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ULNAR NERVE LACERATION

Introduction

Ulnar nerve lacerations have been identified as the most common major upper extremity peripheral nerve injury when compared with the median, radial, and brachial plexus nerves. They can occur directly from a penetrating injury or secondary to a forearm fracture, and most are seen either at or distal to the elbow. The complete transection of the ulnar nerve remains a challenging problem for hand surgeons and their patients, and outcomes are typically worse than those seen after other peripheral nerve lacerations. Despite advances in microsurgical nerve repair, repairs often leave patients with functional deficits, especially in adults.1-5

Pathophysiology

  • When a nerve is transected, the distal segment of the nerve undergoes Wallerian degeneration.
    • Distal axons degenerate secondary to calcium-activated calpain enzymes;6,7 degenerating myelin is phagocytized by Schwann cells and macrophages.
    • In the proximal stump, degeneration also occurs in a proximal direction for a distance of ≥1 nodes of Ranvier.
    • In the distal segment, Schwann cells proliferate forming the bands of Bunger after nerve transection.
    • In the proximal segment, the axon cone develops and grows distally at a rate of 1-2mm/day (1 inch/mo) after the cut ends of the nerve have been approximated and realigned by microsurgical repair.
  • Ulnar nerve lacerations are usually classified as complete or partial.
    • Partial: some intact nerve tissue connections between the nerve endings
    • Complete is a lacertion with no physical connection between the transsected nerve endings. 
  • Neurotomesis:  no physical connection between the transsected nerve endings
  • Axonotomesis: nerve is subjected to severe crush, stretch, or blast injury; axon can be severed with distal degeneration, while the Schwann cell basil lamina remains intact
  • Neuropraxia: nerve is stretched and stops conducting impulses while the neural anatomy remains intact; there is no Wallerian degeneration after this type of stretch injury, and they usually recover without surgical intervention.7
  • Lacerations of the ulnar nerve may occur secondary to closed or open fractures of the ulna and/or radius, such as in a Galeazzi fracture, or directly from a penetrating injury (eg, stab or gunshot wound, fall onto broken glass, etc.).8

Related Anatomy

  • The ulnar nerve is the terminal branch of the medial cord of the brachial plexus. It traverses the axilla with the neurovascular bundle deep to the pectoralis major and minor, and consists of four major branches in the forearm: 1) the motor branch to the flexor digitorum profundus (FDP) for the ring and small fingers, 2) the palmar cutaneous branch, 3) the dorsal cutaneous branch, and 4) the nerve of Henle.5
  • The ulnar nerve is composed of nerve fibers and axons covered by connective tissue called epineurium.
  • The axon has a cell membrane (axolemma) surrounding a tube of neural cytoplasm (axoplasm).7Axons are encased by the endoneurium.
  • Axons are grouped in fascicles that are surrounded by the perineurium.9
    • Perineurium provides a diffusion and conduction barrier between the fascicles.7
  • In the ulnar nerve, groups of fascicles are arranged in fascicular groups, defined by the connective tissue called the internal epineurium.
  • In the distal part of the nerve, there are few connections between the fascicular groups; thus, the internal epineurium provides a safe surgical plane that can be dissected with microsurgical techniques.9
  • These fascicular groups together compose the ulnar nerve; external surface of the ulnar nerve is the external epineurium.
  • When the ulnar nerve is cut, the nerve ends separate producing a functional gap due to the  inherent elasticity of the fascicular grouips.
  • There is no loss of nerve tissue, ie, no true defect; therefore, these ends can be repaired without excessive tension even if a few millimeters of neuroma are resected.9
  • If there is a long delay between laceration and nerve repair, the functional elastic gap may become more of a true defect because of scarring.
  • Most surgeons recommend mobilizing the nerve in gentle flexion of adjacent joints after end-to-end repair to further minimize the tension at the suture site. 
  • However, if the true defect is 3-4 cm, nerve grafting would be indicated.10,11

Incidence

  • Peripheral nerve injury remains a common injury in civilian life.
  • In one report, an estimated 20 million Americans suffer peripheral nerve injuries annually.12
  • Between 1993-2006, there were 3,996 admissions for ulnar nerve lacerations, making them the most common major upper extremity peripheral nerve injury when compared with medial, radial, and brachial plexus injuries; 76.4% of these patients were male, and 59% were in the 18-44 age group.4
  • Another report showed that 13.4% of wartime nerve injuries were lacerations of the ulnar nerve.13

Differential Diagnosis

  • Complete nerve laceration
  • Partial nerve laceration
  • Neuropraxia (stretch injury)
  • Neuroma-in-continuity
  • Nerve tumor
  • Compression neuropathy
ICD-10 Codes

ULNAR NERVE LACERATION

Diagnostic Guide Name

ULNAR NERVE LACERATION

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
ULNAR NERVE LACERATION (FOREARM LEVEL)   S54.02X_ S54.01X_  
ULNAR NERVE LACERATION (WRIST/HAND LEVEL)   S64.02X_ S64.01X_  

Instructions (ICD 10 CM 2020, U.S. Version)

CODE ALSO ANY ASSOCIATED OPEN WOUND (S61.-)

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Ulnar Nerve Laceration
  • Testing sensation in a patient with a mid-forearm ulnar nerve laceration.
    Testing sensation in a patient with a mid-forearm ulnar nerve laceration.
  • Claw deformity from a chronic untreated ulnar nerve laceration.
    Claw deformity from a chronic untreated ulnar nerve laceration.
Basic Science Photos and Related Diagrams
Ulnar Nerve Basic Science
  • Ulnar Nerve with axons enclosed in endoneurium (1); Fascicle enclosed in perineurium (2); Fascicular groups enclosed in connective tissue called internal epineurium (3); Internal epineurium (4); External epineurium (5); Epineural blood vessels (6)
    Ulnar Nerve with axons enclosed in endoneurium (1); Fascicle enclosed in perineurium (2); Fascicular groups enclosed in connective tissue called internal epineurium (3); Internal epineurium (4); External epineurium (5); Epineural blood vessels (6)
Pathoanatomy Photos and Related Diagrams
Ulnar Nerve anatomy
  • Ulnar nerve and its motor branches.
    Ulnar nerve and its motor branches.
  • Anterior (palmar or volar ) Sensation by Nerve: 1 = median nerve; 2 = dorsal radial sensory nerve; 3 = ulnar nerve; 4 = lateral antebrachial cutaneous nerve; 5 = medial antebrachial cutaneous nerve; 6 = radial dorsal antebrachial cutaneous nerve; 7 = medial brachial cutaneous nerve; 8 = intercostobrachial nerve; 9 = axillary nerve (superior lateral brachial cutaneous nerve.
    Anterior (palmar or volar ) Sensation by Nerve: 1 = median nerve; 2 = dorsal radial sensory nerve; 3 = ulnar nerve; 4 = lateral antebrachial cutaneous nerve; 5 = medial antebrachial cutaneous nerve; 6 = radial dorsal antebrachial cutaneous nerve; 7 = medial brachial cutaneous nerve; 8 = intercostobrachial nerve; 9 = axillary nerve (superior lateral brachial cutaneous nerve.
  • Posterior (Dorsal) Sensation by Nerve: 1 = median nerve; 2 = dorsal radial sensory nerve; 3 = ulnar nerve (dorsal ulnar sensory nerve); 4 = lateral antebrachial cutaneous nerve; 5 = medial antebrachial cutaneous nerve; 6 = posterior brachial cutaneous nerve, inferior lateral cutaneous nerve, posterior antebrachial cutaneous nerve; 7 = medial brachial cutaneous nerve; 8 = intercostobrachial nerve; 9 = axillary
    Posterior (Dorsal) Sensation by Nerve: 1 = median nerve; 2 = dorsal radial sensory nerve; 3 = ulnar nerve (dorsal ulnar sensory nerve); 4 = lateral antebrachial cutaneous nerve; 5 = medial antebrachial cutaneous nerve; 6 = posterior brachial cutaneous nerve, inferior lateral cutaneous nerve, posterior antebrachial cutaneous nerve; 7 = medial brachial cutaneous nerve; 8 = intercostobrachial nerve; 9 = axillary
Symptoms
History of trauma with a laceration in the area of the ulnar nerve
Wound pain and paresthesias
Sensory loss to dorsal and/or palmar ulnar aspect of the hand
Impaired grasp and/or pinch secondary to loss of ulnar innervated muscle function
Muscle weakness
Clawing of ring and little fingers in chronic cases
Typical History

A 21-year-old male was playing a game of baseball with his friends at a local park, which also happened to be a popular hangout spot at night. After hitting the ball into the outfield, he ran past first base and on to second, where he slid into the base headfirst and was called safe. Upon sliding, however, he failed to notice several shards of broken glass, one of which sliced through his right forearm during the slide. The glass cut deeply into his forearm and the man was subsequently taken to the ED, where they examined the injury and noticed that he had lost some sensation in the ulnar nerve distribution of his right arm. The wound was anesthetized with 1% local, and the wound exploration showed a lacerated ulnar nerve. The wound was irrigated, debrided, the skin sutured and a dressing and splint applied. The patient saw a hand surgeon who did a microsurgical ulnar nerve repair in the local ambulatory surgery center the following week.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Identify the presence of a complete ulnar nerve laceration, a partial ulnar nerve laceration, or a ulnar nerve neuropraxia.
  • Repair the complete or partial nerve laceration.
  • Carefully follow the patient with a ulnar nerve stretch injury; a few patients with neuropraxia will require neurolysis if function fails to recover with observation.
  • Improve function of injured upper extremity with an ulnar nerve laceration.
Conservative
  • Nonoperative treatment of ulnar nerve complete or partial lacerations is appropriate when the patient’s associated injuries or medical comorbidities prevent anesthesia and a lengthy microsurgical repair.
  • Isolated ulnar nerve complete and partial lacerations should be repaired early, but repair is not an emergency.
  • Irrigation, debridement, and closure of the skin laceration with a scheduled operative nerve repair 1-3 weeks after injury is reasonable.
  • Neuropraxia of the ulnar nerve secondary to a stretch injury is rare, but a stretch injury can be watched for signs of spontaneous recovery.
Operative

Complete Nerve Laceration

  • Complete ulnar nerve lacerations in civilian practice are usually seen acutely and are usually caused by sharp lacerations from broken glass, knives, saws, or vehicular accidents.
  • Complete nerve lacerations should be repaired with microsurgical procedures.
  • Choices for microsurgical repair include:
    1. Epineural repair
    2. Group fascicular repair
    3. Nerve repair with nerve grafts
    4. Nerve repair with nerve conduit
    5. Nerve transfers
  • Neurolysis of the ulnar nerve for a neuropraxia is uncommon.1,7
  • Ulnar nerve lacerations should be repaired in a timely fashion and the ulnar artery should also be repaired if appropriate.
  • Compared with the median nerve, in which it is difficult to regain lost nerve length, the ulnar nerve can be transposed anterior to the elbow, usually deep with respect to the pronator and the flexor carpi ulnaris muscles. This maneuver typically gains 2.5-3.8 cm of length and this may obviate the need for nerve grafting.14
    • High-level lesions should be treated with subcutaneous transposition to help reduce tension on the repair, while forearm-level lesions should be approached by extending the laceration through an extensile longitudinal approach that allows the ulnar nerve and artery to be inspected.
    • More distal lacerations that are close to the wrist often requirre Guyon’s canal releases to visualize and mobilize the ulnar nerve at the time of repair.5
    • More distal lacerations at the wrist level should also be splinted postoperatively in wrist flexion and/or elbow extension. 

Partial Nerve Laceration

  • Partial nerve lacerations can be repaired by dissecting the internal epineurium and isolating the transected fascicular groups, gently looping the intact fascicular groups and then repairing the cut fascicular groups by suturing the internal epineurial sheaths.
  • If there is a significant true defect, for example after a bullet wound, then repairing the cut fascicular groups with nerve grafts between the cut fascicular groups is indicated.

Nerve Transfers19

  • Nerve transfer for brachial plexus reconstruction are well defined in the literature6; however, their usefulness for reconstructing ulnar nerve lacerations is less well studied.  However, nerve transfer(s) have been gaining in popularity as an alternative to tendon transfers/nerve grafting for patients with severe proximal nerve injuries, but the field is still evolving with new techniques being described as microsurgical techniques improve and more patients experience good outcomes.
  • Proposed Advantages of Nerve Transfer

-       Able to also restore sensory function

-       Multiple muscle groups can be reinnervated with a single nerve transfer

-       Muscle origin/insertions are not disrupted

  • Principles of Nerve Transfer

-       Ideally pick a donor nerve near the motor endplates of the target muscle to minimize time to innervation.  A shorter distance means shorter time  for reinnervation

-       Use expendable or redundant nerve fibers

-       Use donors that have a large number of axons

-       Use donors that already innervate synergistic muscles with the target muscle (helps facilitate re-education)

-       Using donors that match the target is ideal, i.e. motor donors for motor targets, sensory donors for sensory targets

-       Re-innervation after 12-18 months may be impossible, as prolonged denervation will cause muscle cell death and fibrosis.

  • Nerve Transfers for Ulnar Nerve Palsy

-       Goals: Restore intrinsic muscle function and ulnar sensation

-       Transferring the branch of the AIN to the motor branch of the ulnar nerve can restore intrinsic function

-       This nerve transfer does not provide synergistic function and will only provide some improvement to prevent clawing

-       Ring and small finger flexion can be improved by side to side tenodesis of the respective FDP tendons to the index and long FDP tendons

-       Ulnar sensory function can be restored by performing a transfer from the third web space nerves which come from the median nerve

Treatment Photos and Diagrams
Ulnar Nerve Repair (Neurorrhaphy)
  • Most ulnar nerve repairs will be done with an operative microscope.
    Most ulnar nerve repairs will be done with an operative microscope.
  • Micro-surgical ulnar nerve repairs will require micro-surgical instruments.
    Micro-surgical ulnar nerve repairs will require micro-surgical instruments.
  • Micro-surgical ulnar nerve repairs will require micro-sutures: 8-O supplemented with 9-O; and 10-O sutures
    Micro-surgical ulnar nerve repairs will require micro-sutures: 8-O supplemented with 9-O; and 10-O sutures
  • Most surgeons will do a micro-surgical ulnar nerve repair with an epieneural repair technique.
    Most surgeons will do a micro-surgical ulnar nerve repair with an epieneural repair technique.
  • Micro-Surgical repair of the ulnar nerve with a group fascicular repair technique.
    Micro-Surgical repair of the ulnar nerve with a group fascicular repair technique.
  • Ulnar nerve laceration with a true loss of nerve tissue repaired with a micro-surgical nerve grafting procedure using a sural nerve graft (see insert).
    Ulnar nerve laceration with a true loss of nerve tissue repaired with a micro-surgical nerve grafting procedure using a sural nerve graft (see insert).
  • Ulnar nerve neuroma-in-continuity being evaluated by intra-operative electrophysiological testing.
    Ulnar nerve neuroma-in-continuity being evaluated by intra-operative electrophysiological testing.
  • Micro-Surgical epineural repair of small ulnar partial nerve laceration.
    Micro-Surgical epineural repair of small ulnar partial nerve laceration.
  • Ulnar nerve 60% partial laceration repaired by separating the intact fascicular groups from the sharply cut groups followed by fascicular group repair of the cut portion of the nerve. Tension temporarily controlled by a epineural suture in the intact fascicular groups (arrow).
    Ulnar nerve 60% partial laceration repaired by separating the intact fascicular groups from the sharply cut groups followed by fascicular group repair of the cut portion of the nerve. Tension temporarily controlled by a epineural suture in the intact fascicular groups (arrow).
  • Larger ulnar nerve partial laceration with significant nerve loss. Nerve graft repair done by separating (yellow line) the intact fascicular groups from the groups with nerve loss. The damage portion of the nerve (red box) removed and graft trimmed and sutured into the gap.
    Larger ulnar nerve partial laceration with significant nerve loss. Nerve graft repair done by separating (yellow line) the intact fascicular groups from the groups with nerve loss. The damage portion of the nerve (red box) removed and graft trimmed and sutured into the gap.
Ulnar nerve laceration
  • Acute ulnar nerve laceration secondary to an MVA. Note deep large laceration (arrows) in the proximal ulnar forearm.
    Acute ulnar nerve laceration secondary to an MVA. Note deep large laceration (arrows) in the proximal ulnar forearm.
  • Ulnar nerve has been surgical exposed. Note the nerve gap between the arrows. This ulnar nerve laceration will have be repaired with an anterior transposition of the ulnar nerve and may require nerve grafting or a conduit.
    Ulnar nerve has been surgical exposed. Note the nerve gap between the arrows. This ulnar nerve laceration will have be repaired with an anterior transposition of the ulnar nerve and may require nerve grafting or a conduit.
CPT Codes for Treatment Options

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Common Procedure Name
Ulnar nerve repair
CPT Description
Suture 1 nerve; hand or foot, ulnar motor
CPT Code Number
64836
Common Procedure Name
Tendon transfer
CPT Description
Tendon transplant or transfer flexor/extensor single each tendon
CPT Code Number
25310
Common Procedure Name
Capsulodesis three or four digits
CPT Description
Capsulodesis, metacarpophalangeal joint, 3 or 4 digits
CPT Code Number
26518
Common Procedure Name
Extensor tendon transfer
CPT Description
Tendon transfer or transplant, CM area or dorsum of hand single w/o free graft
CPT Code Number
26480
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

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Complications
  • Permanent loss of sensory and/or motor function
  • Persistent pain and/or paresthesias
  • Neuroma-in-continuity
  • Infection
  • Complex regional pain syndrome
  • Clawing of ring and/or little fingers with the MP joints hyperextended and the PIP joints flexed
Outcomes
  • Permanent deficits after nerve repair remain a problem, especially for adults.1
  • Chemnitz, et al3reported function of patients <12 years of age had an 87% functional return; older patients’ functional recovery averaged 67%. Functional assessment was done with the Disabilities of the Arm, Shoulder and Hand (DASH) score and the Rosen score.
  • Since World War II, the results of nerve repair also have been classified using a grading system designed by the British Medical Research Council.7,15,16
THE MEDICAL RESEARCH COUNCIL SYSTEM7,15,16
Motor Recovery
M0 No contraction
M1 Return of perceptible contraction in the proximal muscles
M2 Return of perceptible contraction in both the proximal muscles and distal muscles
M3 Return of perceptible contraction in both the proximal muscles and distal muscles of such a degree that all important muscles are sufficiently powerful to act against resistance
M4 Return of function as in stage 3 with the addition that all synergic and independent movements are possible
M5 Complete recovery
   
Sensory Recovery
S0 Absence of sensibility in the autonomous area
S1 Recovery of deep cutaneous pain sensibility within the autonomous area of the nerve
S2 Return of some degree of cutaneous pain and tactile sensibility within the autonomous area
S3 Return of some degree of superficial cutaneous pain and tactile sensibility within the autonomous area with disappearance of any previous overreaction within the autonomous area
S3+ Return of some sensibility as in stage 3 with the addition that there some recovery of two point discrimination within the autonomous area
S4 Complete recovery
  • Other factors that affect the outcome of ulnar nerve repair include:
    • The age of patient (young patients do better). One study identified patient age as the most important prognostic factor, with younger patients achieving significantly better results.5
    • The level of the laceration (distal lacerations do better)
    • The type of nerve (pure motor or pure sensory nerves do better)
    • The delay between injury and repair (earlier repairs do better) 
    • The cause of the ulnar nerve laceration (sharp clean cuts do better).1,7
  • Even though the ulnar nerve can be transposed anterior to the elbow, positive results of ulnar nerve repair at almost any level occur less frequently than with median or radial repairs. As a result, there are fewer good or excellent recoveries in function with ulnar nerve repair, and they are considered the least favorable nerve injury of the upper extremity.14,17
    • In addition, because of the long distance between the injury site and the target hand muscles, functional recovery following proximal ulnar nerve lacerations is often poor. Even with primary surgical repair, functional recovery of the intrinsic hand muscles is often unsatisfactory, resulting in semi-claw hand deformity, and marked pinch and grip weakness.18 More understanding and use of nerve transfers may help this intrinsic deficiency in the future.
  • Superior outcomes have been identified when an arterial repair is combined with an ulnar nerve repair, especially in low-level ulnar nerve lacerations.5
  • In one study, 76 patients with ulnar nerve lacerations required surgical repair.
    • Lesions not in continuity caused by a sharp laceration and repaired with an end-to-end suture within 72 hours of injury predominantly attained favorable outcomes that were moderate or better in 16 of 22 patients (73%).
    • In patients in which repair was delayed, mobilization of both nerve stumps and secondary end-to-end suture resulted in moderate or better functional outcomes for 11 of 16 patients (69%).14
Key Educational Points
  • Dry skin (anhydrosis) in the ulnar sensory distribution of a potentially cut ulnar nerve suggests a chronic complete or partial laceration.
  • Pre-operative EMG/NCV electrodiagnostic testing can help define the level of the nerve injury and the completeness of a closed nerve injury (ie, neuropraxia vs axonotomesis).1,7Electrodiagnostic testing may also show signs of recovery before recovery can be identified by physical examination. Early EMG/NCV may be less helpful than studies done after a few weeks.
  • MRI can help identify and define nerve tumors, some nerve stretch injuries, and neuromas-in-continuity.1
  • High-level ulnar nerve lesions have such a poor prognosis that some authors recommend nerve repair combined with early tendon transfers to restore power pinch and ring and little finger flexion.5 Nerve transfers may also offer hope for these patients deficient ulnar nerve function.
  • The ulnar nerve is a mixed motor and sensory nerve, making nerve repair more difficult because of the need for very accurate fascicular group matching, i.e. sensory to sensory and motor to motor.
  •  Ulnar nerve functional recovery after laceration and repair is  less predictable than repair of a pure sensory or pure motor nerve.5
References

New and Cited Articles

  1. Pederson, WC. Median nerve injury and repair.J Hand Surg Am 2014;39(6):1216-22. PMID: 24862118
  2. Galanakos, SP, Zoubos, AB, Ignatiadis, I, et al. Repair of complete nerve lacerations at the forearm: an outcome study using Rosen-Lundborg protocol. Microsurgery 2011;31(4):253-62.PMID: 21557303
  3. Chemnitz, A, Bjorkman, A, Dahlin, LB, et al. Functional outcome thirty years after median and ulnar nerve repair in childhood and adolescence. J Bone Joint Surg Am 2013;95(4):329-37. PMID: 23426767
  4. Lad, SP, Nathan, JK, Schubert, RD, et al. Trends in median, ulnar, radial, and brachioplexus nerve injuries in the United States. Neurosurgery 2010;66(5):953-60.PMID: 20414978
  5. Pfaeffle, HJ, Waitayawinyu, T and Trumble, TE. Ulnar nerve laceration and repair. Hand Clin 2007;23(3):291-9. PMID: 17765581
  6. Fernandez, L, Komatsu, DE, Gurevich, M, et al. Emerging Strategies on Adjuvant Therapies for Nerve Recovery. J Hand Surg Am 2018;43(4):368-373. PMID: 29618417
  7. Birch R. Nerve Repair. In: Green’s Operative Hand Surgery, Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (eds), Philadelphia, Elsevier Churchill Livingstone, 2011, pp. 1035-1092.
  8. Payne, RA, Sieg, EP, Patrick, N, et al. Fracture related ulnar and sciatic nerve transections: a report of two cases and literature review. Childs Nerv Syst 2018;34(11)2187-2194.PMID: 30187183
  9. Hurst, LC, Dowd, A, Sampson, SP, et al. Partial lacerations of median and ulnar nerves. J Hand Surg Am 1991;16(2):207-10. PMID: 2022827
  10. Millesi, H. The nerve gap. Theory and clinical practice. Hand Clin 1986;2(4):651-63.PMID: 3539948
  11. Terzis, J, Faibisoff, B and Williams, B. The nerve gap: suture under tension vs. graft. Plast Reconstr Surg 1975;56(2):166-70. PMID: 1096197
  12. Taylor, CA, Braza, D, Rice, JB, et al. The incidence of peripheral nerve injury in extremity trauma. Am J Phys Med Rehabil 2008;87(5):381-5. PMID: 18334923
  13. Birch, R, Misra, P, Stewart, MP, et al. Nerve injuries sustained during warfare: part II: Outcomes. J Bone Joint Surg Br 2012;94(4):529-35. PMID: 22434471
  14. Kim, DH, Han, K, Tiel, RL, et al. Surgical outcomes of 654 ulnar nerve lesions. J Neurosurg 2003;98(5):993-1004. PMID: 12744359
  15. Seddon HJ. Surgical Disorders of the Peripheral Nerves, ed 7. Edinburgh, Churchill-Livingstone, 1975, pp. 276-280.17.
  16. Seddon HJ (ed): Peripheral Nerve Injuries, Medical Research Council Special Report Series No. 282, London, Her Majesty’s Stationery Office, 1954.
  17. Atiyya, AN and Nassar, WA. Ulnar Nerve Repair With Simultaneous Metacarpophalangeal Joint Capsulorrhaphy and Pulley Advancement. J Hand Surg Am 2015;40(9):1818-23.PMID: 26100986
  18. Chan, KM, Olson, JL, Morhart, M, et al. Outcomes of nerve transfer versus nerve graft in ulnar nerve laceration. Can J Neurol Sci 2012;39(2):242-4. PMID: 22343162
  19. Weber RV, Mackinnon SE. Nerve transfers in the upper extremity. J Hand Surg Am. 2004; 4(3): 200-213.

Reviews

  1. Woo A, Bakri K, and Moran SL. Management of ulnar nerve injuries. J Hand Surg Am2015;40(1):173-81. PMID: 25442770
  2. Pfaeffle, HJ, Waitayawinyu, T and Trumble, TE. Ulnar nerve laceration and repair. Hand Clin 2007;23(3):291-9. PMID: 17765581

Classics

  1. Puzey C. Case of Progressive Paralysis of the Ulnar Nerve, Consequent upon Injury: Operation: Successful Result. Br Med J1885;1(1272):979-80. PMID: 20751259
  2. Woodward C. Injury to the Deep Branch of the Ulnar Nerve. Proc R Soc Med1914;7:151. PMID: 19978290