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Ulnar N. Compression

Ulnar Nerve Compression PPT

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)
Created by: 1190550002