What are the treatment options for ulnar (ulnar nerve) compression at the elbow?

Treatment of Ulnar Nerve Compression at the Elbow

For idiopathic ulnar nerve entrapment at the elbow, simple decompression and decompression with transposition are equally effective, but simple decompression should be preferred as the initial surgical approach because it has fewer wound infections while achieving the same clinical outcomes. 1

Initial Conservative Management

Start with conservative treatment for mild to moderate cases, particularly when symptoms are acute or subacute. 2, 3

• Provide specific information to patients about avoiding prolonged elbow flexion and positions that compress the nerve - this alone reduces subjective discomfort in mild cases 1
• Rest the affected arm and avoid direct pressure on the ulnar groove 2, 3
• Immobilize the elbow and wrist with splinting if symptoms persist despite activity modification 2, 3
• Prescribe paracetamol (up to 4g/day) as first-line oral analgesic 4
• Consider topical NSAIDs for localized pain with fewer systemic side effects 4
• Use oral NSAIDs at the lowest effective dose for shortest duration if paracetamol is inadequate 4

Evidence on Conservative Treatment Effectiveness

Conservative treatment shows approximately 50% success in mild neuropathies but is generally unsuccessful for moderate neuropathies 2. Night splinting and nerve gliding exercises added to information provision do not provide additional benefit beyond education alone 1. Corticosteroid injection shows no difference versus placebo at three months 1.

Surgical Indications

Proceed to surgery when: 2, 3

• Chronic neuropathy is associated with muscle weakness
• Symptoms persist despite 3+ months of conservative treatment
• Progressive nerve damage is evident
• Moderate to severe neuropathy is present on initial evaluation

Surgical Options: Algorithm for Selection

Primary Surgery (First-Time Intervention)

Perform simple decompression (in situ) as the initial surgical procedure for most cases 1

• Simple decompression achieves clinical improvement in approximately 70% of patients (91/131 in pooled data) 1
• This approach has significantly fewer wound infections compared to transposition (RR 0.32,95% CI 0.12 to 0.85) 1
• No difference exists in neurophysiological outcomes between simple decompression and transposition 1

Reserve submuscular transposition for: 2

• Failed prior surgery
• Severe perineural scarring
• Recurrent symptoms after initial decompression

Alternative Surgical Approaches

Subcutaneous transposition is appropriate for: 2

• Elderly patients
• Patients with thick adipose tissue in the arm
• Concurrent elbow fracture reduction or arthroplasty
• Secondary nerve repairs

Avoid medial epicondylectomy as primary treatment - it shows only 50% effectiveness and has the highest recurrence rate among surgical options 2

Endoscopic decompression shows no difference in clinical outcomes compared to open decompression, though patients undergoing endoscopic surgery have higher risk of hematoma 1

Important Surgical Caveat

Avoid intramuscular transposition - despite favorable results reported by some proponents, this procedure can result in severe postoperative perineural scarring 2

Perioperative Nerve Protection

During any surgical procedure involving elbow positioning: 5, 6, 4

• Position the forearm in supination or neutral position to decrease pressure on the postcondylar groove (ulnar groove) 5, 6
• Avoid elbow flexion greater than 90° as this increases risk of ulnar neuropathy 5, 4
• Use padding at the elbow (foam or gel pads) to decrease compression risk 5
• Periodically assess upper extremity position during procedures to ensure maintenance of desired position 5, 4

Diagnostic Workup Before Treatment

Obtain radiographs of the elbow initially to rule out bony abnormalities or joint pathology 6

For persistent symptoms with normal radiographs, order MRI without IV contrast - this is the reference standard showing T2-weighted high signal intensity and nerve enlargement 4

Ultrasound is an effective alternative with high accuracy (sensitivity 77-79%, specificity 94-98%) for assessing nerve cross-sectional area and thickness 4

Long-Term Outcomes

Surgical treatment maintains effectiveness beyond 20 years, with no significant difference in outcomes between 1-year and 20+ year follow-up 7. Success rates exceed 90% for mild neuropathies treated surgically, regardless of procedure type 2. However, results are clearly worse when direct trauma is the underlying cause 8.

Common Pitfalls to Avoid

• Do not perform decompression in situ for moderate neuropathies - this approach is generally unsuccessful for anything beyond mild cases 2
• Do not add transposition routinely - it increases infection risk without improving outcomes 1
• Do not delay surgery in moderate cases with muscle weakness - conservative treatment is ineffective in this population 2
• Avoid inappropriate padding that is too tight during positioning, as this may paradoxically increase neuropathy risk 5