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Ulnar nerve entrapment

Ulnar nerve entrapment is a condition where the ulnar nerve
Ulnar nerve entrapment
becomes physically trapped or pinched, resulting in pain,
numbness, or weakness.

Contents
Signs and symptoms
Diagnosis
Differential diagnoses
Classification Anatomy of ulnar nerve
Cubital tunnel syndrome Specialty Neurology
Guyon's canal syndrome
Prevention
Treatment
Prognosis
Epidemiology
References
External links

Signs and symptoms

Ulnar neuropathy causes symptoms in a specific anatomic distribution, corresponding parts of the arm innervated by the
ulnar nerve:

the little finger

ulnar half of the ring finger
intrinsic muscles of the hand
The specific type of symptoms may be either motor, sensory, or mixed motor/sensory type symptoms. Motor symptoms
consistent of muscle weakness; sensory symptoms or paresthesias consist of numbness or tingling in the areas innervated
by the ulnar nerve.

The type of symptoms depend on the location of ulnar nerve impingement, because the ulnar nerve consists of different
sub-types of nerves along its course.

proximal impingement (closer to the shoulder) is associated with mixed symptoms, as the proximal nerve consists of
mixed sensory and motor innervation.
distal impingement (closer to the hand) is associated with variable symptoms, as the ulnar nerve separates near the
hand into distinct motor and sensory branches.
In cubital tunnel syndrome (a type of proximal impingement), sensory and motor symptoms tend to occur in a certain
sequence. Initially, there may be numbness of the small and ulnar fourth finger which may be transient. If the
impingement is not corrected, the numbness may become constant and progress to hand weakness. A characteristic

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resting hand position of "ulnar claw," where the small and ring fingers curl up, occurs late in the disease and is a sign of
severe neuropathy.

By contrast, in Guyon's canal syndrome (distal impingement) motor symptoms and claw hand may be more pronounced, a
phenomenon known as the ulnar paradox. Also the back of the hand will have normal sensation.

Diagnosis
The distinct innervation of the hand usually enables diagnosis of an ulnar nerve impingement by symptoms alone. Ulnar
nerve damage that causes paralysis to these muscles will result in a characteristic ulnar claw position of the hand at rest.
Clinical tests such as the card test (https://www.youtube.com/watch?v=yJTIhm1VfSI) for Froment's sign, can be easily
performed for assessment of ulnar nerve. However, a complete diagnosis should identify the source of the impingement,
and radiographic imaging may be necessary to determine or rule-out an underlying cause.

Imaging studies, such as ultrasound or MRI, may reveal anatomic abnormalities or masses responsible for the
impingement. Additionally, imaging may show secondary signs of nerve damage that further confirm the diagnosis of
impingement. Signs of nerve damage include flattening of the nerve, swelling of the nerve proximal to site of injury,
abnormal appearance of nerve, or characteristic changes to the muscles innervated by the nerve.[1]

Differential diagnoses
Symptoms of ulnar neuropathy or neuritis do not necessarily indicate an actual physical impingement of the nerve;
indeed, any injury to the ulnar nerve may result in identical symptoms. In addition, other functional disturbances may
result in irritation to the nerve and are not true "impingement". For example, anterior dislocation and "snapping" of ulnar
nerve across the medial epicondyle of the elbow joint can result in ulnar neuropathy.[2]

Entrapment of other major sensory nerves of the upper extremities result in deficits in other patterns of distribution.
Entrapment of the median nerve causes carpal tunnel syndrome, which is characterized by numbness in the thumb, index,
middle, and half of the ring finger. Compression of the radial nerve causes numbness of the back of the hand and thumb,
and is much rarer.

A simple way of differentiating between significant median and ulnar nerve injury is by testing for weakness in flexing and
extending certain fingers of the hand. Median nerve injuries are associated with difficulty flexing the index and middle
finger when attempting to make a fist. However, with an ulnar nerve lesion, the pinky and ring finger cannot be unflexed
when attempting to extend the fingers.

Some people are affected by multiple nerve compressions, which can complicate diagnosis.[3]

Classification
Ulnar nerve entrapment is classified by location of entrapment. The ulnar nerve passes through several small spaces as it
courses through the medial side of the upper extremity, and at these points the nerve is vulnerable to compression or
entrapment—a so-called "pinched nerve". The nerve is particularly vulnerable to injury when there has been a disruption
in the normal anatomy. The most common site of ulnar nerve entrapment is at the elbow, followed by the wrist.[4]

Causes or structures which have been reported to cause ulnar nerve entrapment include:[5]

Problems originating at the neck: thoracic outlet syndrome, cervical spine pathology, compression by anterior scalene
muscles
Problems originating in the chest: compression by pectoralis minor muscles
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Brachial plexus abnormalities

Elbow: fractures, growth plate injuries, cubital tunnel syndrome, flexorpronator aponeurosis, arcade of Struthers[6]
Forearm: tight flexor carpi ulnaris muscles[7]
Wrist: fractures, ulnar tunnel syndrome, hypothenar hammer syndrome
Artery aneurysms or thrombosis
Other: Infections, tumors, diabetes, hypothyroidism, rheumatism, and alcoholism

Cubital tunnel syndrome

The most common location of ulnar nerve impingement at the elbow is within the cubital tunnel, and is known as cubital
tunnel syndrome.[3] The tunnel is formed by the medial epicondyle of the humerus, the olecranon process of the ulna and
the tendinous arch joining the humeral and ulnar heads of the flexor carpi ulnaris muscle.[8] While most cases of injury
are minor and resolve spontaneously with time, chronic compression or repetitive trauma may cause more persistent
problems. Commonly cited scenarios include:

Sleeping with the arm folded behind neck, elbows bent.

Pressing the elbows upon the arms of a chair while typing.
Resting or bracing the elbow on the arm rest of a vehicle.
Bench pressing.
Intense exercising and strain involving the elbow.
Compression of the ulnar nerve at the medial elbow may occasionally be caused by epitrocheloanconeus muscle, an
anatomical variant.[9]

Guyon's canal syndrome

Ulnar nerve impingement along an anatomical space in the wrist called Guyon's canal is known as Guyon's canal
syndrome, or ulnar tunnel syndrome.[10] Recognized causes of ulnar nerve impingement at this location include local
trauma, fractures, ganglion cysts,[11] and classically avid cyclists who experience repetitive trauma against bicycle
handlebars.[12] This form of ulnar neuropathy comprises two work-related syndromes: so-called "hypothenar hammer
syndrome," seen in workers who repetitively use a hammer, and "occupational neuritis" due to hard, repetitive
compression against a desk surface.[11]

Prevention
Cubital tunnel syndrome may be prevented or reduced by maintaining good posture and proper use of the elbow and
arms, such as wearing an arm splint while sleeping to maintain the arm is in a straight position instead of keeping the
elbow tightly bent.[3][13] A recent example of this is popularization of the concept of cell phone elbow and game
hand.[13]

Treatment
While pain symptoms may be effectively controlled using medications such as NSAID, amitriptyline, or vitamin B6
supplementation, effective treatment generally requires resolving the underlying cause.

Mild to moderate symptoms, such as pain or paresthesia, are treated conservatively with non-surgical approaches.
Physiotherapy treatments can prove effective at treating cubital tunnel syndrome symptoms and can include:

Joint mobilizations
Neural flossing/gliding
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Strengthening/stretching exercises
Activity modification[14]
It is important to identify positions and activities that aggravate symptoms and to find ways to avoid them.[3] For example,
if the person experiences symptoms when holding a telephone up to the head, then the use of a telephone headset will
provide immediate symptomatic relief and reduce the likelihood of further damage and inflammation to the nerve. For
cubital tunnel syndrome, it is recommended to avoid repetitive elbow flexion and also avoiding prolonged elbow flexion
during sleep, as this position puts stress of the ulnar nerve.[15]

Surgery is recommended for those who are not improved with conservative therapy or those with serious or progressive
symptoms. The surgical approaches vary, and may depend on the location or cause of impingement. Cubital and ulnar
tunnel release can be performed wide awake with no general anaesthesia, no regional anaesthesia, no sedation and no
tourniquet,[16] and are usually done by plastic surgeons.

Prognosis
Most patients diagnosed with cubital tunnel syndrome have advanced disease (atrophy, static numbness, weakness) that
might reflect permanent nerve damage that will not recover after surgery.[17] When diagnosed prior to atrophy, weakness
or static numbness, the disease can be arrested with treatment. Mild and intermittent symptoms often resolve
spontaneously.[3]

Epidemiology
People with diabetes mellitus are at higher risk for any kind of peripheral neuropathy, including ulnar nerve
entrapments.[3]

Cubital tunnel syndrome is more common in people who spend long periods of time with their elbows bent, such as when
holding a telephone to the head.[3] Flexing the elbow while the arm is pressed against a hard surface, such as leaning
against the edge of a table, is a significant risk factor.[3] The use of vibrating tools at work or other causes of repetitive
activities increase the risk, including throwing a baseball.[3]

Damage to or deformity of the elbow joint increases the risk of cubital tunnel syndrome.[3] Additionally, people who have
other nerve entrapments elsewhere in the arm and shoulder are at higher risk for ulnar nerve entrapment. There is some
evidence that soft tissue compression of the nerve pathway in the shoulder by a bra strap over many years can cause
symptoms of ulnar neuropathy, especially in very large-breasted women.[3]

References
1. Miller TT, Reinus WR (September 2010). "Nerve entrapment syndromes of the elbow, forearm, and wrist". Am J
Roentgenology. 195 (3): 585–94. doi:10.2214/AJR.10.4817 (https://doi.org/10.2214%2FAJR.10.4817).
PMID 20729434 (https://www.ncbi.nlm.nih.gov/pubmed/20729434).
2. Carroll, John (2011-10-03). "Snapping Triceps" (http://www.radsource.us/clinic/1110). RadSource.
3. Cutts, S. (2007). "Cubital tunnel syndrome" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2599973). Postgraduate
Medical Journal. 83 (975): 28–31. doi:10.1136/pgmj.2006.047456 (https://doi.org/10.1136%2Fpgmj.2006.047456).
PMC 2599973 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2599973). PMID 17267675 (https://www.ncbi.nlm.nih.g
ov/pubmed/17267675).
4. Posner, MA (Sep–Oct 1998). "Compressive ulnar neuropathies at the elbow: I. Etiology and diagnosis". J Am Acad
Orthop Surg. 6 (5): 282–288. doi:10.5435/00124635-199809000-00003 (https://doi.org/10.5435%2F00124635-19980
9000-00003). PMID 9753755 (https://www.ncbi.nlm.nih.gov/pubmed/9753755).

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5. Guardia, Charles. "Ulnar Neuropathy" (http://emedicine.medscape.com/article/1141515-overview). Medscape.

Retrieved 4 May 2014.
6. Miller, Theodore T.; Reinus, William R. (2010). "Nerve Entrapment Syndromes of the Elbow, Forearm, and Wrist".
American Journal of Roentgenology. 195 (3): 585–594. doi:10.2214/AJR.10.4817 (https://doi.org/10.2214%2FAJR.10.
4817). PMID 20729434 (https://www.ncbi.nlm.nih.gov/pubmed/20729434).
7. "16 Passive Treatments for the Ulnar Nerve so you can Sleep Longer" (http://www.p2sportscare.com/rehab/printable-
exercise-instructions/ulnar-nerve-stretch/).
8. Moore, Keith L. (2010). Clinically Oriented Anatomy 6th Ed. Baltimore, MD: Lippincott, Williams and Wilkins. p. 770.
ISBN 978-07817-7525-0.
9. Erdem Bagatur, A.; Yalcin, Mehmet Burak; Ozer, Utku Erdem (2016-09-01). "Anconeus Epitrochlearis Muscle Causing
Ulnar Neuropathy at the Elbow: Clinical and Neurophysiological Differential Diagnosis". Orthopedics. 39 (5): e988–
991. doi:10.3928/01477447-20160623-11 (https://doi.org/10.3928%2F01477447-20160623-11). ISSN 1938-2367 (htt
ps://www.worldcat.org/issn/1938-2367). PMID 27398787 (https://www.ncbi.nlm.nih.gov/pubmed/27398787).
10. "Guyon's Canal Syndrome" (http://orthopedics.about.com/cs/handwristsurgery/g/guyonscanal.htm).
11. Shea JD, McClain EJ (1969). "Ulnar-nerve compression syndromes at and below the wrist". J Bone Joint Surg Am. 51
(6): 1095–1103. doi:10.2106/00004623-196951060-00004 (https://doi.org/10.2106%2F00004623-196951060-00004).
12. Patterson JM, Jaggars MM, Boyer MI (2003). "Ulnar and median nerve palsy in long-distance cyclists. A prospective
study". Am J Sports Med. 31 (4): 585–589. doi:10.1177/03635465030310041801 (https://doi.org/10.1177%2F036354
65030310041801). PMID 12860549 (https://www.ncbi.nlm.nih.gov/pubmed/12860549).
13. Thomas, Jennifer (2 June 2009). " 'Cell Phone Elbow' -- A New Ill for the Wired Age" (http://news.health.com/2009/06/
02/cell-phone-elbow-new-ill-wired-age/). HealthDay News. Retrieved 2 June 2009.
14. "Is This Serious? Why is My Pinky Finger Numb?" (https://www.pthealth.ca/blog/is-this-serious-why-is-my-pinky-finger
-numb/). 2016-07-06. Retrieved 2016-07-12.
15. Guardia, Charles F (2014-08-24). "Ulnar Neuropathy Treatment & Management: Non-surgical therapy" (http://emedici
ne.medscape.com/article/1141515-treatment#aw2aab6b6b2). Medscape.
16. Bismil QMK, Lowe S, Viner L, Bismil MSK. "The wide awake approach to ulnar nerve entrapment: results of an
integrated one stop wide awake surgical pathway (http://www.oapublishinglondon.com/images/article/pdf/137183699
9.pdf)." OA Case Reports 2013 June 21; 2(5):44.
17. Mallette, Paige; Zhao, Meijuan; Zurakowski, David; Ring, David (2007). "Muscle Atrophy at Diagnosis of Carpal and
Cubital Tunnel Syndrome". The Journal of Hand Surgery. 32 (6): 855–8. doi:10.1016/j.jhsa.2007.03.009 (https://doi.or
g/10.1016%2Fj.jhsa.2007.03.009). PMID 17606066 (https://www.ncbi.nlm.nih.gov/pubmed/17606066).

External links
Classification ICD-10: G56.2 (htt D
p://apps.who.int/cla
ssifications/icd10/br
owse/2016/en#/G5
6.2) · ICD-9-CM:
354.2 (http://www.ic
d9data.com/getICD
9Code.ashx?icd9=3
54.2)
External Patient UK: Ulnar
resources nerve entrapment
(https://patient.info/
doctor/Cubital-Tunn
el-Syndrome)

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