Cubital Tunnel Syndrome

Cubital tunnel syndrome occurs due to compression of the ulnar nerve at the elbow. It is the second most common nerve compression and causes para/anaesthesia of the little and ulnar half of the ring finger with weakness of small muscles of the hand and/or the thumb.

Diagnosis

Diagnosis is made on a combination of subjective history and clinical findings.

Signs and symptoms

Mild to moderate

• Intermittent paraesthesia in ulnar nerve distribution
• Intermittent nocturnal wakening
• +/- pain
• Reversible numbness or pain
• "Weakness"/ clumsiness
• Interference with ADLs

Moderate to severe

• Diminished sensation/ constant paraesthesia
• Nocturnal wakening
• Disabling pain
• Wasting of hypothenar and intrinsic muscles, including 1st dorsal interosseous muscle
• Clawing of the little and ring fingers
• Marked interference with ADLs

Differential Diagnosis

• Ulnar nerve compression elsewhere
• Cervical nerve root entrapment (C8/T1 radiculopathy)
• Thoracic outlet syndrome
• Diabetic polyneuropathy
• Post fracture/ trauma of upper limb - secondary complication which may resolve with time or require review by orthopaedics
• Pancoast Tumour
• Other nerve entrapments

Physical examination

• Inspect for evidence of hypothenar and first doral interosseous wasting and intrinsic muscle loss. In severe disease clawing of the little and ring fingers may occur.
• Froment's Sign (video link):
  The patient is asked to hold a piece of paper between the thumb and a flat palm as the paper is pulled away. Positive response: flexion of the thumb to try to maintain a hold on the paper.
• Assess for sensory loss in the correct distribution, although more likely to be positive in severe cases. Decreased sensation should be restricted to the ulnar nerve distribution (the little and ulnar half of the ring finger). Preserved dorsal ulnar hand sensation suggests a more distal lesion, such as compression within Guyon’s canal.
• Elbow flexion test: Elbow held fully flexed, with the wrist in neutral for 1 minute

First line management

Information on the nature and management of cubital tunnel syndrome should be given to the patient. Advice on avoiding movements or positions that aggravate activities, i.e. leaning on the elbow, maintaining the elbow in a flexed position for long periods. May be given advice on use of towel, taping or splint to prevent elbow flexion.

Treatment with limited evidence

Splinting: guidelines provide conflicting information on night splints.

Second line management

Assess level of compliance to conservative management.  Consider referral for nerve conduction studies, if positive discuss if patient is willing to consider surgery. List for surgery if appropriate.

National Patient Information Leaflet for Cubital Tunnel Syndrome

Review in 6 weeks (use clinical judgement as to whether on hold, telephone or pre booked appointment).  If symptoms have diminished, then discharge. 

Escalation

If there has been:

• Poor or no response to conservative management
• Severe presentation

then consider referral to Orthopaedics. Ensure the patient is willing to consider surgical management.  

Research states that reoccurrence rates are high and if intrinsic atrophy is noted need to refer urgently for surgical intervention.

If patient does not wish to consider surgery, then discharge.

NHSGGC Hand Service Orthopaedic and Therapy Post Operative Guidelines: Ulnar Nerve Decompression

Day of Surgery

• Dressing in situ, to be reduced in 48 - 72hrs by the patient.
• Discharge with/without sling as per surgeon’s protocol.
• Check circulation, sensation and movement.
• Encourage full active movement of shoulder, wrist and hand.
• Advise regarding the use of ice and elevation.
• Patient provided with post operative patient information leaflet if they do not already have it.
• Specify how and who to contact at clinic, if there are any problems.
• Fit note provided for the duration of expected absence if required.

Review Clinic (10-21 days) (in some localities suture removal may be done by practice nurse with/without additional post operative review)

• Remove dressing/ sutures if required (most wounds will be closed with a subcuticular suture).
• Check wound
  • Any evidence of infection contact surgical team
• Apply dressing (if required).
• Splinting may be indicated if fingers are clawed.
• Check ROM of elbow.
• Encourage full active movement of shoulder, wrist and hand.
• Active assisted progressing to active exercises for elbow flexion
  • Aim for full active range of movement at each joint, avoid over- stretching.
• Scar Care
  • Once wound has healed gently massage with an emollient hand cream 3-4 times daily.
• Returning to work
  • Avoid dirty environments and ensure dressing remains dry for 7 days.
  • Light manual 2-3 weeks.
  • Heavy manual 4-6 weeks.
• Driving
  • Once feels safe to do so and they feel they are in complete control of the car. Advice that they may want to check with their insurance company.
• Provide post operative patient information leaflet if they don’t already have one.
• Specify how and who to contact at clinic, if there are any problems.

Problematic Pain

Consult the Pain Service for information and guidelines on diagnosis and management of Complex Regional Pain Syndrome.

Treatment of painful tingling fingers : commissioning guide (2013) Treatment of painful tingling fingers commissioning guide

Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD006839.  https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006839.pub4/full  

Treatment for ulnar neuropathy at the elbow
Publisher: Centre for Reviews and Dissemination (CRD) Date Published: 2012

Cutts S. Cubital tunnel syndrome. Postgrad Med J. 2007 Jan;83(975):28-31.

Cubital Tunnel Syndrome, Patient Information BSSH

National Cubital Tunnel Patient Information Sheet

Wrist Hand and Finger Problems - NHS Inform