1. MEDIAN NEUROPATHY.pdf
- 1. MEDIAN NEUROPATHY P/B :- DR NIYATI PATEL 1
- 2. ANATOMY The median nerve controls coarse movements of the hand, as it supplies most of the long muscles of the front of the forearm. It is, therefore, called the 'labourer's nerve'. ROOT VALUE- C5,C6,C7,C8,T1 Arising from medial and lateral cords of brachial plexus Motor supply ◦ Pronator teres ◦ Flexor digitorum superficialis ◦ Flexor digitorum profundus (1st & 2nd) ◦ Flexor carpi radialis ◦ Palmaris longus ◦ Flexor pollicis longus ◦ Pronator quadratus ◦ 1st & 2nd lumbricals ◦ Thenar muscles P/B :- DR NIYATI PATEL 2
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- 4. CAUSES Axilla • Axillary aneurysm • Traction injury Arm ◦ Penetrating injury Elbow • Penetrating injury • Hansen’s disease • Golfer’s elbow P/B :- DR NIYATI PATEL 4
- 5. Forearm Pronator teres syndrome; A fibrous band that travels between the deep and superficial head of the pronator teres can compress the median nerve due to over use or violent contraction of the muscle. A fibrous arch which originates just proximal to the origin of the flexor digitorum superficialis can compress the median nerve causing selected paralysis of FDS and FDP. P/B :- DR NIYATI PATEL 5
- 6. Wrist Glass cut injury can cause isolated involvement of the median nerve or alongwith the ulnar nerve. Anterior interosseous nerve can get involved due to fracture or laceration of the forearm. It can be compressed by the flexor digitorum superficialis or pronator teres.. P/B :- DR NIYATI PATEL 6
- 7. Carpal tunnel syndrome This is a syndrome characterised by the compression of the median nerve as it passes beneath the flexor retinaculum P/B :- DR NIYATI PATEL 7
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- 9. The patient is generally a middle aged woman complaining of tingling, numbness or discomfort in the thumb and radial one and a half fingers i.e., in the median nerve distribution. Tingling is more prominent during sleep. There is a feeling of clumsiness in carrying out fine movements. Nerve conduction studies show delayed or absent conduction of impulses in the median nerve across the wrist. Treatment is by dividing the flexor retinaculum, and thus decompressing the nerve. P/B :- DR NIYATI PATEL 9
- 10. SIGN AND SYMPTOMS Sensory There will be loss of sensation over the volar aspect of lateral 3½ fingers up to the distal phalanx on the dorsal side, skin overlying the thenar eminence. The autonomous zone for the median nerve is the pulp of the thumb. P/B :- DR NIYATI PATEL 10
- 11. Motor The muscles supplied by the median nerve namely the pronator teres, flexor carpi radialis, flexor digitorum superficialis, palmaris longus, flexor digitorum profundus( the lateral half), pronatus quadratus, flexor pollicis longus, thenar muscles, the first and second lumbricals P/B :- DR NIYATI PATEL 11
- 12. Deformity The deformity seen in median nerve palsy are as follows depending upon the site and extent of lesion. 1. The commonest deformity seen is ape hand or monkey hand which occurs due to flattening of the thenar eminence, lack of opposition of the thumb because of which the thumb is held beside the index finger due to over action of the adductor pollicis and extensor pollicis longus. P/B :- DR NIYATI PATEL 12
- 13. 2. Partial claw hand occurs due to paralysis of the first and second lumbricals due to which there is unopposed action of the extensor digitorum giving rise to hyperextension of the metacarpophalangeal joint of the index and middle finger alongwith flexion of the interphalangeal joint of these fingers. P/B :- DR NIYATI PATEL 13
- 14. 3. Pointing index finger: When there is a higher lesion involving even the long flexors of the hand, on asking to make a fist the index finger will point forward. P/B :- DR NIYATI PATEL 14
- 15. 4. When patient with anterior interosseous nerve palsy is asked to make a tip to tip pinch using the index and the thumb then due to paralysis of the flexor digitorum profundus and flexor pollicis longus the tip to tip pinch will show a tear drop appearance instead of ‘O’. P/B :- DR NIYATI PATEL 15
- 16. RECOVERY SIGN The first sign of recovery of median nerve following its lesion in the wrist will be the ability of the thumb to rotate when the thumb is supported in slight amount of palmar abduction and flexion. P/B :- DR NIYATI PATEL 16
- 17. SPECIAL TESTS Phalen's test: In carpal tunnel syndrome palmar flexion of the wrist to 90 degrees for one minute exacerbates or reproduces the symptoms. P/B :- DR NIYATI PATEL 17
- 18. Tinel's sign: Tapping over the dorsum of the wrist precipitates pain in the median nerve distribution P/B :- DR NIYATI PATEL 18
- 19. Carpal Compression Test.: The examiner holds the supinated wrist in both hands and applies direct, even pressure over the median nerve in the carpal tunnel for up to 30 seconds . Production of the patient's symptoms is considered to be a positive test for carpal tunnel syndrome. P/B :- DR NIYATI PATEL 19
- 20. Wrinkle (Shrivel) Test The patient's fingers are, placed in warm water for approximately 5 to 20 mintues. Then removes the patient's fingers from the water and observes whether the skin over the pulp is wrinkled . Normal fingers show Tinkling, but denervated ones do not. The test is valid only within the first few months after injury. P/B :- DR NIYATI PATEL 20
- 21. ULTT P/B :- DR NIYATI PATEL 21
- 22. INVESTIGATION RADIOGRAPH :- shows whether there is presence of fracture MRI :- To delineate complete avulsion of nerve roots SD CURVE:- abnormality in conduction can be verified. Sharp curve, long chronaxie, low rheobase and the absence of contraction with repetitive stimuli indicates denervation. If it is done 2-3 weeks after injury, it shows the sign of denervation and to find out whether it is moderate or severe injury NCV:- To find out the severance of nerve fibers with wallerian degeneration. EMG:- it will help to find out reversible and irreversible nerve damage and will help map out whether it pre ganglionic/ post ganglionic lesion P/B :- DR NIYATI PATEL 22
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- 24. TYPES OF INJURIES In Neuropraxia pain, numbness, muscle weakness, minimal muscle wasting is present. Recovery occurs within minutes to days In Axonotmesis there is pain, evident muscle wasting, complete loss of motor, sensory and sympathetic functions. Recovery time– months (axon regeneration at 1-1.5 mm/day) In Neurotmesis no pain, complete loss of motor, sensory and sympathetic functions. Recovery time – months and only with surgery P/B :- DR NIYATI PATEL 24
- 25. SURGICAL TREATMENT The basic requirement for hand function in median nerve injury consist of the following component. ◦ Thumb abduction to perform opposition ◦ Flexion across the metacarpophalangeal joint of the thumb ◦ Flexion of the index and middle finger ◦ Sensation over the thenar eminence and pulp of the thumb. Tendon transfer surgeries Transfer of FDS of ring finger to abductor pollicis brevis Transfer of Brachioradialis to flexor pollicis longus Transfer of FDP of ring and little finger to middle and index finger Following surgery, immobilisation with POP for 3 weeks and opposition splint can be given for another 6 weeks P/B :- DR NIYATI PATEL 25
- 26. PHYSIOTHERAPY TREATMENT Passive movement to the wrist and fingers to keep the parts mobile Gentle stretching of the long flexors to prevent any form of tightness IG stimulation to all the muscles supplied by the median nerve Care of the anaesthetic hand Splints: Opposition splints are given to maintain the thumb in opposition and also to prevent contracture of the first web space. The two types of splints which are commonly given are C- bar and cockup splints. P/B :- DR NIYATI PATEL 26
- 27. C-BAR This is used to maintain the first web space and is held in place with the help of 3 velcro straps one over the index finger, one over the thumb and one at the deepest part of the first web space COCK UP SPLINT an opposition out trigger is also used to maintain the thumb in opposition P/B :- DR NIYATI PATEL 27