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21 Cards in this Set
- Front
- Back
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Cubital Tunnel Syndrome
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• ulnar nerve passes through intermuscular septum in mid-arm
• passes behind medial epicondyle & between the 2 heads of FCU at the elbow |
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Causes of Ulnar Nerve Entrapment
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• trauma
• cubitus valgus • bony spurs • tumours • ‘arcade of Struthers’ – 8 cm proximal to the medial epicondyle • hypertrophied flexor carpi ulnaris |
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Arcade of Struthers
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• Band of thickened fascia that runs atop ulnar nerve
• Proximal - medial upper arm ~ medial head of triceps |
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Injury to Ulnar Nerve - Presentation
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• results in distal symptoms below injury - in ulnar distribution
• injury in the mid-forearm results in preservation of function of the FDP to the 4th and 5th fingers - patient can flex the DIP joints of the 4th and 5th fingers, but has lost all ulnar hand sensation + paralysis of the hypothenar and intrinsic hand muscles (supplied by the ulnar nerve) |
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Injury to Ulnar Nerve - Signs & Symptoms
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• dull achy forearm pain
• intermittent parasthesia &/or numbness along the ulnar side of hand (ie. both volar & dorsal) • +ve Tinel’s test • +ve Wartenberg’s sign = little finger is in an abducted position due to paralysis of the hand intrinsic muscles • +ve Froment’s sign • ulnar clawing if severe (Note - ulnar paradox - no clawing if FDP & intrinsics weak) • wasting of : - 1st dorsal interosseus - hypothenar eminence - ulnar border of forearm (FDP & FCU) • NCS reduced nerve conduction velocity • EMG evidence of denervation of muscles |
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Injury to Ulnar Nerve - Treatment
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• extension block night splint
• avoidance of repetitive bending of elbow • injection contraindicated |
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Cubital Tunnel versus Guyon Tunnel Syndrome - Signs & Symptoms
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Cubital Tunnel:
• pain and/or paraesthesia and/or numbness along the ulnar border of the forearm, wrist, hand & ulnar 1.5 fingers • wasting of the ulnar border of the forearm & hypothenar eminence • claw hand deformity Guyon Tunnel Syndrome • pain and/or paraesthesia and/or numbness along the ulnar border of the hand & ulnar 1.5 fingers • wasting of the hypothenar eminence • claw hand deformity |
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Cubital Tunnel versus Guyon Tunnel Syndrome - Special Tests
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Cubital Tunnel Syndrome
• +ve Tinel’s test over the cubital tunnel but NOT over the Guyon tunnel • +ve Wartenburg’s sign • +ve Froment’s test • +ve NCS distal to elbow Guyon Tunnel Syndrome • +ve Tinel’s test over the Guyon tunnel but NOT over the cubital tunnel • +ve Wartenburg’s sign • +ve Froment’s test • +ve NCS distal to wrist |
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Ulnar Nerve - Anatomy
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• C 7, 8, T1
• medial & lateral cords of brachial plexus |
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Radial Nerve - Anatomy
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• C 5, 6, 7, 8
• posterior cord of brachial plexus (continuation) • divides into superficial branch & posterior interosseous nerve (PIN) or deep radial nerve • passes between 2 heads of supinator |
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Radial Tunnel Syndrome - Causes
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• fibrous tendinous band at origin of supinator (30%) or hypertrophy
• ECRB fascial fibrosis • thickening of Arcade of Frohse • RA of elbow • Monteggia fracture/dislocation • surgical resection of radial head |
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Radial Tunnel Syndrome versus Tennis Elbow Syndrome - Aggravating Factors
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Tennis Elbow
• wrist extension & ulnar deviation Radial Tunnel Syndrome • forearm supination |
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Radial Tunnel Syndrome versus Tennis Elbow Syndrome - Resisted Movements
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Tennis Elbow
• pain &/or weakness with wrist extension + RD Radial Tunnel Syndrome • pain &/or weakness with supination |
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Radial Tunnel Syndrome versus Tennis Elbow Syndrome - Special Tests
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Tennis Elbow
• +ve tennis elbow test Radial Tunnel Syndrome • +ve tennis elbow test • +ve middle finger test • - ve Tinel’s test as the PIN is a motor nerve |
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Median Nerve - Sites of Compression
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• lacertus fibrosus
• between 2 heads of pronator teres (aka pronator teres syndrome) • fibrous arcade of FDS • under the ligament of Struthers |
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Pronator Teres Syndrome - Causes
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• repeated minor trauma
• repetitive use of the elbow • fracture/fracture dislocation • tight/scarred lacertus fibrosus • tendinous bands in pronator teres • abnormal anatomy of pronator teres • tight fibrous arch at proximal FDS |
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Pronator Teres Syndrome - Signs
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• aching fatigue in forearm after heavy use
• clumsiness • vague, intermittent paraesthesia but rarely numbness in the median nerve distribution in the hand |
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Pronator Teres Syndrome - Symptoms
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• motor - weakness in the median innervated thenar muscles (LOAF)
• normal function of muscles innervated by the AIN • thenar & proximal forearm wasting • local TOP to deep pressure with reproduction of symptoms • +ve Tinel’s test • pain on resisted pronation of the forearm with the elbow flexed = pronator teres is the site of entrapment • pain on resisted flexion of the D3 PIP joint = FDS arch the site of entrapment • pain on resisted elbow flexion & supination = lacertus fibrosus the site of entrapment |
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Pronator Teres Syndrome - Commonalities with Cubital Tunnel Syndrome
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• numbness + paraesthesia in the median innervated digits
• weakness of the thenar muscles • pain in the wrist and/or forearm |
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Pronator Teres Syndrome - Differences with Cubital Tunnel Syndrome
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• no nocturnal complaints
• no +ve Tinel's sign at the wrist but not over the anterior forearm • NCS may be delayed but not at the wrist • dysesthesia in the palmar triangle at base of the thumb • repeated pronation & supination exacerbates PTS but not CTS |
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Ulnar Paradox
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• "the closer the Paw, the worse the Claw"
• ulnar nerve innervates 1/2 of FDP • proximal ulnar nerve injury = potential denervation of FDP • flexion of the IP joints is weakened - reduces claw-like appearance b/c 4th & 5th fingers are paralyzed in extension • the more proximal the injury - the lesser the deformation and clawlike appearance of the hand - one would normally expect a more proximal and thus debilitating injury to result in a more deformed appearance • deformity will GET WORSE with re-innervation |
