Peripheral nerve injury

Types of lesion - Assessment - Rehablitation

1. Ahmed Shawky Ahmed Shawky
Assistant lecturer of Physical TherapyAssistant lecturer of Physical Therapy
Cairo UniversityCairo University
[email protected][email protected]

2. Peripheral Peripheral
nerve injuriesnerve injuries

4. Structure of a nerveStructure of a nerve
It has an outer covering It has an outer covering
which forms a sheath which forms a sheath
around the nerve, called around the nerve, called
the the epineuriumepineurium. .
Nerve fibers, which are Nerve fibers, which are
axons, organize into axons, organize into
bundles known as bundles known as
fasciclesfascicles with each with each
fascicle surrounded by fascicle surrounded by
the the perineuriumperineurium. .
Between individual Between individual
nerve fibers is an inner nerve fibers is an inner
layer of layer of endoneuriumendoneurium..

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

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

8. Classification of Nerve Classification of Nerve
InjuriesInjuries
myelin myelin axonaxon endoneurium endoneurium perineuriumperineurium epineurium epineurium
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

9. Sunderland`s Sunderland`s
classificationclassificationGrade IGrade I
Same as Seddon's Same as Seddon's neuropraxianeuropraxia. .
Grade IIGrade II
Same as Seddon's Same as Seddon's axonotmesisaxonotmesis. .
Grade IIIGrade III
NeurotmesisNeurotmesis with with preservation of the perineuriumpreservation of the perineurium. .
Grade IVGrade IV
Neurotmesis with Neurotmesis 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.

10. 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 nerve Winging of scapula ---- thoracodorsal nerve
injuryinjury
Pointing index ---- median nerve injuryPointing index ---- median nerve injury

11. Simple screening tests Simple 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 finger Loss of pain at tip of index finger
Radial nerve injury :Radial nerve injury :
Inability to extend thumbInability to extend thumb

12. Incidence of Incidence 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 %

14. Ulnar nerve injuryUlnar nerve injury
Causes : Causes :
General causesGeneral causes : metabolic diseases , collagen : metabolic diseases , collagen
diseases , malignancies , endogenous or diseases , malignancies , endogenous or
exogenous toxins , chemical or mechanical exogenous 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

15. 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 strains Repeated occupational strains
Recurrent subluxation of the nerveRecurrent subluxation of the nerve
Compression by the osteophytes as in rheumatoid Compression by the osteophytes as in rheumatoid
and osteoarthritis and osteoarthritis
Causes in the forearm :Causes in the forearm :
# both bones forearm# both bones forearm
Incised wounds , gunshot wounds and penetrating Incised wounds , gunshot wounds and penetrating
injuries of the forearminjuries of the forearm

16. 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 trauma Blunt trauma
Penetrating injuriesPenetrating injuries
Ulnar nerve injuries gives rise to Ulnar nerve injuries gives rise to claw hand claw hand
deformitydeformity

17. Claw hand deformityClaw hand deformity
It is a deformity It is a deformity
with with
hyperextension of hyperextension of
the MCP joints and the MCP joints and
flexion of the IP flexion of the IP
joints of the fingersjoints of the fingers
( loss of flexon at ( loss of flexon at
MCP and MCP and
extension at IP extension at IP
joints )joints )

18. Clinical features Clinical features
Loss of sensationLoss of sensation along the ulnar along the ulnar
nerve distribution nerve distribution

and and
WastingWasting of the hypothenar muscles , of the hypothenar muscles ,
intrinsic muscles of the hand leading intrinsic muscles of the hand leading
to hollow intermetacarpal spaces on to hollow intermetacarpal spaces on
the dorsum of the handthe dorsum of the hand

19. ..

20. Levels of the lesion Levels of the lesion
HighHigh : above the level of elbow , entire nerve : above the level of elbow , entire nerve
function is lost function is lost

Low :Low :
Below the elbowBelow the elbow at the junction of the middle at the junction of the middle
and lower third of forearm :and lower third of forearm :
Spared Spared : :
- 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 half Sensory : dorsal aspect of hand and one and half
fingersfingers

21. Cont ..Cont ..
Proximal to Guyon`s Proximal to Guyon`s
canalcanal : :
Spared : FDP , FCU and Spared : FDP , FCU and
dorsal sensationdorsal sensation
Lost : same as above + Lost : same as above +
loss of volar sensationloss of volar sensation

22. Cont ..Cont ..
Distal to Guyon`s canalDistal to Guyon`s canal : : - -
Spared : FDP , FCU , HTM , PB, dorsal and Spared : 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 – lumbricals Lum – lumbricals
Its - interosseiIts - interossei

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

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

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

26. Treatment of ulnar nerve Treatment of ulnar nerve
injuryinjury
Unless there is a lot of muscle Unless there is a lot of muscle
wasting, (nonsurgical treatment )wasting, (nonsurgical treatment )
Prevention Prevention
Avoid frequent use of the arm with Avoid frequent use of the arm with
the elbow bent the elbow bent
If you use a computer frequently, If you use a computer frequently,
make sure that your chair is not too make sure that your chair is not too
low. Do not rest the elbow on the low. Do not rest the elbow on the
armrest. armrest.
Avoid putting pressure on the inside Avoid putting pressure on the inside
of the arm (do not drive with the arm of the arm (do not drive with the arm
resting on the open window ). resting on the open window ).
Keep the elbow straight at night Keep the elbow straight at night
when you are sleeping (done by when you are sleeping (done by
wrapping a towel around the straight wrapping a towel around the straight
elbow, wearing an elbow pad elbow, 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

27. Nonsurgical TreatmentNonsurgical Treatment
If symptoms have only If symptoms have only
just started, just started,
Anti – inflammatory Anti – inflammatory
drugs, ibuprofen,( to drugs, ibuprofen,( to
reduce swelling around reduce swelling around
the nerve ). the nerve ).
Steroid (cortisone) Steroid (cortisone)
injections around the injections around the
ulnar nerve are not ulnar nerve are not
generally used because generally used because
there is a risk of damage there is a risk of damage
to the nerve. to the nerve.
Exercises ( prevents arm Exercises ( 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.

28. Surgical TreatmentSurgical Treatment
If the nerve is very compressed; or if there is If the nerve is very compressed; or if there is
muscle wasting muscle wasting
Surgery Surgery : :
Around the elbow and the wrist or both Around the elbow and the wrist or both
More commonly, the nerve is moved from its More commonly, the nerve is moved from its
place behind the elbow to a new place in front of place behind the elbow to a new place in front of
the elbow. This is called an the elbow. This is called an anterior anterior
transpositiontransposition of the ulnar nerve. of the ulnar nerve.
The nerve can be moved : - The nerve can be moved : -
under the skin and fat under 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). ).

29. ..
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.

30. ..
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.

31. Ulnar paradoxUlnar paradox
The higher the lesion of the median and The higher the lesion of the median and
ulnar nerve injury , the less prominent is ulnar nerve injury , the less prominent is
the deformity and vice versa, because in the deformity and vice versa, because in
higher lesions the long finger flexors are higher lesions the long finger flexors are
paralysed .paralysed .
The loss of finger flexion makes the The loss of finger flexion makes the
deformity look less obviusdeformity look less obvius

35. Radial nerve injuryRadial nerve injury
Causes : -Causes : -
General causesGeneral causes : metabolic diseases , collagen : metabolic diseases , collagen
diseases , malignancies , endogenous or diseases , malignancies , endogenous or
exogenous toxins , chemical or mechanical exogenous toxins , chemical or mechanical
trauma , etc.trauma , etc.
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

36. 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 and Between 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

37. 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

38. Levels of lesion Levels 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 , finger Motor : wrist extensor , thumb extensor , finger
extensorextensor
Sensory : dorsum of first web space Sensory : dorsum of first web space

39. Cont ..Cont ..
Low Low
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

40. Clinical features Clinical features
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 muscles Paralysis 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 the wrist drop and finger drop - paralysis of the
extensors of the wrist and digitsextensors of the wrist and digits
weakness of the long thumb abductor and weakness of the long thumb abductor and
extensor musclesextensor muscles

41. Cont .. Cont ..
Sensory lossSensory loss on the dorsum of hand and on 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 and spare 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 extension weakness 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.

42. Fig : - Wrist drop Fig : - Wrist drop
. .

43. Tests Tests
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 between C5,6: 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 side C6,7: 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.

44. Sensation:Sensation:
The cutaneous The cutaneous
branches of the radial branches of the radial
nerve supply the dorsal nerve supply the dorsal
aspect of the forearm aspect of the forearm
from below the elbow from below the elbow
down over the lateral down over the lateral
part of the hand to part of the hand to
include the thumb to the include the thumb to the
interphalangeal joint and interphalangeal joint and
the fingers to the distal the fingers to the distal
interphalangeal joint. interphalangeal joint.

45. Exams and TestsExams and Tests
An examination of the arm, hand, and wrist identify An examination of the arm, hand, and wrist identify
radial nerve dysfunction.radial nerve dysfunction.
Decreased ability to extend the arm at the elbow Decreased 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 muscle Difficulty lifting the wrist or fingers (extensor muscle
weakness) weakness)
Muscle loss (atrophy) in the forearm Muscle loss (atrophy) in the forearm
Weakness of the wrist and finger Weakness of the wrist and finger
Wrist or finger drop Wrist or finger drop
Tests for nerve dysfunctionTests for nerve dysfunction : :
EMG EMG
MRI of the head, neck, and shoulder MRI of the head, neck, and shoulder
Nerve biopsy Nerve biopsy
Nerve conduction tests Nerve conduction tests

46. Treatment Treatment
Closed fracture Closed fracture
CONTROL OF SYMPTOMSCONTROL OF SYMPTOMS
Analgesics ( to control pain neuralgia) Analgesics ( to control pain neuralgia)
Phenytoin, carbamazepine, or tricyclic antidepressants (amitriptyline) to Phenytoin, carbamazepine, or tricyclic antidepressants (amitriptyline) to
reduce stabbing pain reduce stabbing pain
Steroids (prednisone) to reduce swelling Steroids (prednisone) to reduce swelling
Other treatments include:Other treatments include:
Braces, splints, Braces, splints,
Physical therapy to help maintain muscle strength Physical 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

47. Surgery ( open # Surgery ( open #
))
Clean woundClean wound : :
Primary repair , splint , physiotherapy Primary repair , splint , physiotherapy
Contaminated woundContaminated wound : :
Delayed primary repair and secondary Delayed primary repair and secondary
repair repair
Late casesLate cases : :
Tendon transfersTendon transfers
ArthrodesisArthrodesis

48. Splints Splints

49. ComplicationsComplications
Mild to severe deformity of the hand Mild to severe deformity of the hand
Partial or complete loss of feeling in the Partial or complete loss of feeling in the
hand hand
Partial or complete loss of wrist or hand Partial or complete loss of wrist or hand
movement movement
Recurrent injury to the hand Recurrent injury to the hand

50. 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 to Conservative treatment is indicated up to
one yearone year

52. Foot drop Foot drop
Causes Causes
General causesGeneral causes : metabolic diseases , : metabolic diseases ,
collagen diseases , malignancies , endogenous collagen diseases , malignancies , endogenous
or exogenous toxins , chemical or mechanical or exogenous toxins , chemical or mechanical
trauma , etc.trauma , etc.
LocalLocal : :
At the spineAt the spine : :
Spina bifidaSpina bifida
Tumors Tumors
Disc prolapseDisc prolapse

53. 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 gunshot Penetrating injury and gunshot
injuryinjury

54. 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 of Surgical damage during application of
skeletal tractionskeletal traction
Gunshot injuries , incised and penetrating Gunshot injuries , incised and penetrating
injuriesinjuries

55. Levels of lesionLevels of lesion
High lesion ( above knee ) :High lesion ( above knee ) :
Both tibial and common peroneal nerve are Both 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 longus extensor 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 anterior Spared : all the above muscles innervated by anterior
tibial nervetibial nerve
Lost : peroneous longus and brevisLost : peroneous longus and brevis
Sensation : over outer leg and foot Sensation : over outer leg and foot

56. Clinical features Clinical features
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 drop High lesions ------total foot drop
Low lesions ------ incomplete foot dropLow lesions ------ incomplete foot drop

57. Low lesions Low lesions
Type 1 : Type 1 :
Dorsiflexion and inversion is not possible Dorsiflexion 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 foot Cannot evert but can dorsiflex and invert the foot
Wasting of the outer half of the leg Wasting 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 .

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

59. Treatment Treatment
Different types of braces Different 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 that Two standard motions that
occur at the ankle joint – occur at the ankle joint –
“dorsiflexion” and “dorsiflexion” and
“plantarflexion”.“plantarflexion”.
 Plantarflexion (toes point Plantarflexion (toes point
downward ). downward ).
Dorsiflexion ( foot points Dorsiflexion ( foot points
upward ). upward ).
Dropfoot ( partial or Dropfoot ( partial or
complete weakness of the complete weakness of the
muscles that dorsiflex the muscles that dorsiflex the
foot at the ankle joint ). foot at the ankle joint ).

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

61. Short Leg AFO with Fixed Short Leg AFO with Fixed
Hinge Hinge (doesn’t flex at (doesn’t flex at
ankle joint) ankle joint)

62. Dorsiflexion Assist AFO Dorsiflexion Assist AFO
(dorsiflex the ankle)(dorsiflex the ankle) ::

63. Plantarflexion Stop AFO:Plantarflexion Stop AFO:

64. Solid AFO:Solid AFO:
(stops plantarflexion and (stops plantarflexion and
also stops or limits also stops or limits
dorsiflexion). dorsiflexion).

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

66. Brachical plexus Brachical plexus
injuriesinjuries

67. Causes Causes
Closed injuryClosed injury : :
Due to Due to birthbirth or or
Due to Due to bikebike trauma trauma
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

68. 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 of Presence 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 )

69. Horner`s syndromeHorner`s syndrome
Remember ( 5 P`s ) : -Remember ( 5 P`s ) : -
Ptosis of the eyelidPtosis of the eyelid
Pupils which are small Pupils which are small
and constrictedand constricted
Protrusion of the eyeball Protrusion of the eyeball
which is slightwhich is slight
Pain even at restPain even at rest
Poor prognosisPoor prognosis

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

71. Investigation Investigation
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

72. Physical Therapy Physical Therapy
InterventionIntervention

1 . Splinting 1 . Splinting
A-Aeroplane splintA-Aeroplane splint

73. 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 correct hyperextension of MCPjoints and correct
flexion in IPJ joints.flexion in IPJ joints.

74. 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 are Mild electrical impulses are
transmitted through the skin transmitted through the skin
Cause body to release endorphins, Cause body to release endorphins,
the body’s own pain-relieving the body’s own pain-relieving
hormones. hormones.
These 'positive signals' to the brain These 'positive signals' to the brain
block the slower-moving pain block the slower-moving pain
messages. messages.

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

76. E-Hot pack & Infrared : to maintain skin visibilty E-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 retraining 3-Motor retraining
A- Passive movement for the affected joints.A- Passive movement for the affected joints.
B-Facilitation for paralysed muscles by B-Facilitation for paralysed muscles by
*Tapping on the muscles.*Tapping on the muscles.
*Quick stretch. *Quick stretch.

77. * 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 distal proximal 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.

78. C- Electrical stimulation : Faradic C- Electrical stimulation : Faradic
stimulation, used for muscle re-education stimulation, used for muscle re-education
,nerve stimulation .,nerve stimulation .
4- Sensory re education : 4- Sensory re education :
A- Protection of desensitized area to A- Protection of desensitized area to
avoid burn & injuries.avoid burn & injuries.
B-Brushing skin with different materials B-Brushing skin with different materials
as :cotton –silk ….as :cotton –silk ….

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

80. Surgical measures Surgical measures
Types of surgeryTypes of surgery
Nerve graft :Nerve graft : - -
the damaged part the damaged part
of the brachial of the brachial
plexus is removed plexus is removed
and replaced with and replaced with
sections of nerves sections of nerves
cut from other cut from other
parts of bodyparts of body

81. Nerve transfersNerve transfers
Done in the Done in the
most serious most serious
types of types of
brachial plexus brachial plexus
injuries, called injuries, called
avulsions, when avulsions, when
the nerve root the nerve root
has been torn has been torn
out of the spinal out of the spinal
cord. cord.

82. Muscle transfersMuscle transfers
Needed if Needed if
arm muscles arm muscles
have have
atrophied atrophied
from lack of from lack of
use. use.

83. ERBS PALSYERBS PALSY

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

85. Clinical features Clinical features
At the shoulderAt the shoulder : :
Loss of shoulder abduction and external rotation ( due Loss of shoulder abduction and external rotation ( due
to paralysis of the deltoid , supra and infraspinatus to 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 of Loss 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 the May 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 .

86. Policeman or Waiter`s Policeman or Waiter`s
tip tip
Shoulder --- Shoulder ---
internally rotated internally rotated
Elbow ----- extensionElbow ----- extension
Forearm --- pronatedForearm --- pronated
Wrist ------ flexion Wrist ------ flexion

87. Treatment Treatment
1 . Splinting 1 . 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 .

88. With the baby, start With the baby, start
range-of-motion range-of-motion
exercises 2 times a day. exercises 2 times a day.

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

90. Cont ..Cont ..

91. Cont ..Cont ..

93. THANK YOUTHANK YOU