A brachial plexus schematic, radial nerve sensory distribution, and . 271 (1-2):75-9. HomeCEU Dynamic splinting. Lubahn JD, Cermak MB. Many patients with radial nerve palsy will see complete recovery or symptom relief after treatment. Clinical presentation varies according to the nerve affected i.e. In posterior interosseous nerve syndrome, institute conservative treatment for 6-12 weeks. lipoma, ganglion), local edema or inflammation, this guideline focuses on RTS and . Chapter Objectives. Top Contributors - Lucinda hampton, Chrysolite Jyothi Kommu, Wendy Walker, Wajeeha Hassan, Rachael Lowe, Naomi O'Reilly, Kim Jackson and Vidya Acharya. 128 0 obj <>/Filter/FlateDecode/ID[<8EBCCAFA1D89EC860FF6D35F03542851><94C4BBB22AE4A94A900CEFE003003A29>]/Index[106 37]/Info 105 0 R/Length 110/Prev 428111/Root 107 0 R/Size 143/Type/XRef/W[1 3 1]>>stream 5. Urgent Care Services, Numbness from the triceps down to the fingers, Weakness or inability to control muscles from the triceps down to the fingers, Wrist drop when the wrist hangs limply and the patient cannot lift it. Physical examination findings should be used in combination with electrodiagnostic studies to increase the accuracy of a carpal tunnel syndrome diagnosis before surgical intervention. It also helps with movement and feeling in the wrist and hand. At this point, the incision joins the anterolateral approach recommended for exposure of the radial nerve at the elbow. Other complications are those that can occur with any form of surgery, including infection, wound dehiscence, keloid formation, and incomplete recovery of function for no apparent reason. Local application of steroids or iontophoresis is used. 2009 Apr. Seddon H. Surgical Disorders of the Peripheral Nerves. To explore and release the nerve in the supinator and surrounding area, the incision is started 20-25 cm above the elbow and is continued to the dorsum of the forearm. Protective splints are frequently needed, and sensory reeducation and desensitization are the mainstays of treatment in the postoperative phase. The primary clinical finding is pain in the proximal volar forearm. [QxMD MEDLINE Link]. Splint or cast: You may need a splint or cast to help support your wrist and hand while the radial nerve heals. At the elbow, the radial nerve divides into a superficial branch (sensory only) and a deep branch (posterior interosseous nerve [motor only]; Figure 4).42 Entrapment of the superficial radial nerve causes pain 3 cm to 4 cm distal to the lateral epicondyle along the proximal lateral forearm with activity or during sleep. 2014 Jun 1;133(6):1420-30. Most cases improve with conservative treatment; however, nearly 20% of . Ulnar nerve:Rooted in C8-T1, it allows for fine motor control of the fingers. The duration of treatment was 2 hours; this protocol . In sensory stimulation pinching and tapping, brushing and icing are regularly used. Great care must be exercised in exposing the posterior interosseous nerve. In addition, functional splints help prevent contracture and improve function as signs of nerve healing follow. Appointments 866.588.2264 Appointments & Locations Request an Appointment Function Anatomy Vol 4: 3162-225. The favored approach begins posterolaterally in the interval between the deltoid and the lateral head of the triceps. Basics of Peripheral Nerve Injury Rehabilitation, Basic Principles of Peripheral Nerve Disorders, Dr. Seyed Mansoor Rayegani (Ed. Fax: 507.288.1225 endobj A 6- to 12-week period of expectancy is indicated to allow the swelling and palsy to subside. [QxMD MEDLINE Link]. 2013. 2015 Jun. endstream endobj 107 0 obj <> endobj 108 0 obj <> endobj 109 0 obj <>stream The first is posterior to the clavicle, occurring with clavicular fractures. Radial nerve palsy is a condition that affects the radial nerve and if damage to this nerve occurs, weakness, numbness and an inability to control the muscles served by this nerve may result. The AANEM offers your company the chance to meet its marketing objectives through participation at the AANEM Annual Meeting or throughout the year by advertising in newsletters, on the website, or supporting AANEM's educational products. The below video clips give a good guide to proper handling techniques involved in passive ROM. Treatment of radial nerve palsy may include: Medication Your physician may recommend prescription or over-the-counter medication to decrease pain associated with radial nerve palsy. At the elbow, the ulnar nerve passes posteriorly and superficially to the medial epicondyle within the cubital tunnel, leaving it susceptible to compression from external and internal sources. The ulnar nerve branches off the brachial plexus nerve system and travels down the back and inside of the arm to the hand. Radial Nerve. Treatment is dependent on the site and cause of the lesion. The radial nerve begins (originates) at the neck and travels through the entire length of the arm. [QxMD MEDLINE Link]. Li H, Cai QX, Shen PQ, Chen T, Zhang ZM, Zhao L. Posterior interosseous nerve entrapment after Monteggia fracture-dislocation in children. Chapter 1, Part 2, Section 150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders, Section 160.12 Neuromuscular Electrical Stimulator (NMES), 160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell's Palsy), Section 160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation Providing your location allows us to show you nearby locations and doctors. This is caused by compensatory actions of the extensor carpi radialis longus, which is not innervated by the posterior interosseous nerve.30 These findings are usually from compression by space-occupying lesions (most commonly lipoma) or synovitis of the elbow.30. The innervation to the glenohumeral joint is complicated and overlapping: the axillary, suprascapular, supraclavicular, and lateral pectoral nerves are chiefly . At the wrist, the superficial radial nerve is susceptible to injury by compression because it runs superficially to the flexor retinaculum. Henry M, Stutz C. A unified approach to radial tunnel syndrome and lateral tendinosis. Available from: Lundborg G. A 25-year perspective of peripheral nerve surgery: evolving neuroscientific concepts and clinical significance. In the absence of traumatic injury, initial treatment of nerve injuries should be conservative and include patient education, physical therapy, and activity modification. For proximal nerve lesions, a sterile tourniquet may be needed, and the lateral decubitus position is preferred. for: Medscape. Mild-to-severe deformities of the hand: Ongoing radial nerve problems can cause joint and muscle stiffening or muscle atrophy. endobj been written for Occupational Therapy on traumatic injuries to the radial nerve have been based on studies made during the last war and about isolated industrial cases. Other findings may include cramping, decreased grip strength, or paresthesia in the first three digits.22, Pronator and anterior interosseous nerve syndromes are the two most common compression neuropathies of the median nerve occurring around the elbow.22 Pronator syndrome occurs with compression of the median nerve between the two heads of the pronator teres (Figure 3)42 or under the proximal edge of the flexor digitorum superficialis (see a video about pronator syndrome). The ultimate goal is not simply to reduce pain but to achieve better QOL. Anti-inflammatory drug therapy Surgical treatment should only be considered if: 1. Splint or Cast It may take weeks to months for a nerve to heal after treatment. Additionally, a lesion proximal to the split, known as radial tunnel syndrome, may have both the motor and sensory symptoms described above. The incision is very superficial, and any area of compression is released. Medications that can lessen muscle tightness might be used to improve functional abilities, treat pain and manage complications related to spasticity or other cerebral palsy symptoms. Carpal tunnel syndrome is the most common with a prevalence of 3% in the general population (15% in the workforce).1 Cubital tunnel syndrome is also relatively common, with one U.S. metropolitan area reporting a prevalence of 1.8% to 5.9%.2 Overall prevalence of peripheral neuropathies in the general population is unclear. Depending on the severity and the cause, either surgical or non-surgical treatment may be recommended. Care must be taken during the dissection because 5-6 cm above the elbow, branches are given off to the brachioradialis and the extensor carpi radialis longus and brevis. [QxMD MEDLINE Link]. Available from: Kelloge community college. I propose to discuss briefly some of the advances in treatment made dur-ing the past five or six years. Radial nerve palsy- Inability to extend the wrist, digits, and thumb and weakness with supination due to loss of the supinator, ECRL, ECRB, ECU, EDC, APL, EPL, and EPB. 1173185. Principles. 2 The management includes early treatment with oral corticosteroids and eye care to prevent corneal injury. Schedule appointments, review lab results, financials, and more! If needed, both approaches can be employed together for wide exposure. Terms and Privacy. In the upper extremity, the brachial plexus branches into five peripheral nerves, three of which are commonly entrapped at the shoulder, elbow, and wrist. The long thoracic nerve is vulnerable to traction injury at its nerve roots located at the middle scalene.20 Other mechanisms of injury include direct blows to the nerve as it exits the pectoralis muscle at the fourth or fifth rib, repetitive stretching (e.g., throwing a baseball, serving a volleyball), or iatrogenic damage (e.g., during a radical mastectomy).20,21 Injury to this nerve is the most common cause of scapular winging.20,21. Once the nerve is exposed, it is followed proximally to the distal margin of the supinator, where numerous branches are given off. 2007. Girdlestone G. R."Occupational Therapy for the Wounded" Rehabilitation of the War Injured 1943. hUmo0+b~iBJTKNB|HBT+~wNoPEs>. i 9Cdd$x g.J\}"'%@,9.w4OmdFCuVq;W!;Eu" c |jN#7kv,x^[[s:4+4&4NC '}`F9@m?_.MVW18 ~6$1:4fO(%aS!=At3vwotwir[$,I 6J/Q*L9IHi\!EULHU^_G8*6aWq;+S$ljwNuRV_mj6jMnZ5q=WO/ xV1v9-y ?ms9'Q"yGa AIyq"f:$;&L(..tlyFK}8D 5HV+f>0'QJU?$dy$=)^`lkjwvzx6`FOOWE|G^~"ZhVS P"x8R!W/hx, r$ s`o2:@nrk9~uq}C"kZQ oX2o>S^?35\[dKIv/~r!fa'p~mCQlx5's^Sx` ld6 Severing or stretching the nerve is not uncommon while attempting to extricate the nerve in the middle and distal thirds of the arm from a bony spicule or healing callus. HWK\@k~@"4d'3|866v:U}{S|b~~_~?5]? Long Thoracic Nerve. It also provides sensation to the back of the hand. 2nd ed. [Full Text]. It controls muscles in the back of the arm. 2008. The most severe form of nerve injury (neurotmesis) rarely results from nerve entrapment. The tendon of palmaris longus was transferred to the tendon of extensor pollicis longus and tendon of flexor carpi radialis was transferred to the tendon of extensor digitorum communis. Your Care Instructions The radial nerve runs down the arm. Ritts GD, Wood MB, Linscheid RL. Radial Nerve Palsy Medical Therapy Conservative treatment for radial nerve damage or palsy depends on the severity of the condition. Eur Radiol. Phys Med Rehabil Clin N Am. Please confirm that you would like to log out of Medscape. 2007 Dec. 15 (12):757-64. J Neurol Sci. Brachial plexopathy is an injury of the brachial plexus, that is commonly caused by trauma. Occupational risks: Jobs that require repetitive motion and awkward postures or working positions may increase the risk of radial nerve palsy. It proceeds distally between the biceps and the lateral head of the triceps, crossing the lateral intermuscular septum 10 cm proximal to the lateral epicondyle. The radial nerve is one of the major nerves of the arm. Clinical Neurophysiology (EMG) Fellowship Portal, American Association of Orthopaedic Surgeons. Sunderland S. Nerves and Nerve Injuries. 5 0 obj A Lee Osterman, MD Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson UniversityDisclosure: Nothing to disclose. C23P7 The nerve roots of the brachial plexus combine to form trunks (superior [C5, C6], middle [C7], and inferior [C8, T1]) that pass between the anterior and middle scalene muscles. 2 Describe a peripheral nerve's response to injury and repair. Jatoi M. Role of sonography in assessment of upper extremity nerve pathologies. Custom orthosis used to straighten the fingers and support the wrist. %%EOF 4 0 obj Nerves typically heal at a rate of 1 mm/day. From proximal to distal, its elements are the . var d=new Date(); yr=d.getFullYear(); document.write(yr); American Association of Neuromuscular & Electrodiagnostic Medicine encoded search term (Radial Nerve Entrapment) and Radial Nerve Entrapment, Orthopaedic Care During COVID-19: Utilization of Telemedicine in Orthopaedic Surgery During the COVID-19 Pandemic, Acute Ulnar Neurapraxia and Carpal Tunnel Syndrome in the Context of a Distal Radius Fracture. With neurotmesis, the results are unsatisfactory even with surgical repair. It controls the muscles that help straighten the elbow, wrist and fingers. [1]A 2018 study found the use of TENS was most beneficial if delayed to one-week post-trauma, the use of 100hz being most beneficial.[14]. In the relearning of functional tasks, the brain is utilized to regain visio-tactile and audio-tactile interaction. :MnpJBSMT]bal`$*U]K. A mild Erb's palsy can be treated with therapy while severe cases may require surgery. PROM lower extremity. In the absence of traumatic injury, initial treatment of nerve injuries should be conservative and includes patient education, relative rest, and activity modification. Clin Ter. Proprioception deficits can be improved using eg exercise balls, balance pads for WB activities, juggling balls for upper limbs, yoga, Tai-chi.[20]. Ultrasonography can evaluate for a variety of changes that occur in peripheral nerve entrapment syndromes. These exercises help make your bones and muscles strong and flexible. 95 (2):114-8. 2006. Processed nerve allografts for peripheral nerve reconstruction: a multicenter study of utilization and outcomes in sensory, mixed, and motor nerve reconstructions. Its fibers are derived from the fifth, sixth, seventh, and eighth cervical and first thoracic nerves. 2022 Feb 8. 1 Identify the components of a peripheral nerve. 3 0 obj Following a first episode, return to play is acceptable when there is complete resolution of symptoms and cervical spine injury has been excluded.32,39 Persistent or recurrent stingers prompt additional evaluation for cervical stenosis or other bony abnormalities.32. Approximately 70% of radial nerve palsy cases have been reported to be resolved with conservative treatment. J Hand Surg Eur Vol. To properly treat a client with neuropathic pain this must be respected. Our 24/7 inpatient neurology and neurosurgery services, as well as our outpatient services, Home Health, physical and occupational therapy services are available to help treat people with radial nerve palsy. It then travels under the arm close to the armpit (axilla). Nerve conduction studies: These tests measure how well individual nerves can send an electrical signal from the spinal cord to the muscles. Radial nerve palsy hand therapy By Nigel Chua Hand TherapyBody parts: Upper Arm, The radial nerve is one of the major nerves of the arm. And 2001 AAN practice perameter suggested that the use of acyclovir for to treatment of Bell palsy is only possibly valid and that therapy with which agent alone is not effective in face recovery. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. PROM upper extremity. Stanley J. Weakness or inability to straighten the wrist and/or fingers are the primary symptoms of radial nerve palsy. <>/Font<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 540 720] /Contents 5 0 R/Group<>/Tabs/S>> This is known as radial neuropathy, or sometimes Saturday night palsy.17 Compression also occurs at the axilla, as it passes through the triceps brachii lateral head.41 The nerve innervates the extensors of the wrist and fingers, causing wrist and finger drop. 2nd ed. [4, 6] <>>> Electrodiagnostic testing should be used as an adjunct to physical examination and imaging to help confirm the diagnosis of peripheral nerve injury, establish the severity of injury, and monitor progression of nerve damage. Data Sources: PubMed, Essential Evidence Plus, the Cochrane database, and the Agency for Healthcare Research and Quality were searched using key terms peripheral nerve entrapment, peripheral nerve injury, radial nerve, median nerve, ulnar nerve, and treatment of peripheral nerve injury/entrapment. We then use advanced diagnostic procedures and technology to effectively diagnose, inform treatment and carefully monitor the condition. After a diagnosis of a peripheral nerve injury, a full subjective and objective examination is required to get a clear picture of the way the lesion is affecting the client. Nerve regrowth in the peripheral nervous system is dependent on the type of injury. A health care practitioner may order a diagnostic test to determine the extent of nerve involvement. endstream endobj startxref Pabari A, Lloyd-Hughes H, Seifalian AM, Mosahebi A. Nerve conduits for peripheral nerve surgery. It develops insidiously over months to years, often exacerbated by activities with the arm in pronation, such as repetitive hammering or a backhand swing with a tennis racket. The initial treatments for radial tunnel syndrome and posterior interosseous nerve syndrome are similar. Lo YL, Fook-Chong S, Leoh TH, Dan YF, Tan YE, Lee MP, et al. Proximal median nerve entrapment is rare. New York: Churchill Livingstone; 1975. McMurrich Kinesiology Notes for Second Year Occupational Therapy Students, University of Toronto. 2015 Aug. 26 (3):539-49. Symptoms include pain and paresthesia in the ulnar nerve dermatome, especially in the fourth and fifth digits of the hand.17,18,35 This is exacerbated by repetitive elbow flexion, which compresses the area of the cubital tunnel. ), ISBN: 978-953-51-0407-0, InTech, Available from: Dr. Simon Freilich. In these cases, the nerve may be encased in scar, buried in the fracture, or surrounded by callus. Before reading this article it would be advised to have a good knowledge of the type of lesion and the denervation consequences[1]. At the wrist, the superficial radial nerve is susceptible to injury by compression because it runs superficially to the flexor retinaculum. See video clip below for examples. J Am Acad Orthop Surg. 2006 Oct. 31 (5):542-6. Splinting and range of motion exercises of the hand are encouraged to prevent contracture formation. General anesthesia without complete paralysis is preferred for proximal lesions so that intraoperative nerve stimulation may be utilized. Recovery time depends on how badly the radial nerve was damaged. Principles of tendon transfers. work capacity = (force) x (amplitude) motor strength will decrease one grade after transfer. . 1998 Nov-Dec. 6 (6):378-86. Copyright 2023 American Academy of Family Physicians. Medications. Patients may have point tenderness over the ulnar nerve and a positive Tinel sign.35 Late findings are motor weakness of finger and thumb abduction.35, Median Nerve. [QxMD MEDLINE Link]. We know the Covid-19 pandemic is causing immeasurable stress to NM disease patients. Protective splints may be utilized along with graduated muscle stretching and then strengthening. [2] Watch the below to grasp the concepts of nerve damage and repair [3] Clinical Presentation Discover MyChart, a free patient portal that combines your Baptist Health medical records into one location. Physical therapy for radial nerve palsy following the transfer of tendons is described in this report. De quervain tenosynovitis of the wrist. In every way, we work to demonstrate the utmost in excellent care to those who trust us with their health. Rotator cuff injury can present similarly; therefore, magnetic resonance imaging, ultrasonography, or electrodiagnostic studies are usually appropriate to determine the specific etiology if initial radiography is inconclusive.18,33, Radial Nerve. %PDF-1.5 Erb's palsy can occur at any time but is the most common brachial plexus classification injury at birth. 2016 Feb 1;87(2):188-97. Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior transposition compared with simple decompression for treatment of cubital tunnel syndrome. [QxMD MEDLINE Link]. It can be difficult to release or let go of objects grasped by the affected hand. These include: fracturing your humerus, a bone in the upper arm. The radial nerve, the largest branch of the brachial plexus, is the continuation of the posterior cord of the brachial plexus. Radial tunnel syndrome. Specific nagging ache or pain more than 10 days? Radial Nerve. Radial nerve palsy occurs in 6% to 18% of humeral shaft fractures. Muscle or nerve injections. Movement and sensation of the wrist and hand. Open exploration is indicated if there is no relief of the palsy or if it is felt that the nerve may be entrapped between the fracture fragments. J Hand Surg Br. A Physiotherapist can employ other modalities that show in various studies to be of benefit as complementary medicine for pain relief[1]. $~] This can lead to subsequent degeneration distal to the lesion. Rehabilitation emphasizes motor and sensory reeducation and must be tailored to the individual patient. Physical Therapy Your physician or physical therapist may prescribe exercises to strengthen your muscles and increase your range of motion. If the humerus has been injured, splinting can be used to help keep the limb stable and allow the body to heal. These exercise Radial Nerve Flossing - Great Results - Ask Dr. Abelson Help for Forearm Pain with Radial Nerve. Ulnar Nerve. Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine; Clinical Professor of Surgery, Nova Southeastern School of Medicine If symptoms continue unabated after 4-6 months and the diagnosis is clear, consider neurolysis or neuroma excision, followed by burying of the nerve ends in bone. With axonotmesis, the results, even after early release, will not be as favorable as those with neurapraxia; complete return of function is rare. If the injury is more severe (axonotmesis), recovery will take longer, and the timetable is determined by how far the regenerating axon must grow to reinnervate the paralyzed muscles. Radial tunnel syndrome is a painful condition caused by pressure on the radial nerve one of the three main nerves in your arm. Shoulder dislocations, repetitive use injuries, humeral neck fractures, and local pressure (e.g., from crutches) are mechanisms of injury.19 Damage to the axillary nerve results in paresthesia or pain of the lateral shoulder and weakness in shoulder external rotation, extension, abduction, and forward flexion. Orthop Traumatol Surg Res. The ulnar nerve transmits electrical signals to muscles in the forearm and hand. 2005 May. <> See permissionsforcopyrightquestions and/or permission requests. endstream endobj 111 0 obj <>stream (219):201-5. They are useful in bridging the gap between nerves. The radial nerve begins (originates) at the neck and travels through the entire length of the arm. This condition may go away over time as accompanying injuries heal, cysts or tumors are removed, or awkward postures are corrected. Electrodiagnostic testing is helpful to confirm the diagnosis, determine severity, and monitor progression of nerve damage. k/?^4JWm^0C+1! K9O)3?? Mechanisms of nerve injury can include direct pressure, stretch, overuse of a joint, or microtrauma. Jacobson JA, Fessell DP, Lobo Lda G, Yang LJ. When there is compression or injury to the radial nerve, the muscles supplied by this nerve may appear weakened and sensation may be affected. The radial nerve aids arm, wrist, hand and finger movements. A range of motion (ROM) exercise program is started at 1 week and is continued throughout treatment. . Robson AJ, See MS, Ellis H. Applied anatomy of the superficial branch of the radial nerve. <> The incision continues in the biceps-brachialis interval. A splint or cast helps extend your fingers and wrist so you can use them as much as possible. Initial treatment is conservative, with surgical options available for refractory injuries or entrapment caused by anatomic abnormality. and Cho, M.S., 2012. A major complication of radial nerve entrapment is injury to the nerve during surgical exploration. Functional disability due to nerve lesions is intertwined with the severity of the lesion. Toros T, Karabay N, Ozaksar K, Sugun TS, Kayalar M, Bal E. Evaluation of peripheral nerves of the upper limb with ultrasonography: a comparison of ultrasonographic examination and the intra-operative findings. Yameen F, Shahbaz NN, Hasan Y, Fauz R, Abdullah M. Cotler HB, Chow RT, Hamblin MR, Carroll J. Su HL, Chiang CY, Lu ZH, Cheng FC, Chen CJ, Sheu ML, Sheehan J, Pan HC. You may have arm weakness, particularly if you're pushing something away. Phone: 507.288.0100 Table 2 summarizes specific physical examination findings and treatment options associated with each nerve.1338, Brachial Plexus. Reza Salman Roghani and Seyed Mansoor Rayegani (2012). In certain cases, your physician may recommend surgery to remove a cyst, tumor or broken bone pressing on the nerve or repair the nerve itself. A splint or cast can support the wrist and hand while the radial nerve heals. When muscle strengthening exercises can commence it is important not to damage the healing nervous tissue: if pins and needles, numbness or increased pain occurs the exercise is too hard and can have a negative effect on healing. The opinions and assertions contained herein are the private views of the authors and are not to be construed as the official policy or position of the U.S. Air Force, the Department of Defense, or the U.S. government. [QxMD MEDLINE Link]. The result of any surgery is dependent on the damage to the nerve preoperatively. Part of the peripheral nervous system, the radial nerve runs down the back of the arm from the armpit to the hand. xXMs6kFG "v:8OLl$!ewP6)KvPBb[0/ $@RAb%H 7x88Ux s"qKbq\YppEY*6(5UppW"umoWlUGXM^ In8 )8`6''t9rT?^rNt\E J Bone Joint Surg Br. I T| With findings of severe weakness or multiple nerve involvement, imaging should be performed immediately; otherwise, it can be initiated after six to eight weeks of conservative treatment.4750 A summary of imaging indications is provided in Table 3.4749, Electrodiagnostic testing is helpful to confirm the diagnosis, determine severity, and monitor progression of nerve damage.50 This can be especially helpful in presurgical planning for more common nerve entrapments, such as carpal tunnel syndrome and cubital tunnel syndrome.51,52 Nerve conduction studies evaluate the speed and time of conduction across the nerve; EMG measures the tested muscle's response to stimulation.50 Changes to both nerve conduction studies and EMG will occur depending on the chronicity and degree of injury, so they should be ordered simultaneously.5052 The ability of EMG or nerve conduction studies to detect nerve injury is variable and requires subjective interpretation; they are best used as an adjunct to physical examination and imaging.50, Magnetic resonance imaging and ultrasonography are used for evaluating deeper soft tissue pathology and bony abnormality compressing a nerve or for increased signal and nerve thickness indicative of nerve injury.40,53 Magnetic resonance imaging can identify local muscular atrophy consistent with denervation.53 Ultrasonography can evaluate for a variety of changes that occur in peripheral nerve entrapment syndromes.47,48 A useful point-of-care application of ultrasonography is determining specific sites of entrapment by compression with the ultrasonography transducer to recreate symptoms.47,48 Specifically, ultrasonography is helpful in the diagnosis of carpal tunnel syndrome; one meta-analysis found that a cross-sectional area of the median nerve at the carpal tunnel inlet of 9 mm2 or more is 87.3% sensitive and 83.3% specific for carpal tunnel syndrome.49 Accurate interpretation is dependent on sonographer experience, and correlation to EMG has yet to be shown.49, In the absence of traumatic injury, initial treatment of nerve injuries should be conservative and includes patient education, relative rest, and activity modification.1322,2931,3335,37,38 Physical therapy, yoga, and acupuncture may be helpful, although conclusive evidence is lacking.1322,2931,3335,37,38 Surgical options include nerve decompression, exploration for anatomic causes and treatment, or nerve transfers.54,55 Despite low complication rates, these procedures are often associated with lack of full resolution of symptoms, even when patients complete a rehabilitation program.54,55 Carpal tunnel syndrome is one of the few entrapment neuropathies to have evidence-based treatment.1316,2428 Conservative treatment options and surgical indications for each of the nerves are listed in Table 2.1338, This article updates a previous article on this topic by Neal and Fields.12.

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