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Positional Tension of the Ulnar Nerve After Decompression Procedures
John Dunn, MD1; Nicholas Kusnezov1; Justin Mitchell, DO2; Derek Ipsen, DO3; Christopher Forthman, MD4; Aaron Dkystra, MD5
1Orthopaedic Surgery, Texas Tech University Medical Center, El Paso, TX; 2Orthopaedic Surgery, William Beaumont Army Medical Center, Fort Bliss, TX; 3Department of Orthopedic Surgery, WRNMMC, Bethesda, MD; 4Hand Surgery, Union Memorial Hospital, Lutherville, MD; 5Hand Surgery, Walter Reed Army Medical Center, Bethesda, MD

Introduction: The elbow is the most common site of ulnar nerve compression, likely due to the superficial location and inherent compressive anatomy of the ulnar nerve. While biomechanical studies have analyzed the effect of strain on nerve conduction, few have applied these principles to the various techniques of ulnar nerve decompression. The purpose of this study is to determine the amount of strain on the ulnar nerve in full flexion and extension of the elbow and determine if tension in full extension is increased after anterior transposition of the nerve.

Methods: Fifteen fresh cadaver upper extremities with intact shoulder girdles were tested. A differential variable reluctance transducer (DVRT) was placed in the ulnar nerve just proximal to the medial epicondyle and the distance between the mounting pins was measured and used as the initial gauge length. The strain was measured in full elbow flexion and extension. An in situ release, a sub-cutaneous transposition, and a submuscular transposition were performed sequentially with the strain being measured after each procedure in the full elbow flexion and extension positions. The strain was then averaged and compared for each procedure. A one-way analysis of variance was used to determine if any observed differences were significant (p?0.05).

Results: After the in situ release there was no statistically significant change in strain compared with the strain before the release in either flexion or extension (p=0.302). With a subcutaneous transposition there was a statistically significant decrease in strain in full elbow flexion (p=0.048) but not in extension. Similarly with a submuscular transposition there was a statistically significant decrease in strain in full flexion (p=<0.0005) but not in extension. There was not a statistically significant change in strain with medial epicondylectomy (p=0.051).

Conclusion: An in-situ release of the ulnar nerve at the elbow may relieve pressure on the nerve but does not address the problem of strain which may be the underlying pathology in many cases of cubital tunnel syndrome. Transposition of the ulnar nerve anterior to the medial epicondyle, as part of a subcutaneous or a submuscular transposition, does address the problem of pressure and strain on the ulnar nerve. In addition it does not create increased strain on the ulnar nerve with elbow extension.

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