UE Injuries
Duran Protocol
"do it yourself" 0-4 1/2 weeks - dorsal block splint - passive flexion, extension exercise 41/2-6 weeks - active flexion, extension in splint 6-8 weeks - exercise, scar management, d/c splint 8-12 weeks - strengthening
flexor tendon zones
- 5 total (distal to proximal) 1. finger tip to center of middle phalanx 2. center of middle phalanx to distal palmar crease (No Man's Land) 3. distal palmar crease to transverse carpal ligament 4. transverse carpal ligament 5. wrist & beyond
extensor tendon zones
- 8 total (distal to proximal) thumb: 1: IP joint 2: proximal phalanx 3: MCP joint 4: first metacarpal 5: wrist digits 2-5: 1. DIP joint 2. middle phalanx 3.PIP joint 4. proximal phalanx 5. MCP joint 6. metacarpal 7. carpals/wrist 8. forearm 1: mallet finger - DIP extension splint 2-4: DIP AROM, PIP extension splint (boutonniere) 5-7: volar wrist splint in 20-30 degrees extension, 0-10 degrees MCP flexion, full IP extension - 6 weeks
carpal tunnel syndrome - CTD
- Source: compression of median nerve in carpal tunnel at wrist - Due to: repetition, awkward positioning, vibration, anatomical deformity, pregnancy, CTD, ganglion, tumor, arthritis, DM, wrist trauma, fluid retention - Symptoms: numbness, tingling in thumb, index, middle finger & radial half of ring finger, paresthesias at night, tendency to drop items, thenar atrophy, impaired fine motor coordination - Clinical testing: tinel's sign at wrist, phalen's sign (bilateral), Moberg's pick up test, Semmes Weinstein monofilament test - Conservative treatment: --- adjustable wrist cock up splint with wrist at 0-10 degrees extension (use at night, day during repetitive activity), Median nerve & differential tendon gliding exercises, activity modification (avoid extreme wrist flexion with finger flexion and static grip), ergonomics education on work station set up, adaptive equipment (ergonomic handles, gel pads, padding, antivibration gloves) - Post Operative Treatment: --- edema control, AROM (1-2 days post), nerve/tendon glides, sensory re-education, strengthening (3-6 weeks post), activity/work modifications, wound care, scar mobilization, pain management -- pillar pain - on both sides of surgical site
Cumulative Trauma Disorder (CTD)
- soft tissue trauma due to repetitive use (overuse syndrome, repetitive strain) Diagnoses include: -tendinitis - nerve compression - myofascial pain -cervical/thoracic/lumbar OA - nerve root impingement - thoracic outlet syndrome - rotator cuff tear - bursitis - epicondylitis - cubital tunnel syndrome - carpal tunnel syndrome - De Quervains syndrome Symptoms: fatigue, pain, chronic inflammation, impaired work, sensory impairment Risk factors: repetition, high force, direct pressure, vibration, cold, posture, female gender, prolonged static position, acute trauma, pregnancy, diabetes, arthritis, wrist structure
digital stenosing tenosynovitis - trigger finger (CTD)
- tenosynovitis of finger flexors - A1 pulley - resulting in tendon sheath inflammation or nodules - Due to: repetition and use of tools placed tool far apart Conservative Treatment: - hand based trigger finger splint (MCP extended, IPs free) for 3-6 weeks -scar massage -edema control -tendon glides -activity and work modifications - avoid repetitive gripping
Ulnar nerve injury
-Due to: ganglion, neuritis, arthritis, carpal fracture -Clinical test: Jeanne's sign (hyperextend thumb MCP), Semmes Weinstein, Tinel's sign, Froment's sign - Motor: affects interossei & lumbricals (intrinsic hand muscles) - injury presents as "claw hand" deformity at rest - MCP hyper extension, IP flexion - affects last 2 fingers - "ultimate fingers" - leads to loss of power grip & pinch -Sensory: ulnar aspect of palmar and dorsal surfaces, ulnar half of ring finger, little finger on palmar and dorsal surfaces Non-operative treatment: ----- use MCP flexion block splint/anti claw splint with dynamic PIP extension splint ---activity modifications, padded antivibration gloves, education on avoiding triggers Operative Treatment: --dorsal block splint: wrist 20-30 degrees flexion, MCP 45 degrees extension (adjust over 6 weeks to bring wrist to neutral) -- wound care and scar mobilization -- sensory desensitization -- AROM at wrist/hand at 6 weeks with progress to strengthening/work conditioning -- sensory re-education at 10-12 weeks once protective sensation has emerged
Radial nerve injury
-compression of radial nerve due to sleep positioning, humeral shaft fracture -Symptoms: weakness, paralysis of extensors to wrist, MCP, thumb - Impacts extensor & supinator muscle groups -sensory: median nerve distribution on dorsal side - low level injury = wrist drop - Affects: hand manipulation, release " Can't keep your radiant bracelet on" - high level injury (humerus) = loss of triceps/elbow extension - affects medial dorsal forearm, radial dorsal palm, thumb, index, middle, radial 1/2 rring finger Conservative Treatment: - dynamic extension splint or cock up splint - work/activity modification - strengthening wrist/finger extensors Post-operative treatment: -ROM/nerve glides strengthening at 6-8 weeks -static wrist extension splint 30 degrees for 4 weeks - progress to neutral
guyon's canal injury
-compression of ulnar nerve at wrist -due to: repetition, ganglion, pressure, fascia thickening -Symptoms: numbness, tingling in ulnar nerve distribution, motor weakness/atrophy -Clinical test: Tinel's sign at guyon canal -Conservative treatment: -wrist splint in neutral - work and activity modification Post-Operative treatment: - edema control -AROM -nerve glides -strengthening at 2-4 weeks (power grip) -sensory re-education
cubital tunnel syndrome (CTD)
-compression of ulnar nerve between medial epicondyle and olecranon - due to: pressure at elbow from leaning on it or extreme flexion -causes: fracture, dislocation, OA/RA, diabetes, alcohol use, tourniquets, assembly line work -Symptoms: numbness, tingling along ulnar aspect of forearm and hand, pain at elbow with extreme flexion, weak power grip, pinch, atrophy -- hand: little finger, ulnar half of ring finger -Clinical test: Tingel's sign at elbow, Froment's sign, Wartenburg's sign (5th digit abdut from 4th digit), elbow flexion test (hold in flexion for 5 minutes, with wrist in neutral) Conservative Treatment: -edema control -ulnar nerve glides -proximal conditioning -elbow splint - prevent prolonged flexion at night - elbow pads - decrease impact when leaning -activity & work modifications, ergonomics training Post-Operative Treatment: --Protective Phase (1-3 days): ROM of uninvolved joints, pain management, 1 handed activity, elbow splint in 70-90 degrees flexion, edema control -- Active Phase (3 weeks+): scar management, AROM/nerve glides (2-3 weeks) in pronation -> supination, with wrist movement w/ elbow flexed, extended, strengthening at 4 weeks, desensitization --- MCP flexion splint if clawing symptoms present ---
radial tunnel syndrome
-entrapment from radial head to supinator muscle -Symptoms: burning in lateral forearm -Non-operative treatment: long arm splint with elbow flexed, forearm supinated, wrist neutral, TENS, massage, pain free ROM, nerve glides, activity modification - Operative treatment: long arm splint with same positioning 2 weeks, wrist cock up 2 weeks, P/AROM pronation/supination, hand strengthening at 3 weeks, add resistance at 6 weeks
humeral fracture
-most often proximal humerus due to fall on outstretched UE - can be displaced vs. non-displaced -can involve articular surface, greater/lesser tuberosity, surgical neck Location: - anatomical head (rotator cuff) - anatomical neck - anatomical shaft (radial nerve injury) Intervention: begin with PROM, AAROM - orthotics to support fracture - humeral fracture brace - ROM @ 2 weeks if no surgery - sling - immobilize post surgery for first 6 weeks - continue for sleep and comfort - ROM: aggressive stretching at 4-6 weeks
pronator teres syndrome
-symptoms occur in proximal volar forearm -associated with median nerve compression between 2 muscular heads -Due to: repetitive pronation/supination, excessive pressure on volar forearm -Symptoms: similar to carpal tunnel plus deep aching pain in proximal forearm -clinical test: tinel's sign at forearm ----Conservative treatment: --elbow splint at 90-100 degrees flexion -- TENS, gentle prolonged stretch --Avoid: tasks requiring repetitive pronation/supination, prolonged flexion ---- Post-Operative Treatment: --half cast, full AROM at 8 weeks, nerve glides, strengthening @ 2 weeks, sensory re-education, work/activity modification
CTD Grades & Intervention
1: pain post activity, resolves quick 2: pain during activity, resolves quick once stopped 3: pain persists after activity, decreased productivity, weakness, sensory loss 4: extremity use = 75% of time, impaired work 5: unrelenting pain, no work productivity Acute: reduce inflammation, pain using static splint, ice, contrast bath, US phonophoresis, ionto, high voltage electric, interferential stimulation Subacute: slow stretch, myofascial release, exercise, body mechanics, education, static splint during painful activity Return to work: assess job site, tools, position, work simulator, weight well, elastic bands, putty, functional activity, strengthening Functional Capacity Eval Work Hardening
Medial Epicondylitis
AKA - golfer's elbow - over use of wrist flexors
Lateral epicondylitis
AKA - tennis elbow - overuse of wrist extensors - especially extensor carpi radialis brevis
adhesive capsulitis
AKA frozen shoulder -symptoms: limited PROM, especially external rotation, abduction, internal rotation, flexion -Due to inflammation, immobility, DM, Parkinson's Conservative treatment: -encourage active use -PROM -PAMs Post-OP: -immediate PROM -modalities targeting pain -encourage use
skier's thumb
AKA game keeper's thumb -rupture of UCL of MCP joint at home OT: - thumb spica for 4-6 weeks -AROM and pinch strengthening at @ 6 weeks -ADLs requiring opposition and pinch Post-OP: - thumb splint 6 weeks - AROM - PROM @ 8 weeks - strengthening @ 10 weeks
elbow fracture
AKA radial head fracture - due to forceful load thru outstretched arm 1: non-displaced - use long arm sling 2: single fragment - immobilize 2-3 weeks with early motion 3: comminuted - post-op - immobilization, early motion
Dupuytren's disease
Affects fascia of palm and digits causes thickening and contraction (presents as cords/bands extending to digits) -creates flexion deformity - requires surgical release (fasciotomy with Z plasty, aponeurotomy, McCash procedure) OT: - Wound care - edema control - scar management -A/PROM -> strengthening - scar massage - purposeful and OB activity working on grip, release
De quervain's
CTD - stenosing tenosynovitis of abductor pollicis longus and extensor pollicis brevis - first dorsal wrist compartment - cause: forceful repetition thumb abduction with wrist in ulnar deviation, CMC OA, scaphoid fracture, intersection syndrome, radial nerve neuritis - Clinical Test: Finkelstein's test Conservative treatment: - forearm based thumb spica (keep IPs free) - activity and work modifications - ice massage over radial wrist - gentle AROM at wrist/thumb at 3 weeks in soft splint, isometrics Post OP Treatment: - thumb spica, gentle AROM 0-2 weeks - wrist at 20 degrees, thumb radially abducted for 3 weeks - strengthening, ADLs 2-6 weeks - unrestricted activity at 6 weeks - scar massage - desensitization
Epicondylitis
CTD - degeneration of tendon origin due to repetitive microtrauma Conservative treatment: - elbow strap, wrist splint - ice and deep friction massage - prolonged stretch - activity and work modifications - strengthening with decreased pain (isometrics -> isotonic/eccentric) - iontophoresis
Fractures
Healing stages: -inflammation -repair -remodeling OT: -safe splinting -functional splinting - PAMs (heat, US, cryo, paraffin, TENS) -Ther ex - controlled AROM 3-6 weeks -- AROM with wrist extended, digits flexed -- blocking exercises -- tendon/nerve glides -- strengthening Immobilization - AROM above/below, edema control, light ADLs mobilization - edema control +contrast bath, AROM 4-8 weeks, light ADLs, pain management, srengthening
Phalanx fracture
Most Common: Proximal: thumb and index Distal: mallet finger
Median nerve injury
Motor: - low lesion (wrist): flat thenar eminence/thumb adduction ---- presents as ape hand at rest - clawing of middle & index fingers ---- loss of abduction, opposition, weak pinch (((( symptoms above plus )))) - high lesion (elbow): loss of thumb opposition and palmar abduction ---- presents as hand of benediction (active, unable to make a fist with digits 1-3) ---- "pope prays to the high almighty god" Sensation: - central palm - thumb to radial half of ring finger - palm surface - " " - dorsal surface - index, middle, radial half of ring finger (Middle, distal phalanx) (begin sensory education once demonstrating decreased protective sensation) Treatment: A/PROM with flexed wrist - 2 weeks, scar management, wrist AROM at 4 weeks, elbow/strengthening at 6 weeks --- use of c-bar splint/static thenar web space splint (nonoperative) ---- 30 degrees flexion dorsal protection splint, 90 degrees elbow flexion (4-6 weeks) (operative)
Mallet finger
avulsion fracture at terminal tendon -splint in full extension for 6 weeks
Fracture Medical Treatment
closed reduction - short arm cast, long arm cast, splint, sling, fracture brace open reduction - internal fixation external fixation arthrodesis - fusion arthroplasty - replacement
anterior interosseous syndrome
compression of nerve, motor loss to FDL, flexor digitorum profundus, pronator quadratus
intraarticular fracture
crosses into joint surface = closed, dorsal, complete
Boutonniere deformity
disruption of central slip of extensor tendon - PIP flexion, DIP hyperextension -PIP splint in extension, do isolated DIP flexion exercise
colles' fracture
distal radius fracture with dorsal displacement
smith's fracture
distal radius fracture with palmar displacement
extraarticular fracture
doesn't extend into joint - open, volar, incomplete
sensory re-education
following nerve injury: - protective: visually compensate & avoid work with machinery and temperature below 60 degrees - discriminative: vision-tactile matching process to identify objects with and without vision - sensory recovery: pain -> vibration in 30 cycles per second, moving touch, constant touch - desensitization - apply different textures/stimuli, re-educate PNS to tolerate sensation
rotator cuff tendinitis
impingement @ coracoacromial arch Due to: -repetitive use -cure/hook acromion - weak muscles at shoulder and scapula - trauma - ligament/capsule tightness Conservative: -no overhead/shoulder activity with pain -sleep posture - no UE overhead or in adduction with internal rotation -decrease pain with positioning -PAMs - rest pain free ROM -strengthening above shoulder level Post Op: -PROM 0-6 weeks - progress to AA/A -decrease pain - ice, heat - strength @ 6 weeks - isometric-> isotonic below shoulder -activity modifications -return to leisure, work at 8-12 weeks
Swan neck deformity
injury to MCP, PIP or DIP joints -PIP hyper extension, DIP flexion -PIP splinted in slight flexion
exercise types
isotonic: -- concentric - muscle shortens -- eccentric - muscle lengthens isometric: -no movement, static, muscle stays same length
tendon injuries
key = early mobilization - to prevent adhesion, facilitate healing -tendon excursion - strengthening - ROM -facilitate performance
shoulder dislocation
most common: anterior due to trauma or repetitive overuse Regain ROM - limit abduction and external rotation pain free OB activity strengthen cuff muscles
Carpal Fracture
occurs at individual carpal bones Examples: -Scaphoid: risk of necrosis -Lunnate - Keinbock's disease
complex regional pain syndrome (CPRS)
pain disproportionate to injury - sympathetically maintained or independent of sympathetic nervous system -vasomotor dysfunction because of abnormal reflect activity -localized or diffuse Types: 1: post noxious event 2: post nerve injury Symptoms: -allodynia: sensation misinterpret as pain -hyperalgia: increased response to painful stimuli -hyperpathia: pain continues after stimuli removed -edema -contracture -bluish/red skin -abnormal sweating and hair growth -muscle spasm -decreased strength -decreased activity tolerance -osteoporosis -sudomotor changes -temperature changes -soft tissue changes Intervention: -PAMs -edema control -joint AROM - pain free activities -stress loading (scrubbing, carrying) - splint - self management -desensitization - exercise - joint protection, energy conservation -pain control - avoid: PROM, passive stretch, joint mobs, dynamic splint, cast
double crush syndrome
peripheral nerve entrapped at 1+ location causing intermittent pain and paresthesias - Treat based on each injury/syndrome -Including: glides, exercise for posture, scapular stability, core strengthening
metacarpal fracture
proximal - 4th-5th = Boxer's fracture -- treat with ulnar gutter splint Benet's fracture - 1st metacarpal base
Avulsion fracture
tendon separates from bone and insertion - remove some bone material
Kleinert Protocol
use with flexor tendon injury - passive flexion, active extension via rubber band traction -- requires "outside" help 0-4 weeks - dorsal block splint wrist: 20-30 degrees flexion MCP: 50-60 degrees flexion IPs: full extension 4-7 weeks - continue splint with wrist in neutral -scar mobilization -tendon glides -place and hold exercise 6-8 weeks - AROM, d/c splint 8-12 weeks - strengthening