CLINICAL EVALUATION OF

ULNAR NERVE

Dr. Bhaskaranand Kumar

Professor of Orthopaedics
Chief of Hand and Microvascular surgery
Kasturba Medical College and Hospital
Manipal
Anatomy is to surgery
what geography is to history
 ANATOMY
• Root value - C8 and T1
• Pierces the medial inter muscular
septum at middle third of arm
• Lies in the groove between medial
epicondyle and forearm
 ANATOMY (Cont)
• Passes b/w two
heads of FCU
• Enters cubital tunnel
• Accompanied by
ulnar artery
• Palmar cutaneous
branch given off at
mid forearm
 ANATOMY (Cont)
• Dorsal cutaneous branch is given off
5cm above the wrist
• Later it passes beneath the superficial
part of flexor retinaculum
 ANATOMY (Cont)
• Lies in the Guyon’s canal
• Divides into superficial and deep
terminal branches
 ANATOMY (Cont)

BRANCHES:
– Articular
– Muscular (near the elbow)
– Palmar cutaneous
– Dorsal cutaneous
– Terminal -Superficial (sensory)
-Deep (motor)
 ANATOMY (Cont)

ARTICULAR BRANCHES:

– ELBOW
– WRIST
– DIGITAL JOINTS
 ANATOMY (Cont)

MUSCULAR (near the elbow):

– Flexor carpi ulnaris

– Medial two slips of Flexor digitorum
profundus
 ANATOMY (Cont)

PALMAR CUTANEOUS
BRANCH:
– Ulnar artery
– Sensory supply to medial and
anterior aspect of lower forearm
– Ends in palmar skin after it
communicates with palmar
cutaneous branch of median
nerve
 ANATOMY (Cont)
Dorsal cutaneous branch

– Descends on the medial side of

back of wrist
– Divides into 2-3 dorsal digital
branches
– Supplies dorsal and medial aspect
of hand
– Terminal part of ring and middle
finger are not supplied by ulnar
nerve
 ANATOMY (Cont)

TERMINAL BRANCHES :
Superficial (sensory)
– Supplies medial palmar skin

Two digital nerves

– One supplies medial side of little finger
– Other further divides into two branches
supplying adjacent surfaces of little and
ring finger
 ANATOMY (Cont)
DEEP TERMINAL BRANCH
(MUSCULAR) :

Soon after the division it

supplies the muscles of
hypothenar eminence

• Adductor digits minimi

• Opponens minimi
• Flexor digits minimi
 ANATOMY (Cont)
DEEP TERMINAL BRANCH (MOTOR)(Cont):

– Later it crosses the hand and runs along the

palmar arch
– As it crosses it supplies the interossei and
medial two lumbricals
– Supplies a branch to Flexor pollicis
brevis(superficial head)
– Ends by supplying Adductor pollicis
 AFFECTIONS OF ULNAR
NERVE
INJURIES:
• TRANSECTION
• TRACTION
• ELECTRICAL
• CHEMICAL
• INFECTION (HANSEN’S DISEASE)
• ENTRAPMENT
• COMPRESSION
 CLINICAL
PRESENTATION

Depends on
• The site of the lesion
• The extent of the damage
 High ulnar nerve paralysis

MOTOR LOSS:

• FCU, medial two FDP

• All small muscles of the hand except those
of thenar eminence and lateral two
lumbricals
 High ulnar nerve paralysis

SENSORY LOSS :
Autonomous zone : Terminal pulp of
little finger
 CLINICAL FEATURES

INSPECTION:
• Deformity-mild clawing of medial two
fingers (hyperextension at MCP joint,
flexion at PIP joint)
 Inspection
• Wasting of first web space
and Inter metacarpal
spaces

• Trophic changes

Lustreless and brittle

nails
Look for burn marks
 CLINICAL FEATURES
(Cont)
PALPATION:
• Palpate the ulnar nerve behind the
medial epicondyle. it may be thickened or
highly mobile
• The tips of little and ring finger may be
cold
 CLINICAL FEAURES
(Cont)
Muscle testing:
FCU :
• Flexion and medial
deviation at the wrist
• tendon can be felt taut
during action
MUSCLE TESTING (cont)
FDP:
• Stabilize the
PIP and MCP
in extension
• Ask the patient
to flex the DIP
 MUSCLE TESTING (Cont)
Palmar interossei:

• Action- Adducts the

digits towards the
centre
• Card test
MUSCLE TESTING (Cont)

DORSAL INTEROSSEI:

• Action- Abduction of
the digits away from
the centre
• Test-ask the patient to
abduct the digits
• Offer resistance
towards the centre
MUSCLE TESTING (Cont)

ADDUCTOR POLLICIS:

• Action- Adducts the thumb towards the

palm
• Book test- Ask the patient to hold a book
with both hands
MUSCLE TESTING (Cont)

ADDUCTOR POLLICIS:
• When adductor pollicis is weak, the IP joint
goes into flexion because of substitution by FPL
( FROMENT’S SIGN)
LOW ULNAR NERVE PALSY

• FCU and FDP are spared

• Sensory deficit only on the volar aspect of

the hand

• Paralysis of small muscles of the hand

except those of thenar eminence and
lateral two lumbricals
 CLINICAL FEATURES

INSPECTION:

• Severe clawing of medial

two digits
• Wasting
• Trophic changes
• Palpation- findings same
as in high nerve palsy
 MUSCLE TESTING

• FCU and median two FDS normal

• Palmar interossei : Card test positive
• Dorsal interossei : Abduction test positive
• Adductor pollicis : Book test positive
 CONCLUSION
CLAWING
• HIGH : MILD
• LOW : SEVERE

Ulnar Paradox
 Conclusion
Sensation
Level Dorsal hand Volar hand and
and medial 2 ½ medial 2 ½
fingers fingers
High Absent Absent

Low Present Absent

 Conclusion
Motor
Level FCU Medial Dorsal Volar Adduct
two pollicis
FDP
High _ _ _ _ _

Low + + _ _ _