Dina Hazwani binti AzlangOrthopedics Posting

4th Year 28th December 2009

DefinitionNerve compression/entrapment is the

restriction in the space around a nerve that can occur due to several reasons.

Functioning of the nerve is compromised.

PATHOPHYSIOLOGYWherever peripheral nerves traverse fibro-

osseous tunnels → high risk for entrapment and compression

What condition??1. Soft tissue increase in bulk.

• Pregnacy,myxoedema and RA

2. Local obstruction.• Ganglion, osteophytic spur

When compressed Epineural blood flowAxonal conduction

Results inNumbnessParaesthesiaMuscle weakness

impaired

symptoms

Decompression leads to improvement of the symptoms

But, in prolong or severe compression, decompression not resolve the symptoms

It leads to segmental demyelination, target muscle atrophy and nerve fibrosis

ULNAR NERVE ENTRAPMENT

Ulnar nerve entrapment occurs when the ulnar nerve in the arm becomes compressed.

> common at the elbow than wrist.Elbow- cubital tunnelWrist - Guyon's canal

Definition

ANATOMY It travels from under the collarbone and along the

inside of the upper arm. It passes through a tunnel of tissue (the cubital

tunnel) behind the inside of the elbow. Here you can feel the nerve through the skin. It is commonly called the " funny bone. " 

1. Cubital tunnel syndrome

A.k.a cell phone elbow,referred to as ulnar neuropathy at elbow level.

Ulnar n.(UN) easily felt behind the medial epicondyle of humerus.

It can be trapped/compressed: Within the cubital tunnel →by bone abN, ganglion,

hypertropic synovium. Proximal to the cubital tunnel Distal to cubital tunnel.

Causes:Stretched by a cubitus valgus deformity.Holding the elbow flexed in long period s.a driving or

talking on the phone.Swelling of the elbow joint, cysts

Clinical featurespain in the forearm → radiates in the

distribution of the ulnar nerveNumbness & tingling in the 5th and ulnar

half of 4th fingerswasting or weakness of intrinsic hand

muscles the reproduction of symptoms with elbow

flexion, with or without wrist extension weakness of the abductor digiti mini.Tinel’s test: tenderness over the nerve

behind the medial epicondyle.

Diagnosis Confirmed by conduction test.However, since the symptoms are often

postural n activity related→ -ve test does not excluded the dx

Treatment Conservative:

Modification of the posture.Splintage of the elbow in mid-extension

If symptoms persist- surgical decompression.

2. Ulnar tunnel syndrome(Guyon canal)

Anatomy: This is the triangular

canal at the base of the ulnar side of the palm.

Laterally - hook of the hamate and transverse carpal ligament.

Medially - pisiform and the attachments of the pisohamate ligament.

Both the ulnar nerve and artery traverse the canal to enter the hand.

As the nerve enters the hand, it travels through another tunnel (Guyon's canal).

CausesRepeated blunt trauma Fractures of the hook of the hamate can

impinge on the nerve. Tumors such as ganglia or lipomas,

anomalous muscle bellies, or hypertrophy of the palmaris brevis.

Aneurysm of the ulnar artery may compress the nerve.

Clinical featuresNumbness, tingling and paresthesias Pain in an ulnar distribution of the palm and

finger Cold intolerance in the ring and half of small

fingersNormal sensation in the dorsal sensory

cutaneous branch of the ulnar nerve A positive Tinel or Phalen sign.

Thoracic outlet syndrome Condition whereby symptoms are produced

from compression of brachial nerves or blood vessels, or both, because of an inadequate passageway through an area (thoracic outlet) between the base of the neck and the armpit.

The thoracic outlet is surrounded by muscle, bone, and other tissues.

Clinical features neck, shoulder, and arm pain, numbness,impaired circulation to the extremities

(causing discoloration). Often symptoms are reproduced when the

arm is positioned above the shoulder or extended.

Pains can extend to the fingers and hands, causing weakness.

Adson, Wright,Roos test - +ve

TreatmentConservative - physical-therapy exercises and

avoiding certain prolonged positions of the shoulder

Surgical treatment indicated if pain is severe, obvious muscle wasting or vascular disturbances.

Double crush syndromeDouble crush syndrome refers to a situation in which

there is compression or local irritation of a peripheral nerve at several separate sites along its course.

An example of this is coexistent C6 radiculopathy (neck site) and carpal tunnel syndrome (wrist site). 

Other examples of the double crush syndrome might be TOS plus CTS and TOS associated with ulnar neuropathy.

Causes : multiple injury sites in repetitive strain injuries

Double crush theoryThe "double crush" theory proposes that

when the double compression is cumulative and cause impairment of conduction and is sufficient to cause symptoms such as motor or sensory impairment.

Clinical Manifestationclinical manifestation of double crush is due to

impaired nerve conduction, and consists of neurological deficit such as

muscle weakness , grip deficit, orwasting or sensory deficit, andnot just vague aches or pains.

On examination,Positive Tinel's sign at multiple sites (i.e., Erb'spoint, cubital tunnel as well as the carpaltunnel).

Managementspine and extraspinal manipulation, myofascial release adjunctive

physiotherapies rehabilitative exercises

Thank YOU for your

ATTENTION!!!

Good Luck in Examination…