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Ulnar Nerve Injury & Repair

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Ulnar Nerve Injury & Repair 1/8/16 Ulnar Nerve Injury & Repair: Philadelphia’s Rehabilita6on & Ortho6c Magic Gardens Intervenon 1020 South Street Jenifer M. Haines,MS,OTR /L,CHT The Philadelphia Hand Center Outcomes Following Ulnar Nerve Repair Purpose: quan4fy variables influencing outcome aer 1. Outcomes & Expectaons ulnar & median nerve repair 2. Anatomy Methods: meta-analysis, literature review, 23 ar4cles 3. Clinical presentaon ulnar Results: nerve injury 1) 45% “sasfactory motor outcome” (71% < median nerve) 4. Func4onal deficits 41% “sasfactory sensory outcome” (approx. = median 5. Acute post-operave stage nerve) 6. ReHabilitaon stage 2) HigH level injury - poor motor outcome *irreversible motor damage by 1 ½-2 years (before re- innervaon of muscle) Ruijs, 2005 Long Term Outcomes of Ulnar 3) Paents < 16 years old 4x more likely sasfactory Nerve Injury motor recovery than those > 40 * neuroplas4city Purposes: 1. assess long term outcomes of paents following 4) Delayed surgery, lower cHance motor & sensory peripHeral repair recovery 2. determine relaonsHips between measures of Hand * Improvement possible up to 3 years func4on and nerve recovery. Methods: evaluated 32 paents approx. 5 years post-op Rosen and Lundborg scale, sensory, motor, and pain/ symptom tests, and self-report measures Ruijs, 2005 MacDermid J, 2010 1 1/8/16 Results: Paents retained 82.91% global func4on: 44.48%-84.90% sensory funcon “Factors that predict outcomes aer the repair of 80.13%-89.89% motor func4on peripHeral nerve injuries of the upper limb include age, 89.75%-93.19% pain/symptom experience gender, repair 4me, repair materials, defect length, duraon of follow-up and nerve injured.” Self-report measures of Hand func4on were more closely related to nerve recovery than were pHysical measures. “Outcomes aer the repair of ulnar nerve injuries are the worst because the ulnar nerve innervates a small Conclusions: Paents with nerve repairs Have incomplete recovery, par4cularly of sensory func4on. volume of muscle with a small muscle fiber size. AMer loos of innervaon, the muscle fibers rapidly Relevance: Long-term outcomes of nerve func4on indicate degenerate and atropHy.” targets for Hand therapy. Liu, 2015 MacDermid J, 2010 Return to Work Outcomes Predictors for return to work within 1 year of Purpose: determine RTW and risk factors for delayed RTW nerve injury: Methods: Retrospec4ve cHart review - 96 paents with ulnar, median, or combined nerve injuries between 1990-1998 Adjusted for age, gender, and severity of trauma HigHer rates of RTW: 59% paents with ulnar nerve injury (80% median nerve) 1. HigHer scores on grip strength, 4p pincH strength, toucH- returned to work within 1 year. pressure ligHt toucH sensaon 2. WHite-collar employment Conclusions: ulnar nerve injury is unique due to: 3. Compliance to Hand therapy 1. Decreased grip strength from loss ulnar intrinsic nerve 4. Injuries at the wrist crease level rather than elbow to funcon forearm 2. regeneraon 4me of ulnar nerve longer than median nerve NOTE: Pain did not influence return to work. Coen, 2012 Coen, 2012 Ulnar Nerve Motor Pathway Ulnar Nerve - Flexor Carpi Ulnaris - Flexor Digitorum Profundus Cutaneous Sensory Distribu4on to ring & small - Abductor Digi Minimi - Flexor Digi Minimi - Opponens Digi Minimi - Dorsal Interossei - Palmar Interossei - Lumbricals to ring & small - Adductor Pollicis Neer, 2006 Neer, 2006 - Flexor Pollicis Brevis (deep) 2 1/8/16 FDP IV &V, Lumbricals IV & V, Interossei, How does the ulnar nerve Hypothenar muscles provide contribute to hand function? ulnar side stability to allow: !ght grasp and pinch Lumbrical, Dorsal & Palmar Interossei ac4on is necessary for: FDP and Lumbricals to ring and small, grasp and Interossei, Hypothenar muscles provide release of ulnar sided stability to allow: objects radial-sided mobility Lumbrical, Dorsal & Palmar Interossei Adductor Pollicis, Flexor Pollicis Brevis (deep Head), ac4on facilitate: 1st Dorsal Interosseous are required for: 3 1/8/16 Ulnar Nerve Laceraon à MOTOR & SENSORY DYSFUNCTION Unbalanced muscle forces across the wrist and Hand create: How does an ulnar nerve injury * altered res4ng posture of Hand due to intrinsic and extrinsic muscle imbalance disrupt hand function? * overstretcHing of weakened muscles by pull of innervated antagonis4c muscles * compensatory movement paerns * joint and soM 4ssue contractures Altered sensory innervaon creates: * altered func4onal sensibility and sensorimotor cor4cal mapping * safety concerns Duff, 2011; Skirven, 1991 MOTOR DEFICITS MOTOR DEFICITS clawing of ring & small fingers Altered grasp loss of Lumbricals IV & V, Dorsal & Palmar Interossei 1. Weak grasp- grip 38%, pincH 77% of normal (Kozin, 1999) HIGH INJURY: LOW INJURY: 2. Unable to accommodate large objects for grasp mild clawing severe clawing à pressure on 4ps of ring and small fingers (Sapienza, 2012) 3. Rolling fist: DIP à PIP à MCP Intact FDP to ring & small Loss of FDP to ring & small àFDP, FDS pull PIP & DIP à FDS pulls PIP into flexion joints into flexion à EDC, EDM pull MCP joints into àEDC, EDM pull MCP joints extension Sapienza, 2012 into extension Froment’s Sign Jeanne’s Sign Loss of AP and FPB (deep) à loss adduc4on force Loss of Adductor Pollicis and Flexor Pollicis Brevis (deep) at CMC and flexion force at MCP joint à flexion at IP joint with key pincH due to FPL forces àIP flexion WITH MCP Hyperextension Ulnar nerve paralysis AP and “normal” lateral pinch FPB (deep head) Differen4al diagnosis: Colditz, 2013 Maitrise-orthop.com due to normal laxity volar plate MCP joint 4 1/8/16 Wartenberg’s Sign HIGH AND LOW CAUSE FOR MOTOR DEFICIT FUNCTIONAL MOTOR DEFICITS 1. Weak grasp Loss of lumbricals to ring and loss of Interossei and Lumbricals à small finger 2. Unable to accommodate large small, dorsal interossei, palmar rests in abduc4on due to unopposed EDM objects for grasp interossei – loss of MCP flexion 3. Loss dexterity force during power grasp forces 4. rolling fist: DIPàPIPàMCP (low) Altered lateral pincH: Loss of adductor pollicis & FPB Froment’s Sign – IP flexion (deep) à FPL flexes IP Altered lateral pincH: Loss deep Head FPB Jeanne’s Sign – MCP à Hyperextension MP Hyperextension/IP flexion Small finger “catcHes” in pocket: Loss of 3rd palmar interossei Wartenberg’s sign – abduc4on à ED and EDM pull to small small finger into abduc4on FUNCTIONAL MOTOR DEFICITS FUNCTIONAL SENSORY DEFICITS connued HIGH (elbow) LOW CAUSE FOR MOTOR DEFICIT (wrist) Mild clawing ring & Severe Loss of lumbricals and small clawing interossei ring & small àED, EDM, FDS, & FDP(low) pulls ring and small into MCP hyperext, IP flexion Weak grasp 1) Loss of FCU ---- àLess stability for power grasp Poor/altered sensory recovery causes: 2) Loss of FDP ring & small allodynia, Hypersens4vity, cold intolerance (grasp weakened 60-80% dexterity deficits, safety concerns Duff, 2011; GolsHalk, 2012; Sapienza, 2013 Cold Intolerance Summary of Events “abnormal pain following exposure to mild cold” Following Nerve Repair 1. Laceraonà Wallerian degeneraon à Axonal Regeneraon - Reported by paents to be most disabling symptom following 2. Axons grow 1-2 mm/day nerve repair - Motor end plates degrade approx 1%/week à irreversible - Post-traumac cold intolerance-56%-83% muscle fibrosis by 24 months (Slutsky, 2012) - “Normal” digital rewarming paern: - Maximum length a nerve can grow to restore motor funcon is 35cm (13 25/32 in) à vasoconstric4on in cold minimizes Heat loss vasodilaon in à poor motor recovery HigH lesions warm returns blood to extremi4es, mediated by central & sympathe4c nervous systems 3. Sensory end organs remain viable (no end plate), retain - PeripHeral nerve injury alters digital rewarming paerns poten4al for re-innervaon several years - Sensory recovery correlates with improvement in cold tolerance 4. Cor4cal representaon of the Hand is immediately altered as the Ruijs, 2009 brain receives new motor and sensory informaon 5 1/8/16 Post-operave THerapy Stages Acute Stage Goals: 1. Immobilize to protect nerve repair 1. Acute 2. Wound care 2. Rehabilita6on 3. Manage edema 3. Chronic 4. Prevent joint contractures 5. Facilitate early nerve gliding 6. Protect from injury due to sensibility deficits Acute Stage: EVALUATION Sensibility Evaluaon 1. History of injury: mechanism of injury, surgical technique– Recommended Test Baoery for individuals with Nerve repair under tension vs. no tension, associated injuries and Laceraons repairs 1. Observaon sympathec dysfuncon: vasomotor, 2. Family situa6on: Is help available? sudomotor, pilomotor, trophic changes 3. Vocaonal and recreaonal pursuits 2. Tinel’s test distal to repair 4. Medical history 3. Semmes Weinstein Touch-Pressure Threshold-mapping 5. Observa6on: skin, posture… 4. Pinprick if areas unresponsive to 6.65 6. Wound: temperature, color, size, ssue quality 5. Sta6c and Moving 2-point Discrimina6on – finger6ps 7. Edema: circumferenal, quality of edema (so, brawny) 6. Touch Localizaon-distal to nerve repair 8. ROM: per post-opera6ve precau6ons 7. Dellon modificaon of Moberg Pick Up Test 9. Pain: pain scale 0-10, visual analog scale 8. Func6onal use in ADL’s 10. Outcome measurement: Quick DASH, PSFS 9. Children under 4 years old: wrinkle test, ninhydrin sweat test, Moberg Pick up Test [Bell-Krotoski, 2011; Duff, 2011] Acute Stage: ORTHOSIS FABRICATION “…ideal period of 4me for immobilizaon to balance protec4on of the nerve coaptaon site and to promote neural mobility remains to be establisHed.” (Novak, 2013) Date of repair-approx. 3 days post-op: bulky dressing, eleva6on, ice 1st post-op therapy visit: immobiliza6on with dorsal block orthosis goal: protect surgical repair 6 1/8/16 Orthosis posi4on dependent upon Orthosis posion dependent upon repair tecHniques: repair techniques: Direct end to end repair: prior to wound closure intra- operavely, joints placed in a posion to unload the repair site. Nerve gra or nerve transfer with no tension: * 3 – 10 days to approximately 3 weeks (talk with * immobilize 3 weeks in unloaded posi6on to prevent surgeon!) tension on the nerve * dorsal block orthosis: wrist slight flexion, as close * dorsal block orthosis: wrist neutral to slight flexion, to neutral as possible, MCP joints 40 degrees flexion, MCP joints approx.
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