International Journal of Surgery Case Reports 114 (2024) 109098

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Functional outcome of tardy ulnar nerve palsy manifests after 25 years due
to nonunion of lateral epicondyle left humerus treated by ulnar nerve
transposition: A case report
Karya Triko Biakto a, Ira Nong a, Tri Kurniawan b, *
a
Department of Orthopedic and Traumatology, Faculty of Medicine, Hasanuddin University/Dr. Wahidin Sudirohusodo General Hospital, Makassar, Indonesia
b
Orthopedic and Traumatology, Faculty of Medicine, Hasanuddin University, Indonesia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Tardy ulnar nerve palsy is a chronic clinical condition characterized by delayed-onset ulnar
Tardy ulnar nerve palsy neuropathy.
Cubitus valgus Case presentation: Male 36 years old with 5 years clawing left ring and little finger, weakness of intrinsic muscle
Anterior subcutaneous transposition
and grip, and paresthesia on ulnar nerve distribution. There was a history of elbow trauma 30 years ago. The
Quick dash score
radiological finding is a non-union of the lateral condyle without significant valgus. Intraoperatively, an intact
Case report
ulnar nerve was discovered with no significant fibrous tissue. The author performed anterior transposition of the
ulnar nerve. After 6 months, there is improvement in power and sensibility, with the quick dash score decreasing
from 18 to 6.
Discussion: Any increase in a valgus deformity at the elbow joint would lead to stretching of the nerve resulting in
neuropraxia. On this case we found there is slight valgus deformity, but there is malunion of lateral epicondyle
that causes incongruency of elbow joint that will lead to chronic impingement ulnar nerve. The patient work as
officer working in front of computer typing for hours and sometimes lifting heavy objects. These activities irritate
ulnar nerve on incongruent joint which causes tardy ulnar nerve palsy. The treatment of choice is ulnar nerve
transposition.
Conclusion: The treatment of choice is anterior ulnar transposition. Any condition that impairs the anatomical
structure of the elbow joint can cause ulnar nerve palsy. From this case, we also learn that it is not necessary to
correct bone deformity or stabilize the non-union condyle if there is no significant deformity.

1. Introduction surgery. Most authors recommend anterior transposition of the ulnar

Tardy ulnar nerve palsy is a chronic clinical condition characterized
by delayed onset ulnar neuropathy. Ulnar nerve is vulnerable because of
its curvature around elbow joint. Any pathological condition which al­
ters the normal anatomy of the elbow joint can lead to stretching or
irritation of the nerve [1]. Late-onset ulnar neuropathy was deemed to
result from fractures of the external condyle of the humerus, with mal­
union leading to a cubitus valgus deformity being thought as the prin­
ciple cause of the posttraumatic ulna nerve palsy [2]. Tardy nerve palsy
can also result from cubitus varus deformity following old supra­
condylar fracture of humerus [1].
The recovery of the ulnar nerve will depend on the severity of the
nerve injury pre-operatively and the correction of the deformity after
nerve to release the tension. This can be done with or without correcting
the cubitus valgus deformity [2]. From that explanation, we present a
follow-up result of a case of tardy ulnar nerve palsy, which was treated
with anterior transposition of the ulnar nerve only without any inter­
vention on the bone. This study was written to provide information
about the outcome of anterior nerve transposition without any inter­
vention to the bone, as long as it doesn't have a significant deformity.
This case report has been written according to the SCARE criteria [3].
2. Case presentation
A male, 36 years old, came to the hospital with a chief complaint of
clawing at the left ring and a little finger that he had initially suffered

* Corresponding author at: Department of Orthopedic and Traumatology, Faculty of Medicine, Hasanuddin University, Makassar 90245, Indonesia.
E-mail address: tri_kurniawan@rocketmail.com (T. Kurniawan).

https://doi.org/10.1016/j.ijscr.2023.109098
Received 15 October 2023; Received in revised form 22 November 2023; Accepted 27 November 2023
Available online 28 November 2023
2210-2612/© 2023 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
K.T. Biakto et al. International Journal of Surgery Case Reports 114 (2024) 109098

from approximately 5 years ago. Patients also complained of numbness

and tingling sensations on the ulnar side of the left forearm, from the left
elbow until the tip of the ring and little finger. These complaints have
been getting worse for six months ago. The complaint increases, espe­
cially when the patient is working in front of a computer for more than
10 min. There was a history of trauma at the left elbow; the patient fell
down while playing football when he was 6 years old (around 30 years
ago) in an outstretched hand position. At the time of injury, the patient
fell down with left upper limb supporting his body with the elbow was in
fully extension and pronation. After the injury, the elbow was left un­
treated. The patient works as an officer with right-handed dominance.
Physical examination revealed clawing at the left ring and little
finger, wasting at the hypothenar muscle and dorsal interosseus muscle,
and weakness of the intrinsic muscle, which is shown by the weakness of
finger adduction of the ulnar-sided fingers. The sensation was reduced
by ulnar nerve distribution. There is a slight valgus deformity observed
Fig. 2. Radiograph of left elbow AP and lateral view.
on the left elbow with a carrying angle of 14◦ and an elbow range of
motion of 0◦ extension and 135◦ flexion (Fig. 1). The radiograph showed
3. Discussion
non-union of the lateral condyle of the left humerus (Fig. 2). The pre­
operative diagnosis was tardy ulnar nerve palsy due to non-union lateral
The ulnar nerve is relatively fixed behind the medial epicondyle of
condyle left humerus.
the humerus. Any increase in a valgus deformity at the elbow joint
The patient was treated with anterior transposition of the ulnar nerve
would lead to stretching of the nerve resulting in neuropraxia. This
with a medial approach, with the incision line and landmark at medial
condition is temporary and usually recovers with remyelination of the
epicondyle (Fig. 3). The incision began with a sharp incision until sub­
axon that takes about three weeks to three months [4].
cutaneous tissue; after that, a blunt dissection was performed until an
If the deforming force is progressive, it might injure the axon within
ulnar nerve was found. We found the ulnar nerve in intact condition
the endo neural tube of the nerve with intra-neural scarring and fibrosis
with less fibrous tissue, and the non-union was not addressed as the
resulting in axonotmesis. The outcome of axonometsis is variable,
patient displayed no elbow symptoms or limitations. Then, the sur­
depending on the magnitude of the intra-neural injury. Neurotmesis is
rounding tissue around the ulnar nerve was removed, and the ulnar
uncommon in tardy ulnar nerve palsy [4].
nerve was fully freed. The ulnar nerve then moves anteriorly in front of
Tardy ulnar nerve palsy is a chronic clinical condition characterized
the medial epicondyle of the humerus.
by a delayed onset ulnar neuropathy after an injury to the elbow.
After 6 months post-operation, the patient reported that clawing was
Common presenting symptoms include the following: vague discomfort
decreased, and numbness and tingling were also decreased. The patient
localized to the medial elbow; paresthesia or numbness in the ring and
also reported that finger movement improved, but there is still weakness
small fingers of the hand; decreased grip and/or pinch strength; fatigue
in finger adduction. Sometimes the patient still felt tingling and numb­
with repetitive tasks involving the hands; worsening of symptoms at
ness when they sat down too long typing in front of the computer (for
night or with flexion of the elbow, such as when talking on the telephone
more than 45 min), but the complaint resolved spontaneously within a
[5].
few minutes, and for everyday activities, the patient didn't report any
On physical examination, atrophy of the intrinsic muscles of the
difficulties or complaints except typing for too long.
hand and, in particular, the first dorsal interosseous muscle and clawing
A physical exam showed the atrophy of the hypothenar and inter­
of the small and ring fingers can be found. Besides that, Wartenberg's
osseus muscles improved (Fig. 4). Sensibility is fully recovered. Table 1
sign can also be observed, in which patients are unable to fully adduct
shows the comparison of quick dash scores before and after the opera­
the small finger or to hold the small finger in a slightly abducted and
tion. The modified Bishop score after 6 months was 8, which means an
extended position [5].
excellent outcome.
Tardy ulnar nerve palsy has a variety of etiological factures including

Fig. 1. Pre-operative clinical finding.

2
K.T. Biakto et al.
Fig. 3. (A) Surgical landmark and incision; (B) Ulnar nerve decompressed and anteriorly placed.
Fig. 4. Clinical finding 6 months post operation.
Table 1
Quick dash score before and after operation.
Pre- Post- Diagnosis
operative operative
Quick 18 6 Tardy ulnar nerve palsy due to nonunion
Dash lateral epicondyle humerus
old fractures around the elbow, arthritis, cyst of elbow, congenital
anomalies, adhesion, recurrent dislocation of the elbow etc. However
majority of cases are as a consequence old fractures around the elbow,
and more than half of which are due to fracture of the lateral condyle
with resultant cubitus valgus deformity [1].
Tardy nerve palsy can also result from cubitus varus deformity
following old supracondylar fracture of humerus [1]. The recovery of
the ulnar nerve will depend on the severity of the nerve injury pre-
operatively and the correction of the deformity after surgery. Most au­
thors recommend anterior transposition of the ulnar nerve to release the
tension. This can be done with or without correcting the cubitus valgus
deformity [2].
In this case, we found there is late-onset ulnar nerve palsy, in which
the symptoms appear after around 25 years. The patient clearly had
ulnar palsy symptoms such as clawing of the ring and little finger,
weakness of intrinsic muscle, hypoesthesia and paresthesia along the
ulnar nerve distribution, and wartenberg's sign. There was a history of
elbow trauma that went untreated.
Nonoperative treatment is the first treatment option for mild-to-
moderate cubital tunnel syndrome. However, most patients presenting
with tardy ulnar nerve palsy are not candidates for conservative treat­
ment because of the mechanical characteristics of the pathology. Sur­
gical treatment is recommended to correct the local bony deformity
and/or to decompress the nerve [5]. Various surgical techniques have
been developed for the management of ulnar neuropathy at the elbow
joint. Decompression and anterior subcutaneous transposition of the
ulnar nerve have become integral parts of the operative treatment of an
ununited fracture of the distal part of the humerus, either by the open
3
International Journal of Surgery Case Reports 114 (2024) 109098
method or by endoscopy [6,7]. In their review of 36 patients treated
using anterior transposition of the ulnar nerve, Stolke et al. reported a
completely recovery in 36 % of these cases, with good results achieved
in 31 % of cases and no change in 33 % [8]. Study by Thomas et al.
which compare pre and post-operative ulnar nerve function showed
significant improvement on patient rated Dellon score (p value = 0.031)
and Q-DASH scores (p value = 0.016) [7]. The advantages of endoscopic
anterior nerve transposition procedure when compared to open ulnar
nerve transposition include the following: the considerably smaller
incision provides better aesthesis and less post-operative morbidity with
potentially faster healing time, better intraoperative visualization of the
nerve in its bed, lesser vascular insult and ischaemia of the nerve,
considerably lesser chance of neuroma of medial cutaneous nerve and its
branches [7].
Beside decompression and anterior subcutaneous of ulnar nerve to
relieve the nerve compression, on the patient with concomitant cubitus
valgus, other surgical management for bony procedure can be per­
formed: distal humerus osteotomy with closed wedge osteotomy on
medial side or supracondylar shortening wedge rotary osteotomy [2,9].
This bony procedure aims to restore the normal biomechanical charac­
teristics of the affected limb and improve elbow joint function [9].
This patient was treated with ulnar nerve anterior transposition
without osteotomy or correcting the malunion of the lateral condyle
because there is no significant deformity. In the intraoperative, the
author found intact ulnar nerve, less scarring or fibrotic tissue com­
pressed the nerve, and there is no pseudo-joint on the lateral epicondyle,
concluding that the lateral epicondyle is mal-union. The causes of nerve
palsy in this case are chronic impingement of the ulnar nerve due to
incongruent left elbow joint activity. The patient works as an officer,
typing in front of a computer for hours and sometimes lifting heavy
objects. These activities further irritate, stretch, or compress the ulnar
nerve on an incongruent joint, which causes tardy ulnar nerve palsy. The
choice of treatment for this condition is ulnar nerve transposition. The
functional outcome after 6 months is satisfied. The quick DASH score
decreased from 18 to 6, with improvements in muscle power, atrophy of
muscle, and sensibility. The modified Bishop score is also used to
K.T. Biakto et al. International Journal of Surgery Case Reports 114 (2024) 109098

evaluate the residual symptoms following surgical treatment. The score publication of this case report and accompanying images. A copy of the
was 8, which means an excellent outcome. written consent is available for review by the Editor-in-Chief of this
journal on request.
4. Conclusion

The treatment of choice for tardy ulnar nerve palsy is anterior sub­ Conflict of interest statement
cutaneous ulnar transposition, which shows a good result. Any condition
that impairs the anatomical structure of the elbow joint can cause ulnar The authors declare that there are no conflicts of interest regarding
nerve palsy. From this case, we also learn that it is not necessary to the publication of this article.
correct bone deformity or stabilize the non-union condyle if there is no
significant deformity. References

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