Cubital Tunnel Syndrome

- 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 first sign of detection;
    - differential diagnosis:
    - concomitant disorders:
           - thoracic outlet syndrome may occur in up to 1/3 patients;
           - carpal tunnel syndrome may occur in up to 40% of patients;
    - anatomy & sites of nerve compression

- Clinical Findings:
    - Clinical validity of the elbow flexion test for the diagnosis of ulnar nerve compression at the cubital tunnel
    - The elbow flexion test. A clinical test for the cubital tunnel syndrome

- 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 and Owen (1998), w/ resistant symptoms, prolonging nonoperative treatment does not reduce cost of care and does
                   not positively influence outcome;
                   - as noted by Kaempffe et al (1998), those w/ 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;
           - Cubital tunnel release with medial epicondylectomy factors influencing the outcome.
           - A modified surgical procedure for cubital tunnel syndrome: partial medial epicondylectomy.
    - 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;
                  - 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 report by Caputo and Watson, authors identified 20 patients w/ recurrent compression who underwent anterior subQ transposition of 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;
           - references:
                   - Subcutaneous anterior transposition of the ulnar nerve for failed decompression of cubital tunnel syndrome
                   - Vein wrapping at cubital tunnel for ulnar nerve problems

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.

Technical problems with ulnar nerve transposition at the elbow: findings and results of reoperation.

Cubital tunnel release with medial epicondylectomy factors influencing the outcome.

A modified surgical procedure for cubital tunnel syndrome: partial medial epicondylectomy.

Long-term clinical and neurologic recovery in the hand after surgery for severe cubital tunnel syndrome.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, May 31, 2012 12:03 pm