Compression Neuropathies of the Upper Extremity
Transcript of Compression Neuropathies of the Upper Extremity
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Compression Neuropathiesof the Upper Extremity
Carla M. Saulsbery LOTR, CHT
Risk Factors
Age and gender
Intercurrent disease
Genetics
Dupuytrens diathesis
Osteoporosis
Pathogenesis specific to nerve:
1. Initially nerve compression leads to blood/nerve barrier changes
2. Neural connective tissue changes occur
3. Continued pressure leads to localized nerve fiber changes. Segmental demyelination
4. Fiber changes occur with Wallerian degeneration
5. Compression at one point decreases the threshold for compression at other points along the same nerve.
6. Grading of compression severity Grade 1-------- 2-----------3 ( muscle atrophy)
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Normal Peripheral nerve
Peripheral nerve compressed
Normal
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Occupational Therapy for compression neuropathies
Management is based on symptom onset, chronicity, degree of muscle weakness and sensory abnormalities.
OT performs a baseline sensory and motor examination, assess both grip and pinch strengths and reassess at least one time monthly
Patient education Conservative treatment based on evaluation findings
Post-operative treatment
Splinting as indicated based on surgical procedure Wound and scar management Splint per nerve deficit Desensitization for dysesthesias Motor and sensory reeducation AROM Strengthening Patient Education ADL’s
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EVALUATION History
Onset
Activities that increase symptoms
Symptom duration
Subjective
Objective
ROM
MMS
Night and daytime paresthesias
Tinels and other provocative testing
Grip and pinch assessment
Sensation—Semmes Weinstein monofilament testing
Moberg
ADLs
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Semmes Weinstein Monofilaments
A sensory threshold test
Can be used on any part of the body
Used to correlate nerve damage with a patients ADL function
“Maps” the extent and degree of the sensory loss
Reliable and reproducible
Screening kit consists of 5 monofilaments
2.83, 3.61, 4.31, 4.56 and 6.6 monofilaments
Testing begins with 2.83
Monofilaments 2.83 and 3.61 --- one response out of 3 considered a correct response
The monofilament is applied for 1.5 seconds and removed for 1.5 seconds
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Sensory patterns
Palmar Dorsal
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Occupational Therapy
Upper Extremity Semmes Weinstein Right Left
Date :______________
OTR/L:_______________________
Volar Dorsal
Axillary nerve
Superior lateral
cutaneous (C5-6)
Radial nerve
Inferior lateral
cutaneous (C5-6)
Lateral cutaneous
nerve (C5-7)
Radial nerve
Median nerve
Palmar branch
(C6-7)
Intercosto-brachial nerve
(T2) and the medial
cutaneous nerve
(C8, T1-2)
Medial cutaneous nerve
(C8,T1)
Ulnar nerve
(C8, T1) Ulnar nerve
(C8, T1)
Radial nerve
Superficial branch
and dorsal digital
(C6-8)
Median nerve
Radial Nerve
Posterior cutaneous
(C5-7)
Inferior lateral
cutaneous
Posterior cutaneous
(C5-8)
Lateral cutaneous
(C5-7)
2.83 Green Normal
3.61 Blue Dim. light touch
4.31 Purple Dim protective
6(4.56) Red Loss of protective
6.6 Orange Deep pressure
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Axillary nerve
Superior lateral
cutaneous (C5-6)
Semmes Weinstein Interpretation
2.83 Green Normal Sensation
3.61 Blue Diminished light touch, diminished texture discrimination
Earliest sign of nerve involvement. Patient has fair use of the hand.
4.31 Purple Diminished protective sensation. Absent texture, impaired stereognosis
and impaired sensation. Pain and temperature sensation should keep
patient from injury.
Patient will c/o of dropping things and decreased ability to perform fine
motor ADL’s and other manipulation tasks.
4.56 Red Loss of protective sensation. Absent protective sensation/stereognosis
Patient cannot manipulated objects outside line of vision
Increased risk of injury secondary to slowed response to hot and sharp
objects.
Present deep pressure sensation
6.65 (Orange) Deep pressure sensation, rudimentary deep cutaneous peripheral nerve
response.
Pt. can recognize a pin prick
Untestable/ Unresponsive to any filament
Red-lined Nonfunctional sensibility
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Test is performed for two trials
Eyes open norms 10-19 sec on the first trail
10-16 on second trial
Eyes closed : 2 seconds per object
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Dellons’ Modification of the Moberg
• A Standardized assortment of 12 everyday objects
( wing nut, screw, key, nail, nickel, dime, safety pin, washer, paper clip, small hex nut,
small square nut and a key).
• Use to assess the patient’s ability to manipulate small objects with and without vision
• Therapist observes and notes prehension pattern used and which digits are used
• Timed test with both hands tested
• Performed with eyes open and again with the eyes closed
Compression Neuropathies of the Upper Extremity
Median Nerve
Pronator Syndrome
Anterior Interosseous Nerve Syndrome (AIN)
Carpal Tunnel
Ulnar Nerve
Cubital Tunnel
Guyons Canal or Handlebar palsy
Radial Nerve
Radial Tunnel
Posterior Interosseous Nerve Syndrome (PIN)
Wartenbergs Syndrome ( entrapment of the superficial sensory branch of the Radial Nerve )
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Median Nerve
Formed by equal contributions of the medial (C5-C7) and lateral (C8-T1) cords of the brachial plexus.
The nerve has an intimate relationship to the brachial artery as it passes down the arm to the elbow
The Martin Gruber anastomosis is of interest in high median nerve neuropathies.
This communication between median and ulnar nerves occurs in approximately 17% of the population
Chronic pain from the proximal median nerve is predominantly caused by trauma.
Non-traumatic compression is predominantly caused by slowly expanding lesions often vascular in nature.
There are four commonly described sites of compression of the median nerve in the elbow and proximal forearm region. (Ligament of Struthers, Lacertus Fibrosis, Pronator Teres muscle and the arch of the FDS).
Supracondylar fractures have been associated with a 5 to 19% incidence of median nerve injury
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Median Nerve (medial cord C5-7 and lateral cords C8-T1 of Brachial Plexus)
Muscle/Sensory Innervation
Pronator Teres Forearm Median Nerve High Lesion
Flexor Carpi Radialis
Palmaris Longus
Flexor Digitorum Superficialis
Palmar Cutaneous Branch
Flexor Digitorum Profundus (Index/Long) Anterior Interosseous Nerve
Flexor Pollicis Longus
Pronator Quadratus
Lumbricals (1,2) Carpal Tunnel Median Nerve Low Lesion
Opponens Pollicis
Abductor Pollicis Brevis
Flexor Pollicis Brevis (superficial)
Digital Cutaneous Branch
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Median Nerve Compression Sites
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Median Nerve : Pronator Syndrome Compression of the most proximal site of the median nerve just inferior to the
antecubital fossa. Compression can occur as the nerve passes between the two heads of the Pronator Teres muscle. The term pronator syndrome can also include median nerve compression by other structures: ligament of Struthers, the lacertus fibrosus or the FDS proximal arch.
Commonly mistaken for carpal tunnel syndrome First described in 1951 Pronator Teres Muscle is usually spared as it receives its innervation before it is
pierced by the nerve.
Signs and Symptoms1. Aching pain in proximal volar forearm. Associated with repetitive motions that
cause hypertonicity in the pronator teres. Occupational activities : hammering, cleaning fish, continual manipulation of tools.
2. Numbness/ paresthesias in the median nerve distribution. Nocturnal complaints uncommon
3. Tenderness over Pronator Teres muscle4. Symptoms exacerbated with activity and diminished with rest5. Easy fatigability6. + Tinels over proximal forearm but takes 4-5 months to develop.7. Pain on resistance to pronation and resistance to flexion of the FDS to 3 and 48. Advance cases will display weakness in all median nerve innervated musculature
distal to the Ligament of Struthers.9. Women are affected more than men (4 times) and presents in the fifth decade of
life.10. Symptoms insidious in onset with a delay in diagnosis ranging from 9 months to 2
years.
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Provocative testing
Pronator Teres test
Patent is standing with the elbow in 90 of flexion. Patient holds position while examiner attempts to supinate the forearm. (forces isometric contraction of the pronator muscle). While holding the resistance against pronation , the examiner
slowly extends the elbow. If motion reproduces the pain the median nerve is probably compressed by the pronator teres.
Test for compression by arch of FDS
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Splinting for Pronator Tunnel
Posterior elbow long arm splint. Elbow at 90 flexion, forearm in pronation with wrist at neutral.
Splint 4-6 weeks followed by night wear for same amount of time NSAIDS Cryotherapy Elbow and wrist AROM Tendon and nerve gliding Ergonomic assessment and recommendations Strengthening of affected muscles Avoidance of aggravating activities Conservative treatment is 8 to 12 weeks.
Postoperative Therapy
Day 3-5 bulky dressing. Allow full AROM to digits. Elbow and wrist AROM limited by patient complaints. Gradually increase range of motion and activity.OR Elbow splinted at 90 for 5-10 days, then AROM as tolerated.
Scar management Strengthening of all affected muscles Nerve and tendon gliding
Ergonomic assessment and recommendations.
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Median Nerve: Anterior Interosseous Syndrome (Kiloh-Nevin Syndrome)
Compression of the anterior interosseus branch of the median nerve usually bythe deep head of the Pronator Teres.
The AIN nerve is purely motor-no sensory findings. Can be resultant of an injury to the forearm, by direct trauma, compression or inflammation of the AIN.
AIN accounts for fewer than 1% of all upper extremity neuropathies Earliest description was in 1952. Rule out Pseudo-Anterior Interosseous Neuropathy FPL is usually the first muscle affected.
Signs and Symptoms
1. Vague pain in the proximal forearm and wrist that increases with activity especially repetitive forearm motion and is relieved with rest.
2. No sensory disturbances3. Weakness or paralysis of the FPL, FDP of the index finger and less commonly the
long finger and the pronator quadratus.4. Unusual pinch demonstrated by the hyper extended IP joint of the thumb and index
finger (Q sign) ( late sign). Inability to make the “OK” sign.
5. Patient reports problems with writing or picking up small objects.6. Examiner must look for the tenodesis effect produced by intact flexor tendons. The
differential diagnosis of AIN. AIN can be misdiagnosed as a tendon rupture of the FPL orFDP
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Inability to make the “OK” sign. Weak pinch of AIN syndrome.
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Anterior Interosseous Nerve Syndrome
Anterior Interosseous Neuropathy Pseudo-Anterior Interosseous
Lesion of the AIN Lesion of fibers that ultimatelyconstitute the AIN
Weakness of FPL,PQ,FDP to Index Weakness of FPL,PQ,FDP to IndexNormal sensibility +/- weakness of shoulder girdleNormal shoulder girdle +/- weakness of thenar muscles
+/- Abnormal sensibility (Median)
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Splinting for Anterior Interosseous Syndrome Posterior long arm splint with elbow at 90 of flexion, forearm pronated and the wrist
in neutral for 3 to 4 weeks Thumb in opposition –splint for function. NSAIDs Cryotherapy Avoidance of aggravating factors AROM of the elbow and wrist Tendon and nerve gliding Ergonomic assessment and recommendations Strengthening of affected muscles Conservative treatment for 8 to 12 weeks
Postoperative therapy Bulky dressing supporting the elbow and wrist, AROM of wrist and digits for 5 to 7
days. Strengthening at 7 to 10 days post op unless pronator was elevated. If pronator was elevated, splint elbow at 45-90 , wrist 45 and full pronation for 2-3
weeks Digit ROM immediately, AROM of the elbow and wrist at week 3 and strengthening
at 3 to 4 weeks Scar Management Nerve and tendon gliding Ergonomic assessment and recommendations
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Carpal Tunnel
Compression under the transverse carpal ligament in the carpal canal
Risk factors
Demographics: female, middle aged, smoker, obesity
Idiopathic process: thickened transverse carpal ligament, Diabetes .
Medical conditions: Decreased canal volume: wrist fracture, dislocation of carpal
bone, Rheumatoid tenosynovitis
Increased canal volume: thyroid disease, renal failure,
pregnancy, mass (tumor or hematoma)
Patient complaints
Awakening at night
Numbness, tingling
Weakness of grip or pinch
Dropping things, inability to perform certain ADL’s
Reports of numbness when driving or reading
Decreased ability to distinguish between hot and cold
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Grading nerve compression for Carpal Tunnel
Grade 1 Mild
Awakening at night. Usually intermittent
Tingling and numbness
Positive Phalens
Symptoms increase with activity
No muscle atrophy
Middle finger most commonly involved
Grade II Moderate
Positive provocative tests. Tinels and Phalens
Weakness of the thenar muscles, but not atrophy
Decreased sweat
Semmes Weinstein test will be abnormal
Decreased grip and pinch strength
Grade III Severe
Thenar atrophy
Sensory symptoms are persistent
Abnormal Semmes Weinstein
Phalens and TInels may be negative
Patient complains of constant numbness during the day and night
Nerve is tender to deep pressure
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Prognosis
Poor outcome with conservative management may occur with:
• Symptoms greater than 10 months in duration
• Constant paresthesias
• Positive Phalen’s test in less than 10 seconds
• Weakness, atrophy
• Marked prolonged latency on NCS
• Abnormal spontaneous activity on EMG
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Thenar atrophy
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Median nerve compression at the carpal tunnel
Conservative Treatment of Carpal Tunnel
Patient education
Splint for night wear
Splint for daytime wear as indicated
Tendon/nerve glide exercises
Home and or job modifications
Hand strengthening
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Median Nerve Glide Exercises
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Post-operative care for Carpal Tunnel release
Range of motion 15 reps hourly
Avoid wrist flexion
Wound care
Massage for scar and skin hydration
Lightweight ADL’s
Desensitization for dysesthesia's
Progress to nerve glide
Sensory re-education
Caution patient against over exercising
No heavy lifting, pushing or pulling for one month
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Post op care
Patient is followed monthly for re-evaluation
Watch for symptomatic neuroma
Program for dysesthesias
Hand strengthening can begin at 3-4 weeks post op.
Patients with sedentary jobs requiring <10# lift may return to work by week 8
Grip strength slowly increases over a two to three month period
Patient needs to be seen by both Ortho and OT at 2 months post op
Patients with grade III CTS may require more than 2 months to regain sensation and hand strength and may develop dysesthesias which can require several months of desensitization/sensory reeducation to resolve.
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Ulnar Nerve Compression Sites
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Ulnar Nerve (medial cord C8-T1 of the Brachial Plexus)
Muscle/Sensory Innervation
Flexor Carpi Ulnaris Forearm Ulnar nerve High Lesion
Flexor Digitorum Profundus (ring, small)
Palmar ulnar cutaneous nerve
Dorsal ulnar cutaneous nerve
Abd. Digiti Minimi Hand Ulnar nerve Low Lesion
Opponens Digiti Minimi
Flexor Digiti Minimi
Lumbricals (3, 4)
Interossei (Palmar/Dorsal)
Flexor Pollicis Brevis (deep head)
Adductor Pollicis
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Tardy Ulnar Palsy
• An ulnar neuropathy that can occur months to years after a distal humerus fracture
• Nerve can be injured secondary to a trauma that results in bone overgrowth or
scar formation
• Nerve traction can occur from an increased carrying angle
• Findings of muscle involvement and complaints are dependent on the site of injury
• In most cases all ulnar nerve innervated muscles can be involved
• Treatment may include therapy or a surgical procedure
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Ulnar Nerve: Cubital Tunnel Syndrome Compression or trauma of the ulnar nerve at the level of the medial aspect of the
elbow. Second most common compression neuropathy. Causative factors include recurrent subluxation, dislocations, RA, excessive elbow
valgus, bony spurs, synovial cysts or external compression or trauma. Ulnar nerve supplies the ulnar intrinsics, FDP to 4 and 5 and the FCU. Sensation in
the 5th digits and ulnar ½ of the ring Cubital tunnel is a bony canal formed by the ulnar collateral ligament, the trochlea,
and the medial epicondylar groove and is roofed by the triangular arcuate ligament. FCU may or may not be involved.
Signs and Symptoms
Pain at medial elbow Sensory disturbance (numbness, paresthesia, dysesthesia) over the hypothenar
eminence, dorsoulnar hand, 5th digit and ulnar 4th digit. Weak intrinsics. Decreased or inability to cross fingers or spread fingers apart + Tinels at Cubital tunnel + Elbow flexion test (Wadsworth flexion test). Elbow flexed, FA supinated with wrist
extended. + at 60 seconds. Froments sign in advanced stage Weak grip and lateral pinch Wartenbergs sign in advanced cases. Paralysis of the 3rd palmar interossei. ( no
adduction of small finger) Claw hand deformity as FDP reinnervates
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Cubital Tunnel
Tinels
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Normal pinch
Positive Froments
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Non-operative Treatment and Splinting
Heelbo pads for day time wear to protect medial elbow/ulnar nerve.
Fabricate a long arm splint with elbow flexed 30 to 45 , anterior based and flared to avoid external compression on the ulnar nerve for night wear.
Can use a rolled towel around the elbow to decrease flexion at night during sleep if splint not fabricated
Postural and positional education is stressed to avoid external nerve compression. Resting elbows on hard surfaces, leaning on elbows, prolonged elbow flexion, repetitive flexion/extension at elbow
Patient education in insensate precautions
Ulnar nerve glide
Ice
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Lumbrical bar splint for Ulnar nerve
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Dynamic Splinting for Ulnar nerve with associated extrinsic tightness
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Ulnar Nerve Surgery
Decompression and medial epicondylectomy
Subcutaneous transposition
Submuscular transposition
Subfascial - submuscular
anterior transposition of the UN
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Postoperative Therapy Cubital Tunnel
Ulnar nerve decompression/ medial epicondylectomy
• Begin gentle AROM immediately, no heavy lifting for 6 weeks. Patient can
use upper extremity for daily activities.
• Sensory assessment
• Wound care and edema control
• Week 2 begin PROM
• Exercises to promote gliding of the ulnar nerve to prevent scarring of the
nerve to the surgical bed.
• Week 4 resisted ROM. Stretching exercises.
• Normal activity resumption in 1-2 months
• As ROM progresses, initiate gentle strengthening exercises
• Desensitization and motor exam.
• Splint as indicated for ulnar nerve deficit
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Cubital Tunnel continued
Subcutaneous transposition
Week 1: Splint in 45 elbow flexion for up to 2 weeks. Gentle AROM is started at all joints. Progress to resistive exercises at 4 weeks.Sensory assessmentWound care and edema control
Week 2: Discontinue splint, progress AROM Week 3: PROM Week 4: Progress resisted ROM
Desensitization, sensory re-educationSplint as indicated for ulnar nerve deficit
Submuscular transposition
Week 1: Splint in long arm splint with elbow flexed 45 , with slight forearm pronation and wrist in neutral for up to 3 weeks to protect the flexor pronator origin.Sensory assessmentWound care and edema control
Week 2: AAROM of elbow. Progressively move elbow into extension with wrist flexed and FA pronated to avoid tension scar massagedigit range of motion
Week 5: Stretching to regain full elbow extension Week 6-8: Progressive strengthening
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Ulnar Nerve: Guyon’s canal Compression of ulnar nerve as it passes through Guyon’s canal at the wrist. Guyon’s
is a bony canal formed by the volar carpal ligament, hook of the hamate and the hamate. Motor and sensory deficits are present distal to the canal as both sensory and motor runs through the canal. There will be volar sensory but no dorsal sensory deficit. Compression of the ulnar nerve at this site is usually associated with trauma, abnormal structures (ganglion cyst or lipoma) fracture of the hamate, ring or small fingers metacarpal bones or anomalous muscles. Thrombosis or aneurysm of the artery may compress the nerve. It has also been called handlebar palsy.
Signs and Symptoms
Numbness/tingling along the volar aspect of the small finger and ulnar ½ of the ring (no dorsal numbness)
Cold intolerance in the ring and small fingers.
Weakness or paralysis of the hand intrinsics innervated by the ulnar nerve
Possible + Tinels at Guyon’s canal
Possible claw deformity
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Classification: (Shea’s System)
Type I: Involvement of the hypothenar and deep ulnar branch
Type II: Involvement of the deep ulnar branch
Type III: Involvement of the superficial sensory branch
Treatment for Guyons Canal
• Protective splint or gel pad if from external compressive forces
• Managed post surgically with splinting ,muscle strengthening and sensory re-education.
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Ganglion compressing the
ulnar nerve in Guyons Canal
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Communications between the ulnar and median nerves in the upper limb
Martin-Gruber anastomosis• First described in 1763
• 10-44% of the population
• Communicating branch may arise from the median nerve and join the ulnar nerve
in the forearm, ultimately innervating the intrinsic hand muscles
• The clinical importance is that an isolated UN lesion at the elbow may produce
an unusual pattern of intrinsic muscle paralysis.
Riche- Cannieu• First described in 1897
• Recurrent branch of the median nerve and the deep branch of the ulnar nerve
are connected in the palm.
• The thenar muscles normally innervated by the median nerve are innervated by the ulnar.
• Even with an injury at the wrist, some intrinsic function occurs
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Martin-Gruber Anastomosis in the forearm
Riche- Cannieu Anastomosis
Ulnar Nerve
Median Nerve
Riche- Cannieu Anastomosis
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Radial Nerve Compression Sites
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Radial nerve
Triceps
Brachioradialis
Extensor carpi radialis longus
Lower lat cut. n. of arm
Post. cut. n. of FA
Post. Interosseous n.
Extensor carpi radialis brevis
Supinator
Extensor digitorum
Extensor digiti quinti
Extensor carpi ulnaris
Abductor pollicis longus
Extensor pollicis longus & brevis
Extensor indicis
Dorsal digital nerves
Axilla
Humeral fractures
Extensor carpi radialis brevis
Arcade of Froshe
Wartenbergs Syndrome
Posterior cut n.
Radial Nerve C5-C8 (Posterior cord of the Brachial Plexus)
Muscle/Nerve Innervation
Triceps Arm Radial Nerve High Lesion
Anconeus
Posterior cutaneous nerve
Lower lateral cutaneous nerve
Innervation below the spiral groove
Brachioradialis
Extensor carpi radialis longus
Superficial Radial Nerve (sensory)
(elbow joint)
Extensor carpi radialis brevis ***Posterior Interosseous Nerve****
Supinator
Extensor digitorum communis
Extensor digiti minimi
Extensor carpi ulnaris
Abductor pollicis longus
Extensor pollicis Longus
Extensor pollicis Brevis
Extensor indicis proprius
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Radial Nerve
Dbrn is above the arcade of Froshe
Dbm deep branch of radial nerve
Sb superficial branch radial nerve
Sm supinator muscle
(asterick) nerves to supinator muscle
Nb nerve to brachioradialis
Nel nerve to the ECRL
Neb nerve to the ECRB
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Radial Nerve
The posterior branch of the radial nerve is being compressed
by the Leash of Henry and the arch of the ECRB
BT Biceps tendon
BA Brachial Artery
Single white arrow Leash of Henry
Multiple black arrows Arch of the ECRB
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Radial Nerve: Radial Tunnel Syndrome Compression of the radial nerve by anatomical structures inferior to the lateral
epicondyle: proximal fibrous edge of the supinator muscle ( arcade of Froshe), fibrous fascia over the radiocapitellar joint, tendinous origin of the ECRB and the fibrous thickenings within an at the distal margin of the supinator muscle.
Signs and Symptoms
Dull, achy pain over the extensor aspect of the forearm, can radiate into the distal forearm and the hand.
Symptom onset after significant repetitive or power grip use Pain absent upon awakening but progressively increases with activity, leaving a dull
persistent ache. Night pain is common Tenderness over the radial head/radial tunnel area Positive radial tunnel compression test involves the examiner rolling the fingers over
the radial nerve region in the proximal forearm eliciting pain and tenderness. Pain reproduced with resisted extension of the fingers with the elbow extended- pain
most severe with stressing the middle finger. (Middle finger test which tenses the ECRB over the nerve)
Pain with resisted forearm supination with the elbow extended (Yergasons test) With advanced stages- weakness of the wrist, finger and thumb extensors. Decreased
grip strength secondary to weakened extensors. May have paresthesias, numbness in the 1st dorsal web space, dorsal thumb and index
finger Radial tunnel syndrome may be distinguished from lateral epicondylitis by exam.
Maximum tenderness is over the neck of the radius and must be compared to the other arm.
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Non-operative treatment for Radial tunnel
Week 0-3:
Wrist splint in 30-45º extension. Splint worn continuously. Patient education in avoidance of tasks requiring Pronation/supination Use appropriate balanced tools in the work environment and avoid high-force tasks
with torque or with heavy pronation and supination
Week 3+
Radial nerve glides Tendon gliding
Basic 4 hand posturesOverhead fisting
Modalities as indicated Patient education on risk factors Patient education on activity modification of ADL’s and job tasks. (lift with palms up
versus palms down) Progressive strengthening with putty and theraband once symptoms have resolved
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Radial Tunnel Operative
Week 1: Bulky dressing is removedGentle active and passive ROM to wrist, FA and elbowPatient education on wound care
Week 3-4: Motor and sensory re-educationScar massageAROM to wrist, forearm and hand.Begin neural glide exercisesPatient is to use extremity in basic self-care ADL activities and IADL tasks such as cooking and meal preparation.
Weeks 6-8: Progressive strengthening within patients comfort level using putty andtheraband, free weights
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Posterior Interosseous Syndrome
Compression or injury of the PIN branch of the radial nerve, secondary to trauma. (dislocation of the elbow or fracture/dislocation of the radial head, Monteggia fracture), lipoma, ganglion cyst, inflammation, postural/occupational or iatrogenic (injection causes.)
Compression of the nerve at proximal edge of the supinator is the most frequent compression site.
Considered a pure motor syndrome
Signs and Symptoms
Pain deep forearm, lateral elbow
Weakness of wrist extension (will have extension in radial deviation from ECRL) Motor loss may be gradual or dramatic. Loss of finger and thumb extension.
No sensory deficit.
History of repeated or strenuous effort involving supination and pronation. Men two
times more than women with dominant arm 2 times more than non-dominant.
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Posterior Interosseous Nerve Splint
Long arm posterior splint with elbow flexed to 90º. Wrist in neutral, forearm in neutral. Buddy tape the fingers.
Paralysis of wrist and finger extensors– support wrist in splint with dynamic extension outriggers for the digits.
Paralysis of finger extensors but active wrist- tenodesis splint.
Post operative Splinting
Long arm posterior splint with the elbow flexed to 90º, wrist and forearm in neutral. Buddy tape the fingers.
Dynamic splinting
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Long arm splint with wrist
Tenodesis style splint
Radial Sensory nerve entrapment or Wartenberg’s disease (Cheiralgia Paresthetica)
A rare clinical feature of entrapment of the superficial sensory branch of the radial nerve at the wrist. It is thought the lesion arises from the point at which the nerve exits the deep tissue between the
brachioradialis and the ECRL Most distal compression can be from external causes. Tight wristbands, scar bands, tight cast or a
direct blow, or from chronic inflammation from first dorsal compartment tendonitis. In patients with de Quervains tenosynovitis secondary irritation of the RSN is frequent
Signs and Symptoms
Radial wrist and dorsal hand pain of thumb, index, first web. Described as burning, numbness, hyperesthesia or tingling.
Test by clenched fist and ulnar- palmar flexion with forearm hyperpronation. Dysesthesia's of the dorsal hand, thumb, index and long fingers + Tinels along the radial styloid to the edge of the brachioradialis Finkelstein’s test may be misleadingly positive. Thumb does not have to be flexed to elicit an
positive test.
Splint
Wrist splint with max. extension, radial deviation NSADIS Restricted activities
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Three main branches of the SBRN (Superficial branch of the radial nerve)
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Treatment Goals for Median Nerve Compression
• Provide appropriate splinting based on diagnosis
• Patient education on positional avoidance of aggravating postures
• Patient education in injury prevention secondary to decreased sensation
• Patient education in tendon and nerve glide exercises
• ADL independence, adaptive equipment as indicated
• Improvement in sensation
• Strengthening of affected muscles
• Ergonomic assessment
Treatment Goals Post Operatively
• Postoperative immobilization as indicated
• Wound/ Incision care
• Scar management
• Increase ROM
• Edema control
• ADL
• Desensitization if needed
• Strengthening
Treatment Goals for Ulnar Nerve Cubital Tunnel Conservative Treatment
• Reduce direct pressure on the ulnar nerve at the elbow
• Minimize stress/stretch to the nerve, reduce inflammation
• Normalize sensation
• Splint for ulnar claw deformity
• Increase strength of weakened musculature
• Ergonomic evaluation and patient education
Treatment Goals Post Operative
• Discuss with MD post-operative immobilization
• Avoid postures that cause paresthesias
• Incision care to promote healing
• Maintain ROM of all uninvolved joints
• Encourage use of the involved extremity in ADL’s
• Scar massage, stretching to minimize scar adhesions
• Strengthen musculature
• Splint for ulnar claw as needed
• Patient home program in desensitization/ sensory re- education
• Nerve glide exercises
• Assess return to work and return to independent ADL’s
Treatment Goals Radial Nerve
• Provide splinting to promote function, decrease pressure
• ROM exercises to prevent extrinsic flexor tightness/intrinsic tightness
• Functional ADL retraining
• Strengthening / re-conditioning
• Patient education to avoid mechanical stress
Treatment Goals Post Operative Repair
• Protective post operative splinting
• ROM exercises to decrease edema and stiffness
• Functional ADL retraining, increase use of the hand in ADL’s
• Incision care to promote healing.
• Splinting to promote functional return
• Scar management
Outcomes Median Nerve
1. Non-operative: Outcome depends on severity and length of time of compression
2. Postoperative: Dependent on symptom duration, severity, incision healing,
scar tenderness, patient motivation, specific work requirements.
A. Light or sedentary work, return is between 2-4 weeks. Work requiring heavy
manual labor the recuperation time is longer
B. Grip and pinch strengths return to preoperative levels 2-3 months, with
maximal improvement by 10 months
C. Compression symptoms may reoccur in 1.7% to 3.1% of patients
Outcomes Ulnar Nerve
1. Dellon reported excellent results in 50% of patients with mild neuropathy
treated non-surgically and 90% excellent results in those treated with
surgery regardless of the procedure.
2. Dellon also reported that non-operative treatment and decompression
surgery were mostly unsuccessful in treating moderate neuropathies;
however epicondylectomy provided excellent results in 50% of cases.
3. Most of the literature describes resumption of full activities by 3 to 4
months post surgery.
4. Nathan and colleagues reported simple decompression and early therapy
resulted in good or excellent long-term relief in 89% of cases and an average
RTW interval of 20 days.
5. A significant reduction in the incidence of elbow flexion contractures was also
reported with early mobilization
Radial Nerve Outcomes
1. The functional outcome of radial nerve lesions is dependent on the severity
index, location of the injury, age of patient.
2. The majority of radial nerve lesions when managed by a hand surgeon
and skilled hand therapist realize functional recovery and independence
in ADL’s.
3. Modification of work or home tasks to reduce those movements or positions
that cause compression needs to be addressed.
4. Some individuals may be restricted from very heavy work or job duties
that aggravate symptoms.
References
Hunter, et al. Rehabilitation of the Hand: Surgery and Therapy 4th ed.
Stanley and Tribuzi. Concepts in Hand Rehabilitation
Burke, et al. Hand and Upper Extremity Rehabilitation 3rd ed.
Cherry, K. Differential Diagnosis for Nerve Entrapment Syndromes
of the Upper Extremity. North American Seminars, Inc.
Dogan,N. et al. The communications between the ulnar and median nerves
in upper limb. Neuroanatomy (2008) 8: 15-19.
Springer Images
Photos: LSUHSC