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Questions and Answers
Within the context of ulnar nerve pathology, which of the following assessment findings would MOST decisively indicate axonotmesis rather than neuropraxia?
Within the context of ulnar nerve pathology, which of the following assessment findings would MOST decisively indicate axonotmesis rather than neuropraxia?
- Complete absence of voluntary motor function in the intrinsic hand muscles innervated by the ulnar nerve, coupled with demonstrable Wallerian degeneration on EMG. (correct)
- Sharp, shooting pain along the course of the ulnar nerve upon palpation at the cubital tunnel, without demonstrable motor weakness.
- Preserved ability to generate a weak voluntary contraction in the abductor digiti minimi, coupled with diminished distal sensation.
- Mild paresthesia in the fourth and fifth digits, exacerbated by sustained elbow flexion, resolving within minutes of elbow extension.
Given the anatomical course of the ulnar nerve, compression within Guyon's canal will invariably manifest as both sensory and motor deficits in the palmar cutaneous distribution.
Given the anatomical course of the ulnar nerve, compression within Guyon's canal will invariably manifest as both sensory and motor deficits in the palmar cutaneous distribution.
False (B)
In the context of ulnar nerve entrapment at the cubital tunnel, explain the biomechanical rationale for why sustained elbow flexion exacerbates compressive forces on the nerve.
In the context of ulnar nerve entrapment at the cubital tunnel, explain the biomechanical rationale for why sustained elbow flexion exacerbates compressive forces on the nerve.
Sustained elbow flexion reduces the volume of the cubital tunnel and increases tension on the arcuate ligament of Osborne, thereby elevating the compressive forces on the ulnar nerve.
Following a complete transection of the ulnar nerve at the level of the wrist, the resulting motor deficit would MOST notably impair the function of the ______ muscle, leading to weakness in thumb adduction.
Following a complete transection of the ulnar nerve at the level of the wrist, the resulting motor deficit would MOST notably impair the function of the ______ muscle, leading to weakness in thumb adduction.
Match the following clinical presentations with the MOST likely underlying mechanism of ulnar nerve injury:
Match the following clinical presentations with the MOST likely underlying mechanism of ulnar nerve injury:
Which of the following interventions would be MOST appropriate, and evidence-based, for the IMMEDIATE management of acute ulnar nerve compression at the elbow following a traumatic injury, assuming no fracture?
Which of the following interventions would be MOST appropriate, and evidence-based, for the IMMEDIATE management of acute ulnar nerve compression at the elbow following a traumatic injury, assuming no fracture?
The presence of anhidrosis (decreased sweating) in the fifth digit is pathognomonic for ulnar nerve injury and definitively localizes the lesion proximal to Guyon's canal.
The presence of anhidrosis (decreased sweating) in the fifth digit is pathognomonic for ulnar nerve injury and definitively localizes the lesion proximal to Guyon's canal.
Explain the neurophysiological basis for the presence of a positive Tinel's sign along the course of a regenerating ulnar nerve following a crush injury.
Explain the neurophysiological basis for the presence of a positive Tinel's sign along the course of a regenerating ulnar nerve following a crush injury.
In the differential diagnosis of hand weakness, a lesion affecting both the median and ulnar nerves at the level of the carpal tunnel is exceedingly rare; however, such a presentation would result in a characteristic loss of both thumb abduction and ______, distinguishing it from isolated carpal tunnel syndrome.
In the differential diagnosis of hand weakness, a lesion affecting both the median and ulnar nerves at the level of the carpal tunnel is exceedingly rare; however, such a presentation would result in a characteristic loss of both thumb abduction and ______, distinguishing it from isolated carpal tunnel syndrome.
Match the following clinical findings with the MOST likely associated classic deformity resulting from chronic ulnar nerve dysfunction
Match the following clinical findings with the MOST likely associated classic deformity resulting from chronic ulnar nerve dysfunction
Which of the following electrodiagnostic findings would MOST strongly suggest a diagnosis of severe ulnar neuropathy at the elbow, characterized by axonal loss?
Which of the following electrodiagnostic findings would MOST strongly suggest a diagnosis of severe ulnar neuropathy at the elbow, characterized by axonal loss?
Surgical transposition of the ulnar nerve is uniformly successful in alleviating symptoms of cubital tunnel syndrome, regardless of the underlying etiology or chronicity of the compression.
Surgical transposition of the ulnar nerve is uniformly successful in alleviating symptoms of cubital tunnel syndrome, regardless of the underlying etiology or chronicity of the compression.
Explain the potential role of aberrant or accessory muscles (e.g., the epitrochleoanconeus) in the pathogenesis of cubital tunnel syndrome.
Explain the potential role of aberrant or accessory muscles (e.g., the epitrochleoanconeus) in the pathogenesis of cubital tunnel syndrome.
During assessment of suspected ulnar nerve dysfunction, performance of the Fromemt's sign is specifically testing weakness of the ______ muscle, which results in compensatory flexion of the thumb to maintain pinch grip.
During assessment of suspected ulnar nerve dysfunction, performance of the Fromemt's sign is specifically testing weakness of the ______ muscle, which results in compensatory flexion of the thumb to maintain pinch grip.
Match each of the following clinical scenarios with the MOST appropriate neurodynamic test to assess ulnar nerve involvement:
Match each of the following clinical scenarios with the MOST appropriate neurodynamic test to assess ulnar nerve involvement:
In the context of rehabilitating a patient following ulnar nerve repair where is the most clinically reasonable point to start PROM exercises?
In the context of rehabilitating a patient following ulnar nerve repair where is the most clinically reasonable point to start PROM exercises?
The efficacy of splinting for cubital tunnel syndrome is primarily attributed to the immobilization effect, which reduces overall upper extremity movement and allows the ulnar nerve to heal.
The efficacy of splinting for cubital tunnel syndrome is primarily attributed to the immobilization effect, which reduces overall upper extremity movement and allows the ulnar nerve to heal.
In the context of post-operative management following ulnar nerve transposition, discuss the rationale for advising patients to avoid sustained elbow flexion and repetitive gripping activities during the initial healing phase.
In the context of post-operative management following ulnar nerve transposition, discuss the rationale for advising patients to avoid sustained elbow flexion and repetitive gripping activities during the initial healing phase.
In patients with ulnar nerve injuries, the presence of muscle wasting in the ______ eminence of the hand is a clinical sign indicating chronic denervation of ulnar nerve innervated intrinsic muscles.
In patients with ulnar nerve injuries, the presence of muscle wasting in the ______ eminence of the hand is a clinical sign indicating chronic denervation of ulnar nerve innervated intrinsic muscles.
Relate the intervention to the goal it addresses based on the information presented.
Relate the intervention to the goal it addresses based on the information presented.
Which of the following strategies represents the MOST evidence-informed approach to preventing contracture of unopposed antagonist muscles in cases of chronic ulnar nerve palsy?
Which of the following strategies represents the MOST evidence-informed approach to preventing contracture of unopposed antagonist muscles in cases of chronic ulnar nerve palsy?
The presence of a Colles' fracture is a contraindication for assessing ulnar nerve tension via ULTT4.
The presence of a Colles' fracture is a contraindication for assessing ulnar nerve tension via ULTT4.
What are the sensory distribution and muscles, respectively, that are tested when assessing the 4th and 5th digits for strength and sensation?
What are the sensory distribution and muscles, respectively, that are tested when assessing the 4th and 5th digits for strength and sensation?
In a patient presenting with suspected cubital tunnel syndrome, exacerbation of symptoms with elbow flexion, coupled with a positive Tinel's sign, suggests compression of the ulnar nerve beneath the ______ ligament.
In a patient presenting with suspected cubital tunnel syndrome, exacerbation of symptoms with elbow flexion, coupled with a positive Tinel's sign, suggests compression of the ulnar nerve beneath the ______ ligament.
Associate the listed MOI for ulnar nerve damage with the location where the damage is most likely to occur.
Associate the listed MOI for ulnar nerve damage with the location where the damage is most likely to occur.
Which of the following best explains the typical progression of motor involvement in the setting of chronic, progressive ulnar nerve compression at the elbow?
Which of the following best explains the typical progression of motor involvement in the setting of chronic, progressive ulnar nerve compression at the elbow?
Sensory assessment of the thenar eminence is critical in differentiating ulnar nerve pathology from median nerve pathology.
Sensory assessment of the thenar eminence is critical in differentiating ulnar nerve pathology from median nerve pathology.
Describe the anticipated findings on a nerve conduction study (NCS) that would be indicative of a demyelinating lesion of the ulnar nerve at the elbow, while sparing axonal integrity.
Describe the anticipated findings on a nerve conduction study (NCS) that would be indicative of a demyelinating lesion of the ulnar nerve at the elbow, while sparing axonal integrity.
When performing the Upper Limb Tension Test 4 (ULTT4) to assess ulnar nerve sensitivity, the addition of contralateral cervical side flexion is thought to increase nerve tension through the mechanism of ______.
When performing the Upper Limb Tension Test 4 (ULTT4) to assess ulnar nerve sensitivity, the addition of contralateral cervical side flexion is thought to increase nerve tension through the mechanism of ______.
Match the following clinical presentations with the MOST likely location of ulnar nerve compression:
Match the following clinical presentations with the MOST likely location of ulnar nerve compression:
In the immediate post-operative phase following ulnar nerve transposition, what specific positioning strategy is MOST critical to preserve the integrity of the surgical repair and optimize nerve healing.
In the immediate post-operative phase following ulnar nerve transposition, what specific positioning strategy is MOST critical to preserve the integrity of the surgical repair and optimize nerve healing.
Following an ulnar nerve injury, sensory re-education techniques are most effective when initiated immediately after the injury, regardless of the degree of nerve damage or the patient's sensory awareness.
Following an ulnar nerve injury, sensory re-education techniques are most effective when initiated immediately after the injury, regardless of the degree of nerve damage or the patient's sensory awareness.
Explain the neurophysiological rationale behind using gentle Swedish techniques or sensory stimulation using different textures in the rehabilitation of a reinnervated nerve
Explain the neurophysiological rationale behind using gentle Swedish techniques or sensory stimulation using different textures in the rehabilitation of a reinnervated nerve
Compression of the ulnar nerve at the wrist as it passes through the canal between the pisiform and hook of hamate is called ______'s canal.
Compression of the ulnar nerve at the wrist as it passes through the canal between the pisiform and hook of hamate is called ______'s canal.
Classify each of the following signs based on the action required to perform (Active) or the the muscle position (Resting) as listed in the document.
Classify each of the following signs based on the action required to perform (Active) or the the muscle position (Resting) as listed in the document.
When assessing a patient with suspected ulnar nerve dysfunction, which of the following clinical findings would MOST strongly indicate a lesion proximal to the bifurcation of the deep and superficial branches in Guyon's canal?
When assessing a patient with suspected ulnar nerve dysfunction, which of the following clinical findings would MOST strongly indicate a lesion proximal to the bifurcation of the deep and superficial branches in Guyon's canal?
Tardy ulnar palsy is caused by pressure to the hypothenar eminence from activities such as biking, jackhammering or typing.
Tardy ulnar palsy is caused by pressure to the hypothenar eminence from activities such as biking, jackhammering or typing.
Elaborate on the rationale for performing differential diagnosis for the source of ulnar nerve injuries.
Elaborate on the rationale for performing differential diagnosis for the source of ulnar nerve injuries.
According to what is presented, the ulnar nerve is derived from nerve roots ______ and ______.
According to what is presented, the ulnar nerve is derived from nerve roots ______ and ______.
Match each lesion area or syndrome with the listed description.
Match each lesion area or syndrome with the listed description.
Flashcards
Ulnar Nerve Origin
Ulnar Nerve Origin
The ulnar nerve originates from the medial cord of the brachial plexus, specifically from nerve roots C8 and T1.
Ulnar Nerve Palpation
Ulnar Nerve Palpation
The ulnar nerve is first palpable in the medial intermuscular septum of the brachium, traveling with the median nerve and brachial artery.
Ulnar Groove Location
Ulnar Groove Location
The ulnar nerve runs through the ulnar groove between the olecranon and the medial epicondyle.
Cubital Tunnel Contents
Cubital Tunnel Contents
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Ulnar Nerve at Elbow
Ulnar Nerve at Elbow
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Ulnar Nerve Sensory Branches
Ulnar Nerve Sensory Branches
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Guyon's Canal Location
Guyon's Canal Location
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Ulnar Nerve Hand Innervation
Ulnar Nerve Hand Innervation
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Claw Hand Deformity
Claw Hand Deformity
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Bishop's Hand
Bishop's Hand
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Ulnar Nerve Compression Causes
Ulnar Nerve Compression Causes
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Fracture-Related Ulnar Injury
Fracture-Related Ulnar Injury
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Repetitive Injury Effect
Repetitive Injury Effect
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Cubital Tunnel Syndrome Cause
Cubital Tunnel Syndrome Cause
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Motor Function: FCU and FDP
Motor Function: FCU and FDP
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Motor Function: Hypothenar Eminence
Motor Function: Hypothenar Eminence
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Motor Function: Intrinsic Compartment
Motor Function: Intrinsic Compartment
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Types of Nerve Injuries
Types of Nerve Injuries
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Ulnar Nerve Assessment: Tinel's Sign
Ulnar Nerve Assessment: Tinel's Sign
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Ulnar Nerve Assessment: Froment's Sign
Ulnar Nerve Assessment: Froment's Sign
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Ulnar Nerve Assessment: 4th/5th Digit Strength
Ulnar Nerve Assessment: 4th/5th Digit Strength
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Study Notes
- Ulnar nerve originates from nerve roots C8 and T1.
- The ulnar nerve is a terminus of the medial cord of the brachial plexus.
Nerve Palpation
- The ulnar nerve is first palpable in the medial intermuscular septum of the brachium.
- The nerve travels alongside the median nerve and brachial artery until the midpoint of the brachium, near the insertion of the coracobrachialis.
- The ulnar nerve runs more medially at this point, while the median nerve continues alongside the brachial artery.
- Indiscriminate palpation from medial to lateral between the biceps and triceps can elicit symptoms of ulnar nerve compression.
- It runs through the ulnar groove between the olecranon and medial epicondyle, covered by the arcuate ligament (ligament of Osborne), also known as the cubital tunnel.
- Immediately at the elbow, the ulnar nerve runs through the two heads of flexor carpi ulnaris, and then deep to that muscle between flexor carpi ulnaris and flexor digitorum profundus.
- Motor fibers continue distally down to the wrist in this space.
- About halfway down the forearm, it gives off palmar and dorsal sensory branches which move superficially to supply the skin of the ulnar side of the palm.
- At the wrist, it travels over the flexor retinaculum and into Guyon's canal (the space between the pisiform and the hook of hamate), beneath the palmaris brevis and volar carpal ligament.
- At the wrist, the nerve gives off a motor branch to the intrinsic hand muscles and sensory branches to the palmar and dorsal sides of digits 4 and 5.
Palpation of Affected Tissue
- Assess health through the intrinsic hand muscles and FCU tone and tissue.
- Perform sensory assessment of the 4th and 5th digits, especially digit 5.
Motor Function
- FCU (flexor carpi ulnaris), FDP (flexor digitorum profundus).
- Hypothenar eminence muscles: ADMM (abductor digiti minimi), FDMM (flexor digiti minimi), ODM (opponens digiti minimi).
- Intrinsic compartment muscles: lumbricals 3 & 4, PIM (palmar interossei muscles), DIM (dorsal interossei muscles), adductor pollicis.
- The flexor pollicis brevis is sometimes innervated by the ulnar and/or median nerve, but is mainly median.
Sensory Function
- Provides sensation to the palmar and dorsal surfaces of the medial hand and digits.
Pathophysiology - Ulnar Nerve Injuries
- Ulnar nerve injuries can include:
- Neuropraxia
- Axonotmesis
- Neurotmesis
- The context of the injury is important in determining the type of treatment.
MOI (Mechanism of Injury)
- Fractures at the medial epicondyle, mid-forearm, or wrist (Colles' fracture).
- Elbow dislocation.
- Prolonged compression from elbow on hard surface, handcuffs, or bicycling.
- Repetitive actions causing fibrosis and compression.
- Trauma such as contusion or laceration.
- The nerve is most vulnerable at the elbow and wrist.
Signs & Symptoms (Degeneration)
- Complete lesion results in claw hand: 5th digit MCP EXT, ABD; IP FLX; 4th digit MCP EXT; IP FLX.
- Loss of thumb adduction.
- Muscle wasting in the hypothenar eminence and interosseous spaces.
- Anhidrosis (decreased sweating) and possible vasomotor changes.
- Altered sensation in the 5th digit and 1/2 of the 4th digits and palm.
- Anesthesia in the 5th digit.
- Classic deformities.
Ulnar Nerve
- Bishop's Hand/Benediction Hand (Magee):
- Resting position of digits 4 & 5 is opposite to the lumbricals action due to loss of ulnar lumbricals.
- Claw Hand (Rattray):
- Resting position similar to Bishop's hand, but with some abduction of digits 4 & 5.
- Froment's Sign:
- Active compensatory recruitment of flexor pollicis longus (innervated by median nerve) due to loss of adductor pollicis (innervated by ulnar nerve).
Palsy/Lesion Descriptions
- Tardy ulnar palsy may occur years after a fracture and is related to callus formation or valgus deformity of the elbow, leading to adverse tension at the ulnar groove.
- Cubital tunnel syndrome causes pressure on the nerve with elbow flexion when the tunnel flattens; sustained elbow flexion is provocative to ulnar nerve compression or lesions.
- Ulnar tunnel/Guyon's tunnel/Guyon's canal syndrome/handlebar palsy results from pressure on the hypothenar eminence such as from biking, jackhammer use, or keyboard use, overuse of wrist (gripping, twisting), trauma to the wrist causing swelling, or from carpal fracture/arthritis.
Ulnar Nerve Assessment
- Degree of Nerve Regeneration:
- Check for Tinel's sign at the ulnar groove; gently tap over the nerve to feel for tingling to the point of regeneration.
- Froment's Sign:
- Have the patient grasp a piece of paper between their thumb and index finger (adductor pollicis).
- The examiner pulls the paper away. If the patient flexes at the IP joint, it is positive.
- 4th & 5th Digit Strength:
- Assess for general weakness in RROM of the 4th and 5th digits (flexion, abduction, adduction).
- Perform the Upper Limb Tension Test 4
- Refer to PNS Tx Notes document for principles of assessment and treatment.
Ulnar Nerve Treatment
- Context:
- Regenerating lesion post-fracture.
Precautions
- Do not traction regenerating nerve or stretch denervated tissue.
- Place arm in a neutral position with pillows (reduce elbow, wrist, and finger flexion).
- Apply segmental treatment proximal to the lesion using techniques perpendicular to the nerve.
- Block or stabilize tissue just proximal to the lesion to prevent drag.
- Treat Flaccid tissue with light stroking and compression.
- Treat Distal to the lesion site by treating unaffected tissue is treated with strain toward (but not onto) flaccid tissue
- PROM is performed to joints in the direction that shortens affected tissue and nerve
Goals & Approach
- Promote relaxation, decrease edema, and decrease tone and TrP in muscles proximal to the lesion.
- Promote tissue health in denervated tissue using light stroking to shorten the nerve/bunch up tissue, cross-fiber techniques, and gentle compressions.
- Prevent contracture of unopposed antagonist muscles.
- Perform segmental work distal to the lesion on unaffected muscles/antagonists only.
- Promote joint health with PROM, if possible.
- Ensure that limb handling does not traction the nerve.
- Encourage returning motor function.
- Once some function has been regained, use facilitatory ROODS techniques or similar or AAROM on the returned function incorporate visualization.
- Promote tissue health in reinnervated tissue using gentle Swedish techniques or sensory stimulation using different textures.
Hydrotherapy
- Contraindicated if dysfunction of autonomics is present.
- Avoid anywhere on affected limb, even proximal to lesion site.
- Use cool compresses over acute injury; modified temperature over affected tissue; mild contrast washes if autonomics are not affected.
Home Care
- Vigilance to pressure sores if wearing a splint and PROM of joints that shortens affected tissue.
- Visualize performing actions with the affected limb.
- Elevate the limb if edema is present.
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