Evaluation and Assessment – Role of the OT for Colles Fractures – Flashcards
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Description of Colles Fracture
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-distal forearm or wrist fractures -results from impact on outstretched hand -most common type of wrist fracture -complete fracture of distal radius -DDD: dorsal displacement of distal fragment (up toward ceiling) -extra-articular, minimally displaced -often seen in post-menopausal women or with osteoporosis
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Healing Time for Colles Fracture
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-extra-articular, stable fractures are generally treated with closed reduction and casting for 3-8 weeks -takes about 6 weeks to heal (typically) -usually seen in therapy at 6 weeks post injury -for fracture, may see someone for up to 18 mos. -sensory complaints are monitored during recovery -unstable fractures may be treated with pinning (k-wires or external fixation) -complication risks are high: therefore ->long treatment: 12-18 months -depending on complexity of injury, recovery can span months or as long as a year.
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Initial interventions for Colles Fracture
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(physician makes this decision) -Casting -Closed reduction: at urgent care - arm up -external apparatus -Open Reduction/Internal Fixation (ORIF) - surgery, plates -External Fixation - bars coming out of the wrist
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Assessment Questions for Colles Fracture
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First - When was the fracture? Was there surgery? -Is there a disruption of radial length, inclination or tilt involved? -Is TFCC (Triangular Fibrocartilage complex) injured? -would show on MRI -pain w/supination, pronation, radial deviation, ulnar deviation -know clinical implications of each condition. -use observation -located between ulna and carpals (lunate & triquetrum) -Are AROM parameters restricted in any way? -When will cast or hardware be removed? -Are there soft tissue considerations? tendon? nerve? -Does the client have pre-existing thumb or wrist arthritis?
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TFCC
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Triangular Fibrocartilage Complex -located between ulna and carpals The triangle involves 3 parts 1. TFC - triangular fibrocartilage discuss 2. RULs - radioulnar ligaments 3. UCLs - ulnocarpal ligaments affects: ulnar side of wrist function: makes it possible for wrist to move in 6 different directions (pronation, supination, radial deviation, ulnar deviation, flexion, extension)
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Components of Evaluation for Colles Fracture
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1. Medical History 2. Medication 3. Patient Profile 4. Occupation 5. Roles, Routines, Habits 6. Possible COPM 7. Mobility 8. Observations 9. Palpation 10. DASH 11. Should AROM (at risk for frozen shoulder) 12. Pain 13. Posture of shoulder, elbow, hand, digits 14. Edema 15. Tendon gliding 16. Distal palmar crease 17. Capsular Tightness 18. EPL integrity 19. MMT (manual muscle testing)
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Description of the (1) Medical History portion of the evaluation for Colles fracture
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pre-existing conditions? hospital visits?
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Description of the (2) Medication portion of the evaluation for Colles fracture
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tells you about current health issues as well as contraindications
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Description of the (3) Patient Profile portion of the evaluation for Colles fracture
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PEO model P - person: for every role, what s their routine and habit? (roles, routines and habits (5) can be own part of evaluation) E - environment O - (4) occupation (can be its own part of the evaluation) examples: driving, studying, cooking, shopping, grooming, sleeping, showering, pet care, & activities that make them up
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Description of the (6) COPM portion of the evaluation for Colles fracture
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COPM is a standardized tool, but is typically done modified -Typically ask: What are your top 5 problems?
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Description of the (7) Mobility portion of the evaluation for Colles fracture
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driving, getting out of bed, assistive device? need to walk a dog?
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Description of the (9) Palpation portion of the evaluation for Colles fracture
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palpate around wrist, at thumb -> gently because it will hurt
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Description of the (10) DASH portion of the evaluation for Colles fracture
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1 page assessment questions: on level of 1-5, how hard is it for you to...
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Description of the (11) Shoulder AROM portion of the evaluation for Colles fracture
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at risk for frozen shoulder -shoulder flexion is 0-180, less concerned with extension -abduction is 0-180 -internal rotation is 0-70 -external rotation is 0-90 -also consider the plane of scaption (middle plane)
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Description of the (12) Pain Scales portion of the evaluation for Colles fracture
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1. the numeric pain rating scale is the most common for this patient 2. Randall - Chronic pain (similar to numeric, 0-10 evens, pt. assigns descriptor words for numbers) 3. Faces 4. visual analogue (visual pain scale) 5. body schematic/body diagram (The Pain Drawing) 6. McGill Questionnaire (similar to pain words) 7. FLACC pain assessment tool 8. Pain words
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Description of the (13) Posture portion of the evaluation for Colles fracture
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Posture of shoulder, elbow, hand, digits -can be determined through visual assessment -look for: self-soothing, tilt, shaking, guarding
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Description of the (14) Edema portion of the evaluation for Colles fracture
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3 assessment types: 1. visual 2. circumferential 3. volumetric
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3 types of visual (1) assessments for Edema
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1. skin assessment -look for pitting edema (push in on skin, stays) -fibrotic edema (hard to lift skin) -buoyancy (does skin drop back down when you lift it up) -color (red, irritated, rash, tear, bruise, scrape, vascularity) 2. symmetrical webspace -compare when hands held in fists 3. arches on hands similar, concave
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description of circumferential (2) assessment for Edema
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-measure distance to distal or proximal wrist crease, -use same crease every time -compare both extremities with landmarks/measuring tape
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description of volumetric (3) assessment for Edema
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"Gold Standard" - standardized -compare both hands -measure in milliliters -dowel goes between web space of digits 3 & 4 -make sure hand goes in in same position on same surface -with same water temperature -go slowly to prevent spill & gas bubbles
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step by step procedure for volumetric displacement for edema assessment
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-need: unit, beaker, graduated cylinder, and water 1. fill volumeter and allow to empty into a large beaker until the water reaches spout level. The beaker is then emptied and dried. 2. Pt immerses hand in unit/plastic volumeter resting digits 3&4 over the dowel gently (without pressure on dowel). The palm faces the client. Avoid contact of arm with the sides of the unit/container. 3. The hand remains still until water no longer drips into beaker. 4. The water is poured from beaker to graduated cylinder. Cylinder is placed on level surface and measured (in mls) -Test bilaterally and compare to uninjured hand. -Results are affected by pressure, gas bubbles, temperature, and hand position
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Description of the (15) Tendon Gliding portion of the evaluation for Colles fracture
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4 fisting patterns 1. hook grasp 2. table top 3. straight fist 4. composite (full) fist
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Description of the (16) Distal Palmar Crease portion of the evaluation for Colles fracture
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measure between crease & digit tip to test stiffness
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Description of the (17) Capsular Tightness portion of the evaluation for Colles fracture
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Can assess during ROM
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Description of the (18) EPL integrity portion of the evaluation for Colles fracture
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(Extensor Pollicis Longus) -located in extensor compartment 3 -Lister's tubercle is the pulley -can rupture under cast -put pt. on hold if can't raise arm to ceiling
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Description of the (19) MMT portion of the evaluation for Colles fracture
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(Manual Muscle Testing) -will not do as much in outpatient, will do more in acute -do more with grip & pinch strength
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Goniometry assessment of joints for Colles fracture
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1. shoulder flexion 2. shoulder abduction 3. shoulder internal rotation 4. shoulder external rotation 5. scaption 6. elbow flexion 7. elbow extension 8. wrist radial deviation 9. wrist ulnar deviation 10. wrist supination 11. wrist pronation 12. DIP flexion/extension 13. PIP flexion/extension 14. MCP flexion/extension
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Description of the Prehension Assessments for Colles fracture
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Standardized: Purdue (white board w/ washer, peg, cap) - timed Non-standardized: Handwriting (how fast can you write this sentence - clinical observation), zip, button, earring
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3 types of pinch
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(in order of assessment) tip-tri-lat 1. tip/tip to tip/two-point 2. tripod/three finger tip/three point/three jaw chuck 3. lateral/key -to standardize, put pt at 90 elbow -three trials each type -measured in lbs. RGE: rapid grip exchange
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Types of Fine Motor Assessments for Colles fracture
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Standardized: Moberg (tupperware with 12 items) -timed test -both hands separately -pick up items Nine Hole -better for research vs Purdue which is better in clinic -valid, reliable -fast -timed (in seconds) -examines dexterity -non dominant hand first -practice trial Purdue -better for clinic vs. Nine Hole which is better in research -tell pt put 10 pegs in 1, 2, or 3 rows -back and forth -add a hat (stack pieces) -timed R vs L (this is similar to Minnesota) -COMPLICATED Grooved Peg Board -harder to manipulate -still simple concept
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Moberg FMA/Prehension for Colles Fracture
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-tupperware with 12 items -timed test -both hands separately -pick up items: wingnut, screw, key, nail, large nut, nickle, dime, washer, safety pin, small hex nut, small square nut -tests Median N. or combined Median N. + Ulnar N. -compare affected & unaffected hand -note digits client uses for prehension
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Nine Hole FMA for Colles Fracture
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-better for research vs Purdue which is better in clinic -valid, reliable -fast -timed (in seconds) -examines dexterity -non dominant hand first -practice trial
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Purdue FMA for Colles Fracture
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-better for clinic vs. Nine Hole which is better in research -tell pt put 10 pegs in 1, 2, or 3 rows -back and forth -add a hat (stack pieces) -timed R vs L (this is similar to Minnesota) -COMPLICATED
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Grooved Peg Board FMA for Colles Fracture
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-harder to manipulate -still simple concept
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Jebsen-Taylor Hand Function Test
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Standardized: proper lighting, seating, table height -timed (takes 15-20 mins) -valid, reliable -assesses effective use of hands in every day tasks -age 5+ to older adults -client begins with non-dominant? hand first then follows with dominant hand -tin cans in big red bag w/checkers, paper clips -consists of 7 parts/subsets 1.writing 2. page turning 3. lifting small objects 4. lifting lightweight objects 5. lifting large, heavy objects 6. simulated feeding 7. stacking
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7 Parts/Subsets of Jebsen-Taylor Hand Function Test
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1.writing 2. page turning 3. lifting small objects 4. lifting lightweight objects 5. lifting large, heavy objects 6. simulated feeding 7. stacking
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5 Components of Fine Motor
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1. Manipulation (4) -prehension -drawing -tapping -handwriting 2. Haptic Perception (5) -temperature -size -texture -weight -shape 3. Drawing (4 stages) -scribbling -combine -aggregate -pictorial 4. Handwriting 5. Tapping Development: -sequential coloring -channeling activities -tracing activities -copying activities
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4 categories of Fine Motor: Manipulation
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-prehension -drawing -tapping -handwriting
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5 categories of Fine Motor: Haptic Perception
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-temperature -size -texture -weight -shape
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4 stages of Fine Motor: Drawing
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-scribbling -combine -aggregate -pictorial
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4 Fine Motor Development Activities
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-sequential coloring -channeling activities -tracing activities -copying activities
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Types of Gross Motor Assessments for Colles fracture
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Standardized: Minnesota Dexterity Test Non-standardized: take off jacket
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Minnesota Dexterity Test GMA for Colles Fracture
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AKA Minnesota Rate of Manipulation -rapid eye hand coordination -placing or turning -R vs L timed test -make red-black pattern to add cognition component
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Types of Vascular Assessments for Colles fracture
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-capillary refill -Allen's test
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Capillary Refill Vascular Assessment for Colles Fracture
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-measuring just one digit, more localized, more distal -place pressure on distal portion of volar digit, over fingernail of the digit, or hypothenar area until it turns white. Capillary refill time is the number of seconds it takes for the color to return to normal after the pressure is released. Normal capillary refill time is less than 2 (to 3) seconds and time can be compared with the same digit on the opposite hand -Doppler study - shows a more advanced technical diagnostic for capillary refill
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Allen's Test Vascular Assessment for Colles Fracture
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-more global, proximal compared to Capillary Refill Test 1. Place firm pressure over the radial and ulnar arteries of the wrist. 2. Instruct/Ask client/patient to make a tight first and then open/close the digits/hand repeatedly until the palm turns white 3. client is instructed to relax the digits in partially opened position 4. release pressure from radial side (then ulnar) allowing blood flow - record time for color to return to normal 5. repeat process on ulnar side of the wrist (in reverse order) 6. normal response is 5 seconds or less 7. compare to opposite hand
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Types of Sensation Assessments for Colles fracture
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-Semmes-Weinstein Monofilament -2 point discrimination
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Semmes-Weinstein Sensation Assessment for Colles Fracture
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-"Gold Standard" for sensory testing -Standardized -used in outpatient for orthopedic problems Procedure: -filaments range in size from 1.65 to 6,65 -vision is occluded -start with 2.83 and progress higher -start with volar surface of hand before dorsal -start distal to proximal -do 3 trials -two of three (2 of 3) is correct response -apply pressure for 1.5 seconds until monofilament bends, release and repeat -if can't feel, travel proximally to determine where sensation can occur -testing Ulnar N, Median N, and Radial NN
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Semmes-Weinstein Sensation Assessment Documentation
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-Use color coding and descriptive terms 1. filament: (1.65 or) 2.36 - 2.83, Color: Green, Results: Normal Light Touch, Impairments: None 2. filament: 3.22 - 3.61, Color: Blue, Results: Diminished Light Touch, Impairments: Slight reduction in sensitivity 3. filament: 3.83 (or 3.84) - 4.31, Color: Purple, Results: Diminished Protective Sensation, Impairments: reduced stereognosis, temperature 4. filament: (4.51 or) 4.56 - 6.65, Color: Red, Results: Loss of Protective Sensation, Impairments: Reduced Deep pressure 5. filament: 6.65, Color: Red-lined, Results: Deep Pressure sensation/unresponsive (only have to test this level ONE time, if they can't feel it, they can't feel it)
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2 Point (crude) Discrimination Sensation Assessment for Colles Fracture
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-non-standardized -Used more for neuro patient 1-5 mm: normal 6-11 mm: fair 11-15 mm: poor 1 point perceived: protective -we're evaluating IF they can feel and....What they can feel
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Hand Dynanometer - Grip strength test for Colles Fracture
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-Handle position (standard) set at 2 -test 3 times -measured in lbs. (read inside circle scores) -use RGE: rapid grip exchange to assess for sincere effort (R, L, R, L, R, L - want consistent # results) -expect to see bell curve (example test 1: 60, test 2: 65, test 3: 60) -dial with strength score faces therapist -normals: women = 60, men = 90 (or equal to other arm if unilateral injury -test legitimacy (score with elbow extended should be lower number than with elbow at 90 degrees) - -
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Complicating Factors of Colles Fracture
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-external fixation (could have exudate/puss with multi-colors, foul odor, or variety of thickness; increased pain, decreased motion, increased infection) -pin care -infection -radial shortening (complication from infection) -TFCC injury: Triangular cartilage (main major stabilizing ligament of wrist) - if snaps, will have to go back to physician -Carpal tunnel syndrome (impingement - backed up fluid will compress median N.) -CRPS "complex regional pain syndrome" -Post-traumatic arthritis -Radiocarpal arthrosis (pain with wrist flexion/extension) -DRUJ "distal radioulnar joint" arthrosis (pain with forearm rotation) -scar (flat, raised, hypo-pigmented, hyperpigmented) -EPL (extensor pollicis longus tendon) rupture over Lister's tubercle of radius -edema
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Provocative Tests for Colles Fracture
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Try to provoke pain for information -Phalen's Test -Reverse Phalen's Test -Froment's test -Wrist drop/Radial N palsy -Finklestein -Cozen's Test/Mill's Test -Glide Test -Tinel's Test -Neer's Test -Flick Test -Empty can test -Grind test
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Provocative tests for Nerves (for Colles Fracture)
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-Phalen's Test -Reverese Phalen's Test -Froment's Test -Wrist drop -Tinel's Test
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Provocative tests for Tendons (for Colles Fracture)
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-Finklestein -Cozen's Test or Mill's Test -Neer's Test -Empty Can Test
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Clinical Observations for Colles Fracture
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-Guarding -self soothing -Flick test (shake it out)
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Phalen's Test
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Provocative test for (Median or Ulnar) nerve -put dorsum of hands together -may have Positive Median N or Positive Ulnar N.
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Reverse Phalen's Test
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Provocative test for (Median or Ulnar) nerve -put palms of hands together -may have Positive Median N or Positive Ulnar N
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Froment's Test
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Provocative test for (Ulnar) nerve -pt. grabs paper, if loses due to hyperextension at IP jt, has Positive Froment's test -Ulnar nerve in adductor pollicis
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Wrist drop Test
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Provocative test for (Radial) nerve -Radial Nerve Palsy -Radial N innervates wrist extensors, if wrist drops when trying to extend wrist, (or cannot extend wrist at all) there is a Radial N. issue
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Tinel's test
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Provocative test for (Median) nerve? -tests for Carpal Tunnel Syndrome -tap on nerve in palm at carpals
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Finklestein
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Provocative test for (thumb) tendon -put thumb in palm, make fist, ulnarly deviate wrist -if no tenderness - negative Finklestein -DeQuervains - tendonitis of the thumb - sustained pinch -Dorsal Compartment 1: abd pollicis longus & ext poll brev
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Cozen's Test
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Provocative test for (wrist) tendon aka Mill's Test -wrist flex, radially deviate, resist middle finger extension -tests for lateral epicondylitis/Tennis elbow
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Mill's Test
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Provocative test for (wrist) tendon aka Cozen's Test -put arm out, flex wrist, radially deviate, extend fingers, resist middle finger extension (since radial tunnel goes through supinator m.) -tests for lateral epicondylitis/Tennis elbow -radial tunnel goes through supinator
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Glide test
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Provocative test for (finger) tendon -test for Trigger Finger -tendon stuck at A1 pulley -A2/A4 are most important because they biomechanically hold onto digit -there are 5 annular pulleys total
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Neer's Test
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Provocative test for (shoulder) tendon -tendonitis of shoulder/shoulder impingement -raise arm up through flexion with humerus interally rotated and forearm pronated
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Empty Can Test
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Provocative test for (shoulder) tendon -tendonitis of shoulder -dumb out fake can of soda
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Grind Test
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Provocative test for (thumb) joint -take thumb and grind at CMC joint to test for arthritis and synovitis
