Anatomy
Upper Limb
Question 161 of 239
A 32 year old woman presents to ED following an injury to her right elbow. She is complaining of weak grip in her right hand. You ask her to hold onto a piece of paper with both hands as you pull it away from her. The result of the test is shown below. Which of the following nerves is most likely damaged:
(Original image by FRCEM Success)
Answer:
The image demonstrates Froment's sign, caused by damage to the ulnar nerve. Loss of adduction of the thumb due to paralysis of the adductor pollicis results in the patient having to flex the distal phalanx in order to hold onto the piece of paper.Ulnar Nerve Injury
Anatomy / Upper Limb / Innervation of Upper Limb
Last Updated: 8th November 2021
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 |
