Updated: 11/16/2020

Cubital Tunnel Syndrome

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https://upload.orthobullets.com/topic/6021/images/Cubital tunnel syndrome_moved.jpg
https://upload.orthobullets.com/topic/6021/images/cubital tunnel syndrome.jpg
 
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 succes 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 topic
    • 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
Tested Differential
  • How to differentiate ulnar tunnel syndrome from cubital tunnel syndrome
    • cubital tunnel demonstrates
      • 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 
    • weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor function)
    • paresthesias in ring and little finger 
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   
      • approach
        • elbow medial approach  
      • 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
Techniques
  • 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
Introduction
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
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
 

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Questions (12)
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(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:
1

Musculocutaneous nerve

0%

(11/4230)

2

Anterior Interosseious Nerve (AIN

20%

(852/4230)

3

Radial nerve

1%

(59/4230)

4

Ulnar nerve

74%

(3138/4230)

5

Median nerve

3%

(141/4230)

L 2 C

Select Answer to see Preferred Response

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(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
1

Osborne's ligament and the MCL

67%

(3356/5008)

2

MCL and Arcade of Struthers

7%

(334/5008)

3

Osborne's ligament and the intermuscular septum

15%

(740/5008)

4

MCL and medial head of the triceps

1%

(71/5008)

5

Ulnar and humeral heads of the flexor carpi ulnaris muscle

10%

(487/5008)

L 3 C

Select Answer to see Preferred Response

(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:
1

Simple ulnar nerve decompression at the cubital tunnel

76%

(1953/2573)

2

Ulnar nerve decompression at the cubital tunnel with anterior submuscular transposition

11%

(293/2573)

3

Ulnar nerve decompression at the cubital tunnel with anterior subcutaneous transposition

11%

(292/2573)

4

Open carpal tunnel release

1%

(16/2573)

5

Endoscopic carpal tunnel release

0%

(3/2573)

L 2 C

Select Answer to see Preferred Response

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

QID: 2814
1

arcade of Struthers

16%

(469/2952)

2

ligament of Struthers

75%

(2228/2952)

3

flexor carpi ulnaris fascia

2%

(72/2952)

4

medial intermuscular septum

4%

(104/2952)

5

Osborne's ligament

2%

(66/2952)

L 2 C

Select Answer to see Preferred Response

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Evidence (18)
VIDEOS (13)
CASES (1)
Topic COMMENTS (28)
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