Wrist & Hand Common Presentations: Nerve Entrapment

Question 1

peripheral nerve entrapment

Answer 1

• typically report vague pain or sensory disturbances

Question 2

what must you rule in/out even if you have ruled in a peripheral nerve entrapment

Answer 2

cervical spine involvement and thoracic outlet syndrome

Question 3

double crush syndrome

Answer 3

compression of a nerve at two or more locations

Question 4

thoracic outlet syndrome

Answer 4

group of disorders that occur when blood vessels or nerves in the space btw the collarbone and first rib are compressed

Question 5

common symptoms of thoracic outlet syndrome

Answer 5

numbness
pain
weakness

Question 6

median nerve sensory loss

Answer 6

• C5 - T1
• palmar aspect of hand: thumb, index, middle and lateral half of ring finger
• posterior: distal third of index, middle and lateral half of ring finger

Question 7

median nerve functional loss

Answer 7

• pronation, wrist flexion, radial deviation weak
• inability to oppose thumb or flex
• thumb abd weak
• gripping weak
• pinching weak/loss
• ape hand deformity

Question 8

pronator syndrome

Answer 8

entrapment of median nerve as passes btw two parts of pronator teres

Question 9

pt history with pronator syndrome

Answer 9

• insidious
• pain at anterior aspect of elbow, radial side of palm, palmar side of first, second, third and fourth digit
• heaviness & weak in forearm & hand

Question 10

ape hand deformity

Answer 10

• thenar wasting
• first digit moving dorsally until it is in line with second
• median n. dysfunction

Question 11

treatment for ape hand

Answer 11

• pain meds
• edema management
• flexibility exercise
• splinting
• functional strengthening/endurance/coordination

Question 12

palpation with pronator teres syndrome

Answer 12

• pressure applied over pronator teres with resisted pronation, elbow and wrist flexion

Question 13

special tests for pronator teres syndrome

Answer 13

• none
• carpal tunnel tests should be negative
• • ULTT median n.

Question 14

treatment for pronator teres syndrome

Answer 14

• RICE
• pain meds
• flexibility/strength of wrist flexors and pronators
• STM
• nerve glides/tensioners

Question 15

median nerve - anterior interosseous sensory loss

Answer 15

none

Question 16

median nerve - anterior interosseous functional loss

Answer 16

• pronation weak
• finger flexion weak
• pinching weak

Question 17

anterior interosseous syndrome

Answer 17

entrapment of AIN

Question 18

possible compression sites for median nerve - anterior interosseous

Answer 18

• tendinous origin of FDS
• accessory head of FPL
• tendinous origin of pronator teres

Question 19

median nerve - anterior interosseous strength loss

Answer 19

triad of weakness:
flexor pollicis longus
flexor digitorum profundus of 2nd & 3rd digit
pronator quadratus

Question 20

median nerve - anterior interosseous pain symptoms

Answer 20

resisted flexion of IP of thumb and DIP of index finger

Question 21

carpal tunnel syndrome

Answer 21

median nerve compression at the wrist as it passes through the carpal tunnel

Question 22

demographics of carpal tunnel

Answer 22

• any age, most common 40-60
• female > male
• half of cases related to repetitive and cumulative trauma at work

Question 23

what should you limit with pt’s who have carpal tunnel

Answer 23

• vibration

- prolonged positioning at end range flexion and end range extension

Question 24

initial characteristics of carpal tunnel

Answer 24

• intermittent pain & parathesisas in median n. distribution of hand
• becomes persistant

Question 25

carpal tunnel weakness

Answer 25

- weakness and paralysis may occur if left untreated | - abductor pollicis brevis, opponens pollicis, lateral 2 lumbricals, flexor pollicis brevis

Question 26

when are symptoms worse for pt's who have carpal tunnel

Answer 26

at night due to position of wrist flexion

Question 27

radial n. sensory loss

Answer 27

- C5 - T1 - posterior side of lateral 2/3s hand - posterior and lateral thumb - proximal posterior 2/3s index, middle and half of ring finger

Question 28

radial n. functional loss

Answer 28

- supination, wrist extension, grasping weak - inability to stabilize wrist - loss of finger extension - extreme difficulty to abduct thumb

Question 29

high radial n. compression pt history

Answer 29

- insidious compression may occur at level of triceps due to strenuous muscle exercise - traumatic: mid shaft humeral fracture

Question 30

high radial n. compression strength loss/sensory loss/palpation site

Answer 30

- loss of wrist extension - inability to extend fingers and thumb - decreased first digit posterior web space - site of entrapment should reproduce symptoms

Question 31

radial n. - posterior interosseous nerve syndrome (PIN) sensory loss

Answer 31

none

Question 32

radial n. - posterior interosseous nerve syndrome (PIN) functional loss

Answer 32

- wrist extension weak - finger extension weak - hard to stabilize wrist - difficulty grasping and abducting thumb

Question 33

radial n. - posterior interosseous nerve syndrome (PIN) common compression sites

Answer 33

- fibrous bands that connect brachialis and brachioradialis - under blood vessels that cross the nerve at the radial neck - medial proximal portion of ECRB - fibrous bands at proximal and distal edge of supinator

Question 34

radial n. - posterior interosseous nerve syndrome (PIN) where would you feel pain

Answer 34

- lateral elbow pain that radiates into distal forearm - repeated pronation/supination - resisted supination

Question 35

treatment for radial n. - posterior interosseous nerve syndrome (PIN)

Answer 35

- nerve glides - STM - rest - activity mod - splinting - gentle stretching

Question 36

ulnar nerve sensory loss sites

Answer 36

- C8 - T1 | - posterior and palmar aspect of little and medial half of ring finger

Question 37

ulnar nerve functional loss

Answer 37

- wrist flexion weak - loss of ulnar deviation, DIP flexion of pinky, abduction and adduction of fingers - inability to extend 2nd and 3rd phalanges of pinky and ring finger

Question 38

cubital tunnel syndrome

Answer 38

- entrapment of ulnar n. as runs through cubital tunnel

Question 39

pt history with cubital tunnel syndrome

Answer 39

- insidious, can be trauma - repetitive motion - prolonged elbow flexion recreates symptoms - overhead throwing athlete - pain or paresthesia worst at night - loss of grip strength

Question 40

observation seen in cubital tunnel syndrome

Answer 40

- excessive elbow varus or valgus - claw contracture of the 4th & 5th fingers (late) --> loss of lumbricals - atrophy or weakness of ulnar intrinsic muscles of hand (late)

Question 41

sensation/palpation/pain felt with cubital tunnel syndrome

Answer 41

- sensation: decreased in ulnar hand distribution - palpation: tender at cubital tunnel - pain: at 4th and 5th digits and elbow

Question 42

guyon canal

Answer 42

entrapment of ulnar n. as passes btw pisiform and hook of hamate

Question 43

pt history with guyon canal

Answer 43

- blunt trauma - hook of hamate fx - use of crutches - repeated vibration

Question 44

strength/sensation loss with guyon canal

Answer 44

- strength: weak hypothenar, adductor pollicis, interossei, medial 1/2 lumbricals - sensation: decreased or absent of 5th and medial half of 4th digit