Hand Surgery-A Guide for Medical Students Revision

7/25/2019 Hand Surgery-A Guide for Medical Students Revision

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HandSurgery:

A

Guide

for

MedicalStudents

TrevorCarrollandMargaretJainMD


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Tableof

Contents

Trigger Finger

3Carpal Tunnel Syndrome 13

Basal Joint Arthritis 23

Ganglion Cyst 36

Scaphoid Fracture 43

Cubital Tunnel Syndrome 54

Low Ulnar Nerve Injury 64


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TriggerFinger

(stenosingtenosynovitis)

AnatomyandMechanismofInjury

RiskFactors

Symptoms

PhysicalExam

Classification

Treatments


4/71

TriggerFinger:AnatomyandMOI

(ThompsonandNetter,p191) Theflexortendonsrunwithinthesynovialtendinoussheathinthefinger

Duringflexion,

the

tendons

contract,

running

underneath

the

pulley

system

Overtime,theflexortendonsand/ortheA1pulleycangetinflamedduringfingerflexion.

Occassionally,theflexortendonsand/ortheA1pulleyabnormallythicken.Thisdecreases

thenormalspacebetweenthesestructuresnecessaryforthetendontosmoothlyglide Inmoreseverecases,patientscanhave

theirfingers

momentarily

or

permanentlylockedinflexionusuallyat

thePIPjoint

(TriggerFingerOrthoInfo )


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TriggerFinger:

Risk

Factors

Age:4060

Female>Male

Repetitivetasksmayberelated

Computers,

machinery

Gout

Rheumatoidarthritis

Diabetes(poorprognosticsign)

Carpaltunnelsyndrome(oftenconcurrently)


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TriggerFinger:

Subjective

C/Ofocaldistalpalmpain

Paincan

radiate

proximally

in

the

palm

and

distallyinfinger

C/Ofinger

locking,

clicking,

stickingoften

worseduringsleeporintheearlymorning

Sometimessnappingduringflexion

Canimprove

throughout

the

day


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TriggerFinger:

Objective

Focaltendernesstopalpationatthefingerbase(atA1pulley)

Mayappreciate

nodule

in

this

location

Tendernessmayincreasewith

finger

extension

Radiographsnotnecessary

BewaresnappingatMPjointmayresembletriggerfingers

BewareassociatedMParthritisptwillhavedorsal

jointtenderness

(Hubspot)


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TriggerFinger:

Classification

GreenClassification

(McKean)


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TriggerFinger:Management

1st line

Stoppingtheoffending

activityNightsplinting

NSAIDS


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TriggerFinger:

Management

2nd line Steroid

injection

Notice

the

steroid

is

placedwithinthe

tendonoussheath.

(ThompsonandNetter,p199)


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TriggerFinger:

Management

3rd Line:SurgicalreleaseofA1pulley

Operation Surgicalsite:~1cmproximal

toproximaldigitalcrease.

Incisioncenteredoverthemetacarpaltoavoid common

digitalarteries

and

nerve

SharpreleaseofA1pulleytorestoresmoothtendongliding

Havept demonstratesmoothflexionbeforeclosingincision

Postoperatively

EarlypassiveandactiveROM.

Complications:infection,PIPstiffness,digitalnerveinjury,bowstringing

(Steffens)

A1Pulley

ProximalDigitalCrease


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WorksCited

Thompson,JonC.,andFrankH.Netter.Netter'sconciseorthopaedicanatomy.Philadelphia,PA:SaundersElsevier,2010.Print.

"TriggerFinger

OrthoInfo

AAOS."

Trigger

Finger

OrthoInfo

AAOS.

N.p.,n.d. Web.08Mar.2014.http://orthoinfo.aaos.org/topic.cfm?topic=a00024

http://cdn2.hubspot.net/hub/30688/images//TriggerFingerlabel.jpg?t=1424796877421

McKean,Jason."TriggerFinger."Orthobullets.N.p.,n.d. Web.08Mar.2014..

Steffens,Kurt."SurgeryofTriggerFinger(SnappingFinger)."

Surgeryof

Trigger

Finger

(Snapping

Finger).

N.p.,

n.d. Web.

08

Mar.

2014..


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CarpalTunnelSyndromeThemostcommonentrapmentneuropathy


RiskFactors

Symptoms

PhysicalExam

Treatments


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CarpalTunnelSyndrome:Anatomyand

MOI

Themediannerveis

entrappedwithin

the

tunnel,whichcreateslocal

nerveischemia

Thiscreatesnumbness,

tingling,andorpaininthe

mediannerve

distribution

Chronicentrapmentcan

producethenar atrophy

(seenatright)

(McKean)


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CarpalTunnel

Syndrome:

Risk

Factors

Females>Males

Inheritingasmallertunnel

Womentend

to

have

smaller

tunnels

OlderAge(mean~54years)

Pregnancy(oftenresolveswithdelivery)

Heavyworkwithhandsandvibrationalequipment Machineryworkers,autoindustry

Usingjackhammer

Thyroiddisease

Trauma

Rheumatoidarthritis

Ganglion

cyst

Amyloidosis

Note:Nogooddatatosupporttypingorkeyboardingasacause


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CarpalTunnel

Syndrome:

Subjective

Fingernumbnessorpainusuallysparespalms

Numbness,tingling,

burning

Radiatingtofirst3digitsandtheradialof

the

ring

finger Sx areoftenatnight,evenwakingpatientsup

Obligatorywristflexionduringsleepdecreases

crosssectional

size

of

the

tunnel,

increases

pressureonthenerve


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CarpalTunnel

Syndrome:

Objective

Handandwristusuallyappearnormal,butmayshowthenaratrophy

Provocativetests:positiveiftheyreproducetheptssymptoms

Tinels testtapoverthemediannerveatthewrist

Phalens Testholdforcedflexionfor60seconds

Durkans Test(Carpalcompressiontest)pressthumbovercarpaltunnelfor30seconds

Radiographsnotnecessary

EMGandNCVobjectivetesttoquantifynerveinjury

Tinnel's Test(MusculoSkeletalExamination)

Phelan'sTest(MusculoSkeletalExamination)

Durkan's Test

(Mckean)


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CarpalTunnel

Syndrome:

Assessment

Diagnosisisclinical

EMGand

NCV

often

obtained

notabsolutelynecessaryfordiagnosis

Generally

recommended

prior

to

surgical

release


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CarpalTunnel

Syndrome:

Plan

1st line

Nightsplints

Activitymodificationavoidwristflexionandextension

2nd

line Steroidinjection

Mostpatientshavesomeimprovementwithinjection

Typically(~75%)Sx return

UsefulinpregnancyandtoconfirmDx

MostsuccessfulinmildCTS(>1yr preservedsensation)


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CarpalTunnel

Syndrome:

Plan

3rd lineCarpalTunnelRelease

Surgicalrelease

of

the

transverse

carpal

ligament

increasessizeofthecarpaltunnel

Decreasespressureonnerve

Keepincision

just

ulnar

to

thenar crease

Thishelpsavoidsinjurytotherecurrentmotorbranch.


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WorksCited

"CarpalTunnelSyndrome."HEALTH,MEDICINEANDANATOMYREFERENCEPICTURES.Health,

MedicineandAnatomyReferencePictures,13Oct.2013.Web.http://healthfavo.com/carpal

tunnel

syndrome

2.html. Thompson,JonC.,andFrankH.Netter.Netter'sconciseorthopaedic anatomy.Philadelphia,

PA:SaundersElsevier,2010.Print.

MusculoSkeletalExamination."APracticalGuidetoClinicalMedicine.Universityof

California,SanDiego,n.d. Web.09Mar.2014.

. McKean,Jason."CarpalTunnelSyndrome."Orthobullets.N.p.,8Mar.2014.Web.09Mar.

2014.


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BasalJointArthritisThe

2nd most

common

hand

osteoarthritis

(after

DIP

OA)


RiskFactors

Symptoms

Physical

Exam

RadiographsandClassification

Treatments


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BasalJoint

Arthritis:

anatomy

and

MOI

Basaljointarthritisoccursbetweenthetrapeziumandthebaseofthefirstmetacarpal

Thisisalsocalledthecarpalmetacarpaljoint(CMC)

Basaljoint

allows

thumb

opposition

Duringpinching,CMCjointsreactiveforceistwelvetimesgreaterthanthepinching

force(Abbasi)

(DoctorRe)

_________

_____



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BasalJoint

Arthritis:

Risk

Factors

Female>Male

Olderthan

40

Priorinjuriestothearea(sprains)

Rheumatoid

arthritis


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BasalJoint

Arthritis:

Symptoms

Painwithgrasping/pinchingactivities

Worsewith

use

Decreaserangeofmotioninthumb

Up

to

40%

have

coexisting

carpal

tunnel

syndrome,orwilldevelopitovertime


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BasalJoint

Arthritis:

Exam

Inspectionmayshow:

BumpatdorsalthumbduetoMCsubluxing dorsallyonthetrapezium

Adductiondeformityof1stmetacarpalinlatestagesofdisease

Ifsevere,

MCP

joint

hyperextension

(seen

in

red)

occurs

to

compensate

for

decreaseCMCmotion

Grindtest:Axiallyloadthefirstmetacarpalandrotateatthejoint,willreproducepain.

1st metacarpaladductiondeformity

Badia

(IndianapolisHandSurgeons)


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BasalJointArthritis: Radiographsand

Classification

EatonandLittlerClassificationofBasilarThumbArthritis


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Classification

WidenedJointSpace NarrowedJointSpace

Osteophytessmaller

than

2mm

(EORIF) (EORIF)


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Classification

Osteoporotic

signs

in

the

scaphtrapezoidaljoint

Sclerosis

Cysticchanges

Osteo h tes>2mm

(EORIF) (EORIF)


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BasalJoint

Arthritis:

Treatment

1st line

NSAIDS

Spicasplint

thumbimmobilization

2nd line

Corticosteroids

Rarely

provided

prolonged

relief


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BasalJointArthritis:SurgicalTreatment

Alwaysinvolvessomeexcisionofthe

articularsurface

of

the

trapezium

Mostcommonprocedure:trapeziectomy

+interpositionofFCRtendon+/

reconstruction

of

the

volar

ligament

(AKA

LTRIorBurtonsarthroplasty)

Incisionatdorsalthumb

Anatomy

to

identify

(above

right) I.1st Metacarpal

II.2nd MetacarpalwithFCRinsertion

b.InterpositiongraftofFCRtendon

3rd lineBasalJointArthroplasty


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BasalJointArthritis:Burtons

Arthroplasty(LRTI)

Excisetrapezium

Harvest

all

or

of

FCRtendonproximally,leavingdistalinsertionat2nd

MCbase

intact

TransferFCRtothe1st

MCbase

Interposeremained

ofcoiledFCRintothespaceleftbytrapeziumexicison

(VanHeest andKallemeier)

TrapeziumremovedandcoiledFCRtendon

occupyingthe

space


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WorksCited

Abbasi,David."BasilarThumbArthritis."Hand.Orthobullets,10Feb.2014.Web.15Mar.2014..

"DoctorRe.com |CommonInjuriesWrist&Hand."DoctorRe.com |CommonInjuriesWrist&

Hand.

N.p.,

n.d. Web.

15

Mar.

2014.

. Thompson,JonC.,andFrankH.Netter.Netter'sconciseorthopaedic anatomy.Philadelphia,PA:

SaundersElsevier,2010.Print.

Badia,Alejandro."TotalJointArthroplastyintheTreatmentofAdvancedStagesofThumbCarpometacarpalJointOsteoarthritis."OsteoarthritisThumbBasalJointOrthopedicFingerSurgeonDr.AlejandroBadia HandtoShoulderCenterHandHospitalMiamiThumbCarpometacarpalJointOsteoarthritis.Badia:HandtoShoulderCenter,12Apr.2007.Web.15Mar.2014.

.

"ArthritisattheBaseoftheThumb."IndianapolisHandSurgeons.IndianaHandtoShoulderCenter,n.d. Web.15Mar.2014..

"ThumbBasilarJointArthritis715.14."EORIF.N.p.,n.d. Web.15Mar.2014..

Mohanty,Satyajit.

"Physiotherapy

Blogging."

:Differential

Diagnosis

of

Anatomic

(Radial)

Snuffbox

Pain:ItIsNotAlwaysDeQuervains Tenosynovitis.N.p.,12May2012.Web.16Mar.2014..

VanHeest,AnnandKallemeier,Patricia, ThumbCarpalMetacarpalArthritis.JAmAcad Orthop SurgMarch2008;16:140151.


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GanglionCyst

Overview

DorsalGanglion

Cysts

VolarWristGanglions

VolarRetinacular

Cysts

SymptomsandPhysicalExam

Treatments


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GanglionCysts:

Overview

Mucinfilledsynovialcystattachedbyastalktothejoint

capsule(Hughes)

70%dorsalcarpal(green)

20%volarcarpal(notpictured)

10%volarretinacular(red)

Occurat

the

A1

or

A2

pulley

commonly

SlowGrowing

Benign

tumor

(Ihealthspot)


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DorsalGanglionCysts

Typicallyoccuroverthescapholunateligament

~70%ofallganglioncysts

Thoughtto

occur

from

recurrent

stress

of

scapholunate

ligament

70%occur2nd4th decade

NearListerstubercleofthedistalradius

(Divya andOsterman ) (Trumble)


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VolarWristGanglions

~20%ofallgangliacysts

UsuallybetweentheFCRandAPLatthe

scaphotrapezoid joint

Notrecommendedtoaspirateb/cradial

artery

is

nearby

(Trumble)(Trumble)(HSSH)


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Digital

Mucous

Cysts

Occuratthedistalinterphalangealjoint

10%

of

hand

cysts

(Hughes) Associatedw/osteoarthritis

usuallyanosteophyteatthe

DIP Women

5070yearsold

Often

with

Heberdens

Nodes

(WheelessTextbook)


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Symptoms Usually

asymptomatic

Canbepainfulwithwristextension

Cosmeticcomplaints

PhysicalExam Firm

Rubbery

Well

circumscribed Transilluminates with

flashlight

Radiographs

normal

(usually)

Ganglion

Cysts


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Ganglion

Cyst:

Treatment1st line

Observation,splintwear

2nd line

Aspiration

Usuallynotrecommendedwithvolarcystsduetoradialartery

50%90%

recurrence

rate

CansendsampleforcytologytoR/Omalignancyifconcerningcharacteristics/location

3rd line

Surgicalexcisionofthecystandstalktopreventrecurrence


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Works

Cited Hughes,Michael."GanglionCysts."Orthobullets.N.p.,06Oct.2013.Web.23Mar.

2014..

"GanglionCystsWristAndHandLumpsAndBumps."GanglionCysts.IHealthSpot,

Inc,n.d. Web.

23

Mar.

2014.

.

Divya,Singh,andA.LeeOsterman."Ganglionectomy."HandSurgery1stEdition.LippincottWilliams&Wilkins,n.d. Web.23Mar.2014.

Trumble,Thomas.

"Ganglion

Cyst."

Ganglion

Cyst.

BBPJ:

Hand

and

Upper

Extremity

Institute,n.d. Web.23Mar.2014..

"GanglionCystTreatment|HandSurgerySpecialistsofHouston."HSSH.HandSurgerySpecialistsofHoustonDallas BeverlyHills LasVegas,6Mar.2013.

Web.

23

Mar.

2014.

. "MucousCyst."Wheeless'TextbookofOrthopaedics.N.p.,20June2010.Web.23

Mar.2014..


43/71

Scaphoid

Fractures AnatomyandMechanismofInjury

RiskFactors

Symptoms

Presentation Imaging

Radiographs

Classification&Treatments


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ScaphoidFracture:AnatomyandMOI

Thescaphoidistheradial

borderof

the

carpal

bones

Mostcommonlyfractured

carpalbone

75%oftheboneisarticular

cartilage

LeftHandPalmarview(wikipedia)


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Scaphoid

Fracture:

Anatomy

and

MOI 80%ofthescaphoidbloodsupplyisfromthedorsalcarpalbranchoftheradialartery

Aminorityofbloodsupplyisfromthesuperficialpalmararchviapalmarbranch

The

most

proximal

portion

of

the

bone

relies

on

retrograde

flow. implicationforfracturesishigherratesofAVN.

100%AVNinfractureofproximal5th and33%AVNinfractureofproximalthird

(Abassi)


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Scaphoid

Fracture:

Mechanism Mostcommonly

associated

with

low

impactfalls

Youngmalesmost

common Extremedorsiflexionof

thehand

Frequentlyoccurs

with

fallsbackward

(FXRX)


47/71

ScaphoidFracture:Presentation

History:

Pts complainofwristpain,

reduced

motion

and/or

grip

weakness

Oftengiveahistoryofsprainedwristnotimproving

withtime

Exam:

Tenderdorsalanatomic

snuffboxScaphoidtubercle

tendernessonvolaraspect

Limitedwristextension

AnatomicSnuff

Box

(Jones)

ScaphoidTubercle

Tenderness

(Abassi)


48/71

Scaphoid

Fracture:

Imaging Xrays

AP,LateralandScaphoidview

Ifinitial

films

are

negative,

cast

and

repeat

in

1week

Bonescanhighestsensitivityandspecificitywithinfirst72hrs.

MRI Generallypreferredexamforoccultfractures

Highestsensitivitywithin1st 24hrs

Usefulforseveralweeksafterinjury

Showsligamentous

damage

and

vascularity

CT Idealfordeterminingfracturedisplacement

Oftenusedforsurgicalplanningortoevaluatehealing


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Scaphoid

Fracture:

Imaging Fxs classifiedbylocation

Mostcommon

fx is

nondisplacedofthe

waist(middle)

Distalfx tendtohealquicklyduetoblood

supply Proximalfx havehighest

rateofnonunion

(Seiler)

S h id F t R di h


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ScaphoidFracture:Radiographs

NonDisplacedwaistfracturemostcommonpattern

12hrspostinjury

Slightlucency

1weekpostinjury

Greaterspacing

3monthspostinjury

NonUnionwithgreater

lucency

(Ren) (Ren)(Ren)

Scaphoid Fracture: Classification and


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ScaphoidFracture:Classificationand

TreatmentNonDisplacedFractures

Majorityof

the

fractures

Tx:ThumbSpicaorshort

armcastuntilunion

Castingcan

be

prolonged upto45

monthsforproximal

fratures

(Boyd)

S h id F t S


52/71

ScaphoidFracture:Surgery

DisplacedFractures

Indications

>1mm

displacment

Comminuted

Pt preferencetoliberatefromcast

Generallytreatedwithscreworpinfixation. Cannulated screwmostcommon(right)

Platesrarely

used

(below)

PercutaneousScrew

(Boyd)LockingPlate(StratMed)

Works Cited


53/71

WorksCited

"ScaphoidBone."Wikipedia.WikimediaFoundation,24Mar.2014.Web.28Mar.2014.

.

Abassi,David."ScaphoidFracture."Orthobullets.N.p.,26Mar.2014.Web.27Mar.

2014..

"TraumaticInjuries

to

the

Hand

&

Wrist

Info

from

an

AZ

Orthopedic."

Traumatic

InjuriestotheHand&Wrist.FXRX:Orthopedics&Bracing,26May2013.Web.27Mar.

2014..

Jones,Oliver."TheAnatomicalSnuffbox."TeachMeAnatomy.N.p.,14Mar.2014.Web.

27Mar.

2014.

.

Seiler,John."EssentialsofHandSurgery1stEdition."CarpalFractures.Lippincott

Williams&Wilkins,n.d. Web.28Mar.2014.

.

Ren,Jack."ScaphoidFracture."Radiopaedia BlogRSS.Radiopedia.org,n.d. Web.29

Mar.2014.

.

Boyd,AnneS.,HollyBENJAMIN,andChadASPLUND."SplintsandCasts:Indicationsand

Methods."AmericanFamilyPhysician.AmericanAcademyofFamilyPhysicians,1Sept.

2009.Web.28Mar.2014..

"Aptus ScaphoidPlate."Stratmed.co.za.N.p.,n.d. Web.28Mar.2014.

.

Cubital Tunnel Syndrome


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CubitalTunnelSyndrome

Anatomy

Mechanismof

Injury

and

Risk

Factors

Presentation

Physical

Exam

Treatments


55/71

Cubital

Tunnel

Syndrome:

Anatomy Theulnarnerverunsthroughthecubitaltunnelattheelbow

BordersofCubitalTunnel Medialepicondyleofthehumerus(green)

Olecranonprocess

of

the

ulna

(blue)

Osbornsligamentrunsbetweenthemedialepicondyleandtheolecranonmaycompresstheulnarnerveattheelbow



56/71

Cubital

Tunnel

Syndrome:

AnatomyUlnarnerve

Sensoryto4th and5th digits Palmardigitalsensorybranches

Dorsalsensorybranchemerges5cmproximaltothewrist.Differentiatesitfromamoredistalneuropathy

(blue)

Motor

Flexorcarpiulnaris

Flexdigitorumprofundus(4th and5th digits)

Hypothenarmuscles

Adductorpollicis

(Wikipedia)


57/71

Cubital

Tunnel

Syndrome

MOIandetiology

2nd mostcommon

upper

extremitycompression

neuropathy(afterCTS)

Canoccur

due

to

nerve

rubbingovermedial

epicondyleduringelbow

flexionand

extension

RiskFactors

Repetitiveelbow

motion

canexacerbatesymptoms

Phonetalking

DiabetesMicroischemiaincreases

vulnerability

Congenitallytight

tunnel

Historyofdirectblow


58/71

Cubital

Tunnel

Syndrome:

Presentation

4th and5th digitnumbnessandtingling

Includingdorsal

aspect

C/Ohandclumsinessordroppingthings

Sx worsewithelbowflexion

Repetitiveactivities

Prolongedpositionalactivities driving,resting

arm

on

armrestSleep

CubitalTunnelSyndrome:PhysicalExam


59/71

Inspection

Interosseousatrophy

(in

severe

disease)

Sensory

Decreasedin4th and5th digit

Motor

Weakpinch

Froments

signthepatientgraspsthepieceofpaperandresistsitbeingremoved. Withulnarpalsy,weakenedadductorpolliciscompensatedwithflexingflexorpollicislongus(FPL)

Wartenbergsign5th digitabductionduringattemptedadduction. Fromweaksmallfingerlumbricaland3rd palmarinterosseous(Allen)

Cannotcrossindexandmiddlefingers(DIOweakness)

(Giovannoni)

Wartenbergs

Sign

(OrthopaedicsOne)

Cubital Tunnel Syndrome: Physical Exam


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CubitalTunnelSyndrome:PhysicalExam

ProvocativeTests

TinelsSign Lightlytappingposteriortothemedialepicondyleoverthe

nervehighlysensitive(oftenoverlysensitive)

Elbow

flexion

Test Holdfor>60sec

(IndianaHandtoShoulder)

TinelsSign ElbowFlexionTest (CRTechnologies)

C bi l T l S d T


61/71

CubitalTunnelSyndrome:Treatment

NonOperative

Activity

modification

NSAIDS

Nighttimeelbow

extensionsplinting

At45degreesina

neutralposition

(HandTherapyCanada)

Cubital Tunnel Syndrome: Treatment


62/71

CubitalTunnelSyndrome:Treatment

Operative

UlnarnerveInsituDecompression

Releasecubitaltunnelretinaculum(red)

Ulnarnerve

Decompression

and

with

anterior

transposition

Ulnarnerveismovedanteriorinthearm eithersubcutaneously,

submuscularly orintramuscularly.

(IndianaHand

to

Shoulder)

(IndianaHandtoShoulder)


63/71

Works

Cited "UlnarNerve."Wikipedia.WikimediaFoundation,24Mar.2014.Web.29Mar.2014.

.

"CompressionNeuropathiesoftheArm."MusculoskeletalMedicineforMedicalStudentsOrthopaedicsOne.N.p.,n.d. Web.29Mar.2014.

.

Giovannoni,Gavin."TeachNeurology:Froment'sSign."TeachNeurology:Froment'sSign.N.p.,n.d.Web.29Mar.2014..

Allen,Deborah."CubitalTunnelSyndrome."Orthobullets.N.p.,6Feb.2014.Web.29Mar.2014..

"CubitalTunnelSyndrome."IndianaElbowSurgeons.N.p.,n.d. Web.29Mar.2014..

CRTechnologies."ElbowFlexionTest."YouTube.YouTube,12Oct.2009.Web.29Mar.2014..

"HandTherapyCanadaTheCanadianHandTherapyResource."HandTherapyCanadaTheCanadianHandTherapyResource.N.p.,n.d. Web.29Mar.2014..


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Low

Ulnar

Nerve

Injury

Anatomy

Causes Presentation

Physical

Exam Testing

Management

LowUlnarNerveInjuryorcompression:


65/71

Anatomy

GuyonsCanal

Beginsatflexorretinaculum

Betweenpisiformandhamate

Containsulnarnerveandartery ulnarnerveulnarinthecanal

Ulnarnervebranchesafterexitingcanal Superficial

branch

of

ulnar

nervethe

sensory

of

palmar4th and

5th digits

Deepbranchofulnarnervemotorbranch

Note:Thedorsalbranchoftheulnarnervebranchesabout5cmproximaltothewrist,soindividualswithlowulnarinjurywillnothavedorsalsensorycomplaints

(Humpal) (Humpal)


66/71

Low

Ulnar

Nerve

Injury:

Causes CompressiontoGuyonscanal

Ganglion

cyst

Cycling(handlebarpalsy)

RepetitiveTasks

Diabeticneuropathy

Knifestaborgunshotwound

LowUlnarNerveInjury:Presentationd


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HandWasting

4th and5th digitpalmarnumbness

4th and5th digitcurling(ulnarclaw)whentryingtoextendfingers ShowsHyperextensionatMCPandflexedatIPjoint

From

loss

of

lumbricalsNote:Thereisalsolossoflumbricalfx incubitaltunnel(CTS),howevertheulnarclawisnotaspronouncedinCTS,becausethereisalsolossofflexordigitorumprofundustothe4th and5th digits,decreasingIPjointflexion.

(StanfordSchoolofMedicine)

Low Ulnar Nerve Injury: Physical Exam


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LowUlnarNerveInjury:PhysicalExam

SimilartoCubitalTunnelSyndrome(seeslide59)

PositiveFromentsSign

PositiveWartenbergs

Sign

Weaknessorinabilitytocrossindexandlongfinger

Tinelsmaybepositiveatthesiteofcompressionorinjury

Differsfrom

CTS

in

that

Sensationintactondorsalaspectof4th and5th

NegativeTinelssignattheelbow

Negative

Elbow

Flexion

Test

Low Ulnar Nerve Injury: Testing


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LowUlnarNerveInjury:Testing

RadiographsandXrays

Usefultoexaminehamatefracture,whichcancause

ulnar

nerve

compression

if

displaced

MRI

Typicallyusedintheworkupofatraumatic ulnar

nervepalsy

Mayshowspacyoccupyinglesion(ganglioncysts)compressingthenerve

Nerve

Conduction

Test

and

Electromyogram Usefultoobjectivelydemonstrateneuropathy

Low Ulnar Nerve Injury: Management


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LowUlnarNerveInjury:Management

NonOperative

Activitymodification

NSAIDS

Wristbrace

Operative

DecompressionofFlexorRetinaculumifcompressionoccursatGuyonsCanal

TendonTransfersifnervehaspoorrecovery Improves

pinch

strength

Amelioratestheclawhand

Works Cited


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WorksCited

"Guyon'sCanalSyndrome."Humpal:PhysicalTherapyandSportsMedicineCenter,n.d. Web.

30Mar.

2014.

.

"#19TheHandinDiagnosis."TheHandinDiagnosis.StanfordSchoolOfMedicine,n.d.Web.31Mar.2014.

.

Hand Surgery-A Guide for Medical Students Revision

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