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Median nerve injuries and mangement
- 1. Median Nerve Injuries DrSD Sanyal
- 2. Anatomy • Mixed nerve(contain motor & sensory fibers). • Root value: C 5,6,7,8 & T1 • Runs in the median plane of the forearm , so its called median nerve
- 4. Anatomy • Arises inthe axilla by joining: 1) Lat Cord of the brachial plexus 2) Med Cord of the brachial plexus
- 6. Anatomy: Axilla • Afterbeing from Lateral Cord Medial Cord of brachial plexus Runs on the lateral aspect of Axillary artery
- 8. Anatomy: Arm • Continuesto run lateral to the brachial artery till the mid-arm • Crosses the artery anteriorly and passes anterior to the elbow joint into forearm
- 13. Anatomy: Forearm • Entersto the forearm b/w two heads of pronator teres . • Runs deep to the fibrous arch of FDS , in proximal 1/3rd • Mid forearm it descends b/w FDS and FDP • About 5 cm above wrist , it comes to lie on the lateral side of the FDS , becomes superficial just above wrist
- 21. Anatomy: Hand • Passesdeep to the flexor retinaculum and enters the Hand • Muscular braches supply muscles of Thenar eminence: - abductor pollicis brevis - opponens pollicis - flexor pollicis brevis
- 23. Anatomy: Hand • Dividesinto 4 to 5 palmar digital branches supplying lateral three and half digit and their nail beds • Motor braches to the first and second lumbrical muscles
- 28. Other branches • Articularbranches: supply the proximal radio- ulnar joint • Palmar cutaneous branch: supplies skin over thenar eminence
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- 31. High Median Nerveinjuries • Injury proximal to the elbow • Due to forearm fractures or elbow dislocation • Stab injuries and GSW’s • Paralysis of all the muscles supplied by the median nerve in the forearm and hand
- 32. Low Median NerveInjuries • Injury in the distal third of the forearm • Sparing of the forearm muscles • Muscles of the hand paralysed • Anaesthesia over the median nerve distribution in the hand • Thenar eminence is wasted and thumb abduction and opposition are weak • Sensation lost over the radial three and half digits and trophic changes may seen
- 33. Examination • Flexor pollicislongus : Tested by holding thumb at its base and patient asked to flex the terminal phalanx
- 34. Examination • Flexor digitorumsuperficialis & profundus (Oscher’s clasping test) - Patient is asked to clasp the hands , the index finger of affected side fails to flex
- 35. Examination • Flexor Carpiradialis : Hand deviates to the ulnar side when flexed against resistance
- 36. Examination • Muscles ofThenar eminance: - abductor pollicis brevis (Pen test) - hand laid flat on the table - pen held above the palm and the patient is asked to touch the pen with his thumb
- 37. Examination • opponens pollicis: brings the tip of the thumb towards the tips of other fingers
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- 40. Klien Nioh/ OKSign
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- 42. Principles of SurgicalManagement 1. Direct Injury: Nerve repair 2. Compression neuropathies: Decompression 3. Long standing cases: Tendon transfers a) Low Median Nerve: - Re-routing of ring/ middle finger superficial flexor around FCU to APB to aid thumb opposition b) High Median Nerve: - Suturing of profundus tendons to ring and small finger tendons for restoration of IP jt movts - ECU re-routing and attachment to dorsal radius/ Transfer of biceps insertion from medial to lat radius for weak forearm pronation
- 43. Median nerve Compression Syndromes •Carpal Tunnel • Pronator • Interosseous
- 44. Carpal Tunnel Syndrome •Compressive neuropathy as the nerve passes through the Carpal Tunnel • Causes: - Idiopathic : Most common - Inflammatory : Rheumatoid Arthritis : Wrist osteoarthritis - Post traumatic : Bone thickening - Endocrine : Myxoedema : Acromegaly - Pregnancy - Gout - Repetitive wrist movts: Typists & Computer users
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- 46. Symptoms • Hand andwrist Pain • Paraesthesia • Hypoaesthsia • Sparing of Palmar cutaneous branch supply • Patient wakes at night with burning or aching pain and shakes the hand to obtain relief and restore sensation • Aggravated by elevation of hand • Thenar atrophy and weakness of thumb opposition and abduction may develop late
- 47. Diagnosis • History • Clinicalexamination: - Thenar wasting - Phalen’s sign - Tinel’s sign - Carpal compression test • Electro Diagnostic Studies: - Very reliable for evaluation - Atypical cases may be present
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- 51. Carpal Compression test/Durkan’s test
- 52. Management • Splinting –prevents wrist flexion • Corticosteroid/anesthetic injection • Surgical decompression:Division of the transverse carpal ligament - Open - Endoscopic
- 56. Complications • Injury topalmar cutaneous/recurrent motor branch of the median nerve • Hypertrophic scarring • Hematoma/Arterial injury • Pillar pain
- 57. Pronator teres syndrome •High Compression neuropathy • It is rare compared to CTS and AIS • Misnomer Proximal forearm median nerve compression
- 58. Symptoms & signs •Symptoms are similar to those of carpal tunnel syndrome • Sensory disturbances - Thumb & Index > Middle finger • Night pain is unusual and forearm pain is more common • Hand numbness on gripping • Phalen’s test negative • Double crush phenomena • Symptoms provoked by resisted elbow flexion with forearm supinated ( tightening of bicipital aponeurosis ) • By resisted forearm pronation with the elbow extended ( pronator tension )
- 59. Management • No reliefwith steroids • Surgical decompression
- 60. Anterior Interosseous Syndrome •Damage to the Anterior Interosseous Nerve • Pain in the forearm • Weakness of the gripping movement of the thumb and index finger( unable to make ok sign ) • Causes: - Injury to elbow - Injury during open/closed reduction
- 61. Management • Corticosteroids • Surgery: -Resection/detachment of deep head of PT
- 62.