肘部尺神经卡压与尺神经半脱位的诊疗进展

肘部尺神经卡压也称为肘管综合征,可造成手部一系列功能障碍,是最常见的上肢神经卡压症之一。尺神经脱位及半脱位为尺神经卡压的影响因素。尺神经卡压按McGowan分级分为Ⅰ、Ⅱ、Ⅲ级。Ⅰ级首选保守治疗 Ⅱ、Ⅲ级保守治疗效果欠佳,多需要手术治疗。手术方式主要有尺神经原位松解术（包括肱骨内髁切除术）、粘膜下尺神经前置术、肌下尺神经前置术及肌内尺神经前置术等,其中原位松解手术操作相对简单,但对于尺神经卡压伴有尺神经脱位者多属禁忌,应首选尺神经前置术。     

尺神经沟扩大成形尺神经松解术治疗肘管综合征

目的探讨肘管综合征的病因、尺神经沟扩大成形松解术的疗效及对肘关节功能的影响。方法对60例肘管综合征的病因、尺神经沟扩大成形手术所见和随访结果进行分析。结果创伤性肘关节炎、尺神经沟变浅、肘外翻畸形、尺神经滑脱、肘管内占位等是肘管综合征的主要致病因素,尺神经沟扩大成形治疗肘管综合征疗效好,肘关节功能正常。结论创伤性肘关节炎、尺神经沟变浅、肘外翻畸形、尺神经滑脱是尺神经沟扩大成形松解术治疗肘管综合综合征的适应征。尺神经沟扩大成形治疗肘管综合征方法可靠,对肘关节功能无影响。     

尺神经沟填埋神经外膜松解治疗肘管综合征

目的 探讨采用尺神经沟填埋、神经外膜松解及尺神经皮下前移、神经外膜松解术治疗肘管综合征的疗效.方法 对肘管综合征采用尺神经沟填埋术治疗20例(治疗组),采用尺神经皮下前移术治疗20例(对照组).结果 两组均获随访,时间10～41个月,平均18.6个月.疗效评定按照上肢功能评定标准:治疗组优良率95％,对照组优良率90％,差异无统计学意义(P＞0.05).结论 尺神经沟填埋术与皮下前移术是治疗肘管综合征的有效方法.     

尺神经沟扩大神经束间松解治疗重度肘管综合征临床研究

目的 总结尺神经沟扩大显微镜下神经束间松解术及尺神经前移显微镜下神经束间松解术治疗重度肘管综合征的疗效. 方法 2002年12月-2007年1月,采用尺神经沟扩大显微镜下神经束间松解治疗22例重度肘管综合征患者(治疗组),与2001年7月-2004年11月,采用尺神经前移显微镜下神经束间松解治疗的22例患者(对照组)进行比较.治疗组:男17例,女5例;年龄21～66岁,平均43.8岁.肘关节骨性关节炎17例,尺神经滑脱3例,肘外翻畸形2例.左侧8例,右侧14例.病程6～69个月.对照组:男18例,女4例;年龄20～64岁,平均42.1岁.肘关节骨性关节炎16例,尺神经滑脱4例,肘外翻畸形及肱骨内髁骨折移位畸形愈合致尺神经沟变窄变浅各1例.左侧7例,右侧15例.病程5～67个月. 结果 两组患者术后切口均I期愈合.治疗组术后1 d,患者小指麻木均明显减轻、消失;对照组术后3～5 d,患者小指麻木明显减轻、消失.两组患者均获随访,随访时间12～45个月,平均20.1个月.肌电图检查示尺神经传导速度均正常.按照中华医学会外科学会上肢部分功能评定试用标准和Lascar分级法评价疗效,治疗组优21例,良1例,优良率100%:对照组优19例,良2例,可1例,优良率95.45%.治疗组和对照组术前评分分别为(2.89±0.15)分和(2.91±0.13)分,差异无统计学意义(P＞0.05);术后分别为(11.32±1.04)分和(9.91±1.48)分,差异有统计学意义(P＜0.01). 结论 尺神经沟扩大神经束间松解和尺神经前移、神经束间松解均是治疗重度肘管综合征的有效方法,前者优于后者.     

肘部尺神经的临床解剖学研究

目的：研究产生肘部尺神经卡压的解剖学基础。方法：观测５０侧成人尸体肘部尺神经的位置及被动屈肘时尺神经的伸长长度。临床调查并检测２００位正常人肘部尺神经的位置。结果：自肘部伸直位（０度）至完全屈肘位（１３５度），尺神经可拉长 ６．６％±０．３％（ｘ±ｓｘ自身对照，下同）；屈曲度大于 ９０度后，伸展性明显减少，为０．８％±０．１％。２００位正常人肘部尺神经半脱位发生率为９．５％（１９／２００）。结论：肘关节反复屈伸时尺神经不断被牵拉和压迫是造成肘部尺神经卡压的解剖学基础。     

肘管综合征原位松解手术中关于尺神经卡压部位的探讨

目的探讨肘管综合征原位松解手术中尺神经的卡压部位并评估治疗效果。方法 2017年1月-2019年1月,采用尺神经原位松解术治疗肘管综合征22例,术前全部经神经肌电图证实,所有病例行尺神经原位松解术,根据术中探查情况,分析尺神经卡压部位。结果术中发现造成肘部尺神经卡压部位中Osborne韧带卡压10例,肘关节腱鞘囊肿卡压7例,被尺侧腕屈肌两头之间腱性组织卡压5例。尺神经功能(主要是感觉)在术后均有显著改善。结论肘管综合征行尺神经原位松解手术中,造成尺神经卡压的部位主要有Osborne韧带、腱鞘囊肿和尺侧腕屈肌两头之间腱性组织。找到尺神经卡压点并予以处理对尺神经原位松解手术的效果至关重要。     

肘部骨赘致尺神经卡压征1例

孙××，男，53岁，木匠。1995年2月14日入院，诉3个月前右手环、小指酸麻不适，抓持无力，精细动作不能。1个月后继发手掌尺侧胀痛，屈肘时为甚。检查：右手环、小指爪样畸形，无明显肌肉萎缩，尺侧1个半指感觉迟钝，环、小指指深屈肌和尺侧腕屈肌肌力均为Ill级s夹指征（＋），肘部尺神经Tinel氏征（十）。其它未见异常。X线检查：右肘关节诸骨骨质增生。诊断：右肘部尺神经卡压征。手术治疗：右肘部尺神经探查。术中见肘部尺神经浅面有一2．ocmXI．ocmXI．ocm囊肿压迫之，其基底附着于神经外膜。手术显微镜下切除该囊肿，其内容物为淡…     

肱骨髁间骨折术中尺神经前置是否有益

目的:探讨肱骨髁间骨折行切开复位内固定术中尺神经前置与不前置处理对肘关节活动度、功能及术后尺神经功能障碍的影响。方法:自2013年1月至2017年5月,采用切开复位内固定术治疗并获得完整随访的168例肱骨髁间骨折患者,根据术中对尺神经的处理方式将患者分为尺神经前置组和尺神经不前置组。尺神经前置组48例,男23例,女25例;年龄14～77(42.5±15.7)岁;在肱骨髁间骨折复位结束后,对尺神经进行充分游离并行皮下前置术。尺神经不前置组120例,男62例,女58例;年龄14～81(43.4±17.3)岁;在肱骨髁间复位结束后,将尺神经返回尺神经沟。末次随访时记录两组患者肘关节屈伸活动范围及前臂旋转活动范围,采用Mayo肘关节功能评分(Mayo elbow performance score,MEPS)对患者的临床疗效进行评价,采用改良Mc Gowan分级评分对尺神经功能障碍进行评估。结果:尺神经前置组1例鹰嘴截骨处延迟愈合,2例肘关节僵硬;尺神经不前置组1例伤口感染,1例骨折不愈合,4例肘关节僵硬。两组并发症发生情况比较差异无统计学意义(P0.05)。尺神经前置组48例获得随访,时间12～59(32.2±14.2)个月,肘关节屈伸活动范围(116±28)°,前臂旋转活动范围(152±12)°,MEPS评分88.6±11.6,优28例,良16例,中3例,差1例;术后17例曾出现过尺神经损伤症状,末次随访时仍有7例存在尺神经功能障碍,Mc Gowan 1级6例,2级1例。尺神经不前置组120例获得随访,时间13～61(32.0±14.9)个月,肘关节屈伸活动度(119±27)°,前臂旋转活动度(154±16)°,MEPS评分88.9±12.5,优67例,良44例,中7例,差2例;术后42例曾出现过尺神经损伤症状,末次随访时仍有22例存在尺神经功能障碍,Mc Gowan 1级18例,2级4例。两组患者随访时间、肘关节屈伸活动范围、前臂旋转活动范围、MEPS评分及尺神经功能障碍发生情况比较差异均无统计学意义(P0.05)。结论:肱骨髁间骨折切开复位内固定术中对尺神经前置或不前置,对术后临床疗效及尺神经功能障碍发生情况无明确影响。     

肘关节僵硬治疗中尺神经的处理与预后

[目的]比较研究尺神经在重度肘关节僵硬治疗中行尺神经松解前置术与否的预后.[方法]2002年7月～2007年10月共收治44例O'[KG-48x]DriscollⅡ型重度肘关节礓硬患者,术前均无尺神经功能障碍.其中22例患者接受彻底的肘关节僵硬切开松解术,14例采用后正中入路,8例采用内外侧联合入路,手术同时行尺神经松解术并予深筋膜下前置.另外22例患者采用同样手术方式松解,16例采用后正中入路,6例内外侧联合入路,但术中尺神经不予处理.根据Amadio肘部尺神经损害的疗效评价标准,对比研究术后尺神经的预后.[结果]尺神经松解前置组22例患者随访13～52个月(平均28.7个月),按照Amadio肘部尺神经损害的疗效评分为平均8.7±0.6;对照组22例患者随访12～52个月(平均30.9个月),Amadio肘部尺神经损害的疗效评分为平均8.0±0.8.两组尺神经的功能评分差异具有统计学意义(P<0.05).[结论]重度肘关节僵硬的治疗过程中常规行尺神经松解前置,可预防尺神经在肘关节松解术后发生功能障碍,改善尺神经预后.     

两种尺神经皮下前置术治疗肘管综合征的疗效比较

目的探讨尺神经带血管蒂深筋膜瓣下前置术在肘管综合征手术治疗中的临床疗效。方法把年龄19～78岁的49例肘管综合征患者随即分为：单纯尺神经皮下前置术组（对照组）18例和尺神经带血管蒂深筋膜瓣下前置术组（治疗组）31例。术后就这两种手术的疗效进行评价。结果两组第一背侧骨间肌萎缩恢复优良数比较,差异无统计学意义（P〉0.05）,但环、小指爪形指畸形,手指内收外展受限及感觉功能障碍恢复情况上比较,差异有统计学意义（P〈0.05）,治疗组术后疗效均显著优于对照组。两组手术治疗后优、良、可、差、有效及无效比较,差异有统计学意义（P〈0.05）,治疗组疗效明显优于对照组。结论治疗肘管综合征,尺神经带血管蒂深筋膜瓣下前置术的临床疗效明显优于单纯尺神经皮下前置术,临床手术中值得推广。     

肌电图辅助定位小切口尺神经松解术治疗肘管综合征

目的 评价肌电图辅助定位小切口尺神经松解术治疗肘管综合征的疗效及手术适应证.方法 选取无明显手内在肌萎缩及肘关节畸形,具有典型临床症状和体征的肘管综合征患者12例,术前通过神经短节段传导(short-segment nerve conduction test,SSCT)检测的方法,以相邻两次动作电位波幅下降＞50%或潜伏期差＞0.5ms为定位标准,对上述患者进行卡压点定位,采用小切口局部尺神经松解术式,并观察卡压点术中与术前定位比较.结果 术中观测结果证明尺神经损害部位位于肱骨内上髁上方3 cm到肱骨内上髁下方1cm之间,与术前SSCT法检测卡压部位相符.12例术后均主诉手部有明显轻松感;术后3个月感觉异常全部恢复,刺痛觉及爪形指恢复,捏力和抓握力恢复;术后6个月时小指展肌肌力已完全恢复至正常,两点分辨觉平均为5.0 mm,神经传导速度(NCV)均＞45.0 m/s,波幅开始增加,SSCT无阳性发现;术后1年肌肉萎缩基本恢复,屈肘试验、肘部Tinel征、夹纸试验阴性,7例肌电图无阳性发现,1例NCV仍低于正常标准,但无临床症状及体征.术中观察神经卡压位置与术前肌电图定位相符.结论 肌电图辅助定位小切口尺神经松解术治疗肘管综合征是一种有效的方法.

Abstract：

Objective To evaluate the therapeutic effect of in situ ulnar nerve decompression at the cubital tunnel via a small incision assisted with electromyography localization and discuss the surgical indications.Methods Twelve patients who were diagnosed with idiopathic cubital tunnel syndrome (CuTS) without intrinsic muscle atrophy and elbow deformity were involved in the study.Before the operation, short-segment nerve conduction test (SSCT) was carried out.The exact compression site was determined by the ＞ 50%reduction in amplitude or ＞ 0.5 ms lengthening in latency of action potentials recorded upon stimulation of the ulnar nerve around the elbow at 1 cm intervals.An in situ ulnar nerve release at the compression site was performed.Compression of the ulnar nerve was observed and documented to verify the accuracy of pre-operative SSCT localization.Results Intraoperative findings confirmed that lesions were located from 3 cm above to 1 cm below the medial epicondyle, which coincided with the compression sites determined by SSCT.All the patients reported alleviation of hand discomfort postoperatively.Follow-up at 3 months postoperatively showed that paresthesia in the distribution of the ulnar nerve in the hand disappeared.Pinprick sensation recovered.There was no subjective or measurable weakness in pinch or grip strength and no clumsiness or loss of coordination.Claw deformity disappeared.Six months after the surgery, the strength of abductor digiti minimi returned to normal.Two-point discrimination of the little finger was 5.0 mm on average.Nerve conduction velocity returned to ＞ 45.0 m/s.Action potential amplitude increased and SSCT yielded no positive findings.Mild atrophy was reversed one year postoperatively.Elbow flexion test, Tinel' s sign and Froment' s test were all negative.Conclusion In situ ulnar nerve decompression via a small incision assisted with electromyography localization is a suitable procedure for certain CuTS cases.     

肘部尺神经卡压的定位诊断和电生理学研究

目的：对肘部尺神经卡压进行精确定位和电生理学研究。方法：对４６例临床诊断为肘部尺神经卡压患者，除进行常规ＥＭＧ、ＮＣＶ、和尺神经混合神经动作电位（ＭＮＡＰ）测定以外，还进行尺神经短段传导时间（ｓｈｏｒｔｓｅｇｍｅｎｔｃｏｎｄｕｃｔｉｏｎｔｉｍｅ，ＳＳＣＴ）测定。结果：４６例经ＳＳＣＴ测定，发现了卡压最常发生的４个部位，即肱骨内上髁后神经沟、肱尺弓、尺侧腕屈肌的出口和内侧肌间隔。结论：和传统的电生理测定方法相比较，ＳＳＣＴ技术可以更精确地对尺神经卡压进行定位诊断     

Cubitus valgus and tardy ulnar nerve palsy due to an intracapsular ulnar nerve

Background

We describe a patient with tardy ulnar neuropathy and cubitus valgus deformity found to have an intracapsular ulnar nerve.

Methods

An 89-year-old woman presented with severe neuropathic pain in the ulnar digits of the hand, advanced degenerative arthritis of the elbow, and tardy ulnar nerve palsy. Her pain was exacerbated with elbow movement, particularly flexion. She had paralysis of ulnar nerve innervated muscles, hypersensitivity with absence of two-point discrimination in her ulnar 1–1/2 digits, and a fixed ulnar claw deformity. She also had a grossly unstable elbow.

Results

Plain films revealed a cubitus valgus deformity (38°), an absent radial head, a dislocated proximal radioulnar joint and advanced arthritic changes. Ultrasonography revealed an indistinct ulnar nerve within the cubital tunnel which penetrated the joint. Electrophysiological studies revealed evidence of a severe ulnar neuropathy at the level of the elbow. Intraoperatively, an attenuated 2 cm length of the retrocondylar ulnar nerve was observed to be incorporated into the joint capsule tethered by a fibrous/synovial band which was released. A large effusion was drained. The ulnar nerve was transposed subcutaneously. The capsular rent was repaired in layers. She noted immediate and sustained (2 year follow-up) pain relief and regained moderate function in her interossei.

Conclusions

We believe that the chronic cubitus valgus deformity and secondary degenerative elbow joint changes led to an altered course of the nerve and attenuation of the medial joint capsule such that the ulnar nerve spontaneously buttonholed itself intra-articularly.     

Long-term follow-up of the ulnar nerve repair: report of 42 cases

A long term follow-up for 42 cases of ulnar nerve repair was reported in this article, and the reason of bad function were analysed. They are: 1. As long as the injured ulnar nerve was sutured perfectly and without delay, the result would be satisfying. 2. The follow-up examination of the repaired nerve showed all the paralysed intrinsic muscles would recover in certain extent. Abductor digiti quinti, adductor pollicis and flexor digiti quinti brevis usually restored easily. Among the intrinsic muscles the best result of the first dorsal interosseous and the first palmar interosseous muscles were obtained. The functional recovery of the second and third palmar interosseous muscles usually was poor. 3. After repairing of the injured ulnar nerve, recovery of the claw hand deformity usually takes long time, so the operative correction of the deformity should not be performed until 2.5 years.     

The effect of operative technique on ulnar nerve strain following surgery for cubital tunnel syndrome

Background

The aim of this study is to compare the amount of strain on the ulnar nerve based on elbow position after in situ release, subcutaneous transposition, submuscular transposition, and medial epicondylectomy.

Methods

Six matched cadaver upper extremity pairs underwent ulnar nerve decompression, transposition in a sequential fashion, while five elbows underwent medial epicondylectomy. A differential variable reluctance transducer (DVRT) was placed in the ulnar nerve. An in situ release, a subcutaneous transposition, and a submuscular transposition were performed sequentially with the strain being measured after each procedure in neutral, full elbow flexion, and extension positions. The strain was then averaged and compared for each procedure. Five cadavers underwent medial epicondylectomy and were similarly tested.

Results

After the in situ release, there was no statistically significant change in strain in either flexion or extension. After a subcutaneous transposition, there was a statistically significant decrease in strain in full elbow flexion but not in extension. Similarly after a submuscular transposition, there was a statistically significant decrease in strain in full flexion but not in extension. There was not a statistically significant change in strain with medial epicondylectomy.

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 ulnar neuropathy at the elbow (UNE). Transposition of the ulnar nerve anterior to the medial epicondyle addresses the problem of strain on the ulnar nerve. In addition, it does not create an increased strain on the ulnar nerve with elbow extension.     

Case report: Double nerve transfer of the anterior and posterior interosseous nerves to treat a high ulnar nerve defect at the elbow

Double neurotization of the deep branch of ulnar nerve (DBUN) and superficial branch of ulnar nerve using the anterior interosseous nerve (AIN) and the recurrent (thenar) branch of the median nerve was first described by Battiston and Lanzetta. This article details the postoperative results after 18 months of a patient who underwent this technique using the posterior interosseous nerve (PIN) instead of the recurrent branch of the median nerve for sensory reconstruction. A 35-year-old, right-handed man suffered major trauma to his right upper limb following a serious motor vehicle accident. One year later, a pseudocystic neuroma of the ulnar nerve was evident on ultrasound examination and MRI. After the neuroma had been resected, the nerve defect was estimated at 8 cm. One and a half years after the initial trauma, with the patient still at M0/S0, we transferred the AIN and PIN onto the deep and superficial branches of the ulnar nerve respectively. Nerve recovery was monitored clinically every month and by electromyography (EMG) every three months initially and then every six months. At 18 months postoperative, 5th digit abduction/adduction was 28 mm. Sensation was present at the base of the 5th digit. The patient was graded M3/S2. Clear re-innervation of the abductor digiti minimi was demonstrated by EMG (motor conduction velocity 50 m/s). Given that the ulnar nerve could not be excited at the elbow, this re-innervation had to be the result of the double nerve transfer. Neurotization of the DBUN using the AIN produces functional results as early as 1 year after surgery. Using PIN for sensory neurotization is easy to perform, has no negative consequences for the donor site, and leads to good recovery of sensation (graded as S2) after 18 months.     

超声在闭合复位内外侧交叉穿针固定治疗儿童肱骨髁上骨折中保护尺神经的可行性研究

目的:探讨超声在闭合复位内外侧交叉穿针固定治疗儿童肱骨髁上骨折中保护尺神经的可行性。方法:自2018年1月至2019年12月收治63例肱骨髁上骨折患儿,根据引导方式不同分为超声引导组和X线引导组。超声引导组32例,采用超声引导下闭合复位经皮内外交叉克氏针固定,男20例,女12例,年龄3~11(6.06±2.02)岁。X线引导组31例,采用X线引导下闭合复位经皮内外交叉克氏针固定,男17例,女14例,年龄2~10(5.61±1.96)岁。记录两组患者的手术时间,接受电透次数,骨折愈合时间,尺神经损伤情况,术后12个月采用Flynn疗效评分评价功能恢复情况。结果:所有患儿获得随访,超声引导组随访时间9~12(11.53±0.76)个月,X线引导组随访时间10~13(11.51±0.72)个月,两组患儿手术时间、随访时间、骨折愈合时间比较,差异无统计学意义(P>0.05)。X线引导组接受电透次数(21.65±5.58)次明显多于超声引导组(3.06±1.24)次(P<0.01)。超声引导组术后未发生医源性尺神经损伤,X线引导组术后2例出现尺神经损伤,两组比较差异无统计学意义(P>0.05)。术后12个月超声引导组Flynn临床功能评定结果优27例,良4例,可1例;X线引导组优23例,良6例,可1例,差1例,两组比较差异无统计学意义(P>0.05)。结论:超声引导与X线引导治疗儿童肱骨髁上骨折在手术时间、骨折愈合方面疗效相当,但超声引导可以在术中清晰地探测到尺神经所在的位置,最大程度避免因尺侧穿针时而导致的医源性尺神经损伤,是一种安全有效的治疗手段。     

正中神经、尺神经部分束支移位术重建屈肘功能

目的 观察正中神经、尺神经部分束支移位术的临床疗效及手术前后供体神经功能的变化,分析影响手术疗效的因素。方法 应用正中神经、尺神经部分束支移接给肱二头肌肌支治疗臂丛神经上千型根性撕脱伤,重建屈肘功能。对施行手术的36例患者进行6个月至5年多的随访,根据肱二头肌肌力和肘关节主动活动范围,将患者术后恢复情况分为三级：优：肱二头肌肌力达4级以上,肘关节屈曲达90度以上;可：肱二头肌肌力达3级,肘关节屈曲达60～90度;差：肱二头肌肌力2级以下,肘关节屈曲60度以下。分析影响疗效的几种因素。结果 手术疗效显著,有效率(肱二头肌肌力3级以上)达94．4％,优良率(肱二头肌肌力4级以上)达63．9％。手术前后供体神经功能没有明显变化。影响手术疗效的主要因素有：损伤类型、损伤原因、手术距损伤的间隔时间、患者年龄、供体神经的选择及术后功能锻炼。准确判断患者的损伤类型,严格掌握手术适应证是手术成功的关键。结论 正中神经、尺神经部分束支移位术是治疗臂丛神经上千型根性撕脱伤的一种安全、可靠、有效的手术方法。     

Reconstruction of high ulnar nerve lesions by distal double median to ulnar nerve transfer

Ulnar nerve lesions around the elbow often carry an unfavorable prognosis due to insufficient sensory and intrinsic muscle recovery. We present a series of 7 cases in which restoration of ulnar innervated intrinsic muscles of the hand and of skin sensibility was achieved. This was accomplished by a distal connection of the anterior interosseous nerve and the superficial sensory palmar branch of the median nerve to the motor and sensory components of the ulnar nerve at Guyon's canal. The length of the follow-up period ranged from 1 to 3.5 years. Results were graded by the Highet-Zachary scale. Good motor and sensory recovery was obtained in 6 cases; only return of protective sensation occurred in the remaining case.