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408 I. J. HARDING, I. M. MORRISTable III. — The results of non-operative treatmentAetiology No Partial No Worse(number) symptoms recovery changeIdiopathic (64)* 28 14 20 0Injury (12) 3 3 6 0Iatrogenic (9) 5 4 0 0Osteoarthritis (9) 3 6 0 0Repeat pressure (7) 6 1 0 0Epicondylitis (4) 2 2 0 0Rheumatoid (2) 1 1 0 0Other (3) 2 1 0 0Overall (110)* 50 32 26 0*2 lost to follow up.Table IV. — Results of surgeryAetiology No Partial No Worse(number) symptoms recovery changeIdiopathic (35) 11 9 15 0(5) (5) (10)Injury (10) 0 5 5 0(2) (2)Iatrogenic (6) 0 2 4* 0(1) (1)Osteoarthritis (4) 0 2 2 0(1) (1)Rheumatoid (2) 0 2 0 0(1)Other (3) 3** 0 0 0Overall (60) 14 20 26 0* including 3 primary repair, ** 2 lipoma, 1 ganglionexcised.Table V. — Comparison of lesions undergoing surgeryPrimary operative Operation following Statistical significancetreatment non-operative (test)(n = 29) treatment(n=31)Months to surgery from 5.0 6.1 p > 0.05electrodiagnosis (range) (2-8) (3-10) (student t-test)No symptoms (%) 17.2 29.0 p > 0.05(Mann-Whitney U)Partial recovery (%) 34.5 32.3 p > 0.05(Mann-Whitney U)No change (%) 48.3 38.7 p > 0.05(Mann-Whitney U)Worse 0 0 n/atreatment had had no effect. Table V compares thepatients undergoing primary operative treatmentand those having surgery following an initial trialof non-operative treatment. There were no complicationsof non-operative treatment whereas surgicalcomplications included one painful scar neuroma,one wound dehiscence, one haematoma, twosuperficial infections and seven cases of persistentnumbness adjacent to the wound.Table VI shows the percentage of patients withfull or partial recovery from their symptoms withrespect to their aetiology at follow up.Ninety five patients required only one EMG,whereas 53 had two or more. The average timefrom first EMG to surgery (if indicated) was5.6 months (range 1-12). Five diabetic patients hadevidence of peripheral neuropathy at the time ofassessment. No double-crush lesions were identified.DISCUSSIONThis study identifies many aetiological factorsleading to ulnar neuropathy. We have described theActa Orthopædica Belgica, Vol. 69 - 5 - 2003
THE AETIOLOGY AND OUTCOME OF 170 ULNAR NERVE LESIONS 409Table VI. — Percentage of patients with full or partialrecovery at follow-upAetiology Operative Non- All lesionsoperativeIdiopathic 57 70 64Injury 50 50 50Iatrogenic 67 100 92Osteoarthritis 50 100 85Inflammatory arthritis 100 100 100Repeated pressure 0 100 100Medial epicondylitis 0 100 100anatomical location of these lesions and assessedtheir outcomes following non-operative and operativetreatments or a combination of both. The agedistribution and predominance in males is similarto that previously reported (3). Symptomatic lesionsoccurred at the elbow in 89.4% of cases, identifyingthis as the most common site of neuropathy.If a lesion is not identified here, the wrist, forearmand hand should be evaluated. This is particularlythe case in injury when a careful history shouldindicate the site of the lesion.The aetiological factors described in this studyare similar to those reported previously : jointdeformity (9), rheumatoid arthritis (11), pressureduring surgery (20), trauma (18), space-occupyinglesions (16), diabetes (15), medial epicondylitis (10).The majority of the patients in our study had noclearly definable aetiology and we termed them‘idiopathic’. Ninety-five percent of these ‘idiopathic’cases had ulnar neuropathy at the elbow, presumablydue to susceptibility to compression of thenerve in the cubital tunnel. Our ‘idiopathic’ groupmay include patients that habitually lean on theelbow without noticing, those who flex theirelbows at night or those who have congenital anomaliesor bands around the elbow. We did not definethese as a separate aetiology as there is nomethod of demonstrating this clinically withoutopen exploration or constant 24 hour observation.Bilaterality of lesions of the ulnar nerve occurred in23% of patients and in all cases this was at theelbow with 56% of them being symptomatic.Bilaterality is uncommon in injury, but relativelyfrequent when the cause is as a result of direct pressure(as in a general anaesthetic), osteoarthritis orwhen no cause could be identified. It therefore followsthat some patients are clearly more susceptiblethan others to pressure on the nerve as it coursesposterior to the medial epicondyle within thecubital tunnel. The contralateral upper limb shouldtherefore always be assessed at presentation toidentify a possible bilateral lesion.Our study shows that non-operative treatmentcan be beneficial to the majority of patients withulnar neuropathy and in particular when arthritis,direct pressure or epicondylitis is an aetiologicalfactor. Of the 12 patients (8%) who had deterioratedfollowing instigation of non-operative treatment,all had partial or complete recovery followingsurgery. From our results there was no statisticalsignificance between patients treated primarilyoperatively to those treated operatively as aresult of failed non-operative treatment. It is possiblethat the patients in the latter group may havehad better outcomes if treated sooner, but we woulddisagree with this as the average time to surgeryfrom the time of the first nerve conduction studyfor the primary operative and failed non-operativegroups was 5.0 and 6.1 months respectively. Nopatients in our study had deteriorated as a directresult of our treatment protocol although 20% ofsurgical patients had complaints relating to the scarfrom the surgery. Eight of these complications relatedto damage to the medial antebrachial cutaneousnerve as previously reported by others (4).Overall, patients in whom injury was an aetiologicalfactor had poor outcomes, as did the threepatients who had primary repair of the nerve followingaccidental damage during surgery : all threeshowed no improvement in their symptoms. This isin contrast to the excellent prognosis of an ulnarnerve lesion that has an aetiology such as directpressure, injudicious positioning with pressure onthe nerve under a general anaesthetic, an adjacentmass lesion (e.g. lipoma) or inflammation/arthritis.When no aetiological factor was identified thenresults achieved were similar to those previouslyreported for both non-operative and operative treatment(1, 5). In this study we do not consider thechronicity of the lesion, but appreciate that thismay be a factor in subsequent recovery. Patient ageand site of lesion may also be factors in theActa Orthopædica Belgica, Vol. 69 - 5 - 2003
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