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

Ulnar nerve is the terminal branch of the medial cord(C8-T1) 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

Posterior branch of the medial antibrachial cutaneos nerve 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 Cadavr anatomy review

Aggravating activities and positions 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)

Long standing ulnar nerve palsy 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 Mild cubital tunnel syndrom If NCV>40m/s Non operative treatment Operative treatment Mild cubital tunnel syndrom If NCV>40m/s In situ decompression Subcutaneous anterior 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 Procedure? 31. Biggs M, Curtis JA. Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery 2006 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) Retrospective study NO statistical difference with simple nerve decompression Acta Neurochir 2009;151:311–316.mpression 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

THANK YOU