hand, wrist and elbow Flashcards
Tendon Glides
- straight hand extended fingers
- claw hand or hook
- straight hand extended fingers
- straight fingers Mp flexed on palm
- straight hand extended fingers
fist - 3 - 5 repetitions 3 times day
Median Nerve Glides
- wrist in neutral, fingers and thumb in flexion
- wrist in neutral, fingers and thumb extended
- wrist and fingers extend, thumb in neutral
- wrist, fingers and thumb extended
- as in position 4 forearm in supination palm up.
- as in position 3 with hand, use other hand to gently stretch the thumb
joint protection
respect pain, balance rest and activity, exercise in a pain free range, avoid positions of deformity, reduce the effort and force, use larger stronger joints.
ergonomics
Arms, knees and hips at 90 degrees sitting in chair belly against desk top and eyes 15 to 30 degrees above computer. Look into L shaped desks and try headsets for phone use
Special tests
cozens for lateral eipcondylitis, tinels for cubital tunnel or other neuropathies, and finkelsteins for DeQuervains, Phalens for carpal tunnel
Finkelsteins test: make fist with thumb in fist, ulnarly deviate wrist, positive if pain in first dorsal compartment dequervains.
CMC arthritis
CMC Arthritis: OA can affect all of the joints of the thumb INFO: with a swan neck deformity as one of the most common at the CMC joint by metacarpal adduction and subluxation from the trapezium, MP joint hyperextension, and IP joint flexion. Pinch is painful because CMC subluxation becomes more pronounced during heavy pinch activities. Exercise programs that combine pain free use AROM and joint protection as opposed to pinch strengthening were found to be more effective. Wrist flexion muscle RE flexor carpi radilais and ulnaris. Wrist extension muscles are ECRB , ECRL and ECU
AROM for hand include wrist flexion and extension, gentle digit flexion and extension(composite in neutral flexion and extension), and thumb opposition and circular ( finger nail touch), palmer and radial abduction. Gentle stretching of the first web space (adductor pollicis) with massage as well as grabbing a 1 inch cone dowel to gently wedge the web space. Use cone for stretching and isometric for ex. 25, 50 and 75 percent squeeze on the cone for isometrics make sure client conscious of muscles used while doing it!.
Adaptive device larger grip handles in kitchen or garden.Pushing a glass sideways with your index finger with your hand stabilized is a nice way to activate the first dorsal interossius strengthening. The hand based thumb spica orthosiss.p.462
Lateral epicondylitis
caused by use of the muscle, repetition causing micro damage to the tissue which does not heal properly. Occurs when gripping due to stabilizers of wrist extensors. Pain when gripping with full elbow extension is biggest issue with this cases. Avoid elbow extension with forceful grip.
Management: adapt techniques so pain does not occur. NSAIDS used. Goal is to control pain, edema and spasm and to maintain soft tissue integrity and joint mobility. . Wrist extension immobilization to 35 degrees which decreases full grip. Remove splint 3 times daily to do gentle AROM” wrist drop and relax, transverse friction massage. Subacute to chronic stages begin gentle contract relax or isometrics, self stretch on wall and table. Increase intensity of massage start gentle. Isometric, isotonic ex 1-2 lb as tolerated, elastic ex is good for eccentric. Work modification and stretch prior to activity.
Colles Fracture
:complete fracture of the distal radius with dorsal displacement( from hyperextension of the wrist) mainly happens Post menopausal women. Manages surgically with closed reduction and casting or ORIF with volar plate and sometimes simultaneous carpal tunnel release as indicated. Will typically need temporary orthosis for support and protection and some therapy to regain full ROM. Fracture healing 4- 8 weeks. Interventions: edema control: retrograde massage. compression wrap. Elevate and Pump, exercise ( apple picking). Contrast bath, tendon gliding arm above heart 10 reps. Scar management, pronation and supination with hammer, isometrics wrist, dynamic splinting. Strengthening arm off wedge with 1-2 lb dumb bell in different positions. ROM = dart throwing
Dequervains tenosynovitis
inflammation of the synovial lining surrounding the extensors within the first dorsal compartment. First extensor compartment is abductor pollcis longus, and extensor pollicis brevis.
management: “Thumb spica” wrist and thumb immobilization splint put thumb out more like flat hand so they do not use it. Splint 3-4 weeks 24-7
Thumb stretch: opposition stretch down and all the way back. Passsive stretch- stretch ext pollicis longus aka finkelsteins test. wrist stretch- flexion and extension hold MPs.
radial and ulnar deviation gravity eliminated. gentle glise back /forth thumb relax then adduct thumb.
functional- use larger muscle group besides wrist use forearms and upper body. Joint protetction techniques, ergonomic garden tools, spring loaded scissors.
Grip strengthening- isometric tubes.
work modification
Trigger finger
A1 pulley tensoynovitis, tendons gliding in constricted space ( palm) splint 24-7 1-2 weeks.
management- tendon glides, after release, scar massage and edema control. adapt activities,work modification can use padded bicycle gloves to help while working.
Carpal Tunnel Syndrome:
carpal tunnel is a confined space between the carpal bones dorsally and the transverse carpal ligament (flexor retinaculum) volarly. CTS is characterized by the sensory loss and motor weakness that occur when the median nerve is compromised in the carpal tunnel. Anything that compresses the median nerve restricts the mobility of the nerve, causing a compression injury and neurological symptoms to the wrist. Compliance with nerve glides will help open up the space in the carpal tunnel to allow fluid to move through and promote healing.
management- Wrist immobilizations with extension in 0- 20 degrees, Work modification protection: Try to keep wrist in a neutral position with daily activities. Avoid sustained pinch or gripping, particularly prolonged pinching when your wrist is in flexed or bent posture. Avoid overuse of wrist in activity. Can use these same techniques for knitting. Avoid positioning your wrist in a bent or flexed posture such as fetal position when sleeping. Use your orthosis at night to help keep wrist in the safe, neutral position. Whenever possible, use tools with larger grips contoured to the arches of your hand in the kitchen, the workplace, the garden
5 repetitions of mobility exercises 3 times a day with a 5- 30 second hold in each position with no provoking symptoms:
Median nerve glides or brachial plexus glide gentle and accurately and tendon glides.
Light isometrics only!
Blocking exercises: 5 repetitions 3 times a day
- Block the MP joint and bend the PIP joint
- Block the PIP joint and bend the DIP joint.
- Block the MP joint of the thumb and bend the IP joint.
Isolated blocking exercise
exercise hold three fingers straight and bend one finger then alternate.
standardized test
he Nine-Hole Peg (NHP) Test is a timed measure
of fine dexterity and involves placing and removing
nine pegs in a pegboard.
1.time how long to put in and out x3.
2.hole side( stores pegs) faces hand being tested.
Metacarpal fracture
Most seen in 1st and 5th ray.
AROM prior to PROM.3-7 weeks to heal.
management- HAve to get scar tissue stretched beofre 4 weeks. ORIF better for this fracture and extensors use after.
Phase one: edema controland immobilization 2-3 weeks for closed reductions and 2-7 says for internally fixed. Splints should maintain arches of hand- position of immobilization is MP = 70-90, IP=0, wrist =20 extension. (intrinsic plus position)
scar management- massage, gel pads, educate client. coban wrap.
Phase two- 3-5 weeks- APROM, isolated EDC, tendon glides, intrinsic plus/minus, fist with wrist flexed.
Minus is claw hand and plus is mps flexed (lumbrical, lumbrical lumbrical). scare management.
phase three, 6-7 weeks- PROM begins, dynamic splinting for stiff joints, do not increase edema or pain. Light to normal use and therapeutic activities. Increase resistance at 8 weeks.
First metacarpal fx; Thumb fracture ( Bennets) intrarticular( thru joint space). !st CMC joint. Blow against a partially flexed MC. Usually reduced with percutaneous pinning and 4 weeks of immobilization.
AROM at 4 weeks, PROM at 6 weeks
Therapeutic managment: dexterity key turning, using a tennis ball turning with fingers. splinting should stretch web space. Pinch activities with tweezers.
Fracture of proximal phalanx- occur on radial side of hand from direct blow. treatment can be buddy taped for 4 weeks also could be used for therapy and exercise ( AAROM). Need to move avoid PIP contractures. Blocking (block lower finger and flex PIP) and isolated joint glides( hold all fingers but one and flex). Edema reduction and walk with hand above heart. AROM tendon glides.
