Download - Ulnar nerve seminar
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ULNAR NERVE ANATOMY & LESIONS
Dr SUBHAKANTA MOHAPATRA IPGME&R,Kolkata,INDIA
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ANATOMY OF ULNAR NERVE
A branch of medial cord of the brachial plexus (C8 & T1). Additional fibers from C7.
Axilla : between axillary vein & artery on a deeper plane.
runs downwards with proximal part of brachial artery.
at middle of humerus pierces medial intermuscular septum.
descends behind medial epicondyle.
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Forearm : enters by passing between two heads of FCU.
lies on medial part of FDP. accompanied by ulnar artery in lower 2/3 rd.
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After it travels down the ulna, the ulnar nerve enters the palm of the hand.
At the wrist, the ulnar nerve and artery lie in a canal formed by the pisiform bone medially and the hook of hamate laterally (Guyon’s canal). In this region the nerve divides into two branches. The Superficial sensory Branch The Deep Motor Branch
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The superficial branch is generally considered a
sensory branch which supplies to distal palm, fifth and half of the fourth digit.
It also supplies palmaris brevis, a thin muscle beneath the skin which cannot be studied electromyographically.
The deep branch gives off motor innervation to the hand muscles.
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WRIST TO (MEDIAL) HAND
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BRANCHES:Muscular FCU, FDP (medial half), palmaris brevis,
hypothenar muscles, medial 2 lumbricals, all palmar & dorsal interossei , thumb intrinsics medial to FPL {adductor pollicis , flexor pollicis brevis (deep head)}
Cutaneous palmar cutaneous supply to hypothenar
eminence Dorsal cutaneous supply dorsum of hand (medial
part), dorsum of little finger , part of dorsum of ring finger.
Digital forms the main sensory branches to the ring and
little fingerVascular & ArticularNo branches above elbow
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DORSAL CUTANEOUS BRANCH
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PALMAR CUTANEOUS BRANCH
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ETIOLOGY OF ULNAR NERVE PALSY Injuries
Primary neurologic diseases
Leprosy
Compression neuropathies
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CHARACTERISTICS OF PALSY
INJURIES- proximal : motor - all muscles affected.
sensory - palmar & dorsal aspects of medial third of hand, whole of little finger & ulnar half of ring finger.
distal : motor - only intrinsic muscles involved
sensory - medial third of palm, palmar & dorsal (distal to PIP joint) aspects of little & ulnar half of ring finger
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Injury to terminal deep branch in palm Motor: spares hypothenar muscle Sensory: sensation in ring & little finger preserved.Compression in distal portion of guyon’s canal Sensation (ring & little) intact Loss of function of all ulnar innervated intrinsic &
hypothenar muscles.In proximal portion of guyon’s canal Preserved sensation over dorsal ulnar aspect of
hand. (by dorsal branch of ulnar nerve which arises in
distal forearm & perforates the deep fascia 6-8 cm proximal to wrist)
LEPROSY sensory changes precede motor paralysis POLIOMYELITIS LMN type flaccid paralysis
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CLINICAL FEATURES Claw deformity . more apparent during use than at rest more in mobile & lax fingers When gripping an object , object is pushed out of
the palm (in order of DIP, PIP, MP joint flexion) Wasting of hypothenar region & shallow mid-
palmar receptacle. Longitudinal palmar furrows between long flexor
tendons. Wasting of dorsum, with shallow concavities in
inter-metacarpal spaces & thumb web. Shape of hand - Isosceles triangle with base
distally. Loss of sensation is not as devastating as
compared to median nerve palsy.
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ASSESSMENT OF MOTOR FUNCTION
Duchenne’s sign : claw deformity of fingers ; ulnar paradox
Bouvier’s maneuver: active extension of middle & distal phalanges on passive dorsal pressure on proximal phalanx.
Andre-Thomas sign : increased clawing on attempted extension of fingers by flexing wrist.
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Pitres-Testut sign : inability to abduct extended middle finger to radial & ulnar sides(2nd &3rd DI)
Cross your fingers test: Inability to cross the middle finger dorsally over the index finger or vise versa.(1st PI & 2nd DI)
Asynchronous finger flexion
Fingers curl or roll into palm & inefficient grasp
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Jeanne’s sign : Hyperextension of MP joint of thumb during key pinch(to compensate thumb adductors)
Masse’s sign : flattened metacarpal arch & loss of hypothenar elevation
Froment’s sign : hyperflexion of IP jt of thumb while attempting a lateral pinch(indicates paralysis of adductor pollicis, 1st DI , with replacement of pinch function by FPL)
Bunnell’s O sign : hyper extension of MP jt & hyper flexion of IP jt
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Wartenberg’s sign: inability to adduct extended little finger to touch the extended ring finger(loss of function of 3rd PI & unopposed abduction of EDM).
Pollock’s sign : inability to flex DIP jt of ring & little fingers while making a fist
Partial loss of wrist flexion with inability to perform power grip : Bowden & Napier
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ASSESSMENT OF SENSORY FUNCTION Static two point discrimination test (6 mm is
normal) for tactile perception. Dynamic two point discrimination test (3 mm
is normal). Semmes – Weinstein monofilament (of
various diameters) for pressure perception. Tune fork 250 cps (pacinian corpuscles) , 30
cps (meissner corpuscles) for vibration perception.
Cold heat test (10 degree, 40 degree water) for free nerve endings of the skin.
Ten test (0- 10 ranking of quality of sensation)
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ANOMALOUS INNERVATION PATTERNS May contain axons from C7 & T2 roots. Motor axons to FCU may arise from C7 root. FDP innervation may be all ulnar/ all median/
combined. Martin-Gruber anomalous motor connections in
proximal forearm between median(AIN) & ulnar nerve.
Riche-Cannieu anomalous connections in hand, resulting in all lumbricals supplied by median nerve & no clawing even after complete ulnar nerve injury.
Ring finger lumbrical dual supply in 50%. 1st dorsal interosseous supplied by median nerve
in 10% & radial nerve in 1%. Area supplied by dorsal sensory branch may be
innervated by superficial branch of radial nerve.
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MANAGEMENTACUTE INJURIES
Closed
Localize clinically
Follow-up with EMG & NCS
Recovery No recovery
Observe surgery
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Open
Surgery
Nerve in continuity not in continuity
As closed injury sharp crush
repairapproxi
mate
Graft
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GOALS OF SURGERY To improve function rather than restore normal
function To improve thumb pinch To correct finger clawing To restore the normal pattern of finger flexion To restore ring & little finger DIP joint flexion
in high ulnar nerve palsy. To restore sensation to ring & little
finger(possible but not attempted) To restore the concavity of the transverse
metacarpal arch & correct little finger abduction deformity.
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PRINCIPLES OF NERVE REPAIR Contused or attenuated nerve usually left
intact. Resection of unhealthy fascicles in nerve ends
should not be compromised to preserve length. Tension free repair with good alignment of
fascicles Mobilisation of 1-2 cm to allow repair Trimming of fascicles & loose epineural sutures
to prevent buckle Nerve grafting is preferable to avoid tension Ends are tagged by prolene 6-0 if staged repair
is planned.
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INTERNAL TOPOGRAPHY At mid forearm - Three distinct fascicular group(dorsal sensory,
volar sensory,motor group). Motor group positioned between ulnar dorsal
sensory & radial volar sensory group. Dorsal sensory group separates from the main
nerve approx 8 cm proximal to wrist. Motor group remains ulnar to the volar sensory
group until the guyon’s canal, then it passes dorsally & radially to become the deep motor branch to the intrinsic muscles.
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ULNAR NERVE TOPOGRAPHY
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LATE DEFORMITIES & DEFICIENCIES
Claw finger: static techniques - Only if passive flexion of MP joint results in
extension of PIP.• Zancolli’s palmar capsulodesis of MCP
joint• Omer’s modification of Zancolli technique• Tenodesis- Parkes(PL & Plantaris)
Fowler (tendon graft sutured to ER)
Riordan( ECRL & ECU )
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DYNAMIC TENDON TRANSFERS
Stiles & Bunnell – Both slips of all the superficialis tendon transfered to both radial & ulnar lateral bands of extensor mechanism.
Modified Stiles & Bunnell- FDS of middle finger Fowler’s technique – EIP & EDM transfer Modified Fowler – EIP transfer (2 slips) Dorsal route transfer of ECRL/ECRB Flexor route transfer of ECRL (through the
carpal tunnel) PL 4 tail transfer
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Ulnar deviation of little finger:
• EDM transfer
Flexion-adduction of thumb :
• Littler-Ring finger superficialis• Smith-ECRB as motor
Z-thumb:
• Split FPL-EPL transfer tenodesis• MP & IP jt arthrodesis
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Index finger abduction:
• Bunnell-EI• Bruner- EPB• Neviaser- accessory APL elongated by tendon
graft
High ulnar palsy-• tenorrhaphy• FCR to FCU
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Restoration of transverse metacarpal arch Bunnell’s tendon T operation
A detached FDS attached to middle of a free tendon graft, one end of graft inserted to base of proximal phalanx, other to little finger metacarpal neck.
Restoration of sensibility:Lewis’ digital nerve transfer
Wasted intermetacarpal spaces:Dermal graft placement
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MANAGEMENT IN LEPROSY
• MDT • Surgery- acute- decompression in severe pain abscess drainage in neuritis quiescent- reconstructions after stopping
steroids.
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Management in case of poliomyelitis Surgery delayed till child is 5 years of age
Cubital tunnel syndrome: Early- conservative for 3 months Static elbow extension splint Simple unroofing of cubital tunnel is not
recommended.Submuscular anterior transposition(so
that elbow flexion relaxes rather stretches the nerve)
& avoiding injury to the medial antebrachial cutaneous nerve to forearm.
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Treatment of Guyon’s tunnel syndrome:
Decompression by incising along radial border of FCU
(avoiding injury to dorsal branch of ulnar nerve which does not pass through this canal)
Dissecting from distal to proximal along ulnar artery branches to ring & small fingers, progressively unroofing & deroofing the guyon canal is more safer.
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THANK YOU