ulnar Entrapment Neuropathy and double crush syndrome


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ulnar Entrapment Neuropathy and double crush syndrome

  1. 1. Dina Hazwani binti Azlang Orthopedics Posting 4 th Year 28 th December 2009
  2. 2. Definition <ul><li>Nerve compression/entrapment is the restriction in the space around a nerve that can occur due to several reasons. </li></ul><ul><li>Functioning of the nerve is compromised. </li></ul>
  3. 3. PATHOPHYSIOLOGY <ul><li>Wherever peripheral nerves traverse fibro-osseous tunnels -> high risk for entrapment and compression </li></ul><ul><li>What condition?? </li></ul><ul><li>Soft tissue increase in bulk. </li></ul><ul><ul><li>Pregnacy,myxoedema and RA </li></ul></ul><ul><li>Local obstruction. </li></ul><ul><ul><li>Ganglion, osteophytic spur </li></ul></ul>
  4. 4. <ul><li>When compressed </li></ul><ul><ul><li>Epineural blood flow </li></ul></ul><ul><ul><li>Axonal conduction </li></ul></ul><ul><li>Results in </li></ul><ul><ul><li>Numbness </li></ul></ul><ul><ul><li>Paraesthesia </li></ul></ul><ul><ul><li>Muscle weakness </li></ul></ul>impaired symptoms
  5. 5. <ul><li>Decompression leads to improvement of the symptoms </li></ul><ul><li>But, in prolong or severe compression, decompression not resolve the symptoms </li></ul><ul><li>It leads to segmental demyelination, target muscle atrophy and nerve fibrosis </li></ul>
  7. 7. <ul><li>Ulnar nerve entrapment occurs when the ulnar nerve in the arm becomes compressed. </li></ul><ul><li>> common at the elbow than wrist. </li></ul><ul><li>Elbow- cubital tunnel </li></ul><ul><li>Wrist - Guyon's canal </li></ul>Definition
  8. 8. ANATOMY <ul><li>  It travels from under the collarbone and along the inside of the upper arm. </li></ul><ul><li>It passes through a tunnel of tissue (the cubital tunnel) behind the inside of the elbow. </li></ul><ul><li>Here you can feel the nerve through the skin. </li></ul><ul><li>It is commonly called the &quot; funny bone. &quot;  </li></ul>
  9. 9. 1. Cubital tunnel syndrome <ul><li>A.k.a cell phone elbow,referred to as ulnar neuropathy at elbow level. </li></ul><ul><li>Ulnar n.(UN) easily felt behind the medial epicondyle of humerus. </li></ul><ul><li>It can be trapped/compressed: </li></ul><ul><ul><li>Within the cubital tunnel ->by bone abN, ganglion, hypertropic synovium. </li></ul></ul><ul><ul><li>Proximal to the cubital tunnel </li></ul></ul><ul><ul><li>Distal to cubital tunnel. </li></ul></ul><ul><li>Causes: </li></ul><ul><ul><li>Stretched by a cubitus valgus deformity. </li></ul></ul><ul><ul><li>Holding the elbow flexed in long period s.a driving or talking on the phone. </li></ul></ul><ul><ul><li>Swelling of the elbow joint, cysts </li></ul></ul>
  10. 11. Clinical features <ul><li>pain in the forearm -> radiates in the distribution of the ulnar nerve </li></ul><ul><li>Numbness & tingling in the 5 th and ulnar half of 4 th fingers </li></ul><ul><li>wasting or weakness of intrinsic hand muscles </li></ul><ul><li>the reproduction of symptoms with elbow flexion, with or without wrist extension </li></ul><ul><li>weakness of the abductor digiti mini. </li></ul><ul><li>Tinel’s test: tenderness over the nerve behind the medial epicondyle. </li></ul>
  11. 12. Diagnosis <ul><li>Confirmed by conduction test. </li></ul><ul><li>However, since the symptoms are often postural n activity related-> -ve test does not excluded the dx </li></ul>
  12. 13. Treatment <ul><li>Conservative: </li></ul><ul><ul><li>Modification of the posture. </li></ul></ul><ul><ul><li>Splintage of the elbow in mid-extension </li></ul></ul><ul><li>If symptoms persist- surgical decompression . </li></ul>
  13. 14. 2 . Ulnar tunnel syndrome(Guyon canal) <ul><li>Anatomy: </li></ul><ul><li>This is the triangular canal at the base of the ulnar side of the palm. </li></ul><ul><li>Laterally - hook of the hamate and transverse carpal ligament. </li></ul><ul><li>Medially - pisiform and the attachments of the pisohamate ligament. </li></ul><ul><li>Both the ulnar nerve and artery traverse the canal to enter the hand. </li></ul>As the nerve enters the hand, it travels through another tunnel (Guyon's canal).
  14. 15. Causes <ul><li>Repeated blunt trauma </li></ul><ul><li>Fractures of the hook of the hamate can impinge on the nerve. </li></ul><ul><li>Tumors such as ganglia or lipomas, anomalous muscle bellies, or hypertrophy of the palmaris brevis. </li></ul><ul><li>Aneurysm of the ulnar artery may compress the nerve. </li></ul>
  15. 16. Clinical features <ul><li>Numbness, tingling and paresthesias </li></ul><ul><li>Pain in an ulnar distribution of the palm and finger </li></ul><ul><li>Cold intolerance in the ring and half of small fingers </li></ul><ul><li>Normal sensation in the dorsal sensory cutaneous branch of the ulnar nerve </li></ul><ul><li>A positive Tinel or Phalen sign. </li></ul>
  16. 17. Thoracic outlet syndrome <ul><li>Condition whereby symptoms are produced from compression of brachial nerves or blood vessels, or both, because of an inadequate passageway through an area (thoracic outlet) between the base of the neck and the armpit. </li></ul><ul><li>The thoracic outlet is surrounded by muscle, bone, and other tissues. </li></ul>
  17. 18. Clinical features <ul><li>neck, shoulder, and arm pain, </li></ul><ul><li>numbness, </li></ul><ul><li>impaired circulation to the extremities (causing discoloration). </li></ul><ul><li>Often symptoms are reproduced when the arm is positioned above the shoulder or extended. </li></ul><ul><li>Pains can extend to the fingers and hands, causing weakness. </li></ul><ul><li>Adson, Wright,Roos test - +ve </li></ul>
  18. 19. Treatment <ul><li>Conservative - physical-therapy exercises and avoiding certain prolonged positions of the shoulder </li></ul><ul><li>Surgical treatment indicated if pain is severe, obvious muscle wasting or vascular disturbances. </li></ul>
  19. 20. Double crush syndrome <ul><li>Double crush syndrome refers to a situation in which there is compression or local irritation of a peripheral nerve at several separate sites along its course. </li></ul><ul><li>An example of this is coexistent C6 radiculopathy (neck site) and carpal tunnel syndrome (wrist site).  </li></ul><ul><li>Other examples of the double crush syndrome might be TOS plus CTS and TOS associated with ulnar neuropathy. </li></ul><ul><li>Causes : multiple injury sites in repetitive strain injuries </li></ul>
  20. 21. Double crush theory <ul><li>The &quot;double crush&quot; theory proposes that when the double compression is cumulative and cause impairment of conduction and is sufficient to cause symptoms such as motor or sensory impairment. </li></ul>
  21. 22. Clinical Manifestation <ul><li>clinical manifestation of double crush is due to impaired nerve conduction, and </li></ul><ul><li>consists of neurological deficit such as </li></ul><ul><ul><li>muscle weakness , grip deficit, or </li></ul></ul><ul><ul><li>wasting or sensory deficit, and </li></ul></ul><ul><ul><li>not just vague aches or pains . </li></ul></ul><ul><ul><li>On examination, </li></ul></ul><ul><ul><li>Positive Tinel's sign at multiple sites (i.e., Erb's </li></ul></ul><ul><ul><li>point, cubital tunnel as well as the carpal </li></ul></ul><ul><ul><li>tunnel). </li></ul></ul>
  22. 23. Management <ul><li>spine and extraspinal manipulation, </li></ul><ul><li>myofascial release adjunctive physiotherapies </li></ul><ul><li>rehabilitative exercises </li></ul>
  23. 24. <ul><li>Thank YOU for your ATTENTION!!! </li></ul><ul><li>Good Luck in Examination… </li></ul>