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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;
    - 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.