Neurologic Impairments
Irreparable nerve injuries, head injuries, neck fractures and stroke can all have serious impact on hand and arm function. The results are paralysis, loss of feeling or loss of control.
Nerve Injuries
Great technological strides have been made in repairing cut or crushed nerves in the hand and arm. Microsurgical methods of nerve repair are now common-place. However, there are still occasions when nerve repair is either not advisable or not possible. This results in varied degrees of muscle paralysis and numbness.
Various reconstructive methods are available to the hand surgeon to restore function and feeling. The transfer of one or more tendons or muscles to replace the function of paralyzed muscles probably forms the centerpiece of these reconstructive methods. In most cases, such tendon transfers have to be delayed to allow recovery from initial wounds and fractures. During this period, a coordinated effort between the hand surgeon, the patient, and the hand therapist is important in preventing stiffness in the joints which cannot be spontaneously worked. Similarly, after surgery the same concentrated effort is required to re-educate the transferred muscles in their new function.
Sensory loss in some respects is similarly addressed by transferring skin with the attached nerve from other areas of the hand, arm, or other parts of the body to the areas of the hand with lost feeling. This frequently requires microsurgical methods and a period of sensory re-education coordinated by the hand therapist.
Spinal Cord and Neck Injuries
Injuries to the spinal cord from neck fractures produce paralysis and numbness similar to nerve injuries, but is generally much more extensive. The treatment principles are similar, but timing and judgment are more critical.
Stroke and Head Injury
Some unique problems in rehabilitating the hand and arm can result from stroke and head injury. They create not only paralysis but violent contractures or spasms of the muscles involved. These spasms place the joints of the hand, wrist, elbow and shoulder in extremely unnatural and non-functional positions.
Nerve blocks by medication injection can relieve these violent spasms and allow therapy to prevent permanent joint stiffness while initial recovery takes place.
After the maximal recovery period, the goals for reconstructive surgery are to relieve pain, to provide passive mobility to contracted joints, to facilitate personal hygiene, or to improve function.
In the most severely affected limbs, violently painful spasm and contractures persist. Simple personal hygiene requirements such as washing under the arm or within the palm are impossible. Release of contracted muscles can relieve pain and provide access to the palm and underarm.
The less severely involved arm with near-normal feeling in the hand will benefit from procedures to restore function. This is generally accomplished by the partial lengthening of residually tight or spastic muscles, combined with selective muscle transfers.