Ulnar Neuropathy at wrist
Electrophysiological Approach
Dr.Roopchand.PS
Senior Resident Academic
Department of Neurology.
Introduction:
• Rare than ulnar neuropathy at elbow.
• Can mimic early MND.
• Good knowledge of local anatomy required.
Anatomy:
• Ulnar nerve enters the wrist at Guyons canal.
– Proximally pisiform bone
– Distally hook of hamate
– Floor : tr...
Supply:
1. Hypothenar motor: At hiatus
– ADM, Opponence digiti minimi, flexor digiti
minimi, palmaris brevis.

2. Superfic...
Clinical:
• Can be typed according to location of lesion
and fibers affected.
– Distal deep palmar motor lesion.
– Proxima...
Presentation:
• Weakness and atrophy of ulnar intrinsic
muscle.
• Thenar and hypothenar wasting can be seen
• Benediction ...
Etiology:
•
•
•
•

Repeated work related trauma.
Wrist fracture.
Ganglion cyst in Guyon’s canal.
Neurofibroma.
Differentials:
• Early MND:
– UNW not all C8 T1 muscles affected.

• Ulnar neuropathy at elbow.
– Correlating sensory loss...
Electrophysiological evaluation.
Normal Values:

•
•
•
•

FDI latency: < 4.5ms
FDI VS ADM Latency comparison: <2ms
Side to side comparison FDI: <1.3ms
2nd ...
Ulnar motor study recording FDI:
• Distal deep palmar br
lesion:
– Latency and CMAP
amplitude affected.
– When compared wi...
Dorsal cutaneous Sensory study:
• Normal SNAP in UNW.
• If abnormal suggests
UNE.
Median Second lumbrical VS Ulnar Int
DML:
• Same as Median study
in CTS.
• Latency diff > 0.4
significant.
• If there is a...
Wrist and Palm stimulation:
• FDI recorded.
• Stimulated 3cm above
the wrist and 4cm distal
to distal palmar crease.
• Dro...
Short segment Incremental studies.
• Inching done from 2 to
4 cm above and 4 to 6
cm below distal wrist
crease.
• 1 cm int...
• Wrist and palm stimulation showing focal
slowing 100% specific.
• Inching is also very sensitive and specific.
• In lumb...
EMG approach:
• FDI and ADM sampled to look for
distal/proximal deep br involvement.
• FDP5 and FCU : to r/o ulnar neuropa...
Recommended EMG Protocol for
UNW:
Ulnar neuropathy at wrist- Electrophysiological approache
Ulnar neuropathy at wrist- Electrophysiological approache
Ulnar neuropathy at wrist- Electrophysiological approache
Ulnar neuropathy at wrist- Electrophysiological approache
Ulnar neuropathy at wrist- Electrophysiological approache
Ulnar neuropathy at wrist- Electrophysiological approache
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Ulnar neuropathy at wrist- Electrophysiological approache

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Electrophysiology study of ulnar neuropathy at wrist.

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Ulnar neuropathy at wrist- Electrophysiological approache

  1. 1. Ulnar Neuropathy at wrist Electrophysiological Approach Dr.Roopchand.PS Senior Resident Academic Department of Neurology.
  2. 2. Introduction: • Rare than ulnar neuropathy at elbow. • Can mimic early MND. • Good knowledge of local anatomy required.
  3. 3. Anatomy: • Ulnar nerve enters the wrist at Guyons canal. – Proximally pisiform bone – Distally hook of hamate – Floor : transverse carpel ligament, hamate, triquetrous bone – Roof loosely formed at inlet and thick band of tissue at outlet – pisiohamate hiatus. – At the hiatus divides in to ulnar sensory branch and deep palmar motor branch.
  4. 4. Supply: 1. Hypothenar motor: At hiatus – ADM, Opponence digiti minimi, flexor digiti minimi, palmaris brevis. 2. Superficial sensory br: – Volar 5th and medial 4th digit. 3. Deep palmar motor br: – 3rd and 4th lumbricals, four dorsal and three palmar interossei, adductor pollicis, flexor pollicis brevis deep head.
  5. 5. Clinical: • Can be typed according to location of lesion and fibers affected. – Distal deep palmar motor lesion. – Proximal deep palmar motor lesion. – Proximal canal lesion. – Pure sensory lesion (rare). Most common
  6. 6. Presentation: • Weakness and atrophy of ulnar intrinsic muscle. • Thenar and hypothenar wasting can be seen • Benediction hand posture, Forment’s sing, Wartenberg’s sign can be seen. • Sensory disturbance over volar 5th and medial 4th finger. – Dorsal medial aspect spared.
  7. 7. Etiology: • • • • Repeated work related trauma. Wrist fracture. Ganglion cyst in Guyon’s canal. Neurofibroma.
  8. 8. Differentials: • Early MND: – UNW not all C8 T1 muscles affected. • Ulnar neuropathy at elbow. – Correlating sensory loss. • C8 T1 radiculopathy • Lower trunk, medial cord brachial plexopathies.
  9. 9. Electrophysiological evaluation.
  10. 10. Normal Values: • • • • FDI latency: < 4.5ms FDI VS ADM Latency comparison: <2ms Side to side comparison FDI: <1.3ms 2nd lumbrical Vs ulnat interossei: <0.4ms
  11. 11. Ulnar motor study recording FDI: • Distal deep palmar br lesion: – Latency and CMAP amplitude affected. – When compared with ADM latency – highly s/o UNW – ADM recordings also affected in more proximal lesions • >2ms difference significant..
  12. 12. Dorsal cutaneous Sensory study: • Normal SNAP in UNW. • If abnormal suggests UNE.
  13. 13. Median Second lumbrical VS Ulnar Int DML: • Same as Median study in CTS. • Latency diff > 0.4 significant. • If there is associated CTS – difficult to interpret.
  14. 14. Wrist and Palm stimulation: • FDI recorded. • Stimulated 3cm above the wrist and 4cm distal to distal palmar crease. • Drop in amplitude or decrease in CV. • Any CV <37m/s is of localizing value.
  15. 15. Short segment Incremental studies. • Inching done from 2 to 4 cm above and 4 to 6 cm below distal wrist crease. • 1 cm intervals. • NL 0.1 to 0.3 ms/cm • Latency >0.5ms – focal slowing.
  16. 16. • Wrist and palm stimulation showing focal slowing 100% specific. • Inching is also very sensitive and specific. • In lumbrical-interossei study increasing the cut off value to 0.7 can eliminate the problem of co existent median neuropathy. • FDI vs ADM latency comparison is least sensitive.
  17. 17. EMG approach: • FDI and ADM sampled to look for distal/proximal deep br involvement. • FDP5 and FCU : to r/o ulnar neuropathy proximal to wrist. • Radial and Median innervated C8 muscles & lower cervical paraspinal muscles: to r/o radiculopathy. – Abd. Pollicis brevis, flex. Pollicis longus, ext. indices proprius.
  18. 18. Recommended EMG Protocol for UNW:
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