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Preface
The diagnosis and treatment of cubital tunnel syndrome remains a challenge for therapists, physicians, and surgeons. Despite years of research, there remains little consensus on the ideal diagnostic criteria, the benefits of nonoperative treatment, and the optimal technique for surgical release. In addition, the results of surgical treatment are more variable and often less successful than those of carpal tunnel release. The purpose of this text is to bring together experts in the fields of hand surgery and hand therapy to review the current state of the art in the diagnosis, nonsurgical management, and surgical management of cubital tunnel syndrome. I am confident that this textbook will improve patient care and outcomes.
Pittsburgh, PA, USA
John R. Fowler
Acknowledgments
I would like to thank Freddie Fu, chairman of the Department of Orthopaedic Surgery at the University of Pittsburgh, for his continued support.
I would like to thank Prakash Marudhu and Kristopher Spring for their tireless efforts in guiding this textbook to completion.
Jodi Seftchick
8 Anterior Transposition in Cubital
Joseph Said and Asif M. Ilyas 9 Minimal Medial Epicondylectomy
Loukia K. Papatheodorou and Dean G. Sotereanos 10 Anterior Interosseous Nerve to Ulnar Nerve
Aaron B. Mull 11 Management of the “Failed” Cubital
Rikesh A. Gandhi, Matthew Winterton, and Stephen Y. Liu
Matthew R. Walker and Anne Argenta
Wesley N. Sivak and Robert J. Goitz
Contributors
Anne Argenta, MD Department of Plastic Surgery, Medical College of Wisconsin, Wauwatosa, WI, USA
Mark Baratz, MD Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
Brian Chenoweth , MD Department of Orthopaedics, University of Oklahoma, Norman, OK, USA
Cassidy Costello, BS Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
Jennifer D’Auria, MD Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
Rafael J. Diaz-Garcia, MD, FACS Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Surgery Institute, Allegheny Health Network, Pittsburgh, PA, USA
John R. Fowler, MD University of Pittsburgh, Pittsburgh, PA, USA
Rikesh A. Gandhi, MD Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
Contributors
Robert J. Goitz, MD Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Asif M. Ilyas, MD, FACS, FAAOS Rothman Orthopaedic Institute, Philadelphia, PA, USA
Thomas Jefferson University, Philadelphia, PA, USA
Nicole J. Jarrett, MD Cooper University Health Care, Camden, NJ, USA
David M. Kahan, MD, FACS Rothman Institute, Philadelphia, PA, USA
Cassandra Lawrence, MD Department of Ortho paedic Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
Stephen Y. Liu, MD Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
Michael J. Mehnert, MD Rothman Orthopaedic Institute, Philadelphia, PA, USA
Michael W. Molter, DO Rothman Orthopaedic Institute, Philadelphia, PA, USA
Aaron B. Mull, MD Orthopaedic Associates, Evansville, IN, USA
Marie Pace, OTR/L, CHT UPMC Centers for Rehab Services, Hand and Upper Extremity Rehab Clinic, Pittsburgh, PA, USA
Loukia K. Papatheodorou, MD, PhD Orthopaedic Specialists – UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Contributors
Joseph Said, MD Summit Medical Group, Westfield, NJ, USA
Jodi Seftchick, MOT, OTR/L, CHT Centers for Rehab Services, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Wesley N. Sivak, MD, PhD Plastic, Reconstructive and Hand Surgery, OhioHealth Plastic and Reconstructive Surgeons, Columbus, OH, USA
Dean G. Sotereanos, MD Orthopaedic Specialists – UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Joseph F. Styron, MD, PhD Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH, USA
Richard J. Tosti, MD Philadelphia Hand to Shoulder Center, Thomas Jefferson University, King of Prussia, PA, USA
David Turer, MD, MS Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Matthew R. Walker, MD Department of Plastic Surgery, Medical College of Wisconsin, Wauwatosa, WI, USA
Matthew Winterton, MD Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
Part I
Chapter 1 Anatomy of the Ulnar Nerve and Cubital Tunnel
Cassandra Lawrence and Richard J. Tosti
Introduction
Compression neuropathy of the fascicles comprising ulnar nerve can occur at several locations along its course from the central nervous system to the peripheral end organ (Table 1.1). The aim of the following chapter is to describe the anatomy of the ulnar nerve from the nerve roots that exit the spine and through the brachial plexus and the upper extremity while focusing on potential sites of compression. Additionally, this description will detail the internal anatomy of the nerve as it relates to management of acute injury and/or reconstruction of function through nerve transfers.
C. Lawrence (*)
Department of Orthopaedic Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
e-mail: cassandra.lawrence@rothmanortho.com
R. J. Tosti
Philadelphia Hand to Shoulder Center, Thomas Jefferson University, King of Prussia, PA, USA
J. R. Fowler (ed.), Cubital Tunnel Syndrome, https://doi.org/10.1007/978-3-030-14171-4_1
C. Lawrence and R. J. Tosti
Table 1.1 Common sites of compression of the ulnar nerve
Location Common etiologies
Spine
Anterior and middle scalene
Intermuscular septum, arcade of Struthers
Osborne’s ligament or anconeus epitrochlearis
Ulnar and humeral heads of FCU
Guyon’s canal (ulnar tunnel)
Trauma, tumors, intervertebral disk herniation, osteophyte
Tumors, spasm, cervical rib
Triceps hypertrophy, iatrogenic following anterior transposition
Idiopathic, elbow flexion contracture, trauma
Muscle hypertrophy, iatrogenic following anterior transposition
Tumor, ulnar artery thrombosis, hook of hamate fracture
Central Nervous System
Clinical manifestation
Cervical radiculopathy
Thoracic outlet syndrome
Cubital tunnel syndrome
Cubital tunnel syndrome
Cubital tunnel syndrome
Ulnar tunnel syndrome
Volitional movement of the upper extremity is initiated in the motor cortex neurons in the dorsal portion of the frontal lobe. These neurons relay to the thalamus, decussate in the brain stem, descend in the lateral corticospinal tract, and synapse in the anterior horn. The lower motor neuron cell bodies originate in the anterior horn, exit via the ventral root, and blend with the dorsal root to become a peripheral nerve that exits the spine through the neural foramina. The lower neurons could potentially become compressed at this level by a herniated intervertebral disk, fracture, or an osteophyte. After exiting the spine, the peripheral nerve root divides to form dorsal or ventral rami. Ventral rami from C5 to T1 coalesce to form the brachial plexus.
Chapter 1. Anatomy of the Ulnar Nerve and Cubital Tunnel
Sensibility of the upper extremity follows an afferent pathway from the periphery to the central nervous system. The first neuron cell body is located in the dorsal root ganglion of the spinal nerve. The dorsal root ganglion cells will relay with neurons in the brainstem or spinal cord. Neurons sensing touch and pain are relayed to the thalamus and then ultimately to the postcentral gyrus of the parietal lobe.
Nerve Roots and Brachial Plexus
The brachial plexus is a network of nerves beginning at the lower cervical and upper thoracic spine, which extend to the axilla (Fig. 1.1). This collection of nerves originates from the ventral rami of the inferior four cervical nerves and first thoracic nerve (C5, C6, C7, C8, T1). These five spinal nerve roots of the brachial plexus course along with the subclavian artery and pass between a potential compression site at interval between the anterior and middle scalene muscles (i.e., thoracic outlet syndrome). The nerve roots of the plexus combine to form three trunks. C5 and C6 unite to form the
Musculocutaneous
Figure 1.1 Schematic of the brachial plexus
C. Lawrence and R. J. Tosti
superior trunk. The continuation of the C7 nerve root constitutes the middle trunk. The C8 and T1 nerve roots unite to form the inferior trunk. Next, the trunks pass through the cervico-axillary canal. This space lies posterior to the clavicle and is bound by the first rib and superior scapula. At this point, the superior, middle, and inferior trunks each divide into anterior and posterior divisions. Derivatives of the anterior division innervate the flexors of the arm, while derivatives of the posterior division innervate extensors of the arm. The anterior divisions of the superior and middle trunks combine to form the lateral cord. The anterior division of the inferior trunk constitutes the medial cord. The posterior divisions of all three trunks (superior, middle, and inferior) constitute the posterior cord. The peripheral nerve branches coming from the brachial plexus can be split broadly into two categories, supraclavicular and infraclavicular. The supraclavicular branches originate from the anterior rami of C5–7 and superior trunk. The infraclavicular branches originate from the lateral, medial, and posterior cords. While the brachial plexus gives rise to several peripheral nerve branches, this text will focus on the ulnar nerve. The ulnar nerve is the terminal branch of the medial cord and receives fibers from C8, T1, and sometimes C7.
Upper Arm to Cubital Tunnel
After exiting the medial cord of the brachial plexus, the ulnar nerve passes anterior to the insertion of teres major and the long head of the triceps. It runs medially in the anterior compartment of the upper arm and remains posteromedial to the brachial artery. Approximately 8 cm proximal to the medial epicondyle (or 2/3 of the distance distally in the arm), the nerve pierces the intermuscular septum and enters the posterior compartment of the arm along with the superior ulnar collateral artery. These structures descend between the intermuscular septum and the medial head of the triceps. In many individuals, the ulnar nerve passes underneath the arcade of
Chapter 1. Anatomy of the Ulnar Nerve and Cubital Tunnel
Struthers. The arcade is a thin band of connective tissue extending from the medial intermuscular septum to the medial head of the triceps approximately 8 cm proximal to the medial epicondyle of the humerus and is one potential site of ulnar nerve entrapment [1] (Fig. 1.2). After descending along the medial head of the triceps, the ulnar nerve then travels posterior to the medial epicondyle of the humerus and medial to the olecranon. The ulnar nerve, medial epicondyle, and olecranon are all palpable structures. The ulnar nerve has no branches in the arm proximal to the elbow, but it does supply articular branches to the elbow joint.
Cubital Tunnel
Distal to the medial epicondyle, the ulnar nerve passes through the cubital tunnel. The roof of the cubital tunnel is formed by Osborne’s ligament. This extends from the medial epicondyle and the humeral head of the flexor carpi ulnaris (FCU) muscle to the olecranon and ulnar head of the FCU muscle [2, 3]. The ligament is typically approximately 2.2 cm
Figure 1.2 Anatomy of the ulnar nerve at the elbow in a cadaver
in length and 4 mm in width [4]. In up to 30% of the population, the anconeus epitrochlearis muscle follows a similar course to that of the Osborne’s ligament, which can also compress the nerve when present [5] (Fig. 1.3). The floor of the cubital tunnel is composed of the medial collateral ligament of the elbow, the elbow joint capsule, and the olecranon.
Forearm
After passing through the cubital tunnel, the ulnar nerve courses through the deep flexor pronator aponeurosis and between the ulnar and humeral heads of the FCU muscle. The deep flexor pronator aponeurosis in the forearm represents another potential site of compression of the ulnar nerve. The nerve then travels along the ulna superficial to the flexor digitorum profundus (FDP) muscle and deep to the FCU muscle (Fig. 1.4). It courses medial to the ulnar artery. The ulnar nerve gives off two motor branches in the anterior fore-
Figure 1.3 Anconeus epitrochlearis muscle above the freer elevator
C. Lawrence and R. J. Tosti
Chapter 1. Anatomy of the Ulnar Nerve and Cubital Tunnel
arm to the FCU and medial half of the FDP muscles. Contraction of the FCU produces flexion and ulnar deviation at the wrist, while the ulnar innervated portion of the FDP muscle flexes the interphalangeal joints of the fourth and fifth digits. The ulnar nerve also gives off the palmar cutaneous branch and dorsal cutaneous branch in the forearm, which provide sensory innervation for the medial half of the palm and the dorsal medial 1½ digits and associated dorsal hand region, respectively [6, 7].
Guyon’s Canal, Wrist, and Hand
At the level of the wrist, the ulnar nerve passes superficial to the flexor retinaculum and enters the hand through Guyon’s canal or the “ulnar tunnel,” which is the most distal site of compression (Fig. 1.4). The canal spans the proximal end of the pisiform to the hook of the hamate, the roof of which is formed by the volar carpal ligament and pisohamate ligament. The canal contains the ulnar nerve and artery (radial to
1.4
Figure
Anatomy of the ulnar nerve at the forearm in a cadaver
C. Lawrence and R. J. Tosti
Table 1.2 Ulnar tunnel zones
Zone Location Symptoms
1 Proximal to bifurcation of deep and superficial branches
2 Deep motor branch
3 Superficial sensory branch
Mixed motor and sensory
Motor only
Motor only
the nerve). The ulnar nerve gives off superficial and deep branches within the canal. The superficial branch travels on the ulnar side, while the deep branch travels on the radial side. The superficial branch provides sensory innervation to the palmar surface of the medial 1½ digits. The deep branch innervates the hypothenar muscles and then courses radially beneath the hook of the hamate with the ulnar artery to innervate the majority of the intrinsic hand muscles, including the ulnar two lumbricals, adductor pollicis, interosseous muscles, deep head of the flexor pollicis brevis, and palmaris brevis. Occasionally the ulnar tunnel is described in zones (Table 1.2).
Internal Anatomy of the Ulnar Nerve
In 1945, Sunderland studied the intraneural topography of peripheral nerves in the upper extremity and determined the distance over which individual peripheral nerves innervating muscular and cutaneous structures maintained their discrete identities [8]. His work is clinically significant as it provides the applied anatomy for nerve transfers in the upper extremity.
When treating upper extremity peripheral nerve injuries, distal median to ulnar nerve transfers can be performed to restore motor and sensory function of the ulnar nerve. Knowledge of ulnar nerve topographic anatomy is of particular importance when performing these procedures. Typically, three discrete fascicles of the ulnar nerve are identified 9 cm proximal to the radial styloid [9, 10]. At this level, the ulnar
Chapter 1. Anatomy of the Ulnar Nerve and Cubital Tunnel
nerve topographic pattern is sensory-motor-sensory. From ulnar to radial, the fascicles are arranged as follows: dorsal cutaneous branch, ulnar motor branch, and superficial sensory branch. The motor fascicular group is smaller, constituting approximately 40% of the main ulnar nerve bundle, while the sensory fascicular group comprises approximately 60% of the ulnar nerve bundle [11]. Intraoperatively, microforceps can be used to apply gentle pressure to distinguish the natural cleavage lines between the motor and sensory groups.
Another clinical application of the topographical anatomy of the ulnar nerve is restoration of elbow flexion after brachial plexus injury. In 1994, Oberlin et al. described a technique for transferring one or more fascicles of the intact ulnar nerve to the nerve to the biceps after C5–6–7 brachial plexus root injury, also recognized as the Oberlin transfer [12]. An anteromedial incision is made in the arm, and the ulnar nerve is identified in the medial mid-brachium adjacent to the brachial artery. An epineural incision is made, and the ulnar nerve fascicles are identified with electrical stimulation. Typically, visual inspection of the fascicles is performed to match the appropriate size of the donor nerve to the recipient. From comparison of the cross-sectional areas of the ulnar nerve and the musculocutaneous nerve, the authors determined that 10% of the ulnar nerve would be required to innervate the biceps muscle at the same level. This percentage typically translates to 1–3 individual fascicles of the ulnar nerve [12]. Fascicles supplying the flexor carpi ulnaris muscle can be distinguished from intrinsic muscles of the hand with electrical stimulation and are selected for transfer. Often the FCU fascicle is anterior and medial within the nerve.
Conclusion
Various potential sites of compression exist as the ulnar nerve courses through the upper extremity. Knowledge of the detailed anatomy of the ulnar nerve is critical for the diagnosis and treatment of cubital tunnel syndrome among other peripheral nerve injuries.
C. Lawrence and R. J. Tosti
References
1. Tubbs RS, Deep A, Shoja MM, Mortazavi MM, Loukas M, Cohen-Gadol AA. The arcade of Struthers: an anatomical study with potential neurosurgical significance. Surg Neurol Int. 2011;2:184. https://doi.org/10.4103/2152-7806.91139
3. Boone S, Gelberman RH, Calfee RP. The management of cubital tunnel syndrome. J Hand Surg Am. 2015;40(9):1897–904. https:// doi.org/10.1016/j.jhsa.2015.03.011.
4. Granger A, Sardi JP, Iwanaga J, Wilson TJ, Yang L, Loukas M, et al. Osborne’s ligament: a review of its history, anatomy, and surgical importance. Cureus [Internet]. 2017 [cited 2018 Aug 7];9(3). Available from: https://www.cureus.com/articles/6467osbornes-ligament-a-review-of-its-history-anatomy-andsurgical-importance
5. Dellon AL. Musculotendinous variations about the medial humeral epicondyle. J Hand Surg (Br). 1986;11(2):175–81.
6. Paulos R, Leclercq C. Motor branches of the ulnar nerve to the forearm: an anatomical study and guidelines for selective neurectomy. Surg Radiol Anat. 2015;37(9):1043–8. https://doi. org/10.1007/s00276-015-1448-1.
7. Mahan MA, Gasco J, Mokhtee DB, Brown JM. Anatomical considerations of fascial release in ulnar nerve transposition: a concept revisited. J Neurosurg. 2015;123(5):1216–22. https://doi. org/10.3171/2014.10.JNS141379
8. Sunderland S. The intraneural topography of the radial, median and ulnar nerves. Brain. 1945;68(4):243–98. https://doi. org/10.1093/brain/68.4.243.
9. Barbour J, Yee A, Kahn LC, Mackinnon SE. Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer for intrinsic musculature reinnervation. J Hand Surg Am. 2012;37(10):2150–9. https://doi.org/10.1016/j.jhsa.2012.07.022.
10. Chow JA, Van Beek AL, Meyer DL, Johnson MC. Surgical significance of the motor fascicular group of the ulnar nerve in the forearm. J Hand Surg Am. 1985;10(6 Pt 1):867–72.
11. Brown JM, Yee A, Mackinnon SE. Distal median to ulnar nerve transfers to restore ulnar motor and sensory function within the hand: technical nuances. Neurosurgery. 2009;65(5):966–77; discussion 977–8. https://doi.org/10.1227/01.NEU.0000358951.64043.73.
Chapter 1. Anatomy of the Ulnar Nerve and Cubital Tunnel
12. Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am. 1994;19(2):232–7. https://doi.org/10.1016/0363-5023(94)90011-6.
Chapter 2 Cubital Tunnel: History and Physical Examination
Joseph F. Styron
Cubital tunnel syndrome is the second most common compressive neuropathy within the upper extremity [1]. The cubital tunnel is the most common location for compression of the ulnar nerve, although there are multiple other potential compression sites along its course from the neck to the hand. Patients rarely present with pain as their primary complaint. The most common presentation is paresthesias within the ulnar nerve distribution. Weakness of the intrinsic muscles within the hand is also a common symptom at presentation which may manifest as subtly as subjective clumsiness, or since the ulnar nerve is a primary driver of grip strength, its compromise often results in weakening of grip strength [2]. Multiple other etiologies can similarly produce paresthesias, weakness, and pain though, including C8/T1 radiculopathy, thoracic outlet syndrome, and ulnar nerve compression within Guyon’s canal at the wrist. An astute clinician must
J. R. Fowler (ed.), Cubital Tunnel Syndrome, https://doi.org/10.1007/978-3-030-14171-4_2
J. F. Styron
distinguish these other potential sources of ulnar nerve impairment from cubital tunnel syndrome.
History
The following are critical aspects of the patient’s history that should be obtained:
1. Duration of symptoms.
2. Consistency of symptoms.
3. Subjective sense of numbness or pain.
4. Location of numbness (radial/ulnar side of hand and volar/ dorsal).
5. Grip or pinch strength weakness.
6. Positional or temporal patterns of symptoms.
7. Aggravating/alleviating factors/positions.
8. Previously attempted interventions and their efficacy.
9. Comorbidities and prior elbow injuries.
It is important to ascertain the duration of symptoms. An acute onset may be secondary to an injury. Recent elbow trauma may produce swelling within the cubital tunnel causing acute compression of the ulnar nerve. Patients typically cannot recall any specific insult but report a more insidious onset of numbness over the previous weeks, months, or even years.
The consistency of symptoms may be the most important information to glean. While the symptoms are still intermittent with periods of normal nerve function, the likelihood for a complete recovery is still a reasonable expectation. However, once the patient develops constant symptoms with intermittent exacerbations, the goal of intervention shifts toward an effort to prevent the symptoms from worsening, because a restoration of their prior “normal” baseline nerve function may be unattainable and is certainly unreliable.
Pain is an uncommon complaint of patients presenting with cubital tunnel syndrome [3]. Patients often will endorse their “entire” hand having episodes of paresthesias; however, when probed and asked to monitor their symptoms more closely, they will admit the numbness is predominantly in
their small finger and the ulnar half of the ring finger. As compression of a sensory nerve progresses, it occurs in a predictable manner. The first threshold change is loss of vibratory perception; then with progressive conduction block or degeneration, there is loss of innervation density manifested as decreased two-point discrimination [4]. If the patient has a sensory disturbance on the dorsum of the hand, it confirms that the compression of the ulnar nerve is proximal to Guyon’s canal based on the origin of the dorsal cutaneous branch of the ulnar nerve in the distal forearm. If the patient does complain of pain, other etiologies must be excluded such as flexor carpi ulnaris tendinitis, medial epicondylitis, and ulnohumeral osteoarthritis. Cubital tunnel syndrome may be associated with pain at the cubital tunnel region, medial epicondyle, and into the forearm.
Weakened grip strength is not uncommon with compression of the ulnar nerve at the cubital tunnel. Fine motor control of the hand may be impaired as these are primarily performed by the ulnar-innervated intrinsic muscles. This may be manifested as difficulty buttoning a shirt, clipping nails, or easy fatiguability. Less chronic compression may result in a subjective sense of clumsiness but not result in muscular atrophy. Intrinsic muscle atrophy is evidence of long-standing compression of the ulnar nerve. In extreme cases, ulnar clawing is possible due to weakness of the third and fourth lumbricals, resulting in hyperextension at the metacarpophalangeal joints and flexion of the interphalangeal joints in the small and ring fingers. Several classic physical exam findings are based on the weakness of ulnar-innervated muscles [5]. The Wartenberg sign is a manifestation of interossei weakness, Froment sign represents weakness in the adductor pollicis, and as mentioned, the claw hand deformity is due to weakness in the ulnar lumbrical muscles. Patients with cubital tunnel syndrome are four times more likely to present with muscle atrophy than are patients with carpal tunnel syndrome [6].
Positional variation in the symptoms is common. Most often, patients will complain of increased numbness in the ulnar nerve distribution with repetitive or prolonged elbow Chapter 2.
J. F. Styron
flexion. Gelberman et al. demonstrated that progressive elbow flexion to 130° resulted in increased intraneural pressure in the ulnar nerve as it courses behind the medial epicondyle in the cubital tunnel [7]. In addition, the nerve itself undergoes significant strain and elongates 4.7 mm with elbow flexion. This further increases to 8 mm with the addition of shoulder abduction and external rotation [8]. There are multiple sites of potential compression for the ulnar nerve around the elbow. Therefore, identifying if a particular movement elicits the symptoms can help distinguish the location of compression. The ulnar nerve travels through the arcade of Struthers, posterior to the medial intermuscular septum, then posterior to the medial epicondyle, into the cubital tunnel, and then through the deep flexor pronator aponeurosis, all of which are potential locations of compression and potential sites for intervention at the time of a surgical release. Unfortunately, it is due to these variable sites of potential compression and the dynamic nature of the compression that lead to false-negative results in electrodiagnostic studies.
Aggravating or alleviating factors are always important to take into consideration as they may help guide non-operative management early in the course of treatment. Frequently patients may experience spontaneous resolution of their mild intermittent symptoms with avoidance of provocative causes. Such alleviating factors will be discussed in greater detail later but may include activity modification (e.g., arm position while driving or using the telephone) and nocturnal splints to prevent maximum or repetitive elbow flexion.
Identifying which treatment modalities the patient may have already attempted can help guide the diagnosis and treatment of cubital tunnel syndrome. For example, wearing nocturnal wrist splints may be effective for the treatment of mild carpal tunnel syndrome, but splinting to prevent elbow flexion is more efficacious in treating cubital tunnel syndrome.
Certain comorbidities are associated with increased risk for the development of cubital tunnel syndrome, including diabetes, thyroid disease, hemophilia, or general peripheral neuropathies [1]. In addition, the practitioner should determine if the patient may have compression due to other struc-
Chapter 2. Cubital Tunnel: History and Physical...
tures such as osteophytes from degenerative arthritis of the elbow, ganglion cysts (Fig. 2.1), tumors, anomalous bands of fibrous tissue, or an anconeus epitrochlearis muscle such that proper excision of these structures can eliminate compression of the ulnar nerve. A distal humerus fracture resulting in cubi-
Figure 2.1 (a) Ganglion cyst compressing the ulnar nerve in the cubital tunnel; (b) the ganglion cyst has been excised and you can see the hourglass compression shape of the ulnar nerve
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The Project Gutenberg eBook of Echo de Paris
This ebook is for the use of anyone anywhere in the United States and most other parts of the world at no cost and with almost no restrictions whatsoever. You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this ebook or online at www.gutenberg.org. If you are not located in the United States, you will have to check the laws of the country where you are located before using this eBook.
Title: Echo de Paris
Author: Laurence Housman
Release date: November 2, 2023 [eBook #72010]
Language: English
Original publication: New York: D. Appleton and Company, 1924
Credits: Bob Taylor, Charlene Taylor and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)
Echo de Paris
Echo de Paris
BY
Laurence Housman
Author of “Angels and Ministers,” “Prunella,” “An Englishwoman’s Love-Letters,” Etc.
D. Appleton and Company New York Mcmxxiv
Copyright, 1924, by D. Appleton and Company
Printed in the United States of America
Foreword
IN a book of political dialogues, published a year ago, I explained (perhaps unnecessarily) that they were entirely unauthentic—a personal interpretation, given in dramatic form, of certain minds and events that had gone to make history.
But the dialogue which here follows differs from those, in that it has a solid basis in fact, and that I myself was a participant in the conversation which, as here recorded, is but a free rendering of what was then actually said.
And if it would interest any of my readers to know where these paraphrases of memory stand nearest to fact, they will find them in those passages dealing with the writings of Carlyle, the Scotsman’s worship of success, and the theory of the complete life of the artist. Other references by the way were the bird with the Berkeleyan philosophy, and the novels of Mr Benjamin Swift. The rest is my own development of the main theme, though it may well be that, here and there, I have remembered better than I know.
The scene, as regards its setting—the outside of a Paris restaurant—is true to history; and if, toward the end, a touch of drama has been introduced, the reader will understand that it is more symbolic than actual. The non-arriving guest, with the unreal name, did not, on that occasion, even begin to arrive. He was, nevertheless, a very real element in the tragic situation which I have tried to depict; and it is likely enough that there were more of his kind than one knew—that he was generic rather than individual.
My choice of initials to represent those who appear upon the scene—a convenient device for the better ordering of the printed page—was not made with any intention to disguise identity where that could be of interest; but it seemed better manners, in a scene where only one character really counted, to adopt the unobtrusive
formula, except in speeches where the names occur naturally The friendly “R.R.” is dead, and will be easily identified; the rest are still living. And though, for the most part, they were listeners not speakers, I have no reason for leaving them out of a scene which, after nearly twenty-five years, I remember so well.
My original intention was to include this dialogue in my book of Dethronements; but I was warned by a good authority that if I did so the interest of my commentators would be largely diverted from the political theme to the personal; there was also a certain objection to including in a set of purely imaginary dialogues another which was so largely founded on fact. I decided, therefore, to let this other “dethronement” stand alone in its first appearing, as different in kind from the rest.
But though different, my reason for writing it was precisely the same. It is, like those others, a record of failure; and failures interest me more, generally, than success. If I am asked why, my answer is that they seem to reveal human nature more truly, and, on the whole, more encouragingly, than anything else in the world. The way a man faces failure is the best proof of him. What he has done before matters little, or only in a minor degree, if as the outcome of all, in the grip of final and irretrievable ruin, he retains the stature of a man. That places him far more truly than the verdicts of juries, or the judgment of contemporary society. Sometimes he may prove his worth more surely by failure than by success, sometimes may only just manage to hold his ground; but if he is able to do that without complaint or greedy self-justification, and without speaking bitterly of those who have compassed his downfall, even so something stands to his credit, and there is a balance on the right side.
And so, the longer I live, the more do failures attract me, making me believe not less in human nature, but more. There are financial vulgarians of our own day whom, in prison, one might find lovable— and so be brought nearer to the great common heart which, with its large tolerance for ill-doers in their gambling day of success, has found them lovable even when they were at their worst. For it is not only Art which holds up the mirror to Nature, or reflects most flatteringly the coarsest of its features. The British public flourishes
its mirror, with all the self-satisfaction of a barber displaying his own handicraft, before characters of a certain type; and a man may follow a thoroughly vicious career with great success, so long as he does it in a thoroughly British way. But what a pity that the mirror should cease from its obsequious civility just when its hero, overwhelmed in failure and disgrace, becomes so much more worthy of study and deserving of sympathy than ever before.
And here, I suppose, lies the great difference between the mirror of Art and the mirror of popular opinion: the mirror of Art is not broken in a tantrum when the object becomes less acceptable to the public gaze. But the public is shocked in its sense of decency when it finds it has been looking at itself under an alias, applauding its own sorry features in the mask of success. The mask falls away, and there, instead, are the quite ordinary features of a poor human criminal, very like all the rest of us, if only it could be known: no wonder, then, that the mirror gets broken. In the mirror there is no such break: the interest holds on.
And so, from the non-popular standpoint, I had sufficient reason for putting on record my last meeting with so conspicuous a failure as Oscar Wilde. Our previous acquaintance, except by correspondence, had been very slight. Only once before had I met him at a friend’s house. He was then at the height of his fame and success, and I an unknown beginner, still undecided whether to be book-illustrator or author. But I had recently published a short story, with illustrations of my own, in the Universal Review; and a few minutes after our introduction Mr. Wilde turned and, addressing me for the first time, said: “And when, pray, are we to have another work from your pen?”
Like most of his remarks, the enquiry was phrased with a certain decorative solemnity, in excess of what the occasion required; but the kindness and the courtesy of it were very real, and of course it pleased and encouraged me. I learned later that a certain descriptive phrase, “The smoke of their wood-fires lay upon the boughs, soft as the bloom upon a grape,” had attracted him in my story; he had quoted it as beautiful, adding that one day he should use it himself, and, sure enough, in The Picture of Dorian Grey, I came upon it not
long afterwards, slightly altered; and again I was pleased and complimented; for it meant that he had really liked something in my story, and had not praised merely to please.
I did not see him again to speak to, until we met in Paris some seven years later, the year before his death.
Upon his release from prison I had sent him my recently published book, All-Fellows: seven legends of lower Redemption, hoping that its title and contents would say something on my behalf, which, in his particular case, I very much wished to convey. A fortnight later a courteous and appreciative letter reached me from the south of France, telling me incidentally that by the same post had come a copy of A Shropshire Lad, sent with the good wishes of the author, whom he had never met. “Thus you and your brother,” he wrote, “have given me a few moments of that rare thing called happiness.”
From that time on I sent him each of my books as they appeared, and received letters of beautifully ornate criticism; and as I passed through Paris on my way back from Italy in the autumn of 1899, we met once more in the company of friends.
My memory of him upon that occasion inclines me to believe that those are right who maintain that as a personality he was more considerable than as a writer. The brilliancy of conversation is doubtfully reproduced in the cold medium of print, and I may have wholly failed to convey the peculiar and arresting quality of what, by word of mouth, sounded so well. But the impression left upon me from that occasion is that Oscar Wilde was incomparably the most accomplished talker I had ever met. The smooth-flowing utterance, sedate and self-possessed, oracular in tone, whimsical in substance, carried on without halt, or hesitation, or change of word, with the quiet zest of a man perfect at the game, and conscious that, for the moment at least, he was back at his old form again: this, combined with the pleasure, infectious to his listeners, of finding himself once more in a group of friends whose view of his downfall was not the world’s view, made memorable to others besides myself a reunion more happily prolonged than this selected portion of it would indicate.
But what I admired most was the quiet, uncomplaining courage with which he accepted an ostracism against which, in his lifetime, there could be no appeal. To a man of his habits and temperament— conscious that the incentive to produce was gone with the popular applause which had been its recurrent stimulus—the outlook was utterly dark: life had already become a tomb. And it is as a “monologue d’outre tombe” that I recall his conversation that day; and whether it had any intrinsic value or no, it was at least a wonderful expression of that gift which he had for charming himself by charming others.
Among the many things he touched on that day (of which only a few disjointed sentences now remain to me), one note of enthusiasm I have always remembered, coming as it did so strangely from him, with his elaborate and artificial code of values, based mainly not on the beauty of human character, but on beauty of form—when, with a sudden warmth of word and tone, he praised Mrs. Gladstone for her greatness and gentleness of heart: “her beautiful and perfect charity” I think was the phrase he used, adding: “But then, she was always like that.”
None of us knew her; but from that day on, the warmth and humility of his praise left an impression upon my mind, which a reading of her life only two years ago came to confirm. Perhaps—I like to think that it was possible—an expression of her “beautiful and perfect charity” had come to him personally, so making her stand differently in his eyes from the rest of the world.
Echo de Paris
Echo de Paris
A Study from Life
The echo is from as far back as the year 1899. It is late September. By the entrance of a café, on a street opening into the Place de l’Opera, three Englishmen sit waiting at a small table, relieved for the moment from the solicitations of the garçon anxious to serve them their aperitifs. It is all very well for the café to call itself the “Vieille Rose”: no doubt by gaslight it lives charmingly up to its name; but seen in the noonday’s glare, its interior upholsterings are unmistakably magenta. From the warm sunshade of its awning the street view is charming; and while one of the trio watches it benevolently with an accustomed eye, the other two, encountering Paris for the first time, find in its brisk movement the attraction of novelty. But it is a reversion to English habit which makes one of them presently look at his watch a little anxiously.
. . Is he generally so late as this?
Generally never as early
. . You are sure you said the Café Vieille Rose?
. . (with a disarming smile). As well as I could, my dear L.H. I can’t say it quite like you.
. . I don’t pretend to talk French: hearing it spoken absorbs all my faculties.
. . Oh, but you should! They are so charming about it: they pretend to understand you.
. . Well, I did screw up courage to go to a French barber yesterday.
. . Ah! That explains it. I was wondering.
You might well. When I looked in the glass after he had finished me I saw myself no longer English, but Parisian.
(enjoying himself). No, L.H., no! Not Parisian, I assure you!— Alsatian.
. . No longer English was all that mattered: “tout à fait transformé,” as I managed to say to the man. And he—magnificently: “Mais oui, Monsieur, c’était bien necessaire!” Is that what you call French politeness?
. . Rather the “amour propre” of the artist, I should say.
. . In this nation of artists one gets too much of it.
. . There isn’t such a thing as a nation of artists. The French only appear so because they take a more transparent pride in themselves than we do. They haven’t yet discovered that modesty is the best vanity.
. . Is that your own, Herbie, or did you get it from Oscar yesterday?
. . No. I didn’t see him. I invented it as I got up this morning, meaning to let it occur as an impromptu. Now it’s gone.
. . Oh, no. Say it again, my dear boy, say it again! We shall all be charmed: so will he.
. . Look; there he is! Who’s with him?
Davray I asked Davray to go and bring him, so as to make sure. You know him, don’t you? You like him?
A Frenchman who can talk English always goes to my heart.
. . Davray is Anglomaniac: he not only talks it, he thinks it: signs himself “Henry,” like an Englishman, and has read more of your books than I have.
. . One?
. . Don’t be bitter, L.H. I read them—in the reviews—regularly.
(While they talk, a fiacre, disentangling itself from the traffic of the main thoroughfare, draws up at the newspaper-kiosk on the further side of the street, and discharges its occupants: one small, alert, and obviously a Frenchman; the other large and sedate, moving with a ponderous suavity, which gives him an air of importance, almost of dignity. But though he has still a presence, its magnificence has departed. Threading his way indolently across the traffic, his eye adventures toward the waiting group. Met by the studied cordiality of their greetings, his face brightens.)
. . Oscar, L.H. thinks you are late.
. . Thought I was going to be late, you mean, my dear Robbie. If I were, what matter? What are two minutes in three years of disintegrated lifetime? It is almost three years, is it not, since we missed seeing each other?
(This studied mention of a tragic lapse of time is not quite as happy as it would like to be, being too deliberate an understatement. The tactful “Robbie” hastens to restore the triviality suitable to the occasion.)
. . Oscar, when did you learn to cross streets? I have just seen you do it for the first time. In London you used to take a cab.
. . No, Robbie, the cab used to take me. But here the French streets are so polite; one gets to the right side of them without knowing it. (He turns to L.H.) How delightfully English of you to think that I was going to be late!
. . I thought you might have done as I am always doing—gone to the wrong place, or lost your way.
. . But that is impossible! In Paris one can lose one’s time most delightfully; but one can never lose one’s way.
. . With the Eiffel Tower as a guide, you mean?
Yes. Turn your back to that—you have all Paris before you. Look at it—Paris vanishes.
You might write a story about that, Oscar
. . In natural history, Robbie, it has already been done. Travellers in South America tell of a bird which, if seen by you unawares, flies to hide itself. But if it has seen you first, then—by keeping its eye on you—it imagines that it remains invisible, and nothing will induce it to retreat. The bird-trappers catch it quite easily merely by advancing backwards. Now that, surely, is true philosophy. The bird, having once made you the object of its contemplation, has every right to think (as Bishop Berkeley did, I believe) that you have no independent existence. You are what you are—the bird says, and the Bishop says—merely because they have made you a subject of thought; if they did not think of you, you would not exist. And who knows?—they may be right. For, try as we may, we cannot get behind the appearance of things to the reality. And the terrible reason may be that there is no reality in things apart from their appearances.
. . You English are always talking what you think is philosophy, when we should only call it theology.
. . How typical of the French mind is that word “only”! But what else, my dear Davray, was the thought of the eighteenth century, so far as it went, but an attempt to bring Religion and Philosophy together in the bonds of holy matrimony?
The misalliance which produced the French Revolution.
. . Robbie, you must not be so brilliant before meals! Or do you wish to divert my appetite? May a guest who was supposed to be late enquire—when, precisely?
. . The situation, my dear Oscar, is of your own making. You insisted upon ortolans; L.H. telegraphed for them; they have only just arrived.
. . If they are still in their feathers, let them fly again! A flight of ortolans across Paris: how romantic, how unexplainable!
Oh, no! Let’s wait for them, please! I want to taste one: I never have.
So young, and already so eager for disappointment! Why give up imagination? “Ortolan,” the word, is far more beautiful than when it is made flesh. If you were wise you would learn life only by inexperience. That is what makes it always unexpected and delightful. Never to realize—that is the true ideal.
. . Still, one goes on liking plovers’ eggs after eating them: at least, I do.
. . Ah, yes; an egg is always an adventure: it may be different. But you are right; there are a few things—like the Nocturnes of Chopin—which can repeat themselves without repetition. The genius of the artist preserves them from being ever quite realized. But it has to be done carelessly.
(There is a pause, while L.H., with due enquiry of each, orders the aperitifs.)
. . Oscar, why did you choose the “Vieille Rose”?
Will you believe me, Robbie, when I say—to match my complexion? I have never before seen it by daylight. Is it not a perfect parable of life, that such depravity by gaslight should become charming? Will our host allow us to have white wine as a corrective? An additional red might be dangerous.
(And with the colour-scheme of the approaching meal made safe, he continues to charm the ears of himself and of his listeners.)
I chose it also for another and a less selfish reason. It is here I once met a woman who was as charming as she was unfortunate, or as she would have been, but for the grace that was in her. To say that she was entirely without beauty is to put it mildly; but she accepted that gift of a blind God with so candid a benevolence, and cultivated it with so delicate an art, that it became a quality of distinction, almost of charm. She was the belle amie of a friend of mine, whose pity she had changed to love. He brought me here to meet her, telling me of the rare reputation she had acquired in this city of
beautiful misalliances, as being a woman of whom nobody could possibly say that she was merely plain. And here, upon this spot, in the first few moments of our meeting, she challenged me, in the most charming manner possible, for that which a woman so rarely seeks to know—the truth about herself. “Tell me, Monsieur,” she said —but no: it can only be told in French: “Dites moi, Monsieur, si je ne suis pas la femme la plus laide à Paris?” And for once in my life I was able to please a woman merely by telling her the truth; and I replied, “Mais, Madame, dans tout le monde!”
. . A poem, in six words! What did she say?
. . What could she say, Robbie? She was delighted. To that impossible question which she had the courage to ask I had given the only impossible answer. Upon that we became friends. How much I have wished since that we could have met again. For the unbeautiful to have so much grace as to become charming is a secret that is worth keeping; and one the keeping of which I should have liked to watch. I would not have asked to know it for myself, for then it would no more be a mystery; but—merely to see her keeping it. In Paris (where almost everything is beautiful), they were very happy together. Now they are gone to America; and in that country, from which all sense of beauty has flown, perhaps she is no longer able to keep, as a secret, that which there would be no eyes to interpret. When I was in America, I did not dare to tell America the truth; but I saw it clearly even then—that the discovery of America was the beginning of the death of Art. But not yet; no, not yet! Whistler left America in order to remain an artist, and Mr. Sargent to become one, I believe.... But now, tell me of England: who are the new writers I ought to be reading, but have not?
. . Isn’t to be told what you ought to like rather irritating?
. . But I did not say “like”; I said “read.” There are many things one ought to read which one is not bound to like: Byron, Wordsworth —even Henry James, if Robbie will allow me to say so. But tell me whom you yourself find interesting. I shall, at least, be interested to know why. I have already had two books—from you and your brother —which have interested me.
Like you, as regards my own, I should be interested to know why?
Yours interested me—shall I confess?—partly because a few years ago it would have interested me so much less. For at that time, believing that I had discovered—that, in a way, I represented the symbol of my age, I was only interested in myself. Now, in an age to which I do not belong, I find myself interested in others. Robbie, who is the most sincere of flatterers, would have me believe that in this transfer of interest I am making a poor exchange. I am not sure. Till recently, absorbed in myself, I might have missed that new strange writer of things impossible in life, who writes under the name of Benjamin Swift. Ought I to have done so? His style has the gleam of a frozen fire. He writes like a sea-pirate driven by contrary winds to a vain search for tropical forests at the North Pole. Why does he look at life only in profile, as though, met face to face, it might mean death to him? Is he as mysterious, as unaccountable to himself, as he seems to others?
. . I don’t know whether the fact that he is a well-to-do Scotsman, who finished his education at a German university, can be said to account for him. We have met, and I find him interesting. He reminds me, somehow, of a lion turned hermit, wearing a hair-shirt, and roaring into it to frighten out the fleas. In other words, he is full of contradictions, and revels in them even while they torment him.
. . A Scotsman? That explains everything. For a man to be both a genius and a Scotsman is the very stage for tragedy. He apparently perceives it. Generally they are unaware of it.
. . My dear Oscar, why cannot a Scotsman be a genius as comfortably as anyone else?
. . I ought to have said “artist”: I meant artist. It is much easier for a Scotsman to be a genius than to be an artist. Mr. Gladstone, I believe, claimed to be a Scotsman whenever he stood for a Scottish constituency or spoke to a Scottish audience. The butter-Scotch flavour of it makes me believe it was true. There was no art in that; and yet how truly typical! It was always so successful....
