Upper Extremity Compression Neuropathies. John Dougherty, DO, FACOFP, FAOASM, FAODME Dean Touro University Nevada AOASM Annual Las Vegas 2017

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1 Upper Extremity Compression Neuropathies John Dougherty, DO, FACOFP, FAOASM, FAODME Dean Touro University Nevada AOASM Annual Las Vegas 2017

2 Nerve L. nervus - sinew Axon Gr. axon - axis - praxia Gr. praxis ac@on - tmesis cuong Tunnel Old English - covered passageway Canal L. canalis pipe Groove - Norse grof "brook, river bed

3 A 23 year old first year medical student is in OMM lab when she she is having a bending her arm at the elbow and has difficulty raising her arm at the shoulder. Her lab partner does an exam and finds no signs of impingement or RC weakness. She does no@ce that she has some numbness over the deltoid. You suspect which of the following is impacted? A. Spinal Accessory (CN XI) nerve B. Axillary nerve C. Long Thoracic nerve D. Suprascapular nerve E. Brachial Plexus

4 Axillary - Altered Sensation

5 Axillary Causes of Lesion

6 Axillary Causes of Lesion

7 The suspected of this diagnosis is due to which of the following? A. Improper Kirksville Crunch technique B. Falling asleep in class with her arm draped over her the back of the chair C. Her extensive use talking on her cellphone D. Excessive use of the mouse on her computer E. Her 70 pound backpack slung over her shoulder

8 Quadrilateral Space Syndrome (QSS): Backpack Shoulder Triceps weakness

10 Saturday Night Palsy Radial Nerve Palsy

Cubital tunnel syndrome Pain, numbness or @ngling of forearm,

loss of muscle strength, coordina@on and mobility; Symptoms are

12 Cubital tunnel syndrome Pain, numbness of forearm, Ulnar nerve compression Cell phone elbow Symptoms include a loss of muscle strength, coordina@on and mobility; Symptoms are not treated, the ring and pinky finger can eventually become clawed

13 What type of injury has occurred to the affected nerve? Neuropraxia Axonotmesis Neurotmesis

Nerve injury secondary to compression or trac@on depends on intensity and dura@on.

14 Nerve injury secondary to compression or depends on intensity and Seddon has classified nerve injuries in order of severity into 3 categories: Neuropraxia Axonotmesis Neurotmesis

15 Normal Function

16 Neuropraxia

17 Neuropraxia A transient episode of motor paralysis with liile or no sensory or autonomic dysfunc@on No disrup@on of the nerve or its sheath occurs incomplete nerve injury With removal of the compressing force, recovery should be complete and rela@vely rapid

18 Axonotemsis

19 Axonotmesis A more severe nerve injury Interup@on of axons & myelin sheath, nerve stroma intact Motor, sensory, and autonomic paralysis results Recovery can occur if the compressing force is removed in fashion and if the axon regenerates Expect 1 mm/day, 1 cm/wk, 1 inch/month

20 Neurotmesis

21 Neurotmesis the most serious injury. The nerve is completely severed or unable to secondary to Although recovery may occur, it is never complete, secondary to loss of nerve require surgery

The e@ology of compression neuropathy may be related to mechanical or dynamic causes Compression, trac@on or scarring can trap a nerve at different points

23 The of compression neuropathy may be related to mechanical or dynamic causes Compression, or scarring can trap a nerve at different points along its course may cause denerva@on of muscles and numbness or paresthesias in the distribu@on of that nerve The result can be pain, weakness, and dysfunc@on

24 Compression of a peripheral nerve leads to impaired venous return Intraneural edema follows Diminished axoplasmic transporta@on and decreased efficiency of the sodium pump promote membrane instability All these factors impede signal conduc@on along the path of the nerve

25 Upper Arm Elbow Forearm

26 Ulnar 2nd most common peripheral nerve entrapment syndrome

27 Ulnar Cell Phone Elbow Late Cocking/ Early phase Wrestling

28 Median

29 Median Late cocking through phase Pianists

31 Radial Humerus Fracture

32 Radial Radial Nerve Palsy Saturday Night Palsy Compression in spiral groove

33 Radial Tennis Elbow Lateral

34 Radial Nursemaids elbow

35 Radial Resistant tennis elbow

36 Radial

37 Radial Posterior Interosseous Syndrome

38 Wrist

39 Ulnar

40 Ulnar and Racquet sports Flute and Violin players

41 Ulnar Handle Bar Palsy

42 Median

43 Median Carpal Tunnel Syndrome Bilateral in 50% of cases Associated with workplace hand Hand paresthesia's occur in 30% of computer users Wheelchair Racket sports Volleyball

44 Median Archery Cycling Racquet and sports

46 Radial Nerve Wartenberg Syndrome

Depends on the cause, the severity and the site of the lesion An@- inflammatories and analgesics are indicated to relieve inflamma@on and pain Physical therapy should be

48 Depends on the cause, the severity and the site of the lesion inflammatories and analgesics are indicated to relieve and pain Physical therapy should be started in the early stages following nerve injury in order to maintain range of and minimize muscle atrophy or bracing to alleviate the compressive insult

49 Questions

Learning Objec'ves. Differen'al Diagnosis of Radial Tunnel Syndrome and Lateral Epicondylosis. Learning Objec'ves. Learning Objec'ves 2/9/15

Learning Objec'ves. Differen'al Diagnosis of Radial Tunnel Syndrome and Lateral Epicondylosis. Learning Objec'ves. Learning Objec'ves 2/9/15 Differen'al Diagnosis of Radial Tunnel Syndrome and Lateral Epicondylosis James J. Lehman, DC, MBA, FACO Director Health Sciences Postgraduate Educa'on University of Bridgeport. Learning Objec'ves Correlate