Upper Extremity
Compressive
Mononeuropathy
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Capt Brendan M. Stroz, PA-C, MPAS
Orthopaedic Surgery PA Resident
Travis AFB, CA
Disclaimer
I DO NOT have a financial interest/arrangement
or affiliation with one or more organizations
that could be perceived as a real or apparent
conflict of interest in the context of the subject
of this presentation.
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Objectives
At the conclusion of this session, the learner will be able to:
Differentiate between the multiple neuropathies of the upper extremities
Properly evaluate, diagnose and treat upper extremity mononeuropathies
Describe specialty exams to evaluate for upper extremity mononeuropathies
Describe ancillary tests to evaluate for upper extremity mononeuropathies
Describe initial non-surgical management of upper extremity mononeuropathy
Describe initial surgical management of upper extremity mononeuropathy
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Compressive Neuropathy-What is it? Chronic condition involving peripheral upper extremity nerve with sensory, motor or
mixed manifestations.
May be acute or secondary to treatment
Paresthesias arise from compression and ischemia
Acute
Chronic
SLT are first, pain and temperature last
Peripheral Compression Neuropathies of
the Upper Extremity Median Nerve
Carpal Tunnel Syndrome
Pronator Syndrome
Anterior Interosseous Nerve Syndrome
Ulnar Nerve
Cubital Tunnel Syndrome
Ulnar Tunnel Syndrome
Radial Nerve
Proper Radial Nerve
Posterior Interosseous Nerve Syndrome
Radial Tunnel Syndrome
Wartenberg Syndrome
Median Nerve Compression
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Median Nerve Compressions
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Pronator Syndrome
Proximal compression of median nerve
Symptoms
Proximal forearm pain, sensory disturbances in palmar cut
branch (median n)
Provocative Tests: elbow flexion, pronosupination, resisted
long finger PIP joint flexion (FDS)
Typically associated with medial epicondylitis and will improve
w/tx
Treatment
Conservative: activity mod, splint, NSAIDs
Surgical Decompression ~ 80 % success rate
Median Nerve Compressions
Anterior Interosseous Nerve Syndrome
Motor loss without sensory disturbance
FPL loss +/- FDP, PQ PQ tested with resistance in full elbow flexion and pronation
EMGs
Treatment
Vast majority recover with observation
Splinting (elbow 90 degrees), activity mod
Surgical decompression (w/in 3-6 mos)
Carpal Tunnel Syndrome
Most common compressive neuropathy in UE
Acute vs chronic
Median nerve compression at the level of the transverse carpal
ligament
CT has 9 tendons and median n.
Common systemic risk factors:
Pregnancy
DM
Thyroid disease
Alcoholism
Advanced age
Carpal Tunnel Syndrome
Evaluation
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Paresthesias, numbness and pain (often at night)
Large sensory affected before small fibers (SW testing)
Repetitive motions (Keyboard, knitting, hammer, etc)
Most sensitive test: Durkans (Tinels and Phalens*)
Spurlings
Flick Test
Examine strength grades (0-5) in chronic cases
2.5-30 mm Hg
Carpal Tunnel Syndrome Evaluation and
Tests
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Testing
Films (Xray)
Injections*
EMG
It depends
Carpal Tunnel Syndrome
Treatment
A wise man once said…
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Carpal Tunnel Release
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Post-operative course
Con Leave?
Limitations
Ulnar Nerve Compression
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Ulnar Nerve Compression
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Ulnar Tunnel Syndrome
Compression of the ulnar nerve in the Guyon Canal
MC Cause: Ganglion cyst
Hook of Hamate non-union, lipoma, PB hypertrophy, ulnar artery thrombosis.
Motor and/or sensory
Treatments
Conservative
Surgical decompression
Treat underlying cause
Cubital Tunnel Syndrome
Second most common UE compression neuropathy
Multiple sites of compression
Other potential causes
Tumors/ganglion
Osteophytes
HO
Medial Epicondyle Non-union
Deformities
Cubital Tunnel Syndrome
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Symptoms
Paresthesias of the ulnar 1½ digits
Night symptoms w/flexion
Provocative Tests
Compression
Hyperflexion
Tinel’s
Check for Subluxation*
Further Evaluation
EMG
Xrays
Cubital Tunnel Syndrome
Treatment
The wise man’s principles
Surgery
In Situ
Anterior Transposition
Medial epicondylectomy
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Radial Nerve Compression
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Radial Nerve Compression
Radial Nerve Palsy
Typically in setting of humeral trauma or related
surgical approaches
“Saturday Night Palsy”
Weakness of innervated muscles
Triceps, BR, ECRL, PIN
EMG for prognosis
Observation x 3 months—refer if no
improvements
Radial Nerve Compression
Posterior Interosseous Nerve Syndrome
Lateral Elbow pain & distal muscle weakness
MC Compression in Arcade of Frohse
Repetitive supination/pronation movements, trauma
Paresis/paralysis of extensors in hand
Dorsal wrist pain where terminal fibers provide sensory innervation
to dorsal wrist capsule
EMG to determine level of compression
Conservative treatment
Splints/bracing
Surgery if no improvements within 3 months (85%)
Radial Nerve Compression
Radial Tunnel Syndrome
Symptoms: Lateral Elbow/radial forearm pain
No sensory or motor dysfunction
Resisted long finger extension/supination
***LE can coexist, POMT is distal to LE (mobile wad)
EMG inconclusive
Extended conservative tx; up to 1 year
Surgical decompression
Wartenberg Syndrome
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Compression of superficial sensory branch
Scissoring between BR and ECRL w/pronation
Handcuffs, wristband, fracture
De quervains associated up to 50%
Symptoms
Pain, numbness, paresthesias on dorsoradial hand, doesn’t like to wear a
watch
Provocative tests: pronation against resistance x 60 seconds and Tinel
sign
Treatment
Surgical decompression if conservative therapy fails
References
1. Miller, M.D. (2016). Miller’s Review of Orthopaedics, Seventh Edition.Philadelphia, PA: Elsevier Inc.
2. Boyer, M.I. (2014). Comprehensive Orthopaedic Review: Volume 2. Rosemont, IL: American Academy of Orthopaedic Surgeons.
3. Franko, O. (2012, November 19). Carpal Tunnel Syndrome. Retrieved from: www.orthobullets.com.
4. Allen, D. (2012, November 25). Cubital Tunnel Syndrome. Retrieved from: www.orthobullets.com.
5. Sheth, U. Vitale, M. (2018, December 12). AIN Compression Syndrome. Retrieved from: www.orthobullets.com.
6. Watts, E. (2012, November 19). PIN Compression Syndrome. Retrieved from: www.orthobullets.com.
Questions?
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