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Cubital Tunnel Syndrome
From WikiSM
Contents
Other Names
- Sulcus Ulnaris Syndrome
- Retrocondylar Groove Syndrome
Background
- This page refers to entrapment of the Ulnar Nerve within the Cubital Tunnel of the Elbow
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
- Primary or idiopathic
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
- Most common
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
- Roof: FCU fascia, arcuate ligament of Osbourne (syn. arcuate ligament, epitrochlear anconeus ligament, humero-ulnar arcade)
- Floor: Ulnar Collateral Ligament, joint capsule, Olecranon
- Walls: Medial epicondyle, olecranon
- 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
- Medial Epicondylitis
- Cubitus varus or valgus deformities
- Burns
- Elbow contracture release
Risk Factors
- Repetitive work[9]
- Obesity
Differential Diagnosis
- Fractures
- Adult
- Pediatric
- Dislocations & Instability
- Tendinopathies
- Bursopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Other
- Pediatric Considerations
- Little League Elbow
- Panners Disease (Avascular Necrosis of the Capitellum)
- Nursemaids Elbow (Radial Head Subluxation)
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
- Tinels Test: Repetitive tapping over the nerve with finger
- Elbow Flexion Compression Test: elbow in maximal flexion, examiner holds pressure at the cubital tunnel
- Scratch Collapse Test: See description
- Froments Sign: Inability to grip piece of paper between the thumb and index finger
- Wartenbergs Sign: Exaggerated abduction of the fifth digit compared to unaffected limb
- Jeanne sign: Weak and unstable pinch with hyperextension of the thumb metacarpophalangeal, thumb adduction
- Masse sign: Palmar arch flattening and loss of ulnar hand elevation
- Pollocks Test: Inability to flex DIPJ of 4th, 5th digits against resistance
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
- Injury to Medial Antebrachial Cutaneous Nerve
- Recurrence of symptoms
- Neuroma
See Also
- Internal
- External
- Sports Med Review Elbow Pain: https://www.sportsmedreview.com/by-joint/elbow/
References
- ↑ Magee RB, Phalen GS. Tardy ulnar palsy. Am J Surg 1949;78:470–4
- ↑ Bozentka DJ. Cubital tunnel syndrome pathophysiology. Clin Orthop Relat Res 1998;351:90 –94
- ↑ 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
- ↑ Assmus H, Antoniadis G,. Hrsg Nervenkompressionssyndrome.. Heidelberg: Steinkopff/Springer; 2008
- ↑ 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
- ↑ Sunderland S. Nerves and nerve injuries.. Edinburgh, London, New York: Churchill Livingstone; 1978
- ↑ 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.
- ↑ Chan RC, Paine KWE, Varughese G. Ulnar neuropathy at the elbow: comparison of simple decompression and anterior transposition. Neurosurgery. 1980; 7 545-550
- ↑ 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
- ↑ https://radiopaedia.org/articles/cubital-tunnel-syndrome
- ↑ 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
- ↑ Kroonen, Leo T. "Cubital tunnel syndrome." Orthopedic Clinics 43.4 (2012): 475-486.
- ↑ 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.
- ↑ 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
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Last edited:
13 October 2022 14:05:23
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