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Instructional Course Lecture

Ulnar Tunnel Syndrome, Radial


Tunnel Syndrome, Anterior
Interosseous Nerve Syndrome,
and Pronator Syndrome

Abstract
Adam B. Strohl, MD In addition to the more common carpal tunnel and cubital tunnel
David S. Zelouf, MD syndromes, orthopaedic surgeons must recognize and manage other
potential sites of peripheral nerve compression. The distal ulnar nerve
may become compressed as it travels through the wrist, which is
known as ulnar tunnel or Guyon canal syndrome. The posterior
interosseous nerve may become entrapped in the proximal forearm as
it travels through the radial tunnel, which results in a pain syndrome
without motor weakness. The median nerve may become entrapped
in the proximal forearm, which can result in a variety of symptoms.
Spontaneous neuropathy of the anterior interosseous nerve of the
median nerve can be observed without external compression.
Electrodiagnostic and imaging studies may aid surgeons in the
diagnosis of these syndromes; however, a thorough physical
examination is paramount to localize compressed segments of these
nerves. An understanding of the anatomy of each of these nerve areas
allows practitioners to appreciate a patient’s clinical findings and
From the Philadelphia Hand Center helps guide surgical decompression.
(Dr. Strohl), and the Thomas Jefferson
University Hospital, Philadelphia, PA
(Dr. Zelouf).
This article, as well as other lectures
presented at the Academy’s Annual
Meeting, will be available in March
P eripheral nerves may become
compressed at multiple anatomic
locations in the upper extremity,
clinical findings of, and treatment
options for compression and intra-
neural pathology of the ulnar, radial,
2017 in Instructional Course Lectures, which can lead to dysfunction, such and median nerves. An understand-
Volume 66. ing of anatomy and nerve topogra-
as motor weakness, sensory distur-
Dr. Zelouf or an immediate family bance, and/or pain. Median nerve phy not only aids in the accurate
member serves as a board member, compression at the wrist, which is diagnosis of peripheral nerve com-
owner, officer, or committee member
of the Eastern Orthopaedic known as carpal tunnel syndrome, pression but also guides appropriate
Association. Neither Dr. Strohl nor any followed by ulnar nerve compression and effective management.
immediate family member has at the elbow, which is known as cu-
received anything of value from or has
bital tunnel syndrome, are the most
stock or stock options held in a
commercial company or institution common compression neuropathies. Ulnar Tunnel Syndrome
related directly or indirectly to the In addition to carpal tunnel and cu-
subject of this article. bital tunnel syndromes, orthopaedic Although the ulnar nerve is most
J Am Acad Orthop Surg 2017;25: surgeons must be familiar with less commonly compressed in the cubital
e1-e10 common compression neuropathies tunnel region at the elbow, compres-
DOI: 10.5435/JAAOS-D-16-00010 that may be encountered in the eval- sion of the ulnar nerve also can occur
uation of patients with peripheral distally at the wrist, which is known
Copyright 2016 by the American
Academy of Orthopaedic Surgeons. nerve entrapment. Surgeons should as ulnar tunnel syndrome. Similar to
understand the patient complaints of, compression of the ulnar nerve in the

January 2017, Vol 25, No 1 e1

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

Figure 1 inent claw deformity. Ulnar nerve


compression at the wrist can occur
in isolation or in conjunction with
compression of the ulnar nerve at
more proximal locations. Further-
more, the physical examination
findings of proximal ulnar nerve
compression may mask concurrent
pathology at the wrist.

Anatomy
In 1861, Jean Casimir Félix Guyon
first described the course and divi-
sion of the ulnar nerve through the
hypothenar region. This space,
which is the location at which
Guyon first suggested potential
pathologic constriction of the ulnar
nerve, is currently referred to as the
Guyon canal or the ulnar tunnel.
Gross and Gelberman1 further
described the unique space of the
distal ulnar tunnel, which they
divided into three zones based on
the internal topography of the
ulnar nerve as it courses through
the ulnar tunnel. Characterization
of the zones of the ulnar tunnel
based on the presence of motor and
Illustration showing the anatomy of the ulnar tunnel at the wrist. H = hamate, P = sensory components within the
pisiform (Reproduced from Earp BE, Floyd WE, Louie D, Koris M, Protomastro P: ulnar nerve allows surgeons to
Ulnar nerve entrapment at the wrist. J Am Acad Orthop Surg 2014;22[11]:699-706.) localize the site of compression
within the ulnar tunnel based on a
patient’s symptomatology and
cubital tunnel, distal compression of muscle atrophy and weakness can clinical findings. The distal ulnar
the ulnar nerve may lead to sensory occur, which may lead to hand tunnel is 4 to 4.5 cm long and
and motor deficits in the hand and weakness, clumsiness, and/or dys- begins at the proximal edge of the
digits. Likewise, sensory paresthesias function. However, in patients with volar carpal ligament (Figure 1).
may affect the little finger and the only distal compression of the ulnar The distal ulnar tunnel extends to
ulnar half of the ring finger. Based on nerve, strength is preserved in the the fibrous arch of the hypothenar
anatomic considerations, important flexor carpi ulnaris and the flexor muscles. The borders of the distal
clinical features of ulnar tunnel syn- digitorum profundus (FDP) muscles ulnar tunnel are not constant
drome distinguish it from cubital of the ring and little fingers. Late because the ulnar nerve courses
tunnel syndrome. Because the palmar clinical findings of ulnar claw between ulnar-sided wrist struc-
cutaneous and dorsal cutaneous deformity, which is referred to as tures, most notably the pisiform
branches of the ulnar nerve branch ulnar paradox, are often more pro- and the hamate. In addition, the
off the ulnar nerve before it enters the nounced in patients with distal ulnar artery accompanies the ulnar
ulnar tunnel at the wrist, the ulnar compression of the ulnar nerve. The nerve through the ulnar tunnel.
palm and dorsum of the hand are preservation of proximally inner- Zone 1 of the ulnar tunnel is slightly
spared. vated FDP muscles allows for more more than 3 cm in length and
In patients with advanced cubital flexion of the interphalangeal encompasses the portion of the ulnar
tunnel syndrome at the elbow, intrinsic joints, which creates a more prom- tunnel that is proximal to the

e2 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Strohl, MD, and David S. Zelouf, MD

bifurcation of the ulnar nerve into its Surgeons should understand that Tenderness over the hamate or
motor and sensory branches. There- the palmar cutaneous branch of the pisiform may suggest a fracture. A
fore, compression of the ulnar nerve ulnar nerve, which is referred to as positive ulnar Allen test and/or
in zone 1 results in both paresthesia the nerve of Henle, is present in only ulceration of the ulnar fingertips
and intrinsic muscle deficit. The ulnar 58% of persons.3 Therefore, the supports a vascular etiology. As
nerve is first compressed between the contribution of the palmar cutane- already mentioned, practitioners
volar carpal ligament palmarly and ous branch of the ulnar nerve to must recognize that ulnar nerve
the transverse carpal ligament dor- palmar innervation is variable, entrapment can occur at multiple
sally. More distally in zone 1 of the unlike the dorsal cutaneous branch locations as part of a double crush
ulnar tunnel, the floor of the ulnar of the ulnar nerve, which consis- phenomenon. In patients without a
tunnel is composed of the pisohamate tently arises approximately 5.5 cm history of trauma to the affected
and pisometacarpal ligaments. Gan- proximal to the ulnar head. As a hand, surgeons should have a high
glion cysts followed by hook of result, sensory examination for suspicion for ganglia, which account
hamate fractures, traumatic adhe- ulnar nerve function is more reliable for 90% of pathology that is present
sions, and anomalous muscles are the in the little and ulnar ring fingers as within zone 1 and zone 2 of the ulnar
most common causes of compression well as the dorsal ulnar hand. tunnel.4 Moreover, patients who
of the ulnar nerve in zone 1 of the have professional duties that require
ulnar tunnel.1,2 Zone 1 of the ulnar the use of repetitive blunt force, such
tunnel is the most commonly Clinical and Diagnostic as jackhammering, and patients who
affected zone of the ulnar tunnel. Findings participate in hobbies such as rac-
After the ulnar nerve bifurcates, the A physical examination, which quet sports should be examined for
deep motor branch of the ulnar nerve should include the Tinel test and possible related factors.
pursues a dorsal and radial course sensory threshold testing, that sug- Electrodiagnostic studies can be
around the hamate as it dives deep to gests distal ulnar nerve compression performed to help support a diag-
the fibrous arch of the hypothenar at the wrist can be further supported nosis of ulnar tunnel syndrome and
muscles. This area composes zone 2 with the use of electrodiagnostic to differentiate the clinical findings
of the ulnar tunnel. Pathology that is studies. Multiple clinical findings, of ulnar tunnel syndrome from
present within zone 2 of the ulnar including the presence of interossei other diagnoses, such as cubital
tunnel leads to deficits in motor wasting, particularly over the first tunnel, thoracic outlet, and cervical
function only, without sensory dis- dorsal interosseous muscle; the radiculopathy syndromes. Surgeons
turbances. Similar to zone 1, ganglion inability to cross fingers; or abducted should expect prolonged motor and/
cysts are the most common patho- positioning of the little finger, which or sensory latencies across the wrist
logic cause of compression of the is known as the Wartenberg sign, but normal values from more proxi-
ulnar nerve in zone 2 of the ulnar suggest motor branch involvement. mal structures. Therefore, palmar
tunnel. Other causes of compression Ulnar claw deformity, which also is and dorsal cutaneous nerves should
of the ulnar nerve in this area include known as the Duchenne sign, may be have normal latencies, and electro-
fractures and a thickened pisohamate observed secondary to lumbrical diagnostic studies should not detect
ligament.1,2 paralysis of the little and ring fingers. abnormality in proximally inner-
Zone 3 of the ulnar tunnel Intact extensor tendons may place vated muscles, such as the flexor
encompasses the superficial sensory the unopposed metacarpophalangeal carpi ulnaris and/or the FDP of the
branch of the ulnar nerve as it joint in hyperextension and the long little finger, which would suggest
courses palmar to the fascia of the flexors may place the proximal cubital tunnel syndrome. Similar to
hypothenar muscles. Pathology that interphalangeal joint and distal all peripheral compression neuropa-
is present within zone 3 of the ulnar interphalangeal joint in a flexed thies, paraspinal muscle findings
tunnel leads to sensory disturbances position. Attempted pinch between suggest cervical radiculopathy.
only. Interestingly, connections the thumb and the index finger may Standard radiographs, including a
between the ulnar and median lead to compensatory thumb inter- carpal tunnel view, may help identify
nerves are identified in zone 3 of the phalangeal flexion (Froment sign) fractures. Advanced imaging, such as
ulnar tunnel. Ulnar artery throm- and, occasionally, hyperextension of MRI or CT, can be obtained to fur-
bosis and ulnar artery aneurysm are the thumb metacarpophalangeal ther evaluate fractures or to assess
the most common causes of com- joint (Jeanne sign), which occur sec- space-occupying lesions within the
pression of the ulnar nerve in zone 3 ondary to paralysis of the adductor ulnar tunnel as well as vascular
of the ulnar tunnel.1,2 pollicis muscle. lesions of the ulnar artery.

January 2017, Vol 25, No 1 e3

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Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

Figure 2 joint. These nerves are subject to


compression at the proximal fore-
arm by various structures; however,
clinical presentation may vary.
Unlike patients with PIN syndrome,
patients with radial tunnel syndrome
(RTS) lack clinical findings of motor
weakness of the PIN-innervated
digital extensors.5 Patients with
RTS have no paresthesias in the
dorsoradial hand but, instead, have
characteristic pain at the area of
entrapment, which, typically, is
located at the lateral forearm distal to
the lateral epicondyle. Occasionally,
vague wrist pain also may be associ-
ated with RTS.6
The diagnosis of RTS, and even the
existence of the phenomenon, has
been a subject of controversy for
many years. The differential diagno-
sis for RTS includes lateral epi-
condylosis, an extensor carpi radialis
brevis (ECRB) tear, osteoarthritis
and/or synovitis of the radiocapitellar
Illustration showing the course of the posterior interosseous nerve through the joint, and posterior plica impinge-
radial tunnel. ECRB = extensor carpi radialis brevis, ECRL = extensor carpi ment. In contrast to carpal tunnel and
radialis longus, EDC = extensor digitorum communis, FCR = flexor carpi radialis cubital tunnel syndromes, the patho-
physiology of RTS is less straight-
forward. Many surgeons believe that
Treatment tunnel. All three zones of the ulnar radial nerve compression in patients
Patients with mild ulnar tunnel syn- tunnel should be addressed, focusing with RTS is not severe enough to
drome may be treated nonsurgically on compressive structures, such as cause radial sensory or motor dys-
with protective splinting and anti- the antebrachial fascia, the volar function, but that, instead, radial
inflammatory medications. In addi- carpal ligament, and the hypothenar nerve irritation is perceived as pain.6
tion, activity modification may help fibrous arch (overlying the deep
alleviate symptoms and prevent the motor branch). The ulnar artery
progression of neuropathy. Aspira- should be inspected, and any vascular Anatomy
tion of ganglion cysts, which has been lesions should be resected, with or Anatomically, the radial tunnel is
used to successfully manage ulnar without vessel reconstruction. approximately 5 cm long and begins
tunnel syndrome, should be per- as the radial nerve courses past the
formed with caution given the prox- Radial Tunnel Syndrome radiocapitellar joint. The roof of the
imity of the neurovascular structures. radial tunnel is formed by the bra-
Surgical treatment should be Located distal to the elbow, the radial chioradialis muscle. Medially, the
reserved for patients with more nerve is composed of the superficial radial tunnel is bounded by the biceps
severe ulnar tunnel syndrome, par- sensory branch, which provides tendon and the brachialis (Figure 2).
ticularly those who have space- innervation to the dorsoradial Laterally, the radial tunnel is
occupying lesions and those in hand, and the posterior interosseous bounded by the ECRB and the
whom nonsurgical treatment fails. nerve (PIN), which provides motor extensor carpi radialis longus muscles
The goals of the surgical management input to the supinator and extensors as well as the brachioradialis muscle.
of ulnar tunnel syndrome include the of the wrist and digits. The terminal Distally, the radial tunnel is classically
removal of compressive masses and PIN also provides sensory innerva- believed to end at the fibrous arch
complete decompression of the ulnar tion and proprioception to the wrist of the proximal edge of the supinator

e4 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Strohl, MD, and David S. Zelouf, MD

muscle, which is referred to as the Electrodiagnostic studies lack spe- (3) between the brachioradialis and
arcade of Frohse. Although constric- cific findings for RTS and often are the extensor carpi radialis longus.
tive, fibrous bands may exist at the normal in patients with RTS. Patients Regardless of the selected approach,
distal end of the supinator muscle, the with conductive slowing of the radial the goal is complete decompression of
supinator fascia is the most common nerve likely have associated motor the PIN within the radial tunnel. Areas
cause of compression of the radial findings, thereby precluding a diag- of focus for decompression include the
nerve. Other causes of compression nosis of RTS. However, abnormal arcade of Froshe, the leading edge of
of the radial nerve include prominent findings on electrodiagnostic studies the proximal ECRB, and the com-
recurrent radial vessels, a thickened may elucidate other causes of pain, pressive fascia of the distal supinator.
edge of the ECRB, and schwannoma- such as cervical radiculopathy. Occasionally, flattening or congestion
like swelling of the radial nerve.7 Sequential, selective lidocaine injec- that is located proximal to the site of
tions can help localize the source of compression may appear as swelling
pain and rule out other diagnoses, such or a pseudoneuroma.10
Clinical and Diagnostic as lateral epicondylosis. In addition, Reported outcomes of patients with
Findings the scratch collapse test, which local- RTS vary in the literature. Studies
On clinical examination, a patient izes the point of maximum compres- have suggested that patients with
sion in cubital tunnel syndrome, has isolated RTS and no concurrent
with RTS will report proximal, lat-
been reported to be a useful adjunct for compressive neuropathy or tendi-
eral forearm or elbow pain that often
worsens with rotational movements the diagnosis of RTS.9 nopathy have more favorable out-
comes compared with patients with
of the forearm. Pressure that is
isolated RTS who have associated
applied over a patient’s lateral fore- Treatment
arm approximately 3 to 5 cm distal conditions. Lee et al12 reported good
Nonsurgical treatment should be the outcomes in 86% of patients with
to the elbow, more specifically over
first-line treatment for patients with isolated RTS compared with 43% of
the supinator muscle, with the wrist
RTS. Nonsurgical treatment may patients with concomitant lateral
in full supination should reproduce
include the use of NSAIDs, wrist epicondylosis and 57% of patients
substantial pain. Pronation of the
splinting, activity modification, and with other compressive neuropa-
wrist during this maneuver, which
supervised physical therapy. Physical thies. Other studies have reported
moves the radial nerve away from
therapy may include nerve-gliding that workers’ compensation patients
the thumb-directed pressure, should
exercises, ultrasonographic therapy, with RTS have poorer outcomes
relieve the pain.6 Loh et al8 pro-
and heat/cold modalities, which also compared with non-workers’ com-
posed the Rule-of-Nine test, in
may be used to manage associated pensation patients with RTS.10,13
which the volar, proximal forearm
symptoms of lateral epicondylosis.
is divided into nine squares, to aid in
the diagnosis of RTS. The authors The use of counterforce or tennis
elbow braces should be avoided
Anterior Interosseous
reported that RTS pain is confined Nerve Syndrome and
because they apply external pressure
to squares one and two, which Pronator Syndrome
overlay the course of the radial on the radial nerve. Steroid injections
also may play a role in the non-
nerve at the most radial, proximal Anterior interosseous nerve (AIN)
surgical management of RTS.10,11
portions of the forearm.8 Other syndrome and pronator syndrome
provocative maneuvers that can be Surgical treatment may be consid-
are clinical entities of proximal
ered to decompress the radial nerve
used to aid in the diagnosis of RTS median neuropathy in the forearm
within the radial tunnel in patients in
include pain with resisted, active that have similar but uniquely dif-
whom nonsurgical treatment mea-
extension of the wrist or the long ferent presentations and etiologies.
sures fail to alleviate symptoms. The
finger. Slight weakness of the Practitioners must have a thorough
PIN can be accessed via multiple
extensors is believed to occur sec- understanding of the anatomy of the
approaches, including the posterior
ondary to pain rather than motor median nerve to distinguish AIN
and anterior approaches. Dorsal
nerve dysfunction. Often, these syndrome from pronator syndrome.
approaches include the following
provocative maneuvers that can be
intervals: (1) between the ECRB and
used to aid in the diagnosis of RTS Anatomy
the extensor digitorum communis,
are positive in patients with lateral
which also is known as the dorsal Typically, no branches of the median
epicondylosis, which is a closely
(Henry) approach; (2) transmuscular nerve occur proximal to the elbow;
associated differential diagnosis.
via splitting of the brachioradialis; and however, a variable branch to the

January 2017, Vol 25, No 1 e5

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Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

Figure 3

Illustrations showing the course of the median nerve with potential compression points. A, Illustration showing the median-
innervated muscles and potential sites of compression (yellow dots), which include the ligament of Struthers (if present) and the
pronator teres. B, Illustration showing the median nerve passing beneath the lacertus fibrosus of the bicipital aponeurosis, which
is another potential site of compression. C, Illustration showing the lacertus fibrosus and pronator teres divided and the median
nerve passing deep to the fibrous arch of the flexor digitorum superficialis, which is another potential site of compression.

pronator teres may be observed in brosus, which is an ulnarly directed (FPL), the FDP of the index and the
some patients (Figure 3). Distal to the extension of the bicipital aponeuro- long fingers, and the pronator
elbow, the median nerve remains sis, to the antebrachial fascia, which quadratus. The AIN has no cutane-
medial to the brachial artery and the also may have a deep component to ous sensory component, which is an
biceps brachii tendon as well as the pronator teres fascia. The median important characteristic to keep
anterior to the brachialis insertion. nerve continues between the heads of in mind in the localization of median
The median nerve provides motor the pronator teres before it dives nerve dysfunction. The palmar
innervation to the muscles of the deep to the fibrous arch of the FDS cutaneous branch of the median
superficial forearm compartment, muscle origin. At this point, the AIN nerve arises 6 to 7 cm proximal to
which include the pronator teres, the branches off, whereas the rest of the the wrist crease on the ulnar side of
palmaris longus, the flexor dig- median nerve continues deep to the the flexor carpi radialis and does not
itorum superficialis (FDS), and the FDS muscle toward the carpal tun- traverse through the carpal tunnel.
flexor carpi radialis. The median nel. The AIN provides motor inner- The distal AIN is believed to provide
nerve passes below the lacertus fi- vation to the flexor pollicis longus capsular sensory innervation to the

e6 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Adam B. Strohl, MD, and David S. Zelouf, MD

radiocarpal, intercarpal, carpometa- attributed to spontaneous AIN palsy ulnar nerve–innervated function of
carpal, and radioulnar joints.14 include viral illness (25% to 55%), thumb adduction against the index
immunizations (15%), preoperative finger. Variations in nerve innerva-
or peripartum periods (.14%), and tion, in which an anastomosis
Pronator Syndrome Versus strenuous exercise (8%).16 A pro- between the ulnar and median nerves
AIN Syndrome dromal phase of flu-like symptoms in the forearm may account for re-
First described by Seyffarth15 in may precede AIN syndrome, and tained motor function despite AIN
1951, pronator syndrome originally patients with AIN syndrome may involvement, are very rare. Although
referred to compression of the report vague forearm pain before similarly rare, intrinsic motor dys-
median nerve between the two heads weakness. Interestingly, Ochi et al17 function may be observed in patients
of the pronator teres through which reported multiple patterns of fas- with AIN palsy if innervation is
the median nerve passes in the cicular constrictions (eg, recessed, median nerve dominant. The FDP of
proximal forearm. Other potential recessed-bulging, rotation, rotation- the long finger also has been reported
sites of median nerve entrapment bulging) of the median nerve in to be innervated by the ulnar nerve.20
include the lacertus fibrosus; the FDS patients with spontaneous AIN Other variations in nerve innervation
aponeurotic arch; the aberrant radial palsy. Other studies also have rec- include AIN innervation to the FDP
artery; the variant muscles; and the ognized intraneural constrictions as muscles of all four fingers and AIN
ligament of Struthers, which is an a potential cause of median nerve innervation to the FDS.21
anomalous extension from the su- dysfunction.18 As mentioned earlier, the presence
pracondylar process of the humerus of sensory deficits rules out an iso-
to the medial epicondyle. In addition lated AIN lesion but supports a
to motor weakness, patients with Clinical and Diagnostic diagnosis of pronator syndrome or
pronator syndrome report paresthe- Findings similar entrapment of the median
sia, most notably of the palm, sec- On physical examination, patients nerve proximal to the point at which
ondary to involvement of the palmar with proximal median neuropathy the AIN branches off the median
cutaneous branch of the median may have motor weakness in the nerve. Palmar paresthesia may help
nerve. muscles that correspond with the surgeons distinguish carpal tunnel
Because the AIN lacks cutaneous branches of the AIN and/or compression from compression at
sensory fibers, patients with a true the median nerve distal to the area(s) more proximal locations. In addition,
AIN palsy, similar to patients with of pathology. Manual motor testing patients with proximal median neu-
pronator syndrome, will lack clini- should focus on the FPL (interpha- ropathy commonly report vague pain
cally relevant sensory deficits. Isolated langeal flexion of thumb), the FDP of in the proximal forearm. Provocative
palsy of the AIN often is spontaneous the index and long fingers (distal maneuvers that reproduce pain and/
in nature and usually is self-limiting. interphalangeal flexion of the respec- or paresthesia may help surgeons to
Iatrogenic injury of the AIN can occur tive digits), and the pronator quad- localize common sites of median
during surgical procedures in the ratus (wrist pronation with the elbow nerve compression. The lacertus fi-
proximal forearm, and direct injury of flexed). The latter may be difficult to brosus can be assessed via resisted
the AIN can occur secondary to pen- assess clinically in patients with a elbow flexion with the forearm in a
etrating trauma. Rarely, entrapment functioning pronator teres muscle. supinated position.22 The pronator
of the AIN is attributed to an acces- Patients with proximal median neu- teres can be assessed via resisted
sory FPL (ie, the Gantzer muscle). If ropathy will be unable to make the forearm pronation. The FDS arch
not related to external forces, such as OK sign, which is known as the Kiloh- can be assessed via resisted finger
trauma or compression, the etiology Nevin sign, whereby the tips of the flexion, particularly the proximal
and pathophysiology of a spontane- thumb and the index finger are interphalangeal joint of the long
ous AIN palsy or AIN syndrome are brought together to form a circle finger. A positive Tinel sign and a
not entirely known; however, spon- shape.16,19 The inability of a patient positive scratch collapse test may be
taneous AIN palsy or AIN syndrome to grip a piece of paper with the tips observed in patients with proximal
is believed to be the result of an of the index finger and the thumb is median neuropathy.23
inflammatory neuritis. AIN syndrome another indication of proximal Practitioners must consider the dif-
often is associated with Parsonage- median neuropathy. To compensate ferential diagnoses of proximal median
Turner syndrome, which is a brachial for this inability, patients with neuropathy, such as Parsonage-Turner
plexus neuritis that also is known proximal median neuropathy will use neuritis of the brachial plexus. Patients
as neuralgic amyotrophy. Triggers a key pinch maneuver, relying on with partial lesions of the lateral cord

January 2017, Vol 25, No 1 e7

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

Figure 4

Images showing targeted surgical epineurotomy of a lesion of the median nerve at the level of the upper arm. Illustration (A)
and high-resolution T2-weighted magnetic resonance image (B) demonstrating localization of the lesion 9.2 cm proximal to
the humeroradial joint space (red circle in panel A). C, Intraoperative photograph taken before epineurotomy showing a
subtle increase in nerve caliber. D, Intraoperative photograph taken after epineurotomy showing neurolysis and subsequent
detorsion of the anterior interosseous nerve (asterisk), which was observed within the median nerve. (Adapted with
permission from Pham M, Bäumer P, Meinck HM, et al: Anterior interosseous nerve syndrome: Fascicular motor lesions of
medial nerve trunk. Neurology 2014;82[7]:598-606.)

may have clinical findings similar to may be observed on MRI.18,24 Elec- rest, activity modification, rotational
those of patients with proximal trodiagnostic studies may reveal immobilization, forearm flexor mus-
median neuropathy. Mannerfelt syn- sharp waves, fibrillations, and cle stretching, nerve-gliding exer-
drome, which refers to attritional abnormal latencies in the affected cises, and the use of NSAIDs. Surgical
rupture of the FPL secondary to a car- muscles of patients with AIN syn- treatment may be considered in
pal osteophyte and is observed in drome. Similar findings as well as patients in whom a 3- to 6-month
patients with rheumatoid arthritis, slowing of conduction across the trial of nonsurgical treatment fails to
may account for spontaneous loss of elbow may be observed in patients alleviate symptoms. The goal of sur-
thumb interphalangeal flexion. Unlike with pronator syndrome; however, gical decompression is to relieve all
Mannerfelt syndrome, however, the the electrodiagnostic study findings potential sites of entrapment along
tenodesis effect of the thumb inter- of patients with pronator syndrome the median nerve. In general, surgical
phalangeal joint is retained in patients may be normal or mimic those of decompression has been reported to
with AIN palsy. Although uncommon, patients with carpal tunnel syn- be beneficial in patients with pro-
patients may have congenital absence drome.22,25 Moreover, positive find- nator syndrome.16,22,26,27
of the FDP or the FPL, accounting for ings on electrodiagnostic studies/
motor dysfunction, without any nerve conduction studies may suggest
median neuropathy. other sites of compression or disease, Management of AIN
In general, traditional imaging particularly in patients with brachial Syndrome
studies do not aid in the diagnosis of plexus involvement. A more prolonged period of obser-
proximal median neuropathy, except vation is warranted for patients in
in patients with space-occupying whom spontaneous AIN palsy of the
lesions or in patients in whom the Management of Pronator neuritic variety is suspected.
rare supracondylar process suggests Syndrome Patients in whom AIN syndrome is
the presence of the ligament of Nonsurgical treatment is recom- diagnosed early may be initially
Struthers. If present, edema of AIN- mended as the initial treatment for treated with high doses of cortico-
innervated muscles or intraneural patients with pronator syndrome. steroids and antiviral medications,
abnormalities of the AIN occasionally Nonsurgical treatment may include such as acyclovir.28 Spontaneous

e8 Journal of the American Academy of Orthopaedic Surgeons

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Adam B. Strohl, MD, and David S. Zelouf, MD

recovery of AIN function can occur; via a physical examination and/or differ from that of patients with AIN
however, patients may require up to electrodiagnostic studies. The unique syndrome.
1 year of observation. Despite anatomy of the ulnar tunnel allows
lengthy expectant treatment, some surgeons to further localize pathol-
patients may not recover AIN func- ogy to one or more of the three zones References
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January 2017, Vol 25, No 1 e9

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Ulnar Tunnel Syndrome, Radial Tunnel Syndrome, Anterior Interosseous Nerve Syndrome, and Pronator Syndrome

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