Summary Cubital Tunnel Syndrome is a common compressive neuropathy of the ulnar nerve usually caused by anatomic compression in the elbow region. The condition typically presents with numbness, tingling, and sensory changes of the ring and little finger that progresses slowly over time. Treatment may be nonoperative modalities such as bracing or surgical decompression depending the the severity and duration of symptoms, and success of nonoperative treatment. Introduction Epidemiology 19-25 cases per 100,000 person-years patients with cubital tunnel syndrome present at a more advanced disease state than those with carpal tunnel syndrome second most common compression neuropathy of upper extremity Pathophysiology Cubital tunnel syndrome results from compression and traction on the ulnar nerve about the elbow 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 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 Classification McGowan and Dellon Type 1 Subjective sensory symptoms without objective loss of two-point sensibility or muscular atrophy Type 2A Sensory symptoms + weakness on pinch and grip without atrophy Type 2B Sensory symptoms + atrophy and intrinsic muscle strength ≤ 3 Type 3 Profound muscular atrophy and sensory disturbance 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 sign inability to flex DIPJ of ring and small fingers (weak FDP) 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 Differential Ulnar Tunnel Syndrome key findings that differentiate cubital tunnel syndrome from ulnar tunnel syndrome found with cubital tunnel syndrome less clawing sensory deficit to dorsum of the hand motor deficit to ulnar-innervated extrinsic muscles Tinel sign at the elbow positive elbow flexion test C8 radiculopathy key finding that differentiate cubital tunnel syndrome from a C8 radiculpathy found with cubital tunnel syndrome weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor function) paresthesias in ring and little finger found with C8 radiculopathy symptoms improve with should abduction Treatment Nonoperative NSAIDs, activity modification, and nighttime elbow extension splinting indications first line of treatment with mild symptoms 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 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 outcomes similar outcomes to in situ release but increased risk of creating a new point of compression Improved outcomes with unstable nerves in the pediatric population medial epicondylectomy indications visible and symptomatic subluxating ulnar nerve thin patients with inadequate subcutaneous tissue to perform a transposition outcomes risk of destabilizing the medial elbow by damaging the medial ulnar collateral ligament Overview X condition is traumatic condition characterized by X, that is [rare; incidnece] and seen in [demographic]. treatment is usually.....x Epidemiology incidence US incidence demographics male : female ratio age bracket location where in the body/bone risk factors smoking etc. Pathophysiology mechanism of injury (trauma) this is the mechanism of injury (valgus force on knee) pathophysiology this is the physiology (hormone feedback loop) pathobiology this is the molecular or cell biology of disease pathoantomy this is the anatomic cascade of disease Genetics inheritance pattern autosomal dominant mutations chromosome gene protein encoded for Associated conditions orthopaedic conditions condition a condition b medical conditions & comorbidities condition a Prognosis natural history of disease prognostic variable favorable negative survival with treatment Anatomy Osteology x Muscles muscles a Ligament ligament a Blood Supply x Biomechanics x Classification Classification A Type A • Characteristic A • Characteristic A Type B • Characteristic B • Characteristic B Type C • Characteristic C Type D • Characteristic D Presentation History (optional) this is a specific event the patient cites. "Heard a pop" Symptoms common symptoms location duration severity aggrevating / aleiving factors Physical exam inspection varus or valgus deformity ecchymosis & swelling diffuse tenderness motion document flexion-extension and pronation-supination crepitus should be noted varus/valgus instability stress test challenging but important for an accurate diagnosis neurovascular provocative tests Imaging Radiographs recommended views xrays that should alwasy be obtained on evaluation optional views secondary views that might give additional information findings disc space narrowing measuerment measurement A (Cobb angle) measurement A (pelvic incidence) criteria dictating treatment > 3mm step of dictates operative treatment sensitivity and specificity CT indications when do you order views best seen on sagital findings sensitivity and specificity MRI indications when do you order views best seen on T2 axial sensitivity and specificity Bone scan indications when do you order sensitivity and specificity Studies Labs serum urine surface (nasal swab, sputum) Invasive studies Histology gross anatomy histology immunostaining Tested Differential (if nothing or NOT and important teaching point, leave blank) Frequently Tested Differential A key distinguishing factor Complete differential tables Prevention Prevention A Prevention B Prevention C Treatment (for surgical residency sites, e.g., orthobullets, ENT bullets) Nonoperative nonoperative treatment A indications outcomes Operative operative treatment A indications indication a indication b outcomes operative treatment B indications indication a indication b outcomes Treatment (for medical residency sites and medical student sites, e.g., medbullets, IM bullets) Lifestyle lifestyle change A indications indication a outcomes Pharmacologic drug A indications indication a outcomes Operative operative treatment A indications indication a outcomes Treatment (for medical residency sites and medical student sites, e.g., medbullets, IM bullets) Nonoperative nonoperative treatment A indications outcomes Operative operative treatment A indications indication a indication b outcomes operative treatment B indications indication a indication b outcomes Techniques Techniques NSAIDs, activity modification, and nighttime elbow extension splinting technique night bracing in 45° extension with forearm in neutral rotation In situ decompression releasing the fascial structures superficial to the ulnar nerve along the medial aspect of the elbow 4-cm incision midway between the olecranon and medial epicondyle distally release Osborne ligament and the superficial and deep fascia of FCU proximally release the fascia between the medial triceps and medial intermuscular septum avoid circumferential dissection of the nerve to minimize devascularization and to avoid creating hypermobility of the nerve endoscopically-assisted cubital tunnel release is an option favorable early results but lacks long-term data Decompression and transposition (submuscular, intramuscular, or subcutaneous) decompress the nerve and circumferentially dissect the nerve to allow for transposition excise the medial intermuscular septum anteriorly transpose the nerve secured with subcutaneous tissue, placed anterior to a fascial sling, or placed within or beneath the flexor pronator mass Medial Epicondylectomy decompress the nerve and then perform an oblique osteotomy of the medial epicondyle preserve the insertion of the MCL + repair the periosteum 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
QUESTIONS 1 of 12 1 2 3 4 5 6 7 8 9 10 11 12 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 3551 FIGURES: V Type & Select Correct Answer 1 Musculocutaneous nerve 0% (11/4288) 2 Anterior Interosseious Nerve (AIN 20% (867/4288) 3 Radial nerve 1% (60/4288) 4 Ulnar nerve 74% (3179/4288) 5 Median nerve 3% (142/4288) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Tested Concept QID: 3172 Type & Select Correct Answer 1 Osborne's ligament and the MCL 67% (3422/5097) 2 MCL and Arcade of Struthers 7% (338/5097) 3 Osborne's ligament and the intermuscular septum 15% (753/5097) 4 MCL and medial head of the triceps 1% (70/5097) 5 Ulnar and humeral heads of the flexor carpi ulnaris muscle 10% (492/5097) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (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? Tested Concept QID: 2837 FIGURES: A Type & Select Correct Answer 1 Simple ulnar nerve decompression at the cubital tunnel 76% (1974/2601) 2 Ulnar nerve decompression at the cubital tunnel with anterior submuscular transposition 11% (297/2601) 3 Ulnar nerve decompression at the cubital tunnel with anterior subcutaneous transposition 11% (295/2601) 4 Open carpal tunnel release 1% (16/2601) 5 Endoscopic carpal tunnel release 0% (3/2601) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ09.1) All of the following are possible sites of compression for the ulnar nerve EXCEPT: Tested Concept QID: 2814 Type & Select Correct Answer 1 arcade of Struthers 16% (473/2991) 2 ligament of Struthers 76% (2261/2991) 3 flexor carpi ulnaris fascia 2% (70/2991) 4 medial intermuscular septum 4% (106/2991) 5 Osborne's ligament 2% (66/2991) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
All Videos (14) Podcasts (1) Login to View Community Videos Login to View Community Videos Ulnar Nerve, Clinical Examination - Everything You Need To Know - Dr. Nabil Ebraheim Nabil Ebraheim (PD) Hand - Cubital Tunnel Syndrome 10/14/2020 194 views 5.0 (1) Login to View Community Videos Login to View Community Videos Cleveland Combined Hand Fellowship Lecture Series 2018-2019 Ulnar and Radial Nerve Compression Neuropathies - Ryan Berger, MD Ryan Berger Hand - Cubital Tunnel Syndrome 10/1/2020 31 views 0.0 (0) Login to View Community Videos Login to View Community Videos Cleveland Combined Hand Fellowship Lecture Series 2019-2020 Cubital Tunnel Syndrome - Anil Akoon, MD Anil Akoon Hand - Cubital Tunnel Syndrome 9/9/2020 35 views 0.0 (0) HandâȘCubital Tunnel Syndrome Team Orthobullets 4 Hand - Cubital Tunnel Syndrome Listen Now 19:21 min 10/15/2019 313 plays 5.0 (1) See More See Less
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