This document discusses median nerve injuries, including locations where entrapment can occur such as the arm, elbow, forearm, wrist, and hand. It outlines associated motor effects such as paralysis of muscles supplied by the nerve and deformities. Sensory loss on the lateral palm and fingers is also described. Carpal tunnel syndrome and pronator syndrome are discussed as specific types of median nerve entrapment. Clinical features, physical exam maneuvers, diagnostics, differential diagnoses, and treatments including splinting, medications, injections, and surgery are summarized. Complications of surgery are also noted.

1. Median Nerve injuries
Prof Nabil Khalil
Suez canal university

2. CONSIDERING Anatomy
Entrapment of Median nerve
Can Occur at :
1)Course in the arm
supracondylar process
* may form accessory origin for
PT MU , thru ligament of
Struthers

3. 2) At the elbow
3) in the forearm
-lacertus fibrosus
-pronator teres
- sublimis bridge
4) at the wrist
5) In the hand

6. paralysis of the muscles supplied by it
deformity of the hand
loss of sensation

7. Above The Elbow
Motor Affection
(1) Paralysis of all muscles supplied .
(2) loss of pronation of the forearm .
(3) weak flexion of the wrist .
(4) loss of the flexion & opposition of the

8. Deformity:
Ape Hand Deformity
(1) hyper-extended thumb .
(2) adduction .
(3) flat thenar eminence .
Sensory Loss
- lat. 2/3 of the palm of the hand .
- lat. 3 ½ fingers anteriorly & their distal halves
posteriorly.

9. Below The Elbow
Motor Affection :
-Paralysis of the 5 hand muscles supplied by the nerve.
-The forearm muscles escape the injury as they are supplied
at elbow.
Deformity : Ape Hand Deformity
Sensory Loss :
- lat. 2/3 of the palm of the hand .
-lat. 3 ½ fingers anteriorly & their distal halves
posteriorly.

10. Clinical Features
•Inability to flex IP joint of thumb
•Ape thumb deformity
•Oppones palsy
•Sensory signs

12. Carpal Tunnel Syndrome

13. Definition
It’s a Clinical Diagnose Of peripheral
neuropathy, results from compression of
the median nerve at the wrist

16. epidemiology
an estimated 3 percent of adult Americans
•Affectstimes more common in women than in men
•Threeprevalence rates have been reported in persons
High
•who perform certain repetitive wrist motions (frequent
computer users)

18. Clinical Features
Pain
Numbness
Tingling
Symptoms are usually worse at night and can awaken
patients from sleep.
difficulty in holding on to a glass or cup securely
To relieve the symptoms, patients often “flick” their wrist
as if shaking down a thermometer (Flick Sign).

21. Clinical Features
Cont.
Pain and paresthesias may radiate to the forearm, elbow, and
shoulder.
Decreased grip strength may result in loss of dexterity, and
thenar muscle atrophy may develop if the syndrome is severe.

22. Atrophy

23. Physical Examination
i. Phalen’s maneuver
ii. Tinel’s sign
iii. two-point discrimination

24. Phalen’s Maneuver

25. Tinel’s Sign

26. Diagnostics
History
Physical examination
Nerve Conduction Study

27. Differential Diagnoses
Tendonitis
Tenosynovitis
Diabetic neuropathy
Kienbock's disease
Compression of the Median nerve at the elbow

28. Treatment
• CONSERVATIVE TREATMENTS
General measures
Wrist splints
Oral medications
Local injection
Predicting the Outcome of Conservative Treatment
• SURGERY

30. ORAL MEDICATIONS
• Diuretics
DO
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
NO
TW
• pyridoxine (vitamin B6)
OR
• Orally administered corticosteroids
K!
!!
▫ Prednisolone
▫ 20 mg per day for two weeks
▫ followed by 10 mg per day for two weeks

31. SURGERY
• Should be considered in patients with symptoms that
do not respond to conservative measures and in patients
with severe nerve entrapment as evidenced by nerve
conduction studies,thenar atrophy, or motor weakness.
• It is important to note that surgery may be effective
even if a patient has normal nerve conduction studies

33. Complications of surgery
• Injury to the palmar cutaneous or recurrent
motor branch of the median nerve
• Hypertrophic scarring
• laceration of the superficial palmar arch
• tendon adhesion
• Postoperative infection
• Hematoma
• arterial injury
• stiffness

34. Pronator Syndrome
- Proximal Forearm Compression
- Because Of :ligament of Struthers,
 lacertus fibrosus,
 pronator teres muscle

35. Same Symptoms As C.T.S But Could Be
Differentiated By :
• include the distribution of the palmar cutaneous nerve
•The Tinel sign is positive at the forearm level
•The Phalen maneuver does not provoke symptoms
•Patients may experience pain with resistance to
contraction of the pronator teres or flexor digitorum
superficialis

36. Anterior Interosseous Syndrome
Clinical Findings
inability to flex either the thumb interphalangeal joint or the
index-finger distal interphalangeal joint .
In contrast to those with pronator syndrome, these patients
do not complain of numbness or pain . WHY ?

37. QUESTIONS?
Thank You !