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Ulnar / Radial Neuropathies

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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