NBCOT Musculoskeletal AOTA Brief: Hands

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Tx for Medial & Lateral Epicondylitis

- elbow strap, wrist strap - ice and deep friction massage - stretching - activity/work modifications - as pain decreases, add strengthening - strengthening: begin with isometric exercises, then proceed to isotonic and eccentric exercises

Conservative tx for de Quervain's

- forearm-based thumb spica splint (IP joint free) - activity/work modification - ice massage over radial wrist gentle AROM of wrist and thumb to prevent stiffness

signs & sx of carpal tunnel syndrome (mild)

- paresthesia (numbness/tingling AKA pins & needles) - often arises at night (side lying positions can make worse) - causal factors: awkward posture, overuse

de quervain's

- post surgical: glides, pinch/tip strengthening after 2 weeks, use isometric first - splint: forearm based thumb spica, then progress to soft splint & isometric exercises

spastic paralysis

- upper motor neuron lesion - hypertonia, hyperreflexia

ROM for elbow flexion

0-150

when can a person recovering from surgery to release 1st dorsal compartment (AKA tx for de Quervains) receive thumb spica splint and gentle AROM (0-2 weeks)

0-2 weeks

elbow rom

1 wk if cleared

when can a person recovering from surgery to release 1st dorsal compartment (AKA tx for de Quervains) return to unrestricted activity?

6 wks

when discharge splint for flexor tendon injury?

6 wks

which extensor zone goes over wrist joint?

7 (where you wear a watch made by Seven Fridays company)

Complex regional pain syndrome symptoms

Allodynia, hyperalgia, temperature sensitivity 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 Low tolerance for activity * Continuous burning or throbbing pain, usually in your arm, leg, hand or foot Sensitivity to touch or cold Swelling of the painful area Changes in skin temperature — alternating between sweaty and cold Changes in skin color, ranging from white and blotchy to red or blue Changes in skin texture, which may become tender, thin or shiny in the affected area Changes in hair and nail growth Joint stiffness, swelling and damage Muscle spasms, tremors, weakness and loss (atrophy) Decreased ability to move the affected body part

A client sustained a nondisplaced humeral neck fracture after a fall. Which course of occupational therapy would be BEST?

Instruct the client in use of a sling with supervised ROM

Double crush syndrome

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

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 to 5 days before suturing it closed.

Sensoryreeducationafternerveinjury

Protective reeducation educates clients to visually compensate for sensory loss and to avoid work- ing with machinery and temperatures below 60o. Discriminative reeducation uses motivation and repetition in a vision-tactile matching process in which clients identify objects with and without vision. Sensory recovery begins with pain perception and progresses to vibration of 30 cycles per second, moving touch, and constant touch. Desensitization is a process of applying different textures and tactile stimulation to reeducate the nervous system so clients can tolerate sensations during functional use of the upper extremity.

treatment for carpal tunnel syndrome

Conservative tx: wrist splint in neutral, median nerve gliding exercises, activity mods, ergonomics post-surgical management: edema control, AROM, nerve/tendon glides, sensory re-ed, strengthening, activity mod Monitor for pillar pain. Splint: wrist volar splint with wrist in neutral

1st thing to do for mallet finger

DIP extension splint continuously for up to 6 weeks

pronator syndrome (radial)

Entrapment of the proximal median nerve between the heads of the pronator muscles Symptoms: deep pain proximal forearm with activity Nonoperative treatment: Splint elbow 90o to 100o 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 all UE joints while wearing cast, muscle strengthening in 1 week, full AROM gained by 8 weeks

An OTR® is working with a client who fractured the distal radius 6 weeks ago. Within what time frame can controlled AROM be initiated if the fracture is healing secondarily?

Initiation of controlled AROM can begin between 3 and 6 weeks postinjury if the fixation of the fracture is adequate.

Radial nerve injury AKA radial nerve palsy AKA Saturday night palsy (decreased conduction of radial nerve due to fractures, compression, laceration)

Symptoms: posture of hand is wrist drop, possible lack of finger and thumb extension 2. Nonoperative treatment: Wrist cock-up splint with or without dynamic finger and thumb extension assist, passive and active ROM, isotonic strengthening exercises upon muscle reinnervation 3. Operative treatment: Static wrist extension splint 30o, after 4 weeks, adjust splint to 10o to 20o extension.

would wrist fracture cause ape hand or sign of benediction?

ape hand (lower level lesion)

Physical agent modalities (PAMs)

are procedures and treatment interventions that use light, sound, water, temperature, and electricity to modify client factors that limit occupational performance (Bracciano, 2008, p. 2).

Ball or cone antispasticity splints

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

ulnar gutter splints

are used for fractures and severe sprains to the fourth and fifth metacarpals and phalanges (ring and pinky fingers). made from hard materials.

strengthening for extensor tendon injuries do not usually occur until

around 8-12 weeks after surgery.

Splints and other orthoses can be classified as

articular or nonarticular according to the location, direction, purpose, type, or number of joints included

client with a chronic median nerve compression at the carpal tunnel has severely diminished functional pinch. In what position should the thumb be splinted to facilitate functional pinch?

The thumb should be splinted in opposition and palmar abduction to facilitate thumb-to-tip prehension.

rotator cuff

avoid overhead motions, codman/pendulum exercises

mallet finger

avulsion of the terminal tendon and is splinted in full extension for 6 weeks Mallet finger is an injury to the thin tendon that straightens the end joint of a finger or thumb. Although it is also known as "baseball finger," this injury can happen to anyone when an unyielding object (like a ball) strikes the tip of a finger or thumb and forces it to bend further than it is intended to go.

An OTR is working with a client with lateral epicondylitis. What is the BEST client education the OTR can offer in terms of wearing a splint for this condition?

To wear the splint during any activity that causes pain

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 (Coppard & Lohman, 2007).

Digital stenosing tenosynovitis (trigger finger)

Trigger finger occurs with sheath inflammation or nodules near the A1 pulley. Treatment includes splinting the MCP at 0° for 3 to 6 weeks or surgically releasing the A1 pulley.

Special considerations (splints) - pediatric

consider age, frame of reference, and child's environment; make the splint appealing to the child by using colored materials or drawing animals on it; limit fit time by using a cold pack to set the splint more quickly; consider using a soft splint

splint for boxer's fracture

Ulnar gutter splint

active wrist, finger, and thumb extension splint

for flexor tendon injuries

resting hand splint

for preventing deformities - OFTEN WORN BY PPL WITH RA

Radial head fractures account for 33% of elbow fractures. These fractures are usually caused by a

forceful load through an outstretched arm.

people with radial tunnel syndrome should avoid

forceful wrist extension and supination

elbows fractures usually result in limited rotation of the

forearm

flexor tendon pulleys

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

OT intervention for CDT acute phase

Reduction of inflammation and pain through static splinting, ice, contrast baths, ultra- sound phonophoresis, iontophoresis, high-voltage electric and interferential stimulation

Which outpatient treatment intervention is contraindicated for decreasing the arm edema and stiffness associated with complex regional pain syndrome of the upper extremity?

WEARING A SLING

An OTR® is treating a client with a boutonniere deformity using conservative splinting. Which statement can the OTR use to educate the client about the proper use of the circumferential proximal interphalangeal (PIP) joint orthosis?

Wear the orthosis continuously up to 6 weeks. BOUTONNIERE WEAR SPLINT CONTINOUSLY. ALLOWS CENTRAL SLIP TO HEAL.

regulatory oversight of PAMs?

Regulatory oversight of the use of PAMs occurs at the local, state, and national levels. State licensure boards determine PAM competency regulations (Bracciano, 2008, Chapter 2). Practitioners must be knowledgeable about PAMs and able to use clinical reasoning in considering indications, contraindication, precautions, and documentation for application of each modality.

Splinting evaluation

Splinting evaluations may include chart or medical report review, interview and observation of the cli- ent, palpation, occupational assessment (e.g., Canadian Occupational Performance Measure [Law et al., 2005]), and assessment of the following components: pain, edema, sensation, ROM, muscle strength, coordination, functional use, and psychosocial issues. Other considerations are work status, motivation, social support, and reimbursement source.

what disease could cause Boutonniere deformity through capsular distension, affecting zones 3-4 (PIP joint and proximal phalanx

Rheumatoid arthritis

A client with chronic inactive rheumatoid arthritis (RA) has been referred for occupational therapy. All the joints in the client's wrists and hands are affected by the RA, but the only visible sign is the beginning of ulnar drift. What type of splint is BEST to prescribe for this client with the goal of reducing pain at night?

Splinting all the joints of the hand reduces the chances of increased stress on unsupported joints. Studies have suggested that compliance increases with soft splints Because the client does not have significant deformities, a prefabricated splint should fit. Compliance at night tends to be greater with soft splints.

What types of splints have no moving parts?

Static splints, static progressive splints, and serial casting

splint for radial nerve injury post-operative tx

Static wrist extension splint 30o, after 4 weeks, adjust splint to 10o to 20o extension. START AT 30 D. THEN GO DOWN

nonoperative tx for radial nerve palsy

Wrist cock-up splint with or without dynamic finger and thumb extension assist, passive and active ROM, isotonic strengthening exercises upon muscle reinnervation

Special considerations (splints) - geriatric

consider age, frame of reference, 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 (Coppard & Lohman, 2007)

CPRS tx

contrast baths, using compression garment, gentle pain free AROM, stress loading = all GOOD for CPRS

Tx for De Quervain tenosynovitis (conservative)

forearm-based thumb spica (covers both wrist and base of thumb) - wrist in neutral, thumb radially abducted - keep splint on for about 3 weeks - after which, pt. may progress to softer splint and do isometric exercises - often done in conjuction with one time corticosteroid injections - activity modification (avoid pinching, forceful gripping, use good body mechanics)

Smith's fracture

fracture of the distal radius with volar/palmar displacement splint: thumb splint

Bennet's fracture

fracture of the first metacarpal base. orthotics used for immobilization as needed. ROM is started early, within 1 week if medically cleared. sling used for type 1 fractures or comfort if patient has pain and is nervous in public places.

radial nerve palsy often occurs as a reaction to

fracture of the humerus bone

flexor tendon injury (MAKES IT IMPOSSIBLE TO BEND FINGER OR THUMB)

flexor tendon protocol using CONTROLLED PASSIVE MOTION. PASSIVE EXTENSION OF DIP IF PIP AND MCP ARE FLEXED to avoid tendon scarring. dorsal blocking splint: kleinert duran protocol (kleinert active extension I think zone 2: no man's land Zone 4: transverse carpal ligament, median nerve runs under zone 5: contains median nerve branch

sign of high median nerve injury

hand of benediction - pt. cannot flex digits 2 and 3 (index & middle fingers)

functional implications of swan neck deformity

inability to flex PIP joint, cannot make fist or hold large objects

Ankle splints

include antifoot drop splints to maintain 90o ankle dorsiflexion and ankle-foot orthoses.

PAMs

include cryotherapy, thermotherapy, ultrasound, phonophoresis, electrotherapy (e.g., TENS, NMES), iontophoresis, low-level laser therapy, and light therapy (Bracciano, 2008).

Clinical signs of low-level radial nerve injury

include incomplete extension of the MP joints of the fingers and thumb.

sensory distribution of radial nerve

anterolateral arm, distal posterior arm, posterior forearm, posterior aspects of the thumb, index finger, middle finger, and the lateral half of the ring finger

A proximal fracture of the hand

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

Hyperalgesia/hyperalgia

is an abnormally increased sensitivity to pain, which may be caused by damage to nociceptors or peripheral nerves and can cause hypersensitivity to stimulus.

Swan neck deformity

is injury to the metacarpophalangeal (MCP), PIP, or DIP joints characterized by PIP hyperextension and DIP flexion; the PIP is splinted in slight flexion. - use AE says PasstheOT

exercises to do with RA during acute flare ups

isometric, not isotonic (b/c more force on joint) isotonic and progressive resistance within tolerance can be done during remission

what might cause mallet finger?

jamming from playing sports where DIP is bent back (baseball finger) - traumatic avulsion (more likely to be avulsion than laceration) or laceration

how measure hand strength

manual muscle testing, dynamometer, and pinch gauge meter

fracture of medial epicondyle

leads to ulnar claw hand, initially splint elbow in 90 d. flexion like cubital tunnel syndrome

type 1 elbow/radial head fractures do not require surgery and can be treated with a

long arm sling

type 1 radial head fracture

long arm splint only type 3 surgically fixed

radial tunnel splint

long arm splint, elbow flexed, forearm SUPINATED wrist neutral for 2 wks, then cock up for 2 more

Wrist cock-up splints (dorsal or volar wrist immobilization)

maintain hand arches, full thumb movement, and full MP flexion

if an unyielding object like a ball strikes the tip of the finger or thumb and forces it to go back, the most likely resulting injury is

mallet AKA baseball finger (avulsion of the terminal central tendon, splinted in full extension for 6 weeksa)

injury that occurs at extensor zone I?

mallet finger (rupture of terminal tendon) at DIP joint

Complications of healing include

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

signs & sx of carpal tunnel syndrome (moderate - advanced)

moderate: muscle weakness, clumsiness, fine motor difficulties advanced: muscle wasting & atrophy of thenar eminence

Anterior interosseous nerve syndrome

motor loss of function without sensory disturbance.

A splint is an

orthopedic device designed, fabricated, or selected in conjunction with a client to tem- porarily support, protect, or immobilize a body part.

while carpal tunnel syndrome is idiopathic (unknown origin), causal factors include

overall cause: increased pressure in the carpal tunnel factors: - edema - trauma - repetitive movement - poor posture - lots of time on computer diseases that contribute to fluid retention - obesity - diabetes - rheumatoid arthritis - hypothyroidism - pregnancy

medial epicondylitis

overuse of wrist extensors. "Golfer's elbow." - elbow strap, wrist strap - ice and deep friction massage - stretching - activity/work modifications

Phonophoresis Contraindications

pacemakers - pregnancy - application over the eyes or testes -deep vein thrombosis (DVT) -tumor/malignancy -infection -active bleeding - over epiphyseal growth plates

Hyperpathia

pain that continues after stimuli removed

humeral fracture

sling support & supervised exercise = best outcome

complete fracture of the distal radius with palmar displacement.

smith's fracture

commonly used in arthritis

soft neoprene splints to position thumb & hand

index finger injury

strap incorporating index & middle fingers provides ROM to index

Joint protection and pacing techniques best address

symptoms of arthritis.

CTD diagnoses

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

flaccidity

resting hand splint

splint for flaccid paralysis

resting splint (AKA resting pan splint)

ulnar nerve injury (wrist fractures)

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.

work-related risk factors for CTD

repetition, high force, direct pressure, vibration, cold environment, poor posture, female gender, and prolonged static position

pain from de quervain's is exacerbated by

repetitive motions of thumb and wrist, especially movements that involve thumb abduction simultaneously with wrist ulnar deviation

extensor tendon injury

tendon excursions to prevent adhesions heat & NMES prepare tissue for tendon excursion & activation important to have clear home exercise program strengthening not until 8 wks after like flexor tendon injury wrist cock up splint (similar to radial nerve injury)

splint for swan neck deformity

silver rings/tripoint or slight flexion in buttonhole splint

distal radius fracture tx

initiation of can begin 3-6 wks after if healing is ok wrist extension splint

distal radius fracture tx timeline

initiation of gentle AROM 3-6 weeks if fixation healed

why would you use an elbow splint in 30 d. of flexion for nonoperative tx and 70-90 d. of flexion post-surgery for cubital tunnel syndrome?

to prevent over-flexion of the elbow, especially at night

distal row of carpal bones

trapezium, trapezoid, capitate, hamate

in addition to wrist drop, what would a high radial nerve injury AKA radial nerve palsy cause loss of?

triceps/elbow extensors - make it difficult to push self up and off of things

tenosyvitis

tx largely conservative w/ rest. ice, compression, elevation. duran dorsal protection splint.

CDT subacute phase tx

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

Tinel's sign

"pins and needles" sensation felt when an injured nerve site is tapped. Can be used to detect both median (eg carpal tunnel) and ulnar nerve injuries (eg Guyon's canal).

pseudomotor activity that is also known as perspiration

(from Latin sudor, 'sweat' and motor) describes anything that stimulates the sweat glands. Sudomotor innervation is the cholinergic innervation of the sympathetic nervous system prominent in sweat glands which causes perspiration to occur via activation of muscarinic acetylcholine receptors.

Finger splints include

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

interventions for wrist fractures

- early ROM for healing & repair - orthotics to protect for motion or allowing protected motion - implementing home exercise programs: blocked exercises (block metacarpals, DIP)

tx for ulnar nerve compression

- elbow pad or splint to decr compression of the nerve - activity modification

Iontophoresis Contraindications

- Damaged skin or open lesions - Allergy to medication - Impaired sensation to heat or pain stimuli - Presence of flammable sprays or solutions - Electronic implants - PREGNANCY

early mobilization protocols

- Duran: passively move fingers in flexion & extension with other hand while fingers in splint - Kleinert: attach rubber band from finger to forearm for passive flexion (active extension via rubber band traction)

Interventions after surgical repair of extensor tendon injuries

- Exercises promote tendon excursion and prevent adhesions. - Modalities include heat, to gradually prepare the tissue for motion, and NMES, to promote tendon excursion and activation. Use of modalities begins once cleared by the prescribing physician. - A clearly identified and planned home exercise program is important to ensure the client's safety and progress toward goals. - Tendon glides are used to promote excursion and prevent adhesions. -ROM - Strengthening usually is not initiated until the late phase of the repair, around 8-12 weeks after surgery.

tx for complex regional pain syndrome

- Gentle, pain-free AROM for short periods; no PROM or painful treatment - Stress loading: for example, scrubbing the floor, carrying a weighted handbag - Pain control techniques: transcutaneous electrical nerve stimulation, splinting (static, then dynamic as tolerated), continuous passive motion - Edema control techniques: elevation, massage, AROM, contrast baths, compression - Desensitization techniques, fluidotherapy - Blocked exercises, tendon gliding - Joint protection, energy conservation - Provide instruction in a stress loading program and incorporate use of UE in functional activities. - Static volar splint in extension as tolerated, then dynamic as tolerated.

brachial plexus injury

- can occur from shoulder trauma - flail arm splint - avoid positions of over 90 d. abduction

surgical intervention for carpal tunnel & post-care

- carpal tunnel release: transverse carpal ligament cut to release pressure on median nerve - monitor for pillar pain on either side of surgery site (may make it hard to grasp objects) post op care: + immediately control edema through retrograde massage, compression gloves, elevation, etc. + after swelling controlled, AROM, tendon gliding, sensory re-education, strengthening

flaccid paralysis

- caused by lower motor neuron lesion - muscle wasting a prominent feature - hypotonia, hyporeflexia defective (flabby) or absent muscle control caused by a nerve lesion

Types of Cumulative Trauma Disorders (CTD): Lateral & Medial Epicondylitis

- de Quervain's - lateral (tennis) and medial (golfer's) epicondylitis - trigger finger - nerve compressions

what could cause a flexor tendon injury?

- deep cuts to the palmar side of the hand - sports "jersey finger" - rheumatoid arthritis

with wrist drop, what functional problems might occur?

- difficulty manipulating objects - impaired release of objects

conservative tx for mild CST

- icing - activity modification - splinting (wrist volar splint) - use orthosis/splint: keep wrist in neutral - wear at night - semi-flexible and soft better than hard rigid splint - avoid awkward side lying positions - splinting may be accompanied by corticosteroid injections to manage swelling - be aware of medication allergies and contraindications -rest - medication (iontophoresis and phonophoresis) - AFTER swelling/pain is controlled, move to exercise phase exercise phase: - stretching - nerve gliding - SLOWLY introduce strengthening & resistance training to avoid exacerbation

Tx for De Quervain tenosynovitis (post-surgical)

- if conservative tx not effective, will receive surgical release of 1st dorsal compartment - after surgery, use forearm-based thumb spica splint same EXCEPT wrist is extended to 20 degrees - a few days postoperatively, gentle AROM & tendon gliding - at 2 weeks, grip and pinch strengthening - desensitization & scar management as needed - 6 wks: pts. resume normal activities

Wound healing phases

- inflammatory - proliferative - remodeling

nerve injuries associated with wrist fractures

- median - ulnar

Colles' fracture

- most common type of wrist fracture complete fracture of the distal radius with dorsal displacement. orthotics used for immobilization as needed. ROM is started early, within 1 week if medically cleared. sling used for type 1 fractures or comfort if patient has pain and is nervous in public places.

clinical signs of upper radial nerve injury

- pronation of forearm - wrist flexion (loss of extension) - thumb held in abduction due to unopposed action of flexor pollicis brevis & abductor pollicis brevis

tx for flexor tendon injury

- requires sutures or stitches - takes about 12 wks to heal - early immobilization key to prevent adhesion/scar formation (must do tendon gliding to prevent this) - splint (dorsal block splint) - wrist: 20-flexion, MCP 50-70 flexion, IP extension - splint is placed within 2-3 days post surgery - early phase: 0-4 weeks (do early immobilization procedures like Kleinert & Duran) - discharge splint at 6 weeks - 4-6 weeks post op: start differential flexor tendon gliding exercises - could also do place and hold where you bring your hand into a fist and HOLD it - 6-8 wks: light occupational activities while still doing tendon gliding - 8 wks strengthening exercises - 12: back to full activity

Splint for Boutonniere deformity

- splint finger in extension silver rings/tripoint PIP splint

postoperative tx for de Quervain's

- thumb spica splint and gentle AROM (0-2 weeks) - strengthening, ADLs, and role activities (2-6 weeks) - unrestricted activity (6 wks)

tests for carpal tunnel syndrome

- tinel's sign (tap over median nerve, see if paresthesia aka numbness/tingling) - durken's test: use two thumb to press on carpal tunnel - phalen's test: flex wrists together

Causes of De Quervain's tenosynovitis

- trauma to wrist implicated - repetitive strain injury (cumulative microtrauma) - conditions that cause swelling/edema exacerbate (eg diabetes, pregnancy) - prolonged use of wrist in awkward static position

occupational deficits of ulnar nerve injury

- weakened power grip (4th and 5th fingers essential for power grip - decr pinch strength (weakened thumb opposition, abduction) - loss of thumb adduction

CDT return to work

-Assessment of job site, tools used, and body positioning - Therapy using a work simulator, weight well, elastic bands, putty, functional activities, and strengthening activities -Functional capacity evaluation - Work hardening

Median nerve injury splints

-Opponens splint, C-Bar, or thumb post splint -dorsal protection with wrist in 30 degrees flexion and includes elbow 90 degrees of flexion for high lesion.

De Quervain's (AKA Gamer's thumb or mother's thumb)

-Stenosing tenosynovitis of the first dorsal compartment of the wrist. - thinkening of the tendon sheaths of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB). - results in impaired tendon gliding because area is constructed. -Pain and swelling over the radial styloid. -Positive Finkelstein's test. A painful condition affecting the tendons on the thumb side of the wrist. Repetitive hand or wrist movements (thumb abduction simultaneously with wrist ulnar deviation) can make the condition worse. The main symptoms are pain and tenderness in the wrist, often below the base of the thumb.

discriminative sensation

-limited touch sensation enough to feel but not localize input and intact protective sensation.-retraining through moving touch localization.-graded discrimination through identification of the object in addition to whether the object is the same of different, as well as the degree to which they are similar or different.

Trophic changes of the skin (3):

-thin -easily damaged -poor healing Trophic changes is a term used to describe abnormalities in the area of pain that include primarily wasting away of the skin, tissues, or muscle, thinning of the bones, and changes in how the hair or nails grow, including thickening or thinning of hair or brittle nails. All of these are sympathetic effects of nerve injuries that can also be observed.

Evaluation of the Hand and Upper Extremity - General Steps

1. Establish rapport, and review medical history and history of the current condition (read chart and operative note). Identify the client's occupational profile. 2. Observe posture, spontaneous use of upper extremity and hand, guarding, scar, wounds, and skin. 3. 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. 4. Interview the client about pain, splints, and functional use; use an ADLchecklist to uncover ADL dysfunction and set goals. 5. Measure outcomes using the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (Quick DASH) before and after therapy.

medical tx for CPRS

1. Stellate or sympathetic block: an injection of local anesthetic into the front of the neck or lumbar region of the back to block pain Intrathecal analgesia: injection of pain medication into the spinal canal Removal of neuroma: surgery to remove a thickened nerve Copyright © 2013 by the American Occupational Therapy Association. All rights reserved. For permissions, contact www.copyright.com. 5 Installation of spinal cord stimulator: a small electrical pulse generator is implanted in the back to control pain Installation of peripheral nerve stimulator: electrodes placed on the peripheral nerves to send elec- trical impulses to control pain

when can a person recovering from surgery to release 1st dorsal compartment (AKA tx for de Quervains) receive strengthening, ADLs, and role retraining?

2-6 weeks

Resting hand splints maintain the wrist

20°-30o extension, thumb at 45o palmar abduction, MCPs at 35°-45o flexion, and PIPs and DIPs in slight flexion

Controlled AROM for hand injuries begin

3-6 weeks after fracture if fixation is stable

boxer's fracture

4th & 5th metacarpal fracture, commonly caused by hitting object with clenched fist with enough force to break MCP neck (tx with ulnar gutter splint)

hronic pain is pain that lasts longer than

6 months.

extensor tendon zones

8 different zones 1- DIP joint 2- middle phalanx 3- PIP joint 4- Proximal phalanx 5- MP joint 6-Metacarpal 7- dorsal retinaculum 8- distal forearm 5 thumb zones 1- IP joint 2- proximal phalanx 3- MP joint 4- Metacarpal 5- CMC joint/radial styloid

when start strengthening exercises for flexor tendon injury?

8 wks

where would you position an elbow following an elbow fracture or cubital tunnel syndrome in the POSTOPERATIVE phase?

90 degrees of elbow flexion

for a high level median nerve injury, you would place the elbow in

90 degrees of flexion

Types of hand fractures

A proximal fracture is a metacarpal fracture, such as a boxer's (4th and 5th finger) fracture. Carpal fractures are fractures to individual carpal bones. a. The most common fracture seen and missed in injuries to the wrist is the scaphoid. b. Lunate fractures are associated with Keinbock's disease.

when should exercise phase of carpal tunnel syndrome commence?

AFTER swelling/pain managed...makesure to introduce strengthening/resistance slowly to avoid exacerbation

Scaphoid Wrist Fracture

A scaphoid (navicular) fracture is a break in one of the small bones of the wrist. This type of fracture occurs most often after a fall onto an outstretched hand. Symptoms of a scaphoid fracture typically include pain and tenderness in the area just below the base of the thumb.

A client fell while skiing downhill and sustained a Type III fracture of the radial head. Which treatment would be MOST appropriate for this type of fracture? A. Long arm cast for 6 weeks B. Therapy alone C. Fragment excision with a long arm cast for 3-4 weeks D. Fragment excision with a long arm splint for 3-4 weeks

A Type III fracture of the radial head requires removal of the fragmented bone and a cast for 3-4 weeks to ensure proper healing and support. Staino, M. J. (2007). Common elbow diagnoses. In C. Cooper (Ed.), Fundamentals of hand therapy: Clinical guidelines and treatment guidelines for common diagnoses of the upper extremity (pp. 183-200). St. Louis, MO: Mosby; pp. 193-194. Explanations of Incorrect Answers A: A long arm cast for 6 weeks would not be appropriate because that time frame would lead to greater stiffness. B: Therapy alone would not be sufficient for a Type III injury. D: A splint would not stabilize the fracture sufficiently for a Type III injury.

nonoperative treatment for carpal tunnel syndrome

A carpal tunnel syndrome splint or wrist cock-up splint at 0°-10° wrist extension is used to re- lieve pressure on the median nerve in the carpal tunnel and control edema; a prefabricated wrist cock-up splint can be used if wrist position is adjustable. Nerve and tendon gliding exercises are used. Activity modification includes ergonomic handles, gel pads, or padding on handles. Client education recommends avoidance of postures and activities that aggravate the condition (e.g., those that involve wrist flexion). Training is provided in the use of an ergonomic keyboard modification, if applicable. Postural retraining and proximal conditioning exercise are provided.

Carpal Tunnel Syndrome

A condition caused by compression of the median nerve in the carpal tunnel and characterized especially by weakness, pain, and disturbances of sensation in the hand and fingers. These sensations usually develop gradually and start off being worse during the night. They tend to affect the thumb, index finger and middle finger. Other symptoms of carpal tunnel syndrome include: pins and needles (paraesthesia) thumb weakness a dull ache in the hand or arm. Diagnosed by Tinel's sign (lightly tapping over nerves).

An OTR® is working in an inpatient setting with veterans who have upper-extremity amputations. Each morning the rehabilitation team, consisting of physician, nurse, psychologist, social worker, OTR, physical therapist, and orthotist, come together to discuss their patients' clients' progress toward the goals set within their individual disciplines. What type of team is this?

A multidisciplinary team is an interprofessional team composed of individuals representing the professional disciplines that serve the client. A: Transdisciplinary teams function without discipline-centered boundaries. C: Interdisciplinary teams set goals and engage in intervention collaboratively across the disciplines. D: Allied health teams are not a recognized, definable type of team collaboration.

An OTR® is treating a client with a proximal interphalangeal (PIP) flexion contracture secondary to a sports injury. To improve extension of the PIP for functional use of the hand, what is the BEST use of limited therapy time?

A prefabricated dynamic PIP extension assist splint will improve PIP extension and takes less therapy time to fit than to custom make this splint. A: Heat and joint mobilization can increase ROM temporarily, but long-term improvement of the PIP flexion contracture requires dynamic splinting. C: Flexion blocking exercises increase flexion, not extension. D: Fabricating a custom dynamic splint takes longer than fitting a client with a prefabricated splint.

Wound classification

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

A client with a chronic median nerve compression at the carpal tunnel has severely diminished functional pinch. In what position should the thumb be splinted to facilitate functional pinch?

A. The thumb should be splinted in opposition and palmar abduction to facilitate thumb-to-tip prehension. B. The thumb should not be included in a carpal tunnel orthotic to allow for functional prehension. C. The thumb should be splinted in opposition and radial abduction to facilitate thumb-to-tip prehension. D. The thumb should be splinted in extension to limit shortening of the extensor pollicus longus. Incorrect. You answered B. B: Chronic median nerve compression, which affects the thumb, severely limits functional prehension. Splinting should address the thumb to maintain a functional position and maintain the first web space. C: Radial abduction does not position the thumb for thumb-to-tip pinch. D: Positioning the thumb in extension shortens the extensor pollicis longus.

how to assess ADL's during interview?

ADL/IADL checklist

what can be useful for goal setting?

ADL/IADL checklists

An OTR is working with a client who presents with digital tenosynovitis in the index finger, or "trigger finger." After the OTR fabricates a splint to support the metacarpophalangeal joint in extension, which exercise should the OTR advise the client to perform FIRST? A. Hook fist with splint on B. Hook fist with splint off C. Full fist with splint on D. Full fist with splint off

A: Trigger finger is a condition in which edema in the tendon and synovium of the digit results in lack of smooth flexion or extension of the finger. To rest the tendon and prevent snapping as the tendon pulls through the finger pulleys, the MCP joint is blocked by splinting, then gentle pull through with bending and straightening of the distal and proximal interphalangeal joints is recommended 20 times every 2 hours while the client is awake. Cooper, C., & Martin, H. A. (2007). Common forms of tendinitis/tendinosis. In C. Cooper (Ed.), Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity (pp. 286-300). St. Louis, MO: Mosby; p. 295. Explanations of Incorrect Answers B: The MCP joint is not supported if the hook fist exercise is performed with the splint off, resulting in increased tendon inflammation. C: A client wearing the MCP extension splint will be unable to make a full fist with the splint on. D: Making a full fist without the splint on will increase tendon inflammation and edema.

RADIAL tunnel syndrome causes burning

ALONG LATERAL FOREARM

PRONATOR TERES SYNDROME MEDIAN PAIN

ALONG MEDIAL ASPECT OF FOREARM (THINK PROMEDFLEX) MED ALSO STANDS FOR MEDIAL ASPECT OF FOREARM

Protective sensation

Ability to accurately perceive sensory input necessary to prevent personal injury or harm (e.g., pain and temperature) often assessed with semmes-weinstein

MOTOR LOSS OF FUNCTION W/O SENSORY DISTURBANCE

ANTERIOR INTEROSSEOUS SYNDROME

for carpal tunnel syndrom, the splint should be worn

AT NIGHT

Finger blocking exercise

Active exercise that involves isolating a specific joint of the hand by supporting the digit just proximal to the joint being moved, used to: target a specific joint restore strength prevent adhesions enhance tendon glide

sensory re-education

Active training strategies used in the presence of a peripheral nerve injury or after a brain injury to enhance sensory awareness or compensate for lack of sensation, distinct categories include: protective sensory re-education discriminative sensory re-education

An OTR® is working with a client who has a dorsal scar resulting in limited metacarpophalangeal (MCP) flexion of the fingers. When fabricating a dynamic MCP flexion splint, what is the correct angle of pull for a finger loop? If the angle of pull is greater or less than 90°, the torque is less effective, and skin breakdown may result.

Nonoperative treatment for ulnar nerve palsy

An ulnar nerve palsy or anticlaw splint is used, and dynamic PIP extension assist may be added if PIP flexion contractures are present. A padded antivibration glove can be used during activity to protect from further nerve irritation. Activity modification includes ergonomic handles, gel pads, or padding on handles of vibratory equipment (e.g., lawnmower). Client education recommends avoidance of postures and activities that aggravate the condition, such as ulnar deviation combined with wrist flexion.

locations of proximal humeral fractures

Anatomical head Anatomical neck Anatomical shaft

Documentation of wound healing

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

A client has a one-week history of symptoms consistent with a work-related carpal tunnel syndrome. The client works on an assembly line and is required to stand at a workstation and tighten bolts into sheet metal at waist level using a pneumatic pistol-grip drill. The client uses the drill approximately 6 hours each 8-hour shift. Which ergonomic modification would be MOST BENEFICIAL for reducing symptoms associated with this condition?

Anti-vibration gloves absorb the vibrations emitted by the pneumatic pistol-grip drill to reduce the symptoms of work-related carpal tunnel syndrome.

protective sensory re-education approaches

Avoiding machinery and low temperatures and using vision to compensate for sensory loss

FIFTH METACARPAL FRACTURE

BOXER'S FRACTURE, VOLAR-BASED ULNAR GUTTER SPLINT WITH RING/5TH IN 70-90 FLEXION, WRIST IN 20 EXTENSION

fracture of the first metacarpal base.

Bennet's fracture

zones 3-4 extensor tendon injury (PIP joint and proximal phalanx)

Boutonniere

injury with PIP flexion & DIP hypextension

Boutonniere deformity

ulnar nerve palsy postop treatment

Bulky dressing is applied for 3-10 days. A dorsal blocking splint is used to maintain the wrist at 20°-30° flexion and an MCP blockto 45° extension to protect nerve repair. The splint is adjusted at 3-6 weeks to increase wrist position to neutral. Discontinue splint at 6 weeks. Use of the preoperative splint continues until muscle function returns. Wound care and scar mobilization are performed. Sensory desensitization begins when the wound has healed and stitches are removed. AROM of the wrist and hand begins at 6 weeks; clients may resume ADLs and begin muscle strengthening and work conditioning, if needed. Sensory reeducation begins at 10-12 weeks postsurgery, once protective sensation has returned. Tendon transfer is done if the nerve has not regenerated within 1 year. After surgery, the practi- tioner may provide electromyography biofeedback, NMES, and instruction in avoiding substitu- tion of movement patterns (Kasch & Walsh, 2013, p. 1053).

what other splints would you use for median nerve injuries?

C-bar to maintain web space & prevent thumb adduction contracture opponens splint

roots of the median nerve

C5-T1

A large outpatient hand clinic employs certified hand therapists who are either licensed OTR®s or licensed physical therapists. COTA®s are used to efficiently manage caseloads. Which description of the supervision requirement for COTAs working in this environment is MOST accurate?

COTAs typically require supervision by a licensed OTR in accordance with state licensure and scope of practice for COTAs.

site in elbow for ulnar nerve compression

CUBITAL TUNNEL. Due to the narrow opening of the cubital tunnel, it can be easily injured or compressed through repetitive activities or trauma.

Carpal tunnel syndrome

Carpal tunnel syndrome is caused by entrapment of the median nerve as it courses through the car- pal tunnel. This is the most common nerve compression of the upper extremity. Causes include tenosynovitis, cumulative trauma disorder, fluid retention (e.g., from pregnancy, en- docrine malfunctions), ganglions, tumors, diabetes, rheumatoid arthritis, and trauma such as wrist fracture or lunate dislocation (Kasch & Walsh, 2013, p. 1064). Sensory impairment generally involves numbness and tingling in the thumb and index and middle fingers, especially at night. Motor impairment presents as diminished fine motor coordination; in advanced cases, the adductor pollicis muscle may be atrophied. Evaluation specific to carpal tunnel syndrome Tinel's sign is a tap on the median nerve at the wrist to elicit symptoms. Phalen's test is holding the wrist in full flexion for 1 minute to elicit changes in sensation. Moberg Pickup Test is a timed test involving picking up, holding, manipulating, and identify- ing small objects. It is used with children and cognitively impaired adults to test median nerve function. d. Semmes-Weinstein monofilament testing is used to test for loss of sensation. Nonoperative treatment A carpal tunnel syndrome splint or wrist cock-up splint at 0°-10° wrist extension is used to re- lieve pressure on the median nerve in the carpal tunnel and control edema; a prefabricated wrist cock-up splint can be used if wrist position is adjustable. Nerve and tendon gliding exercises are used. Activity modification includes ergonomic handles, gel pads, or padding on handles. Client education recommends avoidance of postures and activities that aggravate the condition (e.g., those that involve wrist flexion). Training is provided in the use of an ergonomic keyboard modification, if applicable. Postural retraining and proximal conditioning exercise are provided. Postoperative treatment (Moscony, 2007a, pp. 227-232) Surgical treatment includes traditional open carpal tunnel release surgery or endoscopic release. After surgery, some clients may not need therapy. For more complicated cases, wound care and scar mobilization are provided. Pain management may include use of gel pads on the scar. Pain on either side of the surgical release is called pillar pain. Splinting is provided only to clients who sleep with the wrist flexed or who will engage in too much activity too soon (e.g., immediate return to work). AROM of wrist, thumb, and fingers begins 1-2 days postsurgery. Nerve and tendon gliding exercises are provided. Strengthening activities begin in 3 to 6 weeks.

Nerve injury splinting

Carpal tunnel syndrome: wrist in neutral to 10o extension Ulnar nerve at wrist: block fourth and fifth MCPs to 30o-45o flexion to prevent hyperextension Radial nerve injury: cock-up splint, with dynamic finger extension assist optional Pronator syndrome: forearm and wrist neutral, elbow in 90o flexion Anterior interosseous: forearm neutral, elbow in 90o flexion Radial tunnel syndrome: wrist in 30o extension, forearm supinated, elbow in 90o flexion (Cop- pard & Lohman, 2007)

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

Carpal tunnel wrist support Antivibratory gloves Neoprene wrap thumb support for CMC osteoarthritis and de Quervain syndrome Forearm bands for medial and lateral epicondylitis MCP anti-ulnar deviation splints for rheumatoid arthritis Buddy taping Neoprene tube digit extension splint Pediatric neoprene thumb abductor and supinator TheraTogs (TheraTogs, Inc., Telluride, CO; Coppard & Lohman, 2007)

median nerve injury

Causes ape hand deformity Symptoms: ape hand deformity; sensory loss in index, middle, and radial side of ringer finger; loss of pinch, thumb opposition, index finger 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 and PROM in splint for digits and thumb, tendon gliding exercises, scar massage, Discontinue splint at 6 weeks and begin strengthening exercises

causes of swan neck deformity

Causes of this deformity include intrinsic muscle tightness, stretching or rupture of the terminal extensor tendon at the DIP joint, and chronic synovitis that leads to stretching of the volar capsular supporting structures at the PIP joint. Here, the lateral bands of the extensor mechanism slip above the axis of the PIP joint, thereby hyperextending the PIP joint and flexing the DIP joint.

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 hyperextend and the IPs flex, hand arches are flattened, and pinch strength is lost (Moscony, 2007a). Evaluation specific to claw deformity Froment's sign is flexion of the IP of the thumb when a lateral pinch is attempted. Wartenberg's sign is the fifth finger held abducted from the fourth finger. Jeanne's sign is hyperextension of the thumb MCP. Semmes-Weinstein monofilament testing is used to test for loss of sensation.

most common wrist fracture

Colles

complete fracture of the distal radius with dorsal displacement

Colles' fracture

Anterior interosseous syndrome (radial nerve)

Compression to the anterior interosseous nerve Results in a motor loss involving the flexor digitorum longus, flexor profundus to the index finger, and pronator quadratus

continuous passive motion

Continuous passive motion (CPM) is a therapy in which a machine is used to move a joint without the patient having to exert any effort. A motor bends the joint back and forth to a set number of degrees.

A client is injured while lifting a 50-lb box at his manufacturing job and files an injury report the next day. He is diagnosed with lower lumbar pain. He sees an OTR® at an outpatient therapy setting 3 days after the injury. Which of the following is the MOST likely source of reimbursement for occupational therapy services related to work injuries? A. Private insurance B. Individual medical plan C. Long-term disability D. Workers' compensation

Correct! You answered D.The right answer is D Workers' compensation is the most likely source of reimbursement for acute work injuries. Pendleton, H. M., & Schultz-Krohn, W. (Eds.). (2011). Pedretti's occupational therapy: Practice skills for physical dysfunction (7th ed.). St. Louis, MO: Elsevier Mosby; p. 343. Explanations of Incorrect Answers A, B: Injuries that occur on the job are not covered by medical plans, and workers should not pay privately for medical bills to avoid filing a workers' compensation claim. C: Not enough time has elapsed for the worker to be covered by long-term disability.

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 syndrome. 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, adduc- tor pollicus, and flexor carpi ulnaris muscles. Evaluation specific to cubital tunnel syndrome (Moscony, 2007a, pp. 233-236) Tinel's sign is a tap over the cubital tunnel to elicit symptoms. Froment's sign is flexion of the IP of the thumb when a lateral pinch is attempted. Wartenberg's sign is the fifth finger held abducted from the fourth finger. The elbow flexion test involves holding the elbow in flexion for 5 minutes with the wrist neutral to elicit symptoms. Nonoperative treatment (Cooper, 2008, pp. 1149-1150) Edema control Pain management Elbow splint or positioning at 30°-60° flexion for 3 weeks Ulnar nerve gliding Proximal conditioning activities Posture and ergonomic training During the protection phase (1 day to 3 weeks), splint the elbow at 70°-90° flexion; provide wound care, edema control, pain management, and AROM of uninvolved joints; and teach one- handed ADL techniques. During the active phase (beginning at 3 weeks), discontinue the elbow splint and anticlaw splint if used before surgery, then add elbow AROM (in pronation first, then supination; add wrist mo- tion with elbow flexed, then extended), ulnar nerve gliding, and desensitization techniques.

to address a contracture, you want movement in what direction?

OPPOSITE EG IF FLEXOR TENDON CONTRACTURE, WANT MOVEMENT IN EXTENSION

Complex Regional Pain Syndrome (CRPS)

Disorder of the sympathetic nervous system typically triggered by a surgery or trauma, resulting in pseudomotor and vasomotor changes and disproportionate pain beyond the region of the surgery or injury. Definition of complex regional pain syndrome (CRPS): pain disproportionate to an in- jury that is either sympathetically maintained or independent of the sympathetic nervous system (traditionally called reflex sympathetic dystrophy) Types of CRPS Type I: develops after a noxious event Type II: develops after a nerve injury Divided into three characteristic stages: Stage I: traumatic stage Stage II: dystrophic stage Stage III: atrophic stage

splint for flexor tendon injury

Dorsal block splint wrist: 20-flexion MCP: 50-70 flexion IP in full extension

Correct! You answered A.The right answer is A Froment's sign occurs when the flexor pollicis longus compensates for a weak or paralyzed adductor pollicis and flexor pollicis brevis. When a client attempts to pinch, the interphalangeal joint of the thumb flexes more than usual. A: Moscony, A. M. B. (2007). Common peripheral nerve problems. In C. Cooper (Ed.), Fundamentals of hand therapy: Clinical guidelines and treatment guidelines for common diagnoses of the upper extremity (pp. 201-250). St. Louis, MO: Mosby; p. 237.

During an assessment, an OTR asks the client to pinch a pinch gauge and notices increased flexion of the thumb interphalangeal joint. What term is used to describe this type of pinch? A. Froment's sign B. Wartenberg's sign C. Jeanne's sign D. Ulnar claw

nonoperative ulnar nerve tx

Edema control Pain management Elbow splint or positioning at 30°-60° flexion for 3 weeks Ulnar nerve gliding Proximal conditioning activities Posture and ergonomic training

Radial tunnel syndrome

Entrapment of the radial nerve in an area extending from the radial head to the supinator muscle Symptoms: 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 strengthen- ing exercise at 3 weeks, resistive exercise as 6 weeks

interventions for flexor tendon injuries

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

extensor tendons

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

flexor tendons

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

For clients who have arthritis, which aspect of an occupational therapy intervention plan is the MOST crucial?

A client is being treated for an extensor tendon repair in Zone VI of the middle finger proximal to the juncturae tendinum. Which orthosis would be MOST appropriate?

Forearm based, including the middle, ring, and index fingers. It is important to consider adjacent digits when applying an orthosis. In this example, the injury falls proximal to the juncturae tendinum, which can apply force to the repaired site if the adjacent digits were to flex, thus compromising the repair.

Evaluation specific to claw deformity

Froment's sign is flexion of the IP of the thumb when a lateral pinch is attempted. Wartenberg's sign is the fifth finger held abducted from the fourth finger. Jeanne's sign is hyperextension of the thumb MCP. Semmes-Weinstein monofilament testing is used to test for loss of sensation.

grades for CTD

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

pain during activity, resolves when activity stopped

Grade II

pain persists after activity, affects work productivity, objective weakness and sensory loss

Grade III

Use of extremity results in pain up to 75% of time, work is limited

Grade IV

A high-level ulnar nerve injury may result in which characteristic deformity?

Hyperextension of the ring and small finger MCP joints because of loss of the extension-controlling forces of the third and fourth lumbricals The third and fourth lumbricals are innervated by the ulnar nerve. Loss of motor function in these muscles allows the extensor digitorum communis to extend the MCP joints without any opposing controlling forces, also known as "claw hand" deformity.

A blocking splint fabricated to maintain the metacarpophalangeal (MCP) joints in extension can be useful to isolate which joint movements?

IP joint flexion and FDP excursion basically you want to avoid overstressing flexor tendon, but flexion is still flexion so just doing it at IPs will prevent tendon from tearing need flexion for FDP to excursion since flexing

A 5-year-old client has been referred for fabrication of an orthosis after a flexor tendon repair. Which protocol would be MOST appropriate for this client?

Immobilization orthosis for 3-4 weeks Children who cannot understand or follow a prescribed protocol for motion are best treated initially with an immobilization orthosis to strengthen the repair before movement to reduce the chance of rupture.

Proliferative phase (wound healing)

In the proliferative process (also called the fibroplastic, granulation, or epithelialization pro- cess), 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 moderately quickly, and circular wounds the most slowly.

Remodeling phase

In the remodeling process, scar tissue first consists of randomly arranged collagen fibers, and as the scar matures, the collagen is broken down and remodeled. The scar is then more elastic, smoother, and stronger. 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.

An OTR® who is a certified hand therapist is responsible for supervising a new COTA® in an outpatient hand clinic. What is the purpose of the supervisory process, as defined by AOTA? A. To ensure that COTAs treat only clients with diagnoses about which they have extensive knowledge B. To ensure that COTAs practice within their scope of practice with regard to state licensure laws C. To ensure the safe and effective delivery of occupational therapy services and to foster professional competence and development D. To provide evaluative feedback on an ongoing basis to the supervisee

Incorrect. You answered B.The right answer is C As stated in the Guidelines for Supervision, Roles, and Responsibilities During the Delivery of Occupational Therapy Services (AOTA, 2014), "Within the scope of occupational therapy practice, supervision is a process aimed at ensuring the safe and effective delivery of occupational therapy services and fostering professional competence and development" (p. S16). A: All practitioners must understand the diagnoses of clients with whom they work; this understanding occurs outside the supervisory process. B: All practitioners must understand scope of practice and state licensure laws; this understanding occurs outside the supervisory process. D: Feedback should be descriptive rather than evaluative. Descriptive feedback clearly states specific information that allows the receiver of the feedback to self-assess. Evaluative feedback is general in nature and does not promote critical reflection.

Increase digital active range of motion to facilitate holding a washcloth during bathing - wanna get that FLEXION going again gently to prevent adhesions/contractures

trigger finger

Inflammation and thickening of the tendons of the finger makes it difficult to flex or extend the finger, may become stuck and then snap into position - diagnosis: static immobilization orthosis that puts MCPs at 0 d. - tx: hand-based trigger finger splint (static immobilization orthosis) that puts MCPs at 0 d. (full extension) with PIP & DIP free for AROM

The occupational profile of a client recently diagnosed with bilateral osteoarthritis of the first carpometacarpal joints of the thumbs reveals that the client is retired and enjoys reading, playing cards with friends, and painting. The client has insurance coverage for only three occupational therapy sessions. What client education topics should the OTR® focus on FIRST? A. Hand strengthening exercises the client can perform independently B. Orthoses that may be fabricated to support and protect affected joints C. Thermal modalities to reduce pain and stiffness D. Joint protection principles

Joint protection principles are ideally taught early in the disease process to decrease joint stress and damage.

Lunate fractures are associated with

Keinbock's disease.

wound healing factors

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. d. Repeated trauma, decreased blood supply, or hypoxic tissue 2. Systemic factors Diabetes mellitus Nutrition deficiency: Vitamins A, C, and E; zinc; and copper Atherosclerosis HIV, AIDS Medications f Agingg. Radiation therapy

operative tx for radial tunnel syndrome

Long arm splint with elbow flexed, forearm supinated, wrist neutral for 2 weeks, then wrist cock up for 2 more weeks passive and active pronation and supination, hand strengthen- ing exercise at 3 weeks, resistive exercise as 6 weeks

non-operative tx for radial tunnel syndrome

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 strengthen- ing exercise at 3 weeks, resistive exercise as 6 weeks

claw hand splint

MCP blocking splint - circular looking splint that wraps around base of MCP and 4th and 5th fingers keeps MCP in 90 flexion, facilitating PIP extension while allowing active grasp

splint for ulnar claw hand

MCP blocking splint with MCP in 90 d. of flexion

ulnar claw hand

MCP blocking splint with MCP in 90 d. of flexion, facilitating PIP extension while still allowing active grasp

splint for ulnar nerve injury

MCP flexion block splint dynamic/static splint to position MPs in flexion (places flexor tendons of hand in a relaxed position by preventing extension while still allowing active grasp)

order of sensation returning

MOVING EASIER THAN 2 POINT SO DIFFICULTY LEVEL AS FOLLOWS: 1: 1 point moving 2: 1 point discrimination 3: 2 point moving 4: 2 point discrimination

Hand: Avulsion injuries occur when the tendon separates from the bone and its insertion and removes bone material with the tendon. Types include:

Mallet finger is avulsion of the terminal tendon and is splinted in full extension for 6 weeks. Boutonniere deformity is disruption of the central slip of the extensor tendon characterized by proximal interphalangeal (PIP) flexion and distal interphalangeal (DIP) hyperextension; the PIP is splinted in extension, and isolated DIP flexion exercises are performed. Swan neck deformity is injury to the metacarpophalangeal (MCP), PIP, or DIP joints character- ized by PIP hyperextension and DIP flexion; the PIP is splinted in slight flexion.

Splinting fabrication principles

Material properties of low temperature thermoplastics include elasticity, memory, bonding, durabil- ity, rigidity, perforations, finish, color, and thickness. Patterns are drawn on a paper towel by outlining the body part using two-thirds the width of the extremity and half the circumference of the bone, marking boney landmarks, and extending 1/2 in. to 2/3 in. past the fingertips and thumb. 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 proxi- mal transverse arches of the hand are maintained (Coppard & Lohman, 2007). Finishing the splint requires applying reinforcement if necessary, rounding all corners, flaring the edges, applying appropriate rounded end straps, adding open-cell padding when appropriate, and making adjustments. The practitioner instructs the client and caregiver in wear and care of the splint, provides contact information for consultation if problems occur, and monitors the client's responses to splint wear.

how to measure outcomes of therapy?

Measure outcomes using the Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (Quick DASH) before and after therapy.

Nonoperative tx for de quervain's syndrome

Medical treatment includes corticosteriod injections. Occupational therapy treatment consists of a forearm-based thumb spica splint with wrist in neutral and thumb radially abducted for 3 weeks. Activity modification and avoidance of pinch are recommended. After 3 weeks, the client progresses to a soft splint and isometric exercise. Computer ergonomics education is provided. Strengthening activities are provided.

operative tx for de quervain's

Medical treatment includes surgical release of the first dorsal compartment. Occupational therapy treatment postsurgery consists of a forearm-based thumb spica splint with wrist at 20° extension and thumb radially abducted for 3 weeks. c. Gentle ROM and tendon gliding exercises are performed. Grip and pinch strengthening begins at 2 weeks. Scar management and desensitization techniques are used.

evaluation process

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

Electrical stimulation

Methods include NMES, TENS, and iontophoresis. Effects on the client 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 three possible mechanisms: gate control, endorphin re- lease, and acupuncture. Iontophoresis decreases inflammation and controls pain. Indications, contraindications, and precautions: Do not use over pacemakers, carotid sinus, preg- nant uterus, eyes, and clients with epilepsy, cancer, infection, decreased sensation, cardiac disease and stroke. With iontophoresis use, be aware of possible drug allergie

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 eyewear when using laser, do not use over vagus nerve, carotid sinus, pregnant uterus, eyes, infection, endocrine glands, or cancer.

Nerve gliding exercises

Nerve flossing is a type of gentle exercise that stretches irritated nerves. This can improve their range of motion and reduce pain. It's sometimes called nerve gliding or neural gliding. Eg for ulnar nerve: 1) Begin with your arm out, palm side of the hand facing up. 2) Bend the elbow toward you, palm side facing you.

complications of flexor tendons

Nerve involvement, usually laceration, is common because of the mechanisms by which tendons are injured. Edema must be therapeutically controlled to maintain motion and reduce pain and joint stiffness. Pain is common at the site of the injury; ADL dysfunction should be assessed with an ADL checklist. Muscle actions are affected by impairment in flexion and deviation of the wrist and digits. Protocols The Duran protocol is an early passive ROM program. The Kleinert protocol involves active extension of digits with passive flexion via traction, typi- cally a rubber band. The early active motion protocol begins within days of surgery to prevent adhesions and pro- mote tendon gliding and excursion. An immobilization protocol is advisable only for patients who are unable to care for themselves or who do not have the cognitive capacity to ensure safety postoperatively. This protocol is sometimes used with children to prevent rupture of the repair. Copyright © 2013 by the American Occupational Therapy Association. All rights reserved. For permissions, contact www.copyright.com. 8 e. Splinting is used to prevent rupture because the repaired tendon is at its weakest 10 to 12 days postsurgery.

tests of hand 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

A client with an acute mild brachial plexus stretch injury affecting the left side reports limited forward shoulder flexion because of pain; limited cervical mobility; forward head and rounded shoulder posture; and decreased sensation in the thumb, index, and radial side of the long finger. The client has full range of motion in internal and external rotation of the shoulder. The occupational profile reveals that the client is an accountant who enjoys surfing and tennis on the weekends. What instruction should the OTR® provide on the first visit?

Nonoperative treatment of a brachial plexus stretch injury includes education on how to minimize further irritation to the brachial plexus, including postural education and education regarding avoidance of provocative positions (e.g., overhead activities).

hand interventions

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

intervention for proximal humeral fractures

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

tx for type 1 radial head fracture (nondisplaced)

Orthotics are used for immobilization as needed. ROM is begun early, within the 1st week if medically cleared. A long arm sling is worn.

interventions for radial head fractures

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

lateral epicondylitis

Overuse of wrist extensors, especially the extensor carpi radialis brevis. Inflammation of the muscle attachment to the lateral epicondyle of the elbow. Often caused by strongly gripping. Commonly called tennis elbow. - elbow strap, wrist strap - ice and deep friction massage - stretching - activity/work modifications - as pain decreases, add strengthening - strengthening: begin with isometric exercises, then proceed to isotonic and eccentric exercises

Tx for boutonniere deformity

PIP extension splint for 6 weeks KEEP DIP JOINT FREE FOR ACTIVE ROM

what should NOT be used for complex regional pain syndrome?

PROM or painful treatment

Sensory receptors of the hand include

Pacinian corpuscles, responsible for vibration; Ruffini end organs, responsible for tension; and Merkel cells, responsible for pressure

Passive extension of the distal interphalangeal joint if the metacarpal and proximal phalangeal joints are flexed DO NOT WANT ANY FLEXION MOTIONS B/C THAT PUTS MORE STRESS ON FLEXOR TENDON SO EXTENSION IS OK IF THE OTHER JOINTS FLEXED

Active Assisted Range of Motion (or AAROM)

Patient uses the muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment (such as a strap).

pillar pain

Pillar pain is the pain experienced to the sides of the incision in the thicker parts of the palm, called the thenar and hypothenar eminence. RESULTS FROM CARPAL TUNNEL SURGERY.

postoperative treatment for cubital tunnel syndrome

Postoperative treatment (Moscony, 2007a, pp. 233-236) During the protection phase (1 day to 3 weeks), splint the elbow at 70°-90° flexion; provide wound care, edema control, pain management, and AROM of uninvolved joints; and teach one- handed ADL techniques. During the active phase (beginning at 3 weeks), discontinue the elbow splint and anticlaw splint if used before surgery, then add elbow AROM (in pronation first, then supination; add wrist mo- tion with elbow flexed, then extended), ulnar nerve gliding, and desensitization techniques. - MCP FLEXION ANTICLAW SPLINT AS NEEDED.

Iontophoresis

Process of infusing water-soluble products into the skin with the use of electric current, such as the use of the positive and negative poles of a galvanic machine.

Interventions for wrist fractures

ROM is allowed in the early phases of healing and repair. Orthotics are used to protect the extremity from motion or allow for protected motion. A home program is provided to increase progression of function and outcomes. Exercises are used to facilitate movement and improve performance of the upper extremity; ex- amples include AROM with wrist extended and fingers flexed; blocking exercises; tendon and nerve gliding exercises; and strengthening exercises, such as theraplast and use of hand exercises Modalities (e.g., heat, ultrasound, cryotherapy, paraffin, TENS) are used to prepare tissues for work and assist with pain relief and tissue healing.

Specific testing for hands

ROM: goniometric measurements 2. Strength: manual muscle testing, dynamometer, and pinch gauge meter 3. Edema: volumeter or centimeter tape 4. Vascular: observation of color and trophic changes, pulse, skin temperature, Allen's test 5. Sensation: Semmes-Weinstein monofilament and two-point discrimination. Monofilament is used for nerve compression, and two-point discrimination is typically used for nerve laceration and recovery. 6. 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

radial nerve palsy

Radial nerve palsy is a result of compression of the radial nerve, often caused by fracture of the humerus bone. This results in pain, weakness, or loss of function in a person's wrist, hand, and fingers.

With which type of client would it be best practice to allow the proximal interphalangeal (PIP) joints to develop a contracture to facilitate functional grasp? A. Client with a C6 spinal cord injury B. Client with rheumatoid arthritis C. Client with cerebrovascular accident (CVA) D. Client with cerebral palsy (CP

Ranging the hand (wrist extension combined with finger flexion and wrist flexion combined with finger extension) of a client with a spinal cord injury preserves a functional tenodesis grasp while encouraging PIP flexion contractures.

dupuytren's disease

Requires EXTENSION splint INITIALLY 24 hours a day, 7 days a week. Scar management including scar massage, scar pad and compression garment. disease of fascia of palm & digits. A/PROM, progress to strengthening once wounds healed.

An OTR® is assessing a new client who has a distal radius fracture. Functional outcome reporting is required by the facility. Which approach to functional outcome measurement is MOST consistent with client-centered care?

Research on qualitative and quantitative measures suggests that practitioners should assess clinical outcomes from both a qualitative and a quantitative perspective and that subjective information plays a crucial role in maximizing therapeutic outcomes. The DASH is a region-specific (not disease-specific) measure. Its focus is too narrow to characterize dysfunction; additional assessments are needed.

how measure hand sensation

Semmes-Weinstein monofilament and two-point discrimination. Monofilament is used for nerve compression, and two-point discrimination is typically used for nerve laceration and recovery.

postoperative tx median nerve

Surgical treatment includes traditional open carpal tunnel release surgery or endoscopic release. After surgery, some clients may not need therapy. For more complicated cases, wound care and scar mobilization are provided. Pain management may include use of gel pads on the scar. Pain on either side of the surgical release is called pillar pain. Splinting is provided only to clients who sleep with the wrist flexed or who will engage in too much activity too soon (e.g., immediate return to work). AROM of wrist, thumb, and fingers begins 1-2 days postsurgery. Nerve and tendon gliding exercises are provided. Strengthening activities begin in 3 to 6 weeks.

injury characterized by hyperextension and DIP flexion

Swan neck deformity

tx for scarring during phase 3 of wound healing

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.

tx for flexor tendon injuries

The Duran protocol is an early passive ROM program. The Kleinert protocol involves active extension of digits with passive flexion via traction, typi- cally a rubber band. The early active motion protocol begins within days of surgery to prevent adhesions and pro- mote tendon gliding and excursion. An immobilization protocol is advisable only for patients who are unable to care for themselves or who do not have the cognitive capacity to ensure safety postoperatively. This protocol is sometimes used with children to prevent rupture of the repair. Splinting is used to prevent rupture because the repaired tendon is at its weakest 10 to 12 days postsurgery.

An OTR is working with a child who has an epiphyseal fracture of the proximal interphalangeal bone with slight malalignment. Which intervention is MOST appropriate for a child with this condition?

The least invasive and most effective treatment for a slight malalignment is buddy taping, and this is the intervention the child would be most likely to tolerate.

wound healing inflammatory phase

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

An OTR® assigned to the stroke unit of an acute care hospital is prioritizing goals and treatment for a patient with a hemiplegic hand. Based on the expected pattern of progression in the acute phase after a stroke, which areas of focus should the OTR consider to enable the patient to overcome barriers to ADL performance? A. Passive range of motion and positioning of the affected upper extremity, bed mobility B. Visual and cognition issues, upper-extremity orthotic needs C. Transfers, therapeutic exercise for upper-extremity strengthening D. Community mobility, fine motor coordination

The right answer is A In the acute stage of recovery, passive range of motion, positioning of the affected extremity, and bed mobility are critical components in restoring function for ADL performance. Porter, G., & Taggart, L. (2014). The neurological hand. In C. Cooper (Ed.), Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity (2nd ed., pp. 551-566). St. Louis, MO: Mosby/Elsevier; pp. 553-554. Explanations of Incorrect Answers B, C, D: Although visual and cognition issues, upper-extremity orthosis needs, transfers, therapeutic exercise for upper-extremity strengthening, community mobility, and fine motor coordination all are areas of concern, in an acute care setting, passive range of motion, positioning of the affected extremity, and bed mobility are areas of focus critical to overcoming barriers to self-care.

An OTR® is treating a client with a cumulative trauma disorder resulting from work in an automotive assembly plant. Acute symptoms have subsided, and the client is preparing to return to work. Which strategies should the OTR® train the client in to prevent symptoms from recurring? A. Deep breathing and relaxation exercises B. Activity modification and proper body mechanics C. Joint protection and pacing techniques D. Energy conservation and work simplification techniques

The right answer is B Activity modification and proper body mechanics are essential for long-term control of an inflammatory cumulative trauma disorder. Kasch, M. C., & Walsh, J. M. (2013). Hand and upper extremity injuries. In H. M. Pendleton & W. S. Krohn (Eds.), Pedretti's occupational therapy: Practice skills for physical dysfunction (7th ed., pp. 1037-1073). St. Louis, MO: Mosby. Explanations of Incorrect Answers A: Deep breathing and relaxation exercises assist in reducing anxiety but will not prevent cumulative trauma disorder symptoms. C: Joint protection and pacing techniques best address symptoms of arthritis. D: Energy conservation and work simplification techniques are recommended for clients with respiratory and cardiac diagnoses.

An OTR® is treating a client who sustained dorsal hand burns secondary to a work-related injury. In the intensive care unit phase of treatment, which technique for completing ROM of the hand is safest? A. Passively range all digits and joints at once B. Passively range each digit and joint one at a time C. Instruct the client to actively make a fist, then straighten the fingers completely D. Instruct the client to wear a resting hand splint at all times

The right answer is B Ranging each joint separately decreases the chance of rupturing finger extensor tendons with dorsal hand burns. Pessina, M. A., & Orroth, A. C. (2008). Burn injuries. In M. V. Radomski & M. C. Trombly Latham (Eds.), Occupational therapy for physical dysfunction (6th ed., pp. 1224-1263). Baltimore: Lippincott Williams & Wilkins. Explanations of Incorrect Answers A, C: AROM or PROM of more than one joint at a time increases the chance of a tendon rupture after a burn to the dorsal hand. D: Wearing a splint inhibits performing ROM of the hand.

An OTR® in an outpatient setting is treating a client who underwent repair of multiple flexor tendons in Zones 2 and 3 approximately 6 weeks ago. The dorsal blocking splint has been removed, and the client is beginning to actively move the digits. The client is eager to return to work as a carpenter, and the OTR is revising the goals with the client. Which goal for this time period is MOST appropriate? A. Increase passive wrist and digit composite extension to improve flexor tendon length B. Increase digital active range of motion to facilitate holding a washcloth during bathing C. Increase grip strength to maintain grasp on woodworking tools D. String 25 beads of various sizes and shapes to improve fine motor coordination

The right answer is B Setting realistic, meaningful goals and revising them as the client progresses is a critical component in treating traumatic injuries. At 6 weeks after operative tendon repair, the client may be ready for light, nonresistive functional activities that promote active flexion. A: Adding too much force at this stage may result in rupture of the repairs. C: At 6 weeks after repair of flexor tendons, strengthening is contraindicated. D: This goal has no functional component or intrinsic value to the client.

A cabinetmaker is referred to occupational therapy with a recent onset of stenosing tenosynovitis of the right middle and ring fingers. The client has a history of rheumatoid arthritis. As part of the ergonomic education, what will the OTR® MOST likely include? A. Prevent static wrist positioning, hold tools close to the fulcrum, and use a thick protective glove. B. Reduce use of excessive gripping force, prevent contact stress, and implement task rotation. C. Stenosing tenosynovitis is common in rheumatoid arthritis; no ergonomic education is needed D. Switch to manual tools to reduce vibration from power tools and conduct a regular tool check for wear and tear.

The right answer is B Stenosing tenosynovitis (trigger finger) is a condition associated with prolonged or high repetitions in forceful gripping. All of these modifications prevent or eliminate exposure to forceful gripping. Explanations of Incorrect Answers A: Holding tools closer to the fulcrum requires more force exertion. A longer handled tool can help to decrease force exertion. Static positioning should also be avoided. C: Clients with rheumatoid arthritis might have a higher incidence of stenosing tenosynovitis but might still have other work-related risk factors leading to it. D: Vibration is a risk factor for other cumulative trauma disorder but does not necessarily contribute to stenosing tenosynovitis.

An OTR is working with a client who has a flexor tendon injury. The referring physician prefers patients to follow the flexor tendon protocol using controlled passive motion. Which movement is indicated? A. Active movement of the metacarpal joint only B. Passive extension of the distal interphalangeal joint if the metacarpal and proximal phalangeal joints are flexed C. Active movement of the distal interphalangeal joint only D. Passive flexion of the distal interphalangeal joint if the metacarpal and proximal phalangeal joints are extended

The right answer is B The distal interphalangeal joint and proximal interphalangeal joint can be passively extended if the other joints of the digit are flexed to initiate tendon glide and prevent scarring of the tendon. A, C: Joints may only be moved passively in this controlled-movement flexor tendon protocol. D: Because this is a flexor tendon repair, extension needs to closely guarded to prevent flexor tendon rupture.

An OTR® has been working with a client recently diagnosed with complex regional pain syndrome of the upper extremity secondary to an improperly casted distal radius fracture. Which modality is BEST to reach the treatment goal of pain control for this client? A. Cold spray B. Neuromuscular electrical stimulation (NMES) C. Transcutaneous electrical nerve stimulation (TENS) D. Iontophoresis

The right answer is C A TENS unit will best aid the client in reaching the treatment goal of pain control. Cooper, C. (2008). Hand impairments. In M. V. Radomski & M. C. Trombly Latham (Eds.), Occupational therapy for physical dysfunction (6th ed., pp. 1131-1170). Baltimore: Lippincott Williams & Wilkins; p. 1159. Explanations of Incorrect Answers A: Cold spray is used to treat trigger points and increase passive stretch of a muscle tendon unit. B: NMES is best used to facilitate muscle contraction. D: Iontophoresis is used to control inflammatory conditions.

An OTR® is treating a 77-year-old client who requires a resting hand splint. Which splint characteristics are MOST important in addressing the natural aging process of skin and adipose tissue? A. Use colored splints and no moving parts B. Use D rings and mark where straps go C. Use soft straps and thick padding D. Label the splint with client's name and left-right and top-bottom instructions

The right answer is C C: As a person ages, the skin thins, and adipose tissue is lost. Soft straps and padding add comfort and prevent skin breakdown. Cooper, C. (2007). Geriatric hand therapy. In C. Cooper (Ed.), Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity (pp. 522-530). St. Louis, MO: Mosby. Explanations of Incorrect Answers A: Colored splints are easier to locate in white institutional bedding. B: Using D rings and marking straps makes it easier for the client to don and doff the splint independently. D: Labeling the splint can compensate for cognitive deficits.

A client was referred to occupational therapy because of persistent pain in the neck and shoulder and the recent onset of paresthesia in the right index and middle fingers. The OTR® decides that the symptoms may be work related and proceeds with an onsite ergonomic assessment. During the ergonomic assessment, the OTR® observes that the client uses the mouse 80% of the time. What will the OTR® MOST likely recommend? A. Using a vertical mouse and placing it at desktop level B. Changing to a laptop so that the client can use the touchpad instead of a mouse C. Performing full upper body stretches after every 20 minutes of mouse use D. Assigning the client other tasks that require less frequent use of the mouse

The right answer is C Frequent stretches and movements away from the static posture and prolonged use of a mouse is another strategy to prevent repetitions and muscle strain. Explanations of Incorrect Answers A: Putting the mouse at regular desktop height is usually too high for most workers and can lead to shoulder tension. B: From an ergonomic standpoint, using a laptop without modifying the level of the monitor screen or the keyboard may lead to other musculoskeletal symptoms. D: Job changes are usually not part of the recommendations after an ergonomic assessment.

Which outpatient treatment intervention is contraindicated for decreasing the arm edema and stiffness associated with complex regional pain syndrome of the upper extremity? A. Instruction in the use of contrast baths several times a day B. Instruction in performing gentle, pain-free AROM movements several times a day C. Provision of an arm sling to wear during the day D. Provision of a compression garment to wear during the day

The right answer is C Wearing an arm sling will increase stiffness and edema because it places the extremity in a dependent and static position for long periods of time. Vacek, K. M., & Aragon, O. (2007). Upper extremity prosthetics. In C. Cooper (Ed.), Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity (pp. 420-435). St. Louis, MO: Mosby. Explanations of Incorrect Answers A, D: Taking contrast baths and using a compression garment are beneficial for edema control of the arm in a client with complex regional pain syndrome. B: Gentle, pain-free AROM encourages circulation, decreases stiffness, and may assist in interrupting the pain cycle.

An OTR is working with a client who has been in a motor vehicle accident. The client has sustained flexor tendon injuries to the index and middle fingers and also presents with a median nerve injury. Which flexor tendon zone corresponds to this client's injuries? A. Zone I B. Zone II C. Zone III D. Zones IV and V

The right answer is D D: Zone IV consists of the transverse carpal ligament, and the median nerve runs under this ligament; Zone V is distal to this ligament and thus contains the median nerve branch. Klein, L. J. (2007). Tendon injury. In C. Cooper (Ed.), Fundamentals of hand therapy: Clinical guidelines and treatment guidelines for common diagnoses of the upper extremity (pp. 320-347). St. Louis, MO: Mosby; p. 333. Explanations of Incorrect Answers A, B, C: Zones I, II, and III do not contain the median nerve branch.

A client with a nondisplaced shaft fracture of the right fifth metacarpal has a physician's order for full-time splinting. Which orthosis would the OTR® be MOST likely to fabricate? A. Dorsal hood splint with the wrist in approximately 20° flexion, all metacarpophalangeal (MCP) joints of the affected hand in 70°-90° flexion, and interphalangeal (IP) joints of the affected hand in 0° extension B. Volar-based ulnar gutter with MCP and IP joints of the ring and fifth fingers in 0° extension and the wrist in neutral C. Dorsal-based wrist cockup splint with MCP and IP joints free and the wrist in approximately 20° extension D. Volar-based ulnar gutter with MCP joints of the ring and fifth fingers in 70°-90° flexion, fourth and fifth IP joints in 0° extension, and the wrist in approximately 20° extension

The right answer is D Holding the MCP joints in flexion helps prevent contracture of the collateral ligaments. Varney, A. C. (2014). Hand fractures. In C. Cooper (Ed.), Fundamentals of hand therapy: Clinical reasoning and treatment guidelines for common diagnoses of the upper extremity (2nd ed., pp. 361-382). St. Louis, MO: Mosby/Elsevier; p. 367. Explanations of Incorrect Answers A: A dorsal hood splint does not offer adequate protection for the fractured metacarpal. B: Maintaining the MCP joint in extension may lead to collateral ligament shortening and decreased ability to flex the MCP joint after the fracture is healed. C: Maintaining the MCP joints in extension may lead to shortening of the lateral bands and joint contractures.

ulnar claw hand (high level lesion)

The third and fourth lumbricals are innervated by the ulnar nerve. Loss of motor function in these muscles allows the extensor digitorum communis to extend the MCP joints without any opposing controlling forces, also known as "claw hand" deformity.

innervates flexor muscles of forearm

ULNAR & MEDIAN NERVE

Evaluation specific to cubital tunnel syndrome

Tinel's sign is a tap over the cubital tunnel to elicit symptoms. Froment's sign is flexion of the IP of the thumb when a lateral pinch is attempted. Wartenberg's sign is the fifth finger held abducted from the fourth finger. The elbow flexion test involves holding the elbow in flexion for 5 minutes with the wrist neutral to elicit symptoms.

dynamic splint purposes

To correct contractures: mechanical stretch of prolonged gentle pull over 8-12 hours to remodel soft tissue To increase passive motion: finger loop angle of pull of 90o; adjust splint as client improves to maintain 90o angle of pull To protect recent hand flexor tendon repair surgery: dorsal blocking splint with hinged wrist and joint wrist blocks to maintain wrist extension at 30o and MCP extension at 60o while allow- ing full wrist flexion (Skirven et al., 2011). To substitute for loss active motion: radial nerve injury splint, with dynamic MCP extension as- sist if needed

An OTR® is explaining the purposes of therapeutic exercise and therapeutic activity to a physician. What are the PRIMARY reasons that OTRs use these interventions for musculoskeletal conditions?

To improve function, increase strength, and prevent muscle imbalances

hyperextension of the metacarpophalangeal joint in the small and ring finger with proximal interphalangeal flexion.

ULNAR claw hand

radial head fractures - 3 types

Type I (nondisplaced) can be treated with a long arm sling. Type II (displaced with a single fragment) is typically treated nonoperatively with immobilization for 2-3 weeks and early motion with medical clearance. Type III (comminuted) is treated operatively, with immobilization and early motion within the first postoperative week as medically prescribed. Doctors classify fractures according to the degree of displacement (how far out of normal position the bones are).

Type 1 radial head fractures (nondisplaced)

Type I fractures are generally small, like cracks, and the bone pieces remain fitted together. can be treated with a long arm sling.

Type 2 radial head fractures (displaced with single fragment)

Type II (displaced with a single fragment) is typically treated nonoperatively with immobilization for 2-3 weeks and early motion with medical clearance. Type II fractures are slightly displaced and involve a larger piece of bone. If displacement is minimal, a sling or splint may be used for 1 to 2 weeks, followed by range-of-motion exercises.

Type III radial head fractures

Type III fractures have multiple broken pieces of bone which cannot be put back together for healing. is treated operatively, with immobilization and early motion within the first postoperative week as medically prescribed. Early movement to stretch and bend the elbow is necessary to avoid stiffness.

type I CRPS happens after

a noxious event (e.g., a fracture) -commonly caused by trauma (Colles' fracture) or surgery

erb's palsy

a paralysis of the arm that most often occurs as an infant's head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal, severing of upper trunk c5-c6. shoulder rotated inward splint: elbow lock splint

Keinbock's disease.

a rare, debilitating condition that can lead to chronic pain and dysfunction. It happens when one of the eight small carpal bones in the wrist, the lunate bone, becomes damaged because there is no blood supply. It is also known as avascular necrosis of the lunate or osteocronosis of the lunate

smith's complete fracture of distal radius most often occurs from falling onto a wrist that is flexed or extended?

flexed

Moberg Pickup Test

a timed test involving picking up, holding, manipulating, and identify- ing small objects. It is used with children and cognitively impaired adults to test median nerve function.

The injury to the flexor tendon is in what is known as "no man's land." The stitches in the fingers are between the distal palmar crease and the proximal interphalangeal joints. In what flexor tendon zone are the injuries located?

ZONE II

Extensor tendon zones Digits II-V

Zone I: distal interphalangeal joint Zone II: middle phalanx Zone III:proximal interphalangeal joint Zone IV: proximal phalanx Zone V: metacarpal phalangeal joint Zone VI: metacarpalphanageal bone Zone VII: carpal bones and wrist

flexor tendon zones

Zone I: extends from fingertip to the center portion of the middle phalanx Zone II: extends from the center portion of the middle phalanx to the distal palmar crease (known as no man's land due to difficulty of tendon gliding without scarring to surrounding tissues) Zone III: extends from the distal palmar crease to the transverse carpal ligament Zone IV: overlies the transverse carpal ligament Zone V: extends beyond the level of the wrist

extensor tendon zones: thumb

Zone I: falls over the interphalangeal (IP) joint Zone II: falls over the proximal phalanx Zone III: falls over the MCP joint Zone IV: falls over the first metacarpal Zone V: falls over the wrist

which zone is known as no man's land, due to difficulty of tendon gliding without scarring to surrounding tissues?

Zone II

Therapeutic exercises provide motion to further enhance performance and function in order to (main goal)

improve ADL performance

Kleinert protocol

active extension of digits with passive flexion via traction, typi- cally a rubber band.

CTD tx

acute: reduce inflammation and pain thru contrast baths, static splinting, ultrasound, interferential stim subacute: slow stretching, activity mod splint: static splint during activities that cause painde

Duran protocol

an early passive ROM program.

Muscles that originate from the lateral epicondyle

anconeus, brachioradialis, supinator, extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor carpi ulnaris (ECU), extensor digitorum (ED), and extensor digiti minimi (EDM).

when administer Quick DASH to assess outcomes?

before & after therapy

fracture of 1st metacarpal base at CMC joint, commonly associated with CMC subluxation?

bennet's fracture

most common site of median nerve compression

between heads of the pronator teres near elbow joint

for trigger finger, tendon gliding exercises w/ splint

blocks MCP joint from moving, protecting tendon from snapping as exercises are done

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

brachial and brachiocephalic arteries

The three common phases of healing are

inflammation, repair, and remodeling

Carpal fractures are fractures to

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

syndrome when median nerve is compressed at the wrist

carpal tunnel

vas·o·mo·tor

causing or relating to the constriction or dilatation of blood vessels. medulla of the brain (the vasomotor center ) that regulates blood pressure by controlling reflex alterations in the heart rate and the diameter of the blood vessels, in response to stimuli from receptors in the circulatory system or from other parts of the brain.

Boutonniere deformity results from damage to the

central slip

Energy conservation and work simplification techniques are recommended for clients with

clients with respiratory and cardiac diagnoses.

intrinsic plus

common for pts. with RA. prevents stiffness. burns? MCP in 90, IPs in extension.

The primary and most severe complication of distal radius fracture is

complex regional pain syndrome

Cryotherapy

cools tissue to 1-2 cm depth (Bracciano, 2008, pp. 85, 92-94). Methods include ice massage, ice, towels, cold packs, cold water immersion baths, cool whirlpools, cold compression units, and vapocoolant sprays. Effects on the client include pain relief, decreased edema, decreased muscle spasms, decreased in- flammation, 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 infec- tions.

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 active motion.

which tendons have more excursion - extensors or flexors?

ext tendons have less tendon excursion than flexors (50mm vs70mm) ext tendons are weaker and there are more issues with lag even before it's injured

abductor pollicis brevis and extensor pollicis work together to

extend & abduct the thumb

colles's fracture most often occurs from falling onto a wrist that is flexed or extended?

extended

de Quervain syndrome

de Quervain syndrome is caused by cumulative microtrauma resulting in tenosynovitis of the thumb muscle tendon unit, the abductor pollicis longus and extensor pollicis brevis, and the tendons in the first dorsal compartment of the wrist. Causes include forceful, repetitive thumb abduction with wrist ulnar deviation, carpometacarpal (CMC) osteoarthritis, scaphoid fracture, intersection syndrome, or radial nerve neuritis. At highest risk are women ages 35-55, women in late pregnancy, mothers of young children, and people who engage extensively in keyboarding, piano playing, knitting, needlepoint, and racket sports. Nonoperative treatment (Cooper & Martin, 2007, pp. 292-293) Medical treatment includes corticosteriod injections. Occupational therapy treatment consists of a forearm-based thumb spica splint with wrist in neutral and thumb radially abducted for 3 weeks. Activity modification and avoidance of pinch are recommended. After 3 weeks, the client progresses to a soft splint and isometric exercise. Computer ergonomics education is provided. Strengthening activities are provided. Operative treatment (Skirven, Osterman, Fedorczyk, & Amadio, 2011, pp. 580-582) Medical treatment includes surgical release of the first dorsal compartment. Occupational therapy treatment postsurgery consists of a forearm-based thumb spica splint with wrist at 20° extension and thumb radially abducted for 3 weeks. c. Gentle ROM and tendon gliding exercises are performed. Grip and pinch strengthening begins at 2 weeks. Scar management and desensitization techniques are used.

muscles of the forearm and upper arm

deltoid, triceps, anconeus, biceps brachii, brachialis, brachioradialis

remodeling

deposits bone

protective sensation

diminished or absent pinprick or hot/cold sensation.-impairements can put pt at risk for burns, blisters and cuts. - address any edema and skin integrity. -use built up handles to decrease grip force. -protect the skin from hot/cold/sharp items. -intact protective sensation allows a pt to be candidate for discriminative sensory training.

Boutonniere deformity

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

most common phalanx (end of finger) fracture

distal phalanx - may result in mallet finger

tendon excursion

distance a tendon travels upon movement

what might a person with a deep laceration to left volar forearm wear as a splint?

dorsal blocking - help flexor tendon heal by not overstretching it

a person recovering from a flexor tendon injury may wear a

dorsal blocking splint to recover

what kind of dynamic splint and positioning should be used for flexor tendon repair?

dorsal blocking splint with hinged wrist and joint blocks to maintain wrist extension at 30 and flexion at 60 while allowing full wrist flexion

tx for low level median nerve injury

dorsal blocking/protection splint (used to prevent stress to flexor tendons following injury or repair)

colles

dorsal displacemntC

are ext tendons more likely to be injured?

ext tendons are superficial and more likely to be injured with dorsal injury-you can see the EDC gliding on dorsum of hand P1 has largest tendon to bone interface and greatest risk for tendon adhesions

splint for radial wrist drop

dynamic extension splint (prevent extensor tendons from being overstretched)

when should ROM for be used for elbow fractures

early, within 1 week if medically cleared

Elbow splints include anterior and posterior

elbow immobilization splints

sequence of tendon gliding exercises

fingers straight, MCP flexion, hook fist, then flat fist

splint for OA/RA

functional or safe splint

Modalities for pain relief and tissue healing include

heat, ultrasound, cryotherapy, paraffin, and transcutaneous electrical nerve stimulation (TENS).

Thermotherapy

heats tissue to 1-2 cm depth (Bracciano, 2008, pp. 109-110). 1. 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, decreased 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 cogni- tion.

Ultrasound

heats tissue to 1-5 cm depth (Bracciano, 2008, Chapter 7, pp. 146-147). Ultrasound has thermal and nonthermal effects and also is used in phonophoresis. Effects on the client 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 to accelerate tissue repair and decrease inflammation. Indications, contraindications, and precautions: Avoid use with pregnancy, over eyes, pacemaker, 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, or sensory impairments.

clinical sign: loss of thumb opposition, palmar abduction, flexion at MCP and IP in 4th and 5th fingers

high median nerve injury

discriminative sensory re-education

identification of objects w/ and w/o vision

supinators and extensors originate from the

lateral epicondyle

in all radial head fractures, rotation of the forearm (movement at the elbow) may be

limited

forward head posture indicates

limited scapular mobility. when limited, imbalanced glenohumeral rhythm.

wartenberg's sign

little finger held in abduction

median nerve injury

loss of pinch, thumb opposition, index finger MCP & PIP flexion, decr pronation Post-surgical: AROM& PROM in splints for digits & thumbs, discontinue splint at 6 wks and begin strengthening, dorsal blocking splint for 4-6 wks C bar splint

clinical sign: flattening/wasting of thenar eminence, thumb adduction, clawing of index and middle fingers

low lesion median nerve injury (e.g., wrist fractures) AKA ape hand

ape hand

lower median nerve injury that happens only after thenar eminence has wasted - loss of pinch strength, loss of thumb oppoisiton & abduction result of injured hand at rest

pronators and flexors originate from the

medial epicondyle

what nerve innervates many of the muscles associated with the flexor tendon?

median

which nerve innervates the forearm pronators?

median (think promedflex)

a flexor tendon injury may coincide with a

median nerve injury (goes through same part of wrist)

pronator teres syndrome

median nerve, elbow splinted at 90, forearm in neutral

what type of injury would you use Semmes-Weinstein monofilaments for?

nerve compression

Type II CPRS typically follows

nerve injury (eg laceration)

what type of injury would you use 2 point discrimination for?

nerve laceration

tx for type 2 radial head fracture

non-operative, immobilization for 2-3 wks, early motion with medical clearance ROM is begun early, within the 1st week if medically cleared.

sx of ulnar nerve compression at elbow

numbness & tingling along ulnar aspect of forearm/hand pain at elbow weak power grip tinel sign at elbow

avulsion injuries

occur when the tendon separates from the bone and its insertion and removes bone material with the tendon - mallet finger - boutonniere deformity - swan neck deformity

Thumb spica splints (volar thumb or radial gutter thumb immobilization) are used

on the long or short opponens to provide CMC immobilization.

should an immobilization protocol be used for flexor tendon injuries?

only for patients who are unable to care for themselves or who do not have the cognitive capacity to ensure safety postoperatively. This protocol is sometimes used with children to prevent rupture of the repair.

elbow fracture splint

posterior elbow splint in 90 d. flexion

Knee extension splints provide

posterior full knee extension to the extent possible.

PAMs are considered a

preparatory method for the therapeutic use of occupations or purposeful activities (AOTA, 2012).

what does dorsal block splint do?

prevent over-stretching flexor tendon so it can heal

what does tendon gliding help with

preventing scar adhesion (making it so tendons can't glide anymore)

Median nerve injury to wrist

produces carpal tunnel-like symptoms, such as palmar numbness and numb- ness of first digit to half of the fourth digit, with generalized weakness and pain. lower lesion: ape hand

muscles that originate from the medial epicondyle

pronator teres,flexor carpi radialis (FCR), flexor carpi ulnaris (FCU), palmaris longus (PL), and FDS (flexor digitorum superficialis).

most common fractures of the upper arm

proximal humeral fractures (involve articular surface, greater or lesser tuberosity, or surgical neck)

functional purpose of lats

pulling things down

functional purpose of triceps

pushing off of things (e.g., for transfers)

what should include in interview?

questions re: pain, splints, and functional use;use an ADL checklist to uncover ADL dysfunction and set goals.

which nerve runs through the thenar/anatomical snuffbox?

radial

The main arteries supplying blood to the hand and wrist

radial and ulnar arteries

wartenburg's sign would indicate

radial nerve lesion

pain, tenderness, swelling from de quervain's is commonly felt in the

radial styloid base of thumb at wrist, radiating up the thumb and distal forearm

burning pain in lateral forearm indicates

radial tunnel syndrome

The bones of the forearm and upper arm

radius, ulna, and humerus

range of quantitative and qualitative measures, to assess clinical outcomes

tx for type 3 radial head fracture

reated operatively, with immobilization and early motion within the first postoperative week as medically prescribed. ROM is begun early, within the 1st week if medically cleared.

The most severe complication of hand fractures

s complex regional pain syndrome

splint for burn

safe/intrinsic plus splint wrist: 20-30 MCP: 60-90 PIP: extended thumb: extended and abducted BURNS LIKE FINGER PUPPETS, DON'T LIKE DEFORMITIES (ANTI DEFORMITY)

radial nerve injuries

saturday night & honeymoon palsies

most common carpal fracture

scaphoid (lunate d/t keinbock's)

The most common carpal fracture (60% of cases)

scaphoid - proximal scaphoid has poor blood supply and can become necrotic

This type of fracture occurs most often after a fall onto an outstretched hand.

scaphoid wrist fracture

proximal row of carpals

scaphoid, lunate, triquetrum, pisiform

functional purpose of rhomboids

scapular retraction as pulling items towards you

CPRS splint

static volar in extension, then dynamic desensitization tx like fluidotherapy NO PROM

The splint (static volar splint) for complex regional pain syndrome should first be __, then ___ (think movement comes later)

static; dynamic

lateral epicondylitis

tennis elbow, overuse of wrist extensors elbow wrap/wrist splint

tx for Boutonniere deformity

the PIP is splinted in extension, and isolated DIP flexion exercises are performed.

repair forms

the callus (thickened and hardened part of the skin or soft tissue) for stabilization

Inflammation provides

the cellular activity needed for healing

Home programs enable

the client to continue safe exercises at home between therapy sessions to ensure continued progress toward goals.

The safe time frame for movement versus protection depends on

the fracture type, stage of healing, and physician orders.

positive Tinel sign for the median injury in wrist results in

tingling in index, middle finger, and radial half of 4th

what condition is indicated by hyperextension of MCP joint and flexion of IP joint, especially at the 4th and 5th fingers?

ulnar claw hand.

in designing splints, take care to avoid areas where nerves are superficial and prone to compression. these include:

ulnar nerve at the elbow in the cubital tunnel and in Guyon's canal at the ulnar border of the wrist, the radial nerve at the elbow and in the thenar snuffbox, and the digital nerves along the medial and lateral borders of the digits

cubital tunnel syndrome is a result of

ulnar nerve compression at the elbow - result of repetitive pressure on elbow or sustained bending of that elbow

guyon's canal

ulnar nerve compression at wrist wrist splint in neutral

Phonophoresis

use of ultrasound waves to introduce medication across the skin and into the subcutaneous tissues

strengthening for flexor tendon injuries

usually is not initiated until the late phase of the repair, around 8-12 weeks after surgery. If the client cannot cognitively follow a protocol, the extremity is cast in a protected position for 6 weeks.

smith's fracture

volar displacement, thumb splint

splints/tx for carpal tunnel

volar hand splint in neutral: post-operative wrist cock-up in about 15 d. of extension conservative tx: Techniques for managing edema, illustrations of tendon glide exercises, changes to daily activites - doesn't HAVE to be immobilized although could be with wrist in neutral to avoid compression on median nerve

RA splint

volar hand splint, address ulnar drift

volar in extension up to 30 degrees

5-6-7 extensor tendon injury

volar wrist splint in 20-30 d. wrist extension and MCPs in 10 d. flexion after couple weeks may do shorter splint so IPs can move around at around 4-5 wks, move splint to allow extension & flexion of MCP

how would measure edema

volumeter, centimeter tape

Double Crush Injuries

when a peripheral nerve is entrapped in more than one location symptoms: intermittent diffuse arm pain and paresthesias with specific postures

guyon's canal syndrome

when ulnar nerve is compressed in guyon's canal at the wrist d/t inflammation or other irritation sx: paresthesia in ulnar areas, motor weakness of ulnar nerve innervated muscles, tinel's sign at Guyon's canal

who are most likely to be affected from de quervain's?

women ages 35-55. "mother's thumb"

most median nerve injuries are due to

wrist fractures

conservative tx for median nerve injury

wrist splint in neutral, median nerve gliding exercises, activity mod, ergonomics post-surg: edema control, AROM, median nerve tendon glides, sensory re-ed, strengthening, activity mod

splint for carpal tunnel syndrome

wrist volar splint with wrist in neutral

AROM position for wrist fracture recovery

wrists extended & fingers flexed

Allodynia

you feel pain from stimuli that don't normally cause pain. For example, lightly touching your skin or brushing your hair might feel painful.

NBCOT Musculoskeletal AOTA Brief: Hands

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