Orthopaedic Blog

CUBITAL TUNNEL SYNDROME

Ulnar nerve entrapment occurs when the ulnar nerve in the arm becomes compressed or irritated.

Anatomy
The ulnar nerve is one of the three main nerves in the arm. It travels from the neck down into the hand.

At the elbow the ulnar nerve travels through a tunnel of tissue (the cubital tunnel) that runs under the inside of the elbow, the medial epicondyle.

The spot where the nerve runs under the medial condyle is commonly referred to as the “funny bone”.

At the funny bone the nerve is close to the skin and bumping it causes a shock like feeling.

Beyond the elbow the ulnar nerve travels under muscles on the inside of the forearm and into the hand on the side of the palm with the little finger.

As the nerve enters the hand it travels through another tunnel (Guyon’s Canal).

The ulnar nerve gives feeling to the little finger and half of the ring finger.

It also controls most of the of the little muscles in the hand that help with fine movements and some of the bigger muscles in the forearm that help make a strong grip.

Common Places for Compression

The ulnar nerve can be constricted in several places along the way such as beneath the clavicle or at the wrist.

The most common place for compression of the nerve is behind the inside part of the elbow.

Ulnar nerve compression at the elbow is called CUBITAL TUNNEL SYNDROME.

Cause
In many cases of CTS the exact cause is unknown.

The ulnar nerve is especially vulnerable to compression at the elbow because it must travel through a narrow tunnel with little soft tissue to protect it.

COMMON CAUSES OF COMPRESSION
There are several things that can cause pressure on the nerve at the elbow.
1. When the elbow is bent, the ulnar nerve must stretch around the bony ridge of the medial condyle. This stretching can irritate the nerve, keeping the elbow bent for long periods or repeatedly bending the elbow can cause painful symptoms.
2. In some people the nerve slides out from behind the medial condyle when the elbow is bent. Over time this sliding back and forth may irritate the nerve.
3. Leaning on the elbow for long periods of time can put pressure on the nerve.
4. Fluid buildup can cause swelling that may compress the nerve.
5. A direct blow to the inside of the elbow can cause pain, an electric shock sensation and numbness in little and ring finger. This is commonly called “hitting your funny bone.”

Risk Factors
Some factors put you more at risk for developing CTS include:
• Prior fracture or dislocation of the elbow
• Bone spurs/arthritis of the elbow
• Swelling of the elbow joint
• Cysts near the elbow joint
• Repetitive or prolonged activities that require the elbow to be bent or flexed.

Symptoms

Sleeping with the elbow bent can aggravate symptoms of ulnar nerve compression and cause a person to wake at night with a sensation that their fingers are asleep.

CTS can cause an aching pain on the inside of the elbow, most of the symptoms, however, occur in the hand.
1. Numbness and tingling in the ring finger and little finger are common symptoms of ulnar nerve entrapment, often these symptoms come and go. They more often happen when the elbow is bent, such as when driving or holding the phone.
2. Some people wake up at night because they feel numbness in the fingers.
3. The feeling of the ring and little finger ‘falling asleep’, especially when the elbow is bent.
4. In some cases it may be harder to move the fingers in and out or to manipulate objects.
5. Weakening of the grip and difficulty with finger co-ordination (such as typing or playing an instrument) may occur. These symptoms are usually seen in more severe cases of nerve compression.
6. If the nerve compression is very severe or has been compressed for a long time, muscle wasting in the hand can occur.

Medical History and Examination
Past Medical History – any fractures, arthritis, spurs in the elbow?
Enquire about work activities and medications.

Examination of the arm and hand to determine which nerve is compressed and where the compression is.

Findings on Physical examination may include:
• Tinel’s sign – A shock sensation of the little and ring finger when tapping over the nerve at the funny bone.
• The ulnar nerve may slide out of normal position when the elbow is bent
• Movement of the elbow may cause symptoms
• In severe cases, feeling and strength in the hand and fingers are affected

Investigation
• X-Rays – Most causes of compression of the ulnar nerve cannot be seen on an x-ray. However, X-Rays of the elbow may show bone spurs, arthritis or other reasons of nerve compression.
• Nerve conduction studies – Help to determine how well the nerve is functioning and help to identify where it is being compressed. Several places along the nerve will be tested and the area where there is delayed conduction is likely to be the place where the nerve is compressed. Nerve conduction studies can also determine whether the compression is also causing muscle damage. Muscle damage is a sign of more severe nerve compression.

Management
In most cases symptoms can be managed with non-surgical treatments like changes in activities and bracing. If non-surgical methods do not improve symptoms or if the compression is causing muscle weakness or damage in the hand, surgery may be necessary

Non-Surgical Management
If symptoms interfere with normal activities or last more than few weeks see a doctor.

There are a few things patient can do at home to relieve symptoms.

• Avoid activities that require you to keep the arm bent for long periods of time.
• If you use a computer, make sure your chair is not too low. Do not rest the elbow on the arm rest.
• Avoid leaning on your elbow or putting pressure on the inside of the arm e.g., do not drive with the arm resting on the open window
• Keep the elbow straight at night when sleeping. This can be done by wrapping a towel around the elbow or wearing an elbow pad backwards.

Non-surgical treatment
• NSAIDS can reduce the swelling around the nerve
• STEROIDS such as cortisone are also effective as anti-inflammatories. Steroid injections are generally not used because there is a risk of damage to the nerve.
• BRACING OR SPLINTING padded brace or splint to wear at night to keep the elbow in a straight position
• NERVE SLIDING EXERCISES may improve symptoms, also prevents stiffness in the arm and wrist

Surgical Treatment
Is indicated if:
1. Non-Surgical methods have not improved the condition.
2. The ulnar nerve is very compressed.
3. Nerve compression has caused muscle weakness or damage.

SURGICAL PROCEDURES
There are different options, often done on an OPD basis.
1. CUBITAL TUNNEL RELEASE in this operation the ligament roof of the cubital tunnel is cut and divided. This increases the size of the cubital tunnel and decreases the pressure on the nerve. After the procedure the ligament begins to heal, and new tissue grows across the division. The new growth heals the ligament and allows more space for the ulnar nerve to slide through. The Cubital tunnel release tends to work best when the nerve compression is mild to moderate, and the nerve does not slide out of the bony ridge of the medial epicondyle when the elbow is bent.
2. ULNAR NERVE ANTERIOR TRANSPOSITION in many cases the nerve is moved from its place behind the medial epicondyle to a new place in front of it. This prevents it from getting caught on the bony ridge and stretching when the elbow is bent. The nerve can be moved to lie under the skin and fat but on top of the muscle (subcutaneous transposition) or within the muscle (intermuscular transposition) or under the muscle (submuscular transposition)
3. MEDIAL EPICONDYLECTOMY another option to release the nerve is to remove part of the medial epicondyle. Like ulnar nerve transposition this technique also prevents the nerve from getting caught on the bony ridge and stretching when the elbow is bent.

SURGICAL RECOVERY
Depending on the type of surgery a splint may be needed after the operation. A submuscular transposition usually requires a longer time (3-6 weeks) in a splint.
Physiotherapy to help regional strength and movement.

SURGICAL OUTCOME
The results of surgery are generally good. Each method of surgery has a similar success rate for routine cases of nerve compression. If the nerve is very badly compressed or there is muscle wasting, the nerve may not be able to return to normal and some symptoms may remain even after surgery. Nerves recover slowly and some may take a long time to know how well the nerve will do after surgery.

Carpal Tunnel Syndrome

Carpal tunnel syndrome is caused by pressure on the median nerve as it travels through the carpal tunnel.

Symptoms of Carpal Tunnel Syndrome

Symptoms of carpal tunnel syndrome may include:

Numbness, tingling, burning, and pain in the thumb and index, middle, and ring fingers.
Occasional shock-like sensations that radiate to the thumb and index, middle, and ring fingers.
Pain or tingling that may travel up the forearm toward the shoulder.

If left unattended, it can result in damage to the median nerve and thus cause symptoms such as

Weakness and clumsiness in the hand, resulting in difficulty performing fine motor movements.
Dropping thing, resulting from weakness, numbness, or a loss of proprioception

Symptoms of carpal tunnel syndrome generally begin gradually and gets progressively worse over time. With patients experiencing symptoms that come and go at first. However, as the condition worsens, symptoms may occur more frequently or be continuous.

Night-time symptoms being very common, due to people bending their wrists during sleep, awakening the patient. During the day, repetitive movements or movements requiring the wrist to bend will aggravate the symptoms. Examples include using a mouse, driving, reading a book.

Many patients find that moving or shaking their hands helps relieve their symptoms.

Anatomy

Watch the animated video.

Carpal Tunnel Syndrome Animation

What are the causes of carpal tunnel syndrome?

Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the median nerve.

Contributing factors include

Repetitive hand movement, repeating the same hand and wrist motions or activities over a prolonged period of time may aggravate the tendons in the wrist, causing swelling that puts pressure on the nerve. Mechanical problems in the wrist joint, repeated use of vibrating hand tools
Trauma to the wrist that caused swelling, such as sprain or fracture.
Hormonal imbalance – an overactive pituitary gland or an underactive thyroid gland, fluid retention during pregnancy or menopause
Rheumatoid arthritis
Heredity, there may be anatomic differences resulting in a narrowed carpal tunnel.
Development of a cyst or tumour in the canal.

Physical Exam

Pressing down along the median nerve on the inside of the wrist will cause numbness or tingling in the fingers (Tinel sign)
Wrist-flexion (Phalen test), press the back of the hands together while the wrists are bent, pointing the fingers down. Carpal tunnel syndrome is suspected if one or more symptoms, such as tingling or increasing numbness, is felt in the fingers within 1 minute.
Test sensitivity in the fingertips and hands by lightly touching them with cotton wool with the patient’s eyes closed.
Check for weakness in the muscles around the base of the thumb
Look for atrophy in the muscles around the base of the thumb. In severe cases, these muscles may become visibly smaller.

Diagnostic tests

Nerve Conduction studies, this will help determine how well your median nerve is working and whether there is too much pressure on the nerve. This test will also help to exclude other nerve condition, such as neuropathy, or other sites of nerve compression.

Ultrasound, an ultrasound of the patient’s wrist may be helpful to evaluate the median nerve for signs of compression.
X-rays, X-rays may be ordered to exclude other conditions, such as arthritis, ligament injury, or a fracture.

Carpal Tunnel Syndrome Treatment

Non-surgical treatments

Splinting, usually a splint worn at night.
Avoiding daytime activities that may provoke symptoms, take frequent breaks from aggravating tasks.
Anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, these provide temporary relief.
Corticosteroids, such as prednisone or the lidocaine can be injected directly into the wrist to relieve pressure on the median nerve.

Surgery

Carpal tunnel release which involves severing a ligament around the wrist to reduce pressure on the median nerve. Many people require surgery on both hands. Almost always there is a decrease in grip strength, which improves over time. Recurrence of carpal tunnel syndrome following treatment is rare. Most patients say that their hands feel normal post-surgery.

Experiencing Hip and Knee Pain?

Most people at some point in their life will experience hip or knee pain. These large joints have an extremely demanding task. They carry the full weight of the body while also allowing for a wide range of motions.

This puts them at risk for wear and tear.

Some common causes of chronic hip and knee pain are osteoarthritis, bursitis, ligament tears, and fractures.

5 Symptoms You Shouldn’t Ignore in your Hips or Knees

When it comes to your hips and knees, the below are 5 symptoms you shouldn’t ignore. If you delay seeing an orthopaedic surgeon, your condition could worsen.

You should make an appointment if you have any of the following:

Not being able to maintain your normal active lifestyle. If you find yourself unable to do the normal activities you enjoy, such as certain sports, cycling, or walking, you should see an orthopaedic surgeon.

Difficulty doing simple tasks. Some patients will experience difficulty putting on shoes and socks or doing other simple activities, such as bending down.

Pain that worsens at night and interferes with your sleep. Inflammation can trigger higher levels of pain.

This could also be a sign that the cartilage in the joint is breaking down. The cartilage may wear out completely if it is left untreated.

Catching, popping, or locking.These are signs that the cartilage in the joint has torn or that bits of cartilage have broken off in the joint space. The cartilage may wear away completely if it is left untreated.

Often people delay seeing an orthopaedic surgeon, because they fear that they will require surgery. This generally isn’t the case as conservative measures are often enough.

Generally, the earlier you see an orthopaedic surgeon, the better your outcome. Conservative measures generally involve medication, physiotherapy and rehabilitation. If you require surgery, it is discussed with you, and you are in full control of your treatment plan.

Do You Have Pain in your Knees?

There are several causes for pain in your knees. It can be caused by a sudden incident such as a fall or twisting of the knee. It can also be caused by overuse, or an underlying diagnosis like osteoarthritis. Some common pathologies are wear of the cartilage, torn ligaments or muscle imbalances.

Your treatment will depend on the cause and the resultant pathology.

Do You Have Hip Pain?

There are many causes of hip pain. The hip is a large ball and socket joint, surrounded by muscle, ligaments and cartilaginous structures. The surfaces of the joints are lined with cartilage to allow smooth movement. Issues in the joint or the ligaments that hold the joint together can cause pain in the hip. Usually, pain or pathology from the hip joint are felt in the groin region, thigh or buttocks. Some common causes of hip pain include:

Arthritis – breakdown of the cartilage that cushions the joint.
Bursitis – inflammation of fluid sacs between tissues such as bone, muscles and tendons
Tendinitis – inflammation or irritation of tendons that attach muscle to bone.
Muscle or tendon strains due to overuse
Hip fractures due to weakened and brittle bones, weakened bones are more likely to fracture.

What Can You Do for Pain in Hips and Knees?

The first recommendation is to see an orthopaedic surgeon so that they can assess you, make a diagnosis and recommend appropriate treatment. If you do high impact exercises, consider changing to low-impact exercise, like a stationary bike, rowing machine, stepping machine, yoga or swimming.

Sometimes all you will need is an orthotic insert in your shoe to help distribute weight away from your arthritic joint. Other non-surgical solutions include oral anti-inflammatories medications. Braces can also be helpful, however long-term use can cause muscle wasting. Pain can also be controlled through corticosteroid injections that will decrease the inflammation in that joint. Physiotherapy can strengthen muscles, and as a result improve the range of motion of the joint.

If conservative measures don’t work, surgery may be the best option. In severe osteoarthritis, hip or knee replacement surgery can be considered.

Dr. van der Berg provides a wide range of surgical procedures for the treatment of hip and knee conditions. These include the Arthroscopic surgery, ligament reconstructions and joint replacements.

If you are interested in scheduling an appointment, contact our practice for further information.

Steroid Injections

Doctor recommended a steroid Injection?

Here is why:

Steroid injections can help reduce inflammation and pain in the affected joint.
They are effective treatment option for conditions such as osteoarthritis, rheumatoid arthritis, and bursitis.
The medication is delivered directly into the affected joint, which thus produces targeted relief.
Steroid injections can also help improve joint function and mobility.
They may be used as stand alone treatment or in combination with other therapies.

Will I experience pain Post Steroid Injection?

Steroids are used to reduce inflammation and pain, however, they can also cause temporary inflammation at the injection site. This can cause pain and discomfort for a few days after the injection.

These symptoms are temporary and will improve over time.

What can I do, to help with the pain?

You can place ice packs on the injection site to reduce inflammation. You can also take pain medication.

However, if the pain persists or worsens, or if you develop other symptoms such as fever or increased redness or swelling at the injection site, it’s important to contact your doctor.