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• A key landmark in the upper arm is the

palpable space posterior to the biceps
muscle ; the median nerve lies in close
apposition to the brachial artery and ulnar
nerve within this space.
• At the level of the elbow, one can divide the
antecubital fossa into thirds, and the median
nerve lies roughly at the junction of the
medial and middle third.
• If the wrist is flexed, there are 1 or 2 creases that are

• The creases mark the proximal boundary of the carpal tunnel.

• If the thumb and fifth finger are apposed, the longitudinal plane
between the thenar and hypothenar muscles will be
exaggerated . The median nerve at the wrist can be readily
found at the intersection of the latter crease and the wrist

• The course of the nerve then can be traced in the forearm by

joining the longitudinal crease at the wrist with the junction of

the medial and middle thirds of the antecubital fossa.

Formed by C5
to C7 roots
from lateral
cord of
brachial plexus

C8 and T1
roots from
medial cord
From the axilla, it enters
the arm at inferior
margin of teres major

Passes vertically down

the medial side of ant
compartment of arm

Proximally, it is
immediately lateral to
brachial artery

Distally, it crosses to
medial side of brachial
artery & lies anterior to
elbow joint
Covered & protected anteriorly in
distal part of cubital fossa by the
bicipital aponeurosis

Leaves cubital fossa by passing

between ulnar & humeral heads of
pronator teres + humero – ulnar &
radial heads of flexor digitorum

No branch in arm, 1 branch to

pronator teres in forearm, which may
originate from nerve immediately
proximal to elbow joint

In forearm, it continues a straight

linear course distally down in the
fascia on deep surface of FDS muscle
Branches to superficial &
intermediate layers of
forearm, originating
medially from nerve just
distal to elbow joint:

• Largest branch: ant

interosseous nerve
 Origin: between 2 heads of
pronator teres
 Pass distally down forearm
with ant interosseous
 Motor innervation to deep
muscles e.g. FPL, lat ½ FDP
& PQ
 Terminates: articular
branches to joints of distal
forearm & wrist
1. Small branch: palmar
cutaneous branch

 Origin: distal forearm,

proximal to flexor

 Passes superficially in

 Innervates skin over base

and central palm

 Sensory innervation to
skin over thenar
Proximal to the wrist, the median nerve
moves lateral to the muscle, becoming
more superficial in position and lying
between tendons of PL & FCR

From the forearm, it passes through the

carpal tunnel deep to the flexor
retinaculum & enters the palm of the
hand where it divides into
2.Palmar digital branches
Recurrent branch
 Origin: lateral side of median nerve near
distal margin of flexor retinaculum, curves
around its margin
 Pass proximal over FPB, then pass between
FPB & abductor pollicis brevis to end in the
opponens pollicis
 Motor Innervation to 3 thenar muscles

 Palmar digital nerves

 Cross palm deep to palmar aponeurosis &
superficial palmar arch & enters the digits
 Sensory Innervation to palmar skin surfaces
of lat 3½ digits + dorsal cutaneous regions
of distal phalanges of same digits
 Distal nerves also supply motor innervation
to the lateral 2 lumbricals
Common Sites Affected & Causes
Axilla: Just Distal to Elbow:
crutch compression
pronator teres syndrome
missle injury
In the Forearm:
anterior shoulder dislocation
anterior interosseous
Upper Arm: syndrome
stab wounds +/- brachial artery injury
fractures of forearm bones
sleep palsy: near pectoralis major tendon
# of shaft of humerus In the Carpal Tunnel:

Elbow: carpal tunnel syndrome

supracondylar # of humerus # & dislocations about the

fracture of medial epicondyle
injection injury
after elbow dislocation
Examination of Median Nerve

Damage to the median N generally results in

weakness of abduction & opposition of thumb

weakness of forearm pronation
deviation of wrist to ulnar side on wrist flexion
weakness of flexion of distal phalanx of thumb & index
wasting of thenar muscles
sensory loss is variable but most marked on index &
middle fingers.
Examination of Median Nerve

High median nerve injuries, in the proximal forearm or

above, lead to loss of:

wrist flexion strength,

ulnar deviation of the wrist,

thumb opposition,

flexion of the thumb, index & long finger interphalangeal


When making a fist, the ring and small fingers flex while
the long and index tend to stay straight. This is known as
the pointing test.

Examination of Median Nerve

The patient’s hand is placed on a flat surface with palm facing

upwards. The examiner holds his finger above palm. The patient is
asked to raise his thumb & try to touch examiner’s finger. This is a
test for Abductor Pollicis Brevis.

Another test may be performed to check for strength of Flexor

Pollicis Longus in thumb & Flexor Digitorum Profundus in
index. The patient is asked to try to flex the appropriate distal
joint while the examiner supports the phalanx proximal to it.
Weakness of these 2 muscles indicates a lesion proximal to the

Examination of Median Nerve

In low median nerve injuries the fingers are still able to

flex, but thumb opposition is often lost.

To test motion, ask the patient to move thumb and fifth

digit so that the finger tips touch and attempt to flex the

Damage is indicated by numbness, tingling and pain in

the palm and fingers, weak thumb movements and proper
flexion of the wrist.
Examination of Median Nerve

APE HAND (no thumb opposition): a deformity marked

by thumb movements being limited to flexion and
extension in the plane of the palm due to the inability to
oppose and limited abduction of the thumb.

The recurrent (thenar) branch of the median nerve

supplying the thenar muscles lies subcutaneously and
may be severed by relatively minor lacerations involving
the thenar eminence.
Severence of this nerve paralyzes the thenar muscles,
and the thumb loses much of its usefulness.
Examination of Median Nerve
Carpal Tunnel Syndrome
disorder characterised by compression of the median nerve at the wrist

congenital predisposition – carpal tunnel
is smaller
trauma / injury to the wrist that cause
swelling, e.g. sprain / fracture
mechanical problems in wrist joint
repeated use of vibrating hand tools
development of cyst / tumor in the canal
fluid retention during pregnancy /
menopause, overactivity of pituitary gland,
obesity, hypothyroidism, rheumatoid
arthritis, diabetes, work stress – predispose
to CTS
in some cases – cause unknown
Carpal Tunnel Syndrome

Signs & Symptoms:

numbness in the distribution of median nerve
burning, tingling, swollen & a prickly pin-like
sensation over the palmar surface of the hand, &
into the thumb, forefinger, middle finger, & half of
the ring finger, esp. at night
with continued nerve compression – may
experience muscle weakness, resulting in
decreased grip strength
some people – unable to tell between hot & cold
eventually – muscle atrophy, esp. muscles at TUNNEL SYNDROME
the base of thumb
if left untreated - may eventually result in
permanent weakness, loss of sensation, or even
paralysis of the thumb and fingers
Carpal Tunnel Syndrome

Conservative Surgical
resting of affected hand & wrist for at least 2 weeks done in most
immobilisation of wrist in a splint to avoid further damage from severe cases of CTS
twisting / bending (specially designed carpal tunnel wrist support)
recommended if
Medications: symptoms last for 6
NSAIDS, e.g. aspirin, ibuprofen
pain relievers involves cutting
the ligament
orally administered diuretics (“water pills”) – to decrease swelling crossing the wrist,
corticosteroids or the drug lidocaine can be taken orally or thus providing more
injected directly into the wrist room to the median
nerve & decreasing
cool packs – reduce swelling
stretching & strengthening exercises (small weights to do flexion
& extension – use of theraband may also be considered)
Note: if underlying causes of CTS are diabetes / arthritis / ….. –
these conditions should be treated 1st
wrist is examined for tenderness, swelling, warmth &
each finger is tested for sensation
muscles at the base of the hand are examined for strength
& signs of atrophy
routine lab tests & X-rays – reveal diabetes, arthritis &

EMG – to determine severity of damage to median nerve
ultrasound imaging – to show impaired movement of median N
MRI – to show anatomy of wrist (but NOT really useful in
diagnosing CTS)
Phalen’s (wrist flexion) Test
• performed by holding the patient’s wrist in
maximum flexion for 1 minute. A positive test is
indicated by tingling in the thumb, index finger,
and middle finger and lateral half of the ring

Tinel’s Sign
• performed by briskly tapping over the carpal
tunnel at the wrist. A positive test causes
tingling or paraesthesia into the thumb, index
finger and middle and lateral half of the ring
finger( median N distribution). Tingling or
paraesthesia must be felt distal to the point of
pressure for a positive test
Carpal Tunnel Syndrome

Carpal Compression Test
a relatively new test

the supinated wrist is held in both hands & direct even

pressure is applied over the median N in the carpal tunnel
for up to 30 secs.

production of the pt’s symptoms is considered to be a

positive test for the carpal tunnel syndrome
Pronator Teres Syndrome
also known as pronator
more common in women

involves entrapment
(compression / pinching) of
the median nerve by the
pronator teres muscle

can also include median

nerve compression by other
structures in the elbow, e.g.
ligament of Sruthers /
bicipital aponeurosis
depending on the site of entrapment – 2 types of
symptoms may occur:
1. compression of median nerve at / just above the
elbow – leads to weakness of pronator teres muscle
(rare occurrence & more commonly seen in children)
2. entrapment of median nerve at the pronator muscle
itself – the median nerve passes between the
superficial & deep heads of the muscle & can
become entrapped due to edema & hypertrophy
(enlargement) of the muscle

Note:Entrapment at the pronator teres muscle does not

involve the muscle since its nervous innervation
comes from a point more proximal than the muscle
itself, thus sparing it.
Pronator Teres Syndrome
Neuropathies (nerve loss) at either site will involve both sensory and motor
deficits on the flexor (palmar) side of the forearm.

Sensory losses Motor losses

include the thumb, index and middle lead to loss of flexion (inability
fingers, and half the ring finger to make a tight fist) & opposition
typically involve all of the palm of the of the thumb & fingers involved
hand to the wrist The exception to this is, as
include numbness, tingling and / or stated before, with involvement of
“pins & needles” sensations along the the pronator teres muscle, which
palm of the hand and sometimes part will make it difficult to pronate the
way up the forearm arm

most significant feature – pain along median nerve axis – helped by rest &
aggravated by activity
Median nerve is tender along its course in the forearm – patient may complain
of aching discomfort & early fatigue of the muscles of the forearm
Pronator Teres Syndrome

Phalen & Tunnel tests are negative
pain upon palpation of origin ,muscle belly & insertion of pronator
teres muscle
pain when pronating forearm against resistance
median nerve symptoms arise when the muscle belly of pronator
teres muscle is deeply compressed
weakness of thenar muscles

EMG (Note: if EMG does not confirm PTS but clinical evidence is
suggestive, then wait for 4-6 weeks before doing EMG once again)
Pronator Teres Syndrome
Pronator Teres Test
The patient stands with the elbow in 90 degrees of
flexion. One hand is placed on his elbow for stabilization
and the other hand grasps his hand in a handshake
position. The patient holds this position as an attempt is
made to supinate his forearm (forcing him to contract
the pronator muscles).
While holding the resistance against pronation, the
patient’s elbow is extended. If pain or discomfort is
reproduced, there is a good chance of median nerve
compression by the pronator teres.
Note: the patient should keep the elbow relaxed
during the test, because holding the elbow firmly in
flexion will NOT allow elbow extension.
Pronator Teres Syndrome

Conservative Surgical
rest exploration of the median
Medications: nerve in the proximal forearm
NSAIDS & release of all possible sites
of compression – done in
Physiotherapy: severe cases
wrist immobilisation splint applied in
15 degrees dorsiflexion for 4-6
electrical stimulation
Anterior Interosseous Syndrome
also known as Kiloh Nevin Syndrome

causes of compression include:

commonest – tendinous origin of the deep head of

pronator teres
impingement of an enlarged bicipital tendon on the
aberrant / thrombosed radial artery in mid-forearm
thrombosed ulnar artery
fascial band at the origin of flexor digitorum
Anterior Interosseous Syndrome

in most cases – this syndrome is a complication of

supracondylar fractures of the humerus in children

described in association with repetitive activities, e.g.

throwing, racket sports & weight-lifting

characterised by a vague feeling of discomfort in the

proximal forearm, which may mimic pronator teres

however, because the anterior anterosseus nerve is a pure

motor division of the median nerve, there are no sensory
complaints or deficits as in pronator teres syndrome
Anterior Interosseous Syndrome

Common Signs & Symptoms:

principal weakness: difficulty in moving index & middle fingers
weakness when turning the palm down against resistance
weakness in IP joint of thumb (FPL) & DIP joints of index & middle
fingers (FDP) – this can be observed by the pitch attitude of the hand
(normally, when an individual pinches something between the index
finger & thumb, MP & IP joints of thumb & index finger are flexed, but
with a nerve deficit, terminal phalanges of thumb & index finger are
extended or hyperextended) – thus, frequent dropping of objects &
difficulty in writing
Anterior Interosseous Syndrome

1. Pinch Grip Test
The patient is asked to pinch the tips of index finger & thumb
Normal – tip-to-tip pinch
Abnormal – pulp-to pulp pinch
Test is indicative of a positive sign for pathloogy to the
anterior interosseus N
This finding is indicative for the entrapment of the ant
interosseus N as it passes between the 2 heads of the pronator
teres muscle.
2. Electroneurography however, these studies are difficult as the
3. EMG nerve is deep as are the muscles it supplies
Anterior Interosseous Syndrome

Conservative Surgical
rest exploration of median
nerve through an
use of splints
approach similar to that of
Medications: pronator syndrome

NSAIDS includes release of

pain relievers bicipital aponeurosis,
division of superficial &
Physiotherapy: more or less to the deep
heads of pronator teres
cold – to relieve pain & reduce inflammation for acute
muscle & ligation of
& chronic cases (ice packs or ice massage are applied
crossing vessels
for 10-15 mins every 2-3 hours)
heat – heat packs or warm soaks may be used
before performing stretching & strengthening exercises

eMedicine- Hand, Nerve Compression Syndromes: Upper Extremity:

Article by Bradon J Wilhelmi, MD
Last Updated, June 28, 2006

Pain Management & Rehabilitation Center

Carpal Tunnel Syndrome Fact Sheet: National Institute of Neurological

Disorders and Stroke (NINDS)
Publication date November 2002.

Grays Anatomy For Students by Richard L. Drake, Wayne Volg and

Adam W. M. Mitchell