compressive neuropathy of upper limb

8/11/2019 Compressive neuropathy of upper limb

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COMPRESSIVE NEUROPATHIES OF

UPPER L IMB


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Defination

The term compressive neuropathies refers toisolated peripheral nerve injuries occurring atspecific locations where a nerve is mechanically

constricted in a fibrous or fibro-osseous tunnel ordeformed by a fibrous band.

In some instances the nerve is injured by chronic

direct compression, and in other instancesangulation or stretching forces cause mechanicaldamage to the nerve.


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Types Upper Limb

-Median Nerve-Carpal Tunnel Syndrome

-Pronator Syndrome-Ulnar Nerve

-Cubital Tunnel Syndrome-Guyon Tunnel Syndrome

-Supraspinatus syndrome-Anterior interosseous syndrome-Posterior interosseous syndrome


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Carpal tunnel syndrome (CTS) is acollection of symptoms and signsthat occurs following entrapmentof the median nerve within thecarpal tunnel.

Usual symptoms includenumbness, paresthesias, and painin the median nerve distribution.

These symptoms may or may notbe accompanied by objectivechanges in sensation and strengthof median-innervated structuresin the hand.

Carpal Tunnel Syndrome


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Borders of the carpal tunnel

Ulnarly : hook of hamate, triquetrum,and pisiform

Radially : trapezium, scaphoid, andflexor carpi radialis retinaculum

Dorsally : the concave arch of thecarpal bones and metacarpal bases ofthe central rays

Anteriorly : the transverse carpalligament (TCL).


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Clinical features

Pain Numbness Tingling Symptom usually worst at night and can awaken

patient from sleep To relieve the symptom, patient often flick their

wrist as if shaking down a thermometer


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Examination

Provocative Testing

1. Phalen's wrist flexiontest: The wrist ismaximally flexed with thefingers slightly curled.

A positive test for CTS isreproduction of symptomswithin 60 sec.


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Examination

Provocative Testing

2. Tinel's nervepercussion test : Themedian nerve is

percussed as it entersthe carpal canal to elicitsymptoms.

It is specific andindicates CTS in cases inwhich Phalen's test isalso positive.


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ExaminationProvocative Testing

3. Direct compressiontest: The examiner'sthumbs apply directpressure to the median

nerve as it enters thecarpal tunnel.

A positive test isreproduction of

symptoms, which appearwithin 30 sec anddisappear with release ofcompression.

Durkan's mediannerve compression

test


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Physical Therapy Given CTS is associated with low

aerobic fitness and increasedBMI, it is inherent to providethe patient with an aerobicfitness program.

Stationary biking, cycling, or anyother exercise that puts strainon the wrists probably shouldbe avoided.

It may be possible to enlarge

the carpal tunnel by specificstretching techniques. Such anexercise program may provide anew non invasive treatment forCTS in the future.

Management


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Splint Wrist splints are recommended for use either at night,

or both day and night although they get in the waywhen doing daily activities. These help to keep wriststraight and reduce pressure on the compressed nerve.

Most individuals with mild-to-moderate carpal tunnelsyndrome (CTS; according to electrophysiologic data)respond to conservative management, usuallyconsisting of splinting the wrist at nighttime for aminimum of 3 weeks.


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Short (1-2 wk) courses of regular NSAIDs can be ofbenefit, particularly if there is any suggestion ofinflammation in the wrist region.

NSAIDs provide pain relief and reduction of

inflammation. Reducing inflammation in the structurespassing through the carpal tunnel decreases pressureand provides some relief to the compressed nerve.

Steroid injection into the carpal tunnel is of benefit, as is

oral prednisone . Vitamin B-6 or B-12 supplements are of no proven

benefit .

Medication


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Patients whose condition does not improvefollowing conservative treatment and patientswho initially are in the severe carpal tunnelsyndrome should be considered for surgery


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Pronator Syndrome Compression of the Median n. in the forearm Between the 2 heads of the Pronator Teres Much less common than CTS Linked to repetitive upper extremity activity


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Clinical features Aching pain in the proximal volar forearm Paresthesias radiating into the thumb, IF, MF and radial of the RF Similar to CTS Decreased sensation over the thenar eminence suggests a more proximal lesion Provocative tests for CTS negative


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Provocative tests Resisted forearm pronation Resisted elbow flexion with forearm supinated Resisted flexion of the MF FDS

Pressure over the leading edge of the pronator teres with the forearm in maximumsupination and the wrist in neutral produces paresthesias in the median sensorydistribution.


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Treatment

Surgery usually not necessary Activity modification, rest NSAIDS, Corticosteroids

Conservative management effective in 50-70% Surgery if space-occupying lesion or if several-month course

of nonsurgical treatment fails. Surgery success rate 90%


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Anterior Interosseous Nerve Syndrome

Weakness or motor loss of: Flexor Pollicis Longus FDP to the IF (and occasionally the MF) Pronator Quadratus


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Weakness or motor loss usually occur spontaneously Patient may describe clumsiness with fine motor skills such as writing and

pinching. AIN does not innervate the skin no sensory loss Pain may be present in the forearm along the course of the nerve


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Treatment

Rest, splinting and observation for severalmonths

Most improve without surgical intervention Surgical decompression for patients who fail a

several-month course of nonsurgical

treatment


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Ulnar Nerve

Cubital Tunnel Syndrome Guyons Canal


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Cubital tunnel roof

formed by FCU fascia and Osborne's ligament (travels from the

medial epicondyle to the olecranon) floor

formed by posterior and transverse bands of MCL and elbow jointcapsule

walls formed by medial epicondyle and olecranon


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Cubital Tunnel Syndrome

Second most common compression syndrome Also a clinical diagnosis Numbness in the ring and small finger

Aching in the medial aspect of the elbow and forearm


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Tinels sign positive at or proximal to CubitalTunnel

Elbow flexion test


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Clawing of the small and ring fingers


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Froment sign

Cant adduct thumb (ulnar nerve)

Flexes thumb IP joint instead (median nerve)


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Wartenberg sign

Ulnar abduction of 5 th digit due to due to intrinsicweakness and unopposed abduction by extensordigiti minimi (because of its slightly ulnar insertion)


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Interosseous wasting


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Treatment Avoid positioning that combines elbow flexion with pressure over the

ulnar nerve Physiotherapy Static night splinting in extension Rigid splints often ineffective due to discomfort and noncompliance


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Compression of Guyons Canal

Guyon's canal syndrome is an entrapment ofthe ulnar nerve as it passes through a tunnelin the wrist called Guyon's canal.


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Anatomy

Guyons canal course is approximately 4 cm long begins at the proximal extent of the transverse

carpal ligament and ends at the aponeurotic archof the hypothenar muscles

contents ulnar nerve bifurcates into the superficial

sensory and deep motor branches


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Boundaries of Guyon's canal

Floor Transverse carpal ligament, hypothenar muscles

Roof Volar carpal ligament

Ulnar border Pisiform and pisohamate ligament, abductor digitiminimi muscle belly

Radial border Hook of hamate


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Compression of Guyons Canal


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Zones of Guyon's canal

Location Common Causes of Compression Symptoms

Zone 1

Proximal tobifurcation of the

nerve

Ganglia and hook of hamate fractures

Mixed motor andsensory

Zone 2 Surrounds deepmotor branch

Ganglia and hook of hamate fractures Motor only

Zone 3 Surroundssuperficial

sensory branch

Ulnar artery thrombosis or aneurysm Sensory only


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Treatment Nonoperative

activity modification, NSAIDS and splinting indications

as a first line of treatment when symptoms are mild Operative

local decompression indications severe symptoms that have failed nonoperative treatment

tendon transfers indications

correction of clawed fingers loss of power pinch Wartenberg sign (abduction of small finger)

carpal tunnel release indications

patients diagnosed with both ulnar tunnel syndrome and CTS


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Radial Nerve

SRN compression PIN Syndrome Radial Tunnel Syndrome


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Posterior Interosseous NerveSyndrome

A compressive neuropathy of the PIN which affects the nerve supply of theforearm extensor compartment

Muscles innervated by PIN are affected: ECRB, Supinator, ECU, EDC, EDQ, EIP, APL, EPL, EPB May occur after trauma or may have insidious onset


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Symptoms insidious onset, often goesundiagnosed

defining symptoms pain in the forearm and wrist

location depends on site of PIN compression e.g., pain just distal to the lateral epicondyle of the elbow may

be caused by compression at the arcade of Frohse

weakness with finger, wrist and thumbmovements Present with dropped fingers and thumb


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Physical exam inspection

chronic compression may cause forearm extensorcompartment muscle atrophy

motion weakness

finger metacarpal extension weakness wrist extension weakness

inability to extend wrist in neutral or ulnar deviation the wrist will extend with radial deviation due to intact ECRL

(radial n.) and absent ECU (PIN).

provocative tests resisted supination

will increase pain symptoms


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Nonoperative rest, activity modification, streching,splinting, NSAIDS

indications recommended as first-line treatment for all cases

lidocaine/corticosteroid injection indications

a compressive mass, such as lipoma or ganglion, has been ruled out isolated tenderness distal to lateral epicondyle

trial of rest, activity modification, anti-inflammatories were noteffective technique

single injection 3-4 cm distal to lateral epicondyle at site ofcompression

surgical decompression indications

symptoms persist for greater than three months of nonoperativetreatment


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Radial Tunnel Syndrome

A compressive neuropathy of the posterior interosseousnerve (PIN) with pain only

no motor or sensory dysfunction Associated conditions

lateral epicondylitis RTS is difficult to distinguish from lateral epicondylitis

and coexists in 5% of patients


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Radial tunnel begins anterior to the radiocapitellar joint Approximately 5cm in length Formed laterally by the ECRL and BR Medially by the biceps tendon and brachialis Posteriorly by the radiocapitellar joint capsule The BR passes over the nerve in a lateral to anterior

direction to form the roof Ends at the arcade of Frohse


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Presentation

Symptoms deep aching pain in dorsoradial proximal forearm

from lateral elbow to wrist increases during forearm rotation and lifting activities

muscle weakness because of pain and not muscle denervation

Physical exam tenderness

over mobile wad over the supinator arch maximal tenderness is 3-5cm distal to lateral epicondyle

more distal than lateral epicondylitis provocative tests

resisted long finger extension test reproduces pain at radial tunnel

resisted supination test (with elbow and wrist in extension) reproduces pain at radial tunnel

passive pronation with wrist flexion reproduces pain at radial tunnel passive stretch of supinator muscle increases pressure inside radial tunnel


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Treatment Nonsurgical management of both PIN syndrome and RTS is recommended initially Rest, activity modification, splinting, stretching, anti-inflammatories Physiotherapy Surgical decompression after trial of

non-operative management


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Superficial Radial Nerve Compressionaka Wartenbergs Syndrome

compressive neuropathy of thesuperficial sensory radial nerve(SRN) also called "cheiralgia paresthetica" sensory manifestation only no motor deficits


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Symptoms are reproduced by forearm pronation and ulnar wrist deviation Tinel sign over the radial sensory nerve at the point where it exits the deep fascia

in the forearm Nerve conduction studies rarely useful


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Treatment Modify activities to maintain a more supinated position wherever possible Avoidance of excessive pronosupination Local corticosteroid injection at the entrapment site between tendons of BR and

ECRB are often successful. Splinting not usually recommended SRN decompression if non-operative treatment unsuccessful

compressive neuropathy of upper limb

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