Download Common Peripheral Nerve Problems

Splinting for Peripheral Nerve
Injuries
Somaya Malkawi, PhD
Radial Nerve Lesions
Radial Nerve Lesions
(table 13-2)
Check weak or lost motions for each
1. Axilla level (M+S) HIGH (wrist drop)
2. Midhumeral compression/shaft fracture
(M+S) HIGH (wrist drop)
3. Forearm level- Posterior Interosseous
Nerve Palsy- fracture/dislocation of
elbow j (M) LOW
Radial Nerve
Common Sites of Injury
4. Radial Tunnel Syndrome (btw radial
head and supinator muscle (pain
syndrome)
5. Superficial Radial Sensory Nerve Palsy
btw ext carpi radialis longus and
bachioradialis or at wrist from tight splint
(S)
(Wartenberg’s syndrome
High Radial Nerve Palsy
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Wrist drop deformity
Lost wrist ext., MCP ext., and thumb
radial abd and ext.
Triceps spared: Elbow extension is
intact (not at Axilla level)
Supinator and brachioradialis are
paralyzed but supination and elbow
flexion is intact bcz biceps is intact
High Radial Nerve Palsy
High Radial Nerve Palsy
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Depending on the level of injury,
triceps paresis may exist, as well as
some posterior arm sensory loss along
the dorsal lateral aspect of the forearm
and hand
Low Radial Nerve Palsy (posterior
interosseous nerve palsy
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Injuries to the nerve at this level can
occur following compression of the
nerve between the humeral and ulnar
heads of the supinator muscle
Radial head fracture-dislocations
Tumors
History of repetitive and strenuous
pronation and supination.
Low Radial Nerve Palsy (posterior
interosseous nerve palsy
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The clinical picture is:
Intact radially directed wrist extension
Absent MCP extension, thumb
extension, and thumb radial abduction
(M)
Splinting for High RNI
Radial nerve motor palsy with wrist drop
• Custom-made dorsal forearm-based dynamic splint
• Promote functional hand use
• Base: dorsal wrist imm. S.
• Substitute for absent ms power
By assisting MCP extensors
• Worn throughout the day
until MMT: fair (3)
• If no improvement within
two months, refer back to physician.
Splinting for High RNI
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Dynamic splint is good for a high radial
nerve palsy or a posterior interosseous
palsy because this splint design does
not preclude use of active wrist
extension and does assist with finger
extension with slight wrist flexion.
Splinting for High RNI
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Dynamic splint not worn at night
Therapist may offer static wrist imm. S. at
night
Therapists may offer both static and
dynamic alternating between them might
maximize function
Watch for MCP joint contractures if the client
insists on using only a static wrist splint
Splinting for post. Interos.
Nerve syndrome
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Long arm elbow and wrist splint with
elbow in flexion, forearm in neutral or
slight sup., wrist in 20-30 degrees of
ext.
Tenodesis splint encourage wrist and
finger function
Splinting for radial tunnel
syndrome
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Long splint elbow 30 flex, forearm in
full supination, wrist in slight wrist ext.
(20-30)
This decompress pressure on RN
Worn all the time with removal for
hygiene
OR thumb imm. S.
Splinting for wartenberg’s
neuropathy
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Wrist immobilization splint : wrist in 2030 ext
If pain include the thumb
Ulnar Nerve Lesion
UlnarNerve Lesions
(table 13-3)
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Low level (wrist level)
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abductor digiti minimi
flexor digiti minimi
opponens digiti minimi
fourth and third lumbrical
three palmar interossei muscles and four dorsal interossei
muscles
deep head of the flexor pollicis brevis
adductor pollicis
High Level (At or above the elbow)
All previously mentioned muscles
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Flexor Carpi Ulnaris
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Flexor Digitorum Profundus for digits 4, 5
Study weak and lost motions from the table
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Sensory
Function
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Strong wrist flexion and ulnar deviation
power grip via full flexion of the ulnar
two digits
powerful tip and lateral or key pinch
powerfully to cup an object
In hand manipulation
Common sites of
Entrapment/Injury
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Cubital tunnel syndrome
Guyon’s canal compression
Anteriorly: The medial
epicondyle
Laterally: the ulnohumeral
Ligament
Posteromedially: the
fibrous arcade of the two
heads of the flexor carpi
ulnaris.
Roof of this tunnel: fibrous
band extending from the
olecranon to the medial
epicondyle of the humerus
Cupital Tunnel syndrome:
description
 Compression
of the ulnar nerve as it
passes through the cubital tunnel at the
elbow.
 Compression leads to paresthesias
along the nerve course.
 Long withstanding compression leads
to residual motor weakness
 Sever, prolonged ulnar nerve
compression may result in the claw
deformity
Cupital Tunnel syndrome:
description
 loss
of simultaneous wrist flexion and
ulnar deviation
 Pain in the medial aspect of the elbow
and tenderness over the cubital tunnel
 Paresthesias in the ring and little finger
are present
Cupital Tunnel syndrome:
description
 The
clinical picture is one of sensory
loss and motor paresis affecting the
intrinsic ulnar-innervated muscles
 The sensory deficit involves the palmar
and dorsal ulnar aspect of the hand
Claw hand deformity
 Flattening
of the
normal arches of
the hand
 Hyper-extension of
MCP and flexion in
PIP and DIP of 4,
5th
 Unable to abd and
add fingers
Splinting for High Ulnar Nerve
compression (at elbow)
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Elbow splint with elbow flexed 30- 45
degrees
If included, wrist is positioned in neutral to
20 degrees of ext
Including the wrist decreases the effects
from flexor carpi ulnaris contraction
The splint is worn to avoid prolonged and
repetitive full flexion of the elbow (like in
sleeping) which increase pressure in the
cupital tunnel
Extreme flexion of the elbow increases
traction on the ulnar nerve
Splinting for High Ulnar Nerve
compression (at elbow)
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Splint is worn during the night for app 3
weeks
If symptoms of decreases sensibility,
continuous symptoms, the client may wear
the splint all the time
Material:
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Rigid, strong enough to carry the weight of the
elbow
Self bonding to help formulation of the crease of
elbow
conformability and drapability to mold material
over olecranon process
Splinting for High Ulnar Nerve
compression (at elbow)
Guyon's tunnel
syndrome
 Symptoms
include a feeling of pins and
needles in the ring and little fingers, and
may progress to a burning pain in the
wrist and hand followed by decreased
sensation in the ring and little fingers
 and/or motor weakness
Ulnarly: pisiform and tendinous
insertion of the flexor carpi
ulnaris
Radially: the hook of the hamate
The roof of the tunnel is the
flexor retinaculum
Guyon's tunnel
syndrome
 cause
of this syndrome is from pressure
of bicycle handlebars seen with cyclists
 Or hard, repetitive compression against
a desk surface while using a computer
mouse.
Causes
 Most
common: a ganglion, followed by
occupational neuritis
 Other causes include a pisiform or hook
of hamate fracture
 arthritis
Symptoms
 Same
as the Cubital Tunnel syndrome
 The sensory deficit involves the palmar
ulnar aspect of the hand, both sides of
the little finger, and the ulnar border of
the ring finger
Hand based Ulnar Nerve splint
intervention
Anti-claw splint
 Ring and little finger in 30- 45 flex
 Correct the claw hand posture
 This splint hand functional grasp
 Continue wear of the splint with
Removal for hygiene and exercise
until the muscle imbalance resolves or
until tendon transfers are performed
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Hand based Ulnar Nerve splint
intervention
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Dynamic splint
Figure 13-13
Finger loops with rubber bands
connected to wrist band
Wear throughout the day with removal
for H and E
Median Nerve Lesion
Causes of Median Nerve
Lesion
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Humeral fracture
Elbow dislocation
Distal radius fracture
Dislocation of lunate into the carpal canal
Laceration of volar wrist
Affected muscles by median
nerve lesion
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Study Figure 13-16 and Table 13-4
Low level: abd policis brevis, flexor policis
previs, opponense policis, 1st and 2nd
lumbricals
High level : Low level muscles and
pronator teres, flexor carpi radialis, flexor
policis longus, lateral half of lex digitorum,
palmaris longus, flex digitorum
superficialis, abd policis brevis
Functional Involvement
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Clumsiness with pinch
Decreased power grip
Power grip is affected
Lumbricals of index and middle finger is
weak
Check sensory supply of the MN
Resulting deformity
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Ape hand deformity
Thumb in adduction, ext.
Thumb web space contract
Lost opposition,
Fingers show trophic changes
Slight clawing of index and middle fingers
bcz of loss of lumbrical innervation
Result of high or low MNI
Common deficits/deformities
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Pronator syndrome
Anterior Interosseous Nerve Palsy
Carpal Tunnel Syndrome
High: Pronator Syndrome
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Result from strong repetitive pronation and
supination as the nerve passes btw the 2 heads of
pronator teres
Diffuse pain in the med. forearm or distal volar
arm
Dysethesias in the radial three and one-half digits
of the hand
Symptoms may be provoked by resisted elbow
flexion, often with concurrent resisted forearm
pronation
High: Anterior Interosseous
Nerve Palsy
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Entrapment neuropathy of the motor branch of
the median nerve.
Vague discomfort in proximal forearm
Typical patient complain: difficulty with writing
and cant make O with thumb and index
Pain develop gradually and is followed by
weakness of the muscles innervated by the
branch
Usually there are no sensory symptoms
Low: Carpal Tunnel Syndrome
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Carpal Tunnel –
opening through the
wrist to the hand
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Formed by:
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Bottom: Bones of
wrist
Top: Transverse
carpal ligament
Diagnosis of CTS
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Most frequently a clinical diagnosis based on the
patient’s reports of symptoms and clinical tests.
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Phalen’s Test: Patient rests elbows on table and allows
wrists to drop into flexion … test is positive if client
reports parasthesias within 1 minute.
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Tinel Test: Tapping over Carpal Tunnel produces
parasthesias.
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EMG’s sometimes ordered to confirm (gold std.)
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What is the difference btw CTS and pronator
syndrome – check book 295 and 296
Splinting for Pronator
syndrome
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Avoid resisted pronation and passive supination
Splint: Place elbow in 90 degrees flexion, forearm
neutral, wrist in neutral to slight flex
Splinting for Ant Int. Nerve
compression
Avoid elbow ext and extreme frearm pronation and
supination
 Splints:
 Immobilize elbow 90 flex, forearm in neutral
OR
 Small splint to block thumb IP and index DIP extension
 Figure 13-17
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Splinting for CTS
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Ergonomic
adaptations for
home, leisure, work
env
Activity modifications
Exercise
Splint:
Wrist immobilization
splint that place wrist
in neutral
Splinting for MNI with involved
thumb
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As in later stage of CTS
Thumb web spacer splint: for low MNI, C bar helps
maintain thumb web space (LOW INJURY)
Allows free wrist mobility
OR
Hand based thumb spica (butterfly)
Splinting for combined ulnar
and median NI
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Splint that inhibits MP EXTENSION
All digits included