Upper Extremity Compression Neuropathies John Dougherty, DO, FACOFP, FAOASM, FAODME Dean Touro University Nevada AOASM Annual Mee@ng Las Vegas 2017
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
A 23 year old first year medical student is par@cipa@ng in OMM lab when she no@ces she is having a hard @me 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
Axillary - Altered Sensation
Axillary Causes of Lesion
Axillary Causes of Lesion
The suspected e@ology 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
Quadrilateral Space Syndrome (QSS): Backpack Shoulder Triceps weakness
Saturday Night Palsy Radial Nerve Palsy
Cubital tunnel syndrome Pain, numbness or @ngling 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
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. Seddon has classified nerve injuries in order of severity into 3 categories: Neuropraxia Axonotmesis Neurotmesis
Normal Function
Neuropraxia
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
Axonotemsis
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 a @mely fashion and if the axon regenerates Expect 1 mm/day, 1 cm/wk, 1 inch/month
Neurotmesis
Neurotmesis the most serious injury. The nerve is completely severed or unable to func@on secondary to scar @ssue Although recovery may occur, it is never complete, secondary to loss of nerve con@nuity, 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 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
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
Upper Arm Elbow Forearm
Ulnar 2nd most common peripheral nerve entrapment syndrome
Ulnar Cell Phone Elbow Late Cocking/ Early accelera@on phase Wrestling
Median
Median Late cocking through accelera@on phase Pianists
Radial Humerus Fracture
Radial Radial Nerve Palsy Saturday Night Palsy Compression in spiral groove
Radial Tennis Elbow Lateral Epicondyli@s
Radial Nursemaids elbow
Radial Resistant tennis elbow
Radial
Radial Posterior Interosseous Syndrome
Wrist
Ulnar
Ulnar S@ck and Racquet sports Flute and Violin players
Ulnar Handle Bar Palsy
Median
Median Carpal Tunnel Syndrome Bilateral in 50% of cases Associated with workplace repe@@ve hand ac@vi@es Hand paresthesia's occur in 30% of computer users Wheelchair Racket sports Volleyball
Median Archery Cycling Racquet and S@ck sports Gymnas@cs
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 started in the early stages following nerve injury in order to maintain range of mo@on and minimize muscle atrophy Splin@ng or bracing to alleviate the compressive insult
Questions