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A pregnant woman who has recently put on weight as a desk worker, reports numbness and tingling into her fingers that was non-specific, however, did not travel into the palm. Tingling was worse at night. She has psoriasis (skin condition that has a correlation with arthritis, therefore the patient is more prone to tenosynovitis, deformation of carpal bones and inflammatory conditions)

What could be the source of her pain?

Carpel tunnel
Compression of median nerve?
Compression of ulnar nerve through tunnel of guyon?


What is the segmental and root supply to the intrinsic muscles?

doral and palmar interossei?


What makes up the carpal tunnel and what goes through it?

The carpal arch is formed by the distal carpal row but its effect is on the hand, not the wrist
The arch is formed by the curved shape of the trapezoid, trapezium, capitate and hamate and maintained by the transverse carpal ligament (TCL) and the transverse intercarpal ligaments. The TCL and distal carpal row give attachment to a number of intrinsic hand muscles, which may also contribute to maintenance of the carpal arch.
The transverse carpal ligament is the distal part of the flexor retinaculum, which runs from the pisiform and hook of hamate medially, to the scaphoid and trapezium laterally.
The trapezoid, trapezium, capitate, hamate, TCL and transverse intercarpal ligaments form the carpal tunnel.
The carpal tunnel contains the median nerve, the extrinsic finger (flexor digitorum profundus and superficialis) and thumb flexors (flexor pollicis) and the tendon of flexor carpi radialis.
Carpal tunnel syndrome is a neuropathy, in which the median nerve is compressed in the tunnel.


At what stages do the different parts of the elbow become ossified?

capitulum 1-2 years of age
radial head 3 years of age
medial epicondyle 5 years of age
trochlea 7-10 years of age
olecranon 9-12 years of age
Lateral epicondyle 11-13 years of age


What are the Flexors of the wrist?

Palmaris longus, flexor carpi radialis and flexor carpi ulnaris are primary wrist flexors.

Flexor digitorum superficialis, flexor digitorum profundus and flexor pollicis longus are flexors of the digits, with secondary actions at the wrist.


What groups of muscles are responsible for upper limb elevation?

posterior axio-appendicular mm
lat dorsi
lev scap
Rotator cuff


Describe the arthrokinematics of wrist in flexion, extension, radio and ulnar deviation



What structures or conditions could be causing this persons tingling?

tunnel of guyon - ulnar nerve
carpal tunnel - median nerve
median nerve impingement at 2 heads of pronator


Discuss thoracic outlet syndrome

Impingement of neurovascular structures in three/four different areas
Thoracic aperture
Scalene triangle
Costoclavicular space
Coracopectoral space


Discuss the pathways of the median, ulnar, radial and axillary nerves, and highlight were they can be trapped plus clinical ssx

(C6-T1) Follows the course of the brachial artery in the arm. It has no branches in the arm.
Enters the forearm between the two heads of pronator teres (can be impinged here) and descends deep to FDS. It supplies the muscles of the anterior forearm except FCU and medial FDP.
Enters the hand via the carpal tunnel.
The median nerve supplies the palmar aspect of the lateral 3 ½ digits. The palmar branch originates proximal to the flexor retinaculum and for this reason sensation to the palm is usually spared by carpal tunnel syndrome.

The median nerve is connected to the CFO via a continuum of the bicipital aponeurosis, antebrachial fascia and epineurium

Ulnar nerve
Initially runs with the axillary artery then pierces the intermuscular septum of the arm to enter to the posterior compartment. It passes posterior to the medial epicondyle through a tight fascial tunnel where it is vulnerable to compression, degeneration and irritation. It has no branches in the arm.
The ulnar nerve enters the forearm between the heads of FCU passes down the medial forearm supplying FCU and the medial FDP.
The nerve enters the hand superficial to the flexor retinaculum just lateral to pisiform.
In the hand it passes through the tunnel of Guyon between the hook of hamate and the pisiform to supply the long finger flexors, adductor pollicis, interossei and medial two lumbricals.
Damage to the ulnar nerve results in clawing of the hand with MCP joint extended and IPs flexed

Radial nerve
Radial nerve enters the posterior compartment of the arm and passes diagonally in the radial groove of the humerus where it is prone to injury in humeral fracture. It winds around to enter the forearm anterior to the medial epicondyle just deep to brachioradialis.
In the arm it supplies triceps and brachioradialis and the skin of the posterior arm.
In the forearm the deep branch supplies the muscles of the posterior forearm and superficial branch innervates the dorsal skin of the forearm and hand. The superficial branch passes over the anatomical snuffbox to innervate the dorsolateral hand

Radial tunnel syndrome may occur with entrapment by supinator or at the arcade of Froshe.
Local pain over the area can mimic lateral epicondylitis but can be differentiated using Tinnel’s sign and by testing for wrist extensor weakness

Passes between two teres and long head triceps
Winds around surgical neck of humerus
Supplies deltoid & teres minor
Supplies skin over regimental patch


What are some orthopaedic tests for each nerve?