Contributing factors

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Ligamentous or synovial thickening

Trauma

Obesity Diabetes Scleroderma Thyroid disease Lupus

Amyloidosis Gout

Acromegaly Paget's disease Mucopolysaccharidoses

Differential diagnosis

Cervical radiculopathy (C6, C7)

Sensory symptoms Numbness and paresthesia. May involve the thumb and index and middle fingers, as in carpal tunnel syndrome, but they may often radiate along the lateral forearm and occasionally the radial dorsum of the hand

Pain In contrast to carpal tunnel syndrome, pain in cervical radiculopathy frequently involves the neck, and may be precipitated by neck movements. Nocturnal exacerbation of pain is more prominent in carpal tunnel syndrome. Patients with radicular pain tend to keep their arm and neck still, whereas in carpal tunnel syndrome they shake their arms and rub their hands to relieve the pain

Weakness and atrophy This involves muscles innervated by C6 and C7, not the muscles innervated by C8. Brachioradialis and triceps tendon reflexes may be decreased or absent in radiculopathy

Provocation tests In carpal tunnel syndrome, the symptoms can be re produced by provocative tests

- By tapping over the carpal tunnel (Tinel's sign)

- By flexion of the wrist (Phalen's sign)

- When a blood pressure cuff is applied to the arm and compression above systolic pressure is used, median paresthesias and pain can be aggravated (the Gilliatt and Wilson cuff compression test)

Electrodiagnostic These are usually diagnostic, although both C6-C7

studies root compression and distal median nerve entrap ment may coexist (double crush injury). Somatosensory evoked response (SSER), electromyography (EMG), orthodromic/antidromic tests, etc.

Brachial plexopathy This is usually incomplete, and characterized by the involvement of more than one spinal or peripheral nerve, producing clinical deficits such as muscle paresis and atrophy, loss of muscle stretch reflexes, patchy sensory changes, and often shoulder and arm pain, which is usually accentuated by arm movement

- Upper plexus Erb-Duchenne type paralysis • The muscles supplied by the C5 and C6 roots are paretic and atrophic (i.e., the deltoid, biceps, bra-chioradialis, radialis, and occasionally the supraspi-natus, infraspinatus and subscapularis muscles), producing a characteristic limb position known as the "porter's tip" position (i.e., internal rotation and adduction of the arm, extension and pronation of the forearm, and with the palm facing out and backward)

• The biceps and brachioradialis reflexes are depressed or absent

• There may be some sensory loss over the deltoid muscle area

- Lower plexus Dejerine-Klumpke type paralysis • The muscles supplied by the C8 and T1 roots are paretic and possibly atrophic (i.e., weakness of wrist and finger flexion and weakness of the small hand muscles), producing a "claw-hand" deformity

• The finger flexor reflex is depressed or absent

• Sensation may be intact or lost over the medial arm, forearm, and ulnar aspect of the hand

• There is an ipsilateral Horner's syndrome with injury of the T1 root

- Neuralgic amyo- Parsonage-Turner syndrome. This is characterized by trophy acute, severe pain in the shoulder, radiating into the arm, neck, and back. The pain is followed within several hours or days by paresis of the shoulder and proximal musculature. The pain usually disappears within several days. The condition is idiopathic, but is thought to be a plexitis, and may follow viral illness or immunization

Thoracic outlet Also known as cervicobrachial neurovascular compres-syndrome sion syndrome. The thoracic outlet syndrome may be purely vascular, purely neuropathic, or rarely, mixed. The true neurogenic thoracic outlet syndrome is rare, occurring more frequently in young women, and affecting the lower trunk of the brachial plexus. Intermittent pain is the most common symptom, referred to the medial arm and forearm and the ulnar border of the hand. Paresthesias and sensory losses involve the same distribution. The motor and reflex findings are essentially those of a lower brachial plexus palsy, with particular involvement of the C8 root causing weakness and wasting of the thenar muscles, similar to carpal tunnel syndrome. However, in contrast to the latter, in the thoracic outlet syndrome wasting and paresis also tend to involve the hypothenar muscles, which derive their innervation from the C8 and T1 roots, and the sensory symptoms involve the medial arm and forearm, whereas the arm discomfort is made worse with movement. Electrodiagnostic studies show evidence of lower trunk brachial plexus dysfunction

Proximal medial nerve neuropathy

Pronator teres syndrome

Lacertus fibrosus syndrome

Flexor superficialis arch syndrome

Anterior interosseous syndrome

This results from compression of the median nerve as it passes between the two heads of the pronator teres. It is characterized by:

- Diffuse aching of the forearm

- Paresthesias in the median nerve distribution over the hand

- Weakness of the thenar and forearm musculature (ranging from mild involvement to none)

- Pain in the proximal forearm on forced wrist supination and wrist extension

Pain in the proximal forearm is caused on resisting forced forearm pronation of the fully supinated and flexed forearm

Pain in the proximal forearm is caused on forced flexion of the proximal interphalangeal joint of the middle finger

- Weakness of the flexor pollicis longus, pronator quadratus, and the median-innervated profundus muscles. Impaired flexion of the terminal phalanx of the thumb and the index finger is characteristic

- There is no associated sensory loss

Entrapment at the elbow (ligament of Struthers)

- Electrodiagnosis

Weakness of median-innervated muscles, including the pronator teres

Associated loss of the radial pulse when the arm is extended

Nerve conduction studies in proximal median nerve compression syndromes are frequently normal Needle EMG will consistently show neurogenic changes in median-innervated forearm and hand median muscles

EMG: electromyography; SSER: somatosensory evoked response.

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