Hand and Upper Extremity

Proximal fracture

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

Immobilization protocol

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 post operatively. This protocol is sometimes used with children to prevent rupture of the repair.

Anatomical landmarks and structures of flexor tendons

Anatomical landmarks and structures of flexor tendons: nutrition provided mainly by synovial diffusion; nerve supply is innervated by the medial, radial, and ulnar branches of the hand. Zones: (1) fingertip to center portion of middle phalanx, (2) center portion of middle phalanx to DPC, (3) DPC to transverse carpal ligament, (4) overlies the transverse carpal ligament, (5) extends beyond the level of the wrist.

Ankle splints

Ankle splints include antifoot drop splints to maintain 90 ankle dorsiflexion and AFOs.

Anterior interosseous syndrome

Anterior interosseous syndrome is compression to the anterior interosseous nerve. It results in a motor loss inolving the FDL, flexor profundus to the index finger, and pronator quadratus.

Antideformity resting hand splints

Antideformity resting hand splints (burn intrinsic plus) maintain the wrist at 30-40 extension, thumb at 45 palmar abduction, MCPs at 70-90 flexion, and PIPs and DIPs in full extension

Avulsion injuries

Avulsion injuries occur 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 and swan neck deformity as well.

Ball or cone antispasticity splints

Ball or cone antispasticity splints are ulnar or volar based and provide thumb palmar or radial abduction, a hard surface in contact with finger flexors, and serial casting for the wrist, elbow, knee, or ankle to decrease soft tissue contractures.

Bennet's fracture

Bennet's fracture is fracture of the first metacarpal base.

Blood supply to the arm

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

Carpal bones of the hand

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

CTD acute phase

CTD acute phase: reduction of inflammation and pain through splinting, ice, contrast baths, ultrasound phonophoresis, iontophoresis, high-voltage electric and interferential stimulation.

CTD return to work

CTD return to work: assessment of job site, tools used, and body positioning. Therapy using work simulator, weight well, elastic bands, putty, functional activities, and strengthening activities. FCE and work hardening also used.

CTD subacute phase

CTD 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.

Carpal fractures

Carpal fractures are fractures to the 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.

Claw deformity

Claw deformity is distal ulnar nerve compression or lesion at the wrist. Causes include ganglion, neuritis, arthritis, or carpal fractures at Guyon's canal. 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. 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 MCPs hyper extend and the IPs flex, hand arches are flattened, and pinch strength is lost.

Colles fracture

Colles fracture is complete fracture of the distal radius with dorsal displacement. This is the most common type of wrist fracture.

Complex regional pain syndrome

Complex regional pain syndrome: pain disproportionate to an injury that is either sympathetically maintained or independent of the sympathetic nervous system (traditionally called reflex sympathetic dystrophy). Type I: develops after a noxious event. Type II: develops after a nerve injury

Complications of flexor tendon injuries

Complications of flexor tendon injuries: nerve involvement usually laceration; edema; pain; muscle actions are affected by impairment in flexion and deviation of the wrist and digits.

Complications of fracture healing

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

Complications of wrist fractures

Complications of wrist fractures include: carpal tunnel syndrome which results in compression of the median nerve as it runs through the carpal tunnel; the primary and most severe complication of distal radius fracture is CRPS.

Cryotherapy

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

Cubital tunnel syndrome

Cubital tunnel syndrome is caused by proximal ulnar nerve compression at the elbow between the medial epicondyle and the olecranon process. This is the second most common nerve compression of the upper extremity after carpal tunnel. Causes include fracture or dislocation of the elbow, osteoarthritis, rheumatoid arthritis, diabetes, alcohol abuse, tourniquets, and assembly line work. Sensation is decreased in the little finger and ulnar half of the ring finger. Motor problems may include decreased grip and pinch strength because of weak interossei, adductor pollicus, and FCU muscles.

Cumulative trauma disorder

Cumulative trauma disorder (CTD): trauma to soft tissue caused by repeated force (aka overuse syndrome and repetitive strain injury); CTD indicates the mechanism of injury but is not a diagnosis. Diagnoses include tendinitis, nerve compression syndrome, myofascial pain, osteoarthritis or nerve root impingement, thoracic outlet syndrome, rotator cuff tear, bursitis, epicondylitis, cubital tunnel syndrome, carpal tunnel, and deQuervain syndrome.

Wound debridement

Debridement options include mechanical, enzymatic, sharp, and autolytic. Techniques should be chosen based on desired outcomes, phase of healing, and assessment of advantages vs disadvantages. Debridement of necrotic tissue can be achieved by mechanical, enzymatic, sharp, or autolytic debridement.

Digital stenosing tenosynovitis (trigger finger)

Digital stenosing tenosynovitis (trigger finger) occurs with sheath inflammation or nodules near the A1 pulley. Treatment includes splinting the MCP at 0 for 3-6 weeks or surgically releasing the A1 pulley.

Discriminative reeducation

Discriminative reeducation uses motivation and repetition in a vision-tactile matching process in which clients identify objects with and without vision.

Documentation of wounds

Documentation of wounds. Anatomical location and area of wound. Length, width, depth, and shape of wound. Color and presence of necrotic tissue. Description of wound exudate. Granulation of epithelial tissue at wound margins. Description of surrounding intact skin.

Double crush syndrome

Double crush syndrome occurs when a peripheral nerve is entrapped in more than one location. Symptoms include intermittent diffuse arm pain and paresthesias with specific postures. Nonoperative treatment: treat according to each nerve injury or syndrome, avoid movement or postures that aggravate the symptoms, nerve gliding exercises, and exercises for scapular stability, posture, and core trunk strengthening.

Duran protocol

Duran protocol is an early PROM program.

Dynamic splints

Dynamic splints 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 motion.

Elbow splints

Elbow splints include anterior and posterior elbow immobilization splints.

Electrical stimulation

Electrical stimulation methods include NMES, TENS, and iontophoresis. NMES promotes wound healing, maintains muscle mass, increases ROM, decreases edema, facilitates voluntary motor control, and decreases spasm and spasticity and can be used as an orthotic substitute. TENS primarily controls pain through 3 possible mechanisms: gate control, endorphin release, and acupuncture. Iontophoresis decreases inflammation and controls pain. Indications, contraindications, and precautions: do not use over pacemakers, carotid sinus, pregnant uterus, eyes, and clients with epilepsy, cancer, infection, decreased sensation, cardiac disease and stroke. With iontophoresis use, be aware of possible drug allergies.

Evaluation of hand and upper extremity

Establish rapport, review medical history and history of current condition. Identify occupational profile. Observe posture, spontaneous use of the upper extremity and hand, guarding, scar, wounds, and skin. 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. Specific testing includes ROM, strength, edema, vascular (color, trophic changes, pulse, skin temperature, and Allen's test), sensation (Semmes-Weinstein monofilament and two point discrimination), and 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). Interview about pain, splints, and functional use. Measure outcomes using Quick DASH before and after therapy.

Evaluation specific to carpal tunnel syndrome

Evaluation specific to carpal tunnel syndrome includes: Tinel's sign (tap on median nerve at wrist to elicit symptoms), Phalen's (holding the wrist in full flexion for 1 minute to elicit changes in sensation), Moberg Pickup Test (timed test involving picking up, holding, manipulating, and identifying small objects; used with children and cognitively impaired adults to test median nerve function); and Semmes-Weinstein monofilament testing.

Evaluation specific to claw deformity

Evaluation specific to claw deformity is Froment's sign, Wartenberg's sign, Jeanne's sign, and Semmes-Weinstein monofilament testing.

Evaluation specific to cubital tunnel

Evaluation specific to cubital tunnel: Tinel's, Froment's (flexion of the IP of the thumb when a lateral pinch is attempted), Wartenberg's sign (5th finger held abducted from the 4th), and the elbow flexion test (holding the elbow in flexion for 5 minutes with the wrist neutral to elicit symptoms).

Extensory tendon zones of digits II-V

Extensor tendon zones digits II-V. I: DIP; II: middle phalanx; III: PIP; IV: proximal phalanx; V: MCP; VI: metacarpal bone; VII: carpal bones and wrist.

Extensor zones of the thumb

Extensor zones of the thumb: I: falls over the IP joint; II: falls over the proximal phalanx; III: falls over MCP joint; IV: falls over the first metacarpal; V: falls over the wrist.

Fabrication principles for splints

Fabrication principles: Material properties of low temperature thermoplastics include elasticity, memory, bonding, durability, rigidity, perforations, finish, color, and thickness. Patterns are drawn on a paper towel by outlining the body part using 2/3 the width of the extremity and ½ the circumferences of the bone, marking boney landmarks, and extending ½ in to 2/3 in past the fingertips and thumb. Molding the splint to the client may involve adding closed-cell padding before conforming 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. Finishing the splint requires applying reinforcement if necessary, rounding all corners, flaring the edges, applying appropriate rounded end straps, adding open-cell padding.

Finger splints

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

Flexor tendon interventions

Flexor tendon interventions include exercises to promote excursion and prevent adhesions; modalities of heat and NMES; home exercise program; ROM; strengthening; and if the client cannot cognitively follow a protocol, the extremity is cast in a protected position for 6 weeks.

Flexor tendon pulleys

Flexor tendon pulleys are found on the flexor side to prevent bowstringing and consist of A1, A2, A3, and A4 and C1, C2, C3, and C4.

Five grades of CTD

I: pain after activity, resolves quickly. II: pain during activity, resolves when activity stops. III: pain persists after activity, affects work productivity, objective weakness and sensory loss. IV: use of extremity results in pain up to 75% of time, work is limited. V: unrelenting pain, unable to work.

Inflammatory phase of healing

Inflammatory phase of healing. The inflammatory process includes clotting and vasoconstriction, WBC migration and release of histamines and prostaglandins that cause vasodilation and increased tissue permeability. The acute phase lasts 24-48 hours to 7 days, and the subacute phase last 7-14 days. Local signs include redness, swelling, heat, and pain; systemic signs are fever and leukocytosis.

Intervention after surgical repair of extensor tendon injuries

Intervention after surgical repair of extensor tendon injuries includes exercises to promote tendon excursion and prevent adhesions; modalities of heat and NMES; home exercise program; tendon glides; ROM; and strengthening (not initiated until late phase of the repair, around 8-12 weeks after surgery)

Intervention for CRPS

Intervention for CRPS includes gentle, pain free AROM for short periods, no PROM; stress loading; pain control techniques (TENS, splinting, continuous passive motion); edema control techniques (elevation, massage, AROM, contrast baths, compression); desensitization techniques, fluidotherapy; blocked exercises, tendon gliding; joint protection, energy conservation.

Interventions for fractures of the forearm

Interventions for fractures of the forearm include orthotics for immobilization, ROM, and a sling for Type I or comfort if the client has pain and is nervous in public places.

Interventions for wrist fractures

Interventions for wrist fractures include ROM, orthotics (protect from motion or allow protected motion), a home program, exercises to facilitate movement and improve performance, and modalities such as heat ultrasound, cryotherapy, paraffin, and TENS.

Knee extension splints

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

Local factors of wounds

Local factors. Presence of foreign debris. Necrotic tissue or eschar (may require surgical debridement). Infection with staphylococcus (including methicillin-resistant s. aureus), streptococcus, or pseudomonas. Infection causes pus, pain, purulent drainage, and odor; treat with antibiotics, proper debridement, cleaning, and dressing techniques. Repeated trauma, decreased blood supply, or hypoxic tissue.

Low level laser and light therapy

Low level laser and light therapy methods include light emitting diodes, super luminous diodes, and low level laser diodes. Effects on the client include decreased pain, edema, and inflammation; increased wound healing and decreased scar tissue. Indications, contraindications, and precautions: wear protective eyeware when using laser, do not use over vagus nerve, carotid sinus, pregnant uterus, eyes, infection, endocrine glands, or cancer.

Median nerve injury

Median nerve injury causes age hand deformity. Symptoms: sensory loss in index, middle, and radial side of RF; loss of pinch, thumb opposition, IF MCP and PIP flexion; and decreased pronation. Nonoperative treatment: static thenar web spacer splint. Operative treatment: dorsal wrist blocking splint worn for 4-6 weeks, AROM/PROM in splint for digits/thumb, tendon gliding exercises, scar massage, discontinue splint at 6 weeks and begin strengthening.

Medical treatment for CRPS

Medical treatment for CRPS includes stellate or sympathetic block (an injection of local anesthetic into the front of the neck or lumbar region of the back to block pain), intrathecal analgesia (injection of pain medication into the spinal canal), removal of neuroma (surgery to remove a thickened nerve), installation of spinal cord stimulator (a small electrical pulse generator implanted in back to control pain), and installation of peripheral nerve stimulator (send electrical impulses to control pain).

Muscles that originate from the lateral epicondyle

Muscles that originate from the lateral epicondyle include the anconeus, brachioradialis, supinator, ECRL, ECRB, ECU, ED, and EDM.

Muscles that originate from the medial epicondyle

Muscles that originate from the medial epicondyle include the pronator teres, FCR, FCU, PL, and FDS.

Nerve injury splinting

Nerve injury splinting. Carpal tunnel: wrist in neutral-10 extension. Ulnar nerve at wrist: block 4th and 5th MCPs to 30-45 flexion to prevent hyperextension. Radial nerve injury: cock up splint, with dynamic finger extension assist optional. Pronator syndrome: forearm and wrist neutral, elbow in 90 flexion. Anterior interosseious: forearm neutral, elbow 90 flexion. Radial tunnel: wrist in 30 extesnion, forearm supinated, elbow in 90 flexion.

Nonoperative vs operative treatment of cubital tunnel

Nonoperative treatment of cubital tunnel: edema control, pain management, elbow splint or positioning at 30-60 flexion for 3 weeks, ulnar nerve gliding, proximal conditioning activities, and posture and ergonomic training. Postoperative treatment: protection phase (splint elbow 70-90 flexion; provide wound care, edema control, pain management, and AROM of uninvolved joints; and teach one handed ADL techniques); active (begins at 3 weeks) discontinue elbow splint and anticlaw splint if used before surgery, then add elbow AROM (pronation first, then supination; add wrist motion with elbow flexed, then extended), ulnar nerve gliding, and desensitization techniques.

Nonoperative vs operative treatment for claw deformity

Nonoperative treatment: anticlaw splint, dynamic PIP extension assist may be added, padded antivibration glove, activity modification, and client education to avoid postures and activities that aggravate the condition. Postoperative treatment: bulky dressing is applied for 3-10 days, dorsal blocking splint (wrist at 20-30 flexion and an MCP block to 45 extension) the splint will be adjusted 3-6 weeks and discontinue at 6 weeks. Wound care and scar mobilization. Sensory desensitization. AROM, sensory reeducation, electromyography biofeedback, and NMES.

Interventions for fractures of the hand

Orthotic fabrications (physician prescription) for safe splinting and functional splinting. Thermoplastic and casting orthoses are commonly used to provide support for healing structures. Modalities for pain relief and tissue healing include heat, ultrasound, cryotherapy, paraffin, and TENS. Therapeutic exercises: controlled AROM begins 3.6 weeks after fracture if fixation is sable. Home programs. The most severe implication of hand fractures is complex regional pain syndrome.

PAMs

PAMs are procedures and treatment interventions that use light, sound, water, temperature, and electricity to modify client factors that limit occupational performance. They include cryotherapy, thermotherapy, ultrasound, phonophoresis, electrotherapy, iontophoresis, low level laser therapy, and light therapy. They are considered a preparatory method for the therapeutic use of occupations or purposeful activiites. Regulatory oversight of their use occurs at the local, state, and national levels. State licensure boards determine PAM competency regulations.

Pillar pain

Pain on either side of the surgical release for carpal tunnel is called pillar pain.

Proliferative phase of healing

Proliferative phase of healing. Also called fibroplastic, granulation, or epithelialization process; lactic and ascorbic acid stimulate fibroblasts to synthesize collagen, and cross linkage of collagen increases the tensile strength of repaired skin to 80%. Epithelialization resurfaces the wound, tissue granulation forms new collagen and blood vessels, and myofibroblasts connect to the wound margins. Wound contraction lasts 5 days to 2-3 weeks. Linear wounds heal quickly, rectangular wounds heal moderately quickly, and circular wounds the most slowly.

Pronator syndrome

Pronator syndrome is entrapment of the proximal median nerve between the heads of the pronator muscles. Symptoms include deep pain proximal forearm with activity. Nonoperative treatment: splint elbow 90-100 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. Operative treatment: half cast, AROM while in cast, muscle strengthening in 1 week, full AROM gained by 8 weeks.

Protective reeducation

Protective reeducation educates clients to visual compensate for sensory loss and to avoid working with machinery and temperatures below 60.

Wound Care

Provide a moist environment. Remove excess exudate but does not allow wound to dry out. Allows gaseous exchange. Provide thermal insulation. Impermeable to microorganisms. Will not adhere to the wound and cause damage to granulating tissue on removal. Removal of necrotic tissue is achieved through debridement. Common wound etiologies have characteristic presentations that aid in determining etiology. Interventions should be based on sound research evidence. Wound cleansing can be achieved by various methods. Appropriate cleansing techniques are chosen with consideration of the phase of healing. Wound characteristics need to be taken into account when choosing appropriate dressings. Moisture-retentive dressings have many advantages over dry gauze dressings.

Proximal humeral fractures

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. Intervention includes orthotics for support, ROM, sling for nonoperative, stretching after 4-6 weeks, and home program.

Radial head fractures

Radial head fractures account for 33% of elbow fractures. Are usually caused by forceful load through an outstretched arm. Type I: nondisplaced, treated with long arm sling. Type II: displaced with a single fragment, treated nonoperatively with immobilization for 2-3 weeks and early motion with medical clearance. Type III: comminuted, treated operatively with immobilization and early motion within the first postoperative week as medically prescribed.

Radial nerve injury

Radial nerve injury symptoms: posture of hand is wrist drip, possible lack of finger and thumb extension. Nonoperative treatment: wrist cock-up splint with or without dynamic finger and thumb extension assist, P/AROM, isotonic strengthening exercises upon muscle reinnervation. Operative treatment: static wrist extension splint 30*, after 4 weeks, adjust splint to 10-20* extension.

Radial tunnel syndrome

Radial tunnel syndrome is the entrapment of the radial nerve in an area extending from the radial head to the supinator. Symptoms include burning pain in lateral forearm. Nonoperative treatment: long arm splint, elbow flexed, forearm supinated, wrist neutral, massage or TENS for pain management, pain free ROM, nerve glides, activity modification avoid forceful wrist extension and supination. Operative treatment: long arm splint, elbow flexed, forearm supinated, wrist neutral for 2 weeks, then wrist cock up for 2 more weeks, passive and active pronation and supination, hand strengthening exercise at 3 weeks, resistive exercise at 6 weeks.

Remodeling phase of healing

Remodeling phase of healing. 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. The remodeling phase lasts 2 weeks to 1-2 years. If collagen synthesis exceeds collagen lysis, hypertrophic and keloid scars can form. Tension theory posits that wearing pressure garments helps collagen fibers realign in a linear and lateral orientation. Dynamic splinting, serial casting, continuous passive motion, positional stretching, NMES, and silastic gel pads can help decrease hypertrophic scarring.

Resting hand splints

Resting hand splints maintain the wrist at 20-30 extension, thumb at 45 palmar abduction, MCPs at 35-45 flexion, PIPs and DIPs in slight flexion.

Sensory receptors of the hand

Sensory receptors of the hand include the Pacinian corpuscles (responsible for vibration), Ruffini end organs (responsible for tension), and Merkel cells (responsible for pressure).

Sensory recovery

Sensory recovery begins with pain perception and progresses to vibration of 30 cycles persecond, moving touch, and constant touch.

Smith's fracture

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

Special consideration when splinting pediatric population

Special considerations when splinting pediatric population. Consider age, frame of reference, and childs environment; make the splint appealing to the child by using colored materials or drawing animals on it; limit fit time by using a cold pack to set the splint more quickly; consider using a soft splint.

Special considerations when splinting the geriatric population

Special considerations when splinting the geriatric population. Consider age, frame or references, elder's environment, existing medical issues, any cognitive or perceptual deficits, low vision, hearing impairments, pain perception, thinning of skin and decreased adipose tissue, and any medication side effects; use stockinette under splint; pad splint well; use soft straps; label splint.

Splint evaluations

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

Splinting flexor tendon

Splinting of flexor tendon is used to prevent rupture because the repaired tendon is at its weakest 10 to 12 days postsurgery.

Static splints

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

Symptoms of CTD

Symptoms of CTD: muscle fatigue, pain, chronic inflammation, sensory impairment, decreased ability to work.

Symptoms of CRPS

Symptoms of complex regional pain syndrome include allodynia (sensation misinterpreted as pain), hyperalgia (increased response to painful stimuli), hyperpathia (pain that continues after stimuli removed), edema, contractures, bluish or red shiny skin, abnormal sweating and hair growth, muscle spasms, decreased strength, and low tolerance for activity.

Systemic factors of wounds

Systemic factors. Diabetes mellitus. Nutrition deficiency: vitamins A, C, and E; zinc; and copper. Atherosclerosis. HIV/AIDS. Medications. Aging. Radiation therapy.

Kleinert protocol

The Kleinert protocol involves active extension of digits wit passive flexion via traction, typically a rubber band.

Early active motion protocol

The early active motion protocol begins within days of surgery to prevent adhesion and promote tendon gliding and excursion.

Blood supply to hand and wrist

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

Three common phases of fracture healing

The three common phases of fracture healing are inflammation, repair, and remodeling. Inflammation provides the cellular activity needed for healing, repair forms the callus for stabilization, and remodeling deposits bone.

Thermotherapy

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

Thumb spica splints

Thumb spica splints (volar thumb or radial gutter thumb immobilization) are used on the long or short opponens to provide CMC immobilization.

Splinting to correct contractures

To correct contractures: mechanical stretch of prolonged gentle pull over 8-12 hours to remodel soft tissue.

Splinting to increase passive motion

To increase passive motion: finger loop angle of pull of 90; adjust splint as client improves to maintain 90 angle of pull.

Splinting to protect recent hand flexor tendon repair surgery

To protect recent hand flexor tendon repair surgery: dorsal blocking splint with hinged wrist and joint wrist blocks to maintain wrist extension at 30 and MCP extension at 60 while allowing full wrist flexion. To substitute for loss active motion: radial nerve injury ssplint, with dynamic MCP extension assist if needed.

Ulnar nerve injury

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.

Ultrasound

Ultrasound heats tissue 1-5 cm depth. Thermal and nonthermal effects and also is used in phonophoresis. Thermal effects increase tissue extensibility and blood flow and decrease pain, joint stiffness, muscle spasm, and chronic inflammation. Nonthermal effects increase protein synthesis and bone healing and decrease inflammation. Phonophoresis is the use of ultrasound to promote absorption of topically applied medication accelerate tissue repair and decrease inflammation. Indications, contraindications, and precuations: avoid use with pregnancy, over eyes, pacemakers, bleeding, infections, cancer, over blood clots, and growth plate of bones in children. Be cautious when using with inflammation, fractures, breast implants, and clients with cognitive, language, and sensory impairments.

Work related factors of CTD

Work related factors of CTD are repetition, high force, direct pressure, vibration, cold environment, poor posture, female gender, and prolonged static position.

Wound classification

Wound classification. A pressure ulcer staging system describes the severity of a wound in four stages for diagnostic purposes. 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. Marion Laboratories describes wounds by color, including red, yellow, and black.

Wound closure

Wound closure. Primary: wound is closed with sutures. Secondary: wound is left open and allowed to close on its own. Delayed primary: wound is cleaned, debrided, and observed 4-5 days before suturing it closed.

Wrist cockup splints

Wrist cockup splints (dorsal or volar wrist immobilization) maintain hand arches, full thumb movement, and full MP flexion.