AFP Journal Review

1. Katina Robertson, MD Emory Family Medicine AFP Journal Review January 15, 2010 Issue

2. Articles Reviewed • Peripheral Nerve Entrapment and Injury in the Upper Extremity • Vocal Cord Dysfunction • Noninfectious Penile Lesions • Outdoor Air Pollutants and Patient Health

3. Peripheral Nerve Entrapment and Injury in the Upper Extremity

4. Peripheral Nerve injury • Peripheral Nerve Injury (PNI) in UE is common • Risk Factors • Superficial position • Long course through area at high risk of trauma • Narrow path through bony canal

5. ANATOMY AND RELATED RISK FACTORS OF UPPER EXTREMITY NERVE INJURY Anatomy and Risk Factors

6. ANATOMY AND RELATED RISK FACTORS OF UPPER EXTREMITY NERVE INJURY Anatomy and Risk Factors

7. ANATOMY AND RELATED RISK FACTORS OF UPPER EXTREMITY NERVE INJURY Anatomy and Risk Factors

8. Pathophysiology • Three categories of nerve injury • Neurapraxia– least severe, focal damage of myelin fibers around axon. Limited course (days-wks) • Axonotmesis– more severe, axonal injury. Nerve regeneration possible but prolonged (months) and incomplete recovery • Neurotmesis– complete disruption of axon. Little chance of regeneration or clinical recovery • Mechanisms of nerve injury • Direct pressure • Repetitive microtrauma • Stretch- or compression- induced ischemia

9. SYMPTOMS OF UPPER EXTREMITY NERVE INJURIES Differential Diagnosis • Consider PNI in pts with pain, weakness, parasthesias not related to known bone/soft tissue/vascular injury

10. Cutaneousinnervation & Dermatomes

11. Shoulder & Arm Axillary Brachial Plexus Long Thoracic Spinal Accessory Suprascapular

12. Axillary Nerve: Quadrilateral Space Syndrome • Mechanism • Shoulder dislocation • Upward pressure (e.g., from improper crutch use) • Repetitive overload activities (e.g., pitching a ball, swimming) • Arthroscopy or Rotator cuff repair • Symptoms • Arm fatigue w/ overhead activity or throwing • +/- associated paresthesias of lateral &posterior upper arm • Signs • Weak abduction • Weak external rotation

13. Brachial Plexus: Stinger • Mechanism • Collision sports (e.g. football) • Symptoms • Classic: acute onset paresthesias in upper arm • Paresthesias in circumferential pattern (not dermatomal) • Short duration: last seconds-minutes • Motor symptoms can develop at any point • Signs • Differentiate from C-spine injury (point tenderness, pain w/ neck motion, bilateral symptoms)immobilize • Motor weakness, can occur hrs-days after injury re-evaluate @ 24hrs, then every few days x 2wks • if recurrent stingers w/up the neck for underlying pathology predisposing to injury • Injury @ sporting event: All sxs resolve in 15 min + no C-spine injury may return to play, but repeat exam during event

14. Long Thoracic Nerve • Mechanism • Blow to the shoulder • Chronic repetitive traction on nerve (e.g., tennis, swimming, baseball) • Symptoms • Diffuse shoulder or neck pain, worse with overhead motions • Signs • Winged scapula and weakness with forward elevation of arm

15. Spinal Accessory Nerve • Mechanism • Trapezius trauma • Shoulder dislocation • Iatrogenic (Radical neck dissection, carotid endarterectomy, and cervical node biopsy) • Symptoms • Generalized shoulder pain and weakness • Signs • Shoulder asymmetry • Shoulder sag, inability to shrug shoulder to ear • Weakness of forward arm elevation above horizontal plane • Chronic injury trapezius atrophy

16. Suprascapular Nerve • Mechanism • repetitive overhead loading • Glenoid labrum tear +/- cyst formation at suprascapular notch • Symptoms • Motor weakness • Signs • Infraspinatus- weak external rotation of the arm • Supraspinatus- weak arm elevation, most @ 90 to 180 degrees • Differentiate from rotator cuff tear MRI

17. Forearm & Elbow Median Radial Ulnar

18. Median Nerve at the elbow: Pronator Syndrome • Mechanism • pronator teres m. -- compress the median nerve • Symptoms • Forearm discomfort and aching w/activities requiring repetitive pronation (especially w/elbow extended) • +/- Paresthesias in the thumb and first two digits • Signs • Sensory loss over thenar eminence (not seen in carpal tunnel) • Negative Tinel • Negative Phalen

19. Radial Nerve at the elbow: Radial Tunnel & Posterior Interosseous Nerve Syndromes • Mechanism • divides into a superficial branch (sensory only) and a deep branch (posterior interosseous nerve) at the lateral elbow– compression at any point • Symptoms • Pain that radiates from lateral elbow to forearm and wrist • Pain with wrist extension or grip (shaking hands, turning doorknob) • Generalized hand and forearm weakness • Signs • Differentiate from lateral epicondylitis (tennis elbow) • Both– pain with supination against resistance w/ elbow and wrist extended • Both– pain resisted extension of middle finger • **Maximal tenderness over anterior radial neck • If motor symptoms (weakness of digit & wrist extension)– likely post. interosseous

20. Ulnar Nerve at the elbow: Cubital Tunnel Syndrome • Mechanism • Very superficial– injury from acute contusion or chronic compression • Symptoms • Paresthesias of the fourth and fifth digits • elbow pain radiating to the hand (sxs may be worse w/ prolonged or repetitive elbow flexion) • Signs • Sensory loss • Motor: Weak digit abduction, weak thumb abduction, and weak thumb-index finger pinch • Late finding– decreased power grip

21. Hand & Wrist Median Radial Ulnar

22. Median Nerve at the wrist: Carpal Tunnel Syndrome • Mechanism • Repetitive fine movements– chronic compression • Symptoms • Paresthesias of thumb, 2nd & 3rd digits • +/- forearm pain • Signs • Hypalgesia (positive LR of 3.1) • Abnormality in a Katz hand diagram • Positive Tinel & Phalen signs • Late findings: weak thumb abduction, thenar atrophy

23. Katz Hand Diagram • classic carpal tunnel syndrome (CTS) for both hands; B. probable CTS, because of symptoms in palm; C. unlikely CTS

24. Radial Nerve at the wrist: Handcuff Neuropathy • Mechanism • Superficial branch of the radial nerve crosses the volar wrist-- vulnerable to compression by anything wound tightly around the wrist (e.g. handcuffs) • Symptoms • Numbness on dorsal hand (usually on radial side) • Signs • Decreased sensation to soft touch and pinprick over the dorsoradial hand, dorsal thumb, and index digit • Motor intact

25. Ulnar Nerve at the wrist: Cyclist’s Palsy • Mechanism • Common in cyclists -- ulnar nerve compressed against handlebar during cycling • Activities involving prolonged pressure on the volar wrist (e.g., jackhammer use) • Symptoms • Paresthesias in the 4th and 5th digits • Weakness uncommon -- motor portion of nerve less superficial at wrist • Signs • Unless activity is prolonged or chronic-- results of the sensory examination are normal • Numbness resolves within hours after stopping the activity

26. Shoulder & Arm

27. Forearm & Elbow

28. Hand & Wrist

29. Diagnostic Testing • Plain XR: fracture or cervical spondyloarthropathy

30. Electrodiagnostic Testing • Nerve Conduction Studies– Evaluate motor and sensory nerves; Demyelination = slowing of conduction velocity • Helpful in confirming diagnosis in pts with atypical presentations • In pts with “classic” presentation, NCS do not change diagnosis or management, i.e. don’t bother • EMG– useful in conjunction with NCS to distinguish central vs peripheral neuropathies

31. Treatment Options

32. Recommendations

33. Peripheral Nerve Injury A football player presents with upper arm paresthesias following a tackle. Which one of the following statements about a brachial plexus nerve injury (i.e., stinger) is correct?  (check one) A. Paresthesias typically have a dermatomal pattern. B. The athlete should not return to competition or activity for two weeks. C. Bilateral symptoms make the diagnosis more likely. D. Paresthesias typically have a circumferential pattern.

34. Peripheral Nerve Injury A patient works on an assembly line doing repetitive overhead work. He has weakness with external rotation of the right arm and when he raises his right arm above his shoulder. Which one of the following nerves is likely involved?  (check one) A. Suprascapular nerve. B. Posterior interosseus nerve. C. Radial nerve. D. Ulnar nerve.

35. Peripheral Nerve Injury Which of the following has/have been shown to provide short-term benefit for patients with carpal tunnel syndrome?  (check all that apply) A. Nonsteroidal anti-inflammatory drugs. B. Corticosteroid injection. C. Vitamin B6. D. Splinting.

36. Vocal Cord Dysfunction

37. Vocal Cord Dysfunction • Definition: inappropriate vocal cord motion produces partial airway obstructionsubjective respiratory distress • Normal-- person breathes  cords move away from midline during inspiration & slightly toward the midline during expiration • Dysfunction-- person breathes  cords move toward the midline during inspiration or expiration = obstruction • Other terms: paradoxical vocal cord dysfunction, paradoxicalvocal fold motion, factitious asthma

38. Clinical Presentation • Women >men; Ages 20-40 • Symptoms -- recurrent , subj. resp distress • Inspiratory stridor • Cough • Choking sensation • Throat tightness • 59% with VCD, previously Dx of asthma • Sxs usually mild, intermittent • Laryngospasm (subtype of VCD) • brief involuntary spasm of vocal cords producing aphonia and acute resp distress • common complication of anesthesia • Spasmodic Dysphonia • hoarseness and voice strain when the abnormal vocal cord motion occurs during speech Vocal Cord Dysfunction

39. Differential Diagnosis Vocal Cord Dysfunction

40. Precipitating Factors • Exercise: consider in pts with exercise-induced asthma not improved with bronchodilators • Psychosocial Conditions: stress disorder, anxiety, depression, and panic attack • Irritants: environmental/occupational ammonia, dust, smoke, soldering fumes, and cleaning chemicals • Rhinosinusitis • GERD • Medications:neuroleptics can cause transient VCD (considered focal dystonic reaction) Vocal Cord Dysfunction

41. Diagnosis • PFT w/ a flow-volume loop = most common diagnostic test • expiratory loop = normal • inspiratory loop = flattened (c/w extrathoracic upper airway obstruction) • Flexible Laryngoscopy= diagnostic standard, direct visualization Vocal Cord Dysfunction

42. Treatment Vocal Cord Dysfunction

43. Vocal Cord Dysfunction Which of the following is/are common triggers of vocal cord dysfunction?  (check all that apply) A. Gastroesophageal reflux disease. B. Airborne irritants. C. Anticholinergics. D. Exercise.

44. Vocal Cord Dysfunction Which of the following is/are the most valuable diagnostic tests for confirming vocal cord dysfunction?  (check all that apply) A. Methacholine challenge test. B. Flexible laryngoscopy. C. Pulmonary function testing with a flow-volume loop. D. Arterial blood gases.

45. Vocal Cord Dysfunction Which of the following symptoms is/are often present in patients with vocal cord dysfunction? (check all that apply) A. Cough. B. Inspiratory stridor. C. Choking sensation. D. Throat tightness.

46. Noninfectious Penile Lesions Inflammatory Papulosquamous Neoplastics

47. Anatomy Noninfectious Penile Lesions

48. Psoriasis • Epidemiology • bimodal peaks at 16-22 yo & 57-60 yo • Prevalence 1-2%, up to 40% have GU involvement • Symptoms • red or salmon-colored, papulosquamous, circinate plaques, w/ white or silvery scales • Pruritis • Exacerbated by-- stress, excess etoh &tobacco use, acute infections (strep), medications(e.g., beta blockers, lithium) Noninfectious Penile Lesions

49. Psoriasis • Treatment • 1st line options for localized disease • mild to mod strength topical corticosteroids (CS)—qDay • Vitamin D3 analogues– qDay or BID • Prevent skin atrophy– • use <50 mg ultrapotent or <100 mg potent topical CS over long-term • dose ultrapotent daily x 2wks then q weekend • Lesions may recur when CS discontinued • If long-term therapy required, tacrolimus (Protopic) or pimecrolimus (Elidel) may decrease risk of atrophy • Refractory cases– dermatology referral • Diagnosis • Clinical systemic signs (nail pitting, arthritis, other skin) • If atypical– punch or shave biopsy Noninfectious Penile Lesions

50. Lichen Sclerosus(balanitisxeroticaobliterans) • Epidemiology • All ages; ave age 42yo • Prevalence..? 1 in 300 • 4-6% assoc w/ squamous cell carcinoma (SCC) • Signs/Symptoms • hypopigmented lesion • texture like crinkled paper/cellophane. • glans penis and prepuce involv • Bullae, erosions, or atrophy • phimosis, painful erections, obstructive voiding, itching, pain, and bleeding • DDX: carcinoma in situ, leukoplakia, and scleroderma Noninfectious Penile Lesions