Median Nerve Palsy presentation

1. MEDIAN NERVE
PALSY
PRESENTER: DR. BIJAY MEHTA
MODERATOR: DR. SIJAN BHATTACHAN

2. CONTENTS
 Anatomy
 Origin
 Course
 Branches
 Causes
 Types
 Tests
 Management
 Median Nerve Compression Syndromes

3. Anatomy of Median Nerve
• Mixed nerve
• Runsin the median plane
of the forearm , so its
called median nerve
• Also calledlabourer’s
nerve.
Anatomy of aperipheral nerve

4. Anatomy of Median Nerve
• The median nerve has
contributions from entire
brachial plexus(C5-T1)
• Formed by Lateral(C5,C6,C7)and
Medial(C8,T1) Roots of lateral and
medial cord of brachial plexus
respectively.

5. • After originating from the
brachial plexus in the axilla, the
median nerve descends down
the arm, initially lateral tothe
brachial artery.
• Halfway down the arm, thenerve
crosses over the brachial artery,
and becomes situated medially.
Anatomy of Median Nerve

6. • No branches in the arm
• In the proximal 3rd – lies between
coracobrachialis anteriorly and long head
of triceps posteriorly
• In the middle 3rd – lies between the biceps
brachi anteriorly and long head of triceps
posteriorly
• In the distal 3rd – lies anteromedial
to brachialis muscle and
posteromedial to biceps brachi.
Anatomy of Median Nerve
Course in the Arm:

7. • In the antecubital fossa, the median nerve lies
deep to the bicipital aponeurosis, medial to
the antecubital vein and brachial artery.
• Gives 4 motor branches to-
• Pronator Teres
• Flexor Carpi Radialis
• Palmaris Longus
• Flexor Dig. Superficialis
Anatomy of Median Nerve
Course in the Elbow:

8.  At the level of the junction of the two heads
of the pronator teres, the median nervegives
off the anterior interosseous nerve about 5-8
cmdistal tomedialepicondyle.
 It 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.
Anatomy of Median Nerve
Course in the Forearm:

9. Anatomy of Median Nerve
• AIN gives branches to :
• Flexor Digitorum Profundus to Index and
Middle Fingers
• Flexor Pollicis Longus
• Pronator Quadratus
• The median nerve also gives a palmar
cutaneous branch, 4 to 5 cm proximal to the
wrist that provides sensation to thenar skin of
the palm.

10. • Within the carpal tunnel: the median nerve
lies immediately palmar and radial to flexor
digitorum tendons and dorsal to transverse
carpal ligaments.
• It gives Recurrent motor branch from the radial
surface – supplies
• Flexor Pollicis Brevis(Superficial Head)
• Abductor Pollicis Brevis
• Oppenens Pollicis
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Anatomy of Median Nerve
Course in the Wrist and Hand:

11. • After exiting carpal tunnel, it splits into two
terminalbranches-theradialandulnardivision
• Radial Division- Common Digital nerve to the
thumb and ProperdigitalNervetoRadialside
ofIndexFinger.
• Ulnar Division- Common digital nerve to
index/middlefingerandmiddle/ringfinger
• The digital nerves also supply 1st
and 2nd Lumbricals
Anatomy of Median Nerve

12. Motor Supplies
superficial volar forearmgroup
• Pronator teres
• Flexor carpiradialis
•Palmaris longus
•Flexor digitorum superficialis
• Deep group
•Flexor digitorum profundus (lateral)
• Flexor pollicis longus
• Pronator quadratus
• Hand
• 1st and 2ndlumbricals
• Opponens pollicis
• Abductor pollicis brevis
• Flexor pollicis brevis
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Anatomy of Median Nerve

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

14. Anatomy of Median Nerve

15. Causes of Median Nerve Palsy
 Trauma
 Chronic Infections : Leprosy, Poliomyelitis
 Compression Syndromes :
• Carpel tunnel syndrome
• Pronator syndrome
• Anterior interossieoussyndrome
 Tumors

16. LOW MEDIAN NERVE LESION
 Causes:
I. Cutsin front of the wrist
II. Carpaldislocation
• Injury Distal to the innervation of forearm
muscles-i.e proximal to forearm

17.  Sparing of the forearm muscles
 Muscles of the hand paralysed
 Anaesthesia over the median nerve
distribution in thehand
 Thenar eminence is wasted and thumb
abduction and oppositionare weak
 Sensation lost over the radial three and half
digits and trophic changesmay seen
LOW MEDIAN NERVE LESION

18. HIGH MEDIANNERVELESION
 AXILLA
Crutch compression
Anterior shoulder dislocation
 UPPER ARM- Stab
wounds
Ligament of struthers :
 ELBOW
Supracondylar Humerus #
Fracture medial epicondyle
Elbow dislocation
• Injury Proximal to the innervation of forearm
muscles-i.e proximal to forearm

19. HIGH MEDIAN NERVE LESION
 Wasting of musclesof forearm
 Wasting of thenareminence
Weaknessof thumb abduction and opposition
Lossof abductor pollicis brevis +flexor pollicis brevis
Thehand is held with ulnar fingers flexed and index
finger straight (pointing sign) Lossof FDP
,FDS,FPL
 Lost sensationat radial three and half digits
 Weak Oksign
 Ape handdeformity

20. High Lesion vs Low Lesion

21. Evaluation of Median Nerve Palsy
History
• Pain , Numbness or Weakness
• History of trauma
• Duration of symptoms
• Acute or chronic
• Associated injuries

22. Clinical Examination
Inspection
• Position of Thumb
• Wasting
• Ulcers
• Skin Appearance
• Scars
• Active opposition
movements of thumb

23. Hand of Benediction

24. Ochsner’s Clasping test(Pointing Index)

25. Ape Hand Deformity
 hyper-extended thumb.
 adduction.
 flatthenar eminence .
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26. Wasting of thenar eminence

27. INDIVIDUAL MUSCLE TESTS
Pronator Teres Assessment

28. Flexor Carpi Radialis Assessment

29. FDS Assessment


30. Palmaris Longus Assessment


31. FDP Assessment


32. FPL Assessment

33. Okay” or “circle” sign

34. Pronator Quadratus Assessment

35. Abductor pollicis brevis
assessment

36. Flexor pollicis brevis Assessment

37. Opponens Pollicis
assessment

38. Lumbrical of second d i g i t
assessment

39. Screening for median nerve

40. Sensory system examination
 Modality test –pain , touch , temperature ,
pressure andvibration
 Functional tests –two point discrimination
,seddons coin test ,ridge sensitometer

41. Objective test
(a)Tinel’s sign
(b)Skin resistancetest
(c)wrinkle test
(d) sweat test (iodine starch test)

42. Tinel’s sign
• Importance ofTinel’s sign
–WhetherNerve interrupted
–Whether inProcess of
regeneration

43. ELECTROPHYSIOLOGICAL STUDY
potential (CMAP)
Electromyography
Todetermine completenessof anerve injury
Technique:
I. Very small needleis inserted into various muscle
II. Then,the signal is magnified by high gain amplifier
III. Finally, the reading are monitored via oscilloscopeand
recorded on the magnetic tape or paper recording
IV. Should performed 3-7daysafter peripheral nerve
Injury
V. It may showlow amplitude evoked compound muscle

44. Nerve Conduction Test
–First calculate thresholdby
stimulating on soundside
 Measure Median motor and
sensory latencies andconduction
velocities across thewrist
 Sensorylatency of greater than
3.5millisecondor amotor latency
of greater than 4.5 millisecond is
considered an abnormalfinding
 Distal compound muscleaction
potential (CMAP)and sensory
nerve action potential (SNAP)
amplitudes may bedecreased
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45. PRINCIPLES OF SURGICAL
MANAGEMENT
1. Direct Injury: Nerverepair-
2. Long standingcases: Tendontransfers
Nervetransfers Nervegraft
3. Compressionneuropathies: Decompression

46. 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 endsfor delayed repair
 When anerve deficit follows blunt or closed trauma and
no clinical or electrical evedence of regeneration has
occurred after an appropriate time

47. Time of surgery
 Primary repair within 6-8 hours gives best
results
 Delayedprimary repair –between 7-18days
 Secondary repair - 3to 6 weeks later preferable
in crushed ,avulsed , contaminated wounds
where patients life is seriously endangerd

48. SURGICAL TECHNIQUES
Coaptation
 Approximating the cut ends of nerve in such a way
that motor fasiculi meets another motor fasiculi and
sensory tosensory
 Conventionally done by 8-0 to 10-0 nylon
suture
 Sutureless methods includes fibrin clots,
adhesive tapes ,collagentubulization

49. Neurorrhaphy
Neurorrhaphy is end to end suturing of nerve
Types
 Partial Neurorrhaphy
 EpineuralNeurorrhaphy
 Perineural (fascicular)Neurorrhaphy
 Epiperineural Neurorrhaphy
 Interfascicular nervegrafting

50. Epineural neurorrhaphy Perineural Neurorrhaphy

51. Epiperineural neurorrhaphy

52. Nerve grafting
Agap between cut ends
more than 2.5-4 cm is
indication of nerve graft
Nerves used forgraft
 Most commonly suralnerve
 Latral antebrachial cutaneousnerve
I n t e r fasc ic ula r nerve grafting

53. 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 lesionsor 12months in low ones.
 Useful sensory recovery only rarely occurs after 9
months in high lesions or 12months in low ones but
it may occur when suture has been delayed aslong
as2years.

54. 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't reach the muscle within 18-
24 months of injury. 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

55. T
endon Transfer
Tendon transfer should be delayed for 6 months
a) Low MedianNerve:
- Re-routing of ring/ middle finger Flexor Digitorum Superficialis
to APBto aid thumb opposition
b) High MedianNerve:
- Suturing of profundus tendons to ring and small finger tendons
for restoration of IPjoint movements

56. Criteria for tendon transfer
 Muscle power grade 5(preferably),if not atleast grade 4
 Should haveits own nerveand blood supply
 Synergisticgroup are chosenbecauseof easier rehabilitation
 Diseaseshould not progress and infection to be controlled
 Prior to transfer joint stiffness,contracture and malunion are
corrected
 Tendontransferred should not be at anacute angle

57. 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.

58. The Superficialis Opponensplasty
 Involves dividing the ring finger FDSdistally 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
FDSis paralyzedin high median nervepalsy

59. The EIP(extensor indicis propius)
opponensplasty
 The most commonly employed opposition transfer in high median
nervepalsy
The Huber Transfer
EmploysThe Ulnar Nerve-innervatedAbductor Digiti Minimi
(ADM) To Restore Opposition
Camitz Procedure
PLtransfer effectively restores palmarabduction, the
pronation and flexion components of opposition are not re-
established.

60. 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
.
 ECU re-routing and attachment to dorsal radius/Transfer of
biceps insertion from medial to lateral radius for weak forearm
pronation

61. Nerve transfers
Toachieve opposition,sensations, flexion&
Pronation
AIN to Median recurrent transfer for lower median
nerve palsy
Thumb
opposition

62. Nerve transfers
 Median recurrent neurotisation for high median
nervepalsy
 Ulner-median nerve transfer(3rdlumbricle branch to
recurrent median nerve branch transfer)
 Radial-median nerve transfer (PIN branches to
Recurrent median nerve branch transfer)

63. Sensory restoration for median nerve
 Essential for fine motor tasks,motor recovery
is dependant on the quality of sensations, some
believe it aprerequisite for motor restoration

64. 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

65. Prognosis
Prognosis of nerve regeneration dependsupon severalfactors
Typeoflesion:
Neuropraxia always recovers fully,axonotmesis may or may not,neurotmesis will not
unlessthe nerve isrepaired
Level oflesion
Thehigherthe lesion the worsethe prognosis
Typeofnerve
Purely motor or purely sensory nerves recover better than mixed nerves,because there is
less likelihood ofaxonal confusion.
Condition ofnerve ends
Nerve ends should be prepared in such away that satisfactoryfascicular pattern is
apparent in 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.

66. Prognosis
Sizeofgap
Above the critical resection length ,suture is not successful
Age
Children do better than adaults .Old people do poorly
Delay insuture
The best results are obtained with early nerve repair, after few months , recovery following
suture becomes progressively lesslikely.
Associatedlesions
Damage to vessels , tendons and other structures makes it more difficult to obtain
recovery of auseful limb even if the nerve itself recovers.
Surgicaltechniques
Skill , experience and suitable facilities are needed to treat nerve injuries

67. MEDIAN NERVE COMPRESSION
• Carpel tunnel syndrome
• Pronator syndrome
• Anterior interosseoussyndrome

68. Carpel Tunnel Syndrome
• It’s aclinical diagnosis
• Results fromcompression of
the median nerve at the
wrist
CTSFirst described by Sir JamesPaget

69. 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.
• 9 tendons runthrough the tunnel:
the 4 FDS, the 4 FDP
,and FPL.
FCR runs in aseparate fascial
compartment onthe radial sideof
the tunnel.

70. C
auses
 Idiopathic : Most common
 Aberrant anatomy
-Anomalous flexortendons
-Congenitally small carpalcanal
-Ganglioniccysts, Lipoma
 Infections
-Lyme disease
-Mycobacterialinfection
-Septic arthritis
•MetabolicConditions
-Acromegaly
-Amyloidosis
-DiabetesMellitus
-Hypothyroidism orHyperthyroidism
•Increased canalvolume
-Congestive heartfailure
-Oedema
-Obesity
-Pregnancy
•Repetitive wrist movements:Typists &
Computer users
• Inflammatory conditions
-Connective tissuedisease
-Gout orpseudogout
-Nonspecific tenosynovitis

71. Clinical Features:
 Hand and wristPain
 Numbness and tingling in thumb and index and
middle fingers
 Sparing ofPalmar cutaneous branch supply
 Patient wakes at night with burning or aching
pain and shakes the hand to obtain relief and
restore sensation
 Aggravatedby 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

72. Diagnosis
 History
 Clinical examination:
-Thenar wasting
- Phalen’s sign
-Tinel’s sign
- Carpal compressiontest
- Scratch Collapse Test
 Electro DiagnosticStudies:
-Very reliable forevaluation
- Atypical casesmay bepresent

73. Signs of CTS
 Thenar muscle wasting due to continued pressure

74. Phalen’s test
 Phalen’stest
Patients is askedto
actively place the wrist
in complete but forced
flexion
+ve if tingling and
numbness is produced
in 60sec.
Sensitive and
specific in80%

75. Median Compression test/ Durkan’s
test
 Median nerve
compression test
Direct pressure is exerted
over bothwrist 1st phase
–timetaken
for symptomsappear(15-
20sec)
2nd phase-time taken for
symptoms to disappear
after releaseof pressure

76.  Tourniquet test
BPcuff tied proximal to elbow and inflated higher
than patient’s Systolic BP
.
+ve ifnumbness and paraesthesia
 Scratch Collapse Test
Applyingastimulusovertheareaofnervecompression
whilethepatientisexertingB/Lshoulderrotation,transient
lossofmuscleresistanceresultinginarmcollapsing.

77. Treatment
 CONSERVATIVETREATMENTS
-Generalmeasures
-Oral medications
-Local injection
- Wristsplints
 Surgical decompression:
Division of the transverse carpal ligament
- Open
- Endoscopic

78. ORALMEDICATIONS
•Diuretics
•Nonsteroidal anti-inflammatorydrugs
(NSAIDs)
•Thiamime (Vitamin B1)pyridoxine(vitamin
B6)
Cyanocobalamin(Vitamin B12)
•Orally administeredcorticosteroids
▫ Prednisolone
▫ 20mg perday for two weeks
▫ followed by 10mg perday for two weeks

79. Steroid Injection
•Transient relief occurs in 80% of patients
after steroid injection
•But only 22% of patients with steroid
injections are pain free at 12months
 (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
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80. Orthoses
 Thefollowing orthoses help manage the carpal
tunnel syndromepain:
–Wrist handorthosis
–Thumb spicasplint
–Cock-up wristsplint

81. Orthotics goals
 Decrease pain andswelling
 Prevent deformity progression
 PreventMovement
 Byrestrict flexion movement of wrist
 Main objective is to position wrist in neutral
but preferably slight extension to get
pressureoff of median nerve

82. SURGERY
 Should be considered in patients with symptoms that do not
respond to conservative measuresand in patients with severe
nerve entrapment
 It is important to note that surgery may be effective even if a
patient hasnormal nerve conduction studies
Methods ofSurgery
 OpenCarpalTunnel Release
 EndoscopicCarpalTunnel Release

83. Open Carpal Tunnel Release

84. Endoscopic Carpal Tunnel Release

85. Pronator Syndrome
-Proximal Forearm Compression
- BecauseOf:-
 ligament ofStruthers,
 Bicipital Aponeurosislacertus fibrosus,
 Fibrous Band of pronator teresmuscle
-Due to repetitive and stenuous work with the arm in
pronated positin-computer workers and manual labourers

86. ClinicalFeatures:
 Volar Forearm Pain
 Sensorydisturbances
-Thumb & Index >Middle finger
 Night pain is unusual and forearm pain ismore common
 Hand numbness ongripping
 Phalen’s testnegative
 Symptoms provoked by resisted elbow flexion with
forearm supinated ( tightening of bicipital aponeurosis )-
Pronator Teres Test

87. Management
 No relief withsteroids
 Surgicaldecompression

88. Anterior Interosseous Syndrome
(Kiloh-Nevin Syndrome)
 Involvement of theAnterior InterosseousNerve only
 Causes
•Compression from Tumor or ganglion
•Tendons from flexor digitorum to flexor policis longus
•Accessoryhead of flexor policis longus (gantzer
muscle)
•Aberrant radialartery

89. Clinical Features:
 Weaknessof the gripping movement of the thumb andindex finger( unableto
makeok -inability to flex either the thumb interphalangeal joint or the index-
finger distal interphalangeal joint
 In contrast to those with pronator syndrome, thesepatients donot complain
of numbnessor pain

90. REFERENCES:
 Last’s Anatomy, 12th Edition
 Greens’ Operative Hand Surgery, 6th Edition
 Apleys and Solomon’s System of Orthopedics
 Miller’s Review of Orthopedics, 8th Edition

91. THANK YOU