Cubital Tunnel Syndrome involves compression or traction of the ulnar nerve around the elbow, causing loss of sensation and muscle weakness in the hand. Non-surgical treatments include splinting and avoiding aggravating activities, which help in mild cases. Surgical treatment may be needed if symptoms are constant or worsening, and includes simple nerve decompression or transposition of the nerve. Recurrence rates after surgery can be as high as 19%, so prevention of iatrogenic nerve damage during surgery is important. Studies have found similar outcomes for nerve function recovery with decompression versus transposition procedures.

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%)