Hand Pain And Weakness After Distal Humerus Open Reduction And Internal Fixation

HISTORY: 70-year-old male with past surgical history significant for Grade 1 open right comminuted intra-articular distal humerus fracture and traumatic laceration of the right triceps tendon status-post open reduction internal fixation (ORIF) of right distal humerus, transposition of the right ulnar nerve, and primary repair of the triceps tendon laceration 3 years ago, who presented with persistent paresthesias in the medial forearm and hand into the 4th and 5th digits and pain the posterior lateral aspect of his elbow since time of surgery. PHYSICAL EXAMINATION: Examination of the right elbow demonstrates well-healed posterior surgical incision. Tenderness to palpation over the olecranon, medial epicondyle, and lateral epicondyle. Passive and active range of motion testing demonstrates 10 degrees short of elbow extension, 130 degrees of flexion, 80 degrees of pronation, and 70 degrees of supination. Strength testing demonstrates 5-/5 right elbow extension, 4/5 first dorsal interosseous, and 5/5 pronation, supination, and wrist extension/flexion. Positive Tinel's anterior to the cubital tunnel. Decreased sensation in the ulnar nerve distribution. DIFFERENTIAL DIAGNOSIS: 1. Ulnar neuropathy2. Cubital tunnel syndrome3. Carpal tunnel syndrome4. Cervical radiculopathy5. Hardware failure TEST AND RESULTS: Electrodiagnostic testing:- Ulnar neuropathy at the elbow that appears electrically moderate in severity- No evidence of cervical radiculopathySonographic evaluation:- Ulnar nerve sits posterior to the medial epicondyle, abut against the medial fixation plate, and partially sublux on flexion FINAL WORKING DIAGNOSIS: 1. Right ulnar neuropathy secondary to hardware malpositioning, failed ulnar nerve transposition, and ulnar nerve subluxation over the medial fixation plate. TREATMENT AND OUTCOMES: Patient to follow-up with orthopaedic surgery for removal of hardware and transposition of the ulnar nerve.