Nerves - Ulnar

Question 1

Nerve roots of ulnar nerve?

Answer 1

C8-T1.

Question 2

What is the anatomical course of the ulnar nerve?

Answer 2

The ulnar nerve arises from the brachial plexus within the axilla region. It is continuous of the medial cord and contains fibres from spinal roots C8 and T1.

After arising from the brachial plexus, the ulnar nerve descends in a plane between the axillary artery (lateral) and the axillary vein (medial). It proceeds down the medial aspect of the arm with the brachial artery located lateral.

At the mid-point of the arm, the ulnar nerve penetrates the medial fascial septum to enter the posterior compartment of the arm. It passes posterior to the elbow through the ulnar tunnel (small space between the medial epicondyle and olecranon). Here, it also gives arise to an articular branch which supplies the elbow joint.

In the forearm, the ulnar nerve pierces the two heads of the flexor carpi ulnar, and travels deep to the muscle, alongside the ulna. Three main branches arise in the forearm:

• Muscular branch - innervates two muscles in the anterior compartment of the forearm.
• Palmar cutaneous branch - inervates the medial half of the palm.
• Dorsal cutaneous branch - innervates the dorsal surface of the medial one and a half fingers, and the associated dorsal hand area.

At the wrist, the ulnar nerve travels superficially to the flexor retinaculum, and is medial to the ulnar artery. It enters the hand via the ulnar canal (Guyon’s canal). In the hand, the nerve terminates by giving rise to superficial and deep branches.

Question 3

What is the motor function of the anterior forearm of the ulnar nerve?

Answer 3

Supplies two muscles:

1) Flexor carpi ulnaris - flexes and adducts the hand at the wrist.
2) Flexor digitorum profundus (medial half) - flexes the ring and little fingers at the distal interphalangeal joint.

The remaining muscles in the anterior forearm are innervated by the median nerve.

Question 4

What is the motor function of the hand of the ulnar nerve?

Answer 4

The majority of the intrinsic hand muscles are innervated by the deep branch of the ulnar nerve:

• Hypothenar muscles (a group of muscles associated with the little finger)
• Medial two lumbricals
• Adductor pollicis
• Palmar and dorsal interossei of the hand
• Palmaris brevis

The other muscles in the hand (such as the thenar eminence) are innervated by the median nerve.

Question 5

Clinical relevance - Froment’s sign

Answer 5

Froment’s sign is a test for ulnar nerve palsy - specifically paralysis of the adductor pollicis.

• The patient is asked to hold a piece of paper between the thumb and index finger, as the paper is pulled away.
• They should be able to hold the paper there with no difficulty (via adduction of the thumb).
• A positive test is when the patient is unable to adduct the thumb. Instead, they flex the thumb at the interphalangeal joint to try to maintain a hold on the paper.

Question 6

What is the sensory functions of the ulnar nerve?

Answer 6

There are three branches of the ulnar nerve that are responsible for its sensory innervation. Two of these branches arise in the forearm, and travel into the hand:

1) Palmar cutaneous branch - innervates the medial half of the palm.
2) Dorsal cutaenous branch - innervates the dorsal surface of the medial one and a half fingers, and the associated dorsal hand area.

The last branch arises in the hand itself:

1) Superficial branch - innervates the palmar surface of the medial one and a half fingers.

Question 7

Clinical relevance - ulnar palsy?

Answer 7

Damage at the elbow

Mechanism of injury: trauma at the level of the medial epicondyle (e.g. isolated medial epicondyle fracture, supracondylar fracture). It can also be compressed in the cubital tunnel.

Motor functions:

• All the muscles innervated by the ulnar nerve are affected.
• Flexion of the wrist can still occur, but is accompanied by abduction (due to paralysis of flexor carpi ulnaris and medial half of flexor digitorum profundus).
• Abuduction and adduction of the fingers cannot occur (due to paralysis of the interossei).
• Movement of the 4th and 5th digits is impaired (due to paralysis of the medial two lumbicals and hypothenar muscles).
• Adduction of the thumb is impaired, and the patient will have a positive Froment’s sign (due to paralysis of adductor pollicis).

Sensory functions - all sensory branches are affected, so there will be a loss of sensation over the area that the ulnar nerve innervates.

Characteristic signs - patients cannot grip paper placed between fingers, positive Froment’s sign, wasting of hypothenar eminence.

Damage at the wrist

Mechanism of injury - lacerations to the anterior wrist.

Motor functions -

• Only the intrinsic muscles of the hand are affected.
• Abduction and adduction of the fingers cannot occur (due to paralysis of the interossei.
• Movement of the 4th and 5th digits is impaired (due to paralysis of the medial two lumbricals and hypothenar muscles).
• Adduction of the thumb is impaired, and the patient will have a positive Froment’s sign (due to paralysis of adductor pollicis).

Sensory functions - the palmar branch and superficial branch are usually severed, but the dorsal branch is unaffected. This results in sensory loss over palmar side of medial one and a half fingers only.

Characteristic signs - patients cannot grip paper placed betwen fingers, positive Froment’s sign, wasting of hypothenar eminence.