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Case Report: Physical therapy for ulnar neuropathy following MVA in a patient with HALO placement and C2 grade 3 fracture

The patient is an otherwise healthy 56 year old white male involved in an MVA resulting in loss of consciousness. The patient was admitted to a local trauma hospital where MRI and X ray imaging revealed a C2 grade 3 fracture and right ulnar dislocation. The patient was treated with a HALO orthosis placement and non-surgical reduction of the ulnar dislocation. The patient was discharged from the hospital after 5 days to his home where he began home health rehabilitation with OT for his hand. Five weeks following his injury onset the patient began therapy in our outpatient PT clinic. The patient completed the Quick Dash scoring 61.3% disability of the right UE. Examination and evaluation revealed the following objective data;

Examination of wrist and hand: Inspection:

  • Swelling: not observable,
  • erythema: none
  • Bruising: none,
  • Thenar atrophy: mild,
  • mallet deformity: none,
  • Boutonniere Deformity: none,
  • Dupuytrens’s Deformity: mild
  • Heberdens nodes: none, (DIP)
  • Bouchard’s nodes: none, (PIP)
  • Other deformity: none


Right wrist

  • Extension 20 degrees, 3-/5
  • Flexion 45 degrees 3-/5
  • Radial Deviation 17 degrees 3-/5
  • Ulnar Deviation 20 degrees 3-/5

Finger ROM and Strength

  • Adduction: trace activation with true adduction, pt compensating with finger flexion
  • Abduction MMT 2-/5 unable to resist
  • Flexion: 2/5 (see grip test)
  • Extension 2/5 unable to resist
  • opposition: partial ability, unable to contact 5th digit with thumb


  • Flexion: 2/5
  • Abduction 2/5
  • Adduction 2/5

Grip Strength dynamometer (arm at side elbow 90 deg)

  • Right: 34 lbs
  • Left: 105 lbs

Special Tests: Tinels test ulnar groove – negative,

  • Carpal Tunnel: Phalens test: NP, Tinels test (wrist): NP,
  • Cubital Tunnel: Tinels test (elbow) NP,
  • DeQuervain’s tenosynovitis: Finkelstein’s test: NP,
  • Scapholunate instability: Watson’s Test NP,
  • Triangular fibrocartilage Injury: NP loaded circumduction NP
  • Lateral epicondylitis: NP
  • Medial epicondylitis: NP
  • 9 hole peg test:
    • Right: 22
    • Left: NP

Palpation (pain elicited, TrP):

  • Distal radius (neg) , Distal ulna (neg), Anatomic snuffbox (neg) scaphoid tubercle (volar) (neg), TFCC (dorsal ulnar) (neg), ulnar collateral lig (thumb) (neg) PIP/DIP joint (neg), ECRB: (neg), Medial elbow: (neg)

Neurovascular: Sensation: 2 point discrimination (<10mm); No sensory issues

  • Medial nerve distribution : intact,
  • Ulnar nerve Distribution affected with hypersensitivity and decreased sensation at ulnar aspect of hand,
  • radial nerve distribution intact,
  • Distal pulses present.

The most noted physical impairment to the patient was “Pinky in R hand does not adduct towards midline nor does it flex when patient clenches his fist. Pt reports 2/10 Pain in elbow. Numbness and tightness is evident when patient tries to clench fist.” Therapy was initiated with the following goals:

Patient presents with: 1. Disused Atrophy of R UE and hand

  1. Ulnar Neuropathy and partial paralysis
  2. Fine motor dexterity impairment
  3. Decreased intrinsic hand musculature strength Plan: Patient will receive physical therapy 3 x a week for 60 minutes for up 24 weeks to meet goals as follows:.
  1. Goal: Patient will demonstrate improved 5th digit ROM as indicated by ability to fully flex and extend 5th digit Actively, to allow improved function in 4 weeks.
  2. Goal: Patient will demonstrate improved hand function as indicated by improved 9 hole peg test score from 22 seconds to 20 seconds to allow improved function in 8 weeks
  3. Goal: Patient will report improved elbow and hand Pain as indicated by NPRS of 0/10 at rest and with activity to allow pain free function in 8 weeks
  4. Goal: Pt will demonstrate comprehension with H.E.P without correction in 4 weeks to prevent pain due to inappropriate exercise, and allow patient expedited return to prior range of motion, strength and function.
  5. Goal: Patient will demonstrate improved 63 % disability as indicated by improved Quick DASH score to less than 5% to allow improved disability in 24 weeks
  6. Goal: Patient will demonstrate improved grip strength as indicated by hand grip dynamometer measurement of 7 lbs improvement per 8 weeks of therapy to allow age and gender average functional grip of 113 lbs in 1 year

The patient attended 8 sessions of physical therapy over the next 4 weeks (11/20 – 12/23) and demonstrated completion of goal 1, improvement in his grip strength to 45 lbs, QUickDASH improved to 43% disability, and pain in his elbow was reported only after excessive activity. The patient reported constant numbness and tingling in his hypothenar eminence which was helped by ice or heat.

The patient had several episodes of pin site infection and antibiotics were prescribed. The AB did not always address the injection and the PT provided encouragement for follow up with the physician for another AB. The patient had developed HTN for which he received medication from his primary physician. The Patient had to return for the HALO to be relocated due to loosening of the orthosis in his skull. The patient had a few follow-up visits with his orthopaedic doctor who stated he would require surgery to recover and referred back rather exclusively to his inability to cross his fingers as the marker for success. The patient had an NCV which revealed ulnar nerve damage. The 3 month CT scan to review healing of the cervical fracture revealed  _ and the patient had ceased therapy due to his anxiety of doing damage to his neck around this milestone imaging appointment from 12/23 through January 4th, during which time he did not perform his home program.

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