Innervations of the Median Nerve
Sieg & Adams, Illustrated Essentials of Musculoskeletal Anatomy; 1996
Etiology
Majority of injuries are at the wrist level
Trauma
Compressive
Other
Laceration
*Carpal Tunnel Syndrome
Charcot-Marie-Tooth disease
Gunshot Wound
Synovitis
(e.g. Rheumatoid Arthritis)
Lipofibrohamartoma
Fracture/Dislocation
Tumor
*Prolonged
CTS most common
Charcot-Marie-Tooth disease:
neuronal or demyelinating disorder that leads to peripheral neuropathy
Lipofibrohamartoma:
rarely occurring, benign neoplasm consisting of fibroadipose tissue that
affects peripheral nerves
Kozin, S 2005; pg 213
Muscle Loss of the Thumb
 Opponens Pollicis (OP)
 Abductor Pollicis Brevis (APB)
 Superficial head of the Flexor Pollicis Brevis (FPB)
www.meded.ucsd.edu
Sensory Loss
 Thumb, Index, Middle, and radial ½ of Ring finger
www.rch.org.au
Functional Loss
 Thumb opposition and manipulation
Pre-Operative Therapy
Objectives
• Prepare patient, physically and psychologically, for surgery
• Enable patient to be as functional as possible prior to surgery
Splinting for Function
 Objective: Position MP in palmer abduction to stabilize
for opposition to digits
 Hand based:
 Ribbon splint
 Hand based thumb spica
Splinting for Function
 Forearm based: high median nerve lesion need to
stabilize the wrist
 Forearm based thumb spica
 Oval 8 to stabilize IP joints if Flexor
Pollicis Longus (FPL) is not working
Splinting to Prevent or Correct
Deformity
 Objective: Maintain 1st web space, reduce pain, and maintain
length of extrinsics
 C-bar splint in palmer abduction for night wear
 Forearm based thumb spica to support wrist
 Resting splint for night
ncmedical.com
Adaptations/Modifications
 Increase ability to complete tasks with weak pinch
 Built up foam for handles/utensils
 Use of adaptive equipment


large pens
Use of jump rings for zipper pulls
 Compensation with gross grasp


Angled knives
Travel mug with a handle
Interventions
 Maintain full PROM for involved joints
 Electrical Stimulation
 Manual Muscle Testing
 Persistent pain management/education
 Patient Education regarding realistic expectations related
to function, timing, and rehab needs
Specific Transfers and Indications
Goal to
Regain
Thumb
Opposition and
Abduction
From: Donor
Tendon (working)
To: Recipient Tendon (deficient)
Low Median Nerve Palsy
Bunnell opponensplasty: base proximal
FDS of ring
phalanx or APB tendon (use FCU as pulley)
APB (pulley around ulnar side of wrist)
EIP
High Median Nerve Palsy
Thumb IP flexion Brachioradialis
Flexor Pollicis Longus
Index and long
finger flexion
FDP of index and middle (side-to-side
transfer)
www.orthobullets.com
FDP of ring and small
finger (ulnar nerve)
Muscle Training for Transfer
 Flexor Digitorum Sublimis (FDS) of Ring Finger is primary
choice to thumb MCP (at APB and/or EPB tendon)
 Use of differential tendon gliding of RF to isolate
Post-Operative Therapy
Tendon Transfer
 First 2-3 wks post-op
 Post-op brace with 30 degrees wrist flexion to relax transfer
and thumb in full opposition
 Immediate AROM of fingers- especially RF if FDS used
 May need night finger extension gutter if RF positions in
flexion
 s/p 3 wks post-op
 Splint in forearm based dorsal blocking splint with wrist in
10-20 degrees wrist flexion
 PROM to maintain joint mobility
 4-6x/day AROM for tendon gliding and retraining
Kozin, S, JHT (2005)
Post-Operative Therapy
Tendon Transfer
 Concomitant RF flexion with thumb opposition
 MP blocking of RF to isolate PIP flexion
 Use of opposite hand
 MP flexion blocking splint
 Use of Chopstick/pen to block MP flexion
 Visualization with place and hold exercises
 Use of Graded Motor Imagery
 Discharge splint at 6 weeks post-op
 Strengthening at 8 weeks post-op
Kozin, S, JHT (2005)
Cortical Re-Mapping
 Cortical Re-mapping
 Graded motor imaging
 Left/Right discrimination
 Explicit Motor Imagery
 Mirror Therapy
 Patient Education
noigroup.com
Joint blocking with a chopstick
Joint Blocking with ICAM
Median Nerve Transfer
 Critical for forearm pronation, wrist and finger flexion, and thumb
opposition
 Options:
 Restoring pronation



Branch to FCU to pronator teres branch
Branch to FDS to pronator teres branch
*Branch to ECRB to pronator teres branch
 Preferred due to synergistic movements of wrist extension and
pronation
 Restoring thumb opposition

Isolated low median nerve injury-use of a short interpositional graft:
proximal branch of the median nerve, specifically the terminal AIN
supplying the pronator quadratus muscle
Moore et al, JHT (2014)
Median Nerve Transfer
Restoring finger and thumb flexion
 Anterior Interosseous Nerve (AIN)- motor nerve that supplies the
FPL and FDP to to the index and middle fingers, and pronator quadratus
 Branches from musculocutaneous, radial, or ulnar nerves to
reinnervate the AIN




Brachialis branch of musculocutaneous to AIN
Supinator branch of the radial nerve to AIN
Brachioradialis branch to AIN
Radial nerve branch of ECRB and supinator to AIN
Moore et al, JHT (2014); www.neurosurgery.med.nyu.edu
Post-Operative Therapy
Nerve Transfer
Immobilization
 Elbow/Forearm: 7-10 days
 Post-op dressing
 May change to splint as early as s/p 2-3 days
 No further protection after 10 days due to no tension on nerve
transfer
 If tendon transfer at same time, protocol paradigm shift related
to tendon
 Shoulder: up to 4 wks
 Allow intermittent ROM for elbow and hand
 Shoulder A/PROM resumes at s/p 4 wks
Moore et al, JHT, (2014)
Precautions Post Operative
 Tendon Transfer
 Same as for Tendon repair
 Nerve Transfer
 Risk of increased tension on nerve repair site
Post Operative Therapy
Tendon and/or Nerve Transfer
 Edema control
 Scar management
 Pain management
 Range of Motion
 Sensory Re-Education
 Strengthening
 Restore Function
Motor Re-education
 Objective: To correct recruitment and restoration of muscle balance and
decrease compensatory patterns
 Motor Re-education
 Challenges:
Alterations in motor cortex mapping (i.e. neuro tag smudging)
 Muscle imbalances due to weakness associated with dennervation
 May persist due to compensatory movement patterns and persistent
weakness of reinnervated muscles
 Method:
 Contract muscle from donor nerve/muscle with new muscle until motor
pattern established
 The more synergistic the action and based on original motor pattern, the
more recruitment and establishment of muscle balance

Moore et al, JHT (2014)
Sensory Re-education
Vibration: Tapping fingers
Stereognosis: Carry 3-4 small items in pocket - throughout the day try to
reach in and identify
Sensory Re-Education
Light to deep Touch
danmicglobal.com
Exercise
 ROM
 PROM
 Place and Hold with visualization and use of RF flexion initially
 AROM through full range
 Opposition exercises
 Light object pick-up
 Marble cup
 3 poker chips
 Strengthening
 Graded putty exercises


Button find
Pushing golf tees in putty
 Tearing paper
Dexterity/Opposition
Strengthening
Bibliography
 Davis KD, Taylor KS, Anastakis DJ. Nerve Injury Triggers Changes in




the Brain. Neuroscientist. 2011; 17 (4).
Hoard AS, Bell-Krotoskie JA, Mathews R. Application of
Biomechanics to Tendon Transfers. Journal of Hand Therapy. AprilJune 1995; 115-123.
Kozin SH. Tendon transfers for radial and median nerve palsies.
Journal of Hand Therapy. April-June 2005; 2: 208-215.
Moore AM, Novak CB. Advances in nerve transfer surgery. Journal
of Hand Therapy. April-June 2014; 27: 96-105.
Moseley GL, Butler DS, Beames TB, Giles TJ. The Graded Motor
Imagery Handbook. Adelaide, Australia. Noigroup Publications.
2012.
Bibliography
 Murphy RKJ, Wilson ZR, Mackinnon SE. Repair of median nerve
transection injury using multiple nerve transfers, with long-term
functional recovery. Journal of Neurosurgery. Nov 2012; 117: 886889.
 Sieg & Adams. Illustrated Essentials of Musculoskeletal Anatomy, 3rd
Edition. Gainesville, Megabooks, Inc. 1996.
 Sultana SS, MacDermid JC, Grewal R, Rath S. The effectiveness of
early mobilization after tendon transfers in the hand: A systematic
review. Journal of Hand Therapy. October 2013; 26: 1-21.
 Wang JHC, Guo Q. Tendon Biomechanics and Mechanobiology-A
minireview of basic concepts and recent advancements. Journal of
Hand Therapy. April-June 2012; 7: 133-140.
Thank you to my family for their never ending support
and encouragement