DIAGNOSIS AND MANAGEMENT OF ULNAR NERVE PALSY

Lecturer Adviser:
dr. Donny H Hamid Sp.S

Amalia Farahtika Srikandi

1102014016

Clinical Science of Neurology

General Hospital Pasar Rebo East Jakarta
16 April 2018 – 18 May 2018
 1. Definition
Ulnar nerve palsy or ulnar nerve neuropathy is a condition when you lose
sensation and have muscle weakness in your hand if you damage your ulnar nerve. This
condition can affect your ability to make fine movements and perform many routine
tasks, it can also result in paresthesia and dysesthesia in the affected hand. In severe
case, ulnar nerve palsy can cause muscle wasting, or atrophy, that makes the hand look
like claw.

2. Epidemiology
Ulnar nerve palsy is the second most common peripheral nerve condition after
median nerve palsy, but it is an extremely rare event with only 30 cases reported
worldwide. According to the Nationwide Inpatient Sample database from the
healthcare cost and utilization project, ulnar nerve palsy was the most frequent major
upper extremity peripheral nerve injury resulting in hospital admission from 1993 to
2006 when compared with median, radial, and brachial plexus injuries. The
demographic of patients with ulnar nerve palsy are disproportionately male in the
working age group (18 – 45 y.o) and mostly affect young people as a result of a high-
energy injury caused by traffic accidents, fall from a height and sports injuries, and is
common in patients with severe displacement and comminution, combined a distal
ulnar fracture.

3. Anatomy

The ulnar nerve is the terminal branch of the medial cord of the brachial plexus.
This cord contains nerve fibers from C7 to T1 nerve roots. It lies medial to the brachial
artery in the upper arm and exits the posterior compartment of the arm as it descends
down the humerus to enter the anterior compartment through the medial intermuscular
septum. It continues anterior to the medial head of the triceps brachii muscle to enter
the cubital tunnel posterior to the medial epicondyle, medial to the elbow joint capsule
and the medial collateral ligament. After exiting the cubital tunnel, the ulnar nerve
gives off 2 or 3 muscular branches to the flexor carpi ulnaris (FCU) muscle. The ulnar
nerve passes beneath the humeral and ulnar heads of the FCU muscle to enter the volar
aspect of the forearm, where it continues deep to the flexor pronator aponeurosis. In
the forearm, the nerve passes anterior to the flexor digitorum profundus (FDP) muscle
to supply motor branches to the ulnar half of FDP. Ulnar nerve gives sensory supply to
both palmar and dorsal surfaces of the ulnar border of the hands. The ulnar nerve travels
the remaining length of the forearm between the FDP and the flexor digitorum
superficialis (FDS) muscles. The ulnar nerve particularly vulnerable to injury at the site
of its passage through the cubital tunnel, on the medial side of the extensor aspect of
the elbow.

Figure 1.

4. Etiology

The ulnar nerve can be damaged by acute trauma or, even more commonly, by
chronic pressure, and entrapment. Ulnar nerve palsy is caused primarily by direct
contusion, traction and compression due to fibrosis of the adjacent tissue or swelling,
injury at elbow, entrapment at elbow or distal to the medial epicondyle, rarely by
laceration in a distal radial fracture. Compression by thick fibrous tissues around the
ulnar nerve resulted in progressive ulnar nerve palsy and demonstrated that a permanent
ulnar nerve injury could be avoided even when it was displaced or extended in a
fracture of the distal radius because it has a higher mobility and extensibility than the
median nerve. The ulnar nerve is more vulnerable to traction and contusion than to
compression because the ulnar nerve is located outside the carpal tunnel and is fixed
by the Guyons canal. Pressure on the nerve in the palm of the hand could damages the
deep branch resulting in wasting and weakness without sensory loss.

5. Pathophysiology

A mild compression can cause segmental demyelination. Conduction across the

injured segment is impaired, however, when distortion of the myelin sheath causes
degeneration of one or several internodes, thereby reducing the ability of the sheath to
act as an electrical insulator. If the myelin is only slightly damaged, the only local
consequence may be a widening of the node of ranvier that can causes slowing
conduction velocity across the nerve segment. More severe compression may involve
most or all myelinated nerve fibers at the injury site and several internodes. Blockade
of conduction across that segment results in weakness or sensory disturbance.
Resulting in conduction slowing or demyelinating conduction block.

5.1 Ulnar Nerve Entrapment at the Elbow

Elbow’s cubital tunnel is a common cause of ulnar palsy (cubital tunnel

syndrome). It causes compression of the ulnar nerve by a thick-ended, fibrotic flexor

carpi ulnaris aponeurosis at the entrance of elbow’s cubital tunnel. Prolonged and

frequent resting of the flexed elbow on a hard surface such as desk or arm chair may
result in external pressure to the nerve (ulnar groove syndrome). A flexed elbow
position may increase both the intraneural and extraneural pressure on the nerve. The
nerve at the site of repeated compression is associated with fibrous thickening.

5.2 Ulnar Nerve Entrapment at the Wrist

Distal entrapment of the ulnar nerve at the wrist (guyons canal) or hand is a
relatively uncommon condition. Ulnar nerve in guyon canal occurs much less
frequently that at the elbow. the usual causes are chronic or repeated external pressure
by hand tools, bicycle handlebars, the handle of canes, or excessive push-ups. Constant
pressure on the palm of the hand can produce symptoms.

6. Clinical Presentation

Symptoms usually begin with tingling in the ulnar distribution, including the
fourth and fifth digits of the hand. Sensory symptoms may be worsened by elbow
flexion due to increase pressure on the nerve. Motor dysfunction can be disabling and
involves most of the intrinsic hand muscles, limiting dexterity, and strength of the grasp
and pinch. Weakness and wasting of muscles supplied, with a characteristic posture of
the hand ulnar claw hand as well as sensory loss. The level of the lesion dictates the
extent of the motor paralysis.

6.1 Ulnar Nerve Entrapment at the Elbow

Ulnar nerve lesion at the elbow may result in numbness and tingling of the little
finger and ring finger, with variable degrees of hand weakness. There is also variable
weakness of the flexor carpi ulnaris and the flexor digitorum profundus of the ring and
little fingers. Grip strength is reduced secondary to weakness of the adductor pollicis,
flexor pollicis brevis, and palmar dorsal interosseous muscles. To compensate for
adductor pollicis weakness during an attempt to pinch a piece of paper between the
thumb and index finger, the flexor pollicis longus, a median nerve-innervated muscle,
becomes involuntary active and flexes the distal phalanx of the thumb (forment sign).
Lumbrical weakness leads to clawing of the fourth and the fifth fingers and flexion of
the proximal and distal interphalangeal joints, with secondary hyperextension of the
metacarpophalangeal joints (ulnar clawing). In chronic condition, the weakness and
atrophy of small muscles of the hand is always more severe than the weakness and
atrophy of the forearm muscles. Sensory loss of hypoesthesia involves the fifth finger,
part of the fourth finger, and the hypothenar eminence and includes he dorsum of the
hand but does not extend above the wrist level.

Cubital Tunnel Syndrome can present in different grades of severity: Grade I:

Mild symptoms (Intermittent paresthesia, minor hypoesthesia of the dorsal and palmar
surfaces of the fifth and medial aspect of fourth digits, no motor changes), Grade II:
Moderate and persistent symptoms (paresthesia, hypoesthesia of the dorsal and palmar
surfaces of the fifth and medial aspect of fourth digits, mild weakness of ulnar
innervated muscles, early signs of muscular atrophy), Grade III: Severe symptoms
(paresthesia, obvious loss of sensation of the dorsal and palmar surfaces of the fifth and
medial aspect of fourth digits, significant functional and motor impairment, muscle
atrophy of the hand intrinsics, possible digital clawing of fourth and fifth digits).

6.2 Ulnar Nerve Entrapment at the Wrist

Ulnar nerve entrapment at the wrist may present with a confusing array of
sensory and motor symptoms or both, depending on which branches of the nerve are
involved. However it involve solely motor fibers and present with painless unilateral
hypothenar and interossei weakness or atrophy. Because the palmar cutaneous and
dorsal cutaneous branches leave the ulnar nerve in distal forearm and do not enter the
guyon canal, sensation in the proximal hypothenar region and the dorsum of the little
and ring fingers is not impaired. The sensory loss, if present, is confined to the palmar
surface of the ulnar-innervated fingers (the little finger and usually the ulnar half of
the ring finger) and the distal hypothenar region. Compression at the distal canal
results in selective involvement of the deep motor branch, with interossei weakness
and atrophy.

7. Diagnosis

7.1 History Taking

A careful history is essential, particularly in cases of blunt trauma, because it is

critical to differentiate between neurapraxia and axonotmesis (which can be treated
without surgery) and neurotmesis, which requires surgical intervention. It is important
to determine when the symptoms began, how long they are lasting, whether they are
transient or continuous, and whether they are related to work, sleep, or recreation. In
addition, although the answer will frequently be negative, one should ask specifically
about trauma and pressure to the arm and wrist, especially the elbow, the medial side
of the wrist, and other sites close to the course of the ulnar nerve. Many patients
complain of sensory changes in the fourth and fifth digits. Rarely, a patient notices
that the unusual sensations are mainly in the medial side of the ring finger (fourth
digit) rather than the lateral side. The sensory changes can include numbness, tingling,
or burning. If the patient rests on the elbows at work, increasing numbness and
paresthesias may be noticed throughout the day. Pain rarely occurs in the hand.
Complaints of pain tend to be more common in the arm, up to and including the elbow
area. Indeed, the elbow is probably the most common site of pain in an ulnar
neuropathy. Occasionally, patients specifically say “I have pain in my elbow”. Patients
rarely notice specific muscle atrophy, but when they do, they often complain that their
hands “look older.” Weakness may also be a presenting complaint. For example,
patients may report difficulty in opening jars or turning doorknobs or may experience
early fatigue or weakness with work that requires repetitive hand motions. The
complaint of weakness may also be expressed in more subtle ways. For example, one
traditional sign of ulnar neuropathy, the Wartenberg sign, is actually a complaint of
weakness. In this scenario, the patient complains that the little finger gets caught on
the edge of the pants pocket when he or she tries to place the hand into the pocket.
The patient also may express the complaint of weakness by saying, “My grip is weak.”
Sometimes, a patient notices that the thumb−index finger pincer grip is weak. Two of
the key muscles involved in this movement are the adductor pollicis (adducting the
thumb) and the first dorsal interosseous muscle (adducting the index finger).

7.2 Physical Examination

The physical examination should include the following steps:

 Check elbow range of motion, and examine the carrying angle; look for areas

of tenderness or ulnar nerve subluxation


 Check for the Tinel sign - This sign is typically present in individuals with
cubital tunnel syndrome; however, as many as 24% of the asymptomatic

population also present with the sign. At the elbow, the ulnar nerve travels

through a tunnel of tissue (cubital tunnel) that runs under the medial epicondyle.
Pressure on the nerve at the elbow can cause numbness or pain in the elbow,
hand, wrist or fingers.
 Perform an elbow flexion test - This test, generally considered the best
diagnostic test for cubital tunnel syndrome, involves having the patient flex the
elbow past 90°, supinate the forearm, and extend the wrist; results are positive

if discomfort is reproduced or paresthesia occurs within 60 seconds


 Consider a shoulder internal rotation test - In this test, the upper extremity is
kept at 90° of shoulder abduction, maximal internal rotation, and 10° of flexion,
with the elbow flexed 90°, the wrist in neutral, and the fingers extended; a result
is considered positive if any symptom attributed to cubital tunnel syndrome
appears within 10 seconds; this test appears specific to cubital tunnel syndrome
and may be more sensitive for the syndrome than the 10-second elbow flexion
test is.
 Test abduction of the little finger against resistance - the abductor digiti minimi
allows for abduction of the little finger away from the other fingers, the function
of the abductor digiti minimi is tested by asking the patient to abduct the little
finger against resistance.
 Test abduction of the index finger against resistance - the function of the dorsal
interossei is tested by asking the patient to abduct the index finger against
resistance, the first dorsal interossei muscle can be seen and evaluated on the
dorsum of the hand, severe atrophy of the first dorsal interosseous muscle could
indicate a bad prognisis for recovery of the ulnar nerve, the condition could be
associated with a claw hand deformity.
 Check for clawing of the 4th and 5th fingers - the ulnar claw hand deformity is
a symptom of lower ulnar nerve entrapment (below the elbow) and typically
causes flexion and clawing of the 4th and 5th fingers due to the unopposed
action of the medial part of the flexor digitorum profundus muscle.
 Froment’s sign - when the adductor pollicis muscle is weak, thumb adduction
will not occur, the froment’s sign is used to test the function of the adductor
pollicis muscle, when pinching a piece of paper between the thumb and the
index finger, the thumb IP joint will flex if the adductor pollicis muscle is weak.
 Unable to cross the middle and index fingers - as a result of ulnar nerve
entrapment and injury the patient is unable to cross or abduct the fingers,
 adduction of the fingers come from the palmar Interossei, abduction of the
fingers come from the dorsal Interossei.

7.3 Laboratory Studies

Routine studies for ulnar nerve entrapment are ordered to rule out anemia,
diabetes mellitus, and hypothyroidism and include the following:

 Complete blood cell (CBC) count


 Urinalysis


 Fasting blood glucose

7.4 Radiography

Radiographs of both the elbow and the wrist are mandatory in ulnar nerve
compression because double-crush syndrome may be present. Entrapment of the
ulnar nerve may occur at more than one level. Radiographs of the elbow reveal
abnormal anatomy, such as a valgus deformity, bone spurs or bone fragments, a
shallow olecranon groove, osteochondromas, and destructive lesions (tumors,
infections, or abnormal calcifications).

7.5 Electromyography

Electromyography (EMG) and nerve conduction studies are indicated to

confirm the area of entrapment. Basic sensory and motor nerve parameters measured
in nerve conduction studies include latency, amplitude, and conduction velocity.
Electrodes (metallic reusable or pregelled disposable tape) are placed over the main
site of the active muscle (the abductor digiti quinti or the first dorsal interosseous
muscle) and the tendon of the fifth or first digit. The ulnar nerve is stimulated at the
wrist and above and below the elbow. A flexed position of the elbow (70 to 90 degrees)
is preferred to the extended position when doing ulnar motor conduction studies to
localize an ulnar lesion at the elbow. Short-segment stimulation (also known as the
inching technique), in which the nerve is stimulated over 1- to 2-cm intervals, can
increase the sensitivity of the procedure and may improve localization by helping the
examiner judge whether a blockage is infracondylar (near the cubital tunnel) or higher
(near the ulnar or epicondylar groove, the location associated with tardy ulnar palsy).
Findings are considered to be positive for cubital tunnel syndrome when the motor
conduction velocity across the elbow is less than 50 m/s or when the difference between
the motor conduction velocity across the elbow and that below the elbow exceeds 10
m/s. If the point of maximum conduction delay and drop in amplitude of the compound
muscle action potential (CMAP) is at or just proximal to the medial epicondyle,
compression of the ulnar nerve is probably at the level of the epicondylar groove. If the
point of maximum conduction delay and drop in CMAP amplitude is 2 cm distal to the
medial epicondyle, compression is probably in the cubital tunnel. However, nerve
conduction velocity studies and the results of electromyography (EMG) can be limited
in cases of severe axonal loss or early after injury, when neurapraxia cannot be
discerned from neurotmesis. EMG can also be limited by pain and an inability to
identify anatomical variability.

8 Differential Diagnosis

Compression of the eight cervical root at (C7-T1) may mimic ulnar nerve palsy.
The pain is along the medial side of the forearm and the sensory loss is in the
distribution of the medial cutaneous nerve of the forearm and of the ulnar nerve in the
hand. The cervical spine and shoulder regions should be examined to rule out diagnoses
that can refer to the elbow. There are numerous differential diagnoses for ulnar nerve
entrapment such as, elbow fracture/dislocation, cervical radiculopathy, alcohol
(Ethanol) related neuropathy, primary bone tumors, peripheral polyneuropathy.
9 Treatment

9.1 Non Surgical Therapy

Medical and other nonsurgical treatments can provide significant help in cases
of ulnar palsy. Conservative measures are most likely to be successful when
paresthesias are transient and caused by malposition of the elbow or blunt trauma. Oral
vitamin B-6 supplements may be helpful for mild symptoms. This treatment should be
carried out for 6-12 weeks, depending on patient response. Occupational therapy and
work hardening programs are also beneficial. Therapist may also use nerve gliding,
sliding, or tensioning exercises aimed at promoting smoother movement of the nerve
within the cubital tunnel and reducing adhesions and other causes of physical nerve
compression. With nonoperative treatment, strengthening the elbow’s flexors and
extensors both isometrically and isotonically within 0-45° of range of motion is helpful.
The patient should be advised to decrease repetitive activities that may exacerbate
symptoms. The ulnar nerve should be protected from prolonged elbow flexion during
sleep and protected during the day through avoidance of direct pressure or trauma. For
initial conservative treatment of cubital tunnel syndrome, use of an elbow pad or night
splinting for a 3-month trial period is recommended. If symptoms do not improve with
splinting, daytime immobilization for 3 weeks should be considered. Surgical release
may be warranted if the symptoms do not improve with conservative treatment. If the
symptoms do improve, conservative treatment should be continued for at least 6 weeks
beyond symptom resolution to prevent recurrence.

For mild cubital tunnel symptoms, a reversed elbow pad that covers the
antecubital fossa, rather than the olecranon, helps remind the patient to maintain the
elbow in an extended position and to avoid pressure on the nerve. At night, a pillow or
folded towel may be placed in the antecubital fossa to keep the elbow in an extended
position. For constant pain and paresthesia, one should consider using a rigid
thermoplastic splint positioned in 45° of flexion to decrease pressure on the ulnar nerve.
Patient education and insight are important. Resting on elbows at work, using elbows
to lift the body from bed, and resting elbows on car windows while driving all are
causes of paresthesia that can be corrected without surgical treatment.

9.2 Surgical Interventions

If nonsurgical methods fail and the patient has severe or progressive weakness
or atrophy, specific surgical techniques are often beneficial in cases of ulnar
neuropathy at the elbow. Surgery is also valuable for correction or stabilization of
traumatic injuries, resection of masses or cysts, and sectioning of fibrous bands.

Decompression in situ is essentially a localized decompression of the nerve,

accomplished by incising the Osborne ligament and opening the tunnel beneath the
two heads of the flexor carpi ulnaris by incising the fascia holding them together. The
main advantage of decompression in situ is the ability to release the ulnar nerve in
areas of compression with minimal disturbance of the blood supply. This procedure
avoids subluxation of the ulnar nerve, which may lead to a recurrence of symptoms.
The disadvantages of simple decompression are the potentially higher recurrence rate
and the risk of continued subluxation of the ulnar nerve over the medial epicondyle,
if that was present preoperatively.

Decompression with anterior transposition is usually the operation of choice for

ulnar nerve compression at the elbow. Its main advantage is that it moves the ulnar
nerve from an unsuitable bed to one that is less scarred. The nerve is effectively
lengthened a few centimeters with transposition, and this decreases the tension placed
on the nerve with elbow flexion. The primary disadvantage of an anterior transposition
is that it is more technically demanding than a simple ulnar nerve decompression. The
risk of complications is increased when the nerve is moved from its natural bed, and
there is a potential for devascularization of the ulnar nerve.
 Medial epicondylectomy is another technique for releasing pressure on the
ulnar nerve at the elbow. Removal of the epicondyle removes a compressive area.
Excision of the proper amount of bone is critical to the success of the procedure. If
too much bone is excised, damage to the medial collateral ligament of the elbow with
valgus instability may occur; if too little is removed, the procedure fails because the
compressive area remains. The main advantage of medial epicondylectomy is that it
provides a more thorough decompression of the ulnar nerve than a simple release does.
The primary disadvantage is that it allows greater migration of the ulnar nerve with
elbow flexion. There is a potential for elbow instability if the collateral ligaments are
damaged. Bone pain and nerve vulnerability at the epicondylectomy site may occur.
Compared with simple decompression, medial epicondylectomy is more likely to
result in elbow stiffness or an elbow flexion contracture.

10 Prognosis

Delays in repair increase the likelihood for nerve grafting, neuron loss, and
fibrosis of the distal stump. High ulnar nerve injuries traditionally have had poor
outcomes with regard to intrinsic muscle recovery. Once the nerve has been injured,
the motor end plates begin the process of degeneration. Functional recovery is
determined by the time required for the motor end plate to be reinnervated and by the
number of regenerated motor axons that can reach target muscle.

Only about 60% of patients, especially those with symptoms of less than 1
year’s duration, benefit from surgery, some experience worsening of symptoms. It
appears that those with more thickening of the nerve at the time of diagnosis. However,
the prognosis of ulnar nerve entrapment at the wrist is usually good after surgical
decompression with effective reinnervation.