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Pathophysiology of Peripheral Nerve Lesions Part 2: Upper Extremity Entrapment Syndromes David A. Lake, PT, PhD Department of Physical Therapy Armstrong.

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Presentation on theme: "Pathophysiology of Peripheral Nerve Lesions Part 2: Upper Extremity Entrapment Syndromes David A. Lake, PT, PhD Department of Physical Therapy Armstrong."— Presentation transcript:

1 Pathophysiology of Peripheral Nerve Lesions Part 2: Upper Extremity Entrapment Syndromes David A. Lake, PT, PhD Department of Physical Therapy Armstrong Atlantic State University Savannah, GA

2 Examination of Entrapment Peripheral Neuropathies History –Focus on occupational/activities that involve repetitive motion –Have patient trace rather than verbalize paresthesia or pain pattern –Distinct symptoms suggest a distal lesion –Complex symptoms suggest a proximal lesion

3 Examination of Entrapment Peripheral Neuropathies Sensory Exam –Sensory symptoms before motor –Light touch, 2 pt discrimination over distribution of nerve –Inspect for trophic changes to skin - often an effect on autonomic fibers to an area

4 Examination of Entrapment Peripheral Neuropathies Motor Exam –Check reflexes bilaterally –Inspect for atrophy - again bilateral comparison –Bilateral testing for muscle strength in muscles along the nerve course

5 Examination of Entrapment Peripheral Neuropathies Reproduction of symptoms –Positioning to narrow tunnel through which the nerve progresses –Muscle contraction against resistance is compression is caused by passing through a muscle –Percussion tests - tapping on nerve or tapping/applying pressure to area of compression

6 Examination of Entrapment Peripheral Neuropathies NCV & EMG testing –> 50% reduction in amplitude of compound action potential in nerve conduction velocity tests (NCV) sign of impairment –EMG shows abnormal spontaneous activity within 2 weeks of acute compression/trauma if deficit in motor axons - and is gold standard if motor deficit

7 Examination of Entrapment Peripheral Neuropathies NCV & EMG testing –Abnormal spontaneous activity includes: Positive sharp waves Fibrillation potentials

8 Examination of Entrapment Peripheral Neuropathies NCV & EMG testing –Abnormal EMG activity also includes: Enhanced insertional activity

9 Examination of Entrapment Peripheral Neuropathies NCV & EMG testing –Abnormal EMG activity also includes: Reduced maximal evoked activity (interference pattern) Normal Interference Pattern Reduced Interference Pattern

10 Examination of Entrapment Peripheral Neuropathies NCV & EMG testing –Abnormal EMG activity also includes: Eventually the replacement of normal biphasic MUAPs with polyphasic MUAPs Biphasic MUAPs Polyphasic MUAPs

11 Examination of Entrapment Peripheral Neuropathies NCV & EMG testing –Compare bilaterally and there are normative standards for Conduction velocity Compound action potential amplitudes Distal latencies

12 Examination of Entrapment Peripheral Neuropathies Brachial Plexus and Early Branches of the Brachial Plexus

13 Entrapment Neuropathies Thoracic Outlet Syndrome (TOS) –Name change suggested to cervico- axillary syndrome because of anatomical terminology Anatomical thoracic outlet from thorax to abdomen - covered by the diaphragm But TOS still most commonly used –Three major forms of TOS Scalene entrapment syndrome Costoclavicular entrapment Costopectoral Tunnel syndrome

14 Entrapment Neuropathies Scalene Entrapment Syndrome –The brachial plexus passes out between the anterior and middle scalene muscle Middle Scalene Anterior Scalene Brachial Plexus

15 Entrapment Neuropathies Scalene Entrapment Syndrome –Most commonly caused by: scalene muscle hypertrophy poor posture prolonged overhead work less often due to abnormal presence of a cervical rib or a scalene minimus muscle –Most commonly affects the lower plexus C8 & T1 spinal nerves

16 Entrapment Neuropathies Scalene Entrapment Syndrome –Symptoms most commonly include: Numbness in fingers, hand and anterior forearm

17 Entrapment Neuropathies Scalene Entrapment Syndrome –Symptoms most commonly include: Clumsiness & loss of fine motor control of the hand Occasionally vascular signs such as: –UE ischemic changes –Raynaud like symptoms –Ischemic finger ulcerations

18 Entrapment Neuropathies Costoclavicular Entrapment –Subclavian artery & brachial plexus pass between clavicle and first rib

19 Entrapment Neuropathies Costoclavicular Entrapment –Most commonly the result of: Poor posture Congenital fibrous bands –Can occur secondary to a clavicular fracture and callus that develops as part of fracture healing –Most commonly affects lower plexus –Vascular problems more common than in scalene entrapment syndrome

20 Entrapment Neuropathies Costoclavicular Entrapment –Symptoms include: Numbness of the fingers, hand and forearm Arm and hand pain When vascular problems occur they are similar to those seen with scalene entrapment syndrome but may also include hand edema secondary to venous compromise

21 Entrapment Neuropathies Costopectoral Tunnel syndrome –Costopectoral tunnel formed by the pectoralis minor lying over the anterior thoracic wall and the corocoid process of the scapula –Brachial plexus (blue) & brachial artery (red) run through it

22 Entrapment Neuropathies Costopectoral Tunnel syndrome –Most common cause is 1) hyper- trophic pectoralic minor or 2) prolonged overhead activities –Less commonly caused by 1) an abnormal muscle, the chondro- epitrochlearis muscle arising from the pectoralis minor or 2) scar tissue in the subpectoral space –More commonly accompanied by vascular problems than the other two forms of TOS

23 Entrapment Neuropathies Costopectoral Tunnel syndrome –Symptoms include: Pain and parethesias in the fingers and hand Made worse by arm abduction Hand ischemia and edema

24 Entrapment Neuropathies Long Thoracic Nerve entrapment –Lies deep to the brachial plexus on top of the 2nd rib and may be compressed against this second rib. Long Thoracic Nerve Potential Entrapment Site

25 Entrapment Neuropathies Long Thoracic Nerve entrapment –C5 and C6 fibers of the long thoracic nerve may pass through the middle scalene muscle and may be compressed by it

26 Entrapment Neuropathies Long Thoracic Nerve entrapment –Compression can come from: Tight bandage across the lateral chest, trauma to the shoulder Poorly adjusted crutches –Symptoms generally include: Vague anterior shoulder pain or paresthesias Distinct winging of the scapula is generally seen

27 Entrapment Neuropathies Long Thoracic Nerve entrapment Scapular winging

28 Entrapment Neuropathies Long Thoracic Nerve Damage –Damage can occur during a radical lymph node resection or mastectomy

29 Entrapment Neuropathies Quadrilateral Space Syndrome –Space formed by teres major, teres minor, shaft of the humerus & long head of the triceps through which runs the axillary nerve Axillary Nerve Post Humeral Circumflex Artery

30 Entrapment Neuropathies Quadrilateral Space Syndrome –Closure of this space results subsequent to: –Scapular or humeral fractures –Shoulder dislocations –Teres major hypertrophy

31 Entrapment Neuropathies Quadrilateral Space Syndrome –Symptoms Paresthesia - lateral shoulder and proximal arm Deltoid paresis and atrophy Shoulder abduction paresis with compensatory actions of the supraspinatus and biceps Tenderness over the quadrilateral space Abnormal scapulohumeral rhythm

32 Entrapment Neuropathies Suprascapular Nerve Syndrome –Suprascapular nerve runs under the transverse scapular ligament through the scapular notch

33 Entrapment Neuropathies Suprascapular Nerve Syndrome –50% of individuals have an inferior transverse scapular ligament as an additional connective tissue roof which can entrap nerve Inferior Transverse Scapular Ligament & Transverse Scapular Ligament Transverse Scapular Ligament Entrapment Inferior Transverse Scapular Ligament Entrapment

34 Entrapment Neuropathies Suprascapular Nerve Syndrome –In addition to possible entrapment beneath the superior and inferior transverse scapular ligaments, other possible causes include: Supraglenoid ganglionic cyst can narrow gap Scapular fracture Repetitive overhead activities Weight bar resting on shoulders during squat exercises

35 Entrapment Neuropathies Suprascapular Nerve Syndrome –Signs and Symptoms Posterior shoulder or acromioclavicular pain Nocturnal pain Positive crossed-arm adduction test Supraspinatus and infraspinatus atrophy Paresis of shoulder abduction and external rotation

36 Entrapment Neuropathies Median Nerve Entrapment Neuropathies

37 Entrapment Neuropathies Median nerve syndromes- there are several potential points of median nerve entrapment: –Supracondylar tunnel - Rare –Pronator teres –Anterior interosseous nerve –Carpal tunnel

38 Entrapment Neuropathies Median nerve syndromes- Supracondylar tunnel (RARE) –Supracondylar process - anomalous growth proximal to the medial epicondyle on the humerus. –More common would be entrapment by the medial intermuscular septum as the supracondylar process is a rare, anomalous structure occurring in only 1-3% of the population

39 Entrapment Neuropathies Median nerve syndromes- Supracondylar tunnel –If the supracondylar process exists, there is a connective tissue link between the supracondylar process and the medial epicondyle (Ligament of Struthers) forms a tunnel through which the median nerve runs –Sometimes seen secondary to humeral fracture or prolonged immobilization of the elbow

40 Entrapment Neuropathies Median nerve syndromes- Supracondylar tunnel –Supracondylar process - anomalous growth proximal to the medial epicondyle on the humerus. –Ligament of Struthers forms the Supra- condylar tunnel Supracondylar Process Ligament of Struthers Supracondylar Tunnel

41 Entrapment Neuropathies Median nerve syndromes- Supracondylar tunnel –Median nerve runs through this supra- condylar tunnel

42 Entrapment Neuropathies Median nerve syndromes- Supracondylar tunnel –Sometimes seen secondary to humeral fracture or prolonged immobilization of the elbow –Symptoms Carpal tunnel like symptoms of paresthesias and pain along the median nerve distribution & atrophy and paresis of hand intrinsic flexors Except that pain radiates up into the forearm & long wrist and finger flexors are also involved. NCV changes both proximal and distal to the carpal tunnel seen

43 Entrapment Neuropathies Median nerve syndromes- Supracondylar tunnel –Symptoms Example of pain radiates up into the forearm along median nerve distribution

44 Entrapment Neuropathies Median nerve syndromes- Pronator teres –Median nerve runs between the two heads of the pronator teres to desend to run superficially to the flexor digitorum profundus and deep to the flexor digitorum superficialis –However at times the nerve can penetrate through the pronator teres or the pronator teres can have an anomalous head that narrowly surrounds the median nerve or has extra fibrous connections between the heads

45 Entrapment Neuropathies Median nerve syndromes- Pronator teres syndrome –Median nerve runs between the two heads of the pronator teres to desend to run superficially to the flexor digitorum profundus and deep to the flexor digitorum superficialis

46 Entrapment Neuropathies Median nerve syndromes- Pronator teres syndrome –However at times: Median nerve can penetrate through the pronator teres Pronator teres can have an anomalous head that narrowly surrounds the median nerve Pronator teres has extra fibrous connections between the heads Pronator teres hypertrophy

47 Entrapment Neuropathies Median nerve syndromes- Pronator teres Syndrome symptoms include: –Carpal tunnel like symptoms of pain and paresthesias along the median nerve distribution –Atrophy and paresis of hand intrinsic flexors –Impaired thumb, index and middle finger flexion –Tinel's sign over the pronator teres –Symptoms get worse with resisted pronation or sustained forearm supination with elbow extension

48 Entrapment Neuropathies Median nerve syndromes- Anterior interosseous Nerve Syndrome –Anterior interosseous nerve is a motor nerve that innervates the flexor digitorum profundus (digits 2 & 3), flexor pollicis longus and pronator quadratus

49 Entrapment Neuropathies Median nerve syndromes- Anterior interosseous Nerve Syndrome –Anterior interosseous nerve dives through the flexor digitorum profundus

50 Entrapment Neuropathies Median nerve syndromes- Anterior interosseous Nerve Syndrome –The nerve runs along the interosseous membrane between radius and ulna Anterior - up Posterior down Medial - right Lateral - left Arrows: Yellow Yellow - Anterior Interosseus Nerve Red - Flexor Digitorum Profundus Blue - interosseus membrane

51 Entrapment Neuropathies Median nerve syndromes- Anterior interosseous Nerve Syndrome –Possible causes include: Forearm bone fracture Fibrous adhesions Dialysis shunts to that area Compartment syndrome of the flexor forearm (Volkmann Contracture or ischemic neuropathy due to pressure buildup in the tissues surrounding the nerve) A combination of forearm fracture, edema & tight casting

52 Entrapment Neuropathies Median nerve syndromes- Anterior interosseous Nerve Syndrome –Symptoms Inability to pinch between thumb and 2nd digit due to lack of distal phalangeal flexion of digits and thumb Decreased ability to handle pen and write, hold onto coffee cup - any strength or coordination involving thumb and first second and perhaps third digit (sparing of perhaps 3rd, 4th and 5th digits) Diffuse ache along proximal third of forearm but no sensory loss

53 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Entrapment of the median nerve as it passes through the carpal tunnel –Occurs most commonly in ages –Occurs more commonly in women 3.5-5:1 ratio –50% bilaterally –Genetic predisposition - small wrists

54 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Mostly associated with: Certain hand, wrist, forearm and finger postures Repetitive motions that put pressures on the wrist even with mild to moderate loads Exposure to high vibratory loads

55 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Carpal tunnel is formed posterior and laterally by carpal bones & their ligaments, and anteriorly by the transverse carpal ligament Transverse Carpal Ligament Hamate Capitate Trapezium Trapezoid

56 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Carpal tunnel is on average 2-5 cm in length & 2-3 cm in width and cm in depth WIDTH DEPTH LENGTH

57 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Carpal tunnel contains, median nerve, fat, 9 tendons & tendon sheaths of finger flexors

58 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –During flexion and extension median nerve can translate 20 mm rubbing against flexor tendons or transverse carpal ligament and any increased pressure in the carpal tunnel will increase friction –During flexion both the median nerve and flexor tendons are thicker filling the tunnel and during extension they are stretched

59 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Normal pressures in the carpal tunnel are 2.5 mm Hg at rest and up to 31 mmHg during flexion and extension. –In radiographically diagnosed carpal tunnel disease, intra-canal pressures have been shown to be 31 mm Hg at rest and up to mm Hg during flexion and extension.

60 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Pressures greater than 50 mm Hg will compress and produce complete conduction block in the median nerve –Flexion of the metacarpophalangeal joints can also increase intra-canal pressures

61 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Contributors to increased pressure & Carpal Tunnel Syndrome include: Sustained or repetitive flexion and extension of the wrist Fracture of the wrist or dislocation of the carpal bones Post-traumatic scarring Inflammatory flexor tenosynovitis Hypertrophic tenosynovitis

62 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Contributors to increased pressure & Carpal Tunnel Syndrome include: Rheumatoid arthritis Extracellular shifts of fluid during pregnancy Neurinoma, lipoma, hemangioma or ganglion cyst Calcium or gouty tophus deposition Amlyoidosis Diabetes Renal insufficiency myxedema

63 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Contributors to increased pressure & Carpal Tunnel Syndrome include: Vitamin B6 difficiency Hypothyroidism Hypoproteinemia

64 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Major clinical signs and symptoms include: Sensory abnormalities in palmar surface of digits 1-3 and half of 4 (in one study of 1059 wrist with carpal tunnel syndrome 42.5% had all fingers affected indicating concurrent ulnar nerve involvement) Sensory abnormalities range from hyperesthesias to numbness and often occur at night with patient waking up with the sensations or being woken up by the sensations

65 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Major clinical signs and symptoms include: Tinel’s sign Early on the sensory changes may be the only ones seen & are enhanced by direct compression or with Phalen's test positions Phalen’s Test Tinel’s Sign

66 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Major clinical signs and symptoms include: Phalen's test has been criticized because of low predictive value relative to electrodiagnostics (Kaul, et al, 2000) –The sensitivity of the Phalen’s Test was 50% –The specificity was 59.1% –The positive predictive value was 61.7% –The negative predictive value was 47.3%

67 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Major clinical signs and symptoms include: Loss of 2 point discrimination and vibratory sense Raynaud's syndrome occurs at higher frequencies than expected in patients with carpal tunnel disease As disease progresses, loss of fine coordinated grasp due to loss of coordinated thumb positioning Atrophy of thenar muscles

68 Entrapment Neuropathies Median nerve syndromes- Carpal Tunnel Syndrome –Major clinical signs and symptoms include: Electrical testing - reduction in SNAP & CMAP potentials, distal motor latencies and EMG of forearm versus instrinsic thumb flexors & abductors for differential diagnosis Positive signs of narrowing of the carpal tunnel seen on CT or MR of wrist

69 Entrapment Neuropathies Radial Nerve Entrapment Neuropathies

70 Entrapment Neuropathies Radial Nerve Entrapment can occur at several points: –C5-T1 - proximal radial nerve –Radial Groove –Lateral Intermuscular Septum –Radial Tunnel –Supinator –Superficial Radial Nerve

71 Entrapment Neuropathies Radial Nerve Entrapment: C5-T1 Syndrome –Once formed the radial nerve runs medial to humeral head and anterior to long head of triceps –Injured by: Glenohumeral subluxation High riding crutches Arm over chair back (Saturday night palsy) Surgery on axillary lymph nodes tumors or radical dissection of axillary lymph nodes following mastectomy

72 Entrapment Neuropathies Radial Nerve Entrapment: C5-T1 Syndrome –Signs & Symptoms include: Paresis/paralysis of elbow extension (if damage high enough such as glenohumeral subluxation) Drop wrist, paresis/paralysis of wrist and finger extension Dorsal forearm and radial side of hand paresthesias, numbness Weakness of elbow flexion in a pronated position

73 Entrapment Neuropathies Radial Nerve Entrapment: Radial Groove –Radial nerve then runs through the radial groove (sulcus) on posterior humerus –Injured by fractured humerus

74 Entrapment Neuropathies Radial Nerve Entrapment: Radial Groove –Signs & Symptoms include: Drop wrist, paresis/paralysis of wrist and finger extension dorsal forearm and radial side of hand paresthesias, numbness Weakness of elbow flexion in a pronated position

75 Entrapment Neuropathies Radial Nerve Entrapment: Lateral Intermuscular Septum –Runs between brachalis & triceps brachii –Adhesions in this area

76 Entrapment Neuropathies Radial Nerve Entrapment: Lateral Intermuscular Septum –Signs & Symptoms include: Drop wrist, paresis/paralysis of wrist and finger extension dorsal forearm and radial side of hand paresthesias, numbness Weakness of elbow flexion in a pronated position Weakness of supination

77 Entrapment Neuropathies Radial Nerve Entrapment: Radial Tunnel Syndome –Deep radial nerve runs under connective tissue of superficial supinator - called the Arcade of Frohse Radial Nerve Nerve to Supinator Arcade of Frohse Supinator Superficial Radial Nerve Pronator Teres Wrist Flexors Medial Epicondyle Brachialis

78 Entrapment Neuropathies Radial Nerve Entrapment: Radial Tunnel Syndrome –Causes of damage: Microtrauma and repetitive motion from supination or wrist/finger extension Extensor carpi radialis brevis often damaged in throwing injuries & subsequent inflammation can result in radial tunnel syndrome

79 Entrapment Neuropathies Radial Nerve Entrapment: Radial Tunnel Syndrome –Sparing of the innervation of the extensor carpi radialis longus and perhaps the brevis –Symptoms Pain with pressure for lateral epicondyle & radial tunnel area Weakness of wrist & finger extension with possible drop wrist and no superficial sensory changes

80 Entrapment Neuropathies Radial Nerve Entrapment: Supinator Syndrome –Posterior interosseous branch of radial nerve which enters the supinator

81 Entrapment Neuropathies Radial Nerve Entrapment: Supinator Syndrome –Results from: Radial head subluxations Distal humeral fractures, proximal radial fractures or Monteggia fracture (seen at right - proximal ulna fracture and radial head subluxation)

82 Entrapment Neuropathies Radial Nerve Entrapment: Supinator Syndrome –Results from: Rheumatoid arthritis particularly of radiohumeral, ulnohumeral joint and proximal radioulnar joints –Sparing of the innervation of the extensor carpi radialis longus and perhaps the brevis

83 Entrapment Neuropathies Radial Nerve Entrapment: Supinator Syndrome –Symptoms Pain with pressure distal to the lateral epicondyle Weakness of wrist & finger extension with possible drop wrist Deep posterior forearm pain Symptoms may be aggrevated by "wringing linen" motion May mimic lateral epicondylitis

84 Entrapment Neuropathies Radial Nerve Entrapment: Superficial Radial Nerve Syndrome (Cheiralgia paresthetica) –Superficial radial nerve passes: superficial to lateral fibers of pronator teres and distal attachment of brachioradialis dorsal radial forearm

85 Entrapment Neuropathies Radial Nerve Entrapment: Superficial Radial Nerve Syndrome –Superficial radial nerve crosses wrist through the dorsal fascial bands of the distal radiocarpal joint - this last point is where it may become trapped

86 Entrapment Neuropathies Radial Nerve Entrapment: Superficial Radial Nerve Syndrome –Can be caused or excerbated by Tension or fibrosis of brachioradialis muscle Tight casts, cuffs, watchstraps and handcuffs have been documented as causes Concurrent with de Quervain's tenosynovitis Chronic use of screwdrivers, writing instruments and keyboards

87 Entrapment Neuropathies Radial Nerve Entrapment: Superficial Radial Nerve Syndrome –Signs & symptoms: Tinel's sign as it exits the fascia Sensory symptoms along radial/dorsal hand Noctural pain Trophic changes on dorsal-radial hand May mimic de Quervain's tenosynovitis

88 Entrapment Neuropathies Ulnar Nerve Entrapment Neuropathies

89 Entrapment Neuropathies Ulnar Nerve Entrapment- Medial Intermuscular Septum –Like the median nerve, there is the possibility of entrapment by the medial intermuscular septum - sometimes referred to as the Arcade of Struthers –Symptoms are often indistinguishable from Ulnar Groove Syndrome so that will be discussed in more detail

90 Entrapment Neuropathies Ulnar Nerve Entrapment- Ulnar Groove Syndrome: –Deep to medial head of triceps & posterior to medial epicondyle & lateral olecranon (ulnar groove)

91 Entrapment Neuropathies Ulnar Nerve Entrapment- Ulnar Groove Syndrome: –Causes Pressure to medial elbow Ulnar fracture

92 Entrapment Neuropathies Ulnar Nerve Entrapment- Ulnar Groove Syndrome: –Causes Adhesions to flexor carpi ulnaris or medial triceps along with traction injury to nerve Hypermobile nerve can be damaged

93 Entrapment Neuropathies Ulnar Nerve Entrapment- Ulnar Groove Syndrome: –Signs and symptoms Parethesias & pain along ulnar distribution in hand (medial palm and dorsal hand of digits 4 & 5

94 Entrapment Neuropathies Ulnar Nerve Entrapment- Ulnar Groove Syndrome: –Signs and symptoms Decreased grip strength, intrinsic muscle atrophy with hollows between metacarpals

95 Entrapment Neuropathies Ulnar Nerve Entrapment- Ulnar Groove Syndrome: –Signs and symptoms Inability to abduct and adduct digits Abduct Adduct

96 Entrapment Neuropathies Ulnar Nerve Entrapment- Ulnar Groove Syndrome: –Signs and symptoms Clawhand deformities + Froment’s sign (- thumb adduction)

97 Entrapment Neuropathies Ulnar Nerve Entrapment- Ulnar Groove Syndrome: –Signs and symptoms + percussion test over ulnar groove EMG, NCV, H-wave & F-wave deficits

98 Entrapment Neuropathies Ulnar Nerve Entrapment- Guyon's Canal (Ulnar Tunnel) Syndrome –Guyon's tunnel formed by pisiform (P), hamate & hook of hamate(H), part of transverse carpal ligament (TCL) referred to as the pisohamate ligament (PHL)& tendon of flexor carpi ulnaris N - ulnar nerve A - ulnar artery VCL - volar carpal ligament

99 Entrapment Neuropathies Three views of the course of the ulnar nerve

100 Entrapment Neuropathies Ulnar Nerve Entrapment- Guyon's Canal (Ulnar Tunnel) Syndrome –Dorsal branch of ulnar nerve passes over the transverse carpal ligament but palmar branch goes under the ligament and through Guyon's canal.

101 Entrapment Neuropathies Ulnar Nerve Entrapment- Guyon's Canal (Ulnar Tunnel) Syndrome –Causes of damage Repetitive motion with some tools Use of heel of hand as hammer Fracture of hamate hook Pisiform bursitis Hypertrophy of flexor carpi ulnaris Tumor, ganglion cysts, inflammation, metabolic diseases or vascular disorder

102 Entrapment Neuropathies Ulnar Nerve Entrapment- Guyon's Canal (Ulnar Tunnel) Syndrome –Causes of damage Ganglion cysts Inflammation Metabolic diseases Peripheral vascular disorders

103 Entrapment Neuropathies Ulnar Nerve Entrapment- Guyon's Canal (Ulnar Tunnel) Syndrome –Symptoms: Similar to higher ulnar nerve damage but sparing of paralysis to flexor carpi ulnaris and portions of flexor digitorum profundus Tinel's sign over medial ventral wrist MRI shows narrowing of Guyon's canal

104 Entrapment Neuropathies Musculocutaneous Neuropathies

105 Entrapment Neuropathies Musculocutaneous Neuropathies –Isolated neuropathies of the musculocutaneous nerve are very rare and most times weakness of the biceps brachii, coracobrachialis or brachialis is due to lesions higher in the brachial plexus than to the proximal musculocutaneous nerve –When it is damaged selectively it is most commonly secondary to penetrating trauma

106 Entrapment Neuropathies Musculocutaneous Neuropathies –Possible non-traumatic causes of musculocutaneous neuropathies include: Excessive weight lifing activities Hypertrophy of the coracobrachialis Excessive traction on the nerve Surgical repair of the shoulder or shoulder arthroscopy

107 Entrapment Neuropathies Musculocutaneous Neuropathies –Symptoms include” Weakness of elbow flexion and forearm supination with atrophy of the biceps brachii and brachialis Paresthesias or pain along the lateral aspect of the forearm


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