Cubital tunnel syndrome - a review and management guidelines.

Cubital tunnel syndrome (CuTS) is the second most common peripheral nerve compression syndrome. In German-speaking countries, cubital tunnel syndrome is often referred to as sulcus ulnaris syndrome (retrocondylar groove syndrome). This term is anatomically incorrect, since the site of compression comprises not only the retrocondylar groove but the cubital tunnel, which consists of 3 parts: the retrocondylar groove, partially covered by the cubital tunnel retinaculum (lig. arcuatum or Osborne ligament), the humeroulnar arcade, and the deep flexor/pronator aponeurosis. According to Sunderland , cubital tunnel syndrome can be differentiated into a primary form (including anterior subluxation of the ulnar nerve and compression secondary to the presence of an anconeus epitrochlearis muscle) and a secondary form caused by deformation or other processes of the elbow joint. The clinical diagnosis is usually confirmed by nerve conduction studies. Recently, the use of ultrasound and MRI have become useful diagnostic tools by showing morphological changes in the nerve within the cubital tunnel. A differential diagnosis is essential in atypical cases, and should include such conditions as C8 radiculopathy, Pancoast tumor, and pressure palsy. Conservative treatment (avoiding exposure to external noxes and applying of night splints) may be considered in the early stages of cubital tunnel syndrome. When nonoperative treatment fails, or in patients who present with more advanced clinical findings, such as motor weakness, muscle atrophy, or fixed sensory changes, surgical treatment should be recommended. According to actual randomized controlled studies, the treatment of choice in primary cubital tunnel syndrome is simple in situ decompression, which has to be extended at least 5-6 cm distal to the medial epicondyle and can be performed by an open or endoscopic technique, both under local anesthesia. Simple decompression is also the therapy of choice in uncomplicated ulnar luxation and in most post-traumatic cases and other secondary forms. When the luxation is painful, or when the ulnar nerve actually "snaps" back and forth over the medial epicondyle of the humerus, subcutaneous anterior transposition may be performed. In cases of severe bone or tissue changes of the elbow (especially with cubitus valgus), the anterior transposition of the ulnar nerve may again be indicated. In cases of scarring, submuscular transposition may be preferred as it provides a healthy vascular bed for the nerve as well as soft tissue protection. Risks resulting from transposition include compromise in blood flow to the nerve as well as kinking of the nerve caused by insufficient proximal or distal mobilization. In these cases, revision surgery is necessary. Epicondylectomy is not common, at least in Germany. Recurrence of compression on the ulnar nerve at the elbow may occur. This review is based on the German Guideline "Diagnose und Therapie des Kubitaltunnelsyndroms" ( www.leitlinien.net ).

[Diagnosis and therapy of cubital tunnel syndrome--state of the art]. / Aktueller Stand der Diagnostik und Therapie des Kubitaltunnelsyndroms.

The cubital tunnel syndrome is one of the most widespread compression syndromes of a peripheral nerve. In German-speaking countries it is known as the sulcus ulnaris syndrome (retrocondylar groove syndrome), which is anatomically incorrect. The cubital tunnel consists of the retrocondylar groove, the cubital tunnel retinaculum (Lig. arcuatum or Osborne band), the humeroulnar arcade and the deep flexor/pronator aponeurosis. According to Sunderland it can be divided into a primary form (including the ulnar luxation and the epitrocheoanconaeus muscle) and a secondary form caused by deformation or other processes of the elbow joint. The diagnosis has to be confirmed by a thorough clinical examination and nerve conduction studies. Neurosonography and MRI are becoming more and more important with improving resolution and enable the direct identification of morphological changes. Differential diagnosis is essential in atypical cases, especially C8 syndrome and pressure palsy. Double crush (double compression syndrome) may occur. Operative treatment is more effective than conservative treatment, which consists primarily of the prevention of exposure to external noxes. According to actual randomised controlled studies the therapy of choice of the primary form in most cases is the simple in situ decompression of the ulnar nerve in the cubital tunnel. This has to be extended at least up to 5-6 cm distally of the medial epicondyle and can be performed in the open or endoscopic technique, both under local anesthesia. Simple decompression is also the therapy of choice in uncomplicated ulnar luxation and in most post-traumatic cases and other secondary forms. In cases of severe bony or tissue changes of the elbow (especially cubitus valgus) the volar transposition of the ulnar nerve may be indicated. This can be performed in a subcutaneous or submuscular technique. Risks of transposition are impairment of perfusion and, above all, kinking caused by insufficient proximal or distal mobilisation of the nerve has to be avoided. In these cases revision surgery is necessary. The epicondylectomy is not common in our country. Recurrences may occur.

[Diagnosis and therapy of carpal tunnel syndrome--guideline of the German Societies of Handsurgery, Neurosurgery, Neurology, Orthopaedics, Clinical Neurophysiology and Functional Imaging, Plastic, Reconstructive and Aesthetic Surgery, and Surgery for Traumatology]. / Diagnostik und Therapie des Karpaltunnelsyndroms--Leitlinie der Deutschen Gesellschaften für Handchirurgie, Neurochirurgie, Neurologie, Orthopädie unter Mitbeteiligung der Gesellschaften für Unfallchirurgie, Klinische Neurophysiologie und Funktionelle Bildgebung sowie Plastiche, Rekonstruktive und Asthetische Chirurgie.

Evidence-based supradisciplinary guideline that deals with the epidemiology, pathogenesis, symptoms, clinical and electrophysiological diagnosis, supplementary imaging investigations, differential diagnosis, conservative and surgical treatments, prognosis and course along with complications and revision surgery. The recommendations on investigation and treatment are based on a comprehensive literature search with critical evaluation and two consensus methods (expert group and Delphi technique) within the participating specialist societies. Besides this long version, a short version and a patient version can be viewed through the AWMF platform. The development of the guideline and the methodological foundations are documented in a method report. MAIN STATEMENTS: Apart from an accurate history and clinical neurological examination (including clinical tests), electrophysiological investigations (distal motor latency and sensory neurography) are particularly important. Radiography, MRI, high-resolution ultrasonography can be regarded as optional supplementary investigations. Among conservative treatment methods, treatment with a nocturnal splint and local infiltration of a corticosteroid preparation are effective. Oral steroids, splinting and ultrasound showed only short-term benefit. Surgical treatment is clearly superior to all other methods. Open and endoscopic procedures (when the endoscopic surgeon has sufficient experience) are equivalent. A routine epineurotomy and interfascicular neurolysis cannot be recommended. Early functional treatment postoperatively is important.

[Development and implementation of the guideline "Diagnosis of and Therapy for Carpal Tunnel Syndrome"]. / Zur Entstehung und Implementierung der Leitlinie "Diagnostik und Therapie des Karpaltunnelsyndroms".

In the period from July 2005 through November 2006, the evidence-based guidelines were developed by a steering committee consisting of three members from each of the societies involved (German Society for Hand Surgery, German Society of Neurosurgery, German Society of Neurology and German Society of Orthopaedics), coordinated by one member each from the DGH and the DGNC, under the methodological guidance of Prof. Selbmann of the German Association of the Scientific Medical Societies (AWMF). Six all-day working sessions and one proceeding to build a consensus (modified Delphi process) were held within the seven specialised societies involved. Degrees of recommendation, based upon the degree of evidence of the underlying literature studies, modified, if necessary, by the expert opinion of the steering committee's members and the external evaluators of the Delphi round, were established for the most important diagnostic and therapeutic methods. In addition to the long version, a short version and a patient information bulletin were prepared as well, and the ways, means, and considerations surrounding their realisation and implementation, and other potential developments were also pursued.

[Dysplasia epiphysealis hemimelica of the carpus]. / Dysplasia epiphysealis hemimelica der Handwurzel.

Dysplasia epiphysealis hemimelica is a rare benign osteochondromatous disorder which develops in childhood mostly on the epiphyses of the bones in the lower extremities. While the tarsal bones are often involved, it is very rare in the carpus. Four patients are reported. Two were treated operatively with good results. In consequence of the experience of Lamesch, an excision was not performed in the other two cases. The patients were followed up for many years with the findings of some reduction in size and figure. Therefore, it is recommended not to operate this special tumour as long as no functional disturbances will occur.

[The value of the Kapandji-Sauvé procedure with considering clinical results and measurement of bone density. A clinical study]. / Die Wertigkeit der Operation nach Kapandji unter Berücksichtigung von klinischer Nachuntersuchung und postoperativer Knochendichtemessung - Eine klinische Studie -

Between 1989 and 1995, 33 patients were treated with a Kapandji-Sauvé procedure for malunited fracture of the distal radius and instabilities of the distal radioulnar joint. Thirty patients were followed up with a mean follow-up time of 91 months. Fourteen patients underwent a measurement of bone density of the distal forearm. Twenty-eight patients showed good ossification of the distal radioulnar arthrodesis. Forearm rotation improved by 17.3 %. Mean grip strength was 72 % of that of the contralateral hand. Evaluation by the Cooney score resulted in 10 % very good, in 65 % good, 22 % fair and in 3 % poor results. The measurement of bone density of the distal radius showed an increase of rotation and flexure firmness. The cortical density remained constant. In the subcortical bone of the distal radius, we found a decrease of the trabecular density in the radial part.

[Vascular pedicled transposition of the pisiform bone for treatment of lunate malacia]. / Die gefässgestielte Transposition des Os pisiforme zur Behandlung der Lunatummalazie.

In a prospective study we investigated the results of 18 patients with Kienböck's disease stage II as defined by Decoulx, treated with transposition of the pedicled pisiform. In eight cases of minus variance of the ulna, a radius shortening osteotomy was performed. There was an average follow-up of 30 months, X-ray investigations were done every six months after operation. 17 patients had less pain, 14 patients showed an improved range of motion of 30 degrees. Magnetic resonance imaging proved vitalizing of the pisiforme in 16 cases.

[Restoration of grip function in both hands after frostbite of all fingers and toes. A case report]. / Wiederherstellung einer Greiffunktion beider Hände nach Erfrierung sämtlicher Finger und Zehen. Ein Fallbericht.

Evaluation, therapeutical possibilities, and surgical planning for the restoration of bilateral grip function are described, based upon a 34-year-old engineer presenting after severe bilateral frostbite of the hands and feet with loss of all fingers and toes. Finally, the given level of amputation and remaining components of the hand together with distraction-lengthening of both thumbs permitted restoring a basic grip on both sides in combination with bone and soft tissue procedures.