final review session Flashcards
annular pulleys are located where?
on bones
cruciate pulleys are located where?
over joints
what is the function of the pulley system?
keep tendon close to bone so when you flex, you don’t get bowstringing affect
why does ulnar drift occur?
MCP joints become swollen and cause fingers to bend ulnarly
what does a splint for swan neck deformity look like?
block PIP joint in slight flexion
what is the starting position for every flexor tendon injury protocol?
dorsal blocking splint
when it is time to start motion, how do you generally start for flexor tendon injuries?
passive flexion and active extension (within confines of protected environment - splint)
when it is time to start motion, how do you generally start for extensor tendon injuries?
passive extension and active flexion (within confines of protected environment - splint)
for PNIs, specifically median and ulnar nerve palsies, what is an important aspect of a splint?
maintaining the web space
which assessments have depth but not breadth?
diagnostic-related assessments
vincula are involved in which type of nutrition system to flexor tendons?
perfusion
the acute phase of PNI focuses on which type of sensory interventions?
desensitization
the intermediate phase of PNI focuses on what type of sensory intervention?
reeducation (only if pt. reaches protective sensibility)
sensory reeducation can only occur if pt. reaches what?
protective sensibility
what can only occur when pt. reaches protective sensibility?
sensory reeducation
which test is used to determine when a patient has reached protective sensibility?
semmes-weinstein test
what levels of PNI typically reach protective sensibility first?
lower levels (distal)
what do 2 pt. moving and static discrimination tests assess?
functional sensibility
how many mm apart is considered normal for static 2 pt. discrimination?
5 mm apart (can say that it’s 2 pts. not 1)
how many mm apart is considered normal for moving 2 pt. discrimination?
2 mm apart - able to sense if it’s 1 or 2 pts. moving proximal to distal on fingertip
what does semmes-weinstein measure?
how much sensory status you have - gives amount of sensation you have
describe an orthosis for boutonniere deformity. (position and length of time)
PIP extension, DIP is free (AROM is allowed for DIP with PIP in splint) - 6 weeks
which time of ROM is typically used first for burn patients?
AROM
when would you not use AROM for burn patients?
-if there is a skin graft that could be damaged doing active range, fracture, muscle cut
if there was a skin graft that must be protected, which type of motion would you use?
no motion
why is mobilization for zones 5 and 6 different?
differs bc there are no finger deformities that are more distal
why is mobilization for zones 5 and 6 different?
differs bc there are no finger deformities that are more distal - still generally, passive extension and active flexion
which type of splint is used for extensor tendon injuries?
volar blocking splint
why is PROM used for early mobilization for extensor tendons?
want the tendons to be able to move through tissue and avoid adhesions and scarring
why is PROM used for early mobilization of flexor tendons?
want the tendons to be able to move through the sheath to avoid adhesions and scarring
describe the relative motion orthosis.
use hand normally but splint directs forces to move the way you want.
boutonniere and swan neck deformities are mostly considered to be in which zone?
zone III
which type of splint/motion is used commonly in tendon transfers?
tenodesis
which type of splint/motion is commonly used for tendon transfers?
tenodesis
how many grades of muscle strength are typically lost after tendon transfers?
1 grade
if the tendon is cut beyond (more distal) the juncturae tendoni, how are splints focused?
you can focus on one finger
if the tendon is cut behind (more proximal) the juncturae tendoni, how should splints be focused?
keep all fingers splinted - connection is lost
describe the specific positioning of each joint in the dorsal blocking splint.
wrist: 20-30 degrees flexion
MCP: 50-70 degrees flexion
PIPs/DIPs - extension
name three main components of the indiana protocol.
- place/hold, then flex wrist (tenodesis)
- actively make a fist (composite and hook) followed by active extension
- blocking exercise
name the 3 common rehab approaches (protocols) of extensor tendon injuries.
- immobilization
- early but controlled mobilization
- early and active mobilization
how many degrees of DIP hyperextension is maintained in a mallet finger splint?
10-15 degrees
describe scoring on the DASH.
0 = best health or no disability 100 = worst health, most disability
DASH is the gold standard of what?
PROMs (patient-rated outcome measures)
what is the age range for the DASH?
18-64
- simple, slow, safe gait
- at any one time there are 3 points of support
- may be used with bilateral lower extremity involvement
four-point gait
describe the sequence of four pt. gait.
- right crutch forward
- left foot forward
- left crutch forward
- right foot forward
- requires more balance than 4-point
- only 2 points of support at any one time
two-point gait
describe the sequence of two-point gait.
- right crutch AND left foot forward simultaneously
2. left crutch AND right foot forward simultaneously
-used when only partial or no weight-bearing is allowed on one LE
three point gait
describe the sequence of three-point gait.
- two crutches AND involved LE forward simultaneously
2. un-involved (or stronger) LE forward
-requires strength, skill, and balance
swing-to gait and swing-through gait
describe the sequence of swing-to gait.
- two crutches forward simultaneously
2. two feet swing forward and are placed behind crutches
describe the sequence of swing-through gait.
- 2 crutches forward simultaneously
- both feet swing forward simultaneously and are placed in FRONT of the crutches
- very rapid means of locomotion
slow, safe, steady with 3 points of support at any one time
sideward four-point gait
describe the sequence of sideward four-point gait.
- right crutch sideways
- right foot sideways
- left foot sideways
- left crutch sideways
describe the sequence of walking with a cane.
- cane and involved LE forward simultaneously
2. the uninvolved LE forward
describe the ascending four/two-point sequence.
- right foot up
- left foot up
- right crutch up
- left crutch up
describe the descending four/two-point sequence.
- right crutch down
- left crutch down
- right foot down
- left foot down
describing the ascending three-point sequence.
- uninvolved LE up
2. involved LE and crutches up simultaneously
describe the descending three-point sequence.
- involved LE and crutches down simultaneously
2. uninvolved LE down
what is the pt. position when measuring hip flexion?
supine
what is the axis when measuring hip flexion?
greater trochanter
what are the stationary and movable arms when measuring hip flexion?
stationary: line from ASIS to PSIS (axis of trunk)
moveable: long axis of femur
what is the pt. position when measuring hip extension?
prone
what is the axis when measuring hip extension?
greater trochanter
what are the stationary and moveable arms when measuring hip extension?
stationary: line from ASIS to PSIS
moveable: long axis of femur
what is the pt. position when measuring hip abduction?
supine
what is the axis when measuring hip abduction?
greater trochanter
what are the stationary and movable arms when measuring hip abduction?
stationary: line from ASIS to PSIS
moveable: long axis of femur
what is the pt. position when measuring hip internal and external rotation?
seated or supine, knee flexed 90 degrees over end of mat
what is the axis when measuring hip internal and external rotation?
patella
what are the stationary and moveable arms when measuring hip internal and external rotation?
- both arms parallel to long axis of tibia
- follows tibia as pt. internally/externally rotates hip
when measuring hip internal rotation, which way does the foot move?
away - laterally
when measuring hip external rotation, which way does the foot move?
medially
what is the pt. position when measuring knee flexion/extension?
prone
what is the axis when measuring knee flexion/extension?
lateral side of knee joint
what are the stationary and moveable arms when measuring knee flexion/extension?
stationary: long axis of femur
moveable: long axis of tibia
what is the pt. positioning when measuring ankle dorsiflexion and plantarflexion?
seated with knee flexed to 90 degrees
what is the axis when measuring ankle dorsiflexion and plantarflexion?
1.5 inches below lateral malleolus
what are the stationary and moveable arms when measuring ankle dorsiflexion and plantarflexion?
stationary: long axis of fibula
moveable: long axis of 5th metatarsal
can you flex the knee when measuring hip flexion?
yes - we’re testing joint motion rather than muscle length
what % of the rule of 9s is the trunk in an adult?
18%
what % of the rule of 9s is the head in an adult?
4.5%
what % of the rule of 9s is each arm in an adult?
4.5% = 9% total
what % of the rule of 9s is each leg in an adult?
9% = 18% total
what % of the rule of 9s is the genitalia in an adult?
1%
what % of the rule of 9s is the trunk in a child?
13%
what % of the rule of 9s is the head in a child?
6.5%
what % of the rule of 9s is each upper leg in a child?
4% = 8% total
what % of the rule of 9s is each upper arm in a child?
4%
what % of the rule of 9s is each forearm in a child?
3%
what % of the rule of 9s is each hand arm in a child?
2.5%
what are the energy requirements for a unilateral BK amputee?
10-20%
what are the energy requirements for a unilateral BK amputee?
10-20%
what are the energy requirements for a bilateral BK amputee?
20-40%
what are the energy requirements for a unilateral AK amputee?
60-70%
what are the energy requirements for a bilateral AK amputee?
> 200%
for OT evals. for PNIs which type of motion is used?
PROM!
name 4 deficits of radial nerve injury.
- loss finger extension
- loss thumb extension
- loss wrist extension
- decrease in forceful opposition
which splint is used for radial nerve injury?
radial palsy splint
describe treatment for a low ulnar nerve injury.
prevent overstretching of the denervated intrinsic muscles of 4th and 5th fingers
describe treatment for a high ulnar nerve injury.
splinting becomes mandatory as FDP to 4th and 5th returns, clawing is more evident
name 7 deficits of median nerve injury/ape hand.
- inability to oppose thumb
- inability to perform 3 jaw chuck
- decrease web space
- decrease in power grasp
- decrease in FDS (high injury)
- decrease in FDP of index and long finger (high injury)
- decrease in pronation (high injury)
which contractures are most common in median nerve injury?
adduction contractures of thumb
describe positioning for palmar abduction measurements of thumb cmc.
forearm in neutral
describe positioning for radial abduction measurements of thumb cmc.
palm flat (prone)
if the PIP is limited when it is passively flexed with the MCP joint in a variety of positions (without regard to the position of the MCP joint), there is what?
joint contracture - PIP joint collateral ligament tightness
if the PIP is passively flexed with the MCP joint in extension and then again with MCP joint in flexion, and the PIP joint has more flexion when the MCP joint is flexed, this is a positive sign of what?
intrinsic muscle tightness (rather than PIP joint tightness)
what will NOT help in PIP intrinsic muscle tightness?
serial casting and splinting
what WILL help for intrinsic muscle tightness?
passive hook fisting
what provides the blood supply for extensor tendons?
paratenons
should static progressive splints bc used for tendon injuries?
NOOO
which splints should NOT be used for tendon injuries?
static progressive splints
in general, describe what happens to contribute to boutonniere deformity.
the central slip and finger misaligns bc the lateral bands slip down and become flexors instead of extensors.
are there bony attachments for the intrinsics?
NOOO - GOOD TO UNDERSTAND FOR CLINICAL QUESTIONS
what is a big concern involved with zone II flexor tendon injuries?
concerns with scarring - tendons can be less mobile and adhere to one another
name an example of an immediate passive flexor tendon protocol.
modified duran
what is the emphasis of the modified duran protocol?
passive extension and passive flexion
name an example of an early active mobilization flexor tendon protocol.
indiana protocol
who is the indiana protocol great for?
pts. who demonstrate minimal edema and minimal complications
name an example of an early dynamic motion flexor tendon protocol.
louisville/kleinhart
name an example of an immediate active flexion flexor tendon protocol.
belfast
which type of motion is critical during the beginning stages (including evals.) for PNIs?
PROM!!!!!!
why is our role to work on PROM with a PNI pt.?
maintain their passive range so that when the muscle does begin to work it’s not pulling on a contracted joint bc it will be weak
are they any contraindications to PROM for PNI pts.?
fractures
IF A NERVE HAS BEEN SURGICALLY REPAIRED THERE SHOULD BE NO MOTION FOR HOW MANY DAYS?
21 DAYS
how fast do nerves regenerate?
1 inch a month
name the 2 levels of nerve injury that don’t require surgery.
- neuropraxia
- axonotmesis
the nerve doesn’t function
neurotmesis
what is the minimal number of semmes weinstein that a pt. must be able to feel in order to do sensory reeducation?
6.65
injury to a digital nerve often leads to what?
hypersensitivity
splints for nerve injuries are for what?
to prevent deformities
be careful of loss of which muscle in radial nerve injury? (important for splints)
EDC
what does a splint do for wrist drop (radial nerve)?
holds wrist up
what does an ulnar nerve splint typically do?
keep digits 4 and 5 hyperextended
what is crucial for median and ulnar nerve splints?
maintaining the web space
what is the biggest difference between median and ulnar nerve injuries?
the muscles innervated by the nerves
name 4 reasons to use a short opponens splints.
- CMC joint arthritis
- thumb MCP joint arthritis
- collateral ligaments of the thumb
- metacarpal or phalangeal fractures of the thumb
which joint of the thumb is free to bend in short opponens splints?
IP joint of thumb
why is short opponens splint not used for tendon injuries?
it would have to cross the wrist since the muscles/tendons also cross the wrist
why is short opponens splint not used for scaphoid fractures?
doesn’t extend past the wrist
what is an ulnar gutter splint used for?
applied to immobilize fractures of the 4th and 5th metacarpals.
describe the position of joints in the burn/safe position.
- slight wrist extension
- MCPs full flexion
- DIPs and PIPs in full extension
- thumb is abducted
why is positioning important for the burn/safe position splint?
saves the length of the collateral ligaments
what is the difference between the burn/safe position and the resting hand splint?
resting hand splint has flexion of all 3 joints
describe positioning of the resting hand splint.
- wrist in slight extension
- gentle flexion of MCPs, PIPs, and DIPs
- slight opposition of thumb
Name 3 reasons to use the resting hand splint.
- RA - during a flare up - need to rest hand
- dupuytren’s contracture
- stroke, CP to position hand in a functional position to maintain the webspace
describe the action of a radial nerve palsy splint.
- dynamic
- tenodesis action - functional position
- holds MCPs and wrist up
describe an MCP extension assist splint.
- used for radial nerve
- supports the MCP joints
- long-standing nerve repair - positions the wrist so they can start to use their fingers more efficiently.
describe the purpose of a static progressive orthosis.
- used for capsular tightness, finger digit/capsular problem
- ex: pt is good with extension, but flexion only 45 degrees at PIP joint, do mobilization, stretching, to keep the gained motion, keep them in SP splint to hold them in this position at 50 degrees flexion
describe a true dynamic orthosis.
pt. can do the opposite motion
describe a zone IV extensor tendon splint.
- hand based splint with involved finger in extension
- MCP 0-30 degrees flexion, PIP full extension
- splint 4-6 weeks, 24 hrs/day
- continue splint for 10 weeks after injury
- can do exercise while in splint with OT
describe a zones V and VI dorsum of hand extensor tendon splint.
-use resting hand splint pattern but omit thumb - MCP in 10-20 degrees flexion, IPs in full extension
describe the positioning of a dorsal blocking splint.
- wrist: 20-30 degrees flexion
- MCP: 50-70 degrees flexion
- PIPs/DIPs - extension
what is a lumbrical blocking splint?
-anti-claw orthosis
passive stretching is only done if what?
if the joint doesn’t have full range aka soft tissue problem or capsular problem
if pt. does heavy work which prosthetic is best?
hook
a pt. presents with atrophy of the 1st dorsal interosseous and has difficulty opening and closing their fingers. what nerve might be involved/contributing to the limitations?
ulnar nerve
when are the Maitland grades appropriate?
when joints are stiff/capsular tightness - trying to stretch out the capsule
Boutonniere deformity and swan neck deformity is commonly seen in which pts.?
RA
describe a splint for boutonniere deformity.
static splint of PIP in full extension, allowed to move DIP
describe a splint for swan neck deformity.
silver ring splint
describe ulnar claw hand.
can’t EXTEND 4th and 5th fingers
describe froment’s sign.
- tests for ulnar nerve palsy (Claw hand)
- tests strength of adductor pollicis
name 3 splints used for claw hand.
- figure of 8 splint
- lumbrical simulation splint
- lumbrical blocking splint
name a splint for wrist drop.
radial nerve palsy splint/tenodesis splint
volar subluxation of MCP and ulnar deviation of fingers is a deformity indicating what?
intrinsic tightness
PIP extension, MCP flexion, and thumb adduction (looks like safe position) is a deformity indicating what?
intrinsic tightness
what does intrinsic weakness look like?
hook-like hand, non-functional grip
which muscles do and don’t work in intrinsic weakness?
extrinsic muscles work, intrinsic not working
if mallet finger is left untreated it could lead to what?
swan neck deformity
- inflammation of 1st dorsal compartment, inflamed tendon sheath
- ulnar deviation wrist pain
dequervain’s tenosynovitis
name a splint for dequervain’s tenosynovitis.
LONG opponens thumb splint
MCP ulnar drift is commonly seen in which patients?
RA (ulnar subluxation)
name a splint used for dupuytren’s contracture.
resting hand splint
what happens at a distal median nerve injury?
can’t EXTEND 2nd and 3rd fingers
what happens at a proximal median nerve injury?
can’t FLEX 2nd and 3rd fingers
what happens at a distal ulnar nerve injury?
can’t EXTEND 4th and 5th fingers
what happens at a proximal ulnar nerve injury?
can’t FLEX 4th and 5th fingers
name the 2 forearm muscles innervated by ulnar nerve.
- FCU
- FDP
name the 7 intrinsic hand muscles innervated by ulnar nerve.
- flexor pollicis brevis
- palmaris brevis
- adductor pollicis
- 3rd and 4th lumbricals
- dorsal and palmar interossei
name the 3 superficial forearm muscles innervated by median nerve.
pronator teres
FCR
palmaris longus
name the 1 intermediate forearm muscles innervated by median nerve.
FDS
name the 3 deep forearm muscles innervated by median nerve.
- FPL
- PQ
- lateral half of FDP
name the 5 hand muscles innervated by the median nerve.
- abductor pollicis brevis
- opponens pollicis
- flexor pollicis brevis
- lateral 2 lumbricals (1 and 2)
name the 7 hand muscles innervated by radial nerve.
- extensor digitorum
- extensor digiti minimi
- ECU
- Extensor pollicis brevis
- extensor pollicis longus
- extensor indicis
- abductor pollicis longus
describe the rule of 9s for an adult.
- trunk: 18%
- head: 4.5%
- arms: each 4.5%, total 9%
- legs: each 9%, total 18%
- genitals: 1%
name 2 assessments for pain in pediatrics.
- observation - FLACC scale (2 months - 7 years)
- wong-baker FACES scale - 3+ years
the top of crutches should be how many inches below axilla?
2 inches
the top of a cane and walker should be at what level?
level of greater trochanter
elbow should be flexed to how many degrees when using a cane?
20-30 degrees
what is another name for a relative motion orthosis?
yoke splint
what is cubital tunnel syndrome?
ulnar nerve entrapment at the elbow
describe the positioning of a wrist splint for carpal tunnel syndrome.
neutral position avoiding wrist extension
dequervain’s typically involves which 2 tendons?
APL
EPB
can extend a long opponens splint to the IP joint if the thumb IP joint is involved in arthritis and or which other tendon is involved in dequervain’s?
EPL
when are relative motion orthoses/yoke orthoses typically used?
used following more proximal extensor tendon lacerations to limit MCP flexion
splint often used for early positioning and motion following athroplasty
MCP extension assist
which wrist orthoses provide the greatest amount of stability?
circumferential
which wrist orthoses are least supportive?
dorsal wrist orthoses
which wrist orthoses provide a moderate amount of stability?
volar wrist orthoses
describe a lumbrical bar orthosis.
- hand-based
- used for ulnar nerve injuries and combined ulnar and median nerve injuries
- extends over the dorsal aspect of the proximal phalanges to restrict unwanted hyperextension of the MCPs
dynamic mobilization orthoses are more effective when used for what?
early contractures
serial casting is best used for which two things?
- fixed contractures
- chronically stiff joints
static progressive mobilization orthoses are often used for which kinds of contractures?
fixed/chronic contractures
static progressive orthoses should be more commonly used with which types of movements?
extension rather than flexion
how are adduction contractures of the thumb most commonly treated?
serial static thumb abduction orthoses - conform to the first web space
how are adduction contractures of the thumb most commonly treated?
serial static thumb abduction orthoses - conform to the first web space
radial nerve palsy is commonly associated with which other injury?
humeral fractures
describe positioning of an anti-claw orthosis.
blocks MCPs in slight flexion allowing the IPs to extend
to immobilize or mobilize a joint using an orthosis, how many points of pressure are used?
3 points - three linear forces are created using a middle force that pulls in an opposite direction from the other two forces.
traction
bones are pulled apart from each other
briefly describe intrinsic tightness.
decreased IP flexion with MP extension
what is wartenburg’s sign?
ulnar nerve impairment - pt. is unable to adduct small finger with hand palm down on table
describe claw hand briefly. (joint positions)
MCP hyperextension and PIP flexion - muscle imbalance
describe extensor lag.
inability to extend a joint actively when passive movement is available.
claw hand is more evident if which muscle is not involved?
FDP
median nerve injury at the level of the wrist results in denervation of which muscles?
- opponens pollicis
- abductor pollicis brevis
- lumbricals to index and long fingers
with the absence of thumb abduction and opposition in median nerve injury at the wrist, the thumb rests in what?
adduction
median nerve injury at the elbow results in denervation to which muscles?
- muscles listed earlier (low median nerve injury)
- FDP to the index and long fingers
- FDS
- pronator teres
- PQ
ulnar nerve injury at the level of the wrist results in denervation of which muscles?
- loss of most of the hand intrinsics
- abductor digiti minimi
- flexor digiti minimi
- opponens digiti minimi
- adductor pollicis
- deep head of FPB
- dorsal and volar interossei
- lumbricals to ring and small fingers
ulnar nerve injury at the level of the elbow results in denervation of which muscles?
- muscles listed earlier (low ulnar nerve injury)
- FDP of the ring and small fingers
- FCU
what is low radial nerve injury also called?
posterior interosseous palsy
high radial nerve injuries (at elbow) usually lead to what?
- absent wrist and digital extensors -wrist drop
- loss of supinator
- tenodesis is lost
determines functional ability of hand with median nerve lesion
moberg pickup test
measures gross manual dexterity
box and block test
assists with the development of the occupational profile through its valid and reliable measures of clients’ functional abilities.
DASH
the more ___ the amputation, the more difficult a prosthesis is to use.
proximal
what is the most often used pain assessment for amputations?
visual analog scale
what is the most frequently contracted joint following a burn?
shoulder
ROM exercises are contraindicated how many days after a skin graft?
5-10 days
T/F - keloids can appear years after an initial injury
true
T/F - hypertrophic scars can appear years after an initial injury
false
what is the most common site of heterotopic ossification in burn pts.?
elbow
in the burn position, which type of thumb abduction is preferred?
palmar abduction
which muscle shortening can result in a first web space contracture?
adductor pollicis brevis
which muscle shortening can result in a first web space contracture?
adductor pollicis brevis
name a low median nerve injury.
ape hand
name a high median nerve injury.
sign of benediction.
name a low radial nerve injury.
wrist drop
what is a c-bar splint used for?
maintains the web space and prevents thumb adduction contractures
