- See:
Nerve Entrapment
- Discussion:
- cubital tunnel serves as major contraint for the
ulnar nerve as it passes behind elbow;
- the syndrome occurs most commonly between 30 to 60 years, and is exceptionally uncommon in children under 15 years;
-
inciting events:
- symptoms may appear several years after trauma (hence tardy ulnar palsy)
- common injures: fx of medial epicondyle, supracondylar fx w/ cubitus valgus deformity,
exuberant callus, or dislocation of the elbow;
- also consider prior iatrogenic injury from intraoperative positioning;
- effects of elbow flexion:
- neural anatomy:
- the internal anatomy of the
ulnar nerve can partially explain the predominace of hand symptoms from in cubital tunnel syndrome;
- nerve fibers to the FCU and FDP are located centrally, where as sensory fibers and nerve fibers to the hand intrinsics are located peripherally;
- generally, the peripheral nerve fibers are more sensitive to external compression, and this may explain
why the hand intrinsics are often more involved than the FCU and FDP;
- ulnar neuropathy following head injury;
- some form of ulnar neuropathy is common in pts w/ brain injury;
- one of the main causes is
heterotopic ossification;
- it usually occurs w/ a spacit extremity;
- because of spacitity and lack of fine motor control, combined w/ the patients inability
to complain, atrophy of the intrinsic musculature is the first sign of detection;
- differential diagnosis:
- concomitant disorders:
-
thoracic outlet syndrome may occur in upto 1/3 patients;
-
carpal tunnel syndrome may occur in upto 40% of patients;
- anatomy & sites of nerve compression
- Clinical Findings:
- EMG in Cubital Tunnel Syndrome:
- Radiographs:
- look for osteophytes and associated DJD which may occur frequently w/ cubital tunnel syndrome;
- Non Operative Treatment:
- sleeping w/ the elbow flexed will worsen symptoms;
- consists mainly of exension splinting at night or wearing a soft (sheep skin) elbow pad;
- splints should hold arm in 70 deg of flexion;
- vitamin B6 50 mg PO tid: some patients will note substantial relief w/ vit B6;
- w/ good compliance 50% of patients can avoid surgery;
- avoidance of repetitive elbow flexion and pronation, and avoidance of vibrating tools;
-
NSAIDS
- references:
-
Treatment of ulnar nerve palsy at the elbow with a night splint.
- Surgical Treatment:
-
indications:
- many surgeons will refuse to operate for sensory changes alone;
- surgical procedure is reserved for those with disability & weakness;
- if weakness is early and mild, esp if Tinel's sign is present or
EMG suggests cubital tunnel syndrome,
simple release is performed;
- if associated DJD of the elbow is present, then consider debridement arthroplasty (see
lateral approach);
- as noted by Seradge et al 1998, w/ resistant symptoms, prolonging nonoperative treatment does not reduce
the cost of care and does not positively influence outcome;
- as noted by Kaempffe et al 1998, those w/ the most severe nerve entrapment (intrinsic atrophy or
abnormal EMG) tend to have worse surgical outcomes;
- note that concomitant nerve compression syndromes may be associated w/ a higher rate of recurrence;
-
preoperative considerations:
- if the patient believes that their CTS syndrome is work related, then he/she should work this out ahead of time;
- be clear with the patient ahead of time, regarding the goals of surgery;
- if the patient tends to over-react to painful stimuli, then they will probably react the same following surgery;
- in patients at risk for poor outcome or delayed return to work (such as workers compensation), consider 10 days
of aggressive nonoperative therapy inorder to assess their subjective response to treatment;
- for instance, consider combining oral steroids, casting w/ elbow in 45 deg flexion (to ensure compliance), and cessation
of repetitive activity for 10 days;
- if the patient insists that no relief has been obtained, then the subjective results of surgery may be in doubt;
-
surgical technique options: (
anatomy & sites of nerve compression)
-
Isolated Division of the Aponeurosis:
-
Medial Epiondylectomy:
-
Subcutaneous Anterior Transposition:
-
Submuscular Anterior Transposition;
-
complications:
- recurrent nerve compression:
- in the report by Caputo and Watson, the authors identified 20 patients w/ recurrent compression who underwent
anterior subcutaneous transposition of the ulnar nerve;
- most common sites of compression were the medial intermuscular septum and the flexor-pronator aponeurosis;
- 15 patients had a good or excellent outcome; 5 patients had a fair or poor outcome;
- relief of pain and paresthesias were the most consistent favorable results;
- ref: Subcutaneous anterior transposition of the ulnar nerve for failed decompression of cubital tunnel syndrome.
Andrew E. Caputo and H. Kirk Watson. J Hand Surg 2000;25A:544-551
The failed ulnar nerve transposition. Etiology and treatment.
Treatment of ulnar nerve palsy at the elbow with a night splint.
The cubital tunnel and ulnar neuropathy.
Ulnar nerve decompression by transposing the nerve and Z-lengthening the flexor-pronator mass: clinical outcome.
Cubital tunnel reconstruction for ulnar neuropathy in osteoarthritic elbows.
The failed ulnar nerve transposition. Etiology and treatment.
Technical problems with ulnar nerve transposition at the elbow: Findings and results of reoperation.
AS Broudy, RD Leffert, RJ Smith.
J. Hand Surg. 3: 1978. p 85-89.
Cubital tunnel release with medial epicondylectomy factors influencing the outcome.
H Seradge et al.
J. Hand Surg. Vol 23-A. No 3. May 1998. p 483.
A modified surgical procedure for cubital tunnel syndrome: partial medial epicondylectomy;
FA Kaempffe et al.
J. hand. Surg. Vol 23-A. No 3. May 1998. p 492.
Long-term clinical and neurologic recovery in the hand after surgery for severe cubital tunnel syndrome.
