HandSurgery:AGuidefor

MedicalStudents
TrevorCarrollandMargaretJainMD

TableofContents
Trigger Finger
3
Carpal Tunnel Syndrome
Basal Joint Arthritis
Ganglion Cyst
Scaphoid Fracture
Cubital Tunnel Syndrome
Low Ulnar Nerve Injury

13
23
36
43
54
64

TriggerFinger
(stenosingtenosynovitis)

AnatomyandMechanismofInjury
RiskFactors
Symptoms
PhysicalExam
Classification
Treatments

TriggerFinger:AnatomyandMOI

(ThompsonandNetter,p191)
Theflexortendonsrunwithinthesynovialtendinoussheathinthefinger
Duringflexion,thetendonscontract,runningunderneaththepulleysystem
Overtime,theflexortendonsand/ortheA1pulleycangetinflamedduringfingerflexion.
Occassionally,theflexortendonsand/ortheA1pulleyabnormallythicken.Thisdecreases
thenormalspacebetweenthesestructuresnecessaryforthetendontosmoothlyglide
Inmoreseverecases,patientscanhave
theirfingersmomentarilyor
permanentlylockedinflexionusuallyat
thePIPjoint

(TriggerFingerOrthoInfo )

TriggerFinger:RiskFactors
Age:4060
Female>Male
Repetitivetasksmayberelated
Computers,machinery

Gout
Rheumatoidarthritis
Diabetes(poorprognosticsign)
Carpaltunnelsyndrome(oftenconcurrently)

TriggerFinger:Subjective
C/Ofocaldistalpalmpain
Paincanradiateproximallyinthepalmand
distallyinfinger
C/Ofingerlocking,clicking,stickingoften
worseduringsleeporintheearlymorning
Sometimessnappingduringflexion
Canimprovethroughouttheday

TriggerFinger:Objective
Focaltendernesstopalpation
atthefingerbase(atA1pulley)
Mayappreciatenoduleinthis
location
Tendernessmayincreasewith
fingerextension
Radiographsnotnecessary
BewaresnappingatMPjoint
mayresembletriggerfingers
BewareassociatedMP
arthritisptwillhavedorsal
jointtenderness

(Hubspot)

TriggerFinger:Classification
GreenClassification

(McKean)

TriggerFinger:Management
1st line
Stoppingtheoffending
activity
Nightsplinting
NSAIDS

TriggerFinger:Management
2nd line
Steroid
injection

Noticethesteroidis
placedwithinthe
tendonoussheath.

(ThompsonandNetter,p199)

TriggerFinger:Management
3rd Line:SurgicalreleaseofA1
pulley

ProximalDigitalCrease

Operation
Surgicalsite:~1cmproximal
toproximaldigitalcrease.
Incisioncenteredoverthe
metacarpaltoavoidcommon
digitalarteriesandnerve
SharpreleaseofA1pulleyto
restoresmoothtendongliding
Havept demonstratesmooth
flexionbeforeclosingincision

A1Pulley

Postoperatively
EarlypassiveandactiveROM.
Complications:infection,PIPstiffness,digitalnerveinjury,bowstringing

(Steffens)

WorksCited
Thompson,JonC.,andFrankH.Netter.Netter'sconciseorthopaedic
anatomy.Philadelphia,PA:SaundersElsevier,2010.Print.
"TriggerFingerOrthoInfo AAOS."TriggerFingerOrthoInfo 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.08
Mar.2014.<http://www.orthobullets.com/hand/6027/trigger
finger>.
Steffens,Kurt."SurgeryofTriggerFinger(SnappingFinger)."
SurgeryofTriggerFinger(SnappingFinger).N.p.,n.d. Web.08Mar.
2014.<http://www.handarm.com/TVS/surgical_treatment.htm>.

CarpalTunnelSyndrome
Themostcommonentrapmentneuropathy

AnatomyandMechanismofInjury
RiskFactors
Symptoms
PhysicalExam
Treatments

CarpalTunnelSyndrome:Anatomyand
MOI
Mediannerve,FDS,FDP,FPLrunwithinthe
carpaltunnel
VolarCTboundary:flexorretinaculum(or
transversecarpalligament)
Mediannervebranches:

Palmarcutaneousb. dividesfrommediann.
proximaltoCT,sparedinCTS
Recurrentmotorb.motortoopponenspollicus,
APB,FPB dividesfrommediann.aroundlevelof
CT
Commonpalmardigitalb. sensorytofingertips
Motorto1st and2nd lumbricals

(CarpalTunnelSyndrome)
(ThompsonandNetter,p210)

CarpalTunnelSyndrome:Anatomyand
MOI
Themediannerveis
entrappedwithinthe
tunnel,whichcreateslocal
nerveischemia
Thiscreatesnumbness,
tingling,andorpaininthe
mediannervedistribution
Chronicentrapmentcan
producethenar atrophy
(seenatright)

(McKean)

CarpalTunnelSyndrome:RiskFactors

Females>Males
Inheritingasmallertunnel
Womentendtohavesmallertunnels

OlderAge(mean~54years)
Pregnancy(oftenresolveswithdelivery)
Heavyworkwithhandsandvibrationalequipment
Machineryworkers,autoindustry
Usingjackhammer

Thyroiddisease
Trauma
Rheumatoidarthritis
Ganglioncyst
Amyloidosis

Note:Nogooddatatosupporttypingorkeyboardingasacause

CarpalTunnelSyndrome:Subjective
Fingernumbnessorpain usuallysparespalms
Numbness,tingling,burning
Radiatingtofirst3digitsandtheradialof
theringfinger
Sx areoftenatnight,evenwakingpatientsup
Obligatorywristflexionduringsleepdecreases
crosssectionalsizeofthetunnel,increases
pressureonthenerve

CarpalTunnelSyndrome: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)

CarpalTunnelSyndrome:Assessment
Diagnosisisclinical
EMGandNCVoftenobtained
notabsolutelynecessaryfordiagnosis
Generallyrecommendedpriortosurgicalrelease

CarpalTunnelSyndrome:Plan
1st line
Nightsplints
Activitymodification avoidwristflexionandextension
2nd line
Steroidinjection

Mostpatientshavesomeimprovementwithinjection
Typically(~75%)Sx return
UsefulinpregnancyandtoconfirmDx
MostsuccessfulinmildCTS(>1yr preservedsensation)

CarpalTunnelSyndrome:Plan
3rd lineCarpalTunnelRelease
Surgicalreleaseofthetransversecarpalligament
increasessizeofthecarpaltunnel
Decreasespressureonnerve

Keepincisionjustulnartothenar crease
Thishelpsavoidsinjurytotherecurrentmotorbranch.

WorksCited
"CarpalTunnelSyndrome."HEALTH,MEDICINEANDANATOMYREFERENCEPICTURES.Health,
MedicineandAnatomyReferencePictures,13Oct.2013.Web.http://healthfavo.com/carpal
tunnelsyndrome2.html.
Thompson,JonC.,andFrankH.Netter.Netter'sconciseorthopaedic anatomy.Philadelphia,
PA:SaundersElsevier,2010.Print.
MusculoSkeletalExamination."APracticalGuidetoClinicalMedicine.Universityof
California,SanDiego,n.d. Web.09Mar.2014.
<https://meded.ucsd.edu/clinicalmed/joints3.htm>.
McKean,Jason."CarpalTunnelSyndrome."Orthobullets.N.p.,8Mar.2014.Web.09Mar.
2014.<http://www.orthobullets.com/hand/6018/carpaltunnelsyndrome>

BasalJointArthritis
The2nd mostcommonhandosteoarthritis(afterDIPOA)

AnatomyandMechanismofInjury
RiskFactors
Symptoms
PhysicalExam
RadiographsandClassification
Treatments

BasalJointArthritis:anatomyandMOI

Basaljointarthritisoccursbetweenthetrapeziumandthebaseofthefirstmetacarpal
Thisisalsocalledthecarpalmetacarpaljoint(CMC)
Basaljointallowsthumbopposition
Duringpinching,CMCjointsreactiveforceistwelvetimesgreaterthanthepinching
force(Abbasi)

_____
_________

(DoctorRe)

(ThompsonandNetter,p185)

BasalJointArthritis:RiskFactors

Female>Male
Olderthan40
Priorinjuriestothearea(sprains)
Rheumatoidarthritis

BasalJointArthritis:Symptoms

Painwithgrasping/pinchingactivities
Worsewithuse
Decreaserangeofmotioninthumb
Upto40%havecoexistingcarpaltunnel
syndrome,orwilldevelopitovertime

BasalJointArthritis:Exam
Inspectionmayshow:
Bumpatdorsalthumb duetoMCsubluxing dorsallyonthetrapezium
Adductiondeformityof1stmetacarpalinlatestagesofdisease
Ifsevere,MCPjointhyperextension(seeninred)occurstocompensatefor
decreaseCMCmotion
Grindtest:Axiallyloadthefirstmetacarpalandrotateatthejoint,willreproducepain.

1st metacarpaladductiondeformity
(Badia)

(IndianapolisHandSurgeons)

BasalJointArthritis: Radiographsand
Classification
EatonandLittlerClassificationofBasilarThumbArthritis

BasalJointArthritis:Radiographsand
Classification

WidenedJointSpace

(EORIF)

(EORIF)
NarrowedJointSpace
Osteophytessmallerthan2mm

BasalJointArthritis:Radiographsand
Classification

Sclerosis
Cysticchanges
Osteophytes>2mm

(EORIF)

(EORIF)

Osteoporoticsignsinthescaphtrapezoidal
joint

BasalJointArthritis:Treatment
1st line
NSAIDS
Spicasplint
thumbimmobilization

2nd line
Corticosteroids
Rarelyprovidedprolongedrelief

BasalJointArthritis:SurgicalTreatment
3rd lineBasalJointArthroplasty
Alwaysinvolvessomeexcisionofthe
articularsurfaceofthetrapezium
Mostcommonprocedure:trapeziectomy
+interpositionofFCRtendon+/
reconstructionofthevolarligament(AKA
LTRIorBurtonsarthroplasty)
Incisionatdorsalthumb
Anatomytoidentify(aboveright)
I.1st Metacarpal
II.2nd MetacarpalwithFCRinsertion
b.InterpositiongraftofFCRtendon

BasalJointArthritis:Burtons
Arthroplasty(LRTI)
Excisetrapezium
Harvestallorof
FCRtendon
proximally,leaving
distalinsertionat2nd
MCbaseintact
TransferFCRtothe1st
MCbase
Interposeremained
ofcoiledFCRintothe
spaceleftby
trapeziumexicison

(VanHeest andKallemeier)

TrapeziumremovedandcoiledFCRtendon
occupyingthespace

WorksCited

Abbasi,David."BasilarThumbArthritis." Hand.Orthobullets,10Feb.2014.Web.15Mar.2014.
<http://www.orthobullets.com/hand/6054/basilarthumbarthritis>.
"DoctorRe.com |CommonInjuries Wrist&Hand."DoctorRe.com |CommonInjuries Wrist&
Hand.N.p.,n.d. Web.15Mar.2014.<http://www.doctorre.com/commoninjuries/wristandhand/>.
Thompson,JonC.,andFrankH.Netter.Netter'sconciseorthopaedic anatomy.Philadelphia,PA:
SaundersElsevier,2010.Print.
Badia,Alejandro."TotalJointArthroplastyintheTreatmentofAdvancedStagesofThumb
CarpometacarpalJointOsteoarthritis."OsteoarthritisThumbBasalJointOrthopedicFingerSurgeon
Dr.AlejandroBadia HandtoShoulderCenterHandHospitalMiamiThumbCarpometacarpalJoint
Osteoarthritis.Badia:HandtoShoulderCenter,12Apr.2007.Web.15Mar.2014.
<http://www.drbadia.com/paramdicosycolegastotaljointarthroplastyinthetreatmentof
advancedstagesofthumbcarpometacarpaljointosteoarthritisarticleid48cat7eng.php>.
"ArthritisattheBaseoftheThumb."IndianapolisHandSurgeons.IndianaHandtoShoulderCenter,
n.d. Web.15Mar.2014.
<http://indianahandtoshoulder.com/medical_education_hand_arthritis.html>.
"ThumbBasilarJointArthritis715.14."EORIF.N.p.,n.d. Web.15Mar.2014.
<http://www.eorif.com/thumbbasilarjointarthritis71514>.
Mohanty,Satyajit."PhysiotherapyBlogging.":DifferentialDiagnosisofAnatomic(Radial)Snuffbox
Pain:ItIsNotAlwaysDeQuervains Tenosynovitis.N.p.,12May2012.Web.16Mar.2014.
<http://physioindia.blogspot.com/2012/05/differentialdiagnosisofanatomic.html>.
VanHeest,AnnandKallemeier,Patricia, ThumbCarpalMetacarpalArthritis.JAmAcad Orthop Surg
March2008;16:140151.

GanglionCyst

Overview
DorsalGanglionCysts
VolarWristGanglions
VolarRetinacularCysts
SymptomsandPhysicalExam
Treatments

GanglionCysts:Overview
Mucinfilledsynovialcystattachedbyastalktothejoint
capsule(Hughes)
70%dorsalcarpal(green)
20%volarcarpal(notpictured)
10%volarretinacular(red)
OccurattheA1orA2pulley
commonly

SlowGrowing
Benigntumor

(Ihealthspot)

DorsalGanglionCysts

Typicallyoccuroverthescapholunateligament
~70%ofallganglioncysts
Thoughttooccurfromrecurrentstressofscapholunateligament
70%occur2nd4th decade
NearListerstubercleofthedistalradius

(Divya andOsterman )

(Trumble)

VolarWristGanglions
~20%ofallgangliacysts
UsuallybetweentheFCRandAPLatthe
scaphotrapezoid joint
Notrecommendedtoaspirateb/cradial
arteryisnearby

(HSSH)

(Trumble)

DigitalMucousCysts
Occuratthedistalinterphalangealjoint
10%ofhandcysts(Hughes)
Associatedw/osteoarthritis
usuallyanosteophyteatthe
DIP
Women
5070yearsold
OftenwithHeberdensNodes

(WheelessTextbook)

GanglionCysts
Symptoms

PhysicalExam

Usuallyasymptomatic
Canbepainfulwith
wristextension

Cosmeticcomplaints

Firm
Rubbery
Wellcircumscribed
Transilluminates with
flashlight
Radiographsnormal
(usually)

GanglionCyst:Treatment
1st line
Observation,splintwear

2nd line
Aspiration
Usuallynotrecommendedwithvolarcystsduetoradialartery
50%90%recurrencerate
CansendsampleforcytologytoR/Omalignancyifconcerning
characteristics/location

3rd line
Surgicalexcisionofthecystandstalktopreventrecurrence

WorksCited

Hughes,Michael."GanglionCysts."Orthobullets.N.p.,06Oct.2013.Web.23Mar.
2014.<http://www.orthobullets.com/hand/6086/ganglioncysts>.
"GanglionCysts WristAndHandLumpsAndBumps."GanglionCysts.IHealthSpot,
Inc,n.d. Web.23Mar.2014.
<http://ccf.eznetpublish.ihealthspot.com/Home/tabid/6851/ctl/View/mid/10838/
Default.aspx?ContentPubID=90>.
Divya,Singh,andA.LeeOsterman."Ganglionectomy."HandSurgery1stEdition.
LippincottWilliams&Wilkins,n.d. Web.23Mar.2014.
<http://www.msdlatinamerica.com/ebooks/HandSurgery/sid524185.html>
Trumble,Thomas."GanglionCyst."GanglionCyst.BBPJ:HandandUpperExtremity
Institute,n.d. Web.23Mar.2014.<http://www.drtrumble.com/ganglion
cyst.html>.
"GanglionCystTreatment|HandSurgerySpecialistsofHouston."HSSH.Hand
SurgerySpecialistsofHoustonDallas BeverlyHills LasVegas,6Mar.2013.
Web.23Mar.2014.<http://carpaltunnelpros.com/portfolioview/ganglioncyst/>.
"MucousCyst."Wheeless'TextbookofOrthopaedics.N.p.,20June2010.Web.23
Mar.2014.<http://www.wheelessonline.com/ortho/mucous_cyst>.

ScaphoidFractures

AnatomyandMechanismofInjury
RiskFactors
Symptoms
Presentation
Imaging
Radiographs
Classification&Treatments

ScaphoidFracture:AnatomyandMOI
Thescaphoidistheradial
borderofthecarpalbones
Mostcommonlyfractured
carpalbone
75%oftheboneisarticular
cartilage

LeftHandPalmarview(wikipedia)

ScaphoidFracture:AnatomyandMOI

80%ofthescaphoidbloodsupplyisfromthedorsalcarpalbranchoftheradialartery
Aminorityofbloodsupplyisfromthesuperficialpalmararchviapalmarbranch
Themostproximalportionofthebonereliesonretrogradeflow.

implicationforfracturesishigherratesofAVN.

100%AVNinfractureofproximal5th and33%AVNinfractureofproximalthird

(Abassi)

ScaphoidFracture:Mechanism
Mostcommonly
associatedwithlow
impactfalls
Youngmalesmost
common
Extremedorsiflexionof
thehand
Frequentlyoccurswith
fallsbackward
(FXRX)

ScaphoidFracture:Presentation
History:
Pts complainofwristpain,
reducedmotionand/orgrip
weakness
Oftengiveahistoryof
sprainedwristnotimproving
withtime

AnatomicSnuffBox(Jones)

Exam:
Tenderdorsalanatomic
snuffbox
Scaphoidtubercle
tendernessonvolaraspect
Limitedwristextension

ScaphoidTubercleTenderness(Abassi)

ScaphoidFracture:Imaging
Xrays
AP,LateralandScaphoidview
Ifinitialfilmsarenegative,castandrepeatin1week

Bonescan
highestsensitivityandspecificitywithinfirst72hrs.

MRI

Generallypreferredexamforoccultfractures
Highestsensitivitywithin1st 24hrs
Usefulforseveralweeksafterinjury
Showsligamentousdamageandvascularity

CT
Idealfordeterminingfracturedisplacement
Oftenusedforsurgicalplanningortoevaluatehealing

ScaphoidFracture:Imaging
Fxs classifiedbylocation
Mostcommonfx is
nondisplacedofthe
waist(middle)
Distalfx tendtoheal
quicklyduetoblood
supply
Proximalfx havehighest
rateofnonunion

(Seiler)

ScaphoidFracture:Radiographs
NonDisplacedwaistfracturemostcommonpattern

12hrspostinjury
Slightlucency

(Ren)

1weekpostinjury
Greaterspacing

(Ren)

(Ren)

3monthspostinjury
NonUnionwithgreater
lucency

ScaphoidFracture:Classificationand
Treatment
NonDisplacedFractures
Majorityofthefractures
Tx:ThumbSpicaorshort
armcastuntilunion
Castingcanbe
prolonged upto45
monthsforproximal
fratures

(Boyd)

ScaphoidFracture:Surgery
DisplacedFractures
Indications
>1mmdisplacment
Comminuted
Pt preferencetoliberatefromcast

Generallytreatedwithscreworpinfixation.
Cannulated screwmostcommon(right)

Platesrarelyused(below)

LockingPlate(StratMed)

PercutaneousScrew(Boyd)

WorksCited

"ScaphoidBone."Wikipedia.WikimediaFoundation,24Mar.2014.Web.28Mar.2014.
<http://en.wikipedia.org/wiki/Scaphoid_bone>.
Abassi,David."ScaphoidFracture."Orthobullets.N.p.,26Mar.2014.Web.27Mar.
2014.<http://www.orthobullets.com/hand/6034/scaphoidfracture>.
"TraumaticInjuriestotheHand&Wrist InfofromanAZOrthopedic."Traumatic
InjuriestotheHand&Wrist.FXRX:Orthopedics&Bracing,26May2013.Web.27Mar.
2014.<http://fxrxinc.com/blog/uncategorized/traumaticinjuriestothehandwrist
infofromanazorthopedic/>.
Jones,Oliver."TheAnatomicalSnuffbox."TeachMeAnatomy.N.p.,14Mar.2014.Web.
27Mar.2014.<http://teachmeanatomy.info/upperlimb/areas/anatomicalsnuffbox/>.
Seiler,John."EssentialsofHandSurgery1stEdition."CarpalFractures.Lippincott
Williams&Wilkins,n.d. Web.28Mar.2014.
<http://www.msdlatinamerica.com/ebooks/EssentialsofHandSurgery/sid113232.html>.
Ren,Jack."ScaphoidFracture."Radiopaedia BlogRSS.Radiopedia.org,n.d. Web.29
Mar.2014.<http://radiopaedia.org/cases/scaphoidfracture12>.
Boyd,AnneS.,HollyBENJAMIN,andChadASPLUND."SplintsandCasts:Indicationsand
Methods."AmericanFamilyPhysician.AmericanAcademyofFamilyPhysicians,1Sept.
2009.Web.28Mar.2014.<http://www.aafp.org/afp/2009/0901/p491.html>.
"Aptus ScaphoidPlate."Stratmed.co.za.N.p.,n.d. Web.28Mar.2014.
<http://www.stratmed.co.za/products/upperextremity/hand/aptusscaphoidplate>.

CubitalTunnelSyndrome

Anatomy
MechanismofInjuryandRiskFactors
Presentation
PhysicalExam
Treatments

CubitalTunnelSyndrome:Anatomy

Theulnarnerverunsthroughthecubitaltunnelattheelbow
BordersofCubitalTunnel
Medialepicondyleofthehumerus(green)
Olecranonprocessoftheulna(blue)
Osbornsligamentrunsbetweenthemedialepicondyleandtheolecranon maycompresstheulnarnerve
attheelbow

(ThompsonandNetter,p120)

CubitalTunnelSyndrome:Anatomy
Ulnarnerve
Sensoryto4th and5th digits
Palmardigitalsensorybranches
Dorsalsensorybranchemerges5cmproximaltothewrist.Differentiatesitfromamoredistal
neuropathy(blue)
Motor
Flexorcarpiulnaris
Flexdigitorumprofundus(4th and5th digits)
Hypothenarmuscles
Adductorpollicis

(Wikipedia)

CubitalTunnelSyndrome
MOIandetiology
RiskFactors
2nd mostcommonupper Repetitiveelbowmotion
extremitycompression
canexacerbatesymptoms
neuropathy(afterCTS)
Phonetalking
Canoccurduetonerve Diabetes
rubbingovermedial
Microischemiaincreases
vulnerability
epicondyleduringelbow
flexionandextension
Congenitallytighttunnel
Historyofdirectblow

CubitalTunnelSyndrome:Presentation
4th and5th digitnumbnessandtingling
Includingdorsalaspect

C/Ohandclumsinessordroppingthings
Sx worsewithelbowflexion
Repetitiveactivities
Prolongedpositionalactivities driving,resting
armonarmrest
Sleep

CubitalTunnelSyndrome:PhysicalExam
Inspection
Interosseousatrophy(inseveredisease)
Sensory
Decreasedin4th and5th digit
Motor
Weakpinch
Fromentssignthepatientgraspsthepieceofpaperandresistsitbeingremoved.
Withulnarpalsy,weakenedadductorpolliciscompensatedwithflexingflexorpollicislongus(FPL)

Wartenbergsign5th digitabductionduringattemptedadduction.
Fromweaksmallfingerlumbricaland3rd palmarinterosseous(Allen)

Cannotcrossindexandmiddlefingers(DIOweakness)

(Giovannoni)

(OrthopaedicsOne)

WartenbergsSign

CubitalTunnelSyndrome:PhysicalExam
ProvocativeTests
TinelsSign
Lightlytappingposteriortothemedialepicondyleoverthe
nervehighlysensitive(oftenoverlysensitive)

ElbowflexionTest
Holdfor>60sec

(IndianaHandtoShoulder)

TinelsSign

ElbowFlexionTest(CRTechnologies)

CubitalTunnelSyndrome:Treatment
NonOperative
Activitymodification
NSAIDS
Nighttimeelbow
extensionsplinting
At45degreesina
neutralposition
(HandTherapyCanada)

CubitalTunnelSyndrome:Treatment
Operative
UlnarnerveInsituDecompression
Releasecubitaltunnelretinaculum(red)

UlnarnerveDecompressionandwithanteriortransposition
Ulnarnerveismovedanteriorinthearm eithersubcutaneously,
submuscularly orintramuscularly.

(IndianaHandtoShoulder)

(IndianaHandtoShoulder)

WorksCited

"UlnarNerve."Wikipedia.WikimediaFoundation,24Mar.2014.Web.29Mar.2014.
<http://en.wikipedia.org/wiki/Ulnar_nerve>.
"CompressionNeuropathiesoftheArm." MusculoskeletalMedicineforMedicalStudents
OrthopaedicsOne.N.p.,n.d. Web.29Mar.2014.
<http://www.orthopaedicsone.com/display/MSKMed/Compression%2Bneuropathies%2Bof%2Bthe
%2Barm>.
Giovannoni,Gavin."TeachNeurology:Froment'sSign."TeachNeurology:Froment'sSign.N.p.,n.d.
Web.29Mar.2014.<http://teachneuro.blogspot.com/2012/04/fromentssign.html>.
Allen,Deborah."CubitalTunnelSyndrome."Orthobullets.N.p.,6Feb.2014.Web.29Mar.2014.
<http://www.orthobullets.com/hand/6021/cubitaltunnelsyndrome>.
"CubitalTunnelSyndrome."IndianaElbowSurgeons.N.p.,n.d. Web.29Mar.2014.
<http://indianahandtoshoulder.com/medical_education_elbow_cubital.html>.
CRTechnologies."ElbowFlexionTest."YouTube.YouTube,12Oct.2009.Web.29Mar.2014.
<https://www.youtube.com/watch?v=gBY1w82J9KI>.
"HandTherapyCanada TheCanadianHandTherapyResource."HandTherapyCanada The
CanadianHandTherapyResource.N.p.,n.d. Web.29Mar.2014.
<http://www.handtherapy.ca/elbow.php>.

LowUlnarNerveInjury

Anatomy
Causes
Presentation
PhysicalExam
Testing
Management

LowUlnarNerveInjuryorcompression:
Anatomy
GuyonsCanal

Beginsatflexorretinaculum
Betweenpisiformandhamate
Containsulnarnerveandartery ulnarnerveulnarinthecanal
Ulnarnervebranchesafterexitingcanal
Superficialbranchofulnarnervethesensoryofpalmar 4th and5th digits
Deepbranchofulnarnervemotorbranch

Note:Thedorsalbranchoftheulnarnervebranchesabout5cmproximaltothewrist,so
individualswithlowulnarinjurywillnothavedorsalsensorycomplaints

(Humpal)

(Humpal)

LowUlnarNerveInjury:Causes
CompressiontoGuyonscanal
Ganglioncyst
Cycling(handlebarpalsy)
RepetitiveTasks

Diabeticneuropathy
Knifestaborgunshotwound

LowUlnarNerveInjury:Presentation
HandWasting
4th and5th digitpalmarnumbness
4th and5th digitcurling(ulnarclaw)whentryingtoextendfingers
ShowsHyperextensionatMCPandflexedatIPjoint
Fromlossoflumbricals
Note:Thereisalsolossoflumbricalfx incubitaltunnel(CTS),howeverthe
ulnarclawisnotaspronouncedinCTS,becausethereisalsolossofflexor
digitorumprofundustothe4th and5th digits,decreasingIPjointflexion.

(StanfordSchoolofMedicine)

LowUlnarNerveInjury:PhysicalExam
SimilartoCubitalTunnelSyndrome(seeslide59)
PositiveFromentsSign
PositiveWartenbergsSign
Weaknessorinabilitytocrossindexandlongfinger
Tinelsmaybepositiveatthesiteofcompressionorinjury
DiffersfromCTSinthat
Sensationintactondorsalaspectof4th and5th
NegativeTinelssignattheelbow
NegativeElbowFlexionTest

LowUlnarNerveInjury:Testing
RadiographsandXrays
Usefultoexaminehamatefracture,whichcan
causeulnarnervecompressionifdisplaced
MRI
Typicallyusedintheworkupofatraumatic ulnar
nervepalsy
Mayshowspacyoccupyinglesion(ganglioncysts)
compressingthenerve

NerveConductionTestandElectromyogram
Usefultoobjectivelydemonstrateneuropathy

LowUlnarNerveInjury:Management
NonOperative
Activitymodification
NSAIDS
Wristbrace
Operative
DecompressionofFlexorRetinaculumif
compressionoccursatGuyonsCanal
TendonTransfersifnervehaspoorrecovery
Improvespinchstrength
Amelioratestheclawhand

WorksCited
"Guyon'sCanalSyndrome."Humpal:Physical
TherapyandSportsMedicineCenter,n.d. Web.
30Mar.2014.
<http://www.humpalphysicaltherapy.com/Injurie
sConditions/Hand/HandIssues/GuyonsCanal
Syndrome/a~286/article.html>.
"#19TheHandinDiagnosis."TheHandin
Diagnosis.StanfordSchoolOfMedicine,n.d.
Web.31Mar.2014.
<http://stanfordmedicine25.stanford.edu/the25/
hand.html>.