Hand and Upper Extremity Disorders and Injuries Flashcards
Dupuytren Disease
Symptoms - Facia becomes thick and contracted, develops cords and bands that extend into the digits. Results in flexion deformities. Surgical reliease required.
Etiology - Unknown
OT intervention - post op Wound care, edema control, extension splint (initally at all times), A/Prom and progress to strengthening, when wounds are healed. scar management( massage, scar pad, and compression garment)
Skier’s Thumb
- Symptoms - Rupture of ulnar collateral ligament of the MCP joint
- Etiology - falling while holding a pole (ski pole)
- OT intervention -
- Conservative - Thumb splint(thumb spica), AROM and pinch strengthening (at 6 weeks), focus on ADL that require opposition and pinch strength.
- Post Op - thumb splint for 6 weeks, AROM. PROM at 8 weeks and strenthening at 10 weeks.
Complex Regional Pain Syndrome (CRPS)
Symptoms - May follow trauma. severe pain, edema, discoloration, osteoporosis, sudomotor changes (stimulation of sweat glands), temperature changes, trophic chnages, and vasomotor instability (dialation/constriction of vessels)
OT intervention - Modalities to decrease pain, edema management (elevation, mobilization, compression glove), AROM to involved joints. ADL encouraging pain-free active use, stress loading (weight bearing and joint distraction), self-management.
Avoid/Use caution - passive range of motion, passive stretching, joint mobilizatoin, dynamic splinting, casting
Fractures
Types: intra articular vs extraarticular, closed vs open, dorsa displacement vs volar displacement, midshaft vs neck vs base, complete vs incomplete, transverse vs spiral vs oblique, comminuted.
Medical Treatment:
- Closed reduction - short arm cast( SAC), long arm cast (LAC), splint, sling, or fracture brace.
- Open reduction Internal fixation (ORIF) - screws, nails, wire.
OT Eval: Mechanism of injury, results of x-ray, MRI, CT scans. Edema. Pain, AROM (DO not assess PROM or strength until ordered by physician.) sensation, roles, occupations, ADL and activities related to rols
OT intervention:
- Imobilization phase: Stabilization and healing are the goals. AROM of joints above and below the stabilized part, edema control (elevation, retrograde massage, and compession garments). Light ADL and rol actvities with no resistance. progress as tolerated
- Mobilization phase: consolidation is the goal. Edema control (same as above). AROM. Progress to PROM when approved by physician 4-8 weeks. (*exceptions are humerus fractures which begin with PROM or AAROM). Light occupation based activities, pain management (positioning and physical agent modalities.) Strengthening beging with isometrics when approved by physician.
Adhesive capsulitis (frozen shoulder)
Symptoms - Loss of active and passive shoulder motion with the most pronounced loss in external rotation and, to a lesser degree, abduction and internal rotation.
OT Intervention -
- conservative - active use through ADL and role activities, PROM, modalities
- Post op - PROM immediately following surgery, pain relief modalitities, use extremitiy for all ADL and role activities
Subacromial impingement
Symptoms - Painful arc of motion between approximately 80 and 100 degrees elevation or at end range of active elevation. In early stages, muscle tests may be strong and painless despite positive impingement test.
OT Treatment -
Rotator cuff tendonitis
Symptoms/Test results - Painful active or resistive rotator cuff muscle use. Painful manual muscle test of scapular plane abduction or external rotation. Nonpainful passive motion end ranges. Tenderness at tendons of supraspinatus or infraspinatus.
Etiology - Repetitive overuse, curved or hook acromion, weakness of rotator cuff, weakness of scapula musculature, Ligament and capsule tightness, trauma
OT Intervention -
- Conservative - Activity mod (avoid above shoulder level activities), educate in sleeping posture (avoid sleeping with arm overhead or combined adduction and internal rotation. Decrease pain: positioning, modalities, and rest. restore ROM, strengthening below shoulder level. Occupation training.
- Post op - PROM 0-6 weeks AA/AROM, decrease pain ice, progress to heat, strengthening (6 weeks post op) begin with isometrics, progress to isotonic (below shoulder level), light ADL progress PRN
Rotator cuff tear
Symptoms - Significant substitution of scapula with attempted arm elevation. Positive drop arm test. Very weak, less than three-fifths abduction or external rotation.
Cumulative trauma Disorders (CTD)/ Repetitive strain injuries (RSI)
Risk Factors - repetition, static position, awkward postures, forceful exertions, and vibration. Acute trauma, pregnancy, diabetes, arthritis,
Types of CTD
DeQuervain’s
Symptoms - pain and swelling over th radial styloid. positive finkelstein’s test (patient makes fist with thumb tucked in palm with elbow at side bent 90, elicits pain when moves in ulnar deviation.
OT treatment -
- Conservative treatment - Thumb spica splint, activity/work modification, ice massage over radial wrist, gentle AROM of wrist and thumb to prevent stiffness.
- Post op treatment - Thumb spica splint, gentle AROM 0-2 weeks, strengthening, ADL, and role activities 2-6 weeks. Unrestricted activity 6 weeks.
Types of CTD
Lateral and medial epicondylitis
Symptoms - Degeneration of the tendon origin, result of repetitive micro trauma. Lateral epicondylitis (tennis elbow) over use of wrist extensors (ECRB). Medial epicondylitis (golfer’s elbow) over use of wrist flexors
OT Treatment -
- Conservative Treatment - Elbow strap, wrist splint, ice and deep friction massage, stretching, activity/work modification. As pain decreases, add strengthening, begin with isometric exercises and progress to isotonic and eccentric exercises.
Trigger Finger
Symptoms - Tenosynovitis of the finger flexors (A1 pulley)
Etiology - Caused by repetition and us of tools that are placed too far apart.
Conservative Treatment - Trigger finger splint. (MCP extended, IP free), scar management, edema control, tendon gliding. activity mod. avoid repetition and far grips, nerve compressions
Functional - position resting hand splint
will Prevent contractures and allow access to hand for cleaning.
Dynamic finger extension splints
appropriate for those who have active finger flexion but limited finter extension.
Tendon repairs
- Early mobilizaiton
- Occupational therapy goals
- Early mobilization - prevents adhesion formation, facilitates wound/tendon healing
- Occupational therapy goals - Increase tendon excursion, improve strength at repair site, increase joint ROM, prevent adhesions, facilitate resuption of meaningful roles, occupationaln and activities
Early mobilization programs form flexor tendons
- Kleinert
- Kleinert -passive flexion using rubber band traction and active extension to the hood of the splint.
- 0-4 weeks dorsal block splint. wrist is positionin 20-30 degrees of flexion, MCP joints in 50-60degrees fo flexion and IP joints extended.Passive flexion and active extension withing limits of splint
- 4-7 week (intermediate phase) continue dorsal block splin, but adjust the wrist neutral. place/hold exercises and differental flexor tendon gliding exercises, scar management.
- 6-8 weeks : AROM differential tendon gliding. Light purposeful and occuaption based activities D/C splint
- 8-12 weeks: strengthening and work and leisure activities.
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Early mobilization programs form flexor tendons
Duran Protocol
- 0-4 weeks - dorsal blocking splint, exercises in splint include passive flexion of PIP joint, DIP joint and th DPC.10 reps every hour
- 4-6 weeks - active flexion and extension withing limits of splitn
- 6-8 weeks - tendon gliding and differential tendon gliding, scare management, and light purposeful and occupation-based activities
- 8-12 weeks - strenthening and work activities
Early mobilization Programs for Extensor tendons
- Zone 1 and 2
- Zone 3 and 4
- Zone 5-7
- Zone 1 and 2 - Mallet finger deformity 0-6 weeks DIP extension splint
- Zone 3 and 4 - Boutinniere deformity
- 0-4 weeks: PIP extension splint (DIP free)
- 4-6 weeks: begin AROM of DIP and flexion of digits to the DPC
- Zone 5-7
- 0-2 weeks: volar wrist splint with wrist in 23-30 degrees of extension, MCP in 0-10 degrees fo flexion and IP joints in full extension
- 2-3 weeks: shourten splint to allow flexion and extension fo IP
- 4 weeks: remove splint to begin MCP active flexion and extension
- 5 weeks: begin active wrist ROM. Wear splint in between exercise session
- 6 weeks: discharge splint
Mallet finger deformity
Boutonniere Deformity
Radial nerve palsy
- Symptoms
- Conservative treatment
- Post operative treatment
- Symptoms - weakness or paraysis of extensors to the wrist, MCPs and thumb; wrist drop
- conservative treatment
- dynamic extension splint
- work/activity modificaiton
- strengthening wrist and finger extensors when motor function returns
- Postoperative treatment -surgical treatment for decompression
- ROM
- nerve cliding
- Strengthening 6-8 weeks post op
- ADL and meaningful role activities
Median nerve laceration
- Symptoms
- low lesion at wrist - ape hand
- high lesion at or proximal to the elbow - benediction sign
- OT intervention
- Symptoms - Sensory loss (palmar surface of thumb, index, middle and radial 1/2 of ring fingers, Dorsal surface of index, middle, and radial 1/2 of ring fingers
- low lesion at wrist -
- motor loss at Lumbricals 1 and 2(digital flexion), Opponens pollicis (oppositioin) Abductor pollicis brevis (abdution), Flexor pollicis brevis (flexion of thumb MCP)
- high lesion at or proximal to the elbow
- motor loss same as low lesion at wrist
- FDP and FPL FCR
- OT intervention - address functional difficiculties related to pinch
- Dorsal proteciton splint with wrist positioned in 30 degree flexion if a low lesion. Include elbow 90 degree flexion if a high lesion
- 2 weeks post op - Begin A/Prom of digits with wrist in flexed position
- Scar Management
- 4 weeks - AROM include elbow if hight lesion
- 9 weeks - strengthening
- consider using a C-bar splint to prevent thumb adduction contracture.
Ulnar nerve laceration
- Symptoms
- Low lesion at wrist
- High lesion wrist or above
- OT intervention
- Symptoms -sensory loss at ulnar aspects of palmar and dorsal sufraces. Ulnar 1/2 of ring and little fingers on palmar and dorsal surface
- Low lesion at wrist - motor loss at balmar and dorsal interossei (adduciton of mcp joints) Lumbricals (flexion of digits 4 and 5) Fpb ADM, ODM, FDM (abduction, opposition , and flxeion of 5th digit)
- High lesion wrist or above - Motor loss of above muscles and FCU and FDP
- OT intervention - need to address funtional loss associated with loss of power grip and decreased pinch stregth
- Same as median nerve repair
- Dorsal proteciton splint with wrist positioned in 30 degree flexion if a low lesion. Include elbow 90 degree flexion if a high lesion
- 2 weeks post op - Begin A/Prom of digits with wrist in flexed position
- Scar Management
- 4 weeks - AROM include elbow if hight lesion
- 9 weeks - strengthening
- MCP flexion block splint
Radial Nerve laceration
- Symptoms
- low lesion at lthe level of the forearm
- High lesion at the level of the humerus
- OT Intervention
- Symptoms - Sensroy loss at the level of the humerus, medial aspect of dorsal forarm. Radial aspect of dorsal palm, thumb, and index, middle and radia half of ring phalanges
- Low lesion at level of the forearm - motor loss of writ extension due to impaired innervation to ECU, EDC, EI, EDM (MCP extension), EPB, EPL, APL (thumb extension
- High lesion at the level of the humerus - all of the above and ECRB, ECRL and brachioradialis, if leve of axilla, loss of triceps
- OT intervention - address issues of inability to extend digits to release objects, difficutly manipulating objects
- Dynamic extension splint
- ROM
- Sensory reed
- hom program and activity modification.
