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Untangling the Research: Radial Nerve Innervation, Wrist Salvage Outcomes, and Other Common Controversies
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Join Miranda Materi and Josh, both Certified Hand Therapists with more than 10 years of experience teaching hand therapy concepts and over 50 years of combined clinical expertise, as they unpack some of the most commonly conflicting topics in the literature. This session explores the debated order of radial nerve muscle innervation, expected outcomes following wrist salvage procedures, and other frequently misunderstood areas of upper extremity rehabilitation.
Through evidence-based discussion and practical clinical insights, Miranda and Josh bridge the gap between research and real-world application—helping therapists make informed, confident treatment decisions for complex upper extremity cases.
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Transcript
Introduction to Hosts and Focus
00:00:05
josh MacDonald
Hi, I'm Josh McDonald.
00:00:06
Miranda Materi
And am I'm Miranda Materi, and we are Ham Therapy Academy. Almost forgot who I was. Yes.
00:00:11
josh MacDonald
Right? It's been a long day for you.
00:00:13
Miranda Materi
yeah
00:00:14
josh MacDonald
We are going to talk today about things that evidence and research kind of disagree about. Depends on what article you read, you may find support for what you like or support for something you disagree with.
Radial Nerve Innervation
00:00:25
josh MacDonald
So let's go through a couple of topics. Miranda, what's one that we you think we get asked the most questions on?
00:00:30
Miranda Materi
Um, I would have to say because Josh and I do a CHT prep group where we do a lot of teaching. So everybody wants to know like, what's that exact answer for the exam. And probably the most common one I think we get is order of innervation for radial nerve, the muscular innervation. What do you think it is? do you think it's that?
00:00:50
josh MacDonald
I would say that's probably it. That's the one that's the starting, because anatomy is the start of everything we do. I feel like that's one that we we get asked the question most when people start and then they're trying to match up. pictures and images from every different source. And what we found when we did a bunch of research was we found a specific open source article that's listed on our our order of innovation that says, yeah, there's so much anatomical variation among people that you can't come up with one consistent, this is what it is.
00:01:19
josh MacDonald
um But here's the article said, here's what we find the most of probability wise. So that would, yeah, that's probably the one we get to ask the most.
00:01:26
Miranda Materi
Yeah, so it's, I think it's knowing that there's variability, right? Like most things, there's variability, but with the radial nerve, especially out of all the peripheral nerves, I think the radial nerve has the most variability.
00:01:30
josh MacDonald
Mm-hmm.
00:01:36
Miranda Materi
So knowing that, and then knowing what the variability is, right? I think if you know that, then you're golden.
00:01:42
josh MacDonald
Yeah. Yeah. And so knowing that the order of um ECU and EDC can vary, knowing the order of like, does the PIN split off before or after ECRL and before after ECRB? And so there's variations in there. And sometimes you've got anatomical van variations that we don't even really track. So, yeah, it can be pretty widely varied.
00:02:04
Miranda Materi
Right. So what do you tell? So when people ask, I think we both kind of have what we tell people, what do you say? Like they're all they all want what's the right answer? What am I going to be quizzed on? Or what do I need to know for the test? What do you say?
00:02:17
josh MacDonald
I usually say no patterns and bulks within that nerve. So know that like EIP is last in the line, almost always last before that are the thumb muscles.
00:02:28
josh MacDonald
And so kind of working upstream. And then you've got like ECU, EDC, EDM, like those are kind of in a little jumble and then ECRL, ECRB and supinator at the top, like top down from those.
00:02:39
josh MacDonald
So kind of know those patterns. And then there can be some variations. But like for the test, for example, they're more going to ask you like patterns, like which one's high, which one's low. And they're going to have the wrong peripheral nervous at muscle from peripheral nervous going to be one of option. So you rule that one out. So, yeah, there's knowing the patterns helps.
00:02:57
Miranda Materi
Yeah, I agree.
00:02:58
josh MacDonald
Yeah.
Wrist Salvage Procedures
00:02:59
josh MacDonald
Yeah.
00:02:59
Miranda Materi
Really agree.
00:03:00
josh MacDonald
Another one we get a lot of questions about, and we're actually just working on some of this stuff right now to put together ah like a a document with making it make sense, is the expected outcomes after varying wrist salvage procedures. So range of motion, strength, what do you expect after a proximal carpectomy or an STT fusion or ah total wrist arthrodesis? Like what do you expect for those outcomes?
00:03:23
josh MacDonald
The research is kind of all over the place.
00:03:26
Miranda Materi
It is, and I think it's so interesting that but that is a potential exam question, right? We're not saying don't know that because it's not going to be a question on the exam because it very well could be. But then which source do you cite, right? Like, how do which one do you memorize?
00:03:41
Miranda Materi
And my suggestion is you memorize, you know, the most common ones and know, like, okay, this source says it's 75%, but the other source says it's 85%. I would know that information.
00:03:53
josh MacDonald
Yeah. Yeah. and know that it's somewhere in that 75 to 85 range. It's not 35, it's not 50 and kind of like, like FIM numbers. Okay.
00:04:04
josh MacDonald
It's in the top quarter or it's in the bottom quarter, somewhere in the middle, kind of know the ballpark range that each of these are in and know like a PRC is more sturdy than, um, uh, than maybe an STT fusion.
00:04:06
Miranda Materi
Right.
00:04:17
josh MacDonald
And so they can handle more, more strength ah load through it so they're going to be a little bit higher on the strength load, maybe not as high as an arthrodesis of the wrist. So the rationale of which ones are sturdier and which ones aren't an arthrodesis is going to have no range of motion afterwards because we locked it in like those kinds of things.
00:04:31
Miranda Materi
right and Yeah, total risk fusion is always going have nothing. And also know, like I think it's important to know for the exam, right? That's what we teach a lot is what to know for the exam. But then know for your patient care too, right? Know that they might not fall within that range, especially when the research data doesn't have large volumes of patients.
00:04:49
Miranda Materi
Like it's not like tons of people are getting risk salvage procedures. So we just don't have the volume that we need to really track it. So we can tell them the expected range, but also letting them know that there's a high variability within that.
00:05:02
Miranda Materi
Thank you.
00:05:03
josh MacDonald
Yeah. Yeah. And letting the patient know. And if the surgeon has comes with like, Hey, how are they doing? Like, Hey, they're getting close to this ballpark range. So we're all like, Hey, this is maybe good outcomes.
00:05:15
josh MacDonald
Maybe we're on a hundred percent, but we're still having good outcomes and making sure that we're all on the same page of what's to be expected.
00:05:20
Miranda Materi
Right. And then I think one thing that's really important to note, and this is for new grads and for patients, that you want a stable wrist over a mobile wrist. So we don't need tons of range of motion at the wrist to be functional, right? We want it to be more stable because these salvage procedures are often done to...
00:05:38
Miranda Materi
limit um pain, right? So they're usually pain, pain procedures. So knowing, okay, we got rid your pain. That's goal. Number one goal. Number two is to be functional, but there's never a goal to have full range of motion. That should never be a goal after these procedures.
00:05:52
josh MacDonald
Yeah. and and patients should go into the surgery knowing maybe my goal is to get back to work, but if it's recreational weightlifting, if it's mountain biking, like that's going to be a continued limitation because this procedure is just not intended to be, to bear super heavy loads. it's just not what it's there for.
00:06:11
Miranda Materi
Right, definitely.
00:06:12
josh MacDonald
Yeah.
Home Exercise vs Outpatient Therapy
00:06:13
josh MacDonald
um How about distal radius fracture therapy planning? What are your thoughts on the, what the research says on that one?
00:06:21
Miranda Materi
Yeah, so this is interesting. And I've had surgeons say this to me before, and I've been in hand therapy groups where we've talked about this, but there was a study done um comparing using hand therapy or using outpatient therapy compared to home exercise patients.
00:06:23
josh MacDonald
Thank you.
00:06:35
Miranda Materi
And this was after plating of a distal radius fraction they compared. And they said, well, they had the exact same outcomes. So therapy was comparable to a home exercise program, um which I thought was interesting. So sometimes a lot of surgeons will say, well,
00:06:50
Miranda Materi
Research shows that a home exercise program is just as good. Why am I sending my patient to hand therapy or to outpatient therapy? um So that's one that I've gotten and had the discussion with physicians about.
00:07:02
josh MacDonald
Yeah, yeah. um We actually just did a rapid review on that maybe four months ago or something or such um that we had a student do ah a journal article review on one of those studies and they're done periodically.
00:07:14
josh MacDonald
And we went through and looked at the research on it. And on one hand, I think, well, yeah, if you're 25 and you're healthy and active, you're going to heal well, you immobilize for a while, maybe you don't need a whole bunch of therapy. But the study itself had some weaknesses. This particular study, when we look at like how that was structured,
00:07:31
josh MacDonald
They said the patients who were just doing the home program, they came in for weekly confirmations that they were doing their home program accurately and reminders of it. Well, that sounds kind of like a therapy session.
00:07:42
Miranda Materi
Yeah, that does.
00:07:42
josh MacDonald
and they were yeah And they were um they were only selecting young adults.
00:07:44
Miranda Materi
Yeah.
00:07:47
josh MacDonald
They weren't selecting people who are diabetic and people who are smokers and people who were 55-year-old females. And so there are populations that lend more towards that. And doctors are taking that to the extent of here's a handout, good luck.
00:08:01
josh MacDonald
come back and see me in six weeks.
00:08:01
Miranda Materi
yeah
00:08:02
josh MacDonald
And then we get those patients who are stuck they're like, well, now go to therapy and give it a try. So yeah, there's, there's gotta be some middle ground.
00:08:08
Miranda Materi
and Yeah. And it's much harder. And what I tell surgeons is just because you're sending them to me doesn't mean I'm going to see them three times a week for 12. Even if the generic script says that if they don't need therapy or if I'm like, you're doing well, come back into like, I feel like we have a pretty good gauge on you know, how well that patient's going to do. and And that's just from watching them, you know, watching all the different variables, maybe doing one or two sessions and seeing where they're at.
00:08:34
Miranda Materi
But just because you send a therapy does not mean we're going to use and abuse.
00:08:37
josh MacDonald
Yeah.
00:08:38
Miranda Materi
their therapy visits, right? If they don't need it, we're going to let them know that.
00:08:42
josh MacDonald
Absolutely. Yeah, for sure.
Ultrasound Use in Therapy
00:08:44
josh MacDonald
um Okay. For our last one, let's hit everybody's favorite um ah trigger issue. Ultrasound. Are there times when research does support the use of ultrasounds?
00:08:55
Miranda Materi
Yeah, I think this is an interesting one. i We don't even have a working ultrasound machine in our clinic. Not that I don't see value in it, um but there isn't a lot of good studies and I would rather use like a laser or something else instead. That's a little more powerful. That's my personal preference. I know other people are going to disagree with me, um but there are some okay studies, some low level studies on it. And I think it's still a fair um exam question for the CHT preppers as well.
00:09:22
josh MacDonald
Yeah. And there's some research that shows that it can help with bone healing and and density. So but we also don't have research showing that ball rolling is good for wrist mobility. We don't have research that shows that translation skills is good for thumb mobility. So sometimes there's things that we know and intuit that, hey, my patients get better when I do this.
00:09:42
josh MacDonald
If you're finding they get better and it's a service you can provide, then go for it if if you feel like it makes your patients feel better.
00:09:49
Miranda Materi
Yeah. And insurance pays for it. That's wild to me, right? They don't pay for like dry needling or some of these other things, but they will pay for ultrasound. So odd enough.
00:09:56
josh MacDonald
Yeah. Odd enough. Yeah.
00:09:58
Miranda Materi
Do you use it in your clinic?
00:10:00
josh MacDonald
I haven't turned on our ultrasound in, I would say probably three years, except to have it calibrated when the gentleman comes and does it. But I did have a physician ask for it maybe two, three weeks ago on a patient who was kind of like, Hey, let's try everything last ditch that we have.
00:10:08
Miranda Materi
That's so funny.
00:10:16
josh MacDonald
And I'm like, you know what? I got this thing in the corner. Let's use it. So I actually had to look up parameters and remind myself on some things just because I haven't used it in a couple of years.
00:10:23
Miranda Materi
Yeah, that's ah us too. Occasionally we'll surgeon, then we have to like go to one of our other offices and pick it up and it.
00:10:29
josh MacDonald
Yeah.
00:10:29
Miranda Materi
But
00:10:29
josh MacDonald
Yeah. Yeah. um All right. So we covered some stuff today. If you have any other things that you feel like you are in favor of or opposed to that research doesn't agree with, definitely share them with us.
Resources and Contact Information
00:10:40
josh MacDonald
um Send us an email. Or if you have questions on some of these things, most of these things we cover in our Hand Therapy Academy membership platforms, the radial nerve handouts, the the article reviews that we have are available for free on our website. So check us out at handtherapyacademy.com and you can email us info at handtherapyacademy.