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Compression Neuropathiesof the Upper Extremity

Carla M. Saulsbery LOTR, CHT

Risk Factors

Age and gender

Intercurrent disease

Genetics

Dupuytrens diathesis

Osteoporosis

Pathogenesis specific to nerve:

1. Initially nerve compression leads to blood/nerve barrier changes

2. Neural connective tissue changes occur

3. Continued pressure leads to localized nerve fiber changes. Segmental demyelination

4. Fiber changes occur with Wallerian degeneration

5. Compression at one point decreases the threshold for compression at other points along the same nerve.

6. Grading of compression severity Grade 1-------- 2-----------3 ( muscle atrophy)

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Normal Peripheral nerve

Peripheral nerve compressed

Normal

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Occupational Therapy for compression neuropathies

Management is based on symptom onset, chronicity, degree of muscle weakness and sensory abnormalities.

OT performs a baseline sensory and motor examination, assess both grip and pinch strengths and reassess at least one time monthly

Patient education Conservative treatment based on evaluation findings

Post-operative treatment

Splinting as indicated based on surgical procedure Wound and scar management Splint per nerve deficit Desensitization for dysesthesias Motor and sensory reeducation AROM Strengthening Patient Education ADL’s

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EVALUATION History

Onset

Activities that increase symptoms

Symptom duration

Subjective

Objective

ROM

MMS

Night and daytime paresthesias

Tinels and other provocative testing

Grip and pinch assessment

Sensation—Semmes Weinstein monofilament testing

Moberg

ADLs

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Semmes Weinstein Monofilaments

A sensory threshold test

Can be used on any part of the body

Used to correlate nerve damage with a patients ADL function

“Maps” the extent and degree of the sensory loss

Reliable and reproducible

Screening kit consists of 5 monofilaments

2.83, 3.61, 4.31, 4.56 and 6.6 monofilaments

Testing begins with 2.83

Monofilaments 2.83 and 3.61 --- one response out of 3 considered a correct response

The monofilament is applied for 1.5 seconds and removed for 1.5 seconds

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Sensory patterns

Palmar Dorsal

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Occupational Therapy

Upper Extremity Semmes Weinstein Right Left

Date :______________

OTR/L:_______________________

Volar Dorsal

Axillary nerve

Superior lateral

cutaneous (C5-6)

Radial nerve

Inferior lateral

cutaneous (C5-6)

Lateral cutaneous

nerve (C5-7)

Radial nerve

Median nerve

Palmar branch

(C6-7)

Intercosto-brachial nerve

(T2) and the medial

cutaneous nerve

(C8, T1-2)

Medial cutaneous nerve

(C8,T1)

Ulnar nerve

(C8, T1) Ulnar nerve

(C8, T1)

Radial nerve

Superficial branch

and dorsal digital

(C6-8)

Median nerve

Radial Nerve

Posterior cutaneous

(C5-7)

Inferior lateral

cutaneous

Posterior cutaneous

(C5-8)

Lateral cutaneous

(C5-7)

2.83 Green Normal

3.61 Blue Dim. light touch

4.31 Purple Dim protective

6(4.56) Red Loss of protective

6.6 Orange Deep pressure

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Axillary nerve

Superior lateral

cutaneous (C5-6)

Semmes Weinstein Interpretation

2.83 Green Normal Sensation

3.61 Blue Diminished light touch, diminished texture discrimination

Earliest sign of nerve involvement. Patient has fair use of the hand.

4.31 Purple Diminished protective sensation. Absent texture, impaired stereognosis

and impaired sensation. Pain and temperature sensation should keep

patient from injury.

Patient will c/o of dropping things and decreased ability to perform fine

motor ADL’s and other manipulation tasks.

4.56 Red Loss of protective sensation. Absent protective sensation/stereognosis

Patient cannot manipulated objects outside line of vision

Increased risk of injury secondary to slowed response to hot and sharp

objects.

Present deep pressure sensation

6.65 (Orange) Deep pressure sensation, rudimentary deep cutaneous peripheral nerve

response.

Pt. can recognize a pin prick

Untestable/ Unresponsive to any filament

Red-lined Nonfunctional sensibility

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Test is performed for two trials

Eyes open norms 10-19 sec on the first trail

10-16 on second trial

Eyes closed : 2 seconds per object

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Dellons’ Modification of the Moberg

• A Standardized assortment of 12 everyday objects

( wing nut, screw, key, nail, nickel, dime, safety pin, washer, paper clip, small hex nut,

small square nut and a key).

• Use to assess the patient’s ability to manipulate small objects with and without vision

• Therapist observes and notes prehension pattern used and which digits are used

• Timed test with both hands tested

• Performed with eyes open and again with the eyes closed

Compression Neuropathies of the Upper Extremity

Median Nerve

Pronator Syndrome

Anterior Interosseous Nerve Syndrome (AIN)

Carpal Tunnel

Ulnar Nerve

Cubital Tunnel

Guyons Canal or Handlebar palsy

Radial Nerve

Radial Tunnel

Posterior Interosseous Nerve Syndrome (PIN)

Wartenbergs Syndrome ( entrapment of the superficial sensory branch of the Radial Nerve )

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Median Nerve

Formed by equal contributions of the medial (C5-C7) and lateral (C8-T1) cords of the brachial plexus.

The nerve has an intimate relationship to the brachial artery as it passes down the arm to the elbow

The Martin Gruber anastomosis is of interest in high median nerve neuropathies.

This communication between median and ulnar nerves occurs in approximately 17% of the population

Chronic pain from the proximal median nerve is predominantly caused by trauma.

Non-traumatic compression is predominantly caused by slowly expanding lesions often vascular in nature.

There are four commonly described sites of compression of the median nerve in the elbow and proximal forearm region. (Ligament of Struthers, Lacertus Fibrosis, Pronator Teres muscle and the arch of the FDS).

Supracondylar fractures have been associated with a 5 to 19% incidence of median nerve injury

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Median Nerve (medial cord C5-7 and lateral cords C8-T1 of Brachial Plexus)

Muscle/Sensory Innervation

Pronator Teres Forearm Median Nerve High Lesion

Flexor Carpi Radialis

Palmaris Longus

Flexor Digitorum Superficialis

Palmar Cutaneous Branch

Flexor Digitorum Profundus (Index/Long) Anterior Interosseous Nerve

Flexor Pollicis Longus

Pronator Quadratus

Lumbricals (1,2) Carpal Tunnel Median Nerve Low Lesion

Opponens Pollicis

Abductor Pollicis Brevis

Flexor Pollicis Brevis (superficial)

Digital Cutaneous Branch

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Median Nerve Compression Sites

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Median Nerve : Pronator Syndrome Compression of the most proximal site of the median nerve just inferior to the

antecubital fossa. Compression can occur as the nerve passes between the two heads of the Pronator Teres muscle. The term pronator syndrome can also include median nerve compression by other structures: ligament of Struthers, the lacertus fibrosus or the FDS proximal arch.

Commonly mistaken for carpal tunnel syndrome First described in 1951 Pronator Teres Muscle is usually spared as it receives its innervation before it is

pierced by the nerve.

Signs and Symptoms1. Aching pain in proximal volar forearm. Associated with repetitive motions that

cause hypertonicity in the pronator teres. Occupational activities : hammering, cleaning fish, continual manipulation of tools.

2. Numbness/ paresthesias in the median nerve distribution. Nocturnal complaints uncommon

3. Tenderness over Pronator Teres muscle4. Symptoms exacerbated with activity and diminished with rest5. Easy fatigability6. + Tinels over proximal forearm but takes 4-5 months to develop.7. Pain on resistance to pronation and resistance to flexion of the FDS to 3 and 48. Advance cases will display weakness in all median nerve innervated musculature

distal to the Ligament of Struthers.9. Women are affected more than men (4 times) and presents in the fifth decade of

life.10. Symptoms insidious in onset with a delay in diagnosis ranging from 9 months to 2

years.

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Provocative testing

Pronator Teres test

Patent is standing with the elbow in 90 of flexion. Patient holds position while examiner attempts to supinate the forearm. (forces isometric contraction of the pronator muscle). While holding the resistance against pronation , the examiner

slowly extends the elbow. If motion reproduces the pain the median nerve is probably compressed by the pronator teres.

Test for compression by arch of FDS

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Splinting for Pronator Tunnel

Posterior elbow long arm splint. Elbow at 90 flexion, forearm in pronation with wrist at neutral.

Splint 4-6 weeks followed by night wear for same amount of time NSAIDS Cryotherapy Elbow and wrist AROM Tendon and nerve gliding Ergonomic assessment and recommendations Strengthening of affected muscles Avoidance of aggravating activities Conservative treatment is 8 to 12 weeks.

Postoperative Therapy

Day 3-5 bulky dressing. Allow full AROM to digits. Elbow and wrist AROM limited by patient complaints. Gradually increase range of motion and activity.OR Elbow splinted at 90 for 5-10 days, then AROM as tolerated.

Scar management Strengthening of all affected muscles Nerve and tendon gliding

Ergonomic assessment and recommendations.

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Median Nerve: Anterior Interosseous Syndrome (Kiloh-Nevin Syndrome)

Compression of the anterior interosseus branch of the median nerve usually bythe deep head of the Pronator Teres.

The AIN nerve is purely motor-no sensory findings. Can be resultant of an injury to the forearm, by direct trauma, compression or inflammation of the AIN.

AIN accounts for fewer than 1% of all upper extremity neuropathies Earliest description was in 1952. Rule out Pseudo-Anterior Interosseous Neuropathy FPL is usually the first muscle affected.

Signs and Symptoms

1. Vague pain in the proximal forearm and wrist that increases with activity especially repetitive forearm motion and is relieved with rest.

2. No sensory disturbances3. Weakness or paralysis of the FPL, FDP of the index finger and less commonly the

long finger and the pronator quadratus.4. Unusual pinch demonstrated by the hyper extended IP joint of the thumb and index

finger (Q sign) ( late sign). Inability to make the “OK” sign.

5. Patient reports problems with writing or picking up small objects.6. Examiner must look for the tenodesis effect produced by intact flexor tendons. The

differential diagnosis of AIN. AIN can be misdiagnosed as a tendon rupture of the FPL orFDP

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Inability to make the “OK” sign. Weak pinch of AIN syndrome.

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Anterior Interosseous Nerve Syndrome

Anterior Interosseous Neuropathy Pseudo-Anterior Interosseous

Lesion of the AIN Lesion of fibers that ultimatelyconstitute the AIN

Weakness of FPL,PQ,FDP to Index Weakness of FPL,PQ,FDP to IndexNormal sensibility +/- weakness of shoulder girdleNormal shoulder girdle +/- weakness of thenar muscles

+/- Abnormal sensibility (Median)

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Splinting for Anterior Interosseous Syndrome Posterior long arm splint with elbow at 90 of flexion, forearm pronated and the wrist

in neutral for 3 to 4 weeks Thumb in opposition –splint for function. NSAIDs Cryotherapy Avoidance of aggravating factors AROM of the elbow and wrist Tendon and nerve gliding Ergonomic assessment and recommendations Strengthening of affected muscles Conservative treatment for 8 to 12 weeks

Postoperative therapy Bulky dressing supporting the elbow and wrist, AROM of wrist and digits for 5 to 7

days. Strengthening at 7 to 10 days post op unless pronator was elevated. If pronator was elevated, splint elbow at 45-90 , wrist 45 and full pronation for 2-3

weeks Digit ROM immediately, AROM of the elbow and wrist at week 3 and strengthening

at 3 to 4 weeks Scar Management Nerve and tendon gliding Ergonomic assessment and recommendations

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Carpal Tunnel

Compression under the transverse carpal ligament in the carpal canal

Risk factors

Demographics: female, middle aged, smoker, obesity

Idiopathic process: thickened transverse carpal ligament, Diabetes .

Medical conditions: Decreased canal volume: wrist fracture, dislocation of carpal

bone, Rheumatoid tenosynovitis

Increased canal volume: thyroid disease, renal failure,

pregnancy, mass (tumor or hematoma)

Patient complaints

Awakening at night

Numbness, tingling

Weakness of grip or pinch

Dropping things, inability to perform certain ADL’s

Reports of numbness when driving or reading

Decreased ability to distinguish between hot and cold

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Grading nerve compression for Carpal Tunnel

Grade 1 Mild

Awakening at night. Usually intermittent

Tingling and numbness

Positive Phalens

Symptoms increase with activity

No muscle atrophy

Middle finger most commonly involved

Grade II Moderate

Positive provocative tests. Tinels and Phalens

Weakness of the thenar muscles, but not atrophy

Decreased sweat

Semmes Weinstein test will be abnormal

Decreased grip and pinch strength

Grade III Severe

Thenar atrophy

Sensory symptoms are persistent

Abnormal Semmes Weinstein

Phalens and TInels may be negative

Patient complains of constant numbness during the day and night

Nerve is tender to deep pressure

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Prognosis

Poor outcome with conservative management may occur with:

• Symptoms greater than 10 months in duration

• Constant paresthesias

• Positive Phalen’s test in less than 10 seconds

• Weakness, atrophy

• Marked prolonged latency on NCS

• Abnormal spontaneous activity on EMG

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Springer Images

Thenar atrophy

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Median nerve compression at the carpal tunnel

Conservative Treatment of Carpal Tunnel

Patient education

Splint for night wear

Splint for daytime wear as indicated

Tendon/nerve glide exercises

Home and or job modifications

Hand strengthening

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Median Nerve Glide Exercises

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Post-operative care for Carpal Tunnel release

Range of motion 15 reps hourly

Avoid wrist flexion

Wound care

Massage for scar and skin hydration

Lightweight ADL’s

Desensitization for dysesthesia's

Progress to nerve glide

Sensory re-education

Caution patient against over exercising

No heavy lifting, pushing or pulling for one month

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Post op care

Patient is followed monthly for re-evaluation

Watch for symptomatic neuroma

Program for dysesthesias

Hand strengthening can begin at 3-4 weeks post op.

Patients with sedentary jobs requiring <10# lift may return to work by week 8

Grip strength slowly increases over a two to three month period

Patient needs to be seen by both Ortho and OT at 2 months post op

Patients with grade III CTS may require more than 2 months to regain sensation and hand strength and may develop dysesthesias which can require several months of desensitization/sensory reeducation to resolve.

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Ulnar Nerve Compression Sites

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Ulnar Nerve (medial cord C8-T1 of the Brachial Plexus)

Muscle/Sensory Innervation

Flexor Carpi Ulnaris Forearm Ulnar nerve High Lesion

Flexor Digitorum Profundus (ring, small)

Palmar ulnar cutaneous nerve

Dorsal ulnar cutaneous nerve

Abd. Digiti Minimi Hand Ulnar nerve Low Lesion

Opponens Digiti Minimi

Flexor Digiti Minimi

Lumbricals (3, 4)

Interossei (Palmar/Dorsal)

Flexor Pollicis Brevis (deep head)

Adductor Pollicis

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Tardy Ulnar Palsy

• An ulnar neuropathy that can occur months to years after a distal humerus fracture

• Nerve can be injured secondary to a trauma that results in bone overgrowth or

scar formation

• Nerve traction can occur from an increased carrying angle

• Findings of muscle involvement and complaints are dependent on the site of injury

• In most cases all ulnar nerve innervated muscles can be involved

• Treatment may include therapy or a surgical procedure

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Ulnar Nerve: Cubital Tunnel Syndrome Compression or trauma of the ulnar nerve at the level of the medial aspect of the

elbow. Second most common compression neuropathy. Causative factors include recurrent subluxation, dislocations, RA, excessive elbow

valgus, bony spurs, synovial cysts or external compression or trauma. Ulnar nerve supplies the ulnar intrinsics, FDP to 4 and 5 and the FCU. Sensation in

the 5th digits and ulnar ½ of the ring Cubital tunnel is a bony canal formed by the ulnar collateral ligament, the trochlea,

and the medial epicondylar groove and is roofed by the triangular arcuate ligament. FCU may or may not be involved.

Signs and Symptoms

Pain at medial elbow Sensory disturbance (numbness, paresthesia, dysesthesia) over the hypothenar

eminence, dorsoulnar hand, 5th digit and ulnar 4th digit. Weak intrinsics. Decreased or inability to cross fingers or spread fingers apart + Tinels at Cubital tunnel + Elbow flexion test (Wadsworth flexion test). Elbow flexed, FA supinated with wrist

extended. + at 60 seconds. Froments sign in advanced stage Weak grip and lateral pinch Wartenbergs sign in advanced cases. Paralysis of the 3rd palmar interossei. ( no

adduction of small finger) Claw hand deformity as FDP reinnervates

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Cubital Tunnel

Tinels

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Normal pinch

Positive Froments

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Non-operative Treatment and Splinting

Heelbo pads for day time wear to protect medial elbow/ulnar nerve.

Fabricate a long arm splint with elbow flexed 30 to 45 , anterior based and flared to avoid external compression on the ulnar nerve for night wear.

Can use a rolled towel around the elbow to decrease flexion at night during sleep if splint not fabricated

Postural and positional education is stressed to avoid external nerve compression. Resting elbows on hard surfaces, leaning on elbows, prolonged elbow flexion, repetitive flexion/extension at elbow

Patient education in insensate precautions

Ulnar nerve glide

Ice

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Lumbrical bar splint for Ulnar nerve

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Dynamic Splinting for Ulnar nerve with associated extrinsic tightness

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Ulnar Nerve Surgery

Decompression and medial epicondylectomy

Subcutaneous transposition

Submuscular transposition

Subfascial - submuscular

anterior transposition of the UN

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Postoperative Therapy Cubital Tunnel

Ulnar nerve decompression/ medial epicondylectomy

• Begin gentle AROM immediately, no heavy lifting for 6 weeks. Patient can

use upper extremity for daily activities.

• Sensory assessment

• Wound care and edema control

• Week 2 begin PROM

• Exercises to promote gliding of the ulnar nerve to prevent scarring of the

nerve to the surgical bed.

• Week 4 resisted ROM. Stretching exercises.

• Normal activity resumption in 1-2 months

• As ROM progresses, initiate gentle strengthening exercises

• Desensitization and motor exam.

• Splint as indicated for ulnar nerve deficit

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Cubital Tunnel continued

Subcutaneous transposition

Week 1: Splint in 45 elbow flexion for up to 2 weeks. Gentle AROM is started at all joints. Progress to resistive exercises at 4 weeks.Sensory assessmentWound care and edema control

Week 2: Discontinue splint, progress AROM Week 3: PROM Week 4: Progress resisted ROM

Desensitization, sensory re-educationSplint as indicated for ulnar nerve deficit

Submuscular transposition

Week 1: Splint in long arm splint with elbow flexed 45 , with slight forearm pronation and wrist in neutral for up to 3 weeks to protect the flexor pronator origin.Sensory assessmentWound care and edema control

Week 2: AAROM of elbow. Progressively move elbow into extension with wrist flexed and FA pronated to avoid tension scar massagedigit range of motion

Week 5: Stretching to regain full elbow extension Week 6-8: Progressive strengthening

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Ulnar Nerve: Guyon’s canal Compression of ulnar nerve as it passes through Guyon’s canal at the wrist. Guyon’s

is a bony canal formed by the volar carpal ligament, hook of the hamate and the hamate. Motor and sensory deficits are present distal to the canal as both sensory and motor runs through the canal. There will be volar sensory but no dorsal sensory deficit. Compression of the ulnar nerve at this site is usually associated with trauma, abnormal structures (ganglion cyst or lipoma) fracture of the hamate, ring or small fingers metacarpal bones or anomalous muscles. Thrombosis or aneurysm of the artery may compress the nerve. It has also been called handlebar palsy.

Signs and Symptoms

Numbness/tingling along the volar aspect of the small finger and ulnar ½ of the ring (no dorsal numbness)

Cold intolerance in the ring and small fingers.

Weakness or paralysis of the hand intrinsics innervated by the ulnar nerve

Possible + Tinels at Guyon’s canal

Possible claw deformity

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Classification: (Shea’s System)

Type I: Involvement of the hypothenar and deep ulnar branch

Type II: Involvement of the deep ulnar branch

Type III: Involvement of the superficial sensory branch

Treatment for Guyons Canal

• Protective splint or gel pad if from external compressive forces

• Managed post surgically with splinting ,muscle strengthening and sensory re-education.

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Ganglion compressing the

ulnar nerve in Guyons Canal

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Communications between the ulnar and median nerves in the upper limb

Martin-Gruber anastomosis• First described in 1763

• 10-44% of the population

• Communicating branch may arise from the median nerve and join the ulnar nerve

in the forearm, ultimately innervating the intrinsic hand muscles

• The clinical importance is that an isolated UN lesion at the elbow may produce

an unusual pattern of intrinsic muscle paralysis.

Riche- Cannieu• First described in 1897

• Recurrent branch of the median nerve and the deep branch of the ulnar nerve

are connected in the palm.

• The thenar muscles normally innervated by the median nerve are innervated by the ulnar.

• Even with an injury at the wrist, some intrinsic function occurs

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Martin-Gruber Anastomosis in the forearm

Riche- Cannieu Anastomosis

Ulnar Nerve

Median Nerve

Riche- Cannieu Anastomosis

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Radial Nerve Compression Sites

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Radial nerve

Triceps

Brachioradialis

Extensor carpi radialis longus

Lower lat cut. n. of arm

Post. cut. n. of FA

Post. Interosseous n.

Extensor carpi radialis brevis

Supinator

Extensor digitorum

Extensor digiti quinti

Extensor carpi ulnaris

Abductor pollicis longus

Extensor pollicis longus & brevis

Extensor indicis

Dorsal digital nerves

Axilla

Humeral fractures

Extensor carpi radialis brevis

Arcade of Froshe

Wartenbergs Syndrome

Posterior cut n.

Radial Nerve C5-C8 (Posterior cord of the Brachial Plexus)

Muscle/Nerve Innervation

Triceps Arm Radial Nerve High Lesion

Anconeus

Posterior cutaneous nerve

Lower lateral cutaneous nerve

Innervation below the spiral groove

Brachioradialis

Extensor carpi radialis longus

Superficial Radial Nerve (sensory)

(elbow joint)

Extensor carpi radialis brevis ***Posterior Interosseous Nerve****

Supinator

Extensor digitorum communis

Extensor digiti minimi

Extensor carpi ulnaris

Abductor pollicis longus

Extensor pollicis Longus

Extensor pollicis Brevis

Extensor indicis proprius

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Radial Nerve

Dbrn is above the arcade of Froshe

Dbm deep branch of radial nerve

Sb superficial branch radial nerve

Sm supinator muscle

(asterick) nerves to supinator muscle

Nb nerve to brachioradialis

Nel nerve to the ECRL

Neb nerve to the ECRB

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Radial Nerve

The posterior branch of the radial nerve is being compressed

by the Leash of Henry and the arch of the ECRB

BT Biceps tendon

BA Brachial Artery

Single white arrow Leash of Henry

Multiple black arrows Arch of the ECRB

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Radial Nerve: Radial Tunnel Syndrome Compression of the radial nerve by anatomical structures inferior to the lateral

epicondyle: proximal fibrous edge of the supinator muscle ( arcade of Froshe), fibrous fascia over the radiocapitellar joint, tendinous origin of the ECRB and the fibrous thickenings within an at the distal margin of the supinator muscle.

Signs and Symptoms

Dull, achy pain over the extensor aspect of the forearm, can radiate into the distal forearm and the hand.

Symptom onset after significant repetitive or power grip use Pain absent upon awakening but progressively increases with activity, leaving a dull

persistent ache. Night pain is common Tenderness over the radial head/radial tunnel area Positive radial tunnel compression test involves the examiner rolling the fingers over

the radial nerve region in the proximal forearm eliciting pain and tenderness. Pain reproduced with resisted extension of the fingers with the elbow extended- pain

most severe with stressing the middle finger. (Middle finger test which tenses the ECRB over the nerve)

Pain with resisted forearm supination with the elbow extended (Yergasons test) With advanced stages- weakness of the wrist, finger and thumb extensors. Decreased

grip strength secondary to weakened extensors. May have paresthesias, numbness in the 1st dorsal web space, dorsal thumb and index

finger Radial tunnel syndrome may be distinguished from lateral epicondylitis by exam.

Maximum tenderness is over the neck of the radius and must be compared to the other arm.

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Non-operative treatment for Radial tunnel

Week 0-3:

Wrist splint in 30-45º extension. Splint worn continuously. Patient education in avoidance of tasks requiring Pronation/supination Use appropriate balanced tools in the work environment and avoid high-force tasks

with torque or with heavy pronation and supination

Week 3+

Radial nerve glides Tendon gliding

Basic 4 hand posturesOverhead fisting

Modalities as indicated Patient education on risk factors Patient education on activity modification of ADL’s and job tasks. (lift with palms up

versus palms down) Progressive strengthening with putty and theraband once symptoms have resolved

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Radial Tunnel Operative

Week 1: Bulky dressing is removedGentle active and passive ROM to wrist, FA and elbowPatient education on wound care

Week 3-4: Motor and sensory re-educationScar massageAROM to wrist, forearm and hand.Begin neural glide exercisesPatient is to use extremity in basic self-care ADL activities and IADL tasks such as cooking and meal preparation.

Weeks 6-8: Progressive strengthening within patients comfort level using putty andtheraband, free weights

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Posterior Interosseous Syndrome

Compression or injury of the PIN branch of the radial nerve, secondary to trauma. (dislocation of the elbow or fracture/dislocation of the radial head, Monteggia fracture), lipoma, ganglion cyst, inflammation, postural/occupational or iatrogenic (injection causes.)

Compression of the nerve at proximal edge of the supinator is the most frequent compression site.

Considered a pure motor syndrome

Signs and Symptoms

Pain deep forearm, lateral elbow

Weakness of wrist extension (will have extension in radial deviation from ECRL) Motor loss may be gradual or dramatic. Loss of finger and thumb extension.

No sensory deficit.

History of repeated or strenuous effort involving supination and pronation. Men two

times more than women with dominant arm 2 times more than non-dominant.

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Posterior Interosseous Nerve Splint

Long arm posterior splint with elbow flexed to 90º. Wrist in neutral, forearm in neutral. Buddy tape the fingers.

Paralysis of wrist and finger extensors– support wrist in splint with dynamic extension outriggers for the digits.

Paralysis of finger extensors but active wrist- tenodesis splint.

Post operative Splinting

Long arm posterior splint with the elbow flexed to 90º, wrist and forearm in neutral. Buddy tape the fingers.

Dynamic splinting

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Long arm splint with wrist

Tenodesis style splint

Radial Sensory nerve entrapment or Wartenberg’s disease (Cheiralgia Paresthetica)

A rare clinical feature of entrapment of the superficial sensory branch of the radial nerve at the wrist. It is thought the lesion arises from the point at which the nerve exits the deep tissue between the

brachioradialis and the ECRL Most distal compression can be from external causes. Tight wristbands, scar bands, tight cast or a

direct blow, or from chronic inflammation from first dorsal compartment tendonitis. In patients with de Quervains tenosynovitis secondary irritation of the RSN is frequent

Signs and Symptoms

Radial wrist and dorsal hand pain of thumb, index, first web. Described as burning, numbness, hyperesthesia or tingling.

Test by clenched fist and ulnar- palmar flexion with forearm hyperpronation. Dysesthesia's of the dorsal hand, thumb, index and long fingers + Tinels along the radial styloid to the edge of the brachioradialis Finkelstein’s test may be misleadingly positive. Thumb does not have to be flexed to elicit an

positive test.

Splint

Wrist splint with max. extension, radial deviation NSADIS Restricted activities

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Three main branches of the SBRN (Superficial branch of the radial nerve)

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Treatment Goals for Median Nerve Compression

• Provide appropriate splinting based on diagnosis

• Patient education on positional avoidance of aggravating postures

• Patient education in injury prevention secondary to decreased sensation

• Patient education in tendon and nerve glide exercises

• ADL independence, adaptive equipment as indicated

• Improvement in sensation

• Strengthening of affected muscles

• Ergonomic assessment

Treatment Goals Post Operatively

• Postoperative immobilization as indicated

• Wound/ Incision care

• Scar management

• Increase ROM

• Edema control

• ADL

• Desensitization if needed

• Strengthening

Treatment Goals for Ulnar Nerve Cubital Tunnel Conservative Treatment

• Reduce direct pressure on the ulnar nerve at the elbow

• Minimize stress/stretch to the nerve, reduce inflammation

• Normalize sensation

• Splint for ulnar claw deformity

• Increase strength of weakened musculature

• Ergonomic evaluation and patient education

Treatment Goals Post Operative

• Discuss with MD post-operative immobilization

• Avoid postures that cause paresthesias

• Incision care to promote healing

• Maintain ROM of all uninvolved joints

• Encourage use of the involved extremity in ADL’s

• Scar massage, stretching to minimize scar adhesions

• Strengthen musculature

• Splint for ulnar claw as needed

• Patient home program in desensitization/ sensory re- education

• Nerve glide exercises

• Assess return to work and return to independent ADL’s

Treatment Goals Radial Nerve

• Provide splinting to promote function, decrease pressure

• ROM exercises to prevent extrinsic flexor tightness/intrinsic tightness

• Functional ADL retraining

• Strengthening / re-conditioning

• Patient education to avoid mechanical stress

Treatment Goals Post Operative Repair

• Protective post operative splinting

• ROM exercises to decrease edema and stiffness

• Functional ADL retraining, increase use of the hand in ADL’s

• Incision care to promote healing.

• Splinting to promote functional return

• Scar management

Outcomes Median Nerve

1. Non-operative: Outcome depends on severity and length of time of compression

2. Postoperative: Dependent on symptom duration, severity, incision healing,

scar tenderness, patient motivation, specific work requirements.

A. Light or sedentary work, return is between 2-4 weeks. Work requiring heavy

manual labor the recuperation time is longer

B. Grip and pinch strengths return to preoperative levels 2-3 months, with

maximal improvement by 10 months

C. Compression symptoms may reoccur in 1.7% to 3.1% of patients

Outcomes Ulnar Nerve

1. Dellon reported excellent results in 50% of patients with mild neuropathy

treated non-surgically and 90% excellent results in those treated with

surgery regardless of the procedure.

2. Dellon also reported that non-operative treatment and decompression

surgery were mostly unsuccessful in treating moderate neuropathies;

however epicondylectomy provided excellent results in 50% of cases.

3. Most of the literature describes resumption of full activities by 3 to 4

months post surgery.

4. Nathan and colleagues reported simple decompression and early therapy

resulted in good or excellent long-term relief in 89% of cases and an average

RTW interval of 20 days.

5. A significant reduction in the incidence of elbow flexion contractures was also

reported with early mobilization

Radial Nerve Outcomes

1. The functional outcome of radial nerve lesions is dependent on the severity

index, location of the injury, age of patient.

2. The majority of radial nerve lesions when managed by a hand surgeon

and skilled hand therapist realize functional recovery and independence

in ADL’s.

3. Modification of work or home tasks to reduce those movements or positions

that cause compression needs to be addressed.

4. Some individuals may be restricted from very heavy work or job duties

that aggravate symptoms.

References

Hunter, et al. Rehabilitation of the Hand: Surgery and Therapy 4th ed.

Stanley and Tribuzi. Concepts in Hand Rehabilitation

Burke, et al. Hand and Upper Extremity Rehabilitation 3rd ed.

Cherry, K. Differential Diagnosis for Nerve Entrapment Syndromes

of the Upper Extremity. North American Seminars, Inc.

Dogan,N. et al. The communications between the ulnar and median nerves

in upper limb. Neuroanatomy (2008) 8: 15-19.

Springer Images

Photos: LSUHSC