Peripheral Nerve Injurie Management.

1. Dr. Rashi Goel (PT)
MPT Orthopedcs (Hand & Upper Extremity Rehabilitation
Manipal Academy of Higher Education,
Manipal, Karnataka, India.

2. PNI
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3. Neurophysiological findings for the categories of
Peripheral Nerve Injury
Neuropraxia Axonotmesis Neurotmesis
Conduction
velocity
Normal in most
cases
Normal/slight
reduction
Absent
CMAP
Amplitude
Normal/
Reduced
Reduced Absent
SNAP
Amplitude
Reduced Reduced Absent
Spontaneous
Activity on
EMG
Absent Maybe present Present
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4. Incidence of Peripheral nerve injury
• Radial nerve - commonly injuried
• Ulnar nerve - 30 %
• Median nerve - 15 %
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5. Etiology
• Penetrating injury
• Crush
• Traction
• Ischemia
• Thermal, electric shock
• Radiation
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6. Factors affecting prognosis of injury
• Nature of injury
• Age
• Mixed versus unmixed nerves
• Motor versus sensory recovery
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7. Nature of injury
• Clean, simple laceration- less damage
• Avulsion injury- most damaging
• Higher the lesion- longer the distal muscle
fibres & sensory end organs will remain
denervated and undergo processes of atroply
& fibrosis
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8. Age
• Children – far better functional recovery than
adults….
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9. Mixed versus unmixed nerves
• 3rd degree- prognosis is better if fibres within a
given funiculus are unmixed
• This allows the regenerating axons to enter
functionally similar tubes
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10. Motor versus sensory recovery
• Denervated muscles can remain viable up to 3
years
• Sensory end organ degenerate more quickly
than motor end organs
• Delay of >6 months b/w injury & suture will
adversely affect potential for recovery
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11. RADIAL NERVE
• # humerus shaft
• #, Ø elbow
• # upper 1/3rd of radius
• Compression b/w radial head &
supinator
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12. Forearm level lesions
•ECU, EDC, Abd PL, EPL, EPB, EI
•Functional loss- Loss of MCP Ext, Thumb Rad
Dev, Ext, Ulnar wrist ext
•Sensory loss- Dorsum of thumb, 2 3 half of 4th
fingers upto PIP joints
•Solely PIN- no cutaneous sensory deficit
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13. Lesion at elbow
• Motor loss- + Supinator, ECRL, ECRB
• Functional loss- loss of ulnar & radial wrist ext,
weak supination, loss of MCP ext, Thumb ext,
RD
• Sensory loss- same
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14. Proximal to elbow lesion
• Motor loss- + brachioradialis
• Weakened ellbow flexion
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15. Upper arm
• Motor loss: + triceps
• Elbow extension is lost
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16. Deformity
• Wrist drop
• Hand grip is compromised
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18. Median Nerve
• # Humerus
• Elbow Ø
• Distal radius #
• Ø of lunate into carpal tunnel
• Knife & glass lacerations of volar wrist
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19. • Pronator syndrome- b/w 2 heads of P.T.
• Anterior interosseous syndrome
• Carpal tunnel syndrome
Compression sites
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20. Thenar muscles-
• FPB
• Abd PB
• Opp P
1st 2nd lumbricals
Functionally: thumb opposition lost required
for fine prehension
Low/ wrist level lesion
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21. Motor- + Pron teres, FCR, FDS, Palmaris
longus, FPL, FDP lat ½, Pron quadratus
functionally: weakened pronation & wrist flx,
thumb & index IP jt flx, thumb opp loss.
High level lesion/elbow
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22. Forearm 8 cm distal elbow
- FPL, FDP to index & long finger, pronator
quad.
- No cutaneous sensory deficit
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23. Deformity
• Ape/ Simian hand
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25. • # medial epicondyle of humerus
• # olecranon of ulna
• Glass & knife injuries of wrist
Ulnar Nerve
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26. Compression sites
• Cubital tunnel syndrome
• Guyons canal
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28. At wrist ( low)
Add. Pollicis
• Hypothenar- FDM, Abd D M, ODM
lumbricals 3rd 4th
8 interossei
deep head of FPB
Functional- grip & pinch affected
Power grip & fine prehension lost due to intrinsics
Sensory loss
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29. Froment’s sign
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30. Motor: + FCU
- FDP to ring & small fingers
Functionally: grip, pinch affected , decrease in
power grip, loss of fine prehension
At / above elbow ( high )
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31. Claw deformity
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33. • HISTORY
Name
Age
Sex
Dominance
Occupation
Nature of injury
Level of injury
Date of injury/repair
EVALUATION
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34. Vasomotor
Sudomotor- sweat
Pilomotor- goose flesh response
Trophic- nourishment
SYMPATHETIC FUNCTION
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35. After initial latent period of 3-4 wks, axonal reg.
at a rate of appox. 1mm/day
Sensation recovery occurs in following
sequence:
 Deep pressure & pinprick i.e. protective
 Moving touch
 Static light touch
 Discriminative touch
Accurate localization is last to recover
SENSIBILITY
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36. • Tinel’s sign
• Sharp/dull discrimination
• Semme’s Weinstein light- touch deep-
pressure testing
• 2 point discrimination
• Both static & moving
• Mober’s Pick up test
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37. • After initial latent period of 3-4 wks, axonal
regeneration at a rate of appox. 1mm/day
• Early sign- sensitivity of a previously insensitive
muscle to pressure
MOTOR FUNCTION
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38. Stages of recovery
Observable & palpable
contractions without any motion
Ability to hold a test position
without any motion
Ability to move the joint through
test motion
Ability to move & hold against
resistance
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39. - Trick motions during MMT
Apparent performance by prime mover can
occur in several ways :
• Rebound- EPL for FPL
• Supplementary action- APL flex wrist
• Antagonist-tenodesis
• Common tendons- APB sends a slip to EPL
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40. Low lesion: atrophy of thenar eminence
resting posture of thumb pulp in
plane of palm
- High lesion: benediction posture of index &
long finger
- Wasting of medial epicondyle muscle mass
MEDIAN NERVE
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41. • MMT:
- Pronation: teres can be palpated not
quadratus
- Wrist flexion
- Finger flexion
- Thumb-tip flexion
- Palmar abduction
- Thumb opposition
- MP flexion of index & long finger
- IP extension of index & long finger
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42. - Pronator syndrome: diffuse forearm pain &
sensory changes
- Ant. Int. syndrome: typical forearm pain, +ve
BALLENTINE’S sign & no sensory changes
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43. • Sign of recovery:
- Thumb rotation
- Maintainence of IP jt ext with MP flexion
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44. Hand of benediction
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45. - Low Lesion:
Atrophy of intrinsic
Hollows between metacarpals
Clawing in ring & small finger
Abduction of small finger
- High lesion:
less clawing due to paralysis of FDP
wasting on medial aspect of upper forearm
ULNAR NERVE TESTING
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46. • MMT:
- Thumb adduction : Froments sign
- Finger abduction
- Finger adduction
- MP flexion
- IP jt extension
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47. • Evaluation tips:
- Froment’s sign
- Elbow flexion test
- FDP muscle strength is imp diagnostic tool
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48. • Sign of recovery:
- Abd digiti minimi
- Absence of trick movts during abd.
- Ability to flex MP jt with IP ext.
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49. Wartenberg’s sign
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50. - High lesion:
Wrist drop
wasting of the triceps
Wasting at supracondylar muscle mass (ECRB,
ECRL, Brachioradialis)
Wasting on dorsal aspect of forearm
- Low lesion:
sparing of triceps
RADIAL NERVE TESTING
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51. • MMT
Elbow ext.
Supination
Wrist ext
Finger ext , MP flexion during finger ext.
Thumb ext
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52. • Evaluation tips:
- Distinguish PIN palsy
- Wrist drop with elbow in flexion and pronation
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53. • Sign of recovery :
- Ext dig.
- EPL
- ECRL
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54. Simple screening tests
• Ulnar nerve injury :
– Loss of pain at tip of the little finger
• Medial nerve injury :
– Loss of pain at tip of index finger
• Radial nerve injury :
– Inability to extend thumb
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57. Therapeutic management
Acute phase
early post injury
& post surgery time
healing &
prevention
Recovery
phase
period of
reinnervation
retraining &
reeducation
Chronic Phase
residual
deficits
compensatory
function
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58. ACUTE PHASE:
• Protection of surgically repaired n. &
prevention of joint contracture & further
injury due to decreased sensibility
• Types of diagnoses seen:
Acute nerve compression
Post surgical decompression and release
Post surgical repair of lacerated nerve
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59. • Period of immobilization:
3 to 4 wks
Splinting
• Post immobilization:
Increase ROM
Enhancement of function
Patient education for protection & prevention
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60. ROM
• Low ulnar/median n.- wrist positioned in
flexion during immobilization
• Begin AROM
• PROM, active assisted ROM ex.
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61. Increase of function
• Splinting
To restore normal resting posture
To prevent secondary joint contractures
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62. Radial nerve splint
• Cock up splint
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63. • Phoenix outrigger- dynamic splint
• Colditz
• Normal tenodesis pattern of the hand
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64. Median nerve splint
• Opponens splint
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65. Thumb web spacer splint
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66. Ulnar nerve splint
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68. Patient education
• Nerve function
• Consequences of injury
• Outcomes expected
• Home program
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69. RECOVERY PHASE
• Motor retraining
Electrical stimulation
Biofeedback
• Desensitization
• Sensory re education
• Training tasks
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70. Motor retraining
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71. Desensitization
• Barber’s approach
1. Textures
2. Contact particles
3. Vibration
• Rank from least to most irritating
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72. • Treatment
• Daily 3- 4 times a day, 10 minutes a session
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73. Sensory reeducation
• Dellon pattern of sensory recovery-
• PAIN is the first to recover
• Then perception of vibration of 30 rps
• Moving touch
• Constant touch
• Vibration of 256 rps
• Proximal to distal
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74. • 1st phase start when- 30 rps & moving touch
have returned
• Goal- localization of stimulus
• Moving V/s constant touch
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75. • 2nd phase start when- moving & constant
touch are perceived at fingertips
• Tactile recognition- use familier household
objects
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76. Training tasks
• Localization of a stimulus
• Identification of sandpaper on dowels
• Identification of textures
• Identification of Velcro letters superimposed on
small wooden blocks
• Braille designs and finger mazes
• Pick up objects from background medium
• Identification of everyday objects
• ADL tasks & work stimulated tasks
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77. Identification of sandpaper on dowels
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78. Identification of Velcro letters superimposed
on small wooden blocks
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79. Braille designs and finger mazes
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80. Chronic Phase
• Focus towards compensation
• Adaptive techniques
• Assistive equipments
• Splints reevaluated & refabricated
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81. • Splinting adaptations
• Surgical alternatives
- Nerve exploration and grafting
- Joint fusion
- Tendon transfer
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82. - Pre-op
1. Full ROM must be obtained
2. Donor muscle strengthened
3. Tissues and scar must be supple & mobilized
Tendon transfers
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83. RADIAL NERVE
1. Wrist ext: pronator teres ECRL, ECRB
2. Finger ext: FCU/ FCR EDC
3. Thumb ext: palmaris longus/ FDS EPL
• Early precautions:
Avoid simultaneous wrist & finger flexion to
prevent overstretch of the transfer
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84. PT to ECRB
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85. FCU to EDC
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86. PL to EPL
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87. MEDIAN NERVE
1. Opposition: FDS /palmaris longus/ EDM
2. Thumb IP flexion ( high lesions): BR FPL
3. DIP flexion of index(high lesions): FDP of long,
ring, small fingers FDP of index finger
Early precautions:
Avoid simultaneous wrist, thumb and finger ext.
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89. ULNAR NERVE
- Correct claw(control MP joint hyperextension):
FDS/EI/EDM intrinsics
- Thumb add.: FDS/ECRL add pollicis
- Index abd: Abd poll long, ECRL/EI 1st DI
- DIP flex of long,ring, small fingers(high
lesions): side to side tenodesis of FDP of index
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90. • Avoid full MP joint extensions, avoid
simultaneous finger, thumb and wrist
extension
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93. Post- op
• Immobilization for 3 to 5 weeks
• Splint to minimize tension on the transfer
• ROM maintained for uninvolved joints
• Edema control as needed
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94. Mobilization of the transfer
• Focus on motion that donor muscle did before
the transfer
• Biofeedback & electrical stimulation to donor
muscle for isolated control
• Massage to mobilize scar & soft tissue
• Splint continued, removed only during the
exercises
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95. - After 6-8 wks passive exs and functional
activities
- After 8-12 wks : strengthening
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96. Revision
• Thumb muscles- 3 nerves??
• Ape thumb?
• Hand of benediction?
• Arcade of froshe
• Guyon’s canal
• Cubital tunnel syndrome
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97. Musician nerve?
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98. Labourer’s nerve?
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