SANA ABU-DAHAB, PHD, OTR Common Peripheral Nerve Problems

Radial Nerve Injuries

Non-operative Treatment Splinting  Dorsal forearm-based dynamic splint that “harnesses” the normal tenodesis pattern of the hand  Wrist cock-up at night and Colditz’s low profile splint during day time

Median Nerve

High (Proximal) Median Nerve Palsy Timelines and Healing  Nonoperative treatment  Splinting  Pain Management  Therapeutic Exercises  Activity Modification

Median Nerve Not in Continuity, Elbow to Wrist Level Diagnosis and Pathology  Timelines and Healing following Surgical repair  Remove the bulky compressive dressing and apply a light compressive dressing for edema control.  Fabricate a custom-made dorsal wrist blocking splint with the wrist in approximately 30 degrees of palmar flexion but not more than 45 degrees of palmar flexion. The amount of wrist flexion is predicated upon the amount of tension at the nerve repair site.  Replicate the wrist position of the postoperative cast if the surgeon is not immediately available to give you guidelines.  Have the client wear the splint continuously for 4 to 6 weeks except for protective skin care. Hygiene should occur with the splint on.  Begin AROM and PROM of the digits and thumb, 10 repetitions every waking hour within the splint.

Clinical Reasoning With a median nerve injury, adduction contractures of the thumb are the most common and preventable deformity that should be addressed by proactive splinting.

CARPAL TUNNEL SYNDROME Low Median Nerve Palsy

Non operative treatment Splinting  Use of wrist splint to rest the inflamed tissue and to minimize intratunned pressure on the median nerve  The proper position for wrist splinting is neutral, with the wrist at 0 to 2 degrees of flexion and about 3 degrees of ulnar deviation.  The splint should be used at night for 6 to 8 weeks and may be used selectively during the day to assist with wrist positioning during provoking activities such as computer use.

Ulnar Nerve

Nonoperative Treatment Splinting  The splint should position the elbow in degrees of elbow flexion and the forearm and wrist in neutral, and the digits should be free to move  The splint can be fabricated anteriorly or posteriorly, though if a posterior splint is used, the elbow must be well padded so as not to cause increased surface pressue at the cubital tunnel  Generally instruct the client to wear the splint at night for at least 3 weeks  If the symptoms did not improve, instruct the client to wear the splint as much as possible, removing it only for hygiene

Nonoperative Treatment – Cont. Splinting – Cont.  If clawing is evident, a hand-based static splint that blocks the MCP joints from extension allows the extension digitorum communis tendon to shunt its terminal force to the distal IP joint, thus allowing IP joint extension  Provide an elbow pad to protect the vulnerable cubital tunnel area whenever the client is unable to wear the long arm splint

ENTRAPMENT AT GUYON’S CANAL Distal Ulnar Nerve Compression

Non-operative Treatment Splinting  Ulnar Nerve Palsy splint, anticlaw splint  Prevent overstretching of the denervated lumbrical muscles and interossie of the ring and small fingers  Instruct the client to remove the splint for hygiene only  Continue use of splint until the muscle imbalance resolves or until tendon transfers are performed  If PIP flexion contractures of the involved digits has developed, a dynamic PIP extension splint is needed to address joint contracture before using static anticlaw splint  Padded antivibration gloves can be used to protect Guyon’s canal

Repair of the Ulnar Nerve Not in Continuity, Elbow to Wrist Level Timelines and healing  Splinting  Dorsal blocking splint with the wrist in deg. of flexion (depending on the amount of tension at the nerve repair junction)  Incorporate in the splint a MCP dorsal block that limits MCP joint extension to 45deg. Minimize tension on the nerve repair Block clawing (hyperextension of the MCP of the ring and little fingers)

Digital Nerve Injury and Repair

Postoperative Treatment Splinting  Dorsal blocking gutter splint is fitted in 30deg. of PIP joint flexion for continuous wear for the first 3-6 weeks  If the splint continues to 6 weeks, therapist can begin to adjust dorsal blocking into lesser degrees of PIP flexion beginning at 4 weeks postoperatively  After 6 weeks of protective splinting, a slight PIP contracture may have developed. Static extension gutter splint may be fabricated to wear at night and for brief periods (2-3 sessions of 45min) during the day