UE Injury, Interventions and Orthotic Management Flashcards
Functional position of hand
- places the hand in a resting or neutral position
- Allows “rest” to digital joints affected by arthritis, to position digits post stroke, for contractures of
burned hands and to control edema of traumatic hand injuries.
Optimal Positioning of the Hand & Wrist
- Wrist will be positioned in extension up to 30 degrees
- facilitates a stronger grip
- flexion of the wrist decreases grip - Metacarpal Joints (MCP’s/MP’s) will be positioned in flexion 50-80 degrees
- allows us to pick up things and to functionally grasp or use our hand
- primary responsibility of the lumbricals is to flex the MCP’s - Interphalangeal Joints (DIP &PIP) will be fully extended or neutral
- Lumbricals and interossei produces flexion of the MCP’s and extension of the IP’s which contribute to precise finger movements required for coordination
- interossei and lumbricals allows a person to put their hand in the intrinsic plus position - Thumb should be positioned in palmar or radial abduction or opposition.
Reduction Techniques for Acute Edema
- bulky dressings
- Elevation of the hand above the heart by placing pillows so that the elbow is above the shoulder, and the
hand is above the elbow and wrist - cold packs
- retrograde message
- High Voltage Pulsed Current (HVPC)
- Elastic Taping
- Manual Edema Mobilization
- Exercise involving proximal trunk and shoulder motion when balanced with rest of involved structures is
excellent
-Limited active motion of uninvolved areas should be included
Reduction Techniques for Subacute and Chronic Edema
- contrast baths
- electrical/thermal modalities
- Pneumatic Pump is used for post trauma/surgery chronic edema such as a massive crush injury to the entire
arm
- Pressures should never be greater than 40 mm Hg.
- A low-stretch bandaging or garment system is applied to the extremity after using the pneumatic pump - elastic taping
- myofascial release
- low stretch bandages
- MEM
- Exercise should start at the trunk followed by shoulder and elbow exercise (if not contraindicated). Next, exercise is completed at the wrist and then at the hand/fingers
Reduction Techniques for Chronic Edema
- LOW STRETCH BANDAGING
- Chip Bags consist of stockinette bags filled with various densities and sizes of foam and they can be worn under
low-stretch bandages, loose elastic gloves, or orthoses - Self-Adherent Wrap creates a squeezing effect, pushing fluid distal or proximal, or both
Lymphedema
- Clients with lymphedema must be treated with a full manual lymphatic drainage (MLT) program performed by a trained and credentialed therapist. MEM is not appropriate for these clients
Evaluation of Edematous Tissue
- circumferential measurements
- volumeters
- Tissue Quality Assessment:
- Acute edema: Tissue pits deeply, rebounds rather quickly, and can be easily moved around.
- Subacute edema (early stage chronic edema): Tissue pits, is very slow to rebound, and has a viscous (thick,
sticky) quality.
-Chronic edema: Tissue pits minimally and has a hard feeling.
- Severe edema: Tissue has no elasticity and is shiny, taut, and cannot be lifted - Color, temperature, and sensory changes may be signs of a problem. Immediately notify the physician of these signs
extrinsic extensor tightness
- PIP and DIP flexion is limited with the MP and wrist flexed
extrinsic flexor tightness
- passive composite digit extension is limited with the wrist extended
intrinsic or interosseous tightness
PIP and DIP flexion is limited with the MP joint hyperextended or
extended
Intrinsic Muscles
Lumbricals: Flex the MCP joint and extend the IP joints extend.
Dorsal Interrosei: Abduct digits. DAB > Dorsal ABduct
Palmer Interrosei: Adduct digits. PAD> Palmer ADDuct
Thenar muscles: Move the thumb. AFO> Abductor Pollicis Brevis, Flexor Pollicis Brevis, Opponens Pollicis.
Adductor Pollicis Muscle: ADDucts the thumb.
Hypothenar Muscles: Move the pinky. AFO> Abductor Digiti Minimi, Flexor Digiti Minimi, Opponens Digiti Minimi.
Forearm Flexor Muscles
Superficial (4)- All flex the wrist.
- Pronator Teres (PT): Pronates forearm. Median nerve pierces through the belly of this muscle.
-Flexor Carpi Radialis (FCR): Flexes the wrist and Palmaris Longus (PL): Flexes the wrist.
- Flexi Carpi Ulnaris (FCU)*: Flexes the wrist. Innervated by the ulnar nerve hence the name ‘ulnaris’.
Intermediate (1)
- Flexor Digitorum Superficialis (FDS): Primarily flexes the PIP joint.
Deep (3)
-Flexor Pollicis Longus (FPL): Flexes the thumb.
- Flexor Digitorum Profundus (FDP): Flex the DIP joints of digit 2-5. *The ulnar half innervated by ulnar nerve.
- Pronator Quadratus (PQ): Pronates the forearm
Forearm Extensor Muscles: All innervated by the radial nerve
Carpi Muscles (3) all extend the wrist
-Extensor Carpi Radialus Longus (ECR),
- Extensor Carpi Radialis Brevis (ECRB),
- Extensor Carpi Ulnaris (ECU)
Pollicis Muscles (3)
-Abductor Pollicis Brevis (APB): Abducts the thumb.
- Extensor Pollicis Brevis (EPB): Extends the thumb.
-Extensor Pollicis: Extends the thumb.
Digit Muscles (3)
-Extensor Digitorum Communis (EDC): Extend the MCP.
-Extensor Digiti Minimi (EDM): Extends the pinky.
- Extensor Indices (EI): Extra extender of the index and pinky finger.
Others (3)
-Brachioradialis: Considered an extensor BUT it flexes the elbow.
-Supinator: Supinates the forearm
-Anconeus: Assists in extending the elbow
Prefabricated Vs. Fabricated
- Fabricated is preferred because it is a unique fit, can be adjusted, and they have a variety of designs
- Prefabricated saves time and effort and they offer sophisticated technology. But they can be expensive and offer
limited control over the therapeutic position.
Making Adjustments: Therapist can modify portions of the orthoses that may potentially cause pressure
areas or any kind
- Heat gun to push out areas of the thermoplastic material that may irritate the bony prominences
- Padding must be added BEFORE the orthosis is formed to provide sufficient space for the thickness of the padding
that you are adding otherwise the pressure may increase over that area - Self adhesive gel disc adheres to the persons skin prior to molding the orthosis. Once the orthosis is cooled, the gel disk is removed and adhered to the corresponding area inside the orthosis.
Orthotic Materials include
Low-temperature thermoplastic (LTT) materials are most commonly used. They soften in water between 135F and 180F degrees and can be placed directly on a patient’s skin while the material is still moldable. *High-temperature
thermoplastic cannot touch a person’s skin while moldable without causing injury. LLT can also be used to adapt
devices for improved function (ex. built up pen)
Plastic materials are highly conforming/drapable and have a low resistance to stretch. Requires great skill to prevent
overstretching and fingerprints. It is recommended to position the client in a gravity-assisted position to prevent
overstretching of the material.
Wrist immobilization orthoses
- Wrist immobilization orthosis provide support to the wrist while allowing full MCP flx and thumb mobility.
- Wrist immobilization orthoses can be used as a base for a mobilization and static progressive orthosis.
The forearm trough should be two-thirds the length and one-half the circumference of the forearm - Wrist immobilization orthoses should be removed for hygiene and exercises if appropriate
-When the goal is functional hand use avoid extreme wrist flexion or extension because either position disrupts thenormal functional position of the hand. An exception to this rule is when the orthotic goal is to increase PROM.
Types of Wrist Orthosis
volar-
- promote rest
- palmer bar interferes with sensory input or tactile sensibility to the hand which may impact grasp and the ability for the hand to conform around objects
- Keep this in mind when a question is promoting engagement in functional
activities. Volar orthosis may be indicated for chronic edema.
dorsal
- provides pressure distribution
- thinner palmer bar is better.
ulnar
- easier to don/doff and provides more protection of the ulnar side of the hand
Circumferential
- provides good forearm support,
controls edema, provides good pressure distribution, and does not have edges which can be an irritant to some clients
Conditions & Wrist Immobilization Orthosis
- Carpal Tunnel Syndrome
- Carpal Tunnel Release
- Radial Nerve Palsy
- Tendinosis
- Rheumatoid Arthritis
- Wrist Fracture
- Complex Regional Pain Syndrome (CRPS)
- Wrist Contracture: Serial static orthotic in the maximal amount of extension that the client can tolerate
CVA: Serpentine orthosis positions the thumb, hand and wrist in an optimal position and allows active wrist
function in those with moderate tone.
Thumb Immobilization Orthoses
- Hand-based
- Thumb immobilization orthoses can be forearm based
- IP joint is usually left free for functional movement, unless there is extreme pain in that joint or unless the
client is engaged in rigorous activity which can place stress on the joint.
Conditions & Thumb Immobilization Orthosis
- De Quervain Tenosynovitis: Forearm or Radial gutter. Wrist 15 degrees ext and thumb CMC 40-45 degrees palmar
abduction. Nighttime wear or during activities that cause pain. - Rheumatoid Arthritis: Forearm based with wrist in 20-30 degrees ext and thumb CMC 40-45 degrees palmar
abduction. Wear continuously during pain and inflammation.
-Osteoarthritis in CMC joint: Hand-based orthosis with MCP’s free. A forearm-based orthosis can be provided if the client needs more support. Wear continuously during acute flare-up.
Skier’s/Gamekeeper’s/UCL injury: Hand-based orthosis with MCP immobilized, thumb CMC abducted 40 degrees,
thumb MCP joint neutral. Important to place thumb CMC joint in a position of comfort. Will wear 3 to 4 weeks for
Grade I, 4 to 5 weeks for Grade II, for Grade III, after immobilization follow protocol for Grade III.
Golfer’s Thumb/RCL injury: Hand-based thumb orthosis with MCP immobilized in palmar abduction and neutral.
Wearing schedule is the same as UCL injury. See above
Scaphoid Fracture: Forearm Volar or Dorsal-Volar thumb immobilization with wrist in neutral and thumb CMC
palmar abduction and MCP in 0-10 degrees flx. Depends on healing stage and location of fracture. Some clients
may benefit from a combination dorsal/volar thumb orthosis for added stability, protection, and pain and edema control
Hypertonicity: Thumb loop orthosis or figure-eight thumb wrap. Wearing schedule depends on therapeutic need.
Thumb flexed and adducte
d into the palm: Short opponens, C-bar orthosis, or Neoprene thumb extension design.
Hand Immobilization Orthoses
- also known as resting hand orthoses or resting pan orthoses
-immobilize the hand and the wrist. - They may or may not involve the thumb.
- Four main components: forearm trough, pan, thumb trough, and the C bar.
- Have client removes the orthoses for exercises, hygiene, and ADL
Conditions & Hand Immobilization Orthosis
-Rheumatoid Arthritis (Acute exacerbation)
- Hand Burns (Dorsal)
- Hand Burns (Volar/Circumferential):
- Dupuytren Disease Contracture
- Crush Injuries of the Hand
- Complex Regional Pain Syndrome (CRPS)
- Acquired Brain Injury
- CVA
functional hand position
- Functional (mid-joint or resting hand) position to relieve stress on the wrist and hand. 20-30 degrees wrist ext,
MCP 35-45 degrees flx, thumb 45 abduction
Conditions & Elbow Immobilization Orthosis
Distal Humerus Fracture & Proximal Radius Fracture: Posterior elbow orthosis in 90 degrees of flexion and forearm in
neutral
Proximal Ulnar Fracture: Braced or dorsally positioned in 30-45 degrees of flexion to minimize tension on the
triceps
Elbow Arthroplasty: After removal of postoperative dressing fit client for a posterior elbow orthosis in 90 degrees of flexion
Elbow Instability: After removal of postoperative dressing fit client for a posterior elbow orthosis in 120 degrees of flexion with forearm in neutral. Wear continuously
.
Biceps Repair: (Partial tears) Posterior elbow orthosis in 90 degrees of flexion with the forearm in neutral to
supination. (Full tears) place forearm in supination to minimize bicep activity
Triceps Repair: Posterior elbow orthosis in 90 degrees of flexion with the forearm in neutral
Cubital Tunnel Syndrome: (Conservative) Anterior elbow extension orthosis with the elbow position in -30 extension or posterior elbow orthosis in -30 extension with padding at the olecranon and medial epicondyle to create space between orthosis and cubital tunnel area. Nighttime wear
Cubital Tunnel Syndrome: (Postoperative) Posterior long arm orthosis with the elbow positioned in 70-90 degrees of flexion and forearm in neutral. Nighttime wear
Tennis Elbow: Combination of counterforce brace and wrist immobilization orthosis with the wrist in 20-30 degrees
extension.
