Review Question - QID 109237

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Ulnar Neuropathies Introduction The most common ulnar neuropathies are QID: 109237 (M2.OR.17.4798)

QID 109237 (Type "109237" in App Search)

A 27-year-old young man presents to his primary care physician for weakness and tingling in his hand. The patient is an avid bodybuilder and has noticed that his grip strength has gradually worsened in both hands with symptoms worse at the end of a long workout. The patient has a past medical history of anabolic steroid use in high school. His current medications include a multivitamin, fish oil, and whey protein supplements. On physical exam, you note a muscular young man with male pattern hair loss. The patient has a loss of sensation bilaterally over the volar and dorsal surfaces of the 4th and 5th digits. The patient has 3/5 grip strength of his left hand and 2/5 grip strength of his right hand. There is also notable weakness of finger adduction and abduction. The rest of the patient's physical exam is within normal limits.

Which of the following is the most likely diagnosis?

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Brachial plexopathy

12%

4/32

Cubital tunnel compression

44%

14/32

Guyon's canal compression

31%

10/32

Carpal tunnel syndrome

2/32

Posterior interosseous nerve compression

1/32

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This patient is presenting with weakness of grip strength and finger abduction/adduction, as well as a loss of sensation in the distribution of the ulnar nerve (volar surface of the medial forearm and medial two digits), suggesting a diagnosis of cubital tunnel compression.

Cubital tunnel compression occurs any time there is trauma or compression of the cubital tunnel such as in athletes or occupational workers where there is repetitive trauma or pressure to this area. It presents with symptoms in the distribution of the ulnar nerve distal to the injury. If the cubital tunnel is compressed, symptoms will include a loss of sensation over the medial two digits, and a weakness of grip strength and finger abduction/adduction.

Incorrect Answers:
Answer 1: A brachial plexopathy is typically a diagnosis of exclusion when there is weakness or loss of sensation of any area innervated by the brachial plexus. This diagnosis is non-specific and there is a better explanation for this patient's symptoms.

Answer 3: Guyon's canal compression occurs due to compression of the ulnar nerve at the wrist and presents with symptoms distal to this location. Symptoms would include weakness of grip and loss of sensation over the volar medial two digits; however, the dorsal medial surface of the ring and little finger would be spared because the dorsal cutaneous branch of the ulnar nerve arises proximal to the Guyon canal.

Answer 4: Carpal tunnel syndrome occurs due to compression of the median nerve as it traverses the carpal tunnel. It presents with weakness and paresthesias of the lateral three digits.

Answer 5: Posterior interosseous nerve compression would present with an inability to contract the muscles on the radial side and dorsal surface of the forearm rather than the ulnar-distributed symptoms in this patient.

Bullet Summary:
Cubital tunnel compression can result in ulnar-distributed symptoms starting at the elbow including loss of sensation over the medial two digits (pointer and ring finger), and decreased grip strength.

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