Ulnar Neuropathy Medication

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

Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Next

Tricyclic Antidepressants (TCA)

Class Summary

TCAs are effective in painful paresthesias. While the dosages are similar, the drugs in this category vary in their sedative properties. Amitriptyline can be used if the patient suffers from insomnia, while nortriptyline and desipramine are better choices when sedation becomes a problem.

View full drug information

Amitriptyline (Elavil)

 

By inhibiting reuptake of serotonin and/or norepinephrine by presynaptic neuronal membrane, may increase their synaptic concentrations in CNS. Dose may be increased slowly up to maximum of 125 mg/d. If no response, different TCA may be of benefit, but more often drugs from different category such as anticonvulsants are preferable.

View full drug information

Nortriptyline (Aventyl HCl, Pamelor)

 

Has demonstrated effectiveness in treatment of chronic pain. By inhibiting reuptake of serotonin and/or norepinephrine by presynaptic neuronal membrane, may increase synaptic concentrations in CNS.

Pharmacodynamic effects, such as desensitization of adenyl cyclase and down-regulation of beta-adrenergic receptors and serotonin receptors, also appear to play role in its mechanisms of action.

View full drug information

Duloxetine (Cymbalta)

 

Indicated for diabetic peripheral neuropathic pain. Potent inhibitor of neuronal serotonin and norepinephrine reuptake.

Previous
Next

Anti-Arrhythmic/Local Anesthetics

Class Summary

Mexiletine, which has been used in various forms as an antiarrhythmic and local anesthetic, tends to blunt some of the stinging and burning of neuropathic pain in some patients. It is categorized as off-label use for diabetic neuropathy.

View full drug information

Mexiletine (Mexitil)

 

An orally active local anesthetic drug structurally related to lidocaine. May operate by reducing spontaneous discharges from damaged primary small nerve fibers; recommended only in intractable cases; can be used for both dysesthetic and paresthetic pain.

Previous
Next

Narcotics

Class Summary

Although traditionally narcotics have been avoided in peripheral neuropathies, they are useful in many cases.

View full drug information

Morphine sulfate (Astramorph, MS Contin, MSIR, Oramorph)

 

DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

Various IV doses are used; commonly titrated until desired effect obtained.

Previous
Next

Anticonvulsants

Class Summary

Many anticonvulsants are used to alleviate painful dysesthesias, which frequently accompany peripheral neuropathies. Although they have many different mechanisms of action, their use to alleviate neuropathic pain probably depends on the fact that they generally tend to reduce neuronal excitability.

View full drug information

Gabapentin (Neurontin)

 

Membrane stabilizer, a structural analogue of inhibitory neurotransmitter GABA, which paradoxically is thought not to exert effect on GABA receptors. Appears to exert action via the alpha(2)delta-1 and alpha(2)delta-2 auxiliary subunits of voltage-gated calcium channels.

Used to manage pain and provide sedation in neuropathic pain.

View full drug information

Pregabalin (Lyrica)

 

Structural derivative of GABA. Mechanism of action unknown. Binds with high affinity to alpha2-delta site (a calcium channel subunit). In vitro, reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.

View full drug information

Lamotrigine (Lamictal)

 

Triazine derivative useful in treatment of neuralgia. Inhibits release of glutamate and inhibits voltage-sensitive sodium channels, which stabilizes neuronal membrane. Follow manufacturer's recommendation for dose adjustments.

View full drug information

Topiramate (Topamax)

 

Precise mechanism unknown, but the following properties may contribute to its efficacy: (1) electrophysiological and biochemical evidence showing blockage of voltage-dependent sodium channels, (2) augments the activity of the neurotransmitter GABA at some GABA-A receptor subtypes, (3) antagonizes AMPA/kainate subtype of the glutamate receptor, and (4) inhibits the carbonic anhydrase enzyme, particularly isozymes II and IV.

View full drug information

Levetiracetam (Keppra)

 

Another new anticonvulsant being used to combat pain of peripheral neuropathies. Mechanism that improves condition not known but probably related to fact that anticonvulsants generally reduce nerve irritability. Not FDA approved for this indication.

View full drug information

Phenytoin (Dilantin)

 

Blocks sodium channels nonspecifically and therefore reduces neuronal excitability in sensitized C-nociceptors. Has been demonstrated effective in neuropathic pain but suppresses insulin secretion and may precipitate hyperosmolar coma in patients with diabetes.

Antineuralgic effects may derive from the blocking of posttetanic potentiation by reducing summation of temporal stimulation.

View full drug information

Carbamazepine (Tegretol, Carbatrol, Epitol)

 

A sodium-channel blocker that typically provides substantial or complete relief of pain in 80% of individuals with both idiopathic and MS-associated TN within 24-48 h. Reduces sustained high-frequency repetitive neural firing. Potent enzyme inducer that can induce own metabolism. Due to potentially serious blood dyscrasias, undertake benefit-to-risk evaluation before drug instituted. Therapeutic plasma levels are between 4-12 mcg/mL for analgesic and antiseizure response. Peak serum levels in 4-5 h. Half-life (serum) in 12-17 h with repeated doses. Metabolized in liver to active metabolite (ie, epoxide derivative) with half-life of 5-8 h. Metabolites excreted through feces and urine.

View full drug information

Oxcarbazepine (Trileptal)

 

Pharmacologic activity primarily by 10-monohydroxy metabolite (MHD). Studies indicate that this drug may block voltage-sensitive sodium channels, inhibit repetitive neuronal firing, and impair synaptic impulse propagation. Anticonvulsant effect also may occur by affecting potassium conductance and high-voltage activated calcium channels. Pharmacokinetics similar in older children (>8 y) and adults. Young children (< 8 y) have 30-40% greater clearance than older children and adults. Children < 2 y have not been studied in controlled clinical trials. Not FDA approved for this indication.

Previous
Proceed to Follow-up
 
 
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.

References

  1. Campbell WW, Pridgeon RM, Riaz G, Astruc J, Sahni KS. Variations in anatomy of the ulnar nerve at the cubital tunnel: pitfalls in the diagnosis of ulnar neuropathy at the elbow. Muscle Nerve. Aug 1991;14(8):733-8. [Medline].

  2. Aguiar PH, Bor-Seng-Shu E, Gomes-Pinto F, Almeida- Leme RJ, Freitas AB, Martins RS, et al. Surgical management of Guyon's canal syndrome, an ulnar nerve entrapment at the wrist: report of two cases. Arq Neuropsiquiatr. Mar 2001;59(1):106-11. [Medline].

  3. Bradshaw DY, Shefner JM. Ulnar neuropathy at the elbow. Neurol Clin. Aug 1999;17(3):447-61, v-vi. [Medline].

  4. Feindel W, J Stratford J. Cubital tunnel compression in tardy ulnar palsy. Can Med Assoc J. Mar 1 1958;78(5):351-3. [Medline].

  5. Miller RG. The cubital tunnel syndrome: diagnosis and precise localization. Ann Neurol. Jul 1979;6(1):56-9. [Medline].

  6. Panas J. Sur une cause peu connue de paralysie du nerf cubital. Archives Generales de Medecine. 1878;2 (VII Serie).

  7. Murphy JB. Neuroma of the Ulnar Nerve, Result of Cicatricial Compression Following Unrecognised Fracture. The Clinics of John B. Murphy. 1914;3:369.

  8. Brickner WM. Late Ulnar Nerve Palsy Following Elbow Fracture in the Adult. Journal of Bone and Joint Surgery Am. 1924;6:477-481.

  9. Mouchet A. Paralysies tardives du nerfcubital a Ia suite des fractures du condyle externe de l’humerus. Journal de Chirurgie. 1914;12:437.

  10. Mouchet A. These de docteur, Paris (as cited in Miller, 1924). 1898.

  11. Miller EM. Late Ulnar Nerve Palsy. Surgery, Gynecology and Obstetrics. 1924;38:37-46.

  12. Buzzard EF. Some varieties of toxic and traumatic ulnar neuritis. Lancet. 1922;1:317-319.

  13. SARGENT P and BUZZARD EF. Some Varieties of Traumatic and Toxic Ulnar Neuritis. Brain. 1922;45:133-140.

  14. Stern M, Steinmann SP. Ulnar Nerve Entrapment. eMedicine. [Full Text].

  15. Posner MA. Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Orthop Surg. Sep-Oct 1998;6(5):282-8. [Medline].

  16. Halikis MN, Taleisnik J, Szabo RM. Compression neuropathies of the upper extremity. In: Chapman MW, ed. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001:40-99.

  17. Ochiai N, Honmo J, Tsujino A. Electrodiagnosis in entrapment neuropathy by the arcade of Struthers. Clin Orthop Relat Res. Sep 2000;129-35. [Medline].

  18. Ochiai N, Hayashi T, Ninomiya S. High ulnar nerve palsy caused by the arcade of Struthers. J Hand Surg [Br]. Dec 1992;17(6):629-31. [Medline].

  19. Siqueira MG, Martins RS. The controversial arcade of Struthers. Surg Neurol. 2005;64 Suppl 1:S1:17-20; discussion S1:20-1. [Medline].

  20. Kane E, Kaplan EB, Spinner M. [Observations of the course of the ulnar nerve in the arm]. Ann Chir. May 1973;27(5):487-96. [Medline].

  21. Bartels RH, Grotenhuis JA, Kauer JM. The arcade of Struthers: an anatomical study. Acta Neurochir (Wien). Apr 2003;145(4):295-300; discussion 300. [Medline].

  22. Wehrli L, Oberlin C. The internal brachial ligament versus the arcade of Struthers: an anatomical study. Plast Reconstr Surg. Feb 2005;115(2):471-7. [Medline].

  23. von Schroeder HP, Scheker LR. Redefining the "Arcade of Struthers". J Hand Surg [Am]. Nov 2003;28(6):1018-21. [Medline].

  24. Neary D, Eames RA. The pathology of ulnar nerve compression in man. Neuropathol Appl Neurobiol. 1975;1:69-88.

  25. Campbell WW. Ulnar neuropathy at the elbow. Muscle Nerve. Apr 2000;23(4):450-2. [Medline].

  26. Olney RK, Wilbourn AJ, Miller RG. Ulnar neuropathy at or distal to the wrist (abstr). Neurology. 1983;33(Suppl 2):185.

  27. Olney RK, Hanson M. AAEE case report #15: ulnar neuropathy at or distal to the wrist. Muscle Nerve. Aug 1988;11(8):828-32. [Medline].

  28. Contreras MG, Warner MA, Charboneau WJ, Cahill DR. Anatomy of the ulnar nerve at the elbow: potential relationship of acute ulnar neuropathy to gender differences. Clin Anat. 1998;11(6):372-8. [Medline].

  29. Stewart JD. The variable clinical manifestations of ulnar neuropathies at the elbow. J Neurol Neurosurg Psychiatry. Mar 1987;50(3):252-8. [Medline].

  30. Ho S. Factors for Ulnar Neuropathy at the Elbow: A Prospective Study. Archives of Physical Medicine and Rehabilitation. 2006;87, Issue 11:e15-e16.

  31. Gay JR, Love JG. Diagnosis and treatment of tardy paralysis of the ulnar nerve. J Bone Jt Surg. 1947;29:1087-1097.

  32. Chang KSF, Low WD, Chan ST, et al. Enlargement of the ulnar nerve behind the median epicondyle. Anat Rec. 1963;145:149-153.

  33. Hwang K, Jin S, Hwang SH, Lee KM, Han SH. Location of nerve entry points of flexor digitorum profundus. Surg Radiol Anat. Dec 2007;29(8):617-21. [Medline].

  34. Jacob A, Moorthy TK, Thomas SV, Sarada C. Compression of the deep motor branch of the ulnar nerve: an unusual cause of pure motor neuropathy and hand wasting. Arch Neurol. May 2005;62(5):826-7. [Medline].

  35. Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg [Am]. Nov 2008;33(9):1518-24. [Medline].

  36. Goldman SB, Brininger TL, Schrader JW, Koceja DM. A Review of Clinical Tests and Signs for the Assessment of Ulnar Neuropathy. J Hand Ther. Feb 1 2009;[Medline].

  37. Rosati M, Martignoni R, Spagnolli G. Clinical validity of the elbow flexion test for the diagnosis of ulnar nerve compression at the cubital tunnel. Acta Orthop Belg. Dec 1998;64(4):366-70. [Medline].

  38. Swenson JD, Hutchinson DT, Bromberg M, Pace NL. Rapid onset of ulnar nerve dysfunction during transient occlusion of the brachial artery. Anesth Analg. Sep 1998;87(3):677-80. [Medline].

  39. Marin R, McMillian D. Ulnar neuropathy associated with subdermal contraceptive implant. South Med J. Sep 1998;91(9):875-8. [Medline].

  40. Masoorli S, Angeles T, Barbone M. Danger points. How to prevent nerve injuries from venipuncture. Nursing. Sep 1998;28(9):34-9; quiz 40. [Medline].

  41. Chang C, Shen M. Mononeuropathy multiplex in hemophilia: an electrophysiologic assessment. Eur Neurol. Jul 1998;40(1):15-8. [Medline].

  42. Richardson JK, Jamieson SC. Cigarette smoking and ulnar mononeuropathy at the elbow. Am J Phys Med Rehabil. Sep 2004;83(9):730-4. [Medline].

  43. Mondelli M, Aretini A, Rossi S. Ulnar neuropathy at the elbow in diabetes. Am J Phys Med Rehabil. Apr 2009;88(4):278-85. [Medline].

  44. Beekman R, Schoemaker MC, Van Der Plas JP, Van Den Berg LH, Franssen H, Wokke JH, et al. Diagnostic value of high-resolution sonography in ulnar neuropathy at the elbow. Neurology. Mar 9 2004;62(5):767-73. [Medline].

  45. Granata G, Martinoli C, Pazzaglia C, Caliandro P, Padua L. Relationships between ultrasonographic, clinical, and neurophysiological findings in ulnar neuropathy at elbow (UNE): author's response to Mauro Mondelli. Neurophysiol Clin. Feb 2009;39(1):49-50; author reply 51-2. [Medline].

  46. Shen PC, Chern TC, Wu KC, Tai TW, Jou IM. The assessment of the ulnar nerve at the elbow by ultrasonography in children. J Bone Joint Surg Br. May 2008;90(5):657-61. [Medline].

  47. Choi AL, Koh SH, Jun SY, Hwang HS, Cho HW, Jang KM, et al. Lymphoma involving the ulnar nerve: sonographic findings. J Ultrasound Med. Oct 2008;27(10):1527-31. [Medline].

  48. Ginanneschi F, Filippou G, Milani P, Biasella A, Rossi A. Ulnar nerve compression neuropathy at Guyon's canal caused by crutch walking: case report with ultrasonographic nerve imaging. Arch Phys Med Rehabil. Mar 2009;90(3):522-4. [Medline].

  49. Yoon JS, Walker FO, Cartwright MS. Ultrasonographic swelling ratio in the diagnosis of ulnar neuropathy at the elbow. Muscle Nerve. Oct 2008;38(4):1231-5. [Medline].

  50. Cartwright MS, Chloros GD, Walker FO, Wiesler ER, Campbell WW. Diagnostic ultrasound for nerve transection. Muscle Nerve. Jun 2007;35(6):796-9. [Medline].

  51. Bianchi S. Ultrasound of the Peripheral Nerves. Joint Bone Spine. September 2008;75:643-649.

  52. Andreisek G, Crook D, Burg D, Marinek B, Weishaupt D. Peripheral Neuropathies of the Median, Radial and Ulnar Nerves: Magnetic Resonance Imaging Features. Radiographics. 2006;26:1267-1287.

  53. Vucic S, Coradato DJ, Yiannikas C, Schwartz RS, Shnier RS. Utility of Magnetic Resonance Imaging in Diagnosing Ulnar Neuropathy at the Elbow. Clinical Neurophysiology. 2006;117:590-595.

  54. Andreisek G et al. Upper Extremity Peripheral Neuropathies: Role and Impact of MRI on Patient Management. Journal of European Radiology. 2008;18:1953-1961.

  55. Husarik DB et al. Elbow Nerves: MRI Findings in 60 Asymptomatic Subjects - Normal Anatomy, Variants and Pitfalls. Radiology. 2009;10:2-13.

  56. Britz GW, Haynor DR, Kuntz C, Goodkin R, Gitter A, Maravilla K, et al. Ulnar nerve entrapment at the elbow: correlation of magnetic resonance imaging, clinical, electrodiagnostic, and intraoperative findings. Neurosurgery. Mar 1996;38(3):458-65; discussion 465. [Medline].

  57. Jewell D. Case Studies in the Diagnosis of Upper Extremity Pain using MRI. Journal of Hand Therapy. 2007;20:132-147.

  58. Aggarwal SK, Schneider LB, Ahmad BK. Clinical usefulness of ulnar motor responses recording from first dorsal interosseous. Muscle Nerve. 1995;18(9):1043.

  59. Gutmann L. AAEM minimonograph #2: important anomalous innervations of the extremities. Muscle Nerve. Apr 1993;16(4):339-47. [Medline].

  60. Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA. Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis. J Hand Surg [Am]. Oct 2008;33(8):1314.e1-12. [Medline].

  61. Nakajima M, Ono N, Kojima T, Kusunose K. Ulnar entrapment neuropathy along the medial intermuscular septum in the midarm. Muscle Nerve. May 2009;39(5):707-10. [Medline].

  62. Neary D, Ochoa J, Gilliatt RW. Sub-clinical entrapment neuropathy in man. J Neurol Sci. Mar 1975;24(3):283-98. [Medline].

  63. Rempel D, Dahlin L, Lundborg G. Pathophysiology of nerve compression syndromes: response of peripheral nerves to loading. J Bone Joint Surg Am. Nov 1999;81(11):1600-10. [Medline].

  64. Toussaint CP, Zager EL. What's new in common upper extremity entrapment neuropathies. Neurosurg Clin N Am. Oct 2008;19(4):573-81, vi. [Medline].

  65. Seror P. Treatment of ulnar nerve palsy at the elbow with a night splint. J Bone Joint Surg Br. Mar 1993;75(2):322-7. [Medline].

  66. Coppieters MW, Butler DS. Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. Jun 2008;13(3):213-21. [Medline].

  67. Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. Feb 16 2011;2:CD006839. [Medline].

  68. Svernlov B, Larsson M, Rehn K, Adolfsson L. Conservative treatment of the cubital tunnel syndrome. J Hand Surg Eur Vol. Apr 2009;34(2):201-7. [Medline].

  69. Matei CI, Logigian EL, Shefner JM. Evaluation of patients with recurrent symptoms after ulnar nerve transposition. Muscle Nerve. Oct 2004;30(4):493-6. [Medline].

  70. Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery. Mar 2005;56(3):522-30; discussion 522-30. [Medline].

  71. Biggs M, Curtis JA. Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery. Feb 2006;58(2):296-304; discussion 296-304. [Medline].

  72. Gervasio O, Gambardella G, Zaccone C, Branca D. Simple decompression versus anterior submuscular transposition of the ulnar nerve in severe cubital tunnel syndrome: a prospective randomized study. Neurosurgery. 2005;56(1):108-17; discussion 117. [Medline].

  73. Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI. Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg Br. Oct 2005;30(5):521-4. [Medline].

  74. Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone Joint Surg Am. Dec 2007;89(12):2591-8. [Medline].

  75. Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA. Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis. J Hand Surg Am. Oct 2008;33(8):1314.e1-12. [Medline].

  76. Geutjens GG, Langstaff RJ, Smith NJ, Jefferson D, Howell CJ, Barton NJ. Medial epicondylectomy or ulnar-nerve transposition for ulnar neuropathy at the elbow?. J Bone Joint Surg Br. Sep 1996;78(5):777-9. [Medline].

  77. Verheyden JR, Palmer AK. Cubital Tunnel Syndrome. eMedicine. [Full Text].

  78. Osborne GV. The surgical treatment of tardy ulnar neuritis. J Bone Joint Surg Am. 1957;39B:782.

  79. Beekman R, Wokke JH, Schoemaker MC, Lee ML, Visser LH. Ulnar neuropathy at the elbow: follow-up and prognostic factors determining outcome. Neurology. Nov 9 2004;63(9):1675-80. [Medline].

  80. Mandelli C, Baiguini M. Ulnar nerve entrapment neuropathy at the elbow: decisional algorithm and surgical considerations. Neurocirugia (Astur). Feb 2009;20(1):31-8. [Medline].

  81. Terzis JK, Kokkalis ZT. Outcomes of secondary reconstruction of ulnar nerve lesions: our experience. Plast Reconstr Surg. Oct 2008;122(4):1100-10. [Medline].

  82. Terzis JK, Kostopoulos VK. Vascularized ulnar nerve graft: 151 reconstructions for posttraumatic brachial plexus palsy. Plast Reconstr Surg. Apr 2009;123(4):1276-91. [Medline].

  83. Beekman R, Van Der Plas JP, Uitdehaag BM, Schellens RL, Visser LH. Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow. Muscle Nerve. Aug 2004;30(2):202-8. [Medline].

  84. Warner MA, Warner DO, Matsumoto JY, Harper CM, Schroeder DR, Maxson PM. Ulnar neuropathy in surgical patients. Anesthesiology. Jan 1999;90(1):54-9. [Medline].

  85. Saint-Cyr M, Kleinert HE. Compression of the ulnar nerve and spasm of the ulnar artery in Guyon's canal caused by a hypermobile pisiform bone. Scand J Plast Reconstr Surg Hand Surg. 2008;42(4):215-7. [Medline].

 
Previous
Next
 
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.



Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.