PN Flashcards
Carpal tunnel symptoms
Numbness in the phone, index, middle, and radial half of the ring finger
Pain in the hand and wrist, sometimes extending to the fore arm
Neck pain suggests cervical radiculopathy
Positive tinnel at the wrist as well as Phalen’s sign
Weakness and atrophy later
Normal two point discrimination of the hand
Contents of the carpal tunnel
Median nerve, flexor tendons
Surrounded by for hand bones
Roof is the flexor retinaculum, A ligament
Motor weakness of carpal tunnel syndrome
Abductor pollicis brevis
Opponens pollicis
Electrodiagnostic studies for CTS
Median nerve conduction velocity greater than 0.4 ms more than ulnar nerve conduction velocity at the wrist
EMG - evidence of the more muscle denervation and reduced compound motor potential (suggesting axontometic injury, or Axon loss)
Carpal tunnel syndrome treatment options
Avoid repetitive injury Ergonomic changes Wrist splint use at night Steroid injection Steroids or anti-inflammatories Surgical decompression
Carpal tunnel syndrome pearls
Symptoms in the median nerve distribution that are worse at night and relieved by flicking the hand strongly support CTS
CTS can occur in combination with other nerve compression problems
Carple tunnel syndrome often occurs during pregnancy and can become symptomatic in patients with endocrine disorders such as acromegaly, hypothyroidism, and diabetes. The primary treatment in such cases is delivery of the baby and treatment of the underlying endocrine disorder, not surgery.
Pronator Teres syndrome
Median nerve compression at the elbow
Most commonly compression of the nerve as it passes between the two heads of pronator Teres
Can also be compressed by the ligament of Struthers or the bicipital aponeuroses
Often occurs with overuse of pronator Teres… Think of athletic activities or carpentry. Nocturnal symptoms of carpal tunnel are often absent.
It often presents with pain and numbness in the distribution of the distal median nerve including the Palmar cutaneous branch with weakness in the muscles innervated by the anterior interosseous nerve. There is aching and fatigability of the forearm.
Muscles innervated by the median nerve
Pronator Teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Anterior interosseous nerve…
Flexor digitorum profundus (index/middle)
Flexor pollicis longus
Pronator quadratus
In hand... LOAF Lumbricals 1 and 2 Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis
Pronator Teres syndrome treatment
Rest Therapy Occupational modification Cortizone injection Surgical decompression
Pronator Teres decompression
Incision 3-4 cm proxy to elbow crease between biceps and triceps, transverse across crease, then midline on forearm.
Median nerve identified on top of or adjacent to the brachial artery
The nerve is followed distally and proximally and decompressed from Struthers the ligament proximately down to anterior interosseous branch distally.
Wartenberg sign
At rest the pinky finger is abducted away from the other fingers due to weakness of the ulnar nerve innervated third Palmar interosseous muscle
Froment sign
Hold a piece of paper between the thumb and index finger. With an intact ulnar nerve The patient is able to use the adductor pollicis and hold the paper. With ulnar neuropathy The patient compensates for weakness by using the flexor pollicis longus, innervated by the median nerve. This results in flexion of the interphalangeal joint of the thumb.
Electrodiagnostic testing and ulnar neuropathy
Decreased conduction velocity less than 50 m/s
Relative slowing of conduction velocity of more than 10 m/s at the site of compression
EMG evidence of denervation
True/classic TOS
Thoracic outlet syndrome with structural abnormalities in the scalene triangle and Evident neurological deficits
- 1:1M
- common structural abnormalities such as cervical rib, elongated C7 transverse process, etc.
- post often involves compression of the lower trunk, C8 and T1, often with a normal median sensory response
- frequent denervation changes of the intrinsic hand muscles, particularly abductor pollicis brevis causing scalloped thenar eminence
