Ahmed Shawky Ahmed Shawky Assistant lecturer of Physical TherapyAssistant lecturer of Physical Therapy

Cairo UniversityCairo UniversityDr.shawky_2011@yahoo.com

Peripheral Peripheral nerve injuriesnerve injuries

Structure of a nerveStructure of a nerve It has an outer covering It has an outer covering

which forms a sheath which forms a sheath around the nerve, called around the nerve, called the the epineuriumepineurium. .

Nerve fibers, which are Nerve fibers, which are axons, organize into axons, organize into bundles known as bundles known as fasciclesfascicles with each with each fascicle surrounded by fascicle surrounded by the the perineuriumperineurium. .

Between individual Between individual nerve fibers is an inner nerve fibers is an inner layer of layer of endoneuriumendoneurium..

Peripheral nerve injuryPeripheral nerve injury

Dermotome :Dermotome : is an area of skin supplied by a single is an area of skin supplied by a single

spinal rootspinal root

Myotome : Myotome : Represents a muscle unit supplied by a Represents a muscle unit supplied by a

single spinal rootsingle spinal root

Seddon's classificationSeddon's classification NeurapraxiaNeurapraxia -- -- temporary paralysistemporary paralysis of a nerve of a nerve

caused by lack of blood flow or by pressure on caused by lack of blood flow or by pressure on the affected nerve with the affected nerve with no lossno loss of structural of structural continuity. continuity.

AxonotmesisAxonotmesis – – neural tube intact, but neural tube intact, but axons are disruptedaxons are disrupted. . nerves are likely to recover. nerves are likely to recover.

NeurotmesisNeurotmesis – – the neural tube is severed. the neural tube is severed. Injuries are likely Injuries are likely permanent without repairpermanent without repair. .

Classification of Nerve InjuriesClassification of Nerve Injuries

myelin myelin axonaxon endoneurium endoneurium perineuriumperineurium epineurium epineurium

Degree of InjuryDegree of Injury

I Neuropraxia +/-I Neuropraxia +/-       II Axonotmesis yes yes no no noII Axonotmesis yes yes no no no III yes yes yes no noIII yes yes yes no no IV yes yes yes yes noIV yes yes yes yes no

V Neurotmesis yes yes yes yes yesV Neurotmesis yes yes yes yes yes

Sunderland`s classificationSunderland`s classification Grade IGrade I

Same as Seddon's Same as Seddon's neuropraxianeuropraxia. . Grade IIGrade II

Same as Seddon's Same as Seddon's axonotmesisaxonotmesis. . Grade IIIGrade III

NeurotmesisNeurotmesis with with preservation of the perineuriumpreservation of the perineurium. . Grade IVGrade IV

Neurotmesis with Neurotmesis with preservation of the epineuriumpreservation of the epineurium.. Everything else is disrupted. Everything else is disrupted.

Nerve grossly appear edematous. Nerve grossly appear edematous. Nerve grafting is required. Nerve grafting is required.

Grade VGrade V Complete transection of the nerve trunk. Complete transection of the nerve trunk.

Typical deformities :Typical deformities : Wrist drop ---- radial nerve injuryWrist drop ---- radial nerve injury

Claw hand ---- ulnar nerve injuryClaw hand ---- ulnar nerve injury

Foot drop ---- lateral popliteal nerve injuryFoot drop ---- lateral popliteal nerve injury

Ape thumb ---- median nerve injuryApe thumb ---- median nerve injury

Winging of scapula ---- thoracodorsal nerve Winging of scapula ---- thoracodorsal nerve injuryinjury

Pointing index ---- median nerve injuryPointing index ---- median nerve injury

Simple screening tests Simple screening tests Ulnar nerve injury : Ulnar nerve injury :

Loss of pain at tip of the little fingerLoss of pain at tip of the little finger

Medial nerve injury :Medial nerve injury : Loss of pain at tip of index finger Loss of pain at tip of index finger

Radial nerve injury :Radial nerve injury : Inability to extend thumbInability to extend thumb

Incidence of Peripheral Incidence of Peripheral nerve injurynerve injury

Radial nerve ------ commonly injuriedRadial nerve ------ commonly injuried

Ulnar nerve ------- 30 %Ulnar nerve ------- 30 %

Median nerve ----- 15 %Median nerve ----- 15 %

Lumbosacral plexus ---- 3 %Lumbosacral plexus ---- 3 %

Ulnar nerve injuryUlnar nerve injury Causes : Causes : General causesGeneral causes : metabolic diseases , collagen : metabolic diseases , collagen

diseases , malignancies , endogenous or diseases , malignancies , endogenous or exogenous toxins , chemical or mechanical exogenous toxins , chemical or mechanical trauma , etc.trauma , etc.

Local causes :Local causes : Causes in the axilla :Causes in the axilla :

Crutch pressureCrutch pressure Aneurysm of the axillary vesselsAneurysm of the axillary vessels

Causes in the arm :Causes in the arm : # shaft of humerus# shaft of humerus Gunshot and penetrating injuriesGunshot and penetrating injuries

Cont ..Cont .. Causes at the elbow :Causes at the elbow :

Compression by the accessory musclesCompression by the accessory muscles # lateral epicondyle of humerus# lateral epicondyle of humerus Repeated occupational strains Repeated occupational strains Recurrent subluxation of the nerveRecurrent subluxation of the nerve Compression by the osteophytes as in rheumatoid and Compression by the osteophytes as in rheumatoid and

osteoarthritis osteoarthritis Causes in the forearm :Causes in the forearm :

# both bones forearm# both bones forearm Incised wounds , gunshot wounds and penetrating Incised wounds , gunshot wounds and penetrating

injuries of the forearminjuries of the forearm

Cont ..Cont .. Causes at the wrist :Causes at the wrist :

Compression by osteophytesCompression by osteophytes # hook of the hamate# hook of the hamate Compression by ganglionCompression by ganglion Wrist injuriesWrist injuries

Causes in the hand:Causes in the hand: Blunt trauma Blunt trauma Penetrating injuriesPenetrating injuries

Ulnar nerve injuries gives rise to Ulnar nerve injuries gives rise to claw hand claw hand deformitydeformity

Claw hand deformityClaw hand deformity It is a deformity with It is a deformity with

hyperextension of hyperextension of the MCP joints and the MCP joints and flexion of the IP flexion of the IP joints of the fingersjoints of the fingers

( loss of flexon at ( loss of flexon at MCP and extension MCP and extension at IP joints )at IP joints )

Clinical features Clinical features Loss of sensationLoss of sensation along the ulnar along the ulnar

nerve distribution nerve distribution and and

WastingWasting of the hypothenar muscles , of the hypothenar muscles , intrinsic muscles of the hand leading intrinsic muscles of the hand leading to hollow intermetacarpal spaces on to hollow intermetacarpal spaces on the dorsum of the handthe dorsum of the hand

..

Levels of the lesion Levels of the lesion HighHigh : above the level of elbow , entire nerve : above the level of elbow , entire nerve

function is lost function is lost Low :Low : Below the elbowBelow the elbow at the junction of the middle at the junction of the middle

and lower third of forearm :and lower third of forearm : Spared Spared : : - function of FDP and FUC- function of FDP and FUC LostLost : :

Motor : HTM ,Its , Lum ,PBMotor : HTM ,Its , Lum ,PB Sensory : dorsal aspect of hand and one and half Sensory : dorsal aspect of hand and one and half

fingersfingers

Cont ..Cont ..

Proximal to Guyon`s Proximal to Guyon`s canalcanal : : Spared : FDP , FCU and Spared : FDP , FCU and

dorsal sensationdorsal sensation Lost : same as above + Lost : same as above +

loss of volar sensationloss of volar sensation

Cont ..Cont .. Distal to Guyon`s canalDistal to Guyon`s canal : : - - Spared : FDP , FCU , HTM , PB, dorsal and Spared : FDP , FCU , HTM , PB, dorsal and

volar sensationvolar sensation Lost : interossei and lumbricalsLost : interossei and lumbricals

FCU – flexor carpi ulnarisFCU – flexor carpi ulnaris FDP – flexor digitorum profundusFDP – flexor digitorum profundus HTM – hypothenar musclesHTM – hypothenar muscles PB – palmaris brevisPB – palmaris brevis Lum – lumbricals Lum – lumbricals Its - interosseiIts - interossei

Clinical tests :Clinical tests : Froment's sign. When the Froment's sign. When the

patient attempts to pinch with patient attempts to pinch with the thumb and index finger, the the thumb and index finger, the long flexor of the thumb is used long flexor of the thumb is used to substitute for the thumb to substitute for the thumb adductor, resulting in flexion of adductor, resulting in flexion of the thumb at the interphalangeal the thumb at the interphalangeal joint. joint.

This characteristic appearance This characteristic appearance is present in this patient's left is present in this patient's left hand, caused by an ulnar nerve hand, caused by an ulnar nerve lesion at the elbowlesion at the elbow

Card testCard test Inability to hold a card or paper in between Inability to hold a card or paper in between

fingers due to loss of adduction by the fingers due to loss of adduction by the palmar interosseipalmar interossei

Pen testPen test Unable to touch the pen due to the loss of Unable to touch the pen due to the loss of

action of abductor pollicic brevisaction of abductor pollicic brevis

Egawa test ( median nerve Egawa test ( median nerve injury )injury ) With palm flat on the table the patient is asked to With palm flat on the table the patient is asked to

move the middle finger sideways( test for the move the middle finger sideways( test for the dorsal interossei of middle finger )dorsal interossei of middle finger )

In total clawing median nerve is also injuriedIn total clawing median nerve is also injuried

Pointing index or oschner`s clasp testPointing index or oschner`s clasp test : : When both the hands are clapsed together , index When both the hands are clapsed together , index

and middle fingers , fail to flex due to the loss of and middle fingers , fail to flex due to the loss of action of long finger flexors of the index and action of long finger flexors of the index and middle fingers which are supplied by the median middle fingers which are supplied by the median nerve . nerve .

Treatment of ulnar nerve Treatment of ulnar nerve injuryinjury Unless there is a lot of muscle Unless there is a lot of muscle wasting, (nonsurgical treatment )wasting, (nonsurgical treatment )

Prevention Prevention Avoid frequent use of the arm with Avoid frequent use of the arm with

the elbow bent the elbow bent If you use a computer frequently, If you use a computer frequently,

make sure that your chair is not too make sure that your chair is not too low. Do not rest the elbow on the low. Do not rest the elbow on the armrest. armrest.

Avoid putting pressure on the inside Avoid putting pressure on the inside of the arm (do not drive with the arm of the arm (do not drive with the arm resting on the open window ). resting on the open window ).

Keep the elbow straight at night Keep the elbow straight at night when you are sleeping (done by when you are sleeping (done by wrapping a towel around the straight wrapping a towel around the straight elbow, wearing an elbow pad elbow, wearing an elbow pad backwards, or using a special brace ) backwards, or using a special brace )

Loosely wrapping a towel around the arm with tape can help you to remember not to bend the elbow during the night

Nonsurgical TreatmentNonsurgical Treatment If symptoms have only If symptoms have only

just started, just started, Anti – inflammatory Anti – inflammatory

drugs, ibuprofen,( to drugs, ibuprofen,( to reduce swelling around reduce swelling around the nerve ). the nerve ).

Steroid (cortisone) Steroid (cortisone) injections around the injections around the ulnar nerve are not ulnar nerve are not generally used because generally used because there is a risk of damage there is a risk of damage to the nerve. to the nerve.

Exercises ( prevents arm Exercises ( prevents arm and wrist from stiffness ). and wrist from stiffness ).

With your arm forward and the elbow straight, curl the wrist and fingers toward the body, then extend them away from you and then bend the elbow

With the arm to the side, curl the wrist and fingers toward the shoulder and then turn the palm up and then stretch the neck to the other side.

Surgical TreatmentSurgical Treatment If the nerve is very compressed; or if there is If the nerve is very compressed; or if there is

muscle wasting muscle wasting Surgery Surgery : : Around the elbow and the wrist or both Around the elbow and the wrist or both More commonly, the nerve is moved from its More commonly, the nerve is moved from its

place behind the elbow to a new place in front of place behind the elbow to a new place in front of the elbow. This is called an the elbow. This is called an anterior anterior transpositiontransposition of the ulnar nerve. of the ulnar nerve.

The nerve can be moved : - The nerve can be moved : - under the skin and fat under the skin and fat (subcutaneous transposition(subcutaneous transposition),), within the muscle (within the muscle (intermuscular transpositionintermuscular transposition) or) or under the muscle (under the muscle (submuscular transpositionsubmuscular transposition). ).

..

For anterior transposition of the ulnar nerve, an incision along the inside of the elbow is used. Nerve moved from behind the elbow to in front of it and will make sure that it is not compressed by any other structures.

..

Entrapment of the ulnar nerve at Guyon's canal. If ulnar nerve is compressed at the wrist, make an incision and free the nerve where it is compressed.

Ulnar paradoxUlnar paradox The higher the lesion of the median and The higher the lesion of the median and

ulnar nerve injury , the less prominent is ulnar nerve injury , the less prominent is the deformity and vice versa, because in the deformity and vice versa, because in higher lesions the long finger flexors are higher lesions the long finger flexors are paralysed .paralysed .

The loss of finger flexion makes the The loss of finger flexion makes the deformity look less obviusdeformity look less obvius

Radial nerve injuryRadial nerve injury Causes : -Causes : - General causesGeneral causes : metabolic diseases , collagen : metabolic diseases , collagen

diseases , malignancies , endogenous or diseases , malignancies , endogenous or exogenous toxins , chemical or mechanical exogenous toxins , chemical or mechanical trauma , etc.trauma , etc.

Local causesLocal causes : - : - In the axilla :In the axilla :

Aneurysm of the axillary vesselsAneurysm of the axillary vessels Crutch palsyCrutch palsy

In the shoulderIn the shoulder:: Proximal humeral #Proximal humeral # Shoulder dislocationShoulder dislocation

Cont.. Cont.. In the spiral groove ( 5 `s )In the spiral groove ( 5 `s )

Shaft #Shaft # Saturday night #Saturday night # Syringe palsySyringe palsy `S ` march`s tourniquet palsy`S ` march`s tourniquet palsy

Between spiral groove and Between spiral groove and lateral epicondylelateral epicondyle : : # shaft humerus# shaft humerus Supracondylar # humerusSupracondylar # humerus Lateral epicondyle # of humerusLateral epicondyle # of humerus Penetrating and gunshot injuriesPenetrating and gunshot injuries Cubitus valgus deformityCubitus valgus deformity

Cont …Cont …

At the elbow :At the elbow : Posterior dislocation of elbowPosterior dislocation of elbow # head of radius# head of radius Monteggia #Monteggia #

Causes in the forearm :Causes in the forearm : # both bones of forearm# both bones of forearm Penetrating and gunshot injuriesPenetrating and gunshot injuries

Levels of lesion Levels of lesion High above spiral groove-High above spiral groove---- total palsy--- total palsy LowLow : : Type 1Type 1 (Between the spiral groove and the lateral (Between the spiral groove and the lateral

epicondyle ) : - epicondyle ) : - Spared : - elbow extensorSpared : - elbow extensor

Lost : -Lost : - Motor : wrist extensor , thumb extensor , finger Motor : wrist extensor , thumb extensor , finger

extensorextensor Sensory : dorsum of first web space Sensory : dorsum of first web space

Cont ..Cont .. Low Low

Type 2Type 2 ( below the elbow ) : ( below the elbow ) : Spared :Spared :

Elbow extensorElbow extensor Wrist extensorWrist extensor

Lost :Lost :

Motor : thumb extensor , finger extensorMotor : thumb extensor , finger extensor Sensory :Sensory : First web spaceFirst web space

Clinical features Clinical features Depend upon the site of the injuryDepend upon the site of the injury: -: - Lesions in or above the axillaLesions in or above the axilla : : Paralysis and wasting of all the muscles Paralysis and wasting of all the muscles

innervated. innervated. Clinically, this is manifest as:Clinically, this is manifest as:

weakness of forearm extension and flexion - weakness of forearm extension and flexion - triceps and brachioradialistriceps and brachioradialis

wrist drop and finger drop - paralysis of the wrist drop and finger drop - paralysis of the extensors of the wrist and digitsextensors of the wrist and digits

weakness of the long thumb abductor and weakness of the long thumb abductor and extensor musclesextensor muscles

Cont .. Cont .. Sensory lossSensory loss on the dorsum of hand and on the dorsum of hand and

forearm appropriate to the cutaneous distributionforearm appropriate to the cutaneous distribution Lesions around the humerusLesions around the humerus

spare brachioradialis and spare brachioradialis and extensor carpi radialis longus. extensor carpi radialis longus.

Posterior interosseous palsyPosterior interosseous palsy (due to a (due to a dislocation or fracture of the elbow ). dislocation or fracture of the elbow ). weakness of finger extension, and of thumb extension weakness of finger extension, and of thumb extension

and abduction. and abduction. little or no wrist drop, and usually, no sensory loss.little or no wrist drop, and usually, no sensory loss.

Fig : - Wrist drop Fig : - Wrist drop . .

Tests Tests Muscles supplied by the radial nerve and how to test each:Muscles supplied by the radial nerve and how to test each:

C7,8: triceps - ask patient to extend elbow against resistance. C7,8: triceps - ask patient to extend elbow against resistance.

C5,6: brachioradialis - ask patient to flex elbow with forearm half way between C5,6: brachioradialis - ask patient to flex elbow with forearm half way between pronation and supination. pronation and supination.

C6,7: extensor carpi radialis longus - ask patient to extend wrist to radial side C6,7: extensor carpi radialis longus - ask patient to extend wrist to radial side with fingers extended. with fingers extended.

C5,6: supinator - with arm by side, ask patient to resist hand pronation. C5,6: supinator - with arm by side, ask patient to resist hand pronation.

C7,8: extensor digitorum - ask patient to keep fingers extended at MCP joint. C7,8: extensor digitorum - ask patient to keep fingers extended at MCP joint.

C7,8: extensor carpi ulnaris - ask patient to extend wrist to ulnar side. C7,8: extensor carpi ulnaris - ask patient to extend wrist to ulnar side.

C7,8: abductor pollicis longus - ask patient to abduct thumb at 90° to palm. C7,8: abductor pollicis longus - ask patient to abduct thumb at 90° to palm.

C7,8: extensor pollicis brevis - ask patient to extend thumb at MCP joint. C7,8: extensor pollicis brevis - ask patient to extend thumb at MCP joint.

C7,8: extensor pollicis longus - ask patient to resist thumb flexion at IP joint. C7,8: extensor pollicis longus - ask patient to resist thumb flexion at IP joint.

Sensation:Sensation: The cutaneous The cutaneous

branches of the radial branches of the radial nerve supply the dorsal nerve supply the dorsal aspect of the forearm aspect of the forearm from below the elbow from below the elbow down over the lateral down over the lateral part of the hand to part of the hand to include the thumb to the include the thumb to the interphalangeal joint and interphalangeal joint and the fingers to the distal the fingers to the distal interphalangeal joint. interphalangeal joint.

Exams and TestsExams and Tests An examination of the arm, hand, and wrist identify An examination of the arm, hand, and wrist identify

radial nerve dysfunction.radial nerve dysfunction. Decreased ability to extend the arm at the elbow Decreased ability to extend the arm at the elbow Decreased ability to rotate the arm outward (supination) Decreased ability to rotate the arm outward (supination) Difficulty lifting the wrist or fingers (extensor muscle Difficulty lifting the wrist or fingers (extensor muscle

weakness) weakness) Muscle loss (atrophy) in the forearm Muscle loss (atrophy) in the forearm Weakness of the wrist and finger Weakness of the wrist and finger Wrist or finger drop Wrist or finger drop

Tests for nerve dysfunctionTests for nerve dysfunction : : EMG EMG MRI of the head, neck, and shoulder MRI of the head, neck, and shoulder Nerve biopsy Nerve biopsy Nerve conduction tests Nerve conduction tests

Treatment Treatment Closed fracture Closed fracture

CONTROL OF SYMPTOMSCONTROL OF SYMPTOMS Analgesics ( to control pain neuralgia) Analgesics ( to control pain neuralgia) Phenytoin, carbamazepine, or tricyclic antidepressants (amitriptyline) to Phenytoin, carbamazepine, or tricyclic antidepressants (amitriptyline) to

reduce stabbing pain reduce stabbing pain Steroids (prednisone) to reduce swelling Steroids (prednisone) to reduce swelling Other treatments include:Other treatments include: Braces, splints, Braces, splints, Physical therapy to help maintain muscle strength Physical therapy to help maintain muscle strength Occupational therapy, or job counselingOccupational therapy, or job counseling Surgery : - Surgery : - Failure of conservative by 12 to 18 monthsFailure of conservative by 12 to 18 months

Surgery ( open # )Surgery ( open # )Clean woundClean wound : : Primary repair , splint , physiotherapy Primary repair , splint , physiotherapy

Contaminated woundContaminated wound : :Delayed primary repair and secondary repair Delayed primary repair and secondary repair

Late casesLate cases : : Tendon transfersTendon transfers ArthrodesisArthrodesis

Splints Splints

ComplicationsComplications Mild to severe deformity of the hand Mild to severe deformity of the hand Partial or complete loss of feeling in the Partial or complete loss of feeling in the

hand hand Partial or complete loss of wrist or hand Partial or complete loss of wrist or hand

movement movement Recurrent injury to the hand Recurrent injury to the hand

Sciatic nerve injurySciatic nerve injury Thickest nerve in the bodyThickest nerve in the body Leprosy is the commonest causeLeprosy is the commonest cause High stepping gait is the characterisicHigh stepping gait is the characterisic Conservative treatment is indicated up to Conservative treatment is indicated up to

one yearone year

Foot drop Foot drop Causes Causes General causesGeneral causes : metabolic diseases , collagen : metabolic diseases , collagen

diseases , malignancies , endogenous or diseases , malignancies , endogenous or exogenous toxins , chemical or mechanical exogenous toxins , chemical or mechanical trauma , etc.trauma , etc.

LocalLocal : : At the spineAt the spine : :

Spina bifidaSpina bifida Tumors Tumors Disc prolapseDisc prolapse

Cont …Cont … At the hipAt the hip : :

Posterior dislocation of the hipPosterior dislocation of the hip # around the hip# around the hip # acetabulum# acetabulum

At the gluteal regionAt the gluteal region : : Deep I.M injectionsDeep I.M injections

At the thighAt the thigh : : # shaft femur# shaft femur Penetrating injury and gunshot Penetrating injury and gunshot

injuryinjury

Cont …Cont …

At the knee ( common causes )At the knee ( common causes ) Forcible inversion of the kneeForcible inversion of the knee Dislocation of kneeDislocation of knee # lateral condyle of tibia# lateral condyle of tibia Tight plaster casts around the kneeTight plaster casts around the knee Surgical damage during application of skeletal Surgical damage during application of skeletal

tractiontraction Gunshot injuries , incised and penetrating injuriesGunshot injuries , incised and penetrating injuries

Levels of lesionLevels of lesion High lesion ( above knee ) :High lesion ( above knee ) : Both tibial and common peroneal nerve are Both tibial and common peroneal nerve are

paralysedparalysed

Low lesion ( below knee )Low lesion ( below knee ) Type 1 ( anterior tibial nerve injury )Type 1 ( anterior tibial nerve injury )

Lost : tibialis anterior , extensor hallucis longus , Lost : tibialis anterior , extensor hallucis longus , extensor digitorium longus extensor digitorium longus

Sensation : over first web space is lostSensation : over first web space is lost Type 2 ( musculocutaneous nerve injury ): Type 2 ( musculocutaneous nerve injury ):

Spared : all the above muscles innervated by anterior Spared : all the above muscles innervated by anterior tibial nervetibial nerve

Lost : peroneous longus and brevisLost : peroneous longus and brevis Sensation : over outer leg and foot Sensation : over outer leg and foot

Clinical features Clinical features

Foot drop :Foot drop : CompleteComplete ( sciatic or lateral popliteal nerve ( sciatic or lateral popliteal nerve

injury )injury )

IncompleteIncomplete ( superficial or deep peroneal ( superficial or deep peroneal nerve )nerve ) High lesions ------total foot drop High lesions ------total foot drop Low lesions ------ incomplete foot dropLow lesions ------ incomplete foot drop

Low lesions Low lesions Type 1 : Type 1 :

Dorsiflexion and inversion is not possible Dorsiflexion and inversion is not possible Front of the leg is wastedFront of the leg is wasted Sensation over the dorsal web space is lostSensation over the dorsal web space is lost

Type 2 : Type 2 :

Cannot evert but can dorsiflex and invert the foot Cannot evert but can dorsiflex and invert the foot Wasting of the outer half of the leg Wasting of the outer half of the leg Sensation lost over outer leg and footSensation lost over outer leg and foot

Gait : - high stepping gait is characteristic .Gait : - high stepping gait is characteristic .

Treatment Treatment Braces or splints.Braces or splints. Physical therapy.Physical therapy. Nerve stimulation : Nerve stimulation :

In some cases, a small, battery-operated electrical In some cases, a small, battery-operated electrical stimulator is strapped to the leg just below the knee. stimulator is strapped to the leg just below the knee.

In other cases, the stimulator is implanted in the leg. In other cases, the stimulator is implanted in the leg.

Surgery.Surgery. Tendon transfer ( for mobile foot drop )Tendon transfer ( for mobile foot drop ) Tendon – Achilles lengthening ( in fixed ) Tendon – Achilles lengthening ( in fixed )

Treatment Treatment Different types of braces Different types of braces

(also known as ankle-foot (also known as ankle-foot orthotics or AFOs) are used . orthotics or AFOs) are used .

Two standard motions that Two standard motions that occur at the ankle joint – occur at the ankle joint – “dorsiflexion” and “dorsiflexion” and “plantarflexion”.“plantarflexion”.

Plantarflexion (toes point Plantarflexion (toes point downward ). downward ).

Dorsiflexion ( foot points Dorsiflexion ( foot points upward ). upward ).

Dropfoot ( partial or Dropfoot ( partial or complete weakness of the complete weakness of the muscles that dorsiflex the muscles that dorsiflex the foot at the ankle joint ). foot at the ankle joint ).

Types of AFOsTypes of AFOs Short leg fixed AFOs Short leg fixed AFOs Dorsiflexion assist short leg AFOs Dorsiflexion assist short leg AFOs Solid ankle AFO (with or without posterior Solid ankle AFO (with or without posterior

stop). Also available with dorsiflexion assist. stop). Also available with dorsiflexion assist. Full leg posterior leaf spring AFO Full leg posterior leaf spring AFO

Short Leg AFO with Fixed Hinge Short Leg AFO with Fixed Hinge (doesn’t flex at ankle joint) (doesn’t flex at ankle joint)

Dorsiflexion Assist AFO Dorsiflexion Assist AFO (dorsiflex the ankle)(dorsiflex the ankle) ::

Plantarflexion Stop AFO:Plantarflexion Stop AFO:

Solid AFO:Solid AFO:(stops plantarflexion and (stops plantarflexion and also stops or limits also stops or limits dorsiflexion). dorsiflexion).

Posterior Leaf Spring AFOPosterior Leaf Spring AFO Patients who have instability of the knee Patients who have instability of the knee

along with their dropfoot. along with their dropfoot.

Brachical plexus injuriesBrachical plexus injuries

Causes Causes Closed injuryClosed injury : :

Due to Due to birthbirth or or Due to Due to bikebike trauma trauma

Open injury :Open injury : Due to penetrating or gunshot injuriesDue to penetrating or gunshot injuries Others ( less common )Others ( less common ) Traction injuriesTraction injuries Tumor removalTumor removal Shoulder dislocationsShoulder dislocations Surgical excision of cervical ribsSurgical excision of cervical ribs Abnormal pressures due to faulty postureAbnormal pressures due to faulty posture

Types of lesionsTypes of lesions Supraclavicular lesion: Supraclavicular lesion: 1 . 1 . Preganglionic lesionPreganglionic lesion : :

Cause could be either birth or bike traumaCause could be either birth or bike trauma Characteristic feature :Characteristic feature :

Presence of Presence of Horner`s syndromeHorner`s syndrome..

2 . Postganglionic2 . Postganglionic lesionlesion : - : - - absence of Horner`s syndrome- absence of Horner`s syndrome - prognosis is slightly better than the preganglionic - prognosis is slightly better than the preganglionic

lesionlesion - - positive Tinel`s sign ( positive Tinel`s sign ( tapping above the clavicle , tapping above the clavicle ,

produces tingling sensation in the anaesthetic limb )produces tingling sensation in the anaesthetic limb )

Horner`s syndromeHorner`s syndrome

Remember ( 5 P`s ) : -Remember ( 5 P`s ) : - Ptosis of the eyelidPtosis of the eyelid Pupils which are small Pupils which are small

and constrictedand constricted Protrusion of the eyeball Protrusion of the eyeball

which is slightwhich is slight Pain even at restPain even at rest Poor prognosisPoor prognosis

Assessment of brachial Assessment of brachial plexus injuryplexus injury

In preganglionic lesionIn preganglionic lesion Horner`s syndrome ---Horner`s syndrome ---

presentpresent Unable to elevate Unable to elevate

scapulascapula

In postganglionic lesionIn postganglionic lesion Horner`s syndrome ----Horner`s syndrome ----

absent absent Able to elevate scapulaAble to elevate scapula

Tinel`s sign --- present Tinel`s sign --- present in the later stagesin the later stages

Investigation Investigation X – ray ( to rule out # )X – ray ( to rule out # )

CT scan ( study cross – section anatomy )CT scan ( study cross – section anatomy )

MRI ( study the soft tissue damages )MRI ( study the soft tissue damages )

Electromyogram (EMG or electromyography)Electromyogram (EMG or electromyography)

Nerve conduction studyNerve conduction study

Physical Therapy Physical Therapy InterventionIntervention

1 . Splinting 1 . Splinting A-Aeroplane splintA-Aeroplane splint

B-Shoulder slingB-Shoulder sling : to protect shoulder joint in : to protect shoulder joint in peripheral nerve injuries as( axillary nerve) peripheral nerve injuries as( axillary nerve)

C-cook up splintC-cook up splint : in Radial nerve injuries. : in Radial nerve injuries.D-Ankle foot orthosisD-Ankle foot orthosis : in Common peroneal : in Common peroneal

nerve lesion.nerve lesion.E-Finger splintE-Finger splint : in Ulnar nerve lesion to correct : in Ulnar nerve lesion to correct

hyperextension of MCPjoints and correct hyperextension of MCPjoints and correct flexion in IPJ joints.flexion in IPJ joints.

Cont ..Cont .. 2 . For pain control :2 . For pain control :

1-Electro therapy:1-Electro therapy:A-TENS method (20 min)A-TENS method (20 min)( ( 'Transcutaneous Electrical Nerve 'Transcutaneous Electrical Nerve

Stimulation‘ ) Stimulation‘ ) Mild electrical impulses are Mild electrical impulses are

transmitted through the skin transmitted through the skin Cause body to release endorphins, Cause body to release endorphins,

the body’s own pain-relieving the body’s own pain-relieving hormones. hormones.

These 'positive signals' to the brain These 'positive signals' to the brain block the slower-moving pain block the slower-moving pain messages. messages. 

C- Continuous Ultrasound : for proximal C- Continuous Ultrasound : for proximal affection.(5 min)affection.(5 min)

D- Deep cold laser (Infra red laser)(3 D- Deep cold laser (Infra red laser)(3 min)min)

B- Interferntial current.B- Interferntial current.

E-Hot pack & Infrared : to maintain skin visibilty E-Hot pack & Infrared : to maintain skin visibilty ( must have intact superfacial sensation to ( must have intact superfacial sensation to avoid burn).avoid burn).

3-Motor retraining 3-Motor retraining A- Passive movement for the affected joints.A- Passive movement for the affected joints.B-Facilitation for paralysed muscles by B-Facilitation for paralysed muscles by *Tapping on the muscles.*Tapping on the muscles.*Quick stretch. *Quick stretch.

* Breif ice application.* Breif ice application. *Squeezing the muscles.*Squeezing the muscles. *P.N.F techniques : Resist strong *P.N.F techniques : Resist strong

proximal muscles to facilitate waek distal proximal muscles to facilitate waek distal muscles using quick stretch.muscles using quick stretch.

*Jendrassic maneuveur : Firing of all *Jendrassic maneuveur : Firing of all motor neuron pool. motor neuron pool.

C- Electrical stimulation : Faradic C- Electrical stimulation : Faradic stimulation, used for muscle re-education stimulation, used for muscle re-education ,nerve stimulation .,nerve stimulation .

4- Sensory re education : 4- Sensory re education : A- Protection of desensitized area to A- Protection of desensitized area to

avoid burn & injuries.avoid burn & injuries. B-Brushing skin with different materials B-Brushing skin with different materials

as :cotton –silk ….as :cotton –silk ….

C-Occlouded vision : ask to recognize C-Occlouded vision : ask to recognize different objects ( sharp – smooth )different objects ( sharp – smooth )

D- Occlouded vision : ask to recognize D- Occlouded vision : ask to recognize quantity of material by touch. quantity of material by touch.

Surgical measures Surgical measures Types of surgeryTypes of surgery Nerve graft :Nerve graft : - - the damaged part the damaged part

of the brachial of the brachial plexus is removed plexus is removed and replaced with and replaced with sections of nerves sections of nerves cut from other cut from other parts of bodyparts of body

Nerve transfersNerve transfers

Done in the most Done in the most serious types of serious types of brachial plexus brachial plexus injuries, called injuries, called avulsions, when avulsions, when the nerve root the nerve root has been torn out has been torn out of the spinal of the spinal cord. cord.

Muscle transfersMuscle transfers Needed if Needed if

arm muscles arm muscles have have atrophied atrophied from lack of from lack of use. use.

ERBS PALSYERBS PALSY

Erb's palsyErb's palsy paralysisparalysis of the of the musclesmuscles in a in a

baby's arm, caused by injury baby's arm, caused by injury of the of the nervesnerves in the shoulder in the shoulder at birth (during delivery).at birth (during delivery).

The baby lies with one arm The baby lies with one arm and hand twisted backward and hand twisted backward and does not move the arm and does not move the arm as much as the other.as much as the other.

If the full range of motion of If the full range of motion of the arm is not kept through the arm is not kept through regular exercise, regular exercise, contracturescontractures will develop . will develop .

Clinical features Clinical features At the shoulderAt the shoulder : :

Loss of shoulder abduction and external rotation ( due Loss of shoulder abduction and external rotation ( due to paralysis of the deltoid , supra and infraspinatus to paralysis of the deltoid , supra and infraspinatus and teres minor muscles )and teres minor muscles )

At the elbowAt the elbow : : Loss of flexion of the elbow joint ( due to paralysis of Loss of flexion of the elbow joint ( due to paralysis of

the biceps and brachialis )the biceps and brachialis )

At the forearmAt the forearm : : Loss of supination of the forearmLoss of supination of the forearm

May be sensory loss on the outer aspects of the May be sensory loss on the outer aspects of the arm and forearm both in the front and back .arm and forearm both in the front and back .

Policeman or Waiter`s tip Policeman or Waiter`s tip Shoulder --- Shoulder ---

internally rotated internally rotated

Elbow ----- extensionElbow ----- extension

Forearm --- pronatedForearm --- pronated

Wrist ------ flexion Wrist ------ flexion

Treatment Treatment 1 . Splinting 1 . Splinting

Aeroplane splintAeroplane splint 2 . For pain control :2 . For pain control :

TENS methodTENS method Types of surgeryTypes of surgery - - Nerve graft .Nerve graft . - - Nerve transfers .Nerve transfers . - Muscle transfers .- Muscle transfers . - release of soft tissue contractures .- release of soft tissue contractures .

With the baby, start range-With the baby, start range-of-motion exercises 2 times of-motion exercises 2 times a day. a day.

When the child is old, have him do exercises When the child is old, have him do exercises himself, for range of motion and to increase himself, for range of motion and to increase

strength.strength.

Cont ..Cont ..

Cont ..Cont ..

THANK YOUTHANK YOU