All right, so I had a couple of questions at the beginning with the audience response system and then I'll circle back to them quickly at the end, let's see, maybe, that's interesting. That's interesting. Of course, there are no A.B. people back there, right? Okay, that's slow. Okay, fine. I think we missed one, but what's the first sign to appear in ulnar neuropathy? So, which of these eponymous signs is the first to appear? Fermat's? Hortenberg's? Okay, good. Switching back and forth. One of them is right, we'll come back to that. Okay. Fermat's is weakness of which of the following? I don't know how one was 100% and one was 17% then, okay. Which procedure can be used to restore power pinch in severe ulnar neuropathy? Excellent. So, now we have our patient that presents. We have a 48-year-old woman who presents with complaints of right smaller ring finger numbness and hand weakness. She denies any antecedent accident or injury. She's had no prior evaluation or treatment before she comes into your office. And this is her hand. So, in addition to maybe noticing the arthritis, what's the first thing that you see? Some atrophy, right? So, where do you see most of the atrophies in the first web? So, it's hard to see adductor atrophy, but she's got first dorsal interosseous atrophy. So, I think you all know compression neuropathy involves 10% of the population. Carpal tunnel is most common, but ulnar neuropathy is the second most common. It can be from intrinsic, but most commonly from extrinsic factors. You always have to think about multiple sites of compression. If a patient has a cervical lesion, they're going to be more susceptible to a lesion at the elbow or the wrist, which is a double-crush phenomenon. And all sites have to be identified and treated, usually with the most severe site first. Know all the presentation symptoms, which are numbness and tingling in the small and ulnar half of the ring finger. They may have medial elbow pain. Their symptoms are often worse with elbow flexion, and they may have nighttime symptoms. So, this is the course of the ulnar nerve in the forearm and into the hand. When you're going to do a decompression at the elbow, you have to think of all sites of possible compression, and you want to decompress all of them. So, for most proximal, it's the arcate of struthers, and then the medial intramuscular septum. The medial head of the triceps is a consideration. The medial epicondyle itself, the cubital tunnel. And then some patients may have an ankyneous epiturchularis, which is an anomalous muscle that spans from the medial olecranon to the medial epicondyle. And in the literature, it's been seen in 28% of cadaver specimens. So, it's something to think about. If it's there, it should be released. Motor innervation from proximal to distal starts at the FCU, and most distally, the adductor pollicis and the deep head of the FPB. So, signs on exam can include a positive TINELS, or elbow flexion test, which is considered positive if the patient has pain. Which is considered positive if the patient has paresthesias and an ulnar nerve distribution. And then in the more severe cases, the patients can present with wasting and with weakness. Like this patient had the first web atrophy and the first dorsal interosseous in the adductor. So, the first sign to appear is a Wartenberg sign, which is an abducted position of the small finger. And that's from unopposed pull of the extensor digiti minimi. Fromad sign, which is often seen, is when the patient tries to pinch a piece of paper between their thumb and their index finger, and they compensate for a weak adductor pollicis by flexing the IP joint. And that puts increased tension on the EPL, and lets the EPL act as an adductor because of its oblique course. And then the patient may also have some clawing of the small and ring finger, which is more pronounced in a low ulnar nerve palsy because you have an active FTP. So, here's a picture of Wartenberg sign, the small finger held in an abducted position. Again, that's because the EDM sits ulnar to the axis of the small finger, so when it's unopposed, it's going to pull the finger into abduction because the intrinsics aren't working. This is a clinical picture of Fromad sign, which is the patient compensating with IP flexion for a weak adductor pollicis. Nerve conduction studies, which are the gold standard in carpal tunnel syndrome, can be helpful in diagnosing ulnar neuropathy, but they can also be negative. They're considered positive if there's a motor drop-off of 10 meters per second or more from above to below the elbow. In our patient that presents, she not only had a motor latency delay at the elbow, but she had EMG changes. Her changes were in the EDM, the first dorsal interosseous, and the FTP to the ring with fibrillations, positive sharp waves, and decreased motor recruitment. Her APB, the EMG, was normal, supporting that she had normal median nerve function. Again, this was her picture of her hand. What would you recommend for this patient? First, how many people in the audience would not operate on this patient? We all agree that we want to do something for this patient surgically. If we want to decompress her ulnar nerve as at least a first step, there are multiple ways of doing that. There is good literature that has shown that in situ versus transposition has equivalent outcomes unless the patient subluxates. Endoscopic ulnar nerve release has also been described. We have this on the audience response too. Faculty as well, how many of you would do an endoscopic release for this patient versus in situ versus some form of transposition? We'll say she does not have subluxation. It was inching up a little bit. Endoscopic cubital tunnel release has been described and has been modified some in the past decade. There's a study that was just out this year showing comparable results through a meta-analysis between endoscopic and open cubital tunnel release. Looking at these results, Dr. Ingari, I know you do some endoscopic cubital tunnel release. What would lead you to do that in this patient versus not? Essentially, to me, I think of it as an in situ release. If you are considering that patient an adequate candidate for in situ release, i.e., she doesn't subluxate or dislocate or have some other compressive condition like arthritis around the medial elbow, then I find endoscopic to be just as effective as in situ. It's very easy to sell to the patient to tell them you're going to have a little 2 cm incision as opposed to a 12 cm incision. There's nothing really in the literature that I saw that would support a transposition versus in situ for a patient who presents with more advanced disease like this with atrophy. Does anyone lean towards a transposition just based on the severity of her presentation? There's nothing that would support that, but I think there are some people that would go for the more aggressive procedure. This is just an image of the initial approach to the ulnar nerve. For the audience, what do you want to look for and protect when you're doing your open approach to the ulnar nerve? I think we have this on the audience response, but it should be. You want to look out for and protect your medial antebrachial cutaneous nerve, which is usually going to sit just anterior and distal to the medial epicana. You also want to make sure you decompress at all the sites that we talked about, from approximately at the arcade of Struthers, progressing distally through the cubital tunnel between the two heads of FCU and releasing anconeus if they have one. These are some pictures from an ulnar nerve transposition. This is protecting the MABC. This is releasing the ulnar nerve. This is a step cut marked in the flexor pernudar mass for a submuscular transposition, and this is the nerve transposed anteriorly, just showing what's all in that area. Coming back to our patient who has this atrophy, and she does complain of weakness with pinch, what else might you consider in this patient along with their decompression? If she had that atrophy but didn't have any complaints of weakness, I don't think you need to consider doing anything else. You would do the decompression and then rehab and see how she does. Because she does have this complaint, two things you might consider would be a nerve transfer or a tendon transfer. We'll talk through those, but anybody in the audience who would do a nerve transfer? Anybody who would do tendon transfers if she complained of decreased power pinch? Okay, and that could certainly be staged and done later, just like we talked about with some of the other topics. One possible consideration is a so-called supercharged end-to-side AIN to ulnar motor transfer. This was described initially in the lab by Jonathan Isaacs and colleagues, and then the clinical procedure was reported by Barbara and McKinnon and colleagues in the Journal of Hand Surgery. There are no clinical results reported that I'm aware of, and the goal of this conceptually is to help improve the odds of regeneration in a situation like this or an proximal ulnar nerve lesion where there's guarded prognosis for good results. So basically what you're doing with this is you're taking the end branch, the anterior neurosseous nerve to the pronator quadratus, and you're taking that end-to-side into the ulnar motor branch here. So this is your AIN terminal branch, end-to-side, into the ulnar motor. And so you don't give up the possibility of there being normal regeneration to the motor end plates, but you give it a possibility of having better regeneration. So I just throw that out there as something to think of. And then the other option, which is a little more tried and true, which is maybe a lot more tried and true, is tendon transfers. And so for power pinch, probably your most reliable tendon transfer is ECRB with a tendon graft to the adductor pollicis described by Smith, with or without an MP arthrodesis. Brachioradialis is also a good consideration. You can do an FDS transfer, but then you're going to end up with a weaker grip strength, and so I would lean against that. And you can also do a transfer to the first dorsal interosseous, but often that's not necessary if you're doing a transfer to the adductor pollicis. And so here's a picture of the ECRB with a graft to the adductor pollicis. I think this picture goes through the third web, but typically we'd go through the second web. And this is a picture of the APL to the first dorsal interosseous. This is a clinical picture of ECRB with graft through the web space to do the adductor plasti. And this is actually the APL to the first dorsal interosseous. And so this was done for this patient, and they had a very good result with getting pinch strength back. But I think most important is doing the decompression of the nerve because that's something that we can definitively treat. So back to our audience response questions. Just make sure we all have the right answers. And this was the one that got missed. Which is a possible source of ulnar nerve compression at the elbow? I think this is going to work. Perfect. Okay. And so that's seen not all the time, but when it's seen it should be released. What's the first sign to appear? This would be asked, but Wurtenberg's is the first one that appears. And then you may see Furman's. And so what's the deficit in Furman's? What's the Furman's sign occurs due to weakness in which muscle? So it's definitely a weakness in power pinch, and it's from weakness in the adductor pollicis. And which tendon transfer can help restore power pinch? Perfect. Right. The one above that is the opposition plasty for median nerve. Good. So that was quick, but any questions about ulnar neuropathy before we move into soft tissue procedures with Dr. Rissek? We did, but you definitely could stage it. Her biggest complaint was her weakness and wanted to do something about it.

ulnar neuropathy

symptoms

treatment options

compression neuropathy

nerve conduction studies