PERIPHERAL NERVE INJURIES
Ahmad A. Fannoon, Msc, Hand Therapist
Part 1
ANATOMY 2
Anatomy review 3
A peripheral nerve consists of a bundle or bundles
of axons whose cell bodies are in the spinal cord or
ganglia just outside the spinal cord.
Motor nerve fibers originate in the anterior column
of the spinal cord.
Anatomy review 4
sensory nerve fibers originate in the dorsal root
ganglia.
Sympathetic fibers are axons of cell bodies in the
sympathetic ganglia of the autonomic nervous
system.
Anatomy review 5
Anatomy review 6
Some fibers are myelinated, others are thinly
myelinated or unmyelinated.
Each fiber is enclosed completely by a protective
sheath of connective tissue (endoneurium).
Anatomy review 7
Endoneurium:
Serve as a packing tissue between individual fibers.
Elastic & resists stretch: protecting individual fibers
from stretch.
After injury, remains as guiding for regeneration of
axons to their terminal endpoints.
Anatomy review 8
Nerve fibers occur in bundles of varying size called
funiculi.
Each funiculus is ensheathed by perineurium.
Perineurium: denser & stronger connective tissue
than endoneurium.
Each funiculus usually contains a mixture of motor,
sensory, & sympathetic fibers.
Anatomy review 9
The funiculi are packed loosely in connective tissue
called epineurium.
Protects against stretch.
Increases at joints to provide more of a cushion
against compressive forces.
Anatomy review 10
Part 2
NERVE RESPONSE TO INJURY 11
Phases 12
Nerve response to injury in two phases:
1. Wallerian degeneration.
2. Neural regeneration.
Phase 1: Wallerian degeneration 13
Disintegration of the axon.
Breakdown of the myelin sheath.
Degeneration occurs distal to the level of injury,
including:
Motor & sensory end receptors.
Phase 1: Wallerian degeneration 14
Distally remains empty Schwann sheaths &
endoneurial tubes:
Shrinkage & collapse.
Phase 2: Neural regeneration 15
Neuronal regeneration with sprouting of the axon.
For nerve regeneration to be successful:
The axon must cross the injury site.
Enter the same endoneurial tube.
Phase 2: Neural regeneration 16
The rate of regeneration is 1 – 3 mm/day after an
initial latency of 3 to 4 weeks with additional
delays at the injury site & at the end organ.
Phase 2: Neural regeneration 17
Nerve regeneration is complicated by many factors
which may include:
Shrinkage of the endoneurial tube (preventing
reentry of the sprouting axons).
Scaring at the site of injury (short-circuiting the
progress of the sprouting axon).
Phase 2: Neural regeneration 18
Mismatching of the motor, sensory, & sympathetic
fibers.
Degeneration of motor & sensory end receptors.
In most favorable conditions: severance of a
peripheral nerve injury usually results in some
degree of residual deficit.
Part 3
CLASSIFICATION OF NERVE INJURIES 19
Classifications of nerve injuries 20
Nerve injuries are classified according to the extent
of injury to the axon & the connective tissue sheath.
Sunderland classification includes 5 degrees of
nerve injury.
Sunderland classification 21
Sunderland 1st degree 22
Axonal conduction is interrupted but structures
remain intact.
Recovery is spontaneous & complete.
Seddon’s “Neuropraxia”.
Sunderland 1st degree 23
Temporary loss of nerve function in the following
order:
Motor.
Proprioception & vibration.
Touch.
Pain.
Sudomotor function.
Sunderland 2nd degree 24
Interruption of axons.
Endoneurium, perineurium, & epineurium are intact.
Wallerian degeneration occurs.
Recovery is spontaneous & good.
Sunderland 3rd degree 25
Occurs in entrapment lesions.
Axon & their endoneurial tubes in discontinuity.
The interior of the funiculi are involved.
Recovery is spontaneous but less complete than in
1st & 2nd degrees?
Sunderland 3rd degree 26
Scarring may prevent axons from bridging to &
reentering their original endoneurial tubes.
Axons may enter a functionally different tube:
o E.g.: Sensory axon might enter a tube that
terminates in a sweat gland.
Sunderland 3rd degree 27
• Axons may enter a functionally similar tube but one
that terminates at a different point than the axon
previously innervated.
o faulty reinnervation residual motor & sensory
deficit need for sensory reeducation & motor
retraining.
Sunderland 4th degree 28
Axon, endoneurium, & perineurium are in
discontinuity.
Scarring & internal disorganization much > than in
3rd degree.
Fiber bundles integrity is lost.
Some spontaneous, but hardly useful, may occur.
Sunderland 4th degree 29
Surgical repair is required to allow for functional
healing to occur.
Residual deficits will occur.
Scarring.
Faulty regeneration & reinnervation.
Sunderland 5th degree 30
The entire nerve trunk is in discontinuity.
Surgical repair required.
Residual deficits persist.
Sunderland degrees 31
Degree Motor Sensory Treatment Recovery Therapy
1st Paralysis Minimal loss Observation Complete Short-term,
focused
2nd Paralysis Complete loss Observation Usually
complete
Moderate
3rd Paralysis Complete loss Surgical may
be required
Incomplete Moderate
4th Paralysis Complete loss Surgical Incomplete Long-term
5th Paralysis Complete loss Surgical
mandatory
Never
complete
Long-term
Part 4
FACTORS AFFECTING PROGNOSIS FOR RECOVERY 32
Nature of injury 33
Simple laceration better than crush or stretch injury.
Damage along a considerable length of nerve.
The higher the level of injury to the axon, the more difficult for the cell body to participate in axonal regeneration.
The higher the level of injury, the more mixing is possible.
Nature of injury 34
The higher the level of injury, the longer the distal
muscle & sensory end organs will remain
denervated & undergo atrophy & fibrosis.
Age 35
Children have far better functional recovery after
suture than adults.
Exact reasons are unknown.
Mixed versus unmixed nerves 36
In 3rd degrees & worse.
Recovery is better if the fibers within a given
funiculus are unmixed.
Axons would enter a functionally similar endoneurial
tube.
Motor versus sensory recovery 37
Denervated muscle can remain viable for up to 3
years.
Atrophy & fibrosis cloud prevent functional
reinnervation.
Sensory end organs degenerate more quickly than
motor end organs.
Recovery Conclusion 38
In 3rd stage & worse, preinjury state can’t be
restored completely in adults.
The goal of therapy is to:
Maximize motor & sensibility recovery.
Assist in compensation for residual deficits.
Part 5
SPECIFIC NERVE LESIONS 39
Radial nerve lesions 40
May be associated with:
Humeral shaft fracture.
Elbow fracture & dislocation.
Upper third of the radius fracture.
Compression between radial head & supinator
muscle (radial tunnel syndrome).
Radial nerve lesions 41
Motor, sensory, & functional loss depends exactly on
the exact site of injury.
42
Motor loss
ECU.
EDC.
EDQM.
APL.
EPL.
EPB.
EIP.
43
Functional loss
MP joints extension of all digits.
Thumb radial abduction & extension.
Ulnar wrist extension.
44
Sensory loss
Dorsum of the thumb.
Dorsum of the 2nd, 3rd, & half of the 4th ray to the
level of PIP joint.
If the posterior interosseous nerve branch is solely
involved:
No sensory deficit occurs.
45
Motor loss
All aforementioned muscles +:
Supinator.
ECRL.
ECRB.
46
Functional loss
Ulnar & radial wrist extension.
weakened supination.
MP extension.
Thumb extension.
Thumb radial abduction.
47
Sensory loss
Same as in forearm level injury.
48
Motor & functional loss
Additional motor loss:
Brachioradialis.
Additional functional loss:
weakened elbow flexion.
49
Motor & functional loss
Additional motor loss:
Triceps.
Additional functional loss:
Elbow extension.
50
Deformity & other loss
Classic deformity is wrist drop.
Hand grip is compromised significantly:
Loss of wrist extensors which position & help
stabilize the wrist during grasp.
51
Wrist drop 52
Median nerve lesions 53
May be associated with:
Humeral fracture.
Elbow dislocation.
Distal radius fracture.
Dislocation of the lunate into the carpal canal.
Knife & glass lacerations of the volar wrist.
Median nerve lesions 54
Compression sites:
Carpal canal (carpal tunnel syndrome).
Between the two heads of the pronator teres in the
forearm (pronator syndrome).
Anterior interosseous nerve between pronator teres
& FDP in the forearm (anterior interosseous nerve
syndrome)
55
Motor loss
Opponens pollicis.
APB.
FPB (superficial head).
1st & 2nd lumbricales.
56
Functional loss
Thumb opposition.
Compromising activities requiring fine prehension.
57
Sensory loss
Volar surface of thumb, index, long, & radial half of
the ring fingers.
Dorsal surface of the distal phalanges of the same
digits.
58
Motor loss
All aforementioned
muscles +:
Pronator teres.
FCR.
FDS.
Palmaris longus.
FPL.
FDP to the index &
long fingers.
Pronator quadratus.
59
Functional loss
Pronation weakened.
Wrist flexion weakened.
Thumb & index IP flexion.
Thumb opposition.
60
Sensory loss
Same as in wrist level injuries.
61
Anterior interosseous nerve
The median nerve gives off the AIN in the forearm
approximately 7-8 cm distal to the elbow.
If the AIN is involved, the following is affected:
FPL.
FDP to the index & occasionally to the long.
Pronator quadratus.
62
Deformity
Classic deformity is called ape or simian hand.
Thenar eminence flattened.
Thumb laying to the side of the palm.
Loss of ability to oppose & palmary abduct the
thumb.
Web space may contract with loss of the span of the
thumb.
63
Deformity
Fingertip prehension is lost because of the loss of the
thenar intrinsics & loss of sensibility of the volar
radial side of the hand.
64
Ape hand deformity 65
Ulnar nerve lesions 66
May be associated with:
Fracture of the medial epicondyle of the humerus.
Fracture of the olecranon of the ulna.
Glass & knife lacerations of the wrist.
Median nerve lesions 67
Common compression sites:
Cubital tunnel (cubital tunnel syndrome).
Guyon’s canal (guyon’s canal syndrome).
68
Motor loss
Abductor digiti minimi.
Flexor digiti minimi.
Opponens digiti minimi.
Lumbricales to the 3rd & 4th digits.
Dorsal & palmar interossei.
FPB (deep head).
Adductor pollicis.
69
Functional loss
Functional grip & pinch.
Finger abduction & adduction.
MP flexion while IPs extended (ring & little).
Froment’s sign: FPL substitutes Adductor Pollicis when
attempting lateral pinch with the thumb.
70
Sensory loss
Superficial terminal branch of the ulnar nerve.
The volar surface of the ulnar aspect of the palm
distally.
The volar surface of the small & ulnar half of the
ring fingers.
71
Motor loss
Additional loss include:
FCU.
FDP to the ring & small fingers.
72
Functional loss
Additional loss include:
Further weakened grip (FDP loss).
73
Sensory loss
In addition to the superficial terminal branch,
palmar & cutaneous branches are also involved
innervating:
Dorsal surface of the small & ulnar half of the ring
fingers.
Proximal palm on the ulnar side.
74
Deformity
Classic deformity is the claw hand.
Ring & small fingers rest in a posture of MP
hyperextension & IP flexion.
o Results from loss of balancing influence of the
intrinsic muscles on the extrinisic flexors * extensors.
75
Deformity
Atrophy of the interossei with hollowing between the
metacarpals.
Flattening of the hypothenar muscle.
76
Deformity 77
Part 6
EVALUATION 78
Evaluation 79
Should include:
Thorough history.
MMT.
ROM.
Sensibility.
Sympathetic function.
History 80
Patient name.
Sex.
Date of evaluation.
Age:
Prognosis is better in children than adults.
History 81
Dominance:
Sensibility & coordination deficit in a median nerve
lesion may require a change of dominance.
History 82
Occupation:
Median nerve lesion will impair performance in a
job that requires manual dexterity.
Ulnar nerve lesion will impair the manual labor’s
ability to perform grasp activities.
Protective versus discriminative sensibility.
History 83
Avocational interest (same as occupation).
Nature of injury:
Suggests the extent of damage & the relative
amount of scarring.
Level of injury:
Prognosis is better for lower-level lesions.
History 84
Date of injury / repair:
Is regeneration still occurring.
Patient’s description of problems:
ADLs?
Motor function 85
Muscle undergoes several stages of recovery:
1. Observable & palpable contracture without
production of motion.
2. Ability to “hold” a test position without being able
to produce that position.
3. Ability to move the joint through the test motion.
Motor function 86
4. Ability to move joint through the test motion & hold
the position against resistance.
Median, ulnar, & radial nerve repairs
POSTOPERATIVE MANAGEMENT PROTOCOLS 87
Part 7
MEDIAN NERVE REPAIR: FOREARM & WRIST LEVEL 88
10 – 14 days postoperative 89
The bulky compressive dressing is removed.
A light compressive dressing is applied for edema
control.
10 – 14 days postoperative 90
A DBS is fabricated with the wrist in 300 of palmar
flexion for continual wear.
Note: The amount of palmar flexion may be
increased if the surgeon indicates the nerve repair
was under significant tension.
The DBS should not position the wrist beyond 450 of
palmar flexion.
10 – 14 days postoperative 91
It is important to not position the wrist beyond 450
of flexion as it could result in
Median nerve compression and carpal tunnel
symptoms.
Extrinsic flexor tightness.
10 – 14 days postoperative 92
Active and PROM exercises are initiated to the
digits and thumb for 10 minute sessions each 2
hours.
Emphasis should be placed on blocking exercises to
ensure the long flexors do not become adherent to
the area of the surgical repair.
10 – 14 days postoperative 93
NMES may be initiated if limited tendon excursion is
noted early in the postoperative course of therapy.
Within 48 hours following suture removal, scar
mobilization techniques may be initiated.
Desensitization if necessary.
4 weeks postoperative 94
The DBS is adjusted to 200 of palmar flexion.
Unrestricted active and PROM are continued to the
hand.
5 weeks postoperative 95
The DBS is adjusted to 100 of wrist flexion.
Unrestricted active and PROM exercises are
continued to the hand.
6 weeks postoperative 96
The DBS is discontinued.
Progressive strengthening.
6 weeks postoperative 97
Additional splints maybe fabricated to enhance
function:
Opponens splint: to facilitate thumb & finger
prehension & maintain webspace.
Some patient prefer no additional splints:
Webspace must be maintained:
o Web spacer at night or web stretching.
Opponens splint 98
Web spacer 99
6 weeks postoperative 100
Unrestricted active and PROM exercises are
initiated to the wrist in conjunction with the exercises
to the hand. Emphasis should be placed on:
ROM exercises to the wrist
Isolated blocking exercises to the FDS & FDP of the
ring and small fingers, and FPL.
Considerations 101
Motor retraining begins at the earliest evidence of
muscle reinnervation.
Sensory re-education may be initiated once
protective sensibility has begun to return.
Considerations 102
NMES can be effective in noting the early return of
motor function by stimulating the thenar muscles
(time for motor retraining).
Recovery of intrinsic motor function is uncommon in
adults.
Secondary tendon transfers are often necessary.
Considerations 103
A web spacer is recommended for night wear until
thenar function returns or tendon transfers are
performed.
Considerations 104
Patient education is critical regarding sensory
impairment.
Patients must be sure their vision is not occluded as
they attempt to use their hand.
Without adequate sensibility, the patient could re-
injure their hand while performing daily activities
and work tasks.
Considerations 105
Typically, an isolated nerve laceration does not
occur at the wrist or forearm level.
Usually, the wrist and forearm flexor tendons are
also involved.
Considerations 106
If the patient has not begun to have return of
median nerve function by 4 to 6 months, tendon
transfers may need to be considered.
Part 8
ULNAR NERVE REPAIR: FOREARM & WRIST LEVEL 107
10 – 14 days postoperative 108
The bulky compressive dressing is removed.
A light compressive dressing is applied for edema
control.
10 – 14 days postoperative 109
A DBS is fabricated positioning the wrist in 300 of
palmar flexion for continual wear.
Note: If the ulnar nerve repair has been repaired
under significant tension, the wrist may need to be
positioned up to 450 of flexion.
10 – 14 days postoperative 110
Active and PROM exercises are initiated to the
digits and thumb for 10 minute sessions each 2
hours.
10 – 14 days postoperative 111
With an ulnar nerve laceration, there will be
clawing of the ring and small fingers due to the lack
of innervation of the ulnar nerve intrinsics.
Therefore, the MP joints to the ring and small fingers
should be blocked in 450 of flexion within the
restraints of the DBS.
10 – 14 days postoperative 112
Within 48 hours following suture removal, scar
mobilization techniques may be initiated.
10 – 14 days postoperative 113
NMES may be initiated to enhance excursion of the
long flexors.
Within 48 hours following suture removal, scar
mobilization techniques may be initiated.
Desensitization.
4 weeks postoperative 114
The DBS is adjusted to 200 of palmar flexion.
Unrestricted active and PROM are continued to the
hand.
5 weeks postoperative 115
The dorsal blocking splint is adjusted to 100 of wrist
flexion.
Unrestricted active and PROM exercises are
continued to the hand.
6 weeks postoperative 116
The DBS is discontinued.
A hand based MP block splint is fitted to prevent
clawing of the ring and small fingers.
The splint is worn continuously to allow the MP joint
volar plates to tighten and/or for intrinsic function
to return.
Claw hand splints 117
Claw hand splints 118
Claw hand splints 119
6 weeks postoperative 120
Unrestricted active and PROM exercises are
initiated to the wrist in conjunction with the exercises
to the hand. Emphasis should be placed on:
ROM exercises to the wrist
Isolated blocking exercises to the FDS & FDP of the
ring and small fingers, and FPL.
6 weeks postoperative 121
Progressive strengthening.
Considerations 122
Motor retraining begins at the earliest evidence of
muscle reinnervation.
Sensory re-education may be initiated once
protective sensibility has begun to return.
Considerations 123
If the patient has not begun to have return of radial
nerve function by 4 to 6 months, tendon transfers
may need to be considered.
Part 9
RADIAL NERVE REPAIR: ELBOW & WRIST LEVEL 124
10 – 14 days postoperative 125
The bulky compressive dressing is removed.
A light compressive dressing or elastic stockinette is
applied for edema control.
10 – 14 days postoperative 126
The bulky compressive dressing is removed.
A light compressive dressing or elastic stockinette is
applied for edema control.
10 – 14 days postoperative 127
A wrist immobilization splint is fitted with the wrist in
300 of extension for continual wear to minimize
tension on the repair.
Active and PROM exercises are initiated to the
digits 6 times a day for 10 minute sessions.
Within 48 hours following suture removal, scar
massage with lotion may be initiated.
4 weeks postoperative 128
The wrist immobilization splint is adjusted to 200 of
extension.
5 weeks postoperative 129
The wrist immobilization splint is adjusted to 100 of
extension.
6 weeks postoperative 130
The wrist immobilization splint is discontinued.
If the level of the radial nerve repair is such that a
radial nerve palsy is present,
either the static wrist immobilization splint may be
continued
or a radial nerve palsy splint may be fabricated
for the wrist.
Radial nerve palsy splints 131
Radial nerve palsy splints 132
Radial nerve palsy splints 133
6 weeks postoperative 134
Active and PROM exercises are initiated to the wrist
6 times a day for 10 minute sessions.
Progressive strengthening may be initiated to the
hand, wrist and forearm.
Considerations 135
Motor retraining begins at the earliest evidence of
muscle reinnervation.
Sensory re-education may be initiated once
protective sensibility has begun to return.
Considerations 136
If the patient has not begun to have return of radial
nerve function by 4 to 6 months, tendon transfers
may need to be considered.
Considerations 137
Keep in mind, a low radial nerve palsy presents with
The EPL, EIP, EDC, APL, ECU, EDQM and supinator out.
The ECRL is functioning.
With a high radial nerve palsy,
all the wrist extensors are out along with the digital extensors.
Considerations 138
If the radial nerve repair is above the elbow, the
following therapy program is recommended:
A static elbow splint is fitted positioning the elbow
in 900 - 1000 of flexion and the forearm in neutral.
In addition, a radial nerve palsy splint is fitted to
the patient.
Considerations 139
At 4 weeks, the elbow is extended to 600 of extension.
At 5 weeks, the elbow is extended to 300 of extension.
At 6 weeks, the splint is discontinued altogether to allow full extension.
At 6 weeks, active and PROM exercises are initiated to the elbow, forearm, wrist and hand.
Considerations 140
The radial nerve palsy splint should be continued
until adequate motor return occurs or tendon
transfers are performed???
Part 10
MOTOR RETRAINING 141
Motor retraining 142
Is simply, encouraging the muscle to do the work!
As stated earlier, motor retraining at the earliest
evidence of muscle reinnervation:
That is observable or palpable muscle contraction.
Motor retraining 143
What’s before that?
Passive exercises.
o Maintain ROM.
o Maintain muscle-tendon length.
NMES.
o Maintain muscle integrity until reinnervation.
o Proprioceptive feedback.
Motor retraining 144
Motor retraining follows the stages of motor
recovery (use biofeedback):
1. Observable & palpable contracture without
production of motion (start).
2. Ability to “hold” a test position without being able
to produce that position (place & hold exercises).
Motor retraining 145
3. Ability to move the joint through the test motion
(AROM exercises & Dexterity).
4. Ability to move joint through the test motion & hold
the position against resistance (resisted exercises:
strength & endurance).
Key-exercise for Radial lesions 146
Wrist, fingers, & thumb extension.
To eliminate intrinsic substitution, IPs should be
fixed flexed during the exercise.
Key-exercise for Radial lesions 147
Key-exercise for Median lesions 148
The action of the intrinsic thenar muscles is
targeted.
Thumb opposition.
Thumb palmar abduction.
Key-exercise for Median lesions 149
Key-exercise for Ulnar lesions 150
Fingers abductions & adductions:
Placing hand palm on a surface with powder to
limit friction.
Lateral pinch (thumb adduction).
Final word 151
Motor retraining is most effective when
incorporated in interesting, purposeful, & goal-
directed activities.
Examples!
Part 11
DESENSITIZATION 152
Desensitization 153
A light touch of the involved area may range from
being mildly irritating to extremely painful in the
case of neuroma formation.
Desensitization 154
Refers to the process of lessening reactivity to an
external stimulus through the use of a graded series
of modalities and procedures.
Treatment begins with exposure to a stimulus that is
slightly irritating but tolerable, and as tolerance
increases, more noxious stimuli are introduced.
Desensitization 155
Three sensory modalities are used in desensitization:
Textures.
Contact particles.
Vibration.
Desensitization 156
In the testing phase, the patient instructed to rank a
series of each of these modalities ranging from the
least to the most irritating.
Textures 157
Graded textures
fixed to dowels.
The textures are
rubbed, tapped,
Or rolled over the
area.
Contact particles 158
Particulate materials, from cotton to sharp-edged
cubes, are arranged in coffee cans.
The hand is immersed in the particulate materials.
Vibratory stimulus 159
Vibratory stimulus is applied with a commercially
available vibrator and is ranked according to
The cycles per second (cps).
The duration of application.
Whether the stimulus is intermittent or sustained.
Treatment time & frequency 160
Treatment is performed daily 3 or 4 times a day,
for 10 minutes a session.
When the stimulus becomes tolerable, the next in the
series is used.
Maximum progress occurs when the most irritating
of the series is tolerated.
Part 12
SENSORY REEDUCATION 161
Sensory reeducation 162
The prognosis for recovery of discriminative sensibility following nerve injury is generally considered poor.
Axon may be blocked by scar at the suture line.
A neuroma may form
The axon may enter a different endoneurial tube or may reinnervate a different end organ.
Sensory reeducation 163
When the affected area is stimulated,
The patient will be unable to interpret the stimulus correctly because
o the nerve impulses received by the brain will be altered compared with the preinjury pattern;
that is, the stimulus may be applied at one place on the hand and be perceived at another place.
Training methods 164
Training must be done in a quiet room to maximize
attention and concentration of the patient.
Method:
Training methods 165
1. The task is attempted with the eyes closed.
2. The patient opens his/her eyes and checks to see
if the task was performed correctly.
3. If it was, he or she closes his or her eyes and
attempts to carry out another task.
Training methods 166
4. If incorrect, the patient repeats the same task with eyes open so that he/she might integrate vision with tactile experience and commit both to memory.
5. Finally, the patient closes his or her eyes again and attempts the same task for reinforcement of what was just learned while his/her eyes were open.
Training Tasks 167
Training tasks chosen will depend on the therapist's
evaluation of present discrimination skills.
Emphasis is placed on training of the fingertips
because these are the sensory surfaces most
involved in discriminative function.
Be creative & use your imagination!
Training Tasks: Examples 168
Localization of a stimulus:
At first, the stimulus is blunt and delivered with firm
pressure.
o Grading is achieved by using a stimulus delivered
with increasingly lighter pressure.
Training Tasks: Examples 169
Identification of sandpaper on dowels:
Identical and different grades of sandpaper are attached to opposite ends of several wood dowels.
The patient is required to state whether two ends of a dowel successively applied to a small area of skin are of the same grade or different.
Training Tasks: Examples 170
Grading is achieved by using similar grades of
sandpaper and by using a light pressure when
applying the stimulus to the skin.
Identification of sandpaper on dowels 171
Training Tasks: Examples 172
Identification of textures:
At first, the patient is required simply to match a
sample texture with one of a small group of
different textures.
Grading is achieved by requiring a match from a
larger group of textures and by requiring
description or identification of the texture.
Training Tasks: Examples 173
Identification of Velcro letters superimposed on
small wooden blocks:
Grading is achieved by setting a time limit and by
requiring identification of three dimensional letters.
Velcro letters 174
Training Tasks: Examples 175
Braille designs and finger mazes:
The patient is required to use an involved fingertip
to trace over and identify features on a Braille
design (e.g., a house) or to trace over a finger
maze made from raised glue on cardboard to
reach a particular "destination" in the Maze.
Training Tasks: Examples 176
Grading is achieved by using closer spacing in the
Braille designs or by making the finger mazes more
intricate.
Braille design 177
Raised glue maze 178
Training Tasks: Examples 179
Picking up objects from a background medium:
At first, large objects must be retrieved from a
background medium such as sand.
Grading is achieved by setting a time limit and by
using smaller objects in a coarser background
medium, such as foam chips.
Training Tasks: Examples 180
Identification of everyday objects:
At first, large dissimilar objects are used.
Grading is achieved by setting a time limit and by
using smaller, more similar objects.
Training Tasks: Examples 181
ADL tasks and work-simulated tasks:
The patient is required to perform selected tasks
with vision occluded.
Grading is achieved by setting a time limit and by
making the tasks more intricate.
Part 13
CHRONIC PHASE 182
Chronic phase 183
When everything plateaus & no more improvement
is expected.
This may be 1 year of the repair.
Chronic phase 184
Three options of treatment:
Adaptive compensatory treatment.
Surgical treatment.
Both.
Compensatory 185
Adaptive techniques & assistive equipments.
New splints to enhance function.
New equipments to enhance function:
o E.g. median nerve lesion, buttonhook to fasten
buttons.
Functional splints 186
Neoprene or leather splint for maintaining functional abduction of the thumb while awaiting median nerve return.
Functional splints 187
Fingertip pinch is
impossible in
anterior
interosseous nerve
palsy, small splints
that prevent joint
extension re-creat
fingertip pinch
Functional splints 188
The Rehabilitation
Institute of Chicago
tenodesis splint
harnesses the
power of wrist
extension into
functional pinch.
Assistive equipments 189
Surgical treatment 190
Surgical treatment means tendon transfer.
Application of motor power of one muscle to
another weaker or paralyzed muscle by transfer of
its tendinous insertion.
o Redistributing power to enhance function.
Considerations 191
Full PROM must be obtained preoperatively.
Tissue & scar must be supple & mobilized.
Donor muscle is strengthen preoperatively.
Isolated control is emphasized.
Prepare patient to be realistic, full ROM is not
expected.
Considerations 192
Postoperatively:
Immobilization for 3-5 weeks.
AROM starts 5 weeks postoperatively.
6-8 weeks, PROM may be initiated.
Strengthening may be initiated 8 – 12 weeks.
Considerations 193
When first attempting to use the muscle in its new
role:
The patient should focus on the motion that the
donor muscle did before transfer:
o E.g. pronator teres to radial wrist extensors: patient
to should attempt wrist extension while thinking
about & initiating pronation.
Common tendon transfers 194
Level Function Transfer Early precaution
Radial Wrist extension Pronator teres to ECRL & B. Avoid concurrent
wrist & digital
flexion. Finger extension FCU or FCR to EDC
Thumb extension PL or FDS to EPL
Median Opposition FDS, PL, or EDQM Avoid concurrent
wrist, thumb, fingers
extension Thumb IP flexion Brachioradialis to FPL
DIP flexion index FDP of long, ring & small to
FDP of index
Common tendon transfers 195
Level Function Transfer Early
precaution
Ulnar Correct claw FDS, EIP, EDQM to intrinsics Avoid MP
extension,
concurrent
fingers,
thumb, &
wrist
extension.
Thumb adduction FDS or ECRL to adductor pollicis
Index abduction APL, ECRL, or IDP to 1st dorsal interosseous
DIP flexion of long,
ring, small fingers
Side-to-side tenodesis of FDP of index
Thank you 196
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