Ulnar Nerve Palsy - Rob Lee 20/10/2005

Low Ulnar Nerve Palsy
 
Some intrinsic may continue to function due to Martin Gruber communication between AIN and the ulnar nerve
There will be loss of 50-80 % of pinch strength, 50% loss of grip strength
An isolated tendon transfer cannot restore all of the power requirements
Need to improve pinch grip and grasp
 
Single FDS tendon transfer to improve integration of the MP joint and interphalangeal joint flexion, key pinch of the thumb, and the flattened metacarpal arch (Omer 1974)
 
1st MCPJ arthrodesed
FDS (IV) is freed and split in to 2 slips
One slip to ADP insertion.
Traction on the transferred tendon should adduct and pronate the first metacarpal.
Other slip split in 2 tails and anchored to radial side of extensor aponeurosis of ring and little fingers
Traction on the transferred slips should flex the MP joint and extend the proximal interphalangeal joint
The MP joints of the claw fingers are placed in 45° flexion, and the proximal interphalangeal joints are placed in 0° extension. The first metacarpal is adducted so that it is parallel to the plane of the second metacarpal. This position is maintained in plaster immobilization for 4 weeks.
The transfer of a single FDS tendon and arthrodesis of the thumb MP joint improves 2/3 of lost motor functions in a person with low distal ulnar nerve palsy.
 
Methods for managing other motor losses associated with ulnar nerve palsy include the following:
 
Transfer to restore thumb adduction - Pinch Grip
BR or radial wrist extensor (ECRL) to adductor tubercle (Boyes)
FDS (IV) to radial aspect thumb (Brand)
FDS (IV) – split into 2 slips and pass to EPL and ADP (Royle-Thompson)
           
Tendon transfer for index finger abduction - Pinch Grip
EIP to 1st Dorsal Interosseus
Slip of APL to 1st Dorsal Interosseus (Nevaiser, Wilson and Gardner)
 
Transfer of FDS (modified Bunnell)– Claw Deformity
FDS tendon is divided into 4 slips and inserted into the lateral band of the dorsal apparatus or into the second annular pulley of the flexor sheath
 
Transfer of ECRL/ECRB (Brand) – Claw Deformity
ECRL/ECRB tendon prolonged with graft and split into 4 tails
Passed to finger extensor aponeuroses
 
Capsulodesis of the MCPJs (Zancolli) – Claw Deformity
If MCPJ stabilised, long finger extensors can extend IPJs
Indicated if muscles not strong enough fro transfer
 
Dorsal tenodesis (Riordan) – Claw Deformity
As above, to stabilise MCPJs if no muscles available for transfer
ECRL and ECU cut at the junction of the middle and distal thirds of the muscle
Each half tendon is then split once longitudinally to obtain 4 slips
Each slip is routed through the interosseous space and passed to the radial side of each finger
Indicated if muscles not strong enough fro transfer
 
High Ulnar Nerve Palsy
 
May lose 60-80% of their grip strength
Restore FDP function of ring and little finger by side to side tenodesis of the profundus tendons of the ring and little fingers to the profundus of the long finger in the forearm
Also restore pinch grip and intrinsic function as above
 
 
Combined lesions of the median and ulnar nerves
 
Low lesions
 
Loss of intrinsic: ECRB - tendon graft - intrinsics (Brand)
Loss of thumb opposition: FDS (ring finger) to FCU pulley to APB  (Riordan)
Loss of thumb adduction: EIP to adductor tubercle or FDS (IV) to radial aspect thumb (Brand)
   
    
High lesions
 
Hand anaesthesia: need arthrodesis of thumb MCPJ
Capsulodesis of all MCPJs (Zancolli)
ECRL to FDP
BR to FPL
ECU with graft to EPB


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