Upper extremity Flashcards
Nerve roots of the axillary nerve
C5, C6
Nerve roots of the radial nerve
C5, C6, C7, C8, T1
Nerve roots of the median nerve
C5, C6, C7, C8, T1
Nerve roots of the ulnar nerve
C8, T1
Cords of the brachial plexus innervating the axillary nerve
Posterior
Cords of the brachial plexus innervating the radial nerve
Posterior
Cords of the brachial plexus innervating the median nerve
Medial and Lateral
Cords of the brachial plexus innervating the ulnar nerve
Medial
Sensory Distribution of Axillary Nerve
Skin over distal portion of deltoid muscle
Sensory Distribution of Radial Nerve
Dorsal surface of forearm
Dorsal aspect of the radial half of the hand
Sensory Distribution for the Median Nerve
Skin on palmar aspect of the thumb
Palmar aspect lateral 2.5 fingers
Sensory Distribution of the Ulnar Nerve
Skin of 5th finger, 4th finger (1/2 palmar, full dorsal), Medial half of the hand (palmar and dorsal)
Motor Distribution for the Axillary Nerve
Deltoid
Teres Minor
Motor Distribution for the Radial Nerve
Triceps Brachii
Anconeus
Brachioradialis
Ext Carp Rad Long
All other Extensor-Supinator muscles of the forearm
Motor Distribution for the Median Nerve
Flexor-Pronator Muscles of the Forearm
1st and 2nd Lumbricals
All Thenar (Thumb) Muscles EXCEPT ADDuctor Pollicus
Motor Distribution of the Ulnar Nerve
Flex Carp ULNARIS
Flex Carp Digitorum Profundus (ulnar head)
Adductor Pollicis
3rd and 4th Lumbricals
Plamar and Dorsal Interossei
Hypothenar Muscles (Everything Minimi!!!)
Mallet Finger
Hyperflexion of DIP joint
Avulsion of the Extensor Digitorum Tendon
Orthotic Treatment
Hold DIPJ in extension/prevent flexion
Hyperextend and immobilize DIP to allow reinsertion
Mallet Finger Cap
Boutonniere Deformity (Secondary to RA, or from trauma)
DIPJ hyperextended, PIPIJ flexed, MCPJ extended
Orthotic Treatment
3PPS to aid extension at PIPJ and allow flexion at DIPJ
Dynamic
(with spring wire) or
Static
Boutenniere splint (ex. Digisplint)
Swan Neck Deformity (contracture of intrinsic hand muscles)
PIPJ hyperextended, DIPJ flexed, MCPJ flexed
3PPS to prevent hyperextension at PIPJ and also allow flexion at the PIPJ
Swan Neck Splint
Static (ex. Digisplint)
RA deformities of the MCPJ, Metacarpal Ulnar Deviation (MUD)
Volar subluxation and ulnar deviation of the proximal phalanges
Align wrist in excessive ulnar deviation to provide optimal alignment of long finger extesnor tendons (reduces the lateral pull)
Static WHO (plastic or leather)
Game Keeper’s Thumb / Skier’s thumb
AKA skier’s thumb, UCL (Ulnar collateral ligament) tear
UCL is torn at its insertion site into prox phalanx
Common cause - falling on outstretched hand
Instability of the MCP joint
Pain
Swelling
Weakness of pinch grasp, poor ability to grasp objects (tying shoes, tearing paper etc.)
Thumb OA
Most common form of osteoarthritis affecting the hand
Cushioning cartilage wears away from adjoining ends of bones making up thumb CMC joint
Severe hand pain
Swelling
Decreased strength/ROM
Difficultly performing ADLs (turning doorknobs, opening jars)
Orthotic Treatment
Hold thumb in opposition to index and middle finger for stabilization with functional pinch/grasp ability
Static Short opponens orthotic (Thumb Post Splint)
De Quervain’s Tenosynovitis
Inflammation of the Ext Pol Brevis and Abd Pol Long tendons
Prevent excursion of EPB and AbPL tendons
Stabilize and thumb and wrist in neutral position as these long tendons cross the wrist joint
Static Long Opponens Orthosis
Ulnar Nerve Palsy
4th an 5th MCPJ hyperextension, PIPJ hyperflexion
Need MCPJ flexion and PIPJ extension assist
Prevent hyperextension at 4th and 5th MCPJs, and allow weak extension of PIPJs
Dynamic Orthosis
Ulnar Nerve Palsy Orthoses (i.e spring wire) encourage joint mobility and augment hand function
Static Orthosis
for positioning and prevention of contracture
Median Nerve Palsy
Loss of opposition of the thumb
Need MPJ flexion, CMCJ Abduction, CMCJ pronation
Static or Dynamic positioning of thumb for function
Static thumb post or Dynamic thumb positioning with elastic component
Radial Nerve Palsy
Loss of wrist and MCPJ extension
Need to assist wrist and MCPJ extension, allow MCPJ flex-ext
Stabilize wrist in functional position while fingers and thumb extend at MCPJs
Static WHO (dorsal shell) with Dynamic MCPJ extension assist (spring wires), stabilize 1st CMCJ, Dynamic wrist extension component
Medial and Ulnar Nerve Palsy (intrinsic minus hand)
Loss of wrist and finger flexion, thumb opposition
Need to pinch or grasp of fingers in release
Stabilize thumb for pinch, prevent hyperextension of MCPJs, allow weak IPJ extension by extensor communis
Dynamic Positioning of the thumb and 4 MCPJs to encourage joint mobility and augment hand function
Static Positioning of thumb and fingers to prevent contracture
Carpal Tunnel Syndrome
Compression of the median nerve within the carpal tunnel
Resulting muscle weakness and sensory disturbances (tingling and numbness)
Stabilization of wrist required to prevent tension or compression of the median nerve, wrist positioned in neutral position for rest and functional use
Static WHO - plastic or leather design
OA/RA of the wrist
Destruction of joint space = painful ROM
Need functional position of wrist, prevention of pain
Stabilize the wrist in 25 degrees of extension and 5 degrees of ulnar deviation
Functional WHO, gauntlet, leather or plastic design
Zig Zag Deformity
Radial deviation of wrist with Ulnar deviation of fingers
Usually caused by rheumatoid arthritis
Correction of deformity
Excessive (>5 degrees) ulnar deviation to counteract the ulnar deviation of the fingers
Function WHO, gauntlet, leather or plastic design
Dupuytren’s contracture
Fixed flexion contraction of the hand due to palmar fibromatosis
Inherited proliferative connective tissue disorder affecting palmar fascia
Fingers bent towards palm, cannot fully extend
Ring and little finger most commonly affected
Index and thumb usually spared
Contractures progress slowly, usually painless
Orthotic treatment to prevent further contracture
Lesions Affecting the Axillary Nerve
Rarely affected alone
May be involved in
Spinal cord and brachial plexus lesions
Fractures and dislocations of the head of the humerus
Violent blows on the shoulder
Bullet, stab, and other wounds
Pressure or stretching of the shoulder during sleep
Deltoid paralysis
- inability to protract/retract arm, abduct it to horizontal position
Teres MInor paralysis
- weakness of external rotation
- atrophy of affected muscles
- sensation lost over deltoid prominence
- pain is present in neuritis
Lesions affecting radial nerve
Most commonly injured peripheral nerve
Involved in cervical and brachial lesions
Peripheral injuries may affect the trunk or some of the branches of the nerve as in
Dislocations of the shoulder Fractures of the humerus Callus formation around the fracture Pressure from crutch Violent blows on the arm Tuberculosis of the bone Fractures of the neck of the radius Toxic or infectious neuritis (inflammation of nerve)
Lesions affecting Median Nerve
Cervical cord and brachial plexus lesions
Lacerations of the arm, forearm, wrist, hand due to auto accidents, stab wounds, bullets, etc.
Prolonged compression in sleep/anesthesia
Dislocations of ulna, fractures to elbow and distal radius
Toxic or infectious neuritis
Lesions affecting Ulnar Nerve
Cervical cord and brachial plexus lesions
Fractures/Dislocations of the head of the humerus
Direct lacerating trauma in lacerating wounds (eg. knife, auto accident etc.)
Pressure on nerve during sleep
Drunkenness, general anesthesia
Callus formaiton
Neurinoma (tumor)
Toxicity (lead)
Median/Ulnar Nerve Lesion
Frequently injured together
If lesion complete, functional disturbances are constant
If one or both nerves are only partially involved, symptoms differ widely
Classified according to varied appearance and functions of the hand
SCI with C8 Escape
Loss of Opposition of intrinsic hand and muscle function
Stabilize thumb for weak opposition
Static thumb post
SCI with C7 Escape
Loss of
Pronation
Wrist Flexion
Finger flexion and extension (but maintains ext car rad l & b, and ext car ulnaris)
FInger flexion and extension for pinch and grasp
Stabilize thumb for pinch against fingers
Harness action of Extensor Carpi Radialis for Tenodesis splint
Wrist driven flexor hinge hand orthosis (Tendodesis splint)
Ideal for this level of injury
SCI with C6 Escape
Loss of
Pronation
Wrist flexion
FInger flexion and extension (Only Ex car radialis l&b left)
Stabilize thumb for pinch against fingers
Harness action of Extensor Carpi Radialis for Tenodesis splint
Wrist driven flexor hinge hand orthosis (Tendodesis splint)
SCI with C5 escape
Loss of all hand and finger function
No longer wirst flexion and finger flex/ext for grasp and pinch
External power need to flex wrist and hand
SCI C4 and above
Loss of all upper extremity function
No longer shoulder, elbow, wrist and finger motion
External power mobile arm support with power drive flexor hinge hand
Brachial plexus injury C8-T1
Loss of intrinsic hand muscles and long finger flexors
Grasp and pinch
Stabilize the wrist
Tenodesis splint
Brachial plexus injury C5-C6
Loss of
shoulder and elbow function
weakness of wrist and finger extensors
Stabilize shoulder in slight abduction
Elbow supported in adjustable flexion/extension
Wrist and hand supported in neutral or functional position if some hand function remains
SEWHO- Shoulder Elbow Wrist Hand Orthosis (“Airplane”)
Elbow orthosis
WHFO to augment hand function
Brachial plexus injury- complete flail arm
Loss of upper extremity function
Support weight of flail arm by stabilizing shoulder joint
Flex elbow for functional positioning of hand in front of the body
Stabilize the wrist and hand
SEWHO- Shoulder elbow wrist hand orthosis (“gun slinger”)
Shoulder stabilizer or positioner
Elbow joint, possibly adjustable
Static WHFO
WHO with MCPJ flexion by external cable or power
Elbow Trauma (burns/dislocation), surgery, self abusive patients
Contracture of skin and soft tissues
Joint instability
Dynamic Elbow Orthosis - apply extension assist or stretch
Static Elbow Orthosis- maintain position, support protect
Hinged Elbow Orthosis- M/L and hyper extension support
CVA (Stroke) involvement
Hemiplegia and Spasticity
Harris Hemi-sling for GH subluxation
Spasticity leads to pronation, wrist flexion, thumb flexion and adduction
Static WHFO or resting hand splint
Maintains wrist/hands in neutral position
Prevent development of contractures
Keep palm open and dry (hygiene)
