567 Test 3

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extensor

clients with LE should begin forearm stretching of _____ muscles

pain and dysesthesia on dorsal radial forearm extending to thumb and index finger

clinical picture of Dorsal Radial sensory nerve/ Wartenburg's syndrome

metacarpal fractures with phalangeal fractures of distal, proximal and middle phalanx (in that order)

half of hand frx are ___________, compromising the other half

trunk flexion or shoulder motion

lack of extension can be compensated with

MP contracts to 30 degrees, PIP to 15 degrees, and loss of function capacity of hand

medical interventions not needed for Dupuytrens until

polyneuropathy

metabolic induced neuropathy to bilateral extremities of 2 or more nerves (bilateral feet and hands) ex: alcoholism, autoimmune diseases, etc.

- AROM f/b PROM if limitation noted - MMT - strength testing with dynamometer and pinch gauge (if appropriate)

motor/joint assessments

60-80%

muscle atrophy reaches a relatively stable state at ____ - ____% weight loss by approximately 4 months

- edema control - scar mgmt - ROM - radial abduction, palmer abduction, MP/IP flex and ext, radial and ulnar deviation, wrist flex/ext - typically very few OT sessions if any

post op mngmt for trigger finger

immobilization x 3 weeks followed by AROM. Night time orthosis if extensor lag

post op treatment of middle phalanx frx

- HEP - edema/pain mngmt - ACTIVE or AAROM exercises, orthosis wear, and light functional activities - same goal; get the pt. MOVING

post operative stable frx you still want to start with...

immobilized x 3-4 weeks then AROM begins, followed by scar and edema mgmt, PROM per MD (typically 8 weeks)

post-op proximal phalanx fracture are treated by

- initially, static long arm elbow orthosis in neutral forearm, wrist extension, and MP in 10-20 degrees flexion - after 3 weeks, extend elbow 30 degrees/week - at 6 weeks, discontinue orthosis : initiate A/PROM, fabricate Radial Nerve Palsy splint until adequate motor return

post-operative management for radial nerve repair: Above the elbow (varies per MD)

finger and thumb AROM exerices

teach pt. _______ exercises while in a cast

3 to 6 months

tendinosis can take ______ to heal

Provocative testing

testing to provoke symptoms to clarify the site of injury and rule out other diagnoses

- age - vitamin D and calcium deficiency - systemic disease (OA, diabetes, etc.) - nicotine use -immunosuppression - long term drug use (NSAIDS, corticosteroids) - delayed time for treatment

factors affecting healing of wrist fracture

within a week post

for stable fractures post surgery, also start OT within

extra-articular fractures

fracture did NOT cross into the joint space; typically stable and non-displaced

intra-articular fractures

fracture that crosses into the joint space; result in greater soft tissue damage; often require reduction and/or pinning

"reduction" (closed or ORIF) ORIF- open reduction internal fixation

fractures that require some type of manipulation by MD for realignment require _______

DASH/QuickDASH Modified COPM Patient interview Occupational profile

functional assessments for Lat. Epicondylitis

the arthritic thumb

thumb CMC osteoarthritis aka basal joint OA - very common - can lead to swan neck deformity at the thumb: metacarpal adduction and subluxation of the trapezium, MCP hyperextension, and IP joint flexion - pinch is painful

more restrictions per MD

treatment of post-operative stable fractures are very similar to non-operative; however there may be

padded glove or orthosis that protects pressure on canal

treatment of ulnar nerve palsy (protective gear) _________ or __________ - activity modifications - other OT interventions

DM, RA, gout, CTS, and Dupuytren's contracture

trigger finger is associated with

froment's sign

when the client attempts powerful lateral pinch the thumb's IP joint flexes as the FPL attempts to compensate for the paralyzed or weak adductor pollicis and flexor pollicis brevis

boxer's fracture

when you punch object with a closed fist, your 4th and/or 5th metacarpal bone takes the force of this impact and breaks at the neck

radial nerve

which of the 3 UE peripheral nerves is the most commonly injured

- crutch palsy

which radial nerve injury is at the site of (Axillia)- involves triceps

protocol

always ask the MD to send ___________

90-110 degrees

angle of elbows, hips, and knees should be

tendinosis

breakdown of collagen

after 40

OA usually begins at what age

impede nerve regeneration

scar tissue around the healing nerve can

- semmes weinstein monofilament - 2 point discrimination -- static and moving - light touch localization - moberg pickup test - tinel's sign

sensory assessments

- 3-4 weeks post manipulation/surgery - full ROM should be achieved by 4 weeks for manipulation; may take longer with fasciectomy - initiate graded progressive strengthening exercises

therapy guidelines following contracture release include (4)

Wartenberg's sign

this sign is present if the fifth finger is postured in an abducted position from the fourth finger. This indicates interosseous muscle weakness (specifically paresis of the palmar adductor interossei)

distal humerus fracture

this type of elbow fracture is most common in children ages 5-9

fall with elbow flexed or direct blow

typical causes of olecranon fracture

more tolerated

why are extension orthoses generally worn at night

- activity modification to avoid activities that cause pain - body mechanics training to avoid lifting objects with the forearm in pronation - educate on the importance of above and taking breaks to allow tissues to recover during repetitive activities

education for clients with lateral epicondylitis includes

absent of inflammatory cells

for decades, studies have shown that repetitive stress injuries have more of a chronic pathology that are ___________________________

bartons frx

intra-articular DRF with dislocation of carpals

Moist heat pack/ice - teach how to make a rice sock ultrasound e-stim

pain management for Lateral epicondylitis includes

smiths frx

distal radius fracture with volar displacement

practice strengthens and expands cortical representation of the are being used (desensitization; sensory re-education)

Cells that 'fire' together will 'wire' together

flexor carpi radialis tendinopathy

- pain with resisted wrist flexion combined with RD - neutral wrist splinting (volar wrist cock-up); rest from aggravating activities and activity modification

and commonly a neuroma forms over the proximal stump

in extreme cases of neurotmesis, complete transection occurs, and ...

AIN syndrome (anterior interosseus nerve)

- entrapment of motor branch - clinical picture: non-specific, deep aching pain in proximal forearm that increases with activity. no sensory involvement but loss of FPL and FDP (to index and middle) - clinical test; inability to make the "OK" sign; + Ballentine's sign

open and endoscopic releases

2 types of CTS operative treatment

- resistive exercises per MD

8-12 weeks metacarpal frx

- neutral - sustained and repetitive - flexed - vibration - PAIN

CTS interventions; EDUCATION: - keep wrist in _____ during ADLS - avoid _____ and ____ gripping and pinching with your wrist flexed (activity modification) - avoid _____ wrist while sleeping (use orthosis at night) - avoid _____ (power tools, vacuums, driving) or recommend anti- _______ gloves - ergonomic education for all tasks - ______ MANAGMENT

- carpal tunnel syndrome - scar care (24-48 hours after suture removal) - pain management (pillar pain) - mobilization (A/PROM of digits and thumb; 10 reps/hour; tendon glides) - orthotic management (as indicated by MD) - strengthening at 8 weeks

CTS operative treatment

Posterior Interossesous Nerve Palsy

PIN Palsy stands for

myoplasticity

adaptive changes within a muscle in response to changes in neuromuscular activity level and to prolonged positioning

dart throwing motion

DTM: early controlled DTM patterns improve ROM in a safe manner; DTM orthosis

Distal humerus fractures make up for ___% of elbow fracture incidence among adults, but incidence increases with age

- tendon glides - blocking - active ROM - Passive ROM - wrist tenodesis - ADL retraining

Dupuytren's Disease post up exercises

between 25-50

RA usually begins around what age

ROM and edema management

educate your client on the precautions and importance of the home program for ________ &_________

- semi structured - provides information that rates the impact on volition, habituation, and perceptions of the environment on psychosocial readiness for the worker role or return to work - used to generate goals and assess outcomes or changes in psychosocial readiness for work

WRI-- Worker Role Interview

- sympathetic- sweating (if sweating is absent, this suggests complete peripheral nerve injury - trophic changes- nail changes, abnormal hair growth, cold intolerance, soft tissue atrophy in fingertips (pencil pointing) - O'Rianin wrinkle test: denervated skin does not wrinkle after hand is placed in water for 30 minutes

autonomic function assessment measures

comfort

avoid positions of

neutral wrist orthosis

orthotic management for CTS

- initially: immobilization (radial or ulnar gutter orthosis) - move uninvolved joints - edema management - ADL retraining

0-3 weeks of metacarpal fractures

flexor carpi ulnaris tendinopathy

- FCU does not have a sheath - pain with resisted wrist flexion with UD & ABD of SF - neutral wrist splinting (ulnar gutter); rest from aggravating activities and activity modification

Dupuytren's Disease

- benign connective tissue disorder affecting the palmar fascia in the hand - progressive thickening can lead to flexion contracture of the MCP and PIP joints - Higher prevalence in men of northern european descent - related to DM, alcoholism, hand trauma, HIV, and medications that treat epilepsy

on and off throughout the day and NOT at night because they are not tolerated and can cause ULNAR neuritis

when are flexion orthoses worn and why

endoneurium

inner membrane (basement) that insulates nerve fibers

osteoarthritis

is the most common form of arthritis- associated with defective articular cartilage and changed in underlying body (wear and tear disease)

- palmar ligaments - dorsal ligaments - radial and ulnar collateral ligaments

ligamentous anatomy of the wrist includes

superficial radial sensory nerve palsy

which radial nerve injury is at the site of compression between ECRL and "BR tendons; sensory only

dorsal

with a boutonniere deformity, the damage occurs at the ______ surface

CRPS malunion soft-tissue injury (lig tears) tendon irritation/rupture nerve compression TFCC/ulnar sided wrist pain

wrist frx complications include

carpal tunnel syndrome

clinical picture: - pain in volar wrist and forearm - paresthesias radial 3 & 1/2 digits-- mostly night symptoms - decrease FM coordination; due to thenar muscle weakness - advanced cases have thenar wasting; -more common in women

- Surgical: release of contracture - non surgical: in clinic; superficial heat (moist heat pack), deep heat (ultrasound- always with joint stretched to end range; preparatory method), manual techniques (hold- relax; contract- relax), ACTIVE motion and functional activities, HEP!!!

Interventions for elbow stiffness

low lesion of median nerve

clinical picture: (what type of injury) - thenar wasting - web space contracture - sensory loss to radial 3 & 1/2 digits - extrinsic digit flexors not involved (FDS/FDP) -- CAN make a fist!

- clients supervisor/coworker relationships - self-perceived identity as a worker - competence as a worker - influence of family support - environmental or organizational climate

Psychosocial factors assessed by OTs

soft tissue massage and mobilization; myofascial techniques, joint mobs; contract-relax or hold-relax, etc.

There is a wide variety of techniques for increasing elbow ROM including...

- skier's thumb - gamekeeper's thumb

Thumb UCL injuries

job analysis

a form of activity analysis that is specific to work tasks and includes the process of gathering and analyzing data related to job task requirements or demands, the environment, and human capacities needed to complete job functions

crush injury

distal phalanx frx is often a result of

flexion

elbow _______ contractures are more common

axons

many ______ make up a fascicle and there are thousands in each peripheral nerve

because of the pull of the triceps at insertion; thus requiring ORIF

many olecranon fractures are displaced because...

chauffers frx

radial styloid fx

intersection syndrome

structures involved: where APL and EPB intersect with ECRB and ECRL (involves 1st and 2nd dorsal wrist compartments) - provocative tests: similar to DeQ's but more proximal; pain/swelling 4cm proximal to wrist; pain with resisted wrist extension - orthotic consideration: same as DeQ's (thumb spica orthosis/brace) - FEINKLESTEINS TEST: positive if pain is more in FOREARM (4cm from wrist) vs snuff box

biceps and supinator

supinators include

functional enhancement

(reason for orthotics in p. nerve injury) to substitute for or enhance impaired function. When we stabilize an arthritic joint, as with the CMC joint of the thumb, we expect improved stability and strength at that joint and a decrease in joint pain during activity. When we develop a STATIC PROGRESSIVE ORTHOTIC that provides a slow and steady stretch to the tissues, we expect to see improved tissue extensibility and thus improved motion and function at that joint.

prevention

(reason for us of orthotics in p. nerve injury) to prevent motions that result in additional compression to the nerve, reducing potential inflammation that could lead to worsening of symptoms. To prevent contractures secondary to to muscle imbalance.

protection

(reason for use of orthotics in p. nerve injury) to diminish neural tension to create a healing environment. Used to abate acute symptoms or symptoms that are observed at rest and increased with activity

medial epicondylitis (aka golfer's elbow)

- degeneration of flexors attaching to medial epicondyle- often pronator teres and FCR - less common than lateral epicondylitis

1. protection 2. prevention 3. functional enhancement

3 reasons orthotics are used in the treatment of peripheral nerve injuries

- if stable, begin controlled AROM of wrist and MCPs

3-5 weeks metacarpal frx

"You'll get more benefit from doing your motion exercises slowly and fully than from doing lots of them quickly. It's best to do the exercises throughout the day. for example, do a set when you first get up in the morning, another at lunch, another when you get back from work, and the last one before bed. It is normal to feel tighter in the morning and looser at the end of the day. When your elbow feels stiff, breath deeply and relax as you slowly move your elbow as far as it will go. Forceful or quick motions will tend to make all your muscles contract and fight the movement you are trying to do,".

About the HEP for a stable elbow fracture (what to say)

thumb lies to the side of the palm as it is unable to abduct and oppose thus get web space contracture

Ape hand deformity

- when can the protective orthosis be discontinued? - when can passive ROM be initiated? - when can the use of static progressive orthosis be initiated (if necessary to increase motion) ? - when can resistive exercise be inititiated?

As the client progresses, you should as the MD

rolando fracture

Comminuted fracture of thumb base extending into carpometacarpal joint.

flexor digitorum profundus

FDP

flexor digitorum superficialis

FDS

flexor pollicis longus

FPL

- pronator syndrome- 4 sites of compression - anterior interosseous syndrome-- deep motor branch (AIN) compression

Median nerve injury sites HIGH

their uninvolved hand

Motor exercise tips: instruct your client to support the involved UE with _____ while performing gentle motion exercises to increase comfort and control

Neurotmesis

Nerve trunk discontinuity: most severe grade of injury to a peripheral nerve. all components are damaged and irreversible. all motor and sensory loss is permanently impaired.

- observation: cast fitting, skin color, edema - ROM of uninvolved joints (I.e. shoulder, elbow, digits) - sensation - circulation: Allen's test - edema - ADL: DASH, QuickDASH, FIM

OT Screening and Assessments ACUTE PHASE (1-6 weeks) WRIST FRACTURE

low referral rate to OT during this phase - education: HEP, pin care as indicated - edema management - AROM exercises: tendon gliding for digits; proximal shoulder and elbow ROM - Activity Modification - Custom orthosis as indicated

OT interventions ACUTE PHASE (1-6 weeks) WRIST FRACTURE

- orthosis- forearm based thumb spica with IP free to prevent painful motions (put in brace if inflamed- red, hot, swollen)

OT interventions for DeQuarvain's Disease (orthosis)

- sensory re-education- protective and discriminative - desensitization - pain management - modalities - nerve gliding/sliding (use cautiously)

Other OT interventions for nerve injuries include

- distal ulna fractures- associated with ulnar side wrist pain - carpal fractures: - scaphoid frx - lunate frx

Other wrist fractures

placed in orthosis in intrinsic plus position x 3-4 weeks

P-1 proximal phalangeal fractures: minimally displaces fractures are treated by

buddy taping to adjacent digit x 4 weeks

P-1 proximal phalangeal fractures: simple, non displaced fractures are treated with

- static wrist ext orthosis with 30 degrees wrist ext to protect the repair; MP joints in 10 degrees flexion; thumb in RA and extension - at 3 week; switch to wrist cock-up orthosis or dynamic extension assist orthosis; continue wear until functional wrist extension returns; A/AAROM are initiated

Radial nerve repair at the elbow and forearm (varies per MD)

tendon glides; lumbrical stretches

What are CTS interventions?

posterior and positioned in a 90 degree elbow flexion with forearm in neutral and the wrist FREE - instruct pt. to remove SEVERAL times a day for exercises

When used for protection (during healing phase)- most custom elbow orthoses are _________ and positioned in a ___________

"While receiving hot pack over the R elbow, pt. participated in therapeutic education regarding......

You cannot bill for hot and cold packs-- instead you should say what?

20%

____% of all fractures involve the hand

the ability to passively extend PIP

______ is an indicator for nonoperative treatment with PIP immobilization orthosis

Guyon's canal is

__________ is the ulnar tunnel

triceps muscles

after an elbow injury, pts. have trouble recruiting and firing the ________ (may be due to hyper-activity of these muscles) - therefore, work on recruitment supine at shoulder at 90 degrees to diminish the pull of gravity on biceps

micro breaks

after bouts of excessive activity (typing) take a _________ (less than 2 min)

long arm orthosis (90 degrees of elbow flexion)

after cubital tunnel release, what type of orthosis?

6-8 weeks

after cubital tunnel release; work on scar management and after _______ wk/s begin working on strengthening

die-punch frx

articular frx resulting in a depressed lunate facet

- place and hold exercises - isotonic exercises (short, frequent sessions) - muscle retraining

as muscle recovery returns....

dependent on nerve fiber regeneration: RATE OF REGENERATION ranges from 1.5 to 3 mm per day (without complications)

axonotmesis (crush injury): more severe with degeneration distal to the injury; recovery is dependent on.....

crushed base injury and not a laceration

axonotmesis is typically caused by a

osteopenia or osteoporosis; either condition may be exacerbated during the postoperative immobilization period

be cautious with initial loading of nearby bone and joints once strengthening is permitted if your client has a history of

- elbow joint (hinge) does not tolerate disruption of articular surfaces - the elbow joint capsule is thin and suseptible to injury and scarring/adhesions (especially anterior) - brachialis muscle can also adhere to the anterior joint capsule - muscle guarding in elbow flexion leads to soft tissue shortening- biceps muscle is prone to adaptive shortening (posturing tends to be 70-80 degrees of flexion) - HO- heterotopic ossification

causes of elbow stiffness include

cubital tunnel syndrome causes

causes: external compression (leaning on elbow); occupational activities that require repetitive elbow flexion; elbow fractures

pronator syndrome

compression of median nerve in 4 typical sites. -clinical picture: diffuse pain medial forearm with dysesthesia in radial 3 & 1/2 digits

pronator syndrome conservative managment

conservative management for ____________ includes fabricating an orthosis to rest the tissues with instructions to use the orthotic as much as possible over the initial 2 to 3 weeks, removing it for hygiene, and gentle AROM and nerve gliding only

demyelination

damage to myelin that results in slowing of loss of nerve impulse conduction

lateral epicondylitis (Tennis Elbow)

degeneration of extensor tendons at lateral epicondyle insertion caused by repetitive stress, typically ECRB most involved

fibrotic adipose tissue

denervated muscle is replaced by _____

wartenburg's syndrome

dorsal radial sensory nerve injury = (AKA)

triceps

elbow extensors include

biceps, brachialis, and brachioradialis

elbow flexors include

ulnohumeral, radiohumeral, and proximal radiulnar

elbow joint consists of

- body mechanics and posture- want neutral positioning - manual handling - repetitive and static tasks - anthropometrics : proportion of body to equipment - environmental considerations- noise, vibration, lighting, contact stress

ergonomic considerations

tendinosis

even tiny movements such as clicking a mouse, when done repeatedly, can lead to

type 1 collagen fibers

healthy tendons have what kind of collagen fibers arranged neatly/parallel?

1-2x/day with 10 reps using 1 lb weight or light theraband; slowly increase reps to 30 reps as this is an endurance exercise; can increase to 2 lbs when this is easy

how often should eccentric strengthening be done?

- active rather than passive ex. sliding in elbow flex/ext patterns across table top - bilateral activities/occupations

in the clinic what should we do for a patient with a non operative elbow fracture? - Focus on _______ exercises and activities rather than _______

- start with assisted AROM if patient is apprehensive (light dowel, move in gravity decreased positions) - gentle PROM (if cleared)

in the clinic what should we do for a patient with a non operative elbow fracture? (ROM)

manual edema mobilization

in the clinic what should we do for a patient with a non operative elbow fracture? (for edema)

- e-stim for pain (IFC), hot/cold packs AS PREPARATORY METHODS

in the clinic what should we do for a patient with a non operative elbow fracture? (for pain)

trigger finger

inability of the finger to perform smooth digit flexion or extension due to inflammatory pathology on the tendon or tendon sheath - also called digital stenosing tenosynovitis

interventions: Pt. education; volar FA-based wrist extension orthosis with thumb extension (no strap near radial styloid)

interventions for dorsal radial sensory nerve/ wartenburg's syndrome

- rehab is beyond entry-level knowledge - consider stages of tissue healing for decisions regarding ROM and progression - in general, will include; edema and pain control, controlled & protected ROM (based on healing stage)- DART THROWING

interventions for wrist instabilities

rheumatoid arthritis

is a chronic, system, inflammatory and autoimmune disorder. Involves synovial tissue

tendonitis

is an inflammation of a tendon that typically occurs after an acute episode of overload of the musculotendinous unit, it usually heals within several days but up to 6 weeks - goals of treatment are aimed at reducing inflammation

arthritis

is the most prevalent and disabling chronic condition worldwide in older adults

neuropathy

is the term used to describe pathological conditions of the peripheral nerve

to provide the most appropriate treatment

it is important for therapists and healthcare providers to distinguish whether an injury is tendonitis or tendinosis

wrist cock-up orthosis

keeps wrist in a functional position. It is less bulky and noticeable than a dynamic orthosis. often more comfortable. you can use intrinsics to extend the IP joints of digits (but not MCPs as ED muscle is out)

60-70 degrees

metacarpal fractures: orthotic frabrication: _____ degrees of MP flexion, IP neutral/straight (intrinsic plus position)

if displaced, intrinsic + position x 3 weeks followed by AROM

middle phalanx fracture treatment

digit based gutter orthosis. Gentle P/AROM with stabilization of fracture at DIP and PIP joint

middle phalanx frx, if no displacement,

neurapraxia

mildest form of injury. conduction block usually due to myelin dysfunction. axonal continuity conserved. nerve conduction is preserved proximal and distal to lesion. nerve fibers are not damaged. recovery will occur within 4/6 weeks. the effects of this class of injury can typically last from hours to several weeks

heterotopic ossification

misplaced formation of bone; bone in non-osseous tissues

scaphoid fracture

most common carpal bone fracture in adults; take longer time to heal due to poor vascularity (especially proximally; can take 24 weeks)

age related

nerve regeneration outcome is

minutes or weeks

neurapraxia (localized compression) can resolve in

complex regional pain syndrome (CRPS)

neuropathic pain; vasomotor issues; leads to extreme stiffness, loss of fx, and significant disability

must have surgical fixation for chance of regeneration

neurotmesis: nerve is cut/transected; must have...

orthosis with MCP in extension and PIPs free x 3 weeks - if no improvement, corticosteroid injection or surgery is recommended

non operative treatment for trigger finger

- education: joint protection principles - modalities for pain - exercise - orthotic intervention

nonoperative treatment/ interventions for arthritis

- distal radius - ulna - 8 carpal bones - joint capsule - several ligaments - TFCC (triangular fibrocartilage complex)

normal anatomy of the wrist is compromised of

30-45 degrees of elbow flexion 70

normal rest position of UE is _______. This flexion increases with injury and "guarding" occurs at ~ _____ degrees

- day: functional, just thumb really, can grab pencil - night: thumb; stretching out web space

orthotic management for low lesion of median nerve

gentle and longterm

orthotics should be designed to be a ________, _______ stretch

- traction or stretch injury - internal pressure causing chronic compression or entrapment (tumor or scar tissue) - external pressure (crutches or a cast) - avulsion or laceration - chemical or electrical burns/radiation - alcoholism - diabetes mellitus - genetic (not common, i.e. charcot-marie-tooth)

peripheral nerve injury causes include

- education - training functional activities - orthosis &/or counterforce brace - pain management - regain tendon length

phase 1 interventions for Lat Epicondylitis

pain is mild and light functional activities are no longer painful; interventions are aimed at restoring flexibility, strength, and endurance

phase 2 of interventions for lateral epicondylitis means

Cosmesis

preservation, restoration, or enhancement of physical appearance

- medical record review - client interview - pain ratings - musculoskeletal screenings- baseline ROM and strength abilities/limitations - physical demands - client's abilities

process of functional capacity evaluation

pronator teres and pronator quadratus

pronators include

elbow flexion contracture (loss of elbow extension)

radial head fractures often result in

mostly pain and no motor involvement (unless severe)

radial tunnel is mostly....

- keep the MCP in slight flexion (20 degrees) - wrist and IP joints are free - think material for comfort is best

purpose of CMC OA orthosis

- injury to TFCC (triangular FibroCartilage Complex) - peripheral nerve injuries - ligament sprain or tear - aggravation of -pre-existing OA

soft tissue injuries commonly associated with wrist fractures are

- supination with elbow extended and wrist passively moved in extension to lengthen the flexor pronator tendon group

stretches for medial epicondylitis

palmar ligaments

strongest and main stabilizers of radiocarpal joints

perineurium

surrounds each nerve fascicle (mostly elastin)

lunate fracture

susceptible to avascular necrosis due to its limited blood supply at the palmer pole; thus associated with KIENBOCK'S DISEASE

PIP hyperextension and DIP flexion

swan neck deformity is characterized by

carpal tunnel syndrome

the causes of ________: - related to increase in pressure in the carpal tunnel from forceful/repetitive motions (wrist), pregnancy, irritation (vibration), compression (sleeping with wrists flexed); associated with diabetes, arthritis, hypothyroidism

the WRI assess psychosocial factors that influence work performance while the WEIS assesses workplace condition that impact the worker

the difference between the WRI and WEIS

carpal bones

the dorsal floor of the carpal tunnel is

ganglian cyst

the most common cause of compression at Guyon's canal (ulnar nerve palsy) is from a _________ but can also occur from pressure from the fracture or irritation by continuous pressure (pushing a cart, cyclists, or pressure from musical instrument)

carpal tunnel: 1-10% of the population

the most common nerve entrapment in the UE

epineurium

the outer, strong sheath that functions to surround and cushion the nerve fascicles

pronator teres

the primary pronator is

biceps

the primary supinator is

ECU tendinopathy

the second most common type of tendinopathy of the wrist (after DeQuervain's) - typically from overuse injury; common in wrist intensive sports- tennis, rowing, golf and baseball - SX: ulnar sided wrist pain (6th dorsal compartment) - Test: resisted extension with UD - RX: rest, orthotic intervention, activity modification, occasionally injection or surgery

Steners lesion

the ulnar collateral ligament is displaced with interposition of the adductor aponeurosis. Surgery is required for this type of injury, because interposition of the adductor aponeurosis prevents healing

cubital tunnel

the ulnar nerve passes through what

1 day to 1 week after first visit - review HEP - reassess wound, pain, edema, sensation, function and orthosis fit - adjust orthosis - reinforce previous education and timeline for resuming more strenuous activities (4-6 weeks post)

therapy guidelines following contracture release include (2nd visit)

- every 2 hours, 2-5 reps of 20-30 second holds

typical stretching HEP for lateral epicondylitis

goal is typically 1 hour on, 1 hour off during the day but may have to start with 15-30 minutes and progress to hour wear time - total wear time= 4 hours a day

typical wearing goal of flexion orthosis

Guyon's canal

ulnar nerve palsy is the entrapment of

LOW compression

ulnar nerve policy is a ________ compression

FIXATION: -ORIF, -external fixator

unstable fractures require

pain and sensory involvement only (no motor)

wartenberg's syndrome (DRSN) is mostly...

radial head, olecranon, and distal humerus

what are the three types of elbow fractures?

typically FOOSH with pronation or direct blow to the elbow

what are the typical causes of a radial head fracture

functional assessment

what assessment is considered the most important

physical demands cognitive demands perceptual demands psychological demands social demands environmental demands

what demands does one have for job performance?

clinical picture of trigger finger

- digit "snaps" or catches during AROM. can occur in ANY digit - catches in the A1 pulley - severe cases- the finger locks into a flexed position and client can't open without prying it open

DeQuervain's Disease / Tenosynovitis (text thumb)

- inflammation or tendinosis of the first dorsal compartment of the dorsal wrist involving APL and EPB

osteoarthritis pathology

- osteophytes (bone spurs) - inflammation and pain - nodules (Bouchard's at PIP, Heberden's at DIP) - deformities- mallet finger, boutonniere - cepitus (popping noise)

clinical picture of medial epicondylitis

- point tenderness at medial epicondyle - pain with forceful pronation and resisted wrist flexion - pain with resisted elbow extension with supination and wrist extension

clinical picture of lateral epicondylitis aka tennis elbow

- point tenderness/pain at lateral epicondyle - pain with gripping, resisted wrist extension, supination, digital extension, and radial deviation - tightness of extrinsic extensors (dorsal forearm) - nighttime aching and morning stiffness

PIP joint area- zone III of extensor tendon

central slip injury is typically located at the

neurotmesis

characterized by not only loss of nerve conduction, but damage to surrounding nerve trunk connective tissue

volar roof

the ______ of the carpal tunnel is the transverse carpal ligament (AKA flexor retinaculum)

clinical picture of dupuytrens disease

- presence of nodules or cords in the palm - typically on the ulnar side but can involve any digit - the cords/nodules may appear slowly and progress slowly (decades) OR they may appear rapidly and progress rapidly (months) - the more aggressive forms have involvement in other sites including plantar surface of feet (Ledderhouse disease) and penis (Peyronie disease)

wrist instability

- the wrist is compromised of several articulations and ligamentous structures - carpal dislocations and instabilities are common injuries- mostly from trauma - carpal instability is dislocation between distal carpal row over carpal row

- begin gentle PROM

6-7 weeks metacarpal frx

- compression of motor branch of PIN between 2 heads of supinator in ARCADE OF FROHSE - weakness of ulnar wrist extension (ECU), digit extension (ED), and thumb ext/abd

clinical picture of PIN palsy:

cubital tunnel syndrom clinical picture

clinical picture: - pain in the medial aspect of the elbow and hand - paresthesia in the ring and middle finger - severe cases: muscle wasting (atrophy) of ulnar intrinsics and "clawing"

jersey finger, mallet, and often associated with soft tissue trauma

complications of distal phalanx frx

- intrinsic tightness - extrinsic tightness - joint capsule tightness - stiffness of uninvolved digits - phalangeal fractures

complications of metacarpal fractures

HIGH ulnar nerve compression

cubital tunnel syndrome is located where (high or low)

removable orthosis or sling

depending on the severity of the fracture, a __________ or ________ may be used in between exercises

regeneration may occur over the timescale of weeks to years

depending on the severity of the injury,

colles' frx

distal radial fracture with dorsal displacement

-mechanism of injury - social and medical history - modified COPM/DASH is helpful

evaluation interview should include

lifting a child under his/her arms, wringing out wash clothes, opening/closing jar lids, using scissors, typing, playing piano, knitting/needle point, or racquet sports - women are 4x more likely to have this than men

examples of what could cause DeQuervain's Disease

- avoid painful AROM and PROM (work in pts. comfort level) - wrist flexion/extension - gentle digit flexion/extension - if thumb adduction contracture, web space stretches

exercise for arthritis

extension

flexion contracture lacks

make sure you are immobilizing the fewest joints and soft tissue possible without compromising the repair to avoid the development of stiff and fibrotic joints and soft tissue in adjacent areas

following nerve laceration, when immobilization is in place to protect the nerve repair site, it is important to

mainly at night; Can wear during the day if necessary to control excessive wrist motions if symptomatic

for CTS, neutral wrist orthosis should be worn when?

Home program

for a non-operative treatment of a stable elbow fracture, you need to set up a _________

for cubital tunnel release, early mobilization after _____ week/s of post op (submuscular may be later?

clinical picture of ulnar nerve palsy

Clinical Picture: - sensory loss and motor loss of ulnar innervated instrinsic muscles

DIP extension orthosis at least 2-3 weeks

for non-displaced distal phalanx fracture

orthotic intervention for wrist drop

for non-dominant (and some dominant cases when cosmesis is important), a wrist cock up orthosis is reasonable

forearm-based orthosis with the hand included

for pronator syndrome, if compression is at the fibrous arch of the heads of the FDS (resistance to FDS of the long finger aggravates symptoms), consider fabricating a

long arm orthosis with the forearm in neutral, the wrist in neutral, and the elbow in about 90 degrees of flexion

if compression is at the pronator teres, pain/paresthesia will be aggravated by resistance to forearm pronation and will be enhanced as the elbow is extended. In this case, fabricate a

carpal tunnel

a passageway that runs from the forearm through the wrist

orthosis in extension until pins removed then begin gentle ROM

if pinned distal phalanx fracture,

connective tissue/collagen

tendons are mostly made up of

Manual Edema Mobilization (MEM)

a technique used for decreasing edema in the orthopedic population. MEM differs from manual lymph drainage, as it is used in an acute condition to decrease edema in an intact lymph system

stable factures

are when the bone fragments are non-displaced and aligned. These require no medical intervention to restore normal bony configuration and are often splinted/casted

- reflect key concepts from MOHO - consider a workers motivation (volition), everyday patterns (habituation), capacity to work (performance), and environmental impact

the WRI and WEIS

- pain - client history - sensory: semmes-weinstein monofilament; 2 point discrimination; localization to touch; moberg pick-up test; - special provocative tests; median nerve compression (Durkan's), Phalen's test, Tinel's sign; Berger's test: to identify lumbrical muscle contributions to CTS - coordination: 9 hole peg test; functional assessment - ROM - strength: MMT, grip, pinch

assessment of carpal tunnel syndrome

clinical tests - Cozen's test: place client's forearm in pronation, full elbow extension, and resisted wrist extension - Mill's test: place the client's forearm in pronation, wrist in flexed position, and the elbow is then into ext slowly Additional tests: - paint history and scales -A/PROM - MMT (include proximal; RC and scap) - grip strength test (strengthen greater when elbow flexed is another sign) - posture assessment

Eval of lateral epicondylitis

- AROM - PROM if permitted - Pain- numeric pain scale - Sensibility (ESPECIALLY ULNAR NERVE) - edema (circumferential) - functional assessment: DASH/QuickDASH, PREE, etc. - strength NOT ASSESSED until cleared by MD (grip and MMT)

Evaluation tips (pg 207): Assess the following

functional capacity evaluation

FCE: - clinical evaluation to determine an individuals capacity to perform work activities related to his/her participation in employment

DIP flexion exercises- AROM x 10 hourly and PROM - if PIP can be passively corrected, non-operative immobilization is indicated. MP and DIP are free. ONLY the PIP is immobilized in full extension. HEP teach to flex DIP joint x 10 hourly to prevent ORL tightness

HEP for Boutenniere Deformity

elbow fracture

HO is a complication following ________- especially high energy mechanisms of injury, open fractures, and non-operatively managed fractures

- strengthening; start isometric: forearm, wrist, and digits; start low resistance and increase as tolerated - education: HEP for strength - IADLs/ Functional activities: continue to increase lifting, carrying, object manipulation, etc.

OT interventions STRENGTHENING phase (8-10 weeks) WRIST FRX

- education; HEP, edema mgmt, scar mgmt - AROM: focus on tenodesis to isolate wrist extensors (extend wrist with digits flexed); tendon glides for digits; continue proximal AROM - stretching/PROM (as approved by MD): prayer stretch - therapeutic activities: grasp release; dexterity activities - edema mgmt: MEM - pain mgmt: Modalities - custom orthosis as indicated support soft tissue and encourage wrist extension (worn in public, during heavy activities, and at night) - scar mgmt/desensitization: scar mobility/massage, pressure garments, modalities

OT interventions SUBACUTE (mobilization) phase (6 weeks and beyond) WRIST FRX

OT interventions for PIN and RT; Radial tunnel

OT interventions for ______ & _______ - orthosis-- that takes tension off nerve: long arm orthosis with elbow in flexion, forearm in supination, and wrist in extension. Not well tolerated - Patient education: rest, activity modification, gentle stretching and ROM-- emphasis on supination, and nerve gliding, and anti-inflammatory medication - for _______ - avoid compression sleeves

- night orthosis with elbow in limited flexion or pillow/towel orthosis - day: elbow pad - pain management - activity/work modification

OT interventions for cubital tunnel syndrome

- paraffin -fluidotherapy - hot packs

PAMS for arthrits

common

pain at end ranges are _________

- monitor rom; if trouble regaining flexion, introduce composite taping or dynamic orthosis/flexion glove - re-eval orthosis - review timelines for resuming activities - watch for "flares" between 2-4 weeks (not common); if occurs- refer back to MD

therapy guidelines following contracture release include (3) (2-3 weeks after surgery or manipulation)

4-6 weeks post - perform final reassessment - finalize the HEP and orthosis needs - d/c with a well-established HEP

therapy guidelines following contracture release include (5) (final)

1st therapy visit (1-2 days after non surgical manipulation, 1 week after surgical) - assessment of wound, edema, ROM, pain, sensation and function - education: wound care, edema management, light ROM exercises focused on digit EXT and intrinsic stretching - fabricate custom hand based night ext. orthosis - instruct client to resume light ADLs- even with effected hand - therapy guidelines following contracture release

therapy guidelines following contracture release include (first visit)

orthosis management for CLAWING

this orthosis works by preventing overstretching of the lumbricals and the interossei muscles of the ring and small fingers (prevents MCP hyperextension) - also redistributes the power to the extensor digitorum to allow IP extension. The ED is innervated by the uninjured radial nerve.

Elbow flexion test

this provocative maneuver is designed to reproduce the symptoms of ulnar nerve compression. The elbow is flexed fully, and the wrist is held in neutral for up to 5 minutes. A positive test is the reproduction of paresthesia and pain symptoms

bennett fracture

this type of metacarpal fracture involved the abductor pollicus longus tendon

- hand based thumb spica with IP free - RCL injuries (less common) treated the same with orthosis designed to support the radial side of thumb

thumb UCL injury interventions

demyelination and injury to nerve itself

what happens when a peripheral nerve is injured?

radial head fracture

what is the most common elbow fracture in adults

viscoelastic structures with unique mechanical properties that allow muscles to transmit forces to create motion at joints

tendons are

poorly

tendons are _____ vascularized

the nerve fibers have a pathway for regrowth back to the target structures they innervate (skin, muscles, etc)

IF the endoneurial tube remains intact

- gel pads to decrease soreness - functional strengthening vs putty - desensitization for hypersensitive scar - massage and modalities for pain

Interventions for pillar pain

- respect pain - balance rest and activity - exercise in a pain free range - avoid positions of deformity - reduce the effort and force - use larger/stronger joints

Joint protection principles

carpal tunnel syndrome

Median nerve injury sites LOW

the first week of injury or post surgery

Most elbow frx (stable) begin gentle AROM by.. __________ .. to reduce contractures/elbow stiffness, get blood flowing, loosen up the muscles, prevent further atrophy, reduce swelling

supine

Motor exercise tips: - Unless contraindicated, it is often most comfortable for your client to begin elbow flexion and extension in _______ with the upper arm supported on a pillow or folded towel alongside their torso. Progress to other gravity-assisted positions, such as elbow extension while seated and elbow flexion in supine with the shoulder flexed at 90 degrees.

- grip and pinch testing - MMT - Begin when MD permits; typically 8-10 weeks post Frx

OT screening and assessment STRENGTHENING phase (8-10 weeks) WRIST FRX

- observation; skin, pain, posture - ROM: wrist AROM and PROM ; proximal/distal as appropriate - Sensory: especially median nerve distribution - edema - pain - scar: adherence and sensitivity - ADL: DASH, PRWE (pt. rated wrist eval)

OT screening and assessment SUBACUTE (mobilization) phase (6 weeks and beyond) WRIST FRX - begin after cast/orthosis removal per MD (6-12 wks); pt. wears removable orthosis post-cast for 2-4 weeks

inflammatory phase

Phase 1 of interventions for lateral epicondylitis does not mean _____________, it means the patient is in pain at rest and pain increases with movement

- currently, not strong evidence supports the need for strengthening, however, strengthening may be beneficial - eccentric strengthening of the forearm extensors loads the tendon in a lengthening position and can be done so without causing pain - concentric strengthening tends to be painful and contradicts instructions to avoid palm down during lifting, thus should be avoided

Phase 2 strengthening for lateral epicondylitis

if client has RTS, do not use elbow clasp splints or straps, and be cautious with compression sleeves for the elbow. Elbow clasp splints can further compress the radial nerve at the radial tunnel

Precautions and concerns for radial tunnel syndrome,,,

clinical picture of low radial nerve palsy/injury

clinical picture of _______: at the forearm level, the radial nerve divides into the posterior interosseous nerve (PIN) and a superficial sensory branch (dorsal radial sensory nerve DRSN)

medial nerve and 9 extrinsic flexor tendons: - 4 x FDS - 4 x FDP - 1 x FPL

The carpal tunnel is a narrow channel that contains ...

neck and wrist flexion

lack of flexion compensated some by _________ and ________, but it is more functionally limiting

- semi-structured - interview works with client to assess environmental impact on participation in the worker role & to identify needed accommodations - used to gather information on the worker's perception and experience of work settings

WEIS-- work environment impact scale

worker role interview & work environment impact scale

WRI and WEIS stand for what?

"you may be surprised to start motion exercise so soon after breaking a bone, but elbow stiffness is the most common problem after an injury like yours. Your fracture is stable enough now to safely do the gentle exercises that I am going to teach you. They will help you maintain and improve your elbow motion."

What can you say to someone following a stable elbow fracture who is hesitant to begin movement?

- recommending work accommodations or modifications to work practices - making job tasks safer - preventing injuries - promoting health and wellness - supporting workers return to work after an injury - providing education and training about the risk factors for musculoskeletal or psychosocial injuries to prevent workplace injuries

What is OTs role to help facilitate work performance

HIGH median nerve laceration

What type of laceration is this: - occurs in forearm typically from knife or glass laceration - clinical picture: sensory and motor loss of FA flexors and hand intrinsics - results in ape hand with loss of ability to pull thumb away from palm. Thus loss of precision pinch, thenar opposition, FDS and radial FDP & lumbricals - weak pronation; sensory loss radial 3 & 1/2 digits - can make a weak/half fist from ulnar 1/2 of FDP

radial tunnel

_______ clinical picture: - compression of radial nerve in proximal forearm - dull aching or burning PAIN along the lateral forearm musculature - causes: compression at the fibrous edge of supinator muscle from external force from pressure (counterforce brace or repetitive supination) - symptoms often confused with lateral epicondylitis but they can coexist. Test: wrist in flexion, resist middle finger extension. Positive if increase in symptoms of pain (or aching/burning) lateral forearm.

middle phalanx

_______ is the least fractured phalanx

distal phalangeal fractures (p-3), followed by proximal phalanx (P-1)

__________ fractures are most common hand fractures, followed by _________

Dorsal Radial sensory nerve/ Wartenburg's syndrome

__________________ (which injury/syndrome): - causes: repetitive pronation- supination results in "scissoring" of BR and ECRL tendons-- compressing the nerve or compression (i.e. wrist watch) - clinical picture: pain and dysesthesia on dorsal radial forearm extending to thumb and index finger - interventions: Pt. education; volar FA-based wrist extension orthosis with thumb extension (no strap near radial styloid)

orthotic options for high radial nerve palsy

a wrist immobilization orthosis with the wrist in a functional position of 30-degrees extension is an option. An advantage of using this type of orthotic is cosmesis. A wrist cock-up orthosis is less conspicuous than a dynamic orthosis. It is also more comfortable without the problems that a bulky outrigger presents, especially when sleeping. furthermore, this orthosis is less costly and easy to put on and take off. This is a reasonable daytime choice when the nerve injury is on the nondominant side, and/or when cosmesis is of greater importance than function for clients

unstable fractures

are those displaced with motion or spontaneously. These require surgical fixation for realignment and to ensure prevention of malunion

- the revised NIOSH lifting equation - rapid upper limb assessment (RULA) - quick exposure checklist - computer workstation eTool - NIOSH generic stress questionnaire - body picture pain diagram - observation-based posture assessment: review of current practice and recommendations for improvement

assessment tools for MSD (musculoskeletal disorder) Risk

Axonotmesis

axon discontinuity, axonal+ endoneurial disruption, perineurial rupture & fascicle disruption: a more severe grade of injury to a peripheral nerve. is reversible injury to damaged fibers. damage occurs to the axons with preservation to endoneurium. nerve can regenerate distal to the site of lesion by one millimeter per day. Myelin sheath still intact.

scarring

because of degeneration of the tendon, ______ results in tendon length insufficiency

High Radial Nerve Palsy

clinical picture of ______? : - mid-humeral compression or shaft frx - triceps is spared (elbow ext intact) - supinator and brachioradialis involved but supination and elbow flx spared) - wrist, digit MCP extensors and thumb ext/abd paralyzed > wrist drop)

Disruption of the central slip of the extensor tendon characterized by PIP flexion and DIP hyperextension. Caused the lateral bands to slip VOLARLY

causes of Boutonniere Deformity

causes: repetitive pronation- supination results in "scissoring" of BR and ECRL tendons-- compressing the nerve or compression (i.e. wrist watch)

causes of dorsal radial sensory nerve/ wartenburg's syndrome

injury primarily to PIP joint to the volar plate/capsule or injury to the transverse retinacular ligaments causing lateral bands to be DORSALLY displaced

causes of swan neck deformity

excessive gripping

causes of trigger finger

Heberden's nodes

clients with OA at the DIP joints often have enlargements called

FOOSH or high velocity injuries in younger individuals (MVA/sports)

common causes of distal humerus fractures

- Colles' frx - smith's frx - bartons frx - chauffers frx - salter-harris frx - die-punch frx

common distal radius patterns

- boxer's frx - bennet frx - rolando frx

common metacarpal fractures

- scapholunate ligament tears - luno- triquetral instability

common types of wrist instabilities

Finklestein's test- instruct client to flex the thumb into the palm of hand, then practitioner ulnarly deviates the wrist= pain - pain history and scales - A/PROM - proximal testing- supination/pronation, elbow flex/ex, shoulder - MMT- include proximal- RC and Scap - grip/pinch (note any paint) - posture assessment - functional assessment/ occupational profile (interview)

evaluation for DeQuarvain's Disease

- pain - arom- prom can be injurious if joints are unstable - strength (be cautious) - joint stability - palpation - ADL- home, work, leisure (COPM and AIMS)

evaluation of arthritis should include

eye breaks

every 20 min, look away 20 ft from screen for 20 seconds (20-20-20 rule)

rest break

every 30-60 min, take a brief rest break- stand, move, do something else away from the desk (lap around the office)

stretch breaks

every couple of hours, stretch briefly in the opposite direction of work position

multiple mononeuropathy

ex: injury to median and ulnar nerve

an anterior long arm orthosis with the forearm in neutral rotation, using the lightest thermoplastic material option possible

if symptoms are aggravated by resisted flexion of elbow with forearm in full supination, compression is likely at the lacertus fibrosus, and the orthosis should limit elbow flexion and forearm supination. Consider fabricating

regeneration and restoration of sensory or motor ability may return

if the neuronal tubes are maintained in place

lengthened

in order to restore tendon dynamics, structures will need to be

tendinitis

inflammatory process characterized by heat, swelling, and pain

stabilize the IP joint of the THUMB and INDEX FINGER for prehension

interventions for AIN syndrome; orthotics to stabilize the ____ (joint) of the ____ & ________ for prehension

mononeuropathy

involves damage to a single nerve (ex: carpal tunnel syndrome)

tendinosis

is a degeneration of the tendons collagen in response to chronic overuse

luno-Triquetral instability

less common wrist instability; associated with ulnar-side injuries; VISI ( at carpals more than wrist) deformity

radial collateral, ulnar collateral, and annular

ligaments of the elbow joint include

- needle aponeurotomy release - collagenase injection - fasciotomy (release) - fasciectomy (remove) (most common, gold standard)

medical interventions fot Dupuytrens include

immature collagen fibers

microscopic view of tendinosis reveals what?

rheumatoid arthritis of the hand

most common AUTOIMMUNE inflammatory arthritis in adults - characterized by synovial inflammation; autoantibody production; cartilage and bone destruction that leads to deformity; systemic manifestations- caridovascular, psychosocial and skeletal - typically affects joints symmetrically and commonly includes the MP, PIP, thumb and wrist joints - early symptoms included morning stiffness, extreme fatigue and swelling of PIP joints

scapholunate ligament tears

most common wrist instability; visual gap on x-ray (+ Terry Thomas sign); DISI (at wrist) deformity- can lead to SLAC wrist

hot/cold packs, compression sleeves for edema (include edema glove if needed)

non-operative treatment, for pain and edema management a client should be educated on and use .....

- used to protect joints - reduce pain by statically holding the joint in place - decrease joint load demand during ADL hand use - prevent deforming forces - worn during the day during activity and only at night if indicated for pain reduction

orthoses for arthritis

- holds digits in extension - can be volar or dorsal (always hand based) - consider wound dressings - may be worn full time for 1-2 weeks post-op (depending on contracture and MD), then worn at night only for up to 3 months

orthosis for contracture release

neutral or slight flexion to take tension off the flexors - counterforce brace on FLEXORS

orthosis for medial epicondylitis: instead of wrist extension, wrist should be

anti swan neck orthosis (goes over PIP)

orthosis for swan neck deformity

- depends on what stage of OA, what joint's involved, client's preferences, and goal of orthosis (i.e. immobilization of a joint, stability of a joint, post-operative, etc.)

orthosis management for thumb CMC OA

edema, cold sensitivity, provocative testing

other assessment measures

-education - HEP for self stretches (what could become tight) - instruct on prognosis of nerve recovery-- can take up to 3-4 months with neuropraxic injuries - functional activities with orthosis on

other interventions for wrist drop include

document holders, lighting (no yellow light, reduce glare), proper lifting (lift from knees, not back)

other office recommendations

- which bone was fractured and what was the nature of the frx? ask for RADIOLOGY REPORT - were there any associated injuries? - was the frx treated surgically, and if so, how? Ask for the OPERATIVE NOTE - is the frx stable enough to begin active motion? - Are there any mvmt limitations or precautions? - What are the preferred type, position, and wearing schedule for the protective orthosis?

567 Test 3

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hi

HLT 145 test #2