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2014 HAND MOC 89-Day Study Plan

Cubital Tunnel Syndrome

Author: Deborah Allen

Topic updated on 02/06/14 8:28am

Introduction

A compressive neuropathy of the ulnar nerve
- 2nd most common compression neuropathy of the upper extremity
Sites of entrapment
- most common
  - between the two heads of FCU/aponeurosis (most common site)
  - within arcade of Struthers (hiatus in medial intermuscular septum)
  - between Osborne's ligament and MCL
- less common sites of compression include
  - medial head of triceps
  - medial intermuscular septum
  - medial epicondyle
  - fascial bands within FCU
  - anconeus epitrochlearis (anomalous muscle from the medial olecranon to the medial epicondyle)
  - aponeurosis of FDS proximal edge
- external sources of compression
  - fractures and medial epicondyle nonunions
  - osteophytes
  - heterotopic ossification
  - tumors and ganglion cysts
Associated conditions
- cubitus varus or valgus deformities
- medial epicondylitis
- burns
- elbow contracture release

Anatomy

Ulnar nerve
- pierces intramuscular septum at arcade of Struthers 8 cm proximal to the medial epicondyle as it passes from the anterior to posterior compartment of the arm
- enters cubital tunnel
Cubital tunnel
- roof
  - formed by FCU fascia and Osborne's ligament (travels from the medial epicondyle to the olecranon)
- floor
  - formed by posterior and transverse bands of MCL and elbow joint capsule
- walls
  - formed by medial epicondyle and olecranon

Presentation

Symptoms
- paresthesias of small finger, ulnar half of ring finger, and ulnar dorsal hand
  - exacerbating activities include
    - cell phone use (excessive flexion)
    - occupational or athletic activities requiring repetitive elbow flexion and valgus stress
- night symptoms
  - caused by sleeping with arm in flexion
Physical exam
- inspection and palpation
  - interosseous and first web space atrophy
  - ring and small finger clawing
  - observe ulnar nerve subluxation over the medial epicondyle as the elbow moves through a flexion-extension arc
- sensory
  - decreased sensation in ulnar 1-1/2 digits
- motor
  - loss of the ulnar nerve results in paralysis of intrinsic muscles (adductor pollicis, deep head FPB, interossei, and lumbricals 4 and 5) which leads to
    - weakened grasp
      - from loss of MP joint flexion power
    - weak pinch
      - from loss of thumb adduction (as much as 70% of pinch strength is lost)
    - Froment sign
      - compensatory thumb IP flexion by FPL (AIN) during key pinch
        
        compensates for the loss of MCP flexion by adductor pollicis (ulna n.)
        
        adductor pollicis muscle normally acts as a MCP flexor, first metacarpal adductor, and IP extensor
    - Jeanne sign
      - compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch
        
        compensates for loss of IP extension and thumb adduction by adductor pollicis (ulna n.)
    - Wartenberg sign
      - persistent small finger abduction and extension during attempted adduction secondary to weak 3rd palmar interosseous and small finger lumbrical
    - Masse sign
      - palmar arch flattening and loss of ulnar hand elevation secondary to weak opponens digiti quinti and decreased small finger MCP flexion
- extrinsic weakness
  - Pollock's test
    - shows weakness of two ulnar FDPs
- provocative tests
  - Tinel sign positive over cubital tunnel
  - elbow flexion test
    - positive when flexion of the elbow for > 60 seconds reproduces symptoms
  - direct cubital tunnel compression exacerbates symptoms

Studies

EMG / NCV
- helpful in establishing diagnosis and prognosis
- threshold for diagnosis
  - conduction velocity <50 m/sec across elbow
  - low amplitudes of sensory nerve action potentials and compound muscle action potentials

Treatment

Nonoperative
- NSAIDs, activity modification, and nighttime elbow extension splinting
  - indications
    - first line of treatment with mild symptoms
  - technique
    - night bracing in 45° extension with forearm in neutral rotation
  - outcomes
    - management is effective in ~50% of cases
Operative
- in situ ulnar nerve decompression without transposition
  - indications
    - when nonoperative management fails
    - before motor denervation occurs
  - technique
    - open release of cubital tunnel retinaculum
    - endoscopically-assisted cubital tunnel release
      - favorable early results but lacks long-term data
  - outcomes
    - meta-analyses have shown similar clinical results with significantly fewer complications compared to decompression with transposition
    - 80-90% good results when symptoms are intermittent and denervation has not yet occurred
    - poor prognosis correlates most with intrinsic muscle atrophy
- ulnar nerve decompression and anterior transposition
  - indications
    - failed in situ release
    - throwing athlete
    - patient with poor ulnar nerve bed from tumor, osteophyte, or heterotopic bone
  - technique
    - subcutaneous, submuscular, or intramuscular transposition
  - outcomes
    - similar outcomes to in situ release but increased risk of creating a new point of compression
- medial epicondylectomy
  - indications
    - visible and symptomatic subluxating ulnar nerve
  - technique
    - in situ release with medial epicondylectomy
  - outcomes
    - risk of destabilizing the medial elbow by damaging the medial ulnar collateral ligament

Complications

Recurrence
- secondary to inadequate decompression, perineural scarring, or tethering at the intermuscular septum or FCU fascia
- higher rate of recurrence than after carpal tunnel release
Neuroma formation
- iatrogenic injury to a branch of the medial antebrachial cutaneous nerve may cause persistent posteromedial elbow pain

Please Rate Educational Value!

4.0

Average 4.0 of 23 Ratings

Qbank (4 Questions)

TAG

(OBQ11.128) The physical exam finding demonstrated on the patient's right hand in the video (Figure V) is found with neuropathy of which of the following nerves? Topic

Review Topic

FIGURES: V

1. Musculocutaneous nerve

2. Anterior Interosseious Nerve (AIN

3. Radial nerve

4. Ulnar nerve

5. Median nerve

PREFERRED RESPONSE ▶

The video demonstrates Froment's sign on the patient's right hand, which is characterized by interphalangeal (IP) flexion during attempted key pinch, and is found in patients with ulnar neuropathy. Therefore it can be found with ulnar nerve compression in the cubital tunnel (Cubital Tunnel Syndrome) or in Guyon's Canal (Ulnar Tunnel Syndrome).

Froment's sign is performed by having the patient pinch a piece of paper with the thumb IP joint extended against resistance (pulling paper away). It should be done with both hands side by side to compare them to each other.

In a hand with a ulnar neuropathy, adductor pollicis (ulnar n.) is deficient, and can not flex the MCP joint to give pinch strength with an extended IP joint. The thumb compensates by recruiting the FPL (median n.) to flex the IP joint to give pinch strength. The result is, in a positive Froment's sign, the IP joint will flex (buckle) to try to give increased strength to the pinch.

Illustration V shows a demonstration of the Froment's sign.

Illustrations: V

REFERENCES:

1. Hurst LC, Gruber MA, Kottmeier SA. Neuromuscular disorders of the upper extremity. In: Dee R, ed. Principles of Orthopaedic Practice. New York, NY: McGraw Hill; 1988:690-728

2. Green D. Ulnar nerve palsy. In: Green DP, ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone; 1993:1449-1482.

Question Authors:

Michael Hughes MD, John Badylak MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 15 Ratings

TAG

(OBQ10.84) Cubital tunnel syndrome is caused by compression of the ulnar nerve between what two structures as it passes posterior to the medial epicondyle? Topic

Review Topic

1. Osborne's ligament and the MCL

2. MCL and Arcade of Struthers

3. Osborne's ligament and the intermuscular septum

4. MCL and medial head of the triceps

5. Ulnar and humeral heads of the flexor carpi ulnaris muscle

PREFERRED RESPONSE ▶

The ulnar nerve passes posterior to the medial epicondyle and medial to the olecranon, then enters the cubital tunnel. The roof of the cubital tunnel is primarily made up of Osborne's ligament, and the floor consists of the medial collateral ligament.

These soft tissue structures can cause narrowing of the tunnel, especially with elbow flexion, leading to ulnar nerve compression and cubital tunnel syndrome. This is shown in Illustration A. The Arcade of Struthers is a band of deep fascia that attaches to the intermuscular septum and covers the ulnar nerve 8 cm proximal to the medial epicondyle. The intramuscular septum is continuous from the medial epicondyle to the coracobrachialis muscle. The ulnar nerve travels through the two heads of the FCU distal to the cubital tunnel. These anatomic landmarks are shown in Illustration B.

Morrey evaluated 26 patients with post-traumatic contracture of the elbow who were treated with either operative release alone, or operative release and distraction arthroplasty. Twenty-four (96%) of the patients had improved elbow function and two had persistent ulnar neuritis treated with nerve transposition.

Cheung et al discuss the various surgical approaches to the elbow and the indications for each.

Video V is an educational lecture that discusses common nerve entrapment diagnosis and managment.

Illustrations: A

REFERENCES:

1. Morrey BF. Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty. J Bone Joint Surg Am. 1990 Apr;72(4):601-18. PMID:2324148 (Link to Abstract)

2. Cheung EV, Steinmann SP. Surgical approaches to the elbow. J Am Acad Orthop Surg. 2009 May;17(5):325-33. PMID:19411644 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Michael Hughes MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 21 Ratings

TAG

(OBQ09.1) All of the following are possible sites of compression for the ulnar nerve EXCEPT: Topic

Review Topic

1. arcade of Struthers

2. ligament of Struthers

3. flexor carpi ulnaris fascia

4. medial intermuscular septum

5. Osborne's ligament

PREFERRED RESPONSE ▶

There are five sites of potential ulnar nerve entrapment around the elbow: arcade of Struthers, medial intermuscular septum, medial epicondyle, cubital tunnel, and deep flexor pronator aponeurosis.

The ulnar nerve emerges from the medial intermuscular septum, under the arcade of Struthers, and lies on the medial head of the triceps. At the level of the elbow, the ulnar nerve continues distally toward the posterior aspect of the condylar groove, passing between the medial epicondyle and olecranon to enter the cubital tunnel. The roof is formed by the arcuate (Osborne’s) ligament. This ligament blends distally with the antebrachial fascia superficial to the aponeurosis and connects the ulnar and humeral heads of the FCU. The ligament of Struthers is a fibrous band extending from the supracondylar process of the humerus to the medial epicondyle which can cause compression of the median nerve.

Elhassan et al discuss the pathogenesis, evaluation, and treatment of entrapment neuropathy of the ulnar nerve.

Illustration A shows the various site of compression at the elbow. Illustration V shows a submuscular ulnar nerve transposition performed Dr. Susan E. Mackinnon

Illustrations: A

REFERENCES:

1. Elhassan B, Steinmann SP: Entrapment neuropathy of the ulnar nerve. J Am Acad Orthop Surg 2007;15:672-681. PMID:17989418 (Link to Abstract)

2. Bainbridge C: Cubital tunnel syndrome, in Berger RA, Weiss APC (eds): Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 887-896.

Question Authors:

Greg Galano MD, Patrick McCulloch MD, Derek Moore MD,

Please Rate Educational Value!

4.0

Average 4.0 of 25 Ratings

TAG

(OBQ09.24) A 50-year-old man complains of numbness and tingling along his right small finger. Physical exam is notable for the finding demonstrated in Figure A. Elbow flexion reproduces the numbness and tingling. Physical therapy and splinting have failed to relieve the symptoms. Which of the following is the most appropriate surgical intervention to alleviate the symptoms while minimizing complications? Topic

Review Topic

FIGURES: A

1. Simple ulnar nerve decompression at the cubital tunnel

2. Ulnar nerve decompression at the cubital tunnel with anterior submuscular transposition

3. Ulnar nerve decompression at the cubital tunnel with anterior subcutaneous transposition

4. Open carpal tunnel release

5. Endoscopic carpal tunnel release

PREFERRED RESPONSE ▶

The patient's clinical presentation and physical exam are consistent with cubital tunnel syndrome. The clinical photograph demonstrates Froment's sign; compensatory IP hyperflexion of FPL (AIN) to compensate for the loss of adductor pollicis (ulnar nerve) during key pinch. Simple decompression of the ulnar nerve is less invasive and achieves clinical outcomes equivalent to decompression with transposition.

Zlowodzki et al conducted a meta-analysis evaluating anterior transposition and simple decompression of the ulnar nerve. No difference in motor nerve-conduction velocities or clinical outcome scores was found.

Bartels performed a prospective randomized trial (included in the Zlowodski meta-analysis) on 152 patients comparing simple decompression to transposition. No difference in clinical results at 1 year were reported, but a significantly higher complication rate occurred in the transposition group (31%) compared to simple decompression (9.6%).

Nabhan et al performed a level 1 study randomizing 66 patients to simple decompression or subcutaneous ulnar nerve transposition. No differences were found with respect to clinical outcome or nerve conduction velocities.

Illustration V is an educational presentation discussing ulnar nerve transposition at the elbow.

Illustrations: V

REFERENCES:

1. Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007 Dec;89(12):2591-8. PMID:18056489 (Link to Abstract)

2. Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery. 2005 Mar;56(3):522-30; discussion 522-30. PMID:15730578 (Link to Abstract)

3. Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI. Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg Br. 2005 Oct;30(5):521-4. PMID:16061314 (Link to Abstract)

Question Authors:

John Badylak MD, Derek Moore MD, Patrick McCulloch MD,

Please Rate Educational Value!

3.0

Average 3.0 of 15 Ratings

Videos

	Ulnar nerve subluxation at cubital tunnel Hand - Physical Exam - Cubital Tunnel Syndrome This video illustrates subluxation of the ulnar nerve anteriorly over the medial...	3/30/2013 820 views 4
	Flexor Digitorum Profundus Tenodesis (Median FDP to Ulnar FDP) - Dr. Susan Mackinnon Hand - Surgical Techniques - Cubital Tunnel Syndrome For paralysis of ulnar-innervated flexor digitorum profundus (FDP) to the ring a...	3/12/2013 145 views 5
	In situ ulnar nerve decompression at the elbow Hand - Surgical Techniques - Cubital Tunnel Syndrome Surgical technique video demonstrating an in situ ulnar nerve decompression at t...	2/20/2013 978 views 2
	Submuscular Ulnar Nerve Transposition - Dr. Susan E. Mackinnon Hand - Surgical Techniques - Cubital Tunnel Syndrome A submuscular ulnar nerve transposition is performed to decompress the ulnar ner...	10/20/2012 1001 views 4
	Transmuscular Ulnar Nerve Transposition in a Case of Traumatic Medial Cord Injury - Dr. Susan E. Mackinnon Hand - Surgical Techniques - Cubital Tunnel Syndrome Cubital tunnel syndrome can present with pain/numbness in the ulnar nerve territ...	10/17/2012 289 views 5
	Transmuscular Ulnar Nerve Transposition Presentation - Dr. Susan Mackinnon Hand - Educational Presentation - Cubital Tunnel Syndrome This presentation was given during the Vumedi on-line webinar on 4/10/2012 regar...	9/6/2012 406 views 4

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Posts

	An Anatomical Basis for Endoscopic Cubital Tunnel Release and Associated Clinical Outcomes. Mirza A, Mirza JB, Lee BK, Adhya S, Litwa J, Lorenzana DJ J Hand Surg Am. 2014 May;:. PMID: 24881897 (Link to Pubmed) Hand - Journal Club - Cubital Tunnel Syndrome	6/20/2014 0 responses 0
	Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA Neurosurgery. 2005 Mar;56(3):522-30; discussion 522-30. PMID: 15730578 (Link to Pubmed) Hand - Journal Club - Cubital Tunnel Syndrome	2/5/2014 17 responses 4
	Anterior Transposition Compared with Simple Decompression for Treatment of Cubital Tunnel Syndrome. A Meta-analysis of Randomized, Controlled Trials. Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W J Bone Joint Surg Am. 2007 Dec;89(12):2591-8. PMID: 18056489 (Link to Pubmed) Hand - Journal Club - Cubital Tunnel Syndrome	5/7/2013 144 responses 4

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Groups

Oral Boards: Cubital Tunnel Syndrome

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery. 2005 Mar;56(3):522-30; discussion 522-30. PMID:15730578 (Link to Abstract)
Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI. Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg Br. 2005 Oct;30(5):521-4. PMID:16061314 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Cheung EV, Steinmann SP. Surgical approaches to the elbow. J Am Acad Orthop Surg. 2009 May;17(5):325-33. PMID:19411644 (Link to Abstract)
Elhassan B, Steinmann SP: Entrapment neuropathy of the ulnar nerve. J Am Acad Orthop Surg 2007;15:672-681. PMID:17989418 (Link to Abstract)
Morrey BF. Post-traumatic contracture of the elbow. Operative treatment, including distraction arthroplasty. J Bone Joint Surg Am. 1990 Apr;72(4):601-18. PMID:2324148 (Link to Abstract)
Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. 2007 Dec;89(12):2591-8. PMID:18056489 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Bainbridge C: Cubital tunnel syndrome, in Berger RA, Weiss APC (eds): Hand Surgery. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 887-896.
Green D. Ulnar nerve palsy. In: Green DP, ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone; 1993:1449-1482.
Hurst LC, Gruber MA, Kottmeier SA. Neuromuscular disorders of the upper extremity. In: Dee R, ed. Principles of Orthopaedic Practice. New York, NY: McGraw Hill; 1988:690-728

Cubital Tunnel Syndrome

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