Download MBBS Anatomy PPT 22 Ulnar Nerve And Its Lesions Notes

ULNAR NERVE ANATOMY & Its LESIONS

Dr Mukesh Singla

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Learning Objectives

1. Ulnar nerve formation , root value and important

relations

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2. Motor and sensory supply

3. Important sites of injuries/entrapment of nerve

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4. Effects of injury of ulnar nerve

5. How to clinically test ulnar nerve injury

Ulnar nerve C8T1

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Origin : medial cord of

brachial plexus , runs medial

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to brachial artery - middle of

arm.

At coracobrachialis insertion, -

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pierces medial intermuscular

septum, is accompanied by

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superior ulnar col ateral

artery ? and enter posterior

compartment of arm.

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At elbow - posterior to

medial epicondyle.
No branches in arm.

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Ulnar nerve in forearm

? It continues downward

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to enter in forearm

? b/w two heads of

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flexor carpi ulnaris.

Passes through CUBITAL

TUNNEL

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? It runs down forearm

between FCU and FDP.

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? In lower half of forearm

it lies medial to ulnar

artery.

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Cubital Tunnel

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Cubital tunnel is a space of dorsal medial

elbow which allows passage of the ulnar

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nerve around the elbow.

It is bordered

Medially - medial epicondyle of the

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humerus,

laterally -olecranon process of the ulna and

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tendinous arch joining the humeral and ulnar

heads of the flexor carpi ulnaris.

Cubital Tunnel

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? Flexor carpi ulnaris.

Ulnar nerve in Forearm

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? Medial ? of FDP

? Articular: elbow joint.

? Dorsal or posterior

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cutaneous branch:

? Dorsal surface - medial

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1/3rd of hand 1? fingers.

? Palmar cutaneous branch :

to supply skin of palm of

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hand and medial 1? fingers.

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Ulnar nerve in Hand

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Ulnar nerve in Hand

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After it travels down the ulna, ulnar nerve enters the

palm of the hand.

At the wrist, the ulnar nerve and artery lie in a canal

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formed by the pisiform bone medial y and the hook of

hamate lateral y (Guyon's canal).
In this region the nerve divides into two branches.

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The Superficial sensory Branch

The Deep Motor Branch

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Ulnar nerve in Hand

The superficial branch is general y considered a

sensory branch which supplies to distal palm, fifth and

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half of the fourth digit.

It also supplies palmaris brevis, a thin muscle beneath

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the skin which cannot be studied electromyographically.

The deep branch gives of motor innervation to the hand

muscles.

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WRIST TO (MEDIAL) HAND
Ulnar nerve in Hand

Deep branch:

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? Runs b/w abductor digiti minimi & flexor digiti minimi.

? pierces opponens digiti minimi.

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? Then passes laterally within concavity of deep palmar

arch.

? lies deep to flexor tendons.

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? It supplies 14 muscles :

? Three hypothenar muscles.

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? Adductor policis.

? Al dorsal & palmar interossei.

? Medial 2 lumbricals.

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BRANCHES: Muscular

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FCU, FDP (medial half), palmaris brevis, hypothenar

muscles, medial 2 lumbricals, all palmar & dorsal

interossei , thumb intrinsics medial to FPL {adductor

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pollicis , flexor pollicis brevis (deep head)}

Cutaneous
palmar cutaneous supply to hypothenar eminence

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Dorsal cutaneous supply dorsum of hand (medial part),

dorsum of little finger , part of dorsum of ring finger.

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Digital

forms the main sensory branches to the ring and little

finger

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Vascular & Articular
No branches above elbow

DORSAL CUTANEOUS BRANCH

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PALMAR CUTANEOUS BRANCH

Guyon Canal or Tunnel

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Semi-rigid longitudinal canal in the wrist that allows passage of

the ulnar artery and ulnar nerve into the hand.
Roof of the canal -superficial palmar carpal ligament,

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deeper flexor retinaculum and hypothenar muscles comprise the

floor.

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The space is medially bounded by the pisiform and pisohamate

ligament more proximally, and laterally bounded by the hook of the

hamate more distally.It is approximately 4 cm long, beginning

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proximally at the transverse carpal ligament and ending at the

aponeurotic arch of the hypothenar muscles.
Lesion of ulnar nerve above elbow - atrophy of

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hypothenar muscles

Lesion of ulnar nerve above elbow
? Weakness of flexion at wrist paralysis of FCU

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? Loss of flexion of terminal phalanges of ring & little

fingers paralysis of medial ? of FDP

? Paralysis of al interossei & medial 2 lumbricals (3rd &

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4th).

? Characteristic deformity is - partial claw hand.
? Atrophy of hypothenar muscles.

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? Fingers - hyperextended at metacarpophalangeal joints

& flexed at interphalangeal joints - ring & little finger.

? Loss of adduction of hand & thumb due to paralysis of

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flexor carpi ulnaris & adductor pollicis.

Lesion of ulnar

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nerve above

elbow - Loss of

cutaneous sensations

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on front & dorsum of

medial 1/3 of hand +

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medial 1 ? fingers.

? It leads to paralysis of

Lesion of ulnar

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intrinsic muscles of hand as

nerve above

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described above.

wrist

? deformity `claw hand'

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? Loss of cutaneous sensations

of medial 1 ? fingers.

Test for Palmar interossei

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Test for adductor &

for adduction of fingers.

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opponens pollicis.


Test for Palmar interossei for

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Test for adductor &

adduction of fingers.

opponens pol icis.

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Ulnar Nerve Injuries

most commonly injured @

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At elbow

where it lies behind the medial epicondyle usually associated with

fracture

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At wrist

where it lies with the ulnar artery in front of the flexor retinaculum.

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Injuries to the Ulnar Nerve at the Elbow

CUBITAL TUNNEL SYNDROME (2ND most common)

Motor

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Flexor carpi ulnaris & medial half of flexor digitorum profundus

ring & little fingers

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No flexion of the terminal phalanges of the ring & little fingers
Flexion of wrist = abduction paralysis of flexor carpi ulnaris

medial border of the front of the forearm flattned/wasted

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Al the smal muscles of the hand paralyzed EXCEPT ?


Injuries to the Ulnar Nerve @ the Elbow

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Motor

Extensor digitorum can abduct the fingers to a small extent

when metacarpophalangeal joints are hyperextended

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Impossible to adduct the thumb adductor pol icis paralyzed

Froment's sign

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Grip a piece of paper between the thumb and index fingers

Froment sign: The patient is asked to hold the paper between the thumb and index finger.

(A) With the intact ulnar nerve, the patient is able to make use of the adductor pol icis. ( B)

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When the ulnar nerve is deficient, the patient compensates for the denervated adductor by

using the flexor pol icis longus (median nerve innervated).

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Injuries to the Ulnar Nerve @ the Elbow

Motor

2 medial lumbricals & interossei Hyperextended metacarpophalangeal joints

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Flexed interphalangeal joints

fourth & fifth fingers

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"claw" deformity main en griffe

Injuries to the Ulnar Nerve @ the Elbow

Motor

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Flattening of hypothenar eminence

Loss of the convex curve to the medial border of the hand

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Holowing between metacarpal bones @ dorsum of the hand

wasting of dorsal interossei

Injuries to the Ulnar Nerve @ the Elbow

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Sensory

Loss of skin sensation

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anterior & posterior surfaces of medial 1/3 of the hand

medial 1 ? fingers

Vasomotor Changes

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warmer and drier skin area

arteriolar dilatation and absence of sweating /loss of sympathetic control

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Injuries to the Ulnar Nerve @ the Wrist

Motor

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Smal hand muscles paralyzed, wasted ? EXCEPT 3 thenar @ first 2 lumbricals

Claw hand

More obvious

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Flexor digitorum profundus intact

Marked flexion of the terminal phalanges

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Ulnar paradox

Higher lesion

Less obvious claw deformity

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More proximal injury

Less claw

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ULNAR NERVE ENTRAPMENT SYNDROMES

PROXIMAL/ @ ELBOW

CUBITAL TUNNEL SYNDROME

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BETWEEN MEDIAL EPICONDYLE & FLEXOR CARPI ULNARIS

Q: Medial half of Flexor digitorum profundus

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DISTAL/ @ WRIST

affected in which one most?

GUYON'S CANAL Roof: Palmaris brevis, hamate,pisiforme bones & FCU

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Froment's sign

To perform the test, a patient is

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asked to hold an object, usually a flat

object such as a piece of paper,

between their thumb and index finger

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(pinch grip). The examiner then

attempts to pull the object out of the

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subject's hands.[2]

Froment's sign : hyperflexion of IP jt of thumb

while attempting a lateral pinch(indicates

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paralysis of adductor pollicis, 1st DI , with

replacement of pinch function by FPL)

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Ulnar paradoxus

In proximal ulnar lesion (closer to the elbow), the Flexor

Digitorum Profundus may also be denervated. As a result,

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flexion of the Interphalangeal joints is weakened, which

reduces the claw-like appearance of the hand.

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In distal lesion, at or below wrist

Condition of claw hand is worse because as FDP is spared

,there is active flexion of interphalangeal joint of medial two

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digits.This is called the "ulnar paradox" because one would

normally expect a more debilitating injury to result in a more

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deformed appearance.
Cross your fingers test:

Inability to cross the middle finger dorsally over the index

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finger or vise versa.(1st PI & 2nd DI)

Some Facts

? At the back of medial epicondyle, ulnar nerve is lodged in a

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groove.

? Pressure on nerve at this site produce " funny bone

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,symptoms with tingling along hypothenar eminence and

little finger

Some Facts

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? Deep branch of ulnar nerve is called "musician" nerve

because it innervates all the small muscles of hand involved

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in fine movement

? Median nerve- eye of hand because it supply sensory

receptors in the tips of medial three and half fingers of hand

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? Median nerve ? laborer's nerve because of motor supply to

long flexor tendons

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which of these symptoms is not caused by damage to the

median nerve at the wrist?

A

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ape/simian hand

B

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loss of pronation

C

loss of sensation in most of thumb and digits 2 and 3.

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D

thenar muscle paralysis
which of these symptoms is not caused by damage to the

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median nerve at the wrist?

A

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ape/simian hand

B

loss of pronation

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C

loss of sensation in most of thumb and digits 2 and 3.

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D

thenar muscle paralysis

? Injury to the ulnar nerve at the ____ causes ______, and at

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the ____ causes ____

? A
? elbow, radial deviation, wrist, wrist drop

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? B
? elbow, radial wrist deviation, wrist, severe clawing of hand
? C
? elbow, severe clawing of hand, wrist, radial deviation
? D

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? elbow, wrist drop, wrist, radial deviation

? Injury to the ulnar nerve at the ____ causes ______, and at

the ____ causes ____

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? A
? elbow, radial deviation, wrist, wrist drop
? B
? elbow, radial wrist deviation, wrist, severe clawing of hand

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? C
? elbow, severe clawing of hand, wrist, radial deviation
? D
? elbow, wrist drop, wrist, radial deviation

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? A patient after injury on hand presents with hand in claw

position with 4th and 5th fingers extended at the

metacarpophalangeal joints and flexed at the

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interphalangeal joints. Which nerve is involved in this injury

? Radial nerve
? Median nerve

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? Ulnar nerve
? Anterior interosseous nerve
? A patient after injury on hand presents with hand in claw

position with 4th and 5th fingers extended at the

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metacarpophalangeal joints and flexed at the

interphalangeal joints. Which nerve is involved in this injury

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? Radial nerve
? Median nerve
? Ulnar nerve
? Anterior interosseous nerve

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2.

Froment's sign is used to

test the strength of which muscle

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a)

Abductor Pollicis longus

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b)

Adductor Pollicis

c)

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Flexor Pollicis longus

d)

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Extensor Pollicis Longus

Froment's sign is used to test the strength of
which muscle
a) Abductor Pollicis longus

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b) Adductor Pollicis
c) Flexor Pollicis longus
d) Extensor Pollicis Longus

? A patient is asked by his physician to hold their wrist in

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complete and forced flexion (pushing the dorsal surfaces of

both hands together) for 30?60 seconds. This maneuver

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compress the nerve within the carpal tunnel and

characteristic symptoms (such as burning, tingling or numb

sensation over the thumb, index, middle and ring fingers)

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conveys a positive test result and suggests carpal tunnel

syndrome. What is the name of manoeuvre physician is

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performing

? Turning Circle maneure
? Phalen's Manoeuvre
? Collision Avoidance Manoeuvre

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? Zig-zag Test Manoeuvre.
1. A patient is asked by his physician to hold their wrist in

complete and forced flexion (pushing the dorsal surfaces of
both hands together) for 30?60 seconds. This maneuver

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compress the nerve within the carpal tunnel and
characteristic symptoms (such as burning, tingling or numb
sensation over the thumb, index, middle and ring fingers)
conveys a positive test result and suggests carpal tunnel
syndrome. What is the name of manoeuvre physician is

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performing

a) Turning Circle maneure
b) Phalen's Manoeuvre
c) Collision Avoidance Manoeuvre

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d) Zig-zag Test Manoeuvre.

?

A clinical condition in which patient shows inability to

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abduct the thumb due to median nerve lesion is called

? a. Pollock `s Sign
? b. Pointing Index

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? c. Ape thumb deformity
? d. Andre- Thomas Sign

A clinical condition in which patient shows inability to abduct
the thumb due to median nerve lesion is called

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a. Pollock `s Sign
b. Pointing Index

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c. Ape thumb deformity
d. Andre- Thomas Sign

The index finger is not flexed at the proximal

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interphalangeal (PIP) and distal interphalangeal (DIP)

joints. This clinical condition is called pointing index. This

condition is due to lesion of

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a)

Ulnar nerve

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b)

Median nerve

c)

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Radial nerve

d)

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Posterior interosseous nerve
The index finger is not flexed at the proximal interphalangeal
(PIP) and distal interphalangeal (DIP) joints. This clinical
condition is called pointing index. This condition is due to
lesion of

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a)

Ulnar nerve

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b)

Median nerve

c)

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Radial nerve

d)

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Posterior interosseous nerve

Pen test in hand is performed to assess the

neuromuscular status of:

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a)

Opponens pollicis

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b)

Flexor pollicis brevis

c)

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Abductor pollicis brevis

d)

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First palmar interossei

Pen test in hand is performed to assess the neuromuscular
status of:

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a) Opponens pollicis
b) Flexor pollicis brevis
c) Abductor pollicis brevis
d) First palmar interossei

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In the phalen's test, the suspected compression of

median nerve is elicited. Which of the following are the other

structures passing through the carpal tunnel?

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? a. Ulnar nerve
? b. Superficial cutaneous branch
? c. Flexor digitorum profundud tendons
? d. Palmaris longus tendon
In the phalen's test, the suspected compression of median

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nerve is elicited. Which of the following are the other

structures passing through the carpal tunnel?
a. Ulnar nerve

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b. Superficial cutaneous branch
c. Flexor digitorum profundud tendons
d. Palmaris longus tendon