Ulnar Neuropathy Clinical Presentation

  • Author: Charles F Guardia III, MD; Chief Editor: Nicholas Lorenzo, MD   more...
 
Updated: May 18, 2011
 

History

Both the onset and progress of the symptoms can be variable. Although the answer is frequently negative, one should ask specifically about trauma and pressure to the arm and wrist, especially the elbow, the medial side of the wrist, and other sites close to the course of the ulnar nerve.

Many patients complain of sensory changes in the fourth and fifth digits. Rarely, a patient actually notices that the unusual sensations are mainly in the medial side of the ring finger (fourth digit) rather than the lateral side, corresponding to the textbook sensory distribution. Sometimes the third digit is also involved, especially on the ulnar (ie, medial) side. The sensory changes can be a feeling of numbness or a tingling or burning. Pain rarely occurs in the hand. Complaints of pain tend to be more common in the arm, up to and including the elbow area. Indeed, the elbow is probably the most common site of pain in an ulnar neuropathy. Occasionally, patients specifically say “I have pain in my elbow,” “I have pain in my funny bone,” or even “I have pain in this little groove in my elbow,” but usually they are not quite so explicit unless prompted. Patients rarely notice specific muscle atrophy.

Weakness may also be a presenting complaint, but the complaint may be expressed in subtle ways.

One traditional sign of ulnar neuropathy, Wartenberg sign, is actually a complaint of weakness. The patient complains that the little finger gets caught on the edge of the pants pocket when he or she puts the hands into the pocket. At first, that complaint seems surprising because most physicians remember that finger abduction is governed by the ulnar nerve. So the physician might think that with an ulnar neuropathy, the patient would have less tendency to have the little finger abducted and thus caught on the edge of the pocket. But adduction is also mediated by the ulnar nerve. In essence, the patient cannot abduct the fifth digit tightly against the fourth because of weakness of the interosseous muscles.

In addition, the muscle that extends the fifth digit at the metacarpal phalangeal joint (extensor digiti quinti) is radially innervated and it inserts on the ulnar side of the joint. Normally this muscle is opposed by ulnar innervated muscles that flex the joints. But with an ulnar neuropathy, the muscle is relatively unopposed so it pulls the finger up and to the ulnar side. This is the perfect position to catch onto the edge of the pocket.

The patient also may express the complaint of weakness by saying “my grip is weak.” Many of the grip muscles are ulnar. Also, when someone tries to grip powerfully, the hand usually deviates in the ulnar direction under the influence of the flexor carpi ulnaris. If this ulnar deviation is impaired, the grip mechanism does not work optimally even for the muscles that are unimpaired.

Sometimes a patient notices that his pincer grip (pinching with the thumb and index finger) is weak. Two of the key muscles involved in this movement are the adductor pollicis (which adducts the thumb) and first dorsal interosseus, which adducts the index finger. Not only may the pincer grip be weak in an ulnar neuropathy, the median innervated flexor pollicis longus partially compensates for the weakened adductor pollicis and the thumb flexes at the distal joint. Usually a patient does not notice the thumb flexion, but when demonstrated by the examiner, this flexion is considered to be Froment sign.

Next

Physical

On physical examination, numerous findings offer clues to the existence of ulnar compression.

In addition to assessing sensation and testing individual muscle strength, inspection of the hand may reveal a clawed posture (called main en griffe in French).

Several factors contribute to the clawed appearance. Wasting of the intrinsic muscles of the hand makes it look bonier. The fourth and fifth digits extend at the metacarpal phalangeal joint because the extensors at that joint are radially innervated, whereas the flexors are innervated by the ulnar. Also, the fifth digit deviates slightly in the medial direction because, as explained for Wartenberg sign, the muscle that extends the fifth digit at the metacarpal phalangeal joint is radially innervated and it inserts on the ulnar side of the joint.

The fourth and fifth interphalangeal joints flex because for them the extensor muscles are also ulnar and the natural tension of the muscles and tendons in the absence of strong muscle activity in either direction leads to flexion. The first 3 digits are extended at both the metacarpal phalangeal joints and the interphalangeal joints because of the unopposed radial nerve innervation. All these factors make the hand look somewhat like a claw.

A different interpretation of the posture is that it looks like the hand gesture that a Catholic priest makes in the process of conferring a blessing, and thus it is sometimes called the benediction sign or the benediction hand.

Froment sign is an observable sign that correlates with the complaint of weakness of the ability to pinch normally between the first and second digits.

This sign is sometimes elicited by asking the patient to grasp a piece of paper between the thumb and index finger. Ordinarily, the grasp is tight and the patient makes heavy use of the adductor pollicis to adduct the thumb and the first dorsal interosseus to move the index finger.

In addition to overt weakness of the pinch, the examiner also notes that the thumb flexes at the interphalangeal joint because the flexor pollicis longus activates in an attempt to compensate for the weakness. Thus, in addition to the weakness, the examiner sees the flexion of the tip of the thumb.

Ulnar neuropathy at the elbow

Positive Tinel sign at the elbow

The examiner taps with a reflex hammer over the ulnar nerve in the ulnar groove and a little further distal over the cubital tunnel. The test is positive if the patient experiences definite paresthesias in the ulnar portion of the hand, especially the last 2 digits. This test is not considered highly sensitive, but it is considered to be quite specific if performed properly (eg, not hit too hard). If the examiner hits hard enough, many normal individuals experience paresthesias in the fourth and fifth digits. Assuming the complaint is unilateral, the opposite side is a good control for this. Sometimes palpating the nerve in the ulnar groove may produce a similar result.

Atrophy and muscle weakness

The most important ulnar hand muscles to test are the first dorsal interosseous and the abductor digiti minimi (abductor digiti quinti). In the forearm, the flexor digitorum profundus of the fourth and fifth digits (which flexes the distal phalanges of those fingers) and the flexor carpi ulnaris (flexion at the wrist in the ulnar direction) are valuable to examine. Of these latter 2 muscles, it is not uncommon for the flexor carpi ulnaris to be spared in ulnar lesions near the elbow, especially the lower (more distal) lesion near the elbow. Sparing occurs because the branch to the flexor carpi ulnaris splits off from the main trunk prior to (ie, above or proximal to) the compression.[33]

The ulnar muscles should not be examined in isolation from other muscles. In particular, several key muscles with C8/T1, lower trunk, medial cord innervation should be examined, especially the abductor pollicis brevis (a thenar muscle typically involved with carpal tunnel syndrome, the major compressive median nerve neuropathy) and the median innervated long thumb and index finger flexors.

If both the ulnar intrinsics hand muscles and the ulnar forearm muscles are involved, then an ulnar nerve lesion should be suspected in the region of the elbow (or, very rarely, above the elbow region). If the ulnar forearm muscles are spared, considering the possibility of a lesion at the wrist is reasonable, but extra caution is warranted in this case. Sometimes the forearm muscles are spared with a lesion near the elbow, especially if the lesion is in the lower elbow region in or around the cubital tunnel. Even for higher elbow lesions, there can be considerable selectivity in which muscles are affected because the ulnar nerve is organized into a number of separate fascicles. Sometimes some fascicles are severely affected by whatever is pinching the nerve and other fascicles are unaffected. If other C8/T1, lower trunk, medial cord muscles are affected, a C8/T1 radiculopathy or a brachial plexus lesion may be the cause.

Ulnar neuropathy at or distal to the wrist

Weakness of the interossei and hypothenar muscles only with no sensory loss: This would most likely be due to compression of the deep motor branch in the hand after it had separated from the superficial terminal sensory branch but before the branch to the hypothenar muscles had taken off.

Interosseus weakness only with no sensory loss: This would most likely be due to compression of the deep motor branch after the branch to the hypothenar muscles has taken off.

Weakness of the interossei and hypothenar muscles with sensory involvement in the fifth digit: This would suggest involvement in Guyon canal with compression of both the deep motor branch and the superficial terminal sensory branch. This might be said to be the typical or classical Guyon canal pattern.

Pure sensory loss with normal dorsal ulnar cutaneous sensory nerve, normal palmar cutaneous sensory nerve, and normal motor responses: This would imply injury to the superficial terminal sensory branch alone, probably a compression distal to Guyon canal.

Interossei weakness and sensory loss with preserved function in the hypothenar and dorsal ulnar cutaneous territories: This would imply a compression of the deep motor branch and the superficial terminal sensory branch distal to the point where the sub-branch to the hypothenar area (eg, the ADM) had split off the deep motor branch.

Sensory examination

Adding information from the sensory examination to that of the motor examination helps to localize the ulnar lesion. The image below, which has been discussed earlier in the context of the anatomy of the ulnar nerve, shows the ulnar sensory regions on the hand. Jacob et al have published a beautiful case report, complete with MRI pictures, on such a case.[34]

This diagram shows the ulnar nerve distal to the eThis diagram shows the ulnar nerve distal to the elbow region. The dorsal ulnar cutaneous nerve (lavender) branches off the main trunk (blue). Although the course is not followed in detail after that, the lavender region on the sensory dermatome diagram shows where this sensory nerve innervates the skin. Similarly, the palmar cutaneous sensory nerve (yellow) branches off to innervate the skin area depicted in yellow. The superficial terminal branch is mostly sensory (see green colored skin on palmar surface), though it also gives a branch to the palmaris brevis muscle. The deep terminal branch has no corresponding skin area because it is solely motor innervating the muscles shown, as well as some others not explicitly depicted. Of course the nerve could be pinched or injured anywhere, but the sites listed with Roman numerals I-IV are the relatively common sites.

Although the area of the palmar cutaneous sensory nerve can extend a bit more proximal than shown, if the sensory involvement extends more than an inch above the wrist crease along the medial aspect of the forearm, the nerve roots (C8/T1) or brachial plexus most likely are involved (but in some cases this could be in addition to an ulnar injury).

As previously noted, both the palmar cutaneous sensory branch of the ulnar and the dorsal ulnar cutaneous branch come off of the main ulnar branch above (proximal to) the wrist. Thus, a lesion exclusively at the wrist (Guyon canal) would miss these branches and the superficial terminal branch would be the only sensory involvement. However, a physician must be cautious in interpretation.

Typically, neuropathic damage, whether generalized or related to nerve compression, affects (or is perceived to affect) the most distal parts of the nerves preferentially. A compression at Guyon canal might be perceived by the patient and might be detectable on examination only in the tips of the fingers. Thus, the compression would appear to be affecting only the superficial terminal branch.[35, 36, 37]

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Next

Causes

Ulnar nerve at or near the elbow

  • Compression during general anesthesia
  • Blunt trauma
  • Deformities (eg, rheumatoid arthritis)
  • Metabolic derangements (eg, diabetes)
  • Transient occlusion of brachial artery during surgery[38]
  • Subdermal contraceptive implant[39]
  • Venipuncture[40]
  • Hemophilia[41] leading to hematomas
  • Malnutrition leading to muscle atrophy and loss of fatty protection across the elbow and other joints
  • Cigarette smoking[42]

Ulnar neuropathy at or distal to the wrist (ie, at Guyon's canal)

  • Ganglionic cysts
  • Tumors
  • Blunt injuries with or without fracture
  • Aberrant artery
  • Idiopathic
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Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Charles F Guardia III, MD  Resident Physician, Department of Neurology, Dartmouth Hitchcock Medical Center

Charles F Guardia III, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, and Radiological Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Stephen A Berman, MD, PhD, MBA  Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Christina J Azevedo MD  Staff Physician, Department of Neurology, Dartmouth-Hitchcock Medical Center

Christina J Azevedo MD is a member of the following medical societies: American Academy of Neurology

Disclosure: Nothing to disclose.

Specialty Editor Board

Paul E Barkhaus, MD  Professor, Department of Neurology, Medical College of Wisconsin; Director of Neuromuscular Diseases, Milwaukee Veterans Affairs Medical Center

Paul E Barkhaus, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Neurological Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

Neil A Busis, MD  Chief, Division of Neurology, Department of Medicine, Head, Clinical Neurophysiology Laboratory, University of Pittsburgh Medical Center-Shadyside

Neil A Busis, MD is a member of the following medical societies: American Academy of Neurology and American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Selim R Benbadis, MD  Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association

Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Chief Editor

Nicholas Lorenzo, MD  Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants

Nicholas Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and American College of Physician Executives

Disclosure: Nothing to disclose.

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This is a schematic diagram of the elbow region. The 5 main sites as given by Posner are labeled 1-5. Other sites and structures are also named. The main regions of interest are circled with pastel colored arrows. Sites 2 and 3 are close together and distinguishing them by EMG and nerve conduction studies is not possible. The term ulnar groove or retrocondylar groove are used to describe this location.
This diagram shows the ulnar nerve distal to the elbow region. The dorsal ulnar cutaneous nerve (lavender) branches off the main trunk (blue). Although the course is not followed in detail after that, the lavender region on the sensory dermatome diagram shows where this sensory nerve innervates the skin. Similarly, the palmar cutaneous sensory nerve (yellow) branches off to innervate the skin area depicted in yellow. The superficial terminal branch is mostly sensory (see green colored skin on palmar surface), though it also gives a branch to the palmaris brevis muscle. The deep terminal branch has no corresponding skin area because it is solely motor innervating the muscles shown, as well as some others not explicitly depicted. Of course the nerve could be pinched or injured anywhere, but the sites listed with Roman numerals I-IV are the relatively common sites.
An example of the inching technique used to isolate conduction block in the left ulnar nerve. Note the significant amplitude drop at the 305-mm distance that correlates with a position 2 cm above the medial epicondyle. This is an example of supracondylar block. Image courtesy of AS Lorenzo, MD.
The normal median and ulnar pattern are compared with that of the 3 commonly recognized types of the Martin-Gruber anomaly.
The first 3 traces correspond to the ulnar compound muscle action potential (CMAP) amplitude while recording at the abductor digitorum quinti (ADQ) and stimulating at the wrist, below the elbow, and above the elbow, respectively. The fourth trace corresponds to stimulation of the median nerve at the elbow while recording at ADQ. Though CMAP amplitude is reduced markedly above the elbow, this is compensated by adding the response seen after stimulating the median nerve; this represents the Martin-Gruber anastomosis.
The first 3 traces correspond to stimulation of the ulnar nerve while recording at the first dorsal interosseous (FDI) muscle at the wrist, below the elbow, and above the elbow, respectively. The fourth trace corresponds to stimulation of the median nerve at the elbow while recording at FDI. This represents the Martin-Gruber anastomosis.
In people with the Martin-Gruber anomaly who do not otherwise have significant neuropathy or nerve compressions, here is what happens when the relevant nerves are stimulated. Median stimulation: Stimulation at the elbow yields a larger compound muscle action potential (CMAP) at the hypothenar muscles, the first dorsal interosseus (FDI), or the thenar muscles (or a combination of these) than does stimulation at the wrist. Ulnar stimulation: Stimulation at the wrist yields a larger CMAP at the hypothenar muscles, the FDI, or the thenar muscles (or a combination of these) than does stimulation at the elbow. Larger and smaller generally means a difference of 1.0 millivolt in amplitude or more.
The Riche-Cannieu anastomosis is a communication between the recurrent branch of median nerve and deep branch of ulnar nerve in the hand. Although it is present in 77% of hands, the extent to which it makes a detectable physiological difference is quite variable. In many hands it seems to contribute little and it does not affect the diagnostic findings at all. Probably the most common effect of the anomaly is to give an ulnar innervation to some muscles that are usually innervated by the median nerve and/or vice versa. The most extreme version of this is the very rare all ulnar hand. Two examples of the confusion this might cause are (1) a median lesion could cause denervation in a typical ulnar muscle such as the adductor digiti minimi (ADM, also called adductor digiti quinti [ADQ]) or the first dorsal interosseus and (2) an ulnar lesion could cause denervation in typically median muscles such as the flexor pollicis brevis (FPB) or the abductor pollicis brevis (APB).
Table 1. Martin-Gruber Anastomosis
TypeAnatomyMost Characteristic FindingConfirmationAdditional VerificationClinical Confusion
ICrossover fibers innervate hypothenar musclesUlnar stimulation at wrist produces larger hypothenar CMAP than stimulation at elbow.Stimulation of median nerve at elbow produces response at hypothenar muscles.Hypothenar CMAP from ulnar stimulation at wrist = Hypothenar CMAP from ulnar stimulation at elbow, plus hypothenar CMAP from median stimulation at elbow Smaller response from proximal stimulation could be mistaken for conduction block.
IICrossover fibers innervate the FDI.Ulnar stimulation at wrist produces larger FDI CMAP than stimulation at elbow.Stimulation of median nerve at elbow produces response at FDI.FDI CMAP from ulnar stimulation at wrist = FDI CMAP from ulnar stimulation at elbow plus FDI CMAP from median stimulation at elbow. Usually none because FDI is not usually a recording site. If it is used, conduction block could be suspected as in type I.
IIICrossover fibers innervate thenar muscles (typically ADP and FPB).Elbow stimulation of median nerve produces greater thenar response than does wrist stimulation.Ulnar stimulation produces thenar CMAP with initial positive deflection. It is higher with wrist stimulation than with elbow stimulation. For thenar CMAP amplitudes, median elbow stimulation amp = median wrist stimulation amp plus ulnar wrist stimulation amp – ulnar elbow stimulation amp Can complicate median nerve studies, especially involving carpal tunnel syndrome.
Abbreviations: CMAP: Compound motor (or muscle) action potential



FDI: First dorsal interosseus



ADP: Adductor pollicis



FPB: Flexor pollicis brevis



Median stimulation: Stimulation at the elbow yields a larger CMAP at the hypothenar muscles, the FDI, or the thenar muscles (or sometimes in a combination of these) than does stimulation at the wrist.



Ulnar stimulation: Stimulation at the wrist yields a larger CMAP at the hypothenar muscles, the FDI, or the thenar muscles (or sometimes in a combination of these) than does stimulation at the elbow.



Note: Larger and smaller generally means a difference of 1 millivolt in amplitude or more.



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