Tomado de: Electrodiagnosis in Diseases of
Nerve and Muscle: Principles and Practice,
3ra.
ed., Jun Kimura. Oxford University Press,
Oxford, 2001. Chapter 26 P.712
Mononeuropathies And Entrapment
Syndromes,
4 Radial Nerve
Proximal and Distal Sites of Compression
Nerve injury at the axilla from an incorrectly
used crutch results in weakness of all the
radial–innervated muscles and in loss of the
triceps stretch reflex. Fractures of the head of
the radius injure the nerve more distally.
External trauma at the spiral groove commonly
injures the nerve with or without a concomitant
supracondylar fracture of the humerus.94, 144,
315 539
, A local compression at this level also
results from improper use of walkers and
wheelchairs.22, 48 The lateral head of the triceps
muscle may entrap the radial nerve following
continuous repetitive arm exercise,498 in
association with focal myositis14 or
spontaneously. 344
An individual, often
intoxicated, may compress the nerve by falling
asleep while leaning against a hard surface or
with an arm draped over a bench as in the so-
called Saturday night palsy. The lesion here
usually spares the triceps but involves all the
remaining long extensor muscles of the hand,
wrist, and fingers as well as the brachioradialis.
A radial nerve injury spares the extension at the
interphalangeal joints subserved by the median-
and ulnar-innervated lumbricalis. The sensory
losses vary but most often affect the dorsum of
the hand and first two digits. Rarely, children
also suffer from traumatic or
atraumaticmononeuropathy involving the
proximal or distal main radial nerve or the
posterior interosseous nerve.132 In newborn
infants, the umbilical cord may play a role in the
entrapment.434
Compression of the recurrent epicondylar
branch causes pain at the elbow, usually with
simultaneous entrapment of the deep branch of
the radial nerve. This syndrome, one of the
many entities commonly known as tennis
elbow, results from repeated indirect trauma by
forceful supination as the predisposing factor.
Pain and tenderness localized to the lateral
aspect of the elbow resemble the symptoms of
lateral epicondylitis, another condition referred
to by some as tennis elbow. In the
entrapment syndrome; however, additional
dysfunctions indicate the involvement of the
radial nerve. Subluxation of the head of the
radius may produce a radial nerve palsy. Focal
damage at this level also results from crush or
twisting injury to the wrist or forearm or from
repetitive pronation and supination at work.105
Superficial radial neuropathy may develop after
wearing a tight watchband.415 Handcuff-related
compression injuries often involve the sensory
fibers of the radial nerve with or without
concomitant involvement of the median or ulnar
nerves at the wrist.115, 290, 317, 497 Nerve
conduction studies should include comparison
with the ipsilateral lateral antebrachial
cutaneous nerve and with the contralateral
superficial radial nerve.482 Surgical maneuver
for trigger release may cause iatrogenic
laceration of the radial digital nerve of the
thumb.64
Conduction studies after a fracture of the
humerus may reveal slowing across the
compression site at the spiral groove or the
absence of both motor and sensory potentials.
The size of the muscle or antidromic sensory
potential elicited by distal stimulation
differentiates between neurapraxia and
axonotmesis. Most cases have prominent
conduction block and a varying degree of axon
loss.48, 535Electromyographic exploration helps
demonstrate the type and location of injury (see
Figs. 14–14 and 14–17).515 Pressure
neuropathy of the radial nerve usually resolves
in 6–8 weeks, but recovery takes considerably
longer after loss of a substantial number of
axons.
Posterior Interosseous Nerve Syndrome
The posterior interosseous nerve, the terminal
motor branch of the radial nerve in the forearm,
penetrates the supinator muscle in its entrance
to the forearm.406 The compression syndrome
here may develop spontaneously or following
closed injuries to the elbow.221 Other conditions
occasionally associated with this syndrome
include rheumatoid arthritis with synovitis,327
congenital hemihypertrophy of the arm,120
therapeutic excision of the radial head for
certain fractures,90lipoma, chondroma,134 and
ganglion cysts arising from the proximal
radicular joint320 and Charcot-Marie-Tooth
disease type 1 (CMT1).65Violin players may
develop transient symptoms as the result of
prolonged pronation of the forearm.305 The
entrapment usually involves the nerve at the
arcade of Frohse between the two heads of the
supinator152, 361, 430
The patient complains of pain over the lateral
aspect of the elbow but no sensory loss. A
lesion at this level causes weakness in the
extensors of the wrist and digits with a notable
sparing of the supinator, which usually receives
innervation proximal to the site of compression.
The radial nerve proper supplies the extensor
carpi radialislongus and brevis. Normal
contraction of these muscles coupled with the
weakness of the extensor carpi ulnaris results in
the characteristic radial deviation of the wrist on
attempted dorsiflexion. Constriction at the distal
portion of the supinator muscle may result in
selective injury of one of the terminal branches,
causing isolated paralysis of the abductor of the
thumb and extensors of the thumb and index.200
Conversely, a compressive lesion may
predominantly involve the extensor
digitorumcommunis, partially or entirely sparing
the extensor indices proprius and, to a lesser
degree, the extensor digitiminimi. In this case,
selective finger drop of the third and fourth
digits with the intact digits on both ends results
in the so-called longhorn sign. Operative
neurolysis usually, but not always, results in
good recovery from posterior interosseous
nerve palsy.562
In addition to electromyographic abnormalities
of the affected muscles, conduction studies may
reveal mild slowing across the entrapment,
especially if tested with the arm supinated
against resistance.429 The differential diagnosis
includes rupture of the extensor tendons,
especially if paralysis affects only the last three
digits, with preservation of the first two. In this
case, weak muscles show no evidence of
denervation, and passive palmar flexion of the
wrist induces no extension of the
metacarpophalangeal joints.
5. Median Nerve
The median nerve traverses three common
sites of constriction along its course. At the
elbow, entrapment may occur between the two
heads of the pronator teres or more distally with
selective involvement of the anterior
interosseous branch. Carpal tunnel syndrome
results from compression at the distal edge of
the transverse carpal ligament or less
commonly within the intermetacarpal tunnel.
Pronator Teres Syndrome and Proximal Sites of
Compression
In 83 percent of dissections, the median nerve
pierces the two heads of the pronator teres
before passing under it. The pronator teres
syndrome develops at this point with trauma,
fracture, muscle hypertrophy, persistent median
artery,218 or an anomalous fibrous band
connecting the pronator teres to the tendinous
arch of the flexor digitorumsublimis. The clinical
features include pain and tenderness over the
pronator teres, weakness of the flexor pollicis
and abductor pollicisbrevis, and preservation of
forearm pronation. Hypoesthesia over the
thenar eminence helps differentiate this entity
from carpal tunnel syndrome, which spares the
sensory branch passing superficially to the
flexor retinaculum. The conduction studies may
reveal mild slowing in the proximal forearm in
conjunction with a normal distal latency.340 Test
maneuvers such as elbow flexion, forearm
pronation, and finger flexion generally fail to
enhance conduction abnormalities across the
entrapment site.343 Injection of corticosteroids
into the pronator teres may relieve the pain to
aid in diagnosis, but definitive treatment
requires a surgical decompression.256
A similar but distinct entrapment may develop
as the median nerve traverses the ligament of
Struthers, a fibrous band attached to an
anomalous spur on the anteromedial aspect of
the lower humerus.33 This ligament may
compress the median nerve together with the
brachial artery above the elbow, proximal to the
innervation to the pronator teres. Compression
of the brachial artery with full extension of the
forearm obliterates the radial pulse. Similar
proximal median neuropathies may result from
entrapment by an enlarged communication
vein42 or an accessory bicipital aponeurosis,485
often involving the pronator teres and flexor
carpi radialis in addition to the more distal
muscles. Incremental short segmental
stimulation near the proximal portion of the
aponeurosis localizes the precise site of
compression.359 Weakness and
electromyographic abnormalities of the pronator
teres and flexor carpi radialis serve to
differentiate these conditions from the classic
pronator teres syndrome, which usually spares
the proximal muscles.8, 181, 503
Anterior Interosseous Nerve Syndrome
Anterior interosseous nerve syndrome, also
called the syndrome of Kiloh and Nevin,234
results from selective injury of the anterior
interosseous nerve that branches off the
median nerve just distal to the pronator
passage, unilaterally or bilaterally.349, 543 The
palsy occurs either spontaneously or as a
complication of an injury such as a forearm
fracture.158 Unlike the pronator syndrome,
examination reveals no distinct sensory
abnormalities despite the common presenting
symptoms of pain in the forearm or elbow. Pure
motor weakness typically involves pronator
quadrates, flexor pollicislongus and the radial
half of the flexor digitorum profundus,19 sparing
the more proximal pronator teres. Asked to
make an OK sign (or money sign in Japan) with
the first two digits, the patient will form a triangle
instead of a circle—the so-called pinch sign.
Spontaneous recovery takes place from 6
weeks to 18 months.
Neuralgic amyotrophy caused by lesions in the
brachial plexus (see Chapter 24–3) may
manifest as an anterior interosseous nerve
palsy421 presumably because the responsible
lesion selectively involves the nerve bundle
already grouped to form the
terminal nerve branch at this level.451 Similarly,
the syndrome may appear acutely in a patient
with hereditary neuropathy with liability to
pressure palsies.136 A partial median nerve
lesion at an antecubital level can also involve
the bundle destined to form the anterior
interosseous nerve544 or, even more selectively,
only the branches innervating the flexor pollicis
longus.87 The anterior interosseous nerve
syndrome may develop bilaterally as an
idiopathic case99 or in association with
cytomegalovirus infection.124
Ordinary nerve conduction studies of the
median nerve reveal no abnormalities.
Stimulation of the anterior interosseous nerve at
the elbow may demonstrate a delayed latency
of the compound muscle action potential
recorded from the pronator quadratus.349
Comparison of the median motor latency to the
pronatusquadratus and abductor pollicisbrevis
may prove useful.432Electromyographic
explorations show the evidence of selective
denervation in the flexor pollicislongus, flexor
digitorumprofundus I and II, and pronator
quadratus.
Although the current recommendation for the
treatment of spontaneous anterior interosseous
nerve paralysis centers on surgical
decompression, some of theses lesions may
represent a form of neuritis. In one series, most
patients treated by observation had signs of
recovery in 6 months and full recovery within 1
year.333
Carpal Tunnel Syndrome
Of all the entrapment neuropathies, carpal
tunnel syndrome is by far the most prevalent,
showing the lifetime risk of approximately 10
percent.207 The median nerve passes, with nine
extrinsic digital flexors, through the tunnel
bound by the carpal bones and transverse
ligament, which is attached to the scaphoid,
trapezoid, and hamate. Anatomically the carpal
tunnel narrows in cross section at 2.0–2.5 cm
distal to the entrance, rigidly bound on three
sides by bony structures and roofed by a
thickened transverse carpal ligament. An
abnormally high intracarpal tunnel pressure also
peaks at this level in patients with carpal tunnel
syndrome.299
Pathologic studies show that a striking
reduction in myelinated fiber size takes place
under the carpal ligament at this point.510
Interestingly, even in normal subjects the
slowest nerve conduction occurs 2–4 cm distal
to the origin of the ligament.241 This finding
suggests a mild compression of the median
nerve at this particular level in some clinically
asymptomatic hands. In fact, a histologic
study357 revealed focal abnormalities at this site
in 5 of 12 median nerves at routine autopsy
despite the absence of any symptoms
suggestive of the carpal tunnel syndrome in
life.163
Certain anatomical peculiarities may predispose
some individuals to the entrapment neuropathy.
These include limited longitudinal sliding of the
median nerve under the ligament,525 a smaller
cross-sectional area of the tunnel,36 greater
anteroposterior diameter of the wrist,175
obesity,353, 540 and small hand.345 Any
expanding lesion in the closed space of the
carpal tunnel enhances compression. Wrist
flexion and extension also substantially alter the
cross-sectional areas of the carpal tunnel as
estimated by magnetic resonance imaging477
and the intracarpal tunnel pressure as
measured by a catheter.506 A measurement of
cross-sectional areas of the carpal tunnel by
computerized axial tomography, however,
paradoxically revealed a significantly larger
area in carpal tunnel patients than in controls.555
A statistical analysis based on median and
ulnar nerve comparisons of motor and sensory
latencies may provide a useful risk prediction
for the diagnosis of carpal tunnel syndrome.130
Carpal tunnel syndrome affects women more
than men, most commonly in the fifth or sixth
decade491 showing a greater prevalence in older
populations.354, 355 Age-related changes of
median nerve conduction, however, also
develop naturally, not necessarily leading to
symptoms of compression. 199, 353 The
symptoms usually involve the dominant hand352
or are contralateral to amputation418 and show a
higher incidence in those who use their hands
occupationally43, 403 or for arnbulation with a
cane, crutch, or wheelchair.518541 Symptoms
may appear during pregnancy and resolve after
delivery. The rare syndrome seen during the
early ages108 causes a characteristic feature of
short-lasting but severe attacks of pain.,444 In
contrast to the sporadic incidence in most adult
cases,192 rare familial occurrence prevails in
children,40, 176, 285, 412 sometimes with
anomalous thickening of the transverse carpal
ligament.326 Other associated abnormalities
include insensitivity to pain in the mutilated
hand.23, 505
The syndrome also accompanies a variety of
polyneuropathies and systemic illnesses.10, 188
Hereditary neuropathy with liability to pressure
palsies should rank high in the differential
diagnosis of familial carpal tunnel syndrome.524,
565
Patients with familial amyloidosis have a
high incidence of carpal tunnel syndrome.268,
346
, 431 Certain secondary amyloidoses,
especially those associated with multiple
myeloma, may also give rise to neuropathy. Of
the endocrine disorders, acromegaly231367
occurs most often, one study reporting 35 of
100 patients with evidence of the entrapment
neuropathy.367 Carpal tunnel syndrome occurs
in a high proportion of patients with rheumatoid
arthritis,143 often as the initial manifestation of
the tenosynovitis affecting the wrist flexor.
Patients with rheumatoid arthritis may also
develop thenar atrophy from disuse, cervical
spine disease, or compression of the ulnar
nerve at the elbow. Other conditions associated
with a high incidence of carpal tunnel syndrome
include eosinophilic fascitis,215 myxedema,450
lupus erythematosus,469 hyperparathyroidism,427
toxic shock syndrome,443 Lyme borreliosis,187
long-term renal hemodialysis,161fibrolipomatous
hamartoma,325 torsion dystonia,118 and other
conditions associated with prolonged wrist and
finger hyperflexion.111
Symptoms may develop with extra tunnel
pressure by an anomalous artery546 or sudden
growth of ganglion cysts.230 A nonspecific
tenosynovitis also gives rise to symptoms
similar to those of idiopathic carpal tunnel
syndrome.229 Patients often have other
evidence of degenerative arthritis such as
trigger fingers, bursitis, tendinitis, and tennis
elbow. In addition, traumatic conditions may
result in acute compression of the median nerve
at the wrist. These include Colles' fracture291
isolated fracture of capitatum452 or hamate,309
acute soft tissue swelling after crushing injury of
the hand, and acute intraneural hemorrhage.195
Most of these cases require emergency
decompression of the median nerve. The lateral
border of the flexor digitorumsuperficialis
muscle may compress the median nerve
against the forearm fascia and other flexor
tendons. This rare entity causes symptoms
similar to those of carpal tunnel syndrome, with
additional findings of local tenderness and
firmness in the forearm.154456
Differential diagnoses also include high median
nerve compression at the elbow, a C6
radiculopathy, and traumatic injury at the wrist,
including a handcuff neuropathy.290 Carpal
tunnel syndrome may accompany degenerative
cervical spine diseases. This combination,
called the ―double-crush syndrome,‖523 probably
represents a chance occurrence of two very
common entities.75, 422 Nonetheless, an
awareness of this possibility underscores the
need of adequate electrophysiologic
assessments because the presence of one
condition does not preclude the other. Some
series67, 458 but not others52, 192 report a high
incidence of electrophysiologic evidence for
median and ulnar nerve lesions at the wrist.
In typical cases of idiopathic carpal tunnel
syndrome, paresthesias in the hand frequently
awaken patients at night. The pain often
extends to the elbow and not uncommonly to
the shoulder, mimicking the clinical features of
cervical spine disease or high median nerve
compression.78The differential diagnosis rests in
part on the symptoms of proximal lesions that
are exacerbated with manipulation of the neck
or shoulder girdle and subside with the arm at
rest. In contrast, moving the hand often
alleviates the pain in carpal tunnel syndrome.
Compression can affect the peripheral
autonomic fibers, causing defective vasomotor
reflex. Thus, Raynaud's phenomenon may
develop, especially in patients with systemic
diseases such as rheumatoid arthritis. Sensory
changes vary a great deal in early
stages.490Hypesthesia involves the first three
digits and the radial half of the fourth digit or,
not uncommonly, only the
second or third digit. Patients may indeed
complain of a sensory loss outside the median
nerve distribution. In one large series, 83
percent of 384 patients had a sensory
disturbance mostly consisting of hypesthesia
often confined to the tip of the third digit.397
Typically, the sensory changes spare the skin of
the thenar eminence innervated by the palmer
cutaneous branch that arises approximately 3
cm proximal to the carpal tunnel. Occasional
patients, however, also have thenar numbness
with the additional entrapment of this branch by
the fascia of flexor digitorum superficialis.468
Examination of the fourth digit usually reveals
characteristic sensory splitting into median and
ulnar halves, a pattern rarely seen in
radiculopathies.
Because of early detection, patients now
seldomly develop major wasting of
thenarmuscles, once considered a distinctive
feature of the syndrome. Nonetheless, a
comparison between the affected hand and the
normal side often reveals a slight weakness. To
test the abductor pollicisbrevis in relative
isolation, the patient presses the thumb upward
perpendicular to the plane of the palm. For the
assessment of the opponens, the patient
presses the tip of the thumb against the tip of
the little finger. The two heads of the flexor
pollicisbrevis receive mixed median and ulnar
innervation with considerable variation.
Passive flexion or hyperextension of the
affected hand at the wrist for more than 1
minute may worsen the symptoms,396whereas a
gentle squeeze of the hand may ease the
pain.307 Hyperextension of the index finger may
exacerbate the symptom with volar forearm
pain.269 Percussion of the median nerve at the
wrist causes paresthesia of the digits, although
it has no localizing value in the carpal tunnel
syndrome.322, 494 In fact, electrophysiologic data
show the focal abnormality about 2–3 cm distal
to the traditional percussion site on the volar
aspect of the wrist.241 The phenomenon
originally described by Tinel513 relates to
tapping the proximal stump of an injured nerve
to elicit a paresthesia as an indication for axonal
regeneration and not for entrapment
neuropathy.484 Symptoms of carpal tunnel
syndrome worsen during ischemia of the arm.
The factors that determine the degree of such
susceptibility include the severity of pain and
paresthesia but not the extent of muscle
wasting or duration of symptoms.149 These
findings suggest rapidly reversible changes in
the nerve fibers associated with ischemic
attacks. Sharply focal structural changes seen
in entrapment neuropathy, however, indicate
that mechanical factors must play an important
role in the pathogenesis.150, 371
Simpson's original contribution475 on carpal
tunnel syndrome, demonstrating focal slowing
at the wrist, paved the way for clinical
conduction studies of this entity. Since then a
number of investigators have published
extensive studies51, 164, 166, 207, 219, 274, 323, 396,
509
Early work yielded a higher sensitivity of
sensory conduction testing than studies of the
motor axons.52323509 In our series,241however,
the sensory and motor axons showed a
comparable incidence of abnormalities. In
addition, we often encountered selective
involvement of motor fibers, with normal
sensory conductions or vice versa. Antidromic
or orthodromic sensory conduction studies find
more abnormalities when tested in all the
median nerve innervated digits.461 In one
series,302 digit 3 proved the most sensitive,
whereas in other studies digit 1259 and digit 4507
provided a better yield than the others. Wrist
flexion may delay motor or sensory conduction
across the wrist,310, 455 but not to the extent of
any diagnostic value.123 Nerve conduction
measures generally show a good relationship to
the clinical symptom
561
severity. Electrophysiologic procedures have,
however, become so sensitive that they cannot
only confirm the clinical diagnosis in most
patients but also detect an incidental finding in
some asymptomatic subjects.419 A sensible
interpretation of the test results in the context of
patients' symptoms and clinical findings avoids
unnecessary or premature surgical
intervention.1
Diagnostic studies should establish selective
conduction abnormalities involving the wrist-to-
palm segment of the median nerve for sensory
or motor fibers.49, 52, 97, 109, 240, 241, 288, 384, 391,
435 489
, In our series,241 palmar
stimulationelucidated sensoryor motor
conductionabnormalities in allbut 13 (8%) of
172 clinicallyaffectedhands. Without palmar
stimulation, anadditional 32 (19%)
handswouldhaveescapeddetection. Recording
of the orthodromic sensoryaction potentialal
sorevealed more abnormalities with the addition
of palmar stimulation.103, 334Palmar stimulation
is a simple means to differentiate compression
by the transverse carpal ligament from diseases
of the most terminal segment, as might be
expected in a distal neuropathy. In advanced
stages, however, the axons may degenerate
distal to the entrapment. Conversely, retrograde
changes may also occur in the forearm as a
result of a severe compression at the wrist.16,
495 519
, The loss of fast-conducting fibers also
leads to slowed conduction velocity proximal to
the site of the lesion if recorded from
digits.145Mixed nerve conduction study in the
forearm measures the segment of interest per
se,392, 495 although a possible cutaneous palmar
branch bypassing the carpal ligament confuses
the issue.190
With serial stimulation from the midpalm to the
distal forearm in 1 cm increments, sensory
axons normally show a latency change of 0.16–
0.21 ms/cm (see Fig. 6–7A, B). In about one
half of the affected nerves, there is an abrupt
latency increase across a 1 cm segment, most
commonly 2–4 cm distal to the origin of the
transverse carpal ligament.241, 351, 354, 355 In
these hands, the focal latency change across
the affected 1 cm segment averages more than
four times that of the adjoining distal or proximal
1 cm segments (see Fig. 6–7C, D). In the
remaining hands, conduction delay affected
more than one 1 cm segment across the carpal
tunnel but was usually maximal at the site
described above. Segmental studies of the
motor axons in short increments are technically
more demanding because of the recurrent
course of the thenar nerve that varies
anatomically from one subject to another.214, 241,
545
Digital stimulation allows simultaneous
multichannel recordings of the orthodromic
sensory potential across the carpal tunnel for
segmental latency studies.201, 242 The inability to
compare the amplitudes and waveform of the
responses recorded from different sites limits
the clinical value of orthodromic incremental
studies (see Chapter 7–6).
A number of other variations may improve the
sensitivity of the motor and sensory conduction
studies. The difference between the right and
left sides, although useful with unilateral
lesions, provides limited help in assessing a
bilateral compression. With palmar stimulation,
the simultaneous recording from the digit and
the median nerve trunk at the wrist has the
advantage of instantaneously assessing the
latencies over the two segments.301 Recording
from two different sites, however, precludes an
accurate amplitude comparison between the
antidromic sensory potential and mixed nerve
potential. Other measures include the relative
latency change of the median sensory latency
to radial, ulnar, or palmar cutaneous sensory
latency for the same nerve length63, 69, 390, 521
and between median and ulnar motor latencies
by lumbrical and interossei or thenar eminence
recording.407, 408, 446, 517, 531
An interesting approach along the same line
takes advantage of simultaneous stimulation of
two nerves, for example, median and ulnar for
recording of sensory potentials from the fourth
digit or median and radial for recording sensory
potentials from the first digit.73, 213, 384, 522
Recording from the fourth digit also allows
comparison of median and ulnar nerve
potentials elicited by palmar and wrist
stimulation. The affected median nerve typically
shows a distally elicited synchronized response
and a proximally evoked temporally dispersed
delayed potential, in sharp contrast to the nearly
identical ulnar responses regardless of stimulus
sites (see Chapter 6–2). These studies
generally fail to serve as a useful test in patients
with polyneuropathy.83
Two motor conduction measures compare the
terminal latency of the distal segment to the
conduction time in the proximal segment
adjusted to the same distance (see Chapter 5–
4). Of these, the residual latency increases,260
and the terminal latency index decreases below
the normal range244, 463, 474 in patients with
carpal tunnel syndrome. Even with complete
denervation of the thenar muscles, the first and
second lumbricals may maintain
part of their innervation presumably because of
a deeper location of their motor funiculi.106, 142
Recognition of lumbrical sparing thus helps
establish the diagnosis especially in advanced
cases with severe loss of axons supplying
thenar muscles.296 Conversely, lumbrical
muscles may show a prolonged latency despite
an otherwise normal motor study.142 In
advanced cases, electromyographic studies
show fibrillation potentials and positive sharp
waves in the median innervated intrinsic hand
muscles. Needle studies, though not necessary
in typical cases of the carpal tunnel syndrome
may aid in excluding other diagnostic
possibilities.86, 170
Other techniques of theoretical interest include
quantitative studies of sensory thresholds178, 324
and strength-duration testing.335 Quantitative
somatosensory thermotesting may demonstrate
impairment of thin nerve fiber function,276 but
the ulnar-innervated digit 5 may also show
abnormal findings.171 Some advocate the use of
portable nerve conduction testing for screening,
but its inability to measure the amplitude and
waveforms poses a major limitation.488
Nonoperative measures sometimes suffice as
the initial treatment212 although some
553
recommend early surgery. Conservative
therapy consists of patient education, wrist
splinting, B vitamins, nonsteroidal anti-
inflammatory medication, steroid injections, oral
administration of steroid, and job change or
modification.72, 194 Splinting works best if
applied within 3 months of symptom onset.264
Local steroid injections for symptomatic relief
help confirm the diagnosis and treat the
disorder. In one series, treatment with a single
dose of 40 mg triamcinolone acetonide resulted
in complete remission in 35 percent of patients
and partial relief in 58 percent.160 An inadvertent
injection into the nerve can result in permanent
damage.293 Two practices can help avoid this
complication: placing the needle carefully
midway between the palmarislongus tendon
and the flexor carpi ulnaris tendon at the
proximal edge of the transverse carpal ligament
in a line with the superficial tendon of the ring
finger146 and discontinuing injection and
redirecting the needle if the patient experiences
paresthesia of any kind. Some advocate
noninvasive laser neurolysis as an alternative
therapy, although its role in management awaits
further study.538
If conservative therapy fails, division of the
transverse carpal ligament is usually the
standard operative procedure for unilateral and
occasionally for bilateral release at one
operation.385 Carpal tunnel decompression also
benefits patients with advanced thenar atrophy
and sensory deficits139, 362 and those with
under-lying peripheral neuropathy.339 Although
surgery is usually successful, 7–30 percent of
patients will have either residual or recurring
symptoms.93, 381 Endoscopic release may
shorten the convalescence time for return to
work7 provided the intraoperative safety and
outcomes equal those of surgery.45
Digital Nerve Entrapment
The interdigital nerves supply the skin of the
index and middle fingers and half of the ring
finger as extensions of the median sensory
fibers. Sensory symptoms may result from
compression of these small sensory branches
against the edge of the deep transverse
metacarpal ligament. Entrapment is associated
with trauma, tumor, phalangeal fracture or
inflammation of the metacarpophalangeal joint
or tendon.256 Patients complain of pain in one or
two digits exacerbated by lateral
hyperextension of the affected digits and
tenderness and dysesthesia over the palmar
surfaces between the metacarpals. Local
infiltration of a steroid may relieve the
symptoms and assist in diagnosis.348 Abnormal
median sensory potentials may result from
unsuspected digital nerve lesions.208
6 Ulnar Nerve
Tardy Ulnar Palsy and Cubital Tunnel
Syndrome
The ulnar nerve enters the flexor carpi ulnaris
between the humeral and ulnar heads of the
muscle. After an intramuscular course of
several centimeters, the nerve exits the flexor
carpi ulnaris to lie
between this muscle and the flexor digitorum
profundus.59 Ulnar neuropathy commonly
results from a focal entrapment in the
retroepicondylar groove or at the
humeroulnaraponeurotic arcade joining the two
heads of the flexor carpi ulnaris.58 In one study
of 130 cadavers, the humeroulnar arcade lay
from 3–20 mm distal to the medial epicondyle,
the intramuscular course ranged from 18–70
mm through the flexor carpi ulnaris, and the
nerve exited the tunnel 28–69 mm distal to the
medial epicondyle.58
Ulnar neuropathy at the elbow results from
widely varying causes.329 These include
repeated trauma at the retrocondylar groove,
pressure from immobilization of the upper limb
during surgery,536 entrapment by the accessory
anconeusepitrochlearis muscle,316 spontaneous
intraneural hemorrhage,405 and a gouty
tophus.9, 533Originally, tardy ulnar palsy implied
antecedent traumatic joint deformity or recurrent
subluxation. Many clinicians, however, now use
the term for entrapment of the ulnar nerve at the
elbow, even without a history of trauma. The
compressive lesion at this site can affect
different fascicles, involving the terminal digital
nerves and the fibers to the hand muscles much
more frequently than those to the forearm
muscles.492 Classic clinical symptoms also
appear with a more proximal involvement at
Erb's point225, 261 or at the level of the upper arm
after injections into the middle deltoid.157 Ulnar
nerve palsy at the elbow may also constitute
part of diffuse neuropathy or develop
concomitantly with lower cervical spine disease
involving C8 and T1 roots or with the thoracic
outlet syndrome.347 In one study, ulnar sensory
and motor nerve fibers showed similar
conduction changes across the elbow in motor
neuron disease. This finding casts doubt on
double crush syndrome, which postulates the
greater susceptibility of the proximalty affected
axons to a distal entrapment.75
Some reports emphasize the cubital tunnel
syndrome as the most common discrete
entity.129, 328, 329 In this condition, nerve
entrapment accompanies neither a joint
deformity nor a history of major trauma. 128 A
number of factors give rise to entrapment of the
nerve under the aponeurosis connecting the
two heads of the flexor carpi ulnaris.330, 502
Here, the nerve has the largest diameter,71 may
show palpable swelling in the ulnar groove, and
appears hyperemic at surgery. Frequent hand
use in the elbow flexed position narrows the
cubital tunnel and exacerbates the
symptoms.328 In one study,357 routine autopsy
revealed focal pathologic changes at the
aponeurosis in 5 of 12 presumably normal
nerves. The appearance of bilateral ulnar
neuropathy in a large number of patients
suggests a congenital predisposition to this
syndrome.191, 328, 329 In fact, the asymptomatic
contralateral nerve may show some
involvement histologically in some cases of
idiopathic ulnar neuropathy.356
The earliest clinical features include impairment
of sensation over the fifth digit and the ulnar half
of the fourth digit. Weakness and wasting
predominate in the first dorsal interosseous and
other ulnarinnervated intrinsic hand muscles,
such as the third and fourth lumbricals, giving
rise to the partial claw hands, and the third volar
interosseous, causing an inability to adduct the
fifth digit, or the Wartenberg sign.
Electromyography further defines the site of
involvement by demonstrating the distribution of
denervation. Typically, the cubital tunnel
syndrome affects the ulnar half of the flexor
digitorumprofundus, which receives the nerve
supply distal to the aponeurosis, sparing the
flexor carpi ulnaris supplied by a proximal
branch. This distinction, however, does not
necessarily hold as commonly believed,
reflecting variable innervation patterns.57
Nerve conduction and electromyographic
studies help localize the site of major pathology
in these patients.249, 417Some have localized
slowing of motor or sensory conduction velocity
across the elbow compared with the more
proximal or distal segments.475 Tests conducted
with the elbow flexed rather than extended
generally yield a more reliable result.257 Test
accuracy is improved by maintaining the
identical limb position during recording and
measuring the surface distance. Waveform
changes provide a more sensitive measure than
the generally accepted criteria for slowing of
conduction exceeding 10 m/s.373 The segment
distal to the presumed compression may show
mild slowing165 associated with a reduction in
amplitude of the compound muscle action
potential elicited by distal stimulation. This
finding usually indicates axonal degeneration,
although on rare occasion it may result from a
quickly reversible change in nerve membrane
excitability.321
Recording from the flexor carpi ulnaris
supplements the conduction study in severe
cases showing atrophy of the intrinsic hand
muscles.520 Recording a normal or nearly
normal compound muscle action potential from
a clinically weak muscle with distal stimulation
indicates the presence of conduction block at a
proximal site of compression. A drop in motor
amplitude greater than 25 percent across the
elbow usually localizes the lesion in this
segment.399
Stimulating the nerve at multiple sites across
the cubital tunnel identifies the precise site of
the lesion.60, 220, 328 A nonlinear change in
amplitude or latency or both serves as the most
sensitive measure of a focal abnormality (see
Chapter 7–5).243 Intraoperative studies pinpoint
the site of entrapment for optimal surgical
therapy, showing a major conduction block at
the point of exit from the cubital tunnel in some
cases. Some electromyographers advocate
near nerve recording for better localization.372
A strict nonoperative regimen should constitute
the initial management of the cubital tunnel
syndrome.104 Surgical treatment consists of
transposition,193 simple decompression,287, 331,
or interfascicular neurolysis.358 Patients may
have some functional recovery if operated on
early.273 Once a moderate degree of motor
deficit has developed, symptoms persist after
operative intervention in 30 percent or more of
patients.129 In selected cases, anterior
transposition of the nerve results in good clinical
and electrophysiologic improvement148, 253, 409
even as a reoperation for failed
decompression.153
Compression at Guyon's Canal
The ulnar nerve enters the hand through
Guyon's canal at the wrist.113 Nerve injury at
this level, seen less commonly than at the
elbow, has clinical features similar to those of
tardy ulnar palsy. Sensory deficit, if present,
characteristically spares the dorsum of the hand
innervated by the dorsal cutaneous branch,
which arises proximal to the wrist. In Guyon's
canal syndrome,464 the responsible lesion may
involve both deep and superficial branches of
the ulnar nerve (type 1) or only the deep
branch, thus producing the palmarisbrevis sign
or sparing of this muscle innervated by the
superficial branch (type 2).202, 402 In either case,
the other ulnar-innervated intrinsic hand
muscles show weakness and atrophy as well as
electromyographic evidence of denervation,
whereas the flexor carpi ulnaris and flexor
digitorumprofundus III and IV function normally.
The reverse, however, does not necessarily
hold because a proximal lesion can selectively
damage the bundle of axons destined for the
more distal muscles. In fact, ulnar nerve lesions
at any level tend to affect the first dorsal
interosseous muscle most consistently.
Predominant involvement of the superficial
branch results in selective paralysis of the
palmarisbrevis and loss of sensation in the fifth
digit and ulnar half of the fourth digit (type 3).
Entrapment in Guyon's canal most commonly
results from a ganglion.380 Less frequent causes
include trauma, rheumatoid arthritis, tortuous
arteries,459 calcium deposits in Guyon's canal in
scleroderma,512 an accessory palmaris muscle
that arises from the base of the fifth
metacarpal,420 and pisiform-hamate coalition.30
Ganglions and fractures usually cause
combined motor and sensory deficits or isolated
motor weakness, whereas synovitis may cause
isolated sensory loss.267 The presence of a
Martin-Gruber anastomosis may confuse the
issue with an unusual presentation.251 Handcuff
neuropathy, which usually involves the
superficial radial nerve, may also affect the
ulnar nerve selectively or concomitantly.449, 457
Ulnar nerve compression in the distal forearm
may result from the enlarged normally
tendinous portion of the flexor carpi ulnaris.56 A
segment of the nerve may anomalously
penetrate this tendon.569 Surgical
decompression generally improves the
224 383
symptoms. ,
In types 1 and 2, motor conduction studies
reveal reduced amplitude and increased digital
latency of the abductor digiti
quinti and first dorsal interosseous responses
showing asymmetry between the affected and
normal sides.380 Other useful techniques include
short incremental stimulation across the wrist383
and comparison between ulnar and median
motor latency by lumbrical and interossei
recording.258, 465 Eliciting a normal sensory
potential from the proximally branching dorsal
ulnar cutaneous nerve usually localizes the
lesion at the wrist,209, 235 although a lesion at
the elbow could possibly spare this branch in
partial involvement.527 Reduced or absent ulnar
sensory action potentials of the fourth and fifth
digits indicate involvement of the superficial
branch. The mixed nerve action potential
between the wrist and elbow remains normal.
Recording from the fourth digit provides a
sensitive measure of comparison between
median and ulnar nerve sensory amplitude and
latency (see Chapters 6–2 and this chapter,
part 5).
Involvement of the Palmar Branch
Further distally, the deep motor branch may
sustain external trauma or compression by a
ganglion arising from the carpal articulations168,
499
or by the arch of origin of the adductor
pollicis muscles439 or tumor.413 Using the heel of
the hand against a crutch causes repeated
injuries to this branch as does an attempt to
shut or raise a window by striking the bottom
edge with the palm. Compression of the ulnar
nerve at the palm has also followed prolonged
bicycle riding.127, 189 Other entities reported
include video-game palsy,147 and pizza cutter's
palsy.437 Damage distal to the origin of the
superficial branch gives rise to no sensory
abnormality clinically or electrophysiologically.
In cyclist's palsy, however, a severe lesion may
also affect the sensory fibers supplying the skin
of the fourth and fifth digits.364
A palmar lesion usually spares the more
proximal motor fibers supplying the hypothenar
muscles. Thus, conduction studies reveal no
abnormalities between the elbow and wrist and
a normal distal latency from the wrist to the
abductor digitiminimi. The compound action
potential recorded from the first dorsal
interosseous, however, may show a prolonged
latency and reduced amplitude compared with
the unaffected side. Segmental stimulation of
the motor branch in the palm can establish
precise localization of the lesion along the
course of the nerve (see Chapter 6–2).
Electromyography shows selective
abnormalities of the ulnar-innervated intrinsic
hand muscles except for the abductor
digitiminimi. These findings indicate slowing or
block of nerve conduction distal to the origin of
the hypothenar branch.39, 126