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Ultrasonic 3D visualisation of ulnar nerve at elbow : Plea for focal decompression

Somesh Beeharry Hopital Schweitzer France

PROVOCATIVE

In a recent survey 44% of surgeons are not satisfied with results After treatment of ulnar neuropathy at elbow C.B. NOVAK and S.E. MACKINNON HAND 2009

Somesh Beeharry Hopital Schweitzer France

PROVOCATIVE

In a recent survey ( JHS ) 44% of surgeons are not satisfied with results after treatment of ulnar neuropathy at elbow
SZABO 1999 success rate :80% 55 Patients 19 endoscopic release : success rate 79% 15 open insitu release : success rate 60% 134 endoscopic release success rate 78% of which recurrence 5 %

R. Hoffmann JHS 2006 A.C. Watts JHS 2009

T.k. COBB

Hand 2009

Somesh Beeharry Hopital Schweitzer France

CAUSES of ULNAR NEUROPATHY G.FILLIPOU Clin Rhumatology

Compression Subluxation, Luxation, Osteophytes,Accessory muscle Articular ganglion,Post-traumatic lesion

TREATMENT 154 hand surgeons C.Novak S.Mackinnon Hand 2009 B.Palmer T.Hugues JHS 2009

Insitu decompression Open decompression Endoscopic decompression Transposition (intramuscular or submuscular) Epicondylectomie

Somesh Beeharry Hopital Schweitzer France

CAUSES of ULNAR compression

Compression Arm Struthers arcade, anomalous anconeus Elbow Retrocondylar groove Osborness ligament=Cubital tunnel retinaculum Deep layer of FCU =Osbornes fascia Forearm Deep layer of fascia FCU Between bellies of FCU and flexor digitorium profundis

TREATMENT 154 hand surgeons C.Novak S.Mackinnon Hand 2009 B.Palmer T.Hugues JHS 2009

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression Ulnar nerve anatomy D. Polatsch Hand clinics 2007

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression Ulnar nerve anatomy D. Polatsch Hand clinics 2007 Die Endoskopiche Dekompression C.Bultmann R.Hoffmann Operative orthopadie 2009

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression Les lesions des gros Troncs nerveux Dejerine Presse medicale 1915 Peripheral nerve Fascicle John D Stewart Muscle and nerve 2003 Internal topogropraphy Of nerves M. Jabaley JHS Somesh 1979

Can we localise site of compression ?


Beeharry Hopital Schweitzer France

Site of ULNAR compression

Clinical exam
Les lesions des gros Troncs nerveux Dejerine Presse medicale 1915 Peripheral nerve Fascicle John D Stewart Muscle and nerve 2003 Internal topogropraphy Of nerves M. Jabaley Somesh JHS 1979

Beeharry Hopital Schweitzer France

Site of ULNAR compression

Clinical exam
Les lesions des gros Troncs nerveux Dejerine Presse medicale 1915 Peripheral nerve Fascicle John D Stewart Muscle and nerve 2003 Internal topogropraphy Of nerves M. Jabaley Somesh JHS 1979

Beeharry Hopital Schweitzer France

Site of ULNAR compression

Clinical exam
Les lesions des gros Troncs nerveux Dejerine Presse medicale 1915 Peripheral nerve Fascicle John D Stewart Muscle and nerve 2003 Internal topogropraphy Of nerves M. Jabaley Somesh JHS 1979

Beeharry Hopital Schweitzer France

Site of ULNAR compression

Clinical exam

NO

Les lesions des gros Selective damage of pedicle Troncs nerveux Dejerine Presse medicale Of five pedicles at elbow very 1915 Often only 2 are damaged Peripheral nerve Fascicle John D Stewart Muscle and nerve 2003 Internal topogropraphy Of nerves M. Jabaley Somesh Beeharry Hopital Schweitzer France JHS 1979

Site of ULNAR compression

Clinical exam Nerve conduction In CTS the Velocity Is measured Precisely In the tunnel

Example of CTS

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

Clinical exam Nerve conduction For ulnar nerve Velocity Is measured On a long distance

Ulnar nerve

We cannot know Precisely Site of compression

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

CTS

Clinical exam Nerve conduction Sonography Static Fusiform swelling proximal to the compression (Nerve oedema ) Sometimes thinning at compression

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

CTS

Clinical exam Nerve conduction Sonography Static CSA 21sq mm

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

CTS

Clinical exam Nerve conduction Sonography Static Tunnel dimension

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

Ulnar nerve normal

Clinical exam Nerve conduction Sonography Static

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

Ulnar nerve normal

Clinical exam Nerve conduction Sonography Static

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

Ulnar nerve normal

Clinical exam Nerve conduction Sonography Static

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

Ulnar nerve normal

Clinical exam Nerve conduction Sonography Static

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

Ulnar nerve normal

Clinical exam Nerve conduction Sonography Dynamic

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

Ulnar nerve normal

Clinical exam Nerve conduction Sonography Dynamic

Somesh Beeharry Hopital Schweitzer France

Site of ULNAR compression

Ulnar nerve normal

Clinical exam Nerve conduction Sonography 3D

Somesh Beeharry Hopital Schweitzer France

Our study compare

Our Study
Compare : Sonographic aspects of nerve Operative foundings
Somesh Beeharry Hopital Schweitzer France

Our study Compare Sonographic aspect

Sonography

High frequency (5-16 MHz) Patient supine Elbow flexed 90 Transverse section (1/2 cm) +longitunidal ? Not used here Computerised 3D recontruction
Somesh Beeharry Hopital Schweitzer France

Our study Compare Sonographic aspect

Sonography
High Pe Tr +

Somesh Beeharry Hopital Schweitzer France

Our study Compare Sonographic aspect Operative findings

Operative findings
Open at the groove Endoscopic at forearm (15 cm) Patient supine Elbow flexed 90 Dimension of nerve Aspects

Somesh Beeharry Hopital Schweitzer France

Our study Compare Sonographic aspect Operative findings

Operative findings

Somesh Beeharry Hopital Schweitzer France

Case no 1 Oedema of nerve Compression at Osbornes ligament

ARM

Elbow nerve oedema

Osbornes lig

Forearm

Somesh Beeharry Hopital Schweitzer France

Forearm

Case no 1 Oedema of nerve Compression at Osbornes fascia

Osbornes fascia

Elbow nerve oedema

ARM

Somesh Beeharry Hopital Schweitzer France

Case no 1 Oedema of nerve Compression at Osbornes ligament

ARM

Somesh Beeharry Hopital Schweitzer France

Case no 2 Hourglass constriction

Somesh Beeharry Hopital Schweitzer France

Case no 2 Hourglass constriction

Somesh Beeharry Hopital Schweitzer France

Case no 3 Compression In the Groove

Somesh Beeharry Hopital Schweitzer France

Case no 3 Compression In the Groove

Somesh Beeharry Hopital Schweitzer France

Reporting 10 cases HUS found the site of compression in all cases

Strongly correlated with operative findings

Somesh Beeharry Hopital Schweitzer France

Reporting 10 cases Six cases compression was in the groove

Four cases compression was distal : Under Osbornes ligament Or under aponevrosis of FCU

Somesh Beeharry Hopital Schweitzer France

Reporting 10 cases Six cases compression was in the groove

Four cases compression was distal : Under Osbornes fascia Or under aponevrosis of FCU No evidence of compression elsewhere although bands are seen in forearm

Somesh Beeharry Hopital Schweitzer France

Reporting 10 cases

No evidence of compression elsewhere although bands are seen in forearm

Somesh Beeharry Hopital Schweitzer France

Reporting last Recent case

Young man Recurrent symptoms 5 years after open decompression NCS positive Treatment options ?

Somesh Beeharry Hopital Schweitzer France

Reporting last case HUS Evidence of Compression At End of Tunnel

Somesh Beeharry Hopital Schweitzer France

Reporting last case HUS Evidence of Compression At End of Tunnel

Somesh Beeharry Hopital Schweitzer France

Reporting last case HUS Evidence of Compression At End of Tunnel

Somesh Beeharry Hopital Schweitzer France

Conclusions

Should we rely on sonography ?


In CTS we do

Should we limit our decompresion ? open question Thank you


Somesh Beeharry Hopital Schweitzer France