Podcast
Questions and Answers
Which of the following best describes the path of the median nerve as it originates from the brachial plexus?
Which of the following best describes the path of the median nerve as it originates from the brachial plexus?
- Starts at the posterior cord (C6, C7, C8) of the brachial plexus.
- Starts at the medial cord (C8, T1) and lateral cord (C5,6,7) of the brachial plexus. (correct)
- Starts at the lateral cord (C4, C5, C6) and medial cord (C7, C8) of the brachial plexus.
- Starts at the anterior cord (C5, C6) and posterior cord (C7, T1) of the brachial plexus.
Where does the median nerve pass relative to the pronator teres muscle?
Where does the median nerve pass relative to the pronator teres muscle?
- Posterior to the two heads of pronator teres.
- Superficial to the pronator teres tendon.
- Between the two heads of pronator teres just distal to the elbow joint. (correct)
- Anterior to the pronator teres insertion on the radius.
Which digits are most directly innervated by the median nerve?
Which digits are most directly innervated by the median nerve?
- Digits 1-3
- Digits 2-4
- Digits 4 and 5 (correct)
- Digits 3-5
What is the primary sensory innervation territory of the palmar cutaneous branch of the median nerve?
What is the primary sensory innervation territory of the palmar cutaneous branch of the median nerve?
Which of the following is least likely to directly cause a median nerve lesion?
Which of the following is least likely to directly cause a median nerve lesion?
A patient presents with an inability to oppose their thumb and has muscle flaccidity in the forearm and hand. Which condition is most likely indicated by these symptoms?
A patient presents with an inability to oppose their thumb and has muscle flaccidity in the forearm and hand. Which condition is most likely indicated by these symptoms?
What is the distinguishing characteristic of 'ape hand' deformity resulting from a median nerve lesion?
What is the distinguishing characteristic of 'ape hand' deformity resulting from a median nerve lesion?
What autonomic changes are associated with median nerve lesions?
What autonomic changes are associated with median nerve lesions?
If a patient has an injury around the elbow affecting the median nerve, what specific muscular weakness is most likely to be observed?
If a patient has an injury around the elbow affecting the median nerve, what specific muscular weakness is most likely to be observed?
Struther's ligament, which can contribute to median nerve compression in the elbow region, is found in what percentage of the population?
Struther's ligament, which can contribute to median nerve compression in the elbow region, is found in what percentage of the population?
Which of the following activities is least likely to contribute to pronator teres syndrome?
Which of the following activities is least likely to contribute to pronator teres syndrome?
How does the pain presentation typically differ in pronator teres syndrome compared to carpal tunnel syndrome?
How does the pain presentation typically differ in pronator teres syndrome compared to carpal tunnel syndrome?
Which anatomical structures form the boundaries of the carpal tunnel?
Which anatomical structures form the boundaries of the carpal tunnel?
Which of the following structures does not pass through the carpal tunnel?
Which of the following structures does not pass through the carpal tunnel?
Nocturnal dysthesia commonly seen in carpal tunnel syndrome is primarily attributed to what?
Nocturnal dysthesia commonly seen in carpal tunnel syndrome is primarily attributed to what?
Why does compression of the median nerve in the carpal tunnel typically spare sensation in the thenar area?
Why does compression of the median nerve in the carpal tunnel typically spare sensation in the thenar area?
Which of the following systemic conditions is least likely to be associated with increased risk of carpal tunnel syndrome?
Which of the following systemic conditions is least likely to be associated with increased risk of carpal tunnel syndrome?
Which occupation is least likely to be associated with a higher incidence of carpal tunnel syndrome?
Which occupation is least likely to be associated with a higher incidence of carpal tunnel syndrome?
When performing upper limb tension tests, what position should the patient be in?
When performing upper limb tension tests, what position should the patient be in?
During the median nerve upper limb tension test #1, what is the typical sequence of movements after the patient is positioned supine?
During the median nerve upper limb tension test #1, what is the typical sequence of movements after the patient is positioned supine?
In upper limb tension test #1 for the median nerve, to further sensitize the test if no symptoms are reproduced, you should:
In upper limb tension test #1 for the median nerve, to further sensitize the test if no symptoms are reproduced, you should:
Which additional nerves are being assessed, in addition to the median nerve, when performing upper limb tension test #2?
Which additional nerves are being assessed, in addition to the median nerve, when performing upper limb tension test #2?
During the Upper Limb Tension Test #2, which sequence of steps is correct?
During the Upper Limb Tension Test #2, which sequence of steps is correct?
What is the primary method for assessing pronator teres syndrome?
What is the primary method for assessing pronator teres syndrome?
During Phalen's test for carpal tunnel syndrome, what position are the patient's wrists placed in, and for how long is the position typically held?
During Phalen's test for carpal tunnel syndrome, what position are the patient's wrists placed in, and for how long is the position typically held?
What is the key difference between Phalen's test and the Reverse Phalen's test for carpal tunnel syndrome?
What is the key difference between Phalen's test and the Reverse Phalen's test for carpal tunnel syndrome?
What is the primary goal of edema management is?
What is the primary goal of edema management is?
Which statement is true?
Which statement is true?
A patient with a median nerve lesion exhibits significant wasting of the thenar eminence. Which of the following exercises is most appropriate to address this?
A patient with a median nerve lesion exhibits significant wasting of the thenar eminence. Which of the following exercises is most appropriate to address this?
A patient is diagnosed with pronator teres syndrome. What specific activity should they temporarily avoid?
A patient is diagnosed with pronator teres syndrome. What specific activity should they temporarily avoid?
What is the primary focus of treatment when addressing sensory changes associated with carpal tunnel syndrome?
What is the primary focus of treatment when addressing sensory changes associated with carpal tunnel syndrome?
Why might carpal bone mobilizations be beneficial?
Why might carpal bone mobilizations be beneficial?
When addressing carpal tunnel syndrome, what should be monitored during and after the exercise?
When addressing carpal tunnel syndrome, what should be monitored during and after the exercise?
Amy, a gardener, comes to you with right wrist pain and clumsiness in her hand and fingers. She spent the last 3 weeks pruning. After performing some tests, you find out the flexor retinaculum is the primary pain generator. What is your recommendation?
Amy, a gardener, comes to you with right wrist pain and clumsiness in her hand and fingers. She spent the last 3 weeks pruning. After performing some tests, you find out the flexor retinaculum is the primary pain generator. What is your recommendation?
Amy, a gardner, comes to you with right wrist pain and clumsiness in her hand and fingers. She spent the last 3 weeks pruning. After performing some tests, you find out the pronator teres is the primary pain generator. What is your recommendation?
Amy, a gardner, comes to you with right wrist pain and clumsiness in her hand and fingers. She spent the last 3 weeks pruning. After performing some tests, you find out the pronator teres is the primary pain generator. What is your recommendation?
Which of the following intrinsic hand muscles is innervated by the median nerve?
Which of the following intrinsic hand muscles is innervated by the median nerve?
A patient presents with weakness in wrist flexion and pronation, but normal finger flexion. Which condition is most likely?
A patient presents with weakness in wrist flexion and pronation, but normal finger flexion. Which condition is most likely?
A patient with a median nerve lesion has difficulty picking up small objects with the thumb and index finger. Which exercise would be most effective in improving this function?
A patient with a median nerve lesion has difficulty picking up small objects with the thumb and index finger. Which exercise would be most effective in improving this function?
Which of the following symptoms is least likely to be associated with a median nerve injury?
Which of the following symptoms is least likely to be associated with a median nerve injury?
Flashcards
Median Nerve Origin
Median Nerve Origin
Originates from the medial (C8, T1) and lateral (C5,6,7) cords of the brachial plexus.
Median Nerve Path (Upper Arm)
Median Nerve Path (Upper Arm)
Travels down the medial side of the humerus from the axilla to the cubital fossa.
Median Nerve Distal Path
Median Nerve Distal Path
Passes distally deep in the forearm and becomes more superficial at the wrist, passing through the carpal tunnel to ends digits 1-3.
Median Nerve Innervation
Median Nerve Innervation
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Causes of Median Nerve Lesions
Causes of Median Nerve Lesions
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Symptoms of median nerve lesions
Symptoms of median nerve lesions
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Symptoms (Elbow Injury)
Symptoms (Elbow Injury)
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Pronator Teres Syndrome
Pronator Teres Syndrome
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Etiology of Pronator Teres Syndrome
Etiology of Pronator Teres Syndrome
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Symptoms of Pronator Teres Syndrome
Symptoms of Pronator Teres Syndrome
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Carpal Tunnel Definition
Carpal Tunnel Definition
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Carpal Tunnel Contents
Carpal Tunnel Contents
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Symptoms of Carpal Tunnel Syndrome
Symptoms of Carpal Tunnel Syndrome
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Causes of Carpal Tunnel Syndrome
Causes of Carpal Tunnel Syndrome
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Upper Limb Tension Tests
Upper Limb Tension Tests
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Upper Limb Tension Test #1
Upper Limb Tension Test #1
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Upper Limb Tension Test #2
Upper Limb Tension Test #2
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Pronator Teres Syndrome Tests
Pronator Teres Syndrome Tests
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Carpal Tunnel Syndrome Test - Phalen's
Carpal Tunnel Syndrome Test - Phalen's
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Carpal Tunnel Syndrome Test - Reverse Phalen's
Carpal Tunnel Syndrome Test - Reverse Phalen's
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Study Notes
- PNS Treatments: Treatment & Management of PNS Disorders
Median Nerve Lesions
- Today's objectives include discussing median nerve anatomy, etiologies of common injuries, clinical presentation of median nerve injuries, assessment options, and carpal tunnel syndrome treatment.
- The median nerve starts at medial chord (C8, T1) and lateral chord (C5,6,7) of brachial plexus.
- The median nerve travels down the medial side of the humerus from the axilla to the cubital fossa.
- The nerve passes between the heads of pronator teres, distal to the elbow joint on the medial side.
- The median nerve travels distally deep in forearm, becoming more superficial at the wrist where is passes through the carpal tunnel.
- It ends at digits 1-3.
- Median nerve is at the center of "M".
- Anterior forearm muscles are innervated by the median nerve: Pronator teres, Flexor capri radialis, Palmaris longus, Flexor digitorum superficialis, Flexor digitorum profundus, and Flexor pollicis longus.
- The sensory distribution of the median nerve includes the palmar cutaneous branch and digital cutaneous branch.
- Median nerve lesions may be damaged in a brachial plexus injury or fractures of elbow, wrist or carpal bones.
- Dislocations of elbow, wrist or carpals, especially lunate & scaphoid (FOOSH) may cause median nerve lesions.
- Compression from pronator teres or carpal tunnel due to fibrosis, inflammation, or hypertonicity or trauma, such as traction, contusion, or laceration all contribute to median nerve lesions.
- Symptoms of Median Nerve Lesions can present as neuropraxia or axonotmesis.
- A complete nerve lesion causes muscle flaccidity in forearm & hand.
- The thumb loses opposition; the 2nd & 3rd fingers cannot flex, resulting in at rest with an "ape hand" appearance.
- When trying to make a fist, it appears as "oath hand / Pope's blessing / hand of benediction.”
- Autonomic function will be altered resulting in vasomotor & trophic changes (edema, nail ridges, thin glossy skin).
- Risk of causalgia.
- If the injury occurs around the elbow, there will be atrophy of forearm flexors & pronators, causing weakness in wrist flexion, abduction & pronation.
Pronator Teres Syndrome
- Pronator Teres Syndrome: The median nerve passes through the 2 heads of pronator teres at the medial side of the elbow, acting as a compression site.
- In 1-13% of people, there is Struther's ligament runs from the medial epicondyle to the supracondylar ridge in which the median nerve passes and can be compressed.
- Etiology: Repetitive movements of forearm/elbow like use of screwdriver, racquet sports, throwing sports (baseball), and massage therapy can cause the syndrome.
- Symptoms: Gradual, insidious onset, Achy, tired, heavy feeling in the forearm, Numbness in thumb & index finger, some weakness/wasting in thenar muscles, and pain in forearm is felt with elbow movement rather than wrist with no nocturnal symptoms.
Carpal Tunnel Syndrome
- Carpal Tunnel Syndrome: The carpal tunnel is formed by the carpal bones on the bottom and the flexor retinaculum, a.k.a. Transverse carpal ligament, on the top.
- The ligament is attached to the pisiform, hook of hamate, scaphoid tubercle, & trapezium.
- Passing through the carpal tunnel: median nerve, 4 tendons of FDS, 4 tendons of FDP, and tendon of FPL.
- Symptoms: Numbness, tingling in median nerve distribution, nocturnal dysthesia (discomfort) from venous stasis or compression (wrist flexion), pain with wrist movement (limiting ROM), swelling from peripheral edema, hypertonicity of forearm flexors, adhesions around flexor retinaculum – RSI and atrophy of thenar & index muscles.
- Palmar cutaneous nerve: the median nerve gives off a branch before passing through the tunnel.
- If the median nerve is compressed in the tunnel, there will be normal sensation over the thenar area.
- If the median nerve is compressed proximal to the tunnel, there will be abnormal sensation in the whole distribution of the median nerve.
- Etiology: Repetitive flexion & extension of wrist, systemic conditions which increase fluid retention (diabetes, pregnancy, hypothyroidism), wrist fracture causing bony callus, ganglia, cysts, lunate dislocation and arthritis like RA.
- Carpal Tunnel Syndrome is commonly seen in: Meat packers, Chefs, Grocery clerks, Assembly line workers, Construction workers, Massage therapists, and Computer workers.
Assessment: Upper limb tension tests
- Used to determine if shoulder or arm pain is due to nerve root or peripheral nerve pathology.
- These test can be used when restricted ROM of shoulder makes other tests like Adson's, Wright's difficult to perform.
- The patient is supine, close to edge of table.
- Therapist maintains shoulder in depression while moving arm & hand.
Upper limb tension test #1 - Median nerve:
- Head in neutral, abduct humerus to 110*, extend 10*, externally rotate 60*, extend wrist & fingers (tingling normal in 1,2,3), and supinate & extend elbow (stretch at elbow). Head can be side bent away from test to see if symptoms change.
- Upper limb tension test #2 - Median, musculocutaneous & axillary nerves:
- Head in neutral, depress shoulder girdle, abduct humerus to 10*, extend wrist & fingers, supinate forearm & extend elbow. Head can be further sensitized by sidebending away from test side Pronator Teres Syndrome tests: Resist active pronation or stretch it.
- Carpal tunnel syndrome tests include Phalen's which involves placing the backs of hands together, flexed wrists, horizontal elbows, relaxed shoulders, and strongly compressing backs of hands together for 1 minute, placing maximum compression on structures in the tunnel presenting with tingling and or pain in digits 1, 2, 3 & ½ of 4.
- A variation of Phalen's test is Reverse Phalen's: patient places palms of hands together & strongly presses together for 1 minute, with same result that may be tingling and or pain in digits 1, 2, 3 & ½ of 4.
Carpal Tunnel Syndrome: Treatment Goals
- Decrease edema via arm support with pillow, cool compress, axillary pump, and light effleurage.
- Reduce nerve compression via fascial restrictions of forearm manipulation, muscle stripping to reduce hypertonicity, trigger point release, flexor retinaculum mobilization, ROM and joint play.
- Amy is presenting with R wrist pain and clumsiness in her fingers after spending the past 3 weeks gardening.
- Rattray/Ludwig recommendations:
- Ch 62 Radial Nerve lesions
- Ch 63 Ulnar Nerve lesions
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