Week 7 Compression Neuropathies of the Elbow, Wrist, and Hand Flashcards
Seddon’s Neuropraxia
“Neurapraxia is the mildest type of PNI commonly induced by focal demyelination or ischemia”
Neuropraxias are the smallest invasive issue that we deal with
These injuries, they recover very quickly
Axon remains intact
Local conduction block involving local demyelination
Prognosis: (good to excellent/poor to worse)
Recovery: complete within (weeks/months)
Example: (chronic nerve compression/crush injury)
good to excellent; weeks; chronic nerve compression
Seddon’s Axonotmesis
Injury to axon > Wallerian degeneration - Removal of the axon and myelin (proximal/distal) to the injury site
“Wallerian degeneration is an active process of degeneration that results when a nerve fiber is cut or crushed and the part of the axon distal to the injury”
(Axon/Endoneurial tube) - intact
From the site of injury going distally to the end organ there is loss of the axon and myelin. The issue here is how far is the injury from the end organ and that will tell you what their recovery is going to be.
Protected from the external environment via endoneurial tube
Prognosis: (good/bad) - Supportive connective tissue remains
Recovery: time is dependent on (speed of injury/distance from injury) to innervated end-organ
Example: (chronic nerve compression/crush injury)
distal; endoneurial tube; good; distance from injury; crush injury
Seddon’s Neurotmesis
(Axon preserved/All layers disrupted)
(Surgical repair required/Conservative treatment required)
They’ll use a graph or conduit for surgical repair. All depends on the length of the defect.
All layers disrupted; Surgical repair required
Seddon vs. Sunderland
Type (I/II) – Wallerian degeneration
Type (I/III) – when there is scar tissue can block regeneration of that nerve
Type (III/IV) – completely blocked by scar tissue
Type (III/V) – complete transection of the nerve
II; III; IV; V
Etiology of Nerve Compression
Pressure Motion - friction/traction Anatomical (aberrant anatomy) Space occupying lesions - ganglion cysts/ tumors Multiple/double crush Systemic/metabolic diseases - obesity, pregnancy, diabetes Repetitive motion Trauma - fractures Iatrogenic
Cool
Typical Clinical Presentation
Primarily a (LOM/pain) problem -
within nerve distribution
Nerve entrapment location - Will get pain in the entrapment location
Nocturnal pain
Paraesthesias
Often intermittent
Activity dependent
+/- night – if positioning thing, will find at night.
Sensory loss
(Before/After) motor weakness
Motor weakness
Typically longstanding condition
Clumsiness (CTS)
Regulatory changes Not common (nerve still intact)
CT and cubital tunnel – fetal position is why we have problems at night (flexing elbow and wrist and even making a fist. All of those positions will (increase/decrease) compression on median and ulnar nerve)
pain; Before; increase
Examination
Patient history
Appearance
Tests and Measures Tinel’s Compression Tests Upper Limb Tension Tests Sensation MMT
Finger dexterity
Review EMG/NCV if available
Appearance – positioning of digits, specific nerve injuries to the digits might sit into a different resting position, is there atrophy?
Tinels – tapping, do it across any nerve to elecit symptoms. Quick and easy way to elecit symptoms.
Finger dexterity – not doing day 1, looking further down the line when chronic issue, can effect job pt can do (return to job stuff
Review EMG/NCV – do full eval first, come up with own differential diagnosis, then use this to further understand the situation
Got it
What is the sensibility testing hierarchy order?
Detection > discrimination > identification
Typical Conservative Management of Nerve Compression
Patient education
Splinting/positioning
Especially at night
avoid the fetal position
Ergonomic changes/on-site job analysis
help with pt education
Nerve mobilization
Maximize excursion while limiting strain
fibrosis can occur at those entrapment sites. If we are hanging out in a shortened position for extended point of time, neural shortening can occur. Want to maximize excursion (gliding of the nerve in its surrounding bed).
Tendon glides (CTS)
Scapular and trunk stabilization exercises
Picture is tendon glides
Coo
Radial Nerve
C_-T_ Nerve Roots > Upper, Middle, Lower Trunks > (Anterior/Posterior) Divisions from all Trunks > (Anterior/Posterior) Cord > Radial Nerve
C5-T1; Posterior; Posterior;
We are going to be looking at the (blueish/purpleish) colour. Dorso-radial side of the hand and thumb and the dorsal aspect of the wrist as well.
Purpleish
Common Entrapment Points
Spiral groove of the humerus
Lateral intramuscular septum
Fibrous edge of the ECRB
Proximal border of supinator – arcade of Frohse
Radial recurrent vessels – leash of Henry
Distal edge of supinator - big issue
Between the brachioradialis and ECRL
(median/radial) nerve
radial
High vs. Low Radial Nerve Palsy
Triceps Anconeus Brachioradialis Extensor carpi radialis longus (High/Low)
Extensor carpi radialis brevis Extensor carpi ulnaris Extensor digitorum communis Extensor digiti minimi Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis Extensor indicis proprius (High/Low)
If you were testing for high vs low. For high wrist extension with the ____\, for low look at finger extension ( ___ ) and thumb extension with the ____
High; Low; ECRL; EDC; EPL
Clinical Presentation of Radial Nerve Palsy
High Radial Nerve Palsy - (wrist/hand) drop.
No wrist extension, fingers are dropped down in to flexion, thumb dropped down into flexion.
Low Radial Nerve Palsy - (wrist/hand) drop.
Would have some wrist extension, but the fingers and thumb would be dropped down into flexion.
wrist; hand
Radial Nerve Palsy
Aka Saturday Night Palsy
Site: spiral groove of the _____
Cause: prolonged pressure on the posterior _____
These pts recover very quickly. When there is an actual fracture that causes damage to the nerve, those are the ones that take longer to heal.
It takes a (cm/mm) a day and an (foot/inch) per month for regeneration of a nerve. Have to educate pts on that. Have to educate and maintain (AAROM/PROM). If the nerves regenerate and they are stiff, problems will occur. If they are stiff they are going to have a difficult time working through that recovery process.
Combined sensory and motor syndrome
Motor: weak wrist, finger, and thumb (flexion/extension)
Sensory: hyperesthesia to (volar/dorsum) of forearm and hand
Think about wrist extension, finger extension, and thumb extension in radial nerve palsy
Could have numbness and paresthesia on the dorsum of the hand
humerus; humerus; mm; inch; PROM; extension; dorsum;
Radial Nerve Compression Syndromes
Posterior Interosseous Nerve (PIN) Syndrome
Site: (Arcade of Frohse/Radial Tunnel) - proximal border of the supinator
Signs:
Weakness of the (supinator/pronator), wrist (flexors/extensors), and digital (flexors/extensors)
ECRL spared- innervated before the split to the PIN , so will see some extension with radial deviation (RD)
Avoid repetitive gripping and forearm rotation
Maintain the length of the supinator and (ECRL/ECRB) to avoid increased compression
Arcade of froshe; supinator; extensors; extensors; ECRB
Radial Nerve Compression Syndromes
Radial Tunnel Syndrome
Sites:
Between superficial and deep heads of the _____
(Arcade of Froshe/Guyon’s canal)
Between ECRB and EDC septum
Anytime you have a nerve traveling between a two headed muscle, there will be a potential entrapment point.
Causes: \_\_\_\_ head fractures Tumors Ganglion cysts Working in elbow (flexion/extension) Maintaining pro/sup during tasks
A lot of people who have radial tunnel originally had lateral ______. Poorly treated lateral ______ can result in radial tunnel syndrome.
supinator; arcade of froshe; radial; extension; epicondylitis; epicondylitis
Radial Nerve Compression Syndromes
Radial Tunnel Syndrome Cont
Clinical Signs:
(Generalized pain on the dorsal forearm/LOM)
Point tenderness - 4 cm (distal/proximal) to lateral epicondyle
Provocative Tests: Resisted (Index/Middle) Finger Test Resisted (supination/pronation) Resisted wrist (flexion/extension) ULNTT
LE – symptoms at the common attachment point
RT – more distally and general area of pain around the mobile wad
When testing radial tunnel syndrome - similar to lateral elbow things, except for upper limb tension tests.
LET – they are going to get one of the little straps around the elbow to the point of a death grip. They are trying to help the lateral elbow issues but they are actually going to compress on the radial nerve which can lead to radial tunnel syndrome. The purpose of the strap is to put pressure thorough the mobile wad and as you pull into to wrist extension want bulk of the force to go through the muscle belly. Sounds good in theory but actually causes problems to the patient. Not a go to for most pts with lateral epicondylalgia because of the issue it creates with the radial nerve.
Wrist splint for pts with lateral epicondylalgia is good because if you block up the wrist in terms of extension it takes pressure off of the mobile wad because the muscles also extend.
Generalized pain on the dorsal forearm; distal; middle; supination; extension
Activity Modification for Radial Tunnel Syndrome
Wrist splint in slight (flexion/extension) if highly irritable - Avoid counterforce brace!
Push with forearm in (pronation/neutral)
Tools with a pistol grip - handshake position
Wrist splint is the gold standard for hand therapists for those with LET.
Radial nerve glide has a component of wrist flexion. If someone is irritable can use wrist splint.
Want to keep pts in a neutral rotation. Push with the forearm in neutral rotation.
Maintain the length of the (ECRB/FCU) (wrist extension stretching and radial nerve glides)
extension; neutral; ECRB
Radial Nerve Compression Syndromes
Wartenberg Syndrome
Dorsal Radial Sensory Nerve
Site: at the (elbow/wrist) as the nerve exits deep tissues between brachioradialis (BR) and ECRL
Causes
(Pronation/Supination), wrist (flexion/extension), and (RD/UD) combined
Carrying bags on wrist - putting direct pressure on the wrist
Handcuffs
Can be associated with deQuervain’s tenosynovitis
Some sort of watch or tight hair ties on the wrist will start to irritate that nerve.
wrist; pronation; flexion; UD;
Wartenberg Syndrome (Cont.)
Clinical Signs Pain - Transitions between pro > sup Resisted wrist ext with RD in supination Passive wrist (flexion/extension) with (RD/UD) in pronation
Provocative Tests
Finklestein’s test in (pronation/Supination)
+ Tinel’s between BR and ECRL - 4 cm proximal to Lister’s tubercle
Activity Modification -
Push with wrist in (supination/neutral)
Avoid tight bracelets
Avoid flex/ext with supination/pronation
Resisted wrist extension with RD – not a typical thing to test, not common position. Other two are the other ones to test
Finklesteins - when we pronate , taking the first dorsal compartment out of the picture, only testing the nerve.
How to differentiate between deQuervain’s and Wartenberg’s is the (Finkelstein’s/Tinels) test.
Can do nerve glides (pronation, fist in thumb, then ulnar deviates. Specific to the dorsal sensory radial nerve.
flexion; UD; pronation; neutral; Finklestein’s
Median Nerve
C_ – T_ Nerve Roots > Upper/Middle/Lower Trunks > (Anterior/Posterior) Divisions > (Medial and Lateral/Medial and posterior) Cords > Median Nerve
C5-T1; Anterior; Medial and Lateral;
Median Nerve Sensory Distribution
Looking at the (purple/gold) colour, (volar radial/dorsal ulnar) aspect of the hand. (Ulnar/Radial) half of ring finger as well. Comes over the tips of those as well.
gold; volar radial; Radial
(Median/Radial) Neuropathy
Common Entrapment Points
Lacertus Fibrosus (AKA bicipital aponeurosis): Resisted elbow flexion at 120-135º with full supination - Full supination because biceps does elbow flexion and supinates as well. The biceps is the strongest supinator
FDS arch: Resisted MF PIP flexion - test middle finger pip flexion. FDS flexes the pip.
Between the 2 heads of the Pronator Teres - Resisted forearm pronation
Accessory Head of the FPL (Gantzer’s muscle) - not present in everyone
Carpal Tunnel - most common entrapment point. Most common nerve compression syndrome of the hand.
Median
High vs. Low Median Nerve Palsy
FDP (index/long) FDS (superficialis) Palmaris Longus Pronator Teres Flexor Carpi Radialis Pronator Quadratus (High/Low) median nerve palsy
Opponens Pollicis Flexor Pollicis Brevis (superficial head) Abductor Pollicis Brevis 1st/2nd Lumbricals (High/Low) median nerve palsy
High – look at ______ and _____.
Low : (thenar/hypothenar) musculature - _____ is the big one to look at.
High; Low; FDS; FCR; thenar; opponens pollicis
Clinical Presentation
High median nerve palsy : Hand of _____ - this is because the _____ and ____ are out and not functioning. The index finger and long finger are resting in extension while the ring and small have the resting curl.
Benediction; FDP; FDS;
Clinical Presentation
Low Median Nerve Palsy: “____ hand” due to flattening of the (thenar/hypothenar) eminence
Ape; thenar
Median Nerve Compression Syndromes
Pronator Syndrome
Between the superficial and deep heads of the ______
Activity Modification
Avoid (pronation/supination) or repetitious forearm/elbow motion
Extremely uncommon.
Be able to tell the difference in some of the signs and test that will be different between this syndrome and CTS.
pronator; pronation
Median Nerve Compression Syndromes
Clinical Signs of Pronator Syndrome
Pain at proximal (dorsal/volar) forearm- Repetitive rotation
Possible paresthesias
Thumb, index, middle, and (ulnar/radial) ½ of ring finger (RF)
Sensory sx’s into palm of hand over (thenar/hypothenar) eminence
Where the red is where they will have pain complaints.
(Motor/Sensory) sxs – different than when in CTS.
volar; radial; thenar; Sensory
Median Nerve Compression Syndromes
Carpal Tunnel Syndrome
Most common compression neuropathy in the hand
Compression at the carpal tunnel
Common after _____ ’ fx - form of a distal radius fracture.
Pressure in carpal tunnel increases after distal radius fracture.
Floor of the carpal tunnel is the carpal bones, transverse carpal ligament is the roof. In the carpal tunnel we have the (median/radial) nerve, 9 flexor tendons (4 ___, ___, and 4 ___).
Colle’s; median; FDP, FPL, FDS
Median Nerve Compression Syndromes
Clinical Presentation of CTS
(Pain/Paresthesia’s) -
Median nerve distribution
Tend to start at (day/night) - fetal position will compress the carpal tunnel. Wrist (flexion/extension) is not a great position to be in at night
Worsened by driving and repetitive forceful hand motion - driving is the sustained gripping and vibration
Possible loss of dexterity/manipulation of small objects - pts can’t tell how hard they are pinching objects and picking things up .
Paresthesia’s; night; flexion;
Screening of CTS
____ - number 1 test ppl will do. Wrist flexion test – put backs of hands together and moving the elbows down for the patient to create more flexion on the wrist. Hold for a minute – positive if symptoms occur.
Reverse – palms together, going into extension
Semmes-Weinstein Monofilaments - not a first go to kind of test. One down the road when figuring out jobs or employment they’ll be able to have.
Tinel’s - right over the carpal tunnel
(Durkan’s/Berger) Test: Pressure over transverse carpal ligament - rather than tapping, putting pressure over the carpal tunnel to compress the median nerve
(Durkans/Berger) Test -
Hold fist in neutral grip
Pain/paresthesias in 30-40 seconds
Phalens; Durkans; Berger
Berger Test for CTS
Lumbrical incursion- (FDS/FDP) tendons pull the proximal portion of the lumbricals into the carpal tunnel
Lumbrical originates from the FDP and inserts into the extensor mechanism. When we make a fist, the lumbricals get pulled proximally and get pulled into the carpal tunnel. The carpal tunnel will stay the same size so we are trying to jam the lumbricals and the pressure within the space will increase and increase symptoms.
Picture: 2nd lumbrical was highlighted
FDP
How would you change your treatment if a patient demonstrated positive lumbrical incursion?
You would want them (to avoid/to do) gripping things, (do/don’t do) grip strengthening right away.
If in wrist splint at night and still have pain it is because they are trying to create a fist by (flexing/extending) their fingers.
TRY TO AVOID A FULL COMPOSITE FIST!!!!
to avoid; don’t do; flexing
Carpal Tunnel Pressures
Neutral wrist has the (least/most) amount of pressure in the carpal tunnel.
Wrist flexion /extension – pressure in the carpal tunnel (increases/decreases)
Finger flexion – 10x as much as wrist flexion/extension
Avoid sustained gripping is so important.
least; increases;
Surgical Management for CTS
Carpal Tunnel Release
Tendon Glides
Nerve glides
Scar management: Desensitization prn
Don’t want a thick scar. Will affect gliding structures. A thick scar in the hand is not the same as a thick scar in the thigh. Will affect motion of the fingers.
Edema control - tendon glides help
For pts who fail conservative management
Opening up the ______ carpal ligament in a carpal tunnel release.
Pain on the sides of the incision is what you will hear pts complain of. It is normal. Will improve with time.
transverse;
Pronator Syndrome vs. CTS
Phalen’s test
Pronator Syndrome - (+/-)
CTS - (+/-)
Nocturnal Paresthesia’s
Pronator syndrome: (+/Not applicable)
CTS - (+/Not applicable)
Sensory Symptoms into palm of hand over thenar eminence
Pronator syndrome - (+/Not applicable)
CTS - (+/Not applicable)
Phalen’s test – wrist flexion test, won’t compress nerve between two heads of the pronator, will be positive for CTS
Paresthesia’s – fetal position, positive with CTS, not with pronator syndrome. Active issue of compression
Sensory symptoms of pronator will be over thenar eminence. Won’t have symptoms in the thenar eminence for CTS.
-; +; NA; +; +; NA
Median Nerve Compression Syndromes
Anterior Interosseous Nerve (AIN) Syndrome
Sites:
deep head of the (pronator teres/pronator quadratus)
Fibrous arch of the (FDS/FDP)
accessory head of the (FPL/FCU)
(Proximal anterior/Distal posterior) forearm pain
(Sensory complaints/No sensory complaints)
Function:
Motor innervation to (FPL/FCU), (FDS/FDP) of the index/long, and pronator (teres/quadratus)
Pts will have complaints of pain of the anterior forearm.
Will have to evaluate the FPL, FDP, and pronator quadratus
pronator teres; FDS; FPL; proximal anterior; No sensory complaints; FPL; FDP; quadratus
Clinical Signs of AIN Syndrome
Inability to make an ____ sign.
During tip pinch:
(Flexion/Extension) of index DIP
(Flexion/Extension) of thumb IP
Compensation:
(Hyperflexion/Hyperextension) of Index Finger (IF) PIP
(Hyperflexion/Hyperextension) of thumb MCP
To make an OK sign what two muscles have to be working?
OK; Extension; Extension; Hyperflexion; Hyperflexion; FDP & FPL
Ulnar Neuropathy
Ulnar Nerve
C_-T_ Nerve Roots > _____ trunk > (anterior/posterior) division > (medial/lateral) cord > ulnar nerve
C7-T1; Lower; anterior; medial;
Ulnar Nerve
Looking at the (bluish/goldish) colour on each side. Dorsal and volar aspect of the (radial/ulnar) side of the hand. Look at the (small finger/thumb) and (radial/ulnar) half of the ring finger. Some carry over on the central portion of the hand.
bluish; ulnar; small finger; ulnar;
Ulnar Neuropathy
Common Entrapment Points
Arcade of Struthers -
8 cm from medial epicondyle and lies medial to the triceps
aponeurotic band extending from the medial IM septum to the medial head of the triceps
(Medial/Lateral) intermuscular septum - goes form the medial supracondylar ridge to the medial epicondyle
Cubital tunnel - (Least/Most) common for the ulnar nerve
Between the 2 heads of the (FCU/FCR)
Guyon’s Canal - also called ulnar tunnel syndrome
Medial; Most; FCU
Clinical Presentation
High Ulnar Nerve Palsy
(More/Less) Clawing - until (FDP/FDS) is reinnervated
Lost or weakened (RD/UD) (FCU/FCR)
(Weakened/strengthened) grip strength
Loss of sensibility (dorsal AND volar/volar) surface of small finger and ulnar ½ of RF
Low Ulnar Nerve Palsy
(Less/More) clawing
Loss of sensibility on (volar AND dorsal/volar) aspect of ulnar palm and SF/ulnar ½ of RF
Low ulnar nerve palsy – FDP is still functioning and still innervated . Have a flexion moment at the DIPs but the lumbricals are out.
See more of this clawing because the FDP is innervated during this time but no counterbalance from the lumbricals.
High ulnar nerve palsy – less clawing because no flexion moment is happening from the FDP.
High ulnar nerve injury with no clawing and they start to develop clawing – would be a (bad/good) thing because the FDP is starting to be reinnervated. Always a good sign to track progress in this way because the nerve is reinnervating the muscles in the order that they are innervated.
High – lose sensation on dorsal and volar sides. With a low they will only lose sensation on the volar (palm) side.
Numbness and tingling – have to know if it is both sides or just the palm. Dorsal cutaneous branch arises proximal to the wrist and will innervate the dorsal aspect of the hand.
Less; FDP; UD; FCU; weakened; dorsal and volar; more; volar; good
Ulnar Nerve Compression Syndromes
Cubital Tunnel Syndrome (CuTS)
Bony canal formed by (lateral/medial) epicondyle and olecranon
Roof: (FCU/FCR) fascia and Osborne’s ligament
Floor: (MCL/LCL)
medial; FCU; MCL
Causes of Cubital Tunnel Syndrome
Ulnar subluxation over (lateral/medial) epicondyle
(Lateral/Medial) epicondyle or olecranon fracture
Cubital (varus/valgus)
Bony spurs
Direct trauma
B – (Cubital valgus/Gun stock deformity)
D – (Cubital valgus/Gun stock deformity)
Cubital valgus – women tend to have (more/less) cubital valgus than a man.
medial; Medial; valgus; cubital valgus; gun stock; more
Cubital Tunnel Syndrome
Clinical Signs
c/o (pain/paresthesia’s) on (volar and dorsal/volar) aspects of ulnar ½ of RF and entire SF
Advanced cases- prolonged cases/ longstanding issues (Intrinsic/extrinsic) muscle wasting Pinch/grip deficits c/o hand clumsiness Mild clawing Froment’s Sign
Provocative Tests:
Elbow (flexion/extension) test
Tinel’s
Scratch _____ Test
Elbow flexion test – push them all the way into elbow flexion and hold them in flexion for 60 seconds (positive for symptoms)
paresthesia’s on volar and dorsal; intrinsic; flexion; Collapse
Scratch Collapse Test
Resisted bilateral shoulder (IR/ER)
Stroke medial elbow along course of ulnar nerve
Repeat resisted bilateral shoulder (IR/ER)
+ Test: a sudden loss of strength on the (uninvolved/involved) side
Cutaneous silent period – when stimulation of the cutaneous nerve there is a brief pause in voluntary muscle contraction. Stimulating the epineurium in the cite of neuritis, central inhibition occurs on the ipsilateral side. If pts left side loses ER strength, the left side should be affected.
Have to give resistance quickly after stroking ulnar nerve. Cant wait too long to give resistance, inhibition will be lost.
ER; ER; involved
Conservative Treatment for CuTS
Patient education:
Activity modification
Positioning
Splinting prn -
Elbow pad during the day - to off load direct pressure especially when resting their elbows on the desk
(Flexion/Extension) splint at night - prevent fetal position
Anti-claw splint for advanced cases
Nerve glides
Restore muscle length - Flexor/pronator mass
A lot of it is pt education.
Avoid elbow (flexion/extension) !!! – arcuate ligament tightens in (flexion/extension), floor of the MCL has increased pressure in flexion.
Extension; flexion; flexion
Activity Modification for CuTS
Avoid terminal elbow (flexion/extension) - Use headset/wireless earpiece for phone
Avoid sleeping in fetal position
Heelbo Pad
flexion;
Ulnar Nerve Compression Syndromes
Guyon’s Canal Syndrome
Also known as the Ulnar Tunnel
Radial border: (Hook of the hamate/Pisiform)
Ulnar border: (Hook of the hamate/Pisiform)
Ulnar Nerve bifurcates into the superficial sensory and deep motor branches
Hook of the hamate; Pisiform
Causes of Guyon’s Canal Syndrome
______ cysts
(Radial/Ulnar) artery thrombosis - _____ Test
(Radial/Ulnar) -sided wrist fractures or dislocations : Hook of the hamate fractures
Repetitive trauma: Bicycling, long-distance truck driving - pressure through the hypothenar eminence
Ganglion cysts - A noncancerous lump, often on the tendons or joints of wrists and hands.
The cause of ganglion cysts is unknown.
A ganglion cyst is round, small, and usually painless. Although rare, it can be painful if it presses a nerve.
Ganglion; ulnar; Allen’s; Ulnar;
Zones of Guyon’s Canal
Zone 1 -
(Proximal/Distal) to bifurcation
(Sensory symptoms/Both sensory & motor symptoms)
Causes:
(Ganglions & Hook of the hamate fracture/Ulnar artery thrombosis)
Zone 2 -
Between abductor digit minimi and flexor digiti minimi
(Superficial sensory branch/Deep motor branch)
(Sensory symptoms only/Motor symptoms only)
Intrinsic muscles of the hand
Causes:
(Ganglions & Hook of the hamate fracture/Ulnar artery thrombosis)
Zone 3
(Deep motor branch/Superficial sensory branch)
(Motor branch/Sensory symptoms only)
Complaints of decreased sensation on the (dorsal/volar) side
Causes:
(Ganglions & Hook of the hamate fracture/Ulnar artery thrombosis or aneurysm)
Proximal; Both sensory and motor symptoms; Ganglions & Hook of the hamate fracture; Deep motor branch; motor symptoms only; Ganglions & Hook of the hamate fracture; Superficial sensory branch; sensory symptoms only; volar; Ulnar artery thrombosis or aneurysm
Guyon’s Canal Syndrome
Clinical Signs
Paresthesia’s on the (dorsal/volar) aspects of the ulnar ½ of the RF and SF only
Possible clawing
______ Sign
(Weakness/atrophy/ Pain) of ulnar-innervated (extrinsic/intrinsic) muscles
Could have clawing
Claw hand is a condition that causes curved or bent fingers. This makes the hand appear like the claw of an animal. Claw hand is a hand characterized by curved or bent fingers, making the hand appear claw-like.
Wasting on the web space on the left hand (right side of pic)
The majority of the intrinsic hand muscles are innervated by the deep branch of the ulnar nerve:
Hypothenar muscles (flexor digiti minimi brevis, abductor digiti minimi, opponens digiti minimi)
Medial two lumbricals
Adductor pollicis
Palmar and dorsal interossei of the hand
volar; Wartenberg’s; Weakness/atrophy; intrinsic;
Guyon’s Canal Syndrome
Allen’s Test
Patient repeatedly makes a fist, then holds a fist
Therapist compresses both radial and ulnar arteries
Patient opens their hand
Therapist releases pressure on one of the arteries to see if if the hand flushes
Repeat test for other artery
Typical time to flush:
Radial: 2.5-3.5 seconds
Ulnar: 2-3 seconds
+ Test: anything >_ seconds
Testing for ulnar artery thrombosis (collateral blood supply in the hand)
If one artery is out, the other artery should be able to supply the hand in terms of blood flow.
If we are testing for the ulnar artery, focusing on keeping pressure on the (radial/ulnar) artery as you let go of the (radial/ulnar) artery.
If testing the ulnar artery, keep ulnar artery compressed and waiting to see how long the ulnar artery takes to supply the hand (redness of the skin returning) once you release.
6; radial; ulnar
Guyon’s Canal Syndrome
Activity modification:
Avoid WB’ing/pressure on (thenar/hypothenar) eminence
Avoid using hand as a hammer
Padded gloves/gel pads
Limit prolonged wrist (flexion/extension) - May consider wrist control orthosis in (flexion/neutral)
Wrist extension can increase compressive force on the (radial/ulnar) nerve.
hypothenar; extension; neutral; ulnar
Postural Changes with Ulnar Nerve Paralysis
Froment’s Sign -
(Hyperextension/Hyperflexion) of IP during key pinch
(FPL/EPL) compensates for adductor pollicis
Froments – have patient take a piece of paper and try to pull it away as they hold. Ideally they should have a flat pinch because the adductor pollicis should be working, ___ will substitute and there will be flexion if not working
Hyperflexion; FPL; FPL
Postural Changes with Ulnar Nerve Paralysis
Jeanne’s Sign
(Hyperflexion/Hyperextension) at MCP during key pinch
Hyperextension;
Postural Changes with Ulnar Nerve Paralysis
Wartenberg’s Sign Inability to (abduct/adduct) small finger
Wartenberg’s sign – space between 4th and 5th digit. Inability to adduct that small finger. Ask them to adduct the finger and if unable, the (lumbricals/interossei) are denervated.
Make sure you don’t compare wartenberg sign vs syndrome. Wartenberg syndrome is the dorsal sensory radial nerve.
adduct; interossei
Postural Changes with Ulnar Nerve Paralysis
Duchenne’s Sign
Clawing of the (RF and SF/thumb and IF)
RF and SF
