PERIPHERAL NERVE INJURIES

Ahmad A. Fannoon, Msc, Hand Therapist

ANATOMY
Part 1

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

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NERVE RESPONSE TO INJURY

Part 2

Phases
12

1. 2.

Nerve response to injury in two phases: Wallerian degeneration. 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 endoneurial tubes: Shrinkage & collapse.

Schwann

sheaths

&

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.

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CLASSIFICATION OF NERVE INJURIES

Part 3

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. Seddons 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: 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. 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 1st

Motor Paralysis

Sensory Minimal loss

Treatment Observation

Recovery Complete

Therapy Short-term, focused

2nd
3rd 4th 5th

Paralysis
Paralysis Paralysis Paralysis

Complete loss
Complete loss Complete loss Complete loss

Observation
Surgical may be required Surgical Surgical mandatory

Usually complete
Incomplete Incomplete Never complete

Moderate
Moderate Long-term Long-term

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FACTORS AFFECTING PROGNOSIS FOR RECOVERY

Part 4

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 cant be restored completely in adults. The goal of therapy is to: Maximize motor & sensibility recovery. Assist in compensation for residual deficits.

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SPECIFIC NERVE LESIONS

Part 5

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.

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Motor loss
43

ECU. EDC. EDQM.

APL. EPL. EPB. EIP.

Functional loss
44

MP joints extension of all digits. Thumb radial abduction & extension. Ulnar wrist extension.

Sensory loss
45

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.

Motor loss
46

All aforementioned muscles +: Supinator. ECRL. ECRB.

Functional loss
47

Ulnar & radial wrist extension. weakened supination. MP extension. Thumb extension. Thumb radial abduction.

Sensory loss
48

Same as in forearm level injury.

Motor & functional loss

49

Additional motor loss: Brachioradialis. Additional functional loss: weakened elbow flexion.

Motor & functional loss

50

Additional motor loss: Triceps. Additional functional loss: Elbow extension.

Deformity & other loss

51

Classic deformity is wrist drop. Hand grip is compromised significantly: Loss of wrist extensors which position & help stabilize the wrist during grasp.

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)

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Motor loss
56

Opponens pollicis. APB. FPB (superficial head). 1st & 2nd lumbricales.

Functional loss
57

Thumb opposition. Compromising activities requiring fine prehension.

Sensory loss
58

Volar surface of thumb, index, long, & radial half of the ring fingers. Dorsal surface of the distal phalanges of the same digits.

Motor loss
59

All aforementioned muscles +: Pronator teres. FCR. FDS. Palmaris longus.

FPL. FDP to the index & long fingers. Pronator quadratus.

Functional loss
60

Pronation weakened. Wrist flexion weakened. Thumb & index IP flexion. Thumb opposition.

Sensory loss
61

Same as in wrist level injuries.

Anterior interosseous nerve

62

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.

Deformity
63

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.

Deformity
64

Fingertip prehension is lost because of the loss of the thenar intrinsics & loss of sensibility of the volar radial side of the hand.

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). Guyons canal (guyons canal syndrome).

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Motor loss
69

Abductor digiti minimi. Flexor digiti minimi. Opponens digiti minimi. Lumbricales to the 3rd & 4th digits. Dorsal & palmar interossei. FPB (deep head). Adductor pollicis.

Functional loss
70

Functional grip & pinch. Finger abduction & adduction. MP flexion while IPs extended (ring & little).
Froments sign: FPL substitutes Adductor Pollicis when attempting lateral pinch with the thumb.

Sensory loss
71

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.

Motor loss
72

Additional loss include: FCU. FDP to the ring & small fingers.

Functional loss
73

Additional loss include: Further weakened grip (FDP loss).

Sensory loss
74

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.

Deformity
75

Classic deformity is the claw hand. Ring & small fingers rest in a posture of MP hyperextension & IP flexion. Results from loss of balancing influence of the intrinsic muscles on the extrinisic flexors * extensors.

Deformity
76

Atrophy of the interossei with hollowing between the metacarpals. Flattening of the hypothenar muscle.

Deformity
77

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EVALUATION
Part 6

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 labors 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. Patients description of problems: ADLs?

Motor function
85

1.

2.

3.

Muscle undergoes several stages of recovery: Observable & palpable contracture without production of motion. Ability to hold a test position without being able to produce that position. 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.

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POSTOPERATIVE MANAGEMENT PROTOCOLS

Median, ulnar, & radial nerve repairs

88

MEDIAN NERVE REPAIR: FOREARM & WRIST LEVEL

Part 7

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: 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 reinjure 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.

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ULNAR NERVE REPAIR: FOREARM & WRIST LEVEL

Part 8

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.

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RADIAL NERVE REPAIR: ELBOW & WRIST LEVEL

Part 9

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???

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MOTOR RETRAINING
Part 10

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

o o o o

Whats before that? Passive exercises. Maintain ROM. Maintain muscle-tendon length. NMES. Maintain muscle integrity until reinnervation. Proprioceptive feedback.

Motor retraining
144

1.

2.

Motor retraining follows the stages of motor recovery (use biofeedback): Observable & palpable contracture without production of motion (start). Ability to hold a test position without being able to produce that position (place & hold exercises).

Motor retraining
145

3.

4.

Ability to move the joint through the test motion (AROM exercises & Dexterity). 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, & goaldirected activities. Examples!

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DESENSITIZATION
Part 11

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.

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SENSORY REEDUCATION
Part 12

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 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. 2.

3.

The task is attempted with the eyes closed. The patient opens his/her eyes and checks to see if the task was performed correctly. If it was, he or she closes his or her eyes and attempts to carry out another task.

Training methods
166

4.

5.

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. 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. 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.

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CHRONIC PHASE
Part 13

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: 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. 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: E.g. pronator teres to radial wrist extensors: patient to should attempt wrist extension while thinking about & initiating pronation.

Common tendon transfers

194

Level Radial

Function Wrist extension Finger extension Thumb extension

Transfer Pronator teres to ECRL & B. FCU or FCR to EDC PL or FDS to EPL FDS, PL, or EDQM Brachioradialis to FPL FDP of long, ring & small to FDP of index

Early precaution Avoid concurrent wrist & digital flexion. Avoid concurrent wrist, thumb, fingers extension

Median

Opposition Thumb IP flexion DIP flexion index

Common tendon transfers

195

Level

Function

Transfer

Early precaution

Ulnar

Correct claw
Thumb adduction Index abduction

FDS, EIP, EDQM to intrinsics

FDS or ECRL to adductor pollicis APL, ECRL, or IDP to 1st dorsal interosseous

DIP flexion of long, ring, small fingers

Side-to-side tenodesis of FDP of index

Avoid MP extension, concurrent fingers, thumb, & wrist extension.

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Thank you