What are the management options for cubital syndrome (ulnar nerve compression) of the elbow?

Management of Cubital Tunnel Syndrome

For cubital tunnel syndrome (ulnar nerve compression at the elbow), begin with conservative management including activity modification, elbow splinting in extension, and nerve gliding exercises, reserving surgical decompression for severe cases or those failing 3-6 months of conservative treatment. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis through:

• Plain radiographs of the elbow as the initial imaging study to rule out osseous pathology, heterotopic ossification, or occult fractures 3, 4
• T2-weighted MR neurography if imaging is needed to confirm nerve entrapment, which demonstrates high signal intensity and nerve enlargement as the reference standard 3
• Ultrasound evaluation showing increased cross-sectional area/nerve thickness or hourglass constriction of the nerve, with shear-wave elastography demonstrating 100% specificity and sensitivity 3
• EMG and nerve conduction studies when neurologic symptoms are present to confirm the diagnosis and localize compression 4

Physical examination should identify Tinel's sign at the cubital tunnel, positive flexion-compression test, and palpable nerve thickening or tenderness along the ulnar nerve course 1. The earliest presentation is typically numbness and tingling in the ring and small fingers 1.

Conservative Management (First-Line)

Conservative treatment should always be pursued before surgical intervention and includes: 1, 2

• Activity modification to eliminate repetitive elbow pressure, flexion, or trauma that compresses the ulnar nerve 1
• Elbow splinting in extension, particularly at night, to prevent prolonged elbow flexion that increases pressure in the cubital tunnel 1, 2
• Nerve gliding exercises to improve ulnar nerve mobility through the cubital tunnel 1
• Avoidance of positions that predispose to external compression, including prolonged severe elbow flexion when in bed, armchairs, or during procedures 5

Conservative management should be attempted for at least 3-6 months before considering surgical options 2. However, if severe chronic nerve compression is present with muscle atrophy or significant motor weakness, early surgical intervention may be warranted to prevent permanent nerve damage 1, 2.

Surgical Management (Second-Line)

Surgical treatment is indicated for:

• Severe cubital tunnel syndrome refractory to conservative treatment after 3-6 months 1, 2
• Chronic cases with progressive motor weakness or muscle atrophy 1, 2
• Presence of first dorsal interosseous muscle atrophy affecting fine motor function 1

The most commonly recommended surgical techniques include: 6

• Simple in-situ decompression - releasing the cubital tunnel without nerve transposition 6
• Decompression with medial epicondylectomy - removing the medial epicondyle to create more space 6
• Anterior subcutaneous transposition - moving the nerve anterior to the medial epicondyle under the skin 6
• Anterior submuscular transposition - transposing the nerve beneath the flexor-pronator muscle mass 6

The choice of surgical technique depends on the exact location of pathologic compression, severity of symptoms, and presence of nerve subluxation with elbow flexion 6. Gentle handling of the nerve and attention to technical details are critical to achieve satisfactory results 2.

Important Clinical Considerations

Common pitfalls to avoid:

• Failing to obtain initial radiographs to rule out osseous causes of compression 4
• Delaying surgical treatment in severe chronic cases, which can lead to permanent nerve damage and irreversible muscle atrophy 1, 2
• Not recognizing anatomical variations such as the epitrochleoanconeus muscle, which can cause compression and create technical difficulties during surgery 7
• Inadequate patient education about avoiding positions that compress the ulnar nerve, leading to worsening of symptoms 5

Prognosis depends on timing of intervention: Early diagnosis and treatment lead to satisfactory results, while severe chronic nerve compression may result in permanent nerve damage even after surgery 2. A compressed nerve is more sensitive to subsequent ischemia from pressure, making prevention of further compression critical 5.