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Eligibility requirements to take CHT exam?

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•Current practice credential in Occupational or Physical Therapy •3 years of practice as an OT or PT •4,000 hours direct practice experience since becoming a licensed PT or OT

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What is the anatomy of the shoulder joint?

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(ball and socket) -Glenoid labrum -Rotator Cuff (stabilizes the glenoid humeral joint): -Axial Skeleton: Sternoclavicular joint is the only joint that connects the UE's to the axial skeleton

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What muscles are included in the Rotator Cuff?

answer

SITS •Supraspinatus--shoulder abduction (only muscle of the RTC that does not facilitate rotation). Most common muscle of the RTC that is torn. •Infraspinatus—shoulder lateral/external rotation and horizontal abduction (same as Teres minor). •Teres Minor—shoulder lateral/external rotation and horizontal abduction (same as infraspinatus). •Subscapularis—shoulder medial/internal rotation and shoulder abduction (only RTC muscle that facilitates internal/medial rotation). Entire RTC counteracts the force of the deltoid and prevents superior glide.SITS

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Weakness in the RTC causes what?

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Shoulder impingement

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What is shoulder impingement?

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-swimmer's shoulder or -thrower's shoulder/baseball -tennis -over head activities ---- caused by the tendons of the rotator cuff becoming impinged as they pass through the shoulder joint

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What are the joints of the shoulder complex?

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•Sternoclavicular joint (very mobile joint) •Acromioclavicular joint •Scapulathoracic joint •Glenohumeral joint

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What space narrows during shoulder impingement?

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the space between the acromion and rotator cuff narrows. -The acromion can rub against (or "impinge" on) the tendon and the bursa, causing irritation and pain.

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Bones of the shoulder complex?

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Sternum Clavicle Scapula Humerus

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The shoulder complex has dynamic stability which means?

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- segment is more dependent on muscles than on joint structures for maintenance of integrity. -Mobility vs stability compromise

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What are susceptible shoulder problems?

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- Instability of shoulder/dislocation - Impingement/Bursitis - RTC tears

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What is the function of the scapular motion?

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- orient the glenoid for optimal contact with the maneuvering arm -Adds range to elevation of the arm -Provides a stable base of support for the controlled rolling and sliding of the articular surfaces of the humeral head

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Adhesive Capsulitis ?

answer

aka frozen shoulder - joint capsule that surrounds joint adheres and doesn't allow for movement • Focusing on problem with the glenohumeral joint • Define glenohumeral joint: • Ball & Socket synovial joint • Surrounded by a joint capsule • Capsule is loose in neutral • Capsule is taught during shoulder elevation

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Shoulder complex ROM?

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Scapula upwardly rotates 60 degrees Glenohumeral flexion/abduction 120 degrees

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Axioscapular and Axioclavicular Muscles?

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Trapezius—Upper, Middle, Lower Serratus Anterior Rhomboids Pectoralis Minor

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Winging?

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-Medial border of scapula protrudes posteriorly from the thorax -Weakness of the serratus anterior -Injury to the long thoracic nerve

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Most commonly associated with shoulder pathology because it becomes impinged under acromion process?

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Supraspinatus

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Clinical signs of winging?

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-Weakness of the Serratus Anterior and Trapezius -Decreased upward rotation of scapulothoracic joint -Decreased shoulder flexion and abduction -Decreased scapular upward rotation results in shoulder impingement

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Function of shoulder:

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•To provide a mobile & strong base of support for the hand •To position the UE in space to allow the hand to perform its tasks

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Cubital Tunnel Syndrome

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•Cubital Tunnel Syndrome- compression of the ulnar nerve in the cubital tunnel •Results in impaired motion of the IV and V digit

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Lateral Epicondylitis?

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Commonly known as "tennis elbow" •Faulty backhand stroke •"Overuse syndrome" involving strain and inflammation

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Cause of Lateral Epicondyltis ? Muscles?

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By many muscles inserting on a small surface area - Extensor Carpi Radialis Brevis

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Typical vocations or avocations associated with lateral epicondylitis include?

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o Carpentry o Gardening o Dentistry o Politicians (from shaking hands) -Resisted wrist extension and palpation will cause pain

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Medial Epicondylitis?

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•"Golfers Elbow" or "Pitchers elbow" •Can result from a faulty forehand stroke in tennis •Inflammation at the site of the medial epicondyle •Involves the pronator teres and wrist flexors •Less common

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Tommy John Surgery aka Pitcher's Elbow

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• "Pitchers Elbow" • Throwing motion puts valgus stress • Can lead to a torn MCL • Kids should not "overthrow"

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"Tommy John" Surgery?

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MCL or UCL is replaced with either a tendon from elsewhere from the patient's own body or a tendon from a cadaver. o Ulnar collateral ligament reconstruction o UCL is replaced with a tendon from elsewhere in the body o Recovery takes about 1 year for pitchers. o Is very common for this to happen with pitchers due to the amount of pressure placed on ACL o Medial collateral ligament - attached to medial epicondyle Resists Valgus stress o Lateral collateral ligament- attaches to the lateral epicondyle (3 bundles) Prevents Varus stress

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DASH - Disabilities of arm, shoulder, and hand

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• Client self-administered • Consists of a 30-item disability/symptom scale • Designed to help portray disability experienced by people with UE disorders • Monitor changes in symptoms and function

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Nerves Compressions on carpel tunnel?

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Compressions may be as far up as in the BP. ie. In carpal tunnel we assume that the compression may be at the wrist however the median nerve has several "vulnerable" points long the pathway leading up to BP where compression may occur, inclusing the BP. Same goes of ulnar and radial nerve.

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Nerve compressions

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-Radial nerve: axilla, spiral groove vulnerable in humeral fxs, deltoid tuberosity,lateral intermuscular septum in distal lateral forearm,albow, superficial radial nerve vulnerable to laceration throughout hand because it's superficial. • Median: neurovacular bundle (in the arm), bicipital aponeurosis, fx or elbow dislocation, compression at pronator or sublimus bridge, carpal tunnel. • Ulnar: neurovacular bundle, posterior compartment in mid-arm, triceps brachii muscle vulnerable to exteranal force or lying on operating table, medial epicondyle and cubital tunnel, Guyon's canal.

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Steps of observation of a pt?

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Observations: • Begins when the patient walks in the clinic • Is the patient guarding? Supporting arm? • Must have patient expose shoulder/UE in order to see scapula and shoulder complex • Females in a gown • Observe for muscle atrophy, wasting, bruising • Asymetery • Scapula winging (Posterior View) • Anterior View • Patient's head and neck should be in the midline • Look for "step deformity" (acromioclavicular dislocation) the distal end of the clavicle lying superior to the acromion process. Looks like a "bump" • Look for sulcus sign - head of humerus comes out of pocket - subluxation? • Dominant side will hang lower than the nondominant and in some cases have hypertrophy

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Palaption?

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•Have patient take one finger and point to the pain

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ROM?

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•Functional quick screen (above head, behind head, behnd back) •Active ROM/Passive ROM •Compare both sides •Cervical ROM to determine if pain is coming from spine/nerve injury (in case you think its carpal tunnel when its really from the neck) •Goniometry •Painful arc (60 to 120 degrees) - (take them through the regular range and have them tell you where it starts to hurts and were it stops hurting) •Deltoid vs RTC •MMT

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Analysis of Occupational Performance •

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-Ask patient to attempt to perform ADL tasks •-What data do you need to collect? Examples: ROM MMT Coordination tests Edema measurements -

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Sensory Evaluation

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• Vision should be occluded for all sensory testing including having the client close their eyes. • Important to support the client's hand • Testing variables to consider: o Environment - minimize background noise o Client's ability to concentrate o Testing instrument o Method: standard instructions o Examiner's skill and experience. • Sensory Assessment components: o Client's History- profile as well as specific description of the sensory problem, date of injury etc.

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Sympathetic Phenomena-

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Skin temperature, color, cold intolerance, sudomotor function (sweat), Pilomotor (goose bumps), Trophic changes: hair changes, atrophy

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Sensory mapping-

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client points to sensory impairment. Clinician can map on the hand or on another piece of paper.

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Sensory Screening of the Hand • "Time saving method to determine some parameters of sensory loss" How to test?

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-Median N.- Thumb tip -Ulnar N.- distal small finger -Radial N. -Thumb web spac

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Proprioception =

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Awareness of joint position in space. •Client vision occluded •Hold body part on the lateral aspect •Move joint in flexion and extension •Client indicates "up or down" to correspond with flexion and extension

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Stereognosis

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•The use of both proprioceptive information and touch to identify an object with vision occluded. •Typical items include: coin, key, pen, spoon, safety pin. •Client identifies object

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Point Localization

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•Client's vision occluded •Examiner touches area with a monofilament •Client points to area that was touched with a small dowel. •Response is correct if within 1 CM of area that was touched.

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Semmes-Weinstein Monofilaments

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•Assesses pressure threshold •Versatile and valid and easy to administer •Typically used on the hands •Client's vision occluded •Start from distal to proximal

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Static Two-Point Discrimination

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•Equipment - Disk-Criminator or the Boley Gauge. •Test pads of the fingers and thumb •Begin with 5 mm distance •Increase distance as needed up to 15 mm •7 out of 10 responses needed •Normal is 1-5 mm

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Moving Two-Point Discrimination

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•Begin with 5-8 mm distance •Move the instrument from proximal to distal in the finger tip. •Normal moving two-point discrimination is 2 mm

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Localization of Touch and Moving Touch

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•Use smallest diameter of the Semmes-Weinstein monofilament kit that the client can feel. •Touch area of involvement. •When client feels the touch, they open their eyes and point to the exact area. •Place a dot on the hand grid/map for accurate responses. •Moving Touch - Stimulus is moved along the midline.

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Moberg Pick up Test

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•Good test to use with injuries involving the median and or ulnar nerves. •Use everyday items such as a coin, key, paperclip and place on the table. •Client picks up items and places in a box. •Time the task takes is recorded •Repeat with client's eyes closed

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Nine Hole Peg Test (also for dexterity)

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•Assesses finger dexterity •Test unaffected hand first •Client places pegs into holes and then takes them out as fast as they can. •Examiner records time using stop watch.

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Minnesota Rate of Manipulation Test- MRMT

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•Series of tests of eye hand coordination and motor abilities. •Measures speed of gross arm and hand movements during rapid eye-hand coordination tasks. •Test consists of 5 sub-tests- Placing, turning, displacing, one-hand turning, and two hand turning and placing.

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Jebsen-Taylor

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7 major hand activities •Feeding, writing, turning pages, stacking checkers, picking up: small objects, large light objects, large heavy objects.

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Purdue Pegboard

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•Measures 2 Types of Dexterity 1. Gross movements of the fingers, hands, and arms. 2. Fine finger tip dexterity necessary in assembly tasks. •Test Right hand, left hand, both hands 30 seconds to place as many pins as possible • Assembly- 60 seconds-Alternate hands

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9-Hole Peg Test (also a functional sensory test)

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• Assesses finger dexterity • Test unaffected hand first • Client places pegs into holes and then takes them out as fast as they can. • Examiner records time using stop watch.

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MMT 0-5?

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•Grade 0 - no evidence of contractility. •Grade 1 - (trace) slight evidence of contractility but no jt. Motion •Grade 2 - (poor) complete ROM with gravity eliminated. •Grade 3 - (fair) complete ROM against gravity •Grade 4 - (good) complete ROM against gravity w/ some resistance. •Grade 5 - (normal) complete ROM against gravity w/ full resistance.

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Grip Strength

answer

• Tool: Jamar Dynamometer : 2nd handle position. Calibrate annually. • Pt is seated with shoulder in Adduction, neutral forearm, flexed elbow, wrist in neutral to 30 deg. extension. • Take average of 3 trials.

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Pinch Strength

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• Lateral • Three-jaw chuck • Tip-to-tip • 3 trials average

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Special test for shoulder?

answer

Apprehension test (Crank) Sulcus sign Neers Impingement Test

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Apprehension test (Crank): test for?

answer

anterior shoulder dislocation - shoulder abducted 90 degrees, elbow flexed 90 degrees- slowly externally rotate the shoulder. Technique: The patient should be position in supine. The therapist will flex the patient's elbow to 90 degrees and abducts the patient's shoulder to 90 degrees, maintaining neutral rotation. The examiner then slowly applies an external rotation force to the arm to 90 degrees while carefully monitoring the patient. Patient apprehension from this maneuver, not pain, is considered a positive test. Pain with the maneuver, but not apprehension may indicate a pathology other than instability, such as posterior impingement of the rotator cuff.

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Purpose of Apprehension test?

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- integrity of the glenohumeral joint capsule, or to assess glenohumeral instability, such as posterior impingement of the rotator cuff

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Sulcus sign: testing for?

answer

- inferior shoulder instability ---- grasp client by forearm with 2 hands and gently pull distally. Test position: sitting or standing Performing the test: The examiner grasps the wrist of the patient's elbow and pulls the arm distally. Observation is made of the amount of "sulcus" (space between the acromion process and humeral head) that is present with the distal arm pull. A positive test is considered for multidirectional instability if 1-2 cm of "sulcus" is noted. -

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Purpose of Needs impingement test?

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-to test for supraspinatus impingement P ----atient's arm is forcibly elevated through forward flexion. Positive sign for impingement if patient complains of pain.

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Test for muscle/ tendon patology?

answer

Drop arm test Impingement test testing for

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Drop arm test for?

answer

-RTC tear - raise client's arm to 90 degrees of shoulder abduction. Purpose: test for supraspinatus tears Test position: patient is seated Performing the test: examiner grasp the patient's wrist and passively abducts the patient shoulder to 90 degrees. Examiner release the patient's arm with instructions to slowly lower the arm. Test is positive if the patient is unable to lower his arm in a smooth, controlled fashion.

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Test for bicipital tendinitis?

answer

Yergason's test Speeds test

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Yergason's test purpose?

answer

-the test is used to check the ability of the transverse humeral ligament to hold the biceps tendon in the occipital groove -clients elbow flexed to 90 degrees- forearm pronated - resisted supination and lateral pronation- positive if there is tenderness in the bicipital groove. Purpose: Test position: seated while examiner stands in front of the client. Performing the test: the patient elbow is flexed to 90 degrees and the forearm is in a pronated position while maintaining the upper arm at the side. Patient is instructed to supinate arm while examiner concurrently resist forearm supination at the wrist. Localized paint at the bicipital groove indicates positive test.

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Speeds test purpose?

answer

this test looks for biceps muscle or tendon pathology -examiner resist shoulder forward flexion by the client while the client while the patient is supinated and elbow extended. Purpose: t Performing the test: the patient's arm is forward flexed to 90 degrees and then the patient is asked to resist an eccentric movement into extension. First with the arm supinated, then pronated. A positive test elicits increased tenderness in the bicipital groove, specially with the arm supinated.

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Test for thoracic outlet syndrome/ Purpose?

answer

-Roos test --: to test the presence of neural or vascular compromise in the thoracic outlet -client stands with arm abducted 90 degrees with shoulder eternally rotated, elbow flexed to 90 degrees. Client opens and closes hands for 3 minutes. Positive if clients is unable to keep arms in starting position ao ? pain. Performing the test: have the patient abduct each shoulder to 90 degrees with the shoulder laterally rotated and the elbows flexed slightly behind the frontal plane. Instruct the patient to open and close their hands slowly for 3 minutes. A positive test is reported if the patent is unable to keep their arms in the starting position for 3 minutes or if ischemic pain, heaviness, or weakness is present in the arm or if the patient reports numbness or tingling in the hand during the test.

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Special test for the elbow

answer

Ligamentous instability test Cozens test: Golfers elbow test Tinel's sign at the elbow: Wartenbergs sign:

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Ligamentous instability test?

answer

test for lateral and medial collateral ligament stability -- stabilize arm at the elbow with one hand and the other hand just proximal to the wrist- apply varus and valgus force checking for instability or pain.

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Cozens test?

answer

test for lateral epicondylitis - client makes a fist, pronate the forearm, and radially deviate and extend the wrist while examiner resist motion. Positive if pain in the lateral epicondyle. -Performing the test: stabilize the patient's forearm and instruct the patient to make a fist, pronate the forearm, radially deviate, and extend the wrist. Next the clinician palpates the lateral epicondyle with the stabilizing hand and applies a flexion force against the patient's resistance. A positive test is reproduction of lateral elbow pain.

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Golfers elbow test?

answer

-test for medial epicondylitis - clients forearm is supinated and the elbow and wrist extended. Positive is pain over the medial epicondyle. Performing the test: patient should have his fingers flexed in a fist position. The examiner palpates the medial epicondyle with one hand and grasp the patient's wrist with his other hand. The examiner then passively supinates the forearm and extends the elbow and wrist. A positive test would be a complaint of pain or discomfort along the medial aspect of the elbow in the region of the medial epicondyle.

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Tinel's sign at the elbow:

answer

-tapping at the cubital tunnel- testing for ulnar nerve regeneration. -Purpose: the therapist identified an irritated nerve through a percussive or tapping technique. At elbow Tinel's test indicates an irritated Ulnar nerve Performing the test: The therapist should locate the Ulnar nerve that is seated in the groove between the olecranon process and the medial epicondyle, the Ulnar nerve is then tapped on repeatedly by the index finger of the therapist. ---A positive sign is indicated by a tingling sensation in the ulnar distribution of the forearm and hand distal to the tapping point.

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Wartenbergs sign?

answer

-test used for assessing integrity of the motor innervations of hand intrinsics in case of suspected ulnar neuropathy. --client place hand on the table - spread fingers apart. Ask client to bring fingers back together. Test is positive for ulnar neuritis if the client can't adduct 5th digit. Performing the test: patient is placed with wrist in neutral position and forearm fully pronated and instructed to perform full extension of all fingers. Once digits are extended patient is asked to fully abduct all finger and then adduct all fingers. A positive sign is indicated with the observation of abduct of the 5th digit, with inability to adduct the 5th finger when extended.

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Special test for the wrist/hand?

answer

-Oppostion -Finkelstein test -Tinel's sign -Phanel's test -Froment's sign:

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2. Finkelstein test:

answer

-test for De Quervains tenosynovitis of the thumb - client makes a fist with the thumb inside the fingers. Ulnar deviate wrist- positive if pain over the abductor pollicis longus and extensor pollicis brevis

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Tinel's sign:

answer

tapping on the wrist level- test for CTS Performing the test: examiner taps the medial nerve as it travels through the carpal tunnel and also just proximal to it (can use reflex hammer or fingers). Tingling or pain in the median nerve distribution (thumb, index, middle, and half of the ring fingers) = Carpal tunnel syndrome.

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Phalens test:

answer

client flexes wrist-reverse prayer for 1 minute - test for CTS -position is held 60 seconds or until symptoms are reproduced. A positive test occurs with numbness and tingling on the palmar aspect of the 1st,2nd, 3rd, and radial half of the 4th digit within 60 seconds of assuming the position.

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Froment's sign:

answer

client attempts to grasp piece of paper between the thumb and index finger. Positive distal thumb flexes. -Indicates nerve paralysis. -Purpose: test for the strength of the adductor pollicis muscle; this muscle is weak when the ulnar nerve is affected (ulnar nerve palsy) P erforming the test: client is asked to hold a piece of paper between his thumb and index finger (pinch grip). An examiner then tries to pull the paper out of the person's hand. A healthy individual will be able to hold a paper without difficulty while an individual with the lack of strength in the adductor pollicis (when the motor branch of the ulnar nerve is affected) will try to keep the hold with the help of the flexor pollicis longus muscle (innervated by the anterior interosseous branch of the median nerve), what will result in the obvious bending of the interphalangeal (distal) joint of the thumb. At the same time, the metacarpophalangeal joint (between the hand and the first phalange) of the thumb will be excessively extended (Jeanne's sign). In a healthy person, both thumb joints will be obviously extended when making a pinch.-

question

Classifications of Fractions

answer

• Location in the bone • Angle of the fracture • Number of Fragments • Skin- closed or open

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Clinical vs. Radiographic Healing

answer

•Clinical Healing is when there is decreased tenderness at the fracture site. •Clinical healing occurs first and allows us to begin ROM sooner. •Radiographic Healing is when the x-ray confirms that the fracture has healed. Takes longer.

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Why is it important to know the classification

answer

•Determines how aggressive you can be •Determines when mobilization/ROM can begin •Gives you an understanding of what complications could occur •How do you get this information? - Medical chart review and history

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•For Operative Clients:

answer

•What structures were repaired? •Ask for a copy of the operative report. •How soon can active motion start? •When can I start resistance exercises?

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•For Non-operative Clients:

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•When can I begin to take off the sling? (can lead to complications) •How much longer does the client need to wear the sling during sleep? •How soon can the client begin ROM? •When can you begin resistance exercises?

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Reduction

answer

•Medical procedure to restore a fracture or dislocation to the correct alignment. •Fractures must be reduced to their normal anatomical position to avoid deformity.

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Closed reduction—

answer

refer to manipulation of the bone fragments without surgery

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Open reduction-

answer

refers to surgery (ORIF)

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Fracture Stabilization Techniques?

answer

• Cast • External Fixation • Internal Fixation o Screws o Plates o K-Wires o Tension Bands o Wire Loop

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Choices for Fracture Fixation?

answer

•Stable Fractures—Closed Reduction •Fractures that have displaced fragments will require internal fixation •External fixation is used when traction is needed to hold a fracture out to length to avoid shortening. (often seen with wrist fractures to prevent radial shortening)

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Reverse Total Shoulder Replacement

answer

•Socket and Metal Ball are switched •Metal ball is fixed to the socket •Plastic cup is fixed to the upper end of humerus •Procedure is beneficial for clients with RTC tears. •Used like if someone breaks shoulder and has RTC tear at same time

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Treatment after Total Shoulder and Hemiarthroplasty Day one? Day 7-10? Week3? Week 4-6? Week 8?

answer

•Sling used for one week •Day 1 - Codman's pendulum •PROM - Flexion and external rotation •Day 7-10 - Remove sling •Continue PROM until radiographic evidence of healing •3 weeks - Pulleys, isometrics •4-6 weeks - AROM (difficult getting normal AROM to complete range; more likely to become functional) •8 weeks — Active Elevation

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Clavical Fracture?

answer

-Mechanism of Injury—Fall on outstretched arms. •Landing directly on the point of shoulder •80% of the time the middle of the bone is fractured •Healing time for adults 6 weeks or longer

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Treatment of Clavicle Fracture?

answer

-Non-Displaced Fracture - Sling x 3 weeks •Displaced fractures sometimes can be reduced without surgery under anesthesia followed by a figure of eight bandage. •Surgery - ORIF —Plates and Screws •Complication if not reduced — shortening of one side of body

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Elbow fracture? Treatment?

answer

• Fractures of the distal humerus • Uncommon • Mostly young males • Usually high velocity injuries: MVA Treatment • Anatomical reduction • Immobilization in a cast 6-8 weeks • ROM of Digits ; Shoulder • After cast is removed: • Edema control • Pain Management • ROM-Flexion, Extension, Pronation, Supination

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Most common elbow fractures in adults?

answer

•Radial head fractures •Common mechanism of injury - falling on an outstretched hand with forearm pronated •Common complication is a elbow flexion contracture. (loss of full extension)

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Treatment of radial head fracture?

answer

Type I: early mobilization Type II: ORIF and early mobilization Type III: Radial head excision "has been advocated" Type IV: Hinged splint to protect against valgus instability

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Olecranon fracture?

answer

• Early mobilization is only possible if ORIF is performed. • ORIF usually is tension band wire fixation • No resistance of triceps for 4 to 6 weeks • Ulnar Nerve is susceptible to injury

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Elbow facts:

answer

• Loss of flexion is more limiting functionally • Extension loss is more common • Extensor loss is more challenging

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Most common carpel fracture?

answer

- Scaphoid • 60 to 70% •Caused by high force to radial half of the hand with the wrist in hyperextension

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Scaphoid fracture causes what?

answer

•Tenderness present in the anatomical snuff box

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Conservative Management for Scaphoid Fractures?

answer

•Immobilization in a cast x 6 weeks •Edema control (what is the best thing for edema - elevation and AROM) •Digit exercise •After cast is removed - Same as wrist protocol •ROM •Retrograde Massage (try to move fluid from distal to proximal) •Compression garment •Grip/pinch

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Fractures of the Hand •

answer

-Metacarpal and Phalangeal Fractures: -Common injuries •-May result in significant stiffness and deformity in poorly treated •-Function can best be restored by anatomical reduction that allows early mobilization.

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Factors to consider with finger fracture?

answer

• 1. Stability • 2. Alignment • 3. Associated soft tissue injury • 4. Pre-existing disease - i.e. osteoporosis • 5. Patient factors — age, general health, occupation, expectation, compliance and motivation.

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Therapy following closed reduction? • If the fracture is stable:

answer

1. Support the hand and fracture in the acute stage 2. Edema control 3. Restore ROM 4. Tendon Glide 5. Restore strength (grip strength ; pinch strength (lateral, tip to tip, 3 prong chuck) 6. Restore functional use

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Treatment for finger fractures

answer

• POSI Splint (Position of safe immobilization) • Wrist 20-30 Degrees in extension • MP Maximum of 70 Degrees Flexion • IP extended • Isolated joint motion/joint blocking

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Surgical Management of hand •Indicated when:

answer

1. inability to achieve or maintain a satisfactory position closed 2. displaced intra-articular fracture 3. fractures associated with soft tissue injury 4. pathological fractures and non union

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Types of Surgical Management

answer

• K-Wires • Composite Wiring • Intramedullary fixation with pins • Screws • Plate Fixation

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Metacarpal Fractures

answer

• May involve head, neck, or shaft. • Metacarpal Head Fractures are unusual. • Complication Extensor lag • Extension splinting at night • E-Stim (can have difficulty with extension - lag) • Metacarpal Neck Fractures are common—Referred to as "Boxer's fracture" (happens from hitting the wall) • "Boxer's fracture"—(hitting a wall) normally IV and V Digit

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Treatment of metacarpal fractures?

answer

•If Stable — gentle AROM is allowed • Edema Control — Dorsum of hand • Isolated extensor digitorum exercises (extend fingers with tips crunched) • Buddy taping (tape it with a working finger and do AROM) • Fracture bracing—circumferential (fingers free) used with stable Metacarpal shaft fractures. • Finger Abduction/Adduction exercises

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Thumb Metacarpal Base Fractures Types?

answer

•Bennett's Fracture - A fracture subluxation of the thumb carpometacarpal joint. •Rolando fracture — A comminuted intra-articular fracture of the base of the thumb metacarpal.

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Treatment following thumb fractures?

answer

•Proximal phalangeal Fractures—Treated with a hand based thumb splint with IP Free. •Include IP if fracture includes neck or head •Metacarpal fractures- forearm based splint •Treatment tips: •Maintain thumb in abduction to avoid web space contracture •Splinting time may increase if fracture is unstable •Early IP motion is indicated to avoid stiffness and adhesions.

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Mallet Finger?

answer

•Dorsal avulsion fracture is attached to extensor tendon. •Frequently caused by a blow to the fingertip with flexion force. •Treatment: •Immobilize in slight extension for 6 to 8 weeks •No DIP flexion during this time •Can be pinned for stability •Patient education and compliance are keys to good results?

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Proximal Humerus

answer

• More common in the elderly resulting from falls • Greatest ROM increase is between 3-8 weeks • Return to normal function is between 3-4 months • Bony healing is typically from 6-8 weeks • Most are treated non-operatively 80% of the time • Most common mechanism of injury - Falling on an outstretched hand • Osteoporosis is a major contributing factor • More common in women • Non-Operative Treatment • Immobilization in a sling • ROM (most can be passively moved by week 3) • Progression of ROM is PROM --- AAROM--- AROM

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Movement for proximal humerus?

answer

• Mobilization • Prolonged shoulder immobilization can lead to "severe stiffness" (no fracture is the same; know the severity of it) • Move it when you can but no sooner (as early as possible) (if you move it before fracture is healed you can disrupt fracture) • "Successful treatment for all proximal humerus fractures depends on early mobility" (if you move it later you can wait too long and develop frozen shoulder and stiffness) • Teach/Educate family members to perform PROM (like with stroke - initially flaccid and become contracted; this could be prevented with PROM and educate movement of shoulder and scapula and stretching in order to prevent pain, independence, nail growth into hands)

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General Rehab Course Following Proximal Humeral Fracture?

answer

• First 2-3 weeks a shoulder immobilizer • ROM of the Elbow, Wrist and Hand • Codmans/Pendulum early • Retrograde massage — Axilla Region (armpit area) • D/C immobilizer in 2 to 3 weeks • Radiographic healing is typically present around 6 weeks.

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Shoulder Dislocations

answer

•Anterior dislocation - Most common >90% •Special Test - Apprehension Test (Crank test) •High incidence of recurrent dislocation due to instability

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Shoulder dislocation Treatment:

answer

•Immobilized in a sling •RTC strengthening - While keeping humerus close to body •Scapula stabilizer strengthening — Trapezius, Rhomboids, Serratus Anterior •Isometrics •Instruct patient to avoid high velocity external rotation movements. (because that's the motion that can cause dislocation)

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Humeral Head Fractures

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• More complicated • Fracture management can take 6 months to a year. • Operative/Surgical Treatment • Total Shoulder Replacement- Humeral head and glenoid socket • Hemiarthroplasty-Humeral head • Sometimes indicated for comminuted fractures • ORIF—Open Reduction Internal Fixation • Pins • Wires

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Humeral Shaft Fractures

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• Mechanism of Injury- Results from direct blow or indirect blow • Treatment: • Sarmiento Style splint if the fracture can be reduced with closed reduction. • Immobilize 1-2 weeks • Early ROM • PROM 2-6 weeks • AROM and stretching at 6 weeks

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Complication of Humeral Shaft Fractures:

answer

• Radial Nerve injury (wrist drop) -Wrist control splint • Spontaneous recovery of nerve • 90% will resolve in 3 to 4 months • Nonunion -- ORIF is required in more severe cases when closed reduction is not possible.

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Fractures for the distal humerus

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• Uncommon • Mostly young males • Usually high velocity injuries: MVA Treatment • Anatomical reduction • Immobilization in a cast 6-8 weeks • ROM of Digits ; Shoulder • After cast is removed: • Edema control • Pain Management • ROM-Flexion, Extension, Pronation, Supination

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Wrist Fractures

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• Distal Radius Fractures • One of the most common fractures in adults • Common in the elderly

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•Colles fracture?

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- Fracture is a dorsally displaced fracture within an inch of the distal radius. (strong man falling with open hand)

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Smith's -

answer

fracture is usually sustained with the wrist volarly flexed resulting in palmar displacement (girly lady falling on flicked wrist)

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Wrist fracture treatments?

answer

•During cast immobilization (can ask for cut to be lower to allow MP flexion) •Edema control (elevation, ice) •ROM Digits, Elbow, Shoulder •Tendon gliding (tips, fingers, and straight fist) and joint blocking (isolated joint AROM) •Check cast for the following: •Is it blocking MP Flexion? •Is it too tight and possibly compressing a nerve?

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Treatment of the Wrist Fracture after Cast Removal

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•Wrist cock up splint is sometimes indicated (to give additional support for transition of cast removal) •Wrist support brace •Pain Management •Massage •ROM - Flexion, Extension, Radial/Ulnar Deviation •Grip and Pinch Strength

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• Treatment of wrist fracture

answer

•Modalities: • Fluidotherapy (allows motion with head) • Ultrasound and E-Stim • Heat and stretch • Table top stretch • prayer/reverse prayer stretch • Cones and putty "making meatballs

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Carpal Tunnel Syndrome

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•A type of compression neuropathy (nerve damage) caused by compression and irritation of the median nerve in the wrist. The nerve is compressed within the carpal tunnel, a bony canal in the palm side of the wrist that provides passage for the median nerve to the hand. The irritation of the median nerve is specifically due to pressure from the transverse carpal ligament.

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Evaluation of Carpal Tunnel Syndrome

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•History/Occupational Profile •Pain Assessment •Sensory Assessment—Semmes Weinstein •Tinel's Test- Examiner taps the hand from fingertips to proximally to palm. Positive if client reports tingling or "electric shocks" •Phalens Test-Client holds wrists in flexed position for x 1 minute-Positive if client reports symptoms.

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Treatment of Carpal Tunnel Syndrome

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•Rest ; Activity Modification/Posture Evaluation •Wrist control splint in neutral to slight extension. 4 to 6 weeks—Wear at night as well as throughout the day •Tendon Gliding •Median N. Gliding

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Surgical management for CTS?

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carpal tunnel release

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Trigger Finger

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Also called stenosing tenosynovitis. Caused by "stenosis" or thickening at or around the A1 pulley. If there is swelling to this area, the tendon becomes locked in flexion and causes painful snapping as it pulls through the A1 pulley. Most commonly affected is the thumb.

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Trigger finger is associated with?

answer

Rheumatoid Arthritis Common in middle aged women Client's who use hand tools with hard/sharp edges

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2 treatments for trigger finger?

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Splinting • Hand based MCP Extension Splint with PIP and DIP Free • Silver Ring Splints for chronic triggering • Steroid Injection Surgical Management of Trigger Finger • Trigger Finger Release-Excision of the A1 Pulley--

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Lateral Epicondyle -

answer

•Commonly known as "tennis elbow" •Faulty backhand stroke •"Overuse syndrome" involving strain and inflammation •Main muscle - Extensor Carpi Radialis Brevis •Decreased blood flow to the area

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Lateral Epicondyle muscles involved?

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-Provides origin to wrist extensor muscles -provides attachment to the lateral collateral ligament -caused by many muscles inserting on a small surface area -main muscle-extensor carpi radialis brevis

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Lateral Epicondyle treatment?

answer

•Rest and Activity Modification •Wrist control splint to immobilize and rest wrist extensors for 2 to 3 weeks •Ice Massage 20 Minutes •Lateral Counterforce Brace •Soft Tissue Massage- Two fingers cross frictional--facilitates tissue extensibility and increases circulation. •Ultrasound—increases circulation •Stretching—Wrist flexors/extensors

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Purpose of Static Orthosis

answer

"Maintain a position to hold anatomical structures at the end of available range of motion, thus exerting a mobilizing effect on a joint"

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Wrist Cock up/Wrist Immobilization---static splint

answer

•Most frequently fabricated orthosis in the clinic •Allows functional use of hand/digits while immobilizing the wrist •Allows full MCP flexion and thumb mobility •Commercially available/Pre Fabricated •Soft material—More comfortable in some cases.

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Wrist cock up indicators:

answer

•Carpal Tunnel Syndrome ----(because of median nerve impingment) •Tennis Elbow - ----lateral flexors (most involved wrist extensors so it lets the wrist extensors rest) •Wrist Drop/Radial Nerve Injury ------ (puts radial nerve back into position) •Wrist Fracture after cast removal or in place of cast -----(additional support until they regain strength) •Tendinitis/Sprains -----(resting) •RA -----(resting the joints)

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Mobilization orthoses can achieve one of 4 possible goals:

answer

• Correction of deformities • Substitution for loss of muscle function • Provide controlled motion • Aid in wound healing

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Dynamic or Mobilization Orthotics

answer

• Have movable parts • Designed to apply force across joints. • Uses constant or adjustable tension or both • Therapist must first understand the person's injury, surgical procedures and physicians protocol for treatment. • If you are not sure, seek clarification • How do you find out this information?

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Goals of Dynamic Orthotics

answer

•Substitute for loss of muscle function •Prevent overstretching on non functioning muscles •Prevent joint deformity •------Example-Radial Nerve Injury •Radial Palsy Orthotic—Allows client to make a full fist. •Correct deformities caused by muscle tendon tightness or joint contractures •Limited PROM due to prolonged immobilization, trauma, or scar formation. •Slow prolonged stretch at end range will give you best results •Composite Finger Flexion Orthotic •Maintain active or passive ROM •Provides controlled motion after tendon repair or joint arthroplasty

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•Flexor tendon repairs

answer

•Moving the tendons increases the flow of nutrient rich synovial fluid to enhance healing. •Tendons allowed early mobilization have demonstrated increased tensile strength. •Reduces adhesion formation •Protocol starts after surgery not on first day they are evaluated

question

Flexor Tendon Splint

answer

•Attach nail hooks on clients fingernails using superglue •Use Dorsal Blocking Orthotic •35 to 45 degrees of wrist flexion •Elastic provide enough tension to flex fingers while allowing extension of the digits •Use a heat gun to create a bubble over radial styloid and distal ulna to avoid pressure

question

Biomechanics of Dynamic Orthotics

answer

•Use caution when applying force to an injured joint until pain and inflammation are under control •Soft tissue structures respond to prolonged stress by changing or reforming "creep" •Excessive force will result in increased pain and inflammation/edema

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Features of a Mobilization Orthotics

answer

• Use of outriggers • Can use wire rods • Or make an outrigger with thermoplastic material • Must use bonding agent to attach thermoplastic material together. • Application of force- • Using rubber bands • Elastic string

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Common Materials for Dynamic Orthotics

answer

• Splinting material • Finger Loops • Nail hooks • Super glue and Bonding solvent • String • Outrigger • Rubber Bands • Safety Pins • Pliers/Wire Cutters

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Composite Finger Flexion Orthotic with Static Progressive Tension

answer

•Helps to increase finger flexion •Provides a low-load prolonged stress to all of the joints. •Uses static progressive tension to allow the person to control the amount of force required to maintain maximal stretch.

question

Precautions with Dynamic Splints:

answer

-Signs of tissue damage: •Redness •Swelling and heat (with no infection) •Check orthotics periodically to look for these signs. Ways to relieve force application: •Padding •Cutting holes to relieve pressure •Protect rough edges from skin. Watch for: •Bony Prominences (lateral sides of index, small fingers, joints, ulnar head) •Impaired sensibility •Superficial nerves •Venous/lymphatic return •Natural arches of hand (proximal, transverse and distal creases of hand) •Bony Prominences (lateral sides of index, small fingers, joints, ulnar head) •Impaired sensibility •Superficial nerves •Venous/lymphatic return •Natural arches of hand (proximal, transverse and distal creases of hand)

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3 phases of wound healing?

answer

Inflammation phase Proliferation phase Maturation/Remodeling phase

question

Inflammation phase =

answer

- initial response to tissue injury - control blood loss and clean up the wounded -vasoconstriction -swelling -vasodilate or open - discoloration around the wound - continues until the area is free of bacteria -acute inflammatory phase usually lasts 2 days to 2 weeks.

question

Proliferation phase =

answer

-clean -Granulation -Angiogenesis -Epithelialization -. few weeks to complete.

question

Maturation/Remodeling phase = T

answer

- newly epithelialized wounds -maturation phase of wound healing. -collagen, is known as scar tissue. It is not as elastic or cosmetically appealing as skin, but serves as an adequate cover for the wound.

question

how wounds are evaluated

answer

-The location and size of the wound -Condition of the periwound skin and wound margins -Wound characteristics such as granulation tissue, hypergranulation tissue, debris or dead tissue - Amount of wound exudate

question

OT interventions for wound care?

answer

-Wound debridement -proper wound cleansing -Maintenance of proper moisture balance in and around the wound

question

Stage I pressure ulcer =

answer

This is the most superficial type of ulcer. The skin remains intact during this stage, but may hurt or itch. It may also feel warm, spongy, or hard. Common characteristics include: - Non-blanchable erythema of intact skin - Edema - Warmth over bony prominence - When an eschar is present, accurate staging isn't possible

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Stage II pressure ulcer =

answer

With this ulcer, some of the outer suface of the skin (epidermis) or the deeper layer of skin (dermis) is damaged, leading to skin loss. Ulcer looks like a wound or a blister. Common characteristics include: • Partial thickness skin loss involving epidermis, dermis or both o Example = abrasion, blister, or shallow crater

question

Stage III pressure ulcer

answer

- skin loss occurs throughout the entire thickness of the skin. Here you will find the underlying tissue is also damaged, but the underlying bone and muscle are not. It appears like a deep cavity wound. Common characteristics include: - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to (but not through) underlying fascia - Deep crater with or without undermining

question

Stage IV pressure ulcer

answer

- most sever type. Here the skin is severely damaged, and the surrounding tissue begins to die. With this ulcer the underlying muscles, bone, or joints may also be damaged. People with these ulcers have a high risk of getting a life-threatning infection. Common characteristics include: - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle/bone/supporting structures (tendons or joint capsule)

question

Superficial partial-thickness burn =

answer

-first and second degree burns - damages the epidermis - red or bright pink, is blistered, soft, and wet. -sensation is still intact. -re-epithelialize spontaneously in 2 weeks -no skin grafting

question

Deep partial thickness burn =

answer

-deep second-degree burn. -epidermis and a deeper portion of the dermis -mottled red or waxy white, soft, wet, and elastic. -Sensation may or may not be there -re-epithelization may occur in 3-6 weeks -skin grafting may still happen to expedite wound -may become full thickness burn

question

Full thickness burn =

answer

- third-degree burn -epidermis and the entire dermis, including hair follicles, nerve endings, and the epithelia bed. -Sebaceous glands may be involved if the burn extends to the subcutaneous fat layer. -Sensation is gone because nerve endings have been destroyed. -white or tan, waxy, dry or leathery, and rigid. -Skin grafting is necessary at this stage due to spontaneous re-epithelialization being impossible.

question

Full thickness burn with subdermal injury =

answer

- fourth-degree burn which involves deep tissue damage to fat, muscle, or possibly bone. - electrical burn. - extensive debridement of necrotic tissue, -skin grafting. -If the burns are severe and the damage is extensive then amputation my be required.

question

Please describe the 2 ways to determine the percentage of body surface burned.

answer

rule of nines Lund-Browder chart.

question

different types of OT interventions used to treat burns

answer

- Dressing =. - Positioning - Orthoses = - Exercise = - Functional Hand Use = - Scar Management .

question

Ultrasound for Lateral Epicondylitis

answer

•Treatment modality that utilizes high or low frequency sound waves to heat deep tissues •Indications- Tight muscles, muscles spasms, chronic tendinitis, pain, sensitive scars, thick scars, trigger points, joint stiffness, tissue healing. •Common diagnosis treated with Ultrasound-Lateral epicondylitis, Adhesive Capsulitis, tendinitis

question

Ultrasound methods?

answer

•Sound waves are administered through a sound head. •Must use "coupling medium" gel, cream, water- helps to eliminate air between U/S head and skin 1 MHZ- Used for deeper tissues (65 mm) 3MHZ- Used for superficial tissues (35 mm)

question

Ultrasound ERA (Effective Radiating Area)? -

answer

Usually smaller than the ultrasound head •Keep head moving in circular movement covering the area. •Do not keep in one spot •Treatment time- 5 to 10 minutes

question

Ultrasound benefits?

answer

•Improves circulation •Decreases tightness of soft tissues •Increases collagen extensibility •Decreases joint stiffness •Decreases pain

question

Ultrasound Contraindications & Precautions

answer

•Poor sensation •Infections-Could cause the infection to spread •Superficial metal implants •Avoid plastics used in replacement surgery •Pacemakers •Pregnant women •Cancer-Could facilitate metastasis Thromboembolic Disease- Increase risk of blood clot dislodging. •Laminectomy- U/S should not be used over the spine after a laminectomy. Could injure spinal cord

question

Phonophoresis

answer

•The use of ultrasound to assist topically applied medications to move through the skin to underlying tissues. •Common medications include: hydrocortisone, dexamethason, lidocaine. •Used to reduce pain and inflammation in the treatment of tendonitis.

question

Electrical Stimulation

answer

•FES (Functional Electrical Stimulation) •Interferential •TENS (transcutaneous electrical nerve stimulation) •Iontophoresis

question

Functional Electrical Stimulation

answer

•Indications: •Poor muscle contraction, weak muscle, adherent tendon muscle unit

question

Functional electronic stimulation?

answer

•Electrical impulses are delivered through electrodes •Electrodes placed on the motor point and peripheral nerve proximal to the muscle. •Patient asked to voluntarily contract muscle being stimulated Effects: •Facilitates and enhances muscle contraction, tendon gliding, and strengthening

question

TENS (Transcutaneous Electrical Nerve Stimulation)

answer

•Indications- Pain, nerve irritability, sensitive scar •Method- TENS electrodes are applied over peripheral nerve proximal to the painful area. •Effects- Alters sensory input and decreases pain Contraindications and Precautions •Sensitive skin •Poor patient tolerance •Poor sensation

question

Iontophoresis

answer

•Induction of topically applied ions into the tissue by application of a low voltage direct current. •Common medication- Dexamethasone •Used to treat pain and inflammation.

question

Fluidotherapy

answer

•Fluidotherapy delivers heat via an air-circulated medium of dry particles. •Indications- Stiff hand, hypersensitivity (desensitization) Method- •Patient places hand into fluidotherapy machine and is instructed to perform ROM exercises during treatment. •Temperature between 102 to 112 degrees F •Treatment time- 20 to 30 minutes

question

Paraffin

answer

•Paraffin wax bath used to provide head to hands. •Indications- Stiff/Painful Joints •Method- Client's hand is dipped in the paraffin wax 8 to 10 times and then placed into a plastic bag or wrapped in aluminum foil. •Cover hand with towel to maintain heat •Heat will last approximately 15 to 20 minutes Precautions and Contraindications •Open wounds •Decreased sensation •Recently healed burns

question

Hot Packs

answer

•Indications- Pain, tight soft tissues •Method- Hot packs are kept in a hydroculator and then removed, placed in a hot pack cover, and then applied to area along with several layers of towels (6-8) or 8-10 if client is laying on hot pack

question

Hot pack effects?

answer

•Increases "pliability/flexibility" of the soft tissues in preparation for exercise •Improves ROM •Reduces strain on the soft tissues •Increases circulation •Decreases pain Contraindications and Precautions: •Infection •Poor sensation • Area suspected of tumor •Acute inflamation •Client who can't communicate thoughts •Fragile skin

question

Cold packs?

answer

Cold Packs •Indications: Edema, Inflammation, Pain •Method: Ice pack/cold pack is applied to swollen area. Most effective in the first 36 to 72 hours post injury/surgery. •Effects- •Decreases edema •Decreases inflammation and pain

question

Cold packs contraindications?

answer

•Nerve Injury •Cold intolerance •Poor sensation •Poor vascularity following artery repair •Use care when applying over wound •Raynauds Phenomenon- condition affecting small blood vessels in the extremities. •Client who is unable to verbalize thoughts

question

Contrast Bath

answer

•Combine the use of hot and cold •Client submerges hand into tubs of cold water and hot water. •Effect- causes vasoconstriction and vasodilatation. •Increases circulation •Decreases pain and edema

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