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Radial Nerve Compression Upper Extremity Compressive Mononeuropathy Capt Brendan M. Stroz, PA-C, MPAS Orthopaedic Surgery PA Resident Travis AFB, CA 1 Disclaimer I DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. 2 Objectives At the conclusion of this session, the learner will be able to: Differentiate between the multiple neuropathies of the upper extremities Properly evaluate, diagnose and treat upper extremity mononeuropathies Describe specialty exams to evaluate for upper extremity mononeuropathies Describe ancillary tests to evaluate for upper extremity mononeuropathies Describe initial non-surgical management of upper extremity mononeuropathy Describe initial surgical management of upper extremity mononeuropathy 3 Compressive Neuropathy-What is it? Chronic condition involving peripheral upper extremity nerve with sensory, motor or mixed manifestations. May be acute or secondary to treatment Paresthesias arise from compression and ischemia Acute Chronic SLT are first, pain and temperature last Peripheral Compression Neuropathies of the Upper Extremity Median Nerve Carpal Tunnel Syndrome Pronator Syndrome Anterior Interosseous Nerve Syndrome Ulnar Nerve Cubital Tunnel Syndrome Ulnar Tunnel Syndrome Radial Nerve Proper Radial Nerve Posterior Interosseous Nerve Syndrome Radial Tunnel Syndrome Wartenberg Syndrome Median Nerve Compression 6 Median Nerve Compressions Pronator Syndrome Proximal compression of median nerve Symptoms Proximal forearm pain, sensory disturbances in palmar cut branch (median n) Provocative Tests: elbow flexion, pronosupination, resisted long finger PIP joint flexion (FDS) Typically associated with medial epicondylitis and will improve w/tx Treatment Conservative: activity mod, splint, NSAIDs Surgical Decompression ~ 80 % success rate 7 Median Nerve Compressions Anterior Interosseous Nerve Syndrome Motor loss without sensory disturbance FPL loss +/- FDP, PQ PQ tested with resistance in full elbow flexion and pronation EMGs Treatment Vast majority recover with observation Splinting (elbow 90 degrees), activity mod Surgical decompression (w/in 3-6 mos) Carpal Tunnel Syndrome Most common compressive neuropathy in UE Acute vs chronic Median nerve compression at the level of the transverse carpal ligament CT has 9 tendons and median n. Common systemic risk factors: Pregnancy DM Thyroid disease Alcoholism Advanced age Carpal Tunnel Syndrome Evaluation Paresthesias, numbness and pain (often at night) Large sensory affected before small fibers (SW testing) Repetitive motions (Keyboard, knitting, hammer, etc) Most sensitive test: Durkans (Tinels and Phalens*) Spurlings Flick Test Examine strength grades (0-5) in chronic cases 2.5-30 mm Hg 10 Carpal Tunnel Syndrome Evaluation and Tests Testing Films (Xray) Injections* EMG It depends 11 Carpal Tunnel Syndrome Treatment A wise man once said… 12 Carpal Tunnel Release Post-operative course Con Leave? Limitations 13 Ulnar Nerve Compression 14 Ulnar Nerve Compression Ulnar Tunnel Syndrome Compression of the ulnar nerve in the Guyon Canal MC Cause: Ganglion cyst Hook of Hamate non-union, lipoma, PB hypertrophy, ulnar artery thrombosis. Motor and/or sensory Treatments Conservative Surgical decompression Treat underlying cause 15 Cubital Tunnel Syndrome Second most common UE compression neuropathy Multiple sites of compression Other potential causes Tumors/ganglion Osteophytes HO Medial Epicondyle Non-union Deformities Cubital Tunnel Syndrome Symptoms Paresthesias of the ulnar 1½ digits Night symptoms w/flexion Provocative Tests Compression Hyperflexion Tinel’s Check for Subluxation* Further Evaluation EMG Xrays 17 Cubital Tunnel Syndrome Treatment The wise man’s principles Surgery In Situ Anterior Transposition Medial epicondylectomy 18 Radial Nerve Compression 19 Radial Nerve Compression Radial Nerve Palsy Typically in setting of humeral trauma or related surgical approaches “Saturday Night Palsy” Weakness of innervated muscles Triceps, BR, ECRL, PIN EMG for prognosis Observation x 3 months—refer if no improvements Radial Nerve Compression Posterior Interosseous Nerve Syndrome Lateral Elbow pain & distal muscle weakness MC Compression in Arcade of Frohse Repetitive supination/pronation movements, trauma Paresis/paralysis of extensors in hand Dorsal wrist pain where terminal fibers provide sensory innervation to dorsal wrist capsule EMG to determine level of compression Conservative treatment Splints/bracing Surgery if no improvements within 3 months (85%) Radial Nerve Compression Radial Tunnel Syndrome Symptoms: Lateral Elbow/radial forearm pain No sensory or motor dysfunction Resisted long finger extension/supination ***LE can coexist, POMT is distal to LE (mobile wad) EMG inconclusive Extended conservative tx; up to 1 year Surgical decompression Wartenberg Syndrome Compression of superficial sensory branch Scissoring between BR and ECRL w/pronation Handcuffs, wristband, fracture De quervains associated up to 50% Symptoms Pain, numbness, paresthesias on dorsoradial hand, doesn’t like to wear a watch Provocative tests: pronation against resistance x 60 seconds and Tinel sign Treatment Surgical decompression if conservative therapy fails 23 References 1. Miller, M.D. (2016). Miller’s Review of Orthopaedics, Seventh Edition. Philadelphia, PA: Elsevier Inc. 2. Boyer, M.I. (2014). Comprehensive Orthopaedic Review: Volume 2. Rosemont, IL: American Academy of Orthopaedic Surgeons. 3. Franko, O. (2012, November 19). Carpal Tunnel Syndrome. Retrieved from: www.orthobullets.com. 4. Allen, D. (2012, November 25). Cubital Tunnel Syndrome. Retrieved from: www.orthobullets.com. 5. Sheth, U. Vitale, M. (2018, December 12). AIN Compression Syndrome. Retrieved from: www.orthobullets.com. 6. Watts, E. (2012, November 19). PIN Compression Syndrome. Retrieved from: www.orthobullets.com. Questions? 25.
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