eMedicine Specialties > Orthopedic Surgery > Elbow
Cubital Tunnel Syndrome: Treatment
Updated: Jun 26, 2009
Treatment
Medical Therapy
With nonoperative treatment, strengthening the elbow's flexors and extensors both isometrically and isotonically within 0-45° ROM is helpful. Limit the arc of elbow motion to an extended range to avoid ulnar nerve impingement in the cubital tunnel.55,56 Recommend that the patient decrease activities of repetition that may exacerbate symptoms. Administer nonsteroidal anti-inflammatory drugs (NSAIDs) in an attempt to decrease inflammation around the nerve. Protect the ulnar nerve from prolonged elbow flexion during sleep, and protect the nerve during the day by avoiding direct pressure or trauma.
Recommendations for initial conservative treatment for cubital tunnel are to use an elbow pad and/or night splinting for a 3-month trial period.57 Consider daytime immobilization for 3 weeks if symptoms do not improve with splinting. Consider surgical release if the symptoms do not improve with conservative treatment. If the symptoms do improve, continue conservative treatment for at least 6 weeks beyond the resolution of symptoms to prevent recurrence.58
For mild cubital tunnel symptoms, a reversed elbow pad that covers the antecubital fossa, rather than the olecranon, serves as a reminder to the patient to maintain the elbow in an extended position and to avoid pressure on the nerve. At night, position a pillow or folded towel in the antecubital fossa to keep the elbow in an extended position. Another option is to apply a commercial soft elbow splint, with a thermoplastic insert, for persistent symptoms.
For constant pain and paresthesia, consider a rigid thermoplastic splint positioned in 45° of flexion to decrease pressure on the ulnar nerve. Initially, patients should wear this splint at all times. As symptoms subside, patients can wear the splint just at night.
Surgical Therapy
If conservative therapy fails, treatment of cubital tunnel syndrome may consist of simple in situ decompression, in situ decompression with medial epicondylectomy,32 or anterior transposition.59,60,61,62,63,64
Intraoperative Details
Simple decompression
Make an incision about 6-10 cm in length along the course of the nerve, midway between the medial epicondyle and the tip of the olecranon. This posterior incision is recommended to avoid damage to the medial brachial and medial antebrachial cutaneous nerves.65 Identify and protect these nerves if encountered. Identify the ulnar nerve proximally. Release the medial intermuscular septum. Consider excising a portion of the thickened distal medial intermuscular septum to prevent kinking. Sharply divide the cubital tunnel retinaculum in a proximal-to-distal direction. Expose the ulnar nerve as it passes between the 2 heads of the FCU. Incise the fascia over the FCU. Expose the nerve as it passes through the FCU. Release the deep flexor-pronator aponeurosis. A neurolysis is not necessary.
Take the elbow through ROM, and examine the nerve for subluxation. If the nerve subluxates, consider a medial epicondylectomy or an anterior transposition. Drop the tourniquet. Obtain hemostasis. Close the subcutaneous and skin layers. Apply a simple soft compressive dressing with early active ROM.
Some believe that the nerve should not be decompressed proximally to avoid possible resultant subluxation and new compression. This risk can be reduced greatly by limiting the decompression distal to a line drawn from the medial epicondyle to the tip of the olecranon. Proximal decompression is recommended when compression is secondary to a hypertrophied medial head of the triceps or to a snapping of the medial head of the triceps with elbow flexion.
Medial epicondylectomy
Make a longitudinal incision 10-15 cm in length over the course of the nerve, and center it 1 cm anterior to the tip of the medial epicondyle.66 Again, identify and protect the posterior branches of the medial brachial and antebrachial cutaneous nerves and decompress the nerve as above. Make a longitudinal incision over the medial epicondyle and expose this by subperiosteal dissection. Detach the flexor pronator origin from the epicondyle and reflect it distally. Protect the nerve, and remove the medial epicondyle, or a portion of it, with an osteotome. Do not enter the elbow joint or cut the ulnar collateral ligament (UCL). Smooth sharp edges of bone with a rongeur or rasp. Close the periosteum to prevent tethering of the nerve to the raw bone surface. Reattach the flexor pronator origin with the elbow in extension to help prevent development of a flexion contracture. Allow the ulnar nerve to slide anteriorly.67 Apply a simple soft compressive dressing with early active ROM.
Anterior transposition
Make a longitudinal incision 15 cm in length over the course of the nerve and decompress the nerve as above. Excise 3-4 cm of the medial intermuscular septum proximal to the medial epicondyle to prevent kinking of the nerve postoperatively. Distally look for the additional, common aponeurosis between the FDS to the ring finger and the humeral head of the FCU. Excise this, if present, to prevent kinking. Identify, protect, and preserve the motor branches to the FCU and FDP. Dissect out the first motor branch to the FCU from the ulnar nerve proper if necessary to prevent kinking. Transpose the nerve into the subcutaneous plane. Examine for any remaining sites of constriction or tethering.
Several modifications are available to maintain the nerve in the transposed position. The fasciodermal sling is the most popular technique. Raise and medially reflect a 1- to 1.5-cm square flap of antebrachial fascia based on the apex of the medial epicondyle. Transpose the nerve anterior to this flap, then, suture the apex to the dermal tissue approximately 1 cm anterior to the medial epicondyle.
Another technique is to use a subcutaneous-to-fascial sling. Suture about 2 cm of the subcutaneous fascia of the anterior skin flap to the flexor-pronator fascia, just anterior to the epicondyle to keep the nerve in the transposed position.
A third option is to create a fascial sling using the medial intermuscular septum. Divide the intermuscular septum 3-4 cm proximal to its insertion on the medial epicondyle, keeping the distal attachment intact. Then, transpose the nerve. Next, use the septum as either a myofascial or fasciodermal sling to prevent posterior subluxation of the nerve. Take care to prevent kinking of the nerve at the sling. Again, apply a simple soft compressive dressing with early active ROM.
For anterior intramuscular transposition, make a longitudinal incision 15-20 cm in length over the course of the nerve and decompress the nerve as above for subcutaneous transposition. Excise the proximal border of the pronator teres and the medial intermuscular septum from the midhumerus to the elbow. Temporarily transpose the nerve and note the position of the nerve on the flexor pronator mass. Replace the nerve in the retrocondylar groove and make a 5 mm deep trough in line with the ulnar nerve in the transposed position in the flexor-pronator mass. Excise the fibrous septa separating the flexor-pronator muscles to provide a soft vascularized muscle bed. Transpose the nerve. Close the flexor-pronator fascia over the nerve with the forearm fully pronated and the elbow flexed 90°. Apply a simple soft compressive dressing with early active ROM.
For anterior submuscular transposition, make a longitudinal incision 15-20 cm in length over the course of the nerve and decompress the nerve as above for subcutaneous transposition. Raise the anterior skin flap until the bicipital aponeurosis is visualized. Incise the overlying fascia and identify and protect the median nerve. Obtaining careful hemostasis in this area is important, as there is an extensive venous system.68
With the nerves protected, delineate the margins of the flexor pronator mass. Using blunt finger dissection, develop the plane between the flexor-pronator mass and the FDS and the UCL. Pass a hemostat in this plane while protecting the nerves. Incise the flexor-pronator mass in a z-cut fashion 1-2 cm distal to the medial epicondyle, and reflect this mass distally. Protect the UCL. Release the tourniquet and obtain hemostasis. Transpose the ulnar nerve adjacent and parallel to the median nerve. Reattach the lengthened flexor-pronator mass with nonabsorbable sutures with the elbow flexed and the arm pronated.
Postoperative Details
Seradge found flexion contractures after medial epicondylectomy in 5% of patients who started rehabilitation at an average of postoperative day 3 and in 52% of patients who started rehabilitation at an average of postoperative day 14.69,70 Patients in the early mobilization group returned to work twice as early as those in the late mobilization group, and they did not experience any adverse effects on their grip strength or other hand functions.
Weirich studied 36 patients after subcutaneous transposition and found no difference in pain relief, weakness, patient satisfaction, grip strength, lateral pinch, or 2-point discrimination in patients who were started on immediate active ROM exercises and those who started rehabilitation an average of 14 days postoperatively.71 The immediate mobilization group returned to work and performed activities of daily living (ADL) earlier (median, 1 mo) than patients with delayed mobilization (median, 2.75 mo; P =0.04).
Complications
The creation of a new compressive site at the time of surgery can occur with any of the decompressive methods.72,73 Injury to the posterior branches of the medial antebrachial cutaneous nerves at dissection is common. This occurred in 24% of cases in one series of 22 patients. This nerve laceration results in loss of sensibility in an area of skin posterior and distal to the incision. Some patients develop a resultant dysesthesia in the nerve distribution; others develop an amputation neuroma.
Other complications include recurrent ulnar nerve subluxation and elbow instability from damage to the elbow collateral ligaments.74 A postoperative flexion contracture can occur, most commonly following a submuscular transposition. This is seen after 5-10% of submuscular transpositions. Medial epicondylitis can occur from detachment of the flexor-pronator mass or as a result of a medial epicondylectomy. In addition, the symptoms may recur from an incomplete anterior transposition. Infection can occur with any surgical procedure.
After medial epicondylectomy, medial instability may occur. In an attempt to prevent medial instability, the flexor-pronator origin is carefully detached to preserve the fibers of the MCL. According to O'Driscoll et al, excision of more than 20% (1-4 mm) of the width of the medial epicondyle in the coronal plane violates the important anterior band of the MCL.47
Removal of the optimal amount of medial epicondyle, without creating instability, also improves results. Heithoff and Millender found in their series that a complete osteotomy resulted in 81% good and excellent results.75 A partial osteotomy resulted in 67% good and excellent results, and a minimal osteotomy resulted in 50% good and excellent results.
After a medial epicondylectomy, tenderness at the operative site can occur and may result in prolonged and persistent discomfort during bone healing. In addition, loss of the protection of the medial epicondyle may make the ulnar nerve more susceptible to trauma. To prevent the nerve from adhering to the osteotomy site postoperatively, it is important to preserve and close the periosteum at the end of the procedure. Weakness can occur with detachment of the flexor-pronator origin. Patients may develop an elbow flexion contracture that is often attributed to reattachment of the flexor pronator muscle origin while the elbow is flexed or from delayed or inadequate postoperative mobilization.
Complications of anterior transposition can include recurrent subluxation of the ulnar nerve. Incomplete release of fascial slings may result in new areas of compression. In one series of subcutaneous transpositions, 90% of the failures were secondary to incomplete release of the medial intermuscular septum. An ineffective sling may not maintain the position of the transposed nerve and prevent resubluxation. Scarring may occur in the new muscular channel for the nerve. Perineural fibrosis may result from an intraneural injury or a nerve transfer to a hypovascular bed. Injury to the FCU motor branches during nerve mobilization can result in potential weakness. Ligation of the posterior ulnar recurrent artery during nerve mobilization may result in nerve devascularization. A postoperative elbow flexion contracture may occur.
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 |
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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
