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
DIABETES, RENAL DISEASE, ALCOHOLISM
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?
Lower median nerve injury affects the motor supply to which muscles?
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?
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
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?
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?
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
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
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