Treatment of Ulnar Neuropraxia: Sling vs Shoulder Immobilizer
Neither a sling nor a shoulder immobilizer is the appropriate treatment for ulnar neuropraxia—the focus should be on positioning modifications to maintain neutral forearm position and avoid elbow flexion beyond 90°. 1, 2
Why Immobilization Devices Are Not Indicated
The evidence does not support using slings or shoulder immobilizers for ulnar neuropraxia treatment. In fact, shoulder braces and immobilizers may increase the risk of brachial plexus neuropathy when used inappropriately, particularly in certain positions. 3 The ASA Task Force found that 66% of consultants and members agree shoulder braces placed over the acromioclavicular joint may increase neuropathy risk. 3
Correct Conservative Management Approach
Positioning modifications are the cornerstone of treatment:
- Maintain neutral forearm position when the arm is tucked at the side 2
- Use supinated or neutral forearm position when the arm is abducted on an armboard 2
- Avoid elbow flexion beyond 90° as this increases ulnar nerve compression risk 1, 2
- Avoid prolonged pressure on the postcondylar groove (ulnar groove) 2
The American Society of Anesthesiologists emphasizes these positioning strategies specifically because ulnar neuropathy occurs most commonly when the forearm is maintained in a pronated position with direct pressure on the ulnar groove. 1
Pain Management Protocol
Follow this stepwise analgesic approach:
- First-line: Paracetamol up to 4g daily 1, 2
- Second-line: Topical NSAIDs for localized pain with fewer systemic effects 1, 2
- Third-line: Oral NSAIDs at lowest effective dose for shortest duration only if paracetamol inadequate 1, 2
Additional Conservative Measures
- Range of motion and strengthening exercises to maintain function 2
- Local heat application before exercise 2
- Periodic position assessment to ensure proper arm positioning 2
Prognosis and Monitoring
The prognosis for ulnar neuropraxia is generally excellent with conservative management, with complete symptom resolution often occurring within one week. 4 However, obtain electrodiagnostic studies (nerve conduction studies and EMG) to confirm diagnosis, localize compression site, and differentiate demyelinating from axonal injury. 1, 2 This testing is critical because it affects prognosis and determines whether surgical intervention may eventually be needed.
Critical Pitfall to Avoid
Do not delay electrodiagnostic studies if symptoms persist or worsen, as these differentiate between demyelinating and axonal injury patterns, which fundamentally affects treatment planning and prognosis. 1 Repeat studies if symptoms worsen to assess progression from demyelinating to axonal injury. 1