January 14, 2015
2:34:05pm
WSPC/135-HS
FA1
1572001
Hand Surgery, Vol. 20, No. 1 (2015) 137–139 © World Scientific Publishing Company DOI: 10.1142/S0218810415720016
CASE REPORTS A CASE REPORT OF ACUTE CUBITAL TUNNEL SYNDROME CAUSED BY VENOUS THROMBOSIS Yoshihiro Abe and Masahiko Saito
Hand Surg. 2015.20:137-139. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/20/15. For personal use only.
Department of Orthopedic Surgery Graduate School of Medicine, Chiba University, Japan Received 24 August 2014; Revised 5 October 2014; Accepted 8 October 2014; Published 20 January 2015 ABSTRACT Compression neuropathy of the ulnar nerve at the elbow is well-recognised as cubital tunnel syndrome (CuTS). Many causes of ulnar neuropathy at the elbow have been identified. A previously unreported finding of ulnar nerve compression in the cubital tunnel caused by a thrombosed proximal ulnar recurrent artery vena comitans is described. Keywords: Venous Thrombosis; Cubital Tunnel Syndrome; Acute Onset; Compression Neuropathy.
INTRODUCTION
Surgical exploration showed a dark-red mass adhered to the ulnar nerve to be continuity with the posterior ulnar recurrent artery vena comitans (Fig. 2). Surgical excision was performed with the aid of operative microscope. After excision of the mass, ossicles were revealed on the ulnar nerve surface (Fig. 3). Histopathologic diagnosis of the mass demonstrated a venous thrombosis (Fig. 4). Symptoms were restored completely and MCV improved from 31 to 48 m/s six months after surgery.
We report a case of cubital tunnel syndrome (CuTS) caused by venous thrombosis. There are no previous reports in English literature of CuTS secondary to a venous thrombosis.
CASE REPORT A 62-year-old woman presented with a 2-week history of pain at the medial side of her right elbow and dysesthesia in the ring and little fingers. The patient had no history of injury to the right elbow. Her remarkable medical history was hypertension and varix of the lower legs, which had not been treated. Her laboratory data was normal except for hyperlipidemia. Hypesthesia was noted in the ring and little fingers. Claw deformity and atrophy of the intrinsic muscles were observed. The patient represented positive Froment sign. Tinel’s sign was positive but any mass was palpable at the cubital sulcus. Motor nerve conduction velocity (MCV) of the ulnar nerve across the elbow was 31 m/s. Three ossicles near the medial epicondyle were observed on X-ray (Fig. 1).
DISCUSSION Compression neuropathy caused by venous thrombosis is very rare; only two reports were found in English literatures.1,2 The sites of compression were in the Guyon’s canal,1 and fibula head.2 In the Bendszus case,2 the patient was treated conservatively by anticoagulants with poor clinical results. In the Grossman’s case,1 surgical intervention was performed with excellent results (Table 1). Those suggest early surgical intervention is necessary both for treatment and early diagnose for this condition.
Correspondence to: Dr. Yoshihiro Abe, Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Cyuo-ku, Chiba-city 2608677, Japan. Tel: (þ81) 43-226-2116, Fax: (þ81) 43-226-2116, E-mail: [email protected] 137
January 14, 2015
Hand Surg. 2015.20:137-139. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/20/15. For personal use only.
138
2:34:05pm
WSPC/135-HS
FA1
1572001
Y. Abe & M. Saito
(A) Fig. 1
(B)
(C)
Initial X-rays: Lateral (B) and cubital tunnel view (C) of the right elbow showing three ossicles in the ulnar sulcus.
Fig. 2 Intraoperative view of the mass (venous thrombosis) prior to resection.
Fig. 3 Intraoperative view of the ulnar nerve after resection of the mass. The ossicles are revealed on the ulnar nerve surface.
Acute CuTS is relatively rare, and most cases were caused by ganglia or hemangiomas.3–5 The remarkable features are acute onset ulnar nerve palsy and resting pain at the medial elbow. Nakamura4 reported a case of acute CuTS caused by extraneural hemangioma that demonstrated similar X-ray findings and clinical features as well as acute onset and resting pain at the medial elbow. Acute onset of ulnar nerve neuropathy and resting pain in the medial elbow were suggestive of a growing mass in the cubital tunnel. Presumably, lesions such as venous thrombosis, ganglion, or hemangioma with
subsequent compression due to the confined space of the cubital tunnel caused the acute onset of cubital pain and ulnar nerve neuropathy. The diagnosis of CuTS is usually based on clinical history, physical examination, and electrophysiologic workup. We cannot diagnose the existence of venous thrombosis with such conventional method preoperatively. Although MRI or ultrasound are rarely used for the diagnosis of CuTS, they should be considered in cases with an acute onset of neuropathy and resting pain at the medial elbow. Preoperative
January 14, 2015
2:34:20pm
WSPC/135-HS
FA1
1572001
A Case Report of Acute Cubital Tunnel
Hand Surg. 2015.20:137-139. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/20/15. For personal use only.
(A)
139
(B)
Fig. 4 (A) Low power photomicrograph of excised specimen (5 magnification). Venous thrombosis was seen in the normal venous wall tissue (Hematoxylin and eosin strain). (B) High power photomicrograph of excised specimen. (40 magnification). Normal endothelial tissue was observed and red blood cells were present in the cavenous space (Hematoxylin and eosin strain).
Table 1 Author Grossman and Beker Bendszus et al.2 Present case
1
Comparison of Three Cases of Peripheral Nerve Palsy Caused by Thrombosis of Veins. Patient
Nerve
Location
Past History
Treatment
Prognosis
35, f 67, m 62, f
Ulnar Peroneal Ulnar
Gyon’s cannel Fibular head Cubital tunnel
None Thrombosis of crural Veins Varix of the lower legs
Surgery Conservative* Surgery
Complete recover Remain motor loss Complete recovery
*2850 IU per day of the low-molecular heparin nadroparine.
reorganisation of the presence of a mass in the cubital tunnel will be of great advantage to both patients and surgeons.
References 1. Grossman JAI, Becker GA, Ulnar neuropathy cause by a thrombosed ulnar vein, Ann Chir Main 4:244–247, 1996.
2. Bendszus M, Reiners K, Perez J, Solymosi L, Koltzenburg M, Peroneal nerve palsy caused by thrombosis of crural veins, Neurology 58:1675– 1677, 2002. 3. Kline SC, Moore JR, Intraneural hemangioma: A case report of acute cubital tunnel syndrome, J Hand Surg Am 17:305–307, 1992. 4. Nakamura I, Hoshino Y, Extraneural hemangioma: A case report of acute cubital tunnel syndrome, J Hand Surg Am 21:1097–1098, 1996. 5. Kato H, Hirayama T, Minami A, Iwasaki N, Hirachi K, J Bone Joint Surg Am 84:1413–1419, 2002.
2:34:05pm
WSPC/135-HS
FA1
1572001
Hand Surgery, Vol. 20, No. 1 (2015) 137–139 © World Scientific Publishing Company DOI: 10.1142/S0218810415720016
CASE REPORTS A CASE REPORT OF ACUTE CUBITAL TUNNEL SYNDROME CAUSED BY VENOUS THROMBOSIS Yoshihiro Abe and Masahiko Saito
Hand Surg. 2015.20:137-139. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/20/15. For personal use only.
Department of Orthopedic Surgery Graduate School of Medicine, Chiba University, Japan Received 24 August 2014; Revised 5 October 2014; Accepted 8 October 2014; Published 20 January 2015 ABSTRACT Compression neuropathy of the ulnar nerve at the elbow is well-recognised as cubital tunnel syndrome (CuTS). Many causes of ulnar neuropathy at the elbow have been identified. A previously unreported finding of ulnar nerve compression in the cubital tunnel caused by a thrombosed proximal ulnar recurrent artery vena comitans is described. Keywords: Venous Thrombosis; Cubital Tunnel Syndrome; Acute Onset; Compression Neuropathy.
INTRODUCTION
Surgical exploration showed a dark-red mass adhered to the ulnar nerve to be continuity with the posterior ulnar recurrent artery vena comitans (Fig. 2). Surgical excision was performed with the aid of operative microscope. After excision of the mass, ossicles were revealed on the ulnar nerve surface (Fig. 3). Histopathologic diagnosis of the mass demonstrated a venous thrombosis (Fig. 4). Symptoms were restored completely and MCV improved from 31 to 48 m/s six months after surgery.
We report a case of cubital tunnel syndrome (CuTS) caused by venous thrombosis. There are no previous reports in English literature of CuTS secondary to a venous thrombosis.
CASE REPORT A 62-year-old woman presented with a 2-week history of pain at the medial side of her right elbow and dysesthesia in the ring and little fingers. The patient had no history of injury to the right elbow. Her remarkable medical history was hypertension and varix of the lower legs, which had not been treated. Her laboratory data was normal except for hyperlipidemia. Hypesthesia was noted in the ring and little fingers. Claw deformity and atrophy of the intrinsic muscles were observed. The patient represented positive Froment sign. Tinel’s sign was positive but any mass was palpable at the cubital sulcus. Motor nerve conduction velocity (MCV) of the ulnar nerve across the elbow was 31 m/s. Three ossicles near the medial epicondyle were observed on X-ray (Fig. 1).
DISCUSSION Compression neuropathy caused by venous thrombosis is very rare; only two reports were found in English literatures.1,2 The sites of compression were in the Guyon’s canal,1 and fibula head.2 In the Bendszus case,2 the patient was treated conservatively by anticoagulants with poor clinical results. In the Grossman’s case,1 surgical intervention was performed with excellent results (Table 1). Those suggest early surgical intervention is necessary both for treatment and early diagnose for this condition.
Correspondence to: Dr. Yoshihiro Abe, Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Cyuo-ku, Chiba-city 2608677, Japan. Tel: (þ81) 43-226-2116, Fax: (þ81) 43-226-2116, E-mail: [email protected] 137
January 14, 2015
Hand Surg. 2015.20:137-139. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/20/15. For personal use only.
138
2:34:05pm
WSPC/135-HS
FA1
1572001
Y. Abe & M. Saito
(A) Fig. 1
(B)
(C)
Initial X-rays: Lateral (B) and cubital tunnel view (C) of the right elbow showing three ossicles in the ulnar sulcus.
Fig. 2 Intraoperative view of the mass (venous thrombosis) prior to resection.
Fig. 3 Intraoperative view of the ulnar nerve after resection of the mass. The ossicles are revealed on the ulnar nerve surface.
Acute CuTS is relatively rare, and most cases were caused by ganglia or hemangiomas.3–5 The remarkable features are acute onset ulnar nerve palsy and resting pain at the medial elbow. Nakamura4 reported a case of acute CuTS caused by extraneural hemangioma that demonstrated similar X-ray findings and clinical features as well as acute onset and resting pain at the medial elbow. Acute onset of ulnar nerve neuropathy and resting pain in the medial elbow were suggestive of a growing mass in the cubital tunnel. Presumably, lesions such as venous thrombosis, ganglion, or hemangioma with
subsequent compression due to the confined space of the cubital tunnel caused the acute onset of cubital pain and ulnar nerve neuropathy. The diagnosis of CuTS is usually based on clinical history, physical examination, and electrophysiologic workup. We cannot diagnose the existence of venous thrombosis with such conventional method preoperatively. Although MRI or ultrasound are rarely used for the diagnosis of CuTS, they should be considered in cases with an acute onset of neuropathy and resting pain at the medial elbow. Preoperative
January 14, 2015
2:34:20pm
WSPC/135-HS
FA1
1572001
A Case Report of Acute Cubital Tunnel
Hand Surg. 2015.20:137-139. Downloaded from www.worldscientific.com by CHINESE UNIVERSITY OF HONG KONG on 02/20/15. For personal use only.
(A)
139
(B)
Fig. 4 (A) Low power photomicrograph of excised specimen (5 magnification). Venous thrombosis was seen in the normal venous wall tissue (Hematoxylin and eosin strain). (B) High power photomicrograph of excised specimen. (40 magnification). Normal endothelial tissue was observed and red blood cells were present in the cavenous space (Hematoxylin and eosin strain).
Table 1 Author Grossman and Beker Bendszus et al.2 Present case
1
Comparison of Three Cases of Peripheral Nerve Palsy Caused by Thrombosis of Veins. Patient
Nerve
Location
Past History
Treatment
Prognosis
35, f 67, m 62, f
Ulnar Peroneal Ulnar
Gyon’s cannel Fibular head Cubital tunnel
None Thrombosis of crural Veins Varix of the lower legs
Surgery Conservative* Surgery
Complete recover Remain motor loss Complete recovery
*2850 IU per day of the low-molecular heparin nadroparine.
reorganisation of the presence of a mass in the cubital tunnel will be of great advantage to both patients and surgeons.
References 1. Grossman JAI, Becker GA, Ulnar neuropathy cause by a thrombosed ulnar vein, Ann Chir Main 4:244–247, 1996.
2. Bendszus M, Reiners K, Perez J, Solymosi L, Koltzenburg M, Peroneal nerve palsy caused by thrombosis of crural veins, Neurology 58:1675– 1677, 2002. 3. Kline SC, Moore JR, Intraneural hemangioma: A case report of acute cubital tunnel syndrome, J Hand Surg Am 17:305–307, 1992. 4. Nakamura I, Hoshino Y, Extraneural hemangioma: A case report of acute cubital tunnel syndrome, J Hand Surg Am 21:1097–1098, 1996. 5. Kato H, Hirayama T, Minami A, Iwasaki N, Hirachi K, J Bone Joint Surg Am 84:1413–1419, 2002.
