What is the recommended management approach for a patient presenting with ulnar nerve compression at the elbow?

Management of Ulnar Nerve Compression at the Elbow

Begin with conservative management for 3-6 months in all patients without significant motor weakness or muscle atrophy, using activity modification, splinting, and physiotherapy as first-line treatment. 1, 2

Initial Conservative Approach

Activity Modification and Positioning

• Avoid elbow flexion beyond 90° as this increases nerve compression and subluxation risk 2
• Maintain neutral forearm position when the arm is at the side to minimize nerve tension 2
• Avoid activities that place excessive load or repetitive pressure on the ulnar nerve distribution 1
• Apply proper padding (foam or gel pads) at the elbow to prevent compression, but ensure padding is not too tight to avoid creating a tourniquet effect 2

Splinting Strategy

• Splinting is the most effective conservative treatment, showing 89% symptom improvement compared to 54% with steroid injections 3
• Implement night splinting to maintain the elbow in extension and prevent prolonged flexion during sleep 1, 3
• Consider rigid immobilization over removable splints for better symptom control in more symptomatic cases 4

Physiotherapy Program

• Implement structured range of motion and strengthening exercises to maintain hand and wrist function 1, 2
• Apply local heat before exercise for additional benefit 1, 2
• Consider nerve gliding exercises, though evidence shows information on avoiding provocative positions may be more effective than exercises alone 5

Pain Management Algorithm

• Start with paracetamol (up to 4g/day) as first-line oral analgesic due to its efficacy and safety profile 1, 2
• Add topical NSAIDs for localized pain with fewer systemic side effects 1, 2
• Only if inadequate response to paracetamol, escalate to oral NSAIDs at the lowest effective dose for the shortest duration 1, 2
• Steroid/lidocaine injections may be used as a bridging option while awaiting effect of other interventions, but avoid long-term glucocorticoid use 1

Diagnostic Monitoring During Conservative Treatment

Neurophysiological Assessment

• Use quantitative ulnar nerve monitoring with train-of-four (TOF) assessment at the adductor pollicis muscle as the most reliable method for assessing nerve function 1
• Electrodiagnostic studies help differentiate between demyelinating versus axonal injury, particularly in atypical presentations 2

Imaging When Indicated

• Dynamic ultrasound is the preferred initial diagnostic modality to directly visualize ulnar nerve subluxation during elbow flexion 2
• MRI without IV contrast serves as the reference standard if ultrasound is inconclusive, showing nerve signal intensity and enlargement 2
• Ultrasound can assess nerve integrity with high accuracy (sensitivity 77-79%, specificity 94-98%) 4

Surgical Indications

Surgery is indicated when any of the following criteria are met: 2

• 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 despite conservative management

Surgical Options

• Simple decompression and decompression with transposition are equally effective, with no significant difference in clinical outcomes (RR 0.93,95% CI 0.80 to 1.08) 5
• Simple decompression has a lower wound infection rate compared to transposition (RR 0.32,95% CI 0.12 to 0.85) 5
• Submuscular transposition is preferred when prior surgery has been unsuccessful 6
• Medial epicondylectomy shows no difference compared to anterior transposition but has higher recurrence rates 6, 5
• Long-term outcomes remain stable more than 20 years after surgery, with no significant difference compared to 1-year follow-up 7

Critical Pitfalls to Avoid

• Do not use padding that is too tight, as this creates a tourniquet effect and paradoxically increases compression risk 2
• Do not proceed directly to surgery in mild to moderate cases without attempting 3-6 months of conservative management, as 89% of patients improve with splinting alone 3
• Avoid intramuscular transposition as the primary procedure due to risk of severe postoperative perineural scarring 6
• Do not rely solely on neurophysiological findings; clinical presentation should guide treatment decisions 1, 5

Monitoring and Follow-Up

• Regular clinical assessment to monitor for progression or improvement of symptoms 2
• In mild cases treated conservatively, information on movements or positions to avoid may reduce subjective discomfort more effectively than exercises alone 5
• Surgical outcomes show 91-97% clinical improvement rates, with results remaining stable long-term 5, 7