SlideShare uma empresa Scribd logo
TINGLING AND NUMBNESS
 IN THE EXTREMITIES


        DR MANOJ R KANDOI
                 M.S.,D’ORTH,DNB,FCPS,
              FRSM(LONDON),FICS(CHICAGO)
        FELLOWSHIP IN HAND AND FOOT SURGERIES
USA,ITALY,FRANCE,GERMANY,UK,TAIWAN,REPUBLIC OF CHINA
THANKS TO MEDICAL
FRATERNITY WORLDWIDE
DR. MANOJ R. KANDOI
M.S.,D.N.B.,D’ORTH,F.C.P.S.,F.I.C.S.,F.R.S.M.,M.N.O.F.

FELLOW:
 UNIVARSITY OF WASHINGTON
 MILANO UNIVARSITY
 HISSINGPARK CLINIC,AUGSBERG,GERMANY
 HARBORVIEW MEDICAL CENTRE,SEATTLE,U.S.A
 POLICLINICO MULTIMEDICA,MILAN,ITALY
 AITS – IRCAD, TAIWAN,R.O.CHINA
 INOR FELLOW,BRITISH ORTHOPEDIC SOCIETY
 INTERNATIONAL COLLEGE OF SURGEONS,CHICAGO
 IRCAD ,STRAUBERG, FRANCE
 AMC,AMSTERDAM,NETHERLAND
What is a peripheral neuropathy?
 Peripheral neuropathy is disorder of nerve(s)
  apart from the brain and spinal cord. Patients
  with peripheral neuropathy may have tingling,
  numbness, unusual sensations, weakness, or
  burning pain.
What causes a peripheral neuropathy?

   Diabetes Mellitus

   Shingles (post herpetic neuralgia)

   Vitamin deficiency, particularly B12 and folate

   Alcohol

   Autoimmune diseases, including lupus, rheumatoid arthritis or Guillain-Barre syndrome

   AIDS, whether from the disease or its treatment, syphilis, and kidney failure

   Inherited disorders, such as amyloid polyneuropathy or Charcot-Marie-Tooth disease

   Exposure to toxins, such as heavy metals, gold compounds, lead, arsenic, mercury, and
    organophosphate pesticides

   Cancer therapy drugs such as vincristine (Oncovin, Vincasar), and other medications [for
    example antibiotics such as metronidazole (Flagyl), and isoniazid (Nydrazid, Laniazid)]
   While diabetes and post herpetic neura
Symptoms
 The symptoms depend on which type of
  nerve is affected. The three main types of
  nerves are:
 Nerves that carry sensations (sensory)
 Nerves that control muscles (motor)
 Nerves that carry information to organs and
  glands (autonomic)
SENSATION CHANGES
 Burning sensations
 Changes in sensation
 Inability to determine joint position, which
  causes lack of coordination
 Nerve pain
 Tingling or numbness
MOVEMENT DIFFICULTIES
 Difficulty breathing or swallowing
 Difficulty or inability to move a part of the
  body (paralysis)
 Falling (from legs buckling or tripping over
  toes)
 Lack of dexterity (such as being unable to
  button a shirt)
 Lack of muscle control
 Loss of muscle tissue (muscle atrophy)
 Muscle twitching or cramping
AUTONOMIC SYMPTOMS
   Abdominal bloating
   Blurred vision
   Constipation
   Decreased sweating
   Diarrhea
   Dizziness that occurs when standing up or fainting due to a drop in
    blood pressure
   Feeling full after eating a small amount (early satiety)
   Heat intolerance with exertion
   Incomplete bladder emptying
   Male impotence
   Nausea or vomiting after meals
   Urinary hesitancy (taking a long time to start urinating)
   Urinary incontinence
   Weight loss without trying
Signs and tests

 Tests that find and help classify neuropathy
  may include:
 Electromyogram (EMG) -- a recording of
  electrical activity in muscles)
 Nerve conduction velocity tests (NCV) -- a
  recording of the speed at which signals travel
  along nerves
 Nerve biopsy -- taking a small sample of a
  nerve to look at under a microscope
Treatment

 Addressing the cause (such as diabetes or
  excess alcohol use)
 Controlling symptoms
 Helping the patient gain maximum
  independence and self-care ability
 Replacing any vitamin or other deficiencies in
  the diet
 Stopping injury to the nerve (for example, in
  cases of neuropathy due to compression
  such as carpal tunnel syndrome)
Complications
   Deformity
   Loss of tissue mass
   Poor healing
   Scarring
   Tissue erosions
   Decreased self-esteem
   Difficulty breathing
   Difficulty swallowing
   Irregular heart rhythms (arrhythmias)
   Need for amputation
   Partial or complete loss of movement or control of movement
   Partial or complete loss of sensation
   Relationship problems related to impotence
Entrapment neuropathies
 Entrapment neuropathies are a group of
  disorders of the peripheral nerves that are
  characterized by pain and/or loss of function
  (motor and/or sensory) of the nerves as a
  result of chronic compression
Common entrappment syndromes
 Carpal tunnel syndrome (CTS), compression of the
  median nerve at the wrist, is the most common
  entrapment neuropathy.
 Cubital tunnel syndrome is caused by a compression
  at the elbow.
 suprascapular nerve compression, which accounts
  for approximately 0.4% of upper girdle pain
  symptoms, and
 meralgia paresthetica, a compression of the lateral
  femoral cutaneous nerve [LFCN] in the groin
CARPAL TUNNEL SYNDROME
            Median nerve
             compression at the
             wrist is at the
             transverse carpal
             ligament (TCL), which
             attaches to and arches
             between the pisiform
             and hamate on the
             ulnar side and the
             scaphoid and trapezium
             on the radial side
CARPAL TUNNEL SYNDROME
            Dull, aching pain at the wrist
             that may extend up the
             forearm to the elbow.
            Often, associated with
             distressing paresthesias in
             the thumb and index finger,
             particularly upon awakening.
            Typically, patients rub their
             wrists or shake their hands
             to try to "get the blood back
             into their wrists.“
            The pain is typically worse
             at night and disturbs their
             sleep
THENAR MUSCLE ATROPHY
CLINICAL TESTS
TINEL’S SIGN
CONSERVATIVE MANAGAEMENT: BRACING
LOCAL STEROIDS INJ
SURGICAL TREATMENT
INTRAOP PHOTOGRAPH
RESULTS OF SURGERY
 SATISFYING
 SYMPTOMS TEND TO COMPLETELY
 RESOLVE
CUBITAL TUNNEL SYNDROME
              The ulnar nerve travels on the
                medial side of the brachial
                artery in the upper arm, pierces
                the medial intermuscular
                septum at mid arm, and
                continues toward the elbow on
                the medial head of the triceps.
                At the elbow, it passes through
                the cubital tunnel, a groove
                between the medial humeral
                epicondyle and the olecranon.
                The nerve travels beneath the
                aponeurotic arcade between the
                2 heads of the flexor carpi
                ulnaris and down the forearm
                between the deep and
                superficial finger flexors.
5 potential areas of ulnar nerve
entrapment :
 The arcade of Struthers stretches from the medial head of the triceps to
    insert into the medial intermuscular septum. It is located approximately
    6-8 cm above the medial epicondyle. It can be a factor in ulnar nerve
    compression after ulnar nerve transposition.
   The medial intermuscular septum presents a sharp edge that can
    indent the nerve, particularly after anterior transposition, in which the
    nerve may be kinked.
   The cubital tunnel is floored by the medial collateral ligament of the
    elbow and roofed by the arcuate ligament (cubital tunnel retinaculum)
    that stretches between the medial humeral epicondyle and the medial
    aspect of the olecranon.
   The arching band of aponeurosis between the 2 heads of the flexor
    carpi ulnaris (so-called Osborne band) may compress the nerve,
    especially during repetitive contraction of the muscle.
   The aponeurotic covering between the flexors digitorum profundus and
    superficialis is occasionally a site of compression.
CLINICAL PRESENTATIONS
             Pain typically presents as a
              deep ache around the elbow
              region
             Pain is exacerbated when
              the medial elbow is impacted
             Intermittent paresthesias and
              numbness in the ring and
              little fingers
             Hand weakness, especially
              with gripping objects
CLINICAL SIGNS
 Sensation over the palmar portion of the fifth digit and the ulnar half of
    the fourth digit specifically is decreased to the following stimuli:
        Pinprick
        Light touch
        Two-point discrimination
 Sensory loss can also be detected along the dorso-ulnar aspect of the
    hand (due to involvement of the dorsal cutaneous branch of the ulnar
    nerve which arises proximal to the wrist).
   Late symptoms include dense numbness and profound weakness and
    atrophy of the intrinsic hand muscles.
   An ulnar claw hand may be present with extension of the little and ring
    fingers.
   Extension at the metacarpophalangeal joints and flexion at the
    intraphalangeal joints is caused by the loss of lumbricals 3 and 4.
   Provocative tests: A gentle tapping of the nerve at and around the
    cubital tunnel elicits distressing electrical shock, tingling, or both down
    into the ulnar fingers (percussion test).
TINEL’ S SIGN
FROMENT SIGN
                Weakness of finger
                 abductors and
                 adductors (interossei)
                 and adductor of the
                 thumb (adductor
                 pollicis) may be
                 detected whereas
                 thumb abduction is
                 normal
Ulnar nerve compression at the wrist
(Guyon canal)
 At the wrist, the ulnar nerve runs above the
  flexor retinaculum lateral to the flexor carpi
  ulnaris tendon and medial to the ulnar artery.
  At the proximal carpal bones, it dips between
  the pisiform and the hook of the hamate at
  the entrance to the Guyon canal, roofed over
  by an extension of the TCL between these 2
  bones
Clinical presentation
 young man with painless atrophy of the
  hypothenar muscles and interossei with
  sparing of the thenar group. Sensory loss and
  pain involving the ulnar 1.5 digits may be
  present.
SIGNS
 A positive Phalen test and percussion
  tenderness over the course of the ulnar nerve
  at the wrist may be present.
posterior interosseous nerve syndrome
Relevant anatomy
 At mid arm, the radial nerve descends behind
   the humerus, deep to the long head of the
   triceps, and then spirals around the humerus
   in between the medial and lateral heads of the
   triceps in the spiral groove. Approximately 5-
   10 cm above the lateral humeral epicondyle,
   the nerve pierces the lateral intermuscular
   septum to gain the anterior compartment of
   the arm. Here, it immediately enters the deep,
   muscular groove bordered medially by the
   biceps and brachialis and laterally by the
   brachioradialis, the extensor carpi radialis
   longus (ECRL), and the extensor carpi radialis
   brevis (ECRB). The nerve then courses
   immediately in front of the radiocapitellar joint
   capsule, where it divides into the (motor) deep
   branch of the radial nerve and the sensory
   superficial radial nerve (SRN).
causes
 PIN compression is most
  commonly associated with
  tendinous hypertrophy of the
  arcade of Frohse and fibrous
  thickening of the radiocapitellar
  joint capsule. Vascular
  compression by the leash of
  Henry has been reported.
  Lesions, such as lipoma,
  synovial cyst, rheumatoid
  synovitis, and a vascular
  aneurysm, have been found in
  some cases.
clinical picture
 Fatigue during finger extension
    and elbow supination.
   The extension in the
    metacarpophalangeal joints is
    weakened,.
   in the early stage of entrapment,
    the hand exhibits a
    characteristic pattern upon
    finger extension, in which the
    middle 2 fingers fail to extend,
    while the index and little fingers
    can be extended ("sign of
    horns").
   Progression of paralysis
    eventually causes weakness in
    all of the finger extensors and in
    thumb abduction.
   No sensory symptoms are
    present.
Suprascapular nerve entrapment
Relevant anatomy
 The suprascapular nerve arises
   from the lateral aspect of the
   upper trunk of the brachial
   plexus, runs across the
   posterior triangle of the neck
   together with the suprascapular
   artery and the omohyoid
   muscle, dips under the
   trapezius, and then passes
   through the suprascapular notch
   at the superior border of the
   scapula. As the nerve enters the
   supraspinous fossa, it supplies
   the supraspinatus muscle, then
   curls tightly around the base of
   the spine of the scapula, enters
   the infraspinous fossa, and
   supplies the infraspinatus
cause
 A stout, strong suprascapular ligament closes
  over the free upper margins of the
  suprascapular notch. Suprascapular nerve
  entrapment is caused by this ligament, often
  in conjunction with a tight, bony notch.
Pain symptoms

 Pain with insidious onset
 Deep, dull aching pain in the posterior part of
  the shoulder and upper periscapular region
 Noncircumscribed pain
 No neck or radicular symptoms
 Shoulder weakness
Signs

 Weakness is confined to the
  supraspinatus, which
  initiates shoulder abduction
  and/or the infraspinatus,
  which externally rotates the
  arm.
 Atrophy can manifest as
  hollowing of the infraspinous
  fossa and prominence of the
  scapular spine.
  Supraspinatus atrophy may
  not be obvious because of
  the overlying trapezius.
  Deep pressure over the
  midpoint of the superior
  scapular border may
  produce discomfort.
Lateral femoral cutaneous nerve
compression(meralgia paresthetica)
 This purely sensory nerve is
   formed just deep to the lateral
   border of the psoas muscle,
   then descends in the pelvis over
   the iliacus muscle deep to the
   iliacus fascia. Just medial to the
   ASIS, the nerve exits the pelvis
   by passing through the deep
   and superficial bands of the
   inguinal ligament as they attach
   to the ASIS. The nerve is almost
   horizontal while still within the
   pelvis before it traverses the
   inguinal ligament, but then it
   takes a vertical course out to
   the surface of the thigh.
etiology
 A protruding, pendulous abdomen, as seen in
  obesity and pregnancy, compresses the
  inguinal ligament downward and onto the
  nerve, causing it to be kinked. This angulation
  of the nerve is further exaggerated with
  extension of the thigh and relaxed with
  flexion.
symptoms
 The main symptoms are
  an uncomfortable
  numbness, tingling, and
  painful hypersensitivity
  in the distribution of the
  LFCN, usually in the
  anterolateral thigh down
  to the upper patella
  region.
Common peroneal nerve entrapment
It is 1 of the 2 terminal divisions
    of the sciatic nerve. It winds
    around the lateral aspect of
    the neck of fibula deep to the
    peroneus longus (fibular
    tunnel), where it divides into
    superficial peroneal, deep
    peroneal, and articular
    branches. Entrapment
    occurs where the nerve is in
    close relationship to the neck
    of fibula.
ETIOLOGY
 Trauma or injury to the knee
 Fracture of the fibula (a bone of the lower leg)
 Use of a tight plaster cast (or other long-term
  constriction) of the lower leg
 Habitual leg crossing
 Regularly wearing high boots
 Pressure to the knee from positions during
  deep sleep or coma
 Injury during knee surgery
Clinical presentation

 Pain radiating from the knee region to the
  dorsal aspect of the foot
 Sensory loss on the dorsum of the foot
 Foot drop (loss of dorsiflexion of the foot) and
  loss of extension of toes, and eversion of
  ankle (This is differentiated from an L5
  radiculopathy, in which posterior tibialis
  function (inversion in plantar flexion) is
  affected.)
sign
 Tinel sign at the fibular neck
 Drawing of the dorsal
  aspect of the foot
  illustrates the territories
  of the deep peroneal
  nerve (DPN), lateral
  plantar nerve (LPN),
  medial plantar nerve
  (MPN), sural nerve
  (SN), and superficial
  peroneal nerve (SPN
Deep peroneal nerve compression
syndrome
                   most common site of
                    compression is at the
                    top of the foot where a
                    small tendon
                    compresses the deep
                    peroneal nerve against
                    the underlying bone
ETIOLOGY
 a crush injury to the foot
 wearing tight shoes or tightly laced boots,
 a broken foot bone,
 or foot surgery
SYMPTOMS
            Symptoms here are
             only sensory, and may
             feel like a knife sticking
             in the top of the foot,
             and pain between the
             first and second toes
Sup per. Nerve compression syndrome
                   It travels in the lateral
                     compartment and supplies
                     the peroneus longus and
                     brevis muscles. In most
                     individuals, the superficial
                     peroneal nerve pierces the
                     deep fascia and emerges
                     into the subcutaneous fat at
                     approximately the level of
                     the middle and lower third of
                     the leg and at an average of
                     about 10-15 cm above the
                     tip of the lateral malleolus
Etiology

 Local trauma or
  compression
 Repeated ankle sprains
 prolonged kneeling and
  squatting
 any procedure about
  the anterior ankle,
  including use of the
  anterolateral ankle
  arthroscopy portal
Clinical

 numbness or
  paresthesia in the
  distribution of the nerve
 have pain about the
  lateral leg
 vague pain over the
  dorsum of the foot
 symptoms increase with
  activity, such as
  running, walking, or
  squatting
treatment
 injection of steroids plus lidocaine near the
  site of involvement in the lower leg can
  reduce symptoms and serve as a diagnostic
  tool in confirming the zone of nerve
  compression
 release of the superficial peroneal nerve at
  the lateral leg for surgical decompression with
  partial or full fasciotomy
Sural nerve compression
                  Sural nerve is a purely
                   sensory nerve
                  Sural nerve arises from the
                   branches of common
                   peroneal and tibial nerve
                  the nerve passes from
                   proximal calf to the ankle
                   posterior to the lateral
                   malleolus
                  Sural nerve supplies skin of
                   the lateral calf and feet
ETIOLOGY
            Sural nerve can be
             affected by
             compression from tight
             socks, Baker's cyst or
             laceration
SYMPTOMS
 Patient complains of abnormal sensation over
  the lateral calf and foot
Tarsal tunnel syndrome
 Compression of the
  tibial nerve behind the
  medial malleolus, or
  tarsal tunnel syndrome
  (TTS),
Tarsal tunnel syndrome
                    The roof of the tunnel is formed by
                     the flexor retinaculum stretched
                     between the medial malleolus and
                     the calcaneus. The tarsal bones are
                     the floor. Numerous fibrous septae
                     between the roof and the floor
                     subdivide the tunnel into separate
                     compartments at various points.
                     The contents of the tarsal tunnel at
                     its proximal end are, from front to
                     back, as follows:
                    The tibialis posterior tendon
                    The flexor digitorum longus tendon
                    The posterior tibial artery and vein
                    The tibial nerve
                    The flexor hallucis longus tendon
   The tibial nerve has 3 terminal branches.
    It bifurcates into the medial and lateral
    plantar nerves within 1 cm of the
    malleolar-calcaneal axis in 90% of cases;
    in the other 10% of cases, the medial
    and plantar nerves are 2-3 cm proximal
    to the malleolus.
   The calcaneal branch usually comes off
    the lateral plantar fascicles, but around
    30% leave the main nerve trunk just
    proximal to the tunnel. Distally, the
    medial and lateral plantar nerves travel in
    separate fascial compartments. The
    medial branch supplies the intrinsic
    flexors of the great toe, the first lumbrical,
    and the sensation over the medial plantar
    surface of the foot inclusive of at least
    the first 3 toes. The lateral branch
    supplies all of the interossei and the
    lateral 3 lumbricals, as well as sensation
    over the lateral plantar surface of the
    foot. The calcaneal branch, which
    traverses its own tunnel, provides
    sensation to the heel.
 Drawing illustrates the
  PTN trifurcation. ADQM
  = abductor digiti quinti
  muscle, AHM =
  abductor hallucis
  muscle
 Drawing of the plantar
  aspect of the foot
  illustrates the territories
  of the lateral calcaneal
  nerve (LCN), lateral
  plantar nerve (LPN),
  medial calcaneal nerve
  (MCN), medial plantar
  nerve (MPN), and sural
  nerve (SN)
 Clinical presentation
 Early symptoms are
  burning, tingling, and
  dysesthetic pain over
  the plantar surface of
  the foot
In advanced cases, the
intrinsic flexors of the great toe
are weak and atrophied,
producing hollowing of the
instep. The lateral toes may
also show clawing due to
paralysis of the intrinsic toe
flexors
PLANTAR FASCIITIS
MORTON, NEUROMA
SURGICAL TREATMENT
Complimentary C.D. BOOKS
THANK YOU

Mais conteúdo relacionado

Mais procurados

Reactive Arthritis
Reactive  ArthritisReactive  Arthritis
Reactive Arthritis
Trinity Angoni
 
Radiculopathy vs peripheral neuropathy
Radiculopathy vs peripheral neuropathyRadiculopathy vs peripheral neuropathy
Radiculopathy vs peripheral neuropathy
SpinePlus
 
Oleandrin
OleandrinOleandrin
Oleandrin
mandirouse378
 
Cervical Spondylosis.ppt
Cervical Spondylosis.pptCervical Spondylosis.ppt
Cervical Spondylosis.ppt
Shama
 
Colles fracture
Colles fractureColles fracture
Colles fracture
Dr.Monica Dhanani
 
Plantar reflex
Plantar reflexPlantar reflex
Plantar reflex
TONY SCARIA
 
Psoriatic arthritis
Psoriatic arthritisPsoriatic arthritis
Psoriatic arthritis
hamidreza227
 
Footdrop
FootdropFootdrop
Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical spondylosis
NeurologyKota
 
Wrist drop
Wrist dropWrist drop
Wrist drop
DrDivya Chandil
 
Baker's cyst
Baker's cystBaker's cyst
Baker's cyst
Siwaporn Khureerung
 
Gouty arthritis
Gouty arthritisGouty arthritis
Gouty arthritis
keerthi samuel
 
Plantar fasciitis
Plantar fasciitisPlantar fasciitis
Plantar fasciitis
mans4ani
 
Septic Arthritis
Septic ArthritisSeptic Arthritis
Septic Arthritis
yuyuricci
 
Gout
GoutGout
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
orthoprince
 
Ulnar nerve injury PPT
Ulnar nerve injury PPTUlnar nerve injury PPT
Ulnar nerve injury PPT
Dr. Sujitkumar Pandey (PT)
 
Cough
Cough Cough
Interstitial lung diseases
Interstitial lung diseases Interstitial lung diseases
Interstitial lung diseases
Dr.Manish Kumar
 
Gout
GoutGout

Mais procurados (20)

Reactive Arthritis
Reactive  ArthritisReactive  Arthritis
Reactive Arthritis
 
Radiculopathy vs peripheral neuropathy
Radiculopathy vs peripheral neuropathyRadiculopathy vs peripheral neuropathy
Radiculopathy vs peripheral neuropathy
 
Oleandrin
OleandrinOleandrin
Oleandrin
 
Cervical Spondylosis.ppt
Cervical Spondylosis.pptCervical Spondylosis.ppt
Cervical Spondylosis.ppt
 
Colles fracture
Colles fractureColles fracture
Colles fracture
 
Plantar reflex
Plantar reflexPlantar reflex
Plantar reflex
 
Psoriatic arthritis
Psoriatic arthritisPsoriatic arthritis
Psoriatic arthritis
 
Footdrop
FootdropFootdrop
Footdrop
 
Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical spondylosis
 
Wrist drop
Wrist dropWrist drop
Wrist drop
 
Baker's cyst
Baker's cystBaker's cyst
Baker's cyst
 
Gouty arthritis
Gouty arthritisGouty arthritis
Gouty arthritis
 
Plantar fasciitis
Plantar fasciitisPlantar fasciitis
Plantar fasciitis
 
Septic Arthritis
Septic ArthritisSeptic Arthritis
Septic Arthritis
 
Gout
GoutGout
Gout
 
Ankylosing spondylitis
Ankylosing spondylitisAnkylosing spondylitis
Ankylosing spondylitis
 
Ulnar nerve injury PPT
Ulnar nerve injury PPTUlnar nerve injury PPT
Ulnar nerve injury PPT
 
Cough
Cough Cough
Cough
 
Interstitial lung diseases
Interstitial lung diseases Interstitial lung diseases
Interstitial lung diseases
 
Gout
GoutGout
Gout
 

Semelhante a Numbness in the extremities 2

Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndrome
Clay Kuethe
 
Surgical anatomy of upper limb nerves and plexus
Surgical anatomy of upper limb nerves and plexusSurgical anatomy of upper limb nerves and plexus
Surgical anatomy of upper limb nerves and plexus
Pirah Azadi
 
Cubital Tunnel Syndrome
Cubital Tunnel SyndromeCubital Tunnel Syndrome
Cubital Tunnel Syndrome
Md Nuruzzaman
 
Entrapment syndrome
Entrapment syndromeEntrapment syndrome
Entrapment syndrome
Hazel Panabe
 
Carpal tunnel syndrome- short case
Carpal tunnel syndrome- short caseCarpal tunnel syndrome- short case
Carpal tunnel syndrome- short case
Yapa
 
Carpal tunnel syndrome @
Carpal tunnel syndrome @Carpal tunnel syndrome @
Carpal tunnel syndrome @
GAMANDEEP
 
Wrist and hand examination
Wrist and hand examinationWrist and hand examination
Ulnarnerveseminar BY KARNA VENKATESWARA REDDY
Ulnarnerveseminar BY KARNA VENKATESWARA REDDYUlnarnerveseminar BY KARNA VENKATESWARA REDDY
Ulnarnerveseminar BY KARNA VENKATESWARA REDDY
KARNA VENKATESWARA REDDY
 
ulnar Entrapment Neuropathy and double crush syndrome
ulnar Entrapment Neuropathy and double crush syndromeulnar Entrapment Neuropathy and double crush syndrome
ulnar Entrapment Neuropathy and double crush syndrome
Home~^^
 
EXAMINATION OF MEDIAN NERVE FOR MBBS UNDERGRADUATES ORTHO
EXAMINATION OF MEDIAN NERVE FOR MBBS UNDERGRADUATES ORTHOEXAMINATION OF MEDIAN NERVE FOR MBBS UNDERGRADUATES ORTHO
EXAMINATION OF MEDIAN NERVE FOR MBBS UNDERGRADUATES ORTHO
ANJANA B.S.
 
15-180531111035.pdf
15-180531111035.pdf15-180531111035.pdf
15-180531111035.pdf
LHusna
 
Peripheral Nerve Injuries
Peripheral Nerve InjuriesPeripheral Nerve Injuries
Peripheral Nerve Injuries
yuyuricci
 
peripheral nerve injuries
peripheral nerve injuriesperipheral nerve injuries
peripheral nerve injuries
Vivek Mathew Philip
 
Ulnar nerve
Ulnar nerveUlnar nerve
Ulnar nerve
Khairul Nizam
 
Structures of the Hand PPT
Structures of the Hand PPTStructures of the Hand PPT
Structures of the Hand PPT
Stacey Turner
 
Disorders of upper limb
Disorders of upper limbDisorders of upper limb
Disorders of upper limb
Muhammad Eimaduddin
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndrome
Hassan Rajab
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndrome
Hemant Aggarwal
 
807_Ulnar-nerve-and-its-lesions.pptx
807_Ulnar-nerve-and-its-lesions.pptx807_Ulnar-nerve-and-its-lesions.pptx
807_Ulnar-nerve-and-its-lesions.pptx
GUNASEKARANM20
 
Median Nerve Injury and Carpal Tunnel Syndrome
Median Nerve Injury and Carpal Tunnel Syndrome Median Nerve Injury and Carpal Tunnel Syndrome
Median Nerve Injury and Carpal Tunnel Syndrome
Veer Abhishek Goud
 

Semelhante a Numbness in the extremities 2 (20)

Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndrome
 
Surgical anatomy of upper limb nerves and plexus
Surgical anatomy of upper limb nerves and plexusSurgical anatomy of upper limb nerves and plexus
Surgical anatomy of upper limb nerves and plexus
 
Cubital Tunnel Syndrome
Cubital Tunnel SyndromeCubital Tunnel Syndrome
Cubital Tunnel Syndrome
 
Entrapment syndrome
Entrapment syndromeEntrapment syndrome
Entrapment syndrome
 
Carpal tunnel syndrome- short case
Carpal tunnel syndrome- short caseCarpal tunnel syndrome- short case
Carpal tunnel syndrome- short case
 
Carpal tunnel syndrome @
Carpal tunnel syndrome @Carpal tunnel syndrome @
Carpal tunnel syndrome @
 
Wrist and hand examination
Wrist and hand examinationWrist and hand examination
Wrist and hand examination
 
Ulnarnerveseminar BY KARNA VENKATESWARA REDDY
Ulnarnerveseminar BY KARNA VENKATESWARA REDDYUlnarnerveseminar BY KARNA VENKATESWARA REDDY
Ulnarnerveseminar BY KARNA VENKATESWARA REDDY
 
ulnar Entrapment Neuropathy and double crush syndrome
ulnar Entrapment Neuropathy and double crush syndromeulnar Entrapment Neuropathy and double crush syndrome
ulnar Entrapment Neuropathy and double crush syndrome
 
EXAMINATION OF MEDIAN NERVE FOR MBBS UNDERGRADUATES ORTHO
EXAMINATION OF MEDIAN NERVE FOR MBBS UNDERGRADUATES ORTHOEXAMINATION OF MEDIAN NERVE FOR MBBS UNDERGRADUATES ORTHO
EXAMINATION OF MEDIAN NERVE FOR MBBS UNDERGRADUATES ORTHO
 
15-180531111035.pdf
15-180531111035.pdf15-180531111035.pdf
15-180531111035.pdf
 
Peripheral Nerve Injuries
Peripheral Nerve InjuriesPeripheral Nerve Injuries
Peripheral Nerve Injuries
 
peripheral nerve injuries
peripheral nerve injuriesperipheral nerve injuries
peripheral nerve injuries
 
Ulnar nerve
Ulnar nerveUlnar nerve
Ulnar nerve
 
Structures of the Hand PPT
Structures of the Hand PPTStructures of the Hand PPT
Structures of the Hand PPT
 
Disorders of upper limb
Disorders of upper limbDisorders of upper limb
Disorders of upper limb
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndrome
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndrome
 
807_Ulnar-nerve-and-its-lesions.pptx
807_Ulnar-nerve-and-its-lesions.pptx807_Ulnar-nerve-and-its-lesions.pptx
807_Ulnar-nerve-and-its-lesions.pptx
 
Median Nerve Injury and Carpal Tunnel Syndrome
Median Nerve Injury and Carpal Tunnel Syndrome Median Nerve Injury and Carpal Tunnel Syndrome
Median Nerve Injury and Carpal Tunnel Syndrome
 

Mais de manoj kandoi

Hypercalciuria
HypercalciuriaHypercalciuria
Hypercalciuria
manoj kandoi
 
Skin pdf
Skin pdfSkin pdf
Skin pdf
manoj kandoi
 
IACP Arthritis clinic Arthroplasty brochure
IACP Arthritis clinic Arthroplasty  brochureIACP Arthritis clinic Arthroplasty  brochure
IACP Arthritis clinic Arthroplasty brochure
manoj kandoi
 
Infectious arthritis
Infectious arthritisInfectious arthritis
Infectious arthritis
manoj kandoi
 
Gouty arthritis
Gouty arthritisGouty arthritis
Gouty arthritis
manoj kandoi
 
Resume manoj r.kandoi
Resume manoj r.kandoiResume manoj r.kandoi
Resume manoj r.kandoi
manoj kandoi
 
Haemophilic arthritis
Haemophilic arthritisHaemophilic arthritis
Haemophilic arthritis
manoj kandoi
 
Low backache
Low backacheLow backache
Low backache
manoj kandoi
 
Knee pain
Knee painKnee pain
Knee pain
manoj kandoi
 
Nobody loves life like him who is growing
Nobody loves life like him who is growingNobody loves life like him who is growing
Nobody loves life like him who is growing
manoj kandoi
 
Living with arthritis
Living with arthritisLiving with arthritis
Living with arthritis
manoj kandoi
 
Adult aquired flatfoot
Adult aquired flatfootAdult aquired flatfoot
Adult aquired flatfoot
manoj kandoi
 
Adshirwad hospital west profile
Adshirwad hospital west profileAdshirwad hospital west profile
Adshirwad hospital west profile
manoj kandoi
 
Ashirwad hospital east profile
Ashirwad hospital east  profileAshirwad hospital east  profile
Ashirwad hospital east profile
manoj kandoi
 

Mais de manoj kandoi (14)

Hypercalciuria
HypercalciuriaHypercalciuria
Hypercalciuria
 
Skin pdf
Skin pdfSkin pdf
Skin pdf
 
IACP Arthritis clinic Arthroplasty brochure
IACP Arthritis clinic Arthroplasty  brochureIACP Arthritis clinic Arthroplasty  brochure
IACP Arthritis clinic Arthroplasty brochure
 
Infectious arthritis
Infectious arthritisInfectious arthritis
Infectious arthritis
 
Gouty arthritis
Gouty arthritisGouty arthritis
Gouty arthritis
 
Resume manoj r.kandoi
Resume manoj r.kandoiResume manoj r.kandoi
Resume manoj r.kandoi
 
Haemophilic arthritis
Haemophilic arthritisHaemophilic arthritis
Haemophilic arthritis
 
Low backache
Low backacheLow backache
Low backache
 
Knee pain
Knee painKnee pain
Knee pain
 
Nobody loves life like him who is growing
Nobody loves life like him who is growingNobody loves life like him who is growing
Nobody loves life like him who is growing
 
Living with arthritis
Living with arthritisLiving with arthritis
Living with arthritis
 
Adult aquired flatfoot
Adult aquired flatfootAdult aquired flatfoot
Adult aquired flatfoot
 
Adshirwad hospital west profile
Adshirwad hospital west profileAdshirwad hospital west profile
Adshirwad hospital west profile
 
Ashirwad hospital east profile
Ashirwad hospital east  profileAshirwad hospital east  profile
Ashirwad hospital east profile
 

Numbness in the extremities 2

  • 1. TINGLING AND NUMBNESS IN THE EXTREMITIES DR MANOJ R KANDOI M.S.,D’ORTH,DNB,FCPS, FRSM(LONDON),FICS(CHICAGO) FELLOWSHIP IN HAND AND FOOT SURGERIES USA,ITALY,FRANCE,GERMANY,UK,TAIWAN,REPUBLIC OF CHINA
  • 3. DR. MANOJ R. KANDOI M.S.,D.N.B.,D’ORTH,F.C.P.S.,F.I.C.S.,F.R.S.M.,M.N.O.F. FELLOW:  UNIVARSITY OF WASHINGTON  MILANO UNIVARSITY  HISSINGPARK CLINIC,AUGSBERG,GERMANY  HARBORVIEW MEDICAL CENTRE,SEATTLE,U.S.A  POLICLINICO MULTIMEDICA,MILAN,ITALY  AITS – IRCAD, TAIWAN,R.O.CHINA  INOR FELLOW,BRITISH ORTHOPEDIC SOCIETY  INTERNATIONAL COLLEGE OF SURGEONS,CHICAGO  IRCAD ,STRAUBERG, FRANCE  AMC,AMSTERDAM,NETHERLAND
  • 4. What is a peripheral neuropathy?  Peripheral neuropathy is disorder of nerve(s) apart from the brain and spinal cord. Patients with peripheral neuropathy may have tingling, numbness, unusual sensations, weakness, or burning pain.
  • 5. What causes a peripheral neuropathy?  Diabetes Mellitus  Shingles (post herpetic neuralgia)  Vitamin deficiency, particularly B12 and folate  Alcohol  Autoimmune diseases, including lupus, rheumatoid arthritis or Guillain-Barre syndrome  AIDS, whether from the disease or its treatment, syphilis, and kidney failure  Inherited disorders, such as amyloid polyneuropathy or Charcot-Marie-Tooth disease  Exposure to toxins, such as heavy metals, gold compounds, lead, arsenic, mercury, and organophosphate pesticides  Cancer therapy drugs such as vincristine (Oncovin, Vincasar), and other medications [for example antibiotics such as metronidazole (Flagyl), and isoniazid (Nydrazid, Laniazid)]  While diabetes and post herpetic neura
  • 6. Symptoms  The symptoms depend on which type of nerve is affected. The three main types of nerves are:  Nerves that carry sensations (sensory)  Nerves that control muscles (motor)  Nerves that carry information to organs and glands (autonomic)
  • 7. SENSATION CHANGES  Burning sensations  Changes in sensation  Inability to determine joint position, which causes lack of coordination  Nerve pain  Tingling or numbness
  • 8. MOVEMENT DIFFICULTIES  Difficulty breathing or swallowing  Difficulty or inability to move a part of the body (paralysis)  Falling (from legs buckling or tripping over toes)  Lack of dexterity (such as being unable to button a shirt)  Lack of muscle control  Loss of muscle tissue (muscle atrophy)  Muscle twitching or cramping
  • 9. AUTONOMIC SYMPTOMS  Abdominal bloating  Blurred vision  Constipation  Decreased sweating  Diarrhea  Dizziness that occurs when standing up or fainting due to a drop in blood pressure  Feeling full after eating a small amount (early satiety)  Heat intolerance with exertion  Incomplete bladder emptying  Male impotence  Nausea or vomiting after meals  Urinary hesitancy (taking a long time to start urinating)  Urinary incontinence  Weight loss without trying
  • 10. Signs and tests  Tests that find and help classify neuropathy may include:  Electromyogram (EMG) -- a recording of electrical activity in muscles)  Nerve conduction velocity tests (NCV) -- a recording of the speed at which signals travel along nerves  Nerve biopsy -- taking a small sample of a nerve to look at under a microscope
  • 11. Treatment  Addressing the cause (such as diabetes or excess alcohol use)  Controlling symptoms  Helping the patient gain maximum independence and self-care ability  Replacing any vitamin or other deficiencies in the diet  Stopping injury to the nerve (for example, in cases of neuropathy due to compression such as carpal tunnel syndrome)
  • 12. Complications  Deformity  Loss of tissue mass  Poor healing  Scarring  Tissue erosions  Decreased self-esteem  Difficulty breathing  Difficulty swallowing  Irregular heart rhythms (arrhythmias)  Need for amputation  Partial or complete loss of movement or control of movement  Partial or complete loss of sensation  Relationship problems related to impotence
  • 13. Entrapment neuropathies  Entrapment neuropathies are a group of disorders of the peripheral nerves that are characterized by pain and/or loss of function (motor and/or sensory) of the nerves as a result of chronic compression
  • 14. Common entrappment syndromes  Carpal tunnel syndrome (CTS), compression of the median nerve at the wrist, is the most common entrapment neuropathy.  Cubital tunnel syndrome is caused by a compression at the elbow.  suprascapular nerve compression, which accounts for approximately 0.4% of upper girdle pain symptoms, and  meralgia paresthetica, a compression of the lateral femoral cutaneous nerve [LFCN] in the groin
  • 15. CARPAL TUNNEL SYNDROME  Median nerve compression at the wrist is at the transverse carpal ligament (TCL), which attaches to and arches between the pisiform and hamate on the ulnar side and the scaphoid and trapezium on the radial side
  • 16. CARPAL TUNNEL SYNDROME  Dull, aching pain at the wrist that may extend up the forearm to the elbow.  Often, associated with distressing paresthesias in the thumb and index finger, particularly upon awakening.  Typically, patients rub their wrists or shake their hands to try to "get the blood back into their wrists.“  The pain is typically worse at night and disturbs their sleep
  • 19.
  • 21.
  • 26.
  • 27.
  • 28. RESULTS OF SURGERY  SATISFYING  SYMPTOMS TEND TO COMPLETELY RESOLVE
  • 29. CUBITAL TUNNEL SYNDROME  The ulnar nerve travels on the medial side of the brachial artery in the upper arm, pierces the medial intermuscular septum at mid arm, and continues toward the elbow on the medial head of the triceps. At the elbow, it passes through the cubital tunnel, a groove between the medial humeral epicondyle and the olecranon. The nerve travels beneath the aponeurotic arcade between the 2 heads of the flexor carpi ulnaris and down the forearm between the deep and superficial finger flexors.
  • 30. 5 potential areas of ulnar nerve entrapment :  The arcade of Struthers stretches from the medial head of the triceps to insert into the medial intermuscular septum. It is located approximately 6-8 cm above the medial epicondyle. It can be a factor in ulnar nerve compression after ulnar nerve transposition.  The medial intermuscular septum presents a sharp edge that can indent the nerve, particularly after anterior transposition, in which the nerve may be kinked.  The cubital tunnel is floored by the medial collateral ligament of the elbow and roofed by the arcuate ligament (cubital tunnel retinaculum) that stretches between the medial humeral epicondyle and the medial aspect of the olecranon.  The arching band of aponeurosis between the 2 heads of the flexor carpi ulnaris (so-called Osborne band) may compress the nerve, especially during repetitive contraction of the muscle.  The aponeurotic covering between the flexors digitorum profundus and superficialis is occasionally a site of compression.
  • 31. CLINICAL PRESENTATIONS  Pain typically presents as a deep ache around the elbow region  Pain is exacerbated when the medial elbow is impacted  Intermittent paresthesias and numbness in the ring and little fingers  Hand weakness, especially with gripping objects
  • 32. CLINICAL SIGNS  Sensation over the palmar portion of the fifth digit and the ulnar half of the fourth digit specifically is decreased to the following stimuli:  Pinprick  Light touch  Two-point discrimination  Sensory loss can also be detected along the dorso-ulnar aspect of the hand (due to involvement of the dorsal cutaneous branch of the ulnar nerve which arises proximal to the wrist).  Late symptoms include dense numbness and profound weakness and atrophy of the intrinsic hand muscles.  An ulnar claw hand may be present with extension of the little and ring fingers.  Extension at the metacarpophalangeal joints and flexion at the intraphalangeal joints is caused by the loss of lumbricals 3 and 4.  Provocative tests: A gentle tapping of the nerve at and around the cubital tunnel elicits distressing electrical shock, tingling, or both down into the ulnar fingers (percussion test).
  • 34. FROMENT SIGN  Weakness of finger abductors and adductors (interossei) and adductor of the thumb (adductor pollicis) may be detected whereas thumb abduction is normal
  • 35.
  • 36.
  • 37. Ulnar nerve compression at the wrist (Guyon canal)  At the wrist, the ulnar nerve runs above the flexor retinaculum lateral to the flexor carpi ulnaris tendon and medial to the ulnar artery. At the proximal carpal bones, it dips between the pisiform and the hook of the hamate at the entrance to the Guyon canal, roofed over by an extension of the TCL between these 2 bones
  • 38. Clinical presentation  young man with painless atrophy of the hypothenar muscles and interossei with sparing of the thenar group. Sensory loss and pain involving the ulnar 1.5 digits may be present.
  • 39. SIGNS  A positive Phalen test and percussion tenderness over the course of the ulnar nerve at the wrist may be present.
  • 40. posterior interosseous nerve syndrome Relevant anatomy  At mid arm, the radial nerve descends behind the humerus, deep to the long head of the triceps, and then spirals around the humerus in between the medial and lateral heads of the triceps in the spiral groove. Approximately 5- 10 cm above the lateral humeral epicondyle, the nerve pierces the lateral intermuscular septum to gain the anterior compartment of the arm. Here, it immediately enters the deep, muscular groove bordered medially by the biceps and brachialis and laterally by the brachioradialis, the extensor carpi radialis longus (ECRL), and the extensor carpi radialis brevis (ECRB). The nerve then courses immediately in front of the radiocapitellar joint capsule, where it divides into the (motor) deep branch of the radial nerve and the sensory superficial radial nerve (SRN).
  • 41. causes  PIN compression is most commonly associated with tendinous hypertrophy of the arcade of Frohse and fibrous thickening of the radiocapitellar joint capsule. Vascular compression by the leash of Henry has been reported. Lesions, such as lipoma, synovial cyst, rheumatoid synovitis, and a vascular aneurysm, have been found in some cases.
  • 42. clinical picture  Fatigue during finger extension and elbow supination.  The extension in the metacarpophalangeal joints is weakened,.  in the early stage of entrapment, the hand exhibits a characteristic pattern upon finger extension, in which the middle 2 fingers fail to extend, while the index and little fingers can be extended ("sign of horns").  Progression of paralysis eventually causes weakness in all of the finger extensors and in thumb abduction.  No sensory symptoms are present.
  • 43. Suprascapular nerve entrapment Relevant anatomy  The suprascapular nerve arises from the lateral aspect of the upper trunk of the brachial plexus, runs across the posterior triangle of the neck together with the suprascapular artery and the omohyoid muscle, dips under the trapezius, and then passes through the suprascapular notch at the superior border of the scapula. As the nerve enters the supraspinous fossa, it supplies the supraspinatus muscle, then curls tightly around the base of the spine of the scapula, enters the infraspinous fossa, and supplies the infraspinatus
  • 44. cause  A stout, strong suprascapular ligament closes over the free upper margins of the suprascapular notch. Suprascapular nerve entrapment is caused by this ligament, often in conjunction with a tight, bony notch.
  • 45. Pain symptoms  Pain with insidious onset  Deep, dull aching pain in the posterior part of the shoulder and upper periscapular region  Noncircumscribed pain  No neck or radicular symptoms  Shoulder weakness
  • 46. Signs  Weakness is confined to the supraspinatus, which initiates shoulder abduction and/or the infraspinatus, which externally rotates the arm.  Atrophy can manifest as hollowing of the infraspinous fossa and prominence of the scapular spine. Supraspinatus atrophy may not be obvious because of the overlying trapezius. Deep pressure over the midpoint of the superior scapular border may produce discomfort.
  • 47.
  • 48. Lateral femoral cutaneous nerve compression(meralgia paresthetica)  This purely sensory nerve is formed just deep to the lateral border of the psoas muscle, then descends in the pelvis over the iliacus muscle deep to the iliacus fascia. Just medial to the ASIS, the nerve exits the pelvis by passing through the deep and superficial bands of the inguinal ligament as they attach to the ASIS. The nerve is almost horizontal while still within the pelvis before it traverses the inguinal ligament, but then it takes a vertical course out to the surface of the thigh.
  • 49. etiology  A protruding, pendulous abdomen, as seen in obesity and pregnancy, compresses the inguinal ligament downward and onto the nerve, causing it to be kinked. This angulation of the nerve is further exaggerated with extension of the thigh and relaxed with flexion.
  • 50. symptoms  The main symptoms are an uncomfortable numbness, tingling, and painful hypersensitivity in the distribution of the LFCN, usually in the anterolateral thigh down to the upper patella region.
  • 51.
  • 52. Common peroneal nerve entrapment It is 1 of the 2 terminal divisions of the sciatic nerve. It winds around the lateral aspect of the neck of fibula deep to the peroneus longus (fibular tunnel), where it divides into superficial peroneal, deep peroneal, and articular branches. Entrapment occurs where the nerve is in close relationship to the neck of fibula.
  • 53. ETIOLOGY  Trauma or injury to the knee  Fracture of the fibula (a bone of the lower leg)  Use of a tight plaster cast (or other long-term constriction) of the lower leg  Habitual leg crossing  Regularly wearing high boots  Pressure to the knee from positions during deep sleep or coma  Injury during knee surgery
  • 54. Clinical presentation  Pain radiating from the knee region to the dorsal aspect of the foot  Sensory loss on the dorsum of the foot  Foot drop (loss of dorsiflexion of the foot) and loss of extension of toes, and eversion of ankle (This is differentiated from an L5 radiculopathy, in which posterior tibialis function (inversion in plantar flexion) is affected.)
  • 55. sign  Tinel sign at the fibular neck
  • 56.  Drawing of the dorsal aspect of the foot illustrates the territories of the deep peroneal nerve (DPN), lateral plantar nerve (LPN), medial plantar nerve (MPN), sural nerve (SN), and superficial peroneal nerve (SPN
  • 57.
  • 58. Deep peroneal nerve compression syndrome  most common site of compression is at the top of the foot where a small tendon compresses the deep peroneal nerve against the underlying bone
  • 59. ETIOLOGY  a crush injury to the foot  wearing tight shoes or tightly laced boots,  a broken foot bone,  or foot surgery
  • 60. SYMPTOMS  Symptoms here are only sensory, and may feel like a knife sticking in the top of the foot, and pain between the first and second toes
  • 61. Sup per. Nerve compression syndrome  It travels in the lateral compartment and supplies the peroneus longus and brevis muscles. In most individuals, the superficial peroneal nerve pierces the deep fascia and emerges into the subcutaneous fat at approximately the level of the middle and lower third of the leg and at an average of about 10-15 cm above the tip of the lateral malleolus
  • 62. Etiology  Local trauma or compression  Repeated ankle sprains  prolonged kneeling and squatting  any procedure about the anterior ankle, including use of the anterolateral ankle arthroscopy portal
  • 63. Clinical  numbness or paresthesia in the distribution of the nerve  have pain about the lateral leg  vague pain over the dorsum of the foot  symptoms increase with activity, such as running, walking, or squatting
  • 64. treatment  injection of steroids plus lidocaine near the site of involvement in the lower leg can reduce symptoms and serve as a diagnostic tool in confirming the zone of nerve compression  release of the superficial peroneal nerve at the lateral leg for surgical decompression with partial or full fasciotomy
  • 65. Sural nerve compression  Sural nerve is a purely sensory nerve  Sural nerve arises from the branches of common peroneal and tibial nerve  the nerve passes from proximal calf to the ankle posterior to the lateral malleolus  Sural nerve supplies skin of the lateral calf and feet
  • 66. ETIOLOGY  Sural nerve can be affected by compression from tight socks, Baker's cyst or laceration
  • 67. SYMPTOMS  Patient complains of abnormal sensation over the lateral calf and foot
  • 68. Tarsal tunnel syndrome  Compression of the tibial nerve behind the medial malleolus, or tarsal tunnel syndrome (TTS),
  • 69. Tarsal tunnel syndrome  The roof of the tunnel is formed by the flexor retinaculum stretched between the medial malleolus and the calcaneus. The tarsal bones are the floor. Numerous fibrous septae between the roof and the floor subdivide the tunnel into separate compartments at various points. The contents of the tarsal tunnel at its proximal end are, from front to back, as follows:  The tibialis posterior tendon  The flexor digitorum longus tendon  The posterior tibial artery and vein  The tibial nerve  The flexor hallucis longus tendon
  • 70. The tibial nerve has 3 terminal branches. It bifurcates into the medial and lateral plantar nerves within 1 cm of the malleolar-calcaneal axis in 90% of cases; in the other 10% of cases, the medial and plantar nerves are 2-3 cm proximal to the malleolus.  The calcaneal branch usually comes off the lateral plantar fascicles, but around 30% leave the main nerve trunk just proximal to the tunnel. Distally, the medial and lateral plantar nerves travel in separate fascial compartments. The medial branch supplies the intrinsic flexors of the great toe, the first lumbrical, and the sensation over the medial plantar surface of the foot inclusive of at least the first 3 toes. The lateral branch supplies all of the interossei and the lateral 3 lumbricals, as well as sensation over the lateral plantar surface of the foot. The calcaneal branch, which traverses its own tunnel, provides sensation to the heel.
  • 71.  Drawing illustrates the PTN trifurcation. ADQM = abductor digiti quinti muscle, AHM = abductor hallucis muscle
  • 72.  Drawing of the plantar aspect of the foot illustrates the territories of the lateral calcaneal nerve (LCN), lateral plantar nerve (LPN), medial calcaneal nerve (MCN), medial plantar nerve (MPN), and sural nerve (SN)
  • 73.  Clinical presentation  Early symptoms are burning, tingling, and dysesthetic pain over the plantar surface of the foot In advanced cases, the intrinsic flexors of the great toe are weak and atrophied, producing hollowing of the instep. The lateral toes may also show clawing due to paralysis of the intrinsic toe flexors
  • 74.
  • 75.
  • 76.
  • 77.
  • 78.
  • 81.
  • 82.
  • 83.
  • 84.
  • 86.
  • 87.
  • 88.