CUBITAL TUNNEL SYNDROME

• compression neuropathies of ulnar N in about the elbow

Compression sites of ulnar n at elbow

• Arcade of Struthers
• medial intermuscular septum
• medial epicondyle
• cubital tunnel
• Osborne's fascia

Pathophysiology and anatomy

• mid arm – ulnar n pierces inter muscular septum – runs distally posterior to it – approx 8cm proximal to medial epicondyle – pass through arcade of struthers
• continues posterior to intermuscular septum – edge of septum can cause compression
• lies in retro condylar groove of medial epicondyle – potential to cause compression
• cubital tunnel – fibro osseous tunnel – anteriorly medial epicondyle – ulno humeral ligament posterolaterally and roof formed by cubitus tunnel retinaculam
• Osbourne's fascia – connects the heads of FCU to medial epicondyle and olecranon – confused with cubital tunnel retinaculam

Mechanism

• flexion of elbow – increased intraneural pressure in Ulnar n – decreased volume of cubital tunnel – normally glides to accommodate elbow flexion -if tethered by scar / fibrosis – nerve experiences traction – affects function
• trauma, deformity, malunion/ non union of medial epicondyle – elbow instability – spur or bony fragments in floor of cubital tunnel – abnormal muscles – tumors

Clinical features

• numbness and paraesthesia along ulnar N distribution – small finger, ulnar half of ring, ulnar aspect of hand – exacerbated by leaning on elbow or flexion
• atrophy of interossei, hypothenar, add.pollicis
• grip weakness – weakness of FDP to small and ring fingers
• loss of dexterity of fingers
• decreased ability to cross fingers
• Froment's sign – hyper flexion of IP jt
• Learner's sign – hyper extension of MCP of thumb
  • both elicited by key pinch
• Waterberg's sign – abduction of the small finger with extension of fingers at MCP – interossei dysfunction
• confrontation test – hands with palmar surface towards face of patient – small fingers brought together – asymmetrical collapse of weak small finger to side of ring finger
• Provocative tests
  • Tinel's sign
  • elbow 90⁰ flexion with forearm supination – wrist extension
  • flexion compression test – elbow maximum flexion – simultaneous finger compression proximal to cubitus tunnel

Differential diagnosis

• ulnar tunnel syndrome
• thoracic outlet syndrome
• cervical radiculopathy

Treatment

• Non surgical
  • education and splinting
  • avoidance of repetitive elbow flexion and extension or prolonged elbow flexion
  • occupational adjustments
  • elbow pad, pillow extension splints – hold elbow in 30-45⁰ flexion during sleep to prevent hyperflexion of elbow
• Surgical
  • medial epicondylectomy
  • anterior transposition of ulnar N (sub cutaneous, intra muscular, sub muscular)

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