Ulnar / Radial Neuropathies

Peter B. J. Wu, M.D

Physical Medicine and Rehabilitation

Anatomy

Ulnar Nerve
C8 and T1
Medial Cord
Sensory & Motor Branches

Ulnar Neuropathy at the Elbow

Anatomy
Pathogenesis
Clinical Manifestations
Electrodiagnosis
Treatment

Ulnar Neuropathy at the Elbow

Clinical Manifestations
Symtoms
Pain
Tingling / Numbness
Weak or clumsy hands

Ulnar Neuropathy at the Elbow

SIGNS

Sensory loss
Muscle weakness / atrophy Wartenbergís sign Fromentís sign
Tinelís sign
The elbow flexion test combined with pressure

Ulnar Neuropathy at the Elbow

Differential Diagnosis

Cervical disc disease
TOS
Pancoast tumor
Lesion at the Guyonís canal
Polyneuropathy
Motor neuron disease

ELECTRODIAGNOSIS

Sensory conduction studies
Motor conduction studies
Mixed nerve conduction studies
EMG

ELECTRODIAGNOSIS

Recording from ADM / FDI
Dorsal ulnar cutaneous nerve
Elbow position (Cadaver studies)
Segment length
Comparison (elbow - forearm, elbow - arm)
Proximal segment motor latencies
Amplitude change - Inching technique

ELECTRODIAGNOSIS

EMG
Fibrillations / positive sharp waves / CRD
MUAP abnormalities
EMG Motor Tinelís sign

ULNAR TUNNEL SYNDROME

ETIOLOGY

Ganglion
Trauma
Anomalous muscle bellies (FDM, ADM, PL)
Lipoma
Giant cell tumor
Schwannoma
Bipartite hamulus
Pisiform-hamate coalition

TREATMEMT - CONSERVATIVE

Avoid aggravating factors
Avoid full flexion
Elbow pad
Splint
Ergonomic workplace modification
NSAID
Local steroid injection
Vitamin B6

TREATMENT - SURGICAL

SURGICAL
Local procedures
Simple decompression
Medial epicondylectomy
Transposition procedures
Subcutaneous
Submuscular
Intramuscular

Radial Neuropathy

Anatomy
Sites of entrapment
Clinical manifestations
Electrodiagnosis
Treatment

Radial Neuropathy

UPPER ARM

Saturday night palsy (Bridegroomís palsy)
Trauma
Excessive muscular effort
Crutches
Alcohol / lead / arsennic
Compression (fibrous myopathy)

Radial Neuropathy

CLINICAL MANIFESTATIONS

Weakness below the triceps --- wrist drop
Sensory impairment
Inferior lateral brachial cutaneous nerve
Posterior lateral brachial cutaneous nerve
Superficial radial nerve

Radial Neuropathy

SLEEP PARALYSIS
The fundamental damage is neuropraxic, but often associated with additional axonal involvement
Signs of denervation persist in the most distal muscle even after 2-4 years

Radial Neuropathy

ELECTRODIAGNOSIS NCS (Trojaborg, 1970)

MCV & SCV: 50% if normal during the first 2 weeks and return to normal at 6 -8 weeks

CMAP: severe reduction above the site of lesion during the first 3 weeks and recover gradually, reaching normal 4 - 5 weeks later

Radial Tunnel Syndrome

PATHOGENESIS

Fibroma
Neuroma
Ganglion
Synovial chondromatosis
Rheumatoid synovitis
Bursitis
Venipuncture
Monteggia fracture
Excessive pronation and supination

Radial Tunnel Syndrome

Michele and Krueger (1956 ): radial pronator syndrome
Roles and Maudsley (1972): RTS
Werner and Lister (1979): establish RTS

Radial Tunnel Syndrome

Symptoms
Pain: dull, aggravated by use, nocturnal, awaken the patient
Paresthesia
Mild weakness

Radial Tunnel Syndrome

Signs
Tenderness at 4-5 cm distal to the lateral epicondyle
Pain induced by supination against resistance
The middle finger extension test

Radial Tunnel Syndrome

ELECTRODIAGNOSIS

Not sensitive
Most likely due to intermittent, rather than continuous compression

Cheiralgia Paresthetica

Wartenbergís disease (1932)
Etiologies
Tight wrist-watch strap
Handcuff
Surgery around the wrist
Trauma
Repeated pronation / supination activities

Cheiralgia Paresthetica

Symptoms
Burning or shooting pain
Radiation pain
Numbness or tingling
Aggravation by ulnar flexion of the wrist or with grasping and pinching

Cheiralgia Paresthetica

Signs
No muscle weakness
Hypoesthesia
Tinelís sign
Finkelstein sign
Provocative test

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