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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. 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