Deep Ulnar & Median Nerve Laceration Injury (Q&A)
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[00:00:00] All right, so let's talk about nerves. So we did we did ner nerve, we did median nerve, and I actually had a great question from Beatrice. I'm actually going to share her question. Right now because she had a question on Ulner nerve, and I want you guys to think about it like this, right? So she has an injury with a 33 year old male patient of hers that he's a medical doctor, studying to be a plastic surgeon, plenty enough is our topic.
[00:00:34] He had the injury back in May of. 2020, he sustained a deep laceration proximal to the wrist. So she sent me a picture and the laceration was right here. So if you see the laceration very ly lacerated, the ulnar nerve, the artery. And the median nerve had a partial repair as well, so [00:01:00] he injured both nerves.
[00:01:03] So if you have the ulnar nerve and then you have your median, right? So when you're thinking high and thinking low, this would essentially be like a low one, right? Because it's below the elbow.
[00:01:18] So any muscle, any nerve above that innovated certain muscles over here. So those muscles will still work. Anything below that laceration won't work. So this is a partial, but I believe this is a full Right. So already in your mind you, you would be thinking of what his potential problems are gonna be.
[00:01:45] Right now, I'm not sure. I believe this is his dominant hand.
[00:01:53] Dominant hand. And I'm gonna make assumptions that his dominant hand, his right hand, right? So already [00:02:00] you should be thinking about setting setting expectations, right? How do I do this again? How do I set myself, oh, here it is. Pin myself to, yeah. Already you would be thinking, okay which nerves are innovated by the on nerve? You're thinking about the the hypo thinner muscles, right? It's all your small finger muscles, you're thinking about certain intrinsic muscles, right? Which is gonna affect the grip, right?
[00:02:34] Because the hand, the ulnar two fingers does all the power grip for you. So when you start thinking through the muscles, You're gonna know that he has decreased grip strength, right? And then also that ulnar nerve remember crosses and it's a thumb adductor. So he's gonna have a certain problem with pinch.[00:03:00]
[00:03:00] Okay. So we already know when you have a full nerve laceration that the it's like turning the lights off to the muscles, right? So one of the things that they do is when they repair it, it's like a jigsaw puzzle. They're trying to match the fibers back up. It's like bundles inside. Bundles, inside bundles.
[00:03:23] Think of electric wiring, right? Bundles. Inside bundles. Inside bundles. And they're trying to match it up. They're so small, but they're gonna try to match it up as close as possible, right? As close as possible. But what happens when you cut something? What are some of your problems? Your problems are gonna be, it's not.
[00:03:45] Fully not fully matched, right? Your other problem is going to be scarring. You're gonna have internal scarring, [00:04:00] right? And that's scarring There is going to stop the flow of electricity further when you have a compression. Once the, there's a certain amount of nerve death. You can't get that back right now if you release it and there's a certain amount of return there, nerve has a certain amount of regeneration.
[00:04:23] And it's going to. Turn around amount, but certain parts that are, that died, stay dead. It's not like pet cemetery, you just can't like, oh my, I think I just aged myself. Does anyone know who pet cemetery is? Bury the little dead animal and it comes back to that. That's not what happens, right?
[00:04:38] Certain amount. It dies, it's dead. And what you're doing is you're just waiting. It's in a way, it's like a waiting game for how much you're going to get in the meantime that you're waiting. For a certain amount to return, you've got to keep the joints protected so that it has a chance, right? So that it has a chance, but [00:05:00] not fully matching.
[00:05:00] Scarring are the two main things that is going to interrupt how well the nerve can regenerate. It's just the nature of the. So compression is one, traction is another, and then laceration is the worst onar nerve type of injury you could have. Right now, the median nerve goes to the thumb. It has, it affects the thumb quite a bit, right?
[00:05:27] So it goes to a lot of thumb muscle. So both of these in the low aspect, Have a lot of intrinsic muscles,
[00:05:37] intrinsic muscle issues, so intrinsic muscles, whether you're talking about your, in your LU goals, they all help to flex the MP and extend the ip. So at some point he is now May, so that's six, about six or seven months. So he is halfway through his recovery.[00:06:00] He's halfway through his recovery. He has claw hand, right? He has edema of his hand and forearm. It says impaired sensation of the fourth and fifth digits. He doesn't have any problems in the back. Why? Cuz that's a radio nerve. So the median nerve. Nerve comes to these three fingers, but it goes to the tips of the nails after that, on the dorsum of the hand, that's the radio nerve, so that would be fine.
[00:06:33] His finger, his middle finger presents with flexion of his fingers, which is good. So he has the best possible chance here cuz it was only a partial. So here's the best possible chance of a, a median nerve. And an on the nerve laceration is probably one of the worst injuries that you have, cuz both nerves affect how functional you can be.
[00:06:58] So he's he's able [00:07:00] to have a certain amount of grasping release. He's progressing well, he's wasting away in the. First dorsal, that's dumb abduction. It's fine. It's expected he's able to oppose all the fingers. The weakness, except for the fifth digit, he can't. It's because he can't rotate. So hypo theor muscles in the ulnar he can't rotate, he can't oppose.
[00:07:23] So to have opposition work, You have to be able to rotate the thumb and you have to be able to rotate the small finger. Both have to work in order to oppose, and this is full opposition. So he having to use different treatment techniques as dynamics. Splinting to get the fingers extend during the day, anti claw splint.
[00:07:45] You're doing therapy, you're doing rubber bands. You're stuck and frustrated with the muscle wasting. First of all, one of the things that I would say is don't be frustrated with the muscle wasting, because if you are frustrated, he's frustrated, and then y'all frustrated for no apparent reason.
[00:07:58] You have to set the [00:08:00] tone of what. Someone should expect, and let's be realistic here. I don't care if they put your nerve together. There is a certain amount of atrophy and once that atrophy sets in, it's not nec, it's not going to come back fully. So you have to set the expectation. Of this is potentially what's going to be happening with your hand.
[00:08:22] What we're gonna do is we're gonna find the muscles that are returning and focusing on the muscles that are returning. That's going to be your median nerve. So I like that he has a, he doesn't have a numbness there. So you didn't mention anything about numbness, so I would've. I would assume that he is doing pretty well with that.
[00:08:42] So I'd have to look and say, okay, where, what's the median? What's the median nerve? What's the median nerve? Is the abductor sis brevis, right? The opponent's policies, which we're hearing that it works. The superficial head of the flexer poly is [00:09:00] brevis, right? So that's coming. And the first and second lumber Coles, right?
[00:09:04] So he can do this. And he should be able to do this with these fingers because it was cut low enough that his profundus and his superficial is working and his flexor poly's longest. Thank goodness. Thank goodness that cuz without the Fluor policy as longest he wouldn't be able to do any of that.
[00:09:27] So we gotta focus on what can you do? And you have to set the tone for we're going to be working on the things that we. See work best, and we're gonna make those strong. We're gonna make it as functional as possible, knowing that the ulnar nerves may not have as great of a chance, right? And so the biggest thing here is that you need to make sure that the joints are supple, right?
[00:09:50] There is no need for a nice. Splint as long as the joints move really well. So if he doesn't have joint stiffness, he shouldn't have that problem. The best thing that you [00:10:00] could do is put him in an anti cloth split and encourage him to wear that all the time during the day. It's the best way to be functional, but it's the best way to give the chance the fingers a chance to be in the best position so that when the nerve.
[00:10:16] As it recovers, it can work. Hey, therapy friends, it's Wong here. Thanks again for watching our video, and if you like videos like this that can help you just crush it in the hand therapy world as an occupational therapist, then hit the subscribe button and enjoy the video. Thanks again for watching.
