Neurology, Ortho, PM&R, or Sports Medicine - who best to evaluate ulnar nerve damage?

[Krony]

I'm interested to hear any perspectives regarding different (or similar?) approaches each of these specialty areas might take to evaluate trauma-related ulnar nerve damage. I would guess ortho would handle the more substantial trauma related nerve damage - knife wounds, crushed elbows, etc. But what about the less severe cases involving tweaking a wrist or occupational situations?

For example, are neurologists the only ones that do EMGs? I suspect not, but is the accuracy or utility of the EMG something that correlates fairly directly with physician skill, or is this a pretty straightforward exercise anyone could perform proficiently with some practice? Who perform EMGs the most?

Would a neurologist do more than just assess the viability of the nerve - for example, endeavor to investigate how the trauma or surrounding anatomy might be contributing to the neuropathy? Or would this be more reserved for ortho, sports medicine, or PM&R?

Thanks in advance for your thoughts.

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[Docxter]

An EMG- or electrophysiology-fellowship trained neurologist would be the best person for the EMG part. Some PM&R docs do EMGs as well, but I'd stick with the neurologist. If a specific location of the damage is identified (e.g. cubital tunnel or Guyon canal or elsewhere), then you will need an MRI to assess the anatomy around the nerve to see if there is anything to fix and have that MRI read by a fellowship trained musculoskeletal radiologist. If a surgically treatable cause is found, go to a hand fellowship trained orthopedic surgeon to have it fixed. If there's nothing to fix surgically, go to PM&R for rehab.

 

[IMGforNeuro]

From what i have seen , even a general neurologist can evaluate most EMGs . The most common cases which need EMG and nerve conduction studies as carpal tunnel syn , peri neuropathy etc can be handled even by gen neurologists because most of them do rotate through Neuromuscular/Clinical Neurophysiology . But the EMG for rare muscle dystrophies as myotonic dystrophy etc could need a fellowship trained neurologist.

 

[Stinky Tofu]

As a PM&R resident, we do 3-4 months of EMGs and nerve conduction studies in the same lab that the Neurology residents do their 1-2 months. We also do EMGs on rotations such as Sports Medicine, Spine, SCI, MSK, etc.

I don't think that it's as simple as whose better in general at performing the studies. I think it depends on the type fo study. Personally, I think that complex neurological disorders are usually best if done by a fellowship-trained Neurologist because they see them more often and can also provide better medical management. I think that suspected mononeuropathies (ulnar, radial, median, etc.) and radiculopathies (C/T/L) are managed best by Physiatrists (especially if they've done a fellowship in Spine, Sports Medicine, or EMG) because we see these things much more and we have more extensive MSK training. We can also decide which studies are needed (EMG/NCS, MRI, CT, etc.), provide better medical management, and refer to a surgeon if necessary. Orthopaedic Surgeons (irregardless of whether or not they've done a Sports Medicine or hand fellowship) are not trained to do EMGs. For this reason and the reasons above, you will often see Physiatrists in a Orthopaedic group.

 

[Krony]

Thanks everyone for the great posts

-Krony

 

[neurologist]

The other group that does pretty well at treating mononeuropathies (although they don't do EMG) is occupational therapists.

While the diagnostic workup of these problems often falls to neurologists, I think the actual treatment of many nerve entrapments is best handled by OT, PT or physiatrists, and in some cases, surgically via orthopedics or neurosurgery.