PERIPHERAL COMPRESSION LESIONS OF THE ULNAR NERVE

D. W. VANDERPOOL, HOUSTON, TEXAS, UNITED STATES OF AMERICA,

J. CHALMERS, EDINBURGH, D. W. LAMB, EDINBURGH, and T. B. WHISTON, MELROSE, SCOTLAND

This paper reviews sixty-one cases of ulnar nerve lesion due to extrinsic pressure
encountered in the past eight years and draws attention to the diverse mechanical hazards
to which the ulnar nerve is vulnerable. The clinical features that may be of value in diagnosis
are described.

ANATOMY
The anatomical course of the ulnar nerve renders it particularly vulnerable at the elbow
and at the wrist. At both sites the nerve or its terminal branches pass through narrow canals
in which small space-occupying lesions may exert pressure.
As the nerve crosses the elbow it passes from the extensor aspect of the arm into the
flexor mass of the forearm, running between the two heads of origin of the flexor carpi ulnaris

FIG. 1 FIG. 2
The cubital tunnel lying deep to the aponeurosis bridging the two origins of flexor carpi ulnaris. In extension
(Fig. 1) the aponeurosis is relaxed but in flexion (Fig. 2) becomes taut.

muscle. The two heads are bridged by an aponeurotic band overlying the nerve and confining
it in an elliptical fibro-osseous canal bordered laterally by the elbow joint and its transverse
ligament and medially by the flexor carpi ulnaris aponeurosis. With flexion of the elbow
this cubital
“ tunnel “ decreases in volume, and the aponeurosis becomes stretched. Eighteen
cadaveric specimens were dissected and the distance measured between the ulnar and humeral
attachments ofthe aponeurosis. It was observed that this distance increased by five millimetres
for each 45 degrees of flexion, elongation being 40 per cent from full extension to 135 degrees
of flexion (Figs. 1 and 2).
The main ulnar trunk and artery enter the hand by passing through a triangular space
(Guyon’s tunnel) which is bordered medially by the flexor carpi ulnaris tendon and pisiform
bone, anteriorly by the anterior carpal ligament and posteriorly by the transverse carpal ligament

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 PERIPHERAL COMPRESSION LESIONS OF THE ULNAR NERVE 793

(Fig. 3). Distal to this tunnel, under cover of the palmaris brevis muscle, the nerve divides
into superficial and deep branches, the superficial branch continuing under cover of the
palmaris brevis muscle to supply it and also to provide cutaneous innervation for the anterior
aspect of the hand. The deep palmar branch passes posteriorly lateral to the pisiform bone
through a tunnel bounded proximally by the piso-hamate ligament and distally by the arched
origins of the abductor, flexor and opponens digiti
minimi which arise from the pisiform, tendon of flexor
carpi ulnaris and the hook of the hamate. Therefore
at the wrist the ulnar nerve is confined in two narrow
canals-proximally in Guyon’s tunnel, and distally as
the deep palmar branch passes between the origins of
the small muscles to the little finger and the piso-hamate
ligament.
The intraneural arrangement of the nerve bundles
is also relevant to a study of the effects of compressive ,,

lesions. Figure 4 shows the arrangement of nerve

bundles within the ulnar nerve at elbow and wrist levels.
It is noteworthy that at the elbow most of the nerve #{149} . FIG. 3
. . . Relationships of the ulnar nerve in
fibres destined for flexor carpi ulnaris and flexor Guyon’s canal.
digitorum profundus lie deeply in the nerve, whereas
the motor fibres for the intrinsic muscles of the hand and the sensory fibres run more
superficially. Theoretically, therefore, compression of the nerve on its superficial aspect would
affect the forearm muscles least, whereas compression arising in the floor of the ulnar groove
would produce early involvement of the forearm muscles. Similarly at the level of the wrist

Motor to intrinsic

LEVEL OF MEDIAL EPICONDYLE LEVEL OF PISIFORM

Sensory

musclcs of hand
Motor to
F.C,U.
RQdiai 4,, Ulriar

Motor to
muscles of hand

FIG. 4
Intraneural relationships of nerve bundles within the ulnar nerve at elbow and wrist levels (adapted from
Sunderland 1945). (F.C.U. =Flexor carpi ulnaris; F.D.P. ==flexor digitorum profundus.)

the motor fibres to the intrinsic muscles are located posteriorly and the sensory fibres anteriorly
within the nerve. If the compressing agent presented on the posterior aspect of the nerve,
motor weakness might precede sensory loss. However, the varying physiological susceptibilities
of motor and sensory nerve fibres also play a role in determining the clinical effects of nerve
compression and may override the purely anatomical considerations (Brooks 1963).

COMPRESSION AT THE ELBOW

There were forty cases of ulnar nerve compression at the elbow, thirty in men and ten in
women, the age range being from seventeen to eighty-one years. Multiple causes of
compression frequently combined to involve the nerve. In the largest group of eighteen cases
compression by the anatomical confines of the cubital tunnel (cubital tunnel syndrome) alone
appeared to be responsible (Fig. 5), but in this group there were five cases with slight

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794 D. W. VANDERPOOL, J. CHALMERS, D. W. LAMB AND T. B. WHISTON

osteoarthritis of the elbow which may have contributed. Of the eighteen cases sixteen occurred
in the dominant arm. The significance of elbow flexion in producing this lesion was shown
by one patient who developed a nerve lesion during the period of attachment of a pectoral
skin flap to the hand. In a further sixteen cases severe osteoarthritis was present. Fifteen of
them gave a history of previous injury, the latent period between the injury and the onset of
neuritis ranging from ten to fifty years, the average being thirty years. In only five cases was

FIG. 6
Figure 5-A typical example of cubital tunnel
compression. Beneath the split aponeurosis (held by haemostats)
the ulnar nerve is narrowed, while proximal to this point the nerve is thickened (Case 26). Figure 6-Another
case. Although the radiographs showed osteoarthritis, at operation the compressing lesion was found to be
the pendunculated ganglion shown here which arose from the joint and passed distally with the nerve deep
to flexor carpi ulnaris, at which level the nerve was narrowed (Case 15).

FIG. 7 FIG. 8
A girl of 1 7, the youngest in the series, had compression of the ulnar nerve by the accessory muscle anconeus
epitrochlearis, which arises from the medial border of the olecranon and the tendon of triceps ; it crosses over
the ulnar nerve as it lies in the ulnar groove and is inserted into the medial epicondyle. Figure 7 shows the
muscle overlying the dissector placed in the ulnar groove. In Figure 8 the muscle has been reflected to reveal
the constricted and hyperaemic nerve.

the precise nature of the injury identifiable ; three had ununited fractures of the medial
epicondyle and two of the lateral condyle. In the remainder secondary degenerative change
obscured the original injury. In only four of the osteoarthritic cases was the neuritis directly
attributable to irregularities of the ulnar groove arising from the marginal osteophytes.
Capsular thickening in the medial wall of the cubital tunnel or an increase in the carrying
angle (which increases the tension of the aponeurotic roof of the cubital tunnel) appeared to
be the significant factor in most cases. In this group also were three cases of ganglia arising

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 PERIPHERAL COMPRESSION LESIONS OF THE ULNAR NERVE 795

from the osteoarthritic joint capsule compressing the nerve within the cubital tunnel (Fig. 6).
There was a further case ofganglion compression at this site without osteoarthritis. Subluxation
of the ulnar nerve over the medial epicondyle was the cause of nerve involvement in one case
in which osteoarthritis was also present. In two cases the accessory muscle anconeus
epitrochlearis (Le Double 1 897) which bridges the ulnar groove was the cause of compression
(Figs. 7 and 8). In three cases no pathology was recognised at operation but all recovered
after simple decompression of the cubital tunnel and these may have been examples of the
cubital tunnel syndrome.

CLINICAL FEATURES

The clinical presentation showed a striking uniformity. Paraesthesiae within the

distribution of the ulnar nerve was usually the earliest complaint and sometimes preceded
subjective motor weakness by months or years. Objective motor weakness and wasting of
the intrinsic muscles were usually more marked than the sensory changes and often had
developed earlier than the patient had realised.
The sensory symptoms were rarely distressing or disabling and lacked the painful nocturnal
character of median nerve compression. The exact distribution of the sensory changes was
of great significance, for if the dorsal cutaneous branch of the nerve was involved, this clearly
established a proximal lesion of the nerve, whereas if it was spared the compression was more
likely to be at the wrist.
The long flexor muscles, flexor carpi ulnaris and flexor digitorum profundus, were
unaffected in twenty-four of the forty cases of ulnar nerve compression at the elbow, usually
when the major compressing agent was the superficial aponeurosis. When the source of
compression lay deep to the nerve, these muscles were usually involved, a fact which may be
explained by the intraneural arrangement of the nerve bundles (Fig. 4).
In one case of cubital tunnel syndrome motor weakness was restricted to the distribution
of the deep palmar branch, the hypothenar and the long flexor muscles being spared, but
the associated sensory disturbance enabled the correct diagnosis of a lesion at the elbow to
be made before operation.
TREATMENT

When the cause of the compression was in the cubital tunnel alone, treatment consisted
of excising the aponeurotic roof of the tunnel, and this simple procedure was also used when
mild osteoarthritis existed with
cubital tunnel compression. Compression by a ganglion or an
accessory muscle was relieved by their excision. Anterior transposition was reserved for the
cases with more severe osteoarthritis and for the case of recurrent subluxation of the nerve.

RESULTS

Rapid subjective improvement was noticed in most cases, often immediately after
operation. Objective motor and sensory recovery usually occurred in a few months after the
operation, the longest period before recovery being eighteen months. Thirty-six cases with
history of symptoms from two months to seven years before operation showed worthwhile
recovery; only two had no benefit from the operation but two other patients were untraced.
A number of cases with complete ulnar paralysis and sensory loss known to have been present
for many years were not included in this series because there was little chance of useful
recovery with operation.
ILLUSTRATIVE CASES

Cubital tunnel compression associated with mild osteoarthritis

Case 26-A fifty-seven-year-oldjoiner gave no history ofinjury to his elbow. One year before admission
he experienced gradual onset of paraesthesiae in the ulnar distribution of his right hand. Nine months
before admission he had noted progressive weakness of his hand and loss of fine movements. On
examination he had marked weakness and wasting of the interossei although the flexor carpi ulnaris

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796 D. W. VANDERPOOL, J. CHALMERS, D. W. LAMB AND T. B. WHISTON

appeared normal. There was reduced pinprick sensation in the ulnar distribution of his hand.
Radiographs showed mild osteoarthritis of the elbow. At operation compression by flexor carpi
ulnaris aponeurosis was found and released (Fig. 5). Immediately after operation the paraesthesiae
had disappeared and within four months he was neurologically normal.

Ganglion compression of ulnar nerve at elbow

Case 15-A sixty-eight-year-old male gardener had for one year before admission noted weakness
and wasting of the left hand with no sensory symptoms. He gave no history of trauma. For the same
period he had suffered occasional pain in the left elbow. On physical examination there was evidence
of clawing of the hand with weakness and wasting of the musculature innervated by the ulnar nerve.
There was decreased pinprick sensation the ulnar distribution
in of the hand. A 20 degrees flexion
contracture was present at the elbow. Radiographs of the elbow showed osteoarthritic changes. At
operation a ganglion one centimetre in diameter was found arising from the elbow joint, passing
distally with the ulnar nerve compressing it against the aponeurosis of the flexor carpi ulnaris
(Fig. 6). The ganglion was excised and the aponeurosis removed. After five months sensation was
normal. At one year the hypothenar muscles had recovered but the remaining intrinsic muscles were
still paralysed.
Case 14-A sixty-four-year-old housewife noticed swelling of her right elbow one year before
admission. There was no history of injury. Approximately five months before admission she had noted
weakness of the grip and paraesthesia in the fourth and fifth fingers of the right hand. Examination
revealed weakness of all the ulnar innervated musculature with decreased pinprick sensation in the
ulnar distribution of her fingers and palm. The elbow lacked 15 degrees of extension and radiographs
showed osteoarthritis. There was a palpable mass in the line of the ulnar nerve. At operation an
elongated ganglion eight centimetres in length was found arising from the joint which extended
proximally and distally in intimate association with the ulnar nerve. The ganglion was removed and
the nerve was not transposed. She had complete recovery after eight months.

COMPRESSION AT THE WRIST

Twenty-one cases of ulnar nerve compression occurred at the wrist. As with the lesions
located at the elbow the compressing agent usually combined with the anatomical fixation of
the nerve at the wrist to produce its effect. The following conditions were encountered:
ganglia (thirteen), occupational trauma (three), acute trauma (two), narrowed canal of deep
palmar branch (one), osteoarthritis of inferior radio-ulnar joint (one), accessory ossicle at
wrist (one).
CLINICAL FEATURES

Ganglia produced the largest number oflesions at this level and were divided into proximal,
arising near the radio-ulnar or piso-triquetral joints, and distal, arising from the distal carpus
deeply in the palm.

FIG. 9 FIG. 10
Figure 9-An example of a “ proximal “ ganglion which arose at the level of the pisiform to produce a nearly
complete motor and sensory loss. Complete recovery followed its removal (Case 42). Figure 10-A distal
ganglion arising deep in the palm, emerging distal to the piso-hamate ligament, and which compressed the deep
palmar branch as it passed beside it to produce a pure motor weakness, but sparing the hypothenar muscles and
sensory branches. Complete recovery followed its removal (Case 52).

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 PERIPHERAL COMPRESSION LESIONS OF THE ULNAR NERVE 797

The seven proximal ganglia, sometimes palpable, were

associated with both motor and sensory symptoms, although
the clinical picture varied, depending upon the exact relation-
ship between the nerve and the ganglion ; thus either motor
or sensory symptoms and signs predominated in individual
cases (Fig. 9). The sensory disturbance spared the dorsal
cutaneous branch which arises more proximally in the forearm.
The motor involvement affected the hypothenar as well as the
interosseous muscles and clawing of the medial two fingers
was usually present.
The five distal ganglia were all impalpable. They exerted
pressure only on the deep branch as it passed through the
narrow tunnel into the deeper layers of the palm, producing
FIG. 11
a pure motor weakness of this branch but sparing the hypo-
The abducted attitude ofthe little
thenar muscles and the sensory nerves (Fig. 10). Clawing of finger was sometimes seen with
involvement of the deep palmar
the fingers occurred only once in this group and was restricted
branch when the abductor was
to the ring finger. Several showed an abducted position of the unopposed.
fifth finger from the unopposed action of the abductor of the
little finger (Fig. 1 1). One case showed first the clinical features of a distal ganglion and later
of a proximal lesion because of the rapid enlargement and migration of the ganglion.
Two cases of carpal ganglia were associated with osteoarthritis of the wrist. Several of
the cases with ganglion compression gave a history of injury to the base of the hypothenar
area including one pneumatic drill operator. Three other cases of occupational injury were
seen ; they were caused by carpentry, the use of a vibrating buffer and of a floor polisher.
These cases were not explored, and cleared up after cessation of the activity concerned.
Two other cases were seen after acute injury ; one case each was seen with a narrowed
deep palmar branch canal, with osteoarthritis of the distal radio-ulnar joint and with
compression by an accessory carpal ossicle (Figs. 12 and 13).

TREATMENT AND RESULTS

Exploration was done on all cases, except those in which there was a clear history of
acute or chronic trauma, which were observed initially for a period of four to six weeks and
operated upon only if recovery did not take place during this period.
After removal of the compressing agent recovery took place within a few months in all
but one case.

FIG. 12 FIG. 13
The accessory ossicle shown in these radiographs (Fig. 12) and at operation (Fig. 13) lay in soft tissue
just distal to the pisiform where it compressed the ulnar nerve. Although there was a vague history of
injury there was no evidence of an old fracture or myositis ossificans to explain the presence of this lesion.
On reflecting the ossicle a narrowed zone was seen in the underlying ulnar nerve (Case 60).

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798 D. W. VANDERPOOL, J. CHALMERS, D. W. LAMB AND T. B. WHISTON

ILLUSTRATIVE CASES

Compression by a proximal ganglion with sensory and motor involvement

Case 42-A woman of forty-three years complained of weakness of the ring and little fingers with
inability to extend them fully, associated with local tenderness over the pisiform bone of one month’s
duration. A stinging
“ pain was felt in the ring and little finger-tips
“ and the grip was markedly
impaired, the patient being unable to hold objects firmly. The little finger tended to stick out” “

in the abducted position when washing the hands. Examination revealed the typical main-en-griffe
deformity due to ulnar nerve palsy with severe sensory loss in the ulnar cutaneous distribution and
local tenderness on pressure over the pisiform bone. Severe intrinsic and hypothenar muscle wasting
was evident. Radiographs of the cervical spine and wrist were normal. At operation the right ulnar
nerve was exposed at the wrist and found to be compressed by a large underlying ganglion adjacent
to the pisiform-triquetral joint (Fig. 9). Immediate relief of pain occurred after removing the ganglion
and she returned to work as a darner ten weeks later. Three months later motor recovery was almost
complete.

Compression by distal ganglion producing a deep palmar branch lesion

Case 52-A fifty-four-year-old electrician struck the palm of his left hand while pulling a heavy
cable four months before admission, with the onset of pain in the hypothenar area. There was gradual
decrease of pain over the ensuing weeks but subsequently he noted weakness in his grip. Physical
examination revealed weakness and atrophy of the intrinsic muscles of the hand with the hypothenar
muscles being spared. Sensation was intact. There was no palpable mass and radiographs of the hand,
elbow and neck were normal. At operation a ganglion measuring 1 5 centimetres in diameter was
removed from the carpus. It was found to be pressing on the deep palmar branch just distal to its
passage beneath the origins of the small muscles to the little finger (Fig. 10). The ganglion was excised
and three months later neurological examination was normal.
Such cases illustrate the need of surgical exploration even when occupational injury seems to be
the cause, if symptoms do not rapidly subside after a change of occupation.

Compression of the ulnar nerve by accessory ossicle at wrist

Case thirty-three-year-old
60-A clerk had been aware of a swelling in the ulnar border of her left
wrist for twenty years, which she had first noticed after a sprain.” Three months before coming to “

hospital she noticed weakness and wasting of the hand. Examination revealed a hard mobile bone-like
swelling three by two centimetres in diameter just distal to the pisiform. There was complete ulnar
intrinsic paralysis and hypoaesthesia. Clawing of the medial two fingers was present. Radiographs
confirmed the swelling to be bone (Fig. 12) and at operation it was found to be loosely connected to
soft tissues lateral to the piso-hamate ligament overlying and compressing the ulnar nerve at that level
(Fig. 13). The ossicle lay outside the wristjoint and was not within muscle. Its origin was quite obscure.

DISCUSSION
In recent years involvement of most large peripheral nerves from mechanical compression
in a narrow anatomical canal has now been reported.
Some lesions such as median nerve compression within the carpal tunnel are common
and well known. Mechanical neuritis of the ulnar nerve, historically one of the first to be
recognised, is much less common and more likely to escape recognition because of the more
insidious and less compelling character of its symptoms. Although ulnar nerve damage has
been described at most levels in the upper extremity in association with fractures or other
injuries, such lesions present little problem in diagnosis because of their close association
with injury and these have not been included in this series.
Of the sixty-one cases of more insidious onset reported here, forty occurred at the elbow
joint level and twenty-one at the wrist. The anatomical relationships discussed in this paper
were important factors in the production of the neuritis, whatever additional pathology might
be present.
Ulnar nerve damage at the elbow-The first type of mechanical ulnar neuritis to be recognised
was the tardy palsy following fracture or osteoarthritis of the elbow. Panas (1878) reported
three cases of slowly progressive ulnar nerve lesions associated with bony abnormality at the
elbow (old fracture, osteoarthritis, shallow ulnar groove). He believed the pathogenesis was
repeated trauma causing hyperaemia, oedema and eventually infiltration of fibrous tissue.

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 PERIPHERAL COMPRESSION LESIONS OF THE ULNAR NERVE 799

Mouchet (1898) reported seven cases following fracture of the lateral humeral condyle in
childhood with subsequent cubitus valgus and progressive ulnar palsy after a latent period of
several years. He considered that traction produced interstitial neuritis and a fusiform neuroma
at the elbow.
By the early 1920’s three main pathological factors were recognised : 1) increased valgus
deformity after injury, leading to traction neuritis as described by Mouchet (1898), Brickner
(1924) and Miller (1924); 2) irregularity of the ulnar groove from osteoarthritis without
previous trauma, or injury to the medial epicondyle causing a friction neuritis (Shelden 1921);
3) subluxation of the ulnar nerve in its groove due to lax or weak ligament either congenital
or acquired, or a shallow groove causing ulnar palsy by repetitive motion of the nerve over
the medial epicondyle (Platt 1926). Other mechanisms were occasionally described, including
scars in the region ofthe medial epicondyle, occupational injuries, ganglia, a variety of tumours
and accessory muscles.
Recently the identification of the “ cubital tunnel syndrome “ (Osborne 1957, Feindel and
Stratford 1958) has caused a reappraisal of the traditional theories of mechanical injury to
the ulnar nerve. In the cubital tunnel syndrome the nerve is compressed between the
aponeurosis joining the heads of origin of flexor carpi ulnaris and the floor of the tunnel
formed by the medial ligament of the elbow joint, especially the transverse ligament. During
flexion the space of the tunnel is diminished both by tightening of the aponeurosis and bulging
of the joint. This was the primary pathology in nearly half of the lesions at the elbow reported
in this paper.
The cubital tunnel syndrome presents more commonly in men, usually affects the dominant
hand and seldom causes pain or nocturnal distress in contrast to the carpal tunnel syndrome.
These differences may be attributed to the increased importance of occupational activity in
the production of cubital tunnel syndrome, whereas fluid retention during pregnancy and the
menopause may be operative in the carpal tunnel syndrome. Osteoarthritis of the elbow or
deformity such as cubitus valgus or fracture of the medial epicondyle could all reduce the
space available in the cubital tunnel, and many of the cases described in this paper have shown
how often these factors combine to produce the nerve damage. Rheumatoid arthritis may
operate in the same way (Pulkki and Vainio 1962) but this condition was not encountered in
this series.
The experience reported in this paper suggests that anterior transposition of the ulnar
nerve may be applied more selectively than has sometimes been recommended, as the lesser
procedure of local excision of the aponeurosis has resulted in recovery of nerve function in
this series even in the presence of osteoarthritis of the joint. When there is clear evidence of
narrowing of the nerve at its entrance to the cubital tunnel local decompression only is required
whatever the associated pathology.
Recurrent subluxation of the ulnar nerve has assumed less significance since the
observation that it occurs in 16 per cent of the population (Childress 1956) and rarely causes
symptoms unless there is some additional factor such as trauma. This series supports this
concept, for in only one case was recurrent subluxation regarded as the main cause of neuritis.
An additional symptomatic case ofsubluxation developed after an earlier extensive mobilisation
of the ulnar nerve for cubital tunnel syndrome, and since this experience we have not deroofed
the ulnar groove when local decompression in the cubital tunnel has demonstrated a significant
lesion. lf more extensive exploration of the nerve is for any reason found necessary then a
formal anterior transposition should be carried out.
Ulnar nerve lesions at the wrist-Since Brooks (1952) and Seddon (1952) emphasised the
importance of ganglia as compressing agents at the wrist, some thirty-five cases have now been
described including the eleven reported in this paper (Jenkins 1952; Boyes 1955; Mallett and
Zilkha 1955; Blunden 1958; Ebeling, Gilliatt and Thomas 1960; Toshima and Kimata 1961;
Richmond 1963: Dupont, Cloutier, Pr#{233}vostand Dion 1965).

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800 D. W. VANDERPOOL, J. CHALMERS, D. W. LAMB AND T. B. WHISTON

As noted by Brooks (1963), the symptoms may vary according to the exact location of
the ganglion in relation to the nerve and according to the degree of compression. These
lesions tend to fall into two general patterns : 1) ganglion lying proximal to the piso-hamate
ligament with both sensory and motor involvement ; and 2) ganglion arising deeply in the
palm distal to the piso-hamate ligament with affection of the interossei but sparing of sensation
and of the hypothenar muscles.
Occupational neuritis of the deep branch of the ulnar nerve may occur from prolonged
repetitive pressure on the hypothenar aspect of the palm. From 1908 to 1914 Hunt reported
the first seven cases in the English literature, and many others have since been recognised
(Harris 1929, Worster-Drought 1929, Russell and Whitty 1947, Bakke and Wolff 1948,
Magee 1955, Moffat 1964). It is important to recognise trauma as an additional insult to a
nerve already threatened by a ganglion as confirmed in two cases in this series and in four
cases recorded by Seddon (1952). Any case which does not recover within a few weeks of
injury deserves exploration.
Osteoarthritis is occasionally the cause of compression at the wrist. One case is reported
of involvement of the ulnar nerve with osteoarthritis of the pisiform-triquetral joint (Jenkins
195 1 ) and one case of osteoarthritis of the inferior radio-ulnar joint is also contained in this
series. Occasional cases have been described with scarring of this area involving the ulnar
nerve, and they tend to occur within weeks or months of an injury (Cameron 1954, Howard
1961, Stein and Morgan 1962, Dupont et a!. 1965, Fenning 1965).

DIFFERENTIAL DIAGNOSIS
Although various neurological affections of the cord or of the brachial plexus may suggest
ulnar nerve involvement, a careful clinical examination will usually demonstrate that the
paralysis or sensory disturbance in these conditions does not exactly conform with the
peripheral distribution of the ulnar nerve. Radiographs of the cervical spine and lung apices
as well as of the elbow and the wrist are advisable before reaching the diagnosis of peripheral
compression syndrome.
Delay in nerve conduction has been found of value by others (Simpson 1956, Gilliatt and
Sears 1958, Ebeling et a!. 1960, Gilliatt and Thomas 1960) in establishing the site of nerve
involvement and although no difficulty in this series was encountered in establishing the correct
level by routine clinical examination alone, this procedure may prove useful if there is any doubt.

SUMMARY

1 . Sixty-one cases of compression of the ulnar nerve are reported, forty at the elbow and
twenty-one at the wrist. Although contributory factors may include deformity, osteoarthritis,
injury, ganglia and other tumours, the narrow anatomical confines of the nerve at these two
levels are noteworthy and alone may produce nerve compression.
2. Careful clinical examination will usually determine the level of involvement if not the
exact pathology. Surgical exploration is indicated both as a diagnostic and therapeutic
procedure in most cases.
3. Following removal of the compressing agent rapid recovery occurred in most cases.

The authors are most grateful to their colleagues in the South-East Region of Scotland for allowing them to
include their cases in this series. Much credit is due to Mr T. C. Dodds of the Department of Medical Illustration
at Edinburgh University and Mr Alan Dodds, Medical Photographer, Princess Margaret Rose Orthopaedic
Hospital, Edinburgh, who were responsible for many of the illustrations.

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