Functional Flashcards
Carpal Tunnel: Symptoms and Workup
Compression of median nerve
Numbness in thumb/first 4 fingers
Workup: Tinel and Phalen sign, EMG (median nerve conduction slowing and axonotmetic grade loss)
Carpal Tunnel - Differential Diagnosis
Carpal tunnel
Cervical radiculopathy
Thoracic outlet
Pronator Teres (differentiate by EMG)
Carpal Tunnel - Indications, Walk through the steps
Avoid exacerbating symptoms, keep wrist in neutral, steroid injection
If severe -surgical approach
- Midline incision ~5cm from distal wrist creast between middle and ring finger
- Dissect skin and subq tissue
- Identify transverse carpal ligament and distal fat pad
- Minimize cutting recurrent motor branch of median (coming off radial side)
- Cut the transverse carpal ligament
- 4-0 nylon mattress sutures
- COnfirm movement of thenar muscle - ensure recurrent motor branch has not been cut
Post op: gentle exercise of wrist and joints, resume activities in 2-3 months
Anterior interosseous syndrome
“O-K sign deficit”
Flexor pollicis longus - impaired thumb flexion
Flexor digitorum profundus of index/middle finger - weak DIP joint flexion
Pronator quadratus - weak pronation
A motor branch of median nerve, resulting in weakness of forearm WITHOUT sensory loss
“Benediction Sign”
Complete median nerve (motor and sensory)
Proximal to AIN
Cannot bend index finger at all (no flexor digitorum superficialis)
Often traumatic
(Trying to flex fingers)
“Claw hand”
Ulnar claw
Cannot straighten the 4th and 5th digit
Lower ulnar nerve lesion (below the elbow)
If there is sensory involvement of the dorsal hand - then is above the wrist at elbow
Trying to extend fingers
Ulnar Nerve Pathology vs ALS
ALS - absent sensory loss, hyper-reflexia, spasticity, babinski, clonus, and widespread denervation on EMG
Ulnar Nerve - localized to ulnar muscles, sensory loss in 4-5th fingers, normal/hyporeflexia, localized denervation, slowed conduction
Thenar and hypothenar atrophy
Both median and ulnar nerve involvement - lower trunk
Neurogenic thoracic outlet syndrome - rule out pancoast tumor with X ray
ALS (amyotrophic lateral sclerosis)
Neurodegenerative - affects both upper and lower motor neurons
Upper motor neurons: hyperreflexia/spasticity
Lower motor neurons: muscle atrophy, fasciculation, weakness
Bulbar - dysarthria, dysphagia, tongue atrophy
Bilateral hand atrophy with normal sensation
SENSORY IS PRESERVED
“Finger Drop”
Radial nerve injury
Posterior interosseous neuropathy
Posterior interosseous neuropathy
Finger drop, radial deviation on wirst extension
NO SENSORY
Entrapment of arcade of Frohse
Often inflammatory
Wrist Drop and Finger Drop
Radial artery - mid arm (spiral groove)
Saturday night palsy or traumatic
Shoulder pain, athlete, shoulder weakness (abduction and external rotation)
Suprascapular ligament
Suprascaular nerve
Get MRI and EMG
