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Perineural fibrosis prevents the nerve from gliding during The evaluation may then proceed to the elbow with the
elbow excursion and may be related to patient predisposition evaluation of the position and extent of the surgical scar,
or to improper intraoperative manipulation of the as well as palpation of the ulnar nerve along its course,
nerve. Fibrosis following simple decompression can which may be inside the epitrochlear‑olecranon channel
[14]
cause adherence of the nerve to the epitrochlear‑olecranon or medial to the epicondyle if nerve transposition was
channel and can additionally cause the channel’s closure performed. Areas of tenderness and nerve instability
due to the scarring at Osborne’s ligament. Fibrosis after during elbow articular motion are carefully investigated.
anterior transposition may occur independently of the In cases of ulnar neuropathy at the elbow, palpation
technique employed and usually occurs at the site of a along the course of the nerve may trigger a Tinel’s sign
technical error or omission. Following superficial nerve with the characteristic spread of paresthesias along
transpositions, in particular, fibrosis preferentially localizes the area innervated by the nerve up to the 4th and
to the anterior soft tissue area and the epitrochlear region. 5th fingers or, in the case of antebrachial sensory nerve
According to the literature, superficial transposition neuropathies, to the medial part of the elbow and the
presents the highest percentage of failure, suggesting that medial proximal third of the forearm. An important
this technique has some intrinsic limitations represented provocative test is the “pressure‑flexion test” in which
[32]
by the position of the nerve under the skin, in a pressure is exerted on the ulnar nerve for 1 min while
relatively hypovascular tissue susceptible to trauma. [13,15] the elbow is flexed. Sensitivity testing of the cutaneous
During anterior transposition, unintended injury to the territories of the ulnar and median nerves of the hand
subcutaneous antebrachial nerves may occur, leading to the should be performed. The clinical evaluation is
[14]
formation of painful neuromas. During harvest of the ulnar completed by motor testing. Advanced neuropathy is
nerve, in 61% of cases, 1 to 3 sensory nerves can be found indicated by muscular hypotrophy or atrophy of the
proximal to the epicondyle (at a mean level of 1.8 cm from intrinsic muscles innervated by the ulnar nerve. Typically,
the epicondyle) or distally in 100% of cases (at a mean atrophy initially involves the first dorsal interosseous
level of 3.1 cm from the epicondyle). [24,13] An unintended muscle and then extends to the hypothenar muscles.
nerve lesion may produce one or more painful neuromas, Assessment for the griffe deformity at the 4th and
creating a hyperalgesic or hyperesthetic area in the medial 5th fingers (hyperextension of the metacarpophalangeal
part of the elbow, jeopardizing achieving satisfactory joint and flexion of the interphalangeal joint),
results from the decompression. Clinical studies have the Froment and Wartenberg signs (abduction of
reported a nerve lesion rate of up to 90%, which is thought the 5th finger) and the inability to cross the long
to occur secondary to the difficulty in locating and fingers (crossed finger test) complete the motor testing.
protecting these nerves during dissection. [25,26] In contrast, When present, muscle impairment represents a negative
lesions of the main trunk of the ulnar nerve are rare. To prognostic factor. In general, the neurological signs are
allow anterior nerve transposition, it is generally necessary less severe, with no alterations in muscle tone, and
to sacrifice the first motor fascicle to the FCU, which does identification is based solely on the clinical evaluation
not impair muscular function. Medial elbow instability of asthenia and/or diminished strength of the intrinsic
[27]
is quite uncommon but may occur following damage to muscles innervated by the ulnar nerve.
the collateral ulnar ligament, particularly during medial
epicondylectomy, or as a consequence of an excessively INSTRUMENTAL EVALUATION
aggressive anterior submuscular transposition. The ulnar
[28]
collateral ligament is located just below the flexor‑pronator Electromyography (EMG) is useful in the differential
group and originates, according to O’Driscoll et al., diagnosis to exclude radiculopathies, thoracic outlet
[28]
from the medial epicondyle. Elbow stiffness presents as syndrome, and median or ulnar nerve compression at the
a flexion contracture due to prolonged immobilization, wrist. However, it fails to reveal neuropathies of the small
inappropriate postoperative rehabilitation, or excessive sensory nerves in the elbow area. When preoperative
fibrosis formation in the soft tissues. The extension lag is EMG is performed, the results are particularly useful
generally from 5° to 30°. [1,29,30] Stiffness occurs after deep when assessing postoperative symptoms. In cases of
transposition in 5‑10% of cases [14,15,31] and is generally due recurrence, the neurological symptoms worsen, which
to prolonged immobilization. Following primary deep correlates well with the conduction values, confirming
transposition, the authors permit the patient to remove the indication for surgical revision. Conversely, when
the orthesis from the 3rd to 7th day postoperatively, worsening of the clinical condition is not confirmed by
for 1‑2 h/day to perform active motion. The orthesis is conduction studies, the indication for revision surgery
definitively removed 20 days after surgery. In cases of should be dictated by the severity and persistence of
persistent stiffness, adequate rehabilitation, and medical symptoms. Notably, in cases of chronic axonal lesions,
therapy are typically required. the conduction study results may be unchanged from the
preoperative values while there is a slight improvement
CLINICAL EVALUATION in the clinical condition. Therefore, when faced with
[14]
worsening symptoms and unchanged conduction studies,
After obtaining a thorough clinical history, it is it is difficult to determine whether it is more useful to
mandatory to verify the absence of neurological disorders base the treatment decision on the symptoms, which
originating from the upper extremities and cervical spine. would suggest surgery, or on the conduction studies,

178 Plast Aesthet Res || Vol 2 || Issue 4 || Jul 15, 2015