TINGLING AND NUMBNESS IN THE EXTREMITIES

DR MANOJ R KANDOIM.S.,D’ORTH,DNB,FCPS,

FRSM(LONDON),FICS(CHICAGO)

FELLOWSHIP IN HAND AND FOOT SURGERIES

USA,ITALY,FRANCE,GERMANY,UK,TAIWAN,REPUBLIC OF CHINA

THANKS TO MEDICAL FRATERNITY WORLDWIDE

DR. MANOJ R. KANDOIM.S.,D.N.B.,D’ORTH,F.C.P.S.,F.I.C.S.,F.R.S.M.,M.N.O.F.

FELLOW: UNIVARSITY OF WASHINGTON MILANO UNIVARSITY HISSINGPARK CLINIC,AUGSBERG,GERMANY HARBORVIEW MEDICAL CENTRE,SEATTLE,U.S.A POLICLINICO MULTIMEDICA,MILAN,ITALY AITS – IRCAD, TAIWAN,R.O.CHINA INOR FELLOW,BRITISH ORTHOPEDIC SOCIETY INTERNATIONAL COLLEGE OF SURGEONS,CHICAGO IRCAD ,STRAUBERG, FRANCE AMC,AMSTERDAM,NETHERLAND

What is a peripheral neuropathy?

Peripheral neuropathy is disorder of nerve(s) apart from the brain and spinal cord. Patients with peripheral neuropathy may have tingling, numbness, unusual sensations, weakness, or burning pain.

What causes a peripheral neuropathy?

Diabetes Mellitus

Shingles (post herpetic neuralgia)

Vitamin deficiency, particularly B12 and folate

Alcohol

Autoimmune diseases, including lupus, rheumatoid arthritis or Guillain-Barre syndrome

AIDS, whether from the disease or its treatment, syphilis, and kidney failure

Inherited disorders, such as amyloid polyneuropathy or Charcot-Marie-Tooth disease

Exposure to toxins, such as heavy metals, gold compounds, lead, arsenic, mercury, and organophosphate pesticides

Cancer therapy drugs such as vincristine (Oncovin, Vincasar), and other medications [for example antibiotics such as metronidazole (Flagyl), and isoniazid (Nydrazid, Laniazid)]

While diabetes and post herpetic neura

Symptoms

The symptoms depend on which type of nerve is affected. The three main types of nerves are:

Nerves that carry sensations (sensory) Nerves that control muscles (motor) Nerves that carry information to organs and

glands (autonomic)

SENSATION CHANGES

Burning sensations Changes in sensation Inability to determine joint position, which

causes lack of coordination Nerve pain Tingling or numbness

MOVEMENT DIFFICULTIES

Difficulty breathing or swallowing Difficulty or inability to move a part of the

body (paralysis) Falling (from legs buckling or tripping over

toes) Lack of dexterity (such as being unable to

button a shirt) Lack of muscle control Loss of muscle tissue (muscle atrophy) Muscle twitching or cramping

AUTONOMIC SYMPTOMS Abdominal bloating Blurred vision Constipation Decreased sweating Diarrhea Dizziness that occurs when standing up or fainting due to a drop in

blood pressure Feeling full after eating a small amount (early satiety) Heat intolerance with exertion Incomplete bladder emptying Male impotence Nausea or vomiting after meals Urinary hesitancy (taking a long time to start urinating) Urinary incontinence Weight loss without trying

Signs and tests

Tests that find and help classify neuropathy may include:

Electromyogram (EMG) -- a recording of electrical activity in muscles)

Nerve conduction velocity tests (NCV) -- a recording of the speed at which signals travel along nerves

Nerve biopsy -- taking a small sample of a nerve to look at under a microscope

Treatment

Addressing the cause (such as diabetes or excess alcohol use)

Controlling symptoms Helping the patient gain maximum

independence and self-care ability Replacing any vitamin or other deficiencies in

the diet Stopping injury to the nerve (for example, in

cases of neuropathy due to compression such as carpal tunnel syndrome)

Complications

Deformity Loss of tissue mass Poor healing Scarring Tissue erosions Decreased self-esteem Difficulty breathing Difficulty swallowing Irregular heart rhythms (arrhythmias) Need for amputation Partial or complete loss of movement or control of movement Partial or complete loss of sensation Relationship problems related to impotence

Entrapment neuropathies

Entrapment neuropathies are a group of disorders of the peripheral nerves that are characterized by pain and/or loss of function (motor and/or sensory) of the nerves as a result of chronic compression

Common entrappment syndromes

Carpal tunnel syndrome (CTS), compression of the median nerve at the wrist, is the most common entrapment neuropathy.

Cubital tunnel syndrome is caused by a compression at the elbow.

suprascapular nerve compression, which accounts for approximately 0.4% of upper girdle pain symptoms, and

meralgia paresthetica, a compression of the lateral femoral cutaneous nerve [LFCN] in the groin

CARPAL TUNNEL SYNDROME

Median nerve compression at the wrist is at the transverse carpal ligament (TCL), which attaches to and arches between the pisiform and hamate on the ulnar side and the scaphoid and trapezium on the radial side

CARPAL TUNNEL SYNDROME

Dull, aching pain at the wrist that may extend up the forearm to the elbow.

Often, associated with distressing paresthesias in the thumb and index finger, particularly upon awakening.

Typically, patients rub their wrists or shake their hands to try to "get the blood back into their wrists.“

The pain is typically worse at night and disturbs their sleep

THENAR MUSCLE ATROPHY

CLINICAL TESTS

TINEL’S SIGN

CONSERVATIVE MANAGAEMENT: BRACING

LOCAL STEROIDS INJ

SURGICAL TREATMENT

INTRAOP PHOTOGRAPH

RESULTS OF SURGERY

SATISFYING SYMPTOMS TEND TO COMPLETELY

RESOLVE

CUBITAL TUNNEL SYNDROME

The ulnar nerve travels on the medial side of the brachial artery in the upper arm, pierces the medial intermuscular septum at mid arm, and continues toward the elbow on the medial head of the triceps. At the elbow, it passes through the cubital tunnel, a groove between the medial humeral epicondyle and the olecranon. The nerve travels beneath the aponeurotic arcade between the 2 heads of the flexor carpi ulnaris and down the forearm between the deep and superficial finger flexors.

5 potential areas of ulnar nerve entrapment : The arcade of Struthers stretches from the medial head of the triceps to

insert into the medial intermuscular septum. It is located approximately 6-8 cm above the medial epicondyle. It can be a factor in ulnar nerve compression after ulnar nerve transposition.

The medial intermuscular septum presents a sharp edge that can indent the nerve, particularly after anterior transposition, in which the nerve may be kinked.

The cubital tunnel is floored by the medial collateral ligament of the elbow and roofed by the arcuate ligament (cubital tunnel retinaculum) that stretches between the medial humeral epicondyle and the medial aspect of the olecranon.

The arching band of aponeurosis between the 2 heads of the flexor carpi ulnaris (so-called Osborne band) may compress the nerve, especially during repetitive contraction of the muscle.

The aponeurotic covering between the flexors digitorum profundus and superficialis is occasionally a site of compression.

CLINICAL PRESENTATIONS

Pain typically presents as a deep ache around the elbow region

Pain is exacerbated when the medial elbow is impacted

Intermittent paresthesias and numbness in the ring and little fingers

Hand weakness, especially with gripping objects

CLINICAL SIGNS Sensation over the palmar portion of the fifth digit and the ulnar half of

the fourth digit specifically is decreased to the following stimuli: Pinprick Light touch Two-point discrimination

Sensory loss can also be detected along the dorso-ulnar aspect of the hand (due to involvement of the dorsal cutaneous branch of the ulnar nerve which arises proximal to the wrist).

Late symptoms include dense numbness and profound weakness and atrophy of the intrinsic hand muscles.

An ulnar claw hand may be present with extension of the little and ring fingers.

Extension at the metacarpophalangeal joints and flexion at the intraphalangeal joints is caused by the loss of lumbricals 3 and 4.

Provocative tests: A gentle tapping of the nerve at and around the cubital tunnel elicits distressing electrical shock, tingling, or both down into the ulnar fingers (percussion test).

TINEL’ S SIGN

FROMENT SIGN

Weakness of finger abductors and adductors (interossei) and adductor of the thumb (adductor pollicis) may be detected whereas thumb abduction is normal

Ulnar nerve compression at the wrist (Guyon canal) At the wrist, the ulnar nerve runs above the

flexor retinaculum lateral to the flexor carpi ulnaris tendon and medial to the ulnar artery. At the proximal carpal bones, it dips between the pisiform and the hook of the hamate at the entrance to the Guyon canal, roofed over by an extension of the TCL between these 2 bones

Clinical presentation

young man with painless atrophy of the hypothenar muscles and interossei with sparing of the thenar group. Sensory loss and pain involving the ulnar 1.5 digits may be present.

SIGNS

A positive Phalen test and percussion tenderness over the course of the ulnar nerve at the wrist may be present.

posterior interosseous nerve syndrome

Relevant anatomy At mid arm, the radial nerve descends behind

the humerus, deep to the long head of the triceps, and then spirals around the humerus in between the medial and lateral heads of the triceps in the spiral groove. Approximately 5-10 cm above the lateral humeral epicondyle, the nerve pierces the lateral intermuscular septum to gain the anterior compartment of the arm. Here, it immediately enters the deep, muscular groove bordered medially by the biceps and brachialis and laterally by the brachioradialis, the extensor carpi radialis longus (ECRL), and the extensor carpi radialis brevis (ECRB). The nerve then courses immediately in front of the radiocapitellar joint capsule, where it divides into the (motor) deep branch of the radial nerve and the sensory superficial radial nerve (SRN).

causes

PIN compression is most commonly associated with tendinous hypertrophy of the arcade of Frohse and fibrous thickening of the radiocapitellar joint capsule. Vascular compression by the leash of Henry has been reported. Lesions, such as lipoma, synovial cyst, rheumatoid synovitis, and a vascular aneurysm, have been found in some cases.

clinical picture Fatigue during finger extension

and elbow supination. The extension in the

metacarpophalangeal joints is weakened,.

in the early stage of entrapment, the hand exhibits a characteristic pattern upon finger extension, in which the middle 2 fingers fail to extend, while the index and little fingers can be extended ("sign of horns").

Progression of paralysis eventually causes weakness in all of the finger extensors and in thumb abduction.

No sensory symptoms are present.

Suprascapular nerve entrapment

Relevant anatomy The suprascapular nerve arises

from the lateral aspect of the upper trunk of the brachial plexus, runs across the posterior triangle of the neck together with the suprascapular artery and the omohyoid muscle, dips under the trapezius, and then passes through the suprascapular notch at the superior border of the scapula. As the nerve enters the supraspinous fossa, it supplies the supraspinatus muscle, then curls tightly around the base of the spine of the scapula, enters the infraspinous fossa, and supplies the infraspinatus

cause

A stout, strong suprascapular ligament closes over the free upper margins of the suprascapular notch. Suprascapular nerve entrapment is caused by this ligament, often in conjunction with a tight, bony notch.

Pain symptoms

Pain with insidious onset Deep, dull aching pain in the posterior part of

the shoulder and upper periscapular region Noncircumscribed pain No neck or radicular symptoms Shoulder weakness

Signs

Weakness is confined to the supraspinatus, which initiates shoulder abduction and/or the infraspinatus, which externally rotates the arm.

Atrophy can manifest as hollowing of the infraspinous fossa and prominence of the scapular spine. Supraspinatus atrophy may not be obvious because of the overlying trapezius. Deep pressure over the midpoint of the superior scapular border may produce discomfort.

Lateral femoral cutaneous nerve compression(meralgia paresthetica) This purely sensory nerve is

formed just deep to the lateral border of the psoas muscle, then descends in the pelvis over the iliacus muscle deep to the iliacus fascia. Just medial to the ASIS, the nerve exits the pelvis by passing through the deep and superficial bands of the inguinal ligament as they attach to the ASIS. The nerve is almost horizontal while still within the pelvis before it traverses the inguinal ligament, but then it takes a vertical course out to the surface of the thigh.

etiology

A protruding, pendulous abdomen, as seen in obesity and pregnancy, compresses the inguinal ligament downward and onto the nerve, causing it to be kinked. This angulation of the nerve is further exaggerated with extension of the thigh and relaxed with flexion.

symptoms

The main symptoms are an uncomfortable numbness, tingling, and painful hypersensitivity in the distribution of the LFCN, usually in the anterolateral thigh down to the upper patella region.

Common peroneal nerve entrapment

It is 1 of the 2 terminal divisions of the sciatic nerve. It winds around the lateral aspect of the neck of fibula deep to the peroneus longus (fibular tunnel), where it divides into superficial peroneal, deep peroneal, and articular branches. Entrapment occurs where the nerve is in close relationship to the neck of fibula.

ETIOLOGY

Trauma or injury to the knee Fracture of the fibula (a bone of the lower leg) Use of a tight plaster cast (or other long-term

constriction) of the lower leg Habitual leg crossing Regularly wearing high boots Pressure to the knee from positions during

deep sleep or coma Injury during knee surgery

Clinical presentation

Pain radiating from the knee region to the dorsal aspect of the foot

Sensory loss on the dorsum of the foot Foot drop (loss of dorsiflexion of the foot) and

loss of extension of toes, and eversion of ankle (This is differentiated from an L5 radiculopathy, in which posterior tibialis function (inversion in plantar flexion) is affected.)

sign

Tinel sign at the fibular neck

Drawing of the dorsal aspect of the foot illustrates the territories of the deep peroneal nerve (DPN), lateral plantar nerve (LPN), medial plantar nerve (MPN), sural nerve (SN), and superficial peroneal nerve (SPN

Deep peroneal nerve compression syndrome

most common site of compression is at the top of the foot where a small tendon compresses the deep peroneal nerve against the underlying bone

ETIOLOGY

a crush injury to the foot wearing tight shoes or tightly laced boots, a broken foot bone, or foot surgery

SYMPTOMS

Symptoms here are only sensory, and may feel like a knife sticking in the top of the foot, and pain between the first and second toes

Sup per. Nerve compression syndrome

It travels in the lateral compartment and supplies the peroneus longus and brevis muscles. In most individuals, the superficial peroneal nerve pierces the deep fascia and emerges into the subcutaneous fat at approximately the level of the middle and lower third of the leg and at an average of about 10-15 cm above the tip of the lateral malleolus

Etiology

Local trauma or compression

Repeated ankle sprains prolonged kneeling and

squatting any procedure about

the anterior ankle, including use of the anterolateral ankle arthroscopy portal

Clinical

numbness or paresthesia in the distribution of the nerve

have pain about the lateral leg

vague pain over the dorsum of the foot

symptoms increase with activity, such as running, walking, or squatting

treatment

injection of steroids plus lidocaine near the site of involvement in the lower leg can reduce symptoms and serve as a diagnostic tool in confirming the zone of nerve compression

release of the superficial peroneal nerve at the lateral leg for surgical decompression with partial or full fasciotomy

Sural nerve compression

Sural nerve is a purely sensory nerve

Sural nerve arises from the branches of common peroneal and tibial nerve

the nerve passes from proximal calf to the ankle posterior to the lateral malleolus

Sural nerve supplies skin of the lateral calf and feet

ETIOLOGY

Sural nerve can be affected by compression from tight socks, Baker's cyst or laceration

SYMPTOMS

Patient complains of abnormal sensation over the lateral calf and foot

Tarsal tunnel syndrome

Compression of the tibial nerve behind the medial malleolus, or tarsal tunnel syndrome (TTS),

Tarsal tunnel syndrome The roof of the tunnel is formed by

the flexor retinaculum stretched between the medial malleolus and the calcaneus. The tarsal bones are the floor. Numerous fibrous septae between the roof and the floor subdivide the tunnel into separate compartments at various points. The contents of the tarsal tunnel at its proximal end are, from front to back, as follows:

The tibialis posterior tendon The flexor digitorum longus tendon The posterior tibial artery and vein The tibial nerve The flexor hallucis longus tendon

The tibial nerve has 3 terminal branches. It bifurcates into the medial and lateral plantar nerves within 1 cm of the malleolar-calcaneal axis in 90% of cases; in the other 10% of cases, the medial and plantar nerves are 2-3 cm proximal to the malleolus.

The calcaneal branch usually comes off the lateral plantar fascicles, but around 30% leave the main nerve trunk just proximal to the tunnel. Distally, the medial and lateral plantar nerves travel in separate fascial compartments. The medial branch supplies the intrinsic flexors of the great toe, the first lumbrical, and the sensation over the medial plantar surface of the foot inclusive of at least the first 3 toes. The lateral branch supplies all of the interossei and the lateral 3 lumbricals, as well as sensation over the lateral plantar surface of the foot. The calcaneal branch, which traverses its own tunnel, provides sensation to the heel.

Drawing illustrates the PTN trifurcation. ADQM = abductor digiti quinti muscle, AHM = abductor hallucis muscle

Drawing of the plantar aspect of the foot illustrates the territories of the lateral calcaneal nerve (LCN), lateral plantar nerve (LPN), medial calcaneal nerve (MCN), medial plantar nerve (MPN), and sural nerve (SN)

Clinical presentation Early symptoms are

burning, tingling, and dysesthetic pain over the plantar surface of the foot

In advanced cases, the intrinsic flexors of the great toe are weak and atrophied, producing hollowing of the instep. The lateral toes may also show clawing due to paralysis of the intrinsic toe flexors

PLANTAR FASCIITIS

MORTON, NEUROMA

SURGICAL TREATMENT

Complimentary C.D. BOOKS

THANK YOU