Median Nerve injuries

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Median Nerve : 

Median Nerve Dr. Nazim Nasir MD

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, 1 st and 2 nd 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

Slide 12: 

Pulley Design Straight Line Of Pull Reduced Friction And Work Tendon Migrates To Run In Straight Line

Tendon Transfers Low Median Nerve Palsy: 

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

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 .

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 DO NOT WORK !!!

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 53: 

COOKING MITTS CYLINDRICAL FOAM

Slide 54: 

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