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Forum Name: Neurology Topics

Question: Two fingers clawing, atrophy,ulnar nerve compression


 toban - Tue Dec 02, 2008 9:01 pm

Age: 37
Female
Medications: Ortho Tricyclen birth control
Health problems: None. No heart problems, diabetes etc.

I've gone through three surgeries for ulnar nerve problems in my left elbow over the past two and half years. Decompression and medial epicondylectomy.

Each time I had nerve conduction tests prior to surgery which showed severe and then mild compression. My third surgery which I had April 2008, the nerve conduction test came back normal. When my symptoms didn't become better the surgeon re operated. My nerve was completely crushed by scar tissue. I never had any transposition surgeries.

Since surgery I've experienced some pain in the funny bone area but it was mild and I figured it takes awhile to heal. Since September that pain has increased slowly over time. If I turn a door knob, pull a door towards me or bend my elbow, the pain becomes worse in the funny bone area. My little and ring finger are also beginning to curl .

I currently do to physiotherapy and they are concerned with what they call 'claw hand' of my little and ring finger. They also noticed I have atrophy on top of my hand not far from little and ring finger and my hand appears smaller compared to my good hand. They made an appt for me to see the surgeon at an earlier date.

I have no idea if I will be sent for another nc test but if it shows compression or comes back normal.. is the 'clawing' , atrophy, and symptoms I described above warrant for another surgery or are there other treatments? I really don't want another surgery but if that is what will help it I will go for it. Are there other types of surgeries for ulnar nerve problems besides the ones I had?

I try not to lean on my elbow, wrap a towel around my elbow to keep it straight at night etc.

What I don't understand is why my last nc test came back as normal, no compression and yet when I was opened up my nerve was crushed and starting to curl from heavy scar tissue. Are nc tests just a guideline or don't always show problems?

Thank you for your help!
 John Kenyon, CNA - Thu Dec 04, 2008 9:42 pm

User avatar Hello -

Starting at the end of your post, I find it interesting -- and odd -- that the one NC test appeared normal when clearly there was a good deal of pressure on the nerve. This can only suggest one of two things: either the test was fautly or there is a potential position wherein the entrapment is relieved at least partially. While the latter does seem unlikely, experience has taught me there can be temporary, unknown changes which can momentarily at least relieve the symptoms. Still, the greater likelihood is that the test was done improperly. The test should be able to virtually pinpoint the locus of the problem.

The only thing that might be considered other than what's been done already is something you did mention, which is transposition surgery, which, if done right and with luck, can sometimes relieve the compression. With time the damage can become permanent, and some loss of function may be expected. However, it seems you're still able to work the ulnar aspect of your hand at least during physiotherapy, and the symptoms certainly do warrant another surgical attempt to prevent permanent damage. Any scar tissue would have to be removed as well as any possible repositioning or transpositioning.

I hope this is helpful. Please keep us updated. Best of luck to you.
 toban - Thu Dec 04, 2008 10:47 pm

Thank you Dr. Kenyon for your help!

With my last surgery the problem was around the funny bone area. It did feel odd prior to surgery. When my test came back as normal the surgeon said he couldn't do anything for me since the test was normal. I had to pursue it a bit tactfully because I knew something didn't feel quite right. Finally decided to re operate and discovered the problem.

My little and ring finger are weak and curling but not totally stiff. Basically if I try to make a fist those fingers will not bend to the palm even with trying to use my own strength. They will bend to the palm if someone else or I pushes them down but I can't hold them down once they let go. I try to use my hand as much as possible even though it is somewhat clumsy as in I drop things at times.

My funny bone area is the source of the pain. I can feel pain in this area when I pull a door towards me, turn a doorknob or elbow in bent position.

Hopefully the surgeon will look into this and reoperate. I know my elbow may never be one hundered percent but I am worried about damage with the clawing, atrophy.

I will have surgery if needed but if I decided to leave it what happens to that nerve? Does it die slowly and I would lose all function in my little, ring finger, that area of the hand?

I'm not going to leave it but was curious as to what happens if someone does?

Also I have my surgery reports. First surgery- decompression, second surgery- decompression with medial epicondylectomy, third surgery- decompression with medial epicondylectomy.

So after the above surgeries not giving too much relief (I know surgery isn't guaranteed)is it usual course for a surgeon to try the transposition method?
 John Kenyon, CNA - Fri Dec 05, 2008 11:57 am

User avatar Hi again -

The ulnar nerve is the one that causes the "shock" sensation when you strike the funny bone, and it passes near the surface in the elbow. It sounds as though your problem lies right in there, which is one of the most common points of entrapment (although it sometimes happens above, in the muscle above the elbow, or even further upstream sometimes, all the way up to the base of the cervical spine. The result is usually the same, though). I'm guessing the reaon you've had difficulty in spite of the surgeries is that you're one of those people who develop scar excessive (and sometimes progressive) scar tissue. A neurologist should be able to pinpoint the current locus of the problem, which may have changed slightly due to incremental scarring. A transposition is sometimes appropriate, but it's difficult to say without having a specialist right there, knowing the specifics of the patient in question. Sometimes, also, a clear channel can be created for the nerve, but with a tendency to scarring this might only be a temporary solution. It's really difficult to say at a distance.

Generally the complications of this, the numbness, tingling, muscle wasting and "clawing" don't become much more severe than what you've described, but I have seen at least one instance of extremely severe (incapacitating) loss of function. Most people with this problem will regain some sensation and lost function, and some recover completely. Most will still have a tendency to drop objects from time to time. While the nerve doesn't die, it's capacity to carry the signals to their destination can be permanently decreased. The incapacity can range from annoying to disabling depending on the individual case. I would think after three ultimately failed surgeries the doctor might want to try a different approach, likely transposition or perhaps creation of a clear channel. Hopefully he will be willing to try one or the other.

Good luck and keep us updated.
 toban - Tue Dec 09, 2008 8:29 pm

Hi Dr. Kenyon, thank you for your help! :)

Update..

I did see the surgeon today and told him where the pain is, bending my elbow , opening a door knob etc causes pain in the funny bone area etc. He said don't use that arm for opening things and don't bend your elbow. I try not to and use my good arm as much as possible but I guess I forget at times. He said its 'strange' what is happening and he doesn't understand since he did a good surgery last time. I will be sent for another nerve conduction test not sure when it will be. Could take a month or two since there are only two places where I live that do this test. I will be going to the same neurologist who did the previous tests. I don't think the surgeon is too pleased with my elbow and honestly I'm not sure what will happen. Hopefully the test will read something but if it doesn't I'm not sure if the surgeon will be keen to do something. I'm keeping my hopes up he will.

I thought about a second opinion but I live in Canada and if I want to see a surgeon or specialist you need a referral through a family doctor. And the wait times to see a plastic surgeon is 9 months to a year just for a consultation. Similar wait after consultation if I need surgery especially if not considered urgent.

One thing I have noticed is my elbow will not completely straighten out. I can easily bend my arm/elbow up,towards my shoulder although I don't do that very often because it aggravates the elbow. But straightening it out is where I have difficulty. It looks like its in a somewhat bent position and will not go completely straight like my good arm will. Is this something to do with the nerve?
 John Kenyon, CNA - Wed Dec 10, 2008 12:21 pm

User avatar Hi there -

I'm sure the surgeon is perplexed and I'm sure the surgery seemed fine at the time, but some people have a greater propensity for scarring, and this may be what's causing the problem -- again. Certainly something is.

The fact that you can't totally straighten your elbow is interesting. While that probably wouldn't be caused by the nerve (although it is possible), it may well be part of the mechanics of whatever's pressing on the nerve and, in fact, may also explain why you had one negative nerve conduction test even though you were still symptomatic. The problem may be positional.

I understand the complexities of Canadian healthcare, so do try and go easy on the elbow. It's a difficult challenge, so just do the best you can and don't kick yourself every time you realize you're using it. Reducing the amount of use (and consequent pressure on the nerve) should be the goal. Otherwise you'd have to have your arm immobilized and I don't think that would be worth the aggravation.

Hang in there til the next test, and please update us at that time. Good luck!
 toban - Sat Jan 10, 2009 6:37 pm

Update..

I had my nerve conduction test yesterday. I have mild compression in my elbow. The neurologist is aware I had three prior surgeries. He didnt say much expect that each time I have surgery it can lead to more scar tissue. He will send the results to the surgeon and for me to discuss the compression with surgeon. I see the surgeon near the end of January.

I think I do scar easily.

After each surgery I go to physiotherapy. I am guessing physio is the only way to break down or keep scar tissue at bay after surgery? Or other treatments?

My little and ring finger are still clawed, some atrophy on top of hand near little and ring finger.

Once you have compression, even if mild, does it ever go away one hundred percent or stays with you? Gradually becomes worse? I try not to lean on my elbow or do anything to aggravate it. Wrapping a towel around it at night to keep arm straight.
 John Kenyon, CNA - Sun Jan 11, 2009 3:33 pm

User avatar Thanks for the update. It's true, especially in people who tend to scar more, that more surgery will usually lead to more scarring. I think a partial solution to this may be in physical therapy, as PT may help keep the nerve's channel intact instead of allowing scarring to build up and get in the way again.

When you have compression, the compression itself can go away of be relivieved, bt the nerve may or may not be permanently affected. This effect can vary a lot over time, but PT should definitely make a difference. This may wind up being a part of your daily agenda, in order to regain some hand function and keep it working.

Best of luck to you, thanks for the update, and we'll be interested to see how things go from here.
 toban - Sun Jan 11, 2009 3:45 pm

Thanks for replying.

So the compression can be relieved or go away but the nerve may or may not be permanently affected?

I go to physio once a week and at home do physio exercises. I'm still finding that turning a door knob, pulling anything towards me causes more pain in the elbow. Fingers are still clawed, atrophy.

I really do not want more surgery but willing to try it again to see if makes a bit of improvement. The physiotherapist said maybe a different type of surgery needs to be done like moving the nerve over. Not sure if the surgeon will want to do more surgery.
 John Kenyon, CNA - Mon Jan 12, 2009 12:54 pm

User avatar Hi - Yes, that's correct; the nerve may or may not have been compressed for too long a time, but PT generally will have a positive effect even on an area served by a damaged nerve. As for the surgery, sometimes transposition of the nerve (forming a new channel or "comfort zone") can free it up to begin to function again.

Please stay in touch and let us know how things go.
 toban - Tue Feb 03, 2009 10:06 pm

Update and questions..

I did see the plastic surgeon today and my physiotherapist was also in attendence. He had my nerve conduction test results. Results are mild compression in elbow. Physio told the surgeon about little,ring finger sensation decreasing, clawing increased etc. Surgeon seemed to be baffled and said he can't operate on me every year. He plans on sending me for an MRI and wants a scan of my neck and down all the way to the hand in case compression is elsewhere besides elbow. After MRI, which is not scheduled yet, he will discuss treatment options. I've gone through two ulnar nerve compression surgeries in 10 months. He said last surgery my scar tissue was bad and nerve curling up, possibly scar tissue again. Some type of nerve dysfunction according to him.

The physiotherapist asked if transpoing the nerve would help.He just said no.

I've never had this test done before. Will an MRI pinpoint the exact location of compression? Shows nerves, muscles etc? Makes it easier for the surgeon to know where the problem is pinpointed as in knowing exactly what the problem is (scar tissue or something else affecting nerve)?

He said after MRI he would discuss treatment options. I've gone for physio and keep doing exercises at home for mobility. Not sure what other treatment options except surgery?
 John Kenyon, CNA - Wed Feb 04, 2009 9:19 pm

User avatar I hadn't realized a plastic surgeon had been doing the surgeries up til now, but the attitude sounds a lot more like plastics than neurosurgery. I also am amazed that no one has, up til now and through all these surgeries, ordered an MRI of the cervical spine, brachial plexus, etc. To answer your question about the MRI: Maybe. If there is a mechanical compression due to structures being too close together in the ulnar pathway, either at the cervical spine or in the brachial plexus/thoracic outlet, then this would be strongly suggestive of a nerve compression, although it is difficult to visualize actual nerve tissue even by MRI. If there's an orthopedic abnormality along the route of this nerve, that would likely be a source of the problem, even though there is also some compression in your elbow.

I'm amazed that a neurosurgeon isn't involved at this point, and hope that if the MRI shows compression at some other location than your elbow, a neurosurgeon will be brought in to at least consult. If there's only "mild" compression in the elbow you may have had a two-point injury all along. We'll see. Please let us know how this goes.
 toban - Tue Mar 03, 2009 3:26 pm

Another update..

I had a MRI test (scanned my neck and upper arm all the way down to the wrist) a few weeks ago and saw the plastic surgeon today. The MRI results show nothing is wrong at the neck level ( I think he termed it cervical spine) or arm/elbow. My nerve conduction test back in January showed some compression in the elbow. The surgeon asked me what did I want to do. I said I wasn't sure what my options are. He decided to go ahead and operate one more time but that will be the final surgery, no more after that. He said maybe I still have some scar tissue building up and also has decided to transpose the nerve. Sounds like from the converstaion he will transpose it above the old incision line. My previous surgeries I never had my nerve transposed.

With transposition surgery is the recovery longer compared to decompression or medial epicondylectomy surgery? I've had decompression and two medial epicondylectomy surgeries in the past.

The wait time for surgery will be a few months or maybe slightly longer. He said he will try to get me in sooner but can't guarantee.

Thanks for your help!
 John Kenyon, CNA - Thu Mar 05, 2009 12:16 am

User avatar This may be the charm this time. I certainly hope so. I think transposition is a very good idea, and that scar tissue may well be causing the ongoing problem, so that would probably help get the nerve away from all that. The recovery time should be about the sime as with the other surgeries, maybe even a little quicker. It's difficult to predict those things, but based on averages it shouldn't be a terribly drawn out ordeal at all.

Best of luck with this, and please do keep us updated.
 toban - Tue Mar 17, 2009 5:50 pm

Thanks for your help!

I'm concerned about something..

I received my post-op forms and my family doctor filled them out. I noticed under 'type of surgery' it said ulnar nerve decompression. Is that the medical term they use for transposing the nerve or is ulnar nerve decompression a different type of surgery? The surgeon said he would move the nerve above the old incision.

I did get a call today and will be having surgery next week. I mentioned to the receptionist it said on the form ulnar nerve decompression but the surgeon mentioned moving the nerve. Receptionist said 'Same thing"

I'm not an expert and I know the surgeon will do what is best.


??
 John Kenyon, CNA - Sat Mar 21, 2009 9:06 pm

User avatar Not to worry. The receptionis is right in this case, since transposition is sometimes the only effective way to decompress the nerve. It does wind up being the same thing, only easier to say. Good luck with this. Hope it turns out well. Keep us updated.
 toban - Thu Mar 26, 2009 10:35 am

I had my surgery yesterday on the 25th. Out of all the surgeries on my elbow this recent one is really painful, worse pain I've had.

The plastic surgeon told me afterwards that my ulnar nerve was curled or kinked again along with lot's of scar tissue. He transposed the nerve above the old incision area and buried it underneath fat or muscle. I think he said submusclar transposition ? . I was half out of it so I am not sure if what I heard is correct with regards to the type of transposition.

This is the second time my ulnar nerve was kinked, curling up. I was wondering what causes that to occur? Scar tissue pressure or anatomy?

They had trouble finding a vein to put the IV needle in. I guess my veins don't show easily.

One thing I have noticed.. I have quite a bit of tingling, buzzing in my little, ring fingers and slightly into the palm of hand below these two fingers. I had some of this prior to surgery but it is worse since the operation. I suppose this is normal symptoms after this type of surgery? The nurses were aware of it and said if it gets worse to phone the surgeon or go to the ER. I have a dressing with a tensor bandage over top of it from my upper arm to just above my wrist. No drainage tube.

Thanks for your help. I better get off the computer and rest. Pain is sinking in.

They gave me tylenol 3 prescription which helps.
 John Kenyon, CNA - Fri Mar 27, 2009 11:15 am

User avatar I'm sorry to hear there's so much post-op pain this time. I hope the Tyenol 3 will do the trick til that subsides. The curling is odd except in consideration of the buildup of scar tissue, so I would definitely suspect that to be what's causing it. The tingling is normal for the ulnar nerve having been disturbed, in exactly the area you describe. If it gets worse or doesn't start to improve you should at least let your doctor know, simply because part of the aim of this surgery is to relieve that sort of thing. I hope it works. It sounds like the nerve was transposed into a more "comfortable", cushioned area, so it may start to relax a little and hopefully that will lead to more normal functioning.

Please keep us updated here. Good luck with this.
 toban - Wed Apr 01, 2009 7:57 pm

Update

The pins n needles in my little, ring finger, palm area below these two fingers have become quite intense and worse. I phoned the surgeons office and couldn't get in for a few days. It ended up being bad enough that I went to the ER and the plastic surgeon looked at me there. I have a high tolerance but this was keeping me awake at night.He can't figure out why I'm having these excessive sensations with the nerve being moved and prescribed me a slightly stronger pain med. Suppose to phone if things become worse or no change within a few days. I've also noticed steady buzzing type sensations in palm of my hand. I had this previous to surgery off and on. At times the affected areas feel heavy or odd. Incision area has some pins n needles. All of symptoms started slowly, within an hour of being in recovery room after surgery.

On the day of surgery he was pressing , manipulating my forearm (palm side) to see if my little and ring fingers would straighten. Also did this in the ER. Plus held the two fingers down and let go to see if I could keep them bent to the palm but i couldn't. I was told in the past I have claw fingers, they do remain in a bent position. Affected fingers are not stiff but if I make a fist they will not bend completely to the palm, remain curled.

Does clawing become better after these types of surgeries or does it depend if nerve damage? Is there anything that can be done to help with clawing? Physio said exercise won't help clawing. I have done some on my own to keep some mobility. i've had clawing since first surgery but slowly has necome worse. Difficult to use hand due to trouble with little, ring finger etc.
 toban - Wed Apr 08, 2009 3:04 pm

Another update and question..

I have been experiencing a crushing type sensation, pain in my elbow. Almost feels like someone is squeezing the life out of my elbow or a large animal is stepping and squishing it. This sensation has gradually become worse. This past Sunday evening it became so bad I yelped out in pain and almost fell to the ground. This is coming from someone who has a high pain tolerance. I was in tears. I did see the surgeon yesterday for a follow up and couldn't stop shaking. I described the crushing feeling above and pins n' needles etc. He didn't say much but plans on referring me to a pain clinic and physiotherapy. I have a stronger dose of pain meds I'm taking right now until I see someone at the pain clinic (no appt yet, waiting for a phone call) It helps with some of the pain but that crushing sensation is still there. Sometimes its steady other times off and on. I have no idea what is causing this or what is happening. I have never experienced this with my past surgeries. All of this started occuring on the day of surgery, slowly building up. I'm not blaming the surgeon because I know this could be anything.

I was wondering if this is normal after the type of procedure I had? Ulnar nerve transposition (buried nerve under fat- subcutaneous transposition?) along with decompression. Nerve once again was curled up and crushed under scar tissue before he moved it.

Thanks for your help :)
 toban - Wed May 20, 2009 11:05 am

Update..

The crushing sensation is still present. The plastic surgeon sent me to a pain clinic. Even with the few meds I am taking, I can still feel that crushing type sensation. Also a electrical/burning type sensation that travels a few inches away from the end of my incision towards my wrist which is new. The pain, crushing is around the funny bone area and somewhat in the area approximately where the nerve was moved.

The surgeon is not sure what is occuring and would like to present my case to a few other plastic surgeons. I would have to be in attendence by the sounds of it. He said maybe there is something he is not aware of and they will have ideas. My next appt isn't for another 7-8 weeks so I am guessing maybe then something will be set up.
 Heather222 - Tue Jul 13, 2010 5:17 pm

I'm having very similar problems and I'm very curious for an update. I've had 3 surgeries on my right ulnar nerve @ the elbow. The 1st surgery was 1 yr ago. It worked great, then around 7 weeks post-op, I did to much to fast and somehow tore the internal nerve sling (?) they built. I had the next surgery 4.5 months later, after another EMI & MRI showed damage. The 2nd surgery was much easier in comparison to the 1st; however, 2 months later, I developed a lot scar tissue. I went in for the 3rd surgery 4 months after the 2nd. The 3rd surgery (which was a submuscular transposition), I was also in incredible pain! I didn't sleep for over a month until the docs up'd the pain meds. My hand is still clawed 3 months after surgery & I'm still in incredible pain daily. To top it off, my left arm is starting to show similar signs and driving (along with many simple tasks) seem harder than ever. I'm looking for any answers that can help.

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