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Wieczorek M, Gnat R, Wolny T. The Use of Physiotherapy in the Conservative Treatment of Cubital Tunnel Syndrome: A Critical Review of the Literature. Diagnostics (Basel) 2024; 14:1201. [PMID: 38893728 PMCID: PMC11171884 DOI: 10.3390/diagnostics14111201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 06/02/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND The lack of a clear answer regarding the efficacy of physiotherapy in the treatment of cubital tunnel syndrome (CuTS) has led to attempts to critically assess the scientific studies conducted to date. MATERIALS AND METHODS Two databases (MEDLINE via PubMed and PEDro) and Google Scholar were used to search for papers. The inclusion criteria were randomized controlled trials, case series, and case reports that evaluate the effects of physiotherapy in the treatment of patients with CuTS. RESULTS A total of 18 studies met the eligibility criteria, capturing a total of 425 participants. Seven papers were randomized controlled trials, three more described prospective studies without a control group, and eight papers contained case reports. An analysis of the literature evaluating the effectiveness of various forms of broadly defined physiotherapy indicates that their use can have a beneficial effect in reducing many subjective and objective symptoms and improving function. In the majority of papers included in this review, their authors indicated positive therapeutic effects. Only one randomized controlled trial reported no change following therapy. It can therefore be stated that the results of the research conducted so far are optimistic. However, only 7 of the 18 papers were randomized controlled trials, while 3 were prospective studies, and 8 papers were case studies, in which 23 people with CuTS were studied. CONCLUSIONS The small number of randomized clinical trials and their considerable heterogeneity do not allow firm conclusions to be drawn about the effectiveness of physiotherapy in the conservative treatment of CuTS.
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Affiliation(s)
- Michał Wieczorek
- Department of Neurological Rehabilitation, The Health Center in Mikołów Ltd., Waryńskiego 2, 43-190 Mikołów, Poland
| | - Rafał Gnat
- Institute of Physiotherapy and Health Sciences, The Jerzy Kukuczka Academy of Physical Education, Mikołowska 72A, 40-065 Katowice, Poland;
| | - Tomasz Wolny
- Institute of Physiotherapy and Health Sciences, Musculoskeletal Elastography and Ultrasonography Laboratory, The Jerzy Kukuczka Academy of Physical Education, Mikołowska 72A, 40-065 Katowice, Poland;
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2
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Hannaford A, Simon NG. Ulnar neuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:103-126. [PMID: 38697734 DOI: 10.1016/b978-0-323-90108-6.00006-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Ulnar neuropathy at the elbow is the second most common compressive neuropathy. Less common, although similarly disabling, are ulnar neuropathies above the elbow, at the forearm, and the wrist, which can present with different combinations of intrinsic hand muscle weakness and sensory loss. Electrodiagnostic studies are moderately sensitive in diagnosing ulnar neuropathy, although their ability to localize the site of nerve injury is often limited. Nerve imaging with ultrasound can provide greater localization of ulnar injury and identification of specific anatomical pathology causing nerve entrapment. Specifically, imaging can now reliably distinguish ulnar nerve entrapment under the humero-ulnar arcade (cubital tunnel) from nerve injury at the retro-epicondylar groove. Both these pathologies have historically been diagnosed as either "ulnar neuropathy at the elbow," which is non-specific, or "cubital tunnel syndrome," which is often erroneous. Natural history studies are few and limited, although many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously. Conservative management, perineural steroid injections, and surgical release have all been studied in treating ulnar neuropathy at the elbow. Despite this, questions remain about the most appropriate management for many patients, which is reflected in the absence of management guidelines.
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Affiliation(s)
- Andrew Hannaford
- Westmead Clinical School, Westmead Hospital, University of Sydney, Westmead, NSW, Australia
| | - Neil G Simon
- Northern Beaches Clinical School, Macquarie University, Sydney, NSW, Australia.
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3
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Shelke S, Ambade R, Shelke A. From Conservative Measures to Surgical Interventions, Treatment Approaches for Cubital Tunnel Syndrome: A Comprehensive Review. Cureus 2023; 15:e51262. [PMID: 38288228 PMCID: PMC10823195 DOI: 10.7759/cureus.51262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
Cubital tunnel syndrome (CuTS) is a neuropathic condition characterized by the compression or irritation of the ulnar nerve at the elbow, resulting in a wide spectrum of symptoms ranging from pain and numbness to muscle weakness and impaired hand function. This comprehensive review delves into the diverse landscape of CuTS treatment approaches, emphasizing the importance of early intervention. The review explores how these strategies aim to alleviate symptoms and enhance patient well-being by beginning with conservative measures encompassing rest, splinting, medications, physical therapy, and lifestyle adjustments. Non-surgical medical interventions, including nerve gliding exercises, ultrasound-guided nerve injections, and orthotic devices, are considered alternative therapies for symptom relief. Surgical interventions, such as decompression procedures and emerging techniques, are discussed in detail, highlighting their indications and expected outcomes. Throughout this review, the critical role of patient-centered care is underscored, emphasizing the need for tailored treatment plans that respect individual preferences and goals. Recognizing the unique nature of each CuTS case, shared decision-making between patients and healthcare providers is advocated, ensuring that interventions align with specific patient needs. As research advances, promising developments in diagnosis, surgical techniques, and drug therapies offer hope for more effective management of CuTS, paving the way for improved symptom relief and enhanced nerve function.
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Affiliation(s)
- Saurabh Shelke
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Ratnakar Ambade
- Orthopaedic Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Aditi Shelke
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Tuaño KR, Fisher MH, Franzoni DV, Iorio ML. Ulnar Nerve Compression at the Elbow Secondary to Intramuscular Lipoma of the Flexor Carpi Ulnaris: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00029. [PMID: 37535766 DOI: 10.2106/jbjs.cc.23.00108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
CASE A 62-year-old right-hand-dominant woman presented with 1 year of persistent radiating pain, weakness, and paresthesias in her left forearm and hand. Electromyography findings were significant for ulnar neuropathy distal to the branch innervating the flexor carpi ulnaris (FCU), without superimposed cervical radiculopathy or other focal entrapment neuropathy. During open ulnar nerve neurolysis, an intramuscular lipoma was encountered within the FCU. Lipoma excision and cubital tunnel release with ulnar nerve transposition were performed with complete relief of neuropraxia. CONCLUSION We demonstrate full neurologic recovery after intramuscular lipoma excision and cubital tunnel release. Although rare, anomalous anatomy and tissue overgrowth should remain on the differential for patients presenting with atypical neuropraxia.
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Affiliation(s)
- Krystle R Tuaño
- Division of Plastic and Reconstructive Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Marlie H Fisher
- Division of Plastic and Reconstructive Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colorado
| | - Demitri V Franzoni
- Division of Plastic and Reconstructive Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colorado
- Department of Plastic and Reconstructive Surgery, University of Nevada, Las Vegas, Kirk Kerkorian School of Medicine, Las Vegas, Nevada
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado, Anschutz Medical Center, Aurora, Colorado
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5
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Graf A, Ahmed AS, Roundy R, Gottschalk MB, Dempsey A. Modern Treatment of Cubital Tunnel Syndrome: Evidence and Controversy. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:547-560. [PMID: 37521554 PMCID: PMC10382899 DOI: 10.1016/j.jhsg.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/14/2022] [Indexed: 11/25/2022] Open
Abstract
Cubital tunnel syndrome is the second most common peripheral mononeuropathy in the upper extremity. However, the diagnosis and treatment of cubital tunnel syndrome remains controversial without a standard algorithm. Although diagnosis can often be made from the patient's history and physical examination alone, electrodiagnostic studies, ultrasound, computed tomography (CT), and magnetic resonance image (MRI) can also be useful in diagnosing the disease and selecting the most appropriate treatment option. Treatment options include conservative nonoperative techniques as well as various surgical options, including in situ decompression with or without transposition, medial epicondylectomy, and nerve transfer in advanced disease. The purpose of this review is to summarize the most up-to-date literature regarding cubital tunnel syndrome and propose a treatment algorithm to provide clarity about the challenges of treating this complex patient population.
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Affiliation(s)
- Alexander Graf
- Department of Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Adil Shahzad Ahmed
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - Robert Roundy
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | | | - Amanda Dempsey
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
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6
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Phan A, Hammert W. Evaluation of PROMIS Outcomes for Surgical Treatment of Cubital Tunnel Syndrome With and Without Carpal Tunnel Syndrome. Hand (N Y) 2023; 18:393-400. [PMID: 34218703 PMCID: PMC10152532 DOI: 10.1177/15589447211028921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Assessment of outcomes for cubital tunnel syndrome (CuTS) surgeries has been difficult due to heterogeneity in outcome reporting. Our objective was to evaluate the outcomes for 2 cohorts treated surgically for isolated CuTS and for combined CuTS and carpal tunnel syndrome (CTS) using Patient Reported Outcomes Measurement Information System (PROMIS). METHODS There were 29 patients in the isolated CuTS cohort and 30 patients in the combined CuTS and CTS cohort. PROMIS Physical Function (PF), Pain Interference (PI), Depression, and Upper Extremity (UE) were completed preoperatively and 1-week, 6-weeks, and 3-months postoperatively. Responsiveness was evaluated by standardized response means (SRM). RESULTS Significant improvements from the 1-week to 6-week postoperative period are shown in the isolated CuTS cohort for PROMIS PF (P = .002), PI (P = .0002), and UE (P = .02), but scores plateau after 6-weeks postoperatively. A similar pattern for the same time points was seen for the combined CuTS and CTS group for PROMIS PF (P = .001), PI (P = .02), and UE (P = .04), with a plateau of scores beyond 6 weeks postoperatively. PROMIS UE was more responsive (SRM range: 0.11-1.03) than the PF (SRM range: 0.02-0.52) and PI (SRM range: 0.11-0.40), which were both mildly responsive for both cohorts. CONCLUSIONS PROMIS lacks the sensitivity to show improvement beyond 6-weeks postoperatively for both isolated CuTS and combined CuTS and CTS. Patients with combined nerve compressions follow similar trajectories in the postoperative period as those with isolated CuTS. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Amy Phan
- University of Rochester Medical Center, NY, USA
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7
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Natroshvili T, van de Warenburg MS, Heine EP, Slater NJ, Walbeehm ET, Bartels RHMA. Conservative Treatment of Ulnar Nerve Compression at the Elbow: A Systematic Review and Meta-Analysis. Arch Plast Surg 2023; 50:70-81. [PMID: 36755648 PMCID: PMC9902076 DOI: 10.1055/s-0042-1757571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/26/2022] [Indexed: 02/08/2023] Open
Abstract
Background The clinical results of conservative treatment options for ulnar compression at the elbow have not been clearly determined. The aim of this review was to evaluate available conservative treatment options and their effectiveness for ulnar nerve compression at the elbow. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, a systematic review and meta-analysis of studies was performed. Literature search was performed using Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). Results Of the 1,079 retrieved studies, 20 were eligible for analysis and included 687 cases of ulnar neuropathy at the elbow. Improvement of symptoms was reported in 54% of the cases receiving a steroid/lidocaine injection (95% confidence interval [CI], 41-67) and in 89% of the cases using a splint device (95% CI, 69-99). Conclusions Conservative management seems to be effective. Both lidocaine/steroid injections and splint devices gave a statistically significant improvement of symptoms and are suitable options for patients who refuse an operative procedure or need a bridge to their surgery. Splinting is preferred over injections, as it shows a higher rate of improvement.
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Affiliation(s)
- Tinatin Natroshvili
- Department of Plastic and Reconstructive Surgery, CWZ, Nijmegen, The Netherlands,Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands,Department of Plastic and Reconstructive Surgery, Martini Hospital, Groningen, The Netherlands,Address for correspondence Tinatin Natroshvili, MD Department of Plastic Surgery, Canisius Wilhelmina ZiekenhuisBurgemeester Daleslaan 27, 6532 CL, NijmegenThe Netherlands
| | - Milly S. van de Warenburg
- Department of Plastic and Reconstructive Surgery, CWZ, Nijmegen, The Netherlands,Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erwin P. Heine
- Department of Plastic and Reconstructive Surgery, CWZ, Nijmegen, The Netherlands
| | - Nicholas J. Slater
- Department of Plastic and Reconstructive Surgery, CWZ, Nijmegen, The Netherlands,Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erik T. Walbeehm
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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8
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Dwivedi N, Goldfarb CA, Calfee RP. The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome. J Hand Surg Am 2023; 48:134-140. [PMID: 35760650 DOI: 10.1016/j.jhsa.2021.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 10/20/2021] [Accepted: 11/05/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome. METHODS A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods. RESULTS A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4-4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9-4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error. CONCLUSIONS The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1-3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms. CLINICAL RELEVANCE Patient-reported outcomes may have varied responsiveness depending on the condition studied.
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Affiliation(s)
- Nishant Dwivedi
- Department of Orthopedics, Washington University, St. Louis, MO
| | | | - Ryan P Calfee
- Department of Orthopedics, Washington University, St. Louis, MO.
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Córdoba-Mosqueda ME, Rasulić L, Savić A, Grujić J, Vitošević F, Lepić M, Mićić A, Radojević S, Mandić-Rajčević S, Jovanović I, Rodríguez-Aceves CA. Quality of life and satisfaction in patients surgically treated for cubital tunnel syndrome. Neurol Res 2023; 45:138-151. [PMID: 36130919 DOI: 10.1080/01616412.2022.2126163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Cubital tunnel syndrome (CuTS) results from compression of the ulnar nerve at the elbow, resulting in pain, weakness, and numbness of the hand and forearm. This work describes the Quality of Life (QoL) and satisfaction after CuTS surgery and identifies the factors associated with those outcomes. METHODS This cross-sectional study included patients surgically treated for CuTS from January 2011 to September 2021 at the Neurosurgery Clinic of the Clinic Center in Serbia. The questionnaires applied were the Short Form 36 (SF-36), EuroQol instrument (EQ-5D-5 L), Bishop's score and Patient-Rated Ulnar Nerve Evaluation (PRUNE). RESULTS Sixty-two patients met the inclusion criteria. Bishop's score: The median score was 10 (7.75-11), 54.8% of the cases presented excellent results. PRUNE: The median score for symptoms was 19 (6-38.5); for functional, was 14 (0.75-38); and the total was 18.25 (5.87-34.12). SF-36: The subscale with the best result was social functioning (84.68 ± 22.79). The scale with the worst value was emotional well-being (49.35 ± 7.87). EQ-5D-5L: Over 50% patients did not present problems with mobility, self-care, activity, and anxiety. The average EQ-VAS was 72.77 ± 18.70; and 0.72 ± 0.21 of the EQ-index, revealing a good QoL. Models for QoL and satisfaction: Ten models showed statistical significance. The variables with major involvement were body mass index and time evolution of the symptoms. CONCLUSION Surgical decompression has proved to diminish the symptoms, improving QoL and satisfaction. Many fixed and changeable factors can affect the satisfaction levels after surgery.
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Affiliation(s)
- María Elena Córdoba-Mosqueda
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Lukas Rasulić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Andrija Savić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Jovan Grujić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Filip Vitošević
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Neuroradiology Department, Center for Radiology and MRI, University Clinical Center of Serbia, Belgrade, Serbia
| | - Milan Lepić
- Clinic for Neurosurgery, Military Medical Academy, Belgrade, Serbia
| | - Aleksa Mićić
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Stefan Mandić-Rajčević
- School of Public Health and Health Management and Institute of Social Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Jovanović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Clinic for Neurosurgery, University Clinical Center of Serbia, Belgrade, Serbia
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Anderson D, Woods B, Abubakar T, Koontz C, Li N, Hasoon J, Viswanath O, Kaye AD, Urits I. A Comprehensive Review of Cubital Tunnel Syndrome. Orthop Rev (Pavia) 2022; 14:38239. [PMID: 36128335 PMCID: PMC9476617 DOI: 10.52965/001c.38239] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Cubital Tunnel Syndrome (CuTS) is the compression of the ulnar nerve as it courses through the cubital tunnel near the elbow at the location colloquially referred to as the "funny bone". CuTS is the most commonly diagnosed mononeuropathy after carpal tunnel syndrome. Cubital tunnel syndrome can manifest as numbness, tingling, or pain in the ring/small fingers and dorsoulnar hand. Repetitive pressure, stretching, flexion, or trauma of the elbow joint are known causes of CuTS. Chronic ulnar nerve compression and CuTS, when left untreated, can lead to atrophy of the first dorsal interosseus muscle and affect one's quality of life to the point that they are no longer able to participate in daily activities involving fine motor function. It is estimated that up to 5.9% of the general population have had symptoms of CuTS. CuTS is underdiagnosed due to lack of seeking of treatment for symptoms. Compression or damage to the ulnar nerve is the main cause of symptoms experienced by an individual with CuTS. Repetitive elbow pressure or a history or elbow joint trauma or injury are additional known causes that can lead to CuTS. Common presentations of CuTS include paresthesia, clumsiness of the hand, hand atrophy and weakness. The earliest sign of CuTS is most commonly numbness and tingling of the ring and 5th finger. Older patients tend to present with motor symptoms of chronic onset; younger patients tend to have more acute symptoms. Pain and point tenderness at the medial elbow may also be seen. CuTS lacks universally agreed upon diagnostic and treatment algorithms. CuTS can be diagnosed by physical exam using Tinel's sign, flexion-compression tests, palpating the ulnar nerve for thickening presence of local tenderness along the nerve. Ultrasound and nerve conduction studies may be used in combination with physical exam for diagnosis. Conservative treatment for CuTS is almost always pursued before surgical treatment and includes elbow splints, braces, and night-gliding exercises. Surgical treatment may be pursued in severe CuTS refractory to conservative treatment. Surgical options include open and endoscopic in-situ decompression, medial epicondylectomy, and anterior transposition of the ulnar nerve. CuTS is a prevalent disease that, if left untreated, can significantly alter an individual's quality of life. Therefore, an accurate diagnosis and appropriate treatment is paramount in reducing further damage and preventing worsening or future symptoms.
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Affiliation(s)
| | - Bison Woods
- Medical School, Medical College of Wisconsin
| | - Tunde Abubakar
- School of Medicine, Louisiana State University Health Science Center Shreveport
| | - Colby Koontz
- School of Medicine, Louisiana State University Health Science Center Shreveport
| | - Nathan Li
- Medical School, Medical College of Wisconsin
| | - Jamal Hasoon
- Anesthesiology, Beth Israel Deaconess Medical Center-Harvard Medical School
| | - Omar Viswanath
- Anesthesiology, Beth Israel Deaconess Medical Center-Harvard Medical School
| | - Alan D Kaye
- School of Medicine, Louisiana State University Health Science Center Shreveport
| | - Ivan Urits
- Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School
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11
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A Review of Current Concepts in Ultrasound Evaluation and Management of Ulnar Nerve Pain. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2022. [DOI: 10.1007/s40141-022-00365-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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12
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Poenaru D, Ojoga F, Sandulescu M, Cinteza D. Conservative therapy in ulnar neuropathy at the elbow (Review). Exp Ther Med 2022; 24:517. [PMID: 35837045 PMCID: PMC9257949 DOI: 10.3892/etm.2022.11444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Ulnar neuropathy at the elbow (UNE) is the second most frequent entrapment syndrome in the upper limb after carpal tunnel syndrome. Clinical features are validated through electromyographic and sonographic examination. Although the two aforementioned entrapment syndromes share common pathophysiological traits, the conservative treatment approach for mild and moderate cases of UNE differs from that for median nerve entrapment. The present study identified 23 different types of scientific articles aimed to address this issue. The research stressed the importance of patient education and activity modification. Night splinting offers clinical and functional improvement. Although corticosteroid injections play a role in selected cases, their utility remains to be validated. Physiotherapy trials evaluated ultrasound, low-level laser therapy, diathermy, extracorporeal shock wave therapy and dry cupping. Neurodynamic mobilization may add value to therapeutic approaches and should be a part of it.
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Affiliation(s)
- Daniela Poenaru
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
| | - Florina Ojoga
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
| | - Miruna Sandulescu
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
| | - Delia Cinteza
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
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13
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Ferguson DP, Grewal R. Cubital Tunnel Syndrome: Review of Diagnosis and Management. HANDCHIR MIKROCHIR P 2022; 54:253-262. [PMID: 35688432 DOI: 10.1055/a-1808-6973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cubital tunnel syndrome is one of the most common upper extremity nerve entrapment conditions. Clinical examination and electrodiagnostic studies assist in the diagnosis. Mild cases can be successfully treated conservatively, aiming to reduce traction and compression on the nerve. Surgical management of cubital tunnel syndrome is increasing in frequency. Multiple surgical options exist ranging from simple decompression to decompression and anterior transposition of the nerve. There is no preferred surgical technique. It is critical to reduce the risk of recurrent cubital tunnel syndrome. Revision surgical procedures have worse outcomes than primary surgical procedures.
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Affiliation(s)
| | - Ruby Grewal
- University of Western Ontario Roth
- McFarlane Hand and Upper Limb Center
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14
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Bowers RL, Cherian C, Zaremski JL. A Review of Upper Extremity Peripheral Nerve Injuries in Throwing Athletes. PM R 2022; 14:652-668. [PMID: 35038233 DOI: 10.1002/pmrj.12762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/13/2021] [Accepted: 12/17/2021] [Indexed: 11/07/2022]
Abstract
Peripheral nerve injuries in the upper extremities may be common in throwing athletes as the throwing motion places extreme stress on the dominant arm. The combination of extreme stress along with repetitive microtrauma from throwing uniquely places the throwing athlete at elevated risk of upper extremity peripheral nerve injury. However, because symptoms can be non-specific and frequent co-exist with pathology in the upper extremity, the diagnosis of peripheral nerve injury is often delayed. Diagnosis of peripheral nerve injuries may require a combination of history and physical exam, diagnostic imaging, electrodiagnostic testing, and diagnostic ultrasound guided injections. The primary management should include physical therapy focusing on throwing mechanics and kinetic chain evaluation. However, some athletes require surgical intervention if symptoms do not improve with conservative management. The purpose of this focused narrative review is to highlight upper extremity peripheral neuropathies reported in throwing athletes and to provide an overview of the appropriate clinical diagnosis and management of the throwing athlete with a peripheral nerve injury. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Robert L Bowers
- Assistant Professor of Rehabilitation Medicine, Emory University School of Medicine, Emory Sports Medicine Center, Atlanta, Georgia, USA
| | - Chris Cherian
- Department of Sports Medicine, Rothman Orthopaedics, Paramus, New Jersey, USA
| | - Jason L Zaremski
- Department of Physical Medicine & Rehabilitation, Department of Orthopaedic Surgery & Sports Medicine, University of Florida Health Orthopaedics and Sports Medicine Institute, Gainesville, Florida, USA
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Rossmann T, Reissig LF, Pfisterer WK, Grisold W, Weninger WJ, Meng S. Angiosomes of the Ulnar Nerve at the Elbow: A Cadaver Trial Using Contrast-Enhanced Ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3393-3402. [PMID: 34479732 DOI: 10.1016/j.ultrasmedbio.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/12/2021] [Accepted: 08/05/2021] [Indexed: 06/13/2023]
Abstract
Three major arteries supplying the ulnar nerve in the cubital tunnel are commonly known. However, their vascular territories (angiosomes) have not been described yet. Contrast-enhanced ultrasound was used to identify the angiosomes of posterior ulnar recurrent artery, inferior ulnar collateral artery and superior ulnar collateral artery in 20 fresh, non-frozen human body donors. The arteries were cannulated, and physiologic blood flow was simulated. Contrast agent was applied in each vessel in a randomized sequence, and the length of the contrast-enhancing ulnar nerve segment was measured by a radiologist blinded to the sequence. The angiosome of the posterior ulnar recurrent artery overlaps both other angiosomes. It fully covers the cubital tunnel in 63.6% of specimens. In addition, collateral flow via nerve and muscle branches of the arterial anastomotic network around the elbow (rete articulare cubiti) partly maintains the intra-neural blood flow in the absence of a vascular pedicle. The posterior ulnar recurrent artery is the dominant nutrient vessel of the ulnar nerve in the cubital tunnel. A potential watershed zone exists proximal to the Osborne ligament. Knowledge of these angiosomes may advance surgery of the ulnar nerve in the cubital tunnel.
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Affiliation(s)
- Tobias Rossmann
- Division of Anatomy, Medical University of Vienna, Vienna, Austria; Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Lukas F Reissig
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | | | - Wolfgang Grisold
- Neurology Consultancy Unit, Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | | | - Stefan Meng
- Division of Anatomy, Medical University of Vienna, Vienna, Austria; Department of Radiology, Hanusch Hospital, Vienna, Austria.
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Rossmann T, Heber UM, Heber S, Reissig LF, Grisold W, Weninger WJ, Meng S. Cubital tunnel perfusion in different postures-An anatomical investigation. Muscle Nerve 2021; 64:749-754. [PMID: 34453352 PMCID: PMC9292220 DOI: 10.1002/mus.27408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 11/21/2022]
Abstract
Introduction/Aims For cubital tunnel syndrome, the avoidance of predisposing arm positions and the use of elbow splints are common conservative treatment options. The rationale is to prevent excessive stretching and compression of the nerve in the cubital tunnel, as this mechanical stress impedes intraneural perfusion. Data regarding those upper extremity postures to avoid, or whether elbow flexion alone is detrimental, are inconsistent. This study aimed to assess perfusion and size changes of the cubital tunnel during different postures in an experimental cadaver setup. Methods Axillary arteries in 30 upper extremities of fresh cadavers were injected with ultrasound contrast agent. High‐resolution ultrasound of the cubital tunnel was performed during five different arm postures that gradually increased tension on the ulnar nerve and caused cubital tunnel narrowing. Contrast enhancement within the tunnel was measured to quantify perfusion. Cubital tunnel cross‐sectional area was measured to detect compression. Results Increasing tension significantly reduced perfusion. When isolated, neither shoulder elevation, elbow flexion, pronation, nor extension of wrist and fingers impaired perfusion. However, combining two or more of these postures led to significant decreases. Significant narrowing of the cubital tunnel was seen in full elbow flexion and shoulder elevation. Discussion Combinations of some upper extremity joint positions reduce nerve perfusion, but isolated elbow flexion does not have a significant impact. We hypothesize that elbow splints alone may not influence cubital tunnel perfusion but may only prevent direct compression of the ulnar nerve. Advising patients about upper extremity postures that should be avoided may be more effective.
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Affiliation(s)
- Tobias Rossmann
- Division of Anatomy, Medical University of Vienna, Vienna, Austria.,Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Ulrike M Heber
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Stefan Heber
- Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Lukas F Reissig
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Grisold
- Neurology Consultancy Unit, Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | | | - Stefan Meng
- Division of Anatomy, Medical University of Vienna, Vienna, Austria.,Department of Radiology, Hanusch Hospital, Vienna, Austria
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Abstract
Compression neuropathies, also known as entrapment neuropathies, are common neurologic conditions seen in medicine. These often are due to mechanical injury, either compression or stretch of the affected nerve, and initially result in focal demyelinating changes. If left untreated, secondary axonal injury and lasting disability can result. Patients typically present with pain, sensory changes, and potentially weakness in the distribution of the affected nerve; therefore, a basic knowledge of neuromuscular anatomy is necessary to identify these conditions. Initial treatment of mild to moderate cases often is conservative. In severe cases or those refractory to conservative therapy, surgery should be considered.
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Affiliation(s)
- Svetlana Faktorovich
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA; Marcus Neuroscience Institute, Boca Raton Regional Hospital, 800 Meadow Road, Boca Raton, FL 33486, USA.
| | - Asia Filatov
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA; Marcus Neuroscience Institute, Boca Raton Regional Hospital, 800 Meadow Road, Boca Raton, FL 33486, USA
| | - Zufe Rizvi
- Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, FL, USA; Marcus Neuroscience Institute, Boca Raton Regional Hospital, 800 Meadow Road, Boca Raton, FL 33486, USA
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DİLEK B. Romatolojik hastalıklarda tuzak nöropatileri: Konservatif tedavi. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.863628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
PURPOSE OF REVIEW Compressive neuropathy of the ulnar nerve across the elbow is a common diagnosis encountered frequently within a hand and upper extremity clinical practice. Appropriate and timely evaluation, diagnosis, objective testing, and evidence-based decisions regarding treatment options are paramount in the optimal care of the patient with this pathology. An understanding of current literature is critical in determining and understanding best practices. RECENT FINDINGS A thorough review of the recent literature regarding physical examination, diagnostic testing, and nonoperative versus operative results was performed. Regarding physical examination, the glenohumeral internal rotation test and scratch collapse test are more effective and sensitive than traditional maneuvers such as Tinel's testing and the elbow flexion test. Electrodiagnostic testing, magnetic resonance imaging, and ultrasound evaluation have all been shown to be effective in diagnosing cubital tunnel syndrome. However, no single test has proven itself to be superior. Nonoperative treatment can be successful for mild cases of cubital tunnel syndrome. Surgical release techniques comparing open with endoscopic release are equivocal, and in situ release versus transposition techniques show that transposition should not be performed routinely. The diagnosis and treatment of cubital tunnel syndrome do not have a well-defined algorithm based on current literature. The treating physician must therefore utilize the available information to determine a diagnostic and treatment plan individualized to the patient. More rigorous scientific studies are needed to determine the most effective surgical approaches for cubital tunnel syndrome.
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Abstract
PURPOSE OF REVIEW During overhead throwing, there are tremendous forces placed on the medial elbow that can result in injury to the ulnar nerve. The purpose of this article is to review the anatomy, biomechanics, and appropriate clinical care of an overhead throwing athlete suffering from injury to their ulnar nerve. The authors preferred clinical work-up; non-operative and operative care are included in this review. RECENT FINDINGS More recent findings support the use of subcutaneous transposition instead of the submuscular transpositions and only to perform a transposition in the setting of specific pre-operative findings. Subcutaneous transpositions have led to decreased rates of post-operative symptoms and complications. Understanding the complexity of the medial elbow is essential to making an accurate diagnosis of ulnar neuritis/neuropathy in the overhead throwing athlete. In general, non-operative management has shown to be successful; however, in those refractory or recurrent cases of ulnar neuritis, ulnar nerve decompression with or without transposition provides these athletes with a surgical procedure that has shown to provide patients with excellent outcomes. Continued refinement surgical indications and surgical technique will allow for a high percentage of athletes who return to competitive sports following surgery for ulnar neuropathy.
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Affiliation(s)
- S Blake Dowdle
- Department of Orthopaedics, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - Peter N Chalmers
- Department of Orthopaedics, University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, UT, 84108, USA
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Evaluation of Sleep Position for Possible Nightly Aggravation and Delay of Healing in Tennis Elbow. J Am Acad Orthop Surg Glob Res Rev 2019; 3:e082. [PMID: 31592507 PMCID: PMC6754212 DOI: 10.5435/jaaosglobal-d-19-00082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Tennis elbow symptoms are reportedly most severe in the morning, which prompted a search for a pathological process while asleep. A “pathological sleep position” was hypothesized that repetitively aggravates an elbow lesion if the arm is overhead and pressure is on the lateral elbow. This hypothesis was tested by using a restraint to keep the arm down while asleep.
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Kooner S, Cinats D, Kwong C, Matthewson G, Dhaliwal G. Conservative treatment of cubital tunnel syndrome: A systematic review. Orthop Rev (Pavia) 2019; 11:7955. [PMID: 31281598 PMCID: PMC6589621 DOI: 10.4081/or.2019.7955] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Indexed: 12/13/2022] Open
Abstract
Cubital tunnel syndrome (CuTS) is one of the most common compression neuropathies of the upper extremity. Conservative management of cubital tunnel syndrome is often considered first line therapy for mild or moderate symptoms; however, there is little evidence-based literature to guide physicians in this regard. As such, the objective of this study is to complete a comprehensive literature search of the conservative therapies available for treatment of CuTS. Additionally, we hope to assess the evidence for each therapy so that we can make evidence- based recommendations regarding the type and duration of optimal treatment. The databases MEDLINE, EMBASE, and CINAHL were search using a sensitive search strategy. Eligibility for studies included any studies or conference abstracts in which patients were treated conservatively for primary CuTS. Any form of non-operative treatment was acceptable. A data extraction form was developed to collect all information and outcomes of interest, including study design, level of evidence, number of patients, treatment modalities, follow- up time, patient reported outcomes, and electrophysiological markers. Qualitative and quantitative analysis was then completed based on the data extraction form. Given the heterogeneity of the included studies, results were summarized as best evidence available. Our sensitive literature search produced 6484 studies. Initial screening based on title and abstract resulted in the selection of 40 studies that underwent full text review. From these 19 studies were included for analysis in our systematic review. There were 3 level I studies, 4 level II studies, 3 level III studies, and 9 level IV studies. In total this included 844 patients. The most commonly reported outcomes included subjective patient reported outcomes and nerve conduction studies. The most common treatment modalities, from most to least common, included education and activity modification, splinting, steroid/lidocaine injection, nerve mobilization/gliding, pulsed ultrasound, laser therapy, non-steroidal antiinflammatory drugs, and physiotherapy. The most common duration of therapy was 3 months with a median follow-up time of 3 months. There was moderate strength evidence to recommend the use of education/activity modification or splinting in mild or moderate CuTS. There is a paucity of literature and highquality studies regarding the conservative management of CuTS. Regardless, there appears to be a role for non-operative management in CuTS, although further studies are needed to delineate this role further. In the cases of mild or moderate CuTS it is reasonable to trial education/activity modification or splinting as both appear to be equally effective.
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Affiliation(s)
- Sahil Kooner
- Department of Orthopedic Surgery, University of Calgary
| | - David Cinats
- Department of Orthopedic Surgery, University of Calgary
| | - Cory Kwong
- Department of Orthopedic Surgery, University of Calgary
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Frantz LM, Adams JM, Granberry GS, Johnson SM, Hearon BF. Outcomes of ulnar nerve anterior transmuscular transposition and significance of ulnar nerve instability in cubital tunnel syndrome. J Shoulder Elbow Surg 2019; 28:1120-1129. [PMID: 30770314 DOI: 10.1016/j.jse.2018.11.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND We investigated the experience of a single surgeon with ulnar nerve anterior transmuscular transposition with the patient in the lateral decubitus position for cubital tunnel syndrome. METHODS The medical records of all patients who underwent primary or revision ulnar nerve anterior transmuscular transposition were screened to define a cohort of 156 patients (162 limbs) for further study of demographic and disease-specific data and retrospective assessment of short-term outcomes. Ulnar neuropathy severity was stratified by McGowan grade. A prospective cohort composed of 49 patients (51 limbs) with a minimum 2-year follow-up volunteered to complete patient outcome surveys, and some presented for an ulnar nerve-focused examination to assess long-term outcomes. RESULTS The overall patient satisfaction rate was 92%, with statistically significant improvements in ulnar sensation and intrinsic strength at short- and long-term follow-up. Outcomes were better for lower McGowan grades than for higher grades and better in primary cases than in revision cases. Ulnar nerve instability was observed in 69 of 162 cases (43%) in this series. A major complication occurred in 7 cases (4.3%), but all were mitigated by contributory patient-related factors. Reoperation for recurrent ulnar paresthesia was required in 4 cases (2.5%). No operations or outcomes were compromised by the lateral decubitus position. DISCUSSION AND CONCLUSION Ulnar nerve anterior transmuscular transposition in the lateral decubitus position is a good surgical option for primary or recurrent cubital tunnel syndrome and remains our preferred procedure. The high prevalence of ulnar nerve instability observed in this study is a factor worthy of consideration by surgeons and patients weighing the surgical options for ulnar neuropathy at the elbow.
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Affiliation(s)
- Lisa M Frantz
- University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | | | | | | | - Bernard F Hearon
- Advanced Orthopaedics Associates, PA, Wichita, KS, USA; Department of Orthopaedic Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA.
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Retrospective, nonrandomized analysis of subcutaneous anterior transposition versus in situ decompression of the ulnar nerve of military service members. J Shoulder Elbow Surg 2019; 28:751-756. [PMID: 30885312 DOI: 10.1016/j.jse.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The objective of this study was to compare the subjective and objective midterm functional clinical outcomes of subcutaneous anterior transposition (SAT) vs. in situ decompression (SD) of the ulnar nerve for the treatment of cubital tunnel syndrome. METHODS The US Military Health System was queried to identify all cases of ulnar neuroplasty (Current Procedural Terminology code 64718) between 2006 and 2010. Patient charts were reviewed to identify cases of isolated SAT and SD, and demographic and surgical variables were collected. The primary outcome variable was the Disabilities of the Arm, Shoulder and Hand score. The inclusion criteria were isolated primary SAT or SD and adult active-duty service members with a minimum 6-year telephone follow-up. Terminal follow-up was determined by a telephone interview. The exclusion criteria were revision procedures, trauma, cases that included other procedures (eg, medial epicondylectomy, submuscular transposition, arthroscopy, or fracture fixation), non-active-duty service members, patients without a minimum 6-year telephone follow-up, and patients who had incomplete medical records or could not be reached to complete the survey. RESULTS A total of 65 SD and 67 SAT patients met the inclusion and exclusion criteria, with a 72% telephone interview response rate. The average age was 32.3 years for all patients, with an average follow-up period of 6.5 years for SD patients and 6.3 years for SAT patients. SD patients had a lower mean Disabilities of the Arm, Shoulder and Hand score than SAT patients. No difference in reoperation rate was found. CONCLUSION The active-duty cohort reported positive outcomes and a low reoperation rate at 6-year follow-up both after SAT and after SD. SD patients had mildly superior clinical outcomes compared with SAT patients.
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Abstract
Upper extremity entrapment neuropathies are common and can cause pain, sensory loss, and muscle weakness that lead to functional disability. In this article, the authors review common entrapment neuropathies of the upper extremities, including median neuropathy at the wrist (carpal tunnel syndrome), ulnar neuropathy at the elbow, and radial neuropathy. The authors discuss the pathophysiology of nerve compression and typical etiologies, as well as strategies for differentiating between common mimics such as cervical radiculopathy and for selecting between various treatment modalities.
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Affiliation(s)
- Christopher T Doughty
- Department of Neurology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Michael P Bowley
- Department of Neurology, Massachusetts General Hospital, 55 Fruit Street, WACC 739B, Boston, MA 02114, USA.
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Long-term outcomes in patients with ulnar neuropathy at the elbow treated according to the presumed aetiology. Clin Neurophysiol 2018; 129:1763-1769. [DOI: 10.1016/j.clinph.2018.04.753] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/19/2018] [Accepted: 04/29/2018] [Indexed: 01/15/2023]
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Reizner W, Rubin TA, Hausman MR. Cubital Tunnel Syndrome in the Athlete. OPER TECHN SPORT MED 2018. [DOI: 10.1053/j.otsm.2017.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
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.
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Zhou XH, Ren YM, Wei ZJ, Lin W, Fan BY, Liu S, Hao Y, Shi GD, Feng SQ. Differential expression of miRNAs in Osborne's ligament of cubital tunnel syndrome. Mol Med Rep 2017; 16:687-695. [PMID: 28586055 PMCID: PMC5482150 DOI: 10.3892/mmr.2017.6663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 02/20/2017] [Indexed: 12/12/2022] Open
Abstract
Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve compression disease, however, the pathogenesis and pathology of CuTS remain to be fully elucidated. The aim of the present study was to compare the expression pattern of microRNAs (miRNAs) in pachyntic Osborne's ligament with that in control tendinous tissue, and select meaningful miRNAs for further investigation of the clinical pathological mechanism underlying CuTS. A microarray assay was performed to examine the expression profiles of miRNAs in the Osborne's ligament and control tendinous tissues. An online bioinformatics algorithms tool (miRWalk) was used to predict putative target genes for the deregulated miRNAs, and functional annotation was performed by Gene Ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. Finally, the results of microarray were partially validated using reverse transcription‑quantitative polymerase chain reaction analysis. The expression of total of 60 miRNAs were found to be significantly different between the pachyntic Osborne's ligament and control tendinous tissues. MiRWalk2.0 predicted 1,804 target genes for these miRNAs, and the GO functional analysis of the predicted genes suggested cellular mechanisms, including metabolic process, regulation of cell growth, cell cycle processes, cell division regulation, cellular metabolic process and signal transmission, were involved. Furthermore, KEGG pathway analysis revealed important pathways, including adherent junction, focal adhesion, lysine degradation, cell adhesion molecules and mitogen‑activated protein kinase. Compared with the heathy tissue, Osborne's ligament tissue from patients with CuTS showed a markedly different miRNA expression profile, which suggested that miRNAs may be involved in the pathogenesis of CuTS.
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Affiliation(s)
- Xian-Hu Zhou
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Yi-Ming Ren
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Zhi-Jian Wei
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Wei Lin
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Bao-You Fan
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Shen Liu
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Yan Hao
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Gui-Dong Shi
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
| | - Shi-Qing Feng
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052, P.R. China
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Affiliation(s)
- Bong Cheol Kwon
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
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Abstract
Ulnar neuropathy is commonly encountered, both acutely after elbow trauma and in the setting of chronic compression neuropathy. Careful clinical evaluation and discerning evaluation of electrodiagnostic studies are helpful in determining the prognosis of recovery with nonoperative and operative management. Appreciation of the subtleties in clinical presentation and thoughtful consideration of the timing and type of surgical intervention are critical to optimizing outcomes after treatment of ulnar neuropathy. The potential need for decompression at both the cubital tunnel and Guyon's canal must be appreciated. Supplementation of decompression with supercharged end-to-side nerve transfer can expedite motor recovery of the ulnar intrinsic muscles in the appropriately selected patient. The emergence of nerve transfer techniques has also changed the management of acute ulnar nerve injuries.
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Affiliation(s)
- Christopher J Dy
- Department of Orthopaedic Surgery - Division of Hand and Upper Extremity Surgery, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, Saint Louis, MO, 63110, USA.,Department of Surgery - Division of Public Health Sciences, Washington University School of Medicine, Campus Box 8233, 660 South Euclid Avenue, Saint Louis, MO, 63110, USA
| | - Susan E Mackinnon
- Department of Surgery - Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Campus Box 8238, 660 South Euclid Ave., Saint Louis, MO, 63110, USA.
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Szekeres M, MacDermid JC, King GJW, Grewal R. The relationship between the Patient-rated Ulnar Nerve Evaluation and the common impairment measures of grip strength, pinch strength, and sensation. J Hand Ther 2016; 28:39-44; quiz 45. [PMID: 25727009 DOI: 10.1016/j.jht.2014.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 10/09/2014] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Prospective cohort study. INTRODUCTION Grip strength, pinch strength, and sensory threshold are common evaluations used on a daily basis. Identifying how these variables relate to function for patients allows these assessments to be used for screening to identify who may benefit from surgical intervention, and provides valuable information about what impairments patients think are important with respect to functional use of their upper extremity. Therapists can use this information to focus rehabilitation programs on the most important impairments. PURPOSE To evaluate the relationship between the Patient-rated Ulnar Nerve Evaluation (PRUNE) and impairment measures of grip strength, pinch strength, and one-point sensory threshold. METHODS Data was prospectively collected from 77 patients before surgery and during regular time points for 2 years following surgery. Patients completed the PRUNE, grip and pinch strength measures, and a one-point sensory threshold evaluation. Correlations between these variables were calculated at baseline, 2 years after surgery, and for change scores during the 2-year follow up. A multiple regression analysis was used to determine the contribution of the impairment variables for determining functional change. RESULTS Grip strength showed moderate, statistically significant correlation with PRUNE scores at both baseline (r = -0.38) and at two years (r = -0.29). There was also a statistically significant correlation between one point sensory threshold for the small finger at two years (r = 0.36), but not at baseline. Change in grip strength (r = -0.28) and pinch strength (r = -0.30) both demonstrated significant correlations with PRUNE change scores. Overall, changes in grip strength, pinch strength, and sensation accounted for 20% of the variance in PRUNE changes. CONCLUSION Since grip strength was most highly correlated with PRUNE scores at baseline and at two years, rehabilitation programs that target grip strengthening is supported. While neither grip nor pinch strength were significant contributors to the regression when used together, each showed significant contributions to PRUNE variability when used in the model independently. Therefore, a combination of grip and pinch strengthening may be important during rehabilitation for improving functional results in patients that undergo surgical intervention for cubital tunnel syndrome. LEVEL OF EVIDENCE 2b.
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Affiliation(s)
- Mike Szekeres
- Health and Rehabilitation Sciences, Western University, London, Ontario, Canada.
| | - Joy C MacDermid
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada; The Roth McFarlane Hand and Upper Limb Centre, London, Ontario, Canada
| | - Graham J W King
- The Roth McFarlane Hand and Upper Limb Centre, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | - Ruby Grewal
- The Roth McFarlane Hand and Upper Limb Centre, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
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Boone S, Gelberman RH, Calfee RP. The Management of Cubital Tunnel Syndrome. J Hand Surg Am 2015; 40:1897-904; quiz 1904. [PMID: 26243318 DOI: 10.1016/j.jhsa.2015.03.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 03/03/2015] [Accepted: 03/07/2015] [Indexed: 02/02/2023]
Abstract
Symptomatic cubital tunnel syndrome is a condition that frequently prompts patients to seek hand surgical care. Although cubital tunnel syndrome is readily diagnosed, achieving complete symptom resolution remains challenging. This article reviews related anatomy, clinical presentation, and current management options for cubital tunnel syndrome with an emphasis on contemporary outcomes research.
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Affiliation(s)
- Sean Boone
- Department of Orthopedic Surgery, Washington University in St. Louis School of Medicine, St Louis, MO
| | - Richard H Gelberman
- Department of Orthopedic Surgery, Washington University in St. Louis School of Medicine, St Louis, MO
| | - Ryan P Calfee
- Department of Orthopedic Surgery, Washington University in St. Louis School of Medicine, St Louis, MO.
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36
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Wilson RJ, Watson JT, Lee DH. Nerve entrapment syndromes in musicians. Clin Anat 2014; 27:861-5. [DOI: 10.1002/ca.22377] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 01/11/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Robert J. Wilson
- Vanderbilt Orthopaedic Institute; Vanderbilt University Medical Center; Nashville Tennessee
| | | | - Donald H. Lee
- Vanderbilt Orthopaedic Institute; Vanderbilt University Medical Center; Nashville Tennessee
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