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Ulnar nerve

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Ulnar nerve

  1. 1. ULNAR NERVE Khairul Nizam bin Abdul Rahman 4262143008
  2. 2. Anatomy ◦ Ulnar Nerve is one of the terminal branches of brachial plexus. ◦ It is the continuation of medial cord of brachial plexus which arises from the anterior division of the lower trunk. ◦ The fibers of ulnar nerve arise from the eight cervical and first thoracic nerve, so the root value of ulnar nerve is C8 and T1. These (C8,T1) coordinate to form the lower trunk of brachial plexus.
  3. 3. Origin of the Ulnar Nerve ◦ The ulnar nerve originates from the C8-T1 nerve roots (and occasionally carries C7 fibres) which form part of the medial cord of the brachial plexus.
  4. 4. Course of Ulnar Nerve
  5. 5. In the Axilla ◦ It descends on the medial side of the 3rd part of axillary artery between it and axillary vein.
  6. 6. In the Arm ◦ It descends on the medial side of brachial artery down to the insertion of coracobrachialis muscle, Pierces the medial intermuscular septum at the arcade of Struthers ~ 8cm from medial epicondyle and lies with triceps. Travels on back of medial epicondyle.
  7. 7. At the Elbow ◦ It reaches the back of med.epicondyle to enter the forearm between 2 heads of flexor carpi ulnaris(and here it is accompanied by sup.ulnar collateral a. and post. branch of inferior ulnar collateral arteries).
  8. 8. In the Forearm ◦ After passing between 2 heads of flexor carpi ulnaris, it descends vertically infront of med. side of flexor digitorm profunds covered by the flexor carpi ulnaris.
  9. 9. In the Hand ◦ It enters the palm of the hand by passing in front of med. part of flexor retinaculum between pisiform(medially) and the ulnar artery(laterally)& finally ends by dividing into superficial and deep branches.
  10. 10. Branches of Ulnar Nerve
  11. 11. At the Elbow ◦ The nerve gives branches to the Flexor Carpi Ulnaris and the medial half of the Flexor digitorum profundus.
  12. 12. In the Forearm ◦ The Ulnar Nerve divides into Dorsal and palmar cutaneous branches.
  13. 13. ◦ The Palmar cutaneous branch of the Ulnar Nerve provides sensation to the palm of the hand. ◦ The Finger sensation is provided by the superficial branch.
  14. 14. ◦ The Dorsal cutaneous branch of the Ulnar Nerve gives innervation to the medial dorsal aspect of the hand and the one and a Half Fingers.
  15. 15. In the hand ◦ The Nerve further divides into superficial and deep branches.
  16. 16. ◦ The superficial branch of the Ulnar nerve divides into Palmer digital nerves after it passes under and supplies the Palmaris brevis muscle.
  17. 17. ◦ The Deep branch of the Ulnar nerve innervates the three hypothenar muscles , the medial two lumbricals , the seven interossei , the adductor pollicis and the deep head of flexor pollicis brevis.
  18. 18. Ulnar innervated muscles Forearm: ◦ Flexor Carpi Ulnaris (C7, C8, T1) ◦ Flexor Digitorum Profundus III & IV (C7, C8) Thenar: ◦ Hypothenar Muscles (C8, T1) ◦ Adductor Pollicis (C8, T1) ◦ Flexor Pollicis Brevis (C8, T1) Fingers: ◦ Palmer Interosseous (C8, T1) ◦ Dorsal Interosseous (C8, T1) ◦ III & IV Lumbricles (C8, T1) Digiti Minimi: ◦ Abductor Digiti Minimi (Quinti) (C8, T1) ◦ Opponens Dgiti Minimi (C8-T1) ◦ Flexor Digiti Minimi. : ( C8-T1)
  19. 19. Functions ◦ The ulnar nerve is responsible for the pain, or 'funny bone', sensation that occurs if the elbow bone is suddenly struck. ◦ Continual pressure on the elbow or inner forearm may cause damage. Injury can also occur from elbow fractures or dislocations. ◦ Damage to the ulnar nerve causes problems with sensation and mobility in the wrist and the hand. ◦ In a patient with ulnar nerve damage, some of the fingers may become locked into a flexed position. This is sometimes nicknamed "claw hand. ◦ " Wrist movement is also often observed to be weaker with damaged ulnar nerves.
  20. 20. Ulnar Nerve Entrapment ◦ The Ulnar Nerve can become pinched in different locations . ◦ 1- Thoracic outlet syndrome . ◦ 2-cubital tunnel syndrome . ◦ 3-Ulnar Tunnel syndrome .
  21. 21. Classification of nerve injuries Mainly the type of nerve trauma depends on the mechanism of injury: ◦ Neuropraxia ◦ Axonotemesis ◦ Neurotemesis
  22. 22. Common sites of ulnar nerve injury The ulnar nerve is most commonly injured ◦ At the elbow, where it lies behind the medial epicondyle. The injuries at the elbow are usually associated with fractures of the medial epicondyle. ◦ At the wrist, where it lies with the ulnar artery in front of the flexor retinaculum. The superficial position of the nerve at the wrist makes it vulnerable to damage from cuts and stab wounds.
  23. 23. Ulnar Nerve injuries at elbow Cubital Tunnel Syndrome ◦ Causes of Ulnar Nerve entrapment around the cubital tunnel : 1.Cubitus Valgus : Deformity in which the elbow is turned outward 2.Spur : A spur on the Medial Epicondyle
  24. 24. Clinical Features Motor: ◦ The flexor carpi ulnaris and the medial half of the flexor digitorum profundus muscles are paralyzed. ◦ The paralysis of the flexor carpi ulnaris can be observed by asking the patient to make a tightly clenched fist. ◦ Normally, the synergistic action of the flexor carpi ulnaris tendon can be observed as it passes to the pisiform bone; the tightening of the tendon will be absent if the muscle is paralyzed.
  25. 25. ◦ The profundus tendons to the ring and little fingers will be functionless, ◦ The terminal phalanges of these fingers are therefore not capable of being markedly flexed. ◦ Flexion of the wrist joint will result in abduction, owing to paralysis of the flexor carpi ulnaris. ◦ The medial border of the front of the forearm will show flattening owing to the wasting of the underlying ulnaris and profundus muscles. ◦ The small muscles of the hand will be paralyzed, except the muscles of the thenar eminence and the first two lumbricals, which are supplied by the median nerve.
  26. 26. ◦ The patient is unable to adduct and abduct the fingers and consequently is unable to grip a piece of paper placed between the fingers. ◦ It is impossible to adduct the thumb because the adductor pollicis muscle is paralyzed. ◦ If the patient is asked to grip a piece of paper between the thumb and the index finger, he or she does so by strongly contracting the flexor pollicis longus and flexing the terminal phalanx (Froment's sign). ◦ The metacarpophalangeal joints become hyperextended because of the paralysis of the lumbrical and interosseous muscles, which normally flex these joints. ◦ The interphalangeal joints are flexed, owing again to the paralysis of the lumbrical and interosseous muscles, which normally extend these joints through the extensor expansion.
  27. 27. ◦ The flexion deformity at the interphalangeal joints of the fourth and fifth fingers is obvious because the first and second lumbrical muscles of the index and middle fingers are not paralyzed. ◦ In long-standing cases the hand assumes the characteristic claw deformity (main en griffe). ◦ Wasting of the paralyzed muscles results in flattening of the hypothenar eminence and loss of the convex curve to the medial border of the hand. ◦ Examination of the dorsum of the hand will show hollowing between the metacarpal bones caused by wasting of the dorsal interosseous muscles.
  28. 28. Sensory: ◦ Loss of skin sensation will be observed over the anterior and posterior surfaces of the medial third of the hand and the medial one and a half fingers.
  29. 29. Vasomotor Changes: ◦ The skin areas involved in sensory loss are warmer and drier than normal because of the arteriolar dilatation and absence of sweating resulting from loss of sympathetic control
  30. 30. Ulnar Nerve injuries at wrist Guyon’s Canal Syndrome ◦ Sometimes called Guyon's tunnel syndrome ◦ Is a common nerve compression affecting the ulnar nerve as it passes through a tunnel in the wrist called Guyon's canal.
  31. 31. Clinical Features Motor: ◦ The small muscles of the hand will be paralyzed and show wasting, except for the muscles of the thenar eminence and the first two lumbricals. ◦ The clawhand is much more obvious in wrist lesions because the flexor digitorum profundus muscle is not paralyzed, and marked flexion of the terminal phalanges occurs.
  32. 32. Sensory: ◦ The main ulnar nerve and its palmar cutaneous branch are usually severed ◦ The sensory loss will therefore be confined to the palmar surface of the medial third of the hand and the medial one and a half fingers and to the dorsal aspects of the middle and distal phalanges of the same fingers.
  33. 33. Vasomotor and trophic changes: ◦ These are the same as those described for injuries at the elbow. It is important to remember that with ulnar nerve injuries, the higher the lesion, the less obvious the clawing deformity of the hand.
  34. 34. Medical Management Non-steroidal anti-inflammatory medicines ◦ Such as ibuprofen to help reduce swelling around the nerve. Steroids injection ◦ Like cortisone are very effective anti-inflammatory medicines.
  35. 35. Surgical Management Cubital tunnel release ◦ In this operation, the ligament ‘roof’ of cubital tunnels is cut and divided. This increases the size of the tunnel and decrease pressure on nerve. Ulnar nerve anterior transposition ◦ Moving the nerve to the front of medial epicondyle to prevents it from getting caught on bony ridge and stretching when bends the elbow. Medial epicondylectomy ◦ Another options to release the nerve is to remove part of medial epicondyle.
  36. 36. Physiotherapy Management Bracing or splinting ◦ To keep the elbow straight in position at night. Nerve gliding exercises ◦ Helps the ulnar nerve slide through the cubital tunnel at the elbow and the Guyon’s canal at the wrist. ◦ Also helps the arm and wrist from getting stiff.