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Peripheral Nerve Injury
211 Plays5 days ago
In this episode, Miranda and Josh talk about choosing the appropriate splint based on the type of peripheral nerve injury and how to match positioning with the specific nerve involved
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Transcript
Introduction to Peripheral Nerve Issues
00:00:06
josh MacDonald
Hi, I'm Josh McDonald.
00:00:07
Miranda Materi
And I'm Randi Materi and we are Ham Therapy Academy. So today we're going to be talking about peripheral nerve issues and what is the appropriate splint. So for instance, we're going to go over what you'd splint the carpal tunnel in.
Carpal Tunnel Splinting Options
00:00:20
Miranda Materi
So which angle, what do you do if they have lumbar poles going into the carpal tunnel space? What do you do for a high median nerve injury, um a high versus low ulnar nerve injury, what type of splint you use, and then a radial nerve palsy splint and what those look like. So we're just going to kind of get into the nitty gritty of the angles and the correct position for each of these types of injuries. So first we'll start with what are you doing for your carpal tunnel splints?
00:00:45
Miranda Materi
And then what are you doing? What angles are you putting them in if you're including a lumbrical block?
00:00:49
josh MacDonald
Yeah. We make a ton of these. We have a neurologist office that sends a ton of patients to us for carpal tunnel stuff. Sometimes it's not carpal tunnel. They have had a stroke, but we still get the referrals. And so we make get ton a ton of carpal tunnel type splints. We're usually going for a like 10 to 15 degree wrist extension. um I excuse me, MCPs and IPs free. If there's no, if they're not positive on the Berger test, which is basically holding a fist for a prolonged time to see if there's tingling or numbness.
00:01:18
josh MacDonald
that indicates lumbrical incursion in that carpal tunnel so if there's none of that we're making ah like a 10 to 15 degree gentle wrist extension um and we make an ulnar based one out of our thinner material but it goes almost full circumferential so that they have lots of support but not a lot of weight behind it
00:01:36
Miranda Materi
Awesome. And I think for this one, and I know this because I just looked it up, but is in the rehab of the hand is five degrees, neutral to five degrees extension, but definitely no flexion. So I think we kind of, ah I do the same thing. I eyeball it and I make sure that they're just in slight extension.
00:01:53
josh MacDonald
And I do feel like that measurement is tricky because on some of our patients, like if you have a patient where the thenar and hypothenar eminence are bigger, whether they're a manual laborer or they're a little heavier set, that can skew that because you're measuring volarly.
00:02:07
josh MacDonald
And so I'll have patients where they're just slightly back. But if I were to put a goniometer, it would be a much bigger read of an angle than if I were to measure ownerly. So, yeah.
High Nerve Palsy Splinting Strategies
00:02:16
Miranda Materi
Right. Yep. Good point. And then for the lumbrical block, what, what position are you putting their MCPs in?
00:02:23
josh MacDonald
ah Zero degrees. I try to get those MCPs entirely extended and then IPs free. So they have some movement there, but I want those MCPs in full extension, almost kind of like a um ah conservative zone five extensor tendon splint.
00:02:37
Miranda Materi
Yep. Same here. And sometimes I'll make that piece removable. So that way they can wear the carpal tunnel splint during the day and then at night put the lumbrical block on.
00:02:46
josh MacDonald
Yeah, yeah.
00:02:47
Miranda Materi
So that's an option as well. Okay. What about high nerve palsy? So this would be if their FPL and their FTP is out, what type of splint are making for them then?
00:02:59
josh MacDonald
So it depends on how much median nerve loss they have. If it's early and they're, we're in like this protective, just kind of be careful. I might even just make like a hand-based thumb spica that puts them in a good opposition position and just kind of see what happens with FDS and FTP.
00:03:12
Miranda Materi
Thank
00:03:17
josh MacDonald
And if we're functioning okay, I might just try to get as much function as I can. But if they've lost a lot and they've atrophied, I might give them a little bit more support and maybe forearm-based something coming a little further to support that, um the radial sighted fingers a little bit more.
00:03:33
Miranda Materi
Right. So opponents, right? So we're either doing ah a short opponents or a forum based opponents for high median nerve injuries.
00:03:35
josh MacDonald
Yeah.
Ulnar Nerve Splinting Techniques
00:03:41
Miranda Materi
Okay. We'll move on to our next one, which is ulnar nerve. So for cubital tunnel, are you doing a tau splint? Are you doing an elbow splint? And what position are you putting their elbow in?
00:03:52
josh MacDonald
That's a good question. I feel like it really, for me, depends case by case on how the patient presents. We get referrals for those a fair amount of times. um And we will, if we're making a s splint, we'll make it out of a non-perforated, like a Taylor splint, or maybe it's prison without perforations. And I'll put that volarly on the, um on the arm And we're going to be about 30 degrees of elbow flexion. I don't feel like that's a need to pull out a goniometer on, but just that that light flexion. But I will do like towel splints, pillow splints. I'll do some education on that stuff. Heel bows sometimes if they have poor skin integrity, if they are bilateral, or if there's like ah if they're a caregiver for someone else, if there's a financial reason why they can't afford or it's a hardship on them. We'll talk about some other options because I feel like those elbow um elbow immobilizing splints are just a pain to deal with at night.
00:04:47
Miranda Materi
yeah they are especially if they have two of them so if they have two and the doctor wants me to make both i'll be like well you can alternate every other night you know wear one one night and the other one other and i generally do mine in around 30 to 45 degrees of flexion anywhere between there and like josh said just kind of eyeballing it um
00:04:53
josh MacDonald
Yeah.
00:05:03
josh MacDonald
Yeah.
00:05:04
Miranda Materi
And if you do have like a student, then of course I i have the student get out the gloniometer and measure it just so they get an idea. Cause I think sometimes students will be like, that looks like 45 degrees, but really, you know, they haven't done it enough to know what that is.
00:05:14
Miranda Materi
So.
00:05:15
josh MacDonald
Yeah, yeah. I do feel like that can be a pretty straightforward splint to make. I'm getting a very basic rectangle around my corners first before I put it on them. um And I just drape it over a supported elbow, sometimes just um dorsum of the of the arm on the table. Then I prop their arm up a little bit. It can be a very simple thing. I'm just waiting for this big, thick material to cool. But it can be a nice, easy splint to make. And I'll even make it short on the distal end if I have to pair it with a carpal tunnel splint.
00:05:42
Miranda Materi
Yeah, yeah, I think they're really simple to make as well. I think the one thing you have to be careful of is where you put that strap around the elbow, because sometimes if you put that strap too tight or you're not careful about the placement, you can cause a compression at the cubicle tunnel. So your splint's not going to make it better. It's going to make it worse. So being aware of those landmarks, I think, is key too.
00:06:00
josh MacDonald
Do you crisscross your straps?
00:06:02
Miranda Materi
I know you do. I don't. I usually put like the blue foam and then I like make a little divot of where their nerve is. And i tell I like educate the patient.
00:06:10
josh MacDonald
Okay.
00:06:11
Miranda Materi
So they kind have like a nice um elevated space around the nerve with the blue foam.
Low Ulnar Nerve Palsy Solutions
00:06:17
josh MacDonald
Yeah. Yeah. I think it's personal preference. I don't think there's a right or wrong way in that. As long as the patient's staying in it, that's what matters.
00:06:22
Miranda Materi
Yeah. And as long as you get the principles of it and quickly, what about, what are you doing for your, um,
00:06:26
josh MacDonald
Yeah.
00:06:29
Miranda Materi
Low ulnar nerve palsy. So that'd be like a compression at Guillen's canal or something like that, where they're having more, more clawing. What type of splint are you doing for that?
00:06:38
josh MacDonald
Yeah.
00:06:38
Miranda Materi
And what angles are you keeping them in?
00:06:41
josh MacDonald
I will make an anti-claw splint. We usually make them, unless they're a big giant hand, strong labor patient um manual labor patient, we'll use the thinner material and I like fold it in a half um and wrap that figure eight around. I will fabricate it with that patient's MCPs in 90 degrees, knowing that when it cools and we're done and they go to extend, there's enough flex in the material It allows them to get like, don't know, minus 10, minus 15 degrees of extension, but it's still going to block them short of full extension and clawing. If I make it in any less than like a full 90 degrees, then they can still plow past it with the flex of the material. So IPs are free, obviously, but those MCPs, I usually fabricated at 90 so they have some flexibility without plowing past.
00:07:26
Miranda Materi
Yeah, same. And then what about, are you doing anything with those patients at nighttime? Like, are you putting them in any sort of splint when they're sleeping?
00:07:33
josh MacDonald
um Yes, i if it's a really dramatic case, if it's like they're they're a little late to come to us, I'll put them in almost like a Dupuytren's resting hand um hand-based palm splint that's just ring and small that kind of keeps it to hopefully fight off that contraction and reestablish range.
00:07:45
Miranda Materi
Okay.
00:07:51
josh MacDonald
I feel like if during the day they're compliant with wearing their daytime splint, I don't know that I need to do a nighttime splint as well. I'm just kind of monitoring it to make sure they don't develop contractures.
00:08:00
Miranda Materi
Right. I usually say if it's going to be an ongoing case, like this is a chronic issue, they're having clawing, it's going to take a long time. I'll make them an ulnar gutter and put them in that intrinsic plus position just to preserve their MCP ligaments and things like that.
Radial Nerve Palsy Splints Overview
00:08:13
Miranda Materi
And then that way, if they later on have to have a tendon transfer procedure something like that, they're they're set up for success.
00:08:19
josh MacDonald
Yeah. Yeah.
00:08:20
Miranda Materi
Yeah. Okay. The last peripheral nerve splunt we're going to talk about is radial nerve. What are you doing for your radial nerve palsies? Um,
00:08:28
josh MacDonald
Yeah. This can be one where it's death by splints and there's just so many options that, that like I want to send them out with three or four things and you just can't.
00:08:33
Miranda Materi
Thank you.
00:08:36
josh MacDonald
So I always go with a low profile version of radial palsy s splint. We actually have one for free on our YouTube channel. If you go looking for hand therapy Academy, there's a version on there for free that you can watch.
00:08:46
josh MacDonald
But it's basically the elastic strapping that loops between their fingers and then the elastic string that tethers that up between the fingers in the web space so that strap stays at P1s.
00:08:59
josh MacDonald
It's a very low profile. Dorsalite extends to PIPs. um I also try to do, especially if i think it's going to be a longer term thing, a nighttime resting hand splint. um just to keep them from developing any nighttime flexion contractures.
00:09:13
josh MacDonald
Then sometimes they want a wrist support because I don't always want this dynamic thing on my hand. Sometimes they just want a wrist support. so now you're talking three splints. Is that covered by insurance? So there's some there's some back and forth on how many of those splints we're going to make.
00:09:26
Miranda Materi
Yeah. And I think my go-to is always the wrist cock up, you know, cause I'm like, well, least they can get their wrist and extension and they can pinch and grab.
00:09:29
josh MacDonald
Okay.
00:09:33
Miranda Materi
So I'm always like, that's the most functional thing, even though I'm like, oh yeah, I want to make a dynamic splint because those are fun. Right. That's what we like to do. But sometimes I start simple and kind of see where they're at. And and then if they have demands, like they want to type and things like that, I'll make the dynamic splint.
00:09:47
Miranda Materi
But yeah.
00:09:47
josh MacDonald
Yeah.
00:09:47
Miranda Materi
Often that's, you know, my go-to is a cock up.
00:09:48
josh MacDonald
Yeah.
00:09:50
Miranda Materi
And then like you said, if they have multiple split needs, I might say, okay, well, I know they can get this risk cock up over the counter. So we might get an over the counter one and then I make the dynamic one.
00:10:00
Miranda Materi
So it it really depends on the case and the patient for sure. So.
00:10:04
josh MacDonald
We have a patient that came to us. He came to us a little late. He kind of missed the boat and getting to us right away. And he came with orders for radial palsy splint before weeks later, by the time he finally gets to us, he only has a little bit of yeah EIP and, and thumb loss.
00:10:17
josh MacDonald
his nerve is dramatically improving. So now we've got to decide, do we go ahead and make the splint? Cause that's what came in the orders. Or we're trying to reach out to the doctor and be like, dude do we still need one? If he's almost done, do we need to find like something more minimal to not burden this self-pay patient? So that's also sometimes a how quickly are they getting get better? Do they need, you know, hundreds of dollars for the splints?
00:10:38
Miranda Materi
Right. That's true too. Versus if it's like a, you know, at the spiral groove, you're like, that's going to be a long recovery.
00:10:44
josh MacDonald
Yeah. Yeah, for sure. Yeah. All right. Well, hopefully this answers some questions for you about splinting options and some things to look at if you have peripheral nerve patients you're making splints for. If you have any questions or if you are interested in peripheral course, we have one of those on our platform as well. That's included with our upper tier memberships.
00:11:02
josh MacDonald
um You can get more information at info at handtherapyacademy.com or you can reach us on our social media platforms at Hand Therapy Academy.