Transcript Loss of Ulnar Nerve Function

Hand SGD
July 25, 2011
Block 10a
PATIENT PROFILE
• Patient is Pedro R. Anonuevo, 42 year-old
male, married with 4 children, Filipino, Roman
Catholic, farmer, left-handed, but uses right
hand for writing, from Luciana, Laguna who
was first seen by our institution at the OPD
last June 1, 2011 due numbing of the left
hand.
HISTORY OF PRESENT ILLNESS:
• 4 mo. PTA: Patient sustained hacking wounds on his
left wrist and upper arm from an unknown drunk
assailant. Said wrist wound produced profuse bleeding
and laceration of wrist tendons. He was brought to a
local hospital in Santa Cruz, Laguna where his vitals
were stabilized and open wounds sutured. He was then
sent home well, given pain and prophylactic antibiotic
medications, and advised to come back immediately
M/W/F which he complied to. Allegedly, there was
already note of loss of sensation on fingers and
decreased finger mobility. Upon follow-up within that
week and note of healing of wound, he was advised to
have PT mgt after a month.
HISTORY OF PRESENT ILLNESS:
• 3 mo. PTA: Patient complied with physician's advise for
PT for 1 mo. There was relative improvement in range
of motion of the left digits, however, there was still
note of decrease sensation on the entire left hand.
• 1 mo. and 3 wks PTA: After a month of PT and no
improvement in sensation, and starting to have
difficulty extending the wrist, patient opted to consult
at PGH-OPD Ortho Dept. where x-ray done on left wrist
showed unremarkable findings. EMG was done but
result unrecalled. Patient was advised for surgery and
was advised to wait for admission. During the waiting
period, patient discontinued PT mgt.
REVIEW OF SYSTEMS:
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•
•
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(-) cough, colds, fever, headache
(-) dizziness (-) BOV (-) dysphagia
(-) nausea
(-) vomiting
(-) DOB, palpitations
(-) bladder and bowel changes
(-) joint pain
(+) LOM Left shoulder elevation, wrist flexion, fingers
flexion and extension
• (+) loss of L palmar sensation
• (+) pins and needle pain radiating towards the fingers
PAST MEDICAL HISTORY
• (+) s/p amputation of distal phalanx, 4th
finger of the left hand in 1990s due to
firecracker explosion (allegedly return of
function upon healing of wound and no loss of
sensation)
• (-) DM, HPN, PTB, BA, CA, liver/kidney disease,
CVD
• (-) food/drug allergies
FAMILY MEDICAL HISTORY
• (-) HPN, DM, PTB, BA, CA, liver/kidney disease,
CVD, allergy
PERSONAL AND SOCIAL HISTORY
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•
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(+) smoker
(+)alcoholic drinker
(-) illicit drug use
Works as a farmer, mostly coconuts and rice
Physical Examination
• Awake, coherent, ambulatory, NICRD.
• BP 120/80 HR 88 RR 16 T: 37.4
• Pink conjunctivae, anicteric sclerae, (-) CLAD,
NVE, ANM, trachea midline
• ECE, CBS, (-) ABS
• AP, NRRR, DHS, (-) murmurs, heaves, thrills
• round abdomen, NABS, (-) masses/tenderness
• (-) cyanosis, edemaa
Wrist
Left
Right
Inspection
(-) swelling, deviation
(+) 10 cm linear,
hypopigmented scar
(+) 6x2 cm, slightly
erythematous patch
(-) swelling, deformity,
deviation
Palpation
(+) weak pulse
(-) swelling, tenderness
Full pulse
(-) swelling, tendernesss
Movement
(+) limited active and
(-) limitation in both active
passive extension,
and passive mov’t
flexion, ulnar and radial
deviation
Hand
Left
Right
Inspection
(+) hypothenar and thenar
eminence atrophy
(+) surgically absent distal phalanx,
3rd digit
(-) swelling, palmar erythema and
squaring, guttering
(-) swan neck, boutonniere
deformity
(-) pitting, onycholysis
(-) swelling, erythema, swelling,
guttering, deformities
(-) atrophy
(-) pitting, onycholysis
Palpation
(+) cold to touch
(+) tenderness, MCP joints
(-) swelling, H&B nodes, crepiti
(+) decreased sensation
Warm to touch
(-) tenderness, swelling, H&B nodes,
crepiti
Movement Cannot fully extend fingers, abduct Can fully extend fingers, abduct
thumb, make a tight fist, pinch grip thumb, make a tight fist, pinch grip
(+) LOM, passive extension
w/o difficulty
Shoulder
Left
Right
Inspection
Symmetric scapulae, (-) swelling, deformity,
atrophy
Palpation
(-) warmth, tenderness
Movement
Active abduction and
flexion up to 90° only
(-) LOM, active and
passive
(-) crepiti
Manual Muscle Testing
Left
Right
C5 (Elbow flexor)
5/5
5/5
C6 (Wrist extensor)
1/5
5/5
C7 (elbow extensor)
5/5
5/5
C8(long finger flexor)
1/5
5/5
T1 (small finger
abductors)
1/5
5/5
Diagnostics
Assessment
Multiple Tendon Transection
Median and Ulnar Nerve Transection
Musculature
• Extrinsic muscles of the wrist and hand originate
on the medial and lateral humeral condyles and
the proximal radius and ulna:
• The extrinsic extensor tendons cross the wrist
and are surrounded by tendon sheaths in six
compartments bounded by the extensor
retinacular ligament.
• The extrinsic finger and thumb flexor tendons
and the median nerve enter the hand through
the carpal canal.
Musculature
• Intrinsic musculature includes thenar,
hypothenar, and interosseous muscles .
• Thenar muscles: abductor pollicis brevis, the
opponens pollicis, and the superficial head of the
flexor pollicis brevis.
• Hypothenar muscles: abductor digiti quinti, the
opponens digiti quinti, and the flexor digiti quinti.
• The dorsal interossei, commonly referred to as
dorsal intrinsics, abduct the fingers; the palmar
interossei (palmar intrinsics) adduct the fingers.
ASSESSMENT
Loss of Median Nerve Function
Results In:
•
- loss of palmar sensation along the volar aspect of
the thumb, index, long, and radial border of the ring
finger
•
- causes weak wrist flexion, and an “ape hand”
with thenar atrophy and weakness of thumb
opposition.
•
- motor strength deficits include loss of thumb
opposition (loss of abductor pollicis brevis), loss of
thumb interphalangeal (IP) joint flexion (loss of flexor
pollicis longus muscle function), and loss of index distal
interphalangeal joint flexion (flexor digitorum
profundus function).
Loss of Median Nerve Function
• - Restoration:
•
- Restoration of thumb IP joint flexion can be
restored using a transferred brachioradialis muscle
(radial nerve innervated) to the FPL tendon.
•
- Restoration of FDP function of the index finger
can be accomplished using the extensor carpi radialis
longus (radial nerve innervated) tendon rerouted to
the index FDP tendon in the mid forearm.
• - Lastly, thumb opposition can be restored with transfer
of the abductor digiti minimi muscle (ulnar nerve
innervated).
Loss of Ulnar Nerve Function:
• “Clawhand” of ulnar nerve palsy is known as
Duchenne's sign.
• Wartenberg's sign is the inability to pull in (adduct) the
small finger against the ring finger.
• Froment's sign is the hyperflexion of the thumb IP joint
to substitute for the lack of thumb-pinch power against
the index finger. Weakness of DIP joint flexion due to
loss of FDP function of the ring and small finger is
known as Pollock's sign.
• The flattening of the natural metacarpal arch of the
hand seen in association with hand muscle wasting is
known as Masse's sign.
Loss of Ulnar Nerve Function:
• Reconstruction
– Tendon transfers for ulnar nerve palsy are limited in
their ability to restore hand strength.
– The ECRB tendon can be transferred to the thumb
proximal phalanx to provide thumb pinch (adduction)
while the extensor pollicis brevis (EPB) tendon is
transferred to the index interosseous muscle.
– Additionally, the thumb MCP joint may be fused to
prevent thumb hyperextension and instability. The
combination of these surgeries has been reported to
restore approximately 50% of the lost pinch strength.