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Entrapment neuropathy of the upper limb

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Entrapment neuropathy of the upper limb

  1. 1. ENTRAPMENT NEUROPATHIES OF THE UPPER LIMB Jerry Antony
  2. 2. • 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 atrophy.
  3. 3. Pathophysiology COMPRESSION VENOUS OBSTRUCTION + ISCHEMIA ANOXIC SEGMENT NEURAL EDEMA & DILATATION OF SMALL VESSELS EXACERBATION OF ORIGINAL COMPRESSION CONT OF VICIOUS CYCLE PERSISTENT EDEMA + ANOXIA/ HYPOXIA FIBROSIS IMPAIRMENT OF SUPPLY DEFICIENCY OF VITAL NUTRIENTS FUNCTIONAL IMPAIRMENT PERMANENT IMPAIRMENT OF FUNCTION IF LEFT UNTREATED
  4. 4. MEDIAN NERVE • 3 important compression neuropathies from distal to proximal CARPAL TUNNEL SYNDROME ANTERIOR INTEROSSEOUS SYNDROME PRONATOR SYNDROME
  5. 5. CARPAL TUNNEL SYNDROME • Results from compression of the median nerve within the carpal tunnel. • Most common compression neuropathy in the upper limb. ANATOMY 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 radialis sheath. • Roof: proximally flexor retinaculum, transverse carpal ligament over the wrist and aponeurosis between thenar & hypothenar muscles distally.
  6. 6. CONTENTS: • Tendons of flexor digitorum superficialis & profundus in a common sheath • Tendon of flexor pollicus longus in an independent sheath • Median nerve
  7. 7. ETIOLOGY: • DECREASE IN SIZE OF CARPAL TUNNEL Bony abnormalities of the carpal bones Acromegaly • INCREASE IN CONTENTS OF CANAL Forearm & wrist fractures (colle’s, scaphoid) Dislocations & subluxations (scaphoid rotary subluxation, lunate volar dislocation) Post traumatic arthritis (osteophytes) Aberrant muscles (lumbricals, palmaris longus, palmaris profundus) Local tumours (neuroma, lipoma, ganglion, cysts, multiple myeloma) Persistent medial artery Hyrertrophic synovium Hematoma (hemophilia, anti coagulation therapy, trauma)
  8. 8. • NEUROPATHIC CONDITIONS DM Alcoholism Double crush syndrome Exposure to industrial solvents • INFLAMMATORY CONDITIONS Rheumatoid arthritis Gout Non specific tenosynovitis Infections • EXTERNAL FORCES Vibration Direct pressure
  9. 9. • ALTERATIONS OF FLUID BALANCE Pregnancy Menopause Eclampsia Thyroid disorders (esp. hypothyroidism) Renal failure Long term hemodialysis Raynaud’s disease Obesity
  10. 10. CLINICAL FEATURES: • 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.
  11. 11. • 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. SENSORY TESTS • 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.
  12. 12. INVESTIGATIONS: • Electro diagnostic studies: Most reliable confirmatory test. Conduction time & latency for both sensory & motor conduction is determined. • 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. TREATMENT: • NON OPERATIVE • OPERATIVE
  13. 13. NON OPERATIVE: Activity modification NSAID’S Splinting Treating the underlying disease Local steroid injections OPERATIVE:  OPEN CARPAL TUNNEL RELEASE  ENDOSCOPIC CARPAL TUNNEL RELEASE INDICATIONS: Failure of non operative treatment Weakness/atrophy of abductor pollicis brevis Objective sensory changes Electrophysiological evidence of thenar muscle denervation
  14. 14. 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. COMPLICATIONS: • Incomplete division of transverse carpal ligament. • 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.
  15. 15. ENDOSCOPIC CARPAL TUNNEL RELEASE Emerging technology for open decompression of the carpal tunnel. CONTRAINDICATIONS: Co existent ulnar tunnel release. Limited wrist & finger extension. Tenosynovitis Previous surgery
  16. 16. 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 teres. • LESS COMMMON CAUSES Anomalous muscles Enlarged / thrombosed vessels Tumours Enlarged bursae
  17. 17. CLINICAL FEATURES: • 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. TREATMENT • INITIALLY: CONSERVATIVE • SURGICAL: INDICATIONS No resolution of symptoms Severe symptoms • SURGICAL EXPLORATION: Identification & division of the offending structure.
  18. 18. PRONATOR SYNDROME Anatomical sites of compression: Below lacertus fibrosus Between the 2 heads of pronator teres
  19. 19. CLINICAL FEATURES • 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.
  20. 20. TREATMENT • CONSERVATIVE: NSAID’S Splinting with the elbow at 90 degrees, slight forearm pronation & wrist flexion. • SURGICAL: Exploration of distal 5 to 8 cm of the course of the median nerve in the arm combined with its course in the upper forearm. Possible sites checked Appropriate release is done.
  21. 21. ULNAR NERVE • Ulnar nerve gets entrapped at 2 common sites: At the elbow (cubital tunnel syndrome) Guyon’s canal (ulnar tunnel syndrome)
  22. 22. CUBITAL TUNNEL SYNDROME • Second commonest nerve entrapment of the upper limb • ANATOMY: CUBITAL TUNNEL Starts at the groove between the olecranon & the medial epicondyle. Tunnel is formed by a fibrous arch connecting the 2 heads of the flexor carpi ulnaris & lies just distal to the medial epicondyle.
  23. 23. 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.
  24. 24. CLINICAL FEATURES • Numbness involving the little finger & the ulnar half of the ring finger. • 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
  25. 25. TREATMENT • NON OPERATIVE: Early stages Activity modification Immobilization of the elbow in 30 degrees of extension, followed by periods of mobilization with elbow padding. • SURGICAL: Decompression of the nerve by dividing of the basic offending structure. Anterior transposition of the ulnar nerve Medial epicondylectomy
  26. 26. 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 elbow.
  27. 27. ANATOMY:GUYON’S CANAL • ROOF: composed of palmar carpal ligament blending into the FCU tendon attaching to the pisiform & the pisiohamate ligaments. • Medial wall : pisiform & pisiohamate ligament. • Lateral wall: hook of hamate & some fibres of the transverse carpal ligament. • Ulnar nerve enters guyon’s canal accompanied by ulnar A & Ulnar V. • Guyon’s canal lies in the space between flexor retinaculum & volar carpal ligaments.
  28. 28. • 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.
  29. 29. Clinical presentations: • 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 OTHER CAUSES: • Malunited fracture of fourth/fifth metacarpal. • Anomalous muscles • Occupational trauma
  30. 30. INVESTIGATIONS • X RAY : Oblique/carpal tunnel views Delineate bony anatomy to diagnose hook of hamate fractures. • MRI: Ganglia, space occupying lesions TREATMENT • 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.
  31. 31. RADIAL NERVE • POSTERIOR INTEROSSEOUS NERVE SYNDROME • RADIAL TUNNEL SYNDROME • WARTENBERG’S SYNDROME
  32. 32. PIN SYNDROME ANATOMY 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.
  33. 33. Clinical features: • Initially, presents with a dull ache in the proximal forearm. • Later, there is difficulty in extending the fingers & the thumb. Etiology:  Ganglion cyst  Proliferative synovitis (rheumatoid arthritis) • Electro diagnostic testing may localize the site of compression. • Initially : observation & non operative treatment. • Operative methods: exploration & appropriate division of compressing structures.
  34. 34. 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 Roof: brachioradialis floor :deep head of the supinator muscle
  35. 35. • 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 epicondyle release.
  36. 36. WARTENBERG’S SYNDROME • 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.
  37. 37. ETIOLOGY • Mass effect • Direct trauma Clinical Features: • Numbness and / pain in the dorsal & radial aspects of the hand. • Positive Tinel's sign • Symptoms can be further elicited by forceful pronation of the forearm. • TREATMENT • Conservative: activity modification, NSAID’S, Steroid injections, splinting & occupational therapy. • Failure of conservative therapy: surgical exploration & decompression.
  38. 38. Thank You

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