Neuropathies of Upper Extremity 1/14 Flashcards
Brachial plexus?
C5-T1
supraclavicular n.
C3,4
top of shoulder
axillary n.
C5,6
deltoid/armpit
radial n.
C5,6
dorsal surface of arm + elbow
- dorsum of hand 1,2,3,4.5
lateral cutaneous n.
C5,6 lateral forearm (dorsally and ventrally)
median n.
C6,7,8
ventral portion of hand 1,2,3,4.5 and tip of thumb
ulnar n.
C8,T1
pinky and half of fourth finger
what would herniated disc b/w C4-5 result in?
- C5 nerve root
- Motor to Deltoid (C5), biceps (C5,6)
- biceps reflex C5
- sensation on upper lateral portion of arm
C6 nerve root impaired?
herniation of C5,6
- decreased Bicep strength and wrist extensors
- no brachioradialis reflex
- sensation lost to lateral portion of forearm and thumb/index finger
C7 nerve root impaired?
- herniation at C6-7
- decreased wrist flexors and finger extensors
- no triceps reflex
- decreased sensation to middle portion of hand and finger
hernation at disk C7,T1
C8 nerve root impaired
- loss of motor to finger flexors
- loss of sensation to medial arm and 4th/5th fingers
what would damage T1
herniation at T1/T2
- be harmful to interossei muscles of hands
- lack of sensation at elbow
thoracic outlet syndrome
structures are actually passing through thoracic inlet
- includes: brachial plexus, subclavian a. and v.
- bound by: spinal column, first rib, sternum, clavicle
causes of thoracic outlet syndrome?
Anything causing narrowing of thoracic outlet or trauma that leads to compression of neurovascular bundle
(cervical rib, tension in scalenes, SD of clavicle, upper ribs, tumor, whiplash, fractured clavicle)
different compression sites of thoracic outlet syndrome?
- b/w middle and anterior scalene
- between pectoralis minor and rib cage
- costoclavicular articulation: between clavicle and first rib
Sx of TOS
- brachial plexus compression - numbness, parasthesia, mm. weakness
- subclavian a. compression: arm pain with exertion, thromboembolism, arterial thrombosis
- subclavian v. compression: DVT, extremity swelling
positive findings with TOS
- Adson’s (loss of radial pulse with rotation of arm)
- Roo’s (tingling in extremities)
- Spurlings (pain with compression of head)
- Hyperabduction test
- tight scalenes and pecks
Ulnar n. entrapment
compression of C7,8 T1 along its pathway (often at epicondyle)
Areas of Compression:
- Epicondylar groove
- Cubital tunnel
- Guyon’s canal
DDx
Proximal lesions of C8 or T1 or in lower trunk / medial cord of brachial plexus
risk factors and causes of ulnar n. entrapment?
Risk factors: Smoking Work experience Professions with repeated flexion at elbow and wrist Male gender Increased Age
Causes: Swelling from pregnancy or trauma Arthritic disease Osteophytes Repeated microtraumas
Tardy Ulnar Palsy
- Entrapment of the Ulnar Nerve in the Epicondylar Groove
- 2nd most common mononeuropathy
Symptoms:
- Aching pain medial aspect of elbow that may migrate distally
- Numbness/Paresthesias in 4th and 5th digits
- Nocturnal pain leading to wakening
- Can be produced with elbow flexion
- Motor symptoms are less common
- May see claw hand deformity
- Weakness and possible wasting of intrinsic muscles of hand
- Possible loss of dexterity
Cubital Tunnel syndrome
- Compression of the ulnar nerve between the 2 heads of the flexor carpi ulnaris
- Hypertonicity of the muscle can cause compression
Symptoms:
- Aching pain medial aspect of elbow that may migrate distally
- Numbness/Paresthesias in 4th and 5th digits
- Possible in palmar and dorsal cutaneous territory
- Nocturnal pain leading to wakening
- Can be produced with elbow flexion
- Motor symptoms are less common
- May see claw hand deformity
- Weakness and possible wasting of intrinsic muscles of hand
- Possible loss of dexterity
Guyon’s canal neuropathy
- Damage to the ulnar nerve as it passes between the pisohamate ligament anteriorly and the flexor retinaculum posteriorly
Causes:
- Lacerations
- Direct repetitive trauma
- Common in cyclists
- Fracture of hook of hamate
- Ganglia in wrist or the nerve its self
Symptoms:
- Hand weakness
- Atrophy of intrinsic hand muscles
- Loss abduction/adduction of fingers
- Loss of dexterity
- Variable sensory loss
- Clawing of 4th and 5th digits
tests for ulnar n. entrapment
- Tinel’s (tap on ulnar n. as it passes through epicondylar groove or guyon’s canal)
- elbow flexion for 1 min.
- pressure test (apply pressure to a zone of entrapment)
- flexion and pressure test
- palpation for local nerve tenderness or thickening
tx of ulnar n. entrapment
OMT
Educate patient not to lean on elbow
Foam pads on elbow to prevent compression of nerve
Wrap elbow with towel at night to limit flexion
NSAIDs
PT
Steroid injections
Medial epicondylectomy
Cubital tunnel release surgery
Ligamentous roof of cubital tunnel is cut
Ulnar nerve transposition surgery
Ulnar nerve moved from behind medial epicondyle to in front of it
carpal tunnel syndrome
Compression of the median nerve (C6-8, T1) as it passes under the flexor retinaculum in the wrist
The Carpal Tunnel:
Transverse carpal ligament
Carpal bones
Median N. and flexor tendons
sx or carpal tunnel styndrom
- pain, parasthesias, numbness in 1st three digits and half of fourth
- weakness of grip strength
- pain with gripping objects
- waking with pain in hand
- thenar atrophy
risk factors/causes of carpal tunnel sydrome
More common in women Pregnancy Repetitive motion (Typing or Using a mouse) Diabetes Obesity RA Hypothyroidism Genetic predisposition Connective tissue disease Structural changes Gout Acute Trauma Aromatase inhibitor use
provocative tests for carpal tunnel syndrome
+ Tinel’s test
+ Phalen’s test (upside down prayer)
+ prayer sign
+ paresthesias with pressure over carpal ligament
OMT tx of carpal tunnel syndrome
- Lymphatic drainage of upper extremity
- Manipulation of carpal bones
- Direct stretching / manipulation of the flexor retanaculum
- SD in the course of the median nerve (At the elbow, at the shoulder, in the cervical spine)
- Hypertonic musculature in the arm and forearm
double crush syndrome
- theory that compression at one point of a peripheral nerve is not significant enough to cause the symptoms present, multiple compression sites may have a cumulative effect leading to impaired neuronal signaling
- Initial Injury reduces axoplasmic flow, 2nd injury drops signaling potential below threshold leading to symptoms
