Subcutaneous Transposition of the Ulnar Nerve in the Athletic Elbow

Abstract

Ulnar neuritis at the elbow is a well described and relatively common entity among compression neuropathies of the upper extremities, especially in the athletic population. Ulnar neuritis in the throwing athlete may occur secondary to traction from valgus stress, compression from adhesions, osteophytes, flexor muscle hypertrophy, or friction because of subluxation of the nerve. Different operative techniques to treat recalcitrant cases have been described in the literature. These include decompression in situ, subcutaneous transposition, and submuscular or intramuscular transposition. In this paper we review our technique for subcutaneous transposition of the ulnar nerve for the treatment of cubital tunnel syndrome in the athlete. Key Words: Ulnar Nerve-Athlete-Elbow-Subcutaneous.In recent decades there has been a sharp rise in the number of participants in overhead throwing sports at all levels, from the recreational athlete to the full-time professional. 10 These sports not only include baseball but also softball, football, racquet sports, weight lifting, and some track and field events. The elbow can be a source of many problems in the throwing athlete. Commonly encountered injuries include: 1) ulnar collateral ligament tears or insufficiency; 2) ulnar neuritis; 3) flexor/pronator strain, tear, or tendonitis; 4) medial epicondyle apophysitis or avulsion; 5) valgus extension overload syndrome with olecranon osteophytes; 6) olecranon stress fractures; 7) osteochondritis dissecans of the capitellum; and 8) loose bodies. 5 Because of the intensity of activity, the number of repetitions, and abnormal forces occurring from valgus stress and recurrent flexion and extension activities the athlete is prone to development of ulnar nerve symptoms. The mechanical basis of injury is usually a combination of traction, friction and compression. The angular velocities and stresses reached with throwing activities are among the highest recorded for any human activity, and can place high tensile loads on the ulnar nerve. 18 For these reasons the rate of ulnar neuritis at the elbow tends to be higher than as seen in the general population. 12 ANATOMY AND BIOMECHANICSThe ulnar nerve has a unique anatomic course with many areas of potential compression, traction or irritation. The ulnar nerve proximally lies medial to the humerus, with the brachial artery in the bicipital sulcus anterior to the axis of elbow rotation. The nerve then courses posteriorly through the medial intermuscular septum at the mid to distal third of the humerus to enter the arcade of Struthers approximately 8 cm proximal to the medial epicondyle, as originally described by Spinner and Kaplan. 17 This arcade consists of an opening through the medial intermuscular septum, a deep fascial band in the arm, and fibers of the medial head of the triceps. The structure is relatively constant, present in 70% of the population, and was noted to be the most common area of recurrent symptoms after ulnar nerve transposition. 11 After passing through the arcade of Struthe...

Elbow Ulnar Neuropathy: Treatment by Anterior Transposition of the Ulnar Nerve

“…However, Macadam et al 20 found a trend towards a better clinical outcome in patients treated with anterior transposition as opposed to simple decompression, requiring prospective studies and additional randomized trials using objective measures to provide statistical support for this finding. Similarly of what has been published in the literature, 6 , 21 we obtained high rates of success and satisfaction with the subcutaneous transposition technique.…”

“…Surgery is indicated in cases of failure of conservative treatment, or in patients with severe symptoms or muscle atrophy. There are several different techniques, such as isolated decompression, 5 decompression with anterior transposition, 6 - 8 medial epicondylectomy, 9 - 11 and endoscopic decompression, 12 - 14 but there is no consensus on which technique is best. 15 …”

Tratamento da síndrome do túnel cubital pela técnica de transposição anterior subcutânea: será este método seguro e eficaz?

“…There are multiple surgical techniques currently recommended for the treatment of CTS (4)(5)(6)(7)(8)(9)(10)(11)(12)(13) , though considerable controversy remains in the literature regarding the best surgical strategy for this compressive neuropathy. Most comparative studies demonstrate similar results and no particular technique has been demonstrated to be associated with statistical differences among the results obtained (14)(15)(16)(17)(18)(19)(20)(21)(22)(23) .…”

Subcutaneous Anterior Transposition for Treatment of Cubital Tunnel Syndrome: Is This Method Safe and Effective?

“…However, there is still no consensus on the ideal surgical technique for the treatment of CTS. Several techniques have been described over the years, including simple decompression (4) , anterior transposition (subcutaneous, intramuscular, or submuscular) 5 , 6 , 7 , medial epicondylectomy 8 , 9 , 10 and in situ endoscopic decompression 11 , 12 , 13 .…”