Ulnar Nerve Compression PPT
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| Causes of Compressive Neuropathies | Macrotraumatic violent force
Repetitive stress (Contusions, Compressions, Traction)
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| Other Causes | Anomalous muscles/vessels;
Fibrous bands;
Osteofibrous tunnels;
Simple muscle hypertrophy;
Ganglia;
Lipomas;
Osteophytes;
Aneurysms;
Local inflammation
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| Seddon's Classifications | Neuropraxia;
Axonotmesis;
Neurotmesis
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| 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
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| 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
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| 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
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| Sites for Ulnar N. Compression | Intermuscular septum;
Area of medial epicondyle;
Epicondylar groove;
Cubital tunnel;
Exit of ulnar n. from FCU
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| 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)
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| Primary Pathologic Tissue | Ulnar n.- spinal roots of C8-T1
Travels lateral to brachial a. until passing posterior under medial triceps
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| Primary Pathologic Tissue | Follows through medial intermuscular septum or arcade of Struthers 8-10 cm proximal to medial epicondyle
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| 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
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| 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
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| Etiology & Epidemiology | Direct trauma;
Hypermobility;
Repetitive elbow flexion;
Cubitus valgus deformity;
Osteophyte or loose body impingement;
Anomalous conditions
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| Who most commonly gets ulnar nerve compression syndromes? | Most commonly seen in throwing athlete, weightlifters, skiers, & players of racquet sports
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| 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
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| 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
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| Physical Exam | Nocturnal pain from sleeping with elbow hyperflexed (strains ulnar n.)
May respond well to night time splinting
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| 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
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| Literature Findings | Elbow flexion test (+) when s/sx reproduced by holding elbow flexed for 60"
(+) in 10% normal pts
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| 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
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| 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
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| Pain/Inflammation Control in Non-Op Acute Phase | Warm WP
Cryotherapy
HVPS
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| Adv. Strengthening Phase: Week 3-6 (Non-Op) Goals | Improve strength, power, endurance
Enhance dynamic joint stability
Initiate high-speed training
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| Ex's for Advanced Strengthening Phase | Throwers 10
Eccentrics wrist/forearm mm
Rhythmic stabilization drills for elbow
Isokinetics for elbow flex/ext
Plyos
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| Return to Activity Phase (Weeks 4-6) Goals | Gradual return to fxnal activities
Enhance mm performance
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| Criteria to begin throwing | Full non-painful ROM
Satisfactory clinical exam
Satisfactory mm performance
Initiate interval throwing
Throwers 10
Stretching ex's
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| 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
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| 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
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| Anterior Intramuscular Transposition | Once fascia released, nerve is ready for transposition anteriorly
Don't want any acute bends or constrictions
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| 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
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| 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
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| 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
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| Phase 2: Intermediate Phase (weeks 3-7) Goals | Restore full pain-free ROM
Improve strength, power, endurance & UE mm
Gradually increase fxnal demands
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| 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
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| Week 6 | Continue all ex's from prior phases
Initiate light sports activities
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| Phase 3: Advanced Strengthening Phase (weeks 8-12) Goals | Increase strength, power & endurance
Gradually initiate sporting activities
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| Week 8 | Initiate eccentric exercise program;
Initiate plyos;
COntinue shoulder/elbow strength & flexibility ex's
Initiate interval throwing program
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| Phase 4: Return to Activity Phase (Weeks 12-16) Goals | Gradual return to sport activities
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| Week 12 | Return to competitive throwing
Continue throwers 10
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| 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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