radial tunnel syndrome
Introduction
Introduction to fistula syndrome As early as 1883, it was suggested that the compression of the sacral or sacral nerve branches may be one of the causes of tennis elbow. In 1905, Guillain reported a case in which a wind musician repeated the supination and pronation of the forearm. , causing compression of the posterior interosseous nerve. Later, cases of post-internal bone compression have been reported clinically. Aneurysms, tumors, and elbow fractures are considered to be the cause of posterior interosseous nerve compression. However, for many years, tennis elbow has been the forearm proximal end. The main diagnosis of lateral pain, in 1956, Michele and Krueger described the clinical signs and symptoms of the radial pronatorsyndrome. In 1960, they further reported the proximal supinator muscle release for the treatment of refractory tennis elbow. Clinical efficacy. In 1972, Roles and Maudsley proposed the concept of radial tunnel syndrome (radialtunnelsyndrome) and analyzed the anatomical region, structural features, nerves that may be crushed, and the causes of tennis elbow. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious complication:
Cause
Causes of fistula syndrome
(1) Causes of the disease
The fistula syndrome is common in the dominant hand. Manual laborers and athletes who need to repeatedly rotate the forearm are prone to this disease. The patients are more common in 40 to 60 years old. The proportion of men and women is similar. There is no obvious history of trauma before the onset, and the symptoms gradually appear. These data support the "minimally invasive theory", that is, the occurrence of fistula syndrome is mainly caused by repetitive forearm chronic injury. It is believed that about 5% of tennis elbow patients are fistula syndrome, and other causes of fistula syndrome are as follows: :
1. Trauma Spinner reported 10 cases of fistula syndrome, 9 of which had a history of forearm trauma, and forearm injury caused by trauma, which can form scars and adhesions in the sacral nerve compression site, causing nerve compression.
2. Tumor sheath cysts and lipomas in the muscles of the tumor.
3. Fracture and dislocation of the humeral head dislocation and Monteggia fracture are prone to sacral nerve injury.
4. Rheumatoid arthritis rheumatoid lesions can thicken the synovial membrane, and can destroy the ankle joint capsule in the late stage, causing dislocation of the humeral head and injuring the nerve.
5. After local scar inflammation and trauma, localized scars gradually appear, which can cause nerve compression.
6. The symptoms of viral neuritis for 3 months, most of them can ask about the history of "cold", can not ask other related causes, after viral infection, can also cause nerve and connective tissue proliferation.
7. The iatrogenic injury is mainly local injection of local blocking drugs, traditional Chinese medicine, etc., which can cause scar formation around the nerve and nerve damage.
(two) pathogenesis
The fistula is located at the anterior side of the proximal humerus and is about 4 cm long. It originates from the proximal end of the humeral humeral head joint. The distal end of the fistula is located on the superficial surface of the supinator, and the phrenic nerve passes through the deep part. The muscle and the lateral wrist long and short extensor muscles, the fascial boundary of the temporal extensor muscle of the temporal side is adjacent to the deep fascia of the forearm, and is in close contact with the posterior interosseous nerve. These muscles cross the nerve to form the anterior wall of the fistula. The bottom of the fistula is composed of the ankle joint capsule, and the inner side wall is composed of the diaphragm and the biceps tendon.
There are 5 anatomical structures of the posterior interosseous nerve compression caused by fistula syndrome, 4 of which are in the fistula.
The first nerve compression point is located at the level of the humeral head, which is caused by the fascia band between the diaphragm and the diaphragm or the tissue adhesion between the two muscles. Because of the variation of the band, it is in this part. Compression is less common in the clinic.
The second nerve compression point is located at the level of the humeral neck, which is caused by the Henry vasospasm. The Henry vasospasm consists of the branch of the radial artery and the branches of the vein. It crosses the nerve. These blood vessels are sometimes entangled with the nerves, and the circumflex muscles. The tendon and forearm extensor muscles branch.
The third nerve compression point is the functional nerve compression caused by the proximal medial aspect of the short extensor digitorum of the radial side of the wrist. The short extensor muscle of the radial wrist originates from the extremity group and the collateral ligament of the elbow joint. Its starting point is The fascia, which is continuous with the starting point of the supinator muscle, has a certain clinical significance. When the Frohse arch is released, the tension of the lateral extensor muscle of the temporal wrist can be reduced, which can be caused by external epicondylitis. To a certain therapeutic effect, however, loosening the lateral extensor of the wrist does not relieve the compression of the Frohse arch.
The fourth nerve compression point is the Frohse arch, which is the most common cause of fistula syndrome. The Frohse arch is a reflexive arch structure, which is 1 cm distal to the border of the short extensor muscle of the temporal wrist and 2 to 4 cm from the ankle joint.
The arch structure is the proximal boundary of the superficial head of the supinator, and the nerve is thereby passed out. The outer side of the structure is from the outermost end of the outer upper jaw, which is an ankle structure. Before the fiber structure forms an arcuate structure to the distal end, the maneuver And combined with the medial fibers, the medial fibers from the medial epicondyle, just outside the humeral head joint surface, the medial fibers are sacral or membranous structure, making the zygomatic arch more rigid.
There is a significant variation in the thickness and size of the fiber arch. Spinner's study of autopsy found that about 30% of adult corpses have thickened Frohse arch and hard inner fibers, due to neonatal cadaveric specimens. It is always a muscular structure, and it can be considered that the formation of fibrous structure is related to the pre-rotation and supination of the forearm.
After the nerve passes through the fistula, it is 1/3 line along the proximal end of the humerus, and the length between the two ends of the supinator muscle is 4 cm. There is a bare area between the two ends, which is located in the posterior biceps nodules of the humerus. Level, here, when the forearm is supinated, the nerve and the periosteum can be in direct contact. When the region is fractured, the humeral head dislocation and internal fixation are easy to damage the phrenic nerve, when the nerve passes through the supinator There are also many bands that can cause nerve compression. The band is occasionally formed in the middle of the supinator muscle. Variations in the fistula, such as the temporal and temporal division of the short extensor muscle of the radial side of the wrist, can cause the occurrence of fistula syndrome. .
After the nerve spins the posterior muscle, on the dorsal side of the forearm, the posterior interosseous nerve separates the shallow branch and the deep branch, and the superficial branch supports the ulnar wrist extensor muscle, which refers to the total extensor muscle, the small finger extensor muscle, and the deep branch supports the long thumb muscle. Long extensor muscles of the thumb, short extensor muscles of the thumb, intrinsic extensors of the index finger, and finally the nerves innervate the dorsal joint capsule and interphalangeal joint of the wrist through the fourth extensor compartment.
Prevention
Fistula syndrome prevention
The symptoms closely related to modern living and working conditions can be completely prevented, and the prevention method is also very simple. That is, try to avoid the long-term stalemate of the upper limbs, the mechanical and frequent working state, and work for a period of time to activate the limbs. Do some relaxing exercises, divert your attention, and don't maintain a long-lasting upper limb movement.
Complication
Complications of fistula syndrome Complication
First, the tennis elbow refers to the inflammation of the lateral tendon of the elbow. The pain is caused by repeated force exerted on the muscles of the wrist and fingers. The patient feels pain in the affected part while gripping or lifting the object. Tennis elbow is a typical example of overwork syndrome. Housewives, bricklayers, carpentry, etc. Those who have repeatedly used force to do elbow activities are also susceptible to this disease. Studies have shown that the wrist stretching muscles, especially the short extensor muscles of the radial side of the wrist, when the wrist is stretched and applied to the temporal side, the tension is very large, and some of the fibers at the joints of the muscles and muscles are prone to excessive stretching and form a slight tear.
Second, nerve fibers undergo demyelination changes, even distal axonal disintegration, Waller degeneration of myelin. During limb movement, nerve fibers in the stenotic channel undergo chronic inflammatory inflammation under mechanical stimulation and aggravate the vicious circle of edema-ischemia.
Symptom
Symptoms of fistula syndrome Common symptoms Reduced muscle tone Dull pain Muscle atrophy
1. Clinical features
(1) Pain: The main clinical manifestation of fistula syndrome is pain, pain is dull pain, lateral elbow pain, can be radiated to the proximal phrenic nerve, or can be radiated to the distal end of the interosseous nerve. Upper limb activity can be The symptoms are aggravated, and the nighttime pain is more obvious. In severe cases, it often wakes up at night, and the veins are stagnant. Especially when the tourniquet is applied, the pain can be aggravated.
(2) weakened muscles: feeling dull and numb is less common, stretching fingers, stretching thumb muscle strength is often caused by pain, and muscle atrophy can occur in the late stage.
2. Physical inspection
(1) fistula compression test: in some patients, about 5 cm away from the iliac crest, a slidable beam is touched. This is the part of the interosseous nerve that passes through the Frohse arch. The tenderness may be tender (Figure 4 ), double-sided comparison should be performed during inspection.
(2) Middle finger extension test: Stretching the middle finger to tighten the short extensor fascia of the temporal wrist and compress the posterior interosseous nerve. The examination method: the elbow pronation position, when the forearm is fully extended, the patient's middle finger is resistant to resistance. The pain in the fistula area is positive, and partial closure therapy is helpful for differential diagnosis.
Examine
Examination of fistula syndrome
X-ray examination can rule out humeral head dislocation and Monteggia fracture.
Diagnosis
Diagnosis and diagnosis of fistula syndrome
Diagnosis can be established based on medical history, clinical features, and physical examination.
The fistula syndrome needs to be differentiated from the external humeral epicondylitis. Fistula syndrome and interosseous nerve compression syndrome: the compression of the phrenic nerve at the elbow can cause two types of compression syndrome: fistula syndrome and interosseous nerve compression syndrome, the two causes are similar, card The pressure sites are similar, and there is no obvious difference in pathology. Clinically, only the clinical manifestations are distinguished. That is, the fistula syndrome is mainly caused by sensory disturbance, and the dyskinesia is not obvious, and the posterior interosseous nerve compression syndrome is mainly caused by dyskinesia.
