Week 12: Upper Extremity Part II

Radial Head Subluxation Tx

-stabilization -stretches/ROM -modalities for inflammation -Strengthening when radial head is stabilized

Symptoms of Vascular Compromise

1) severe pain in the forearm muscles 2) limited and extremely painful finger movement 3) purple dislocatoin of the hand w/ prominent veins 4) initial parsthsia followed by loss of sensation 5) Loss of radial pulse and later loss of capillary return 6) pallor, anesthesia, and paralysis

Prehension Grips

1. Digital prehension Pad of thumb and pads of 2nd and 3rd fingers over the object 2. Lateral prehension Pad of thumb against middle phalanx of index finger 3. Tip-to-Tip prehension Tip of thumb against tip of index finger

b) Dupuytren's contracture

A patient reports feeling tenderness and sensitivity to pressure in an area of the hand consistent with the marking in image. This subjective finding is MOST consistent with: a) carpal tunnel syndrome b) Dupuytren's contracture c) De'Quervain's disease d) ulnar nerve entrapment

Valgus Stress Overload Syndrome

A valgus stress overload of the elbow that occurs to the CAPSULOLIGAMENTOUS structures -medial capsule of the elbow -ulnocollateral ligament Usually caused by repetitive force Common in throwing or raqcuet sports

Skier's (Gamekeeper's) Thumb

Acute sprain of the ulnar collateral ligament of the MCP joint of the thumb M.O.I. -sudden valgus stress & hyperextension of the thumb -from ski poles in skies Avoid extremes of abduction and extension during the recovery process

Dupuytren's Contracture

Bishop's Deformity Proliferative fibrodysplasia of the palmar fascia lead to contractures from nodules and cords that progressively develop development immature type III collagen Usually affects men > 40 y/o Most common in the ulnar digits (4th & 5th) Generally not painful

Smith's Fracture

Collie's Fracture FOOSH injury- but with wrist flexion Volar displacement of the fractured distal radius

Fixation of Supracondylar Fractures

Commonly casted in: -90 degrees of elbow flexion -Mid Pronation/supination Types of casts: -long arm cast -external fixation

Finger Flexor Tendon Injuries

Complicated & challenging to treat due to: The need to protect structures and stress structures at the same time Provide proper stimuli for proper collagen formation Prevention adhesion Maintain ROM Prevent undue stress to compromised tendinous structures

Radial Tunnel or Supinator Entrapment Syndrome

Compression of the deep branch of the RADIAL NERVE (PIN) as it passes through the two heads of the supinator Can mimic tennis elbow symptoms

General Wrist Rehab Program after Wrist Ligament Injury MODERATE- PROTECTION Phase "Sub-Acute Phase"

Continue protection, slowly reduce immobilization If no inflammation, then use warm whirlpool before AROM of the wrist Slowly progress resistive exercises starting with wrist flexion exercises in the inner to mid ranges Progress finger and gripping exercises as tolerated Continue elbow and shoulder exercises and general conditioning program

Entrapment Syndromes of the Distal Arm

Direct or indirect compression of -Nerves -Arteries

Radial Head Subluxation

Dislocation of the elbow joint caused by a sudden pull on the extended pronated arm. Ex. adult tugging on an kids arm

Blood Supply of the Scaphoid

Distal & mid Portion -very vascular Proximal pole -Prone to AVN following a fracture due to its distal to proximal blood supply

6 P's of entrapment Syndromes

Early Signs: 1) pain 2) pallor (paleness, lack of color, pastiness) 3) paresthesia (tingling, numbness) 4) paresis (weakness, partial paralysis) Late signs: 5) paralysis 6) pulselessness (weak or lacking pulse)

Pronator Teres Syndrome

Entrapment of the deep branch of the MEDIAN NERVE (AIN) as it passes through the two heads of the pronator teres

Extensor Versus Flexor Tendons

Extensor Tendons: Extra-synovial No pulley system Weaker than flexors Flatter, thinner Less tensile strength Undergo significant lengthening with flexion Adhesions: significant impact on hand function Immobilized longer Flexor Tendons: In synovial sheath Strong pulley system Stronger than extensors Thicker, larger diameter Good tensile strength

Flexor Tendon Adhesion Exercises

Flexor test: No resistance to passive DIP extension during active MCP extension with active PIP flexion. Hook exercise (for both): Keep MCP extended and IPs flexed; extend fingers. Fist exercise (FDP): Flex MCP and IPs; open and close fist. Modified fist (FDS): MCP and PIPs flexed, DIPs extended; extend fingers.

Colle's Fracture

Foosh Injury Dorsal displacement of the fractured distal radius

Edema in Hand

Frequently accumulates in dorsum. Can lead to contractures. Excessive swelling on dorsum can cause hand arches to collapse anteriorly and adduct the thumb. Finger range of motion (ROM) can be impaired. Edema causes reduced mobility and function of the hand in short term and in long term if fibrous formations occur.

General Wrist Rehab Program after Wrist Ligament Injury MINIMUM- PROTECTION "Maturation Phase)

Functional splint for protection Active motion, whirlpool before exercise Isotonic resistive exercises Hand and finger resistive exercise

Tx of Fractures

Immoblized so ligaments of the joints are placed on stretch to reduce risk of contracture Open reduction and internal fixation (ORIF) is used w/ unstable fractures. Immobilization is used for only as many joints as necessary to stabilize fracture

Olecranon Bursitis

Inflammation of the bursa that protects the tissues surrounding the olecranon process May follow traumatic accident or repedtitve prolonged compression

Prehensile Grips

Intricate tasks = 80% of time Digital prehension pinch Lateral prehension pinch Tip-to-tip pinch Fingers: flexed and abducted at MCP Radial digits used

Measuring Grip Strength

Jamar Grip Dynameter 1) Measures isometric grip strength 2) dominant hand is usually 10-15 lbs stronger than non-dominant hand

Scaphoid Fracture

Largest WB bone of the wrist -wb exercises are reserved for the last stages of rehab Most commonly fractured Poor vascular supply High chance of Avascular Necrosis Occurrence - most commonly fractured carpal bone -highest chance of complications due to poor blood supply M.O.I. -fall onto HYPEREXTENDED wrist with Ulnar Deviation Pain usually centered in "anatomical snuff box" Clinically diagnosed w/ tuning fork placed on scaphoid in anatomical snuff box (need x-rays of conformation)

Characteristics

M.O.I. Repetitive ulnar deviation Signs & Symptoms include: Pain & swelling around the radial styloid Decreased thumb motion Pain Increases with: Passive or active thumb flexion & wrist ulnar deviation Resistive thumb extension & wrist radial deviation Finkelstein's Test Passively stretches EPB & APL over radial styloid Positive (+) test if pain is increased

MCL Rupture

M.O.I. Traumatic injury due to sudden VALGUS force usually in WB on extended elbow MCL is already most susceptible ligament at the elbow due to carrying angle ***VALGUS STRESS TEST FOR: 1) MCL and joint laxity 2) Grade (I,II,III) MCL injury

Signs & Symptoms of MCL Injury

MCL most taught with: 1) valgus stress 2) closed packed position of the ulnohumeral joint (full elbow extension & supination) -Pain over the MEDIAL and POSTERIOR aspect of the elbow -Pain usually occurs w/ full or excessive elbow extension - Resistive pronation or passive supination can also cause ↑'d symptoms especially when elbow is extended

Dorsal Soft- Tissue Zones

Mallet or swan neck deformities Boutonniere deformity Adhesions of tendons and extensor hood (Extensor expansion mechanism) Adhesions of synovial sheaths, retinaculum

General Wrist Rehab Program after Wrist Ligament Injury MAXIMUM-Protection Phase "ACUTE PHASE"

Maximum-Protection Phase "Acute Phase" Immobilization, protection, rest NSAID's and pain meds Ice packs AROM exercises for fingers, elbow, and shoulder Precautions/contraindications Avoid wrist extension

Radial Head Fractures

Most common limitation following radial head fracture w/ dislocation is PRONATION / SUPINATION followed by EXTENSION

Signs & Symptoms for Ulnar Nerve Entrapment

Motor Weakness: -FCU -FDP 4th & 5th fingers - Hand Intrinsics Sensory Loss: -Medial hand -5th finger -Medial 1/2 of the 4th finger

Signs and Symptoms of Pronator Teres Syndrome

Motor: FPL weakness FDP (digits 2 & 3) weakness Characterized by pinch deformity Sensory: none

Radial Tunnel or Supinator Syndrome Symptoms

Motor: Paresis or Paralysis of the wrist and finger extensors Wrist drop deformity Sensory: None

Special Tests for Ulnar Nerve Entrapment

Nerve Tension Test Elbow Flexion Test

Tx of Dupuytren's Contracture

Non-Surgical: -Correction of deformity - Restoration of function - Splint fabrication and application of: 1) static/ resting splint 2) progress to dynamic splint Post Fasciectomy: -Wound care - Infection control - Splint fabrication and applicaiton of: 1) static/ resting splint 2) progress to dynamic splint

Complications of Wrist Fractures

Non-union or malunion Tendon adhesions Median nerve compression Wrist and/or carpal instability Contractures Reflex Sympathetic Dystrophy (CRPS)

Supracondylar Fracture Complications

Nonunion or malunion Joint Contractures - Lack of full elbow extension -MOST COMMON COMPLICATION Myositis Ossificans -Calcium deposition in the brachialis muscle -Due over aggressive stretching or stretching too early in the rehabilitation program Vascular compromise -Volkmann's ischemic contracture -MOST DISASTROUS COMPLICATION

Medial Epicondylitis (Golfer's Elbow)

Overuse of common flexor tendon muscles -Pronator Teres and Flexor Carpi Ulnaris Ration is 7:1 Lateral to Medial Epicondylitis

Tx of Medial Epicondylitis

PROTECT: minimize active contraction and passive stretch CROSS FRICTION soft tissue mobilization: release tension in the tendon and promote fiber re-alignment DEEP PRESSURE: deep pressure/ stretch to inhibit muscle activity Eccentric Loading: assisted concentric w/ independent eccentric

Signs & Symptoms of Medial Epicondylitis

Pain w/ palpation of CFT junction & medial epicondyle Pain w/ active or resistive: -wrist flexion -finger flexion -forearm pronation Pain when muscles are active or passively elongated over some or all of their joints: -Finger and wrist extension -supination -elbow extension

Signs & Symptoms of Lateral Epicondylitis

Pain w/ palpation of common extensor tendon junction and lateral epicondyle Pain w/ active or resistive wrist extension Pain w/ active or passive wrist and finger flexion

Special Tests for LE Cozen't Test Method 2

Passive elbow extension and wrist flexion passive stretch

Internal Fixation for Wrist Stabilization

Pins are used when carpal bone instability exists Allows ligaments to heal in a more shortened position Performed w/ Grade III wrist sprains

Controlled Motion Splint of Finger Flexors

Postoperative protective splint with rubber band traction Purpose: Maintain passive IP flexion Encourage active, but controlled IP extension Helps prevent adhesions to the flexor tendons

Power Grips

Power grips = 20% of the time Ulnar direction Thumb opposes other fingers. Fingers flex and rotate and move into ulnar deviation. Fingers point toward thenar eminence.

Tx Pro's & Con's

Pro's: -relieves excess force from CET muscles -minimizes symptoms Con's: ↓ circulation should not be worn at all times not a cure or excuse to continue injurious behaviour

Tx for Lateral Epicondylitis

Protect: minimize active contraction and passive stretch Cross friction soft tissue mobilization: release tension to the tendon & promote fiber re-alignment Deep Pressure (using a counterforce brace): deep pressure / stretch in inhibit muscle activity Eccentric Loading: assisted concentric w/ independent eccentric

No Man's Land

Region between the distal palmar crease and the middle phalanx Damage to the flexor tendons in this region that require surgical repair usually leads to the formation of adhesive bands that restrict gliding. Tendons may also become ischemic, being replaced by scar tissue Prognosis after surgery in this area is poor

DeQuervain's Tenosynovitis

Repetitive motion or cumulative trauma tendinopathy of the tendons of the APL (Abductor Pollicis Longus) and EPB (Extensor Pollicis Brevis) as they pass through the 1st dorsal compartment of the wrist directly over the radial styloid Splint: wrist = 15° extension; #1= abduction, 10° flexion May require surgery if unresolved Corticosteroid injection before surgery a possible option

Special TEsts for LE Cozen's Test Method 3

Resistive middle finger extension ED Resistance

Special Tests for LE Cozen's Test Method 1

Resistive wrist extension w/ Elbow flexed Active Resistive

Boutonniere Deformity

Rupture or overstretch of the central extensor tendon at the PIP joint Often seen in patients with Direct trauma to the middle phalanx Rheumatoid Arthritis Description Flexion of PIP joint Hyperextension of DIP joint Deformity prevents the finger from fully straightening.

Olecranon Bursitis Tx

Stretches/ ROM Ice modalities esp soft tissue intervention for effusion & scar tissue that may impede lymphatic return

Cock-Up Splint

Takes tension off the CET muscles by keeping splint in slight EXTENSION Used w/ severe cases of Lateral epicondylitis as it immobilizes the wrist and hand

Lateral Epicondylitis (Tennis Elbow)

Tears, scarring and inflammation of common extensor tendon of the lateral humeral epicondyle -TendinOSIS of wrist extensor origin -caused by overuse of the elbow w/ repeated wrist extension against resistance. **ECRB and ED most involved

Finger Tendon Injuries

Tendon gliding exercises are key to preventing adhesions. Inhibition of normal tendon gliding can inhibit normal hand function. Tendon glide must be possible before resistive exercises begin. Must avoid disruption of extensor tendon, causing extensor lag.

Extensor Tendon Adhesions

Test: Full extension occurs passively but not actively (especially if flexion is also limited). MCP restriction (due to adhesion of the extensor digitorum communis tendon): Keep IPs flexed and move MCPs from extension to flexion (grip straw). IP restriction (due to adhesion in the extensor mechanism): 1. In MCP flexion, extend IPs. 2. In MCP extension, stabilize PIP, extend DIP.

Swan- Neck Deformity

This condition is a result of a contracture of the intrinsic muscles Often seen in patients with: Rheumatoid Arthritis Post hand trauma to the extensor ligament of the DIP Description Flexion of MCP joint Hyperextension of PIP joint Flexion of IP joint

Surgical Repair of MCL: "Tommy John"

Two common surgeries: Direct repair -reattachment of ligament Tendon Graft -palmaris longus tendon graft is used to reconstruct the MEDIAL STABILITY of the elbow

Supracondylar Fractures

Type I: -Distal segment is displaced posteriorly -M.O.I.: FOOSH -Usually occurs in children Type II: -Distal segment is displaced anteriorly -M.O.I.: direct trauma to posterior aspect of the elbow

Measuring Pinch Strength

When testing a patient's pinch strength be sure to document the type of pinch you are using Pad to pad Lateral prehension

Wrist Ligament Injuries

Wrist depends primarily on the ligaments and capsule for stability Falling onto the extended wrist is the most common MOI Stabilization of the wrist: -brace -cast - pins ( for carpal instability)

Tennis Backhand

Wrist extensor muscles contract isometrically and concentrically against great REACTION FORCES from the ball.

A patient with mallet finger admits to being noncompliant with the recommended splinting regimen. The patient was instructed to wear the prescribed splint continuously for six weeks. Which impairment would be MOST likely based on the described scenario? a) inability to fully extend the distal interphalangeal joint b) inability to fully flex the distal interphalangeal joint c) inability to fully extend the proximal interphalangeal joint d) inability to fully flex the proximal interphalangeal joint

a) inability to fully extend the distal interphalangeal joint

A PTA reviews the surface anatomy of the hand in preparation for a patient status post wrist arthrodesis. Which bony structure does NOT articulate with the lunate? a) trapezium b) radius c) capitate d) scaphoid

a) trapezium

A patient with a suspected scaphoid fracture is referred to physical therapy. Which clinical sign is MOST indicative of a scaphoid fracture? a) localized edema along the dorsum of the hand b) crepitus with active range of motion c) localized bony tenderness in the anatomic snuff box d) pain with resisted wrist extension

c) localized bony tenderness in the anatomic snuff box

A PTA reads a recent entry in a patient's medical record that indicates aspiration was performed in the elbow region. This scenario is MOST commonly associated with: a) dorsal ganglion cyst b) lateral epicondylitis c) medial epicondylitis d) olecranon bursitis

d) olecranon bursitis

Non-Operative Treatment

↓ pain and inflammation wrist & thumb immobilization -wrist in neutral or slight radial deviation -thumb in slight extension/ abduction slowly integrate ulnar deviation