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To investigate the feasibility of ultrasound (US)-guided steroid injection by in-plane approach for cubital tunnel syndrome (CuTS), based on symptomatic, morphologic and electrophysiological outcomes.
A total of 10 patients, who were clinically diagnosed as CuTS and confirmed by an electrodiagnostic study, participated in this study. US-guided injection into the cubital tunnel was performed with 40 mg triamcinolone and 2 mL of 1% lidocaine. Outcomes of the injections were evaluated at pre-injection, 1st week and 4th week after injection. Visual analog scale, self-administered questionnaire of the ulnar neuropathy at the elbow (SQUNE), and McGowan classification were used for clinical evaluation. Cross-sectional area of the ulnar nerve by US and the electrophysiological severity scale through a nerve conduction study were utilized in the evaluation of morphologic and electrophysiological changes. The cross-sectional area of the ulnar nerve was measured at 3 points of condylar, proximal, and distal level of the cubital tunnel.
No side effects were reported during the study period. The visual analog scale and cross-sectional area showed a significant decrease at 1st week and 4th week, as compared to baseline (p<0.05). The electrophysiological severity scale was significantly decreased at the 4th week, as compared with baseline and 1st week (p<0.05). Among the quantitative components of the scale, there were statistically significant improvements with respect to the conduction velocity and block.
The new approach of US-guided injection may be a safe tool for the treatment of CuTS. Symptomatic and morphologic recoveries preceded the electrophysiological improvement.
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This study reports a rare case of ulnar neuropathy around the arm with Martin-Gruber anastomosis of a moderate conduction block in the forearm segment and a severe conduction block in the arm segment. Inching tests and ultrasonography showed a lesion between 12 and 14 cm from the medial epicondyle. It is concluded that axilla stimulation may provide diagnostic clues, and inching tests and ultrasonography may be helpful for localizing a lesion.
Citations
Method: Ulnar motor nerve conduction studies were performed bilaterally in twenty healthy adult volunteers. For each limb, nerve conduction study was carried out in two different positions. In the first position, shoulder were abducted, elbow and wrist flexed to 90o. For the second position, all joints were kept constant except for the wrist where it was extended. Routine conduction study was performed in both wrist positions. All data were statistically analyzed.
Results: The average conduction velocities in the wrist flexed position were 61.6 m/sec for the forearm segment and 62.3 m/sec across elbow. With the wrist extended, the average was 62.6 m/sec and 64.1 m/sec, respectively. The differences in conduction velocities between two different wrist positions were statistically significant (p＜0.05). In the wrist flexed position, the average measured latencies were 2.3 msec with wrist, 5.4 msec below elbow, and 7.4 msec above elbow stimulation, compared to wrist extended which showed 2.4, 5.4 and 7.2 msec, respectively. The difference of latencies at wrist between the two wrist positions was statistically significant (p＜0.05).
Conclusion: The authors conclude that wrist position affect ulnar nerve conduction velocity.
Objective: This study was designed to assess the ulnar nerve using ultrasonographic measures at the elbow in patients with cubital tunnel syndrome.
Method: We examined 20 healthy men as control and 10 patients with cubital tunnel syndrome. We measured the short, long axis and area of ulnar nerve with the shoulder abducted at 60o and elbow fully extended posture in prone position. The mean age of control and patients were 46.4 (30∼60) years old and 48.8 (30∼61) years old, respectively.
Results: In normal group, the size of ulnar nerve at medial epicondyle, 5 cm proximal to medial epicondyle and 5 cm distal to medial epicondyle was 4.0×2.0 mm, 6.2 mm2, 3.7×2.1 mm, 5.8 mm2 and 3.7×2.0 mm, 6.0 mm2 respectively,
where as in the patients group, it was 5.7×2.9 mm, 13.1 mm2, 5.2×3.1 mm, 12.7 mm2 and 4.7×2.8 mm, 10.2 mm2 respectively. In cubital tunnel syndrome, the size of ulnar nerve was smaller in the distal portion of the medial epicondyle compared to the size measured at proximal or medial epicondyle. There was significant differences between the size of the ulnar nerve in controls and patients with cubital tunnel syndrome (p＜0.05).
Conclusion: The ultrasonography can accurately detect the morphologic changes in the ulnar nerve, so it will be useful in diagnosis of cubital tunnel syndrome. (J Korean Acad Rehab Med 2002; 26: 167-171)
Objective: We tried to make real time observation of the ulnar nerve with elbows in an extended and flexed state at 100 degrees.
Method: We examined 58 elbows of 29 healthy volunteers. The participants were symptomless and showed normal conduction across the elbow. The transducer was applied between the line connecting medial epicondyle and olecranon. We measured the distances between the center of nerve, medial epicondyle, olecranon, skin, and investigated the flattening ratio with elbows extended. Afterwards, we repeated the measurement with the elbows flexed at 100 degrees. We classified the position of the nerves into three groups according to the flexed position. We used the Okamoto classification.
Results: The distance between nerve and skin, between nerve and medial epicondyle was 0.57⁑0.11 cm, 0.83⁑0.15 cm, with the elbow extended. But with the elbow flexed, the distance decreased to a value of 0.45⁑0.11 cm, 0.64⁑0.25 cm, respectively. The flattening ratio was 0.52⁑0.13 at extension, and 0.31⁑0.11 at flexion. Subluxation and dislocation of the ulnar nerve were seen in 20.7% and 5.2% respectively. With the elbow flexed, the ulnar nerve moved anteromedially and superficially in the dislocated group.
Conclusion: With the elbow flexed, the ulnar nerve moves superficially and medially, and the flattening ratio is greater when the elbow is extended. (J Korean Acad Rehab Med 2002; 26: 61-66)
Objective: To investigate the anatomy of the ulnar nerve according to the degree of elbow flexion and to obtain optimal elbow position for ulnar nerve conduction study.
Methods: Eleven elbows in nine cadavers were dissected. We estimated the 10 cm elbow segment to be the distance between 2 points, 4 cm distal and 6 cm proximal to the center of the cubital tunnel, which was determined to be the halfway point between the medial epicondyle and olecranon with elbow position in extension and 45o, 90o, 135o flexion. Anatomical measurements of the actual length of ulnar nerve, distance between medial epicondyle and ulnar nerve, and distance between medial epicondyle and olecranon were obtained in each position. The actual length of the ulnar nerve was measured between two points of the ulnar nerve closest to the landmarks of the estimated 10 cm with flexible ligature.
Results: The actual lengths of ulnar nerve were 10.23 cm, 10.00 cm, 9.44 cm, and 9.08 cm in elbow extension, and 45o, 90o, 135o flexion, respectively. The difference between actual length and estimated lengths were least in 45o elbow flexion (p=0.0001). The distance between medial epicondyle and olecranon increased with increasing elbow flexion (p=0.0001). However, there was no difference in the distance between medial epicondyle and ulnar regardless of the elbow position. As a result, the ulnar nerve seemed to have migrated anteriorly in the cubital tunnel with increasing elbow flexion.
Conclusion: This study suggest that the optimal angle in ulnar nerve conduction study would be 45o flexion, under the condition that the distance measurement is through the halfway point between the medial epicondyle and olecranon.
Objective: There is a room for considerable error in the measurement of across-elbow conduction velocity due to the different possible positions of the elbow and the difficulty in measuring distance accurately. We propose a technique for the measurement of conduction velocity through the elbow segment in a fully flexed elbow position with the arm abducted at 90o.
Method: We assumed 'ideal' across-elbow segmental conduction velocity is the mean of the forearm and arm segmental conduction velocities, and established an optimal deflection point at the elbow, which best reflects the ideal conduction velocity in normal healthy subjects. Five deflection points were examined at the elbow. Segmental conduction velocities of across-elbow segments were calculated at each of these points, using the sum of the linear distances from each point to the proximal above-elbow cathode stimulation site and to the distal below-elbow cathode stimulation site.
Results: The optimal deflection point was the midpoint between the epicondyle and the olecranon in an arm abducted 90o and elbow fully flexed position.
Conclusion: Our data suggests that an across-elbow segment velocity lower than 54.2 m/sec, or a difference of more than 11.6 m/sec between the across-elbow and forearm segments is to be considered abnormal. The lower limit values expressed as mean - 2 S.D. for absolute across-elbow segmental conduction velocity and relative velocity difference between the across- elbow segment and forearm segments at other possible deflection points of the elbow were also calculated.
Objective: To establish the reference values of the sensory conduction for all the digits in the hand, conduction studies were performed using the standard technique.
Method: One hundred hands of fifty neurologically healthy adults with mean age of 45 years (range, 23∼69) were tested. Depending on ages, the 50 adults were devided into three groups: group 1, 20∼45 years old; group 2, 46∼60 years old; group 3, 61∼ years old. Antidromic sensory nerve conduction techniques using a fixed distance were performed. The onset latency and baseline to peak amplitude of the sensory nerve action potentials (SNAPs) were measured. During the test, the skin temperature of the hand was maintained at 34oC or above. These variables from SNAPs were compared according to age, gender, side, and recording digits.
Results: Comparison of the median and ulnar SNAPs between age groups revealed longer onset latency and smaller amplitude in the elderly group. The amplitude of SNAPs was larger in females than in males and the left side than the right side. Comparison of the latencies and amplitudes between the second and third digits showed no significant difference statistically. Also, the latencies and amplitudes of the median and ulnar nerves recorded from the fourth digits showed no significant difference statistically.
Conclusion: Based on these results, the reference values for sensory conductions from all the digits were obtained. These values would be helpful in evaluation of CTS or unspecified finger pain or upper extremity neuropathy.
Objectives: Six cases of tardy ulnar neuropathy caused by cubitus varus deformity are presented. Clinical features and electrodiagnostic study of six cases were analysed to understand the mechanim of nerve palsy and the usefulness of electrodiagnostic study.
Methods: Electrodiagnostic study and elbow flexion test were performed and elbow varus angle, internal rotation angle of shoulder, biceps and brachioradialis muscle activities were measured in 6 patients
Results: Decreased ulnar nerve motor conduction velocities in the elbow segment was shown in 5 patients. Prolonged distal latency and reduced amplitude of ulnar sensory nerve action potentials were shown in one patient. Needle electromyography showed large amplitude motor unit action potentials in ulnar innervated forearm or hand muscles. The mean values of varus angle and internal rotation angle of humerus were 21o, and 28o, respectively. Brachioradialis showed relatively higher activity than biceps brachii in the early phase of elbow flexion. Three patients underwent surgery and showed immediate symptom relief.
Conslusion: Tardy ulnar nerve palsy in cubitus varus thought to be caused by internal rotation of distal segment of humerus, stretching of ulnar nerve, snapping of the medial head of triceps on ulnar nerve and anterior transposition and compression of ulnar nerve. The three dimensional corrective osteotomy could be the most efficient treatment to restore the anatomic alignment of the elbow joint.
Objective: To determine the prevalence, location, and risk factors for the peripheral nerve entrapments of upper extremity among the crutch or cane users.
Method: We performed the clinical and electrodiagnostic assessments of both upper extremities in 43 crutch or cane users and 49 able-bodied controls.
Results: The prevalence for the nerve entrapment of upper extremity among the crutch or cane users was 27.9% by the clinical criteria and 86.0% by the electrodiagnostic criteria. Electrodiagnostically, the median nerve entrapment was 76.7%, and the ulnar nerve entrapment was 72.1% among the crutch or cane users. The carpal tunnel was the most common site for the entrapment. Body weight, duration of disability, and duration of crutch or cane use were found to be significantly correlated with the emtrapments of median nerve, whereas duration of crutch or cane use alone was significantly correlated with the entrapments of ulnar nerve.
Conclusion: The peripheral nerve entrapments of upper extremity is associated with the chronic crutch or cane use and the preventive strategies need to be developed for the patients with risks.
Objectives: The current literature gives confusing advice on the position of the elbow in ulnar nerve conduction study. The purpose of this study was to determine the appropriate position of elbow flexion for a segmental ulnar nerve conduction study and to attain the basic information for an evaluation of ulnar neuropathy.
Methods: Segmental ulnar motor and sensory nerve conduction studies were performed bilaterally on 40 healthy korean adults(20 men and 20 women) with the age range from 19 to 56 years(mean age：29.86). The ulnar nerve was stimulated at 7 cm & 10 cm proximal to the active recording electrode respectively and 5 cm distal, and poximal to the medial epicondyle of the humerus for motor and sensory nerves at each elbow flexion position of 0o, 45o, 90o, and 135o. The segmental distances were measured in each position.
Results: The segmental nerve conduction velocity(NCV) of the elbow segment increased with the degree of elbow flexion, and it was faster than the forearm segment at 90o and 135o of elbow flexion. The NCV showed no statistical difference in each elbow position.
Conclusion: We conclude that the degree of elbow flexion should be maintained 90o or above in an ulnar nerve conduction study.
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