Cubital Tunnel Syndrome

1. Cubital Tunnel Syndrome
Presenter : Dr. Shubhanshu
Guide : Dr. John Mukhopadhaya

2. Introduction
• Term coined by Feindel and Stratford,1958
• Ulnar nerve compression or traction around
elbow
• Loss of sensation, muscle weakness, joint
contractures.
• Non surgical treatment
• Surgical treatment if constant symptoms or
worsening

3. Site
• Arcade of Struthers
• Osborne ligament
• Arcade of Osborne
• Fascia of FCU,FDS; B/W two head of FCU

4. Anastomosis
• Martin Gruber anastomosis (Forearm)
• Riche Cannieu anastomosis (Palm)

5. Differential Diagnosis for ulnar wrist
pain
• C8/T1 radicular
compression
• Thoracic outlet
symdrome
• Ulnar nerve
compression within
guyon’s canal
• Non union of hook of
Hamate
• Medial epicondylitis
• Ulnohumeral
osteoarthritis
• Hypothenar hammer
syndrome
• FCU tendinitis
• Pisotriquestral arthritis

6. Clinical examination
• Altered sensation (two point discrimination,
vibratory stimulation) over the volar and
dorsal aspect of little finger and ring
• Exacerbated by flexion
• Muscle weakness or atrophy mostly
appreciate in first web space

7. Special test for ulnar nerve
• Wartenberg test
• Froment sign (APL)
• Jeanne sign
• Claw hand deformity
• Provocative Maneuvers – Nerve percussion,
elbow flexion test
• Scratch collapse test
• Ulnar nerve stability

9. Electro diagnostic criteria
• <50m/s or relative drop in conduction velocity
of >10m/s across a measured interval around
elbow

10. Classification
• Dellon
– Type 1 or mild
• Sensory symptoms
without loss of two
point sensibility or
muscular atrophy
– Type 2 - weakness on
pinch and grip
without atrophy
– Type 3 - Weakness
cant do cross finger
• McGowan
– Type 1
– Sensory symptoms without
loss of two point sensibility or
muscular atrophy
– Type 2A
– weakness on pinch and
grip without atrophy
– Type 2B
– Atrophy and intrinsic
muscle strength <3/5
– Type 3
– Profound muscle atrophy
sensory disturbance

11. Management
• Non surgical
– Splints- limited elbow flexion
– Avoid
• Direct pressure over medial aspect of elbow
• Repetitive triceps strengthening exercises
• Prolonged rest in flexed elbow
• 88% Dellon 1 or 2 type responded Shah et al. Hand Surg Am 2013
• 21% in mild, 33% in moderate, 66% in severe cases requires
surgery. Dellon et al. Neurology 1993
• Author offers surgical treatment for muscle atrophy, two point
sensation impaired or worsening of symptoms which denotes
ongoing nerve compression

12. Surgical Mangement
• Simple Decompression – M/C
• Medial epicondylectomy
• Anterior transposition
– Subcutaneous
– Intramuscular
– Submuscular
• During dissection avoid potential for
iatrogenic devascularization of nerve, mostly
in transposition surgery.

13. • Surgical decompression has high recurrence
rate
• 19% (44/231) recurrence for persisting or
recrrent symptoms Song JW et al. JSES, 2015
• Medial epicondylectomy had complication like
flexion contracture, residual medial elbow
pain as determined by O’Driscoll
• Transposition having increased rate of
infection than others methods

14. • Biggs and Curtis Neurosurgery, 2006
– Method : 45% Transposition & 57% Decompression
– No differ in neurologic recovery
– At 1 year followup patient improved by McGowan
guide
• Bartels et al, Neurosurgery, 2005
• By In situ Decompression 48%, subcutaneous
60% treated show similar outcomes in clinical
examination/SF-36 McGill Pain Questionnaire
• Surgical time,complication longer in
Transposition(31%over 10%)