Radial Nerve Injury

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Root Value

C5, C6, C7, C8 AND T1

FROM

Posterior Cord

TO

Posterior Interosseous Nerve

MUSCLE INNERVATION

Posterior Compartment of Arm and Forearm

COMMON SITES AND CAUSES

Injury to Radial Nerve at different levels causes different syndromes with varying motor and sensory deficits.

AXILLA

(1) Saturday night palsy

(2) Crutch Palsy

Motor deficit

Loss of extension of forearm, weakness of supination, and loss of extension of hand and fingers.

Presence of Wrist Drop, inability to extend the hand and fingers.

Sensory deficit

Loss of sensation in lateral arm, posterior forearm, the radial half of hand, and dorsal aspect of radial ​three and a half digits.

ARM

(1) Mid-Shaft Humerus Fracture

(2) Holstein-Lewis Fracture

Motor deficit

Weakness of supination

Loss of extension of hand and fingers

Presence of wrist drop , inability to extend the hand and fingers.

Sensory deficit

Loss of sensation in posterior forearm, the radial half dorsum of hand, and dorsal part of radial ​three and half digits.

Elbow

(1) Neck of radius fracture

(2) Elbow dislocation or fracture

(3) Pressure due to tight cast

(4) Rheumatoid nodules

(5) Injections due to tennis elbow

Deep branch of the radial nerve injury piercing the radial head causing Posterior Interosseous Nerve (PIN) syndrome

Motor deficit

Weakness in extension of hand and loss of extension of fingers

Presence of finger drop, and partial wrist drop

Sensory deficit

None, as sensation is supplied by the superficial radial nerve

Distal forearm:

Wartenberg Syndrome

Motor deficit

None

Sensory deficit

Numbness and tingling in radial half of dorsum of hand, and dorsal aspect of radial ​three and half digits

In Wartenberg’s Syndrome , there is typical radial wrist pain, Finkelstein’s test may be positive

SPECIAL TESTS

RADIAL NERVE TEST

https://youtu.be/kODPvHYNvlU

Upper Limb Neurodynamic Test for Radial Nerve

https://youtu.be/x3ivtuDwCDI

EMG AND NERVE CONDUCTION STUDIES

https://youtu.be/rfbcKF9pENE

Wrist Drop Test

Patient should be seated well during the procedure.

The patient should adopt a praying position with the hands and palms together.

The patient pulls the palm apart.The patient holds hands for about 15 cm apart for a minute.

He should maintain wrist extension till one minute.

The examiner takes note of poor range of motion or the inability to hold wrist in extension.

A positive Wrist Drop Test is the presence of weakness and the inability of a patient to maintain this position of the upper limb

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Flexor Compartment Or Anterior Compartment of Forearm (Muscles)

SUPERFICIAL MUSCLES

(1) Flexor Carpi Radiallis
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Origin

Medial epicondyle of humerus

Insertion

Anterior aspect of base of second metacarpal, base of third metacarpal and trapezial tuberosity

Artery Supply

Radial Artery

Nerve Supply

Median Nerve

Movement

Flexion and Abduction of hand at wrist

Associated Pathology

Flexor Carpi Radiallis Tendonitis

(2) Palmaris longus

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Origin

Medial epicondyle of humerus

Insertion

Central part of flexor retinaculum and lower part of palmar aponeurosis

Artery Supply

Ulnar Artery

Nerve Supply

Median Nerve

Movement

Flexion of Wrist

Associated Pathology

Palmaris Longus Tendon Rupture

It is also used in tendon graft

(3) Flexor Digitorum Superficialis

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Origin

Muscle has two heads – the humeroulnar and radial

Medial epicondyle of humerus and anterior portion of radius

Insertion

It inserts into the anterior margin of bases of the middle phalanges of the medial four digits

Artery Supply

Ulnar Artery

Nerve Supply

Median Nerve

Movement

Fingers Flexion mainly of Proximal Interphalangeal joint

Associated Pathology

Flexor Digitorum Superficialis tendon rupture occurs in rugby players

(4) Flexor Carpi Ulnaris

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Origin

Humeral head at Medial epicondyle of humerus

Ulnar head at Medial aspect of olecranon process of ulna

Insertion

Pisiform, Hook of Hamate and base of 5th metacarpal

Artery Supply

Ulnar Artery

Nerve Supply

Ulnar Nerve

Movement

Flexion and Abduction of hand at wrist

Associated Pathology

Cubital tunnel syndrome

(5) Pronator Teres

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Origin

Humeral head at medial supracondylar ridge of humerus

Ulnar head at coronoid process of ulna

Insertion

Middle of lateral surface of body of radius

Artery Supply

Ulnar And Radial Artery

Nerve Supply

Median Nerve

Movement

Pronation of forearm and flexion of elbow

Associated Pathology

Pronator Teres Syndrome

Deep Muscles

(1) Flexor Digitorum Profundus

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Origin

upper 3/4 of the anterior and medial surfaces of the body of the ulna, interosseous membrane and deep fascia of the forearm

Insertion

Base of Distal Phalanges of fingers

Artery Supply

Anterior interosseous Artery

Nerve Supply

Anterior Interosseus Nerve and Ulnar Nerve

Movement

Flexor of Wrist, Metacarpophalangeal joint and Interphalangeal joint

Associated Pathology

Jersey Finger
Linburg – Comstock Syndrome

(2) Flexor Pollicis Longus

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Origin

Middle 2/4th of the anterior surface of the radius and the interosseous membrane

Insertion

Base of Distal Phalanx of Thumb

Artery Supply

Anterior Interosseous Artey

Nerve Supply

Anterior Interosseous Nerve

Movement

Thumb Flexion

Associated Pathology

Linburg-Comstock Syndrome
FPL tendon rupture

(3) Pronator Quadratus

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Origin

Medial and Anterior Surface of Ulna

Insertion

Lateral and Anterior Surface of Radius

Artery Supply

Anterior Interosseous Artey

Nerve Supply

Anterior Interosseous Nerve

Movement

Pronation of forearm

Associated Pathology

Overuse injury, Overactive and Short Pronator Quadratus

Scoliosis

It is a complex deformity of spine characterized by abnormal sideways curvature of spine or increased lateral curvature and rotation of vertebrae involving deformity of rib cage.

EPIDEMIOLOGY AND CAUSES

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CAUSES

Congenital Scoliosis – bone malformation present at birth.

Neuromuscular Scoliosis – results from abnormal muscles or nerves seen in people with spina bifida and cerebral palsy.

Degenerative Scoliosis – results from traumatic bone collapse.

Idiopathic Scoliosis – results from no specified identifiable cause.

CLINICAL FEATURES AND PATHOPHYSIOLOGY

Deformities like skew back, rib hump

Asymmetrical breast and shoulder level

One shoulder blade is more prominent than other

On bending rotation of spine becomes more prominent

Asymmetrical hip

Associated with skin pigmentation

Associated back pain

PATHOPHYSIOLOGY

Idiopathic Scoliosis is associated with CHD7 and MATN1 gene.

Congenital scoliosis has been associated with malformation of the spine during 3-6 weeks in utero due to a failure of formation, a failure of segmentation, or a combination of stimuli.

PHYSICAL EXAMINATION AND DIAGNOSIS

Various diagnosis and physical examination is applied to evaluate Scoliosis spine curvature

COBB METHOD
In this a horizontal line is drawn on the upper part of the first vertebrae involved in the curve and a horizontal line is drawn from the lower part of the last vertebrae involved in the curve now a perpendicular line is drawn from both horizontal lines, the angle formed at the intersection is the “Cobb Angle”.

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RISSER FERGUSON METHOD

In this method a line is drawn from the centre of the first vertebrae involved and a line us drawn from the centre of the last vertebrae involved in the curve, the point of intersection of these lines gives the Angle of Scoliosis according to Risser Ferguson Method.

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ADAM’S FORWARD BEND TEST

Bend forward flexion reveals abnormal uneven framework of spine suggestive of Scoliosis.

COMPLICATIONS

Lung and Heart Disease

Chronic Back Pain

Long term Postural Abnormalities

Physiotherapy Management

Physiotherapist have three important considerations firstly is to inform, advice and instruct. For the treatment of scoliosis, it’s not only important to do the correct exercises but the physical therapist also needs to inform the patient &/or parents about his/her situation. An educational program makes sure that the therapy accuracy from the patient improves. Some physiotherapists recommend a brace to prevent the worsening of the scoliosis. An often used brace is the Milwaukee Brace. We can conclude that bracing is recommended as a treatment for female patients with a Cobb angle of 25-35°. In this it is evident that bracing and exercises have positive effects on patients with idiopathic Scoliosis

Schroth Method for Scoliosis Management

Goals -:

Stabilization of the curves

Mobilization of stiff body parts

Improve postural alignment

Teach activities of daily living

Promotes corrections

Enhance neuromuscular control

Increase muscle strength and endurance

Pain reduction

Improve Cardio-pulmonary function

Exercises given are

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Pilates for Scoliosis

The SEAS exercises are, according to the Italian Scientific Spine Institute, based on a specific form of Active Self-correction, that is advised and taught individually to every patient. This is to achieve the maximum possible structural correction

Manipulation and Electrical Stimulation
are also used for Scoliosis management

Knee Osteoarthritis

It is Chronic progressive, degenerative, painful disease of knee joint present with chronic pain, loss of joint ROM, bony crepitus, joint deformities in later stage like “genu valgum”.

EPIDEMIOLOGY AND CAUSES

Most common form of joint arthritis.

15% population is affected.

Strongly age related OA knee occurs with 70% population in age group 60 and above.

Leading cause of long term movement disability

11.6 millions cases expected to be in US till 2020.

CAUSES

Age
Overuse injury
Repetitive Stress Fracture
Obesity
Joint Imbalance or mal-alignment
Genetics like FRZB, LRP5 gene etc

CLINICAL FEATURES AND PATHOPHYSIOLOGY

knee pain

swelling in the joint area

pain worsen up in the morning

pain increases after activity

buckling of the knee

inability to straighten up your knee

grinding or snapping noises when perform movements ( bony crepitus )

weakness in the knee joint

PATHOPHYSIOLOGY

Damage at more weight bearing joint like knee joint

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PHYSICAL EXAMINATION AND DIAGNOSIS

Physical examination includes

Check joint alignment

Access quadriceps strength

Evaluation of tenderness point and pain

Access Joint ROM

Palpation for bony swelling

Access Bony Crepitus

Gait Evaluation

Radiographically we find

X-rays show up cartilage loss is revealed by a narrowing of the joint space. An X-ray may also show bone spurs around a joint. Presence of subchondral cyst, bony erosion, inflammed synovium.

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PHYSIOTHERAPY MANAGEMENT

A study found that a combination of manual physical therapy and supervised exercise has functional benefits for patients with knee osteoarthritis.

Physical therapy can help to reduce the pain, swelling, and stiffness of knee osteoarthritis, and it can help improve knee joint motion. It can also make it easier for you to walk, bend, kneel, squat, and sit. The two main types of physical therapy — passive and active treatments. It can help make your knee OA more manageable.

Common Passive Treatments for Knee Osteoarthritis

Cold therapy: It reduces circulation and can help decrease swelling.

Heat therapy: Heat therapy increases blood flow to decrease stiffness in the knee joints and muscles surrounding the knee.

Hydrotherapy: This treatment uses water to decrease your symptoms. There are several advantages of hydrotherapy, you can do gentle exercises in the water and warm water help facilitate motion as well as help you provide pain relief.

Common Active Treatments for Knee Osteoarthritis

Strengthening exercises: Your physical therapist will show you certain exercises that you can do at home to strengthen your muscles. Working out muscles in the leg can help make your knee joints stronger. Strengthening these muscles alone can help decrease the pain of knee OA.

Flexibility exercises: Flexibility exercises are very important. Regular sessions can help increase range of motion, make your knees more flexible, and restore normal knee joint function.

Both strengthening and flexibility exercises are important because they assist in taking strain off the knee.

Rehabilitation Exercise includes

Knee flexion

Hamstring Stretch

Leg Flexion

Hip Extension

Squats

Stair up and down

Heel slide knee extension

Side lying leg lifts

IlioTibial (IT) band Syndrome

IT band Syndrome is an overuse injury of connective tissue present at the lateral aspect of thigh it runs along the outer part of thigh extending from pelvis to tibia covering both hip and knee joint when this connective band or tissue rubs against bony prominence due to overuse activities leads to inflammation and irritation of this band causing symptoms. It is also known as ITBFS ( IT Band Friction Syndrome).

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EPIDEMIOLOGY

ITBS is the most common cause of lateral knee pain in runners. Studies show incidence of ITBS in athletes, especially Runners with an incidence as high as 12% of all running – related injuries. US Marine Corps soldiers undergoing basic training reported the incidence of ITBS among this group to vary from 5% to 22%

CLINICAL FEATURES AND PATHOPHYSIOLOGY

The ITB is the amalgamation of fascia formed by the tensor fascia lata and the gluteus medius and minimus muscles. The ITB is a wide, flat structure that originates at the iliac crest and inserts at the Gerdy tubercle on the lateral aspect of the proximal tibia. This band serves as a ligament between the lateral femoral condyle and the lateral tibia to stabilize the knee. The ITB helps in the following 4 movements :

Abduction of hip

Internal rotation of the hip when the hip is flexed to 30°

Knee extension when the knee is in less than 30° of flexion

Knee flexion when the knee is in greater than 30° of flexion

The ITB is not connected to bone as it runs between the Gerdy tubercle and the lateral femoral epicondyle. This lack of attachment allows it to move anteriorly and posteriorly with knee flexion and extension, this movement may cause the ITB to rub against the lateral femoral condyle, causing inflammation.

Patient with ITBS presents with an insidious onset of lateral knee pain that is present during running.

Early in the  injury, the pain usually resolves after running or during rest

The athlete is able to pin point location of the lateral knee pain to approximately 2 cm above the lateral joint line.

Pain aggravates when the athlete climbs stairs or runs downhill.

Pain may develop with any activity that places the knee in a weight-bearing position at approximately 30º of knee flexion.

Pain at rest and is usually associated with severe tendinitis.

Point tenderness is noted upon palpation of the lateral femoral epicondyle, as well as with palpation of a site 2-4 cm above the lateral joint line and at the Gerdy tubercle.

Pain may be elicited with knee flexion to 30° when varus stress is applied to the knee.

Swelling of the band and structures

PHYSICAL EXAMINATION AND DIAGNOSIS

Ober Test

In this test  patient is side lying with test side facing up

Knee may be extended or flexed to 90° or 30°

Hip in slight extension

The test leg is abducted, then allowed to lower the leg i.e adduction towards the table

Inability to perform adduction indicates tightness of IT band.

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PHYSIOTHERAPY MANAGEMENT

Treatments such as ultrasound, friction massage, and ice may also be used to calm inflammation in the IT Band. Iontophoresis, in which physiotherapist uses a mild electrical current to push anti-inflammatory medicine to the sore area to relief inflammation.

Myofascial Release also helps to loosen up the tight fascia or band

Kinesiotaping also helps in  providing relief from pain, swelling and inflammation

Rehabilitation Exercise Regime includes

Standing IT band stretch

Side leaning IT band stretch

Side bending IT band stretch

Standing Calf Stretch

Hamstring Stretch on wall

Quadriceps Stretch