Median Nerve Palsy

Innervation (motor)
• Superficial volar forearm group
• Pronator Teres
• Flexor carpi radialis
• Palmaris longus
• Intermediate group
• Flexor digitorum superficialis
• Deep group
• Flexor digitorum profundus (lateral)
• Flexor pollicis longus
• Pronator quadratus
• Hand
• 1st and 2nd lumbricals
• Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis
Origin
• OTA classification of radius/ulna
Course
• Anterior compartment of arm
• Anterior compartment (anteromedial to humerus)
• Runs with brachial artery (lateral in upperarm, medial at elbow)
• No branches in the arm
• Forearm
• Enters the forearm between the pronator teres and biceps
tendon
• Travels between FDS and FDP
• Emerges between the FDS and FPL
• Hand
• Enters the hand via the carpal tunnel, along with FDS, FDP, and
FPL tendon
Course
• Anterior compartment of arm
• Anterior compartment (anteromedial to humerus)
• Runs with brachial artery (lateral in upperarm, medial at elbow)
• No branches in the arm
• Forearm
• Enters the forearm between the pronator teres and biceps
tendon
• Travels between FDS and FDP
• Emerges between the FDS and FPL
• Hand
• Enters the hand via the carpal tunnel, along with FDS, FDP, and
FPL tendon
Course
Terminal Branches
• Anterior interosseous branch (AIN)
• Innervates the deep volar compartment of forearm
except the ulnar half of FDP
• Palmar Cutaneous Branch
• Supplies sensory innervation to lateral palm
• Recurrent branch (to the thenar compartment)
• Digital cutaneous branches
• Supply the radial 3 ½ digits (palmar)
• Can also supply the Index, long, and ring fingers dorsally
Clinical Conditions
• Carpal Tunnel Syndrome
• AIN Neuropathy
• Pronator Syndrome
Carpal Tunner Syndrome (CTS)
• Most common compressive neuropathy
• Pathologic (inflamed) synovium most common cause of idiopathic CTS

• Epidemiology
• Affects 0,1-10% of general populati
• Risk factors
• Female sex
• Obesity
• Pregnancy
• Hypothyroidism
• Rheumatoid arthritis
• Advanced age
• Chronic renal failure
• Smoking
• Alcoholism
• Repetitive motion activities
• Mucopolysaccharidosis
• mucolipidosis
Pathophysiology
• Precipitated by
• Exposure to repetitive motions and vibrations
• Certain athletic activities
• Cycling
• Tennis
• throwing
• Pathoanatomy, compression may be due to :
• Repetitive motions in a patient with normal anatomy
• Space occupying lesions
• Associated conditions
• Diabetes Mellitus
• Hypothyroidism
• Rheumatoid arthritis
• Pregnancy
• Amyloidosis
Prognosis
• Good prognostic indicators:
• Night symptoms
• Short incisions
• Relief of symptoms with steroid injection
• Not improved when incomplete release of transverse
carpal ligament is discovered
Anatomy
• Carpal tunnel define by
• Scaphoid tubercle and trapezium radially
• Hook of hamate and pisiform ulnarly
• Transverse carpal ligament palmarly (roof)
• Proximal carpal row dorsally (floor)
• Carpall tunner consist of
• Nine flexor tendons
• One nerve (median nerve)
• FPL is the most radial structure
• Carpal tunnel is narrowest at the level of the hook
of the hamate
Anatomy
• Branches of median nerve
• Palmar cutaneous branch
lies between PL and FCR at level of the wrist flexion
crease
• Recurrent motor branch
• 50% are extraligamentous with recurrent innervation
• 30% are subligamentous with recurrent innervation
• 20% are transligamentous with recurrent innervation
Cut transverse ligament far ulnar to avoid cutting if nerve is
transligamentous
Symptoms
• Numbness and tingling in radial 3 ½ digits
• Clumsiness
• Pain and paresthesias that awaken patient at night
• Self administered hand diagram
The most specific test (76%) for CTS
Physical Exam

• Inspection : Thenar atrophy

• Carpal tunnel compression test (Durkan’s test)
• The most sensitive test
• Pressing the thumb over the carpal tunnel and holding pressure for 30 seconds
• Onset of pain or paresthesia in the median nerve distribution within 30 seconds is postive
result
• Phalen test
• Wrist volar flexion for 60 sec produces symptoms
• Tinel’s test
• Provocative test performed by tapping the median nerve over the volar carpal
tunnel
• Semmes-Weinstein testing
• Most sensitive sensory test for detecting early CTS
• Innervation density test
Diagnostic Criteria
• Numbness and tingling in the median nerve
distribution
• Nocturnal nummbness
• Weakness and/or atrophy of the thenar
musculature
• Positive Tinel sign
• Positive Phalen test
• Loss of two-point discrimination
EMG ad NCV
• Often the only objective evidence of a compressive neuropathy (valuable in
work comp patients with secondary gain issues)
• Not needed to establish diagnosis (diagnosis is clinical)
• Demyelination leads to
• NCV
• Increase latencies (slowing) of NCV
Distal sensory latency of > 3,5 ms
Motor latencies > 4,5 ms
• Decreased conduction velocities less specific than latencies
Velocity of < 52 m/sec is abnormal
• EMG
• Test the electrical activity of individual muscle fibers and motor units
• Detail insertional and spontaneous activity
• Potential pathologic findings
• Increased insertional activity
• Sharp waves
• Fasciculations
• Complex repetitive discharges
EMG ad NCV
• Electrodiagnostic Study (EDS) results are associated with
outcomes after carpal tunnel surgery
• Patients with severe findings on EDS or minimal to no
findings tend to improve less than patients with middle-
range finsings.
Histology
Nerve histology characterized by
• Edema, fibrosis, and vascular sclerosis are most
common findings
• Scattered lymphocytes
• Amyloid deposits shown with special stains in some
cases
Treatment
Nonoperative
• NSAID, night splints, activity modifications
• Indication : first line of treatment
• Modalities
• Night splints (good for patients with nocturnal symptoms only)
• Activity modification (avoid aggravating activity)
• Steroid Injection
• Indication
• Adjunctive conservative treatment
• Diagnostic utility in clinically and electromyographically equivocal cases
• Outcomes
• 80% have transient improvement of symptoms (of these 22% remain
symptoms free at one year)
• Failure to improve after injection is poor prognostic factor. Surgery is less
effective in these patients
Treatment
Operative
• Carpal Tunnel Release
• Indication :
• Failure of nonoperative treatment (including steroid injections)
• Acute CTS following ORIF of a distal radius fracture
• Outcomes
• Pinch strength return in 6 weeks
• Grip strength is expected to return to 100% preoperative levels by 12 weeks
postop
• Rate of continued symptoms at 1+ years is 2% in moderate and 20% in severe CTS
• Revision CTR for Incomplete Release
• Indication : Failure to improve following primary surgery
• Outcomes
• Only 25% will have complete relief after revision CTR
• 50% some relief
• 25% will have no relief
Technique
• Open Carpal Tunnel Release
• Antibiotics :
• Prophylactic antibiotics, systemic or local, are not indicated for patients
undergoing a clean, elective carpal tunnel release
• Technique
• Internal neurolysis, tenosynovectomy, and antebrachial fascia release do
not improve outcomes
• Guyon’s canal does not need to be released as it is decompressed by
carpal tunnel release
• Lengthened repair of transverse carpal ligament only required if flexor
tendon repair performed (allows wrist immobilization in flexion
postoperatively)
• Complications
• Correlate most closely with experience of surgeon
• Incomplete release
• Progressive thenar atrophy due to injury to an unrecognized
transligamentous motor branch of the median nerve 
Technique
• Endoscopic Carpal Tunnel Release
• Advantage is accelerated rehabilitation
• Long term results same as open CTR
• Most common complication is an incomplete division of
transverse carpal ligament
AIN Neuropathy
A compressive neuropathy of the AIN that result
in motor deficit only.

Pathoanatomy
• Potential sites of entrapment:
• Tendinous edge of deep head of pronator teres
(most common cause)
• FDS arcade
• Edge of lacertus fibrosus
• Accessory head of FPL (Gantzer’s Muscle)
• Accessory muscle from FDS to FDP
• Abberant muscles (FCRB, palmaris profundus)
• Thrombosed ulnar radial or ulnar artery
• Complete AIN palsy should have no motor function
to all muscles innervated by AIN
• Incompletes palsies or with Martin-Gruber
anastamoses (anomalous anatomy in 15% of
population where axons of AIN may cross over and
connect to ulnar nerve and innervate other muscle
groups) present with intrinsic weakness
Associated conditions
Parsonage-Turner Syndrome
• Bilateral AIN sign caused by viral brachial neuritis
• Motor loss preceded by intense shoulder pain and viral
prodrome
Anatomy
AIN is terminal motor branch of median nerve
• AIN arises from the median nerve approximately 4-6 cm distal
to the medial epicondyle
• Travels between FDS and FDP initially, then it lies on the anterior
surface of the interosseous membrane traveling with the
anterior interoseous artery to pronator quadratus
• Terminal branches innervate the joint capsule and the
intercarpal, radiocarpal and distal radioulnar joints

AIN innervate 3 muscles :

• FDP (index and middle finger)
• FPL
• Pronator quadratus
Symptoms
• Motor deficit only
• No complain of pain (unlike other median
compression neuropathies)
Physical Exam
• Weakness of grip and pinch, specifically thumb,
index, and middle finger flexion
• Patient unable to make OK sign (test FDP and FPL)
• Pronator quadratus weakness shown with weak
resisted pronation with elbow maximally flexed
• Distinguish from FPL attritional rupture (seen in
rheumatoids) by passively flexing and extending
wrist to confirm tenodesis effect in intact tendon
if tendons intact, passive wrist extension brings thumb IP joint and
index finger DIP joint into relatively flexed position
EMG NCV Studies
• Helpful to make diagnosis
• May reveal abnormalities in the FPL, FDP index and
middle finger and pronator quadratus muscles
• Assess severity of neuropathy
• May rule out more proximal lesions
Treatment
Nonoperative
Observation, rest, and splinting in 90o flexion
• Indication : vast majority of patients, unless clear space
occupying mass
• Technique : elbow splinting in 90o of flexion (8-12 weeks)

Operative
Surgical decompression of AIN
• Indication : If nonoperative treatment fails
 Techniques
Surgical Decompression of AIN
• Release of superficial arch of FDS and lacertus fibrosus
• Detachment of superficial head of pronator teres
• Ligation of any crossing vessels
• Removal of any space occupying lesion

Complications
Reccurance
Pronator Syndrome
A compressive neuropathy of the median
nerve at the level of the elbow

• Epidemiology
• More common in woman
• Common in 5th decade
• has been associated with well-developed
forearm muscles (e.g. weight lifters)

• Associated conditions : Medial

epicondylitis
Pathoanatomy
5 potential sites of entrapment
include
• Supracondyler process
• Residual osseous structure on
distal humerus present in 1% of
population
• Ligament of Struthers
• Travels from tip of supracondylar
process to medial epicondyle
• Not to be confused with arcade of
Struthers
• Bicipital aponeurosis (lacertus fibrosus)
• Between ulnar and humeral heads of pronator teres
• FDS aponeurotic arch
Symptoms
• Paresthesia in thumb, index, middle finger, and
radial half of ring finger as seen in CTS
• In pronator syndrome, paresthesia often made worse
with repetitive pronosupination
• Characteristics differentiating from CTS:
• Aching pain over proximal volar forearm
• Sensory disturbances over the distribution of palmar
cutaneous branch
• Lack of night symptoms
Physical Exam
Provocative test are spesific for different site
• Positive Tinel sign in the proximal anterior forearm but no
Tinel sign at wrist nor provocative symptoms with wrist
flexion as would be seen in CTS
• Resisted elbow flexion with forearm supination
(compression at bicipital aponeurosis)
• Resisted forearm pronation with elbow
extended (compression at two heads of pronator teres)
• Resisted contraction of FDS to middle finger (compression
at FDS fibrous arch)

Possible coexisting medial epicondylitis

Imaging
Xray Elbow are mandatory, it may see
supracondyler process.

EMG and NCV Studies

• May helpful if positive but are usually inconclusive
• May exclude other sites of nerve compression or
identify double-crush syndrome
Treatment
Nonoperative
Rest, splinting, and NSAID for 3-6 months
• Indication : Mild to moderate symptoms
• Technique : splint should avoid forearm rotation

Operative
Surgical decompression of median nerve
• Indication : Only when nonoperative management fails for
3-6 months
• Technique : Decompression of the median nerve at all 5
possible site of compression
• Outcomes : 80% patients have relief of symptoms