Nerve and tendon injuries, fractures, other UE diagnoses Flashcards
low lesion radial nerve
“saturday night palsy” wrist drop
fx deficit: manipulating objects, release
intervention: dynamic wrist and MCP extension splint
high lesion radial nerve
loss of triceps
intervention: dynamic extension splint
ulnar nerve injury
CLAW HAND
loss of lumbricals
hyperextension of MCP joints and flexion of IP joints of ring and pinky fingers
fx deficit: loss of power grip
intervention: MCP flexion block splint
low lesion median nerve
APE HAND
flattening of thenar eminence and thumb adduction with clawing of index and middle fingers
intervention: dorsal blocking with wrist in 30 deg flexion; maintain thumb webspace (C bar)
high lesion median nerve
HAND OF BENEDICTION
when attempting to make a fist, unable to do so because thumb index and middle fingers are paralyzed
fx deficit: loss of opposition and palmar abduction
intervention: dorsal blocking with wrist in 30 deg flexion and include elbow in 90 deg flexion
difference between claw hand, ape hand, and hand of benediction
claw hand (ulnar) and ape hand (median low) are permanent, fixed positions at rest. hand of benediction (median high) is an active sign.
flexor tendon injury
deep cuts to the PALMAR side of the hand, jersey finger (gets caught and tendon pulls on bone), RA (weakens tendons and can tear)
needs sutures, 12 weeks healing
early mobilization reason and types
prevent adhesion formation
duran and kleinert protocols
type of splint for flexor tendon injuries
dorsal blocking splint
wrist in 20-30 deg FLEXION
MCPs 50-70 deg flexion
IPs extended
Duran protocol
passive flexion and extension of fingers
duran = do it yourself (while hand is in the splint)
Kleinert protocol
passive flexion and active extension via rubber band traction
post op of flexor tendon injuries weekly progression with both protocols
4-6 weeks: flexor tendon gliding exercises (prevent scar adhesions)
6 weeks: d/c splint, continue tendon gliding
8 weeks: strengthening
12 weeks: resume normal activities
tendon gliding exercises
- straight hand
- hook/claw
- full fist
- table top
- straight fist (thumb out and DIP ext)
zone 2 flexor tendon injuries
no man’s land; hard to dx and treat due to complications
metacarpal space
extensor tendon injury zone 1
mallet finger
flexed DIP; inability to extend
intervention: DIP extension splint
extensor tendon injury zones 2 & 3
Boutienere deformity
flexed PIP and hyperextension of DIP (inability to extend PIP)
intervention: PIP extension splint with DIP free to move
extensor tendon injury zones 5, 6, 7
volar wrist splint with wrist in 20 deg ext
De Quervains
tenosynovitis of abductor policis longus and extensor policis brevis (pass through the 1st dorsal wrist compartment; abduct and extend the thumb)
risk factors de quervains
RA, diabetes, pregnancy, women 4x likely, ages 35-55, repetition and overuse
test and intervention for de quervains
Finklestein’s (hold thumb in fist and ulnarly deviate)
forearm thumb spica cast (IP free), steroid injection, activity modification, ice massage over radial wrist, gentle AROM of wrist and thumb to prevent stiffness
surgery to release first dorsal compartment
Dupuytren’s
- disease of the fascia of the palm and digits; becomes contracted and results in flexion deformities in the digits
intervention: fasciotomy with z-plasty, aponeurotomy, enzyme injections
OT intervention: wound/scar care, edema control, extension splint (full is ideal, but consult with surgeon), ROM and progress to strengthening, grip/release
Skier’s/gamekeepers thumb
- rupture of ulnar collateral ligament of MCP joint of the thumb
- most common cause is fall while skiing with thumb held in the ski pole
- intervention: thumb splint 4-6 weeks, AROM and pinch strength at 6 weeks, PROM 8 weeks, strengthen at 10
complex regional pain syndrome (CRPS)
- vasomotor dysfunction as a result of an abnormal reflex
may follow trauma or surgery, but actual cause is unknown
s/s: severe pain, edema, discoloration, temp and tropic changes, vasomotor instability
intervention:
1. Stress loading: compress the joint, then distract it
2. Reduce pain with gentle AROM and desensitization
modalities to reduce pain, splinting to prevent contractures
- Modalities to decrease pain: use contrast baths to facilitate opening and closing of vessels is preferred modality
- edema management
- ADLs to encourage pain free active use
colles fracture
fracture of distal radius with dorsal displacement
smith’s fracture
fracture of distal radius with volar displacement
carpal fractures
(scaphoid most common)
boxer’s fracture
fracture of 5th metacarpal
ulnar gutter splint
proximal phalanx fx
most common is thumb and index
distal phalanx fx
most common finger fx
mallet finger
OT evaluation for fractures
occupational profile, history of injury, special test results, edema, pain, AROM (*no PROM or strength until ordered by physician)
intervention for fractures
- immobilization phase: stabilization and healing (splint and one arm techniques, AROM, edema control, light ADLs)
- mobilization phase: consolidation is the goal (edema control, AROM then PROm then strength - usually start with isometric exercises)
cumulative trauma disorders
repetitive strain injuries
ex: de quervains, lateral and medial epicondylitis, trigger finger
lateral epicondylitis
medial epicondylitis
tennis elbow - overuse of wrist extensors
golfer’s elbow - overuse of wrist flexors
tx:
- elbow strap, wrist splint
- ice and deep friction massage
- stretching
- activity/work modification
- as pain decreases, add strengthening. begin with isometric exercises, then progress to isotonic and eccentric
trigger finger
tenosynovitis of finger flexors (most common A1 pulley)
tx:
- hand or finger based trigger finger splint (MCP extended, IP free)
- scar massage
- edema control
- tendon gliding
- activity modification (avoid repetitive gripping activities)
carpal tunnel
compression of median nerve
etiology: repetition, awkward postures, vibrations, pregnancy
s/s: tingling (at night) and numbness of thumb, index, middle, and radial 1/2 ring finger, weakness
carpal tunnel tests
tinel’s sign (tapping)
phalen’s (dorsal hands together)
durkan’s (press thumbs on carpal tunnel, have s/s)
tx carpal tunnel
conservative: splint in neutral, nerve gliding, activity modification, modalities
surgical: carpal tunnel release
pronator teres syndrome
compression of median nerve between 2 heads of pronator teres
- positive tinel’s sign at the FOREARM, not the elbow, no night symptoms
Guyon’s canal
ULNAR nerve compression at the wrist
s/s: numbness and tingling in ulnar nerve distributions of the hand, motor weakness, positive tinnels at the canal
impairs hypothenar muscles - difficulty turning key/lateral pinch
cubital tunnel syndrome
ulnar nerve compression at the elbow
weakness, numbness on ulnar elbow/forearm, positive tinels at elbow
adhesive capsulitis
frozen shoulder
restricted passive shoulder ROM
etiology: inflammation, immobility, diabetes, parkinsons
conservative intervention: active use through light ADLs, PROM, modalities
surgical: arthroscopic
positioning and isometric
o Positioning: start at BOS (pelvis)
o Isometric: M, but no movement
o Isotonic: move a G&T to your mouth
CRPS interventions to avoid or use with caution
PROM, passive stretching, joint mobilization, dynamic splinting, and casting
fracture that is exception with PROM
humerus fractures often begin with PROM or AAROM
intervention for pronator trees syndrome
conservative: elbow splint at 90 deg with forearm in neutral, avoid activities that include repetitive forearm pronation and supination
surgical: decompression
guyon’s canal intervention
conservative: wrist splint in neutral, work/activity modification
surgical: decompression
cubital tunnel intervention
conservative: elbow splint at 30 deg of flexion, especially at night, elbow pad to decrease compression of nerve when leaning on elbows, activity/work modification
surgical: decompression or transposition
sensory reeducation
begin when individual demonstrates a level of diminished protective sensation (4.31) on femmes-weinstein
