Pain & Paraesthesia in the Upper Limb

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1 Pain & Paraesthesia in the Upper Limb Dr. PC Ho Numbness Paraesthesia Paraesthesia =?? Pain Consultant & Chief Division of Hand & Microsurgery Department of Orthopaedic & Traumatology Prince of Wales Hospital Paresthesia Hyperesthesia Hypoesthesia Anaesthesia Dysesthesia Causes of Paraesthesia Neurogenic Vascular Psychological Neurogenic Causes Mechanisms Cerebral cortex Spinal cord Cord Root Brachial Plexus Peripheral Nerve Main course Terminal fibre Inflammation Traumatic injury Tumour infiltration Degenerative Mechanical compression/irritation 1

2 Nerve Entrapment Mass lesion Scarring Abnormal fibrous band Aberrant vessel Aberrant muscle Osteophyte Pattern of Paraesthesia Radiation Symmetry LL Involvement Distribution Motor symptoms Associated Symptoms Posture related Symptoms Distribution Associated Symptoms Dermatome Peripheral Nerve Glove & Stock Vasovagal Neck Shoulder Elbow Wrist Posture Related Neck movement Shoulder overhead activity Elbow Prolonged flexion Wrist Flexion/Extension Common Entrapment Thoracic Outlet Syndrome Cubital Tunnel Syndrome Carpal Tunnel Syndrome Double Crash Syndrome 2

Aware of the uncommon Radial Tunnel Syndrome PronatorSyndrome Guyon canal compression Posterior interosseous nerve entrapment Quadrilateral space syndrome

3 Aware of the uncommon Radial Tunnel Syndrome PronatorSyndrome Guyon canal compression Posterior interosseous nerve entrapment Quadrilateral space syndrome Superscapular nerve entrapment Approach to Entrapment Where is the site ( level of compression ) of the peripheral nerve? At the wrist? At the elbow? At the thoracic outlet? Paraesthesia in the Upper Limb Assessment of a peripheral nerve lesion : Remember : Sensation : the Dermatomes Muscle power : Myotomes Autonomous zome Radial Nerve Median Nerve Ulnar nerve Important Techniques Radial Nerve Palpation of nerve Tinel sign Nerve Percussion Ulnar nerve Median Nerve Provocative tests Compression Stretching 3

4 Provocative Tests in Wrist Phalentest Reversed Phalen Direct compression Sphygomanometer compression Guyon canal compression Provocative Tests in Elbow Cubital Tunnel Syndrome Elbow Flexion Test Radial Tunnel Syndrome Hyperpronation Resisted supination Finger extension Provocative Tests in Thoracic Outlet Roo s test Wright s test (Hyperabduction) Adson stest Costo-Clavicular Compression (CCC) Quantification of Sensory Loss 2-point discrimination Monofilament test Investigation Nerve conduction velocity Electromyogram Imaging USG MRI Distal Motor Latency Sensory Conduction velocity Amplitude Motor conduction velocity 4

Some examples of motor nerve Stimulation (

Distal Proximal Myopathic EMG <4ms >50m/s

5 Some examples of motor nerve Stimulation ( motor conduction Velocity ) Normal EMG The nerve segment Is abnormal between The 2 sets of electrodes Neurogenic EMG Neuropathy or the nerve was Cut further proximally. Distal Proximal Myopathic EMG <4ms >50m/s Carpal Tunnel Syndrome Carpal Tunnel Syndrome Commonest in yrs old F:M =3-4:1 Work-related CTS : higher % of male Incidence : 1 in 1000 (USA, 1994) Bilateral 50% 5

Carpal Tunnel Syndrome Idiopathic in majority Need to r/o secondary causes DM : without neuropathy 14% with

Watch out for congenital anomaly in younger patients Splint Local steroid injection Conservative Rx Medication:

Exercise Intermittent finger and wrist exercise decrease CT pressure Yoga Tendon & nerve gliding Improve failure

tunnel pressure vary with wrist position (Weiss 1995) Least pressure at 2 ±9 flexion & 1 ±9 ulnar deviation

muscles / lumbrical Indication for surgery Open Release Fail to conservative Rx for 3-6 months Sensory deficit

paraesthesia Phalen test +ve in <30 sec.

6 Carpal Tunnel Syndrome Idiopathic in majority Need to r/o secondary causes DM : without neuropathy 14% with neuropathy 30% Pregnancy 50% Obesity Hypothyroidism Renal disease/amyloidosis Acromegaly Inflammatory arthritis Watch out for congenital anomaly in younger patients Splint Local steroid injection Conservative Rx Medication: Oral steroid * Pyridoxine (Vitamin B 6 ) Diuretics NSAID Physiotherapy Ultrasound Iontophoresis with dexamethasone Exercise Intermittent finger and wrist exercise decrease CT pressure Yoga Tendon & nerve gliding Improve failure rate from 71% to 43% Activity modification Tendon & Nerve Gliding Exercise Wrist Splint Neutral position Carpal tunnel pressure vary with wrist position (Weiss 1995) Least pressure at 2 ±9 flexion & 1 ±9 ulnar deviation Nocturnal vs day use Influence of MCPJ Highest pressure with MCPJ in full extension/flexion Extrinsic flexor muscles / lumbrical Indication for surgery Open Release Fail to conservative Rx for 3-6 months Sensory deficit Motor deficit CTS 2 to SOL in carpal tunnel Poor prognostic signs (Kaplan) Age >50 Duration > 10 months Constant paraesthesia Phalen test +ve in <30 sec. Stenosing flexor tenosynovitis Failure rate : 7-25% Prolonged scar sensitivity : 36% Hypertrophic scar : 1-5 % Palmer cut. nerve injury : 4-6.5% Neurapraxia : 6.5% Grip weakness up to 3-6 months Success : 86.8% -91% Hour-glass Deformity 6

7 Limited Open CTR Endoscopic carpal tunnel release (ECTR) Endoscopic carpal tunnel release (ECTR) 5 Camitz transfer with palmaris longus 7

8 Pronator Teres Humeral Head (cut Away). Ulnar head Netter Median Nerve Fibrotic Origin of The FDS Median Nerve The Median nerve may also be compressed at other sites along its course. Shown here the humeral head of the pronator teres is cut away, and the fibrotic arc like origin of the flexor digitorum superficialis is seen. These structures may compress the nerve, causing the Pronator Syndrome and the Anterior Interosseous Nerve Syndrome. Cubital Tunnel Syndrome The ulnar nerve is asking for trouble!! 8

Intraneural pressure Pechan J (J Biomech 1975) Elbow extended 7mmHg Elbow flexed to

Orthop Scand 1985) 10 patients with CuTS Elbow extended 8 mmhg Elbow flexed 41-86 mm

elbow Paresthesia and alteration of sensation over ulnar 1 ½ digits and ulnar dorsum

Clumsiness Dropping things Weakness Dystonia like Usually no pain Intrinsic wasting,

variation Anomalous communication between ulnar and median nerve Anomalous median

Claw hand Dorsal sensory spare FDP(V), FCU NCT false ve in 50%.

nerve thickening Tinel sign Subluxability of nerve Osteophyte Elbow flexion test

9 Intraneural pressure Pechan J (J Biomech 1975) Elbow extended 7mmHg Elbow flexed to 90 deg 11 mmhg Wrist extended 18 mmhg Shoulder elevated 46 mmhg Werner CO (Acta Orthop Scand 1985) 10 patients with CuTS Elbow extended 8 mmhg Elbow flexed mm Hg FCU stimulated mmhg Cubital Tunnel Syndrome Ulnar nerve entrapment at elbow Paresthesia and alteration of sensation over ulnar 1 ½ digits and ulnar dorsum of hand symptom aggravation by elbow flexion Subtle loss of motor functions Clumsiness Dropping things Weakness Dystonia like Usually no pain Intrinsic wasting, loss of sensation Cubital Tunnel Syndrome Myelopathy/T1 vs Ulnar nerve Clinical variation Anomalous communication between ulnar and median nerve Anomalous median nerve motor branch innervation 3rd and 4th lumbricals Proximal vs distal compression Claw hand Dorsal sensory spare FDP(V), FCU NCT false ve in 50%. FROMENT SIGN Cubital Tunnel Syndrome Look for elbow sign Cubital valgus ROM Ulnar nerve thickening Tinel sign Subluxability of nerve Osteophyte Elbow flexion test Elbow pathology Lateral condyle non-union OA elbow Subluxable ulnar nerve Look for wrist sign Wrist deformity Direct compression Guyon canal Tinel sign 9

10 Sites of Compression Conservative Rx Absence of any detectable sensory/motor deficit Soft elbow splint in extension Adjust elbow posture/loading Avoid prolonged elbow flexion for 3 months (80%) Local steroid Depigmentation Fat necrosis Nerve injury NSAID, pyridoxine Surgical Rx Decompression in situ Decompression + medial epicondylectomy (King & Morgan 1950) Anterior transposition of ulnar nerve Sub-cutaneous (Roux 1897, Curtis 1898) Sub-muscular (Learmonth 1942) Intra-muscular (Adson 1918) Ulnar tunnel plasty Medial Epicondylectomy M Anterior Transposition of Ulnar Nerve 10

Above : Scalene muscles Thoracic Outlet Syndrome Clavicle Below: Deep to pectoralis Minor muscle Anatomically : thoracic

Neurogenic or Vasogenic symptoms are produced When these structures are compressed.

C8/T1 Fibrosis /edema around scalene muscle C2 Fibrous band Cervical rib (rare) Pancoast tumour Fracture clavicle, 1 st /2

Hyperabduction test A cervical rib may occur here, and usually passes deep to the nerves SA subclavian artery SV- vein

11 Above : Scalene muscles Thoracic Outlet Syndrome Clavicle Below: Deep to pectoralis Minor muscle Anatomically : thoracic outlet consists of region above the clavicle, Occupied by layers of the scalene muscles; deep to the clavicle, and Below it, deep to the pectoralis minor muscle. The important neuro- Vascular structures within it are : the brachial plexus, and the Subclavian vessels. Neurogenic or Vasogenic symptoms are produced When these structures are compressed. Thoracic Outlet Syndrome Assessment of TOS Compression of brachial plexus between 1 st rib and clavicle Commonly affect C8/T1 Fibrosis /edema around scalene muscle C2 Fibrous band Cervical rib (rare) Pancoast tumour Fracture clavicle, 1 st /2 nd rib General : Roo s test Above clavicle : Adson test Behind clavicle : Costo-clavicular manoeuvre Below clavicle : Hyperabduction test A cervical rib may occur here, and usually passes deep to the nerves SA subclavian artery SV- vein Scalene Medius SA Normal Anatomy Scalene Anticus SV For the region above the clavicle, the scalene muscles lie in front of and behind the neurovascul ar structures, and may compress them. Arteriogram of The subclavian artery Compression by The clavicle During abduction Of the shoulder 11

Cervical Rib TOS Middle aged women Obese, short neck, large breast Slouch posture SA

presentation (rare) Clinical Dx by exclusion Provocative Test Roo s test Wright

Maneuver) Tinel sign at Erb s point Conservative Rx Anxioltyic Weight reduction

/ shoulder physiotherapy Steroid injection to Erb spoint Surgical Rx Pain in the

12 Cervical Rib TOS Middle aged women Obese, short neck, large breast Slouch posture SA SV Anxious personality Excessive overhead activities Neurogenic vs Vascular presentation (rare) Clinical Dx by exclusion Provocative Test Roo s test Wright hyperabduction test Adson s test Costo-clavicular compression test (Halstead Maneuver) Tinel sign at Erb s point Conservative Rx Anxioltyic Weight reduction Muscle relaxation/ stretching Scapular musicle strengthening Postural exercise Neck / shoulder physiotherapy Steroid injection to Erb spoint Surgical Rx Pain in the Upper Limb Seldom required Scalenectomy 1st rib resection Referred pain Pain of systemic involvement Regional pain 12

13 Regional Pain Syndrome- An Approach Clarification of symptom Severity Working diagnosis Investigation Treatment plan Clarification of Symptoms Onset Nature Site Pattern Aggravation factors Relieving factors Associated symptoms Severity Pain score Visual Analogue Scale(VAS) Sleep ADL Work Self care Leisure Feeding Dressing Bathing Toileting Grooming Self Care Traumatic Degenerative Inflammatory Metabolic Infective Neoplastic Neurogenic Psychogenic Etiologies Source of Pain Bone Joint Chondralcartilage Synovium Peri-articular Soft Tissue Tendon Nerve Vessel Skin 13

14 Regional Pain Hand Wrist Common Causes Forearm Elbow Pain in Hand Osteo-arthritis DIPJ CMCJ Rheumatoid Arthritis PIPJ MCPJ Trigger finger (Stenosing Tenovaginitis) Infection Trauma 4 14

15 The pathology lies at the origin of the digital fibrous flexor sheath, also known as the A1 pulley by the Hand Surgeons. 6 A cadaveric specimen showing the A1 pulley. The gree line shows where the surgical release will be. A1 pulleys Notice that the digital neurovascular bundles are very close to the sides of the flexor tendons and the A1 pulleys. Percutaneous Release Open release 15

16 11 9 Site Radial Central Ulnar Diffuse Pain in Wrist Common causes Fracture scaphoid, distal radius, triquetrum Arthritis RA Gout Pseudo-gout Tenovaginitis Dequervain disease Ligamentous injury TFCC (Triangular fibrocartilage Complex) SL (Scapho-lunate ligament) Occult ganglion 16

$Test A case of Scaphoid fracture.$ $weeks, therefore the fracture line is$ The acute case is more subtle, hence

17 Superficial radial nerve First extensor compartment deep to the extensor retinaculum Extensor Pollicis Brevis Abductor Pollicis Longus Finkelstein Test A case of Scaphoid fracture. This fracture has occurred over a few weeks, therefore the fracture line is more sclerotic and distinct. The acute case is more subtle, hence frequently missed. S Notice also here the space distal to the ulnar head and styloid (S), which is occupied by the Triangular Fibrocartilage Complex (TFCC) 17

You may also noticed that there is an abnormal shape of the Lunate

$scaphoid fracture, a complex injury known as Perilunate fracture$ $An acute scaphoid fracture is usually rather subtle, and the fracture$ $The fracture line subtle The fracture is shown clearly by CT scan : A$ under X-ray control, as is shown here.

Protection is required until bone union which takes about 3 months.

Its function is like a meniscus, and also binds the radius and ulnar

$When in this case there is a fracture in the styloid, the TFCC may be$

18 You may also noticed that there is an abnormal shape of the Lunate bone, There was actually dislocation of the lunate, together with the scaphoid fracture, a complex injury known as Perilunate fracture dislocation. An acute scaphoid fracture is usually rather subtle, and the fracture line unclear. Then, what can you do? The fracture line subtle The fracture is shown clearly by CT scan : A scaphoid fracture may be stabilized by a screw passed percutaneously under X-ray control, as is shown here. The patient can then has early mobilization ( not exertion ). Protection is required until bone union which takes about 3 months. The TFCC occupies the space distal to the ulnar head. Its function is like a meniscus, and also binds the radius and ulnar together. It attaches to the ulnar styloid. When in this case there is a fracture in the styloid, the TFCC may be ruptured. The TFCC may also be injured where there is no fracture. Triangular Fibrocartilage Complex Dorsal capsule & Bed of ECU tendon This schematic picture shows you what the TFCC looks like. There are also other attahments to the dorsal and palmar aspect of the TFCC. 18

19 This patient has a chronic rupture of TFCC and instability of the distal ulnar, shown here as a prominence of the ulnar head. Ulnar Impaction Syndrome Pain in Elbow Tennis elbow Golfer elbow Osteoarthritis Radial-tunnel syndrome Cubital tunnel syndrome Infalmmatory arthritis 19

PIN Nerve The posterior interosseous nerve is the motor branch

It passes through the supinator muscle before supplying the

The nerve may therefore be compressed by the supinator muscle.

The presentation is very similar to tennis elbow, except that

and also the pattern of muscle weakness is different.

demonstrated here after cutting open the supinator muscle.

20 PIN Nerve The posterior interosseous nerve is the motor branch of the radial nerve that supplies the extensor muscles. It passes through the supinator muscle before supplying the extensor muscles in the dorsal aspect of forearm. The nerve may therefore be compressed by the supinator muscle. The condition is therefore also known as Supinator Syndrome. The presentation is very similar to tennis elbow, except that the site of tenderness lies more distally over the muscle belly, and also the pattern of muscle weakness is different. The full course of the Posterior Interosseous Nerve is demonstrated here after cutting open the supinator muscle. The superficial radial nerve, a sensory nerve, travels deep to the brachioradialis and follows a different course. D101 D101 20

Update on Management of Common Hand Disorders Dr. PC Ho

Update on Management of Common Hand Disorders Dr. PC Ho Head, Division of Hand & Microsurgery Department of Orthopaedic & Traumatology Prince of Wales Hospital Common Hand Disorders Compression Neuropathy