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Peripheral Nerve Injuries
Peripheral Nerve Injuries
ANATOMY
Part 1
Anatomy review
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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
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Anatomy review
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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
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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
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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
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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
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Phases
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1. 2.
Disintegration of the axon. Breakdown of the myelin sheath. Degeneration occurs distal to the level of injury, including: Motor & sensory end receptors.
Schwann
sheaths
&
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.
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.
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).
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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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
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Axonal conduction is interrupted but structures remain intact. Recovery is spontaneous & complete. Seddons Neuropraxia.
Temporary loss of nerve function in the following order: Motor. Proprioception & vibration. Touch. Pain. Sudomotor function.
Interruption of axons. Endoneurium, perineurium, & epineurium are intact. Wallerian degeneration occurs. Recovery is spontaneous & good.
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?
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.
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.
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.
Surgical repair is required to allow for functional healing to occur. Residual deficits will occur. Scarring. Faulty regeneration & reinnervation.
The entire nerve trunk is in discontinuity. Surgical repair required. Residual deficits persist.
Sunderland degrees
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Degree 1st
Motor Paralysis
Treatment Observation
Recovery Complete
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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Part 4
Nature of injury
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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
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The higher the level of injury, the longer the distal muscle & sensory end organs will remain denervated & undergo atrophy & fibrosis.
Age
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Children have far better functional recovery after suture than adults. Exact reasons are unknown.
In 3rd degrees & worse. Recovery is better if the fibers within a given funiculus are unmixed. Axons would enter a functionally similar endoneurial tube.
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
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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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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).
Motor, sensory, & functional loss depends exactly on the exact site of injury.
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Motor loss
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Functional loss
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MP joints extension of all digits. Thumb radial abduction & extension. Ulnar wrist extension.
Sensory loss
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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
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Functional loss
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Ulnar & radial wrist extension. weakened supination. MP extension. Thumb extension. Thumb radial abduction.
Sensory loss
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Additional motor loss: Brachioradialis. Additional functional loss: weakened elbow flexion.
Classic deformity is wrist drop. Hand grip is compromised significantly: Loss of wrist extensors which position & help stabilize the wrist during grasp.
Wrist drop
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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.
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
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Opponens pollicis. APB. FPB (superficial head). 1st & 2nd lumbricales.
Functional loss
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Sensory loss
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Volar surface of thumb, index, long, & radial half of the ring fingers. Dorsal surface of the distal phalanges of the same digits.
Motor loss
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Functional loss
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Pronation weakened. Wrist flexion weakened. Thumb & index IP flexion. Thumb opposition.
Sensory loss
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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
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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
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Fingertip prehension is lost because of the loss of the thenar intrinsics & loss of sensibility of the volar radial side of the hand.
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.
Common compression sites: Cubital tunnel (cubital tunnel syndrome). Guyons canal (guyons canal syndrome).
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Motor loss
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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
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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
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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
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Additional loss include: FCU. FDP to the ring & small fingers.
Functional loss
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Sensory loss
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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
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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
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Atrophy of the interossei with hollowing between the metacarpals. Flattening of the hypothenar muscle.
Deformity
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EVALUATION
Part 6
Evaluation
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History
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Patient name. Sex. Date of evaluation. Age: Prognosis is better in children than adults.
History
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Dominance: Sensibility & coordination deficit in a median nerve lesion may require a change of dominance.
History
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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
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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
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Date of injury / repair: Is regeneration still occurring. Patients description of problems: ADLs?
Motor function
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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
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4.
Ability to move joint through the test motion & hold the position against resistance.
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Part 7
10 14 days postoperative
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The bulky compressive dressing is removed. A light compressive dressing is applied for edema control.
10 14 days postoperative
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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
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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
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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
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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
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The DBS is adjusted to 200 of palmar flexion. Unrestricted active and PROM are continued to the hand.
5 weeks postoperative
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The DBS is adjusted to 100 of wrist flexion. Unrestricted active and PROM exercises are continued to the hand.
6 weeks postoperative
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6 weeks postoperative
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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
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Web spacer
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6 weeks postoperative
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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
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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
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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
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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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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
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The DBS is adjusted to 200 of palmar flexion. Unrestricted active and PROM are continued to the hand.
5 weeks postoperative
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The dorsal blocking splint is adjusted to 100 of wrist flexion. Unrestricted active and PROM exercises are continued to the hand.
6 weeks postoperative
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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.
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
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Progressive strengthening.
Considerations
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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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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
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5 weeks postoperative
129
6 weeks postoperative
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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.
6 weeks postoperative
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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
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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
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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
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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).
Wrist, fingers, & thumb extension. To eliminate intrinsic substitution, IPs should be fixed flexed during the exercise.
The action of the intrinsic thenar muscles is targeted. Thumb opposition. Thumb palmar abduction.
Fingers abductions & adductions: Placing hand palm on a surface with powder to limit friction. Lateral pinch (thumb adduction).
Final word
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Motor retraining is most effective when incorporated in interesting, purposeful, & goaldirected activities. Examples!
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DESENSITIZATION
Part 11
Desensitization
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A light touch of the involved area may range from being mildly irritating to extremely painful in the case of neuroma formation.
Desensitization
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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
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Three sensory modalities are used in desensitization: Textures. Contact particles. Vibration.
Desensitization
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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
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Graded textures fixed to dowels. The textures are rubbed, tapped, Or rolled over the area.
Contact particles
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Particulate materials, from cotton to sharp-edged cubes, are arranged in coffee cans. The hand is immersed in the particulate materials.
Vibratory stimulus
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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 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
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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
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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!
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.
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.
Grading is achieved by using similar grades of sandpaper and by using a light pressure when applying the stimulus to the skin.
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.
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
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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.
Grading is achieved by using closer spacing in the Braille designs or by making the finger mazes more intricate.
Braille design
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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.
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.
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
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When everything plateaus & no more improvement is expected. This may be 1 year of the repair.
Chronic phase
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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
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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.
Level Radial
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
Level
Function
Transfer
Early precaution
Ulnar
Correct claw
Thumb adduction Index abduction
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Thank you