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Median Nerve injuries

Presented By

M.Mathanraj David

Median nerve
Anatomy
Derived from C5-T1 Runs medial to axillary and brachial arteries Passes deep to bicipital aponeurosis and flexor muscle mass 80% passes between two heads of pronator teres Continues between FDS and FDP Emerges in forearm radial to superficialis tendons Passes under transverse carpal ligament

Median nerve

Median nerve
Anatomy
Superficial trunk supplies:
Pronator teres FCR PL FDS index FDP to index and middle FPL Pronator quadratus Sensation to radial carpal joint

Deep trunk supplies (anterior interosseus nerve):

Median nerve injury

Median nerve
Anatomy
5-6 cm proximal to anterior wrist crease
Palmar cutaneous branch
Innervates skin at base of palm Does not pass through carpal tunnel

Beneath transverse carpal ligament


Recurrent motor branch
Supplies thenar muscles, 1st and 2nd lumbricals

Three proper digital nerves and two common digital nerves

Etiological factors
A. Elbow level - High median nerve lesion B. Wrist level - Knife cuts C. Carpal tunnel - Dislocated lunate bones - Chronic compressions

Clinical features
Pointing index Inability to flex IP joint of thumb Ape thumb deformity Pencil test for APB Oppones palsy. Sensory signs

Median nerve

Hand function evaluation

Tendon Transfers

Tendon Transfers
Definition
The Detachment Of A Functioning Muscle-Tendon Unit From Its Insertion And Reattachment To Another Tendon Or Bone To Replace The Function Of A Paralyzed Muscle Or Injured Tendon

Tendon Transfers
Indications
Restore Function To A Muscle Paralyzed As A Result Of Injury Of The Peripheral Nerves, Brachial Plexus Or Spinal Cord 2) To Restore Function After Closed Tendon Ruptures Or Open Injuries To The Tendons Or Muscles 3) Restore Balance To A Hand Deformed From Neurological Conditions
1)

Tendon Transfers
General Principles
1) 2) 3) 4) 5) 6) 7) 8)

Straight Line Of Pull Expendable Donor Adequate Strength Correction Of Contracture One Tendon One Function Amplitude Of Motion Synergism Tissue Equilibrium

Tendon Transfers
Median Nerve Palsy Reconstructive Goals
Thumb Opposition FPL Function Index FDP Function

Sensation
Prime Determinant In Hand Function Restoration Of Sensation Abandoned
Neurovascular Island Flaps

Tendon Transfers
Median Nerve Palsy Classification
1)

High
Above Origin Of Anterior Interosseous Nerve Pronator Teres And Quadratus, FCR, FDS (II V), FDP(II & III) And FPL Paralyzed Thenar Intrinsic Muscles Paralyzed
Abductor Pollicis Brevis, Opponens Pollicis, And Superficial Head Of Flexor Pollicis Brevis

2)

Low

Tendon Transfers
Low Median Nerve Palsy
Deficit And Deformity
Abduction And Opposition Frequently Retained
Due To Diverse Innervation Of Intrinsics
Median And Ulnar Nerves

Tendon Transfers
Low Median Nerve Palsy Prevention Of Contractures
Good Therapy And Splinting Position Of Thumb
Supinated And Adducted Contracted First Web Space

Correct Contracture Before Opponensplasty


Release Fascia Over Adductor Pollicis And First Dorsal Interosseous

Tendon Transfers
Low Median Nerve Palsy
Pulley Design
Straight Line Of Pull
Reduced Friction And Work Tendon Migrates To Run In Straight Line

Tendon Transfers
Low Median Nerve Palsy
Opponensplasty Insertions
Abductor Pollicis Brevis
Radial Aspect Of Thumb Produces Good Opposition

Dual Insertions
Probably Unnecessary Attempt Opposition Plus Stabilization

Tendon Transfers
Low Median Nerve Palsy Standard Opponensplasties
1)

FDS Opponensplasty
Royle-Thompson Technique Bunnell Technique

Extensor Indicis Proprius Opponensplasty 3) Huber Transfer


2)

4)

Abductor Digiti Minimi Palmaris Longus

Camitz Procedure

Tendon Transfers
Low Median Nerve Palsy
1)

FDS Opponensplasty Royle-Thompson


FDS Brought Around Ulnar Border Of Palmar Aponeurosis FDS Has A Large Potential Excursion
Adjusting Tension Not As Critical Margin For Error

Tendon Transfers
Low Median Nerve Palsy
1)

FDS Opponensplasty Bunnel Technique


Ring Finger FDS Divided FCU Exposed
4cm Proximal To Pisiform Insertion

Tendon Split Into Two Halves Free End Looped Back Onto Its Base
Ensure Loop Not Too Tight

Tendon Transfers
Low Median Nerve Palsy Sublimis Tendon Harvest
Ring Finger Commonly Used As Motor
May Weaken Power Grip Some Surgeons Prefer Middle Finger

Recommend Division Proximal To Bifurcation


Avoids Destruction To Vincula Does Not Disrupt Blood Supply To FDP Avoids Injury At The Level Of The PIP
Possible Stiffness

Tendon Transfers
Low Median Nerve Palsy Sublimis Tendon Harvest
Potential Complications
Swan-Neck Deformity
Suture Distal Ends Of Tendon Across Palmar Plate Prevent Hyperextension

DIP Joint Extension Lags

Tendon Transfers
Low Median Nerve Palsy
2)

Extensor Indicis Proprius Opponensplasty


Popular In High Median Nerve Palsy
Ring And Middle FDS Unavailable

Does Not Weaken Grip Tendon Must Be Superficial To FCU


Avoid Compression To Ulnar Nerve

Tendon Transfers
Low Median Nerve Palsy
3.

Huber Transfer
Difficult Procedure
Neurovascular Pedicle Easily Damaged
Dorsoradial Aspect

Insertions Divided
Base Of Prox. Phalynx And Ext. Apparatus

Freed Off Pisiform


Attachments To FCU Retained

Attached To Abductor Pollicis Brevis Insertion

Tendon Transfers
Low Median Nerve Palsy
4)

Camitz Procedure
Usually For Complication Of Severe Carpal Tunnel Syndrome
Performed At Same Time As Carpal Tunnel Release Restores Palmar Abduction
Rather Than Opposition

Not Recommended With Traumatic Median Nerve Injuries


Palmaris Longus Usually Scarred

Tendon Transfers
Low Median Nerve Palsy Other Options For Opponensplasty
Extensor Carpi Ulnaris Extensor Carpi Radialis Longus Extensor Digiti Minimi Flexor Pollicis Longus Extensor Pollicis Longus

Tendon Transfers
High Median Nerve Palsy
Deficit
All Flexor Compartment Forearm Muscles
Apart From Ulnar-Innervated FCU And FDP

Aim Of Tendon Transfers


Flexion Of Index And Thumb Opposition

Potential Motors
Brachioradialis FPL ECRL Index FDP

Tendon Transfers
High Median Nerve Palsy Timing Of Transfers
Dependent On Prognosis
Sensory Deficit Most Important Disability Early Transfers
Should Be Attached End-To-Side If Reinnervation Expected Act As Internal Splint

Tendon Transfers
High Median Nerve Palsy Extrinsic Transfers
Restoration Of Index Function
ECRL Index FDP Side-To-Side Suturing Of Profundus Tendons
Restores Range Of Motion Strength Is Not Restored

Restoration Of Thumb Function


Brachioradialis FPL

Tendon Transfers
High Median Nerve Palsy Thumb Opposition
Early Transfer
Allows Pronation Of Hand
Compensates For Loss Of Sensation

Possible Transfers
EIP EPL Extensor Digiti Minimi FCU Eliminates Only Functioning Wrist Flexor

Carpal Tunnel Syndrome

Definition Carpal tunnel syndrome, the most common focal peripheral neuropathy, results from compression of the median nerve at the wrist.

epidemiology
Affects an estimated 3 percent of adult Americans Three times more common in women than in men High prevalence rates have been reported in persons who perform certain repetitive wrist motions (frequent computer users)
30% hand paresthesias 10% clinical criteria for carpal tunnel syndrome 3.5% abnormal nerve conduction studies

Clinical Features
Pain Numbness Tingling Symptoms are usually worse at night and can awaken patients from sleep. To relieve the symptoms, patients often flick their wrist as if shaking down a thermometer (flick sign).

Clinical Features
Pain and paresthesias may radiate to the forearm, elbow, and shoulder. Decreased grip strength may result in loss of dexterity, and thenar muscle atrophy may develop if the syndrome is severe.

Atrophy

Physical examination
Phalens maneuver Tinels sign weak thumb abduction. two-point discrimination

Phalens maneuver

Tinels sign

Diagnostic
History Physical examination Nerve Conduction Study

Differential Diagnostics
Tendonitis Tenosynovitis Diabetic neuropathy Kienbock's disease Compression of the Median nerve at the elbow

Treatment
CONSERVATIVE TREATMENTS
GENERAL MEASURES WRIST SPLINTS ORAL MEDICATIONS LOCAL INJECTION ULTRASOUND THERAPY Predicting the Outcome of Conservative Treatment

SURGERY

GENERAL MEASURES
Avoid repetitive wrist and hand motions that may exacerbate symptoms or make symptom relief difficult to achieve. Not use vibratory tools Ergonomic measures to relieve symptoms depending on the motion that needs to be minimized

WRIST SPLINTS
Probably most effective when it is applied within three months of the onset of symptoms Optimal splinting regimen ?

WRIST SPLINTS

ORAL MEDICATIONS
Diuretics Nonsteroidal anti-inflammatory drugs (NSAIDs) pyridoxine (vitamin B6) Orally administered corticosteroids
Prednisolone 20 mg per day for two weeks followed by 10 mg per day for two weeks

ULTRASOUND THERAPY
May be beneficial in the long term management More studies are needed to confirm its usefulness

SURGERY
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. It is important to note that surgery may be effective even if a patient has normal nerve conduction studies

SURGERY
Complications of surgery Injury to the palmar cutaneous or recurrent motor branch of the median nerve Hypertrophic scarring laceration of the superficial palmar arch tendon adhesion Postoperative infection Hematoma arterial injury stiffness

SURGERY

PREGNANCY
Alterations in fluid balance may predispose some pregnant women to develop carpal tunnel syndrome. Symptoms are typically bilateral and first noted during the third trimester. Conservative measures are appropriate, because symptoms resolve after delivery in most women with pregnancy-related carpal tunnel syndrome.

ADL adaptations

modified Handle

BUTTON HOOK

CYLINDRICAL FOAM

COOKING MITTS

ZIPPER PULL

UNIVERSAL CUFF

INSULATED MUG T TURNING HANDLEOR GRIPPER KNOB TURNER