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 |