Phalen maneuver

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Phalen maneuver
Phalen's Maneuver.jpg
Phalen's maneuver
Purposetest carpal tunnel syndrome
Transverse section across the wrist and digits. (The median nerve is the yellow dot near the center. The carpal tunnel is not labeled, but the circular structure surrounding the median nerve is visible.) Gray422.png
Transverse section across the wrist and digits. (The median nerve is the yellow dot near the center. The carpal tunnel is not labeled, but the circular structure surrounding the median nerve is visible.)

Phalen's maneuver is a diagnostic test for carpal tunnel syndrome [1] by an American orthopedist named George S. Phalen. [2]

Contents

Technique

The patient is asked to hold their wrists in complete and forced flexion (pushing the dorsal surfaces of both hands together) for 30–60 seconds. The lumbricals attach in part to the flexor digitorum profundus tendons. As the wrists flex, the flexor digitorum profundus contracts in a proximal direction, drawing the lumbricals along with it. In some individuals, the lumbricals can be "dragged" into the carpal tunnel with flexor digitorum profundus contraction. As such, Phalen's maneuver can moderately increase the pressure in the carpal tunnel via this mass effect, pinching the median nerve between the proximal edge of the transverse carpal ligament and the anterior border of the distal end of the radius. By compressing the median nerve within the carpal tunnel, characteristic symptoms (such as burning, tingling or numb sensation over the thumb, index, middle and ring fingers) conveys a positive test result and suggests carpal tunnel syndrome. Because not all individuals will draw the lumbricals into the carpal tunnel with this maneuver, this test cannot be perfectly sensitive or specific for carpal tunnel syndrome. [3]

Accuracy

In studies of diagnostic accuracy, the sensitivity of the Phalen's maneuver ranged from 51% to 91% and its specificity from 33% to 88%.[ citation needed ]

Reverse Phalen's test

Reverse Phalen's test Reverse Phalen's Maneuver.jpg
Reverse Phalen's test

This test is performed by having the patient maintain full wrist and finger extension for two minutes. The reverse Phalen's test significantly increases pressure in the carpal tunnel within 10 seconds of the change in wrist posture and the carpal tunnel pressure has the tendency to increase throughout the test's duration. In contrast, the change in carpal tunnel pressure noted in the standard Phalen's test is modest and plateaus after 20 to 30 seconds.

The average pressure change for Phalen's test at one and two minutes was only 4 mm Hg.[ citation needed ] The average pressure changes in the carpal tunnel for the reverse Phalen's test were 34 mm Hg at one minute into the test and 42 mm Hg at the two-minute point.[ citation needed ]

The extended wrist posture significantly changes the pressure within the carpal tunnel and may be more useful as a provocative examination maneuver. Reverse Phalen's maneuver results in a significantly higher intracarpal canal hydrostatic pressure as compared to a traditional Phalen's. [4] This is thought to add to the sensitivity of conventional screening methods.

Comparison

Phalen's maneuver is more sensitive than Tinel's sign. [5]

Related Research Articles

Repetitive strain injury injury to the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions, vibrations, mechanical compression, or sustained or awkward positions

A repetitive strain injury (RSI) is an injury to part of the musculoskeletal or nervous system which is caused by repetitive use, vibrations, compression or long periods in a fixed position. Other common names include repetitive stress disorders, cumulative trauma disorders (CTDs), and overuse syndrome.

Carpal tunnel syndrome medical condition due to compression of the median nerve as it travels through the wrist at the carpal tunnel

Carpal tunnel syndrome (CTS) is a medical condition due to compression of the median nerve as it travels through the wrist at the carpal tunnel. The main symptoms are pain, numbness and tingling in the thumb, index finger, middle finger and the thumb side of the ring finger. Symptoms typically start gradually and during the night. Pain may extend up the arm. Weak grip strength may occur, and after a long period of time the muscles at the base of the thumb may waste away. In more than half of cases, both hands are affected.

Median nerve Nerve of the upper limb

The median nerve is a nerve in humans and other animals in the upper limb. It is one of the five main nerves originating from the brachial plexus.

Wrist part of the arm between the lower arm and the hand

In human anatomy, the wrist is variously defined as 1) the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand; (2) the wrist joint or radiocarpal joint, the joint between the radius and the carpus and (3) the anatomical region surrounding the carpus including the distal parts of the bones of the forearm and the proximal parts of the metacarpus or five metacarpal bones and the series of joints between these bones, thus referred to as wrist joints. This region also includes the carpal tunnel, the anatomical snuff box, bracelet lines, the flexor retinaculum, and the extensor retinaculum.

Lumbricals of the hand

The lumbricals are intrinsic muscles of the hand that flex the metacarpophalangeal joints and extend the interphalangeal joints.

The flexor digitorum profundus is a muscle in the forearm of humans that flexes the fingers. It is considered an extrinsic hand muscle because it acts on the hand while its muscle belly is located in the forearm.

Flexor digitorum superficialis muscle

Flexor digitorum superficialis is an extrinsic flexor muscle of the fingers at the proximal interphalangeal joints.

Ulnar nerve nerve which runs near the ulna bone

In human anatomy, the ulnar nerve is a nerve that runs near the ulna bone. The ulnar collateral ligament of elbow joint is in relation with the ulnar nerve. The nerve is the largest in the human body unprotected by muscle or bone, so injury is common. This nerve is directly connected to the little finger, and the adjacent half of the ring finger, innervating the palmar aspect of these fingers, including both front and back of the tips, perhaps as far back as the fingernail beds.

Upper limb arm (hand + forearm + upper arm + shoulder)

The upper limb or upper extremity is the region in a vertebrate animal extending from the deltoid region up to and including the hand, including the arm, axilla and shoulder.

Tinels sign

Tinel's sign is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve. It takes its name from French neurologist Jules Tinel (1879–1952).

The flexor pollicis longus is a muscle in the forearm and hand that flexes the thumb. It lies in the same plane as the flexor digitorum profundus.

Anterior interosseous nerve branch of the median nerve

The anterior interosseous nerve is a branch of the median nerve that supplies the deep muscles on the anterior of the forearm, except the ulnar (medial) half of the flexor digitorum profundus. Its nerve roots come from C8 and T1.

Tarsal tunnel

The tarsal tunnel is found along the inner leg posterior to the medial malleolus.

Carpal tunnel passageway on the palmar side of the wrist that connects the forearm to the hand

In the human body, the carpal tunnel or carpal canal is the passageway on the palmar side of the wrist that connects the forearm to the hand.

Ulnar claw

An ulnar claw, also known as claw hand, or 'Spinster's Claw' is a deformity or an abnormal attitude of the hand that develops due to ulnar nerve damage causing paralysis of the lumbricals. A claw hand presents with a hyper-extension at the metacarpophalangeal joints and flexion at the proximal and distal interphalangeal joints of the 4th and 5th fingers. The patients with this condition can make a full fist but when they extend their fingers, the hand posture is referred to as claw hand. The ring- and little finger can usually not fully extend at the proximal interphalangeal joint (PIP).

Anterior interosseous syndrome is a medical condition in which damage to the anterior interosseous nerve (AIN), a distal motor and sensory branch of the median nerve, classically with severe weakness of the pincer movement of the thumb and index finger, and can cause transient pain in the wrist.

Pronator teres syndrome compression neuropathy of the median nerve at the elbow

Pronator teres syndrome is a compression neuropathy of the median nerve at the elbow. It is rare compared to compression at the wrist or isolated injury of the anterior interosseous branch of the median nerve.

Durkan's test is a medical procedure to diagnose a patient with carpal tunnel syndrome. It is a new variation of Tinel's sign that was proposed by JA Durkan in 1991.

Median nerve palsy

Injuries to the arm, forearm or wrist area can lead to various nerve disorders. One such disorder is median nerve palsy. The median nerve controls the majority of the muscles in the forearm. It controls abduction of the thumb, flexion of hand at wrist, flexion of digital phalanx of the fingers, is the sensory nerve for the first three fingers, etc. Because of this major role of the median nerve, it is also called the eye of the hand. If the median nerve is damaged, the ability to abduct and oppose the thumb may be lost due to paralysis of the thenar muscles. Various other symptoms can occur which may be repaired through surgery and tendon transfers. Tendon transfers have been very successful in restoring motor function and improving functional outcomes in patients with median nerve palsy.

PTs and OTs are involved in the assessment and intervention process with clients with carpal tunnel syndrome. Within the area of intervention, PTs and OTs provide education; symptom management techniques such as splinting; and modification of specific tasks, equipment and environment.

References

  1. " Phalen maneuver " at Dorland's Medical Dictionary
  2. Sawaya RA, Sakr C (April 2009). "When is the Phalen's test of diagnostic value: an electrophysiologic analysis?". J Clin Neurophysiol. 26 (2): 132–3. doi:10.1097/WNP.0b013e31819d8046. PMID   19279501.
  3. Urbano, F. (2000). Tinel's sign and Phalen's maneuver: Physical signs of carpal tunnel syndrome. Hospital Physician, Jul, 39-44. (Retrieved 19:15:10 UTC Monday, December 15, 2008 Archived March 19, 2014, at the Wayback Machine
  4. Werner R, Bir C, Armstrong T (1994). "Reverse Phalen's maneuver as an aid in diagnosing carpal tunnel syndrome". Archives of Physical Medicine and Rehabilitation. 75 (7): 783–6. doi:10.1016/0003-9993(94)90010-8. PMID   8024425.
  5. Cherian A, Kuruvilla A. 2006. "Electrodiagnostic approach to carpal tunnel syndrome." Ann Indian Acad Neurol 9:177-182.