ulnar nerve reconstruction ppt
DESCRIPTION
Powerpoint presentation of ulnar nerve reconstruction, types of ulnar nerve injury, cubital tunnel syndrome, & Guyon's tunnel syndrome. By Dr. Diyar Abdulwahid Salih, plastic surgery resident.TRANSCRIPT
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