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Concept: Cubital tunnel

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Purpose: Snapping ulnar nerve syndrome (dislocation of the ulnar nerve over the medial epicondyle) is one of many causes of ulnar neuropathy at the elbow. This preliminary study was performed to search for sonographic signs suggesting the presence of this condition.Methods and Materials: We retrospectively investigated 11 patients with snapping ulnar nerve syndrome (SNAP) in comparison with an age-matched group of 20 patients with idiopathic cubital tunnel syndrome (SNU). Patients were grouped according to the presence of paretic or merely sensory deficits. Nerve cross section area (CSA) and thickness of outer epineurium (ET) was measured and correlated with neurological findings. Statistical differences were evaluated with the Mann-Whitney U-Test.Results: 5 SNAP (10 SNU) patients had sensory symptoms only, 6 SNAP (10 SNU) patients had paretic deficits. CSA in sensory SNU was 0.14 cm2, in paretic SNU 0.19 cm2, in sensory SNAP 0.15 cm2 and in paretic SNAP 0.14 cm2. ET in sensory SNU was 0.85 mm, 0.8 mm in paretic SNU, 1.05 mm in sensory SNAP and 1.1 in paretic SNAP. Differences in CSA were not significant depending on symptoms or group, differences in ET were not significant depending on symptoms but on group (SNAP versus SNU) at α = 0.05.Conclusion: A thickened, hyperechoic outer epineurium in a patient with ulnar neuropathy at the elbow might be a statistically significant differential feature of snapping ulnar nerve syndrome and should be involved in a further functional sonographic evaluation during flexion/extension of the elbow.

Concepts: Statistics, Statistical significance, Humerus, Upper limb anatomy, Ulnar nerve, Median nerve, Cubital tunnel, Ulnar nerve entrapment

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Endoscopic cubital tunnel release was originally described in 1989 by Tsai, and his technique has been modified by other surgeons including Mirza and Cobb. In 2006, Hoffmann and Siemionow described an endoscopic technique quite different from Tsai’s original description. Instead of working from the “inside out,” Hoffmann’s technique is performed through an incision similar to that which would be used for an in situ release of the ulnar nerve. The main difference being that the nerve can be explored and decompressed 10 cm proximal and distal to the arcuate ligament as the surgeon looks down on the nerve and the surrounding tissues while viewing the anatomy through a camera attached to a soft tissue endoscope that is inserted in the wound. The arcuate (Osborne’s) ligament is released under direct vision much like a standard in situ decompression. Using a blunt dissection instrument, a workspace is created proximally and distally to the cubital tunnel. Next an illuminated speculum is introduced, the nerve is directly visualized between 4 and 5 cm proximal and distal to the cubital tunnel, and potential compressive forearm fasciae or fibrous bands are released. Finally, a 15-cm, 30° soft tissue endoscope is introduced into the incision, and viewing the internal anatomy on a video monitor, the decompression continues using longer scissors. Any potential bleeding is controlled with a long bayonet bipolar cautery. The authors discuss indications, contraindications, and the surgical technique. Postoperative management and associated complications are also discussed.

Concepts: Surgery, Tissues, Surgeon, Ulnar nerve, Ulnar artery, Cubital tunnel, Ulnar nerve entrapment, Cauterization

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The wide-awake hand surgery (WAHS) technique involves injecting lidocaine with adrenaline for hand surgical procedures that are done without the use of tourniquets, sedation, regional or general anaesthetic. This is a retrospective review of the first 100 consecutive patients who underwent operations using this technique at our centre. The operations included carpal and cubital tunnel decompression, trapeziectomy, tendon transfer, and tenolysis. A questionnaire adapted from Lalonde’s previous work on wide-awake surgery was used to assess patients' experiences. Sixty-five percent of the patients responded to the postal questionnaire, the majority reporting a high satisfaction level. Ninety-one percent of responders reported that the operation was less painful or comparable with a procedure at the dentist; 86% would prefer to be wide-awake if they needed to have hand surgery again, and 90% stated they would recommend WAHS to a friend.

Concepts: Hospital, Surgery, Physician, Anesthesia, Dentistry, Upper limb anatomy, Ulnar nerve, Cubital tunnel

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BACKGROUND:: Both open and retractor-endoscopic ulnar nerve decompression have been shown to yield good results; a comparative evaluation of the techniques is lacking. Objective: To compare the results of open and endoscopic surgery in cubital tunnel syndrome. METHODS:: One hundred fourteen patients undergoing open (n=59) and endoscopic (n=55) decompression of the ulnar nerve for CbTS were retrospectively compared. The long-term and the short-term outcomes were compared with respect to the time until return to full activity and the duration of postoperative pain. Additionally, matched pairs between the two groups were chosen for analysis (n= 34). RESULTS:: Long-term results in the open versus endoscopic groups, respectively, were: 54.2% vs 56.4%- excellent, 23.8% vs 32.7%- good, 20.3% vs 9.1%- fair, and 1.7% vs 1.8%- poor. For the matched pairs, the results returned similar significance levels (p=0.84). The times until return to full activity in the open versus the endoscopic groups were: 18.6% vs 76.4% (2-7 days), 55.9% vs 10.9% (7-14 days), and 25.4% vs 12.7% (> 14 days) (p<0.001 between non-matched & matched pairs). The durations of postoperative pain in the open versus the endoscopic groups were: 45.8% vs 67.3% (1-3 days), 42.5% vs 25.4% (3-10 days), and 11.7% vs 7.3% (> 10 days) (p=0.04 non-matched and p=0.05 matched pairs). CONCLUSION:: There are no significant differences in long-term outcomes after open and retractor-endoscopic in situ decompressions of the ulnar nerve in cubital tunnel syndrome. The short-term results are significantly better in endoscopic surgery.

Concepts: Time, Cohort study, Statistical significance, Ulnar nerve, Median nerve, Ulnar artery, Cubital tunnel, Ulnar nerve entrapment

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The aim of the present study was to investigate a new clinical classification of cubital tunnel syndrome that provides an improved basis for the clinical diagnosis and treatment of the disease. Retrospective analysis was performed on 341 patients with cubital tunnel syndrome. Based on the etiology, signs and symptoms, neurophysiological tests and computed tomography (CT) imaging, a new clinical classification was proposed. The patients enrolled in the study were treated according to the new classification. According to the new classification, cubital tunnel syndrome cases were divided into types I-IV. Treatment for patients with type I consisted of rest, immobilization or physiotherapy, while patients with type II received simple ulnar neurolysis. Type III patients underwent ulnar neurolysis with expansion of the ulnar nerve sulcus or ulnar nerve anterior transposition surgery. Type IV patients represented a subgroup of cubital tunnel syndrome cases caused by factors other than degenerative joint diseases, including cysts, tumors, traumatic fracture, deformity and elbow deformity. Patients of this type received appropriate surgical treatment according to the specific etiology. Based on previous classifications that relied on sensation and strength symptoms, a new clinical classification of elbow tunnel syndrome has been established in the present study that adopts a CT imaging evaluation index. The new classification is reasonable, simple and practical, and therapies based on this classification are more targeted than those based on previous classifications.

Concepts: Medicine, The Canon of Medicine, Humerus, Ulnar nerve, Median nerve, Ulnar artery, Cubital tunnel, Ulnar nerve entrapment

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Cubital tunnel syndrome is the second most common upper extremity compressive neuropathy. In recent years, rates of surgical treatment have increased, and the popularity of in situ decompression has grown. Nonsurgical treatment, aiming to decrease both compression and traction on the ulnar nerve about the elbow, is successful in most patients with mild nerve dysfunction. Recent randomized controlled trials assessing rates of symptom resolution and ultimate success have failed to identify a preferred surgical procedure. Revision cubital tunnel surgery, most often consisting of submuscular transposition, may improve symptoms. However, ulnar nerve recovery after revision cubital tunnel surgery is less consistent than that after primary cubital tunnel surgery.

Concepts: Hospital, Surgery, Anesthesia, Upper limb anatomy, Ulnar nerve, Median nerve, Cubital tunnel, Ulnar nerve entrapment

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We describe an unusual case of ulnar nerve compression (cubital tunnel syndrome) caused by synovial protrusion in primary synovial chondromatosis of the elbow in a 59-year-old man. Magnetic resonance imaging is a useful tool for diagnosing this rare condition. Surgical excision of the intra-articular multiple loose bodies and ulnar nerve decompression were performed. The clinician should be aware of primary synovial chondromatosis as one of the causative factors of cubital tunnel syndrome.

Concepts: Surgery, Nuclear magnetic resonance, Magnetic resonance imaging, Ulnar nerve, Median nerve, Ulnar artery, Cubital tunnel, Ulnar nerve entrapment

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This study aimed to retrospectively analyze the clinical results of anterior submuscular transposition of the ulnar nerve using a flexor-pronator V-Y lengthening technique in patients with severe cubital tunnel syndrome (CTS).

Concepts: Ulnar nerve, Carpal tunnel, Carpal tunnel syndrome, Median nerve, Ulnar artery, Cubital tunnel, Ulnar nerve entrapment

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This case series describes three patients who presented with right medial elbow pain managed unsuccessfully with conservative treatment that included medication, massage, exercise therapy, ultrasound therapy, neurodynamic mobilization, and taping. Diagnosis of cubital tunnel syndrome was based on palpatory findings, a positive elbow flexion test, and a positive Tinel’s sign. Conventionally, the intervention for this entrapment has been surgical decompression, with successful outcomes. This is potentially a first-time description of the successful management of cubital tunnel syndrome with dry needling (DN) using a recently published DN grading system. The patients were seen twice a week for 2 weeks with immediate improvements noted in all the outcome measures after the first treatment session. At discharge, they were pain-free and fully functional, which was maintained up to a 6-month follow-up.

Concepts: Medicine, Extension, Upper limb anatomy, Conservatism, Political spectrum, Liberalism, Cubital tunnel, Ulnar nerve entrapment

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This prospective observational study assessed the prevalence of cold sensitivity in patients with nerve compression using the Cold Intolerance Symptom Severity (CISS) questionnaire. One hundred patients (72 women, 28 men; mean age 59 years) with carpal tunnel syndrome ( n = 95) or cubital tunnel syndrome ( n = 5) were studied. Fifty-two patients reported symptoms of cold sensitivity with a mean CISS score of 50. Overall, significantly more women (58% vs. 36%) reported cold sensitivity with significantly worse CISS scores than men.

Concepts: Observational study, Syndromes, Wrist, Carpal tunnel, Carpal tunnel syndrome, Median nerve, Cubital tunnel, Ulnar nerve entrapment