What is the initial treatment for a patient with subluxation of the ulnar nerve at the elbow?

Initial Treatment for Ulnar Nerve Subluxation at the Elbow

For patients with ulnar nerve subluxation at the elbow, begin with conservative management including elbow positioning modifications, protective padding, and activity modification, reserving surgical intervention (anterior transposition or medial epicondylectomy) for cases with persistent symptoms, nerve instability causing recurrent subluxation, or progressive motor/sensory deficits. 1, 2

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with appropriate imaging:

• Dynamic ultrasound is the preferred initial diagnostic modality to directly visualize ulnar nerve subluxation during elbow flexion, with high accuracy for demonstrating nerve dislocation and snapping triceps syndrome 3, 4
• CT with axial images in flexion and extension can demonstrate recurrent ulnar nerve dislocation due to snapping of the medial head of the triceps 3
• MRI with T2-weighted neurography serves as the reference standard if ultrasound is inconclusive, showing nerve signal intensity and enlargement 3, 1
• Electrodiagnostic studies help support the diagnosis, particularly in atypical presentations, and differentiate between demyelinating versus axonal injury 1, 5

Conservative Management (First-Line Treatment)

Conservative treatment should be attempted for 3-6 months in patients without significant motor weakness or muscle atrophy: 2, 6

Positioning and Protection

• Maintain neutral forearm position when arm is at side to minimize nerve tension 1, 5
• Avoid elbow flexion beyond 90° as this increases risk of nerve compression and subluxation 1, 5
• Apply proper padding (foam or gel pads) at the elbow to prevent compression, ensuring padding is not too tight to avoid tourniquet effect 1
• Limit repetitive elbow flexion motions and eliminate sustained flexion postures 2

Pharmacologic Management

• Paracetamol (up to 4g/day) as first-line oral analgesic for pain management 1, 5
• Topical NSAIDs for localized pain with fewer systemic side effects 1, 5
• Oral NSAIDs at lowest effective dose for shortest duration if inadequate response to paracetamol 5

Physical Therapy

• Range of motion and strengthening exercises to maintain function 1, 5
• Local heat application before exercise 5

Emerging Conservative Options

• Ultrasound therapy (1 MHz frequency, 1.5 W/cm² intensity, continuous mode) applied five times weekly for 2 weeks has shown significant clinical and electrophysiological improvements sustained at 3 months 7
• Low-level laser therapy (0.8 J/cm² with 905 nm wavelength) applied five times weekly for 2 weeks provides short-term effectiveness, though improvements may not be as sustained as ultrasound 7

Surgical Indications

Surgery is indicated when: 2, 6

• Conservative treatment fails after 3-6 months
• Progressive motor weakness or muscle atrophy is present at initial evaluation
• Recurrent nerve subluxation/dislocation is documented on dynamic imaging
• Significant sensory deficits persist or worsen

Surgical Options Based on Nerve Stability

For Unstable Nerve (Subluxation/Dislocation Present)

Anterior subcutaneous transposition is the primary surgical option for unstable ulnar nerves: 2, 6

• Subcutaneous transposition is least complicated and effective, particularly in elderly patients or those with thick adipose tissue 6
• Submuscular transposition is preferred when prior surgery has been unsuccessful or for most chronic neuropathies requiring primary surgery, with high success rates 6
• Medial epicondylectomy can be performed but has the highest recurrence rate (50% success for moderate neuropathies) and should be considered a secondary option 2, 6

For Stable Nerve

In-situ nerve decompression is first-line surgical treatment when the nerve is stable (no subluxation), though this is not the primary scenario for subluxating nerves 2, 8

Critical Pitfalls to Avoid

• Do not use padding that is too tight, as this creates a tourniquet effect and paradoxically increases compression risk 1
• Do not perform in-situ decompression alone for unstable/subluxating nerves, as this fails to address the dynamic instability and has poor outcomes 2, 6
• Do not delay surgery in patients with moderate-to-severe neuropathy, as conservative treatment is generally unsuccessful in these cases 6
• Avoid intramuscular transposition as it can result in severe postoperative perineural scarring 6

Monitoring and Follow-Up

• Regular clinical assessment to monitor for progression or improvement of symptoms 1
• Repeat electrodiagnostic studies if surgical treatment fails to identify persistent compression points, nerve instability, or neuroma formation 2
• Periodic assessment of upper extremity position during any procedures to prevent complications 1, 5