Radial Volar zone Flashcards
radial volar zone
- scaphoid tubercle
- FCR tendon
- median nerve
CARPAL TUNNEL SYNDROME (MEDIAN NERVE COMPRESSION)
Pathophysiology • A fibro-osseous tunnel • Decrease in the size of the tunnel - Bony abnormality - Thickened transverse carpal ligament • Increase in contents of tunnel - Muscle bellies: lumbricals, FDS - Mass: ganglia, lipoma - Haematoma • Inflammatory - Rheumatoid arthritis, gout, overuse • Fluid balance - Pregnancy, hemodialysis, Reynaud’s disease, obesity • Neuropathic - Diabetes, alcoholism
Symptoms:
• Pain, paraesthesia and numbness in the median nerve distribution area
• Sensory median nerve affected first, then motor component
Prevalence
• Job that involves lots of typing
• Female, Caucasian, older age, obesity, diabetes, trauma at wrist, pregnancy, hypothyroidism, RA
Patient history
• Complain of
o Numbness, paraesthesia and pain in the fingers
o Disturbed sleep NOCTURNAL PINS AND NEEDLES
o Feeling of a ‘dead hand’ or ‘loss of circulation’
o Loss of sensation in radial digits (D1, D2, D3) as well as thenar eminence (median n.) although symptoms can be in all fingers
o Driving makes it worse, or vibrating tools
o Sense of congestion or finger swelling
• MEDIAN NERVE:
o Course: (from elbow) arises from the cubital fossa and passes between two heads of pronator teres, travels between FDS and FDP before emerging between FDS and FPL. The median nerve then enters the hand through the carpal tunnel deep to the flexor retinaculum.
o Innervates: pronator teres, FCR, palmaris longus, FDS, 1st and 2nd lumbricals, muscles of the thenar eminence, half of FDP (only the lateral half, not 2nd and 3rd digits)
Carpal Tunnel Ax
• Observation
o Wasting of the thenar eminence (in chronic cases)
• Movement examination
o Weakness and loss of dexterity in the hand
o Reduced strength in thenar muscles (e.g. opposition strength)
o Reduced gripping/pinching ability
o Esp. AbPB muscle power
• Sensibility tests
o Altered/reduced sensory discrimination in median nerve distribution (monofilament testing)
o Nerve conduction tests
- tinnels, phalen’s, flick test, durkens, modified durkens
Differential diagnosis
• Pronator teres syndrome (no increase in symptoms during resisted pronation and no change in thenar opposition strength whether forearm supinated or pronated)
• Diabetic peripheral neuropathy
• Cervical radiculopathy
Other assessment
Nerve conduction tests -> decrease in time and speed of conduction
positive nerve tests for median
o Tinnel’s test
♣ Tapping over the course of the median nerve
♣ Positive: feeling of a jolt of electricity
o Phalen’s test
♣ Dropping wrist into flexion
♣ Can be done unilaterally but best to do it bilaterally
♣ Positive if tingling occurs after 30 - 60 seconds may radiate into hand
o Flick test
♣ Need to flick hand to get sensation back
o Durken’s
♣ Examiner presses there thumb over the carpal tunnel and holds the pressure for 30 seconds
♣ Positive if onset of pain or paraesthesia in the median nerve distribution within 30 seconds
o Modified Durkens
combining wrist flexion and compression
Mary recommends single hand maintained in flexion
Mx
Work and ADL modifications • Avoid awkward wrist positions • Avoid prolonged, repeated grip • Avoid vibration and force • Padded steering wheel for truck drivers
Splint
• Worn to prevent flexion
• Nocturnal splint holding the wrist in neutral
Manual therapy
• Median nerve and finger tendon gliding exercises
Oedema control
• Especially for late stage pregnant women
Holist approach
• Assess cervical spine and proximal joints
• Assess and correct posture
• Weight loss (diabetes), aerobic fitness, stop smoking
Surgical
• Carpal tunnel release
o Only if chronic case or is patient has had 6 weeks of unsuccessful conservative Mx
o Either open (OCTR) or endoscopic (ECTR)
carpal tunnel post op
• Post-operation
o Wound management
o Early hand ROM
o Avoid heavy lifting/pushing for 4 weeks
o Median nerve tendon gliding exercises
o No need for splinting
o Scar Mx- including internal scar
Prognosis
• CTR surgery provides the highest benefit at 6 and 12 months and has a high likelihood of recovery
Factors improving surgical recovery: use of antibiotics pre-surgery and no immobilisation of the wrist post -surgery
FLEXOR CARPI ULANRIS TENDINOPATHY
Patient history
• MOI
o Overuse
Ax
• Palpation: Pain on palpation of most prominent tendon of ulnar volar surface of the wrist
• Movement exam
o Pain of resisted wrist flexion and radial deviation
o Pain after repeated movement and stiffness after a period of rest
Management
• deload
• address biomechanics
• ADL modifications
• Gradually reload to facilitate healing
Scaphoid pathology
Palpate Scaphoid Tubercle
Palpate base of the thenar crease, then move wrist from RD to UU
