NERVE IMPINGEMENTS OF THE UPPER EXTREMITY Michael Erickson In-Service 11/20/2012 SALT LAKE ORTHOPAEDIC CLINIC PHYSICAL THERAPY 1160 EAST 3900 SOUTH, SUITE 4050 Salt Lake City, Utah 84124 Telephone (801) 892-2480/Fax (801) 284-8686 www.sloc.org

Objectives To define the nerve and identify the necessary parts for impulse conduction To define the different types of nerve injuries To define nerve compression (neuropraxia) in the upper extremity To identify syndromes by location, proximally to distally To identify symptoms of each syndrome To determine possible treatment interventions for each syndrome

Anatomy of the Peripheral Nerve The endoneurium is the innermost collagen layer surrounding individual axons within the perineural layer The perineurium encircles each fascicle and protects nerve fibers Epineurium is divided into two layers: External is the outermost layer Internal fills between fascicles and provides cushion

Radial Nerve It is mainly responsible for the extension and supination of the upper extremity.

Median Nerve It is mainly responsible for flexion and pronation of the upper extremity.

Ulnar Nerve It is mainly responsible for intrinsic wrist and finger flexion

Nerve Injury Classification Neuropraxia Minimal nerve injury characterized by a temporary, mostly reversible nerve conduction block, with good prognosis Axonotmesis Moderate nerve injury characterized by a disruption of the axons and myelin sheath with the epineurium left intact to guide regeneration; has a fair prognosis Neurotmesis Severe injury characterized by complete destruction of the nerve with poor prognosis for regeneration

Spinal Accessory Nerve Injury can occur: Very superficial course in posterior neck and directly under the trapezius muscle Trapezuis trauma Shoulder dislocation Iatrogenic sources of injury include: Radial neck disection Carotid endarterectomy Cervical note biopsy

Spinal Accessory Nerve Symptoms include: Generalized shoulder pain and weakness Shoulder asymmetry Affected side appears to sag Unable to shrug the shoulder Weakness of forward arm elevation Above horizontal plane Possible treatment options include: Avoid carrying heavy weights on the affected side. Use an arm sling to reduce pain Passive forward flexion in supine and half-sitting positions External rotation with the elbow at the side and flexed at 90° Internal rotation

Long Thoracic Nerve Injury can occur: Acutely from a blow to the shoulder or surgery to the neck Activities that involve chronic repetitive traction of the nerve Tennis Swimming Baseball

Long Thoracic Nerve Symptoms include: Shoulder or neck pain That gets worse with overhead activites Scapular winging Weakness with forward elevation of the arm Possible treatment options include: Shoulder ROM exercises Prevent contracture Strengthen trapezius, rhomboids, and levator scapula

Axillary Nerve: Axillary Nerve Dysfunction Injury can occur from: Direct trauma Upward pressure from improper crutch use for example Fracture of the upper arm bone as well as pressure from casts and splints Shoulder dislocation

Axillary Nerve: Axillary Nerve Dysfunction Typical symptoms: Loss of movement or sensation of the shoulder because of nerve damage Numbness over part of the outer shoulder Difficulty lifting objects with the sore arm Difficulty lifting arm above the head The deltoid muscle of the shoulder shows visual signs of muscle atrophy Possible treatment options include: EMG will be normal right after the injury; performed several weeks after the injury or symptoms Nerve biopsy MRI PT to help maintain muscle strength Job changes, muscle retraining

Suprascapular Nerve Injury can occur: Repetitive overhead loading Can result from other shoulder pathologies Cyst formation at the spinoglenoid notch secondary to a slap lesion

Suprascapular Nerve Symptoms include: Weak external rotation With loss of infraspinatus Weak arm elevation With loss of supraspinatus Possible treatment options include: Maintain full shoulder ROM Avoid heavy lifting repetitive overhead activities Mostly surgery

Radial Nerve at the Upper Arm Injury can occur: "Crutch palsy," Fracture of the humerus "Saturday night palsy" hanging the arm over the back of a chair arm positions during sleep or coma Pinching of the nerve during deep sleep, such as when a person is intoxicated Long-term pressure on the nerve, usually caused by swelling or injury of nearby body structures

Radial Nerve at the Forearm Symptoms include: Abnormal sensations "back" of the hand or forearm "Thumb side“ of the hand 2nd and 3rd fingers Difficulty straightening the arm at the elbow Difficulty bending the hand back at the wrist, or even holding the hand in neutral Pain in the upper forearm Possible treatment options include: Allow use the hand and arm as much as possible Braces, splints, or other appliances to help you use the hand in severe cases Strengthen + Stretch muscles Same as for lateral epicondylitis

Median Nerve at the Elbow: Pronator Syndrome Injury can occur: Pronator teres can compress the median nerve Causes symptoms that mimic carpal tunnel syndrome Forearm discomfort and aching From repetitive pronation with elbow extended

Median Nerve at the Forearm: Pronator Syndrome Symptoms include: Parasthesis in the thumb and second finger Sensory loss in the thenar eminence Negative Tinel sign and Phalen maneuver at the wrist Possible treatment options include: Activity modification Monitor for loss of ROM

Radial Nerve at the Forearm: Radial Tunnel Syndrome Injury can occur: To the superficial branch Forearm pain exacerbated by repetitive forearm pronation Similar mechanisms of injury to patients with tennis elbow Supination against resistance with the elbow and wrist extended Resisted extension of middle finger

Radial Nerve at the Forarm: Radial Tunnel Syndrome Symptoms include: Point of maximal tenderness Differentiating factor from tennis elbow: more medial Possible treatment options include: PT for extensor- supinator muscle groups: Stretch + Strength

Ulnar Nerve at the Elbow: Cubital Tunnel Syndrome Injury can occur: Acute contusion Osteo-Arthritis Chronic compression External source Internal source Cubital tunnel volume decreases with elbow flexing

Ulnar Nerve at the Elbow: Cubital Tunnel Syndrome Symptoms include: Parasthesias of the fourth and fifth digits Elbow pain radiating to the hand Worse with prolonged or repetitive elbow flexion Weakness may occur Digit abduction Thumb abduction Thumb-index finger pinch Possible treatment options include: Pad external elbow against external compression PT for stretch of ulnar sided flexors Decrease repetitive elbow flexion Extension splint 40 degrees of elbow extension Worn at night

Median Nerve at the Wrist: Carpal Tunnel Syndrome Injury can occur: Compression of the median nerve as it passes through the carpal tunnel Distal radius fracture Most common nerve entrapment

Median Nerve at the Wrist: Carpal Tunnel Syndrome Symptoms include: Parasthesis of the thumb, index digit, and long digit Possible forearm pain Abnormality in a Katz hand diagram Positive Tinel sign and Phalen maneuver Sensory loss in median nerve distribution Weak thumb abduction Thenar atrophy Possible treatment options include: Activity modification Splints worn at night and day Oral steroids or AINS Yoga Ultrasound

Guyon's Carpal Tunnel Syndrome Injury can occur: Space between the hamate and pisiform bones Entrapment of the ulnar nerve can occur here

Guyon's Carpal Tunnel Syndrome Symptoms include: Inability to extend second and distal phalanges of fingers Inability to adduct or abduct fingers or oppose fingertips Inability to oppose thumb Loss of sensation to ulnar side of hand, ring finger, and little finger Possible treatment options include: Same guidelines for carpal tunnel syndrome Modify activity Avoid pressure to the base of the palm Cock-up splint

References Hunter, Mackin, Callahan. Rehabilitation of the Hand and Upper Extremity. 5th Edition. Volume 1 & 2 Trumble, Buddoff, Cornwall. Hand, Elbow & Shoulder. Core Knowledge with Orthopaedics. Dutton, Mark. Orthopaedics for the Physical Therapist Dugdale, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine; Hoch, PhD, MD, Assistant Professor of Neurology, Harvard Medical School, Department of Neurology, Massachusetts General Hospital reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc. MedlinePlus. http://www.nlm.nih.gov/medlineplus/ency/article/000790.htm Update Date: 9/26/2010 Walvekar, MD Assistant Professor, Department of Otolaryngology, Louisiana State University School of Medicine in New Orleans; Li, MD Resident Physician, Department of Otolaryngology- Head and Neck Surgery, Johns Hopkins Hospital and Health System http://emedicine.medscape.com/article/1298684-treatment Updated: Jul 10, 2012 Peripheral Nerve Entrapment and Injury in the Upper Extremity. SARA L. NEAL, MD, MA, and KARL B. FIELDS, MD, Moses Cone Health System, Greensboro, North Carolina. American Family Physician. 2010 Jan 15;81(2):147-155. http://www.aafp.org/afp/2010/0115/p147.html http://brachialplexus.wustl.edu/injury.html Robert J. Spinner, M.D. Outcomes for Peripheral Nerve Entrapment Syndromes Clinical Neurosurgery • Volume 53, 2006 © 2006 Lippincott Williams & Wilkins http://www.cns.org/publications/clinical/53/pdf/cnb00106000285.pdf http://www.scripps.org/articles/3552-axillary-nerve-dysfunction

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