peripheral nerve injuries

PERIPHERAL NERVE INJURIES

Ahmad A. Fannoon, Msc, Hand Therapist

Part 1

ANATOMY 2

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

Part 2

NERVE RESPONSE TO INJURY 11

Phases 12

Nerve response to injury in two phases:

1. Wallerian degeneration.

2. 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 Schwann sheaths &

endoneurial tubes:

Shrinkage & collapse.

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.


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.

Part 3

CLASSIFICATION OF NERVE INJURIES 19

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.

Seddon’s “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?


Scarring may prevent axons from bridging to &

reentering their original endoneurial tubes.

Axons may enter a functionally different tube:

o 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.

o 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.


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 31

Degree Motor Sensory Treatment Recovery Therapy

1st Paralysis Minimal loss Observation Complete Short-term,

focused

2nd Paralysis Complete loss Observation Usually

complete

Moderate

3rd Paralysis Complete loss Surgical may

be required

Incomplete Moderate

4th Paralysis Complete loss Surgical Incomplete Long-term

5th Paralysis Complete loss Surgical

mandatory

Never

complete

Long-term

Part 4

FACTORS AFFECTING PROGNOSIS FOR RECOVERY 32

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 can’t be

restored completely in adults.

The goal of therapy is to:

Maximize motor & sensibility recovery.

Assist in compensation for residual deficits.

Part 5

SPECIFIC NERVE LESIONS 39

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.

Motor loss

ECU.

EDC.

EDQM.

APL.

EPL.

EPB.

EIP.

43

Functional loss

MP joints extension of all digits.

Thumb radial abduction & extension.

Ulnar wrist extension.

44

Sensory loss

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.

45

Motor loss

All aforementioned muscles +:

Supinator.

ECRL.

ECRB.

46

Functional loss

Ulnar & radial wrist extension.

weakened supination.

MP extension.

Thumb extension.

Thumb radial abduction.

47

Sensory loss

Same as in forearm level injury.

48

Motor & functional loss

Additional motor loss:

Brachioradialis.

Additional functional loss:

weakened elbow flexion.

49

Motor & functional loss

Additional motor loss:

Triceps.

Additional functional loss:

Elbow extension.

50

Deformity & other loss

Classic deformity is wrist drop.

Hand grip is compromised significantly:

Loss of wrist extensors which position & help

stabilize the wrist during grasp.

51

Wrist drop 52

Median nerve lesions 53


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)

Motor loss

Opponens pollicis.

APB.

FPB (superficial head).

1st & 2nd lumbricales.

56

Functional loss

Thumb opposition.

Compromising activities requiring fine prehension.

57

Sensory loss

Volar surface of thumb, index, long, & radial half of

the ring fingers.

Dorsal surface of the distal phalanges of the same

digits.

58

Motor loss

All aforementioned

muscles +:

Pronator teres.

FCR.

FDS.

Palmaris longus.

FPL.

FDP to the index &

long fingers.

Pronator quadratus.

59

Functional loss

Pronation weakened.

Wrist flexion weakened.

Thumb & index IP flexion.

Thumb opposition.

60

Sensory loss

Same as in wrist level injuries.

61

Anterior interosseous nerve

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.

62

Deformity

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.

63

Deformity

Fingertip prehension is lost because of the loss of the

thenar intrinsics & loss of sensibility of the volar

radial side of the hand.

64

Ape hand deformity 65

Ulnar nerve lesions 66


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).

Guyon’s canal (guyon’s canal syndrome).

Motor loss

Abductor digiti minimi.

Flexor digiti minimi.

Opponens digiti minimi.

Lumbricales to the 3rd & 4th digits.

Dorsal & palmar interossei.

FPB (deep head).

Adductor pollicis.

69

Functional loss

Functional grip & pinch.

Finger abduction & adduction.

MP flexion while IPs extended (ring & little).

Froment’s sign: FPL substitutes Adductor Pollicis when

attempting lateral pinch with the thumb.

70

Sensory loss

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.

71

Motor loss

Additional loss include:

FCU.

FDP to the ring & small fingers.

72

Functional loss

Additional loss include:

Further weakened grip (FDP loss).

73

Sensory loss

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.

74

Deformity

Classic deformity is the claw hand.

Ring & small fingers rest in a posture of MP

hyperextension & IP flexion.

o Results from loss of balancing influence of the

intrinsic muscles on the extrinisic flexors * extensors.

75

Deformity

Atrophy of the interossei with hollowing between the

metacarpals.

Flattening of the hypothenar muscle.

76

Deformity 77

Part 6

EVALUATION 78

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 labor’s

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.

Patient’s description of problems:

ADLs?

Motor function 85

Muscle undergoes several stages of recovery:

1. Observable & palpable contracture without

production of motion.

2. Ability to “hold” a test position without being able

to produce that position.

3. 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.

Median, ulnar, & radial nerve repairs

POSTOPERATIVE MANAGEMENT PROTOCOLS 87

Part 7

MEDIAN NERVE REPAIR: FOREARM & WRIST LEVEL 88

10 – 14 days postoperative 89

The bulky compressive dressing is removed.

A light compressive dressing is applied for edema

control.


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.


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.


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.


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.


The DBS is adjusted to 100 of wrist flexion.

Unrestricted active and PROM exercises are

continued to the hand.


The DBS is discontinued.

Progressive strengthening.


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:

o Web spacer at night or web stretching.

Opponens splint 98

Web spacer 99



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 re-

injure 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.

Part 8

ULNAR NERVE REPAIR: FOREARM & WRIST LEVEL 107



A light compressive dressing is applied for edema

control.


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.



digits and thumb for 10 minute sessions each 2

hours.


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.


NMES may be initiated to enhance excursion of the

long flexors.



Desensitization.


The DBS is adjusted to 200 of palmar flexion.

Unrestricted active and PROM are continued to the

hand.


The dorsal blocking splint is adjusted to 100 of wrist

flexion.


continued to the hand.


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



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.


Progressive strengthening.

Considerations 122





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.

Part 9

RADIAL NERVE REPAIR: ELBOW & WRIST LEVEL 124



A light compressive dressing or elastic stockinette is

applied for edema control.


A wrist immobilization splint is fitted with the wrist in

300 of extension for continual wear to minimize

tension on the repair.


digits 6 times a day for 10 minute sessions.


massage with lotion may be initiated.


The wrist immobilization splint is adjusted to 200 of

extension.


The wrist immobilization splint is adjusted to 100 of

extension.


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


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





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???

Part 10

MOTOR RETRAINING 141

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.


What’s before that?

Passive exercises.

o Maintain ROM.

o Maintain muscle-tendon length.

NMES.

o Maintain muscle integrity until reinnervation.

o Proprioceptive feedback.


Motor retraining follows the stages of motor

recovery (use biofeedback):

1. Observable & palpable contracture without

production of motion (start).

2. Ability to “hold” a test position without being able

to produce that position (place & hold exercises).


3. Ability to move the joint through the test motion

(AROM exercises & Dexterity).

4. 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, & goal-

directed activities.

Examples!

Part 11

DESENSITIZATION 152

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.

Part 12

SENSORY REEDUCATION 161

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

o 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:


1. The task is attempted with the eyes closed.

2. The patient opens his/her eyes and checks to see

if the task was performed correctly.

3. If it was, he or she closes his or her eyes and

attempts to carry out another task.


4. 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.

5. 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.

o 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 sandpaper on dowels 171


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 174


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 177

Raised glue maze 178


Picking up objects from a background medium:

At first, large objects must be retrieved from a

background medium such as sand.


using smaller objects in a coarser background

medium, such as foam chips.


Identification of everyday objects:

At first, large dissimilar objects are used.


using smaller, more similar objects.


ADL tasks and work-simulated tasks:

The patient is required to perform selected tasks

with vision occluded.


making the tasks more intricate.

Part 13

CHRONIC PHASE 182

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:

o 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.


Fingertip pinch is

impossible in

anterior

interosseous nerve

palsy, small splints

that prevent joint

extension re-creat

fingertip pinch


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.

o 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:

o E.g. pronator teres to radial wrist extensors: patient

to should attempt wrist extension while thinking

about & initiating pronation.

Common tendon transfers 194

Level Function Transfer Early precaution

Radial Wrist extension Pronator teres to ECRL & B. Avoid concurrent

wrist & digital

flexion. Finger extension FCU or FCR to EDC

Thumb extension PL or FDS to EPL

Median Opposition FDS, PL, or EDQM Avoid concurrent

wrist, thumb, fingers

extension Thumb IP flexion Brachioradialis to FPL

DIP flexion index FDP of long, ring & small to

FDP of index

Common tendon transfers 195

Level Function Transfer Early

precaution

Ulnar Correct claw FDS, EIP, EDQM to intrinsics Avoid MP

extension,

concurrent

fingers,

thumb, &

wrist

extension.

Thumb adduction FDS or ECRL to adductor pollicis

Index abduction APL, ECRL, or IDP to 1st dorsal interosseous

DIP flexion of long,

ring, small fingers

Side-to-side tenodesis of FDP of index

Thank you 196