Nerve entrapment disease Thoracic outlet syndrome Cubital tunnel

Nerve entrapment disease • Thoracic outlet syndrome • Cubital tunnel syndrome • Ulnar tunnel syndrome • Carpal tunnel syndrome • Nerve palsy

Thoracic outlet syndrome • Neurovascular symptom cause by compression at thoracic outlet • Incidence : 0. 3% • Neurogenic 95%, vascular 5% • female > male • Symptom : pain, paresthesia, ischemia, pulselessness, headache, syncope, amnesia

Thoracic outlet syndrome • Roo’s test(elevated arm stress test) – Upper arm ischemic pain – Shoulder 90 flexion external rotation and elbow 90 flexion then grasp and release – Pain or paresthesis for 1 minute or less (+) – Sensitivity 94% <Sanders et al. J Vasc Surg 2007>

Thoracic outlet syndrome • Adson test – Narrowing between anterior and mid scalene muscle – Neck extension and rotation to ipsilateral, forearm external rotation, breath deeply and stop then check radial artery – Radial artery pulselessness or pain (+) – Sensitivity 22~100% <Sanders et al. J Vasc Surg 2007>

Thoracic outlet syndrome • Costoclavicular test(halstead maneuver, military test) – Narrowing between first rib and clavicle – Extending chest wall to anterior, press patient’s shoulder to inferior and posterior then check radial artery – Radial artery pulselessness or pain (+)

Thoracic outlet syndrome • Hyperabduction test(Wright’s test) – Compression of brachial plexus or axillary artery by coracoid process – Additional compression by pectoralis minor muscle – Shoulder abduction and external rotation – Pain or paresthesis (+)

Thoracic outlet syndrome <Gillard J. et al. Joint Bone Spine 2001>

Thoracic outlet syndrome • Other diagnosis – Structure • X-ray : apical lordotic view • CT or MRI – Vascular • Color duplex sonography – Sensitivity 92%, specificity 95% • Angiography : gold standard in arterial thoracic outlet syndrome • Helical CT • MRA – Electrodiagnostic test • Nerve conduction velocity • Electromyography

Nerve entrapment disease • Thoracic outlet syndrome • Cubital tunnel syndrome • Ulnar tunnel syndrome • Carpal tunnel syndrome • Nerve palsy

Cubital tunnel syndrome • Compression of the ulnar nerve at the cubital tunnel • Repeat elbow flexion, post-traumatic scarring • Incidence : 0. 2 % • • • Forearm, 4, 5 th finger ulnar pain and paresthesia Interossei, adductor pollicis, ulnar lumbrical weakness FDP FCU weakness, but FDP cause Martin-Gruber anastomosis

Cubital tunnel syndrome • Elbow flexion test – Provocation test – Full active elbow flexion, with forearm supinated, wrist in extension, sustain for 60 seconds – Pain / worsening of numbness / paresthesia (+) – Sensitivity 75% <Novak CB, et al. J Hand Surg 1994>

Cubital tunnel syndrome • Cubital tinel test – Percussion on medial condyle posterior part of humerus – Tingling / paresthesia / a ‘shocking’ sensation (+) – Sensitivity 54~70% <Novak CB, et al. J Hand Surg 1994> – After elbow flexion test, sensitivity 75% – Specificity 98% <Bradley A, et al. J Hand Surg 2010>

Cubital tunnel syndrome • Cubital compression test – Compresstion on medial condyle posterior part of humerus for 60 seconds – Pain / paresthesia (+) – Sensitivity 46~70% – After 60 seconds, sensitivity 89% – After elbow flexion test, sensitivity 98% <Bradley A, et al. J Hand Surg 2010>

Cubital tunnel syndrome • Scratch collapse test – Patient faces the examiner with adducted, elbows flexed, and hands outstretched with the wrists at neutral – A : resists – B : scratches – C : A is immediately repeated – Loss of the patient’s external resistance tone (+) – Sensitivity 69% <Cheng CJ, et al. J Hand Surg AM 2008>

Cubital tunnel syndrome • Egawa sign – Abduct fingers against Examiner’s resistance palm facing downwards – Inability to perform this action as compared with uninvolved side – Interossei muscle weakness

Cubital tunnel syndrome • Froment’s sign – Diminishing key pinch strength – Adductor pollicis weakness – flexor pollicis longus compensation IP joint hyperflextion

Cubital tunnel syndrome • Wartenberg’s sign – Ulnar deviation of little finger – Difficulty of Adduction little finger with the forearm in pronation – Interosseous, hypothenar weakness

Cubital tunnel syndrome • Cutaneous pressure thresholds – Slowly adapting receptors – Semmes-Weinstein monofilament examination – Various diameter and different force

Cubital tunnel syndrome • Cutaneous pressure thresholds – Normal mean threshold values average 0. 158 g on the palm, 0. 055 g on the fingertips – Threshold is greater than the 2. 83 monofilament

Cubital tunnel syndrome • 2 point discrimination – Finger tip normal : 3~8 mm – Diminished ability of 4, 5 th finger

Cubital tunnel syndrome • Vibration thresholds – Quickly adapting receptors – Tuning fork 128 or 256 Hz – Diminished ability to vibratory sensation

Cubital tunnel syndrome • Vibration thresholds – Biothesiometer <Temlett JA J Clin Neurosci 2009>

Cubital tunnel syndrome • Other diagnosis – Structure • X-ray • CT or MRI – High-resolution ultrasound • Enlargement ulnar nerve on cubital tunnel • Gold standard in image study <Wiesler ER, et al. J Hand Surg 2006> – Electrodiagnostic test • Nerve conduction velocity(<50 m/s) • Debate on necessity to predict the surgical outcomes

Nerve entrapment disease • Thoracic outlet syndrome • Cubital tunnel syndrome • Ulnar tunnel syndrome • Carpal tunnel syndrome • Nerve palsy

Ulnar tunnel syndrome • Ulnar nerve entrapment at the ulnar tunnel in the wrist known as Guyon canal • Pain, paresthesia, numbness in 4, 5 th finger • DDx. cubital tunnel syndrome – Ulnar nerve dorsal sensory branch intact – 4, 5 finger severe claw deformity

Ulnar tunnel syndrome • Zone I – Proximal Guyon canal before bifurcation – Motor weakness and sensory deficits • Zone II – Compression ulnar distal motor branch from bifurcation – Intrinsic muscle weakness & intact sensation • Zone III – Compression superficial branch – Sensory loss without hypothenar and interosseous weakness

Ulnar tunnel syndrome • Radiologic study – Carpal tunnel view : hook of hamate – CT or MRI – Ultrasound • Electrodiagnostic tests – Electromyography – Nerve conduction velocity • Localization the level

Nerve entrapment disease • Thoracic outlet syndrome • Cubital tunnel syndrome • Ulnar tunnel syndrome • Carpal tunnel syndrome • Nerve palsy

Carpal tunnel syndrome • Compression of the median nerve at the wrist • female : male = 3: 1 • Paresthesia or numbness in the median nerve distribution • pain in thenar eminence

Carpal tunnel syndrome <Kuhlman KA, et al. Am J Phys Med Rehabil 1997>

Carpal tunnel syndrome • Tinel sign – Paresthesia in the distribution of median nerve when tapping the distal wrist crease over the median nerve – Sensitivity 23~60%, specificity 67~87% <Christopher A. D’Arcy, et al. JAMA 2000>

Carpal tunnel syndrome • Phalen’s test – Paresthesia in the distribution of median nerve when the patient flexes both wrist 90 degree for 60 seconds. – Sensitivity 10~91%, specificity 33~86% <Christopher A. D’Arcy, et al. JAMA 2000>

Carpal tunnel syndrome • Thenar muscle atrophy • Sensitivity 4~28%, specificity 82~99% <Christopher A. D’Arcy, et al. JAMA 2000>

Carpal tunnel syndrome • Carpal compression test – Compression on carpal tunnel for 20 seconds

Carpal tunnel syndrome • Flick sign – To relieve the symptoms, patients often “flick” their wrist as if shaking down a thermometer – Sensitivity 93%, specificity 96% <Pryse-Phillips WE, et al. J Neurosurg Psychiatry 1984>

Carpal tunnel syndrome • Square-shaped wrist – Measurement technique of wrist dimension using a standard sliding caliper • (A) "rectangular" wrist with low risk • (B) "Square" wrist with higher risk – Sensitivity 69%, specificity 73% <Kuhlman KA, et al. Am J Phys Med Rehabil 1997>

Carpal tunnel syndrome • Cutaneous pressure thresholds – Slowly adapting receptors – Semmes-Weinstein monofilament examination – Various diameter and different force – Normal mean threshold values average 0. 158 g on the palm, 0. 055 g on the fingertips – Threshold is greater than the 2. 83 monofilament

Carpal tunnel syndrome • 2 point discrimination – Normal index finger approximately 2 mm – Diminished ability of index

Carpal tunnel syndrome • Vibration thresholds – Quickly adapting receptors – Tuning fork 128 or 256 Hz – Diminished ability to vibratory sensation

Nerve entrapment disease • Thoracic outlet syndrome • Cubital tunnel syndrome • Ulnar tunnel syndrome • Carpal tunnel syndrome • Nerve palsy

Nerve palsy • Ulnar nerve – Forearm prox. Part – FCU, FDP 4, 5 finger • Upper level palsy – FCU, FDP – Whole Intrinsic muscle except Median nerve portion • Lower level palsy – FCU, 4, 5 th finger FDP function intact – Adductor pollicis, 3 hypothenar, 4, 5 th lumbricals – claw finger : MP hyperextension, IP flexion intrinsic minus finger

Nerve palsy • Median nerve – All extrinsic flexor muscle except 4, 5 th FDP – PT, PQ, FCR, FDS, PL, FPL • Upper arm level – Forearm pronation, wrist flexion weakness – Impossibility of 1, 2, 3 rd finger flexion – 4, 5 th finger flexion weakness • Lower arm level – Wrist, finger flexion intact – 3 thenar, 2, 3 thlumbricalis – Thumb abdution, apposition weakness

Nerve palsy • Anterior interosseous syndrome – Cause by nerve injury or irritation of the anterior interosseous nerve, motor branch of medial nerve – FPL, FDP(1, 2 nd finger), pronator quadratus – Result in pain and difficulties to pinch or hold object with thumb and index finger

Nerve palsy • Radial nerve – Extensor, supinator – proximal : supination, MP jt. extension palsy, wrist drop • Upper arm level – Impossibility elbow, MP joint extension – DIP, PIP joint intact cause intrinsic muscle • Lower arm level – Elbow intact – Impossibility MP joint extension

Nerve palsy • Posterior interosseous syndrome – Extensor carpi radialis brevis and supinator – Usual entrapment site : arcade of Frohse – Weakness of paralysis of the wrist and digital extensors – No sensory deficit