Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Transfer of Nerve, Ulnar (Transposition)


Related Terms

  • Cubital Tunnel Syndrome
  • Ulnar Nerve Decompression
  • Ulnar Nerve Elbow Entrapment
  • Ulnar Nerve Transposition

Specialists

  • Hand Surgeon
  • Neurosurgeon
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)

Comorbid Conditions

  • Compression of the ulnar nerve at other sites
  • Elbow osteoarthritis
  • Elbow rheumatoid arthritis
  • Inflammatory diseases
  • Previous fracture elbow

Factors Influencing Duration

Job requirements and the individual's ability to avoid aggravating activities influence disability. Loss of function of the small (intrinsic) hand muscles influences disability in jobs that require dexterity. Recovery of the nerve (regeneration) may take longer in older individuals.

The type of surgery performed will also influence disability durations. For example, in situ decompression usually allows for a light dressing and early return to modified light work the next day (Melhorn). Transposition may require the application of a splint for 10 to 14 days, thereby increasing the disability duration unless the employer can accommodate the additional restriction of modified work with splint on.

Medical Codes

ICD-9-CM:
04 - Operations on Cranial and Peripheral Nerves
04.0 - Operations on Cranial and Peripheral Nerves; Incision, Division, and Excision of Cranial and Peripheral Nerves
04.04 - Operations on Cranial and Peripheral Nerves; Other Incision of Cranial and Peripheral Nerves
04.6 - Transposition of Cranial and Peripheral Nerves; Nerve Transplantation

Overview

Transfer of the ulnar nerve refers to a procedure in which the nerve is repositioned in order to treat ulnar neuropathy. The nerve is moved from the bony tunnel around the elbow (cubital tunnel) to a new bed in the muscle more proximal to the front of the elbow (anterior transposition). This procedure is performed when conservative treatment for ulnar nerve damage (ulnar neuropathy) has failed.

Ulnar neuropathy usually refers to ulnar nerve entrapment at the elbow but also applies to entrapment at the wrist as the nerve passes into the hand through Guyon's canal on the little finger side of the hand. There are several structures that can entrap the ulnar nerve at the elbow. Proximal to distal they are: brachialis muscle, arcade of Struthers, intermuscular septum, medial epicondyle, and flexor carpi ulnaris muscle. (James). Ulnar nerve entrapment can happen as a result of previous elbow fracture, bone spurs, elbow swelling, or cysts in Guyon's canal. Ulnar neuropathy can be caused by a direct injury or repetitive activity. See the topic Neuropathy of Ulnar Nerve (Entrapment) for additional details.

Transfer or transposition of the ulnar nerve at the elbow is indicated for subluxation or recurrent ulnar nerve elbow entrapment. Subluxation occurs as the ulnar nerve “pops” over or slides over the medial epicondyle with flexion of the elbow. The “transfer procedure” can be of several types: in situ decompression or “simple decompression” with or without medical epicondylectomy, or the more complex anterior transposition procedures (subcutaneous, submuscular, or intramuscular) (Cho). The goal of the transfer procedure is to decrease the angle the nerve travels, which reduces irritation from compression during elbow bending. To further decrease irritation from friction, the bump on the bone on the inside border of the elbow (medial epicondyle) may also be removed (medial epicondylectomy) during the procedure. The epicondylectomy increases the likelihood of complications. The transfer procedure may alter the blood supply to the nerve.

Current medical literature suggests the in situ decompression provides the same outcomes as the more complex subcutaneous anterior transposition (Nabhan; Gervasio).

Many individuals affected with mild ulnar neuropathy can be treated successfully with conservative measures such as anti-inflammatory medications, specific exercises, and application of heat or cold packs. Local steroid injections can reduce the pain during variable periods of time. Other individuals may need surgical intervention to prevent irreversible nerve damage and loss of muscle function beyond the elbow. Again as outlined above decompression in situ surgery may be performed instead of anterior transposition in cases in which the ulnar nerve is compressed locally by the retaining ligament (retinaculum) of the cubital tunnel (Regan).

Source: Medical Disability Advisor



Reason for Procedure

Ulnar nerve transfer is done to treat ulnar neuropathy at the elbow usually associated with subluxation of the nerve. Moving the nerve provides relief from irritation caused by compression along the nerve route. The procedure follows failure of conservative management of the neuropathy.

Source: Medical Disability Advisor



How Procedure is Performed

Regional anesthesia is required for this outpatient procedure; general anesthesia may also be required.

Through an incision along the inner side of the elbow (posterior medial), the nerve is explored and the entrapped structures are released. If a transposition is performed, the nerve along with the arteries and veins that supply blood to the nerve are moved anteriorly (above the medial epicondyle) and sutured (stitched) into a new space created in a position under the skin and fatty tissue but on the top of the muscle (subcutaneous transposition), under the muscle (submuscular transposition), or within the muscle (intermuscular transposition). Many factors are involved in deciding which position is right for the individual, including whether the nerve is compressed at both the elbow and the wrist.

For the ulnar nerve entrapment at the wrist, at the Guyon’s canal, the nerve is decompressed but is not transferred or transposed. The most common cause for ulnar nerve entrapment at the wrist is a cyst. In this case the surgical treatment is removal of the cyst.

After surgery, a soft, dressing is applied and left in place for at least 10 days. Rarely is a splint used for in situ decompression. Splints are more commonly used with transposition to limit bending (flexion) of the elbow.

Source: Medical Disability Advisor



Prognosis

Results of transposition surgery, regardless of the site of relocation of the nerve, are usually good (Regan). The advantages of simple decompression make it the procedure of choice for most cases of ulnar neuropathy (Nathan).

Relief of aching, gradual improvement in sensation, and decreased tingling and burning (paraesthesia) should occur fairly quickly. It may take 4 to 5 months for gripping strength in the hand to begin to return (Regan). Full function in the small muscles of the hand may take 1 to 1.5 years to return (Regan).

Damage to the nerve may be permanent, resulting in little or no improvement of weakness in the small (intrinsic) muscles in the hand.

Source: Medical Disability Advisor



Rehabilitation

Gentle mobilization of the elbow, followed by muscle strengthening exercises, usually begins 7 to 10 days after surgery. Rehabilitation usually lasts 4 to 6 weeks.

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistTransfer of Nerve, Ulnar (Transposition)
Physical or Occupational TherapistUp to 6 visits within 8 weeks

Source: Medical Disability Advisor



Complications

Infection and bleeding are possible complications of any surgery. This procedure may result in increased nerve damage and pain, as well as loss of function. Depending on the extent of nerve compression and the presence or absence of muscle wasting, nerve function may be permanently impaired ("Ulnar Nerve Entrapment"). For additional information refer to the topic Neuropathy of Ulnar Nerve (Entrapment).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Elbow function in individuals recovering from ulnar nerve transfer is restricted for several weeks. After return to work, accommodating devices, such as phone headsets, may be recommended.

Modification of activities is the best approach to the treatment of wrist or elbow symptoms of ulnar nerve entrapment that are associated with activities at home and work.

Return to work is dependent on three conditions: capacity, risk, and tolerance. Capacity is the actual ability to perform activities, risk is the likelihood of recurrence of the condition from performing the activity, and tolerance is the individual's willingness to endure some discomfort in the healing phase. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function (Melhorn). Restrictions should address sustained posturing with the elbow in flexion of greater than 90°, highly repetitive elbow flexion, and repetitive contusion of or sustained pressure on the nerve. For more information, refer to "Work Ability and Return to Work," pages 194-195.

Ergonomic evaluation of the work area is helpful to identify possible factors that may contribute to symptoms such as positioning keyboards too high, sitting too close to the keyboard or steering wheel of a car, or holding a telephone with the elbow in sustained flexion of 90° or more for repeated or extended periods of time. Addressing these factors may allow an earlier return to work, at least in a limited capacity. Some individuals may not be able to return to aggravating activities such as constant hammering.

Risk: If nerve function is documented at multiple office visits, and if it is clearly worsening with continued work activity and subsequently improves with temporary work restrictions, it is reasonable to conclude that this work activity is a risk to this patient’s ulnar nerve. Either permanent work restrictions or surgical treatment would be indicated. Generally the weight lifted at work is not a problem.

Capacity: Capacity is dependent on the function of the nerve and muscles. Capacity may also be modified by the requirement of a splint post-surgery. As the condition becomes chronic, permanent nerve damage may occur, resulting in a reduction of muscle mass and therefore grip and pinch strength.

Tolerance: Tolerance for symptoms such as pain and paresthesia is the most frequent problem. But if documented function loss is occurring, surgical decompression is recommended to maintain function. Pain after transposition may be greater than with in situ decompression.

Accommodations: Accommodations are usually provided to limit prolonged elbow flexion, as well as direct pressure on the nerve elbow or wrist.

Source: Medical Disability Advisor



Maximum Medical Improvement

8 to 12 weeks post surgery

Continued improvement is possible over 18 months, but the amount of improvement is limited.

Source: Medical Disability Advisor



References

Cited

"Ulnar Nerve Entrapment." Your Orthopaedic Connection. Aug. 2011. American Academy of Orthopaedic Surgeons. 6 Jun. 2013 <http://orthoinfo.aaos.org/topic.cfm?topic=a00069>.

Cho, Yong-Jun, et al. "Simple Decompression of the Ulnar Nerve for Cubital Tunnel Syndrome." Journal of Korean Neurosurgery 42 5 (2007): 382-387. National Institutes of Health. U.S. Department of Health and Human Services. 5 Jun. 2013 <http://www.nih.gov>.

Gervasio, O. , et al. "Simple decompression versus anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome: a prospective randomized study." Neurosurgery 56 (1) (2005): 108-117.

James, J. , et al. "Morphology of the cubital tunnel: an anatomical and biomechanical study with implications for treatment of ulnar nerve compression." Journal of Hand Surgery 36 (12) (2011): 1988-1995.

Melhorn, J. M. Unpublished paper given at the 14th Annual Occupational Orthopaedics and Workers' Compensation: A Multidisciplinary Perspective. Eds. J. M. Melhorn and E. J. Carragee. American Academy of Orthopaedic Surgeons, 2012.

Melhorn, J. Mark, and William Ackerman, eds. Disease and Injury Causation, Guides to the Evaluation of. AMA Press, 2008.

Nabhan, A. , et al. "Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome." Journal of Hand Surgery - British and European Volume 30 (5) (2005): 521-524.

Nathan, P. A. , et al. "Simple decompression of the ulnar nerve: an alternative to anterior transposition." Journal of Hand Surgery - British and European Volume 17 (3) (1992): 251-254.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

General

Regan, William D., and Bernard F. Morrey. "Ulnar Neuropathy at the Elbow: Cubital Tunnel Syndrome." DeLee and Drez's Orthopaedic Sports Medicine. Eds. Jesse DeLee and David Drez. 2nd ed. 2 vols. Philadelphia: W.B. Saunders, 2003. 1331-1334. MD Consult. Elsevier, Inc. 6 Jun. 2013 <http://www.mdconsult.com>.

Source: Medical Disability Advisor






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