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AMERICAN ASSOCIATION OF NEUROMUSCULAR &
ELECTRODIAGNOSTIC MEDICINE
2621 Superior Drive NW
Rochester, MN 55901
(507) 288-0100
[email protected]
www.aanem.org
AMERICAN ASSOCIATION OF NEUROMUSCULAR &
ELECTRODIAGNOSTIC MEDICINE
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Workshop handouts are prepared as background didactic material to complement a hands-on workshop
session. This workshop handout was originally prepared in September 1994 and was revised in
September 2000. The idea and opinions in this publication are solely those of the author(s) and do
not necessarily represent those of the AANEM.
Copyright © September 2000
AMERICAN ASSOCIATION OF NEUROMUSCULAR &
ELECTRODIAGNOSTIC MEDICINE
2621 Superior Drive NW
Rochester, MN 55901
Ulnar Techniques
Jacqueline J. Wertsch, MD
Department of Physical Medicine and Rehabilitation
Medical College of Wisconsin
Theresa A. Oswald, MD
Prevea Clinic
John C. Kincaid, MD
Department of Neurology
Indiana University
INTRODUCTION
A “tardy” paralysis of the ulnar nerve was described as early as
1878 by Panas. He noted the relationship between a fracture of
the elbow and a slowly progressive ulnar nerve palsy. In 1958
Feindel and Stratford recognized the occurrence of ulnar neuropathies at the elbow in patients without elbow deformities and
introduced the cubital tunnel syndrome.1 Many other etiologies
of proximal ulnar neuropathies are now recognized (Table 1).
Distal ulnar nerve compromise at the wrist or within the palm
has been reported as early as 1908 when occupational neuritis of
the deep ulnar nerve was described. The Shea classification of
Guyon canal ulnar entrapments defines type I as occurring
when there is both hypothenar and deep ulnar motor involvement and sensory involvement.4 Type II is with only deep
motor branch involvement and type III with only superficial
ulnar sensory involvement.
Since initial ulnar motor conduction studies by Hodes in 1948,
the role of electrophysiologic data in the evaluation of suspected
ulnar neuropathies has been the subject of many publications.42
Parameters which have been utilized have included motor,
mixed nerve, and sensory conduction velocity of the elbow
segment,11,23,39,41,44,48,56,57,63,64 comparison of the elbow segment velocity to that of an adjacent nerve segment,23,39,56 latency from the
elbow to wrist,39 latency from the elbow to the flexor carpi
ulnaris (FCU) or flexor digitorum profundus (FDP),23,53,56 change
in the size or configuration of the compound muscle action potential (CMAP) or sensory nerve action potentials (SNAP),
evoked proximal and distal to the elbow,23,36,48,56,57,63 and the
pattern of needle examination abnormalities in ulnar supplied
muscles.23,39 For evaluation of distal ulnar neuropathy, two additional electrodiagnostic studies may be helpful: evaluation of the
dorsal ulnar cutaneous branch and ulnar motor studies to the
first dorsal interosseous muscle.3
Interpretation of conduction studies should take into account that
cadaver studies show slack and wrinkling of the ulnar nerve at the
elbow with the elbow in an extended position.65,66 Thus, it is more
difficult to measure accurately the actual length of the ulnar nerve
segment across the elbow in the extended position. In normals,
conduction studies across the elbow frequently show velocity
slowing if an extended elbow position is used; 23,36,39,43,44,65,67,68,69
this is not noted with a flexed position.45,57,65-67
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TABLE 1. Proximal Ulnar Neuropathy Etiologies
Anatomic Sites of Possible Compression
Arcade of Struthers
Medial epicondylar groove
Cubital tunnel (between the two heads of the
flexor carpi ulnaris muscle)
Muscle anomalies (anconeus epitrochlearis)
Snapping triceps tendon
Other Mechanical Causes
Acute trauma
fracture/dislocation
soft tissue injury
Old fractures
medial epicondyle
supracondylar humeral shaft
Bony deformities
rheumatoid arthritis
osteoarthritis
Paget’s disease
cubitis valgus
sesamoid bone
Ganglia
Recurrent dislocation or subluxation of the
ulnar nerve at the elbow
External pressure
single episode
multiple episodes
related to anesthesia
related to prolonged bedrest
related to unconsciousness
related to casting
Postinoculation (tetanus)
Vascular
Ischemia or venous engorgement
Related to AV-fistula placement
Metabolic or Toxic
Diabetes
Alcoholism
Hereditary Neuropathies
Tumors
Infection
Leprosy
AANEM Workshop
At the elbow, the ulnar travels between the medial epicondyle
and the olecranon in the retrocondylar groove. Continuing distally, the nerve passes between the two heads of the FCU. The
tendinous arch between the heads of the FCU, along with the
underlying bone and ligaments, form the cubital tunnel. Motor
branches to the FCU most commonly arise distal to the medial
epicondyle, but may arise at or above the epicondyle.5 The
motor branch to the FDP comes off the ulnar nerve in the
proximal forearm. The ulnar nerve continues in the forearm,
resting on the FDP and covered by the FCU.
At the wrist, the ulnar nerve courses across the flexor retinaculum into Guyon’s canal, which is bound medially by the pisiform and laterally by the hook of the hamate. The superficial
volar carpal ligament and palmaris brevis comprise the floor of
the canal. In the hand, the ulnar nerve divides into superficial
and deep branches. The superficial branch innervates the palmaris brevis and divides into the palmar digital branches which
supply the ulnar side of the little finger and the fourth interspace. The deep branch supplies all other ulnar innervated hand
muscles. The dorsal ulnar cutaneous nerve branch is off the
main ulnar nerve 5 to 10 cm proximal to the wrist but can be
identified as an independent bundle for some distance proximal.
It passes under the FCU tendon to reach the dorsum of the
hand. The palmar cutaneous branch arises at a variable point in
the distal half of the forearm and travels with the ulnar artery to
innervate the skin of the hypothenar eminence.5
ANATOMY
The ulnar nerve is composed of C-8, T-1 fibers and is the distal
continuation of the medial cord of the brachial plexus. The
ulnar nerve travels with the brachial artery, median nerve, medial
cutaneous nerves of the arm, and forearm until mid-arm at the
level of the attachment of the coracobrachialis muscle.
Generally no branches arise from the ulnar nerve in the arm.
The deep fascia which overlies the nerve from the surface of the
medial triceps to the medial intermuscular septum is called the
arcade of Struthers. Proximal to the arcade of Struthers the
nerve is freely mobile. In the area of the arcade, as the nerve
travels from the anterior to posterior compartments of the arm,
it is firmly bound to the triceps.
Figure 1. Sites of Ulnar Nerve Entrapment
Reprinted with permission from: Wertsch JJ, Park TA. Electrodiagnostic medicine. In: Moore JS, Garg A, editors. Ergonomics: low-back pain, carpal tunnel
syndrome, and upper extremity disorders in the workplace. Occupational
medicine: state of the art reviews. Philadelphia: Hanley & Belfus; 1992.
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Ulnar Techniques
EMG EXAMINATION
ULNAR MOTOR STUDIES - TO HYPOTHENAR
Muscles frequently examined in evaluating an ulnar neuropathy
include the flexor carpi ulnaris, flexor digitorum profundus, and
ulnar hand intrinsic muscles. The first dorsal interossei manus
and hypothenar muscles are often studied although the adductor pollicis, other dorsal interossei, the volar interossei, and the
ulnar lumbricals can also be examined. EMG examination may
help localize the site of an ulnar lesion. Abnormalities in the
FCU or medial half of the FDP can help localize the lesion to
near or proximal to the elbow. Abnormalities in the interossei
with sparing of the hypothenar muscles localize the lesion at or
distal to Guyon’s canal. The internal topography of the ulnar
nerve may be useful to consider in interpreting EMG findings
(Figure 2). The relatively protected lateral position in the retrocondylar groove of the fascicles forming the branch to the
flexor carpi ulnaris has been suggested as an explanation for reported sparing of the flexor carpi ulnaris in some proximal ulnar
lesions.6,7 Differential fascicular vulnerability has also been postulated to explain the observation that ulnar abnormalities are
more frequently detected in the first dorsal interossei manus
than the hypothenar muscles.7
Hypothenar recording site: The G1 electrode is placed over the
belly of the hypothenar eminence and the G2 electrode over the
distal interphalangeal (DIP) joint of the fifth digit. Various G1
sites may be evaluated to determine the point which will yield
the maximum amplitude. Stimulation site is at the wrist 6 or 8
cm proximal. The ground is placed over the dorsum of the
hand.
In the evaluation of the ulnar nerve, the conduction velocity of
the elbow segment is often compared to the conduction velocity of an adjacent nerve segment. Velocities may be calculated
for the forearm, the elbow segment, and the upper arm.2 In
normals, conduction studies across the elbow frequently show
velocity slowing if an extended elbow position is used; this is not
noted with a flexed position.11,23,36,43-45,57,65-69 Recording from the
first dorsal interosseous in addition to the hypothenar muscles
has also been advocated, since these may be differentially
affected.23,56
REFERENCE VALUES: Hypothenar Recording
(DeLisa 1987)37
Onset latency
3.2+ 0.5 msec
Amplitude
6.1 + 1.9 mV
ULNAR INCHING ACROSS THE ELBOW
Figure 2. Diagram of a transverse section of an ulnar nerve
at the elbow. TCH=terminal cutaneous of the hand,
TMH=terminal motor of the hand, DCH=dorsal cutaneous
fibers of the hand, FCU=flexor carpi ulnaris, FDP=flexor digitorum profundus.
Reprinted with permission from: Sunderland S: Nerves and Nerve Injuries.
Edinburgh, Churchill Livingston, 1978 p 755.
Inching allows comparison of superimposed waveforms
obtained by stimulating across short, precisely measured intervals. Inching can help define focal ulnar entrapment in the
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Ulnar Techniques
retrocondylar groove or more proximally in the arm. Caution is
needed in interpreting an amplitude drop distal to the retrocondylar groove as this may simply reflect submaximal stimulation when there is a very proximal cubital tunnel entrance.
The patient is supine with shoulder abducted 40 to 45 degrees
and externally rotated, the elbow flexed 70 to 90 degrees and the
forearm supinated. The flexed elbow position is recommended
to provide the greatest correlation between surface measurements and actual nerve length.68-70 Recording can be done from
the hypothenar muscles or the first dorsal interosseous manus
(FDIM). The ulnar nerve is stimulated distally at the wrist and
waveform saved for comparison to proximal responses. The
ulnar nerve is then palpated to confirm its location in the retrocondylar groove. Successive stimulations in 2 cm intervals are
done distally as far as possible and proximally even into the
axilla to assure inclusion of the arcade of Struthers site.
Successive responses are evaluated for abrupt concomitant
changes in morphology, amplitude, and latency. Inching should
be repeated to confirm any focal changes noted. (Original techniques use a supramaximal stimulus intensity. However,
Campbell58 discusses a subthreshold stimulus technique and
notes care is needed to avoid excessively supramaximal stimuli
causing distal migration of the effective cathode, erroneous
latency determinations appearing as abnormal inching.) The
AAEM Ulnar Practice Parameter suggests that the following
may be significant (listed in ascending order by strength of evidence): a) absolute NCV AE-to-BE of less than 50 m/sec, b) an
AE-to-BE segment greater than 10 m/s slower than the BE-towrist segment, c) a decrease in CMAP negative peak amplitude
from BE to AE greater than 20%, and d) a significant change in
CMAP configuration at the AE site compared to BE site.70
ULNAR MOTOR STUDIES - TO FDIM
initial positivity which is usually seen when the G2 is placed on
the index finger.52 Wrist stimulation is done at the same site used
for the hypothenar study.
REFERENCE VALUES: FDIM
(Olney 1985)49
Onset latency
2.3-4.5 msec
Amplitude
6-24 mV
ULNAR MOTOR STUDIES - TO FCU
The G1 electrode is placed over the motor point of the FCU at
the junction of the proximal third and middle third of the
forearm. G2 is placed adjacent to G1 over the ulna shaft, with
3 cm separation. The ground is placed between the stimulating
and recording electrodes on the volar aspect of the forearm. The
ulnar nerve is stimulated 10 cm proximally in the medial arm.
REFERENCE VALUES: FCU
(Felsenthal 1986)54
Onset latency
2.6 + 0.3 msec
Amplitude
5.2 + 1.8 mV
ULNAR DIGITAL SENSORY NERVE CONDUCTION
First Dorsal Interosseous Manus recording site: The G1 electrode is placed between the first and second metacarpals over
the belly of the first dorsal interosseous muscle. The G2 is
placed distally over the thumb interphalangeal joint, to avoid the
For antidromic digital studies the G1 ring electrode is placed
around the proximal phalanx of the little or ring finger with the
G2 ring electrode around the distal phalanx. Care is needed to
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Ulnar Techniques
maintain adequate interelectrode distance. If the interelectrode
distance is less than 4 cm, this needs to be noted and considered
in the interpretation. Stimulation is performed at the distal wrist,
10 to 14 cm proximal to the G1 electrode. At the wrist, the ulnar
nerve is frequently best stimulated lateral to the FCU tendon.
However, in some individuals the ulnar nerve may be easier to
stimulate medial to the FCU tendon.
REFERENCE VALUES: DUC
(Park 1994)33
Peak latency
1.8 + 0.20 msec
Amplitude
32 + 13 µV
MEDIAL ANTEBRACHIAL CUTANEOUS NERVE
The orthodromic ulnar digital technique uses the same set-up
except that stimulation is delivered through the ring electrodes
and recorded at the wrist. Often a bar electrode is used for
recording at the wrist, but again the interelectrode distance of
the recording electrodes must be controlled and recording may
need to be tried both lateral and medial to the FCU tendon.
REFERENCE VALUES: Ulnar Digital
Sensory Technique at 14 cm
(Melvin 1966)19
Antidromic
Peak latency 3.2 + 0.20 msec (4 cm interelectrode)
Orthodromic Peak latency 3.0 + 0.20 msec (2 cm interelectrode)
DORSAL ULNAR CUTANEOUS BRANCH
The medial antebrachial cutaneous (MAC) nerve study can
help distinguish between proximal ulnar lesions (MAC preserved) and medial cord plexopathy (MAC involved).
Antidromic stimulation is performed 5 cm proximal to the
medial epicondyle. The MAC is found medial to the median
nerve. A point midway between the bicipital tendon and the
medial epicondyle is connected by a line to the pisiform bone
or ulnar styloid. A recording bar electrode (usually 3 cm interelectrode distance) is placed 14 cm distal to the stimulation site
along this line. The ground is placed between the stimulating
and recording electrodes.
REFERENCE VALUES: MAC
(Izzo 1985)25
Peak latency
2.7 + 0.20 msec
Amplitude
11.4 + 5.2 µV
TRANSCARPAL ULNAR TECHNIQUE
The dorsal ulnar cutaneous (DUC) nerve of the forearm can
help distinguish a Guyon canal ulnar entrapment (DUC preserved) from more proximal lesions. A 3 cm bar electrode over
the dorsal 4th metacarpal interspace is used for recording. The
DUC nerve can be stimulated distally as it wraps around the
ulnar styloid. The DUC can be stimulated separately from the
entire ulnar nerve in this location. With this technique, the distances between the recording G1 and the cathode are in the
range of 4 to 7 cm. With such short distances, the ground electrode needs to be placed carefully between the cathode and
recording electrodes.
Transcarpal ulnar conduction can be evaluated by stimulation of
the ulnar nerve within the palm and recording from the ulnar
nerve at the wrist. A bar electrode at the wrist may be used. The
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Ulnar Techniques
ulnar nerve is stimulated at the distal palm crease between the
4th and 5th metacarpals. Although it is recognized that there
may be some lumbrical motor fiber contributions, sensory
bandpass filtering is usually used.
REFERENCE VALUES: Ulnar Transcarpal Technique
(Mills 1985)10
Peak latency
1.9 + 0.20 msec
Amplitude
28.7 + 11 µV
Recording Interelectrode Distance
3 cm
Distance Between G1 and Cathode
8.5 to 11 cm
Filters
3.2KHz - 32 Hz
CONCLUSION
The AAEM Practice Parameter for Electrodiagnostic Studies in
Ulnar Neuropathy at the Elbow has defined practice standards
to include monitoring and controlling limb temperature, to rule
out diffuse processes and to specify and control elbow position
with 70 to 90 degrees from the horizontal recommended. The
articles which formed the basis of the Practice Parameter reported sensitivities of electrodiagnostic studies ranging from
37% to 86% and specificities of 95% or greater.70
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AANEM Workshop
Ulnar Digital Sensory Nerve Conduction
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Medial Antebrachial Cutaneous Nerve
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Dorsal Ulnar Cutaneous Branch
Transcarpal Ulnar Technique
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AANEM Course
Ulnar Techniques
32. Ma DM, Liveson JA. Nerve Conduction Handbook. Philadelphia:
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Ulnar Motor Studies - Hypothenar/FDI
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42. Hodes R, Larrabee MG, German W. The human electromyogram in
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43. Jebsen RH. Motor conduction velocities in the median and ulnar
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44. Krogness K. The cubital ratio method. Electromyogr Clin
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45. Kaeser HE. Erregungsleitungsstorungen bei ulnarlsparesen. Dtsch Z
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47. Melvin JL, Harris DH, Johnson EW. Sensory and motor conduction
studies in the ulnar and median nerves. Arch Phys Med Rehabil 1966;
47:511-519.
48. Odusote K, Eisen A. An electrophysiological quantification of the
cubital tunnel syndrome. Canad J Neurol Sci 1979; 6:403-410.
49. Olney RK, Wilbourn AJ. Ulnar nerve conduction study of the first
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54. Felsenthal G, Brockman PS, Mondell DL, Hilton EB. Proximal
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Neurol Neurosurg Psychiatry 1969; 32:208-220.
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Ulnar Inching About the Elbow
57. Brown WF, Yates SK. Percutaneous localization of conduction abnormalities in human entrapment neuropathies. Canad J Neurol Sci
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Effect of Elbow Position
64. Bielawski MA, Hallett M. Motor conduction of ulnar in flexion and
extension of elbow in normals and in patients with lesions at the
elbow. Muscle Nerve 1989; 12:803-809.
65. Checkles NS, Russakov AD, Piero DL. Ulnar nerve conduction velocity-effect of the elbow position on measurement. Arch Phys Med
Rehabil 1971; 53:362-365.
66. Harding C, Halar E: Motor and sensory ulnar nerve conduction velocities: effect of elbow position. Arch Phys Med Rehabil 1983;
64:227-232.
67. Kincaid JC, Phillips LH, Daube JR. The evaluation of suspected
ulnar neuropathy at the elbow. Arch Neurol 1986; 43:44-47.
68. Kothari MJ, Preston DC. Comparison of the flexed and extended
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Nerve 1995; 18:336-340.
69. Nelson RM. Effects of elbow position on motor conduction velocity of the ulnar nerve. Phys Therapy 1980; 69:780-783.
Practice Parameter
Ulnar Motor Studies - FCU
53. Benecke R, Conrad B. The value of electrophysiological examination
of the flexor carpi ulnaris muscle in the diagnosis of ulnar nerve
lesions at the elbow. J Neurol 1980; 223:207-217.
70. Practice parameter for electrodiagnostic studies in ulnar neuropathy
at the elbow: Summary Statement. Muscle Nerve 1999; 22:408-411.
NEM
AA
ULN
P
HO
RKS
WO
, MD
h
c
s
t
Wer
J
MD
e
,
n
i
d
l
l
e
a
u
Osw D
Jaq
A
a
s
M
a
There . Kincaid,
C
John,
AMERICAN ASSOCIATION OF NEUROMUSCULAR &
ELECTRODIAGNOSTIC MEDICINE
2621 Superior Drive NW
Rochester, MN 55901
(507) 288-0100
[email protected]
www.aanem.org
AMERICAN ASSOCIATION OF NEUROMUSCULAR &
ELECTRODIAGNOSTIC MEDICINE
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