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Compressive Neuropathy of the Upper Extremity ::::

Compressive Neuropathy of the Upper Extremity ::::. Review of the anatomy of Median,Ulnar, and Radial Nerves. Upper Extremity Nerves.

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Compressive Neuropathy of the Upper Extremity ::::

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  1. Compressive Neuropathyofthe Upper Extremity::::

  2. Review of the anatomy of Median,Ulnar, and Radial Nerves

  3. Upper Extremity Nerves

  4. Carpal Tunnel Syndrome: Median Neuropathy at the wrist.Cubital Tunnel Syndrome: Ulnar neuropathy at the elbow.Radial Nerve Palsy at the spiral groove of the humerus.

  5. Median Nerve

  6. CT- a natural bottleneck in the course of median nerve. Disproportion between available space and its contents = increased pressure within CT Median nerve most delicate: mostly affected: functional disturbance Carpal Tunnel Syndrome :Etiology

  7. Carpal Tunnel Syndrome :Etiology • Disproportion between Space vs. Contents Actual narrowing of the walls of the canal vs. Increase in the volume of its contents But usually multifactorial.

  8. Carpal Tunnel Syndrome :Etiology: nerve compression • 2.5 mm Hg healthy subjects • 20 mm Hg decreased epineural perfusion • 30 mm Hg decreased axonal transport • 40 mm Hg paresthesia • 50 mm Hg epineural edema • 60 mm Hg intraneural ischemia,sensory/motor block.

  9. Thickening of the paratenon • Chronic non-specific Tenosynovitis: occupational,reactive, hormonal (Idiopathic CTS) Idiopathic 85% Rheumatoid 9% Post-traumatic 3% Acute 3% Other cases <1%

  10. Idiopathic CTS • Largest number of cases • Thickening of para-tendinous tissue- specially of the FDP tendons • Chronic edema, fibrinoid swelling, hyaline and mucoid degeneration followed by • Fibrotic thickening, increased collagen formation. • Influenced by hormonal factors and repetitive occupational overuse.

  11. Chronic non-specific tenosynovitis • Chronic edema : primary causative factor • Other conditions: • Trigger finger • de Quervain’s disease

  12. Hormonal factors • Edematous thickening of paratenons: third trimester of pregnancy or shortly after delivery • 45 % of all pregnant women complain of some tingling, numbness of the fingers- resolves in most cases after delivery. • Pre-menopausal • Contraceptive drugs

  13. Chronic/Acute Specific Inflammation • Rheumatoid Tenosynovitis • JRA • Tuberculous tenosynovitis • Acute pyogenic Infection • Acute thrombophlebitis • Erroneous I.V. infusion

  14. Post-traumatic CTS • Blunt trauma- edema, bleeding • Carpal bone dislocation- lunate • Distal radial fracture • Compartment syndrome • Abnormal wrist position • Malunited distal radial fracture • Osteophytes from chronic arthritis

  15. Systemic disease • Gout • Myxedema • Amyloidosis • Diabetes • Myeloma • Acromegaly • Chronic Renal failure

  16. Diagnosis-History • Nocturnal paresthesia • Numbness/tingling/burning or cramplike sensations-median nerve distribution • Pain of the resting hand-pathognomonic • May subside with manual activity • Weaknes/clumsiness • Postural aggravation

  17. Diagnosis-History • Proximal pain: may radiate upto shoulder • Pain may subside in advanced cases • Feeling of cold, and swollen fingers: disturbance of autonomous function of median nerve. • Flattenning of thenar eminence

  18. Median nerve:findings Depends on stages: Tinel’s Sign Digital sensibility Phalen’s wrist flexion Brain’s wrist extension Tourniquet test Median nerve compression Muscle testing: abductor pollicis brevis

  19. Sensory Distribution

  20. Median Nerve testing

  21. Median nerve

  22. Median nerve

  23. Median nerve:findings Imaging studies: Plain radiographs: cervical,chest,wrist,hand Magnetic resonance imaging: unclear diagnosis,anatomic causes, failure of CTR Ultrasound: space occupying lesion

  24. Electrodiagnostic testing • Nerve Conduction study Segmental demyelination-> slowed nerve conduction:conduction block • Electromyography Axonal loss-> Wallerian degeneration; muscle denervation

  25. Electrodiagnostic testing • Confirm clinical diagnosis • Provide baseline data • Rule out proximal compression,double crush, polyneuropathy

  26. Electrodiagnostic testing:limitations: • Measure large myelinated fibers • Abnormal only after Wallerian degeneration • False negative results (10%) • Static test- not dynamic

  27. Treatment: conservative • Wrist splint • Activity modification • Steroid injection • NSAID • ?Vit B6 • Stretching exercises / ergonomic equipments ( prevention)

  28. Carpal Tunnel Release (CTR) • Open • Endoscopic • Limited incision

  29. Ulnar Nerve Arcade of Struthers Cubital tunnel Guyon’s tunnel

  30. Cubital Tunnel Syndrome • Paresthesia in ulnar digits • Weakness • Intrinsic wasting • Elbow pain

  31. Cubital Tunnel Syndrome:findings • Ulnar nerve subluxation • Tinel’s sign • Elbow flexion test • Intrinsic muscles • Sensation

  32. Ulnar Nerve Testing

  33. Ulnar Nerve testing

  34. Ulnar Nerve testing

  35. Sensory Distribution

  36. Radial Nerve

  37. Radial Nerve Palsy • Wrist drop: weak wrist/ finger extension • Sensation changes Findings dependant on etiology: Saturday night palsy Fracture humerus: post reduction Gunshot wound Post operative compression

  38. Sensory Distribution

  39. Radial Nerve Test

  40. Scratch-Collapse Test • Annual Meeting of the American Society for Hand Surgery: San Francisco 2009 • Median Nerve • Ulnar nerve • Radial nerve

  41. Upper Extremity Nerves <- Spiral groove: RADIAL <- Cubital tunnel: ULNAR <- Carpal tunnel: MEDIAN

  42. Thank you!

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