Swindon Orthopaedics Limited
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Ulnar shortening osteotomy

Cause - the ulnar nerve runs around the inner side of the elbow, in a tunnel where it can be compressed.  When you bash your elbow and strike your "funny bone" it is actually the nerve that you have knocked. The condition usually occurs spontaneously, occasionally there is specific injury.

Symptoms - tingling is felt in the little and ring fingers.  It is often fairly constant.  In severe cases weakness and loss of dexterity of the hand with thinning of the muscles also occur.  Numbness of these fingers can develop.

 

Diagnosis - sometimes the condition can be confused with compression of nerves in the neck and the hand, so electrical tests may be done to test the nerve conduction and confirm that the problem is at the elbow. Scans are sometimes needed.

Treatment options - some people find that the position of the elbow, particularly sleeping with it bent causes symptoms.  Changing the sleeping position can relieve the symptoms.

  In the majority of people the symptoms are due to mechanical compression of the nerve, and surgery is required.

Surgery - the operation is usually done under general anaesthetic as a day case; local anaesthetic is also given during the operation to prevent pain afterwards.

The curved incision is over the inner side of the elbow.  The tunnel that the nerve runs in is opened, freeing the nerve.  Dissolving stitches are routinely used to close the skin. The dressings allow reasonable elbow movement immediately after the operation. 

(Some surgeons move or “transpose” the nerve to lie in front of the elbow.  I do not feel that there is any evidence that the results are better, and the risks are certainly higher, therefore I normally simply decompress the nerve without lifting and moving it.)

Recovery – the elbow should be moved and used as normally as possible. The dressings can come off after about 5 days, following which you can get the wound wet. Any knots from the dissolving stitches should be picked off after two weeks when you are washing.

Painkillers may be needed for the first few days. Physiotherapy is not usually needed.

The recovery from tingling is variable, but generally there are two phases – a very rapid improvement over the first 24 hours, and then if there are still symptoms, potentially a much slower further improvement over many months. If there is constant numbness or weakness pre-operatively then the recovery is always over a long period, and may not be complete.

The scar remains tender for at least two months. It should be massaged with cream (lanolin, E 45, DoubleBase).  The operation is relatively superficial, with no muscles being cut, so return to near normal function should be possible in only about three weeks

Ability to drive post-operatively varies from person to person - it is up to you to decide when you can do so. It will probably be after a few days if the right elbow is operated on, it may be longer for the left because of the need to use the gear lever.

Manual workers normally need about 3 weeks off work; office workers can get back sooner.

Things you possibly do not want to know about ulnar nerve decompressions, but have to be informed about:

 Specific risks of the operation

The commonest adverse result is that the operation does not always work, particularly if the nerve is badly damaged.

Because the operation is directly on a nerve, there is a risk that the nerve will be injured during or by the operation.  This is however very unlikely to occur. This could cause increased numbness and pain.

Due to injury to little nerves that run under the skin there is sometimes an area of numbness on the back of the arm beyond the incision. If this occurs it will be permanent, but does not cause any problems.

 General Risks of all operations

With planned operations complications are unusual, overall probably about 5% of patients have a post-operative problem, of which the vast majority are temporary and do not affect the final result.

Infection – the signs may develop after a few days, with increasing pain, swelling and redness. Treatment with antibiotics is usually sufficient. Very occasionally an infection can be severe and cause major problems.

Wound healing problems – for instance excessive bleeding, causing a painful swollen wound (haematoma) or delayed healing may slow down the recovery. A few people react to the dissolving suture material and this can lead to localized areas of tenderness and swelling that persist for a couple of months.

Swelling and stiffness – these always occur to a certain extent, and it is very important to exercise the elbow.  Occasionally the swelling is severe, prolonged and associated with pain, due to the development of the poorly understood condition of reflex sympathetic dystrophy (algodystrophy, CRPS type 1).

Scar tenderness – all scars are tender for at least two months, and often longer. In about 10% of people the scar, after healing well initially, thickens and becomes itchy, red and more painful after the first month.  If this happens the full process of maturation of the scar (settling down to normal, thin, mobile skin) can take more than a year. Occasionally nerves running in or just under the skin at the site of an incision are damaged, resulting in persistent tenderness of the scar.

 Conclusion

The operation is generally worthwhile because it has a reasonable success rate, the recovery is not particularly troublesome, and the serious complication rate is very low.