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Management

Pre-operative: The patient was maintained in a protective splint for her ulnar clawing.

Surgical: Re-exploration was performed under 4.5x loupe magnification. The ulnar nerve was first identified in Guyon’s canal and decompression of Guyon’s canal was performed, along with decompression of the deep motor branch distally. The ulnar nerve was then followed proximally until the site of prior conduit reconstruction was reached. The conduit was excised; breadloafing through the conduit revealed dense scar tissue. Once the nerve had been cut back to healthy fascicles, a 4 cm gap was present. The medial antebrachial cutaneous nerve (MABC) was harvested through a separate incision. The topography of the ulnar nerve was mapped out both proximally and distally to ensure appropriate matching of sensory and motor components. Three cables of MABC, each 5 cm in length, were used to reconstruct the ulnar nerve under the operating microscope using 9-0 nylon microsutures. Fibrin glue was also used at the repair sites. The posterior branch of the MABC was reconstructed in an end-to-side fashion to the sensory side of the median nerve, whose sensory component was identified by its lack of motor activity with intraoperative nerve stimulation.

Post-operative: A pain pump placed intraoperatively was used for 3 days. The patient was then started on nortriptyline and referred for hand therapy. Initial hand therapy included scar mobilization and silicone sheeting, ulnar gliding exercises, passive range of motion exercises, and use of a hand-based ulnar nerve palsy splint.