Compressive neuropathies of upper limb

Etiology, Anatomy , clinical presentation , examination ,provocative tests , Diagnosis , conservative and surgical management of all entrapment neuropathies of upper limb.

1. COMPRESSIVE NEUROPATHIES
OF UPPER LIMB
Dr.Prasanth

2. Entrapment neuropathy
Definition : Focal neuropathy due to restriction or
mechanical distortion of nerve within the fibrous or fibro-
osseous tunnel.
•The nerve is injured by
1.chronic direct compression,
-external
-internal
2.Angulations
3. stretching forces
causing mechanical damage to
the nerve.

3. In General
•All entrapments may have one of the basic structure
a)Fibro-osseous tunnel
-Carpal tunnel
-Tarsal tunnel
-Suprascapular nerve tunnel
b)Fibrotendinous archade
-supinator (archade of frohse)
-pyriformis syndrome
-peroneal nerve entrapment
-interosseous nerve entrapment
c)Abnormal bands causing compression
-Thoracic outlet syndrome
-meralgia parasthetica

4. PATHOPHYSIOLOGY

5. Specific entrapment syndromes
•Upper limb
a)median nerve
-carpal tunnel syndrome
-anterior interosseoussyndrome
-pronatorsyndrome
b)Ulnarnerve
--at elbow
--Guyonscanal
c)radial nerve
-radial tunnel
-wartenberg’ssyndrome

6. SUPRASCAPULAR NERVE ENTRAPMENT
•Throwers, other overhead athletes and weight-lifters and
usually associated with cysts, Ganglia or SLIP tears.
•Arises from superior trunk of brachial plexus
•Innervates supraspinatus and infraspinatus
•Compression most commonly suprascapular or
spinoglenoid notch.

14. Causes
•Notch narrowing
•Ganglion cyst from intraarticular defect
–Often indicative of a labral (SLAP) tear
•Nerve kinking or traction from excessive
infraspinatus motion
•Superior or inferior (spinoglenoid) transverse
scapular ligament hypertrophy causing
compression

15. Investigations and Treatment
•MRI may exclude rotator cuff tears, demonstrate
atrophy and/or reveal a ganglion or space-
occupying lesion-if present, strongly consider
surgical excision
•NCS/EMG may assist with the diagnosis
•Typically begin with non-operative mgmt.
•Rx:Rest from repetitive hyperabduction
•NSAIDs and corticosteroid injections considered
•Nonrespondersmaybenefitfromaspinoglenoid

17. MEDIAN NERVE
ENTRAPMENTS

18. •Median nerve entrapments
-carpal tunnel syndrome
-Pronator teres syndrome &
-Ant. Interosseous syndrome

19. CARPAL TUNNEL SYNDROME
•Is a cylindrical cavity connecting the volar forearm
with the palm.
•MC among compressive neuropathies.
•Incidence 1-3.5 cases / 1 lak persons per year.
•Depth of tunnel 10mm to 13mm.
•Pressure with in a tunnel measures 2.5mmHg
•10 structures from volar arm passes through tunnel
-8 Flexor tendons (FDS + FDP).
-FPL
-Median nerve

20. Boundaries
Floor: transverse arch of carpal bones
Medially: hook of hamate & pisiform
Laterally: Tubercle of scaphoid, trapezium crest &
fibro osseous flexor carpi radialis sheath.
Roof: proximally flexor retinaculum, transverse
carpal ligament over the wrist and aponeurosis
between thenar & hypothenar muscles distally.

21. At the distal edge of the TCL , Median nerve gives 6 branches
( 2common digital nerves, 3 proper digital nerves &
1 Recurrent motor branch )

22. •MEDIAN NERVE –MOTOR
INNERVATION:
1
st and the 2
nd lumbricals
Muscles of thenar eminence:
1.Opponens pollicis
2.Flexor pollicis brevis
3.Abductor pollicis brevis
SENSORY INNERVATION:
Skin of the palmar side of the lateral
3 and half fingers.

24. Signs and symptoms
•Tingling
•Numbness or discomfort in the
lateral 3 1/2 fingers
•Intermittent pain in the
distribution of the median
nerve
•To relieve the symptoms,
patients often “flick” their
wrist as if shaking down a
thermometer (flick sign).

25. •MC symptom “Nocturnal acroparesthesia” , painful
tingling and numbness in a thumb and one of radial
digits , which may even disturb sleep .
•Day time paresthesias occurs –Activities involve
extremes of wrist flexion.

26. •Motor changes :
Apelike thumb deformity
Loss of opposition of thumb
Index and middle finger lag behind when making the fist.

27. Thenar atrophy(Late sign in neglected cases )

31. SENSORY CHANGES:
Lossofsensationoflateral31/2digitsincludingthenailbedand
distalphalangesondorsumofhand
(AnimportantpointtorememberforCarpaltunnelsyndromeis
thatthereisnosensorylossoverthethenareminenceinCarpal
tunnelsyndromebecausethebranchofmediannervethat
innervatesit(palmarcutaneousbranch)passessuperficialto
Carpaltunnelandnotthroughit).

32. •Most sensitive test for early CTS :
Semmes weinstein monofilament test (Detects
sensory changes early)
Monofilaments of increasing diameters are touched to
palmar side of the digit until the patient can tell which digit
is touched.

33. Provocative tests
•PHALEN’S TEST: It is POSITIVE, If symptoms develop
within a minute, CTS is indicated.
•TINEL’S SIGN TEST:
In the Tinel's sign test, the doctor taps over the median
nerve to produce a tingling or mild shock sensation.

34. •DURKAN TEST:
Press over the carpal tunnel for 30 seconds to produce
tingling or shock in the median nerve.
Durkansafter phalenstest might increase its sensitivity.
•TORNIQUET TEST:
Torniquetinflated above systolic for one
minute intensifies the symptoms

35. •Reverse phalens test / Prayers hand test:
useful but in moderate to advanced
compression predominently.
•HAND ELEVATION TEST:
The patient raises his or her hand overhead for
2 minutes to produce symptoms of CTS.

37. Evaluation
•History
•Physical examination
•Nerve Conduction Study

38. Imaging
•X-ray for any degenarative cases and calcifications.
•MRI
•USG-Triad
1.Palmar bowing of flexor retinaculum.
2.Distal flatenning of the nerve at the level of
hook of hamate.
3.Enlargement of nerve proximal to flexor
retinaculum(most sensitive and specific criterion)
[ The difference in nerve cross section between level of
pronator quadratus and carpal tunnel has 99% sensitivity
and 100% specificity ]

39. Palmar bowing

40. Management
•CONSERVATIVE TREATMENTS
–GENERAL MEASURES
–WRIST SPLINTS
–ORAL MEDICATIONS
–LOCAL INJECTION
–ULTRASOUND THERAPY
–Predicting the Outcome of Conservative Treatment
•SURGERY

41. •Avoidrepetitivewristandhandmotionsthat
mayexacerbatesymptomsormakesymptom
reliefdifficulttoachieve.
•Notusevibratorytools
•Ergonomic measures to relieve symptoms
depending on the motion that needs to be
minimized

42. Probably most effective when it is applied
within three months of the onset of
symptoms

43. •Nonsteroidal anti-inflammatory drugs
(NSAIDs)
•pyridoxine (vitamin B6)
•Orally administered corticosteroids
–Prednisolone
–20 mg per day for two weeks
–followed by 10 mg per day for two weeks

45. Surgical management
•Should be considered in patients with symptoms
that do not respond to conservative measures and
in patients with severe nerve entrapment as
evidenced by nerve conduction studies,thenar
atrophy, or motor weakness.
•It is important to note that surgery may be
effective even if a patient has normal nerve
conduction studies

46. •Open release
•Endoscopic release

47. •longitudinal incision made between proximal
palmar crease and 1 cm distal to hamate hook in
line with radial border of ring finger.

48. ANTERIOR INTEROSSEOUS SYNDROME
& PRONATOR SYNDROME
•Pronator teres syndromeis a compression
neuropathy of the median nerve at the elbow.
•Anterior interosseoussyndromeis a isolated
injury of the anterior interosseous branch of
the median nerve( purely motor branch ).
•Site of compression essentially same for both
Pronator syndrome(PS) and Ant. Int. nerve
syndrome (AIS).

49. Causes
•MC cause due to fibrous bands between ulnar and
humeral heads of pronator teres where median
passes.
•Thickened or tight bicipital aponeurosis( Lacertus
fibrosus )
•Hypertrophic pronator teres
•Iatrogenic ( compression due to casting )
•Anamalous insertion of coracobrachialis muscle.
•Ligament of struthers( Band of connective tissues
arise from supracondylar humerus process to the
medial humeral epicondyle ).
•FDS arch

51. Clinical presentation
•Pronator syndrome(sensory+motor) :
•Proximal
•sensory involvement
•Vague volar forearm pain,Median nerve
parasthesias, minimum motor findings.
•Anterior interosseous syndrome :
•Pure motor palsy of any or all three
1.FPL,2.FDP of index and middle fingers,3.PQ

52. Differential diagnosis of sites of
compression
•PROVOCATIVE TESTS
•Flexion of elbow against resistance between 120-135 degrees
–struthers ligament
•Flexion of elbow with forearm pronation
--lacertus fibrosus
•Pronation against resistance combined with wrist flexion
-2 heads of pronator teres
•Resisted flexion of FDS of middle finger
-musculotendinous arch of FDS

53. OK sign

54. Treatment
•INITIALLY: CONSERVATIVE
•SURGICAL: INDICATIONS
No resolution of symptoms
Severe symptoms
•SURGICAL EXPLORATION: Identification &
division of the offending structure.

55. ULNAR NERVE
ENTRAPMENT

56. Ulnar nerve gets entrapped at 2 common sites:
-At the elbow (cubital tunnel syndrome)
-Guyon’s canal (ulnar tunnel syndrome)

57. CUBITAL TUNNEL SYNDROME
Second commonest nerve entrapment of the upper limb
Commonly people called as “Funny Bone”
ANATOMY: CUBITAL TUNNEL
Starts at the groove between the olecranon & the medial
epicondyle.
Tunnel is formed by a fibrous arch connecting the 2 heads
of the flexor carpi ulnaris & lies just distal to the medial
epicondyle.

58. Anatomical Boundaries
•Roof –Osborne’s fascia and Arcuate ligament of
Osborne’s ( fibrous band from medial epicondyle to
olecranon ).
•Floor –Ulnar collateral ligament and joint capsule.
•Walls –formed by medial epicondyl and olecranon.

59. CAUSES OF ENTRAPMENT
Aponeurosis of FCU or B/W FCU heads [ MC site ].
ARCADE OF STRUTHER’S :Band of connective tissues
arise from supracondylar humerus process to the
medial humeral epicondyle [ 2
nd
MC site ]
Tight fascial band over the cubital tunnel.
Medial head of triceps
Recurrent subluxation of ulnar nerve, results in
neuritis.
Osteophytic spurs
Cubitus valgus following supra condylarfracture.

60. Clinical features
Numbness involving the little finger & the ulnar half
of the ring finger.
Hand weakness & clumsiness
Tenderness over the ulnar nerve at the elbow.
Tinel’s sign is positive: exacerbation of paraesthesia’s
with light percussion over the ulnar nerve.
Advanced cases : clawing of the ring & little
fingers(less marked than in lower ulnar nerve palsy)
Atrophy of first web space and interosseous muscles.
Reduced strength of FPB , Adductor pollicis, 4
th
& 5
th
lumbricals and All Hypothenar muscles.

62. Special tests and signs

65. •Conversion of “X” crease to “Y” pattern of
intersected crease ( Loss of DIP flexion in ulnar
nerve palsy in little finger )

66. Treatment
NON OPERATIVE: Early stages
Activity modification
Immobilization of the elbow in 30 degrees of extension,
followed by periods of mobilization with elbow padding.
SURGICAL:
Decompression of the nerve by dividing of the basic
offending structure.
Anterior transposition of the ulnar nerve
Medial epicondylectomy ( for subluxated nerves /
Recurrent cases / very severe neural compression ).

67. ULNAR TUNNEL SYNDROME
Ulnar nerve is compressed as it passes through
GUYON’S canal in the wrist.
•Also known as “Handle bar palsy”
Less common than entrapment of the ulnar nerve at the
elbow.

68. •ANATOMY:GUYON’S CANAL
–ROOF : Volar carpal ligament.
–Medial wall : pisiform & pisiohamate ligament.
–Lateral wall: hook of hamate
–Floor : Transverse carpal ligament
–Ulnar nerve enters guyon’s canal accompanied by
ulnar Artery & Ulnar Vein.
–Guyon’s canal lies in the space between flexor
retinaculum & volar carpal ligaments

69. The anatomy of distal ulnar tunnel is divided into 3
zones.
Zone 1:proximal to the bifurcation of the ulnar nerve
& consists of both sensory & motor fibres of the
nerve.
Zone 2: represents the motor branch of the ulnar N
distal to the bifurcation.
Zone 3: represents the sensory branches of the ulnar
nerve beyond its bifurcation

71. Clinical presentation
ZONE 1 LESIONS : Mixed sensory & motor loss.
ZONE 2 LESIONS : Isolated motor deficit.
ZONE 3 LESIONS : Isolated ulnar N sensory loss.
Common Causes in zone 1 & 2: ganglions,
fractures of the hook of hamate.
Zone 3: ulnar artery thrombosis / Aneurysm.
OTHER CAUSES:
Malunited fracture of fourth/fifth metacarpal.
Anomalous muscles
Occupational trauma

72. Investigations
X RAY : Oblique/carpal tunnel views
Delineate bony anatomy to diagnose hook of hamate
fractures.
MRI: Ganglia, space occupying lesions
Treatment
•Operative release of the canal by reflecting the FCU,
pisiform & pisiohamate ligament ulnarly.
•Distal deep fascia of the forearm below the wrist crease
should
be released.
•Resection of any space occupying lesion
•Treatment of hook of hamate fractures

73. RADIAL NERVE ENTRAPMENTS

74. •Radial nerve entrapments
-Posterior interosseous nerve syndrome
-radial tunnel syndrome
-wartenberg’s syndrome

75. RADIAL TUNNEL SYNDROME
The PIN passes between the 2 heads of the supinator
muscle in the radial tunnel.
•Boundaries of radial tunnel
Medial: Brachialis prox. & Biceps tendon distally.
Roof & Lateral : Brachioradialis ,
ECRL and ECRB tendons
Floor : Capsule of radiocapitellar
joint

76. •It is a compressive neuropathy of the radial nerve main
trunk in the proximal forearm before / at /just after it splits
into main trunk PIN nerve and sensory branch which results
in both sensory and motor symptoms.
•More common in male manual labourers and Body
builders.

77. Potential sites of compression
•Between Brachialis and Brachioradialis.
•“Leash of Henry” are recurrent radial vessels that
fan out across the PIN at the level of radial neck.
•Distal border of supinator muscle at its edge.
•At the origin of ECRB or fibrous bands with ECRB.
•“Arcade of Frohse” (supinator fibrous arch)

78. Leash of Henry Arcade of Frohse

79. •Examination:
patient has pain and inability to extend the middle
finger against the resistance with elbow extended and
forearm pronated with wrist neutral.
•Provocative tests:
-painful resisted supination : compression at the arcade
of frohse.
-painful resisted middle finger extension test :
compression at ECRB and Brachioradialis.
Physical examination –Atrophy can be noted in the extensor
compartment in long stand cases.

80. Pain is often acute & can mimic tennis elbow.
Electrophysiological studies shows no abnormality.
Treatment: non-operative: Activity modification,
splinting, NSAID’S & rest.
Surgical decompression is often combined with
lateral epicondyle release.

82. POSTERIOR INTEROSSEOUS NERVE
SYNDROME
•ANATOMY
Proximal to the elbow joint, the radial nerve branches
into the superficial radial nerve & the PIN.
The PIN travels around the radial neck and through the
interval between the 2 heads of the supinator muscle.
This opening which has an overlying compressive fibrous
arch is known as arcade of frosche.

83. Presentation
•Only motor dysfunction.
•Present with dropped fingers and thumb.
•ECRL is preserved as it receives supply along with
brachioradialis before the nerve enters radial tunnel.

84. Etiology:
Ganglion cyst, lipomas , septic arthritis of elbow
Proliferative synovitis (rheumatoid arthritis), vasculitis
•Electro diagnostic testing may localize the site of
compression.
•Initially : observation & non operative treatment.
•Operative methods: exploration & appropriate
division of compressing structures.

85. WARTENBERG’S SYNDROME
Also called Cheralgia paresthetica , Hand cuff neuropathy /
Wristlet watch neuritis.
Commonly associated with De Quervains disease in
20% -50% patients.
Compression of the superficial branch(sensory) of the radial
nerve can occur most commonly as it exits from beneath
the brachioradialis in the forearm.
Nerve can get trapped b/w the ECRL & the brachioradialis,
especially with pronation in the forearm.

87. On examination
•Dellons provocative test is positive : Increased
symptoms on wrist flexion , ulnar deviation and
pronationfor 1 min.
•Finkelstein test is positive in 96% of cases because
of traction on the nerve.

92. Thank you