Download - ULNAR NERVE INJURY ,DIAGNOSIS AND TREATMENT
Ulnar nerveUlnar nerve
The effect of long distance The effect of long distance bicycling on ulnar and bicycling on ulnar and
median nervesmedian nerves
AcknowledgementsAcknowledgements
Venu Akuthota, MDVenu Akuthota, MD
Christopher Plastaras, Christopher Plastaras, MDMD
Kristin Lindberg, MDKristin Lindberg, MD
Joel Press, MDJoel Press, MD
Cyndi Garvan, PhDCyndi Garvan, PhD
OverviewOverview
Cyclist palsyCyclist palsy HistoryHistory AnatomyAnatomy ClassificationClassification EtiologyEtiology Other studies / Other studies /
reportsreports Our studyOur study
Electrodiagnostic Electrodiagnostic datadata
Cyclist palsy Cyclist palsy
Also known as ‘Handlebar Also known as ‘Handlebar palsy’palsy’
Compression or entrapment Compression or entrapment neuropathy of ulnar nerve at neuropathy of ulnar nerve at or distal to Guyon’s canal at or distal to Guyon’s canal at the wristthe wrist
Cyclist Palsy - HistoryCyclist Palsy - History
1896 - Destot1896 - Destot Ulnar neuropathy in cyclists Ulnar neuropathy in cyclists
first described first described Paris-Brest-Paris 1200 km Paris-Brest-Paris 1200 km
bicycling race.bicycling race.
European journals European journals
1970’s – American journals1970’s – American journals
Guyon’s CanalGuyon’s CanalAnatomy Anatomy
Ulnar BorderUlnar Border pisiform bone and FCU tendonpisiform bone and FCU tendon
Radial BorderRadial Border Hook of HamateHook of Hamate
FloorFloor Pisohamate ligament Pisohamate ligament
RoofRoof Palmer carpal ligamentPalmer carpal ligament Palmaris brevis musclePalmaris brevis muscle
Branches:Branches: Dorsal ulnar cutaneousDorsal ulnar cutaneous
Superficial Sensory Superficial Sensory branchbranch
Deep branchDeep branch Branch to hypothenars Branch to hypothenars
Deep motor branchDeep motor branch
AnatomyAnatomy
Location of Location of compression:compression:
Within Guyon’s Within Guyon’s canal canal
Distal to canalDistal to canal
Wu’s Classification –Wu’s Classification –Ulnar nerve compression at the Ulnar nerve compression at the
wristwristTypeType Fibers Fibers
AffectedAffectedLocationLocation
II MixedMixed Proximal to or within Guyon’s canalProximal to or within Guyon’s canal
IIII SensorySensory At wrist, just distal to branch to At wrist, just distal to branch to palmaris brevis musclepalmaris brevis muscle
IIIIII MotorMotor Proximal to the branch to the Proximal to the branch to the hypothenar muscleshypothenar muscles
IVIV MotorMotor Distal to the branch to the hypothenar Distal to the branch to the hypothenar musclesmuscles
VV MotorMotor Proximal to the branches to the first Proximal to the branches to the first doral interosseous and adductor pollicis doral interosseous and adductor pollicis musclesmuscles
Etiology: Cyclist palsyEtiology: Cyclist palsy
Chronic repetitive Chronic repetitive traumatrauma
Chronic pressureChronic pressure
VibrationVibration
HyperextensionHyperextension
Cycling specific factorsCycling specific factors
Long biking excursions Long biking excursions
Hand positionHand position
Hyperextension of wristHyperextension of wrist
Forward weight shiftForward weight shift
SymptomsSymptoms PainPain
ParesthesiasParesthesias
NumbnessNumbness
WeaknessWeakness
BackgroundBackground Eckman – ’75 Eckman – ’75
3 case reports of ulnar neuropathy at the wrist in cyclists3 case reports of ulnar neuropathy at the wrist in cyclists
Jackson – ’89Jackson – ’89 20 long distance cyclists20 long distance cyclists 9 with symptoms9 with symptoms Normal NCS of median and ulnar sensory & motor studiesNormal NCS of median and ulnar sensory & motor studies
Wilmarth – ’88 Wilmarth – ’88 Ulnar sensory nerve conductions while within normal Ulnar sensory nerve conductions while within normal
limits in cyclists did vary signficantly compared to non-limits in cyclists did vary signficantly compared to non-cyclists.cyclists.
Patterson – ’03 Patterson – ’03 92% (23 out of 25) cyclists had either motor or sensory 92% (23 out of 25) cyclists had either motor or sensory
symptoms after a 600 km ride.symptoms after a 600 km ride.
The effect of long distance The effect of long distance bicycling on ulnar and median bicycling on ulnar and median
nerves:nerves:
An electrophysiologic evaluation of cyclist’s An electrophysiologic evaluation of cyclist’s palsypalsy
Objective:Objective: To objectively quantify To objectively quantify
changes in the ulnar and changes in the ulnar and median nerves associated median nerves associated with a long distance multi-with a long distance multi-day cycling event.day cycling event.
Design:Design: A prospective cohort studyA prospective cohort study
SubjectsSubjects
14 adult subjects14 adult subjects Total of 28 handsTotal of 28 hands Seven men, seven womenSeven men, seven women
Bike tour 6 day6 day 420 miles (Avg - 70 miles. 420 miles (Avg - 70 miles.
Max - 85.9 miles) Max - 85.9 miles) Flat and rolling terrain on Flat and rolling terrain on
asphalt & chip-coat roadsasphalt & chip-coat roads
Nerve Conduction StudiesNerve Conduction StudiesPre & Post RidePre & Post Ride
Ulnar motor (Dual Channeled) Ulnar motor (Dual Channeled) abductor digiti minimiabductor digiti minimi first dorsal interosseusfirst dorsal interosseus
Median motor Median motor abductor pollicis brevisabductor pollicis brevis
Ulnar sensory Ulnar sensory little fingerlittle finger
Median sensory Median sensory index fingerindex finger
QuestionnaireQuestionnaire Post ridePost ride
DemographicsDemographics
Experience levelExperience level
Hand positionsHand positions
Symptoms Symptoms experienced during experienced during rideride
Onset motor latenciesOnset motor latencies
3.7
3.453.1
3.03.5
3.7
0.450.72
00.5
11.5
22.5
33.5
44.5
5
Median Ulnar toADM
Ulnar to FDI
FDI - ADM
BeforeAfter
p = 0.5020 p = 0.2357 p = 0.0044 p < 0.0001
Peak sensory latenciesPeak sensory latencies
3.33.15
3.23.1
0
0.51
1.52
2.53
3.54
4.55
Median Ulnar
BeforeAfter
p = 0.31 p = 0.6466
Ulnar nerve resultsUlnar nerve results
Motor StudiesMotor Studies FDI & ADM within normal FDI & ADM within normal
rangesranges
Comparison of Pre/PostComparison of Pre/Post Significant DifferencesSignificant Differences
FDI FDI FDI – ADM FDI – ADM
Median nerve resultsMedian nerve results
Median nerve palsy due to cycling is rare.Median nerve palsy due to cycling is rare.
No significant difference between the hands No significant difference between the hands before or after the ride for median motor or before or after the ride for median motor or sensory.sensory.
Pre-ride – 3/28 hands with onset > 4.2 msecPre-ride – 3/28 hands with onset > 4.2 msec
Post-ride – all three with increases of latencyPost-ride – all three with increases of latency
Post-ride – 1 hand with 3.9 msec to 4.8 msecPost-ride – 1 hand with 3.9 msec to 4.8 msec
DiscussionDiscussion
Changes occur in Changes occur in the deep branch of the deep branch of the ulnar nervethe ulnar nerve Despite usual Despite usual
preventative preventative measuresmeasures
Sub-clinical changesSub-clinical changes
Pre-existing nerve Pre-existing nerve abnormalities may abnormalities may be exacerbatedbe exacerbated
LimitationsLimitations
Small sample numberSmall sample number Lack of temperature Lack of temperature
measurementmeasurement Technical errorsTechnical errors
Submaximal stimulationSubmaximal stimulation Distance differencesDistance differences
Same electromyographer Same electromyographer performed all examinationsperformed all examinations
ConclusionsConclusions
• Cyclist palsy or handlebar palsy is a Cyclist palsy or handlebar palsy is a compressive neuropathy of the ulnar compressive neuropathy of the ulnar nerve seen in cyclistsnerve seen in cyclists
• Early recognition of symptoms & Early recognition of symptoms & intervention with rest & cessation of intervention with rest & cessation of biking, then modification of biking, then modification of equipment and alteration in riding equipment and alteration in riding style is important for the avoidance style is important for the avoidance of nerve damageof nerve damage
ConclusionsConclusions
• Significant changes can Significant changes can occur to the deep branch occur to the deep branch of the ulnar nerveof the ulnar nerve
• May cause or exacerbate May cause or exacerbate symptoms of carpal tunnel symptoms of carpal tunnel syndromesyndrome