CHAPTER 12: HAND - NERVES AND TENDON TRANSFERS Flashcards
1
Q
Describe the levels of the brachial plexus
A
Rob Tucker Drinks Cold Beer
Roots
• Enter post triangle between Scalenus anterior and Scalenus medius
• Plexus surrounded by fascial sheath axillary sheath from the prevertebral fascia.
Trunks
• Around 3rd part of subclavian artery, lower behind it
• Each trunk divides into anterior and posterior divisions.
• In posterior triangle
Divisions
• Behind clavicle
• Anterior divisions from upper and middle trunks form Lateral Cord
• Anterior divisions from the Lower trunk form the Medial cord
• All 3 Posterior divisions form the Posterior cord
Cords
• In axilla
• Cords lie above and lateral to the 1st part of the axillary artery.
• Medial cord crosses behind the artery to lie to the medial side of the 2nd part of the artery under pec minor.
• Post cord is behind the artery.
• Lateral cord lateral to the artery at this point.
• Cords leave the post triangle by descending behind the clavicle into axilla.
Branches
2
Q
What are the myotomes of the branchial plexus?
A
Myotomes C5 Shoulder abduction C6,7,8 Shoulder adduction C5,6 Elbow flexion C7,8 Elbow extension C6,7 Wrist movements C7,8 Finger movements T1 Intrinsics
3
Q
Which nerves originate from the roots of BP?
A
Long thoracic nerve descends behind the plexus and subclavian vessels crosses outer border of 1st rib and enters axilla. Supplies serratus anterior.
Dorsal scapular nerve pierces Scalenus medius and supplies levator scapulae and rhomboids.
Nerve to subclavius runs in front of plexus and 3rd part subclavian art. Behind clavicle and in front of subclavian vein to supply subclavius. May have accessory phrenic fibres which join the phrenic in the superior mediastinum if present this is called accessory phrenic nerve.
4
Q
Which nerve emerges from the upper trunk?
A
Suprascapular nerve passes lat and down with suprascapular vessels. Enters the supraspinous fossa through suprascapular notch. Supplies supraspinatus and infraspinatus.
5
Q
Which nerves originate from the lateral cord?
A
Lateral pectoral nerve pierces clavipectoral fascia and supplies Pec Major
Musculocutaneous supplies coracobrachialis in axilla, then biceps, brachialis and elbow joint in upper arm and becomes the lateral cutaneous nerve of forearm.
6
Q
Which nerves originate from the medial cord?
A
Medial pectoral nerve supplies and pierces Pec Minor and supplies Pec Major
Medial cutaneous nerve of the arm joined by intercostobrachial nerve to supply sensation of medial side of arm.
Medial cutaneous nerve of the forearm descends in front of axillary artery.
Ulnar nerve descends between axillary arty and vein. No branches in axilla. Upper arm to elbow only. Forearm branches to FCU, FDP (medial) Palmar cut branch, Post cut branch - skin on dorsum of ulnar side of hand. PB, digital nerves, hypothenar muscles, Add P, 3 and 4 lumbricals, interosseii.
7
Q
Which nerves originate from the posterior cord?
A
Upper and lower subscapular nerves supply the upper and lower parts of the subscapularis muscle. Lower subscapular also supplies teres major muscle.
Thoracodorsal nerve runs down on the subscapularis to lat dorsi. Accompanies the subscapular vessels.
Axillary nerve passes backwards through the quadrilateral space with the posterior circumflex humeral arty. It supplies shoulder joint, and divides into ant and post. Anterior division supplies Deltoid and regimental badge area of skin. Posterior division supplies deltoid, teres minor, then terminates as upper lateral cutaneous nerve of arm to skin over lower half of deltoid.
Radial Nerve direct continuation of Posterior cord lies behind axillary artery. Largest branch of plexus. In axilla gives off branches to long and medial heads of triceps and the post cut nerve of arm. Then goes on to supply the extensor compartment
8
Q
What is the median nerve made up of?
A
Medial root of Median nerve is direct continuum of Medial Cord crosses in front of 3rd part of axillary arty to join lateral root.
Lateral root of median nerve is the direct continuum of the Lateral cord. Joins with medial root to make the main trunk of the median nerve. No branches in axilla, eventually supplies pronator teres, FCR, PL,FDS, thenar muscles, 1st 2 lumbricals and digital nerves. Branches Anterior Interosseous nerve to FPL,FDP (lateral) PQ and wrist joint. Palmar cutaneous branch.
9
Q
What are the 5 stages of embryogenesis?
A
- Cell differentiation
- Morphogenesis
- Pattern formation
- Apoptosis
- Development and Growth
10
Q
What is the embryology of the upper limb?
A
wk 4
limb bud begins to develop
limb bud elongates
wk 5
hand paddle well-formed
nerve trunks enter arm
wk 6 fingers separate (by apoptosis)
wk 7
upper limbs rotate by 90deg & elbow flexes
wk 9-10
finger nails start to form and resembles adult limb
11
Q
What happens in the process of cell differentiation?
A
The process by which individual cells under genetic control become specialised for carrying out specific functions
CONNECTIVE TISSUE (mesoderm) – forms skeletal elements – bone, joints, tendon, ligaments, fascia
MUSCLE migrates in from somites and connects w dorsal & ventral tendons already in limb
VESSELS (Median artery, basilic & cephalic veins) grow in from vascular axis (aorta and cardinal vein). Median artery degenerates (persistent in 10%)
NERVES grow in from the CNS – last to enter – motor axons grow into dorsal & ventral muscle masses before they divide
12
Q
What is morphogenesis?
A
Morphogenesis - formation of shape - e.g. that of individual bones and muscles
- Dorsoventral WNT Pathway
- Wingless = Wnt-7a gene = dorsal patterning
- Engrailed 1 = ventral patterning
- loss of Wnt → double palm, loss of engrailed → double dorsum - Ulnar-Radial (antero-posterior) axis – ZPA
- Sonic Hedgehog gene & retinoic acid signals here
- thumb to little - Proximodistal – AER
- Mesenchymal Interaction
- remove AER - limb development ceases
- duplications and deletions - Hox A-D gene clusters
- mediated by 1-3
- Mutations in Hox d13 are assoc with central polydactyly
- Gli 3 is another gene in limb development→ variety of polydactylies
13
Q
What is apoptosis?
A
- Programmed cell death
- Interdigital mesenchymal cells are inhibited from forming cartilage by ectoderm
- Persistence - syndactyly
14
Q
When does development and growth occur? What are the developmental milestones after birth?
A
In Utero
Foetal period growth – 9-40/40
After Birth At birth → grasp reflex 3 months → power grip with ulnar digits 5 months → finger grip with adducted thumb 7 months → thumb opposition 9 months → small object pinch 10 months → fine pinch 3 – 4 yrs → hand preference established
15
Q
What is the course of the median nerve?
A
Axilla - C5-T1 roots
Arm - initially lateral to brachial artery then → medial
Forearm - under bicipital aponeurosis, b/t 2 heads of PT, emerges & gives off AIN, travels under fibrous arch FDS, b/t FDS & FDP
AIN - Passes downwards on IO membrane between FPL and FDP accompanied by AI artery, Ends on anterior surface of carpus
Wrist - lies b/t PL & FCR
PCBMN arises 6cm proximal to wrist crease
Carpal Tunnel - 10 structures = MN, FPL, 4xFDS, 4xFDP
Hand - enters palm passing behind TCL & divides into muscular, lateral and medial branches
16
Q
What is the nerve of Berettini?
A
Nerve of Berettini - Communication between 4th web CDN (ulnar) and 3rd web CDN (median) just distal to carpal tunnel
17
Q
What branches come off the median nerve?
A
Muscular branches in cubital fossa
- PT, FCR, PL and FDS
Articular to elbow
Anterior Interosseous Nerve
- FPL, radial FDPs, PQ. Wrist, DRUJ, carpus
- IO membrane and radial periosteum
Palmar cut branch
- 6cm prox to TCL → palmar triangle
Recurrent motor branch
- recurrent around lower border of TCL ~1cm distal to scaphoid tubercle
- supplies OP,APB,FPB.
Variations in anatomy. (Lanz 1977) Extraligamentous branch emerging distal to flexor retinaculum and recurrent to thenar muscles (50%).
Sub-ligamentous – under flexor retinaculum and recurrent (30%)
Trans-ligamentous – emerging beneath flexor retinaculum and piercing it (20%)
18
Q
What happens to median nerve after TCL?
A
Lateral branch gives off -
- Muscular to 1st lumbrical
- Cutaneous branch to both sides of thumb and radial side index
Medial branch gives off
- Muscular branch to 2nd lumbrical
- Cutaneous branches to ulnar side of index and both sides of middle and radial side of ring finger
19
Q
What connections may exist b/t ulnar & median nerves?
A
Martin-Gruber Anastomosis
Ulnar intrinsic fibres travel with the median nerve to the forearm (can come from median trunk or anterior interosseous) before crossing to join the ulnar nerve → in high ulnar lesion the intrinsics may be spared.
Riche-Cannieu Anastomosis
Ulnar Nerve fibres contribute to Median Nerve more distally in palm
20
Q
How do you examine the median nerve?
A
LOOK
- wasting of thenar muscles
- sudomotor changes in radial digits
FEEL
- moving 2pd
MOVE At elbow - Palpable tendon of FCR with resisted wrist flexion Anterior interosseous sign – ‘O’ sign – FDP index and FPL. - Pronation of the forearm with elbow extended to neutralise PT (PQ) Motor Branch of Median - APB - Opposition Thumb little OP
Compression tests
21
Q
What are the compression tests of the median nerve?
A
Pronator syndrome
- Ligament of Struthers – resisted elbow flexion
- Lacertus fibrosis – resisted elbow flexion with forearm pronated
- Pronator Teres 2 heads – resisted pronation with elbow extended
- FDS arch - resisted FDS flexion of the middle finger
Carpal tunnel
- Tinel’s - paraesthesia
- Phalen’s
- carpal compression (if wrist stiff)
- reverse Phalen’s
22
Q
What do you find with a median nerve injury at the elbow?
A
Motor
- Pronator muscles, wrist & finger flexors paralysed except FCU and ulnar FDPs.
- Forearm supinated, weak wrist flexion with ulnar deviation.
- No index and middle DIPJs flexion, weak ring - and little flexion.
- Weak MCPJ flexion from interossei.
- No thumb IPJ flexion, thenar eminence wasted. Thumb laterally rotated and adducted. Hand flattened and ape-like.
Sensory
o No sensation radial side of hand and palm.
o Vasomotor – areas warmer and dryer than normal. Due to arterial dilatation and absence of sweating resulting from loss of sympathetic control.
Trophic changes
o Skin dry and scaly, nails crack easily and atrophy of finger pulps.
23
Q
What do you find with a median nerve injury at the wrist?
A
Motor
o Thenar muscles paralysed and wasted. Simian thumb. APB & OP not possible.
o 2 Lumbricals paralysed (make a fist slowly middle and index will lag behind ring and little)
Sensory
o As for elbow lesions.
24
Q
What compression syndromes are there of the median nerve?
A
- Pronator Syndrome - PAIN
- Anterior Interosseous syndrome - MOTOR
- Carpal Tunnel Syndrome (P&N, palm spared)
25
What is pronator syndrome and what are the signs?
Pain in proximal volar forearm ↑ with activity, ↓ median sensation
Tinels at PT
4 sites of compression
1. Between 2 heads of PT
2. Ligament of Struthers
3. Beneath bicipital aponeurosis (lacertus fibrosus)
4. Under arch of FDS
Distinuish from CTS by
- Altered sensation in the palmar triangle → PCBMN
- Tinels +ve over forearm not wrist
- Phalen’s negative
- NCS ↑ latency at elbow or forearm (or no change as intermittent compression)
26
What is the treatment for pronator syndrome?
```
Conservative
Splint (pronation and slight wrist flexion)
and change habits
```
Surgical
dissect out the median nerve from 5cm above elbow to below the bicipital aponeurosis. Release one head of PT, FDS bridge and anything else compressing.
27
What is anterior interosseous syndrome?
- Compression neuropathy of ant interosseus nerve. (FPL, PQ and radial FDP)
- Rare <1% of upper limb compressions.
28
What is the aetiology of AIN syndrome?
```
Tendinous bands
o deep head of PT
o Origin of FDS of middle
o Origin of a palmaris profundus
o Accessory bicipital aponeurosis
```
```
Accessory muscles
o from FDS to FDP
o Gantzer’s muscle (accessory head of FPL)
o Palmaris Profundus
o Flexor Carpi Radialis Brevis
```
Vascular
o Thrombosis of ulnar collateral vessels
o Aberrant radial artery
Other
o Enlarged bicipital bursa
29
What are the symptoms and signs of AIN syndrome?
Symptoms
- Writing gone off
- post-viral
- purely motor paresis but - ache in forearm
- Weak pinch grip esp. FPL weakness
Signs
FPL – absent or weak IPJ flexion
FDP – absent/weak DIPJ flex of index or less commonly middle finger, can't make O sign
PQ – pronate with elbow flexed to reduce power of PT
FDS Middle finger – flexion test
Multiple compression sites in proximal forearm
NCS ↑latency in upper forearm
30
What is the treatment of AIN syndrome
wait 6-12wks
Surgical
- dissect out AIN from origin to lower 1/3 of forearm +/- detach 2 heads of PT
If it doesn't resolve
- internal neurolysis
- tendon transfers
31
Carpal tunnel syndrome
Paget 1954
most common upper limb compression synd
1-10% popn, 60% w repetitive grip tasks
50% b/n 40 – 60, F>M 6:1, 40% bilateral
32
Do you know a classification system for CTS severity?
```
Classification
(Chang & Dellon, J Hand Surg 1993, 18B, 467.)
No impairment
0. Paraesthesia – intermittent
1. Threshold - mild (SWM = 2.83 - 3.84)
2. Abduction - weak
3. Threshold - severe (SWM >3.84)
4. Paraesthesia - persistent
5. S2PD - mild (7-10mm)
6. Atrophy - mild
7. S2PD - severe (>10mm)
8. Anaesthesia
9. Atrophy – severe
```
33
How do you examine for CTS?
Signs
LOOK
thenar muscle atrophy, sudomotor
FEEL
- sensation in median nerve distribution, test palmar triangle
MOVE
Abd PB
Provocation tests
Tinels
Phalen’s (+ve if signs <40 sec) - forearm supinated on pillow
Reversed Phalen’s palms together and raising elbows as high as possible
Median nerve compression test
34
What investigations may be appropriate for CTS?
Electrophysiological changes median nerve distal motor latency >4ms is diagnostic (present in 2/3 of compressed nerves) but normal latency does not exclude TS – 10% NCS are false negative
ESR (if high check for RhA and collagen disorders), Blood sugar, Uric acid, TFTs.
X-rays for compressing source – Carpal tunnel view.
35
What is the aetiology of CTS?
Reduction in size of tunnel or ↑ in contents.
o ↓ tunnel → Acromegaly, Trauma, OA
o ↑ contents → swellings (ganglion, lipoma), inflammation (tenosynovitis, gout, amyloid) Endocrine (pregnant, diabetes, thyrotoxicosis,)
```
Congenital - rare
o median art
o long FDS belly
o abnormal lumbrical
o palmaris profundus
```
Trauma
o Direct – Carpal #, CMC dislocation, lunate disloc
o Indirect – hand trauma / burn → swelling
Swellings
o Ganglion, Fibroma, Lipoma, Aneurysm of median artery
Inflammatory
o RhA Synovitis, Gout, TB, gonorrhoea, Scleroderma, Amyloid
Metabolic
o Pregnancy, Diabetes, Thyroid - Myxoedema, Peripheral neuropathy, vit B6 deficiency
Obesity?
Iatrogenic
Idiopathic
o fibrous hyperplasia of flexor synovium
36
What are the non-operative treatments for CTS?
Non operative
- Activity Modification
- Steroid injection 25mg hydrocortisone
- 80% initial relief
- 1/3 still better at 3/12
- 22% at 12/12
- 11% still better at 18mths
- classical indication is temporary reversible CTS (pregnancy)
- Futuro splint night and protective
- NSAIDs
- Diuretics
37
How do you perform CTS release? What other additional procedures can be done?
Marking
o Fingers adducted, 3rd web to PL
o Longitudinal release of flexor retinaculum (Brain 1947)
o Synovectomy where indicated
o External neurolysis or epineurotomy– not recommended even in selected pts
Endoscopic release
o 1-2 portal technique
o Indications as for open
o Grip strength back quicker. No difference in low-demand hands
Complications
o sensitive volar scar (common) nerve injury, pillar pain, flexion weakness, pisotriquetral pain syndrome, CRPS type 1 (or 2 if nerve injury)
Adjuncts
o Epineurolysis
o Decompress the motor branch if APB weak.
o PL to APB transfer (Camitz opponensplasty) in patients with thenar wasting
o Internal Neurolysis – NO benefit.
38
How do patients recover after OCTR?
- Immediate relief of pins and needles
- s2pd = 2/52
- sensory and motor nerve latencies = 3-6 months
- pinch and grip strength = 6-9 months
39
What are the differences b/t CTS and pronator syndrome?
- Both have numb/paraesthesia in median distribution
- Both have weak thenar muscles
- Both have pain in wrist and forearm
- CTS more night problems
- Pronator syndrome = no Tinels at wrist, NCS not delayed at wrist
- Pronator get dysaesthesia in palmar triangle
- But Phalen’s +ve in 50% of pronator syndrome.
40
What causes recurrent CTS and how can it be treated?
Causes – incomplete release, scar causing new compression, flexor tenosynovitis
Explore if - +ve Phalen’s, night symptoms, +ve NCS after 6 months
Surgery - Re-release TCL, external neurolysis, synovectomy, revascularise nerve with PQ turnover flap
41
What is affected in high and low median nerve palsy?
```
High = Proximal to the origin of AIN (PT, FCR, FDS, radial FDPs, FPL, PQ + Thenar)
Low = Distal to AIN (only Thenar muscles
```
42
What are the causes of median nerve palsy?
Congenital: absence of thenar muscles, Syringomyelia, Charcot-Marie-Tooth (AD hypertrophic neuropathy
Infection: Polio, Leprosy
Trauma, Compression
Spinal Muscular Atrophy
43
What tendon transfer is required for low median nerve palsy?
OPPONENSPLASTY
1. Ring FDS → through palmar fascia → APB or EPB (Royle Thompson)
2. EIP rerouted around ulnar side of hand → APB or EPB (Burkhalter 1973)
3. ADM across palm → APB/EPB (Huber 1921)
4. PL lengthened with strip of palmar fascia → APB (Camitz 1929)
5. Others: ECU (EPB tendon attached to it), ECRL, EDM
44
What tendon transfers are used for high median nerve palsy?
- FCU split to restore balanced wrist flexion
- Re-route biceps to restore pronation
- BR→FPL for thumb flexion
- Opponensplasty using EI or ADM → thumb abduction and opposition
- Suture together ulnar FDPs to median FDPs to get mass action finger flexion
45
What is the course of the ulnar nerve?
C8, T1 +/- C7
Arm: medial to brachial artery, pierces medial fascial septum with superior ulnar collateral artery and enters post compartment
Medial intermuscular septum - medial epicondyle → coracobrachialis
Arcade of Struthers - 8cm prox to medial epicondyle. Made up of corachobrachialis insertion/fascia and superficial muscle fibres of triceps/ intermuscular septum
Elbow: passes behind medial epicondyle (humerus) - Osbournes canal
Forearm: b/t 2 heads of FCU. Supplies FCU, FDP little ring, elbow joint
Pierces flexor-pronator aponeurosis
Travels medial to ulnar artery
Wrist - b/t FCU & FDS, enters palm superficial to TCL & radial to pisiform. Divides into superficial & deep branches in Guyon's canal
46
What branches come off ulnar nerve?
| What communications may exist b/t ulnar and median nerves?
Elbow - FCU, FDP ring & little
Articular br to elbow
Palmar cutaneous to palm - mid forearm
Dorsal or Posterior Cutaneous Branch – from distal 1/3 forearm - dorsum of ulnar side of hand.
Superficial Branch - in palm between pisiform and hook of hamate. Ulnar artery = radial. 2 branches: muscular to PB and cutaneous to ring and little fingers.
Deep Branch - Runs backwards between ADM and FDM before it pierces ODM. Supplies palmar and dorsal interossei, 3rd and 4th lumbricals and Adductor Pollicis.
47
Examination of the ulnar nerve
```
LOOK
Interosseous guttering and 1st dorsal IO wasting
Hypothenar wasting
Ulnar claw hand
Sudomotor skin changes
```
FEEL
Moving S2PD, sharp/blunt, note sensation of dorsal cutaneous branch
MOVE
1. Froment’s test – Add Pollicis
2. Individual Froment’s for fingers – Palm IO
3. Resisted abduction of index finger (1st Dorsal IO) and little (ADM)
4. Flex MCPJ of little with PIPJ straight (FDM)
5. Absent flexion at DIPJs of ring and little
6. C-Spine – Spurling’s test for radiculopathy - Extend neck and rotate head toward affected shoulder whilst exerting pressure on head (axial load on spine)
48
What compression tests can be performed?
Cubital Tunnel syndrome
Phalen’s test (flexion of elbow)
Tinels unreliable
Note lack of claw due to FDP denervated
Ulnar tunnel syndrome (Guyon’s canal)
Pressure over canal
49
What deficits are observed when the ulnar nerve is injured at the elbow?
LOOK
Ulnar guttering, 1st WS & hypothenar wasting
Ulnar forearm wasting
FEEL
paraesthesia in ulnar distribution including dorsum
MOVE
1. FCU and medial 2 FDPs paralysed
- radial wrist deviation
- DIPJ flexion little & ring
2. Froment's sign
3. Inability to wriggle middle finger side to side with palm on table
4. Ulnar claw (main en griffe)
- MCPJ’s hyperextend due to paralysis of lumbricals and interossei (normally flexes MCPJ & extends PIPJ) & unopposed extrinsic extensors
- Fingers don't claw if MCPJs cannot hyperextend
5. Wartenberg's sign: persistent abducted & extended little finger - due to EDM's indirect insertion into abductor tubercle on prox phalanx
Bouvier manoeuvre - manually block MCPJ in 90 deg flexion and ask pt to extend fingers.
Bouvier +ve = finger extends ok → need anticlaw procedure only, because long extensors and IPJs are ok.
Bouvier –ve = finger does not extend at IPJs then it is either
- Passive Positive – can extend IPJs passively = extensor apparatus incompetent
- Passive Negative – can’t passively extend = skin short or flexor adhesions or volar plate contracture etc
50
What deficits are observed when the ulnar nerve is injured at the wrist?
FEEL
Main nerve and palmar cut branch usually divided
Posterior cutaneous branch intact - arises 7 cm above the pisiform.
MOVE
Paralysed small muscles of hand
Claw hand MORE obvious as the FDP is not paralysed so there is marked flexion of the DIPJs = Ulnar Paradox
51
What is the anatomy of the cubital tunnel?
Floor - Elbow capsule and ulnar collateral ligament
Roof - Deep investing fascia of FCU and Arcuate/Osborne Ligament (medial epicondyle to olecranon - slack in extension, tight in flexion)
52
What causes cubital tunnel syndrome?
1. Anatomical
- Arcade of Struthers hypertrophy (aponeurotic band)
- Anconeus epitrochlearis
2. Trauma - acute / chronic (cubital valgus)
3. Recurrent subluxation of nerve
4. Arthritis → cysts or bone spurs
5. Swellings - ganglia, lipoma, osteophytes
53
What are the symptoms of cubital tunnel syndrome?
Pain → medial forearm
↓ sensation in ulnar 1.5 fingers, nocturnal, worse with elbow flexed when sleeping
Weakness in ulnar muscles → esp. Add poll and 1st dorsal IO due to ↓ pinch grip strength and wasting of 1st web.
54
What are the signs of cubital tunnel syndrome?
Dysasthesia - with symptoms on dorsum of hand
Phalens at elbow (Tinels unreliable)
Motor weakness
FCU & 2FDPs less affected than intrinsics
55
Who classified cubital tunnel syndrome?
McGowan 1950
Grade 1 -Minimal compression with no motor weakness
Grade 2 - I - intermediate compression with obvious atrophy
Grade 3 - Severe with paresis/paralysis of intrinsics and/or claw deformity
56
What is the surgical options for cubital tunnel syndrome?
Conservative:
Splint - rolled towel
Surgical: objective = decompression & stabilisation of ulnar nerve and preserve blood supply
Early surgery probably more important
1. In Situ decompression - check elbow flexion. If nerve subluxes then do 1 of the following:
2. Anterior transposition - but risk to FCU muscular branches
3. Medial Epicondylectomy
4. Eaton - Fasciodermal sling in addition to ant transposition
Endoscopic - ?safe
57
Describe the cubital tunnel release procedure
- GA/RA
- Arm tourniquet
- Longitudinal curved Incision 15cm, posterior to, centred on medial epicondyle
- Preserve cutaneous nerve branches - medial cutaneous and medial antebrachial cut br
- Identify cubital canal
- Divide roof of tunnel
- Release proximally (Arcade of Struthers)
- Release into FCU 2-3 cm
- Assess stability
Partial medial epicondylectomy
- Transverse over soft tissues
- Get to bone and stick on bone
- Remove bone generously (osteotome/nibbler)
- NB medial collateral ligament attaches deep and distal
- Close the soft tissues over raw bone
- Mobilise skin & common flexor origin
- Mobilise nerve forwards with blood supply
- Check for distal and proximal tenting
- Proximally = intermuscular septum
- Distally = FCU
- Rehabilitation, gentle EAM. ?splint if epicondylectomy
- Wound massage
58
What are the complications?
General
- Infection
- Nerve injury
- Scar sensitivity
- Stiffness
In particular
- Incomplete recovery
- Instability
- Recurrent symptoms
59
What is Guyons canal / ulnar tunnel syndrome? What is the aetiology?
Volar carpal ligament – less rigid than TCL. Not a discrete tunnel
No synovium in tunnel → no synovitis
Causes = trauma or abnormal anatomy (anomalous hypothenar muscle, ganglion)
Trauma – single heavy blow or repetitive occupational trauma → thrombosis of ulnar artery (hypothenar hammer syndrome), # hook of hamate
60
How can ulnar tunnel syndrome be classified?
Zone 1 Mixed - hamate fracture / ganglion
Zone 2 Motor - hamate fracture / ganglion
Zone 3 Superficial sensory - ulnar artery thrombosis
61
What are the symptoms and signs?
Pain in hand and forearm, weakness, paraesthesia, hypaesthesia
+/- motor deficit +/- intrinsics +/- hypothenars +/- ADM
```
LOOK: Claw
FEEL: Sensation, ↓ dorsal sensory branch spared
MOVE:
Motor loss.
Wasting of hypothenars.
Weak key pinch.
+ve Froment’s.
```
62
Are there any diagnostic tests and what is the treatment?
NCS ↓ conduction velocity at wrist
Guyons canal decompression (incision along radial border of FCU)
BUT if have CTS too then do JUST CTR first.
63
What motor deficits are observed in ulnar nerve palsy?
Motor Deficits
1. ↓ thumb adduction (adductor pollicis)
2. add and abd ↓ in fingers
3. Ulnar claw – hyperextension of MCPJ+ flexion of PIPJ and DIPJ of little and ring.
Ulnar paradox – the more distal the injury the worse the deformity → in a high ulnar lesion the FDPs are injured so can’t flex but in low lesions FDP is OK so these flex the fingers down.
64
What tendon transfers may help function in ulnar nerve palsy?
1. Improve thumb adduction
(a) FDS 3 or 4 detached distally and attached to insertion of adductor pollicis.
(b) ECRB lengthened with tendon graft and inserted into adductor tubercle of thumb
(c) BR + tendon graft → passed into palm from dorsum through 3rd web → insertion of Add Pol.
2. Correct claw deformity
Surgery to limit MCPJ hyperextension & control claw.
(a) Zancolli lasso → FDS slips divided at insertion and reflected proximally volar to A1 pulley and attached proximally to themselves. Lasso around A1 limits extension of MCPJ.
65
What course does the radial nerve take?
C5,6,7,8, T1 roots of plexus
- From posterior cord, largest branch of plexus
- Nerve of the extensor compartments of arm and forearm.
- Lies on tendon of LD, through triangular space (Humerus/Teres Major/Long head of triceps)
- With profunda brachii vessels spiral behind humerus from medial to lateral separated from the bone by medial head of triceps in upper part
- In contact with periosteum in lower end of groove deep to lateral triceps.
- Pierces the lateral IM septum (10-12cm proximal to the lateral epicondyle) → anterior compartment → cubital fossa under brachioradialis.
- In flexor compartment descends between brachialis and BR.
- Gives off PIN (deep branch – purely motor) in cubital fossa.
- PIN goes under supinator and Arcade of Frohse.
- Superficial branch runs from cubital fossa on the surface of supinator, pronator teres tendon and FDS on lateral forearm under the brachioradialis. Lies on radial side of radial artery under BR.
- A few cm before radial styloid goes back under BR tendon (anatomical snuff box) to the surface and goes over EPL tendon.
66
What is the anatomy of the radial tunnel?
5cm long
Begins: anterior to humeroradial joint (cubital fossa)
medial wall = biceps tendon
floor = radiocapitellar joint capsule
lateral wall = ECRL ECRB and BR
roof = BR (spirals around and over nerve, lateral → anterior direction)
Ends: just distal to the arcade of Frohse (at the prox end of supinator)
Surgically: ends at distal end of supinator
67
What are the branches of the radial nerve?
SENSORY
1. Posterior Cutaneous Nerve of Arm - extensor surface to elbow (axilla)
2. Lower lateral cut nerve of arm - lateral surface arm to elbow (spiral groove)
3. Post cut nerve of forearm - extensor surface of forearm to wrist (spiral groove)
4. Sup Branch Radial - dorsum of hand (Cubital fossa)
Motor branches (prox to PIN) to:
1. Triceps (3 heads)
2. Branch to Anconeus
3. Lateral part of Brachialis
4. Brachioradialis (supinates)
5. ECRL
68
What are the branches of PIN?
B/t 2 layers of supinator → extensor compartment.
Sensory to interosseous membrane, periosteum of radius and ulnar and the wrist and carpus.
Motor
1. ECRB (Cubital fossa)
2. Supinator (Cubital fossa)
3. EDC
4. EDM
5. ECU
6. APL
7. EPL
8. EPB
9. EIP
69
What are the normal injury patterns and what are the causes?
```
Axilla
- Sat night palsy, crutches
- fractures prox humerus
- shoulder dislocation
→ can't extend elbow
→ wrist drop
→ can't extend fingers (IPJ extend because of intrinsics)
→ Sensory loss posterior surface of lower part of arm, narrow strip on dorsum of forearm and dorsum of hand.
```
```
Spiral Groove
- fractures
- prolonged tourniquet, pressure from op table
- penetrating injury
→ wrist drop, can extend elbow
→ dec sensation in hand only
```
```
PIN Injury
- Fractures of proximal radius
- Dislocation of radial head
→ weak wrist extension (no ECRB, but ECRL present)
→ Finger extension reduced
→ No sensory loss
```
SRN
- Penetrating injury
→ Sensory: snuff box area
70
Radial nerve examination
LOOK
- Sudomotor Changes in superficial branch
- Wasting of triceps, BR and extensor compartment
FEEL
- Moving S2PD, Sharp/blunt sensation
MOVE
1. Above elbow
o Elbow extension (Triceps)
2. At elbow
o Elbow flexion arm in mid-pronation to neutralize biceps (BR)
o Wrist extension and radial deviation, fist clenched (ECRL and ECRB)
3. Below elbow (PIN)
o Supination with the elbow extended to neutralise biceps (Supinator)
o Thumb extension with the palm flat (EPL)
71
What provocation tests are there for radial nerve compression?
Radial Tunnel Syndrome
1. Middle finger test
o resisted extension of the middle finger
o ECRB inserts into base of 3rd MC, tendinous medial edge compresses radial nerve in radial tunnel (b/t supinator and head of radius).
2. Resisted supination with elbow extended
(to eliminate biceps)
Wartenberg’s Syndrome
o Dysaesthesia with compression of the superficial branch.
o Finkelstein test (de Quervain’s) may be misleadingly positive
72
What radial nerve compression syndromes are there?
1. Radial Tunnel Syndrome (most common)
2. Posterior Interosseous Syndrome
3. Wartenberg’s Syndrome
73
What is radial tunnel syndrome and where are the points of constriction?
Radial nerve enters radial tunnel, gives off PIN and then becomes sensory
ECRL and BR not PIN – direct from main nerve
4 constriction points in radial tunnel
1. Medial border of ECRB
2. Leash of Henry = Fan of vessels from radial recurrent artery
3. Arcade of Frohse = free aponeurotic proximal margin of supinator (PIN passes beneath this = PIN SYNDROME) – compressed between this and radial head
4. Fibrous bands tethering nerve to radiohumeral joint
74
What are the symptoms of RTS?
M=F, 30 – 50yrs, usually dominant side.
Pain in radial tunnel (usually only symptom)
- localised to the extensor mass just below elbow
- radiates to dorsal wrist
- worse with use
75
What are the signs of RTS?
1. Sensory in hand
2. Tender supinator
(Palpate lateral epicondyle → 4 fingers distal, radial head then radial tunnel)
3. Wrist extension weakness → reduced grip strength (less common)
4. reduced finger extension (2ndary to pain or PIN palsy).
5. Pos middle finger test
Distinguish from tennis elbow (pain over lat epicondyle)
76
What investigations aid diagnosis and what is the treatment of RTS?
Investigation
- Intermittent, NCS may be -ve
- Pre op nerve block - good prognosis if symptoms are relieved
Management
1. Try rest, wrist brace to prevent wrist flexion, exclude lateral epicondylitis with steroid injection.
2. Decompression
- BR muscle-splitting or anterolateral approach
77
What is the classification for Posterior Interosseus Nerve Syndrome?
Classification (Hirachi 1998)
I Complete Palsy
II Loss of little, ring and middle finger extension (recurrent branch)
III Loss of extension and abduction of thumb and extension of index (descending branch)
78
What aetiological factors are there for Posterior Interosseus Nerve Syndrome?
1. Anatomical: Postural/Occupational – distal edge of supinator compression
2. Trauma – dislocated elbow, #/dislocation of radial head
3. Inflammatory – synovitis RhA radiohumeral joint, subluxation of radial head
Bicipital Bursitis
4. Swelling – ganglia ,lipoma, fibroma
5. Iatrogenic – injections for tennis elbow
79
What are the symptoms for PIN syndrome?
- Pain first
- Weakness and Paralysis later (gradual / sudden onset)
- NO sensory disturbance – so distinguishes it from radial nerve syndrome.
80
What are the findings on examination?
```
NO sensory changes
LOOK
wasting of extensor mass except BR + ECRL
MOVE
weak wrist extension
Extrinsic minus hand - Attempting extension of fingers results in full extension of IPJs but only 45° of MCPJ extension
exclude intrinsic tightness
weak thumb radial abduction (APB & AP)
```
81
What is Wartenberg syndrome?
Radial sensory nerve entrapment
1. under BR (6-8 cm prox to radial styloid)
2. edge of ECRL
3. anomalous fascial bands
4. handcuffs, tight jewellery or watches
neuritis of SBRN
Tender 4cm proximal to wrist, exacerbated with wrist movement
Numb or pain in distribution
Treatment
splint
release, neurolysis, step lengthening of BR
82
What are the motor deficits in complete radial nerve palsy?
1. ↓ wrist extension
2. ↓ finger extension
3. ↓ thumb abduction and extension
Treatment
early nerve repair
late nerve repair with interposition graft (<5cm)
Tendon transfers
PT → ECRB - wrist extension
FCU (or FCR, FDS) → EDC - finger extension
PL (or FCR, FDS) → EPL - thumb extension
83
What is the difference between intrinsic tightness and extrinsic tightness?
Bunnell-Littler test
- hold the MP joint in maximum extension and passively flex the PIP joints
- now hold MP joints in flexion and passively flex the PIP joints.
If the PIP joint can be passively flexed more when the MP joints are flexed than they can when the MP joints are in extension = tightness in intrinsic muscles.
Extrinsic Tightness test
- do the same test in both positions
- results are opposite.
If you can passively flex the PIP joint more when the MP joint is extended then you can when the MP joint is flexed = extrinsic tightness.
84
What are the symptoms of RTS?
M=F, 30 – 50yrs, usually dominant side.
Pain in radial tunnel (usually only symptom)
- localised to the extensor mass just below elbow
- radiates to dorsal wrist
- worse with use
85
What are the signs of RTS?
1. Sensory in hand
2. Tender supinator
(Palpate lateral epicondyle → 4 fingers distal, radial head then radial tunnel)
3. Wrist extension weakness → reduced grip strength (less common)
4. reduced finger extension (2ndary to pain or PIN palsy).
5. Pos middle finger test
Distinguish from tennis elbow (pain over lat epicondyle)
86
What investigations aid diagnosis and what is the treatment of RTS?
Investigation
- Intermittent, NCS may be -ve
- Pre op nerve block - good prognosis if symptoms are relieved
Management
1. Try rest, wrist brace to prevent wrist flexion, exclude lateral epicondylitis with steroid injection.
2. Decompression
- BR muscle-splitting or anterolateral approach
87
Musculocutaneous nerve anatomy and branches
C5-7
Motor branches
1. Coracobrachialis
2. Biceps brachii
3. Brachialis (also has small radial n supply)
Sensory branches
1. Lateral antebrachial cutaneous nerve (lat cut n of forearm)
2. Articular branches to elbow
88
What are the signs of MC nerve injury?
Signs
- weakness of elbow flexion (CB, B &Br)
- brachialis has small radial supply, BR and ECRL can flex elbow with forearm pronated
sensory loss in forearm
89
How is the nerve explored?
| What can be done for biceps reconstruction?
explore deltopectoral groove and where nerve enters coracobrachialis
1. free muscle transfer e.g. gracilis and re-innervated with motor branch of musculocutaneous nerve.
2. LD or Pec Major flap
90
When are muscle / tendon transfers indicated?
1. Nerve injury
2. Muscle / tendon injury secondary to trauma or rheumatoid arthritis
3. Spastic disorders (cerebral palsy, arthrogryposis)
4. Polio
5. Leprosy
91
What are the principles of tendon transfer?
Aim: to identify specific task deficits and re-establish this function through the use of existing muscles / tendons
Existing donor muscle should
1. Adequate power (1 MRC grade will be lost on transfer)
2. Expendable
3. In a straight line of pull (only change direction once)
4. Passage through vascularised tissue planes, tissue in equilibrium (i.e. not dense woody oedematous tissue)
5. Adequate excursion - wrist tendons 3cm, finger extensors 5cm, finger flexors 7cm.
6. 1 function per muscle transferred
7. Stable joints proximally
8. Ideally sensate recipient site
9. Transfer within synergistic muscle groups e.g. wrist flex, finger extend, wrist extend, finger flex
10. Patient: compliant, well-motivated patient, adequate local hand therapy services
92
What are the contraindications of tendon transfer?
Advanced age (reduce recover, re-education and reduced demands)
Poor motivation / compliance
Lack of specific task deficit
Local or systemic disease affecting surgery e.g. RA should be controlled
93
What tendon transfer options are there for:
| low median nerve palsy?
OPPONENSPLASTY
1. Camitz - PL with strip of palmar fascia
2. Bunnell - FDS ring with pulley around FCU
3. Burkhalter - EI brought around ulnar side of wrist to palmar surface
4. Huber - AbDM (esp congenital hypoplastic thumb)
94
What tendon transfer options are there for:
| High median nerve palsy (elbow)?
Muscle weakness → donors available
1. Thumb muscles → OPPONENSPLASTY
2. FPL → BR (or ECRL/B)
3. FDS, ulnar FDPs → tenodese to ulnar FDPs
4. FCR, PL → FCU split
5. PT → Biceps
95
What are the signs of ulnar nerve palsy?
Froment's sign = hyperextension of thumb IPJ
Jeanne's sign = hyperextension of MCPJ with key pinch
Duchenne's sign = Clawing - MCPJ hyperextension, inability to fully extend IPJs of little and ring due to absent intrinsics
Petrus-Testu sign = cannot make cone shape
96
How do you treat a:
| Low ulnar nerve palsy - claw hand (injury at wrist)
1. Claw correction
→ FDS to radial lat band / A1 pulley
→ Zancolli lasso - FDS looped back on itself around A1 pulley
→ ECRL
→ Zancolli capsulodesis (VP stitched down to flex MCPJ)
```
2. Restore key pinch (lumbricals absent)
→ BR + PL graft (Boyes)
→ ECRB + PL graft (Smith)
→ FDS ring / middle (Littler)
→ MCPJ / IPJ arthrodesis
```
3. Thumb adduction (AP absent)
→ BR + graft
3. Correct Wartenberg's sign (unopposed EDM due to absent palmar I/O)
→ reroute EDM ulnar slip to radial PP collat lig
97
How do you treat a:
| High ulnar nerve palsy
Muscle weakness → donors available
1. FCU → split FCR
2. FDP ring and little → suture to radial FDPs
98
How do you treat a:
| Radial nerve palsy
Muscle weakness → donors available
1. BR → resite flexor mass higher on humerus
2. ECRB → PT + periosteum strip (to ECRB = base of 3rd MC - more central)
3. EC, EI, EDM → FCU / FDS middle ring (routed through a I/O membrane in forearm)
4. EPL → PL or FDS middle
99
What is the post-operative care following tendon transfers?
4-5wks : splint in position of function
then night splints
6-8wks : mobilise under supervision until strength regained
100
What are the complications?
ruptures
adhesions
inadequate tension
101
What are the common mechanism of closed brachial plexus injuries in adults?
- traction, crush and compression
- caudal traction → upper trunk injuries
- traction of abducted arm → lower trunk
- ant to post force to shoulder → C7
- anterior dislocation of shoulder → axillary and suprascapular nerve injury
102
What is the best method to determine level and severity of a brachial plexus injury?
Thorough hx and examination
Electrodiagnostic - NCS, EMG
Radiology - cspine, CXR, CT myelogram, MRI
Angiography
103
What are the common clinical patterns of closed brachial plexus injuries in adults?
Supraclavicular (proximal) injuries
(a) Erb's palsy - C5,6 (waiter's tip posn)
suprascapular n (supra and infraspinatus)
axillary n - deltoid
musculocutaneous n - brachialis, biceps
If C7 also injured → weak elbow wrist and finger extension
(b) whole plexus injury
flail arm
(c) Klumpke's palsy - C8, T1 (rare)
loss of hand function with sparing of elbow and shoulder
Infraclavicular injuries
loss of shoulder abduction and flexion +/- hand wrist and elbow function
104
What is the significance of a pre and postganglionic brachial plexus lesion
Postganglionic = Tinel's +ve = can be grafted and has regeneration potential
Preganglionic lesion = root avulsion = injury within intervertebral foramen proximal to sensory root ganglion. No regeneration potential.
105
What electrodiagnostic evaluation is useful to determine pre or postganglionic lesions?
CMAPs (compound motor action potentials)
- absent in both pre and post ganglionic
SNAPs (sensory nerve action potentials)
- preserved in postganglionic
106
What is noted in a preganglionic injury?
What treatment will they require?
Tinels -ve
Horner's syndrome (ipsilateral ptosis, miosis, anhidrosis, enophthalmos) - due to interruption of sympathetic fibres to the face, from a root avulsion of C8 T1
serratus ant, rhomboids, hemidiaphragm paralysis
transverse processes fractures
CT myelogram - traumatic meningoceles
MRI - proximal nerve lesions
Preganglionic lesions will require nerve transfers and not nerve repair or graft
107
What techniques are used in reconstruction of the brachial plexus?
NERVE TRANSFERS
1. Oberlin - FCU to musculocutaneous nerve → biceps
2. spinal accessory → suprascapular nerve
3. radial nerve long head of triceps branch → axillary nerve
4. fascicle to FCR → BR?
NEUROTISED FREE MUSCLE TRANSFERS
CABLE GRAFTS
SHOULDER FUSION
108
What are the degrees of nerve injury?
Seddon
Neuropraxia - demyelination injury
Axonotmesis - nerve fibre injury
Neurotomesis - transection of nerve trunk
1st - 5th degree (Sunderland)
109
What is the optimal timing of exploration?
- intervention and reconstruction if no signs of recovery after 12wks
- op too early - may downgrade function of a nerve that would otherwise regenerate spontaneously
- op too late - reinnervation successful but functionless muscle
1wk - muscle atrophy starts
3mths - progressive interstitial fibrosis
18-14mths - motor end plates deteriorate
110
Obstetric palsy causes
What are the indications for exploration?
1:10000 births
breech delivery
large infants - shoulder dystocia
Indications for exploration
- absence of any return of biceps or deltoid function by 3 mths
- absence of elbow flexion/extension, wrist extension, thumb/finger extension by 9mths
111
Thoracic outlet syndrome anatomy
- Results from compression of the subclavian vessels and brachial plexus in the base of the neck.
- Constricted in triangle of - Scalenus anterior (anteriorly) Scalenus medius (posteriorly) and 1st rib (inferiorly).
112
What are the causes of TOS?
Cervical ribs (present in 0.5% of normals and 10% of thoracic outlet)
Rudimentary 1st ribs
Abnormal scalenes
Bone or soft tissue tumours → inc lung apex
Trauma i.e. # clavicle
Poor posture
113
What are the symptoms of TOS?
Neurogenic or vascular often vague
Provoked by activities such as carrying heavy loads or working with arms overhead.
Neurogenic symptoms (90% of cases)
Pain, paraesthesia, weakness, sympathetic symptoms.
Vascular symptoms (10%)
Claudication, splinter haemorrhages and digital emboli,
Venous engorgement of the limb.
114
What findings are there in TOS?
Assess sensation and motor function
Auscultate over the subclavian artery with arms dependent then raised
Differential blood pressure between the limbs with arms dependent then raised
Specific provocation tests
115
What investigations are used to diagnose TOS?
Chest and C spine x-ray → bony abnormalities / lung path
CT/MRI scanning → space occupying lesions.
Angiography or venography.
116
What is the medical and surgical management of TOS?
Medical
o Analgesics, Carbamazepine, amitriptyline, benzodiazepines and NSAIDS
o 75% of pts improve with physio
```
Surgical
o Exploration and decompression
o Supraclavicular (Adson) → generally used as get the best exposure.
o Transaxillary (Roos)
o Posterior parascapular (Claggett)
o Transthoracic
```
117
For tendon transfers:
What are the patient selection factors?
What are the recipient site factors?
Patient Selection
- Well motivated
- understands nature and limitations of surgery
- co-operates with post op physio
Recipient site factors
- Good soft tissue cover
- Stable skeleton
- Full passive ROM
- Normal sensation
118
What are the donor muscle factors for tendon transfers?
```
Amplitude of motion→ similar excursion
Power and control → similar pull
One tendon – one function
Synergistic Action
Line of Pull
Expendability
```
APOSLE
119
Elaborate!
Amplitude of motion→ similar excursion
o Wrist flex and ext = 3 cm Finger extensors = 5cm Finger flex = 7cm
o Effective amplitude of donors can be ↑ by use of tenodesis, freeing fascial attachments of the donor muscle unit.
Power and control → similar pull
o Motor power 5 = good, 4 acceptable, 3 poor.
o Not good after reinnervation.
o BR does not adapt well (naughty boy of the wrist!)
o Loose at lease 1 grade after transfer.
One tendon – one function
o effectiveness if try to do 2 functions
Synergistic Action
o Muscles which normally act together to produce a composite movement should be used to replace each other whenever possible.
o Finger flex assoc with synergistic wrist extension
o Finger ext assox with wrist flex
o A transfer of a wrist flexor to a finger extensor = synergistic → better function
Line of Pull
o Best if travel directly from their origin to their insertion
o Deviations around pulleys ↓ effectiveness
Expendability
o Only transfer expendable tendons
o Important that one wrist flexor remains intact when producing wrist and finger extension in radial palsy.
120
What is the surgical technique for tendon transfers?
1. Operate in reverse order → prepare recipient site and tunnel before raising the muscle
2. Avoid interference with other structures → ensure transfer does not press on nerves etc
3. Apply correct tension → EIP to EPL need to start tight as loosen. Opponensplasties should start looser to avoid adduction deformity of the thumb.
121
What are the main nerve transfers?
Donors
1. intercostals
2. spinal accessory (distal, so u don't denervate trapezius)
3. ulnar (isolate fascicle, not for intrinsics)
4. median (fcr branch)
5. radial
spinal accessory to suprascap
→ shoulder control
oberlins transfer
→ biceps and brachialis function
→ median to biceps, ulnar to brachialis
somsak transfer
→ deltoid function
→ motor to long head of biceps
intercostals
→ biceps triceps function
Functional muscle transfer
1. gracilis
2. biceps tendon or distal …..
122
Summarise the nerve roots and associated movements (myotomes)
```
movements
c5 shoulder abduction, ext rotation
c6 shoulder adduction, elbow fl
c5 triceps ext, forearm ext
c8 long flexors
t1 intrinsics
```
main plexus – behind clavicle
cords – behind pec minor
123
What are the injury patterns?
injury – open / closed (ruptures (supra&inf clav), avulsion (supraclav only)
conduction block - compression from haematoma, clavicle (should improve with removal of compression)
anatomic location – supra/infraclavicular, mixed pattern – don't mention!!
functional deficit – which nerve?
high / low energy (e.g. subclavian rupture, trochanteric fracture, dislocation = hi energy)
patterns – extended arm (axillary nerve, musculotcutaneous nerve), shouder luxation (axillary nerve), diffuse
can't externally rotate – is it ext rotator cuff tear?
124
What are the strategic aims of brachial plexus surgery?
1. Shoulder – fusion, (for stability) abduction, external rotation (mvmt)
2. Elbow extension (he says is more impt than flexion!!)
3. Elbow flexion
4. RELIEVE PAIN
No point reinnervating hand if upper jts not working
125
What is the timing of surgery?
Timing of surgery
- Primary
- Recovery
- Palliative surgery (bone, tendon, free functional muscle transfers)
Progressive approach = Early exploration
- direct assessment – intraop neurophysiology, see, and feel nerve
- dissection, degeneration, end plates, evidence
Traditional approach
- wait 3mths, and see if there is any recovery, preservation, maximise
125
What is Wartenberg's sign?
When the little finger is slightly more abducted when compared to normal hand. This occurs because the 3rd palmar interosseous muscle which addicts the little finger is paralysed. The unopposed EDM and EDC (radial innervation) causes the slightly more abducted position.
