Peripheral nerve lesions Cecilia Katzke 2010

What is a peripheral nerve lesion?

Superior surface of the fourth cervical vertebra: spinal cord in its vertebral foramen spinal nerve in its intervertebral foramen

General structure of the spinal cord, nerve roots and meninges

What causes peripheral nerve injuries? Penetrating wounds Pressure Ischemia Fractures Dislocations Traction Continuous stretching Tumour Neuritis

Extent of nerve injuries differ Classification of nerve injuries Neuropraxia Axonotmesis Neurotmesis

Neuropraxia Nature of injury: Contusion of nerve- Inflammatory response Nerve cell & - fibre intact Temporary loss of conduction Prognosis: Good Recover within 6-8 weeks Medical Tx: If no open wound, “wait & see approach” Splint + NSAIDS

Neuron / Nerve cell

Axonotmesis Nature of injury: Usually a traction injury More severe injury Axon injured – degenerate Neurilemma sheath intact Degree of injury vary Prognosis: Relatively good Recovery incomplete→complete Medical Tx: Usually no open wound, “wait & see” Medication(NSAIDS & pain) & splint Physiotherapy NB!

Cross section through a peripheral nerve

Neurotmesis Nature of injury: Axon & sheaths are damaged Complete degeneration distally Nerve must be sutured Prognosis: Not good Incomplete recovery Medical Tx: Penetrating wound →investigate Primary repair / debridement

Regeneration / Degeneration / Surgery ? ? ? ? ? ?

Surgery: Nerve Repair Primary / Secondary repair Epineural /Fascicular repair General regime: Post Nerve Repair

General regime: Post Nerve Repair 0-3 weeks → immobilisation of adjacent joints 3-6 weeks → strengthening of antagonist muscles, gentle mobilisation of adjacent joints and repaired nerve(distal from area of surgery), dynamic splint > 6 weeks → stretching of surrounding muscles, mobilisation of neural tissue

Rate of nerve recovery: Extent of lesion Distance between lesion and cell body / end organ Type of surgical suture Elapsed time between the injury and surgery Scar tissue formation Type of nerve Age of patient General health Diet

Mixed spinal peripheral nerve

Consequences of peripheral nerve injury How does the patient present? Motor system Sensory system Autonomic system Pain Function

Motor system Decreased / loss of muscle power Decreased muscle tone Decreased / loss of reflexes Muscle atrophy → Fat & fibrous tissue

Sensory system Decreased / loss of skin sensation Decreased / loss of proprioception

Autonomic system Oedema Changes in the skin: ▪ scaly Osteoporosis ▪ smooth & shiny ▪ loss of perspiration ▪ nails brittle & suppressed growth Osteoporosis

Pain Trauma Immobilisation Hypersensitivity Overuse

Function Functionality is influenced due to : Loss / decreased motor function Loss /decreased sensation Changes in autonomic function Pain

Possible complications Deformities Adhesions Trauma Dislocations / Sublaxations Muscle strains or tears Slow wound healing CRPS

Evaluation: Interview History Medical / Surgical management (precautions) Socio-economic background: ▪occupation, possibility of returning ▪finances – paid leave? ▪support at home – physical & emotional What problems does the patient experience with ADL? Participation in community? What does the patient expect of physiotherapy?

Evaluation: Objective (compare with same & opposite side) Observation: Palpation Sensation ROM Muscle testing Neurodynamic tests Function

Observation General: Local: Posture Compensation Skin (colour, condition, ? wounds) Oedema Atrophy

Palpation Skin temperature Skin texture Oedema

Sensation Temperature Sharp / blunt Deep pressure Proprioception Stereognosis Tinell’sign

Range of Movement Passive – of all joints underlying affected muscles Muscle lengths

Muscle testing Beware trick movements Use Oxford scale Test in groups → individual muscles

Neurodynamic tests Within limits of pain Precaution surgery Test applicable nerve ▪confirmed nerve injury ▪base test ▪mechanism of injury

Function With & without splint (static and / or dynamic splint)

PROBLEM AIM / AIMS TREATMENT Paralysed muscles AIM / AIMS Support / Protect Prevent contacture Maintain muscle characteristics TREATMENT Provide / Arrange splint Passive muscle stretches Electric muscle stimulations

PROBLEM AIM / AIMS TREATMENT Decreased muscle strength AIM / AIMS Facilitate, re- educate and strengthen affected muscles TREATMENT Ice Tapping Suspension Re-education board PNF Active functional exercises

PROBLEM AIM / AIMS TREATMENT Loss / Decreased sensation AIM / AIMS To give advice regarding loss / decreased sensation Retrain sensation TREATMENT Education: care for skin Proprioception exercises Fine discrimenation exercises

PROBLEM AIM / AIMS TREATMENT Autonomic changes (↓ circulation) AIM / AIMS Increase circulation and prevent edema or Increase circulation and decrease edema TREATMENT Passive joint movements Positioning (day - sling / pressure bandage night - elevation) Massage Electrotherapy

PROBLEM AIM / AIMS TREATMENT Pain ( ? cause) AIM / AIMS Decrease pain TREATMENT Mobilising neural tissue Trigger points Massage Electrotherapy

Decreased functionality PROBLEM Decreased functionality AIM / AIMS Improve functionality TREATMENT Functional exercises, with / without splints Functional exercises using trick movements

Possible complications PROBLEM Possible complications Deformities Dislocations / Sublaxations Muscle strains Wounds AIM / AIMS Prevent complications from developing TREATMENT Patient education: nature of injury prognosis role of physiotherapy patient responsibility

Food for thought Each patient is unique Problem list differ from patient to patient Priorities of physiotherapy problems for each patient are different Generally: patient education high priority for peripheral nerve injuries

Radial Nerve Wrist and fingers hang limp in flexion, the forearm in pronation (- Elbow slightly flexed, if lesion affects Triceps)

Ulnar Nerve Deformity is a clawed hand. Hyperextention at MP-joint of small & ring finger (absent Lumbricales I & II), flexion of IF-joints. (-This deformity does not always develop with Ulnar lesion)

Ulnar Nerve Note the atrophy of the hipothenar muscles (all muscles to small finger), and intrinsic hand muscles (palmar & dorsal interossei) Flexion of the DIF-joint of med 2 fingers absent (FDP III &IV) - Loss of ulnar deviation when injury is at elbow (FCU)

Ulnar Nerve - Note the atrophy of dorsal interossei. Especially noticeable between thumb & index finger, due to absence of FPB & Add Pollicis

Ulnar Nerve - Severe clawed hand deformity.

Ulnar Nerve - Irreversible deformity.

Median Nerve Not a very noticeable deformity in rest. - Monkey hand. The thumb lies on the same level as the hand and the wrist is in slight extention. The tenar height is flat due to atrophy.

Median Nerve - Ulnar deviation due to absence of FCR

Median Nerve - Notice the prominence of FPB(deep head)(Ulnar nerve), in the absence of APB, OP, FPB(sup head)(Median nerve)

Group work A 40 year old man was involved in a high speed MVA, during which he sustained a posterior dislocation of his right hip. The hip dislocation was reduced and the patient was referred for physiotherapy. Upon evaluation you find that the patient’s hip extension is weak, and that there is total motor loss of knee flexion, as well as ankle and foot movements. Furthermore there is also sensory loss of almost the complete area below the knee. 1. Which structure was most probably also injured with the dislocation of the hip? 2. What will the immediate aims of physiotherapy be for this patient? 3. Explain how you will achieve these aims.