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Mod 8:Neuropathies
Peripheral Entrapment Neuropathies
| Question | Answer |
|---|---|
| Name some causes of compression of the Median nerve in the Carpal Tunnel. | 1. any space occupying lesion2. increased pressure in the tunnel to 32 mmHg or greater3. structureal abnormalities4. inflammation |
| What is considered normal resting pressure of the carpal tunel? | 2-14 mmHG |
| CTS is present at pressures increases greater than __ mmHG. | 32 |
| Why do people with CTS only get the symptoms in their fingers and not their palms? | because the palmar branch of the median nerve is outside of the carpal tunnel |
| Why is it not good to use forced wrist flexion with Phalens test? | you may get false (+) because you are increasing the pressure |
| What type of stressors is increased pressure in the carpal tunnel often associated with? | occupational stressors |
| What are some causes of increased pressure in the carpal tunnel? | irritation of the FDP sheath, tumor, swelling, occupational stresses involving prolonged flexion or extension position of the wrist |
| What are the structural abnormalities that are associated with CTS? | arthritic changes, osteophytes, fractures, subluzations, lumbrical attachment to the tunnel(during forceful flex), decreased cross sectional area, smaller c-spine canal |
| What is a double crush injury? | When a nerve is compressed in 2 different spots |
| Where will a C6 radiculopathy produce symptoms? | thumb |
| where will a C7 radiculopathy produce symptoms? | middle finger |
| How can you distiguish between if the problem is occurring in the nerve root or in the carpal tunnel? | if it is a nerve root, you may see sx more proximally, do foraminal compression or spurlings test,pacottes, do myotomes (weak c7), you may see diminished reflexes, |
| What are some causes of inflammation within the carpal tunnel? | finger flexor tensynovitis (most common), RA, SLE, edema from trauma, frequent prolonged flexion of the wrist, external compression (like braces on the volar part of the wrist) |
| Name some space occupying lesions that may be a part of the carpal tunnel? | tumors, ganglions, sarcoidosis, amyloidosis, fluid retention(in pregnancy, endocrine disorders) |
| What is a sarcoidosis? | mimics cancer, like deposits of the granuloma tissue |
| What is an amyloidosis? | deposits of amyloid (fatty substances) |
| Did you know... | work relateded CTS has a high incidence of concurrence of other medical conditions/illnesses |
| What is the most common population for carpal tunnel syndrome? | middle aged females |
| CTS accounts for ? % of all occupational diseases. | 60 |
| What are the top 2 diseases for lost work hours? | LBP #1, CTS #2 |
| Did you know... | People who were obese and lived sedentary lifestyles have an increased rate of CTS |
| Where are the carpal bones located in relation to the carpal tunnel? | dorsal and lateral |
| What structure is volar to the carpal tunnel? | transverse carpal ligament |
| What bony structures are the carpals attached? | tubrical of scaphoid, trapezium, hook of hamete, pisoform |
| What are the contents of the carpal tunnel? | median nerve, radial and ulnar bursae, 9 extrinsic digital flexor tendons, FDS, FDP, FPL |
| What happens with compression of a nerve? | it may be red and swollen, increased endoneurial pressure, increased vascular permeability of endoneural vessels, closing of capillariess and venules that cross perineurium into endoneurium (when this happens you cant get the fluid out), inflammation |
| When a nerve is compressed, you get altered axoplasmic flow which causes trophic changes in what? | target tissues of the nerve, and the nerve cell body and axon |
| In the late stages of compression of a nerve, what happens to the epineurium? | It gets thicker, causing scar formation and decreased neural mobility |
| Radiculopathy of what cervical root can mimic CTS? | 6th |
| Name some things that may cause you to lean toward a radiculopathy as opposed to CTS. | pain with coughing, sneezing, valsalsa, neck and shoulder pain, daytime pain when you use the arm, weakness to the ms proximal to the wrist |
| Name some things that may cause you to lean toward a CNS lesion. | usually no pain, positive CNS tests, |
| Name some things that may cause you to lean towards a vascular disorder like raynauds. | all of the fingers or palm affected, also with CTS, there is no relationship to the cold |
| Name some things that would cause you to lean towards a dx of RSD (CRPS) | generalized burning or parasthesias in the whole hand |
| What are some causes of generalized peripheral neuropathies? | malnutrition, toxic exposure to drugs and chemicals, uremia, diabetes, leprosy... c these, there is nerve involvment in all 4 extremities, not just the median nerve. |
| At the early stages of CTS what are the results of a sensory exam? | the results are usually negative. |
| What do you see during the more advanced stages of CTS in a sensory exam? | hypesthesia to the loss of sensation, loss of 2 point discrimination (discern between the volar tips of the index and middle finger |
| How do you perform Phalen's test? | place the wrist into unforced, complete flexion for 30-60 sec. (+) if u get a reproduction or excasserbation of symptoms |
| What structures are innervated by the median nerve? | (2-LOAF) 2 lumbricals (the index and middle fingers), Oponens policis, ABD pollicis brevis, lateral portion of the flexor pollicis brevis, also u could look for thenar atrophy |
| What group of CTS would people with the following symptoms be classified into?intermittent numbness, tingling, pain in median nerve dist., sx @ night, patient must shake hand to “get circulation going”, symptoms sporadic, frequency inc. c time | GROUP 1 |
| What group of CTS would a pt with the following sx be classified into?hypesthesia, clumsy, loss of dexterity (fine motion), weak pinch, exacerbated at night, or c use of hand, inc. numbness, burning pain, swelling or congestion in the hand, major pain. | GROUP 2 |
| What is a hypesthesia? | a decreased tactile sensation |
| If someone is CTS in group 1, what will you notice in your exam? | may have no abnormal findings, possible (+)tinnels or phelans test |
| If someone is CTS in group 2, what will you notice in your exam? | thenar weakness, atrophy, skin changes, sensory loss, (+) tinels or phalens, if u see swelling or if the hand feels swollen, do artery tests too |
| If someone is CTS in group 3, what will you notice in your exam? | marked thenar atrophy, skin atrophy, significant loss of dexterity and functional impairment, loss of 2-point discrimination |
| What is the most sensitive test for establishing a diagnosis of CTS? | sensory conduction (NCV tests)? |
| When you do a motor conduction test for CTS, what response will you see if it is postitive | prolonged distal latency of the median nerve |
| What is the most sensitive test for establishing a diagnosis of CTS? | sensory conduction (NCV tests)? |
| When you do a motor conduction test for CTS, what response will you see if it is postitive | prolonged distal latency of the median nerve |
| If someones NCV tests are positive for CTS but their clinical signs are negative, would you perform an EMG? | NO! do not need to perform EMG if NCV tests are positive |
| When is it worthwhile to perform an EMG? | When the clinical signs are positive and the NCV are negative |
| If someone has CTS, when should u do splinting? | in the early stages (1st 3 months) |
| When is cortisone injected for relief of CTS and how long does it take to kick in? | it is injected in the early stages, it takes like 3 or 4 days to kick in |
| Name 2 oral medications that could be taken for CTS. | diuretics, vitamin B6 |
| Name some pros and cons of CTR | pros- faster return to work if endoscopiccons- more complications, may alter hand function, decrease grip strength, pain, and scar formation may decrease nerve mobility |
| What are the three sites of median nerve compression at the elbow? | 1. compression by a dense band of tissue 2. pronator teres ms 3. compression of the anterior interosseous branch of the nerve |
| What is the second most common UE entrapment? | ulnar nerve at the elbow |
| What are some causes of entrapment of the ulnar nerve at the elbow? | external pressure from an osteophyte, cast, splint, bony or scar impingment, cubital tunnel syndrome, chronic subluxation of the nerve, constriction of the nerve as it passes through the aponeurotic origin of the FCU (1.5-3.5cm distal to med epicondyle) |
| Compression of the ulnar nerve at the wrist (dorsal sensory branch) occurs where? | within or distal to the tunnel of guyon... 2ndary to chronic external pressure |
| What is the least common nerve to be compressed in the UE? | radial |
| Describe the symptoms of a radial nerve compression. | symptoms include post. interosseous nerve, causing weakness of the wrist and finger extensors (pain similar to lat epicondylitis) |
| How can radial nerve compression occur? | can occur by high radial nerve lesions proximal to the elbow or at wrist, may be traumatic or spontaneous, post interosseous n caused by weak extensors, watch, handcuffs |
| What % of ppl have martin gruber anastomosis | about 20% |
| What is a martin greuber anastomosis? | when some of the motor nerve fibers that are destined for the ulnar hand ms, traven within the median nerve at the elbow and then cross over to the ulnar nerve in the forearm... this may affect electrophysiologic result |
| What is TOS caused by? | often caused by a constriction of the brachial plexus by an anomolous fibrous band and less often by a rib |
| What is the most common cause of sciatica? | it is referred from nerve roots, literature varies about the piriformis being the cause |
| What are the causes of fibular or peroneal nerve compression? | acute compression from fx or other trauma, forced inversion stretch, external compression from stockings, casts ect |
| Where do you get pain with tarsal tunnel syndrome? | in the sole of the foot b/c of entrapment of post tib nerve @ medial maleolus or deep fibular nerve over the dorsum of the foot |
| What types of sprains can damage the tibial nerve? | eversion sprain, medial deltoid ligament sprain |
| This nerve can be entrapped as it enters the leg at the level of the inguinal ligament causing "meralgia parasthetica" in the upper and lateral thigh | Lateral cutaneous nerve of the thigh |
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PTROCKS
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