Sections

Medication

Medication Summary

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

Class Summary

Tricyclic antidepressants (TCAs) are effective in painful paresthesias. Whereas the drugs in this category are administered in similar dosages, their sedative properties vary. Amitriptyline may be given if the patient suffers from insomnia, whereas nortriptyline and desipramine are better choices when sedation becomes a problem.

Amitriptyline

View full drug information

Amitriptyline inhibits the reuptake of serotonin and norepinephrine by the presynaptic neuronal membrane and thus may increase their synaptic concentrations in the central nervous system (CNS). Therefore, the dosage may be increased slowly up to a maximum of 125 mg/day. If no response is obtained, a different TCA may provide some benefit, but more often, it is preferable to use a drug from another category (eg, an anticonvulsant).

Nortriptyline (Pamelor)

View full drug information

Nortriptyline has demonstrated effectiveness in the treatment of chronic pain. It inhibits the reuptake of serotonin and norepinephrine by the presynaptic neuronal membrane and thus may increase their synaptic concentrations in the CNS. In addition, the pharmacodynamic effects of nortriptyline (eg, desensitization of adenyl cyclase and downregulation of beta-adrenergic receptors and serotonin receptors) also appear to play a role in its mechanisms of action.

Desipramine (Norpramin)

View full drug information

Desipramine is a neurotransmitter reuptake inhibitor for norepinephrine and serotonin. It inhibits reuptake by the neuronal membrane, and it may also down-regulate beta-adrenergic receptors and serotonin receptors.

Duloxetine (Cymbalta, Irenka)

View full drug information

Duloxetine is indicated for diabetic peripheral neuropathic pain. It is a potent inhibitor of neuronal serotonin and norepinephrine reuptake.

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 used off label for diabetic neuropathy.

Mexiletine

View full drug information

Mexiletine is an orally active local anesthetic that is structurally related to lidocaine. It may operate by reducing spontaneous discharges from damaged primary small nerve fibers. Mexiletine is recommended only in intractable cases and can be used for both dysesthetic and paresthetic pain.

Class Summary

Traditionally, narcotics have been avoided in patients with peripheral neuropathies; however, they are useful in many cases.

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

View full drug information

Morphine sulfate is the drug of choice for analgesia in ulnar neuropathy because of its reliable and predictable effects, good safety profile, and ease with which its effects can be reversed with naloxone. Various intravenous dosages are used; the dosage is commonly titrated until the desired effect is obtained.

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 for alleviating neuropathic pain probably depends on their general tendency to reduce neuronal excitability.

Gabapentin (Neurontin, Gralise)

View full drug information

Gabapentin is a membrane stabilizer, a structural analogue of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA); paradoxically, it is thought not to exert an effect on GABA receptors. Instead, it acts via the alpha2-delta1 and alpha2-delta2 auxiliary subunits of voltage-gated calcium channels. Gabapentin is used to manage pain and provide sedation in neuropathic pain.

Pregabalin (Lyrica)

View full drug information

Pregabalin is a structural derivative of GABA. Its mechanism of action is unknown; it is known to bind with high affinity to alpha2-delta subunits of calcium channels. In vitro, pregabalin reduces the calcium-dependent release of several neurotransmitters, possibly by modulating calcium-channel function. It is approved by the US Food and Drug Administration (FDA) for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.

Lamotrigine (Lamictal)

View full drug information

Lamotrigine is a triazine derivatives useful in the treatment of neuralgia. It inhibits glutamate's release and voltage-sensitive sodium channels, stabilizing the neuronal membrane. The manufacturer's recommendation for dosage adjustments should be followed.

Topiramate (Topamax, Qudexy XR, Trokendi XR)

View full drug information

The precise mechanism by which topiramate acts is unknown. Still, the following properties may contribute to efficacy: (1) electrophysiologic and biochemical evidence showing blockage of voltage-dependent sodium channels, (2) augmentation of GABA activity at some GABA-A receptor subtypes, (3) antagonism of the AMPA/kainate subtype of the glutamate receptor, and (4) inhibition of carbonic anhydrase, particularly isozymes II and IV.

Levetiracetam (Keppra, Keppra XR)

View full drug information

Levetiracetam is another new anticonvulsant used to combat the pain of peripheral neuropathies. The mechanism by which it alleviates pain is not known but is probably related to the fact that anticonvulsants generally reduce nerve irritability. Levetiracetam is not FDA-approved for this indication.

Phenytoin (Dilantin, Phenytek)

View full drug information

Phenytoin blocks sodium channels nonspecifically and therefore reduces neuronal excitability in sensitized C-nociceptors. It is effective in neuropathic pain but suppresses insulin secretion and may precipitate hyperosmolar coma in patients with diabetes. Its antineuralgic effects may derive from blocking post-tetanic potentiation by reducing the summation of temporal stimulation.

Carbamazepine (Tegretol, Carbatrol, Epitol, Equetro)

View full drug information

Carbamazepine is a sodium-channel blocker that typically provides substantial or complete relief of pain in 80% of individuals with idiopathic and multiple sclerosis−associated trigeminal neuralgia within 24-48 hours. It reduces sustained high-frequency repetitive neural firing and is a potent enzyme inducer that can induce own metabolism. Because of the risk of potentially serious blood dyscrasias, a benefit-to-risk evaluation should be undertaken before drug administration is initiated.

Therapeutic plasma levels are between 4 and 12 µg/mL for analgesic and antiseizure response. Peak serum levels are reached in 4-5 hours. The serum half-life is 12-17 hours with repeated doses. Carbamazepine is metabolized in the liver to its active metabolite (ie, epoxide derivative) with a half-life of 5-8 hours. Metabolites are excreted via feces and urine.

Oxcarbazepine (Trileptal, Oxtellar XR)

View full drug information

The pharmacologic activity of oxcarbazepine is primarily exerted by the 10-monohydroxy metabolite (MHD). Studies indicate that this drug may block voltage-sensitive sodium channels, inhibiting repetitive neuronal firing and impairing synaptic impulse propagation. The anticonvulsant effect also may occur by affecting potassium conductance, and high-voltage activated calcium channels.

Pharmacokinetics are similar in older children (>8 years) and adults; young children (< 8 years) have 30-40% greater clearance than older children and adults. Children younger than two years have not been studied in controlled clinical trials. Oxcarbazepine is not FDA-approved for this indication.

Questions

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. 2001 Mar. 59(1):106-11. [QxMD MEDLINE Link].
Spinner M, Spencer PS. Nerve compression lesions of the upper extremity. A clinical and experimental review. Clin Orthop Relat Res. 1974 Oct. 46-67. [QxMD MEDLINE Link].
FEINDEL W, STRATFORD J. The role of the cubital tunnel in tardy ulnar palsy. Can J Surg. 1958 Jul. 1(4):287-300. [QxMD MEDLINE Link].
Hobson-Webb LD, Juel VC. Common Entrapment Neuropathies. Continuum (Minneap Minn). 2017 Apr. 23 (2, Selected Topics in Outpatient Neurology):487-511. [QxMD MEDLINE Link].
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. 1991 Aug. 14(8):733-8. [QxMD MEDLINE Link].
Szabo RM, Steinberg DR. Nerve Entrapment Syndromes in the Wrist. J Am Acad Orthop Surg. 1994 Mar. 2(2):115-123. [QxMD MEDLINE Link].
Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar nerve. J Am Acad Orthop Surg. 2007 Nov. 15(11):672-81. [QxMD MEDLINE Link].
Pearce C, Feinberg J, Wolfe SW. Ulnar neuropathy at the wrist. HSS J. 2009 Sep. 5(2):180-3; quiz 184-5. [QxMD MEDLINE Link]. [Full Text].
Kerr AT. The brachial plexus of nerves in man; the variations in its formation and branches. Am J Anat. 1918. 23:285.
Khoo D, Carmichael SW, Spinner RJ. Ulnar nerve anatomy and compression. Orthop Clin North Am. 1996 Apr. 27(2):317-38. [QxMD MEDLINE Link].
Spinner M, Kaplan EB. The relationship of the ulnar nerve to the medial intermuscular septum in the arm and its clinical significance. Hand. 1976 Oct. 8(3):239-42. [QxMD MEDLINE Link].
Spinner M. Nerve decompression. The Elbow. 1994. 183-206.
O'Driscoll SW, Horii E, Carmichael SW, Morrey BF. The cubital tunnel and ulnar neuropathy. J Bone Joint Surg Br. 1991 Jul. 73(4):613-7. [QxMD MEDLINE Link].
Gelberman RH, Yamaguchi K, Hollstien SB, Winn SS, Heidenreich FP Jr, Bindra RR, et al. Changes in interstitial pressure and cross-sectional area of the cubital tunnel and of the ulnar nerve with flexion of the elbow. An experimental study in human cadavera. J Bone Joint Surg Am. 1998 Apr. 80(4):492-501. [QxMD MEDLINE Link].
Lim BH, Toh CL, Wong HP, Pho RW. Cadaveric study on the vascular anatomy of the ulnar nerve at the elbow--a basis for anterior transposition?. Ann Acad Med Singapore. 1992 Sep. 21(5):689-93. [QxMD MEDLINE Link].
Bradshaw DY, Shefner JM. Ulnar neuropathy at the elbow. Neurol Clin. 1999 Aug. 17(3):447-61, v-vi. [QxMD MEDLINE Link].
Feindel W, J Stratford J. Cubital tunnel compression in tardy ulnar palsy. Can Med Assoc J. 1958 Mar 1. 78(5):351-3. [QxMD MEDLINE Link].
Miller RG. The cubital tunnel syndrome: diagnosis and precise localization. Ann Neurol. 1979 Jul. 6(1):56-9. [QxMD MEDLINE Link].
Panas J. Sur une cause peu connue de paralysie du nerf cubital. Archives Generales de Medecine. 1878. 2 (VII Serie):
Murphy JB. Neuroma of the Ulnar Nerve, Result of Cicatricial Compression Following Unrecognised Fracture. The Clinics of John B. Murphy. 1914. 3:369.
Brickner WM. Late Ulnar Nerve Palsy Following Elbow Fracture in the Adult. Journal of Bone and Joint Surgery Am. 1924. 6:477-481.
Mouchet A. Paralysies tardives du nerfcubital a Ia suite des fractures du condyle externe de lâ€™humerus. Journal de Chirurgie. 1914. 12:437.
Mouchet A. These de docteur, Paris (as cited in Miller, 1924). 1898.
Miller EM. Late Ulnar Nerve Palsy. Surgery, Gynecology and Obstetrics. 1924. 38:37-46.
Buzzard EF. Some varieties of toxic and traumatic ulnar neuritis. Lancet. 1922. 1:317-319.
SARGENT P and BUZZARD EF. Some Varieties of Traumatic and Toxic Ulnar Neuritis. Brain. 1922. 45:133-140.
Stern M, Steinmann SP. Ulnar Nerve Entrapment. Medscape Reference. [Full Text].
Posner MA. Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis. J Am Acad Orthop Surg. 1998 Sep-Oct. 6(5):282-8. [QxMD MEDLINE Link].
Halikis MN, Taleisnik J, Szabo RM. Compression neuropathies of the upper extremity. Chapman MW, ed. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001. 40-99.
Ochiai N, Honmo J, Tsujino A. Electrodiagnosis in entrapment neuropathy by the arcade of Struthers. Clin Orthop Relat Res. 2000 Sep. 129-35. [QxMD MEDLINE Link].
Ochiai N, Hayashi T, Ninomiya S. High ulnar nerve palsy caused by the arcade of Struthers. J Hand Surg [Br]. 1992 Dec. 17(6):629-31. [QxMD MEDLINE Link].
Siqueira MG, Martins RS. The controversial arcade of Struthers. Surg Neurol. 2005. 64 Suppl 1:S1:17-20; discussion S1:20-1. [QxMD MEDLINE Link].
Kane E, Kaplan EB, Spinner M. [Observations of the course of the ulnar nerve in the arm]. Ann Chir. 1973 May. 27(5):487-96. [QxMD MEDLINE Link].
Bartels RH, Grotenhuis JA, Kauer JM. The arcade of Struthers: an anatomical study. Acta Neurochir (Wien). 2003 Apr. 145(4):295-300; discussion 300. [QxMD MEDLINE Link].
Wehrli L, Oberlin C. The internal brachial ligament versus the arcade of Struthers: an anatomical study. Plast Reconstr Surg. 2005 Feb. 115(2):471-7. [QxMD MEDLINE Link].
von Schroeder HP, Scheker LR. Redefining the "Arcade of Struthers". J Hand Surg [Am]. 2003 Nov. 28(6):1018-21. [QxMD MEDLINE Link].
Neary D, Eames RA. The pathology of ulnar nerve compression in man. Neuropathol Appl Neurobiol. 1975. 1:69-88.
Kleinman WB. Cubital tunnel syndrome: anterior transposition as a logical approach to complete nerve decompression. J Hand Surg Am. 1999 Sep. 24(5):886-97. [QxMD MEDLINE Link].
Merolla G, Staffa G, Paladini P, Campi F, Porcellini G. Endoscopic approach to cubital tunnel syndrome. J Neurosurg Sci. 2008 Sep. 52(3):93-8. [QxMD MEDLINE Link].
Gellman H. Compression of the ulnar nerve at the elbow: cubital tunnel syndrome. Instr Course Lect. 2008. 57:187-97. [QxMD MEDLINE Link].
Campbell WW. Ulnar neuropathy at the elbow. Muscle Nerve. 2000 Apr. 23(4):450-2. [QxMD MEDLINE Link].
Olney RK, Wilbourn AJ, Miller RG. Ulnar neuropathy at or distal to the wrist (abstr). Neurology. 1983. 33(Suppl 2):185.
Olney RK, Hanson M. AAEE case report #15: ulnar neuropathy at or distal to the wrist. Muscle Nerve. 1988 Aug. 11(8):828-32. [QxMD MEDLINE Link].
Watchmaker GP, Lee G, Mackinnon SE. Intraneural topography of the ulnar nerve in the cubital tunnel facilitates anterior transposition. J Hand Surg Am. 1994 Nov. 19(6):915-22. [QxMD MEDLINE Link].
Pechan J, Julis I. The pressure measurement in the ulnar nerve. A contribution to the pathophysiology of the cubital tunnel syndrome. J Biomech. 1975 Jan. 8(1):75-9. [QxMD MEDLINE Link].
Bozentka DJ. Cubital tunnel syndrome pathophysiology. Clin Orthop Relat Res. 1998 Jun. 90-4. [QxMD MEDLINE Link].
Dellon AL. Musculotendinous variations about the medial humeral epicondyle. J Hand Surg Br. 1986 Jun. 11(2):175-81. [QxMD MEDLINE Link].
Green JR Jr, Rayan GM. The cubital tunnel: anatomic, histologic, and biomechanical study. J Shoulder Elbow Surg. 1999 Sep-Oct. 8(5):466-70. [QxMD MEDLINE Link].
Lundborg G, Dahlin LB. Anatomy, function, and pathophysiology of peripheral nerves and nerve compression. Hand Clin. 1996 May. 12(2):185-93. [QxMD MEDLINE Link].
Wilgis EF, Murphy R. The significance of longitudinal excursion in peripheral nerves. Hand Clin. 1986 Nov. 2(4):761-6. [QxMD MEDLINE Link].
Yang SN, Yoon JS, Kim SJ, Kang HJ, Kim SH. Movement of the ulnar nerve at the elbow: a sonographic study. J Ultrasound Med. 2013 Oct. 32(10):1747-52. [QxMD MEDLINE Link].
Yamaguchi K, Sweet FA, Bindra R, Gelberman RH. The extraneural and intraneural arterial anatomy of the ulnar nerve at the elbow. J Shoulder Elbow Surg. 1999 Jan-Feb. 8(1):17-21. [QxMD MEDLINE Link].
Childress HM. Recurrent ulnar-nerve dislocation at the elbow. Clin Orthop Relat Res. 1975 May. 168-73. [QxMD MEDLINE Link].
Sunderland S. Nerves and nerve injuries. 2nd ed. New York, NY: Churchhill Livingston; 1987. 728-74.
Sunderland S. Blood supply of the nerves of the upper limb in man. Arch Neurol Psychiatry. 1945. 53:91-115.
Sunderland S. Nerves and Nerve Injuries. New York, NY: Churchill Livingstone; 1968. 816-28.
Sunderland S, Hughes ES. Metrical and non-metrical features of the muscular branches of the ulnar nerve. J Comp Neurol. 1946. 85:113.
Dellon AL, Mackinnon SE. Human ulnar neuropathy at the elbow: clinical, electrical, and morphometric correlations. J Reconstr Microsurg. 1988 Apr. 4(3):179-84. [QxMD MEDLINE Link].
Szabo RM. Entrapment and compression neuropathies. Green D, Hotchkiss R, Pederson W, eds. Green’s Operative Hand Surgery. New York, NY: Churchill Livingstone; 1999. Vol 2.: 1422-9.
Posner MA. Compressive ulnar neuropathies at the elbow: II. treatment. J Am Acad Orthop Surg. 1998 Sep-Oct. 6(5):289-97. [QxMD MEDLINE Link].
Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973 Aug 18. 2(7825):359-62. [QxMD MEDLINE Link].
Seddon HJ. Surgical Disorders of the Peripheral Nerves. Edinburgh, Scotland: Churchill Livingstone; 1972.
Sunderland S. Nerves and Nerve Injuries. 2nd ed. London, England: Churchill Livingstone; 1978. 780-95.
McGOWAN AJ. The results of transposition of the ulnar nerve for traumatic ulnar neuritis. J Bone Joint Surg Br. 1950 Aug. 32-B(3):293-301. [QxMD MEDLINE Link].
Zimmerman NB, Kaye MB, Wilgis EF, Zimmerman RM, Dubin NH. Are standardized patient self-reporting instruments applicable to the evaluation of ulnar neuropathy at the elbow?. J Shoulder Elbow Surg. 2009 May-Jun. 18(3):463-8. [QxMD MEDLINE Link].
Charness ME. Unique upper extremity disorders of musicians. Millender, ed. Occupational Disorders of the Upper Extremity. New York, NY: Churchill Livingstone; 1992. 227-52.
McPherson SA, Meals RA. Cubital tunnel syndrome. Orthop Clin North Am. 1992 Jan. 23(1):111-23. [QxMD MEDLINE Link].
Rettig AC, Ebben JR. Anterior subcutaneous transfer of the ulnar nerve in the athlete. Am J Sports Med. 1993 Nov-Dec. 21(6):836-9; discussion 839-40. [QxMD MEDLINE Link].
Swenson JD, Hutchinson DT, Bromberg M, Pace NL. Rapid onset of ulnar nerve dysfunction during transient occlusion of the brachial artery. Anesth Analg. 1998 Sep. 87(3):677-80. [QxMD MEDLINE Link].
Marin R, McMillian D. Ulnar neuropathy associated with subdermal contraceptive implant. South Med J. 1998 Sep. 91(9):875-8. [QxMD MEDLINE Link].
Masoorli S, Angeles T, Barbone M. Danger points. How to prevent nerve injuries from venipuncture. Nursing. 1998 Sep. 28(9):34-9; quiz 40. [QxMD MEDLINE Link].
Chang C, Shen M. Mononeuropathy multiplex in hemophilia: an electrophysiologic assessment. Eur Neurol. 1998 Jul. 40(1):15-8. [QxMD MEDLINE Link].
Richardson JK, Jamieson SC. Cigarette smoking and ulnar mononeuropathy at the elbow. Am J Phys Med Rehabil. 2004 Sep. 83(9):730-4. [QxMD MEDLINE Link].
Gay JR, Love JG. Diagnosis and treatment of tardy paralysis of the ulnar nerve. J Bone Jt Surg. 1947. 29:1087-1097.
Chang KSF, Low WD, Chan ST, et al. Enlargement of the ulnar nerve behind the median epicondyle. Anat Rec. 1963. 145:149-153.
Ho S. Factors for Ulnar Neuropathy at the Elbow: A Prospective Study. Archives of Physical Medicine and Rehabilitation. 2006. 87, Issue 11:e15-e16.
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. [QxMD MEDLINE Link].
Stewart JD. The variable clinical manifestations of ulnar neuropathies at the elbow. J Neurol Neurosurg Psychiatry. 1987 Mar. 50(3):252-8. [QxMD MEDLINE Link].
Osborne GV. The surgical treatment of tardy ulnar neuritis. J Bone Joint Surg Am. 1957. 39B:782.
Beekman R, Wokke JH, Schoemaker MC, Lee ML, Visser LH. Ulnar neuropathy at the elbow: follow-up and prognostic factors determining outcome. Neurology. 2004 Nov 9. 63(9):1675-80. [QxMD MEDLINE Link].
Mandelli C, Baiguini M. Ulnar nerve entrapment neuropathy at the elbow: decisional algorithm and surgical considerations. Neurocirugia (Astur). 2009 Feb. 20(1):31-8. [QxMD MEDLINE Link].
Terzis JK, Kokkalis ZT. Outcomes of secondary reconstruction of ulnar nerve lesions: our experience. Plast Reconstr Surg. 2008 Oct. 122(4):1100-10. [QxMD MEDLINE Link].
Terzis JK, Kostopoulos VK. Vascularized ulnar nerve graft: 151 reconstructions for posttraumatic brachial plexus palsy. Plast Reconstr Surg. 2009 Apr. 123(4):1276-91. [QxMD MEDLINE Link].
Bartels RH, Menovsky T, Van Overbeeke JJ, Verhagen WI. Surgical management of ulnar nerve compression at the elbow: an analysis of the literature. J Neurosurg. 1998 Nov. 89(5):722-7. [QxMD MEDLINE Link].
Heithoff SJ. Cubital tunnel syndrome does not require transposition of the ulnar nerve. J Hand Surg Am. 1999 Sep. 24(5):898-905. [QxMD MEDLINE Link].
Steiner HH, von Haken MS, Steiner-Milz HG. Entrapment neuropathy at the cubital tunnel: simple decompression is the method of choice. Acta Neurochir (Wien). 1996. 138(3):308-13. [QxMD MEDLINE Link].
Lluch AL. Release of ulnar nerve compression at the elbow through a transverse incision. J Shoulder Elbow Surg. 1998 Jan-Feb. 7(1):38-42. [QxMD MEDLINE Link].
Heithoff SJ, Millender LH, Nalebuff EA, Petruska AJ Jr. Medial epicondylectomy for the treatment of ulnar nerve compression at the elbow. J Hand Surg Am. 1990 Jan. 15(1):22-9. [QxMD MEDLINE Link].
Kaempffe FA, Farbach J. A modified surgical procedure for cubital tunnel syndrome: partial medial epicondylectomy. J Hand Surg Am. 1998 May. 23(3):492-9. [QxMD MEDLINE Link].
Seradge H, Owen W. Cubital tunnel release with medial epicondylectomy factors influencing the outcome. J Hand Surg Am. 1998 May. 23(3):483-91. [QxMD MEDLINE Link].
Seradge H. Cubital tunnel release and medial epicondylectomy: effect of timing of mobilization. J Hand Surg Am. 1997 Sep. 22(5):863-6. [QxMD MEDLINE Link].
Glowacki KA, Weiss AP. Anterior intramuscular transposition of the ulnar nerve for cubital tunnel syndrome. J Shoulder Elbow Surg. 1997 Mar-Apr. 6(2):89-96. [QxMD MEDLINE Link].
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. 1996 Sep. 78(5):777-9. [QxMD MEDLINE Link].
Kleinman WB, Bishop AT. Anterior intramuscular transposition of the ulnar nerve. J Hand Surg Am. 1989 Nov. 14(6):972-9. [QxMD MEDLINE Link].
Asami A, Morisawa K, Tsuruta T. Functional outcome of anterior transposition of the vascularized ulnar nerve for cubital tunnel syndrome. J Hand Surg Br. 1998 Oct. 23(5):613-6. [QxMD MEDLINE Link].
Nouhan R, Kleinert JM. Ulnar nerve decompression by transposing the nerve and Z-lengthening the flexor-pronator mass: clinical outcome. J Hand Surg Am. 1997 Jan. 22(1):127-31. [QxMD MEDLINE Link].
Tsujino A, Itoh Y, Hayashi K, Uzawa M. Cubital tunnel reconstruction for ulnar neuropathy in osteoarthritic elbows. J Bone Joint Surg Br. 1997 May. 79(3):390-3. [QxMD MEDLINE Link].
Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2011 Feb 16. 2:CD006839. [QxMD MEDLINE Link].
Dunselman HH, Visser LH. The clinical, electrophysiological and prognostic heterogeneity of ulnar neuropathy at the elbow. J Neurol Neurosurg Psychiatry. 2008 Dec. 79(12):1364-7. [QxMD MEDLINE Link].
Iyer V, Thirkannad S. Focal hand dystonia in a patient with ulnar nerve neuropathy at the elbow. Hand (N Y). 2010 Dec. 5(4):453-7. [QxMD MEDLINE Link]. [Full Text].
Buehler MJ, Thayer DT. The elbow flexion test. A clinical test for the cubital tunnel syndrome. Clin Orthop Relat Res. 1988 Aug. 213-6. [QxMD MEDLINE Link].
Rayan GM, Jensen C, Duke J. Elbow flexion test in the normal population. J Hand Surg Am. 1992 Jan. 17(1):86-9. [QxMD MEDLINE Link].
Ochi K, Horiuchi Y, Tanabe A, Morita K, Takeda K, Ninomiya K. Comparison of shoulder internal rotation test with the elbow flexion test in the diagnosis of cubital tunnel syndrome. J Hand Surg Am. 2011 May. 36(5):782-7. [QxMD MEDLINE Link].
Hwang K, Jin S, Hwang SH, Lee KM, Han SH. Location of nerve entry points of flexor digitorum profundus. Surg Radiol Anat. 2007 Dec. 29(8):617-21. [QxMD MEDLINE Link].
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. 2005 May. 62(5):826-7. [QxMD MEDLINE Link].
Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg [Am]. 2008 Nov. 33(9):1518-24. [QxMD MEDLINE Link].
Goldman SB, Brininger TL, Schrader JW, Koceja DM. A Review of Clinical Tests and Signs for the Assessment of Ulnar Neuropathy. J Hand Ther. 2009 Feb 1. [QxMD MEDLINE Link].
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. 1998 Dec. 64(4):366-70. [QxMD MEDLINE Link].
Aggarwal SK, Schneider LB, Ahmad BK. Clinical usefulness of ulnar motor responses recording from first dorsal interosseous. Muscle Nerve. 1995. 18(9):1043.
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. 2004 Aug. 30(2):202-8. [QxMD MEDLINE Link].
Mondelli M, Aretini A, Rossi S. Ulnar neuropathy at the elbow in diabetes. Am J Phys Med Rehabil. 2009 Apr. 88(4):278-85. [QxMD MEDLINE Link].
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. 2004 Mar 9. 62(5):767-73. [QxMD MEDLINE Link].
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. 2009 Feb. 39(1):49-50; author reply 51-2. [QxMD MEDLINE Link].
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. 2008 May. 90(5):657-61. [QxMD MEDLINE Link].
Choi AL, Koh SH, Jun SY, Hwang HS, Cho HW, Jang KM, et al. Lymphoma involving the ulnar nerve: sonographic findings. J Ultrasound Med. 2008 Oct. 27(10):1527-31. [QxMD MEDLINE Link].
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. 2009 Mar. 90(3):522-4. [QxMD MEDLINE Link].
Yoon JS, Walker FO, Cartwright MS. Ultrasonographic swelling ratio in the diagnosis of ulnar neuropathy at the elbow. Muscle Nerve. 2008 Oct. 38(4):1231-5. [QxMD MEDLINE Link].
Frijlink DW, Brekelmans GJ, Visser LH. Increased nerve vascularization detected by color doppler sonography in patients with ulnar neuropathy at the elbow indicates axonal damage. Muscle Nerve. 2013 Feb. 47(2):188-93. [QxMD MEDLINE Link].
Chiou HJ, Chou YH, Cheng SP, Hsu CC, Chan RC, Tiu CM, et al. Cubital tunnel syndrome: diagnosis by high-resolution ultrasonography. J Ultrasound Med. 1998 Oct. 17(10):643-8. [QxMD MEDLINE Link].
Cartwright MS, Chloros GD, Walker FO, Wiesler ER, Campbell WW. Diagnostic ultrasound for nerve transection. Muscle Nerve. 2007 Jun. 35(6):796-9. [QxMD MEDLINE Link].
Bianchi S. Ultrasound of the Peripheral Nerves. Joint Bone Spine. September 2008. 75:643-649.
Simon NG, Ralph JW, Poncelet AN, Engstrom JW, Chin C, Kliot M. A comparison of ultrasonographic and electrophysiologic 'inching' in ulnar neuropathy at the elbow. Clin Neurophysiol. 2014 Jun 4. [QxMD MEDLINE Link].
Shen L, Masih S, Patel DB, Matcuk GR Jr. MR anatomy and pathology of the ulnar nerve involving the cubital tunnel and Guyon's canal. Clin Imaging. 2016 Mar-Apr. 40 (2):263-74. [QxMD MEDLINE Link].
Husarik DB, Saupe N, Pfirrmann CW, Jost B, Hodler J, Zanetti M. Elbow nerves: MR findings in 60 asymptomatic subjects--normal anatomy, variants, and pitfalls. Radiology. 2009 Jul. 252(1):148-56. [QxMD MEDLINE Link].
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.
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.
Andreisek G et al. Upper Extremity Peripheral Neuropathies: Role and Impact of MRI on Patient Management. Journal of European Radiology. 2008. 18:1953-1961.
Husarik DB et al. Elbow Nerves: MRI Findings in 60 Asymptomatic Subjects - Normal Anatomy, Variants and Pitfalls. Radiology. 2009. 10:2-13.
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. 1996 Mar. 38(3):458-65; discussion 465. [QxMD MEDLINE Link].
Bäumer P, Pham M, Ruetters M, et al. Peripheral Neuropathy: Detection with Diffusion-Tensor Imaging. Radiology. 2014 May 17. 132837. [QxMD MEDLINE Link].
Razek AAKA, Shabana AAE, El Saied TO, Alrefey N. Diffusion tensor imaging of mild-moderate carpal tunnel syndrome: correlation with nerve conduction study and clinical tests. Clin Rheumatol. 2017 Oct. 36 (10):2319-2324. [QxMD MEDLINE Link].
Bäumer P, Pham M, Ruetters M, Heiland S, Heckel A, Radbruch A, et al. Peripheral neuropathy: detection with diffusion-tensor imaging. Radiology. 2014 Oct. 273 (1):185-93. [QxMD MEDLINE Link]. [Full Text].
Agarwal A, Chandra A, Jaipal U, Saini N. Imaging in the diagnosis of ulnar nerve pathologies-a neoteric approach. Insights Imaging. 2019 Mar 20. 10 (1):37. [QxMD MEDLINE Link]. [Full Text].
Jewell D. Case Studies in the Diagnosis of Upper Extremity Pain using MRI. Journal of Hand Therapy. 2007. 20:132-147.
Caliandro P, Foschini M, Pazzaglia C, La Torre G, Aprile I, Granata G, et al. IN-RATIO: a new test to increase diagnostic sensitivity in ulnar nerve entrapment at elbow. Clin Neurophysiol. 2008 Jul. 119(7):1600-6. [QxMD MEDLINE Link].
Bartels RH, Meulstee J, Verhagen WI, Luttikhuis TT. Ultrasound imaging of the ulnar nerve: correlation of preoperative and intraoperative dimensions. Clin Neurol Neurosurg. 2008 Jul. 110(7):687-90. [QxMD MEDLINE Link].
Yoon JS, Hong SJ, Kim BJ, Kim SJ, Kim JM, Walker FO, et al. Ulnar nerve and cubital tunnel ultrasound in ulnar neuropathy at the elbow. Arch Phys Med Rehabil. 2008 May. 89(5):887-9. [QxMD MEDLINE Link].
Toros T, Karabay N, Ozaksar K, Sugun TS, Kayalar M, Bal E. Evaluation of peripheral nerves of the upper limb with ultrasonography: a comparison of ultrasonographic examination and the intra-operative findings. J Bone Joint Surg Br. 2009 Jun. 91(6):762-5. [QxMD MEDLINE Link].
Ozçakar L, Cakar E, Kiralp MZ, Dinçer U. Static and dynamic sonography: a salutary adjunct to electroneuromyography for cubital tunnel syndrome. Surg Neurol. 2009 Sep. 72(3):311-2. [QxMD MEDLINE Link].
Gutmann L. AAEM minimonograph #2: important anomalous innervations of the extremities. Muscle Nerve. 1993 Apr. 16(4):339-47. [QxMD MEDLINE Link].
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]. 2008 Oct. 33(8):1314.e1-12. [QxMD MEDLINE Link].
Nakajima M, Ono N, Kojima T, Kusunose K. Ulnar entrapment neuropathy along the medial intermuscular septum in the midarm. Muscle Nerve. 2009 May. 39(5):707-10. [QxMD MEDLINE Link].
Neary D, Ochoa J, Gilliatt RW. Sub-clinical entrapment neuropathy in man. J Neurol Sci. 1975 Mar. 24(3):283-98. [QxMD MEDLINE Link].
Rempel D, Dahlin L, Lundborg G. Pathophysiology of nerve compression syndromes: response of peripheral nerves to loading. J Bone Joint Surg Am. 1999 Nov. 81(11):1600-10. [QxMD MEDLINE Link].
Charles YP, Coulet B, Rouzaud JC, Daures JP, Chammas M. Comparative clinical outcomes of submuscular and subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg Am. 2009 May-Jun. 34(5):866-74. [QxMD MEDLINE Link].
Gellman H, Campion DS. Modified in situ decompression of the ulnar nerve at the elbow. Hand Clin. 1996 May. 12(2):405-10. [QxMD MEDLINE Link].
Fernandez E, Pallini R, Lauretti L, Scogna A, La Marca F. Neurosurgery of the peripheral nervous system: cubital tunnel syndrome. Surg Neurol. 1998 Jul. 50(1):83-5. [QxMD MEDLINE Link].
Folberg CR, Weiss AP, Akelman E. Cubital tunnel syndrome. Part II: Treatment. Orthop Rev. 1994 Mar. 23(3):233-41. [QxMD MEDLINE Link].
Novak CB, Mackinnon SE. Selection of operative procedures for cubital tunnel syndrome. Hand (N Y). 2009 Mar. 4(1):50-4. [QxMD MEDLINE Link]. [Full Text].
Keiner D, Gaab MR, Schroeder HW, Oertel J. Comparison of the long-term results of anterior transposition of the ulnar nerve or simple decompression in the treatment of cubital tunnel syndrome--a prospective study. Acta Neurochir (Wien). 2009 Apr. 151(4):311-5; discussion 316. [QxMD MEDLINE Link].
Dy CJ, Mackinnon SE. Ulnar neuropathy: evaluation and management. Curr Rev Musculoskelet Med. 2016 Jun. 9 (2):178-84. [QxMD MEDLINE Link].
Toussaint CP, Zager EL. What's new in common upper extremity entrapment neuropathies. Neurosurg Clin N Am. 2008 Oct. 19(4):573-81, vi. [QxMD MEDLINE Link].
Coppieters MW, Butler DS. Do 'sliders' slide and 'tensioners' tension? An analysis of neurodynamic techniques and considerations regarding their application. Man Ther. 2008 Jun. 13(3):213-21. [QxMD MEDLINE Link].
Dellon AL. Techniques for successful management of ulnar nerve entrapment at the elbow. Neurosurg Clin N Am. 1991 Jan. 2(1):57-73. [QxMD MEDLINE Link].
Dellon AL. Review of treatment results for ulnar nerve entrapment at the elbow. J Hand Surg Am. 1989 Jul. 14(4):688-700. [QxMD MEDLINE Link].
Sailer SM. The role of splinting and rehabilitation in the treatment of carpal and cubital tunnel syndromes. Hand Clin. 1996 May. 12(2):223-41. [QxMD MEDLINE Link].
Seror P. Treatment of ulnar nerve palsy at the elbow with a night splint. J Bone Joint Surg Br. 1993 Mar. 75(2):322-7. [QxMD MEDLINE Link].
Idler RS. General principles of patient evaluation and nonoperative management of cubital syndrome. Hand Clin. 1996 May. 12(2):397-403. [QxMD MEDLINE Link].
Svernlov B, Larsson M, Rehn K, Adolfsson L. Conservative treatment of the cubital tunnel syndrome. J Hand Surg Eur Vol. 2009 Apr. 34(2):201-7. [QxMD MEDLINE Link].
Matei CI, Logigian EL, Shefner JM. Evaluation of patients with recurrent symptoms after ulnar nerve transposition. Muscle Nerve. 2004 Oct. 30(4):493-6. [QxMD MEDLINE Link].
Zhong W, Zhang W, Zheng X, Li S, Shi J. Comparative study of different surgical transposition methods for ulnar nerve entrapment at the elbow. J Int Med Res. 2011. 39(5):1766-72. [QxMD MEDLINE Link].
Yamaguchi K, Sweet FA, Bindra R, Morrey BF, Gelberman RH. The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg Am. 1997 Nov. 79(11):1653-62. [QxMD MEDLINE Link].
Eisen A. Early diagnosis of ulnar nerve palsy. An electrophysiologic study. Neurology. 1974 Mar. 24(3):256-62. [QxMD MEDLINE Link].
Jones RE, Gauntt C. Medial epicondylectomy for ulnar nerve compression syndrome at the elbow. Clin Orthop Relat Res. 1979 Mar-Apr. 174-8. [QxMD MEDLINE Link].
Kuschner SH. Cubital tunnel syndrome. Treatment by medial epicondylectomy. Hand Clin. 1996 May. 12(2):411-9. [QxMD MEDLINE Link].
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. 2005 Mar. 56(3):522-30; discussion 522-30. [QxMD MEDLINE Link].
Biggs M, Curtis JA. Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery. 2006 Feb. 58(2):296-304; discussion 296-304. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. 2005 Oct. 30(5):521-4. [QxMD MEDLINE Link].
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. 2007 Dec. 89(12):2591-8. [QxMD MEDLINE Link].
Kamat AS, Jay SM, Benoiton LA, Correia JA, Woon K. Comparative outcomes of ulnar nerve transposition versus neurolysis in patients with entrapment neuropathy at the cubital tunnel: a 20-year analysis. Acta Neurochir (Wien). 2014 Jan. 156(1):153-7. [QxMD MEDLINE Link].
Boyer M. Simple decompression did not differ from simple decompression plus anterior transposition of the nerve for cubital tunnel syndrome. J Bone Joint Surg Am. 2006 Aug. 88(8):1893. [QxMD MEDLINE Link].
Greenwald D, Blum LC 3rd, Adams D, Mercantonio C, Moffit M, Cooper B. Effective surgical treatment of cubital tunnel syndrome based on provocative clinical testing without electrodiagnostics. Plast Reconstr Surg. 2006 Apr 15. 117(5):87e-91e. [QxMD MEDLINE Link].
Karthik K, Nanda R, Storey S, Stothard J. Severe ulnar nerve entrapment at the elbow: functional outcome after minimally invasive in situ decompression. J Hand Surg Eur Vol. 2012 Feb. 37(2):115-22. [QxMD MEDLINE Link].
Macnicol MF. The results of operation for ulnar neuritis. J Bone Joint Surg Br. 1979 May. 61-B(2):159-64. [QxMD MEDLINE Link].
Eaton RG, Crowe JF, Parkes JC 3rd. Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling. J Bone Joint Surg Am. 1980 Jul. 62(5):820-5. [QxMD MEDLINE Link].
Pribyl CR, Robinson B. Use of the medial intermuscular septum as a fascial sling during anterior transposition of the ulnar nerve. J Hand Surg Am. 1998 May. 23(3):500-4. [QxMD MEDLINE Link].
Janes PC, Mann RJ, Farnworth TK. Submuscular transposition of the ulnar nerve. Clin Orthop Relat Res. 1989 Jan. 225-32. [QxMD MEDLINE Link].
Dellon AL. Operative technique for submuscular transposition of the ulnar nerve. Contemp Orthop. 1988. 16:17-24.
Jaddue DA, Saloo SA, Sayed-Noor AS. Subcutaneous vs Submuscular Ulnar Nerve Transposition in Moderate Cubital Tunnel Syndrome. Open Orthop J. 2009 Aug 27. 3:78-82. [QxMD MEDLINE Link]. [Full Text].
Baek GH, Kwon BC, Chung MS. Comparative study between minimal medial epicondylectomy and anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome. J Shoulder Elbow Surg. 2006 Sep-Oct. 15(5):609-13. [QxMD MEDLINE Link].
Craven PR Jr, Green DP. Cubital tunnel syndrome. Treatment by medial epicondylectomy. J Bone Joint Surg Am. 1980 Sep. 62(6):986-9. [QxMD MEDLINE Link].
Froimson AI, Anouchi YS, Seitz WH Jr, Winsberg DD. Ulnar nerve decompression with medial epicondylectomy for neuropathy at the elbow. Clin Orthop Relat Res. 1991 Apr. 200-6. [QxMD MEDLINE Link].
Weirich SD, Gelberman RH, Best SA, Abrahamsson SO, Furcolo DC, Lins RE. Rehabilitation after subcutaneous transposition of the ulnar nerve: immediate versus delayed mobilization. J Shoulder Elbow Surg. 1998 May-Jun. 7(3):244-9. [QxMD MEDLINE Link].
Yoshida A, Okutsu I, Hamanaka I. Endoscopic anatomical nerve observation and minimally invasive management of cubital tunnel syndrome. J Hand Surg Eur Vol. 2009 Feb. 34(1):115-20. [QxMD MEDLINE Link].
Mariani PP, Golanò P, Adriani E, Llusà M, Camilleri G. A cadaveric study of endoscopic decompression of the cubital tunnel. Arthroscopy. 1999 Mar. 15(2):218-22. [QxMD MEDLINE Link].
Tsai TM, Chen IC, Majd ME, Lim BH. Cubital tunnel release with endoscopic assistance: results of a new technique. J Hand Surg Am. 1999 Jan. 24(1):21-9. [QxMD MEDLINE Link].
Ruchelsman DE, Lee SK, Posner MA. Failed surgery for ulnar nerve compression at the elbow. Hand Clin. 2007 Aug. 23(3):359-71, vi-vii. [QxMD MEDLINE Link].
Bednar MS, Blair SJ, Light TR. Complications of the treatment of cubital tunnel syndrome. Hand Clin. 1994 Feb. 10(1):83-92. [QxMD MEDLINE Link].
Jackson LC, Hotchkiss RN. Cubital tunnel surgery. Complications and treatment of failures. Hand Clin. 1996 May. 12(2):449-56. [QxMD MEDLINE Link].
Broudy AS, Leffert RD, Smith RJ. Technical problems with ulnar nerve transposition at the elbow: findings and results of reoperation. J Hand Surg Am. 1978 Jan. 3(1):85-9. [QxMD MEDLINE Link].
Warner MA, Warner DO, Matsumoto JY, Harper CM, Schroeder DR, Maxson PM. Ulnar neuropathy in surgical patients. Anesthesiology. 1999 Jan. 90(1):54-9. [QxMD MEDLINE Link].
Masear VR, Meyer RD, Pichora DR. Surgical anatomy of the medial antebrachial cutaneous nerve. J Hand Surg Am. 1989 Mar. 14(2 Pt 1):267-71. [QxMD MEDLINE Link].

Media Gallery

A schematic diagram of the elbow region with 5 main sites (as given by Posner) labeled 1-5; other sites and structures are also named. The main regions of interest are colored circles. Sites 2 and 3 are close together and cannot be distinguished by means of electromyography and nerve conduction studies. This location is referred to as ulnar (or epicondylar) groove.
The diagram shows the ulnar nerve distal to the elbow region. The dorsal ulnar cutaneous nerve (lavender) branches off the main trunk (purple). Although the course is not followed in detail after that, the lavender region on the sensory dermatome diagram shows where this sensory nerve innervates 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 off a branch to the palmaris brevis. The deep terminal branch has no corresponding skin area, because it is solely motor-innervating the muscles shown, as well as others not explicitly depicted. A nerve could be pinched or injured anywhere, but sites labeled I-IV are more commonly involved.
Inching technique used to isolate conduction block in left ulnar nerve. Note significant amplitude drop at 305 mm, which correlates with position 2 cm above medial epicondyle. This is example of supracondylar block. Image courtesy of A S Lorenzo, MD.
Normal median and ulnar patterns are compared with those of 3 commonly recognized types of Martin-Gruber anomaly.
First 3 traces correspond to ulnar compound muscle action potential (CMAP) amplitude during recording at abductor digiti quinti (ADQ) and stimulating at wrist, below elbow, and above elbow, respectively. Fourth trace corresponds to stimulation of median nerve at elbow during recording at ADQ. Although CMAP amplitude is reduced markedly above elbow, this is compensated for by adding response seen after stimulation of median nerve; this represents Martin-Gruber anastomosis.
First 3 traces correspond to stimulation of ulnar nerve during recording at first dorsal interosseous (FDI) muscle at wrist, below elbow, and above elbow, respectively. Fourth trace corresponds to stimulation of median nerve at elbow during recording at FDI muscle; this represents Martin-Gruber anastomosis.
In those with Martin-Gruber anomaly who have no other significant neuropathy or nerve compression, stimulation of specific nerves at different sites yields differing results. With the median nerve, stimulation at the elbow yields larger compound muscle action potential (CMAP) at hypothenar muscles, first dorsal interosseous (FDI) muscle, or thenar muscles (or combination thereof) than does stimulation at the wrist. With the ulnar nerve, stimulation at the wrist yields larger CMAP at hypothenar muscles, FDI muscle, or thenar muscles (or combination thereof) than does stimulation at the elbow. In this context, "larger" and "smaller" generally refer to amplitude differences ≥1.0 mV.
Riche-Cannieu anastomosis is communication between the recurrent branch of the median nerve and the deep branch of the ulnar nerve in the hand. Although it is present in 77% of hands, it yields highly variable degrees of detectable physiologic difference. In many hands, it contributes little and does not affect diagnostic findings at all. The most common effect is probably to give ulnar innervation to some muscles usually innervated by the median nerve, median innervation to muscles usually innervated by the ulnar nerve, or both. The most extreme version is the so-called all-ulnar hand (very rare). Two examples of confusion this might cause are as follows: (1) a median lesion could cause denervation in typically ulnar muscle, such as adductor digiti minimi (adductor digiti quinti) or first dorsal interosseous muscle, and (2) an ulnar lesion could cause denervation in typically median muscle, such as flexor pollicis brevis or abductor pollicis brevis.

of 8

Table. Types of Martin-Gruber Anastomosis

Table. Types of Martin-Gruber Anastomosis

Type	Anatomy	Most Characteristic Finding	Confirmation	Additional Verification	Potential Clinical Confusion
I	Crossover fibers innervate hypothenar muscles	Ulnar 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 is equal to 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
II	Crossover fibers innervate FDI muscle	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 is equal to FDI CMAP from ulnar stimulation at elbow plus FDI CMAP from median stimulation at elbow	Usually none, because FDI muscle is not usually recording site; if it is used, conduction block could be suspected, as in type I
III	Crossover fibers innervate thenar muscles (typically ADP and FPB)	Elbow stimulation of median nerve produces greater thenar response than 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 is equal to median wrist stimulation amplitude plus ulnar wrist stimulation amplitude minus ulnar elbow stimulation amplitude	Can complicate median nerve studies, especially when carpal tunnel syndrome is involved
ADP—adductor pollicis; CMAP—compound motor (or muscle) action potential; FDI—first dorsal interosseous; FPB—flexor pollicis brevis. *Ulnar stimulation at the wrist yields larger CMAP at hypothenar muscles, FDI, or thenar muscles (or sometimes a combination of these) than stimulation at the elbow. †Median stimulation at the elbow yields larger CMAP at hypothenar muscles, FDI, or thenar muscles (or sometimes a combination of these) than stimulation at the wrist. Note: "Larger" and "smaller" generally mean amplitude difference ≥1.0 mV.

Back to List

Author

Elanagan Nagarajan, MD, MS Assistant Professor of Neurology, University of Tennessee College of Medicine-Chattanooga, Erlanger Health System

Elanagan Nagarajan, MD, MS is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Epilepsy Society, American Headache Society, Movement Disorder Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sireesha Murala, MBBS Postdoctoral Research Associate, Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center

Sireesha Murala, MBBS is a member of the following medical societies: Indian Medical Association, Medical Council of India

Disclosure: Nothing to disclose.

Chief Editor

Nicholas Lorenzo, MD, CPE, MHCM, FAAPL Co-Founder and Former Chief Publishing Officer, eMedicine and eMedicine Health, Founding Editor-in-Chief, eMedicine Neurology; Founder and Former Chairman and CEO, Pearlsreview; Founder and CEO/CMO, PHLT Consultants; Former Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, CPE, MHCM, FAAPL is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association for Physician Leadership

Disclosure: Nothing to disclose.

Additional Contributors

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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Charles F Guardia, III, MD Instructor in Neurology, Department of Neurology, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth; Associated Neurologists, Nuvance Health

Charles F Guardia, III, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Epilepsy Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Acknowledgements

Sandeep K Aggarwal, MD Clinical Assistant Professor of Neurology, Department of Neurology, Northwestern University Medical School