Therapy Considerations for the Ulnar Nerve

1. Therapy Considerations for the Ulnar Nerve

2. Innervations of the Ulnar Nerve

3. Sieg & Adams, Illustrated Essentials of Musculoskeletal Anatomy (1996)

4. Etiology High Lesion: Proximal to elbow Recovery of intrinsic function rare due to long distance from site of injury

5. Compression at Guyon’s Canal sportinjuriesandwellnessottawa.blogspot.com

6. Muscle Loss • Low: Intrinsic musculature • PalmarInterossei • Dorsal interossei • 3rd and 4thLumbricals • Adductor Pollicis • Flexor PollicisBrevis (deep head) • Flexor DigitiMinimi • OpponensDigitiMinimi • Abductor DigitiMinimi • High: Intrinsic + Extrinsic musculature • Flexor DigitorumProfundus of Ring and Small • Flexor Carpi Ulnaris

7. Muscle Loss: Presentation • Claw hand • low nerve palsy only • Froment’s Sign • Jeanne’s Sign • Swan Neck • Boutonniere Deformity

8. Functional Loss • Decreased grip strength- often as much as 60-80% • Key Pinch- as much as 70-80% • Relies on the adductor pollicis, 1st dorsal interossei, and flexor pollicisbrevis for stability and strength • Froment’s Sign • Hyperflexion of the thumb IP joint during pinch • Jeanne’s Sign • Hyperextension of the thumb MP joint during pinch Dell, P et al, JHT (2005)

9. Froment’s Sign www.studyblue.com

10. Jeanne’s Sign www.ehealthstar.com

11. Boutonniere and Swan Neck www.merckmanuals.com

12. Sensory Loss • Ulnar ½ of Ring Finger, Small finger, hypothenar eminence, and similar on dorsum of hand • Dorsal sensory branch of the ulnar nerve originates approximately 7 cm proximal to ulnarstyloid www.rch.org.au

13. Pre-Operative Therapy Objectives • Prepare patient, physically & psychologically, for surgery • Enable patient to be as functional as possible prior to surgery

14. Splinting for Function • Objectives: • Reduce MP joint hyperextension due to normal function of the EDC unopposed by the intrinsic flexors • Stability of thumb for key pinch • Hand Based: • Dorsal Knuckle Bender • Figure 8 or Lumbrical Bar • Hand based thumb spica for pinch • Thumb MP stabilizer for Jeanne’s sign • Oval 8 for Froment’s sign

15. Dorsal Knuckle Bender ncmedical.com

16. Figure 8 or Lumbrical bar

17. Hand based thumb spica

18. MP blocking fingers & thumb

19. Thumb MP stabilizer

20. Oval 8 for IP stabilization

21. Splint for function • Forearm Based: if high ulnar nerve lesion may need to stabilize forearm • Ulnar gutter allegromedical.com

22. Splinting to Prevent or Correct Deformity • Objective: • Prevent or reduce PIP joint contractures of ring and small fingers • Prevent or reduce Boutonniere & Swan Neck deformities • Reduce pain in thumb due to imbalance in pinch

23. Serial Casting To reduce PIP contractures prior to surgery www.msdlatinamerica.com

24. Silver Ring Splint For Boutonniere and Swan Neck

25. Functional Adaptations/Modifications • Increase ability to complete tasks with weak pinch • Use of adaptive equipment Elastic shoelaces Adaptive light switch • Compensation • Modified writing position • Adaptive key pinch for car

26. Interventions • Maintain full PROM for involved joints • Manual Muscle Testing • Electrical Stimulation • Persistent pain management/education • Patient Education regarding realistic expectations related to function, timing, and rehab needs

27. Specific Transfers and Indications www.orthobullets.com

28. Tendon Transfers:Thumb Adduction • Use of ECRB or ECRL w/ free tendon graft (usually Palmaris Longus) to restore Adductor Pollicis function • Advantage: • Strong motor component and avoids sacrificing finger flexor • Good excursion • Disadvantage: • Doesn’t reproduce same line of pull Dell, P. JHT (2005); http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html

29. Tendon Transfer: Finger Abduction • Objective: provide more stability to index during pinch than strength • Transfers typically provide 25-50% of normal pinch strength Dell, P. JHT (2005); http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html

30. Tendon Transfer:Reduce clawing effect Dell, P. JHT (2005)

31. Tendon Transfer:Reduce clawing effect Flexor digitorumsuperficialis (FDS) tendon transfers for correction of clawing. The FDS can be sewn to the lateral band (A), to bone (B), or on itself in the Zancolli lasso (C). http://www.msdlatinamerica.com/ebooks/HandSurgery/sid731790.html

32. Post Op Protocol • For Brand procedure: • 3 ½ weeks post-op • Splint: • Volar routing: Dorsal Blocking splint with wrist in 30 degrees flexion, MP 60 degrees flexion, and IP neutral • Dorsal routing: Dorsal Blocking splint with wrist in 30 degrees of extension, MP blocked in 60 degrees of flexion, and IP extended • ROM • AROM w/ in splint 10 minutes every hour • Passive extension to PIP and DIP • Passive flexion-only if tendon inserted into bone; for insertion into lateral bands: no passive flexion until 6 wks due to risk of stretching out transfer • NMES to facilitate excursion • Scar Management Indiana Hand Protocol (2001)

33. Post Op Protocol • 6 weeks post-op • Splint • Reduced to MP block with palmar bar in 45 degrees of flexion to be worn at all times • If PIP extensor lag-continue with dorsal blocking splint • ROM • PROM to MPs, PIPs, and DIP joints • All completed within the restrains of the MP block Indiana Hand Protocol (2001)

34. Post Op Protocol • 7-8 weeks post-op • Dynamic flexion initiated prn • Monitor for PIP extensor lags • 10-12 weeks post-op • MP blocking splint discontinued if hyperextension not present and minimal (<15 degrees) PIP extensor lag Indiana Hand Protocol (2001)

35. Post Op Protocol To ensure good excursion of long flexors, concentration on blocking exercises and use of NMES to restore flexion of FDS and FDP can be helpful Indiana Hand Protocol (2001)

36. Ulnar nerve Transfers • Objective: Restore intrinsic muscle function for pinch strength, power grip, and dexterity • Options • Terminal branch of AIN to deep motor branch of ulnar nerve • Not synergistic but increases pinch/grip strength and decreases clawing • Branches of Posterior Interosseous Nerve (PIN), EDM and ECU branch, to ulnar nerve

37. Post-Operative TherapyNerve Transfer Immobilization • Elbow/Forearm: 7-10 days • Post-op dressing • May change to splint as early as s/p 2-3 days • No further protection after 10 days due to no tension on nerve transfer • If tendon transfer at same time, protocol paradigm shift related to tendon Moore et al, JHT (2014)

38. Precautions Post Operative • Tendon Transfer • Same as for Tendon repair • Nerve Transfer • Risk of increased tension on nerve repair site

39. Post Operative TherapyTendon and/or Nerve Transfer • Edema control • Scar management • Pain management • Range of Motion • Sensory Re-Education • Strengthening • Restore Function

40. Motor Re-education • Objective: To correct recruitment and restoration of muscle balance and decrease compensatory patterns • Motor Re-education • Challenges: • Alterations in motor cortex mapping (i.e. neuro tag smudging) • Muscle imbalances due to weakness associated with dennervation • May persist due to compensatory movement patterns and persistent weakness of reinnervated muscles • Method: • Contract muscle from donor nerve/muscle with new muscle until motor pattern established • The more synergistic the action and based on original motor pattern, the more recruitment and establishment of muscle balance

41. Cortical Re-Mapping • Cortical Re-mapping • Graded motor imaging • Left/Right discrimination • Explicit Motor Imagery • Mirror Therapy • Patient Education

42. Sensory Re-education Vibration-Clapping Stereognosis-Contact particles

43. Sensory Re-Education Light to deep Touch blog.physiotek.com

44. Exercise • ROM • PROM • Place and Hold with visualization • AROM through full range • Opposition exercises • Light object pick-up • Marble cup • 3 poker chips • Strengthening • Graded putty exercises • Button find • Pushing golf tees in putty • Tearing paper

45. Exercise

46. Strengthening Putty Exercises for grip and pinch

48. Bibliography • Cannon, N, et al. Diagnosis and Treatment manual for Physician and Therapists. Upper Extremity Rehabilitation, 4th edition. Indianapolis. 2001. • Davis KD, Taylor KS, Anastakis DJ. Nerve Injury Triggers Changes in the Brain. Neuroscientist. 2011; 17 (4). • Dell PC, Sforzo CR. Ulnar Intrinsic Anatomy and Dysfunction. Journal of Hand Therapy. April-June 2005; 2:198-207. • Hoard AS, Bell-Krotoskie JA, Mathews R. Application of Biomechanics to Tendon Transfers. Journal of Hand Therapy. April-June 1995; 115-123. • Moore AM, Novak CB. Advances in nerve transfer surgery. Journal of Hand Therapy. April-June 2014; 27: 96-105.

49. Bibliography • Moseley GL, Butler DS, Beames TB, Giles TJ. The Graded Motor Imagery Handbook. Adelaide, Australia. Noigroup Publications. 2012. • Sieg & Adams. Illustrated Essentials of Musculoskeletal Anatomy, 3rd Edition. Gainesville, Megabooks, Inc. 1996. • Sultana SS, MacDermid JC, Grewal R, Rath S. The effectiveness of early mobilization after tendon transfers in the hand: A systematic review. Journal of Hand Therapy. October 2013; 26: 1-21. • Wang JHC, Guo Q. Tendon Biomechanics and Mechanobiology-A minireview of basic concepts and recent advancements. Journal of Hand Therapy. April-June 2012; 7: 133-140.