Peripheral Nerve Entrapment and Injury in the Upper Extremity

 

Am Fam Physician. 2021 Mar 1;103(5):275-285.

Author disclosure: No relevant financial affiliations.

Peripheral nerves in the upper extremities are at risk of injury and entrapment because of their superficial nature and length. Injury can result from trauma, anatomic abnormalities, systemic disease, and entrapment. The extent of the injury can range from mild neurapraxia, in which the nerve experiences mild ischemia caused by compression, to severe neurotmesis, in which the nerve has full-thickness damage and full recovery may not occur. Most nerve injuries seen by family physicians will involve neurapraxia, resulting from entrapment along the anatomic course of the nerve. In the upper extremity, the brachial plexus branches into five peripheral nerves, three of which are commonly entrapped at the shoulder, elbow, and wrist. Patients with nerve injury typically present with pain, weakness, and paresthesia. A detailed history and physical examination alone are often enough to identify the injury or entrapment; advanced diagnostic testing with magnetic resonance imaging, ultrasonography, or electrodiagnostic studies can help confirm the clinical diagnosis and is indicated if conservative management is ineffective. Initial treatment is conservative, with surgical options available for refractory injuries or entrapment caused by anatomic abnormality.

Peripheral nerves in the upper extremity are at risk for injury and entrapment. Their long course from the central nervous system through the extremity puts them at risk of compromise at narrow anatomic tunnels and areas of edema and trauma. The brachial plexus branches into five peripheral nerves, three of which are commonly entrapped at the shoulder, elbow, and wrist. Epidemiology data on entrapment neuropathies are sparse. 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.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physical examination findings should be used in combination with electrodiagnostic studies to increase the accuracy of a carpal tunnel syndrome diagnosis before surgical intervention.26,43

C

Expert opinion and clinical practice guideline

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.50

C

Expert opinion

Ultrasonography and magnetic resonance imaging should be used for diagnosing anatomic causes of nerve entrapment.47,48

C

Disease-oriented evidence, expert opinion

In the absence of traumatic injury, initial treatment of nerve injuries should be conservative and include patient education, physical therapy, and activity modification.1322,2931,3335,37,38

B

Patient-oriented evidence in systematic review, expert opinion, randomized controlled trial, case series, Cochrane review


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Physical examination findings should be used in combination with electrodiagnostic studies to increase the accuracy of a carpal tunnel syndrome diagnosis before surgical intervention.26,43

C

Expert opinion and clinical practice guideline

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.50

C

Expert opinion

Ultrasonography and magnetic resonance imaging should be used for diagnosing anatomic causes of nerve entrapment.47,48

C

Disease-oriented evidence, expert opinion

In the absence of traumatic injury, initial treatment of nerve injuries should be conservative and include patient education, physical therapy, and activity modification.1322,2931,3335,37,38

B

Patient-oriented evidence in systematic review, expert opinion, randomized controlled trial, case series, Cochrane review


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

show all author info

SABRINA SILVER, DO, CAQSM, is an associate director of the Eglin Family Medicine Residency Program, Eglin Air Force Base, Fla., and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

CHRISTOPHER C. LEDFORD, MD, CAQSM, FAAFP, is faculty at the Eglin Family Medicine Residency Program, and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

KENDALL J. VOGEL, DO, is a sports medicine fellow at the National Capital Consortium, Military Primary Care Sports Medicine Fellowship, Fort Belvoir, Va. At the time this article was written, Dr. Vogel was a resident in the Eglin Family Medicine Residency Program.

JAMES J. ARNOLD, DO, FACOFP, FAAFP, is director of osteopathic education and family medicine obstetric faculty at the Eglin Family Medicine Residency Program, and an associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to Sabrina Silver, DO, CAQSM, 490 Soundview Ct., Mary Esther, FL 32569 (email: silvesab@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Wipperman J, Goerl K. Carpal tunnel syndrome: diagnosis and management. Am Fam Physician. 2016;94(12):993–999. https://www.aafp.org/afp/2016/1215/p993.html...

2. An TW, Evanoff BA, Boyer MI, et al. The prevalence of cubital tunnel syndrome: a cross-sectional study in a U.S. metropolitan cohort. J Bone Joint Surg Am. 2017;99(5):408–416.

3. Otani Y, Yermakov LM, Dupree JL, et al. Chronic peripheral nerve compression disrupts paranodal axoglial junctions. Muscle Nerve. 2017;55(4):544–554.

4. Osborne NR, Anastakis DJ, Davis KD. Peripheral nerve injuries, pain, and neuroplasticity. J Hand Ther. 2018;31(2):184–194.

5. Gupta R, Rummler L, Steward O. Understanding the biology of compressive neuropathies. Clin Orthop Relat Res. 2005;(436):251–260.

6. Kaya Y, Sarikcioglu L. Sir Herbert Seddon (1903–1977) and his classification scheme for peripheral nerve injury. Childs Nerv Syst. 2015;31(2):177–180.

7. Nicholls K, Furness ND. Peripheral nerve compression syndromes of the upper limb. Surgery. 2019;37(5):288–293.

8. Zarkadas PC, Throckmorton TW, Steinmann SP. Neurovascular injuries in shoulder trauma. Orthop Clin North Am. 2008;39(4):483–490, vii.

9. Netter FH, Colacino S. Atlas of Human Anatomy. CIBA-GEIGY Corporation; 1989.

10. Hoppenfeld S, Thomas H, Hutton R. Physical Examination of the Spine and Extremities. Prentice Hall; 1976.

11. Thompson J. Netter's Concise Orthopaedic Anatomy, Updated Edition. 2nd ed. Elsevier; 2015:416.

12. Neal SL, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician. 2010;81(2):147–155. Accessed October 1, 2019. https://www.aafp.org/afp/2010/0115/p147.html

13. Page MJ, Massy-Westropp N, O'Connor D, et al. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012;(7):CD010003.

14. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007;(2):CD001554.

15. Verdugo RJ, Salinas RA, Castillo JL, et al. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev. 2008;(4):CD001552.

16. Vasiliadis HS, Georgoulas P, Shrier I, et al. Endoscopic release for carpal tunnel syndrome. Cochrane Database Syst Rev. 2014;(1):CD008265.

17. Doughty CT, Bowley MP. Entrapment neuropathies of the upper extremity. Med Clin North Am. 2019;103(2):357–370.

18. Caliandro P, La Torre G, Padua R, et al. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2016;(11):CD006839.

19. Mitchell JJ, Chen C, Liechti DJ, et al. Axillary nerve palsy and deltoid muscle atony. JBJS Rev. 2017;5(7):e1.

20. Safran MR. Nerve injury about the shoulder in athletes, part 2: long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome. Am J Sports Med. 2004;32(4):1063–1076.

21. Didesch JT, Tang P. Anatomy, etiology, and management of scapular winging. J Hand Surg Am. 2019;44(4):321–330.

22. Dang AC, Rodner CM. Unusual compression neuropathies of the forearm, part II: median nerve. J Hand Surg Am. 2009;34(10):1915–1920.

23. Brüske J, Bednarski M, Grzelec H, et al. The usefulness of the Phalen test and the Hoffmann-Tinel sign in the diagnosis of carpal tunnel syndrome. Acta Orthop Belg. 2002;68(2):141–145.

24. Padua L, Coraci D, Erra C, et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15(12): 1273–1284.

25. Huisstede BM, Hoogvliet P, Randsdorp MS, et al. Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments—a systematic review. Arch Phys Med Rehabil. 2010;91(7):981–1004.

26. Graham B, Peljovich AE, Afra R, et al. The American Academy of Orthopaedic Surgeons evidence-based clinical practice guideline on: management of carpal tunnel syndrome. J Bone Joint Surg Am. 2016;98(20):1750–1754.

27. Shi Q, MacDermid JC. Is surgical intervention more effective than non-surgical treatment for carpal tunnel syndrome? A systematic review. J Orthop Surg Res. 2011;6:17.

28. De Kleermaeker FGCM, Meulstee J, Claes F, et al. Treatment outcome in patients with clinically defined carpal tunnel syndrome but normal electrodiagnostic test results: a randomized controlled trial. J Neurol. 2017;264(12):2394–2400.

29. Page MJ, O'Connor D, Pitt V, et al. Exercise and mobilisation interventions for carpal tunnel syndrome. Cochrane Database Syst Rev. 2012;(6):CD009899.

30. Dang AC, Rodner CM. Unusual compression neuropathies of the forearm, part I: radial nerve. J Hand Surg Am. 2009;34(10):1906–1914.

31. Kim KH, Park KD, Chung PW, et al. The usefulness of proximal radial motor conduction in acute compressive radial neuropathy. J Clin Neurol. 2015;11(2):178–182.

32. Concannon LG, Harrast MA, Herring SA. Radiating upper limb pain in the contact sport athlete: an update on transient quadriparesis and stingers. Curr Sports Med Rep. 2012;11(1):28–34.

33. Boykin RE, Friedman DJ, Higgins LD, et al. Suprascapular neuropathy. J Bone Joint Surg Am. 2010;92(13):2348–2364.

34. Momaya AM, Kwapisz A, Choate WS, et al. Clinical outcomes of suprascapular nerve decompression: a systematic review. J Shoulder Elbow Surg. 2018;27(1):172–180.

35. Andrews K, Rowland A, Pranjal A, et al. Cubital tunnel syndrome: anatomy, clinical presentation, and management. J Orthop. 2018;15(3):832–836.

36. Popinchalk SP, Schaffer AA. Physical examination of upper extremity compressive neuropathies. Orthop Clin North Am. 2012;43(4):417–430.

37. Coraci D, Loreti C, Piccinini G, et al. Ulnar neuropathy at wrist: entrapment at a very “congested” site. Neurol Sci. 2018;39(8):1325–1331.

38. Earp BE, Floyd WE, Louie D, et al. Ulnar nerve entrapment at the wrist. J Am Acad Orthop Surg. 2014;22(11):699–706.

39. Standaert CJ, Herring SA. Expert opinion and controversies in musculoskeletal and sports medicine: stingers. Arch Phys Med Rehabil. 2009;90(3):402–406.

40. Ljungquist KL, Martineau P, Allan C. Radial nerve injuries. J Hand Surg Am. 2015;40(1):166–172.

41. Latef TJ, Bilal M, Vetter M, et al. Injury of the radial nerve in the arm: a review. Cureus. 2018;10(2):e2199.

42. Chumbley EM, O'Connor FG, Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician. 2000;61(3):691–700. Accessed August 27, 2020. https://www.aafp.org/afp/2000/0201/p691.html

43. Keith MW, Masear V, Chung K, et al. Diagnosis of carpal tunnel syndrome. J Am Acad Orthop Surg. 2009;17(6):389–396.

44. Shehab R, Mirabelli MH. Evaluation and diagnosis of wrist pain: a case-based approach [published correction appears in Am Fam Physician. 2013;88(7):427]. Am Fam Physician. 2013;87(8):568–573. Accessed August 27, 2020. https://www.aafp.org/afp/2013/0415/p568.html

45. Murata K, Shih J-T, Tsai T-M. Causes of ulnar tunnel syndrome: a retrospective study of 31 subjects. J Hand Surg Am. 2003;28(4):647–651.

46. Duncan SFM, Saracevic CE, Kakinoki R. Biomechanics of the hand. Hand Clin. 2013;29(4):483–492.

47. Kalia V, Jacobson JA. Imaging of peripheral nerves of the upper extremity. Radiol Clin North Am. 2019;57(5):1063–1071.

48. Deniel A, Causeret A, Moser T, et al. Entrapment and traumatic neuropathies of the elbow and hand: an imaging approach. Diagn Interv Imaging. 2015;96(12):1261–1278.

49. Tai T-W, Wu C-Y, Su F-C, et al. Ultrasonography for diagnosing carpal tunnel syndrome: a meta-analysis of diagnostic test accuracy. Ultrasound Med Biol. 2012;38(7):1121–1128.

50. Freedman M, Helber G, Pothast J, et al. Electrodiagnostic evaluation of compressive nerve injuries of the upper extremities. Orthop Clin North Am. 2012;43(4):409–416.

51. American Association of Electrodiagnostic Medicine; American Academy of Neurology, and American Academy of Physical Medicine and Rehabilitation. Practice parameter for electrodiagnostic studies in carpal tunnel syndrome: summary statement. Muscle Nerve. 2002;25(6):918–922.

52. Practice parameter for electrodiagnostic studies in ulnar neuropathy at the elbow: summary statement. American Association of Electrodiagnostic Medicine, American Academy of Physical Medicine and Rehabilitation, American Academy of Neurology. Arch Phys Med Rehabil. 1999;80(3):357–359.

53. Small KM, Adler RS, Shah SH, et al.; Expert Panel on Musculoskeletal Imaging. ACR Appropriateness Criteria shoulder pain–atraumatic. J Am Coll Radiol. 2018;15(11S):S388–S402.

54. Isaacs J, Cochran AR. Nerve transfers for peripheral nerve injury in the upper limb: a case-based review. Bone Joint J. 2019;101-B(2):124–131.

55. Rinker B. Nerve transfers in the upper extremity: a practical user's guide. Ann Plast Surg. 2015;74(suppl 4):S222–S228.

 

 

Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Related Content


More in Pubmed

MOST RECENT ISSUE


Apr 15, 2021

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article