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Total ulnar nerve transection following elbow dislocation
Injury Extra (2005) 36, 319—320
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CASE REPORT
Total ulnar nerve transection following elbow dislocation Dogan Tuncali *, Nurten Yavuz, Gurcan Aslan Ankara Education and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Ankara, Turkey Accepted 15 December 2004
Introduction
Case report
Ulnar nerve entrapment or palsy following forearm fractures9,11 and supracondylar humerus fractures with early6 or late13 onset of symptoms are well described in the literature. A significant number of tardy1,3,5,7 or secondary2 ulnar nerve palsies have also been reported. These usually result from some type of elbow trauma with onset of symptoms from 2 to 29 months.2,5 An immediate or late ulnar nerve palsy following dislocation of the elbow, although a well described clinical entity, is relatively rare4,10 and not the rule.12 Neurological examination of the upper extremity must be performed before and after elbow manipulation, since neurovascular complications occur in a significant number of patients, the most frequent being injury to the ulnar nerve. However, we are not aware if the term ‘injury’ includes a total transection of the nerve because to the best of our knowledge a total transection following elbow dislocation has not been reported previously in the English literature. We present an unusual case of an overlooked total ulnar nerve transection following elbow dislocation.
A 24-year-old male attended an emergency department having fallen on his left elbow. Elbow dislocation was diagnosed, about 50 ml of haematoma was evacuated and, following traction and closed reduction, the elbow was placed in a cast for about 45 days. During follow-up, the patient’s complaints of little finger hypoaesthesia and forearm muscle atrophy were interpreted as being due to compression from the haematoma or cast. Because of established muscle atrophy and persistent hypoaesthesia, the patient attended our outpatient clinic at 18 months following the injury. On examination he had an ulnar claw hand deformity, with atrophy of the interosseous muscles, lack of adduction power of the fingers and anaesthesia in the ulnar nerve distribution. A total lesion of the ulnar nerve at the wrist level was reported on electromyography. Surgical exploration revealed total transection of the ulnar nerve at the level of the medial epicondyle, with neuroma formation at the proximal stump (Fig. 1). Neuroma excision and anterior transposition of the nerve allowed for epineurial coaptation. Unfortunately, at 18 months after operation, the patient still has no significant improvement in the motor function of the ulnar nerve although a limited amount of protective sensation has recovered.
* Corresponding author. Present address: Mahatma Gandi cad., Mesa Ufuk 1 sitesi 51/28, Gaziosmanpasa 06700, Ankara, Turkey. Tel.: +90 312 595 36 62; fax: +90 312 437 69 86. E-mail address: [email protected] (D. Tuncali).
1572-3461 # 2005 Published by Elsevier Ltd. Open access under CC BY-NC-ND license. doi:10.1016/j.injury.2004.12.059
320
D. Tuncali et al.
Figure 1 Ulnar nerve transection at the level of the medial epicondyle as a result of elbow dislocation (see arrow). The nerve was dissected free from the joint space.
Discussion Ulnar nerve palsy following elbow dislocations are rare4,10 although tardy palsies following trauma to the elbow region have been more commonly reported.1—3,5,7 Early recognition of such injuries is known to give excellent results, but treatment of established lesions does not always produce such favourable results,8 so timely detection of such lesions is of primary importance. To the best of our knowledge, a total transection of the ulnar nerve at the level of the medial epicondyle following elbow dislocation has not been reported previously in the English literature. In clinical practice any neurological complaints should raise a high degree of suspicion of such a nerve injury. A thorough examination before and after reduction and following cast removal will certainly reduce the likelihood of overlooking these disabling, serious and unfortunate complications.
References 1. Abe M, Ishizu T, Shirai H, et al. Tardy ulnar nerve palsy caused by cubitus varus deformity. J Hand Surg 1995;20A:5—9.
2. Faierman E, Wang J, Jupiter JB. Secondary ulnar nerve palsy in adults after elbow trauma: a report of two cases. J Hand Surg 2001;26A:675—8. 3. Goldware S, Maxwell JA. Tardy ulnar palsy. A review of 62 cases and discussion of current concepts. J Kans Med Soc 1972;73:51—3. 4. Grobler GP. Unusual cause of ulnar nerve palsy. Clin Orthop 1996;323:192—3. 5. Holmes JC, Hall JE. Tardy ulnar nerve palsy in children. Clin Orthop 1978;135:128—31. 6. Lalanandham T, Laurence WN. Entrapment of the ulnar nerve in the callus of a supracondylar fracture of the humerus. Injury 1984;16:129—30. 7. Paine KW. Tardy ulnar palsy. Can J Surg 1970;13:255—61. 8. Perreault L, Drolet P, Farny J. Ulnar nerve palsy at the elbow after general anaesthesia. Can J Anaesth 1992;39: 499—503. 9. Prosser AJ, Hooper G. Entrapment of the ulnar nerve in a greenstick fracture of the ulna. J Hand Surg 1986;11B: 211—2. 10. Sharma RK, Covell NA. An unusual ulnar nerve injury associated with dislocation of the elbow. Injury 1976;8:145—7. 11. Stahl S, Rozen N, Michaelson M. Ulnar nerve injury following midshaft forearm fractures in children. J Hand Surg 1997;22B:788—9. 12. Tayob AA, Shively RA. Bilateral elbow dislocations with intraarticular displacement of the medial epicondyles. J Trauma 1980;20:332—5. 13. Uchida Y, Sugioka Y. Ulnar nerve palsy after supracondylar humerus fracture. Acta Orthop Scand 1990;61: 118—9.
www.elsevier.com/locate/inext
CASE REPORT
Total ulnar nerve transection following elbow dislocation Dogan Tuncali *, Nurten Yavuz, Gurcan Aslan Ankara Education and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Ankara, Turkey Accepted 15 December 2004
Introduction
Case report
Ulnar nerve entrapment or palsy following forearm fractures9,11 and supracondylar humerus fractures with early6 or late13 onset of symptoms are well described in the literature. A significant number of tardy1,3,5,7 or secondary2 ulnar nerve palsies have also been reported. These usually result from some type of elbow trauma with onset of symptoms from 2 to 29 months.2,5 An immediate or late ulnar nerve palsy following dislocation of the elbow, although a well described clinical entity, is relatively rare4,10 and not the rule.12 Neurological examination of the upper extremity must be performed before and after elbow manipulation, since neurovascular complications occur in a significant number of patients, the most frequent being injury to the ulnar nerve. However, we are not aware if the term ‘injury’ includes a total transection of the nerve because to the best of our knowledge a total transection following elbow dislocation has not been reported previously in the English literature. We present an unusual case of an overlooked total ulnar nerve transection following elbow dislocation.
A 24-year-old male attended an emergency department having fallen on his left elbow. Elbow dislocation was diagnosed, about 50 ml of haematoma was evacuated and, following traction and closed reduction, the elbow was placed in a cast for about 45 days. During follow-up, the patient’s complaints of little finger hypoaesthesia and forearm muscle atrophy were interpreted as being due to compression from the haematoma or cast. Because of established muscle atrophy and persistent hypoaesthesia, the patient attended our outpatient clinic at 18 months following the injury. On examination he had an ulnar claw hand deformity, with atrophy of the interosseous muscles, lack of adduction power of the fingers and anaesthesia in the ulnar nerve distribution. A total lesion of the ulnar nerve at the wrist level was reported on electromyography. Surgical exploration revealed total transection of the ulnar nerve at the level of the medial epicondyle, with neuroma formation at the proximal stump (Fig. 1). Neuroma excision and anterior transposition of the nerve allowed for epineurial coaptation. Unfortunately, at 18 months after operation, the patient still has no significant improvement in the motor function of the ulnar nerve although a limited amount of protective sensation has recovered.
* Corresponding author. Present address: Mahatma Gandi cad., Mesa Ufuk 1 sitesi 51/28, Gaziosmanpasa 06700, Ankara, Turkey. Tel.: +90 312 595 36 62; fax: +90 312 437 69 86. E-mail address: [email protected] (D. Tuncali).
1572-3461 # 2005 Published by Elsevier Ltd. Open access under CC BY-NC-ND license. doi:10.1016/j.injury.2004.12.059
320
D. Tuncali et al.
Figure 1 Ulnar nerve transection at the level of the medial epicondyle as a result of elbow dislocation (see arrow). The nerve was dissected free from the joint space.
Discussion Ulnar nerve palsy following elbow dislocations are rare4,10 although tardy palsies following trauma to the elbow region have been more commonly reported.1—3,5,7 Early recognition of such injuries is known to give excellent results, but treatment of established lesions does not always produce such favourable results,8 so timely detection of such lesions is of primary importance. To the best of our knowledge, a total transection of the ulnar nerve at the level of the medial epicondyle following elbow dislocation has not been reported previously in the English literature. In clinical practice any neurological complaints should raise a high degree of suspicion of such a nerve injury. A thorough examination before and after reduction and following cast removal will certainly reduce the likelihood of overlooking these disabling, serious and unfortunate complications.
References 1. Abe M, Ishizu T, Shirai H, et al. Tardy ulnar nerve palsy caused by cubitus varus deformity. J Hand Surg 1995;20A:5—9.
2. Faierman E, Wang J, Jupiter JB. Secondary ulnar nerve palsy in adults after elbow trauma: a report of two cases. J Hand Surg 2001;26A:675—8. 3. Goldware S, Maxwell JA. Tardy ulnar palsy. A review of 62 cases and discussion of current concepts. J Kans Med Soc 1972;73:51—3. 4. Grobler GP. Unusual cause of ulnar nerve palsy. Clin Orthop 1996;323:192—3. 5. Holmes JC, Hall JE. Tardy ulnar nerve palsy in children. Clin Orthop 1978;135:128—31. 6. Lalanandham T, Laurence WN. Entrapment of the ulnar nerve in the callus of a supracondylar fracture of the humerus. Injury 1984;16:129—30. 7. Paine KW. Tardy ulnar palsy. Can J Surg 1970;13:255—61. 8. Perreault L, Drolet P, Farny J. Ulnar nerve palsy at the elbow after general anaesthesia. Can J Anaesth 1992;39: 499—503. 9. Prosser AJ, Hooper G. Entrapment of the ulnar nerve in a greenstick fracture of the ulna. J Hand Surg 1986;11B: 211—2. 10. Sharma RK, Covell NA. An unusual ulnar nerve injury associated with dislocation of the elbow. Injury 1976;8:145—7. 11. Stahl S, Rozen N, Michaelson M. Ulnar nerve injury following midshaft forearm fractures in children. J Hand Surg 1997;22B:788—9. 12. Tayob AA, Shively RA. Bilateral elbow dislocations with intraarticular displacement of the medial epicondyles. J Trauma 1980;20:332—5. 13. Uchida Y, Sugioka Y. Ulnar nerve palsy after supracondylar humerus fracture. Acta Orthop Scand 1990;61: 118—9.