- 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 upto 1/3 patients;
-
carpal
tunnel syndrome may occur in upto 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 et al 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;;
-
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. J Hand Surg 2000;25A:544-551
-
Vein wrapping at cubital tunnel for ulnar nerve problems