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Actaorthop. scand.49,151-153,1978

RECURRENT ULNAR NERVE DISLOCATION A T T H E E LB OWReport of a Non Trauma tic Case with Ulna r Entrapment NeuropathySVENGREVSTENULF LIN SJO EN OLERUDDepa rtmen t of Orthop aedic Surgery, University Hospital, U ppsala, Sweden

An unusual case of habitual recurrent ulnar nerve dislocation at the elbow isdescribed. The case wa s complicated by non-traumatic u lnar entra pm entneuropathy interfering with the patients profession as a musician (cello).Key words: ulnar nerve; recurrent dislocation; non-traumatic entrapmentneuropathyAccepted 17.x.77

The reported incidence of habitual ulnar nervedislocation varies between 2 and 19 per cent(Collinet 1896, Mom berg 1903, D ub s 1918,Burman Su rtro 1939, Childress 1956).Dislocation to the extent of complete forwardluxation a t the internal condyle of the h um erusmay be present without caus ing anysymptoms and without the knowledge of theindividual. The lower incidences include onlycomplete dislocations (Cobb 1903). T h e higherincidences include complete as well asincomplete dislocation.It is suggested that recurrent dislocation ofthe ulnar nerve a t the elbow arises a s a resultof trauma but can also occur nontraumatically(Cobb 1903). In the latter case it is calledhabitual, congenital or idiopathicdislocation.

Cases of habitual dido catio n are, however,much more common than the traumatic ones.Usually the affected person is only aware ofthe habitual dislocation when an ulnarentrapment neuropathy is present.Ulnar nerve neuritis is thus a rare diagnosisin connection with habitual dislocation of theulnar nerve unless it is combined with trauma.T h is paper reports, how ever, a case of non-

traumatic ulnar nerve neuritis in a patientwith habitual dislocation. T h e disability wass great that i t was necessary to perform anulnar nerve transposition. The diagnosis andthe operative procedure is discussed.

CASE REPORTT he patient was a 21-year-old studen t of music andphilosophy who had been previously healthy. Hehas been playing the cello since the age of fifteen.The patient complained of increasing disabilitywhen playing t he cello. Wh en h is left rmwa s liftedinto the ho riton tal plane w ith the elbow flexed over90 holding the chord s there was a slowlyprogressing sensation of num bness occurring in hisulnar fingers and pain at the elbow. The samesensations occurred in his right rmwhen using thebow (Figure 1). There was no history of trauma tothe elbows.Clinical examination revealed the ulnar nervesliding in front of the ulnar epicondyle when theelbows were flexed. Registration of the conductionvelocity in the ulnar nerve at the elbows (Table 1)comparing elbows flexed and elbows fully extendedshowed a decrease in the conduction velocity onboth sides with the elbows in 90 flexion. With theelbows extended the patient did not feel anysensations in the rm or hand, nor could any

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152 S. G R E V ST E N , U. LINDSJO S OLERUI)

Figure I The posit ion of the arms when play ing the cello. Note the scars after the ulnar nervetranspositions.

decreased sensibility in the ulnar nerve area befound. X-ray ex am inatio n of the elbows showed noabnormality. Th ere were no sym ptom s or sign s ofother possible causes of the pain such asrheumatoid arthritis (Chang et al. 1972), post-trau ma tic arth ritis, cervical syndrom e, etc.The patient was operated on with transpositionof the ulnar nerve on bot h sides. T h e operation w asperformed in a bloodless field. The nerve wasdissected free for about 5 cm proximal an d distal tothe ulnar epicondyle, mobilized and adapted in frontof the epicondyle. The adaptation was made by afew sutures in the soft tissues around the nerve.Mobilization was started immediately after theoperation.

Four weeks postoperatively the patient was ableto take up his cello playing again, now withoutdiscomfort. A second nerve conduction test wasmade 6 weeks after the operation using the sameprocedure as before the operation. This testshowed no significant difference in the conductionvelocity of the ulnar nerves on either side with theelbows t o flexed 90 and in full extension.

DISCUSSIONC o m p l a i n t s of n u m b n e s s i n t h e u l n a r a r e a inb o t h h a n d s a r e ve ry c o m m o n in o r t h o p a e d i c

Table I Uln ar nerve conductionFull extension in the elbow 9 lexion in the elbow

Right 67 m/second 57 m/secondLeft 67 m/second 52 mlsecondRight *63 m/second 62 m/secondLeft 74 m/second 79 mlsecond

Preop. test___ __Postop. test

Nerve conduction values obtained on various occasions from the same nerve candiffe r depending on th e position of the electrode.

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RECURRENT ULNAR NERVE DISLOCATION 153practice. T h is particular person being amusician ertainly found it disturbing to hisplaying of th e cello. Havin g diagnosed an ulnarnerve neuritis on the basis of recurrentdislocations of the nerve it was necessary toperform an ulnar nerve t ranspos i t ion .Transposi t ion of the ulnar nerve is a simpleoperative procedure. However, perhaps itwould be of value to point out som e details ofthe operative procedure and the postoperativecare. The nerve should be dissected free asufficient distance proximally and distally tothe epicondyle so that i t is possible to place thenerve in its new p osition without stretching it(Learmonth 1943, Childress 1956, LevyApfelberg 1972). Mo reover, we d o notadvocate any form of firmer fixation of thenerve to keep it in the a nterior position. Suchproced ures involve th e risk of the developmentof strangulating fibro tic processes. W e think itis very important also to start exercisesimmediately after the operation in order topreven t scar fixation arou nd th e nerve.

Childress (1956) classified ulnar nervehypermobil i ty into two groups: type A andtype B. In type A the nerve moves out of i t spost-condylar groove on the t ip of the humeralepicondyle when the elbow is maximallyflexed, i.e., sub luxa tion occu rs in extre meflexion. Ty pe B hypermobil i ty means that t henerve passes completely across and anterior tothe epicondyle when the elbow is flexed morethan 90.Our case had a hypermobility of type B.T y p e B possesses greater mobility and is saidto be more susceptible to friction neuritis(Cobb 1903, Dubs 1918, Learmonth 1943,Childress 1956). This theory is supported byour case.

Ch i ld re s s (1956) found u lnar ne rvedislocations in 16.2 per cen t of 1,000 selectedindividu als (2,000 ulnar nerves), no ne of who mknew that he had such an anomaly. Mom berg(1903) discovered in the military hospital inSpa nda u an inciden ce of th e anom aly of 19.8per cent am ong 140 soldiers. In non-traum aticcases of habitual ulnar nerve dislocation it isknown that severe symptoms rarely occur andthere is seldom need for operative interven-tion. It is the traumatic cases which give riseto all the cases which have been operated onwith a few ex ceptions such as in our case.R E F E R E N C E SBurman, M. S Surtro, C. J. 1939) Recurrentluxation of the ulnar nerve by congenitalposterior position of the medial epicondyle ofthe humerus.J. B o n e J t Surg. 21,958-96 2.Chang, L. W ., Gowans, J D. C., Granger, C. V.Millener, L. H. 1972) Entrapment neuropathyof the posterior interosseous nerve. Acomplication of rheumatoid arthritis. Arth. andRheum. 15,350-352.Childress, H M. 1956) Recurrent ulnar nerve

dislocation at the elbow . J Bone J t Surg. 38-A,Cobb, F. 1903) Report of a case of recurrentdislocation of the ulnar nerve cured byoperation. Ann Surg. 38, 652-663.Collinet, P. 1896) Luxation congenital du nerfcubital. Bull . SOC nat. de Paris 7 1 , 358-361.Dubs, J. 1918) Uber die Traumatische Luxationdes Nervus Ulnaris. Corresp. BI. schweia. Ara.Learmonth, J. R. 1943) A technique or trans-planting the ulnar nerve. Surg. Gynec. Obstet.Levy, D. M . Apfelberg, D. B. 1972) Results ofanterior transposition for ulnar neuropathy atthe e lbow . Amer. J Surg. 123, 304-308.Momberg, Stabsarzt 1903) Die luxation des N e w sUlnaris.Arch. klin. Chir. 70,215-232.

978-984.

48, 1711-1718.

75,792-801.

Correspondence to: Sven Grevsten, Dept. of Orthopaedic Surgery, University Hospital, S-750 14Uppsala, Sweden.

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