Clinical exam of peripheral nerves

Stefanie Hirsiger, Dominique Merky, Department of Plastic and Hand Surgery Inselspital Bern Instructional Course SGH 17.09.2020 Overview

1. Inspection

2. Sensibility • Light touch / Vibration / 2PD / Monofilament • Allodynographie vs. sensitive Mapping

3. Funktion • Force of signature muscles • Functional tests

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 2 Peripheral nerves - Sensory Innervation Forearm

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 3 Muskulocutaneous nerve e.g. Piercing of conjoined tendon

1. Sensibility • Hyposensibility lateral forearm

2. Funktion • Elbow flexion paresis • Paresis of supination in flexed elbow

Klepps, Steven J., et al. "Anatomic evaluation of the subcoracoid pectoralis major transfer in human cadavers." Journal of Shoulder and Elbow Surgery 10.5 (2001): Eintritt: 6.1 cm (range, 3.5-10cm; 95% CI, 3.1-9.1 cm) 453-459.

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 4 Radial nerve - proximal compression Lateral intermuscular septum

1. Sensibility • Hyposensibility in first commissure +/- posterior and lateral arm, posterior forearm

2. Funktion • +/- Triceps paresis • Classic wrist drop and extension deficit of thumb and fingers

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 5 Radial nerve - distal compression e.g. Midshaft Fractures 1. Sensibility • NO hyposensibility in first commissure

2. Funktion • NO Triceps paresis • NO Classic wrist drop • extension deficit of thumb and fingers

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 6 Radial nerve - proximal PIN compression Supinator Syndrome 1. Sensibility • NO hyposensibility in first commissure

2. Funktion • NO Triceps paresis • NO Classic wrist drop • ECRL works, ECRB NOT!!! • extension deficit of thumb and fingers

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 7 Radial nerve - Pearls • PIN-Palsy: test wrist extension by palpating the bump of ECRL to define location of lesion

• Test Supination in Extension of the Elbow, as Biceps is strongest Supinator in Flexion!

• Test Tinel in de Quervain (DD Wartenberg Syndrome)

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 8 Median nerve - proximal compression Struthers lig., Biceps aponeurosis 1. Sensibility • Hyposensibility first three fingers and Hypothenar

2. Funktion • Partial flexion deficit of wrist and fingers and pronation (no activation of FCR, Pronator, all FDS, FDP II- III, FPL, long palmar, thenar muscles), "swear hand" • Hypotrophy in Forearm and Thenar

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 9 Median nerve - forearm compression Pronator syndrome

95% 2% 3%

Insel Gruppe – 10 Median nerve - forearm compression Pronator Syndrome

1. Sensibility • Hyposensibility first three fingers and Hypothenar

2. Funktion • wrist flexion and pronation works fine • Bottle sign positive (Palsy APB and Opponens muscle)

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 11 Peripheral nerves - Sensory Innervation Hand

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 12 Median nerve – sites of nerve compression

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 13 Median nerve - AIN compression FDS-Septum 1. Sensibility • NO Hyposensibility

2. Funktion • loss of function of FDP II, Pronator quadratus and FPL • No thenar atrophy! • O-sign positive

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 14 Median nerve - AIN compression

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 15 Median nerve - distal compression Carpal Tunnel Syndrome 1. Sensibility • Hyposensibility first three fingers, NOT Hypothenar

2. Funktion • Thenar atrophy • opposition impossible • no "swear hand"

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 16 Median nerve - distal compression Carpal Tunnel Syndrome Clinical Tests • Tinel over Carpal tunnel

• Phalen and reversed Phalen

• Durkan • Combined Durkan/Phalen

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 17 Carpal Tunnel Syndrome, Ramus Thenaris

46% 31% 23%

Insel Gruppe – 18 Ulnar nerve - proximal compression Sulcus ulnaris 1. Sensibility • Hyposensibility ulnar distal forearm and ulnar 2.5 fingers palmar and dorsally

2. Funktion • no function of FCU, FDP IV-V, lumbricals IV and V, all interossei, Hypothenar

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 19 Ulnar nerve - distal compression Loge de Guyon 1. Sensibility • Dorsal branch intact --> only fingers

2. Funktion • FCU, FDP IV-V works fine! • no function of lumbricals IV and V, all, all interossei, Hypothenar

"closer to the paw, worse the claw"

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 20 Ulnar nerve - Clinical Tests • Tinel over Compression/Lesion site • For Sulcus ulnaris: Elbow flexion as provocative maneuver

• Froment sign • compensatory FPL activationto compensate first interosseous

• Wartenberg-Sign • impossible adduction of

Insel Gruppe – Clinicallittle exam of peripheralfingernerves 14.09.2020 21 Ulnar nerve - Clinical signs

• Atrophie • Wartenberg-Sign • impossible adduction of little finger

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 22 Ulnar nerve - Clinical Tests

• Pitres-Test • loss of interossei

• Ulnar claw hand • no lumbrical function • worse if FDP not deinnervated • "the closer to the paw, the worse the claw"

Insel Gruppe – Clinical exam of peripheral nerves 14.09.2020 23