SANA ABU-DAHAB, PHD, OTR

1
Common Peripheral Nerve Problems

• SANA ABU-DAHAB, PHD, OTR

2
Radial Nerve Injuries
3
Non-operative Treatment

• Splinting
• Dorsal forearm-based dynamic splint that
  harnesses the normal tenodesis pattern of the
  hand
• Wrist cock-up at night and Colditzs low profile
  splint during day time

4
Median Nerve
5
High (Proximal) Median Nerve Palsy

• Timelines and Healing
• Nonoperative treatment
• Splinting
• Pain Management
• Therapeutic Exercises
• Activity Modification

6
Median Nerve Not in Continuity, Elbow to Wrist
Level

• Diagnosis and Pathology
• Timelines and Healing following Surgical repair
• Remove the bulky compressive dressing and apply a
  light compressive dressing for edema control.
• Fabricate a custom-made dorsal wrist blocking
  splint with the wrist in approximately 30 degrees
  of palmar flexion but not more than 45 degrees of
  palmar flexion. The amount of wrist flexion is
  predicated upon the amount of tension at the
  nerve repair site.
• Replicate the wrist position of the postoperative
  cast if the surgeon is not immediately available
  to give you guidelines.
• Have the client wear the splint continuously for
  4 to 6 weeks except for protective skin care.
  Hygiene should occur with the splint on.
• Begin AROM and PROM of the digits and thumb, 10
  repetitions every waking hour within the splint.

7
Clinical Reasoning

• With a median nerve injury, adduction
  contractures of the thumb are the most common and
  preventable deformity that should be addressed by
  proactive splinting.

8
Low Median Nerve Palsy

• CARPAL TUNNEL SYNDROME

9
Non operative treatment

• Splinting
• Use of wrist splint to rest the inflamed tissue
  and to minimize intratunned pressure on the
  median nerve
• The proper position for wrist splinting is
  neutral, with the wrist at 0 to 2 degrees of
  flexion and about 3 degrees of ulnar deviation.
• The splint should be used at night for 6 to 8
  weeks and may be used selectively during the day
  to assist with wrist positioning during provoking
  activities such as computer use.

10
Ulnar Nerve
11
Nonoperative Treatment

• Splinting
• The splint should position the elbow in 45-60
  degrees of elbow flexion and the forearm and
  wrist in neutral, and the digits should be free
  to move
• The splint can be fabricated anteriorly or
  posteriorly, though if a posterior splint is
  used, the elbow must be well padded so as not to
  cause increased surface pressue at the cubital
  tunnel
• Generally instruct the client to wear the splint
  at night for at least 3 weeks
• If the symptoms did not improve, instruct the
  client to wear the splint as much as possible,
  removing it only for hygiene

12
Nonoperative Treatment Cont.

• Splinting Cont.
• If clawing is evident, a hand-based static splint
  that blocks the MCP joints from extension allows
  the extension digitorum communis tendon to shunt
  its terminal force to the distal IP joint, thus
  allowing IP joint extension
• Provide an elbow pad to protect the
• vulnerable cubital tunnel area whenever
• the client is unable to wear the long
• arm splint

13
Distal Ulnar Nerve Compression

• ENTRAPMENT AT GUYONS CANAL

14
Non-operative Treatment

• Splinting
• Ulnar Nerve Palsy splint, anticlaw splint
• Prevent overstretching of the denervated
  lumbrical muscles and interossie of the ring and
  small fingers
• Instruct the client to remove the splint for
  hygiene only
• Continue use of splint until the muscle imbalance
  resolves or until tendon transfers are performed
• If PIP flexion contractures of the involved
  digits has developed, a dynamic PIP extension
  splint is needed to address joint contracture
  before using static anticlaw splint
• Padded antivibration gloves can be used to
  protect Guyons canal

15
Repair of the Ulnar Nerve Not in Continuity,
Elbow to Wrist Level

• Timelines and healing
• Splinting
• Dorsal blocking splint with the wrist in 20-30
  deg. of flexion (depending on the amount of
  tension at the nerve repair junction)
• Incorporate in the splint a MCP dorsal block that
  limits MCP joint extension to 45deg.
• Minimize tension on the nerve repair
• Block clawing (hyperextension of the MCP of the
  ring and little fingers)

16
Digital Nerve Injury and Repair
17
Postoperative Treatment

• Splinting
• Dorsal blocking gutter splint is fitted in 30deg.
  of PIP joint flexion for continuous wear for the
  first 3-6 weeks
• If the splint continues to 6 weeks, therapist can
  begin to adjust dorsal blocking into lesser
  degrees of PIP flexion beginning at 4 weeks
  postoperatively
• After 6 weeks of protective splinting, a slight
  PIP contracture may have developed.
• Static extension gutter splint may be fabricated
  to wear at night and for brief periods (2-3
  sessions of 45min) during the day