Cubital Tunnel Syndrome and Carpal Tunnel Syndrome: Current Concepts
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Transcript of Cubital Tunnel Syndrome and Carpal Tunnel Syndrome: Current Concepts
David Moss, MD
Cubital Tunnel
Anatomy
H&P
EMG?
Non-op – splint/inj
SMUNT vs SQUNT vs ISUNT
Endoscopic
Carpal Tunnel
Anatomy
H&P
Fact or fiction?
Arises from C8-T1
Cubital Tunnel
Floor – elbow joint capsule
Walls – medial epicondyle and olecranon
Roof – Osbourne’s ligament
First branch is to the elbow joint
No branches in the brachium
Numb SF and half of RF
Grip weakness, intrinsic weakness
Positional exacerbation
Tinel’s test 23-34% + in normal
volunteers
EFT 10% + in normal
volunteers
Intrinsic strength
FDP SF and RF strength
Scratch collapse 99% PPV, 99% sensitive
C-spine exam
Adductor pollicis weakness & FPL compensation
• Similar to Froment’s, with MCP hyperextension
Wartenburg sign
Abduction of SF with attempted active extension due to unopposed EDQ action (ulnar insertion)
Clawing SF & RF (Duchenne’s sign)
more severe in low ulnar palsy
What to look for:
CV < 50 m/s
10 m/s delta slowing from contralateral side
20% amplitude reduction from contralat side
Shortcomings
Patient discomfort
~75% sensitive
Unclear location of nerve compression
Cervical?
Cubital tunnel?
Guyon’s canal?
Revision surgery
Not routinely recommended for “classic” CuTS
Some will obtain for a baseline measurement
Limited value unless prior fracture or suspicion of a mass
Anconeus epitrochlearis
Cubitus valgus
Activity modification
Avoid prolonged elbow flexion
Ergonomic workstation analysis
Night splinting in 45° extension (Gelberman)
Nerve glides and therapy
Mild symptoms (intermittent paresthesias)
42% resolution at 6 months
Moderate (no muscle wasting)
32% resolution at 6 months
False Hong et al. 2007
Medial epicondylectomy
Transposition
Subcutaneous - SQUNT
Intramuscular - IMUNT
Submuscular - SMUNT
In situ decompression - ISUND
Open
Endoscopic
High rate of nerve subluxation
Valgus instability
Bony tenderness
Of historic interest
SMUNT and IMUNT
Longer post-op immobilization to allow healing of the flexor/pronator mass
SQUNT
Shorter post-op immobilization
Relative contraindicated in very thin patients
Common if concommitant elbow trauma
Most data shows no difference in long term outcomes between SQUNT, IMUNT, AND SMUNT
Kose et al. Adv Ther 2007
Shi et al JHS 2011
Shortest operative time
Post-op immobilization is not necessary
Can be performed under local anesthesia
Endoscopic ISUND is trending
Higher patient satisfaction ratings compared to open ISUND in literature
More expensive
No difference! Macadam et al. JHS 2008
Callandro et al. Cochrane Database 2012
No difference between ISUND and transposition
No consensus on when to treat surgically versus conservatively
Most authors recommend transposition for frank subluxation
No consensus in the literature for treatment of perched ulnar nerve
63 yr old anesthesiologist c/o 6 month h/o medial elbow pain with occasional numbness to SF and RF. No c/o weakness.
No systemic disease or h/o trauma
PE:
+Tinel’s
+EFT
+ scratch collapse
Normal c-spine exam
No weakness or wasting
No subluxation
What is the next step?
I recommend activity modification, prescribe nighttime extension splint
Re-examine at 6-8 weeks
If no improvement then ISUND is offered
EMG is not routinely prescribed
No evidence that transposition is superior to simple decompression
Trend towards less invasive - ISUND
Unless frank ulnar nerve subluxation - SQUNT
Night pain
Tingling
Loss of dexterity and fine motor skills
Earrings
Buttons
Grip weakness
Women: Men = 3:1
Obesity
Diabetes
Hyperthyroidism
Pregnancy
Trauma
History
Physical examination
Nerve conduction test
Lalonde, Evidence based medicine: carpal tunnel syndrome. PRS 2014
Treatment of CTS, AAOS Clinical Practice Guideline Summary, 2008
Wrist flexion-carpal compression exam
82% sensitive
99% specific
Carpal tunnel (Durkan’s) compression test
87% sensitive
90% specific
MRI
Ultrasound
Nerve conduction studies
CT scan
73-100% sensitive
97.5% specific
Negative nerve test does not preclude positive surgical result
False
Splint in neutral is the most effective way to reduce neural pressure
Cortisone injection is acceptable for mild CTS
Acupuncture is equivalent to placebo
No literature to support splinting MCPs in extension
NSAIDs have not proven to be beneficial
Oral steroids have limited benefit
False
Large studies show no difference
Risk of adverse reaction to ABX > risk of infxn
Diabetics, TJA, stents, RA
True
18 days vs. 38 days
Improved scar sensitivity, pinch and grip at 3 months with ECTR
No long term difference
Critical element: complete division of the transverse carpal ligament regardless of he method
False
Post-op splint led to worse results in one study
No difference in most studies
No proven advantage or disadvantage of post-op therapy
73 yr old widow, lives alone, presents with 1 yr h/o nocturnal numbness in T, IF, MF. She c/o difficulty buttoning her blouse and putting in earrings.
Non-contributory PMH
PE:
Decreased sensation T, IF, MF to D2PD
+ Tinel’s test
- Phalen’s
+ CTCT
Thenar wasting
Normal c-spine
What is the next step?
I offer endoscopic CTR to expedite her return to independent living
EMG is not ordered in this scenario due to the clear diagnosis
Non-op treatment is not indicated in the setting of severe CTS (muscle wasting)