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Questions Answered: 238

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200
38

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Anatomy

Upper Limb

Question 20 of 239

A patient presents to ED having fallen on her left arm at a roller disco party. She has fractured the medial epicondyle of the humerus and damaged the nerve most commonly associated with this type of injury. Which of the following would you most expect to be affected:

Answer:

The ulnar nerve is the most commonly injured nerve in a medial epicondyle fracture. Abduction of the index finger is produced by the dorsal interossei, innervated by the ulnar nerve. Flexion of the proximal interphalangeal joint of the ring finger is produced by the flexor digitorum superficialis, innervated by the median nerve. Flexion of the distal interphalangeal joint of the index finger is produced by the lateral half of the flexor digitorum profundus, innervated by the median nerve. Abduction of the thumb is produced by the abductor pollicis longus (innervated by a branch of the radial nerve) and abductor pollicis brevis (innervated by the median nerve). Sensation over the middle finger is supplied by the median nerve.

Table: Clinical Features of Ulnar Nerve Injury

Lesion Proximal (at elbow) Distal (at wrist)
Mechanism Fracture of medial epicondyle Laceration at wrist
Motor Loss Wrist flexion and adduction, finger abduction and adduction, flexion of ring and little finger, abduction and opposition of little finger, thumb adduction, extension of IPJs of all digits (less so at index and middle finger due to sparing of lateral two lumbricals) Finger abduction and adduction, flexion of ring and little finger, abduction and opposition of little finger, thumb adduction, extension at IPJs
Sensory Loss Medial half of palm, palmar and dorsal surface of medial one and a half fingers and medial dorsum of hand Palmar surface of medial one and a half fingers
Signs Hand held in abduction (due to unopposed action of flexor carpi radialis), Froment’s sign (patient is asked to hold a piece of paper between thumb and flat palm as paper is pulled away, patient will flex thumb at IPJ to maintain hold – tests adductor pollicis muscle), hypothenar eminence wasting, N.B. claw hand not typically seen due to paralysis of the flexor digitorum profundus Claw hand (unopposed extension at MCPJ and unopposed flexion at IPJs of ring and little finger), hypothenar eminence wasting, Froment’s sign

Proximal Ulnar Nerve Injury

MECHANISM OF INJURY:

The ulnar nerve is most likely to be injured proximally by a medial epicondyle fracture

CLINICAL FEATURES:

  • There is weak wrist flexion and adduction due to paralysis of the flexor carpi ulnaris and the medial half of the flexor digitorum profundus; the hand may be held in abduction (due to unopposed action of the flexor carpi radialis).
  • There is loss of abduction and adduction of the fingers due to paralysis of the interossei.
  • There is loss of flexion at the MCPJ of the ring and little finger due to paralysis of the medial two lumbricals and the flexor digiti minimi.
  • There is loss of flexion at the DIPJ of the ring and little finger due to paralysis of the medial half of the flexor digitorum profundus (but flexion at the PIPJ is likely preserved as this is a function of the flexor digitorum superficialis).
  • There is weakened extension at the IPJs of the ring and little finger due to paralysis of the interossei and medial two lumbricals (and to a lesser extent at the IPJs of the index and middle finger).
  • There is loss of abduction and opposition of the little finger due to paralysis of the hypothenar muscles (hypothenar wasting may be seen).
  • There is loss of adduction of the thumb due to paralysis of the adductor pollicis (Froment's sign).
  • There is loss of sensation to skin over the medial half of the palm, the palmar and dorsal surface of the medial one and a half fingers and the medial dorsum of the hand.
  • There is not typically a claw hand appearance (as may be seen in a lesion at the wrist) due to paralysis of the flexor digitorum profundus.

Distal Ulnar Nerve Injury

MECHANISM OF INJURY:

A distal lesion most commonly occurs due to laceration at the wrist.

CLINICAL FEATURES:

  • Only intrinsic hand muscles are affected (the flexor carpi ulnaris and medial half of the flexor digitorum profundus are spared).
  • A loss of sensation will only affect the palmar surface of the medial one and a half fingers (the medial palm and the dorsum of the hand are spared).
  • A claw hand deformity may be seen due to unopposed extension at the MCPJ (by the extensor digitorum) and unopposed flexion at the IPJs (by the FDP and FDS) of the ring and little finger.

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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