Musculoskeletal system disorders (ch 6) Flashcards
Dupuytren’s disease
- Disease of fascia of the palm and digits. Fascia becomes thick and contracted.
- Surgical release required.
- OT intervention: wound care; edema control; extension splint; A/PROM and eventually strengthening, scar management (massage), purposeful tasks that emphasize flexion and extension.
Skier’s Thumb (Gamekeeper’s Thumb)
Rupture of ulnar collateral ligament of the MCP joint of thumb.
OT intervention: thumb splint (for 4-6 weeks); AROM (at 6 weeks); PROM (8 weeks) and pinch strengthening (10 weeks)
CRPS (Complex Regional Pain Syndrome)
Can be localized to one area or spread to other parts of extremity. May follow trauma/surgery, but cause is really unknown.
Symptoms: severe pain, edema, discoloration, osteoporosis, sudomotor (sweat) changes, temp changes, trophic changes, and vasomotor instability.
-OT intervention: modalities to decrease pain; edema management; AROM to involved joints; ADL to encourage use; stress loading (weight bearing and joint distraction); splinting t prevent contractures; CAREFUL about PROM, stretching, joint mobilization, dynamic splinting.
comminuted fracture is…
when bone is broken into many pieces.
what is arthrodesis?
fusion (of joint)
what is arthroplasty?
joint replacement
what is Colles’ fracture?
fracture of distal radius with dorsal displacement
what is Smith’s fracture?
fracture of distal radius with volar displacement
most common carpal fracture is…
scaphoid (60%). Proximal scaphoid has poor blood supply and may become necrotic.
A Boxer’s fracture is…
fracture of 5th metacarpal (requires ulnar gutter splint)
most common proximal phalanx fractures are…
thumb and index finger. Common complication is loss of PIP A/PROM
Distal phalanx fracture is the most common finger fracture! It may result in…
mallet finger
Humeral shaft fractures may cause injury to the radial nerve resulting in…
wrist drop.
OT eval of fractures should include…
- hx of injury and fracture management
- results of tests (xrays, MRI, CT)
- edema
- pain
- AROM (do NOT assess PROM until ordered by physician. Exception is humerus fractures, which often begin with PROM or AAROM)
- sensation
- roles, occupations, ADL and activities related to roles
OT intervention for fractures….
- immobilization phase (stabilization and healing are the goals)… AROM of joints above/below the stabilized part; edema control (elevation, retrograde massage, and compression garments); light ADL with no resistance.
- mobilization phase (consolidation is the goal)… edema control (can now do compression baths), AROM (progress to PROM when approved by physician 4-8 weeks), light occupation activities, pain management, strengthening (begin with isometrics when approved by MD)
Cumulative trauma disorders (CTD) aka repetitive strain injuries (RSI) from overuse or musculoskeletal disorders. Just know that :)
That’s all :)
de Quervain’s (what is it? tx?)
Stenosing tenosynovitis of abductor pollicis longus and extensor pollicis brevis. Pain and swelling over radial styloid; positive Finkelstein’s test.
Tx: thumb spica splint (IP joint free); activity/work modification; ice; gentle AROM of wrist and thumb to prevent stiffness. Maybe surgery.
Lateral epicondylitis (what is it? tx?)
degeneration of the tendon origin as a result of repetitive microtrauma from overuse of wrist extensors, especially extensor carpi radialis brevis. aka tennis elbow.
Tx: elbow strap; wrist splint; ice and deep friction massage; stretching. Later begin isometric exercises.
Medial epicondylitis (what is it? tx?)
Degeneration of the tendon origin as a result of repetitive microtrauma from overuse of wrist flexors. aka golfer’s elbow.
Tx: elbow strap; wrist splint; ice and deep friction massage; stretching. Later begin isometric exercises.
Trigger finger (what is it? tx?)
tenosynovitis of the finger flexors, most commonly is is A1 Pulley. Caused by repetition and the use of tools that are placed too far apart.
Tx: hand based trigger finger splint (MCP extended, IP joints free), scar massage, edema control, tendon gliding, work modification (avoid repetitive gripping activities)
Kleinert Protocol
following tendon repair, passive flexion using rubber band traction and active extension to the hood of the splint.
0-4 weeks: dorsal block splint. wrist flex, MCP flex, IP ext… passive flexion and active extension within limits of splint.
4-7 weeks: continue dorsal block splint, but adjust wrist to neutral. place/hold exercises and differential flexor tendon gliding exercises; scar management.
6-8 weeks: AORM. differential tendon gliding; light purposeful activity. d/c splint.
8-12 weeks: strengthening and work and leisure activities.
Duran Protocol
following tendon repair, passive flexion and extension of digit.
0-4.5 weeks: dorsal blocking splint. exercises in splint include passive flex of PIP, DIP, and to DPC. 10 reps/hour.
4.5-6 weeks: active flexion and extension within limits of splint.
6-8 weeks: tendon gliding and differential tendon gliding, scar management, and light activity.
8-12 weeks: strengthening and work activities.
for Mallet finger deformity, what kind of splint?
DIP extension splint
for Boutonniere deformity, what kind of splint?
PIP extension splint (DIP free)
Carpal tunnel syndrome (CTS) is a compression of what nerve?
median!
Symptoms of carpal tunnel syndrome
numbness and tingling of the thumb, index, middle, and radial half of the ring fingers. Positive Tinel’s sign at wrist. Positive Phalen’s sign.
what is Tinel’s sign?
indicative of nerve irritation- lightly tapping nerve causes pins and needles.
what is Phalen’s sign?
indicative of carpal tunnel syndrome- put backs of hands together facing down (wrist flexed, fingers extended) and if tingling/numbness occurs it is positive for CTS.
Pronator teres syndrome
a median nerve compression between the two heads of pronator teres, caused by repetitive pronation and supination and excessive pressure on volar forearm.
Symptoms: same as CTS + aching pain in proximal forearm. Positive Tinel’s sign at forearm.
Tx: elbow splint at 90 degrees w/ forearm in neutral.
Guyon’s canal
an ulnar nerve compression at the wrist. From repetition, ganglion, pressure, and fascia thickening.
Symptoms: numbness and tingling in the ulnar nerve distribution of hand; motor weakness of ulnar nerve-innervated musculature; positive Tinel’s sign at Guyon’s canal.
Tx: wrist splint in neutral.
Cubital tunnel syndrome
an ulnar nerve compression at the elbow. Caused by pressure at elbow (leaning on elbow) and extreme elbow flexion.
Symptoms: numbness/tingling along ulnar aspect of forearm and hand; pain at elbow with extreme position of elbow flexion; weakness of power grip; positive Tinel’s at elbow
Tx: elbow splint to prevent positions of extreme flexion; elbow pad to decrease compression of nerve when leaning on elbows.
Radial nerve palsy
a radial nerve compression. “Saturday night palsy”… term used to describe sleeping in a position what places stress on the radial nerve. Also, compression as result of humeral shaft fx.
Symptoms: weakness/paralysis of extensors to the wrist, MCPs, and thumb; wrist drop.
Tx: dynamic extension splint; work mod; strengthening wrist and finger extensors when motor fn returns.
Median nerve laceration (sensory losses, motor losses, deformities, functional loss, and OT tx)
- sensory loss (central palm; palmar surface of thumb, index, middle, and radial 1/2 of ring fingers; dorsal surface of index, middle, and radial 1/2 of ringer fingers.
- motor loss: for a low lesion at the wrist… lumbricals I & II; opponens pollicis; abductor pollicis brevis; flexor pollicis brevis
- motor loss for a high lesion at or proximal to the elbow…. all of above; flexor digitorum profundus of index and middle fingers; flexor pollicis longus of index, middle, and thumb; flexor carpi radialus.
- deformity: flattening of thenar eminence (“ape hand”); clawing of index and middle fingers for low lesion; “benediction sign” for high lesion.
- functional loss: loss of thumb opposition; weakness of pinch
- OT tx: dorsal protection splint with wrist positioned in 30 degrees flexion (low lesion); include elbow (90 deg) for high lesion. A/PROM of digits with wrist flexed at 2 weeks post-op. C-bar in splint to prevent thumb adduction contracture.
Ulnar nerve laceration (sensory losses, motor losses, deformities, functional loss, and OT tx)
- sensory loss: ulnar aspects of palmar and dorsal surfaces; ulnar 1/2 of ring and little fingers on palmar and dorsal surfaces.
- motor loss: for low lesion at wrist… palmar and dorsal interossei; lumbricals III & IV; FPB and adductor pollicis; ADM, ODM, FDM (5th digit!)
- motor loss: for high lesion wrist or above… same as above & FCU; FDP IV & V
- deformity: claw hand; flattened metacarpal arch; + Froment’s sign (assessment of thumb adductor while laterally pinching paper)
- functional loss: loss of power grip; decreased pinch strength
- OT tx: splinting MCP flexion block splint; all same as median nerve…A/PROM of digits with wrist flexed at 2 weeks post-op.
Radial nerve laceration (sensory losses, motor losses, deformities, functional loss, and OT tx)
- sensory loss: high lesions at level of the humerus… medial aspect of dorsal forearm; radial aspect of dorsal palm, thumb, and index, middle, and radial 1/2 of ring phalanges.
- motor loss: low lesion at level of forearm… loss of wrist extension due to absent or impaired innervation to ECU; EDC, EI, EDM (MCP ext); EPB, EPL, APL (thumb ext).
- motor loss: high lesion at level of humerus… all of above, including ECRB, ECRL and brachioradialis; if level of axilla, loss of triceps.
- functional loss: inability to extend digits to release objects; difficulty manipulating objects
- deformity: wrist drop
- OT tx: dynamic extension splint; ROM, sensory re-ed; home program
What are the rotator cuff muscles?? and functions?!
Supraspinatus: abduction and flexion
Infraspinatus and teres minor: external rotation
Subscapularis: internal rotation
OT tx for rotator cuff tendonitis
- activity modification (avoid above shoulder level activities until pain subsides)
- educate in sleeping posture (avoid sleeping w/ arm overhead or combined adduction and internal rotation)
- decrease pain (positioning, modalities, and rest)
- restore pain free ROM
- strengthening (below shoulder level)
Adhesive capsulitis aka…
frozen shoulder!
Adhesive capsulitis is
restricted passive shoulder ROM. greatest limitation is external rotation, then abduction, internal rotation, and flexion. (At glenohumeral ligaments and join capsule)
OT tx for adhesive capsulitis
- encourage active use through ADLs
- PROM
- modalities
OT tx for adhesive capsulitis post-surgery
- PROM immediately following surgery
- pain relief using modalities
- encourage use of extremity for all ADLs
OT tx for post- operative rotator cuff injury
- PROM (0-6 weeks); progress to AA/AROM
- decrease pain- begin with ice, progress to heat
- strengthening (6 weeks post-op)- begin with isometrics, progress to isotonic (below shoulder)
- light ADLs
- leisure and work (8-12 weeks post-op)
OT tx for shoulder dislocations
- regain ROM: avoid combined abduction and external rotation with anterior dislocation
- pain free ADL activities
- strengthen rotator cuff
Rheumatoid arthritis is systemic, symmetrical, and affects many joints. Most commonly attacks which joints?
small joints of the hand
Symptoms of rheumatoid arthritis
pain stiffness limited ROM fatigue weight loss limited ADL status; diminished role performance swelling deformities
Common deformities of rheumatoid arthritis
- ulnar deviation and subluxation of the wrists and MCP joints
- Boutonneire deformity (flexion of PIP and hyperextension of DIP)
- Swan neck deformity (hyperextension of PIP and flexion of DIP)
Osteoarthritis commonly affects which joints?
Weight bearing joints! Attacks hyaline cartilage.
Symptoms of osteoarthritis
pain
stiffness
limited ROM
bone spurs
Two types of bone spurs with osteoarthritis
Heberden’s nodes (DIP joints)
Bouchard’s nodes (PIP joints)
OT tx for arthritis
- Avoid PROM in inflammatory strage
- splinting! Resting hand splints in the acute stage; wrist splint only if arthritis specific to wrist; ulnar drift splint to prevent deformity; silver ring splints to prevent Boutonniere and Swan Neck; dynamic MCP extension splint w/ radial pull for post-op MCP arthroplasties.
- joint protection
- energy conservation
- AROM (pain free)
- Heat: hot packs before exercise but avoid during inflammatory stage; paraffin for hands.
- strengthening: (not inflammatory stage); gentle while avoiding positions of deformity.
- AE as necessary
Osteogenesis imperfecta caused by…
dysfunction of one of several genes responsible for producing collagen to strengthen bones; inherited from one or both parents.
Signs/symptoms of osteogenesis imperfecta
- malformed bones (short/small body; triangular face; barrel-shaped rib cage; brittle bones; multiple fractures as child grows; developmental growth problems)
- losse joints
- sclera of the whites of eyes look blue or purple
- brittle teeth
- hearing loss (staring in 20’s-30’s)
- respiratory problems
- insufficient collagen
8 types of osteogenesis imperfecta, classified by…
the genes involved:t
types 1= mild symptoms
types 4,5,6= mod symptoms
types 2,3,7,8= severe symptoms
OT tx for osteogenesis imperfecta
- enviro modifications for safety
- AE and activity adaptation
- preventative positioning & protective splinting/padding
- activities to increase muscle strength
- weightbearing activities to facilitate bone growth
- health education
- all other tx for fractures.
Types of hip fracture (3)
- femoral neck fracture
- intertrochanteric fracture
- subtrochanteric fracture
OT eval for hip fx
- review precautions and weight bearing status before eval!!!
- OT role requirements and expectations
- ADL (dressing, bathing, transfers)
- ROM and strength of UE
OT tx for hip fx
- bed mobility and bedside ADL
- UE strengthening
- functional ambulation and transfers with appropriate weight bearing status and AE
- instruct in/practice use of AE (shower chair, BSC)
- practice occupation-based activities using precautions and device
Posterolateral hip replacement precautions:
- no flexion beyond 90 degrees
- no adduction or crossing legs (no internal rotation)
- do not pivot at hip
- sit only on raised chair/raise toilet seat
- transfer sit to stand by keeping operated hip in slight abduction and extended out in front
Antereolateral hip replacement precautions:
- do not externally rotate
- do not extend hip
- precautions vary for anterior THR. Some surgeons follow a no restriction protocol.
Amputations: forequarter means loss of…
clavicle, scapula, and entire UE
Amputations: shoulder disarticulation means loss of…
entire UE
Amputations: hemipelvectomy means amputation of….
half of pelvis and entire LE.
Amputations: hip disarticulation means loss of…
entire LE (at hip joint)
Complications of amputation
- neuromas (nerve ending adhered to scar tissue; very painful/hypersensitive)
- skin breakdown
- phantom limb syndrome & phantom limb pain
- infection
- knee flexion contractures in transtibial amputation
- psychological impairments from shock/grief
Preprosthetic tx
- change of dominance activities, if needed
- ROM of uninvolved joints
- prepare limb for prosthesis
- desensitization
- wrapping to shape and shrink the residual limb (wrap distal to proximal; tension should decrease w/ proximal wrapping)
- ADL training; education on skin car
- supportive counseling to facilitate adjustment
Prosthetic tx
- functional training with prosthesis
- donning/doffing prosthesis
- increase wearing tolerance
- individualize tx to enhance physical/psych adjustment
Burns: Superficial (first degree)
- min pain/edema; no blisters
- healing time 3-7 days
Burns: Superficial partial thickness
- second degree; involves epidermis and upper portion of dermis
- ex: sunburn
- appears red, blistering, wet
- painful, no grafting needed, heals on own.
- healing time 7-21 days
Burns: Deep partial thickness burn
- deep second degree burn; involves epidermis and deep portion of dermis; hair follicles and sweat glands.
- appearance: red, white, and elastic
- sensation may be impaired
- potential to convert to full thickness burn due to infections
- healing time 21-35 days
Burns: full thickness burn
- third degree burn; invlves epidermis and dermis, hair follicles, sweat glands, and nerve endings.
- appearance: white, waxy, leathery, and non-elastic
- sensation absent; requires skin graft
- hypertrophic scar
- healing could take months
Burns: fourth degree
- involves fat, muscle, and bone
- electrical burn: destruction of nerve along pathway
OT eval and tx for superficial partial-thickness burns
Eval: ROM (72 hours); sensation & strength (when wounds healed); ADL and roles (ASAP)
Tx: wound care and dressing changes; gentle AROM and PROM to tolerance; edema control; splinting PRN; ADLs
OT tx for deep partial-thickness burns
Tx: wound care and dressing changes; gentle AROM and PROM to tolerance; edema control; splinting; strengthening (when wounds heal); ADLs
OT eval and tx for full thickness burn (requires grafting)
Eval: ROM (5-7 days post-op); sensation; strength; ADLs
Tx: at 72 hours dressing changes, splint at all times; 5-7 days begin AROM, light ADL; 7+ days PROM as tolerated, ADL; when wounds healed use massage, order compression garments, strengthening, use otoform/elastomer inserts.
Hand splints for hand burns
- wrist in 20-30 degrees extension
- MCP joints in 70 degrees flexion
- IP joints in full extension
- thumb abducted and extended
If burns to volar surface of hand develop flexion contractures, use what splint?
Palmar extension splint!
- wrist in 0-30 degrees extension
- MCP joints in neutral to slight extension and abducted (monitor collateral ligaments)
If web space burn, what kind of splint?
C-splint
What is myofascial pain syndrome (MPS)?
persistent, deep aching pains in muscle, nonarticular in origin. Characterized by well-defined, highly sensitive tender spots (trigger points).
What is fibromyalgia syndrome?
a musculoskeletal pain and fatigue disorder that can vary in intensity. widespread pain accompanied by tenderness of muscles and adjacent soft tissues. A nonarticular rheumatic disease of unknown origin.
