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CONDITION/DISORDER SYNONYMS
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Ape-hand deformity
Median nerve palsy
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G56.10 Other lesions of median nerve, unspecified upper limb
S44.10XA Injury of median nerve at upper arm level, unspecified arm, initial encounter
S54.10XA Injury of median nerve at forearm level, unspecified arm, initial encounter
S64.10XA Injury of median nerve at wrist and hand level of unspecified arm, initial encounter
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PREFERRED PRACTICE PATTERNS
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4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation1
5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2
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PATIENT PRESENTATION
Patient is a 44-year-old male who works in a new home construction. He spends the majority of his day using power tools, such as a drill and nail gun, in various positions of the elbow and forearm. After a long period of part time work he has returned to work 60+ hours/week and spent the interim lifting weights. Over the past 2 weeks, he has begun to notice a burning/achy pain at his volar/medial forearm. This pain is exacerbated while at work and seems to get worse throughout the day, especially with usage of hand power tools. He also reports a painful tingling that radiates all the way to his thumb and first two fingers when he is really symptomatic. Functionally, he reports that he feels as if his hand fatigues quickly at work.
Clinically, he is a mesomorphic male with hyperalgesia reported across median nerve distribution of hand (thenar eminence, volar surface and tips of digits I, II, and radial side of III. No weakness of pronator teres but overall grip strength is decreased 20 lb on the affected side. Forearm pain is aggravated by sustained forearm pronation, especially with elbow extension. Palpable tenderness deep in the pronator teres with positive pronator compression test and median nerve neurodynamic testing.
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Entrapment neuropathy of the median nerve other than within the carpal tunnel of the wrist3,4
Common entrapment sites include; ligament of Struthers, bicipital aponeurosis, and pronator teres (all generically called pronator syndrome—PN), fibrous arch of flexor digitorum superficialis (anterior interosseous syndrome—AINS)
Signs and symptoms typical of neuropathy, includes:
Symptoms are seen in the distribution of the median nerve in the hand3, distal upper arm, and volar forearm
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Essentials of Diagnosis
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Pain, paresthesias, and sensory loss perceived on radial side of the palm and the palmar side of thumb, index, middle, and radial side of the ring fingers (no sensory loss if AINS)
Pain may radiate up to the elbow, ...