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Ortho Eval > Week 8 - Peripheral Nerve Injuries > Flashcards

Week 8 - Peripheral Nerve Injuries Flashcards

1
Q
  • communication network btwn the CNS and the body parts

- consists of the nerves that branch out from the brain and spinal cord.

A

PNS

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2
Q

Name the 6 parts of the brachial plexus.

A
  • roots
  • trunks
  • divisions
  • cords
  • branches
  • digital nerves
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3
Q

How does PNI occur? Name 3 causes.

A
  • trauma
  • non-traumatic compression (nerve injury in continuity, compressed by anatomy)
  • at birth
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4
Q

Name Seddon’s 3 classifications of PNI.

A
  • neurapraxia
  • axonotmesis
  • neurotmesis
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5
Q

classification of PNIs is based on the degree of disruption of what?

A

internal structures of the peripheral nerve

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6
Q

nerve reconstruction is based on a foundation of principles that facilitate what?

A

the natural regeneration process of the nerve

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7
Q

Name 5 methods of PN repair.

A
  • end to end repair
  • conduit tube
  • nerve graft
  • nerve transfer
  • muscle (tendon) transfer
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8
Q

injury - mild recovery; lowest and least severe, usually recovers on its own

A

neuropraxia

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9
Q

injury - severe; regeneration 1 mm day; recovery

A

axonotmesis

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10
Q

injury, degeneration, neuroma formation; nerve is cut or crushed

A

neurotmesis

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11
Q
  • working muscles too hard

- repetitive movements

A

compressed by anatomy

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12
Q

a conduit tube is made out of what?

A

collagen

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13
Q

used when there is a large gap between nerve endings

A

nerve grafting

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14
Q

used after a nerve surgery to assess repair

A

advancing Tinel’s sign

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15
Q

nerve is taken from somewhere else in the body

A

nerve graft

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16
Q
  • take a branch of working nerve and put it in nerve/muscle that is not working
  • most popular
A

nerve transfer

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17
Q

what is the most common nerve used in nerve grafts?

A

surel nerve from leg is often used in median nerve grafts

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18
Q

how do you know whether to use a nerve graft or transfer?

A

method often depends upon how much of nerve is missing

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19
Q
  • can’t move AROM or PROM for a few weeks

- quicker method

A

end-to-end repair

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20
Q

a surgical technique that may be used when a pt. has a nerve injury resulting in complete loss of muscle function or sensation

A

nerve transfer

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21
Q

involves taking nerves with less important roles - or branches of a nerve that performs redundant functions to others nerves - and moving them to restore function in a more crucial nerve that has been severely damaged.

A

nerve transfer

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22
Q

surgical treatment is mandatory when there is reasonable suspicion of what? and why?

A

a root avulsion or nerve rupture - such injuries are not expected to heal spontaneously

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23
Q

describe a nerve transfer for restoration of elbow flexion.

A

transfer of part of the ulnar nerve for re-inervation of the musculocutaneous nerve (biceps brachii muscle)

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24
Q
  • nerve repair or graft not possible, unsuccessful

- to restore balance that has been lost through injury or disease

A

tendon, muscle transfer

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25
Q
  • there is a predictable sequence of events

- axonal growth can be stopped anywhere along path by impenetrable scar

A

nerve regeneration

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26
Q

name 5 factors that influence regeneration.

A
  • mechanical
  • delay
  • age of pt.
  • level of injury
  • associated injuries.
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27
Q

describe a tendon/muscle transfer.

A
  • muscle on flexor surface is put into extensor surface

- we have to help pt. relearn how to extend wrist, fingers, etc. bc that muscle never worked in that way before

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28
Q

what always occurs during a muscle/tendon transfer?

A

pt. always loses a grade of muscle strength - important to tell pt. this

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29
Q

describe 3 changes to skeletal muscle after denervation.

A
  • muscle ceases to function, there is gross atrophy
  • decrease of muscle weight and cross sectional areas (no decrease in number of fibers)
  • increase in connective tissue
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30
Q

what is the avg. rate of decrease in muscle mass after 1-3 weeks of denervation?

A

40%

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31
Q

functional re-innervation is unlikely after how many years?

A

2 years

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32
Q

what can play a role in preventing atropy?

A

NMES

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33
Q

Name 2 sensory changes after PNI.

A
  • response of end organ varies - atrophy, degeneration, disappearance
  • if sensory receptor degenerates after long-term denervation, it is lost the receptor pool bc we cannot form new sensory receptors
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34
Q

atrophy, never completely disappear

A

meissner and pacinian corpuscles

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35
Q

reduce in number, atrophy, become differentiated; atrophies faster than other sensory organs

A

merkel cells

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36
Q

skin color/temperature

A

vasomotor

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37
Q

sweat

A

sudomotor

38
Q

gooseflesh response

A

pilomotor

39
Q
  • soft tissue atrophy
  • nail changes
  • hair growth
  • rate of healing
A

trophic

40
Q

describe early sympathetic changes after PNI.

A
  • sudomotor: dry skin, rosy/warm
  • pilomotor: absent
  • trophic: soft/smooth, slight atrophy
  • blemished nails
  • healing slowed
41
Q

describe late sympathetic changes after PNI.

A
  • vasomotor: mottled/cyanotic/cool
  • sudomotor: dry/moist
  • pilomotor: absent
  • trophic: non-elastic; pronounced, finger tip atrophy
  • talon-like nails
  • healing slowed
42
Q

retrain pt. to recognize the distorted cortical impression; helps pt. achieve potential for functional sensory recovery given to him by the surgeon at the time of nerve repair

A

sensory re-education

43
Q

Name 4 principles of sensory re-education treatment.

A
  • pt. must have protective sensibility
  • tasks are done with and without visual feedback
  • environment free from distraction
  • pts. must be motivated!
44
Q

how often should sensory re-education intervention sessions occur?

A

brief session 2-4 times per day

45
Q

describe the early phase of sensory re-education.

A
  • perception of 30 cps vibration

- moving touch has returned

46
Q

describe the late phase of sensory re-education.

A

-moving touch and constant touch can be perceived and localized at the fingertip.

47
Q

*sensory re-education cannot be done until pt. has what?

A

at least protective sensibility

48
Q

what should be done if pt. only has anesthetic sensibility?

A

pt. education (don’t touch stove, be careful with…)

49
Q

the more ___ a nerve injury is the ___ it is to heal.

A

proximal, harder

50
Q
  • when stimuli that would not normally cause pain, causes severe pain in affected area.
  • pts. typically hold affected part in protected position.
  • can lead to disability through non-use of body part.
A

hypersensitivity

51
Q

what is the OTs initial (first) treatment for hypersensitivity.

A

compensation and education

52
Q

what is the second treatment that an OT utilizes for hypersensitivity?

A

“sensory desensitization” program

-OT introduces progressively irritating stimuli

53
Q

Name 4 aspects of a baseline OT PNI evaluation.

A
  • MMT
  • Sensibility
  • ROM
  • ADL
54
Q

what does MMT do in an evaluation?

A

helps determine level/extent of injury

55
Q

what is the purpose of threshold sensibility tests in an OT eval?

A

to help determine nerve potential

56
Q

what is the purpose of functional sensibility tests in an OT eval?

A

to help determine adaptation and compensation

57
Q

which type of ROM should be used in a PNI OT eval?

A

PASSIVE

58
Q

describe week 1 OT management of an acute PNI.

A
  • post op dressing/cast to position joints to protect nerve repair
  • AROM to non-involved joints
  • elevation
59
Q

describe day 7 OT management of acute PNIs.

A
  • remove post op dressing/case, wound suture case, apply light dressing
  • fabricate splint
  • light compression may be indicated
  • continue AROM of non-involved joints
  • PROM of specific joints to prevent deformity
  • patient education
60
Q

describe one method of treatment for sensory re-education.

A

bucket of rice - try to find the marbles

61
Q

person has enough sensibility in their fingers to pull away from something that would hurt them

A

protective sensibility

62
Q

sensory desensitization is most common in pts. with which type of injuries?

A

finger injuries (digital nerve)

63
Q

describe treatment for desensitization.

A
  • gradually calm nerve down
  • start with OT or pt. massaging their fingers, rubbing towel on them.
  • rice bucket - prob wouldn’t start with this.
64
Q

what kind of ROM would you perform in an initial OT eval if nerve doesn’t work?

A

PROM

65
Q

Describe ROM interventions 3 weeks post injury.

A
  • PROM of fingers to prevent contractures

- intrinsics are atrophied

66
Q

How would you design/change a splint during day 7-21?

A
  • wrist in neutral/extended if possible

- still full hand but want fingers to move more

67
Q

when should you change a splint?

A

after 7-10 days

68
Q

describe OT management of acute PNI during days 7-21.

A
  • discontinue dressing when wound closes
  • provide compression if indicated
  • adjust splint to decrease angle of joints
  • initiate light activities within confines of splint
69
Q

describe OT management of acute PNI during days 22-35.

A
  • discontinue splint with MD ok.
  • scar massage and desensitization
  • incorporate functional activities in therapy (discourage excessive force when gripping or manipulating objects, differential tendon glide, evaluate pts. psychological status)
  • re-evaluate sensory and motor function
  • document tinel’s
  • emphasis on edema, scar management, prevention of deformity
70
Q

Describe the progression of tendon gliding exercises.

A
  1. start with your fingers straight every time. (straight)
  2. make one type of fist at a time with your fingers - hook, straight, full, straight, straight fist.
  3. curl your thumb down in your palm as much as possible, then stretch it out as far as possible
71
Q

when is NMES useful?

A

helpful when muscle is beginning to work, not when it’s deinnervated.

72
Q

major part of PNI repair

A

orthotics

73
Q

name 7 aspects of OT management of intermediate PNI.

A
  • begin NMES when motor recovery is present.
  • continue to incorporate functional activities.
  • avoid “trick” or substitute motions
  • begin UE strengthening program
  • begin sensory re-education
  • re-evaluate 2x/month
  • emphasis on re-training and functional use while preventing deformity
74
Q

Name 5 aspects of OT management of chronic PNI.

A
  • pt. plateaued
  • re-evaluate goals with pt.
  • prioritize therapy for function
  • continue methods to decrease deformity
  • pt. education with rehabilitation team regarding reconstruction option - in preparation for tendon transfers, strengthen donor muscles, achieve full PROM
75
Q

name 4 purposes of orthotics for PNI.

A
  • splint to protect healing nerve or surgical repair
  • splint to prevent deformity
  • splint to facilitate function
  • splint to correct deformity
76
Q

what is a deformity of radial nerve PNI?

A

drop wrist/hand

77
Q

name 4 deficits of radial nerve PNI/drop wrist/hand.

A
  • loss of finger extension
  • loss of wrist extension (high injury)
  • loss of thumb extension
  • decrease in forceful opposition
78
Q

describe 4 aspects of splinting for radial nerve lesions.

A
  • pts. have greater potential for normal use of hand
  • provide radial palsy splint to enhance function
  • forearm splint with outrigger
  • called tenodesis splint sometimes
79
Q

describe management of a LOW ulnar nerve PNI.

A

prevent overstretching of the denervated intrinsic muscles of 4th and 5th fingers.

80
Q

describe management of a HIGH ulnar nerve PNI.

A
  • splinting becomes mandatory as FDP to 4th and 5th fingers returns
  • clawing is more evident
81
Q

what would a strengthening program for PNI begin with?

A

isometric

82
Q

describe a froment’s sign assessment.

A
  • pt. holds a piece of paper while OT tries to grab it out of his/her hands.
  • if finger flexes it’s a positive sign.
83
Q

what does the bar in an ulnar nerve orthotic prevent?

A

hyperextension of MP joint - keeps them slightly flexed.

84
Q

what is a deformity of median nerve PNI?

A

ape hand

85
Q

name 7 deficits of median nerve PNI/ape hand.

A
  • inability to oppose thumb
  • decrease in web space
  • inability to perform 3 jaw chuck
  • decrease in power grasp
  • decrease in FDS (high injury)
  • decrease in FDP index and long fingers (high injury)
  • decrease in pronation (high injury)
86
Q

which contractures are most common in median nerve PNI?

A

adduction contractures of the thumb - addressed by proactive splinting

87
Q

which PNIs are the most devastating and impactful on function regarding sensory loss?

A

median nerve injuries

88
Q
  • affects digits 4 and 5 at rest
  • ulnar nerve lesion at the wrist
  • loss of flexion at MCP joints and loss of extension at IP joints.
  • lumbricals to digits 4 and 5 are paralyzed
A

ulnar claw hand

89
Q
  • affects digits 2 and 3 when attempting to make a fist
  • median nerve is affected when there is a lesion at the wrist or elbow.
  • lumbricals and FDP to digits 2 and 3 are paralyzed.
  • loss of flexion at MCP joint and DIP joints.
  • if pt. is asked to make a fist they will be able to flex digit 4 and 5 but not digits 2 and 3.
A

sign of benediction

90
Q

Name 4 implications for OT practice.

A
  • contractures - pt. should exercise AROM or PROM with the affected extremity when they are not wearing splint.
  • performing ADLs with splints on
  • one-handed techniques (temporarily)
  • providing clear instructions to donning and duration or length of wear.
91
Q

a muscle cannot work on a ___ joint.

A

fused

92
Q

a ____ cannot work on a fused joint.

A

muscle

Ortho Eval (24 decks)

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