1. Splinting for Peripheral Nerve Injuries
Somaya Malkawi, PhD

2. Radial Nerve Lesions

3. Ulnar nerve: Arises from the medial cord of brachial plexus (C7 to T1 roots)
The nerve runs medial to the humeral artery, travels through the medial intermuscular septum, and passes superficially between the medial epicondyle of the humerus and the olecranon at the elbow joint.
The ulnar nerve enters the forearm between the two heads of the flexor carpi ulnaris and descends within the anteriomedial forearm under the cover of the fl exor carpi ulnaris. In the lower third of the forearm the ulnar nerve gives off a dorsal cutaneous branch, which supplies the skin of the ulnar half of the
dorsum of the hand.
At the wrist the ulnar nerve sits medially to the ulnar artery and runs with this artery in the osseofibrous carpal canal called Guyon’s canal, a superficial passageway between the pisiform and hamate bones of the carpus. Just distal to the pisiform the ulnar nerve divides into two terminal branches: the superficial (palmar) cutaneous branch and the deep motor branch.
The motor branch winds around the hook of the hamate and innervates the three intrinsic hypothenar muscles,
the ulnar two lumbrical muscles, and the three palmar adductors and four dorsal abductors. The ulnar nerve terminates at the adductor pollicis and the deep head of the flexor pollicis brevis. The sensory branch supplies the
skin of the ulnar half of the volar hand and the fifth digit and the medial half of the fourth digits

4. Radial Nerve Lesions (table 13-2)
Check weak or lost motions for each 1. Axilla level (M+S) HIGH (wrist drop) 2. Midhumeral compression/shaft fracture (M+S) HIGH (wrist drop) 3. Forearm level- Posterior Interosseous Nerve Palsy- fracture/dislocation of elbow j (M) LOW

5. Radial Nerve Common Sites of Injury
4. Radial Tunnel Syndrome (btw radial head and supinator muscle (pain syndrome) 5. Superficial Radial Sensory Nerve Palsy btw ext carpi radialis longus and bachioradialis or at wrist from tight splint (S) (Wartenberg’s syndrome

6. High Radial Nerve Palsy
Wrist drop deformity
Lost wrist ext., MCP ext., and thumb radial abd and ext.
Triceps spared: Elbow extension is intact (not at Axilla level)
Supinator and brachioradialis are paralyzed but supination and elbow flexion is intact bcz biceps is intact

7. High Radial Nerve Palsy

8. High Radial Nerve Palsy
Depending on the level of injury, triceps paresis may exist, as well as some posterior arm sensory loss along the dorsal lateral aspect of the forearm and hand

9. Low Radial Nerve Palsy (posterior interosseous nerve palsy
Injuries to the nerve at this level can occur following compression of the nerve between the humeral and ulnar heads of the supinator muscle
Radial head fracture-dislocations
Tumors
History of repetitive and strenuous pronation and supination.

10. Low Radial Nerve Palsy (posterior interosseous nerve palsy
The clinical picture is:
Intact radially directed wrist extension
Absent MCP extension, thumb extension, and thumb radial abduction (M)
Posterior interosseous nerve palsy is distinguished
from high radial nerve palsy by the preservation of
radial wrist extensors, brachioradialis function, and
superfi cial radial nerve sensibility.
Check for intact
sensibility using the Semmes-Weinstein monofi laments
at the fi rst dorsal web space. Assess radial wrist
extension via an MMT with the forearm positioned
in pronation and the elbow fl exed.

11. Splinting for High RNI Radial nerve motor palsy with wrist drop
Custom-made dorsal forearm-based dynamic splint
Promote functional hand use
Base: dorsal wrist imm. S.
Substitute for absent ms power
By assisting MCP extensors
Worn throughout the day
until MMT: fair (3)
If no improvement within
two months, refer back to physician.

12. Splinting for High RNI
Dynamic splint is good for a high radial nerve palsy or a posterior interosseous palsy because this splint design does not preclude use of active wrist extension and does assist with finger extension with slight wrist flexion.

13. Splinting for High RNI Dynamic splint not worn at night
Therapist may offer static wrist imm. S. at night
Therapists may offer both static and dynamic alternating between them might maximize function
Watch for MCP joint contractures if the client insists on using only a static wrist splint

14. Splinting for post. Interos. Nerve syndrome
Long arm elbow and wrist splint with elbow in flexion, forearm in neutral or slight sup., wrist in degrees of ext.
Tenodesis splint encourage wrist and finger function

15. Splinting for radial tunnel syndrome
Long splint elbow 30 flex, forearm in full supination, wrist in slight wrist ext. (20-30)
This decompress pressure on RN
Worn all the time with removal for hygiene
OR thumb imm. S.

16. Splinting for wartenberg’s neuropathy
Wrist immobilization splint : wrist in ext
If pain include the thumb

17. Ulnar Nerve Lesion

18. UlnarNerve Lesions (table 13-3)
Low level (wrist level)
abductor digiti minimi
flexor digiti minimi
opponens digiti minimi
fourth and third lumbrical
three palmar interossei muscles and four dorsal interossei muscles
deep head of the flexor pollicis brevis
adductor pollicis
High Level (At or above the elbow)
All previously mentioned muscles
Flexor Carpi Ulnaris
Flexor Digitorum Profundus for digits 4, 5
Study weak and lost motions from the table

19. Arises from the medial cord of brachial plexus (C7 to T1 roots)
The nerve runs medial to the humeral artery, travels through the medial intermuscular septum, and passes superficially between the medial epicondyle of the humerus and the olecranon at the elbow joint.
The ulnar nerve enters the forearm between the two heads of the flexor carpi ulnaris and descends within the anteriomedial forearm under the cover of the fl exor carpi ulnaris. In the lower third of the forearm the ulnar nerve gives off a dorsal cutaneous branch, which supplies the skin of the ulnar half of the
dorsum of the hand.
At the wrist the ulnar nerve sits medially to the ulnar artery and runs with this artery in the osseofibrous carpal canal called Guyon’s canal, a superficial passageway between the pisiform and hamate bones of the carpus. Just distal to the pisiform the ulnar nerve divides into two terminal branches: the superficial (palmar) cutaneous branch and the deep motor branch.
The motor branch winds around the hook of the hamate and innervates the three intrinsic hypothenar muscles,
the ulnar two lumbrical muscles, and the three palmar adductors and four dorsal abductors. The ulnar nerve terminates at the adductor pollicis and the deep head of the flexor pollicis brevis. The sensory branch supplies the
skin of the ulnar half of the volar hand and the fifth digit and the medial half of the fourth digits

20. Sensory Sensory loss, although problematic, is not as
severely disabling as with the median nerve

21. Function Strong wrist flexion and ulnar deviation
power grip via full flexion of the ulnar two digits
powerful tip and lateral or key pinch
powerfully to cup an object
In hand manipulation
The ulnar nerve allows for simultaneous strong wrist fl exion and ulnar deviation, as well as
power grip via full fl exion of the ulnar two digits. This is necessary for tasks such as swinging a
golf club or a hammer. Ulnar nerve integrity is also necessary to allow for powerful tip and
lateral or key pinch, for the adductor pollicis and fi rst dorsal interossei assist in stabilizing the
thumb and index during pinching. The hypothenar muscles and the interossei muscles allow
the hand powerfully to cup an object, such as a doorknob or a basketball.

22. Common sites of Entrapment/Injury
Cubital tunnel syndrome
Guyon’s canal compression

23. Anteriorly: The medial epicondyle
Laterally: the ulnohumeral
Ligament
Posteromedially: the fibrous arcade of the two heads of the flexor carpi ulnaris.
Roof of this tunnel: fibrous band extending from the olecranon to the medial epicondyle of the humerus

24. Cupital Tunnel syndrome: description
Compression of the ulnar nerve as it passes through the cubital tunnel at the elbow.
Compression leads to paresthesias along the nerve course.
Long withstanding compression leads to residual motor weakness
Sever, prolonged ulnar nerve compression may result in the claw deformity

25. Cupital Tunnel syndrome: description
loss of simultaneous wrist flexion and ulnar deviation
Pain in the medial aspect of the elbow and tenderness over the cubital tunnel
Paresthesias in the ring and little finger are present
High-level lesions, such as lesions to the nerve proximal to the innervation of the flexor carpi ulnaris 25

26. Cupital Tunnel syndrome: description
The clinical picture is one of sensory loss and motor paresis affecting the intrinsic ulnar-innervated muscles
The sensory deficit involves the palmar and dorsal ulnar aspect of the hand
The clinical picture is one of sensory loss and motor paresis affecting the intrinsic ulnar-innervated muscles
including the interossei, and the adductor pollicis. Occasionally, the hypothenar muscles are spared
The sensory deficit involves the palmar and dorsal ulnar aspect of the hand
the hypothenar opponens, abductor, and flexor digiti minimi muscles are spared.
The dorsal, ulnar aspect of the hand is spared because it is supplied by the more proximal dorsal cutaneous branch 26

27. Claw hand deformity Flattening of the normal arches of the hand
Hyper-extension of MCP and flexion in PIP and DIP of 4, 5th
Unable to abd and add fingers
Index and middle is not affected because the lateral two lumbrical muscles, which serve to flex the metacar- pophalangeal joints, remain innervated by the median nerve.)
balance between extrinsic and intrinsic muscles is lost, resulting from paresis of most of the intrinsic muscles of the hand. This results in a flattening of the normal arches of the hand.
The hand will show hyper-extension of the metacarpophalangeal joints (MCP) and flexion at the distal and proximal Interphalangeal (IP) joints of the 4th and 5th digits (ring and little finger) [4]. The clawing will become most obvious when the person is asked to straighten their fingers.
Patients exhibiting an ulnar claw are also very frequently unable to spread (abduct) or pull together (adduct) the fingers against resistance. This occurs because the ulnar nerve also innervates the palmar and dorsal interossei of the hand. Patients with this deficit will become increasingly easy to identify over time as the paralyzed first dorsal interosseous muscle atrophies, leaving a prominent hollowing between the thumb and forefinger.
[edit] 27

28. Splinting for High Ulnar Nerve compression (at elbow)
Elbow splint with elbow flexed degrees
If included, wrist is positioned in neutral to 20 degrees of ext
Including the wrist decreases the effects from flexor carpi ulnaris contraction
The splint is worn to avoid prolonged and repetitive full flexion of the elbow (like in sleeping) which increase pressure in the cupital tunnel
Extreme flexion of the elbow increases traction on the ulnar nerve

29. Splinting for High Ulnar Nerve compression (at elbow)
Splint is worn during the night for app 3 weeks
If symptoms of decreases sensibility, continuous symptoms, the client may wear the splint all the time
Material:
Rigid, strong enough to carry the weight of the elbow
Self bonding to help formulation of the crease of elbow
conformability and drapability to mold material over olecranon process

30. Splinting for High Ulnar Nerve compression (at elbow)

31. Guyon's tunnel syndrome
Symptoms include a feeling of pins and needles in the ring and little fingers, and may progress to a burning pain in the wrist and hand followed by decreased sensation in the ring and little fingers
and/or motor weakness

32. Ulnarly: pisiform and tendinous insertion of the flexor carpi ulnaris
Radially: the hook of the hamate
The roof of the tunnel is the flexor retinaculum
After giving off the dorsal cutaneous branch about 5 to 6 cm proximal to the wrist, the ulnar nerve enters Guyon’s canal medial to the artery. Within the canal, the ulnar nerve divides into two branches: the superficial sensory branch and the deep motor branch
The claw hand is worse for Guyon canal stenosis, or nerve compression at the wrist. This is an example of the ulnar paradox. Also, if the nerve is compressed at the wrist, the back of the hand will have normal sensation. 32

33. Guyon's tunnel syndrome
cause of this syndrome is from pressure of bicycle handlebars seen with cyclists
Or hard, repetitive compression against a desk surface while using a computer mouse.

34. Causes Most common: a ganglion, followed by occupational neuritis
Other causes include a pisiform or hook of hamate fracture
arthritis

35. Symptoms Same as the Cubital Tunnel syndrome
The sensory deficit involves the palmar ulnar aspect of the hand, both sides of the little finger, and the ulnar border of the ring finger
the hypothenar opponens, abductor, and flexor digiti minimi muscles are spared.
The dorsal, ulnar aspect of the hand is spared because it is supplied by the more proximal dorsal cutaneous branch 35

36. Hand based Ulnar Nerve splint intervention
Anti-claw splint
Ring and little finger in flex
Correct the claw hand posture
This splint hand functional grasp
Continue wear of the splint with
Removal for hygiene and exercise
until the muscle imbalance resolves or
until tendon transfers are performed

37. Hand based Ulnar Nerve splint intervention
Dynamic splint
Figure 13-13
Finger loops with rubber bands connected to wrist band
Wear throughout the day with removal for H and E

38. Median Nerve Lesion

39. Median nerve arises from the lateral and medial cords of the brachial plexus. The median nerve runs distally in the anteromedial compartment of the arm. In the cubital fossa of the anterior elbow and in the forearm, the median nerve lies medial to the brachial artery. Just distal to the elbow joint, the median nerve passes below the bicipital aponeurosis and between the two heads of the pronator teres. The median nerve gives off a purely motor branch, the anterior interosseous nerve, to the flexor pollicis longus, to the flexor digitorum profundus tendon to the index finger, and to the pronator quadratus.

40. Causes of Median Nerve Lesion
Humeral fracture
Elbow dislocation
Distal radius fracture
Dislocation of lunate into the carpal canal
Laceration of volar wrist

41. Affected muscles by median nerve lesion
Study Figure and Table 13-4
Low level: abd policis brevis, flexor policis previs, opponense policis, 1st and 2nd lumbricals
High level : Low level muscles and pronator teres, flexor carpi radialis, flexor policis longus, lateral half of lex digitorum, palmaris longus, flex digitorum superficialis, abd policis brevis

42. Functional Involvement
Clumsiness with pinch
Decreased power grip
Power grip is affected
Lumbricals of index and middle finger is weak
Check sensory supply of the MN

43. Resulting deformity Ape hand deformity Thumb in adduction, ext.
Thumb web space contract
Lost opposition,
Fingers show trophic changes
Slight clawing of index and middle fingers bcz of loss of lumbrical innervation
Result of high or low MNI

44. Common deficits/deformities
Pronator syndrome
Anterior Interosseous Nerve Palsy
Carpal Tunnel Syndrome

45. High: Pronator Syndrome
Result from strong repetitive pronation and supination as the nerve passes btw the 2 heads of pronator teres
Diffuse pain in the med. forearm or distal volar arm
Dysethesias in the radial three and one-half digits of the hand
Symptoms may be provoked by resisted elbow flexion, often with concurrent resisted forearm pronation

46. High: Anterior Interosseous Nerve Palsy
Entrapment neuropathy of the motor branch of the median nerve.
Vague discomfort in proximal forearm
Typical patient complain: difficulty with writing and cant make O with thumb and index
Pain develop gradually and is followed by weakness of the muscles innervated by the branch
Usually there are no sensory symptoms

47. Low: Carpal Tunnel Syndrome
Carpal Tunnel – opening through the wrist to the hand
Formed by:
Bottom: Bones of wrist
Top: Transverse carpal ligament

48. Diagnosis of CTS
Most frequently a clinical diagnosis based on the patient’s reports of symptoms and clinical tests.
Phalen’s Test: Patient rests elbows on table and allows wrists to drop into flexion … test is positive if client reports parasthesias within 1 minute.
Tinel Test: Tapping over Carpal Tunnel produces parasthesias.
EMG’s sometimes ordered to confirm (gold std.)
What is the difference btw CTS and pronator syndrome – check book 295 and 296

49. Splinting for Pronator syndrome
Avoid resisted pronation and passive supination
Splint: Place elbow in 90 degrees flexion, forearm neutral, wrist in neutral to slight flex
LONG ARM SPLINT
If the suspected site of entrapment
is at the ligament of Struthers, at the lacertus fibrosis,
or at the pronator teres, fabricate a long arm splint
or a sugar tong splint. Place the elbow at 90 to 100 flexion, and position the forearm in neutral rotation
IMMOBILIZE WRIST IN SPLINT IF
If the suspected site of entrapment is along
the flexor digitorum sublimus arch

50. Splinting for Ant Int. Nerve compression
Avoid elbow ext and extreme frearm pronation and supination
Splints:
Immobilize elbow 90 flex, forearm in neutral OR
Small splint to block thumb IP and index DIP extension
Figure 13-17

51. Splinting for CTS Ergonomic adaptations for home, leisure, work env
Activity modifications
Exercise
Splint:
Wrist immobilization splint that place wrist in neutral

52. Splinting for MNI with involved thumb
As in later stage of CTS
Thumb web spacer splint: for low MNI, C bar helps maintain thumb web space (LOW INJURY)
Allows free wrist mobility OR
Hand based thumb spica (butterfly)

53. Splinting for combined ulnar and median NI
Splint that inhibits MP EXTENSION
All digits included