Evaluation of the Hand Flashcards
Hand therapy as a specialty area
- Grown as specialty area for both OT and PT.
- Many of the treatments have evolved from the profession’s specialties (both OT and PT).
- Requires additional training beyond entry level
- A more thorough understanding of thermal modalities, wound care and protocols is required.
- CHT: Certified Hand Therapist (after 3 years experience, 4000 documented hours and certification exam 50% pass rate)
hand therapy
primarily
- private therapy offices- SERC, select therapy
- Outpatient rehab clinics
- Hospitals- adult and pediatric
- job sites- Harley Davidson
Secondarily in
- Nursing homes
- Home health care
- Schools
clinical assessment
- Must have an understanding of the functional anatomy of the hand and upper extremity.
- Must have knowledge of tissue and bone healing in a healthy person and be able to identify factors that would affect the normal rate and use good clinical judgment in choosing evaluations and interventions.
What do we address during an evaluation
- Occupational Profile: Includes client and their occupational history (prior and current level of function, context, supports and barriers)
- History and mechanism of injury
- Past medical history
- Symptom interview
- Physical assessment
- Functional assessment
- Psychological/cognitive assessment
History of Injury
- Mechanism of injury: Trauma, gradual onset, insidious
- Environmental conditions at the time of injury
- Date of injury
- Previous treatment including immediate care (ER, ice etc.). Did they receive therapy or require surgery?
- If the diagnosis was not due to trauma then document the length of time the individual has experienced the symptoms and what effects the intensity.
- Medications or injections
- Infections
General Medical History/Co-morbidities
- Cardiac or respiratory problems, allergies, high blood pressure, arthritis, diabetes, circulatory problems. Other co-existing diagnoses
- It is especially important to document allergies, pacemaker, fractures, diabetes and history of cancer.
- looking at patient’s hear health is vital.
occupational Profile
Develop an understanding of the client’s occupational history and experiences, patterns and routines of daily living, interests, values, and needs. The client’s problems and concerns about performing occupations and daily life activities are identified, and the client’s priorities are determined”
Informal Clinical Observations
-Evaluation of the upper extremity begins as soon as you meet the patient and escort them to the treatment area.
- Notice whether the patient’s upper extremity has a normal swinging motion when walking.
-Does the patient spontaneously use their arm?
-Does the patient cradle the arm, guard or try to protect the arm
by keeping in locked into their chest? - Are the shoulders symmetrical?
-Does the patient spontaneously place the arm or does he/she
use the uninjured hand to assist?
evaluation of pain
- Is there pain?
- Describe it
- When does it occur?
- What makes it better/worse?
- How does it affect occupational performance?
pain assessment options
- Questionnaires
- Body Diagrams
- Rating Scales (verbal or visual)
skin evaluation
Color, tone, moisture Skin creases- make sure doctor makes a good z-plasty Edema Deformities Thenar/hypothenar atrophy Contractures
wounds
Location Size – ruler or saran wrap method Color: Red Yellow Black Drainage
creases of the hand
Creases of the Normal Hand. Distal palmar crease and thenar crease important in splinting.
arches of the hand
Observe the arches. Nerve injuries, muscular diseases, stroke, spinal cord injuries and arthritis are example of thing that can effect the normal arches of the hand and impair function. The distal transverse arch, The proximal transverse arch and the longitudinal arch are important to keep in mind during splint fabrication.
Volar Surface Anatomy
Volar surface starting from the thumb side of the hand: Radial artery, FCR, median nerve, palmaris longus, FDS, ulnar artery and FCU
Physical Evaluation ROM
- Individually, each finger should point to scaphoid tuberosity and when all fingers flex, they should go toward scaphoid
- Don’t forget to look at joints proximal and distal to the injury, especially if they have been immobilized
document deformities
Boutonniere, Mallet finger, intrinsic minus hand, swan neck, ulnar sweep, nodules (Herberden’s and Bouchard’s)
Claw hand
nerves affected-
-Ulnar and median nerve
Wrist drop
nerves affected:
-radial nerve
Physical Assessment
- ROM
- Edema
- Blood flow
- Sensation and Nerve function
- Wound healing and measuring of wound or incision line
- Functional task assessments
- strength dynamometer, pinch meter and MMT if wound healing allows
Total active or Total passive ROM
TAROM
- calculate by adding flexion of MP, PIP, and DIP joints of individual finger.
- subtract extension deficits
hyperextension is not included
limitations of ROM
Edema Inflammation Pain Capsular tightness Tendon glide- ruptured or adhered Strength Muscle tightness
grip and pinch patterns
Power grips:
- Cylindrical grip
- Hook grip
- Spherical grip
Precision grip (pinch):
_ 2 pt pad to pad pinch
-3 jaw chuck
-lateral key pinch
-tip to tip pinch
-Pen/pencil tripod grasp
Cylindrical Grip
- A more equally divided pressure across the whole palmar surface
- Stability weakens with increased girth of object
- the heavier the object the more ulnar deviation of the wrist.
Hook grip
- Partially gravity dependent.
- Main control provided by the fingers never the thumb
- Not a particularly strong grip, but may be sustained for long periods of time
Spherical grip
- Similar to the cylindrical
- Equal strength applied across the object’s surface
- control is reduced with increased object size
- The intrinsic muscles are called intrinsic because they originate in the hand. There are 4 dorsal interossei that abduct the fingers, 3 volar or palmer interossei that adduct the digits and 4 lumbricals that enable us to assume the intrinsic plus position. The thenars and hypothenars are also intrinsic muscles. Omar will be lecturing on this later.
Pad to Pad pinch and 3 jaw chuck
- also called pad to pad prehension or pincer grasp
- 2 jaw chuck involved opposition of the pad of the thumb to the pad of the index finger
- 3 jaw chuck includes the middle finger. often used when buttoning up a shirt.
- 80% of precision handling uses this mode of prehension
Lateral Key Pinch
- also called lateral key pinch
- Differs from other forms only in that the thumb is more adducted and less rotated
- Least precise grip (i.e. it can be performed by a person with paralysis of all hand muscles - tenodesis)
- Lateral prehension: when an object is held between two adjacent fingers
Tip pinch
- Also called tip-to-tip prehension or 2-point tip pinch. Not always tested. Inability to perform or maintain posture is indicative of anterior interosseous nerve injury.
- most precise form of grasp
- the IPs must have the range and force for nearly full joint flexion
vascular assessment (circulation)
- Allen’s test
- Fingernail blanch test
Veins and Lymphatic assessment
- Veins are on the dorsum side of the hand
- Check for tenderness, pain, redness, or firmness
- Venous thrombosis, subcutaneous, fibrosis, and lymphatic obstruction will all cause edema
-Check lymph nodes- Brawny , pitted edema, molecules to large for capillaries and venous system to remove. Need to open lymph channels in the skin. Manual Edema Mobilization verses retrograde massage. Opposite in nature distal to proximal verses proximal to distal and deep pressure verses superficial pressure.
Nerve assessment
Sensory evaluations determine areas of diminished or absent sensibility
- two point discrimination
- moving two point discrimination
- Semmes Weinstein Monofilaments
- Moberg/Dellon pick up test
grip and pinch strength rules
These are not performed on acute injuries or post surgical patients. They can be performed on general medical conditions seen in the hospital, nursing home or home health as long as the person does not have pain. Depending on the diagnosis and body part involved strengthening can not be assessed or performed until 8 weeks (tendon and bone ). Decompression surgeries such as carpal tunnel release allow strengthening at 4 week. Rotator cuff strengthening can not begin until 10 to 12 weeks post repair depending on the surgeon. Do not perform strengthening when there is a lot of swelling.
Psychological effects of hand injuries
- Change in body-image and self-image
- Depression
- Anxiety
- Decreased self worth
- Acute stress/ PTSD if linked to trauma
How pt. treats the disease or injury should be observed.
How do they react during the evaluation?
Do they need to be referred to a support group, counseling, etc….
OT’s connect with their pts, so we often are the first ones to notice signs of depression, etc… We must address this with our client.
Why would PROM > AROM
scaring, adhesions, guarding are all reasons why AROM may be greater than PROM
important note
Trigger finger can look like Deuputrens or a sagittal band rupture (doesn’t get locked, and the EDC would pop over the metacarpal head)
