Ulnar nerve seminar


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Ulnar nerve seminar

  2. 2. 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. 
  3. 3.  Forearm : enters by passing between two heads of FCU. lies on medial part of FDP. accompanied by ulnar artery in lower 2/3 rd.
  4. 4. 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
  5. 5. 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. 
  7. 7. 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 finger Vascular & Articular No branches above elbow 
  10. 10. ETIOLOGY OF ULNAR NERVE PALSY  Injuries  Primary neurologic diseases  Leprosy  Compression neuropathies
  11. 11. CHARACTERISTICS OF PALSY  INJURIESproximal : 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
  12. 12. 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
  13. 13. 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 intermetacarpal spaces & thumb web.  Shape of hand - Isosceles triangle with base distally.  Loss of sensation is not as devastating as compared to median nerve palsy. 
  14. 14. 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.
  15. 15.  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
  16. 16.  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
  17. 17.  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
  18. 18. 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) 
  19. 19. 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. 
  20. 20. MANAGEMENT ACUTE INJURIES Closed Localize clinically Follow-up with EMG & NCS Recovery No recovery Observe surgery
  21. 21. Open Surgery Nerve in continuity As closed injury not in continuity sharp crush repair approxi mate Graft
  22. 22. 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. 
  23. 23. 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. 
  24. 24. 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.
  26. 26. 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 • TenodesisParkes(PL & Plantaris) Fowler (tendon graft sutured to ER) Riordan( ECRL & ECU ) 
  27. 27. 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 
  28. 28.  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 •
  29. 29.  Index finger abduction: • Bunnell-EI Bruner- EPB Neviaser- accessory APL elongated by tendon graft • •  • • High ulnar palsytenorrhaphy FCR to FCU
  30. 30.  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 
  31. 31. MANAGEMENT IN LEPROSY MDT • Surgery acute- decompression in severe pain  abscess drainage in neuritis  quiescent- reconstructions after stopping steroids. •
  32. 32. 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.
  33. 33. 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. 