Median Nerve

MEDIAN NERVE
And Carpal Tunnel Syndrome

Introduction
◦ The median nerve, formed by the junction of the lateral and medial cords of the brachial
plexus in the axilla, is composed of fibers from C6, C7, C8, and T1.
◦ Median nerve injuries often result in painful neuromas and causalgia.
◦ From the sensory standpoint they are more disabling than injuries of the ulnar nerve because
they involve the digits used in fine volitional activity.
Course
◦ Medial root crosses axillary artery to join lateral root and median nerve runs on the lateral side
of axillary artery.
◦ Runs on the lateral side of brachial artery till the middle of arm, where it crosses in front of the
artery, passes anterior to elbow joint into the cubital fossa.
◦ Lies medial in cubital fossa and gives off three branches to flexor muscles of forearm. It leaves
cubital fossa by passing between two heads of pronator teres muscle.
◦ Median nerve enters the forearm it lies in the centre of forearm. It lies deep to fibrous arch of
flexor digitorum superficialis on the flexor digitorum profundus muscle. Adheres to deep
surface of flexor digitorum superficialis, leaves the muscle, along its lateral border to lie deep
and lateral to palmaris longus.
◦ Median nerve lies deep to flexor retinaculum to enter palm.
Etiology
◦ Median nerve injuries often are caused by lacerations, usually in the forearm or wrist.
◦ Sunderland pointed out that in the upper arm the nerve can be injured by relatively superficial
lacerations, excessively tight tourniquets, and humeral fractures, and when it is injured near the axilla,
the ulnar and musculocutaneous nerves and the brachial artery also are commonly injured.
◦ In the arm, the median nerve may be compressed by the ligament of Struthers.
◦ At the elbow, the nerve may be injured in supracondylar fractures and posterior dislocations of the elbow.
◦ Struthers' ligament consists of a band of connective
tissue at the medial aspect of the distal humerus. It
courses from the supracondylar process of the
humerus (also known as avian spur) to the medial
humeral epicondyle.
◦ It is not a constant ligament, and can be acquired or
congenital.
◦ Occurence is in about 0.7% to 2.5% of the population.
Clinical Correlations
When the median nerve is injured above the level of the elbow, as might happen in supracondylar fracture
of the humerus, the following features are seen.
◦ The flexor pollicis longus and lateral half of flexor digitorum profundus are paralysed. The patient is
unable to bend the terminal phalanx of the thumb and index finger when the proximal phalanx is held
firmly by the clinician (to eliminate the action of the short flexors).
◦ The forearm is kept in a supine position due to paralysis of the pronators.
◦ The hand is adducted due to paralysis of the flexor carpi radialis, and flexion at the wrist is weak.
◦ Flexion at the interphalangeal joints of the index and middle fingers is lost so that the index (and to a
lesser extent) the middle fingers tend to remain straight while making a fist. This is called pointing index
finger occurs due to paralysis of long flexors of the digit.
◦ Ape or monkey thumb deformity is present due ◦ The area of sensory loss corresponds to its
to paralysis of the thenar muscles. distribution in the hand.
◦ Vasomotor and trophic changes
Carpal Tunnel syndrome:
◦ The carpus is deeply concave on its anterior

surface and forms a bony gutter. The gutter is
converted into a tunnel by the flexor
retinaculum.
◦ All eight tendons of the flexor digitorum
superficialis and profundus invaginate a
common synovial sheath from the lateral side.
This allows the arterial supply to the tendons to
enter them from the lateral side.
◦ The median nerve passes beneath the flexor
retinaculum in a restricted space between the
flexor digitorum superficialis and the flexor
carpi radialis muscles.
◦ Clinically, the syndrome consists of a burning pain or “pins and needles” along the distribution of the
median nerve to the lateral three and a half fingers and weakness of the thenar muscles.
◦ No paresthesia occurs over the thenar eminence because this area of skin is supplied by the palmar
cutaneous branch of the median nerve, which passes superficially to the flexor retinaculum
◦ It is produced by compression of the median nerve within the tunnel. The exact cause of the compression
is difficult to determine, but thickening of the synovial sheaths of the flexor tendons or arthritic changes
in the carpal bones are thought to be responsible in many cases.
Causes
Pressure on the nerve can happen several ways:

◦ Swelling of the lining of the flexor tendons, called tenosynovitis.
◦ Joint dislocations.
◦ Fractures.
◦ Osteoarthritis can narrow the tunnel.
◦ Posture – keeping the wrist bent for long periods of time
◦ Repetitive wrist movements.
◦ Fluid retention during pregnancy can cause swelling in the tunnel and symptoms of carpal tunnel
syndrome, which often go away after delivery.
◦ Thyroid conditions (e. g. hypothyroidism)
◦ Women are three times as likely as men are to develop carpal tunnel syndrome, according to the National
Institute of Neurological Disorders and Stroke.
◦ Heredity.
Diagnosis
◦ History
◦ Physical examination
◦ Tinel sign is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the
nerve to elicit a sensation of tingling or “pins and needles” in the distribution of the nerve
◦ Phalen’s maneuver is a diagnostic test for carpal tunnel syndrome discovered by an American orthopedist
named Dr. George S Phalen.
◦ Nerve conduction studies.
◦ Electromyogram.
Examination
Sensory
◦ Variations in the sensory supply of the median nerve also may be confusing, but usually the volar surface
of the thumb, of the index and middle fingers, and of the radial half of the ring finger and the dorsal
surfaces of the distal phalanges of the index and middle fingers are supplied by the median nerve.
◦ The smallest autonomous zone of the median nerve covers the dorsal and volar surfaces of the distal
phalanges of the index and middle fingers.
◦ The iodine starch test or ninhydrin print test may be helpful in diagnosis. Autonomic changes, such as
anhidrosis, atrophy of the skin, and narrowing of the digits because of atrophy of the pulp, also are
valuable signs of sensory deficit.
Examination
Motor
◦ Flexor pollicis longus
The patient is asked to bend the terminal phalanx of the thumb against resistance while the proximal
phalanx is being steadied by the clinician. This muscle is only paralysed when the median nerve is injured
at or above the elbow.
◦ Flexor digitorum supcrficialis and profundus (lateral half)
In case of injury to the median nerve if the patient is asked to clasp the hands, the index finger of the
affected side fails to flex and remains as a “pointing index”. This test is known as Ochsner’s clasping test.
◦ Abductor pollicis brevis
This muscle is concerned in abduction of the thumb that means the thumb moves upwards at right angle to
the palm of the hand when the hand is laid flat on the table. This is done by asking the subject to touch the
pen which is kept at a slight higher level than the palm of the hand with the thumb. This is known as pen
test.
◦ Opponens pollicis
This muscle swings the thumb across the palm to touch the tips of the other fingers. The patient with
paralysis of this muscle will be unable to do this movement.
It is worthy of mention that a vicarious movement short of proper opposition movement is possible by
adductor pollicis supplied by the ulnar nerve.
Treatment
◦ The goal of treatment for CTS is to reduce the swelling and pressure on the median nerve.
◦ Wrist brace.
◦ Avoid inadequate posture and repetitive wrist movements.
◦ Corticosteroids and Lidocaine (local anesthetic) can be injected directly into the wrist.
◦ The local injection and oral cortisone are used to relieve pressure (inflammation) on the median nerve
and provide immediate, temporary relief to persons with mild or intermittent symptoms.
◦ If symptoms are severe or persist after trying nonsurgical therapy, surgery may be the most appropriate
option.
◦ The goal of carpal tunnel surgery is to relieve pressure on your median nerve by cutting the ligament
pressing on the nerve. The surgery may be performed with two different techniques
FIN.

Median Nerve

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MEDIAN NERVE

And Carpal Tunnel Syndrome

◦ The carpus is deeply concave on its anterior

Pressure on the nerve can happen several ways:

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