1. Median Nerve Compression syndromes
Jeff Auyeung SpR Freeman
23 April 2007 RVI

2. Content Anatomy Median Nerve Pronator Syndrome
Anterior Interosseous Nerve Syndrome
Carpal Tunnel Syndrome
23 April 2007 RVI

3. Anatomy Formed by 2 cords anterior to 3rd part of axillary artery
Crosses Brachial artery from lateral to medial
Lies medial to brachial artery in cubital fossa
Passes between 2 heads of PT
Lies between FDS and FDP then deep to flexor retinaculum
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4. XXXX Pronator Syndrome XXXX Anterior Interosseous Syndrome
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5. Pronator Syndrome Sites of Compression Supracondylar process
Ligament of Struthers
Bicipital aponeurosis
Between two heads of pronator teres
Under origin of FDS
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6. Pronator Syndrome Symptoms: Signs:
Forearm pain
Hand numbness
No night pain
Signs:
Resisted elbow flexion with supinated forearm (bicipital aponeurosis)
Resisted forearm pronation with elbow extended (PT heads)
Isolated long finger PIPJ Flexion (FDS)
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7. Pronator Syndrome Investigation Xray Elbow EMG/NCT Treatment
Splint/NSAIDs
Release all potential sites of compression
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8. Anterior Interosseous Nerve Syndrome
Characterised by motor loss without sensory involvement
Muscles affected: FDP(radial half), FPL and Pronator Quadratus
Beware bilateral cases - ?Parsonage-Turner syndrome
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9. Anterior Interosseous Nerve Syndrome
Sites of compresion
Fibrous bands in PT
FDS origin
Enlarged bicipital bursa
Gantzer’s muscle
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10. Anterior Interosseous Nerve Syndrome
OK sign to test FPL and FDP
Beware Isolated FPL rupture (Mannerfelt-Norman Syndrome)
Pronation in max elbow flexion for PQ
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11. Anterior Interosseous Nerve Syndrome
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12. Anterior Interosseous Nerve Syndrome
Investigation
EMG/NCT
Treatment
Splint elbow at 90°/NSAIDs
Release all potential sites of compression
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13. 23 April 2007 RVI

14. Carpal Tunnel Syndrome- Epidemiology
Most common peripheral nerve compression syndrome
F>M
43 to 74/100’000 decompression in UK
Plus countless conservatively treated
23 April 2007 RVI

15. Carpal Tunnel Syndrome – Aetiology/Pathophysiology
Increase pressure in Carpal tunnel
( 8mm vs 90mm Hg)
Ischaemia
Focal demyelination
Risk factors: DM, RA, OA, Hypothyroidism wrist trauma, obesity, pregnancy
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16. Carpal Tunnel Syndrome – Work
Prescribed disease if related to use of vibrating tools
Vibrating tool = more than 2 fold increase in risk
Keyboard and computer work not risk for CTS
Palmer KT, Harris EC, Coggon D.Carpal tunnel syndrome and its relation to occupation: a systematic literature review. Occup Med (Lond) Jan;57(1): Epub 2006 Nov 2
No relationship between work and CTS
Except “work that involves very cold temperatures (possibly in conjunction with load and repetition) such as butchery “
Falkiner S, Myers S When exactly can carpal tunnel syndrome be considered work-related? ANZ J Surg Mar;72(3):204-9.
23 April 2007 RVI

17. Carpal Tunnel Syndrome Diagnosis
History and Exam (structured? – %)
Tinel’s ( 38-62%/57%), Phalen’s (77-86%/ 48%)
Neurophysiology (?worse in men)
Kamath V, Stothard J. A clinical questionnaire for the diagnosis of carpal tunnel syndrome. J Hand Surg [Br] Oct;28(5): Erratum in: J Hand Surg [Br] Feb;29(1):95..
Gunnarsson LG, Amilon A, Hellstrand P, Leissner P, Philipson L. The diagnosis of carpal tunnel syndrome. Sensitivity and specificity of some clinical and electrophysiological tests. J Hand Surg [Br] Feb;22(1):34-7.
Padua L, Padua R, Aprile, Tonali P. Italian multicentre study of carpal tunnel syndrome. Differences in the clinical and neurophysiological features between male and female patients J Hand Surg [Br] Oct;24(5):
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18. Carpal Tunnel Syndrome Management - Conservative
Oral Meds
Vit B6
Steroid injection(? Most useful in reversible causes/holding measure)
Splint - ? Positions ? Rigidity
Likely to fail:
50+years
> 10/12 symtoms
Constant paraesthesia
Atrophy of APB
+ve Phalen’s
Giele H. Evidence-based treatment of carpal tunnel syndrome. Current Orthopaedics 15,
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19. Carpal Tunnel Syndrome Management - Surgical
Open CTR
Endoscopic CTR
Limited CTR
Lengthening of Flexor Retinaculum
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20. Carpal Tunnel Syndrome Open Release
Beware motor branch
Reconstruction vs. Lengthening
24% increase in volume(AP)
96% Satisfaction
Pinch and grip strength return 6-12 weeks
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21. Carpal Tunnel Syndrome Endoscopic
Uniportal vs Two portal technique
Leave palmar skin and fat alone, not disturbed thenar and hypothenar muscles
Faster recovery
No Difference by 12 weeks
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22. Carpal Tunnel Syndrome Outcome
>80% satisfied (?meaning)
Boston Carpal Tunnel Questionnaire
Scar tenderness
Pillar pain
Weakness
Slower return to work in manual worker
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23. Thank you!
23 April 2007 RVI