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Boomeritis: The Elbow
Biceps RupturesTennis Elbow
Triceps RupturesCubital Tunnel Syndrome
James T. Mazzara, M.D.Connecticut Center for Orthopedic Surgery, LLC
Manchester Memorial Hospital / Hartford HospitalManchester / Wethersfield
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Patient Education Disclaimer
This presentation provides information to educate consumers on varioushealth topics. Its is NOT intended to provide instruction on medicaldiagnosis or treatment. The information contained in this presentation is compiled from a variety ofsources. It may not be complete or timely. It does not cover alldiseases, physical conditions, ailments or treatments. You should NOTrely on this information to determine a diagnosis or course oftreatment. The information should NOT be used in place of anindividual consultation, examination, visit or call with your physician or otherqualified health care provider. You should never disregard the advice of yourphysician or other qualified health care provider because of any informationyou read in this handout or on any websites you visit as a result of thispresentation. If you have any health care questions, please consult your physician or otherqualified health care provider promptly. Always consult your physician orother qualified health provider before you begin any new treatment, diet orfitness program.
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My Background
• Manchester Orthopedic Surgery and Sports Medicine since 1991
• Board Certified• Recertified Adult Reconstructive
Orthopedic Surgery, 2003• Hartford Hospital• Manchester Memorial Hospital• Surgery of the Upper Extremity and Knee
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A second of shameless self promotion
• Only one ECHN orthopedic surgeon made the Top Docs List
• Can you guess who?
April, 2007
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A Physician’s Role
• A significant part of our role as physicians is to educate our patients about why they hurt and how we can help them get better.
• I hope this presentation helps someone get the relief they need from a painful shoulder problem.
• More information can be obtained on the internet from my website www.OrthoOnTheWeb.com
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What is Boomeritis?• Describes wear and tear changes, vulnerabilities
and injuries that most of us have or will develop with our musculoskeletal system
• Nicholas DiNubile, MD
• Baby boomers have a desire to remain active despite age-related changes
• Boomers are born between 1946 and 1964
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Elbow Tendinopathies
• This presentation reviews many of the common elbow tendon problems that I frequently treat in my practice.
• The topics reviewed include:– Biceps tendon ruptures at the elbow– Tennis elbow and Golfer’s elbow– Triceps tendon ruptures– Cubital tunnel syndrome
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Distal Biceps Tendon Ruptures
• Predominantly male – 3% of all biceps
ruptures• Average age 40-50
years (21-70 years)• Usually involved in
heavy labor or activity• Fails by complete
rupture from radial tuberosity
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Distal Biceps Tendon Ruptures• Preexisting
degenerative changes in tendon
• Seen in younger weight-lifters in association with anabolic steroid use
• Requires early repair– Tendon often retracts
making repair difficulty or impossible
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Distal Biceps Tendon Ruptures• Sudden overload in
midflexion• Ecchymosis in antecubital
fossa several days after injury
• Exam– Pain, weak supination,
maybe flexion– Tendon is not palpable
• MRI can be diagnostic
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History • Sudden unanticipated
overload to the elbow in midflexion
• Sudden forceful hyperextension of the elbow
• Painful pop, snap or tearing sensation in the elbow or upper forearm
• Acute pain may subside in hours
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History
• Continued activity may be difficult but possible• Symptoms may be minimal after the initial
rupture• Ache may persist for weeks
– Anterior elbow or upper or mid forearm aching, pain or weakness with resisted flexion, supination or use of the forearm
• As swelling diminishes, asymmetric biceps contour becomes apparent
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Physical Examination
• Strength testing for bilateral elbow flexion and supination strength– Elbow flexion
weakness in notable in early ruptures
– Forearm supination weakness is always present
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Physical Examination• Pain and weakness on resisted
supination– Average 40% loss
• Mild weakness on resisted flexion
• Loss of grip strength is common• Ecchymosis may or may not be
present• Pain and tenderness on direct
palpation of the biceps tendon in the antecubital fossa
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Physical Examination• With elbow flexion the
tendon retracts proximally and may be visible
• Tendon may not be palpable
• Tendon may not be retracted if the bicipital aponeurosis is intact
• Range of motion is normal with– May have pain at the
extremes of motion
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Diagnostic Studies
• X-rays– Subtle hypertrophic
changes is the bicipital tuberosity
• MRI– Helpful in diagnosing
partial ruptures when soft tissue attachments prevent tendon retraction
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Biceps Imaging
• MRI using FABS Tech:• Flexed, Abducted,
Supinated, Prone• Differentiate from
bicipitoradial bursitis
AJR 2004; 182:944-946
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MRI with FABS Protocol
NormalPartial Tear
bicepsAJR 2004; 182:944-946
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MRI with FABS Protocol
Partial tear biceps Complete tear bicepsAJR 2004; 182:944-946
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Distal Biceps Tendon Ruptures
• Nonoperative treatment may be accepted in sedentary patients
• 30-36% Loss of flexion strength• 40-55% Loss of supination strength• No loss of motion• Persistent weakness and fatigue with repetitive
activities• Active patients
– Early surgical repair yields excellent results
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Single Incision Repair
This is a larger incision than normal and is not the approach that I use for biceps tendon repair.
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Two Incision Repair
I always use the 2 incision approach. These incisions heal well and are usually inconspicuous. These incisions are larger than average in this particular patient.
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Acute Biceps Tendon Repair
• 2 incision technique is preferred
• More rapid recovery of flexion strength
• Fewer complications• Repair becomes more
difficult after 2-3 weeks
(J Hand Surg, 29(3), 2003)
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Acute Biceps Tendon Repair
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Acute Biceps Tendon Repair
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Acute Biceps Tendon Repair
The bone tunnel in the radius. The distal biceps
repaired into that tunnel.
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Acute Biceps Repair
• Single incision with endobotton
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Acute Biceps Repair
• Pull out strength
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Acute Biceps Repair• Single incision with anchors
– Good clinical results– Associated with
musculocutaneous and radial nerve injuries (J Hand Surg, 29(3), 2003)
• 44% in 1-incision group• 10% in 2 incision group• “Mostly” minor and transient
paresthesias
– Not as strong as 2-incision bone tunnel repair (Am J Sports Med 30(3), 2002)
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Acute Biceps Tendon Repair• Postoperatively
– Splint @ 90 degrees for 1 week– Passive elbow flexion and extension to -30
degrees 5 times per day– 3 weeks: Allow gentle full extension– 4 weeks: Allow flexion / extension against
gravity– 6 weeks: Flexion-strengthening 1 kg wts.– 3 months: Activity as tolerated– 6 months: Full activity without restrictions
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Results of Acute Repairs
• 100% restoration in flexion and supination strength
• Loss of flexion / extension is uncommon• Slight loss of supination is common• Rerupture is uncommon
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Delayed Biceps Tendon Reconstruction
• Retracted tendon may not be of adequate length
• Tendon tract to radial tuberosity may be obliterated
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Delayed Biceps Tendon Reconstruction
• Delay of more than 4 weeks– More extensive
dissection required– Achilles tendon
allograft may be required
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Delayed Biceps Tendon Reconstruction
Achilles tendon allograft may be used to extend a contracted chronic biceps rupture.
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Delayed Biceps Tendon Reconstruction
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Delayed Biceps Tendon Reconstruction
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Delayed Biceps Reconstruction
• Tendon extenders may be required– Achilles allograft (Morrey, Mayo Clinic)
– Autologous semitendinosis, Fascia Lata• Consider reinsertion to brachialis muscle
for patients not requiring normal supination strength
• Patients requiring normal supination strength should undergo a full reconstruction
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Delayed Biceps Reconstruction
• Postoperatively– Protected for 3 weeks– 3-6 weeks: Passive assisted motion (-30-150)– 6 weeks: Full extension is allowed– 6-12 weeks: Active motion for ADLs– 3-6 months: Activity as tolerated progresses
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Results of Delayed Repairs
• 13% Loss of strength• 15% Loss of endurance
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Partial Distal Biceps Tendon Ruptures
• More commonly recognized– Females as well as
males• Pain and aching in
anterior elbow with stressful tasks
• Locally tender• Confirmed on MRI
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Differential Diagnosis
• Bicipitoradial bursitis
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Partial Distal Biceps Tendon Ruptures
• Repair or reimplantation of the torn tendon alonedoes not reliably relieve pain
• Complete removal of the remaining fibers and reattachment is the treatment of choice
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Complications
• Complication rate doubles if more than 21 days occurs before surgery
• Radial nerve injury – 5% – More common in the single anterior incision
technique
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Complications• Ectopic bone
– Results from exposing the lateral periosteum of the ulna
– Minimized with the 2-incision muscle splitting approach
– May require resection 8-9 months after initial surgery
• After ectopic bone resection– Irradiation (700cGy)
reduces recurrences
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Lateral / Medial Epicondylitis
• Usually 30-40’s (Range 12-80 years)• Males = Females• 75% dominant arm
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Etiology
• Overuse and overexertion– Intensity and duration of arm use– Inadequate or compromised physical
condition• Sudden trauma, extreme effort or activity
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Etiology
• Constitutional Factors – Mesenchymal syndrome– Bilateral rotator cuff
tendinopathies– Medial and lateral elbow
tendinosis– Carpal tunnel syndrome– Triggering tenosynovitis– De Quervain’s tenosynovitis
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Pathophysiology
• Starts as a microtear in the ECRB
• Repetitive microtearing results in mucoid degeneration and reactive granulation in the origins of the ECRB and/or EDC
• Large numbers of nerve endings contained within
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Pathophysiology• Tendon appears grayish,
friable, edematous• Fibers appear fibrillated• 35% reveal gross tendon
rupture and entry into the joint
• Significant vascular and fibrous proliferation
• Lack of acute or chronic inflammatory components
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History
• Pain at the lateral or medial epicondyle
• Radiates into the forearm
• Sense of finger weakness with grasping
• History of overuse of repetitive activity
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Examination
• Tenderness at the conjoined tendon origin at the ECRB
• Max tenderness is 2-5mm distal and anterior to the midpoint of the lateral epicondyle
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Examination• Pain with grasping or pinching with wrist in
extension• Resisted wrist and finger extension with elbow in
full extension• Resisted long finger extension• Wrist extensor weakness may be due to pain• Elbow ROM and hand sensation are unaffected
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Studies• X-rays usually
normal– 25% may have
calcification in the soft tissue around the lateral epicondyle
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Associated Problems
• Ulnar Nerve Neuropraxia –Associated with medial epicondylitis
• Carpal Tunnel Syndrome – 10%
• Radial Tunnel Syndrome – 5%
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Differential Diagnosis
• Cervical radiculopathy• Intra-articular elbow disease (arthritis)• Joint laxity (ligament tears and instability)
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Nonsurgical Treatment
• Avoidance of aggravating activities• Ice (Local analgesia and vasoconstriction)
• NSAIDs for 2-3 weeks• Wrist immobilizer places ECRB in resting
position
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Nonsurgical Treatment
• Corticosteroid injection– Marcaine (0.5%) 2 cc and 40mg Depo-medrol– Injected into ECRB tendon with “peppering”
technique– One injection preferred– 2nd and 3rd injections just buy time – Ease of flow of the injection indicates
significant loose tendinosis tissue
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Nonsurgical Treatment
• Physical therapy with iontophoresis– 4-6 sessions in the initial 2-3 weeks of
treatment
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Nonsurgical Treatment
• Resumption of sport or work with altered technique or equipment
• Counter force bracing– Inhibits full muscular
expansion and decreases force on the injured tissue
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Surgical Treatment
• Persistent debilitating pain despite proper treatment for 6 months
• 3-8% may require surgery• 35% may reveal a discrete tear in the
extensor mechanism
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Surgical Treatment
• Damaged tissue is easily noted in the extensor brevis origin
• Sharply debrided, epicondyle is decorticated and the tendon is closed
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Lateral epicondylar debridement
The damaged region of the tendon is exposed over the lateral elbow
Here that damaged region has been excised
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Post op Rehabilitation
• Start activity as tolerated after 48 hours• Early strength training for first 3 weeks• Gradual strengthening started @ 3 weeks
with counterforce brace• Counter force bracing for ADL’s for 2-3
months then for sports and occupational activity thereafter
• Full unrestricted activity @ ~ 6 months
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Medial Epicondylitis
• 1/4 as common as lateral epicondylitis • Due to acute or chronic loads applied to
the medial flexor pronator mass• 30-50% also have ulnar neuropathy
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Medial Epicondylitis
• Pain along medial elbow
• Worsened with resisted forearm pronation or wrist flexion
• May report ulnar nerve symptoms
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Nonsurgical Treatment
• Rest, avoidance of offending activity• NSAIDs, Iontophoresis, corticosteroid
injection• Guided rehab, technique and equipment
modification
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Surgical treatment
• Indicated when pain persists despite proper treatment for 6 months
• Requires debridement of pathologic tissue from the undersurface of the flexor pronator mass
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Triceps Tendinopathy• Tears are rare
– Male : female 3:2– Mean age 33 years– Spontaneous or traumatic
• Predisposing factors– Olecranon bursitis– Diabetes– Steroids– Renal disorders– Others
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Diagnosis• Fall on outstretched
hand• Pain, sometimes a
palpable defect• Pain and weakness on
resistance testing• May still be able to
extend elbow• Unable to extend elbow
overhead against gravity
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MRI
• Used to differential partial from complete tears
Partial tear distal posterior triceps
Complete tear
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Treatment
• Partial tears– May be treated
nonoperatively• Complete tears
– Should be treated surgically to avoid significant functional impairment
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Degenerative Tear
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Degenerative Tear
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Degenerative Tear
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Degenerative Tear
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Degenerative Tear
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Gout
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Cubital Tunnel Syndrome
• Ulnar nerve compression at the elbow
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Cubital Tunnel Syndrome• Sources of
compression– fascial bands– exuberant synovium– tumors – ganglions– anconeus
epitrochlearis– bone spurs
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Cubital Tunnel Syndrome
• Symptoms– Numbness along the
little finger and ulnar ½ring finger
– Weakness of grip & torque
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Cubital Tunnel Syndrome
• Pain medial elbow
• Tinel’s sign @ cubital tunnel
• Symptoms worse with elbow flexion
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Cubital Tunnel Syndrome
• Pain and numbness on dorsal and volarulnar hand
• Weakness ring& little finger flexors
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Cubital Tunnel Syndrome
• Froment’s sign
– Weak intrinsics
– FPL compensates for paralyzed thumb adductor
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Cubital Tunnel Syndrome
• Intrinsic muscle weakness
– Unable to adduct little and ring fingers
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Cubital Tunnel Syndrome
• Jeanne’s sign
– Compensatory hyperextension of the thumb MP joint
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Cubital Tunnel Syndrome
• Thumb adductor weakness
• Severe atrophy
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Cubital Tunnel Syndrome
• Pollock’s test
– Weakness of the ulnar 2 FDP
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Cubital Tunnel Syndrome
• Nonoperative treatment– Activity
modification– NSAIDs– Night-time
extension splints
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Cubital Tunnel Syndrome
• Surgical options– Simple decompression– Medial epicondylectomy– Submuscular transposition– Subcutaneous transposition
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Cubital Tunnel Syndrome
• Medial Epicondylectomy
Ulnar nerve compression after release of Osborne’s
ligament
Hand
Medial epicondyle
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Cubital Tunnel Syndrome
• Medial EpicondylectomyMedial
epicondyle removed
Flexor-pronator
attachment released
Relaxed ulnar nerve
Elbow @ 90 degrees flexion
Hand
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Cubital Tunnel Syndrome
• Medial EpicondylectomyFlexor-
pronator mass
reattached to medial
epicondyle
Elbow flexed 90 degrees
Hand
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Cubital Tunnel Syndrome
• Submuscular Transposition
Hand
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Cubital Tunnel Syndrome
• 88% Good-excellent results• 8% failure or recurrence• Compared to 25 – 40% other techniques
JBJS July, 2003
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Cubital Tunnel Syndrome
• Submuscular Transposition
Preserved sensory nerves
Decompressed ulnar nerve
Hand
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Cubital Tunnel Syndrome
• Submuscular TranspositionPreserved sensory nerves
Decompressed ulnar nerve
Hand
A
B
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Cubital Tunnel Syndrome
• Submuscular Transposition
Preserved sensory nerves
Transposed ulnar nerve
A
B
Hand
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Cubital Tunnel Syndrome
• Subcutaneous Transposition
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Cubital Tunnel Syndrome
• Surgical results– 80-90% good results– Functional recovery 6 months
• Moderate – severe compression– Recurrence rates or poor results in 25-30%
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Thank You