Hand Therapy Basics

Question 1

What are we evaluating with the hand?

Answer 1

—Physical limitations

• —ROM
• —Strength
• —Sensation
• —Coordination

—Functional limitations

—Substitution patterns

—Deformities

—Appearance

• —Color
• —Edema
• —Scarring
• —Trophic changes

Question 2

What are the goals for nerve injuries? What is the prognosis for re recovery?

Answer 2

—Goals:

—Maximize Daily Function

—Prevent overstretching

—Prevent muscle imbalance

—Prevent contractures

—Sensory & motor retraining

—Prognosis Depends on…

—Extent of injury (Seddon or Sutherland rating)

—Level of injury

—Timing & technique of repair

—Age & motivation of patient

Question 3

Explain Nerve Healing

Answer 3

• —2 week latency
• 1mm/day or 1in/mo
• Sensory recovery from 1st to last
  
  • Pain & temperature
  • Vibration
  • Moving touch
  • Constant touch

Acute Phase

—Protect healing nerve and/or surgical intervention

• —Immobilization (3-4 weeks)

—Edema & wound care

—Prevent joint contracture

• —Splinting

—Prevent further injury

• —Sensory precautions

—Facilitate function

• —Splinting
• —Adaptive equipment & techniques

Post Immobilization/ Recovery Phase

—Regain ROM

• —PROM
• —AROM
• —Gliding exercises

—Splints to enhance function

—Motor retraining

—Sensory retraining

Chronic Phase

—Compensation for any remaining deficits

• —Adaptive equipment
• —Tendon transplants

Question 4

What are the deficits with a Radial nerve injury? Causes? Interventions?

Answer 4

Major Deficits: Radial Nerve:

Wrist extension

—Finger extension

—Thumb abduction

—Thumb extension

—Supination

—Elbow extension

—Sensation—dorsal—usually not a functional problem

Common Causes:

—Humeral fractures & trauma

—Fx & dislocation of elbow

—Fx of upper third of radius

—Radial tunnel compression

—Space occupying lesions

—Radiation

—Handcuffs, jewelry, watches

—Intravenous cannulas

—Fixators

Intervention:

—Adaptive equipment

—Wrist splint

—Edema management

—Desensitization

—Scar management

Question 5

What are major Ulnar nerve deficits?

Answer 5

—Intrinsics

• —Interossei/ Lumbricals (3rd and 4th)
• —Flexor, abductor & Opponens digit minimi
• —Adductor pollicis

—Extrinsics

• —FCU
• —FDP (4th and 5th)

—Decreased sensation

—Decreased power grip and pinch

—Loss fine prehension

—Froment’s sign (flexion of IP during pinch)

—Claw deformity

Common Causes:

—Thoracic outlet

—Humeral epicondyle fx

—Olecrenon fx of ulna

—Cubital tunnel

—Guyon’s canal

—Wrist lacerations

Treatment:

—Conservative

—Padded handles

—Edema control

—Avoid repetitive or prolonged elbow flexion

—Splints

• —Elbow extension
• —Claw hand

Question 6

What are the major deficits of the median nerve?

Answer 6

—Intrinsics

—Thumb Opponens, FPB, APB

—Lumbricales

—Extrinsics

—FDS

—FDP (2nd and 3rd)

—Pronator Teres

—FPL

—FCR

—Loss sensation palmar/radial hand

—Wrist flexion

—Pronation

—Ape Hand

Common Causes:

—Humeral fractures

—Elbow dislocation

—Distal fx of radius

—Wrist fractures

—Volar wrist injuries

—Carpal tunnel syndrome

—Pronator syndrome

Treatment:

—Adaptive equipment

—Wrist splint

—Edema management

—Desensitization

—Scar Management

Question 7

What are the phases of wound healing?

Answer 7

—Stage I: Inflammatory phase

• —days 1-10
• —area red, warm, swollen
• —immobilization to rest injured or surgically repaired tissues
• —splints
• —motion begun too early will increase and prolong inflammation
• —inflammation normal, but should be minimized
• —modalities

—Stage 2: Proliferative (reparative) phase

• —Day 3-21
• —less red, warm, and swollen
• —wound healing, new tissues laid down
• —one wound-one scar
• —Low stress ROM, tendon gliding

—Stage 3: Maturation phase (restorative)

• —21 days –18 months (up to 2 years)
• —permanent tissues laid down
• —tissues fix, shrink, remodel
• —if scar not under stress will lay down tissues randomly
• —pressure garments & splints
• —keloid or hypertrophic scarring
• —exercise to return to normal function
• —Therapist goal to return to function without causing exaggerated inflammatory response

Question 8

What is scar management?

Answer 8

—Goal to promote supple, nonadherent scar.

—A. nonadherent

—tendon gliding exercises

—soft tissue massage

—ROM, strtc

—B. supple (flat) scar

—pressure

—massage

—ROM

—modalities

Question 9

What are Dupuytren’s Contracture?

Answer 9

—Thickening of deep facia in palm

—Leads to flexion contracture of finger(s)

—Cause unknown

—Viking ancestry

—Progressive

—Surgery

Question 10

What are fasciectomy’s? Care of?

Answer 10

Fasciectomy—

Remove fascia

—Z stitched wound

Dermofasciectomy

Remove fascia & overlying skin

—Skin graft from groin

Open Palm Technique

—Mc Cash Technique

—Healing by secondary intention

• —3-5 weeks for closure

—Decreases flexion force of skin closure

• —Allows extension of digits

Post-op Rehab

—Post op dressing/splint

—Whirlpool if open palm technique

—Wound care

—Scar Management

—Edema control

—ROM exercise

—Progress to Functional Activities/Strengthening