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
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.
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)
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)
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.
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)
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
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
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
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
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
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.
