b{xw|v

axz
Dr Mohamed Sobhy

Ain Shams University Date

[Orthopedic Neurology]

Page | 439

Neuro-Anatomy
Neuron:
Is the specialized cell of the nervous system that capable of electrical exciation (action
potential) along their axons

440 | Page

Peripheral nerve has a mixture of neurons:

1]. Motor
2]. Sensory
3]. Reflex
4]. Sympathetic
5]. Parasympathetic
Types of fibers: A (, , , ), B, C

Motor
Neuron AHC
Anterior
Root
Tract
1- Direct pyramidal
2- Indirect pyramid
Fibre

[Orthopedic Neurology]

Motor (12-20 m)

Sensory
Dorsal root ganglia
Dorsal root
1- Spinothalamic (Pain, temp,
crude)
2- Lemniscal (DC)
(proprioception, fine touch)
Propriocep
(12-20 m)
Touch, vib
(5-12 m)
fast pain, temp (2-5m)
C Slow pain, crude (0.2-2m)

Ms reflex
AHC
Ant

sympathetic
IHC
Ant

Parasymp
relay at organ
Ant

Stretch reflex
arc from ms
spindle

fibers

B preganglionic B fibres
C Postganglionic

A fibers are most affected by pressure

C fibers are most affected by anesthesia and are the principle fibers in the dorsal root
GroupToFor m
Neurons are surrounded by endoneurium fascicles surrounded by
GroupToFor m
perineurium nerve surrounded by epineurium
Muscle:
Motor unit is the unit responsible for motion and formed of the group of ms fibers and
neuromuscular junction and feeding neuron
Ms fibers types:
1- Smooth ms fibers
2- Cardiac ms fibers
3- Skeletal ms fibers:
Type I: slow twitching, slow fatiguability, posture
TypeII: fast twitiching, fast fatigue
MS CONTRACTION: is the active state of a ms, in which
there is response to the neuron action potential either
by isometric or iso tonic contraction
ISOMETRIC CONTRACTION: is the contraction in there is
y tension out change in the ms length
ISOTONIC CONTRACTION: is the contraction in here is a
change in the length of the ms out change in the tone
MS TONE: is the resting state of tension
MS CONTRACTURE: is the adaptive structural changes in a
ms prolonged immobilization in a shortened position,
in the form of shortening and fibrosis
MS WASTING: is the adaptive structural changes in a ms prolonged disuse of denervation,
in the form of hypoplasias and hypotrophy, and eventually shortening and fibrosis
SPASTICITY: Abnormal y contraction of a ms in response to stretch. Growth of ms is
impaired
RIGIDITY: Involuntary sustained contraction of a ms not stretch-dependent. Growth of ms is
fair

[Orth
hopedic Ne
eurology]

Page | 441

Sa
arcomere
A band ......................................Actin + myocin (= H + ove
erlap zone)
H band .....................................Myocin
M line ........................................Myocin Intercon
nnect
I band
b
........................................Actin
Z line
l
.........................................Actin Anchors

Contraction
Isoto
onic

Deffinition
Con
nstant ms te
ension & z
length (dynam
mic)
Con
nstant ms le
ength (staticc)
Max contractio
on constan
nt
velo
ocity over a full ROM
In the
t presence
e of O2
In the
t absence
e of O2
ou
ut O2

Isom
metric
Isok
kinetic
Aero
obic
Ane
erobic
ATP
P hydrolysiss

Phasses
Conccentric: ms shortens du
uring contra
action
Eccentric: ms len
ngthens du
uring contraction
Conccentric
Eccentric
Reple
enishes 34 ATP
A via Kreb
bs
Glyco
olysis into la
actic and 2 A
ATP
ATP hydrolysis
h
to
o produce d
direct, fast en
nergy

Derrmatome:
o

Is th
he area of skin suppliied by a sp
pecific nervve root

Is th
he group of
o muscles supplied by
b a specificc nerve roo
ot

Is th
he area of bone and fascia supp
plied by a specific
s
nerve root

Tea
aring or inju
ury of a no
on contracttile motion
n unit, e.g. Ligament

Tea
aring or inju
ury of a co
ontractile motion
m
unitt, e.g. Musccle

My
yotome
Scle
erotome
Sprrain:
Stra
ain

442 | Page

[Orthopedic Neurology]

Muscle injuries:
1]. Muscle Strain:
Occurs at Musculo-tendinous junction of the ms that cross 2 joint (e.g. gastroc,
hamstring)
First there is inflammation then ends by fibrosis
2]. Muscle tears:
Occurs at the Musculo-tendinous junction
During the higher eccentric contractions & Heal by dense scarring
3]. Muscle soreness: During the higher eccentric contractions
4]. Muscle denervation: Causes atrophy and y sensitivity to acetyl-choline and fibrillation in
2wk
Tendons
COMPOSED OF:
1]. Collagen I .........................................80%
2]. Fibroblasts synthesis tropocollagens micro-fibrils sub-fibril fibril fascicle
3]. Loose areolar CT ..........................Endotenon epitenon paratenon
TYPES OF TENDONS:

a. PARATENON covered tendons rich capillary supply = better healing

b. Sheathed tendons .......................segmental bl.supply via mesotenon (VINCULA)

MUSCULO-TENDINOUS JUNCTION:
1]. Tendon
2]. Fibro-cartilage
3]. Mineralized fibrocartilage (SHARPEYS fibers)
4]. Bone
HEALING STARTS by fibroblasts and macrophages of the epitenon in 3 phases:
1]. ................................................................Initial fibroblastic phase: 10 days (weak)
2]. ................................................................Intermediate Collagen phase
30 days (most of

the strength is regained)

3]. ................................................................Late remodeling phase

strength is regained)

month

(maximal

Collagen tends to arrange along stress lines; so immobilization causes weak healing

Ligaments

COMPOSED OF:
1]. Collagen I (same ultrasturcture) ........ 70%
2]. Elastin
3]. Fibroblasts + Loose areolar CT
BL SUPPLY is uniformly arranged via the ligament insertion at bone
Types of ligamentous insertions:
1]. Indirect: .............................................superficial fr insert to periosteum @ acute angle
2]. Direct .................................................Deep fr insert to bone @ 90
BONY LIGAMENTOUS JUNCTION:
1]. Ligament
2]. Fibro-cartilage
3]. Mineralized fibrocartilage (SHARPEYS fibers)
4]. Bone
HEALING starts by fibroblasts and macrophages of the epitenon

Phase
1].Hemostasis
2].Inflammatory
3].Fibrogenesis
4].Remodeling

1].
2].
3] .

Time
10 min
10 days
30 days
6-18 mo

Process
platelet plug fibrin clot
macrophages debride granulation tissue
UMC fibroblasts strong type I collagen
Realignment & cross linking of collagen bundles

Strength
Weak
Weak
most strength regained
Max strength

LIGAMENTS GRAFTING:
Autografts: .....................................................Faster healing, no disease transmission
Allograft: .........................................................no donor morbidity but may transmit diseases
Synthetic: (Gortex, Leeds Keio) ................no initial weakness, but cause sterile effusion

[Orthopedic Neurology]

Page | 443

TendonTransfers
Definition
A tendon transfer is a procedure in which the tendon of insertion or of origin of the functioning

muscle is mobilized, detached or divided and reinserted into a bony part or onto another tendon,
to supplement or substitute for the action of the recipient tendon, in order to correct muscle
imbalance and keep the corrected position rather than to correct a deformity

Indications

1]. Irreparable nerve damage

2]. Loss of function of a musculotendinous unit due to trauma or disease
3]. In some nonprogressive or slowly progressive neurological disorders

Contraindications
1].
2].
3].
4].
5].
6].

Unstable joint
Stiff joint
Fixed deformity
Advanced arthritis
If affection of all muscles at the same degree
If no suitable tendon or muscle is available for transfer

Principles

Preoperative
1]. Age:
It is better to delay operations >5y so you can get cooperation in physiotherapy:
o If the patient is skeletally immature do tendon transfers (TT)
o If the patient is skeletally mature
do fusion + removal of appropriate wege TT
o If the patient is has talipes valgus
add stabilizing bony op. e.g. Grice Green or Evans
2]. Timing:
Early tendon transfers within 12 weeks of injury: If no chance of functional recovery, transfers
should be performed ASAP
Late tendon transfers -- If reasonable return of function not present for 3m after the expected
Following nerve injury repair, the date of expected recovery can be calculated by measuring the
distance between the injury to the most proximal muscle supplied, assuming a rate of
regeneration of 1mm/day
3]. Planning
Make a list of deficient functions
Make a list of available donor muscles
Availability of tendon for transfer:
o If many tendons are available
do tendon transfers for all deficient muscles
o If 2 tendons are available
do TT for the most crucial functional muscle
o If one agonist tendon is available
do TT to the middle line e.g. Tohen transfer
o If one antagonist tendon
do split TT & suture under equal tension
Operative
Joint:
1]. Should be stable
2]. Should be a freely mobile joint (free ROM)
3]. Should not have fixed deformity
4]. Should not have advanced arthritis

444 | Page

[Orthopedic Neurology]

Muscles:
1]. Adequate donor muscle Strength (G IV, V)
2]. Adequate recipient muscle Excursion:
o Wrist flexors ........................................... 33cm
o Finger extensor ..................................... 50cm
o Finger flexor ........................................... 70cm
3]. Adequate neurologic & blood supply
4]. Agonists better than antagonists
5]. Synergestic better than non synergestic
6]. Start Proximal then distal
Tendon
1]. Should be of an adequate Length
2]. Should pass in a Straight line
3]. Should pass through a Gliding Medium (the best is fat or superficial fascia)
4]. Should be sutured under Moderate Tension
5]. Should be Covered
6]. Better to suture tendon To Bone (pull-out technique)
Techniques
1]. Multiple short transverse incisions rather than long longitudinal incisions
2]. Careful tendon handling
3]. Joining the tendons
o End to end anastomoses
o End to side anastomoses
o Side to side anastomoses
o Tendon weave procedures can all be used
4]. Achieving proper tension - No general rule, but reasonable to place limb in the position of
maximal function of the tendon transfer and suture without tension
Postoperative:
1]. Protect the transferred tendon to avoid stretching
2]. Physiotherapy & training
Famous Transfers
Pronator teres to ECR
FCU to EDL
Palmaris longus to EPL (or split FCU)
ECRL to sublimis or profundus
Tibialis anterior & Peroneus brevis are preferred in the transfer as Tibialis posterior & Peroneus
longus are important for foot arch Skeletally immature with Varus (alone or with other
deformities)
In Drop foot (NO deformity) + skeletally immature Tibialis posterior is the ONLY tendon
available for transfer

[Orthopedic Neurology]

Page | 445

CerebralPalsy
Definition
Disorder of movement and posturing
Caused by static non progressive brain UMNL lesion
Acquired during the stage of rapid brain development (perinatal)

Classification
1- Spastic ............................................................................. (60%)
o
o
o

MOST AMENABLE TO SURGERY

UMNL involvement - mild to severe motor impairment

Contractures:

1- Hemiplegia

%
40

2- Diplegia

30

3- Quadriplagia 25
4567-

Monoplagia
Double hemi
Total body
Triplagia

4
<1
<1
?

Walking
limb UL:LL Associated problems
3mo later than N 2
UL>LL Mild learning
Seizures
4y
4
LL>UL Delayed develop milestones
Strabismus
25% at 7y
4
UL=LL Floppy baby
pseudobulbar palsy fail to thrive
IQ, hearing, vision
as hemi
1
4
UL>LL As hemi
4
Severe trunk, neck, limb affection
3

2- Hypotonic Usually a stage through which an infant passes.

3- Hemiballistic Sudden movements . As if throwing ball.
4- Ataxic ..........................................................................................................10
o
o
o

%
Involvement of the cerebellum or its pathways
Weakness, incoordination, and intention tremor unsteadiness, wide based gait

POORLY AMENABLE TO SURGICAL CORRECTION

5- Combination
6- Athetoid / Dyskinetic .......................................................................20%
o
o
o
o
o
o

Writhing involuntary movements: y excited, wriggle as if tickled. z sleep

basal ganglia involvement (deposition of bilirubin or erythroblastosis fetalis)
Hips & knees ext+ stepping gait + Lean backward, shouler & trunk extension.
Intelligence normal (often above average)
MOST DIFFICULT TO CORRECT - results are unpredictable & POP hazardous friction
Types:
1- TENSION ATHETOSIS:

Child is hypertonic but not hyperreflexive (no clonus or Spasticity)

Deafness and absence of an upward gaze.

2- DYSTONIC ATHETOSIS:

Continuous, tortuous, slow, twisting type of motion.

All extremities, as well as the neck and trunk, tend to be involved.
3- CHOREIFORM ATHETOSIS.
More common than dystonic athetosis
Continual movement of the patient's wrist, fingers, ankles, toes, and
tongue.
4- DRAMATIC BALLISMUS ATHETOSIS.
Continuous dramatic movement of the trunk and proximal extremities
These patients can injure themselves or their caregivers by this

5- RIGID ATHETOSIS

The most hypertonic & stiff of all CP (Yet no spasticity or clonus)

446 | Page

[Ortho
opedic Neurrology]

Epiidemiolog
gy
1-5 in 1000 live birrths. More common in
n advanced
d countries ( Advanced perinata
al care)
Aettiology
1- Prena
atal ...............................................................(30%)
o Maternal in
nfection - To
oxoplasmosis . Rubella
a . Cytomeg
galovirus . H
Herpes . Syp
philis
o Maternal exposure
e
- Alcohol
A
. Drrugs
o Congenital brain malfformations
2-Perina
atal
o Difficult pro
olonged lab
bour y Birth wt >2.5
5kg
(25-40%)
o Anoxia ........................................................(10-20%))
3-Postn
natal ..............................................................(10%)
o Encephalittis
o Head injury
y
o Carbon Mo
ono Oxide poisoning
p
Patthogenessis
1- Bra
ain Damag
ge: accordin
ng to the siite of involvvement:
Area 6 precentral gyru
us:.....................SPASTIC UMNL
Area 4 precentral gyru
us: ................ FLACCID UMNL
Combined: ...................................... RIGIDITY
Basal gang
glia: ................................. ASTHETOSIS
Cerebellum
m: .................................... ATAXIA
Mid brain: ................................................. TREMORS
2- We
eakness
Loss of volu
untary movvement & Weakness
W
(
co contra
action of ag
gonist & anttagonist)
3- Spa
asticity
Feature of all lesions of
o pyramida
al system: Cerebral,
C
cap
psular, pon
ntine, midbrrain lesions
Related to DISINHIBITED STRETCH REFLEX is regulated by
b descend
ding tracts
SPASTICITY, HYPER-REFLEXIA, CLONUS may ap
ppear
CLASP-KNIFE PHENOMENON: Attem
mpt to chan
nge position initial rresistance + quickly yie
eld
4- Con
ntracture.
Normally ms
m adds sa
arcomeres at muscullotendinous junction in response to consstant
stretch
When mu
uscles spasttic, this me
echanism cannot
c
occcur relative shorte
ening of ms
m in
contrast to
o bone prolonged shortening and
a contracture
5- Defformity unopposed
u
d muscle co
ontracture.
Hip
Adductiion
Flexion
n
Flexion
Recurva
atum
Knee
Eqinovarus
Equinovvalgus
Ankle
shoulder add IR
Elbow flex
f
UL

Flexio
on + IR
Genu valgum
v
calcaneus
Wrist & finger flexx

Disloccation
Patella
a alta
Claw & metatarsu
us
Thum
mb in palm

st

p dislocatio
on: (usuallyy correct 1rry 1 )
1. Hip

1ry: paralyzed abdu

uctors & exttensors (anttigravity mss) + good antagonists
2ry: adap
ptive chang
ges:
o Coxa va
alga: abse
ent gluteal pull
o Shallow
w acetabulu
um
o Lax cap
psule

2. Kne
ee Flexion
n deformitty

1ry: tightt hamstring

g Or tight Gracilis
G
2ry: compe
ensation to hip flexion deformity or equinus
Prolonged flexion defformity le
engthening
g of patellarr tendon & tight latera
al retinaculu
um

[Orthopedic Neurology]

Page | 447

Clinical Feature
History
Abnormal birth history & Prematurity
Neonatal nursery
Delayed Developmental milestones (brackets are 95th percentile)
o Head control ..................................3 mo ........................ (6 mo)
o Sitting independently ................. 6 mo ........................ (9 mo)
o Crawling ...........................................8 mo ........................ (never)
o Pulling to stand .............................. 9 mo ........................ (12 mo)
o Walking .............................................12 mo....................... (18 mo)
Examination
General:
1. Mentality
3- Speech
2. hearing
4- Vision
Gait:
1- Trunk leans forward, SCISSORING, STIFF-LEGGED, TIP-TOE GAIT, CROUCHED
2- z Stride length, Narrow walking base
3- Lordosis . Co-ordination in turning.
Hip deformities:
1- Adduction: ..................................... adductor spasm (GRAB TEST +VE z Hip Abduction)
2- Flexion: ............................................ rectus spasm ....... (ELY & THOMAS & STAHELI +VE)
3- Flexion internal rotation: ........... psoas spasm (true scissoring pseudo scissoring
flexion + yanteversion +VE W SIGN)
4- Hip dislocation ............................... 1ry & 2ry...............(GALEAZZI TEST +VE)
WINDSWEPT POSTURE - one hip adducted & other side abducted
SCISSORED GAIT if bilateral
Apparent LLD if unilateral
STAHELI TEST is better than Thomas as it is not affected by the other side
y lumbar lordosis + prominent bottom standing / z sacrofemoral angle
z SLR because of flexed pelvis from FFD.
Knee deformities:
1- Knee flexion contracture (tight hamstring): ........+VE TRIPOD SIGN & TOE TOUCH
2- Knee recurvatum .................... ....................................REVERSED POPLITEAL ANGLE
3- Genu valgum
4- Patella alta (BLUEMANSAAT, INSALL-SALVATI RATIO<1) flexed knee & quad spasm
Flexion deformity angle is best assessed by the popliteal angle
Flexion contracture lead to CROUCHED GAIT (also hip flexion & calcaneus)
Tight rectus femoris stiff legged gait (prolonged stance & diff. foot clearance)
Sitting - Legs forward
Ankle deformities:
1- Ankle EQUINUS (NB, False equinus = flexed knee lifts heel from ground)
23456-

CALCANEUS
V AR U S
VALGUS
CLAW TOES
METATARSUS ADDUCTUS
TIPTOE GAIT
SILFVERSKILD TEST: equinus z knee flexion = gastroc tight > soleus

Equinus y knee recurvatum in stance phase

Calcaneus y crouch gait
Kneeling eliminates contracture effect

448 | Page

[Orthopedic Neurology]

Upper limbs
Shoulder adduction internal rotation
Elbow flexion
Forearm pronation
Wrist & finger flexion
Thumb in palm
o Hand placement. Ask patient to place hand on knee and then head.
o Stereognosis. Test ability to recognise shape in palm
Spine
o Scoliosis usually present at age 5. Reaches 50. by age 15
o Treated initially with chair that fits the curve.
o Braces of little benefit. Only 15% respond.
o If curve reaches 60 segmental fusion indicated.
o Indications for Surgery = curves > 50. or progression > 10.
o Scoliosis curves are divided into Group 1 (ambulators) or 2 (non-ambulators):

12345-

Group 1 Double small curves- thoracic & lumbar

Group 2 large thoracolumbar or lumbar curve pelvic
obliquity

Posterior fusion Luque rods & sublaminar wires

Ant + Post Fusion Luque rods & sublaminar wires &
Galveston pelvic fixation

Neurology
o
o

CLASP-KNIFE phenomenon

Primitive reflexes:

A, ASYMMETRICAL TONIC NECK: as head

is turned to one side, contralateral
arm and knee flex.
B, MORO REFLEX: Hold child at 45o.
Allow head to drop back, UL extend
away from body and then come
together in embracing pattern.
C, EXTENSOR THRUST: as child is held
upright by armpits, lower extremities
stiffen out straight.
D, NECK-RIGHTING REFLEX: as head is
turned, shoulders, trunk, pelvis, and
lower limbs follow turned head.
E, PARACHUTE REACTION: as child is
suspended at waist and suddenly
lowered forward toward table, arms
and hands extend to table in
protective manner.
F, SYMMETRICAL TONIC NECK: as neck is
flexed, arms flex and legs extend.
Opposite occurs as neck is extended.
G, FOOT PLACEMENT REACTION: when
top of foot is stroked by underside of
flat surface, child places foot on
surface.

Page | 449

[Orth
hopedic Ne
eurology]
Potentia
al for
walking
Assesss (midbrain
n & perinatal)
If mid
m brain re
eflexes appear
(early balan
nce reaction)

Parach
hutte reflex
x
Steppiing
Can walk

Perina
atal reflexess persist >1y
y
(norm
mally disappe
ear at 4-6m)

Moro
Tonic neck (symmetric & asymm)
a
Neck righting (body follow
w head turn)
Extensor th
hrust on vertica
al susp

Will not walk

w

If any 2 of 7 are ina

appropriate
e by 1y it is highly
h
unlikkely to walkk independently

Rad
diography
y:
Hip:
WIBERG CE angle
MP of REIMER (migrration perce
entage = he
ead coverage %)
Sacrofem
moral angle
e: between
n top of sacrrum and femoral shaftt (N 40-60)) z in FFD
Acetabu
ular dysplassia
Dislocattion
Knee:
Flexion Deformity
Recurva
atum
Insall-Salvati Ratio <1
<
Blumansaat Line Below The Patella
P
Alta
Prin
nciple Dia
agnostic Features:
F
:
UMNL
Delayed mile
estones
Pe
ersistent Priimitive refle
exes
Abnormal po
osture & mo
ovement

450 | Page

[Orthopedic Neurology]

TreatmentofCP
Aphorisms.
A little equinus better than calcaneus.
A little valgus better than varus.
A little varus better than a lot of valgus.
A little knee flexion better than recurvatum.

Priorities Patient priorities are

1]. Communication
2]. Activities of daily living
3]. Mobility & Walking
Objectives
1]. Maintain straight spine and level pelvis
2]. Maintain located, mobile, painless hips
3]. Maintain mobile knees for sitting and bracing for transfer
4]. Maintain plantigrade feet
5]. Provide maximal functional positions for sitting, feeding, and hygiene
6]. Provide appropriate adaptive equipment, incl. Wheelchairs
7]. Avoid hip dislocation.
o Painful
o Make nursing difficult
o y pelvic obliquity & scoliosis difficult wheelchair ambulation
o zquality of life.
8]. Strategy
o 0-3 y .................................... physiotherapy
o 4-6 y .................................... surgery
o 7-18 y .................................. schooling and psychosocial development
o 18 yrs + ............................... work, residence and marriage.
ggggggbiiiiiii

LOWER LIMBS
1- PHYSIOTHERAPY - physiotherapy approaches z contractures or y development, y ROM:

Neurodevelopmental approach ( exaggerated reflexes by certain positions)

o Sensorimotor approach ( exaggerated reflexes by sensory )
o Proprioceptive approach (proprioception used to improve posture)
o Neuromuscular reflex approach (graduated pattern of movement learning)
CAST CORRECTION - Inhibitive casting. Stimulation of sole can cause muscles to contract
was basis of inhibitive casting. Not used much now.
CORRECTIVE CASTING - for mild fixed equinus. Well-padded POP max dorsiflexion
BRACING - Useless for treating fixed deformity AFO's useful for Dynamic equinus
NEUROSURGERY - Selective posterior RHIZOTOMY of rootlets used. Via laminectomy. 30-70%
of posterior rootlets cut. Decreases feedback from stretch receptors. Can rootlets to find
which mediate spinal reflex. If only these cut, sensation unchanged. Results promising.
CHEMONEURECTOMY: selective neurectomy is done using certain chemical substances:
a. ALCOHOL 45% gives improvement for 6 wks
b. PHENOL 5% 2ml gives permanent effect
c. BOTULINUM TOXIN gives 6m improvement ( acetyle choline)
d. BACLOFEN intrathecal implanted pump (GABA agonist excitatory
transmitters)
o

2345-

6-

Page | 451

[Orthopedic Neurology]
7- Orthopaedic operations

Indications:
1]. Postural contractures
2]. Correction of fixed deformities
3]. Stabilizing unstable joints
4]. Spastic CP: Quadri hip release at 3y / hemi TAL at 4y / Diplegics 5y hip release
5]. Rigidity signify marked brain damage so only correct severe deformities
6]. Tendon transfers: remove the dynamic force and serve as motorized tenodesis (unlike
polio and nerve injury where it act as coordinated functional solution):
1- Impaired & slow voluntary control
2- Spasticity &sensory problems
3- Dysphasic contractions i.e. antagonistic activity unrelated to the action
4- Skilled coordinated learning of movement after transfer is difficult
7]. Athetosis will not benefit from transfer as this shift the problem to another region not ttt
A. Hip Procedures:

1. Hip at risk :

<50% REIMERS MIGRATION PERCENTAGE

Abduction < 25
Broken Shenton
Treated by psoas, adductor and hamstring LENGTHENING.
2. Subluxed hip RMP > 50%.

VARUS DEROTATION OSTEOTOMY

3. Adducted hip:
COMPLETE ADDUCTOR TENOTOMY obturator neurectomy

All the Add longus, brevis, most of magnus, & gracilis

Still the patient can adduct with pectineus
4. Adducted subluxed hip:

ADDUCTED SUBLUXED HIP

Assess RMP

<50%

>50%

<5y
<50% MP
No dislocation

Bony
operations

Soft tissue
operations

>45 flexion

<30Abd

Subluxed

>50% MP

Total Add
tenotomy
Psoas

Adductor
Brevis
lengthen

Ant.
Obturator
nurectomy

VDO

Hip Dysplasia

Dislocated

OR+VDO+
Chiari
Acetabulo-plasty

452 | Page

[Ortho
opedic Neurrology]

5. Flex
xtion defo
ormity (<20
0 may corrrect by tracction)
1]. SOUTTERS sartorius,
s
re
ectus, & tensor fascia la
ata (flexor release) via Smith Peterrson
2]. MUSTARD: iliopsoas
i
tendon transsfer to GT
3]. SHARRARD: iliopsoas transfer
t
+ iliacus inserrtion transffer

from anterior to posterior iliacc wing, th

he latter ca
an
compensatte for Glut maximus
m
4]. All followed by hip sp
pica in neutrral rotation and sagitta
al
5]. Other alternative: OBERS op
peration (sacrospina
(
alis
transfer to act as hip extensor
e

6. Flex
xion + inte
ernal rota
ation
F
Flexion

Fle
exion Pure
S
Soutters

Flexiibl

Then do
d Thomas test
t
Still there is FFD
D

Mustard
d

So
out

No FFD

Sharrard

Ilio
rece
ess
ca

Neutral spica

Late
era
ham
mst

7. Dislocation:
Dislocation
n
Painless
Reducible
Correct
M
Muscle
Sh
harrar
d or
Mustard

Correct
C
valgus
v
VDO

Painless
Irreducible
e
Correct
dysplasia
Salter

Chiari

Adductorr
release
neurectom
my
+ traction
n
When head
d
at acetab
do OR &
proceed ass
painless
reducible

8. Pelv
vic obliqu
uity

Fixed
d obliquity
z
P
PSF

Ad
ddress ipsila
ateral
kne
ee deformitty & lig
beffore hip fussion

Dyn
namic obliq
quity
z
Abd
d release off opposite sside

Page | 453

[Orth
hopedic Ne
eurology]
B. Knee Procedurre
es
I.
Flexion de
eformity:
Due to:
A. 1ry hamstring Spasticity
B. 2ry to hip FFD
D or equinuss
Treatme
ent:
K
Knee
Flexion

Correctable

Check Hip &

ankle forr
deformity
y

Prolonged
= Pate
ellar
malalign
nment

Fixed

+ Hip adduction
a
Testt abd in
flex
xion &
exte
ension

+ IR

P
Pure
Flexion

Eggers
Release

Same

y in flexio
on

Egg
gers

= Gracilis

= Hamstrin
ng

+ Gage
G

Adductor
tenotomy
neurectomy

Eggers release

Eggers +
Insall lat ret
release

Egge
ers
+
Patelllar
plicatiion

1. EGGERS Ha
amstring tra
ansfer:
Transfer the hamstrring from th
he back of the
t tibia to the back off the femurr
Some ad
dvocated th
he lengthen
ning of mem
mbranosus to prevent recurvatum
m
Followed
d by a long leg cast forr 6 wk
Disadvan
ntages:
A].. Genu rec
curvatum: contraindica
c
ated in equ
uinus
B].. lumbar lo
ordosis
C]. weak kne
ee flexion
2. TACHDJIAN Fractional Lengthenin
ng of Hamsstring Tend
dons:
Z-plasty of gracilis and
a semiten
ndinosus biceps + re
ecession of semimemb
branosus
3. SUTHERLAND TRANSFER
Lateral Transfer
T
of Medial
M
Ham
mstrings forr Internal Ro
otational D
Deformity off Hip
r
4. GAGE DISTAL RECTUS TRANSFER + hamstring release
Gives an
n advantag
ge of enhan
ncing the kn
nee flexion in the swin
ng phase
berosity tran
nsfer to bacck of femur
5. Ischeal tub
gthening plasty
p
6. EVANS leng
eurectomyy of hamstrin
ng
7. Selective ne
E
osteotomy
o
(better in po
olio)
8. all may be added ITB division Extension

Eggers +
E
H
Hauser

454 | Page
II.

[Orthopedic Neurology]

Knee Recurvatum:
Recurvatum may be:
1]. 1ry: quadriceps spasticity or quadriceps spasticity > hamstrings & gastroc spasticity
2]. 2ry to Eggers or Equinus (to detect equinus causation apply POP in dorsiflexion
and see if the recurvatum is corrected or not)
Treatment:
1- Sage proximal rectus femoris Z plasty lengthening
2- Equinus TAL
3- Neurectomy of femoral nerve
4- Irwin femoral flexion osteotomy

III.

Genu valgum:
Usually :
1- hip adduction and coupled Flexion IR
2- Tight ITB
Treatment:
1- Correct the hip via Adductor and iliopsoas release
2- Yount ITB resection
3- Supracondylar varus osteotomy

IV.

V.

Patella alta:
quad spasm or long knee FFD
ttt as in prolonged knee FFD

Patellar subluxation and dislocation:

1]. In valgus knee
2]. Flexion adduction and IR of the hip y Q angle
Treatment: ttt the cause + Insall release of Fulkerson osteotomy

[Orthopedic Neurology]

Page | 455

C. Ankle deformities:
Any calcaneus must have cavus as the pt can not walk on the heal only
Calcaneocavus = calcaneus started 1st. Pes cavus means that the cavus started 1st.
In skeletally immature; stabilizing operations are done only in valgus. In varus soft tissue op.
When tendon transfer is considered if there is only one tendon then transfer it to the mid foot.

If many tendons then transfer one to the affected side.

I. Equinus:
Pathology (5types according to Triceps surae vs Dorsiflexors):
1- Spastic vs spastic
2- Spastic vs normal
3- Spastic vs flaccid
4- Normal vs flaccid
5- Flaccid vs flaccid
The exact offending ms (gastroc or soleus) can be done by Silfverskild Test
The muscle nature must be determined - spastic or contractured - by procain injection
Non Operative Ttt in the form of manual stretching, bracing, casting
Operative Ttt: if failed non operative ttt:
1- Neurectomy: for spastic equinus (not contractures) & for clonus WB cut it from
origin or at insertion
2- Triceps surae release:
a. Silfverskild Gastroc recession (spasm): distal recession of gastroc origin
b. Gastroc slide (contracture): lengthening of gastroc tendon
c. TAL (this is for gastroc and soleus after Silfverskild testing):
Strayer transverse release
Vulpius V-shaped release
Baker tongue shaped release
Semi open (lateral distal release if equinovalgus)
Percutaneus (medial distal release if equinovarus)
3- MURPHY Heel cord advancement:

In spastic vs spastic dorsiflexors replacing TA more ant in front of FHL

II. Varus:
Due to:
TP spasm
TA or Tendoachillis tightness & evertor

weakness may assist

Treatment

operation):

(according

to

rule

no

bony

SKELETALLY IMMATURE:
1- TP Lengthening (MAJESTRO)
2- TP Rerouting in front of med malleolus (BAKER)
3- TP transfer via Interosseous membrane to dorsum of Foot (BISLA)
4- TP split transfer to the proneus Brevis (KAUFER)
5- TA split transfer to the cuboid (HOFFER)
6- FDL & FHL transfer to Dorsum (ONO)
7- TA & EHL transfer to the mid dorsum or lateral Dorsum (TOHEN)
SKELETALLY MATURE:
Triple fusion + Laterally based wedge (DWYER) + tendon transfer

456 | Page

[Ortho
opedic Neurrology]

III. Valgus
s: more com
mmon than
n varus
o Pathology::
Usu
ually it is asssociated witth equinus
More tight trriceps surae
e (less eve
ertor inverto
or imbalancce)
Dorrsiflexion oc
ccur at the mid tarsal + eversion of
o the calca
aneus + MT abduction
Susttentaculum
m tali is shifted lat & do
ownward talar head
d sublux me
edially
o Treatment::
Ta
alipes
Equin
noValgus

Imma
ature
TAL + post
capsulotomy
y

P.Brev
vis to
cunieform

Mature
Grice Green or
D
Dillwyn
Evan

Triple fussion

Rem
move Med
W
Wedge

Other softt
tissue

GRICE GREEN extra-articula

e
ar lateral su
ubtalar arth
hrodesis
DENNYSON AN
D FULFORD MODIFICATION uses screw
s
betw
ween talus and
a calcan
neus.
ND

Iliacc crest graftt in sinus tarrsi. Walking

g cast for 12
2 weeks.
DILLWYN-EVANS transversse calcanea
al osteotom
my + fibular BG (lateral lengthenin
ng)
Medial sliding
g calcanea
al osteotom
my may be done in
nstead of medial
m
closing
wed
dge
IV. Calcan
neocavus:
o Due to:
2ry to excessiv
ve TAL
1ry to spastic dorsiflexors
d
(EDL & TA) in relation
n to weak T
Triceps surae

SKELETALLY IMMATURE:

2ry ..................Ta
alectomy but painfu
ul pseudoarthrosis, LLD, deformin
ng, one wa
ay
1ry .................. Partial
P
EDL denervatio
on
TA shortening
g & transfer to Tendo A
Achilles
Cav
vus Steindle
er Samilso
on calcanea
al crescent osteotomyy
Valg
gus
Grice or Dillwyn
D

SKELETALLY MATURE:
1- The
ere is tendo
on to transffer:
(1) ELMSLI 2 stage op
peration:
Stage 1
Osteotom
my Dorsal Weedge
TNJ
Fusion
Steindler
Cut
Full dorsi-fflexion to corrrect cavus
POP
(2) Triple fusion
f
+ Ten
ndon transfer
2- No tendon forr transfer:

Pantala
ar fusion

Stage 2
Posterior W
Wedge
subtalar
TA + PL tran
nsfer to tendo
o-achilles
In plantar fle
exion to aid healing
h

[Orthopedic Neurology]

Page | 457

V. Claw toes:
o Neurectomy of the motor br of the lateral pantar nerve
o Release of the insertion of the FDB
VI. Metatarsus adductus
o Resection of the abductor hallucis & its tendon

Four Stages of Winter:

Weak TA No tightness of triceps surae .
Stage I
Above + tight triceps surae + TP
Stage II
Above + quad & hams spasticity.
Stage III
Above + hip flexor & add spasticity
Stage IV

Treatment
AFO.
TA lengthening + split TP transfer.
+ hams lengthening + rectus transfer
+ psoas + adductor release.

D. Upper Limb deformity:

I.

Shoulder adduction internal rotation

1- SEVERS release: subscap, pec major, coracobrachialis, short head biceps, coraco-

humeral lig.

2- LEPISCOPO ZACHARY: Severs + Teres & latissimus transfer to post-lat aspect of prox

humerus

3- ROTATIONAL HUMERAL OSTEOTOMY

II.

Elbow flexion
1. Flexor tenotomy
2. Biceps transfer to triceps

III.

Forearm pronation
1. Pronator tenotomy
2. FCU to ECR

Gershwind & Tonkin Classification

Active supination beyond neutral
Group 1
Active supination to neutral or less
Group 2
No active sup, loose passive sup
Group 3
No active sup, tight passive sup
Group 4
IV.

Wrist & finger flexion

1. Arthrodesis wrist
2. Release common flexor origin
3. FDP high cut & FDS low cut; then suture the tendons together

ZANCOLLI CLASSIFICATION
1 finger ext wrist <20 flex
2A Finger ext wrist > 20 flexion + active ext
2B same + No active wrist extensor
3 No Finger extension

V.

TREATMENT
No surgery
Pron quad release flexor aponeurotic release
Pronator teres transfer
Pron quad release flexor aponeurotic release

TREATMENT
Flexor Aponeurotic Release (FAR) FCU tenotomy
FAR + FCU tenotomy
FAR + FCU to ECRB
FCU to EDL or Prox row carpectomy or Wrist Fusion
or FDS to FDP.

Thumb in palm
1. Cut pollicis (adductor, flexor, opponense) & 1st interossei
2. Tendon transfer to restore the thumb abduction: Pronator teres transfer

458 | Page

[Orthopedic Neurology]

Poliomyelitis
It is a neuromuscular disorder 2ry to viral infection subsequent development of deformities
Epidemiology
It is considered to be eradicated from all the developed countries
Our county is declared to be eradicated from endemic polio especially after free vaccination
programs (SABIN live attenuated vaccine oral drops, SALK IM killed vaccine)
tiology::
Organism:
o Polio virus: small RNA virus (3 types; BRNHILDE, LANSING, LEON)
Route of infection:
o The virus enters the body via feco-oral route
o 10 Incubation period during which the virus reaches the peripheral circulation
o Viraemia then occurs till the virus reaches the CNS
Pathogenesis::
Subclinical infection: no manifestation even of viraemia (local immunity)
Minor illness
Abortive infection: no paralysis
Major illness
Pathology::
CNS: (AHC, Dorsal root ganglia, Internuclear cells)
Affect the AHC:
1- Irritative: temporary paralysis
2- Reversible toxic changes: cloudy swelling and chromatolysis reversible paralysis
in 2y
3- Irreversible damage
Motor cranial nerve nuclei (bulbar palsy)
Brain stem and cerebellar nuclei may lead to sympathetic and extrapyramidal manif
Meningitis
Dorsal root ganglia & internuclear cells pain & spasm of ms continuous contraction that
may end with a contracture as well
Peripheral nerves: Axonal degeneration and replacement by fibrofatty tissue
Muscle
1]. Fibrofatty degeneration and atrophy
2]. Fibrosis and shortening
Bone:
1]. Disuse atrophy z ms stresses
2]. Short limbs
Joints: Unbalanced and instability

[Orthopedic Neurology]

Page | 459

Polio In The Upper Limb

1- Shoulder: Deltoid, subscapularis, supraspinatus, infraspinatus, and serratus paralysis
Skeletally immature (SAHA TENDON TRANSFERS)
1]. Deltoid ...................................................................... trapezius to humerus transfer
2]. Subscapularis .......................................................... superior 2 digits of serratus to subscap transfer
3]. Suraspinatus .......................................................... levator scapulae or sterno-mastoid transfer
4]. Infraspinatus .......................................................... latissimus or teres transfer
5]. Serratus .................................................................... pec minor transfer
Skeletally mature:
1]. Shoulder fusion .................................................... 45 abd, 30 IR, 15 flexion (hand to face)
2- Elbow:
Flexor paralysis: (MUST HAVE GOOD HAND FUNCTION)
1]. BROOKS-SEDDON ................................................ all pec major to biceps
2]. CLARKS .................................................................... sternal pec major to biceps
3]. HOVNAN ................................................................. Latissimus origin to biceps
4]. Pec mior to biceps
5]. Sterno-mastoid to biceps (fascial graft to give more length webbing of neck)
6]. Triceps to biceps
7]. STEINDLER FLEXORPLASTY................................ advancement of the common flexor origin to lower humerus; before op
assess flexors, doing elbow flexion 90 hand clench test, if he can not do, cancel the operation
8]. BUNNEL modification ......................................... augment the transfer by fascia and attach it to the lat border of
humerus for better pronation
9]. MAYER-GREEN ...................................................... flexor palsty to the anterior aspect of humerus (better pronation)
Extensor paralysis:
1]. Latissimus transfer
2]. Brachio-radialis transfer
3- Forearm
1]. Pronation deformity (supinator weak):
2]. Pronator teres + FCR ........................................... around ulna to radius
3]. Supination deformity (pronation paralysis)
4]. ZANCOLLI ................................................................. biceps rerouting around radial neck
4- Wrist:
1]. Extensor paralysis ................................................ Pronator to ECR
2]. Flex paralysis (wrist & hand) ............................ ECRL to sublimis
3]. Wrist Drop: ............................................................. wrist fusion
5- Fingers:
1]. Flexor paralysis....................................................... ECRL to sublimis or profundus
2]. Extensor paralysis ................................................ FCU to EDL + palmaris longus to EPL (or split FCU)
6-

Thumb: Loss of pinch:

o

Loss of adduction (as in Ulnar) ...................... 1] Brachioradialis............................. (B

BOYES)
2] ECRL ............................................... (B
BRAND)
3] Sublimis ......................................... (R
ROYLE THOMPSON)

Loss of opposition (as in median) ................. 1] Ring sublimis ................................ (R

RIORDAN)
(= Abd & rotation at CMCJ + flex IP)
2] EIP .................................................... (B
BURKHALTER)
3] Riordan + FCU

7- Intrinsic Minus hand

o Claw hand as low ulnar & median ............ 1] ECRL ................................................ (B
BRAND)
2] Sublimis .......................................... (B
BUNELL)
3] EIP ..................................................... (R
RIORDAN)
8- Index:
o Loss of abduction (Ulnar): ............................... EIP or Abd Pollicis ........................... (N
NAVIASER)

460 | Page
THUMB ADDUCTION

THUMB OPPOSITION

CLAW HAND

GENU RECURVATUM

[Orthopedic Neurology]

Page | 461

[Orth
hopedic Ne
eurology]
Pollio in Low
wer Limb

1- Hip
1]. FLEXION DEFORMITY ........................................... As
A CP
2 PARALYTIC DISLOCATION .................................. As
2].
A CP
3 FLAIL HIP : (according to the co
3].
ondition of spine,
s
epsilatteral knee, co
ontralateral hip)
a. Frree .................................................................. Fusion
b. Ab
bnormal ...................................................... Orthosis
O
4]. FLEXION ABDUCTION
c. Mild
M .................................................................... YOUNTS ITB & lateral IM septum
s
relea
ase
d. Se
evere .............................................................. CAMPBELL Ilia
ac crest transsfer above th
he acetabulu
um
e. Allternative ..................................................... IRWIN COMBINATIONS:
i. Mild ..................................................... Younts
Y
+ Sou
utters
ii. Severe ..........................
.
...................... Younts
Y
+ Cam
mpbell
2- Knee:
1]. FLEXION DEFORMITY:
a. Mild
M .................................................................. POP wedging
g
b. Moderate
M
(30
0-40) ..................................... Su
upracondyla
ar extension osteotomy (REVERSED IRWIN)
c. Se
evere (90) ...................................................... Po
ost capsulotomy + hamstrin
ng lengthen/ttransfer to patella
2 RECURVATUM :
2].
a. Typ
pe I ................................................................... (Q
Quad =0 / Hamstring
H
=5
5) with bonyy changes.
i. IRWIN Supratubercu
S
ular open wedge
w
tibial osteotomy.
o
ii. Biceps to
t patella
b. Typ
pe II .................................................................. (Q
Quad = 5 / Hamstring
H
= 0).
i. Long Le
eg Brace ............................. if <30.
ii. PERRY, OBRIEN, HODGSON ....... if >30 (triple tenodesis).

Posterior ca
apsular advancement.
Gracilis & ST
T posteior ch
heckrein.
ITB to Sem
mimembranosus & Bicceps to Me
edial
gastroc orig
gin (in a diag
gonal fashion
n).
iii. Bony blo
ock operatio
ons ............... if severe degrree.
HEYMAN ........................... Tibilaization of
o patella.
MAYER .............................. Iliiac crest intra
a-articular pa
atella to tibia
a BG.
HONG-XUE ..................... In
nverted pate
ella to tibia (a
after patellecctomy).
iv. Fusion .................................................. fa
ails due to ba
ad muscle an
nd other join
nts condition
n.
3 GENU VALGUM: ...................................................... MODIFIED MCEWINS ostteotomy ( o
3].
osteotomy/ clasis)
4 FLAIL KNEE: .............................................................. Lo
4].
ong Leg Bra
ace or Fusion
n
3- Foot & Ank
kle
De
eformity

Immatu
ure
We
edge
Lateral (Dwyer)

ure
Matu
Fusion Tendo
on transfer
No Tendon
n
TF
Same
TF
T + Dwyer

Mild ............. Hoffer, Kaufer,

K
Tohe
en
Severe ........
.
Drennan
n TA Post transsfer
GG or EV
2].Valgus
E
TF
F
P.B to C
TF
T + GG or EV
V
P. Breviss to cuneiform
m + GG or EV
3].Equinus
TF
TAL + Bisla
Ankle
A
Fusion
TAL + Bisla
B
Ankle fusion
Lambrinudi
4].TEV
AnteroLLateral
TF
TAL + Bisla
Ankle
A
or Panttalar
TAL + Bisla
B
Steind
dler
5].TE valgus
TAL + PB to Cuneiform + GG or EV
E
Anterom
medial
TF
TAL + PB to C
Ankle
A
or Panttalar
6].TC Valgus
omedial
TF
F
Banta
Pantalar
P
Banta + PL & PB reloccation + GG orr EV Postero
7].Cavus (Plantaaris) Steindle
er + Jones or Hibbus
Japas Dorsal
D
V-shap
ped osteotom
my of the tarsu
us
TF
8].Calcaneo Ca
avus Steindle
F
Banta
Pantalar
P
er + Banta + Samilson
Elmsli or
o
9].Pes cavovaru
us Steindle
er + BISLA + Tohen
T
Dwyer or lateral calccaneal displa
acement oste
eotomy
10].Claw Toes
Same
If therre is OA
Big ............... Jones
on
+ IP fusio
DuVrries MP excision arthropla
asty
Toes ............. Hibbus
+ MP cap
psulotomy
or Fusion
Or ................. Taylor FD
DL to EDL
11].Hammer Toe
e
FDL ten
notomy
DuVrie
es PIP Excision
n arthroplastyy or Fusion
12].Mallet Toe
FDL ten
notomy
DuVrie
es DIP Excision arthroplastty or Fusion
13].Dorsal Bunnion Lapiduss (TA to Nav + FHL to P.Phx base + Nav-Cu
uneiform fusion + Cuno-MT ffusion + plantaar IP capsuloto
omy)
GG=
= Grice Green
n (Tibial graft) / EV= Evans (Fibular Graftt) / PB= Pron
neus Brevis / PL= Proneus Longus / C = Cuneiform
Proneus
P
Tra
anslocation
n must be do
one before
e age of 1 ye
ear:
1]. Eliminattes the calcaneus and va
algus force early
e
before 2ry
2 bone cha
anges
2 No orth
2].
hosis can con
ntrol the calccaneus deforrmity at the walking
w
age
e
1].Varus

462 | Page

[Ortho
opedic Neurrology]

B chial Plex
Brac
P us Injuries
I
s
Introduction
It is nott a common
nly encountered thoug
gh grave in
njury

Brachial plexus anatomy

5 roots: C5,6,7,8,T1
1
3 Trunkss: Upper, Middle,
M
Low
wer
6 divisio
ons: 3 anterior, 3 poste
eior
3 cords: lateral, me
edial, posterrior
Nerves from
f
the ro
oots: Long thoracic
t
(C5
5,6, 7), Phre
enic (C5), Dorsal scapu
ular (C5)
Nerves from
f
the tru
unks: Supra
ascapular nerve, n to subclavius (fform upperr)
Nerves from
f
cords::
Lateral cord:
c
LL Mu
usculocutan
neous
Medial cord:
c
MMM
MM Ulnar
Posterio
or cord: ULN
NAR

[Orthopedic Neurology]

Page | 463

tiology:
12-

Open Plexus injury: sharp knif & glass (usually associated vascular and visceral injuries)
Closed Brachial plexus injury:
1- Obstetric birth plasy:
High birth wt > 4 kg
Shoulder dystocia
Breach
2- Traumatic:
Traction injury: mostly due to motor cycle accidents & sport injury sudden fall on tip of
the shoulder sudden traction injury
Compression by:
(1) Direct blunt trauma to the side of the neck
(2) Fractures: transverse process, rib, clavicale, scapula
(3) Dislocations: shoulder, AC, Sternoclavicular
3- Inflammatory: Radiation plexopathy: pain after radiation DXT
4- Tumors:
Neural: neurolemmoma, plexiform neurofibromatosis
Non neural: Pancoast tumor
5- Compression neuropathy:
Thoracic outlet syndrome: thoracic rib,
6- Vascular ischemia
7- Iatrogenic: mal position of a patient on the operative table (usually neuropraxia)

Pathology:
1]. Preganglionic injury:
o Avulsions form the spinal cord herniation of the dura
o Injury proximal to the DRG i.e. intact axons the DRG cells does not degenerate but there is

loss of sensation
Back muscles are denervated
Usually + phrenic + long thoracic + dorsal thoracic + Horner
All nerves that emerges from the roots are injured
2]. Postganglionic:
o Ruptures distal to the DRG they degenerate + loss of sensation
o Back muscles only are intact
o No herniation of dura
3]. Trunks
o Intact nerves: long thoracic and pectoral nerves
o Suprascapular nerve is affected
o Upper trunk (deltoid & biceps)
o Middle trunk (radial n)
o Lower trunk (ulnar + median)
4]. Cords
o All the 3 nerves are intact
o Medial (UMMMM)
o Lateral (LLM)
o Posterior (ULNAR)
o
o
o

464 | Page

[Orthopedic Neurology]

Microscopically:
SEDDONS CLASSIFICATION:

1]. Neuroparaxia (conduction block that recover = 1 Sunderland)

2]. Axonotemesis (cutting of axons but intact peri and epineurium = 2.3)
3]. Neurotemesis (all are cut = 4,5)

SUNDERLAND CLASSIFICATION
1].
2].
3].
4].
5].

Type 1 : neuraparaxia
Type 2 : axonotemesis with intact endoneurium
Type 3 : severe axontemesis with only intact peri & epineurium
Type 4 : neurotemesis only intact epineurium
Type 5 : neurotemesis is complete with fibrosis

1-NEURAPARAXIA:
1].
2].
3].
4].

Physiological Conduction block

No degeneration reaction occur
Due to myelin disintegration
Regeneration of myelin occur with schwann cells with regain of the full function

2- WALLERIAN DEGENERATION FOR AXONO & NEUROTEMESIS

Proximal to axonotemesis or neurotemesis

1]. Perikaryon: swell then retract, nucleus becomes more peripheral, chromatolysis (Niessers

granules desintigrate)

2]. Adjacent cells show similar changes

3]. Retrograde degeneration of the axon till the next NODE OF RANVIER
Distal to the cut:
1]. Axon maintain activity for 4 days then degeneration starts
2]. Axonal Degenration and disintegration down till the end of the nerve fiber
3]. Myelin disintegrate
4]. Schwann cells and macrophages clean the debris
5]. Schwann cells multiply and form Bunger tubes for future axon sprouts to come in
6]. Muscle atrophy, fasciculations, polyphasia
Regeneration:
1]. 30-40 days latency occurs till the beginning of the regeneration
2]. Axon sprouts starts to bridge the gap till it finds the way in the distal end
3]. Axons travel 1mm/d till reach the distal organ
4]. MUSCLE: y of motor end plate, y sensitivity, then starts to respond &z fasciculation
5]. SENSORY IS BETTER THAN MOTOR: and can wait for longer periods till start to regenerate

[Orthopedic Neurology]
Clinically:
1-

Page | 465

Motor: Flaccid paralysis or weakness (LMNL):

1- ERBS DUCHENNE: Upper roots C5,6 (30%) + C7 (50%) :
Arm adducted, elbow flexed, forearm pronated, fingers flexed (C7)
Winging of scapula + lost protraction = preganglionic injury
2- DEJERINE KLUMPKE PALSY: Lower roots (C8,T1) avulsion + upper roots rupture (20%)
Complete flail paralysis
Phrenic
3- COMPLETE + Horner marble skin

Sensory:
o Diminished spinothalamic sensations:
Pain, Temp, Crude touch
o Diminished Lemniscal sensation:
Fine touch (tactile discrimination, 2 point discrimination, moving discrimination,
depth discrimination, streognosis)
Proprioception: sense of position, sense of movement
Sense of vibration
3- Autonomic:
Vasomotor: VD followed by VC
Sodomotor: anhydorsis (in complete) hypohydrosis (in incomplete) using the
Guttman quinizarine test + coffee and aspirin powder turns purple
Atrophy
4- Reflexes: Lost deep and superficial reflexes
5- Causalgia: pain due to injury of a sensory nerve (e.g. median)
2-

466 | Page

[Ortho
opedic Neurrology]

Electodiagnosis:
Reaction of
o degenrattion:
lost resp
ponse to fa
aradic curre
ent (sustaine
ed contracttion)
Slow re
esponse to galvanic
g
cu
urrent
Polar re
eversal: ano
odal closing
g current > cathodal
c
clo
osing curre
ent
2- y CHRONAXIE (time needed for DOUBLE RHEOBASE = th
he minimal current can
n cause a co
ontraction))
3- SD (streng
gth duration
n) curve:
Normally: 100 mssec voltage threshold is
i < double 10 msec th
hreshold
Denerv
vation: the curve is ste
eep and th
he 100 mse
ec voltage tthreshold iss > 2x 10 msec
m
thresho
old is slow
wer than no
ormal
4- EMG:
1- No
ormal patterrn
Insertio
onal potential; normally
ly immediatte and brieff
Resting
g potential: normally no fibrillation
n nor fascicculation
Motor unit
u firing: bizarre,
b
gian
nt, dublette
e, polyphasia are abno
ormal
Recruitment patte
ern (normallly complete
e interferen
nce pattern = disapp of
o baseline)
2- Can
n detect the
e level
3- Can
n detect the
e acute and
d chronic
4- Can
n detect the
e regeneration pattern
n: polyphassia, and giant waves
5- Sev
verity
Butt purely motor, does no
ot evaluate
e the motorr root functiion, does not measure
e pain
5- Nerve con
nduction:
1- Nerve conduc
ction velociity: by of a nerve at a point & record
r
the stimulus att another point
p
in the
t course of
o the same
e nerve the
en measure the velocity
ty of conduction
a. If slow conduction
c
n .... Myelin problems & compresssion
b. If moto
or is absent + intact sen
nsory ........................prega
anglionic in
njury
c. If both are intact despite
d
the injury ......................neura
apraxia
d. If both are absent ...... .................................................neuro
otemesis
2- Roo
ot assessme
ent by delayyed respon
nses:
H-REFLEX (electric
c ankle jerkk) by subm
maximal nerrve fibers dorsal roo
ot
monosyynaptic of
o AHC ms
m contracttion
ONSE: (anttidromic motor
F RESPPO
m
nerve
e conductiion) stimullation of a motor nerve
producce normal orthodromi
o
c propagattion of actio
on potentia
al to the mu
uscle and in
n the
same tiime there is
i an antidromic volle
ey that travvel to the p
perikaryon Rensh
haw
cells till the ce
ell itself another
a
ressponse F ressponse
Still botth are moto
or, not for muscles th
hat are inne
ervated by multiple ro
oots or you can
not diffferentiate, and
a can not differentia
ate bet acutte and chro
onic
6- Bulbocave
ernosus reflex perin
neal contracction
7- SEP: Stimu
ulation of ne
erve elecctrodes at sp
pine & corttex
1- Can
n purely me
easure the root functio
on
2- Can
n measure the conducction velosity
3- Do
oes not depe
end on mo
otor function
4- Can
n detect de
elays due to
o CNS delayys e.g. MS
5- Can
n detect the
e root avulssions in Erb
bs plasy
1-

PXR
Detect
D
phre
enic paralyssis
Detect
D
fracttures of 1st rib
r or tumo
ors
Cervical
C
myyelography diverticu
ulosis of the
e preganglionic injury

[Orthopedic Neurology]

Page | 467

Treatment:
Non operative:
Literature indicates that the spontaneous recovery is the rule in 80%
Usually if closed injury early biceps twitches
Physiotherapy is mandatory to maintain normal ROM
Ms is important to keep active ms
Operative:
1- INDICATIONS AND TIMING:
1]. If the point of 3mo passed without evidence of biceps regeneration
2]. Reconstructive surgery for late sequelae
2- FINDINGS:
1]. Root avulsion
2]. Continuous root and trunk (traction injury)
3]. Neuroma formation
3- TECHNIQUE:
1]. Neurolysis if the lesion is in continuity
2]. Direct repair (not in root avulsions; but in peripheral nerves):
o Timing:
Acute repair if clean cut and every thing is ready
2 weaks: is the rule for the oedema to subside & the soma is fully active
Delayed if (6wk) if contaminated or vascular and tendon injury to avoid fibrosis
o Methods:

a.
b.
c.
d.
o Avoid:

Perineural
Fascicular
Group Fascicular
Perineural and fascicular

Gaps
Infection
Tension:
(1) <5cm: transposition, limb position, neurolysis, cut of unnecessary branche
(2) >5 cm: nerve grafting:
o Fibrin & plasma glue: may be used to z operative time and z the use of suture z fibrosis
o Postoperative:
Immobilization: 2-6 wk
Physiotherapy

3]. Nerve Grafting

o Nerves to be used: sural, medial cut n of fore arm, superficial radial
o Technique:

a.
b.
c.
d.

Interfascicular
Inlay: in neuroma
Cable grafting
Pedical rotational intergrafting (bet ulnar and median)

4]. Homografts are immunogenic

468 | Page

[Orthopedic Neurology]

5]. Neurotization: two types:

1]. Internal Plexo-Plexus:
C7 to upper trunk
C3,4 to upper trunk
2]. External: (to upper trunk, musculocutaneous, axillary, suprascapular, radial, median)
Pectoral nerves
Intercostal n
Spinal accessory
Long thoracic, thoraco-dorsal, subscapular
6]. Late Reconstructive surgery to shoulder:
1]. FAIRBANK release of the subscapularis + pec major + ant capsule
2]. SEVERS release of the subscapularis + Pec major lengthening
3]. LEPISCOPO: transfer of Latissimus & teres major to the back of the humerus ER (Z
ZACHARY,
4].
5].
6].
7].
8].
9].

TACHIDJIAN modifications)
HOFFER transfer of latissimus and teres into the rotator cuff ER + abduction
OBER long head triceps + short head biceps transfer to acromion
GILBERT & MAYER trapezius transfer to humerus
SAHA acromion with the attached trapezius advancement to humerus as distal as possible
Humerus derotation osteotomy
Arthrodesis is the last resort

Lesion
Adduction + IR
Supra or infraspinatus Dysfunction
Deltoid Dysfunction
IR or ER + incongruent shoulder joint
Severe dysfunction of shoulder
7]. Elbow reconstruction:

procedure as recommended by AAOS

Subscapularis Release
Latissimus to greater tuberosity
Saha or Hoffer
Humeral derotation osteotomy
Glenohumeral arthrodesis

Flexor paralysis: (MUST HAVE GOOD HAND FUNCTION)

BROOKS-SEDDON .................... all pec major to biceps
CLARKS ...................................... sternal pec major to biceps
HOVNAN .................................... Latissimus origin to biceps
Pec mior to biceps
Sternomastoid to biceps ..... using a fascia to give more length webbing of neck
Triceps to biceps
STEINDLER FLEXORPLASTY...... advancement of common flexor origin to lower humerus;
assess 1st flexors condition by doing elbow flexion 90 hand clench test
BUNNEL modification............ augment by fascia &fix to lat humerus (better pronation)
MAYER-GREEN .......................... flexor palsty to the anterior humerus (better pronation)
Extensor paralysis:
Latissimus transfer
Brachio-radialis transfer
8]. Forearm
Pronation deformity (supinator weak): Pronator teres + FCR around ulna to radius
Supination deformity ........... ZANCOLLI biceps rerouting around the radial neck
9]. Wrist:
Wrist Drop ............................... FCU to ECRB

[Orthopedic Neurology]
Prognosis
A]. Preoperative:
1]. Level of injury: the distal the better
2]. Delay of injury: the more acute the better
3]. Type of injury: the apraxia the better
4]. Type of nerve: the pure the better & the small the better
5]. Type of pt: the younger the better
B]. Operative:
6]. Huge gaps
7]. Huge tension
8]. Huge suture (we use 8-0 or 9-0)
C]. Postoperative
9]. Hematoma
10]. Infection
11]. Inadequate physiotherapy

RECENT TRENDS IN NERVE REPAIR

1. Phamacoloical agents
1- Gangliosides
2- Polyamines
2. Immune system modulators
1- Azathioprine
2- Corticosteroids
3- Cyclosporin A
4- Cvclophosphamides
3. Enhancing factors
1234-

Nerve growth factor

Fibronectin
Insulin-like growth factor
Ciliarv neurotrophic factor

4 Entubulation chambers

1- Autogenous vein
2- Silicone Polvglycolic acid G
3- Gore-tex

Page | 469

470 | Page
THUMB ADDUCTION

THUMB OPPOSITION

CLAW HAND

[Orthopedic Neurology]

[Orthopedic Neurology]

Page | 471

Carpal Tunnel Syndrome

Commonest middle aged F:M = 3-5:1
Anatomy Of Carpal Tunnel
floor and walls
bony carpus
roof
flexor retinaculum /transverse carpal ligt
radial attachment tubercle of scaphoid + ridge of trapezium
ulnar attachment hook of hamate + pisiform
Contents
FPL / FCR (deep to FPL) / FDS - middle & ring lie superficial / FDP
Median Nerve
Flexor tendons run deep to nerve
Causes (ICRAMPS)
Idiopathic
Colles, Cushings
Rheumatoid
Acromegaly, amyloid
Myxoedeoma, mass, (diabetes) mellitus
Pregnancy, Persistent median a.
Sarcoidosis, SLE
Symptoms not always classical
1- Aching and parasthesia in thumb , index middle and 1/2 of ring finger
2- worse at night
3- forearm pain
4- dropping things
Signs

Hand normal looking

If severe, thenar wasting, trophic ulcers
weakness of thumb abduction
Semmes Weinstein monofilament test & Vibration test are more sensitive than 2 point
discrimination test in assessment of the slowly progressive sensory compression change
5]. Tinels Sign -74% sensitivity, 91 % specificity: Gentle tapping over median nerve at the wrist
in a neutral position. Positive if this produces paraesthesia or dysaesthesia in the distribution
of the median nerve
6]. Phalens Sign 61% sensitivity, 83% specificity: Elbows on the table allowing the wrists to
passively flex. If symptoms provoked within 60 secs then positive
7]. Median Compression Test 86% sensitivity, 95% specificity* : Elbow ext, forearm
supination, wrist flex 60, one thumb pressure over the carpal tunnel. Test positive if
parasthesia or numbness within 30 secs
1].
2].
3].
4].

Differential diagnoses
Cervical radiculopathy
Spinal cord lesions - tumour, MS, syrinx
Peripheral neuropathy- toxic, alcoholic, ureamic, diabetic

472 | Page

[Orthopedic Neurology]

Investigations
Nerve conduction studies :
sensory conduction prolongation ......... >3.5ms (more sensitive)
distal motor latency .................................... >4.0 ms
accuracy = 85-90%
10-15% false negative
Reminder of how nerve conduction studies are performed:
Motor
1]. stimulus to skin over nerve, Motor Action Potential recorded in muscle supplied
2]. Latency = time between stimulus and MAP
3]. Conduction velocity, normal = 40-60 m/s
4]. compression causes z CV in a segment
5]. If very severe MAP also reduced
Sensory
1]. SNAP recorded in proximal nerve after distal stimulation
2]. sensation often affected before motor function
3]. SEP (Somato sensory evoked potential) record response in brain or spinal cord, used to
diagnose brachial plexus injuries
Management
Conservative Night splint, injection, NSAIDs, correct any cause (75-81% relief short term)
Surgical1]. open /endoscopic decompression
1]. Need to bear in mind anatomical variations
2]. Beware palmar cutaneous branch of median nerve, and motor branch
3]. Apply volar splint to hold the wrist in extension z bowstring & RDS
Complications of surgery
1]. Complex Regional Pain Syndrome
2]. Tender hypertrophic scar pillar pain
3]. neuroma in palmar branch
4]. tenosynovitis / tendon adhesions
5]. bowstringing of tendons
Endoscopic release Okutso&Agee
1]. one or two incisions
2]. less scarring
3]. less pillar pain
4]. quicker return of strength and to work
5]. but:
6]. Anecdotal reports of disasters
7]. Big learning curve
8]. Time consuming, expensive

[Orthopedic Neurology]

Page | 473

Pronator Teres Syndrome

Compression at
Lacertus Fibrosus = biceps aponeurosis
pronator teres muscle
fibrous arcade of FDS
Ligamentum Struthers (present in 1.5 % of people)
Causes
1]. Repeated minor trauma/ repetitive use of elbow
2]. fracture / fracture dislocation of elbow
3]. Tight/scarred lacertus fibrosus
4]. Tendinous bands in pronator teres
5]. Tight fibrous arch at prox FDS
Symptoms
1]. Aching / fatigue of forearm after heavy use
2]. Clumsiness
3]. Vague, intermittent parasthesia, but rarely numbness
Signs
1]. local tenderness to deep pressure and reproduction of symptoms
2].
3].
4].
5].

TINELS TEST
pain on resisted pronation of forearm with elbow extended = Pronator teres
pain on resisted elbow flexion and supination= lacertus fibrosus
pain on resisted flexion of PIP joint middle finger = FDS arch

Investigations
1]. NCS not much use, intermittent symptoms
2]. EMG z innervation of muscles & differentiate from CTS
Management
1]. Conservative-avoidance of repetitive elbow movements, NSAIDS, Splintage with elbow
flexed with pronation
2]. Surgical- Decompress all the structures

Anterior Interosseous Syndrome

Compression under humeral part of pronator teres
Anterior interosseous nerve motor to FPL, radial side of FDP and pronator quadratus
Does not supply skin sensation
Afferent sensory fibres from capsular ligament structures of wrist and DRUJ
Clinical diagnosis
spontaneous vague forearm pain
reduced dexterity
weakness of pinch
unable to make 'OK Sign' due to weakness of FPL & FDP index finger (makes square
instead of circle)
weak pronation with elbow in full extension (isolates PQ)
direct pressure over nerve can elicit symptoms
Tinels sign usually negative
Investigations
EMG + NC unhelpful
Management
Conservative- NSAIDS, avoiding aggravating movements
Surgical exploration- most common compressing structure deep head of pronator teres

474 | Page

[Orthopedic Neurology]

Cubital Tunnel Syndrome

Ulnar nerve entrapment about the level of the elbow
Aetiology:
1]. At elbow:
o Cubitus Valgus
Trauma
o Bony spurs
Tumours
2]. Proximal 8cm by Arcade Of Struthers ligament of Struthers. It is a
thin aponeurotic band extending From Medial Head Of Triceps To The
Medial Intermuscular Septum; it is 8 cm proximal to the medial
epicondyle; it may look like triceps fibers crossing superficial to the ulnar n.
& usually it is not site for entrapment under ordinary circumstances, but it
do anterior transposition of ulnar nerve is performed
3]. Distal by hypertrophied FCU

Symptoms

Vague dull aching forearm, intermittent parasthesia, ulnar side of hand

Signs
Hypoesthesia ulnar side of hand + 1 fingers
Tinels TEST, behind medial epicondyle
Wartenburgs sign weakness of abduction of little finger
Froments Sign pinch grip and grasping, both of which are impaired by a low ulnar nerve
palsy due to weakness of adductor pollicis
5]. Ulnar clawing if severe (Note - Ulnar Paradox - no clawing if FDP & intrinsics weak)
6]. Wasting: 1st dorsal Interosseus + hypothenars + ulnar FA (FDP & FCU)
Differential Diagnosis
Cervical radiculopathy
Thoracic outlet $
Amyotrophic lateral sclerosis (MND)
Localized peripheral neuropathy
Investigation
1]. NCS reduced nerve conduction velocity
2]. EMG evidence of denervation of muscles
Management
1].
2].
3].
4].

Conservative

1]. Avoidance of repetitive bending of elbow; Extension Block night splint.

1]. injection contraindicated

Surgical -controversy

1]. Decompression- Cubital Tunnel $ Does Not require transposition of the ulnar n
2]. Transposition: - subcutaneously/ Submuscularly (better)
3]. +/- medial epicondylectomy

Results

Sensation improves better than motor function over 3-5 y period

Complications

1]. Recurrence inadequate decompression or irritation or redislocation or neuoma

2]. CRPS

[Orthopedic Neurology]

Page | 475

Ulnar Tunnel Syndrome

Guyons Canal
Anatomy Of Guyons Canal
Floor
transverse carpal ligt to pisiform
Ulnar wall
pisiform
Radial distal wall hook of hamate
Roof
volar carpal ligt
Contains
Ulnar nerve + art
Causes
Repetitive indirect trauma most common
Tumours- ganglion, lipoma
Pisiform instability
Pisotriquetral arthritis
Fractured hook of hamate / pisiform
Ulnar artery thrombosis
Symptoms
Weakness atrophy para / hypoasthesia ulnar side of hand motor sensory or both
Dorsoulnar sensory branch spared
Signs
Local tenderness, tinels test, phalens sign, local swelling, negative allens test, severe ulnar
clawing (remember Ulnar Paradox)
Investigations
Ncs, show delayed motor latency from wrist to 1st dorsal interosseous
Management
Conservative
1]. Splinting
2]. Avoidance of repetitive trauma
Surgical
1]. Decompression of motor and sensory branches
2]. +/- excision of pisiform/ hook of hamate

476 | Page

[Ortho
opedic Neurrology]

P or Intterrosseoous Syndrom
Posterio
S
me
(Pain And Pa
aresis)
Cau
uses (FREA
AS & Montteggia)
1]. Fibrous tendinou
us band at origin of supinator (3
30% of peo
ople)
2 Radial recurrent vessels
2].
v
(the Leash Of
O Henry) (less convincing evid
dence)
3 Extensor carpi radialis brevis
3].
4 Arcade
4].
e of Frohse
5 Supina
5].
ator (the distal borderr).
6 Monte
6].
eggia fractture especiaally types ! & III
7]. R.A of elbow
7
e
8 surgical resection of
8].
o radial hea
ad
9 mass lessions
9].

Sym
mptoms
pain in
n 50%
weakness of exte
ension of wrist
w
and MCP
M joints
Sig
gns
Radial deviation of
o wrist witth dorsiflexxion (ECRLL supplied by
b Radial n
nerve)
If partia
al, pseudo clawed ha
and
Able to
o extend IP
P joints due
e to interro
ossei
no losss of sensation

Investigations
NCS -decreased la
atency across arcade
e of Frohse
e
EMG denervation
d
n fibrillation
ns of affectted muscle
es
Treatment
Conserrvative obsserve for 8--12 wks if no
n evidencce of mass lesion
Surgica
al decomprression

Im
mportantttests

Jeann
ne's Sign
Frome
ent's Sign
Warte
enberg's Sign
S
Duche
enne's Sig
gn
Polloc
ck's Sign
Phalen
ns Sign

umb MP hyyperextenssion 10 -15 key pin

nch or gro
oss grip.
Thu
Thu
umb IP hyp
perflexion key puncch by FPL iin ulnar ne
erve palsiess.
Inability to ad
dduct the extended
e
liittle finger ulnar ne
erve palsy
Clawing of th
he ring and
d small fing
gers ulnar nerve palsy
Inability to fle
ex the DIP of
o the ring and small fingers in high palsie
es
Elb
bows on the table allo
owing the wrists to p
passively fle
ex. If media
an
nerrve sympto
oms provokked within 60 secs = positive

[Orthopedic Neurology]

Page | 477

Radial Tunnel Syndrome

(Pain & No Paresis)

Mild compression of post interosseous nerve without paresis

Causes
As for posterior interosseus syndrome but not usually any mass lesions
Diagnosis
Symptoms
dull aching in extensor muscle mass
worse at end of day
Signs
local tenderness 5cm distal to lat epicondyle
pain elicited by resisted active supination
Middle Finger Test.
o Each finger is tested under resisted extension. Testing the middle finger increases the
pain. Due to ECRB inserting into base of 3rd metacarpal.
o Performed with the elbow and middle finger completely extended with the wrist in
neutral position.
o Firm pressure is applied by the examiner to the dorsum of the proximal phalanx of
the middle finger.
o The test is positive if it produces Pain At The Edge Of The ECRB in the proximal
forearm.
Investigation
NCS
Increased motor latency in active forceful supination
Injection of local anaesthetic into radial tunnel
Differential diagnosis
Tennis elbow
Management
Conservative, anti inflammatories, avoidance of repetitive provoking activities
Surgical, decompression. Internervous plane between ECRB and E Digitorum developed.
PIN found just proximal to arcade of Frohse.

Wartenberg Syndrome

Described in 1932- isolated neuritis of superficial sensory branch of radial nerve

As it winds out from deep fascia beneath brachio-radialis, to be superficial to ECRL
Both tendons may act as scissors entrapping the n
Pain & parasthesia over the distribution of RSN; y with hyperpronation + Tinels sign
Treatment- local steroid injection, surgical exploration and release.

478 | Page

[Orthopedic Neurology]

Nerve Entrapment in Lower Limb

NE R V E
ILIO-INGUINAL
OBTURATOR
FEMORAL LAT. CUT.
SCIATIC
SAPHENOUS
COMMON PERONEAL
SUPERF PERONEAL
SURAL
DEEP PERONEAL
POSTERIOR TIBIAL
1ST LAT.PLANTAR
MEDIAL PLANTAR
INTERDIGITAL

SITE
Hypertrophied abdominal ms
Hip adductor
ASIS
Meralgia paresthetica
Ischial tuberosity, pyriformis ms
Hunters canal
Fibular head
12 cm above Lat.Maleolus, as it
pierce the deep fascia
12 cm distal to Lat Malleolus
Inf. extensor retinaculum
(anterior tarsal tunnel $)
Flexor retinaculum
(Tarsal tunnel $)
Bet AHL fascia, quadratus plantae
Henry Knot (cross of FDL & FHL)
Bet MT3-4 plantar to deep MT lig
(Mortons Neuroma)

CAUSE
Intense training
Skaters
Tight belt

SYMPTOM

Pyriformis
Quad or sartorius
Direct blow
Inversion injury

Sciatica
Infero-medial knee pain
Foot drop
Dorsal foot pain &
paresthesia
Lat. foot parasthesia
Sole pain & parasthesia

Jones fr
Inversion injury
FDL accessorius, RA,
tumors, ganglion
High heels
Orthotics
Push phase in runners

Pain & parasthesia

Medial thigh pain
Lateral thigh pain

Sole pain & paresthesia

Plantar fasciitis
Big toe pain & parasthesia
Digital pain, parasthesia,
dead toe

[Orthopedic Neurology]

Page | 479

Thoracic Outlet Syndrome

Impingement of subclavian v v, and lower trunk (C8 /T1) of

brachial plexus

Boundries: scalenus anterior and medius, and the 1st rib

Age 18-40 (never before puberty rare after 50yr)

Aetiology:
1]. Neck:
Cervical Rib ......... 10 % will have TOS
Fibrous bands
Scaleneus anterior constriction
2]. Shouder
o G VI Acromio-clavicular dislocations & Clavicular fractures
o In some cases, y by recurrent anterior shoulder instability, Dead Arm $
3]. Pancoast tumour
Examination::
1].
Tenderness or mass in supra-clavicular fossa
2].
Lower trunk C8/T1 manifestation:
3].
Sensory changes in the Ring and Little finger
4].
Intrinsic weakness
5].
Vascular Examination
o Radial pulse obliteration + Reproduction Of Symptoms is specific (radial alone is not)
Provocative Tests
1. Adsons TEST
o Arm of the affected side adducted with forearm supinated
o Turn head toward the affected side
o Extend neck and hold breath
o Positive test is obliteration of the radial pulse
2. Reverse Adsons TEST
o As above but head turned away from the affected side
3. Wrights test (Hyperabduction stress test)
o Axillary vessels and plexus bent 90 at the junction of the glenoid and humeral head
o Place extremity in full abduction, external rotation and reach back as far possible. Turn
head away and check for decrease or loss of radial pulse
o Creation of a bruit in the supraclavicular area is further evidence
4. Roos overhead exercise test
o Above head repeated forearm exercise may reproduce symptoms
Investigations:
1- X-ray -Cervical ribs may be seen but more commonly the cause is a fibrous band (not seen)
2- CXR to rule out pancoast tumour
3- MR scan to exclude cervical disc disease
Treatment
1- Non-Operative (for At Least 4 Months)
o Postural re-education
o Activity modification
o Weight loss
2- Operative (rarely required)
o Excision of first rib with fibrous band and anterior scalene muscle via supra-clavicular,
subclavicular or axillary approach
o
o
o