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Radial nerve damage ➔ wrist drop
↓ wrist extension
↓ thumbs up
↓ tricep strength
Median nerve damage
Proximal - Hand of benediction: make fist ➔ ↓ ability to flex middle and index finger
Anterior interosseous - ↓ OK sign (pinching of index and thumb). No sensory deficit
Distal - Attempt to extend fingers ➔ middle and index stuck flexed
Ulnar nerve damage
Inability to spread fingers against resistance
Ulnar claw (at rest) hyperextension at MCP and hyper flexion at IP
Carpal tunnel
Carpal tunnel
↑ pressure on wrist ➔ compression and inflammation of median nerve and axon degeneration over time
SSX - Median nerve
Pain, burning sensation, worse at night (massaging or shaking hand out may ↓ pain)
Severe median nerve compression ➔ weak grip, difficulty with thumb opposition, thenar (thumb) atrophy
DX
Phalen test (specific): wrist held in full flexion by examiner (fingers pointing down) ➔ median nerve sx within 1min
Tinel sign: tapping carpal tunnel ➔ sx with median nerve distribution
EMG shows evidence of demyelination (slow conduction velocity/conduction block)
TX
Volar splint. PO or glucocorticoid injection. Severe/refractory ➔ surgery (release of the transverse carpal ligament)
Cubital tunnel
Cubital tunnel
Ulnar nerve compression at cubital tunnel along medial elbow
Prolonged elbow flexion (leaning on desk), trauma, neuropathy (DM)
SSX - Ulnar nerve
Paresthesia/sensory deficit (MC) along ulnar nerve distribution, ↑ with elbow flexion
Pain (LC) usually described as forearm pain (referred)
DX
Tinel's sign at elbow (tapping ➔ sx with ulnar distribution)
EMG shows evidence of demyelination (slow conduction velocity/conduction block)
TX
Activity modification to avoid compression and splinting. Surgery if refractory or severe
Thoracic Outlet
Thoracic Outlet
Compression of neurovascular structures
Scarred scalenes from trauma (MCC) or aging/obesity ➔ sagging shoulder girdle
Usually affecting brachial plexus, sometimes subclavian arteries/veins
SSX
Combination of pain, numbness, weakness, swelling
Spontaneous aggravation of sx with specific positioning of arm
Pain radiates to neck/axilla/shoulder/arm/hand
Paresthesia to volar fourth and fifth digits
Arterial ischemia ➔ pallor of fingers with elevation
Venous obstruction ➔ edema
DX
Sx with arms in “stick em up” position (abducted 90° in external rotation)
Adson's sign - lost radial pulse with turning head to affected side
Neuro TOS conduction testing usually negative
Vascular TOS - Duplex US
Arterial TOS almost always has born abnormalities (CXR)
Always rule out spinal disease
TX
Physical therapy and posture changes. Rarely surgery
Lateral andMedial Epicondylitis
Lateral andMedial Epicondylitis
Should be called tendinosis because not acute
Medial AKA golfer’s elbow
Repetitive/excessive pronation and wrist flexion ➔ tendon insertion of wrist flexors
Pain with arm extended and wrist flexed
Tenderness directly over epicondyle where the tendon inserts with resisted wrist pronation and wrist flexion
Lateral AKA tennis elbow
Repetitive/excessive pronation and wrist extension ➔ tendon insertion of wrist extensors
Pain with arm and wrist extended (shaking hands, using computer mouse, hitting backhand)
Tenderness directly over epicondyle where the tendon inserts with resisted wrist extension and third digit extension
DX
Spurling test for cervical radiculopathy (patient sitting, push down on head, extend and turn to affected side ➔ sx down arm)
US or MRI if conservative treatment doesn't help
TX
RICE and NSAIDs
Corticosteroid injection
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