Median Nerve Compression syndromes

Content
Anatomy Median Nerve Pronator Syndrome Anterior Interosseous Nerve Syndrome Carpal Tunnel Syndrome

Anatomy
Formed by 2 cords anterior to 3rd part of axillary artery Crosses Brachial artery from lateral to medial Lies medial to brachial artery in cubital fossa Passes between 2 heads of PT Lies between FDS and FDP then deep to flexor retinaculum

Pronator Syndrome Anterior Interosseous Syndrome

Pronator Syndrome
Sites of Compression Supracondylar process Ligament of Struthers Bicipital aponeurosis Between two heads of pronator teres Under origin of FDS

Pronator Syndrome
Symptoms:
Forearm pain Hand numbness No night pain

Signs:
Resisted elbow flexion with supinated forearm (bicipital aponeurosis) Resisted forearm pronation with elbow extended (PT heads) Isolated long finger PIPJ Flexion (FDS)

Pronator Syndrome
Investigation Xray Elbow EMG/NCT Treatment Splint/NSAIDs Release all potential sites of compression

Anterior Interosseous Nerve Syndrome

Characterised by motor loss without sensory involvement Muscles affected: FDP(radial half), FPL and Pronator Quadratus Beware bilateral cases - ?Parsonage-Turner syndrome

Anterior Interosseous Nerve Syndrome

Sites of compresion Fibrous bands in PT FDS origin Enlarged bicipital bursa Gantzers muscle (the accessory head of flexor pollicis longus; FPL)

Anterior Interosseous Nerve Syndrome

OK sign to test FPL and FDP Beware Isolated FPL rupture (MannerfeltNorman Syndrome) Pronation in max elbow flexion for PQ

Anterior Interosseous Nerve Syndrome

Anterior Interosseous Nerve Syndrome

Investigation Treatment Splint elbow at 90/NSAIDs Release all potential sites of compression

EMG/NCT

Carpal Tunnel Syndrome

Most common peripheral nerve compression syndrome F>M

Carpal Tunnel Syndrome Aetiology/Pathophysiology

Increase pressure in Carpal tunnel ( 8mm vs 90mm Hg) Ischaemia Focal demyelination
Risk factors: DM, RA, OA, Hypothyroidism wrist trauma, obesity, pregnancy

Carpal Tunnel Syndrome Work

Prescribed disease if related to use of vibrating tools Vibrating tool = more than 2 fold increase in risk Keyboard and computer work not risk for CTS
Palmer KT, Harris EC, Coggon D.Carpal tunnel syndrome and its relation to occupation: a systematic literature review. Occup Med (Lond). 2007 Jan;57(1):57-66. Epub 2006 Nov 2

No relationship between work and CTS Except work that involves very cold temperatures (possibly in conjunction with load and repetition) such as butchery
Falkiner S, Myers S When exactly can carpal tunnel syndrome be considered work-related? ANZ J Surg. 2002 Mar;72(3):204-9.

Carpal Tunnel Syndrome Diagnosis

History and Exam (structured? 85-100%) Tinels ( 38-62%/57%), Phalens (77-86%/ 48%)
Neurophysiology (?worse in men)
Kamath V, Stothard J. A clinical questionnaire for the diagnosis of carpal tunnel syndrome. J Hand Surg [Br]. 2003 Oct;28(5):455-9. Erratum in: J Hand Surg [Br]. 2004 Feb;29(1):95.. Gunnarsson LG, Amilon A, Hellstrand P, Leissner P, Philipson L. The diagnosis of carpal tunnel syndrome. Sensitivity and specificity of some clinical and electrophysiological tests. J Hand Surg [Br]. 1997 Feb;22(1):34-7. Padua L, Padua R, Aprile, Tonali P. Italian multicentre study of carpal tunnel syndrome. Differences in the clinical and neurophysiological features between male and female patients J Hand Surg [Br]. 1999 Oct;24(5):579-82.

Carpal Tunnel Syndrome Management - Conservative

Oral Meds Vit B6 Steroid injection(? Most useful in reversible causes/holding measure) Splint - ? Positions ? Rigidity Likely to fail: 50+years > 10/12 symtoms Constant paraesthesia Atrophy of APB +ve Phalens

Giele H. Evidence-based treatment of carpal tunnel syndrome. Current Orthopaedics 15, 249-255

Carpal Tunnel Syndrome Management - Surgical

Open CTR Endoscopic CTR Limited CTR Lengthening of Flexor Retinaculum

Carpal Tunnel Syndrome Open Release

Beware motor branch Reconstruction vs. Lengthening 24% increase in volume(AP) 96% Satisfaction Pinch and grip strength return 6-12 weeks

Carpal Tunnel Syndrome Endoscopic

Uniportal vs Two portal technique Leave palmar skin and fat alone, not disturbed thenar and hypothenar muscles Faster recovery No Difference by 12 weeks

Carpal Tunnel Syndrome Outcome

>80% satisfied (?meaning) Boston Carpal Tunnel Questionnaire Scar tenderness Pillar pain Weakness Slower return to work in manual worker