Download COMPRESSION OF THE DEEP PALMAR BRANCH OF THE ULNAR

COMPRESSION
OF THE
DEEP
Case
J.
Paralysis
following
The
Report
BRANCH
and Anatomical
R. C. MULHOLLAND
HAYES,
R.
PALMAR
B. T.
and
OF THE
of this region
study
confirms
pisiform
bone
to
the
and a series
that there
hook
of
of anatomical
is in all hands
the
hamate,
O’CONNOR,
OSWESTRY,
dissections
a ligamentous
lying
superficial
suggested
this structure,
anatomical
by
reference
Kopell
which our
texts (Quain
Spalteholz
1959;
1967) or by other
as
Zuckerman
writers
of the
and
(1963).
Thompson
dissections
demonstrated,
1836; Morris
1953; Grant
described
hypothenar
due
suddenly
aged
about
forty-six
ten
days
engineer.
He
On examination
of the ring and little
to light
touch
and
service
weakness
minimi
of the
The
before.
to the
nerve,
and
of the
(Nicolle
and
(Torok
deep
branch
Giora
supplied
patient,
by the
is not
a
ulnar
presence
of
in the standard
and Fyfe 1959;
1964;
neuropathy.
Last
Woolhouse
the
ulnar
of the
the constant
and
the
1966;
Gray
One previous
1965)
and
another
1964).
REPORT
of clumsiness
The
of
Nevertheless,
to trauma
from
branch
who
of
was
his
left
hand.
right-handed,
This
worked
had
as
ulnar
nerve
with
the
three
months,
exception
of the
come
on
a refrigerator
could
not recall any recent
injury
to the hand.
the only abnormal
findings
were in the left hand,
where
there
fingers
of the type associated
with ulnar
nerve
lesions.
No
pinprick,
and no abnormality
of sweating
were
detected.
muscles
patient
was
gradually
the ulnar
Operation
Stretched
nerve.
sharply
it were
its
angled
pushed
the
course
the
by
the
Since
the
the
operation
was
not
the
was clawing
sensory
loss
There
was
abductor
(Fig.
I).
excised,
of the
above
surgical
to
under
which
explore
a ligamentous
as immediately
The
and
digiti
the
the
clawing
deep
ganglion,
the
band
band;
proximal
which
was
divided
and
branch
was found.
deep branch
it appeared
to this
appeared
of
the
to
because
to
nerve
be
be
was
arising
it seemed
to
nerve.
four
has
noticed
months
gradual
findings,
improvement
in his
muscle
weakness,
later.
ANATOMICAL
In view
during
decided
filled with reddish
mucoid
material
branches
of the ulnar
nerve.
The
pass
band,
was
patient
complete
to
of the
ganglion
in compressing
recovery
seen
edge
joint,
therefore
a ganglion
superficial
was
free
for
It was
operation
deep and
triquetro-hamate
a factor
observation
worse.
the
normal
round
forward
from
under
became
and progress-At
over
in resuming
but
deep
passes
deep
muscle.
weakness
be
complained
is well recognised.
a review
of the
is not well recognised
either
1958; Lockhart,
Hamilton
it as an anomaly
muscles
CASE
man
A
the
1961 ; Hollinshead
1962; Cunningham
this type of peripheral
entrapment
on
to this structure
fibrosis
ENGLAND
of the area.
band which
to
nerve.
This
is not the pisohamate
ligament,
which
lies
superficial
part of the flexor
retinaculum.
The role of this fibrous
band
as a cause of compression
was
NERVE
Study
of the muscles
supplied
by the deep branch
of the ulnar nerve
case is reported
because
the findings
at operation
prompted
anatomy
This
nerve
ULNAR
twenty-one
STUDY
hands
in
twelve
necropsy
subjects
were
dissected.
VOL.
51 B,
NO.
3, AUGUST
1969
469
470
J. R. HAYES,
Exposure
branch
deep
extended
of the
with
the
pisiform
gained
fascia
to
part
The
MULHOLLAND
branches
supplying
nerve,
distal
the hook
of their
overlying
structure
was rather
attenuated
the pisiform
with the ligamentous
the ulnar
sometimes
C.
AND
of the ulnar
nerve on the medial
passed
superficial
to the piso-hamate
from
the
little
finger
medially
R.
of the
ligament
O’CONNOR
hand
showed
and beneath
that in all cases the
a fibrous
arch which
of the hamate
(Fig.
2). The abductor
origin
from
this arch,
which
blended
the
and
side
B. T.
abductor
digiti
minimi
there were muscle
fibres
arch represented
on their
the
hypothenar
but the branch
to the ligamentous
to the
arch.
muscles
In
two
passing
between
deep surface.
always
abductor
muscle.
arose
muscle
from
the
the
sometimes
and
distally
subjects
the
hamate
and
deep
arose
flexor
and
branch
of
proximal
and
7SUPERFICIAL
I
BRANCH
DEEP
---.
----
t
1
__I
-,
1G.
Photograph
BRANCH
SHARP
EDGE
LIGAMENTOUS
*:N<::
-y
at operation.
The superficial
branch
of the
ulnar
nerve
is being retracted
by a blunt hook on the right.
A probe
is being passed
at the side of the deep branch,
so
that its tip lies under
the ligament.
The deep branch
of
the ganglion.
I,zset:
Diagrammatic
-
OF
BAND
GANGLION
PtSIFORM
BONE
the nerve can be seen
key to the photograph.
to be pushed
forwards
by
DISCUSSION
In the early
to
be neuritis
descriptions
of paralysis
of occupational
1908,
deep
branch
Harris
of the
1929,
due
Seddon
(.1952) then described
four cases
in which
exploration
to a ganglion,
Since Seddon’s
paper
further
cases have been
There
are three
different
patterns
of presentation
of paralysis
I) With
Richmond
sensory
1963,
Dupont
by
the
nerve
(Richmond
by
the
nerve
with
and
1948).
loss
the
weakness
1965);
2) with
1963);
the anatomical
is explained
loss
3)with
exception
Correlating
the ganglion is in the proximal
part of the flexor retinaculum
nerve
it was
1929,
thought
Russell
.
and
sensory
ulnar
Worster-Drought
Whitty
.
Wolff
of the
(Hunt
and
hand
1947,
origin
of the
by
of
no
no
all
rnucles
sensory.loss,
sensory
lypothenar
loss,
supplied
but
by
the.
weakness
but
muscles
showed
the
reported.
of the ulnar
to
nerve
in the
(Brooks
of all muscles
weakness
(Seddon
nerve
lesion
of
the
muscles
be
1952,
supplied
supplied
1952)
findings with the varying clinical presentation; complete motor
compression
of the nerve
before itdivides: This occurs whe9
part of the hand and compresses
(syndrome
de Ia loge de Guyon)
the n#{231}rve
against the superficial
(Merle
d’Aubign#{233} and Benassy
1956).
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
COMPRESSION
More
suggests
The
that,
distal
that
constant
whereas
beneath
the
previously
here.
ulna
PALMAR
do not
ganglia
compress
this
in
BRANCH
the
situation
also
is compressed
by Kopell
and
suggest
hand
be caused
dissections
that
some
between
Thompson
of the
OF
ULNAR
THE
superficial
enlarge
presence of the ligament described above
the superficial
branch
is free to be displaced
branch.
distally
provides
forwards,
of the
Richmond
rather
(1963)
thati
forwards.
an alternative explanation:
the deep branch,
passing
it and the ganglion.
This
(1963),
is well illustrated
atrophy
471
NERVE
intrinsic
method
of entrapment,
by the case reported
muscles
seen
in rheumatoid
where
there is marked
subluxation
of the carpal
bones
on the radius
and
by stretch
of the deep palmar
branch
against
this fibrous
arch.
show
that the level of the origin
of the nerve
supplying
the abductor
of the
may
Our
I)EEP
TUE
however,
is because
ligament,
suggested
They
arthritis
ganglia,
this
OF
ULNAR
NERV>!
DEEP
BRANCH
TO
ABDUCTOR
DIGITI
MINIMUS
FIG.
PISIFORM
Photograph
superficial
BONE
branch
On
the
medial
the deep
digiti
with
side
of
it the
branch
before
branch
to
passing
the
under
minimi
muscle
may be proximal
the possible
role of the ligament
abductor
digiti
of dissection
branch
is being
can be seen to pass
minimi
Inset:
the ligament.
can
be
or distal
to the ligament.
in producing
compression
the abductor
digiti
minimi
which
is so often
supply
to the abductor
digiti
minimi
probably
seen,
Diagrammatic
seen. In patients
arises
proximal.
2
of necropsy
specimen.
retracted
laterally.
The
under
arising
the ligamentous
from
the
main
The
deep
arch.
part
This variability
may explain
the
with this sparing,
to the ligament
combined
sparing
of
the nerve
and passes
beneath
it separately
from the main branch,
thus avoiding
compression.
It has been evident from these dissections that many minor variations occur in the anatomy
of the ulnar sideof
the hand.
Unusual
muscles
have been described
in this region
(Lipscomb
1960) and it is of interest
that both hands
in one subject
in this series showed
a well developed
accessory
palmaris
longus
muscle.
Cases
of ulnar nerve compression
due to an anomalous
muscle
have
been
reported
(Thomas
1958;
Schjeldetup
1964):
SUMMARY
I:
2.
A case of compression
Anatomical
evidence
to be compressed
VOL.
51 B,
NO.
3,
of the
is presented
by ganglia
AUGUST
1969
deep
branch
of the
that the reason
in this region
is its
ulnar
nerve is described.
the special
liability
of the deep
for
relationship
of
key to the photograph.
to a ligamentous
band
branch
which
472
i. R. hAYES,
passes
nerve.
3.
from
This
the
band,
pisiform
though
R. C. MULHOLLAND
bone
to
constant,
the
has
We would
like to thank
Mr D. A. Foster
Davies
and Miss B. Hood
for secretarial
AND
hamate
not
superficial
been
for the
assistance.
B. T. O’CONNOR
well
to
the
deep
branch
of
the
photographs
the
ulnar
recognised.
diagrams,
Mr
P. G.
Green
for
and
Mrs
G.
Branch
of
the
REFERENCES
BAKKE,
J. L.,
Ulnar
and
WOLFF,
Nerve.
D.
BROOKS,
M.
(1952):
CUNNINGHAM,
D.
Nerve
London : Oxford
C., CLOUTIER,
GRANT,
GRAY,
of Bone
J. C.
H.
by Simple
Press.
Joint
Surgery,
A Method
Y.,
Neuritis
Jour,zal
M.
(1929):
HOLLINSHEAD,
A.
W.
H.
Sixth
Descriptive
Pressure
(1962):
Textbook
Occupational
Diseases,
R. D.,
LOCKHART,
Faber
35,
34-B, 391.
J. Ronianes.
Surgery,
edited
by G.
Syndrome
at the Wrist.
edition.
and
London:
Bailli#{232}re, Tindall
Thirty-fourth
Applied.
edition,
& Cox
edited
Ltd.
by D. V. Davies.
Neuritis
of
the
Deep
Palmar
Branch
of
the
Ulnar
Nerve.
British
New
ofAnatomy.
Neuritis
ofthe
Deep
York
: Harper
Palmar
& Row.
Branch
ofthe
Ulnar
Nerve.
Jourizal
of Nervous
673.
HAMILTON,
G.
F., and
FYFE,
F. W.
(1959):
Baltimore:
Neuropathies.
London:
J. & A.
Soft-tissue
Anatomy
ofthe
Churchill
Ltd.
ofthe
Hand.
Tumor
Huma,z
The
London:
Body.
Williams
Report
Faber
&
Limited.
R.,
and
Paralysies,
p. 162.
MoRRIS, Sir H. (1953):
Blakiston
Company.
D’AUBIGNE,
By
NICOLLE,
F. V.,
and
of Trauma,
J. (1836):
D.
45-B,
513.
W.
RUSSELL,
Nerve.
The
R.,
H.
SCHJELDERUP,
d’Aubign#{233}, J. B#{233}nassy and
F.
Syndrome
Eleventh
Anatomy.
WOOLHOUSE,
Muscles
and
M.
(1965):
de Ia Loge
edition,
Nerve
de Guyon.
J.-O.
edited
In Chirurgie
Ramadier.
Paris:
by J. Parsons
Compression
Orthop#{233}dique
Masson
Schaeffer.
Syndromes
of
the
des
et Cie.
New
Upper
York:
Limb.
The
Journal
WHITTY,
Human
Ganglion
C. W.
Body.
with
M.
(1947):
London:
Ulnar
Nerve
Traumatic
Taylor
& Walton.
Compression.
Neuritis
Journal
of the Deep
ofBoize
Palmar
a,zdJoiizt
Branch
Surgery,
of the Ulnar
1, 828.
(1964):
Aberrant
361.
46-B,
H. J. (1952):
Carpal
and
ofthe
Carpal
Surgery,
of Bone
J. (1956):
Merle
Human
A. (1963):
Lancet,
Joi,zt
&NASSY,
R.
5, 313.
RICHMOND,
SEDDON,
a,zdJoi,zt
edition,
Ulnar-tunnel
(1965):
KOPELL, H. P., and THOMPSON,
W. A. L. (1963):
Peripheral
Entrapment
& Wilkins
Company.
LAST, R. J. (1966): Anatomy,
Regional
and Applied.
Fourth edition.
LIPSCOMB,
P. R. (1960):
Duplication
of Hypothenar
Muscles
Simulating
of a Case.
Journal
ofBone
and Joint
Surgery,
42-A,
1058.
and
Palmar
1, 98.
Me,ztal
QUAIN,
Deep
757.
ofAnatomy.
Occupational
J. R. (1908):
MERLE
the
ofBo,ze
Tenth
Anatomy.
DI0N,
of
549.
Ganglia.
of
and
47-A,
Anatomy,
60,
Textbook
PREvOST,
E.,
Pressure
Psychiatry,
: Longmans.
W.
and
Compression
Cunningham’s
Gray’s
MedicalJournal,
HUNT,
Occupational
and
G.
B. (1958):
London
HARRIS,
(1948):
University
and
(1967):
G.
of Neurology
J. (1964):
DUPONT,
Journal
H.
Archives
Joint
Surgery,
Muscle
Ganglion
34-B,
in the Hand
as a Cause
Causing
of Paralysis
Ulnar
of the
Nerve
Deep
Compression.
Branch
of the
Ulnar
Journal
of Bone
Nerve.
Jourizal
386.
(1959): Atlas of Human
Anatomy.
London:
Butterworth
& Co. (Publishers)
Ltd.
Jun. (1958):
Clinical
Manifestations
of an Accessory
Palmaris
Muscle.
Journal
of Boize and
Joint
Surgery,
40-A, 929.
TOROK,
G., and GI0RA, A. (1964):
Ulnar Nerve Lesion in the Palm Entrapment
Neuropathy
of Deep Branch
of
Ulnar Nerve.
Israel
Medical
Journal,
23, 121.
WORSTER-DROUGHT,
C. (1929):
Pressure
Neuritis
of Deep Palmar
Branch
of the Ulnar Nerve.
Britislz
Medical
W.
SPALTEHOLZ,
THOMAS,
C. G.,
Jour,zal,
ZUCKERMAN,
1, 247.
Sir 5. (1961):
A New
System
of Anatomy.
London:
Oxford
TIlE
University
JOURNAL
Press.
OF
BONE
AND
JOINT
SURGERY