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Ulnar Neuropathy in the Distal Ulnar Tunnel

DAVID W. SHUPE, PT, ATC'
A brief anatomical review of the ulnar nerve and areas of ulnar nerve entrapment is discussed. The importance of the dorsal cutaneous nerve is presented with regard to localizing a lesion to the ulnar nerve in the forearm. A classification system is described for ulnar entrapment that occurs distal to the wrist. The case of a nine-yearold girl with a fibrous entrapment of the ulnar nerve in the distal ulnar tunnel is presented. The clinical and diagnostic procedures required for localizing the level of the ulnar nerve entrapment are described, along with the operative findings of this case report.

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When evaluating and treating patients with trauma to the upper extremity, a vital part of the assessment is the basic neurological examination. One component of this examination is the evaluation of peripheral nerve function. If ulnar nerve involvement is suspected, then particular assessment of this nerve is warranted. Conclusions derived from this assessment will allow the physical therapist to develop more realistic treatment goals and to enhance communication with patients and others in the medical community. The purpose of this article is to give a brief anatomical review of the ulnar nerve and potential areas of ulnar nerve entrapment, with emphasis on the distal ulnar tunnel. A case report of a patient with a fibrous entrapment of the ulnar nerve in the distal ulnar tunnel is presented. ANATOMY OF THE ULNAR NERVE An anatomical review of the ulnar nerve shows that after originating from the medial cord of the brachial plexus, it descends along the medial aspect of the arm with the median nerve. In the distal aspect of the arm, it becomes more superficial after passing through the intermuscular s e p tum of the triceps brachii (Arcade of Struthers). At the elbow, the nerve passes through a fibroosseous tunnel, known as the cubital tunnel. Laterally, this tunnel is bordered by the elbow joint,

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medially by the heads of the flexor carpi ulnaris, and anteriorly by the medial epicondyle (1). After passing through the cubital tunnel. the nerve enters the forearm, taking a less superficial course when it descends between the two heads of the flexor carpi ulnaris muscle (7). The ulnar nerve then takes a straight course along the medial aspect of the forearm after giving muscular branches to the flexor carpi ulnaris and the flexor digitorum profundus to the ring and little fingers (barring any anomalies). It is important to note that entrapments may occur at the Arcade of Struthers, in the cubital tunnel, and within the fibrous tunnel formed by the two heads of the flexor carpi ulnaris. Approximately eight to ten centimeters proximal to the ulnar styloid process, the dorsal cutaneous nerve branches from the ulnar nerve (Figure 1). Four to five centimeters proximal to the styloid process, the dorsal cutaneous nerve crosses the medial aspect of the ulna to take a position dorsal to the ulna (4, 7). This branch provides sensory innervation to the ulnar portion of the dorsum of the hand and parts of the dorsal aspect of the little and ring fingers (Figure 2). The ulnar nerve enters the hand through the distal ulnar tunnel (2, 5). This tunnel is four to four and one-half centimeter long, beginning at the proximal edge of the palmar carpal ligament and extending to the fibrous arch of the hypothenar muscles (Figure 3). As described by Gross and Gelberman (2), the roof of the tunnel from proximal to distal is composed of the palmar carpal ligament, palmaris brevis muscle, and hypothenar fat and fibrous tissue. Kleinert and Hayes (5) reported that this roof is multilayered, with the palmar
JOSPT 13:1 January 1991

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SHUPE

A thorough assessment of the motor function of the hand. A lesion distal to the origin of this small cutaneous branch would only produce a sensory deficit in the little finger and medial aspect of the ring finger (7). The floor of the tunnel is formed by the tendons of the flexor digitorum prcifundus.carpal ligament blending distally with the hypothenar fascia. The radial wall is formed by the tendons of the extrinsic flexors. Any involvement of the nerve in this zone would lead to motor deficits only. The superficial branch supplies the skin on the palmar aspect of the little finger and the medial half of the ring finger. After innervating the abductor digiti minimi. the deep palmar branch turns laterally to supply the dorsal and palmar interossei. and proximally with the volar forearm fascia. and opponens digiti minimi muscles. Along with any functional tests. Motor fibers to the palmaris brevis also take their origin from the superficial branch. the same motor deficit would exist. a detailed manual muscle test should always be performed. the ulnar nerve divides into a superficial branch and a deep branch (5). and the abductor digiti minimi comprise the ulnar wall. Zone one is the portion of the tunnel proximal to the bifurcationof the nerve. Figure 1. All rights reserved. and the hook of the hamate. fingers. these 7 ENTRAPMENT AT DISTAL ULNAR TUNNEL . Any lesion at this level would lead to sensory involvement and a motor deficit of the palmaris brevis. and thumb is an essential component of the evaluation process. JOSPT 13:1 January 1991 Understanding the distribution of the dorsal cutaneous branch of the ulnar nerve is extremely important in helping to differentiate the approximate level of any lesion of the ulnar nerve in the distal one-half of the forearm. Strength deficits in the hand muscles innervated by the ulnar nerve can result directly from an ulnar motor branch dysfunction as discussed. The superficial branch is located in zone three. Within the distal ulnar tunnel. In their anatomical study of the distal ulnar tunnel. Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. the adductor pollicis. SENSORY AND MOTOR EVALUATION Figure 2. Zone two encompasses the deep motor branch of the nerve. flexor digiti minimi. Along with the ulnar nerve. Sensory distribution of the dorsal cutaneous branch of the ulnar nerve. The flexor carpi ulnaris. Any problem proximal to the dorsal cutaneous branch would result in a sensory disturbance to the dorsal and ulnar aspect of the hand. the transverse carpal ligament.jospt. 2013. and the deep head of the flexor pollicis brevis muscles. the transverse carpal ligament.org at on November 30. and the opponens digiti minimi (2). Regardless of where an ulnar nerve lesion in the distal forearm would be located. the ulnar artery lies within the distal ulnar tunnel. radially with the palmar aponeurosis. Course of the dorsal cutaneous nerve. Gross and Gelberman (2) used an anatomical basis for dividing the tunnel into three zones. parts of the dorsal aspect of the ring and little fingers. For personal use only. However. the pisiform. Ulnaris Dorsal Cutaneous Branch Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www. No other uses without permission. and a sensory deficit on the palmar surface of the little finger and medial aspect of the ring finger. Any lesion of the ulnar nerve in this zone would lead to both motor and sensory deficits. the third and fourth lumbricals. the pisohamate and pisometacarpal ligaments.

the Steinman pins were removed and the patient was referred to physical therapy for rehabilitation. Finger tip prehension (thumb to index) was possible. Trophic changes were present in the ring and little fingers. Other sources of dysfunction may include motor neuron diseases. strength deficits may also arise from other sources that should not be ignored.org at on November 30.Opponens Digiti Minimi Flexor Digiti Minimi Superficial Branch Deep Branch Ulnar Nerve Abductor Digiti Minimi Hamate Pisohamate Ligament Transverse Carpal Ligament Palmar Carpal Ligament Flexor Carpi Ulnaris Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www. Atrophy of the intrinsic hand muscles innervated by the ulnar nerve was noted. Stabilization was maintained with percutaneous pinning. Normal function of the flexor carpi ulnaris and flexor digitorum profundus to all fingers was present. All rights reserved. Marked tenderness was found with palpation in the area of the hook of the hamate. and pronation was 0-73'. After x-ray examination revealed a displaced fracture of the medial epicondyle of the right humerus. brachial plexopathy from various etiologies. nerve root compression. although a minimal degree of abduction of the little finger was present. mechanical abnormalities as a result of a disease process. ridged look to the nails. and a posterior plaster splint was applied with the elbow at 60' of flexion. Figure 3. A sensory evaluation was normal to light touch and pinprick. After carpal tunnel views of the right wrist ruled out a fracture of the hook of the hamate (6). Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®.jospt. now less focused on the elbow. consisting of a white. An AROM and gravity-assisted. CASE REPORT A nine-year-old girl fell from a balance beam during gymnastics practice. even in the presence of known trauma to the ulnar nerve. static-stretching program was begun. The patient. After five weeks. No function of the intrinsic hand muscles innervated by the ulnar nerve was noted. Diagram of the distal ulnar tunnel. with supination and pronation showing normal ROM measurements. Two-point discrimination was also normal at five millimeters. For personal use only. elbow AROM was 48-1 13O. A negative Tinel's sign was present at the elbow and wrist over the ulnar and median nerves. but lateral prehension was not." Examination of the right hand revealed an abnormal resting finger position that consisted of clawing of the fourth and fifth fingers (6). No other uses without permission. She landed on her right hand with the wrist extended and the elbow in a fully extended position (Figure 4). 2013. and nerve entrapments (3). leathery appearance to the skin and a brittie. JOSPT 13:1 January SHUPE . A positive Tinel's sign was also present at this location. reported that her ring and little fingers 'felt cold at times. This was in the presence of no palpable contraction of the abductor digiti minimi and was thought to have resulted from aponeurotic attachments from the flexor carpi ulnaris to the abductor digiti minimi. diseases of peripheral nerves. supination was 0-45'. Immediate pain and disability were reported in the right elbow. These findings were documented and reported to the referring physician. At the seventh postoperative week. an open reduction and internal fixation of the displaced fragment were performed (Figure 5). Active range of motion (AROM) of the right elbow was 50-1 05'. Manual muscle testing revealed normal function of all muscles innervated by the median nerve.

along with supination and pronation of the forearm. Electromyographic sampling of the right a b ductor pollicus brevis and the flexor carpi ulnaris muscles showed normal. This was a somewhat surprising finding since sensory testing of the dorsal cutaneous nerve was normal. were normal. however. Ulnar sensory testing for the dorsal cutaneous nerve showed significant slowing. 2013. At five months postinjury. minimal insertional activity with 2+ denervation potentials at rest was noted in both muscles.0 pV. Motor units were normal for shape. and duration. Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. No other uses without permission. insertional activity with electrical silence at rest. further evaluation was requested by her physician. respectively.3 pV. the latency on the left was 1.8 msec with an amplitude JOSPT 13:1 January 1991 of 21. with the amplitude of evoked sensory action potential somewhat decreased compared to the contralatera1 side. and there was a normal interference pattern in the abductor pollicus brevis with a slightly reduced interference pattern in the flexor carpi ulnaris. the decision was made in favor of nonsurgical management to see if spontaneous recovery of function would occur. Postoperative radiographs of right elbow: A) lateral view. No 9 ENTRAPMENT AT DISTAL ULNAR TUNNEL . Figure 4.jospt. The decreased interference pattern in the flexor carpi ulnaris was associated with subjective complaints of pain at the sampling site. seemed to be supported by the electromyographic (EMG) findings. Figure 5.Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www. remained unchanged. When the abductor digiti minimi and the first dorsal interosseous muscles were sampled. At this time. For personal use only. Motor and sensory nerve conduction studies of the right median nerve were normal. The values on the right were 4. B) anterior-posterior view. The slowing. thought to result from a retrograde demyelination rather than from a more proximal process. Mechanism of injury for nine-yearsld patient in case study. All rights reserved.org at on November 30. ROM measurements of the right. Over a six centimeter segment. elbow.2 msec and 11. amplitude. Ulnar nerve studies using a needle electrode showed no response from the abductor digiti minimi or the first dorsal interosseous muscles. No evoked sensory action potential was elicited when recording from the little finger using an antidromic testing technique. The neurological status.

V d 2. Dissection. Recognizing an orthopaedic injury and its soft tissue and/or neurological components is critical. 1986 7. Klemert HE. 2013.Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt. 1985 3. 1971 6. Philadelphia: WE Saunders SHUPE JOSPT 13:1 January 1991 . Gross MS. Berkowitz MS. Spmner M: Injuries to the Major Branches of Peripheral N w e s of the Forearm. Gelbennan RH: The Anatomy of the Distal Unar Tunnel." According to the surgeon. Appreciation is extended to Hospital Services. Plast Reconstr Surg 47:21-24.org at on November 30. After this time. REFERENCES 1. Jabre JF: Unar nerve lesions at the wrist: new technique for recording f r o m the sensory dorsal branch of the ulnar nerve. Neurology 30373-876. Bohl WR: Hook of the harnate fractures in athletes. Churchill/Livingstm: New York. for all of t h e i r assistance. Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. Clin Orthop 196:238-247. release of the entrapment.1985 4. Hayes JE: The Unar Tunnel Syndrwne. All rights reserved. 1982 2. the patient reported that the fourth and fifth fingers "felt warmer. Brahrns MA. A surgeon localized the ulnar nerve lesion and performed surgery at a level distal to the wrist. Hogue RE: Compression of the deep palmar branch of the ulnar nerve: A case report. Parker RD. The hook of the hamate was found to be stable. Neurological assessment should be a routine part of a thorough physical therapy examination in any orthopaedic and sports rehabilitation practice. but a significant fibrosis of the motor branch of the ulnar nerve and a lesser degree of fibrosis of its sensory branch was observed. objective information and the opportunity for further evaluation of the patient were no longer available to the author. For personal use only. at four months postsurgery. an uncomplicated recovery was reported by the 0 surgeon. and an external neurolysis were performed in all three zones (2). some interossei muscle function was noted at four weeks following surgery. Green DP: Operative Hand Surgery. At two weeks postsurgery. pp 114-127. SUMMARY Peripheral nerve injury can be a common sequelae in trauma involving the upper extremity. No other uses without permission. Am J Sports Med 14517-523. Phys Ther 65203-205. 1980 5. motor units were located at multiple sampling sites in either of the latter muscles. Inc. However.