Cumulative Trauma Disorders (CTD) of UE

NIGHT POSITIONING FOR SPLINT for rehab following Tendon Repairs

(night position-fingerstrap only comes off for PROM)

TREATMENT (Acute Phase) FOR REPLANTATION OF UE

- 0-4 weeks: promote vascular healing, wound care, ROM, splinting - 4-8 weeks: wound care, edema control, ROM, pain mgmt, sensibility, splinting

Success rates/Best results for replantations

- Adults - 80% - Children - 70% (likely b/c docs take more risks w/providing replants for children) - Best results - thumb, hand, distal forearm

Pathogenesis of Median Nerve Compression Carpal Tunnel Syndrome (CTS) - part 1

- Anatomical (structural-carpal tunnel) - Developmental (anomalous structures may 'overfill' a compartment or stretch a nerve - Postural - repetitive finger/wrist motion, prolonged static positioning of wrist, prolonged use of vibratory tools. - Inflammatory - synovitis, RA, Lupus

ETIOLOGY of Carpal Tunnel Syndrome (CTS)

- Compression, adhesion, traction of the median N beneath the volar carpal ligament or flexor retinaculum (often preceded by tenosynovitis of flexor tendons of thumb/fingers). Assoc. w/RA, lupus, diabetes, pregnancy - Repetitive finger/wrist motion - prolonged static positioning of wrist, prolonged use of vibratory tools

Prevention & Management Strategies of Common CTDs of UE

- Decrease risk factors - Education/awareness - Modify work/worker/workplace

SPLINTING for rehab following Tendon Repairs

- Dorsal protective or dorsal blocking (DBS) w/or w/out rubber band traction, depending on protocol - DBS w/rubberband traction (ROM exer, MP flexion, PIP flexion, composite flexion) - specifications can vary by protocol & doc - removed ONLY by therapist

Complications of replantation of UE surgery

- Early - arterial insufficiency, infections - Late - functional - related to 'one wound/one scar' w/resultant loss of differential gliding b/w the tissues (joint stiffness, tendon adhesions, scar contracture), non-unions, traumatic arthritis

Physiological changes from CTDs

- Nerve compression - Tendonitis / soft tissue inflammation

SIGNS & SYMPTOMS of Carpal Tunnel Syndrome (CTS)

- Pain - Paresthesias in sensory distribution of nerve - Decrease in sensibility - Weakness of intrinsic thenar muscles - Decrease strength, Decreased Fine Motor Skills

INCREASE STRENGTH & FUNCTION w/CTS

- ROM exercises - Theraputty/gripper exercises - Wrist strengthening exercises (this will also help grip) - Fine Motor tasks

Common Characteristics of Cumulative Trauma Disorders (CTD) of UE

- Related to intensity of the work (repetition & force) - involves both biomechanical & physiologic mechanisms - may occur after wks/mos/yrs on the job & may require wks/mos/yrs for recovery - Symptoms may be poorly localized and non-specific - May have occupational & non-occupational causes

Other terms for Cumulative Trauma Disorders (CTDs) of UE

- Repetitive trauma disorders - Repetitive strain injuries - Overuse syndrome - Work related disorders - Repetitive motion injuries - Musculoskeletal disorders

EXTENSOR TENDONS for rehab following Tendon Repairs

- Same principles as flexors - Splint - Extension outrigger w/flexion block (~45 degrees flexion), dynamic traction keeps MP in slight hyperext) - Treatment - follows same timeline - Active flexion to block, passive extension via rubberband traction EXTENSOR TENDON REPAIR SPLINT

Pathogenesis of Median Nerve Compression Carpal Tunnel Syndrome (CTS) - part 2

- Traumatic (acute CTS in distal radius fx and carpal fx/dislocations) - Metabolic (diabetes, pregnancy, thyroid disease) - Neoplastic (tumors/cysts)

EXERCISES for rehab following Tendon Repairs

- Varies by protocol Therapist - passive flexion & extension (w/in splint) - Patient - active extension only, passive flexion per protocol - ACTIVE FLEXION - 4-4.5 weeks (earliest to start exercises).

Surgical technique for replantation of UE

- shorten & fix the bone - repair the flexor/extensor tendons - repair the nerves - anastamose veins - Close the skin; provide skin coverage

Management of CTDs

-Assessment of causes/risks (treat causes, not just symptoms - Eval of work, worker, workplace - Modalities (heat, cold, electrical - TENS, massage) - Exercise, splinting, education (worker/employer)

EVALUATION & NON-OPERATIVE MGMT of Carpal Tunnel Syndrome (CTS)

-Pain - Edema - Muscle pathology (Thenar muscle atrophy & grip strength - Sensibility (Semmes Weinstein - Touch pressure) - Function (Stereognosis - Moberg pick up test & Purdue Pegboard) - Decrease symptoms by: NSAIDS, Splinting (night vs continuous), nerve/tendon gliding exercises

Describe ULNAR GLIDING EXERCISES - 2

1. Straighten affected elbow out to your side (90 degree angle from shoulder, forearm facing up) bend wrist twd your body (fingertips pointed to the ceiling) 2. Rotate your arm backward (fingertips pointed behind you) 3. Tilt your head away from the affected arm (as if to touch your ear to the opposite shoulder).

Describe ULNAR GLIDING EXERCISES - 1

1. Straighten affected elbow, move it across midline of your body, bend wrist up. 2. Now extend wrist (keep elbow straight, forearm facing up, fingertips twd floor) 3. Maintainn forearm facing up & wrist back, but bend elbow in twd you until you feel a stretching sensation.

TREATMENT (Chronic Phase) FOR REPLANTATION OF UE

4 months & longer: ROM, strength, sensory concerns, function, need for further surgical interventions. - Determine functional outcome- primary goal, final measure of success, sensibility

TREATMENT (SubAcute Phase) FOR REPLANTATION OF UE

8 weeks - 4 mos: edema mgmt, scar mgmt, ROM, sensory re-education, function, splinting as needed.

INDICATIONS FOR REPLANTATION OF UE

Any pt w/: a thumb loss, amputation of multiple digits, partial hand/through the metacarpal, child w/amputation (or single digit), single digits distal to the PIP, beyond FDS insertion, wrist/forearm amputation.

MEDIAN NERVE SYNDROME Common CTDs of UE

Carpal tunnel syndrome Pronator Syndrome

Modification of Workplace Prevent Common CTDs of UE

Chair - need adjustable height & back tilt, adequate size seat pan that is firm and supportive, ring w/casters. Develop habit of adjusting chair & station for each task.

Chronic Compression of 'The Nerve Fiber' of Carpal Tunnel Syndrome (CTS)

Chronic compression of a nerve has been shown to cause swelling of axons proximal to the site of compression inducing levels of injury ranging from slight inflammation to widespread Wallerarian degeneration.

Common CTDs of UE in FOREARM/WRIST

DeQuervain's Stenosing Tenosynovitis Intersection Syndrome FCR Tendonitis

ISCHEMIA TIME FOR REPLANTATION

Digit - warm ischemia up to 12 hrs, cool ischemia up to 24hrs Significant amt of muscle present: warm ischemia up to 6 hrs, cool ischemia up to 12 hrs

LATERAL EPICONDYLITIS Common CTDs of UE

Elbow

Clearly documented INTRINSIC RISK FACTORS for CTS are:

Female gender RA Pregnancy Hypothyroidism Diabetes

DIAGNOSIS of Carpal Tunnel Syndrome (CTS)

History - rule out cervical radiculopathy and other proximal conditions - Provacative tests: Phalen's and Tinel's - Nerve conduction studies - most definitive & usually required for surgery

Modification of Work Prevent Common CTDs of UE

Instruments/tools that have enlarged or ergonomically shaped handles - decrease amt of pinch force needed - Variation of tasks

CURRENT TX APPROACHES for rehab following Tendon Repairs

Kleinert, Duran, Chow et al (Washington), combo

Modification of Worker Prevent Common CTDs of UE

Posture Aware!! * Lean back in chair every 20-30 min. * Exercises - to stretch tight structures, strengthen weak muscles, restore postural balance, mobilize joints, relieve stress. * Practice prevention - on job stretches - improve blood flow to static body parts. * Leisure time activities (contribute to problem?) Gen. conditioning exercises (help reduce stress, relaxation, DIET & TOBACCO USE

POST OP INTERVENTION for rehab following Tendon Repairs

Progression of intervention - Day 2-3 post-op (DBS, exercises, edema mgmt (w/coban wrap-wrap distal to proximal), pain, precautions) - 3-5 weeks post-op - continue all of above, add scar mgmt (prevent adherence), begin gentle active flexion at week 5 (promotes tendon gliding). - Week 6 post-op - discontinue DBS, continue all of above, begin light use of hand (brushing teeth, eating, hygeine, not resistive exercises) - 8 weeks post-op - can begin strengthening, dynamic splinting as needed.

INCREASE STRENGTH & FUNCTION of Carpal Tunnel Syndrome (CTS)

ROM exercises, theraputty/gripper exercises, wrist strengthening exercises, FM tasks, pt education on ergonomic factors, job modification, leisure time activity modification.

RADIAL NERVE SYNDROME Common CTDs of UE

Radial Tunnel Syndrome Posterior Interosseous Syndrome

THORACIC OUTLET SYNDROME Common CTDs of UE

Shoulder

Common CTDs of UE in FINGERS/THUMB

Trigger Fingers/Thumb Tenosynovitis Raynaud's Phenomenon Degenerative Arthritis

ULNAR NERVE SYNDROME Common CTDs of UE

Ulnar Tunnel Syndrome (Canal of Guyon) Cubital Tunnel Syndrome

RISK FACTORS & CAUSES (work) of Cumulative Trauma Disorders (CTD) of UE

Work (repetition - most commonly cited) - Forceful exertions (Pinch vs grip, heavy items - Mechanical Stress (squeezing, pounding w/hand, tool use) - Posture - (wrist, shoulder, spine)

RISK FACTORS & CAUSES (worker) of Cumulative Trauma Disorders (CTD) of UE

Worker - gender, health status (diabetes, previous injury, obesity, degenerative arthritis, age) - Fitness/physical condition - Lifestyle - Body mechanics/mvmt patterns - Job satisfaction/psychological factors

RISK FACTORS & CAUSES (work place) of Cumulative Trauma Disorders (CTD) of UE

Workplace - vibration, temperature (cold), tool design, work station design

EVAL/POST-OP MGMT & INTERVENTION of Carpal Tunnel Syndrome (CTS)

Wound - open CT release vs endoscopic release Intervention - Week 1-2: wound care, splinting, edema/pain mgmt as needed, ROM (fingers/thumb) Week 3 - scar mgmt (massage, desensitization, pressure as needed), splinting (night only) Week 6 - Begin gentle strengthening Week 8 - Work hardening, (pt educ in causative factors, prevention, behavior mod).

WRIST EXTENSION SPLINT for CTS

Wrist position - neutral to slight 15-20 degrees extension

Cumulative Trauma Disorders (CTD) of UE (Defn)

disorders of soft tissue caused by repeated or sustained mvmts of the body; occurs when strain exceeds the body's normal daily recuperative ability.

CONTRAINDICATIONS FOR REPLANTATION OF UE

severe crush or mutilation of the part, multiple level injury in same digit, poor surgical risk, peripheral vascular disease (diabetes), single digits proximal to PIP level (FDS insertion), other life threatening injury, warm ischemia (>12 hrs), avulsion injuries