UE Orthopedics Flashcards

1
Q

Hand Evaluation (purpose)

A

To identify:

1) physical limitations (ie: loss of ROM);
2) functional limitations (ie: inability to perform ADLs);
3) substitution patterns to compensate for loss of sensibility or motor function; and
4) abnormalities (ie: joint contracture).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Most Important Small Joint of Hand

A

Proximal Interphalangeal Joint (PIP): Critical for grasp and is considered the most important small joint. Limitations in flexion or extension result in significant functional impairment (ie: boutonniere deformity, etc.).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Thoracic and Cervical Curvature of Spine in relation to UE Use

A

Cervical or thoracic curvature abnormalities may reduce potential for shoulder movement. Muscle imbalances in the area are also important to note (if imbalanced strength or length, may appear asymmetric and might indicate weakness or torn rotator cuff).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Adhesive Capsulitis

A

Also called: Frozen Shoulder.

Pattern: Loss of active & passive shoulder motion w/most pronounced loss in EXTERNAL ROTATION and, lesser, abd and int rotation

Characteristics/Tests: Capsular end feel to passive motions in restricted planes of movement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Subacromial Impingement

A

Shoulder Condition. Pattern: Painful arc of motion betw ~80 & 100˚ of ELEVATION or at end range of active elevation

Characteristics/Tests: In early stages, muscle tests may be strong & painless despite positive impingement test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Rotator Cuff Tendinitis

A

Shoulder Condition. Pattern: Painful active or resistive use of rotator cuff muscle, especially in ABDUCTION or EXT ROTATION

Characteristics/Tests:
• Painful MMT of scapular plane abd or ext rotation
• Pain-free passive motion end ranges
• Tenderness at tendons of supraspinatus/infraspinatus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Rotator Cuff Tear

A

Shoulder Condition. Pattern: Significant substitution of scapula w/attempted arm elevation, especially in ABDUCTION or EXT ROTATION

Characteristics/Tests:
• Positive drop arm test
• Very weak, less than three-fifths abd or ext rotation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Soft Tissue Tightness in Shoulder

A

After trauma, immobilization or disuse, joints may develop dysfunction. May be restored through joint mobilization techniques before attempting P/AROM.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Joint Mobilization

A

Use of passive muscle movement applied to resolve when there is soft tissue tightness; when there is abnormal joint play or accessory motions (ie: joint rotation/distraction—passive movements), and when the movements can only be performed with assistance. Usually when there is restriction of accessory motions, when pain is present bc of tightness of joint capsule, meniscus displacement, muscle guarding, ligamentous tightness, or adherence. Limitations in motion can also be caused by tightness of extrinsic/intrinsic muscles and tendons.

Contraindications to joint mobilization: infection, recent fracture, neoplasm (abnormal growth of cells; a tumor), joint inflammation, RA, OA, degenerative joint disease, and many chronic diseases.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Cubital Tunnel Syndrome

A

Tingling/numbness in hand/ring/pinky, esp. with bent elbow. Weak grip. Pain on inside of elbow. CAUSED by injury/bending often of elbow or leaning on. Ulnar nerve compression.

TESTS:
• Elbow Flexion Test
• Wartenberg’s Sign

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Carpal Tunnel Syndrome

A

Tingling/numbness in fingers or hand, usually thumb/index/mid/ring. Worse at night/during activity. CAUSED by pressure on median nerve (wrist); repetitive motion like typing/wrist movement.

TESTS:
• Tinel’s Sign at wrist
• Phalen’s Test
• Reverse Phalen’s Test
• Carpal Compression Test
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Ulnar Nerve Paralysis

A

Paralysis of adductor pollicis muscle. Lost sensation/coordination in ring/pinky. Tingling/burning/pain in hand. Weakness increases with activity. Loss of grip. CAUSED by long-term pressure on elbow or base of palm; elbow fracture/dislocation; repeated elbow bending.

TESTS:
• Froment’s/Jeanne’s/Wartenberg’s Sign

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Gamekeeper’s Thumb / Skier’s Thumb

A

Ulnar collateral ligament (UCL) is injured (strained or torn). Weakened grasp/pinching ability in thumb. CAUSES: Acute injury or chronic overuse. FOOSH when thumb pulled violently away from index finger. RA and smoking can also weaken ligaments, making them prone to injury. Instability in thumb MP joint.

TEST: Movement >35˚ when valgus instability stress is applied to thumb MP joint.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

De’Quervains Syndrome / Tenosynovitis

A

Painful condition affecting tendons on thumb side of wrist. Hurts to turn wrist, grasp or make fist. Pain/swelling near base of thumb (tendon sheath is irritated). CAUSE is unknown, but can be repetitive hand/wrist movement can worsen; direct injury to wrist/tendon; RA.

TESTS:
• Pain with pressure on thumb side of wrist.
• Finkelstein Test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Tx of Fractures of the Hand/Wrist

A

Surgeon attempts to achieve good anatomic position through a closed (non-operative) or open (operative) reduction. Internal fixation with Kirshner wires, metallic plates, or screws may be used. External fixation may also be used. Hand usually immobilized in wrist ext and MP joint flex, with ext of distal joints whenever injury allows. Also consider any trauma to tendons or nerves. Recovery of all injured structures influence tx of fx. OT may begin at period of immobilization, ~3-5 wks. Uninvolved fingers kept mobile through active motion. Edema monitored (use elevation). Mobilization of injured part allowed once bone stabile. Surgeon guides on amt of resistance. Activities to correct poor motor patterns and encourage use of affected hand as soon as pain free (avoids adherence of tendons and reduces edema). When cast removed, hand/edema are assessed and orthosis may be used to correct abnormal joint changes or protect finger from addtl trauma.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Orthoses Used for Hand/Wrist Fractures

A

Dorsal block orthosis: to limit full ext of finger, and avoid overstretching flexor tendon.

Dynamic orthosis: to achieve full ROM or prevent dev of further abnormal joint changes (6-8 wk post fracture)

Velcro “buddy” orthosis: to correct abnormal joint changes or to protect a finger from addtl trauma, or to encourage movement of a stiff finger.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Intraarticular Fractures

A

Assessed for joint surface damage if pain/stiffness. X-ray exam used, and thermal modalities, restoration of joint play, or joint mobilization/corrective or dynamic orthoses used, followed by active use. Resistive exercises after bony healing has been achieved.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Scaphoid Fractures

A

Fracture of bone in wrist, most proximal below thumb. 2nd most common bone to fx, ie when hand dorsiflexed at time of injury. May require longer healing time due to lack of vascularity. When the proximal pole is fractured it may result in a nonunion because of poor blood supply to this area.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Lunate Fractures

A

Bone in wrist, most proximal below pinky; trauma may result in avascular necrosis (Kienbock’s Disease), from one-time trauma or repetitive. Kienbock’s treated with bone graft, removal of proximal carpal row, or partial wrist fusion.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Kienbock’s Disease

A

Avascular necrosis, often seen in lunate bone fractures. Treated with bone graft, removal of proximal carpal row, or partial wrist fusion.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Colles’ Fracture

A

Dorsal displacement and angulation of distal radius. Most common injury to wrist from FOOSH. May limit wrist flex/ext, and pronation/sup due to involvement of distal radioulnar joint. Tx ranges from closed reduction/cast to external fixator. Unstable fx may use ORIF to restore bone alignment.

(Opposite is a SMITH’S FRACTURE, when falling on flexed wrist, and fragment displaces volarly (toward palm).)

22
Q

Ulnar Nerve Injury

A

INNERVATION: Anterior forearm (flex/adduct hand); medial half of palm (ring/pinky); intrinsic hand muscles.

CAUSES OF INJURY: long-term pressure on elbow/base of palm; elbow fracture/dislocation; repeated elbow bending.

INJURIES: Claw hand effect, esp in ring/pinky.

23
Q

Median Nerve Injury

A

INNERVATION: Forearm flexors; intrinsic hand for flexion of wrist/digits and forearm pronation. It is often called the “eyes” of the hands because of its importance in sensory innervation of the volar surface of the thumb, index, and middle fingers.

CAUSES OF INJURY: lacerations and compression syndromes of wrist (ie: CTS).

INJURIES: Opposition issues, pinching issues. Clawing of index/middle. No active pronation.

24
Q

Radial Nerve Injury

A

INNERVATION: Innervates the extensor-supinator group of muscles of the forearm.

CAUSES OF INJURY: pressure by awkward/prolonged body positions; bruises/tumors/cysts that put pressure on it; tight watches on wrist or crutches pressing under arm.

INJURIES: “Finger/Wrist Drop” - Fingers/thumb won’t fully extend at MPs, wrist won’t straighten.

25
Q

Flexor Tendon Injuries

A

May be isolated or in conjunction with other injuries like fractures, lacerations or crushes. Difficult to treat bc tendons lie in their sheaths beneath fibrous pulley system, and scarring causes adhesions. Factors in successful tx of flexor tendon injury: strength of surgical repair, quality of tendon, tension of repair, if sheath/pulleys were restored. Tx depends on: age, cognition level, financial/family supports, motivation, and compliance with therapy program. Treated with:
• Immobilization
• Early Passive Mobilization
• Early Active Mobilization
• Post-Acute Flexor Tendon Rehabilitation
• Flexor Tendon Reconstruction

26
Q

Immobilization of flexor tendon injury

A

Preferable early; when conditions not optimal to allow safe, controlled movement. Young children or cognitive dysfunction may require casts for 3-4 wk. PROM only in therapy.

27
Q

Early Passive Mobilization of flexor tendon injury

A

When tendon repair conditions not optimal (ie: involving other structures that require more surgery, prolonging inflammation/edema); controlled passive motion to prevent adherence of repaired tendons; use of dorsal blocking orthosis; gradually increase motion over several weeks.

28
Q

Early Active Mobilization of flexor tendon injury

A

Active movement within days of surgery due to better tendon suturing; must work closely with surgeon and close monitoring; Improved results with stronger, more sophisticated repairs. Prevent rupture of tendon by overstressing repair site. Exercise orthosis with hinged wrist and blocked MP joints may be used (wrist extends, fingers passively flex).

29
Q

Post-Acute Flexor Tendon Rehabilitation (after flexor tendon injury)

A

Active flexion out of orthosis, after postop mgmt techniques, facilitate differential tendon gliding. Maximize gliding of flexor digitorum superficialis and flexor digitorum profundus tendons, while stretching intrinsic muscles and gliding of extensor mechanism. Blocking orthosis or use of opposite hand may be used to isolate/assist tendon gliding. Passive extension started after 6-8 wk; may use orthoses to correct limitations in movement. Hand may be used for light ADLs/light resistive exercises. Full resistance/normal work started 3 mo after surgery.

30
Q

Flexor Tendon Reconstruction

A

If tendon damaged due to crush or if laceration cannot be cleaned up enough to allow primary repair, delayed or staged reconstruction may be needed to provide return of tendon function. Primary surgery/repair may include tendon transfers, lengthening, or grafting. In severe cases, “staged” reconstruction is used: rod inserted below pulley system and attached to distal phalanx. As it heals, a pseudosheath lined with mesothelial cells forms around the rod, and fluid similar to synovial fluid forms. 4 mo later, 2nd stage: when digit moves passively to palm, tendon graft inserted and rod removed. Postop recovery similar as for primary repair. Tenolysis (surgery to remove adhesions due to scar tissue) performed as early as 3 mo after repair if progress plateaus and substantial diff in A/ROM. Adhesions removed and tendon gliding assessed during tenolysis. Active motion begun w/in first 24 hr.

31
Q

Edema / How it’s controlled

A

Swelling. Must be quickly/aggressively treated to prevent permanent stiffness or disability. Occurs within hours of trauma due to increase in white blood cells/inflammatory response. Early, use ELEVATION, massage, compression and AROM. Pitting more pronounced on dorsal surface where venous/lymphatic systems return fluid to heart. AROM important to produce retrograde venous/lymph flow. Monitor for persistent edema, use volume and circumference measurement. BEST TX: ELEVATION AND ACTIVE MOTION.

Manual Edema Mobilization (MEM): method of edema redux by activating lymphatic system. Massage, compression bandaging, exercise, external compression adapted to meet needs. (Requires specialized training!)

Compression: Light compression using Coban wraps, or compressive garments like Isotoner/Jobst gloves help control swelling esp. at night.

32
Q

Neuromas

A

Complication of nerve suture or amputation. “Traumatic Neuroma” is unorganized mass of nerve fibers that results from accidental or surgical cutting of nerve. “Neuroma in Continuity” occurs with nerve intact. May be clinically identified by specific, sharp pain. Stimulation of neuroma causes client to pull hand quickly away, or report burning pain radiating up forearm. Disabling bc causes intense pain and client avoids the area.

Tx: Cortisone acetate injections to help break it up and allow desensitization techniques to be effective; surgical excision of neuroma; or burying nerve endings deeper.

33
Q

Complex Regional Pain Syndrome (CRPS)

A

CRPS is a group of disorders that involve pain and dysfunction of severity/duration out of proportion to those expected from the initiating event. Hallmarks of CRPS are extraordinary pain; edema; blotchy, shiny skin; and coolness in extremity. Can also have sensory changes, excessive sweating or dryness. HELP CLIENT PREVENT CRPS BY MOVING the joint ROM (use it) as much as possible to increase circulation. Use the limb as an assist to tasks. Squeeze a ball. Incorporate other, unaffected joints (so they don’t become affected, too!).

34
Q

When to suspect CRPS?

A

Should be suspected in any client who seems to complain excessively of pain, appears anxious, and complains of profuse sweating/temperature changes in hand. Some have nausea when hand is touched. Client may overprotect hand. Best recognized EARLY and treated with TEMPERED AGGRESSIVENESS and empathy.

35
Q

Categories of Nerve Injuries

A
  1. Neuropraxia = contusion of nerve w/out wallerian degeneration (active process of degeneration when nerve fiber is cut/crushed). Nerve recovers function w/out intervention in days/weeks.
  2. Axonotmesis = injury in which nerve fibers distal to site of injury degenerate but internal organization of nerve remains intact. No surgery; recovery w/in 6 mo, depending on level of injury.
  3. Neurotmesis = complete laceration of both nerve and fibrous tissues; surgery required; micro-surgical repair of fascicles is common; nerve graft if gap exists between nerve endings.
36
Q

Peripheral Nerve Injury

A

Result of disruption by fractured bone, laceration or crush injury. Weakness/paralysis of muscles innervated by motor branches of injured nerve, and sensory loss to areas innervated by sensory branches.

37
Q

Peripheral Nerve Tests

A
  • Adson Maneuver
  • Roos Test
  • Upper Limb Tension Test/Brachial Plex Tension Test
  • Tinel’s Sign
  • Phalen’s Test/Reverse Phalen’s Test
  • Carpal Compression Test
  • Elbow Flexion Test
  • Froment’s Sign
  • Jeanne’s Sign
  • Wartenberg’s Sign
38
Q

Adson Maneuver

A

Peripheral Nerve Test. Disappearance/slowing of radial pulse with head movement shows presence of THORACIC OUTLET SYNDROME.

39
Q

Roos Test

A

Peripheral Nerve Test. Maintain cactus arms while slowing alternating betw open hand/fist. Inability to maintain or onset of symptoms shows THORACIC OUTLET SYNDROME.

40
Q

Upper Limb Tension/Brachial Plexus Tension Test

A

Tension stress placed on brachial plexus; client supine, arm out to side (T); elbow passively extended w/wrist in ext. Symptoms of stretch/ache in cubital fossa (triangle area anterior to elbow joint/forearm) or tingling in thumb/first 3 fingers shows positive tension on MEDIAN NERVE (ADVERSE NEURAL TENSION).

41
Q

Tinel’s Sign

A

Peripheral Nerve Test. Examiner taps gently along peripheral nerve, starting distally and moving proximally to elicit tingling in fingertip. Point where tapping begins sensation indicates location of nerve compression. USED FOR CTS.

42
Q

Phalen’s Test/Reverse Phalen’s Test

A

Peripheral Nerve Test. USED FOR CTS. Fully flex wrists with back of palms pressing together. Reverse is by holding hands in “prayer” position for 1 min. Positive if client reports tingling in median nerve distribution (thumb, index, mid and radial ring).

43
Q

Carpal Compression Test

A

Peripheral Nerve Test. USED FOR CTS. Place pressure over median nerve in CT for up to 30 sec. Test is positive if tingling in median nerve distribution (thumb, index, mid and radial ring).

44
Q

Elbow Flexion Test

A

Peripheral Nerve Test. Used for CUBITAL TUNNEL SYNDROME. Client fully flexes elbows with wrists fully extended for 3-5 min. Positive if tingling in ulnar nerve distribution (ulnar ring finger and pinky) of forearm/hand.

45
Q

Froment’s Sign Test

A

Peripheral Nerve Test. For ULNAR NERVE PARALYSIS. Pt grasps a piece of paper between the thumb and index finger. With weakness of the pinch, thumb also flexes at the interphalangeal joint (tip of finger bends) because the flexor pollicis longus compensates for the weakness.

46
Q

Jeanne’s Sign Test

A

Peripheral Nerve Test. For ULNAR NERVE PARALYSIS. Similar to Froment’s sign (weak grasp on paper with thumb/index), Jeanne’s sign is also seen in response to pinch forces. Instead of isolated thumb IP flexion, the IP flexion is accompanied by MP joint hyperextension.

47
Q

Wartenberg’s Sign Test

A

Peripheral Nerve Test. For ULNAR NERVE PARALYSIS. Client unable to adduct pinky when hand placed palm down with fingers passively abducted.

48
Q

Stages of Wound Healing

A
  • Acute Inflammatory Phase: First phase of wound healing initiated w/in hours; tissues disrupted by injury/surgery; vasodilation, edema, migration of WBCs and phagocytic cells (remove tissue fragments/foreign bodies) to area. Fibroblasts invade the wound w/in first 72 hrs, replacing phagocytes.
  • Collagen/Granulation Phase: Second phase of healing betw 5th-14th day; formation of collagen fiber follows fibroblasts; wound rich with fibroblasts, capillary network and collagen fibers by end of second week. Increased vascularization results in erythema of new scar. 3rd-6th weeks, scar collagen fibers cause wound to become stronger.
  • Scar Maturation Phase: Third/Last phase of healing; tissue strength continues to increase for 3+ mo. New collagen replaces old while wound remains stable. Dense scar adhesions and whorl-like patterns of collagen deposits form; scar architecture/fiber organization changes wound over time. Gliding tissues more likely to resemble state before injury, while nongliding scar fixes to surrounding structures. Controlled tension on scar shown to facilitate REMODELING. Scar also influenced by age and quantity of scar deposited.
49
Q

Scar Remodeling Techniques

A

Pressure: applying pressure can reduce thickening of hypertrophic (thick, raised, abnormal) scar. Pressure garments or Cica-Care silicone gel sheets may be used.

Massage: gentle, firm massage using thick ointment softens scar tissue; should be used with active hand so tendons glide against softened scar. Vibration can also be used. May start 4 wk after injury.

50
Q

Thoracic Outlet Syndrome

A

BVs/nerves betw collarbone and first rib (thoracic outlet) compressed. Paresthesias/heaviness with sustained positioning/activity above shoulder level or behind body. Pain in shoulders/neck and numb fingers.

TESTS: • Adson’s Test; Roos Test

51
Q

Adverse Neural Tension

A

Nonspecific pain or paresthesias with reaching in positions that put tension on brachial plexus.

TEST: Positive Upper Limb Screening Test

52
Q

Finkelstein Test

A

Bend thumb across the palm of hand and bend fingers down over thumb (fist with thumb inside). Then you bend wrist toward little finger. Positive if this causes pain on the thumb side of wrist. For DE’QUERVAINS SYNDROME/TENOSYNOVITIS.