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Ulnar and Radial Nerve Entrapment Anton Sharapov, PGY 3

Ulnar and Radial Nerve Entrapment - Memorial University

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Page 1: Ulnar and Radial Nerve Entrapment - Memorial University

Ulnar and Radial Nerve Entrapment

Anton Sharapov,PGY 3

Page 2: Ulnar and Radial Nerve Entrapment - Memorial University

Anatomic considerations: Ulnar nerve

median cord, C7-T1btw axillary a. and v.medial to arterypierces im septum a->panterior to medial head of triceps

Page 3: Ulnar and Radial Nerve Entrapment - Memorial University

cubital tunnel: med. epicondyle & olecranon, under fibrous arcade of aponeurosis of two heads of FCU.

Page 4: Ulnar and Radial Nerve Entrapment - Memorial University

no branches in armenters forearm btw humeral and ulnarhead of FCU.first branch is articular - behind med epicondyle.next - FCU and medial FDP

Page 5: Ulnar and Radial Nerve Entrapment - Memorial University

Travels on surface of FDP, deep to FCU.accompanied by ulnar a. in distal 2/3.at musculotendinous junction - a. and n. are subcutaneous.palmar branch of ulnar n. - 5-7 cm prox to

wrist, dorsal - 5-10 cm prox to wrist.

Page 6: Ulnar and Radial Nerve Entrapment - Memorial University

Floor - transverse carpal lig to pisiform. Pisiform - ulnar border, hook of hamate - radial border. Roof - volar carpl lig.sup branch - supplies palmaris brevis, skin med palm, two digital n.

Page 7: Ulnar and Radial Nerve Entrapment - Memorial University
Page 8: Ulnar and Radial Nerve Entrapment - Memorial University
Page 9: Ulnar and Radial Nerve Entrapment - Memorial University

Specifically:

deep terminal - passes around hook -abductor/flex digiti minimi; pierces opponents DM and accompl deep palmar arch dorsal to flexor tendons:

Page 10: Ulnar and Radial Nerve Entrapment - Memorial University

all interosseilumbricals of the ring/small finger,aDDuctor policis,

deep head of the flexor policis brevis. (in some - both heads of FPB and aBDuctor brevis)

Page 11: Ulnar and Radial Nerve Entrapment - Memorial University

entrapment:

at elbow (10 times more)in Guyon's canal

Page 12: Ulnar and Radial Nerve Entrapment - Memorial University

Elbow:2nd to CTS in frequencydescribed 100 years ago

Page 13: Ulnar and Radial Nerve Entrapment - Memorial University

Wide DD:cervical disc diseasepancoast tumorlower trunk brachial plexopathylower motor neuron diseasecompression at Guyon's canal

Page 14: Ulnar and Radial Nerve Entrapment - Memorial University

Surgical indications:if intermittent sx and no motor signs -conservativelyavoid extreme flexion, repetitive flex/ext, leaning.splints, NO steroid (no synovium), role for NSAIDs

Page 15: Ulnar and Radial Nerve Entrapment - Memorial University

surgery - if sx after 3-6/12 on conservative OR sooner if motor sxs. Check: arcade of Struthers, intermuscularseptum, medial epicondyle, two heads of FCU.

Page 16: Ulnar and Radial Nerve Entrapment - Memorial University

Surgical options

in situ decompresssion +/-epicondylectomysc anterior transpositionintramuscular anterior transpositionsubmuscular transposition

Page 17: Ulnar and Radial Nerve Entrapment - Memorial University

id branches of medial antebrachialcutaneous nerve and preserve - or else painful neuromas result

Page 18: Ulnar and Radial Nerve Entrapment - Memorial University

in situ: no transposition ->no risk to devascularisation

epicondylectomy - amount of bone taken off important.

transposition - need to decompress along the entire course (IM, muscular heads)

Page 19: Ulnar and Radial Nerve Entrapment - Memorial University

comparison of in situ, ant sc trans, and epicondylectomy -

no difference in EMGs/strength, better satisfaction for med epicondylectomy.

85-95% success regardless procedure. Recovery continues for 3-5 years, better for sensory then motor sxs.

Page 20: Ulnar and Radial Nerve Entrapment - Memorial University

Poor prognosticators:age>50DMalcoholismmore advanced neuropathy

Page 21: Ulnar and Radial Nerve Entrapment - Memorial University

fare better if no motor involvement, sensory response obtainable, good two point discrimination

Page 22: Ulnar and Radial Nerve Entrapment - Memorial University

complications: scar, neuromas, recurrence, persistent sxs, RSD.

Page 23: Ulnar and Radial Nerve Entrapment - Memorial University

Ulnar tunnel syndrome

trauma to hook of hamate/pisiformrepetitive trauma (hypothenar trauma syndrome)cyclingpisiform instabilitypiso-triquetral arthritisulnar a. thrombosis/ aneurism

Page 24: Ulnar and Radial Nerve Entrapment - Memorial University

Causes cont’d

masses - ganglions, lipomas, neurolemmomas - 32-48%, anomalous muscles - 16%,tendinous bands within canal

Page 25: Ulnar and Radial Nerve Entrapment - Memorial University

sxs - sensory, motor, or bothmay coexist with CTStreat: conservatively -> surgery

Page 26: Ulnar and Radial Nerve Entrapment - Memorial University

Radial n.

posterior cord, C5-T1enters arm btw brachial a/long headaccompanied by deep brachial a. , spirals in the groove behind humeruspasses - btw long-medial, then medial-lat heads - then goes deep to lateral headsinnervates triceps

Page 27: Ulnar and Radial Nerve Entrapment - Memorial University

at distal 1/3 traverses IM septum to enter anterior compartment -> branch to anconeus, joint, brachialis, brachioradialis, ECRL, occasionally ECRBthen passes anterior to the lateral epicondyle/ant joint capsule of elbow: between brachialis/brahioradialis. There it divides into superficial/deep branches

Page 28: Ulnar and Radial Nerve Entrapment - Memorial University

Superficial branch: under cover of BR, on top of supinator, pronator teres, FDS, FPL.

Accompanies radial a. as it emerges from BR, goes to dorsum of the hand (thumb web space)

Deep (post interosseous) - btw humeral/radial heads of supinator.

Page 29: Ulnar and Radial Nerve Entrapment - Memorial University
Page 30: Ulnar and Radial Nerve Entrapment - Memorial University

Deep branch

Passes deep to supinator, close to radial shaft with post interosseous a.lie sandwiched between sup and deep

extensor muscles. Supplies ED, EDM, ECU, EC, EI, ABD policis longus. Then sensory to wrist join from dorsum.

Page 31: Ulnar and Radial Nerve Entrapment - Memorial University

High Radial Neuropathies Proximal to the Spiral Groove

weakness of elbow extensors and wrist extensorsdecreased sensation over the posterior arm and the forearm, weakness and numbness in the distributions of the PIN and SRN.Triceps and BR reflexes may be reduced or absent. Proximal humerus #.

Page 32: Ulnar and Radial Nerve Entrapment - Memorial University

High Radial Neuropathies At, or Distal to, the Spiral Groove

intact elbow extensors and intact posterior arm and forearm sensation; exhibits wrist drop, decreased sensation in the posterolateral hand, weakness in a PIN distribution. The triceps reflex present, BR reflex may be reduced or absent.A common cause is a "Saturday night palsy."

Page 33: Ulnar and Radial Nerve Entrapment - Memorial University

Posterior Interosseus Neuropathies

fingerdropintact sensation in a radial distribution.Wrist drop may be partial with radial deviationThumb abduction and forearm supination may

also be weak. radial reflexes and sensation normal. Common causes include radial tunnel syndrome and Supinator syndrome.

Page 34: Ulnar and Radial Nerve Entrapment - Memorial University

Superficial Radial Neuropathies

Wartenberg syndromedecreased sensation over the posterolateral hand and thumb and the proximal dorsum of the index, middle, and ring fingers. Radial reflexes again should be normal. Common causes include external compression from handcuffs, wristwatches, casts, and penetrating or blunt trauma.

Page 35: Ulnar and Radial Nerve Entrapment - Memorial University

Entrapment at elbow

anatomic variants at the arcade of Frohse: fibrous band at origin at the origin of the supinator, or at the distal end of it.Leash of Henry (arcade of vessels)Tendinous origin of hte ECRBFibrous band from radiocapitellar joint.

Page 36: Ulnar and Radial Nerve Entrapment - Memorial University

mass lesions (rheumatoid synovitis, bicipital bursitis)lateral epicondylitis may have confounding effect

Page 37: Ulnar and Radial Nerve Entrapment - Memorial University

Treatment: conservative initially if no motor involvementrest, avoid aggravation, splint, NSAIDs.splint: writs extended, elbow flexed, Surgery if no supinated - max relief for RTS.improvement after 3-6/12

Page 38: Ulnar and Radial Nerve Entrapment - Memorial University

CLINICAL CONDITIONS THAT MAY PRESENT SIMILARLY TO RADIAL NEUROPATHIES

Page 39: Ulnar and Radial Nerve Entrapment - Memorial University

C7 (and C8) Radiculopathy

presents with weakness in the elbow extensors, wrist extensors, and finger flexors, may have sensory loss over the posterior arm,

forearm, and hand. A radiculopathy is accompanied by neck painradiating down the arm and, in the case of a C7 radiculopathy, into the middle finger

Page 40: Ulnar and Radial Nerve Entrapment - Memorial University

Sensory loss may be less in a C7 radiculopathy than in a radial neuropathy may also involve the palmar surface of the hand and the middle finger. Weakness may also be less severe as only one myotome is affected.

Page 41: Ulnar and Radial Nerve Entrapment - Memorial University

Physical examination may reproduce radiating pain down the upper extremity with provocative tests such as Spurling's maneuver (ipsilateralcervical rotation and extension). The triceps reflex may be reduced in both C7 radiculopathies and radial neuropathiesBR reflex should be normal in a C7 radiculopathy.

Page 42: Ulnar and Radial Nerve Entrapment - Memorial University

EMG is helpful. Imaging studies of the cervical spine to evaluate neural foraminal impingement (OA, DDD)

Page 43: Ulnar and Radial Nerve Entrapment - Memorial University

Posterior Cord Brachial Plexopathy

presents with weakness in elbow, wrist, and finger extensors.

Page 44: Ulnar and Radial Nerve Entrapment - Memorial University

may have weakness in …

shoulder abduction (axillary nerve to deltoid muscle),shoulder internal rotation (axillary

nerve to teres minor, subscapular nerves to subscapularis, and thoracodorsal nerve to latissimus dorsi),and shoulder adduction (thoracodorsalnerve to latissimus dorsi).

Page 45: Ulnar and Radial Nerve Entrapment - Memorial University

impaired sensation over the posterior arm, the forearm, and the hand (radial nerve)……as well as over the lateral shoulder (upper lateral cutaneous nerve of arm, a cutaneous branch of the axillary nerve).

Page 46: Ulnar and Radial Nerve Entrapment - Memorial University

physical examination:

muscle testing of axillary, subscapular, and thoracodorsal-innervated muscles, sensory examination of the lateral shoulder

Page 47: Ulnar and Radial Nerve Entrapment - Memorial University

Deep tendon reflexes in the triceps and BR should be absent in both radial neuropathy and posterior plexopathy.EMGs helpful