upper extremity compressive mononeuropathy

Upper Extremity

Compressive

Mononeuropathy

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Capt Brendan M. Stroz, PA-C, MPAS

Orthopaedic Surgery PA Resident

Travis AFB, CA

Disclaimer

I DO NOT have a financial interest/arrangement

or affiliation with one or more organizations

that could be perceived as a real or apparent

conflict of interest in the context of the subject

of this presentation.

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Objectives

At the conclusion of this session, the learner will be able to:

Differentiate between the multiple neuropathies of the upper extremities

Properly evaluate, diagnose and treat upper extremity mononeuropathies

Describe specialty exams to evaluate for upper extremity mononeuropathies

Describe ancillary tests to evaluate for upper extremity mononeuropathies

Describe initial non-surgical management of upper extremity mononeuropathy

Describe initial surgical management of upper extremity mononeuropathy

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Compressive Neuropathy-What is it? Chronic condition involving peripheral upper extremity nerve with sensory, motor or

mixed manifestations.

May be acute or secondary to treatment

Paresthesias arise from compression and ischemia

Acute

Chronic

SLT are first, pain and temperature last

Peripheral Compression Neuropathies of

the Upper Extremity Median Nerve

Carpal Tunnel Syndrome

Pronator Syndrome

Anterior Interosseous Nerve Syndrome

Ulnar Nerve

Cubital Tunnel Syndrome

Ulnar Tunnel Syndrome

Radial Nerve

Proper Radial Nerve

Posterior Interosseous Nerve Syndrome

Radial Tunnel Syndrome

Wartenberg Syndrome

Median Nerve Compression

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Median Nerve Compressions

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Pronator Syndrome

Proximal compression of median nerve

Symptoms

Proximal forearm pain, sensory disturbances in palmar cut

branch (median n)

Provocative Tests: elbow flexion, pronosupination, resisted

long finger PIP joint flexion (FDS)

Typically associated with medial epicondylitis and will improve

w/tx

Treatment

Conservative: activity mod, splint, NSAIDs

Surgical Decompression ~ 80 % success rate

Median Nerve Compressions

Anterior Interosseous Nerve Syndrome

Motor loss without sensory disturbance

FPL loss +/- FDP, PQ PQ tested with resistance in full elbow flexion and pronation

EMGs

Treatment

Vast majority recover with observation

Splinting (elbow 90 degrees), activity mod

Surgical decompression (w/in 3-6 mos)


Most common compressive neuropathy in UE

Acute vs chronic

Median nerve compression at the level of the transverse carpal

ligament

CT has 9 tendons and median n.

Common systemic risk factors:

Pregnancy

DM

Thyroid disease

Alcoholism

Advanced age


Evaluation

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Paresthesias, numbness and pain (often at night)

Large sensory affected before small fibers (SW testing)

Repetitive motions (Keyboard, knitting, hammer, etc)

Most sensitive test: Durkans (Tinels and Phalens*)

Spurlings

Flick Test

Examine strength grades (0-5) in chronic cases

2.5-30 mm Hg

Carpal Tunnel Syndrome Evaluation and

Tests

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Testing

Films (Xray)

Injections*

EMG

It depends


Treatment

A wise man once said…

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Carpal Tunnel Release

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Post-operative course

Con Leave?

Limitations

Ulnar Nerve Compression

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Ulnar Nerve Compression

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Ulnar Tunnel Syndrome

Compression of the ulnar nerve in the Guyon Canal

MC Cause: Ganglion cyst

Hook of Hamate non-union, lipoma, PB hypertrophy, ulnar artery thrombosis.

Motor and/or sensory

Treatments

Conservative

Surgical decompression

Treat underlying cause


Second most common UE compression neuropathy

Multiple sites of compression

Other potential causes

Tumors/ganglion

Osteophytes

HO

Medial Epicondyle Non-union

Deformities


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Symptoms

Paresthesias of the ulnar 1½ digits

Night symptoms w/flexion

Provocative Tests

Compression

Hyperflexion

Tinel’s

Check for Subluxation*

Further Evaluation

EMG

Xrays


Treatment

The wise man’s principles

Surgery

In Situ

Anterior Transposition

Medial epicondylectomy

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Radial Nerve Compression

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Radial Nerve Palsy

Typically in setting of humeral trauma or related

surgical approaches

“Saturday Night Palsy”

Weakness of innervated muscles

Triceps, BR, ECRL, PIN

EMG for prognosis

Observation x 3 months—refer if no

improvements


Posterior Interosseous Nerve Syndrome

Lateral Elbow pain & distal muscle weakness

MC Compression in Arcade of Frohse

Repetitive supination/pronation movements, trauma

Paresis/paralysis of extensors in hand

Dorsal wrist pain where terminal fibers provide sensory innervation

to dorsal wrist capsule

EMG to determine level of compression

Conservative treatment

Splints/bracing

Surgery if no improvements within 3 months (85%)


Radial Tunnel Syndrome

Symptoms: Lateral Elbow/radial forearm pain

No sensory or motor dysfunction

Resisted long finger extension/supination

***LE can coexist, POMT is distal to LE (mobile wad)

EMG inconclusive

Extended conservative tx; up to 1 year

Surgical decompression

Wartenberg Syndrome

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Compression of superficial sensory branch

Scissoring between BR and ECRL w/pronation

Handcuffs, wristband, fracture

De quervains associated up to 50%

Symptoms

Pain, numbness, paresthesias on dorsoradial hand, doesn’t like to wear a

watch

Provocative tests: pronation against resistance x 60 seconds and Tinel

sign

Treatment

Surgical decompression if conservative therapy fails

References

1. Miller, M.D. (2016). Miller’s Review of Orthopaedics, Seventh Edition.Philadelphia, PA: Elsevier Inc.

2. Boyer, M.I. (2014). Comprehensive Orthopaedic Review: Volume 2. Rosemont, IL: American Academy of Orthopaedic Surgeons.

3. Franko, O. (2012, November 19). Carpal Tunnel Syndrome. Retrieved from: www.orthobullets.com.

4. Allen, D. (2012, November 25). Cubital Tunnel Syndrome. Retrieved from: www.orthobullets.com.

5. Sheth, U. Vitale, M. (2018, December 12). AIN Compression Syndrome. Retrieved from: www.orthobullets.com.

6. Watts, E. (2012, November 19). PIN Compression Syndrome. Retrieved from: www.orthobullets.com.

http://www.orthobullets.com/




Questions?

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upper extremity compressive mononeuropathy

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