Clinical testing ulnar nerve

Clinical testing ulnar nerve

• 1.
  Clinical Testing- Ulnarnerve Dr.Roopchand.PS Senior Resident Academics Department of Neurology
• 2.
  Introduction: • A mixednerve. • Main branch of the medial cord of the brachial plexus. • Root value is C7 C8 T1 • Main supply to the small muscles of hand. • Also called musicians nerve.
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  • ARM –crosses the axilla beneath the pectoralis minor – medial to the brachial artery in upper arm – distal arm it enters a groove between the medial humeral epicondyle and the olecranon process. – The cubital tunnel: Aponeurosis between the olecranon and medial epicondyle forms the roof of an osseous fibrous canal the floor of which is formed by the medial ligament of the elbow joint.
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  • ELBOW: – passes between the humeral and ulnar heads of the flexor carpi ulnaris to rest on the flexor digitorum profundus. – Immediately distal to the elbow joint • Br to flexor carpi ulnaris • Br to flexor digitorum profundus III and IV • FOREARM: – descends beneath the flexor carpi ulnaris – palmar cutaneous branch at distal forearm – supplies the skin over the hypothenar eminence.
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  – then givesof dorsal cutaneous branch. – supplies the dorsal ulnar aspect of the hand and the dorsal aspect of the 5th finger and half of the 4th finger. • WRIST: – enters the wrist lateral to the tendon of the flexor carpi ulnaris muscle. – gives of the superficial terminal branch – skin of the distal part of the ulnar aspect of the palm and the palmar aspect of the fifth and half of the 4th finger. – passes between the pisiform carpal bone medially and the hook of the hamate carpal bone laterally: canal of Guyon
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  • Passes asdeep muscular branch supplies: – Palmaris brevis (C8–T1). – Abductor digiti minimi (C8–Tl) – Opponens digiti minimi (C8–T1) – Flexor digiti minimi (C8–T1) – Lumbricals III and IV (C8–T1) – Interosseous muscles (C8–Tl) – Adductor pollicis (C8–T1) – Deep head of the flexor pollicis brevis (C8–Tl)
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  NERVE LESIONS: • Lesionsabove the Elbow: – May present as triad neuropathy. – sleeping with the arm hanging over a sharp edge or the head of a sleeping partner compressing the nerve against the humerus, crutches or tourniquets, arteriovenous fistulas in dialysis patients, aneurysms, hematomas, nerve tumors, and other masses. – Supracondylar fractures of the humerus – Ulnar entrapment neuropathy in the midarm: compression by the medial intermuscular septum
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  • “claw-hand” • Paresisor paralysis of the ulnar flexion • Impaired extension at the interphalangeal joints. • Impaired adduction and abduction of the second to 5th fingers. • Impaired abduction and opposition of the fifth finger. • Froment’s thumb sign : adductor pollicis weakness- proximal phalanx of the thumb is extended and the distal phalanx is flexed when a paper grasped between thumb and index finger is pulled. • Sensory abnormalities.
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  • Martin-Gruber anastomosis:a median-ulnar communication. – the crossing of fibers from the median to the ulnar nerve usually occurs 3 to 10 cm distal to the medial humeral epicondyle. – median fibers ultimately innervate the intrinsic hand muscles. – The overall incidence of Martin-Gruber anastomoses is approximately 17%. – Four types exsists.
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  • Cubital TunnelSyndrome: lesion at the elbow – most commonly compressed at the elbow in the cubital tunnel. – Narrowing of tunnel during flexion, thickening of aponeurotic arch, ganglion cyst, mass lesions, fibrous bands, bony spurs… – More in patients with renal disease undergoing dialysis and during general anesthesia. – Tardy ulnar nerve palsy: ulnar nerve palsy occurring long after original injury. – A reliable sign of ulnar entrapment by the flexor carpi ulnaris muscle is the ulnar extension manoeuvre, in which increased paresthesias in the fourth and fifth digits follow 3 minutes of elbow and wrist flexion in ulnar deviation.
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  Cubital tunnel syndVs tardy ulnar palsy: • No evidence of joint deformity or prior trauma • Frequent occurrence of bilateral symptoms and signs of ulnar neuropathy • A taut, palpably enlarged nerve in the ulnar groove • Electrophysiologic (electromyographic) localization to the cubital tunnel • Operative findings of a swollen, taut, hyperemic nerve, distally limited by the proximal border of the aponeurosis joining the two heads of the flexor carpi ulnaris muscle.
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  • Ulnar neuropathyat the elbow often spares the flexor carpi ulnaris • involvement of flexor carpi ulnaris more often correlates with the severity of the neuropathy. • Involvement related to the internal topography of the nerve, severity of compression, level of compression. • preferentially compress the nerve fascicle to distal hand muscles
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  • Lesions inthe Forearm: – Causes: hypertrophied flexor carpi ulnaris muscle, fibrous and fibrovascular bands, hematomas, and handcuffs. – flexor carpi ulnaris and the flexor digitorum profundus iand II muscles are often spared
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  Lesions at theWrist and in the Hand: • Flexor carpi ulnaris and the flexor digitorum profundus III and IV are spared. • Compression of the nerve as it enters the hand. • Compression of the proximal part of the terminal motor branch(with in Guyons canal) • Distal compression of the terminal motor br.
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  • Common causes: – Ganglion, occupational neuropathy, laceration, ulnar artery aneurysm, carpal bone fracture. • Palmaris brevis spasm syndrome: following the prolonged use of a computer mouse and keyboard. • Lesions of the Dorsal Cutaneous Branch of the Ulnar Nerve – Handcuff palsy, Pricer palsy • Pseudoulnar Nerve Palsy: isolated hand weakness apparently in an ulnar distribution that is due to • contralateral cerebral infarction in the white matter of the angular gyrus of the inferior parietal lobe