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Goals of examining peripheral nerve: -what nerves involve (median/ Ulnar/ Radial) -level of the lesions (High/ low) -Causes of the injury (from scars or deformity present) # Must know anatomyyy.... Anatomy is very important!! Median Nerve 1. Motor Flexor compartment of the forearm: -Flexor pollicis longus (Flex the thumb) -Flexor digitorum profundus(Index finger: Flex index finger)(DIP joint) -Flexor digitorum superficialis(PIP joint) -Flexor Carpi Radialis (Flexion of the wrist: make a fist, flex wrist and resist at the radial side) Hand -L: 1st and 2nd lumbricals -O: opponent Pollucis -A: Abductor Pollucis brevis -F: Flexor Pollicis brevis 2. Sensory -Lateral 3 fingers -Thenar muscle LOOK -Wasting: thenar (both hands at the eye level) / Radial side of arm - Scars -Benedict sign: finger pointing -Ape hand deformity -Deformity FEEL -Feel for all the muscle bulk involved -If there are scars present: check for tenderness over the scar
MOVE 1. Motor -Flexion(flexion of wrist at radial side) -Opposition (Do Ok sign)(lawan OK sign dgn patient) -abduction (ask the patient to point his thumb towards the nose then resist) * if all 3 have problems : Median nerve Palsy ( to answer what nerve involve) 2. Sensory (must use sharp orange stick) - Lateral 3 of fingers (First test on chest for the sharpness, then test on both thumb, and test on lateral and medial of 3 fingers: ask for any reduce sensation) * if reduced confirmed median nerve palsy. -Then proceed with checking for sensation over the thenar( still need to proceed as if sensory on thenar still intact, the lesion is after the branches5 cm above wrist joint:palmar cutaneous branch-superficial to flexor retinaculum)Carpal tunnel - sensation here intact #if FDP & FDS are paralyzed: High lesion (elbow) Ape-like hand: thenar muscle paralysed. Thus, lack ability to oppose and abduct. Special test for carpal tunnel synd: Tinels sign- tap carpal bone(pin and needle-positive sign), Phalens test-(numbness-positive sign) put dorsal of hands together for 1 minute , flexion compression test-flex the wrist joint and compress median nerve at carpal bones for 30 seconds 30 second- median nerve 1-muscle wasting thenar 2-muscle wasting radial forearm(spared if lower lesion) 3-lawan OK sign 4-lawan thumb abduction 5-lawan flexion of DIP joint on index finger(spared if lower lesion)
6-lawan wrist flexion on radial side(spared if lower lesion) 7-sensation 3 jari 8-sensation thenar(spared if carpal tunnel)
ULNAR NERVE 1. Motor -Flexor Carpi Ulnaris : flex the hand at the wrist (ulnar side) -Ulnar of Flexor digitorum Profundus : flexes the fingers -Hands: Hypothenar/ 3th and 4th lumbricals (flex MCP and extend IP)/Adductor pollicis/Interrosei muscle 2. Sensory -ulnar 1 of the fingers -Dorsal of the hand over the ulnar side
LOOK -wasting of hypothenar, -guttering over the dorsal and ulnar half of the forearm (feel the muscle bulk) - scar -Clawing of the ring and little fingers. FEEL -Muscle bulk of nerve innervations -If scars or deformity present, palpate for tenderness MOVE 1. Motor -Interroseous muscle : PAD (card test) and DAB -Adductor pollicis : Froment test: put both palm of the hands together, and MUST test both sides together.(positive sign-patient flex IP joint of thumb on the affected hand) -Flexor digitorum Profundus: Flex distal phalanx of little finger
-FCU: Flex the wrist at ulnar side *if it is intact:Low lesion (at the wrist:wrist laceration), but if FCU and medial half of FDP affected it is a high lesion (at the elbow-medial epicondyle) . [Link] : -same technique with median nerve , but over the ulnar 1 of the fingers, hypothenar ). - ulnar side dorsal aspect Ulnar Claw: Hyperextension of MCP joint of little and ring fingers due to paralysis of 3rd and 4rd lumbricals .Flexion of DIP and PIP by FDP Ulnar Paradox: the higher the lesion the less claw is. -why: if in high lesion, the flexor digitorum profundus will be paralysed. Guyon canal sydrome: entrapment of ulnar nerve at guyon canal Guyon canal: between flexor retinaculum and palmar carpal ligament Cubital tunnel syndrome: entrapment ulnar nerve at cubital fossa. 30 saat - Ulnar nerve 1-muscle wasting hypothenar 2-guttering 3-muscle wasting ulnar forearm 4-card test 5-froments test 6-5th DIP joint flexion (spared in lower lesion) 7-wrist flexion on ulnar side (spared in lower lesion) 8-sensation ulnar 1 9-sensation at dorsal ulnar side special test ulnar nerve- tinels sign and nerve compression at: 1- carpal bone on the ulnar side 2-behind medial epicondyle of humerus
RADIAL NERVE [Link] -Triceps -Brachioradialis -Supinator -Extensor pollicis longus -Abductor pollicis longus -Extensor pollicis brevis -Extensor carpi radialis -Extensor carpi ulnaris -Extensor digitorum/digiti minimi/ [Link] -First web space of dorsal part
LOOK -scars -no muscle wasting -Observe for wrist drop (deformity) FEEL -Triceps and extensors wasting MOVE [Link] -Ask the patient to extend the wrist -Check for finger drop (ask the pt to flex the wrist n extend the fingers) -Thumb extension against resistance If involved PIN: able to extend the wrist weakly(radial deviation-ECRL supply by radial N before become PIN) with finger drop. If all drop (wrist and finger) :proceed to check for elbow extension Finger drop: low lesion Wrist drop: high lesion Saturday night palsy: higher palsy
[Link] -At first web space If intact: lower lesion 30 second radial nerve: 1-muscle wasting triceps 2-thumb extention 3-finger extention 4-wrist extension (spared if lower lesion-with radial deviation) 5-elbow extension (spared if lower lesion) 6-sensation 1st dorsal web space(spared if lower lesion)
