Ulna Nerve neuropathies Flashcards
Describe the anatomy/ course of the ulna nerve?
- From medial cord of brachial plexus C8- T1
- Arm
- Lies posteriomedial to Brachial artery-in ant compartment - upper arm
- Pierces Intramuscular sceptm at Arcade of Struthers
- 8cm from medial epicondyle & medial to triceps
- Arcade = band of aponeurotic band from medial im septum to medial head of triceps
- Elbow
- Runs behind medial epicondyle with Superior ulna collateral artery
- Cubital tunnel= roof - Osborne’s ligament ( fascia extension from 2 heads of FCU, and aponeurosis distally. floor = transverse and posterior bands of MCL
- Forearm
- 2 heads of FCU
- FCU and FDP
- Wrist
- Ulna nerve and Artery pass SUPERFICIAL to transverse carpal ligament
- Bificates into sensory and motor at Gyon’s canal
- Gyon canal
- roof - volar carpal ligament
- floor transverse carpal ligament, hypothenar muscles,
- ulna border- pisiform, psihamate ligaments, abductor digiti minimi-
- radial border- hook of hamate
Describe the motor supply of ulna nerve?
- Forearm
- FCU
- FDP 3/4 - Ring and little
- Thenar
- Adductor pollicis
- Deep head of flexor pollicis brevis
- Fingers
- Interossei- palmar
- 3rd/4th lumbricals
- Hypothenar muscle
- abductor digit minimi
- opponens digiti minimi
- flexor digiti minimi
What is Cubital Tunnel syndrome?
- A compressive neuropathy of the ulna nerve
- 2nd most common neuropathy
Describe the sites of entrapment?
- Between 2 heads of FCU - most common
- Arcade of Struthers
- Between Osborne’s ligament
- “FAO”
- less common
- Medial head of triceps
- medial intermuscualr septum]
- medial epicondyle
- Fascial bands within FCU
- Aconeus epitrochlearis
- External sources
- fracture and medial epicondyle non unions
- osteophytes
- heterotrophic ossification
- tumour and ganglionic cysts
Name any associated conditions of cubital tunnel syndrome?
- Cubitus varus/ vlagus
- Medial epicondylitis
- Burns
- Elbow contracture release
Describe the signs and symptoms of cubital tunnel syndrome?
Symptoms
- Parathesia of 1/2 of ring finger, small finger and ulnar dorsal hand
- Night symptoms- caused by sleeping arm in flexion
Signs
- Interosseous and First Web Space atrophy
- Ring and Small finger Clawing
- Ulna nerve subluxing over medial epicondyle during arm of movement in elbow
- Decrease sensation small, 1/2 ring fingers
- Motor
- Loss of ulna n- loss of inrinsics- interossei, lumbricals 4/5, Adductor pollicis
- Weakness gasp- Loss of MP joint flexion power
- Weak Pinch- loss of adductor pollicis- approx 70% strength lost
- Fromens sign- conpensatory flexion at IPJ by FPL due to loss of MCPJ flexion by adductor pollicis
- Jeannes sign- with key pinch- compensatory MCPJ hyperextension and thumb adduction by EPL due to loss of Adductor pollicis ( flexes MCPJ, Extends IPJ and adducts thumb)
- Warternberg’s sign- Persistent 5th MC abduction & extension during attempted adduction of finger- weak 3rd palmar interossei & small finger lumbrical.
- Pollock’s test- weakness of 2 ulnar FDP
- Tinels postive over cubital tunnel
- Elbow flexion test- postive if symptoms start w elbow flexion >60 seconds
Describe investigations useful to identify cubital tunnel syndrome?
EMG/NCV
- useful in diagnosis/prognosis
- Ulna nerve conduction velocity <50m/s across elbow
- reduction in amplitude for sensory n action potential and motor n action potential
Decribe the Tx for cubital tunnel syndrome?
Non operative
-
Nsaids, activity modification, & night time elbow splinting
- splinting =45o of extension , neutral rotation at night
- effective in 50% cases
Operative
-
Insitu ulna nerve decompresion without transposition
- When non op fails before motor function results
- Open release of cubital tunnel retinaculum
- arthroscopic release- favourable early data but no long term data
- Similar results with less complications cf transposition of nerve
- 80-90% gf results if denervation hasn’t occurred
- Poor prognosis associated with intrinsic Muscle Atrophy
-
Ulna nerve decompression and anterior transposition
- failed insitu release/throwing athelete,pt with poor ulna bed from tumour/osteophyte
- Subcutaneous, Submuscular, or intramuscular TRANSPOSITION of nerve
- similar outcomes to insitu release but can cause new site of compression
-
medial epicondylectomy
- Visible and subluxing ulna nerve
- Insitu release with medial epicondylectomy
- risk of destabilising elbow by damaging medical Ulnar Collateral ligament
what are the complications of cubital tunnel syndrome?
- Reocurrance - due to incomplete release. perineural scarring, or tethering of intermuscular septum of FCU fascia
- Neuroma formation-iatrogenic injury to medial antebrachial cutaneous branch of ulna nerve-> persistent posteriomedial elbow pain.
What is Ulnar tunnel syndrome?
- Ulnar nerve neuropathy caused by direct compressionin Guyon’s canal
- Aka Handlebar palsy- seen in cyclist
Describe the pathoantomy of ulnar tunnel syndrome?
cause of compression include:
- ganglion cyst
- lipoma
- ulnar artery thrombosis/ aneurysm
- Hook of hamate fracture
- Pisiform dislocation
- Inflammatory athritis
- Fibrous band / bony anamaly
- Congential bands
- Palmaris brevis bypertrophy
Describe the anatomy of Guyon’s canal?
- 4cm long
- begins at proximal extent of transverse carpal ligament
- Ends at aponeurotic arch of hypothenar muscle
- Ulna n branches into SUPERFICIAL SENSORY and DEEP MOTOR
- Floor= Transverse carpal ligament, hypothenar muscle
- Roof= Volar carpal ligament
- Ulnar border= Pisiform & psiohamate ligament, abductor digit minimi muscle belly
- radial border= hook of hamate
Describe the Zones of Guyon’s canal?
-
Zone 1- Proximal bifurcation of nerve
- Ganglia and Hook of hamate fr= compression
- Mixed Motor and Sensory symptoms
-
Zone 2- Surrounds deep motor branch
- Ganglia and hook of hamate fractures= comp
- Motor only symptoms
-
Zone 3- Surrounds superficial sensory branch
- Ulnar artery thrombosis / aneurysm
- Sensory symptoms only
What does the deep motor branch supply?
- All interossei and 3/4 lumbrical
- Hypothenar muscles- abductor digit minimi, Flexor digit minimi brevis, opponens digiti minimi, palmaris brevis
- Adductor pollicis
- Medial head ( deep) flexor pollicis brevis
Describe the signs and symptoms of ulnar tunnel syndrome?
Presentation depends on location of compression within Guyon’s canal and maybe
- Pure motor/ Pure Sensory/ Mixed sensory/motor
- Ulna n palsy -> paralysis of intrinsics (adductor pollicis, deep head of FPB, interossei, Lumbricals 4/5)
Symptoms
- Pain and parathesisa in ulnar 1-2 digits
O/E
- Clawing of ring and little fingers
- Loss of Intrinsics flexing the MCPs /extending IPJ
- Allen’s test - helps dx ulnar artery thrombosis
- Weakened Gasp- loss MCPJ flexion power
- Weak Pinch- loss thumb adduction ( AP)
- Froment sign- IP flexion compensates for loss of thumb adduction when attempting to hold peice of paper. IP Hyperflexion by FPL ( AIN)
- Wartenberg sign- adduction posturing of little finger
- Jeane’s sign- compensatory thumb MC hyperextension & thumb adduction by EPL. compensates for loss of IP extension and thumb adduction by adductor pollicis ( Ulnar)