Ulnar Nerve Palsy

Examination
Rule out median, radial and brachial neuritis
Inspecting
Wasting of the muscles of the hands, hypothenar eminence and partial clawing
of the 4th and 5th fingers, sparing of the thenar eminence, ulnar paradox
Proceed to tests for finger abduction and Froments sign (weakness of the
adduction of the thumb)
Test finger flexion of the 5th finger for flexor digitorum profundus
involvement; test for wrist flexion at the ulna side and look for the tendon of
the flexor carpi ulnaris
Rule out median nerve (thenar eminence and ext rot thumb, pen touch test and
Oschner clasping test) and radial nerve
Sensory testing in the medial 1 fingers; test T1 sensory loss
Examine the wrist and elbows (feel for thickened nerve, wide carrying angle))
Function
Thickened nerve (cf with Pb for radial and Acromeg etc for median)
Presentation
Sir, this patient has got a isolated left ulnar palsy as evidenced by a left ulnar
claw hand with wasting of the small muscles of the hands with dorsal guttering as
well as wasting of the hypothenar eminence. There is sparing of the thenar eminence.
There is weakness of finger abduction and Froments sign is positive. There is
preservation of the flexion of the DIPJ of the 4th and 5th fingers; when the hand is
flexed to the ulna side against resistance, the tendon of the flexor carpi ulnaris is
palpable. This is associated with reduced sensation to pinprick in the medial 1/1/2
fingers. There are no associated median or radial nerve palsies and T1 involvement.
In terms of aetiology, there is a scar at the wrist associated with a marked ulnar
claw hand, demonstrating the ulna paradox. I did not find any signs to suggest leprosy
such as thickened nerves, hypopigmentation patches or finger resorption.
Both coarse and fine motor function of the hand is preserved.
In summary, this patient has a left ulna claw hand due to a traumatic injury to
the left wrist.
Questions
What is the anatomical course of the ulnar nerve?
It provides motor to all muscles of the hands except the LOAF; flexor carpi
ulnaris and flexor digitorum profundus to the 4th and 5th fingers.
Sensory to the ulna 1 fingers
Begins from the medial cord of the brachial plexus (C8 and T1)
No branches in the arm
Enters the forearm via the cubital tunnel (medial epicondyle and the olecranon
process) and motor supply to the flexor carpi ulnaris and ulna half of the flexor
digitorum profundus
It gives off a sensory branch just above the wrist and enters Guyons canal and
supplies the sensory medial 1 fingers and hypothenar as well as motor to all
intrinsic muscles of the hands except LOAF.

What is the level of lesions and its clinical correlation?

Wrist Hypothenar eminence wasting, Froments positive, weakness of finger
abduction, pronounced claw and loss of sensation
Elbow less pronounced claw and loss of terminal flexion of the DIPJ and loss of
flexor carpi ulnaris tendon on ulna flexion of the wrist
How do you differentiate ulnar nerve palsy vs a T1 lesion?
Motor wasting of the thenar eminence in addition for T1
Sensory loss in T1 dermatomal distribution
What is the ulna claw hand?
It refers to the hyperextension of the 4th and 5th MCPJ associated with flexion
of the IPJs of the 4th and 5th fingers as a result of ulnar nerve palsy.
It is due to the unopposed long extensors of the 4th and 5th fingers in contrast to
the IF and MF which are counteracted by the lumbricals which are served by the
median nerve.
What is the ulnar paradox?
It means that the ulnar claw deformity is more pronounced for lesions distally
e.g. at the wrist as compared to a more proximal lesion e.g. at the elbow.
This is because a more proximal lesion at the elbow also causes weakness of
the ulnar half of the flexor digitorum profundus, resulting in less flexion of the IPJs of
the 4th and 5th fingers.
What is Froments sign?
Patient is asked to grasp a piece of paper between the thumbs and the lateral
aspect of the index finger. The affected thumb will flex as the adductor pollicis
muscles are weak. (Patient is trying to compensate by using the flexor pollicis longus
supplied by median nerve)
What are the causes of an ulnar nerve palsy?
Compression or entrapment (Cubital tunnel at the elbow and Guyons canal at the
wrist)
Trauma (Fractures or dislocation cubitus valgus leads to tardive ulnar nerve
palsy)
Surgical
Mononeuritis multiplex
Infection leprosy
Ischaemia Vasculitis
Inflammatory - CIDP
How would you investigate?
Blood Ix to rule out DM if no obvious cause
X-rays of the elbow and wrist (both must be done to rule out double crush
syndrome) (KIV C-spine and CXR)

EMG(axonal degeneration for chronic) and NCT(motor and sensory conduction

velocities useful for recent entrapment as well as chronic) to locate level and
monitor

How would you manage?

Education and avoidance of resting on elbow
OT, PT
Medical NSAIDs and Vit B6
Surgical decompression with anterior transposition of the nerve
NB: LOAF lateral 2 lumbricals, opponens pollicis, abductor pollicis brevis and
flexor pollicis brevis