Neurophysiologie clinique 33 (2003) 219–222

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Original article

Ulnar nerve entrapment at wrist associated with carpal tunnel syndrome

Les lésions du nerf cubital au poignet associées au syndrome
du canal carpien
E. Gozke a,*, N. Dortcan a, A. Kocer a, M. Cetinkaya a, G. Akyuz b, O. Us b
a
Department of Neurology, PTT Teaching and Research Hospital, Istanbul, Turkey
b
Marmara University Institute of Neurological Science, Istanbul, Turkey
Received 9 January 2003; accepted 8 August 2003

Abstract

In this study, ulnar nerve entrapments at the wrist were investigated using nerve conduction studies in cases with established diagnosis of
carpal tunnel syndrome (CTS). Cases with cervical radiculopathy and polyneuropathy as well as patients with ulnar nerve entrapment at elbow
were excluded from the study. Fifty-three cases (46 females, seven males) whose ages ranged between 20 and 72 years (mean: 49.31 ± 13.78)
were evaluated. Among 53 cases, 12 (22.6%) bilateral and 41 (77.3%) unilateral CTS were detected. Totally 65 wrists evaluated and
prolongation of median nerve wrist-3rd digit distal sensory latencies (DSL; n: 59; 90.7%) and wrist-abductor pollicis brevis distal motor
latencies (n: 48; 73.8%) were seen. In six wrists, diagnoses were established with the detection of an increase in the differences between
wrist-4th digit DSL of median and ulnar nerve. This test was used if other test results were in normal limits. Prolongation of ulnar nerve
wrist-5th digit DSL were found in 12 wrists (18.4%) in cases with CTS. Among these 12 wrists mild (n: 2), moderate (n: 7) and severe (n: 3)
CTS were detected. Ulnar nerve motor conduction studies provided normal results. In conclusion, we are in the opinion that for the detection
of associated ulnar nerve wrist entrapments, ulnar nerve conduction studies paying special attention to DSL convey importance in established
cases with CTS.
© 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved.

Résumé

Les auteurs ont étudié l’atteinte associée du nerf cubital au poignet chez des patients diagnostiqués de syndrome du canal carpien (SCC) sur
la base des vitesses de conduction à l’électromyographie. Les cas porteurs de radiculopathies cervicales, de polyneuropathies et ceux
présentant un syndrome de compression du nerf cubital au coude ont été exclus de l’étude. Les 53 (46 F, 7 H) patients retenus pour cette étude
étaient âgés de 20 à 72 ans, avec un âge moyen de 49,31 ± 13,78 ans. Douze cas (22,6 %) avaient un SCC unilatéral et 41 (77,3 %) un SCC
bilatéral. Des 65 poignets étudiés, 59 (90,7 %) présentaient un allongement de la latence sensitive distale du nerf médian entre le poignet et le
troisième doigt, 48 (73,8 %) un allongement de la latence motrice distale entre le poignet et le court abducteur du pouce. Pour six poignets, le
diagnostic a été posé par la détection d’un allongement de la différence des latences sensitives distales entre le poignet et le quatrième doigt des
nerfs médian et cubital. Ce test a été utilisé si les autres résultats étaient normaux. Chez les patients ayant un SCC, 12 poignets (18,4 %) avaient
un allongement de la latence sensitive distale du nerf cubital entre le poignet et le cinquième doigt. De ces 12 poignets, deux avaient un SCC
léger, sept modéré et trois sévère. Les études de conduction moteur du nerf cubital se sont avérées normales. Les auteurs attirent l’attention sur
l’importance des études des vitesses de conduction du nerf cubital et en particulier de la prise en compte de l’allongement de la latence
sensitive distale pour pouvoir mettre en évidence l’atteinte du nerf cubital associée chez les patients ayant un SCC.
© 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved.

Keywords: Carpal tunnel syndrome; Entrapment neuropathies; Ulnar nerve entrapment; Guyon canal; Nerve conduction studies; EMG

Mots clés : Le syndrome du canal carpien ; Les syndromes canalaires ; Neuropathie cubitale ; Canal de Guyon

* Corresponding author. Sedef sk. Onur sit. Kayin, Ap. 3/17 Kosuyolu, 34662 Istanbul, Turkey.
E-mail address: [email protected] (E. Gozke).

© 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved.

doi:10.1016/j.neucli.2003.08.002
220 E. Gozke et al. / Neurophysiologie clinique 33 (2003) 219–222

1. Introduction ing parameters were adjusted at 10 ms, 10–20 µV and 20 Hz–

2 kHz, respectively.
Sensory nerve conduction studies occupy the most impor- Nerve conduction studies of median and ulnar nerves were
tant place in the electrophysiologic diagnosis of the most performed as follows: sensory conduction studies were per-
frequently seen entrapment neuropathy, i.e. carpal tunnel formed antidromically. For median nerve sensory conduction
syndrome (CTS). These studies essentially include the wrist- studies ring electrodes were placed on third finger, with
3rd digit and wrist-2nd digit distal sensory latencies (DSL) active electrode at the proximal interphalangeal joint, and
and sensory conduction velocities, the sensory conduction reference on distal interphalangeal joint 2 cm apart from the
velocity of wrist–palm, the ratio of sensory conduction ve- active. Stimulations were delivered from wrist, at a distance
locity of palm-3rd digit to wrist–palm (distoproximal ratio) of 16 cm away from the active electrode between the tendons
and the differences between median and ulnar nerve wrist- of flexor carpi radialis and palmaris longus. For ulnar nerve
4th digit DSL [2–7]. sensory conduction studies, an active ring electrode on the
Median and ulnar nerves pass through the carpal tunnel proximal interphalangeal joint of the 5th digit and a reference
and the Guyon canal, respectively. Ulnar nerve enters Guyon electrode on the distal interphalangeal joint 2 cm apart from
canal at the level of the distal wrist crease. A close contiguity the active electrode were used. The stimulatory impulse was
exists between carpal tunnel and Guyon canal at the wrist delivered 13 cm away from the just over of flexor carpi
level, since these two canals are separated from each other by ulnaris tendon at the level of the wrist. For median–ulnar
the pisiformis bone. The volar carpal ligament forms the roof nerve-4th digit sensory conduction studies on metacarpopha-
of carpal tunnel and the floor of the Guyon canal. Therefore, langeal joint an active electrode and on proximal interpha-
pathologic processes causing CTS might also be expected to langeal joint a reference electrode 2 cm away from the active
affect ulnar nerve at the wrist level [1,8,9]. electrode were attached. Responses were obtained by stimu-
In this study, we aimed at investigating, using nerve con- lating median and ulnar nerves separately from a distance of
duction studies and needle electromyography (EMG), the 14 cm away from the active electrode at the wrist.
existence of possible associated ulnar nerve entrapments at Motor conduction studies were recorded using 9 mm disc
the wrist level in cases with established diagnoses of CTS. electrodes. For median nerve, an active electrode on the
muscle belly of abductor pollicis brevis (APB) and a refer-
ence electrode on the first metacarpophalangeal joint were
2. Materials and methods placed. The nerve was stimulated at a distance of 6 cm away
from the active electrode, between tendons of flexor carpi
Fifty-three cases (46 females and seven males) were in- radialis and palmaris longus at the wrist. For ulnar nerve, an
cluded in the study. Mean ages were 49.31 ± 13.78 years active electrode on the muscle belly of abductor digiti minimi
(range 20–72 years). Nerve conduction studies and needle (ADM) and a reference electrode on the fifth metacarpopha-
EMG were performed with a Medelec Synergy EMG appa- langeal joint were placed. Nerve was stimulated from a
ratus. Bilateral median and ulnar nerves were investigated in distance of 6 cm away from the active electrode from just
all of the cases. Among cases with clinical CTS symptoms over of flexor carpi ulnaris tendon at the wrist.
(nocturnal paresthesiae, wrist pain, abductor pollicis brevis A supramaximal stimulation was used for motor conduc-
weakness) patients with diagnoses of CTS confirmed by tion studies, while 30–40 mA stimulation intensity were
nerve conduction studies and needle EMG were enrolled in delivered for sensory conduction studies. Sensory responses
the study. Nerve conduction studies of lower extremities obtained were averaged. According to the evaluation criteria
(bilateral peroneal and tibial nerves motor conduction, and of our laboratory, median nerve-3rd digit peak DSL measure-
sural nerve sensory conduction studies) as well as needle ments of 4.1–4.5, 4.6–5.0 and >5.1 ms signified mild, mod-
EMG were used to exclude polyneuropathies. Cervical ra- erate and severe cases of CTS, respectively.
diculopathies were also excluded on the basis of needle EMG
and cervical magnetic resonance imaging (MRI) findings. In
cases with diminished ulnar sensory nerve action potential 3. Results
(SNAP) amplitudes, medial antebrachial cutaneous nerve
sensory conduction studies were performed to exclude tho- Among 53 cases examined we detected 12 (22.6%) bilat-
racic outlet syndrome. Cases with decreased ulnar SNAP eral and 41 (77.3%) unilateral cases of CTSs. As a whole,
amplitudes associated with decreased or lack of medial ante- 65 wrists were evaluated. Among them, mild, moderate and
brachial cutaneous nerve SNAP amplitudes were not in- severe CTS were detected in 31 (47.6%), 18 (27.6%) and 16
cluded in the study. Also, cases presenting evidence of ulnar (24.6%) wrists, respectively. In cases with CTS, paresthesias
nerve entrapment at elbow were excluded. During examina- (100%), wrist pain (72%) APB weakness (13.8%) and atro-
tions dermal temperatures were kept over 34 °C. Monitor phic APB (4.6%) were observed in a variable number of
analysis time, sensitivity, filter settings for motor conduction patients. Patients had these complaints for 6–116 weeks
studies were set at 30 ms, 500 µV–1 mV and 20 Hz–10 kHz, (mean: 45.7 ± 30.9). Weakness and atrophy were not detected
while for sensory nerve conduction studies the correspond- in muscles innervated by ulnar nerve.
 E. Gozke et al. / Neurophysiologie clinique 33 (2003) 219–222 221

Table 1
Results obtained from nerve conduction studies performed as diagnostic measurements for carpal tunnel syndrome
Nerve conduction study (median nerve) Number of wrists Number of wrists with detected
studied abnormalities (%)
Wrist-3rd digit DSL (negative peak) ↑ 65 59 (90.7)
Wrist-APB DML ↑ 65 48 (73.8)
Wrist-4th digit DSL (negative peak) difference (median–ulnar nerve) ↑ 6 6 (100)
DSL, distal sensory latency; APB, abductor pollicis brevis; DML, distal motor latency; ↑, increase.

In 59 out of 65 wrists (90.7%), the diagnosis of CTS was 4. Discussion

established by prolongation of wrist-3rd digit DSL. Pro-
longed median nerve wrist-APB distal motor latency (DML) Slowing of sensory conduction of the median nerve within
was detected in 48 (73.8%) wrists (Table 1). DSL were also carpal tunnel provides objective confirmation of the clinical
prolonged in all of the cases with longer DML. Both of these impression of CTS. Pathological processes leading to me-
parameters were normal in six wrists only. In these six wrists, dian nerve entrapment at wrist are expected (though in a
diagnoses were established by the detection of an increase in lesser degree) to affect ulnar nerve at the Guyon canal. Since
the differences between wrist-4th digit DSL of median and comparison tests with ulnar nerve have been used for the
ulnar nerve. We did not perform this test for cases already diagnosis of CTS, it is also important to evaluate ulnar nerve
diagnosed as CTS. These six wrists with mild degrees of CTS conduction studies in order not to reach misleading conclu-
had normal ulnar nerve wrist-5th digit DSL. Although the sions. Although median nerve provides sensory innervation
diagnoses of CTS for these wrists were established in com- for the first three fingers and lateral half of the fourth finger,
parison with ulnar nerve conduction studies, the objective of paresthesias in CTS cases often involve the hand as a whole.
the study was to assess the rate of ulnar nerve wrist involve- Though this complaint does not always imply ulnar nerve
ment in cases with CTS, therefore, these wrists were not involvement, it demonstrates the necessity of examining the
excluded from the study in order to ensure a higher accuracy parameters relating to ulnar nerve together with electrophysi-
in calculations of average rates. In all cases with CTS ulnar ologic studies of median nerve.
nerve wrist-ADM, DML measurements were within normal The first statistical description of ulnar nerve entrapments
limits. associated with CTS comes from a study performed by Sedal
et al. [8]. These investigators reported the incidence of ulnar
Ulnar nerve DSL were normal in 53 wrist (49 wrists with
nerve entrapments at wrist as being 44%, while the rates of
prolonged wrist-3rd digit DSL and six wrists with increased
decreased amplitude of ulnar nerve sensory action potential
differences between 4th digit DSL), while 12 wrists (18.4%)
and prolongation of DSL were 39.3% and 4.8%, respectively.
manifested prolongation in both median and ulnar nerve
Lower rates for prolongation of latency are seemingly related
DSL. Among these 12 wrists mild (n: 2), moderate (n: 7) and
to acceptance of 4.0 ms for the cut-off value of wrist-5th digit
severe (n: 3) CTS were detected.
sensory distal latency. In the relevant study, prolongation of
Mean and cut-off values for median nerve-3rd digit DSL, median nerve DSL and decreased sensory nerve action po-
wrist-APB DML; ulnar nerve wrist-5th digit DSL, wrist- tential amplitudes in CTS were reported to be 88% and
ADM DML; median–ulnar nerve wrist-4th digit DSL differ- 76.5%, respectively. In another study, significant improve-
ence and numbers of ulnar nerve conduction abnormalities in ments were reported in ulnar nerve symptoms after surgical
cases with CTS are shown on Tables 2 and 3, respectively. release of carpal tunnel [9]. These rates of improvement were
Cut-off values (mean + 2 S.D.) shown in Table 2 were attributed to the close contiguity between carpal ligament
calculated from measurements of 228 wrists (87 female and and Guyon canal.
27 male, mean age: 45.2 ± 11.4 years) with normal conduc- In a study in 300 cases with CTS, the incidences of
tion studies. associated unilateral or bilateral ulnar nerve entrapments at

Table 2
Parameters used in nerve conduction studies and mean ± S.D. values obtained in patients with carpal tunnel syndrome
Nerve Nerve conduction study Distance (cm) Latency mean ± S.D. (ms) Cut-off value (ms)
Median nerve Wrist-3rd digit DSL (negative peak) 16 5.0 ± 0.6 4.0
n: 65 Wrist-APB DML 6 5.1 ± 1.9 4.0
Ulnar nerve Wrist-5th digit DSL (negative peak) 13 3.3 ± 0.5 3.6
n: 65 Wrist-ADM DML 6 2.5 ± 0.4 3.4
Median–ulnar nerve Wrist-4th digit DSL (negative peak) 14 0.77 ± 0.13 0.5
n: 6 difference
S.D., standard deviation; n, number of wrists; DSL, distal sensory latency; APB, abductor pollicis brevis; DML, distal motor latency; ADM, abductor digiti
minimi.
222 E. Gozke et al. / Neurophysiologie clinique 33 (2003) 219–222

Table 3 expected from the release of ulnar nerve at Guyon channel

Ulnar nerve conduction parameters at wrist in cases with CTS during surgical intervention in cases where ulnar nerve en-
Ulnar nerve conduction study Number of wrist with CTS (%) trapment at wrist in combination with moderate and severe
n: 65 CTS.
Wrist-5th digit DSL ↑ 12 (18.4)
In conclusion, these results reveal that consideration of
Wrist-5th digit DSL N 53 (81.6)
ulnar nerve sensory conduction studies (especially wrist-5th
Wrist-ADM DML ↑ 0
Wrist-ADM DML N 65 (100) digit DSL) have crucial importance in detecting ulnar nerve
entrapments at wrist associated with CTS.
DSL, distal sensory latency; DML, distal motor latency; ADM, abductor
digiti minimi; ↑, increase; N, normal.

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