Dr. David Moss

1. David Moss, MD

2.  Cubital Tunnel
 Anatomy
 H&P
 EMG?
 Non-op – splint/inj
 SMUNT vs SQUNT
vs ISUNT
 Endoscopic
 Carpal Tunnel
 Anatomy
 H&P
 Fact or fiction?

5.  Arises from C8-T1
 Cubital Tunnel
 Floor – elbow joint capsule
 Walls – medial epicondyle and olecranon
 Roof – Osbourne’s ligament
 First branch is to the elbow joint
 No branches in the brachium

6.  Numb SF and half of RF
 Grip weakness, intrinsic
weakness
 Positional exacerbation
 Tinel’s test
 23-34% + in normal
volunteers
 EFT
 10% + in normal
volunteers
 Intrinsic strength
 FDP SF and RF strength
 Scratch collapse
 99% PPV, 99% sensitive
 C-spine exam

8.  Adductor pollicis weakness & FPL
compensation

9. • Similar to Froment’s, with MCP hyperextension

10.  Wartenburg sign
 Abduction of SF with attempted active extension
due to unopposed EDQ action (ulnar insertion)
 Clawing SF & RF (Duchenne’s sign)
 more severe in low ulnar palsy

13.  What to look for:
 CV < 50 m/s
 10 m/s delta slowing from contralateral side
 20% amplitude reduction from contralat side
 Shortcomings
 Patient discomfort
 ~75% sensitive

14.  Unclear location of nerve compression
 Cervical?
 Cubital tunnel?
 Guyon’s canal?
 Revision surgery
 Not routinely recommended for “classic” CuTS
 Some will obtain for a baseline measurement

15.  Limited value unless prior fracture or suspicion
of a mass
 Anconeus epitrochlearis
 Cubitus valgus

19.  Activity modification
 Avoid prolonged elbow flexion
 Ergonomic workstation analysis
 Night splinting in 45° extension (Gelberman)
 Nerve glides and therapy

20.  Mild symptoms (intermittent paresthesias)
 42% resolution at 6 months
 Moderate (no muscle wasting)
 32% resolution at 6 months

21. False
Hong et al. 2007

22.  Medial epicondylectomy
 Transposition
 Subcutaneous - SQUNT
 Intramuscular - IMUNT
 Submuscular - SMUNT
 In situ decompression - ISUND
 Open
 Endoscopic

23.  High rate of nerve subluxation
 Valgus instability
 Bony tenderness
 Of historic interest

24.  SMUNT and IMUNT
 Longer post-op immobilization to allow healing of
the flexor/pronator mass
 SQUNT
 Shorter post-op immobilization
 Relative contraindicated in very thin patients
 Common if concommitant elbow trauma

26.  Most data shows no difference in long term
outcomes between SQUNT, IMUNT, AND
SMUNT
 Kose et al. Adv Ther 2007
 Shi et al JHS 2011

27.  Shortest operative time
 Post-op immobilization is not necessary
 Can be performed under local anesthesia
 Endoscopic ISUND is trending
 Higher patient satisfaction ratings compared to open
ISUND in literature
 More expensive

28.  No difference!
 Macadam et al. JHS 2008
 Callandro et al. Cochrane Database 2012
 No difference between ISUND and transposition
 No consensus on when to treat surgically versus
conservatively

29.  Most authors recommend transposition for
frank subluxation
 No consensus in the literature for treatment of
perched ulnar nerve

30.  63 yr old
anesthesiologist c/o 6
month h/o medial
elbow pain with
occasional numbness
to SF and RF. No c/o
weakness.
 No systemic disease
or h/o trauma
 PE:
 +Tinel’s
 +EFT
 + scratch collapse
 Normal c-spine exam
 No weakness or
wasting
 No subluxation
 What is the next step?

31.  I recommend activity modification, prescribe
nighttime extension splint
 Re-examine at 6-8 weeks
 If no improvement then ISUND is offered
 EMG is not routinely prescribed

32.  No evidence that transposition is superior to
simple decompression
 Trend towards less invasive - ISUND
 Unless frank ulnar nerve subluxation - SQUNT

37.  Night pain
 Tingling
 Loss of dexterity and fine motor skills
 Earrings
 Buttons
 Grip weakness

38.  Women: Men = 3:1
 Obesity
 Diabetes
 Hyperthyroidism
 Pregnancy
 Trauma

41.  History
 Physical examination
 Nerve conduction test

44. Lalonde, Evidence based medicine:
carpal tunnel syndrome. PRS 2014
Treatment of CTS, AAOS Clinical
Practice Guideline Summary, 2008

45.  Wrist flexion-carpal
compression exam
 82% sensitive
 99% specific
 Carpal tunnel
(Durkan’s)
compression test
 87% sensitive
 90% specific

46.  MRI
 Ultrasound
 Nerve conduction
studies
 CT scan
 73-100% sensitive
 97.5% specific
 Negative nerve test
does not preclude
positive surgical
result

47.  False
 Splint in neutral is the most effective way to
reduce neural pressure
 Cortisone injection is acceptable for mild CTS
 Acupuncture is equivalent to placebo
 No literature to support splinting MCPs in
extension

48.  NSAIDs have not proven to be beneficial
 Oral steroids have limited benefit

49.  False
 Large studies show no difference
 Risk of adverse reaction to ABX > risk of infxn
 Diabetics, TJA, stents, RA

50.  True
 18 days vs. 38 days
 Improved scar sensitivity, pinch and grip at 3
months with ECTR
 No long term difference
 Critical element: complete division of the
transverse carpal ligament regardless of he
method

51.  False
 Post-op splint led to
worse results in one
study
 No difference in most
studies
 No proven advantage
or disadvantage of
post-op therapy

52.  73 yr old widow, lives
alone, presents with 1
yr h/o nocturnal
numbness in T, IF,
MF. She c/o
difficulty buttoning
her blouse and
putting in earrings.
 Non-contributory
PMH
 PE:
 Decreased sensation
T, IF, MF to D2PD
 + Tinel’s test
 - Phalen’s
 + CTCT
 Thenar wasting
 Normal c-spine
 What is the next step?

53.  I offer endoscopic CTR to expedite her return
to independent living
 EMG is not ordered in this scenario due to the
clear diagnosis
 Non-op treatment is not indicated in the setting
of severe CTS (muscle wasting)