Download Cubital tunnle syndrom

Cubital tunnel syndrom
(current concepts)
‫سندرم تونل کوبیتال‬
Hossein Saremi MD
Orthopaedic Hand&shoulder surgeon
Hamedan University of Medical sciences
Hamedan,IRAN
Entrapment of ulnar nerve
The second most common compression neuropathy
in the upper extremity after CTS
Anatomy

Ulnar nerve is the terminal branch of the medial
cord(C8-T1)
Continues between
medial head of the
triceps brachi and
the brachialis
muscles
postromedial
tobrachial artery and
just posterior to
intermuscular
septum
Anatomy of ulnar nerve
A band of facia
that connects
medial head of
triceps whith
the inter
muscular
septum of the
arm and crosses
the ulnar nerve
approximately
8cm proximal to
the medial
epicondyle
Arcade of Struthers
A band of facia
that connects
medial head of
triceps whith
the inter
muscular
septum of the
arm and crosses
the ulnar nerve
approximately
8cm proximal to
the medial
epicondyle
Arcade of Struthers
Becomes more
superficial3.5cm
proximal
tomedial
epicondyle
Courses
posterior to
medial
epicondyle and
medial to the
ulecranon then
enters the
cubital tunnel
Anatomy of ulnar nerve
Cubital tunnel
 Roof: osbourne’s lig
A thickened transverse band between the humeral
and ulnar head of FCU
 Floor:
 medial collateral ligament of the elbow
 Elbow joint capsule
 olecranon
Cubital
tunnel
After passing
through the
cubital
tunnel,the
nerve courses
deep into the
forear,between
the ulnar and
humeral head
of the FCU
Anatomy
Posterior
branch of the
medial
antibrachial
cutaneos
nerve
Potential ulnar nerve entrapment
 The arcade of struthers
 Medial intermuscular symptom
 Medial epicondyle
 Cubital tunnel
 Deep flexor pronator aponeurosis
Anatomical
variations of
fibrous bands
Karatsa A, Apaydin
N, Uz A, Tubbs SR,
Loukas M, Gezen
F.
Regional anatomic
structures of the
elbow that may
potentially
compress the
ulnar. J Shoulder
Elbow Surg
2009;18:627– 631
Anatomy
Diagnosis
History
 Co morbidities such as diabetes,thyroid
disease,hemophilia and peripheral neuropathies
 Onset of symptoms ,
 Grip or pinch weakness
 Aggravating activities and positions
History
 May be the most important historical piece of
information is whether or not the symptoms are
constant
 Numbness and paresthesias are the predominant
presenting features( difficulty in localizing)
 Pain is less common
 Questions focusing on hand activity
 Buttoning buttons
 Opening bottles
 typing
Physical Examination
 Presentation with muscle atrophy 4 times thanCTS
Muscle atrophy at diagnosis of carpal and cubital
tunnel syndrome
.
J Hand Surg 2007;
32A;855–858
Physical Examination
The extent of ulnar nerve dysfunction has been divided
into three categories:
 Mild:intermittent paresthesias,
subjective
weakness
 Moderate:intermittent paresthesias, measurable
weakness
 Severe:persistent paresthesias,measurable weakness
Provocative tests
 Tinel test------------------70% sensitive
 Elbow flexion test----------75%sensetive after60
seconds
 Pressure test----------------89%sensetive after 60
seconds
 Combined elbow flexion-pressure test------98%sensetive
 Scratch collapse test(recently)
Provocative tests
Scratch collapse test for evaluation of
carpal and cubital tunnel
syndrome. J Hand Surg
2008;33A;1518–1524
Physical Examination
 Thorough Elbow Examination is needed to look for
other sources of pain
 Athlete-------elbow instability such as chronic valgus
stress
Physical Examination
 Trauma------childhood supracondylar FX
(Tardy ulnar nerve palsy)
 Ulnar nerve subluxation
Full ROM exam is mandatory
 Medial elbow pain can be seen after elbow Fx that
are treated without ulnar nerve transposition
(olecranon fx,distal humerus,medial epicondyle)
Physical Examination
LONG STANDING
ULNAR NERVE PALSY
Physical Examination
Radiography
Should be obtained in all patients to evaluate for elbow
arthritis which may lead to osteophytic
impingement on the cubital tunnel
Electrodiagnostic study
 Ulnar nerve conduction velocity<50m/s is positive
 Can be used for diagnosis and prognosis(advanced)
 Help to localize site of compression
 Have a false-negative rate in excess of 10%
High –resolution ultrasound
?
 Enlargement of the ulnar nerve is seen in cubital
tunnel
 More standardization is required
Treatment
Operative treatment
Non operative treatment
 Mild cubital tunnel
syndrom
 In situ decompression
 Subcutaneous anterior

 If NCV>40m/s



transposition
Intramuscular
transposition
Submuscular
transposition
Medial epicondylectomy
Endoscopic
decompression
Non surgical Treatment
 Activity modification
 Splinting
 Specific stretching and nerve gliding EX
 80-89.5% improved
Non surgical Treatment
24. Svernlov B, Larsson M, Rehn K, Adolfsson L.
Conservative treatment of the cubital tunnel
syndrome. J Hand Surg 2009;34B:201–207.
In situ decompression
 6-8cm incision is made along the course of the ulnar
nerve between the medial epicondyle and the
olecranon
 Struther’s and osbourne’s ligaments are released
 Neurolysis is not performed
 Prospective randomized studies have shown results
of simple decompression to be equal to those of
anterior transposition
Subcutaneous anterior transposition
 Prevents tension during flexion
 May compromise the blood supply to the nerve
 Care should be taken to insure a new site of
compression
 A longer incision is required
 Care should be taken to preserve the motor branches
to the FCU and FDPs
Operative treatment
which
31. Biggs M, Curtis
JA. Randomized,
prospective study
comparing ulnar
neurolysis in situ with
submuscular
transposition.
Neurosurgery 2006
Procedure?
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 2005;30B:
Study of 56
patient(69
extremities):
7% had
persistant
symptoms post
operatively
which were
relived after
anterior
submuscular
transposition
34. Goldfarb CA, Sutter MM,
Martens EJ, Manske PR.
Incidence of
re-operation and subjective
outcome following in situ
decompression
of the ulnar nerve at the cubital
tunnel. J Hand Surg 2009;34B:379–
.
Intra muscular transposition
 A groove is created in the flexor pronator muscles to
serve as a tract into which the nerve is transposed
 Proponents: it places the nerve in a straighter line
across the elbow joint
 Opponents: it can cause scarring of the nerve
Sub muscular transposition
 Requires the largest incision and most extensive
dissection
 The flexor pronator mass is incised 1-2cm distal to
medial epicondyle in a step-cut fashion to allow for
fractional lengthening of the muscle
 Identification and protection of UCL and the median
nerve is required
 Ulnar nerve is transposed anteriorly adjacent and
parallel to the median nerve
Sub muscular transposition
Prospective randomized
study(only subjective)
 NO statistical
difference with simple
nerve decompression
Acta Neurochir
2009;151:311–
316.mpression
Retrospective study
No statistical difference 
with sub cutaneous
transpostransposition
J Hand Surg
2009;34A:866–874.ition
Meta analysis of litrature
No statistical differences in reported outcomes
between simple decompression and anterior
transposition of any type,in patients with cubital
tunnel syndrom
J Bone Joint Surg 2007;
J Hand Surg 2008;
Medial epicondylectomy
 The nerve is decompressed as insitu decompression
 Osteotomy plane is between the sagital and coronal
plane to avoid detachment of the anterior band
ofUCL
 The flexor pronator origin is reattached to the
perioseal sleeve with absorbable suture
 45%had medial elbow pain at 6 month follow-up
 Prospective randomized trials comparing to other
surgical treatment options are needed
Endoscopic decompression
 Was first discribed in 1995 Tsai et al
 All techniques use a small 15-35mm incision located over
the ulnar nerve at the condylar groove
In the study of76nerves in75 patien
sensory loss improved in96%
grip strength significantely improved
4 patient had superficial hematoma
9 patient developed decreased feeling in
the medial antibrachial nerve which

resolved by 3 month in 8 patient
J Hand Surg 2006;
Endoscopic decompression
 A recent comparison between endoscopic technique and
insitu decompression demonstrated statistically
significant less pain and greater satisfaction with the
endoscopic technique
Patient-rated outcome of ulnar nerve decompression:
a comparison of endoscopic and open in situ
decompression.
J Hand Surg 2009;34A:1492–1498.
Treatment Algorithm
 In most cases simple decompression is adiquate
 In the future the simplest technique may be an
endoscopic release
 Certain situations will likely recommend a different
surgical treatment
 Nerve subluxation
 Post traumatic elbow stiffness
 Over head throwing athletes with valgus instability
 Surgical options for failed cubital tunnel syndrom
include anterior transposition(sub
muscular,intramuscular,subcutaneous)
Treatment Algorithm
Selection of a surgical approach is based on the
ETHIOLOGY.of nerve compression,ANATOMIC
VARIATIONS,andsurgeon’s EXPERIENCE