoperative, but it was no longer associated with better outcomes at 12 months. A worse baseline MHQ score was associated with significant improvement in MHQ scores at 3 months (coefficient, -0.38; 95% CI, -.67 to -.09), and baseline MHQ score was the only significant predictor of 12 month MHQ scores (coefficient, -.40; 95% CI, -.79 to -.01). CONCLUSIONS Subjects with <3 months of symptoms and worse baseline MHQ scores showed significantly greater improvement in functional outcomes as reported by the MHQ. However, duration of symptoms was only predictive at 3 or 6 months because most patients recovered within 3 to 6 months after surgery.

Intra-Articular Fractures of the Hand

Fractures of the hand are common injuries and in particular, fractures involving the articular surfaces can present difficulties to the orthopedic surgeon in practice. Although the treatment of these fractures needs to be individualized based on fracture pattern and location, the goals for these fractures are to restore the alignment, stability, and congruity and to allow for early motion to prevent stiffness and traumatic arthritis. This article classifies the various types of intra-articular hand fractures as well as the workup and management of these injuries.

Biceps and Triceps Ruptures in Athletes

Although rare, biceps and triceps tendon ruptures constitute significant injuries that can lead to profound disability if left untreated, especially in the athletic population. Biceps rupture is more common than triceps rupture, with both resulting from a forceful eccentric load. Surgical repair is the treatment method of choice for tendinous ruptures in athletes. Nonoperative management is rarely indicated in this population and is typically reserved for individuals with partial ruptures that quickly regain strength and function. Surgical anatomy, evaluation, diagnosis, and surgical management of these injuries are covered in this article.

Management of Complications of Forearm Fractures

Forearm fractures may be complicated by the disruption of the distal radioulnar, proximal radioulnar, or radiocapitellar joints. The key principles in treating this unique subset of fractures include early recognition and management of the injury and restoration and maintenance of the anatomic alignment. This articles addresses radial diaphyseal fractures with distal radioulnar joint disruption, proximal ulnar fractures with radiocapitellar disruption, and disruption of the forearm longitudinal axis and how to properly recognize and manage these forearm fracture-dislocations.

Ulnar collateral ligament strain of the thumb metacarpophalangeal joint: biomechanical comparison of two postoperative immobilization techniques

BackgroundThe aim of this study was to compare postoperative immobilization techniques of the thumb metacarpophalangeal (MP) ulnar collateral ligament (UCL) in a cadaver model of a noncompliant patient.MethodsA cadaveric model with fresh-frozen forearms was used to simulate pinch under two immobilization conditions: (1) forearm-based thumb spica splint alone and (2) forearm-based thumb spica splint with supplemental transarticular MP Kirschner wire fixation. Pinch was simulated by thumb valgus loading and flexor pollicis longus (FPL) loading. Ulnar collateral ligament displacements were measured and strain values calculated. Statistical analysis was performed using a repeated measures analysis of variance model.ResultsWith valgus thumb loading, we noted a significantly lower UCL strain in the splint and pin group compared to splint immobilization alone. Increased load was associated with a statistically significant increase in UCL strain within each immobilization condition. FPL loading resulted in negative displacement, or paradoxical shortening, of the UCL in both immobilization groups.ConclusionsWhile immobilized, valgus thumb force, as opposed to MP flexion, is a likely contributor to UCL strain during simulated pinch representing noncompliance during the postoperative period. Supplemental thumb MP pin fixation more effectively protects the UCL from valgus strain. UCL shortening with FPL loading likely represents paradoxical MP extension due to flexion of the distal phalanx against the distal splint, suggesting attempted thumb flexion with splint immobilization alone does not jeopardize UCL repair.Clinical RelevanceThis study provides a foundation to aid clinical decision-making after UCL repair. It reinforces the practice of surgeons who routinely pin their MP joints, but also brings to attention that the use of temporary MP pin fixation may be considered in difficult cases, such as those with potential noncompliance or tenuous repair.