Transcript Therapy Considerations for the Ulnar Nerve

Innervations of the Ulnar Nerve
Sieg & Adams, Illustrated Essentials of Musculoskeletal Anatomy (1996)
Etiology
High Lesion: Proximal to elbow
Recovery of intrinsic function rare due to long distance from site
of injury
Trauma
Compressive
Other
Laceration
Cubital Tunnel Syndrome
Peripheral Neuropathy (i.e.
Diabetes)
Gunshot/stab wound
Prolonged or repetative
compression at Guyon’s Canal
(i.e. bicycling, tennis)
Charcot-Marie-Tooth disease
Fracture/dislocation
Tumor
Compression at Guyon’s Canal
sportinjuriesandwellnessottawa.blogspot.com
Muscle Loss
 Low: Intrinsic musculature
 Palmar Interossei
 Dorsal interossei
 3rd and 4th Lumbricals
 Adductor Pollicis
 Flexor Pollicis Brevis (deep head)
 Flexor Digiti Minimi
 Opponens Digiti Minimi
 Abductor Digiti Minimi
 High: Intrinsic + Extrinsic musculature
 Flexor Digitorum Profundus of Ring and Small
 Flexor Carpi Ulnaris
Muscle Loss: Presentation
 Claw hand
 low nerve palsy only
 Froment’s Sign
 Jeanne’s Sign
 Swan Neck
 Boutonniere Deformity
Functional Loss
 Decreased grip strength- often as much as 60-80%
 Key Pinch- as much as 70-80%
 Relies on the adductor pollicis, 1st dorsal
interossei, and flexor pollicis brevis for stability
and strength
 Froment’s Sign

Hyperflexion of the thumb IP joint during pinch
 Jeanne’s Sign

Hyperextension of the thumb MP joint during pinch
Dell, P et al, JHT (2005)
Froment’s Sign
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Jeanne’s Sign
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Boutonniere and Swan Neck
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Sensory Loss
 Ulnar ½ of Ring Finger,
Small finger, hypothenar
eminence, and similar on
dorsum of hand
 Dorsal sensory branch of
the ulnar nerve originates
approximately 7 cm
proximal to ulnar styloid
www.rch.org.au
Pre-Operative Therapy
Objectives
 Prepare patient, physically & psychologically, for surgery
 Enable patient to be as functional as possible prior to surgery
Splinting for Function
 Objectives:
 Reduce MP joint hyperextension due to normal function of
the EDC unopposed by the intrinsic flexors
 Stability of thumb for key pinch
 Hand Based:
 Dorsal Knuckle Bender
 Figure 8 or Lumbrical Bar
 Hand based thumb spica for pinch
 Thumb MP stabilizer for Jeanne’s sign
 Oval 8 for Froment’s sign
Dorsal Knuckle Bender
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Figure 8 or Lumbrical bar
Hand based thumb spica
MP blocking fingers & thumb
Thumb MP stabilizer
Oval 8 for IP stabilization
Splint for function
 Forearm Based: if high ulnar nerve lesion may need to stabilize
forearm
 Ulnar gutter
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Splinting to Prevent or
Correct Deformity
 Objective:
 Prevent or reduce PIP joint contractures of
ring and small fingers
 Prevent or reduce Boutonniere & Swan Neck
deformities
 Reduce pain in thumb due to imbalance in
pinch
Serial Casting
To reduce PIP contractures
prior to surgery
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Silver Ring Splint
For Boutonniere and Swan Neck
Functional
Adaptations/Modifications
 Increase ability to complete tasks with weak pinch
 Use of adaptive equipment
Elastic shoelaces
Adaptive light switch
 Compensation
 Modified writing position
 Adaptive key pinch for car
Interventions
 Maintain full PROM for involved joints
 Manual Muscle Testing
 Electrical Stimulation
 Persistent pain management/education
 Patient Education regarding realistic expectations related
to function, timing, and rehab needs
Specific Transfers and Indications
Goal to Regain
From: Donor Tendon
(working)
To: Recipient
Tendon (deficient)
Thumb Adduction
FDS, ECRB or ECRL, EIP, or
Brachioradialis
Adductor pollicis
Finger Abduction
APL, ECRL, or EIP
1st dorsal interossei
(index most important)
Reverse Clawing
effect
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FDS, ECRL (must pass volar Lateral bands of
to transverse metacarpal ulnar digits
ligament to flex proximal
phalanx)
Tendon Transfers:
Thumb Adduction
 Use of ECRB or ECRL w/ free tendon
graft (usually Palmaris Longus) to
restore Adductor Pollicis function
 Advantage:
 Strong motor component and avoids
sacrificing finger flexor
 Good excursion
 Disadvantage:
 Doesn’t reproduce same line of pull
Dell, P. JHT (2005);
http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html
Tendon Transfer:
Finger Abduction
 Objective: provide more
stability to index during pinch
than strength
 Transfers typically provide 2550% of normal pinch strength
Dell, P. JHT (2005);
http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html
Tendon Transfer:
Reduce clawing effect
Procedure
Concept
Bunnell
Release of A1 & A2 pulleys to allow flexors to bowstring, often
combined with tightening of volar capsule
Zancolli
Volar plate advanced proximally to produce flexion contracture of
MP
Stiles-Bunnell Splits FDS (usually MF) and transfers to radial lateral bands of RF/SF
Zancolli lasso
FDS of MF, passed through A1 pulley and sutured onto self
Fowler
Active tenodesis w/ 2 tendon grafts sutured to lateral bands
Must have active wrist flexion to elicit tightening for MP flexion and
IP extension
Brand
ECRB or ECRL to radial lateral bands
Dell, P. JHT (2005)
Tendon Transfer:
Reduce clawing effect
Flexor digitorum
superficialis (FDS) tendon
transfers for correction of
clawing.
The FDS can be sewn to the
lateral band (A), to bone
(B), or on itself in the
Zancolli lasso (C).
http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html
Post Op Protocol
 For Brand procedure:
 3 ½ weeks post-op




Splint:
 Volar routing: Dorsal Blocking splint with wrist in 30 degrees
flexion, MP 60 degrees flexion, and IP neutral
 Dorsal routing: Dorsal Blocking splint with wrist in 30 degrees of
extension, MP blocked in 60 degrees of flexion, and IP extended
ROM
 AROM w/ in splint 10 minutes every hour
 Passive extension to PIP and DIP
 Passive flexion-only if tendon inserted into bone; for insertion
into lateral bands: no passive flexion until 6 wks due to risk of
stretching out transfer
NMES to facilitate excursion
Scar Management
Indiana Hand Protocol (2001)
Post Op Protocol
 6 weeks post-op
 Splint


Reduced to MP block with
palmar bar in 45 degrees of
flexion to be worn at all times
If PIP extensor lag-continue
with dorsal blocking splint
 ROM


PROM to MPs, PIPs, and DIP
joints
All completed within the
restrains of the MP block
Indiana Hand Protocol (2001)
Post Op Protocol
 7-8 weeks post-op
 Dynamic flexion initiated prn
 Monitor for PIP extensor lags
 10-12 weeks post-op
 MP blocking splint discontinued if hyperextension not
present and minimal (<15 degrees) PIP extensor lag
Indiana Hand Protocol (2001)
Post Op Protocol
To ensure good excursion of
long flexors, concentration
on blocking exercises and
use of NMES to restore
flexion of FDS and FDP can
be helpful
Indiana Hand Protocol (2001)
Ulnar nerve Transfers
 Objective: Restore intrinsic muscle function for pinch
strength, power grip, and dexterity
 Options
 Terminal branch of AIN to deep motor branch of ulnar nerve

Not synergistic but increases pinch/grip strength and decreases
clawing
 Branches of Posterior Interosseous Nerve (PIN), EDM and ECU
branch, to ulnar nerve
Post-Operative Therapy
Nerve Transfer
Immobilization
 Elbow/Forearm: 7-10 days
 Post-op dressing
 May change to splint as early as s/p 2-3 days
 No further protection after 10 days due to no
tension on nerve transfer
 If tendon transfer at same time, protocol
paradigm shift related to tendon
Moore et al, JHT (2014)
Precautions Post Operative
 Tendon Transfer
 Same as for Tendon repair
 Nerve Transfer
 Risk of increased tension on nerve repair site
Post Operative Therapy
Tendon and/or Nerve Transfer
 Edema control
 Scar management
 Pain management
 Range of Motion
 Sensory Re-Education
 Strengthening
 Restore Function
Motor Re-education
 Objective: To correct recruitment and restoration of muscle
balance and decrease compensatory patterns
 Motor Re-education
 Challenges:
 Alterations in motor cortex mapping (i.e. neuro tag smudging)
 Muscle imbalances due to weakness associated with dennervation
 May persist due to compensatory movement patterns and
persistent weakness of reinnervated muscles
 Method:
 Contract muscle from donor nerve/muscle with new muscle until
motor pattern established
 The more synergistic the action and based on original motor
pattern, the more recruitment and establishment of muscle balance
Cortical Re-Mapping
 Cortical Re-mapping
 Graded motor imaging
 Left/Right discrimination
 Explicit Motor Imagery
 Mirror Therapy
 Patient Education
Sensory Re-education
Vibration- Clapping
Stereognosis-Contact particles
Sensory Re-Education
Light to deep Touch
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Exercise
 ROM
 PROM
 Place and Hold with visualization
 AROM through full range
 Opposition exercises
 Light object pick-up
 Marble cup
 3 poker chips
 Strengthening
 Graded putty exercises


Button find
Pushing golf tees in putty
 Tearing paper
Exercise
Strengthening
Putty Exercises for grip and pinch
Bibliography
 Cannon, N, et al. Diagnosis and Treatment manual for Physician




and Therapists. Upper Extremity Rehabilitation, 4th edition.
Indianapolis. 2001.
Davis KD, Taylor KS, Anastakis DJ. Nerve Injury Triggers Changes in
the Brain. Neuroscientist. 2011; 17 (4).
Dell PC, Sforzo CR. Ulnar Intrinsic Anatomy and Dysfunction.
Journal of Hand Therapy. April-June 2005; 2:198-207.
Hoard AS, Bell-Krotoskie JA, Mathews R. Application of
Biomechanics to Tendon Transfers. Journal of Hand Therapy. AprilJune 1995; 115-123.
Moore AM, Novak CB. Advances in nerve transfer surgery. Journal
of Hand Therapy. April-June 2014; 27: 96-105.
Bibliography
 Moseley GL, Butler DS, Beames TB, Giles TJ. The Graded
Motor Imagery Handbook. Adelaide, Australia. Noigroup
Publications. 2012.
 Sieg & Adams. Illustrated Essentials of Musculoskeletal
Anatomy, 3rd Edition. Gainesville, Megabooks, Inc. 1996.
 Sultana SS, MacDermid JC, Grewal R, Rath S. The effectiveness
of early mobilization after tendon transfers in the hand: A
systematic review. Journal of Hand Therapy. October 2013;
26: 1-21.
 Wang JHC, Guo Q. Tendon Biomechanics and
Mechanobiology-A minireview of basic concepts and recent
advancements. Journal of Hand Therapy. April-June 2012; 7:
133-140.