Hand and Upper Extremity

II. Anatomy of the Hand What are the sensory receptors of the hand?

- Pacinian corpuscles: responsible for vibration -Ruffini end organs: responsible for tension -Merkel cells: responsible for pressure

IV. Fractures of the Hand What are the different types of fractures to the hand?

-Boutonniere deformity is disruption of the central slip of the extensor tendon characterize by proximal interphalangeal (PIP) flexion and distal interphalangeal (DIP) hyperextension; the PIP is splinted in extension, and isolated DIP flexion exercises are performed

IV. Fractures of the Hand What are the different types of fractures to the hand?

-Mallet finger: is avulsion of the terminal tendon and is splinted in full extension for 6 weeks

IV. Fractures of the Hand C. Evaluation What are the methods for evaluation?

-Methods for evaluation are visual examination and observation, client interview, and complete medical history; including a history of the event -Sensory assessment includes monofilament testing for nerve compression and two-point discrimination for nerve laceration and recovery -Motion assessment includes goniometric measurements if the client is able to track total active motion -Strength is assessed using a dynamometer and pinch gauge meter to measure hand pinch strength -Occupational performance is assessed using an ADL and/or IADL checklist, which also is a useful goal-setting -Outcomes are assessed using the Quick DASH before and after therapy

IV. Fractures of the Hand What are the different types of fractures to the hand?

-Swan neck deformity: is injury to the metacapohphalangeal (MCP), PIP, DIP joints characterized by PIP hyperextension and DIP flexion; the PIP is splinted in slight flexion

IV. Fractures of the Hand What are the different types of fractures to the hand?

1. A proximal fracture: is a metacarpal fracture, such as a boxer's (4th and 5th finger) fracture

IX Cumulative Trauma Disorder F. Occupational therapy intervention

1. Acute phase: Reduction of inflammation and pain through static splinting, item contrast baths, ultrasound phonophoresis, iontophoresis (Iontophoresis is a safe medical procedure that involves sending mild electrical currents through water and into the skin. It's usually used to treat excessive sweating. However, it can also be used to treat sports injuries by delivering anti-inflammatory medications directly into the skin), high-voltage electric and interferential stimulation 2. Subacute phase: Slow stretching, myofascial release, progressive resistive exercise as tolerated, proper body mechanics, education on identifying triggers and returning to acute phase treatment with flareups; static splint during activities that cause pain 3. Return to work -Assessment of job site, tools used, and body positioning -Therapy using a work simulator , weight well, elastic bands, putty, functional activities, and strengthening activities 4. Functional capacity evaluation 5. Work hardening

V. Fractures of the Wrist D. Complications

1. Carpal tunnel syndrome 2. Distal radius fracture

V. Fractures of the Wrist D. Complications 1. Carpal tunnel syndrome

1. Carpal tunnel syndrome may be caused by a wrist fracture that results in compression of the median nerve as it runs through the carpal tunnel; see the action on nerve injuries for more information

VIII Complex Regional Pain Syndrome (CRPS) E. Occupational therapy Intervention

1. Gentle, pain-free AROM for short periods; no PROM or painful treatment 2. Stress loading: for example, scrubbing the floor, carrying a weighted handbag 3. Pain control techniques: transcutaneous electrical nerve stimulation, splinting (static, then dynamic as tolerated), continuous passive motion 4. Edema control techniques: elevation, massage, AROM, contrast baths, compression 5. Desensitization techniques, fluidotherapy 6. Blocked exercises, tendon gliding 7. Joint protection, energy conservation

V. Fractures of the Wrist B. Nerve injuries associated with wrist fractures 1. Median nerve injury

1. Median Nerve Injury: produces carpal tunnel-like symptoms, such as palmar numbness and numbness of first digit to half of the forth digit, with generalized weakness and pain

V. Fractures of the Wrist B. Nerve injuries associated with wrist fractures

1. Median nerve injury 2. Ulnar nerve injury

V. Fractures of the Wrist C. Interventions

1. ROM is allowed in the early phases of healing and repair 2. Orthotics are used to protect the extremity form motion or allow for protected motion 3. A home program is provided to increase progression of function and outcomes 4. Exercises are used to facilitate movement and improve performance of the upper extremity; examples include AROM with wrist extended and fingers flexed; blocking exercises; tendon and nerve gliding exercises; and strengthening exercises, such as therapist and use of hand exercises. 5. Modalities (e.g., heat, ultrasound, cryotherapy, paraffin, TENS) are used to prepare tissues for work and assist with pain relief and tissue healing) Blocking exercise: (https://www.youtube.com/watch?v=-8gSUwK2j4Y

XIV. Splinting Types of splints 1. Static splints

1. Static splints, static progressive splint, and serial casting have no moving parts

VIII Complex Regional Pain Syndrome (CRPS) D. Medical Treatment

1. Stellate or sympathetic block: an injection of local anesthetic into the front of the neck or lumbar region of the back to block pain 2. Intrathecal analgesia: injection of pain medication into the spinal canal 3.Removal of neuroma: surgery to remove a thickened nerve 4. Installation of spinal cord stimulator: a small electrical pulse generator is implanted in the back to control pain 5. Installation of peripheral nerve stimulator: electrodes placed on the peripheral nerves to send electrical impulses to control pain

IV. Fractures of the Hand B. Fracture healing What are the phases of healing?

1. The three common phases of healing are inflammation, repair, and remodeling. Inflammation provides the cellular activity needed for healing, Repair forms the callus (the bony healing tissue that forms around the ends of broken bone.) for stabilization and Remodeling deposits (put or set down) bone

X. Extensor Tendons B. Zones What are the zones?

1. Thumb 2. Extensor tendon zones Digits II-V

X. Extensor Tendons B. Zones 1. Thumb

1. Thumb a. Zone I: Falls over the interphalangeal (IP) joint b. Zone II: Falls over the proximal phalanx c. Zone III: Falls over the MCP joint d. Zone IV: Falls over the first metacarpal e. Zone V: Falls over the wrist

VIII Complex Regional Pain Syndrome (CRPS) B. Types of CRPS

1. Type I: Develops after a noxious (harmful, poisonous, or very unpleasant.) event 2. Type II: Develops after a nerve injury

XIV. Splinting 10. Ankle splints

10. Ankle splints include antiriot drop splints to maintain 90 degree ankle dorsiflexion and ankle-foot orthotics

XIV. Splinting 11. Nerve injury splinting

11. Nerve injury splinting a. Carpal tunnel syndrome: wrist in neutral to 10 degrees extension b. Ulnar nerve at wrist: block fourth and fifth MCPs to 30-45 degree flexion to prevent hyperextension c. Radial nerve injury: Wrist cock-up splint, with dynamics finger extension assist optional d. Pronator syndrome: forearm and wrist neutral, elbow in 90 degree flexion e. Anterior interosseous: forearm neutral, elbow 90 degrees flexion f. Radial tunnel syndrome: wrist 30 degrees extension, forearm supinated, elbow in 90degree flexion

XIV. Splinting 12. Special considerations

12. Special considerations a. Pediatric: consider age, frame of reference, and child's environment; make the splint appealing to the child by using colored materials or drawing animals on it; limited fit time by using a cold pack to set the splint more quickly; consider using a soft splint b. Geriatric: consider age; frame of reference, elder's environment, existing medial issues, any cognitive or perceptual deficits, low vision, hearing impairment, pain perception, thinning of skin and decreased adipose tissue, and any medication side effects; use stockinette under splint; pad splint well; use soft strapes; label splint

XIV. Splinting 13. Dynamic splinting

13. Dynamic splinting have moving parts, and soft splints allow movement. Dynamic splints are designed to correct contractures, increase passive motion, protect recent surgery, or substitute for lost active motion. a. To correct contractures: mechanical stitch of prolonged gentle pull over 8-12 hours to remodel soft tissue b. To increase passive motion: finger loop angle of pull of 90 degrees; adjust splint as client improves to maintain 90 degrees angle of pull c. To protect recent hand flexor tendon repair surgery: dorsal blocking splint with hinged wrist and joint wrist blocks to maintain wrist extension at 30 degree and MCP extension at 60 degree while allowing full wrist flexion d. To substitute for loss active motion: radial nerve injury splint, with dynamic MCP extension assist if needed

XIV. Splinting 14. A soft, circumferential orthosis improves client compliance with wearing it

14. A soft, circumferential orthosis improves client compliance with wearing it a. Carpal tunnel wrist support b. Antivibratory gloves c. Neoprene wrap thumb support for CMC osteoarthritis and de Quervain syndrome d. Forearm bands for medial and lateral epicondylitis e. MCP anti-ulnar deviation splints for rheumatoid arthritis f. Buddy taping g. Neoprene tube digit extension splint h. Pediatric neoprene thumb abductor and supinator TheraTogs

IV. Fractures of the Hand What are the different types of fractures to the hand?

2. Carpal fractures: are fractures to individual carpal bones -The most common fracture seen and missed in injuries to the wrist is the scaphoid -Lunate fractures are associated with Keinbock's disease

V. Fractures of the Wrist D. Complications 2. Distal radius fracture

2. Distal radius fracture: The primary and most severe complication of distal radius fracture is CRPS (Complex Regional Pain Syndrome)

X. Extensor Tendons B. Zones 2. Extensor tendon zones Digits II-V

2. Extensor tendon zones Digits II-V a. Zone I: Distal interphalangeal joint b. Zone II: Middle phalanx c. Zone III: Proximal interphalangeal joint Zone IV: Proximal phalanx Zone V: Metacarpal phalangeal joint Zone VI: Metacarpal bone Zone VII: Carpal bones and wrist

XIV. Splinting 2. Resting hand splints

2. Resting hand splints Resting hand splints maintain the wrist 20-30 degrees extension, thumb at 45 degrees palmer abducted, MCPs at 35-45 degrees flexion, PIPs and DIPs in slight flexion

V. Fractures of the Wrist B. Nerve injuries associated with wrist fractures 2. Ulnar nerve injury

2. Ulnar nerve injury: results in ulnar claw deformity and numbness of the ulnar side of the hand and the fifth and half of the fourth digits, with generalized weakness of the ulnar side of the hand and pain

XIV. Splinting 3. Antideformity resting hand splint

3. Antideformity resting hand splint maintain the wrist at 30-40 degrees extension, Thumb at 45 degrees palmer abducted MCPs at 70-90 degrees flexion PIP and DIPs in full extension

XIV. Splinting 4. Ball or cone antispasticity splint

4. Ball or cone antispasticity splint are ulnar or polar based and provide thumb palmer or radial abduction, a hard surface in contact with finger flexor, and serial casting for the wrist, elbow, knee, or ankle to decrease soft tissue contractors

XIV. Splinting 5. Wrist cock-up splint

5. Wrist cock-up splint (dorsal or volar wrist immobilization) maintain hand arches, full thumb movement, and full MP flexion

XIV. Splinting 6. Thumb spica splints

6. Thumb spica splints (solar thumb or radial gutter thumb immobilization) are used n the long or short opponens to provide CMC immoblization

XIV. Splinting 7. Finger splints include PIP extension

7. Finger splints include PIP extension (i.e., Boutonniere, Capener, prefabricated dynamic extension assist, and serial casting) splints, PIP flexion splints, PIP hyperextension block (swan neck) splints, DIP extension (mallet finger serial casting)splints, DIP flexion splints, and silver ring splints.

XIV. Splinting 8. Elbow splints

8. Elbow splints include anterior and posterior elbow immobilization splint

XIV. Splinting 9. Knee extension splint

9. Knee extension splints provide posterior full knee extension to the extent possible

XI Flexor Tendon A. Anatomy

A. Anatomy: Flexor digitorum superficialis (FDS), Flexor digitorum profundus (FDP). Tendons are long and thin in the hand compared with other areas of the body; they glide and run under a tight pulley system 1. Pulleys are found on the flexor side to prevent bowstringing and consist of A1, A2, A3, and A4 and C1, C2, C3, and C4. 2. Anatomical landmarks and structures a. Blood supply is limited, but nutrition is mainly provided by synovial diffusion. b. Nerve supply is innercated by the medial, radial, and ulnar branches of the hand. c. Zones: -Zone I: extends from the fingertip to the enter portion of the middle phalanx -Zone II: extends from the center portion of the middle phalanx to the distal palmar crease (known as no man's land, due to difficulty of tendon gliding without scarring to surrounding tissues). -Zone III extends from the distal palmar crease to the transverse carpal ligament -Zone IV:overlies the transverse carpal ligament -Zone V: extends beyond the level of the wrist

XIV. Splinting A. Definition

A. Definition 1. A splint is an orthopedic device designed, fabricated, or selected in conjunction with a client to temporarily support, protect, or immobilize a body part 2. Splints and other orthoses can be classified as articular or nonarticular according to the location, direction, purpose, type, or number of joints included 3. Splints should be comfortable and lightweight, aesthetically pleasing, and convenient to use should enable participation in valued occupations

IX Cumulative Trauma Disorder A. Definition

A. Definition of Cumulative Trauma Disorder (CTD): trauma to soft tissue caused by repeated force (also called overuse syndrome and repetitive strain injury). CTD indicates the mechanism of injury but is not a diagnosis

VIII Complex Regional Pain Syndrome (CRPS) A. Definition

A. Definition of complex regional pain syndrome (CPRS): pain disproportionate to an injury that is either sympathetically maintained or independent of the sympathetic nervous system (traditionally called reflex sympathetic dystrophy)

III. Evaluation of the Hand and Upper Extremity How is the hand and upper extremity evaluated?

A. Establish rapport, and review medical history and history of current condition (read chart and operative note). Identify the client's occupational profile. B. Observe posture, spontaneous use of upper extremity and hand, guarding, scar, wounds, and skin C. Use a gentle approach to palpation to check for pain, adhesions, and edema, and use provocative nerve tests to elicit symptoms and clarify the injury D. Specific testing: - ROM: goniometric measurements -Strength: manual muscle testing, dynamometer, and pinch gauge meter -Edema: volumeter or centimeter tape -Vascular: observation of color and trophic changes, pulse, skin temperatures, Allen's test -Sensation: Semmes-Weinstein monofilament and two-point discrimination. Monofilament is used for nerve compression, and two-point discrimination is typically used for nerve laceration and recovery -Coordination: O'Conner Dexterity Test, Nine-hole peg test, Jebsen-Taylor Hand Function test, Minnesota Rate of Manipulation Test, Crawford Small Parts Dexterity Test, and Purdue Pegboard Test E. Interview that client about pain, splints, and functional use; use ADL checklist to uncover ADL dysfunction and set goals F. Measure outcomes using the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire before and after therapy

XIII. Physical Agent Modalities What are physical agent modalities?

A. Physical agent modalities (PAMs) are procedures and treatment intervention that use light, sound, water, temperature, and electricity to modify client factors that limit occupational performance

VII. Fractures of the Upper Arm 1. Location

A. Proximal humeral fractures are the most common fracture of the upper arm and may involve the articular surface, greater or lesser tuberosity, or surgical neck 1. Location -Anatomical head -Anatomical neck -Anatomical shaft

XII. Nerve Injuries and Syndromes A. Radial Nerve Injury

A. Radial Nerve Injury 1. Symptoms: posture of hand is wrist drop, possible lack of finger and thumb extension 2. Nonoperative treatment: Wrist cock-up splint with or without dynamic finger and thumb extension assist, passive and active ROM, isotonic ((of muscle action) taking place with normal contraction.)) strengthening exercises upon muscle reinnervation 3. Operative treatment: Static wrist extension splint 30 degrees, after 4 weeks, adjust splint to 10 to 20 degrees extension

XII. Nerve Injuries and Syndromes What are all the nerve injuries and syndromes?

A. Radial Nerve Injury B. Radial Tunnel Syndrome C. Anterior interosseous Syndrome D. Pronator Syndrome E. Median Nerve Syndrome F. Double Crush Syndrome G. Carpal Tunnel Syndrome H. Cubital Tunnel Syndrome I. de Quervian syndrome J Claw Deformity K. Digital Stenosing Tenosynovitis L. Sensory Reeducation after Nerve Injury

V. Fractures of the Wrist A.Types What are the different types of fractures in the wrist?

A. Types 1. Colles Fracture 2. Smith's Fracture 3. Bennet's Fracture

IV. Fractures of the Hand What are the different types of fractures to the hand?

A. Types of fracture 1. A proximal fracture: is a metacarpal fracture, such as a boxer's (4th and 5th finger) fracture 2. Carpal fractures: are fractures to individual carpal bones -The most common fracture seen and missed in injuries to the wrist is the scaphoid -Lunate fractures are associated with Keinbock's disease Kienbock's disease, is a rare, debilitating condition that can lead to chronic pain and dysfunction. It happens when one of the eight small carpal bones in the wrist, the lunate bone, becomes damaged because there is no blood supply. It is also known as avascular necrosis of the lunate or osteocronosis of the lunate. 3. Avulsion injuries occurs when the tendon separates from the bone and its insertion and removes bone material with the tendon -Mallet finger: is avulsion of the terminal tendon and is splinted in full extension for 6 weeks -Boutonniere deformity is disruption of the central slip of the extensor tendon characterize by proximal interphalangeal (PIP) flexion and distal interphalangeal (DIP) hyperextension; the PIP is splinted in extension, and isolated DIP flexion exercises are performed -Swan neck deformity: is injury to the metacapohphalangeal (MCP), PIP, DIP joints characterized by PIP hyperextension and DIP flexion; the PIP is splinted in slight flexion

XV. Wound Healing A. Wound classification

A. Wound classification 1. A pressure ulcer staging system describes the severity of a wound in four stages for diagnostic purposes 2. Depth of tissue involvement descriptions include superficial and deep partial or full thickness; descriptions for burns include the Rule of 9s or Lund-Browder chart 3. Marion Laboratories describes wounds by color, including red, yellow, black

IX Cumulative Trauma Disorder A.Diagnoses?

A.Diagnoses: Tendinitis; nerve compression syndrome; myofascial pain; cervical, thoracic, and lumbar osteoarthritis or nerve root impingement; thoracic outlet syndrome; rotator cuff tear; bursitis; epicondylitis; cubital tunnel syndrome; carpal tunnel syndrome; de Quervain syndrome

X. Extensor Tendons A. Anatomy

Anatomy: Extensor digitorum communis (EDC), extensor indices proprius (EIP), and extensor digiti minimi (EDM). Tendons cross wrist dorsally under the extensor retinaculum, separating into 8 compartments to prevent bowstringing. Sagittal bands center the extensor tendons over the MCP joint.

XI Flexor Tendon B. Complications

B. Complications 1. Nerve involvement, usually laceration, is common because of the mechanisms by which tendons are injured 2. Edema must be therapeutically controlled to maintain motion and reduce pain and joint stiffness. 3. Pain is common at the site of the injury; ADL dsyfuctin should be assessed with an ADL checkelist 4. Muscle actions are affected by impairment in flexion and deviation of the wrist and digits 5. Protocols: -The Duran protocol is an early passive ROM program -The Kleinert protocol involves active extension of digits with passive flexion via traction, typically a rubber band -The early active motion protocol begins within days of surgery to prevent adhesions and promote tendon gliding and excursion -An immobilization protocol is advisable only for patients who are unable to care for themselves or who do not have the cognitive capacity to ensure safety postoperatively. This protocol is sometimes used with children to prevent rupture of the repair. -Splinting is used to prevent rupture because the repaired tendon is at its weakest 10 to 12 days post surgery

XIV. Splinting B. Evaluation

B. Evaluation Splinting evaluations may include chart or medical report review, interview and observation of the client, palpation, occupational assessment, and assessment of the following components: pain, edema, sensation, ROM, muscle strength, coordination, functional use, and psychosocial issues. Other considerations are work status, motivation, social support, and reimbursement source

XIII. Physical Agent Modalities What are physical agent modalities?

B. Phyisical agent modalities include cryotherapy, thermotherapy, ultrasound, phonophoresis, electrotherapy (e.g., NMES, TENS), iontophoresis (Iontophoresis is a safe medical procedure that involves sending mild electrical currents through water and into the skin. It's usually used to treat excessive sweating. However, it can also be used to treat sports injuries by delivering anti-inflammatory medications directly into the skin), low-level laser therapy, and light therapy C. PAMs are considered a preparatory method for the therapeutic use of occupations or purposeful activities D. Regulatory oversight of the use of PAMs occurs at the local, state, and national levels. State licensure boards determine PAM competency regulations E. Practitioners must be knowledgeable about PAMs and able to use clinical reasoning in considering indication, contraindication, precautions, and documentation for application of each modality

XII. Nerve Injuries and Syndromes B. Radial Tunnel Syndrome

B. Radial Tunnel Syndrome 1. Entrapment (act of being trapped) of the radial nerve in an area extending from the radial head to the supinator muscle. 2. Symptoms: Burning pain in lateral forearm 3. Nonoperative treatment: long arm splint, elbow flexed, forearm supinate, wrist neutral, massage or TENS for pain management, pain free ROM, nerve glides, activity modification avoid forceful wrist extension and supination 4. Operative treatment: Long arm splint, elbow flexed, forearm supinate, wrist neutral for 2 weeks, then wrist cock up splint for 2 more weeks, passive and active pronation and supination, hand strengthening exercises at 3 weeks, resistive exercise at 6 weeks.

XV. Wound Healing B. Wound closure

B. Wound closure 1. Primary-Wound is closed with sutures 2. Secondary- Wound is left open and allowed to close on its own 3. Delayed primary-Wound is cleaned, derided, and observed 4 to 5 days before suturing it closed

V. Fractures of the Wrist A.Types 3. Bennet's Fracture

Bennet's Fracture is fracture of the first metacarpal base

I. Anatomy of the Forearm and Upper Arm What is the flow of blood supply to the forearm and upper arm?

Blood supply to the forearm and upper arm flows through multiple arteries, such as the brachial and brachiocephalic arteries.

II. Anatomy of the Hand What are the hand and wrist bones?

Bones of the hand and wrist include tow rows of carpal bones. The distal row captures the hazmat, capitate, trapezoid, and trapezium The proximal row captures the pisiform, lunate, triquetrum, and scaphoid

XII. Nerve Injuries and Syndromes C. Anterior interosseous Syndrome

C. Anterior interosseous Syndrome 1. Compression to the anterior interosseous nerve 2. Results in motor loss involving the flexor digitorum longs, flexor profundus to the index finger and pronator quadratus

XIV. Splinting C. Fabrication principles

C. Fabrication principles 1. Material properties of low temperature theroplastics include elasticity, memory, bonding, durability, rigidity, perforation, finish, color, and thickness 2. Patterns are drawn on a paper towel by outlining the body part using two-thirds the width of the extremity and half the circumference of the bone, marking boney landmarks, and extending 1/2 in. to 2/3 in. past the fingertips and thumb 3. Molding the splint to the client may involve adding close-cell padding before confirming the splint to the body part and using gravity as an assist. For hand splints, the longitudinal, distal, and proximal transverse arches of the hand are maintained 4. Finishing the splint requires applying reinforcement if necessary, rounding all corners, flaring the edges, applying appropriate rounded end straps, adding open-cell padding when appropriate, and making adjustments 5. The practitioner instructs the client and caregiver in wear and care of the splint, provides contact information for consultation if problems occur; and monitors the client's responses to splint wear.

XI Flexor Tendon C. Interventions

C. Interventions 1. Exercise promote tendon excuersion and prevent adhesions 2. Modalities include heat, to gradually prepare the tissue for motion, and neuromuscular electrical stimulation (NMES), to promote tendon excursion and activation. Use of modalities begins once cleared by the prescribing physician 3. A clearly identified and planned home exercise program is important to ensure the client's safety and progress towards goals 4. Tendon glides are used to promote excursion and prevent adhesions. Tendon glides are a sequence of movements used to promote full tendon excursion and full AROM and prevent adhesions (the sequence of movements is fingers straight, MCP flexion, hook fist, then flat fist) 5. ROM 6. Strengthening usually is not initiated until late phase of repair, around 8-12 weeks after surgery 7. If the client cannot cognitively follow a protocol, the extremity is cast in a protective position for 6 weeks

X. Extensor Tendons C. Interventions after surgical repair

C. Interventions after surgical repair 1. Exercise promote tendon excursion (a movement outward and back or from a mean position or axis excursion of the femur: the distance traversed.) and prevent adhesions (are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connects tissues not normally connected.) 2. Modalities include heat, to gradually prepare the tissue for motion, and NMES, to promote tendon excursion and activation. Use of modalities begins once cleared by the prescribing physician. 3. A clearly identified and planned home exercise program is important to ensure the client's safety and progress towards goals 4. Tendon glides are used to promote excursions and prevent adhesions Video on tendon glides: https://www.youtube.com/watch?v=iN4-UcoSGcU 5. ROM 6. Strengthening usually is not limited until the late phase of repair, around 8-12 weeks after surgery

VIII Complex Regional Pain Syndrome (CRPS) C. Symptoms

C. Symptoms: 1. Allodynia (sensation misinterpreted as pain) 2. Hyperalgia ( increased response to painful stimuli) 3. Hyperpathia (pain that continues after stimuli removed) 4. Edema 5. Contractures 6. Bluish or red shiny skin 7. Abnormal sweating and hair growth 8. Muscle spasms 9. Decreased strength 10. Low tolerance for activity

IX Cumulative Trauma Disorder C. Work-related risk factors?

C. Work-related risk factors: repetition, high force, direct pressure, vibration, cold environment, poor posture, female gender, and prolonged static position

XV. Wound Healing C. Wound healing phases

C. Wound healing phases 1. Inflammatory phase a. The inflammatory process includes clotting and vasoconstriction, white blood cell migration and release of histamines and prostaglandins that cause vasodilation and increase tissue permeability b. The acute phase last 24-48 hours to 7 days, and the subacute phase lasts 7-14 days. Local signs include redness, swelling, heat, and pain; systemic signs are fewer and leukocytosis 2. Proliferative phase a. In the proliferative process (also called the fiboplatic, granulation, or epithelialization process), lactic and ascorbic acid stimulate fibroblasts to synthesize collagen, and cross linkage of collagen increase the tensile strength of repaired skin to 80 percent b. Epithelialization resurfaces the wound, tissue granulation forms new collagen and blood vessels, and myofibroblast connect to the wound margins c. Wound contraction lasts 5 days to 2-3 weeks. linear wounds heal quickly, rectangular wounds moderately quickly, and circular wounds the most slowly 3. Remodeling phase a. In the remodeling process, scar tissue first consists of randomly arranged collagen fibers, and as the scar matures, the collagen is broken down and remodeled. The scar is then more elastic, smoother, and stronger b. The remodeling phase lasts 2 weeks to 1-2 years. If collagen synthesis exceeds collagen lysis, hypertrophic and keloid scars can form c. Tension theory posits that wearing pressure garments help collagen fibers realign in a linear and lateral orientation d. Dynamic splinting, serial casting , continuous passive motion, positional stretching, NMES, and silastic gel pads can help decrease hypertrophic scarring

V. Fractures of the Wrist A.Types 1. Colles Fracture

Colles Fracture: is complete fracture of the distal radius with dorsal(posterior) displacement. This is the most common type of fracture

IV. Fractures of the Hand B. Fracture healing What are complications of healing?

Complications of healing include misaligned fracture, pain, decreased nutrition to the area, and decreased healing potential. Age and bone disease also affect healing

XII. Nerve Injuries and Syndromes D. Pronator Syndrome

D. Pronator Syndrome 1. Entrapment of the proximal median nerve between the head of the pronator muscles 2. Symptoms: deep pain proximal forearm with activity 3. Nonoperative treatment: Splint elbow 90 to 100 degrees flexion, forearm neutral. TENS for pain, Gentle prolonged stretching supination and elbow, wrist, and finger extension, activity modification avoid repetitive forearm rotation with resistance and prolonged elbow flexion 4. Operative treatment: Half cast, AROM all UE joints while wearing cast, muscle strengthening in 1 week, full AROM gained by week 8.

IX Cumulative Trauma Disorder D. Symptoms?

D. Symptoms: Muscle fatigue, pain, chronic inflammation, sensory impairment, decreased ability to work

XV. Wound Healing D. Wound healing factors

D. Wound healing factors 1. Local factors a. Presence of foreign debris b. Necotic tissue or eschar (may require surgical debridement) c. Infection with Staphylococcus ( including methicillin-resistant S. aureus), Streptococcus, or Pseudomonas. Infection causes pus, pain, purulent drainage, odor; treat with antibiotics, proper debridement, cleaning, and dressing techniques d. Repeated trauma, decreased blood supply, or hypoxic tissue 2. Systemic factors a. Diabetes mellits b. Nutrition deficiency: Vitamins A, C, and E, zinc; and copper c. Atherosclerosis d. HIV, Aids e. Medications f. Aging g. Radiation therapy

D. Interventions What are interventions

D.Interventions 1. Orthotic fabrications can be used as prescribed by the physician for safe splinting and functional splinting. Materials should be chosen to fit the client and the condition. Thermoplastic and casting orthoses are commonly used to provide support for healing structures. 2. Modalities for pain relief and tissue healing including heat, ultrasound, cryotherapy, paraffin, and transcutaneous electrical nerve stimulation (TENS) 3. Therapeutic exercises provide motion to further enhance performance and function to ultimately improve ADL performance. Controlled AROM begins 3-6 weeks after fracture if fixation is stable 4. Home programs enable the client to continue safe exercises at home between therapy sessions to ensure continued progress towards healing 5. The most severe complication of hand fractures is complex regional pain syndrome (talked about later on in packet).

E. Median Nerve Syndrome

Dorsal wrist blocking splint

IX Cumulative Trauma Disorder E. Five grads (I-V) according to severity

E. Five grads (I-V) according to severity 1. Grade I: pain after activity, resolves quickly 2. Grade II: pain during activity, resolves when activity stopped 3. Grade III: Pain persists after activity, affects work productivity, objective weakness and sensory loss 4. Grade IV: Use of extremity results in pain up to 75% of time, work is limited Grade V: Unrelenting pain, unable to work

XII. Nerve Injuries and Syndromes E. Median Nerve Syndrome

E. Median Nerve Syndrome 1. Caused by ape hand deformity 2. Symptoms: ape hand deformity; sensory loss in index, middle , and radial side of ring finger; loss of pinch, thumb opposition, index finger MCP and PIP flexion; and decreased pronation 3. Nonoperative treatment: Static thenar web spacer splint 4. Operative treatment: Dorsal wrist blocking splint worn for 4-6 weeks, AROM and PROM in splint for digits and thumb, tendon gliding exercises, scar management, discontinue splint at 6 weeks and begin strengthening exercises

XIII. Physical Agent Modalities F. Cyrotherapy cools tissue to 1-2 cm depth

F. Cyrotherapy cools tissue to 1-2 cm depth 1. Methods include ice massage, ice, towels, cold packs, cold water immersion baths, cool whirlpools, cold compression units, and vapocoolant sprays 2. Effects on client include pain relief, decreased edema, decreased muscle spasms, decreased inflammation, decreased metabolic activity of tissue, and reduced nerve conduction velocity 3. Indications, contraindications, and precautions: Avoid use with clients with impaired circulation peripheral vascular disease, hypersensitivity to cold, impaired sensation, open wounds, or infections

XII. Nerve Injuries and Syndromes F. Double Crush Syndrome

F. Double Crush Syndrome 1. Occurs when a peripheral nerve is entrapped in more than one location 2. Symptoms: Intermittent diffuse arm pain and paresthesias with specific posture 3. Nonoperative treatment: Treat according to each nerve injury or syndrome, avoid movements or postures that aggravate the symptoms, nerve gliding exercises, and exercises for scapular stability, posture, and core trunk strengthening

XII. Nerve Injuries and Syndromes G. Carpal Tunnel Syndrome

G. Carpal Tunnel Syndrome 1. Carpal tunnel syndrome is caused by entrapment of the median nerve as it courses through the carpal tunnel. This is the most common nerve compression of the upper extremity 2. Cause include tenosynovitis, cumulative trauma disorder, fluid retention (e.g., from pregnancy, endocrine malfunctions), ganglions, tumors, diabetes, rheumatoid arthritis, and trauma such as wrist fracture or lunate dislocation 3. Sensory impairment generally involves numbness and tingling in the thumb and index and middle fingers, especially at night 4. Motor impairment present as diminished fine motor coordination; in advanced cases, the adductor policis muscle may by atrophied ((of body tissue or an organ) waste away, typically due to the degeneration of cells, or become vestigial during evolution:)) 5. Evaluation specific to carpal tunnel syndrome: a. Tinel's sign: is a tap on the median nerve at the wrist to elicit symptoms b. Phalen's test: is holding the wrist in full flexion for 1 minute to elicit changes in sensation c. Moberg Pickup Test: is a timed test involving picking up, holding, manipulating, and identifying small objects. It is used with children and cognitively impaired adults to test median nerve function. d. Semmes-Weinstein monofilament testing: is used to test for loss of sensation 6. Nonoperative treatment: a. A carpal tunnel syndrome splint or wrist cock up splint at 0-10 degrees wrist extension is used to relieve pressure on the median nerve in the carpal tunnel and control edema; a prefabricated wrist cock-up splint can be used if the wrist position is adjustable b. Nerve and tendon gliding exercises are used c. Activity modification include ergonomic handles, gel pads, or padding on handles d. Client education recommendations avoidance of postures and activities that aggravate the condition (e.g., those that involve wrist flexion). Training is provided in the use of an ergonomic keyboard modification, if applicable e. Postural retaining and proximal conditioning exercise are provided 7. Postoperative treatment a. Surgical treatment includes traditional open carpal tunnel release surgery or endoscopic release b. After surgery, some clients may not need therapy c. For more complicated cases, wound care and scar mobilization are provided d. Pain management may include us of perl pads on the scar. Pain on either side of the surgical release is called pillar pain e. Splinting is provided only to client who sleep with the wrist flexed or who will engage in too much activity too soon f. AROM of wrist, thumb, and fingers begin 1-2 days post surgery g. Nerve and tendon gliding exercises are provided h Strengthening activities begin in 3 to 6 weeks

XV. Wound Healing G. Documentation

G. Documentation 1. Anatomical location and area of wound 2. Length, width, depth, and shape of wound 3. Color and presence of necrotic tissue 4. Description of wound exudate 5. Granulation and epithelial tissue at wound margins 6. Description of surrounding intact skin

XIII. Physical Agent Modalities G. Thermotherapy heat tissue to 1-2 cm depth

G. Thermotherapy heat tissue to 1-2 cm depth 1. Methods include warm whirlpools, fluidotherapy, hot packs, contrast baths, and paraffin baths 2. Effects on the client include increased blood flow, increased rate of cell metabolism, increased inflammation, increased muscle contraction velocity, increase capillary permeability, increased oxygen consumption, decreased fluid viscosity, decreased muscle spasms, and decreased pain 3. Indications, contraindications, and precautions: Avoid use with clients wit hackie inflammation edema, sensory impairment, cancer, blood clot, infections, cardiac problems, and impaired cognition

XII. Nerve Injuries and Syndromes H. Cubital Tunnel Syndrome

H. Cubital Tunnel Syndrome 1. Cubital tunnel syndrome is caused by proximal ulnar nerve compression at the elbow between the medial epicondyle and the olecranon process. This is the seconded most common nerve compression of the upper extremity after carpal tunnel syndrome 2. Causes include fracture or dislocation of the elbow, osteoarthritis, rheumatoid arthritis, diabetes, alcohol abuse, tourniquets, and assembly line work 3. Sensation is decreased in the little finger and ulnar half of the ring finger 4. Motor problems may include decreased grip and pinch strength because of weak interossei, adductor pollicus, and flexor carpi ulnas muscles 5. Evaluation specific to cubital tunnel syndrome a. Tinel's sign: is a tap over the cubital tunnel to elicit symptoms b.Froment's sign: is flexion of the IP of the thumb when a lateral pinch is attempted c. Wartenberg's sign: is the fifth finger held abducted from the fourth finger d. The elbow flexion test involves holding the elbow in flexion for 5 minutes with the wrist neutral to elicit symptoms 6. Nonoperative treatment a. Edema control b. Pain management c. Elbow splint or positioning at 30-60 degrees flexion for 3 weeks d. Ulnar nerve gliding e. Proximal conditioning activities f. Posture and ergonomic training 7. Postoperative treatment a. During the protection phase (1 day to 3 weeks), splinting the elbow at 70-90 degrees flexion; provide wound care, edema control, pain management, and AROM of uninvolved joints; and teach one-handed ADL techniques b. During the active phase (beginning at 3 weeks), discontinue the elbow splinting and anticlaw splint if used before surgery, then add elbow AROM ( in pronation first, then supination; add wrist motion with elbow flexed, then extended), ulnar nerve gliding, and desensitization techniques

XIII. Physical Agent Modalities H. Ultrasound heats tissue to 1-5 cm depth

H. Ultrasound heats tissue to 1-5 cm depth 1. Ultrasound has thermal and nonthermal effects and also is used in phonophoresis (Phonophoresis is the use of ultrasound to enhance the delivery of topically applied drugs. Phonophoresis has been used in an effort to enhance the absorption of topically applied analgesics and anti-inflammatory agents through the therapeutic application of ultrasound.) 2. Effects on the client: a. Thermal effects increase tissue extensibility and blood flow and decrease pain, joint stiffness, muscle spams, and chronic inflammation b. Nonthermal effects increase protein synthesis and bone healing and decrease inflammation. c. Phonophoresis is the use of the ultrasound to promote absorption of topically applied medication to accelerate tissue repair and decrease inflammation 3. Indications, contraindications, and precautions: Avoid use with pregnancy, over eyes, pacemaker, bleeding, infections, cancer, over blood clots, and growth plates of bone in children. Be cautious when using with inflammation, fractures, breast implants, and clients with cognitive, language or sensory impairments

XIII. Physical Agent Modalities I. Electrical stimulation

I. Electrical stimulation 1. Methods include NMES, TENS, and iontophoresis 2. Effects on client: a. NMES promotes wound healing, maintains muscle mass, increases ROM, decrease edema, facilitates voluntary motor control, and decreases spasm and spasticity and can be used as an orthotic substitute b. TENS primarily controls pain through possible mechanisms: gate control, endorphin release, and acupuncture C. Iontophoresis decreases inflammation and controls pain 3. Indications, contraindications, and precautions: Do not use over pacemakers, carotid sinus, pregnant uterus, eyes and clients with epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain.), cancer, infection, decreased sensation, cardiac disease, and stroke. With iontophoresis use, be aware of possible drug allergies

XII. Nerve Injuries and Syndromes I. de Quervian syndrome

I. de Quervian syndrome 1.de Quervain syndrome is caused by cumulative micro trauma resulting in tenosynovitis of the thumb muscle tendon unit, the abductor policies longs and extensor policis brevis, and the tendons in the first dorsal compartment of the wrist 2. Cause include forceful, repetitive thumb abduction with wrist ulnar deviation, carpometacarpal (CMC) osteoarthritis, scaphoid fracture, intersection syndrome, or radial nerve neuritis 3. At the highest risk are women ages 35-55, women in late pregnancy, mothers of young children and people who engage extensively in keyboarding, playing piano, knitting, needlepoint, and racket sports 4. Nonoperative treatment a. Medical treatment includes corticosteroid injections b. Occupational therapy treatment consists of forearm-base thumb spica splint with wrist in neutral and thumb radially abducted for 3 weeks c. Activity modification and avoidance of pinch are recommended d. After 3 weeks, the client progresses to a soft splint and isometric exercises e. Computer ergonomics education is provided f. Strengthening activities are provided 5. Operative treatment a. Medical treatment include surgical release of the first dorsal compartment b. Occupational therapy treatment postsurgery consists of forearm-based thumb spica splint with wrist 20 degrees extension and thumb radially abducted for 3 weeks c. Gentle ROM and tendon gliding exercises are performed d. Grip and pinch strengthening begin at 2 weeks e. Scar management and desensitization techniques are used

XII. Nerve Injuries and Syndromes J Claw Deformity

J Claw Deformity 1.Claw deformity is distal ulnar nerve compression or lesion at the wrist 2. Causes include ganglion, neuritis, arthritis, or carpal fractures at Guyon's canal 3. Sensory loss occurs in the little finger and ulnar side of the ring finger plus the palmar ulnar hand; if sensory loss is on the dorsal side of the hand, the injury is proximal to Guyon's canal 4. Loss of intrinsic ulnar innervated muscles (interossei and adductor pollicis, flexor and abductor digiti minimi) and resulting motor loss result in deformity in which the MCP's hyperextend and the IP's flex, hand arches are flattened, and pinch strength is lost 5. evaluation specific to claw deformity a. Froment's sign: is flexion of the IP of the thumb when a lateral pinch is attempted. b. Wartenberg's sign: is the fifth finger held abducted from the fourth finger c. Jeanne's sign: is hyperextension of the thumb MCP d. Semmes-Weinstein monofilament testing is used to test for loss of sensation 6. Nonoperative treatment a. An ulnar nerve palsy or anticlaw splint is used, and dynamic PIP extension assist may be added if PIP flexion contractors are present b. A padded anti vibration glove can be used during activity to protect from further nerve irritation c. Activity modification includes ergonomic handles, gel pads, or padding on handles of vibratory equipments (e.g., lawnmower) d. Client education recommends avoidance of posture and activities that aggravate the condition, such as ulnar deviation combined with wrist flexion 7. Postoperative treatment a. Bulky dressing is applied for 3 to 10 days b.A dorsal blocking splint is used to maintain thewrist at 20-30 degrees flexion and an MCP block to 45 degrees extension to protect nerve repair The splint is adjusted at 3-6 weeks to increase wrist position to neutral. Discontinuation splint at 6 weeks. Use of the preoperative splint continues until muscle function returns c. Wound care and scar mobilization are performed d. Sensory desensitization begins when the wound has healed and stitches are removed e. AROM of the wrist and hand begins at 6 weeks; clients may resume ADLs and begin muscle strengthening and work conditioning, if needed f. Sensory reeducation begins at 10-12 weeks post surgery, once protective sensation has returned g. Tendon transfer is done if the nerve has not regenerated within 1 year. After surgery, the practitioner may provide electromyography biofeedback, NMES, and instruction in avoiding substitution of movement patterns

XIII. Physical Agent Modalities J. Low-level laser and light therapy

J. Low-level laser and light therapy 1. Methods include light e=mitting diodes, super luminous diodes and low-level laser diodes. 2. Effects on the client include decreased pain, edema, and inflammation; increased wound healing; and decreased scar tissue 3. Indications, contraindications, precautions: Wear protective eyewear when using laser, do not use over vagus nerve, carotid sinus, pregnant uterus, eyes, infection, endocrine glans, or cancer

XII. Nerve Injuries and Syndromes K. Digital Stenosing Tenosynovitis SOMETHING IS WRONG WITH THE DEGREES OF THE SPLINT

K. Digital Stenosing Tenosynovitis 1. Trigger finger occurs with sheath inflammation or nodules near the A1 pulley 2. Treatment includes splinting the MCP at 0 degrees for 3-6 weeks or surgically releasing the A1 pulley

XII. Nerve Injuries and Syndromes L. Sensory Reeducation after Nerve Injury

L. Sensory Reeducation after Nerve Injury 1. Protective reeducation: educates clients to visually compensate for sensory loss and to avoid working with machinery and temperature below 60 degrees 2. Discriminative reeducation: uses motivation and repetition in a vision-tactile matching process in which clients identify objects without vision 3. Sensory recovery begins with pain perception and progresses to vibration of 30 cycles per second, moving touch, and constant touch 4. Desensitization is a process of applying different textures and tactile stimulation to reeducate the nervous system so clients can tolerate sensations during functional use of the upper extremity

B. Radial Tunnel Syndrome

Long arm splint:elbow flexed, forearm supinate, wrist neutral

II. Anatomy of the Hand What are the muscles that originate from the lateral epicondyle ?

Muscles that originate from the lateral epicondyle include the anconeus, brachioradialis, supinator, extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ularis, extensor digitorum, extensor digiti minimi

II. Anatomy of the Hand What are the muscles that originate from the medial epicondyle?

Muscles that originate from the medial epicondyle include pronator teres, flexor carpi radialis, flexor carpi ulnaris, palmaris longus, and flexor digitorum superficialis

V. Fractures of the Wrist A.Types 2. Smith's Fracture (the opposite of colles)

Smith's Fracture is complete fracture of the distal radius with palmar displacement

E. Median Nerve Syndrome

Static thenar web spacer splint

I. Anatomy of the Forearm and Upper Arm What are the bones of the forearm and upper arm?

The bones of the forearm and upper arm are the radius, ulna, and the humerus

II. Anatomy of the Hand What are the main arteries that supply blood to the hand and wrist?

The main arteries supplying blood to the hand and wrist are the radial and ulnar arteries

I. Anatomy of the Forearm and Upper Arm What are the muscles of the forearm and the upper arm?

The muscles of the forearm and the upper arm are the deltoid, triceps, anconeus, biceps brachii, brachialis, brachioradialis

IV. Fractures of the Hand B. Fracture healing When is the safe time for movement?

The safe time frame for movement versus protection depends on the fracture type, stage of healing, and physician orders

VII. Fractures of the Upper Arm 2. Intervention

a. Orthotics (e.g., humeral fracture brace) can be worn for support of the fracture ends. b. ROM may begin as early as 2 weeks after a nonoperative fracture as medically prescribed c. A sling is used to immobilize the fracture in nonoperative treatments d. A ROM protocol consists of aggressive stretching and can begin 4-6 weeks after the fracture as prescribed by the physician e. Management at home: -A home exercise program is crucial for return of motion and function and for ADL performance -The home program can include a sling for comfort and sleeping for the first 6 weeks as needed

VI Fractures of the Forearm B. Interventions

a. Orthotics are used for immobilization as needed b. ROM is begun early, within the 1st week if medically cleared c. A sling is used for Type I fractures or comfort if the client has pain and is nervous in public places

VI Fractures of the Forearm A. Radial head fractures account for 33% of elbow fractures. Theres fractures are usually caused by a forceful load through an outstretched arm What are the three types?

a. Type I (non displaced) can be treated with a long arm sling. b. Type II (displaced with a single fragment) is typically treated nonoperatively with immobilization for 2-3 weeks and early motion with medical clearance c. Type III (comminuted) is treated operatively, with immobilization and early motion with the first postoperative week as medically prescribed