eMedicine Specialties > Orthopedic Surgery > Elbow

Cubital Tunnel Syndrome: Workup

Author: James R Verheyden, MD, Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades
Coauthor(s): Andrew K Palmer, MD, Chair, Professor, Department of Orthopedics, State University of New York-Upstate Medical University
Contributor Information and Disclosures

Updated: Jun 26, 2009

Workup

Imaging Studies

  • Radiography
    • Obtain a cubital tunnel projection radiograph with a history of trauma or arthritis to exclude medial trochlear lip osteophytes.
    • If a supracondylar process on the medial aspect of the humerus is suspected, obtain an elbow radiograph 5 cm proximal to the medial epicondyle.
    • Obtain a chest radiograph if the patient has a history of smoking and symptoms in the ulnar nerve distribution to exclude a Pancoast tumor in the apical lung.
  • Magnetic resonance imaging (MRI)
    • MRI is both sensitive and specific in the diagnosis of ulnar nerve entrapment at the elbow. It may be useful if the patient has previously undergone an anterior transposition of the ulnar nerve. On MRI, increased signal intensity is better than enlargement of the nerve for detecting ulnar nerve entrapment. A disadvantage of MRI in diagnosing cubital tunnel syndrome is its expense.
    • Britz et al examined the use of MRI in diagnosing cubital tunnel syndrome using a short tau inversion recovery sequence.51 They studied 31 elbows with documented ulnar nerve entrapment and found increased signal intensity in the ulnar nerve in 97% of their cases and enlargement of the ulnar nerve in 75%.
  • High-resolution ultrasonography52
    • High-resolution ultrasonography has been used to evaluate the morphologic changes in the ulnar nerve at the cubital tunnel in ulnar nerve neuropathy.
    • Using high-resolution ultrasonography, Chiou et al found that the mean value of the area of the ulnar nerve at the level of the medial epicondyle in symptomatic patients was significantly larger than that of the control group and that of the unaffected, contralateral side.53 Their P value was less than 0.001. Their conclusions were that if the area of the ulnar nerve was greater than 0.075 cm2, at the level of the medial epicondyle, the patient probably had cubital tunnel syndrome.

Other Tests

  • Electromyography
    • An electromyograph (EMG) is not essential when the diagnosis of cubital tunnel syndrome is obvious on clinical examination, as a false test result can be misleading; however, it is important to perform an EMG when the diagnosis of cubital tunnel syndrome is unclear or to determine the efficacy of conservative treatment.52
    • EMG findings are considered positive for cubital tunnel syndrome when the motor conduction velocity across the elbow is less than 50 m/s or when the difference between the motor conduction velocity across the elbow and that below the elbow is greater than 10 m/s. During the test, it is important to stimulate the nerve over 2-cm intervals to precisely localize the area of entrapment. Compression of the ulnar nerve is probably at the level of the retrocondylar groove when the point of maximum conduction delay and drop in amplitude of the compound muscle action potential is at or just proximal to the medial epicondyle. In contrast, compression is probably in the cubital tunnel when the point of maximum conduction delay and drop in amplitude of the compound muscle action potential is 2 cm distal to the medial epicondyle. Unfortunately, false-positive results are obtained in 15% of cases.
  • Scratch collapse test54

More on Cubital Tunnel Syndrome

Overview: Cubital Tunnel Syndrome
Workup: Cubital Tunnel Syndrome
Treatment: Cubital Tunnel Syndrome
Follow-up: Cubital Tunnel Syndrome
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Feindel W, Stratford J. The role of the cubital tunnel in tardy ulnar palsy. Can J Surg. Jul 1958;1(4):287-300. [Medline].

  2. Feindel W, Stratford J. Cubital tunnel compression in tardy ulnar palsy. Can Med Assoc J. Mar 1 1958;78(5):351-3. [Medline].

  3. Curtis BF. Traumatic Ulnar Neuritis: Transplantation of the Nerve. J Nerve Ment Dis. 1898;25:580.

  4. Charness ME. Unique upper extremity disorders of musicians. In: Millender, ed. Occupational Disorders of the Upper Extremity. New York, NY: Churchill Livingstone;. 1992: 227-52.

  5. McPherson SA, Meals RA. Cubital tunnel syndrome. Orthop Clin North Am. Jan 1992;23(1):111-23. [Medline].

  6. Rettig AC, Ebben JR. Anterior subcutaneous transfer of the ulnar nerve in the athlete. Am J Sports Med. Nov-Dec 1993;21(6):836-9; discussion 839-40. [Medline].

  7. Watchmaker GP, Lee G, Mackinnon SE. Intraneural topography of the ulnar nerve in the cubital tunnel facilitates anterior transposition. J Hand Surg [Am]. Nov 1994;19(6):915-22. [Medline].

  8. Pechan J, Julis I. The pressure measurement in the ulnar nerve. A contribution to the pathophysiology of the cubital tunnel syndrome. J Biomech. Jan 1975;8(1):75-9. [Medline].

  9. Bozentka DJ. Cubital tunnel syndrome pathophysiology. Clin Orthop. Jun 1998;(351):90-4. [Medline].

  10. Dellon AL. Musculotendinous variations about the medial humeral epicondyle. J Hand Surg [Br]. Jun 1986;11(2):175-81. [Medline].

  11. Green JR Jr, Rayan GM. The cubital tunnel: anatomic, histologic, and biomechanical study. J Shoulder Elbow Surg. Sep-Oct 1999;8(5):466-70. [Medline].

  12. Lundborg G, Dahlin LB. Anatomy, function, and pathophysiology of peripheral nerves and nerve compression. Hand Clin. May 1996;12(2):185-93. [Medline].

  13. Neary D, Earnes R. The pathology of ulnar nerve compression in man. Neuropathol Appl Neurobiol. 1975;1:69-88.

  14. Wilgis EF, Murphy R. The significance of longitudinal excursion in peripheral nerves. Hand Clin. Nov 1986;2(4):761-6. [Medline].

  15. Yamaguchi K, Sweet FA, Bindra R. The extraneural and intraneural arterial anatomy of the ulnar nerve at the elbow. J Shoulder Elbow Surg. Jan-Feb 1999;8(1):17-21. [Medline].

  16. Childress HM. Recurrent ulnar-nerve dislocation at the elbow. Clin Orthop. May 1975;(108):168-73. [Medline].

  17. Sunderland S. Nerves and nerve injuries. 2nd ed. New York, NY: Churchhill Livingston;1987:728-74.

  18. Sunderland S. Blood supply of the nerves of the upper limb in man. Arch Neurol Psychiatry. 1945;53:91-115.

  19. Sunderland S. In: Nerves and Nerve Injuries. New York, NY: Churchill Livingstone;. 1968: 816-28.

  20. Sunderland S, Hughes ES. Metrical and non-metrical features of the muscular branches of the ulnar nerve. J Comp Neurol. 1946;85:113.

  21. Dellon AL, Mackinnon SE. Human ulnar neuropathy at the elbow: clinical, electrical, and morphometric correlations. J Reconstr Microsurg. Apr 1988;4(3):179-84. [Medline].

  22. Szabo RM. Entrapment and compression neuropathies. In: Green D, Hotchkiss R, Pederson W, eds. Green's Operative Hand Surgery. Vol 2. New York, NY: Churchill Livingstone;. 1999: 1422-9.

  23. Posner MA. Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Orthop Surg. Sep-Oct 1998;6(5):282-8. [Medline].

  24. Posner MA. Compressive ulnar neuropathies at the elbow: II. treatment. J Am Acad Orthop Surg. Sep-Oct 1998;6(5):289-97. [Medline].

  25. Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. Aug 18 1973;2(7825):359-62. [Medline].

  26. McGowan AJ. The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg Br. Aug 1950;32-B(3):293-301. [Medline].

  27. Buehler MJ, Thayer DT. The elbow flexion test. A clinical test for the cubital tunnel syndrome. Clin Orthop. Aug 1988;(233):213-6. [Medline].

  28. Rayan GM, Jensen C, Duke J. Elbow flexion test in the normal population. J Hand Surg [Am]. Jan 1992;17(1):86-9. [Medline].

  29. Boero S, Sénès FM, Catena N. Pediatric cubital tunnel syndrome by anconeus epitrochlearis: A case report. J Shoulder Elbow Surg. Sep 29 2008;[Medline].

  30. Yamaguchi K, Sweet FA, Bindra R. The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am. Nov 1997;79(11):1653-62. [Medline].

  31. Boyer M. Simple decompression did not differ from simple decompression plus anterior transposition of the nerve for cubital tunnel syndrome. J Bone Joint Surg Am. Aug 2006;88(8):1893. [Medline].

  32. Gellman H, Campion DS. Modified in situ decompression of the ulnar nerve at the elbow. Hand Clin. May 1996;12(2):405-10. [Medline].

  33. Greenwald D, Blum LC 3rd, Adams D, et al. Effective surgical treatment of cubital tunnel syndrome based on provocative clinical testing without electrodiagnostics. Plast Reconstr Surg. Apr 15 2006;117(5):87e-91e. [Medline].

  34. Jones RE, Gauntt C. Medial epicondylectomy for ulnar nerve compression syndrome at the elbow. Clin Orthop. Mar-Apr 1979;(139):174-8. [Medline].

  35. Kuschner SH. Cubital tunnel syndrome. Treatment by medial epicondylectomy. Hand Clin. May 1996;12(2):411-9. [Medline].

  36. Baek GH, Kwon BC, Chung MS. Comparative study between minimal medial epicondylectomy and anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome. J Shoulder Elbow Surg. Sep-Oct 2006;15(5):609-13. [Medline].

  37. Eisen A. Early diagnosis of ulnar nerve palsy. An electrophysiologic study. Neurology. Mar 1974;24(3):256-62. [Medline].

  38. Kleinman WB. Cubital tunnel syndrome: anterior transposition as a logical approach to complete nerve decompression. J Hand Surg [Am]. Sep 1999;24(5):886-97. [Medline].

  39. Eaton RG, Crowe JF, Parkes JC 3d. Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling. J Bone Joint Surg [Am]. Jul 1980;62(5):820-5. [Medline].

  40. Pribyl CR, Robinson B. Use of the medial intermuscular septum as a fascial sling during anterior transposition of the ulnar nerve. J Hand Surg [Am]. May 1998;23(3):500-4. [Medline].

  41. Macnicol MF. The results of operation for ulnar neuritis. J Bone Joint Surg [Br]. May 1979;61-B(2):159-64. [Medline].

  42. Janes PC, Mann RJ, Farnworth TK. Submuscular transposition of the ulnar nerve. Clin Orthop. Jan 1989;(238):225-32. [Medline].

  43. Kerr AT. The brachial plexus of nerves in man; the variations in its formation and branches. Am J Anat. 1918;23:285.

  44. Khoo D, Carmichael SW, Spinner RJ. Ulnar nerve anatomy and compression. Orthop Clin North Am. Apr 1996;27(2):317-38. [Medline].

  45. Spinner M, Kaplan EB. The relationship of the ulnar nerve to the medial intermuscular septum in the arm and its clinical significance. Hand. Oct 1976;8(3):239-42. [Medline].

  46. Spinner M. Nerve decompression. In: The Elbow. 1994:183-206.

  47. O''Driscoll SW, Horii E, Carmichael SW. The cubital tunnel and ulnar neuropathy. J Bone Joint Surg [Br]. Jul 1991;73(4):613-7. [Medline].

  48. Gelberman RH, Yamaguchi K, Hollstien SB. Changes in interstitial pressure and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow. An experimental study in human cadavera. J Bone Joint Surg Am. Apr 1998;80(4):492-501. [Medline].

  49. Lim BH, Toh CL, Wong HP. Cadaveric study on the vascular anatomy of the ulnar nerve at the elbow-a basis for anterior transposition?. Ann Acad Med Singapore. Sep 1992;21(5):689-93. [Medline].

  50. Contreras MG, Warner MA, Charboneau WJ. Anatomy of the ulnar nerve at the elbow: potential relationship of acute ulnar neuropathy to gender differences. Clin Anat. 1998;11(6):372-8. [Medline].

  51. Britz GW, Haynor DR, Kuntz C. Ulnar nerve entrapment at the elbow: correlation of magnetic resonance imaging, clinical, electrodiagnostic, and intraoperative findings. Neurosurgery. Mar 1996;38(3):458-65; discussion 465. [Medline].

  52. Ozçakar L, Cakar E, Kiralp MZ, Dinçer U. Static and dynamic sonography: a salutary adjunct to electroneuromyography for cubital tunnel syndrome. Surg Neurol. Jan 13 2009;[Medline].

  53. Chiou HJ, Chou YH, Cheng SP. Cubital tunnel syndrome: diagnosis by high-resolution ultrasonography. J Ultrasound Med. Oct 1998;17(10):643-8. [Medline].

  54. Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg [Am]. Nov 2008;33(9):1518-24. [Medline].

  55. Dellon AL. Techniques for successful management of ulnar nerve entrapment at the elbow. Neurosurg Clin N Am. Jan 1991;2(1):57-73. [Medline].

  56. Dellon AL. Review of treatment results for ulnar nerve entrapment at the elbow. J Hand Surg [Am]. Jul 1989;14(4):688-700. [Medline].

  57. Sailer SM. The role of splinting and rehabilitation in the treatment of carpal and cubital tunnel syndromes. Hand Clin. May 1996;12(2):223-41. [Medline].

  58. Idler RS. General principles of patient evaluation and nonoperative management of cubital syndrome. Hand Clin. May 1996;12(2):397-403. [Medline].

  59. Fernandez E, Pallini R, Lauretti L. Neurosurgery of the peripheral nervous system: cubital tunnel syndrome. Surg Neurol. Jul 1998;50(1):83-5. [Medline].

  60. Folberg CR, Weiss AP, Akelman E. Cubital tunnel syndrome. Part II: Treatment. Orthop Rev. Mar 1994;23(3):233-41. [Medline].

  61. Novak CB, Mackinnon SE. Selection of Operative Procedures for Cubital Tunnel Syndrome. Hand (N Y). Sep 19 2008;[Medline].

  62. Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA. Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis. J Hand Surg [Am]. Oct 2008;33(8):1314.e1-12. [Medline].

  63. Charles YP, Coulet B, Rouzaud JC, Daures JP, Chammas M. Comparative clinical outcomes of submuscular and subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg Am. May-Jun 2009;34(5):866-74. [Medline].

  64. Keiner D, Gaab MR, Schroeder HW, Oertel J. Comparison of the long-term results of anterior transposition of the ulnar nerve or simple decompression in the treatment of cubital tunnel syndrome--a prospective study. Acta Neurochir (Wien). Apr 2009;151(4):311-5; discussion 316. [Medline].

  65. Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg [Am]. Mar 1989;14(2 Pt 1):267-71. [Medline].

  66. Craven PR Jr, Green DP. Cubital tunnel syndrome. Treatment by medial epicondylectomy. J Bone Joint Surg [Am]. Sep 1980;62(6):986-9. [Medline].

  67. Froimson AI, Anouchi YS, Seitz WH Jr. Ulnar nerve decompression with medial epicondylectomy for neuropathy at the elbow. Clin Orthop. Apr 1991;(265):200-6. [Medline].

  68. Dellon AL. Operative technique for submuscular transposition of the ulnar nerve. Contemp Orthop. 1988;16:17-24.

  69. Seradge H, Owen W. Cubital tunnel release with medial epicondylectomy factors influencing the outcome. J Hand Surg [Am]. May 1998;23(3):483-91. [Medline].

  70. Seradge H. Cubital tunnel release and medial epicondylectomy: effect of timing of mobilization. J Hand Surg [Am]. Sep 1997;22(5):863-6. [Medline].

  71. Weirich SD, Gelberman RH, Best SA. Rehabilitation after subcutaneous transposition of the ulnar nerve: immediate versus delayed mobilization. J Shoulder Elbow Surg. May-Jun 1998;7(3):244-9. [Medline].

  72. Bednar MS, Blair SJ, Light TR. Complications of the treatment of cubital tunnel syndrome. Hand Clin. Feb 1994;10(1):83-92. [Medline].

  73. Jackson LC, Hotchkiss RN. Cubital tunnel surgery. Complications and treatment of failures. Hand Clin. May 1996;12(2):449-56. [Medline].

  74. Broudy AS, Leffert RD, Smith RJ. Technical problems with ulnar nerve transposition at the elbow: findings and results of reoperation. J Hand Surg [Am]. Jan 1978;3(1):85-9. [Medline].

  75. Heithoff SJ, Millender LH, Nalebuff EA. Medial epicondylectomy for the treatment of ulnar nerve compression at the elbow. J Hand Surg [Am]. Jan 1990;15(1):22-9. [Medline].

  76. Bartels RH, Menovsky T, Van Overbeeke JJ. Surgical management of ulnar nerve compression at the elbow: an analysis of the literature. J Neurosurg. Nov 1998;89(5):722-7. [Medline].

  77. Heithoff SJ. Cubital tunnel syndrome does not require transposition of the ulnar nerve. J Hand Surg [Am]. Sep 1999;24(5):898-905. [Medline].

  78. Steiner HH, von Haken MS, Steiner-Milz HG. Entrapment neuropathy at the cubital tunnel: simple decompression is the method of choice. Acta Neurochir (Wien). 1996;138(3):308-13. [Medline].

  79. Lluch AL. Release of ulnar nerve compression at the elbow through a transverse incision. J Shoulder Elbow Surg. Jan-Feb 1998;7(1):38-42. [Medline].

  80. Kaempffe FA, Farbach J. A modified surgical procedure for cubital tunnel syndrome: partial medial epicondylectomy. J Hand Surg [Am]. May 1998;23(3):492-9. [Medline].

  81. Glowacki KA, Weiss AP. Anterior intramuscular transposition of the ulnar nerve for cubital tunnel syndrome. J Shoulder Elbow Surg. Mar-Apr 1997;6(2):89-96. [Medline].

  82. Geutjens GG, Langstaff RJ, Smith NJ. Medial epicondylectomy or ulnar-nerve transposition for ulnar neuropathy at the elbow?. J Bone Joint Surg Br. Sep 1996;78(5):777-9. [Medline].

  83. Kleinman WB, Bishop AT. Anterior intramuscular transposition of the ulnar nerve. J Hand Surg [Am]. Nov 1989;14(6):972-9. [Medline].

  84. Asami A, Morisawa K, Tsuruta T. Functional outcome of anterior transposition of the vascularized ulnar nerve for cubital tunnel syndrome. J Hand Surg [Br]. Oct 1998;23(5):613-6. [Medline].

  85. Nouhan R, Kleinert JM. Ulnar nerve decompression by transposing the nerve and Z-lengthening the flexor-pronator mass: clinical outcome. J Hand Surg [Am]. Jan 1997;22(1):127-31. [Medline].

  86. Tsujino A, Itoh Y, Hayashi K. Cubital tunnel reconstruction for ulnar neuropathy in osteoarthritic elbows. J Bone Joint Surg Br. May 1997;79(3):390-3. [Medline].

  87. Merolla G, Staffa G, Paladini P, Campi F, Porcellini G. Endoscopic approach to cubital tunnel syndrome. J Neurosurg Sci. Sep 2008;52(3):93-8. [Medline].

  88. Yoshida A, Okutsu I, Hamanaka I. Endoscopic anatomical nerve observation and minimally invasive management of cubital tunnel syndrome. J Hand Surg Eur Vol. Oct 20 2008;[Medline].

  89. Mariani PP, Golano P, Adriani E. A cadaveric study of endoscopic decompression of the cubital tunnel. Arthroscopy. Mar 1999;15(2):218-22. [Medline].

  90. Tsai TM, Chen IC, Majd ME. Cubital tunnel release with endoscopic assistance: results of a new technique. J Hand Surg [Am]. Jan 1999;24(1):21-9. [Medline].

[ CLOSE WINDOW ]

Keywords

cubital tunnel syndrome, ulnar nerve entrapment, ulnar nerve, ulnar nerve compression, ulnar nerve neuropathy at the elbow, nerve entrapment syndromes, numb finger, compressive neuropathy

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

James R Verheyden, MD, Consulting Surgeon, Department of Orthopedic Surgery, The Orthopedic and Neurosurgical Center of the Cascades
James R Verheyden, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, and American Society for Surgery of the Hand
Disclosure: Nothing to disclose.

Coauthor(s)

Andrew K Palmer, MD, Chair, Professor, Department of Orthopedics, State University of New York-Upstate Medical University
Andrew K Palmer, MD is a member of the following medical societies: American Osteopathic College of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Mark D Lazarus, MD, Associate Professor of Orthopedic Surgery, Medical College of Pennsylvania-Hahnemann University, Chief of Shoulder and Elbow Service, Department of Orthopedic Surgery, Hahnemann University Hospital
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael Yaszemski, MD, PhD, Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.