23 April 2007 RVI Median Nerve Median Nerve Compression Compression syndromes syndromes Jeff Auyeung SpR Freeman Jeff Auyeung SpR Freeman
Dec 19, 2015
23 April 2007 RVI
Median Nerve Median Nerve Compression Compression syndromessyndromes
Median Nerve Median Nerve Compression Compression syndromessyndromes
Jeff Auyeung SpR FreemanJeff Auyeung SpR Freeman
23 April 2007 RVI
Content• Anatomy Median
Nerve• Pronator Syndrome• Anterior
Interosseous Nerve Syndrome
• Carpal Tunnel Syndrome
23 April 2007 RVI
Anatomy•Formed by 2 cords anterior to 3rd part of axillary artery
•Crosses Brachial artery from lateral to medial
•Lies medial to brachial artery in cubital fossa
•Passes between 2 heads of PT
•Lies between FDS and FDP then deep to flexor retinaculum
23 April 2007 RVI
XXXX Pronator SyndromeXXXX Pronator Syndrome
XXXX Anterior InterosseousXXXX Anterior Interosseous SyndromeSyndrome
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Pronator SyndromeSites of Compression• Supracondylar
process• Ligament of
Struthers• Bicipital aponeurosis• Between two heads
of pronator teres• Under origin of FDS
23 April 2007 RVI
Pronator SyndromeSymptoms:
• Forearm pain
• Hand numbness
• No night pain
Signs:• Resisted elbow
flexion with supinated forearm (bicipital aponeurosis)
• Resisted forearm pronation with elbow extended (PT heads)
• Isolated long finger PIPJ Flexion (FDS)
23 April 2007 RVI
Pronator SyndromeInvestigation
• Xray Elbow
• EMG/NCT
Treatment
• Splint/NSAIDs
• Release all potential sites of compression
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Anterior Interosseous Nerve Syndrome
• Characterised by motor loss without sensory involvement
• Muscles affected: FDP(radial half), FPL and Pronator Quadratus
• Beware bilateral cases - ?Parsonage-Turner syndrome
23 April 2007 RVI
Anterior Interosseous Nerve Syndrome
Sites of compresion• Fibrous bands in
PT• FDS origin• Enlarged bicipital
bursa• Gantzer’s muscle
23 April 2007 RVI
Anterior Interosseous Nerve Syndrome
• OK sign to test FPL and FDP
• Beware Isolated FPL rupture (Mannerfelt-Norman Syndrome)
• Pronation in max elbow flexion for PQ
23 April 2007 RVI
Anterior Interosseous Nerve Syndrome
23 April 2007 RVI
Anterior Interosseous Nerve Syndrome
Investigation
• EMG/NCT
Treatment
• Splint elbow at 90°/NSAIDs
• Release all potential sites of compression
23 April 2007 RVI
23 April 2007 RVI
Carpal Tunnel Syndrome-
Epidemiology• Most common peripheral nerve
compression syndrome • F>M• 43 to 74/100’000 decompression in
UK• Plus countless conservatively
treated
23 April 2007 RVI
Carpal Tunnel Syndrome –
Aetiology/Pathophysiology
• Increase pressure in Carpal tunnel ( 8mm vs 90mm Hg)• Ischaemia• Focal demyelination
• Risk factors: DM, RA, OA, Hypothyroidism wrist trauma, obesity, pregnancy
23 April 2007 RVI
Carpal Tunnel Syndrome –
Work• Prescribed disease if
related to use of vibrating tools
• Vibrating tool = more than 2 fold increase in risk
• Keyboard and computer work not risk for CTS
• Palmer KT, Harris EC, Coggon D.Carpal tunnel syndrome and its relation to occupation: a systematic literature review. Occup Med (Lond). 2007 Jan;57(1):57-66. Epub 2006 Nov 2
• No relationship between work and CTS
• Except “work that involves very cold temperatures (possibly in conjunction with load and repetition) such as butchery “
• Falkiner S, Myers S When exactly can carpal tunnel syndrome be considered work-related? ANZ J Surg. 2002 Mar;72(3):204-9.
23 April 2007 RVI
Carpal Tunnel SyndromeDiagnosis
• History and Exam (structured? – 85-100%)• Tinel’s ( 38-62%/57%), Phalen’s (77-86%/ 48%)
• Neurophysiology (?worse in men)
• Kamath V, Stothard J. A clinical questionnaire for the diagnosis of carpal tunnel syndrome. J Hand Surg [Br]. 2003 Oct;28(5):455-9. Erratum in: J Hand Surg [Br]. 2004 Feb;29(1):95..
• Gunnarsson LG, Amilon A, Hellstrand P, Leissner P, Philipson L. The diagnosis of carpal tunnel syndrome. Sensitivity and specificity of some clinical and electrophysiological tests. J Hand Surg [Br]. 1997 Feb;22(1):34-7.
• Padua L, Padua R, Aprile, Tonali P. Italian multicentre study of carpal tunnel syndrome. Differences in the clinical and neurophysiological features between male and female patients J Hand Surg [Br]. 1999 Oct;24(5):579-82.
23 April 2007 RVI
Carpal Tunnel SyndromeManagement - Conservative
• Oral Meds• Vit B6• Steroid injection(?
Most useful in reversible causes/holding measure)
• Splint - ? Positions ? Rigidity
Likely to fail:• 50+years• > 10/12 symtoms• Constant
paraesthesia• Atrophy of APB• +ve Phalen’s
Giele H. Evidence-based treatment of carpal tunnel syndrome. Current Orthopaedics 15, 249-255
23 April 2007 RVI
Carpal Tunnel Syndrome
Management - Surgical• Open CTR• Endoscopic CTR• Limited CTR• Lengthening of
Flexor Retinaculum
23 April 2007 RVI
Carpal Tunnel Syndrome
Open Release• Beware motor branch
• Reconstruction vs. Lengthening
• 24% increase in volume(AP)
• 96% Satisfaction• Pinch and grip strength
return 6-12 weeks
23 April 2007 RVI
Carpal Tunnel SyndromeEndoscopic
• Uniportal vs Two portal technique
• Leave palmar skin and fat alone, not disturbed thenar and hypothenar muscles
• Faster recovery
• No Difference by 12 weeks
23 April 2007 RVI
Carpal Tunnel SyndromeOutcome
• >80% satisfied (?meaning)• Boston Carpal Tunnel Questionnaire• Scar tenderness• Pillar pain• Weakness• Slower return to work in manual
worker
23 April 2007 RVI
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