Professional Documents
Culture Documents
• If the thumb and fifth finger are apposed, the longitudinal plane
between the thenar and hypothenar muscles will be
exaggerated . The median nerve at the wrist can be readily
found at the intersection of the latter crease and the wrist
crease.
C8 and T1
roots from
medial cord
From the axilla, it enters
the arm at inferior
margin of teres major
Proximally, it is
immediately lateral to
brachial artery
Distally, it crosses to
medial side of brachial
artery & lies anterior to
elbow joint
Covered & protected anteriorly in
distal part of cubital fossa by the
bicipital aponeurosis
Passes superficially in
hand
Sensory innervation to
skin over thenar
eminence
Proximal to the wrist, the median nerve
moves lateral to the muscle, becoming
more superficial in position and lying
between tendons of PL & FCR
thumb opposition,
When making a fist, the ring and small fingers flex while
the long and index tend to stay straight. This is known as
the pointing test.
Examination of Median Nerve
Examination of Median Nerve
Causes:
congenital predisposition – carpal tunnel
is smaller
trauma / injury to the wrist that cause
swelling, e.g. sprain / fracture
mechanical problems in wrist joint
repeated use of vibrating hand tools
development of cyst / tumor in the canal
fluid retention during pregnancy /
menopause, overactivity of pituitary gland,
obesity, hypothyroidism, rheumatoid
arthritis, diabetes, work stress – predispose
to CTS
in some cases – cause unknown
Carpal Tunnel Syndrome
Conservative Surgical
resting of affected hand & wrist for at least 2 weeks done in most
immobilisation of wrist in a splint to avoid further damage from severe cases of CTS
twisting / bending (specially designed carpal tunnel wrist support)
recommended if
Medications: symptoms last for 6
months
NSAIDS, e.g. aspirin, ibuprofen
pain relievers involves cutting
the ligament
orally administered diuretics (“water pills”) – to decrease swelling crossing the wrist,
corticosteroids or the drug lidocaine can be taken orally or thus providing more
injected directly into the wrist room to the median
nerve & decreasing
Physiotherapy:
compression
cool packs – reduce swelling
stretching & strengthening exercises (small weights to do flexion
& extension – use of theraband may also be considered)
Note: if underlying causes of CTS are diabetes / arthritis / ….. –
these conditions should be treated 1st
Examination:
wrist is examined for tenderness, swelling, warmth &
discoloration
each finger is tested for sensation
muscles at the base of the hand are examined for strength
& signs of atrophy
routine lab tests & X-rays – reveal diabetes, arthritis &
factures
Diagnosis:
EMG – to determine severity of damage to median nerve
ultrasound imaging – to show impaired movement of median N
MRI – to show anatomy of wrist (but NOT really useful in
diagnosing CTS)
Tests:
Phalen’s (wrist flexion) Test
• performed by holding the patient’s wrist in
maximum flexion for 1 minute. A positive test is
indicated by tingling in the thumb, index finger,
and middle finger and lateral half of the ring
finger
Tinel’s Sign
• performed by briskly tapping over the carpal
tunnel at the wrist. A positive test causes
tingling or paraesthesia into the thumb, index
finger and middle and lateral half of the ring
finger( median N distribution). Tingling or
paraesthesia must be felt distal to the point of
pressure for a positive test
Carpal Tunnel Syndrome
Tests:
Carpal Compression Test
a relatively new test
involves entrapment
(compression / pinching) of
the median nerve by the
pronator teres muscle
most significant feature – pain along median nerve axis – helped by rest &
aggravated by activity
Median nerve is tender along its course in the forearm – patient may complain
of aching discomfort & early fatigue of the muscles of the forearm
Pronator Teres Syndrome
Examination:
Phalen & Tunnel tests are negative
pain upon palpation of origin ,muscle belly & insertion of pronator
teres muscle
pain when pronating forearm against resistance
median nerve symptoms arise when the muscle belly of pronator
teres muscle is deeply compressed
weakness of thenar muscles
Diagnosis:
EMG (Note: if EMG does not confirm PTS but clinical evidence is
suggestive, then wait for 4-6 weeks before doing EMG once again)
Pronator Teres Syndrome
Test:
Pronator Teres Test
The patient stands with the elbow in 90 degrees of
flexion. One hand is placed on his elbow for stabilization
and the other hand grasps his hand in a handshake
position. The patient holds this position as an attempt is
made to supinate his forearm (forcing him to contract
the pronator muscles).
While holding the resistance against pronation, the
patient’s elbow is extended. If pain or discomfort is
reproduced, there is a good chance of median nerve
compression by the pronator teres.
Note: the patient should keep the elbow relaxed
during the test, because holding the elbow firmly in
flexion will NOT allow elbow extension.
Pronator Teres Syndrome
Treatment:
Conservative Surgical
rest exploration of the median
Medications: nerve in the proximal forearm
NSAIDS & release of all possible sites
of compression – done in
Physiotherapy: severe cases
wrist immobilisation splint applied in
15 degrees dorsiflexion for 4-6
weeks
massage
ice
electrical stimulation
Anterior Interosseous Syndrome
also known as Kiloh Nevin Syndrome
Diagnosis:
1. Pinch Grip Test
The patient is asked to pinch the tips of index finger & thumb
together.
Normal – tip-to-tip pinch
Abnormal – pulp-to pulp pinch
Test is indicative of a positive sign for pathloogy to the
anterior interosseus N
This finding is indicative for the entrapment of the ant
interosseus N as it passes between the 2 heads of the pronator
teres muscle.
2. Electroneurography however, these studies are difficult as the
3. EMG nerve is deep as are the muscles it supplies
Anterior Interosseous Syndrome
Treatment:
Conservative Surgical
rest exploration of median
nerve through an
use of splints
approach similar to that of
Medications: pronator syndrome