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
–Antagonistic Muscles
Muscle that contracts while another relaxes
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
(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
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
-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
-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
-Humeral cuff
-Abduction pillow (bed bound patients)

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

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