scottish adult brachial plexus injury service

Scottish Adult Brachial Plexus Injury ServiceThe Victoria Infirmary

Langside Road, Glasgow G42 9TY

BPI Service Administrator (direct line) 0141 201 5436

Scottish Adult Brachial Plexus Injury Service

Information for Physiotherapists

IntroductionThe Scottish Adult Brachial Plexus Service was established in April 2004 to offer specialist treatment for patients with brachial plexus injuries. The team comprises of an orthopaedic surgeon, orthopaedic nurse specialist, occupational therapist and a clinical specialist physiotherapist.

In the UK, traumatic injuries to the brachial plexus are relatively uncommon, about 600 per annum. There are on average 40 such injuries in Scotland a year.

These are complex and disabling injuries and require specialist input. It is essential that they are carefully assessed and managed from the outset.

Lateral cord

Musculocutaneousnerve

Axillarynerve

MediannerveRadialnerveUlnarnerve

Medial cord

Lowertrunk

Middletrunk

T2

Suprascapular nerveUppertrunk

From C4

Posteriorcord

C5

C6

C7

C8

T1

Nerves of the Brachial Plexus

Mechanism of injury• Highvelocityinjury-stretchinjury

• Lowimpactinjury-stretchinjury

• Lacerations

If the injury was sustained due to a high velocity accident e.g. a motorcycle RTA, then the likelihood of a more serious pathology is much greater than someone who has sustained an injury from a fall. Patients involved in high velocity accidents are also more likely to sustain other injuries e.g. head injuries, spinal and upper limb fractures and vascular damage.

Patients who have sustained a brachial plexus lesion will present with motor and sensory loss in all or part of the upper limb depending on the extent of the injury.

Clinical factors indicating a relatively mild lesion:

• Lowimpact

• Incompletelesion

• Nopain

• Tinel’ssign

• AbsentHorner’ssign

Clinical factors indicating a more serious lesion:

• Highimpactinjury

• Completelesion

• Burningorshootingpainspresentsincethetimeofinjury

• ?Horner’ssign(ptosisordroopingoftheeyelidwithdilationofthepupil)

Damage to the BP can also occur as the result of tumours or as a result of radiation treatment.

Brachial plexus injuries may occur at the time of birth (Obstetric brachial plexus palsy). There is a separate service for children based at the Royal HospitalforSickChildren,Yorkhill,Glasgow.

Grades of injuryThe damage to the brachial plexus nerves can be classified into four different grades:

1. Pre-ganglionictear ................Nerverootavulsion

2. Post-ganglionictear ..............Neurotmesis

3. Severelesionin-continuity ....Axonotmesis

4. Mildlesionin-continuity .......Neurapraxia

The number and combination of nerves injured are very variable. It should be noted that some patients can present with a combination of root avulsions,post-ganglionictearsandlesionsin-continuity.

Adult brachial plexus injuries fall into two categories:

1. Supraclavicular injuries ..........Nervesdamagedabovetheclavicle

2. Infraclavicular injuries ............Nervesdamagedbelowtheclavicle

It is possible for nerves to be injured both above and below the clavicle.

Supraclavicular injuriesSupraclavicular injuries can be caused by a traction injury to the brachial plexus e.g. in a motorcycle accident where the head is side flexed and the shoulder girdle is depressed, or through direct trauma e.g. knife injury or gunshot wound.

Preganglionic tear

Surgicalrepair impossible

Neurotmesis - surgical repair

possible

Postganglionictear

Axonotmesis - recovery possible

Neurapraxia

Common patterns of supraclavicular injury occur and can be subdivided into three groups:

1. UpperplexusC5,6(+/-C7and+/-C8)IfC7andC8areinvolvedtheroots are sometimes avulsed. There is less likelihood that the roots of C5andC6willbeavulsed.

2. Totalplexus-thereisdamagetoallnerveroots.C5,C6mayhavepostganglionicruptureswiththerootsofC8andT1avulsed.

3. Lowerplexus-therootsofC8andTIareavulsedbutC5andC6areworking normally.

Avulsion injury/Preganglionic injuryA high velocity accident is more likely to cause avulsion of the nerve roots from the spinal cord. If the nerve roots are avulsed in this way, there is no successful method available for re-implanting the rootlets(experimentalworkisunderwayattheRoyalNationalOrthopaedicHospitalin Stanmore). Patients presenting with avulsion injuries usually complain of an instantaneous onset of pain. This is commonly described as a deep burning pain with frequent shocks of shooting pains throughout the day. The pain is caused by deafferentation of the dorsal horn, which means that with no input from the periphery, pain information passes from the dorsal horn to the brain unmodulated. Interestingly, these patients usually do not have problems with sleep disturbance due to pain.

Apart from the clinical examination, an MRI scan will often help to confirm the diagnosis. From the scan results, the location of the root avulsion can sometimes be seen, as there is the presence of a meningocele (sack filled withCSFleakingfromthespinalcord).

Althoughre-implantationofnerverootletsisnotwidelyused,othermethodsof restoring nerve supply can be undertaken, e.g. nerve transfers. This will vary from patient to patient and will depend on the extent of the damage andthereforethefeasibilityofusingunaffectednerves.Commonlyusednerves for nerve transfers are the intercostals, accessory nerve and the medial pectoral nerve.

This group of patients will always have some form of motor deficit. Secondary operationsmaybeconsidered-forexampleanunstableshouldermaybenefit from a shoulder arthrodesis.

Infraclavicular injuriesThis type of injury can affect any one or all of the peripheral nerves. The most common presentations are:

• Acompletelesion

• Damagetoaxillarynerve

• Damagetomusculocutaneousnerve

These injuries are usually caused by excessive tractioning of the brachial plexus e.g. following shoulder dislocation or in conjunction with a fractured humerus.

As with all BPI, assessment including muscle testing, sensation testing and neurophysiology tests help to complete the clinical picture. It is especially important to check with those patients presenting following shoulder dislocation that the disruption of shoulder movement is not caused by a tear in the rotator cuff.

Where there has been a severe infraclavicular injury affecting several peripheral nerves, the surgeon may choose to reconstruct only some of the peripheral nerves. This could be because the gap between the damaged nerve ends is too wide to successfully bridge. Sometimes if a nerve is irreparable it is used to reconstruct another peripheral nerve.

Surgical patientBefore deciding to operate the surgeon will take into consideration the age of the patient. Older patients are known to not recover as well from reconstruction surgery as younger patients.

There are two categories of surgical patient:

1. Primary

2. Secondary

Primary repairsThese are normally carried out as soon as possible and usually within 3 months of injury.

1.Nervegrafting/reconstruction

2.Nervetransfer

Nerve graft/Nerve transfer

Post-operativelypatientswhoundergonervegraftingandnervetransfersare managed in a similar way.

Patients are normally admitted to the Orthopaedic ward, one day prior to surgery. They will usually have been assessed (see appendix 1) at the Brachial PlexusInjuriesClinicpre-operatively.Inadditionotherinvestigationssuchas neurophysiology tests and MRI will already have been done.

OtherassessmenttoolsusedattheclinicaretheDASHquestionnaire,HADScore (HospitalAnxietyandDepressionScore)and theNarakasScore.These are recorded at regular intervals.

When a patient is admitted to the ward the physiotherapy inpatient staff liaisewiththeClinicalLead,SpecialistNurseandOccupationalTherapist.A unified approach is important to avoid conflicting information being given to the patient.

Rehabilitation1-4 weeks post-op Patients are usually discharged from the ward on Day 2 or 3 post- operatively.

Outpatientfollow-upisarrangedwhenthedischargedateisknown.Thisisorganisedbythephysiotherapyin-patientstaff.Oncethereisconfirmationof the arrangements, the information is passed to the BPI physiotherapist. Operation notes are available and a copy can be requested from the BPI administrator.

After nerve grafting and nerve transfers, the patients are immobilised in a polysling for 4 to 6 weeks. During this time they are not allowed to move their shoulder, however they should be encouraged to maintain the movements of their wrist and fingers.

It is possible that patients will have sustained multiple injuries, which will also require rehabilitation. If the patient has been treated at another hospital for other injuries sustained at the time of their BPI then it is usual for that hospitaltocontinuewiththereview/managementoftheseinjuries.TheBPIserviceisspecificallyfundedtotreatBPI’sonly.

4-6 weeks post-opThepatient isnormally reviewedat theBPIclinicoroneofMr.Hems’Orthopaedicclinicsbeforethepolyslingisremoved.However,ifthetimingdoes not coincide with the next clinic appointment and the operation notes clearly specify when the sling is to be removed you can go ahead and remove the sling. If in doubt contact a member of the BPI team.

When the sling is initially removed the patient will be apprehensive. Sometimes there is increased pain due to the change in position, so it is important to advise the patient to take their pain medication before treatment.

As one would expect once the sling is removed the patients have restricted passive movements of the upper limb. It is therefore important to start on a passive movement programme (see Appendix 4). If they have any active movements then this should also be started. There are usually no restrictions as to what they are allowed to do.

Characteristic limitations of movementShoulder joints: ........................Elevation, abduction, lateral rotation

Elbow joints: ..............................Extension and supination

Wrist joints: ................................Flexion and extension

MCPjoints: ................................Flexion

PIP joints: ...................................Extension

Soft tissue changes• Reducedwebspace

• Shorteningofthelongflexors

• Fibrosisoftheintrinsicmuscles

(Victoria Frampton 1999 Journal of Hand Therapy)

If the movements of the shoulder are very restricted it is useful to show a relative how to help with the exercises, particularly lateral rotation and abduction. Once a reasonable passive range has been achieved, the patientcanstart tocombinemovements (i.e.elevation/abductionandlateral rotation) and continue their exercise independently. This is an importantaspectofthepatient’supperlimbmanagement.

If the patient is happy to keep the sling off then this should be encouraged. If not, gradually reduce the amount of time that the sling is worn for. Some patients like the comfort of the sling when they go out, or when they are playing football.

Aims of treatment• ·Increase/maintainrangeofmovement

• ·Mobilisetightscartissue

• ·Maintaingoodjointposition,splintifnecessary

• ·Discuss/helpwithpaincontrol

• ·Improvepostureandbalance

• ·Encouragereturntoworkorsport

In terms of rehabilitation, the main aim is to maintain joint range of movement, improving muscle power in any group of muscles that have surviving motor units and regain a maximum level of function.

PainSome patients who have severe pain may find pain relief modalities helpful (i.e.TENSoracupuncture).Themosteffectivemethodofeasingpatient’sawarenessofpainisbyactionanddistraction.TheClinicalNurseSpecialistoffers relaxation therapy and counselling whilst Occupational Therapists can also utilise relaxation and visualisation techniques as a part of a pain management programme and discuss various coping skills that can be utilised with chronic pain.

Since causalgia is related to tension and stress, relaxation techniques are beneficial in pain management. Some patients may be referred to their localpaincontrolteam.However,theirpainmedicationisdiscussedatthe clinic and recommended changes in their drugs are conveyed to the patient’sGP.

For patients complaining of mechanical pain related to shoulder sub- luxation, it may be worthwhile trying a shoulder support. A variety of these are on the market.

“Return to work is vital in the rehabilitation of these patients, not only to get back to normal life, but, if they are suffering pain, this is probably the only consistent means of providing distraction from pain”.

(WynnParry,1984)

One year +Patients should be starting to show signs of recovery in the nerves that havebeenreconstructed.EarlysignswouldbeaprogressiveTinel’ssignwhich would become apparent before other signs of recovery. Once a flicker can be detected in a muscle it is important to intensify treatment again.Itmaybethatpatientsareshownanti-gravitypositionstoexercisein, or use muscle stimulators over motor points (see Appendix 1) or ice brushing. Sometimes it is hard to convince the patient that the muscle is working as no movement is being produced. Once recovery starts it normally continues to progress. Recovery may continue for 4 to 5 years.

Aim of surgery and expected outcome The aim of a primary repair is principally to improve motor function. However,primary surgical repair can aim to improve sensory functionparticularly protective sensation in the hand.

The expectation from primary repair is to achieve elbow flexion. Results in terms of effective shoulder control have so far been mixed with some patients requiring a secondary operation for shoulder arthrodesis.

Handandwrist functioncanbe improvedwithprimary surgerybut ifnecessary can benefit from secondary operations e.g. tendon transfers and bony fusions.

Secondary operationsSecondary operations fall into two categories:

·1. Bonyfusions

·2. Tendontransfers

Bony fusions will only be considered when there is no chance of further useful recovery. The joints most commonly fused are the wrist and the shoulder.

Shoulder arthrodesisThis is one of the most common secondary operations undertaken. It is performed because the patient has poor shoulder control but has gained other functional return in the hand and elbow. Due to the lack of control at theshouldertherestoftheupperlimb’sfunctioncannotbemaximised.Inorder for the patient to be suitable for this procedure they must have good thoracoscapular muscle power e.g.upper trapezius, serratus anterior.

Rehabilitation

Following shoulder arthrodesis patients are immobilised in an abduction brace for at least 6 weeks. They are advised about the position, function and appearance of the brace. Once the brace is removed they can start passive and active movements. The range of movement usually progresses quite quickly, with the expectation that they will be able to achieve between 60 to 90 degrees of elevation and abduction.

The patient is warned that they will have loss of medial rotation, hand behind back and that the arm will hang in a slightly abducted position.

Tendon transfersTendon transfers are considered at a later stage, usually at about two years post injury. Sometimes tendon transfers will be considered before this to aid function while recovery in the nerves takes place.

Tendontransfersaremostcommonlyperformedinthehand.However,occasionally free muscle transfers may be used to improve elbow flexion e.g. gracilis.

Patientswhopresentwithavulsionoftherootsoflowertrunk(C8-T1)only may eventually be appropriate for tendon transfer. In order for this

to be successful it is important to teach the patient how to maintain joint range of movement and to maximise the strength in the muscle groups which are still functional. Tendons used for transfer must be a Grade 4 or better. Tendon transfers in the hand must be planned so that pinch and grip will be improved.

Rehabilitation involves the re-education of function, occasionally withtrickmovementsorwiththeco-ordinationofothermovementse.g.wristextension with finger flexion. Operation notes will be available with some indicationoftheexercises/functionalmovementsthatthepatienthastoperform.

The non-surgical group of patientsPatients who fit into this category are those who have suffered temporary damage to the conduction of the nerve for example a neurapraxia or an axonotmesis or those who have had a virus causing a brachial neuritis. These injuries/pathologiescantakefromseveralmonthstooverayearto recover and it is therefore essential that the patient understands this and knows the importance of maintaining joint range of movement while waiting for recovery.

Rehabilitation of the non-surgical patientPhysiotherapy input is important and it needs to be tailored to suit the individual patient. Reassurance is one of the key issues and it is important to fulfil this role. It may be that the patient only needs to have treatment once every 4 to 6 weeks if they are managing their exercises and have good range of movement.

It may be necessary to provide some form of splinting to aid function or to maintain hand position. If you feel that this would be beneficial and are unable to provide this type of splinting please contact the BPI service.

When planning return visits you should take into consideration the stage of recovery and estimated time for signs of recovery starting. Sometimes early signs of recovery are difficult to detect and this highlights the importance of accurate record keeping. Once a flicker of muscle contraction can be detected the patient should then be started on exercises to maximise this improvement e.g. ice brushing, muscle stimulation (see Appendix1AandBformotorpointchart),gravity-assistedexercises.

Even the smallest sign of recovery gives the patient tremendous encouragement.

The Brachial Plexus Service also has a number of muscle stimulators which areavailableonloan.ContacttheBPIServicePhysiotherapist.

Simplified diagram of the brachial plexus

Adduction -Pectoral nerves(C5, 6, 7, 8)

SHOULDERExternal Rotation -Suprascapular nerve (C5)

Abduction -Axillary nerve (C5)

Ulnar nerve

Extension -Radial nerve (C6, 7, 8)

FINGERS

Adduction -Ulnar nerve (T1)

Flexion -Median (and Ulnar) nerve(s) (C7, 8)

THUMBAbduction -Median nerve (C8, T1)

WRISTExtension -Radial nerve

ELBOWFlexion -Musculocutaneous nerve (C5, 6)

Median nerve

Radial nerve

C5C6C7C8T1

Musculocutaneous nerve

Extract from 'Guidelines on management and transfer of Brachial Plexus Injury', Scottish Brachial Plexus Injury

Service.

Brachial plexus peripheral nerve distributionSuprascapular nerve C5,6

Shoulder Girdle:

Supraspinatus

Infraspinatus

Long thoracic nerve C5,6,7

Shoulder Girdle:

Serratus anterior

Axillary nerve C5,6

Shoulder Girdle:

Teres minor

Deltoid

Musculocutaneous nerve C5,6

Arm:

Biceps

Coracobrachialis

Brachialis

Median nerve C6-T1

ForearmandHand:

Pronator teres; Pronator quadratus; APB; Opponens; FCR; Palmaris longus; FDS; FDP to index and middle fingers; FPB (lateral head); Lumbricals

Radial nerve C6-T1

Arm:

Triceps - long, lateral and medial head

Brachioradialis

ForearmandHand:

ECRL

ECRB

Supinator; EDC; EDM; ECU; APL; EPB; EI

Ulnar nerve (C7) C8-T1

Forearm and hand:

FCU

FDP (ring and little fingers)

FDMB; ADM; ODM; Interossei; Lumbricals; Adductor pollicis; FPB (medial head)

Brachial plexus peripheral nerve distribution and functional limitationsNerves Muscles Functional limitations

SuprascapularnerveC5,6

(Shoulder girdle)

Supraspinatus

Infraspinatus

Weakened lateral rotation of humerus.

LongthoracicnerveC5-7

(Shoulder girdle)

Serratus interior 'Winged scapula'.

Difficulty flexing outstreched a r m a b o v e l e v e l o f shoulder.

D i f f i cu l ty p rot rac t ing shoulder.

AxillarynerveC5,6 Teres minor

Deltoid

Loss of arm abduction.

Weakened lateral rotation of humerus.

Musculocutaneous nerve C5-7

(Arm)

Biceps

Coracobrachialis

Brachialis

Loss of forearm flexion and supination.

MediannerveC5-T1 Pronator terres

Pronator quadratus

APB;Opponens;FCR,Palmarlongus; FDS; FDP (to index and middle); FPB (lateral head)

Lumbricals

'Monkey hand' deformity.

Weakened grip.

Thenar atrophy.

Unopposed thumb, loss of pinch grip.

RadialnerveC5-T1

(Arm)

Triceps (long, lateral and medial head)

Brachioradialis

Absent/weaksupination.

'Wrist drop'

Extensor paralysis of fingers and thumb.

RadialnerveC5-T1

(Forearm and hand)

ECRL;ECRB

Supinator

EDC; EDM;ECU;APL; EPB;EI

Loss of wrist, thumb and finger extension.

UlnarnerveC8-T1

(Forearm and hand)

FCU

FDP (ring and little)

FDMB; ADM; ODM

Interossei

Lumbricals

AP; FPB (medial head)

'Clawhanddeformity'.

Interosseus atrophy.

Loss of thumb abduction.

Modified from Pedretti, L in Pendleton & Krohn (2006)

Further reading

Birch,R.,Bonney,G.W.L.,&Parry,W.C.B.(1998)

Surgical Disorders of the Peripheral Nerves

Churchill Livingstone

Lundborg, G. (2004)

Nerve Injury and Repair. Regeneration, Reconstruction and Cortical Remodelling (2nd Ed.)

Elsevier Churchill Livingstone

Pendleton,H.M.&Krohn,W.S.(2006)

Pedretti’s Occupational Therapy (6th Ed.)

Elsevier Mosby

Salter.M,&Cheshire,L.(2000)

Hand Therapy, Principles and Practice

Butterworth Heinmann

Spinner, R., Shin, A., Bishop, A. (2004)

Update on brachial plexus surgery in adults

Current Opinion in Orthopaedics, 15. pp 203-214

WynnParry,C.,B.(1984)

Clinics in Plastic Surgery

Brachial Plexus Injury Service Team - contact names and telephone numbers

Lead Clinician: TimHems

(Contactbelow*)

Clinical Specialist Physiotherapist: Jane Green

0141 201 5541

Clinical Nurse Specialist: Beverley Wellington

0141 201 5394

Occupational Therapist: DebbieClyde

0141 201 1500

BPI Service Administrator: *DavidMcKay

0141 201 5436

Brachial Plexus Injury Service Websitewww.brachialplexus.scot.nhs.uk

Brachial plexus injury management guidelines (see Appendix 2) and referral forms can be viewed and downloaded.

Appendix 1A - Motor points (anterior aspect of right arm)

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0-5)

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time:

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er fl

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Det

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of

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t (l

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or

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sloc

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EDIC

AL

ILLU

STRA

TIO

N

• O

RTH

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2/21

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REF

ER A

ND

TR

AN

SFER

Add

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Pect

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ian

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)

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dial

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culo

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ian

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culo

cuta

neou

sne

rve

Appendix 2 - Guidelines on management and transfer of Brachial Plexus InjuryAlso available at www.brachialplexus.scot.nhs.uk

Appendix 3 - BPI Injury Patient Assessment Form

The Victoria Infirmary, Glasgow

National Brachial Plexus Injury ServicePatient Assessment

Patient details

Name; DoB; Address; Telephone

Use addressograph label if available

Dominant hand:

Occupation:

Date of injury:

Social support: Yes No Family Partner Alone

List other injuries:

Previous treatments:

Brachial Plexus details

Side affected:

Open or closed injury:

Arterial Injury: Yes No

Pulses affected in limb:

If absent, is there critical limb ischaemia?:

Horner’s Sign: Yes No

Tinel’s Sign: Yes No Site:

Site of bruising:

Referring hospital:

Consultant:

Chest x-ray:

C-spine:

C-spine MRI:

Relevant past medical history:

List of medications:

Excessive alcohol use: Yes No Units/week:

Drugs (IVDA): Yes No

MRSA status + / - OR swabs taken:

Date / /

Details of incident (low or high energy. penetrating etc.)

Chart continues overleaf

Motor Assessment(Grade 1-5) Comments

Trapezius

Serratus Anterior

Supra / Infraspinatus

Deltoid

Pectoralis Major

Lat. Dorsi / Teres Major

Biceps

Triceps

Wrist Extensors

Extensor Digitorum

EPL

FCR

Palmaris Longus

FCU

FDPs

FDSs

FPL

Thenar Muscles

Interossei

Sensory Assessment(Normal, Altered, Absent)

C5

C6

C7

C8

T1

Median nerve

Ulnar nerve

Radial nerve

Passive movement

Shoulder

Elbow

Hand

Functional Scores

DASH Score

Narakas Score

VAS Score

HAD Score

Employment status

Employment status key:Return to previous employment 1Return to different employment 2Training 3Not working 4

VI MEDICAL ILLUSTRATION • ORTHO • 10849

Appendix 4 - Exercise Programme

The text and illustrations below are an extract from the patient information bookletforbrachialplexusinjurypatients'ScottishNationalBrachialPlexusInjuryService-InformationforPatients'.

Physiotherapy Exercise ProgrammeThe following programme of exercises is designed to help you be as independent as possible while doing the exercises.

You will be told when you are ready to start these exercises. A physiotherapist will show you exactly what you have to do.

The shoulder and elbow exercises are usually started at 4 to 6 weeks, once the Polysling has been removed. The wrist and hand exercises can be done while the Polysling is on. You should repeat each exercise 10 times, twice or three times each day.

Shoulder exercises1. Lying on your back, clasp

your affected arm by the wrist or hand and lift your arm above your head. This should gradully improve until you are able to take your arm all the way above your head as shown.

2. You will need help with this exercise. The person helping you puts one hand across the top of your shoulder to stop it moving. With their other hand they grasp around your elbow and then fix your forearm between their body and side. Your arm is then moved out to the side as far as possible

1. Shoulder

2. Shoulder

3. Shoulder

3. You will need help with this exercise. The helper holds around your elbow to keep your arm close to your side. Their other hand holds around the wrist and in this position turns your arm out towards them.

4. Once your movement improves enough for you to reach above your head, you can stop exercises 2 and 3 and use this combined exercise instead.

Lift your affected arm up as far as you can and put your hands behind your head. In this position, stretch your elbow back towards the pillow.

Elbow exercises5. While standing, hold your

affected arm around the wrist and help bend your elbow up as far as you can.

4. Shoulder

5. Elbow

6. Straighten your elbow out as far as you can. To help you get more straightening, place your other hand behind the point of elbow.

If you find this difficult, try adding a light weight as shown below.

Wrist exercises7. While seated, help your

affected hand by putting palm to palm and push the wrist back.

8. While seated, place yourunaffected hand over the back of your affected hand and bend the wrist forward.

6. Elbow. Try adding a light weight to help straighten your elbow.

7.Wrist

8.Wrist

9. Holdyouraffectedhand inthe mid part of the palm and turn your hand up.

10. Holdyouraffectedhand inthe mid part of the palm and turn your palm down.

Hand exercises11. Use your unaffected hand to

help bend your fingers into your palm. Make sure you bend your fingers from the knuckles so you are curling your fingers as much as possible.

9. Wrist

10. Wrist

11.Hand

12. Spread your fingers by placing the fingers of your unaffected hand in between the fingers of your affected hand and strech them apart.

Thumb exercises13. Stretch your thumbs across

your palm as far as you can.

12.Hand

13. Thumb

14. Thumb

14. While seated, fix your hand between your knees and stretch your thumb away from the fingers.

VIMEDICALILLUSTRATION • ORTHO • 10679

scottish adult brachial plexus injury service

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