1. NERVE IMPINGEMENTS OF THE UPPER EXTREMITY
Michael Erickson
In-Service 11/20/2012
SALT LAKE ORTHOPAEDIC CLINIC
PHYSICAL THERAPY
1160 EAST 3900 SOUTH, SUITE 4050
Salt Lake City, Utah 84124
Telephone (801) /Fax (801)

2. Objectives
To define the nerve and identify the necessary parts for impulse conduction
To define the different types of nerve injuries
To define nerve compression (neuropraxia) in the upper extremity
To identify syndromes by location, proximally to distally
To identify symptoms of each syndrome
To determine possible treatment interventions for each syndrome

3. Anatomy of the Peripheral Nerve
The endoneurium is the innermost collagen layer surrounding individual axons within the perineural layer
The perineurium encircles each fascicle and protects nerve fibers
Epineurium is divided into two layers:
External is the outermost layer
Internal fills between fascicles and provides cushion

4. Radial Nerve
It is mainly responsible for the extension and supination of the upper extremity.

5. Median Nerve
It is mainly responsible for flexion and pronation of the upper extremity.

6. Ulnar Nerve
It is mainly responsible for intrinsic wrist and finger flexion

8. Nerve Injury Classification
Neuropraxia
Minimal nerve injury characterized by a temporary, mostly reversible nerve conduction block, with good prognosis
Axonotmesis
Moderate nerve injury characterized by a disruption of the axons and myelin sheath with the epineurium left intact to guide regeneration; has a fair prognosis
Neurotmesis
Severe injury characterized by complete destruction of the nerve with poor prognosis for regeneration

9. Spinal Accessory Nerve
Injury can occur:
Very superficial course in posterior neck and directly under the trapezius muscle
Trapezuis trauma
Shoulder dislocation
Iatrogenic sources of injury include:
Radial neck disection
Carotid endarterectomy
Cervical note biopsy

10. Spinal Accessory Nerve
Symptoms include:
Generalized shoulder pain and weakness
Shoulder asymmetry
Affected side appears to sag
Unable to shrug the shoulder
Weakness of forward arm elevation
Above horizontal plane
Possible treatment options include:
Avoid carrying heavy weights on the affected side.
Use an arm sling to reduce pain
Passive forward flexion in supine and half-sitting positions
External rotation with the elbow at the side and flexed at 90°
Internal rotation

11. Long Thoracic Nerve Injury can occur:
Acutely from a blow to the shoulder or surgery to the neck
Activities that involve chronic repetitive traction of the nerve
Tennis
Swimming
Baseball

12. Long Thoracic Nerve Symptoms include:
Shoulder or neck pain
That gets worse with overhead activites
Scapular winging
Weakness with forward elevation of the arm
Possible treatment options include:
Shoulder ROM exercises
Prevent contracture
Strengthen trapezius, rhomboids, and levator scapula

13. Axillary Nerve: Axillary Nerve Dysfunction
Injury can occur from:
Direct trauma
Upward pressure
from improper crutch use for example
Fracture of the upper arm bone
as well as pressure from casts and splints
Shoulder dislocation

14. Axillary Nerve: Axillary Nerve Dysfunction
Typical symptoms:
Loss of movement or sensation of the shoulder because of nerve damage
Numbness over part of the outer shoulder
Difficulty lifting objects with the sore arm
Difficulty lifting arm above the head
The deltoid muscle of the shoulder shows visual signs of muscle atrophy
Possible treatment options include:
EMG
will be normal right after the injury;
performed several weeks after the injury or symptoms
Nerve biopsy
MRI
PT to help maintain muscle strength
Job changes,
muscle retraining

15. Suprascapular Nerve Injury can occur: Repetitive overhead loading
Can result from other shoulder pathologies
Cyst formation at the spinoglenoid notch secondary to a slap lesion

16. Suprascapular Nerve Symptoms include:
Weak external rotation
With loss of infraspinatus
Weak arm elevation
With loss of supraspinatus
Possible treatment options include:
Maintain full shoulder ROM
Avoid heavy lifting repetitive overhead activities
Mostly surgery

17. Radial Nerve at the Upper Arm
Injury can occur:
"Crutch palsy,"
Fracture of the humerus
"Saturday night palsy"
hanging the arm over the back of a chair
arm positions during sleep or coma
Pinching of the nerve during deep sleep, such as when a person is intoxicated
Long-term pressure on the nerve, usually caused by swelling or injury of nearby body structures

18. Radial Nerve at the Forearm
Symptoms include:
Abnormal sensations
"back" of the hand or forearm
"Thumb side“ of the hand
2nd and 3rd fingers
Difficulty straightening the arm at the elbow
Difficulty bending the hand back at the wrist, or even holding the hand in neutral
Pain in the upper forearm
Possible treatment options include:
Allow use the hand and arm as much as possible
Braces, splints, or other appliances to help you use the hand in severe cases
Strengthen + Stretch muscles
Same as for lateral epicondylitis

19. Median Nerve at the Elbow: Pronator Syndrome
Injury can occur:
Pronator teres can compress the median nerve
Causes symptoms that mimic carpal tunnel syndrome
Forearm discomfort and aching
From repetitive pronation with elbow extended

20. Median Nerve at the Forearm: Pronator Syndrome
Symptoms include:
Parasthesis in the thumb and second finger
Sensory loss in the thenar eminence
Negative Tinel sign and Phalen maneuver at the wrist
Possible treatment options include:
Activity modification
Monitor for loss of ROM

21. Radial Nerve at the Forearm: Radial Tunnel Syndrome
Injury can occur:
To the superficial branch
Forearm pain exacerbated by repetitive forearm pronation
Similar mechanisms of injury to patients with tennis elbow
Supination against resistance with the elbow and wrist extended
Resisted extension of middle finger

22. Radial Nerve at the Forarm: Radial Tunnel Syndrome
Symptoms include:
Point of maximal tenderness
Differentiating factor from tennis elbow: more medial
Possible treatment options include:
PT for extensor- supinator muscle groups: Stretch + Strength

23. Ulnar Nerve at the Elbow: Cubital Tunnel Syndrome
Injury can occur:
Acute contusion
Osteo-Arthritis
Chronic compression
External source
Internal source
Cubital tunnel volume decreases with elbow flexing

24. Ulnar Nerve at the Elbow: Cubital Tunnel Syndrome
Symptoms include:
Parasthesias of the fourth and fifth digits
Elbow pain radiating to the hand
Worse with prolonged or repetitive elbow flexion
Weakness may occur
Digit abduction
Thumb abduction
Thumb-index finger pinch
Possible treatment options include:
Pad external elbow against external compression
PT for stretch of ulnar sided flexors
Decrease repetitive elbow flexion
Extension splint
40 degrees of elbow extension
Worn at night

25. Median Nerve at the Wrist: Carpal Tunnel Syndrome
Injury can occur:
Compression of the median nerve as it passes through the carpal tunnel
Distal radius fracture
Most common nerve entrapment

26. Median Nerve at the Wrist: Carpal Tunnel Syndrome
Symptoms include:
Parasthesis of the thumb, index digit, and long digit
Possible forearm pain
Abnormality in a Katz hand diagram
Positive Tinel sign and Phalen maneuver
Sensory loss in median nerve distribution
Weak thumb abduction
Thenar atrophy
Possible treatment options include:
Activity modification
Splints worn at night and day
Oral steroids or AINS
Yoga
Ultrasound

27. Guyon's Carpal Tunnel Syndrome
Injury can occur:
Space between the hamate and pisiform bones
Entrapment of the ulnar nerve can occur here

28. Guyon's Carpal Tunnel Syndrome
Symptoms include:
Inability to extend second and distal phalanges of fingers
Inability to adduct or abduct fingers or oppose fingertips
Inability to oppose thumb
Loss of sensation to ulnar side of hand, ring finger, and little finger
Possible treatment options include:
Same guidelines for carpal tunnel syndrome
Modify activity
Avoid pressure to the base of the palm
Cock-up splint

29. References
Hunter, Mackin, Callahan. Rehabilitation of the Hand and Upper Extremity. 5th Edition. Volume 1 & 2
Trumble, Buddoff, Cornwall. Hand, Elbow & Shoulder. Core Knowledge with Orthopaedics.
Dutton, Mark. Orthopaedics for the Physical Therapist
Dugdale, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine; Hoch, PhD, MD, Assistant Professor of Neurology, Harvard Medical School, Department of Neurology, Massachusetts General Hospital reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc. MedlinePlus. Update Date: 9/26/2010
Walvekar, MD Assistant Professor, Department of Otolaryngology, Louisiana State University School of Medicine in New Orleans; Li, MD Resident Physician, Department of Otolaryngology- Head and Neck Surgery, Johns Hopkins Hospital and Health System Updated: Jul 10, 2012
Peripheral Nerve Entrapment and Injury in the Upper Extremity. SARA L. NEAL, MD, MA, and KARL B. FIELDS, MD, Moses Cone Health System, Greensboro, North Carolina. American Family Physician Jan 15;81(2):
Robert J. Spinner, M.D. Outcomes for Peripheral Nerve Entrapment Syndromes Clinical Neurosurgery • Volume 53, 2006 © 2006 Lippincott Williams & Wilkins

30. Any Questions?