median nerve power point presentation.pptx

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1. Presented by - Dr AVINASH KHARE, PG RESIDENT DEPARTMENT OF ORTHOPAEDICS

2. Anatomy:Axilla After arising from lateral and medial cord of brachial plexus It runs on lateral aspect of axillary artery. Anatomy:Arm Continues to run lateral to the brachial artery till the mid-arm. Crosses the artery anteriorly and passes anterior to the elbow joint into forearm.

3. INJURIES HIGH LOW

4. Motor functions- The flexors and pronators in the forearm are paralysed,with the exception of the flexor carpi ulnaris and medial half of FDP. The forearm constantly supinated,and flexion is weak(often accompanied by adduction,because of the pull of the flexor carpi ulnaris). Flexion at thumb is also prevented,as both the longus and brevis muscles are paralysed. The lateral two lumbrical muscles are paralysed,and the patient will not be able to flex at MCP joints or extend at IP joints of the index and middle fingers.

5. Sensory functions: lack of sensation over the areas that the median nerve innervates. The thenar eminence is wasted,due to atrophy of thenar muscles.

6. Examination Pronator teres assessment: The patients forearm is extended and fully pronated.The patient is then instructed to resist supination of forearm by the examiner.

7. Flexor carpi radialis assessment- The patient flexes the wrist along trajectory of forearm- wrist deviates ulnarly .

8. Pronator quadratus assessment- Have the patient resist supination of a fully flexed and pronated forearm. With full forearm flexion ,pronation by usually dominant pronator teres is minimised.

9. When AIN injury is present,the patient will be unable to bring together the tips of distal phalanx of the thumb and the index finger. Will be unable to make the OK SIGN. OK SIGN / KLEIN NIOH SIGN

10. APE THUMB DEFORMITY The thumb is adducted and laterally rotated so that the thumb lies in the same plane as the other fingers.It is due to over action of adductor pollicis(supplied by ulnar nerve).

11. MEDIAL NERVE COMPRESSION SYNDROMES CARPAL TUNNEL SYNDROME PRONATOR TERES SYNDROME ANTERIOR INTEROSSEOUS SYNDROME

12. KAPLAN’S CARDINAL LINE It is a more predictable landmark for the superficial palmer arch. In referencing this landmark as the distal most extent of an open or endoscopic carpal tunnel release,the superficial palmar arch should be free of transection.

13. Complications Injury to palmar cutaneous/recurrent motor branch of the median nerve. Hypertrophic scarring. Hematoma/Arterial imjury.

14. Pronator teres syndrome High compression neuropathy It is rare compared to CTS and AIS It is caused by compression of median nerve by PT muscle in proximal forearm.

15. Symptoms and signs Symptoms are similar to those of carpal tunnel syndrome. Sensory disturbances. Night pain is unusual and forearm pain is more common. Hand numbness on gripping. Phalen’s test negative. Symptoms provoked by - resisted elbow flexion with forearm supinated (tightening of bicipital aponeurosis). resisted forearm pronation with the elbow extended (pronator tension).

16. General indications of surgery In sharp injury exploration for diagnostic as well as therapeutic purpose.Neurorrhaphy (end to end suturing of nerve) can be done at time of exploration. In avulsion or blast injury-to identify and suture nerve ends for delayed repair. No improvements since last 12 weeks following close injury.

17. Time of surgery Primary repair within 6-8 hours gives best results. Delayed primary repair-between 7-18 days. Secondary repair- 3-6 weeks later.preferable in crushed,avulsed,contaminated wounds where patients life is seriously endangered.

18. Critical limit of delay of suture Motor recovery in the intrinsic muscles of the hand does not occur if suture is delayed 9 months in high lesions or 12 months in low ones. Useful sensory recovery only rarely occurs after 9 months in high lesions or 12 months in low ones.

19. THANK YOU!!!