Week 3 Flashcards
What is a dermatome?
An area of skin innervated by a single spinal nerve
What is cutaneus innervations?
Areas innervated by specific peripheral nerves which can contain fibers from multiple spinal nerve roots.
What is cutaneus innervation a result of?
Spinal nerve plexuses (brachial, lumbar, sacral) which in turn form terminal nerves
What are plexus injuries due to?
MVA
Trauma
What is the patient’s result after or during plexus injuries?
Generally active and able to carry out ADL’s with the use of one hand unless disabled by pain
What might plexus injured patients prefer?
To use sound limb and remain one-handed
What must be considered with plexus injured patients?
Due to sensory feedback loss from skin, muscles and joints, patients have to do skin checks, skin cleaning, and be aware during ADL’s
What are the biomechanical principles for plexus injuries?
Prevent deformity
Correct deformity
Position limb to obtain maximal function
5 degrees of supination
What should be considered with the device for plexus injured patients?
Most patients are independent with one hand and no device
Device shouldn’t interfer with remaining ability
Device should allow independent donning/doffing
Cost must be considered/length of use and benefit
What is an axillary nerve injury?
Loss of active shoulder abduction and flexion
Sensory loss of lateral side of proximal arm
How do patients compensate for axillary nerve injury?
By using rotator cuff musculature to abduct the arm
How does axillary nerve injury present?
Deltoid is atrophied
What is the orthotic considerations for axillary nerve injury?
Treatment is limited to functional arm support to decrease gravitational pull on the glenohumeral joint
What is musculocutaneous nerve lesion?
loss of biceps and brachialis, and all useful elbow flexor strength
How can the patient compensate for musculocutaneous nerve lesion?
Can compensate with pronator teres and brachiradialis if they are well conditioned
What are the orthotic considerations for musculocutaneous nerve lesion?
Use of an orthosis for elbow control and assistance is difficult due to soft tissue of the arm, which creates an unstable base
What are the three levels of involvement associated with radial nerve lesion?
Below elbow
Mid-humerus
Axillary level
Radial nerve lesion is often referred to as?
Wrist drop
What is the below elbow radial nerve lesion?
The finger and thumb extensors and long thumb abductor loses motor function
What is the presentation of below elbow radial nerve lesion?
MCPs, fingers and thumb will begin to contract
What is the orthotic treatment recommendations for below elbow radial nerve lesion?
HO or WHO with IP extension assist (MP extesnion stop if patient becomes hypermobile at MP joint)
What is mid-humerus radial nerve lesion?
Wrist extensor paralysis is added to the absence of finger and wrist-extensor control
What is affected due to mid-humerus radial nerve lesion?
grasp-and-pinch coordination because the finger flexors cannot contract sufficiently to maintain grasp
What is the orthotic treatment for mid-humerus radial nerve lesion?
Static control at the wrist to counteract the effects of gravity and pull of the finger flexors as they contract. (Static WHO or Thermoplastic WHO)
What is axillary level radial nerve lesion?
Triceps motor function loss in addition to the wrist and hand extensors.
What should be considered with axillary level radial nerve lesion?
Deformity of the elbow is rarely a problem due to gravitational pull when the patient is upright.
What is the most common mechanism for radial nerve lesion at the axillary level?
Poorly fit crutches
Falling asleep with arm over a chair
Saturday night palsy
What are the levels of involvement for a ulnar nerve lesion?
Wrist
Elbow or above
What is wrist ulnar nerve lesion?
absent intrinsic muscle action in the ring and little finger
How does the patient present with wrist ulnar nerve lesion?
A claw position with incomplete IP extension and hyperextension of the MCP.
Where does sensory loss occur for an wrist ulnar nerve lesion?
On the palmar and dorsa aspect of 5th digit and 1/2 of 4th digit
What is the common mechanism of injury for the wrist ulnar nerve injury?
A cut horizontally at the wrist
Suicide attempt
What is claw hand also referred to as?
Intrinsic minus hand
What is Volkmann’s ischemic contracture?
Trauma to the arm, including a crush injury or fracture, that can lead to swelling that presses on blood vessels and can decrease blood flow to the arm.
Lack of blood to the arm
What can occur if there is a prolonged decrease in blood flow to the arm?
Injury to the nerves and muscles, causing them to become stiff (scarred) and shortened
What is also weakened due to Wrist ulnar nerve lesion?
Grasp because the loss of direct MP flexion and usual intrinsic tie between extensors and flexors.
The IP joints hyperflex and the distal transverse arch flattens
What orthotic treatment can be given for the claw hand?
Orthotic MP extension stop
Allows long extensor muscles to complete IP extension
What are the four aspects of the ulnar nerve?
Formed from medial cord of brachial plexus
Lies behind medial epicondyl
Gives off dorsal branch
Forms deep superficial branches
What is elbow and above ulnar nerve injury?
When the injury is at the elbow, the flexor digitorum profundus muscle (of the 4th and 5th fingers) loses motor function, in addition to the intrinsic hand muscles.
What is deprived of the patient with elbow and above ulnar nerve injury?
Ulnar grasp
What is the orthotic treatment for elbow and above ulnar nerve injury?
Same as below: HO with MP extension stop
Which way will the hand deviate for a patient with elbow and above ulnar nerve injury?
Radially because of flexor carpi ulnaris paralysis during radiocarpal flexion
What is the common mechanism of injury for elbow and above ulnar nerve injury?
fracture of the medial epicondyle of the humerus
What is the nerve lesion that causes the most critical loss of function?
Median Nerve lesion
What are the two sites of injury of involvement for median nerve lesion?
Wrist
Elbow and above
What is critical of Median nerve lesion?
Motor and sensory loss deficiency
It is the absolute pathway for all sensory fibers from critical areas, which also includes the radial side of the index finger.
The motor supply includes the thumb’s intrinsic muscles and the extrinsic flexors of the thumb, index and middle finger
What is wrist median nerve injury?
Only the thumb intrinsics (Lumbricals to index and middle finger) are paralyzed
What is the orthotic treatment for wrist median nerve injury?
Prevent deformity, and encourage useful hand function due to the lack of sensation.
How can the patient present with elbow and above median nerve injury?
Ape hand
Hand of Benediction
How does ape hand occur?
When the thenar eminence is flattened
How does the hand of benediction occur?
When the patient attempts to make a fist and the index and middle fingers remain extended, while the 4th and 5th fingers flex
What does BPI stand for?
Brachioplexus injury
What are the four types of BPIs?
Neuroma
Rupture
Avulsion
Neuropraxia
What is neuroma BPI?
Nerve root has attempted to heal on its own.
The neuroma is the scar tissue that grows around and decreases the signal strength sent to the muscles
What is Rupture BPI?
Where the nerve is torn, but not at the spinal attachement
What is Avulsion BPI?
When the nerve root is torn at the location where it exits the vertebral foramen
What is neuropraxia BPI?
When the nerve is damaged (stretched) but not torn
What is Erb’s Palsy?
Upper portion of brachial plexus affected-C5,C6
How does Erb’s Palsy present?
Adducted internally rotated shoulder, extended elbow and pronated wrist (Waiter’s tip)
How often does Erb’s Palsy occur?
0.7 in 1000 births
What is the mechanism of injury for Erb’s Palsy?
Traction on the plexus during delivery
When should treatment occur for Erb’s palsy?
7-10 days with physical therapy and splinting
What is Klumpke’s Palsy?
Lower segment involvement (loss of hand intrinsic muscles-C7-T1
What is the cause of Klumpke’s palsy?
A sudden shoulder abduction motion
What is the result of Klumpke’s palsy?
Loss of ulnar nerve sensory areas with shoulder and elbow stability and function
What is the orthotic treatment for Klumpke’s palsy?
WHO
How will the patient present with Klumpke’s palsy?
Claw hand because of impingement of ulnar nerve.
Wrist in extreme extension because of unopposed wrist extensors
hyperextension of MCP and Flexion of IP because of loss of hand intrinsic muscles
What are the ADL’s for C1-3 level impairment?
Total dependence on caregiver
What is the available movement of C1-3 impairment?
Neck control
What is the orthotic treatment for C1-3 impairment?
Positional WHO’s
What are the ADL’s for C4 impairment?
Total dependence (may incorporate external power systems)
What is the available muscles of C4 impairment?
Diaphragm and trapezius
What is the orthotic treatment for C4 impairment?
Mobile arm support, powered tenodesis WHO and/or static WHO
What are the ADL’s for C5 impairment?
Can independently feed, groom and complete light home-keeping duties
What are the available muscles for C5 impairment?
Deltoid, Biceps, Supinator, Rotator cuff group
What is the orthotic treatment for C5 impairment?
Mobile arm support (initally) RATCHET WHO or powered tenodesis WHO (Ratchet WHO not bilaterally)
What are the ADL’s for C6 impairment?
Can independently feed, groom, transfer and drive with hand controls
What are the available muscles for C6 impairment?
Extensor carpi radialis longus and brevis, prontator teres, pectoralis major.
What is the orthotic treatment for C6 impairment?
Wrist-driven WHO (Flexor hinge WHO)
What are the ADL’s for C7 impairment?
Total independence and driving car with hand controls
What are the available muscles for C7 impairment?
Triceps, latissimus dorsi, extensor digitorum, flexor carpi radialis, flexor digitorum
What is the orthotic treatment for C7 impairment?
Wrist-driven WHO (initially) Static WHO
What are the ADL’s for C8-T1 impairment?
Total independence and driving car with hand controls
What are the available muscles for C8-T1 impairment?
Interossei, lumbricals, thenar and hypothenar muscles
What is the orthotic treatment for C8-T1 impairment?
HO (initially) during recovery
