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The physical exam finding demonstrated on the patient's right hand in the video (Figure V) is found with neuropathy of which of the following nerves?
Anterior Interosseious Nerve (AIN
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The video demonstrates Froment's sign on the patient's right hand, which is characterized by interphalangeal (IP) flexion during attempted key pinch, and is found in patients with ulnar neuropathy. Therefore it can be found with ulnar nerve compression in the cubital tunnel (Cubital Tunnel Syndrome) or in Guyon's Canal (Ulnar Tunnel Syndrome).
Froment's sign is performed by having the patient pinch a piece of paper with the thumb IP joint extended against resistance (pulling paper away). It should be done with both hands side by side to compare them to each other.
In a hand with a ulnar neuropathy, adductor pollicis (ulnar n.) is deficient, and can not flex the MCP joint to give pinch strength with an extended IP joint. The thumb compensates by recruiting the FPL (median n.) to flex the IP joint to give pinch strength. The result is, in a positive Froment's sign, the IP joint will flex (buckle) to try to give increased strength to the pinch.
Illustration V shows a demonstration of the Froment's sign.
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Cubital tunnel syndrome is caused by compression of the ulnar nerve between what two structures as it passes posterior to the medial epicondyle?
Osborne's ligament and the MCL
MCL and Arcade of Struthers
Osborne's ligament and the intermuscular septum
MCL and medial head of the triceps
Ulnar and humeral heads of the flexor carpi ulnaris muscle
The ulnar nerve passes posterior to the medial epicondyle and medial to the olecranon, then enters the cubital tunnel. The roof of the cubital tunnel is primarily made up of Osborne's ligament, and the floor consists of the medial collateral ligament.
These soft tissue structures can cause narrowing of the tunnel, especially with elbow flexion, leading to ulnar nerve compression and cubital tunnel syndrome. This is shown in Illustration A. The Arcade of Struthers is a band of deep fascia that attaches to the intermuscular septum and covers the ulnar nerve 8 cm proximal to the medial epicondyle. The intramuscular septum is continuous from the medial epicondyle to the coracobrachialis muscle. The ulnar nerve travels through the two heads of the FCU distal to the cubital tunnel. These anatomic landmarks are shown in Illustration B.
Morrey evaluated 26 patients with post-traumatic contracture of the elbow who were treated with either operative release alone, or operative release and distraction arthroplasty. Twenty-four (96%) of the patients had improved elbow function and two had persistent ulnar neuritis treated with nerve transposition.
Cheung et al discuss the various surgical approaches to the elbow and the indications for each.
Video V is an educational lecture that discusses common nerve entrapment diagnosis and managment.
J Bone Joint Surg Am. 1990 Apr;72(4):601-18. PMID: 2324148 (Link to Abstract)
Cheung EV, Steinmann SP.
J Am Acad Orthop Surg. 2009 May;17(5):325-33. PMID: 19411644 (Link to Abstract)
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All of the following are possible sites of compression for the ulnar nerve EXCEPT:
arcade of Struthers
ligament of Struthers
flexor carpi ulnaris fascia
medial intermuscular septum
There are five sites of potential ulnar nerve entrapment around the elbow: arcade of Struthers, medial intermuscular septum, medial epicondyle, cubital tunnel, and deep flexor pronator aponeurosis.
The ulnar nerve emerges from the medial intermuscular septum, under the arcade of Struthers, and lies on the medial head of the triceps. At the level of the elbow, the ulnar nerve continues distally toward the posterior aspect of the condylar groove, passing between the medial epicondyle and olecranon to enter the cubital tunnel. The roof is formed by the arcuate (Osborne’s) ligament. This ligament blends distally with the antebrachial fascia superficial to the aponeurosis and connects the ulnar and humeral heads of the FCU. The ligament of Struthers is a fibrous band extending from the supracondylar process of the humerus to the medial epicondyle which can cause compression of the median nerve.
Elhassan et al discuss the pathogenesis, evaluation, and treatment of entrapment neuropathy of the ulnar nerve.
Illustration A shows the various site of compression at the elbow. Illustration V shows a submuscular ulnar nerve transposition performed Dr. Susan E. Mackinnon
Elhassan B, Steinmann SP.
J Am Acad Orthop Surg. 2007 Nov;15(11):672-81. PMID: 17989418 (Link to Abstract)
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A 50-year-old man complains of numbness and tingling along his right small finger. Physical exam is notable for the finding demonstrated in Figure A. Elbow flexion reproduces the numbness and tingling. Physical therapy and splinting have failed to relieve the symptoms. Which of the following is the most appropriate surgical intervention to alleviate the symptoms while minimizing complications?
Simple ulnar nerve decompression at the cubital tunnel
Ulnar nerve decompression at the cubital tunnel with anterior submuscular transposition
Ulnar nerve decompression at the cubital tunnel with anterior subcutaneous transposition
Open carpal tunnel release
Endoscopic carpal tunnel release
The patient's clinical presentation and physical exam are consistent with cubital tunnel syndrome. The clinical photograph demonstrates Froment's sign; compensatory IP hyperflexion of FPL (AIN) to compensate for the loss of adductor pollicis (ulnar nerve) during key pinch. Simple decompression of the ulnar nerve is less invasive and achieves clinical outcomes equivalent to decompression with transposition.
Zlowodzki et al conducted a meta-analysis evaluating anterior transposition and simple decompression of the ulnar nerve. No difference in motor nerve-conduction velocities or clinical outcome scores was found.
Bartels performed a prospective randomized trial (included in the Zlowodski meta-analysis) on 152 patients comparing simple decompression to transposition. No difference in clinical results at 1 year were reported, but a significantly higher complication rate occurred in the transposition group (31%) compared to simple decompression (9.6%).
Nabhan et al performed a level 1 study randomizing 66 patients to simple decompression or subcutaneous ulnar nerve transposition. No differences were found with respect to clinical outcome or nerve conduction velocities.
Illustration V is an educational presentation discussing ulnar nerve transposition at the elbow.
Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W
J Bone Joint Surg Am. 2007 Dec;89(12):2591-8. PMID: 18056489 (Link to Abstract)
Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA
Neurosurgery. 2005 Mar;56(3):522-30; discussion 522-30. PMID: 15730578 (Link to Abstract)
Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI.
J Hand Surg Br. 2005 Oct;30(5):521-4. PMID: 16061314 (Link to Abstract)
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HPI - patient came with complains of wasting of hand musculature since a week as per his history.
operative or conservative
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