Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Cubital Tunnel Syndrome
Cubital Tunnel Syndrome
Dawn M. LaPorte MD
BasicsDescription
-
Cubital tunnel syndrome consists of pain
and paresthesias over the medial border of the forearm and hand, as
well as weakness in an ulnar nerve distribution from compression of the
ulnar nerve as it passes through the cubital tunnel at the elbow. -
It affects the elbow, forearm, and hand in the ulnar nerve distribution and is most commonly seen in adults.
-
Synonym: Ulnar tunnel syndrome
Epidemiology
Incidence
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The 2nd most common entrapment neuropathy (after CTS) in the upper extremity
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Males and females are affected equally.
Risk Factors
Diabetes
Etiology
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The ulnar nerve is compressed as it
passes through the cubital tunnel at the medial side of the elbow,
which may compress the blood vessels that feed the nerve and create
symptoms. -
Possible causes of the compression include:
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Enlarged medial head of the triceps muscle
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Trauma
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Recurrent dislocation of the nerve from the tunnel
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Arthritis (bony spurs)
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Ganglia
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Abnormal muscles (anconeus epitrochlearis)
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Associated Conditions
TOS
DiagnosisThe diagnosis is made clinically, with aid from nerve conduction studies.
Signs and Symptoms
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Vague, aching pain
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Paresthesias
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Numbness over the medial forearm, hand, and (occasionally) upper arm
Physical Exam
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Note decreased sensation in the ulnar nerve distribution.
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Check for intrinsic weakness by placing a
sheet of paper between the patient’s thumb and 1st finger and
attempting to pull the paper away as the patient resists. -
Look for intrinsic muscle wasting, especially of the 1st dorsal interosseous muscle.
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Percussion test (Tinel sign): Tapping over the ulnar nerve at the elbow causes a reproduction of symptoms (Fig. 1).
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Elbow flexion test: Keeping the elbow
fully flexed (and the wrist in neutral or extension to avoid carpal
tunnel symptoms) for 1 minute causes a reproduction of the symptoms. -
Order nerve conduction studies (nerve conduction is slowed across the elbow).
Fig. 1. Tinel sign. Tapping over the ulnar nerve at the cubital tunnel produces paresthesias in the small and ring fingers.
Tests
Imaging
AP radiography of the elbow may be indicated.
Pathological Findings
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At decompression, specific sites of nerve compression usually can be found.
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Inspect the arcade of Struthers,
intermuscular septum, cubital tunnel, and Osborne fascia (between 2
heads of flexor carpi ulnaris).
Differential Diagnosis
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Thoracic outlet syndrome
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C8–T1 cervical root compression
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Compression of the ulnar nerve at the wrist (Guyon canal)
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CTS
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Guillain-Barré syndrome
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Amyotrophic lateral sclerosis
TreatmentGeneral Measures
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Nonoperative treatment involves splinting the elbow in extension to relieve acute symptoms.
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Patients wear the splint when sleeping.
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Nighttime elbow extension splints with the forearm held in neutral or supination
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Avoid prolonged elbow flexion.
P.91
Surgery
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Consider surgery if symptoms continue after 3 months of nonoperative therapy.
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Many procedures have been described (1–6):
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Procedures usually consist of some form of decompression of the nerve in the canal.
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Operations often involve transposition of the nerve out of the canal in an anterior direction.
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Follow-upPrognosis
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Nonoperative therapy: 50% excellent results (7)
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Surgical therapy: Good to excellent results in nearly all patients
Complications
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Reflex sympathetic dystrophy and nerve irritation may occur after surgery.
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If left untreated, severe ulnar
neuropathy can lead to clawing of the small finger and ring finger,
atrophy of intrinsic muscles, and positive Froment and/or Wartenberg
signs.
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Patient Monitoring
Motor and sensory examinations are performed at follow-up visits.
References
1. Dellon
AL, Coert JH. Results of the musculofascial lengthening technique for
submuscular transposition of the ulnar nerve at the elbow. Surgical
technique. J Bone Joint Surg 2004;86A: 169–179.
AL, Coert JH. Results of the musculofascial lengthening technique for
submuscular transposition of the ulnar nerve at the elbow. Surgical
technique. J Bone Joint Surg 2004;86A: 169–179.
2. Dinh PT, Gupta R. Subtotal medial epicondylectomy AS a surgical option for treatment of cubital tunnel syndrome. Tech Hand Up Extrem Surg 2005;9:52–59.
3. Eaton RG, Crowe JF, Parkes JC, III. Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling. J Bone Joint Surg 1980;62A:820–825.
4. Gervasio
O, Gambardella G, Zaccone C, et al. Simple decompression versus
anterior submuscular transposition of the ulnar nerve in severe cubital
tunnel syndrome: a prospective randomized study. Neurosurgery 2005;56:108–117.
O, Gambardella G, Zaccone C, et al. Simple decompression versus
anterior submuscular transposition of the ulnar nerve in severe cubital
tunnel syndrome: a prospective randomized study. Neurosurgery 2005;56:108–117.
5. Learmonth JR. A technique for transplanting the ulnar nerve. Surg Gynecol Obstet 1942;75:792–793.
6. Nabhan
A, Ahlhelm F, Kelm J, et al. Simple decompression or subcutaneous
anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg 2005;30B:521–524.
A, Ahlhelm F, Kelm J, et al. Simple decompression or subcutaneous
anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg 2005;30B:521–524.
7. Padua L, Aprile I, Caliandro P, et al. Natural history of ulnar entrapment at elbow. Clin Neurophysiol 2002;113:1980–1984.
Additional Reading
Mackinnon SE, Novak CB. Compression neuropathies. In: Green DP, Hotchkiss RN, Pederson WC, et al., eds. Green’s Operative Hand Surgery, 5th ed. Philadelphia: Elsevier Churchill Livingstone, 2005;999–1045.
Jobe MT, Martinez SF. Peripheral nerve injuries. In: Canale ST, ed. Campbell’s Operative Orthopaedics, 10th ed. St. Louis: Mosby, 2005:3221–3283.
MiscellaneousCodes
ICD9-CM
354.2 Cubital tunnel syndrome
Patient Teaching
Patients are counseled to avoid activities that exacerbate their symptoms.
Prevention
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Avoid:
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Repetitive work activities if they cause symptoms
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Prolonged elbow flexion
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FAQ
Q: Is there a nonoperative treatment for cubital tunnel syndrome?
A:
Mild or mild/moderate cubital tunnel syndrome can be treated with a
nighttime elbow extension splint to minimize elbow flexion during
sleep. Patients also are advised to avoid prolonged activity with the
elbow flexed. Nerve glides (active exercises that help to prevent
scarring around the nerve) may be of some benefit.
Mild or mild/moderate cubital tunnel syndrome can be treated with a
nighttime elbow extension splint to minimize elbow flexion during
sleep. Patients also are advised to avoid prolonged activity with the
elbow flexed. Nerve glides (active exercises that help to prevent
scarring around the nerve) may be of some benefit.
Q: Once a patient has intrinsic wasting, what can be done to restore intrinsic strength?
A:
Once intrinsic atrophy occurs, nothing can be done specifically to
restore the intrinsic motor loss. Ulnar nerve decompression and
transposition can halt additional progression of motor loss and, if the
patient has a functional deficit, tendon transfers could be considered.
Once intrinsic atrophy occurs, nothing can be done specifically to
restore the intrinsic motor loss. Ulnar nerve decompression and
transposition can halt additional progression of motor loss and, if the
patient has a functional deficit, tendon transfers could be considered.
Q: What are the symptoms of cubital tunnel?
A:
Patients typically present with complaints of numbness and tingling in
their small and ring fingers. Symptoms frequently are worse during
extended periods of elbow flexion, for example, talking on the phone or
blow-drying hair.
Patients typically present with complaints of numbness and tingling in
their small and ring fingers. Symptoms frequently are worse during
extended periods of elbow flexion, for example, talking on the phone or
blow-drying hair.