This document discusses median nerve injuries, including locations where entrapment can occur such as the arm, elbow, forearm, wrist, and hand. It outlines associated motor effects such as paralysis of muscles supplied by the nerve and deformities. Sensory loss on the lateral palm and fingers is also described. Carpal tunnel syndrome and pronator syndrome are discussed as specific types of median nerve entrapment. Clinical features, physical exam maneuvers, diagnostics, differential diagnoses, and treatments including splinting, medications, injections, and surgery are summarized. Complications of surgery are also noted.
2. CONSIDERING Anatomy
Entrapment of Median nerve
Can Occur at :
1)Course in the arm
supracondylar process
* may form accessory origin for
PT MU , thru ligament of
Struthers
3. 2) At the elbow
3) in the forearm
-lacertus fibrosus
-pronator teres
- sublimis bridge
4) at the wrist
5) In the hand
4.
5.
6. ๏ผparalysis of the muscles supplied by it
๏ผdeformity of the hand
๏ผloss of sensation
7. Above The Elbow
Motor Affection
(1) Paralysis of all muscles supplied .
(2) loss of pronation of the forearm .
(3) weak flexion of the wrist .
(4) loss of the flexion & opposition of the
8. Deformity:
Ape Hand Deformity
(1) hyper-extended thumb .
(2) adduction .
(3) flat thenar eminence .
Sensory Loss
- lat. 2/3 of the palm of the hand .
- lat. 3 ยฝ fingers anteriorly & their distal halves
posteriorly.
9. Below The Elbow
Motor Affection :
-Paralysis of the 5 hand muscles supplied by the nerve.
-The forearm muscles escape the injury as they are supplied
at elbow.
Deformity : Ape Hand Deformity
Sensory Loss :
- lat. 2/3 of the palm of the hand .
-lat. 3 ยฝ fingers anteriorly & their distal halves
posteriorly.
13. Definition
Itโs a Clinical Diagnose Of peripheral
neuropathy, results from compression of
the median nerve at the wrist
14.
15.
16. epidemiology
an estimated 3 percent of adult Americans
โขAffectstimes more common in women than in men
โขThreeprevalence rates have been reported in persons
High
โขwho perform certain repetitive wrist motions (frequent
computer users)
17.
18. Clinical Features
๏ผPain
๏ผNumbness
๏ผTingling
๏ผSymptoms are usually worse at night and can awaken
patients from sleep.
๏ผdifficulty in holding on to a glass or cup securely
๏ผTo relieve the symptoms, patients often โflickโ their wrist
as if shaking down a thermometer (Flick Sign).
19.
20.
21. Clinical Features
Cont.
๏ผPain and paresthesias may radiate to the forearm, elbow, and
shoulder.
๏ผDecreased grip strength may result in loss of dexterity, and
thenar muscle atrophy may develop if the syndrome is severe.
30. ORAL MEDICATIONS
โข Diuretics
DO
โข Nonsteroidal anti-inflammatory drugs (NSAIDs)
NO
TW
โข pyridoxine (vitamin B6)
OR
โข Orally administered corticosteroids
K!
!!
โซ Prednisolone
โซ 20 mg per day for two weeks
โซ followed by 10 mg per day for two weeks
31. SURGERY
โข 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.
โข It is important to note that surgery may be effective
even if a patient has normal nerve conduction studies
32.
33. Complications of surgery
โข Injury to the palmar cutaneous or recurrent
motor branch of the median nerve
โข Hypertrophic scarring
โข laceration of the superficial palmar arch
โข tendon adhesion
โข Postoperative infection
โข Hematoma
โข arterial injury
โข stiffness
34. Pronator Syndrome
- Proximal Forearm Compression
- Because Of :๏ligament of Struthers,
๏ lacertus fibrosus,
๏ pronator teres muscle
35. Same Symptoms As C.T.S But Could Be
Differentiated By :
โข include the distribution of the palmar cutaneous nerve
โขThe Tinel sign is positive at the forearm level
โขThe Phalen maneuver does not provoke symptoms
โขPatients may experience pain with resistance to
contraction of the pronator teres or flexor digitorum
superficialis
36. Anterior Interosseous Syndrome
Clinical Findings
๏ผinability to flex either the thumb interphalangeal joint or the
index-finger distal interphalangeal joint .
๏ผIn contrast to those with pronator syndrome, these patients
do not complain of numbness or pain . WHY ?
Median Nerve.
The median nerve enters the palm via the carpal tunnel, running between the flexor digitorum superficialis (FDS) and flexor carpi radialis (FCR). At the proximal border of the transverse carpal ligament (TCL), it gives off a palmer cutaneous branch (PCB) from its radial border running between the palmaris longus and FCR that provides sensation to the thenar skin. The PCB of the median nerve is at risk for injury during carpal tunnel surgery. At the distal border of the TCL, the median nerve divides into 5 or 6 branches: the recurrent motor branch to the muscles of the thenar eminence, a common digital nerve for the thumb, the proper digital nerve for the radial side of the index finger, and two common digital nerves for the adjacent areas of the index and long, and long and ring fingers respectively. The origin of the recurrent motor branch varies with respect to the TCL, with the majority being extraligamentous. It is responsible for innervating the superficial head of the FPB, the abductor pollicis brevis (APB), the opponens pollicis, and the two radial lumbricals.
lacertus fibrosus
Is tightened w/ pronation of forearm as bicipital tuberosity of the radius passes posteriorly
FIGURE 6.13 Cross section of the wrist demonstrating the relationship of the carpal tunnel (CT) and the ulnar tunnel (UT). A, ulnar artery; C, capitate; H, hamate; M, median nerve, P, pisiform; PCL, palmar carpal ligament; S, scaphoid; t, flexor tendon; T, triquetrum; TCL, transverse carpal ligament; U, ulnar nerve. (Source: Szabo RM, Steinberg DR. Nerve entrapment syndromes in the wrist. J Am Acad Orthop Surg 1994;82:115รขโฌโ123
.)