Case Study: Nerve Injury

Mr. Finch is a 40-year man who ruptured his right biceps tendon when lifting heavy legal file boxes.

Medical Information

Following surgical repair of the biceps tendon, Mr. Finch was found to have a posterior interosseous nerve palsy, for which he required an additional three surgeries. These included tendon transfers (pronator teres to EPL and FCU to EDC and EIP), intrinsic releases (index - ring fingers), FDS tenodesis (index - ring fingers) and pinning (index - little PIP joints).

Activities of Daily Living

Mr. Finch is independent in his personal care activities, but has difficulties performing all tasks that require fine manipulation and bilateral gripping, hand strength, and lifting. He now prefers to use his non-dominant hand whenever control, holding or speed is required. He requires assistance for many homemaking activities and relies mainly on the left hand when driving. He writes very slowly and deliberately and cannot control his right fingers at the computer keyboard. Mr. Finch unsuccessfully tried switching to write with his left hand.

Occupational Performance Issues

Mr. Finch has not regained full usage of his dominant right hand and has been unable to return to work as a paralegal. He cannot perform the typing required for this work.

Recreation

Mr. Finch can no longer do weight training with free weights, ride a bicycle or play the piano.

Key Evaluation Findings

• Reduced forearm rotation (40% for supination, 25% for pronation)
• Reduced wrist flexion (75%) and deviation
• Requires tenodesis to facilitate finger flexion
• Limited isolated finger movement
• Inability to close fingers to the palm; lacks about 5 centimeter closure
• Minimal proximal thumb mobility
• Significant limitations in hand strength relative to men his age
     • Grasp of 25 pounds, reduced 80%
     • Pulp pinch reduced 70%
     • Lateral and 3-point pinch, each reduced 50%
• Weakness of dominant hand relative to non-dominant hand (75%)
• Consistent effort on multiple hand strength tests
• Inability to use hand in a coordinated manner for fine and medium manipulation
• Slow and deliberate writing
• Minimal use of hand to type
• Poor control for brief and light lifting/carrying; < 10 pounds with only RUE

Summary

Mr. Finch has limited mobility of the right forearm, wrist, fingers and thumb. He uses compensatory whole arm posturing, cannot supinate the forearm to receive objects; uses a tenodesis motion to facilitate opening and closing of the fingers and has limited isolated finger motion. Mr. Finch’s right hand is very weak: his grip is reduced 80% relative to that of men his age and 75% relative to his non-dominant hand. All functional pinch grips are reduced by >50%. Mr. Finch has very restricted abilities to use the right hand for fine and medium manipulation, sustained holding, lifting and carrying.

In summary, Mr. Finch’s right hand usage is limited to that of a gross functional assist. This hand can no longer be used as the dominant hand for manipulative or strength activities, or the performance of daily home or recreational activities. Mr. Finch is also unable to resume work as a paralegal as he cannot write or type more than briefly.

Contracted right finger postures affect easy of performance of everyday tasks.

Mr. Finch is unable to firmly grip a shopping bag with his right hand and now
relies on the left hand for this and similar lifting/carrying tasks.

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