Wrist/Hand Nerve Injuries Flashcards Preview

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Flashcards in Wrist/Hand Nerve Injuries Deck (57):

With a median nerve repair, what position is the patient splinted in by the surgeon?

MP joints in flexion with a dorsal block cast or splint


What is the research for estim on full or partially denervated muscles?

It is still controversial


What are other conditions which cause one to be more at risk for CTS



Which detects nerve compression earlier...2PD or Semmes Weinstein monofilaments?



What 2 hand positions do you want to avoid with ppl w CTS?

Tight full composite fist or intrinsic plus--these pull lumbricals into the tunnel


What aspect of the nerve is the "blood-nerve barrier"?

perineurium--regulates diffusion into the fascicles


What is the order of endoneurium, epineurium, and perineurium

Perineurium surrounds individual fascicles
epineurium: surrounds groups of fascicles
Endoneurium: made up of collagen and reticulin holding the axons within each fascicle


What is neurapraxia?

simplest form of nerve injury
transient reduction or complete blocking of nerve connection at the lesion site


What is the recovery time for neurapraxia?

a few days to 3 months after removal of compression


What is axonotmesis? What type of injury is it seen with?

usually with crush or traction injuries
axon damage but nerve sheath or endoneurial tub is intact
Wallerian degeneration occurs distal to the level of the injury


What is the prognosis of recovery for axonotmesis?

depends of axonal regeneration; more severe injuries that produce endoneurial scarring and partial disruption have a poorer prognosis


What is neurotmesis?

laceration to the entire nerve
requires surgical repairs


Which shows greater cell death over time if not repaired...sensory or motor?

Sensory--up to 50% of neurons in the DRG may die following a sensory nerve injury


What would you expect to see clinically if a patient's new axons innervate a diff part of the skin?

Poor touch localization


What is the deformity seen with lower median nerve injury?

Ape hand


Lower median nerve injury affects the motor supply to which muscles?

1st/2nd lumbricals
Flex Pollicis Brevis (superficial head)
Abd pollicis Brevis


Following median nerve repair, how is the patient's hand positioned?

wrist and MP joint flexion with a dorsal block cast or splint (repair site and muscles are placed on slack)


Later in the rehab process of a median nerve repair, what splint should be constructed and why (3 reasons)?

Static hand based opponens splint
functionally positions thumb, facilitates prehension, preserves the web space


What aspect is not affected by CTS?

Sensory changes do not affect the center of the volar wrist because it is supplied by the palmar cutaneous branch of the median nerve (arises 4 cm proximal to carpal tunnel)


What finger is initially involved in CTS?

long finger


What are the CTS special tests recommended? Which one according to MacDermid and Wessel is the most sensitive?

Phalen, Tinel, MMT for APB, Semmes Weinstein monofilaments and static 2PD

Semmes (72%) then Phalen's 68%


Why should CMC OA be evaluated in pts with CTS?

excessive pull of the OP muscle during pinch through its attachment to the flexor retinaculum causes increase in intraneural pressure--avoid holding a book for sustained periods


What is the splint used for CTS? What does the research say about splinting with CTS in the conservative management phase?

neutral wrist position with metal stay & with MP joints in 20-40 flex (dec lumbrical activity and incursion)
Literature: supports use for mild cases of CTS for at least short term relief


What have systematic reviews said about CTS and modalities? Exercise? Low level laser? Heat modalities?

Modalities and exercise = inconsistent results

Low level laser, heat, US, diff tendon gliding, neural/carpal bone mobilizations can be used, but there is a need for high-quality studies


What would you say is the "clinical prediction rule" for someone to get a carpal tunnel release surgery?

sx > 3 months
thenar atrophy present
Semmes exceeds 3.61
conservative tx does not resolve symptoms within a considerable time

**if these are true PT should consider CTR


Following carpal tunnel release how is the patient splinted?

Research suggests no benefits to post-op immobilization


What is the early mobilization suggested for a patient s/p carpal tunnel release?

gentle composite fist and progressing to differential tendon gliding by Day 4 s/p


When do most patient's resume full activity s/p Carpal tunnel release? Can strengthening begin at 2 weeks s/p--why or why not?

4-6 weeks = full activity
repetitive gripping/strengthening is not recommended at 2 weeks because these activities can contribute to inflame in the flexor sheath, A1 pulley, and thumb


What are predictors for a poor outcome following carpal tunnel release?

poor health status
smoking/alcohol use
presence of TOS
double crush injuries
APB atrophy preop
worker's comp with attorney involvement


What is usually the biggest complaints following CTR and what can be done?

excess scarring and pain at the surgical incision for 2 months--
use silicone gel sheeting or micropore tape


What is the motor involvement following ulnar nerve lesion?

dorsal/palmar interossei, 3rd/4th lumbrical, deep head of flex pollicis brevis, Add policis


What deformity is seen with ulnar nerve injury? What causes this?

Claw hand (intrinsic minus)
ED and FDS/FDP causes MP ext and PIP flex


What nerve innervates flexor pollicis longus?



What is the clinical test for ulnar nerve lesions?

Froment's sign--key pinch is done by FPL instead of ADD poll


What splint is used for an ulnar nerve lesion repair?

anti-claw splint: dorsal block or cast with wrist and MP joints flexed--PIPs splinted in extension; DIPs free to move


How long is someone in the splint following ulnar nerve repair?

3-4 weeks


What areas are spared if an ulnar nerve lesion occurs at the tunnel or distal?

medial aspect of the wrist, hypothenar area, dorsal aspect of the hand over the 4th metacarpal--innervated by the palmar and dorsal sensory branches of the ulnar nerve


What is another name for Wartenberg's syndrome? What nerve is affected and where is the area of sensory changes?

cheiralgia paresthetica
radial nerve affects over the dorsum of the hand and lateral 3.5 fingers


What condition is commonly confused with Wartenberg's syndrome?



What two muscles does the radial nerve get trapped b/w in Wartenberg's syndrome?

ECRL and brachioradialis


What motions of the wrist/hand create pain in Wartenbergs syndrome

resisted wrist ext with radial deviation in supination
passive wrist flex with ulnar deviation in pronated position


What is one treatment one could do for Wartenberg's syndrome?

Myofascial technique to increase mobility of the brachioradialis and ECRL


What are the 6 factors which affect nerve regeneration recovery?

1. age--kids under 10 = great outcome
2. verbal/visiospatial learning capacity
3. Timing--earlier repair is associated with less cell death/scarring
4. pure motor or pure sensory involvement--mixed is more likely to have mismatch during regeneration
5. level of injury--distal injuries travel a shorter distance to their target tissue
6. type of injury--clean cut lacerations with min tissue injury has better outcome


What is the first sensory perception to return following nerve injury/nerve regeneration?

Pain perception due to C fibers regenerating the fastest


What do B fibers of nerves transmit?

pain temp proprioception


What doe A fibers transmit (A beta/A gamma)

touch, pressure, and movement sensation


What is the order of gain for nerve fiber type?
What does this mean clinically?

C > B > A
pain > temperature/pain > touch/tactile gnosis


What takes longer to regenerate--motor or sensory fibers?



What do Meissner corpuscles detect?

moving touch and 30 cycles/sec vibration


What do Pacinian corpuscles detect?

moving touch and 256 cps vibration


What does Merkle-neurite cells detect

constant touch


Speak to the number of fibers to receptors for nerve regeneration? What does that mean for Merkle, Pacinian, Meissner

> # of fibers supplying a receptor, greater likelihood of recovery

Meissner (numerous fibers supply 1 receptor) > Merkle (1 fiber to 4 receptors) > Pacinian (1 nerve fiber supplies each receptor)--pacinian should precede merle, but they have a barrier which slows them down


Clinically, what is the order of sensory perception return?

1. pain via pin prick
2. 30 cps vibration
3. moving touch and moving 2 PD
4. Constant touch and static 2PD
5. 256 cps vibration


What happens during phase 1 of sensory re-education?

occurs immediately after repair when no sensation is present
integrate sensory information to maintain cortical map
mirror therapy


When does phase 2 of sensory re-education occur? What occurs in this phase?

starts when patient can feel 30 cps vibration tuning fork
some suggest starting once pt can feel at least 6.65 monofilament in the palm and fingertips
**progress in the way sensory perception returns
moving touch before constant touch etc


When should desensitization programs be used?

since pain is the 1st to come back, patients may have allodynia or hyperalgesia; do de-sensitization before sensory re-education


What is shown clinically with a deep branch of ulnar nerve injury?

Claw hand with no sensory disturbances (superficial branch is intact)