The ulnar nerve is a mixed nerve that supplies muscles in the hand and provides sensory innervation. It can be compressed or injured at several points along its path - in the arm above the elbow, at the elbow in the cubital tunnel, in the forearm, at the wrist, or in the hand. Common symptoms of ulnar nerve injury include clawing of the fingers, weakness of finger abduction and adduction, and sensory loss. The site of injury determines which specific muscles are affected. Cubital tunnel syndrome is the most common type of ulnar nerve injury, caused by compression at the elbow.

1. Clinical Testing- Ulnar nerve
Dr.Roopchand.PS
Senior Resident Academics
Department of Neurology

2. Introduction:
• A mixed nerve.
• Main branch of the medial cord of the brachial
plexus.
• Root value is C7 C8 T1
• Main supply to the small muscles of hand.
• Also called musicians nerve.

4. • ARM
– crosses the axilla beneath the pectoralis
minor
– medial to the brachial artery in upper arm
– distal arm it enters a groove between the
medial humeral epicondyle and the
olecranon process.
– The cubital tunnel: Aponeurosis between
the olecranon and medial epicondyle forms
the roof of an osseous fibrous canal the
floor of which is formed by the medial
ligament of the elbow joint.

5. • ELBOW:
– passes between the humeral and ulnar heads of
the flexor carpi ulnaris to rest on the flexor
digitorum profundus.
– Immediately distal to the elbow joint
• Br to flexor carpi ulnaris
• Br to flexor digitorum profundus III and IV
• FOREARM:
– descends beneath the flexor carpi ulnaris
– palmar cutaneous branch at distal forearm
– supplies the skin over the hypothenar eminence.

6. – then gives of dorsal cutaneous branch.
– supplies the dorsal ulnar aspect of the hand and the
dorsal aspect of the 5th finger and half of the 4th finger.
• WRIST:
– enters the wrist lateral to the tendon of the flexor carpi
ulnaris muscle.
– gives of the superficial terminal branch
– skin of the distal part of the ulnar aspect of the palm
and the palmar aspect of the fifth and half of the 4th
finger.
– passes between the pisiform carpal bone medially and
the hook of the hamate carpal bone laterally: canal of
Guyon

7. • Passes as deep muscular branch supplies:
– Palmaris brevis (C8–T1).
– Abductor digiti minimi (C8–Tl)
– Opponens digiti minimi (C8–T1)
– Flexor digiti minimi (C8–T1)
– Lumbricals III and IV (C8–T1)
– Interosseous muscles (C8–Tl)
– Adductor pollicis (C8–T1)
– Deep head of the flexor pollicis brevis (C8–Tl)

9. NERVE LESIONS:
• Lesions above the Elbow:
– May present as triad neuropathy.
– sleeping with the arm hanging over a sharp edge
or the head of a sleeping partner compressing the
nerve against the humerus, crutches or
tourniquets, arteriovenous fistulas in dialysis
patients, aneurysms, hematomas, nerve tumors,
and other masses.
– Supracondylar fractures of the humerus
– Ulnar entrapment neuropathy in the midarm:
compression by the medial intermuscular septum

10. • “claw-hand”
• Paresis or paralysis of the ulnar flexion
• Impaired extension at the interphalangeal joints.
• Impaired adduction and abduction of the second
to 5th fingers.
• Impaired abduction and opposition of the fifth
finger.
• Froment’s thumb sign : adductor pollicis
weakness- proximal phalanx of the thumb is
extended and the distal phalanx is flexed when a
paper grasped between thumb and index finger is
pulled.
• Sensory abnormalities.

11. • Martin-Gruber anastomosis: a median-ulnar
communication.
– the crossing of fibers from the median to the ulnar
nerve usually occurs 3 to 10 cm distal to the
medial humeral epicondyle.
– median fibers ultimately innervate the intrinsic
hand muscles.
– The overall incidence of Martin-Gruber
anastomoses is approximately 17%.
– Four types exsists.

12. • Cubital Tunnel Syndrome: lesion at the elbow
– most commonly compressed at the elbow in the cubital
tunnel.
– Narrowing of tunnel during flexion, thickening of
aponeurotic arch, ganglion cyst, mass lesions, fibrous
bands, bony spurs…
– More in patients with renal disease undergoing dialysis
and during general anesthesia.
– Tardy ulnar nerve palsy: ulnar nerve palsy occurring long
after original injury.
– A reliable sign of ulnar entrapment by the flexor carpi
ulnaris muscle is the ulnar extension manoeuvre, in which
increased paresthesias in the fourth and fifth digits follow
3 minutes of elbow and wrist flexion in ulnar deviation.

13. Cubital tunnel synd Vs tardy ulnar
palsy:
• No evidence of joint deformity or prior trauma
• Frequent occurrence of bilateral symptoms and
signs of ulnar neuropathy
• A taut, palpably enlarged nerve in the ulnar
groove
• Electrophysiologic (electromyographic)
localization to the cubital tunnel
• Operative findings of a swollen, taut, hyperemic
nerve, distally limited by the proximal border of
the aponeurosis joining the two heads of the
flexor carpi ulnaris muscle.

14. • Ulnar neuropathy at the elbow often spares
the flexor carpi ulnaris
• involvement of flexor carpi ulnaris more often
correlates with the severity of the neuropathy.
• Involvement related to the internal
topography of the nerve, severity of
compression, level of compression.
• preferentially compress the nerve fascicle to
distal hand muscles

15. • Lesions in the Forearm:
– Causes: hypertrophied flexor carpi ulnaris muscle,
fibrous and fibrovascular bands, hematomas, and
handcuffs.
– flexor carpi ulnaris and the flexor digitorum
profundus iand II muscles are often spared

16. Lesions at the Wrist and in the Hand:
• Flexor carpi ulnaris and the flexor digitorum
profundus III and IV are spared.
• Compression of the nerve as it enters the
hand.
• Compression of the proximal part of the
terminal motor branch(with in Guyons canal)
• Distal compression of the terminal motor br.

17. • Common causes:
– Ganglion, occupational neuropathy, laceration, ulnar
artery aneurysm, carpal bone fracture.
• Palmaris brevis spasm syndrome: following the
prolonged use of a computer mouse and
keyboard.
• Lesions of the Dorsal Cutaneous Branch of the
Ulnar Nerve
– Handcuff palsy, Pricer palsy
• Pseudoulnar Nerve Palsy: isolated hand weakness
apparently in an ulnar distribution that is due to
• contralateral cerebral infarction in the white
matter of the angular gyrus of the inferior
parietal lobe