How to distinguish if nerve entrapment is in hand or elbow with carpal tunnel?
2. How would you differentiate between median nerve problem and nerve root lesion?
Carpal tunnel will have no sensory motor loss on the thenar eminence - the recurrent branch of the median nerve will be spared as it passes over the retinaculum.
-the palmar branch of median nerve exits proximal to CT, this more likely to produce symptoms in a pronator terres syndrome
- NRL will have affected reflexes but median nerve won’t
How is it that you can get Ulnar nerve and artery compression?
What will symptoms be?
The Guyons canal which is the depression between the pisiforms and hook of hamate?
Entrapment may cause motor, sensory or mixed deficits depending on side of compression.
What do you have to be careful of when adjusting the wrist?
If person has had an injury it can predispose them to hyper mobility - if you adjust could give them chronic pain.
There is tendency for wrist to be hyper mobile so evaluate first before adjusting.
Just list all the possible disorders of the wrist.
7
- carpal tunnel syndrome
- Ulnar nerve entrapment
- De Quervain’s Tenosynovitis
- Triangular Fibrocartilage complex (TFCC) injury
- Ganglion
- Scaphoid Fracture
- Colles fracture
How would you evaluate the wrist and hand?
- look at symmetry, atrophy, colour, swelling
- ROM- active, passive +resisted if indicated
- Palpation- inflammation or pain, anatomical snuff box, extensor carpi radials brevis + longus tendons , joint play
TOS may be the cause of whole hand symptoms.
What are the 3 potential sources of compression of the neuromuscular bundle.
What are the symptoms of TOS?
- Scalenes
- Between clavicle and first rib
- Under pec minor
Symptoms:
- Vascular (subclavian artery)- vascular insufficiency to upper limb esp. hand
- Neurogenic (brachial plexus)
- sensory and/or motor disturbances to entire hand due to generalised involvement of bachial plexus
- different to CTS- as thenar eminence isn’t spared.
What ortho tests would you do to test what?
- Phalens test- for carpal tunnel syndrome
- Finkelsteins test- for DeQuervains tendosynovitis
- Scaphoid compression test- scaphoid fracture
Read treatment of CTS
j
Whats symptoms of carpal tunnel and who are you more likely to see it in?
-mean age 45-60yrs Female> male
symptoms:
-numbness, paresthesia, and pain in median nerve distribution
-loss of grip strength, dropping of objects (hand weakness)
Whats De Quervains Tendosynovitis?
What must you differentiate it from?
Inflammation of extensor pollicis brevis and abductor pollicis longs tendons
-Repetative ulnar deviation is m.c cause
C6 dermatome and C7 sclerotome
Review biomechanics on slide 13 How do you get scapholunate instability
- due to disruption of scapholunate ligament following a FOOSH injury
- Gap seen on X-ray
- treated well with surgery.
Triangular fibrocartilage complex (TFCC) Injuries.
How do they happen?
What are the signs and symptoms?
TFCC functions as cushion for the ulnar carpus as well as a sling support for the lunate and triquestrum
-MOI usually compression of TFCC between the lunate and the head of the ulna, as in FOOSH, or rotational forces as in racket throwing and throwing sports.
Signs and symptoms:
- ulnar-side wrist pain & swelling, including point tenderness distal to the ulnar styloid in the area of the TFCC
- loss of grip strength
- may be a click with active ulnar deviation
- pain with passive pronation and supination (rotation) as well as with ulnar deviation
Ganglion
trigger finger
what are they?
treatments?
Ganglion/ dorsal ganglion cyst (expansion of synovial capsule)
-herniation of the dorsal scapholunate ligament.
Treatment? immobilisation, corticosteroid injection (if symptomatic), surgery- but reoccurrence is likely.
Trigger finger: -they try to open their hand, it sticks then snaps open.
Cause: narrowing of synovial sheath surrounding flexor tendons. A palpable nodule is often present within tendon due to telescoping of the sheath.
m.c in females and diabetic patients.
Scaphoid fracture.
why is it more susceptible to fracture?
complication?
because it is between the radius and triquetrum? na its coz its unique position bridging the proximal and distal rows of the carpal bones.
-MOI is FOOSH with extension and radial deviation.
Complication? AVN- only 1 dorsoradial artery to proximal pole, so 30% get AVN depending on location of fracture.
-AVN doenst show on initial x-rau so should repeat within the 10 days.
Colles fracture
Boxes fracture
MOI?
Colles? Distal radius fracture
FOOSH
Boxers fracture:
5th metacarpal neck fracture.
