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Compression Neuropathies of the Upper Extremity

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... assess both grip and pinch strengths and reassess at least one time monthly. Patient education ... Grip strength slowly increase over a two to three month period ... – PowerPoint PPT presentation

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Title: Compression Neuropathies of the Upper Extremity


1
Compression Neuropathies of the Upper
Extremity
Carla M. Saulsbery LOTR, CHT
2
  • Risk Factors
  • Age and gender
  • Intercurrent disease
  • Genetics
  • Dupuytrens diathesis
  • Osteoporosis
  • Pathogenesis specific to nerve
  • Initially nerve compression leads to blood/nerve
    barrier changes
  • Neural connective tissue changes occur
  • Continued pressure leads to localized nerve fiber
    changes. Segmental demyelination
  • Fiber changes occur with Wallerian degeneration
  • Compression at one point decreases the threshold
    for compression at other points along the same
    nerve.
  • Grading of compression severity Grade
    1-------- 2-----------3 ( muscle atrophy)

3
  • Occupational Therapy for compression neuropathies
  • Management is based on symptom onset, chronicity,
    degree of muscle weakness and sensory
    abnormalities.
  • OT performs a baseline sensory and motor
    examination, assess both grip and pinch strengths
    and reassess at least one time monthly
  • Patient education
  • Conservative treatment based on evaluation
    findings
  • Post-operative treatment
  • Splinting as indicated based on surgical
    procedure
  • Wound and scar management
  • Splint per nerve deficit
  • Desensitization for dysesthesias
  • Motor and sensory reeducation
  • AROM
  • Strengthening

4
  • EVALUATION
  • History
  • Onset, activities that increase symptoms
  • Subjective
  • Objective
  • ROM
  • MMS
  • NT/DT paresthesias
  • Tinels and other provocative testing
  • Grip and pinch testing
  • Sensation
  • Moberg
  • ADLs

5
  • Semmes Weinstein Monofilaments
  • A sensory threshold test
  • Can be used on any part of the body
  • Used to correlate nerve damage with a patients
    ADL function
  • Maps the extent and degree of the sensory loss
  • Reliable and reproducible
  • Screening kit consists of 5 monofilaments
  • Testing begins with 2.83
  • Monofilaments 2.83 and 3.61 --- one response out
    of 3

6
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7
  • Semmes Weinstein Interpretation
  • 2.83 Green Normal Sensation
  • 3.61 Blue Diminished light touch,
    diminished texture discrimination
  • Earliest sign of nerve
    involvement.
  • 4.31 Purple Diminished protective
    sensation. Absent texture, impaired stereognosis
  • and impaired sensation.
  • Patient c/o of dropping
    things and decreased ability to perform fine
    motor
  • ADLs.
  • 4.56 Red Loss of protective sensation.
    Absent protective sensation/stereognosis
  • Patient cannot
    manipulated objects outside line of vision
  • Increased risk of injury
    secondary to slowed response to hot and sharp
  • objects.
  • Present deep pressure
    sensation
  • 6.65 (Orange) Deep pressure sensation,
    rudimentary deep cutaneous peripheral nerve
  • response.
  • Pt. can recognize a pin
    prick

8
Test is performed for two trials Eyes open norms
10-19 sec on the first trail 10-16 on second
trial Eyes closed 2 seconds per object
9
  • Compression Neuropathies
  • Median Nerve
  • Carpal Tunnel
  • Pronator Syndrome
  • Anterior Interosseous Nerve Syndrome
  • Ulnar Nerve
  • Cubital Tunnel
  • Guyons Canal
  • Radial Nerve
  • Radial Tunnel
  • Posterior Interosseous Nerve Syndrome
  • Superficial Radial Nerve

10
  • Median Nerve
  • Formed by equal contributions of the medial
    (C5-C7) and lateral (C8-T1) cords of the brachial
    plexus.
  • The nerve has an intimate relationship to the
    brachial artery as it passes down the arm to the
    elbow
  • The Martin Gruber anastomosis is of interest in
    high median nerve neuropathies.
  • This communication between median and ulnar
    nerves occurs in approx. 17 of the population
  • Chronic pain from the proximal median nerve is
    predominantly caused by trauma.
  • Non-traumatic compression is predominantly caused
    by slowly expanding lesions often vascular in
    nature.
  • There are four commonly described sites of
    compression of the median nerve in the elbow and
    proximal forearm region. (Ligament of Struthers,
    Lacertus Fibrosis, pronator teres muscle and the
    arch of the FDS).
  • Supracondylar fractures have been associated with
    a 5 to 19 incidence of median nerve injury

11
  • Carpal Tunnel
  • Compression under the transverse carpal ligament
  • Risk factors
  • Demographics female, middle aged, smoker,
    obesity
  • Genetics thickened transverse carpal ligament.
    Diabetes, thyroid disorder.
  • Medical conditions wrist fracture, dislocation
    of carpal bone, space occupying lesions,
    Rheumatoid arthritis, renal dialysis
  • Patient complaints
  • Awakening at night
  • Numbness, tingling
  • Weakness of grip or pinch
  • Dropping things, inability to perform certain
    ADLs
  • Reports of numbness when driving or reading
  • Decreased ability to distinguish between hot and
    cold

12
  • Grading nerve compression for Carpal Tunnel
  • Grade 1 Mild
  • Awakening at night. Usually intermittent
  • Tingling and numbness
  • Positive Phalens
  • Symptoms increase with activity
  • No muscle atrophy
  • Middle finger most commonly involved
  • Grade II Moderate
  • Positive provocative tests. Tinels and Phalens
  • Weakness of the thenar muscles, but not atrophy
  • Decreased sweat
  • Semmes Weinstein test will be abnormal
  • Decreased grip and pinch strength
  • Grade III Severe
  • Thenar atrophy

13
  • Ultrasound

14
  • Normal Median Nerve
    Carpal Tunnel

15
  • Conservative Treatment of Carpal Tunnel
  • Patient education
  • Splint for night wear
  • Tendon/nerve glide exercises
  • Home and or job modifications
  • Hand strengthening

16
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17
  • Post-operative care
  • Range of motion
  • Avoid wrist flexion
  • Wound care
  • Massage for scar and skin hydration
  • Lightweight ADLs
  • Desensitization for dysesthesias
  • Progress to nerve glide
  • Sensory re-education
  • Caution patient against over exercising
  • No heavy lifting, pushing or pulling for one
    month

18
  • Post op care
  • Patient is followed monthly for re-evaluation
  • Watch for symptomatic neuroma
  • Program for dysesthesias
  • Hand strengthening can begin at 3-4 weeks post
    op.
  • Patients with sedentary jobs requiring lt10 lift
    may return to work by week 8
  • Grip strength slowly increase over a two to three
    month period
  • Patient needs to be seen by both Ortho and OT at
    2 months post op
  • Patients with grade III CTS may require more than
    2 months to regain sensation and hand strength
    and may develop dysesthesias which can require
    several months of desensitization/sensory
    reeducation to resolve.

19
  • Median Nerve Pronator syndrome
  • Compression of the most proximal site of the
    median nerve just inferior to the antecubital
    fossa. Compression can occur as the nerve passes
    between the two heads of the Pronator teres
    muscle. The term pronator syndrome can also
    include median nerve compression by other
    structures ligament of Struthers or the
    lacertus fibrosus).
  • Commonly mistaken for carpal tunnel syndrome
  • First described in 1951
  • Signs and Symptoms
  • 1. Aching pain in proximal volar forearm.
    Associated with repetitive motions that cause
    hypertonicity in the pronator teres.
    Occupational activities hammering, cleaning
    fish, continual manipulation of tools.
  • Numbness/paresthesia in the median nerve
    distribution. Nocturnal complaints uncommon
  • Tenderness over Pronator teres muscle
  • Symptoms exacerbated with activity and diminished
    with rest
  • Easy fatigability
  • Tinels over proximal forearm but takes 4-5
    months to develop.
  • Pain on resistance to pronation and resistance to
    flexion of the FDS to 3 and 4
  • Advance cases will display weakness in all median
    nerve innervated musculature distal to the
    Ligament of Struthers.
  • Women are affected more than men (4 times) and
    presents in the fifth decade of life.
  • Symptoms insidious in onset with a delay in
    diagnosis ranging from 9 months to 2 years.

20
  • Provocative testing is extremely useful
  • Pronator teres test
  • Patent is standing with the elbow in 90 of
    flexion. Patient holds position while examiner
    attempt to supinate the forearm. (forces
    isometric contraction of the pronator muscle).
    While holding the resistance against pronation ,
    the examiner
  • slowly extends the elbow. If motion
    reproduces the pain the median nerve is probably
    compressed by the pronator teres.
  • Test for compression by arch of FDS
  • www.simmonsortho.com

21
  • Splint for Pronator Tunnel
  • Posterior elbow long arm splint. Elbow at 90
    flexion, forearm in pronation with wrist at
    neutral.
  • Splint 4-6 weeks followed by night wear for same
    amount of time
  • NSAIDS
  • Cryotherapy
  • Elbow and wrist AROM
  • Tendon and nerve gliding
  • Ergonomic assessment and recommendations
  • Strengthening of affected muscles
  • Avoidance of aggravating activities
  • Conservative treatment is 8 to 12 weeks.
  • Postoperative Therapy
  • Day 3-5 bulky dressing. Allow full AROM to
    digits. Elbow and wrist AROM limited by patient
    complaints. Gradually increase range of motion
    and activity.
  • OR Elbow splinted at 90 for 5-10 days,
    then AROM as tolerated.
  • Scar management
  • Strengthening of all affected muscles
  • Nerve and tendon gliding
  • Ergonomic assessment and recommendations.

22
  • Median Nerve Anterior Interosseous Syndrome
    (Kiloh-Nevin Syndrome)
  • Compression of the anterior interosseous branch
    of the median nerve usually by deep head of the
    Pronator teres.
  • The AIN nerve is purely motor. Can be resultant
    of an injury to the forearm, by direct trauma,
    compression or inflammation of the AIN.
  • AIN accounts for fewer than 1 of all upper
    extremity neuropathies
  • Earliest description was in 1952.
  • Rule out Pseudo-Anterior Interosseous Neuropathy
  • Signs and Symptoms
  • 1. Vague pain in the proximal forearm and wrist
    that increases with activity especially
  • repetitive forearm motion and is relieved
    with rest.
  • 2. No sensory disturbances
  • 3. Weakness or paralysis of the FPL, FDP of the
    index finger and less commonly the
  • long finger and the pronator quadratus.
  • 4. Unusual pinch demonstrated by the hyper
    extended IP joint of the thumb and index finger
  • (Q sign) ( late sign)
  • 5. Patient reports problems with writing or
    picking up small objects.

23
Inability to make the OK sign. Weak pinch of
AIN syndrome. www.simmonsortho.com
24

Anterior
Interosseous Nerve Syndrome Anterior
Interosseous Neuropathy
Pseudo-Anterior Interosseous
Lesion of the AIN
Lesion of fibers
that ultimately

constitute the
AIN Weakness of FPL,PQ,FDP to Index
Weakness of
FPL,PQ,FDP to Index Normal sensibility

/- weakness of shoulder girdle Normal
shoulder girdle
/- weakness of
thenar muscles

/- Abnormal sensibility
(Median)
25
  • Splint for Anterior Interosseous Syndrome
  • Posterior long arm splint with elbow at 90 of
    flexion, forearm pronated and the wrist in
    neutral for 3 to 4 weeks Thumb in opposition
    splint for function.
  • NSAIDs
  • Cryotherapy
  • Avoidance of aggravating factors
  • AROM of the elbow and wrist
  • Tendon and nerve gliding
  • Ergonomic assessment and recommendations
  • Strengthening of affected muscles
  • Conservative treatment for 8 to 12 weeks
  • Postoperative therapy
  • Bulky dressing supporting the elbow and wrist,
    AROM of wrist and digits for 5 to 7 days.
  • Strengthening at 7 to 10 days post op unless
    pronator was elevated.
  • If pronator was elevated, splint elbow at 45-90,
    wrist 45 and full pronation for 2-3 weeks
  • Digit ROM immediately, AROM of the elbow and
    wrist at week 3 and strengthening at 3 to 4 weeks
  • Scar Management

26
  • Ulnar Nerve Cubital tunnel syndrome
  • Compression or trauma of the ulnar nerve at the
    level of the medial aspect of the elbow.
  • Second most common compression neuropathy.
  • Causative factors include recurrent subluxation,
    dislocations, RA, excessive elbow valgus, bony
    spurs, synovial cysts or external compression or
    trauma.
  • Ulnar nerve supplies the ulnar intrinsics, FDP to
    4 and 5 and the FCU. Sensation in the 5th digits
    and ulnar ½ of the ring
  • Cubital tunnel is a bony canal formed by the
    ulnar collateral ligament, the trochlea, and the
    medial epicondylar groove and is roofed by the
    triangular arcuate ligament.
  • Signs and Symptoms
  • Pain at medial elbow
  • Sensory disturbance (numbness, paresthesia,
    dysesthesia) over the hypothenar eminence,
    dorsoulnar hand, 5th digit and ulnar 4th digit.
  • Weak intrinsics. Decreased or inability to cross
    fingers or spread fingers apart
  • Tinels at Cubital tunnel
  • Elbow flexion test (Wadsworth flexion test).
    Elbow flexed, FA supinated with wrist extended.
    at 60 seconds.
  • Froments sign is advanced stages
  • Weak grip and lateral pinch
  • Wartenbergs sign in advanced cases. Paralysis of
    the 3rd palmar interossei. ( no adduction of
    small finger)
  • Claw hand deformity as FDP reinnervates

27
  • Non-operative Treatment and Splint
  • Heelbo pads for day time wear to protect medial
    elbow/ulnar nerve.
  • Limit elbow range of motion using either a
    neoprene elbow splint for day or fabricating a
    long arm splint with elbow flexed 30 to 45
    anterior based and flared to avoid external
    compression on the ulnar nerve for night wear.
  • Can use a rolled towel around the elbow to
    decrease flexion at night during sleep if splint
    not fabricated
  • Postural and positional education is stressed to
    avoid external nerve compression. Resting elbows
    on hard surfaces, leaning on elbows, prolonged
    elbow flexion, repetitive flexion/extension at
    elbow
  • Patient education in insensate precautions
  • Ulnar nerve glide
  • Ice

28
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29
Dynamic Splinting for Ulnar nerve
30
  • Ulnar Nerve Surgery
  • Decompression and medial epicondylectomy
  • Subcutaneous transposition
  • Submuscular transposition

31
  • Postoperative therapy Cubital Tunnel
  • Ulnar nerve decompression/ medial epicondylectomy
  • Begin gentle AROM immediately, no heavy lifting
    for 6 weeks. Patient can
  • use upper extremity for daily activities.
  • Sensory assessment
  • Wound care and edema control
  • Week 2 begin PROM
  • Exercises to promote gliding of the ulnar nerve
    to prevent scarring of the
  • nerve to the surgical bed.
  • Week 4 resisted ROM. Stretching exercises.
  • Normal activity resumption in 1-2 months
  • As ROM progresses, initiate gentle
    strengthening exercises
  • Desensitization and motor exam.
  • Splint as indicated for ulnar nerve deficit

32
  • Cubital Tunnel cont.
  • Subcutaneous transposition
  • Week 1 Splint in 45 elbow flexion for up to 2
    weeks.
  • Gentle AROM is started at all joints.
    Progress to resistive exercises at 4 weeks.
  • Sensory assessment
  • Wound care and edema control
  • Week 2 Discontinue splint, progress AROM
  • Week 3 PROM
  • Week 4 Progress resisted ROM
  • Desensitization, sensory re-education
  • Splint as indicated for ulnar nerve
    deficit
  • Submuscular transposition
  • Week 1 Splint in long arm splint with elbow
    flexed 45, with slight forearm pronation
  • and wrist in neutral for up to 3 weeks
    to protect the flexor pronator origin.
  • Sensory assessment

33
  • Ulnar Nerve Guyons canal
  • Compression of ulnar nerve as it passes through
    Guyons canal at the wrist. Guyons is a bony
    canal formed by the volar carpal ligament, hook
    of the hamate and the hamate. Motor and sensory
    deficits are present distal to the canal as both
    sensory and motor runs through the canal. There
    will be volar sensory but no dorsal sensory
    deficit. Compression of the ulnar nerve at this
    site is usually associated with trauma, abnormal
    structures (ganglion cyst or lipoma) fracture of
    the hamate, ring or small fingers metacarpal
    bones or anomalous muscles. It has also been
    called handlebar palsy.
  • Signs and Symptoms
  • Numbness/tingling along the volar aspect of the
    small finger and ulnar ½ of the ring (no dorsal
    numbness)
  • Weakness or paralysis of the hand intrinsics
    innervated by the ulnar nerve
  • Possible Tinels at Guyons canal
  • Possible claw deformity
  • Treatment for Guyons
  • Protective splint or gel pad if from external
    compressive forces
  • Managed post surgically with splinting, muscle
    strengthening and sensory re-education

34
  • Radial Nerve Radial Tunnel Syndrome
  • Compression of the radial nerve by anatomical
    structures inferior to the lateral epicondyle
    (Tendinous origin of ECRB)
  • Signs and Symptoms
  • Dull, achy pain over the extensor aspect of the
    forearm, can radiate into the distal forearm and
    the hand.
  • Symptom onset after significant repetitive or
    power grip use
  • Pain absent upon awakening but progressively
    increases with activity, leaving a dull
    persistent ache. Night pain is common
  • Tenderness over the radial head/radial tunnel
    area
  • Positive radial tunnel compression test involves
    the examiner rolling the fingers over the radial
    nerve region in the proximal forearm eliciting
    pain and tenderness.
  • Pain reproduced with resisted extension of the
    fingers with the elbow extended- pain most severe
    with stressing the middle finger. (Middle finger
    test which tenses the ECRB over the nerve)
  • Pain with resisted forearm supination with the
    elbow extended (Yergasons test)
  • With advanced stages- weakness of the wrist,
    finger and thumb extensors. Decreased grip
    strength
  • May have paresthesias, numbness in the 1st dorsal
    web space, dorsal thumb and index finger
  • Radial tunnel syndrome may be distinguished from
    lateral epicondylitis by exam. Maximum
    tenderness is over the neck of the radius and
    must be compared to the other arm.

35
  • Non-operative treatment for Radial tunnel
  • Week 0-3
  • Wrist splint in 30-45º extension. Splint worn
    continuously.
  • Patient education in avoidance of tasks requiring
    Pronation/supination
  • Use appropriate balanced tools in the work
    environment and avoid high-force tasks with
    torque or with heavy pronation and supination
  • Week 3
  • Radial nerve glides
  • Tendon gliding
  • Basic 4 hand postures
  • Overhead fisting
  • Modalities as indicated
  • Patient education on risk factors
  • Patient education on activity modification of
    ADLs and job tasks. (lift with palms up versus
    palms down)
  • Progressive strengthening with putty and
    theraband once symptoms have resolved

36
  • Radial Tunnel Operative
  • Week 1 Bulky dressing is removed
  • Gentle active and passive
    ROM to wrist, FA and elbow
  • Patient education on wound
    care
  • Week 3-4 Motor and sensory re-education
  • Scar massage
  • AROM to wrist, forearm and
    hand.
  • Begin neural glide
    exercises
  • Patient is to use extremity
    in basic self-care ADL activities and IADL tasks
  • such as cooking and meal
    preparation.
  • Weeks 6-8 Progressive strengthening within
    patients comfort level using putty and
  • theraband, free weights

37
  • Posterior Interosseous Syndrome
  • Compression or injury of the PIN branch of the
    radial nerve. Secondary to trauma. (dislocation
    of the elbow or fracture/dislocation of the
    radial head). Inflammation, postural/occupational
    or iatrogenic (injection causes.)
  • Signs and Symptoms
  • Pain deep forearm, lateral elbow
  • Weakness /paralysis. Motor loss may be gradual
    or dramatic. Wrist extension is intact but loss
    of finger and thumb extension.
  • No sensory deficit.
  • History of repeated or strenuous effort involving
    supination and pronation. Men two times more
    than women with dominant arm 2 times more than
    non-dominant.

38
  • Posterior Interosseous Nerve Splint
  • Long arm posterior splint with elbow flexed to
    90º. Wrist in neutral, forearm in neutral.
    Buddy tape the fingers.
  • Paralysis of wrist and finger extensors support
    wrist in splint with dynamic extension outriggers
    for the digits.
  • Paralysis of finger extensors but active wrist-
    tenodesis splint.
  • Post operative Splinting
  • Long arm posterior splint with the elbow flexed
    to 90º, wrist and forearm in neutral. Buddy tape
    the fingers.
  • Dynamic splinting

39
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40
  • Radial Sensory nerve entrapment or Wartenbergs
    disease
  • Compression of the sensory branch of the radial
    nerve as it emerges from beneath the edge of the
    brachioradialis muscle. History of trauma often
    repetitive in nature involving supination/pronatio
    n.
  • Most distal compression can be from external
    causes. Tight wristbands, scar bands, tight cast
    or a direct blow, or from chronic inflammation
    from first dorsal compartment tendonitis.
  • Signs and Symptoms
  • Radial wrist and dorsal hand pain of thumb,
    index, first web. Described as burning,
    numbness, hyperesthesia or tingling.
  • Test by clenched fist and ulnar-palmar flexion
    with forearm hyperpronation.
  • Dysesthesia of the dorsal hand, thumb, index and
    long fingers
  • Tinels along the radial styloid to the edge of
    the brachioradialis
  • Finkelsteins test may be misleadingly positive.
    Thumb does not have to be flexed to elicit an
    positive test.
  • Splint
  • Wrist splint with max. extension, radial
    deviation
  • NSADIS
  • Restricted activities

41
  • FINI
  • Any questions??
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