Peripheral nerve injury

Ahmed ShawkyAhmed Shawky
Assistant lecturer of Physical TherapyAssistant lecturer of Physical Therapy
Cairo UniversityCairo University
Dr.shawky_2011@yahoo.comDr.shawky_2011@yahoo.com

PeripheralPeripheral
nerve injuriesnerve injuries

Structure of a nerveStructure of a nerve
 It has an outer coveringIt has an outer covering
which forms a sheathwhich forms a sheath
around the nerve, calledaround the nerve, called
thethe epineuriumepineurium..
 Nerve fibers, which areNerve fibers, which are
axons, organize intoaxons, organize into
bundles known asbundles known as
fasciclesfascicles with eachwith each
fascicle surrounded byfascicle surrounded by
thethe perineuriumperineurium..
 Between individualBetween individual
nerve fibers is an innernerve fibers is an inner
layer oflayer of endoneuriumendoneurium..

Peripheral nerve injuryPeripheral nerve injury
Dermotome :Dermotome :
 is an area of skin supplied by a singleis an area of skin supplied by a single
spinal rootspinal root
Myotome :Myotome :
 Represents a muscle unit supplied by aRepresents a muscle unit supplied by a
single spinal rootsingle spinal root

Seddon's classificationSeddon's classification
NeurapraxiaNeurapraxia ---- temporary paralysistemporary paralysis of a nerveof a nerve
caused by lack of blood flow or by pressure oncaused by lack of blood flow or by pressure on
the affected nerve withthe affected nerve with no lossno loss of structuralof structural
continuity.continuity.
AxonotmesisAxonotmesis ––
 neural tube intact, butneural 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 likelyInjuries are likely permanent without repairpermanent without repair..

Classification of NerveClassification of Nerve
InjuriesInjuries
myelinmyelin axonaxon endoneuriumendoneurium perineuriumperineurium epineuriumepineurium
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`sSunderland`s
classificationclassification Grade IGrade I
 Same as Seddon'sSame as Seddon's neuropraxianeuropraxia..
 Grade IIGrade II
 Same as Seddon'sSame as Seddon's axonotmesisaxonotmesis..
 Grade IIIGrade III
 NeurotmesisNeurotmesis withwith preservation of the perineuriumpreservation of the perineurium..
 Grade IVGrade IV
 Neurotmesis withNeurotmesis 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 nerveWinging of scapula ---- thoracodorsal nerve
injuryinjury
 Pointing index ---- median nerve injuryPointing index ---- median nerve injury

Simple screening testsSimple 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 fingerLoss of pain at tip of index finger
 Radial nerve injury :Radial nerve injury :
 Inability to extend thumbInability to extend thumb

Incidence ofIncidence of
Peripheral nerve injuryPeripheral nerve 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 ordiseases , malignancies , endogenous or
exogenous toxins , chemical or mechanicalexogenous 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 strainsRepeated occupational strains
 Recurrent subluxation of the nerveRecurrent subluxation of the nerve
 Compression by the osteophytes as in rheumatoidCompression by the osteophytes as in rheumatoid
and osteoarthritisand osteoarthritis
Causes in the forearm :Causes in the forearm :
 # both bones forearm# both bones forearm
 Incised wounds , gunshot wounds and penetratingIncised 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 traumaBlunt trauma
 Penetrating injuriesPenetrating injuries
 Ulnar nerve injuries gives rise toUlnar nerve injuries gives rise to claw handclaw hand
deformitydeformity

Claw hand deformityClaw hand deformity
 It is a deformityIt is a deformity
withwith
hyperextension ofhyperextension of
the MCP joints andthe MCP joints and
flexion of the IPflexion of the IP
joints of the fingersjoints of the fingers
( loss of flexon at( loss of flexon at
MCP andMCP and
extension at IPextension at IP
joints )

Clinical featuresClinical features
 Loss of sensationLoss of sensation along the ulnaralong the ulnar
nerve distributionnerve distribution
andand
 WastingWasting of the hypothenar muscles ,of the hypothenar muscles ,
intrinsic muscles of the hand leadingintrinsic muscles of the hand leading
to hollow intermetacarpal spaces onto hollow intermetacarpal spaces on
the dorsum of the handthe dorsum of the hand

Levels of the lesionLevels of the lesion
HighHigh : above the level of elbow , entire nerve: above the level of elbow , entire nerve
function is lostfunction is lost
Low :Low :
Below the elbowBelow the elbow at the junction of the middleat the junction of the middle
and lower third of forearm :and lower third of forearm :
SparedSpared ::
- 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 halfSensory : dorsal aspect of hand and one and half
fingersfingers

Cont ..Cont ..
Proximal to Guyon`sProximal to Guyon`s
canalcanal ::
 Spared : FDP , FCU andSpared : 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 andSpared : 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 – lumbricalsLum – lumbricals
 Its - interosseiIts - interossei

Clinical tests :Clinical tests :
 Froment's sign. When theFroment's sign. When the
patient attempts to pinch withpatient attempts to pinch with
the thumb and index finger, thethe thumb and index finger, the
long flexor of the thumb is usedlong flexor of the thumb is used
to substitute for the thumbto substitute for the thumb
adductor, resulting in flexion ofadductor, resulting in flexion of
the thumb at the interphalangealthe thumb at the interphalangeal
joint.joint.
 This characteristic appearanceThis characteristic appearance
is present in this patient's leftis present in this patient's left
hand, caused by an ulnar nervehand, caused by an ulnar nerve
lesion at the elbowlesion at the elbow

Card testCard test
 Inability to hold a card or paper in betweenInability to hold a card or paper in between
fingers due to loss of adduction by thefingers due to loss of adduction by the
palmar interosseipalmar interossei
Pen testPen test
 Unable to touch the pen due to the loss ofUnable to touch the pen due to the loss of
action of abductor pollicic brevisaction of abductor pollicic brevis

Egawa test ( median nerveEgawa test ( median nerve
injury )injury ) With palm flat on the table the patient is asked toWith palm flat on the table the patient is asked to
move the middle finger sideways( test for themove 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 , indexWhen both the hands are clapsed together , index
and middle fingers , fail to flex due to the loss ofand middle fingers , fail to flex due to the loss of
action of long finger flexors of the index andaction of long finger flexors of the index and
middle fingers which are supplied by the medianmiddle fingers which are supplied by the median
nerve .nerve .

Treatment of ulnar nerveTreatment of ulnar nerve
injuryinjury Unless there is a lot of muscleUnless there is a lot of muscle
wasting, (nonsurgical treatment )wasting, (nonsurgical treatment )
PreventionPrevention
 Avoid frequent use of the arm withAvoid frequent use of the arm with
the elbow bentthe elbow bent
 If you use a computer frequently,If you use a computer frequently,
make sure that your chair is not toomake sure that your chair is not too
low. Do not rest the elbow on thelow. Do not rest the elbow on the
armrest.armrest.
 Avoid putting pressure on the insideAvoid putting pressure on the inside
of the arm (do not drive with the armof the arm (do not drive with the arm
resting on the open window ).resting on the open window ).
 Keep the elbow straight at nightKeep the elbow straight at night
when you are sleeping (done bywhen you are sleeping (done by
wrapping a towel around the straightwrapping a towel around the straight
elbow, wearing an elbow padelbow, 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 onlyIf symptoms have only
just started,just started,
 Anti – inflammatoryAnti – inflammatory
drugs, ibuprofen,( todrugs, ibuprofen,( to
reduce swelling aroundreduce swelling around
the nerve ).the nerve ).
 Steroid (cortisone)Steroid (cortisone)
injections around theinjections around the
ulnar nerve are notulnar nerve are not
generally used becausegenerally used because
there is a risk of damagethere is a risk of damage
to the nerve.to the nerve.
 Exercises ( prevents armExercises ( 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 isIf the nerve is very compressed; or if there is
muscle wastingmuscle wasting
SurgerySurgery ::
 Around the elbow and the wrist or bothAround the elbow and the wrist or both
 More commonly, the nerve is moved from itsMore commonly, the nerve is moved from its
place behind the elbow to a new place in front ofplace behind the elbow to a new place in front of
the elbow. This is called anthe elbow. This is called an anterioranterior
transpositiontransposition of the ulnar nerve.of the ulnar nerve.
The nerve can be moved : -The nerve can be moved : -
 under the skin and fatunder the skin and fat (subcutaneous(subcutaneous
transpositiontransposition),),
 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 andThe higher the lesion of the median and
ulnar nerve injury , the less prominent isulnar nerve injury , the less prominent is
the deformity and vice versa, because inthe deformity and vice versa, because in
higher lesions the long finger flexors arehigher lesions the long finger flexors are
paralysed .paralysed .
 The loss of finger flexion makes theThe 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 ordiseases , malignancies , endogenous or
exogenous toxins , chemical or mechanicalexogenous toxins , chemical or mechanical
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 andBetween 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 lesionLevels 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 , fingerMotor : wrist extensor , thumb extensor , finger
extensorextensor
 Sensory : dorsum of first web spaceSensory : dorsum of first web space

Cont ..Cont ..
LowLow
 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

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 musclesParalysis 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 thewrist drop and finger drop - paralysis of the
extensors of the wrist and digitsextensors of the wrist and digits
 weakness of the long thumb abductor andweakness of the long thumb abductor and
extensor musclesextensor muscles

Cont ..Cont ..
 Sensory lossSensory loss on the dorsum of hand andon 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 andspare 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 extensionweakness 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 dropFig : - Wrist drop
 ..

TestsTests 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 betweenC5,6: 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 sideC6,7: 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 cutaneousThe cutaneous
branches of the radialbranches of the radial
nerve supply the dorsalnerve supply the dorsal
aspect of the forearmaspect of the forearm
from below the elbowfrom below the elbow
down over the lateraldown over the lateral
part of the hand topart of the hand to
include the thumb to theinclude the thumb to the
interphalangeal joint andinterphalangeal joint and
the fingers to the distalthe fingers to the distal
interphalangeal joint.interphalangeal joint.

Exams and TestsExams and Tests
An examination of the arm, hand, and wrist identifyAn examination of the arm, hand, and wrist identify
radial nerve dysfunction.radial nerve dysfunction.
 Decreased ability to extend the arm at the elbowDecreased 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 muscleDifficulty lifting the wrist or fingers (extensor muscle
weakness)weakness)
 Muscle loss (atrophy) in the forearmMuscle loss (atrophy) in the forearm
 Weakness of the wrist and fingerWeakness of the wrist and finger
 Wrist or finger dropWrist or finger drop
Tests for nerve dysfunctionTests for nerve dysfunction ::
 EMGEMG
 MRI of the head, neck, and shoulderMRI of the head, neck, and shoulder
 Nerve biopsyNerve biopsy
 Nerve conduction testsNerve conduction tests

TreatmentTreatment
Closed fractureClosed fracture
CONTROL OF SYMPTOMSCONTROL OF SYMPTOMS
 Analgesics ( to control pain neuralgia)Analgesics ( to control pain neuralgia)
 Phenytoin, carbamazepine, or tricyclic antidepressants (amitriptyline) toPhenytoin, carbamazepine, or tricyclic antidepressants (amitriptyline) to
reduce stabbing painreduce stabbing pain
 Steroids (prednisone) to reduce swellingSteroids (prednisone) to reduce swelling
Other treatments include:Other treatments include:
 Braces, splints,Braces, splints,
 Physical therapy to help maintain muscle strengthPhysical 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 , physiotherapyPrimary repair , splint , physiotherapy
Contaminated woundContaminated wound ::
Delayed primary repair and secondaryDelayed primary repair and secondary
repairrepair
Late casesLate cases ::
 Tendon transfersTendon transfers
 ArthrodesisArthrodesis

ComplicationsComplications
 Mild to severe deformity of the handMild to severe deformity of the hand
 Partial or complete loss of feeling in thePartial or complete loss of feeling in the
handhand
 Partial or complete loss of wrist or handPartial or complete loss of wrist or hand
movementmovement
 Recurrent injury to the handRecurrent 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 toConservative treatment is indicated up to
one yearone year

Foot dropFoot drop
CausesCauses
 General causesGeneral causes : metabolic diseases ,: metabolic diseases ,
collagen diseases , malignancies , endogenouscollagen diseases , malignancies , endogenous
or exogenous toxins , chemical or mechanicalor exogenous toxins , chemical or mechanical
LocalLocal ::
At the spineAt the spine ::
 Spina bifidaSpina bifida
 TumorsTumors
 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 gunshotPenetrating 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 ofSurgical damage during application of
skeletal tractionskeletal traction
 Gunshot injuries , incised and penetratingGunshot injuries , incised and penetrating
injuriesinjuries

Levels of lesionLevels of lesion
High lesion ( above knee ) :High lesion ( above knee ) :
 Both tibial and common peroneal nerve areBoth 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 longusextensor 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 anteriorSpared : all the above muscles innervated by anterior
tibial nervetibial nerve
 Lost : peroneous longus and brevisLost : peroneous longus and brevis
 Sensation : over outer leg and footSensation : over outer leg and foot

Foot drop :Foot drop :
CompleteComplete ( sciatic or lateral popliteal( sciatic or lateral popliteal
nerve injury )nerve injury )
IncompleteIncomplete ( superficial or deep( superficial or deep
peroneal nerve )peroneal nerve )
 High lesions ------total foot dropHigh lesions ------total foot drop
 Low lesions ------ incomplete foot dropLow lesions ------ incomplete foot drop

Low lesionsLow lesions
Type 1 :Type 1 :
 Dorsiflexion and inversion is not possibleDorsiflexion 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 footCannot evert but can dorsiflex and invert the foot
 Wasting of the outer half of the legWasting 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 .

TreatmentTreatment
 Braces or splints.Braces or splints.
 Physical therapy.Physical therapy.
 Nerve stimulation :Nerve stimulation :
 In some cases, a small, battery-operated electricalIn 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 )

TreatmentTreatment
 Different types of bracesDifferent 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 thatTwo standard motions that
occur at the ankle joint –occur at the ankle joint –
“dorsiflexion” and“dorsiflexion” and
“plantarflexion”.“plantarflexion”.
 Plantarflexion (toes pointPlantarflexion (toes point
downward ).downward ).
 Dorsiflexion ( foot pointsDorsiflexion ( foot points
upward ).upward ).
 Dropfoot ( partial orDropfoot ( partial or
complete weakness of thecomplete weakness of the
muscles that dorsiflex themuscles that dorsiflex the
foot at the ankle joint ).foot at the ankle joint ).

Types of AFOsTypes of AFOs
 Short leg fixed AFOsShort leg fixed AFOs
 Dorsiflexion assist short leg AFOsDorsiflexion assist short leg AFOs
 Solid ankle AFO (with or without posteriorSolid ankle AFO (with or without posterior
stop). Also available with dorsiflexion assist.stop). Also available with dorsiflexion assist.
 Full leg posterior leaf spring AFOFull leg posterior leaf spring AFO

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

Dorsiflexion Assist AFODorsiflexion 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 limitsalso stops or limits
dorsiflexion).dorsiflexion).

Posterior Leaf Spring AFOPosterior Leaf Spring AFO
 Patients who have instability of the kneePatients who have instability of the knee
along with their dropfoot.along with their dropfoot.

Brachical plexusBrachical plexus
injuriesinjuries

CausesCauses
Closed injuryClosed injury ::
 Due toDue to birthbirth oror
 Due toDue to bikebike traumatrauma
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 ofPresence 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 smallPupils which are small
and constrictedand constricted
 Protrusion of the eyeballProtrusion of the eyeball
which is slightwhich is slight
 Pain even at restPain even at rest
 Poor prognosisPoor prognosis

Assessment ofAssessment of
brachial plexus injurybrachial plexus injury
In preganglionic lesionIn preganglionic lesion
 Horner`s syndromeHorner`s syndrome
---present---present
 Unable to elevateUnable to elevate
scapulascapula
In postganglionic lesionIn postganglionic lesion
 Horner`s syndromeHorner`s syndrome
----absent----absent
 Able to elevate scapulaAble to elevate scapula
 Tinel`s sign --- presentTinel`s sign --- present
in the later stagesin the later stages

InvestigationInvestigation
 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 TherapyPhysical Therapy
InterventionIntervention
1 . Splinting1 . 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 correcthyperextension 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 areMild electrical impulses are
transmitted through the skintransmitted through the skin
 Cause body to release endorphins,Cause body to release endorphins,
the body’s own pain-relievingthe body’s own pain-relieving
hormones.hormones.
 These 'positive signals' to the brainThese 'positive signals' to the brain
block the slower-moving painblock the slower-moving pain
messages.messages.

 C- Continuous Ultrasound : for proximalC- Continuous Ultrasound : for proximal
affection.(5 min)affection.(5 min)
 D- Deep cold laser (Infra red laser)(3D- Deep cold laser (Infra red laser)(3
min)min)
 B- Interferntial current.B- Interferntial current.

E-Hot pack & Infrared : to maintain skin visibiltyE-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 retraining3-Motor retraining
A- Passive movement for the affected joints.A- Passive movement for the affected joints.
B-Facilitation for paralysed muscles byB-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 distalproximal 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 : FaradicC- Electrical stimulation : Faradic
stimulation, used for muscle re-educationstimulation, used for muscle re-education
,nerve stimulation .,nerve stimulation .
 4- Sensory re education :4- Sensory re education :
 A- Protection of desensitized area toA- Protection of desensitized area to
avoid burn & injuries.avoid burn & injuries.
 B-Brushing skin with different materialsB-Brushing skin with different materials
as :cotton –silk ….as :cotton –silk ….

 C-Occlouded vision : ask to recognizeC-Occlouded vision : ask to recognize
different objects ( sharp – smooth )different objects ( sharp – smooth )
 D- Occlouded vision : ask to recognizeD- Occlouded vision : ask to recognize
quantity of material by touch.quantity of material by touch.

Surgical measuresSurgical measures
 Types of surgeryTypes of surgery
Nerve graft :Nerve graft : --
 the damaged partthe damaged part
of the brachialof the brachial
plexus is removedplexus is removed
and replaced withand replaced with
sections of nervessections of nerves
cut from othercut from other
parts of bodyparts of body

Nerve transfersNerve transfers
 Done in theDone in the
most seriousmost serious
types oftypes of
brachial plexusbrachial plexus
injuries, calledinjuries, called
avulsions, whenavulsions, when
the nerve rootthe nerve root
has been tornhas been torn
out of the spinalout of the spinal
cord.cord.

Muscle transfersMuscle transfers
 Needed ifNeeded if
arm musclesarm muscles
havehave
atrophiedatrophied
from lack offrom lack of
use.use.

Erb's palsyErb's palsy
 paralysisparalysis of theof the musclesmuscles in ain a
baby's arm, caused by injurybaby's arm, caused by injury
of theof the nervesnerves in the shoulderin the shoulder
at birth (during delivery).at birth (during delivery).
 The baby lies with one armThe baby lies with one arm
and hand twisted backwardand hand twisted backward
and does not move the armand does not move the arm
as much as the other.as much as the other.
 If the full range of motion ofIf the full range of motion of
the arm is not kept throughthe arm is not kept through
regular exercise,regular exercise,
contracturescontractures will develop .will develop .

At the shoulderAt the shoulder ::
 Loss of shoulder abduction and external rotation ( dueLoss of shoulder abduction and external rotation ( due
to paralysis of the deltoid , supra and infraspinatusto 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 ofLoss 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 theMay 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`sPoliceman or Waiter`s
tiptip
 Shoulder ---Shoulder ---
internally rotatedinternally rotated
 Elbow ----- extensionElbow ----- extension
 Forearm --- pronatedForearm --- pronated
 Wrist ------ flexionWrist ------ flexion

TreatmentTreatment
1 . Splinting1 . 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, startWith the baby, start
range-of-motionrange-of-motion
exercises 2 times a day.exercises 2 times a day.

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

Peripheral nerve injury

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