Peripheral nerve entrapment

Provocative test

Median Nerve

Ligament of strutherPronator teres muscle

Bicipital aponeurosis (Lacertus fibrosus)FDS arch

Pronator teres

Flexor carpi radialis

Palmaris longus

Flexor digitorum superficialis

Abductor pollicis brevis

½ Flexor pollicis brevis

Opponens pollicis

1st lumbrical

2nd lumbrical

½ Flexor digitorum profundus 1st 2nd

Flexor pollicis longus AIN

Pronator quadratus

Carpal tunnel syndrome

• Phalen test *• Tinel test *

• Durkan test

*Positive เมื่��อเป็�น sunderland 2 ขึ้��นไป็ (CTS ส่�วนใหญ่�เป็�น Sunderland 1 ส่�วนน�อยเป็�น 2 หรื�อ 3)

* * Kaplan (success of non-operative treatment)

* * P-R-A-G-M-A-T-I-C

Pronator syndrome

• PROVOCATIVE TEST– LIGAMENT OF STRUTER

• resist to elbow flexion 120-135 degree

– BICIPITAL APONEUROSIS• resist elbow flexion in supination position

– TWO HEAD OF PRONATOR TERES M.• resist forearm pronate when elbow extension

– FIBROUS ARCH OF FDS• resist flexion of PIP jt. Of middle finger

Anterior Interosseous Nerve Syndrome

– Pinch deformity (Spinner ‘s sign)

*Pure motor neuropathy ( FPL, 2nd &3rd FDP, pronator quadratus)

*DDX Parsonage Turner Syndrome

Radial Nerve

Fibrous band of radiocapitellar joint

Recurrent radial artery (leash of Henry)

ECRB

Proximal supinator (Arcade of Frohse )

Distal supinator

Triceps

Brachioraldialis

Anconeous

Extendor carpi radialis longus

Extendor carpi radialis brevis

Supinator

Extensor carpi ulnaris

Extensor digitorum communis

Extensor digiti quinti PIN

Abductor pollicis longus

Extensor pollicis longus

Extensor pollicis brevis

Extensor indicis propius

Superficial radial nerve

Posterior interosseous nerve syndrome

• Finger and thumb extension weakness*• Radial deviation**

*No sensory loss

**Intact ECRL

Radial tunnel syndrome

• Provocative test:– Pain with resist forearm supination– Pain at the edge of ECRB with resist middle finger extension

Superficial radial nerve entrapment (Wartenberg syndrome)

• Provocative test:– Forearm pronation with ulnar flexion– Pressure over junction of brachioradialis/ECRL

*Cheiralgia paresthetica

*แยกจาก radial nerve 8 cm เหน�อ radial styloid

*ถู�กกดจาก BR ก�บ ECRL

*DDx de Quervain ‘s disease

Ulnar Nerve

Arcade of strutherMedial intermuscular septum

Medial epicondyleCubital tunnel

Osbourne ‘ s ligamentFlexor pronator aponeurosis

Flexor carpi ulnaris

½ Flexor digitorum profundus 3rd 4th

Abductor digiti minimi

Opponens digiti minimi

Flexor digiti minimi

3rd & 4th lumbrical

1st -3rd palmar interosseous Deep Motor br.

1st -4th dorsal interosseous

½ Flexor pollicis brevis

Adductor pollicis

Dorsal cutaneous branch

Palmar cutaneous branch

Superficial terminal branch

Cubital tunnel syndrome

• Provaocative test:Elbow flexion-forearm supination-wrist extension

Elbow FlexionElbow FlexionTestTest

Symptom developedin 1 min = + ve

Guyon ‘s canal compression

• Zone 1: motor+ sensory• Zone 2: motor+/- sensory• Zone 3: sensory

END