Theresa last exam no butterflies!

Question 1

• Lateral Epicondylitis – Conservative Management Interventions and the reason why you do the intervention (what does it address in terms of etiology) as well as occupational simulation tasks

Answer 1

caused by excessive use of the muscle, repetition, causing micro damage to tissue which does not heal properly due to poor technique and/or weak muscles.( prox and distal)
Clinical picture: gradually increasing pain in elbow following activity.Pain when gripping with full extension. Pronator teres ( medial epicondyle) and Supinator(lateral epicondyle)
Extensors muscles used are: 1.ext carpi radilais longus action wrist ext and radial dev.
2. ext radialis brevis action wrist ext and radial dev. more medial side of thumb
3. extensor carpi ulnaris action wrist ext and ulnar dev.
4. extensor digitorum communis action is extend and flex fingers like cat! Proximal attachment lateral epicondyl
5. ext indicis action move pointer finger up and down can see moving by epicondyle.
6. ext digiti minimi action move pinky up and down while hand flat see moving by epicondyle.
occupational simulation: sleep positioning, gentle stretching of forearm. use hammer for pronation and supination. eccentric strengthen with weight or therband. use other hand as a support to guide. No extreme flexion or extension! can wear elbow pad as a reminder.

Question 2

• Name the three nerves that course through the elbow. What is the innervation in terms of sensation and the resultant deformity if a neuropathy exists. Name muscles innervated by those nerves.

Answer 2

median- Ape hand ( Benedictine hand): FPL, FDS, FDP lumbricals, index and middle will lose these.
Ulnar- claw hand cause loss of interossei, ring and little lumbricals.
median- starts at the vein on the volar side of wrist to flexor retinaculum.
radial- wrist drop: ECRB/L, EDC, EPL/B.
Radial nerve: goes to thumb, middle and pointer finger.
ulnar nerve passes thru the cubital tunnel to pinky and ring finger.
Hypothenar- flattening deformity of muscles do not work.
Interossei do abduction and addcution.

Question 3

How would you palpate for the three nerves in the elbow region?

Answer 3

cubital tunnel- ulnar
median nerve- bicipital groove
radial nerve- brachial radilalis area

Question 4

What are the 4 elbow special tests in terms of what they are used to test for?

Answer 4

Tinels- tapping Peripheral Neuropathys ( cubital tunnel)
frohment sign- lateral pinch with paper pulling.
cozens test- lateral epicondylitis, MMT wrist extension hold at lateral epicondyle.
Golfers elbow test- median epicondyle, MMT wrist flexion.

Question 5

Why is it potential harmful to aggressively stretch a child/adult’s elbow?

Answer 5

May cause Myositis ossification’s. Ossification or the deposit of bone in muscle tissue, causing pain and swelling. also called Heterotopic ossification.

Question 6

4. Explain the reason to use the following interventions for lateral epicondylitis: wrist splints, transverse friction massage to origin of ECRB and eccentric wrist extensors exercise.

Answer 6

1. massage- breakup scar tissue
2. for extensors muscles do isotonics.
3. ECRB is 1st dorsal compartment want weight to help pull down and avoid contracture.
4. wrist immobilization splint

Question 7

5. What are two common treatments for cubital tunnel syndrome?

Answer 7

sleep positioning, ulnar nerve glides and, hike shoulder with pillow under while working.

Question 8

6. Review anatomy from Fall regarding load of radiocarpal joint, function of TFC, and extensor compartments.

Answer 8

p 326 cooper. load of radiocarpal joint is 80 percent.

Question 9

7. What is the course of the 3 major nerves at the wrist? What muscles are innervated distally? What is the sensory distribution of the nerves in the hand?

Answer 9

Ulnar at wwrist travels thru Guyons canal, pinky and ring covered by volar carpal ligamnet will result motor changes interrrosei and lumbricals 3 and 4, hyperthenar, adductor pollicis and Flexor pollicis brevis
Radial- only changes sensory dorsum of hand except little finger.
Median- passes through wrist carpal tunnel and rest against flexor retinicumlum. Sendory changes thumb, index and middle.

Question 10

What are the standardized assessments used to assess fine motor and functional impairment in the wrist and hand from lab? Why would you use one over the other?

Answer 10

Minnesota- involves shoulder and elbow, tests for longer endurance and fine motor.
jebsen- functional activities. such as writing, simulated page turning, lifting small objects and simulated feeding. when can they go back to work or home?
9 hole peg- Fine motor, grip, speed, pinch, dexterity, grasp, release, manipulation.

Question 11

What is important to focus on during rehabilitation after distal radius fracture? See page 319 for specifics.

Answer 11

Colles, smith, Barton

check for edema, pain, ROM of uninvolved joint, desensitization and gliding.

Question 12

What clinical signs will be seen in a client with scaphoid fracture? What are common interventions?

Answer 12

May think its just a sprain! Tender and pain in scaphoid area and aggravated by palpation in snuffbox, often undetected on xray, decreased vascular supply.
Interventions: edema control, hourly HEP sh. strengthening. Palmer and radial abduction and adduction, massage, larger pen grips, opposition circular, all wrist pivots
No wrist extension and grip strength reduced to 50%

Question 13

What kind of immobilization and interventions are appropriate for someone with acute/subacute CMC OA?

Answer 13

CMC/MP immobilization splint wear 3- 6weeks night and day. Day immobilize CMC joint while holding pencil.
Interventions: moist hot pack, paraffin, joint protection, cautious when loading thumb for ex. use jar opener. Use two hands to grab onto something, Can use dragon dictate for typing, stretch CMC and hold MPs, adaptive kitchen and garden devices with larger handles and sleep positioning.

Question 14

What is the best (evidence based) OT intervention for someone with acute/subacute DeQuervains tenosynovitis? What is the pathology that causes this diagnosis? (p. 388)

Answer 14

effects mothers of young children and pregnant women, women grater than men in general 35 -55 yrs.radial or volar orthosis used wrist in neutral, also radial gutter spica orthosis. Evidence based;forceful repetitive or sustained thumb abduction with ulnar deviation of wrist may contribute to this condition.
Interventions: Avoid provoking activities such as wringing out washrags, using scissors, opening jars, using keyboard, playing piano, pinch. joint protection use larger joints and body to lift and move objects. If loading heavy boxes turn box a bit and use three corners to lift. heavy stuff in front of van and lights in back. ( UPS)

Question 15

What are the evidence based interventions for conservative management for Carpal Tunnel Syndrome?

Answer 15

wrist immobilization splint at night wrist in neutral.
sleep positioning
tendon gliding, median nerve glides, massage across retinaculum, work modification using ergonomics. Aka using headphones for phone use, L shaped desk…

Question 16

What will you add to the intervention list post operatively?

Answer 16

wound care, massage gentle across flexor retinaculum, strengthening after 4 weeks, isolated tendon glides, silicone gel sheet for scar. 2 months return to manual labor.

Question 17

Review your anatomy related to hand muscles and ligaments (triangular, sagittal bands, volar plates, collateral ligaments, pulleys)

Answer 17

triangular- trampoline that connects radius to ulna near hammate at DRUJ stabilizes the ulnar carpus.
sagittal bands - are ribbonlike tendinous attachments which maintain the central dorsal alignment of the common digital extensor tendon at the level of the metacarpal head.
volar plates- very thick ligament that prevents hyperextension from occurring. If there is enough force during hyperextension, the disruption may cause a rupture of the Volar Plate at its insertion on the middle phalanx of a finger.
collateral ligaments-one of a pair of ligaments occurring on the medial or lateral sides of hinge joints that typically serve a major role in uniting the articulating bones and establish the radius of movement for the joint.
pulleys- There are five pulleys in the fingers, called annular pulleys, and they are named A1 through A5 (Figure 1). The A1, A3, and A5 pulleys are smaller and considered minor pulleys (mostly due to size and lack of importance). The A2 and A4 pulleys are larger and are sometimes called the major pulleys.1 The A1, A3, and A5 pulleys are located at the MCP, PIP and DIP joints respectively. The A2 and A4 pulleys are located in the middle of the proximal and middle phalanx.

Question 18

What is the standardized position for measuring grip strength?

Answer 18

elbow 90 degrees at side of body, wrist in neutral.

Question 19

What is the progression of textures for desensitization versus sensory reeducation?

Answer 19

buckets 1-10 (fine -Bulk) are for desensitization

buckets 10-1 are for sensory re-education.

Question 20

What muscles are you exercising when doing tendon glides? Intrinsic plus? Blocking exercises?

Answer 20

tendon glides- flexor muscles in fist ussing lumbricals.
intrinsic plus- lumbrical and interrosei
Blocking- FDS=pip, FDP=dip,FDS=intrinsic minus.

Question 21

Describe common concerns with metacarpal fracture injuries?

Answer 21

if angualtion is to much problems in fx are loss of normal joint contour extensor lag may happen, pain in palm with tight grasp, hyperextension of MP, cosmetic result poor. Tendon adherence, intrinsic contracture.
Extensor lag- holds joint in one position and can not extend past MP actively past 30 degrees. Scar tissue is binding it down.

Question 22

What is the position of immobilization for a recent MP fracture?

Answer 22

splints should maintain arches of the hand, immobilization is MP at 70-90 degrees, IP @ zero and wrist @ 20 degrees.

Question 23

What specific interventions will promote tendon glide after metacarpal fracture?

Answer 23

edema control, isolated EDC tendon glides. Stretch EDC= fist, EDC just extend MPs intrinsic plus position- actively contract.

Question 24

What structures will get overstretched or torn after PIP joint dislocation?

Answer 24

The box around the joint consists of joint capsule, volar plate, collateral ligaments, central slip.
BUT the answer Theresa gave was collateral ligaments! so i guess this is the answer?

Question 25

Describe the signs and symptoms of a trigger finger? What is the location of the pathology?

Answer 25

inflammation due to gliding in a constricted space in palm. Pain with finger extension in palm, finger extension is paused.
location is A1 pulley

Question 26

What are the physiologic changes that occur with Rheumatoid Arthritis in the hand? What are the usual interventions that assist with decreasing pain and increasing function?

Answer 26

Increased synovial fluid causes increased pressure on capsule, may cause permanent joint damage.
deformities include, subluxation, dislocation, loss of joint space and bony coalition ( 2 or more bones joined as one).
Interventions; joint protection, active rest, edema reduction, splinting day/night, tendon glides, maintain tendon function, modalities hot/cold and paraffin, energy conservation, no strong or repetitive movements. Active light use, isometrics.

Question 27

What are common deformities with RA? OA?

Answer 27

OA:Heberdens nodes ( looks like calluses on PIP)
joint crepitus and synovitis
deformities are swan neck, Boutonniere, MP ulnar drift.

Question 28

What is the physiology related to Dupuytrens contracture? Why do some patients have an open area in their palm after surgery? What are the common interventions after surgical release?

Answer 28

dupuytrens- benign connective tissue disorder of palmer fascia. symptoms include, flexion contrature of MP and DIP, starts with a thickening as if trigger finger, begins with nodules or cords in the distal palmer crease.
interventions after surgical release: 1st week is dressing changes, gentle tendon glides,PROM and edema control.
Dorsal orthosis od theMP, PIP,DIP,exyension immobilization of involved digits plus one.
weeks 2-3: gentle scar massage, increase A/PROM, light ADLs, minimize dressings
after 3 weeks: increase P/AROM and move to isometric grip strengthening as indicated.
Surgical procedures: Fasciectomy or an injection of collagenese enzyme “ Xiaflex inj.”. The enzyme softens the adhesion’s and surgeon can pull finger and snap thru the adhesion’s to its correct position. much less recovery time and no incisions.
1. Why do some patients have an open area in their palm after surgery? due to secondary intention healing.

Question 29

What is the physiology related to CRPS (RSD)? What symptoms will you commonly see? Explain the common interventions including stress loading.

Answer 29

Symptoms: extreme pain 10/10, pain is usually post op, joint stiffness, disuse edema. Skin changes such as, altered temperature, abnormal sweating, nail growth, wirey hair growth in isolated area, bone demineralization. vascular instability results of controlled vasomotor phenomenon sympathetic nervous system.
Interventions: scrub and carry 20 min alternating between scrub with constant pressure and carrying purse.
Gentle AROM, resume activities, Iostoner gloves for warmth, edema control and cardio.

Question 30

Know the terms tenolysis and tendon grafts.

Answer 30

Tenolysis-is surgery to release a tendon affected by adhesions. A tendon is a type of tissue that connects muscle to bone. An adhesion happens when scar tissue forms and binds tendons to surrounding tissue. This can make it difficult for the affected body part to work correctly.
Tendon grafts- a free graft of tendon used to replace a damaged tendon segment.