567 Test 3
extensor
clients with LE should begin forearm stretching of _____ muscles
pain and dysesthesia on dorsal radial forearm extending to thumb and index finger
clinical picture of Dorsal Radial sensory nerve/ Wartenburg's syndrome
metacarpal fractures with phalangeal fractures of distal, proximal and middle phalanx (in that order)
half of hand frx are ___________, compromising the other half
trunk flexion or shoulder motion
lack of extension can be compensated with
MP contracts to 30 degrees, PIP to 15 degrees, and loss of function capacity of hand
medical interventions not needed for Dupuytrens until
polyneuropathy
metabolic induced neuropathy to bilateral extremities of 2 or more nerves (bilateral feet and hands) ex: alcoholism, autoimmune diseases, etc.
- AROM f/b PROM if limitation noted - MMT - strength testing with dynamometer and pinch gauge (if appropriate)
motor/joint assessments
60-80%
muscle atrophy reaches a relatively stable state at ____ - ____% weight loss by approximately 4 months
- edema control - scar mgmt - ROM - radial abduction, palmer abduction, MP/IP flex and ext, radial and ulnar deviation, wrist flex/ext - typically very few OT sessions if any
post op mngmt for trigger finger
immobilization x 3 weeks followed by AROM. Night time orthosis if extensor lag
post op treatment of middle phalanx frx
- HEP - edema/pain mngmt - ACTIVE or AAROM exercises, orthosis wear, and light functional activities - same goal; get the pt. MOVING
post operative stable frx you still want to start with...
immobilized x 3-4 weeks then AROM begins, followed by scar and edema mgmt, PROM per MD (typically 8 weeks)
post-op proximal phalanx fracture are treated by
- initially, static long arm elbow orthosis in neutral forearm, wrist extension, and MP in 10-20 degrees flexion - after 3 weeks, extend elbow 30 degrees/week - at 6 weeks, discontinue orthosis : initiate A/PROM, fabricate Radial Nerve Palsy splint until adequate motor return
post-operative management for radial nerve repair: Above the elbow (varies per MD)
finger and thumb AROM exerices
teach pt. _______ exercises while in a cast
3 to 6 months
tendinosis can take ______ to heal
Provocative testing
testing to provoke symptoms to clarify the site of injury and rule out other diagnoses
- age - vitamin D and calcium deficiency - systemic disease (OA, diabetes, etc.) - nicotine use -immunosuppression - long term drug use (NSAIDS, corticosteroids) - delayed time for treatment
factors affecting healing of wrist fracture
within a week post
for stable fractures post surgery, also start OT within
extra-articular fractures
fracture did NOT cross into the joint space; typically stable and non-displaced
intra-articular fractures
fracture that crosses into the joint space; result in greater soft tissue damage; often require reduction and/or pinning
"reduction" (closed or ORIF) ORIF- open reduction internal fixation
fractures that require some type of manipulation by MD for realignment require _______
DASH/QuickDASH Modified COPM Patient interview Occupational profile
functional assessments for Lat. Epicondylitis
the arthritic thumb
thumb CMC osteoarthritis aka basal joint OA - very common - can lead to swan neck deformity at the thumb: metacarpal adduction and subluxation of the trapezium, MCP hyperextension, and IP joint flexion - pinch is painful
more restrictions per MD
treatment of post-operative stable fractures are very similar to non-operative; however there may be
padded glove or orthosis that protects pressure on canal
treatment of ulnar nerve palsy (protective gear) _________ or __________ - activity modifications - other OT interventions
DM, RA, gout, CTS, and Dupuytren's contracture
trigger finger is associated with
froment's sign
when the client attempts powerful lateral pinch the thumb's IP joint flexes as the FPL attempts to compensate for the paralyzed or weak adductor pollicis and flexor pollicis brevis
boxer's fracture
when you punch object with a closed fist, your 4th and/or 5th metacarpal bone takes the force of this impact and breaks at the neck
radial nerve
which of the 3 UE peripheral nerves is the most commonly injured
- crutch palsy
which radial nerve injury is at the site of (Axillia)- involves triceps
protocol
always ask the MD to send ___________
90-110 degrees
angle of elbows, hips, and knees should be
tendinosis
breakdown of collagen
after 40
OA usually begins at what age
impede nerve regeneration
scar tissue around the healing nerve can
- semmes weinstein monofilament - 2 point discrimination -- static and moving - light touch localization - moberg pickup test - tinel's sign
sensory assessments
- 3-4 weeks post manipulation/surgery - full ROM should be achieved by 4 weeks for manipulation; may take longer with fasciectomy - initiate graded progressive strengthening exercises
therapy guidelines following contracture release include (4)
Wartenberg's sign
this sign is present if the fifth finger is postured in an abducted position from the fourth finger. This indicates interosseous muscle weakness (specifically paresis of the palmar adductor interossei)
distal humerus fracture
this type of elbow fracture is most common in children ages 5-9
fall with elbow flexed or direct blow
typical causes of olecranon fracture
more tolerated
why are extension orthoses generally worn at night
- activity modification to avoid activities that cause pain - body mechanics training to avoid lifting objects with the forearm in pronation - educate on the importance of above and taking breaks to allow tissues to recover during repetitive activities
education for clients with lateral epicondylitis includes
absent of inflammatory cells
for decades, studies have shown that repetitive stress injuries have more of a chronic pathology that are ___________________________
bartons frx
intra-articular DRF with dislocation of carpals
Moist heat pack/ice - teach how to make a rice sock ultrasound e-stim
pain management for Lateral epicondylitis includes
smiths frx
distal radius fracture with volar displacement
practice strengthens and expands cortical representation of the are being used (desensitization; sensory re-education)
Cells that 'fire' together will 'wire' together
flexor carpi radialis tendinopathy
- pain with resisted wrist flexion combined with RD - neutral wrist splinting (volar wrist cock-up); rest from aggravating activities and activity modification
and commonly a neuroma forms over the proximal stump
in extreme cases of neurotmesis, complete transection occurs, and ...
AIN syndrome (anterior interosseus nerve)
- entrapment of motor branch - clinical picture: non-specific, deep aching pain in proximal forearm that increases with activity. no sensory involvement but loss of FPL and FDP (to index and middle) - clinical test; inability to make the "OK" sign; + Ballentine's sign
open and endoscopic releases
2 types of CTS operative treatment
- resistive exercises per MD
8-12 weeks metacarpal frx
- neutral - sustained and repetitive - flexed - vibration - PAIN
CTS interventions; EDUCATION: - keep wrist in _____ during ADLS - avoid _____ and ____ gripping and pinching with your wrist flexed (activity modification) - avoid _____ wrist while sleeping (use orthosis at night) - avoid _____ (power tools, vacuums, driving) or recommend anti- _______ gloves - ergonomic education for all tasks - ______ MANAGMENT
- carpal tunnel syndrome - scar care (24-48 hours after suture removal) - pain management (pillar pain) - mobilization (A/PROM of digits and thumb; 10 reps/hour; tendon glides) - orthotic management (as indicated by MD) - strengthening at 8 weeks
CTS operative treatment
Posterior Interossesous Nerve Palsy
PIN Palsy stands for
myoplasticity
adaptive changes within a muscle in response to changes in neuromuscular activity level and to prolonged positioning
dart throwing motion
DTM: early controlled DTM patterns improve ROM in a safe manner; DTM orthosis
2%
Distal humerus fractures make up for ___% of elbow fracture incidence among adults, but incidence increases with age
- tendon glides - blocking - active ROM - Passive ROM - wrist tenodesis - ADL retraining
Dupuytren's Disease post up exercises
between 25-50
RA usually begins around what age
ROM and edema management
educate your client on the precautions and importance of the home program for ________ &_________
- semi structured - provides information that rates the impact on volition, habituation, and perceptions of the environment on psychosocial readiness for the worker role or return to work - used to generate goals and assess outcomes or changes in psychosocial readiness for work
WRI-- Worker Role Interview
- sympathetic- sweating (if sweating is absent, this suggests complete peripheral nerve injury - trophic changes- nail changes, abnormal hair growth, cold intolerance, soft tissue atrophy in fingertips (pencil pointing) - O'Rianin wrinkle test: denervated skin does not wrinkle after hand is placed in water for 30 minutes
autonomic function assessment measures
comfort
avoid positions of
neutral wrist orthosis
orthotic management for CTS
- initially: immobilization (radial or ulnar gutter orthosis) - move uninvolved joints - edema management - ADL retraining
0-3 weeks of metacarpal fractures
flexor carpi ulnaris tendinopathy
- FCU does not have a sheath - pain with resisted wrist flexion with UD & ABD of SF - neutral wrist splinting (ulnar gutter); rest from aggravating activities and activity modification
Dupuytren's Disease
- benign connective tissue disorder affecting the palmar fascia in the hand - progressive thickening can lead to flexion contracture of the MCP and PIP joints - Higher prevalence in men of northern european descent - related to DM, alcoholism, hand trauma, HIV, and medications that treat epilepsy
on and off throughout the day and NOT at night because they are not tolerated and can cause ULNAR neuritis
when are flexion orthoses worn and why
endoneurium
inner membrane (basement) that insulates nerve fibers
osteoarthritis
is the most common form of arthritis- associated with defective articular cartilage and changed in underlying body (wear and tear disease)
- palmar ligaments - dorsal ligaments - radial and ulnar collateral ligaments
ligamentous anatomy of the wrist includes
superficial radial sensory nerve palsy
which radial nerve injury is at the site of compression between ECRL and "BR tendons; sensory only
dorsal
with a boutonniere deformity, the damage occurs at the ______ surface
CRPS malunion soft-tissue injury (lig tears) tendon irritation/rupture nerve compression TFCC/ulnar sided wrist pain
wrist frx complications include
carpal tunnel syndrome
clinical picture: - pain in volar wrist and forearm - paresthesias radial 3 & 1/2 digits-- mostly night symptoms - decrease FM coordination; due to thenar muscle weakness - advanced cases have thenar wasting; -more common in women
- Surgical: release of contracture - non surgical: in clinic; superficial heat (moist heat pack), deep heat (ultrasound- always with joint stretched to end range; preparatory method), manual techniques (hold- relax; contract- relax), ACTIVE motion and functional activities, HEP!!!
Interventions for elbow stiffness
low lesion of median nerve
clinical picture: (what type of injury) - thenar wasting - web space contracture - sensory loss to radial 3 & 1/2 digits - extrinsic digit flexors not involved (FDS/FDP) -- CAN make a fist!
- clients supervisor/coworker relationships - self-perceived identity as a worker - competence as a worker - influence of family support - environmental or organizational climate
Psychosocial factors assessed by OTs
soft tissue massage and mobilization; myofascial techniques, joint mobs; contract-relax or hold-relax, etc.
There is a wide variety of techniques for increasing elbow ROM including...
- skier's thumb - gamekeeper's thumb
Thumb UCL injuries
job analysis
a form of activity analysis that is specific to work tasks and includes the process of gathering and analyzing data related to job task requirements or demands, the environment, and human capacities needed to complete job functions
crush injury
distal phalanx frx is often a result of
flexion
elbow _______ contractures are more common
axons
many ______ make up a fascicle and there are thousands in each peripheral nerve
because of the pull of the triceps at insertion; thus requiring ORIF
many olecranon fractures are displaced because...
chauffers frx
radial styloid fx
intersection syndrome
structures involved: where APL and EPB intersect with ECRB and ECRL (involves 1st and 2nd dorsal wrist compartments) - provocative tests: similar to DeQ's but more proximal; pain/swelling 4cm proximal to wrist; pain with resisted wrist extension - orthotic consideration: same as DeQ's (thumb spica orthosis/brace) - FEINKLESTEINS TEST: positive if pain is more in FOREARM (4cm from wrist) vs snuff box
biceps and supinator
supinators include
functional enhancement
(reason for orthotics in p. nerve injury) to substitute for or enhance impaired function. When we stabilize an arthritic joint, as with the CMC joint of the thumb, we expect improved stability and strength at that joint and a decrease in joint pain during activity. When we develop a STATIC PROGRESSIVE ORTHOTIC that provides a slow and steady stretch to the tissues, we expect to see improved tissue extensibility and thus improved motion and function at that joint.
prevention
(reason for us of orthotics in p. nerve injury) to prevent motions that result in additional compression to the nerve, reducing potential inflammation that could lead to worsening of symptoms. To prevent contractures secondary to to muscle imbalance.
protection
(reason for use of orthotics in p. nerve injury) to diminish neural tension to create a healing environment. Used to abate acute symptoms or symptoms that are observed at rest and increased with activity
medial epicondylitis (aka golfer's elbow)
- degeneration of flexors attaching to medial epicondyle- often pronator teres and FCR - less common than lateral epicondylitis
1. protection 2. prevention 3. functional enhancement
3 reasons orthotics are used in the treatment of peripheral nerve injuries
- if stable, begin controlled AROM of wrist and MCPs
3-5 weeks metacarpal frx
"You'll get more benefit from doing your motion exercises slowly and fully than from doing lots of them quickly. It's best to do the exercises throughout the day. for example, do a set when you first get up in the morning, another at lunch, another when you get back from work, and the last one before bed. It is normal to feel tighter in the morning and looser at the end of the day. When your elbow feels stiff, breath deeply and relax as you slowly move your elbow as far as it will go. Forceful or quick motions will tend to make all your muscles contract and fight the movement you are trying to do,".
About the HEP for a stable elbow fracture (what to say)
thumb lies to the side of the palm as it is unable to abduct and oppose thus get web space contracture
Ape hand deformity
- when can the protective orthosis be discontinued? - when can passive ROM be initiated? - when can the use of static progressive orthosis be initiated (if necessary to increase motion) ? - when can resistive exercise be inititiated?
As the client progresses, you should as the MD
rolando fracture
Comminuted fracture of thumb base extending into carpometacarpal joint.
flexor digitorum profundus
FDP
flexor digitorum superficialis
FDS
flexor pollicis longus
FPL
- pronator syndrome- 4 sites of compression - anterior interosseous syndrome-- deep motor branch (AIN) compression
Median nerve injury sites HIGH
their uninvolved hand
Motor exercise tips: instruct your client to support the involved UE with _____ while performing gentle motion exercises to increase comfort and control
Neurotmesis
Nerve trunk discontinuity: most severe grade of injury to a peripheral nerve. all components are damaged and irreversible. all motor and sensory loss is permanently impaired.
- observation: cast fitting, skin color, edema - ROM of uninvolved joints (I.e. shoulder, elbow, digits) - sensation - circulation: Allen's test - edema - ADL: DASH, QuickDASH, FIM
OT Screening and Assessments ACUTE PHASE (1-6 weeks) WRIST FRACTURE
low referral rate to OT during this phase - education: HEP, pin care as indicated - edema management - AROM exercises: tendon gliding for digits; proximal shoulder and elbow ROM - Activity Modification - Custom orthosis as indicated
OT interventions ACUTE PHASE (1-6 weeks) WRIST FRACTURE
- orthosis- forearm based thumb spica with IP free to prevent painful motions (put in brace if inflamed- red, hot, swollen)
OT interventions for DeQuarvain's Disease (orthosis)
- sensory re-education- protective and discriminative - desensitization - pain management - modalities - nerve gliding/sliding (use cautiously)
Other OT interventions for nerve injuries include
- distal ulna fractures- associated with ulnar side wrist pain - carpal fractures: - scaphoid frx - lunate frx
Other wrist fractures
placed in orthosis in intrinsic plus position x 3-4 weeks
P-1 proximal phalangeal fractures: minimally displaces fractures are treated by
buddy taping to adjacent digit x 4 weeks
P-1 proximal phalangeal fractures: simple, non displaced fractures are treated with
- static wrist ext orthosis with 30 degrees wrist ext to protect the repair; MP joints in 10 degrees flexion; thumb in RA and extension - at 3 week; switch to wrist cock-up orthosis or dynamic extension assist orthosis; continue wear until functional wrist extension returns; A/AAROM are initiated
Radial nerve repair at the elbow and forearm (varies per MD)
tendon glides; lumbrical stretches
What are CTS interventions?
posterior and positioned in a 90 degree elbow flexion with forearm in neutral and the wrist FREE - instruct pt. to remove SEVERAL times a day for exercises
When used for protection (during healing phase)- most custom elbow orthoses are _________ and positioned in a ___________
"While receiving hot pack over the R elbow, pt. participated in therapeutic education regarding......
You cannot bill for hot and cold packs-- instead you should say what?
20%
____% of all fractures involve the hand
the ability to passively extend PIP
______ is an indicator for nonoperative treatment with PIP immobilization orthosis
Guyon's canal is
__________ is the ulnar tunnel
triceps muscles
after an elbow injury, pts. have trouble recruiting and firing the ________ (may be due to hyper-activity of these muscles) - therefore, work on recruitment supine at shoulder at 90 degrees to diminish the pull of gravity on biceps
micro breaks
after bouts of excessive activity (typing) take a _________ (less than 2 min)
long arm orthosis (90 degrees of elbow flexion)
after cubital tunnel release, what type of orthosis?
6-8 weeks
after cubital tunnel release; work on scar management and after _______ wk/s begin working on strengthening
die-punch frx
articular frx resulting in a depressed lunate facet
- place and hold exercises - isotonic exercises (short, frequent sessions) - muscle retraining
as muscle recovery returns....
dependent on nerve fiber regeneration: RATE OF REGENERATION ranges from 1.5 to 3 mm per day (without complications)
axonotmesis (crush injury): more severe with degeneration distal to the injury; recovery is dependent on.....
crushed base injury and not a laceration
axonotmesis is typically caused by a
osteopenia or osteoporosis; either condition may be exacerbated during the postoperative immobilization period
be cautious with initial loading of nearby bone and joints once strengthening is permitted if your client has a history of
- elbow joint (hinge) does not tolerate disruption of articular surfaces - the elbow joint capsule is thin and suseptible to injury and scarring/adhesions (especially anterior) - brachialis muscle can also adhere to the anterior joint capsule - muscle guarding in elbow flexion leads to soft tissue shortening- biceps muscle is prone to adaptive shortening (posturing tends to be 70-80 degrees of flexion) - HO- heterotopic ossification
causes of elbow stiffness include
cubital tunnel syndrome causes
causes: external compression (leaning on elbow); occupational activities that require repetitive elbow flexion; elbow fractures
pronator syndrome
compression of median nerve in 4 typical sites. -clinical picture: diffuse pain medial forearm with dysesthesia in radial 3 & 1/2 digits
pronator syndrome conservative managment
conservative management for ____________ includes fabricating an orthosis to rest the tissues with instructions to use the orthotic as much as possible over the initial 2 to 3 weeks, removing it for hygiene, and gentle AROM and nerve gliding only
demyelination
damage to myelin that results in slowing of loss of nerve impulse conduction
lateral epicondylitis (Tennis Elbow)
degeneration of extensor tendons at lateral epicondyle insertion caused by repetitive stress, typically ECRB most involved
fibrotic adipose tissue
denervated muscle is replaced by _____
wartenburg's syndrome
dorsal radial sensory nerve injury = (AKA)
triceps
elbow extensors include
biceps, brachialis, and brachioradialis
elbow flexors include
ulnohumeral, radiohumeral, and proximal radiulnar
elbow joint consists of
- body mechanics and posture- want neutral positioning - manual handling - repetitive and static tasks - anthropometrics : proportion of body to equipment - environmental considerations- noise, vibration, lighting, contact stress
ergonomic considerations
tendinosis
even tiny movements such as clicking a mouse, when done repeatedly, can lead to
type 1 collagen fibers
healthy tendons have what kind of collagen fibers arranged neatly/parallel?
1-2x/day with 10 reps using 1 lb weight or light theraband; slowly increase reps to 30 reps as this is an endurance exercise; can increase to 2 lbs when this is easy
how often should eccentric strengthening be done?
- active rather than passive ex. sliding in elbow flex/ext patterns across table top - bilateral activities/occupations
in the clinic what should we do for a patient with a non operative elbow fracture? - Focus on _______ exercises and activities rather than _______
- start with assisted AROM if patient is apprehensive (light dowel, move in gravity decreased positions) - gentle PROM (if cleared)
in the clinic what should we do for a patient with a non operative elbow fracture? (ROM)
manual edema mobilization
in the clinic what should we do for a patient with a non operative elbow fracture? (for edema)
- e-stim for pain (IFC), hot/cold packs AS PREPARATORY METHODS
in the clinic what should we do for a patient with a non operative elbow fracture? (for pain)
trigger finger
inability of the finger to perform smooth digit flexion or extension due to inflammatory pathology on the tendon or tendon sheath - also called digital stenosing tenosynovitis
interventions: Pt. education; volar FA-based wrist extension orthosis with thumb extension (no strap near radial styloid)
interventions for dorsal radial sensory nerve/ wartenburg's syndrome
- rehab is beyond entry-level knowledge - consider stages of tissue healing for decisions regarding ROM and progression - in general, will include; edema and pain control, controlled & protected ROM (based on healing stage)- DART THROWING
interventions for wrist instabilities
rheumatoid arthritis
is a chronic, system, inflammatory and autoimmune disorder. Involves synovial tissue
tendonitis
is an inflammation of a tendon that typically occurs after an acute episode of overload of the musculotendinous unit, it usually heals within several days but up to 6 weeks - goals of treatment are aimed at reducing inflammation
arthritis
is the most prevalent and disabling chronic condition worldwide in older adults
neuropathy
is the term used to describe pathological conditions of the peripheral nerve
to provide the most appropriate treatment
it is important for therapists and healthcare providers to distinguish whether an injury is tendonitis or tendinosis
wrist cock-up orthosis
keeps wrist in a functional position. It is less bulky and noticeable than a dynamic orthosis. often more comfortable. you can use intrinsics to extend the IP joints of digits (but not MCPs as ED muscle is out)
60-70 degrees
metacarpal fractures: orthotic frabrication: _____ degrees of MP flexion, IP neutral/straight (intrinsic plus position)
if displaced, intrinsic + position x 3 weeks followed by AROM
middle phalanx fracture treatment
digit based gutter orthosis. Gentle P/AROM with stabilization of fracture at DIP and PIP joint
middle phalanx frx, if no displacement,
neurapraxia
mildest form of injury. conduction block usually due to myelin dysfunction. axonal continuity conserved. nerve conduction is preserved proximal and distal to lesion. nerve fibers are not damaged. recovery will occur within 4/6 weeks. the effects of this class of injury can typically last from hours to several weeks
heterotopic ossification
misplaced formation of bone; bone in non-osseous tissues
scaphoid fracture
most common carpal bone fracture in adults; take longer time to heal due to poor vascularity (especially proximally; can take 24 weeks)
age related
nerve regeneration outcome is
minutes or weeks
neurapraxia (localized compression) can resolve in
complex regional pain syndrome (CRPS)
neuropathic pain; vasomotor issues; leads to extreme stiffness, loss of fx, and significant disability
must have surgical fixation for chance of regeneration
neurotmesis: nerve is cut/transected; must have...
orthosis with MCP in extension and PIPs free x 3 weeks - if no improvement, corticosteroid injection or surgery is recommended
non operative treatment for trigger finger
- education: joint protection principles - modalities for pain - exercise - orthotic intervention
nonoperative treatment/ interventions for arthritis
- distal radius - ulna - 8 carpal bones - joint capsule - several ligaments - TFCC (triangular fibrocartilage complex)
normal anatomy of the wrist is compromised of
30-45 degrees of elbow flexion 70
normal rest position of UE is _______. This flexion increases with injury and "guarding" occurs at ~ _____ degrees
- day: functional, just thumb really, can grab pencil - night: thumb; stretching out web space
orthotic management for low lesion of median nerve
gentle and longterm
orthotics should be designed to be a ________, _______ stretch
- traction or stretch injury - internal pressure causing chronic compression or entrapment (tumor or scar tissue) - external pressure (crutches or a cast) - avulsion or laceration - chemical or electrical burns/radiation - alcoholism - diabetes mellitus - genetic (not common, i.e. charcot-marie-tooth)
peripheral nerve injury causes include
- education - training functional activities - orthosis &/or counterforce brace - pain management - regain tendon length
phase 1 interventions for Lat Epicondylitis
pain is mild and light functional activities are no longer painful; interventions are aimed at restoring flexibility, strength, and endurance
phase 2 of interventions for lateral epicondylitis means
Cosmesis
preservation, restoration, or enhancement of physical appearance
- medical record review - client interview - pain ratings - musculoskeletal screenings- baseline ROM and strength abilities/limitations - physical demands - client's abilities
process of functional capacity evaluation
pronator teres and pronator quadratus
pronators include
elbow flexion contracture (loss of elbow extension)
radial head fractures often result in
mostly pain and no motor involvement (unless severe)
radial tunnel is mostly....
- keep the MCP in slight flexion (20 degrees) - wrist and IP joints are free - think material for comfort is best
purpose of CMC OA orthosis
- injury to TFCC (triangular FibroCartilage Complex) - peripheral nerve injuries - ligament sprain or tear - aggravation of -pre-existing OA
soft tissue injuries commonly associated with wrist fractures are
- supination with elbow extended and wrist passively moved in extension to lengthen the flexor pronator tendon group
stretches for medial epicondylitis
palmar ligaments
strongest and main stabilizers of radiocarpal joints
perineurium
surrounds each nerve fascicle (mostly elastin)
lunate fracture
susceptible to avascular necrosis due to its limited blood supply at the palmer pole; thus associated with KIENBOCK'S DISEASE
PIP hyperextension and DIP flexion
swan neck deformity is characterized by
carpal tunnel syndrome
the causes of ________: - related to increase in pressure in the carpal tunnel from forceful/repetitive motions (wrist), pregnancy, irritation (vibration), compression (sleeping with wrists flexed); associated with diabetes, arthritis, hypothyroidism
the WRI assess psychosocial factors that influence work performance while the WEIS assesses workplace condition that impact the worker
the difference between the WRI and WEIS
carpal bones
the dorsal floor of the carpal tunnel is
ganglian cyst
the most common cause of compression at Guyon's canal (ulnar nerve palsy) is from a _________ but can also occur from pressure from the fracture or irritation by continuous pressure (pushing a cart, cyclists, or pressure from musical instrument)
carpal tunnel: 1-10% of the population
the most common nerve entrapment in the UE
epineurium
the outer, strong sheath that functions to surround and cushion the nerve fascicles
pronator teres
the primary pronator is
biceps
the primary supinator is
ECU tendinopathy
the second most common type of tendinopathy of the wrist (after DeQuervain's) - typically from overuse injury; common in wrist intensive sports- tennis, rowing, golf and baseball - SX: ulnar sided wrist pain (6th dorsal compartment) - Test: resisted extension with UD - RX: rest, orthotic intervention, activity modification, occasionally injection or surgery
Steners lesion
the ulnar collateral ligament is displaced with interposition of the adductor aponeurosis. Surgery is required for this type of injury, because interposition of the adductor aponeurosis prevents healing
cubital tunnel
the ulnar nerve passes through what
1 day to 1 week after first visit - review HEP - reassess wound, pain, edema, sensation, function and orthosis fit - adjust orthosis - reinforce previous education and timeline for resuming more strenuous activities (4-6 weeks post)
therapy guidelines following contracture release include (2nd visit)
- every 2 hours, 2-5 reps of 20-30 second holds
typical stretching HEP for lateral epicondylitis
goal is typically 1 hour on, 1 hour off during the day but may have to start with 15-30 minutes and progress to hour wear time - total wear time= 4 hours a day
typical wearing goal of flexion orthosis
Guyon's canal
ulnar nerve palsy is the entrapment of
LOW compression
ulnar nerve policy is a ________ compression
FIXATION: -ORIF, -external fixator
unstable fractures require
pain and sensory involvement only (no motor)
wartenberg's syndrome (DRSN) is mostly...
radial head, olecranon, and distal humerus
what are the three types of elbow fractures?
typically FOOSH with pronation or direct blow to the elbow
what are the typical causes of a radial head fracture
functional assessment
what assessment is considered the most important
physical demands cognitive demands perceptual demands psychological demands social demands environmental demands
what demands does one have for job performance?
clinical picture of trigger finger
- digit "snaps" or catches during AROM. can occur in ANY digit - catches in the A1 pulley - severe cases- the finger locks into a flexed position and client can't open without prying it open
DeQuervain's Disease / Tenosynovitis (text thumb)
- inflammation or tendinosis of the first dorsal compartment of the dorsal wrist involving APL and EPB
osteoarthritis pathology
- osteophytes (bone spurs) - inflammation and pain - nodules (Bouchard's at PIP, Heberden's at DIP) - deformities- mallet finger, boutonniere - cepitus (popping noise)
clinical picture of medial epicondylitis
- point tenderness at medial epicondyle - pain with forceful pronation and resisted wrist flexion - pain with resisted elbow extension with supination and wrist extension
clinical picture of lateral epicondylitis aka tennis elbow
- point tenderness/pain at lateral epicondyle - pain with gripping, resisted wrist extension, supination, digital extension, and radial deviation - tightness of extrinsic extensors (dorsal forearm) - nighttime aching and morning stiffness
PIP joint area- zone III of extensor tendon
central slip injury is typically located at the
neurotmesis
characterized by not only loss of nerve conduction, but damage to surrounding nerve trunk connective tissue
volar roof
the ______ of the carpal tunnel is the transverse carpal ligament (AKA flexor retinaculum)
clinical picture of dupuytrens disease
- presence of nodules or cords in the palm - typically on the ulnar side but can involve any digit - the cords/nodules may appear slowly and progress slowly (decades) OR they may appear rapidly and progress rapidly (months) - the more aggressive forms have involvement in other sites including plantar surface of feet (Ledderhouse disease) and penis (Peyronie disease)
wrist instability
- the wrist is compromised of several articulations and ligamentous structures - carpal dislocations and instabilities are common injuries- mostly from trauma - carpal instability is dislocation between distal carpal row over carpal row
- begin gentle PROM
6-7 weeks metacarpal frx
- compression of motor branch of PIN between 2 heads of supinator in ARCADE OF FROHSE - weakness of ulnar wrist extension (ECU), digit extension (ED), and thumb ext/abd
clinical picture of PIN palsy:
cubital tunnel syndrom clinical picture
clinical picture: - pain in the medial aspect of the elbow and hand - paresthesia in the ring and middle finger - severe cases: muscle wasting (atrophy) of ulnar intrinsics and "clawing"
jersey finger, mallet, and often associated with soft tissue trauma
complications of distal phalanx frx
- intrinsic tightness - extrinsic tightness - joint capsule tightness - stiffness of uninvolved digits - phalangeal fractures
complications of metacarpal fractures
HIGH ulnar nerve compression
cubital tunnel syndrome is located where (high or low)
removable orthosis or sling
depending on the severity of the fracture, a __________ or ________ may be used in between exercises
regeneration may occur over the timescale of weeks to years
depending on the severity of the injury,
colles' frx
distal radial fracture with dorsal displacement
-mechanism of injury - social and medical history - modified COPM/DASH is helpful
evaluation interview should include
lifting a child under his/her arms, wringing out wash clothes, opening/closing jar lids, using scissors, typing, playing piano, knitting/needle point, or racquet sports - women are 4x more likely to have this than men
examples of what could cause DeQuervain's Disease
- avoid painful AROM and PROM (work in pts. comfort level) - wrist flexion/extension - gentle digit flexion/extension - if thumb adduction contracture, web space stretches
exercise for arthritis
extension
flexion contracture lacks
make sure you are immobilizing the fewest joints and soft tissue possible without compromising the repair to avoid the development of stiff and fibrotic joints and soft tissue in adjacent areas
following nerve laceration, when immobilization is in place to protect the nerve repair site, it is important to
mainly at night; Can wear during the day if necessary to control excessive wrist motions if symptomatic
for CTS, neutral wrist orthosis should be worn when?
Home program
for a non-operative treatment of a stable elbow fracture, you need to set up a _________
1
for cubital tunnel release, early mobilization after _____ week/s of post op (submuscular may be later?
clinical picture of ulnar nerve palsy
Clinical Picture: - sensory loss and motor loss of ulnar innervated instrinsic muscles
DIP extension orthosis at least 2-3 weeks
for non-displaced distal phalanx fracture
orthotic intervention for wrist drop
for non-dominant (and some dominant cases when cosmesis is important), a wrist cock up orthosis is reasonable
forearm-based orthosis with the hand included
for pronator syndrome, if compression is at the fibrous arch of the heads of the FDS (resistance to FDS of the long finger aggravates symptoms), consider fabricating a
long arm orthosis with the forearm in neutral, the wrist in neutral, and the elbow in about 90 degrees of flexion
if compression is at the pronator teres, pain/paresthesia will be aggravated by resistance to forearm pronation and will be enhanced as the elbow is extended. In this case, fabricate a
carpal tunnel
a passageway that runs from the forearm through the wrist
orthosis in extension until pins removed then begin gentle ROM
if pinned distal phalanx fracture,
connective tissue/collagen
tendons are mostly made up of
Manual Edema Mobilization (MEM)
a technique used for decreasing edema in the orthopedic population. MEM differs from manual lymph drainage, as it is used in an acute condition to decrease edema in an intact lymph system
stable factures
are when the bone fragments are non-displaced and aligned. These require no medical intervention to restore normal bony configuration and are often splinted/casted
- reflect key concepts from MOHO - consider a workers motivation (volition), everyday patterns (habituation), capacity to work (performance), and environmental impact
the WRI and WEIS
- pain - client history - sensory: semmes-weinstein monofilament; 2 point discrimination; localization to touch; moberg pick-up test; - special provocative tests; median nerve compression (Durkan's), Phalen's test, Tinel's sign; Berger's test: to identify lumbrical muscle contributions to CTS - coordination: 9 hole peg test; functional assessment - ROM - strength: MMT, grip, pinch
assessment of carpal tunnel syndrome
clinical tests - Cozen's test: place client's forearm in pronation, full elbow extension, and resisted wrist extension - Mill's test: place the client's forearm in pronation, wrist in flexed position, and the elbow is then into ext slowly Additional tests: - paint history and scales -A/PROM - MMT (include proximal; RC and scap) - grip strength test (strengthen greater when elbow flexed is another sign) - posture assessment
Eval of lateral epicondylitis
- AROM - PROM if permitted - Pain- numeric pain scale - Sensibility (ESPECIALLY ULNAR NERVE) - edema (circumferential) - functional assessment: DASH/QuickDASH, PREE, etc. - strength NOT ASSESSED until cleared by MD (grip and MMT)
Evaluation tips (pg 207): Assess the following
functional capacity evaluation
FCE: - clinical evaluation to determine an individuals capacity to perform work activities related to his/her participation in employment
DIP flexion exercises- AROM x 10 hourly and PROM - if PIP can be passively corrected, non-operative immobilization is indicated. MP and DIP are free. ONLY the PIP is immobilized in full extension. HEP teach to flex DIP joint x 10 hourly to prevent ORL tightness
HEP for Boutenniere Deformity
elbow fracture
HO is a complication following ________- especially high energy mechanisms of injury, open fractures, and non-operatively managed fractures
- strengthening; start isometric: forearm, wrist, and digits; start low resistance and increase as tolerated - education: HEP for strength - IADLs/ Functional activities: continue to increase lifting, carrying, object manipulation, etc.
OT interventions STRENGTHENING phase (8-10 weeks) WRIST FRX
- education; HEP, edema mgmt, scar mgmt - AROM: focus on tenodesis to isolate wrist extensors (extend wrist with digits flexed); tendon glides for digits; continue proximal AROM - stretching/PROM (as approved by MD): prayer stretch - therapeutic activities: grasp release; dexterity activities - edema mgmt: MEM - pain mgmt: Modalities - custom orthosis as indicated support soft tissue and encourage wrist extension (worn in public, during heavy activities, and at night) - scar mgmt/desensitization: scar mobility/massage, pressure garments, modalities
OT interventions SUBACUTE (mobilization) phase (6 weeks and beyond) WRIST FRX
OT interventions for PIN and RT; Radial tunnel
OT interventions for ______ & _______ - orthosis-- that takes tension off nerve: long arm orthosis with elbow in flexion, forearm in supination, and wrist in extension. Not well tolerated - Patient education: rest, activity modification, gentle stretching and ROM-- emphasis on supination, and nerve gliding, and anti-inflammatory medication - for _______ - avoid compression sleeves
- night orthosis with elbow in limited flexion or pillow/towel orthosis - day: elbow pad - pain management - activity/work modification
OT interventions for cubital tunnel syndrome
- paraffin -fluidotherapy - hot packs
PAMS for arthrits
common
pain at end ranges are _________
- monitor rom; if trouble regaining flexion, introduce composite taping or dynamic orthosis/flexion glove - re-eval orthosis - review timelines for resuming activities - watch for "flares" between 2-4 weeks (not common); if occurs- refer back to MD
therapy guidelines following contracture release include (3) (2-3 weeks after surgery or manipulation)
4-6 weeks post - perform final reassessment - finalize the HEP and orthosis needs - d/c with a well-established HEP
therapy guidelines following contracture release include (5) (final)
1st therapy visit (1-2 days after non surgical manipulation, 1 week after surgical) - assessment of wound, edema, ROM, pain, sensation and function - education: wound care, edema management, light ROM exercises focused on digit EXT and intrinsic stretching - fabricate custom hand based night ext. orthosis - instruct client to resume light ADLs- even with effected hand - therapy guidelines following contracture release
therapy guidelines following contracture release include (first visit)
orthosis management for CLAWING
this orthosis works by preventing overstretching of the lumbricals and the interossei muscles of the ring and small fingers (prevents MCP hyperextension) - also redistributes the power to the extensor digitorum to allow IP extension. The ED is innervated by the uninjured radial nerve.
Elbow flexion test
this provocative maneuver is designed to reproduce the symptoms of ulnar nerve compression. The elbow is flexed fully, and the wrist is held in neutral for up to 5 minutes. A positive test is the reproduction of paresthesia and pain symptoms
bennett fracture
this type of metacarpal fracture involved the abductor pollicus longus tendon
- hand based thumb spica with IP free - RCL injuries (less common) treated the same with orthosis designed to support the radial side of thumb
thumb UCL injury interventions
demyelination and injury to nerve itself
what happens when a peripheral nerve is injured?
radial head fracture
what is the most common elbow fracture in adults
viscoelastic structures with unique mechanical properties that allow muscles to transmit forces to create motion at joints
tendons are
poorly
tendons are _____ vascularized
the nerve fibers have a pathway for regrowth back to the target structures they innervate (skin, muscles, etc)
IF the endoneurial tube remains intact
- gel pads to decrease soreness - functional strengthening vs putty - desensitization for hypersensitive scar - massage and modalities for pain
Interventions for pillar pain
- respect pain - balance rest and activity - exercise in a pain free range - avoid positions of deformity - reduce the effort and force - use larger/stronger joints
Joint protection principles
carpal tunnel syndrome
Median nerve injury sites LOW
the first week of injury or post surgery
Most elbow frx (stable) begin gentle AROM by.. __________ .. to reduce contractures/elbow stiffness, get blood flowing, loosen up the muscles, prevent further atrophy, reduce swelling
supine
Motor exercise tips: - Unless contraindicated, it is often most comfortable for your client to begin elbow flexion and extension in _______ with the upper arm supported on a pillow or folded towel alongside their torso. Progress to other gravity-assisted positions, such as elbow extension while seated and elbow flexion in supine with the shoulder flexed at 90 degrees.
- grip and pinch testing - MMT - Begin when MD permits; typically 8-10 weeks post Frx
OT screening and assessment STRENGTHENING phase (8-10 weeks) WRIST FRX
- observation; skin, pain, posture - ROM: wrist AROM and PROM ; proximal/distal as appropriate - Sensory: especially median nerve distribution - edema - pain - scar: adherence and sensitivity - ADL: DASH, PRWE (pt. rated wrist eval)
OT screening and assessment SUBACUTE (mobilization) phase (6 weeks and beyond) WRIST FRX - begin after cast/orthosis removal per MD (6-12 wks); pt. wears removable orthosis post-cast for 2-4 weeks
inflammatory phase
Phase 1 of interventions for lateral epicondylitis does not mean _____________, it means the patient is in pain at rest and pain increases with movement
- currently, not strong evidence supports the need for strengthening, however, strengthening may be beneficial - eccentric strengthening of the forearm extensors loads the tendon in a lengthening position and can be done so without causing pain - concentric strengthening tends to be painful and contradicts instructions to avoid palm down during lifting, thus should be avoided
Phase 2 strengthening for lateral epicondylitis
if client has RTS, do not use elbow clasp splints or straps, and be cautious with compression sleeves for the elbow. Elbow clasp splints can further compress the radial nerve at the radial tunnel
Precautions and concerns for radial tunnel syndrome,,,
clinical picture of low radial nerve palsy/injury
clinical picture of _______: at the forearm level, the radial nerve divides into the posterior interosseous nerve (PIN) and a superficial sensory branch (dorsal radial sensory nerve DRSN)
medial nerve and 9 extrinsic flexor tendons: - 4 x FDS - 4 x FDP - 1 x FPL
The carpal tunnel is a narrow channel that contains ...
neck and wrist flexion
lack of flexion compensated some by _________ and ________, but it is more functionally limiting
- semi-structured - interview works with client to assess environmental impact on participation in the worker role & to identify needed accommodations - used to gather information on the worker's perception and experience of work settings
WEIS-- work environment impact scale
worker role interview & work environment impact scale
WRI and WEIS stand for what?
"you may be surprised to start motion exercise so soon after breaking a bone, but elbow stiffness is the most common problem after an injury like yours. Your fracture is stable enough now to safely do the gentle exercises that I am going to teach you. They will help you maintain and improve your elbow motion."
What can you say to someone following a stable elbow fracture who is hesitant to begin movement?
- recommending work accommodations or modifications to work practices - making job tasks safer - preventing injuries - promoting health and wellness - supporting workers return to work after an injury - providing education and training about the risk factors for musculoskeletal or psychosocial injuries to prevent workplace injuries
What is OTs role to help facilitate work performance
HIGH median nerve laceration
What type of laceration is this: - occurs in forearm typically from knife or glass laceration - clinical picture: sensory and motor loss of FA flexors and hand intrinsics - results in ape hand with loss of ability to pull thumb away from palm. Thus loss of precision pinch, thenar opposition, FDS and radial FDP & lumbricals - weak pronation; sensory loss radial 3 & 1/2 digits - can make a weak/half fist from ulnar 1/2 of FDP
radial tunnel
_______ clinical picture: - compression of radial nerve in proximal forearm - dull aching or burning PAIN along the lateral forearm musculature - causes: compression at the fibrous edge of supinator muscle from external force from pressure (counterforce brace or repetitive supination) - symptoms often confused with lateral epicondylitis but they can coexist. Test: wrist in flexion, resist middle finger extension. Positive if increase in symptoms of pain (or aching/burning) lateral forearm.
middle phalanx
_______ is the least fractured phalanx
distal phalangeal fractures (p-3), followed by proximal phalanx (P-1)
__________ fractures are most common hand fractures, followed by _________
Dorsal Radial sensory nerve/ Wartenburg's syndrome
__________________ (which injury/syndrome): - causes: repetitive pronation- supination results in "scissoring" of BR and ECRL tendons-- compressing the nerve or compression (i.e. wrist watch) - clinical picture: pain and dysesthesia on dorsal radial forearm extending to thumb and index finger - interventions: Pt. education; volar FA-based wrist extension orthosis with thumb extension (no strap near radial styloid)
orthotic options for high radial nerve palsy
a wrist immobilization orthosis with the wrist in a functional position of 30-degrees extension is an option. An advantage of using this type of orthotic is cosmesis. A wrist cock-up orthosis is less conspicuous than a dynamic orthosis. It is also more comfortable without the problems that a bulky outrigger presents, especially when sleeping. furthermore, this orthosis is less costly and easy to put on and take off. This is a reasonable daytime choice when the nerve injury is on the nondominant side, and/or when cosmesis is of greater importance than function for clients
unstable fractures
are those displaced with motion or spontaneously. These require surgical fixation for realignment and to ensure prevention of malunion
- the revised NIOSH lifting equation - rapid upper limb assessment (RULA) - quick exposure checklist - computer workstation eTool - NIOSH generic stress questionnaire - body picture pain diagram - observation-based posture assessment: review of current practice and recommendations for improvement
assessment tools for MSD (musculoskeletal disorder) Risk
Axonotmesis
axon discontinuity, axonal+ endoneurial disruption, perineurial rupture & fascicle disruption: a more severe grade of injury to a peripheral nerve. is reversible injury to damaged fibers. damage occurs to the axons with preservation to endoneurium. nerve can regenerate distal to the site of lesion by one millimeter per day. Myelin sheath still intact.
scarring
because of degeneration of the tendon, ______ results in tendon length insufficiency
High Radial Nerve Palsy
clinical picture of ______? : - mid-humeral compression or shaft frx - triceps is spared (elbow ext intact) - supinator and brachioradialis involved but supination and elbow flx spared) - wrist, digit MCP extensors and thumb ext/abd paralyzed > wrist drop)
Disruption of the central slip of the extensor tendon characterized by PIP flexion and DIP hyperextension. Caused the lateral bands to slip VOLARLY
causes of Boutonniere Deformity
causes: repetitive pronation- supination results in "scissoring" of BR and ECRL tendons-- compressing the nerve or compression (i.e. wrist watch)
causes of dorsal radial sensory nerve/ wartenburg's syndrome
injury primarily to PIP joint to the volar plate/capsule or injury to the transverse retinacular ligaments causing lateral bands to be DORSALLY displaced
causes of swan neck deformity
excessive gripping
causes of trigger finger
Heberden's nodes
clients with OA at the DIP joints often have enlargements called
FOOSH or high velocity injuries in younger individuals (MVA/sports)
common causes of distal humerus fractures
- Colles' frx - smith's frx - bartons frx - chauffers frx - salter-harris frx - die-punch frx
common distal radius patterns
- boxer's frx - bennet frx - rolando frx
common metacarpal fractures
- scapholunate ligament tears - luno- triquetral instability
common types of wrist instabilities
Finklestein's test- instruct client to flex the thumb into the palm of hand, then practitioner ulnarly deviates the wrist= pain - pain history and scales - A/PROM - proximal testing- supination/pronation, elbow flex/ex, shoulder - MMT- include proximal- RC and Scap - grip/pinch (note any paint) - posture assessment - functional assessment/ occupational profile (interview)
evaluation for DeQuarvain's Disease
- pain - arom- prom can be injurious if joints are unstable - strength (be cautious) - joint stability - palpation - ADL- home, work, leisure (COPM and AIMS)
evaluation of arthritis should include
eye breaks
every 20 min, look away 20 ft from screen for 20 seconds (20-20-20 rule)
rest break
every 30-60 min, take a brief rest break- stand, move, do something else away from the desk (lap around the office)
stretch breaks
every couple of hours, stretch briefly in the opposite direction of work position
multiple mononeuropathy
ex: injury to median and ulnar nerve
an anterior long arm orthosis with the forearm in neutral rotation, using the lightest thermoplastic material option possible
if symptoms are aggravated by resisted flexion of elbow with forearm in full supination, compression is likely at the lacertus fibrosus, and the orthosis should limit elbow flexion and forearm supination. Consider fabricating
regeneration and restoration of sensory or motor ability may return
if the neuronal tubes are maintained in place
lengthened
in order to restore tendon dynamics, structures will need to be
tendinitis
inflammatory process characterized by heat, swelling, and pain
stabilize the IP joint of the THUMB and INDEX FINGER for prehension
interventions for AIN syndrome; orthotics to stabilize the ____ (joint) of the ____ & ________ for prehension
mononeuropathy
involves damage to a single nerve (ex: carpal tunnel syndrome)
tendinosis
is a degeneration of the tendons collagen in response to chronic overuse
luno-Triquetral instability
less common wrist instability; associated with ulnar-side injuries; VISI ( at carpals more than wrist) deformity
radial collateral, ulnar collateral, and annular
ligaments of the elbow joint include
- needle aponeurotomy release - collagenase injection - fasciotomy (release) - fasciectomy (remove) (most common, gold standard)
medical interventions fot Dupuytrens include
immature collagen fibers
microscopic view of tendinosis reveals what?
rheumatoid arthritis of the hand
most common AUTOIMMUNE inflammatory arthritis in adults - characterized by synovial inflammation; autoantibody production; cartilage and bone destruction that leads to deformity; systemic manifestations- caridovascular, psychosocial and skeletal - typically affects joints symmetrically and commonly includes the MP, PIP, thumb and wrist joints - early symptoms included morning stiffness, extreme fatigue and swelling of PIP joints
scapholunate ligament tears
most common wrist instability; visual gap on x-ray (+ Terry Thomas sign); DISI (at wrist) deformity- can lead to SLAC wrist
hot/cold packs, compression sleeves for edema (include edema glove if needed)
non-operative treatment, for pain and edema management a client should be educated on and use .....
- used to protect joints - reduce pain by statically holding the joint in place - decrease joint load demand during ADL hand use - prevent deforming forces - worn during the day during activity and only at night if indicated for pain reduction
orthoses for arthritis
- holds digits in extension - can be volar or dorsal (always hand based) - consider wound dressings - may be worn full time for 1-2 weeks post-op (depending on contracture and MD), then worn at night only for up to 3 months
orthosis for contracture release
neutral or slight flexion to take tension off the flexors - counterforce brace on FLEXORS
orthosis for medial epicondylitis: instead of wrist extension, wrist should be
anti swan neck orthosis (goes over PIP)
orthosis for swan neck deformity
- depends on what stage of OA, what joint's involved, client's preferences, and goal of orthosis (i.e. immobilization of a joint, stability of a joint, post-operative, etc.)
orthosis management for thumb CMC OA
edema, cold sensitivity, provocative testing
other assessment measures
-education - HEP for self stretches (what could become tight) - instruct on prognosis of nerve recovery-- can take up to 3-4 months with neuropraxic injuries - functional activities with orthosis on
other interventions for wrist drop include
document holders, lighting (no yellow light, reduce glare), proper lifting (lift from knees, not back)
other office recommendations
- which bone was fractured and what was the nature of the frx? ask for RADIOLOGY REPORT - were there any associated injuries? - was the frx treated surgically, and if so, how? Ask for the OPERATIVE NOTE - is the frx stable enough to begin active motion? - Are there any mvmt limitations or precautions? - What are the preferred type, position, and wearing schedule for the protective orthosis?
other questions to ask the MD include
pain scales/ pain assessment tools
pain interview should include
dysesthesia
painful sensation
salter-harris frx
pediatric frx of the growth plate; varying types
- epineurium: outer (strong sheath) - functions to surround and cushion the nerve fascicles - perineurium: surrounds each nerve fascicle (mostly elastin) - endoneurium-- inner membrane (basement) that insulates nerve fibers - axon is a nerve fiber. many axons make up a fascicle. Many fascicles make up a nerve. There are thousands of axons in a peripheral nerve
peripheral nerves are protected from injury by multiple layers of connective tissue coverings including:
- AROM in pain-free ranges (short arc, gravity eliminated). Use tenodesis to isolate wrist extensors vs digit extensors - pain free PROM - gentle isometric exercises (muscle contraction without movement) - proximal UE ROM/ stretching and postural strengthening - massage - cross friction over tendons
phase 1 therapeutic exercise intervention for lateral epicondylitis continued
1. inflammatory phase 2. repair phase 3. remodeling phase
phases of bone healing
counterforce brace/strap
place over the proximal end of the forearm extensor muscle bellies to decrease the tension on the common tendon insertion
motor weakness (ulnar wrist extension & digit extension) & pain
posterior interosseous nerve palsy is mostly...
- break the cycle of injury - overuse> microtrauma > swelling > pain > limitations in ROM > rest >disuse > weakness - reduce pathologic changes - optimize collagen production so that tendon regains normal tensile strength
primary goals when treating tendinosis
Kienbock's disease
refers to the necrosis of the lunate, which may develop after trauma
cubital tunnel release
release of fibrous bands or moving the nerve subcutaneously or submuscular for better protection - submuscular ulnar nerve transposition - subcutaneous ulnar nerve transposition
3-4 weeks post surgery at a rate of 1-3 mm/day or ~ 1 inch/month
repaired peripheral nerves start to heal after....
clawing
results from paralysis of the digit's lumbricals and the unopposed pull of it's anatagonist muscle, extensor digitorum
- client education - modalities - orthoses - joint protection principles on SPECIFIC DEFORMITIES - adaptive equipment
rheumatoid arthritis differs from OA but OT still provides
cubital tunnel syndrome
second most common nerve entrapment in the UE (at the elbow)
Neurapraxia: Axonotmesis: Neurotmesis:
seddon's classification of Peripheral Injuries
First therapy visit
start the HEP on the __________ therapy visit. In addition to moving the elbow- include the shoulder and wrist/hand to promote circulation and preserve AROM
manual therapy, followed by AROM of all motions in the elbow
start treatment in supine position with superficial heat an end-range followed by...
orator's sign
this is typical of a high median nerve palsy, in which there is paralysis of the flexor pollicis longus and the flexor digitorum profundus of the second digit. This leads to an inability to pinch together the thumb and index finger
distal
ulnar nerve clawing is worse when injury is _______
orthotic options for radial tunnel syndrome
what SYNDROME are these ORTHOTIC OPTIONS for??as with PIN syndrome, treatment involves rest, splinting, activity modification, gentle stretching of the involved muscles, nerve gliding, and anti-inflammatory medications. If splinting the elbow and forearm/wrist, fabricate a long arm orthosis with the wrist extension, elbow in flexion, and forearm in pronation to neutral rotation. This is the classic position recommended in the literature. However, most people will not wear a long arm orthosis that limits elbow and forearm use during the day; therefore consider recommending a wrist immobilizing orthosis for waking hours, and educating your client about activity modifications
- carrying a bag with a light object (soup can) during prolonged walking (only if this does not recruit biceps contraction) - hanging clothes in a closet - wiping a table - pouring a glass of water from a pitcher - washing your face over the sink
what is an example of a functional activity or exercise you could implement?
this is pain on either side of the carpal tunnel release incision - exact cause is unknown - can be debilitating making grip and weight bearing difficult
what is pillar pain?
ulnar nerve
what nerve can be irritated after an olecranon fracture due to its adjacent location
"when you have RA, the lining of the joint becomes active and damages the structures around the joints, causing them to move
what to say to a client regarding RA
sharp/electric pain at end range
what type of pain is a red flag for ulnar nerve irritation/compression
the tendon does not have a chance to heal and tendinosis results
when overuse or repetitive stress continues
Saturday night palsy
which radial nerve injury is at the site of (HIGH radial nerve palsy)-- mid-humerus, does NOT involve triceps
radial tunnel syndrome
which radial nerve injury is at the site of between radial head and supinator (mostly pain)
PIN palsy
which radial nerve injury is at the site of elbow/proximal forearm between 2 heads of supinator (mostly motor)
tensile
with age, _____ strength decreases
1. inflammatory phase- 1 - 7 days 2. repair phase- lasts up to 4 months 3. remodeling phase- lasts up to several months to over a year
wrist fractures 3 phases of healing