Transcript peripheral nerve injuryies mhd bashar alboshi

PERIPHERAL NERVE
INJURYIES
MHD BASHAR ALBOSHI
Microscopic anatomy 
INTERNAL TOPOGRAPHY
OF PERIPHERAL NERVES

NEURONAL DEGENERATION
AND REGENERATION:
Phagocytosis
Secondary or wallerian
degeneration
Primary or retrograde egeneration
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CLASSIFICATION OF NERVE INJURIES: ( Seddon1943):
Neurapraxia
Axonotmesis
neurotmesis
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(Sunderland 1951) classification
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Etiology of peripheral nerve injuries:
- Metabolic or collagen diseases
- Malignancies
-Endogenous or exogenous toxins
-Thermal
-Chemical
-Mechanical trauma
Clinical diagnosis of nerve injuries:
Highet Scale:
0 – total paralysis.
1- muscle flicker.
2-muscle contraction.
3- muscle contraction against gravity.
4- muscle contraction against gravity and
resistance.
5-normal muscle contraction .
Diagnostic tests:
Electrodiagnostic studies provide the clinician with a
:base of knowledge as follows:
1-Documentation of injury
2 - Location of insult
3-Severity of injury
4-Recovery pattern
5-Prognosis
6-Objective data for impairment documentation
7-Pathology
8-Selection of optimal muscles for tendon transfer
9-procedures
The most common electrodiagnostic methods
used for the study of peripheral nerve
injuries are :
@- nerve conduction studies and
@-electromyography (EMG)
Fig. 59-10 Diagram 
of EMG tracing
depicting normal
insertion activity,
which also may be
present immediately
after denervation.
Fig. 59-11 A, Diagram of
EMG tracing demonstrating
positive sharp wave
consistent with denervation
10 to 14 days after injury.
Rhythm is regular,
amplitude is 100 to 400 uV,
duration is 5 to 150 msec,
and rate is 2 to 40 Hz.
B, Diagram of EMG tracing
demonstrating spontaneous
denervation fibrillation
potentials present within 14
to 18 days after injury.
Rhythm is regular,
amplitude is 50 to 1000 uV,
duration is 0.5 to 2 msec,
.and rate is 2 to 30 Hz
Tinel sign :
A positive Tinel sign is presumptive evidence that
regenerating axonal sprouts that have not
obtained complete myelinization are
progressing along the endoneurial tube.
@- neuropraxia(sunderland1) -------negative
Tinel sign.
@- axonotmesis (sunderland2,3) -------positive
Tinel sign.
(sunderland4-------- negative Tinel sign )
@- neurotmesis (sunderland 5) ------- negative
Tinel sign.
Other diagnostic test:
Sweat test.,skin resistance test, electrical
stimulation
GENERAL CONSIDERATIONS OF TREATMENT.
FACTORS THAT INFLUENCE REGENERATION AFTER
NEURORRHAPHY :
1-Age
2-Gap Between Nerve Ends
3-Delay Between Time of Injury and Repair
4-Level of Injury
5-Condition of Nerve Ends
TECHNIQUE OF NERVE REPAIR:
Endoneurolysis (Internal Neurolysis
Partial Neurorrhaphy
Neurorrhaphy and Nerve Grafting
Methods of Closing Gaps Between Nerve
Ends:
Mobilization
Positioning of Extremity
Transposition
Bone Resection
Nerve Stretching and Bulb Suture
Nerve Grafting
Techniques of
Neurorrhaphy:
Epineurial
Neurorrhaphy
Perineurial
(Fascicular)
Neurorrhaphy
Interfascicular Nerve
Grafting
Brachial Plexus
ETIOLOGY AND CLASSIFICATION OF
BRACHIAL PLEXUS INJURIES :
-birth,
-missiles,
- stab wounds,
- traction applied to the plexus during falls,
-vehicular accidents,
- sports activities,
-as well as radiation.
Rupture of the axillary or subclavian artery occurs in
20% of patients.
Common associated injuries include:
@fractures of the proximal humerus, the scapula, the
ribs, the clavicle, and the transverse processes of
the cervical vertebrae
@dislocation of the shoulder, the acromioclavicular,
and the sternoclavicular joints.
@ A torn rotator cuff also has been described in
.conjunction with brachial plexus injury
Upper plexus injury (Erb)
involves the segments innervated by the C5 and C6
nerve roots with or without dysfunction of the
C7 root.
-Typically the limb is extended at the elbow(the
biceps, brachialis, and brachioradialis muscles)
-flaccid at the side of the trunk,
-Adducted (deltoid and supraspinatus muscles) -internally rotated (infraspinatus and teres minor muscles, supinator muscle)
Lower plexus injury (Klumpke)
can be diagnosed by finding segmental sensory and motor
deficits involving C8 and T1 with or without C7
dysfunction.
@ The primary dysfunction is apparent in :
-the intrinsic musculature of the hand along with paralysis
of the wrist and finger flexors.
- The sensory deficit is along the medial aspect of the arm,
forearm, and hand.
@Associated Horner syndrome should alert the examiner to
the possibility of an avulsing injury of the lower plexus,
.
Injuries to the upper or lower
trunks
produce essentially the same sensory and
motor deficits as do injuries to their
respective rami, except for preservation of
function of the long thoracic and dorsal
scapular nerves in the upper trunks and
absence of Horner syndrome in the lower
.trunks
Injuries of the lateral cord
deficits in the distribution of:
-musculocutaneous nerve (paralysis of the biceps).
-lateral root of the median nerve (paralysis of the flexor carpi radialis and pronator teres).
-lateral pectoral nerve (clavicular head of the pectoralis major).
@Glenohumeral subluxation may result. This may be prevented
by an aggressive program of rehabilitation of the remaining intact
musculature.
@Sensory deficit can be detected over the anterolateral aspect of
the forearm in the relatively small autonomous zone of the
.musculocutaneous nerve
-
-
Injuries of the posterior cord
deficits in the distribution of the following nerves:
-subscapular (paralysis of the subscapularis and teres major),
-thoracodorsal (paralysis of the latissimus dorsi).
- axillary (paralysis of the deltoid and teres minor),
-radial nerve (paralysis of extension of the elbow, wrist, and fingers).
@The disability consists mainly of inability to internally rotate the
shoulder, elevate the limb, and extend the forearm and hand.
@ Sensory loss most often is apparent only in the autonomous zone of the
.axillary nerve overlying the deltoid muscle.
Injuries of the medial cord
produce the motor deficit of:
- a combined ulnar and median nerve lesion
(except for the flexor carpi radialis and
pronator teres) and
- extensive sensory loss along the medial aspect of
the arm and hand
TREATMENT OF BRACHIAL
PLEXUS INJURIES
Open injuries: exploration and primary repair can be attempted.
Usually, however, injuries to adjacent vessels or to the mediastinal or
thoracic viscera must be treated first, and thus repair of the plexus
injury must be delayed.
@. Leffert emphasized the poor prognosis after lower trunk injuries but
advised surgical exploration for sharp injuries of the upper and middle
.trunks
@When an open injury has been caused by a low-velocity missile, early
exploration is not indicated unless injuries to adjacent vessels or
viscera make immediate treatment necessary.
@Consequently a period of observation is indicated because considerable
function may return spontaneously
@Again electromyograms should be obtained 3 to 4 weeks after injury to
aid in determining the extent of denervation. Thereafter periodic
examinations are indicated every 4 to 6 weeks
@When such examinations during a reasonable period of time reveal the
absence of recovery or that any recovery has halted, exploration and
neurorrhaphy, grafting, or neurolysis may be beneficial
Surgical Goals
Surgical Goals
The surgeon should have clear and reasonable
surgical goals, which are in order of priority:
(1) restoration of elbow flexion.
(2) restoration of shoulder abduction.
(3) restoration of sensation to the medial border of
the forearm and hand.
@After brachial plexus repair and reconstruction, 12
to 18 months are required to determine the extent
.of neural regeneration
/
Tendon transfers about the shoulder that may be .
considered include
trapezius to deltoid transfer to improve abduction -latissimus dorsi transfer to improve external rotation. - Shoulder arthrodesis is helpful if active scapulothoracic motion is preserved and has been
shown to improve elbow flexion by preventing
uncontrolled internal rotation of the shoulder. The
shoulder should be fused in only 20 to 30 degrees of
.abduction because most of these patients.
@Operations to restore elbow flexion include
transfers of the latissimus dorsi, the pectoralis
major, the triceps, the sternocleidomastoid, and the
flexor-pronator mass).
- Marshall et al. reviewed 50 such transfers and
found the latissimus dorsi and triceps transfers
to be the most reliable. Restoration of elbow
flexion is helpful to the patient even if the hand is
functionless
The long thoracic
nerve arises
from C5, C6,
and C7
immediately
after they
emerge from
the
intervertebral
.foramina
It traverses the .
neck posterior to
the brachial
plexus, continues
distally along the
lateral aspect of
the thoracic wall,
and innervates the
serratus anterior
.muscle
injuries may result from:
-either sharp or blunt trauma - or from traction when the head is forced acutely away from the shoulder or when the shoulder is
depressed, as when carrying heavy weights.
- Other causes include exposure to cold, viral infections, and placing patients in the
Trendelenburg position with shoulder braces that
.compress the supraclavicular areas
Examination:
-When the serratus anterior is paralyzed, the
patient cannot fully flex the arm above the
level of the shoulder anteriorly, and active
abduction also may be restricted.
- When the patient attempts to exert forward
pushing movements with the hands,
"winging" of the scapula occurs and its
vertebral border and inferior angle become
.unduly prominent
Treatment:
When the nerve has been stretched rather than
severed, it usually is enough to immobilize the
shoulder girdle in extension with the arm against
the chest.
Care should be taken to avoid contractures of the shoulder, elbow, and wrist while awaiting
recovery.
-According to Sunderland, the nerve may recover after 3 to 12 months. If paralysis persists or if the
nerve has been severed, the prognosis for recovery
is poor, and a reconstructive operation may be
indicated
Arising from the
upper trunk of
the brachial
plexus
The only surgically
significant nerve.
This is the first
important branch
seen when the plexus
is explored superior
to the clavicle. This
nerve proceeds
distally, passing
through the scapular
notch to the posterior
aspect of the scapula,
where it supplies the
supraspinatus muscle
and, after proceeding
around the lateral
border of the scapular
spine, supplies the
.infraspinatus muscle.
The nerve may be injured by:
-penetrating trauma in the posterior triangle of the neck
- cancer surgery in the same area, - blunt or penetrating trauma in the supraclavicular region,
- fractures of the superolateral portion of the scapula, especially involving the region of the suprascapular
notch,
- anterior dislocations of the shoulder joint - entrapment in the suprascapular notch, - space-occupying lesions such as a ganglion at the .spinoglenoid notch
Examination
-Pain in the shoulder and weakness of the shoulder
girdle are common complaints.
- Atrophy of both the supraspinatus and
infraspinatus muscles may be seen if the nerve is
injured at or proximal to the suprascapular notch.
- - Atrophy of only the infraspinatus muscle
suggests entrapment distal to the supraspinatus
fossa, as may occur at the spinoglenoid notch.
@Electrodiagnostic studies are helpful in confirming
the diagnosis
The axillary nerve, composed of fibers from C5 and C6, is a
branch of the posterior cord of the brachial plexus.
emerging inferior to the subscapular and thoracodorsal nerves at the
level of the humeral head; it then winds around the neck of the
humerus

passing through the quadrangular space to supply the deltoid and teres ,
minor muscles, , and the skin overlying the deltoid.
.
This nerve commonly is injured by:
-fractures or dislocations about the shoulder,
-penetrating wounds, and direct blows.
- Rarely, compression of the axillary nerve or one of
its major branches may occur in the quadrilateral
space and cause chronic pain and paresthesia
aggravated by forward flexion or abduction and
external rotation of the humerus
Examination:
-Because a lesion of the axillary nerve sometimes does not cause
anesthesia, the diagnosis must rest solely on the presence or absence of
function in the deltoid muscle.
-Usually deltoid paralysis is easily detected by the inability to actively
abduct the arm.
However, it is well documented that full abduction of the arm is possible in the presence of deltoid paralysis because of the action of
the supraspinatus and because of rotation of the scapula. Therefore it is
essential to observe and palpate the deltoid muscle for contraction
during the examination.
- Electrical stimulation of the nerve in situ is easily accomplished by inserting the needles along the posterior border of the deltoid.
Treatment: -Transfer of the insertion of the trapezius is the most satisfactory operation
for complete paralysis of the deltoid.
-Transfer of Deltoid Origin for Partial Paralysis.
.
The musculocutaneous nerve, composed of fibers from C5 and
C6, is a branch of the lateral cord of the brachial plexus
muscles supplied by the musculocutaneous nerve are the
biceps; the brachialis and the coracobrachialis.
It most commonly is injured by:
-penetrating injuries -occasionally by anterior dislocation of the
shoulder or fractures of the humeral neck.
- When this nerve is injured in the axilla, the
injury often is in conjunction with injuries
.to other components of the brachial plexus
Examination:
-The only muscle supplied by the musculocutaneous nerve
that can be examined accurately is the biceps; the
brachialis and the coracobrachialis are difficult to palpate.
-Complete division of the nerve may be overlooked because
the sensory loss may be ill defined and flexion of the
elbow by the brachioradialis may be strong enough to
mask biceps paralysis. In these instances it is essential to
palpate the biceps while testing its function to identify
specific muscle contractions
- Sensory examination is of no great value because complete
anesthesia is rare. Division of this nerve may cause less
disability than that of any other major nerve in the body,
and for this reason, especially in older patients, suture
.occasionally is not even indicated
The radial nerve, a continuation of the posterior cord of the brachial
.plexus, consists of fibers from C6, C7, and C8 and sometimes T1.
It is primarily a motor nerve that innervates the triceps, the
supinators of the forearm, and the extensors of the wrist,
fingers, and thumb.
This nerve is injured most often by:
-fractures of the humeral shaft.
-Gunshot wounds are the second most common cause of radial nerve injury.
Other causes include lacerations of the arm
and proximal forearm,
- injection injuries, - and prolonged local pressure.
-
Entrapment syndromes of the radial
nerve
-may develop when the nerve or one of its branches is compressed at
some point along its course.
-Compression of the radial nerve in the arm may be caused by the fibrous arch of the lateral head of the triceps muscle.
-The posterior interosseous nerve may be compressed by the fibrous
arcade of Frohse, fracture-dislocations or dislocations of the elbow,
fractures of the forearm, Volkmann ischemic contracture, neoplasms,
enlarged bursae, aneurysms, or rheumatoid synovitis of the elbow.
-According to Spinner, posterior interosseous nerve entrapment is of
two types. In one type all the muscles supplied by the nerve are
completely paralyzed; these include the extensor digitorum
communis, extensor indicis proprius, extensor digiti quinti, extensor
carpi ulnaris, abductor pollicis longus, and extensor pollicis brevis. In
the second type only one or a few of these muscles are paralyzed.
-
-
radial tunnel syndrome
-entrapment of the posterior interosseous nerve cause chronic and refractory tennis elbow.
-can occur at four potentially compressive anatomical structures:
- the origin of the extensor carpi radialis brevis,
-adhesions about the radial head,
- the radial recurrent arterial fan,
-and the arcade of Frohse as the posterior
interosseous nerve enters the supinator.
@Lotem et al. found that when symptoms and signs of radial nerve entrapment in the arm develop only after muscular effort, spontaneous
recovery can be anticipated.
@However, when entrapment is caused by other conditions, especially in the forearm, surgical exploration and decompression of
the nerve usually are beneficial.
@Compression of the superficial radial nerve causes pain in the forearm
and sensory impairment on the dorsum of the thumb. The nerve may
.be caught in scar tissue at the wrist after surgery or trauma
Examination
The following muscles supplied by the radial
nerve can be tested accurately because their bellies
or tendons or both can be palpated:
- the triceps brachii,
- brachioradialis,
- extensors carpi radialis,
-extensor digitorum communis,
-extensor carpi ulnaris,
- abductor pollicis longus, and
- extensor pollicis longus.
@ Injury to this nerve results in inability to extend
the elbow or supinate the forearm and in a typical
wristdrop
@The triceps is not seriously affected by injuries of
the nerve at the level of the middle of the humerus
or distally.
@ In injuries of the nerve at its bifurcation into the
deep and superficial branches the brachioradialis
and the extensor carpi radialis longus continue
to function; thus the arm can be supinated and the
.wrist can be extended.
@Sensory examination is relatively unimportant,
even when the nerve is divided in the axilla,
because usually there is no autonomous zone.
The ulnar nerve is composed of fibers from C8 and T1 coming
.from the medial cord of the brachial plexus
Injuries:
-When it is injured in the upper arm, other nerves or
the brachial artery because of their proximity also
may be injured.
-In the middle of the arm the ulnar nerve is relatively protected,.
-in the distal arm and at the elbow it often is injured by dislocations of the elbow and
supracondylar and condylar fractures.
-The nerve is injured most commonly in the distal
forearm and wrist; in these locations it may be
injured by gunshot wounds, lacerations, fractures,
or dislocations.
- In civilian life lacerations cause most of the injuries
.at the wrist
Tardy ulnar nerve palsy
may develop after:
malunited fractures of the lateral humeral condyle in children, - displaced fractures of the medial humeral epicondyle, -dislocations of the elbow, - contusions of the nerve. - In malunion of the lateral humeral condyle, cubitus valgus develops; in this deformity the ulnar nerve is gradually stretched
and can become incompletely paralyzed.
-also may develop in patients who have a shallow ulnar groove on
the posterior aspect of the medial humeral epicondyle,.
- hypoplasia of the humeral trochlea, .
- an inadequate fibrous arch that normally keeps the nerve in the groove, resulting in recurrent subluxation or dislocation of the
.nerve.
cubital tunnel syndrome
compression neuropathy of the
ulnar nerve about the elbow with
no antecedent trauma.
- As the ulnar nerve enters the
cubital tunnel it is first bordered
by the medial epicondyle
anteriorly, then by the elbow
joint laterally, and finally by the
two heads of the flexor carpi
ulnaris medially.
-In other areas the nerve may be
compressed by ligaments,
neoplasms, rheumatoid
synovitis, aneurysms, vascular
Postoperative ulnar nerve palsy:
- may result from either direct pressure on the ulnar
nerve at the elbow or prolonged flexion of the
elbow during surgery.
- The ulnar nerve is especially vulnerable to
compression when the forearm is allowed to rest
in pronation.
-Alvine and Schurrer suggested that some patients
may have a preexisting subclinical cubital tunnel
syndrome that may predispose them to this
.complication
Examination
-Interrupting the ulnar nerve proximal to the elbow is
followed by paralysis of:
- the flexor carpi ulnaris, -the flexor profundus to the little and ring fingers, -the lumbricals of the same fingers, - all of the interossei, - the adductor of the thumb, - and all of the short muscles of the little finger. @Occasionally when a nerve is completely divided at this
level, the intrinsic muscles of the hand function normally
because of anomalous innervation of these muscles by the
median nerve. In these instances the fibers that supply the
intrinsic muscles may be incorporated in the median nerve
down to the middle of the forearm where they leave the
median nerve to join the ulnar nerve (Martin- Gruber
.anastomosis).
Complete division of the ulnar nerve at the wrist
usually causes paralysis of all ulnar-innervated
intrinsic muscles unless an anatomical variation
connects the median and ulnar nerves in the palm
(Riche-Cannieu anastomosis). Usually when the
nerve is divided at the wrist, only the opponens
pollicis, the lateral or superficial head of the flexor
pollicis brevis, and the lateral two lumbricals
remain functional
@In practice only three muscles
-the flexor carpi ulnaris,
- the abductor digiti quinti, and
- the first dorsal interosseus—can be
tested accurately. The bellies or tendons (or
both) of these muscles may be easily
palpated or seen
@Atrophy of the muscles supplied by the ulnar nerve and
clawing of the little and ring fingers usually are
confirmatory evidence of paralysis of the muscles supplied
by this nerve.
@ However, if the nerve has been injured proximal to the
elbow, clawing of these two fingers may be absent because
the flexor digitorum profundus to the ring and little fingers
also is denervated.
@The sensory examination usually is straightforward,
although anatomical variations may cause confusing
sensory findings. One need examine only the middle and
distal phalanges of the little finger, which make up the
autonomous zone of the ulnar nerve .
-Complete anesthesia to pinpricks in this area strongly
.suggests total division of the nerve
@In patients suspected of having cubital tunnel
syndrome:
-a positive percussion test over the ulnar nerve at the level
of the medial epicondyle
- and a positive elbow flexion test are strongly suggestive
of a significant compressive neuropathy.
-With the elbow fully flexed, the patient will complain of
numbness and tingling in the small and ring fingers, often
within 1 minute.
- Nerve conduction studies are helpful and should demonstrate slowing in the ulnar nerve velocities across
the elbow, although normal velocities may be maintained
during early involvement. Electromyography may
demonstrate fibrillations in the ulnar innervated intrinsic
.muscles
-
The treatment for refractory tardy ulnar
nerve palsy
- may require removal of the nerve from its groove,
neurolysis if necessary, and anterior transposition of
the nerve to the flexor surface of the elbow.
-Conservative treatment for this syndrome should be
attempted before surgical treatment.
Patients are instructed to avoid prolonged elbow flexion in the workplace and are given elbow
extension splints for sleeping. The splint should not be
fitted with the forearm held in pronation because this
may aggravate the symptoms.
- Towels or pillows secured about the elbow may adequately limit elbow flexion during sleep.
-Conservative treatment usually is attempted for a period of 3 months before surgical treatment is
considered
The surgical treatment of cubital tunnel
syndrome :
-includes simple decompression, medial
epicondylectomy, and anterior transposition of the
ulnar nerve either into a subcutaneous,
intramuscular, or submuscular bed
-For a moderate degree of compression the greatest .
number of excellent results and fewest recurrences
were obtained with the submuscular technique.
The anterior intramuscular technique yielded the
fewest excellent results
The median nerve, formed by the junction of the lateral and
medial cords of the brachial plexus in the axilla, is
composed of fibers from C6, C7, C8, and T1
Median nerve injuries :
-often result in painful neuromas and causalgia.
- From the sensory standpoint they are more disabling than
injuries of the ulnar nerve because they involve the digits
.used in fine volitional activity
-Median nerve injuries often are caused by lacerations, usually
in the forearm or wrist.
Sunderland pointed out that in: - the upper arm the nerve can be injured by relatively superficial lacerations, excessively tight tourniquets, and
humeral fractures, and when it is injured near the axilla, the
ulnar and musculocutaneous nerves and the brachial artery
also are commonly injured.
- In the arm the median nerve may be compressed by the ligament of Struthers.
-At the elbow the nerve may be injured in supracondylar .fractures and posterior dislocations of the elbow
@Median nerve deficits, as seen in the
pronator syndrome, may result from
compression of the nerve at the pronator
teres, the lacertus fibrosus, or the fibrous
flexor digitorum sublimis arch or from
anomalies including a hypertrophic
pronator teres, a high origin of the
pronator teres, fibrous bands within the
pronator teres, the median nerve passing
posterior to both heads of the pronator
teres, or an accessory tendinous arch of
the flexor carpi radialis arising from the
.ulna.
@The anterior interosseous nerve may be injured in
fractures and lacerations or may be compressed or
entrapped by any of the following: the tendinous
origins of the flexor digitorum sublimis or the
pronator teres, variant muscles such as the
palmaris profundus and flexor carpi radialis
brevis, tendons from the flexor digitorum sublimis
to the flexor pollicis longus, an accessory head of
the flexor pollicis longus (Gantzer muscles), an
aberrant radial artery, thrombosis of the ulnar
collateral vessels, enlargement of the bicipital
bursa, or a Volkmann ischemic contracture.
@At the wrist the median nerve may be injured by
fractures of the distal radius and by fractures and
.dislocations of the carpal bones
Examination
The muscles of the forearm and hand supplied by
the median nerve that can be tested with relative
accuracy are:
the pronator teres, - flexor carpi radialis, - flexor digitorum profundus (index), - flexor pollicis longus, - flexor digitorum sublimis, -and abductor pollicis brevis.
@ Substitution movements caused by action of intact
muscles may cause confusion during the
examination.
@ Usually if the forearm can be actively maintained in pronation against
resistance, the pronator teres is intact.
@ If the wrist can be actively maintained in flexion and a contracting
flexor carpi radialis is palpated, this muscle is intact.
@Similarly if the interphalangeal joint of the thumb can be maintained in
flexion against resistance with the wrist in the neutral position and the
thumb adducted, the flexor pollicis longus is functioning.
@ The flexor digitorum sublimis to each finger is examined separately
while the remaining fingers are held in full passive extension.
@ Although opposition of the thumb can be difficult to confirm, if the
thumb can be actively maintained in palmar abduction and a
contracting abductor pollicis brevis is palpated, this muscle is
functioning.
@The lumbricals cannot be discretely tested because they cannot be
palpated and because their function may be confused with that of the
.interosseus muscles.
According to Spinner, the anterior interosseous
syndrome:
-can cause varying signs and symptoms.
-Typically, the patient has pain in the proximal
forearm lasting for several hours and is found to
have weakness or paralysis of the flexor pollicis
longus, the flexor digitorum profundus to the
index and long fingers, and the pronator
quadratus.
-When the patient attempts to pinch, active flexion of
the distal phalanx of the index finger is
.impossible
Treatment:
In patients who have symptoms of carpal tunnel
syndrome and pronator teres syndrome,
particular attention should be paid to the nerve conduction studies during preoperative planning.
- If the nerve conduction test is positive for carpal tunnel syndrome, we agree in recommending carpal
tunnel release in anticipation that the proximal
symptoms will resolve.
-If the nerve conduction test is negative for carpal tunnel syndrome, we recommend proximal median
nerve exploration and proximal decompression as the
initial procedure of choice.
@. For the anterior interosseous syndrome. If the onset
of paralysis has been spontaneous, the initial treatment
is nonoperative. Surgical exploration is indicated in
the absence of clinical or electromyographic
. improvement after 12 weeks
PERIPHERAL
NERVE
INJURYIES
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lecture.
Dr. Muayad Kadhim
‫ مؤيد كاظم‬.‫د‬