Natural History and Conservative Management of Syndrome Robert Szabo, Christine Kwak

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Robert Szabo, Christine Kwak. Natural History and Conservative Management of Cubital Tunnel Syndrome. Hand Clinics, 2007, 23 (3), pp.311-318. ￿10.1016/j.hcl.2007.05.002￿. ￿hal-01631011￿

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52 53 54 Hand Clin j (2007) j–j 55 56 57 58 59 1 Natural History and Conservative Management 60 2 61 3 of Cubital Tunnel Syndrome 62 4 a,* b 63 5 ½Q2 Robert M. Szabo, MD, MPH , Christine Kwak, MD 64 6 a 65 ½Q3 Department of Orthopaedic , University of California, Davis School of , 7 4860 Y Street, Suite 3800, Sacramento, CA 95817, USA 66 8 bDepartment of Orthopedics, University of California, Davis Medical Center, 2580 Stockton Boulevard, 67 68 9 ½Q4 Sacramento, CA 95817, USA 10 69 70 11 Cubital tunnel syndrome is the second-most with the two heads of the flexor carpi ulnaris mus- 12 71 common nerve compression syndrome, second to cle [4,6,7]. 13 PROOF 72 14 . It is, however, the most The is a dynamic joint. Its arc of motion 73 15 common site for compression [1,2]. typically ranges from full extension to 150 degrees 74 16 Accuracy in diagnosis is key in identifying the of flexion, with the functional range of motion 75 17 cubital tunnel as the site of compression, and, being from 30 to 130 degrees. Throughout the 76 18 depending on the severity of the symptoms, non- day, the elbow flexes and extends to place the 77 19 operative and operative treatment options have hand in positions of function. With motion, 78 20 been proposed. In this article, we discuss the associated changes occur to the shape and space 79 21 course of ulnar neuropathy caused by compres- within the cubital tunnel. 80 81 22 sion at the cubital tunnel and the conservative The tunnel is most patent with the elbow in 23 82 management of this syndrome. extension. With each degree of flexion, the tunnel 24 83 25 changes its shape. Patel and colleagues [8], by us- 84 ing magnetic resonance imaging (MRI), showed 85 26 The natural course of cubital tunnel syndrome 27 that the tunnel is circular in shape and most spa- 86 28 Buzzard [3], in 1922, described chronic neuritis cious in extension. With flexion, the tunnel adopts 87 29 of the elbow and attributed its causes to ‘‘exces- a wider and flatter configuration. Beginning as 88 30 sive use of the hand and arm in flexed positions,’’ a rounded tunnel, the tunnel becomes triangular 89 90 31 ulnar nerve subluxation, and ‘‘some form of toxic or, as some describe, ellipsoid in flexion with 32 a measurable height decrease of 2.5 mm. Vander- 91 agent.’’ The term cubital tunnel was first proposed 92 33 pool and colleagues [9] showed that with the el- 34 by Feindal and Stratford [4] in 1958. They empha- 93 bow in flexion, the aponeurosis stretches 5 mm 35 sized that anatomic peculiarities that predispose 94 36 the ulnar nerve to compression are present in for every 45 degrees of flexion. With the stretching 95 37 this region of the elbow and noted a similarity be- of the aponeurosis and the innate tightness of the 96 38 tween ulnar nerve compression at the elbow and arcuate ligament, the tunnel has been shown to 97 39 compression in the carpal tunnel flatten and narrow by 55% with elbow flexion 98 40 [4,5]. They observed the ulnar nerve being com- [10]. This decreases the space surrounding the 99 41 pressed in a fibro-osseous space defined by a liga- nerve, making the nerve susceptible to compres- 100 101 42 ment, which extends from the medial epicondyle sion [4,9,11]. 43 With the change in shape, an associated change 102 to the olecranon. Its aponeuroticlike fibers adjoin 103 44 in pressure occurs within the tunnel. Werner and 45 UNCORRECTED 104 colleagues [12] studied the cubital tunnel pressure 46 105 47 measurements with the elbow in extension and 106 48 * Corresponding author. flexion. The average pressure measured in 107 49 E-mail address: [email protected] extension was 9 mm Hg, and with flexion, the 108 50 (R.M. Szabo). pressure increased to approximately 63 mm Hg. 109 51 110 0749-0712/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.hcl.2007.05.002 hand.theclinics.com HCL365_proof 21 June 2007 8:09 pm ARTICLE IN PRESS

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111 ½Q5 Gelberman [13] studied the extraneural and intra- effects of nerve conduction with stretch using tib- 170 112 neural pressures and showed that with flexion, the ial nerves. At 6% stretch, the nerve conduction 171 113 extraneural pressure increased dramatically. decreased by 70%; with 12% strain, conduction 172 114 Using cadaveric specimens, Gelberman showed was completely blocked at 1 hour. Once decom- 173 115 that extraneural pressure measurements increased pressed, the recovery of nerve function was noted 174 116 175 from 7 to 28 mm Hg with flexion and intraneural to be related to the severity and duration of the 117 176 118 pressure measurements increased from 8 to 41 mm compression [2,20–23]. 177 119 Hg with flexion. Macnicol [14] also showed a rise 178 120 in extraneural pressure with elbow flexion, record- 179 ing pressure measurements as high as 200 mm Hg. 121 Causes 180 122 ½Q6 They also showed a decrease in pressure by 50% 181 123 with release of the flexor aponeurosis. Iba and Cubital tunnel syndrome might be caused by 182 124 colleagues [7] studied cubital tunnel pressure mea- constricting fascial bands, soft-tissue structures 183 125 surements in patients and found that the highest (hypertrophied synovium, tumor, ganglion, anco- 184 126 extraneural pressure measurements were 1 cm neus epitrochlearis muscle), bony abnormalities 185 127 186 distal from the proximal edge of the arcuate liga- (cubitus valgus, bone spurs), or subluxation of the 128 187 129 ment. They also found that those with severe neu- ulnar nerve over the medial epicondyle with elbow 188 130 ropathy had the highest pressure measurements flexion. Although work-related activities involving 189 131 with flexion. repetitive elbowPROOF flexion and extension might ag- 190 132 As the cubital tunnel changes with elbow gravate cubital tunnel syndrome, no scientific 191 133 flexion, so does the ulnar nerve. With elbow data have supported work as a causal risk factor 192 134 flexion, the excursion of the nerve proximal to [24]. Many common themes are seen, however, 193 135 the medial epicondyle has been recorded to be as in patients presenting with cubital tunnel syn- 194 136 long as 10 mm. Apfelberg and Larson [10] showed drome. Environmental factors, such as specific 195 137 that the nerve elongates approximately 4.7 mm occupations, have been associated with the diag- 196 138 197 with the elbow in flexion. Distal to the medial epi- nosis, and jobs that require repetitive motions in- 139 198 140 condyle, the nerve stretches approximately 3 to volving elbow flexion have been implicated. 199 141 6 mm with flexion. Other studies have shown the Repetitive flexion can make one prone to develop- 200 142 nerve elongating even up to 8 mm [15]. This in- ing traction neuritis because of the constant 201 143 creases when the shoulder is held in abduction stretching of the ulnar nerve [25]. Baseball pitchers 202 144 and the wrist is held in extension. and tennis players often feel pain at the elbow and 203 145 It is already clear that the environment sur- experience numbness in the ring and small fingers 204 146 rounding the ulnar nerve at the elbow is a dynamic caused by the stress placed on the elbow. The 205 147 one. The natural course of the nerve is to wind-up while throwing a baseball or while serving 206 148 experience some traction and some excursion a tennis ball stretches the ulnar nerve by placing 207 149 208 with the elbow in motion. It is thought that with a valgus force at the elbow while the shoulder is 150 209 151 repetitive motion, the nerve becomes inflamed. abducted. This position places the nerve under 210 152 With the inflammation comes edema and swelling maximum compression and traction [26]. 211 153 in the nerve, which then affects its ability to glide. Similarly, people who partake in occupations 212 154 This has been well described both histologically such as carpentry, painting, and music typically 213 155 and with imaging studies [1,11,16]. Studies have are more prone to developing ulnar nerve symp- 214 156 shown that blood flow and axonal transport are toms, most commonly because of prolonged 215 157 affected by compression [17–19]. With low exter- elbow flexion. Charness [27] reported that with 216 158 nal compression, extraneural and intraneural 117 musicians, cubital tunnel syndrome was the 217 159 blood flow is impaired, leading to an increase in most commonly diagnosed nerve entrapment syn- 218 160 219 pressure and change in nerve conduction. With drome. Another well-studied group involves 161 220 162 higher pressures, thickening in the nervous tissue wheelchair athletes, who are known to be prone 221 163 and severe impairment in nerveUNCORRECTED conduction occur. to upper extremity injuries caused by repetitive 222 164 Clark and colleagues [20] showed a decrease in impact and overuse. The prevalence of nerve 223 165 neural blood flow with elongation. Using sciatic entrapment in this group was 23%. The majority 224 166 nerves in rats, they measured a 50% decrease in of the neuropathies were from median nerve 225 167 blood flow with 8% stretch of the nerve and an compression at the carpal tunnel. Thirty-nine per- 226 168 80% reduction in nerve blood flow with 15% of cent of the nerve entrapment syndromes, however, 227 169 elongation. Wall and colleagues [21] studied the involved the ulnar nerve, with a large subset of 228

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229 those patients having cubital tunnel syndrome. Weakness of the deep flexors to the ring and little 288 230 The strong forceful contractions of the flexor fingers and weakness of the flexor carpi ulnaris, 289 231 carpi ulnaris and the repetitive elbow flexion however, signal proximal . 290 232 have been thought to cause compression of the Sunderland [32] studied the topography of the ul- 291 233 ulnar nerve at the elbow [28]. nar nerve at the level of the elbow and noted that 292 234 293 Mechanical compression of the nerve at the the fascicles innervating the flexor carpi ulnaris 235 294 236 elbow also is common because very little soft and flexor digitorum profundus to the fourth 295 237 tissue surrounds the nerve. Postoperative ulnar and fifth digits are more central whereas the sen- 296 238 nerve compression caused by inadequate padding sory fascicles and hand muscles are distributed 297 239 at the elbow has been reported [29]. The superfi- more peripherally. The fibers are susceptible to 298 240 cial course of the ulnar nerve predisposes it to changes in the environment, such as compression, 299 241 injury during patient positioning in the operating frequent traction with elbow flexion, and direct 300 242 room. In the supine position, with the arm tucked trauma. 301 243 to the side, direct compression can occur and Provocative tests also are used to help identify 302 244 will be accentuated if the arm slips slightly over ulnar neuropathy at the elbow. Tinel sign is 303 245 304 the edge of the table. Wheelchair users who positive when percussion of the ulnar nerve at 246 305 247 constantly place their on the armrests of- the medial epicondyle reproduces in 306 248 ten have symptoms of ulnar neuropathy [28]. the ring and small fingers. However, nearly 24% 307 249 Other sources include soft-tissue and bony abnor- of asymptomaticPROOF people have this finding [33]. The 308 250 malities, such as cubitus valgus, ganglions, and elbow flexion test also has been used to corrobo- 309 251 space-occupying lesions in the cubital tunnel. rate the diagnosis of cubital tunnel syndrome. 310 252 311 As described by Buehler [34], results of an elbow ½Q7 253 flexion test are positive when ulnar nerve symp- 312 254 toms are reproducible with the elbow flexed, the 313 Clinical presentation 255 forearm supinated, and the wrist in extension for 314 256 315 The most frequent way of diagnosing cubital 3 minutes. Novak and colleagues [35] studied 257 316 258 tunnel syndrome is by obtaining a history and four different provocative tests, including Tinel 317 259 performing a . Patients com- sign, elbow flexion test, pressure provocation, 318 260 monly present with complaints of numbness and and combined flexion with pressure provocation, 319 261 tingling in the small and ulnar half of the ring and found that the combined test was the most 320 262 fingers, often accompanied by weakness of grip, sensitive and specific in diagnosing cubital tunnel 321 263 particularly during activities for which torque is syndrome. Only 2 of the 66 control participants 322 264 applied to a tool. Sensory involvement on the experienced ulnar nerve symptoms with the com- 323 265 ulnar dorsal aspect of the hand also suggests bined test, whereas 43 of the 60 affected partici- 324 266 cubital tunnel syndrome, as the dorsal cutaneous pants had positive results of the tests. Despite 325 267 326 branch of the ulnar nerve originates proximal to studies supporting the use of provocative tests, it 268 327 269 the canal of Guyon. On rare occasions, patients is well known that the tests can also render posi- 328 270 present with wasting of the intrinsic musculature tive results in asymptomatic people. The fre- 329 271 in the hand. Depending on the severity, the quency of false positives has been reported with 330 272 paresthesias might be intermittent or constant. the use of the elbow flexion test and Tinel sign. 331 273 The Semmes Weinstein monofilament test and With the wrist and shoulder in neutral position, 332 274 vibration testing are helpful in detecting sensory Rayan and colleagues [33] showed that 10% of 333 275 impairment during the earlier stages of nerve their asymptomatic patients had positive results 334 276 compression. For more severe cases, static and of the flexion tests. The number of false positives 335 277 moving two-point discrimination can be used. increased when the test was performed with the 336 278 337 Weakness might also be present, although at shoulder abducted and the wrist extended. There- 279 338 280 times subtle. Comparison with the contralateral fore, care should be taken when interpreting the 339 281 asymptomatic side can identifyUNCORRECTED motor weakness results of these tests, and an emphasis should be 340 282 with the intrinsic musculature. Patients also might made on finding a positive correlation between 341 283 complain of pain at the elbow and hypersensitivity the clinical examination and the history before 342 284 with palpation of the ulnar nerve as it travels making a diagnosis. 343 285 around the elbow [20–31]. In most cases, the The use of electrodiagnostic testing can help 344 286 forearm muscles are spared because their innerva- locate, confirm, and quantify the severity of nerve 345 287 tion might arise proximal to the cubital tunnel. compression. The ulnar nerve at the elbow has 346

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347 been studied, and guidelines have been formulated MRI has been studied as a modality with 406 348 with the use of nerve conduction studies to aid in which to visualize changes to the ulnar nerve 407 349 the diagnosis. Conduction velocities are measured around the elbow [8]. Britz and colleagues [6] 408 350 across the elbow with the intrinsic musculature showed a strong correlation with positive MRI 409 351 used for motor velocity and the small finger for findings, such as an increase in signal around the 410 352 411 sensory velocity. Parameters for accurate testing nerve, and nerve compression. The authors found 353 412 354 include flexing the elbow between 70 and 90 that MRI was more sensitive than electrodiagnos- 413 355 degrees when measuring conduction at the elbow tic studies in diagnosing ulnar nerve compression 414 356 [6]. The recommended length across the elbow at the elbow. 415 357 is 100 mm; however, studies have supported 416 358 measuring 50 to 80 mm across the elbow to obtain 417 359 the most accurate measurement of conduction 418 Staging 360 [15]. The American Association of Electrodiag- 419 361 nostic Medicine criteria for a positive diagnosis In 1950, McGowen [22] introduced a staging 420 362 of ulnar neuropathy include one of the following: system that solely reflected the motor aspect of 421 363 422 absolute slowing of nerve conduction at the the ulnar nerve. Grade I had undetectable motor 364 423 365 elbow, decreased conduction velocity of more weakness. Grade II showed some motor weak- 424 366 than 10 m/s across the elbow, decreased amplitude ness, and Grade III was described as severe motor 425 367 of more than 20%, absence of sensory responses, weakness. SensoryPROOF findings were later included 426 368 or evidence of muscle atrophy [36]. Electromyog- into the staging classification. For mild cases, 427 369 raphy will reveal whether axonal degeneration symptoms are intermittent and include occasional 428 370 has occurred. The first dorsal interosseous muscle . The patient might have complaints of 429 371 is most commonly affected. The abductor pollicis weakness, but findings of the motor examination 430 372 brevis should be examined to exclude a C8T1 typically are normal. For moderate cases, pares- 431 373 nerve root or inferior brachial plexus lesion. thesias are intermittent, and clinically, a decrease 432 374 433 Radiographic examination of the elbow is use- in vibratory sensation might be present. A dis- 375 434 376 ful in a small percentage of patients: those with crepancy in intrinsic strength when compared 435 377 arthritis, history of trauma, or abnormal elbow with the unaffected side might be present. Results 436 378 motion or carrying angle revealed by physical of provocative tests are also positive. In more se- 437 379 examination. most com- vere cases, patients might complain of constant 438 380 monly involves the medial components of the numbness in the ulnar nerve distribution in the 439 381 brachial plexus and might be mistaken for cubital hand and might have abnormal results of the 440 382 tunnel syndrome. An apical tumor of the lung can two-point discrimination test. The patients pres- 441 383 also compress or invade the inferior brachial plexus ent with atrophy of the ulnar innervated intrinsics 442 384 causing ulnar nerve symptoms. Chest radiography and have obvious weakness. 443 385 444 to rule out a Pancoast tumor should be obtained Dellon [2] and Gabel [40] developed more com- 386 ½Q9 445 387 whenever a history of smoking, ulnar nerve symp- prehensive staging classifications by using addi- 446 388 toms, and shoulder pain is reported by the patient. tional diagnostic criteria and creating a more 447 389 Ultrasonography also has been used to aid in precise tool for reporting research data. Dellon ½Q10 448 390 the diagnosis of cubital tunnel syndrome. Studies [41] used a numeric grading scale to categorize pa- 449 391 have shown a difference in ulnar nerve size in tients based on symptoms. A numeric score of 0 in- 450 392 patients diagnosed with cubital tunnel syndrome dicated normal results. Scores of 1 and 2 included 451 393 452 ½Q8 [37–39]. Wiesler and colleagues [38] showed that intermittent paraesthesias and mild weakness 394 the affected patients had a statistically significant observed during pinch and grip tests. Scores of 3 453 395 increase in the cross-sectional area of the nerve and 4 included vibratory changes and moderate 454 396 455 when compared with normal controls. The in- objective weakness. A score of 5 indicated persis- 397 456 398 crease in size correlated with the idea that com- tent paresthesias, and a score of 6 showed abnor- 457 399 pression induced a cascadeUNCORRECTED of events that mal two-point discrimination. Scores 7 through 10 458 400 included endoneurial edema and inflammation. evidenced muscle atrophy. Based on the numeric 459 401 The authors showed a positive correlation between grading, the authors showed that mildly affected 460 402 nerve conduction studies and measure- patients achieved better outcomes with conserva- 461 403 ments. Ultrasonography, therefore, might provide tive , whereas those with higher scores 462 404 a noninvasive way to help diagnose cubital tunnel were more likely to need surgical treatment. This 463 405 syndrome. confirmed the findings of an earlier study in which 464

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465 Dellon [2] found that for 50% of patients with did not progress with any worsening symptoms 524 466 a minimal degree of nerve compression, excellent or any motor involvement, thus implying that 525 467 results were achieved by using nonoperative treatment can halt the progression of the 526 468 techniques. neuropathy. 527 469 Night splinting has been successfully used in 528 470 529 patients presenting with cubital tunnel syndrome. 471 530 Seror and colleagues [47] studied 22 patients with 472 Conservative therapy ½Q13 531 473 electrodiagnostically confirmed ulnar nerve palsy 532 474 Conservative therapy has been proposed and and treated them with night splints. The splints 533 475 adopted for patients presenting with mild symp- limited flexion from 15 to 60 degrees but allowed 534 476 toms [2,31,42,43]. The goals of the treatment are unrestricted pronation and supination. During the 535 477 to eliminate or decrease the frequency of symp- daytime, the patients were advised not to rest the 536 478 toms and to prevent further progression of the elbow on hard surfaces or partake in prolonged el- 537 479 disease. A detailed history is important and helps bow flexion. The splints were worn regularly for 538 480 identify the activities that aggravate the symp- 6 months. After 11.3 months, fewer symptoms 539 481 540 toms. Patient education plays an important part were present in every patient treated and five of 482 541 483 in treating the mild symptoms. Activities that the patients reported 80% to 90% subjective im- 542 484 reproduce symptoms such as repetitive elbow flex- provement in symptoms. Sixteen of the 17 patients 543 485 ion or direct pressure to the medial epicondyle additionally experiencedPROOF electrodiagnostic im- 544 486 should be avoided or limited, and elimination of provement. The best responders for the treatment 545 487 these inciting activities has been shown to provide were those who underwent splinting less than 546 488 relief. The patient might be required to modify 3 weeks after the onset of symptoms. The first 547 489 habits and the work environment [43,44]. symptom to resolve was nocturnal paresthesias. 548 490 In conjunction with activity modification, Those more severely affected also showed 549 491 splinting has played a successful role in the improvements with sensation and strength; how- 550 492 551 conservative management of cubital tunnel ever, the authors noted that the time to recovery 493 552 494 syndrome. An elbow pad can help prevent direct was more prolonged compared with the mildly af- 553 495 trauma to the nerve. Wearing a splint also can act fected patients. Interestingly, three of the patients 554 496 as a reminder to the patient to avoid flexing the included in the study had undergone previous sur- 555 497 elbow. By limiting flexion to 45 to 70 degrees, gical decompressions that did not achieve resolu- 556 498½Q11Dimond [15] and Lister [45] reported an 86% tion of symptoms. Nighttime splinting did 557 499 558 ½Q12improvement of symptom severity in 73 patients improve symptoms in all three patients, and clin- 500 who underwent splinting during an average ical improvement for the three ranged from 60% 559 501 8.7 months. Studies have shown as high as 90% to 95%. Two of the patients additionally had im- 560 502 successful treatment achieved by using conserva- provement shown by electromyography. 561 503 562 tive modalities [15,45]. Dellon and colleagues [41] prospectively studied 504 563 505 Beekman and colleagues [46] prospectively 121 patients treated nonoperatively for a minimum 564 506 studied 74 patients who had cubital tunnel syn- of 3 months up to 6 months. The nonoperative 565 507 drome. Based on diagnostic testing, the authors management included thermoplastic splints or 566 508 divided the patients into two treatment groups. towel wrapping at night, patient education, and 567 509 Forty-six patients were treated conservatively, work modification. Alterations included placing 568 510 and 28 were treated surgically. The division was pillows under the elbow for computer users. Tele- 569 511 decided based on the presenting symptoms, with phones were to be used with the contralateral 570 512 the conservative group having more mild symp- arm. Crossing arms was avoided, and patients 571 513 toms, limited to intermittent paresthesias and were taught to place their hands on their thighs 572 514 573 mild intrinsic weakness. The instructions for con- with their forearms supinated. Of the patients 515 574 516 servative treatment included avoiding leaning on with intermittent paresthesias, 42% became symp- 575 517 the elbow, avoiding crossingUNCORRECTED the arms while sit- tom free after conservative treatment. Thirty-four 576 518 ting, and keeping the elbow extended as much as percent of patients with moderate symptoms, 577 519 possible. After the 6 months of treatment, 35% which included electromyographic findings but no 578 520 of the conservatively treated patients achieved clinical signs of intrinsic wasting or abnormal 579 521 improvement and 11% experienced complete re- two-point discrimination, became symptom free 580 522 mission. The authors noted that during the course after 6 months of treatment. Twenty percent of 581 523 of 6 months, those with only sensory symptoms the more severely affected patients also reported 582

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583 being symptom free. The need for surgical treat- Little support is offered for local steroid in- 642 584 ment was 21% within 6 years for patients with jections into the cubital tunnel. Unlike with carpal 643 585 mild symptoms, 33% within 3 years for moderate tunnel syndrome, the response to cubital tunnel 644 586 symptoms, and 62% within 3 years for severe syndrome from steroid injections has not been as 645 587 symptoms. beneficial [37,44]. Hong and colleagues [48] stud- 646 588 ½Q15 647 Many varieties of splints are available. Home- ied 12 ulnar nerves, dividing the patients into 589 648 590 made, custom fitted, and pre-made commercially two groups. Group A was treated with nocturnal 649 591 available splints have been used to prevent elbow and intermittent daytime splinting, limiting elbow 650 592 flexion. Apfel and Sigafoos [48] studied five differ- flexion to 35 degrees. The splint was molded to 30 651 593 ent types of splints, four of which are commer- to 35 degrees of elbow flexion, forearm to 10 to 20 652 594 cially available, to learn how effective they are in degrees of pronation, and wrist held in neutral. At 653 595 preventing flexion. The five splints consisted of the elbow, padding was added with added space 654 596 the following: a large bath towel applied circum- medially. Compliance was monitored closely dur- 655 597 ferentially around the elbow joint; Pil-O Splint ing the course of 6 months. Group B was treated 656 598 elbow support adjustable with rigid plastic stay with a similar splinting regimen and local steroid 657 599 658 (IMAK Corp., San Diego, CA); Pil-O-Splint injection. The follow-up duration was 6 months, 600 659 601 elbow support adjustable with rigid plastic stay re- and the results showed that splinting alone was 660 602 moved (IMAK Corp.); the Hely & Weber cubital sufficient for treating mild symptoms. The addi- 661 603 tunnel splint (Hely & Weber, Santa Paula, CA); tion of the steroidPROOF injection did not provide any 662 604 and the AliMed Cubital Tunnel Syndrome Sup- further improvement in sensory or motor conduc- 663 605 port (AliMed, Inc., Dedham, MA). Using cadav- tion. After 1 month of treatment, Group A par- 664 606 eric limbs, the authors studied the splints’ ability ticipants reported symptomatic improvement 665 607 to prevent elbow flexion against gravity and with and showed improvement in motor conduction, 666 608 an added weight. They found that the AliMed whereas Group B participants did not show any 667 609 splint allowed for the most flexion against gravity, improvement in motor conduction at that time. 668 610 669 allowing the elbow to flex to 110 degrees. The At 6 months, however, a significant decrease in 611 670 612 Hely & Weber splint allowed only 53 degrees of conduction time was shown in both groups. No 671 613 flexion. This splint also prevented full extension: change in sensory conduction occurred in either 672 614 on average, 17 degrees of extension. The remain- group at 1 or 6 months, most likely because recov- 673 615 ing splints allowed for elbow flexion, although ery of the sensory type Ia fibers took longer than 674 616 none exceeded 90 degrees. By preventing the el- 6 months [49]. It is important to view all the 675 617 bow to bend beyond 90 degrees, the products min- findings in perspective with the natural history 676 618 imized compression on the ulnar nerve. of untreated cubital tunnel syndrome with which 677 619 A consensus exists that limiting elbow flexion approximately half of patients improve spontane- 678 620 is what makes splinting effective; however, the ously [51]. 679 621 680 degree of flexion that is tolerable has not been 622 681 established. Gelberman [43] showed that the low- 623½Q14 Summary 682 624 est mean extraneural and intraneural pressures of 683 625 the ulnar nerve occurred when the elbow was Conservative therapy with splinting is an 684 626 flexed to 40 to 50 degrees. The highest pressures effective way to treat cubital tunnel syndrome. 685 627 were recorded with the elbow in maximal flexion, The variables of splinting include the type and 686 628 which was approximately 130 degrees. Interest- durability of the splint and the patient’s compli- 687 629 ingly, the elbow in full extension also recorded ance. Factors such as comfort, practicality, and 688 630 higher pressures at the cubital tunnel than when cosmesis play a large role in a patient’s compli- 689 631 the elbow was flexed between 30 and 70 degrees ance with the treatment protocol [45,48,50]. Like- 690 632 691 [13]. Hong and colleagues [49] recommended lim- wise, the rigidity of the splint, preventing flexion 633 692 634 iting flexion to 35 degrees, whereas other studies at angles beyond 90 degrees, is a very important 693 635 [1,50] reported using 45 degreesUNCORRECTED as the limit. Al- factor in the success of the management of mild 694 636 though it seems the studies used different parame- cubital tunnel syndrome. Although a consensus 695 637 ters for splinting, an underlying consistency exists regarding duration of treatment, type of splinting, 696 638 in that a slight amount of flexion is more benefi- and degree of splinting is lacking, overall, a consis- 697 639 cial in decreasing the pressure in the cubital tunnel tency in the support of the effectiveness of this 698 640 and that patients find slight flexion more tolerable modality in the spectrum of treatment options 699 641 than full extension [43]. for cubital tunnel syndrome exists. 700

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