Splinting for Peripheral Nerve Injuries

Somaya Malkawi, PhD

Radial Nerve Lesions

Radial Nerve Lesions (table 13-2)

Check weak or lost motions for each

1. Axilla level (M+S) HIGH (wrist drop)

2. Midhumeral compression/shaft fracture (M+S) HIGH (wrist drop)

3. Forearm level- Posterior Interosseous Nerve Palsy- fracture/dislocation of elbow j (M) LOW

Radial Nerve Common Sites of Injury

4. Radial Tunnel Syndrome (btw radial head and supinator muscle (pain syndrome)

5. Superficial Radial Sensory Nerve Palsy btw ext carpi radialis longus and bachioradialis or at wrist from tight splint (S)

(Wartenberg’s syndrome

High Radial Nerve Palsy

Wrist drop deformity Lost wrist ext., MCP ext., and thumb

radial abd and ext. Triceps spared: Elbow extension is

intact (not at Axilla level) Supinator and brachioradialis are

paralyzed but supination and elbow flexion is intact bcz biceps is intact

High Radial Nerve Palsy

High Radial Nerve Palsy

Depending on the level of injury, triceps paresis may exist, as well as some posterior arm sensory loss along the dorsal lateral aspect of the forearm and hand

Low Radial Nerve Palsy (posterior interosseous nerve palsy Injuries to the nerve at this level can

occur following compression of the nerve between the humeral and ulnar heads of the supinator muscle

Radial head fracture-dislocations Tumors History of repetitive and strenuous

pronation and supination.

Low Radial Nerve Palsy (posterior interosseous nerve palsy The clinical picture is: Intact radially directed wrist extension Absent MCP extension, thumb

extension, and thumb radial abduction (M)

Splinting for High RNI

Radial nerve motor palsy with wrist drop• Custom-made dorsal forearm-based dynamic splint• Promote functional hand use• Base: dorsal wrist imm. S.• Substitute for absent ms power By assisting MCP extensors• Worn throughout the dayuntil MMT: fair (3)• If no improvement within two months, refer back to physician.

Splinting for High RNI

Dynamic splint is good for a high radial nerve palsy or a posterior interosseous palsy because this splint design does not preclude use of active wrist extension and does assist with finger extension with slight wrist flexion.

Splinting for High RNI

Dynamic splint not worn at night Therapist may offer static wrist imm. S. at

night Therapists may offer both static and

dynamic alternating between them might maximize function

Watch for MCP joint contractures if the client insists on using only a static wrist splint

Splinting for post. Interos. Nerve syndrome

Long arm elbow and wrist splint with elbow in flexion, forearm in neutral or slight sup., wrist in 20-30 degrees of ext.

Tenodesis splint encourage wrist and finger function

Splinting for radial tunnel syndrome

Long splint elbow 30 flex, forearm in full supination, wrist in slight wrist ext. (20-30)

This decompress pressure on RN Worn all the time with removal for

hygiene OR thumb imm. S.

Splinting for wartenberg’s neuropathy

Wrist immobilization splint : wrist in 20-30 ext

If pain include the thumb

Ulnar Nerve Lesion

UlnarNerve Lesions (table 13-3)

Low level (wrist level) abductor digiti minimi flexor digiti minimi opponens digiti minimi fourth and third lumbrical three palmar interossei muscles and four dorsal interossei

muscles deep head of the flexor pollicis brevis adductor pollicis

High Level (At or above the elbow) All previously mentioned muscles Flexor Carpi Ulnaris Flexor Digitorum Profundus for digits 4, 5Study weak and lost motions from the table

Sensory

Function

Strong wrist flexion and ulnar deviation power grip via full flexion of the ulnar

two digits powerful tip and lateral or key pinch powerfully to cup an object In hand manipulation

Common sites of Entrapment/Injury

Cubital tunnel syndrome Guyon’s canal compression

Anteriorly: The medial epicondyle

Laterally: the ulnohumeral

Ligament

Posteromedially: the fibrous arcade of the two heads of the flexor carpi ulnaris.

Roof of this tunnel: fibrous band extending from the olecranon to the medial epicondyle of the humerus

Compression of the ulnar nerve as it passes through the cubital tunnel at the elbow.

Compression leads to paresthesias along the nerve course.

Long withstanding compression leads to residual motor weakness

Sever, prolonged ulnar nerve compression may result in the claw deformity

Cupital Tunnel syndrome: description

loss of simultaneous wrist flexion and ulnar deviation

Pain in the medial aspect of the elbow and tenderness over the cubital tunnel

Paresthesias in the ring and little finger are present

Cupital Tunnel syndrome: description

The clinical picture is one of sensory loss and motor paresis affecting the intrinsic ulnar-innervated muscles

The sensory deficit involves the palmar and dorsal ulnar aspect of the hand

Cupital Tunnel syndrome: description

Claw hand deformity Flattening of the

normal arches of the hand

Hyper-extension of MCP and flexion in PIP and DIP of 4, 5th

Unable to abd and add fingers

Splinting for High Ulnar Nerve compression (at elbow) Elbow splint with elbow flexed 30- 45

degrees If included, wrist is positioned in neutral to

20 degrees of ext Including the wrist decreases the effects

from flexor carpi ulnaris contraction The splint is worn to avoid prolonged and

repetitive full flexion of the elbow (like in sleeping) which increase pressure in the cupital tunnel

Extreme flexion of the elbow increases traction on the ulnar nerve

Splinting for High Ulnar Nerve compression (at elbow) Splint is worn during the night for app 3

weeks If symptoms of decreases sensibility,

continuous symptoms, the client may wear the splint all the time

Material: Rigid, strong enough to carry the weight of the

elbow Self bonding to help formulation of the crease of

elbow conformability and drapability to mold material

over olecranon process

Splinting for High Ulnar Nerve compression (at elbow)

Symptoms include a feeling of pins and needles in the ring and little fingers, and may progress to a burning pain in the wrist and hand followed by decreased sensation in the ring and little fingers

and/or motor weakness

Ulnarly: pisiform and tendinous insertion of the flexor carpi ulnaris

Radially: the hook of the hamate

The roof of the tunnel is the flexor retinaculum

cause of this syndrome is from pressure of bicycle handlebars seen with cyclists

Or hard, repetitive compression against a desk surface while using a computer mouse.

Most common: a ganglion, followed by occupational neuritis

Other causes include a pisiform or hook of hamate fracture

arthritis

Same as the Cubital Tunnel syndrome The sensory deficit involves the palmar

ulnar aspect of the hand, both sides of the little finger, and the ulnar border of the ring finger

Hand based Ulnar Nerve splint intervention

Anti-claw splint Ring and little finger in 30- 45 flex Correct the claw hand posture This splint hand functional grasp Continue wear of the splint with

Removal for hygiene and exercise

until the muscle imbalance resolves or

until tendon transfers are performed

Hand based Ulnar Nerve splint intervention

Dynamic splint Figure 13-13 Finger loops with rubber bands

connected to wrist band Wear throughout the day with removal

for H and E

Median Nerve Lesion

Causes of Median Nerve Lesion

Humeral fracture Elbow dislocation Distal radius fracture Dislocation of lunate into the carpal canal Laceration of volar wrist

Affected muscles by median nerve lesion

Study Figure 13-16 and Table 13-4 Low level: abd policis brevis, flexor policis

previs, opponense policis, 1st and 2nd lumbricals

High level : Low level muscles and pronator teres, flexor carpi radialis, flexor policis longus, lateral half of lex digitorum, palmaris longus, flex digitorum superficialis, abd policis brevis

Functional Involvement

Clumsiness with pinch Decreased power grip Power grip is affected

Lumbricals of index and middle finger is

weak Check sensory supply of the MN

Resulting deformity

Ape hand deformity Thumb in adduction, ext. Thumb web space contract Lost opposition, Fingers show trophic changes Slight clawing of index and middle fingers bcz

of loss of lumbrical innervation Result of high or low MNI

Common deficits/deformities

Pronator syndrome Anterior Interosseous Nerve Palsy Carpal Tunnel Syndrome

High: Pronator Syndrome Result from strong repetitive pronation and

supination as the nerve passes btw the 2 heads of pronator teres

Diffuse pain in the med. forearm or distal volar arm

Dysethesias in the radial three and one-half digits of the hand

Symptoms may be provoked by resisted elbow flexion, often with concurrent resisted forearm pronation

High: Anterior Interosseous Nerve Palsy

Entrapment neuropathy of the motor branch of the median nerve.

Vague discomfort in proximal forearm Typical patient complain: difficulty with writing

and cant make O with thumb and index Pain develop gradually and is followed by

weakness of the muscles innervated by the branch

Usually there are no sensory symptoms

Low: Carpal Tunnel Syndrome Carpal Tunnel –

opening through the wrist to the hand Formed by:

Bottom: Bones of wrist

Top: Transverse carpal ligament

Most frequently a clinical diagnosis based on the patient’s reports of symptoms and clinical tests.

Phalen’s Test: Patient rests elbows on table and allows wrists to drop into flexion … test is positive if client reports parasthesias within 1 minute.

Tinel Test: Tapping over Carpal Tunnel produces parasthesias.

EMG’s sometimes ordered to confirm (gold std.)

What is the difference btw CTS and pronator syndrome – check book 295 and 296

Avoid resisted pronation and passive supination Splint: Place elbow in 90 degrees flexion, forearm

neutral, wrist in neutral to slight flex

Avoid elbow ext and extreme frearm pronation and supination

Splints: Immobilize elbow 90 flex, forearm in neutral

OR Small splint to block thumb IP and index DIP extension Figure 13-17

Ergonomic adaptations for home, leisure, work env

Activity modifications Exercise Splint: Wrist immobilization

splint that place wrist in neutral

As in later stage of CTS Thumb web spacer splint: for low MNI, C bar helps

maintain thumb web space (LOW INJURY) Allows free wrist mobility OR Hand based thumb spica (butterfly)

Splint that inhibits MP EXTENSION All digits included