MR anatomy and pathology of the ulnar nerve involving the cubital tunnel and
Guyon’s canal

Luyao Shen, Sulabha Masih, Dakshesh B. Patel, George R. Matcuk

Jr.

PII: S0899-7071(15)00302-2
DOI: doi: 10.1016/j.clinimag.2015.11.008
Reference: JCT 7949

To appear in: Journal of Clinical Imaging

Received date: 22 July 2015

Revised date: 12 November 2015
Accepted date: 18 November 2015

Please cite this article as: Shen Luyao, Masih Sulabha, Patel Dakshesh B., Matcuk Jr.
George R., MR anatomy and pathology of the ulnar nerve involving the cubital tunnel and
Guyon’s canal, Journal of Clinical Imaging (2015), doi: 10.1016/j.clinimag.2015.11.008

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MR anatomy and pathology of the ulnar nerve involving the cubital tunnel and Guyon’s canal

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Luyao Shen, MD1, Sulabha Masih, MD2, Dakshesh B. Patel, MD3, and George R. Matcuk Jr., MD3

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1
Department of Radiologic Sciences, Ronald Reagan-UCLA Medical Center, David Geffen School of
Medicine, University of California, Los Angeles, Los Angeles, CA 90095

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Department of Radiology, Greater Los Angeles Veterans Affairs Medical Center, Los Angeles, CA
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Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles,
CA 90033-5313
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Grants received: None

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Disclosures: None
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Presented at ARRS 2015

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Author Correspondence:
George R. Matcuk Jr., MD
Department of Radiology
Keck School of Medicine
University of Southern California
1500 San Pablo Street, 2nd Floor Imaging
Los Angeles, CA 90033-5313
Tel: (323) 442-8721
Fax: (323) 442-8755
Email: [email protected]

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Abstract

Ulnar neuropathy is a common and frequent reason for referral to hand surgeons. Ulnar neuropathy

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mostly occurs in the cubital tunnel of the elbow or Guyon’s canal of the wrist, and it is important for

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radiologists to understand the imaging anatomy at these common sites of impingement. We will review

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the imaging and anatomy of the ulnar nerve at the elbow and wrist, and present magnetic resonance

imaging examples of different causes of ulnar neuropathy, including trauma, overuse, arthritis, masses

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and mass-like lesions, and systemic diseases. Treatment options will also be briefly discussed.
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Keywords

Ulnar nerve; Musculoskeletal MRI; cubital tunnel; Guyon’s canal

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1. Introduction
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Ulnar neuropathy is a common peripheral neuropathy, and in the recent decade, its incidence has
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increased, mostly due to the overwhelming increase in duration and frequency of computer use and desk

jobs. Ulnar neuropathy is most often due to compression at fibro-osseous tunnels at either of two
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locations: the cubital tunnel of the elbow (more common) or Guyon’s canal of the wrist [1]. Diagnosis

and evaluation usually starts with a comprehensive history, a thorough physical exam, and then nerve

conduction studies. In equivocal, recalcitrant, or cases referred for surgery, imaging may be performed.

There are many causes of ulnar neuropathy. We have categorized them into extrinsic (trauma, overuse,

degenerative arthritis, masses and mass-like lesions) and intrinsic (systemic or metabolic diseases)

causes. As secondary causes are excluded, ulnar neuropathy can be idiopathic, with no clinically

identifiable etiologic factor in up to 58.2% of cases diagnosed by electrophysiologic testing [2].

Traumatic ulnar neuropathy can result from external compression (e.g. soft tissue hematoma or bone

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fragments) or simply from direct physical impact (contusion). Degenerative arthritis usually produces

osteophytes that narrow the tight space through which the ulnar nerve travels, and the nerve can be

externally compressed. Active inflammation of degenerative arthritis can also produce adjacent joint or

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soft tissue inflammation that involves the ulnar nerve secondarily. Masses and mass-like lesions produce

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external compression. Systemic/metabolic diseases have different pathophysiology that involve the

ulnar nerve and will be discussed separately below. Other causes of ulnar neuropathy include ulnar

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nerve subluxation or dislocation and snapping triceps syndrome. [3,4]. Ulnar nerve subluxation or

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dislocation can occur when there is congenital absence of the cubital tunnel retinaculum, allowing the

nerve to sublux or dislocate over the medial epicondyle with elbow flexion. Snapping triceps syndrome
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results when the medial head of the triceps dislocates over the medial epicondyle and may occur as a

second palpable “snap” with dislocation of the ulnar nerve.

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2. Normal Anatomy of the Ulnar Nerve

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The ulnar nerve is derived from the C8-T1 nerve roots of the lower cervical spine and is a component of
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the medial cord of the brachial plexus. It lies posteromedial to the brachial artery in the anterior
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compartment of the upper arm initially, then pierces the medial intermuscular septum at the arcade of

Struthers (an aponeurotic band extending from the medial intermuscular septum to the medial head of

the triceps) and travels medial to the triceps until it comes close to the medial epicondyle of elbow [5-7].

There is no muscular or sensory innervation of the ulnar nerve in the upper arm.

At the elbow, the ulnar nerve runs behind the medial epicondyle in the cubital tunnel with the posterior

ulnar recurrent artery. The anatomy of the cubital tunnel will be studied in detail separately.

In the forearm, the ulnar nerve continues medially between the two heads of the flexor carpi ulnaris,

where it joins the ulnar artery, and then between the flexor carpi ulnaris and flexor digitorum profundus

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before entering the wrist [5-7]. The ulnar nerve innervates the flexor carpi ulnaris and medial half of the

flexor digitorum profundus (III and IV which control the 4th and 5th digits).

The ulnar nerve accompanies the ulnar artery at the medial aspect of the wrist and passes superficial to

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the transverse carpal ligament. Then, it continues through Guyon’s canal where it bifurcates into sensory

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and motor branches. The anatomy of Guyon’s canal will be studied in detail separately. The muscular

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branches innervate the adductor pollicis, deep head of the flexor pollicis brevis, hypothenar muscles

(opponens digiti minimi, abductor digiti minimi, and flexor digiti minimi brevis), palmaris brevis, and

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finger musculature (dorsal and palmar interossei and 3rd and 4th lumbricals). The sensory distribution of
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the dorsal cutaneous branch, palmar cutaneous branch, and superficial terminal branches of the ulnar

nerve includes the 5th digit (little finger) and medial half of the 4th digit (ring finger), medial palmar and
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dorsal hand, and their corresponding skin [7].

2.1 Elbow: Cubital Tunnel Anatomy

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The cubital tunnel is located posterior to the medial epicondyle of the humerus, along the posteromedial
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aspect of the elbow. The roof consists of the cubital tunnel retinaculum proximally and flexor carpi
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ulnaris (FCU) aponeurosis between the humeral and ulnar heads of the FCU distally, although these

structures are often continuous. The cubital tunnel retinaculum expands from the olecranon to the medial

epicondyle and is also known as Osborne’s band or ligament and the FCU aponeurosis is also known as

the arcuate ligament. It may be complete, partial, or absent. The capsule of the elbow and the posterior

and transverse portions of the ulnar collateral ligament form the floor of the cubital tunnel (Fig. 1-2) [5-

8]. The cross-sectional area at the inlet of the cubital tunnel is larger than the inlet in extension (37.7

mm2 vs. 25.4 mm2) and narrows in both places with elbow flexion (32.2 mm2 vs 21.9 mm2) [9]. The

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cubital tunnel retinaculum is postulated to be a remnant of the accessory anconeus muscle (anconeus

epitrochlearis), which can cause nerve compression when present [10].

2.2 Wrist: Guyon’s Canal Anatomy

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Guyon’s canal, along the medal and palmar aspect of the wrist, is located between the pisiform and

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pisohamate ligament which is the ulnar border, and the hook of the hamate which is the radial border.

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With the palmar side up, the roof consists of the volar carpal ligament, and the floor consists of the

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transverse carpal ligament and the hypothenar muscles [5-7]. The ulnar artery also courses through

Guyon’s canal, immediately adjacent and radial to the ulnar nerve (Fig. 3-4). There are also accessory
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muscles (the accessory abductor digiti minimi and accessory palmaris longus muscles) that can be space

occupying and problem causing within Guyon’s canal [11]. The canal has a mean length of 40 mm with
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a cross-sectional area of 33 mm2 proximally widening to 45 mm2 distally [12].

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3. Clinical Presentations of Ulnar Neuropathy

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Clinical presentations of ulnar neuropathy in general can have both muscular weakness and sensory

deficits. Impaired sensation of the volar fingertips is the most common sensory deficit. Numbness and
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tingling in digits 4 and 5 are also common. In more chronic cases, patients can have weakness of

handgrip with atrophy of the intrinsic hand muscles. “Claw” or “Benedictine” hand deformities can

result from long standing severe ulnar neuropathy. Combined sensory and motor syndrome can occur

anywhere before the ulnar nerve bifurcation in Guyon’s canal. Distal to the bifurcation, patients can

experience either pure sensory deficit or pure motor syndrome, depending on which branch of the ulnar

nerve is involved [13].

4. Imaging of Ulnar Neuropathy

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When imaging is needed for evaluation, ultrasound is an inexpensive and convenient tool to start with.

Some of the sonographic features which suggest neuropathy include fusiform hypoechoic swelling with

loss of the normal fascicular pattern, marked enlargement of the nerve, external compression of the

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nerve, and surrounding soft tissue edema [14, 15]. Studies have shown that the maximal cross-sectional

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area (CSA-max) ranging 8-10 mm2 has high sensitivity and specificity for ulnar entrapment at the elbow

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[16]. Recent research using sonoelastography which measures stiffness of the peripheral nerve and the

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surrounding tissue has shown promising results in evaluating peripheral neuropathy [17]. Dynamic

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ultrasound evaluation during elbow flexion and extension can also be helpful for diagnosing ulnar nerve

subluxation/dislocation or snapping triceps syndrome [4].

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MRI remains the most sensitive and specific imaging method for evaluation of ulnar nerve, including the
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causes and extent of ulnar neuropathy, as well as its complications such as muscle atrophy. In addition,

MRI is the best tool for surgical planning. MRI is very useful for assessment of neuromuscular disorders
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with its high-resolution depiction of nerves, visualization of primary abnormalities such as mass-lesions
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causing external compression and secondary involvement from systemic disease, as well as

complications such as denervation muscle edema and atrophy. Conventional MR images of the elbow
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and wrist are obtained on either a 1.5 or 3 Tesla magnet in the axial, sagittal, and coronal planes using a

combination of T1, T2 fat-saturation (T2FS), short tau inversion recovery (STIR), proton density (PD),

and post contrast T1 fat-saturation (T1FS) sequences. Axial T1 and PD are good sequences to study

anatomy. STIR and T2FS are fluid sensitive sequences, and increased signal defines edema; however,

STIR is more fluid sensitive than T2FS. Gadolinium-based intravenous contrast can be given when

tumor is suspected.

Starting in the 1990s, research has shown that MR neurography (MRN), with high resolution T1, STIR

or T2FS sequences, has the greatest degree of soft tissue contrast for evaluating peripheral nerves. In

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addition to conventional sequences, many new sequences can have added value to the evaluation of

peripheral neuropathy. Frequency selective or adiabatic inversion recovery fat suppression (SPAIR)

sequence provides better fat suppression and better signal-to-noise ratio than conventional STIR

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sequence. Other new sequences such as 3-D diffusion-weighted reverse fast imaging with steady state

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precession sequence (3-D DW-PSIF) can suppress signal void from adjacent vessels. Diffusion tensor

imaging (DTI) is being investigated for water proton diffusion within the nerve itself. 3-D

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reconstruction can further evaluate the entire course of the nerve and help surgical planning [18, 19].

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Although as promising as MRN is, it is only practiced in few experienced centers [19].
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Normal nerves demonstrate intermediate to low signal intensity on T1 weighted sequence and slightly

higher signal intensity on T2 weighted sequence [20]. Abnormal findings of the ulnar nerve include
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nerve caliber enlargement, increased T2 signal, subluxation, flattening, disruption of fascicles, and

contrast enhancement [8, 18-21]. However, increased signal intensity of the ulnar nerve at the elbow can
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be seen on fluid sensitive sequences in up to 60% of asymptomatic patients, so caution and careful
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clinical correlation must be made when this is the only significant imaging finding [22]. Enhancement of

the nerve itself indicates that the blood-nerve barrier has been breached. One study demonstrates that
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using 8 mm2 as a cut-off (cross-sectional area) to predict ulnar neuropathy at the elbow has 95%

sensitivity and 80% specificity [23]. Another study shows that decreased fractional anisotropy derived

from DTI is a reliable finding in peripheral neuropathy [24]. Many associated findings and

complications of ulnar neuropathy need to be evaluated as well, such as subcutaneous soft tissue edema

or hematoma, adjacent bone fractures, adjacent mass and mass-like lesions, and hyperintense muscle

indicating edema or fatty infiltration indicating atrophy [20].

5. Causes of Ulnar Neuropathy

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In this section, examples of ulnar neuropathy will be presented with conventional MR images.

5.1 Trauma

Direct impact to the nerve in the wrist or the elbow can cause ulnar nerve edema and/or subluxation

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(Fig. 5-7). The ulnar nerve can also be compressed by a displaced bone fragment or adjacent soft

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tissue inflammation. Atrophy of the hypothenar and interossei muscles can be secondary to long

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standing ulnar neuropathy due to remote trauma (Figure 7).

5.2 Overuse

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Since the ulnar nerve passes through tight spaces at both the elbow and the wrist, chronic abnormal
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arm or wrist position or repetitive motion can cause nerve compression. Sometimes not only the

ulnar nerve is involved, but often other nerves or structures are involved. Especially at the wrist,
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both the ulnar and median nerves can demonstrate inflammatory changes (Fig. 8). In other

situations, there can be coexistent tendinopathy (Fig. 9). Ulnar neuropathy is also common among
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athletes, especially baseball pitchers, as the nerve is compressed at the elbow due to repetitive valgus
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forces (Fig. 9) [25].

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5.3 Degenerative Arthritis

The ulnar nerve is vulnerable to arthritic changes, such as compression from surrounding

inflammation or adjacent osteophytes (Fig. 10).

5.4 Masses and Mass-like lesions

These lesions as a group, when they occur near the cubital tunnel or Guyon’s canal or within the

nerve sheath, can cause mass effect on the ulnar nerve.

5.4.1 Pigmented villonodular synovitis (PVNS)

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PVNS is a disorder of inflammation and proliferation of synovium with hemosiderin deposition.

On MRI, there are heterogeneous non-discrete T1 and T2 hypointensities in the joint space.

When severe, it can cause exuberant joint inflammation and bone destruction. In such cases, the

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ulnar nerve can be secondarily involved (Fig. 11).

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5.4.2 Peripheral nerve sheath tumors

Peripheral nerve sheath tumors (schwannomas and neurofibromas) are usually heterogeneous,

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enhancing, isointense on T1-weighted sequences and hyperintense on fluid sensitive sequences.

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Often, MRI demonstrates a “string sign” indicating the lesion’s origin from the nerve (Fig. 12).

Patients’ neuropathy usually improves after surgical resection.

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5.4.3 Accessory anconeus muscle

The accessory anconeus muscle is a normal variant found in approximately 15% of the
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population (range 3-28%) [26]. It is usually unilateral, but it can be bilateral in up to 25% of
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patients [10]. It is postulated that the cubital tunnel retinaculum is a remnant of this atavistic

muscle. As it forms the roof of the cubital tunnel, it can compress the ulnar nerve (Fig. 13).
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5.4.4 Ganglion cyst

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Ganglion cysts are common mass lesions occurring at the wrist. They follow fluid signal on all

sequences and demonstrate rim-enhancement on post-contrast sequences. A ganglion cyst in

Guyon’s canal can cause ulnar neuropathy, and as a consequence, lead to denervation edema of

the interossei muscles (Figure 14).

5.4.5 Post-surgical scar tissue

Sometimes after any surgery in the vicinity of the ulnar nerve, such as resection of a mass lesion

that caused ulnar neuropathy, scar formation can obliterate the normal fat planes and compress

the ulnar nerve, leading to recurrence of the ulnar neuropathy many years later (Fig. 15). Scar

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tissue is generally T1 and T2 hypointense and can have a variable enhancement pattern

depending on time and presence of granulation tissue.

5.4.6 Lipoma

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Lipomas follow fat signal intensity on all sequences. They do not enhance. Although usually

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benign and asymptomatic, in small spaces such as Guyon’s canal, even a pliable lipoma can

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cause debilitating ulnar neuropathy (Fig. 16).

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5.5 Systemic/Metabolic Disease

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5.5.1 Juvenile idiopathic arthritis (JIA)

Juvenile idiopathic arthritis is a chronic systemic inflammatory disorder affecting children with
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onset before the age of 16 years. It is classified into different subtypes, such as oligoarticular

disease, polyarticular disease, and systemic (Still’s) disease; and they differ in age of onset,
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number and location of joints involved, disease course, and presence of antinuclear antibodies or
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rheumatoid factor. Imaging demonstrates bone marrow edema, subchondral cystic changes, and

synovitis. Adjacent nerves can be secondarily involved (Fig. 17). Proposed etiologies of
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neuropathy include soft tissue inflammation and destruction from increased circulation of
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cytokines, vasculitis, or other unidentified mechanisms [27].

5.5.2 Diabetes mellitus (DM)

Diabetes mellitus is a group of metabolic diseases in which there is hyperglycemia over a long

period of time, and it is classified into two types. Type 1 results from the body’s failure to

produce enough insulin, and usually presents at a younger age; and type 2 results from the

body’s resistance to insulin, usually seen in the later age group. DM is the most common cause

of peripheral neuropathy, and its pathogenesis has been studied extensively. In summary,

chronic hyperglycemia can lead to accumulation of advanced glycosylation end products,

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sorbitol and hexosamine as well as activation of the protein kinase C pathway. These products

are proinflammatory and cause microvascular injury, oxidative stress, cell damage,

vasoconstriction or occlusion, and nerve hypoxia or ischemia (Fig. 18) [28, 29].

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5.5.3 Behςet’s disease

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Behςet’s disease is a multisystem, recurrent, and inflammatory disorder. Patients have variable

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presentations, such as recurrent oral aphthous ulcers, genital ulcers, skin rash or ulcers, skin

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hypersensitivity to pinprick, uveitis, and central neurologic involvement including seizures, brain

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tumors, meningitis, venous thrombosis, ischemic stroke, vasculitis, and psychiatric and cognitive

disorders. Although peripheral neuropathy is relatively rare, when it occurs, vasculitis has been
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proposed as a mechanism. There are only case reports of Behςet’s peripheral neuropathy, and it

is a diagnosis of exclusion (Fig. 19) [30, 31].

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5.5.4 Leprosy
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Leprosy, also known as Hansen’s disease, is a chronic infection caused by the bacterium

Mycobacterium leprae, which is transmitted through droplets and other secretions. It is an

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extremely rare infection in developed countries. Signs and symptoms have a slow onset, usually
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over 2-10 years. Patients present with thick and dry skin growth, severe pain, numbness and loss

of cutaneous sensation, muscle weakness or paralysis (especially of the hands and feet),

blindness, and hypertrophic nerves. There are two histologic types of leprosy: paucibacillary

(tuberculoid) and multibacillary (lepromatous). In tuberculoid disease, although there is a low

bacterial burden, the M. leprae antigens incite cell-mediated hypersensitivity resulting in

destruction of affected nerves with marked perineural and epineural thickening, fibrosis, and

granuloma formation. With lepromatous disease, there is a predilection for Schwann cells, with

destruction of myelin, axonal loss, and secondary inflammation producing onion-skinning of the

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nerve fascicles, but the connective tissue proliferation is not as prominent as with tuberculoid

disease (Fig. 20) [32-33].

6. Treatment

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The treatment of ulnar neuropathy depends on its cause, clinical assessment, duration and severity of

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symptoms, and patient factors such as age and comorbidities. Conservative management is usually the

treatment of choice, especially for mild to moderate ulnar neuropathy and those cases not caused by a

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surgical lesion. Splints, pads, and avoidance of aggravating factors are helpful. In cases of conservative

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management failure, presence of a surgical lesion, or development of complications (e.g. muscle

atrophy), surgery is indicated. Space occupying masses need to be surgically resected. Decompression
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is the main surgical option for treatment of ulnar neuropathy secondary to impingement.

Decompression frees the ulnar nerve from the tight space by excising surrounding structures such as the
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flexor carpi ulnaris aponeurosis or the medial epicondyle at the elbow or release of Guyon’s canal at the
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wrist. At the elbow, anterior transposition may also be performed to effectively lengthen the nerve and

decrease tension with flexion [35, 36]. Although there is extensive research comparing various
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management and surgical options for ulnar neuropathy, there is no consensus, and treatment should be
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tailored to the individual and consider the surgeon’s experience [37].

7. Conclusion

Ulnar neuropathy is a common peripheral neuropathy, usually occurring at the level of the cubital tunnel

of the elbow or Guyon’s canal of the wrist. Musculoskeletal radiologists need to understand the

anatomy of the cubital tunnel and Guyon’s canal to better interpret MRI performed for ulnar neuropathy.

It is important to evaluate the ulnar nerve and identify causes of neuropathy such as trauma, overuse,

degenerative arthritis, masses and mass-like lesions, and systemic diseases. Currently, conventional MRI

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is more prevalent; however, in the near future, MR neurography which offers better soft tissue contrast

and 3-D reconstruction will become the new standard for evaluation of peripheral neuropathies.

8. Conflicts of interest

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The authors declare that they have no conflict of interest.

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References

1.

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2. Harding IJ, Morris IM. The aetiology and outcome of 170 ulnar nerve lesions confirmed with

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electrophysiological testing. Acta Orthop Belg. 2003;69(5):405-11.

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3.

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4. Jacobson JA, Jebson PJ, Jeffers AW, Fessell DP, Hayes CW. Ulnar nerve dislocation and

snapping triceps syndrome: diagnosis with dynamic sonography--report of three cases.

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Radiology. 2001;220(3):601-5.
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7.

9. Yoon JS, Kim BJ, Kim SJ, et al. Ultrasonographic measurements in cubital tunnel syndrome.

Muscle Nerve. 2007;36(6):853-5.

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Figures and Legends

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Fig. 1 MR anatomy of the cubital tunnel. Axial T1 of the elbow at the level of humeral epicondyles.
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Medial epicondyle (ME), olecranon (O), ulnar nerve (white arrow), cubital tunnel retinaculum

(arrowhead), posterior ulnar recurrent artery (black arrow), cubital tunnel (box).

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Fig. 2 MR anatomy of the cubital tunnel. Coronal T1 (A) and sagittal T2FS (B) of the elbow. Triceps

muscle (T), biceps brachii muscle (BB), brachialis muscle (B), pronator teres muscle (PT), flexor
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muscles (F), medial epicondyle (ME), olecranon (O), ulnar nerve (arrow).
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Fig. 3 MR anatomy of Guyon’s canal. Axial T1 of the wrist at the level of the hook of hamate. Hook of
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hamate (HH), carpal tunnel (CT), hamate (H), capitate (C), trapezoid (Td), trapezium (Tm), ulnar nerve
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(white arrow), ulnar artery (black arrow), Guyon’s canal (box).

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Fig. 4 MR anatomy of Guyon’s canal. Coronal T1 (A) of the palmar wrist, coronal T1 (B) of the palmar

wrist just volar to (A), and sagittal STIR (C) of the wrist. Hook of hamate (HH), hamate (H), carpal

tunnel (CT), trapezium (Tp), triquetrum (Tq), scaphoid (S), metacarpal (MC), ulna (U), Guyon’s canal

(box).

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Fig. 5 Ulnar neuropathy secondary to trauma to the elbow. Axial (A) and coronal (B) T2FS of the elbow
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show edema of the ulnar nerve in the cubital tunnel (arrows).

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Fig. 6 Ulnar neuropathy secondary to trauma to the elbow. Axial STIR (A) and axial T1 (B) of the

elbow show edema of the ulnar nerve (arrows) which is also subluxed medially out of the cubital tunnel.

Stars indicate where the ulnar nerve should normally reside in the cubital tunnel. Axial T1 (C) of the

elbow: The patient underwent anteromedial transposition of the subluxed ulnar nerve (arrow).

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Fig. 7 Ulnar neuropathy secondary to trauma to the wrist. Axial STIR (A) of the wrist shows edema of

the ulnar nerve in Guyon’s canal (arrow). Axial T1 (B) of the hand shows atrophy of the hypothenar
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muscles (white arrow) and the interossei muscles (arrowheads) secondary to long standing ulnar

neuropathy.
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Fig. 8 Ulnar and median neuropathy secondary to overuse of the wrist. Axial PD (A) and axial STIR (B)
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of the wrist show edema in both the ulnar nerve in the Guyon’s canal (arrows) and the median nerve in

the carpal tunnel (arrowheads).

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Fig. 9 Ulnar neuropathy secondary to overuse of the elbow. Axial T2FS (A) of the arm just proximal to

the elbow shows edema of the ulnar nerve from repetitive pitching motion in a baseball player (arrow).
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Axial T2FS (B) of the elbow shows edema of the ulnar nerve in the cubital tunnel (arrow) from work-
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related overuse in another patient who also has co-existent triceps tendinopathy (arrowhead).
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Fig. 10 Ulnar neuropathy secondary to degenerative arthritis of the elbow. Axial T2FS (A & B) of the

elbow show edema of the ulnar nerve in the cubital tunnel (arrows) from compression by large

osteophytes arising from the anteromedial surface of the olecranon (arrow head, A) and the medial

surface of the olecranon fossa of the humerus (arrowhead, B).

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Fig. 11 Ulnar neuropathy secondary to pigmented villonodular synovitis (PVNS) of the elbow. Axial PD

(A), axial STIR (B), and sagittal T1 (C) of the elbow show extensive bone destruction and soft tissue

inflammation involving the elbow joint, including the cubital tunnel (arrows). The ulnar nerve is

compressed and not well seen owing to the surrounding inflammation. Olecranon (O), humerus (H),

medial epicondyle (ME).

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Fig. 12 Ulnar neuropathy secondary to a schwannoma at the elbow. Coronal oblique STIR (A), sagittal

PD FS (B), axial T1FS post-contrast (C) of the arm show a schwannoma arising from the ulnar nerve in

the arm which extends into the cubital tunnel (white arrows). The string sign is seen indicating origin

from the nerve (black arrow).

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Fig. 13 Ulnar neuropathy secondary to compression by the accessory anconeus muscle at the elbow.

Sagittal T2FS (A & B) and axial T2FS (C) of the elbow show edema of the ulnar nerve (white arrows)

due to compression by an accessory anconeus/anconeus epitrochlearis muscle (black arrows).

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Fig. 14 Ulnar neuropathy secondary to compression by a ganglion cyst at the wrist. Axial T1FS post-

contrast (A) and axial T2FS (B) of the wrist show slight enhancement (white arrow, A) and trace edema
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(white arrow, B) of the ulnar nerve in Guyon’s canal caused by compression by a ganglion cyst (black

arrows). Axial T2FS (C) of the hand shows denervation edema of the interossei muscles secondary to

ulnar nerve neuropathy (arrows).

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Fig. 15 Ulnar nerve neuropathy secondary to compression by scar tissue resulting from resection of a

ganglion cyst inside of Guyon’s canal at the wrist. Axial T1 (A) of the wrist shows soft tissue thickening

and obliteration of fat in Guyon’s canal (arrow). Axial T1FS post contrast (B) and axial T2FS (C & D)

of the wrist show distortion, edema, and slight enhancement of the ulnar nerve (arrows).

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Fig. 16 Ulnar neuropathy secondary to compression by a lipoma at the wrist. Axial T1 (A) of the wrist,

sagittal T1 (B) and coronal T1FS post-contrast (C) of the hand show a lipoma (arrows) in the medial

palmar hand and wrist which compresses Guyon’s canal. The ulnar nerve is also compressed and not

well seen.

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Fig. 17 Ulnar neuropathy secondary to juvenile idiopathic arthritis (JIA) of the elbow. Axial T2FS (A)

of the elbow shows medial subluxation and edema of the ulnar nerve (white arrow). Star indicates

normal ulnar nerve position, inside the cubital tunnel. Axial T2FS (B) of the forearm just distal to the

cubital tunnel shows irregularity and edema in the region of the ulnar nerve (white arrow). Coronal

T2FS (C) of the elbow shows edema of the ulnar nerve (white arrow). There are other findings of JIA

which include bone marrow edema, subchondral cystic changes, and synovitis (black arrows).

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Fig. 18 Ulnar neuropathy at the elbow secondary to type II diabetes mellitus. Axial T2FS (A of the

elbow & B of the arm) and coronal T2FS (C) at the elbow show edema of the ulnar nerve in the arm and

in the cubital tunnel (white arrows).

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Fig. 19 Ulnar neuropathy at the elbow secondary to Behςet’s disease. Axial T1 (A), axial T1FS post-

contrast (B), and sagittal STIR (C) of the elbow show enhancement and edema of the ulnar nerve near

and in the cubital tunnel (arrows). Medial epicondyle (ME).

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Fig. 20 Ulnar neuropathy in the arm and at the elbow secondary to leprosy. Axial T1 (A) of the elbow

and axial T2FS (B of the elbow & C of the arm) show enlargement and edema of the ulnar nerve (white

arrows) with surrounding soft tissue stranding and edema (black arrow).

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