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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
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