Ortho Quizzes

Elements of a resistive exercise program

•Alignment and stabilization - ensure alignment of body segments during physical activity and that proximal and distal segments are appropriately stabilized to prevent any substitutions •Intensity - the level of exercise load or resistance •Repetition maximum (RM) - the greatest amount of weight (load) a muscle can move through the available ROM a specific number of times •Volume - summation of the total number of repetitions and sets of a particular exercise multiplied by the resistance used •Repetitions - number of times a particular movement is repeated •Sets - a predetermined number of repetitions grouped together •To improve muscle strength - develop an exercise load that causes fatigue after 6 to 12 repetitions for 2 to 3 sets - when fatigue no longer occurs after the target number of repetitions has been completed, increase the level of resistance to once again overload the muscle •More weight, fewer repetitions/sets •To improve endurance - perform many repetitions of a submaximal load; i.e. - as many as 3 to 5 sets of 40-50 repetitions with a low-level resistance; when increasing the number of repetitions to induce fatigue no longer works, increase the resistance; isometric muscle contractions can also be used to build endurance •Less weight, more repetitions/sets •Exercise order - the sequence of types of exercise during a session has an impact on muscle fatigue and adaptive training effects •When targeting multiple muscle groups, large muscle groups should be exercised before small muscle groups and multi-joint muscles before single joint muscles •After a warm-up, higher intensity exercises should occur before lower intensity exercises •Frequency - number of exercise sessions per day or per week •The greater the intensity and volume of exercises per session, the more rest and recovery time is needed •Duration - total number of weeks or months the exercise program is carried out (depends on the impairment and the client's goals) •Rest interval - rest and recovery period between sets and sessions of exercise •For low-intensity workouts: less than two minutes after each set •For moderate-intensity workouts: 2-3 minutes after each set •For high-intensity workouts: 4-5 minutes after each set •Mode of exercise - includes the type of muscle contraction, position of the client, form or source of resistance, arc of movement, primary energy system utilized •Type •Isometric - sustained muscle contraction, static movement •Concentric and eccentric (dynamic) - shortening and lengthening of muscle •Isokinetic - dynamic contraction that occurs under controlled conditions (velocity is held constant often with a rate-controlling device) •Position •Limb is weight bearing or non-weight bearing •Form or source of resistance •Manual and mechanical resistance - two forms of how resistance can be applied •Constant or variable (i.e. free weights or weight machines) •Constant = weight machine •Body weight or partial body weight •Arc •Short-arc - exercise occurs only through partial ROM •Full-arc - exercise occurs through the full available ROM •Energy •Anaerobic - involves high-intensity exercise carried out for few repetitions due to quick onset of fatigue •Aerobic - low-intensity, repetitive exercise carried out over an extended period of time •Velocity of exercise - the rate a which a muscle contracts •Training with both slow and fast muscle velocities are important in a physical activity program •Resistance training is often more effective with slow to medium velocities, however many functional activities occur at higher velocities •Velocities for resistance exercises should be geared toward or match the demands of the desired functional activities •Integration of function - integrate functional task demands into a physical activity program

Types of distal radius fractures

•Colle's fractures - complete fracture of the distal radius with dorsal displacement; most common type of wrist fracture; usually result of a fall on an outstretched hand •Smith's fracture - complete fracture of the distal radius with palmar displacement

Wound indications/precautions for therapy

•Indications for therapy - wound affecting daily functioning or at risk for affecting daily function •Precautions for therapy: •Infection •Damage to deep vital structures •Extreme pain •Severe edema

Fracture healing - inflammation stage

•Inflammation stage (~time of injury to day 5): •Bleeding from the fracture site and surrounding soft tissue creates a hematoma •Clinically, this stage is marked by significant localized pain and swelling •Fibroblasts, mesenchymal cells, and osteoprogenitor cells are present at the fracture site •Fracture hematoma is gradually replaced by granulation tissue around the fracture ends -Fibroblasts - cells in connective tissue that produce collagen and other fibers, playing an important role in wound healing -Mesenchymal cells - adult stem cells -Osteoprogenitor cells - arise from mesenchymal stem cells playing a role in fracture repair

Scar evaluation

•Location - does the scar cross joints, tendons •Type - normal, hypertrophic, keloid •Pliability - gently moving top layer of skin, compare to healthy area of skin •Size •Color •Sensation (hypersensitive, diminished sensation) - client report of sensation •Temperature

Pediatric fractures

•Pediatric Fractures: •Greenstick - the bone is partially broken and partially bent; this type of fracture only occurs in children and is frequently found in children with rickets •Intrauterine - bone is broken in utero •Epiphyseal - the break occurs between the shaft of the bone and the epiphysis or physeal growth plate; this type of fracture only occurs in children; accurate reduction of these fractures is very important to avoid articular incongruity and deformity -Salter Harris classification of physeal fractures

Humeral shaft fractures - Postoperative treatment

•Postoperative treatment •Depends on the surgery and requires close communication with the physician •May be similar to the nonoperative protocol but more advanced due to fracture stabilization

Proximal humeral fractures

•Proximal humerus fractures - most common fracture of the upper arm and may involve the articular surface, greater or lesser tuberosity, or surgical neck •Most common mechanism of injury is from a fall on an outstretched hand; 80% of cases do not involve significant displacement and are treated nonsurgically •Location: •Humeral head •Anatomic neck (fractures at this level are at increased risk for disrupted blood supply and avascular necrosis) •Surgical neck (more common and have a better prognosis) •Proximal shaft

Reversibility Principle

•Reversibility principle - adaptive changes in the body's systems (such as increased strength or endurance) in response to an exercise program are transient unless the improvements are regularly used during functional activities or the individual participates in a maintenance program of exercises Ensure carryover in all home exercise programs. Discuss long-term maintenance. To maintain improvements from exercises, body must be continually challenged to maintain those changes Must be regular and intentional about exercise and HEPs, educate clients about maintenance

Dislocations of the elbow

•Account for 1/5 of dislocations in the body, often a result of falls; in younger adults, common as a result of athletic injuries; in older adults, often a result of periarticular bone injuries •In most cases, dislocations are managed with closed reduction under mild sedation, or for more difficult dislocations, general anesthesia; open reduction is rarely necessary

Rehabilitation - Carpal bone fractures and dislocations

•Acute care: •Edema control (can occur through massage and compressive wraps to the fingers) and patient education on gentle active exercise of the fingers and thumb including tendon gliding •Clients are often in a cast at this point •Dynamic splinting can be used while cast is on and after cast removal to increase finger ROM when adhesions at the flexor or extensor tendons have developed; dynamic splinting addresses finger ROM by providing constant pull/stretch on fingers •As with any distal upper extremity injury, ROM to proximal joints should be addressed to prevent loss of motion (i.e. - elbow and shoulder ROM exercises) •Possible complications after injury may include compressive neuropathy (nerve pain) or inflammation of nerves passing adjacent to bony structures •Nerve type pain can be described as sharp, shooting, burning •Postacute care: •Early active ROM can be initiated as early as 2 weeks after surgical stabilization; at this point, often clients are in a wrist orthosis or splint that can be removed for gentle active-assisted and gravity-assisted exercises for the wrist and forearm •Postimmobilization treatment of stiffness for those clients who have had to be in a cast long-term •Treatment may include thermal modalities such as hot packs or ultrasound on thermal setting and joint mobilization •Usually occurs after wearing a cast or orthosis for a long period of time •Treatment of severe stiffness - when clients exhibit very firm end-feel of joint mobility, can't achieve full ROM, low-load prolonged stress exercises may be used (i.e. to promote wrist flexion and to address stiffness in this position, a client may hold a 1-lb weight over a bolster x several minutes to facilitate elongation of dorsal wrist soft tissue, let hand hang in flexion position) •Dynamic and static progressive splinting for stiffness •Dynamic splinting - provides a constant pull and stretch on the area being addressed •Static progressive splinting - allows constant stretch, adjust amount of stretch, maintain at that level, can then tighten or loosen splint •Strengthening at ~3 months after surgery to be introduced slowly and gradually

Orthopedic evaluation: assessment

•Assess pain •Use of Visual Analogue Scale (VAS) or FACES pain scale •Where is your pain? •What is your current level of pain? •At what level and when is your pain at it's worst? •At what level and when is your pain at it's least? •What are the symptoms of your pain? (sharp, shooting, tingling, numb, aching, dull, burning, throbbing, tight, heavy, etc.) •What aggravates your pain? •What alleviates your pain? •Observation •Posture (alignment of spine, positioning of head, shoulders, hips) •Spontaneous movements including use of upper extremity and hand (what are they doing with their injured extremity?) •Guarding (are they guarding/protecting any body part?) •Scars - indicate previous injuries or surgeries •Incision - stitches or glue present, closed/open, clean, dry/seeping •Wounds - may indicate impaired sensation or circulatory issues •Skin color, tone, moisture, and trophic changes - dry skin can be an indication of a peripheral nerve laceration; increased sweating can be a sign of increased sympathetic activity related to CRPS; color changes can be due to metabolic conditions or disease; denervated skin can be atrophic •Muscle atrophy - muscle weakness due to disuse or nerve injury •Gross deformities - congenital, acquired, traumatic •Edema - indicates acute tissue injury and healing •Needle marks - may indicate current or past substance abuse or the use of injectable prescription medication (i.e. - DM Type II) •Palpation •Temperature - warm temperature may be due to acute inflammation, cool temperature may be due to circulatory issues •Edema - pitting edema leaves depressions with palpation; also there is non pitting edema •Pitting edema grades •1+ A pit of 2 mm or less; presents as slight pitting with no distortion. Pitting disappears immediately. •2+ A deeper pit measuring between 2 mm and 4 mm. It will have no easily discernible distortion and the pitting will disappear in 10 - 15 seconds. •3+ A noticeably deep pit measuring between 4 mm and 6 mm. The area affected will look distinctly fuller and swollen. The indentation will take as long as 1 minute before it disappears. •4+ A very deep pit is seen which will last between 2 to 5 minutes before it disappears. This indentation will measure 6 - 8 mm in depth and the body part affected by the edema will look gross and distorted. •Capillary refill - skin should blanch when palpated and resume normal color when pressure is removed •Skin mobility - lack of mobility may be due to fibrosis, edema, myofascial tension •Scar - mobility, sensitivity •Nodules - likely benign that may be associated with arthritis, trigger points, or other soft tissue conditions

Dupuytren's Disease

•Benign condition where soft tissue tumors develop in the palmar ligaments •Starts as a palpable nodule near the distal palmar crease that may be mildly painful •The nodule enlarges and forms pathological cords that extend proximally and distally •The cords thicken and shorten causing flexion contractures of the affected joints •Often affects the 4th and 5th digits, but the thumb and other fingers may also be involved •Severity varies and may require one or more surgeries depending on the extensiveness and impairment of hand function •Dupuytren's diathesis (more aggressive form of condition) is hereditary amongst white males with a positive family history, bilateral disease, and age onset younger than 50

Stiffness of the hand

•Can occur after an injury and is characterized by multiple dimensions: loss of motion, discomfort, altered tissue dynamics, potential elements of neurovascular dysfunction, and functional compromise (affecting patient's ability to use their hands) •Evaluate and treat edema •Early motion: PROM, AROM (may involve splinting) •Intrinsic hand stretching •Avoid overly-aggressive movement or over-stretching (may result in negative tissue response of pain, edema, and stiffness) •Low-load prolonged stress - client may use external weight and work on stretching in the hand or the wrist •Joint mobilization

Classification of fractures

•Classified according to location within bone: •Diaphyseal - within the midportion of the bone shaft •Metaphyseal - within the area of the bony flare close to the articular surface •Articular - engages the end of the bone and enters the joint; can be further subclassified as: •Condylar, T-condylar, Y-condylar, articular avulsion, or articular depression •Classified according to amount of displacement •Classified according to pattern: •Transverse •Linear or longitudinal •Oblique •Spiral •Simple (or complete) - two major fragments •Comminuted - multiple fragments of bone •Classified according to deformity of the body part involved: •For example: with metacarpal or phalangeal fractures assessment, when the client simultaneously flexes all of their digits and if there is significant overlap of the digits in composite digital flexion, corrective surgery would be considered. •Open versus Closed injuries: •Open fracture (also referred to as a compound fracture) - when there is an open wound or break in the skin as a result of a nearby fracture

Rotator cuff tendinopathies and tears - rehabilitation

•Conservative rehabilitation treatment (for no tear or a small tear; no surgery) - clients often present with limited forward flexion and internal rotation, decreased rotator cuff strength, and occasionally decreased scapular muscle strength and coordination •Phase I - PROM or AAROM in pain-free ranges of motion including forward elevation and external rotation; (sub-maximal isometric) strengthening for ER, IR, and extension •Phase II (conservative rehab; progress to this phase once pain and inflammation resolve and ROM and strength improve) •ROM exercises should approach end-range (without pain); phase I strengthening exercises are progressed and start to include abduction & forward elevation to 45 degrees, and ER to 45 degrees (with elbow supported)

Subacute and chronic edema treatment

•Contrast baths •Alternate between warm water and cold water for period of time back and forth, can help temporarily minimize swelling •Electrical modalities •Ex. electrical stimulation, ultrasound on pulse setting •Not a strong evidence base •Thermal modalities for tx of stiffness •Not necessarily for edema, more to address stiffness issue •KT •Myofascial release •Manual therapy technique •Exercise - proximal to distal •Exercises with compression is helpful •Low-stretch bandaging •Manual edema mobilization •Massage to manually move fluid distal to proximal lymph nodes, the purpose is to stimulate the lymphatic system to process the fluid

Humeral shaft fractures - Nonoperative treatment

•Days 5-7: fracture brace is on continuously (can be taken off in therapy for hygiene, skin inspection, and adjustments); assess for radial nerve palsy; instruct client in sleeping position (~45 degrees scaption with a small pillow placed between sling and trunk and a pillow under the entire UE) •Days 7-14: instruct client in pendulum exercises to be completed in brace 5-10 reps, 4-6x/day; pain management (PAM); scapular isometric exercise; gentle AAROM of the elbow; one-handed ADLs and adaptive equipment ASAP •Weeks 2-3: continue pendulum exercises and initiate gentle AAROM at the shoulder with no abduction or flexion above 60 degrees until radiologic evidence of union (fracture is reduced) •Weeks 4-6: continue previous exercises, initiate AROM of the shoulder and elbow progressing from gravity-eliminated to against gravity; isotonic exercises for pronation and supination; grip strengthening if indicated •Weeks 6-8: continue with previous exercises; initiate gentle (sub-maximal) isometric exercises for elbow flexion and extension; light functional use of the extremity by the side and supported on a table top; depending on physician, fracture brace may be discharged •Weeks 8-10: reestablishing ROM of the shoulder and elbow, light functional activities, and submaximal isometric shoulder strengthening - fracture should be pretty stable by this point •Weeks 10-12: full weight bearing activities, progress shoulder and elbow strengthening, progressive return to functional activities

Phases of rehabilitation - Distal radius fractures

•Early protective phase (1-6 weeks following fracture) •Active motion of the digits, elbow, and shoulder (and wrist and forearm if permitted) and "overhead fisting" - arm is raised, fingers open and closed, should be encouraged to perform several times per day, helps with ROM and edema •Address swelling with cold packs, retrograde massage, and elevation above heart-level •Mobilization/motion phase (starts at 6 weeks) -Joints - passive ROM (and compare with uninjured side) -Tendons - compare PROM with AROM -Intrinsic hand muscles - Bunnel Littler Test is used to assess intrinsic hand tightness -Increase motion and mobilization at distal radius -Identify where stiffness is occurring post fracture -Compare PROM and AROM -Individual can have problems with stiffness in the joints, tendons, and/or intrinsic hand muscles •Function and strengthening phase (~ 8 weeks) •When fracture healing has progressed, generally around 8 weeks s/p fracture, the wrist is stable enough to handle progressive loading from light grip to wrist isometrics to progressive resisted exercises -Strengthening is slowly introduced during this period

Types of edema

•Edema as a result of injury -Local edema = standard edema, usually post injury •Lymphedema - protein-rich fluid build up as a result of lymphatic insufficiency •Cause of swelling is different in lymphedema compared to regular edema; lymphedema is due to lymphatic insufficiency -Full body segment associated with lymphatic system issues = lymphedema •Edema as a result of systemic issues, such as from cardiac or kidney issues •Appears evenly all over the body -Swelling all over body, bilateral, even distribution = usually a systemic issue

Overview of edema

•Edema can result immediately following an injury, such as a tissue laceration •Edema consists of excess fluid and plasma proteins are trapped in the interstitium of the tissue -Expect edema during inflammatory stage of healing, but edema can linger and negatively impact healing process

Acute edema treatment

•Elevation •Cold packs •Helps with pain as well •Retrograde massage •Gently massage affected area or limb, going distal à proximal; therapist or client can perform this •Light compression •Elastic taping - KT (kinesiotape) •Can be used to redistribute swelling •Manual edema mobilization •Using gentle, light massage, working the fluid out of affected area moving it toward nearest functional lymph nodes in the body •Exercise - proximal to distal •Start with trunk, deep breathing, gentle ROM exercises distal to proximal

Factors that influence the force-producing capacity of a muscle

•Energy stores and adequate blood supply •Age •Fatigue •Muscle fatigue - diminished response of a muscle to a repeated stimulus •Cardiopulmonary fatigue - diminished response of an individual (the entire body) as a result of prolonged physical activity •Threshold for fatigue - the length of time a contraction is maintained or the number of repetitions of an exercise that can initially be performed •Sets a baseline to measure adaptive changes in physical performance •Factors that influence fatigue: health status, diet, lifestyle (sedentary or active), environmental factors (such as temperature, air quality, altitude), and medical conditions (such as neuromuscular, cardiopulmonary, oncologic, inflammatory, or psychological disorders), the onset of fatigue happens more rapidly •Recovery from exercise - adequate time for recovery (during the session and between sessions) must be included with every physical activity program •For vigorous exercise, the body needs time to restore itself to the state prior to the exhaustive exercise •Initial recovery from acute exercise usually occurs in the first 3-4 minutes •Oxygen stores are replenished in muscles •Energy stores are replenished •Lactic acid is removed from skeletal muscle and blood within ~1 hour after exercise •Glycogen is replaced after several days •Light exercise during the recovery period speeds up the recovery process (compared to total rest) •Psychological and cognitive factors •Fear of pain, injury, or re-injury •Depression •Attention and memory - ability to focus on a task and learn how to perform it correctly, then remember how to carry out a physical activity program •Motivation and feedback - willingness to put forth and maintain effort (importance of meaningful physical activities); positive feedback, documenting progress, improves motivation

Dupuytren's Disease treatment

•Examples of nonoperative management would include: enzymatic fasciotomy, traction with serial casting, radiation, ultrasound therapy, steroid injection •Other than the needle fasciotomy, other conservative measures have only shown limited term improvement •Postoperative treatment: •Weeks 1 & 2: wound care; dorsal blocking splint with wrist at neutral, MCP joints at 35-45 degrees flx, IP joints relaxed in ext, thumb in mild abd (if was operated on); instructed on sleeping techniques and hand elevation, keeping dressing dry, and avoiding exercise in the first two days •Return to the clinic 48 hours after surgery - wound care (advances to mild soap and water following dressing application) and start gentle exercise (gentle composite digit flexion with the orthosis on avoiding end ranges of motion) •Weeks 2-3: exercise increased for digit flexion and extension conservatively (aggressive exercise compromises the wound and increases inflammation); digit proximal, middle, and distal phalanx orthoses 4-5x/day; continue wound care until sutures are removed at 10 days post-op or greater, then scar management •At week three, the dorsal splint is remolded to a volar-based extension splint for nighttime wear; tendon gliding, finger blocking, intrinsic hand stretching (no strengthening) •Weeks 4-6: wounds should be healed, swelling controlled, and ROM mostly restored - if this is the case, decrease therapy intensity •Exercises progress to strengthening starting with isometrics; continue finger blocking, tendon gliding, and stretching intrinsics; assess strength of proximal joints •Gloves with a palmar gel pad for heavy activities •Nighttime composite digit extension splint wear continued 3-6 months; intermittent use of daytime extension splint as needed •Client may benefit from brief period long-term visits to therapy to ensure compliance with HEP and proper healing

Scarring and maturation

•Formation of scarring is critical to wound healing (part of the last phase) •Too little scar = delayed healing; too much scar = joint contractures, scar adhesions, hypertrophic or keloid scars •The remodeling phase is when scar formation occurs; can last several months to several years •Complications can occur: contractures, adhesion formation, or deformity that impact function -Hypertrophic scar: red, raised beyond surface level but stays within original wound boundaries -Keloid scar: very raised, extends beyond boundaries of initial injury or wound site, can impact movement

Total shoulder joint replacement considerations and precautions

•Full ROM is not typically achieved after shoulder joint replacement •A shoulder sling is typically worn for 3-4 weeks following surgery, including when the client is moving and sleeping •A swathe (long, wide strap that encircles the arm in the sling and the trunk) may also be prescribed to provide extra support to the arm •Precautions following surgery (memorize this): -No weight bearing through surgical UE -No lifting more than 1-2lbs with surgical UE -Avoid shoulder extension past neutral -Avoid shoulder abduction past 45º -Avoid shoulder external rotation past 30º -Avoid internal rotation past 60º -Limit shoulder PROM in flexion to approx. 90-100º

Shoulder joint replacement and medical management

•Hemiarthroplasty or humeral head replacement - with a humeral head fracture, the humeral head and fractured area are removed and replaced with an endoprosthesis •Total shoulder replacement (TSR) - more often performed for a person with degenerative or inflammatory conditions, such as OA; in this procedure, the humeral head is replaced by a ball-shaped prosthesis and the glenoid is resurfaced or replaced with a prosthetic component •Reverse total shoulder replacement (RTSR) - indicated for clients with a degenerative or inflammatory condition present in the shoulder complex, but also with some involvement or deficiency with the rotator cuff; the ball and socket of the GH joint are reversed

Factors that affect tissue repair

•Individuals with DM (diabetes mellitis) have less granulation tissue formation, collagen deposition, and defects in collagen maturation àresults in slow and ineffective wound healing •Poor nutrition slows the healing process •Vitamin C is important for collagen synthesis in healing •Conditions that compromise blood flow (i.e. - cardiac insufficiency, arteriosclerosis) delay delivery of necessary factors and cells to the wound, slowing healing •Certain drugs may slow healing (i.e. - glucocorticoids inhibit inflammation and collagen formation) •Other factors: wound size, location, and presence of foreign bodies at the wound •Infection - impedes healing including epithelialization, collagen deposition, and wound contraction -Individual factors can impact how quickly an individual is able to heal a wound -People with DM can be at a higher risk for infection

Precautions for therapy (wounds)

•Infection - stay in close contact with referring physician •Delayed wound closure •Edema •Wound tension •Hypersensitivity - be very careful not to reopen wound or cause extra pain •Lack of sensation/hyposensitivity - caution with modalities and provide client education •Pain •Avoid early/aggressive scar massage - should not be initiated until wound has healed, could potentially reopen wound •Skin maceration - softening and breaking down of skin as a result of too much moisture, sometimes from improper wound care

Wound healing - Inflammatory phase

•Inflammatory phase (injury to 6 days) •Neutrophils and macrophages are responsible for phagocytizing the wound of debris and bacteria and preparing for subsequent repair •Epithelialization (migration of epithelial cells) is stimulated within hours of injury by loss of cellular contact during wounding and seals the wound within 6-48 hours when advancing cells meet other advancing cells - closing in to help create a cover over the wound -Neutrophils and macrophages - blood vessels are opening up and neutrophils are able to pass through interstitial layer and migrate toward the injury, macrophages and neutrophils help get rid of debris and bacteria, set up the body for repair

Intra-articular hand fractures

•Intra-articular hand fractures involve the joint space •Avulsion injuries - occur when the tendon separates from the bone and its insertion and removes bone material with the tendon •Mallet finger - avulsion of the terminal tendon •DIP is splinted in full extension for 6 weeks, immediate splinting is important for proper healing •Boutonniere deformity - disruption of the central slip of the extensor tendon characterized by PIP flexion and DIP hyperextension •PIP is splinted in extension and isolated DIP flexion exercises are performed •Swan neck deformity - injury to the MCP, PIP, or DIP joints characterized by PIP hyperextension and DIP flexion •PIP is splinted in slight flexion

Complications of fractures

•Malunion - common bony complication of fracture healing and describes the nonanatomic positioning of the bone; malunion can cause deformity, reduce limb mobility, and cause pain •Fracture is reduced but bone doesn't appropriately realign •Nonunion - failure of the fracture ends to unite by bone (requirements for fracture healing include mechanical stability, adequate blood supply, and bone-to-bone contact) •Fracture isn't reduced, ends of bones don't come back together, not stable •Nonunion can occur with extensive soft tissue injury, bone loss, and open fractures with contamination and infection •Stiffness (of joints around fracture area) •Joint stiffness may result if clients receive an improperly placed orthosis (like a cast) or if the orthosis is in place too long •Following surgery, loss of motion at joints may be secondary to tendon adherence •Especially at the level of the PIP joint in the hand •Stiffness can also occur secondary to heterotopic bone formation, which can be seen following burns, trauma, repair of distal biceps tendon rupture, or operative treatment of forearm fractures •Osteoarthritis - post-traumatic OA may result from a failure to restore articular congruity of affected joints •Impact ROM in area

Types of resistance exercise

•Manual and mechanical resistance exercise •Manual - resistance applied by therapist or healthcare professional •Mechanical - resistance is applied through the use of equipment or a mechanical apparatus •Isometric exercise •Dynamic exercise (concentric and eccentric) •Concentric - dynamic muscle loading where muscle tension develops and there is physical shortening of the muscle as an external force is overcome •Eccentric - dynamic muscle loading beyond its force producing capacity, resulting in physical lengthening of the muscle as it attempts to control the load (i.e. - lowering a weight) •Open-chain and closed-chain exercise •Open-chain - unrestricted movement in space of a peripheral segment of the body •Closed-chain - movement of a peripheral segment of the body that meets considerable external resistance (terminal segment is fixed)

Wound healing - Maturation and remodeling phase

•Maturation and remodeling phase (21 days to 2 years) •Disorganized collagen fibers are rearranged, cross-linked, and aligned according to tension •Fibers are rearranging to create appropriate tension, critical to wound healing •Tensile strength increases - trying to close-up wound •Wound site color becomes less red due to decreased cellular activity, circulation near wound normalizes

Wound-specific evaluation

•Mechanism of injury - how did the injury happen? •Time between injury and OT treatment (acute inflammatory phase should last no longer than 2 weeks) •Pain description •Wound bed: •Red (well-vascularized and bleeds easily) •Yellow (devitalized tissue) •Black (necrotic tissue that prevents healing) •Wound size •Exudate (fluid coming from wound) •Type - clear (healthy), red (as a result of trauma), purulent (thick yellow, gray, or green as a result of infection) •Amount (look at wound dressing) •Monitor signs of infection - important role of OT •Warning signs of infection: •Redness around wound •Increased exudate or change in exudate color •Malodorous •Increased pain or heat •Delayed or abnormal healing •Wound breakdown

Wound evaluation

•Medical and social history: •Age - older adults heal more slowly •Work and vocational interests •Alcohol or tobacco use? - affect body's circulation, impairs healing process •Comorbid conditions, such as DM and obesity cause impaired healing •Obesity because it can affect the circulatory system •Nutritional status - balance of diet, adequate amount of Vit C •Medications - glucocorticoids (often used to treat autoimmune conditions and allergies/asthma), NSAIDS, chemotherapy drugs can impact healing •Cognitive status (ex. follow directions to help with wound care)

Evaluation of distal radius fractures

•Medical history and cause of injury •Client self-report measures/questionnaires (esp. as it relates to function) •ROM •Strength testing only when indicated Movements commonly impacted with distal radius fracture: -Wrist flexion and extension -Supination -Full closed grip

Scar management

•Medical intervention - can include medication prescribed by physician •Silicone gel sheets - silicone sheet to go over scar, helps soften scar •Compression garments - can be used to manage swelling, promote tissue healing, and hold gel sheets in place (mainly related to swelling) •Scar massage - can begin once wound is healed; hydrating, mobilizing, and massaging the scar •AROM or PROM facilitates tissue gliding and scar tissue length to prevent adhesions or contractures, help internally to warm the area •Modalities - superficial or deep heat - moist hot pack, ultrasound to provide deep heat to scar and wound area •Topical creams - such as those with vitamin A or E help with appearance, hydrocortisone to reduce itchiness

Extra-articular hand fractures

•Metacarpal and phalangeal extra-articular fractures (that do not involve a joint space) •Accounts for up to 20% of fractures in adults and children, with metacarpal fractures being the most common hand fracture (versus phalangeal), especially at 5th metacarpal (boxer's fracture) •Most clients with simple, closed extra-articular hand fractures are managed non-surgically with closed reduction x ~3-4 weeks; in other instances, percutaneous transfixing (external fixation?) or intramedullary K-wire fixation will be used to help maintain fracture alignment during initial healing

Causes of impaired muscle performance

•Neurologic pathology - could be due to central or peripheral neurologic pathology, or due to neurologic conditions such as MS, stroke, peripheral nerve injury, etc. •Muscle strain - can be caused by traumatic strain, eccentric loading, chronic overuse, or continuous overstretching •Disuse and deconditioning - could be a result of illness, surgery, or injury that requires a period of decreased activity •Effects of alcohol - alcohol abuse causes myopathic changes; with chronic alcohol abuse, type II (slow twitch) muscle fiber atrophy has been shown •Effects of medication •Widespread use of corticosteroids has led to cases of steroid atrophy including muscle weakness •A side effect of statins can include statin-induced myopathy - muscle aching, pain, cramping, stiffness, and fatigue

Proximal humeral fractures - Nonoperative treatment

•Nonoperative treatment (for nondisplaced or minimally displaced fractures that are stable) *Don't need to memorize specifics, but be able to apply generally to stages of healing •Day 1: use of sling for proximal stabilization (usually worn for 4-6 weeks continuously until removal for physician-approved hygiene and exercise); physical agent modalities (PAM) for pain management; wrist and hand ROM exercises; edema management •Days 3-7: initiate pendulum exercises (anywhere from day 7-14 depending on fracture site and clearance from physician); include elbow and forearm ROM in addition to wrist and hand ROM exercises; initiate scapular stabilization exercises in sitting position •Day 7-14: shoulder PROM and AAROM exercises in flx, scaption, and ER - can be done in a supine position (to protect shoulder); in weeks 1-2, limit flexion to 90 degrees and ER to 20 degrees (to avoid further displacing the fracture); encourage AROM for the elbow, forearm, wrist, and hand •Weeks 2-3: progress PROM and AAROM with continued protected ER to 30 degrees; progress ROM in a gravity-eliminated position while sitting or standing with the arm supported on a table top •Weeks 3-4: sling weaned as instructed by physician; progress PROM and AAROM in extension and IR; initiate pulleys with flexion (to slowly allow increased ROM at shoulder) •Weeks 4-6: AROM in supine at the shoulder; start active reaching activities •Weeks 6-8: add rotator cuff, deltoid, and biceps strengthening with light sub-isometric strengthening; light functional activities - reaching, overhead dressing, bathing, etc) •Weeks 8-10: continue exercises focusing on pain-free shoulder ROM •Weeks 10-12: initiate gentle isotonic exercise (using outside weight) •Weeks 12+: progress strengthening and functional return

OT evaluation: shoulder joint replacement

•Occupational profile •Assessment: motor, cognitive, social, and emotional factors, specifically as they relate to occupational performance •Upper extremity assistive range of motion and muscle strength can be tested in joints of the elbow, wrist, and hand following movement; weight bearing, and resistance precautions must be observed in the shoulder in the postoperative phase •Only gentle, controlled PROM may be performed at the shoulder •Sensory and coordination functions are assessed distally •Mental functions, such as memory, problem solving, and sequencing must be considered in light of a person's ability to follow precautions, practice safety awareness, and perform occupations •Assess ADLs and other occupations through standardized assessments, direct observation, or interview

Humeral shaft fractures

•Often sustained in a fall or high-energy accident such as a motor vehicle accident; often managed nonoperatively and with functional bracing

Overload Principle

•Overload principle -states that, if muscle performance is to improve, the muscle must be challenged to perform at a level greater than that to which it is accustomed •Strength training - incrementally and progressively increase amount of resistance •Endurance training - increase the time a muscle contraction is sustained or increase the number of repetitions performed

Contraindications/significant precautions for resistance exercise

•Pain •Inflammation •Severe cardiopulmonary disease (i.e. - severe coronary artery disease, myocardial infarction within 12 weeks)

Intervention - Fractures and dislocations of the elbow

•Phase I: Inflammatory phase (0-2 weeks): •Client education on the plan of care •Pain control - can occur through various physical agent modalities, therapeutic exercise, and manual therapy •Edema control - elevation, cold packs, manual edema mobilization or retrograde massage, compression garments or bandaging as needed •ROM - AROM, active-assisted ROM (AAROM), or controlled passive elbow motion; AROM of uninvolved joints •Strengthening (if not contraindicated) can occur through isometrics of the biceps, triceps, shoulder girdle, and forearm muscles •Continuous passive motion (CPM) machine for stable fractures, rigid fixation, or postsurgical contracture release - may be recommended by physician •Orthotic intervention to protect and support healing structures in a position that is dictated by the extent of the injury, the surgical procedure, the elbow's stability, and the surgeon's preference •Phase II: Fibroblastic Phase (2-8 weeks): •Edema and scar control and management •Thermal agents to increase blood flow, improve tissue extensibility, and modulate pain •Range of motion with passive range of motion initiated in this phase •Strengthening exercises and functional activities - progress from isometric to isotonic exercise including for biceps, triceps, and forearm muscles; light functional activities can be incorporated in a home program to target strength, endurance, and fine motor coordination •Orthotic intervention and CPM is determined by the healing of the structures involved •Phase III: Remodeling phase (2 to 6 months): •Physical agents including use of thermal agents to increase ROM with therapeutic intervention •ROM - continue PROM and stretching •Soft tissue mobilization and myofascial techniques •Joint mobilization •Orthotic intervention - usually not required in this phase •Strengthening and functional retraining are progressed in this phase *Can be difficult to restore full ROM at elbow after fracture

Edema assessment

•Pitting edema •Graded on a 1-4 scale 0+ = no edema 1+ = slight pitting edema, hard to see, approx. 2mm indentation, disappears almost immediately when you remove finger 2+ = mild pitting edema, approx. 4mm indentation, indentation disappears in 10-25 seconds 3+ = moderate pitting edema, between 4-6mm indentation, indentation lasts for significant amount of time (more than 1 min), usually obvious to the naked eye 4+ = severe pitting edema, 6mm+ indentation, lasts a long time, several minutes, edema is obvious, texture is almost like play doh (moldable) •Volumetry (look at water displacement) •Circumferential measurements

Post-surgical proximal humeral fractures

•Postoperative treatment (for fractures stabilized by surgical reduction) •Follows similar protocol to nonoperative treatment, however often progresses faster due to stabilization of the fracture after surgery •When considering any protocol, consider the client factors, the research, and physician

Wound healing - Proliferative phase

•Proliferative phase (around day 6 - day 25) •Angiogenesis and neovascularization occur (development of new blood vessels) •Fibroblasts enter the wound 2-5 days post-injury and utilize the fibrin cross-linking fibers to migrate across the wound; granulation tissue is created from new blood vessels, myofibroblasts, and extracellular matrix components •Helps to close wound, create more tissue and support at wound site •Collagen is deposited from the fibroblasts •Epithelialization continues •Contraction occurs ~1 week after initial wound •Contraction = wound is trying to close

Wound treatment goals

•Promote wound closure, using scar management techniques •Manage swelling •Maintain or restore AROM and PROM in the involved area (can be achieved through scar mgmt, splinting, exercise, or functional activities) •Wound can impact surrounding tissue/joints, cause limitations •Maintain ROM of uninvolved joints •Maintain or restore functional strength

Evaluation of muscle strength (MMT)

•Purpose of manual muscle testing (MMT): •Can be used as a diagnostic aid (i.e. - in the event of a nerve injury) •Used to determine amount of muscle power thus establishing a baseline for intervention •To determine how weakness is limiting participation in occupations •To prevent deformities that can result in muscle imbalances •To determine the need for assistive devices •To aid in the selection of occupations within a person's capabilities •To evaluate the effectiveness of intervention strategies and modalities •Contraindications for MMT: •When the client has inflammation or pain in the region to be tested (particularly of unknown etiology); a dislocation or unhealed fracture, recent surgery, particularly of musculoskeletal structures; myositis ossificans; or bone carcinoma or any fragile bone condition •Precautions for MMT: •Follow precautions when resisted movement could aggravate the client's condition, such as with osteoporosis, subluxation or hypermobility of a joint, hemophilia or any type of cardiovascular risk or disease, abdominal surgery or an abdominal hernia, and fatigue that exacerbates the client's condition •Client requirements to participate in MMT: •Willingness to expend true effort •Ability to endure some discomfort •Cognitive ability to follow commands and understand the requirements of the test •Screening: •Observe the client's movements •Observe the client performing functional activity •Observe the client performing the motions against gravity (or in a gravity-eliminated position is against gravity is not possible)

Fractures of the elbow

•Radial head fractures: •Type I - non-displaced and can be treated with an arm sling •Type II - displaced with a single fragment; is typically treated non-operatively with immobilization for 2-3 weeks and early motion with medical clearance •Type III - comminuted and is treated operatively, with immobilization and early motion within the first postoperative week as medically prescribed •Distal humerus fractures •Capitellum and trochlea fractures •Olecranon process fractures

Orthopedic evaluation: assessment (ROM)

•Range of Motion (Goniometry) •Purpose: determine limitations that interfere with functioning or may produce deformity, determine additional ROM needed to increase functional capacity or reduce deformity, determine the need for splints and assistive devices, measure progress objectively, and record progression or regression •Contraindications - joint dislocation, unhealed fracture, immediately after surgery on any soft tissue structures surrounding joints, myositis ossificans (development of bone tissue in muscle tissue following an injury), or when ectopic ossification is a possibility (bone development in an abnormal anatomical site) •Precautions - joint inflammation, infection, client is taking pain medication or muscle relaxants, osteoporosis, hypermobility of a joint, subluxation of a joint, hemophilia (ability to blood clot is reduced increasing risk for bleeding with a slight injury), hematoma, injury to soft tissue, newly united fracture, prolonged immobilization, bony ankylosis is suspected (stiffness of a joint due to abnormal adhesion and rigidity of the bones of the joint as a result of injury or disease) •Steps to measure ROM: •Visual observation - the joint to be measured should ideally be exposed, and the therapist should instruct the client to move the joint through the available ROM watching for compensatory movements, posture, muscle contours, comparing the joint with the non-injured side (if possible) •As applicable, have the client note any movements that produce pain symptoms •Palpation - feel the bony landmarks around the joint to determine placement of the goniometer •Measure active range of motion (AROM) •Measure passive range of motion (PROM) if AROM is limited

Range of Motion Measurements (trunk, shoulder, arm, hand, hip, knee, ankle)

•Range of Motion - Cervical Spine: •Measurements of the neck are the least accurate due to few bony landmarks and the soft tissue overlying the bony segments •Cervical flexion 0-45 degrees •Cervical extension 0-45 degrees •Cervical lateral flexion 0-45 degrees •Cervical rotation 0-60 degree •Range of Motion - Thoracic and Lumbar Spine: •Flexion - 4" (to palpate the first sacral vertebra, note that L4 is at the level of the iliac crests and count down) •Lateral flexion - 0-40 degrees •Extension - 0-30 degrees •Rotation - 0-45 degrees •Range of Motion - Shoulder: •Shoulder flexion - 0-170 degrees •Shoulder extension - 0-60 degrees •Shoulder abduction - 0-170 degrees •Shoulder internal rotation - 0-60 degrees •Used if abduction cannot be achieved •Shoulder internal rotation (alternative position in shoulder abduction) - 0-70 degrees •Shoulder external rotation - 0-80 degrees •Used if abduction cannot be achieved •Shoulder external rotation (alternative position in shoulder abduction) - 0-90 degrees •Shoulder horizontal abduction - 0-40 degrees •Shoulder horizontal adduction - 0-130 degrees •Range of Motion - Forearm: •Supination - 0-80 or 90 degrees •+ alternative method - 0-80 or 90 degrees •Pronation - 0-80 or 90 degrees •+alternative method - 0-80 or 90 degrees •Range of Motion - Wrist: •Flexion - 0-80 degrees •Extension - 0-70 degrees •Ulnar deviation - 0-30 degrees •Radial deviation - 0-20 degrees •Range of Motion - Fingers (document which digit being measured): •MP flexion - 0-90 degrees •MP hyperextension - 0-45 degrees •MP abduction - 0-25 degrees •PIP flexion - 0-110 degrees •DIP flexion - 0-80 degrees •Range of Motion - Thumb: •MP flexion - 0-50 degrees •IP flexion - 0-90 degrees •CMC extension - 0-50 degrees •CMC flexion - 0-50 degrees •Opposition - if unable to oppose thumb and 5th digit, measure the distance with a centimeter ruler •Range of Motion - Hip: •Flexion - 0-120 degrees •Extension - 0-40 degrees •Abduction - 0-40 degrees •Adduction - 0-35 degrees •Internal rotation - 0-45 degrees •External rotation - 0-45 degree •Range of Motion - Knee, Ankle: •Extension-flexion - 0-135 degrees •Ankle dorsiflexion - 0-15 degrees •Ankle plantar flexion - 0-50 degrees •Ankle Inversion - 0-35 degrees •Ankle Eversion - 0-20 degrees

Shoulder instability - rehab

•Rehabilitation after anterior shoulder dislocation (conservative): •After immobilization (~2-4 wks), therapy is started: hand squeezes, elbow AROM, pendulum exercises, closed chain activity such as dusting •4-6 weeks: AAROM in forward flexion with 45 degrees abduction (caution not to overstretch) and ER limited to 30 degrees •6 weeks+: posterior capsule stretching to include extension, IR up the back, and cross body adduction; RTC strengthening with arm in adduction with gradual progression to abduction and forward elevation •Rehabilitation of atraumatic instability (multidirectional instability): •Assess AROM and PROM, observe scapular motion, assess for subluxation •AROM exercises to encourage functional use •RTC strengthening in nonprovocative positions

Fracture healing - remodeling stage

•Remodeling stage (~Day 21-18 mos): •Begins during the middle of the repair phase and continues long after the fracture has clinically healed - fracture is reduced but there's still repair and remodeling happening •Allows the bone to assume its normal configuration and shape based on stresses to which it is exposed •Controlled, active movement is important to help person return to functional activities •During this stage, woven bone formed during the repair phase is replaced with lamellar bone (stronger bone tissue) •Fracture healing and remodeling is complete when the marrow space is repopulated •Fracture healing is influenced by a variety of biologic and mechanical factors - most important biologic factor in fracture healing is blood supply: •Nicotine from smoking has been shown to increase time to fracture healing, increase the risk of nonunion, and decrease the strength of the fracture callus •Clients with systemic diseases (i.e. - DM) also experience delays in healing due to poor limb vascularity

Fracture healing - repair stage

•Repair stage (~Day 5-Day 21): •Occurs within 2 weeks from the time of injury •If the bone ends are not in continuity (not reduced), bridging (soft) callus develops and is replaced later by woven bone (hard callus) •In this stage, associated swelling, pain, and tenderness generally diminish rapidly as the callus forms (soft or hard callus) •Generally, by the 4th-6th week in most fractures in adults (and the 3rd-4th week in most fractures in the hand and forearm in children), therapists can begin to apply forces of AROM and AAROM can be increased •However, this depends on full assessment of the fracture and considerations of initial stability, type of reduction used, general health and reliability of the client, and radiographic appearance

Scar management goals

•Restore or maintain functional use of the involved area •Promote tissue gliding for ROM •Improve appearance of the scar •Address pain, itchiness, and hypersensitivity •Prevent or address joint contractures

Rotator cuff tendinopathies and tears

•Rotator cuff anatomy - comprises four muscle-tendon units: supraspinatus, infraspinatus, teres minor, and subscapularis •Function of rotator cuff: glenohumeral joint compression, rotation, and dynamic stability throughout a wide range of movement •Factors contributing to rotator cuff disease and lesions (often more than one involved): •Tendon degeneration (often occurs with age) •Vascular insufficiency •Subacromial impingement (may result from a hooked type III acromion, a subacromial spur, or irregularities at the coracoacromial arch) •Muscle imbalance and capsular tightness (both can cause compression of the glenohumeral joint) •Glenohumeral instability •Trauma •Congenital anomalies

SAID Principle - Specific Adaptation to Imposed Demands

•SAID principle - Specific Adaptation to Imposed Demands •Specificity of training - suggests that the adaptive effects of resistance training are specific to the training method used - therefore, the exercise should mimic the anticipated function (mimic in terms of mode, velocity, limb position, and movement pattern) •Transfer of training - a small degree of carryover of training effects from one variation of exercise or task to another •Only a small degree of transfer training occurs, therefore, it is best to closely employ a program that replicates the desired functional activity

Carpal bone fractures

•Scaphoid fractures - most common carpal fracture produced by wrist hyperextension greater than 90 degrees combined with radial deviation •Capitate fractures - isolated capitate fractures are uncommon •Hamate fractures - can involve the hook of the hamate (most commonly occur when force transmitted through the base of the palm from an object that is gripped with force) or the body of the hamate; both are difficult to diagnose on routine radiographs; fall while gripping something •Lunate fractures - are unusual and usually the manifestation of Kienbock's disease (when blood supply to the lunate in interrupted and results in avascular necrosis of the lunate; cause is unknown - may be due to trauma) •Triquetrum fractures - second most common carpal fracture with three main types: dorsal rim chip fracture, body fracture, and avulsion fracture off the volar aspect •Pisiform fractures - uncommon and typically result from impaction or a fall directly on the hypothenar eminence •Trapezium fractures - third most common carpal fracture usually the result of forceful injury and often occur with 1st metacarpal and distal radius fractures •Trapezoid fractures - most rare carpal fracture due to the security of the bony architecture and secure ligament attachments

Orthopedic evaluation: screening, review of PMH, interview and occupational profile

•Screening prior to evaluation •Is there a physician order for occupational therapy services? •Diagnosis meeting OT intervention? (OT/PT) •If there is an order, is the diagnosis and client information provided suggest a need for occupational therapy to address that is within our scope of practice outlined in the OTPF? •Has the client completed all necessary paperwork, including authorization for evaluation and treatment, past medical history forms, allergy forms, etc.? •Review past medical history •Complete a full review of paperwork from the physician's office regarding the client's condition and review the client's completed paperwork regarding past medical history and current condition. •Note any precautions •Precautions may include those related to diet or swallowing, lack of sensation, movement restrictions, weight-bearing restrictions, seizures, behavioral or cognitive impairments, infection control, open wounds or surgical sites, precautions related to medications, etc. •Interview and occupational profile •Interviews can occur in a structured and/or unstructured format •Conversation with the client can guide questions •Review past medical history and fill in the blanks, including for any information that has been left out or for further clarification •Obtain details regarding current health condition, including precipitating factors, onset date, imaging results (i.e. - x-ray), medical interventions received •Establish an occupational profile: Is the person working/retired/disabled, etc.? If working, what are the work requirements? Does the person have dependent children? Who lives in their household? What is their mode of transportation? Do they require assistance with any activities of daily living (prior to health condition and currently)? Does the person have any leisure pursuits, volunteer roles, physical activity routines? •This is your chance to build rapport with the client •If there is a concern for cognitive limitation, plan to verify medical and occupational history with the physician's office, family, etc.

Shoulder instability

•Shoulder instability - occurs across a spectrum and may present as a subluxation, dislocation and can occur in individuals with or without hyperlaxity of the joint; can be painful and limiting to functional activities •Anterior instability (most common) - usually a result of falls or other trauma with the arm abducted and externally rotated; first-time dislocation is often treated nonoperatively with immobilization; recurrent dislocation is treated surgically •Posterior instability - usually a result of trauma, such as with the arm in forward flexion or microtrauma in overhead athletes •Multidirectional instability - usually a result of hyperlaxity

OT intervention - Shoulder joint replacement

•Sleeping and bed mobility: •Sling and swathe are worn during sleeping usually for the first 4-6 weeks following surgery. A pillow or towel should be placed under the scapula or elbow as needed for comfort to ensure the shoulder is supported in front of the body, in slight flexion, and in adherence to the precautions •When entering or exiting the bed, the client may roll over on the non-operative side only •Going to the bathroom at nighttime should be addressed •Functional mobility: •If a cane was used prior to surgery, it may only be used on the nonoperated side only •Use of the operative UE should be avoided during transfers •Upper body dressing and bathing: •Clothing should be chosen based on ease. Button-front shirts or oversized shirts are suitable. Sit while dressing and bend forward at the waist to promote passive flexion of the shoulder while extending the elbow to put the operated arm in the sleeve first. Once this sleeve is pulled onto the UE and the client returns to sitting upright, they can reach around the back to pull the shirt to the other side and to reach to slide the nonoperated arm into the other sleeve. Client can use the hand of the operated shoulder to stabilize and assist in buttoning the shirt. Women should use a bra with a closure in the front. •OT should ensure the client is able to don/doff the sling •Bathing: sling is removed, a rolled towel can be used to support the arm while bathing seated. Follow precautions while bathing. A long-handled sponge may help the client reach the back using the nonoperative arm •Lower-body dressing: •Sit to pull on pants and underclothes to maintain balance and to avoid the use of the operated arm to brace the body •Leaning forward in the seated position also ensures precautions are maintained •Homemaking: •Performed with shoulder in sling for the first few weeks •Nonoperated arm can primarily be used for cooking and homemaking •Lifting should only occur in accordance with precautions •Rocker knife and pan stabilizer may be helpful •Further adaptive equipment and adaptive techniques should be determined for each client

Elements of muscle performance

•Strength - broad term used to describe the ability of contractile tissue to produce tension and a resultant force based on the demands placed on the muscle; muscle reaction to outside forces •Strength training - the systematic method of a muscle or muscle group lifting, lowering, or controlling heavy loads for a relatively low number of repetitions over a short period of time; imposing outside force on muscle or muscle group •Power - related to the strength and speed of movement, the rate of performing work (force x distance) •Power training - increasing the work a muscle must perform during a specified period of time or reducing the amount of time required to produce a given force •Endurance - the ability to perform low-intensity, repetitive, or sustained activities over a prolonged period of time •Endurance training - can include a muscle contracting and lifting or lowering a light load for many repetitions or sustaining a muscle contraction for an extended period of time; key elements: low-intensity muscle contractions, large number of repetitions, and a prolonged time period

Precautions for resistance exercise

•Substitute motions •Overtraining and overwork •Exercise-induced muscle soreness •Pathological fracture - fracture of a bone already weakened by disease that occurs as a result of minor stress to the skeletal system •Individuals with osteoporosis are at increased risk for pathological fractures

Triangular Fibrocartilage Complex injuries

•TFCC - consists of ligaments, meniscus homologue (MH), ECU tendon sheath, and a fibrocartilaginous articular disk •Provides stability to the distal radio-ulnar joint (DRUJ) •TFCC tears can include the articular disk and ligaments; fairly common •When TFCC injury is suspected, to evaluate: •History and mechanism of injury (often occurs as a result of a fall on outstretched hand with forearm rotation, clients will report ulnar-sided wrist pain; more than 50% of extra-articular distal radius fractures have TFCC lesions) •Physical examination: edema, ROM, strength, sensation and function, provocative maneuvers •Conservative treatment: ulnar gutter splint - hand-based, protecting ring and little finger on ulnar side of hand (if doesn't provide relief, then a long-arm splint to restrict forearm rotation, splint goes beyond the hand); education to avoid functional activities that require forearm pronation and gripping; progressing a HEP to include strengthening must be approached cautiously with pain monitoring •Post-op treatment for debridement of the central articular disk: wrist support splint worn between AROM and PROM exercises progressing as tolerated if no adverse consequences; return to functional activities after 2 weeks •Arthroscopic or open repair: immobilized x 4-8 weeks with therapy progression of active to AAROM to passive wrist and forearm ROM with splinting continued x 1-2 additional months after immobilization

Orthopedic Traumatology

•The study of the body's response to injury to the musculoskeletal system •Bodily response to trauma (as a process) follows a predictable pattern regardless of the tissue involved or the mechanism of injury •General pattern that body follows in response to trauma is predictable, but there's always individual variation •To understand traumatology, one must understand the tissue repair process... •Stage 1: Inflammation •Stage 2: Proliferation and repair •Stage 3: Maturation and remodeling

OT intervention - Total shoulder joint replacement

•Therapeutic exercises: •Immediate post-operative phase - PROM is limited to 90 degrees shoulder flx, 45 degrees shoulder abd, and extension to neutral. Clients are typically allowed to lay their hand across the abdomen in internal rotation, and limited to 30 degrees external rotation. Codman's pendulum exercises can be initiated on the first day. Distal AROM should be performed (based on surgeon's preference) to avoid distal edema and to promote functional hand use •2-4 weeks, larger PROM ranges may be initiated at the shoulder, including table slides for shoulder flexion. Some physicians also allow dowel exercises •4-6 weeks post-op: precautions related to movement may be relaxed with greater PROM expected; weightbearing and lifting are still restricted. AAROM exercises are initiated. Light strengthening can be initiated at the elbow, wrist and hand joints in preparation for greater functional use •6 weeks post-op: shoulder strengthening and full movement through all planes is typically initiated. Monitored therapeutic exercise to ensure full AROM and strength may continue for several months as indicated

OT intervention - Reverse total shoulder joint replacement

•Therapeutic exercises: •Immediate post-operative phase: AAROM and PROM of the shoulder in protected ranges only. In addition to following shoulder precautions, no actions that require reaching behind the back should occur as a result of the limited support of the rotator cuff. Codman's pendulum exercises are only performed with the permission of the physician due to rotator cuff instability. PROM only at the shoulder may occur for the first 5-7 days post-op. Active movement of the distal extremity should be delayed until all anesthesia and nerve blocks that may have been used during surgery have cleared the client's system and good motor control returns. •5-7 days post-op: isometric exercise in the scapula and shoulder, and AAROM up to 90 degrees flx and abd, and up to 30 degrees of external rotation •2 weeks post-op: AROM may be initiated, transitioning from table slides, dowel exercises to actively pushing items up an incline •6 weeks post-op: light strengthening, including isometric exercise, may be initiated •12 weeks post-op: moderate strengthening (with careful monitoring of progression)

Thumb CMC joint arthroplasty

•Thumb carpometacarpal is the second-most common joint in the UE to acquire osteoarthritis •Includes the articulations of the scaphoid, trapezoid, and radial facet of the 2nd metacarpal •Conservative management: splint use, steroid injection, NSAIDS, joint protection and activity modification •If conservative management fails and the client still has disabling pain and loss of function, surgery may be indicated •Postoperative therapy (post CMC arthroplasty): •0-2 wks: client immobilized in thumb cast •2-4 wks: control swelling, thumb spica with IP joint free for ROM on continuously until week 4; pain mgmt. •4-6 wks: AAROM and AROM at thumb and wrist emphasizing CMC abduction, extension, and opposition; isometric thumb abduction; avoid flexion until thumb can oppose first (finger slides) (due to stress placed at joint); splint is continued when not exercising and nighttime •7 wks: dynamic splinting PRN (as needed) if joint is well stabilized •8-10 wks: discontinue splint; start gentle strengthening (no pinching to 4th and 5th digit due to risk of ligament tearing) •10-12 wks: Normal use of hand without restrictions; healing may continue for 6-12 months for full return to PLOF (prior level of function)

Fracture fixation

•Types of fracture fixation to ensure proper reduction of fractures: •Kirschner wires (k-wires) •Multiple screws •Open reduction and internal fixation (ORIF) - provides the greatest rigidity for fracture repair thereby permitting early ROM •Common surgical procedure, internal fixation of bone (may include installing steel plate and screws) •Intramedullary fixation - rod is installed in shaft of bone to hold bone in place •External fixation - used when internal fixation options are not most optimal for fracture healing in the case of unstable fractures and/or dislocations Part holding bone together is on outside

Therapist evaluation post-fracture

•Visual examination and observation, client interview, and complete medical history, including history of the event causing the fracture •Sensory assessment includes monofilament testing (Semmes-Weinstein) for nerve compression and two-point discrimination for nerve laceration and recovery •Range of motion assessment using goniometry (as appropriate) •Strength assessment using MMT, dynamometer (grip strength), and pinch gauge (as appropriate) •Occupational performance assessment using an ADL and/or IADL checklist, which can also be a useful goal-setting tool and outcome assessment tool - see list of functional assessments in lab folder

Impaired range of motion and joint mobility

•What can cause impaired ROM and joint mobility? •Injury, surgery, bedrest, immobilization, joint disease such as OA or RA, pain, etc. •What happens as a result of this impairment? •Injury occurs --> immobility --> decreased use of muscles --> muscle shortening --> diminished mobility and function --> disuse and substitution --> pain •Joint ROM impairments can include hypomobility, hypermobility, or instability (excessive range with no protective muscle control) •Can be tested with joint play motions and treated with joint mobilization •Muscle ROM is the muscle excursion from a fully lengthened position to a fully shortened position •Can be tested by PROM and AROM and treated with stretching exercises or activities •PROM (can be combined with stretching) •Indications - if active movement would disrupt the healing process, client has physical or cognitive limitations impacting their ability to move actively, active movement is too painful, relaxation is the goal •Techniques - various exercises or activities that allow for full ROM, and holding the position at the end range allows for a stretch; can use pulleys, assistance from others, self-mobilization, or household objects •AAROM - occurs when some active muscle activation occurs, but requires some assistance to complete the ROM •Indications - indicated for clients unable to complete full ROM due to weakness; indicated when the weight of the limb may impede proper mechanics during active movement; some injuries or surgeries limit active movement in the early phase of healing •Techniques - examples could include use of pulleys, wands/canes, surfaces, aquatic environment •AROM - active movement in G+ or G- positions •Indications - when active muscle contraction is desired •Techniques - moving limbs through ROM arc •Static stretching - when muscle and connective tissue are held in a stationary position at their greatest possible length •Advantages: uses less force, lower energy requirements, lower likelihood of muscle soreness, minimized danger of exceeding tissue extensibility limits •Holding static stretches: research has shown little difference in holding a static stretch for 15, 30, 45, or 60 seconds - it is the total stretch time that matters; however, older adults benefit from 60-second duration stretches •Dynamic stretching - when the limb is repeatedly taken through a ROM actively by the participant (i.e. - lunge walking forward and backward for stretching the hip, arm circles for stretching the shoulders) •Indications - often used as a warm-up and stretch prior to participating in activities that require power or speed •MAINTAINING POSTURE IS KEY WHEN STRETCHING TO ACHIEVE TARGETED STRETCH AND AVOID INJURY

Special tests for shoulder and elbow conditions

Apprehension test - posterior and anterior Drop arm test Elbow varus and valgus test Empty can test Hawkins Kennedy impingement test Jobe relocation Neer impingement Sulcus sign

Special tests for hand and wrist conditions

Box and block test Jebson-Taylor test of hand function Sharpey's test for TFCC injury Bunnel-Littler test Murphy's sign test Tap or percussion test Watson test TFCC compression test

Neer's Classification System for proximal humeral fractures

Neer's classification system - most commonly used; one-part, two-part, three-part, or four-part depend on the major segments that are displaced How many parts of bone are displaced, location of fracture