PERIPHERAL

NERVE INJURY
& ENTRAPMENT
SYNDROME
 Physical
examination of
peripheral nerve
1.Look

Proper exposure up
to axilla
Scar
Muscle wasting
Swelling
Deformity
2. feel
Tenderness
Tinels sign- along
ulna, median nerve
distribution
3.Screening Test-radial nerve

Extend wrist Extend MCPJ

Screening test median nerve

opposition OK!
Screening test ulnar nerve

Adduct and Abduct fingers

4. Special test
Example
Fromens sign ( Ulna)
Pointing finger sign (median)
5. Neurological investigation
Sensory
Muscle power
reflexes
Investigation
ELECTRO-DIAGNOSTIC STUDIES
Nerve conduction studies
Measure velocity of conduction of impulse in a
nerve
Strength-duration curve
Graphic representation of the excitability of muscle
and nerve tissue under stress
Electromyography (EMG)
Graphic recording of the electrical activity of a
muscle at rest and during activity
Management
General consideration: Arterial, bone & joint repair b4
nerve repair
Conservative tx
This alone or in addition to operative treatment.

Aim : preserve mobility of affected limb while nerve

recover by :
Splintage of the paralyzed limb
Preserve joint mobility
Care of skin
Physiotherapy
Relief of pain
Principle of Operative treatment
Nerve exploration
Indication
Nerve seen to be divided and needs to be repaired

Type of injury suggest that the nerve is likely to be

cut or severely damaged e.g. knife wound
Recovery inappropriately delayed & diagnosis in
doubt

Primary repair
Is best repaired as soon as this can be done safely
Suture at epineurium with fine (10/0) suture
Limb splinted in a position for minimal tension on
nerve for 3-6 week
 Delayed repair
Indication
No sign of recovery at expected time

Diagnosis missed and patient present late

Primary repair failed

Nerve grafting
Bridge gaps too large for direct suture
Free autogenous nerve grafts (e.g: Sural nerve,

lat.cutaneous n. of the thigh, saphenous n.)

Vascularized grafts (eg. in Volkmanns ischaemia)
 Nerve transfer
If the lesion is too proximal (eg. Root
avulsion of upper brachial plexus)

Tendon transfer
Axons do not reach muscle within 18-24
months of injury
 UPPER LIMB
NERVE INJURY
Median Nerve
( C5 - T1)
Origin
 ANATOMI N. MEDIANUS
N.medianus (C5-Th1)
Berasal dari pleksus brachialis.
Mulai bercabang setinggi siku untuk
mempersarafi otot-otot flexor lengan bawah:
M.pronator teres, M.flexor carpi radialis,
M.palmaris longus dan M.flexor digitorum
superficialis. Sesudah menembus M.pronator
teres beberapa cabangnya juga
mempersarafi M.flexor pollicis longus,
M.flexor digitorum profundus (pars radialis)
dan M.pronator quadratus. Selanjutnya saraf
ini berjalan dibawah ligamenntum carpalis
transversum dalam terusan carpal bersama
tendo-tendo flexor-flexor panjang untuk jari-
Dermatom Nerve Medianus
Cabang-cabang terminal sensorik
yang menginnervasi kulit disebelah
radial telapak tangan sebelah voler
ibu jari, jari telunjuk, jari tengah,
sebelah radial telunjuk, sebelah
dorsal ujung jari telunjuk dan jari
tengah. Kerusakan proximal pada
N.medianus berakibat tidak dapat
mengepal membuat tinju, fleksi jari-
jari hanya yang di persarafi oleh
N.ulnaris dengan posisi tangan
pengchotbah (preachers hand
Persarafan tangan terdiri atas saraf
radialis, medianus, dan ulnaris. Dari
ketiga saraf ini hanya saraf medianus
yang melewati terowongan carpal,
sehingga pada CTS menimbulkan
gangguan fungsi saraf medianus dari
terowongan carpal ke distal,
walaupun rasa nyerinya dapat
dirasakansampai ke arah proksimal di
leher tempat saraf medianus berasal.
Selain fungsi motoris dansensoris,
saraf medianus juga merupakan saraf

Anatomy
Arise from the medial & lateral cords of the brachial plexus
Gives off no branches to the arm
Passes into forearm between heads of pronator teres
Innervates muscles in forearm :
a) Superficialis flexor- Pronator Teres (PT)
- Flexor Digitorum Superficialis (FDS)
- Flexor Carpi Radialis (FCR)
- Palmaris Longus (PL)
b) Deep flexor (AIN) - Flexor Digitorum Profundus (FDP)
- Flexor Pollicis Longus (FPL)
- Pronator Quadratus (FQ)
In the distal third of forearm, gives rise to palmar cutaneous branch, which
crosses in front of the flexor retinaculum & supplies the skin on lateral half
of the palm
In the hands, innervates (L.O.A.F)
Lateral 2 lumbricals
Opponens pollicis

Abductor policis brevis

Flexor pollicis brevis

Also gives sensory innervation to the skin of the palmar aspect of the lateral
three and one-half fingers, including the nail beds on the dorsum.
Anatomy
Palmar
cutaneous
branch of
median nerve
 Structures of The Forearm &Function :
BRANCHES STRUCTURE INNERVATED FUNCTION

1. Muscular a.Pronator teres Pronates & flexes forearm

branches of median (at elbow)
nerve b.Flexor carpi radialis (FCR) Flexes and abducts hand
(at wrist)
c.Palmaris longus Flexes hand (at wrist) and
tenses palmar aponeurosis
d.Flexor digitorum superficialis Flexes PIPJ of four fingers
& flexes phalanges at
MCPJ

2. Anterior a.Flexor digitorum profundus Flexes 2nd & 3rd fingers at

interosseous nerve (lateral: 2nd & 3rd fingers) DIPJ
(AIN) b.Flexor pollicis longus
c.Pronator quadratus Flex the thumb
Pronate forearm
3. Palmar Supply sensation of palm (central
cutaneous branch part)
of median nerve
 Structures at the hand:
-through carpal tunnel, deep into flexor retinaculum
BRANCHES
1. Recurrent branch of
median nerve
2. Lateral branch of median
nerve
3. Medial branch of median
nerve
STRUCTURE FUNCTION
INNERVATED
Thenar muscle:
a.Abductor pollicis brevis Abduct the thumb
b.Opponens pollicis Opposition of the thumb
c.Flexor pollicis brevis Flex the thumb
a.1st lumbrical Flex MCPJ,
b.Skin of palmar and distal extend IPJ of 2nd-5th fingers
dorsal aspect of thumb &
radial half of 2nd finger
a.2nd lumbrical Flex MCPJ,
b.Skin of palmar and distal extend IPJ of 2nd-5th fingers
dorsal aspect of adjacent
sides of 2nd-4th fingers

4. Palmar cutaneous branch Supply sensation of palm

of median nerve (central part)
 Low Lesion
( below elbow)

Median Nerve Injury

High Lesion
( above elbow)
 Low Lesion
Causes
Cuts in front of the wrist

Carpal dislocation

Fracture of lower end of radius

Carpal tunnel syndrome (CTS)

Muscles affected : L.O.A.F

Clinical features
Unable to abduct thumb (tested by Pen Test) and
opposition
Apes hand

Loss of sensation over the radial 3 digits

Wasting of the thenar eminence

Trophic changes (brittle nails, shiny atrophic skin)

APES HAND

inability to oppose &

limited abduction of
thumb
thumb movement limited
to flexion & extension of
the thumb in the plane of
palm
 High Lesion
Causes
Trauma eg: stabs and gunshot wounds

Fracture

Forearm
Supracondylar humerus
Elbow dislocation

Clinical features
Paralyze of long flexors of thumb, index and
middle fingers, radial wrist flexors and forearm
pronator + L.O.A.F
Pointing index finger

Pinch sign
 Pointing index
Pinch sign finger
 Management
Suture/nerve grafting

Postop : wrist splinted in flexion

Late lesion: no recovery because of sensory loss &

deficient opposition.

If sensory recover with no opposition, tendon transfer:

EI re-routed to opponens pollicis
ECR transfer for FDP
Brachioradialis for flexor pollicis longus
Carpal tunnel syndrome
- commonest entrapment syndrome

-The median nerve is compressed at the wrist

- leading to paresthesias, numbness and
muscle weakness in the hand

- > common in (40-50 y.o.)

- Young pts ( pregnancy, rheumatoid d/s,

chronic renal failure/gout)
 Insiden
Lebih banyak pada wanita dibanding
pria (10:1)
Usia terbanyak 40-50 th
Angka kejadian + 515 /10.000
populasi
CARPAL TUNNEL SYNDROME
(CTS)
CARPAL TUNNEL SYNDROME (CTS)
adalah Salah satu penyakit yang paling
sering mengenai nervus medianus dan
merupakan neuropati tekanan/jebakan
(entrapment neuropathy). Di
pergelangan tangan nervus medianus
berjalan melalui terowongan karpal
(carpal tunnel) dan pada saat berjalan
melalui terowongan inilah nervus
medianus paling sering mengalami
tekanan yang menyebabkan terjadinya
neuropati tekanan.
 Patologi
Carpal tunnel syndrom dapat dikategorikan
menjadi dua yaitu akut dan kronis. Ada
beberapa hipotesa mengenai patogenesis dari
carpal tunnel syndrom. Sebagian berpendapat
bahwa faktor mekanik clan vaskuler memegang
peranan penting dalam terjadinya carpal tunnel
syndrom (Maxey, 1990).
Tapi pada umumnya Carpal tunnel syndrome ini
terjadi secara kronis dimana terjadi penebalan
flexor retinakulum, yang menyebabkan tekanan
terhadap nervus medianus. Tekanan yang
berulang-ulang dan lama akan mengakibatkan
peninggian tekanan intrafasikuler. Akibatnya
aliran darah vena intrafasikuler melambat.
Kongesti yang terjadi ini akan
mengganggu nutrisi intrafasikuler lalu
diikuti oleh anoxia yang akan merusak
endotel. Kerusakan endotel ini akan
mengakibatkan kebocoran protein
sehingga terjadi edema epineural.
Apabila kondisi ini terus berlanjut akan
tejadi fibrosis epineural yang merusak
serabut saraf. Lama-kelamaan saraf
menjadi atrofi dan akan digantikan
oleh jaringan ikat yang mengakibatkan
fungsi dari nervus medianus terganggu
(Rambe, 2004)
 Gejala
Tingling pada kulit telapak tangan dan punggung
tangan di daerah ibu jari, jari telunjuk, jari tengah
dan setengah sisi radial jari manis.Biasanya terjadi
setelah aktifitas berat dan berulang, riwayat trauma,
seringkali idiopatik.
Terjadi gangguan sensorik, pada awalnya nyeri
terutama pada malam hari, rasa tebal (hipoesthesia)
dan paraesthesia, menghilang/berkurang jika tangan
digoyang atau diposisikan tergantung.
Bila berlanjut, terjadi nyeri spontan ujung-ujung
jari, nyeri menjalar hingga ke lengan, siku dan bahu,
gangguan sensasi seperti terbakar sepanjang
distribus n. medianus distal pergelangan tangan (jari
1, 2, 3).
Terjadi gangguan motorik seperti kelemahan otot-
otot thenar (fleksor, abduktor dan opponen pollicis)
serta atrofi otot-otot thenar (gembos)
 CLINICAL FEATURES
1. Pain & paraesthesia occur in the distribution of the median nerve
in the hand. (radiate up from arm shoulder - neck).

2. Weakness of hand/forearm (morning)

3. Disturb sleep ( woken with burning pain, tingling & numbness)

4. aggravated by daily activities eg. driving, holding a book or the

phone, and combing the hair

5. Hanging arm over the side of the bed/ shaking the arm to relieve
the symptoms

6. Loss of function: trouble pinching/grasping onto objects.

7. Advance case - clumsiness & weakness

8. Tinels sign/ Phalen test +ve

9. Late case- wasting of thenar muscles, weakness of thumb
abduction & loss of sensory in median nerve territory
 Penyebab
Tidak jelas
Penebalan jaringan ikat: rheumatism (RA,
OA, gout), gangguan metabolisme (DM,
acromegali, hypothyroidisme)
Infiltrasi ligamen, seperti penyakit amiloid
Retensi cairan, seperti kegemukan,
kehamilan
Trauma atau trauma kronik pergelangan
tangan
Tumor
Herediter, berupa sempitnya terowongan
karpal
 ETIOLOGY
Anything that causes swelling on the Tendons or produces repeated
pressure on the Median Nerve can lead to CTS.

Repetitive Motion-workplace/ hobbies: typing, knitting, cooking

(excessive exercise of finger-swelling of tendons/synovial sheaths)

Genetic Predisposition -differences in the amount of lubrication of

the Flexor Tendons of the wrist

Injuries And Trauma -swelling of the tendons / # of wrist bones

Tenosynovitis inflammation/infection of the synovial sheath

Medical / Physiological -Thyroid Diseases, Amyloidosis, Gout,

Rheumatoid Arthritis, chronic renal failure and Diabetes, hormonal
changes relating to Pregnancy, Menopause and the use of oral
contraceptive pills & alcoholics.
 PROGNOSIS
Baik: hilang dlm beberapa
bulan/tahun
Buruk: bertambah berat & ada
kelainan/penyakit yg
melatarbelakangi
Biasanya manifestasi hanya
pada ggn sensorik lebih baik
drpd yg disertai ggn motorik
No Stadium Gejala Tanda-tanda

1 Asimptomatik Tidak ada Tidak ada

(Sub klinis) Tes Phalen (+)
Tes Tinel (+)

2 Ringan- sedang Ada, Tes Phalen (+)

intermiten Tes Tinel (+)

3 Berat Kontinyu (+/-) Tes Phalen (+)

(Simptomatik menetap) Tes Tinel (+)
Kadang defisit
neurologis (+)
4 Berat sekali Selalu ada Tes Phalen (+)
Tes Tinel (+)
Defisit neurologis (+)
Atrofi otot-otot thenar
 Investigation
Acute CTS can be diagnosed through history
and physical examination alone .

Electrodiagnostic test (ncs)- slowing of nerve

conduction across the wrist
Sensory latency of greater than 3.5
millisecond
Motor latency of greater than 4.5
millisecond
Pemeriksaan khusus
Tes Phalen PF
Tes Tinel Perkusi
Tes Prayer DF
Tes fungsional otot-otot
thenar
Tes diskriminasi 2 titik
Wasting of thenar muscle
 a. Tes Phalen
Cara : Pergelangan tangan
diposisiskan fleksi palmar
maksimal selama min. 30 detik.
Hasil : positif (+), bila pasien
merasa kesemutan / parestesia
- < 30 detik,

- digerakkan setelah palmar fleksi

Signs of carpal tunnel syndrome-
special test 1

Phalens test further reduce the

Phalens sign (left) space of carpal tunnel, thus
aggrevates the compression. +ve if
Reversed Phalens pt felt tingling sensation within 1 min
sign of the test
 c. Tes Prayer
Cara : Pergelangan tangan
diposisiskan ekstensi dorsal
maksimal selama min. 30
detik.
Hasil : positif (+), bila

pasien merasa kesemutan /

parestesia
 b. Tes Tinel
Cara : memberikan
ketukan ringan pada n.
medianus, melalui fleksor
retinakulum di lipat
pergelangan tangan, tepat
pada tendo palmaris longus.
Hasil : positif (+) apabila
timbul nyeri kejut di dalam
tangan serta parestesia di
dalam jari.
 Signs of carpal tunnel
syndrome-special test 2
Tinels sign
Tapping along the median nerve will produce a tingling
sensation in patient with carpal tunnel syndrome
Signs of carpal tunnel
syndrome-special test 3

Median
Compression test
Examiner press his/her
hand on patients wrist
then flex patients wrist

The test is positive if patient

feels tingling sensation/
current at the median
nerve distribution area
 Terapi
Umum: simptomatis (fisioterapi)
Medis: penyakit/kelainan yang
melatarbelakangi (penurunan
berat badan, obat diuretik, dll)
Operatif: irisan pd lig. Carpi
transversum (hasil baik, 90%
nyeri/keluhan akan hilang)
 Treatment
Early:
-avoid compromising postures of the affected limb
-light weight splint to prevent wrist flexion
-corticosteroid injection into the carpal canal
(temporary relief pain)
Surgery:
- Open surgical division of the transverse carpal ligament
- Endoscopic carpal tunnel release + postop.
rehabilitation
 Fisioterapi
Sesuai problematik dari hasil pemeriksaan
Causatif: menghilangkan penekanan: US
Simptomatik:
mengurangi nyeri
Heating: SWD, MWD, IR, Parafin, hot
pack/rendaman, US kontinyu, Laser
Pemblokiran impulse nyeri: TENS, AFM

Relaksasi/sedasi: pasif ROM, gentle massage

Mobilisasi saraf

ggn motorik
Terapi latihan (tu pada otot-otot thenar)

Mencegah indirect impairment

Pemakaian splint (wrist hand orthose)
Latihan fungsional
Supportif/edukasi
Mobilisasi saraf u/ n. Medianus :
Skapula Depresi
Bahu Abduksi + Ekso
Siku Ekstensi
Lengan bawah Supinasi
Pergel tangan Ekstensi
Jari-jari (ibu jari) Ekstensi
Gerakan ABDUKSI BAHU
 Modalitas FT
A. ULTRA SOUND
B. TERAPI LATIHAN
C. TERAPI SUPORTIF
 US pada CTS
Pengaruh gelombang US pada kasus CTS :
(Wads worth, 1981)
Dapat mempercepat proses inflammasi
normal dengan meningkatkan produksi
dan pelepasan wound-healing factors.
Dapat meningkat proses sintesa collagen
dan meningkatkan permeabilitas
membran sel, hal tersebut akan
menyebabkan lebih banyak collagen
yang terbentuk dan juga meningkatkan
tensile strength pada ligamen.
 Dapat memperbaiki extensibilitas
jar.collagen yang telah terbentuk
setelah proses inflamasi melalui
mobilisasi matriks jar. Collagen.
Dapat terjadi capillary hyperaemia
dengan pelepasan histamin-like
substances yang akan membantu
pengangkutan dan mengurangi
pengaruh algogenic chemicals
yang dihasilkan selama prose
inflamasi, sehingga dapat
mengurangi nyeri.
 DOSIS
Karena letaknya yang superficial dan
banyak terdapat tendon serta ligamen,
sehingga US diberikan dengan:
Frekuensi = 3 MHz
Intensitas = < 0,3 W/cm2 ( intensitas
rendah)
Continuous
Waktu terapi = luas area : era
Pada area ligamentum carpi tranversum
Pemberian terapi tergantung pada
kondisi penyakit.
Akut = tiap hari
Kronis = 2-3 kali / minggu
 Terapi Latihan Pada
CTS
1. Latihan gerakan aktif
o Fleksi-Extensi pergelangan tangan
o Ulnar & Radial deviasi pergelangan
tangan
2. Latihan Gerakan Pasif
o Fleksi-Extensi pergelangan tangan
o Ulnar & Radial deviasi pergelangan
tangan
3. Resisted Exc
Fleksi-Extensi pergelangan
tangan
4. Peregangan
o Peregangan pergelangan tangan
o Peregangan n.medianus
 EDUKASI
meredam tangan dalam air
hangat kuranglebih 10 menit
setelah bangun tidur dan
aktifitas
Menekankan tangan ke arah
tembok dan leher heterolateral
(8 hitungan 3 kali pengulangan)
Penguatan fleksi 15-16 kali per
hari
Thank You