Ulnar Neuropathy at the Elbow, an overview

Learning Objectives:
Fascicle – a bundle of axons with a common destination.

Ulnar nerve compression at the elbow is the second most common mononeuropathy seen in the electrodiagnostic laboratory. Because of the way the fascicles are arraigned the clinical and the electrodiagnostic findings can be puzzling and complex. In this paper will review ulnar nerve anatomy, clinical features of ulnar neuropathy at the elbow (UNE), differential diagnosis, nerve conduction findings, techniques and case studies. The reader will gain insight to this common entrapment as well as the importance of the nerve conduction studies used to confirm the diagnosis of UNE.

Anatomy of the Ulnar Nerve:
Understanding ulnar nerve anatomy is important to help sort out the various conditions in that make up the differential diagnosis, whether it is a cervical radiculopathy or brachial plexopathy.
Medial Antebrachial Cutaneous nerve supplies sensation to the medial forearm.

The ulnar nerve, a mixed nerve, arises from cervical roots C8-T1, continuing through the lower trunk and medial cord. Unlike the median and radial nerve the motor and sensory portions of the ulnar nerve travel together through the brachial plexus. The ulnar nerve is essentially an extension of the medial cord. The medial brachial and the medial antebrachial cutaneous nerve come directly off the medial cord and the MABC is an important nerve when separating brachial plexus lesions with ulnar nerve lesions.
Trunks Upper Cords Lateral Branches/Nerves Musculocutaneous Axillary Middle Posterior Radial Median

Roots C5 C6 C7 C8 T1

Lower

Medial MABC

Ulnar

There are no ulnar nerve innervations in the upper arm. At the elbow the ulnar nerve continues through the retroepicondylar groove which is Page 1 of 24

Ulnar Neuropathy at the Elbow, an Overview formed by medial epicondyle of the humerus and the olecranon process of the ulna. This is the most common of the compression sites. Slightly distal to the elbow, the ulnar nerve dives beneath a tendon that connects the heads of the flexor carpi ulnaris muscle, known as the humeral-ulnar aponeurosis (HUA) or cubital tunnel. This is the second most common entrapment site of the ulnar nerve at the elbow. In this area, the ulnar nerve gives off branches to the FCU and the flexor digitorum profundus muscles. The ulnar nerve continues in the forearm, but does not give off any additional muscle branches until the wrist. Five to eight centimeters proximal to the wrist the dorsal ulnar cutaneous sensory branch comes off to supply sensation to the dorsal medial hand, dorsal fifth and dorsal medial fourth digits. A little more distally the palmar cutaneous sensory branch exits to supply sensation to the proximal medial palm. At the level of the wrist, the ulnar nerve enter Guyon’s canal. In the canal the ulnar nerve divides into the deep palmar motor branch and the superficial sensory branch. At the end of Guyon’s canal, motor fibers for the hypothenar muscles are given off. Finally, after the canal, the superficial sensory branch to the palmar 5th and medial palmar 4th digits and the palmar motor branches are given off. Ulnar nerve compression at Guyon’s canal will be addressed in a subsequent paper.

Figure 19.2 in Preston and Shapiro has a very good picture of the ulnar anatomy at the elbow. See page 292.

Clinical Features of Ulnar Neuropathy at the Elbow
There is a great deal of variability of the signs and symptoms depending on the location and severity of the compression. Early in the course of the compression, symptoms include sensory loss and paresthesias over digits 4 and 5. In more advanced cases, weakness of the interosseous muscles of the hand becomes apparent and the patient may complain of worsened grip and clumsiness. Pain in the region of the elbow also is common, although not universal. Involvement of ulnar innervated forearm muscles leads to weakness in finger and wrist flexion. A positive Tinel's sign (pain with tapping over the nerve) in the region of the elbow also may be present. Ulnar neuropathy at the elbow can be broken into two distinct sites of compression. 1. The most common location is the nerve at the epicondylar groove. This specific problem is often attributed to prolonged inadvertent compression of the nerve by leaning on the elbows while at a desk or table. Repeated subluxation of the nerve with elbow flexion over the medial epicondyle also may contribute. Studies show this location accounts for 62% - 69% of the elbow compressions. 2. Entrapment of the nerve as it enters the cubital tunnel is the next most common site. The cubital tunnel consists of the two heads of

Subluxation is a partial dislocation of bones that leaves them misaligned but still in some contact with each other

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Use standard sensory amplifier and stimulator settings as noted. separate The differential diagnosis for ulnar neuropathy at the elbow includes: a. Many laboratories use antidromic stimulation. consider a lesion at the wrist instead of the elbow. with conduction block affecting fibers to the FDI while those to the ADM display a pure axon loss picture. While the actual technique is not important it is necessary to be consistent. an Overview the flexor carpi ulnaris muscle and the aponeurosis between them. weakness on thumb abduction and flexion) Nerve Conduction Findings Although it appears straight forward. however. while others prefer orthodromic stimulation. Page 3 of 24 . Differential Diagnosis Remember the median motor fibers to the hand share the same pathways with the ulnar nerve through the brachial plexus. so if the patient has intact sensation to the medial dorsal portion of their hand. and sensitivity to 10 or 20 µV/div to start. Median and Ulnar Sensory fibers are. Full technique descriptions follow the introductions: 1. In some individuals. Median sensory study Digit II or III – wrist at 12-14 cm is considered standard for comparison. the electrophysiological findings vary and can be confusing because of the fascicular arraignment inside the nerve. If the patient has these symptoms.Ulnar Neuropathy at the Elbow. b.g. Set the Sweep speed at 1 or 2 ms/div. Ulnar neuropathy at the wrist – ulnar neuropathy at the wrist will spare the dorsal ulnar cutaneous nerve. consider a plexopathy lesion. If index finger extension is spared you would tend to think lower trunk. Many laboratories use antidromic stimulation. 2. Different fascicles may exhibit different pathophysiology.g. this tunnel is small and compression of the nerve occurs with repeated elbow flexion. while others prefer orthodromic Standard low filter settings for SNC are 20 or 30 Hz and the standard high filter setting is 3kHz. c. weakness on thumb abduction) and medial forearm sensory loss. Ulnar sensory study digit V – wrist at 11-13 cm is standard. For these reasons careful nerve conduction studies of the ulnar nerve are required. We sometimes see the dorsal ulnar cutaneous branch may paradoxically escape injury with lesions at the elbow. Studies show this location accounts for 23% . The fibers to the first dorsal interosseous (FDI) seem more susceptible to injury than those to the abductor digiti minimi (ADM). Lower trunk and Medial Cord.28% of the elbow compressions. C8-T1 radiculopathy – C8-T1 radiculopathies would include neck pain and median motor symptoms (e. Medial cord/Lower trunk plexopathies – lower trunk or medial cord lesions would include median motor signs (e. not medial cord.

4. While the actual technique is not important it is necessary to be consistent. 5. Remember a cool extremity can slow conduction velocity and could mimic an abnormality. Abnormalities to look for are as follows: a. but it is more convincing if the abnormality involves both a change in latency and a change in either amplitude.Ulnar Neuropathy at the Elbow. Make sure to measure at least 10 cm across the elbow. but less than 13 cm. especially in patients with only sensory symptoms. CMAP amplitude. and sensitivity to 2 or 5 mV/div to start. Remember to keep the limb temperature in the reference range as your lab protocols dictate. Be sure the below elbow stimulation is not more than 3 cm distal to the medial epicondyle as the nerve buries quite deep there. Ulnar motor study to the hypothenar muscle is a standard. so use caution if slowing of the sensory CV is your only abnormality. (see case study later in this paper) b. A more proximal stimulation (i. axilla may be necessary as well) Use standard motor amplifier and stimulator settings as noted. 3. d. c. Use standard sensory amplifier and stimulator settings as noted. assuming anomalies are not present. and by keeping it relativity short there is less risk of masking a focal abnormality. Set the Sweep speed at 2 or 5 ms/div. Perform this study using the same stimulation sites as the study to the ADM. Page 4 of 24 . Antidromic sensory nerve action potential (SNAP) recordings may be useful. Assuming anomalies such as Martin-Gruber anastamosis are not present. SNAP studies have pitfalls and limitations. A significant change in CMAP configuration at the AE site compared to the BE site. When the dorsal ulnar sensory study shows reduced SNAP Standard low filter setting for MNC is 2 Hz and the standard high filter setting is 10 kHz. fibers to the FDI may show abnormalities not evident when recording from the abductor digiti minimi. d. Additional studies if above are equivocal or as the clinical picture dictates. Median motor study to the thenar muscles is a standard and will be used as a comparison. However. Inching study to look for changes in the latency.e. Motor studies to the first dorsal interosseous. a. or configuration. area or configuration over precisely measured 1 or 2 cm increments from BE to AE. an Overview stimulation. Use standard motor amplifier and stimulator settings as noted. Again. area. Latency changes in isolation are significant. A decrease CMAP amplitude from BE to AE greater than 20%. Comparing the BE to AE segment with the AE to axilla segment is useful when there is wallerian degeneration and the distal low CMAP amplitude hinders localization. By using at least 10 we minimize measurement mistakes. suggests conduction block or temporal dispersion indicative of focal demyelination. b. c. Due to differential fascicular involvement. An above elbow (AE) to below elbow (BE) segment greater than 10 m/s slower than the below elbow to wrist segment. Place the arm at 90º and carefully examine both below and above the elbow.

medial cord) We place the elbow at 70-90° to pull the nerve taut. however they are of little value when the lesion is at the elbow. temperature check Placed on the belly of the Abductor Digiti Minimi (ADM) ½ distance between the distal wrist crease and the base of the fifth digit Placed on the proximal phalanx of the fifth digit Placed between the stimulating and recording electrodes (cathode distal) Applied 2 cm proximal to the distal wrist crease. as the DUC sensory study can be normal in elbow lesions because of differential fascicular involvement. Specific Nerve Conduction Techniques Ulnar nerve (C8-T1. lower trunk. anterior to the flexor carpi ulnaris tendon Applied 2-4 cm distal to the ulnar groove on the medial side of the forearm Applied at least 10 cm proximal to the below elbow site on the medial aspect of the arm Between the active recording electrode and wrist following a straight line Wrist to BE following contour of the medial aspect of the arm Between BE and AE though the ulnar groove following contour of the medial aspect of the arm Latency and amplitude for CMAP recordings Reference: Ground: Stimulation: Wrist: Below elbow(BE): Above elbow(AE): Measurements: Page 5 of 24 . Recording the medial antebrachial cutaneous nerve is useful to exclude lesions of the lower trunk and medial cord. an Overview amplitude it helps confirm a lesion at the elbow as this nerve is spared in wrist lesions.Ulnar Neuropathy at the Elbow. e. but twice. 6. or on their side with arm supinated and abducted 70-90 degrees Clean area with alcohol. Needle EMG as performed by the physician is useful to gauge severity when the clinical signs indicate. Ulnar motor study to the ADM Patient Position: Skin Prep: Recording site: Active: Supine. thus making the skin measurement best match the nerve length. if clinically indicated. Caution should be exercised however. the F-wave latency from the ADM may be prolonged simply because it passes the lesion. If you have an ulnar neuropathy at the elbow. F-waves can be performed. 7. not once.

an Overview Calculations: Motor conduction velocity wrist to BE and wrist to AE Wrist Below Elbow Above Elbow Page 6 of 24 .Ulnar Neuropathy at the Elbow.

anterior to the flexor carpi ulnaris tendon Applied 2-4 cm distal to the ulnar groove on the medial side of the forearm Applied at least 10 cm proximal to the below elbow site on the medial aspect of the arm Between the active recording electrode and wrist following a straight line Wrist to BE following contour of the medial aspect of the arm Between BE and AE though the ulnar groove following contour of the medial aspect of the arm Latency and amplitude for CMAP recordings Motor conduction velocity wrist to BE and wrist to AE (or BE to AE) Reference: Ground: Stimulation: Wrist: Below elbow(BE): Above elbow(AE): Measurements: Calculations: FDI Muscle (recording electrode) Page 7 of 24 .Ulnar Neuropathy at the Elbow. an Overview Ulnar motor study to the FDI Patient Position: In Buschbacher he leaves the reference electrode on the knuckle of the fifth digit. or on their side with arm supinated and abducted 70-90 degrees Clean area with alcohol. Supine. temperature check Skin Prep: Recording site: Active: Placed on the belly of the First dorsal interosseous (FDI) in the web space between the thumb and forefinger. Be consistent with your lab’s normal values. Have the patient make a peace sign. This possibly gives a better onset and higher amplitude. Placed on the proximal phalanx of the digit II Placed between the stimulating and recording electrodes (cathode distal) Applied 2 cm proximal to the distal wrist crease. or where we place it for the ADM recording.

This is even more pronounced as we move to proximal recordings. as in the BE and AE sites. Below Elbow Above Elbow Antidromic sensory study to the fifth digit Patient Position: Supine. or on their side with arm supinated and abducted 70-90 degrees Clean area with alcohol. but slowed CV from BE to AE does show the focus. an Overview Wrist The amplitude of antidromic recordings tend to be larger. Recording site: Active: Ring electrode placed on the midportion of the proximal phalanx of the 5th finger Ring electrode placed on the midportion of the middle phalanx of the 5th finger Placed between the stimulating and recording electrodes Reference: Ground: Page 8 of 24 .Ulnar Neuropathy at the Elbow. but they tend to have more motor artifact that can obscure the waveforms. temperature check Skin Prep: Reduced amplitude at the wrist does not localize a lesion.

of the Wrist – BE and the BE – AE segments Ulnar sensory – antidromic Below elbow(BE): Remember the amplitude of antidromic sensory responses may drop as much as 50% as you move proximal because of phase cancellation.5 cm proximal to cathode) Applied 2 cm proximal to the distal wrist crease anterior to the flexor carpi ulnaris tendon – many labs record only from the wrist Applied 2-4 cm distal to the ulnar groove on the medial side of the forearm Applied at least 10 cm proximal. Wrist Below elbow Above elbow Page 9 of 24 . Above elbow(AE): Measurements: Calculations: Phase cancellation occurs because the different fibers travel at different speeds. so over the long distance the repolarization of the fast fibers cancel some of the slow fibers. from baseline.Ulnar Neuropathy at the Elbow. an Overview Stimulation: Wrist: (anode is 2. but not more than 13 cm to the below elbow site on the medial aspect of the arm Between active recording electrode and wrist Latency and amplitude for SNAP Conduction velocity.

Ulnar Neuropathy at the Elbow. an Overview Orthodromic sensory study to the wrist Patient Position: Orthodromic stimulation gives lower amplitude than the equivalent antidromic recording. Supine with arm supinated and extended at side Clean area with alcohol. In theory this is because the recording electrodes over the wrist are farther from the actual nerve than recording electrodes over the digit. 3cm from the cathode Between active recording electrode and cathode Latency and amplitude None required Measurements: Calculations: Ulnar sensory – orthodromic Page 10 of 24 . temperature check Skin Prep: Recording site: Active: Placed 11 cm proximal to the stimulating cathode in the wrist crease anterior to the flexor carpi ulnaris tendon Placed 3 or 4 cm proximal to the active recording electrode along the ulnar nerve Placed between the stimulating and recording electrodes Reference: Ground: Stimulation: Cathode: Anode: Applied with a ring electrode on the proximal phalanx of the 5th digit Applied with a ring electrode on the distal phalanx.

Recording point FDI Recording point ADM 3. 2 cm marks proximal Stimulation points Page 11 of 24 .Ulnar Neuropathy at the Elbow. or the FDI in the web space between the thumb and forefinger. Placed on the proximal phalanx of the fifth digit Placed between the stimulating and recording electrodes (cathode distal) Start at the “zero” mark in the epicondylar groove and make a mark. Stimulate these 7 positions. 2 cm marks distal “Zero” point 3. then mark 3. 2 cm increments both proximal and distal to this “zero” mark. or on their side with arm supinated and abducted 70-90 degrees Clean area with alcohol. temperature check Skin Prep: Recording site: Active: Placed on the belly of the ADM ½ the distance between the distal wrist crease and the base of the fifth digit. starting distal and moving proximal. Reference: Ground: Stimulation: Measurements: Look for segmental changes in latency or amplitude that is asymmetrical as compared to the others segments. an Overview Inching technique Patient Position: Supine.

lateral and medial cords) Median motor study to the APB The median nerve is used as a comparison study. temperature check Placed over the belly of the Abductor Pollicis Brevis (APB). Patient Position: Skin Prep: Recording site: Active: Supine with arm supinated and extended at side Clean area with alcohol.Ulnar Neuropathy at the Elbow. ½ distance between metacarpophalangeal (MCP) joint of thumb and midpoint of the distal wrist crease Placed on the distal phalanx of the thumb Placed between the stimulating and recording electrodes (cathode distal) Applied 2 cm proximal to the distal wrist crease between the flexor carpi radialis (FCR) and the palmaris longus (PL) tendons Applied at the elbow crease. an Overview Median nerve (C6-T1. all trunks. just medial to biceps tendon Between active recording electrode and wrist Between wrist and elbow Latency and amplitude for CMAP recordings Conduction velocity wrist to elbow Reference: Ground: Stimulation: Wrist: Elbow: Measurements: Calculations: Page 12 of 24 .

an Overview Antidromic sensory study to the index finger Patient Position: If a patient has a CTS as well as an UNE.5 cm proximal to cathode) Applied 2 cm proximal to the distal wrist crease between the flexor carpi radialis (FCP) and palmaris tendons (PL) Between active recording electrode and wrist Latency and amplitude for SNAP Sensory conduction velocity Reference: Ground: Stimulation: Wrist: Measurements: Calculations: Page 13 of 24 . validate the CTS by performing a sensory comparison study to the radial nerve.Ulnar Neuropathy at the Elbow. Supine with arm extended at side Wipe with alcohol. temperature check Skin Prep: Recording site: Active: Ring electrode placed on midportion of the proximal phalanx of the index finger Ring electrode placed on the midportion of the middle phalanx of the index finger Placed between the stimulating and recording electrodes (anode is 2. thus eliminating confusion with an abnormal ulnar sensory.

but because of the fascicular arraignment it is often spared. medial cord) You would think the DUC would be abnormal in lesions at the elbow. Between active recording electrode and wrist Latency and amplitude for SNAP None required. Anatomically the nerve curves around the ulna so the best response may be found on either side of the ulna. temperature check In the web space between the 4th and 5th metacarpal. Side-to-Side comparison is often necessary Reference: Ground: Stimulation: Measurements: Calculations: Page 14 of 24 . Patient Position: Skin Prep: Recording site: Active: Supine with arm pronated and extended at side Clean area with alcohol.Ulnar Neuropathy at the Elbow. an Overview Dorsal ulnar cutaneous nerve (C8-T1. although some may calculate the CV from cathode to recording electrode. lower trunk. 3-4 cm distal Placed between the stimulating and recording electrodes 10 cm proximal along the ulna bone.

Ulnar Neuropathy at the Elbow. lower trunk. Pressing hard or strong stimulation activates the median and/or the ulnar nerves. which. but after a little practice it becomes easier. medial cord) Patient Position: Some believe the MABC is a difficult nerve to record. Supine with arm supinated and extended at side Clean area with alcohol. will obliterate your response with motor artifact. Reference: Ground: Stimulation: Measurements: Calculations: Place the active electrode 10 cm along the straight line from 2cm proximal to the medial epicondyle to the ulna styloid Medial epicondyle Ulna styloid Stimulate at that point 2 cm proximal to the medial epicondyle Page 15 of 24 . because they are mixed nerves. Between active recording electrode and wrist Latency and amplitude for SNAP None required. too much pressure or too much stimulus will cause extensive motor artifact. Use a soft touch. an Overview Medial antebrachial cutaneous nerve (C8-T1. One key is using a light touch with low intensity. temperature check Skin Prep: Recording site: Active: Placed 10 cm along a line extending from 3 cm proximal to the medial epicondyle to the ulnar styloid Placed 3-4 cm distal along the nerve course Placed between the stimulating and recording electrodes At the tip of the measurement point 3 cm above the medial epicondyle. although some may calculate the CV from cathode to recording electrode.

0 100 25.64 mV 12. Note: Normal waveform screen shots of the left radial SNC and the right ulnar SNC were omitted for space considerations.2 6.33 mV 11.42 mV 12.47 mV 3.2 S u sS tim lu ite A W 1: rist A B 2: elow elb ow A A ove elb 3: b ow L t1 a m s D r u m s A p m m V 2.0 m D r: : 100 m S R 10. Normal values for this age are stated below the tables.0 6.5 H Level: z #4 09:06:14 57.1 7.3 ms 6.Case Study 1: Age: Gender: 27 Female Temperatures: Left wrist: 31.8 10. e: ff ig R ecord g S in ite: A d ctor p bu ollicis b revis S A sS tim lu ite u 1 A W 1: rist 1 0 A 0 m A E ow 2: lb 2m V L t1 a m s D r u m s A p m m V A a T m re e p o m m V s C 1 0 A 0 m 5m V A 1 3.28 mV 0.8 ms 11.5 ms 7.0 ms 7.8 ms A Stim .0 7.24 mV 3.0 5 0m 0 s 2m V A 3 1 0 A 0 m 5m V A p 1: 2-10kH m z T p 22.52 31. REASON FOR STUDY: Patient with numbness and tingling in the 4th and 5th fingers of the left hand.0 98.0 u 0.7 ms 7. Motor Nerve Conduction: Nerve and Site Segment Left Median Wrist Elbow Distance Rec: APB Latency Amplitude Conduction Velocity Abductor pollicis brevis-Wrist Wrist-Elbow 60 mm 230 mm 3.14 mV 7.00 mV 12.8 6.8 C em : o rv C De O id N -W v s S C A 11.5 m/s Page 16 of 24 .8 7.24 mV 25.0 m/s 25.8 ms Record S itc : w h S O T P 0.05 mm 1 gate: u s in le Median Left 55.0 ms 7.5 98.8 C em : o A p 1: 2-10kH m z T p 22.14 30.5 m/s Left Ulnar Wrist Below elbow Above elbowSwitch: S tim : Rec: ADM ADM-Wrist Wrist-Below elbow S O T P Below elbow-AboveLevel: ate: 0.0 R p S a e N N S e tim M N U E C D V N w N rv e e e O e S e M C F th r id N -W v s S C A S R p S a e N N e tim H -W v N MN Ee Vth r S e M C F a e e Ue s w N Left Ulnar .8 6.5 H elbow z 1 R Left 60 mm 2.9 12.8 ms 10.54 mV 12.2 7.94 31.3 7.8 ms MNC 220 mm 6.0 ms 120 mm 12.0 m D r: .22 mV 3.90 mV 11.Inching D6 D4 D2 P P2 P4 P6 Rec: ADM Abductor digiti minimi (manus)-D6 D6-D4 D4-D2 D2-P P-P2 P2-P4 P4-P6 D6-P6 6.2 Normal Left Median motor study AS m t 2 eg en A B rist P -W W rist-E ow lb D t is m m C V m /s rA p m % rA a re % 1 0 A 0 m 5m V A 2 1 0 A 0 m 2m V 2m V Left Ulnar motor study shows reduced amplitude and slowed CV across elbow 60 230 57.5°C For your convenience values outside the normal range are bolded.3 11.2 ms 7. Evaluate for underlying neuropathic process.6 S m t eg en A M rist D -W W rist-B elow elb ow B elow elb -A ove elb ow b o D t is m m C V m /s 60 220 55.05 m S g A m/s s in le S : tep H old R ecord g S in ite: A M D Ulnar MNC Record 2m s S : tep 1 A verag O S . E h cer: O e: ff ig n an ff 2m s A verag O S .00 30.7 3. There is no neck pain.

3 2-P -1 .4 ms Left Left Median (orthodromic) Digit II (index finger) Rec: Wrist Wrist-Digit II (index finger) 130 mm 110 mm Left Left 1m s 35.90 + .5 35.7 2. an Overview Left S itc : w h S tim : S O T P 1 Ulnar MNC Record #6 09:06:46 R ate: 0.3 5m V P 2 2 proximal -Pcm -0 .7 +2.4 15.5 H Level: z S tim 2 R Wrist-Mid palm (Ulnar) 80 mm S O T P 0.0 o Sensory Nerve Conduction: Nerve and Site Segment N w N rv e e e O e S e M C F th r id N -W v s S C A S R p S a e N N e tim M N U E C D V Distance Amplitude Peak Latency 2.4 ms Right Ulnar (Orthodromic) Digit V (little finger) Rec: Wrist Wrist-Digit V (little finger) Page 17 of 24 .3 2 u 0 V N : 4 1 u 0 V N : 4 S u sS tim lu ite A M p 1: id alm(M edian ) A M p 3: id alm(U ar) ln L t a m s 1 1 Normal Left Median Orthodromic Sensory Normal Left Ulnar Orthodromic Sensory S m t eg en W rist-D it II (in ex fin er) ig d g W rist-D it V(little fin er) ig g Normal Left Transcarpal Studyist D m m 130 110 S m t eg en W rist-M p id alm(M ian ed ) W rist-M p id alm(U lnar) B 3 1 2 1 2 3 4 3 4 A 3 1 u 0 V N : 4 1 1 0 u1 2 0 V2 3 4 3 4 5 0m 0 s 2 u 0 V N : 4 2 0u 0 V A p 1: 20-3kH m z T p 22.2 A P 6: 4 10. Med-Uln Compariso SNC 1.54 + .4 2 2 6 D distal cm A 2: 4 6.05 m S g A s in le A verag O S .2 m S g A u s in le S : tep 2 A verag O S .0 P 4 2-P + 3 5 1 0 A P 0 m 4-P 6 0. E h cer: O e: ff ig n an ff S : tep 3 A verag O S .7 C em : o A p 1: 20-3kH m z T p 22.2 1 0 A A 0 m 7: P 6 11.35 V 15.8 -1.6 5m V A D 3: 2 7.63 31.7 C em : 11.35 31.7 C em : 11.9 Du 0.64 + .3 1 0 A D 0 m 0 . E h cer: O e: ff ig n an ff A 1 A 2 Left ulnar inching study – note the amplitude drop and prolonged latency between 2 and 4 cm proximal to the “zero” point.20 V 09:05:46 49.4 1 7 4 P2 distal cm 5m V A 5: 7.0 o Left Radial (Antidromic) Forearm N w N rv e e e O e S e M C F th r id N -W v s S C A S R p S a e N N e tim H -W v s e U e e Vth r S e S C M N a e D N MN E CO e w N rv id N U E Rec: Snuffbox Anatomical snuff box-Forearm 100 mm 110 mm 35. e: ff ig R ecord g S in ite: W rist L t1 a m s A p m u V T m e p o C A 1 1 2 1 2 3 4 3 4 2.9 2 4: P 7.3 12.4 3 4 .2 5m V 4 cm proximal 6 cm proximal D 6 6-P 1 0 A 0 m 5m V 5m V 120 4.3 1 0 A 0 m 0 .8 0 0 .4 D“0”4 6-D epicondylar groove + .0 m D r: .0280 mm R A u m S gate: s 1 le in S : tep 3 R ecord g S A W in ite : rist R ecord g S B W in ite : rist S u sS tim lu ite A D it II (in ex fin er) 1: ig d g A 1 1 2 1 2 B D3 4 V(little fing 3: ig it er) 3 4 1m s Transcarpal.28 V 17.0 m ms r: .9 3 .7 25.5 V z #1 Left Ulnar (Orthodromic) Digit V (little finger) Rec: Wrist Wrist-Digit V (little finger) Median SNC Ulnar Median/Ulnar Digits Record S itc : w h S tim : Left Transcarpal.5 ms 2.0 -1.Ulnar Neuropathy at the Elbow.0 m D r: 0.6 3 4 .5 D 2 4-D + .4 2 cm distal 5m V D t is D iff C V S m t eg en m m m s m /s A Mm 6 D -D 6. Med-Uln Comparison Mid palm (Median) Wrist-Mid palm (Median) Median/Ulnar Digits S itc w S O T P Mid palm (Ulnar):h: ate: 0.8 +2.5 12. A 3 A 4 A 5 A 6 A 7 R ecord g S in ite: A d ctor d iti m im (m u bu ig in i an s) L t1 a A p m S u sS tim lu ite m s m V A D 1: 6 6.33 V 2.6 0 5m V 0 .5 H Level: z 2m s 0.2 12.7 ms Record 1.0 ms 2.5 5 0m 0 s A p 1: 2-10kH m z T p 22.4 2 1 0 A 0 m 1 .75 H Level: 0.1 3 1 0 A A 0 m 1 .63 V 79.

The symmetry in ulnar sensory amplitudes and the lack of denervation changes on needle exam argue against axonal loss injury.8. Amp: ≥ 12 Peak Lat: ≤ 2. Page 18 of 24 . There was an amplitude drop of 71% upon stimulation above the elbow with marked slowing of conduction velocity across the elbow. This is an example of sparing to some fascicles (the fascicles going to the sensory innervations) while others are affected (the fascicles going to the ADM). The ulnar sensory nerve amplitude was symmetric upon side to side comparison. which usually corresponds to a good prognosis for recovery. Amp: ≥ 6. an Overview Normal values: Median MNC Ulnar MNC DML: ≤ 4. DISCUSSION: There is electrical evidence to suggest the presence of a left ulnar neuropathy that localizes to the region of the retroepicondylar groove. Amp: ≥ 10 ≤ 0. The segmental slowing in conduction velocities and partial conduction block suggests a focus of demyelination. Motor conduction study of the left median nerve was within normal limits.2. Sensory nerve conduction studies of the left median.8. CV across elbow may slow ≤ 10 Median SNC Ulnar SNC Palmar diff Peak Lat: ≤ 3.4 NERVE CONDUCTION STUDIES: 1. Amp: ≥ 4. CV ≥ 49 DML: ≤ 3. left radial and both ulnar nerves were within normal limits. CV ≥ 49. Motor conduction study of the left ulnar nerve revealed normal distal latency and amplitude. 2.2.Ulnar Neuropathy at the Elbow. An inching study of the left ulnar nerve revealed a 79% amplitude drop with a 3 ms delay between the epicondylar groove and 2 cm proximal to the groove.

7 C em : o N w N rv e e e O e S e M C F th r id N -W v s S C A S R p S a e N N e tim H -W v s e U e eV th r S e M C F a e N w N rv M N E CO e D id N -W v s S C A11. He denies left hand weakness.38 mV 0.9 5. His exam today shows weakness in ulnar distribution bilaterally.3 100 25.9 A 4 m 2m V S u sS tim lu ite A W 1: rist A B 2: elow elb ow A A ove elb 3: b ow L t1 a m s D r u m s A p m m V 2.2 2m V A 3 1 0 A 0 m 2m V A p 1: 2-10kH m z T p 22.6 ms 8. He also notes tingling in the left shoulder that does not radiate further down the arm.05 m S1g ate: A u : 100 mm inR 11.5 A 7 m 5m V 5m V amplitude with additional amplitude reduction and slowed CV in the across elbow segment.8 ms MNC 225 mm 7.3 8. Motor Nerve Conduction: Nerve and Site Segment Left Median Wrist Elbow Distance Rec: APB Latency Amplitude Conduction Velocity Abductor pollicis brevis-Wrist Wrist-Elbow 60 mm 250 mm 3.Ulnar Neuropathy at the Elbow.2 9.81 33.1 9. an Overview Case Study 2: Age: Gender: 63 Male Temperatures: Right wrist: 33°C Left wrist: 33°C For your convenience values outside the normal range are bolded.9 W rist-B elow elb ow B elow elb -A ove elb ow b o D t is m m C V m /s A 2 6 .5 A 7 m A E ow 2: lb 5m V L t1 a m s D r u m s A p m m V A a T m re e p o m m V s C A 1 3.1 5.0 11.1 10.5 5.3 ms 9.2 m S g A s in le S : tep 3 R ecord g S in ite: A M D Ulnar MNC Record 2m s S : tep 2 A verag O S .53 mV 5.3 Normal Left Median Motor Study D t is C V rA p m rA a re 1 0 A 0 m AS m t 2 eg en S m t eg en m m m /s % % 2m V A M rist D -W A B rist P -W 60 W rist-E ow Left Ulnar Motor Study shows reduced distal lb 250 53. REASON FOR STUDY: Numbness in the fifth digit in the left hand for the past three months.8 9.3 m/s 25. Normal values for this age are stated below the tables.95 29. He denies neck pain.1 ms Record S itc : w h S O T P 0.0 m Dm/s 0. Symptoms began in the tip of the fifth digit and have spread to the left wrist.5 H Level: z 1 Left 60 mm 2.79 33. E h cer: O e: ff ig n an ff 2m s A verag O S .2 ur: 0.7 C em : o A p 1: 2-10kH m z T p 22.1 m/s Left Ulnar Wrist Below elbow Above elbowSwitch: S tim : Rec: ADM ADM-Wrist Wrist-Below elbow S O T P RBelow elbow-Above elbow ate: 0.09 mV 0.3 5.3 0.0 89. This study is to evaluate for a left ulnar mononeuropathy versus a left lower cervical radiculopathy.5 7. E e: ff ig R ecord g S in ite: A d ctor p bu ollicis b revis S u sS tim lu ite A 1 A W 1: rist 6 .1 ms r: s le Median Left 52.0 R p S a e N N S e tim M N U E C D V Page 19 of 24 .0 m D Stim .95 mV 8.1 86.5 9 .56 mV 5.56 26. 5 0m 0 s 60 225 52.5 H Level: z #3 09:03:37 53. symptoms involving the right hand or the feet.6 8.

35 mV 7.2 S u sS tim lu ite A W 1: rist A B 2: elow elb ow A A ove elb 3: b ow L t1 a m s D r u m s A m m V 2. 5 0m 0 s 60 245 54.9Ulnar m/s 33.9 1 0 A 0 m 1 u 0 V B D it V(little fing 3: ig er) Normal Left Median Orthodromic Sensory Left Ulnar Orthodromic Sensory shows reduced amplitude and prolonged peak latency B 3 1 2 1 2 3 4 3 4 S m t eg en W rist-D it II (in ex fin er) ig d g W rist-D it V(little fin er) ig g D t is m m 130 110 1 u 0 V N : 4 1 0u 0 V 5 0m 0 s A p 1: 20-3kH m z T p 22.8 5m V A 3 1 0 A 0 m 5m V A p 1: 2-10kH m z T p 22.3 2.4 m/s Right Ulnar Wrist Below elbow S Above elbow witch: S tim : Rec: ADM ADM-Wrist Wrist-Below elbow S O T P ate: 0.0 o N w N rv e e e O e S e M C F th r id N -W v s S C A S R p S a e N N e tim H -W v s M N a e U E C D V Page 20 of 24 .3 6.1 m Single 0.25 mV 8.8Dur: 0.2 25. E h cer: O e: ff ig n an ff 2m s A verag O S .6 91. e: ff ig R ecord g S in ite: A d ctor p bu ollicis b revis S u sS tim lu ite 1 A WA 1: rist 9 .82 mV 8.0 8.5 9.55 33.2 8.5 7.5 H Level: z #6 09:04:15 54.0 m D r: w .27 V s in le u S : tep 3 A verag O S .9 115 33.8 6.43 mV 10.8 ms 8.3 A 6 m 5m V A 1 3.21 mV 0.5 H Level: z 1 R Below elbow-Above elbow Right 2m s 60 mm 2.0 m m/s A s S : tep 3 R ecord g S in ite: A M D MNC Record S : tep 2 A verag O S .9 6.5 H110 mm z Level: 1m s 3.23 33.2 A 0 m A E ow 2: lb 5m V L t1 a m s D r u m s A p m m V A a T m re e p o m m V s C 8 .3 ms 0.2 ms SNC Record #1 09:03:13 Left Median (Orthodromic) Digit II (index finger) Rec: Wrist 130 mm Left Left Wrist-Digit II (index finger) 25.5 3.2 Normal Right Median Motor Study A eg en 2 S m t A B rist P -W W rist-E ow lb D t is m m C V m /s rA p m % rA a re % 1 0 A 0 m 5m V A 2 9 .05 m STO1 leate: ms A u Stim h: mm in R 9. an Overview Right Median Wrist Elbow Rec: APB Abductor pollicis brevis-Wrist Wrist-Elbow 60 mm 245 mm 3.7 C em : 11.0 e Ne e N -W v s S C A S R p S a e N N e tim M N U E C D V Sensory Nerve Conduction: Nerve and Site Segment Distance Amplitude Peak Latency 3.0 m D r: .25 31.8 C em : o A p 1: 2-10kH m z T p 22.7 ms MNC 205 mm 6.27 33.40 33.7 6.5 ms Record itc 115 s S P 0.3 4.43 34.3 ms 11.3 10.9 11.4 89. E h cer: O e: ff ig n an ff R ecord g S A W in ite : rist R ecord g S B W in ite : rist S u sS tim lu ite A D it II (in ex fin er) 1: ig d g L t1 a m s A p m u V T m e p o C A 1 1 1 3.Ulnar Neuropathy at the Elbow.8 8.9 g S : Median Right 53.2 5.55 V Median Ulnar Left Ulnar (Orthodromic) Digit V (little finger) Rec: Wrist Median/Ulnar Digits Wrist-Digit V (little finger) ate: R S itc : w h S tim : S O T P 2 0.7 C em : o N w N rv e e e O e S e M C F th r id N -W v s S C A S R p S a e N N e tim H -W v s N U N rv V O e S e M C F a e Mw E C D th r id 11.7 S m t eg en A M rist D -W W rist-B elow elb ow B elow elb -A ove elb ow b o D t is m m C V m /s 60 205 53.2 A 0 m 5m V 5m V Right Ulnar Motor Study shows normal distal amplitude without reduced amplitude but with slowed CV across the elbow.05 m S g A 2.

7 msr: . Right sural sensory conduction was normal.93 32.05 m S g m D A u s in le S : tep 3 A verag O S .9 5. There is however additional electrical evidence for some degree of axonal loss in the territory of the left ulnar nerve based on the low distal compound muscle action potential amplitude. Motor conduction studies of both median nerves are normal. however.5 1 u 0 V R ecord g S A Lateral m in ite : alleolu s R ecord g S B Lateral m in ite : alleolu s L t1 a S u sS tim lu ite m s A Low leg 1: er B Low leg 3: er 3 Normal Right Median Orthodromic Sensory Right Ulnar Orthodromic Sensory shows reduced amplitude and normal peak latency B 3 1 2 1 2 3 4 3 4 S m Sensory Response eg en t W rist-D it II (in ex fin er) ig d g W rist-D it V(little fin er) ig g Normal Right Sural Antidromict D is m m 130 110 S m t eg en Lateral m alleolu s-Low leg er Lateral m alleolu s-Low leg er B 3 1 u 0 V N : 4 1 2 0u1 2 0 V2 3 4 3 4 5 0m 0 s 1 u 0 V N : 4 1 0u 0 V A p 1: 20-3kH m z T p 22.7 C em : 11.93 V 5. e: ff ig S : tep 3 A verag O S .05 m mmR ate: 0. which usually corresponds to a good prognosis for recovery. The left ulnar motor conduction revealed low amplitude with conduction block upon proximal stimulation and conduction velocity slowing across the elbow.5 2. Amp: ≥ 12 Peak Lat: ≤ 2. Sensory conductions of both ulnar nerves were of low amplitude with normal peak latency on the right and prolonged peak latency on the left.8.2.84 V Level: 0. Sensory nerve conduction studies of the median nerves were normal on both sides. CV ≥ 49 DML: ≤ 3. there was conduction velocity slowing across the elbow.5 H Level: z A u : 140 S gate: r: s 1 le in 0. The right ulnar motor conduction was of normal distal latency and amplitude. Amp: ≥ 4. Page 21 of 24 . Amp: ≥ 5 NERVE CONDUCTION STUDIES: 1.2.Ulnar Neuropathy at the Elbow.0 o w Nrv id N U E N w N rv e e e O e S e M C F th r id N -W v s S C A S R p S a e N N e tim H -W v s e U e e V th r S e S C M N a eN M N E CO e D Normal values: Median MNC Ulnar MNC DML: ≤ 4. Amp: ≥ 10 Peak Lat: ≤ 4.3 ms 2.0 m DStim .8 C em : o A p 1: 20-3kH m z T p 22.Bilateral .43 32.8.5 H z #5 09:04:05 3.3 21.9 ms Left Right 1m s Right Ulnar (Orthodromic) Digit V (little finger) Lower leg S itc : w h S tim : S O T P 2 Rec: Wrist Wrist-Digit V (little finger) Right Sural (Antidromic) Median/Ulnar Digits Rec: Lat.2.03. CV ≥ 49.ET Record Ulnar Wrist-Digit II (index finger) 21. DISCUSSION: There is electrical evidence to suggest the presence of bilateral ulnar neuropathies that localize to the region of the retroepicondylar groove. CV across elbow may slow ≤ 10 Median SNC Ulnar SNC Sural SNC Peak Lat: ≤ 3. Mall 1m s Sural Sural SNC Record S itc : w h S O T P R Lateral malleolus-Lower leg 0. 2. Amp: ≥ 6. an Overview Right Median (Orthodromic) Digit II (index finger) Rec: Wrist 130 mm 110 mm Right Right Median SNC Sural .43 V 6. E h cer: O e: ff ig n an ff A 1 1 2 1 2 3 4 3 4 1 u 0 V N : 4 R ecord g S A W in ite : rist R ecord g S B W in ite : rist S u sS tim lu ite A D it II (in ex fin er) 1: ig d g A 1 B D it V(little fing 3: ig er) L t1 a m s A p m u V T m e p o C 3. The segmental slowing in conduction velocities suggests a focus of demyelination.

0 99.3 94.0 150 48.9 A 4 m 5m V D t is m m C V m /s rA p m % rA a re % S m t eg en A M rist D -W W rist-B elow elb ow B elow elb -A ove elb ow b o 240 55. but slowing to the FDI is apparent.05 m S g s in le A verag O S .64 32.3 7.5 H Level: z 2m s 0.78 A 2 7 . Left S itc : w h S tim : S O T P 1 Ulnar #5 10:19:25 R ate: 0.32 35.8 150 50.3 90.0 R ecord g S in ite: FD I A 1 1 0 A 0 m 5m V S u sS tim lu ite A W 1: rist A B 2: elow elb ow A A ove elb 3: b ow L t1 a m s D r u m s A p m m V A a re m m V s 2.2 A 2 m 5m V D t is m m C V m /s rA p m % rA a re % S m t eg en FD rist I-W W rist-B elow elb ow B elow elb -A ove elb ow b o 60 240 60.7 A 7 m 5m V This is a normal Ulnar motor study to the ADM A p 1.0 m D r: A u S : 3 tep .7 12.0 11.96 19.Ulnar Neuropathy at the Elbow.61 6.5 5.0 5. The fascicles going to the FDI are involved. 2-10kH m: z T p 24.6 7. 2-10kH m: z Ulnar Motor-ET S itc : w h S tim : S O T P 1 T p 24.5 C em : o Page 22 of 24 .4 C em : Left Ulnar #4 09:48:03 o R ate: 0.5 97.5 97.2 10. but the fascicles going to the ADM are spared.05 m S g s in le A verag O S .86 5.20 5.13 33.9 6.0 R ecord g S in ite: A M D A 1 1 0 A 0 m 5m V S u sS tim lu ite A W 1: rist A B 2: elow elb ow A A ove elb 3: b ow L t1 a m s D r u m s A p m m V A a re m m V s 3. an Overview Case Study 3: 54 year-old man with left arm pain and numbness in the 4th and 5th digits for several months.78 A 2 5 .0 96.2 7.9 10.84 18.6 99.5 10. E h cer: O e: ff ig n an ff 10.5 A 6 m 5m V Same patient.88 19.5 A 3 5 .9 95.5 H Level: z 2m s 0. A p 1. E h cer: O e: ff ig n an ff 10.41 6.8 A 3 7 .0 m D r: A u S : 3 tep .7 7.

MNC – The median nerve recording is normal. The ulnar nerve recording from the ADM is normal. Ulnar nerve recording from the FDI reveals slowing across the elbow. an Overview NCS summary: SNC – Orthodromic stimulation of the median nerve is normal. Page 23 of 24 .Ulnar Neuropathy at the Elbow. Orthodromic stimulation of the ulnar nerve reveals reduced amplitude and normal peak latency.

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