Upper Extremity Compression Neuropathies
John Dougherty, DO, FACOFP, FAOASM, FAODME Dean – Touro University Nevada AOASM Annual Mee ng – Las Vegas 2017 • Nerve L. nervus - sinew • Axon Gr. axon - axis • -praxia Gr. praxis – ac on • -tmesis – cu ng • Tunnel – Old English - covered passageway • Canal – L. canalis pipe • Groove - Norse grof "brook, river bed” • A 23 year old first year medical student is par cipa ng in OMM lab when she no ces she is having a hard me bending her arm at the elbow and has difficulty raising her arm at the shoulder. Her lab partner does an exam and finds no signs of impingement or RC weakness. She does no ce that she has some numbness over the deltoid. You suspect which of the following is impacted?
A. Spinal Accessory (CN XI) nerve B. Axillary nerve C. Long Thoracic nerve D. Suprascapular nerve E. Brachial Plexus Axillary - Altered Sensation Axillary – Causes of Lesion Axillary – Causes of Lesion • The suspected e ology of this diagnosis is due to which of the following?
A. Improper “Kirksville Crunch” technique B. Falling asleep in class with her arm draped over her the back of the chair C. Her extensive use talking on her cellphone D. Excessive use of the mouse on her computer E. Her 70 pound backpack slung over her shoulder Quadrilateral Space Syndrome (QSS): Backpack Shoulder Triceps weakness
Saturday Night Palsy
• Radial Nerve Palsy
Cubital tunnel syndrome • Pain, numbness or ngling of forearm, • Ulnar nerve compression • “Cell phone elbow” • Symptoms include a loss of muscle strength, coordina on and mobility; • Symptoms are not treated, the ring and pinky finger can eventually become clawed • What type of injury has occurred to the affected nerve?
• Neuropraxia • Axonotmesis • Neurotmesis • Nerve injury secondary to compression or trac on depends on intensity and dura on.
• Seddon has classified nerve injuries in order of severity into 3 categories:
• Neuropraxia • Axonotmesis • Neurotmesis Normal Function Neuropraxia • Neuropraxia • A transient episode of motor paralysis with li le or no sensory or autonomic dysfunc on • No disrup on of the nerve or its sheath occurs – incomplete nerve injury • With removal of the compressing force, recovery should be complete and rela vely rapid Axonotemsis • Axonotmesis • A more severe nerve injury • Interup on of axons & myelin sheath, nerve stroma intact • Motor, sensory, and autonomic paralysis results • Recovery can occur if the compressing force is removed in a mely fashion and if the axon regenerates • Expect 1 mm/day, 1 cm/wk, 1 inch/month Neurotmesis • Neurotmesis • the most serious injury. • The nerve is completely severed or unable to func on secondary to scar ssue • Although recovery may occur, it is never complete, secondary to loss of nerve con nuity, require surgery
• The e ology of compression neuropathy may be related to mechanical or dynamic causes • Compression, trac on or scarring can trap a nerve at different points along its course may cause denerva on of muscles and numbness or paresthesias in the distribu on of that nerve • The result can be pain, weakness, and dysfunc on • Compression of a peripheral nerve leads to impaired venous return • Intraneural edema follows • Diminished axoplasmic transporta on and decreased efficiency of the sodium pump promote membrane instability • All these factors impede signal conduc on along the path of the nerve Upper Arm Elbow Forearm Ulnar • 2nd most common peripheral nerve entrapment syndrome Ulnar
• Cell Phone Elbow • Late Cocking/ Early accelera on phase • Wrestling Median Median • Late cocking through accelera on phase • Pianists
Radial
• Humerus Fracture Radial
• Radial Nerve Palsy • “Saturday Night Palsy” • Compression in spiral groove Radial
• Tennis Elbow • Lateral Epicondyli s Radial
• Nursemaids elbow Radial
• Resistant tennis elbow Radial Radial
• Posterior Interosseous Syndrome Wrist Ulnar Ulnar • S ck and Racquet sports • Flute and Violin players Ulnar
• Handle Bar Palsy Median Median
• Carpal Tunnel Syndrome • Bilateral in 50% of cases • Associated with workplace repe ve hand ac vi es • Hand paresthesia's occur in 30% of computer users • Wheelchair • Racket sports • Volleyball Median • Archery • Cycling • Racquet and S ck sports • Gymnas cs
Radial Nerve
• Wartenberg Syndrome
• Depends on the cause, the severity and the site of the lesion • An -inflammatories and analgesics are indicated to relieve inflamma on and pain • Physical therapy should be started in the early stages following nerve injury in order to maintain range of mo on and minimize muscle atrophy • Splin ng or bracing to alleviate the compressive insult Questions