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Radial Nerve Injury Outcomes
296 Plays20 days ago
Josh and Emily discuss the treatment of radial nerve injuries, exploring rehabilitation strategies and expected outcomes. They share insights on recovery timelines, therapy techniques, and factors that influence patient progress.
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Transcript
Introduction and Patient Care Inquiry
00:00:06
Miranda Materi
Hi, I'm Josh McDonald.
00:00:06
Emily Kerr
thanks Hi, I'm Emily Kerr.
00:00:09
Miranda Materi
And we are Hand Therapy Academy. So Emily's joining us again as one of our staff members asking us a couple of questions. So Emily, what question do you have for us today?
00:00:18
Emily Kerr
Yeah, my question for you, Josh, is what are your thoughts on the plan of care for patients um after a humeral fracture that um present with a radial nerve palsy?
Monitoring and Managing Humeral Fractures
00:00:31
Miranda Materi
Yeah, so let's start with the um with a caveat that if you have any patient with a humeral fracture, specifically anything managed conservatively with no ORIF, no hardware, that we need to be super, super careful. And every time I begin and end a session, I need to have them put their hand flat on a surface and do thumb retropulsion to make sure that um that they still have radial nerve motor nerve function.
00:00:53
Miranda Materi
um If at any point they don't, stop what you're doing, send them back to the doctor. um let's talk about the patient where we know they have a radial nerve injury.
Splinting for Radial Nerve Injury
00:01:03
Miranda Materi
Maybe it's from a gunshot wound to the shoulder. Maybe it's from a humeral fracture.
00:01:07
Miranda Materi
Maybe it's from, I had a patient with a, I'll say botched maybe, um distal bicep rupture repair. And basically the radial nerve was just pinned under the hardware. um and And so we started this whole plan, right? So- Emily, someone like that pops onto your doorstep.
00:01:29
Miranda Materi
What's the, what's the first thing? What's the, not first thing. What's, what's your first thoughts when they come in for a session? Like day one, we've got a radial palsy. You're making all the splints.
00:01:40
Miranda Materi
What's your expectation for them moving forwards?
00:01:45
Emily Kerr
I think that's what I struggle with because we do have a fair number of patients that right now, actually, that have had the ORF that come to us, we already know that they have a radial nerve palsy and um You know, I've made them the the splint to help with the wrist extension and digit extension.
Challenges in Early Surgical Intervention
00:02:06
Emily Kerr
um And we're working on range of motion, scar sensitivity stuff, functional strengthening, and even strengthening those tendons for possible tendon transfer.
00:02:18
Emily Kerr
But like at what point... um I guess I feel like the the plan of the length of plan of care seems to be so long um before any intervention is done on the surgeon side of things.
00:02:32
Miranda Materi
Yeah. Yeah. And that's something that I feel like most of the surgeons, PAs, providers are really reluctant to jump in and do anything because who knows, maybe it will spontaneously heal as sometimes does.
00:02:48
Miranda Materi
And we don't want to have done something that you can't reverse that locks us in that says like, oh, we did this big tendon transfer, but we didn't need to, or where we went and do the nerve surgery and all that was needed was this little thing. So it's,
00:02:59
Miranda Materi
We find in our clinics, it's always a wait and see, wait and see, wait and see, wait and see. Every month they go when they're told let's wait because it' it'll take a while. And then every two months and then every three months.
00:03:10
Miranda Materi
And before you know it, we've reached a year. We're burning through visits. We're using up co-pays and they reset deductibles. And the doctor just keeps saying, go back into therapy. But at some point, the muscles are wasting away.
00:03:24
Miranda Materi
So we try to do things like e-stim to let's slow the
Timeline for Spontaneous Recovery
00:03:29
Miranda Materi
wasting. We try to get them a home e-stim unit and say, put this on extensor bundle. let's Let's get as much of that muscle activation as possible so that we slow, if not pause that wasting process.
00:03:40
Miranda Materi
We try to get them functional with things, but the doctor says, you got to keep going to therapy. And I think sometimes the surgeons are at a loss and we are their blank check to write.
00:03:55
Miranda Materi
We are there escape to say like therapy is going to help you because I can't do anything. I don't know anything yet. Go to therapy. Therapy is the default answer for lack of anything else.
00:04:06
Miranda Materi
um An article came out maybe six months ago and they talked about the expected return if you're going to see spontaneous recovery. And it does happen.
00:04:19
Miranda Materi
From the date of injury, you should see a slow but progressive return that ramps up over time so that by the six to eight week mark, you have a noticeable change in ah in ah manual muscle testing grade.
00:04:38
Miranda Materi
based on ah compared to initial eval. So within six to eight weeks, maybe you were zero and now I'm a one. Maybe you were a zero and now I'm a two minus, but i should be so I should see something by six to eight weeks. And if you don't, your chances for spontaneous recovery are really, really low and it's time to go look at options.
Weighing Surgery Against Natural Recovery
00:04:57
Emily Kerr
Um, if you, in your experience, if you have the patient where you've done a progress note, maybe you've done two progress notes. So me get that six to eight week mark and, um, you're noticing everything is pretty much staying the same.
00:05:11
Emily Kerr
Um, what options do you have at that point? If, you know, they, they go back to the doctor and the doctor says, nope, keep going, like keep waiting. But as a therapist, I feel like we kind of know, like it's not going to regenerate. So Mm-hmm.
00:05:27
Miranda Materi
Yeah. um I feel like we recently learned this by talking to one surgeon about some options for a patient of ours. And the the theory about waiting says, if it's going to spontaneously return, we don't want to have done tendon transfers too early.
00:05:42
Miranda Materi
So let's wait until, honestly, they're waiting until the 12-month mark in our area. Sometimes nine months, but they're kicking it down the curb to 12 months. But if that was something that just needed, just needed a decompression on the nerve,
00:05:56
Miranda Materi
or needed ah neurolysis, cleaning up scar tissue around a nerve, or maybe it needed a nerve graft, that nerve surgery option has to be done before nine months.
00:06:09
Miranda Materi
Because if you wait until after nine months, the muscles have so wasted away, there's nothing there for the new nerve, the cleaned nerve, or the improved nerve to actually activate. So it's this two-sided coin. You don't want to do um tendon transfer too early, but you have to send them to someone that says like, well, let's look at the nerve side of this because we're not just sitting dormant and waiting on our front porch to see if muscle spontaneous.
00:06:34
Miranda Materi
Let's look at the nerves. And so I feel like it's about knowing the providers in your area. And if you've got an orthopedic doctor who says, if it doesn't spontaneously return, if not A, then B, we do tendon transfers.
00:06:46
Miranda Materi
Well, let's look at c because there's another option in here. So you have, now we have a list of providers to say, let's send you to this person to say, let's look at the nerves.
00:06:57
Miranda Materi
We had this this patient go for an EMG and they did an EMG on the wrong nerves.
Importance of Accurate Nerve Testing
00:07:01
Emily Kerr
Thank you.
00:07:01
Miranda Materi
They did median and ulnar and said, you look great. And we're reading the EMG saying didn't even do radial nerve and the provider missed it. So we wanted to send her to someone who had the nerve specialty to say, should we do a neurolysis? Should we do nerve grafting, nerve transfers?
00:07:15
Miranda Materi
Should we do something else? so that we don't get to this something to preempt the option B to say you don't need to do a tendon transfer. Nerve transfers are kind of the direction we're headed. But we know by certainly by week 12, it's either going to come back or it's not. And if you have zero, if you are at manual muscle test, zero out of five by three months, it is extremely unlikely that it's going to spontaneously recover at any point after
Therapist and Patient Frustrations
00:07:42
Miranda Materi
that. It's just not going to happen.
00:07:45
Emily Kerr
Yeah, and I feel like as a therapist, sometimes you like going throughout that waiting period um can be a little frustrating because we want the patients to get better. And um with a radial nerve palsy, we see how limiting function-wise that is, especially when it's ah the dominant hand that's affected.
00:08:05
Emily Kerr
And so seeing the patient ah you know two, three times a week um over time can feel... um I don't kind of sad, I guess, in my opinion.
00:08:17
Miranda Materi
Yeah. And, and defeating and the patients feel that too. And it's tough because we want to be encouraging for our patients. You're here to get better. You're not here to tread water. We're not supposed to do maintenance in our notes, right? We're not here to tread water.
00:08:32
Miranda Materi
There's times when we're like, if I'm seeing a patient with maybe Parkinson's or something, I'm trying to slow the progression of things. That's fine. But here it is so hard to not to, to try to stay positive. And, and with that patient knows like this is getting worse.
00:08:47
Miranda Materi
Like I've got nothing. My arm is getting smaller. I can't use, I can't do anything. I need people to do things for me more and more now. That's really tough. It is really hard.
Advocating for Second Opinions and Communication
00:08:56
Miranda Materi
And And so we'll drop them maybe maybe one time a week and say, like, if you feel like there's a functional need, we can jump up to two times a week. But usually we can kind of keep an eye on things. But sometimes the doctors are sending them. You need to go two times a week. And they're like, I'm here for it. So they want to keep coming.
00:09:11
Miranda Materi
We'll do everything we can. But we try to keep it as functional as possible. Get fun. Get creative. Have them use that hand with and without the support and this of the splint as much as they can.
00:09:21
Miranda Materi
Yeah.
00:09:21
Emily Kerr
Yeah, that makes sense.
00:09:22
Emily Kerr
Thanks for sharing.
00:09:23
Miranda Materi
Yeah, yeah. It's a tough diagnosis. And I feel like we don't always have um much power in the dynamic, much say in the dynamic, because it's all resting on the surgeon who's saying, sit and wait.
00:09:35
Miranda Materi
And sometimes the patients only want to listen to the one with the white coat and the stethoscope. And they're saying like, that person knows that's a PA. That's a PA that isn't really sure.
00:09:46
Miranda Materi
And maybe it's even a surgeon who's an orthopedic looking for tendon transfer and trying to hold off on doing that, maybe gently and subtly make that recommendations for a second opinion, like that you should never hesitate to get a second opinion if you want one. There's nothing wrong with a second opinion and any provider who tells you otherwise shouldn't be, like, should be questioned.
00:10:06
Miranda Materi
um But it's hard to suggest that to therapists, or excuse me, to patients sometimes because We have relationship with these doctors and I don't want to undermine them and be the one that says you should go talk to this doctor, but it's in my patient's best interest. That's a possibility. That's and maybe talk to the doctor and say, like, hey, what do you think about sending them to Dr. Larson? Because Dr. Larson does this whole nerve thing on the front end. What do you think about that? And so it can be a way to keep that open conversation.
00:10:30
Emily Kerr
Yeah, that conversation is important for sure.
00:10:32
Miranda Materi
Yeah.
Contact Information for Further Inquiries
00:10:33
Miranda Materi
All right. If you guys have any questions about this or anything else, reach out to us on our email info at hand therapy academy.com or on our social media accounts at a hand therapy academy.