Median nerve injuries

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  • Median Nerve.
    The median nerve enters the palm via the carpal tunnel, running between the flexor digitorum superficialis (FDS) and flexor carpi radialis (FCR). At the proximal border of the transverse carpal ligament (TCL), it gives off a palmer cutaneous branch (PCB) from its radial border running between the palmaris longus and FCR that provides sensation to the thenar skin. The PCB of the median nerve is at risk for injury during carpal tunnel surgery. At the distal border of the TCL, the median nerve divides into 5 or 6 branches: the recurrent motor branch to the muscles of the thenar eminence, a common digital nerve for the thumb, the proper digital nerve for the radial side of the index finger, and two common digital nerves for the adjacent areas of the index and long, and long and ring fingers respectively. The origin of the recurrent motor branch varies with respect to the TCL, with the majority being extraligamentous. It is responsible for innervating the superficial head of the FPB, the abductor pollicis brevis (APB), the opponens pollicis, and the two radial lumbricals.
  • lacertus fibrosus
    Is tightened w/ pronation of forearm as bicipital tuberosity of the radius passes posteriorly
  • FIGURE 6.13 Cross section of the wrist demonstrating the relationship of the carpal tunnel (CT) and the ulnar tunnel (UT). A, ulnar artery; C, capitate; H, hamate; M, median nerve, P, pisiform; PCL, palmar carpal ligament; S, scaphoid; t, flexor tendon; T, triquetrum; TCL, transverse carpal ligament; U, ulnar nerve. (Source: Szabo RM, Steinberg DR. Nerve entrapment syndromes in the wrist. J Am Acad Orthop Surg 1994;82:115–123
    .)
  • Median nerve injuries

    1. 1. Median Nerve injuries Prof Nabil Khalil Suez canal university
    2. 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. 3. 2) At the elbow 3) in the forearm -lacertus fibrosus -pronator teres - sublimis bridge 4) at the wrist 5) In the hand
    4. 4. paralysis of the muscles supplied by it deformity of the hand loss of sensation
    5. 5. 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
    6. 6. 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.
    7. 7. 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.
    8. 8. Clinical Features •Inability to flex IP joint of thumb •Ape thumb deformity •Oppones palsy •Sensory signs
    9. 9. Carpal Tunnel Syndrome
    10. 10. Definition It’s a Clinical Diagnose Of peripheral neuropathy, results from compression of the median nerve at the wrist
    11. 11. 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)
    12. 12. 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).
    13. 13. 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.
    14. 14. Atrophy
    15. 15. Physical Examination i. Phalen’s maneuver ii. Tinel’s sign iii. two-point discrimination
    16. 16. Phalen’s Maneuver
    17. 17. Tinel’s Sign
    18. 18. Diagnostics History Physical examination Nerve Conduction Study
    19. 19. Differential Diagnoses Tendonitis Tenosynovitis Diabetic neuropathy Kienbock's disease Compression of the Median nerve at the elbow
    20. 20. Treatment • CONSERVATIVE TREATMENTS General measures Wrist splints Oral medications Local injection Predicting the Outcome of Conservative Treatment • SURGERY
    21. 21. 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
    22. 22. 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
    23. 23. 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
    24. 24. Pronator Syndrome - Proximal Forearm Compression - Because Of :ligament of Struthers,  lacertus fibrosus,  pronator teres muscle
    25. 25. 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
    26. 26. 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 ?
    27. 27. QUESTIONS? Thank You !

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