 Introduction

The ulnar nerve can be broadly described as the nerve of the hand, since it
innervates most of the intrinsic hand muscles. It is one of the most
substantial clinically-related nerves, due to its superficial route and apparent
role in hand function. This essay will discuss its anatomical structure, the
physiological functional aspects, and lastly methods treating injuries to the
ulnar nerve.

 The structural (anatomical) principles

In the arm, the ulnar nerve is the terminal branch of the medial cord of the
brachial plexus, from roots of C8-T1 and sometimes C7. It descends down
from the medial aspect of the arm, medial to biceps brachii and anterior to
brachialis. It pierces the medial intermuscular septum and passes anterior to
the medial head of triceps brachii muscle. It passes posterior to the medial
epicondyle of the humerus and then into the anterior compartment of the
forearm. The ulnar nerve has no major branches in the arm.

In the forearm, the ulnar nerve passes through the forearm and into the hand,
where most of its major branches occur. In the forearm, the ulnar nerve
innervates only the flexor carpi ulnaris muscle and the medial part (ring and
little fingers) of the flexor digitorum profundus muscle.

The nerve descends down the forearm over the flexor digitorum profundus.
In the upper part it is covered by flexor carpi ulnaris, while in the lower part
of forearm it is only covered by fascia and skin and lies lateral to flexor carpi
ulnaris. The artery lies lateral to the nerve. It gives two muscular branches:
one to the flexor carpi ulnaris and second to the ulnar part of the flexor
digitorum profundus.
The ulnar nerve enters the anterior compartment of the forearm by passing
posteriorly around the medial epicondyle of the humerus and between the
humeral and ulnar heads of the flexor carpi ulnaris muscle. After passing
down the medial side of the forearm in the plane between the flexor carpi
ulnaris and the flexor digitorum profundus muscles.

In the hand, the ulnar nerve innervates all intrinsic muscles of the hand. The
ulnar nerve enters the hand lateral to the pisiform and posteromedially to the
ulnar artery. Immediately distal to the pisiform, it divides into a deep branch
which is mainly motor, and a superficial branch, which is mainly sensory.

The deep branch of the ulnar nerve passes with deep branch of the ulnar
artery. It penetrates and supplies the hypothenar muscles to reach the deep
aspect of the palm, arches laterally across the palm, deep to the long flexors
of the digits, and supplies the interossei, the adductor poliicis, and the two
medial lumbricals.

As the deep branch of the ulnar nerve passes across the palm, it lies in a
fibro-osseous tunnel (Guyon’s canal) between the hook of the hamate and
the flexor tendons. Occasionally, small outpouchings of the synovial
membrane (ganglia) from the joints of the carpus compress the nerve within
this canal, producing sensory and motor symptoms.

The superficial branch of the ulnar nerve innervates the palmaris brevis
muscle and continues across the palm to supply the skin on the palmar
surface of the little finger and the medial half of the ring finger.

 The functional (physiological) principle

Ulnar nerve is also known as "musician's nerve" as it controls the fine

movements of the fingers.
Superficial branches (sensory)

The superficial branch of the ulnar nerve supplies the anterior aspect of the
ulnar one and a half fingers (little finger and half of the ring finger) and
medial palmar skin. Dorsal cutaneous branch supplies medial half and one
and a half ulnar fingers dorsally. The palmar sensation is provided by the
palmar cutaneous branch, which also supplies palmar aponeurosis.

Motor branches

Anterior forearm

 Flexor carpi ulnaris

 Medial half of Flexor digitorium profundus

Hand

 Hypothenar muscles
 Medial two lumbricals
 Adductor pollicis
 Interossei of the hand
 Palmaris brevis

Clinical significance (claw hand deformity): Ulnar nerve injury in the area
around mid-forearm is characterized by “clawing” of the hand, in which the
metacarpophalangeal joints of the fingers are hyperextended and the
interphalangeal joints are flexes because the function of most of the intrinsic
muscles of the hand is lost.

Clawing is most pronounced in the medial fingers because the function of all
intrinsic muscles of these digits is lost while in the lateral two digits, the
lumbricals are innervated by the median nerve. Function of the adductor
pollicis muscle is also lost.

In lesions of the ulnar nerve at the elbow, function of the flexor carpi ulnaris
muscle and flexor digitorum profundus to the medial two digists is lost as
well. Clawing of the hand, particularly of the little and ring fingers, is worse
with lesions of the ulnar nerve at the wrist than the elbow.

Ulnar nerve lesions at the elbow and wrist result in impaired sensory
innervation of the palmar aspect of the medial one and one-half digits.

 The pharmacological principle

Treatment here is immediate surgery to repair the nerve wound.

 Nonoperative treatment of ulnar nerve complete or partial lacerations

is appropriate when the patient’s associated injuries or medical
comorbidities prevent anesthesia and a lengthy microsurgical repair.
 Complete ulnar nerve lacerations in civilian practice are usually seen
acutely and are usually caused by sharp lacerations from broken glass,
knives, saws, or vehicular accidents.
 Complete nerve lacerations should be repaired with microsurgical
procedures.
 Choices for microsurgical repair include:
o Epineural repair
o Group fascicular repair
o Nerve repair with nerve grafts
o Nerve repair with nerve conduit
o Nerve transfers
  Conclusion

The ulnar nerve is one of the 5 terminal branches of the brachial plexus,
arising from the medial cord. It supplies motor and sensory innervation to
the upper extremity. The ulnar nerve provides motor innervation to part of
the forearm and majority of the hand. And any damage to it would result in
substantial damage in those areas. In case of gunshot injury to the ulnar
nerve, immediate surgery repair is required.