Ulnar Nerve Reconstruction Ppt

ULNAR NERVE INJURY Dr. Diyar A. Salih Plastic Surgery Resident KURDISTAN, SLEMANI

Main branch of the medial cord

Axilla: post (bet. Axillary A. & V)

Arm: medial to brachial A. Elbow: post. to medial epicondyle (Cubital tunnel) bet. FCU heads. Forearm: along medial side of FDP, adjacent to ulnar A. Wrist: Guyon’s tunnel, adjacent to pisiform, deep to ulnar art. Superficial sensory branch Deep motor branch

Brachial A.

Sensation

Motor Forearm: 1. 2.

FCU. FDP (ring & little finger).

Hand: 1.

Hypothenar M: • • •

2. 3. 4. 5.

Abductor digiti minimi M. Flexor digiti minimi. Oppenens digiti minimi.

Seven interosseous M. (4 dorsal & 3 palmar). Adductor pollicis. Ring & little finger lumbricals. Flexor pollicis brevis.

Forearm

FDP (ring & little finger)

4 dorsal & 3 palmar interosseous

Hypothenar muscles

Lumbricals (ring & little finger)

Adductor pollicis

Flexor pollicis brevis

35% overlap by Median nerve.

Types of injuries 1. Neuropraxia. 2. Axonotmesis. 3. Neurotmesis.

CLASSIFICATION Upper

Lower

Neck

Below elbow

Brachial plexus

Wrist

At Elbow

Causes Causes 1. ACUTE • Trauma (fracture) • Wrong posture • Surgery • Electrical burn 2. CHRONIC • Tight nerve passages • Tumors

Presentations Presentations • • • • • • • •

Pain Sensation loss Motion loss Power loss Reflexes loss Wasting Trophic changes (skin,sc,neurovascular,bones,muscles) Contractures

Diagnosis • • • • •

Clinical examination X-RAY EMG (electromyography). NCS (nerve conduction studies). MRI

Ulnar nerve examination • F:\Ulnar nerve exam.flv

Low ulnar nerve palsy

Claw deformity

Lumbrical muscles palsy

Adductor pollicis

1st dorsal interosseous

Compensation FPL (stabilize thumb)

Froment’s sign EPL (adduct thumb)

Froment’s sign

Atrophy Normal

Wartenburg’s sign

Little fingerto Inability ulnar deviation adduct little finger against EDM pull.

Earle’s sign • Inability to abduct the middle finger to cross over the index finger dorsally.

High ulnar nerve palsy • Less clawing. • Reconstruction can improve function but not total improvement.

Treatment of injuries • Direct repair (tension free)

Nerve graft • If > 1 cm defect or repaired under tension.

Nerve conduit

Tendon transfer

Incisions Upper arm: Medial incision

At the elbow: over cubital tunnel

Forearm: along ulnar mid-axial line, splitting FCU two heads.

At the wrist: at the pisiform, extending distally parallel to the skin crease at the base of thenar eminence

Low ulnar nerve injury repair • F:\Low ulnar nerve injury.flv

Other measures (alone or with Tendon transfer) •

Prevention of MCP joint hyperextension:

3. MCP joint arthrodesis. 4. MCP joint capsulodesis. 5. Bone block on the dorsum of the MCP joint head.

Guyon’s tunnel syndrome (Handlebar palsy) Palmar sensory branch Motor branch Intrinsic M. Hypothenar M.

Ulnar A.

GTS causes

Direct trauma

Ulnar A. aneurysm

Sensation loss

Not dorsal surfaces: surfaces Ulnar N. branch 4-5 cm above Guyon’s canal (subcutaneously, distal to ulnar styloid process).

GTS treatment (surgical decompression) Pisohamate ligament

Cubital tunnel syndrome

Post. to MEC

Cubital tunnel syndrome

Strong fibrous conduit

•True nerve compression. •Nerve adhesion. •Prevent nerve gliding. •Stretch ischemia. ischemia •Impairs nerve conduction

Sensation loss

Dorsal surfaces

Cubital tunnel syndrome • Acute flexion of elbow for 30 min accentuates the sensory symptoms. • cubital tunnel.flv

Tinel sign & Froment test • F:\Tinel test & Froment test.flv

Treatment • Early cases: static elbow extension splint.

Treatment • Chronic cases: Ulnar nerve transposition anterior to the elbow axis of rotation.

Incision over the cubital tunnel

Medial epicondyle

Anterior to MEC

Posterior to MEC

Ulnar nerve anterior transposition • F:\Anterior transposition of the ulnar nerve.flv