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Running Head: BRACHIAL PLEXUS NEUROPRAXIA

Brachial Plexus Neuropraxia- Radial Nerve: Saturday Night Palsy


Ashley Burzynski, Kayla Ortega, Heather Pantea, & Dereck Temple
OT 525
Saginaw Valley State University

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Brachial Plexus Neuropraxia- Radial Nerve, Saturday Night Palsy
Radial nerve palsy is an injury of the peripheral nerve system, specifically the
radial nerve. The case discussed in this paper demonstrates compression of the radial
nerve versus nerve laceration or fracture of the shaft of the humeral bone. This condition
presents with drop-wrist deformity, in which the wrist and fingers are not able to actively
extend. This deformity impacts normal functional use of the hand during daily tasks
(Hannah & Hudak, 2001).
Occupational Profile
Don is a 22 year old Caucasian male from the Saginaw Bay area. He lives alone
in a single apartment with his family living about half an hour away. Don is currently a
full-time student at Delta College, majoring in data information. He attends around 4
hours of class per week. Don also works as a part-time cashier at Toys-R-Us at 20 hours
per week with 5 hours per shift. For leisure, he enjoys spending time with his friends and
participating in recreational sports, such as volleyball and bowling.
While Dons previous medical history is not extensive, his history does specify
suffering from depression. Don stated that he takes Prozac on a regular basis to treat this
condition. He did not indicate if this has been the only form of treatment he receives for
his depression. Don does not currently have any specific precautions or allergies.
5 days ago, Don went out on the town drinking with friends. When he came
home, he went to sleep with his right arm underneath his head. The next morning he
woke up and found his wrist in the drop-wrist deformity position. He reported that his
condition has not improved since the date of injury, stating that he has had trouble
extending his arm (including wrist and fingers), and cannot flip his arm over in
supination. Don has not received any treatment for this condition prior to occupational

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therapy and is waiting to take a nerve conduction test in 4 weeks to determine the exact
etiology of his injury. Because of his condition, Don has not been able to work and does
not receive unemployment. He is still attending classes at Delta, but is now struggling to
keep up with taking notes and completing assignments.
Don is very concerned about falling behind in school and being able to complete
his school work efficiently, as well as losing his job as a cashier. He states that while his
employer is supportive, long-term absence is not tolerated well and that he could easily
be replaced. His condition of depression also seems to be negatively impacted by his
drop-wrist deformity. Prior to admit, Don was independent with all of his daily activities.
He hopes in therapy that he can improve his injury status enough so that he can maintain
his grades at school and return to work.
Analysis of Occupational Performance
Trophic Changes
No remarkable skin, color, hair growth, or odor changes were observed in the
affected extremity.
Edema
No significant swelling was observed in the affected extremity.
Scars/Adhesions
No significant scarring or adhesions were observed in the affected extremity.
Pain
Don rated his current pain as 0 out of 10. He stated that he does not experience
any pain in the affected extremity and his sleep has not been affected.
Sensation

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When asked about sensation, Don stated that his affected arm feels dead on the
dorsal side. Sensation was examined with two different assessments, the SemmesWeinstein and Tinels test.
Semmes-Weinstein
Sensation of the affected arm was tested on the dorsal web space between digits
one and two (the highest concentration area of the radial nerve.) Testing indicated that
Don was rated at the level of Diminished Protective Sensibility. At this level, Don still
has proper pain and temperature recognition to avoid further injury, but in-hand
manipulation and functional hand use is affected.
The unaffected left arm was cross-tested with the right. Testing indicated that Don
was at a normal level of sensation on the left upper extremity.
Tinels
This test was only conducted on the affected right arm. Finger percussion/tapping
was used over the dorsal side of the arm to test for parasthesias (pins and needles.) A
positive test was indicated at above the elbow and near the brachial plexus area.
Range of Motion (ROM)
Movements that were measured and assessed of the right and left upper
extremities are indicated in the table below. Measurements were taken with a standard
goniometer and were measured in degrees.
ROM
Right
Elbow
Extension
-60
Forearm Supination
30
Wrist
Extension
-5
Radial
0
Deviation
Thumb
Extension
0
Abduction
0
Radial Abduction 0
Finger
Extension
D1-D5: AROM=0,
PROM=Full/WNL

Left
0
80
60
15
25
30
30
WFL

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Manual Muscle Testing (MMT)
Movements that were measured and assessed are indicated in the table below. The
break test was used.
MMT
Right
Elbow
Extension
2/5
Forearm Supination
2/5
Wrist
Extension
1/5
Radial
1/5
Deviation
Thumb
Extension
1/5
Abduction
1/5
Radial Abduction 1/5
Finger
Extension
D1-D5:
1/5

Left
5/5
5/5
5/5
5/5
5/5
5/5
5/5
D1-D5:
5/5

Grip Strength
Dons grip strength test was conducted with the Jamar dynamometer and
measured in pounds. 3 trials were given for each hand and scores are indicated in the
table below.
Jamar
Dynamometer
Trial 1
Trial 2
Trial 3

Pinch Strength

Right

Left

30
15
5

100
80
80

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Pinch strength testing was conducted with the pinch dynamometer and measured
in pounds. 3 functional pinches were tested: pad-to-pad, lateral, and tripod. 3 trials were
given for each hand and scores are indicated in the tables below.
Pinch Dynamometer (padpad)
Trial 1
Trial 2
Trial 3

Right

Left

2
2
5

18
20
18

Pinch Dynamometer (lateral)


Trial 1
Trial 2
Trial 3

Right
5
3
5

Left
25
25
25

Pinch Dynamometer (tripod)


Trial 1
Trial 2
Trial 3

Right
8
7
8

Left
22
21
21

Coordination
The Minnesota Rate of Manipulation (MRMT) was used to test Dons
coordination of the right and left extremity. The test was nonstandardized and only two
rows were used. Don completed the test with his right extremity in 52.96 seconds, while
with his left extremity he completed it in 8.17 seconds.
Daily Living Activities
As previously stated, Don was independent with all activities of daily living prior
to his injury. Don reported that he now has difficulty in a number of areas when
attempting to use the affected extremity, such as using silverware for eating, brushing his
teeth, and pulling up his pants for dressing. Driving is also difficult to do, as he is unable

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to turn the key in the ignition and shift gears with his right extremity and must use the left
extremity to do so.
At work, Don cannot use the scanner to scan items at the cash register and has
trouble with bagging items. He also reported issues with trying to press the buttons on the
register and manipulating money in his hand.
Don stated that at school he is unable to write notes or use his right hand to type
on the computer. Because of this, he cannot complete his school work on time or
sufficiently.
Don stated that he has not currently sought out any assistance from family or
friends to help with daily activities, however, he recognized that he may require some
assistance soon if his injury does not improve. He is very concerned with the quality of
his school work suffering and being let go from his job, stressing that he just wants his
hand working again.
Assessment
Strengths

Other than his current injury, Don is a physically healthy young adult.
Dons condition does not affect his sleep.
Don has support of family and friends available if needed.
Don does not experience pain or discomfort from his injury.
Don is involved in his community through school, his job, and participation in
activities such as bowling and volleyball.

Problems

Decreased pinch strength of the three functional pinches in the right hand

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Decreased muscle strength and active range of motion in elbow extension and
supination, wrist extension and radial deviation, thumb extension, abduction, and

radial abduction, and finger extension of the right hand


Decreased sensation in the right upper extremity (Don is at the diminished
protective sensibility level demonstrated by testing the dorsal web space of the

hand)
Decreased activities in daily living (Don is impacted in areas that include feeding
himself with silverware, personal hygiene such as brushing his teeth, and pulling

his pants up when dressing)


Decreased in work and education occupations (Don is unable to go to work and is
not able to fully participate in necessary tasks at school such as note writing and

typing)
Presentation of wrist-drop deformity of the right hand
History of depression that may impact success of treatment for current injury
Goals
Don will perform the home exercise program when not wearing his dynamic
splint, consisting of AAROM/PROM at least 3 times per day to decrease the risk

of contracture formation and increase functional range of motion in 1 week.


Don will demonstrate proper use and wearing of the dynamic splints for work and

school related tasks within 1 week.


Don will wear and use the dynamic splint 75-85% of the day to correct his dropwrist deformity and increase his functional performance in daily activities within

1 week.
Don will demonstrate proper techniques to compensate for his decreased
sensation in his right hand during the activity of dressing within 1 week.

Current Treatment
Preparatory Methods

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The first intervention of treatment was sensory re-education. This included the use of
sharp/dull objects of eraser and paper clip to test various areas of Dons right dorsal hand
(Earley, 2014). NMES electrical stimulation was also utilized to facilitate wrist extension
and supination for performance of purposeful and occupational activities (Reynolds,
2002). Education was provided for splint wear/care on the two forearm based dynamic
splints and static wrist-cock splint provided. Don was also educated on joint protection
through use of the splints (Moscony, 2007).
Purposeful Activity
Don then was instructed on performance of an active assisted range of
motion/passive range of motion exercise program to do 3-5 times per day with 10
repetitions per exercise (Moscony, 2007). Cone stacking was then performed with both of
the dynamic splints to practice functional splint use related to gross and fine motor
movement. The first splint provided individual finger active flexion and passive
extension. The other had a dowel with a mold to allow active finger flexion and passive
extension of Dons fingers.

Occupation Based Activities


Education/School Based Activity
A desk top keyboard and laptop were utilized to simulate participating in school
activities while Don wore a dynamic splint. Therapists contacted the Delta College
disability services and advocated for Dons current disability and needs, to fully
participate in school-related tasks. During the therapy session, Don was provided with
detailed information on possible services to assist with his current condition which could

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be provided to him if needed. These services include Dragon Natural Speak and assigning
a scribe/transcriber to Don free of charge.
Work/Cashier Activity
A cash register, play money and coins, credit card machine and credit card, price
scanner with items to scan were utilized to simulate work tasks while Don wore a
dynamic splint.
Continuing Treatment
For future treatment, therapists should continue to monitor Dons nerve
progression through sensory reeducation to the right affected limb. As Dons strength and
endurance of the affected right extremity progresses, isometric (place and hold exercises,
reverse blocking) and isotonic (through use of the BTE Simulator) will be provided for
his exercise program. Throughout therapy sessions, the therapists will monitor the
progress of splint effectiveness in Dons functional performance through graded
purposeful and occupation based tasks. Therapists will continue use of NMES to
stimulate wrist extensors for associated movements to allow for increase in range of
motion.
At home, Don will continue to perform A/AROM exercises for 3-5 times per day
with 10 repetitions per exercise. These repetitions per exercise will be increased with the
regained abilities in strength and endurance. Don will also participate in daily living tasks
and work activities, with use of either one of two dynamic splints presented in this
treatment session. Don will include use of the wrist cock up splint during sleep to keep
the wrist in a safe, neutral position and prevent the affected hand from regressing back
into the drop-wrist deformity.

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References
Earley, Donald. Peripheral Nerve Injuries. Powerpoint presentation. Saginaw Valley
State University, University Center, MI. March 2014.
Hannah, S.D, & Hudak, P.L. (2001). Splinting and radial nerve palsy: A single-subject
experiment. Journal of Hand Therapy, 14, 195-201.
Moscony, A. (2007). Common peripheral nerve problems. In C. Cooper (Ed.),
Fundamentals of Hand Therapy (pg. 201-250). St. Louis, Missouri: Mosby
Elsevier.
Reynolds, C. Christopher (2002). Preoperative and postoperative management of tendon
transfers after radial nerve injury. In Mackin, Callahan, Skirven, Schneider, and
Osterman (Ed.), Rehabilitation of the Hand and Upper Extremity, Fifth Edition
(pg. 821-831). Elsevier Health Sciences.