What is the treatment for an ulnar nerve injury?

Treatment for Ulnar Nerve Injury

Treatment of ulnar nerve injury should begin with conservative management including patient education, positioning modifications, and pharmacological therapy, progressing to surgical intervention if symptoms persist or worsen after approximately 3 months of conservative treatment. 1

Initial Assessment and Risk Factors

• Identify risk factors that may contribute to ulnar nerve injury:

  • Body habitus
  • Pre-existing neurologic symptoms
  • Diabetes mellitus
  • Peripheral vascular disease
  • Alcohol dependency
  • Arthritis 2

• Distinguish ulnar neuropathy from other conditions:

  • Cervical radiculopathy
  • Thoracic outlet syndrome
  • Vitamin B12 deficiency
  • Hypothyroidism 1

Conservative Management (First-Line)

Positioning and Activity Modification

• Avoid prolonged elbow flexion
• Maintain neutral forearm position
• Limit arm abduction to 90° when supine
• Avoid direct pressure on the ulnar groove
• Maintain optimal postural alignment 1

Physical Therapy Interventions

• Night splinting to maintain neutral elbow position
• Nerve gliding exercises
• Heat application
• Regular reassessment of function 1

Pharmacological Management

• First-line medications:
  • Calcium channel α2-δ ligands:
    • Gabapentin (900-3600 mg/day)
    • Pregabalin (300-600 mg/day)
  • Tricyclic antidepressants:
    • Nortriptyline or desipramine (start at 10 mg/day, titrate up to 75 mg/day)
    • Avoid dosages >100 mg/day due to cardiac risk
  • SNRIs:
    • Duloxetine (60-120 mg/day)
    • Venlafaxine (150-225 mg/day)
  • Topical agents:
    • Lidocaine patches/creams
    • Amitriptyline-ketamine combinations 1

Surgical Management

Indications for Surgery

• Severe symptoms unresponsive to conservative measures
• Progressive neurological deficits
• Failed conservative treatment after approximately 3 months
• Significant functional limitation
• Habitual ulnar nerve subluxation/dislocation at the elbow 1

Surgical Options

• Simple decompression (fewer wound infections)
• Ulnar nerve transposition (subcutaneous or submuscular)
• Medial epicondylectomy
• Endoscopic decompression 1

Special Considerations for Traumatic Injuries

• For nerve lacerations or entrapment within fracture sites:
  • Nerve exploration
  • Neurolysis
  • Nerve repair or grafting may be required 3
  • Early exploration rather than simple pin removal is safer in cases of iatrogenic injury 4

Monitoring and Follow-up

• Regular reassessment of pain and function
• Monitor for medication side effects, especially with tricyclic antidepressants
• For diabetic patients, optimize glucose control 1
• Consider advanced imaging:
  • MRI (T2-weighted MR neurography) is the reference standard
  • Ultrasound assessment of cross-sectional area/nerve thickness 1

Recovery Expectations

• Recovery rates vary based on intervention type:
  • Neurolysis: 92% achieve functional recovery (Grade 3 or better)
  • Suture repair: 72% achieve functional recovery
  • Graft repair: 67% achieve functional recovery 3
• Earlier intervention (within 6 months of injury) tends to yield better functional outcomes 5

Pitfalls and Caveats

• Failing to protect pressure points during surgery or procedures can put the ulnar nerve at risk
• Using only clinical tests to assess recovery has low sensitivity
• Delayed treatment (>6 months) may result in poorer outcomes
• Ulnar nerve recovery tends to be less complete than median or radial nerve recovery 1, 3
• In pediatric patients with forearm fractures, the ulnar nerve is at particular risk due to anatomical constraints 6