Download Anterior traslocation of the ulnar nerve

Dipartimento dell’Apparato Locomotore
S.C. di Chirurgia della Mano e Microchirurgia: Dir. Dr. A. Landi
Azienda Ospedaliero-Universitaria
Policlinico di Modena (ITALY)
LESION IN CONTINUITY OF P.N.:
COMPRESSION
OF THE ULNAR NERVE
A. Landi
Responsabile servizio Archiviazione Informatica: M. Mancini
11 maggio 2010
COMPRESSION OF THE ULNAR NERVE
Ulnar Nerve Innervation
Arises from the medial cord of the brachial plexus
Roots C7,C8, T1
Wrist and Hand
• Abductor digiti minimi C8,
T1
• Flexor digiti minimi C8, T1
• Lumbricales (3rd and 4th)
C8, T1
• Flexor pollicis brevis (deep
branch) C8, T1
• Adductor pollicus C8, T1
Ulnar Nerve Innervation
Arises from the medial cord of the brachial plexus
Roots C7,C8, T1
Wrist and Hand
• Opponens digiti minimi C8, T1
Ulnar Nerve Innervation
Arises from the medial cord of the brachial plexus
Roots C7,C8, T1
Wrist and Hand
• Interossei (palmar and
dorsal) C8, T1
C7
C6
C8
C6
T1
C5
C7
Assessment of injury to
C8
the roots
of the brachial plexus
or disruption of the
spinal cord
necessitates testing
of dermatomes
C8
C6
C6
T1
C5
Anatomical variation on sensory distribution
Anatomical variation on motor distribution
How to assess the level of
compression
• Inspection
• Palpation
• The provocative manoeuvres
• The sensory evaluations
• The motor evaluations
• The anatomical variations
• The electrophysiological assessment
• The Jamar and Pinch tests
Muscular evaluation
(M0 - M5 grading system)
Ulnar Nerve Paralysis
Wartemberg Sign
Inability to adduct the
extended little finger to
the extended ring finger
X
Grasp Strength Test
Pinch Strength Test
Sensory evaluation
Semmes-Weinstein
Monofilaments
ASSESSMENT OF THE
UNDERLYING JOINT
• The unstable MP Joint
• The stiff claw hand
Compression of the ulnar nerve
at the elbow
Motor deficits:
- FCU
- FDP 4th and 5th
- ulnar intrinsic
- usually no claw-hand deformity
- sensory deficit volar + dorsal aspect 4th and 5th
finger
Cubital Tunnel Compression
Symptoms: patient
complains of hand
weakness and
numbness of the ring
finger and small finger
with a diminished
sensory test both volar
and dorsally
Compression of the ulnar nerve
at the wrist
Motor deficits:
- ulnar intrinsic
- claw-hand deformity
- sensory deficit volar + dorsal aspect 4th and 5th
finger
Guyon’s Canal Compression
Symptoms: Sensory
deficit in the volar aspect
of the fifth digit and the
ulnar side of the fourth,
intrinsic muscle weakness
Decreased pinch and grip
strength with pain over
volar wrist and fifth digit
Adjunctive investigations in the
diagnosis of compressive syndromes of
the ulnar nerve
• X-rays: Cervical rib, malunions of the
humerus, osteofytes, pseudotumoral uremic
calcinosis, systemic sclerodermia…
• Ultrasonography: Ganglions, Muscles…
• MRI: Definitions of soft tissue tumours
+ MRI angiography
• Electrophysiological investigations
• Doppler: pseudoaneurism, thrombosis of the
ulnar artery
Compression of the ulnar nerve at the
elbow: indication for simple decompression
• Absence of trauma on history
• Absence of skeletal deformities
• Absence of subluxation or frank dislocation of the
nerve
• Hyatropatic compressions following general
anaesthesia
Diabetic neuropathy
The compression of the median nerve at the
wrist and the unlnar nerve at the elbow
Compression of the ulnar nerve at the
elbow: indication to anterior transposition
• Post-traumatic varus and valgus deformities
• Subluxation or frank dislocation of the nerve
• In association to oedematous neuropathies
Epiphiseal trauma of the throclea
• Salter Type V
• Varus deformity of the elbow
Ulnar nerve compression
Children:
Vedge osteotomy
Adult:
Ulnar nerve transposition
Anterior traslocation of the
ulnar nerve
Surgical technique
Submuscolar transposition of the
ulnar nerve
• In presence of functional failures
following previous surgery
• In association with initial or hyatrogenic
neuropathic conditions
• In presence of a scarred bed
THE FASCIO- SEPTAL RELEASE
The painful conditions of the
ulnar nerve
• The neurodesis effect = inflammatory response
= generation of ectopic impulses
• The hyatropatic lesions
a) Chemical injections
b) Following coronaries by pass surgery
c) Injury of the medial brachial and antibrachial
cutaneous sensory branches*
* I Sarris, F Goebel, M Gainer et Al. Medial brachial and antibrachial cutaneous nerve injuries:
effect on outcome revision cubital tunnel surgery. Journal of Reconstructive microsurgery 18
(8): nov 2002
• Chemical lesion by local injection of reparil on the ulnar
nerve at the elbow…
• Complete motor and sensory recovery following external
neurolysis but… unberable pain, the patient is placing the
hand undfer a pillow and had to give up any avocational
activities
The entrapment neuropaties at the
elbow: Differential diagnosys
beetwen
•
•
•
•
The post traumatic compression
The hyatropathic lesions
The compression in tumoral conditions
The compression in infectious diseases:
lepromatous neuropathy
Elbow dislocation
• Posterior dislocation might be
associated to radial nerve palsy
• Pure lateral elbow dislocation
causes traction of the ulnar nerve,
due to the integrity of the cubital
tunnel
• In postero lateral dislocation the
ulnar nerve may escape to traction
for the damage of the roof of the
cubital tunnel
The dislocation of the medial epicondyle
into the elbow joint
• The medial epicondyle usually
completes its maturation at 18 yrs of age
• When the medial epicondyle is not
visible on X-ray, following an elbow
trauma, it might have been entrapted
into the elbow joint, with consequences
for joint functionality and with ulnar
nerve entraptment
The foreign body reaction
Compression of the ulnar nerve
in lipofibromatous hamartoma
Compression of the Ulnar
Nerve at the wrist
Compression of the Ulnar Nerve in Guyon’s Canal
Symptoms: Sensory deficit
in the volar aspect of the
fifth digit and the ulnar side
of the fourth,
intrinsic muscle weakness
Decreased pinch and grip
strength with pain over volar
wrist and fifth digit
The Ulnar Nerve at the Wrist
The dorsal cutaneous
branch of the ulnar
nerve comes off
proximal to Guyon’s
Canal therefore,
dorsal sensory
involvement of the
4th and 5th digit
would indicate a
problem proximal to
the wrist.
Ulnar nerve
Dorsal digital
branch
Palmar cutaneous branch
COMPRESSION BY A GANGLION
The vascular lesions in association to the
ulnar nerve compression at the wrist
with no vascular
related symptoms
The vascular lesions in association to
the ulnar nerve compression at the
wrist
with vascular related symptoms
Compression of the dorsal
coutaneous branch*
* JAI Grossman,I Yen, D Rapaport: The dorsal cutaneous branch of the ulnar nerve.
Annales de la chirurgie de la main 1998 (17) 2
Ulnar Nerve Paralysis
Classification of Distal Ulnar Nerve Compression
Type I = both motor and sensory branches proximal to the
wrist
Type II = involves only the motor branch at the hook of the
hamate and at the distal part of the canal
Type III = involves only the superficial volar sensory
branch
The entrapment neuropaties at the wirst:
Differential diagnosys beetwen
The post-traumatic
compression
The stiff claw-hand
deformity
The ulnar nerve within the
double crush syndromes
• The Cervical cord compression and
osteoarthryties of the cervical spine
• Thoracic outlet syndrome:
a) Clinical assessment
b) Adjunctive investigations
- MRI: (Scalenic space)
- F-wave
- SEPs
- Magnetic stimulation of the brain
The clinical sign of the double crush
syndrome
Differential Diagnosis
• Amyotrofic Lateral Sclerosis
• M.N.D.
• The Thoracic Outlet syndrome
• The pseudoclaw by muscle sarcoidosis
• The psycotic hand
Paralisi dell’abduttore breve
ed opponente del pollice
provocato dal margine anteriore
tagliente dello scaleno medio
By curtesy of dr P. Raimondi
TPI
Paralisi degli intrinseci tenari e
”griffe”ulnare provocata da marcata
compressione-frizione del tronco
primario inferiore davanti al margine
anteriore dello scaleno medio
By curtesy of dr P. Raimondi
*
Conclusions
• The level of compression of the ulnar
nerve (be aware of the anatomical
variations)
• The multiple sites of compression
• The priority of distal decompression
• The different aetiologies
• The exclusion of the different D.D.
• Treatment tailored on individual basis