Orthopaedic New Patient Consultation

Reason For Visit

Right elbow pain, lateral swelling, and progressive numbness in the ring and small fingers.

Onset approximately 6 months ago, following a minor hyperextension injury on 14/09/2023.

Subjective

The patient is a 54-year-old right-hand-dominant male carpenter who enjoys recreational tennis and presents with chronic right elbow pain and ulnar-sided hand paraesthesia without other associated injuries.

He reports insidious worsening of right lateral elbow pain and medial-sided numbness over the past 6 months after catching a falling timber beam on 14/09/2023. Pain is rated 6/10 at rest and 8/10 with forceful grip, forearm supination, or prolonged elbow flexion. Symptoms are relieved temporarily by rest and ice. He notes progressive weakness in grip strength and difficulty holding heavy tools at work. Prior conservative management—including 8 weeks of physiotherapy, a counterforce brace, and oral NSAIDs—provided minimal relief.

He works full-time in finish carpentry requiring repetitive wrist extension and forearm rotation, and he has been unable to play tennis for the past 3 months due to pain.

He is a former smoker (quit 10 years ago, 15 pack-year history), consumes 2–3 alcoholic beverages per week, denies illicit drug use, and lives with his wife in a single-storey home with stable socioeconomic support.

Past Medical History

Hypertension, Type 2 diabetes mellitus (well-controlled, last HbA1c 6.8%), and left arthroscopic rotator cuff repair in 2019 with full functional recovery and no perioperative complications. No history of venous thromboembolism or bleeding disorders.

• Lisinopril (Prinivil®) 10 mg PO daily

• Metformin (Glucophage®) 500 mg PO BID

• Meloxicam (Mobic®) 15 mg PO daily

• Cholecalciferol (Vitamin D3) 1,000 IU PO daily

• Penicillin (rash)

• Latex (contact dermatitis)

Physical Exam

Well-healed surgical scars noted on the contralateral left shoulder; right upper extremity skin is intact without open wounds, erythema, induration, or drainage.

Right elbow active ROM: flexion 135°, extension lacking 10°, supination 75°, and pronation 80°. Passive ROM matches active limits with painful end-range extension. He makes a full fist with the right hand and easily reaches his face and head.

Right elbow is stable to varus and valgus stress at 0° and 30° of flexion; posterolateral rotatory drawer test is negative. Focal tenderness is present over the right lateral epicondyle, radial tunnel, and medial epicondylar groove.

Motor strength is 4/5 in right finger abduction (first dorsal interosseous) and thumb adduction, and 5/5 in wrist extension and flexion. Decreased light touch sensation and 2-point discrimination (8 mm) noted in the right small finger and ulnar half of the ring finger. Positive Tinel’s sign at the right cubital tunnel and positive elbow flexion compression test at 30 seconds. Negative Tinel's sign at the wrist, negative carpal tunnel compression test, and negative Spurling's sign.

Investigations/Other Studies Reviewed

• Right Elbow XR (3 views, 10/03/2024): Small traction spur at the lateral epicondyle; joint spaces preserved without acute fracture, dislocation, or loose bodies.
• Right Upper Extremity EMG/NCS (02/03/2024): Moderate-to-severe right ulnar neuropathy across the elbow with conduction velocity slowing (34 m/s) and mild axonal loss; normal median and radial nerve studies.

Assessment & Plan

1. Right cubital tunnel syndrome (ulnar nerve entrapment at the elbow).

• G56.21: Lesion of ulnar nerve, right upper limb
• G56.01: Carpal tunnel syndrome, right upper limb

Non-operative measures have failed to halt progression, with electrodiagnostic evidence of early axonal loss and clinical motor weakness.

Differential diagnosis includes C8-T1 cervical radiculopathy, thoracic outlet syndrome, and Guyon's canal compression, all considered unlikely given negative Spurling's test and localised EMG/NCS findings.

Preoperative laboratory tests ordered: CBC, basic metabolic panel (BMP), and coagulation profile to be completed prior to surgery.

Referred to certified hand therapy for postoperative splinting and rehabilitation coordination.

Discussed continued non-operative management (night splinting, activity modification) versus surgical intervention (in situ ulnar nerve decompression vs subcutaneous transposition).

Given motor weakness and EMG findings, the patient elected to proceed with right ulnar nerve decompression and possible anterior subcutaneous transposition. Expected outcome is arrest of neurological progression and gradual improvement in paraesthesia. Risks discussed include infection, bleeding, medial antebrachial cutaneous nerve injury, painful neuroma, incomplete symptom resolution, and persistent weakness.

The procedure will be performed as an outpatient day case at the ambulatory surgery centre under regional brachial plexus block with intravenous sedation, lasting approximately 45 minutes.

The patient will be discharged home the same day in a soft bulky dressing and sling, keeping the wound clean and dry for 3 days, with immediate gentle finger ROM, no lifting > 2 kg for 4 weeks, and analgesia via paracetamol (acetaminophen, Tylenol®) 1,000 mg PO QID PRN and tramadol (Ultram®) 50 mg PO Q6H PRN severe pain.

The patient was instructed to monitor for fever > 38.0 °C, worsening redness, purulent drainage, or acute worsening of numbness/severe pain, and to contact the clinic immediately or attend the nearest emergency department if these occur.

Comprehensive education was provided regarding the pathophysiology of ulnar nerve compression, surgical expectations, slow timeline for nerve recovery, and strict adherence to postoperative lifting restrictions.

The patient expressed concern regarding return-to-work timelines as a carpenter; advised he may return to light duty at 2 weeks and full heavy manual labour at 6–8 weeks postoperatively.

2. Right lateral epicondylitis.

• M77.11: Lateral epicondylitis, right elbow
• M25.521: Pain in right elbow

Symptoms remain persistent despite 8 weeks of physiotherapy and oral NSAIDs.

Differential diagnosis includes radial tunnel syndrome, osteochondral defect of the capitellum, and posterolateral rotatory instability.

No further imaging required at this stage; will monitor clinically.

Continue home eccentric strengthening exercises as previously taught by physiotherapy.

Options discussed included continued conservative management, platelet-rich plasma (PRP) injection, corticosteroid injection, or open debridement of the extensor carpi radialis brevis (ECRB) origin at the time of ulnar nerve surgery.

The patient elected to proceed with non-operative management for the lateral epicondylitis for now, opting for a right lateral epicondyle corticosteroid injection today (triamcinolone acetonide (Kenalog®) 40 mg / 1 mL mixed with 1 mL of 1% lidocaine injected into the ECRB origin under sterile technique) rather than concurrent surgical debridement.

Advised to ice the lateral elbow for 15 minutes TID today and avoid heavy gripping for 72 hours post-injection.

Educated on the potential for temporary steroid flare, skin hypopigmentation, or tendon weakening following corticosteroid injection.

Follow-up

Return to the orthopaedic clinic in person in 2 weeks postoperatively for wound review, suture removal, and range-of-motion assessment. Preoperative laboratory studies (CBC, BMP, coagulation panel) must be completed and available prior to the scheduled surgery date. No repeat XRs will be obtained at the next clinic visit.

CPT Codes

1. 99204 - Office or other outpatient visit for the evaluation and management of a new patient, requiring a medically appropriate history and/or examination and moderate level of medical decision making (chronic illnesses with progression, prescription drug management, and elective major surgery decision).
2. 20550 - Injection(s); single tendon sheath, or ligament, aponeurosis (performed today for right lateral epicondylitis into the ECRB origin).
3. 64718 - Neuroplasty and/or transposition; ulnar nerve at elbow (planned surgical procedure discussed and scheduled during this encounter).
4. 73080 - Radiologic examination, elbow; complete, minimum of 3 views (reviewed and interpreted during the visit to rule out bony pathology).
5. 95907 - Nerve conduction studies; 1-2 studies (reviewed during the consultation to confirm ulnar neuropathy across the elbow).
6. 95886 - Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied (reviewed to assess axonal loss in intrinsic hand muscles).
7. J3301 - Injection, triamcinolone acetonide, not otherwise specified, 10 mg (4 units billed for the 40 mg corticosteroid administered into the right elbow).
8. 99024 - Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure (applicable for the planned 2-week postoperative wound review).
9. 24359 - Tenotomy, elbow, lateral or medial (e.g., epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment (discussed as the surgical alternative for refractory lateral epicondylitis).
10. 29105 - Application of long arm splint (shoulder to hand) (applicable if postoperative immobilisation is utilised following ulnar nerve transposition).