PMC4702610_01
Photograph of the right hand depicts flattening of hypothenar eminence with ulnar claw hand (main-en-griffe).
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A 23-year-old male presented with gradual-onset weakness and clawing of medial two digits (Figures 1, 2) of the right hand since eighteen months.
Photograph shows extension at metacarpophalangeal joints and flexion at proximal and distal interphalangeal joints of the fourth and fifth digit.
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A 23-year-old male presented with gradual-onset weakness and clawing of medial two digits (Figures 1, 2) of the right hand since eighteen months.
Transverse scan at the upper arm (just distal to the axilla) shows normal appearance of the right ulnar nerve (dotted ellipse; Cross-sectional area=5 mm2). The nerve comprises of multiple hypoechoic dot-like nerve fascicles (honeycomb appearance on a transverse scan). The arrow points to nerve fascicles of the median nerve that are not oriented transversely on the present scan. [a=high bifurcation of the brachial artery, v=basilic vein, M=medial aspect].
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It showed normal morphology of the nerve in the proximal arm (Figure 3) with an extensive fusiform enlargement of the nerve from mid-arm till the cubital tunnel (Figure 4).
Panoramic view of the right ulnar nerve from the arm to the upper forearm through the cubital tunnel (d) demonstrates normal segments of the nerve (a, f), transition zones (b, e), region of fusiform thickening (c, d). The nerve is maximally thickened (c) proximal to the segment within the cubital tunnel (d).
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It showed normal morphology of the nerve in the proximal arm (Figure 3) with an extensive fusiform enlargement of the nerve from mid-arm till the cubital tunnel (Figure 4). The maximal thickening was proximal to the cubital tunnel (Figures 4, 7, 8).
Transverse ultrasonogram reveals thickening (cross-sectional area=16.8 mm2) of each of the nerve fascicles of the right ulnar nerve (dotted ellipse). However, individual fascicle can be seen distinctly.
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In the mid-arm, there was preservation of the fascicular architecture with thickening of individual fascicles (Figure 5).
At lower-thirds of the arm, the thickened right ulnar nerve shows loss of internal architecture (dotted ellipse). It measures 33.6 mm2 in cross-section. The enlarged nerve indents the margin of the triceps.
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The fascicular morphology was, however, lost in the lower arm (Figures 6-8).
Axial scan just proximal to the medial epicondyle shows presence of Doppler signals within the substance of the thickened nerve. The spectral waveform was suggestive of low-resistance flow (not shown). The nerve measures 37.9 mm2 in cross-section.
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The fascicular morphology was, however, lost in the lower arm (Figures 6-8). The maximal thickening was proximal to the cubital tunnel (Figures 4, 7, 8). On Doppler interrogation, there was presence of low-resistance flow within the thickened nerve suggestive of acute neuritis (Figure 7).
Ultrasonogram performed with the transducer positioned posteromedially on the medial epicondyle and olecranon process with the elbow in mid-flexion demonstrates thickened ulnar nerve (cross-sectional area=18.2 mm2) in the cubital tunnel.
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The fascicular morphology was, however, lost in the lower arm (Figures 6-8). The maximal thickening was proximal to the cubital tunnel (Figures 4, 7, 8).
Axial view at upper forearm reveals normal fascicular morphology of the right ulnar nerve (cross-sectional area=4.2 mm2). In the figure, the nerve rests on flexor digitorum profundus (FDP). Flexor digitorum superficialis (FDS) lies laterally and flexor carpi ulnaris (FCU) is medial to the nerve.
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The nerve morphology was normal again in the forearm (Figures 9, 10).
At mid-forearm, the ulnar nerve retains its normal sieve-like morphology on a transverse scan (cross-sectional area= 2.2 mm2). The nerve is accompanied by the ulnar artery.
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The nerve morphology was normal again in the forearm (Figures 9, 10).