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Cubital tunnel syndrome 1
- 1. EXTERN CONFERENCE EXT. RUNGSIMASILPRACHAWONG
- 2. Patient Profile ▪ผู้ป่วยชายไทย อายุ40 ปี ▪อาชีพ พระภิกษุ ▪ภูมิลำเนา อ.ด่านขุนทด จ.นครราชสีมา 2 Chief complaint ▪ชานิ้วนางและนิ้วก้อยมือขวา 1 เดือน PTA
- 3. Present Illness 3 ▪1 เดือนPTA ข้อศอกขวากระแทกขอบปูน ไม่มีบาดแผล ภายนอก จากนั้นเริ่มมีอาการชานิ้วนางและนิ้วก้อยมือขวา เหมือนมีเข็มมาจิ้ม รู้สึกร้อนๆบริเวณเดียวกัน อาการค่อยๆ เป็นมากขึ้น ▪3 week PTA มือขวาอ่อนแรง จับขันน้ำไม่อยู่
- 4. Physical Examination ▪Heart: normalS1S2, no murmur ▪Lungs: equal breath sound, no adventitious sound ▪Abdomen: soft, no tender ▪Neuro: E4V5M6, pupil 2 mm RTLBE, ▪ Affected part : Rt. Arm ▫ Ulnar Claw hand ▫ Hypothenar and 1st DI atrophy ▫ Slight wasting of IOM ▫ Tinel’s sign positive at medial epicondyle and negative at wrist ▫ Loss of sensation over the palmar and dorsal surfaces of medial 11/ 2 fingers ▫ Froment’s sign positive 4
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- 7. Investigation 7 ▪Film Rt. elbowAP, Lateral
- 8. Diagnosis 8 ▪Cubital Tunnel Syndromeat right elbow
- 9. Management 9 ▪Set OR forDecompression with anterior transposition right ulnar nerve
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- 12. INJURIES OF THEULNAR NERVE Injury of the ulnar nerve at elbow: ▪ Fracture, dislocation of the medial epicondyle. ▪ Thickening of the fibrous roof of the cubital tunnel (cubital tunnel syndrome). ▪ Compression between the 2 heads of flexor carpi ulnaris (FCU) muscle. ▪ Valgus defect of elbow (tardy or late ulnar nerve palsy). ▪ Injury of the ulnar nerve at wrist: ▪ Superficial position of ulnar nerve at this site makes it susceptible to cuts and injuries. ▪ Compression in the Guyon’s canal/Piso hamate tunnel. 12
- 13. CUBITAL TUNNEL SYNDROME ▪ Acompressive neuropathy of the ulnar nerve ▪ 2nd most common compression neuropathy of the upper extremity 13
- 14. CUBITAL TUNNEL SYNDROME Cubitaltunnel ▪ Roof ▫ formed by FCU fascia and Osborne's ligament ▪ Floor ▫ formed by posterior and transverse bands of MCL and elbow joint capsule ▪ Walls ▫ formed by medial epicondyle and olecranon 14
- 15. SYMPTOMS ▪ Paresthesia ofsmall finger, ulnar half of ring finger, and ulnar dorsal hand ▪ Pain - medial elbow area, ulnar hand and 4th and 5th fingers ▪ Exacerbating activities include ▫ cell phone use (excessive flexion) ▫ occupational or athletic activities requiring repetitive elbow flexion and valgus stress ▪ Night symptoms ▪ Hand Weakness ▪ Painful clicking at the olecranon groove (ulnar nerve subluxation) 15
- 16. ULNAR NERVE EXAMINATION Inspectionand palpation ▪ interosseous and first web space atrophy ▪ ring and small finger clawing ▪ observe ulnar nerve subluxation over the medial epicondyle as the elbow moves through a flexion-extension arc 16
- 17. ULNAR NERVE EXAMINATION 17 Sensory ▪decreased sensation in ulnar 1-1/2 digits Motor ▪ paralysis of intrinsic muscles (adductor pollicis, deep head FPB, interossei, and lumbricals 4 and 5) o weakened grasp o weak pinch
- 18. ULNAR NERVE EXAMINATION Advancesigns ▪ Froment’s sign ▪ Wartenberg’s sign ▪ Jeanne’s sign ▪ Masse’s sign ▪ Cross Finger Test ▪ Intrinsic Atrophy 18
- 19. ULNAR NERVE EXAMINATION Froment’ssign ▪ compensatory thumb IP flexion by FPL (AIN) during key pinch ▪ compensates for the loss of MCP flexion by adductor pollicis (ulnar n.) ▫ adductor pollicis muscle normally acts as a MCP flexor, first metacarpal adductor, and IP extensor 19
- 20. ULNAR NERVE EXAMINATION Wartenberg’ssign ▪ persistent small finger abduction and extension during attempted adduction ▪ weak 3rd palmar interosseous and small finger lumbrical 20 Jeanne’s sign ▪ compensatory thumb MCP hyperextension and thumb adduction by EPL (radial n.) with key pinch ▪ compensates for loss of IP extension and thumb adduction by adductor pollicis (ulnar n.)
- 21. ULNAR NERVE EXAMINATION Masse’ssign ▪ Loss of hypothenar and flattened palmar metacarpal arch. 21 Pollock's test ▪ Inability to flex DIPJ of little and ring fingers.
- 22. ULNAR NERVE EXAMINATION Duchenne'ssign (Ulnar clawing) ▪ Hyperextension MCP joints and Flexion at IP joints of two ulnar fingers 22 Cross Finger test ▪ Inability to cross index and middle finger over each other.
- 23. ULNAR NERVE EXAMINATION PitresTestut sign / Egawa’s sign ▪ Inability to abduct middle finger to either side. Bouvier manoeuvre ▪ Correct the hyperextension of MCPJ and ask the patient to extend IPJ. If IPJ extension is improved then Bouvier test is positive and claw and is termed simple claw hand. If IPJ extension doesn’t improve then test is negative and clawing is called complex claw hand. 23
- 24. ULNAR NERVE EXAMINATION Provocativetests 24 ▪ Tinel sign positive over cubital tunnel ▪Elbow flexion test ▫ positive when flexion of the elbow for >60 sec reproduces symptoms
- 25. ULNAR NERVE EXAMINATION Provocativetests Elbow flexion compression test ▪ Direct cubital tunnel compression exacerbates symptoms 25
- 26. INVESTIGATIONS EMG : Electromyography ▪Diagnosis ▫ conduction velocity <50 m/sec across elbow ▫ low amplitudes of sensory nerve action potentials and compound muscle action potentials 26
- 27. INVESTIGATIONS MRI MRI maybe helpful if a space-occupying lesion is suspected 27
- 28. MCGOWAN CLASSIFICATION Classification ▪ Grade1: Purely subjective symptoms and mild hypaesthesia ▪ Grade 2: Sensory loss and weakness of intrinsic hand muscles, with or without slight wasting ▪ Grade 3: Severe sensorimotor deficit 28
- 29. NON-OPERATIVE TREATMENT Indications ▫ firstline of treatment with mild symptoms Treatment ▪ NSAIDs ▪ Activity modification ▫ Avoid maximum elbow flexion ▫ Avoid resting elbow on hard surfaces ▫ Avoid repetitive hyperflexion elbow exercises ▪ Night-time elbow extension splinting ▫ night bracing in 45 degree extension with forearm in neutral rotation 29
- 30. OPERATIVE TREATMENT ▪ insitu ulnar nerve decompression without transposition ▪ ulnar nerve decompression and anterior transposition ▪ medial epicondylectomy 30
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- 32. COMPLICATIONS ▪ Recurrence ▫ secondaryto inadequate decompression, perineural scarring, or tethering at the intermuscular septum or FCU fascia ▫ higher rate of recurrence than after carpal tunnel release ▪ Neuroma formation ▫ iatrogenic injury to a branch of the medial antebrachial cutaneous nerve may cause persistent posteromedial elbow pain 32
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- 34. “ Reference 1. https://www.handsurgeryresource.com/ 2. CubitalTunnel Syndrome, Manuel F. Dasilva M.D. and Katia A. Dasilva B.A., Ferri's Clinical Advisor 2019, 396.e2-396.e4 3. Entrapment Neuropathy of the Ulnar Nerve, Jane Aitken OTR/L, CHT, Journal of Hand Therapy, 2008-07- 01, Volume 21, Issue 3, Pages 300-301, Copyright © 2008 Hanley & Belfus 4. https://www.orthobullets.com/hand/6021/cubital- tunnel-syndrome 5. 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. 34
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