1. science
2. medicine
3. surgery

TREATMENT
ELBOW
P.
OF
WITH
ULNAR
NERVE
A NIGHT
PALSY
AT
THE
SPLINT
SEROR
From
the Laboratoire
Twenty-two
patients
confirmed
splint
splint
d’Electromyographie,
with
ulnar
Paris,
nerve
by electromyography,
palsy
were
France
at the elbow,
treated
lesions.
which prevented
flexion
of the elbow beyond 60#{176}.
The
was worn all night regularly
for at least six months.
At a mean follow-up
of 1 1.3 months,
17 patients
had clinical
and electromyographic
assessment
and five were contacted
by telephone.
There
was improvement
in the symptoms
in every
patient,
including
three
who had failed
to respond
to
surgical
decompression.
There
was electromyographic
improvement
in 16 ofthe 17 patients
re-examined
up. The mean improvement
in motor
nerve
velocity
was 6.5 m/s and in sensory
nerve
velocity
9.5 m/s.
that nocturnal
nerve lesions
The
efficacy
of this
is
that
patients
with
ulnar
suffer from symptoms
sleeping
with the elbow
flexed (Seror
1992).
The results
are now reported
of the use of a night
splint
to limit
elbow
flexion
in 22 patients
with
ulnar
nerve palsy at the elbow.
PATIENTS
AND
Twenty-two
consecutive
patients,
They had presented
studied.
and
METHODS
electromyography
nerve
suggests
cause
experience
at the elbow regularly
after
were
at followconduction
conduction
treatment
is an important
elbow flexion
at the elbow.
My
neuropathy
by a night
lesions
12 men and
with clinical
(EMG)
at the elbow.
had
Their
10 women,
symptoms
demonstrated
mean
ulnar
age was 52 years
(39 to 81). The symptoms
were in the right arm in 15 and
the left in seven,
but EMG
showed
bilateral
signs in 14.
The mean
duration
of symptoms
was 8.3 months
(0.5 to
of ulnar
24).
J Bone
Joint
Received
The
Surg
[Br]
5 February
1993 ; 75-B
1992:
treatment
of
Accepted
decompression
which
suggests
Sixteen
16 June
ulnar
contentious.
Infiltration
but its efficacy
is very
surgical
techniques
The
results
are
: 322-7.
nerve
1992
palsy
idiopathic
at
the
with corticosteroid
uncertain
and at least
have
been described
much
less spectacular
of the median
that narrowing
elbow
is
is often used,
five different
(Dellon
1989).
than
those
of
nerve
in the carpal
tunnel,
of the cubital
tunnel
is not
the only element
responsible
for the lesion.
As early as 1899, Gowers
suggested
that prolonged
flexion
of the elbow could itself induce
ulnar nerve
palsy,
but subsequently
this finding
appears
to have been largely
The
forgotten.
cubital
nerve
description
by
tunnel
as the anatomical
palsy placed
ulnar nerve
category
of tunnel
the
therapeutic
Osborne
1957
of the
feature
responsible
lesions
at the elbow
for
in the
syndromes,
and
methods
usually
in
implied
employed
the
need for
for such
of
the
MD
d’Electromyographie,
148 Avenue
Parmentier,
France.
©1993
British
O3Ol-62OX/93/2484
322
Editorial
Society
$2.00
of Bone
and
Joint
Surgery
7501
1 Paris,
and
were
three
classified
of these
as
had
having
undergone
unsuccessful
surgical
decompressions.
Five
cases
had
developed
after a general
anaesthetic
and there
was one
case of tardy ulnar palsy after an old fracture.
Clinical
signs and symptoms.
The patients
had subjective
symptoms
ulnar
or objective
intrinsic
sensory
muscles
signs
of the hand
of paraesthesia
were experienced
at night
or in the morning
on
resolved
after
moving
the limb
esiae ; or permanent
paraesthesiae
night or in the morning
first two types.
EMG
signs.
In every
nerve
lesion
at the
wrist
also
wrist,
symptoms.
at the
the
case,
elbow
showed
but
corticosteroid
plexus
slight
signs
confirmed
excluded
types
of the
the
a lesion
ulnar
at the
or a polyneuropathy.
of a median
the ulnar
nerve
lesion
This was demonstrated
(Cortivazol;
of the
Three
a combination
EMG
and
of atrophy
or both.
: intermittent
tingling
waking,
which
rapidly
; permanent
paraesthwhich
were worse
at
on waking,
or in the brachial
patients
tunnel
was ineffective
of the elbow
rapidly
P. Seror,
Laboratoire
patients
symptoms,
Roussel,
was
when
Paris)
in both cases and
relieved
the symptoms.
Two
nerve
lesion
the cause
injection
of
of
into the carpal
immobilisation
In all cases the ulnar
nerve
lesion
at the elbow
was
confirmed
by an alteration
in the motor
and sensory
nerve
conduction
velocities.
The
nerve
conduction
velocity
(NCV)
at the
elbow
was
always
recorded
separately
from
that
THE
in the
JOURNAL
forearm,
OF BONE
by means
AND
JOINT
of a focal
SURGERY
TREATMENT
study
below
OF
ULNAR
NERVE
PALSY
of the elbow
region
over a distance
of 10 cm (6 cm
and 4 cm above
the medial
epicondyle
with the
flexed
elbow
to 35#{176}).
The
NCV
was
considered
to
be
pathological
when it was less than 45 m/sec
and 20% less
than the motor
nerve conduction
velocity
in the forearm
or the sensory
nerve conduction
velocity
at the wrist.
AT
THE
ELBOW
evaluation
muscle
WITH
of pain
muscle
static
score
(Table
in little and
or on waking
Semmes-Weinstein
Treatment.
limited
but
allowed
unrestricted
was advised
for six months
as possible.
intermittently
were advised
to between
by a splint
to between
pronation
15#{176}
and 60#{176}
flexion.
(Fig.
15#{176}
and
The
and
supination.
The
of the joint while working.
each
patient
was
clinically
patients
were
questioned
at each
visit
the
evaluation
ring fingers,
criteria
were : paraesthesia
of the little
and
whether
nocturnal,
intermittent
or perma-
nent
VOL.
; Tinel’s
sign
of use of the splint.
on palpation
75-B, No. 2, MARCH
1993
45%
4%
31%
6.4
5.8
I)
2.0
1.3
3.1
0.2
0 to 10)
wasting
(present)
4
3
Tinel’s
sign (present)
8
6
Overall
improvement
0%
87%
static
two-point
The
EMG
;
score
discrimination
test
evaluation
criteria
the orthodromic
ofthe sensory
were
: the motor
sensory
NCV
action
potential
NCV
at the elbow;
(SAP) above
detection
muscle
the amplitude
of the SAP at the wrist;
the
of motor
denervation
in the first interosseous
or adductor
digiti
minimi
; and the distal
motor
latency
(DML)
elbow;
at the epitrochlear
Seventeen
months
patients
concerning
regularity
100%
73%
77%
Muscle
months.
Clinical
1 5 days
after
application
of the splint.
The
and EMG
examinations
were repeated
at two
and then at six months
or later.
Evaluation.
At final
review
87%
1) which
to wear the splint all night and every
and thereafter
to use it as regularly
flexion
possible,
Before
treatment
fingers
=
before
and
tests,
pain,
55%
60#{176}
flexion
In most
cases,
its use
was
continued
after
six months.
In addition,
patients
not to rest the elbow on a hard surface
and
to avoid
prolonged
Whenever
reviewed
clinical
months
was
movements
nerve
palsy
for sensory
and
sensory
NCV
at the wrist
(Table
II).
RESULTS
1
movements
Treatment
elbow
patient
night
elbow
scale
the
overall
patient
(normal)
the
limits
using
and
strength
the amplitude
splint
ring
of ulnar
are given
test (normal
analogue
at the elbow
night
test
Muscle
*
The
scale;
testing
I).
<6)
Pain(visual
analogue
sensory
discrimination
and symptoms
Mean
values
and wasting
STPD(normal
Fig.
to a visual
test (Omer
1979);
and the
evaluated
at each visit by the
by the physician
Table
I. Signs
after
treatment.
muscle
strength
323
strength;
two-part
Semmes-Weinstein
improvement
Paraesthesiae
Nocturnal
Permanent
SPLINT
according
wasting;
Weber’s
and
A NIGHT
The
clinical
groove;
at
patients
were
followed
up for a mean
(4 to 30) after adoption
of the night
splint.
were
reviewed,
The
by
data. The clinical
review
are given
last
there
contacted
in eight
at a mean
of
12
findings
before
treatment
and
in Table
I. Of the patients
symptoms
was 80% to 90%
five patients
who
themselves
telephone
1 1.3
Five
had
disappeared,
relief and in four 50%
had not been reviewed
in five
to 70% relief.
all declared
to be cured.
Nocturnal
paraesthesiae
(present
in 16 patients)
always
improved
first. Permanent
paraesthesiae
(present
in 17 patients)
improved
more gradually
with time.
Pain
was rarely intense
and was felt in the forearm
and hand
as well as in the region
of the medial
epicondyle.
The
initial mean score for pain was
to 0.2 by the end of treatment.
Overall,
in more than
first.
When
the
half
muscle
of the
it had
been
strength
patients,
initially
3. 1 which
had
decreased
was unchanged,
since
it had been normal
at
markedly
decreased,
P. SEROR
324
Table
II. Electromyographic
(17 cases)
data
(mean
± SD) before
Sensory
velocity(m/s)
conduction
Sensory
action
Elbow
Wrist
Distal
motor
Sensory
velocity(m/s)
potential
latency
conduction
Needle
after
treatment
p value
32.2±10.7
+6.5±5.2
<lOs
36.2±6.5
+9.5±6.7
<
0.98±1.25
8.8±6.0
+1.0±1.21
+4.6±8.3
<lO
<0.02
3.4 (2.5 to 7.9)
-0.35
53.6±9.7
+ 3.2 ± 2.2
4
3
5
5
+2
+ 4
+ 3
-4
treatment
1O’
(jtV)
at wrist
(m/s)
velocity
at wrist
(m/s)
Denervation*
Interference
pattern
Reduced
interference
pattern
Very reduced
interference
pattern
Single potential
* the number
after treatment
and
at review
Before
Motorconduction
(22 cases)
of patients
showing
each
pane
rn before
treatment
,
± 0.42
-
I
-4
and the changes
of pattern
electrode
n = 200
23
1
P
_____j
0.2tV
A
2 msec
_____j
1
n=21
2 msec
B
0.5 tV
___j
___j
2 msec
0.5
2 msec
n
=
200
.__.___j
O.51V
A
2 msec
n=73
___j
B
______1
2
2 msec
O.5tV
2msec
Fig.
The
after
upper
traces
starting
are before
treatment.
conduction
velocity
at the
increase
in amplitude
(0.3
the sensory
action potential.
was possible, because
than at initial testing
treatment
There
elbow
tV to
2
and
is an
the lower
improvement
traces
two
of the
months
Fig.
3
sensory
from 23 to 38 rn/s. There
is also
1 tV) and a resynchronisation
>
At follow-up,
surface electrode
recording
ofthe higher amplitude
ofsensory
action potential
by needle recording.
an
of
Same
case as in Figure
the lower traces
are two
2. The
months
upper
after
traces
are before
treatment.
There
treatment
is improvement
(22 to > 42 m/s)
of the motor conduction
velocity
at the elbow
almost complete
resolution
of the motor conduction
block
20%). A = wrist; B = below elbow;
C = above
elbow.
THE JOURNAL
OF BONE
AND
JOINT
(from
and
and
95% to
SURGERY
TREATMENT
however,
there
muscle
strength
restored
to
resolution
was
an
resynchronisation
at first
after
of a very
severe
wasting,
reduced
AT
THE
Motor
was
due
conduction
was
PALSY
patient,
probably
(Figs
which
one
much
days,
motor
NERVE
In
was
15
of the SAP
Muscle
ULNAR
improvement.
which
normal
OF
block
to
ELBOW
WITH
conduction
Initial
60
A NIGHT
(mis)
velocity
Final
SPLINT
325
Sensory
conduction
Initial
velocity
(mis)
Final
with
2, 3).
initially
present
in only
four
patients,
persisted
in three
at follow-up.
The
frequencyofTinel’s
sign wasnot
significantly
diminished,
decreasing
from 36% to 27% of cases
at the end of the
study.
Weber’s
test
was
abnormal
in
only
initially
and did not significantly
alter.
Weinstein
test appeared
to be slightly
with improvement
in 10 of the 15 patients
a mean
decrease
from 2 to 1.3.
EMG
data.
Initial
EMG
data
patients,
data
but
only
17 were
before
and
The mean
32.2
rn/s
test
=
and
after
for
all 22
treatment.
The
are given in Table
II.
at the elbow
was initially
by a mean
108;Fig.4a).
sensory
NCV
<
patients
available
examined
after treatment
motor
NCV
improved
S.9,p
The mean
were
six
The
Semmesmore
sensitive
examined
with
of6.5
at the
m/s
elbow
(Student’s
was
t-
Fig.
36.2
m/s, but it could not be recorded
in the most severe
in which
the sensory
potential
was less than 0.2 .tV.
It was improved
by a mean of9.5
m/s (Student’s
t-test
=
lO9;Fig.4b).
SAP
at
<
The
amplitude
doubled
(Student’s
beyond
the
is the MCV.
the
elbow
always
had
indicator
the
of the
compression
axonal
; it
a low
reserve
was
of the
initially
nerve
decreased
to
Sindou
recently
on the
Tests
criteria
conduction
at the
wrist
showed
only
2000
slight
variations.
treatment.
treatment
Ofthe
during
22 patients,
the first
four stopped
treatment
completely
and six developed
a partial
recurrence
responded
to the
reintroduction
nerve
14 regularly
six months.
Thereafter
recurrence
of treatment.
without
which
The
less well
Although
understood
the ulnar
one
The
(1968),
of ulnar
than
nerve
nerve
palsy
at the
75-B, No. 2, MARCH
1993
shown
In these
by a broken
line,
elbow
is
that of carpal
tunnel
syndrome.
certainly
lies in an inextensible
to compression
can
the
during
that
elbow
the
ulnar
flexion,
be caused
by this,
particularly
lowered
level
of consciousness
and
during
allows
prolonged
maintenance
of harmful
positions.
During
the
day, nociceptive
reflexes
cause the harmful
position
to be
altered
before
the development
of a nerve lesion.
fact
positions
anatomical
osseofibrous
tunnel,
it does not share
the tunnel
with
tendons,
and tenosynovitis
cannot
therefore
reduce
the
space
occupied
by the nerve.
Moreover,
opening
up the
osteofibrous
tunnel
does not always
provide
the expected
therapeutic
result
(Thomsen
1977 ; Chaise
et al 1983;
Dellon
1989). Some authors
have tried to modify
the bed
VOL.
is subject
lesions
sleep
when
DISCUSSION
pathophysiology
velocity,
for choosing
between
them.
study is based
on the hypothesis
that
patient
with
tardy
ulnar
palsy
developed
a complete
recurrence,
and later agreed
to undergo
surgery.
The
in two of these at final follow-up.
conduction
et al 1982;
Mansat
et al 1984).
Dellon
(1989)
analysed
the results
of five surgical
techniques
basis of 50 papers
describing
a total of more than
patients
and concluded
that there
were no sound
This
Compliancewith
complied
with
initial
of the ulnar
nerve
by enlarging
the epitrochlear
groove
(de la Caffini#{233}re and Bex 1983 ; Dellon
1989 ; Heithoff
et
al 1990) or by changing
the course
ofthe
nerve by anterior
transposition
(Lugnegard,
Walheim
and Wennberg
1977;
8.8 .tV (normal
: 22 .tV) and was subsequently
increased
by an average
of4.6 j.tV (Student’s
t-test
=
2.6, p < 0.02).
Motor
denervation,
initially
normal
in four patients,
remained
unchanged
in eight and was improved
in nine.
of nerve
4b
initial
It was
virtually
gain
of 1 .00 .tV
SAP at the wrist
=
is a good
text) but was recorded
patients
with
a mean
of 0.98 j.tV.
after
treatment
with
a mean
t-test
3.8, p < l0).
The
Fig.
Figure
4a - Improvement
in motor
conduction
velocity
of the
ulnar
nerve
at the elbow
in 1 7 patients
after
treatment
by the
splint.
Figure
4b - Improvement
in orthodromic
sensory
conduction
velocity
(SCV)
in I 7 cases
after
treatment
by the
splint.
The initial
SCV was not obtained
in four patients
(see
initially
cases
6.8,p
4a
that
the cubital
than
in
studies
and
tunnel
others
has
of Osborne
Apfelberg
and
Larson
is narrower
been
(1957),
in some
known
since
Vanderpool
the
et al
(1973).
Macnicol
(1980) studied
the pressures
exerted
on the
nerve
in various
degrees
of flexion
of the elbow,
and
reported
values
of about
5 mmHg
in extension
with no
major
increase
up to 90#{176}
flexion.
Above
this, however,
the pressure
increased
up to 50 mmHg
in apparently
normal
cadavers
and up to 100 mmHg
in the presence
of
the abnormality
50% after opening
compatible
with
described
by Osborne.
the osteofibrous
canal.
those
reported
for
It decreased
These
data
carpal
tunnel
by
are
syn-
P. SEROR
326
drome
(Kuhlmann,
man
et al
experimental
conduction
Tubiana
and
Lisfranc
1978;
1981 ; Chaise
and Witvo#{235}t 1984)
data
on the effect
of pressure
(Hargens
et al 1979).
Gelber-
recordings
indicated
block
(Fig.
improvement
and with
on nerve
disappearance
of
3) and
regrowth
was also reflected
resynchronisation
of the
SAP
the
conduction
of some
in some
(Fig.
axons.
cases
This
the
by
2).
The major
role of elbow
flexion
in the pathogenesis
of ulnar
nerve
lesions
was first proposed
by Gowers
in
1899. In a personal
study of 312 patients
with ulnar nerve
analysis
of compliance
was particularly
interesting
for the
five patients
in whom
recovery
was
incomplete.
The splint
was used
irregularly
in four of
lesions
thirds
worst
them
and one patient
four months
and opted
at the
of the
symptoms
elbow
(Seror
1992),
symptomatic
patients
at night
or in the
and most of them
flexed.
Postanaesthetic
reported
ulnar
I showed
that
twoexperienced
their
morning
on waking,
sleeping
paralysis
same
cause,
and ulnar
palsies
develop
in hemiplegic
patients
with
may
their
elbows
well have the
have
been
reported
to
with hyperfiexed
elbows
(Della
Santa
and Reust
1990).
There
has been
one previous
treatment
by splintage
of the elbow
(Dimond
and
in 23 patients
improvement.
ment
Lister
1985). In that series the overall
result
after
a mean
of 8.7 months
was 86%
This was compared
with the 58% improve-
obtained
team over
are similar
improved
severe
report
of a trial of
in 45#{176}
to 70#{176}
flexion
by surgical
decompression
by the
same
and
after
the
failure
ofsurgical
patients
case
of tardy
long
time,
ulnar
and
had
palsy,
had
very
the
recently
become
useless.
incomplete,
improvement
was
70% in the other.
In the
obtained
after 1 5 days.
Three
of my
patients
assessed
fourth
case,
to be 50%
in one
a clinical
cure
from
60%
to 95%,
an improvement
EMG
monitoring
It showed
the
was
efficacy
treatment
patient
is suggested
which
of three
showed,
times
that
at two
seen
at six
months.
Another
case showed
the value
of early treatment.
When
splintage
was started
less than three
weeks
after the onset of symptoms
the quality
and the rapidity
of the recovery
were
remarkable,
the initial
severity
of the EMG
signs
especially
in view
(Figs 2, 3).
of
Conclusion.
Prolonged
flexion
of the elbow
by more than
900 during
sleep is an important
cause
of lesions
of the
ulnar
nerve.
The symptoms
and the EMG
signs can be
continuously
author
chose
not
for six months.
to respond
to the
request
for a conflict
of interest
BIBLIOGRAPHY
Adelaar
RS, Foster
tunnel
syndrome.
deep
C.
[Am]
The treatment
1984; 9:90-5.
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