ORTHOPEDICS

1. ULNAR NERVE PALSY
AND TENDON
TRANSFERS
DR. N .BENTHUNGO TUNGOE
MS(ORTHOPEDICS), PG
CENTRAL INSTITUTE OF ORTHOPEDICS, NEW DELHI

2. Ulnar nerve: introduction
 Spinal roots: C8-T1.
 Motor functions: Innervates the muscles of the hand (apart from the thenar
muscles and two lateral lumbricals), flexor carpi ulnaris and medial half of
flexor digitorum profundus.
 Sensory functions: Innervates the anterior and posterior surfaces of the
medial one and half fingers, and the associated palm area.

3. Anatomy of ulnar nerve:
 In the arm, the ulnar nerve lies anterior to the triceps muscle. It travels through the cubital tunnel at the
elbow, and then passes between the two heads of the FCU, which it innervates.
 As it courses distally, it lies on the volar aspect of the FDP, and innervates the FDP to the small and ring
fingers.
 Approximately 7 cm proximal to the wrist, it gives off a dorsal sensory branch, which provides sensibility to the
ulnar aspect of the dorsal hand.
 At the wrist, the main nerve passes into Guyon’s canal along with the ulnar artery. Within Guyon’s canal it
divides into deep and superficial branches.
 The superficial branch gives sensibility to the small finger and the ulnar half of the ring finger.
 The deep motor branch innervates the hypothenar muscles, the ulnar two lumbricals, the interossei, the
adductor pollicis, and the deep head of the flexor pollicis brevis (FPB).
 The most distal motor branch innervates the first dorsal interosseous.
 Anomalous ulnar nerve anatomy is common in the forearm and hand.
 The Martin-Gruber connection is seen when the median nerve contributes motor fibers to the ulnar nerve in the
forearm, resulting in median nerve innervation of intrinsic hand muscles. This anomaly can result in intact intrinsic hand
function following proximal ulnar nerve injury.
 The Riche-Cannieu anomaly is a connection between the motor branch of the ulnar nerve and the recurrent motor
branch of the median nerve in the hand, with ulnar to median innervation.3 This anomaly can result in preservation of
thenar function after median nerve injury at the wrist or more proximally.

4. Motor Functions
 The Anterior Forearm
 In the anterior forearm, the muscular branch of the ulnar nerve supplies two muscles:
 Flexor carpi ulnaris – Flexes and adducts the hand at the wrist.
 Flexor digitorum profundus (medial half ) – Flexes the fingers.
 The remaining muscles in the anterior forearm are innervated by the median nerve.
 The Hand
 The majority of the intrinsic hand muscles are innervated by the deep branch of the ulnar
nerve.
 The hypothenar muscles (a group of muscles associated with the little finger) are
innervated by the ulnar nerve. It also innervates some other muscles of the hand:
 Medial two lumbricals
 Adductor pollicis
 Interossei of the hand

5. Sensory Functions
 There are three branches of the ulnar nerve that are
responsible for its cutaneous innervation.
 Two of these branches arise in the forearm, and travel
into the hand:
 Palmar cutaneous branch: Innervates the skin of the
medial half of the palm.
 Dorsal cutaneous branch: Innervates the skin of the
medial one and a half fingers, and the associated palm
area.
 The last branch arises in the hand itself:
 Superficial branch – Innervates the palmar surface of the
medial one and a half fingers

6. Clinical findings:
 Ulnar nerve palsy is a more devastating injury than radial nerve palsy.
 In both high and low ulnar nerve palsy, key pinch is lost because of absent adductor pollicis and first dorsal
interosseous muscle function.
 Clawing occurs as a result of paralysis of the interosseous muscles in the presence of functioning extrinsic finger
flexors. Clawing causes a loss of active IPJ extension and MCPJ flexion, which prevents the patient from cupping
thehand around objects.
 In addition, integration of MCPJ and IPJ flexion is lost.
 In the normal hand, integrated finger flexion begins at the MCPJ powered by the intrinsic muscles, followed by
flexion of all three finger joints powered by the FDP and FDS, folding the fingers smoothly into the palm.
 In ulnar nerve palsy, MCPJ flexion is not initiated by the intrinsic muscles, and finger flexion begins at the IPJ’s,
followed by late MCPJ flexion. This results in a rolling motion of the fingers, which prematurely closes them before
they reach the palm, making it difficult to grasp objects.
 In addition to the above findings, high ulnar nerve palsy results in loss of the FCU and FDP to the ring and little
fingers. This causes diminished grip strength as well as the loss of ulnar deviation with wrist flexion.
 A small benefit of diminished FDP function is that clawing is less severe than in low ulnar nerve palsy, in which the
FDP to the ring and small fingers remains intact.
 Unlike radial nerve palsy, the sensory deficit in ulnar nerve palsy is clinically disabling.
 Protective sensation in the ulnar nerve distribution is important for preventing injury when the hand is placed in
resting positions.

7. Mode of injury and assossciated clinical findings:
 Injury at the Elbow:
 The nerve is most vulnerable to injury at the medial epicondyle, so fracture of the medial
epicondyle is the most common way of damaging the ulnar nerve
 Motor functions: Flexor carpi ulnaris and medial half of flexor digitorum profundus paralysed.
Flexion of the wrist can still occur, but is accompanied by abduction.
 The interossei are paralysed, so abduction and adduction of the fingers cannot occur. Movement
of the little and ring fingers is greatly reduced, due to paralysis of the medial two lumbricals.
 Sensory functions: All sensory branches are affected, so there will be a loss of sensation over
the areas that the ulnar nerve innervates.
 Characteristic signs: Patient cannot grip paper placed between fingers.

8. INJURY AT THE WRIST
 MOTOR FUNCTIONS:
 The interossei are paralysed, so abduction and adduction of the fingers cannot occur.
Movement of the little and ring fingers is greatly reduced, due to paralysis of the medial two
lumbricals. The two muscles in the forearm are unaffected.
 SENSORY FUNCTIONS:
 The palmar branch and superficial branch are usually severed, but the dorsal branch is
unaffected. Sensory loss over palmar side of medial one and a half fingers only.
 Characteristic signs: Patient cannot grip paper placed between fingers. For long-term
cases, a hand deformity called ‘Ulnar Claw’ develops.
 Ulnar claw consists of:
 Hyper-extension of the metacarpophalangeal joints of the little and ring fingers – this is
because of the paralysis of the medial two lumbricals, and the now unopposed action of the
extensor muscles
 Flexion at the interphalangeal joints (if the lesion has occurred close to the elbow, this might
not be evident, as the flexor digitorum profundus will be paralysed)

10. Bouvier’s test:
 Bouvier’s test involves passively correcting the MCPJ hyperextension, and
checking for improved IPJ extension.
 If the patient’s flexed IPJ posture improves, then Bouvier’s test is positive,
and the clawing is defined as simple.
 If the IPJ’s remain flexed even after passive correction of the MCJP
hyperextension, then Bouvier’s test is negative, and the clawing is defined
as complex.

11. Clinical assessment of ulnar nerve:
1. Flexor carpi ulnaris (C7–T1) assessment,
stabilizing the pisiform:
 While the patient abducts the
ipsilateral fifth digit, observe and
palpate the flexor carpi ulnaris’ tendon
just proximal to the wrist. The flexor
carpi ulnaris contracts to stabilize the
pisiform so that the abductor digiti
minimi may function.

12. 2. Flexor carpi ulnaris (C7-T1) assessment, wrist
flexion
:
 Have the patient flex his or her
wrist against resistance in an
ulnar direction, which is the
primary action of this muscle.

13. 3. Flexor digitorum profundus (C8, T1) assessment:
 This muscle is tested in thesame
fashion as its median innervated
half, except to evaluate the
ulnar nerve contribution
 one uses the fifth digit. To test,
immobilize the proximal
interphalangeal joint while the
patient flexes the distal
interphalangeal joint against
resistance.

14. 4. Palmaris brevis (C8, T1) assessment:
 Test this muscle by having the patient
forcibly abduct the fifth digit and then
instructing them to “contract” the
hypothenar eminence simultaneously.
 Skin corrugation should occur.

15. 5. Abductor digiti minimi (C8, T1) assessment:
 This muscle is tested when the
patient abducts the fifth digit
against resistance.
 One should keep in mind that
this muscle is delicate, the
patient’s resistance is easily
overcome even with normal
strength.

16. 6. Flexor digiti minimi (C8, T1) assessment
 : This muscle is tested by immobilizing the
interphalangeal joints of the fifth digit and
having the patient flex the metacarpal-
phalangeal (knuckle) joint against
resistance.
 One cannot isolate this muscle’s function,
however, because flexion of the fifth digit’s
metacarpal-phalangeal joint is performed
by not only theflexor digiti minimi, but also
by the fourth lumbrical and the interossei.

17. 7. Opponens digiti minimi (C8, T1) assessment:
 Have the patient hold the volar pads of
the distal thumb and fifth digit together.
While the patient maintains this position,
try to force the proximal digit and distal
fifth metacarpal away from the thumb.

18. 8. Third and fourth lumbrical (C8, T1) assessment:
 Immobilize the metacarpalphalangeal
joints of these two fingers in
hyperextension and then test extension
of the proximal interphalangeal joints
against resistance.

19. 9. First dorsal interosseous (C8, T1) assessment
 : On a flat surface, the patient
 abducts his or her index finger
against resistance.
 Contraction or atrophy of the first
dorsal nterosseous muscle can be
observed and palpated on the
dorsum of the hand.

20. 9. Second palmar interosseous (C8, T1)
assessment
 : On a flat surface, the patient adducts the
index finger against resistance.

21. 10. Adductor pollicis assessment:
 Ask the patient to grasp a book between
extended thumb and index finger.
 If the ulnar nerve is intact, he will grasp with
extended thumb taking full advantage of
adductor pollicis and first palmar interossei,
 In ulnar nerve injury, the patient will hold the
book by flexing the thumb with the help of
flexor pollicis longus.(FROMENT’S SIGN)

22. 11. Test for palmar interossei: Card
Test
 A card inserted between two
extended fingers and the patient is
asked to grasp it between the
fingers while the clinician gently
tries to pull the card.

23. Goals of tendon transfer in ulnar nerve
pasly:
 The primary goals of tendon transfer procedures for ulnar nerve palsy are
restoration of
 small and ring finger DIPJ flexion (in cases of high ulnar nerve palsy),
 restoration of key pinch,
 correction of clawing,
 integration of MCPJ and IPJ flexion,
 and improvement in grip strength.

24. 1. Restoring small and ring finger DIP joint flexion:
 Restoration of small and ring finger DIPJ flexion can be achieved by
adjacent suturing of their respective FDP tendons to the functioning
middle finger FDP.
 The index finger FDP should not be included in the adjacent suturing in
order to preserve its independent functioning

25. Adjacent suturing of ring and small
finger FDP to middle finger FDP for
restoration of DIP
flexion in ulnar palsy.

26. 2. Restoring key pinch:
 In the normal hand, key pinch is the result of combined first dorsal interosseous and
adductor pollicis function
 Both the ECRB (Smith) and brachioradialis (Boyes)are strong donor MTU’s that can be used
to restore key pinch, and that do not leave a functional deficit when harvested.
 They must be lengthened by tendon grafts and then passed between the 2nd and 3rd
metacarpals into the palm. Here they are routed towards the thumb, using the 2nd
metacarpal as a pulley, and inserted on the adductor pollicis insertion.
 The direction change that occurs at the 2nd metacarpal pulley orients the tendon along the
original direction of pull of the adductor pollicis.

27. ECRB (with tendon graft) transfer to
adductor pollicis insertion for restoration
of key pinch in
ulnar palsy.

28. 3. Correction of clawing
 This requires correction of MCPJ hyperextension, the problem that initiates clawing.
 Procedures can be categorized as static or dynamic. If Bouvier’s test is positive, static
procedures may be successful.
 Dynamic tenodesis can be performed, as popularized by Fowler and Tsuge.
 A tendon graft is looped through the extensor retinaculum at the wrist. The two free ends of the
tendon graft are passed through the intermetacarpal spaces into the palm, along the course of the
lumbricals, and out to the fingers where they are inserted to the lateral bands. When the wrist is flexed,
an active tenodesis effect occurs, resulting in MCPJ flexion and IPJ extension.

29. Dynamic tenodesis with tendon
graft for correction of clawing.

30.  Brand, Riordan, and others described the use of wrist-level motors to treat
clawing and integrate finger flexion as well as augment grip strength.
 The FCR, ECRL, ECRB, or brachioradialis may be used. These MTU’s require
a free tendon graft which is split into two or four slips to pass through the
intermetacarpal spaces into the corresponding lumbrical canals.
 The insertion can be into the lateral band, the proximal phalanx, or the A1
or A2 pulley.
 The main advantage of these tendon transfer procedures over the
superficialis transfers is that they improve rather than worsen grip strength.

31. ECRB transfer (extended with
tendon graft to all four fingers) for
correction of clawing.

32. modified Stiles-Bunnell procedure
 There are a number of tendon transfer procedures available that provide dynamic
correction of clawing, integrate MCPJ and IPJ flexion, and in some cases augment
grip strength.
 These can be divided into superficialis transfers and transfers powered by wrist
motors.
 In the modified Stiles-Bunnell procedure, the middle finger superficialis tendon is
divided distally in the finger and retrieved into the palm. It is then split into four
slips.
 Each slip is then passed along the path of the lumbrical, volar to the deep
transverse metacarpal ligament, and back into the finger, where it is inserted on
the lateral band.
 The main drawback of superficialis transfers is that although they reliably correct
clawing and integrate finger flexion, they do not improve grip strength, and may
even result in further weakening of an already diminished grip.

33. Modified Bunnell’s procedure:

34. Zancolli lasso insertion technique:
Zancolli described a “lasso” insertion,
wherein the FDS is passed through the A1
pulley, then sutured back onto itself,
resulting in improved MCPJ flexion while
avoiding PIPJ hyperextension.

36. Zancolli Lasso Procedure:
 A transverse incision was made at the level of the distal palmer crease.
 The flexor tendon sheaths were exposed from the middle of the metacarpal to the middle of the proximal phalanx.
 The proximal pulley was identified by its thick, glistening fibrous strands.
 The flexor tendon sheath was opened proximal to the pulley by making a T-shaped incision. Distally the digital fibrous
tunnel was opened in an L-shaped incision at the level of the proximal arciform ligament.
 The flexor tendons were identified through the distal opening.
 The flexor digitorum superficialis tendon of the middle finger was hooked up and cut as distally as feasible without
injuring the profundus tendon that lies beneath it. The distal cut end was allowed to retract.
 The tendon was withdrawn through a small curved incision at the base of the palm along the thenar crease. The
tendon was split into 4 slips, one slip for each finger.
 The slips were passed deep to the palmar aponeurosis along the flexor sheath with the help of a tendon tunneller. The
slips were then passed under the proximal pulley of the corresponding finger and through the opening distal to the
pulley, and the tendon was taken out and brought palmar to the pulley and proximally.
 The slip was sutured to the same slip (thus forming a lasso) under proper tension with the metacarpophalangeal joint in
20º to 30º flexion and the wrist in 30º flexion.
 Any excess tendon slip was cut off. This procedure was performed for all 4 fingers starting from the index finger, using
the flexor digitorum superficialis of the middle finger