ULNAR NERVE COMPRESSION AT T H E E L B O W C A U S E D B Y A

PROMINENT MEDIAL HEAD OF THE TRICEPS AND AN

ANCONEUS EPITROCHLEARIS MUSCLE

J. J. O'HARA and J. H. STONE

From the Torrance Memorial Medical Center, Torrance, California, USA

A number of musculo-tendinous variations around the medial epic,ondyle have been alleged to cause
ulnar nerve compression. Subluxation of the ulnar nerve, a "snapping" separate medial head of
triceps, a prominent medial head of triceps covering the ulnar nerve, anconeus epitrochlearis,
Osborne's band, and the ligament of Struthers have been implicated. We present a case of clear-
cut compression of the ulnar nerve at two levels just at and posterior to the epicondyle by a tightly
applied prominent head of the triceps, and at a more distal level beneath an anconeus epitroch-
learis muscle.
Journal of Hand Surgery (British and European Volume, 1996) 21B: 1:133-135

The pathogenesis of compression neuropathy of the
ulnar nerve at the elbow is more complex than simple
stretch and angulation around the medial epicondyle,
scarring by external trauma, previous fracture with or
without deformity, or subluxation of the nerve (Dahners
and Wood, 1984; Dellon, 1986; Hirasawa et al, 1979;
Mackinnon and Dellon, 1988; Spinner, 1978). Other
factors are prominent in mechanical compression of the
nerve at the elbow including Osborne's band (the fascia
covering the two heads of the origin of FCU), a
hypertrophic or occasionally "snapping" medial head
of triceps (Dellon, 1986), and the presence of the
anconeus epitrochlearis muscle (Dahners and Wood,
1984; Hirasawa et al, 1979; Mackinnon and Dellon,
1988). The anconeus epitrochlearis is an anomalous
muscle in man but present in amphibians, reptiles and
most mammals (Dahners and Wood, 1984; Dellon, 1986;
Hirasawa et al, 1979; Mackinnon and Dellon, 1988).
Spinner (1978) considered the muscle to be an extension
of the medial head of the triceps.
CASE R E P O R T
A 34-year-old female grocery store employee noted
numbness and tingling in the little and ring fingers of
both hands while recovering from previous sequential
bilateral carpal tunnel surgery. Tinel's sign was present
over the ulnar nerve just proximal to the medial epicond-
yle, and there was palpable thickening of the ulnar nerve
and tenderness just proximal to the medial epicondyle.
The elbow flexion test produced numbness and tingling
in the little and ring fingers within 10 seconds. There

Fig 1 The hypertrophic medial head of the triceps (TRI) compresses the ulnar nerve (UN) against the epicondyle (ME). The anconeus
epitrochlearis (AE) is seen distally. (Left elbow with hand to the right of figure).

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was no evidence of isolated or diffuse motor deficit.
Conservative measures failed to improve her situation
and electrodiagnostic studies were undertaken which
revealed slowing in the ulnar nerve across the elbow. It
was found on surgical exploration that the ulnar nerve
was covered with a prominent medial head o f triceps
which required division of a dense fascial attachment to
the medial intermuscular septum to reveal the ulnar
nerve. The nerve was compressed against the posterior
aspect of the epicondyle by the prominent medial head
of triceps with flattening of the fascicles and proximal
thickening of the nerve (Figs 1 and 2). Flexion of the

Fig 2 The triceps (TRI) has been reflected. Note the impression of the ulnar nerve (UN) at that level.

Fig 3 The anconeus epitrochlearis (AE) is seen extending from the olecranon to the inferior surface of the medial epicondyle(ME).
U L N A R NERVE COMPRESSION 135

Fig4 T h e a n c o n e u s e p i t r o c h l e a r i s ( A E ) h a s b e e n reflected. N o t e t h e i m p r e s s i o n in the u l n a r n e r v e ( U N ) b e n e a t h the a n c o n e u s e p i t r o c h l e a r i s

(AE).

elbow increased nerve compression. Approximately 2 cm English literature which has demonstrated compression
distally a small muscle was found approximately 1 cm of the ulnar nerve by both entities. It is probable that
wide and 2 cm long originating on the medial aspect of the syndrome is more common than it is thought to be.
the olecranon and inserting on the epicondyle (Fig 3). If isolated compression can be identified by adequate
Thickening of the ulnar nerve just proximal to this exploration, the need for anterior transposition, submus-
muscle was noted. After release of the muscle from the cular redirection, or medial epicondylectomy might be
epicondyle, the fascicles were noted to be flattened avoided.
beneath the area of the muscle (Fig 4). The fascia over
the heads of F C U was divided, although no constriction
was obvious at that level. Because of the obvious findings References
of compression in the cubital tunnel, anterior transpo- DAHNERS, L. E. and WOOD, F. M. (1984). Anconeus epitrochlearis, a rare
cause of cubital tunnel syndrome: A case report. Journal of H a n d Surgery,
sition was not undertaken. Prompt resolution of sensory 9A: 579-580.
dysfunction in the ulnar nerve distribution ensued in the DELLON, A. L. (1986). Musculo-tendinous variations about the medial
humeral epicondyle. Journal of H a n d Surgery, llB: 175-18t.
early post-operative period. The elbow flexion test was HIRASAWA, Y., SAWAMURA, H. and S A K A K I D A , K. (1979). Entrapment
not present. neuropathy due to bilateral epitrochleoanconeus muscles: A case report.
Journal of H a n d Surgery, 4: 181-184.
M A C K I N N O N , S. E. and DELLON, A. L. Surgery of the Peripheral Nerve.
DISCUSSION New York, Thieme, 1988: 226.
SPINNER, M. (1978). Injuries to the major branches of peripheral nerves of
The anconeus epitrochlearis muscle is not uncommon the foreama. Philadelphia, Saunders, 1978: 240-241.

according to cadaver and clinical studies (11 to 17%).

In Dellon's (1988) studio it was associated with promi- Accepted: 30 May 1995
nence of the medial head of the triceps. However, this Dr J. J. O'Hara, 4201 Torrance Boulevard, Suite 640, Torrance, California 90503, USA.
is the only case that we have found described in the © 1996 The British Society for Surgery of the Hand