ULNAR NERVE ULNAR NERVE INJURYINJURY

Dr. Diyar A. Salih

Plastic Surgery Resident

KURDISTAN, SLEMANI

Main branch of the medial cord

Axilla: post (bet. Axillary A. & V)

Arm: medial to brachial A.

Elbow: post. to medial epicondyle (Cubital tunnel) bet. FCU heads.

Forearm: along medial side of FDP, adjacent to ulnar A.Wrist: Guyon’s tunnel, adjacent to pisiform, deep to ulnar art.

Superficial sensory branch

Brachial A.

Deep motor branch

SensationSensation

Forearm:Forearm:1.1. FCU.FCU.2.2. FDP (ring & little finger).FDP (ring & little finger).

HandHand::1.1. Hypothenar M:Hypothenar M:

• Abductor digiti minimi M.Abductor digiti minimi M.• Flexor digiti minimi.Flexor digiti minimi.• Oppenens digiti minimi.Oppenens digiti minimi.

2.2. Seven interosseous M. (4 dorsal & 3 palmar).Seven interosseous M. (4 dorsal & 3 palmar).3.3. Adductor pollicis.Adductor pollicis.4.4. Ring & little finger lumbricals.Ring & little finger lumbricals.5.5. Flexor pollicis brevis.Flexor pollicis brevis.

MotorMotor

ForearmForearm

FDP (ring & FDP (ring & little finger)little finger)

4 dorsal & 3 palmar interosseous4 dorsal & 3 palmar interosseous

Hypothenar musclesHypothenar muscles

Lumbricals (ring & little finger)Lumbricals (ring & little finger)

Adductor pollicisAdductor pollicis

Flexor pollicis brevisFlexor pollicis brevis

35% overlap by Median nerve.

1.1. Neuropraxia.Neuropraxia.

2.2. Axonotmesis.Axonotmesis.

3.3. Neurotmesis.Neurotmesis.

Types of injuriesTypes of injuries

UpperUpper Lower Lower

CLASSIFICATIONCLASSIFICATION

NeckNeck

Brachial plexusBrachial plexus

At ElbowAt Elbow

Below elbowBelow elbow

WristWrist

Causes

1. ACUTE1. ACUTE• Trauma (fracture)Trauma (fracture)• Wrong postureWrong posture• SurgerySurgery• Electrical burnElectrical burn

2. CHRONIC2. CHRONIC• Tight nerve passagesTight nerve passages• TumorsTumors

CausesCauses

Presentations

1.1. PainPain2.2. Sensation lossSensation loss3.3. Motion lossMotion loss4.4. Power lossPower loss5.5. Reflexes lossReflexes loss6.6. WastingWasting7.7. Trophic changes Trophic changes (skin,sc,neurovascular,bones,muscles)(skin,sc,neurovascular,bones,muscles)

8.8. ContracturesContractures

PresentationsPresentations

• Clinical examinationClinical examination

• X-RAYX-RAY

• EMG (electromyography).EMG (electromyography).

• NCS (nerve conduction studies).NCS (nerve conduction studies).

• MRIMRI

DiagnosisDiagnosis

• F:\Ulnar nerve exam.flv

Ulnar nerve examinationUlnar nerve examination

Low ulnar nerve palsyLow ulnar nerve palsy

Claw deformityClaw deformity

Lumbrical muscles palsy

Adductor pollicis

1st dorsal interosseous

CompensationCompensation

FPL (stabilize thumb)

EPL (adduct thumb)Froment’s sign

Froment’s signFroment’s sign

AtrophyAtrophy

NormalNormal

Wartenburg’s signWartenburg’s sign

Inability to Inability to adduct little adduct little finger against finger against EDM pull.EDM pull.

Little finger ulnar deviation

Earle’s signEarle’s sign

• Inability to abduct the middle finger to cross over the index finger dorsally.

High ulnar nerve palsyHigh ulnar nerve palsy

• Less clawing.

• Reconstruction can improve function but not total improvement.

Treatment of injuriesTreatment of injuries

• Direct repair (tension free)

Nerve graft

• If > 1 cm defect or repaired under tension.

Nerve conduit

Tendon transferTendon transfer

IncisionsIncisions

Upper arm: Medial incision

At the elbow: over cubital tunnel

Forearm: along ulnar mid-axial line, splitting FCU two heads.

At the wrist: at the pisiform, extending distally parallel to the skin crease at the base of thenar eminence

Low ulnar nerve injury repair

• F:\Low ulnar nerve injury.flv

Other measures (alone or with Other measures (alone or with Tendon transfer)Tendon transfer)

• Prevention of MCP joint hyperextension:

1. MCP joint arthrodesis.

2. MCP joint capsulodesis.

3. Bone block on the dorsum of the MCP joint head.

Guyon’s tunnel syndromeGuyon’s tunnel syndrome(Handlebar palsy)(Handlebar palsy)

Palmar sensory branchPalmar sensory branch

Motor branchMotor branch

Ulnar A.Ulnar A.

Intrinsic M.Intrinsic M.

Hypothenar M.Hypothenar M.

GTS causesGTS causes

Direct traumaDirect trauma

Ulnar A. Ulnar A. aneurysmaneurysm

Sensation lossSensation loss

Not dorsal surfacesNot dorsal surfaces:

Ulnar N. branch 4-5 cm above Guyon’s canal (subcutaneously, distal to ulnar styloid process).

GTSGTS treatment (surgical treatment (surgical decompression)decompression)

Pisohamate ligament

Cubital tunnel syndromeCubital tunnel syndrome

Post. to MEC

Cubital tunnel syndromeCubital tunnel syndrome

Strong fibrous Strong fibrous conduitconduit

•True nerve compression.

•Nerve adhesion.

•Prevent nerve gliding.

•Stretch ischemiaischemia.

•Impairs nerve conduction

Sensation lossSensation loss

Dorsal surfacesDorsal surfaces

Cubital tunnel syndromeCubital tunnel syndrome

• Acute flexion of elbow for 30 min30 min accentuates the sensory symptoms.

• cubital tunnel.flv

• F:\Tinel test & Froment test.flv

Tinel sign & Froment testTinel sign & Froment test

• Early cases: static elbow extension splint.

TreatmentTreatment

• Chronic cases: Ulnar nerve transposition anterior to the elbow axis of rotation.

TreatmentTreatment

Incision over the cubital tunnel

Posterior to MECPosterior to MEC

Anterior to MECAnterior to MEC

Medial epicondyle

Ulnar nerve anterior Ulnar nerve anterior transpositiontransposition

• F:\Anterior transposition of the ulnar nerve.flv