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UE Nerve Entrapment
UE Nerve Entrapment Syndromes at Elbow, Wrist, Hand
| Question | Answer |
|---|---|
| Seddon's Classification- Neuropraxia | Mildest; Loss of conduction along course of nerve due to loss of axon excitability/segmental demyelination; Prognosis good; Improvement may be swift; Most common in athletic injuries |
| Seddon's Classification- Axonotmesis | Injury & distal degeneration; Connective tissue supporting structure & nerve intact; More chronic injury; Prognosis good but depends on amount of axonal regeneration req'd from injury site to end organ |
| Seddon's Classification- Neurotmesis | More severe injury; Complete disruption in nerve structure; Recovery slower, less complete; Recovery depends on anatomic re-opposition of separated nerve ends |
| Sunderland's Classification: I- neuropraxia | Progressive obstruction of venous return; Hypoxic nerve spontaneous d/c due to hyperstimulation; Pain/paresthesia from imbalance of fiber activity/dissociation; Nocturnal paresthesia often present; Night splint advocated in this stage |
| Sunderland's Classification: 2- axonotmesis | Capillary circulation slows so much that anoxia damages endoneurium; Edema occurs; Promotion of proliferation of fibroblasts & formatio of constrictive endoneurial connective tissue; Segmental demyelination; Damage to sensory & motor fibers |
| Sunderland's Classification: 3 | Wallerian degeneration; Compressed nerve undergoes fibrosis; Reduction of number of axons available for regeneration |
| Sunderland's Classification: 4 & 5 | 4: Neuroma; 5: Neurotmesis |
| Peripheral Nerve Anatomy | Connective tissue; Epineurium surrounds nerve (protection/elasticity); Perineurium surrounds fascicles (tensile strength; elasticity; diffusion barrier; protection from compression) |
| Peripheral Nerve Anatomy | Endoneurium- intrafascicular connective tissue (collagen, elastic fibers, fat, protection from compression); Vascular supply (vas nervorum: intrinsic & extrinsic circulation) |
| Traction Injury of Peripheral Nerve | stretch applied to nerve- elastic & deforming capacity of nerve & surround tissues |
| Entrapment Injury of Peripheral Nerve | group of disorders produced by anatomical arrangements compressing or constricting a peripheral nerve & interfering with conduction |
| Entrapment Sites of Peripheral Nerves | Narrow channels formed by other tissues; Angulated by adjacent structures; Crossing bony structures; Abnormal structures; Accompanying structures; Direct trauma; Compressive neuropathy; Mechanical & intrinsic factors |
| Mechanical & Intrinsic factors of Entrapment Injury | Intraneural edema (no lymphatics in endoneurial space; increase in intrafascicular pressure; decreased endoneurial blood flow); Axonal transport mechanisms; Degeneration of myelin; Axonal damage |
| Pathophysiology of entrapment injuries | Chronic nerve compression: Schwann cell proliferation; Schwann cells produce & release vascular endothelial growth factor |
| Clinical presentation of entrapment injuries | Types of nerves (sensory, motor, mixed); Location of compression; Etiology; Duration of entrapment; S/sx: pain, weakness, altered sensation: numbness, paresthesias, often more evident at night; variable fxn recovery |
| Radial Nerve | Spirals around humeral midshaft; injury usually associated with humeral fx's b/c of contusion/mild stretch; Mixed nerve; Posterior cord: C5-8 & T1 |
| Sensory distribution of radial n. | Dorsal sensation: cutaneous to skin overlying extensor surface of arm & dorsum of hand; Deep & superficial branches |
| Radial Nerve | Pierces lateral intermuscular septum & runs from posterior to anterior compartment of humerus; At radiocapitellar joint divides into 2 major branches (PIN & superficial radial); Enters radial tunnel; PIN passes b/t 2 heads of supinator |
| Radial nerve | Proximal edge of supinator forms "Arcade of Frohse"; Superficial radial n passes superficially to supinator & is covered anteriorly by brachioradialis |
| Entrapment sites of Radial Nerve | Spiral groove of humerus; Lateral head of triceps at lateral intermuscular septum; Strong contraction of triceps |
| Entrapment sites of Radial Nerve | Musculoaponeurotic furrow- lateral epicondyle to distal edge of supinator; lies b/t brachioradialis & ECRL laterally & brachialis & biceps medially |
| Entrapment sites of Radial nerve | Deep branch of Radial n. (fibrous band at level of radial head, radial recurrent a., tendinous edge of ECRB, arcade of Frohse; within supinator); Superficial branch of radial n- antebrachial fossa |
| Other Causes of Radial Nerve compression | Proliferation of rheumatoid synovium form radiocapitellar joint; Radial head fx's/dislocations; Vascular aberrations; Anomalies; Tumors |
| Symptoms of proximal radial nerve palsy | Significant wrist weakness, possible elbow extension weakness; Loss of sensation in 1st dorsal webspace; diminished sensory fxn in dorsoradial aspect of hand & dorsal aspect of radial 3.5 digits |
| MOI proximal radial nerve palsy | Humeral fx; Saturday night palsy; Repetitive triceps activity |
| Presentation of proximal radial n. palsy | Wrist extensor atrophy; Weak wrist/finger extension/supination; TTP at lateral intermuscular septum of humerus |
| Intervention for proximal radial n. palsy | Activity modification- avoid compressive postures; decrease triceps loads; Soft tissue mob- lateral intermuscular septum; Nerve mob; Surgical release |
| Symptoms of radial tunnel syndrome | Lateral elbow pain; Tennis elbow; RO TE via Maudsley's Test (Lat. epicon. method 3) |
| MOI radial tunnel syndrome | Repetitive elbow extension & forearm pronation/flexion |
| Presentation of radial tunnel syndrome | Intact neurovascular; TTP brachioradialis/ECRB; Loacalized pain lateral to extensor mass just below elbow (5 cm distal to lat epicondyle); Aching characteristic |
| Provocation- radial tunnel syndrome | Resisted wrist extension; 3rd digit extension (tightening of ECRB; resisted supination with elbow ext reproduces pain); Passive elbow ext with wrist flexion; Radial n. tension test |
| Intervention for radial tunnel syndrome | Activity modification (limit elbow extension; rest; splinting); Soft tissue mob- ECRB, supinator; Nerve mob; Modalities (US, ionto); Surgical release |
| Symptoms of Deep radial/PIN pathology | Motor weakness; "Tennis elbow" |
| MOI Deep radial/PIN pathology | Repetitive elbow extension & resisted forearm rotation; Radial head dislocation |
| Neurovascular- Deep radial n./PIN | Motor- weak wrist/finger extensors; ECRB & ECRL spared b/c nerve can innervate them prior to entrance into radial tunnel; Sensory intact |
| Palpation & Provocation- Deep radial n/PIN | TTP 3-4 cm distal to lat dpicondyle where RN crosses radial head & penetrates supinator; Passive elbow extension with wrist flexion; Radial n. tension test; EMG/NCV |
| Intervention for Deep radial n/PIN | Activity modification (limit elbow extension; wrist cockup splint); Soft tissue mob- supinator; Nerve mob; Surgical release |
| Symptoms Superficial branch radial n. | Distal radial forearm pain/burning; Paresthesia dorsal radial hand, thumb; Exacerbated with radial deviation |
| MOI superficial branch radial n. | Compression (handcuffs)- fascia b/t brachioradialis & ECRL tendon; Repetitive wrist ulnar deviation & pronation |
| Neurovascular, Palpation, Provocation superficial branch radial n. | Sensory diminished dorsal radial hand; TTP distal 1/3 forearm b/t ECRB & brachioradialis; False-positive FInkelstein's; Tinel's |
| Intervention for superficial branch radial n. | Activity modification- limit ulnar deviation; thumb spica; Soft tissue mob- distal fascia; Nerve mob; Modalities- ionto; Surgical release |
| Effect of Radial N. Injury | Loss of triceps DTR; Weak elbow flexion; Loss of supination when elbow extended; Loss of wrist extension; Weak ulnar/radial dev; Loss of MCP extension; Loss of thumb extension/abduction |
| Musculocutaneous Nerve | Mixed; Lateral cord; C5-6; Motor to: coracobrachialis; brachialis; biceps; Cutaneous to: skin overlying lateral (radial) antebrachium |
| Causes of musclocutaneous nerve entrapment | Anterior shoulder dislocation; Closed clavicle fx's; Surgery for recurrent shoulder dislocations; Rowing; Throwing fb; Weightlifting |
| Proximal musculocutaneous nerve entrapment | S/sx: Elbow flexion wkness & lateral forearm paresthesia; MOI: coracobrachialis hypertrophy; Neurovascular- Motor: elbow flexion wkness; Sensory: diminished lateral forearm; TTP coracobrachialis; Provocation: resisted shoulder flexion |
| Distal musculocutaneous nerve entrapment symptoms & MOI | Lateral forearm painful hyperesthesia & atnerior elbow pain; Repetitive pronation; nerve entrapped as it passes through coracobrachialis |
| Distal musculocutaneous nerve entrapment neurovascular, palpation, provocation | Motor intact, sensory diminished lateral forearm; TTP anterolateral elbow crease; Tinel's anterolateral elbow crease, passive pronation with elbow flexion; EMG/NCV |
| Intervention for musculocutaneous nerve entrapment | Limit shoulder & elbow flexion; Soft tissue mob: surrounding tissues; Nerve mob; Surgical decompression |
| Effect of Musculocutaneous nerve entrapment | Severe elbow flexion weakness; Supination weakness; Loss of biceps DTR; Loss of sensation, cutaneous distribution |
| Ulnar Nerve | Mixed; Medial cord; C7-8, T1; Motor: 1.5 forearm mm & intrinsic hand mm; Cutaneous: skin of medial hand; From anterior to posterior compartment at Arcade of Struthers; Posterior to med epicondyle & enters cubital tunnel; Roof of tunnel: retinaculum |
| Ulnar Nerve | Medial border: UCL; Lateral border: medial edge of trochlea; After exiting cubital tunnel, nerve continues into forearm b/t humeral & ulnar heads of FCU; Volume of tunnel reduced with elbow flexion |
| Ulnar Nerve | UCL relaxes with elbow flexion, reducing volume; Positional changes through arc of elbow flexion; Elongates, moves medially by medial head of triceps during flexion; Hypermobility: congenital/developmental laxity; Friction: subluxation to dislocation |
| Ulnar N. entrapment sites | Arcade of Struthers; Condylar groove; Cubital tunnel; Ulnar tunnel (Guyon's canal); Tendinous arch of adductor pollicis |
| Symptoms of Ulnar n. entrapment at elbow | Pain at night or with activity; Medial elbow forearm pain; Exacerbated with elbow flexion/pressure; Decreased hand fxn; Clumsiness, heaviness; Decreased ulnar distribution of sensation; Weak FCU & interossei, adductor |
| Ulnar N. entrapment | MOI- repeated elbow flexion; Neurovascular: Motor- intrinsic wkness, FCU, FDP; Sensory: diminished ulnar aspect of hand, pareshtesias/dysesthesias/anesthesia |
| Ulnar N. entrapment | Late signs: atrophy/weakness of ulnar intrinsic mm of hand, clawing/contracture of ring & 5th finger; TTP along nerve, may feel thickened/doughy; Provocation: Tinel's, nerve tension, passive elbow flexion with FCU contraction; EMG/NCV |
| Intervention for ulnar n. entrapment | Activity modification: limit elbow flexion; Soft tissue mob: surrounding tissues; Nerve mob; Surgical decompression |
| Symptoms Ulnar n. entrapment at wrist | Medial elbow/forearm pain; Exacerbated with elbow flexion/pressure; Decreased hand fxn |
| MOI/Neurovascular/Palpation/Provocation ulnar n. entrapment at wrist | Macro/microtrauma to palmar aspect ulnarly; Motor- intrinsic wkness; Sensory- diminished ulnar aspect of hand (including dorsal); TTP Guyon's canal; Provocation- tinel's/nerve tension EMG/NCV |
| Intervention for ulnar n. entrapment at wrist | Activity modification- limit contact pressure; Soft tissue mob; Nerve mob; Joint mob; Surgical |
| Effect of Ulnar n. injury | Weak wrist flex/ulnar dev; Loss of DIP flexion of ring/little fingers; Unable to abd/adduct fingers, can't adduct thumb; Can't flex fingers (esp ring & little fingers at MCP); Loss of finger ext (esp ring & little at IP) |
| Median N. | Mixed; Formed by branches of lateral & medial cords; C5-7, C8-T1; Motor: anterior compartment of forearm & thenar mm; C5-7: wrist flex, pron, wrist flex & radial dev; C8-T1: thumb flex/opposition; 2 & 3 abd/flex; Cutaneous- skin of lateral hand |
| Median N. path | Formed ant. to axillary a.; Travels with brachial a. in arm b/t brachialis & median intermuscular septum; Passes through antecubital fossa deep to bicipital aponeurosis; B/t 2 heads of pronator teres; Deep to FDS; Through carpal tunnel to enter hand |
| Entrapment Sites- brachialis, ligament of struthers, bicipital aponeurosis | Brachialis; Ligament of Struthers- s/sx aggravated by elbow flexion vs. resistance 120-135 deg flexion; Bicipital aponeurosis- indention of pronator mass below med epicondyle causing constriction; s/sx increase with active "resisted" pronation |
| Entrapment Sites- Pronator Teres (Pronator Syndrome) | Hypertrophy of pronator trees; Compression b/t deep & superficial heads of ponator teres; Pain with resisted pronation >60"; |
| Pronator Syndrome Symptoms | Diffuse medial elbow/forearm pain; Exacerbated with elbow flexion/pressure; Fatigue-like pain; Decreased hand fxn |
| Pronator Syndrome | MOI: repeated forearm rotation Neurovascular: Motor- 1st IP flex & 2nd DIP flex ("O" sign); Sensory- diminished 1-3 & thenar aspect; TTP pronator teres ~4 cm distal to antebrachial crease; Provocation: Tinel's, nerve tension, resisted pronation; EMG/N |
| Intervention for Pronator Syndrome | Activity modification- limit pronation & wrist flexion; splint in neutral; Soft tissue mob; Nerve mob; Surgical decompression/transposition |
| FDS | Arch of FDS; Pain with resisted flexion of FDS of middle finger; Passive stretch may accentuate symptoms |
| Anterior interosseous nerve | Branch of median n.; Lies ulnar to median n: FPL, lateral 1/2 of FDP, pronator quadratus |
| Symptoms, MOI, neurovascular, palpation, provocation of anterior interosseous syndrome | Deep anterior forearm pain & decreased thumb fxn; Repeated pronation with elbow flexion; Motor: IP flexion/2nd DIP flexion ("O" sign), Sensory intact; TTP pronator; Tinel's/nerve tension provokes |
| Intervention for anterior interosseous syndrome | Activity modification- limit pronation/wrist flexion, splint in neutral; Soft tissue mob; Nerve mob; Ther Ex- FPL & 2nd FDP; Surgical decompression if no improvement in 8-12 wks |
| Symptoms & MOI Carpal Tunnel | Hand N/T, pain, Exacerbated at night (wrist flexed more, compresses tunnel); Extra fluid/swelling (diabetes, RA, renal failure, thyroid, pregnancy, carpal fx, repetitive use) |
| Observation, Neurovascular,Provocation: Carpal Tunnel | Thenar atrophy; Motor: thumb and; Sensory: diminished 1-3 digits; Tinel's/Phalen's/Reverse Phalen's/Nerve tension; EMG/NCV |
| Intervention for Carpal Tunnel | Activity Modification- modify hand mvmts, splint; Joint mob- flexor retinaculum stretch; Modalities- heat, US; Ther Ex; Nerve mob |
| Surgical Intervention for Carpal Tunnel | Thenar atrophy & persistent sensory loss; Failure of conservative intervention; CT release |
| Effect of Carpal Tunnel | Loss of complete pronation (brachioardialis can bring forearm to mid-pronation but not beyond); Weakness with flexion/radial dev; Loss of flexion at MCPs; Loss of thumb opposition/abd, loss of flexion at IP & MCP joints |
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