Ulnar nerve Palsy and tendon transfer

1. Ulnar nerve Palsy and
tendon transfer
Dr Muhammad Anwar khilji
Pgr Plastic surgery BMCH

2. Ulnar nerve: introduction
● Spinal roots: C8-T1.
● Motor functions: Innervates the muscles of the hand (apart from the
thenar muscles and two lateral lumbricals), flexor carpi ulnaris and medial
half of flexor digitorum profundus.
● Sensory functions: Innervates the anterior and posterior surfaces of the
medial one and half fingers, and the associated palm area.

3. Anatomy of ulnar nerve:
● In the arm, the ulnar nerve lies anterior to the triceps muscle. It
travels through the cubital tunnel at the elbow, and then passes
between the two heads of the FCU, which it innervates.
● As it courses distally, it lies on the volar aspect of the FDP, and
innervates the FDP to the small and ring fingers.
● Approximately 7 cm proximal to the wrist, it gives off a dorsal
sensory branch, which provides sensibility to the ulnar aspect of the
wrist
● At the wrist, the main nerve passes into Guyon's canal along with
the ulnar artery. Within Guyon's canal it divides into deep and
superficial branches.

4. ● The superficial branch gives sensibility to the small finger and the ulnar half of the
ring finger.
● The deep motor branch innervates the hypothenar muscles, the ulnar two
lumbricals, the interossei, the adductor pollicis, and the deep head of the flexor
pollicis brevis (FPB).The most distal motor branch innervates the first dorsal
interosseous.
● Anomalous ulnar nerve anatomy is common in the forearm and hand.
○ The Martin-Gruber connection is seen when the median nerve contributes
motor fibers to the ulnar nerve in the forearm, resulting in median nerve
innervation of intrinsic hand muscles. This anomaly can result in intact intrinsic
hand function following proximal ulnar nerve injury.
○ The Riche-Cannieu anomaly is a connection between the motor branch of
the ulnar nerve and the recurrent motor branch of the median nerve in the
hand, with ulnar to median innervation.This anomaly can result in preservation
of thenar function after median nerve injury at the wrist or more proximally.

5. Sensory Functions
There are three branches of the ulnar nerve that are
responsible for its cutaneous innervation.
● Two of these branches arise in the forearm, and travel
into the hand:
● Palmar cutaneous branch: Innervates the skin of the
medial half of the palm.
● Dorsal cutaneous branch: Innervates the skin of the
medial one and a half fingers, and the associated
palm
area.
● The last branch arises in the hand itself.
● Superficial branch - Innervates the palmar surface of
the medial one and a half fingers

6. Motor Functions
● The Anterior Forearm
○ In the anterior forearm, the muscular branch of the ulnar nerve supplies two muscles:
○ Flexor carpi ulnaris - Flexes and adducts the hand at the wrist.
○ Flexor digitorum profundus (medial half) - Flexes the fingers.
○ The remaining muscles in the anterior forearm are innervated by the median nerve.
● The Hand
○ The majority of the intrinsic hand muscles are innervated by the deep branch of the ulnar nerve.
○ The hypothenar muscles (a group of muscles associated with the little finger) are
innervated by the ulnar nerve. It also innervates some other muscles of the hand
Midial two lumbricals
○ Adductor pollicis
○ Interossei of the hand

7. Clinical findings:
● Ulnar nerve palsy is a more devastating injury than radial nerve palsy.
● In both high and low ulnar nerve palsy, key pinch is lost because of absent adductor pollicis and first
dorsal interosseous muscle function.
● Clawing occurs as a result of paralysis of the interosseous muscles in the presence of functioning
extrinsic finger flexors. Clawing causes a loss of active IPJ extension and MCPJ flexion, which
prevents the patient from cupping the hand around objects.
● In addition, integration of MCPJ and IPJ flexion is lost.
● In the normal hand, integrated finger flexion begins at the MCPJ powered by the intrinsic muscles,
followed by flexion of all three finger joints powered by the FDP and FDS, folding the fingers
smoothly into the palm.
● In ulnar nerve palsy, MCPJ flexion is not initiated by the intrinsic muscles, and finger flexion begins
at the IPJ's, followed by late MCPJ flexion. This results in a rolling motion of the fingers, which
prematurely closes them before they reach the palm, making it difficult to grasp objects.
● In addition to the above findings, high ulnar nerve palsy results in loss of the FCU and FDP to the
ring and little fingers. This causes diminished grip strength as well as the loss of ulnar deviation with
wrist flexion.
● A small benefit of diminished FDP function is that clawing is less severe than in low ulnar nerve
palsy, in which the FDP to the ring and small fingers remains intact.
● Unlike radial nerve palsy, the sensory deficit in ulnar nerve palsy is clinically disabling.
● Protective sensation in the ulnar nerve distribution is important for preventing injury when the hand is
placed in resting positions.

8. Bouvier's test:
● Bouvier's test involves passively correcting the
MCPJ hyperextension, and checking for improved
IPJ extension.
● If the patient's flexed IPJ posture improves, then
Bouvier's test is positive, and the clawing is defined
as simple.
● If the IPJ's remain flexed even after passive
correction of the MCJP hyperextension, then
Bouvier's test is negative, and the clawing is
defined as complex.

9. 2. Flexor carpi ulnaris (C7-T1)
assessment, wrist flexion
○ Have the patient flex his or her
wrist against resistance in an
ulnar direction, which is the
primary action of this muscle.

10. 3. Flexor digitorum profundus (C8,
T1) assessment:
○ This muscle is tested in the same
fashion as its median innervated half, except
to evaluate the
ulnar nerve contribution
▸ one uses the fifth digit. To test,
immobilize the proximal interphalangeal
joint while the patient flexes the distal
interphalangeal joint against resistance.

11. 4. Palmaris brevis (C8, T1)
assessment:
○ Test this muscle by having the
patient forcibly abduct the fifth
digit and then instructing them to
"contract" the hypothenar
eminence simultaneously.
○ Skin corrugation should occur

12. 5. Abductor digiti minimi (C8, T1) assessment:
○ This muscle is tested when the patient
abducts the fifth digit against resistance.
○ One should keep in mind that this muscle
is delicate, the patient's resistance is easily
overcome even with normal strength.

13. 6. Flexor digiti minimi (C8, T1)
assessment
○ This muscle is tested by immobilizing the
interphalangeal joints of the fifth digit and
having the patient flex the metacarpal-
phalangeal (knuckle) joint against resistance.
○ One cannot isolate this muscle's function,
however, because flexion of the fifth digit's
metacarpal-phalangeal joint is performed by
not only the flexor digiti minimi, but also by
the fourth lumbrical and the interossei.

14. 7. Opponens digiti minimi (C8, T1)
assessment:
○ Have the patient hold the volar pads
of the distal thumb and fifth digit
together. While the patient maintains
this position, try to force the proximal
digit and distal fifth metacarpal away
from the thumb.

15. 8. Third and fourth lumbrical (C8, T1)
assessment:
○ Immobilize the metacarpalphalangeal
joints of these two fingers in
hyperextension and then test extension of
the proximal interphalangeal joints against
resistance.

16. 9. First dorsal interosseous (C8, T1)
assessment
○ On a flat surface, the patient ‣
abducts his or her index finger
against resistance.
○ Contraction or atrophy of the first
dorsal nterosseous muscle can be
observed and palpated on the
dorsum of the hand.

17. 9. Second palmar interosseous (C8,
T1) assessment
● On a flat surface, the patient adducts the
index finger against resistance.

18. 10. Adductor pollicis assessment
○ Ask the patient to grasp a book
between extended thumb and index
finger.
○ If the ulnar nerve is intact, he will
grasp with extended thumb taking full
advantage of adductor pollicis and
first palmar interossei
○ In ulnar nerve injury, the patient will
hold the book by flexing the thumb
with the help of flexor pollicis
longus.(FROMENT'S SIGN)

19. 11. Test for palmar interossei: Card
Test
○ ▸ A card inserted between two extended
fingers and the patient is asked to grasp
it between the fingers while the clinician
gently tries to pull the card.

20. Claw hand Definition
● Flattening of transverse
metacarpal arch and
longitudinal arches
● Hyperextension of MCP joints
● Flexion of PIP and DIP joints

21. CLINICAL SIGNS OF ULNAR NERVE
1. Duchenne's sign: Hyperextension at MCP joints &
flexion at IP joint
1. Pitres-Testut sign: Inability to actively move long
fingers in radial and ulnar deviation with palm placed
flat
2. Cross your fingers test: Inability to cross middle
finger dorsally over index finger, or index over middle
finger
3. Masse's sign: Flattened metacarpal arch and loss
of hypothenar elevation
4. Jeanne's sign: Hyperextension of MP joint of thumb
during key pinch or gross grip
5. Bunnell's O sign: Combined hyperextension at MP
joint and hyperflexion of IP joint (noticed when
patient makes a pulp to pulp pinch with thumb and
index finger)

22. 8. Froment's sign: Thumb IP joint flexion while
attempting to perform lateral pinch
9. WARTENBERG SIGN
In ulnar nerve compression the third volar
interosseous muscle is weak and allows the
extensor digiti minimi to abduct the fifth finger
during extension causing finger catching while
placing the affected hand in pocket.
10. Pollock's sign: Inability to flex distal
phalanges of ring and little fingers
> Partial loss of wrist flexion may occur because of
paralysis of FCU
> Weakness of ulnar sidegrip

23. Intrinsic Plus Hand
● Caused by muscles imbalance
between spastic intrinsics
(interosseoi and lumbricals) weak
extrinsics (FDS, FDP, EDC)
● Characterized by MCP flexion PIP &
DIP extension

24. Intrinsic Minus Hand (Claw
Hand)
● Caused by imbalance between
strong extrinsics and deficient
intrinsics Characterized by MCP
hyperextension
● PIP & DIP flexion

25. Claw thumb in Ulnar palsy
● CMC joint affected by paralysis of adductor pollicis, FPB, and first dorsal
interosseous
● MP and IP joints of thumb under control of extrinsic flexors and extensors,
with proximal phalanx behaving like intercalated bone.
● MP joint will go into hyperextension and IP joint into flexion because of the
greater extensor moment at the MP joint and the lesser extensor moment at
the IP joint, respectively.
● "Z"-thumb deformity

26. Patho-anatomy of deformity
● Paralysis of interossei and lumbricals
● Unopposed MCP joint extension & IP joint flexion by digital extensors &
flexors
● Without stabilization of MCP joints in neutral/slight flexed position, long
extensor function "blocked" at MP joint by diversion of this tension to
sagittal band, producing hyperextension and effectively blocking the
extensor's ability to extend PIP joint.+
● Middle and distal phalanges collapse into flexion
● Normal cascade of digital extension disrupted, in that during any attempt to
actively open finger, MP joint extends first and will extend more than the
PIP joint,
● Normal sequence of digital closure also reversed, in that IP joint flexion
precedes MP joint flexion
● Independence of MP and IP joint motion lost

27. Types of claw hand
● Partial: due to paralysis of ULNAR nerve; clawing is seen in little and ring
fingers only
○ a) Low Ulnar nerve palsy
○ b) High Ulnar nerve palsy
● Total: due to paralysis of both ULNAR & MEDIAN nerves; clawing seen in
all 5 fingers
○ a) Low Mixed Ulnar & Median nerve palsy
○ b) High Mixed Ulnar & Median nerve palsy

30. COMBINED MEDIAN & ULNAR NERVE PALSY
LOW:
● Complete anaesthesia of palm and loss of function of all intrinsics of
both finger and thumb
HIGH:
● Entire hand is anaesthetic except for its dorsal surface and only
muscles available for transfer are those innervated by radial
muscles-
Brachioradialis,ECRL, ECU, EIP.

31. Goals of tendon transfer in ulnar nerve pasly:
The primary goals of tendon transfer procedures for ulnar
nerve palsy are restoration of
1. Small and ring finger DIPJ flexion (in cases of high ulnar
nerve palsy),
2. Restoration of key pinch,
3. Correction of clawing,
4. Restoration of transverse metacarpal arch
5. Restoration of little finger adduction

32. 1. Restoring small and ring finger
DIP joint flexion:
○ Restoration of small and ring finger
DIPJ flexion can be achieved by
adjacent suturing of their respective
FDP tendons to the functioning
middle finger FDP.
○ The index finger FDP should not be
included in the adjacent suturing in
order to preserve its independent
functioning

33. 2. Restoring key pinch:
● In the normal hand, key pinch is the result of combined first
dorsal interosseous and adductor pollicis function
○ Thumb adduction
○ Index abduction

34. A.Thumb Adduction
● Both the ECRB (Smith) and brachioradialis
(Boyes)are strong donor MTU's that can be used
to restore key pinch, and that do not leave a
functional deficit when harvested.
● They must be lengthened by tendon grafts and
then passed between the 2nd and 3rd
metacarpals into the palm. Here they are routed
towards the thumb, using the 2nd metacarpal as a
pulley, and inserted on the adductor pollicis
insertion.
● The direction change that occurs at the 2nd
metacarpal pulley orients the tendon along the
original direction of pull of the adductor pollicis.

35. B. RESTORATION OF INDEX FINGER ABDUCTION
Slip of APL (Neviaser) transfer - Technique
● APL exposed & one slip that inserts onto thumb MC
base identified and preserved
● Another accessory slip detached
● Subcutaneous tunnel from radial styloid to an incision
on radial side of PPX index

37. 3. Correction of clawing
○ This requires correction of MCPJ hyperextension, the problem that initiates
clawing.
○ Procedures can be categorized as
■ STATIC
■ DYNAMIC
If Bouvier's test is positive, static procedures may be successful.

38. STATIC PROCEDURE
1. Fasciodermodesis
2. A1 pulley release
3. Tenodesis
4. Capsulodesis
5. Arthrodesis

39. Fasciodermodesi
s
(Zancolli)
● Excision of 2 cms
of
palmar skin at MP joint
level with shortening of
pretendinous band of
palmar aponeurosis

40. 2.Flexor pulley
advancement
(Bunnell)
• A1 pulley system split about
1.5 to 2.5 cm upto mid PPx
Flexor tendons are then
bowstringed to bring about
Flexion at MP joint

41. 3.Zancolli
capsulodesis
Capsule is cut longitudinally
from both sides and
approximated proximally
towards metacarpal head

42. 4. TENODESIS
○ Dynamic tenodesis can be performed, as
popularized by Fowler and Tsuge.
■ A tendon graft is looped through the
extensor retinaculum at the wrist.
The two free ends of the tendon
graft are passed through the
intermetacarpal spaces into the
palm, along the course of the
lumbricals, and out to the fingers
where they are inserted to the
lateral bands. When the wrist is
flexed, an active tenodesis effect
occurs, resulting in MCPJ flexion
and IPJ extension.

43. Bone blocks
• Dorsal metacarpo-phalangeal bone block
• Mikhail - inserted bone block over dorsal metacarpal
head
• Harvard - elevated bone wedge from dorsal aspect of
metacarpal head as block
5. MCP Arthrodesis
MCP joint arthrodesis in 20° flexion -No flexion or
extension possible

44. 2. DYNAMIC PROCEDURES FOR CLAW HAND
● Motors
● The insertion can be into the
○ Lateral band
○ Proximal phalanx,
○ The A1 or A2 pulley

45. 1. Modified Stiles-Bunnell Procedure
● In the modified Stiles-Bunnell procedure, the middle finger superficialis tendon
is divided distally in the finger and retrieved into the palm. It is then split into
four slips.
● Each slip is then passed along the path of the lumbrical, volar to the deep
transverse metacarpal ligament, and back into the finger, where it is inserted
on the lateral band.
● The main drawback of superficialis transfers is that although they reliably
correct clawing and integrate finger flexion, they do not improve grip strength,
and may even result in further weakening of an already diminished grip.
○ Burkhalter - PPX
○ Riordan - A1 pulley
○ Zancolli - Lasso
○ Omer - A2 pulley
○ Anderson and Oberlin - A1 and A2 pulley

46. Modified Stiles-Bunnell procedure

47. Zancolli lasso insertion technique:
○ Zancolli described a "lasso" insertion,
wherein the FDS is passed through the A1
pulley, then sutured back onto itself, resulting
in improved MCPJ flexion while avoiding PIPJ
hyperextension.

48. 2. Finger extensors
Fowler's Procedure - Technique
(EIP EDM)
• Split into two slips each
• Passed through interosseous
routes to palm and through
lumbrical canal
Modification by
○ Riorden used EIP for ring & little
○ Anderson took 3cm of extensor
hood for excessive lenght.

49. 3. Wrist extensors
Brand's EF4T Procedure - Features
● Extensor to flexor four tailed graft
● Donor tendon - ECRL extended by tendon graft
– palmaris, fascia lata, plantaris and ECRL turn
down flap (Malaviya)
● Tendon graft is split into 4 tails and passed
through lumbrical canal of finger volar to DTML.

50. 3. Wrist flexors
FCR (Riordan) transfer- Technique
• FCR tendon is divided at the wrist, retrieved proximally
• Lengthened with graft
• Passed subcutaneously around radial metaphysis to extensor side of forearm
Split into four longitudinal strips
• Through intermetacarpal spaces, lumbrical canals
• Attachments on radial lateral bands of the involved
fingers

51. 4. RESTORATION OF TRANSVERSE METACARPAL
ARCH
● FDS (BUNNELL)
● EDM (RANNEY)
● ECRL (PALANDE)

52. Bunnell's 'T' operation
● FDS is detached from ring finger, retrieved proximally in
palm
● A free tendon graft harvested.
● One end of the graft is inserted into radial aspect of base
of PPX of thumb
● other is inserted into the ulnar aspect of neck of little
finger metacarpal
● The retrieved FDS is attached to
● middle of this free tendon graft
● Contraction of the superficialis produces adduction and
flexion of the thumb and the little finger, and
● "T" is converted into a “Y,” with restoration of the
metacarpal arch.

53. 5. Correction of Little Finger Abduction Deformity
● Altered dynamics
• The EDM, as well as the ADM, can abduct the little finger
• Countered by third palmar interosseous normally
• In ulnar palsy, ADM & 3rd Pl paralyzed
• Unopposed action of EDM (Wartenberg's sign)
• Aim: To provide adduction of little finger
● Split EDM transfer - Technique
● The ulnar half of the EDM tendon detached from the
extensor hood of little finger
● Retrieved through incision just distal to extensor
retinaculum
● EDM tendon passed through fourth intermetacarpal
space into the palm.

54. Split EDM transfer - Technique
● If the little finger is not clawed -
tendon slip sutured onto the insertion
of its MP radial collateral ligament on
the proximal phalanx.
● If the little finger is clawed - tendon slip
is inserted onto a radially based flap of
the flexor tendon sheath just distal to the
A2 pulley (Brooks
insertion)

55. Outcome assessment
● Claw correction -
○ - FDS transfer - 92% good - excellent results
○ - EF4T - 86% good - excellent results
○ - Palande's procedure - Cupping of hand
● Restoring Grip strength -
○ - EF4T - Most effective
● Restoring Key pinch -
○ - ECRB to AP & APL TO 1st DI - Most Effective

57. Postoperative Hand Therapy for Claw Correction
● In In first week patient supervised to attain and maintain lumbrical-plus position
and use a thermoplastic splint between exercises
● Over next 7 to 10 days active IP joint flexion begun while MP joints remain in
flexion
● At no point during first and second stages patient allowed to extend MP joints
● During third stage patient encouraged to maintain IP joint in absolute neutral
extension and then extend MP joints
● Exercises at this stage combined with supervised light functional activities that
encourage lumbrical posture

58. Thank you