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UE Nerve Entrapment

UE Nerve Entrapment Syndromes at Elbow, Wrist, Hand

QuestionAnswer
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
Created by: 1190550002