J Korean Neurosurg Soc.  2016 Jan;59(1):75-77. 10.3340/jkns.2016.59.1.75.

Ultrasound Diagnosis of Double Crush Syndrome of the Ulnar Nerve by the Anconeus Epitrochlearis and a Ganglion

• Lee SU
• Kim MW
• Kim JM

• KMID: 2152923
• DOI: http://doi.org/10.3340/jkns.2016.59.1.75

Abstract

Double compression of the ulnar nerve, including Guyon's canal syndrome associated with cubital tunnel syndrome caused by the anconeus epitrochlearis muscle, is a very rare condition. We present a case of double crush syndrome of the ulnar nerve at the wrist and elbow in a 55-year-old man, as well as a brief review of the literature. Although electrodiagnostic findings were consistent with an ulnar nerve lesion only at the elbow, ultrasonography revealed a ganglion compressing the ulnar nerve at the hypothenar area and the anconeus epitrochlearis muscle lying in the cubital tunnel. Careful physical examination and ultrasound assessment of the elbow and wrist confirmed the clinical diagnosis prior to surgery.

Keyword

Double crush syndrome; Ulnar nerve; Ultrasound; Anconeus epitrochlearis

MeSH Terms

Crush Syndrome*
Cubital Tunnel Syndrome
Deception
Diagnosis*
Elbow
Ganglion Cysts*
Humans
Middle Aged
Physical Examination
Ulnar Nerve*
Ultrasonography*
Wrist

Figure

• 

  Fig. 1 Ultrasonographic findings, revealing (A) the anconeus epitrochlearis muscle (arrowhead) in close proximity to a swollen ulnar nerve (arrow), and (B) a hypoechoic ganglion cyst (G) and ulnar nerve (circle) between the hamate hook (HAM) and pisiform.

• 

  Fig. 2 Operative findings, showing (A) the anconeus epitrochlearis muscle (arrowhead) compressing the ulnar nerve (arrow), and (B) a ganglion (arrowhead) compressing the ulnar nerve (arrow).

Reference

1. Bargalló X, Carrera A, Sala-Blanch X, Santamaría G, Morro R, Llusá M, et al. Ultrasound-anatomic correlation of the peripheral nerves of the upper limb. Surg Radiol Anat. 2010; 32:305–314. PMID: 19890595.

2. Beekman R, Van Der Plas JP, Uitdehaag BM, Schellens RL, Visser LH. Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow. Muscle Nerve. 2004; 30:202–208. PMID: 15266636.

3. Chalmers J. Unusual causes of peripheral nerve compression. Hand. 1978; 10:168–175. PMID: 710998.

4. Flak M, Durmala J, Czernicki K, Dobosiewicz K. Double crush syndrome evaluation in the median nerve in clinical, radiological and electrophysiological examination. Stud Health Technol Inform. 2006; 123:435–441. PMID: 17108465.

5. Jeon IH, Fairbairn KJ, Neumann L, Wallace WA. MR imaging of edematous anconeus epitrochlearis : another cause of medial elbow pain? Skeletal Radiol. 2005; 34:103–107. PMID: 15252695.

6. Jung JH, Kim KH, Choi SK, Shim JH. Usefulness of ultrasound for detecting suspected peripheral nerve lesions in diagnosis of peripheral neuropathy : case report and brief review of the literature. J Korean Neurosurg Soc. 2013; 53:132–135. PMID: 23560182.

7. Khoo D, Carmichael SW, Spinner RJ. Ulnar nerve anatomy and compression. Orthop Clin North Am. 1996; 27:317–338. PMID: 8614581.

8. Koyuncuoglu HR, Kutluhan S, Yesildag A, Oyar O, Guler K, Ozden A. The value of ultrasonographic measurement in carpal tunnel syndrome in patients with negative electrodiagnostic tests. Eur J Radiol. 2005; 56:365–369. PMID: 15994046.

9. Macnicol MF. The results of operation for ulnar neuritis. J Bone Joint Surg Br. 1979; 61-B:159–164. PMID: 438266.

10. Monacelli G, Spagnoli AM, Pardi M, Valesini L, Rizzo MI, Irace S. [Double compression of the ulnar nerve at the elbow and at the wrist (double-crush syndrome). Case report and review of the literature]. G Chir. 2006; 27:101–104. PMID: 16681870.

11. Richardson JK, Forman GM, Riley B. An electrophysiological exploration of the double crush hypothesis. Muscle Nerve. 1999; 22:71–77. PMID: 9883859.

12. Simpson RL, Fern SA. Multiple compression neuropathies and the double-crush syndrome. Orthop Clin North Am. 1996; 27:381–388. PMID: 8614586.

13. Suden R, Wilhelm A. [Proximal ulnar nerve compression syndrome with special reference to the m. epitrochleo-anconaeus]. Handchir Mikrochir Plast Chir. 1987; 19:33–42. PMID: 3557204.

14. Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973; 2:359–362. PMID: 4124532.

15. Vanderpool DW, Chalmers J, Lamb DW, Whiston TB. Peripheral compression lesions of the ulnar nerve. J Bone Joint Surg Br. 1968; 50:792–803. PMID: 4303276.

16. Wood J. Variations in human mycology observed during the winter session of 1867-1868 at King's College, London. Proc R Soci Lond. 1868; 16:483–525.

17. Yoon JS, Walker FO, Cartwright MS. Ulnar neuropathy with normal electrodiagnosis and abnormal nerve ultrasound. Arch Phys Med Rehabil. 2010; 91:318–320. PMID: 20159139.