Hands Midterm

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What is a macrophage/what does it do in the healing process?

"pac man" cell that helps clean up non viable tissue

From medial to lateral, the bones in the proximal row of the carpals are . . .

(pisiform) triquetrium, lunate, scaphoid.

What is ulnar nerve tension?

Lateral flexion of the head away from the target UE Shoulder external rotation and abduction Elbow flexion and pronation Wrist and finger extension

What does "one wound, one scar" mean?

Layers heal as one scar (not like in individual layers)

What will be affected by the length of the healing time in a burn?

Length of healing time will affect quality of the scar and thus mobility of the resulting skin/scar

What do you do in rehabilitation for a wrist fracture in the mobilization phase?

Mobilization phase Interval protective splinting to maintain or enhance functional gains Continue with protective phase guidelines Increase ROM and mobility Individual joint mobility Extrinsic tendon Intrinsic tendon

What are exercise considerations when doing exercise late in burn rehabilitation?

Moisturize to start - "oil up" Progressively aggressive stretches with exercise, activity, and orthotic devices as the healing scar tolerates Warm-up with light activity and progress in the session to deeper stretches

Severe cases of carpal tunnel have . . .

Most severe have motor involvement in thenar muscles Poor opposition Weak tripod pinch Decreased fine motor coordination Reports of dropping things

A high ulnar nerve lesion will have _______ deficits, and the purpose of early therapy is . .

Motor and sensory deficits: 1. Prevent contracture 2. Education for safety 3. Map deficits 4. Track progress 5. Update HEP as appropriate

What are exercise considerations when doing exercise early in burn rehabilitation?

Move the parts that won't disturb healing grafts Full thickness grafts need to be immobilized, they will do well with delay Split thickness grafts need time to adhere but can tolerate limited AROM Always watch for SHEAR

Extensor inidicis is innervated by . . .

PIN

What are the three branches of the radial nerve you should know?

PIN, Deep branch of the radial nerve superficial branch of the radial nerve

What exercises in the early period should be used in an early mobilization protocol

PIP and DIP exercises with the MP at 0 twice a day MP flexion in the splint 15 times each hour After 3 weeks the patient can "help" the rubber bands extend the MP's

In the boutonniere deformity

PIP flexed, DIP hyperextended. Central slip breaks and lateral bands migrate volarly

In an early mobilization program, after 6 weeks

PROM begins

What are important complications with distal radius fractures?

Pain Pain is difficult to assess and measure. Watch for signs of median nerve compression Watch for signs of increased sympathetic reactivity Subjective and psychological components of pain can be influenced by positive supportive rapport

Cubital tunnel compression will result in

Pain and numbness and tingling in ulnar hand with elbow flexion (Wadsworth Sign)

What is radial tunnel syndrome?

Pain in extensor muscles No numbness and mild weakness in wrist and finger extensors Confused and associated with tennis elbow

How can a repaired tendon rupture?

Passive Stretch Active use of the muscle/tendon unit: (e.g. actively flexing the digits.)

According to the pyramid of power, the least stressful to most stressful on flexor tendon:

Passive protected Place and hold Active composite Hook and straight fist Isolated joint motion Resisted composite fist Resisted hook and straight fist Resisted isolated joint motion

Why can cold cause MSD-UE?

constricts blood vessels, muscles, etc.

What are the three layers of gauze?

contact, absorbing, securing

What processes on the ulna help you orient anterior/posterior?

coronoid process on the anterior, olecranon process on the posterior

wadsworth sign is a sign of

cubital tunnel compression

What is the effect of radiation on soft tissue?

dense scarring

One splint used for extrinsic extensor tightness is the

dinosaur splint (can be turned around to the other side of the forearm to be used for flexion) ; this is a type of dynamic wrist mobilization splint.

Extensor zone landmarks: zone 8 fingers

distal forearm

After 4 weeks of immobilization, in extensor zone II-IV tendon repair, you should

do blocked DIP and PIP exercises and composite AROM

How would you educate the patient about extensor tendon zone I injury

do not bend the finger at any time

What are some real-world, practical considerations for maintaining splint integrity

dogs, hot cars

What kind of splint do you use in flexor tendon repairs?

dorsal blocking splint

The _______ attach to the extensor hood tendons and help to abduct and extend the digits

dorsal interossei

The sensory branch of the radial nerve that breaks off at the elbow is the

dorsal radial sensory nerve

Extensor zone landmarks: zone 7 fingers

dorsal retinaculum

After initial immobilization, central slip injuries should do AROM how often

each hour

A disturbed vein is likely to cause

edema

Viral infections can cause

edema

In what motions will you see impingement between the AC joint and the coracoid process?

elevation of the shoulder.

What kind of movements can we see at the clavicle?

elevation, roll, anterior-posterior movement. These movements combined to make a "circular" type movement.

Extensor zone landmarks: zone 1 thumb

ip joint

During DRUJ fracture treatment, the pronator quadratus

is often shaved off and replaced--causes tightness in supination!

What is purulent exudate

is thick, yellowish and may have odor or can be green/blue/gray ... indicates presence of microorganisms

The goal of treatment in a yellow wound

is to evolve it into a red wound

Contraction of the wound refers to . . .

it getting smaller

Why is lister's tubercle important?

it is an anchor for the extensor pollicis longus.

How does stress affect wound healing?

it slows it down by causing vasoconstriction!

If the lateral band or triangular ligaments are injured

it will make the boutonniere look worse

What are the specifications for a contact layer of gauze?

should be a sterile dressing like xeroform or adaptic (non adherent)

What are the muscles of the rotator cuff?

sits - supraspinatus, infraspinatus, teres minor, subscapularis.

What do the volar wrist ligaments do?

so many! keep carpal bones in line.

Why should you do small reps many times a day in extensor zones II-IV?

so you don't wear out the tendon repair!

What is duration of exertion?

static postures . . . the % of time exertion is maintained in a cycle. Takes into account both exertion and recovery time.

If a person has frozen shoulder, what is happening on an anatomical level?

sticking together of anterior, inferior shoulder capsule.

What is a common form of axontomesis related to birth trauma?

stretch injury to the brachial plexus

What exercise should central slip injuries do?

stretch the ORL! (literally hold the middle phalanx and have them wiggle). They don't have to come the therapy!

Because of the shape of the collateral ligaments of the IPs of the phalanx, they are

stretched when extended and relaxed when flexed

Collagen makes the wound _____, but it also ___.

stronger, contracts.

Pain is always a _____ measure

subjective

The ____ nerve (a division of the radial nerve), provides sensation to the back of the hand in the area near the _____

superficial branch of the radial nerve, thumb

Because it is superficial to the thumb extensor tendons and retinaculum, the _____ is prone to injury

superficial branch of the radial nerve.

During ______, the ulna is less prominent dorsally (in relation to the radius)

supination

What muscles provide supination of the hand?

supinator, BICEPS

The radial nerve, after passing on the lateral side of the elbow, goes under the _______ muscle.

supinator.

If there is a central slip injury (zone II-IV) . . .

surgery may not be needed. Just immobilization!

Because it it is a ________ joint, there is very little movement at the _______ end of the clavicle

syndesmotic, sternal

What kind of therapeutic techniques can you use for metacarpal fracture?

Passive stretch of MP flexion after 8 weeks with "putty push" or dynamic MP flexion orthosis IP flexion taping Composite flexion wrapping with ace wrap Active pick-up objects alternating fingers to thumb

How do you measure thumb retropulsion?

Pencil across metacarpals just proximal to the MCP joints. Measure how many centimeters away from pencil is the tip of the leading edge of the thumb. Once you can touch the pencil, then put ruler on table and see how high they can get on tip of leading edge of the thumb away from the table (in centimeters)

What is intrinsic tightness? How is it measured?

Tightness of the intrinsic muscles of the hand. Measured with Bunnell-Littler.

What medications/drugs can delay wound healing? How and why?

Tobacco use will also delay wound healing by decreasing available hemoglobin Caffeine can cause vasoconstriction Steroids and other medication may suppresses the normal immune system

Whose perception is the intensity of exertion based on?

Worker's perceptions or Rater's perceptions

What conditions can delay wound healing?

Wound healing will be delayed if the patient has poor circulation, diabetes, anemia, COPD etc.

Post surgically, what kind of care can a hand therapist offer for a ganglion that was around a joint)

Wound/scar care (elastic sleeve, elastomer scar pad) Mobilizing the joint with PROM/AROM education Progressive light activity to encourage joint movement in a wrist ganglion, last stage of recovery is usually progressive weightbearing (bathroom scale, press as hard as they can w/o pain - work up to 10x)

CAM action of the metacarpal causes mcp-pp ligaments to be tightest in . . .

a fist.

Sweating under a splint can cause

a fungal infection

Studies have shown that early motion results in . . .

a stronger repair with less adhesions, however this must be accomplished safely.

What is histamine/what does it do in the healing process?

active once bleeding is controlled to produce vasodilation of non injured capillaries

Failure of the ______ will result in froment's sign

adductor policis

Why does a distal radius fracture often cause ulnar sided pain?

affects the tfcc or causes ulnar styloid fracture. affecting tfcc = causing ulnar sided soft tissue pain.

Flexor tendon zone 1 includes:

after insertion of the FDS

In the hand, the ulnar nerve's motor innervations are . . .

all intrinsics, lumbricals of the ring and small fingers, adductor pollicis, flexor pollicis brevis

An "A" pulley is . . .

an annular pulley. these are thicker, can be palpated more easily as they are more prominent, and serve to prevent bowstringing.

The ulnar nerve (forearm) travels . . .

close to the median nerve, then goes back under epicondyle, under the flexor surface, and proceeds ulnarly

Extensor zone landmarks: zone 5 thumb

cmc joint/radial styloid

What are the juncturae tendium

connect fingers tendons in the extensor mechanism. This is why flipping people the bird is hard and ring fingers are almost impossible to extend.

What is the viniculum?

connection between blood supply and tendon; provide a framework for blood supply to reach the profundus and superficiailis tendons

LOOK AT THE COLORFUL SLIDE OF NERVES

LOOK A THE COLORFUL SLIDE OF NERVES

What is serous exudate

clear or slightly yellow: indicator of health of open wound

What kind of splint do you fit for in extensor zones II - IV?

A gutter splint is fitted for continual wear

What happens in fibroplasia?

A network of fibrin is constructed onto which the capillaries can grow Results in healing; healing is granulation tissue (red beefy look in wound) The epithelial cells migrate across this granulated tissue forming fragile skin

After 4 weeks, what kind of AROM should you do for extensor zones 5 and 6

After 4 weeks, AROM begins to wrist and MP's (splint between exercises sessions). Isolate MP motion by taping the PIP/DIP in flexion for exercise

With extensor zones VII and VIII, after 6 weeks, you may need to do some

After 6 weeks, May need to do dynamic flexion splinting

After surgical repair in extensor zones 5 and 6

After surgical repair, edema control to hand and fingers

According to the CHT people, the maximum extension at the finger joints is ______.

0. Do not use pluses or minuses for extension! Instead, record degrees from full extension. Important for things like TAM.

What general factors will affect the wound healing process?

Age, overall health and nutritional status will impact the wound healing process.

What are common OT interventions in burn management?

1. Positioning splints 2. exercises 3. activities 4. pressure garments/devices

What are kanavel's cardinal signs (e.g., list them)

1. Semi flexion finger 2. tenderness only flexor tendon sheath 3. excruciating pain with passive extension 4. uniform volar swelling of the finger

What are the structures of the TFCC?

1.) articular disk. 2.) (luno-carpal) meniscus homologue. 3.) multidirectional ligaments 4.) DRUJ

What are the five groups of things we see on the (mostly volar) forearm?

1.) brachioradialis, 2.) pronators 3.) flexor muscles, 4.) extensor muscles, 5.) median and ulnar nerves.

What are the steps for clean technique of dressing changes?

1.Assemble all materials (dressings topical agents and tape etc) 2. Clean surface being used (towel on table) 3. Open packages of sterile bandaging taking care to leave bandages resting in the package 4. Wash hands and arms thoroughly from elbow down 5.Don clean gloves 6. Remove old bandages, dispose of gloves and bandages. Sanitize hand and put on clean gloves. 7.Don't touch anything that is not clean. Apply the new bandages you have opened. 8.Take off gloves off to apply tape

What is the distribution of the median nerve in the hand?

1/2 of ring middle, index, pad to back of thumb. volar = all, dorsal to pip joint.

Distal radius fractures are estimated to account for approximately ______ of all fractures treated in the ER

1/6

When icing for edema, ____ minutes is plenty for icing

10

How hot should the whirlpool be for whirlpool therapy?

100 degrees

Flexor tendon zone _______ is "no man's land"

2

How many flexor tendon zones are there on the thumb?

2

If you are treating extensor I tendon injury, and you are less than _______ weeks post injury, you can treat ________-

3, without surgery

When does early mobilization for extensor tendons begin? why?

3-5 days after repair; repair weakens if not mobilized

How much tendon excursion do you need in early mobilization for extensor tendons? why?

3-5 mm of tendon excursion keeps the tendons from adhering, keeps the MP joint loose and decreases edema

If I have a volar plates avulsion fracture, it has to be splinted in (TEST QUESTION)

30 degrees of flexion

What is Phalen's test?

30 seconds of wrist flexion (hands back to back) - numbness is tingling in the median nerve distribution. Pain or general numbness is not positive.

What is the most stable CMC joint of the hand?

3rd metacarpal to capitate.

How many flexor tendon zones are there?

5

How many sesamoid bones do you have in each hand?

5 (3 thumb, 1 index, 1 little finger)

How long does the inflammatory phase usually last

5 days

How long is the maturation phase?

6 months to a year? can be earlier and longer.

After ____ weeks, you can wean someone off of a volar DIP hyper-extension splint as long as there is no

6, extensor lag in AROM

How many extensor zones are there?

8 for the EDC; and 5 for EPL

What is the standard for coordination measurement

9-hole peg test

Less than 3 weeks from a central slip injury

< 3weeks from injury, immobilize in PIP cast for 6 weeks

Greater than 3 weeks from a central slip injury

> 3weeks, serial cast to achieve 0 degrees, then 8 weeks of PIP cast

What is meant by place and hold

@ 2/3rds fit - Stay in protected position, and passively place the fingers in a 2/3rds fist and ask if the patient can HOLD the position (splinted)

If there is a problem getting passive ROM in flexor tendon repairs

A dynamic flexion component is added to the splint

What is antideformity position?

A position of the hand that will stretch the PIP and MP ligaments to their maximum, while also allowing muscles to work best when released.

What is a clean technique?

A way of minimizing infection; not quite as strict as a sterile technique, which would require a sterile field.

How can you treat stiffness/pain in the forearm post DRUJ

A/PROM Joint mobilization Splinting FES (to encourage supination)

Joint stiffness in fingers post DRUJ fx can be treated?

A/PROM exercises (tendon glide positions) Taping into flexion (5 minutes) Dynamic or static progressive splinting (30 minutes3x/day) Joint mobilization FES

What are the most important flexor pulleys?

A2, A4 (A2 is the most important)

The most important pulley to prevent bowstringing is

A2, which is by far the fattest.

The best treatment for digital edema is

AROM with isotoner gloves @ night (make a dent in finger by morning where seam was)

What is intensity of exertion?

An estimation of the force requirement of the task. The magnitude of muscular effort required to perform the task 1x

What does "hand wrist postures" refer to in the strain index?

Anatomical position of the wrist and hand relative to neutral position (awkward postures) Based on raters perceptions

What surgical procedures are available for cubital tunnel syndrome

Anterior Transposition: The nerve is moved out of the cubital tunnel so that the tension on it is reduced Submuscular Transposition: The nerve is placed under the flexor/pronator muscle groups ... in this case the muscles will have been cut and resisted pronation/wrist and digit flexion should not be performed strenuously too early.

Should you use antibiotic creams in a red wound?

Antibiotic creams should be avoided unless wound is too dry

Should you use antiseptics in a red wound?

Antiseptics such as hydrogen peroxide or iodine are cytotoxic and can delay healing

How can we reduce awkward postures?

Appropriate position of material to worker Put objects on jigs Tilt/rotate objects Reduce reach requirements Avoid putting materials above shoulder or below knee levels Work at proper heights (to keep hands low and elbows at your sides) Use appropriate tools

What is the "pyramid of power", conceptually?

Article Uses the information from experiments with force on tendon with various exercises to guide post tendon repair exercises

How do you treat extrinsic extensor tightness?

Combination digital flexion and wrist flexion exercises Digital taping with passive wrist flexion Dynamic composite flexion splinting

In an early mobilization program, after 7 weeks

At 7 weeks begin weaning off the splint and strengthening begins

How can you treat radial tunnel syndrome?

Avoid deep massage of extensor bellies (which is often told to do for tennis elbow) Muenster splint to neutralize wrist and forearm No tennis elbow straps Pulsed U.S. and/or hivolt estim over painful area

Explain the branching of arteries from axillary down.

Axillary - brachial - divides at elbow - radial and ulnar.

How do you measure radial abduction of the thumb in degrees?

Axis at CMC joint (the part stays still when moving the thumb from adduction to radial abd). Put hand on table. one of the arms is on the second metacarpal, one is at the first metacarpal.

What are the three ways of making a fist

B: "Rooftop" - Intrinsic plus C: straight fist D: hook E: composite fist

Explain the path of the radial nerve on the dorsal upper arm.

Comes out from underneath teres major and wraps around the humerus. Goes through the intermuscular septum. Branches off to the posterior cutaneous nerve.

Where is the labrum of the shoulder and what can happen if it is damaged?

Large ring of cartilage at the edge of the glenoid fossa. Tears can cause joint instability.

The musculocutaneous nerve is formed by branches of ___________.

C5, C6, C7

If there is a median nerve laceration, what are the steps of the evaluation and treatment?

Careful motor and sensory evaluation Opponens splint or strap After 3 weeks, wrist tenodesis exercises begin After 6 weeks, composite finger wrist, elbow extension as tolerated Strengthening as muscles return

Flexor tendon zone 4 includes:

Carpal tunnel, thenar muscles

What is closed reduction

Casts, splints Percutaneous pins External fixator

What changes can we make to hand tools?

Change handle type/shape/size Improve grip surface/size Lighter or counterbalance tool Anti-vibratory material Spring opening Electric tool Tool maintenance

How do you treat a yellow wound?

Clean and remove nonviable tissue. Wound can be washed with soap and water and irrigated with water pik or syringe or sterile whirlpool.

How can you keep pin-site infections clean?

Clean with new "Q-tip" on each area (some people use peroxide on the q-tip).

How can you clean a red wound?

Cleaned with saline/water

Before assigning a subtask, what do you need to assess?

Clearly define the sub task being assessed Which hand are you assessing Measure the average cycle duration time

What steps are important in caring for an infection?

Client education (hygiene, home wound care, signs of spreading, reinforce MD instructions) When in doubt, refer back to MD Careful measuring and documenting Avoid modalities that cross contaminate or spread infection Keep the area and equipment sanitized

What is a foam dressing?

Comprised of polyurethane, foam dressings have small open cells that absorb wound drainage and keep moisture away from the periwound area the outer covering is waterproof and will act as a bacteria barrier

What do the palmar arches do? How many are there?

Connect radial and ulnar arteries. There is a superficial arch and a deep arch. If one side is injured, the other side received blood from the anastamoses.

What is conservative treatment for ganglions?

Conservative treatment is compensatory strategies

What are major considerations when treating burns?

Consider the depth of the burn, total area, how the skin was repaired, part of body affected

What causes cubital tunnel syndrome?

Continuous positioning with elbow flexed Direct Pressure (bumping or leaning on elbow) Hypertrophy of flexor/pronator muscle groups Subluxation of Ulnar nerve on medial epicondyle

Where is flexor tendon zone 4? What's good about this? What's bad about this?

Flexor tendons are in the carpal tunnel They have good nutrition The median nerve is often involved with injuries in this zone

When is immobilization a good choice in tendon repair?

It is fine to immobilize young people with clean simple lacerations

What are the pinch meter contact surfaces for each type of pinch

Lateral - thumb to side of fist Tripod - finger tips to pad of thumb Tip pinch - just index pad to thumb

What is radial nerve tension?

Lateral flexion of the head away from the target UE Scapular depression and shoulder extension Elbow extension and pronation Wrist flexion and thumb adduction

What treatment activities may you be doing in the strengthening/functional activities phase?

Grip/UE strengthening through repetitive active motion , activities first then PRE's Return to work/ work conditioning Functional activities

When are gripping and pinching introduced post carpal fractures

Gripping and pinching gradually introduced as tolerated

How can we reduce efforts per minute?

Design task to reduce steps and to improve efficiency Let tools do the work Eliminate piece work Reduce pace Discontinue overtime

What is median nerve tension?

Lateral flexion of the head away from the target UE Scapular depression and shoulder horizontal abduction Elbow extension and supination Wrist, thumb and finger extension

Extensor zone landmarks: zone 2-3 fingers

Middle phalanx, PIP joint

What is the strain index? Who developed it? What does it assess? What does it consider?

Developed by Moore & Garg (1995) A semi-quantitative job analysis methodology to assess if a distal upper extremity job task is potentially "hazardous" (ie. may cause MSD-UE). Combination of physiological, biomechanical, and epidemiological considerations

What do you in rehabilitation for a wrist fracture in the immobilization/protective phase?

Immobilization/protective phase ADL training /compensatory techniques Protect injury Decrease pain Edema control Mobilization of uninvolved joints Digits and thumb, elbow and shoulder

What are special considerations with nerve injuries?

Extra care with use of heat with any nerve injury When a repair has been done, review the precautions of overly stretching the nerve Nerve glides put slack on one portion of the nerve and tension on another

Which tendon is the most medial tendon on the wrist?

FCU

What are the borders of the flexor tendons?

FCU, FCR

High ulnar nerve lesions will not have strong clawing because

FDP is not flexing the digit

What muscles do we see in the deep volar view?

FDP, FPL, FCU, FCR

What muscles do we see in the volar view of the forearm.

FDS

90% of wrist injuries are a result of

FOOSH

What is the anti-deformity position for the hand?

FOR THE HAND: MP's flexed, IP's extended, thumb abducted Wrist 15-30° extension, neutral forearm Elbow is extension, but if the burn is dorsal a 90° flexed posture Shoulder abducted and externally rotated as tolerated (airplane splint)

The ____ is the only tendon that goes to and can flex the tip of the thumb.

FPL

The AIN innervates the

FPL, FDP to index and long, pronator quadratus

What kinds of problems are common at the level of the cervical plexus?

Impingement caused by bone spur, arthritis, disk rupture.

What are common tests to measure hand function?

DASH COPM Informal interview Checklists Jebson hand function test Hand Dominance

Describe what an infection might look like in skin with more melanin?

Darker in color, can be ashy, compare to non-injured side.

In what order does sensation usually return?

Deep pain (muscle, bone, often poorly localized) Vibration (tuning forks) Hot/cold Moving touch Light touch

What are signs of increased sympathetic reactivity

Course hair growth, swelling in fingers, excessively dry or sweaty, pain outside of the normal fracture area

Joint stiffness in fingers post DRUJ fx are because

Digits - limitations due to restrictive casting, extrinsic tightness or limited excursion of flexor tendons

What can be done to treat limitations in digits post DRUJ fx?

Digits - limitations due to restrictive casting, extrinsic tightness or limited excursion of flexor tendons A/PROM exercises (tendon glide positions) Taping into flexion (5 minutes) Dynamic or static progressive splinting (30 minutes3x/day) Joint mobilization FES

What causes carpal tunnel syndrome

Direct pressure over volar wrist Hyperflexed or extended postures (day or night) Increased edema (trauma, pregnancy, metabolic or cardiac disease) Arthritic changes in the wrist Lumbrical muscle hypertrophy

What can prolong the inflammation phase?

Dirty wounds and overly aggressive therapy prolongs the process

What is the piano key test?

Disruption at distal radioulnar joint. See how "bouncy" the ulna is. Stabilize radius front and back with one hand and depress the ulna. Should feel stable if normal

What is the DRUJ?

Distal radial ulnar joint.

Where is flexor zone 3? What does this have to do with the lumbricals

Distal to the carpal tunnel to the 1st pulley Lumbricals take their origin from FDP in this zone

What is the modified duran program

Dorsal blocking splint with the wrist in 20 degrees flexion, MP in 70, IPs extended Passive ROM within the splint each hour (goal is to get all the way to the palm within a week or so) After 4 weeks, add AROM within the splint At 4 ½ weeks the DBS can be removed to do AROM of the wrist and fingers in isolation and in combination No resisted gripping until 8 weeks!!

How are wrist flexor tendons treated in therapy

Dorsal blocking splint with the wrist in 20-30 degrees flexion, MP and IPs FREE Passive ROM within the splint each hour At 4 ½ weeks the DBS can be removed to do AROM of the wrist Wear the splint except during therapy and home exercise until 8 weeks!!

What is the distribution of the radial nerve in the hand?

Dorsal hand surface not covered by median or ulnar nerve (superficial branch of the radial nerve)

What is happening in proliferation?

Fibrin formed, then crosslinked with actual cells (collagen).

What are good treatment activities for ulnar nerve injuries?

Finger "scissors" Smooth wrinkled paper Sign language alphabet Shadow animals Pick up game pieces with SF/RF to thumb

What structures are involved in damage to extensor zones IV, V, VI

EDC, EIP, EDM

Measurement of thumb retropulsion is useful in rehab of the ___ tendon

EPL

What tendons form the anatomical snuffbox?

EPL dorsally, EPB, APL volarly

What are OT general treatment techniques for fracture

Edema control Pain Management Immobilization fracture Mobilization for the non-involved joints Training in adaptive ADL's and IADL's

In early mobilization for extensor tendons, _________ is critical

Edema control is critical (elevation, ice, compression)

Elbow fractures have what kind of outcomes?

Elbow fractures have a high complication rate and poorer outcomes.

What types of control are used to address hazards in the workplace? (e.g., what kinds of changes in control are there?)

Engineering Administrative Work Practice

What is the finkelstein's test?

For dequervains tenosynovitis. Positive = pain at RADIAL STYLOID.

What forearm structures are commonly affected in DRUJ?

Forearm- result of tightness of radiocarpal ligament, interosseous membrane, avulsion of the TFCC or tearing of the pronator quadratus

Where is flexor tendon zone II? What makes it no man's land?

From the A1 pulley to the insertion of the FDS FDS and FDP must closely glide against one another in this zone - cutting here often makes so much scar tissue that the finger cannot move

How can you palpate the coracoid process?

From the concavity at the lateral (distal) end of the clavicle, drop inferiorly off the clavicle to find the coracoid process of the scapula

What is included in flexor tendon zone 1

From the insertion of the FDS to the insertion of FDP Includes pulleys A4, C3, A5

What are the motor innervations for the radial nerve

From the posterior interosseous nerve ECRB Supinator Extensor digitorum EDC EDM Extensor carpi ulnaris EPL Extensor indicis Abductor pollicis longus Extensor pollicis brevis

What are critical considerations in activity participation for the patient?

Full thickness grafts need to be immobilized, they will do well with delay Split thickness grafts need time to adhere but can tolerate limited AROM

What are important differences between full and split thickness grafts?

Full thickness grafts need to be immobilized, they will do well with delay Split thickness grafts need time to adhere but can tolerate limited AROM

What are the priorities in management of tendon injuries.

Get a surgical report Observing edema and wounds/sutures Pain management Following the orders and communicating with the physician

What is the ligament of struthers?

Goes from supracondylar process of humerus to medial epicondyle. forms a tunnel that holds down the brachial artery and median nerve.

How do you measure palmar abduction of the thumb in degrees?

Goniometer axis is at CMC joint. One arm on the first metacarpal, one at the second. (degrees)

Describe how you would measure supination of the wrist

Goniometer horizontal between tendons of FCU and FCR. Vertical parallel to humerus.

Describe how you would measure pronation of the wrist.

Goniometer horizontal on Lister's tubercle of the radius down to the ulnar styloid. nice, flat, two points of contact. Vertical parallel to humerus.

What is one way to measure finger abduction?

Have the client spread the fingers as wide as possible.Trace the "turkey hand picture". Use middle finger as the stable center. Measure distance from the center of the middle finger to center of each finger in centimeters.

What is the most common kind of vascular tumor in hand practice?

Hemangiomas - raised red bumps Only intervention required from therapist is to provide protection strategies if it is getting bumped

What is a hydrogel dressing? What are they designed to do?

Hydrogel dressings are primarily water in an inert matrix or gel form. Hydrogels are designed to hydrate a dry wound.

Where is the triangular ligament

It's job is to hold the lateral bands where there are and keep them from slipping volarly

How can we reduce duration per day?

Job rotation Job enlargement

In extensor zones ________________, after surgical repair, __________ is the most critical

II-IV, edema control

PROM to conteract ulnar claw hand is

IP extension with MP flexion

The contracture for damage to the ulnar nerve is

IP flexion with MP hyperextension

Kanavel's cardinal signs are used to determine what?

Infection in the flexor tendon (may or may not know there was an injury)

What is intrinsic muscle tightness and how do you treat it?

Intrinsic Muscle tightness-limitation in digital flexion of the PIP and DIP joints with MP's in extension Interosseous stretches Lumbrical stretches

What are some methods of open reduction

Kirscher's wires, plates with screws

What does the splint look like for early extensor mobilization?

Long dorsal outrigger with the wrist in 40 degrees extension The finger slings hold the IP's extended MP motion allowed by the splint should be 0-35 degrees For night wear an MP block splint is made (make this 1st in case the patient can't tolerate the process of making 2 splints)

What can happen after collagen formation, in terms of therapy

Loss of motion can occur if the wound does not heal promptly and normal tissue motion is not achieved

FPB does what motions?

MCP flexion and palmar abduction

What do the lumbricals do?

MCP flexion, IP extension

How do you measure radial abduction of the thumb in centimeters?

MP crease of index finger to IP crease of thumb.

What are therapy considerations for radial nerve therapy

Maintain passive extension, supination, and intrinsic stretch A wrist splint may be enough Tendodesis or dynamic extension splint TAP splint to facilitate supination

What are some limitations of the strain index?

Many measures are subjective Does not take into account compression forces Does not take into account increased strain due multiple tasks Does not account for cold, vibration, etc.

How do we treat finger phalanx fractures in therapy

Maximal tendon glide while protecting the bone Edema control Anti-deformity position is IP's extended, MP's flexed

Are ganlions on tendons mobile?

May move with tendon excursion; May feel mobile if it moves with the tendon

What information should you gather in assessment?

Medical past Description of current issue Normal activities before problem Surgical report/x-rays if available

Flexor tendon zone 3 includes:

Middle of palm, complicated, before carpal tunnel

Homemade elastic garments are better than nothing! What are some good ideas for this?

Muscle shirts and sports sleeves are comfortable Socks with elastic can work on arms Foam wedges between the fingers

What is MSD-UE?

Musculoskeletal disorders of the upper extremity

Once cast is off, central slip injuries must wear . . . .

Must wear the PIP splint between exercises another 2-3 weeks and at night

How can you treat carpal tunnel syndrome?

Night splints in neutral wrist with or without MP extension Nerve glides Finger stretches lumbrical Finger flexors preventing aggravating postures in daily life

Flexor tendon zone 2 includes:

No man's land - insertion of FDS to A1 pulley

What does a pin site infection normally look like?

Normal to have some pinkness and crusty exudate

What is a carpal boss?

Not a ganglion A bone spur "bump" on the dorsal hand Can be arthritic in origin or from fracture or dislocation Not usually symptomatic

What things should you notice re: posture?

Notice the way a person carries their arm The position of the head and neck Normal vs. Abnormal finger postures

carpal tunnel syndrome is

Numbness and tingling in the radial hand (thumb, index middle and half of ring) Starts with night numbness More severe cases have symptoms in the day

Boutonniere deformity can be differentiated from psuedo-boutonniere deformity

ORL tightness (test for PIP flexion contracture... eg., trying to determine why they can't straighten their PIP and you need to determine if central tendon was ruptured.) IF THEY CANNOT ACTIVELY FLEX THE DIP, THIS INDICATES B.D.

How does motor recovery usually progress? How can we track it?

Occurs generally proximal-distal from the site of the lesion Progress can be tracked through isolated MMT using the innervation charts Approximately one inch a month

Where is lister's tubercle?

On the back of the hand. Find the radial styloid under the thumb. Move medially.

What are the three phases of wound healing?

Phase 1: Inflammation Phase 2: Fibroplasia (Proliferation) Phase 3: Maturation

What is the first phase of fracture healing?

Phase I - prior to stability or clinical healing ( 0-2 weeks)

What is the second phase of fracture healing?

Phase II - Fracture site is stable, early AROM (2-8 weeks)

What is the third phase of fracture healing?

Phase III - Fracture is healed, PROM and strengthening initiated (>8 weeks)

What is efforts per minute?

Repetition Number of efforts occurring per minute Synonymous with frequency formula=(number of exertions / total observation time in min)

What is a black wound?

Presence of eschar will increase the work required by the macrophage and delay healing ... will need debridement:

_______________ can make a huge difference in skin quality in the long term. This is why it is important to emphasize this in patient education.

Pressure garments and/or scar pads (gel pads)

What is the treatment for cubital tunnel syndrome?

Prevent prolonged elbow flexion in daily activity Headset for phone Elbow extension splint for night (30-60°) (volar) Wear an elbow pad stretch the wrist flexors and pronator ulnar nerve glides

What is the conservative treatment for ganglions around joints?

Rest of the joint in a splint (6-8 weeks) to remind you not to put excessive stress on a joint. Avoiding aggravating activity (e.g. no push-up with a wrist ganglion)

What does the median nerve innervate, motor, in order as you cross the elbow?

Pronator teres Palmaris longus FCR FDS Then the anterior interosseous branch >FPL, FDP to index and long, pronator quadratus > Motor branch to the thenar muscles 1st and 2nd lumbricals

What is the primary objective in treating a red wound?

Protecting the wound environment.

How can we reduce duration of exertion?

Provide jig/machine to hold object Increase efficiency of operation Break task into smaller operations Ambidexterous work Adequate rest breaks

How should we medically treat phalanx fractures?

Proximal phalanx usually requires MP immobilization Middle phalanx requires PIP and DIP to be immobilized Distal phalanx usually in a mallet finger type splint Tuft fractures, just a finger tip protector

What surface anatomy aspects should you notice?

Proximal to distal scan Shape of bony prominences Joint shape Comparison of right to left

What is a yellow wound?

Pseudomonas bacteria can be present ... wound may have odor ... draining and purulent ... semiliquid slough .. Dominant cellular activity is the macrophage ... epithelialization will be delayed due to infection

In extensor zones VII, VIII, you can put the person in what kind of positions? . . .

Put wrist in progressive positions for the MP extension exercises - > e.g, wrist flexion to allow for mp extension. also experiment with supinated and pronated position

What are medical goals for elbow fracture management?

Re-establish articular congruity Obtain acceptable alignment Provide rigid fixation to begin active motion ASAP Stable anatomic reduction and early mobilization will prevent or minimize loss of joint functional motion

What are signs of pin site infections?

Redness that is increasing in size; thick drainage; Increasing pain and edema

What are some ways to resume exertion (force)

Reduce force required for job Optimal grip/pinch size/shape Reduce weight, size of object Increase friction between object and hand Optimal relationship of objects to body Move objects closer Have machines/tools do exertion

What are common causes of MSD-UE?

Repetition Force Awkward/static postures Cold Contact Stress Vibration Stress

What is an AC joint rupture?

Rupture of the ligaments that attach the acromion process to the calvicle. Can be palpated as a large bump at the AC joint (step deformity)

Early care for zones VII and VIII . . .

Same early care as Zone V &VI

What should you look for about skin quality?

Scars- color, size, shape and texture Edema - soft, hard, pitting Color of the skin

When is surgical treatment recommended for ganglions on tendons?

Surgical treatment is only recommended when pain and dysfunction are not tolerable

What is a low ulnar nerve injury?

Sensory and motor deficits based on exact location of injury Therapy starts with MMT of the affected muscles "Turkey hand" picture is helpful for measuring progress of abduction Padded palm protection Activity modification Ultrasound or low level laser

When should hydrogel dressings not be used?

Should not be used on moderate to heavily exuding wounds due to risk of maceration

How can you treat joint stiffness in the shoulder versus DRUJ

Shoulder - limitations are the result of disuse and dependent positioning Avoid arm slings A/PROM exercises Overhead pulleys Joint mobilization

Should you use antibiotic creams in a yellow wound?

Silvadene or Bactroban or other antibiotic OK

How can you debride a black wound?

Surgically or mechanically; Proteolytic enzymes ie. Trevase or elase

What are metacarpal fractures treated medically?

Splint or casted with MP in flexion, IP's free to prevent deformity Axial Rotation (adjacent fingers must be included) Contractures from bone to tendon adhesions or ligament shortening After 6 weeks, start with light activity out of the splint After 8 weeks, may begin strengthening

What kind of splints do you do for extensor zones 5 and 6

Splint with wrist in 20 degrees of extension and MP's extended, with PIP and DIP free for AROM

What do the interosseous membranes of the forearm do? What do they allow for?

Stability during pronation and supination, while allowing for longitudinal movement - > the ratio of the ulna and radius at the distal end changes during pronation and supination!

How does strength compare in dominant and non-dominant sides?

Strength: dominant extremity has 10 -15% greater power than the non-dominant side

Is surgical intervention necessary on ganglions around joints?

Surgical intervention is not necessary unless pain or pressure on other structures is a problem

What is herpes whitlowe?

Swelling, red

This part of the wrist is OFTEN injured in wrist sprains and fractures.

TFCC

The ligaments between the _____ and _______ form a sling for the ____ (carpal bone).

TQ, radius, lunate. (meniscus homologue)

What is tinel's test

Tapping over median nerve as it goes into carpal tunnel; tap just proximal to the carpal tunnel. See if the nerve is hypersensitive to touch. Tingle = positive.

What is early mobilization a good choice in tendon repair?

Tendon injuries that were dirty or had other soft tissue damage do better when they are mobilized early

What is resisted wrist extension test a test for?

Tennis elbow--will hurt at lateral epicondyle.

What is the alcohol drop test?

Test for cold sensitivity. Drop of alcohol, e.g., on back of skin. Positive if painful.

Extensor zone landmarks: zone 1 fingers

The DIP joint

The UE is a functional unit, and the elbow . . .

The UE is a functional unit, and the elbow is the link for placing hand in space.

What is intersection syndrome?

The angle of the extrinsic wrist/finger extensors vs thumb extensors is different; they can rub together.

What happens in the maturation phase?

The collagen content gradually decreases The wound becomes stronger

The elbow functions as . . .

The elbow functions as a stabilizer for power and fine motor function

What happens in the inflammation phase?

The immediate response of the body to cleanse and debride Clots are formed Macrophages go to work

How does a patient use a dynamic flexion assist in flexor tendon repairs

The patient the extends the fingers against the rubber bands then relaxes for the exercises The fingers are strapped in against the splint at night

What do the pulleys of the fingers essentially do?

The pullyes are straps that hold down the FDS and FDP straps in the fingers.

The terminal branches of the brachial plexus include . . .

The radial, axial, median, ulnar, musculocutaneous nerve.

What is the capitulum?

The section of the humerus that articulates with the radius.

What is the trochlea?

The section of the humerus that articulates with the ulna. Looks like a spool of thread.

What does the clavicle connect?

The sternal end connects to the sternum. The acromial end connects to the acromion process of the scapula.

What is included in flexor tendon zone 5?

The tendon and muscle tendon junction proximal to the carpal tunnel

What does "duration of task per day" refer to in the strain index?

The total time that a task is performed during the day Measured in hours per day Obtained by either direct measurement or by asking plant personnel Video - 8 hours per day

How can you treat edema in DRUJ fractures?

The trauma to the soft tissues can be more significant than the fracture itself. Tight casts can also impede venous drainage Edema decreases mobility, elevation is the best way to control edema in the early stages. Distal to proximal massage helps reduce edema and provides tactile input Compressive wraps helps decrease digital edema

What are therapeutic goals for elbow fracture management?

Therapeutic goals are to Minimize edema Up to week 3, AROM in limits per physician Up to week 8, Low load AA/PROM to full range Addressing elbow flexion and extension and forearm pronation and supination Functional adaptation and safe use education

What are techniques for elbow fracture management?

Therapeutic techniques Edema: compression stockinette or wrap Manual edema mobilization AROM: Reaching activities with upper arm supported Low load stretch: Upper arm supported with "just right" weight on wrist Static progressive or dynamic extension or flexion devices Pronation/supination stretch activity: Stretch with a hammer Towel stretch

What is the innervation of the lumbricals?

They are divided right. Ring and little finger - ulnar, index and middle = median

An infection in the flexor tendon is important because . . .

This is an emergency and can spread and lead to loss of limb and life; can easily go septic.

How long does fibroplasia last?

This is the proliferative phase that last 2-4 weeks

Can you use antibiotic creams with a black wound?

Topical antibiotics OK

What is TAM

Total active motion

How can we reduce speed?

Train workers to work efficiently Slow production line/requirements Add more workers

What does TP stand for, and where is it?

Trapezium, distal row, closest to the thumb.

What is the treatment for malignant tumors?

Treatment would proceed based on the structures that were compromised by the surgery (e.g. bone, nerve, skin, tendon)

Which ligament of the elbow has 3 bands? What are they?

UCL. anterior, posterior, oblique

What is the UCL? What does it do?

Ulnar collateral ligament. It provides stability against varus and valgus movement.

What is a red wound

Uninfected, definite borders, granulation tissue present, apparent revascularization Myofibroblasts, epithelial cells present

What is sterile whirlpool therapy?

Use Chlorazene packet in whirpool Turn whirpool on for a few minutes to let Chlorazene circulate Whirpool can help hydrate wound and do gentle debridement apply for 12 minutes

When do you use early mobilization for extensor tendons?

Use especially if periosteum was violated along with tendons in zones V-VII

What treatments should be avoided after malignant tumors?

Use of heat modalities and ultrasound and e-stim would be avoided as a general rule

What is a lipoma?

Usually soft and somewhat mobile Can be anywhere in the UE Can be large Not usually surgically removed

What are some common report measures for pain?

Visual analog (scale of 1-10) Body diagram Quality description of the pain (aching, tingling, burning, throbbing) Time line of changes in pain

How is extensor I tendon injury treated?

Volar Splint the DIP in hyper-extension 15 degrees

How can you measure edema?

Volumeter: Stick between middle and ring finger, thumb toward the spout. Figure-8 - is a tape measure technique of the dorsal hand edema

Cubital tunnel usually results in what kind of motor impairment

Weak lateral pinch Weak finger abd/add weak intrinsic + (MP flexed with IP extended)

What is a wet-to-dry dressing? How is it performed?

Wet to dry dressings are used to help debride wounds with significant debris/necrotic tissue ie. yellow wound. First a gauze pad is soaked in saline solution, balled up and placed over the wound ... then a dry pad is placed on top and then the securing layer ... when the dressing is changed ... non viable tissue is pulled off .... Needs to be changed ever 6 hours.

What is happening in fibroplasia.

When the fibrin matrix is being created - > in late fibroplasia (2nd phase, e.g., proliferation), collagen crosslinks are being formed.

What is a neurofibroma?

With removal can cause nerve damage and require reconstruction

What are the specifications for an absorbing layer of gauze?

a 2x2 inch sterile gauze pad etc. ... can cut to desired shape

If someone has continuous bursitis of the elbow capsule, this will look like

a big bursa bump on the back of the elbow.

Comminuted fracture means

a bone is broken into many pieces

What is a neuroma?

a bundle of nerves that are bundled up, like a tumor of nerve cell tissue. It will not regrow down to its original destination

A "C" pulley is . . .

a cruciate pulley. These go around the joints, are thinner and small, and allow the fingers to bend.

How do you measure opposition?

a.k.a., full flexion (tip of thumb to base of small finger) in centimeters, down to half-centimeter - put ruler at base of small finger and have them crawl their thumb down the ruler. (0 cm is the thumb tip touching the base of the small finger).

`what muscle forms the bulk of the hypothenar muscles?

abductor digiti minimi

What does the abductor digiti minimi do?

abducts and pulls the small finger out for cupping. (out and down)

When is the coracoid process a common location of impingement?

anterior dislocation. It is possible to fracture this process.

The ok sign is a sign of

anterior interosseous injury (AIN palsy) - ok collapses.

After an injury, the _____ portion of the elbow is often stiff. Why is this?

anterior--> capsule shortens volarly during immobilization, in which fibrin replaces collagen in the joint capsule. This limits extension of the joint capsule!

Ulnar styloid fractures post DRUJ . . .

are generally not treated as they will heal normally; however, this will often cause lingering pain and stiffness that takes a long time to go away

Dorsal ganglions are usually . . .

around lunate in wrist flexion.

Disruption of the radioulnar ligaments is likely to cause . . .

arthritis, instability, pain.

After identifying subtasks, you . . .

assign a criterion rating.

After assigning a criterion rating, you

assign rating values based on criterion

When does the collagen content of the wound increase?

at about 3 weeks

How long does low-load long stretch need to be applied to produce change?

at minimum, 20 seconds. up to 5 mins. (in clinic). At home . . . can use a splint up to 30 mins.

Figure 8 measurement generally measures swelling . . . .

at the back of the hand

This nerve can get pinched under the teres minor, causing impingement

axillary nerve

What is no longer a recommended cure for ganglions around joints?

bible method

The ____ tendon of this muscle inserts on the radius and provides force during what movement?

biceps, supination

WHAT DO YOU NEVER DO ON THE SMALL FINGER

blocking. ever.

What is sanguinous exudate

bloody drainage

If someone cannot make a full fist, you want to measure

both full finger flexion and full finger extension!

What is a boxer's fracture

break in the 5th metacarpal at the head

Describe the FDS

broad, very flat muscle that flexes PIPs.

Should you use bacitracin/neosporin to clean a wound?

can be applied to retain moisture and decrease wound bacterial load, but you need to be aware of the potential for allergies. Vaseline is a better choice for a lot of wounds.

If someone is unable to identify their pain via number on a likert scale

can use faces in wong backer

What does CA stand for, and where is it?

capitate, in distal row, between hamate and trapezoid.

Where do the wrist flexors generally insert, e.g., what is the relation of the FDS and FDP?

carpal bones and proximal portion of the metacarpals. The FDS travels on top and inserts into the middle phalanx, where it splits like a snake tongue and inserts on radial and ulnar portions. The FDP goes through the split.

What is a fibroplast/what does it do in the healing process?

cell that produces collagen

Examples of extensor zone 2-3 ruptures are

central slip injuries, boutonniere deformity, lateral bands, triangular ligament

What are the main veins in the arm?

cephalic, basilic, median cubital. (basilic is most medial.)

The nerves of the _____ _______ come out of the spinal cord, and travel through the __________.

cervical plexus, intervertebral foramina.

What is maceration?

excessive fluid retention of wound. Peri-wound area becomes white, and then skin begins to die and peel off.

What does the extensor pollicis brevis do?

extend the mcp of the thumb (due to insertion on proximal phalanx)

In extensor zones VII and VIII, you must try to decrease the ____________ to no less than ___________ and the ________.

extensor lag; 30 degrees; MP

The ____________ prevents bowstringing @ the level of the carpus

extensor retinaculum

People whose __________________ . . . are more viscerally upset, which means . . .

extensor tendons are cut; make the night splint first because they can't tolerate the process of making 2 splints

The extensor pollicis brevis is an (extrinsic/intrinsic) muscles

extrinsic

There are special devices for ______________ and other ________ areas (pressure garments)

face, contoured

How can you palpate the biceps tendon?

feel the anterior part of the shoulder, and have the person internally and externally rotate their shoulder. (This will feel tender if they have tendonitis of the long head of the biceps.)

A _____ splint may be good for claw hand

figure 8

A medicine ball can be used for

flexion/extension stretching, e.g., rolling hand over medicine ball

Compared to extensor tendons

flexor tendons are rounder and thicker

Treatment is the same as the DRF for which carpal bones

for scaphoid and lunate

What splint is used on a scaphoid fracture

forearm based thumb spica with no wrist or CMC motion

What is a barton's fracture?

fracture of the radial styloid, by definition, this fracture is intraarticular

Disorders likely to affect the scaphoid include . . .

fracture, arthritis at the articulation with the proximal radius.

This occupation causes a lot of flexor tendon infections.

gardening -> people get stuck by thorn

What are advantages of whirlpool therapy?

good for dirty, icky wounds that are oozing a lot.

Protocols for therapy following tendon repair are . . .

guidelines only and should be influenced by patient specific factors like age, health, rate and quality of scar formation, location of injury, timing and quality of repair and motivation/ability of the patient to understand the protocol

From medial to lateral, the bones in the distal row of the carpals are

hamate, capitate, trapezoid, trapezium (trapezium connects to the thumb.)

What does HA stand for and where is it?

hamate, in distal row, closest to pinky.

How can you test the FDP

have them bend the DIP of their ring and small fingers while stabilizing the proximal phalanx

For someone recovering from an ulnar nerve injury or an ulnar-median nerve injury, a _____ splint can be helpful

helmet splint--dorsal blacking for ip extension

When is the posterior capsule of the shoulder stretched tightest?

internal rotation + horizonal adduction

What does an intrinsic tightness stretch look like

holding a pen, and stretching the MPs. You want to make sure you are FLEXING the IPs and EXTENDING the MPS.

Where do you lay the goniometer for supination?

horizontal between tendons of FCU and FCR. vertical parallel to humerus.

After assigning rating values you

identify multipliers based on ratings

how are carpal fractures treated

immobilization

What is meant by active composite

in protected position, as them to make a fist (splinted)

Golfers elbow is . . .

inflammation of the wrist flexors that attach to the medial elbow.

How do you define MSD-UE

injury to muscles, tendons, nerves; occurs gradually; combination of physical, emotional, and organizational factors

What innervates the FDP? (motor)

innervations are divided. The median nerve innervates the index and middle fingers. The ulnar nerve innervates the ring and small fingers.

The radial head is always (medial) (lateral) to the ulna

lateral

Where is the common extensor origin?

lateral epicondyle/elbow

For most carpal bones . . .immobilization time

less immobilization time is necessary (3-4 weeks) with early AROM

What is the meniscus homologue?

ligament. borders open space, tfcc crosses over it. it is often the site of scoping.

What is a gutter splint

like a trough. Can be for fingers, wrist - lots of different kinds

Where do you lay the goniometer for pronation?

lister's tubercle on the radius down to the ulnar styloid. nice, flat, two points of contact. vertical parallel to humerus.

What is neuropraxia?

localized pressure on the nerve (symptoms are reversible)

Sesamoid bones may form a part of the pulley system of the hand. When do they "matter"?

looking at x rays.

When you flex your wrist, what carpal bone pops up

lunate

What does LU stand for, and where is it?

lunate, proximal row between scaphoid and the triquetrum.

One example of an extensor zone 1 rupture is

mallet finger--terminal tendon injury

Ulnar side carpal fractures

may require splinting with ulnar gutter

How do volar plates in the MCPS compare to in the PIPs?

mcp = more flexible. pip = less flexible, restrain the joint more (orthotics can cause volar plate tightness).

The ulnar nerve of the elbow progresses from the ______ and through the ______

medial epicondyle, cubital tunnel

Where is the common flexor origin?

medial epicondyle.

The brachial plexus has three cords, the . . .

medial, posterior, lateral

The AIN is a branch of the

median nerve

The abductor policis brevis is innervated by the

median nerve

Extensor zone landmarks: zone 4 thumb

metacarpal

Extensor zone landmarks: zone 6 fingers

metacarpal

What is interval protective splinting?

might use that splint during the day for certain protective activities

Why are the cmc joints more stable in the midline of the hand?

mobility at the sides allows for the arc of motion that allows for palming or cupping the hand.

What is a resisted isolated joint motion

most stressful- on small finger, you would NEVER do blocking and resist the movement of the isolated joint. EVER. EVER.

The PIN is a _____ nerve

motor

What is meant by isolated joint motion?

moving one finger that is usually blocked at the pip or dip

What is intrinsic minus position of the hand?

mp extended, ip flexed (think ulnar claw hand)

What in intrinsic plus position of the hand?

mp flexion ip extension (think lumbricals)

Extensor zone landmarks: zone 3 thumb

mp joint

Extensor zone landmarks: zone 5 fingers

mp joint

What is neurotomesis?

neural tube and axons disrupted (if nerve ends are surgically approximated, axon can recover)

What is axontomesis

neural tube is intact, but the axon is damaged (longer healing time with possibility of residual deficits)

What is a possible effect of chemo?

neuropathy

What is meant by hook and straight fist

no splint - do an active hook (intrinsic minus) and a straight fist

Should you use antiseptics in a yellow wound?

no.

What is a good choice for cleaning wound

normal saline--> can even use contact solution in a big pinch. Comes in a spray can with a straw to squirt and concentrate it.

What is meant by passive protected?

not fully stretching the tendons out, eg, holding the hand in the safe position and passively bending the fingers (splinted)

Should you use betadine for cleaning a wound?

not usually, it's cytotoxic.

ORL means

oblique retinacular ligament

Where do the lumbricals originate? attach?

on the FDP. they attach to the extensor hood.

The "cupping" of the little finger is made by the action of the

opponens digiti minimi and abductor digiti minimi

The DASH is a _________ questionnaire, and the resulting number is a _____________

self-report, percentage of perceived disability.

What is a resisted hook and straight fist

picking something up in hook, like shopping bag or briefcase

What are platelets/what do they do in the healing process?

pile up after initial blood vessel damage and help stop bleeding

Where does the FCU tendon attach?

pisiform

The superficial branch of the radial nerve does what?

sensation for the radial nerve innervated regions of the hand. It is sensitive to pressure on the lateral aspect of the forearm, such as carrying bags, poorly fitting cast, etc.

What are the types of exudate

serous, purulent, sanguinous, serosanguinous

The APB does what motion?

palmar abduction

What does the opponens pollicis do?

palmar abduction, turns the metacarpal during opposition

The digital arteries form off of the

palmar arches

This tendon of this weak wrist flexor is often used for tendon grafts.

palmaris longus

Why is ulnar claw hand a safety hazard

people burn their fingers often (especially in things like hot water, french fries)

What does "speed of work" refer to in the strain index?

perceived speed - how are they able to keep up, pacing?

Provocative tests are usually graded as ....

positive or absent.

Why should people not use old socks from their sock drawer under their splints?

possible transmission of fungus (athlete's foot)

The _____ innervates the supinator, anconeus, and extensor muscles

posterior interosseous nerve, a branch of the radial nerve

_____________ garments are best.

professionally measured

What muscles provide pronation of the hand?

pronator teres, pronator quadratus

The median nerve (forearm) passes under . . . .

pronator teres.

What is fibrin/what does it do in the healing process?

protein strand added to platelets to help stop bleeding

Extensor zone landmarks: zone 2 thumb

proximal phalanx

Extensor zone landmarks: zone 4 fingers

proximal phalanx

P1 means

proximal phalanx 1!

Flexor tendon zone 5 includes:

proximal to carpal tunnel

If the EPL ruptures . . .

pt will lose hyperextension, retropulsion of the thumb above the level of the palm, and IP extension

What is shear?

pushing one part of a body in one direction, and another part of the body in the opposite direction -> like sliding sheets on a bed.

What is a resisted composite fist?

put something in the hand, like putty

Humerus fractures can cause palsy of the ___ nerve

radial

Of the dorsal wrist ligaments, the ____ side is more stable

radial

What does the APL provide?

radial abduction of the thumb (movement of the thumb away from the radius in the plane of the palm)

What is the RCL? What does it attach to? What does it do?

radial collateral ligament. It attaches to the annular ligament and the humerus. Provides stability to the radial head.

Identify the nerves of the shoulder that are the most important.

radial, subscapular, axillary n

What multidirectional ligaments are part of the TFCC?

radius -> ulna styloid. styloid to carpus.

What is a colles fracture

radius fragments go dorsally

What is a smith's fracture

radius fragments go volarly

Where does the FPL originate?

radius, interosseous membranes, coronoid process

Wounds can also be assessed with the ______________classification system

red, yellow, black

What are the cardinal signs of infection in a wound

redness, swelling, heat and pain (rubor, tumor, calor, dolor)

What are the three biggies of MSD-UE?

repetition, stress, and posture

radial side carpal fractures

require immobilization of the thumb

What is the volar plate?

restrains against hyperextension. One in each joint.

How do you treat extrinsic flexor tightness?

scale press "prayer" stretch (prayer stretch first, moving on to scale press once fracture is definitely healed)

What does SC stand for, and where is it?

scaphoid. proximal row, closest to the thumb.

What is the SL? What happens if it fails?

scapholunate ligament. ripping this can cause gap when gripping and throw off the F/E wrist rhythm. This is a serious problem that causes arthritis.

Compression on a scar

tends to make it flatter and smoother - use from time it closes to 2-3 months after.

Radial tunnel syndrome is often confused with

tennis elbow

One good way to guess the level of an ulnar nerve lesion is

testing the FDP--because the FDP cannot flex the digit in the high ulnar nerve lesion

In the forearm, the ulnar nerve's motor innervations are . . .

the FCU, the FDP to the ring and small finger.

What forms the "roof" of the shoulder?

the acromion process

The last muscle innervated by the ulnar nerve that you can test is

the adductor pollicis! flexor pollicis brevis is also partially innervated by the ulnar nerve, but partially not, so adductor poliicis the last testable nerve. you can ask them to adduct the thumb.

One way of measuring perception of exertion is . . .

the borg scale

In an early mobilization program, after 4 weeks,

the dynamic splint is discontinued and Unrestricted AROM with night splint used between exercise sessions

Damage to extensor zones IV, V, and VI doesn't retract like flexor tendons do, because

the extensor hood restrains distal portions from retraction

If the sagittal band of the extensor hood mechanism ruptures

the finger deviates; you will be able to see the tendons slide off when the person makes a fist

When should patients be educated about the principles of tendon rupture

the first session before the half cast and bulky dressings are removed. Even the most educated people have a hard time thinking about this.

The acromion process can be the location of impingement if . . .

the humerus rides too high.

Ganglions around joints are usually associated with

the joint capsule

What does the musculocutaneous nerve innervate

the lateral forearm (in line with thumb) (lateral cutaneous) coracobrachialis, biceps brachii and brachialis muscles. (remember this nerve is sensory and motor)

The primary carpal bones of wrist articulation are . . . .

the lunate and the scaphoid.

What does the median cutaneous nerve innervate?

the medial forearm.

FPB is innervated by

the median AND ulnar nerves.

What innervates the FDS? (motor)

the median nerve.

The position of passive stretch for flexor tendons is

the position of passive stretch for finger flexor tendons is wrist, MCP, IP extension

The extensor muscles are innervated by . . . .

the radial nerve

the most serious carpal fracture is

the scaphoid

After taping, you want to identify . . .

the subtasks that you're going to assess

What is tertiary intention?

the wound is left open for a time until inflammation is controlled and then surgically closed.

What is secondary intention

the wound is left open to heal on it's own ... used with Dupytren's release sometimes

What is primary intention?

the wound is surgically closed with stitches, staples etc.

Human bites are concerning because . . .

they are highly infectious. (fight bites!)

What are some benefits of wet-to-dry dressings

they are very cheap -> debridement may not be available depending on cost, etc.

Are ganglions around joints palpable?

they can be, but aren't always. Can be hard to palpate, especially in the wrist.

What is open reduction

they cut somebody open and do something inside to realign the bone

What are some negatives of wet-to-dry dressings

they have to be a very compliant patient and used correctly-> e.g., short term only

If the patient is experiencing increasing edema with redness

they need to be referred to a doctor!

What is serosanguinous exudate

thin watery and pink or red

What factors can contribute to tenderness at the coracoid process?

tightness in pectoralis minor, especially as a result of forward shoulder posture.

If you had a patient with no extensor retinaculum, one therapeutic technique you could use in therapy is

to use tape to substitute as the retinaculum and prevent bowstringing

What carpal bone articulates with the first metacarpal

trapezium

What are the muscles of the volar shoulder?

trapezius, deltoid, long head of the biceps, triceps brachii, serratus anterior (scapula)

What does TZ stand for, and where is it?

trapezoid, distal row, between trapexium and captiate.

What is collagen/what does it do in the healing process?

triple helix protein strand that imparts strength to the wound

What does TQ stand for, and where is it?

triquetrium, proximal row closest to pinky.

This carpal bone articulates with the ulna during ulnar deviation

triquetrum.

The adductor pollicis is innervated by the

ulnar n

What innervates the Abductor Digiti Minimi?

ulnar n

Sensation to the dorsal portion of the distal 4th and 1/2 of the 5th fingers is provided by

ulnar nerve

What innervates the interossei?

ulnar nerve

What does a Tinel's at the cubital tunnel mean?

ulnar nerve is irritated.

What is semple's test a test for

ulnar nerve lesion (adductor pollicis)

What is guyon's canal

underneath flexor retinaculum and between hook of hamate and fascia - > can have compression of the ulnar nerve from inflammation

What are the specifications for a securing layer of gauze?

usually "Cling" or sterile gauze roll use figure 8 application ... not too tight ... apply distal to proximal

Are ganglions around joints mobile?

usually Non-mobile; Can disappear with joint movement

Why does vibration cause MSD-UE?

vibration can "turn off" certain receptors; and you no longer have a grasp of how tight you are squeezing

_______________ is one of the first tactile sensations to come back

vibration; tested with middle c.

The first, preferred step of a strain index overview is

videotaping the assessment, but many employers won't allow this

What are ganglions around joints usually filled with?

viscous fluid

What is the distribution of the ulnar nerve in the hand?

volar and dorsal 1/2 of ring finger, small finger --> up to wrist crease

Metacarpals have more material on the (volar/dorsal) side. This causes . . . .

volar; CAM action of the metacarpal, in which the flexion of the proximal phalanx causes the ligaments to become tighter.

If you want a measure of edema of the whole wrist, what is the best method?

volumeter, circumferential. Figure 8 is mostly back of the hand!

What kind of dressings can you use in a yellow wound?

wet to dry dressings and frequent dressing changes

What is dehiscence?

when a well-healed wound starts to separate and break down; fluid often starts to come out (serous, serosanguinous)

What is extensor lag?

when there is a difference between PROM and AROM. Is often in extensor mechanism due to not fully gliding

When do you discharge the MP splint in extensor zone V and VI tendon repair?

when there is no lag of the MPs

immobilization of carpal fractures depends on

which carpal fracture you have

What are drawbacks of whirlpool therapy?

whirlpools are almost impossible to truly sterilize

The wound can be measured in terms of . . .

width and length (and depth c sterile measuring tool)

What is the most common kind of dressings used?

will be the most common form of dressing used: (woven fabric of cotton, rayon or other material) the fabric absorbs drainage and lets air into the wound ... manufacturers may also add antimicrobial agents and other substances to the gauze

What is semple's test

with the finger straight, bring the thumb and the index fingers together

Ganglions on tendons may be associated with. . .

with the synovial sheath or reticulation

Fractures of the distal radius are more common in

women

Radial nerve palsy looks like

wrist drop

What three things are measured in the hand/wrist postures section of the strain index

wrist extension, wrist flexion, ulnar deviation

After 7 weeks, in extensor zone II-IV tendon repair, you should

you may begin passive flexion, but watch for that extension lag (gutter at night)

After you identify multipliers, you

you multiply together to find strain index score

When you remove the pressure on a low-load long stretch

you want it to hurt a little bit! it means you did something (but it shouldn't hurt when it's on.)

Should you use zinc to on a wound?

zinc products promote wound healing

In zones ___________, the extensor tendons are not restrained to the muscles

zones 7, 8


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