COMPRESSIVE NEUROPATHIES OF

UPPER LIMB
Defination
The term compressive neuropathies refers to
isolated peripheral nerve injuries occurring at
specific locations where a nerve is mechanically
constricted in a fibrous or fibro-osseous tunnel or
deformed by a fibrous band.
In some instances the nerve is injured by chronic
direct compression, and in other instances
angulation or stretching forces cause mechanical
damage to the nerve.
Types
Upper Limb
-Median Nerve
-Carpal Tunnel Syndrome
-Pronator Syndrome
-Ulnar Nerve
-Cubital Tunnel Syndrome
-Guyon Tunnel Syndrome
-Supraspinatus syndrome
-Anterior interosseous syndrome
-Posterior interosseous syndrome

Carpal tunnel syndrome (CTS) is a
collection of symptoms and signs
that occurs following entrapment
of the median nerve within the
carpal tunnel.
Usual symptoms include
numbness, paresthesias, and pain
in the median nerve distribution.
These symptoms may or may not
be accompanied by objective
changes in sensation and strength
of median-innervated structures
in the hand.
Carpal Tunnel Syndrome
Borders of the carpal tunnel

Ulnarly: hook of hamate, triquetrum,
and pisiform

Radially: trapezium, scaphoid, and
flexor carpi radialis retinaculum

Dorsally: the concave arch of the
carpal bones and metacarpal bases of
the central rays

Anteriorly: the transverse carpal
ligament (TCL).
Clinical features
Pain
Numbness
Tingling
Symptom usually worst at night and can awaken
patient from sleep
To relieve the symptom, patient often flick their
wrist as if shaking down a thermometer
Examination
Provocative Testing
1. Phalen's wrist flexion
test: The wrist is
maximally flexed with the
fingers slightly curled.
A positive test for CTS is
reproduction of symptoms
within 60 sec.

Examination
Provocative Testing
2. Tinel's nerve
percussion test: The
median nerve is
percussed as it enters
the carpal canal to elicit
symptoms.
It is specific and
indicates CTS in cases in
which Phalen's test is
also positive.

Examination
Provocative Testing
3. Direct compression
test: The examiner's
thumbs apply direct
pressure to the median
nerve as it enters the
carpal tunnel.
A positive test is
reproduction of
symptoms, which appear
within 30 sec and
disappear with release of
compression.

Durkan's median
nerve compression
test
Physical Therapy
Given CTS is associated with low
aerobic fitness and increased
BMI, it is inherent to provide
the patient with an aerobic
fitness program.
Stationary biking, cycling, or any
other exercise that puts strain
on the wrists probably should
be avoided.

It may be possible to enlarge
the carpal tunnel by specific
stretching techniques. Such an
exercise program may provide a
new non invasive treatment for
CTS in the future.

Management
Splint
Wrist splints are recommended for use either at night,
or both day and night although they get in the way
when doing daily activities. These help to keep wrist
straight and reduce pressure on the compressed nerve.
Most individuals with mild-to-moderate carpal tunnel
syndrome (CTS; according to electrophysiologic data)
respond to conservative management, usually
consisting of splinting the wrist at nighttime for a
minimum of 3 weeks.



Short (1-2 wk) courses of regular NSAIDs can be of
benefit, particularly if there is any suggestion of
inflammation in the wrist region.
NSAIDs provide pain relief and reduction of
inflammation. Reducing inflammation in the structures
passing through the carpal tunnel decreases pressure
and provides some relief to the compressed nerve.
Steroid injection into the carpal tunnel is of benefit, as is
oral prednisone .

Vitamin B-6 or B-12 supplements are of no proven
benefit.
Medication
Patients whose condition does not improve
following conservative treatment and patients
who initially are in the severe carpal tunnel
syndrome should be considered for surgery
Pronator Syndrome
Compression of the Median n. in the forearm
Between the 2 heads of the Pronator Teres
Much less common than CTS
Linked to repetitive upper extremity activity



Clinical features
Aching pain in the proximal volar forearm
Paresthesias radiating into the thumb, IF, MF and radial of the RF
Similar to CTS
Decreased sensation over the thenar eminence suggests a more proximal lesion
Provocative tests for CTS negative
Provocative tests
Resisted forearm pronation
Resisted elbow flexion with forearm supinated
Resisted flexion of the MF FDS

Pressure over the leading edge of the pronator teres with the forearm in maximum
supination and the wrist in neutral produces paresthesias in the median sensory
distribution.


Treatment
Surgery usually not necessary
Activity modification, rest
NSAIDS, Corticosteroids
Conservative management effective in 50-70%
Surgery if space-occupying lesion or if several-month course
of nonsurgical treatment fails.
Surgery success rate 90%
Anterior Interosseous Nerve Syndrome
Weakness or motor loss of:
Flexor Pollicis Longus
FDP to the IF (and occasionally the MF)
Pronator Quadratus


Weakness or motor loss usually occur spontaneously
Patient may describe clumsiness with fine motor skills such as writing and
pinching.
AIN does not innervate the skin no sensory loss
Pain may be present in the forearm along the course of the nerve




Treatment

Rest, splinting and observation for several
months
Most improve without surgical intervention
Surgical decompression for patients who fail a
several-month course of nonsurgical
treatment

Ulnar Nerve
Cubital Tunnel Syndrome
Guyons Canal
Cubital tunnel
roof
formed by FCU fascia and Osborne's ligament (travels from the
medial epicondyle to the olecranon)
floor
formed by posterior and transverse bands of MCL and elbow joint
capsule
walls
formed by medial epicondyle and olecranon

Cubital Tunnel Syndrome
Second most common compression syndrome
Also a clinical diagnosis
Numbness in the ring and small finger
Aching in the medial aspect of the elbow and forearm
Tinels sign positive at or proximal to Cubital
Tunnel
Elbow flexion test



Clawing of the small and ring fingers
Froment sign

Cant adduct thumb (ulnar nerve)
Flexes thumb IP joint instead (median nerve)
Wartenberg sign






Ulnar abduction of 5
th
digit due to due to intrinsic
weakness and unopposed abduction by extensor
digiti minimi (because of its slightly ulnar insertion)

Interosseous wasting


Treatment
Avoid positioning that combines elbow flexion with pressure over the
ulnar nerve
Physiotherapy
Static night splinting in extension
Rigid splints often ineffective due to discomfort and noncompliance
Compression of Guyons Canal
Guyon's canal syndrome is an entrapment of
the ulnar nerve as it passes through a tunnel
in the wrist called Guyon's canal.
Anatomy
Guyons canal course
is approximately 4 cm long
begins at the proximal extent of the transverse
carpal ligament and ends at the aponeurotic arch
of the hypothenar muscles
contents
ulnar nerve bifurcates into the superficial
sensory and deep motor branches

Boundaries of Guyon's canal
Floor Transverse carpal ligament, hypothenar muscles
Roof Volar carpal ligament
Ulnar border Pisiform and pisohamate ligament, abductor digiti
minimi muscle belly

Radial border Hook of hamate


Compression of Guyons Canal
Zones of Guyon's canal
Location Common Causes of Compression Symptoms
Zone 1
Proximal to
bifurcation of the
nerve
Ganglia and hook of hamate fractures
Mixed motor and
sensory
Zone 2 Surrounds deep
motor branch
Ganglia and hook of hamate fractures Motor only
Zone 3 Surrounds
superficial
sensory branch
Ulnar artery thrombosis or aneurysm Sensory only

Treatment
Nonoperative
activity modification, NSAIDS and splinting
indications
as a first line of treatment when symptoms are mild
Operative
local decompression
indications
severe symptoms that have failed nonoperative treatment
tendon transfers
indications
correction of clawed fingers
loss of power pinch
Wartenberg sign (abduction of small finger)
carpal tunnel release
indications
patients diagnosed with both ulnar tunnel syndrome and CTS

Radial Nerve
SRN compression
PIN Syndrome
Radial Tunnel Syndrome

Posterior Interosseous Nerve
Syndrome
A compressive neuropathy of the PIN which affects the nerve supply of the
forearm extensor compartment
Muscles innervated by PIN are affected:
ECRB, Supinator, ECU, EDC, EDQ, EIP, APL, EPL, EPB
May occur after trauma or may have insidious onset



Symptoms insidious onset, often goes
undiagnosed
defining symptoms
pain in the forearm and wrist
location depends on site of PIN compression
e.g., pain just distal to the lateral epicondyle of the elbow may
be caused by compression at the arcade of Frohse
weakness with finger, wrist and thumb
movements
Present with dropped fingers and thumb


Physical exam

inspection
chronic compression may cause forearm extensor
compartment muscle atrophy
motion
weakness
finger metacarpal extension weakness
wrist extension weakness
inability to extend wrist in neutral or ulnar deviation
the wrist will extend with radial deviation due to intact ECRL
(radial n.) and absent ECU (PIN).
provocative tests
resisted supination
will increase pain symptoms

Nonoperativerest, activity modification, streching,
splinting, NSAIDS
indications
recommended as first-line treatment for all cases
lidocaine/corticosteroid injection
indications
a compressive mass, such as lipoma or ganglion, has been ruled out
isolated tenderness distal to lateral epicondyle
trial of rest, activity modification, anti-inflammatories were not
effective
technique
single injection 3-4 cm distal to lateral epicondyle at site of
compression
surgical decompression
indications
symptoms persist for greater than three months of nonoperative
treatment
Radial Tunnel Syndrome
A compressive neuropathy of the posterior interosseous
nerve (PIN) with pain only
no motor or sensory dysfunction
Associated conditions
lateral epicondylitis
RTS is difficult to distinguish from lateral epicondylitis
and coexists in 5% of patients

Radial tunnel begins anterior to the radiocapitellar joint
Approximately 5cm in length
Formed laterally by the ECRL and BR
Medially by the biceps tendon and brachialis
Posteriorly by the radiocapitellar joint capsule
The BR passes over the nerve in a lateral to anterior
direction to form the roof
Ends at the arcade of Frohse
Presentation
Symptoms
deep aching pain in dorsoradial proximal forearm
from lateral elbow to wrist
increases during forearm rotation and lifting activities
muscle weakness
because of pain and not muscle denervation
Physical exam
tenderness
over mobile wad over the supinator arch
maximal tenderness is 3-5cm distal to lateral epicondyle
more distal than lateral epicondylitis
provocative tests
resisted long finger extension test
reproduces pain at radial tunnel
resisted supination test (with elbow and wrist in extension)
reproduces pain at radial tunnel

passive pronation with wrist flexion
reproduces pain at radial tunnel
passive stretch of supinator muscle increases pressure inside radial tunnel
Treatment
Nonsurgical management of both PIN syndrome and RTS is recommended initially
Rest, activity modification, splinting, stretching, anti-inflammatories
Physiotherapy
Surgical decompression after trial of
non-operative management



Superficial Radial Nerve Compression
aka Wartenbergs Syndrome
compressive neuropathy of thesuperficial sensory radial nerve(SRN)
also called "cheiralgia paresthetica"
sensory manifestation only
no motor deficits


Symptoms are reproduced by forearm pronation and ulnar wrist deviation
Tinel sign over the radial sensory nerve at the point where it exits the deep fascia
in the forearm
Nerve conduction studies rarely useful




Treatment
Modify activities to maintain a more supinated position wherever possible
Avoidance of excessive pronosupination
Local corticosteroid injection at the entrapment site between tendons of BR and
ECRB are often successful.
Splinting not usually recommended
SRN decompression if non-operative treatment unsuccessful