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Ulnar N. Compression
Ulnar Nerve Compression PPT
| Question | Answer |
|---|---|
| Causes of Compressive Neuropathies | Macrotraumatic violent force Repetitive stress (Contusions, Compressions, Traction) |
| Other Causes | Anomalous muscles/vessels; Fibrous bands; Osteofibrous tunnels; Simple muscle hypertrophy; Ganglia; Lipomas; Osteophytes; Aneurysms; Local inflammation |
| Seddon's Classifications | Neuropraxia; Axonotmesis; Neurotmesis |
| Neuropraxia | Mildest form of nerve injury Loss of conduction along course of nerve caused by loss of axon excitability/segmental demyelination Prognosis is good Improvement may be swift Most common in athletic injuries |
| Axonotmesis | Injury & distal degeneration Connective tissue supporting structure & nerve intact; More chronic form of injury; Prognosis good but depends on amount of axonal regeneration req'd from injury site to end organ |
| Neurotmesis | Usu. associated with more severe injury COmplete disruption in nerve structure Recovery slower, less complete Recovery dependent on anatomic reapposition of separated nerve ends |
| Sites for Ulnar N. Compression | Intermuscular septum; Area of medial epicondyle; Epicondylar groove; Cubital tunnel; Exit of ulnar n. from FCU |
| Ulnar Neuritis | Cubital tunnel syndrome Ulnar n. symptom seen in 50% of throwing population Susceptible (tight path that changes dimensions as elbow flexes & extends; sub-q location; considerable excursion) |
| Primary Pathologic Tissue | Ulnar n.- spinal roots of C8-T1 Travels lateral to brachial a. until passing posterior under medial triceps |
| Primary Pathologic Tissue | Follows through medial intermuscular septum or arcade of Struthers 8-10 cm proximal to medial epicondyle |
| Primary Pathologic Tissue | Nerve then passes through ulnar groove posterior to medial epicondyle which is bordered medially by the UCL & laterally by the medial epicondyle with the arcuate lig forming the roof |
| Primary Pathologic Tissue | Nerve then enters cubital tunnel formed by aponeurosis & 2 heads of FCU; Continues distal b/t the FDP dorsally & the FCU palmarly |
| Etiology & Epidemiology | Direct trauma; Hypermobility; Repetitive elbow flexion; Cubitus valgus deformity; Osteophyte or loose body impingement; Anomalous conditions |
| Who most commonly gets ulnar nerve compression syndromes? | Most commonly seen in throwing athlete, weightlifters, skiers, & players of racquet sports |
| Physical Exam | C/O posteromedial elbow pn; Episodic paresthesias along ring & small fingers; Ssy deficits may involve: ulnar 1/2 of ring finger; 5th finger; palmar hypothenar area; dorsal ulnar aspect of hand |
| Physical Exam | May have palpable fullness & tenderness along cubital tunnel +/- (+) Tinel's Sign EMG's show significant diminution of nerve conduction velocity at the elbow |
| Physical Exam | Nocturnal pain from sleeping with elbow hyperflexed (strains ulnar n.) May respond well to night time splinting |
| Literature Findings | (+) Tinel's in 23.5% of 200 normal volunteers Presented bilaterally in 1/2 of those with (+) tests Use of Tinel's must be carefully evaluated Ulnar n. subluxes in 16% & dislocates in 4% asymptomatic people when elbow flexed past 90 |
| Literature Findings | Elbow flexion test (+) when s/sx reproduced by holding elbow flexed for 60" (+) in 10% normal pts |
| Non-Op Acute Phase Goals | Diminish ulnar n inflammation Restore normal motion Maintain/improve mm strength Brace: optional, only it pt externally inflamed ROM: restore full non-painful ROM ASAP Start wrist, forearm, elbow mm stretches |
| Non-Op Acute Phase Strengthening | If pt is extremely painful & inflamed, use isometrics for 1 week Isotonic ex's: Wrist flex/ext; Forearm sup/pron; Elbow flex/ext; Shoulder program |
| Pain/Inflammation Control in Non-Op Acute Phase | Warm WP Cryotherapy HVPS |
| Adv. Strengthening Phase: Week 3-6 (Non-Op) Goals | Improve strength, power, endurance Enhance dynamic joint stability Initiate high-speed training |
| Ex's for Advanced Strengthening Phase | Throwers 10 Eccentrics wrist/forearm mm Rhythmic stabilization drills for elbow Isokinetics for elbow flex/ext Plyos |
| Return to Activity Phase (Weeks 4-6) Goals | Gradual return to fxnal activities Enhance mm performance |
| Criteria to begin throwing | Full non-painful ROM Satisfactory clinical exam Satisfactory mm performance Initiate interval throwing Throwers 10 Stretching ex's |
| Anterior Sub-Q Transposition Goals | Release nerve from all potential sites of entrapment Move nerve anterior to motion axis of the elbow, thereby relieving tension |
| Anterior Intramuscular Transposition of Ulnar Nerve | Nerve is released from the medial intermuscular septum & Arcade of Struthers Cut through F-P mass, then re-suture muscle so ulnar n is behind F-P mass so it is unable to sublux |
| Anterior Intramuscular Transposition | Once fascia released, nerve is ready for transposition anteriorly Don't want any acute bends or constrictions |
| Post-Op Rehab after Ulnar N. Transposition Phase 1 (weeks 0-1) Goals | Allow soft-tissue healing of relocated nerve Decrease pain & inflammation Retard mm atrophy |
| Immediate Post-Op Phase (Week 0-1) | Week 1- post. splint at 90 elbow flex w/ wrist free for motion; compression dressing Ex's: Gripping ex's; Wrist ROM; Shoulder isometrics |
| Week 2 of Immediate Post-Op Phase | Remove posterior splint for exercise & bathing; Progress elbow ROM (PROM 15-120 deg) Initiate elbow & wrist isometrics Continue shoulder isometrics |
| Phase 2: Intermediate Phase (weeks 3-7) Goals | Restore full pain-free ROM Improve strength, power, endurance & UE mm Gradually increase fxnal demands |
| Week 3 | D/c post. splint; Progress elbow ROM, emphasize full extension Initiate flexibility ex for wrist ext/flex, forearm sup/pron, elbow flex/ext |
| Week 6 | Continue all ex's from prior phases Initiate light sports activities |
| Phase 3: Advanced Strengthening Phase (weeks 8-12) Goals | Increase strength, power & endurance Gradually initiate sporting activities |
| Week 8 | Initiate eccentric exercise program; Initiate plyos; COntinue shoulder/elbow strength & flexibility ex's Initiate interval throwing program |
| Phase 4: Return to Activity Phase (Weeks 12-16) Goals | Gradual return to sport activities |
| Week 12 | Return to competitive throwing Continue throwers 10 |
| Notes of Interest | Rehab after sub-q transposition of ulnar n. (20 immediate mob, 16 delayed immob) Both groups had improvement of strength of interosseous & adductor pollicius; Immediate mob group: RTW/ADLs was earlier (~1 month) as compared to delayed (~2.75 months) |
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