The ulnar nerve entrapment is a common condition caused by compression of the ulnar nerve. It results in numbness and pain in the hand, particularly in the ulnar aspect of the ring and little fingers and the medial side of the wrist.
The ulnar nerve begins at the cervical spine, travels across the arm, forearm and wrist to innervate the outer hand. It is enclosed in a tunnel of connective tissue that lies under the medial epicondyle. The ulnar nerve regulates sensation to the little finger and outer side of the ring finger (ulnar side) on both the palmar and dorsal sides of the hand. It also innervates the muscle of the forearm and hand to allow the flexion of the fingers and forearm during a grip. When hit, this nerve triggers an electric shock type of reaction. The tunnel of the ulnar nerve located in the hand is called Guyon’s canal. The constriction, or entrapment, of the nerve is caused by swelling of the surrounding soft tissue, resulting in neuropathy. This can occur at the neck, collarbone and wrist but it is mostly observed at the posterior side of the elbow. In this case it is named cubital tunnel syndrome. Depending on the entrapment point, there are different regional locations of neurological symptoms.
There are various classification systems for a shoulder impingement syndrome.
Stages of subacromial impingement in athletes - Jobe’s Classification
Pure impingement with no instability
Primary instability, with capsular and labral injury with secondary impingement, which can be internal or subacromial impingement
Primary instability due to intrinsic ligament laxity with secondary impingement
Pure instability with no impingement.
Grading of impingement changes - Milgrom’s Ultrasound Classification:
Stage 1 Bursal thickness from 1.5 to 2.0 mm
Stage 2 Bursal thickness over 2.0 mm
Stage 3 Partial or full thickness tear of the rotator cuff.
Impingement lesions - Copeland Levy Classification:
This is based on the location of the impingement, either on the acromial or the bursal side.
A0 normal - smooth surface
A1 minor deterioration, haemorrhage or local inflammation
A2 marked scuffing/damage of the undersurface of the acromion and coraco-acromial ligament
A3 exposed bone areas.
B0 normal - smooth surface
B1 minor deterioration, haemorrhage, inflammation
B2 major deterioration of the cuff, partial thickness tear
B3 full thickness tear of the rotator cuff
B4 massive cuff tear.
According to the Habermeyer Classification the fractures to the proximal humerus are divided into:
Type 0 one fractured part without dislocation
Type A two-part fracture of the great tuberosity and lesser tuberosity avulsion
Type B involves the humerus “surgical” neck below the femoral head as two-part, three-part and four-part with one or both tuberosities
Type C involves the humerus anatomical neck (between the head and greater tuberosity) as two-part, three-part and four-part with one or both the greater and lesser tuberosities.
These are defined further as:
One-part fractures are non-displaced fractures or fractures with minimal displacement
Two-part fractures only involve a single segment
Three-part fractures involve two segments
Four-part fractures occur when all humeral segments are involved (see image in pathology section)
The injury severity is proportional to the increasing number of fractures.
The aetiology of ulnar nerve entrapment also called cubital tunnel syndrome or sulcus ulnaris syndrome at the elbow is unknown. Due to the restricted space and the different anatomical locations the ulnar nerve can be easily compressed. The pathology is thought to origin from of the following causes:
Degeneration of the cervical spine
Fracture and dislocation to the elbow, causing nerve compression, or cubital tunnel syndrome
Pressure on the ulnar nerve caused by long periods of leaning on the elbows direct blow to the elbow at the “funny bone”
Repetitive and prolonged bending of the elbow
Cyst in the elbow
Fracture and dislocation to the wrist causing nerve compression at the Guyon’s canal, or Guyon’s canal syndrome.
There are various risk factors thought to predispose for ulnar nerve entrapment at the elbow:
History of fracture or dislocation of the elbow
Arthritis and bone spur growth at the elbow
Swelling of the elbow joint
Physical activities or postures involving prolonged bending/leaning on the elbow
Diabetes increasing risk of neuropathy
The symptoms of ulnar nerve entrapment depend on the location where the nerve compression occurs. The symptoms usually begin gradually and increase over time. With cubital tunnel syndrome at the elbow symptoms include numbness at:
Along outer side of the ring finger
Outer half of the dorsal hand
When the nerve is severely damaged the fingers remain partially bent (ulnar claw). Hand claw is more severe when the ulnar entrapment is located at the wrist (Guyon’s canal syndrome) but the sensation on the dorsal hand remains preserved.
Other symptoms are:
Sleepy sensation of the little and ring fingers particularly when the elbow is bent
Pain radiating to the forearm
Weakening of grip strength
Failure in coordinating fine finger movement
Medical history will be discussed with the patient. During the clinical evaluation the doctor will examine:
Both hands, arms, shoulders and neck to identify the area of nerve compression based on symptoms arising following movement and palpation
Reaction to the small and ring fingers when the funny bone is tapped (Tinel’s sign)
Ulnar nerve displacement when bending the elbow
Changes in the sensation of fingers and muscle strength during grip
X-rays to examine the bone quality and rule out fractures, arthritis
Electrodiagnostic tests to monitor nerve conduction when stimuli are applied to electrodes placed on the nerve
Electromyography to test nerve activity directly of the muscle using a needle placed in the muscle
Blood tests to exclude the existence of other medical conditions (diabetes, hypothyroidism).
Early conservative treatment is key for reducing the symptoms of ulnar nerve entrapment. If diabetes, injury and arthritis are present they are given medical priority.
Specific measures for conservative treatment are:
Immobilisation of the arm with a splint (especially at night) is the first remedy to reduce symptoms
Application of cool pads and administration of NSAIDs in case of concomitant swelling and inflammation
Local steroid injections around the ulnar nerve with more severe symptoms
Physical therapy such as ‘nerve gliding’
Exercise directed to the ulnar nerve by stretching and strengthening elbow and wrist
In case of prolonged or worsening of symptoms despite conservative treatment, surgery is necessary. This aims to release the entrapped ulnar nerve.
Two surgical approaches are available:
1. Cubital tunnel release or nerve decompression
This procedure is used in mild forms of ulnar nerve entrapment at the elbow. Following an incision along the inner side of the elbow, the ligamentous roof of the cubital tunnel is severed and separated. The cut ligament will repair spontaneously and provide more room for the ulnar nerve and release the symptoms.
2. Anterior transposition of the ulnar nerve
With an incision at the elbow the ulnar nerve is transferred from behind the elbow to the anterior area of the elbow. The nerve is moved under the skin and fat, either under or above the muscle. These procedures are named subcutaneous transposition or submuscular transposition of the ulnar nerve, respectively. The post-operative recovery takes longer with this approach.
After surgery the initial care includes:
Elbow immobilisation for a few weeks with a bandage or splint to prevent joint bending
Treatment with analgesics and NSAIDs
Ice pads to reduce inflammation and swelling
Elbow rehabilitation soon after surgery possibly with the support of a brace.
Exercises guided by a physiotherapist will assist in gaining strength of the operated elbow. Minor symptoms may persist for a few months after surgery. Although strength in grasping activity may return after 4 weeks post-surgery full recovery can take up to 1 year.
The causality of manual work and the ulnar nerve entrapment syndrome remains unclear, however a number of measures, including occupational health and safety rules at workplace, should be implemented to reduce the risk of the condition. These recommendations include:
Ergonometric education for correct posture during manual activities to avoid longer periods in which the elbow is kept bent
Wear splint at night if symptoms arise
Regular stretching exercises
Frequent rests when involved in heavy industrial manual work