ULNAR NERVE

INJURY
Dr. Diyar A. Salih
Plastic Surgery Resident
KURDISTAN, SLEMANI
Main branch of the medial cord
Axilla: post (bet. Axillary A. & V)

Arm: medial to brachial A.

Elbow: post. to medial

epicondyle (Cubital
tunnel) bet. FCU heads.

Forearm: along medial Brachial A.

side of FDP, adjacent
to ulnar A.
Wrist: Guyon’s tunnel,
adjacent to pisiform,
deep to ulnar art.
Superficial
sensory branch
Deep motor
branch
Sensation
 Motor
Forearm:
1. FCU.
2. FDP (ring & little finger).

Hand:
1. Hypothenar M:
• Abductor digiti minimi M.
• Flexor digiti minimi.
• Oppenens digiti minimi.
2. Seven interosseous M. (4 dorsal & 3 palmar).
3. Adductor pollicis.
4. Ring & little finger lumbricals.
5. Flexor pollicis brevis.
Forearm

FDP (ring &

little finger)
4 dorsal & 3 palmar interosseous
Hypothenar muscles
Lumbricals (ring & little finger)
Adductor pollicis
 Flexor pollicis brevis

35% overlap by
Median nerve.
 Types of injuries
1. Neuropraxia.
2. Axonotmesis.
3. Neurotmesis.
 CLASSIFICATION

Upper Lower

Neck Below elbow

Brachial plexus Wrist
At Elbow
 Causes
Causes
1. ACUTE
• Trauma (fracture)
• Wrong posture
• Surgery
• Electrical burn

2. CHRONIC
• Tight nerve passages
• Tumors
 Presentations
Presentations

• Pain
• Sensation loss
• Motion loss
• Power loss
• Reflexes loss
• Wasting
• Trophic changes (skin,sc,neurovascular,bones,muscles)
• Contractures
 Diagnosis
• Clinical examination
• X-RAY
• EMG (electromyography).
• NCS (nerve conduction studies).
• MRI
 Ulnar nerve examination

• F:\Ulnar nerve exam.flv

Low ulnar nerve palsy
Claw deformity
Lumbrical muscles palsy
 Adductor pollicis

1st dorsal interosseous

 Compensation

FPL (stabilize thumb)

Froment’s sign
EPL (adduct thumb)
 Froment’s sign

Atrophy

Normal
Wartenburg’s sign

Little fingerto
Inability
ulnar deviation
adduct little
finger against
EDM pull.
 Earle’s sign
• Inability to abduct the middle finger to
cross over the index finger dorsally.
 High ulnar nerve palsy
• Less clawing.
• Reconstruction can improve function
but not total improvement.
 Treatment of injuries
• Direct repair (tension free)
 Nerve graft
• If > 1 cm defect or repaired under
tension.
Nerve conduit
Tendon transfer
 Incisions

Upper arm: Medial incision

At the elbow: over cubital tunnel
Forearm: along ulnar mid-axial line,
splitting FCU two heads.
At the wrist: at the pisiform, extending distally parallel
to the skin crease at the base of thenar eminence
 Low ulnar nerve injury repair
• F:\Low ulnar nerve injury.flv
 Other measures (alone or with
Tendon transfer)
• Prevention of MCP joint
hyperextension:

3. MCP joint arthrodesis.

4. MCP joint capsulodesis.
5. Bone block on the dorsum of the MCP
joint head.
 Guyon’s tunnel syndrome
(Handlebar palsy)
Palmar sensory branch

Motor branch
Intrinsic M.
Hypothenar M.

Ulnar A.
 GTS causes

Direct trauma

Ulnar A.
aneurysm
 Sensation loss

Not dorsal surfaces:

surfaces
Ulnar N. branch 4-5 cm
above Guyon’s canal
(subcutaneously, distal to
ulnar styloid process).
GTS treatment (surgical
decompression)
Pisohamate ligament
 Cubital tunnel syndrome

Post. to MEC
 Cubital tunnel syndrome

Strong fibrous •True nerve compression.

conduit
•Nerve adhesion.
•Prevent nerve gliding.
•Stretch ischemia.
ischemia
•Impairs nerve conduction
 Sensation loss

Dorsal surfaces
 Cubital tunnel syndrome
• Acute flexion of elbow for 30 min
accentuates the sensory symptoms.

• cubital tunnel.flv
 Tinel sign & Froment test

• F:\Tinel test & Froment test.flv

 Treatment
• Early cases: static elbow extension splint.
 Treatment
• Chronic cases: Ulnar nerve transposition
anterior to the elbow axis of rotation.
Incision over the cubital tunnel
Medial epicondyle

Anterior to MEC

Posterior to MEC
 Ulnar nerve anterior
transposition
• F:\Anterior transposition of the ulnar
nerve.flv