Upper Extremity- Peripheral Nerves

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3 Nerves of UE
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Radial, ulnar, median nerves *special noteUlnar nerve travels down ulnar side (Suprise) and into 4&5 digit, however it has a small branch that reaches out in the palm that affects the thumb as well. Median and ulnar nerve both travel into that 4th digit, however one side will be affected (ulnar side/radial side of finger)Radial NerveAllows elbow, wrist, MP extension DR CUMA- Wrist drop, radial Radial nerve passes along posterior side of arm, where those extensor tendons are.You are going to have more problems with a more _____ vs ______ nerve injury (where it gets injured along the arm)proximal vs distal (like at humerus vs at wrist)Names for Radial Nerve injury at different levels-Crutch palsy (axila) wearing crutches too long. -Saturday Night Palsy (arm over back of chair- mid humeral) -PINS: Posterior Interosseous Nerve Syndrome (think of anatomy)Mnemonic to remember radial nerve injuries:Gonna need a Doctor and Crutches after Saturday night am I right? Doctor: DR CUMA Crutches: Crutch palsy Saturday Night: Saturday night palsy Then just remember PINS: posterior=radial nerveMost common orthoses for Radial Nerve injury:wrist cock-up splint (Cocky surfer bro squid, radial dude, my best friend is a carp) -An elbow flexion orthosis might be needed for a high-level injury. -Limit tension on the area of the nerveUlnar Nerve-Needed for power grip, strong wrist flexion, and key pinch. -DR CUMA- Claw hand, ulnar nerve Think of gripping something: your 4&5 digits add more power.Names for Ulnar Nerve injuries (2)-Cubital Tunnel (elbow injury) -Guyon's Canal Compression (aka ulnar canal, anterior wrist)mnemonic to remember ulnar nerve injuries:CU, CU, GU: CU (DR CUMA) CU- CUbital GU-GUyonCommon functional issues for Ulnar nerve injury:grip strength, key pinch, and being able to hold objects in hand. "The Claw is the Key""The Claw is the Key"just a way to remember ulnar nerve injury goes with claw hand deformity, key pinch, grip strength/holding objects.test for ulnar nerveFroment's sign/Jeanne's sign: holding a paper with thumb and fingers (sideways) and pulling it awayFroment's sign/Jeanne's sign Mnemonic:"I'm Jeanne Froment, key pinch specialist" (hands you business card). OR Froment= "Meant for me"Ulnar "claw" and key "pinch" are relatedCommon treatment for ulnar nerve injury:nighttime splint to limit elbow flexion. Can be as simple as a towel duct taped around elbow. (Elbow extension splint)Median NerveImportant for the fine motor and sensation of the 1-3 digits, basically the lumbricals and opposition of the thumb. (DR CUMA: Median, Ape hand)Median nerve innervates:lumbricalsNames for Median Nerve injuries at different levels: (2)-Pronator syndrome (anterior forearm) -Anterior interosseous syndrome (anterior forearm) Mnemonic: Straight shot up into the carpal tunnel.Common orthoses for median nerve:Wrist cock-up splint with wrist in neutral (radial dude my best friend is a carp, cocky surfer squid)Test for median nerve injury:Moberg pickup test: picking up objects from the table (coins, screws, etc.) with first three digits. "Moberg Pickup= Median Pickup"sign of benedictionInability to flex thumb, 1st and 2nd fingers due to median nerve damage It looks just like claw hand, but it is caused by MEDIAN nerve damage. Think of an ape dressed as a pope, doing this sign.Main Concept: Proximal vs DistalPeripheral nerve injuries will vary based on the location and severity of the injury. Example: a radial nerve could have a lesion or impingement in the axilla, mid humerus, elbow, or any one of several forearm locations with impairments ranging from limited sensory loss to complete motor/sensory loss of muscles innervated by the radial nerve. Proximal is worse than distal, use anatomy to intuit the rest. (we aren't trying to memorize every variation)Role as OT in nerve injuries: -Manage/prevent: -Maintain: -Facilitate:-complications including pain and further injury. -function: ROM and nerve gliding. -Facilitate regaining function.Non-surgical treatments-Nerve gliding -Sensory re-ed -Pain management (eduaction, desensitization, modalities)Nerve Gliding"motion is lotion" Goal: maximize movement, minimize strain. -Don't apply force at the end of movement, this increases strain. Floss example (didn't really make sense to me- but basically no need for the extra positions (head tilted/shoulder abducted) just basic distal movement)Sensory Re-EducationHelp healing sensory system reorganize correctly. -FIRST: emphasize protection (compensate for loss of hot, cold, pain) use vision or protective clothing/orthoses, compensatory techniques. -Then: discriminatory sensation (stereognosis- what's in my pocket) Sensory re-edPossible test question for Sensory Re-Education: What would you do FIRST for someone with sensory loss?SAFTEY FIRST Establish if they have lost sensory protection, then emphasize protection/compensation. Do this before you do other stuff because they could hurt themselves at home.Pain managementBody ramps up pain sensitivity following injury (can lead to CRPS). -Education on source and minimizing fear is important. -Pain is an experience in the mind, and heightened by fear! -Educate pt on this process, help them decrease fear.Desensitizationsensory system is oversensitive, can become permanently fixated on all stimuli being noxious. Having client touch around or on the sensitive areas with a cloth/toothbrush while relaxing to train sensation as non-noxiousnoxious stimulipainful stimuliModalitiesModalities will depend on whatever is effective/safe for client. CAUTION: if protective sensation is compromised DO NOT use superficial heat/coldPost-Surgical TreatmentsOrthosis to limit tension on nerve, follow-up with surgeon regarding progression of therapy.Details that I don't need to memorize for test: Dermatomesif they had this on the test, they would have to basically give you the answer.Memorize a few tests:-Phalen's test: median nerve/carpal tunnel ("failing" to pray) -Froment's: ulnar nerve ("meant for me") -Tinel's sign: any nerve (tapping like rain on a tin roof)Phalen's test**Another detail/testWartenberg's sign: ulnar nerve, involuntary abduction of 5th digit (makes a "W", wants to get away from the warry 4th digit)Wartenberg's signFromont's SignQuestion: Parents of a 14-month-old child report a decrease in use of the LUE. The OT suspects peripheral nerve injury. How would you confirm this suspicion? -Tinel's sign -Have parents check for wrinkling pattern while bathing -Semmes-Weinstein monofilament testing -Two-point discrimination testingsecond answerA client who works full-time as a hairdresser experienced a distal radial nerve injury. They are having difficulty at their job because of their injury. What compensatory method would be the most beneficial for this patient?radial nerve- think DR CUMA DR- wrist drop wrist cock-up splint (she's probably struggling to keep her wrist up while working)KeylineDR CUMA