THE UPPER LIMB
• Entrapment neuropathy is caused by the direct pressure
on a single nerve.
• Symptoms & signs depend on which nerve is affected.
• Earliest symptoms to occur: tingling & neuropathic pain.
• Followed by reduced sensation or complete numbness
• Muscle weakness is noticed later, followed by muscle
• 3 important compression neuropathies from distal to
CARPAL TUNNEL SYNDROME
ANTERIOR INTEROSSEOUS SYNDROME
CARPAL TUNNEL SYNDROME
• Results from compression of the median nerve within the
• Most common compression neuropathy in the upper limb.
Cylindrical cavity connecting the volar forearm with the palm.
• Floor: transverse arch of carpal bones
• Medially: hook of hamate, triquetrum & pisiform
• Laterally: scaphoid, trapezium & fibro osseous flexor carpi
• Roof: proximally flexor retinaculum, transverse carpal ligament
over the wrist and aponeurosis between thenar & hypothenar
• Tendons of flexor digitorum superficialis & profundus in a
• Tendon of flexor pollicus longus in an independent sheath
• Median nerve
• DECREASE IN SIZE OF CARPAL TUNNEL
Bony abnormalities of the carpal bones
• INCREASE IN CONTENTS OF CANAL
Forearm & wrist fractures (colle’s, scaphoid)
Dislocations & subluxations (scaphoid rotary subluxation, lunate
Post traumatic arthritis (osteophytes)
Aberrant muscles (lumbricals, palmaris longus, palmaris profundus)
Local tumours (neuroma, lipoma, ganglion, cysts, multiple
Persistent medial artery
Hematoma (hemophilia, anti coagulation therapy, trauma)
• SIGNS : Tinel's sign, thenar atrophy, sensory changes in the
distribution of median nerve
• Tinel’s sign: percussing the
median nerve at the wrist.
• Phalen’s test:
Patient places elbow on table,
forearm vertical with wrist flexed.
Numbness & Tingling in median nerve
distribution occurs in 60 seconds in + ve cases.
• Reverse Phalen’s test:
Sustained extension of the wrist may also
aggravate the symptoms. Not a reliable test.
• TOURNIQUET TEST:
Inflating a BP cuff on the arm to a pressure above systolic
pressure will initiate symptoms (paraesthesia & numbness).
• DURKAN’S TEST:
Application of direct pressure on the carpal tunnel with either
pressure manometer or by thumb of the examiner for 30
seconds will produce the symptoms.
• Weber’s 2 point discrimination test:
Test is positive in about one-third cases.
• Semmes - Weinstein monofilaments:
Monofilaments of increasing diameters are touched to
palmar side of the digit until the patient can tell which
digit is touched.
• Electro diagnostic studies:
Most reliable confirmatory test.
Conduction time & latency for both sensory & motor conduction is
• CT & MRI:
If mass is suspected within the carpal tunnel
• LABORATORY TESTS: specific cause is suspected
Renal & thyroid function, RA factor, ESR, Anti nuclear antibody, uric
acid, blood sugars.
Radiographs: Wrist AP, Lateral, Carpal tunnel views. Useful in
detecting congenital anomalies, fractures, Calcific deposits or tumours
of carpal bones.
• NON OPERATIVE
Treating the underlying disease
Local steroid injections
OPEN CARPAL TUNNEL RELEASE
ENDOSCOPIC CARPAL TUNNEL RELEASE
Failure of non operative treatment
Weakness/atrophy of abductor pollicis brevis
Objective sensory changes
Electrophysiological evidence of thenar muscle denervation
OPEN CARPAL TUNNEL RELEASE:
• Incision & deeper dissection are performed ulnar to the
longitudinal plane between the ulnar border of the ring finger &
a point along the wrist crease noted by flexing the ring finger
against the palm.
• Transverse carpal ligament is divided proximally to distally.
• Complete demonstration of the recurrent branch of median
nerve should be performed.
• Incomplete division of transverse
• Division of palmar cutaneous branch or
motor branch of median nerve.
• Injury to superficial palmar vascular arch.
• Reflex sympathetic dystrophy.
• Palmar hematoma.
• Loss of grip strength.
ENDOSCOPIC CARPAL TUNNEL RELEASE
Emerging technology for open decompression of the carpal
Co existent ulnar tunnel release.
Limited wrist & finger extension.
ANTERIOR INTEROSSEOUS SYNDROME
• Anterior interosseous branch of the median nerve
supplies the flexor digitorum profundus to the index finger,
flexor pollicis longus & pronator quadratus.
• Provides sensation to the volar aspect of carpus.
• POTENTIAL SITES OF COMPRESSION:
Fibrous bands of the flexor digitorum superficialis
Fibrous bands of the deep or superficial heads of the pronator
• LESS COMMMON CAUSES
Enlarged / thrombosed vessels
• Weakness of flexion in the IP joint of the thumb.
• Weakness of flexion in the DIP joint of index finger.
• No sensory loss
• Pain is exacerbated by exercise & relieved by rest.
• Number of cases occur due to a viral neuropathy.
• INITIALLY: CONSERVATIVE
• SURGICAL: INDICATIONS
No resolution of symptoms
• SURGICAL EXPLORATION: Identification & division of the
Anatomical sites of compression:
Below lacertus fibrosus
Between the 2 heads of pronator teres
• Ache or discomfort in the fore arm associated with
weakness or clumsiness of the hand.
• Numbness in the distribution of the median nerve.
• Night pain is not common.
• Phalen’s test & Tinel's sign: negative
• Difficult to demonstrate electrophysiological abnormality.
Splinting with the elbow at 90 degrees, slight forearm
pronation & wrist flexion.
Exploration of distal 5 to 8 cm of the course of the
median nerve in the arm combined with its course in the
Possible sites checked
Appropriate release is done.
• Ulnar nerve gets entrapped at 2 common sites:
At the elbow (cubital tunnel syndrome)
Guyon’s canal (ulnar tunnel syndrome)
CUBITAL TUNNEL SYNDROME
• Second commonest nerve entrapment of the upper limb
• ANATOMY: CUBITAL TUNNEL
Starts at the groove between the olecranon & the medial
Tunnel is formed by a fibrous arch connecting the 2 heads of
the flexor carpi ulnaris & lies just distal to the medial
CAUSES OF ENTRAPMENT
• ARCADE OF STRUTHER’S: Formed by superficial muscle
fibres of the medial head of triceps attaching to the medial
epicondyle ridge by a thickened condensation of fascia.
• Tight fascial band over the cubital tunnel.
• Medial head of triceps
• Aponeurosis of flexor carpi ulnaris
• Recurrent subluxation of ulnar nerve, results in neuritis.
• Osteophytic spurs
• Cubitus valgus following supra condylar fracture.
• Numbness involving the little finger & the ulnar half of the
• Hand weakness & clumsiness
• Tenderness over the ulnar nerve at the elbow.
• Tinel’s sign is positive: exacerbation of paraesthesia’s with
light percussion over the ulnar nerve.
• Advanced cases : clawing of the ring & little fingers
• NON OPERATIVE: Early stages
Immobilization of the elbow in 30 degrees of extension, followed by
periods of mobilization with elbow padding.
Decompression of the nerve by dividing of the basic offending
Anterior transposition of the ulnar nerve
ULNAR TUNNEL SYNDROME
• Ulnar nerve is compressed as it passes through
GUYON’S canal in the wrist.
• Less common than entrapment of the ulnar nerve at the
• ROOF: composed of palmar carpal ligament blending into
the FCU tendon attaching to the pisiform & the pisiohamate
• Medial wall : pisiform & pisiohamate ligament.
• Lateral wall: hook of hamate & some fibres of the transverse
• Ulnar nerve enters guyon’s canal accompanied by ulnar A &
• Guyon’s canal lies in the space between flexor retinaculum &
volar carpal ligaments.
• The anatomy of distal ulnar tunnel is divided into 3 zones.
• Zone 1:proximal to the bifurcation of the ulnar nerve &
consists of both sensory & motor fibres of the nerve.
• Zone 2: represents the motor branch of the ulnar N distal
to the bifurcation.
• Zone 3: represents the sensory branches of the ulnar
nerve beyond its bifurcation.
• ZONE 1 LESIONS : Mixed sensory & motor loss.
• ZONE 2 LESIONS : Isolated motor deficit.
• ZONE 3 LESIONS : Isolated ulnar N sensory loss.
• Common Causes in zone 1 & 2: ganglions, fractures of
the hook of hamate.
• Zone 3: ulnar artery thrombosis
• Malunited fracture of fourth/fifth metacarpal.
• Anomalous muscles
• Occupational trauma
• X RAY : Oblique/carpal tunnel views
Delineate bony anatomy to diagnose hook of hamate fractures.
• MRI: Ganglia, space occupying lesions
• Operative release of the canal by reflecting the FCU,
pisiform & pisiohamate ligament ulnarly.
• Distal deep fascia of the forearm below the wrist crease
should be released.
• Resection of any space occupying lesion
• Treatment of hook of hamate fractures.
Proximal to the elbow joint, the radial nerve branches into the
superficial radial nerve & the PIN.
The PIN travels around the radial neck and through the interval
between the 2 heads of the supinator muscle.
This opening which has an overlying compressive fibrous arch is
known as arcade of frosche.
• Initially, presents with a dull ache in the proximal
• Later, there is difficulty in extending the fingers & the
Proliferative synovitis (rheumatoid arthritis)
• Electro diagnostic testing may localize the site of
• Initially : observation & non operative treatment.
• Operative methods: exploration & appropriate division of
RADIAL TUNNEL SYNDROME
• The PIN passes between the 2 heads of the supinator
muscle in the radial tunnel.
• Boundaries of radial tunnel
Medial: biceps tendon
Lateral : brachioradialis & extensor carpi
radialis longus & brevis tendons
floor :deep head of the supinator muscle
• Pain is often acute & can mimic tennis elbow.
• Electrophysiological studies shows no abnormality.
• Treatment: non-operative: Activity modification, splinting,
NSAID’S & rest.
• Surgical decompression is often combined with lateral
• Compression of the superficial branch of the radial nerve
can occur most commonly as it exits from beneath the
brachioradialis in the forearm.
• Nerve can get trapped b/w the ECRL & the
brachioradialis, especially with pronation in the forearm.
• Mass effect
• Direct trauma
• Numbness and / pain in the dorsal & radial aspects of the
• Positive Tinel's sign
• Symptoms can be further elicited by forceful pronation of
• Conservative: activity modification, NSAID’S, Steroid
injections, splinting & occupational therapy.
• Failure of conservative therapy: surgical exploration &