Week 7 Compression Neuropathies of the Elbow, Wrist, and Hand Flashcards by Michael Obi

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

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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

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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

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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

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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

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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

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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

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What is the sensibility testing hierarchy order?

Detection > discrimination > identification

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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

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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;

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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

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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

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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

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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

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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;

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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

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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

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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

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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

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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;

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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

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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;

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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

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(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

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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;

Conservative Treatment for CTS Patient education Activity modification Positioning Splinting - As needed; often at night If going to splint a patient, put the wrist in (flexion/neutral). The wrist positions are usually already in extension and it pulls them up into extension. Modify the splint by pushing on the metal to make it into neutral. Nerve glides Tendon glides

neutral

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

Parsonage – Turner Syndrome May be indicated when there is sudden bilateral weakness with the ____ and ____ muscles after vaccination or viral illness (viral brachial neuritis) Compare to contralateral side!! Have to evaluate both sides due to parsonage – turner syndrome

FPL and FDP

Activity Modification for AIN Syndrome (Small/Large) diameter zippers/pulls Avoid repetitive gripping/forearm rotation Trouble with fine motor control in these patients Potential entrapment points could be the FDS and the pronator so don’t want to further irritate compression on that nerve.

Large;

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

High vs. Low Ulnar Nerve Palsy ``` Flexor Carpi (Radialis/Ulnaris) (FDP (ring/small) / FDS) ``` (High/Low) ulnar nerve palsy ``` Abductor Digiti Minimi Flexor Digiti Minimi Opponens Digiti Minimi Adductor Pollicis 3rd/4th Lumbricals Interossei Flexor Pollicis Brevis (deep head) ``` (High/Low) ulnar nerve palsy When checking for a low ulnar nerve palsy, check the (lumbricals/interossei) FDP and the lumbricals have to balance each other out a little bit. The FDP flexes the DIP and the lumbricals flex the MCPS and extend the IPS.

Ulnaris; FDP; High; Low; interossei;

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;

Surgical Intervention for CuTS Endoscopic Cubital Tunnel Release - release tunnel to release the pressure. These patients do extremely well. Not needing long bouts of therapy. Elbow pad for comfort prn Typically minimal role for PT Ulnar Nerve Anterior Transposition - where they move the nerve out of the cubital tunnel to put it in a more anterior position to have less pressure on the nerve Subcutaneous Intramuscular Submuscular Medial Epicondylectomy Not common

Got it

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

Review: General Principles for Conservative Treatment of Compression Neuropathies ``` Activity modification Splinting PRN Nerve glides Tendon glides (CTS) Maintain (AROM/PROM) ``` If they have CTS, have to use tendon glides because of the 9 tendons in there

AROM

Appropriate Timeline? Initial concern: Symptom management Nerve glides TGE (CTS) Symptom-free at rest? Regain (AROM/PROM) if there is a loss No increase in symptoms with AROM? May consider progression of (PROM/strengthening) Special considerations? CTS – caution with gripping. Can improve overall hand and grip strength by using the hook fist as opposed to a full fist.

AROM; strengthening;

Review: General Principles for Post-Op Treatment for Compression Neuropathies Pain control Edema control Scar management - elastic tape/paper tape Desensitization - hypersensitivity is a real issue after surgery Nerve glides (as appropriate) Tendon glides (CTR - Carpal Tunnel Release) Restore ROM (protected ROM depending on surgery)

Got it

Appropriate Post-Op Timeline? ``` s/p CTR (Carpal tunnel release) 1st post-op visit (7-10 days) (TGE/Elbow PROM) (Median/Ulnar) nerve glides Wound care Splinting prn - post op pain relief ``` 2nd visit (week 2) Initiate (AROM/PROM) and scar management/desensitization Wrist flexion?? -potential for bowstringing so hold off on active wrist flexion as far as a therx home program Week 3-4 Addition of light resistance? ``` s/p CuTR - Cubital tunnel release 1st post-op visit (7-10 days) (Median/Ulnar) nerve glides Gentle (wrist/elbow) ROM as able Wound care Splinting prn ``` 2nd visit (week 2) (Wrist/Elbow) AROM Scar management/desensitization Week 3-4 Light resistance for wrist PRE’s? More specific for intramuscular and submuscular ulnar nerve transpositions Do tendon glides for CTS

TGE; Median; AROM; ulnar; elbow; Wrist;