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High Ulnar Nerve Lesions

- See:
    - Tendon transfers:
    - Nerve Repair:
    - Combined Injuries of the Median and Ulnar Nerves:

- Discussion:
    - ulnar innervated intrinsic muscles of hand, FCU, & FDP units to ring & little fingers & part of long finger;
    - functional deficit:
         - opening the hand:
         - power grip:
                  - pts w/ high ulnar nerve lesions may lose 60-80% of their grip strength;
         - grasping and closing the hand;
                  - w/ ulnar nerve lesion, there is a noticeable deficit in all activities requiring pinch and grasp;
                  - becacuse of loss of intrinsics, pinch strength in ulnar nerve palsy is reduced by over 80%, w/ palmar adduction strength reduced by 75%;
    - results of nerve repair:
          - after repair of ulnar nerve lacerations above the elbow, return of extrinsic function can be expected, but return of intrinsics are often poor;

- Transfers:
    - tendon transfers will improve pinch and grasp:
           - only EPL & FPL  remain functional in terms of thumb adduction;
           - arthrodesis may be used to improve pinch strength;
                  - pts complain more of loss of MP arthrodesis
                  - ECRB adductorplasty w/ MP fusion can double pinch strength & is most successful pinch procedure;
    - FDP deficit:
           - reinforced by ECRL to the long, ring, and little fingers;
    - adductor pollicis deficit:
           - reinforced by FDS thru interosseous membrane & under pulley of ECU, w/ insertion into proximal phalanx of thumb;
           - note that FDS harvest from the ring finger may be problematic in high ulnar nerve palsy, since this may significantly decrease power grip;
    - APL deficit:
           - brachioradialis (reroute) to APL;
           - suture to other tendons (w/ or w/o ECRL) for power;

- Operative Correction of Intrinsic Deficit:
    - Burkhalter Transfer
          - procedure of choice;
    - Bunnell Transfer:
          - involves FDS transfer to the lateral bands;
          - interosseous & lumbricals muscles of ring finger and little fingers, substituted by the FDS of ring finger, inorder to improve clawing and to improve
                 flexion at the MP joint;
          - first dorsal interosseous muscle substituted by ECRL & split FDS of ring finger w/ one half to first lumbrical & one half to first dorsal interosseous;
                 - half the tendon is passed dorsally thru the 1st interosseous, where as the other half of the tendon is passed volarly to the lumbrical;
          - main complication is creation of intrinsic plus hand, which preferentially extends PIP joint w/ minimal flexion of the MPJ;
                 - this is exacerbated by the PIP flexion lost from the FDS harvest;
    - Zancolli Volar Capsulorraphy:
          - performed thru a volar approach;
          - goal is to create a MPJ flexion contracture, preventing claw deformity

Restoration of pinch in ulnar nerve palsy by transfer of split extensor digiti minimi and extensor indicis.

A new tendon transfer for ulnar clawhand: use of the palmaris longus extended with the palmar aponeurosis.

Early Tendon Transfers in Upper Extremity Peripheral Nerve Injury

Studies on the hand in ulnar nerve paralysis. A clinical experimental investigation in normal and anomalous innervation

Three tendon transfer methods in reconstruction of ulnar nerve palsy.