Hand and Upper Extremity Flashcards
Pacinian corpuscles
sense vibration
Ruffini end organs
sense tension
merkel cells
sense pressure
why is it important to assess cognition with UE evaluations
to learn more about adherence to HEP
Important observations for UE evaluations
- nonverbals
- positioning
- guarding
- posture
- spontaneous use of UE
- skin, wounds, scarring
Pain assessment
when is it occurring and how much
vascular assessment
color and trophic changes, temperature
4 regions where TOS can occur
- sternocostovertebral space
- scalene triangle
- costoclavicular space
- pectoralis minor space
TOS level of restriction is based on what
severity, neural sensitization, intra/perineural scarring
nonoperative treatments of TOS
- minimize irritation with safe motions
- diaphragmatic breathing
-safe sleeping positions - posture and scapular proprioception
- strengthen scapular stabilizers
signs of frozen shoulder
loss in ROM at glenohumeral joint
- ER, abduction, IR
freezing phase of frozen shoulder
shoulder pain with ADLs and rest, close to full ROM
Frozen phase of frozen shoulder
pain with stretching movements, compensation for decreased ROM
Thawing phase of frozen shoulder
gradual return of motion for up to 26 months
operative treatment of frozen shoulder
manipulation and release of glenohumeral capsule ligaments
nonoperative treatment of frozen shoulder
ADL modifications
- avoid overstretching and pushing joint to point of restarting inflammation
What makes of a majority of shoulder disorders
rotator cuff disorders
operative treatment for rotator cuff disorders
- 2-4 weeks immobilization
- week 6-7 ROM passive working to active
- weeks 8-10 begin strengthening
nonoperative treatment of rotator cuff
- rest and anti-inflammatory modalities
- ROM with pendulums and wand based elevation
-strengthening healthy parts of RC and scapular stabilizers
where do half of all hand fractures occur
metacarpals
boxers fracture
head of MC 4 and 5
bennett’s fracture
thumb base fracture
skier’s thumb
torn ligament in thumb
avulsion injuries
when the tendon separates from bone and insertion
mallet finger
avulsion of terminal finger tendon
treatment for mallet finger
splint in extension for 6 weeks
boutonniere deformity
- disruption of central slip of extensor tendon
- PIP flexion and DIP hyperextension
treatment for boutonniere deformity
splint PIP in extension and perform isolated DIP flexion exercises
swan neck deformity
injury to MCP, PIP or DIP characterized by PIP hypertension and DIP flexion
treatment of swan neck deformity
splint PIP in slight flexion
3 phases of bone fracture healing
inflammation, repair, remodeling
inflammation phase of fracture healing
provides cellular activity
repair phase of fracture healing
forms callus for stabilization
remodeling phase of fracture healing
deposits bone
complications of fracture healing
misaligned fracture, wounds and pain, decreased nutrition, age, bone disesase
rehab for bone fractures
- orthotic fabrications
- pain relief
- ther ex
- monitor CPRS
colles fracture
dorsal placement
- fall on extended hand
smith’s fracture
palmar displacement
- fall on flexed hand
what is the most common carpal fracture
scaphoid- 90%
kienbocks disease
associated with lunate fracture because of decreased blood flow
medical management of fractures
surgical intervention or casting
nondisplaced fracture
fractured bone with no misalignment
displaced fracture
fractured bone and no longer aligned
extraarticular fracture
occurs outside of joint and does not interrupt articular cartilage
intraarticular fracture
extends into the joint
which type of fracture can lead to OA
intraarticular fracture
acute phase of wrist fractures
- 0-6 weeks
- immobilization is common
- edema and pain management
- functional use with NWB status
subacute phase of wrist fractures
- 6+ weeks
- casting and orthotics to support soft
- edema and pain management
- ROM and functional use graded up
- strengthening at 8-10 weeks
what is the most common elbow fracture
radial head fracture
common complications of radial head fractures
elbow flexion contracture
what is susceptible to injury after a olecranon fracture
ulnar nerve
medical management of nondisplaced elbow fractures
long arm sling with emphasis on elbow extension
medical management of displaced elbow fractures
surgical fixation
rehab for elbow fractures
- stabilization before motion
- ROM once cleared (~1 week)
- strengthening at 8-12 weeks
- pain and edema management
medical management of 1 part humerus fracture
immobilization with sling 1-3 weeks and passive movements
medical management of 2-4 part humerus fractures
- 4-6 weeks of immobilization
- PROM day 1
- commonly ORIF
rehab for humerus fractures
- grip and AROM exercises
- ROM at 2 weeks
- aggressive stretching 4-6 weeks
- strengthening at 8-12 weeks
what do saggital bands do
center the extensor tendons over MCP joint
common extensor tendon injuries to zone 1
-cut, laceration or jamming finger
-mallet finger
common extensor tendon injuries to zone 2
- laceration, evulsion, RA
- Boutonniere deformity
thumb extensor tendon zones
1- IP joint
2- Over prox. phalanx
3- over MCP joint
4- over MC1
5- over wrist
thumb extensor tendon zones over fingers
1- over DIP joint
2-middle phalanx
3- PIP joint
4- proximal phalanx
5- MCP joint
6- metacarpals
7- carpal bones and wrist
goals of extensor tendon rehabd
- achieve tendon gliding and decrease tension on repaid
- decrease edema and stiffness
rehab of zones 1 and 2 extensor tendons
immobilize then gradually increase DIP flexion
early phase of rehab of zones 3 and 4 extensor tendons
- 0-3,4 weeks
- orthosis worn full time with PIP in full extension
Intermediate phase of rehab of zones 3 and 4 extensor tendons
- 4-8 weeks
- d/c orthosis and begin AROM individual joint flexion
- at 5 weeks begin gentle composite flexion
late phase of rehab of zones 3 and 4 extensor tendons
- 8-12 weeks
- full normal use of hand
- stretching
- static progressive or dynamic flexion orthosis
early phase of rehab of zones 5-7 extensor tendons
- 0-3,4 weeks
- full-length resting cast
intermediate phase of rehab of zones 5-7 extensor tendons
- 4-8 weeks
- orthosis used during work and heavy activities
- gradual increase in active flexion
- begin composite flexion
late phase of rehab of zones 5-7 extensor tendons
- 8-12 weeks
- strengthening and functional UE exercise
- static progressive or dynamic orthoses
Anatomy of flexor tendons
glide and run under tight pulley system
where is “no man’s land” and why is it called that
- Zone 2 of flexor tendons
- hard to treat and diagnose
Zones of flexor tendons
1- finger tip to center of middle phalanx
2- center of middle phalanx to distal palmar crease
3- distal palmar crease to transverse carpal ligament
4- overlies transverse carpal ligament
5- extends beyond wrist
complications of flexor tendon injuries
- often nerve involvement
-edema and pain - PIP flexion contractures
when is immobilization approach to flexor tendon rehab used
- rare
- children under 12
- significant loss in skin requing graft
- cognitive limitations
describe the immediate passive flexion approach to flexor tendon rehab
- initiated 3-4 days following repair
- dorsal blocking splint with wrist and MP joints in flexion and IP joints in extension
- Duran protocol
duran protocol
- passively flex fingers while wearing dorsal blocking splint
- used for flexor tendon rehab
immediate active flexion approach to flexor tendon rehab
- achieve flexor tendon gliding before adhesions form
- dorsal blocking orthosis at rest
when can strengthening begin for flexor tendon rehab
8 weeks
what is the most common nerve injury after a humeral fracture
radial nerve
symptoms of radial nerve injury
wrist drop, decreased finger and thumb extension
nonoperative treatment of radial nerve
- wrist cock up splint
- PROM and AROM
- isotonic strengthening upon reinnervation
operative treatment of radial nerve injury
static wrist extension splint at 30 degrees adjusted to 10 to 20 degrees at 4 weeks
describe radial tunnel syndrome
- entrapment in area extending radial head to supinator
- causes burning pain in lateral forearm
nonoperative treatment of radial tunnel syndrome
- long arm splint with elbow flexion, supination and wrist in neutral
- massage, TENS
- pain-free ROM
-nerve glides
operative treatment of radial tunnel syndrome
- 2 weeks of long arm splint with elbow flexion, supination and wrist in neutral
- wrist cock up 2 weeks
- PROM and AROM supination and pronation
- strengthening 3 weeks
-resistive ex at 6 weeks
posterior interosseus nerve syndrome
- rare nerve palsy of extensors
-weak or paralyzed wrist and digit extension and thumb radial abduction - deep ache pain with palpation of lateral forearm
- worse at night
-nerve compression at radial tunnel
nonoperative treatment of PINS
splint with elbow flexion, supination, wrist extension
ape hand deformity
fingers are close together
hand of benediction
- occurs with high median nerve lesion
- D4+5 flexed, D1-3 extended
describe median nerve injuries
- ape hand or hand of benediciton
- sensory loss in radial fingers
- decreased pinch, thumb opposition and radial flexion
nonoperative treatment for median nerve injuries
static thenar web spacer splint
operative treatment for median nerve injuries
- dorsal blocking splint
- digit and thumb AROM and PROM
-tendon glides, scar massage - strengthening
anterior interosseous syndrome
- compression of anterior interosseous nerve
- nonspecific deep aching pain to proximal forearm that increases with activity
- decreased flexion in D1-3
provocative testing of anterior interosseous syndrome
negative tinels sign
positive Ballentines sign
Ballentine’s sign
collapsed DIP joint when making OK sign
treatment of anterior interosseous syndrome
orthosis stabilizes IP joint of D1 and flexion of D2 to promote tip pinch function
pronator syndrome
- entrapment of proximal median nerve between pronator muscle heads
- deep pain in proximal forearm
provocative testing of pronator syndrome
negative tinels
provoke with pronation and elbow flexion resistance
nonoperative treatment of ponator syndrome
- splint 90-100 degrees in elbow flexion, forearm neutral
- TENS
-gentle prolonged stretch supination, elbow, wrist digit extension - no repetitive rotation and elbow flexion
operative treatment for pronator syndrome
- 1/2 cast
- AROM while wearing cast
- strengthening in 1 week
Carpal tunnel syndrome
- entrapment of median nerve in carpal tunnel
- weak thenar muscles and opposition
- numbness and tingling that gets worse at night
non operative treatment of carpal tunnel
- splint in neutral position
- nerve and tendon glides
- postural retraining, avoid pinching and gripping with flexed wrist
operative treatment in carpal tunnel syndrome
- may or may not need therapy
- pain and scar management
- AROM 1-2 days, strengthening 3-6 weeks
- nerve and tendon glides
parasthesia
numbness and tingling
pillar pain
pain on either side of the carpal tunnel release
ulnar nerve injury
causes flattening of normal arches of hand, claw deformity
claw deformity
hyperextension of D5 MCP joint and flexion of PIP and IP joints
Wartenberg’s sign
D5 is abducted from D4
Froment’s sign
flexion of DIP joint with lateral pinch
Jeanne’s sign
D1 MCP hyperextension
sensory loss to the dorsal side of hand
ulnar nerve injury is proximal to Guyon’s canal
ulnar tunnel/guyon’s canal
- sensory loss in D5 and ulnar D4
- claw deformity
-decreased movement of intrinsic movements
nonoperative treatment of ulnar tunnel
anticlaw splint or antivibration glove
operative treatment of ulnar tunnel
- dorsal blocking splint with wrist MCP flexion
- wound care, scar mobilization, desensitization
-AROM at 6 weeks
Cubital tunnel
- decreased sensation at D5 and ulnar D4
- decreased pinch and grip strength
nonoperative treatment of cubital tunnel
- edema and pain control
- elbow splint with 30-70 flexion
- nerve gliding
- postural training
operative treatment of cubital tunnel
- pain managment and desensitization
- AROM and nerve gliding
Double crush syndrome
- peripheral nerve trapped in more than 1 location
- intermittent diffuse arm pain and parasthesia
- treat according to each nerve injury
De Quervain Syndrome
- cumulative microtrauma to abductors of D1
- pain felt on radial styloid exacerbated iwth thumb and wrist movements
- caused by forceful, repetitive thumb abduction
stenosing
narrowing
nonoperative treatment of De Quervain Syndrome
- corticosteroir injections
- forearm based thumb spica
operative treatment of de quervain syndrome
- AROM at 2 weeks
- strengthening at 4 weeks
Assessments of Sensation
- semmes-weinstein monofilaments
- 2-point discrimination
- Moberg pickup test
-Tinel’s sign
When to use moberg pick up test
- for those with cognitive impairments
- median nerve injury
CPRS
- pain disproportionate to injury that is either maintained or independent of SNS
symptoms of CPRS
- neuropathic pain
- hyperathia
-edema
-bluish-red/shiny skin - muscle spasm
- allodynia
-hyperalgia
-contracture
-abnormal sweating
-decreased strength and endurance
allodynia
sensation misinterpreted as pain
hyperalgia
increased response to painful stimuli
type 1 CPRS
- no definitive major nerve injury
- may be spontaneous
type 2 CPRS
develops s/p nerve injury
