1	Cubital Tunnel Syndrome Chris Bainbridge
2	History Panas 1878 Curtis 1898 anterior transposition Adson 1913 intramuscular Buzzard 1922 reported good results
3	Sites of compression Where ulnar nerve pierces intermuscular septum Arcade of Struthers Osbornes fascia and the medial epicondyle The deep flexor pronator aponeurosis
4	Anatomy of Ulnar nerve C8 T1 medial cord Medial to axillary artery and brachial artery Nerve pierces intermuscular septum in the middle third of the humerus as coracobrachialis inserts. Joined by superior Ulnar Collateral artery
5	Cubital tunnel Fibro osseous Entrance posterior to medial epicondyle Osborne’s fascia Muscle bellies of FCU Changes from smooth round to flattened triangle. Cross section decreases by 55% Pressure >63 mmHg in flexion Add in FCU and > 209mmHg
6	Compression versus Stretch Nerve elongates by 47mm from extension to flexion After decompression site of elongation changes 10% have subluxation Women have thicker fat pad
7	Intraneural Anatomy Sensory layers outermost Intrinsics FCU and FDP May need interfascicular dissection Segmental blood supply
8	Aetiology Idiopathic in 30-50% M:F 3:1 Tardy ulnar palsy Direct injury Osteoarthritis and RA Anconeus Subluxation
9	Presentation Paraesthesia in little and ring Elbow pain (medial) Dorsal branch Intrinsic loss
10	Diagnosis Tenderness over nerve Tinels over entrapment Subluxation +ve flexion test +ve reproduction with pressure over nerve Flexion and pressure have 90% sensitivity and high specificity
11	Differential diagnosis Root lesions TOS Guyons canal Double crush Systemic conditions, diabetes, HSPP
12	Electrophysiologic investigation Are there normals? Leffert 55.7m/s >10m/s difference 15% of normals have >10m/s slowing My rules: Velocity <48m/s or difference>10m/s Increased or unobtainable distal motor latentcies Amplitude dec by 50%
13	Management Normal NCS, intermittent symptoms Conservative Mild NCS In situ decompression Severe NCS or wasting Anterior transposition with mobilisation
14	Other options Intramuscular transposition Birch “I can see no place for this operation” Medial epicondylectomy Throwing athlete Large bony dissection, risk of bleeding, Risk of valgus instability, 74% of partial epi. Only 19% can be removed without damaging the ligament
15	Submuscular transposition Learmonth 1942 Main indication in literature is recurrent disease. Some sense in site
16	Failed Decompression Elbow contracture Medial epicondylitis Sensory branch neuromas Elbow instability Persistent symptoms
17	Management Allow time Redo NCS Poor Px Age >50, Denervation RSD, >1 operation Submuscular transfer Alcohol, Diabetes Neurolysis
18	Management Every op has been revised to every other op!! Redo with wide exposure from intermuscular septum to mid forearm Remove all bands Microneurolysis Vein wrapping? Adcon gel?