Hands Midterm
What is a macrophage/what does it do in the healing process?
"pac man" cell that helps clean up non viable tissue
From medial to lateral, the bones in the proximal row of the carpals are . . .
(pisiform) triquetrium, lunate, scaphoid.
What is ulnar nerve tension?
Lateral flexion of the head away from the target UE Shoulder external rotation and abduction Elbow flexion and pronation Wrist and finger extension
What does "one wound, one scar" mean?
Layers heal as one scar (not like in individual layers)
What will be affected by the length of the healing time in a burn?
Length of healing time will affect quality of the scar and thus mobility of the resulting skin/scar
What do you do in rehabilitation for a wrist fracture in the mobilization phase?
Mobilization phase Interval protective splinting to maintain or enhance functional gains Continue with protective phase guidelines Increase ROM and mobility Individual joint mobility Extrinsic tendon Intrinsic tendon
What are exercise considerations when doing exercise late in burn rehabilitation?
Moisturize to start - "oil up" Progressively aggressive stretches with exercise, activity, and orthotic devices as the healing scar tolerates Warm-up with light activity and progress in the session to deeper stretches
Severe cases of carpal tunnel have . . .
Most severe have motor involvement in thenar muscles Poor opposition Weak tripod pinch Decreased fine motor coordination Reports of dropping things
A high ulnar nerve lesion will have _______ deficits, and the purpose of early therapy is . .
Motor and sensory deficits: 1. Prevent contracture 2. Education for safety 3. Map deficits 4. Track progress 5. Update HEP as appropriate
What are exercise considerations when doing exercise early in burn rehabilitation?
Move the parts that won't disturb healing grafts Full thickness grafts need to be immobilized, they will do well with delay Split thickness grafts need time to adhere but can tolerate limited AROM Always watch for SHEAR
Extensor inidicis is innervated by . . .
PIN
What are the three branches of the radial nerve you should know?
PIN, Deep branch of the radial nerve superficial branch of the radial nerve
What exercises in the early period should be used in an early mobilization protocol
PIP and DIP exercises with the MP at 0 twice a day MP flexion in the splint 15 times each hour After 3 weeks the patient can "help" the rubber bands extend the MP's
In the boutonniere deformity
PIP flexed, DIP hyperextended. Central slip breaks and lateral bands migrate volarly
In an early mobilization program, after 6 weeks
PROM begins
What are important complications with distal radius fractures?
Pain Pain is difficult to assess and measure. Watch for signs of median nerve compression Watch for signs of increased sympathetic reactivity Subjective and psychological components of pain can be influenced by positive supportive rapport
Cubital tunnel compression will result in
Pain and numbness and tingling in ulnar hand with elbow flexion (Wadsworth Sign)
What is radial tunnel syndrome?
Pain in extensor muscles No numbness and mild weakness in wrist and finger extensors Confused and associated with tennis elbow
How can a repaired tendon rupture?
Passive Stretch Active use of the muscle/tendon unit: (e.g. actively flexing the digits.)
According to the pyramid of power, the least stressful to most stressful on flexor tendon:
Passive protected Place and hold Active composite Hook and straight fist Isolated joint motion Resisted composite fist Resisted hook and straight fist Resisted isolated joint motion
Why can cold cause MSD-UE?
constricts blood vessels, muscles, etc.
What are the three layers of gauze?
contact, absorbing, securing
What processes on the ulna help you orient anterior/posterior?
coronoid process on the anterior, olecranon process on the posterior
wadsworth sign is a sign of
cubital tunnel compression
What is the effect of radiation on soft tissue?
dense scarring
One splint used for extrinsic extensor tightness is the
dinosaur splint (can be turned around to the other side of the forearm to be used for flexion) ; this is a type of dynamic wrist mobilization splint.
Extensor zone landmarks: zone 8 fingers
distal forearm
After 4 weeks of immobilization, in extensor zone II-IV tendon repair, you should
do blocked DIP and PIP exercises and composite AROM
How would you educate the patient about extensor tendon zone I injury
do not bend the finger at any time
What are some real-world, practical considerations for maintaining splint integrity
dogs, hot cars
What kind of splint do you use in flexor tendon repairs?
dorsal blocking splint
The _______ attach to the extensor hood tendons and help to abduct and extend the digits
dorsal interossei
The sensory branch of the radial nerve that breaks off at the elbow is the
dorsal radial sensory nerve
Extensor zone landmarks: zone 7 fingers
dorsal retinaculum
After initial immobilization, central slip injuries should do AROM how often
each hour
A disturbed vein is likely to cause
edema
Viral infections can cause
edema
In what motions will you see impingement between the AC joint and the coracoid process?
elevation of the shoulder.
What kind of movements can we see at the clavicle?
elevation, roll, anterior-posterior movement. These movements combined to make a "circular" type movement.
Extensor zone landmarks: zone 1 thumb
ip joint
During DRUJ fracture treatment, the pronator quadratus
is often shaved off and replaced--causes tightness in supination!
What is purulent exudate
is thick, yellowish and may have odor or can be green/blue/gray ... indicates presence of microorganisms
The goal of treatment in a yellow wound
is to evolve it into a red wound
Contraction of the wound refers to . . .
it getting smaller
Why is lister's tubercle important?
it is an anchor for the extensor pollicis longus.
How does stress affect wound healing?
it slows it down by causing vasoconstriction!
If the lateral band or triangular ligaments are injured
it will make the boutonniere look worse
What are the specifications for a contact layer of gauze?
should be a sterile dressing like xeroform or adaptic (non adherent)
What are the muscles of the rotator cuff?
sits - supraspinatus, infraspinatus, teres minor, subscapularis.
What do the volar wrist ligaments do?
so many! keep carpal bones in line.
Why should you do small reps many times a day in extensor zones II-IV?
so you don't wear out the tendon repair!
What is duration of exertion?
static postures . . . the % of time exertion is maintained in a cycle. Takes into account both exertion and recovery time.
If a person has frozen shoulder, what is happening on an anatomical level?
sticking together of anterior, inferior shoulder capsule.
What is a common form of axontomesis related to birth trauma?
stretch injury to the brachial plexus
What exercise should central slip injuries do?
stretch the ORL! (literally hold the middle phalanx and have them wiggle). They don't have to come the therapy!
Because of the shape of the collateral ligaments of the IPs of the phalanx, they are
stretched when extended and relaxed when flexed
Collagen makes the wound _____, but it also ___.
stronger, contracts.
Pain is always a _____ measure
subjective
The ____ nerve (a division of the radial nerve), provides sensation to the back of the hand in the area near the _____
superficial branch of the radial nerve, thumb
Because it is superficial to the thumb extensor tendons and retinaculum, the _____ is prone to injury
superficial branch of the radial nerve.
During ______, the ulna is less prominent dorsally (in relation to the radius)
supination
What muscles provide supination of the hand?
supinator, BICEPS
The radial nerve, after passing on the lateral side of the elbow, goes under the _______ muscle.
supinator.
If there is a central slip injury (zone II-IV) . . .
surgery may not be needed. Just immobilization!
Because it it is a ________ joint, there is very little movement at the _______ end of the clavicle
syndesmotic, sternal
What kind of therapeutic techniques can you use for metacarpal fracture?
Passive stretch of MP flexion after 8 weeks with "putty push" or dynamic MP flexion orthosis IP flexion taping Composite flexion wrapping with ace wrap Active pick-up objects alternating fingers to thumb
How do you measure thumb retropulsion?
Pencil across metacarpals just proximal to the MCP joints. Measure how many centimeters away from pencil is the tip of the leading edge of the thumb. Once you can touch the pencil, then put ruler on table and see how high they can get on tip of leading edge of the thumb away from the table (in centimeters)
What is intrinsic tightness? How is it measured?
Tightness of the intrinsic muscles of the hand. Measured with Bunnell-Littler.
What medications/drugs can delay wound healing? How and why?
Tobacco use will also delay wound healing by decreasing available hemoglobin Caffeine can cause vasoconstriction Steroids and other medication may suppresses the normal immune system
Whose perception is the intensity of exertion based on?
Worker's perceptions or Rater's perceptions
What conditions can delay wound healing?
Wound healing will be delayed if the patient has poor circulation, diabetes, anemia, COPD etc.
Post surgically, what kind of care can a hand therapist offer for a ganglion that was around a joint)
Wound/scar care (elastic sleeve, elastomer scar pad) Mobilizing the joint with PROM/AROM education Progressive light activity to encourage joint movement in a wrist ganglion, last stage of recovery is usually progressive weightbearing (bathroom scale, press as hard as they can w/o pain - work up to 10x)
CAM action of the metacarpal causes mcp-pp ligaments to be tightest in . . .
a fist.
Sweating under a splint can cause
a fungal infection
Studies have shown that early motion results in . . .
a stronger repair with less adhesions, however this must be accomplished safely.
What is histamine/what does it do in the healing process?
active once bleeding is controlled to produce vasodilation of non injured capillaries
Failure of the ______ will result in froment's sign
adductor policis
Why does a distal radius fracture often cause ulnar sided pain?
affects the tfcc or causes ulnar styloid fracture. affecting tfcc = causing ulnar sided soft tissue pain.
Flexor tendon zone 1 includes:
after insertion of the FDS
In the hand, the ulnar nerve's motor innervations are . . .
all intrinsics, lumbricals of the ring and small fingers, adductor pollicis, flexor pollicis brevis
An "A" pulley is . . .
an annular pulley. these are thicker, can be palpated more easily as they are more prominent, and serve to prevent bowstringing.
The ulnar nerve (forearm) travels . . .
close to the median nerve, then goes back under epicondyle, under the flexor surface, and proceeds ulnarly
Extensor zone landmarks: zone 5 thumb
cmc joint/radial styloid
What are the juncturae tendium
connect fingers tendons in the extensor mechanism. This is why flipping people the bird is hard and ring fingers are almost impossible to extend.
What is the viniculum?
connection between blood supply and tendon; provide a framework for blood supply to reach the profundus and superficiailis tendons
LOOK AT THE COLORFUL SLIDE OF NERVES
LOOK A THE COLORFUL SLIDE OF NERVES
What is serous exudate
clear or slightly yellow: indicator of health of open wound
What kind of splint do you fit for in extensor zones II - IV?
A gutter splint is fitted for continual wear
What happens in fibroplasia?
A network of fibrin is constructed onto which the capillaries can grow Results in healing; healing is granulation tissue (red beefy look in wound) The epithelial cells migrate across this granulated tissue forming fragile skin
After 4 weeks, what kind of AROM should you do for extensor zones 5 and 6
After 4 weeks, AROM begins to wrist and MP's (splint between exercises sessions). Isolate MP motion by taping the PIP/DIP in flexion for exercise
With extensor zones VII and VIII, after 6 weeks, you may need to do some
After 6 weeks, May need to do dynamic flexion splinting
After surgical repair in extensor zones 5 and 6
After surgical repair, edema control to hand and fingers
According to the CHT people, the maximum extension at the finger joints is ______.
0. Do not use pluses or minuses for extension! Instead, record degrees from full extension. Important for things like TAM.
What general factors will affect the wound healing process?
Age, overall health and nutritional status will impact the wound healing process.
What are common OT interventions in burn management?
1. Positioning splints 2. exercises 3. activities 4. pressure garments/devices
What are kanavel's cardinal signs (e.g., list them)
1. Semi flexion finger 2. tenderness only flexor tendon sheath 3. excruciating pain with passive extension 4. uniform volar swelling of the finger
What are the structures of the TFCC?
1.) articular disk. 2.) (luno-carpal) meniscus homologue. 3.) multidirectional ligaments 4.) DRUJ
What are the five groups of things we see on the (mostly volar) forearm?
1.) brachioradialis, 2.) pronators 3.) flexor muscles, 4.) extensor muscles, 5.) median and ulnar nerves.
What are the steps for clean technique of dressing changes?
1.Assemble all materials (dressings topical agents and tape etc) 2. Clean surface being used (towel on table) 3. Open packages of sterile bandaging taking care to leave bandages resting in the package 4. Wash hands and arms thoroughly from elbow down 5.Don clean gloves 6. Remove old bandages, dispose of gloves and bandages. Sanitize hand and put on clean gloves. 7.Don't touch anything that is not clean. Apply the new bandages you have opened. 8.Take off gloves off to apply tape
What is the distribution of the median nerve in the hand?
1/2 of ring middle, index, pad to back of thumb. volar = all, dorsal to pip joint.
Distal radius fractures are estimated to account for approximately ______ of all fractures treated in the ER
1/6
When icing for edema, ____ minutes is plenty for icing
10
How hot should the whirlpool be for whirlpool therapy?
100 degrees
Flexor tendon zone _______ is "no man's land"
2
How many flexor tendon zones are there on the thumb?
2
If you are treating extensor I tendon injury, and you are less than _______ weeks post injury, you can treat ________-
3, without surgery
When does early mobilization for extensor tendons begin? why?
3-5 days after repair; repair weakens if not mobilized
How much tendon excursion do you need in early mobilization for extensor tendons? why?
3-5 mm of tendon excursion keeps the tendons from adhering, keeps the MP joint loose and decreases edema
If I have a volar plates avulsion fracture, it has to be splinted in (TEST QUESTION)
30 degrees of flexion
What is Phalen's test?
30 seconds of wrist flexion (hands back to back) - numbness is tingling in the median nerve distribution. Pain or general numbness is not positive.
What is the most stable CMC joint of the hand?
3rd metacarpal to capitate.
How many flexor tendon zones are there?
5
How many sesamoid bones do you have in each hand?
5 (3 thumb, 1 index, 1 little finger)
How long does the inflammatory phase usually last
5 days
How long is the maturation phase?
6 months to a year? can be earlier and longer.
After ____ weeks, you can wean someone off of a volar DIP hyper-extension splint as long as there is no
6, extensor lag in AROM
How many extensor zones are there?
8 for the EDC; and 5 for EPL
What is the standard for coordination measurement
9-hole peg test
Less than 3 weeks from a central slip injury
< 3weeks from injury, immobilize in PIP cast for 6 weeks
Greater than 3 weeks from a central slip injury
> 3weeks, serial cast to achieve 0 degrees, then 8 weeks of PIP cast
What is meant by place and hold
@ 2/3rds fit - Stay in protected position, and passively place the fingers in a 2/3rds fist and ask if the patient can HOLD the position (splinted)
If there is a problem getting passive ROM in flexor tendon repairs
A dynamic flexion component is added to the splint
What is antideformity position?
A position of the hand that will stretch the PIP and MP ligaments to their maximum, while also allowing muscles to work best when released.
What is a clean technique?
A way of minimizing infection; not quite as strict as a sterile technique, which would require a sterile field.
How can you treat stiffness/pain in the forearm post DRUJ
A/PROM Joint mobilization Splinting FES (to encourage supination)
Joint stiffness in fingers post DRUJ fx can be treated?
A/PROM exercises (tendon glide positions) Taping into flexion (5 minutes) Dynamic or static progressive splinting (30 minutes3x/day) Joint mobilization FES
What are the most important flexor pulleys?
A2, A4 (A2 is the most important)
The most important pulley to prevent bowstringing is
A2, which is by far the fattest.
The best treatment for digital edema is
AROM with isotoner gloves @ night (make a dent in finger by morning where seam was)
What is intensity of exertion?
An estimation of the force requirement of the task. The magnitude of muscular effort required to perform the task 1x
What does "hand wrist postures" refer to in the strain index?
Anatomical position of the wrist and hand relative to neutral position (awkward postures) Based on raters perceptions
What surgical procedures are available for cubital tunnel syndrome
Anterior Transposition: The nerve is moved out of the cubital tunnel so that the tension on it is reduced Submuscular Transposition: The nerve is placed under the flexor/pronator muscle groups ... in this case the muscles will have been cut and resisted pronation/wrist and digit flexion should not be performed strenuously too early.
Should you use antibiotic creams in a red wound?
Antibiotic creams should be avoided unless wound is too dry
Should you use antiseptics in a red wound?
Antiseptics such as hydrogen peroxide or iodine are cytotoxic and can delay healing
How can we reduce awkward postures?
Appropriate position of material to worker Put objects on jigs Tilt/rotate objects Reduce reach requirements Avoid putting materials above shoulder or below knee levels Work at proper heights (to keep hands low and elbows at your sides) Use appropriate tools
What is the "pyramid of power", conceptually?
Article Uses the information from experiments with force on tendon with various exercises to guide post tendon repair exercises
How do you treat extrinsic extensor tightness?
Combination digital flexion and wrist flexion exercises Digital taping with passive wrist flexion Dynamic composite flexion splinting
In an early mobilization program, after 7 weeks
At 7 weeks begin weaning off the splint and strengthening begins
How can you treat radial tunnel syndrome?
Avoid deep massage of extensor bellies (which is often told to do for tennis elbow) Muenster splint to neutralize wrist and forearm No tennis elbow straps Pulsed U.S. and/or hivolt estim over painful area
Explain the branching of arteries from axillary down.
Axillary - brachial - divides at elbow - radial and ulnar.
How do you measure radial abduction of the thumb in degrees?
Axis at CMC joint (the part stays still when moving the thumb from adduction to radial abd). Put hand on table. one of the arms is on the second metacarpal, one is at the first metacarpal.
What are the three ways of making a fist
B: "Rooftop" - Intrinsic plus C: straight fist D: hook E: composite fist
Explain the path of the radial nerve on the dorsal upper arm.
Comes out from underneath teres major and wraps around the humerus. Goes through the intermuscular septum. Branches off to the posterior cutaneous nerve.
Where is the labrum of the shoulder and what can happen if it is damaged?
Large ring of cartilage at the edge of the glenoid fossa. Tears can cause joint instability.
The musculocutaneous nerve is formed by branches of ___________.
C5, C6, C7
If there is a median nerve laceration, what are the steps of the evaluation and treatment?
Careful motor and sensory evaluation Opponens splint or strap After 3 weeks, wrist tenodesis exercises begin After 6 weeks, composite finger wrist, elbow extension as tolerated Strengthening as muscles return
Flexor tendon zone 4 includes:
Carpal tunnel, thenar muscles
What is closed reduction
Casts, splints Percutaneous pins External fixator
What changes can we make to hand tools?
Change handle type/shape/size Improve grip surface/size Lighter or counterbalance tool Anti-vibratory material Spring opening Electric tool Tool maintenance
How do you treat a yellow wound?
Clean and remove nonviable tissue. Wound can be washed with soap and water and irrigated with water pik or syringe or sterile whirlpool.
How can you keep pin-site infections clean?
Clean with new "Q-tip" on each area (some people use peroxide on the q-tip).
How can you clean a red wound?
Cleaned with saline/water
Before assigning a subtask, what do you need to assess?
Clearly define the sub task being assessed Which hand are you assessing Measure the average cycle duration time
What steps are important in caring for an infection?
Client education (hygiene, home wound care, signs of spreading, reinforce MD instructions) When in doubt, refer back to MD Careful measuring and documenting Avoid modalities that cross contaminate or spread infection Keep the area and equipment sanitized
What is a foam dressing?
Comprised of polyurethane, foam dressings have small open cells that absorb wound drainage and keep moisture away from the periwound area the outer covering is waterproof and will act as a bacteria barrier
What do the palmar arches do? How many are there?
Connect radial and ulnar arteries. There is a superficial arch and a deep arch. If one side is injured, the other side received blood from the anastamoses.
What is conservative treatment for ganglions?
Conservative treatment is compensatory strategies
What are major considerations when treating burns?
Consider the depth of the burn, total area, how the skin was repaired, part of body affected
What causes cubital tunnel syndrome?
Continuous positioning with elbow flexed Direct Pressure (bumping or leaning on elbow) Hypertrophy of flexor/pronator muscle groups Subluxation of Ulnar nerve on medial epicondyle
Where is flexor tendon zone 4? What's good about this? What's bad about this?
Flexor tendons are in the carpal tunnel They have good nutrition The median nerve is often involved with injuries in this zone
When is immobilization a good choice in tendon repair?
It is fine to immobilize young people with clean simple lacerations
What are the pinch meter contact surfaces for each type of pinch
Lateral - thumb to side of fist Tripod - finger tips to pad of thumb Tip pinch - just index pad to thumb
What is radial nerve tension?
Lateral flexion of the head away from the target UE Scapular depression and shoulder extension Elbow extension and pronation Wrist flexion and thumb adduction
What treatment activities may you be doing in the strengthening/functional activities phase?
Grip/UE strengthening through repetitive active motion , activities first then PRE's Return to work/ work conditioning Functional activities
When are gripping and pinching introduced post carpal fractures
Gripping and pinching gradually introduced as tolerated
How can we reduce efforts per minute?
Design task to reduce steps and to improve efficiency Let tools do the work Eliminate piece work Reduce pace Discontinue overtime
What is median nerve tension?
Lateral flexion of the head away from the target UE Scapular depression and shoulder horizontal abduction Elbow extension and supination Wrist, thumb and finger extension
Extensor zone landmarks: zone 2-3 fingers
Middle phalanx, PIP joint
What is the strain index? Who developed it? What does it assess? What does it consider?
Developed by Moore & Garg (1995) A semi-quantitative job analysis methodology to assess if a distal upper extremity job task is potentially "hazardous" (ie. may cause MSD-UE). Combination of physiological, biomechanical, and epidemiological considerations
What do you in rehabilitation for a wrist fracture in the immobilization/protective phase?
Immobilization/protective phase ADL training /compensatory techniques Protect injury Decrease pain Edema control Mobilization of uninvolved joints Digits and thumb, elbow and shoulder
What are special considerations with nerve injuries?
Extra care with use of heat with any nerve injury When a repair has been done, review the precautions of overly stretching the nerve Nerve glides put slack on one portion of the nerve and tension on another
Which tendon is the most medial tendon on the wrist?
FCU
What are the borders of the flexor tendons?
FCU, FCR
High ulnar nerve lesions will not have strong clawing because
FDP is not flexing the digit
What muscles do we see in the deep volar view?
FDP, FPL, FCU, FCR
What muscles do we see in the volar view of the forearm.
FDS
90% of wrist injuries are a result of
FOOSH
What is the anti-deformity position for the hand?
FOR THE HAND: MP's flexed, IP's extended, thumb abducted Wrist 15-30° extension, neutral forearm Elbow is extension, but if the burn is dorsal a 90° flexed posture Shoulder abducted and externally rotated as tolerated (airplane splint)
The ____ is the only tendon that goes to and can flex the tip of the thumb.
FPL
The AIN innervates the
FPL, FDP to index and long, pronator quadratus
What kinds of problems are common at the level of the cervical plexus?
Impingement caused by bone spur, arthritis, disk rupture.
What are common tests to measure hand function?
DASH COPM Informal interview Checklists Jebson hand function test Hand Dominance
Describe what an infection might look like in skin with more melanin?
Darker in color, can be ashy, compare to non-injured side.
In what order does sensation usually return?
Deep pain (muscle, bone, often poorly localized) Vibration (tuning forks) Hot/cold Moving touch Light touch
What are signs of increased sympathetic reactivity
Course hair growth, swelling in fingers, excessively dry or sweaty, pain outside of the normal fracture area
Joint stiffness in fingers post DRUJ fx are because
Digits - limitations due to restrictive casting, extrinsic tightness or limited excursion of flexor tendons
What can be done to treat limitations in digits post DRUJ fx?
Digits - limitations due to restrictive casting, extrinsic tightness or limited excursion of flexor tendons A/PROM exercises (tendon glide positions) Taping into flexion (5 minutes) Dynamic or static progressive splinting (30 minutes3x/day) Joint mobilization FES
What causes carpal tunnel syndrome
Direct pressure over volar wrist Hyperflexed or extended postures (day or night) Increased edema (trauma, pregnancy, metabolic or cardiac disease) Arthritic changes in the wrist Lumbrical muscle hypertrophy
What can prolong the inflammation phase?
Dirty wounds and overly aggressive therapy prolongs the process
What is the piano key test?
Disruption at distal radioulnar joint. See how "bouncy" the ulna is. Stabilize radius front and back with one hand and depress the ulna. Should feel stable if normal
What is the DRUJ?
Distal radial ulnar joint.
Where is flexor zone 3? What does this have to do with the lumbricals
Distal to the carpal tunnel to the 1st pulley Lumbricals take their origin from FDP in this zone
What is the modified duran program
Dorsal blocking splint with the wrist in 20 degrees flexion, MP in 70, IPs extended Passive ROM within the splint each hour (goal is to get all the way to the palm within a week or so) After 4 weeks, add AROM within the splint At 4 ½ weeks the DBS can be removed to do AROM of the wrist and fingers in isolation and in combination No resisted gripping until 8 weeks!!
How are wrist flexor tendons treated in therapy
Dorsal blocking splint with the wrist in 20-30 degrees flexion, MP and IPs FREE Passive ROM within the splint each hour At 4 ½ weeks the DBS can be removed to do AROM of the wrist Wear the splint except during therapy and home exercise until 8 weeks!!
What is the distribution of the radial nerve in the hand?
Dorsal hand surface not covered by median or ulnar nerve (superficial branch of the radial nerve)
What is happening in proliferation?
Fibrin formed, then crosslinked with actual cells (collagen).
What are good treatment activities for ulnar nerve injuries?
Finger "scissors" Smooth wrinkled paper Sign language alphabet Shadow animals Pick up game pieces with SF/RF to thumb
What structures are involved in damage to extensor zones IV, V, VI
EDC, EIP, EDM
Measurement of thumb retropulsion is useful in rehab of the ___ tendon
EPL
What tendons form the anatomical snuffbox?
EPL dorsally, EPB, APL volarly
What are OT general treatment techniques for fracture
Edema control Pain Management Immobilization fracture Mobilization for the non-involved joints Training in adaptive ADL's and IADL's
In early mobilization for extensor tendons, _________ is critical
Edema control is critical (elevation, ice, compression)
Elbow fractures have what kind of outcomes?
Elbow fractures have a high complication rate and poorer outcomes.
What types of control are used to address hazards in the workplace? (e.g., what kinds of changes in control are there?)
Engineering Administrative Work Practice
What is the finkelstein's test?
For dequervains tenosynovitis. Positive = pain at RADIAL STYLOID.
What forearm structures are commonly affected in DRUJ?
Forearm- result of tightness of radiocarpal ligament, interosseous membrane, avulsion of the TFCC or tearing of the pronator quadratus
Where is flexor tendon zone II? What makes it no man's land?
From the A1 pulley to the insertion of the FDS FDS and FDP must closely glide against one another in this zone - cutting here often makes so much scar tissue that the finger cannot move
How can you palpate the coracoid process?
From the concavity at the lateral (distal) end of the clavicle, drop inferiorly off the clavicle to find the coracoid process of the scapula
What is included in flexor tendon zone 1
From the insertion of the FDS to the insertion of FDP Includes pulleys A4, C3, A5
What are the motor innervations for the radial nerve
From the posterior interosseous nerve ECRB Supinator Extensor digitorum EDC EDM Extensor carpi ulnaris EPL Extensor indicis Abductor pollicis longus Extensor pollicis brevis
What are critical considerations in activity participation for the patient?
Full thickness grafts need to be immobilized, they will do well with delay Split thickness grafts need time to adhere but can tolerate limited AROM
What are important differences between full and split thickness grafts?
Full thickness grafts need to be immobilized, they will do well with delay Split thickness grafts need time to adhere but can tolerate limited AROM
What are the priorities in management of tendon injuries.
Get a surgical report Observing edema and wounds/sutures Pain management Following the orders and communicating with the physician
What is the ligament of struthers?
Goes from supracondylar process of humerus to medial epicondyle. forms a tunnel that holds down the brachial artery and median nerve.
How do you measure palmar abduction of the thumb in degrees?
Goniometer axis is at CMC joint. One arm on the first metacarpal, one at the second. (degrees)
Describe how you would measure supination of the wrist
Goniometer horizontal between tendons of FCU and FCR. Vertical parallel to humerus.
Describe how you would measure pronation of the wrist.
Goniometer horizontal on Lister's tubercle of the radius down to the ulnar styloid. nice, flat, two points of contact. Vertical parallel to humerus.
What is one way to measure finger abduction?
Have the client spread the fingers as wide as possible.Trace the "turkey hand picture". Use middle finger as the stable center. Measure distance from the center of the middle finger to center of each finger in centimeters.
What is the most common kind of vascular tumor in hand practice?
Hemangiomas - raised red bumps Only intervention required from therapist is to provide protection strategies if it is getting bumped
What is a hydrogel dressing? What are they designed to do?
Hydrogel dressings are primarily water in an inert matrix or gel form. Hydrogels are designed to hydrate a dry wound.
Where is the triangular ligament
It's job is to hold the lateral bands where there are and keep them from slipping volarly
How can we reduce duration per day?
Job rotation Job enlargement
In extensor zones ________________, after surgical repair, __________ is the most critical
II-IV, edema control
PROM to conteract ulnar claw hand is
IP extension with MP flexion
The contracture for damage to the ulnar nerve is
IP flexion with MP hyperextension
Kanavel's cardinal signs are used to determine what?
Infection in the flexor tendon (may or may not know there was an injury)
What is intrinsic muscle tightness and how do you treat it?
Intrinsic Muscle tightness-limitation in digital flexion of the PIP and DIP joints with MP's in extension Interosseous stretches Lumbrical stretches
What are some methods of open reduction
Kirscher's wires, plates with screws
What does the splint look like for early extensor mobilization?
Long dorsal outrigger with the wrist in 40 degrees extension The finger slings hold the IP's extended MP motion allowed by the splint should be 0-35 degrees For night wear an MP block splint is made (make this 1st in case the patient can't tolerate the process of making 2 splints)
What can happen after collagen formation, in terms of therapy
Loss of motion can occur if the wound does not heal promptly and normal tissue motion is not achieved
FPB does what motions?
MCP flexion and palmar abduction
What do the lumbricals do?
MCP flexion, IP extension
How do you measure radial abduction of the thumb in centimeters?
MP crease of index finger to IP crease of thumb.
What are therapy considerations for radial nerve therapy
Maintain passive extension, supination, and intrinsic stretch A wrist splint may be enough Tendodesis or dynamic extension splint TAP splint to facilitate supination
What are some limitations of the strain index?
Many measures are subjective Does not take into account compression forces Does not take into account increased strain due multiple tasks Does not account for cold, vibration, etc.
How do we treat finger phalanx fractures in therapy
Maximal tendon glide while protecting the bone Edema control Anti-deformity position is IP's extended, MP's flexed
Are ganlions on tendons mobile?
May move with tendon excursion; May feel mobile if it moves with the tendon
What information should you gather in assessment?
Medical past Description of current issue Normal activities before problem Surgical report/x-rays if available
Flexor tendon zone 3 includes:
Middle of palm, complicated, before carpal tunnel
Homemade elastic garments are better than nothing! What are some good ideas for this?
Muscle shirts and sports sleeves are comfortable Socks with elastic can work on arms Foam wedges between the fingers
What is MSD-UE?
Musculoskeletal disorders of the upper extremity
Once cast is off, central slip injuries must wear . . . .
Must wear the PIP splint between exercises another 2-3 weeks and at night
How can you treat carpal tunnel syndrome?
Night splints in neutral wrist with or without MP extension Nerve glides Finger stretches lumbrical Finger flexors preventing aggravating postures in daily life
Flexor tendon zone 2 includes:
No man's land - insertion of FDS to A1 pulley
What does a pin site infection normally look like?
Normal to have some pinkness and crusty exudate
What is a carpal boss?
Not a ganglion A bone spur "bump" on the dorsal hand Can be arthritic in origin or from fracture or dislocation Not usually symptomatic
What things should you notice re: posture?
Notice the way a person carries their arm The position of the head and neck Normal vs. Abnormal finger postures
carpal tunnel syndrome is
Numbness and tingling in the radial hand (thumb, index middle and half of ring) Starts with night numbness More severe cases have symptoms in the day
Boutonniere deformity can be differentiated from psuedo-boutonniere deformity
ORL tightness (test for PIP flexion contracture... eg., trying to determine why they can't straighten their PIP and you need to determine if central tendon was ruptured.) IF THEY CANNOT ACTIVELY FLEX THE DIP, THIS INDICATES B.D.
How does motor recovery usually progress? How can we track it?
Occurs generally proximal-distal from the site of the lesion Progress can be tracked through isolated MMT using the innervation charts Approximately one inch a month
Where is lister's tubercle?
On the back of the hand. Find the radial styloid under the thumb. Move medially.
What are the three phases of wound healing?
Phase 1: Inflammation Phase 2: Fibroplasia (Proliferation) Phase 3: Maturation
What is the first phase of fracture healing?
Phase I - prior to stability or clinical healing ( 0-2 weeks)
What is the second phase of fracture healing?
Phase II - Fracture site is stable, early AROM (2-8 weeks)
What is the third phase of fracture healing?
Phase III - Fracture is healed, PROM and strengthening initiated (>8 weeks)
What is efforts per minute?
Repetition Number of efforts occurring per minute Synonymous with frequency formula=(number of exertions / total observation time in min)
What is a black wound?
Presence of eschar will increase the work required by the macrophage and delay healing ... will need debridement:
_______________ can make a huge difference in skin quality in the long term. This is why it is important to emphasize this in patient education.
Pressure garments and/or scar pads (gel pads)
What is the treatment for cubital tunnel syndrome?
Prevent prolonged elbow flexion in daily activity Headset for phone Elbow extension splint for night (30-60°) (volar) Wear an elbow pad stretch the wrist flexors and pronator ulnar nerve glides
What is the conservative treatment for ganglions around joints?
Rest of the joint in a splint (6-8 weeks) to remind you not to put excessive stress on a joint. Avoiding aggravating activity (e.g. no push-up with a wrist ganglion)
What does the median nerve innervate, motor, in order as you cross the elbow?
Pronator teres Palmaris longus FCR FDS Then the anterior interosseous branch >FPL, FDP to index and long, pronator quadratus > Motor branch to the thenar muscles 1st and 2nd lumbricals
What is the primary objective in treating a red wound?
Protecting the wound environment.
How can we reduce duration of exertion?
Provide jig/machine to hold object Increase efficiency of operation Break task into smaller operations Ambidexterous work Adequate rest breaks
How should we medically treat phalanx fractures?
Proximal phalanx usually requires MP immobilization Middle phalanx requires PIP and DIP to be immobilized Distal phalanx usually in a mallet finger type splint Tuft fractures, just a finger tip protector
What surface anatomy aspects should you notice?
Proximal to distal scan Shape of bony prominences Joint shape Comparison of right to left
What is a yellow wound?
Pseudomonas bacteria can be present ... wound may have odor ... draining and purulent ... semiliquid slough .. Dominant cellular activity is the macrophage ... epithelialization will be delayed due to infection
In extensor zones VII, VIII, you can put the person in what kind of positions? . . .
Put wrist in progressive positions for the MP extension exercises - > e.g, wrist flexion to allow for mp extension. also experiment with supinated and pronated position
What are medical goals for elbow fracture management?
Re-establish articular congruity Obtain acceptable alignment Provide rigid fixation to begin active motion ASAP Stable anatomic reduction and early mobilization will prevent or minimize loss of joint functional motion
What are signs of pin site infections?
Redness that is increasing in size; thick drainage; Increasing pain and edema
What are some ways to resume exertion (force)
Reduce force required for job Optimal grip/pinch size/shape Reduce weight, size of object Increase friction between object and hand Optimal relationship of objects to body Move objects closer Have machines/tools do exertion
What are common causes of MSD-UE?
Repetition Force Awkward/static postures Cold Contact Stress Vibration Stress
What is an AC joint rupture?
Rupture of the ligaments that attach the acromion process to the calvicle. Can be palpated as a large bump at the AC joint (step deformity)
Early care for zones VII and VIII . . .
Same early care as Zone V &VI
What should you look for about skin quality?
Scars- color, size, shape and texture Edema - soft, hard, pitting Color of the skin
When is surgical treatment recommended for ganglions on tendons?
Surgical treatment is only recommended when pain and dysfunction are not tolerable
What is a low ulnar nerve injury?
Sensory and motor deficits based on exact location of injury Therapy starts with MMT of the affected muscles "Turkey hand" picture is helpful for measuring progress of abduction Padded palm protection Activity modification Ultrasound or low level laser
When should hydrogel dressings not be used?
Should not be used on moderate to heavily exuding wounds due to risk of maceration
How can you treat joint stiffness in the shoulder versus DRUJ
Shoulder - limitations are the result of disuse and dependent positioning Avoid arm slings A/PROM exercises Overhead pulleys Joint mobilization
Should you use antibiotic creams in a yellow wound?
Silvadene or Bactroban or other antibiotic OK
How can you debride a black wound?
Surgically or mechanically; Proteolytic enzymes ie. Trevase or elase
What are metacarpal fractures treated medically?
Splint or casted with MP in flexion, IP's free to prevent deformity Axial Rotation (adjacent fingers must be included) Contractures from bone to tendon adhesions or ligament shortening After 6 weeks, start with light activity out of the splint After 8 weeks, may begin strengthening
What kind of splints do you do for extensor zones 5 and 6
Splint with wrist in 20 degrees of extension and MP's extended, with PIP and DIP free for AROM
What do the interosseous membranes of the forearm do? What do they allow for?
Stability during pronation and supination, while allowing for longitudinal movement - > the ratio of the ulna and radius at the distal end changes during pronation and supination!
How does strength compare in dominant and non-dominant sides?
Strength: dominant extremity has 10 -15% greater power than the non-dominant side
Is surgical intervention necessary on ganglions around joints?
Surgical intervention is not necessary unless pain or pressure on other structures is a problem
What is herpes whitlowe?
Swelling, red
This part of the wrist is OFTEN injured in wrist sprains and fractures.
TFCC
The ligaments between the _____ and _______ form a sling for the ____ (carpal bone).
TQ, radius, lunate. (meniscus homologue)
What is tinel's test
Tapping over median nerve as it goes into carpal tunnel; tap just proximal to the carpal tunnel. See if the nerve is hypersensitive to touch. Tingle = positive.
What is early mobilization a good choice in tendon repair?
Tendon injuries that were dirty or had other soft tissue damage do better when they are mobilized early
What is resisted wrist extension test a test for?
Tennis elbow--will hurt at lateral epicondyle.
What is the alcohol drop test?
Test for cold sensitivity. Drop of alcohol, e.g., on back of skin. Positive if painful.
Extensor zone landmarks: zone 1 fingers
The DIP joint
The UE is a functional unit, and the elbow . . .
The UE is a functional unit, and the elbow is the link for placing hand in space.
What is intersection syndrome?
The angle of the extrinsic wrist/finger extensors vs thumb extensors is different; they can rub together.
What happens in the maturation phase?
The collagen content gradually decreases The wound becomes stronger
The elbow functions as . . .
The elbow functions as a stabilizer for power and fine motor function
What happens in the inflammation phase?
The immediate response of the body to cleanse and debride Clots are formed Macrophages go to work
How does a patient use a dynamic flexion assist in flexor tendon repairs
The patient the extends the fingers against the rubber bands then relaxes for the exercises The fingers are strapped in against the splint at night
What do the pulleys of the fingers essentially do?
The pullyes are straps that hold down the FDS and FDP straps in the fingers.
The terminal branches of the brachial plexus include . . .
The radial, axial, median, ulnar, musculocutaneous nerve.
What is the capitulum?
The section of the humerus that articulates with the radius.
What is the trochlea?
The section of the humerus that articulates with the ulna. Looks like a spool of thread.
What does the clavicle connect?
The sternal end connects to the sternum. The acromial end connects to the acromion process of the scapula.
What is included in flexor tendon zone 5?
The tendon and muscle tendon junction proximal to the carpal tunnel
What does "duration of task per day" refer to in the strain index?
The total time that a task is performed during the day Measured in hours per day Obtained by either direct measurement or by asking plant personnel Video - 8 hours per day
How can you treat edema in DRUJ fractures?
The trauma to the soft tissues can be more significant than the fracture itself. Tight casts can also impede venous drainage Edema decreases mobility, elevation is the best way to control edema in the early stages. Distal to proximal massage helps reduce edema and provides tactile input Compressive wraps helps decrease digital edema
What are therapeutic goals for elbow fracture management?
Therapeutic goals are to Minimize edema Up to week 3, AROM in limits per physician Up to week 8, Low load AA/PROM to full range Addressing elbow flexion and extension and forearm pronation and supination Functional adaptation and safe use education
What are techniques for elbow fracture management?
Therapeutic techniques Edema: compression stockinette or wrap Manual edema mobilization AROM: Reaching activities with upper arm supported Low load stretch: Upper arm supported with "just right" weight on wrist Static progressive or dynamic extension or flexion devices Pronation/supination stretch activity: Stretch with a hammer Towel stretch
What is the innervation of the lumbricals?
They are divided right. Ring and little finger - ulnar, index and middle = median
An infection in the flexor tendon is important because . . .
This is an emergency and can spread and lead to loss of limb and life; can easily go septic.
How long does fibroplasia last?
This is the proliferative phase that last 2-4 weeks
Can you use antibiotic creams with a black wound?
Topical antibiotics OK
What is TAM
Total active motion
How can we reduce speed?
Train workers to work efficiently Slow production line/requirements Add more workers
What does TP stand for, and where is it?
Trapezium, distal row, closest to the thumb.
What is the treatment for malignant tumors?
Treatment would proceed based on the structures that were compromised by the surgery (e.g. bone, nerve, skin, tendon)
Which ligament of the elbow has 3 bands? What are they?
UCL. anterior, posterior, oblique
What is the UCL? What does it do?
Ulnar collateral ligament. It provides stability against varus and valgus movement.
What is a red wound
Uninfected, definite borders, granulation tissue present, apparent revascularization Myofibroblasts, epithelial cells present
What is sterile whirlpool therapy?
Use Chlorazene packet in whirpool Turn whirpool on for a few minutes to let Chlorazene circulate Whirpool can help hydrate wound and do gentle debridement apply for 12 minutes
When do you use early mobilization for extensor tendons?
Use especially if periosteum was violated along with tendons in zones V-VII
What treatments should be avoided after malignant tumors?
Use of heat modalities and ultrasound and e-stim would be avoided as a general rule
What is a lipoma?
Usually soft and somewhat mobile Can be anywhere in the UE Can be large Not usually surgically removed
What are some common report measures for pain?
Visual analog (scale of 1-10) Body diagram Quality description of the pain (aching, tingling, burning, throbbing) Time line of changes in pain
How is extensor I tendon injury treated?
Volar Splint the DIP in hyper-extension 15 degrees
How can you measure edema?
Volumeter: Stick between middle and ring finger, thumb toward the spout. Figure-8 - is a tape measure technique of the dorsal hand edema
Cubital tunnel usually results in what kind of motor impairment
Weak lateral pinch Weak finger abd/add weak intrinsic + (MP flexed with IP extended)
What is a wet-to-dry dressing? How is it performed?
Wet to dry dressings are used to help debride wounds with significant debris/necrotic tissue ie. yellow wound. First a gauze pad is soaked in saline solution, balled up and placed over the wound ... then a dry pad is placed on top and then the securing layer ... when the dressing is changed ... non viable tissue is pulled off .... Needs to be changed ever 6 hours.
What is happening in fibroplasia.
When the fibrin matrix is being created - > in late fibroplasia (2nd phase, e.g., proliferation), collagen crosslinks are being formed.
What is a neurofibroma?
With removal can cause nerve damage and require reconstruction
What are the specifications for an absorbing layer of gauze?
a 2x2 inch sterile gauze pad etc. ... can cut to desired shape
If someone has continuous bursitis of the elbow capsule, this will look like
a big bursa bump on the back of the elbow.
Comminuted fracture means
a bone is broken into many pieces
What is a neuroma?
a bundle of nerves that are bundled up, like a tumor of nerve cell tissue. It will not regrow down to its original destination
A "C" pulley is . . .
a cruciate pulley. These go around the joints, are thinner and small, and allow the fingers to bend.
How do you measure opposition?
a.k.a., full flexion (tip of thumb to base of small finger) in centimeters, down to half-centimeter - put ruler at base of small finger and have them crawl their thumb down the ruler. (0 cm is the thumb tip touching the base of the small finger).
`what muscle forms the bulk of the hypothenar muscles?
abductor digiti minimi
What does the abductor digiti minimi do?
abducts and pulls the small finger out for cupping. (out and down)
When is the coracoid process a common location of impingement?
anterior dislocation. It is possible to fracture this process.
The ok sign is a sign of
anterior interosseous injury (AIN palsy) - ok collapses.
After an injury, the _____ portion of the elbow is often stiff. Why is this?
anterior--> capsule shortens volarly during immobilization, in which fibrin replaces collagen in the joint capsule. This limits extension of the joint capsule!
Ulnar styloid fractures post DRUJ . . .
are generally not treated as they will heal normally; however, this will often cause lingering pain and stiffness that takes a long time to go away
Dorsal ganglions are usually . . .
around lunate in wrist flexion.
Disruption of the radioulnar ligaments is likely to cause . . .
arthritis, instability, pain.
After identifying subtasks, you . . .
assign a criterion rating.
After assigning a criterion rating, you
assign rating values based on criterion
When does the collagen content of the wound increase?
at about 3 weeks
How long does low-load long stretch need to be applied to produce change?
at minimum, 20 seconds. up to 5 mins. (in clinic). At home . . . can use a splint up to 30 mins.
Figure 8 measurement generally measures swelling . . . .
at the back of the hand
This nerve can get pinched under the teres minor, causing impingement
axillary nerve
What is no longer a recommended cure for ganglions around joints?
bible method
The ____ tendon of this muscle inserts on the radius and provides force during what movement?
biceps, supination
WHAT DO YOU NEVER DO ON THE SMALL FINGER
blocking. ever.
What is sanguinous exudate
bloody drainage
If someone cannot make a full fist, you want to measure
both full finger flexion and full finger extension!
What is a boxer's fracture
break in the 5th metacarpal at the head
Describe the FDS
broad, very flat muscle that flexes PIPs.
Should you use bacitracin/neosporin to clean a wound?
can be applied to retain moisture and decrease wound bacterial load, but you need to be aware of the potential for allergies. Vaseline is a better choice for a lot of wounds.
If someone is unable to identify their pain via number on a likert scale
can use faces in wong backer
What does CA stand for, and where is it?
capitate, in distal row, between hamate and trapezoid.
Where do the wrist flexors generally insert, e.g., what is the relation of the FDS and FDP?
carpal bones and proximal portion of the metacarpals. The FDS travels on top and inserts into the middle phalanx, where it splits like a snake tongue and inserts on radial and ulnar portions. The FDP goes through the split.
What is a fibroplast/what does it do in the healing process?
cell that produces collagen
Examples of extensor zone 2-3 ruptures are
central slip injuries, boutonniere deformity, lateral bands, triangular ligament
What are the main veins in the arm?
cephalic, basilic, median cubital. (basilic is most medial.)
The nerves of the _____ _______ come out of the spinal cord, and travel through the __________.
cervical plexus, intervertebral foramina.
What is maceration?
excessive fluid retention of wound. Peri-wound area becomes white, and then skin begins to die and peel off.
What does the extensor pollicis brevis do?
extend the mcp of the thumb (due to insertion on proximal phalanx)
In extensor zones VII and VIII, you must try to decrease the ____________ to no less than ___________ and the ________.
extensor lag; 30 degrees; MP
The ____________ prevents bowstringing @ the level of the carpus
extensor retinaculum
People whose __________________ . . . are more viscerally upset, which means . . .
extensor tendons are cut; make the night splint first because they can't tolerate the process of making 2 splints
The extensor pollicis brevis is an (extrinsic/intrinsic) muscles
extrinsic
There are special devices for ______________ and other ________ areas (pressure garments)
face, contoured
How can you palpate the biceps tendon?
feel the anterior part of the shoulder, and have the person internally and externally rotate their shoulder. (This will feel tender if they have tendonitis of the long head of the biceps.)
A _____ splint may be good for claw hand
figure 8
A medicine ball can be used for
flexion/extension stretching, e.g., rolling hand over medicine ball
Compared to extensor tendons
flexor tendons are rounder and thicker
Treatment is the same as the DRF for which carpal bones
for scaphoid and lunate
What splint is used on a scaphoid fracture
forearm based thumb spica with no wrist or CMC motion
What is a barton's fracture?
fracture of the radial styloid, by definition, this fracture is intraarticular
Disorders likely to affect the scaphoid include . . .
fracture, arthritis at the articulation with the proximal radius.
This occupation causes a lot of flexor tendon infections.
gardening -> people get stuck by thorn
What are advantages of whirlpool therapy?
good for dirty, icky wounds that are oozing a lot.
Protocols for therapy following tendon repair are . . .
guidelines only and should be influenced by patient specific factors like age, health, rate and quality of scar formation, location of injury, timing and quality of repair and motivation/ability of the patient to understand the protocol
From medial to lateral, the bones in the distal row of the carpals are
hamate, capitate, trapezoid, trapezium (trapezium connects to the thumb.)
What does HA stand for and where is it?
hamate, in distal row, closest to pinky.
How can you test the FDP
have them bend the DIP of their ring and small fingers while stabilizing the proximal phalanx
For someone recovering from an ulnar nerve injury or an ulnar-median nerve injury, a _____ splint can be helpful
helmet splint--dorsal blacking for ip extension
When is the posterior capsule of the shoulder stretched tightest?
internal rotation + horizonal adduction
What does an intrinsic tightness stretch look like
holding a pen, and stretching the MPs. You want to make sure you are FLEXING the IPs and EXTENDING the MPS.
Where do you lay the goniometer for supination?
horizontal between tendons of FCU and FCR. vertical parallel to humerus.
After assigning rating values you
identify multipliers based on ratings
how are carpal fractures treated
immobilization
What is meant by active composite
in protected position, as them to make a fist (splinted)
Golfers elbow is . . .
inflammation of the wrist flexors that attach to the medial elbow.
How do you define MSD-UE
injury to muscles, tendons, nerves; occurs gradually; combination of physical, emotional, and organizational factors
What innervates the FDP? (motor)
innervations are divided. The median nerve innervates the index and middle fingers. The ulnar nerve innervates the ring and small fingers.
The radial head is always (medial) (lateral) to the ulna
lateral
Where is the common extensor origin?
lateral epicondyle/elbow
For most carpal bones . . .immobilization time
less immobilization time is necessary (3-4 weeks) with early AROM
What is the meniscus homologue?
ligament. borders open space, tfcc crosses over it. it is often the site of scoping.
What is a gutter splint
like a trough. Can be for fingers, wrist - lots of different kinds
Where do you lay the goniometer for pronation?
lister's tubercle on the radius down to the ulnar styloid. nice, flat, two points of contact. vertical parallel to humerus.
What is neuropraxia?
localized pressure on the nerve (symptoms are reversible)
Sesamoid bones may form a part of the pulley system of the hand. When do they "matter"?
looking at x rays.
When you flex your wrist, what carpal bone pops up
lunate
What does LU stand for, and where is it?
lunate, proximal row between scaphoid and the triquetrum.
One example of an extensor zone 1 rupture is
mallet finger--terminal tendon injury
Ulnar side carpal fractures
may require splinting with ulnar gutter
How do volar plates in the MCPS compare to in the PIPs?
mcp = more flexible. pip = less flexible, restrain the joint more (orthotics can cause volar plate tightness).
The ulnar nerve of the elbow progresses from the ______ and through the ______
medial epicondyle, cubital tunnel
Where is the common flexor origin?
medial epicondyle.
The brachial plexus has three cords, the . . .
medial, posterior, lateral
The AIN is a branch of the
median nerve
The abductor policis brevis is innervated by the
median nerve
Extensor zone landmarks: zone 4 thumb
metacarpal
Extensor zone landmarks: zone 6 fingers
metacarpal
What is interval protective splinting?
might use that splint during the day for certain protective activities
Why are the cmc joints more stable in the midline of the hand?
mobility at the sides allows for the arc of motion that allows for palming or cupping the hand.
What is a resisted isolated joint motion
most stressful- on small finger, you would NEVER do blocking and resist the movement of the isolated joint. EVER. EVER.
The PIN is a _____ nerve
motor
What is meant by isolated joint motion?
moving one finger that is usually blocked at the pip or dip
What is intrinsic minus position of the hand?
mp extended, ip flexed (think ulnar claw hand)
What in intrinsic plus position of the hand?
mp flexion ip extension (think lumbricals)
Extensor zone landmarks: zone 3 thumb
mp joint
Extensor zone landmarks: zone 5 fingers
mp joint
What is neurotomesis?
neural tube and axons disrupted (if nerve ends are surgically approximated, axon can recover)
What is axontomesis
neural tube is intact, but the axon is damaged (longer healing time with possibility of residual deficits)
What is a possible effect of chemo?
neuropathy
What is meant by hook and straight fist
no splint - do an active hook (intrinsic minus) and a straight fist
Should you use antiseptics in a yellow wound?
no.
What is a good choice for cleaning wound
normal saline--> can even use contact solution in a big pinch. Comes in a spray can with a straw to squirt and concentrate it.
What is meant by passive protected?
not fully stretching the tendons out, eg, holding the hand in the safe position and passively bending the fingers (splinted)
Should you use betadine for cleaning a wound?
not usually, it's cytotoxic.
ORL means
oblique retinacular ligament
Where do the lumbricals originate? attach?
on the FDP. they attach to the extensor hood.
The "cupping" of the little finger is made by the action of the
opponens digiti minimi and abductor digiti minimi
The DASH is a _________ questionnaire, and the resulting number is a _____________
self-report, percentage of perceived disability.
What is a resisted hook and straight fist
picking something up in hook, like shopping bag or briefcase
What are platelets/what do they do in the healing process?
pile up after initial blood vessel damage and help stop bleeding
Where does the FCU tendon attach?
pisiform
The superficial branch of the radial nerve does what?
sensation for the radial nerve innervated regions of the hand. It is sensitive to pressure on the lateral aspect of the forearm, such as carrying bags, poorly fitting cast, etc.
What are the types of exudate
serous, purulent, sanguinous, serosanguinous
The APB does what motion?
palmar abduction
What does the opponens pollicis do?
palmar abduction, turns the metacarpal during opposition
The digital arteries form off of the
palmar arches
This tendon of this weak wrist flexor is often used for tendon grafts.
palmaris longus
Why is ulnar claw hand a safety hazard
people burn their fingers often (especially in things like hot water, french fries)
What does "speed of work" refer to in the strain index?
perceived speed - how are they able to keep up, pacing?
Provocative tests are usually graded as ....
positive or absent.
Why should people not use old socks from their sock drawer under their splints?
possible transmission of fungus (athlete's foot)
The _____ innervates the supinator, anconeus, and extensor muscles
posterior interosseous nerve, a branch of the radial nerve
_____________ garments are best.
professionally measured
What muscles provide pronation of the hand?
pronator teres, pronator quadratus
The median nerve (forearm) passes under . . . .
pronator teres.
What is fibrin/what does it do in the healing process?
protein strand added to platelets to help stop bleeding
Extensor zone landmarks: zone 2 thumb
proximal phalanx
Extensor zone landmarks: zone 4 fingers
proximal phalanx
P1 means
proximal phalanx 1!
Flexor tendon zone 5 includes:
proximal to carpal tunnel
If the EPL ruptures . . .
pt will lose hyperextension, retropulsion of the thumb above the level of the palm, and IP extension
What is shear?
pushing one part of a body in one direction, and another part of the body in the opposite direction -> like sliding sheets on a bed.
What is a resisted composite fist?
put something in the hand, like putty
Humerus fractures can cause palsy of the ___ nerve
radial
Of the dorsal wrist ligaments, the ____ side is more stable
radial
What does the APL provide?
radial abduction of the thumb (movement of the thumb away from the radius in the plane of the palm)
What is the RCL? What does it attach to? What does it do?
radial collateral ligament. It attaches to the annular ligament and the humerus. Provides stability to the radial head.
Identify the nerves of the shoulder that are the most important.
radial, subscapular, axillary n
What multidirectional ligaments are part of the TFCC?
radius -> ulna styloid. styloid to carpus.
What is a colles fracture
radius fragments go dorsally
What is a smith's fracture
radius fragments go volarly
Where does the FPL originate?
radius, interosseous membranes, coronoid process
Wounds can also be assessed with the ______________classification system
red, yellow, black
What are the cardinal signs of infection in a wound
redness, swelling, heat and pain (rubor, tumor, calor, dolor)
What are the three biggies of MSD-UE?
repetition, stress, and posture
radial side carpal fractures
require immobilization of the thumb
What is the volar plate?
restrains against hyperextension. One in each joint.
How do you treat extrinsic flexor tightness?
scale press "prayer" stretch (prayer stretch first, moving on to scale press once fracture is definitely healed)
What does SC stand for, and where is it?
scaphoid. proximal row, closest to the thumb.
What is the SL? What happens if it fails?
scapholunate ligament. ripping this can cause gap when gripping and throw off the F/E wrist rhythm. This is a serious problem that causes arthritis.
Compression on a scar
tends to make it flatter and smoother - use from time it closes to 2-3 months after.
Radial tunnel syndrome is often confused with
tennis elbow
One good way to guess the level of an ulnar nerve lesion is
testing the FDP--because the FDP cannot flex the digit in the high ulnar nerve lesion
In the forearm, the ulnar nerve's motor innervations are . . .
the FCU, the FDP to the ring and small finger.
What forms the "roof" of the shoulder?
the acromion process
The last muscle innervated by the ulnar nerve that you can test is
the adductor pollicis! flexor pollicis brevis is also partially innervated by the ulnar nerve, but partially not, so adductor poliicis the last testable nerve. you can ask them to adduct the thumb.
One way of measuring perception of exertion is . . .
the borg scale
In an early mobilization program, after 4 weeks,
the dynamic splint is discontinued and Unrestricted AROM with night splint used between exercise sessions
Damage to extensor zones IV, V, and VI doesn't retract like flexor tendons do, because
the extensor hood restrains distal portions from retraction
If the sagittal band of the extensor hood mechanism ruptures
the finger deviates; you will be able to see the tendons slide off when the person makes a fist
When should patients be educated about the principles of tendon rupture
the first session before the half cast and bulky dressings are removed. Even the most educated people have a hard time thinking about this.
The acromion process can be the location of impingement if . . .
the humerus rides too high.
Ganglions around joints are usually associated with
the joint capsule
What does the musculocutaneous nerve innervate
the lateral forearm (in line with thumb) (lateral cutaneous) coracobrachialis, biceps brachii and brachialis muscles. (remember this nerve is sensory and motor)
The primary carpal bones of wrist articulation are . . . .
the lunate and the scaphoid.
What does the median cutaneous nerve innervate?
the medial forearm.
FPB is innervated by
the median AND ulnar nerves.
What innervates the FDS? (motor)
the median nerve.
The position of passive stretch for flexor tendons is
the position of passive stretch for finger flexor tendons is wrist, MCP, IP extension
The extensor muscles are innervated by . . . .
the radial nerve
the most serious carpal fracture is
the scaphoid
After taping, you want to identify . . .
the subtasks that you're going to assess
What is tertiary intention?
the wound is left open for a time until inflammation is controlled and then surgically closed.
What is secondary intention
the wound is left open to heal on it's own ... used with Dupytren's release sometimes
What is primary intention?
the wound is surgically closed with stitches, staples etc.
Human bites are concerning because . . .
they are highly infectious. (fight bites!)
What are some benefits of wet-to-dry dressings
they are very cheap -> debridement may not be available depending on cost, etc.
Are ganglions around joints palpable?
they can be, but aren't always. Can be hard to palpate, especially in the wrist.
What is open reduction
they cut somebody open and do something inside to realign the bone
What are some negatives of wet-to-dry dressings
they have to be a very compliant patient and used correctly-> e.g., short term only
If the patient is experiencing increasing edema with redness
they need to be referred to a doctor!
What is serosanguinous exudate
thin watery and pink or red
What factors can contribute to tenderness at the coracoid process?
tightness in pectoralis minor, especially as a result of forward shoulder posture.
If you had a patient with no extensor retinaculum, one therapeutic technique you could use in therapy is
to use tape to substitute as the retinaculum and prevent bowstringing
What carpal bone articulates with the first metacarpal
trapezium
What are the muscles of the volar shoulder?
trapezius, deltoid, long head of the biceps, triceps brachii, serratus anterior (scapula)
What does TZ stand for, and where is it?
trapezoid, distal row, between trapexium and captiate.
What is collagen/what does it do in the healing process?
triple helix protein strand that imparts strength to the wound
What does TQ stand for, and where is it?
triquetrium, proximal row closest to pinky.
This carpal bone articulates with the ulna during ulnar deviation
triquetrum.
The adductor pollicis is innervated by the
ulnar n
What innervates the Abductor Digiti Minimi?
ulnar n
Sensation to the dorsal portion of the distal 4th and 1/2 of the 5th fingers is provided by
ulnar nerve
What innervates the interossei?
ulnar nerve
What does a Tinel's at the cubital tunnel mean?
ulnar nerve is irritated.
What is semple's test a test for
ulnar nerve lesion (adductor pollicis)
What is guyon's canal
underneath flexor retinaculum and between hook of hamate and fascia - > can have compression of the ulnar nerve from inflammation
What are the specifications for a securing layer of gauze?
usually "Cling" or sterile gauze roll use figure 8 application ... not too tight ... apply distal to proximal
Are ganglions around joints mobile?
usually Non-mobile; Can disappear with joint movement
Why does vibration cause MSD-UE?
vibration can "turn off" certain receptors; and you no longer have a grasp of how tight you are squeezing
_______________ is one of the first tactile sensations to come back
vibration; tested with middle c.
The first, preferred step of a strain index overview is
videotaping the assessment, but many employers won't allow this
What are ganglions around joints usually filled with?
viscous fluid
What is the distribution of the ulnar nerve in the hand?
volar and dorsal 1/2 of ring finger, small finger --> up to wrist crease
Metacarpals have more material on the (volar/dorsal) side. This causes . . . .
volar; CAM action of the metacarpal, in which the flexion of the proximal phalanx causes the ligaments to become tighter.
If you want a measure of edema of the whole wrist, what is the best method?
volumeter, circumferential. Figure 8 is mostly back of the hand!
What kind of dressings can you use in a yellow wound?
wet to dry dressings and frequent dressing changes
What is dehiscence?
when a well-healed wound starts to separate and break down; fluid often starts to come out (serous, serosanguinous)
What is extensor lag?
when there is a difference between PROM and AROM. Is often in extensor mechanism due to not fully gliding
When do you discharge the MP splint in extensor zone V and VI tendon repair?
when there is no lag of the MPs
immobilization of carpal fractures depends on
which carpal fracture you have
What are drawbacks of whirlpool therapy?
whirlpools are almost impossible to truly sterilize
The wound can be measured in terms of . . .
width and length (and depth c sterile measuring tool)
What is the most common kind of dressings used?
will be the most common form of dressing used: (woven fabric of cotton, rayon or other material) the fabric absorbs drainage and lets air into the wound ... manufacturers may also add antimicrobial agents and other substances to the gauze
What is semple's test
with the finger straight, bring the thumb and the index fingers together
Ganglions on tendons may be associated with. . .
with the synovial sheath or reticulation
Fractures of the distal radius are more common in
women
Radial nerve palsy looks like
wrist drop
What three things are measured in the hand/wrist postures section of the strain index
wrist extension, wrist flexion, ulnar deviation
After 7 weeks, in extensor zone II-IV tendon repair, you should
you may begin passive flexion, but watch for that extension lag (gutter at night)
After you identify multipliers, you
you multiply together to find strain index score
When you remove the pressure on a low-load long stretch
you want it to hurt a little bit! it means you did something (but it shouldn't hurt when it's on.)
Should you use zinc to on a wound?
zinc products promote wound healing
In zones ___________, the extensor tendons are not restrained to the muscles
zones 7, 8
