these are the various entrapment syndromes we come across in orthopaedics. starting with general information of all entrapments

1. ENTRAPMENT SYNDROMES
DR.GURU PRASAD (DNB ORTHO)

2. INTRODUCTION
AND
GENERAL FEATURES

3. Definition
• Focal neuropathy due to restriction or
mechanical distortion of nerve within the
fibrous or fibro-osseous tunnel

4. • The nerve is injured by
1. chronic direct compression,
-external
-internal
2. angulations
3. stretching forces
causing mechanical damage to
the nerve.

5. IN GENERAL
• All entrapments may have one of the basic structure
a)Fibro-osseous tunnel
- Carpal tunnel
- Tarsal tunnel
- Suprascapular nerve tunnel
b)Fibrotendinous archade
-supinator (archade of frohse)
-pyriformis
-peroneal nerve entrapment
-interosseous nerve entrapment
c)Abnormal bands causing compression
-Thoracic outlet syndrome
-meralgia parasthetica

7. Pathophysiology

8. COMPRESSION
Compromised
intraneural
circulation
Reduced
axoplasmic
flow
Hypoxia and
altered
microvascular
permiability
Subperineural
edema &
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

14. This would lead to…
• Abnormal level of
excitability of the
nervous system
– Pain (often deep)
– Parasthesia
– Dysesthesia
• Hyperalgesia
• Allodynia
– Spasm
• Reduced impulse
conduction of neural
tissue
– Hypoestesia/anesthesia
– weakness

15. CLINICAL SCENARIO
Either or all
• Pain
• Numbness
• Tingling
• Burning
• Weakness
• Muscle wasting(severe cases)
in respective anatomical areas

16. Evalution
• History
• Physical examinations
• Investigations

17. General conditions associated that
lead to neuropathy
• Systemic
• Guillain-Barre syndrome
• Double crush syndrome
- A proximal level of nerve compression could cause
more distal sites to be susceptible to compression.

19. Physical examination
• Motor changes
• -deformity
• -loss of movements
• -lagging
• Sensory changes
• - areas of loss of sensation
• Autonomous
• -vasomotor
• -pilomotor
• -tropic

20. • Provocative tests
• Special tests
• Tinels sign

21. INVESTIGATIONS
• Eletromyography
• Nerve conduction studies
• Imaging
• Sweat tests
• General investigations

22. Treatment
• Conservative
• surgical

23. Conservative
• CONSERVATIVE TREATMENTS
– GENERAL MEASURES
– SPLINTS
– MEDICATIONS
– LOCAL INJECTION/BLOCKS
– PHISIOTHERAPY AND PHYSIOTHERAPY DEVICES

24. SURGICAL MANAGEMENT
• Removing the offending structure
• Release/decompression/exploration
• Neuroma excision
• Nerve resection
• Nerve repair
• Nerve grafting
• Nerve or muscle transfer

25. General anatomy

30. SPECIFIC ENTRAPMENT
SYNDROMES

31. • Upper limb
a)median nerve
-carpal tunnel syndrome
- anterior interosseous syndrome
- pronator syndrome
b)ulnar nerve
-at elbow
-at guyon’s canal
c)radial nerve
- radial tunnel
-wartenberg’s syndrome
• Lower limb
a) sciatic nerve
- pyriformis syndrome
b)peroneal nerve
-tarsal tunnel syndrome
c) lateral femoral cutaneous nerve
- meralgia parasthetica

32. SUPRASCAPULAR NERVE
ENTRAPMENT

33. SUPRASCAPULAR NERVE
ENTRAPMENT
• Throwers, other overhead athletes and weight-
lifters
• Arises from superior trunk of brachial plexus
• Innervates supraspinatus and infraspinatus
• Compression most commonly suprascapular or
spinoglenoid notch

46. • Notch narrowing
• Ganglion cyst from intraarticular defect
– Often indicative of a labral (SLAP) tear
• Nerve kinking or traction from excessive infraspinatus
motion
• Superior or inferior (spinoglenoid) transverse scapular
ligament hypertrophy causing compression

48. • MRI may exclude rotator cuff tears, demonstrate atrophy and/or
reveal a ganglion or space-occupying lesion- if present, strongly
consider surgical excision
• NCS/EMG may assist with the diagnosis
• Typically begin with non-operative mgmt.
• Rx:Rest from repetitive hyperabduction
• NSAIDs and corticosteroid injections considered
• Nonresponders may benefit from a spinoglenoid notchplasty,
transverse scapular ligament release, nerve decompression or
surgical exploration

49. Suprascapular notch
With the patient prone, make an incision
parallel to and
about 3 cm superior to the scapular spine
Suprascapular
artery is above and suprascapular
nerve is beneath ligament
Elevate the trapezius subperiosteally, and
expose the
supraspinatus muscle.
■ Identify the nerve by elevating the
supraspinatus
muscle and dissecting superior and inferior to
the
muscle.
■ Identify the suprascapular notch, and release
the transverse
ligament.

50. UPPER LIMB

51. MEDIAN NERVE ENTRAPMENTS

52. CARPAL TUNNEL SYNDROME

53. CARPAL TUNNEL SYNDROME
Is a cylindrical cavity connecting the volar
forearm with the palm
boundaries
– It is bounded by bones on 3 sides and a fibrous
sheath(flexor retinaculum)on one side
• floor : formed by transverse arch of carpal bones
• Medially : hook of hamate,triquetrum,pisiform
• Laterally : scaphoid,trapizium,fibro osseous flexor carpi
radialis sheath
• Roof : transverse carpal ligament,deep forearm fascia
proximally,aponeurosis between thenar and hypothenar
muscles distally

55. MEDIAN NERVE – MOTOR INNERVATION:
 1st and the 2nd lumbricals
 Muscles of thenar eminence:
1. Opponens pollicis brevis
2. Flexor pollicis brevis
SENSORY INNERVATION:
Skin of the palmar side of the thumb, index and
middle finger.
Half the ring finger and nail bed of these fingers.

56. Signs and symptoms
• Tingling
• Numbness or discomfort in the
lateral 3 1/2 fingers
• Intermittent pain in the
distribution of the median nerve
• Symptoms gets aggravated at
night.
• To relieve the symptoms, patients
often “flick” their wrist as if
shaking down a thermometer
(flick sign).

57. MOTOR CHANGES:
 Apelike thumb deformity
 Loss of opposition of thumb
 Index and middle finger lag behind when making the fist.
SENSORY CHANGES:
Loss of sensation of lateral 3 1/2 digits including the nail bed and distal phalanges on
dorsum of hand
(An important point to remember for Carpal tunnel syndrome is that there is no sensory loss over
the thenar eminence in Carpal tunnel syndrome because the branch of median nerve that
innervates it (palmar cutaneous branch) passes superficial to Carpal tunnel and not through it).

60. VASOMOTOR CHANGES:
• Skin area with sensory loss is warmer
• Dry skin
TROPHIC CHANGES:
• Long standing cases leads to dry and scaly skin
• Nail crack easily
• Atrophy of the pulp of the fingers.

61. Physical Assessment Tests:
• Less sensitivity to pain where the median nerve runs to
the fingers
• Thumb weakness
• Inability to tell the difference between one and two
sharp points on the fingertips
• Flick Signal. The patient is asked, "What do you do
when your symptoms are worse?"
If the patient responds with a motion that resembles
shaking a thermometer, the doctor can strongly
suspect carpal tunnel.

62. PHALEN’S TEST:
 The patient rests the elbows on
a table
 The wrists dangle( flexion) with
fingers pointing down and the
backs of the hands pressed
together.
POSITIVE: If symptoms develop
within a minute, CTS is
indicated.

63. • TINEL’S SIGN TEST:
In the Tinel's sign test,
the doctor taps over
the median nerve to
produce a tingling or
mild shock sensation.

64. o DURKAN TEST:
The doctor presses over the carpal tunnel for 30 seconds to
produce tingling or shock in the median nerve.
o HAND ELEVATION TEST:
The patient raises his or her hand overhead for 2 minutes
to produce symptoms of CTS.

66. • Torniquet test:
Torniquet inflated above systolic for one
minute intensifies the symptoms
• Carpal compression test:
Pressure with both the thumbs to the
median nerve in the carpal tunnel for 30 sec will
aggravate the symptoms
• Tests for sensations :

67. Evaluation
• History
• Physical examination
• Nerve Conduction Study

68. • CONSERVATIVE TREATMENTS
– GENERAL MEASURES
– WRIST SPLINTS
– ORAL MEDICATIONS
– LOCAL INJECTION
– ULTRASOUND THERAPY
– Predicting the Outcome of Conservative
Treatment
• SURGERY

69. • Avoid repetitive wrist and hand motions that
may exacerbate symptoms or make symptom
relief difficult to achieve.
• Not use vibratory tools
• Ergonomic measures to relieve symptoms
depending on the motion that needs to be
minimized

72. splintss
Probably most effective
when it is applied within
three months of the onset
of symptoms

73. • Diuretics
• Nonsteroidal anti-inflammatory drugs
(NSAIDs)
• pyridoxine (vitamin B6)
• Orally administered corticosteroids
– Prednisolone
– 20 mg per day for two weeks
– followed by 10 mg per day for two weeks

76. • Splinting is generally recommended after local
corticosteroid injection.
• If the first injection is successful, a repeat
injection can be considered after a few
months
• Surgery should be considered if a patient
needs more than two injections

77. • ULTRASOUND THERAPY

78. Surgical management
• 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

79. • Open release
• Endoscopic release

80. • Transverse incision proximal to the anterior
wrist crease between flexor carpi ulnaris and
flexor carpi radialis tendons. Distal
longitudinal incision made between proximal
palmar crease and 1 cm distal to hamate hook
in line with radial border of ring finger.

85. ANTERIOR INTEROSSEOUS SYNDROME
&
PRONATOR SYNDROME
• Site of compression essentially same for both
Pronator syndrome(PS) and Ant. Int. nerve

88. Pronator syndrome :
Proximal
sensory involvement
Vague volar forearm pain,Median nerve
parasthesias,minimum motor findings
Anterior interosseous syndrome :
Pure motor palsy of any or all three
1.FPL,2.FDP of index and middle fingers,3.PQ.

89. differential diagnosis of sites of
compression
• PROVOCATIVE TESTS
• Flexion of elbow against resistance between 120-135
degrees
– struthers ligament
• Flexion of elbow with forearm pronation
-- lacertus fibrosus
• Pronation against resistance combined with wrist
flexion
- 2 heads of pronator teres
• Resisted flexion of FDS of middle finger
- musculotendinous arch of FDS

90. OK sign

91. TREATMENT
• INITIALLY: CONSERVATIVE
• SURGICAL: INDICATIONS
No resolution of symptoms
Severe symptoms
• SURGICAL EXPLORATION: Identification &
division of the offending structure.

92. ULNAR NERVE ENTRAPMENT

93. • Ulnar nerve gets entrapped at 2 common sites:
At the elbow (cubital tunnel syndrome)
Guyon’s canal (ulnar tunnel syndrome)

94. 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.

96. 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.

97. 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

98. 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

100. GUYON’S CANAL
• 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.

101. 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

103. • 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

105. 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

106. 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.

108. RADIAL NERVE ENTRAPMENTS
• POSTERIOR INTEROSSEOUS NERVE SYNDROME
• RADIAL TUNNEL SYNDROME
• WARTENBERG’S SYNDROME

109. POSTERIOR INTEROSSEOUS NERVE
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.

110. 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.

111. 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

113. • 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.

116. 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.

131. LOWER LIMB

132. SCIATIC NERVE

138. LATERAL FEMORAL CUTANEOUS
NERVE

149. PERONEAL NEUROPATHY

150. PERONEAL NEUROPATHY
AT FIBULAR HEAD
• Usually involves both
deep and superficial
peroneal nerves
• Therefore weakness in
ankle df and eversion
• Sensory loss over
dorsum of the foot and
lat calf
• May be pain and Tinel’s
over fib neck
• Ankle inversion spared
as innervated by Tib
nerve.

151. Causes
• Habitual leg crossing
• Repetitive stretch from squatting
• Thin pt’s
• Ganglions etc
• Associated to ankle inversion injury including
# fib
– Traction to nerve
– Prolonged immobilisation (especially sedated pt’s)

152. • Differential diagnosis
• Sciatic neuropathy
• L5 radiculopathy
• Investigations
• EMG and NCS
• MRI’s in slowly progressing to check for
masses

153. Treatment
• Local injection
• AFO
• Stretches to prevent
contractures
• Gait rehab
• Proprioceptive work
• Eliminate offending
activities ie leg crossing
• Surgery rarely needed
except where extensive
nerve damage or mass
present

154. TARSAL TUNNEL SYNDROME

155. Tarsal tunnel syndrome
• Compression of the tibial
nerve branches under the
flexor retinaculum
• Pain medial ankle, burning,
numbness, tingling under foot
• More common women than
men
• Worst with weight bearing
• Possible wasting of intrinsics in
foot
• Tinel’s positive in tarsal tunnel
• Reduced light touch on soles
of foot

156. Presentation
• Always pain abductor
hallucis
• Pain after rest
particularly morning
• Pain may radiate
distally with palp of
nerve (should not in
plantar fascitis)
• Pain may easy with
walking
• Reduce d sensation
over medial sole

157. Differential diagnosis
• Plantar Fascitis
– DF with eversion then SLR
– Tinel’s not +ve in pf
– EMG/NCS
– High resolution US
• Fat pad atrophy
– More pain over fat pad
– Visible loss of fat pad

158. • Good evidence very limited
• Rest
• NSAID’s
• Steroid Injections
• Heel pads
• Orthoses
• Stretching exercises for PF and calf
• Surgical intervention

159. MORTONS NEUROMA

160. MORTON’S NEUROMA
(INTERDIGITAL NEUROPATHY)
• Compression of the Plantar
digital nerves in the space
between the metatarsal
heads
• Usually 3rd space followed by
2nd and rarely 1st or 4th space
• Can give pain which is
debilitating as mobility
severely limited
• Pain often relieved by
removing tight footwear
• May be accompanied by
numbness of toes adjacent to
pain

161. Differential diagnosis
• TTS
– Can be very difficult to differentiate
• Plantar fascitis
• TMT OA
– Both of these will have no neurological S&S
– Also compression of the MT heads should not be
exquisitely painful

162. Treatment
• No good evidence
• Conservative treatment helps 50%
– Insoles
– Stop offending activities
– Steroid inj
– Alcohol inj x4
– Physio (not specified)
• Surgery neurectomy/neurolysis (variable
outcomes)

163. THANK YOU