PERIPHER

NERVE
DISODERS
Ken Wirastuti
Bagian IP.Saraf-FK.UNISSULA

Review of Nerve Anatomy

 A cut-away view of a single nerve fiber.

Note the swelling of the axon on either side of the

node of Ranvier.

Axon:yellow ;myelin:blue; basal lamina: orange.

Disorders of Nerve
Cell

body, axon & myelin

Fiber size: large, small
Motor, sensory, autonomic
Distribution: focal, multifocal,
generalized.
Course: acute, subacute, chronic,
lifelong
Etiology: genetic, toxic, metabolic,
autoimmune, traumatic, vascular,
infectious...

Tendonitis

Normal tendon glides smoothly in a tendon sheath

When under pressure, the capillary flow to the sheath is temporarily
interrupted.
When blood supply returns, swelling occurs.
Tendonitis: inflammation of tendon only
Tenosynovitis: inflammation of tendon plus its sheath

Spring 2006

IEOR 170

[Chung]

Peripheral Nerve Stretch

Injuries
Neurapraxia

(mild)

nerve is stretched but remains intact

transient recovery spontaneous & complete
Axonotmesis

(moderate)

involves disruption of the axon & myelin

sheath
last longer, recovery is unpredictable
Neurotmesis

(severe)

complete disruption of nerve

poor prognosis

 3 classes of injury
Class 1 conduction block (by e.g. transient ischemia
(rapidly reversible) or paranodal demyelination),
recovery occurs in wks (mild structural damage with
loss of small areas of myelin around nodes of Ranvier)

Class 2 - severe crush injuries with axonal

interruption but endoneurium undamaged;
prognosis good (regeneration through original
Schwann cell tubes); may be muscle atrophy
(denervation) and recovery may take mos

Class 3 severe injury to axons, Schwann cells and

endoneurium, with denervation atrophy of skeletal muscle;
formation of neuromas, aberrant regeneration common

Regeneration
Outgrowth

of multiple sprouts
from distal end of axon
(regenerating cluster)
Slow process (1 mm/day) limited
by rate of slow component of axonal
transport (tubulin, actin and
intermediate filaments)

CAUSA
Major categories:

Inflammatory, infectious (e.g., varicellarZoster)

Hereditary
Acquired metabolic
Toxic (industrial or environmental chemicals)
Malignancy (invasion or paraneoplastic)
Traumatic (lacerations, avulsions, compressions
(carpal tunnel syndrome and `Saturday night
palsy-ulnar nerve compression)

Entrapment Neuropathy

Nerves in the Hand

Elbow and Wrist

CARPAL TUNNEL
SYNDROME
Anatomi:

The first reported symptoms of CTS are tingling and

numbness of the hand, much like the feeling of a limb
"falling asleep." Any actions which put prolonged pressure
on the median nerve can excite these symptoms. Physical
labor, typing, sleeping with wrists bent can all cause CTS
symptoms to occur.

The shaded area represents the area usually affected by carpal tunnel
syndrome. As you can see, it can and usually does involve half of your
ring finger as well as your palm and first 2 fingers. In some people a part
of the thumb may also be involved.
(Photograph courtesy of Christopher-Patrick Photography, Winston-Salem, NC)

Phalen sign. Hold your hands back-to-back as shown with your

wrist bent at 90 degrees. If you develop pain, numbness, or
tingling within 60 seconds, you may have carpal tunnel syndrome.
(Photograph courtesy of Christopher-Patrick Photography,
Winston-Salem, NC)

Tinel sign. Have someone hold your hand with your wrist bent slightly back.
With the other hand, your assistant should tap on your wrist as shown. If you
experience pain, numbness, or tingling while they are tapping, you may have
carpal tunnel syndrome. You can also perform this on yourself by tapping on
your wrist as shown in the picture. Having someone else bend your wrist back
slightly is a little more effective. (Photograph courtesy of Christopher-Patrick
Photography, Winston-Salem, NC)

DIFFERENTIAL
DIAGNOSIS

A splint or brace
NSAIDs.
Cortisone injections.
Surgery: open incision
or endoscopic.

Carpal Tunnel Exercises

(at the start of each shift and
after each break)

Extend and stretch both wrists

and fingers acutely as if they are
in a hand-stand position. Hold for
a count of 5.

Make a tight fist with both hands

Straighten both wrists and

relax fingers

Then bend both wrists down while

keeping the fist. Hold for a
count of 5.

Straighten both wrists and relax

fingers, for a count of 5.

Repeat exercise 10 times, then

hang arms loosely at side and
shake them for a couple of seconds.
Total exercise time: 5-10 minutes

Cubital Tunnel Syndrome

Ulnar

nerve passes through cubital

tunnel just behind ulnar elbow
Numbness and pain small and ring
fingers
Initial treatment: rest, splint

Cubital Tunnel, or Funny

Bone
The ulnar nerve passes by

Spring 2006

the inside of the elbow

through a fibrous tunnel.
Swelling can put pressure
on the ulnar nerve.
Symptoms are felt at the
elbow and into the little
finger.
This is called Cubital
Tunnel Syndrome.

IEOR 170

[Chung]

31

Guyon's canal syndrome

Guyon's canal syndrome

is caused by entrapment of
the ulnar nerve in the
Guyon canal as it passes
through the wrist.
Symptoms begin with a
feeling of pins and needles
in the ring and little
fingers. This is followed by
decreased sensation and
eventually weakness and
clumsiness in the hand as
the small muscles of the
hand are involved.
If the nerve is compressed
at the wrist, the back of the
hand will have normal
sensation.

Epicondylitis Lateralis (Tennis

Elbow)
Nyeri

tekan dan nyeri pada epikondilus

lateralis humeri yang meliputi tendon dan
tulang (epicondylus lateral)
Muskulus yang terlibat adalah M.Extensor
carpi radialis brevis ekstensi dan
supinasi timbul nyeri
Causa:
Overuse: repetitive activities
Trauma:
pukulan

langsung pada elbow pembengkakan

tendon degenerasi.
Gerakan ekstrim yang mendadak cedera tendon

Diagnosis:
1.

Anamnesis:

Daily activities?
Past injuries?

X ray ?
3. MRI ?
2.

Terapi:
1.

Conservatif (non-surgical)

Modifikasi aktivitas
Medikasi: obat anti inflamasi
(NSAID)
Brace
Terapi fisik: exercise
Steroid injection
2.

Surgery

Medial epicondylitis (golfer's

elbow)
Nyeri

dan nyeri tekan pada daerah

epikondilus medialis humeri
Gerakan fleksi dan pronasi lengan
bawah terasa nyeri

TRIGGER FINGER / THUMB

(Jari Macet)
Kriteria

Diagnosis :

Tendovaginitis otot-otot fleksor jari tangan

Bila jari difleksikan akan sulit diekstensikan
kembali secara aktif, sering disertai bunyi
klek disertai rasa nyeri daerah MCP
Kemacetan dikarenakan kelainan pada
tendon dan sarungnya
Tendon macet karena benjolannya terjebak
di dalam retinokulum

Daerah Pergelangan Tangan

(De QUERVAIN)
Kriteria

Diagnosis :

Tendovaginitis m.abductor polisis longus atau

ekstensor polisis brevis menimbulkan nyeri dibagian
lateral pergelangan tangan
Tenaga pengepalan tidak kuat dan tangan sukar
diluruskan pada pergelangan tangan karena nyeri
Nyeri tekan dapat pada penekanan prosesus
stiloideus radii.

Pemeriksaan

Test Finkelstein
Pasien

ulnar

disuruh mengepal ibu jarinya lalu difleksikan ke

Adakalanya Krepitasi kalau ibunya digerak-gerakkan

de Quervains Disease
Chronic tenosynovitis due to
narrowed tendon
sheaths around
abductor policis
longus and
extensor pollicis
brevis muscles

Frozen shoulder /
Adhesivecapsulitis
Frozen

shoulder is a
disorder where the
connective tissue
surrounding the
glenohumeral joint of
the shoulder becomes
inflamed and stiff and
abnormal bands of
tissue form restricting
motion and causing
chronic pain.

Plantar Fasciitis
Policeman's

heel / soldier's heel:

associated with heel spurs
Degenerated plantar fascial band at
origin on medial calcaneous
Heel pain worse in morning and after
long periods of rest
May be relieved with activity

Plantar Fasciitis

Tarsal Tunnel Syndrome

is

caused by the entrapment of the tibial

nerve (Between medial malleolus and
flexor retinaculum)
Vague pain in sole of foot: burning or
tingling
Worse with activity, especially standing,
walking for long periods and is relieved
by rest
weakness

Tarsal Tunnel Syndrome =

Posterior Tibial Nerve
Neuralgia.

Differential diagnosis
Repetitive

stress injury: athletes, who stand

a lot
Benign tumors or cysts
Bone spurs
Nerve ganglion
Fracture
Systemic conditions: alcoholism, diabetes
mellitus, rheumatoid arthritis, thyroid
disorders

Diagnosis
Symptomps
EMG

& nerve Conductions

velocity test
MRI

Treatment
Rest
NSAID
Steroid

injection
surgical

Peroneal Palsy

Drop Foot
The inability to lift the front part of the foot.
Paralysis of anterior muscles of lower leg
Inability to dorsiflex at the ankles and toes
Causes the toes to drag along the ground while
walking.
Can happen to one or both feet at the same
time.
It can strike at any age.
Temporary or permanent

Causes
Injury

to the peroneal nerve.

sports injuries
diabetes
hip orknee replacementsurgery
spending long hours sitting cross-legged or squatting
childbirth
large amount of weight loss

Injury

to the nerve roots in the spine (L5)

 Neurological

conditions that can contribute to foot

drop include:
stroke
multiple

sclerosis (MS)
cerebral palsy
Charcot-Marie-Tooth disease

Conditions

that cause the muscles to progressively

weaken or deteriorate may cause foot drop:
muscular

dystrophy
amyotrophic lateral sclerosis (Lou Gehrigs disease)
polio

 Rupture

of Anterior Tibialis
Fracture of fibula
Compartment Syndrome
Diabetes
Alcohol Abuse

SYMPTOMS
Difficulty

in lifting the foot.

Dragging the foot on the floor as one
walks.
Slapping the foot down with each step.
Raising thigh while walking (high
stepping gait)
Pain, weakness or numbness in the foot.

Sensory Symptomp

Superfici
al
peroneal

IMAGING

X-Ray
Post-Traumatic - tibia/fibula and ankle - any bony
injury.
Anatomic dysfunction (eg. Charcot joint)

Ultrasonography
If bleeding is suspected in a patient with a hip or
knee prosthesis

Magnetic Resonance Neurography

Tumor or a compressive mass lesion to the
peroneal nerve

Electromyelography
(EMG)
This study can confirm the type of
neuropathy, establish the site of the lesion,
estimate extent of injury, and provide a
prognosis.
Sequential studies are useful to monitor
recovery of acute lesions.

TREATMENT
Depends

on the underlying cause.

If cause is successfully treated foot drop
may improve or even disappear.
Medical treatment - Painful Paresthesia
Sympathetic

block

Amitriptyline
Nortriptyline
Pregabalin
Gabapentin

Laproscopic

Synovectomy

SPECIFIC TREATMENT
Braces

or splint
Brace on the ankle and foot or splint
that fits into the shoe can help to hold
the foot in the normal position
Surgical

Physical Therapy
Exercises

that strengthen the leg muscles

Maintain

the range of motion in knee and ankle

Improve

gait problems associated with foot drop.