Median nerve injury

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Presentation Description

Median nerve palsy and management

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Presentation Transcript

Median Nerve injuries : 

Median Nerve injuries Presented By M.Mathanraj David

Median nerve : 

Median nerve Anatomy Derived from C5-T1 Runs medial to axillary and brachial arteries Passes deep to bicipital aponeurosis and flexor muscle mass 80% passes between two heads of pronator teres Continues between FDS and FDP Emerges in forearm radial to superficialis tendons Passes under transverse carpal ligament

Median nerve : 

Median nerve

Median nerve : 

Median nerve Anatomy Superficial trunk supplies: Pronator teres FCR PL FDS index Deep trunk supplies (anterior interosseus nerve): FDP to index and middle FPL Pronator quadratus Sensation to radial carpal joint

Median nerve injury : 

Median nerve injury

Median nerve : 

Median nerve Anatomy 5-6 cm proximal to anterior wrist crease Palmar cutaneous branch Innervates skin at base of palm Does not pass through carpal tunnel Beneath transverse carpal ligament Recurrent motor branch Supplies thenar muscles, 1st and 2nd lumbricals Three proper digital nerves and two common digital nerves

Etiological factors : 

Etiological factors A. Elbow level - High median nerve lesion B. Wrist level - Knife cuts C. Carpal tunnel - Dislocated lunate bones - Chronic compressions

Clinical features : 

Clinical features Pointing index Inability to flex IP joint of thumb Ape thumb deformity Pencil test for APB Oppones palsy. Sensory signs

Median nerve : 

Median nerve

Hand function evaluation : 

Hand function evaluation

Tendon Transfers : 

Tendon Transfers

Tendon Transfers : 

Tendon Transfers Definition The Detachment Of A Functioning Muscle-Tendon Unit From Its Insertion And Reattachment To Another Tendon Or Bone To Replace The Function Of A Paralyzed Muscle Or Injured Tendon

Tendon Transfers : 

Tendon Transfers Indications Restore Function To A Muscle Paralyzed As A Result Of Injury Of The Peripheral Nerves, Brachial Plexus Or Spinal Cord To Restore Function After Closed Tendon Ruptures Or Open Injuries To The Tendons Or Muscles Restore Balance To A Hand Deformed From Neurological Conditions

Tendon Transfers : 

Tendon Transfers General Principles Straight Line Of Pull Expendable Donor Adequate Strength Correction Of Contracture One Tendon – One Function Amplitude Of Motion Synergism Tissue Equilibrium

Tendon TransfersMedian Nerve Palsy : 

Tendon TransfersMedian Nerve Palsy Reconstructive Goals Thumb Opposition FPL Function Index FDP Function Sensation Prime Determinant In Hand Function Restoration Of Sensation Abandoned Neurovascular Island Flaps

Tendon TransfersMedian Nerve Palsy : 

Tendon TransfersMedian Nerve Palsy Classification High Above Origin Of Anterior Interosseous Nerve Pronator Teres And Quadratus, FCR, FDS (II – V), FDP(II & III) And FPL Paralyzed Low Thenar Intrinsic Muscles Paralyzed Abductor Pollicis Brevis, Opponens Pollicis, And Superficial Head Of Flexor Pollicis Brevis

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Deficit And Deformity Abduction And Opposition Frequently Retained Due To Diverse Innervation Of Intrinsics Median And Ulnar Nerves

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Prevention Of Contractures Good Therapy And Splinting Position Of Thumb Supinated And Adducted Contracted First Web Space Correct Contracture Before Opponensplasty Release Fascia Over Adductor Pollicis And First Dorsal Interosseous

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Pulley Design Straight Line Of Pull Reduced Friction And Work Tendon Migrates To Run In Straight Line

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Opponensplasty Insertions Abductor Pollicis Brevis Radial Aspect Of Thumb Produces Good Opposition Dual Insertions Probably Unnecessary Attempt Opposition Plus Stabilization

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Standard Opponensplasties FDS Opponensplasty Royle-Thompson Technique Bunnell Technique Extensor Indicis Proprius Opponensplasty Huber Transfer Abductor Digiti Minimi Camitz Procedure Palmaris Longus

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy FDS Opponensplasty – Royle-Thompson FDS Brought Around Ulnar Border Of Palmar Aponeurosis FDS Has A Large Potential Excursion Adjusting Tension Not As Critical Margin For Error

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy FDS Opponensplasty – Bunnel Technique Ring Finger FDS Divided FCU Exposed 4cm Proximal To Pisiform Insertion Tendon Split Into Two Halves Free End Looped Back Onto Its Base Ensure Loop Not Too Tight

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Sublimis Tendon Harvest Ring Finger Commonly Used As Motor May Weaken Power Grip Some Surgeons Prefer Middle Finger Recommend Division Proximal To Bifurcation Avoids Destruction To Vincula Does Not Disrupt Blood Supply To FDP Avoids Injury At The Level Of The PIP Possible Stiffness

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Sublimis Tendon Harvest Potential Complications Swan-Neck Deformity Suture Distal Ends Of Tendon Across Palmar Plate – Prevent Hyperextension DIP Joint Extension Lags

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Extensor Indicis Proprius Opponensplasty Popular In High Median Nerve Palsy Ring And Middle FDS Unavailable Does Not Weaken Grip Tendon Must Be Superficial To FCU Avoid Compression To Ulnar Nerve

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Huber Transfer Difficult Procedure Neurovascular Pedicle Easily Damaged Dorsoradial Aspect Insertions Divided Base Of Prox. Phalynx And Ext. Apparatus Freed Off Pisiform Attachments To FCU Retained Attached To Abductor Pollicis Brevis Insertion

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Camitz Procedure Usually For Complication Of Severe Carpal Tunnel Syndrome Performed At Same Time As Carpal Tunnel Release Restores Palmar Abduction Rather Than Opposition Not Recommended With Traumatic Median Nerve Injuries Palmaris Longus Usually Scarred

Tendon TransfersLow Median Nerve Palsy : 

Tendon TransfersLow Median Nerve Palsy Other Options For Opponensplasty Extensor Carpi Ulnaris Extensor Carpi Radialis Longus Extensor Digiti Minimi Flexor Pollicis Longus Extensor Pollicis Longus

Tendon TransfersHigh Median Nerve Palsy : 

Tendon TransfersHigh Median Nerve Palsy Deficit All Flexor Compartment Forearm Muscles Apart From Ulnar-Innervated FCU And FDP Aim Of Tendon Transfers Flexion Of Index And Thumb Opposition Potential Motors Brachioradialis  FPL ECRL  Index FDP

Tendon TransfersHigh Median Nerve Palsy : 

Tendon TransfersHigh Median Nerve Palsy Timing Of Transfers Dependent On Prognosis Sensory Deficit Most Important Disability Early Transfers Should Be Attached End-To-Side – If Reinnervation Expected Act As Internal Splint

Tendon TransfersHigh Median Nerve Palsy : 

Tendon TransfersHigh Median Nerve Palsy Extrinsic Transfers Restoration Of Index Function ECRL  Index FDP Side-To-Side Suturing Of Profundus Tendons Restores Range Of Motion Strength Is Not Restored Restoration Of Thumb Function Brachioradialis  FPL

Tendon TransfersHigh Median Nerve Palsy : 

Tendon TransfersHigh Median Nerve Palsy Thumb Opposition Early Transfer Allows Pronation Of Hand Compensates For Loss Of Sensation Possible Transfers EIP EPL Extensor Digiti Minimi FCU – Eliminates Only Functioning Wrist Flexor

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome

Definition : 

Definition Carpal tunnel syndrome, the most common focal peripheral neuropathy, results from compression of the median nerve at the wrist.

epidemiology : 

epidemiology Affects an estimated 3 percent of adult Americans Three times more common in women than in men High prevalence rates have been reported in persons who perform certain repetitive wrist motions (frequent computer users) 30% hand paresthesias 10% clinical criteria for carpal tunnel syndrome 3.5% abnormal nerve conduction studies

Clinical Features : 

Clinical Features Pain Numbness Tingling Symptoms are usually worse at night and can awaken patients from sleep. To relieve the symptoms, patients often “flick” their wrist as if shaking down a thermometer (flick sign).

Clinical Features : 

Clinical Features Pain and paresthesias may radiate to the forearm, elbow, and shoulder. Decreased grip strength may result in loss of dexterity, and thenar muscle atrophy may develop if the syndrome is severe.

Atrophy : 

Atrophy

Physical examination : 

Physical examination Phalen’s maneuver Tinel’s sign weak thumb abduction. two-point discrimination

Phalen’s maneuver : 

Phalen’s maneuver

Tinel’s sign : 

Tinel’s sign

Diagnostic : 

Diagnostic History Physical examination Nerve Conduction Study

Differential Diagnostics : 

Differential Diagnostics Tendonitis Tenosynovitis Diabetic neuropathy Kienbock's disease Compression of the Median nerve at the elbow

Treatment : 

Treatment CONSERVATIVE TREATMENTS GENERAL MEASURES WRIST SPLINTS ORAL MEDICATIONS LOCAL INJECTION ULTRASOUND THERAPY Predicting the Outcome of Conservative Treatment SURGERY

GENERAL MEASURES : 

GENERAL MEASURES Avoid repetitive wrist and hand motions that may exacerbate symptoms or make symptom relief difficult to achieve. Not use vibratory tools Ergonomic measures to relieve symptoms depending on the motion that needs to be minimized

WRIST SPLINTS : 

WRIST SPLINTS Probably most effective when it is applied within three months of the onset of symptoms Optimal splinting regimen ?

WRIST SPLINTS : 

WRIST SPLINTS

ORAL MEDICATIONS : 

ORAL MEDICATIONS Diuretics Nonsteroidal anti-inflammatory drugs (NSAIDs) pyridoxine (vitamin B6) Orally administered corticosteroids Prednisolone 20 mg per day for two weeks followed by 10 mg per day for two weeks

ULTRASOUND THERAPY : 

ULTRASOUND THERAPY May be beneficial in the long term management More studies are needed to confirm it’s usefulness

SURGERY : 

SURGERY Should be considered in patients with symptoms that do not respond to conservative measures and in patients with severe nerve entrapment as evidenced by nerve conduction studies,thenar atrophy, or motor weakness. It is important to note that surgery may be effective even if a patient has normal nerve conduction studies

SURGERY : 

SURGERY Complications of surgery Injury to the palmar cutaneous or recurrent motor branch of the median nerve Hypertrophic scarring laceration of the superficial palmar arch tendon adhesion Postoperative infection Hematoma arterial injury stiffness

SURGERY

PREGNANCY : 

PREGNANCY Alterations in fluid balance may predispose some pregnant women to develop carpal tunnel syndrome. Symptoms are typically bilateral and first noted during the third trimester. Conservative measures are appropriate, because symptoms resolve after delivery in most women with pregnancy-related carpal tunnel syndrome.

ADL adaptations : 

ADL adaptations BUTTON HOOK modified Handle

Slide 76: 

COOKING MITTS CYLINDRICAL FOAM

Slide 77: 

ZIPPER PULL UNIVERSAL CUFF INSULATED MUG “T” TURNING HANDLE–OR GRIPPER KNOB TURNER