Compression Neuropathies of the Upper Extremity

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Compression Neuropathiesof the Upper
Extremity
Carla M. Saulsbery LOTR, CHT
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• Risk Factors
• Age and gender
• Intercurrent disease
• Genetics
• Dupuytrens diathesis
• Osteoporosis
• Pathogenesis specific to nerve
• Initially nerve compression leads to blood/nerve
  barrier changes
• Neural connective tissue changes occur
• Continued pressure leads to localized nerve fiber
  changes. Segmental demyelination
• Fiber changes occur with Wallerian degeneration
• Compression at one point decreases the threshold
  for compression at other points along the same
  nerve.
• Grading of compression severity Grade
  1-------- 2-----------3 ( muscle atrophy)

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• Occupational Therapy for compression neuropathies
• Management is based on symptom onset, chronicity,
  degree of muscle weakness and sensory
  abnormalities.
• OT performs a baseline sensory and motor
  examination, assess both grip and pinch strengths
  and reassess at least one time monthly
• Patient education
• Conservative treatment based on evaluation
  findings
• Post-operative treatment
• Splinting as indicated based on surgical
  procedure
• Wound and scar management
• Splint per nerve deficit
• Desensitization for dysesthesias
• Motor and sensory reeducation
• AROM
• Strengthening

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• EVALUATION
• History
• Onset, activities that increase symptoms
• Subjective
• Objective
• ROM
• MMS
• NT/DT paresthesias
• Tinels and other provocative testing
• Grip and pinch testing
• Sensation
• Moberg
• ADLs

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• Semmes Weinstein Monofilaments
• A sensory threshold test
• Can be used on any part of the body
• Used to correlate nerve damage with a patients
  ADL function
• Maps the extent and degree of the sensory loss
• Reliable and reproducible
• Screening kit consists of 5 monofilaments
• Testing begins with 2.83
• Monofilaments 2.83 and 3.61 --- one response out
  of 3

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• Semmes Weinstein Interpretation
• 2.83 Green Normal Sensation
• 3.61 Blue Diminished light touch,
  diminished texture discrimination
• Earliest sign of nerve
  involvement.
• 4.31 Purple Diminished protective
  sensation. Absent texture, impaired stereognosis
• and impaired sensation.
• Patient c/o of dropping
  things and decreased ability to perform fine
  motor
• ADLs.
• 4.56 Red Loss of protective sensation.
  Absent protective sensation/stereognosis
• Patient cannot
  manipulated objects outside line of vision
• Increased risk of injury
  secondary to slowed response to hot and sharp
• objects.
• Present deep pressure
  sensation
• 6.65 (Orange) Deep pressure sensation,
  rudimentary deep cutaneous peripheral nerve
• response.
• Pt. can recognize a pin
  prick

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Test is performed for two trials Eyes open norms
10-19 sec on the first trail 10-16 on second
trial Eyes closed 2 seconds per object
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• Compression Neuropathies
• Median Nerve
• Carpal Tunnel
• Pronator Syndrome
• Anterior Interosseous Nerve Syndrome
• Ulnar Nerve
• Cubital Tunnel
• Guyons Canal
• Radial Nerve
• Radial Tunnel
• Posterior Interosseous Nerve Syndrome
• Superficial Radial Nerve

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• Median Nerve
• Formed by equal contributions of the medial
  (C5-C7) and lateral (C8-T1) cords of the brachial
  plexus.
• The nerve has an intimate relationship to the
  brachial artery as it passes down the arm to the
  elbow
• The Martin Gruber anastomosis is of interest in
  high median nerve neuropathies.
• This communication between median and ulnar
  nerves occurs in approx. 17 of the population
• Chronic pain from the proximal median nerve is
  predominantly caused by trauma.
• Non-traumatic compression is predominantly caused
  by slowly expanding lesions often vascular in
  nature.
• There are four commonly described sites of
  compression of the median nerve in the elbow and
  proximal forearm region. (Ligament of Struthers,
  Lacertus Fibrosis, pronator teres muscle and the
  arch of the FDS).
• Supracondylar fractures have been associated with
  a 5 to 19 incidence of median nerve injury

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• Carpal Tunnel
• Compression under the transverse carpal ligament
• Risk factors
• Demographics female, middle aged, smoker,
  obesity
• Genetics thickened transverse carpal ligament.
  Diabetes, thyroid disorder.
• Medical conditions wrist fracture, dislocation
  of carpal bone, space occupying lesions,
  Rheumatoid arthritis, renal dialysis
• Patient complaints
• Awakening at night
• Numbness, tingling
• Weakness of grip or pinch
• Dropping things, inability to perform certain
  ADLs
• Reports of numbness when driving or reading
• Decreased ability to distinguish between hot and
  cold

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• Grading nerve compression for Carpal Tunnel
• Grade 1 Mild
• Awakening at night. Usually intermittent
• Tingling and numbness
• Positive Phalens
• Symptoms increase with activity
• No muscle atrophy
• Middle finger most commonly involved
• Grade II Moderate
• Positive provocative tests. Tinels and Phalens
• Weakness of the thenar muscles, but not atrophy
• Decreased sweat
• Semmes Weinstein test will be abnormal
• Decreased grip and pinch strength
• Grade III Severe
• Thenar atrophy

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• Ultrasound

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• Normal Median Nerve
  Carpal Tunnel

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• Conservative Treatment of Carpal Tunnel
• Patient education
• Splint for night wear
• Tendon/nerve glide exercises
• Home and or job modifications
• Hand strengthening

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• Post-operative care
• Range of motion
• Avoid wrist flexion
• Wound care
• Massage for scar and skin hydration
• Lightweight ADLs
• Desensitization for dysesthesias
• Progress to nerve glide
• Sensory re-education
• Caution patient against over exercising
• No heavy lifting, pushing or pulling for one
  month

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• Post op care
• Patient is followed monthly for re-evaluation
• Watch for symptomatic neuroma
• Program for dysesthesias
• Hand strengthening can begin at 3-4 weeks post
  op.
• Patients with sedentary jobs requiring lt10 lift
  may return to work by week 8
• Grip strength slowly increase over a two to three
  month period
• Patient needs to be seen by both Ortho and OT at
  2 months post op
• Patients with grade III CTS may require more than
  2 months to regain sensation and hand strength
  and may develop dysesthesias which can require
  several months of desensitization/sensory
  reeducation to resolve.

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• Median Nerve Pronator syndrome
• Compression of the most proximal site of the
  median nerve just inferior to the antecubital
  fossa. Compression can occur as the nerve passes
  between the two heads of the Pronator teres
  muscle. The term pronator syndrome can also
  include median nerve compression by other
  structures ligament of Struthers or the
  lacertus fibrosus).
• Commonly mistaken for carpal tunnel syndrome
• First described in 1951
• Signs and Symptoms
• 1. Aching pain in proximal volar forearm.
  Associated with repetitive motions that cause
  hypertonicity in the pronator teres.
  Occupational activities hammering, cleaning
  fish, continual manipulation of tools.
• Numbness/paresthesia in the median nerve
  distribution. Nocturnal complaints uncommon
• Tenderness over Pronator teres muscle
• Symptoms exacerbated with activity and diminished
  with rest
• Easy fatigability
• Tinels over proximal forearm but takes 4-5
  months to develop.
• Pain on resistance to pronation and resistance to
  flexion of the FDS to 3 and 4
• Advance cases will display weakness in all median
  nerve innervated musculature distal to the
  Ligament of Struthers.
• Women are affected more than men (4 times) and
  presents in the fifth decade of life.
• Symptoms insidious in onset with a delay in
  diagnosis ranging from 9 months to 2 years.

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• Provocative testing is extremely useful
• Pronator teres test
• Patent is standing with the elbow in 90 of
  flexion. Patient holds position while examiner
  attempt to supinate the forearm. (forces
  isometric contraction of the pronator muscle).
  While holding the resistance against pronation ,
  the examiner
• slowly extends the elbow. If motion
  reproduces the pain the median nerve is probably
  compressed by the pronator teres.
• Test for compression by arch of FDS
• www.simmonsortho.com

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• Splint for Pronator Tunnel
• Posterior elbow long arm splint. Elbow at 90
  flexion, forearm in pronation with wrist at
  neutral.
• Splint 4-6 weeks followed by night wear for same
  amount of time
• NSAIDS
• Cryotherapy
• Elbow and wrist AROM
• Tendon and nerve gliding
• Ergonomic assessment and recommendations
• Strengthening of affected muscles
• Avoidance of aggravating activities
• Conservative treatment is 8 to 12 weeks.
• Postoperative Therapy
• Day 3-5 bulky dressing. Allow full AROM to
  digits. Elbow and wrist AROM limited by patient
  complaints. Gradually increase range of motion
  and activity.
• OR Elbow splinted at 90 for 5-10 days,
  then AROM as tolerated.
• Scar management
• Strengthening of all affected muscles
• Nerve and tendon gliding
• Ergonomic assessment and recommendations.

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• Median Nerve Anterior Interosseous Syndrome
  (Kiloh-Nevin Syndrome)
• Compression of the anterior interosseous branch
  of the median nerve usually by deep head of the
  Pronator teres.
• The AIN nerve is purely motor. Can be resultant
  of an injury to the forearm, by direct trauma,
  compression or inflammation of the AIN.
• AIN accounts for fewer than 1 of all upper
  extremity neuropathies
• Earliest description was in 1952.
• Rule out Pseudo-Anterior Interosseous Neuropathy
• Signs and Symptoms
• 1. Vague pain in the proximal forearm and wrist
  that increases with activity especially
• repetitive forearm motion and is relieved
  with rest.
• 2. No sensory disturbances
• 3. Weakness or paralysis of the FPL, FDP of the
  index finger and less commonly the
• long finger and the pronator quadratus.
• 4. Unusual pinch demonstrated by the hyper
  extended IP joint of the thumb and index finger
• (Q sign) ( late sign)
• 5. Patient reports problems with writing or
  picking up small objects.

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Inability to make the OK sign. Weak pinch of
AIN syndrome. www.simmonsortho.com
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Anterior
Interosseous Nerve SyndromeAnterior
Interosseous Neuropathy
Pseudo-Anterior Interosseous
Lesion of the AIN
Lesion of fibers
that ultimately

constitute the
AINWeakness of FPL,PQ,FDP to Index
Weakness of
FPL,PQ,FDP to IndexNormal sensibility

/- weakness of shoulder girdleNormal
shoulder girdle
/- weakness of
thenar muscles

/- Abnormal sensibility
(Median)
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• Splint for Anterior Interosseous Syndrome
• Posterior long arm splint with elbow at 90 of
  flexion, forearm pronated and the wrist in
  neutral for 3 to 4 weeks Thumb in opposition
  splint for function.
• NSAIDs
• Cryotherapy
• Avoidance of aggravating factors
• AROM of the elbow and wrist
• Tendon and nerve gliding
• Ergonomic assessment and recommendations
• Strengthening of affected muscles
• Conservative treatment for 8 to 12 weeks
• Postoperative therapy
• Bulky dressing supporting the elbow and wrist,
  AROM of wrist and digits for 5 to 7 days.
• Strengthening at 7 to 10 days post op unless
  pronator was elevated.
• If pronator was elevated, splint elbow at 45-90,
  wrist 45 and full pronation for 2-3 weeks
• Digit ROM immediately, AROM of the elbow and
  wrist at week 3 and strengthening at 3 to 4 weeks
• Scar Management

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• Ulnar Nerve Cubital tunnel syndrome
• Compression or trauma of the ulnar nerve at the
  level of the medial aspect of the elbow.
• Second most common compression neuropathy.
• Causative factors include recurrent subluxation,
  dislocations, RA, excessive elbow valgus, bony
  spurs, synovial cysts or external compression or
  trauma.
• Ulnar nerve supplies the ulnar intrinsics, FDP to
  4 and 5 and the FCU. Sensation in the 5th digits
  and ulnar ½ of the ring
• Cubital tunnel is a bony canal formed by the
  ulnar collateral ligament, the trochlea, and the
  medial epicondylar groove and is roofed by the
  triangular arcuate ligament.
• Signs and Symptoms
• Pain at medial elbow
• Sensory disturbance (numbness, paresthesia,
  dysesthesia) over the hypothenar eminence,
  dorsoulnar hand, 5th digit and ulnar 4th digit.
• Weak intrinsics. Decreased or inability to cross
  fingers or spread fingers apart
• Tinels at Cubital tunnel
• Elbow flexion test (Wadsworth flexion test).
  Elbow flexed, FA supinated with wrist extended.
  at 60 seconds.
• Froments sign is advanced stages
• Weak grip and lateral pinch
• Wartenbergs sign in advanced cases. Paralysis of
  the 3rd palmar interossei. ( no adduction of
  small finger)
• Claw hand deformity as FDP reinnervates

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• Non-operative Treatment and Splint
• Heelbo pads for day time wear to protect medial
  elbow/ulnar nerve.
• Limit elbow range of motion using either a
  neoprene elbow splint for day or fabricating a
  long arm splint with elbow flexed 30 to 45
  anterior based and flared to avoid external
  compression on the ulnar nerve for night wear.
• Can use a rolled towel around the elbow to
  decrease flexion at night during sleep if splint
  not fabricated
• Postural and positional education is stressed to
  avoid external nerve compression. Resting elbows
  on hard surfaces, leaning on elbows, prolonged
  elbow flexion, repetitive flexion/extension at
  elbow
• Patient education in insensate precautions
• Ulnar nerve glide
• Ice

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Dynamic Splinting for Ulnar nerve
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• Ulnar Nerve Surgery
• Decompression and medial epicondylectomy
• Subcutaneous transposition
• Submuscular transposition

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• Postoperative therapy Cubital Tunnel
• Ulnar nerve decompression/ medial epicondylectomy
• Begin gentle AROM immediately, no heavy lifting
  for 6 weeks. Patient can
• use upper extremity for daily activities.
• Sensory assessment
• Wound care and edema control
• Week 2 begin PROM
• Exercises to promote gliding of the ulnar nerve
  to prevent scarring of the
• nerve to the surgical bed.
• Week 4 resisted ROM. Stretching exercises.
• Normal activity resumption in 1-2 months
• As ROM progresses, initiate gentle
  strengthening exercises
• Desensitization and motor exam.
• Splint as indicated for ulnar nerve deficit

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• Cubital Tunnel cont.
• Subcutaneous transposition
• Week 1 Splint in 45 elbow flexion for up to 2
  weeks.
• Gentle AROM is started at all joints.
  Progress to resistive exercises at 4 weeks.
• Sensory assessment
• Wound care and edema control
• Week 2 Discontinue splint, progress AROM
• Week 3 PROM
• Week 4 Progress resisted ROM
• Desensitization, sensory re-education
• Splint as indicated for ulnar nerve
  deficit
• Submuscular transposition
• Week 1 Splint in long arm splint with elbow
  flexed 45, with slight forearm pronation
• and wrist in neutral for up to 3 weeks
  to protect the flexor pronator origin.
• Sensory assessment

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• Ulnar Nerve Guyons canal
• Compression of ulnar nerve as it passes through
  Guyons canal at the wrist. Guyons is a bony
  canal formed by the volar carpal ligament, hook
  of the hamate and the hamate. Motor and sensory
  deficits are present distal to the canal as both
  sensory and motor runs through the canal. There
  will be volar sensory but no dorsal sensory
  deficit. Compression of the ulnar nerve at this
  site is usually associated with trauma, abnormal
  structures (ganglion cyst or lipoma) fracture of
  the hamate, ring or small fingers metacarpal
  bones or anomalous muscles. It has also been
  called handlebar palsy.
• Signs and Symptoms
• Numbness/tingling along the volar aspect of the
  small finger and ulnar ½ of the ring (no dorsal
  numbness)
• Weakness or paralysis of the hand intrinsics
  innervated by the ulnar nerve
• Possible Tinels at Guyons canal
• Possible claw deformity
• Treatment for Guyons
• Protective splint or gel pad if from external
  compressive forces
• Managed post surgically with splinting, muscle
  strengthening and sensory re-education

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• Radial Nerve Radial Tunnel Syndrome
• Compression of the radial nerve by anatomical
  structures inferior to the lateral epicondyle
  (Tendinous origin of ECRB)
• Signs and Symptoms
• Dull, achy pain over the extensor aspect of the
  forearm, can radiate into the distal forearm and
  the hand.
• Symptom onset after significant repetitive or
  power grip use
• Pain absent upon awakening but progressively
  increases with activity, leaving a dull
  persistent ache. Night pain is common
• Tenderness over the radial head/radial tunnel
  area
• Positive radial tunnel compression test involves
  the examiner rolling the fingers over the radial
  nerve region in the proximal forearm eliciting
  pain and tenderness.
• Pain reproduced with resisted extension of the
  fingers with the elbow extended- pain most severe
  with stressing the middle finger. (Middle finger
  test which tenses the ECRB over the nerve)
• Pain with resisted forearm supination with the
  elbow extended (Yergasons test)
• With advanced stages- weakness of the wrist,
  finger and thumb extensors. Decreased grip
  strength
• May have paresthesias, numbness in the 1st dorsal
  web space, dorsal thumb and index finger
• Radial tunnel syndrome may be distinguished from
  lateral epicondylitis by exam. Maximum
  tenderness is over the neck of the radius and
  must be compared to the other arm.

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• Non-operative treatment for Radial tunnel
• Week 0-3
• Wrist splint in 30-45º extension. Splint worn
  continuously.
• Patient education in avoidance of tasks requiring
  Pronation/supination
• Use appropriate balanced tools in the work
  environment and avoid high-force tasks with
  torque or with heavy pronation and supination
• Week 3
• Radial nerve glides
• Tendon gliding
• Basic 4 hand postures
• Overhead fisting
• Modalities as indicated
• Patient education on risk factors
• Patient education on activity modification of
  ADLs and job tasks. (lift with palms up versus
  palms down)
• Progressive strengthening with putty and
  theraband once symptoms have resolved

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• Radial Tunnel Operative
• Week 1 Bulky dressing is removed
• Gentle active and passive
  ROM to wrist, FA and elbow
• Patient education on wound
  care
• Week 3-4 Motor and sensory re-education
• Scar massage
• AROM to wrist, forearm and
  hand.
• Begin neural glide
  exercises
• Patient is to use extremity
  in basic self-care ADL activities and IADL tasks
• such as cooking and meal
  preparation.
• Weeks 6-8 Progressive strengthening within
  patients comfort level using putty and
• theraband, free weights

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• Posterior Interosseous Syndrome
• Compression or injury of the PIN branch of the
  radial nerve. Secondary to trauma. (dislocation
  of the elbow or fracture/dislocation of the
  radial head). Inflammation, postural/occupational
  or iatrogenic (injection causes.)
• Signs and Symptoms
• Pain deep forearm, lateral elbow
• Weakness /paralysis. Motor loss may be gradual
  or dramatic. Wrist extension is intact but loss
  of finger and thumb extension.
• No sensory deficit.
• History of repeated or strenuous effort involving
  supination and pronation. Men two times more
  than women with dominant arm 2 times more than
  non-dominant.

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• Posterior Interosseous Nerve Splint
• Long arm posterior splint with elbow flexed to
  90º. Wrist in neutral, forearm in neutral.
  Buddy tape the fingers.
• Paralysis of wrist and finger extensors support
  wrist in splint with dynamic extension outriggers
  for the digits.
• Paralysis of finger extensors but active wrist-
  tenodesis splint.
• Post operative Splinting
• Long arm posterior splint with the elbow flexed
  to 90º, wrist and forearm in neutral. Buddy tape
  the fingers.
• Dynamic splinting

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• Radial Sensory nerve entrapment or Wartenbergs
  disease
• Compression of the sensory branch of the radial
  nerve as it emerges from beneath the edge of the
  brachioradialis muscle. History of trauma often
  repetitive in nature involving supination/pronatio
  n.
• Most distal compression can be from external
  causes. Tight wristbands, scar bands, tight cast
  or a direct blow, or from chronic inflammation
  from first dorsal compartment tendonitis.
• Signs and Symptoms
• Radial wrist and dorsal hand pain of thumb,
  index, first web. Described as burning,
  numbness, hyperesthesia or tingling.
• Test by clenched fist and ulnar-palmar flexion
  with forearm hyperpronation.
• Dysesthesia of the dorsal hand, thumb, index and
  long fingers
• Tinels along the radial styloid to the edge of
  the brachioradialis
• Finkelsteins test may be misleadingly positive.
  Thumb does not have to be flexed to elicit an
  positive test.
• Splint
• Wrist splint with max. extension, radial
  deviation
• NSADIS
• Restricted activities

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• FINI
• Any questions??