“Compressive Neuropathies of the Elbow and Wrist”

1. “Compressive Neuropathies of the Elbow and Wrist” Sepein Chiang, D.O. Garden City Hospital

2. Introduction • Localized ischemia due to mechanical pressure • “Double crush”: blockage of axonal transport at one point makes the entire axon more susceptible to compression

3. Etiology • Systemic/inflammatory: DM, alcoholism, hypothyroidism, tenosynovitis, RA, infection, gout • Alterations of fluid balance: pregnancy, Raynaud’s, obesity • Congenital:mucopolysaccharidosis, mucolipidosis

4. Etiology • Anatomy • Increased canal contents: tumor, hematoma, hypertrophic synovium • Ideopathic

5. Surgical Indications • Failure of conservative treatment • Acute, rapidly progressing symptoms • Severe chronic symptoms • Recurrence • Motor weakness

6. Median Nerve • Carpal tunnel syndrome • Anterior interosseous syndrome • Pronator syndrome

7. Carpal Tunnel Syndrome • Most common • Transverse carpal ligament • Flexor tenosynovitis • Diabetes, thyroid disease, alcohol abuse, amyloidosis

8. Carpal Tunnel Syndrome • Night pain • Clumsiness • Thenar weakness/atrophy muscles • Numbness first 3 digits and radial ½ of 4th

9. Carpal Tunnel Syndrome • Most sensitive: compression test • Positive Tinel’s • Positive Phalen’s • EMG • Loss of sweat glands

10. Carpal Tunnel Syndrome • Activity modification • Night wrist splints • NSAIDS • Steroid injections • 80% transient relief • 22% symptom free at 1 year

11. Carpal Tunnel Syndrome Surgery: ulnar based incision to avoid recurrent motor and palmar cutaneous branches • Most common complication: incomplete release • 25% complete relief after redo surgery • Pinch strength returns in 6 weeks • Grip strength returns in 3 months

12. Pronator Syndrome • Supracondylar process • Ligament of Struthers • Lacertus fibrosis (bicipital aponeurosis) • Pronator teres muscle • Flexor digitorum superficialis

13. Pronator Syndrome • Pain in volar forearm • Weak thenar muscles • Numbness radial 3½ digits • Positive Tinel’s in forearm • Negative Phalen’s • No night pain

14. Pronator Syndrome Provocative tests • Lacertus/Struthers ligament: elbow flexed 130º, resisted supination • Pronator: elbow extended, resisted pronation • FDS: resisted flexion of PIP of long and ring fingers

15. Pronator Syndrome Treatment • Rest and splinting for 4 – 6 wks • NSAIDS • Surgery: global decompression yields a variable outcome

16. Anterior Interosseous Syndrome • Entrapment at the origin of the deep head of the pronator teres • FDS arcade • Edge of lacertus fibrosus • Enlarged bicipital bursa • Gantzer’s muscle (accessory head of FPL)

17. Anterior Interosseous Syndrome • Motor loss, no sensory findings • Loss of precise pinch/unable to make “OK” sign (FDP (radial 2), FPL and pronator quadratus) • Ruleout Mannerfelt syndrome (rupture of FPL)

18. Anterior Interosseous Syndrome • Splint 90º flexion for 6 – 8 wks • Surgery: good results if done within 3 – 6 months from onset of symptoms

19. Ulnar Nerve • Cubital tunnel syndrome • Ulnar tunnel syndrome

20. Cubital Tunnel Syndrome • Compression at origin of flexor carpi ulnaris at the elbow • Positive Tinel’s • Paresthesias over 5th and ulnar ½ of 4th finger • Grip and intrinsic muscle weakness • Froment’s sign (FPL compensating for thumb adductor)

21. Cubital Tunnel Syndrome Causes • Trauma • Cubitus valgus • Subluxation of the nerve • Bony spurs • Tumors • Aberrant muscles, arcade of Struthers, Osborne’s fascia

22. Cubital Tunnel Syndrome Treatment • Conservative • Decompression • Transposition • Medial epicondylectomy

23. Ulnar Tunnel Syndrome • Guyon’s canal • Repetitive trauma • Hook of the hamate fracture non-union • Ulnar artery thrombosis or aneurysm (Allen’s test) • Ganglia from triquetrohamate joint • Anomalous muscle, ligament or palmaris brevis hypertrophy

24. Radial Nerve • Proximal entrapment • Posterior interosseous nerve syndrome (PIN) • Radial tunnel syndrome • Superficial radial nerve syndrome

25. Proximal Entrapment • Compressed by fibrous arch from the lateral head of the triceps • Commonly associated with humerus fractures (Holstein-Lewis) • Weakness of muscles innervated by the PIN and mobile wad of Henry

26. PIN Syndrome • Arcade of Frohse (proximal supinator) • Ganglia, lipoma, fibroma • Trauma: radial head dislocations, iatrogenic injections • “Saturday night” or “honeymoon” palsy

27. PIN Syndrome • Symptoms • Loss of extension of all digits and extensor carpi ulnaris • Dorsiflexion of wrist results in radial deviation • No sensory deficits

28. Radial Tunnel Syndrome • Fibrous bands proximal to the supinator • Radial recurrent vessels (leash of Henry) • Arcade of Frohse • Extensor carpi radialis brevis origin

29. Radial Tunnel Syndrome • No motor or sensory deficits • Often confused with tennis elbow • Pain 5 cm distal to the lateral epicondyle • Pain with extension of the middle finger (ECRB inserts at base of 3rd metacarpal) • Pain with resisted supination

30. Superficial Radial Nerve Syndrome • Cheiralgia paresthetica • Wartenberg’s syndrome • Compression between brachioradialis and extensor carpi radialis with forearm pronation • Pain with forceful forearm pronation • Positive Tinel’s (6 – 8 cm proximal to the radial styloid)