We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Cubital Tunnel Syndrome

From WikiSM
Jump to: navigation, search

Other Names

  • Sulcus Ulnaris Syndrome
  • Retrocondylar Groove Syndrome

Background

History

  • First described by Magee and Phalen in 1949[1]

Epidemiology

  • Second most common entrapment neuropathy of upper extremity behind Carpal Tunnel Syndrome[2]
    • This is also the most common location for compression of the ulnar nerve
    • Incidence is 1/13 that of CTS[3]
  • Incidence 24.7 per 100,000 (need citation)
  • Male > Female[4]
  • Bilateral 18.6-38.8% of the time[5]

Pathophysiology

  • General
    • Marked by both sensory and motor deficiencies or dysesthesias
  • Can be differentiated into[6]
    • Primary or idiopathic
      • No morphological abnormalities, especially no bony changes of the elbow joint or space occupying lesions
    • Secondary
      • Deformation or other processes of the elbow joint

Etiology

  • Entrapment occurs at many potential places[7]
    • Most common
      • Cubital tunnel (most common)
      • Deep flexor pronator aponeurosis
      • Arcade of Struthers
      • Osborns ligament
    • Less common
      • Medial intermuscular septum
      • Medial epicondyle
      • Hypertrophy of the medial head of the Triceps Brachii
      • Fascial bands within FCU
      • Accessory anconeus epitrochlearis muscle (3-23% of population)[8]
      • Aponeurosis of FDS proximal edge

Pathoanatomy

  • Ulnar Nerve
    • C8, T1 nerve roots
    • Enters ulnar sulcus 3.5 cm proximal to medial epicondyle
    • Courses posterior to medial epicondyle, posterior to olecranon before entering cubital tunnel
  • Cubital Tunnel
  • Distal to cubital tunnel, courses deep into the forearm between the ulnar and humeral heads of the FCU
  • Note Medial Antebrachial Cutaneous Nerve is very proximal to cubital tunnel

Associated Conditions

Risk Factors

  • Repetitive work[9]
  • Obesity

Differential Diagnosis

Clinical Features

History

  • Diagnosis can often be made clinically
  • Onset is usually acute, or subacute as opposed to chronic and insidious
  • Parasthesias in ulnar nerve distribution
  • Pain is not a common or dominant feature but will report vague discomfort of medial elbow, forearm
  • Difficulty with certain activities like opening doors, jars, bottles
  • Rapidly fatigues with repetitive activities
  • Symptoms worse at night, with flexion

Physical: Physical Exam Elbow

  • Weakness, atrophy of intrinsic muscles of hand, especially 4th and 5th digit
  • Web space atrophy
  • Clawing of 4th, 5th digits
  • May see subluxing ulnar nerve at elbow with flexion-extension

Special Tests

Evaluation

Radiographs

  • Standard Radiographs Elbow
    • Useful screening tool
    • Unlikely to show any pathology in the setting of cubital tunnel syndrome
    • Can see osseus spurring in chronic patients

MRI

  • Findings[10]
    • Ulnar nerve thickening
    • Ulnar nerve T2 hyperintensity
    • Edema-like signal changes

Ultrasound

  • Findings
    • Nerve appears hypoechoic
    • Ulnar nerve thickening > 9 mm[11]
    • Edematous changes

EMG/NCS

  • Useful to confirm diagnosis, especially pre-operatively and to exclude other diagnosis
  • Can see decrease in absolute conduction velocity to less than 50 m/s
  • Relative drop in conduction velocity of 10 m/s or more across a segment (usually the cubital tunnel)

Classification

McGowan classification of ulnar nerve dysfunction

  • Grade I: Sensory neuropathy only
  • Grade II: Sensory and motor neuropathy, without muscle atrophy
  • Grade III: Sensory and motor neuropathy, muscle atrophy present

Management

Nonoperative

  • Initial management is conservative almost universally
  • Activiity modification[12]
    • Avoid certain positions particularly elbow flexion, such as when talking on the telephone
    • Positions in which the medial elbow is resting on a hard surface, such as elbows on arm rests when working on a computer
  • Nighttime Elbow Flexion Block Splint
    • Night bracing in 45° extension with forearm in neutral rotation
  • Physical Therapy
    • Specifically, nerve glide exercises[13]

Operative

  • Indications
    • When conservative therapy fails
  • Technique
    • In situ decompression
    • Medical Epicondylectomy
    • Endoscopic Cubital Tunnel Release
    • Anterior Transposition

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Variable
  • Nonsurgical cases can return to play when symptoms resolve

Complications and Prognosis

Prognosis

  • Conservative management
    • Svernlov et al: 89.5% of patients demonstrated improvement in their symptoms with conservative management at the 3-month follow-up[14]

Complications

See Also

References

  1. ↑ Magee RB, Phalen GS. Tardy ulnar palsy. Am J Surg 1949;78:470–4
  2. ↑ Bozentka DJ. Cubital tunnel syndrome pathophysiology. Clin Orthop Relat Res 1998;351:90 –94
  3. ↑ Mondelli M, Giannini F, Ballerini M. et al . Incidence of ulnar neuropathy at the elbow in the province of Siena (Italy). J Neurol Sci. 2005; 15 5-10
  4. ↑ Assmus H, Antoniadis G,. Hrsg Nervenkompressionssyndrome.. Heidelberg: Steinkopff/Springer; 2008
  5. ↑ Artico M, Pastore FS, Nucci F. et al . 290 surgical procedures for ulnar nerve entrapment at the elbow: physiopathology, clinical experience and results. Acta Neurochir. 2000; 142 303-308
  6. ↑ Sunderland S. Nerves and nerve injuries.. Edinburgh, London, New York: Churchill Livingstone; 1978
  7. ↑ Ochiai N, Honmo J, Tsunjino A, Nisiura Y. Electrodiagnosis in entrapment neuropathy by the arcade of struthers. Clin Orthop Relat Res 2001;378:129 –135.
  8. ↑ Chan RC, Paine KWE, Varughese G. Ulnar neuropathy at the elbow: comparison of simple decompression and anterior transposition. Neurosurgery. 1980; 7 545-550
  9. ↑ Descatha A, Leclerc A, Chastang JF. et al. Study Group on RepetitiveWork Incidence of ulnar nerve entrapment at the elbow in repetitive work. Scand JWork Environ Health. 2004; 30 234-240
  10. ↑ https://radiopaedia.org/articles/cubital-tunnel-syndrome
  11. ↑ Choi SJ, Ahn JH, Ryu DS, Kang CH, Jung SM, Park MS, Shin DR. Ultrasonography for nerve compression syndromes of the upper extremity. (2015) Ultrasonography (Seoul, Korea). 34 (4): 275-91. doi:10.14366/usg.14060 - Pubmed
  12. ↑ Kroonen, Leo T. "Cubital tunnel syndrome." Orthopedic Clinics 43.4 (2012): 475-486.
  13. ↑ Bryon PM. Upper extremity nerve gliding: programs used at the Philadelphia Hand Center. In: Hunter JM, Mackin EJ, Callahand AD, editors. Rehabilitation of the hand: surgery and therapy. 4th edition. St Louis (MO): Mosby; 1995. p. 951–6.
  14. ↑ Svernlov B, Larsson M, Rehn K, et al. Conservative treatment of the cubital tunnel syndrome. J Hand Surg Br 2009;34:201–7.
Created by:
John Kiel on 4 July 2019 07:21:35
Authors:
Last edited:
27 April 2023 10:37:00
Categories:

Retrieved from "https://wikism.org/w/index.php?title=Cubital_Tunnel_Syndrome&oldid=19664"