Compression Neuropathies Flashcards
There is no single decompression technique at the cubital
tunnel that has been shown to be superior
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Recovery of index and thumb flexion strength is generally
rapid following release ofthe median nerve at the pronator
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Initial symptoms of nerve compression are paresthesia and deep
aches.
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Recovery depends upon
duration and degree of compression and damage, secondary factors
such as hypertension, diabetes, and hypothyroidism, and the presence
of multiple sites ofcompression
the presenting complain of nerve compression
Numbness
Sensory loss is measured subjectively or quantitatively
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Abnormal deep tendon
reflexes are signs of nerve root or spinal cord compression
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The roles ofultrasound, MRI, and
MR neurograms in evaluation ofperipheral nerve compression are
controversial
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MRis can show painful conditions that are not apparent on plain
radiographs, such as ligament or cartilage tears, and ganglion cysts
and other soft tissue processes
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patients can have grossly abnormal tests with no symptoms
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Patients should stop taking anticoagulants before surgery
F Patients may often continue taking anticoagulants because expected
blood loss is minimal
The use of a tourniquet is not necessary for the majority of patients,
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persistence of symptoms for
9 to 12 months is a reasonable indication for surgical
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There is rapid deterioration, a diagnosis of tumor, or penetrating trauma in this case we need to urgent intervention
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Routine postoperative splinting is not indicated,
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CTS is the most commonly recognized compressive neuropathy in
the upper extremity,
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The sensory part of the median nerve
innervates the the thenar eminence.
F innervatesthe volar surfacesofthe thumb, index finger, long finger, and the radial halfofthering finger, but not the thenar eminence
Most cases ofCTS are presumed to be idiopathic in origin
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Causes of carpal tunnel syndrome
idiopathic
metabolic (obesity, diabetes, pregnancy, hypothyroidism, renal failure, amyloidosis, autoimmune disease)
infectious (leprosy)
mechanical (trauma, large lumbrical muscles, fibrosis of the tenosynovium
Early symptoms of CTS
Early symptoms of CTS include aching pain in the carpal tunnel area, numbness and/or tingling in the tips of the radial digits,
particularly at night or on waking
There is no single clinical finding that defines CTS
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Wrist splints decrease tendon excursion and hold the wrist in a position ofdecreased tunnel pressure
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Hand exercise (tendon excursion
under load) tends to aggravate CTS
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stretching exercises
seem to reduce swelling, and thus pain
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Direct intraneural injections can cause severe,
irreversible nerve damage
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Diuretics and oral steroids are notindicated
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The TCL and distal
antebrachial fascia of the forearm are divided via a palmar incision
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Internal neurolysis is indicated in most cases
F Internal neurolysis is not indicated in most cases
Revision surgery or
decompression in the setting of rheumatoid arthritis generally calls
for an extended incision crossing the wrist crease
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Long-term
relief of symptoms is achieved in up to 91% of cases
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Surgical complications
are pillar pain (aching of the proximal palm), tendon subluxation
over the hook of the hamate, and injury to the ulnar nerve and local
median nerve branches
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Revision carpal tunnel surgery can be performed
endoscopically,24 or open with or without hypothenar fat grafting
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Pronator syndrome is becoming recognized as being
more common than previously thought
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In CTS the pain is away from the site of compression
F At the site of compression
compression of the median nerve
at the elbow causes pain in the hand or wrist: there is no spontaneous pain in the region of the pronator
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Th site of pain in pronator syndrom
Pain is typically in the palm,
wrist, and distal forearm and is exacerbated by activities involving
sustained forearm pronation.
the presenting symptoms of crapal tunnel is sensory whule in pronater syndrom is motor
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The involved mucsle id FPL and FDP of index pronator quadratus (PQ)
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Numbness with PMNE is a relatively late symptom and typically occurs at nigh
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The thenar area tends to be spares ,
distinctly different from CTS
F The thenar area tends to be involved,
distinctly different from CTS
Thenar
muscles maintain normal strength with PMNE
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numbness related to PMNE can be provoked
by firm palpation of the median nerve just proximal and distal to the
elbow crease and with pronation against resistance. Numbness occurring in less than 60 seconds is considered abnormal
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Weakness of FDP IF and FPL resolves
immediately in the recovery room following surgical release.
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The area of possible compression of the median nerve around the elbow.
From proximal to distal,
fascia of Struthers, the ligament of Struthers (if present),
the deep fascia of the proximal pronator teres muscle,
the bicipital aponeurosis,
the deep fascia of the ulnar origin of the pronator teres muscle,
the deep fascia of the humeral origin of the pronator teres muscle,
and the fascia of the arch of the superficial flexors
If wrist pain
is the main indication for surgery, release of the bicipital aponeurosis
under local anesthesia can be highly effective with a quick recovery
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spontaneous AIN palsy,
expressed as an acute loss of active flex.ion of the FPL and the FDP IF
and paralysis of the PQ
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The differential diagnosis od AIN
includes
Parsonage-Turner Syndrome and Kiloh-Nevin Syndrome
Cubital tunnel syndrome is the second most commonly recognized
compressive neuropathy in the upper extremity
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most common
sites of compression of the ulnar nerve?
the Arcade of Struthers and intermuscular
septum proximal to the elbow, Osborne ligament at the medial epicondyle, and the pronator muscle and flexor fascia distal to the elbow
Risk factors for cubital tunnel syndrome
include male gender, performance of heavy manual labor, and tobacco use
Early symptoms include numbness and tingling along the ulnar aspect of the hand
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How you can distinguishes compression of the ulnar nerve in the elbow from the wrist?
An altered sensation of both the dorsal and volar aspects of the ulnar hand occurs with elbow compression
At the wrist causes numbness on the volar surface of the hand
compression may be present at both
sites
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weakness of ulnar-innervated muscles, a positive Froment sign, and loss of ability to concomitantly flex the MCP joints and extend the PIP
and DIP joints (the ulnar negative posture)
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In the case of Intrinsic muscle atrophy combined with sensory loss without a peripheral explanation what is mean?
an unusual underlying neurologic
disorder such as Charcot-Marie-Tooth, or syringomyelia
Loss of
muscle strength with a normal sensory exam mean what ?
Is an early sign of amyotrophic lateral sclerosis
Electrodiagnostic tests, ultrasound, and MRI have all been used to
isolate the level ofcompression and look for other pathology
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for mild disease treatment
Nonoperative management with night splinting, physical therapy,
and activity and postural modification is indicated
Surgical treatment incude anterior (subcutaneous) transposition, and intra- or submuscular transposition of ulnar nerve
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simple decompression
for mild disease
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submuscular transposition for severe or recurrent disease
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Positive functional and sensory outcomes of cubital tunnel release are high and have been
measured at 77% to 86% 1 year after surgery
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ulnar nerve passes between the hamate
and pisiform dorsal to the palmar carpal ligament and volar to the carpus
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studies have shown improvement
in ulnar nerve symptoms after median nerve decompression alone
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The incision extends from approximately 4 cm proximal to the wrist crease over the flexor carpi ulnaris (FCU) tendon onto
the hypothenar eminence.
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Radial nerve
entrapment with palsy is relatively rare and presents as loss of finger
extension
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the site of neuropathy is proximal to the posterior
interosseous nerve (PIN), lead to loss of finger extension
F loss of wrist extension
The most vulnerable
area ofthe radial nerve is in the spiral groove along the lateral aspect of
the distal humerus.
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Saturday Night Palsy
temporary paralysis ofthe motor aspect of the radial nerve from sustained local pressure on this aspect of the upper arm while sleeping or unconscious
due to intoxication and generally resolves completely
Radial tunnel syndrome (RTS), defined as pain without weakness in the dorsal forearm and wrist
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Provakting test for radial tunnel syndrom
resisted supination
extension of the wrist
isolated middle finger extension
41% overlap with lateral epicondylitis,
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Electrodiagnostic studies are
helpful for evaluating either condition(RTS &epicondylitis)
F Electrodiagnostic studies are
not helpful for evaluating either condition
sometimes resolve spontaneously
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posterior approach in RTS
an be tedious
because of arborization of the motor nerves to the finger extensors
The anterior approach
avoids intramuscular dissection but requires
attention to cutaneous nerves and numerous enveloping vessels
Muscular dissection through the extensor carpi radialis brevis may
result in a wide scar
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The structure that need to release
fascia of the supinator is released over the PIN (the arcade of Frohse),
and a transverse tenotomy of the common extensor fascia
The other cause of PIN compression
Parsonage-Turner (neuralgic amyotrophy)
and spontaneous hourglass deformity of the nerve
Compression can
lead to loss of wrist extension
F Compression can
lead to loss of finger extension and radial deviation on extension
Treatment of PIN ?
exploration and release of the
arcade of Frohse is indicated ifthere is no recovery after 6 weeks
Wartenberg Syndrome (WS) or cheiralgia paresthetica?
Radial sensory nerve entrapment in the distal forearm
provocation of
symptoms
ulnar deviation, wrist flexion, or resisted pronation
The differential diagnosis of distal radial forearm pain
de Quervain tenosynovitis,
thumb carpometacarpal osteoarthritis,
lateral antebrachial cutaneous neuritis, intersection syndrome,
proximal nerve compression
Dorsal-radial wrist/hand
pain that responds to a nerve block will reliably respond to surgical
decompression
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WS vs de Quervain tenosynovitis
WS mimics de Quervain tenosynovitis but does not
improve with a steroid injection to the first dorsal extensor compartment
A longitudinal incision is made at the point of maximal
tenderness along the radial forearm where the nerve emerges from
beneath fascia
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the AIN is not a pure motor nerve. The AIN is a motor nerve to the FPL, FDP IF, and PQ, and terminates in a large sensory nerve
to the volar wrist bones
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