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PHYS-DYS
Musculoskeletal and orthopedic conditions (PNI)
| Term | Definition | Definition 2 | Nerve | Location | Affected | Test |
|---|---|---|---|---|---|---|
| 3 Categories of nerve injuries | 1. Neurapraxia 2. Axonotmesis 3. Neurotmesis | |||||
| Neurapraxia nerve injuries | ● Contusion of the nerve without wallerian degeneration. ● The nerve recovers function without intervention within a few days or weeks. | |||||
| Axonotmesis nerve injuries | ● An injury in which nerve fibers distal to the site of injury degenerate, but the internal organization of the nerve remains intact. ● No surgical intervention is necessary ● Recovery occurs within 6 months | |||||
| Neurotmesis nerve injuries | ● A complete laceration of both nerve and fibrous tissues. ● Surgical intervention is required. ● Microsurgical repair of the fascicles is common ● Nerve grafting may be necessary | |||||
| Nerve grafting | a gap between nerve endings | |||||
| CAUSE OF PNI | Result of disruption of the nerve by a fractured bone, laceration and crush injury | |||||
| SYMPTOMS OF PNI | ● Motor branches of the injured nerve ○ Weakness or paralysis of muscles that are innervated by motor branches | ● Sensory branches of the injured nerve ○ sensory loss to areas that are innervated by sensory branches | ||||
| MOTOR DISTRIBUTION OF THE RADIAL NERVE | ● Extensor-supinator group of muscles of the forearm ● Brachioradialis ● Extensor carpi radialis longus ● Extensor carpi radialis brevis ● Extensor digitorum communis ● Extensor digiti minimi ● Extensor indicis | ● Extensor carpi ulnaris ● Supinator ● Abductor pollicis longus ● extensor pollicis brevis ● extensor pollicis longus | ||||
| Sensory distribution of the Radial Nerve | ● Strip of the posterior upper arm and the forearm ● Dorsum of the thumb, and index and middle fingers ● Radial half of the ring finger to the PIP joints ● Sensory loss of the radial nerve does not usually result in dysfunction | |||||
| CLINICAL SIGNS OF INJURY | ● Forearm pronation ● Wrist flexion ● The thumb held in palmar abduction | |||||
| The thumb held in palmar abduction | ○ resulting from the unopposed action of the ■ Flexor pollicis brevis ■ Abductor pollicis brevis | |||||
| CLINICAL SIGNS OF LOW-LEVEL RADIAL NERVE INJURY | ● incomplete extension of the MP joints of the fingers and thumb ● Interossei extend the interphalangeal (IP) joints of the fingers, but the MP joints rest in about 30 degrees of flexion | |||||
| Nerve Injuries of the Upper Extremity | Radial Nerve (posterior cord fibers C5, C6, C7, C8) | upper arm | ○ Triceps and all distal motors ○ Sensory to SRN | ○ MMT ○ Sensory test | ||
| Radial Nerve | above elbow | ○ Brachioradialis and all distal motors ○ Sensory to SRN | ○ MMT ○ Sensory | |||
| Radial Nerve | at elbow | ○ Supinator, ECRL, ECRB, and all distal motors ○ Sensory to SRN | ○ MMT ○ Sensory | |||
| Posterior interosseous nerve | forearm | ○ ECU, ED, EDM, APL, EPL, EPB, EIP ○ No sensory | ○ Wrist extension—if present, indicates PIN rather than high radial nerve | |||
| Radial nerve at ECRB, radial artery, arcade of Frohse, origin of supinator | radial tunnel syndrome | ○ Weakness of muscles innervated by PIN ○ No sensory loss | ○ Palpate for pain over extensor mass ○ Pain with wrist flexion and pronation ○ Pain with wrist extension and supination ○ Pain with resisted middle finger extension | |||
| RADIAL NERVE SPLINTING | ● Dynamic or static splint ● applied to the dorsum of the hand to provide wrist extension, MP extension, thumb extension ● Dynamic splint is commonly provided | |||||
| Purpose of Radial Nerve Splinting | ○ To protect the extensor tendons from overstretching during the healing phase ○ To position the hand for functional use | |||||
| MEDIAN NERVE | ● Innervates the flexors of the forearm and hand ● often called the “eyes” of the hands ○ its importance in sensory innervation of the volar surface of the thumb, index, and middle fingers. | ● Median nerve loss may result from lacerations and compression (Carpal Tunnel Syndrome) | ||||
| MOTOR DISTRIBUTION OF MEDIAN NERVE | ● Pronator teres ● palmaris longus ● flexor carpi radialis ● flexor digitorum profundus of the index and middle fingers ● Flexor digitorum superficialis ● flexor pollicis longus ● pronator quadratus ● abductor pollicis brevis | ● opponens pollicis ● Superficial head of the flexor pollicis brevis ● First and second lumbricals | ||||
| Sensory distribution of the Median Nerve | ● Volar surface of the thumb, index, and middle fingers ● Radial half of the ring finger and dorsal surface of the index and middle fingers ● Radial half of the ring finger distal to the PIP joints | |||||
| CLINICAL SIGNS OF HIGH-LEVEL MEDIAN NERVE INJURY | ● Ulnar flexion of the wrist caused by loss of the flexor carpi radialis ● Loss of palmar abduction, and opposition of the thumb. ● Active pronation is absent, but the client may appear to pronate with the assistance of gravity | |||||
| CLINICAL SIGNS OF WRIST-LEVEL MEDIAN NERVE INJURY | ● Thenar eminence appears flat ● Loss of thumb flexion, palmar abduction, and opposition | |||||
| Importance of sensory distribution of the median nerve | ● Sensory loss is particularly disabling because of the NO sensation to the volar aspects of the thumb and index and middle fingers and the radial side of the ring finger. ● Results to poor pinch | ● Substitutes pinch to the ring and small fingers to compensate for this loss | ||||
| Nerve Injuries of the Upper Extremity | Median nerve (lateral from C5, C6, C7, medial cord from C8, T1) | high lesions (elbow and above) | ○ Paralysis/weakness of FCP, PL, all FDS, FDP I and II ○ FPL, pronator teres and quad., opponens pollicis, APB, FPB (radial head), lumbricals I and II ○ Sensory cutaneous branch of median nerve | ○ MMT ○ Sensory | ||
| Median nerve | Low (at wrist) | ○ Weakness of thenars only | ○ Inability to flex thumb tip and index fingertip to palm ○ Inability to oppose thumb ○ Poor dexterity | |||
| Median nerve under fibrous band in PT, beneath heads of pronator, arch of FDS, origin of FCR | Pronator syndrome | ○ Weakness in thenars, but not muscles innervated by AIN ○ Sensory in median nerve distribution in hand | ○ Provocative tests to isolate compression site | |||
| Median nerve under origin of PT, FDS to middle | Anterior interosseous nerve syndrome | ○ Pure motor, no sensory ○ Forearm pain precedes paralysis ○ weakness of FPL, FDP I and II, PQ | ○ Inability to flex IP joint of thumb and DIP of index ○ Increased pain with resisted pronation ○ Pain with forearm pressure | |||
| Median nerve at wrist | carpal tunnel syndrome | ○ weakness of medial intrinsics sensory | ○ Provocative tests ○ Tinnel's sign ○ Sensory | |||
| MEDIAN NERVE SPLINTING | ● Splints that position the thumb in palmar abduction and slight opposition increase functional use of the hand ● If clawing of the middle and index finger are present ○ Splint to prevent hyperextension of MP joints | |||||
| MEDIAN NERVE COMPRESSION | ● Median Nerve Gliding Exercises (Trombly) (PPT) | |||||
| ULNAR NERVE | ● Innervates FCU and medial half of FDP, intrinsic muscles of the hand – PB, ADM, FDM, ODM, dorsal and volar interossei, 3rd and 4th lumbricals, FPB ● travels down the volar forearm through the canal of Guyon ● Cubital Tunnel Syndrome | |||||
| Cubital Tunnel Syndrome | ○ Ulnar nerve compression at the level of elbow | |||||
| MOTOR DISTRIBUTION OF ULNAR NERVE | ● Intrinsic muscles of the hand, including the palmaris brevis ● abductor digiti minimi, ● opponens digiti minimi ● flexor digiti minimi ● dorsal and volar interossei | ● third and fourth lumbricals ● Medial head of the flexor pollicis brevis | ||||
| Sensory distribution of Ulnar Nerve | ● dorsal and volar surfaces of the small finger ray ● ulnar half of the dorsal and volar surface of the ring finger ray | |||||
| CLINICAL SIGNS OF HIGH-LEVEL ulnar NERVE INJURY | ● Results in hyperextension of the MP joints of the ring and small fingers | |||||
| hyperextension of the MP joints of the ring and small fingers | ○ also called clawing ○ Response to overaction of the extensor digitorum communis that is not held in check by the third and fourth lumbricals | |||||
| CLINICAL SIGNS OF HIGH-LEVEL ulnar NERVE INJURY | ● Paralysis of flexor digitorum profundus ● Absent hypothenar muscles and interossei ● Loss of flexor carpi ulnaris | |||||
| Paralysis of flexor digitorum profundus: | The IP joints of the ring and small fingers do not demonstrate a great flexion deformity | |||||
| Loss of flexor carpi ulnaris: | The wrist assumes a position of radial extension | |||||
| CLINICAL SIGNS OF LOW-LEVEL ulnar NERVE INJURY | ● Ring and small fingers claw at the MP joints ● Present Flexor Digitorum Profundus: IP joints exhibit a greater tendency toward flexion ● Wrist extension is normal. | |||||
| CLINICAL SIGNS OF LOW-LEVEL ulnar NERVE INJURY | ● Flexor digitorum profundus and flexor carpi ulnaris are present ○ Unopposed by the intrinsic muscles ● (+) Froment’s sign | |||||
| Nerve Injuries of the Upper Extremity | Ulnar nerve at elbow (branch of medial cord from C7, C8, T1) | Cubital tunnel syndrome | ○ Weakness/paralysis of FCU, FDP III and IV, ulnar intrinsics ○ Numbness in palmar cutaneous and dorsal cutaneous distribution ○ Loss of grip and pinch strength | Pain with elbow flexion and extension | ||
| ULNAR NERVE splinting | ● Low-level ulnar nerve injury ○ To prevent hyperextension of the small and ring fingers without limiting full flexion at the MP joints ○ Stabilization of the MP joints will allow digitorum the extensor communis extend the IP joints fully | Ulnar nerve at wrist | Compression at canal of Guyon | ○ Weakness and pain in ulnar intrinsics | Reproduced by pressure at site | |
| ulnar NERVE compression | ● Ulnar Nerve Gliding Exercises (Trombly) (PPT) | |||||
| PNI NERVE SENSORY DISTRIBUTION | look ka sa ppt | |||||
| Post-operative management | ● Hand positioning / immobilization to minimize tension on the nerve ● 2 to 3 weeks 🡪 protective stretching of joints ● Precaution: not to put excessive traction | ● Contracture correction (~4 to 6 weeks) ○ AROM (preferred method to gain full extension) ○ Light dynamic orthosis | ||||
| OT intervention | ● Minimize or prevent deformity ● Correction of poor positioning ● Visual protection for sensory loss of the area ● Improve ROM and strength ● PNF ● Neuromuscular electrical stimulation (NMES) ● Sensory reeducation | |||||
| PNF | ○ Hold-relax, contract-relax, quick stretch, and icing—may assist a fair strength muscle and increase ROM | |||||
| Sensory reeducation | ○ Goal is to maximize the functional level of sensation or tactile gnosis | |||||
| Immobilization | Immobilization usually lasts 2 to 3 weeks - protective stretching of the joints may begin. |
Created by:
avemaria