Hand AND UE: Disorders and Injuries Flashcards
Dupuytren’s Disease
Disease of the fascia of the palm and digits
1. fasica becomes thick & contracted (shortens over time)
2. develops cords and bands that extend into the digits (often affects 4th & 5th)
Treatment for Dupuytren’s Disease
- wound care
- edema control
- AROM/PROM; strengthening when healed
- scar management (massage, scar pad, and compression garment)
- splint/occupation-based task
Splint for Dupuytren’s Disease
Extension splint
1. Ideally splint should be in full extension (consult with surgeon for
Hand-based splint can be dorsal or volar
What should the occupation-based task for Dupuytren’s emphasize on?
Purposeful and occupation-based tasks that emphasize flexion (gripping) and extension (release)
Skier’s Thumb
or Game keeper’s Thumb
Rupture of the ulnar collateral ligament of the MCP joint of the thumb; hyperabduction trauma of the thumb
Etiology: most common cause is a fall
Treatment for Skier’s thumb
Conservative treatment:
1. splint (for 4-6 weeks)
2. AROM and pinch (at 6 weeks)
3. ADLs that require certain hand motions
Post-op:
1. splint (for 6 weeks), followed by AROM.
2. PROM (begin at 8 weeks)
3. strengthening (at 10 weeks)
Splint for Skier’s Thumb
UCL hand based thumb splint
Thumb IP and CMC free
Focus on ADLs that require _________ and __________ for Skier’s thumb.
- opposition
- pinch strength
Complex Regional Pain Syndrome (CRPS)
- Characterized by continuous, severe burning pain that may have resulted from trauma (Colles’ fracture), postsurgical inflammation, infection, or laceration to an extremity causing a cycle of vasospasm and vasodilation
- Primary and most severe complication of distal radial fractures
Vasomotor dysfunction from an abnormal reflex
What are the 3 stages of CRPS?
Stage 1: Traumatic Stage
Stage 2: Dystrophic Stage
Stage 3. Atrophic Stage
Stage 1:
Pain, pitting edema, discoloration;
may last up to 3 mo.
Stage 2:
Pain, brawny edema, stiffness, redness, heat, bony demineralization, may last an additional 6-9 mo.; ** pain peaks in this stage**
Stage 3:
Thickening around joints,fixed contractures, swelling appears hard, appears pale, dry, and cool, substantial dysfunction, pain decreases.
Treatment for CRPS
- Edema management
- AROM to involved joints
- ADLs to encourage pain-free active use
- Stress loading (WBing/joint distraction activities; carrying/scrubbing)
- Splinting
- Avoid or to proceed with caution include PROM, joint mobilization, dynamic splinting, and casting
- pain management (TENS)
- Desensitization (fluidotherapy)
- blocked exercises, tendon glinding
- joint protection, EC
Colles’ fracture
fracture of the distal radius with DORSAL displacement
Smith’s fracture
fracture of the distal radius with VOLAR displacement
Boxer’s fracture
description, splint, treatment post-op
- fracture of the 5th metacarpal
- forearm-based ulnar gutter splint w/ 4thand 5th MCP 60d
- Begin active/passive tendon glides for wrist and digit mobility; positioning, and/or light massage to promote edema control
Metacarpal fractures are classified based on location (head, neck, shaft, or base).
Bennett’s fracture
an intraarticular fracture of the thumb metacarpal bone (base of MCP thumb)
Which type of fracture is most common with thumb and index?
a] Proximal phalanx fracture
b] Middle phalanx fracture
c] Distal phalanx fracture
d] Carpal fracture
a] Proximal phalanx fracture
A common complication is loss of PIP AROM/PROM
Which type of fracture is most common with finger fracture?
a] Proximal phalanx fracture
b] Middle phalanx fracture
c] Distal phalanx fracture
d] Carpal fracture
c] Distal phalanx fracture
May result in mallet finger (which involves terminal extensor tendon
Which type of fracture is not a commonly fractured?
a] Proximal phalanx fracture
b] Middle phalanx fracture
c] Distal phalanx fracture
d] Carpal fracture
b] Middle phalanx fracture
What results with an elbow fracture?
limited rotation of the forearm
radial head involved
What type of fracture is most common with carpal fractures?
Proximal scaphoid
1. 60% of carpal fractures
2. poor blood supply
What is a common complication of metacarpal fractures?
Rotational deformities
Radial head fx
treatment, 3 types
- most common elbow fx caused by FOOSH)
- Types:
a. Type I (nondisplaced)-long arm sling
b. Type II (displaced with single fragment): nonoperative; immobilization for 2-3 weeks; early motions with medical clearance.
c. Type III (comminuted)-operatively, immobilization; early motion within first week post op.
FOOSH
- Caused by fall onto the wrist
- Fall on an outstrectched hand (FOOSH)
- Results in limitations in wrist flexion and extension; pronation and supination (from involvement of distal radioulnar joint)
FOOSH treatment
Conservative
1. Closed reduction and cast immobilization: used if stability of fracture can be acheived/maintained
2. Long arm cast exending past the elbow (2-3 weeks) to prvent mobility of forearm rotation and wrist)
3. Switch to shorter cast with elbow free (additionally 4-6 weeks)
Post op: ORIF
1. Early motion of wrist when cleared by surgeon
2. Wrist orthosis
3. AROM (forearm rotation to wrist in all planes and to the unaffected fingers to prevent joint stiffness
4. Gradually decrease wear of orthosis at 3-6 weeks
5. Motion, strength, and return to ADLs
Proximal humeral fx
Treatment (non-op, op), orthrosis
- humeral fx brace
- ROM (2 weeks) for non op
- sling (non-op)
- ROM aggressive stretching (4-6 weeks)
- home exercise program
- sling for sleep (first weeks PRN]
Kienbock’s disease
Description, treatment
- a condition where the blood supply to one of the small bones (lunate)in the wrist is interrupted
- Immobilzed for 6 weeks
- control of edema with early motion, good support will minimize stiffness and pain
What fracture may result in rotator cuff injuries?
Humerus fracture at the greater tuberosity
What injury may occur with a humeral shaft fracture?
Radial nerve injury resulting in wrist drop
What contraindication should we be aware of when evaluating a fracture?
Do not assess PROM or strength until ordered by physican
Exceptions for humerus fx. (begin with PROM or AAROM)
AROM is OK
What are the 2 phases of intervention for fractures?
-
Immobilization phase: Stabilize and heal
- AROM of joints above and below stabilized part
- edema control (elevation, manual edema mobilization, gentle massage, compression garments)
- Light ADLs/role activities (no resistance/as tolerated)
- one-handed techniques if in sling/brace/ORIF) -
Mobilization phase:
-edema control
splint
-AROM, PROM/AAROM (with approval)
-light purposeful activities
-pain management
-strengthening (with approval)
de Quervain’s
- Stenosing tenosynovitis of the APL, EPB
- Pain and swelling over radial styloid
What test is used to diagnosis de Quervain’s?
a] Tinel’s sign
b] Froment’s sign
c] Finkelstein’s test
c] Finkelstein’s test
What splint is used for de Quervain’s?
Thumb spica splint
When should strengthening, ADLs, and role activities start with de Quervain’s?
2-6 weeks
6 week: unrestricted
True/False
AROM should not occur before 2 weeks post-op for de Quervain.
False:
Gental AROM should occur 0-2 weeks post-op.
Lateral epicondylitis (Tennis elbow)
Overuse of wrist extensors (ECRB (mostly involved, folled by EDC), ECU, ED)
Assessment: Cozen test, Mills Test
Medial epicondylitis (Golfer’s elbow)
Over use of wrist flexors (PT, FCR, PL, FDS)
Conservative Treatment for Lateral/Medial Epicondylitis
- Elbow strap (takes tension off wrist insertion at the lateral elbow), wrist splint (decrease use and loading of the wrist extensors by immobilizing the wrist)
- Ice and deep friction massage
- Stretching
- Activity/work modifications
- Exercise
Lateral: Volar wrist cock-up; splint should only used during any activit
For a conservative treatment to lateral/medial epicondylitis, as pain decreases we should add strengthening by beginning:
a] Isotonic exercises and then progress to isometric exercises and eccentric exercises
b] Isometric exercises and progress with isotonic exercises and eccentric exercises
c] eccentric exercises and progress with isometric exercises and isotonic exercises
b] Isometric exercises and progress with isotonic exercises and eccentric exercises
Isotonic muscle contracts and shortens
Isometric muscle contracts, but does not shorten
It is proposed that isometric exercise be used at the beginning of treat
https://www.mdpi.com/2077-0383/12/1/94
Trigger finger
Tenosynovitis of the finger flexor (A1 pulley); caused by repetition and use of tools too far apart
Along with scar massage, edema control, and tendon gliding, what type of splint treatment should be used for trigger finger?
Hand-or finger-based splint
(MCP extended, IP joints free)
3-6 weeks
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
Solution: The correct answer is A.
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.
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.
What are the 2 types of isotonic contractions? What are the difference?
Concentric contraction: the muscle tension rises to meet the resistance then remains stable as the muscle shortens. Works against force of gravity.
Eccentric contraction: the muscle lengthens as the resistance become greater than the force the muscle is producing. Works with force of gravity
Kleinert
Passive flexion using rubber band traction and active extension to the hood of the splint
Early mobilization for flexor tendons
Kleinert Protocol (early phase)
treatment, splint
0-4 weeks:
dorsal block splint
wrist: 20 deg- 30 deg flexion
MCP joints: 50 deg- 60 deg flexion
IP joints: extended
Passive flexion and active extension within limits of splint
Kleinert Protocol (intermediate phase)
treatment, splint
4-7 weeks:
1. Continue dorsal block splint but adjust the wrist to neutral
2. Flexor tendon gliding exercises
3. Scar management
Kleinert Protocol (final phases)
6-8 weeks:
1. ROM
2. Tendon gliding
3. Light purposeful activities
4. D/C splint
8-12 weeks:
1. strengthening, work, and leisure activities
Duran
passive flexion and extension of digit
Early mobilization for flexor tendon
Duran Protocol
treatment, splint
0-4.5 weeks:
1. dorsal blocking splint (passive flexion of PIP joint, DIP joint and to DPC 10rep/hr)
4.5-6 weeks:
1. active flexion and extension within limits of splint
6-8 weeks:
1. tendon fliding and differential tendon gliding
2. scar management
3. light purposful activities
8-12 weeks:
1. strengthening
2. work activities
Mallet finger deformity
treatment, splint
DIP flexion
Zones I and II
0-6 weeks:
DIP extension splint
(static orthosis holding the DIP joint in slight HYPEREXTENSION)
6-8 weeks:
Electrical stimulation and ultrasound to facilitate extensor tendon gliding
avoid gripping activities to prevent further tendon damage initially.
later swan neck deformity (PIP hyperextension, DIP flexion)
Boutonniere deformity
treatment, splint
PIP=flex, MCP=hyperextension
Zones III and IV
0-4 weeks:
1. PIP extension splint (DIP free)-oval 8
2. AROM of DIP while in splint
4-6 weeks:
1. begin AROM of DIP and flexion of digits to the DPC
Zones V, VI, and VII
splint
0-2 weeks:
1. volar wrist splint with wrist in 20 deg-30 deg of extension
2. MCPs in 0 deg-10 deg of flexion
3. IP joints in full extension
2-3 weeks:
1. shorten splint to allow flexion and extension of IP joints
4 weeks:
1. remove splint to begin MCP active flexion and extension
5 weeks:
1. begin active wrist ROM
2. Wear splint in between exercise sessions
6 weeks:
1. D/C splint
Zone VI: over MCP (most common zone of injury)
Z
VI: MCP(most common)
VII: tendon&rectinaculm overwrist
Swan neck deformity
splint
injury to the metacarpophalangeal (MCP), PIP, or DIP joints characterized by PIP hyperextension and DIP flexion
SPLINT: the PIP is splinted in slight flexion.
Carpal tunnel syndrome
A median nerve compression resulted by repetition, awkward postures, vibration, anatomical anomalies, and pregnancy
Symptoms: numbness and tingling of the thumb, index, middle, and radial half of the ring fingers
1. Paresthesias usually occurs at night
2. c/o dropping things
3. Advanced stage can result in muscle atrophy of the thenar eminence
Testing for Carpal Tunnel Syndrome
carpal tunne;
- Positive Tinel’s sign at wrist
- Phalen’s sign
- press doral hands/fingers together with flexed
- Moberb Pickup Test
- Semmes-Weinstein
1. tap nerve location
Conservative Treatment for Carpal Tunnel
Splint
- Wrist splint in neutral (at night & day w/ repetitive activity)
- Median nerve gliding (gentle sliding, should not place tension on nerve)
- Differential tendon gliding
- Activity modifications (avoid finger/wrist flexion)
- Ergonomics
Operative Treatment for Carpal Tunnel Syndrome
- Edema control (elevation, retrograde massage, compression glove, and/or contrast bath)
- AROM
- Nerve and tendon gliding exercises
- Sensory re-education
- Strengthening of thenar muscles (6 week, post-op)
- Work/activity modification
Post op: Carpal tunnel release
Pronator Teres Syndrome
Description, assessment, splint
- Median n compression
- Positive Tinel’s sign
- Elbow splint at 90 deg with forearm in neutral (non-op); avoid repetitive pro/sup; half cast (post-op)
- post-op: AROM/nerve glide; strengthening (2 weeks); act. mod
operative treat: AROM all UE; strengthening (1wk); full AROM (by 8 wk)
Guyon’s Canal
Description, symptoms, assess, splint, post-op
1. ulnar n. compression at wrist
2. numbness/tingling
3. motor weakness/can lead to atrophy
4. Positive Tinel’s sign
5. Splint: wrist in neutral
6. Post op: AROM/nerve glide, strengthening (2-4 weeks)/focus: power grip; sensory re-ed
Cubital Tunnel Syndrome
Description, symptoms, assess, splint, post-op
- ulnar n. compression at elbow (2nd common; leaning on elbows/extreme elbow flexion)
- Weak powergrip, pain, numbness/tingling
- Positive Tinel’s Sign; Froment’s sign (flex IP thumb when lateral pinch is attempted; Wartenberg’s sign{5th Abducted); elbow flexion test {hold for 5 mins with wrist neutral)
- Advanced: atrophy of FCU, FDP to digits IV to V, and ulnar nerve-innervated intrinsic muscles of the hand
- Splint: Elbow splint at 30 deg flexion
(prevent extreme flexion)[esp. at night] MCP flexion anti-claw splint if clawing noted - Post-op: AROM/nerve gliding (2 weeks); strengthening (4 weeks)
A high-level ulnar nerve injury may result in which characteristic deformity?
A] Flexion of the ring and small finger metacarpophalangeal (MCP) joints because of loss of the extension-controlling forces of the third and fourth lumbricals
B] Hyperextension of the index and middle finger MCP joints because of loss of the extension-controlling forces of the first and second lumbricals
C] Unchecked abduction of the ring and small finger MCP joints because of lack of motor innervation of the third and fourth lumbricals
D] Hyperextension of the ring and small finger MCP joints because of loss of the extension-controlling forces of the third and fourth lumbricals
AOTA
Solution: The correct answer is D.
The third and fourth lumbricals and palmar interossei that flex the MCP joints of the 4th and 5th digits are innervated by the ulnar nerve. Loss of flexor tone in the third and fourth lumbricals and the palmar interossei leads to hyperextension of the ring and small finger MCP joints due to their inability to provide counter force to the extensor digitorum communis, creating “claw hand” deformity.
A, C: The third and fourth lumbricals are prime flexors of the MCP joints. A high ulnar nerve injury would result in the inability to use the lumbricals for flexion.
B: The first and second lumbricals are innervated by the median nerve and therefore are not affected in ulnar nerve injuries.
A 10-year-old child sustained a Zone 2 flexor digitorum profundus tendon laceration and underwent primary repair. Which flexor tendon repair protocol represents best practice standards?
A] Active mobilization approach
B] Immobilization approach
C] Passive mobilization approach
D] Controlled early active mobilization approach
AOTA
Solution: The correct answer is B.
Children younger than age 12 are usually placed on an immobilization protocol because of their low maturity level and low ability to comply with the exercises and precautions of other protocols.
A, C, D: Immediate or early mobilization protocols involve glide of the tendon in the early phases of postoperative healing. Children under age 12 may not have the maturity level or ability to understand precautions and adhere to exercise guidelines
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
Solution: The correct 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.
Radial Nerve Palsy
Description, symptoms
- radial n compression
- Saturday Night Palsy (wrist drop), weeknea/paralysis of extensors to the wrist, MCPs, and thumb [from sleep/humeral shaft fx.]
Conservative treatment of
Radial N. palsy
inc. splint
- Splint: [non-op] wrist cock-up splint with or without dynamic finger and thumb extension; isotonic strengthening and MCP extension [op] static wrist extension splint 30d; after 4 weeks, adjust splint to 10-20d extension
- Work/act mod
- Strenthening wrist and finger extensors when motor function returns
Post-op intervention for
Radial nerve palsy
Post op: Surgical decompression
1. AROM
2. Strengthening (6-8 weeks)
3. ADls/meaningful activities
4.mAvoid combined forearm pronation, elbow extension, and wrist flexion (can put tension on n.)
Sensory Loss for
Median Nerve Laceration
(Low lesion/at wrist & high lesion)
Sensory Loss:
1. central palm (#1-half of #4)
2. Palmar surface (#1-half of #4)
3. dorsal surface (#2-half of #4 middle and distal phalanges)
Motor Loss for
Median Nerve Laceration
(Low lesion at wrist)
Motor Loss:
1. Lumbricals I and II (MCP flexion of II and III)
2. Opponens pollicis (opposition)
3. APB (thumb abduction)
4. FPB (thumb MCP flexion)
Motor Loss for
Median Nerve Laceration
(High lesion, at/proximal to elbow)
Motor Loss:
1. Same as [low lesion]
2. FDP to #2-#3, and FLP (flexion of tip of #1-#3)
3. FCR (inability to flex to radial aspect of wrist)
[Low lesion]
Motor Loss:
1. Lumbricals I and II (MCP flexion of II and III)
2. Opponens pollicis (opposition)
3. APB (thumb abduction)
4. FPB (thumb MCP flexion)
Deformities of
Median Nerve Laceration
- Ape hand (flattening of thenar eminence; loss precision pinch, thenar opposition, and theability to flex digits #2#3; injury at elbow/proximal forearm)
- Claw hand (#2-#3, low lesion)
- Benediction sign (high lesion)
Claw Hand
- Inability to extend digits #2-#3 to
- Injury to lumbricals #1-#2 (extrinsic flexors)
- Low lesion of median nerve
Benediction Sign
- Inability to flex #1-#3.5
when making a fist - High lesion median nerve
Ape hand
- inability to oppose and abduct the thumb’
- Impaired thenar muscle functions
- D/t injury of high/low median n.
Functional Loss of
Median nerve laceration
Functional loss
- loss of thumb opposition
- weakness of pinch
Splinting conseration for
Median nerve laceration
- Non-op: C-bar to prevent thumb adduction contractures
- Post-op: dorsal wrist blocking splint (4-6 wks), AROM/PROM in splint for fingers; discontinue splint (6 wks)
Sensory re-education should begin (d/t* MEDIAN/ULNAR nerve injury*) ____ .
when an individual demonstrates a level of diminished protective sensation
(4.31) on Semmes-Weinstein
Ulnar nerve laceration
(Sensory Loss)
Sensory Loss:
1. Ulnar aspects of palmar & dorsal surface
2. Ulnar half of #4-#5 on palmar and dorsal surfaces
Ulnar nerve laceration
(motor loss: low lesion at the wrist)
Motor Loss
1. palmar and dorsal interossei (adduction & abduction of MCP joints)
2. Lumbricals #3-#4 (MCP flexion of digits #4-#5)
3. FPB & adductor pollicis (flexion/add at thumb)
4. ADM, ODM, FDM (abduction, opposition, and flexion of #5)
Ulnar nerve laceration
(high lesion wrist or above)
Motor Loss:
1. same as low lesion, including FCU (flexion toward ulnar wrist)
2. FDP #4-#5 (flexion of DIPs)
[Low lesion motor loss]
1. palmar and dorsal interossei (adduction & abduction of MCP joints)
2. Lumbricals #3-#4 (MCP flexion of digits #4-#5)
3. FPB & adductor pollicis (flexion/add at thumb)
4. ADM, ODM, FDM (abduction, opposition, and flexion of #5)
Deformity and Functional Loss
of Ulnar Nerve Laceration
Deformity:
1. claw hand
2. flattened metacarpal arch
3. Positive Froment’s sign (assessment of thumb adductor while laterally pinching paper)
Functional Loss:
1. loss of powergrip
2. decreased pinch strength
Splinting considerations for
Ulnar nerve laceration
MCP (extension) block splint
Claw hand
Treatment for
Median/Ulnar Nerve Laceration
Splint
Treatment:
1. dorsal protection splint w/ wrist positioned in 30 deg flexion (low lesion); include elbow 90 deg flexion (high lesion)
2. A/PROM of digits w/ wrist in flexion (2 weeks post-op)
3. Scar management
4. AROM of wrist (4 weeks); include elbow if high lesion
5. Strengthening (9 weeks)
Sensory Loss for
Radial Nerve Injury
(high lesions at the level of the humerus)
- Medial aspect of dorsal forearm
- Radial aspect of dorsal palm, thumb, and index, middle and radial half of ring phalanges
Motor Loss for
Radial Nerve Injury
(low lesion/at forearm)
Motor Loss:
1. loss of wrist extension d/t absent/impaired innervation to ECU
2. EDC, EI, EDM (MCP extension)
3. EPB, EPL, APL (thumb extension)
Motor Loss for
Radial Nerve Injury
(high lesion/at humerus)
Motor Loss:
1. same as all [low lesion]; including ECRB, ECRL, and brachioradialis
2. If level of axilla: loss of triceps (elbow extension)
[Low lesion loss:]
1. loss of wrist extension d/t absent/impaired innervation to ECU
2. EDC, EI, EDM (MCP extension)
3. EPB, EPL, APL (thumb extension)
Functional Loss for
Radial Nerve Injury
- Inability to extend digits to release objects
- Difficulty manipulating objects
Deformity of
Radial Nerve
Wrist drop
Treatment for
Radial Nerve Injury
splint
- Dynamic extension splint/wrist cock-up)
- ROM
- Sensory re-education PRN
- Instruct in home program
- Activity modification
- Neuromuscular electrical stimulation (NMES) for muscle re-education
Wrist drop
Zones of Flexor Injuries
Rotator Cuff Tendonitis
treatment, splint
Loss of/weakness: AB/Flex; ER/IR
Impingement site; rep. overuse/trauma
Treatment:
1. modify activity
2. sleep position (avoid arm overhead/combined ADD/IR)
3. Sling/aduction orthosis inbetween exercises
4. dec. pain: ice>heat
Post op:
1. 0-6 weeks: PROM
2. 6-8 weeks: AARM/AROM
3. 8-12 weeks: strengthening [begin with isometrics, progres to isotonice (below shoulder level)
Adhesive Capulitis
treatment, splint
Frozen shoulder @ joint capsule: restricted passive shoulder ROM [limitation: greatest: ER, ABD, IR, Flex]
Treatment:
1. Active use ADLs
2. PROM
3. modalities
4. Post op: PROM immediately, pain relief (modalities), use of extremeit of all ADLs
Link to diebetes mellitus and PD
Shoulder dislocation
treatment
- regain ROM
- pain-free ADLs
- strengthen rotator cuffs
anterior most common
What two muscle actions should be avoided with an anterior dislocation?
combined abduction and external rotation
Cumulative Trauma Disorder (CTD)
- trauma to soft tissue caused by repeated force
- 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
Treatment for CTD (acute phase)
Reduction of inflammation and pain through static splinting, ice, contrast baths, ultrasound phonophoresis, iontophoresis, and high-voltage electric and interferential stimulation
Treatment for CTD (subacute phase)
Slow stretching, myofascial release, progressive resistive exercise as tolerated, proper body mechanics, education on identifying triggers and returning to acute phase treatment with flareups; static splint during activities that cause pain
Modalities used for tendon injuries
- heat, to gradually prepare the tissue for motion
- neuromuscular electrical stimulation (NMES) to promote tendon excursion/activation (begin when cleared)
Assessment used for CTS for dysfunction
ADL checklist
Splinting is used to prevent rupture because the repaired tendon is at its weakest ___ to ___ days postsurgery.
the repaired tendon is at its weakest 10 to 12 days postsurgery
Cozen’s Test
The affected elbow is stabilised at 90degrees flexion, forearm pronated (palm down), hand clenched and in radial deviation. The patient attempts to extend the wrist (lift the hand up) while the examiner resists the movement. Pain at the lateral epicondyle indicates a positive test for lateral epicondylitis
Mill’s Test
The examiner palpates the lateral epicondyle, pronates the patient’s forearm, fully flexes the wrist and extends the elbow. Pain over the lateral epicondyle indicates tennis elbow
Maudsley’s Test
The examiner places their finger over the tip of the patient’s middle finger and resists finger extension. Pain over the lateral epicondyle is positive for tennis elbow
Zones of Extensor Injuries
An OTR is advising a client who has had a flexor tendon repair on the timing for resuming ADLs. During what time period is the flexor tendon repair the weakest and most likely to rupture?
A] 1–3 days postsurgery
B] 4–9 days postsurgery
C] 10–12 days postsurgery
D] 4–8 weeks postsurgery
Solution: The correct answer is C.
A tendon repair is typically at its weakest 10–12 days postsurgery during the fibroplasia phase, in which collagen is just beginning to be laid down to strengthen the repair.
A, B: At 1–9 days postsurgery, the tendon is still newly repaired and has the strength of the original suture.
D: The period 4–8 weeks postsurgery is considered the intermediate phase, during which the tendon gains strength
An OTR® is working with a client who has been in a motor vehicle accident. The client presents with a median nerve injury and has loss of sensation in the index and middle finger with difficulty touching thumb to index finger. Which flexor tendon zone corresponds to this client’s injuries?
A] Zone I
B] Zone II
C] Zone III
D] Zone IV
Solution: The correct answer is D.
D: Zone IV consists of the transverse carpal ligament, and the median nerve runs under this ligament.
A, B, C: In order for both the index and the middle finger to be affected by the nerve injury, it would have to occur in Zone IV, before the nerve branches.
Salter Harris Fracture
define, treatment
- proximal IP joint fracture that’s slightly malaligned
- buddy tape to an adjacent finger
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
Solution: The correct 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.
B: Wartenberg’s sign is the little finger held in abduction.
C: Jeanne’s sign is hyperextension of the proximal phalanx of the thumb when pinching.
D: Ulnar claw refers to hand posture with ulnar nerve injury.
Question
An OTR® is treating a client who sustained second- and third-degree burns on the dorsal forearm and hand. Which splint would be appropriate for this client?
A] Resting hand splint
B] Intrinsic plus splint
C] Cone antispasticity splint
D] Dorsal flexor tendon repair splint
Solution: The correct answer is B.
Burns to the dorsum of the hand require the metacarpophalangeal joints to be splinted in 50°–70° of flexion to prevent clawing of the fingers and shortening of the tendons and ligaments. This type of splint is also referred to as an antideformity splint or a safe position splint.
A: A resting hand splint is for support or immobilization.
C: A cone antispasticity splint is used for clients with cerebrovascular accident, traumatic brain injury, or cerebral palsy.
D: A dorsal flexor tendon repair splint is used for clients with flexor tendon repair.
Intrinsic plus (or Edinburg) position
the safe position for hand splinting. The hand can be immobilized in this position for long periods of time without developing as much stiffness as would occur if the digits were positioned differently.
An OTR has been working with a client diagnosed with carpal tunnel syndrome. The client’s symptoms have diminished, but now the client reports more pain at the elbow in the median nerve area. When a client reports dual sites of impingement of a single nerve without a history of trauma, what condition is MOST likely the cause?
A] Thoracic outlet syndrome
B] Double crush syndrome
C] Ulnar tunnel syndrome
D] Cubital tunnel syndrome
Solution: The correct answer is B.
B: Over time, diminished blood flow to a peripheral nerve can result in serial impingements, called double crush syndrome.
A: Thoracic outlet syndrome involves the shoulder region.
C: Ulnar tunnel syndrome involves the ulnar nerve.
D: Cubital tunnel syndrome involves the ulnar nerve.
An OTR® is describing a client with a hand injury to an occupational therapy student. The OTR® states that the client presents with burning and stabbing pain in the hand, shiny skin, very stiff joints, and abnormal sweating and hair growth. What medical condition does this client MOST likely have?
A] Fibromyalgia
B] Carpal tunnel syndrome
C] Neuroma secondary to index proximal interphalangeal amputation
D] Complex regional pain syndrome
Solution: The correct answer is D.
Symptoms of complex regional pain syndrome often include pain, swelling, stiffness, and sudomotor and trophic changes.
A: Fibromyalgia presents with pain, fatigue, and tender trigger points.
B: Carpal tunnel syndrome presents with numbness and tingling in the thumb and index and middle fingers.
C: Neuroma is hypersensitive and painful to touch
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
Solution: The correct answer is C.
A TENS unit will best aid the client in reaching the treatment goal of pain control.
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 seeing a client in the upper extremity outpatient clinic. During the initial assessment, the client describes an area extending from the radial head to the proximal aspect of the supinator muscle as having a dull ache and burning sensation. Which syndrome is the client describing?
Radial tunnel syndrome
Pronator syndrome
Carpal tunnel syndrome
Anterior interosseous nerve syndrome
Solution: The correct answer is A.
Radial tunnel syndrome is compression of the radial nerve in the proximal forearm resulting in a dull ache and burning sensation along the lateral forearm.
B: Pronator syndrome is compression of the median nerve and causes diffuse pain along the medial aspect of the forearm.
C: Carpal tunnel syndrome is median nerve compression with pain and numbness into the hand and fist through half of the fourth digit.
D: Anterior interosseous nerve syndrome is motor loss of function without sensory disturbance.
An OTR is working with a client who has sustained injuries in a knife attack. 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 I
Zone II
Zone III
Zone IV
Solution: The correct answer is B.
Zone II of the flexor tendon system has been called no man’s land because excessive scarring makes it difficult to get good results from a repair.
A, C, D: Zones I, III, and IV of the flexor tendon system do not have the overlap of the flexor digitorum profundus and the flexor digitorum superficialis to increase scarring and decrease tendon gliding.
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?
Long arm cast for 6 weeks
Therapy alone
Open reduction and internal fixation (ORIF) followed by a long arm cast for 3–4 weeks
ORIF followed by a long arm splint for 3–4 weeks
Solution: The correct answer is D.
ORIF is often used to treat a Type III fracture of the radial head; it is a surgical procedure to hold the fragments of bone in place with wires, screws, pins, or metal plates attached to the outer surface of the bone. Splints are worn for 3–4 weeks after surgery to ensure proper healing and support, but early range of motion is important to prevent long-term mobility issues.
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.
C: Immobilization in a cast for 3–4 weeks would lead to greater stiffness.
An OTR® is designing treatment sessions for a client with Type I complex regional pain syndrome (CRPS). Which occupational therapy treatment activities for the affected upper extremity would be MOST appropriate for this client?
Instruction in PROM and application of joint mobilization techniques
Use of cold packs followed by application of ultrasound
Instruction in a stress loading program and incorporation of use of the upper extremity in functional activities
Serial casting
Solution: The correct answer is C.
The most recognized treatment of complex regional pain syndrome is a stress loading program and use of the upper extremity in functional activities that promote occupational engagement.
A: PROM increases pain and swelling and is often contraindicated.
B: People with CRPS are often cold intolerant.
D: Serial casting does not increase active ROM and may add to joint stiffness.
An OTR® is working with a client who fractured the distal radius 3 weeks ago. Within what time frame can controlled AROM be initiated if the fracture is healing secondarily?
1–3 weeks postinjury
3–6 weeks postinjury
6–9 weeks postinjury
9–12 weeks postinjury
Solution: The correct answer is B.
Initiation of controlled AROM can begin between 3 and 6 weeks postinjury if the fixation of the fracture is adequate.
A: The fracture may not tolerate AROM this early, and edema and pain will result if AROM is initiated.
C, D: These time ranges may be too late to prevent scar adhesions from forming at the fracture site.
A blocking splint fabricated to maintain the metacarpophalangeal (MCP) joints in extension can be useful to isolate which joint movements?
MCP joint flexion and flexor digitorum profundus (FDP) excursion
Interphalangeal (IP) joint extension and FDP excursion
IP joint flexion and FDP excursion
Proximal IP joint extension and FDP excursion
Solution: The correct answer is C.
MCP joint extension helps isolate proximal and distal IP joint flexion and allows maximum FDP excursion.
A: This splint holds the MCP joints in extension, not flexion.
B: FDP excursion occurs with distal IP joint flexion, not extension.
D: Proximal IP joint extension is facilitated when the MCP joints are blocked in flexion, not extension
90.0% complete
Question
An OTR is providing education to a client who has undergone surgical nerve repair to the median nerve. The client has a medical background, so when the OTR explains nerve regeneration, which sensation should the OTR indicate is likely to return FIRST?
A.One-point moving
B.One-point discrimination
C.Two-point moving
D.Two-point discrimination
Solution: The correct answer is A.
In the realm of nerve healing and testing, the order in which recovery occurs is one-point moving, one-point discrimination, two-point moving, and finally two-point discrimination.
B, C, D: In nerve healing and testing, the order in which recovery can be seen is one-point moving, one-point discrimination, two-point moving, and finally two-point discrimination.
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?
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
Volar-based ulnar gutter with MCP and IP joints of the ring and fifth fingers in 0° extension and the wrist in neutral
Dorsal-based wrist cockup splint with MCP and IP joints free and the wrist in approximately 20° extension
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
Solution: The correct answer is D.
Holding the MCP joints in flexion helps prevent contracture of the collateral ligaments. Hand-based thermoplastic splints may also be used for this type of fracture.
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.
