Ulnar nerve entrapment at the elbow, also known as cubital tunnel syndrome is a condition where the ulnar nerve in your arm becomes irritated or compressed. This nerve is one of the three important arm nerves that travel from your neck all the way down into your hand. Constriction can occur in a number of places along this path, and depending on the site of irritation or compression, this pressure causes numbness, elbow pain, hand and wrist discomfort, or finger pain. When the ulnar nerve is compressed at the elbow, it is called, Cubital Tunnel Syndrome.   This condition is now also commonly called “cell phone elbow”.

Causes of Cubital Tunnel Syndrome

The ulnar nerve gives you feeling in your little finger and half of your ring finger. Additionally, it controls the muscles of the hand that allow you to pick stuff up and do other fine movements. It also controls bigger muscles of the forearm that allow you to grip objects.  The exact cause of cubital tunnel syndrome is not completely understood, but it is believed that the ulnar nerve is susceptible to compression at the elbow because it passes through a narrow space where there is not much tissue for protection.

Keeping your elbow bent for long periods of time (like when you hold a cell phone to your ear) may cause ulnar nerve irritation and symptoms.   Other common reasons for this condition include:

• -A direct blow to the inside of the elbow or “hitting the funny bone”
• -Fluid buildup in the elbow that leads to swelling and nerve compression
• -Irritation when the nerve slides in and out of place with bending
• -Pressure on the nerve from prolonged leaning on your elbow
• -Sleeping with your elbow bent

Home Remedies for Cubital Tunnel Syndrome

The simplest thing you can do is to lay down your cell phone and avoid other activities that require you to bend your arm for long periods of time. Also, make sure your computer chair is not too low, and do not rest your elbow on the armrest a lot. Keep your elbow straight when sleeping, if possible, by wrapping a towel around your elbow region or wear an elbow pad backwards.

What the Doctor May Do at Your Visit

If the orthopedic specialist suspects you have cubital tunnel syndrome, he may order special X-rays to see if bony deformities are the cause of the problem.  Additionally, he may order electrical nerve conduction studies to determine how well your ulnar nerve is working and to identify exactly where the compression site is located.

Nonsurgical Treatment

Sometimes, non-steroidal anti-inflammatory medicines can alleviate your symptoms. The orthopedic specialist will want to decrease the swelling around the nerve with these medications. Also, he may inject a “steroid”, like cortisone around the ulnar nerve area of compression. It is not uncommon for the doctor to recommend a brace or splint for you to wear at night to keep your elbow straight. Finally, there are certain nerve gliding exercises that may help your nerve slide through the cubital tunnel so that symptoms can improve or resolve completely. These special exercises help keep the wrist and forearm from getting stiff and sore.

Surgical Treatment

For some people, nonsurgical measures are not enough to relieve the symptoms of cubital tunnel syndrome. In these cases, the orthopedic specialist recommends surgery to take the pressure off the ulnar nerve. Also, surgery is indicated for those who have severe nerve compression or muscle wasting due to the condition. The surgical procedures available include:

Endoscopic or Open Cubital Tunnel Release:  In this surgery, the ligament “roof” of the cubital tunnel is divided. This allows for an increased tunnel space and a decreased nerve pressure.   This procedure minimizes the dissection around the nerve and allows for the quickest recovery.  Dr. Weil is one of the only surgeons in the northwest performing Endoscopic Cubital Tunnel Ulnar Nerve Decompression surgery.  This method is the least invasive and allows for the fastest recovery of all ulnar nerve decompression surgeries.  Dr. Weil was highlighted on King 5 news Health Link for his treatment of cubital tunnel syndrome.

Ulnar Nerve Anterior Transposition:  With this procedure, the nerve is moved from the cubital tunnel and placed in front of that region. Ulnar nerve anterior transposition allows the nerve to lie under the skin and fat but on the muscle, within the muscle, or under the muscle. Placement will depend on your particular problem and the surgeon’s choice.

Medical Epicondylectomy:  One great option to release the ulnar nerve is to remove part of a bony section called the medial epicondyle. This technique prevents the nerve from becoming caught on one of the bony ridges so that it can adequately stretch with bending motions.

Surgical Recovery

If you must undergo a surgical procedure, the orthopedic specialist may put you in a splint following the surgery. For the endoscopic technique no splint is required, for the transposition technique, you may have to wear it as long as 6 weeks. Also, your doctor may recommend that go to physical therapy to learn exercises that will help you regain strength and motion in your arm.

I see three major types of arthritis that affect the elbow and shoulder joints. Osteoarthritis is the “wear-and-tear” arthritis caused from degenerative conditions, and occurs most frequently. Rheumatoid arthritis is less common and is a systemic inflammatory condition of the joint lining (the synovium). Posttraumatic arthritis is a form of arthritis that develops from an injury, such as a dislocation or fracture.

Elbow Arthritis

Many patients wonder, “What is arthritis”. For any joint, arthritis means, “joint inflammation”. In the case of the elbow, if the cartilage surface of the elbow becomes worn from age or damaged, elbow arthritis occurs. If you have elbow arthritis, you probably have pain, swelling, stiffness, and loss of normal range of motion. Some people complain of a “locking” or “grating” sensation in the joint.

These sensations are related to the loss of normal smooth joint surface and when pieces of loose bone or cartilage lodge between the joint surfaces interfering with normal movement. Often, my patients may notice numbness of the ring finger and pinky finger. This is related to the pressure placed on the ulnar nerve or funny bone from the swelling.

How is elbow arthritis diagnosed?

I can diagnose elbow arthritis based on your symptoms, a simple physical examination, and standard X-rays. This disease tends to be more common in men than women, and it generally occurs in people over the age of 50 years. You are at increased risk for elbow arthritis if you have a history elbow injury, inflammatory arthritis, or a family history of arthritis. Others at risk for elbow arthritis include people who have jobs or participate in activities that place demands on the elbow joint, such as professional baseball pitchers.

How is elbow arthritis treated?

I treat elbow arthritis predominantly based on your symptoms. Factors to consider include the stage of the disease, patient goals, and your overall medical condition and physical health. Nonsurgical treatment for elbow arthritis involves measures to alleviate or reduce pain, increase range of motion, and restore function. This includes physical therapy, activity restrictions and limitations, and oral anti-inflammatory or pain medications. If these conservative measures do not work, many patients benefit from corticosteroid injections, which can give several months of relief and can be both therapeutic and diagnostic.

Surgery may be necessary if nonsurgical measures do not control and alleviate symptoms. If the damage is not too severe, I can do minimally invasive and sometimes even arthroscopic procedures to remove loose bodies and degenerative, inflammatory tissue from the joint. This smoothes out the irregular joint surfaces and provides symptom relief. If the joint space is severely worn, I may suggest a joint replacement for you.

Shoulder Arthritis

The shoulder is made up of two joints. One of these is the acromioclavicular (AC) joint, located where the collarbone (the clavicle) meets the tip of the shoulder blade (the acromion). The other is located at the junction of the upper arm bone (the humerus) and the shoulder blade (the scapula), and this is called the glenohumeral joint. Both of these shoulder joints are often affected by arthritis. The symptoms of shoulder arthritis include pain, stiffness, decreased or limited range of motion, and crepitus. Crepitus is a “clicking” or “snapping” sound made with shoulder movement.

How is shoulder arthritis diagnosed?

I diagnose shoulder arthritis based on a thorough physical examination, symptoms, and basic X-rays. Most people with shoulder arthritis have a narrowing of the joint spaces, formation of bone spurs, and changes in the bone structure. People over the age of 50 years are at increased risk for shoulder arthritis. Also, having a history of an injury to your shoulder joint puts you at risk for developing this condition.

How is shoulder arthritis treated?

I treat shoulder arthritis based on the severity of the disease, health status and overall condition, activity level and work responsibilities, and prior history. Nonsurgical measures include oral medications, physical therapy, and activity restrictions and limitations. Patients that do not respond to these methods could have a corticosteroid or hyaluronic acid injection. When the joint is severely damaged or worn, or if the patient does not improve with conservative measures, the glenohumeral joint can be replaced with a prosthesis in a procedure called a total shoulder arthroplasty.

If necessary, the head of the humerus is replaced. For arthritis of the AC joint, a resection arthroplasty could help. I do this by taking a small piece of bone from the collarbone to leave room for movement.

A thumb sprain is an injury of the main thumb ligament at the base of the thumb, the ulnar collateral ligament. Skier’s thumb is another term for a thumb sprain. Ligaments are the soft tissue components that hold two bones together to stabilize a joint. You weaken your pinching and grasping abilities if you tear the ulnar collateral ligament. Because of the popularity of recreational skiing in the United States, skier’s thumb is a common orthopedic injury. When the ulnar collateral ligament is completely torn, the injury must be surgically repaired.

What is the cause of skier’s thumb?

It is normal to extend your arms in front of you when you fall. People do this to reduce the impact from hitting the ground. With skiers and other who pitch forward, falling on the hand can stretch or tear the ulnar collateral ligament. Another cause of this injury is an automobile accident, with the driver’s thumb being impacted over the steering wheel. Basically skier’s thumb can result from any injury where the thumb is abnormally bent backward or to the side.

What are the symptoms of skier’s thumb?

The signs and symptoms of skier’s thumb can occur minutes to hours after the initial injury:

• Swelling of the thumb
• Pain at the base of the thumb and in the space between the thumb and index finger
• Bruising of the skin over the thumb
• Inability to grasp or weak grasp
• Tenderness along the index finger side of the thumb
• Thumb pain that is worse with movement
• Pain in the wrist

How is skier’s thumb diagnosed?

To determine if you have a sprained thumb, I will examine your thumb in different positions to determine if your joint is stable. Also, diagnosis depends on your signs and symptoms as well as the history of your injury. I may perform X-rays to evaluate the joint with tension applied to the injured ligament. In addition, I check for normal functioning of the three major nerves of your hand.

What is the treatment for skier’s thumb?

Nonsurgical Treatment

Treatment depends on whether the ligament is stretched, partially torn, or completely torn. If only stretched or partially torn, I immobilize your thumb joint with a splint or bandage until it heals. For relief of pain and swelling, I recommend ice application 3 or 4 times each day. You will wear the splint or bandage for at least three weeks. After a specified amount of time, I encourage you to do strengthening exercises for your thumb. Physical therapy helps with this. This will continue for another 2 or 3 weeks. Most stretching and partial tearing injuries of this ligament heal after 4 to 6 weeks.

Surgical Treatment

When the ulnar collateral ligament is completely torn, surgery is often necessary. This procedure involves reconnecting the ligament to the bone to regain normal movement. With a skier’s thumb injury, the fragments of the bone may be pulled away with the torn ligament. These types of injuries require fixation with a pin or screw. After your surgical procedure, you will wear a short arm cast or splint for 6 to 8 weeks while the ligament heals.

What is my prognosis like with skier’s thumb?

The prognosis of this type of injury depends on the severity of the tear, how soon you get treatment, and your current bone and joint health. If a sprained thumb is treated promptly and properly, full normal function will be preserved and restored. If you delay treatment of skier’s thumb, however, chronic weakness, instability, and/or arthritis could develop. These late complications can be repaired with a joint fusion procedure or ligament rebuilding procedure.

Can I prevent skier’s thumb?

If you ski, you should discard the ski pole when you fall. Falling onto an outstretched hand without the pole will lessen your chance of a sprained thumb. Also, you should use a ski pole with finger-groove grips without restraining devices such as a closed grip or a wrist strap.

What should I do if I suspect I have skier’s thumb?

If you think you have sprained your thumb, I recommend you be evaluated as soon as possible in our office. While you are making your appointment, apply ice to the injury for around 30 minutes at a time. Avoid moving the thumb, and immobilize it with an ACE wrap. Take some ibuprofen for pain relief and anti-inflammation action.

Congenital anomalies are deformities that your child has at birth. Congenital hand deformities are particularly disabling for children and present a challenge to the orthopedic specialist. These deformities vary from minor types, such as a digital disproportion, to severe forms, such as the total absence of a bone.

If your child has a congenital hand deformity, I recommend early consultation with an orthopedic specialist who specializes in hand surgery. Reconstructive surgery may not be an option for your child, but I have many different prosthetic devices that can increase hand function for your child.

What are the different classifications of congenital hand deformities?

I use the classification for hand deformities accepted by the American Society for Surgery of the Hand (ASSH). This classification system recognizes six groups of deformities.

Problems in Development of the Parts – This occurs when a specific part or parts of the body stop developing when the baby is in the womb. This results in either complete absences of the hand or a missing structure, such as the thumb. Two kinds of problems in development are radial clubhand and ulnar clubhand. Radial clubhand is a type of deformity involving the tissue on the thumb side of the forearm and hand. This condition could lead to shortening o the bone, absence of the thumb, or a small thumb.

I typically operate on radial clubhand at age 6 months. Ulnar clubhand is a deformity where there is underdevelopment of the bone on the side of the little finger (the ulna). This could result in absence of the little finger or a short fifth digit.

Failure of Parts of the Hand to Separate – This occurs when either the bones or the tissues fail to separate in the womb. The most common form of this congenital anomaly is syndactyly, the condition where two or more fingers fuse together. This condition typically involves both hands. Simple syndactyly involves the fusion between the tissues only, whereas complex syndactly involves the fusion between the bones.

Contractures of the hand develop when there is failure of the cells to differentiate during formation in utero. With a contracture, there is abnormal pulling forward of the digits of the hand, and the digits are unable to extend. Surgery is necessary for children with this condition and is recommended around the age of 3.

Duplication of Digits – This is also called polydactyly, and the little finger is most commonly affected. There are three types of polydactyly: 1, 2, and 3. With type 1, there is an extra digit attached by nerves and skin only. Type 2 involves an extra digit attached to the bone or joint. Type 3 is more complex, with an extra digit connected to extra normal metacarpal bone of the hand. Surgery can easily correct these types of deformities.

Undergrowth of Digits – When fingers or thumbs are underdeveloped, there could be a digit that is small, missing muscles or bones, or the complete absence of a digit. Surgery is not always necessary for the correction of these types of deformities.

Overgrowth of Digits – When there is an abnormally large digit, the medical term used is macrodactyly. Some conditions also involve the forearm. The most common digit that overgrows is the index finger. Surgical treatment is complex and I often recommend complete amputation of the large digit.

Congenital Constriction Band Syndrome – This condition is the result of the formation of a tissue band around a finger or limb. This causes problems of blood flow and normal growth. The cause of this syndrome is unknown, but some experts believe that amniotic banding leads to constrictions around a finger or limb. There are four degrees of severity, ranging from simple constrictions to serious constrictions where amputation is necessary.

What is the treatment for congenital hand deformities? 

I base treatment of congenital hand deformities on several factors. These include:

• The extent of the condition
• The cause of the condition
• The child’s age, medical history, and overall health status
• The child’s tolerance to procedures, medications, and therapies
• The parents’ opinion and preference

Treatment measures include:

• Splinting the affected limb
• Correction of contractures
• Limb manipulation and stretching
• Tendon transfer
• Skin grafting to replace or attach skin that is missing or removed during the procedure
• Physical therapy to increase function and strength
• External appliances to realign misshapen hands or digits
• Prosthetics used when surgery is not an option or in conjunction to surgery

Surgical Correction

When is surgical correction performed?

Surgery that is performed within the first 2 years of life is considered early surgery. There are several advantages to early surgery including potential for growth and development, improved scarring, early use of the reconstructed portion, and reduce psychological impact. The disadvantages to early surgery are possible increased anesthetic risk and technical difficulties. Most surgical correction is done after the age of 2 or 3.

What are the different types of surgeries to treat congenital hand deformities?

There are several methods of surgery I perform to treat congenital hand deformities. These include:

Reduction and Fixation of a Broken Bone – This procedure can be open or closed depending on the type of deformity or injury. Many times, I employ a combination of the open and closed approaches using internal fixtures to realign broken or misshapen bones. Immobilization of the hand with a splint follows to assure that the fracture heals properly.

Drainage and Debridement – This technique is done when there is formation of an abscess from infection. This promotes faster healing of the affected region.

Micro-Surgical Replantation – This procedure involves the reattachment of the finger, part of the finger, or hand by way of precise micro-surgical methods.

Skin Grafting – During this method, skin is taken from a healthy body area and used to replace the skin missing on the hand. This is done when there is an amputation of a finger or portion of a finger and in burn deformities.

Skin Flap – This procedure is used when there is damage to the deep tissues of the hand. The tissue take from an area of the body has fat, muscles, and blood vessels that must be attached during the operation.

Tendon and Nerve Repairs – Some hand deformities require repair of a tendon and/or nerve component. These deformities cause decreased movement of the hand, numbness, and weakness.

The treatment of sprains and strains involves the “R.I.C.E.” method. You should take the advice of your orthopedic specialist before you begin this regimen. The following is a brief description of this treatment modality:

REST – Our orthopedic specialists consider the first 24 to 48 hours after an injury to be a critical treatment period and activities should be limited. You can gradually use the injured extremity, as long as your doctor advises it. Sometimes it is necessary for you to use a sling, splint, or crutches while the injured body part heals.

ICE – It is wise for you to apply ice to the sprain or strain for the first 48 hours after the injury. You do this for 20-minute intervals every 3 or 4 hours. Do not apply the ice directly to the skin; use a towel or soft cloth between the skin and the ice bag. One popular way to ice an area is to use a bag of frozen vegetables, such as peas or corn.

COMPRESSION – It is recommended by our orthopedic specialists that you used a compression wrap in early treatment of your sprain or strain. Wrap the ACE bandage over the region by one-half of the width of the wrap. Make sure this bandage is not too tight, as cutting off circulation to the extremity prevents healing. If your toes or fingers turn blue, cold, or tingle, re – wrap!

ELEVATION – As much as possible, you should elevate your sprain or strain. Our surgeons recommend that you make the elevation higher than your heart if possible. You can achieve elevation by placing pillows under your leg or arm.

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