ANATOMY, CAUSES OF INJURY, SIGN & SYMPTOMS, INVESTIGATION , SURGICAL & PHYSIOTHERAPY TREATMENT

1. ULNAR
NEUROPATHY
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2. ANATOMY
oThe ulnar nerve is also known as the musician's nerve'
because it controls fine movements of the fingers
oRoot value – C8 – T1
oArising from medial cord of brachial plexus
oMotor supply
1. Flexor carpi ulnaris
2. Flexor digitorum profundus (3 & 4)
3. Hypothenar muscles
◦ 1. palmaris brevis
◦ 2. flexor digiti minimi
◦ 3. abductor digiti minimi
◦ 4. opponens digiti minimi
5. Adductor pollicis
6. 4 palmar interossei
7. 4 dorsal interossei
8. 2 lumbrical
Sensory supply
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4. CAUSES
.
At the Cervical Spine
• Prolapse intervertebral disc
• Osteophyte due to cervical spondylitis
• Rheumatoid diseases of the cervical spine
At the Base of the Neck
• Cervical rib
• Thoracic outlet syndrome
At the Axilla
Crutch palsy
Arm
• Tourniquet palsy
• Fracture of the supracondylar region of
humerus
• Hansen’s disease
Elbow
• Cubitus valgus causing Tardy ulnar nerve
palsy
• Dislocation of the elbow
• Fracture of the medial epicondyle of the
humerus
• Hansen’s disease
At the Forearm
• Volkmann’s ischemic contracture
• Tight plaster
At the Wrist
• Glass cut injury
• Guyon’s canal syndrome
• Fracture of the carpus bone
• Tumors
• Osteoarthritis
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5. TOURNIQUET PALSY
– Compression palsy
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6. Guyon’s canal syndrome
Compression of the ulnar nerve as it passes through the canal of Guyon.
The medial border of this canal is formed by the tendon of flexor carpi
ulnaris and pisiform bone.
The floor of the canal is formed by the flexor retinaculum and the roof is
formed by the superficial part of the flexor retinaculum
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7. Cubital Tunnel Syndrome/ Tardy
Ulnar Palsy
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8. Tardy ulnar nerve palsy
Cubitus valgus causing Tardy ulnar nerve palsy: At
the elbow the ulnar nerve passes through a
tunnel the roof of which is formed by a fibrous
arch.
This arch becomes tight during elbow flexion as
the floor of the capsule bulges out.
In cubitus valgus the floor is already elevated
which increases the compression on the ulnar
nerve.
Initially this leads to only conduction block but
later to degeneration.
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9. SIGN & SYMPTOMS
Sensory Loss
The patient will have loss of sensation on the skin overlying the
hypothenar eminence, the medial 1½ finger up to the nail beds
Motor Loss
The muscles that will be affected are flexor carpi ulnaris, medial
half of the flexor digitorum profundus, the hypothenar muscles,
medial two lumbricals, the adductor pollicis and all interossei.
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10. DEFORMITY
Ulnar paradox:
oWith lesion at the elbow there is reduced flexion at
the distal interphalangeal joint due to paralysis of
flexor digitorum profundus.
oWith reinnervation the flexion at the DIP joint will
increase giving an appearance of increase deformity
although this is a prognostic sign.
Claw hand deformity:
oIt is a deformity with hyperextension of the MCP
joints and flexion of the IP joints of the fingers(loss
of flexon at MCP and extension at IP joints )
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11. FUNCTIONAL DISABILITY
• The patient will lack intrinsic plus position or lumbrical grip
• Power grip is more affected due to lack of the elevation of the
hypothenar eminence, inability of the fingers to wrap around
the object and due to the lack of clamping action of the thumb.
• Pinch power reduces
• Spherical grip is lacking due to absence of lateralization of fingers
• Lateral pinch becomes inefficient due to paralyzed adductor
pollicis.
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12. INVESTIGATION
RADIOGRAPH :- shows whether there is presence of fracture
MRI :- To delineate complete avulsion of nerve roots
SD CURVE:- abnormality in conduction can be verified. Sharp curve, long
chronaxie, low rheobase and the absence of contraction with repetitive
stimuli indicates denervation. If it is done 2-3 weeks after injury, it
shows the sign of denervation and to find out whether it is moderate or
severe injury
NCV:- To find out the severance of nerve fibers with wallerian
degeneration.
EMG:- it will help to find out reversible and irreversible nerve damage
and will help map out whether it pre ganglionic/ post ganglionic lesion
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13. TYPES OF INJURY
In Neuropraxia  pain, numbness, muscle weakness,
minimal muscle wasting is present. Recovery occurs
within minutes to days
In Axonotmesis  there is pain, evident muscle
wasting, complete loss of motor, sensory and
sympathetic functions. Recovery time– months (axon
regeneration at 1-1.5 mm/day)
In Neurotmesis  no pain, complete loss of motor,
sensory and sympathetic functions. Recovery time –
months and only with surgery
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14. SPECIAL TESTS
1. FROMENT’S TEST
2. WARTENBERG’S SIGN
3. CARD TEST
4. EGWAS SIGN
ALL TESTS ARE POSITIVE IN ULNAR NEUROPATHY
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15. SURGICAL MANAGEMENT
Surgical management Tendon transfer surgery are the usual surgical
approach practiced in ulnar nerve injury.
1. Paul Brand’s transfer
The commonest tendon transfer done is Paul Brand’s transfer where
Extensor carpi radialis is detached from its insertion
This is then slit into four, moved through the lumbrical canal and got to
the dorsal aspect where it is attached to the extensor aponeurosis.
2. Riordan’s technique
When there is severe clawing of the hand with wrist flexion, Riordan’s
technique is used where the flexor carpi radialis is detached from its
insertion, lengthened and then inserted to the extensor aponeurosis
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16. 3. Bunnell’s surgery
When there is no habitual flexion of the wrist, Bunnell’s surgery may be
tried in which case the flexor digitorum of the ring finger is slit into four
tendon and then inserted inserted to the extensor aponeurosis
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17. PHYSIOTHERAPY
1. PNF
2. IG stimulation
3. Active & Passive ROM exercises
4. Care of anesthetic hand
5. Splintage: The splint used should be able to keep the metacarpo-
phalangeal joint in flexion and to maintain the interphalangeal joint in
extension. Hence a knuckle bender splint is used. This splint consists of
a volar support at the metacarpophalangeal joint and two dorsal
supports on the proximal phalanx and on the metacarpal bones
6. Hydrotherapy
7. Passive stretching
8. Gripping activities
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18. 9. Strengthening exercise
To progress from MMT Grade 2 to grade 3
◦ Activities in re education board or table. (activities in gravity eliminated
plane to inclined plane till the muscle strength reaches the grade 3)
To progress from MMT grade 3 to grade 4/5
◦ Manual resisted exercises
◦ Resisted exercises with pulley & spring
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20. THANK YOU
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