Contracture Management + Nerve Injuries

What do muscles act on?
Joints, not bones in a straight line
Single muscles relies on what to extend?
Outside forces
–Gravity
–Environment
–Antagonistic Muscles
Agonist
Muscle that contracts while another relaxes
Antagonist
Muscle that opposes the action of another
Dysfunction definition
Absence/impair of normal function
–Dysfunction of agonist/antagonist leads to dysfunction of the other
Total ROM
The degree through which a joint may move, actively or passively
Active ROM
Degree to which a voluntary muscle group is capable of directly moving a joint it acts upon
Passive ROM
Degree to which a joint may be moved from force outside of muscles acting directly on the joint
Active ROM Determinants
Muscle contractility
Muscle strength
Nerve conduction
Pain
(All P-ROM)
Passive ROM Determinants
-Bony joint features
-Articular surface integrity and alignment
-“Allowed” by regional anatomy/physiology
—Muscles, tendons, ligaments and other non-bony elements
—Adipose or other soft tissues about the joint
Muscle Protective Feedback Mechanism
Inhibition of muscle action secondary to swelling/inflammation to avoid pain
–Disappears with anesthesia
Contracture definition
Adaptive muscle shortening
-Fibrous connective tissue stiffness
-Scarring from burns
Collagen Fibers
Inelastic, strong, fibrous tissue present in every component of the musculoskeletal system
-Fascial Sheaths, Joint Capsules, ligaments, aponeuroses
Proteoglycan function
Gel-like substance surrounding collagen
-Provides support and lubrication
Inactivity effect on collagen/proteoglycan
-Proteoglycan undergoes water loss, chemical breakdown, thickening
-Collagen fibers start to lose ability to alter alignment relative to each other
-ROM Decreases
-As soon as 3 days!
Major causes of contracture
-Inactivity during acute illness
-Rigid immobilization
-Stretch inhibition by spasticity
-Scar tissue accumulation
Elastic Contracture
Yields under body weight or use to allow near-normal function
-Rare
Rigid Contracture
Obstructs motion without allowing functional use
-Often treated orthotically
Naming contractures
-Named by joint and shortened muscles acting on joint

-Quantified by number of (-) degrees lacking from normal ROM
–Elbow ROM 0-150 flex
–Elbow Flexion Contracture of -15
(15-150 degrees)

Therapeutic vs Functional
Therapeutic; short term, during therapy

Functional; longer term, for use throughout the day

Upper Motor Neuron Syndrome
Accompany stroke/CVA/TBI
-Impairment of motor control
-Spasticity
-Muscle weakness

-Limited by pain, skin breakdown, harm to limb and time involved in preventing contractures

Pharmacological treatments
Phenol or Chemodenervation/Botox to overcome spasticity
4-10 weeks to take effect
Remains for 3-6 months; paralysis of contracted muscles to target weakened muscles
Brachial Plexus Injuries
-Orthotists involved with C5-T1 level injuries
Flail Arm
-Full brachial plexus injury
-No shoulder movement or anything distal
-Shoulder subluxes over time w/o muscles to support ligaments
-Orthotic treatment to limit displacement and maintain distance between GH/Elbow
–Sling/Wilmer SEWHO
Erb’s Palsy
C5-C6/Upper BP

Waiters Tip: GH internal rotation, elbow extension, wrist flexion

Orthotic treatment; prevent/limit contractures and maintain arm in functional position
–Sling/SEWWHO after tendon transfer
-Atrophy can occur in as little as a week

Klumpke’ Palsy
C8-T1/Lower BP
-Ulnar nerve palsy with intrinsic minus hand
-Treat the same as ulnar nerve injury (Claw hand)
Radial Nerve Palsy Causes
C6-T1/Peripheral nerve

Causes: dislocation of shoulder, humerus mid shaft fracture, crutch pressure, Saturday Night Palsy, heavy trauma

Radial Nerve Palsy motor signs
-Extensor paralysis, inability to supinate, muscle atrophy of forearm/triceps within 2-3 days of injury

-Distal to triceps; elb. E possible
-Distal to BR; Supination possible
-Distal to Forearm; Wrist Extension possible

Radial Nerve Palsy Orthotic Treatment
-Prevent Wrist Flexion
-Prevent Finger/Thumb flexion contracture

-Static WHO
-Need thumb spica and outriggers to extend fingers
-MCP Flexion stop
“Resting Who +Thumb spica + MCP Flexion stop

Median Nerve Palsy Causes
Lacerations of the arm, forearm, wrist or hand
Trama due to MVC, stab, GSW, attempted suicide, SNP
Median Nerve Palsy Signs
-Loss of pronators, finger flexion, thumb opposition/abduction

-Ape Hand; atrophy of thenar eminence, thumb is in plane of hand, weakened grip in thumb/index finger
-Inability to make fist

Median Nerve Palsy Orthotic Treatment
-Maintain web space (C-bar/spica)
-Maintain thumb abduction
-Maintain Palmar Arch

-WD-Who w/ thumb bar
-RIC WD-WHO
-HO is insufficient

Ulnar Nerve Palsy
-Cause; same as others
-Claw Hand
-Weak wrist flexion/ulnar deviation
-Inability to extend middle phalanges w/o intinsics or abd/add fingers
-Atrophy of interossei/hypothenar eminence
Ulnar Nerve Orthotic Goals
Stabilize the thumb
-Prevent hyper extension of 1st MCP
-4/5 mcp ext stop
Median + Ulnar Nerve Palsy
Claw hand + Ape Hand
-Can’t flex PIP/DIPS
-Ext of all 4 MCPs
-Whole hand atrophy
-Thumb; everything gone but extension

-WD Who w/ 4/5 digit incorporated w/ MCP Stop

Prevention Goals
-Short term devices as clinical scenario may be rapidly changing

-Casting to maintain muscle fiber length, combine with injections

-Decreased sensation warrants extra attention

Correction Goals
Serial castings at 1-2 week intervals

-Manipulate/stretch limb prior to application
-Static progressive could be effective

-Maintenance; durable orthosis once joint has reached desired position

Electrical Stimulation function
-Applied as dynamic orthoses; especially if deficit believed to be transient since Estim not tolerated well long term
Shoulder post TBI
Flaccid paralysis may recover after weeks/months
–Concern of dislocating/subluxing

-Lap board
-Slings
-Humeral cuff
-Abduction pillow (bed bound patients)
-E-stim

Elbow following TBI
-Elbow flexor spasticity is common in post CVA/TBI population
-Chemodenervation, Dynamic elbow orthoses; provide force across elbow to increase joint motion