DIAGNOSIS AND MANAGEMENT

OF ULNAR NERVE PALSY

BY:
AMA L I A FA R A HT IKA S R I KANDI
1 1 0 2014016

L EC T UR E A DV I S ER:
DR . DON N Y H HAMI D S P.S
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.
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.
 The demographic of patients with ulnar nerve palsy are disproportionately male in the working age
group (18 – 45 y.o)
 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.
Anatomy
Etiology
The ulnar nerve can be damaged by:
Acute trauma
Chronic pressure
Entrapment
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.
Patophysiology
To help clinicians grade the degree of injury to a peripheral nerve, various systems have been
developed which correlate microscopic changes after injury with symptoms of the patient.
Seddon's classification, which is used more frequently in a clinical setting, consists of three
terms to describe injury to a peripheral nerve.
Ulnar Nerve Entrapment at the Elbow
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).
Ulnar Nerve Entrapment at the Wrist
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.
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.
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.
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).
Ulnar Nerve Entrapment at the Wrist
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.
Diagnosis
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.
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.
Complaints:
sensory changes in the fourth and fifth digits
pain tend to be more common in the arm, up to and including the elbow area.
hands “look older.”
Weakness
PHYSICAL EXAMINATION
Check elbow range of motion
Check for the Tinel sign
Perform an elbow flexion test
Consider a shoulder internal rotation test
Test abduction of the little finger against
resistance
Test abduction of the index finger against
resistance
Check for clawing of the 4th and 5th fingers
Froment’s sign
Unable to cross the middle and index fingers
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
RADIOGRAPHY
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).
ELECTROMYOGRAPHY
Electromyography (EMG) and nerve conduction studies are indicated to confirm the area of
entrapment.
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).
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.
Differential Diagnosis
 Compression of the eight cervical root at (C7-T1) may mimic ulnar nerve palsy.
 Elbow fracture/dislocation
Cervical radiculopathy
 Alcohol (Ethanol) related neuropathy
Primary bone tumors, peripheral polyneuropathy
Treatment
NON-SURGICAL THERAPY
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.
Strengthening the elbow’s flexors and extensors both isometrically and isotonically within 0-45°
of range of motion
The patient should be advised to decrease repetitive activities that may exacerbate symptoms.
If symptoms do not improve with splinting, daytime immobilization for 3 weeks should be
considered.
If the symptoms do improve, conservative treatment should be continued for at least 6 weeks
beyond symptom resolution to prevent recurrence
SURGICAL THERAPY
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.
Decompression with anterior transposition is usually the operation of choice for ulnar nerve
compression at the elbow.
Medial epicondylectomy is another technique for releasing pressure on the ulnar nerve at the
elbow. Removal of the epicondyle removes a compressive area.
Prognosis
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 years 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.