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Complied by:
Aditya Pratama Saanin

Advised by :
Dr. Donny H. Hamid Sp.S

Clinical Rotation in Neurology Department of RSUD Pasar Rebo

Period of Desember 24th 2018 – January 25th 2019
• Muscles that inervated by Ulnar
Muscles that inervated by
Median Nerve

• occur due to damage to the

ulnar nerve and median

• hyperextension on MCP joint

+ flexion on IP joint
• Complete : Involving all digits and resulting from
combined Ulnar and Median Nerve palsy

• Incomplete : Involving only ulnar 2 digits as in

isolated Ulnar Nerve palsy
• Traumatic
• Compressive neuropathy
• Brachial plexus injury
• Infective ( Leprosy, Polimyolitis )
• Peripheral neuropathies
• Systemic diseases ( DM, Uremia,
ETIOLOGY Porphyria, Malignancies )
• Drugs and Toxins (Leas, Arsenic,
Dapsone, etc )
• Hereditary (CMTD, Syringomyelia, Lipid
storage diseases )
• Ischemia
• Primary Nerve neoplasm

• 1. Weakness / paralysis in M. Interossei

and M. lumbrical.
• Wasting of interossei
• Hypothenar wasting
• Brittle nails
• Abnormal sensation on fingers 4 or 5, usually on the
sides of the palm
Clinical • Numbness, decreased sensation
Symptom •

Tingling, burning sensation
Hand weakness
• Pain and / or paresthesia such as tingling that
radiates downward from the elbow to the arm until
the ulnar border of the hand
• Loss of hand sensation in the distribution of the ulnar
• Claw hand deformity that is typical of chronic lesions
Physical Examination

Range of
Inspection Palpation

Flexor Carpi Ulnaris: When Dorsal Interrossei: The

the wrist joint is flexed patient is asked to abduct
against resistance, the hand his fingers against Card test for Palmar Interossei: A card is
tends to deviate towards resistance inserted between the two fingers which are
radial side kept extended. The patient is asked to hold the
card by adducting these two fingers as tightly as
possible. The clinician will try to pull the card
out of his fingers
• Abductor digiti minimi: Ask the patient to abduct the little finger
against resistance. Inability to do so indicates ulnar nerve palsy

• Flexor digitorum profundus: The middle phalanx of ring or little finger

is supported and the distal IP joint is flexed against resistance. Failure
to flex implies high ulnar nerve palsy

• Sensation: There will be loss of sensation over the ulnar distribution

(medial 1/3 of palm & dorsum of hand and ulnar one & half fingers)
(First Palmar Interossei
and Adductor Pollicis)
• The patient is asked to grasp a book
between the extended thumb and
the other fingers

• But if the ulnar nerve is injured,

these two muscles will be paralysed
and the patient will hold the book
by flexing the thumb with the help
of flexor pollicis longus. This sign is
known as “Froment sign”
Clinical features of median nerve palsy
• Thenar wasting
• Simian or ape thumb deformity
• Atrophy of pulp of index finger
• Cracking of nails
• Tropic changes
• Wasting of lateral aspects of forearm
• Flexor Pollicis Longus:

• The patient is asked to

bend the terminal
phalanx of the thumb
against resistance while
the proximal phalanx is
being steadied by the

• This muscle is only

paralysed when the
median nerve is injured
at or above the elbow


• Opponens Pollicis:
-This muscle swings the
thumb across the palm to
touch the tips of the other
-The patient with paralysis
of this muscle will be
unable to do this
Oschsner’s clasping test
Flexor Digitorum Superficialis &
Profundus(lateral half):

• If the patient is asked to clasp the

hands, the index finger of the affected
side fails to flex and remains as a
“Pointing Index”
Management of deformed hands
• Exercises-physiotherapy

• Splinting:
-- To immobilize all or part of a hand in a position that will promote healing and
prevent deformity
-- To correct an existing deformity and promote function in that part
-- To supply power to compensate for weakness

• Surgical correction:
-- Active or dynamic procedure: Called so because they bring extra active muscular
forces in places of those lost because of muscle paralysis

-- Passive or static procedure: Called so because they attempt to restore equilibrium

without introducing new active muscle forces
Non-progressive or
Irreparable nerve slowly progressive
damage neurological
for tendon
Loss of function of
• Modified bunnell technique
• Brand technique
Operations for the • Fowler
• Srinivasan’s Extensor Diversion Graft
restoration of operation
intrinsic function • Zancolli technique
of fingers • Fowler’s Tenodesis
• He devised a technique using
the extensor carpi radialis
brevis tendon lengthened by
a free graft from the
plantaris tendon

Brands transfer
Srinivasan’s Extensor Diversion Graft operation
• to divert part of the
excessive extensor force
acting on the MCP joint &
causing hyper-extension of
the same towards its flexor
• The advantage of this
operation is that, it is
technically less demanding
than brand’s operation and
fingers can be individually
• Elliptical segment of
plate is resected
Suture the volar
plate with heavy
silk; If desired insert
transarticular ‘K’
wires to maintain
position of the joints
Zancolli’s capsulodesis
Thank you