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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;
- 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.