median nerve injury ppt and wrist

CTS

most common upper extremity compression neuropathy

CTS definition

entrapment of the median nerve within the carpal tunnel

CTS risk factors

pregnancy

diabetes

hyperthyroidism

RA

repetitive work

prolonged wrist positioning

palmar ligament

superficial and deep aspect

purpose is to hold extendor muscles in the wrist

transverse carpal ligament

flexor retinaculum

hold long tendons of the FDS and palmaris longus tendon

CTR

carpal tunnel release

CTS facts

78.5% more prevalent in women

bilateral in 50% of cases (compensation)

CTS intrinsic factors

anatomic

physiologic

behavioural

CTS extrinsic factors

enviromental influences

CTS anatomy

median nerve passes through the carpal tunnel into the hand

gives sensation to thumb, index, long and half of ring finger

sends nerve branch to control the thenar muscles of the thumb

CTS motor branch affected

dropping things

decreased grip

initial signs of CTS

sesnory brach affected

tingling, radiation etc

CTS tendon causes

repetitive mvmt causes swelling

dull sharp pain

CTS nerve cause

compressed by inflammed tendonds

nerve compression causes tingling, pain, burning

CTS physiology

swelling

compression

carpal bones and carpal ligament

CTS risk factors manual

repetition

force

bending

vibration

impact

CTS higher risk factors

heavy use of hand tools

repetitive keyboarding

sewing

instruments

assembling

cutting

CTS mediacal evaluation

tinel

phalens

reversed phalens

NCV - nerve conduction test

CTS eval

comprehensove history

observation

sensation testing

motor testing

special tests

functional assessment

comprehenisve history

onset

aggravating

activities

nocturnal sympotoms

observation

hand posture

thenar atrophy

compensatory movements

sensation testing

Semmes-Weinstein

2pt discrimination

special tests

phalens

tinels

resisted pronation

motor testing

opposition

pinch

grip

strength

functional assessment

ADL/IADL

occupational performance impact

CTS symptoms

sensory - numbness, tingling in thumb, middle, ring - worse at night

motor - weakness or loss of thumb oppositon, fine motor deficits

advanced - thenar atrophy (APB, opponens pollicus)

early stage of CTS

swelling and irritation begins

tigling and numbness

clumsiness

feelings return to normal after rest

may be caused by hormonal changes or sturctural conditions

CTS intermediate stage

more numbness, burning, aching

radiating pain to forearm

waking up at night

loss of coordination

increased clumsiness

scar tissue forms around irritated nerve tendons

advanced stage

continued swelling

permanent damage

decreased / lost grip strength - difficulty holding objs, inability to grasp

coordination greatly reduced

advanced loss of funcion

muscle waste

highly uncomfortable combination of nummbess, tingling and pain

medical treatment

prescribe stonger NSAID medication or cortisone-type medication

prescribes hand therapy and/or custom prescription splint

cortisone shot into the carpal tunnel

surgery

CTS non operative tx

splint wrist in neutral position to prevent flexion

nerve and tendon gliding excersises

activity modification - avoid sustained pinch, repetitiv oeruse, prolonged flexion

ergonomics - padded handles, workstation modification

proximal conditioning and postural retraining

CTS surgical tx

surgical release - traditional or endoscopic

therapy often not required

scar mobilizaion, gel pads for pain, pillar pain common

orthosis only for high risk clients

AROM wrist, thumb, fingers being 1-2 days post op

strengthening starts 3-6 wks post op

working safely

tool handles

gripping surface

reduction in vibration

pinch grip

hand tools

anterior interosseus syndrome (AIS)

cause - compression of the anterior interosseus branch of median nerve

motor only syndrome

AIS symptoms

deep proximal forearm pain, worse with activity

negative tinels sign

AIS motor loss

FPL - thumb

FDP - index / long

pronator quadraus

Ballentines OK sign - collapse of diatal joints when forming

AIS orthotic management

stabilize thumb IP and index DIP flexion to enhance pinch

AIS clinical features

cause - compression of the anterori interosseus branch of the median nerve

symptoms- non specific dee aching pain in proxmal forearm, worse w/ activity

no sensory involvement

negative tinels sign - no tingling w/ tapping

AIS functional impact and tx

motor deficits - flexor pollicus longus - thumb IP flexion

FDP - index and long finger DIP flexion

possible paresis of pronator quadratus

clilncical hallmar - OK sign

AIS orthotics

stablize thumb IP anf index DIP in flexion to enhance pinch function

AIS rehab focus

activity modification

functional training

progressive strenghtening

pronator syndrome

entrapment of proximal median nerve between pronator teres heads

pronator syndrome symptoms

deep proximal forearm pain, sometimes sensory changes

provoked by resisted elbow flexion and pronation

negative tinels sign

pronator synrome nonpoerative tx

elbow split

neutral forearm

TENS

stretching

avoid repetitive pronaton/ elbow flexion

pronator syndrome operative tx

half cast

AROM all joints in cast

strengthening at 1 wk

full AROM by 8 wks

Ape hand deformity cause

severe median nerve injury at wrist or forearm

ape hand apperance

thenar atrophy

thumb rests in adduction / extension plane

ape hand symptoms

sensory loss in index, middle, radial ring fingers

motor loss - pinch, thumb opposition, index MCP and PIP flexion, decreased pronation

ape hand nonoperative tx

static thenar we spacer splint

ape hand operative tx

dorsal wrist blocing splint (4-6wks)

AROM/ PROM in splint

tendon gliding

scar massage

strengthening at 6 wks