3. Cubital tunnel syndrom (current concepts) سندرم تونل کوبیتال
Hossein Saremi MD
Orthopaedic Hand&shoulder surgeon
Hamedan University of Medical sciences
Hamedan,IRAN

4. Entrapment of ulnar nerve
The second most common compression neuropathy in the upper extremity after CTS

5. 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)

8. 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

9. 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

10. 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

11. 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

12. 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

13. Cubital tunnel
After passing through the cubital tunnel,the nerve courses deep into the forear,between the ulnar and humeral head of the FCU

14. Posterior branch of the medial antibrachial cutaneos nerve
Anatomy
Posterior branch of the medial antibrachial cutaneos nerve

15. Potential ulnar nerve entrapment
The arcade of struthers
Medial intermuscular symptom
Medial epicondyle
Cubital tunnel
Deep flexor pronator aponeurosis

16. 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

17. Anatomy
Cadavr anatomy review

18. 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

19. 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

20. 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

22. 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

23. Provocative tests Tinel test------------------70% sensitive
Elbow flexion test %sensetive after60 seconds
Pressure test %sensetive after 60 seconds
Combined elbow flexion-pressure test %sensetive
Scratch collapse test(recently)

24. Provocative tests
Scratch collapse test for evaluation of carpal and cubital tunnel
syndrome. J Hand Surg 2008;33A;1518–1524

25. Physical Examination
Thorough Elbow Examination is needed to look for other sources of pain
Athlete elbow instability such as chronic valgus stress

26. 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)

27. Long standing ulnar nerve palsy
Physical Examination
Long standing ulnar nerve palsy

28. Physical Examination

33. Radiography
Should be obtained in all patients to evaluate for elbow arthritis which may lead to osteophytic impingement on the cubital tunnel

34. 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%

35. High –resolution ultrasound?
Enlargement of the ulnar nerve is seen in cubital tunnel
More standardization is required

37. 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

38. Non surgical Treatment
Activity modification
Splinting
Specific stretching and nerve gliding EX
% improved

39. 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.

40. 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

41. 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

42. 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:

43. 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– .

44. 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

45. 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

46. 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

47. 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;

48. 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

49. 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;

50. 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.

51. 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)

52. Treatment Algorithm
Selection of a surgical approach is based on the ETHIOLOGY.of nerve compression,ANATOMIC VARIATIONS,andsurgeon’s EXPERIENCE

53. THANK YOU