今日の臨床サポート

肘部管症候群

著者: 尼子雅敏 防衛医科大学校病院 リハビリテーション部

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2020/06/19
患者向け説明資料

概要・推奨   

  1. 肘部管症候群は手根管症候群に続く2番目に多い絞扼性神経障害である。
  1. fibrous band(Osborne band)が絞扼点となることが多いが、変形性関節症、神経脱臼、外傷に続発するもの、腫瘍(ガングリオン、神経線維腫、神経鞘腫など)、関節リウマチ、解剖学的破格(滑車上肘筋など)肘の変形(外反肘、内反肘など)の有無などによってもこる。職業の影響もある(O)
  1. 診察は、指の変形環・小指の鉤爪指変形claw finger deformity)の有無、尺側手根屈筋、第1背側骨間筋、小指外転筋の筋力小指と環指の尺側1/2の感覚障害を診る。Tinel様徴候、肘屈曲テスト、Froment徴候などを診る
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
尼子雅敏 : 特に申告事項無し[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. システマティック・レビューを参考にした。
  1. 推奨を検討した。
  1. 超音波検査を取り入れた。
  1. 鑑別疾患に神経疾患を追加した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 肘部管症候群とは肘関節周囲における尺骨神経の絞扼性神経障害により、手部の尺側の感覚異常や手内筋の筋力低下などの症状である。
  1. 尺骨神経は上腕骨内側上顆の8㎝近位でStruthers’ arcadeを通過し、上腕骨尺骨神経溝から尺側手根屈筋二頭間に張るfibrous band(Osborne band)を通過する。
 
肘部管の解剖

1:尺骨神経、2:滑車上肘靭帯、3:尺側手根屈筋腱膜、4:尺側手根屈筋上腕頭、5:尺側手根屈筋尺骨頭、6:Fibrous band、7:上腕三頭筋、8:deep flexor-pronator aponeurosis(common flexor aponeurosis)

 
  1. 上記部位での絞扼性神経障害を肘部管症候群と呼ぶ。
  1. 発生頻度は絞扼性神経障害の中で手根管症候群に続き、2番目である。
  1. 病態は肘周辺の外傷後の変形に伴うもの、特発性(原因不明)、変形性関節症、神経脱臼、外傷に続発するもの、腫瘍(ガングリオン、神経線維腫、神経鞘腫など)、関節リウマチ、解剖学的破格(滑車上肘筋など)などによるものがある。
  1. 変形に伴うものは上腕骨外顆骨折後偽関節(図<図表>)による外反肘、上腕骨顆上骨折後の内反肘、先天性滑車形成不全、陳旧性橈骨頭脱臼などがある。
 
上腕骨外顆偽関節

上腕骨外顆は偽関節を形成し、外反変形を呈しているため、尺側を走行する尺骨神経は牽引され遅発性尺骨神経障害をひき起こす。

出典

img1:  著者提供
 
 
 
外反肘と内反肘

15~20°外反位が正常である。それより外反位であれば外反肘、内反位であれば内反肘という。
a:内反肘、b:正常、c:外反肘

出典

 
  1. 男性に多く発生する。30歳前後と50歳代に二峰性のピークがある。30歳代は変形の伴うもの、50歳代は変形性関節症によるものが多い。
  1. 重労働者の予後は不良である。また、仕事で手を使う頻度と予後は関連がある[1]
  1. 未治療の場合、症状が増悪し、しびれ、疼痛から手内筋力低下・筋萎縮が進行し、かぎ爪指変形に至る場合もある。
  1. 手術的治療により症状の進行をとどめ改善することが多い。しかし筋萎縮の改善は得られないことが多い。
問診・診察のポイント  
問診:
  1. 外傷歴(特に小児期の肘周辺骨折)、職業歴、スポーツ歴を詳細に聞く。

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文献 

著者: M Fadel, R Lancigu, G Raimbeau, Y Roquelaure, A Descatha
雑誌名: Hand Surg Rehabil. 2017 Sep;36(4):244-249. doi: 10.1016/j.hansur.2017.03.004. Epub 2017 May 18.
Abstract/Text Although ulnar nerve entrapment is the second most common entrapment neuropathy, there is a dearth of studies identifying occupational prognosis factors. We carried out a systematic review of the occupational prognosis factors for ulnar nerve entrapment in order to identify professions at risks and allow better follow-up for their workers. Using the key words, "ulnar OR cubital", "neuropathy OR tunnel", and "work OR occupational" without limitations, original prospective studies were selected from four databases (PubMed, Embase, Web of Science, Cochrane Library) after two rounds (valid design, valid prognosis outcome reported, valid work exposure). Associations between prognosis for ulnar neuropathy and occupational factors were extracted and analyzed qualitatively. Dating from 1981 to 2013, three prospective studies were included; 1420 cases of ulnar nerve entrapment were followed for an average of 4 years and occupational exposure was retrieved. The only high-quality study (related to this question) found a significant relationship between occupational exposure and prognosis with an odds ratio for ulnar nerve entrapment of 1.78 (1.10-2.88). The two other studies were less focused on the occupational prognosis factors; one found that work activity requiring effort had worse prognosis after surgery, while the other found no significant relationship between occupational hand exposure and prognosis. Occupations requiring high effort may be associated with more severe ulnar neuropathies, but further studies (exposure as well as associated disorders) are mandatory for clinicians to provide work task information to their patients.

Copyright © 2017 SFCM. Published by Elsevier Masson SAS. All rights reserved.
PMID 28528878  Hand Surg Rehabil. 2017 Sep;36(4):244-249. doi: 10.1016・・・
著者: A J McGOWAN
雑誌名: J Bone Joint Surg Br. 1950 Aug;32-B(3):293-301.
Abstract/Text
PMID 14778847  J Bone Joint Surg Br. 1950 Aug;32-B(3):293-301.
著者: Sahil Kooner, David Cinats, Cory Kwong, Graeme Matthewson, Gurpreet Dhaliwal
雑誌名: Orthop Rev (Pavia). 2019 May 23;11(2):7955. doi: 10.4081/or.2019.7955. Epub 2019 Jun 12.
Abstract/Text Cubital tunnel syndrome (CuTS) is one of the most common compression neuropathies of the upper extremity. Conservative management of cubital tunnel syndrome is often considered first line therapy for mild or moderate symptoms; however, there is little evidence-based literature to guide physicians in this regard. As such, the objective of this study is to complete a comprehensive literature search of the conservative therapies available for treatment of CuTS. Additionally, we hope to assess the evidence for each therapy so that we can make evidence- based recommendations regarding the type and duration of optimal treatment. The databases MEDLINE, EMBASE, and CINAHL were search using a sensitive search strategy. Eligibility for studies included any studies or conference abstracts in which patients were treated conservatively for primary CuTS. Any form of non-operative treatment was acceptable. A data extraction form was developed to collect all information and outcomes of interest, including study design, level of evidence, number of patients, treatment modalities, follow- up time, patient reported outcomes, and electrophysiological markers. Qualitative and quantitative analysis was then completed based on the data extraction form. Given the heterogeneity of the included studies, results were summarized as best evidence available. Our sensitive literature search produced 6484 studies. Initial screening based on title and abstract resulted in the selection of 40 studies that underwent full text review. From these 19 studies were included for analysis in our systematic review. There were 3 level I studies, 4 level II studies, 3 level III studies, and 9 level IV studies. In total this included 844 patients. The most commonly reported outcomes included subjective patient reported outcomes and nerve conduction studies. The most common treatment modalities, from most to least common, included education and activity modification, splinting, steroid/lidocaine injection, nerve mobilization/gliding, pulsed ultrasound, laser therapy, non-steroidal antiinflammatory drugs, and physiotherapy. The most common duration of therapy was 3 months with a median follow-up time of 3 months. There was moderate strength evidence to recommend the use of education/activity modification or splinting in mild or moderate CuTS. There is a paucity of literature and highquality studies regarding the conservative management of CuTS. Regardless, there appears to be a role for non-operative management in CuTS, although further studies are needed to delineate this role further. In the cases of mild or moderate CuTS it is reasonable to trial education/activity modification or splinting as both appear to be equally effective.

PMID 31281598  Orthop Rev (Pavia). 2019 May 23;11(2):7955. doi: 10.408・・・
著者: Willem D Rinkel, Ton A R Schreuders, Bart W Koes, Bionka M A Huisstede
雑誌名: Clin J Pain. 2013 Dec;29(12):1087-96. doi: 10.1097/AJP.0b013e31828b8e7d.
Abstract/Text OBJECTIVE: To provide an evidence-based overview of the effectiveness of interventions for 4 nontraumatic painful disorders sharing the anatomic region of the elbow: cubital tunnel syndrome, radial tunnel syndrome, elbow instability, and olecranon bursitis.
METHODS: The Cochrane Library, PubMed, Embase, PEDro, and CINAHL were searched to identify relevant reviews and randomized clinical trials (RCTs). Two reviewers independently extracted data and assessed the quality of the methodology. A best-evidence synthesis was used to summarize the results.
RESULTS: One systematic review and 6 RCTs were included. For the surgical treatment of cubital tunnel syndrome (1 review, 3 RCTs), comparing simple decompression with anterior ulnar nerve transposition, no evidence was found in favor of either one of these. Limited evidence was found in favor of medial epicondylectomy versus anterior transposition and for early postoperative therapy versus immobilization. No evidence was found for the effect of local steroid injection in addition to splinting. No RCTs were found for radial tunnel syndrome. For olecranon bursitis (1 RCT), limited evidence for effectiveness was found for methylprednisolone acetate injection plus naproxen. Concerning elbow instability, including 2 RCTs, one showed that nonsurgical treatment resulted in similar results compared with surgery, whereas the other found limited evidence for the effectiveness in favor of early mobilization versus 3 weeks of immobilization after surgery.
DISCUSSION: In this review no, or at best, limited evidence was found for the effectiveness of nonsurgical and surgical interventions to treat painful cubital tunnel syndrome, radial tunnel syndrome, elbow instability, or olecranon bursitis. Well-designed and well-conducted RCTs are clearly needed in this field.

PMID 23985778  Clin J Pain. 2013 Dec;29(12):1087-96. doi: 10.1097/AJP.・・・
著者: M Amako, K Nemoto, M Kawaguchi, N Kato, H Arino, K Fujikawa
雑誌名: J Hand Surg Am. 2000 Nov;25(6):1043-50. doi: 10.1053/jhsu.2000.17864.
Abstract/Text We have performed minimal medial epicondylectomy for cubital tunnel syndrome since 1990 to preserve the anterior medial collateral ligament. In this study we compared surgical outcomes between partial medial epicondylectomy (14 patients) and minimal medial epicondylectomy (18 patients) combined with ulnar nerve decompression for the treatment of cubital tunnel syndrome. Mean preoperative Yasutake scores were 57 +/- 17 points (+/-SD) in the partial epicondylectomy group and 60 +/- 15 points in the minimal medial epicondylectomy group. The postoperative scores were 79 +/- 19 points and 87 +/- 10 points, respectively. Both groups had significant improvement in their Yasutake scores following medial epicondylectomy. Similar improvements in motor conduction velocity were observed. There was no significant difference in improvement of either the Yasutake scores or the motor conduction velocity between the 2 groups. Valgus instability of the elbow was significantly greater in the partial epicondylectomy group. We therefore conclude that minimal medial epicondylectomy combined with ulnar nerve decompression is an effective treatment for cubital tunnel syndrome and that a larger excision of the medial epicondyle should be avoided.

PMID 11119661  J Hand Surg Am. 2000 Nov;25(6):1043-50. doi: 10.1053/jh・・・
著者: S W O'Driscoll, R Jaloszynski, B F Morrey, K N An
雑誌名: J Hand Surg Am. 1992 Jan;17(1):164-8.
Abstract/Text The anatomic features of the origin of the anterior medial collateral ligament of the elbow were studied in 10 cadaver elbows to determine the percentage of the medial epicondyle that can be removed without violating the ligament, and whether or not this ligament attaches to the condyle as well as to the epicondyle. In all specimens the anterior medial collateral ligament originated exclusively from the anteroinferior surface of medial epicondyle and had no attachment to the condyle. Only 20% of the width of the medial epicondyle in the coronal plane can be removed without violating a portion of the origin of the anterior medial collateral ligament, an essential stabilizer of the elbow. Excision of the entire epicondyle for ulnar neuropathy would completely detach this ligament from its origin and might therefore potentiate instability. Since the ligament originates on the anteroinferior surface of the epicondyle, more bone can be removed with less violation of the anterior medial collateral ligament origin if the plane of the osteotomy lies between the sagittal and coronal planes.

PMID 1538101  J Hand Surg Am. 1992 Jan;17(1):164-8.
著者: K Nemoto, H Arino, M Amako, N Kato
雑誌名: J Hand Surg Eur Vol. 2007 Jun;32(3):296-301. doi: 10.1016/j.jhsb.2007.01.002.
Abstract/Text Transfer of the abductor pollicis longus tendon to restore index abduction was performed simultaneously with ulnar nerve decompression in severe cases of cubital tunnel syndrome. Eighteen elbows in 18 patients were evaluated with an average follow-up period of 46 (range 12-120) months. The status of the ulnar nerve palsy was evaluated by the Yasutake's scoring method. The mean score improved from 48 points pre-operatively to 78 points at final follow-up (maximum score 100 points). Pinch strength improved from 39% of the opposite side pre-operatively to 81% finally and it reached a plateau one year postoperatively. Despite this improvement in pinch strength, atrophy of the interosseous muscle did not disappear in nine of 12 patients with a follow-up of more than two years. All patients were satisfied with the results of increased strength and stability in pinching ability. No complications occurred.

PMID 17321649  J Hand Surg Eur Vol. 2007 Jun;32(3):296-301. doi: 10.10・・・
著者: R J Neviaser, J N Wilson, M M Gardner
雑誌名: J Hand Surg Am. 1980 Jan;5(1):53-7.
Abstract/Text One of the tendinous slips of the abductor pollicis longus has been used to replace the first dorsal interosseous. One of the slips which does not insert on the first metacarpal is prolonged by a tendon graft through a subcutaneous tunnel to the insertion of the first dorsal interosseous. This technique has been used in 18 patients who have been followed from 2 to 12 years. All patients had improved stability in pinch, were able to abduct and to flex the index finger independently, and were satisfied with the results. No significant complications were encountered.

PMID 6245125  J Hand Surg Am. 1980 Jan;5(1):53-7.
著者: Kensuke Ochi, Yukio Horiuchi, Aya Tanabe, Kozo Morita, Kentaro Takeda, Ken Ninomiya
雑誌名: J Hand Surg Am. 2011 May;36(5):782-7. doi: 10.1016/j.jhsa.2010.12.019. Epub 2011 Feb 23.
Abstract/Text PURPOSE: To compare the shoulder internal rotation test-a new, provocative test-with the elbow flexion test in the diagnosis of cubital tunnel syndrome (CubTS).
METHODS: Twenty-five patients with CubTS were examined before and after surgery with 10 seconds each of the elbow flexion and shoulder internal rotation tests. Fifty-four asymptomatic individuals and 14 neuropathy patients with a diagnosis other than CubTS were also examined as control cases. For the shoulder internal rotation test, the patient's upper extremity was kept at 90° abduction, maximum internal rotation, and 10° flexion at the shoulder, with 90° elbow flexion and neutral position of the forearm and wrist, with finger extension. Test results were considered positive if any slight symptom attributable to CubTS occurred within 10 seconds. Extraneural pressure inside the cubital tunnel was intraoperatively measured with the positions of both the elbow flexion and shoulder internal rotation tests, in 15 of the CubTS cases. Statistical analyses were performed using Student's t-test with a confidence level of 95%.
RESULTS: The preoperative sensitivity in CubTS cases was 80% in the 10-second shoulder internal rotation test and 36% in the 10-second elbow flexion test, and these differences were significant. None of the control cases had positive results in either test. All the CubTS cases improved with surgery; after surgery, neither test provoked symptoms in any surgical patient. The extraneural pressure increased in both provocative positions with no significant difference.
CONCLUSIONS: Positive results for the 10-second shoulder internal rotation test were more sensitive than that for the elbow flexion test of the same duration and seemed specific to CubTS.

Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
PMID 21349657  J Hand Surg Am. 2011 May;36(5):782-7. doi: 10.1016/j.jh・・・

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