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-ABPMR Board Review > UE PNS Disease > Flashcards

UE PNS Disease Flashcards

1
Q

median neuropathy at wrist - PE findings

A

positive tinel at wrist, phalen, carpal compression test, +/- thenar atrophy

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2
Q

median neuropathy at wrist - NCS/EMG findings

A

NCS:
abnormal median SNAP to thumb, digit 2, digit 3
abnormal medial CMAP to APB (w increasingly mod-sev disease)

EMG:
normal v decreased recruitment (i.e., axonal loss)
+/- fibs/sharps (active deinnervation)
polphasicity (reinnervation, i.e., Hx n. damage)

milder disease only w abnormal SNAPs; increasing severity w motor involvement, consider surgical flexor retinaculum release

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3
Q

median neuropathy at elbow - Px

A

similar to CTS, typically by tight PT, tight bicipital aponeurosis, or tight ligament of Struthers

any of these can squeeze the median n. and cause a compressive neuropathy

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4
Q

median neuropathy at elbow - PE findings

A

possibly

weak wrist flexion (FCR), PIP flexion (FDS), thumb flexion (FPL), DIP flexion of digits 2, 3 (FDP 2, 3), pronation (PQ)

in PT syndrome, usually PT is spared because its innervation occurs more proximally

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5
Q

median neuropathy at elbow - NCS/EMG findings

A

NCS: abnormal median SNAP and CMAP

EMG: decreased recruitment +/- fibs/sharps
in every medial muscle except PT (if PT syndrome), polyphasicity

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6
Q

median neuropathy at elbow - muscles affected depending on etiology

A

all median n. innervated muscles will be affected if compression at bicipital aponeurosis or ligament of Struthers

PT will be spared if PT syndrome

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7
Q

median n. innervated muscles

A

PT, FCR, FDS, PQ, FPL, FDP 2,3, APB, FPB, lumbricals 1,2, opponens pollicis

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8
Q

anterior interosseous innervated muscles

A

AIN is pure motor branch of median n.

innervates “P” muscles → FPL, FDP 2,3, PQ

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9
Q

anterior interosseous neuropathy - PE findings

A

cannot make “OK” sign (FPL and FDP 2,3)

cannot make fist

(Froment’s sign is basically reverse…)

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10
Q

Ulnar neuropathy at wrist (Guyon’s canal), types

A

I motor and sensory

II motor

III sensory

borders: ligament superiorly, flexor retinaculum/hypothenar muscles inferiorly, hook hamate laterally, pisiform medially

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11
Q

localization of ulnar neuropathy at wrist (Guyon’s canal) on NCS

A

dorsal ulnar cutaneous n. (DUC) SNAP because DUC branches off to innervate web space between digits 4,5 proximal to guyon’s canal

if normal → Guyon’s canal

if abnormal → lesion proximal to Guyon’s canal
should also see abnormal SNAPs to digits 4,5; abnormal CMAP to ADM, FDI

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12
Q

ulnar neuropathy at wrist (Guyon’s canal) NCS/EMG findings

A

NCS: abnormal SNAPs to digits 4,5; abnormal CMAP to ADM, FDI

EMG: abnormal activity (decreased recruitment, +/- fibs/sharps) to ulnar hand muscles (ADM, FDI, interossei, lumbricals 3,4), polyphasicity

EMG: normal activity in proximal ulnar muscles (FCU, FDP 4,5)

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13
Q

ulnar neuropathy at elbow (Arcade of Struthers or cubital tunnel syndrome (2 heads FCU)) NCS/EMG findings

A 
NCS: abnormal ulnar SNAPs to digits 4,5; abnormal CMAP to ADM, FDI
abnormal DUC (branches off before Guyon's canal), normal MAC SNAP (branches off before cubital tunnel)

if MAC SNAP abnormal → lower trunk injury or somewhere more proximal to elbow

EMG: abnormal activity (decreased recruitment = axonal loss, fibs/sharps = active deinnervation, polyphasicity = reinnervation) - to ulnar hand muscles (ADM, FDI)
abnormal activity in proximal ulnar muscles (FDP 4,5)(+/- FCU); polyphasicity

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14
Q

radial neuropathy at elbow, DDx spiral groove, NCS/EMG findings

A

Px same, DDx based on Hx humeral shaft fracture or prolonged compression (spiral groove, Honeymooner’s palsy, Saturday Night Palsy)

Px: weakness of wrist extensors and finger extensors with numbness and tingling in posterior forearm and thumb/snuff box
(ECRL/ECRB, [PIN: EIP, ED, ECU])
elbow flexion may be weak w brachioradialis involvement

triceps and anconeus preserved bc innervation proximal to elbow/spiral grove

NCS: abnormal SNAP to thumb and snuff box
abnormal CMAP to EIP

EMG: abnormal activity in all muscles except triceps and anconeus

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15
Q

radial neuropathy at elbow etiology

A

often d/t compression between brachialis and brachioradialis

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16
Q

DDx: radial neuropathy at elbow v spiral groove v improper crutch use NCS/EMG findings

A

radial neuropathy at elbow (brachialis/BR compression) same as at spiral groove, except latter w Hx humeral shaft fx

improper crutch use → affects posterior cord → therefore triceps and anconeus will be abnormal as well on EMG

sensation will also be affected in entire arm (rather than just forearm) w improper crutch use

can also find axillary n. findings d/t posterior cord involvement

17
Q

superficial radial neuropathy - Px, NCS/EMG

A

pure sensory → posterior forearm and dorsal hand

usually hx tight handcuffs or IV

NCS: only abnormal SNAP to thumb and snuff box
normal CMAP

EMG: normal

18
Q

PIN-opathy etiology

A

compression at Arcade of Frohse (over supinator muscle) or trauma (Monteggia fx)

Monteggia fx: fx of proximal ⅓ ulna → proximal radius dislocation

19
Q

PIN-opathy NCS/EMG findings

A

PIN is pure motor n.

NCS: normal SNAPs to radial, ulnar, median n.
abnormal CMAP to EIP

EMG: abnormal activity in all PIN muscles (ED, EIP, EPL; ECU) +/- supinator
ECRL, ECRB, BR, triceps, anconeus all spared

20
Q

Axillary neuropathy - Px/EDX findings

A

improper crutch use, trauma, stretching compression

→ weak shoulder abduction (deltoid) and external rotation (teres minor) with impaired sensation over deltoid

NCS: SNAP unavailable (nothing good to test)
abnormal CMAP to deltoid

EMG: abnormal activity in deltoid, teres minor

21
Q

Musculocutaneous neuropathy - px/edx

A

injury to musculocutaneous n. usually d/t trauma/compression → terminal portion is LAC (lateral cutaneous n.) supplies lateral forearm

Px: weakness of elbow flexion (brachialis); perhaps supination (biceps); numbness of lateral forearm

NCS: abnormal SNAP to forearm, abnormal CMAP to biceps

EMG: abnormal activity in biceps, brachialis

Tx: rehab, remove surgery

22
Q

Suprascapular neuropathy - Px/EDX

A

C5, C6 → upper trunk → suprascapular n. → supraspinatus → n. passes through spinoglenoid notch → infraspinatus

injury d/t trauma, cysts, stretching, upper trunk lesions (Parsonage-Turner Syndrome - neuralgic amyotrophy) → weakness w shoulder abduction (SS) and/or external rotation (IS)

NCS: SNAP unavailable
CMAP abnormal to supraspinatus

EMG: abnormal activity w SS and/or IS

Tx: rehab/surgery

23
Q

spinoglenoid notch - clinical significance

A

suprascapular n. courses through, if entrapped will have abnormal IS EDX findings

if lesion more proximal (e.g., upper trunk, cysts), abnormal SS and IS findings

24
Q

scapular winging ddx

A

“SALT” serratus anterior (long thoracic n.) → medial winging

trapezius (spinal accessory n.) → lateral winging

25
Q

long thoracic neuropathy Px/EDX

A

medially winged scapula

“SALT” = serratus anterior, long thoracic n.

NCS: SNAP unavailable
CMAP abnormal to serratus anterior

EMG: abnormal activity in serratus anterior

Tx: rehab

26
Q

Erb Palsy

A

upper trunk (C5, C6) brachial plexopathy d/t excessive traction forces

S/SX:
Weakness of all upper trunk muscles: deltoid, teres minor (axillary n.); SS, IS (suprascapular n.); biceps, brachialis (musculocutaneous n.); ECRL, ECRB (radial n.)

Waiter’s tip → arm adducted, internally rotated, pronated, wrist flexed
Sensory loss over lateral arm and dorsolateral forearm (radial n., musculocutaneous n. → LAC)

27
Q

upper trunk brachial plexopathy - EDX

A

NCS: abnormal median sensory (C5, C6), abnormal LAC (musculocutaneous n.)

EMG: abnormal activity and decreased recruitment in upper trunk muscles

remember median motor is C8-T1

28
Q

Klumpke Palsy

A

lower trunk (C8, T1) brachial plexopathy → affects median motor and ulnar inn’v muscles → FDS, FDP, FCU, lumbricals, intrinsic hand muscles + sensory loss of medial arm, medial forearm, and hand

PE: claw hand, wartenberg sign, froment sign, OK sign

29
Q

lower trunk brachial plexopathy - EDX

A

NCS: abnormal ulnar SNAP, normal median SNAP (clues that this is lower trunk injury)

EMG: abnormal activity and decreased recruitment in lower trunk muscles

lower trunk muscles: lumbricals, intrinsic hand, FDS, FDP, FCU

30
Q

Brachial Plexus pathyway

A

pass between anterior and middle scalenes and emerges underneath the clavical as cords

31
Q

Riche Cannieu Anastomaosis

A

ulnar n. essentially controls motor fibers of hand

median motor fibers in hand cross over to join the ulnar n.
median n. will show no CMAP
ulnar n. stim over APB will show CMAP

32
Q

Martin Gruber Anastomosis

A

will appear as though there is conduction block at the elbow w ulnar n.

in some, median fibers cross over in forearm to join ulnar n. → median n. innervates ADM, FDI, and APB etc.

stimulate median n. at elbow recording over ADM → normal CMAP

33
Q

thoracic outlet syndrome

A

rare, vascular / neurogenic

vascular: compression of subclavian/axillary vessels → UE pulse loss, color changes, cold limb, swollen limb, aching pain
neurogenic: lower trunk brachial plexopathy (C8, T1) → lower trunk compressed by clavicle and first cervical rib, anterior and middle scalenes, pec major → pain, sensory distubrance in medial arm and medial forearm, 4th and 5th digits, all worse w overhead activity e.g., swimming

34
Q

thoracic outlet syndrome EDX findings

A

PE: Roos and Adson tests

NCS: abnormal ulnar SNAP/CMAP, abnormal median CMAP (C6 fibers are sensory), MAC

EMG: abnormal spontaneous activity and possible decreased recruitment of median and ulnar muscles in the hand (lower trunk muscles)

35
Q

Parsonage-Turner Syndrome

A

AKA neuralgic amyoptrophy, brachial neuritis, idiopathic brachial plexopathy

usually u/l and follows viral illness or surgery

Px: shoulder pain ~2wks → weakness

suprascapular n./long thoracic n./AIN are commonly involved

EDX depends on fibers involved
likely active denervation, decreased recruitment in affected muscles on EMG
serial EMGs have value for prognosis

may be self limited 1-2 years

36
Q

Radiation plexopathy v Pancoast syndrome

A

XRT plexopathy: typically upper trunk w Hx radiation
Myokimia on EMG
NO PAIN → painless myokimia

Pancoast: upward invasion of lung CA → compresses lower trunk fibers
PAINFUL, without myokimia on EMG
may have i/l Horner syndrome

-ABPMR Board Review (19 decks)

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