HANDS & UE ORTHO: general Info Flashcards
gross/cylindrical grasp
all fingers/thumb wrap around object handle
- OPPOSITION = YES
- used by small children before finger control required
- impaired in CMC OA
EX: holding onto a handle, grasping a steering wheel
power grasp
- variation of gross grasp
- used when extra force is required, thumb STABILIZES, ulnar fingers most involved
THUMB OPPOSITION = NO - greater effort to control with this grasp = greater risk for injury
EX: holding a hammer while building
hook grasp
fingers “hook” around object without thumb
- radial nerve palsy = can’t form this grasp
- OPPOSITION = NO
EX: carrying a shopping bag/briefcase
spherical grasp
thumb & fingers form “cup” shape to grasp round objects
- OPPOSITION = YES
EX: holding an apple
conoid grasp
hold a cone shaped object, with the apex of the cone at the ulnar side of the palm
- The ring and little fingers provide extra control and stability at the smaller end of the cone
- OPPOSITION = YES
EX: holding an ice cream cone
lateral pinch
- thumb pushes against the side of the index finger to secure an object
- Often used to compensate for weakness or instability of the tip and palmar pinches
- Also used to compensate for poor thumb opposition
- OPPOSITION = NO
EX: holding car keys while starting a car, gathering & sorting paperwork into piles
palmar pinch/3 jaw chuck
- thumb opposes against the tips of the index and middle fingers to secure a small object
- OPPOSITION = YES
EX: pick up, place and push small building blocks together
tip pinch
- thumb opposes the tip of a finger, usually the index finger, to secure a small object
- OPPOSITION = YES
EX: pulling a pin out of a pin cushion
tripod grasp
- variation of palmar pinch, used to hold writing and drawing tools
- shaft of the tool is held by the tips of the thumb and index finger and stabilized by the side of the middle finger near the PIP joint (3 fingers)
- OPPOSITION= YES
quadruped grasp
- Another variation of palmar pinch, used to hold writing and drawing tools
- The shaft of the tool is held by the tips of the thumb, index and middle fingers and stabilized by the side of the ring finger near the PIP joint (4 fingers)
- OPPOSITION = YES
which type of grasp is impaired in radial nerve palsy?
hook grasp
which type of grasp is impaired in CMC OA?
gross/cylindrical grasp
flexors are on what part of the hand/arm?
volar
extensors are on what part of the hand/arm?
dorsal
nerve distribution of the UE
C3-C4 = supraclavicular
C6-C8 = radial
C5-C8 & T1 = median
C8-T1 = ulnar
ulnar nerve distribution of the hand
DORSAL & VOLAR: pinky, ulnar side of ring finger
median nerve distribution of the hand
VOLAR: radial half of ring, middle, index, and ulnar side of thumb
DORSAL: index, middle, radial half of ring finger PIP, ulnar side of thumb
radial nerve distribution of the hand
VOLAR: radial side of thumb
DORSAL: index, middle, radial side of ring below PIP
pillar pain
pain on either side of the carpal tunnel (source is unknown)
Carpal tunnel syndrome
Compression of MEDIAN nerve due to inflammation & repetitive motion with poor positioning
- palmar numbness of 1st – half of 4th finger, general weakness & pain, including pain at NIGHT, NO ROM LIMITATIONS
Assess: sensation, fine motor coordination, weakness
ASSESSMENTS: Semmes Weinstein Monofilament test, Nine hole peg test, dynamometer & pinch gauge (DO NOT TAKE GONI MEASUREMENTS UNLESS SYMPTOMS HAVE BEEN PRESENTS FOR A LONG TIME & ROM IS LIMITED)
+ Tinels sign
+ Phalens sign
+ Moberg Pick Up test
Cubital tunnel syndrome
- Compression of the ulnar nerve at the elbow
- due to repetitive elbow pressure or sustained elbow bending
- Numbness and tingling along ulnar aspect of forearm/ hand, pain at elbow with extreme, weak power grip
- advanced stages = FCU, FDP atrophy to digits 4 & 5, atrophy of ulnar nerve innervated muscles of the hand
+ Tinel’s sign at elbow (pain or sensation)
+ Phalens test
+ elbow flexion test
Double crush injury
a peripheral nerve is entrapped in more than one location
- Intermittent diffuse arm pain and paresthesias with specific postures
Guyon’s Canal
inflammation/irritation due to compression of the ulnar nerve at the wrist
- Numbness and tingling in ulnar nerve distribution of hand; motor weakness of ulnar nerve innervated musculature
- due to ganglion, pressure, fascia thickening
- advanced stages = ulnar nerve innervated muscles atrophy
+ Tinel’s sign at Guyon’s canal
Pronator teres syndrome
Compression of the median nerve between the 2 heads of the pronator muscles
- cause: trauma to the forearm or repetitive overuse, especially against resistance (i.e. turning a manual screwdriver)
- Palmar numbness and numbness of digit 1 - half of 4th digit, with generalized weakness and pain, aching pain in the PROX VOLAR FA, No pain at NIGHT
+ Tinels sign at FA, no night symptoms
Radial nerve palsy
Decreased conduction of the radial nerve
- cause: compression, fractures, and laceration
- Weakness/paralysis of extensors to wrist, MCPs, thumb
- wrist drop/Saturday night palsy
- Slow nerve regeneration
Radial tunnel syndrome
Compression of the radial nerve in the proximal FA
- cause: inflammation, repetitive motion, injury to the lateral side of the elbow, tumor
- lateral FA dull ache & burning sensation
Thoracic outlet syndrome
excess pressure is placed on a neurovascular bundle passing between the anterior scalene and middle scalene muscles
- cause is repetitive motion in the upper arm and shoulder, injury, poor posture, anatomical defects, tumors, or pregnancy)
- Vascular symptoms: swelling or puffiness in the arm or hand, bluish discoloration of the hand, feeling of heaviness in the arm or hand, pulsating lump above the clavicle, deep, boring toothache-like pain in the neck and shoulder region which seems to increase at night, easily fatigued arms and hands, superficial vein distention in the hand
- Neurologic symptoms: paresthesia along the inside forearm and the palm (C8, T1 dermatome), muscle weakness and atrophy of the gripping muscles (long finger flexors) and small muscles of the hand (thenar and intrinsics), difficulty with fine motor tasks of the hand, cramps of the muscles on the inner forearm (long finger flexors), pain in the arm and hand, tingling and numbness in the neck, shoulder region, arm and hand
what are the gripping muscles called?
long finger flexors (muscles on the inner FA)
what are the small muscles of the hand called?
thenar & intrinsics
nerve laceration or lesion is due to
Laceration = partially or completely severed
Lesion = damaged by trauma or prolonged compression
how does ape hand deformity/simian hand present?
high or low median nerve injury, thenar muscles paralyzed
- Loss of thumb abduction/opposition/pinch, sensory loss in index, middle, and radial side of the ring finger; index finger MCP and PIP flexion; & decreased pronation
- not its own dx, default position of the injured hand at rest when thenar muscles have atrophied
Brachial plexus
housed in the spinal canal of the vertebral column/spine
- network of nerves that conducts signals from the spinal cord to the shoulder, arm, & hand
which vertebrae does the brachial plexus originate in?
C5-C8, T1 spinal nerves, innervate the muscles and skin of the chest, shoulder, arm and hand
brachial plexus injuries causes
- shoulder trauma, tumors, or inflammation
- Pain, including avulsion pain (a burning pain in the injured nerve area), loss of sensation distal to the brachial plexus, muscle weakness, partial or total paralysis of the affected upper extremity
Erb’s palsy
- C5-C6 injury
- arm paralyzed/hangs limp with shoulder IR due to atrophy/paralysis in the biceps, deltoid, brachialis, and brachioradialis muscles
- limits functional movement
- paralysis can resolve on its own over a period of months, require therapy, or surgery
Long thoracic nerve palsy
- causing pain and limited movement in the shoulder
- Shoulder pain, limited overhead movement, and abnormal protruding/WINGING of the scapula
median nerve laceration results in
loss of thumb opposition, weak pinch, APE HAND DEFORMITY (thenar eminence flattening)
LOW LESION: wrist = Clawing of index/mid fingers
- motor loss = MCP flexion of digits 2 & 3, opposition, abduction, thumb flexion
HIGH LESION: at/prox to elbow = Benedictine hand
- motor loss: all in low lesion + 1,2,3,flexion, unable to flex to radial aspect of wrist
median & ulnar nerve injury involves
- Can be caused by car accidents and glass injuries
- Loss of sensation to the front surface of all digits, loss or impairment of finger flexion, thumb opposition. Clawing of all digits
radial nerve laceration presents as
Can’t release objects, difficulty manipulating objects
ulnar nerve injury presents as
ulnar claw deformity and numbness of the ulnar side of the hand and the fifth and half of the fourth digits, with generalized weakness of the ulnar side of the hand and pain
- MCP hyperextends
- Trouble cutting with small knife
- Trouble with power grip and lateral pinch
when does tenosynovitis occur?
when the tendon and its sheath become inflamed
when does tendonitis occur?
when the tendon becomes inflamed due to repetitive use of a muscle
DeQuervain’s tenosynovitis
cause is cumulative microtrauma, repetitive motion- inflammation of the thumb muscle/tendon unit
- involves abductor pollicis longus (APL), extensor pollicis brevis (EPB) —> (1st dorsal compartment)
- Pain & swelling over radial styloid, limited motion in APL & EPB & tendons in the first dorsal compartment of the wrist
+ Finklesteins test
lateral epicondylitis
tennis elbow
- inflammation of the tendons of the wrist extensors at the insertion points on and around the lateral epicondyle, caused by repetitive motion
Pain, inflammation, limited movement of the wrist extensors, especially ECRB
medial epicondylitis
golfer’s elbow
- inflammation of wrist flexors (flexor pronator, FCR, FCU) at the insertion points around the medial epicondyle, caused by repetitive motion
Pain, inflammation, limited movement of the wrist flexors.
rotator cuff tendonitis
inflammation of rotator cuff, caused by repetitive motion, chronic joint inflammation
- impingement at coracoacromial arch (acromian, coracoacromial ligament, coracoid process)
- Pain, swelling, limited movement of the tendons of the shoulder
trigger finger
tenosynovitis of the finger flexors. Caused by cumulative trauma
- Most commonly occurs in the A1 pulley, edema in the tendon and synovium of the digit results in lack of smooth flexion or extension of the finger
wrist tendonitis
inflammation of the tendons of the wrist
- Pain, inflammation, limited movement in the wrist
avulsion injuries/avulsion fracture
A small piece of bone that is attached to a tendon breaks away from the main bone. Mallet finger is an example of an avulsion fracture
extensor tendon injury
EDC or EIP injury, requires surgery
flexor tendon injury
A deep cut on the palm side of the fingers, hand, wrist, or forearm (laceration), can’t bend the fingers or thumb
mallet finger
avulsion of the terminal tendon
cumulative trauma disorder
Trauma to soft tissue caused by repeated force (deQuervains, lateral/medial epicondylitis, trigger finger)
- muscle fatigue, pain, chronic inflammation, sensory impairment, decreased ability to work
due to repetitive strain/overuse, musculoskeletal disorders OR acute trauma, pregnancy, diabetes, arthritis, wrist size/shape
Example: playing piano 10 hours a day.
MCP flexion limitation
Difficulty flexing the MCP’s due to ligament tightness
- MCPs = condyloid joints (reception of rounded heads of the MC bones into shallow cavities on the proximal ends of digit 1 (exception of the thumb = hinge thumb)
PIP flexion contracture
Shortening and tightening of the tendons and ligaments surrounding the PIP joint due to injury
Skier’s Thumb/Gamekeepers Thumb
Rupture of the ulnar collateral ligament of the MCP joint of the thumb. (i.e., skiing with the thumb held in a ski pole)
Boutonniere deformity
PIP joint flexed, and the DIP joint hyperextended
swan neck deformity
injury to the MCP, PIP, or DIP joints characterized by PIP hyperextension and DIP flexion
ulnar drift
Hand deformity in which the swelling of the metacarpophalangeal joints (the big knuckles at the base of the fingers) causes the fingers to become displaced, tending towards the little finger. The hand including the fingers move towards the ulna. Ulnar deviation is a disorder in which flexion by ulnar nerve innervated muscles is intact while flexion on the median nerve side is not.
bennetts fx
Fracture of the first metacarpal base
boxer’s/proximal fracture
A boxer’s fracture is the result of a clenched fist hitting an object with enough force to break the metacarpophalangeal neck, most commonly seen in the fourth and fifth digits.
carpal fracture
Fracture to the individual carpal bone. Most common injury to the wrist is the scaphoid. Lunate fractures are associated with Kienbock’s disease
colles fracture
Complete fracture of the distal radius with dorsal displacement. Most common type of wrist fracture.
distal radius fracture
The 3 most common eponymous distal radius fracture types, the Colles’ fracture, the Smith’s fracture, and the Barton’s fracture
elbow fracture
Involvement of radial head may result in limited rotation of forearm. Usually caused by a forceful load through an outstretched arm
fracture of medial epicondyle
broken via injury
humeral fracture
Most common fracture of the upper arm and may involve the articular surface, greater or lesser tuberosity, or surgical neck
- nondisplaced vs displaced fx
- due to FOOSH
- greater tuberosity fx = RTC injury
- humeral shaft fx = wrist drop/radial nerve injury
Fracture of the bones of the hand
metacarpal fracture
radial head fracture
33% of elbow fractures, FOOSH is common cause
smith’s fracture
Complete fracture of the distal radius with palmar displacement.
wrist fracture
Injury to the wrist. The wrist is variously defined as the carpus or carpal bones, the complex of eight bones forming the proximal skeletal segment of the hand; the wrist joint or radiocarpal joint, the joint between the radius and the carpus; and the anatomical region surrounding the carpus including the distal parts of the bones of the forearm and the proximal parts of the metacarpus or five metacarpal bones and the series of joints between these bones, thus referred to as wrist joints. This region also includes the carpal tunnel, the anatomical snuff box, the flexor retinaculum, and the extensor retinaculum
adhesive capsulitis/frozen shoulder
Restricted active and passive shoulder range of motion
dupuytren’s contracture
Disease of the fascia of the palm and digits. Results in flexion deformities of the involved digits (i.e., mostly ring finger). Frequently treated with surgical release of the affected fascia
flaccid wrist
Lacking firmness, resilience, or muscle tone in the wrist. No active movement present.
focal hand dystonia
Involuntary muscle contractions of the hand, causing the fingers to curl into flexion or straighten into extension involuntarily. Abnormal movement of the hand, usually related to specific tasks. Often happens in people who push themselves too hard; musicians, computer programmer. Writer’s cramp is a form of focal hand dystonia.
ligament injuries occur when
the ligament attaching one bone to another bone is sprained or ruptured due to trauma.
muscle overuse injuries occur when
microtears and scarring form in the muscles due to overuse
tendon laceration occurs when
the tendon is severed by a sharp object (trauma)
isometrics
Not changing muscle length
Planks, pushing your fist into a ball
isotonics
Changing length of muscle
Push ups, squats
Ruffini end organs
Sensory receptor of the hand
responsible for tension
merkel cells
Sensory receptor of the hand
Responsible for pressure
Charcot Marie Tooth disease
- genetic neurological disorder, voluntary muscle control & strength impacted
- Muscle atrophy
- Progressive weakness of the distal muscles of the arms & feet, damages nerves in arms & legs
- Muscle weakness, decreased muscle size, decreased sensation, hammertoe, high arches
- LATER STAGES = orthosis to compensate for hand weakness and promote function, improve function for active grasp & release
Klumpke’s palsy
C8-T1 injury
- compression/traction of lower brachial plexus, less common
- Paralysis of the hand & wrist muscles (claw hand deformity)
- Severe (rare) = full UE paralysis
waiter’s tip position is seen in which injury?
Erb’s palsy (brachial plexus injury)
Thumb position for functional pinch
Splint in
Thumb opposition with palmar abduction
Tip-to-tip pinch
Phalen’s test
Hold wrist in full flexion for 1 minute to elicit symptoms to provoke pain
Carpal tunnel
Cubital tunnel
Tinel’s test
Tapping on median nerve in volar wrist to elicit symptoms
Carpal tunnel
Cubital tunnel
Wartenberg’s sign
5th finger held abducted from 4th finger
Ulnar nerve injury/claw deformity
Cubital tunnel
Jeanne’s sign
Hyperextension of the proximal thumb phalanx when pinching
Ulnar nerve injury/claw deformity
Froment’s sign
hyperflexion of thumb IP when lateral pinch attempted
Tests for ULNAR NERVE PALSY
Adductor pollicis is thumb muscle innervated by the ulnar nerve & is tested in this sign
If positive: indicative of ulnar nerve palsy
Conditions:
Ulnar nerve injury/claw deformity
Cubital tunnel syndrome
Finklestein’s test
tests for de Quervain’s tenosynovitis
elbow flexion test tests for
cubital tunnel syndrome
Semmes weinstein
Sensation testing
For carpal tunnel
Ulnar nerve injury
moberg pickup test
For carpal tunnel
Median nerve controls
- dexterity (Pad to pad, 3 jaw chuck)
- innervates volar 1-4 digits
Ulnar nerve controls
(C8-T1)
- abductor pollicis
- lateral pinch
- gross grasp/power
- innervates half of 4th, 5th digits
Radial nerve controls
Wrist extension, extensors (make client more functional)
- innervates 1-quarter of 4th digits
Hand of benediction
- loss of flexors due to median nerve injury (can’t flex digits/make full fist)
How is edema usually measured?
Volumeter is gold standard
- circumferential if there is an infection or open wound
Provocative tests for carpal tunnel syndrome
Phalens, Tinels, mohberg pick up test
Concentric strengthening
Muscle shortening (EX: wrist extensions with a weight)
Eccentric strengthening
Muscle lengthening (EX: bring wrist up, place weight in hand then bring wrist down & remove weight then bring wrist back up)
When strengthening a patient, what is the order of strengthening tactics?
Isometrics —> isotonics —> eccentrics (especially with lateral epicondylitis)
Extensor dorsal compartments
1: abductor pollicis longus, extensor pollicis brevis
2: ECRB & ECRL
3.
Cross friction massage
Find origin (Ex lateral/medial epicondyle) then go back-forth quickly until they get numb (about 1 min or more) & repeat 3-4x depending on how much they can take
This is an active sign which only occurs when a patient with a high median nerve injury attempts to make a fist (flex the digits)
Hand of benediction
Purpose of a compression garment
Prevent re-accumulation of fluids after retrograde massage
- types: isotopes gloves, tubigrip (elastic stockinette), aces wraps, Coban (wrapped distal to proximal) for digit edema during exercise or ADL
- avoid too much tension
Kleinert protocol
For flexor tendon injury repair
- ACTIVE extension of digit with PASSIVE flexion using rubber band traction- rubber bands on patients nails w/active IP extension & when rubber band recoils, IP joints are passively flexed
0-4 weeks: dorsal blocking splint with wrist 20-45 deg flexed, MCPs 50-60 deg flexed, IPs extended
4-7 weeks: wrist adjusted to NEUTRAL in splint, place/hold exercises, differential flexor tendon glides
6-8 weeks: AROM, dfferential tendon glides, purposeful/occupational activities, discharge splint
6-12 weeks: strengthening, work/leisure activities
Duran protocol
For flexor tendon injury repair - passive flexion & extension of the digits
0-4.5 weeks: dorsal blocking splint with exercises in splint (passive PIP flexion to DIP to DPC) 10 reps per hr
4.5-6 weeks: active flexion/extension within splint limits
6-8 weeks: tendon glides, differential tendon glides, scar management, light/purposeful occupational activity
8-12 weeks: strengthening, work activities
Ulnar claw
Ulnar nerve lesion, permanent/fixed position of hand at rest
4th & 5th finger MCP hyperextension (due to strong extrinsics and weak intrinsics), IP hyperflexion (due to weak intrinsics)
Strong FDP & FDS muscles keep PIP and DIP joints in unopposed flexion
Hand of benediction
High median nerve injury that only appears when making a fist (active sign only) and goes away when hand is relaxed
- digits 4 & 5 flex but digits 2 & 3 can’t flex at MCP or IPs (due to loss of lateral lumbricals)
Ape hand
Median nerve deformity
- default position of injured hand at rest
- thenar muscles paralyzed, can’t abduct/oppose thumb
- adductor pollicis unopposed
If the radial nerve is injured at the axilla then,
Sensory & motor lost
- triceps paralyzed
If the radial nerve is injured at the middle of the arm, what happens
Wrist drop, decreased grip, can’t extend hand at the wrist, numbness/parenthesis/pain along lateral back of arm
Reasons for radial nerve injury
- Saturday night palsy: falling asleep with arm hanging over chair arm rest, compressing radial nerve at spiral groove
- honeymoon palsy: sleeping on someone’s arm overnight
- handcuff neuropathy: tight fitting hand cuffs compress superficial branch of distal radial nerve
- crutch palsy: from poor fitting crutches
- squash palsy: due to squash sport
Superficial radial nerve injury
Sensory issues of dorsal radial hand & digits 1– radial half of digit 3
Median nerve lesion proximal location deficits
Above elbow:
1. Hand of benediction
2. Thumb opposition/abduction
3. Wrist pronation/flexion
4. Flexion of index/middle fingers
5. Thenar muscle atrophy (chronic injury)
Median nerve distal below elbow injury deficits
anterior interosseous nerve syndrome (flexion of distal thumb, index finger joints “pinch sign”)
Median nerve distal within wrist injury deficits
- Carpal tunnel
- Palmar cutaneous nerve: sensation to palm
- Recurrent beach of median nerve: innervates thenar eminence, no thumb flexion, opposition, abduction
Screen ulnar nerve via
Peace sign/scissors sign
Screen radial nerve via
Hitchhiker/thumbs up sign, paper position of rock/paper/scissors
Screen median nerve via
Power to the people sign/Rock position of rock/paper/scissors & OK sign (anterior interosseous median nerve)
Wartenberg’s syndrome
Entrapment of superficial branch of radial nerve with only sensory issues (no motor)
OK sign
Unable to make OK sign due to thumb IP flexion & distal IP of index finger impaired (anterior interosseous nerve damage)
Ulnar tunnel/handlebar palsy
Direct compression in Guyon’s canal (due to ganglion, respective trauma, chronic pressure in hand of a cyclist from handlebars)
Retrograde massage
- reduce swelling from lack of movement (CVA)
- pushes fluid back towards heart (be aware of cardiac conditions)
- not effective for lymphedema
- 10-15 min long with hand above elbow/heart level using lotion with hand/wrist neutral from tips of fingers down towards elbow on both sides of the hand
- use compression garments after massage
Lymphatic drainage
Type of massage technique to reduce lymphedema in RA, fibromyalgia, chronic venous insufficiency, lipedema, post breast cancer tx
- clear/release lymphatic fluid from tissues & reabsorbs/moves it to lymph nodes
- DO NOT USE WITH HEART CONDITION, KIDNEY FAILURE, BLOOD CLOTS, INFECTION
Intrinsic minus
Also known as claw hand (MCP hyperextension, PIP/DIP flexion); imbalance between strong extrinsics, weak intrinsics
Elbow fractures
Types: olecranon, radial head, distal humerus fractures
Which condition often begins with PROM before AROM?
Humeral fracture
Intra-articular vs extra-articulatar fracture
Intra-articular: break crosses into surface of a joint
Extra-articular: break does not extend into the joint
Closed vs open fractures
Closed/simple fracture: bone broken but skin intact
Open/compound fracture: bone pokes through skin; can be seen
Complete vs incomplete fractures
Complete: bone completely broken into separate pieces
Incomplete: bone crack but not broken into 2+ pieces
Transverse vs spiral vs oblique fractures
Transverse: break perpendicular to bone length
Spiral: broken via twisting motion- corkscrew fx line
Oblique: diagonal break
ORIF
Nails, screws, plates, wire
Closed reduction
Short & long arm cast, splint, sling, fracture brace
Arthrodesis
Fusion
Arthroplasty
Joint replacement
Treatment for shoulder fractures often begins with
Isometrics
General OT intervention for fractures
- Immobilization phase: stabilization & healing
- AROM, edema control (edema, manual edema mobilization, gentle retrograde massage, compression garments), light ADLs with no resistance - Mobilization phase: consolidation (strengthening) is goal
- edema control (elevation, manual edema mobilization, gentle retrograde massage, contrast baths, compression garments- Tubigrip, Isotoner glove), splint, AROM —> PROM with MD approval (except humerus fx), occupational activities, pain management (positioning, PAMS), strengthening with MD approval (shoulder fx = isometrics first)
Klienert and Duran protocols are for
Flexor tendon repairs
Early mobilization programs for extensor tendon zones I & II
Mallet finger
0-6 weeks: DIP extension splint
Early mobilization programs for extensor tendon zones III & IV
Boutonnière deformity
0-4 weeks: PIP extension splint (DIP free), AROM of DIP while in splint
4-6 weeks: AROM of DIP & digit flexion to DPC
Early mobilization programs for extensor tendon zones V, VI, VII
0-2 weeks: volar wrist splint, wrist 20-30 deg extension, MCPs 0-10 deg flexion, IPs full extension
2-3 weeks: shorten splint to allow flexion/extension of IPs
4 weeks: remove splint, begin MCP active flexion/extension
5 weeks: begin active wrist ROM, wear splint between exercise sessions
6 weeks: discharge splint
Flexor tendon zones
I: FDP (middle of middle phalanx)
II: FDS & FDP (middle of middle phalanx to DPC)
!!!!!!!!!!!NO MANS LAND!!!!!!!!!!!!!
III: distal palmar crease to transverse carpal ligament
IV: carpal tunnel
V: prox to transverse carpal ligament —> musculotendinous junction
THUMB
1: distal to thumb IP
2: thumb A1 pulled to IP joint
3: thenar eminence
Extensor tendon zones
I: DIP
II: middle phalanx
III: PIP
IV: proximal phalanx
V: MCP
VI: metacarpals
VII: wrist
Incomplete vs complete nerve injuries
Incomplete: compression or nerve entrapment
complete: laceration/avulsion injury
Radial nerve injury
sensory loss (high lesion at humerus): medial dorsal FA, radial back of palm, thumb - radial half of ring finger loss
motor loss
- (low lesion at FA level): wrist extension, EDC, EI, EDM (MCP extension), EPB, EPL, APL (thumb extension) loss
- (high lesion at humerus): all of above + ECRB, ECRL, brachioradialis, triceps (if at axilla level- elbow extension) loss
Parts of the rotator cuff
- Supraspinatus: abduction, flexion
- Infraspinatus & teres minor: ER
- subscapularis: IR
functions together to control head of humerus in glenoid fossa
Isotonic muscle contraction
Muscle contracts to actively move a joint
1. Concentric: muscle actively counters resistance to move a joint (EX: client’s biceps contract to bend elbow to lift &d raw hammer back to pound a nail)
- Eccentric: muscle contracts to slow movement, stabilize joint in reaction to quick movement or gravity (EX: client’s biceps contracts to stabilize elbow as he sets his hammer down on a bench)
Isometric muscle contraction
muscle contracts but does not actively move a joint (EX: a client tenses and relaxes muscles as part of a relaxation technique)
General guidelines for muscle strengthening
- AAROM, AROM & resistive exercises increase muscle strength
- exercise/activity must suit muscle grade & patient’s fatigue tolerance level
- activity grading via increasing/decreasing resistance (changing plane of movement from gravity eliminated to against gravity, adding weights to equipment/client, using weighted tools, grading texture of materials from soft to hard or fine to rough, changing to more/less resistive activity
- resistance applied manually via weights, springs, elastic bands, sandbags, special devices
- resistance graded progressively by increasing amount of resistance (gravity is a form of resistance)
