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Ulnar Nerve Injury & Repair: Philadelphia’s Rehabilita on & Ortho c Magic Gardens Interven on 1020 South Street
Jenifer M. Haines,MS,OTR /L,CHT The Philadelphia Hand Center
Outcomes Following Ulnar Nerve Repair
Purpose: quan fy variables influencing outcome a er 1. Outcomes & Expecta ons ulnar & median nerve repair 2. Anatomy Methods: meta-analysis, literature review, 23 ar cles 3. Clinical presenta on ulnar Results: nerve injury 1) 45% “sa sfactory motor outcome” (71% < median nerve) 4. Func onal deficits 41% “sa sfactory sensory outcome” (approx. = median 5. Acute post-opera ve stage nerve) 6. Rehabilita on stage 2) High level injury - poor motor outcome *irreversible motor damage by 1 ½-2 years (before re- innerva on of muscle) Ruijs, 2005
Long Term Outcomes of Ulnar 3) Pa ents < 16 years old 4x more likely sa sfactory Nerve Injury motor recovery than those > 40 * neuroplas city Purposes: 1. assess long term outcomes of pa ents following 4) Delayed surgery, lower chance motor & sensory peripheral repair recovery 2. determine rela onships between measures of hand
* Improvement possible up to 3 years func on and nerve recovery. Methods: evaluated 32 pa ents approx. 5 years post-op Rosen and Lundborg scale, sensory, motor, and pain/ symptom tests, and self-report measures Ruijs, 2005 MacDermid J, 2010
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Results: Pa ents retained 82.91% global func on: 44.48%-84.90% sensory func on “Factors that predict outcomes a er the repair of 80.13%-89.89% motor func on peripheral nerve injuries of the upper limb include age, 89.75%-93.19% pain/symptom experience gender, repair me, repair materials, defect length,
dura on of follow-up and nerve injured.” Self-report measures of hand func on were more closely related to nerve recovery than were physical measures. “Outcomes a er the repair of ulnar nerve injuries are the worst because the ulnar nerve innervates a small Conclusions: Pa ents with nerve repairs have incomplete recovery, par cularly of sensory func on. volume of muscle with a small muscle fiber size. A er loos of innerva on, the muscle fibers rapidly Relevance: Long-term outcomes of nerve func on 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: Retrospec ve chart review - 96 pa ents with ulnar, median, or combined nerve injuries between 1990-1998 Adjusted for age, gender, and severity of trauma
Higher rates of RTW: 59% pa ents with ulnar nerve injury (80% median nerve) 1. Higher scores on grip strength, p pinch strength, touch- returned to work within 1 year. pressure light touch sensa on 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 func on forearm 2. regenera on me 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 Distribu on to ring & small
- Abductor Digi Minimi - Flexor Digi Minimi - Opponens Digi Minimi - Dorsal Interossei - Palmar Interossei - Lumbricals to ring & small - Adductor Pollicis Ne er, 2006 Ne er, 2006 - Flexor Pollicis Brevis (deep)
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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 ac on 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), ac on facilitate: 1st Dorsal Interosseous are required for:
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Ulnar Nerve Lacera on à MOTOR & SENSORY DYSFUNCTION
Unbalanced muscle forces across the wrist and hand create: How does an ulnar nerve injury * altered res ng posture of hand due to intrinsic and extrinsic muscle imbalance disrupt hand function? * overstretching of weakened muscles by pull of innervated antagonis c muscles * compensatory movement pa erns * joint and so ssue contractures
Altered sensory innerva on creates: * altered func onal sensibility and sensorimotor cor cal 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 ps 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 adduc on 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)
Differen al diagnosis: Colditz, 2013 Maitrise-orthop.com due to normal laxity volar plate MCP joint
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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 abduc on 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 – abduc on à ED and EDM pull to small small finger into abduc on
FUNCTIONAL MOTOR DEFICITS FUNCTIONAL SENSORY DEFICITS con nued 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, hypersens vity, cold intolerance (grasp weakened 60-80% dexterity deficits, safety concerns
Duff, 2011; Go shalk, 2012; Sapienza, 2013
Cold Intolerance Summary of Events
“abnormal pain following exposure to mild cold” Following Nerve Repair 1. Lacera onà Wallerian degenera on à Axonal Regenera on
- Reported by pa ents 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-trauma c cold intolerance-56%-83% muscle fibrosis by 24 months (Slutsky, 2012) - “Normal” digital rewarming pa ern: - Maximum length a nerve can grow to restore motor func on is 35cm (13 25/32 in) à vasoconstric on in cold minimizes heat loss vasodila on in à poor motor recovery high lesions warm returns blood to extremi es, mediated by central & sympathe c nervous systems 3. Sensory end organs remain viable (no end plate), retain - Peripheral nerve injury alters digital rewarming pa erns poten al for re-innerva on several years - Sensory recovery correlates with improvement in cold tolerance 4. Cor cal representa on of the hand is immediately altered as the Ruijs, 2009 brain receives new motor and sensory informa on
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Post-opera ve Therapy Stages Acute Stage Goals: 1. Immobilize to protect nerve repair 1. Acute 2. Wound care 2. Rehabilita on 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 Evalua on
1. History of injury: mechanism of injury, surgical technique– Recommended Test Ba ery for individuals with Nerve repair under tension vs. no tension, associated injuries and Lacera ons repairs 1. Observa on sympathe c dysfunc on: vasomotor, 2. Family situa on: Is help available? sudomotor, pilomotor, trophic changes 3. Voca onal and recrea onal pursuits 2. Tinel’s test distal to repair 4. Medical history 3. Semmes Weinstein Touch-Pressure Threshold-mapping 5. Observa on: skin, posture… 4. Pinprick if areas unresponsive to 6.65 6. Wound: temperature, color, size, ssue quality 5. Sta c and Moving 2-point Discrimina on – finger ps 7. Edema: circumferen al, quality of edema (so , brawny) 6. Touch Localiza on-distal to nerve repair 8. ROM: per post-opera ve precau ons 7. Dellon modifica on of Moberg Pick Up Test 9. Pain: pain scale 0-10, visual analog scale 8. Func onal 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 me for immobiliza on to balance protec on of the nerve coapta on site and to promote neural mobility remains to be established.” (Novak, 2013)
Date of repair-approx. 3 days post-op: bulky dressing, eleva on, ice
1st post-op therapy visit: immobiliza on with dorsal block orthosis goal: protect surgical repair
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Orthosis posi on dependent upon Orthosis posi on dependent upon repair techniques: repair techniques: Direct end to end repair: prior to wound closure intra- opera vely, joints placed in a posi on 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 posi on 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. 70 degrees flexion, PIP and DIP joints as PIP and DIP in extension close to extension as possible
Novak, 2013; Pe engill, 2011 Novak, 2013; Pe engill, 2011
Associated Injuries priori ze acute care therapy goals Protect repaired structures: Nerve Artery Tendon Bone Joint
Connec ve ssue structures Pe engill, 2011
Acute Stage: WOUND CARE & EDEMA MANAGEMENT * Wound care: clean and dry
* Edema Management: - eleva on - cold packs - coban, compression gloves, low stretch bandages, chip bag (varying density foam pieces)
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Acute Stage: Acute Stage: RANGE OF MOTION Pa ent Educa on
• 2-3 days post op: AROM uninvolved joints promotes neural Home Exercise Program: gliding full me use of orthosis except 1x/day for skin, wound, orthosis care • post op 7-10 days (Smith, 2011), 3-10 days-several weeks (Novak, 2013): AAROM involved joints 3-5x/day short-arc AAROM (loosen straps, keep - gentle short arc mo on facilitates nerve orthosis in posi on) gliding, prevents scar adhesions - do not extend beyond limits of dorsal block orthosis Sensory Precau ons: • Gentle PROM if necessary Altered sensa on ulnar aspect of hand, small finger, - isolated joints, do not overstretch weakened muscles ulnar half ring finger Ac vity Precau ons – be specific! * emphasize preven on of joint contractures, especially PIP joints Expected Outcomes ring and small fingers
Thoughts Regarding Pa ent Educa on
1. Tailor to suit pa ent’s learning style visual, auditory, kinesthe c 2. Flow sheets for home program – tally marks at comple on of each session 3. PERSONALIZE HEP handouts: - pictures and descrip ons - pa ent writes own descrip ons 4. Smart phones
Sensory and Ac vity Precau ons * Protec on: Thermal extremes, sharp objects, mechanical stresses - Avoid hot, cold, and sharp objects during ac vi es such as cooking, bathing, outdoor ac vi es (test with uninjured hand first) - Mi ens or wool cap over hand/orthosis - Take care when reaching into drawers, cabinets. Use vision to assure no sharp objects - Take care when handling objects and tools to diminish mechanical stress on skin (padded gloves, silicone gel finger sleeves) * Skin Care: - Use lo on daily on injured area Blackmore,2013 - Nails may grow slowly and become bri le
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Acute Stage: Cold Intolerance Sensory Reeduca on Phase I Timing: day of nerve repair un l signs of re-innerva on are evident Descrip ve, qualita ve study of experiences of cold sensi vity-15 pa ents (Tinel’s at finger ps, Semmes Weinstein 4.56)
Triggering factors: temperature, wind/dra , Within 24 hours of nerve transec on, corresponding sensory cor cal humidity, water, materials, objects, tools areas shrink and receive in-growth from adjacent cor cal areas.
Relieving Strategies: mi ens, close fi ng sleeves, Phase I SR Goal: maintain cor cal hand representa onal map padded handles, using body heat, AROM - techniques bypass the interrupted sensory pathways by using other senses (Miller, 2012; Rosen, 2007) - Cor cal Reorganiza on Protocol – “Early sensory re-educa on using Carlsson, 2010 cor cal reorganiza on techniques may improve sensory outcomes.” (Walbruch & Kalliainen, 2015)
Sensory Re-educa on Phase 1
Home Program
1. Mirror Therapy – at least 2x/day 5-10 minutes Place uninjured arm in front of mirror and perform all wrist and finger mo ons.
2. Use other senses to explore mul -sensory ac vity - at least 2x/ day few minutes * smell, vision, taste, hearing *
ex. peeling an orange, digging in the sand Blackmore, 2013 Walbruch, 2015
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Rehabilita on Stage
Goal - enhance func on through: 1. Orthosis Fabrica on 2. ROM 3. Strengthening 4. Sensory re-educa on 5. Pain control 6. Pa ent Educa on
An -Claw Orthosis: Client Centered Care High and Low Ulnar Nerve Palsy *Restores normal res ng posture of hand & prevents joint contractures * Pa ent Specific Func onal Scale * Quick DASH * ADL evalua on * Adap ve Technique
Training * Redirects EDC, EDM force to extend PIP & DIP joints à promotes grasp and release of large objects and prevents PIP contractures Kastkutas V, Powell, R, 2013 Powell, RK, von der Heyde, 2014 * Allows FDS and FDP (low) to flex digits
Combined Median and Ulnar AROM and PROM Nerve Repair
1. Place-hold and ac ve tendon gliding exercises
2. PIP/DIP/reverse blocking goal: 5° improvement weekly
3. PROM of isolated joints to prevent joint contractures if not making expected AROM gains
Avoid intrinsic stretch (may need ght intrinsics to prevent MCP hyperextension long term)
Duff, 2011; Skirven, 1992
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Beware Compensatory Mo ons Electrical S mula on 1. EDC can extend PIP and DIP joints if MCP joint blocked from hyperextension (subs tute for lumbrical and interossei ac on) “Electrical s mula on of innervated muscle may provide test: ac ve tabletop posi on increased strength… but muscle strength is only one
2. EDC and EDM can abduct index through small fingers component of…motor func on…establishment of good (subs tute for dorsal interossei) motor func on following nerve injury also requires the test: palm on table, ac vely abduct fingers restora on of full passive joint range of mo on, muscle balance, and normal motor pa erns.” Novak, 2013 3. FDS and FDP can adduct index through smalL fingers (subs tute for palmar interossei) NMES augments muscle ac va on when evidence of test: palm on table, ac vely adduct fingers innerva on…provides propriocep ve & tac le input to
4. FPL can adduct thumb (subs tute for adductor pollicis) enhance muscle ac va on and awareness...use of test: block thumb IP flexion during adduc on electrical s mula on in full or par ally denervated
muscle remains controversial.” Duff, 2011
Strengthening In-Hand Manipula on * FOCUS ON EACH MUSCLE* Assess and individually address each ulnar nerve innervated muscle [FCU, FDP ring & small, ADM, FDM, ODM, DI, PI, Lumbricals ring & small, AP, FBP (deep)]
- AROM gravity eliminated - AROM against gravity - Isometric manual resistance – gravity eliminated - Isometric against gravity - Isotonic
*FUNCTIONAL ACTIVITIES* - s mulate central and peripheral nervous systems
Dorsal Interossei Palmar Interossei Func on & Abductor Digi Minimi Func on
yes no
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Sensory Re-Educa on PHC: Sensory Re-educa on Program PHASE II - Timing: begins when re-innerva on is confirmed by posi ve Tinel’s at finger p (Miller, 2012) or Semmes Few minutes several mes a day: Weinstein 4.56 at finger ps - Phase II relies on brain’s ability for neuroplas city 1. Localiza on of Moving Touch - Combines sensory input to injured nerve territory 2. Localiza on of Sta c Touch with vision, memory, and learning 3. Two Handed Sta c Touch - Miller et al -Systema c review 2012 concluded: 4. Texture Discrimina on Limited evidence to support phase I and phase II 5. Object Discrimina on sensory relearning to improve func onal sensibility a er median and ulnar nerve repair - Walbruch & Kallianinen, 2015 – early posi ve findings
Re-evalua on
Each Session – component skills, ADLs Monthly – complete
Consistent re-evalua on facilitates mo va on, provides data to though ully and accurately modify treatment plan
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At what speed does this muscle typically func on? Is this the best Effec ve therapeu c exercise: the right exercise at speed to ini ate training? the right dose “The effec ve applica on of therapeu c exercise is What is the pa ent’s baseline strength? What are the func onal equal parts science and art.” Brody, 2012 strength demands?
What muscle func on is the primary requirement? (i.e., power, What muscle is impaired? How does this muscle func on primarily in this pa ent’s strength, endurance) and at what frequency? ac vi es? Is this the appropriate contrac on type to begin with?
What other associated muscle or muscle groups need training? In what range does the muscle func on, and does it need to be trained through that full range? How do they work with the muscle group of interest? What is the best mode for applying the resistance? Are there any medical precau ons or contraindica ons? What posture or posi on is this muscle used in func onally for this pa ent? Is this the best posi on to ini ate training? What is the stage of healing?
Brody, 2012 Brody, 2012
EARLY STAGE: PROTECT REPAIRED STRUCTURES PREVENT IMPAIRMENT DUE TO SCAR ADHERENCE, JOINT CONTRACTURES, EDEMA FACILITATE TENDON & NERVE GLIDING, EDEMA Thank CONTROL, ADL SAFETY you! REHABILITATION STAGE: CUSTOMIZE THERAPY TO MEET INDIVIDUAL GOALS RESTORE BALANCE OF MUSCLE FORCES [email protected] FACILITATE SENSORY RE-MAPPING PROMOTE FUNCTION
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