Peripheral Nerve Entrapment and

Injury in the Upper Extremity

Sabrina Silver, DO, and Christopher C. Ledford, MD, Eglin Family Medicine Residency Program,
Eglin Air Force Base, Florida;​Uniformed Services University of the Health Sciences, Bethesda, Maryland
Kendall J. Vogel, DO, National Capital Consortium, Fort Belvoir, Virginia
James J. Arnold, DO, Eglin Family Medicine Residency Program, Eglin Air Force Base,
Florida;​Uniformed Services University of the Health Sciences, Bethesda, Maryland

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 diagnos-

Illustration by Steve Oh
tic 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. (Am Fam Physician. 2021;​103(5):275-285.
Copyright © 2021  American Academy of Family Physicians.)

Peripheral nerves in the upper extremity are at risk for larger degree of injury.3-5 More specifically, nerve injury is
injury and entrapment. Their long course from the central divided into three grades of increasing severity:​neurapraxia,
nervous system through the extremity puts them at risk of axonotmesis, and neurotmesis. Neurapraxia is injury that
compromise at narrow anatomic tunnels and areas of edema damages the myelin sheath but not the axon. Complete
and trauma. The brachial plexus branches into five periph- recovery is possible in days to weeks. Axonotmesis extends
eral nerves, three of which are commonly entrapped at the damage to the axon but preserves the connective tissue
shoulder, elbow, and wrist. Epidemiology data on entrap- framework. This can lead to subsequent degeneration distal
ment neuropathies are sparse. Carpal tunnel syndrome is to the lesion. Because of the slow rate of axonal regenera-
the most common with a prevalence of 3% in the general tion, recovery can take years, with complete recovery often
population (15% in the workforce).1 Cubital tunnel syn- unachievable. Neurotmesis is the total or partial disruption
drome is also relatively common, with one U.S. metropol- of the entire nerve fiber, including the connective tissue
itan area reporting a prevalence of 1.8% to 5.9%.2 Overall framework. Full clinical recovery is usually not achieved.6,7
prevalence of peripheral neuropathies in the general popu- How long compression must be present to cause perma-
lation is unclear. nent loss of conduction or fibrosis is not well defined in the
literature.
Pathophysiology
Mechanisms of nerve injury can include direct pressure, History and General Examination
stretch, overuse of a joint, or microtrauma. Prolongation of Nerve entrapment should be suspected when limb weak-
these injurious mechanisms causes fibrosis, resulting in a ness, pain, or paresthesia is present and not caused by
another etiology, such as systemic disease or muscle injury.
CME This clinical content conforms to AAFP criteria for History should focus on known trauma, time course, aggra-
CME. See CME Quiz on page 267. vating activities, and distribution of symptoms. In the
Author disclosure:​ No relevant financial affiliations. absence of significant trauma, evaluation of range of motion
and muscle strength is needed, and inspection, palpation,

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 PERIPHERAL NERVE ENTRAPMENT AND INJURY

and neurologic testing of the area should be performed with during a radical mastectomy).20,21 Injury to this nerve is the
assessment of the cervical spine.8 Knowledge of myotomes most common cause of scapular winging.20,21
and dermatomes helps localize the specific nerve injured9-11 Spinal Accessory Nerve. The spinal accessory nerve is vul-
(Table 1,10,11 Figures 112 and 212). nerable to injury in the posterior triangle of the neck from
direct trauma or iatrogenic damage. Findings on exam-
Common Nerve Injuries and Entrapment ination include scapular winging and weakness in shoul-
Syndromes of the Upper Extremity der shrugging and shoulder abduction past 180 degrees.21
Table 2 summarizes specific physical examination findings Chronic injury may result in trapezius atrophy.
and treatment options associated with each nerve.13-38 Suprascapular Nerve. The suprascapular nerve is vulner-
able at several locations. The first is posterior to the clav-
SHOULDER AND ARM icle, occurring with clavicular fractures. It is susceptible
Brachial Plexus. Brachial plexus injury is commonly asso- to stretching injuries related to overhead activities at the
ciated with contact sports. Known as a stinger, this injury suprascapular and spinoglenoid notches. 33 It can also be
causes transient paresthesia and weakness radiating from entrapped by glenoid labral cysts that extend from the
the neck in the distribution of the injured nerve root. Pro- capsule with labral injury. 33 Symptoms of suprascapular
posed mechanisms are traction, compression, or direct nerve entrapment include shoulder pain and shoulder
trauma to the brachial plexus or cer-
vical nerve root (e.g., leading with
the shoulder during a tackle in foot- TABLE 1
ball). The most common distribu-
20

tion is the C5 and C6 myotomes and Joint Function and Cervical Root Myotomes with Associated
dermatomes. Following a first episode, Muscles and Nerves in the Upper Extremities
return to play is acceptable when there Cervical
is complete resolution of symptoms Joint function root Muscles Nerves
and cervical spine injury has been Shoulder abduction C5 Deltoid Axillary
excluded.32,39 Persistent or recurrent
stingers prompt additional evaluation Elbow flexion C5, C6 Biceps Musculocutaneous

for cervical stenosis or other bony Elbow extension C7 Triceps Radial

abnormalities.32
Forearm pronation C6, C7 Pronator teres Median
Axillary Nerve. The axillary nerve
is vulnerable as it passes around the Forearm supination C6 Supinator Radial
humerus and through the quadrilat-
Wrist flexion C7 Flexor carpi radialis, flexor Median and ulnar
eral space of the posterior shoulder.
carpi ulnaris
Shoulder dislocations, repetitive use
injuries, humeral neck fractures, and Wrist extension C6, C7 Extensor carpi radialis bre- Radial
vis, extensor carpi radialis
local pressure (e.g., from crutches) are
longus
mechanisms of injury.19 Damage to the
axillary nerve results in paresthesia or Finger flexion C8 Flexor digitorum profundus, Ulnar and median
pain of the lateral shoulder and weak- flexor digitorum superficialis

ness in shoulder external rotation, Finger extension C7, C8 Extensor digitorum, exten- Radial (posterior
extension, abduction, and forward sor indicis, extensor digiti interosseous)
flexion. minimi
Long Thoracic Nerve. The long tho- Thumb abduction C7, C8 Abductor pollicis longus Radial (posterior
racic nerve is vulnerable to traction interosseous)
injury at its nerve roots located at the
Thumb flexion C8, T1 Flexor pollicis longus Median (anterior
middle scalene.20 Other mechanisms of interosseous)
injury include​direct blows to the nerve
as it exits the pectoralis muscle at the Finger abduction or T1 Intrinsic hand muscles Ulnar
adduction
fourth or fifth rib, repetitive stretching
(e.g., throwing a baseball, serving a Information from references 10 and 11.
volleyball), or iatrogenic damage (e.g.,

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 PERIPHERAL NERVE ENTRAPMENT AND INJURY

abduction and forward flexion weakness. Rotator cuff Sensory deficit usually affects the posterior forearm and
injury can present similarly;​therefore, magnetic reso- dorsal hand.17
nance imaging, ultrasonography, or electrodiagnostic
studies are usually appropriate to determine the specific FOREARM AND ELBOW
etiology if initial radiography is inconclusive.18,33 Median Nerve. Proximal median nerve entrapment is rare.
Radial Nerve. The radial nerve is vulnerable to injury The primary clinical finding is pain in the proximal volar
and entrapment at several locations. Proximally, mid- forearm. Other findings may include cramping, decreased
dle to distal third humeral shaft fractures are the most grip strength, or paresthesia in the first three digits.22
common cause of traumatic injury.40 The most common Pronator and anterior interosseous nerve syndromes
compressive cause results from sustained pressure on are the two most common compression neuropathies of
the posterior arm at the location of the radial groove, the median nerve occurring around the elbow.22 Pronator
where the nerve lies directly on periosteum and is not syndrome occurs with compression of the median nerve
protected by muscle. This is known as radial neuropa- between the two heads of the pronator teres (Figure 3)42
thy, or sometimes Saturday night palsy.17 Compression or under the proximal edge of the flexor digitorum super-
also occurs at the axilla, as it passes through the triceps ficialis (https://​w ww.youtube.com/watch?​v=ZqhO​1dz​
brachii lateral head.41 The nerve innervates the extensors qTtY). It develops insidiously over months to years, often
of the wrist and fingers, causing wrist and finger drop. exacerbated by activities with the arm in pronation, such

FIGURE 1 FIGURE 2

C3

C4
C3
C5
C4
C6
Supraclavicular nerve C5
C7
Axillary nerve C6
C8
T1
Radial nerve T1

Terminal part of
musculocuta-
neous nerve

Radial nerve

C6

Ulnar nerve Ulnar nerve C8 C8

Posterior Median nerve Anterior C7

Posterior Anterior

Posterior and anterior views of the upper limb nerve Posterior and anterior views of the upper limb derma­
cutaneous innervation. tomes.
Illustration by Renee Cannon Illustration by Renee Cannon

Reprinted with permission from Neal SL, Fields KB. Peripheral nerve Reprinted with permission from Neal SL, Fields KB. Peripheral nerve
entrapment and injury in the upper extremity. Am Fam Physician. entrapment and injury in the upper extremity. Am Fam Physician.
2010;​81(2):​149. 2010;​81(2):​149.

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 PERIPHERAL NERVE ENTRAPMENT AND INJURY
TABLE 2

Nerve Injury or Compression in the Upper Extremities with Associated Findings and Treatment
Nerve Characteristics Sensory deficits Motor deficits

Axillary nerve Lateral shoulder region paresthesia, shoulder Lateral shoulder Deltoid, teres minor
movement weakness in all planes, difficulty with
overhead activities

Long thoracic Scapular winging None Serratus anterior

nerve

Median nerve at the No pain;​thumb weakness;​unable to make OK None Flexor pollicis longus, flexor digi-
elbow or forearm sign;​if patient is unable to make OK sign but has torum profundus
anterior interosse- sensory deficits, consider a proximal median
ous nerve branch nerve injury

Median nerve at the Aching pain in the proximal volar forearm;​palm, Thumb, index and mid- Varied but may include weakened
elbow (pronator thumb, or index finger paresthesia dle fingers, and radial grip strength
syndrome) side of ring finger

Median nerve at the Pain in the wrist and hand, occasionally radiating Thumb, index and mid- Abductor pollicis brevis, first or
wrist (carpal tunnel to the forearm;​paresthesia in the first three digits;​ dle fingers, and radial second lumbrical
syndrome) weak grip strength due to weakness of thumb side of ring finger
abduction and opposition resulting in difficulty
with tasks such as opening doors;​thenar emi-
nence atrophy in advanced disease

Radial nerve at the Weakness in finger extension, weakness of ulnar None Extensor carpi radialis brevis,
elbow (posterior deviation, wrist extension can be maintained extensor digitorum, extensor dig-
interosseous nerve) (because of sparing of extensor carpi radialis iti minimi, extensor carpi ulnaris,
longus), pain is rare abductor pollicis longus, extensor
pollicis brevis, extensor pollicis
longus, extensor indicis, supinator

Radial nerve at the Pain 3 cm to 4 cm distal to lateral epicondyle, Lateral forearm None
elbow (superficial often causes pain at night
radial nerve)

Radial nerve at the Weakness in finger and wrist extension, paresthe- Posterior forearm and Brachioradialis (elbow flexion);​
spiral groove (radial sia of forearm and hand dorsal hand extensor carpi radialis longus;​
neuropathy [Satur- branches distally include super-
day night palsy]) ficial radial nerve and posterior
interosseous nerve, which can
also be affected

Radial nerve at the Pain and paresthesia of the hand;​if motor find- Dorsal radial hand None
wrist (handcuff ings are present, consider a higher radial nerve
neuropathy) lesion

Spinal accessory Weakness in shoulder abduction (> 180 degrees), None Trapezius (shoulder shrug) and
nerve scapular winging sternocleidomastoid

Various nerves at Transient paresthesia and weakness from neck or Varied based on Varied based on affected nerves
brachial plexus level shoulder traveling down the arm affected nerves

NSAIDs = nonsteroidal anti-inflammatory drugs.

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Conservative therapy Surgical indications

Physical therapy, monitoring recovery No electrophysiologic improvement after

as repetitive hammering or a back-
with serial examination vs. electromyog- 3 to 4 months of conservative treatment hand swing with a tennis racket. The
raphy and nerve conduction studies pronator syndrome test is performed
by resisting the patient’s pronation
Physical therapy, avoidance of aggravat- Penetrating trauma resulting in nerve
ing activities transection, no improvement after 18 to 24 starting with the elbow in neutral and
months of conservative treatment moving into extension. When positive,
it will induce paresthesia and pain22
Rest, splinting, and observation Space-occupying lesion, no improve-
ment after 3 to 4 months of conservative (https://w w w.youtube.com/watch?​
treatment v=ufCw​Qx0c​FNk).
The anterior interosseous nerve is
Avoidance of aggravating activities, rest, Space-occupying lesion, no improve-
the motor-only nerve for deep mus-
trial of NSAIDs, steroid injection ment after 3 to 4 months of conservative cles of the forearm. The most common
treatment examination finding in anterior inter-
Splinting, physical therapy, yoga, and Early surgery:​evidence of moderate
osseous nerve syndrome is weakness
acupuncture for the short term​ to severe median nerve damage on in the flexor pollicis longus and flexor
Cochrane review:​nocturnal splinting electro­myo­graphy digitorum profundus, resulting in the
more effective than placebo13 Significant weakness of grip strength;​thenar inability to make an OK sign. Subtle
Maximal benefit of conservative treat- eminence atrophy;​no improvement after weakness can be detected by attempt-
3 to 4 months of conservative treatment
ment typically achieved around 3 months ing to break apart the thumb and sec-
Cochrane review:​surgical decompression is
Steroid injection ond digit while the patient makes an
better at long-term symptom management
Cochrane review:​symptomatic improve- than splinting alone;​unclear if surgery is OK sign22 (https://​w ww.youtube.com/
ment for up to one month with steroid better than steroid injection, especially in watch?v=R15I0JzYIDc).
injection;​more recent studies show up
to 10 weeks of improvement and delay of
those with mild symptoms15 Radial Nerve. At the elbow, the
surgery for up to 1 year14 Cochrane review:​endoscopic and open radial nerve divides into a superfi-
techniques are equally effective;​however,
cial branch (sensory only) and a deep
endoscopic recovery is shorter by 8 days16
branch (posterior interosseous nerve
Rest, activity modification, splinting, Significant motor weakness is present, no [motor only];​ Figure 4).42 Entrapment
stretching, NSAIDs;​steroid injection can improvement after 3 to 4 months of conser-
of the superficial radial nerve causes
be therapeutic and diagnostic vative treatment
pain 3 cm to 4 cm distal to the lateral
epicondyle along the proximal lateral
forearm with activity or during sleep.
Rest, activity modification, splinting, Surgery rarely required
Pain is exacerbated by extending the
stretching, NSAIDs;​steroid injection can elbow, pronating the forearm, and
be therapeutic and diagnostic flexing the wrist.30
Avoidance of repeat compression, Fracture of the humerus resulting in nerve
Posterior interosseous nerve syn-
physical therapy nearly 100% effective at compromise drome results in motor-only weakness.
6 months based on small observational Examination findings include loss
study, cock-up splint for normal hand of finger extension (finger drop) but
function
preserved wrist extension with radial
deviation of the wrist. This is caused
Eliminate external compression, steroid Surgery rarely required, no improve- by compensatory actions of the exten-
injection ment after 3 to 4 months of conservative
treatment
sor carpi radialis longus, which is not
innervated by the posterior interosse-
Physical therapy, avoidance of aggravat- Penetrating trauma resulting in nerve ous nerve.30 These findings are usually
ing activities transection, no improvement after 18 to 24
from compression by space-occupying
months of conservative treatment
lesions (most commonly lipoma) or
Rest, physical therapy, pain control Evidence of anatomic abnormalities (foram- synovitis of the elbow.30
inal stenosis) predisposing to repeat injury Additionally, a lesion proximal to
continues
the split, known as radial tunnel syn-
drome, may have both the motor and
sensory symptoms described above.

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 PERIPHERAL NERVE ENTRAPMENT AND INJURY
TABLE 2 (continued)

Nerve Injury or Compression in the Upper Extremities with Associated Findings and Treatment
Nerve Characteristics Sensory deficits Motor deficits

Suprascapular Weakness in shoulder flexion, abduction, external Sensory to shoulder Supraspinatus (shoulder abduc-
nerve rotation joint tion) and infraspinatus (external
rotation of the shoulder)

Ulnar nerve at the Pain, paresthesia, numbness in the fourth and Hypothenar eminence, Intrinsic hand muscles, flexor
elbow (cubital tun- fifth digits;​weakness in finger abduction, thumb fifth finger, and ulnar carpi ulnaris
nel syndrome) abduction, and thumb-index pincer;​positive side of fourth finger
Tinel sign at the cubital tunnel;​weak wrist flexion
not due to the median nerve innervation of flexor
carpi radialis and flexor digitorum superficialis,
which compensate for loss of flexor carpi ulnaris

Ulnar nerve at Atrophy of intrinsic hand muscles (hypothenar, Hypothenar eminence, Intrinsic hand muscles (grip
the wrist (cyclist’s lumbrical, interosseous);​pain, paresthesia, numb- fifth finger, and ulnar side strength)
palsy) ness of the hand;​positive Froment sign (Figure 6;​ of fourth finger
https://​w ww.youtube.com/watch?​v=WnTV​WnT​
FymA)

NSAIDs = nonsteroidal anti-inflammatory drugs.

Information from references 13-38.

FIGURE 3 FIGURE 4

Humerus

Median nerve

Radial nerve

Humeral head Deep branch

Radius of pronator of radial nerve
teres muscle (posterior inter-
osseous nerve)
Superficial
branch of
radial nerve
Ulnar head of Arcade of
pronator teres Frohse
Supinator muscle
muscle (superficial head)
Ulna

Note the median nerve traveling through the two pro­ Deep and superficial radial nerve branches at the
nator heads at the elbow . elbow.
Illustration by Myriam Kirkman-Oh Illustration by Myriam Kirkman-Oh
Reprinted with permission from Chumbley EM, O’Connor FG, Reprinted with permission from Chumbley EM, O’Connor FG,
Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician. Nirschl RP. Evaluation of overuse elbow injuries. Am Fam Physician.
2000;​61(3):​693. 2000;​61(3):​693.

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Conservative therapy Surgical indications

Physical therapy to maintain range of Early surgery for space-occupying lesion handcuff neuropathy because of the
motion, activity modification to limit (i.e., ganglion cyst) potential for injury by circumferential
overhead activities Systematic review of 21 studies (275 ath- pressure on the wrist. The superficial
letes) showed lower patient-reported pain radial nerve has no motor component
as tracked by visual analog scale and a but provides sensation to the dorsal
return to sport of 92% of athletes17
aspect of the hand and wrist.40
Activity modification, NSAIDs, elbow No improvement after 3 to 4 months of Ulnar Nerve. The ulnar nerve can
pads, physical therapy,​night splinting conservative treatment become entrapped at the wrist in the
in 45 degrees of extension with neutral
forearm,​steroid injection
Most common procedures are surgical Guyon canal, which is a fibro-osseous
decompression or nerve transposition;​in
one Cochrane review they were equally
tunnel bordered by the hook of hamate
effective 18 and the pisiform (Figure 5).44 Occupa-
tional causes include activities that put
Patient education, activity modification, Management of anatomic cause (e.g., gan- pressure on the volar surface of the
padding on handlebars, splinting, physi- glion cyst, lipoma, hook of hamate fracture), wrist, such as operating a jackhammer,
cal therapy, and NSAIDs;​steroid injection no improvement after 2 to 4 months of cycling (i.e., cyclist’s palsy), or weight-
not indicated because causes are usually conservative treatment
related to structural or mechanical
lifting. Other causes include fractures,
Postsurgical splinting and rehabilitation
abnormality;​drain ganglion cyst if this is recommended
lipomas, ganglion cysts, and systemic
the cause diseases (e.g., diabetes mellitus, rheu-
Typical return to work in 6 to 8 weeks
matoid arthritis, hypothyroidism) that
cause localized edema.38,45
Findings of ulnar nerve entrapment
include atrophy of the hypothenar,
lumbrical, and interosseous muscles.38
Ulnar Nerve. At the elbow, the ulnar nerve passes poste- Motor dysfunction is less common because of the deep
riorly and superficially to the medial epicondyle within the nature of the motor branch, but it results in weakness of
cubital tunnel, leaving it susceptible to compression from abduction and adduction of the fingers as well as the pincer
external and internal sources. Symptoms include pain and mechanism.46 The Froment sign (Figure 6) can be observed
paresthesia in the ulnar nerve dermatome, especially in the with ulnar nerve entrapment at any anatomic location, but
fourth and fifth digits of the hand.17,18,35 This is exacerbated it is more common when injury occurs to the deep branch at
by repetitive elbow flexion, which compresses the area of the wrist.38,46 Sensory disturbances occur over the hypoth-
the cubital tunnel. Patients may have point tenderness over enar eminence, the fifth digit, and half of the fourth digit.38
the ulnar nerve and a positive Tinel sign.35 Late findings are
motor weakness of finger and thumb abduction.35 Diagnostic Testing
The primary diagnostic tests for evaluation of nerve injury
HAND AND WRIST and entrapment include electrodiagnostic tests, subdi-
Median Nerve. At the wrist, the median nerve travels under vided into nerve conduction studies and electromyography
the transverse carpal ligament (i.e., carpal tunnel syn- (EMG), and imaging, which includes magnetic resonance
drome), which has been reviewed previously in American imaging and ultrasonography. With findings of severe
Family Physician.1 Symptoms include pain in the wrist and weakness or multiple nerve involvement, imaging should be
hand, numbness and tingling in the first three digits, and performed immediately;​otherwise, it can be initiated after
weak grip strength. Atrophy of the thenar muscles occurs six to eight weeks of conservative treatment.47-50 A summary
with prolonged injury.36 The Tinel sign and Phalen test are of imaging indications is provided in Table 3.47-49
often used in the evaluation of carpal tunnel syndrome but Electrodiagnostic testing is helpful to confirm the diag-
have a wide range of sensitivity (38% to 100% and 42% to nosis, determine severity, and monitor progression of nerve
85%, respectively) and specificity (54% to 98% and 55% to damage.50 This can be especially helpful in presurgical
100%, respectively).23,24 Electrodiagnostic testing is used to planning for more common nerve entrapments, such as
increase the diagnostic likelihood of carpal tunnel syndrome carpal tunnel syndrome and cubital tunnel syndrome.51,52
and should be performed if surgery is being considered.26,43 Nerve conduction studies evaluate the speed and time of
Radial Nerve. At the wrist, the superficial radial nerve is conduction across the nerve;​EMG measures the tested
susceptible to injury by compression because it runs super- muscle’s response to stimulation.50 Changes to both nerve
ficially to the flexor retinaculum. This has been termed conduction studies and EMG will occur depending on the

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FIGURE 5

chronicity and degree of injury, so they should be ordered

Deep motor
simultaneously.50-52 The ability of EMG or nerve conduction
branch studies to detect nerve injury is variable and requires sub-
jective 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
Flexor digiti
nerve thickness indicative of nerve injury.40,53 Magnetic res-
minimi onance imaging can identify local muscular atrophy consis-
tent with denervation.53 Ultrasonography can evaluate for a
Superficial
sensory branch variety of changes that occur in peripheral nerve entrapment
Hamate bone syndromes.47,48 A useful point-of-care application of ultra-
Guyon canal
Transverse sonography is determining specific sites of entrapment by
Pisiform bone carpal ligament compression with the ultrasonography transducer to recre-
Ulnar nerve
ate symptoms.47,48 Specifically, ultrasonography is helpful in
Tendon of flexor
carpi ulnaris
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
Guyon canal (fibro-osseous tunnel bordered by the
hook of hamate and the pisiform).
83.3% specific for carpal tunnel syndrome.49 Accurate inter-
pretation is dependent on sonographer experience, and cor-
Illustration by Christy Krames
relation to EMG has yet to be shown.49
Reprinted with permission from Shehab R, Mirabelli MH. Evalua-
tion and diagnosis of wrist pain:​a case-based approach [published
correction appears in Am Fam Physician. 2013;​88(7):​427]. Am Fam
Treatment
Physician. 2013;​87(8):​571. In the absence of traumatic injury, initial treatment
of nerve injuries should be conservative and includes

FIGURE 6

A B

Froment sign. The Froment sign is a finding of ulnar nerve entrapment as a result of the patient using flexor pollicis
longus (median nerve innervation) instead of adductor pollicis (ulnar nerve innervation) to perform opposition pinch.
Most patients will default to using adductor pollicis for this action because of the increased strength over flexor pol­
licis longus39 (some patients may need to be coached to attempt the maneuver without flexing the thumb). This sign
is commonly present in prolonged entrapment at the wrist but can also occur as a result of ulnar compression at the
elbow (cubital tunnel) or arise more proximally in the cervical spine. (A) Test is positive (abnormal) due to weakness
in adductor pollicis muscle secondary to ulnar neuropathy and inability to pinch without flexing the thumb. (B) This
image demonstrates the absence of an ulnar injury. See also:​https://​w ww.youtube.com/watch?v=WnTVWnTFymA.

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 PERIPHERAL NERVE ENTRAPMENT AND INJURY

TABLE 3

Imaging Uses and Indications for Specific Nerves

Median nerve Radial nerve
Imaging General use and technique assessment assessment Ulnar nerve assessment

Magnetic Fat-suppressed highly T2-weighted Carpal tunnel Posterior interosse- Cubital tunnel syndrome:​
resonance images demonstrate nerve pathology syndrome:​ eval- ous nerve:​thickened perform with extended
imaging the best uate persistent superficial head elbow, shows nerve
Low slice thickness:​2 mm to 3 mm in nerve distress of supinator (most enlargement, external com-
distal extremity and 4 mm to 5 mm in and/or inadequate common entrapment pression by loose bodies or
proximal extremity surgical release point of posterior space-occupying lesions,
interosseous nerve), and regional inflammatory
Identify anatomic abnormalities such as denervation of the and denervation changes
ganglion cysts or bony abnormalities supinator muscle Guyon canal:​useful for
Rule out other causes by identifying Superficial radial persistent symptoms with
abnormalities of surrounding soft tissues nerve:​imaging of normal electromyogra-
Evaluate for muscle denervation choice for evaluation phy or tumor noted on
Evaluate for nerve tumors of surrounding muscle ultrasonography

Ultraso- Use high-resolution (15 to 18 MHz) Carpal tunnel Posterior interosse- Cubital tunnel syndrome:​
nography transducers syndrome:​ assess ous nerve:​superficial nerve appears enlarged and
Identify causes of entrapment such as nerve thickness nerve is easy to visual- hypoechoic, loss of normal
fibrous bands, ganglion cysts, anoma- within the carpal ize, enlargement and fibrillar appearance;​com-
lous muscles, and bony abnormalities tunnel and prona- hypoechogenicity of parison of cross section to
tor quadratus for the nerve can be seen contralateral side, shows
Evaluate for changes in nerve thickness a change greater dynamic snapping of nerve
(by cross-sectional area) and fascicular than 2 mm
appearance Guyon canal:​shows
thickened and hypoechoic
Assessment of nerve and surrounding nerve and ganglion cyst or
tissue vascularization accessory muscle
Easy comparison to contralateral arm
Dynamic testing

Information from references 47-49.

SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments

Physical examination findings should be used in combination with elec- C Expert opinion and clinical practice
trodiagnostic studies to increase the accuracy of a carpal tunnel syndrome guideline
diagnosis before surgical intervention. 26,43

Electrodiagnostic testing should be used as an adjunct to physical examina- C Expert opinion

tion and imaging to help confirm the diagnosis of peripheral nerve injury,
establish the severity of injury, and monitor progression of nerve damage. 50

Ultrasonography and magnetic resonance imaging should be used for diag- C Disease-oriented evidence, expert
nosing anatomic causes of nerve entrapment.47,48 opinion

In the absence of traumatic injury, initial treatment of nerve injuries should B Patient-oriented evidence in systematic
be conservative and include patient education, physical therapy, and activity review, expert opinion, randomized con-
modification.13-22,29-31,33-35,37,38 trolled 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://​w ww.aafp.org/afpsort.

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 PERIPHERAL NERVE ENTRAPMENT AND INJURY

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