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 www.studyblue.com Jeanne’s Sign www.ehealthstar.com Boutonniere and Swan Neck www.merckmanuals.com 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 ncmedical.com 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 allegromedical.com 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 www.msdlatinamerica.com 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 www.orthobullets.com 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 blog.physiotek.com 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.