the numb hand - hartfordsportsorthopedics.com · – radial tunnel syndrome • posterior...
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The Numb Hand
James T. Mazzara, M.D.
Shoulder and Elbow Surgery Sports Medicine Occupational Orthopedics
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Patient Education Disclaimer
This presentation describes information to educate consumers on various health topics. It is NOT intended to provide instruction on medical diagnosis or treatment. The information contained in this handout is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. You should NOT rely on this information to determine a diagnosis or course of treatment. Theinformation should NOT be used in place of an individual consultation, examination, visit or call with your physician or other qualified health care provider. You should never disregard the advice of your physician or other qualified health care providerbecause of any information you read in this presentation or on any websites you visit as a result of this presentation. If you have any health care questions, please consult your physician or other qualified health care provider promptly. Always consult your physician or other qualified health provider before you begin any new treatment, diet or fitness program.
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The Nerve
• 3 Types of nerves– Motor
• Muscle control• Go from brain to muscles
– Sensory• Sensation• Go from body to brain
– Autonomic• Involuntary• Heart rate, blood pressure,
digestion, sweating
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Idiopathic Nerve Damage
• Unknown cause• Older than 60• Numbness, tingling and pain• Unsteady gait• Weakness or cramps
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Toxic Nerve Damage
• Lead, mercury, arsenic, thallium• Anticonvulsants• Cancer medications• Heart or blood pressure medications• Infection fighting drugs• Skin condition treatment drugs
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Alcohol-Related Nerve Damage• Abnormal sensations
– Pain • Feels like "pins and needles"
– Numbness – Muscle weakness, cramps, or aches – Muscle spasms / contractions – Tingling
• Constipation / Diarrhea • Incontinence (leaking urine) or difficulty with urination • Impotence in men • Nausea / vomiting
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Inflammatory Nerve DamageInfectious (with a specific casual agent identified) • Lyme disease• HIV / AIDS• Herpes Zoster (Shingles)• Hepatitis B and C
Autoimmune or possibly infectious (but with no specific causal infectious agent identified)
• Sarcoidosis• Polyarteritis Nodosa (PAN)• Rheumatoid Arthritis• Systemic Lupus Erythematosus (Lupus)• Sjögren's Syndrome
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AnatomyThe nerves exit from the cervical spine through bone tunnels called foramen. They then pass beneath the clavicle (collar bone) as they enter the arm where they become individually named nerves. The network of nerves between the cervical spine and the arm is called the brachial plexus.
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Anatomy
The nerves then pass down the arm and innervate different groups of muscles and give sensation to different parts of the arm and hand.
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Cervical Nerve CompressionEach nerve provides sensation to a specific area of the arm and hand. Each nerve root from the cervical spinal cord supplies its own particular nerve as seen here.
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Sensory Nerve Anatomy
This is the anatomy of the sensory nerves to the arm and hand.
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Types of Nerve Injury
• Neuropraxia– Slow nerve conduction with and intact nerve– Damage is reversible
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Types of Nerve Injury
• Axonotmesis– Severe injury with
nerve degeneration– Intact nerve fibers– Recovery is possible
and depends on the distance of nerve lesion to the site of innervation
Muscle atrophy
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Types of Nerve Injury
• Neurotmesis– Complete
disruption of the nerve
– Full recovery is unlikely
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Our Focus
• Nerve compression conditions of the arm and hand– Carpal Tunnel Syndrome
• Anterior interosseus nerve syndrome• Pronator Syndrome
– Cubital Tunnel Syndrome– Radial Tunnel Syndrome
• Posterior interosseus nerve syndrome• Wartenberg’s syndrome
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Nerve Injuries of the Arm
• More common in younger industrial workers– 1994: 93,000 cases of repetitive
use disorders– 41% of these were carpal tunnel syndrome
• Overall 1 million adults/year require treatment for CTS
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Epidemiology
Carpal Tunnel Syndrome
Mean age @ diagnosis
Distribution
Males 50 years 22%
Females 51 years 78%
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Compressive Neuropathy
• Associated symptoms
– Poorly characterized & difficult to label tendon and muscle symptoms
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Contributing Factors
• Work place– Repetitiveness– Force– Mechanical stress– Posture– Vibration– Temperature
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Contributing Factors
• Carpal tunnel epidemiology studies
– Higher correlation with health habits & lifestyle
• Obesity• Tobacco use• Caffeine
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Contributing Factors
• Definitive risk factors– Female– Pregnancy– Diabetes– Hypothyroidism– Rheumatoid arthritis
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Contributing Factors
• Study of idiopathic carpal tunnel syndrome– Analyzed the synovium of patients with CTS
• Findings suggested that repeated episodes of ischemia and reperfusion may lead to the development of CTS
• Freeland, Microsurgery, 22, 2003
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Contributing Factors
• Occupational risk factors alone do notexplain the occurrence of carpal tunnel syndrome in the workforce
• Carpal tunnel syndrome is due to multiple overlapping factors
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Contributing Factors
• Nerve traction injuries – Compression at one site may tether the nerve – Leads to restricted nerve mobility with traction
and stretching of the nerve
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Contributing Factors
• Nerve compression impairs microcirculation
Hyperemia (increased circulation) after nerve release of ulnar verve at elbow
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Systemic Factors
• Certain conditions lower the threshold for compressive neuropathy
• This may lead to involvement of both sides when nerve compression syndromes occur
• For example– Obesity– Diabetes– Alcoholism– Hypothyroidism– Industrial solvent exposure– Aging
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Phases of Compressive Neuropathy
• Early
• Intermediate
• Late / Advanced
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Early Phase
• Low grade compression
• Symptoms come and go
• Conservative treatment is effective– NSAIDS– Steroid injections– Splints
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Intermediate Phase
• Intraneural circulation is persistentlycompromised
• Constantparesthesias and numbness
• Respond best to nerve decompression
Hyperemia after carpal tunnel release
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Advanced Phase• Continuous edema and
compression induce intraneural fibrosis
• Irreversible damage with some permanent loss of sensation and motor function
• Surgery stops the continuing nerve damage but does not assure full recovery– Permanent nerve damage
already exists before surgery
Atrophy (loss of muscle mass, tone and function) due to prolonged, advanced nerve compression
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Double Crush Phenomenon
• 2 separate points of nerve compression
– Compression proximally lowers the threshold for compression neuropathy at a distal point
• Interrupted transport of enzymes and neurotransmitters along the axon
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Double Crush Phenomenon• Surgical decompression may
lead to incomplete symptom relief– A nerve may be compressed in
2 locations: e.g., the neck and the wrist
– Release of the wrist compression (carpal tunnel) may or may not improve symptoms but should be considered to avoid further damage to the nerve
– Cervical radiculopathy & CTS• Still consider CT release• Advise the patient
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Clinical Presentation
• Dynamic– Symptoms are
activity specific– Exertional
• Insidious– Gradual onset– Unrelated to activity– Worse at night
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Carpal Tunnel Syndrome
• Anatomic predisposing factors– Decreased size of
carpal tunnel• Bony abnormalities• Thickened transverse
carpal ligament
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Carpal Tunnel Syndrome
• Anatomic predisposing factors– Increased contents of
carpal tunnel• Ganglion cysts• Neuroma, lipoma,
myeloma, hypertrophic synovium, fracture callus, osteophytes, hematoma
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Carpal Tunnel Syndrome
• Neuropathic conditions– Diabetes– Alcoholism– Thyroid dysfunction– Double crush
phenomenon• Proximal compression of
median nerve
A patient with a history of cervical nerve root injury
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Carpal Tunnel Syndrome
• Inflammatory predisposing conditions– Tenosynovitis– Rheumatoid arthritis– Infection– Gout
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Carpal Tunnel Syndrome
• Alterations in fluid balance– Pregnancy– Long-term
hemodialysis– Raynaud’s disease– Obesity
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Carpal Tunnel Syndrome• Position and use of wrist
– Repetitive flexion / extension
– Repetitive forceful squeezing and releasing or torsion of a tool
– Finger motion with wrist extension
• Typists, musicians– Vibration exposure
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Carpal Tunnel Syndrome
• Weightbearing with wrist extension
– Paraplegia– Long-distance cycling
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Carpal Tunnel Syndrome
• Immobilization with the wrist flexed
– Wrist fractures can cause scarring, swelling and crowding of the carpal tunnel
– Awkward sleep position
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Carpal Tunnel Syndrome
• Pain & paresthesias palmar radial hand
• Symptoms worse at night
• Symptoms worse with repetitive forceful use of hands
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Carpal Tunnel Syndrome Diagnostic Tests
• Phalen’s test
– Numbness / tingling < 60 sec
– Sensitivity 0.75
– Specificity 0.47
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Carpal Tunnel Syndrome Diagnostic Tests
• Percussion test (Tinel’s sign)
– Tingling at site of nerve tapping
– Sensitivity 0.60
– Specificity 0.67
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Carpal Tunnel Syndrome Diagnostic Tests
• Compression test
– Paresthesias < 30 sec
– Sensitivity 0.87
– Specificity 0.90
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Carpal Tunnel Syndrome Diagnostic Tests
• Hand diagram– Appropriate markings
on radial digits not on palm
– Sensitivity 0.96– Specificity 0.73– Value of a negative
test 0.91
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Carpal Tunnel Syndrome Diagnostic Tests
• 2-point discrimination
– Unable to discriminate 6mm
– Advanced nerve dysfunction
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Carpal Tunnel Syndrome Diagnostic Tests
• Vibrometry
– Note asymmetry with contralateral hand or radial versus ulnar
– Sensitivity 0.87
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Carpal Tunnel Syndrome Diagnostic Tests
• Semmes-Weinstein monofilaments
– Positive if unable to feel filaments less than 2.83
– Sensitivity 0.83
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Carpal Tunnel Syndrome Diagnostic Tests
• X-rays are valuable in many cases– Trauma
– Rheumatoid disease
– Basal joint arthritis
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Carpal Tunnel Syndrome Diagnostic Tests
• Nerve conduction testing
• Sensory testing– Positive if latency
>3.5mm/sec or if 0.5mm/sec > other hand
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Carpal Tunnel Syndrome Diagnostic Tests
• EMG• Tests the motor part
of the nerve– Positive if latency >4.5
mm/sec or if 1.0 mm/sec > other hand
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Carpal Tunnel Syndrome Diagnostic Tests
• EMG– Tests for denervation
of thenar muscles
– Very advanced nerve damage
– Objective confirmation
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Carpal Tunnel Syndrome Diagnostic Tests
• Chest x-ray– Smokers– Ulnar nerve
symptoms– Shoulder pain
• MRI– Evaluate nerve
compression in forearm
Ganglion cyst compressing carpal
tunnel
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Carpal Tunnel Syndrome Diagnostic Tests
• Most sensitive
– Semmes-Weinstein filament
– Vibrometry
• Threshold tests A simple way to test light touch sensitivity
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Carpal Tunnel Syndrome
• Consider overall health• If both hands are involved
– Consider systemic or metabolic causes• Consider proximal compression
– Cervical radiculopathy– Pronator syndrome
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Carpal Tunnel Syndrome
• Conservative treatment– Nighttime splinting in
neutral
– NSAIDs to reduce synovitis
– Manage contributing systemic causes
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Carpal Tunnel Syndrome
• Corticosteroid injections
– Transient relief in 80%
– Only 22% symptom free at 1 year
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Carpal Tunnel Syndrome
• Injections are an excellent predictor of a patients response to surgery
• Excellent prognostic tool– 87% with a positive response to injection had
successful surgery– 54% with a negative response to injection had
successful surgery
• Edgell J Hand Surg {Am} 28, 2003
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Carpal Tunnel Syndrome
• Corticosteroid injections– Most effective if
symptomatic for < 1 year
– Diffuse and intermittent numbness
– Normal 2-point discrimination
– No weakness or thenar atrophy
– EMG reveals no denervation
– 1-2 millisecond prolongation on NCS
– 40% of this group symptom free at 1 year
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Carpal Tunnel Syndrome
• Alternative treatments– Vitamin B6 (Pyridoxine)– Cold Laser– Acupuncture– TENS– Chiropractic manipulations
• There is no scientific evidence that any of these treatments are effective
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Carpal Tunnel Release
• Indicated for failed conservative treatment
• Earlier surgery yields better results– CTR within 3 years of symptom onset yields
better results
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Carpal Tunnel Release
• Advanced cases– CTR may only
prevent progression
– CTR may not lead to improvement
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Carpal Tunnel Release
• Patients with intermittent pre-op symptoms obtain better sensory recovery than patients with constant symptoms
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Carpal Tunnel Release
• Endoscopic– Minimal effect on
post-op recovery
– Poor visualization of nerve
– Increased risk of NV injury
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Carpal Tunnel Release
• Randomized trial comparing endoscopic to open CTR
• Endoscopic group– Less pain & more grip strength @ 1 and 6 w– No different from open group @ 12 w– Less satisfied than open group
• The re-operation rate in the endoscopic group was 5% v. 0% in the open CTR group
– Macdermid J Hand Surg {Am} 28, 2003
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Carpal Tunnel Release
• Mini-open– Good visualization of
nerve & ligament– Fewer complications– Re-operations are rare– Grip strength recovery
in 3 months– Pinch strength
recovers in 6wTransverse
Carpal
Ligament
Median Nerve
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Carpal Tunnel Release Complications
• Transient
– Infection
– Sensitivity
– Pillar pain
• Permanent
– Nerve injury
• Anatomic variations involving motor branches
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Carpal Tunnel Syndrome
• May be associated with ulnar neuropathy @ Guyon’s canal– Responds to CTR
alone
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Carpal Tunnel Release• Post-op
– Bulky dressing for 48 hours
– Remove dressing and use hand as tolerated
– Keep wound clean, dry and covered with a Band-aid
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Carpal Tunnel Release
• Post op course with the open CT release– Progressive activities as
tolerated at 48 hours
– Return to work 21 days without restrictions
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Carpal Tunnel Release
• The incision @ 3 weeks– There may be some
wound sensitivity at 6-12 weeks but this resolves in time
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Pronator Syndrome
• Median nerve entrapment @ elbow
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Pronator Syndrome
• Symptoms– Weakness and
aching of the thumb muscles
– Numbness in the thumb, index & middle finger
– Numbness in the area of the palmar cutaneous nerve
• mid palm and thenar eminence
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Pronator Syndrome
• Diagnostic findings– Pain in upper forearm– Positive Tinel’s sign in forearm– No finger numbness with wrist flexion – No symptoms at night
• Unlike CTS
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Pronator SyndromeCompression Sites
• Compression @ bicipital aponeurosis
– Resisted elbow flexion with forearm supination
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Pronator SyndromeCompression Sites
• Compression @ pronator muscle
– Resisted forearm pronation with elbow extended
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Pronator SyndromeCompression Sites
• Compression @ origin of FDS
– Resisted isolated flexion of the PIP of middle finger
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Pronator Syndrome
• Nerve conduction tests
– Not helpful
– 20-30% of patients with CTS may have conduction delays in forearm
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Anterior Interosseous Nerve Syndrome
• Median nerve compression in the forearm– Motor deficit
• Weakness of the long flexors of the thumb and index finger
– No sensory deficit
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Anterior Interosseous Nerve Syndrome
• Examination– Precision tip to tip
pinch
• “A OK sign”
• Pinch (thumb and index finger) weakness
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Anterior Interosseous Nerve Syndrome
• Spontaneous onset
• EMG-NCS is helpful
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Anterior Interosseous Nerve Syndrome
• Nonoperative Treatment– Observation– Splinting in elbow
flexion– Surgery if not
improved in 8-12 weeks
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Anterior Interosseous Nerve Syndrome
• Surgical decompression of all potential sites of compression
• May take up to 6 months to improve
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Cubital Tunnel Syndrome
• Ulnar nerve compression at the elbow– “The Funny Bone”
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Cubital Tunnel Syndrome• Sources of
compression– fascial bands– exuberant synovium– tumors – ganglions– anconeus
epitrochlearis– bone spurs
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Cubital Tunnel Syndrome
• Symptoms– Numbness along the
little finger and ulnar ½ring finger
– Weakness of grip & torque
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Cubital Tunnel Syndrome
• Pain medial elbow
• Tinel’s sign @ cubital tunnel
• Symptoms worse with elbow flexion
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Cubital Tunnel Syndrome
• Pain and numbness on dorsal and volarulnar hand
• Weakness ring& little finger flexors
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Cubital Tunnel Syndrome• Froment’s sign
– Weak intrinsic muscles of the hand
– Flexor pollicis longus (flexes the tip of the thumb) compensates for paralyzed thumb adductor
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Cubital Tunnel Syndrome• Intrinsic muscle
weakness– Unable to adduct little
and ring fingers due to advanced cubital tunnel syndrome
Intrinsic muscles innervated by ulnar nerve
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Cubital Tunnel Syndrome
• Jeanne’s sign
– Compensatory hyperextension of the thumb MP joint
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Cubital Tunnel Syndrome
• Thumb adductor weakness
• Severe atrophy– Muscle wasting
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Cubital Tunnel Syndrome
• Pollock’s test
– Weakness of the flexor strength of the ring and little fingers
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Cubital Tunnel Syndrome
• Examine cervical spine• Consider thoracic outlet syndrome• Assess elbow for arthritis• Check for ulnar nerve subluxation
(snapping)
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Cubital Tunnel Syndrome
• Tinel’s sign @ cubital tunnel
• Elbow flexion test (<60 sec)
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Cubital Tunnel Syndrome
• Ulnar nerve pressure test– Direct pressure– Elbow 20o
– Forearm supinated– Positive if < 60 seconds
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Cubital Tunnel Syndrome
• Sensory exam
– Numbness on all surfaces of little finger
– S-W monofilament test
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Cubital Tunnel Syndrome
• Nonoperative treatment– Activity
modification– Don’t lean on the
elbow– NSAIDs– Night-time
extension splints
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Cubital Tunnel Syndrome
• Surgical options– Simple decompression– Medial epicondylectomy– Submuscular transposition– Subcutaneous transposition
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Cubital Tunnel Syndrome
• Medial Epicondylectomy
Hand
Medial epicondyle
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Cubital Tunnel Syndrome
• Medial Epicondylectomy
Ulnar nerve compression after release of Osborne’s
ligament
Hand
Medial epicondyle
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Cubital Tunnel Syndrome
• Medial EpicondylectomyMedial
epicondyle removed
Flexor-pronator
attachment released
Elbow @ 90 degrees flexion
Ulnar nerve
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Cubital Tunnel Syndrome
• Medial EpicondylectomyMedial
epicondyle removed
Flexor-pronator
attachment released
Relaxed ulnar nerve
Elbow @ 90 degrees flexion
Hand
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Cubital Tunnel Syndrome
• Medial EpicondylectomyFlexor-
pronator mass
reattached to medial
epicondyle
Elbow flexed 90 degrees
Hand
Ulnar nerve relaxed
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Cubital Tunnel Syndrome
• Medial EpicondylectomyFlexor-
pronator mass
reattached to medial
epicondyle
Elbow flexed 90 degrees
Hand
Ulnar nerve relaxed
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Cubital Tunnel Syndrome
• Submuscular Transposition
Hand
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Cubital Tunnel Syndrome
• 88% Good-excellent results• 8% failure or recurrence• Compared to 25 – 40% other techniques•• This is the procedure I have performed since 2003This is the procedure I have performed since 2003
JBJS July, 2003
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Cubital Tunnel Syndrome
• Submuscular Transposition
Preserved sensory nerves
Decompressed ulnar nerve
Hand
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Cubital Tunnel Syndrome
• Submuscular TranspositionPreserved sensory nerves
Decompressed ulnar nerve
Hand
A
B
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Cubital Tunnel Syndrome
• Submuscular Transposition
Preserved sensory nerves
Transposed ulnar nerve
A
B
Hand
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Cubital Tunnel Syndrome
• Subcutaneous Transposition
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Cubital Tunnel Syndrome• Surgical results
– 80-90% good results– Functional recovery 6 months
• Moderate – severe compression– Recurrence rates or poor results in 25-30%
• In revision ulnar nerve translocation the ulnar nerve is moved from its previous subcutaneous position and placed in a submuscular position.– Studies have shown that placing the nerve in a
submuscular position (with tendon z-plasty) is highly successful and reduces the rate of recurrence significantly
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Ulnar Tunnel Syndrome
• Ulnar nerve compression in Guyon’s canal
• Symptoms depend on site of compression– Motor– Sensory– Mixed
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Ulnar Tunnel Syndrome• Causes of compression
– Ganglion cysts– Synovial inflammation– Fractures of hook of
hamate– Ulnar artery thrombosis– Anomalous muscle– Palmaris brevis
hypertrophy
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Ulnar Tunnel Syndrome
• Evaluation– CT scan for hook
of hamate fracture– MRI for ganglion
cyst– Doppler ultrasound
for ulnar artery thrombosis
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Ulnar Tunnel Syndrome
• Treatment– Nonoperative
• Splints• NSAIDs
– Operative• Treat underlying
cause (cyst, fracture)
• Nerve decompression
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Radial Nerve
• Compression above the elbow• Posterior interosseous nerve syndrome• Radial tunnel syndrome• Wartenberg’s syndrome
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Radial Nerve
• Compression above the elbow– Rare– Fibrous arch of lateral head of
triceps– Weakness of wrist extensors– Sensory changes on top
forearm up to the thumb
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Radial Nerve• May be related to
humeral fracture callus
• EMG-NCS confirms the diagnosis
• Surgical decompression if not improved in 3 months
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Posterior Interosseous Nerve (PIN) Syndrome
• Motor portion of radial nerve compressed in proximal forearm
• Motor only, no sensory function
• Innervates wrist and finger extensors
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Posterior Interosseous Nerve (PIN) Syndrome
• Gradual onset
• Subtle loss of strength with radial deviation in wrist extension
– ECRL (the long wrist extensor muscle) still functional
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Posterior Interosseous Nerve (PIN) Syndrome
• EMG: diagnostic• X-rays: evaluate for
radial head – Fractures– Arthritis– Dislocations
• MRI: ganglions cysts, lipomas
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Posterior Interosseous Nerve (PIN) Syndrome
• Compression sites
– Thick fascia @ the front of the elbow joint (radiocapitellar joint)
– Recurrent radial artery branches
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Posterior Interosseous Nerve (PIN) Syndrome
• Compression sites– Fibrous edge
of ECRB (wrist extensor) muscle
– Arcade of Frohse @ proximal edge of supinator muscle
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Posterior Interosseous Nerve (PIN) Syndrome
• Treatment– Avoid aggravating activities– NSAIDs– Surgical release if not improved in 4-12 weeks– Strength recovery may take 18 months– 85% good – excellent results
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Radial Tunnel Syndrome
• Pain • No motor or sensory deficits• Same nerve and compression sites as PIN
syndrome• Work-related
– Associated with forceful elbow extension or forearm rotation
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Radial Tunnel Syndrome
• Symptoms– Deep ache on lateral
elbow & forearm– Night pain
– Confused with lateral epicondylitis
• 5% of lateral epicondylitis patients have concurrent radial tunnel syndrome
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Radial Tunnel Syndrome
• Examination
– Provocative tests• Resisted supination test
with wrist extension
• Passive pronation with wrist flexion
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Radial Tunnel Syndrome
• Examination
– Tender over radial tunnel
– Middle finger test
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Radial Tunnel Syndrome
• EMG-NCS not helpful
• Diagnostic injection into radial tunnel– Causes a temporary posterior interosseus
nerve palsy– Relieves symptoms at least temporarily
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Radial Tunnel Syndrome
• Nonoperative– Activity modification– Wrist splinting– NSAIDs– Therapy with modalities
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Radial Tunnel Syndrome
• Surgical release– 51% good results (Mayo)– Maximal recovery @ 9-18 months– Workers’ comp do not do as well– Worst results
• Work-related injuries• Chronic pain• Poorly localized symptoms on exam
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Radial Tunnel Syndrome• Surgical release
Radial Nerve
Sensory branch
Posterior Interosseusnerve motor branch
Supinator m.
Arcade of Frohse
Left Hand
Elbow
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Wartenberg’s Syndrome
• Sensory branch of radial nerve
– Compressed between Brachioradialis & Extensor Carpi Radialis Longus with forearm pronation
– Constricting jewelry
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Wartenberg’s Syndrome
• Symptoms– Pain, numbness,
paresthesias over dorsal-radial hand
– Worse with wrist movement & tight pinch with thumb-index finger
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Wartenberg’s Syndrome
• Examination– Pain with forced forearm pronation– Tinel’s sign over nerve– Injection test into junction of BR confirms
diagnosis– Differentiate from deQuervain’s tenosynovitis
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Wartenberg’s Syndrome
• Nonoperative Treatment– Rest– NSAIDs– Avoid aggravating activities– Wrist splints
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Wartenberg’s Syndrome
• Surgical decompression after 6 months of nonoperative treatment
• 75% good results
Tendon of Brachioradialis
Radial Nerve
Sensory Branch
Hand
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Thank You
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The End