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Median nerve injury
1. MEDIAN NERVE INJURY
Dr CHINMOY MAZUMDER
INDOOR MEDICAL OFFICER
DEPARTMENT OF ORTHOPAEDICS
EMCH
1/7/2019
2. Outline
• Anatomy
Course
Motor distribution
Sensory distribution
• Common sites affected
• Level of median nerve injury
• Clinical feature with various test performed
•Treatment
• Various syndromes related to median nerve
• Summary
1/7/2019
3. Anatomy of Median Nerve
• Mixed nerve (contain
motor & sensory
fibers).
• Runs in the median
plane of the forearm ,
so its called median
nerve
Also called labourer’s
nerve.
Anatomy of a peripheral nerve
1/7/2019
4. Anatomy of Median Nerve
The median nerve
has contributions
from essentially the
entire brachial
plexus (C5-T1), and
is formed by
portions of the
lateral and medial
cord. 1/7/2019
5. Anatomy of Median Nerve
After originating from
the brachial plexus in
the axilla, the median
nerve descends down
the arm, initially lateral
to the brachial artery.
Halfway down the
arm, the nerve crosses
over the brachial
artery, and becomes
situated medially.
1/7/2019
6. Anatomy of Median Nerve
The median nerve does not
provide motor or sensory
innervation until it reaches the
elbow.
The median nerve courses down
the arm within the lateral
intermuscular septum, deep to the
short head of the biceps and
lateral to the brachial artery.
At the midbrachium, it crosses to
the medial side of the brachial
artery and descends to the
antecubital fossa.
1/7/2019
7. Anatomy of Median Nerve
In the antecubital fossa, the
median nerve lies deep to the
bicipital aponeurosis, medial to the
antecubital vein, and medial to the
brachial artery,
Although the median nerve is
anterior to the trochlea and
superficial to the brachialis, it
occasionally can be found medial to
the trochlea, such that it lies
anterior to the medial epicondyle.
This is of clinical importance in
elbow dislocations. 1/7/2019
8. Anatomy of Median Nerve
At the level of the junction
of the two heads of the
pronator teres, the median
nerve gives off the anterior
interosseous nerve
The anterior interosseous
nerve quickly dives deep to
the flexor and pronator
mass and travels with the
anterior interosseous artery
(a branch of the ulnar artery)
to travel on the volar surface
of the interosseous
membrane
1/7/2019
9. Anatomy of Median Nerve
Distal to the elbow, the
median nerve courses down
the forearm deep to the flexor
digitorum superficialis and
superficial to the flexor
digitorum profundus.
In the distal 1⁄3 of the
forearm, the median nerve
emerges from beneath the
flexor digitorum superficialis
to lie medial to the flexor
carpi radialis and lateral to the
palmaris longus, before
entering the carpal tunnel.
1/7/2019
10. Anatomy of Median Nerve
The median nerve gives a palmar
cutaneous branch that provides
sensation to thenar skin of the
palm, and is most commonly
branches 4 to 5 cm proximal to the
wrist, lying on the ulnar side of the
flexor carpi radialis
Within the carpal tunnel, the
median nerve divides into three
terminal branches.
The lateral branches : thumb and
radial side of the index finger
Terminal branches of the medial
division:
middle finger and radial aspect of the
ring finger. 1/7/2019
11. Anatomy of Median Nerve
The lateral-most division
gives off the terminal motor
innervation of the median
nerve, the recurrent motor
branch, that innervates the
abductor pollicis brevis,
flexor pollicis brevis,
opponens pollicis, and the
lateral two lumbricals
before to dividing into its
terminal sensory branches.
1/7/2019
12. Anatomy of Median Nerve
•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 1/7/2019
13. Sensory innervations
The median nerve is
responsible for the
cutaneous innervation
of part of the hand.This
is achieved via two
branches:
Palmar cutaneous
branch
Palmar digital
cutaneous branch
1/7/2019
17. HIGH MEDIAN NERVE LESION
AXILLA
Crutch compression
Anterior shoulder dislocation
UPPERARM
Stabs wound
Ligament of struthers : It is seen 5 cm
proximal to the medial epicondyle and is a
fibrous band that interconnects a bony
spur on the distal humerus to the medial
epicondyle
ELBOW
Fracture humerus supracondylar in
children
Fracture medial epicondyle
Elbow dislocation
1/7/2019
18. HIGH MEDIAN NERVE LESION
SIGNS
Wasting of muscles of forearm
Wasting of thenar eminence
Weakness of thumb abduction and opposition
Loss of abductor pollicis brevis + flexor pollicis brevis
The hand is held with ulnar fingers flexed and index
finger straight (pointing sign) Loss of FDP, FDS, FPL
Lost sensation at radial three and half digits
Weak Ok sign
Ape hand deformity
1/7/2019
19. LOW MEDIAN NERVE LESION
INJURYTO DISTALTHIRD OFTHE
FOREARM
I. Cuts in front of the wrist
II. Carpal dislocation
1/7/2019
20. Low Median Nerve Injuries
Injury in the distal third of the forearm
Sparing of the forearm muscles
Muscles of the hand paralysed
Anaesthesia over the median nerve
distribution in the hand
Thenar eminence is wasted and thumb
abduction and opposition are weak
Sensation lost over the radial three and half
digits and trophic changes may seen
1/7/2019
23. Hand of Benediction
Lesion Location: Proximal (near the elbow)
Deficiency:When the patient tries to make a fist,
they are unable to flex the index and middle fingers
due to loss of lateral lumbrical action, leading to the
hand of benediction.The fingers are extended due to
unopposed radial nerve action on the finger
extensors.
1/7/2019
24. Ape Hand Deformity
(1) hyper-extended thumb .
(2) adduction .
(3) flat thenar eminence .
This lesion is related to ape
hand due to the fact that loss
of opponens pollicis means
one has an unopposable
thumb (like an ape). It seems
some also believe the term
ape hand refers to the thenar
atrophy. 1/7/2019
26. Pronator teres (C6, C7) assessment
The patient’s forearm is extended and fully
pronated.The patient is then instructed to resist
supination of the forearm by the examiner.
1/7/2019
27. Flexor carpi radialis (C6, C7) assessment
The patient flexes the wrist a long the trajectory of
the forearm.
1/7/2019
28. FDS (C8, T1) assessment
To test proximal interphalangeal joint flexion, the
supinated forearm and hand are placed straight.
Each finger is tested separately. Placing the fingers
between the single finger to be tested and the
remaining fingers that are immobilized isolates
this movement.This maneuver places the finger to
be tested in mild flexion at the metacarpal–
phalangeal (knuckle) joint, and stabilizes the
remaining fingers in extension, a position that
allows isolation of the flexor digitorum
superficialis.
1/7/2019
30. FDP (C8, T1) assessment
To assess the median
innervation of the flexor
digitorum profundus one
should concentrate on the
index finger.To do so, holding
the metacarpal-phalangeal
and proximal interphalangeal
joints immobile, and have the
patient flex the distal phalanx
against resistance.
1/7/2019
32. FPL (C8, T1) assessment
: Immobilize the thumb,
except the
interphalangeal joint,
and then ask the patient
to flex the distal phalanx
against resistance.
1/7/2019
33. Okay” or “circle” sign
with anterior interosseous nerve
weakness.
A quick way to assess the flexor
digitorum profundus and flexor
pollicis longus innervation from
the anterior interosseous nerve is
to ask the patient to make an okay
sign by touching the tips of the
thumb and index finger together.
With weakness in these muscles, the
distal phalanges cannot flex, and
instead of the fingertips touching,
the volar surfaces of each distal
phalanx make contact 1/7/2019
34. Pronator quadratus (C7, C8) assessment
Have the patient resist
supination of a fully
flexed and pronated
forearm.With full
forearm flexion,
pronation by the usually
dominant pronator teres
is minimized
1/7/2019
35. Abductor pollicis brevis (C8, T1) assessment
:Resist movement of
the thumb away from
the plane of the palm
(palmar abduction),
while stabilizing the
metacarpals of the
remaining fingers.
1/7/2019
36. Flexor pollicis brevis (C8, T1)assessment
The patient flexes the thumb at
the metacarpalphalangeal joint
against resistance placed over
both the proximal and distal
phalanges.
Make certain the distal
interphalangeal joint does not
flex because in allowing this,
substitution by the flexor pollicis
longus occurs.
Use other hand to immobilize the
first metacarpal to reduce
substitution by the opponens
pollicis. 1/7/2019
37. Opponens pollicis (C8, T1)assessment
Have the patient forcibly
maintain contact between the
volar pads of the distal thumb
and fifth digit, while try to pull
the distal first metacarpal away
from the fifth digit.Although
thumb opposition is only
innervated by the median
nerve, a combination of thumb
adduction (adductor pollicis,
ulnar nerve) and thumb flexion
(flexor pollicis brevis, deep
head, ulnar nerve) may mimic
thumb opposition even when
there is complete median
nerve palsy present
1/7/2019
38. Lumbrical of second digit assessment
Stabilize the patient’s
index finger in a hyper-
extended position at the
metacarpal-phalangeal
joint and then provide
resistance as the patient
extends the finger at the
proximal interphalangeal
joint.
1/7/2019
40. Sensory system examination
Modality test – pain , touch , temperature ,
pressure and vibration
Functional tests –two point discrimination
,seddons coin test ,ridge sensitometer
1/7/2019
42. Tinel’s sign
Tested by gentle percussion
along course of nerve from
distal to proximal direction.
–Tingling sensation felt by
patient in distribution of
nerve.
–Tingling should persist for
several seconds
• Importance ofTinel’s sign
–Whether Nerve
interrupted
–Whether in Process of
regeneration
1/7/2019
43. Electrophysiological study
Electromyography
To determine completeness of a nerve injury
Technique:
I. Very small needle is inserted into various muscle
II. Then, the signal is magnified by high gain amplifier
III. Finally, the reading are monitored via oscilloscope and
recorded on the magnetic tape or paper recording
IV. Should performed 3-7 days after peripheral nerve
Injury
V. It may show low amplitude evoked compound muscle
potential (CMAP)
1/7/2019
44. Nerve conduction test
– First calculate threshold by
stimulating on sound side
Measure Median motor and
sensory latencies and conduction
velocities across the wrist
Sensory latency of greater than
3.5 millisecond or a motor latency
of greater than 4.5 millisecond is
considered an abnormal finding
Distal compound muscle action
potential (CMAP) and sensory
nerve action potential (SNAP)
amplitudes may be decreased 1/7/2019
45. CLASSIFICATION OF NERVE
INJURIES
SEDDON’S CLASSIFICATION
Neuropraxia – temporary paralysis of a nerve
caused by lack of blood flow or by pressure on
the affected nerve with no loss of structural
continuity.
Axonotmesis – neural tube is intact but axons
are disrupted. Nerves are likely to recover.
Neurotmesis – neural tube is severed. Injuries
are likely to be permanent without repair.
1/7/2019
47. Principles of Surgical
Management
1. Direct Injury:
Nerve repair-
2. Long standing cases:
Tendon transfers
Nerve transfers
Nerve graft
3. Compression neuropathies:
Decompression
1/7/2019
48. General indications of surgery
In sharp injury exploration for diagnostic as
well as therapeutic purpose .Neurorrhaphy
can be done at time of exploration or delayed
In avulsion or blast injury –to identify and
suture of nerve ends for delayed repair
When a nerve deficit follows blunt or closed
trauma and no clinical or electrical evedence
of regeneration has occurred after an
appropriate time
1/7/2019
49. Time of surgery
Primary repair within 6-8 hours gives best
results
Delayed primary repair – between 7- 18 days
Secondary repair - 3 to 6 weeks later
preferable in crushed ,avulsed , contaminated
wounds where patients life is seriously
endangerd
1/7/2019
50. Surgical techniques
Coaptation
Approximating the cut ends of nerve in such a
way that motor fasiculi meets another motor
fasiculi and sensory to sensory
Conventionally done by 8-0 to 10-0 nylon
suture
Sutureless methods includes fibrin clots,
adhesive tapes ,collagen tubulization
1/7/2019
51. Neurorrhaphy
Neurorrhaphy is end to end suturing of nerve
Types
Partial Neurorrhaphy
Epineural Neurorrhaphy
Perineural (fascicular) Neurorrhaphy
Epiperineural Neurorrhaphy
Interfascicular nerve grafting
1/7/2019
56. Nerve grafting
A gap between cut ends more than 2.5-4 cm is
indication of nerve graft
Types of grafts
Trunk graft
Cable graft
Pedicle nerve graft
Inter fascicular nerve graft
Pre vascularised nerve graft
A cutaneous nerve for nerve grafting should be selected with great
care .Nerves used for graft
Most commonly sural nerve
Latral antebrachial cutaneous nerve
1/7/2019
57. Critical Limit of Delay of Suture
Motor recovery in intrinsic muscles of the
hand does not occur if suture is delayed 9
months in high lesions or 12 months in low
ones.
Useful sensory recovery only rarely occurs
after 9 months in high lesions or 12 months in
low ones but it may occur when suture has
been delayed as long as 2 years.
1/7/2019
58. Prognosis
Prognosis of nerve regeneration depends upon
several factors
Type of lesion:
Neuropraxia always recovers fully,axonotmesis
may or may not,neurotmesis will not unless the
nerve is repaired
Level of lesion
The higher the lesion the worse the prognosis
Type of nerve
Purely motor or purely sensory nerves recover
better than mixed nerves,because there is less
likelihood of axonal confusion.
1/7/2019
59. Prognosis
Condition of nerve ends
It is generally agreed that the nerve ends should be
prepared in such a way that satisfactory fascicular pattern
is apparent I both proximal and distal stumps.no scar
,foreign material or necrotic tissue should be allowed to
remain about the ends to interfere with axonal
regeneration.
Size of gap
Above the critical resection length ,suture is not
successful
Age
Children do better than adaults . Old people do poorly
1/7/2019
60. Prognosis
Delay in suture
The best results are obtained with early nerve repair,
after few months , recovery following suture becomes
progressively less likely.
Associated lesions
Damage to vessels , tendons and other structures
makes it more difficult to obtain recovery of a useful
limb even if the nerve itself recovers.
Surgical techniques
Skill , experience and suitable facilities are needed to
treat nerve injuries
1/7/2019
61. Results of suture of Median nerve
Under favorable circumstances about 50% of the
patients with median nerve suture recover
sensitivity to pain touch and some degree of
stereognosis .
Under the same circumstances about 90% of
these patients recover a useful degree of maotor
function in the long flexors of the forearm
A much smaller number , perhaps 33% obtain
useful recovery in the thenar muscles as well
when the lesion is in the upper arm
In more distal lesions about 67% will attain some
useful motor recovery. 1/7/2019
62. Reconstructive procedure
Tendon transfer
Motor recovery may not occur if the axons
,regenerating at about 1 mm per day / 2-3 cm per
month , don not reach the muscle within 18-24
months of injury.This is most likely when there is a
proximal injury I a nerve supplying distal muscles.
In such circumstances , tendon transfers should be
considered
When neighboring tendons are intact and if all
criteria for tendon transfer met ,then tendon
transfer is treatment of choice 1/7/2019
63. Tendon transfer
Tendon transfer should be delayed for 6 months
a) Low Median Nerve:
- Re-routing of ring/ middle finger superficial
flexor around FCU to APB to aid thumb
opposition
b) High Median Nerve:
- Suturing of profundus tendons to ring and
small finger tendons for restoration of IP joint
movements
1/7/2019
64. Criteria for tendon transfer
Muscle power grade 5 (preferably),if not atleast
grade 4
Should have its own nerve and blood supply
Synergistic group are chosen because of easier
rehabilitation
Age should be more than 5 years
Disease should not progress and infection to be
controlled
Prior to transfer joint stiffness,contracture and
malunion are corrected
Tendon transferred should not be at an acute angle
1/7/2019
65. Restoring thumb opposition:
Thumb opposition is a complex movement that
involves palmar abduction, pronation, and flexion of
the thumb metacarpal and proximal phalanx.
The ideal insertion for an opposition transfer is the
APB insertion. Insertion at this point most reliably
causes the combination of movements that result in
thumb opposition.
The angle of pull should be from the location of the
pisiform, because this approximates the normal
direction of pull of the APB.
1/7/2019
66. The superficialis opponensplasty
Described by Royle in 1938,
involves dividing the ring finger
FDS distally in the finger,
retrieving the FDS proximal to
the carpal tunnel, re-directing
the tendon distally through the
FPL sheath, and inserting it into
the thumb.
The main disadvantage of the
superficialis opponensplasty is
that it can only be used in cases
of low median nerve palsy,
because the FDS is paralyzed in
high median nerve palsy 1/7/2019
67. The EIP(extensor indicis
propius)opponensplasty
In cases of both low and high median nerve injury, and is
the most commonly employed opposition transfer in
high median nerve palsy
Although the EIP is a weak motor, it is sufficiently
strong to move the thumb into opposition.
The EIP is tunneled around the ulnar aspect of the wrist,
routed across the palm from the level of the pisiform,
and inserted on the APB.
It is important to close the extensor hood of the index
MCPJ after EIP harvest to prevent postoperative
extension lag at the index MCPJ.
Functional loss with the EIP transfer is minimal, and
retraining the EIP to perform thumb opposition is not
difficult. 1/7/2019
69. The Huber transfer
Employs the ulnar nerve-innervated abductor
digiti minimi (ADM) to restore opposition.
This transfer is usually used in cases of
congenital absence of the thenar muscles, and in
cases where the FDS and EIP are not available.
The ADM is released from its insertion, turned
over 180 degrees, and inserted on the APB
insertion.
Strength and excursion are well matched to the
deficit, and the transfer is synergistic
1/7/2019
71. Tendon transfers
Other procedures
In cases of high median nerve injury, thumb IPJ
flexion and index finger DIPJ flexion can be restored
with transfer of the BR, the ECRL, or ECU.
The most common transfers are BR to FPL and
ECRL to index FDP. However, it should be
remembered that reinnervation of the FPL and FDP
is common after a high median nerve injury has
been repaired.
- ECU re-routing and attachment to dorsal
radius/Transfer of biceps insertion from medial to
lateral radius for weak forearm pronation
1/7/2019
72. Camitz procedure
PL transfer effectively
restores palmar abduction,
the pronation and flexion
components of opposition
are not re-established.
The primary indication for
performing a Camitz
transfer is to augment
palmar abduction in
patients who have motor
loss from severe carpal
tunnel syndrome.
1/7/2019
73. Rehabilitation
First 4 weeks:
Splint that should take tension off the tendon
transfer(s) performed. For example, if a transfer was
performed to improve clawing, the splint should keep
the MCPJ’s flexed and the IPJ’s extended.
Maintain mobility in the non-immobilized joints of the
upper extremity. After 4 weeks:
Mobilization should start with gentle active and
assisted range of motion exercises. It is important to
mobilize one joint at a time to prevent placing too
much tension on the transfer. For example, if an ECRB
transfer to treat clawing was performed, the therapist
should mobilize the MCPJ’s while keeping the wrist and
IPJ’s immobile. 1/7/2019
74. Rehabilitation
6 weeks: exercises that activate the muscles
used in the tendon transfer, and should begin
muscle retraining. Electrical stimulation and
biofeedback may be used to assist with
retraining.
8 weeks: At eight weeks postoperatively,
strengthening exercises should be initiated,
and the splint can be weaned off over the
next four weeks.
Full activity is resumed at twelve weeks.
1/7/2019
75. Nerve transfers
To achieve opposition,sensations, flexion &
Pronation
AIN to Median recurrent transfer for lower median
nerve palsy
Thumb
opposition
1/7/2019
76. Nerve tranfers
Median recurrent neurotisation for high
median nerve palsy
Ulner-median nerve transfer (3rd lumbricle
branch to recurrent median nerve branch
transfer)
Radial-median nerve transfer (PIN branches
to Recurrent median nerve branch transfer)
1/7/2019
77. Sensory restoration for median nerve
Essential for fine motor tasks,motor recovery
is dependant on the quality of sensations, some
believe it a prerequisite for motor restoration
1/7/2019
78. Nerve transfers
Nerve transfers for restoration of flexion in
high median nerve palsy ECRB branch of
the radial nerve to the AIN transfer without
grafts
1/7/2019
79. Nerve transfers
Nerve transfers for restoration of flexion in
high median nerve palsy Isolated AIN
injuries, nerves of FDS, PL & FCR can be
utilized
1/7/2019
81. Carpel tunnel syndrome
Definition
It’s a Clinical Diagnose Of
peripheral neuropathy,
results from compression of
the median nerve at the
wrist
CTS First described by Sir James Paget 1854
• First CTR performed by Sir James Learmonth 1933
• Popularised by Phalen in the 1950s with a series of
articles
• Introduction of endoscopic release 1985-1987
1/7/2019
82. Anatomy - Carpal Tunnel
The bony borders are:
radially, the tubercle of
the scaphoid and the
tubercle of the
trapezium; ulnarly the
triquetrum, pisiform and
hook of the hamate.The
lunate lies in the floor of
the tunnel.
• Nine tendons run through
the tunnel: the 4 FDS,
the 4 FDP, and FPL. FCR
runs in a separate fascial
compartment on the
radial side of the tunnel.; 1/7/2019
84. Symptoms
Hand and wrist Pain
Paraesthesia
Hypoaesthsia
Sparing of Palmar cutaneous branch
supply
Patient wakes at night with burning
or aching pain and shakes the hand to
obtain relief and restore sensation
Aggravated by elevation of hand
Difficulty in holding on to a glass or
cup securely
Thenar atrophy and weakness of
thumb opposition and abduction may
develop late 1/7/2019
86. Pathophysiology of CTS
Night numbness is caused by a number of
factors:
• Horizontal position results in a redistribution
of fluid to the upper limbs
• Drainage by the action of the muscle pump is
diminished
•There is a tendency towards wrist flexion at
night
•The blood pressure drops during late night and
early morning, resulting in decreased perfusion
pressure
1/7/2019
87. Diagnosis
History
Clinical examination:
-Thenar wasting
- Phalen’s sign
-Tinel’s sign
- Carpal compression test
Electro Diagnostic Studies:
-Very reliable for evaluation
- Atypical cases may be present
1/7/2019
88. Signs of CTS
Thenar muscle wasting due to continued pressure
1/7/2019
89. Phalen’s test
Phalen’s test
Patients is asked to
actively place the
wrist in complete
but forced flexion
+ve if tingling and
numbness is
produced in 60 sec.
Sensitive and
specific in 80%
1/7/2019
90. Median Compression test/ Durkan’s
test
Median nerve
compression test
Direct pressure is
exerted over both wrist
1st phase –time taken
for symptoms appear(15-
20sec)
2nd phase-time taken
for symptoms to
disappear after release of
pressure
1/7/2019
91. Tourniquet test
BP cuff tied proximal to elbow and inflated
higher than patient’s Systolic BP.
+ve if numbness and paraesthesia
1/7/2019
93. ORAL MEDICATIONS
• Diuretics
• Nonsteroidal anti-inflammatory drugs
(NSAIDs)
•Thiamime (Vitamin B1)pyridoxine (vitamin
B6)
Cyanocobalamin(Vitamin B12)
• Orally administered corticosteroids
▫ Prednisolone
▫ 20 mg per day for two weeks
▫ followed by 10 mg per day for two weeks
1/7/2019
94. Steroid Injection
•Transient relief occurs in 80% of patients after
steroid injection
• But only 22% of patients with steroid
injections are pain free at 12 months
(These patients were also splinted).
– It is most useful early in the disease, when
there has been less than 1yr of symptoms
– there is no weakness or thenar atrophy
•Technique of injection:
– a 22-gauge needle is introduced between FCR
and PL
– angled dorsally and distally at 45 degrees
– It is advanced until it reaches the floor of the
tunnel, and then withdrawn 5mm
– A water soluble preparation is used
• e.g. dexamethasone acetate plus lignocaine
• if any immediate paraesthesias occur the
injection is stopped. 1/7/2019
95. Orthoses
The following orthoses help manage the carpal
tunnel syndrome pain:
–Wrist hand orthosis
–Thumb spica splint
– Cock-up wrist splint
1/7/2019
96. Orthotics goals
Decrease pain and swelling
Prevent deformity progression
Prevent Movement
By restrict flexion movement of wrist
Main objective is to position wrist in neutral
but preferably slight extension to get
pressure off of median nerve
1/7/2019
97. SURGERY
Should be considered in patients with symptoms
that do not respond to conservative measures and in
patients with severe nerve entrapment as evidenced
by nerve conduction studies,thenar atrophy, or
motor weakness.
• It is important to note that surgery may be effective
even if a patient has normal nerve conduction
studies
Methods of Surgery
Open CarpalTunnel Release
– Open technique
– Limited incision technique
Endoscopic CarpalTunnel Release 1/7/2019
100. Complications Of Surgery
Early
–Transection of the
median nerve or the
superficial arch
– Haematoma
– Pain, swelling and
stiffness
– Recurrent Branch injury
– Infection
•Late
– RSD
– Hypertrophic scar
– Median nerve neuritis
– Palmar fasciitis
– Fibrosis of carpal tunnel
– Recurrence
•Revision carpal tunnel
release
– Only 25% of patients have
complete relief of symptoms.
25% have no relief.The rest
have partial relief.1/7/2019
101. Postoperative course and
results for Open CTR
Grip strength returns to normal in 3 months.
Surgery is most successful when done early;
Patients with intermittent numbness do better than
patients with constant numbness.
Overall excellent results in 80% (Mayo clinic). 5%
have worsened function.
MRI shows a 20-30% increase in the carpal tunnel
volume after surgery. MRI also shows that Guyon’s
canal enlarges after carpal tunnel release.
Measurement of pressures within the carpal tunnel
before and after release demonstrate marked
decreases in resting pressures after release of the
ligament.
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102. Differential Diagnoses of CTS
Tendonitis
Tenosynovitis
Diabetic neuropathy
Kienbock's disease
Compression of the Median nerve at the
elbow
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103. Pronator Syndrome
- Proximal Forearm Compression
- Because Of :-
ligament of Struthers,
lacertus fibrosus,
pronator teres muscle
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104. Symptoms & signs
Symptoms are similar to those of carpal tunnel syndrome
Sensory disturbances
-Thumb & Index > Middle finger
Night pain is unusual and forearm pain is more common
Hand numbness on gripping
Phalen’s test negative
Symptoms provoked by resisted elbow flexion with
forearm supinated ( tightening of bicipital aponeurosis )
By resisted forearm pronation with the elbow extended
( pronator tension )
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105. Same Symptoms As C.T.S But
Could Be
Differentiated By
include the distribution of the palmar
cutaneous nerve
TheTinel sign is positive at the forearm level
The Phalen maneuver does not provoke
symptoms
Patients may experience pain with resistance
to contraction of the pronator teres or flexor
digitorum superficialis
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107. Anterior Interosseous
Syndrome
Damage to the Anterior Interosseous Nerve
Causes
•Tentinous origin of flexor digitorum
•Pronater teres
•Tendons from flexor digitorum to flexor policis
longus
•Accessory head of flexor policis longus (gantzer
muscle)
•Aberrant radial artery
•Thrombosis of ulnar colleteral artery
•VIC
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108. Anterior Interosseous
Syndrome
Pain in the forearm
Weakness of the gripping movement of the
thumb and index finger( unable to make ok sign
)
Clinical Findings
-inability to flex either the thumb
interphalangeal joint or the index-finger distal
interphalangeal joint
-In contrast to those with pronator syndrome,
these patients do not complain of numbness or
pain 1/7/2019
