eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity
Ulnar Nerve Entrapment: Treatment
Updated: Sep 21, 2009
Treatment
Medical Therapy
Conservative treatment of ulnar nerve compression is most successful when paresthesias are transient and caused by malposition of the elbow or blunt trauma. Patient education and insight are important. Resting on elbows at work, using elbows to lift the body from bed, and resting elbows on car windows while driving all are causes of paraesthesia that can be corrected without surgical treatment. Patient education, anterior elbow extension splinting (if necessary), and correction of ergonomics at work should correct these transient palsies.
Nonsteroidal anti-inflammatory medications also are useful adjuncts to relieve nerve irritation. Oral vitamin B-6 supplements may be helpful for mild symptoms. This treatment should be carried out for 6-12 weeks, depending on patient response. Surgical intervention is indicated if increasing paresthesias occur despite adequate conservative treatment and at the first sign of motor changes.
Surgical Therapy
Surgical treatment of ulnar nerve entrapment depends on the site of compression. The 2 most common sites are the elbow and the wrist. Surgical treatment at the elbow falls into 2 categories, decompression in situ and decompression with anterior transposition.Decompression in situ
Decompression in situ essentially is a localized decompression of the nerve, accomplished by incising the Osborne ligament and opening the tunnel beneath the 2 heads of the flexor carpi ulnaris by incising the fascia holding them together. It is carried out through a small incision, beginning at a midpoint between the olecranon and the medial epicondyle and extending 6-8 cm distally over the flexor carpi ulnaris. It is carried out under tourniquet control for better visualization of the nerve. Postoperatively, no immobilization is needed, and active use of the extremity is encouraged. Continued release proximally into the epicondylar groove is discouraged because of the possibility of nerve subluxation occurrence.
Medial epicondylectomy, although not a true decompression in situ, is another procedure to release pressure on the ulnar nerve at the elbow. Removal of the epicondyle removes a compressive area. Excision of the proper amount of bone is critical to the success of this procedure. If too much bone is excised, damage to the medial collateral ligament of the elbow with valgus instability may occur. If too little is removed, the procedure is unsuccessful because the compressive area remains.
Decompression with anterior transposition
Decompression with anterior transposition usually is the operation of choice for ulnar nerve compression at the elbow because it removes the nerve from its compressive bed and puts it in one that is more suitable. By transferring the nerve anteriorly, it effectively lengthens the nerve, decreasing tension on it in flexion. Three types of transposition are possible, each with its own set of advocates.
Initial surgical approach essentially is the same with each type of transposition. Under sterile tourniquet control, an incision begins 8 cm above the medial epicondyle and continues downward to a point midway between the medial epicondyle and the olecranon groove. It then continues for about 6 cm distally over the flexor carpi ulnaris. As skin flaps are developed, the posterior branches of the medial antebrachial cutaneous nerve must be protected. If they are injured, numbness and neuroma over the olecranon and medial epicondyle develops.
Once the nerve has been visualized from about 8 cm proximal to the medial epicondyle to 6 cm distal to the epicondyle, the distal portion of the medial intermuscular septum, the fibroaponeurotic roof of the epicondylar groove, the Osborne ligament, and the fascia of flexor carpi ulnaris are incised, freeing the ulnar nerve. When surgically removing the distal medial intermuscular septum, beware of large collateral vessels in this area. Also, in mobilizing the ulnar nerve from the epicondylar groove, small motor branches to the flexor carpi ulnaris must be preserved. The articular branch may be sacrificed.
The main indications for subcutaneous transposition are necessity of transposition following fracture reduction during elbow arthroplasty and when length is needed following nerve injury. It is the most commonly used method of transposition because it is easy to perform and results are good. The nerve is positioned beneath the subcutaneous tissue and held to the muscle fascia with a few sutures through the epineurium. However, the preferred method is to construct a fasciodermal sling based laterally, passing it under the nerve and then suturing it to the subcutaneous tissue. Postoperatively, immobilize the elbow in a cast or splint at 45 degrees of flexion for 2 weeks.
In submuscular transposition, the origin of the flexor-pronator muscle group must be released. This can be accomplished in a number of ways, and the most important part of any of these releases is to be able to reattach the muscle origin securely. Once the nerve has been transposed to its new bed deep to the flexor pronator muscle group and on the brachialis muscle, the flexor carpi ulnaris fascia is closed, as is the roof of the epicondylar groove. Postoperatively, the elbow is immobilized in 45 degrees of flexion in a post mold or cast for 3-4 weeks.
In intramuscular transposition, once the ulnar nerve has been freed proximally and distally, it is laid across the flexor pronator muscle group to ensure that no kinks are present in the new path of the nerves. Then, a gutter is cut in the muscle, and the nerve is gently placed in this gutter. The fascia is sutured over the nerve to hold it in place.
Preoperative Details
Appropriate blood work, chest radiography (if indicated), and a careful clinical examination are required for ulnar nerve entrapment. The usual surgical preparation of the affected extremity from fingers to neck is indicated. This is followed by the application of a tourniquet, if necessary.
Intraoperative Details
See Surgical therapy.
Postoperative Details
Release and removal of the sterile tourniquet is useful. Subcuticular skin closure is preferred. With decompression in situ, no postoperative immobilization is necessary, and active motion is started immediately according to patient tolerance. Within 1-2 months, full activity should be resumed.
With medial epicondylectomy, no postoperative immobilization is necessary, and active motion is started immediately according to patient tolerance. Within 1-2 months, normal activities should be resumed.
With subcutaneous transposition, postoperative immobilization of the elbow in 45º of flexion for 2 weeks is necessary. Then, active mobilization with muscle stretching and strengthening is carried out for 2-3 months.
Submuscular transposition requires immobilization for 3-4 weeks in a sugartong splint with slight pronation and the wrist in neutral position. Active range of motion, stretching, and strengthening are then carried out for 3-4 months.
Intramuscular transposition requires 3 weeks of immobilization at 90º of elbow flexion with the forearm in full pronation. This is followed by gradual active range-of-motion exercises, stretching, and muscle strengthening.
Follow-up
Follow-up after surgery for ulnar nerve entrapment is at 1 month, 3 months, 6 months, and 1 year.
Complications
The most serious complications of any of the surgical procedures are the following20 :
- Injury to the nerve while decompressing it or transposing it
- Neuromata of the medial antebrachial cutaneous
- Failing to decompress it adequately, causing a new area of entrapment with the decompression
- Failing to recognize a double crush syndrome
- Infection, failure to heal, thrombophlebitis, atelectasis, and failure of the operation due to unknown cause
More on Ulnar Nerve Entrapment |
| Overview: Ulnar Nerve Entrapment |
| Workup: Ulnar Nerve Entrapment |
 Treatment: Ulnar Nerve Entrapment |
| Follow-up: Ulnar Nerve Entrapment |
| References |
| Further Reading |
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References
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Further Reading
Related eMedicine topics
Nerve Entrapment Syndromes
Cubital Tunnel Syndrome
Elbow and Forearm Overuse Injuries
Hand, Nerve Compression Syndromes: Upper Extremity
Ulnar Neuropathy
Acute Nerve Injury
Clinical guidelines
Chronic elbow pain.
American College of Radiology - Medical Specialty Society. 1998 (revised 2005). 5 pages. NGC:004605
Elbow disorders.
American College of Occupational and Environmental Medicine - Medical Specialty Society. 1997 (revised 2007). 67 pages. NGC:005681
European Federation of Neurological Societies/Peripheral Nerve Society Guideline on management of multifocal motor neuropathy. Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society.
European Federation of Neurological Societies - Medical Specialty Society
Peripheral Nerve Society - Disease Specific Society. 2006 Mar. 8 pages. NGC:005171
Keywords
ulnar nerve entrapment, cubital tunnel syndrome, ulnar tunnel syndrome, ulnar neuropathy, ulnar neuropathy, Guyon canal entrapment, decompression in situ, decompression with anterior transposition, acute nerve injury, elbow and forearm, elbow dislocation, nerve entrapment, ulnar nerve compression, entrapment neuropathy, nerve compression
