All Protocols for UE – Flashcards
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*Conservative mgmt of PIP collateral lig strain
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immobilize @ 0 or slight flex x 1 wk until pain subside buddy strap with immediate AROM hourly ext gutter splint at night early DIP jt motion to prevent ORL tightness flexion contr. common, can use dyn splint @6-8 wks:
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*Surgical mgmt of PIP coll. lig. jt tear
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3-4 weeks immoblized in hand based splint w/adj finger AROM at 3-4 weeks with buddy straps:
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Dorsal PIP dislocation-conservative mgmt
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REDUCED=Figure 8 x 3 wks, AROM immed pain allows STABLE=DBS @20-30 w/protected flexion AROM- @ 3 weeks DBS d/c and AROM ext begins- @ 6wks PROM, splinting, strengthening: UNSTABLE=DBS @ 20-30 (no AROM)- @ 3wks if stable AROM w/splint removed- @ 6wks PROM if PIPJ contracture and ext splinting as needed
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Dorsal PIP dislocation- surgical mgmt Volar plate arthoplasty
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@ 10-14 days kwire removed & placed in DBS @30 w/ A/PROM into flex in splint @4wks AROM out of splint @5wks passive ext, dyn ext splint @6wks strengthening:
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Dorsal PIP dislocation-Fixation- fixator thru middle/prox phalanx
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3-5 days AROM 6 wks fixator removed- unrestricted A/PROM 8 wks strengthening
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Volar PIP dislocation- conservative mgmt
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Central slip tear not complete= immobilize in PIP ext gutter splint w/DIP free x 6weeks w/ IPJ A/PROM 6wks AROM 7wks PROM + dynamic splinting Central slip avulsed= 6 wks PIP ext splint w/DIP free OR surgical repair required
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Volar PIP dislocation- surgical mgmt
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K-wire x 2-3 weeks PIP ext splint for additional 4 weeks 6 weeks AROM PIPJ 8 weeks PROM PIPJ, dyn splinting
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MPJ ligament mgmt- conservative
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Immobilize w/Hand based splint w/adj finger MPJ @ 30-50 degrees, @ 3 weeks transition to buddy straps w/AROM
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MPJ ligament mgmt- surgical
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Immobilize w/Hand based splint w/adj finger MPJ @ 30-50 degrees x 3 weeks (not more flex because this places the ligament on its full stretch since its tight in flexion), @ 3 weeks transition to buddy straps w/AROM for 3 more weeks, 6wks PROM/dyn splint to increase MP flex, 8wks strengthening
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Sagittal band responsible for
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Primary lateral stabilizer of EDC @ MCP, limits EDC excursion, prevents bowstringing/subluxation
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Sagittal band mgmt- conservative
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Buddy strap x 3 weeks w/AROM OR hand based splint with MCPJ extended
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Sagittal band mgmt- surgical
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Hand based splint w/MCPJ full extension, AROM @ 3-4 weeks
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MPJ dislocation management- due to hyperextension injury typically
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Conservative: Dorsal extension block splint @ 30-40 x 3-4 wks- in few days AROM in splint, 3wks gentle flexion PROM, 6wks prog. strength, Surgical: DBS @30-40 for 4-6 weeks, 2 weeks flexion in splint, 3 weeks gentle PROM flexion, 6 wks strength
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Thumb ligament injury txmt conservative (UCL most common - skier's or gamekeeper's thumb)
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Conservative: immobilize in thumb spica 3-6 weeks w/IP free- DIPJ ROM immediately, 4 weeks AROM of MPJ, 5 weeks PROM of MPJ, 6 weeks dyn splinting, after 8 weeks can begin strength/tip pinch,
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Thumb ligament injury txmt: Surgical:
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Surgical: Casted then spica w/IP free 4-6 weeks, 4-6 weeks AROM of MPJ, 6-8 weeks PROM/dyn splint, 8-10 weeks strengthening including pinches, mild discomfort x 3-4 months after repair
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Thumb dislocation txmt
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Simple- thumb spica with MPJ at 20-30 x 3 weeks, @ 3 weeks AROM of entire thumb *focus on strength/function and not max flexion, Complex- they excise FPL tendon & repair collaterals, Dorsal blocking thumb spica splint @ 30 x 2 weeks, @ 2wks protected ext, @ 6-8 wks gentle PROM
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DISI management
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NON SURGICAL Casted, perc pins needed- total 6 weeks, Avoid wrist loading, wt bearing, strong grasp and extremes of wrist ROM/Deviation
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DISI surgical mgmt
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acute vs chronic Acute: debridement, lig repair, capsulodesis, Chronic: ligament reconstruction with tendon graft, partial fusions (SL or STT OR SC), Casted 4-6 wks, @ 4 wks protected wrist AROM/tenodesis, 6 wks gentle PROM & grip stgth, @12 wks full resistance + sports, * forceful passive stretch CI to avoid overstretch 2 repair
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LT ligament tear
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Conservative: cast/splint 6-8 wks, 6 wks AROM wrist, 8 wks gentle strength, Surgical: cast 6-8 wks, additional 4 weeks splint, 8 wks AROM, @ 10-12 gentle resistive EVEN SURGICAL REPAIR IS VERY CONSERVATIVE- DR HAHN SAYS THESE OFTEN FAIL
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OVERALL TFCC treatment and conservative mgmt
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6 weeks immobilized in LAS- all neutral, gentle painfree AROM out of splint, 6 weeks gentle A/PROM as tolerated, 8 weeks gentle strengthening if pain down- neutral wrist and FA ONLY, 10-12 weeks weight bearing , wrist deviation, FA rotation strengthening
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TFCC txmt and surgical mgmt Central debridement:
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immobilize 1-2 wks in cock up splint w/AROM, 4-6wks AAROM/PROM + gentle strength at neutral, progress others as tolerated
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TFCC txmt and surgical mgmt: Peripheral repair
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LAS or Muenster splint 6-8 weeks in neutral, 3-4 wks gentle wrist AROM, 6-8 wks FA AROM-still in splint + 2-4 weeks, 8 weeks gentle PROM, 10-12 weeks gentle strength in neutral, 12+ weeks strength in rotation and wt bearing
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DeQuervain's Tenosynovitis conservative
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txmt: thumb spica 3-6 wks, rest, modalities, steroids inj.
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DeQuervain's Tenosynovitis surgical:
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TSS cast x 1 week then AROM, 2 weeks gentle strength
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Intersection syndrome txmt:
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TSS 1-2 weeks, 1-2 weeks A/PROM, 5-6 weeks gentle strength
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Entire Flexor tendon Immobilization protocol:
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DBS:wrist 10-30, MP 40-60, IP 0 0-3/4 WEEKS: Early stage: wound care, mobility of elbow/shoulder, passive flexion in therapy only 3/4 - 5/6 WEEKS: Intermediate stage: Splint to neutral, remove splint hourly for exercises, Passive flex/ext of digits w/wrist at 10 extension Active and passive tendosis Active flexion of all types of fist- GENTLY! Assess tendon gliding after several days of protocol for tendon gliding- TAM vs TPM- if >50 degrees move to late stage (=adhesions). if <50 continue this phase until 6 weeks post op 5/6 WEEKS: D/C DBS- may use resting pan for flexor tightness in comfortable position-serially straighten Gentle blocking exercises (not to small finger), dont resist FDS with FDP blocking After 1 week of gentle blocking, start lite resistance- delay if tendon gliding is good
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Kleinart: flexor tendon protocol -ECPM
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0-4 weeks to 6 weeks Active IP ext in splint with rubberband flexion, Exercises: 20 per hour 4-6 weeks, Remove splint for wrist only motion at 4 weeks, Gentle active flexion of fingers - early if adhesions, Exercises: 20 per hour 6 weeks DC DBS, Begin differential tendon gliding exercises ie blocking, Exercises: 20 per hour 6-8 weeks Begin gentle resistance, Exercises: 20 per hour
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Washington/ Chow ECPM
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Washington Splint position: DBS w/ wrist 30 flexion, MP 35-40, IP full ext Safety pin to palmar strap @ DPC and on FA strap- nylon line from injured digits under saftey pin @ DPC w/2 RBs- one RB is cut (=3 strands). Washington Exercises: 0-3 weeks DBS adjusted to neutral Fist to DPC can be attempted in RB traction Washington Exercises: 4-5 weeks D/C RB traction, maintain DBS - active & passive flex & ext in splint followed by active hold 10 sec, Active extension 10 sec. in splint 5 wks: blocking for tendon glide begins if needed, allow some pts out splint for hygenie/lt activity Washington Exercises: 8 weeks D/C splint, gradual increase in use/resistance Back to full use at 10 weeks
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Zone 1 Flexor tendon protocol: Evans
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Rationale for Evans Zone 1 flexor protocol: place repaired FDP tendon in shortened position to rest proximal to the area of repair and control gap formation Zone 1 Early stage (0 -3 weeks) SPLINT Splint: DBS wrist 30 flex, MP 30 flex, full IP extension + Finger based dorsal gutter splint over DIP in 45 flex. Zone 1 Early stage (0 -3 weeks Exercises *Passive composite flexion, DIP flex to 75, IP flexion with MP's resting at 30 in splint (mod hook) *While MPs held in 90, full ACTIVE PIP extension- NOT DIP jt extension *Use strap to hold other digits in extension while therapist places injured digit in flexion and pt attempts to hold for injured FDS (PIPJ only)= place and hold Zone 1 Intermediate stage (3 weeks) D/C DIP dorsal gutter splint * gentle active place/hold flexion * 4 weeks- tendodesis, hook fist, gentle DIP blocking * 4 1/2 weeks- begin DIP extension splinting What kind of flexor tendon protocol is Zone 1? Early controlled passive mobilization Is Zone 1 Evans a moderate or aggressive protocol in regards to the injured digit? more aggressive to digit- earlier active place/hold, tenodesis and extension splinting to the injured FDP- but still in the DBS- all done at 3 weeks rather than 4-6 weeks with other CPM protocols
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FPL Zone 2/3 repair: ECPM
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FPL zone 2, 3 repair splint: Wrist 30 flex, thumb MCPJ 15 flexion, IPJ in 15 flex FPL zone 2, 3: weeks 1-3 *Passive flex/ext of IPJ and MPJ seperately *Composite passive flexion to joints *In therapy: 1) Passive MP & IP flex while wrist ext 20 (tenodesis) 2) passive wrist flex while ext thumb to 0 FPL zone 2, 3: week 3 Place and hold flexion IN SPLINT FPL zone 2, 3: week 4 Remove splint for AROM and active tendodesis FPL zone 2, 3: week 6 D/C blocking splint FPL zone 2, 3: week 8 Gradually add strengthening What type of protocol is FPL zone 2, 3? Early controlled passive mobilization
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Indiana Early Controlled Active Motion Flexor tendon protocol
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What type of protocol is the Indiana? Early controlled active motion protocol Repair technique required for Indiant ECMP: Tajima core suture plus horizontal mattress, 4 strand repair plus running lock peripheral epitendonousuture- sheath repaired as possible Criteria for Indiana early controlled active motion protocol: motivated, understanding patients with minimal wound complications or edema taking 400mg Ibuprofen Indiana early controlled active motion: weeks 0-4 SPLINT DBS wrist 20 flex, MP 50, IP straight at all times except Strickland hinged splint 1x an hour Indiana early controlled active motion: weeks 0-4 EXERCISES 25 reps per hour 15 reps passive flex/ext to PIPJ then DIPJ then entire digit within splint Then Strickland splint- passive flex in fist while extending wrist at same time- gently contract & hold 5 sec, then tenodesis relaxation Indiana early controlled active motion: week 4 D/C Strickland splint- use DBS b/t exercises until 6 weeks Exercises: 25 reps per hour Remove splint- same passive flex while ext wrist- hold 5 sec, relax into flexion- *lt. active finger flexion AVOIDING simultaneous finger and wrist extension Indiana early controlled active motion: week 5 DBS b/t exercises Exercises: 50 reps every 2 hours, tenodesis exercises continue- Add isolated tendon excursion ex (MP ext, IPs flex) Indiana early controlled active motion: week 6 D/C DBS exercises: 50 reps every 2 hours- continue previous Add blocking ex. if more than 3 cm from DPC No blocking to small finger Indiana early controlled active motion: week 7 Exercises:exercises: 50 reps every 2 hours- continue previous Add passive extension exercises Indiana early controlled active motion: week 8 Exercises:exercises: 50 reps every 2 hours- continue previous Add light resistance 3x/day if needed Indiana early controlled active motion: week 14 Return to normal activity Indiana early controlled active motion: overview 0-4 weeks DBS w/strickland 25 reps/hr, lt place & hold 4- d/c strickland, + lt active finger flex/ext 5- + isolated tendon excursion 6-D/C DBS, increase reps to 50 q. 2 hrs, + blocking if >3cm to DPC 7- + add passive extension 8- + light resistance 3x/day 14- return to normal activity
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Silverskold/May- Early active motion flexor tendon protocol
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What kind of protocol is the Silverskold/May? Early controlled active motion Repair technique of Silverskold/May: FDP modified Kessler w/epitendinal circumfrential cross-stitch, FDS mattress suture Silverskold/May post repair protocol splint: DBS of plaster with neutral wrist, MP 50-70, IPs 0 Silverskold/May protocol: days 1-3 to 4-5 :splint: inpatient DBS of plaster neutral wrist, MP 50-70, IPs to 0-splint ends at level of PIPs so DIPs free- RB traction to all fingers under a palmar pulley to prox. FA Silverskold/May protocol: days 1-3 to 4-5: exercises: inpatient Exercises: 10 rep/hr - active IP ext holding MPs in further flexion to decrease tension - passive flexion w/simultaneous active flexion- hold 2 seconds x2 reps - Day 4-5: pt is able to actively flex to PIP 80 and DIP 40 under therapist supervision- not done @ home Silverskold/May protocol: days 4-5 to 4 weeks: discharged from hospital Splint: continue plaster DBS w/ RB traction- at night, extend digits with volar attachment w/no RB Exercises:-10 rep/hr -A IP extension A-flex with simultaneous P-flex Weekly checks for AROM Silverskold/May protocol: 4 weeks Splint: splint removed Exercises: A-flex and ext exercises- no passive 10 rep/hr Silverskold/May protocol: 6 weeks Exercises: 10 rep/hr Add gentle resistive flexion- be cautious Finger cast or dynamic ext splint for contractures Silverskold/May protocol: 8 weeks Exercises: progressive resistive ex. No power grip until 12 weeks post op
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Modified Duran Protocol
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Resistance starts earlier with immobilization and modified Duran because: there will be more adhesions therefore you can be more aggressive due to greater extrinsic healing Modified Duran protocol no rubber band traction, DBS to fingertips, straps fingers in IP extension at night splint 20-30 wrist flexion, MCPJ 50 flexion and IP's 0 Modified Duran protocol: weeks 1-3 Exercises: 10x every 2 hrs Passive flexion (ind + comp), ACTIVE IP ext. to splint Passive blocking of DIP and PIP joints (bout & swan) Passive fist then 20 passive wrist extension Passive hyperflex wrist for passive hook fist- MCP 0 Gentle ACTIVE PLACE & HOLD straight fist if FDP NOT repaired Modified Duran protocol: week 3 DBS to NEUTRAL wrist Begin ACTIVE place and hold in splint- this is EARLIER than other CPM protocols which begin at 4-41/2 weeks Modified Duran protocol: week 4 Remove splint for ACTIVE tenodesis @ HOME Modified Duran protocol: week 6 D/C Splint Active composite flex/ext & gentle BLOCKING if needed Gentle STRENGTHENING only if more gliding needed Entire Modified Duran protocol: no rubber band traction, DBS to fingertips, straps fingers in IP extension at night, splint 20-30 wrist flexion, MCPJ 50 flexion and IP's 0 Weeks 1-3: Exercises: 10x every 2 hrs Passive flexion (ind + comp), active IP ext. to splint Passive blocking of DIP and PIP joints (bout & swan) Passive fist then 20 passive wrist extension Passive hyperflex wrist for passive hook fist- MCP 0 Gentle active place/hold straight fist if FDP NOT repaired Week 3:DBS to neutral wrist Begin ACTIVE place and hold in splint Week 4:Remove splint for ACTIVE tenodesis @ home Week 6:D/C Splint Active composite flex/ext & gentle blocking if needed Gentle strengthening only if more gliding needed What type of flexor tendon protocol is Modified Duran? Early controlled passive mobilization
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Duran and Houser ECPM protocol:
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Duran/Houser protocol: 0-4 1/2 weeks DBS ends at PIP joints: wrist 20 flex, ?? MP's, IPs free w/loose rubberband traction to injured finger-all digits rest flexed w/pinned stockinette except w/exercises: Ex: 8 reps 2x/day IN SPLINT: PASSIVE DIP ext w/PIP flexed, PASSIVE PIP ext with DIP flexed (bout & swan) Duran/Houser protocol: 4 1/2 weeks Splint: wristband & rubberband traction- DC DBS Exercises: 10x every 2 hrs Gentle active extension against rubber band + passive blocking of DIP and PIP joints (bout & swan) Duran/Houser protocol: 5 1/2 weeks Splint: none- remove rubberband attachments Active flexion= gentle blocking, full fist and extension Passive: all joints in flexion * Passive IP extension with MP in flexion- no FULL passive extension Duran/Houser protocol: 6 weeks Begin gentle PIP extension dynamic splints as needed Duran/Houser protocol: 7 1/2 weeks Begin gentle resistance- sponge to putty No strong resistance to tendon for +2-4 weeks Entire Duran and Houser flexor protocol: Week 0- 4 1/2 weeks: DBS ends at PIP joints: wrist 20 flex, ?? MP's, IPs free w/loose rubberband traction to injured finger-all digits rest flexed w/pinned stockinette except w/exercises: Ex: 8 reps 2x/day IN SPLINT:PASSIVE DIP ext w/PIP flexed, PASSIVE PIP ext with DIP flexed (bout & swan) Week 4 1/2:Exercises: 10x every 2 hrs Splint: wristband & rubberband traction- DC DBS Gentle ACTIVE extension against rubber band + PASSIVE blocking of DIP and PIP joints (bout & swan) WEEK 5 1/2: Splint: none- remove RB attachments Active flexion= gentle blocking, full fist and extension Passive: all joints in flexion * Passive IP extension with MP in flexion- no FULL passive extension WEEK 6:Begin gentle PIP extension dynamic splints as needed WEEK 7 1/2: Begin gentle resistance- sponge to putty No strong resistance to tendon for +2-4 weeks
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Immediate Active Short Arc Flexor protocol: Zone 2
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Immediate Active Short Arc Motion protocol (SAM) : SPLINT Splint: Full DBS wrist 30-40 flex, MP 45, IP's to 0 RB traction to all fingers- filament+RB under palmar pulley attached to FA strap Immediate Active Short Arc Motion protocol (SAM): HEP exercises In splint: 10-20 passive fists Out of splint: Hold MPs at 90 and actively ext IPs Night: straps IPs into full extension Immediate Active Short Arc Motion protocol (SAM) begins when? 1-3 days post repair Immediate Active Short Arc Motion protocol: HEP exercises 10-20 reps PASSIVE flexion to DPC 10-20 reps ACTIVE IP extension holding MP's @ 90 Night: detach RB and strap into full extension DBS What amount of pressure is the patient allowed to use during active hold component exercise in early controlled movement protocol? 15-20 grams of force When is patient allowed to do ACTIVE hold exercises by themselves with early controlled active movement protocol? 21 days post op= 3 weeks When does therapy begin to follow regular flexor tendon protocols? 3 weeks What kind of protocol is the immediate active short arc motion program for flexor tendon repair? early active controlled motion protocol Short arc active motion portion of protocol: Done in therapy only! *Therapist slow PROM into flexion < less than 30gm pressure * Active hold (really place and hold): Therapist puts all 4 digits in position: wrist 20-30 ext, MP to 80, PIP to 75, DIP 30-40, then asks patient to hold position using 15-20 gm of force * passive wrist tenodesis: therapist makes passive fist & extends the wrist to 30-40 degrees- then passive wrist flexion to 60 while digits relax When does Short arc active motion portion of protocol begin? post op 1-3 days in therapy only Remainder of SAM protocol after 3 weeks: Blocking 6 weeks, out of splint for AROM 4 weeks, D/C splint 6 weeks, resistance 6-8 weeks depending on adhesions
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Camitz Transfer for low median nerve injury: MOST COMMON
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Palmaris Longus to Abductor Pollicis Brevis Excellent thumb abduction, limited thumb pronation Splint: LAS opponens with wrist 20 flex & max palmar abduction under IF high median to low median transfer
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Bunnell FDS of ring (IV) Transfer for low median nerve injury: MOST PREFERRED
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FDS TO APB also can use index finger pulley at Pisiform for pron/sup of thumb Splint: LAS opponens with wrist neutral to 20 flex & max palmar abduction under IF high median to low median transfer
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Huber Transfer for low median nerve injury:
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Abductor Digiti Minimi to Abductor Pollicis Brevis (ADM to APB) for abduction of thumb intrinsic transfer radial to median Splint: Hand based opponens with max palm. abd.
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Burkhalter EIP Transfer for low median nerve injury:
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Extensor Indicis Proprius to Abductor Pollicis Brevis (EIP to APB) for abduction of thumb intrinsic transfer radial to median
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High Median nerve transfers: common muscles used
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1. ECRL/B to FDP for MCP flexion SPLINT: DBS wrist neutral to flexed 2. Brachioradialis to FDS then FPL for MCP flexion SPLINT: long arm dorsal blocking splint- elbow 90, wrist & thumb flexed, full palmar abduction- (treat like flexor tendon repair) 3. ECU also used for FPL for thumb flexion (Phalen-Miller)
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Low median nerve injury post-op tendon transfer protocol:
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0-3 weeks splint 24/7 3 weeks AROM IN splint to activate transfer 4 weeks AROM out of splint- active use of transfer, mobilize unaffected joints 6-8 weeks DC splint per MD, unrestricted AROM 8 weeks- resistance as allowed, prevent fatigue 12 weeks- no restrictions *Wait longer to dc splint, wait til 8 for strength
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High median nerve injury post-op tendon transfer protocol:
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0-3 weeks splint 24/7 3 weeks AROM in splint to activate transfer 4 weeks AROM out of splint, NMES to activate 6 weeks DC splint, + PROM and Splinting for tightness 7-8 weeks progressive resistance *NMES for long muscles, resistance & PROM earlier
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Post op management of Pronator Syndrome:
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Keep motion at the elbow limited to 90 flexion x 5-10 days then motion as tolerated Digits and wrist AROM as tolerated by patient
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Post op management of AIN syndrome:
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Splint if pronator elevated= ELBOW SLIGHT FLEXION, 45 pro and 45 wrist flex Digits and wrist AROM as tolerated by patient Composite AROM & nerve/tendon glides at 3 weeks Strengthening at 4 weeks
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Post op management of Carpal tunnel release:
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1- 14 days Digit AROM, nerve and tendon glides 2 weeks Sutures removed, wrist AROM, desensit, scar 3 weeks Strengthening 4 weeks Sensory eval, retraining, work hardening
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Cubital tunnel conservative mgmt:
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LAS nights @30-45 degrees w/neutral wrist to put FCU @ rest, heelbo, activity modification, nerve mob/glides, modalities
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Side to side transfer (high):
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index and middle FDP connected to ring and small- digits 2-5 flex as a unit (medial to ulnar)
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ECRB/L to FDP (high):
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ECRB routed volarly and attached to FDP tendons- flex as a unit
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Smith-Hastings (high):
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ECRB to ADP (1st MC) for restoration of power pinch
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Low Ulnar nerve injury:
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distal to innervation of FDP
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Brand procedure: (low)
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ECRB/L routed volarly thru carpal tunnel to transverse MC ligament into the lateral bands becoming an MP flexor Goal: restore MP flexion and control clawing
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Stiles-Bunnell procedure: (low)
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2 FDS slips harvested & attached to lateral bands at proximal phalanx of RF/SF- thus imitating the lumbricals, MP flexors Goal: restore MP flexion and control clawing
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Zancoli-lasso procedure: (low )
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for combined median + ulnar lesion FDS is looped through A1 pulley and folded back to form a lasso effect- FDS becomes MP flexor again Goal: restore MP flexion and control clawing
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Boyes procedure:
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ULNAR: Brachioradialis extended w/graft, tendon passed thru space between 3/4 MC to insert on thumb
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Smith-Hastings: (low)**********
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ECRB to ADP for POWER PINCH FDS of RF to Adductor pollicis:(low) splint DBS w/ neutral to flexed wrist Post OP splinting of intrinsic transfer: MP flexed, IP 0, wrist flex or extend depending on muscle used for transfer Post operative txmt guidelines: intrinsic transfers Gradual increase of MP extension- expect MP lag due to tendon transfer tension (internal splint), Full MP extension avoided x 3 weeks, avoid fist x 3 weeks, @ 4-6 weeks use lumbrical bar splint as splint assist with light functional activities, no heavy use x 3 mo.
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Radial tunnel: conservative txmt
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LAS @ 90, full supination to rest supinator, wrist 20-30 ext- worn as much as possible Modify act. to lift w/supinated, 2 hands, STM, radial nerve glides, NO counterforce strap
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PIN syndrome: conservative txmt
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LAS @ 90, FA supinated, wrist 20 ext-NO counterforce strap, activity modification- radial nerve glides, modalities, stretching
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Wartenberg's Syndrome: management
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Wrist ext. splint @ 20, anti-infl, edema control, desensitization, radial nerve glides, modalities Neurolysis if conservative management fails
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Post-op Radial nerve injury TENDON TRANSFER mgmt:
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Splint: LAS 90, FULL PRONATION, wrist ext 30-45, MP 0, IPs free, thumb in radial abduction for 7-8 weeks 3-4 weeks mobilization- combined elbow ext, pronation and wrist extension 4 weeks- gentle active ex. of each jt done with support to wrist in extension ( see other card) * Avoid composite wrist flex/finger flex until 8 weeks post op 8 weeks- resistance exercises *Avoid over stretching the transfers WHY PRONATION? In radial nerve tendon transfer, the pronator teres is used to restore wrist extension, so you want pronation to avoid overstretching the transfer!!!! Fully Supinated position is indicated in radial tunnel syndrome splinting to decrease the supinator muscles compression of the nerve in the pronated position. AROM exercises started at 4 weeks post op: MP flex/ext w/IP 0- TABLETOP IP flex/ext w/MP in ext - HOOK wrist flex to neutral- avoid stretch of extensors Thumb IP flex/ext while in radial abduction) Elbow flex/ext w/PRONATED FA FA rotation w/flexed elbow but extended wrist/fingers
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Boyes transfer aka "superficialis" transfer
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PT to ECRB, FDS III to EDC, FDS IV to EPL, FCR to APL/EPB
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Zone I/II extensor treatment txmt protocol:
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closed injury 6-8 weeks immobilized at 0 ext. with PIPJ free for flex. 6 weeks- assess tendon- if flexes and returns to ext, allow pt. to remove occ. for cleaning & exercises- Progression:week 1(6): 20-25 flex w/full extension week 2(7): 35 flex- use template weeks total 8-10: DC splint to night/heavy activities Continue + 5-10 degrees per week- comp. fisting weeks 10 total: passive flexion if limited and ext. good * if lag starts, back off flexion and resume splint Mallet finger with bony fragment txmt: advance more quickly after 6 weeks - if xray shows healed, initiate A/P flex immediately Mallet finger plus swan neck deformity txmt: limit PIP ext by 15 degrees to tighten volar plate & lateral bands do not migrate dorsally Chronic untreated mallet finger txmt: regain DIP extension via dynamic or serial cast/splints then DIP extension splinting x 8 weeks begins
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Zone I/II treatment protocol: open repair
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splint and pinning x 5-6 weeks initiate motion when pin removed w/ progressive flexion of 5 degrees/week maintaining extension After motion initiated: DIP ext splint for 3-6 weeks more for heavy activity & between exercises
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Zone III/IV extensor treatment txmt protocol:
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closed injury ACUTE: conservative with splinting- 6-8 weeks continuously with DIP and MP free at 0 degrees PIP extension: After 6-8 weeks, continue splint b/t AROM exercises until 10 weeks CHRONIC: serial splint/cast to 0 then 8-12 weeks of continuous splinting - After 6-8 weeks start AROM at 30 flexion gaining 5-10 per week- splint b/t exercises & at night for 2 more weeks after immobilization ends *Full aggressive DIPJ P/AROM throughout txmt * lag? continue splint & decrease flexion * not progressing? +PROM/modalities 2 weeks after splint D/C'd
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Zone III/IV extensor treatment protocol: open repair
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CONSERVATIVE=immobilized 4 weeks immobilized splint at 0 PIP extension *DIP free if LATERAL BANDS NOT INJURED OR REPAIRED Start AROM @ 4 weeks @ 30 flex, increasing 5-10 degrees weekly
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Zone III/IV extensor treatment protocol:
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open repair Early Cont. Passive Motion SPLINT: outrigger supporting PIP at 0 w/RB traction allowing controlled flexion few days after surgery THOMES- outrigger hand based splint-MP 20 flex, PIP ext: 30 flexion then 10 per week- DC at 3 weeks WALSH- outrigger hand based splint- MP ext, PIP ext: 30 flexion for 3 weeks then DC splint General info: RB outrigger for 3 weeks only!!
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Zone III/IV extensor treatment protocol: open repair-Early Cont. Active Motion- SAM ROZ EVAN SHORT ARC MOTION PROG.
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Starts 48 hours after surgery(2 days post op) 3 splints total 1. Finger length gutter w/PIP&DIP full extension: all times except exercise 2. EXERCISE SPLINT:Gutter template- Flex up to @ PIP 30, DIP 20 flexion & actively extends to 0 extension, w/ wrist in 30 flexion and MPs at 0 extension (looks like claw exercises w/gutter splint on) 3.EXERCISE SPLINT: PIP only gutter, DIP free for FULL flexion IF lateral bands not injured- if repaired, limit to 30 DIP flex. *exercises= 10-20 reps every 1-2 hours Adjust template splint to 40 flex after 2nd wk if no lag, 50 degrees @ 3 weeks, @ 4 weeks 70-80 flexion if PIP ACTIVELY extends to 0- can do intermittant flexion splinting @ 4 weeks if stiff- static ext splinting until week 5/6. @ 5 weeks composite flexion & gentle strength- @ 6 weeks D/C to HEP and regular strengthening
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Zone V/VI/VII: conservative txmt= immobilization
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SPLINT: wrist 30-40 ext, MP 0 ext , full IP ext Exercises: 3-4 weeks: tenodesis, IP full flexion w/MP & wrist extension, MP full extension slightly flexed to neutral wrist 4-5 weeks: *composite finger flexion w/wrist ext; IP ext w/wrist flexion, claw, ind. finger extension 3-5 weeks: gentle dyn. MP flexion splint if needed OR MP block splint for PIP tightness 6 weeks: composite finger/wrist ex., mild strength, DC splint if no lag 12 weeks: strong resistive exercises
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Zone 5,6,7: ECPM extensor protocol (Evans)
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SPLINT: controlled stress 24hr to 3 days post op (NEEDS A MP VOLAR BLOCK COMPONENT, PIPs FREE) -continuous dorsal dynamic ext. splint w/volar block or stop bead for 30-40 degrees MP flex, wrist 40-45 ext, MP & PIP at 0 w/sling at PIPJ or middle phalanx - if PIP lag, then individual gutters added- can also do full ext. static sleep splint *exercises: 20 reps/hr- Active MP flex to 30-40 block, PIPJ full ROM, - in therapy LIMITED RANGE TENODESIS=wrist flex 20 w/ full IP ext, then MP 40 flexion with full wrist extension 3 weeks: remove stop/or volar block and increase MP flex, ex=gentle MP extension with slight wrist flexion 4-5 weeks: remove splint to exercise, isolated digit extension, claw, active composite finger flexion w/ext wrist, active wrist flexion with relaxed fingers 6 weeks: DC splint unless lag- begin composite wrist and finger flexion 7-8 weeks: begin light resistance
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Zone V/VI/VII: ECAM using MAMTT (Evans) extensor:
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Pt does same ECPM protocol at home wearing dynamic splint In txmt only, limited passive wrist tenodesis wrist flex 20 w/ full IP ext, then MP 40 flexion with full wrist extension- done as a warm up to stretch Then wrist flexed 20 with fingers extended by therapist- pt HOLDS here then, with wrist at 20 flex & pt holding , pt actively flexes the MPJ to 30 w/IPs 0 then actively extends MPs to 0 ext- "light tabletops" Active motion component is done when resistance during this passive component is minimized- use Haldex pinchmeter at less than 25 grams of force MAMTT= Minimum active muscle tendon tension
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Zone VII Wrist extensor tendon protocol: NO FINGER TENDONS INJURED- ECU, ECRL, ECRB, BR affected
answer
SPLINT; wrist 20-30 ext 4 weeks Exercises: 0-3 weeks PASSIVE wrist tenodesis with NO MORE THAN 20 extension to prevent stress x 3 weeks 3-4 weeks: gravity eliminated full active wrist ext from 0 to full extension, gentle RD/UD 5-8 weeks: gradual increase in flexion & RD/UD RD/UD in sup and pro to maximize ECU glide
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Zone VIII Dorsal extensor FA, proximal to ext. retinac.
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SPLINT; wrist 20-30 ext 4 weeks extrinsic extensor tendon tightness common
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Thumb extensor tendon injury; Zone TI
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IP extension splint- full ext to slight hyperext., slightly longer splinting for 8 weeks, then gradual flexion in 20 degree increments, watching for lag surgical repair- splint 5-6 weeks, gentle AROM at 5-6 weeks IPJ splint between exercises and at night 2 weeks longer (10 weeks splinting total, repair 8 weeks total)
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Thumb extensor tendon injury; Zone TII
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Hand based splint immobilizing MP and IP at 0 w/radial extension of CMCJ Gentle motion (25-30) at 3-4 weeks, increasing x 3 more weeks- splint protection b/t exercises x 6 weeks extensor tendon adherence a problem
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Thumb extensor tendon injury; Zone TIII/IV
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Wrist based splint at 30-40 extension w/ MP & IP at 0 No hyperextension of MP- hard to get flexion back Gentle motion at 3-4 weeks
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Thumb extensor tendon injury; Zone TV
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Wrist based splint at 30-40 extension w/ MP & IP at 0 Gentle motion at 3-4 weeks Can do dyn. flexion splinting @ 3-4 weeks Recommend early passive motion protocol due to dense adhesions under extensor retinaculum
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Thumb extensor tendon injury; Zone TV early controlled passive motion protocol
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Splint: dynamic ext. wrist 30-40 ext, CMC radial ext., MP @ 0, IP in full extension in sling- Volar block allows 60 IP FLEXION ONLY for tendon excursion purposes Exercises: hourly flexion of IPJ x 3 weeks 3 weeks: remove block, IP flex as tolerated IN THERAPY= PASSIVE MP flex w/ wrist & IP ext then hold, active wrist ONLY from 30-60 ext, gentle active IP extension 4 1/2 weeks: continue splint, IN THERAPY=gentle composite flex/ext of thumb, wrist flex w/relax thumb 6 weeks: DC splint, PROM as needed, if lag then night ext. splint 8 weeks: dynamic flexion splint if needed
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Zone VII extensor tendon protocol: FINGER TENDONS INJURED (EIP/EDC/EDM)
answer
SPLINT; wrist 40-45 extension, full finger extension w/dynamic splint x 4 weeks Exercises: 0-3 weeks *PASSIVE wrist tenodesis with NO MORE THAN 10 extension to prevent stress to EDC x 3 weeks *individual MP jt flexion 30-40 degrees w/ext wrist, then increase to MPJ flexion 40-60 @ 4weeks, 70-80 @ 5 weeks 3-4 weeks: GRAVITY ELIMINATED ONLY FULL ACTIVE WRIST EXT FROM 0 TO FULL EXTENSION, gentle RD/UD, 50% fist with some wrist flexion, 5-8 weeks: gradual increase in flexion & RD/UD RD/UD in sup and pro to maximize ECU glide- IF IMMOBILIZED, THEN MP JT/DIGITS MUST BE SPLINTED IN EXTENSION- PASSIVE FULL EXTNESION OF PIP/MP/WRIST EXTENSION IS PASSIVE ONLY
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TENS Sensory level stimulation: "conventional TENS" HIGH rate
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stimulation at/above sensory threshold but below motor threshold- (no muscle contraction) frequency 50-150 pps pulse duration 40-100 usec/microseconds intensity 20-30 mA duration 20-30 min quick onset of pain relief but little carryover electrode placement:over pain site, bracket, trigger pt
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TENS Motor level stimulation: "high intensity/acupuncture-like " TENS LOW rate
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produces visible muscle contraction frequency 1-10 pps pulse duration 150-400 usec intensity 30-40 mA visible contraction duration 30-60 min electrode place: remote but anatomically linked (cervical level or trigger point) slow onset of pain relief but good carryover
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TENS Noxious level stimulation: "Brief-Intense"
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painful stimulus in/or remote from pain site frequency 100-150 pps pulse duration 150-400 usec intensity to maximal tolerance duration 1-15 min pain relief equal to txmt time- short carryover
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High Voltage Galvanic stimulation (HVGS) Interrupted monophasic waveform
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for pain control, edema, wound healing frequency vary- high 50-120 acute pain, 5-15 chronic pulse duration 2-50 per pulse intensity noxious, below motor thresh. 2000-2500 mA voltage > 100 volts polarity controlled by clinician (-) vasoconstrict (+) dil.
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NMES Neuromuscular Electrical Stimulation: txmt parameters
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frequency 10-60 pps pulse duration 300 usec on:off ratio 1:2/3 general ortho, 1:5 debilit/neuro pt ramp time up/down= 2-4 sec/6-8 sec intensity 20-40 mA NMES @ 30 pps use 1:3 on/off ratio NMES @ 50-80 pps use 1:5 on/off ratio
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NMES Neuromuscular Electrical Stimulation: Asymmetric biphasic
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=electrodes, (-) 60% (+) 40% ≠electrodes red 50% larger than white (-) 80% (+) 20% good for isolated recruit of small m.=intrinsics
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NMES Neuromuscular Electrical Stimulation: Symmetric biphasic
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equal sized electrodes (-) 50% (+) 50% good for large m. recruit. (triceps) OR 2 muscles at same time w/out having to use 2 channels (FPL/FPB)
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To reduce ACUTE pain, what ES is used?
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high volt, low rate of 50-120 Hz for 10-30 min continuous, allowing muscle relaxation and pain reduction
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What TENS rate is used with painful procedures like debridement, passive stretch or minor surgery?
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Brief, intense high rate 100+ pps and high width 200+ microseconds/usec current as high as the patient can tolerate- produces tetanic contraction/noxious
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What are the parameters for treating wounds with ES to accelerate healing?
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neg electrode over wound for granulation OR pos electrode over wound for epitheliazation, pulse rate around 100 pps, 75-100 volts direct current
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What waveform do you use for edema and wound healing?
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MP- monophasic (HV for edema)
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What waveform do you use for AROM, strength, edema, and spasm?
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ABP/SBP- asymmetrical biphasic, symmetric biphasic
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What are the two TENS currents used at the sensory level only?
answer
interferential and HVPGS
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NMES pulse width=
answer
its wider to elicit a muscle contraction for a longer period of time
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Interferential pulse rate=
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high pulse rate, 4000+ per second
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Typical parameters for conventional TENS are as follows:
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* Pulse rate: 50-200 pulses per second (pps) Pulse width: 20-100 µs Intensity: maximum tolerated tingling, no muscle contractions.
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Typical parameters for motor level TENS are as follows:
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Pulse rate: < 20 pps Pulse width: 50-600 µs Intensity: Maximum tolerated contraction.
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Typical parameters for noxious level TENS are as follows:
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Pulse rate: 100-200 pps Pulse width: > 200 µs Intensity: maximum tolerated tingling or contraction
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Wrist fracture txmt weeks
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6-8: wrist ext splint between exercises, AROM, edema cntrl Wrist fracture txmt week 8: if healed, begin PROM and jt. mobs, wean splint, start strengthening Ex- fix treatment: 6-12 weeks in fixator +6-12 weeks: AROM, wrist immobilization splint +8-12 weeks: PROM, dynamic splinting, strengthening
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Wrist ORIF treatment:
answer
1-2 wks: wrist splint between exercises, gentle AROM 3-4: gentle PROM 5-8: wean from splint, AROM/PROM progression 9-12: strengthen, static progressive/dynamic if needed
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Scaphoid ORIF w/Herbert screw, Russe techn)
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immobilize 4-16 wks, splint until bone union then start AROM, 1 week later PROM, 3-4 weeks later strength Splint= thumb spica IP free
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Triquetrum txmt:
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2nd most common fracture, fall w/wrist ext & UD, DORSAL ulnar sided pain, 4-6 weeks immobilized
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Hamate txmt:
answer
pain at base of hypothenar, tender w/direct pressure or resisted abduction of 5th digit, can have ulnar nerve symp. since part of Guyon canal, 6-8 weeks immobil.
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Lunate txmt:
answer
fall on outstretched hand cause compression b/t capitate and distal radius, short arm cast 6-8 weeks due to FA involvement, can be from Kienbock's dz
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Trapezium txmt:
answer
direct blow to abducted thumb or on hyperextended wrist in radial deviation, tender thumb base, pain w/ resisted wrist flexion- 4-6 weeks in thumb spica
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Pisiform txmt:
answer
ulnar nerve irritation since it makes up medial wall of Guyon canal, 3-6 weeks immobilized, can be excised
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Capitate txmt:
answer
dorsal wrist trauma or hyperextended wrist w/RD, often with other carpal fx, 6 wks immobilized or ORIF, ext. tendon adherence problem
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Trapezoid txmt:
answer
rarest fracture, crush or high impact injury, 6 weeks immobilized or fusion
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Metacarpal fracture:
answer
40% of all hand fractures, heal 3-5 weeks, neck most common fracture site (boxer) which can angulate into palm due to pull of lumbricals, more angulation allowed @ 4/5 due to increased CMC mvmt- splint in 40-50 MP flex, IP 0 PIPJ flexion contractures an issue- can use 2nd ext splint at night to increase PIP extension
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Middle/Proximal phalanx fractures splint:
answer
MP 70-90, IP in as much ext as possible, dorsal allows drop out to increase flex., 3-4 weeks then buddy tape
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Distal phalanx fracture: TUFT
answer
usually stable, may have nailbed injury, painful, 3-6 weeks protective splint (stax or alumofoam), Kirschner wires often
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Distal phalanx fracture: SHAFT
answer
usually stable, splint 4-6 weeks (stax or alumofoam)
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Distal phalanx fx general:
answer
avoid overzealous DIP flexion to prevent mallet, isometric DIP extension to strengthen terminal tendon, desensitization, monitor nail growth non-op txmt: AA/AROM 2-4 weeks oper. txmt:AA/AROM 5days or as late at 5-6 weeks PROM: 4-8 weeks Lt. resistive: 6-10 weeks
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Fracture fixation & initiation of ROM with radial head fx:
answer
Absolute stability: 24-72 hours Type I, IIa Sufficient stability: 3 to 7 days Type IIb Minimal stability: 3-6 weeks Type III, IV I & II 1-3 days AROM and sling IIb, III, IV- 3-5 days LAS 90 FA 0, AROM 10-14 days PROM 6 weeks strength, DC splint
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5th finger CMC jt= reverse bennetts
answer
dorsal extension block splint of the MCPJ in flexion with wrist at neutral k wires x 6 weeks then PROM/AROM of MP/CMC jts want 0 ext- MP blocking in flex to increase pull thru at IPjoints, dynamic splinting later for flexion contracture
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MPJ synovectomy w/tissue reconstruction arthoplasty post-op therapy;
answer
Early phase: 0-2 weeks- gentle AROM, PROM if no ext. tendon repair, resting splint w/MPJ in comf. extension b/t exercises, dynamic ext splint if needed Intermediate/Late phase: 2-6 weeks +- ROM progress & strengthening, dyn flexion splint prn, goal-pain free functional ROM Reminder- since its an arthoplasty, EXT of MPs
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Silastic MCPJ RA post- op therapy:
answer
-FA BASED dyn. ext. splint to neutral worn x 6 weeks slight radial pull, supinatory force may be needed -MP ext. rest splint x night; PIP flex if swan or PIP ext if bout., A/PROM of MP, PIP, DIP, dynamic flexion @ 3 weeks if needed, 6 weeks strength NO CASTING so splint immediately! Silastic MCPJ RA post-op ROM goals: IF 0-45 flex, MF 0-60 flex, RF/SF 0-70 flex
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Silastic PIPJ OA replacement: Post op therapy splint decision making indications
answer
3-5 days DIGIT BASED DORSAL splint- position depends on pre-surgery deformity lat deviation= splint laterally to align digit bout deform= full PIP ext swan deform= 20-30 PIP flexion
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Silastic PIPJ OA replacement: Post op therapy
answer
3-5 days dorsal PIP splint (NO CAST, So splint immed. and does not require a hand/FA based splint) 1-2 weeks bout= PIP full ext splint x 4-6 weeks " " swan= PIP splint DBS 20-30-flex ok but NO ext " " lat deviation- no ROM for 2-6 weeks** IF STIFF, initiate AROM 1st week, PROM later if needed can buddy tape later 6-12 weeks- DC splint, graded strength, increase fun. use w/jt protection principles- ((similar to PIP repair))
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Ascension implant: Pyrocarbon 2 component total joint replacement for RA MPJs
answer
After surgery :CASTED 10-15 wrist ext & slight UD, MPJ full ext, PIPJ 5-15 flexion *4 days post op: plaster splint MPJ full ext w/slight RD, wrist extended, full PIP/DIP AROM *4 days to 3 weeks:PIP/DIPJ AROM+PROM- NO MP ROM *3 WEEKS POST OP: 1st OT visit change to FA BASED dyn MP ext splint x day w/de- rotational rings + distal radial pull outriggers to correct ulnar drift, MP stop to 45 flexion- Static night splint w/MP ext & same as above PIP/DIP comfortable flexion + optional MP exercise, flexion blocking splint w/IPs free to increase AROM Hourly AROM exercises in dyn. splint- NO MP flex >45 *4 weeks post op: light object prehension in dyn. splint *6 weeks post op: INCREASE MP FLEXION TO 60, light ADLs in splint, light activity in therapy without splint *12 weeks: ADLs OOS, NO MPJ flexion greater than 60 x 1 year, static night splint x 1 year RA: MP ROM goals 60 MPJ flexion, 0 MPJ extension
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Ascension Implant: Pyrocarbon total MCP jt replacement for OA
answer
Same plaster cast as w/RA Ascension 2 days post plaster cast full MP ext, PIP jt 5-10 flexion 1 WEEK POST OP: 1ST OT VISIT FA BASED dynamic ext splint, MP flex to 60 x 2 weeks, NO PROM OF MP JT, gentle opposition, P/DIP flex/ext- static night splint, can leave IPs free 4 weeks: light ADL oos, INCREASE MP FLEX TO 90, dyn. MP splinting and PROM if 60 flexion not obtained 6 weeks: full ADL as tolerated
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Ascension Implant: Pyrocarbon total MCP jt replacement for OA for central digits
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Central digits can use buddy system to adj. fingers for ROM w/ static splint at night
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Ascension Implant: Pyrocarbon total PIP jt replacement for OA
answer
RA- 3 weeks immobilized before 1st OT visit OA- 4-7 DAYS POST OP: 1st OT visit FA BASED static night splint EVEN THOUGH PIP JT REPAIR, with MPs in slight flexion, full PIP ext unless pt has PIP hyperextension then splint PIP in up to 60 flexion- Dynamic splint: FA Based w/ 10-15 wrist ext, MP 20 flex, dyn. extension of PIPJ to 0- avoid hyperextension *IF HYPEREXTENSION OF PIP, static splint PIP 30 flex and allow flexion arc of motion of 45 (30-75 flex)- splint at night in 60 PIP flexion x 3 weeks, then return to dynamic ext splint *IF EXTENSION LAG OCCURS, splint PIP full ext x 3 weeks, then return to dyn splint *IF LATERAL DEVIATION OCCURS, fit w/hinged PIPJ splint to allow flex/ext but no deviation *IF STIFFNESS IS EVIDENT=LESS THAN 30 FLEXION 2 WEEKS POST OP, fit w/dyn. intermittant PIP flexion splint- if flexion less than 30 at 3 weeks post op, then allow AROM OOS *Hourly PIP ACTIVE FLEX TO 45 for 10-12 reps 4 WEEKS POST OP- PIP AROM to 60 flex, buddy tape, DC dyn ext splint if 0 ext 6 WEEKS POST OP-AROM to 75 flex, PROM, light act OOS 3 MONTHS +- GOAL 75 FLEXION, avoid hyperextension
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Thumb CMC arthoplasty: post op txmt
answer
0-3 weeks: TSS or cast, ROM at all other 3-6 weeks: k-wire removed if used, AROM 3 weeks or possible AROM/PROM at 6 weeks, splint between exercises most of time, hand based TSS if ok 6-12 weeks: lt functional use, jt protection, 8 weeks: progressive grip strength, avoid painful pinching strengthening to avoid stress to repair goal= pain free stable joint
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Tendon reconstruction for Swan neck deformity: general txmt regimen
answer
digit gutter splint PIP 30-40 flexion 1-3 weeks: AROM begins, generally in DBS to block ext PROM if indicated 6-8 weeks: DC day splint, night splint for at least 3 mo Goals: functional flex/ext, 20-30 flexion contracture to prevent recurrence, oval 8 splints for management
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PIPJ arthroplasty quick guide:
answer
digit ext splint at 3-5 days post op AROM 3-5 days PROM 3 weeks Lt strength 6 weeks splint to nights at 6 weeks
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Wrist arthoplasty quick guide:
answer
cast 3-4 weeks, wrist splint after, AROM 3-4 weeks, PROM at 6 weeks, strength 8 weeks, splint prn 6-8 wks
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Treatment of Radial Head Fx: TYPE I:
answer
non-surgical: Sling, ROM as indicated
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Treatment of Radial Head Fx:TYPE II non-surg
answer
Sugartong/Muenster splint 2-3 weeks, ROM esp. supination
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Treatment of Radial Head Fx: TYPE II surgical
answer
ORIF vs excision w/head replacement hinged brace OR sugartong OR LAS= excision LAS at 90=ORIF focus on supination and extension
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Olecranon fx: non surg versus surgical txmt
answer
non surg= immobilized cast/splint- NO active elbow ext until heals! surgical= ORIF or excision, day splint @ 90, night 0, ROM & strength as ordered
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Coronoid fx outpatient txmt:
answer
non-op= splint/cast surg= ORIF, cast 2-3 weeks, hinged brace if stable
question
Posterior elbow dislocation:
answer
closed reduction w/LAS 3-6 weeks at 90 w/full pronation OR hinged splint w/extension block Op for lig repair- LAS 2-4 weeks, FA neutral, wrist free Uncomplicted dislocation=A/AAROM in flex/ext & pro/sup at 1 week, strength at 4-6 weeeks
question
Total elbow arthoplasty: post op txmt
answer
immobilized x 1 week protected ROM 3-5 post op if ligament repair stable LAS for rest and sleep
question
Length of return to sports competition after tendinosis open release?
answer
5-8 months
question
Length of return to throwing program after UCL repair?
answer
4 months
question
How long is compression CI for vessel repairs?
answer
6 weeks post op
question
When can thermal heat be used on vessel repairs?
answer
safely after 8 weeks- CI before that
question
When can sensibility be tested?
answer
6-8 weeks post injury
question
Digital Replants Early Motion Protocol- Silverman
answer
SPLINT- dorsal blocking splint, wrist 0 to slight flexion, fingers in max MP flex & IP ext CONTROLLED ACTIVE TENODESIS BEGIN: 4-14 days post op patient actively moves wrist ONLY and fingers can be gently moved by the therapist Digital Replants Early Motion Protocol- II Silverman PASSIVE INTRINSIC MINUS BEGIN: 7-14 days post op wrist neutral, therapist does passive hook/table top THEN PLACE AND HOLD *with PIP flexion limited to 60 for 4-6 weeks to avoid central slip attenuation Digital Replants Early Motion Protocol- III Silverman ACTIVE INTRINSIC MINUS BEGIN: 2 weeks post op active hook and table top exercises w/therapist assist NO REAL AROM UNTIL 3 WEEKS, 4 WEEKS NMES, 6 WEEKS DYN SPLINT, 6 WEEKS PROM, 6 WEEKS ADLS, 8-10 WEEKS STRENGTH FAIL DUE TO VENOUS INSUFFICIENCY, SO NO TIGHT COMPRESSION- ONLY WANT TO MAINTAIN WHAT GOT, NOT DECREASE IT
question
When is passive stretching initiated with digital replants?
answer
6 weeks
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PCL(PROPER COLLATERAL), ACL(ACCESSORY COLLATERAL), RCL(RADIAL COLLATERAL) AND UCL (ULNAR COLLATERAL) TXMT: CONSERVATIVE
answer
BUDDY STRAP DAY W/IMMEDIATE AROM, EXT. GUTTER SPLINT AT NIGHT- MAY USE SLIGHT FLEX. IF PAINFUL IN SPLINT AND WEAR AT ALL TIMES EXCEPT AROM EX., EARLY DIPJ MOTION TO PREVENT ORL TIGHTNESS, PIP CONTRACTURES COMMON INDEX FINGER AND SMALL FINGER LIGAMENT CONSIDERATIONS: RCL OF INDEX AND UCL OF SMALL SHOULD BE SPLINTED W/ GUTTER SPLINT AT ALL TIME EXCEPT AROM B/C CANT USE BUDDY STRAPS
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PCL, ACL, RCL AND UCL TXMT: OPERATIVE DUE TO UNSTABLE
answer
IMMOBILIZE 3-4 WEEKS IN HAND BASED GUTTER SPLINT AROM AT 3-4 WEEKS W/BUDDY STRAPS
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DORSAL DISLOCATION OF PIPJ: STABLE TXMT PROTOCOL AFTER CLOSED REDUCTION
answer
DBS @ 20-30 FLEXION, BEGIN PROTECTED EARLY PIP AROM IN FLEXION- 3 WEEKS SPLINT DC, INITIATE EXTENSION EXER., 6 WEEKS GRADUAL STRENGTH, PROM, DYN SPLINTING
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DORSAL DISLOCATION OF PIPJ: UNSTABLE TXMT PROTOCOL AFTER CLOSED REDUCTION
answer
DBS @ 20-30 FLEXION, NO AROM OF JOINT, 3 WEEKS PROTECTED AROM OOS, 6 WEEKS PROM IF PIPJ FLEXION CONTRACTURE, EXTENSION SPLINTING PRN
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DORSAL DISLOCATION OF PIPJ: VOLAR PLATE ARTHOPLASTY FOR JTS THAT CANNOT BE REDUCED
answer
EXCISE COLLATERAL LIGAMENTS, STABILIZE W/WIRES 10-14 DAYS WIRE REMOVED, DBS @30, A/PROM IN FLEXION 4 WEEKS- AROM OUT OF SPLINT, JT BLOCKING 5 WEEKS- PASSIVE EXT, DYNAMIC EXT SPLINT 6 WEEKS- STRENGTH
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VOLAR DISLOCATION OF PIPJ: TXMT IF CENTRAL SLIP NOT COMPLETELY DISRUPTED
answer
PIP EXT. SPLINT W/DIP FREE X 6 WEEKS 6 WEEKS: AROM 7 WEEKS: PROM AND DYNAMIC SPLINTING *IF CENTRAL SLIP AVULSED, REPAIR OR 6 WEEKS PIP EXT SPLINT
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VOLAR DISLOCATION OF PIPJ: SURGICAL TXMT
answer
CENTRAL SLIP REPAIR W/KWIRES 2-3 WEEKS KWIRES PIP EXT SPLINT FOR 4 ADDITIONAL WEEKS= 6 WKS IMMOBILE 6 WEEKS- AROM PIPJ 8 WEEKS - PROM, DYNAMIC SPLINT
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MPJ SPRAIN: CONSERVATIVE TXMT FOR INCOMPLETE COLLATERAL LIGAMENT TEAR OR MINOR AVULSIONS
answer
HAND BASED GUTTER SPLINT MP @ 30-50 @ 3-4 WEEKS CHANGE TO BUDDY STRAPS W/AROM
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MPJ SPRAIN: SURGICAL PROTOCOL
answer
HAND BASED GUTTER SPLINT MP @30-50 3-4 WEEKS- AROM W/BUDDY TAPE 6 WEEKS- PROM, DYNAMIC SPLINTING 8 WEEKS-STRENGTH
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GENERAL LIGAMENT INJURY TXMT INFO:
answer
START AROM 3-4 WEEKS, PROM AT 6 WEEKS, STRENGTH @ 8
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MPJ DISLOCATION: CONSERVATIVE TXMT PROTOCOL
answer
DBS EXTENSION BLOCK AT 30-40 FLEXION X 3-4 WEEKS WEEK 1- MPJ AROM IN SPLINT WEEK 3- MPJ PROM FLEXION ONLY WEEK 6- PROG. STRENGTH DONT SACRIFICE MOBILITY FOR STABILITY OF JOINT!
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MPJ DISLOCATION: SURIGICAL TXMT PROTOCOL
answer
DBS EXTENSION BLOCK AT 30-40 FLEXION X 4-6 WEEKS WEEK 2- MPJ AROM IN SPLINT WEEK 3- MPJ PROM FLEXION ONLY WEEK 6- PROG. STRENGTH * DIFFERENCE BETWEEN TXMTS = 3-4 WEEKS VERSUS 4-6 WEEKS IN SPLINT
question
RCL LIGAMENT INJURY SPLINT POSITION:
answer
HAND OR FA BASED THUMB SPICA- THUMB IN SLIGHT FLEXION AND RADIAL DEVIATION W/IP FREE 3-6 WEEKS
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UCL LIGAMENT INJURY SPLINT POSITION:
answer
HAND OR FA BASED THUMB SPICA- THUMB IN SLIGHT FLEXION AND ULNAR DEVIATION W/IP FREE 3-6 WEEKS
question
UCL/RCL CONSERVATIVE MANAGEMENT:
answer
THUMB SPICA SPLINT IP FREE, AROM MP @ WEEK 4, PROM MP @ WEEK 5, DYNAMIC FLEXION SPLINT @ 6 WEEKS, NO TIP PINCH FOR 8 WEEKS
question
UCL/RCL SURGICAL MANAGEMENT:
answer
CAST THEN THUMB SPICA SPLINT W/ IP FREE X 4-6 WEEKS, PROM + DYNAMIC SPLINTING @ 6-8 WEEKS, STRENGTH @ 8-10 WEEKS
question
THUMB DISLOCATION: SIMPLE (CLOSED REDUCT)
answer
THUMB SPICA W/MP 20-30 X 3 WEEKS 3 WEEKS- AROM OF THUMB *FOCUS ON STRENGTH/FUNCTION NOT MAXIMAL FLEXION
question
THUMB DISLOCATION: COMPLEX (SURGERY)
answer
OPEN REDUCTION W/FPL TENDON SHEATH EXCISION & COLLATERAL REPAIR- DORSAL BLOCK THUMB SPICA MP @ 30 X 2 WEEKS 2 WEEKS- BLOCKED EXTENSION EXERCISES 6-8 WEEKS GENTLE PROM
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DISI POST OP MANAGEMENT: SL INSUFFICIENCY
answer
CAST 4-6 WEEKS TENODESIS AROM 4 WEEKS GENTLE PROM & GRIP 6 WEEKS FULL RESISTANCE 12 WEEKS DISI POST OP GOALS: SL INSUFFICIENCY ROM 40 FLEXION (FUNCTIONAL)
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4 CORNER FUSION IMMOBLIZATION TIME:
answer
IMMOBILIZED 6-7 WEEKS
question
PROXIMAL ROW CARPECTOMY: MANAGEMENT
answer
2-4 WEEKS IMMOBILIZED 4 WEEKS- AROM 6 WEEKS- STRENGTH MAY HAVE DECREASED FINGER FLEXION*******?
question
TOTAL WRIST FUSION: MANAGEMENT
answer
6-8 WEEKS CASTED WRIST COCK UP ADDITIONAL 8-12 WEEKS 10-12 WEEKS- STRENGTHENING
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LUNOTRIQUETRAL LIGAMENT INJURY: CONSERVATIVE MANAGEMENT
answer
CAST/SPLINT 6-8 WEEKS AROM 6 WEEKS GENTLE GRIP 8 WEEKS
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LT LIGAMENT INJURY POST OP MANAGEMENT:
answer
CAST 6-8 WEEKS SPLINT ADDITIONAL 4 WEEKS AROM 8 WEEKS GENTLE RESISTIVE 10-12 WEEKS
question
TFCC CONSERVATIVE MANAGEMENT:
answer
LAS NEUTRAL FA AND WRIST X 6 WEEKS- GENTLE PAINFREE AROM WRIST/FA OK BUT NO PHYSICAL ACTIVITY OOS 6 WEEKS- GENTLE AROM/PROM AS TOLERATED 8 WEEKS-IF NO PAIN, GENTLE STRENGTH W/NEUTRAL FA, NO WT BEARING OR ROTATION 10-12 WEEKS, IF ASYMPTOMATIC, ADD WT BEARING, DEVIATION, AND FA ROTATION STRENGTHENING
question
TFCC SURGICAL MANAGEMENT: CENTRAL DISK
answer
WRIST COCK UP SPLINT 1-2 WEEKS 1-2 WEEKS POST OP :AROM WRIST/FA 4-6 WEEKS POST OP: AAROM/PROM & GENTLE STRENGTH IN NEUTRAL ROTATION- PROGRESS IN ROTATION/WT BEAR AS ABLE GOAL- ELIMINATE PAIN- NOTHING TO PROTECT SO FASTER TXMT
question
TFCC SURGICAL MANAGEMENT: PERIPHERAL
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IMMOBILIZED IN LAS OR MUENSTER SPLINT 6-8 WEEKS W/ NEUTRAL FA AND WRIST 3-4 WEEKS GENTLE WRIST AROM-NO GRASP, ROTATION, WT 6-8 WEEKS FA ROTATION AROM, NOW WRIST SPLINT X 2-4 MORE WEEKS 8 WEEKS GENTLE PROM FA AND WRIST 10-12 WEEKS GENTLE STRENGTH W/FA IN NEUTRAL 12+ WEEKS- GENTLE STRENGTH W/ROTATION & WT BEARING
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EXTENSOR INSERTIONAL TENOSYNOVITIS/TENDINOSIS AN EXTENSOR TENDON CROSSING THE WRIST 2ND COMP MOST COMMON- FIBROSIS AT INSERTIONS
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CONSERVATIVE: WRIST SPLINT & AVOID PAIN X 4-6 WEEKS SURGICAL: NEUTRAL WRIST SPLINT 1-2 WEEKS THEN @1-2 WKS AROM/PROM, 6 WEEKS STRENGTH
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ECU TENOSYNOVITIS: CONSERVATIVE VS SURGERY
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NEUTRAL WRIST SPLINT X 4-6 WEEKS LAS 4-6 WEEKS, THEN INITIATE WRIST AROM, 8 WEEKS INITIATE SUPINATION AND PRONATION
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TRIGGER FINGER: MGMT
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2 CHOICES: HAND BASED MP EXTENSION OR PIP ONLY EXTENDED 3-6 WEEKS- WITH THUMB, INCLUDE IP IN EXT.
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TRIGGER FINGER: POST OP MGMT
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WEEK 1- STATIC PIP EXT SPLINT, PROM, SCAR/WOUND, DESENSITIZATION, W/STRENOUS TASKS SPLINT IN HAND BASED MP OR FINGER BASED PIP EXT
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FCR TENDINITIS:
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SYNOVITIS VISIBLE/PALPABLE PROXIMAL TO WRIST CREASE, PROXIMAL RADIATING PAIN MODIFY ACTIVITIES- WRIST SPLINT NEUTRAL TO SLIGHT FLEXION TO PREVENT RD FOR 4-6 WEEKS POST OP: SMALE SPLINT X 2 WEEKS REMOVING FOR GENTLE AROM, IF STT OR CMC INVOLVED INCLUDE THUMB, STRENGTH & STRETCH AS TOLERATED
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FCU TENDINITIS:
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PAIN ALONG ULNAR VOLAR WRIST- DORSAL SPLINT W/SLIGHT FLEXION POST OP: DORSAL SLIGHT FLEXED WRIST SPLINT X 2 WEEKS, STRETCH / STRENGTH AS TOLERATED
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When is tendon gliding initiated in digital repalnts?
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4 weeks post op
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Digital Replant general info:
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All exercises start in first 2 weeks, beginning with (4)days passive tenodesis, (7)days passive tabletop/claw, then (14)days active tabletop/claw Limit PIP flexion to 60 to avoid bout. deformity Contraindicated for replant=at PIP joint level
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Treatment of different stages of shoulder impingement:
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Stage I of shoulder impingement: abd>IR Stage II of shoulder impingement: treatment same as previous, restore full A/PROM, stretching and manual techniques Stage III of shoulder impingement: presentation & txmt disruption of RTC tendons, bone spurs, painful arc with loss of ROM + weak/painful tests txmt:same as stage II-may need surgery if no improvement
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RTC repair REHAB PROTOCOL;%%%%%%%%
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DELTOID reflected to get to the SUPRASPINATUS which is repaired: Sling/pillow x 4 weeks for tendon healing, regain scap control immediately 1-3 days pendulum, NO other AROM 3-5 days PROM all EXCEPT EXTENSION & ABDUCTION, can do table top FF, careful with ER 4 weeks AROM except shlrd ext/abd 5 weeks A/P shlrd EXT/abd begins passively 6 weeks full PROM including extension/abd, isometrics, dc immobilizer 8+ weeks isotonic 3-6 months sports When can cane exercises begin after RTC repair? 4-8 weeks AAROM
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Shoulder instability non-op txmt:
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retrain dynamic stabilizers of GHJ, decrease pain/infl., restore ROM avoiding excessive ER/ABD, scap muscle control by delts, RTC & scap mm, progress to overhead, progress to ER/ABD control
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Shoulder instability operative txmt: Bankart repair w/capsular shift
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Repair of ANTER-INFERIOR GH LIGAMENT on the front of the anterior capsule which is the primary stabilizer of the shoulder in the 90/90 position and also anteriorly restrains the GH head in ER of the shoulder AVOID: 90/90 for ligament repair, No ER>30 for ligament repair (IGHL restricts ER @90 so some ER is allowed at 0), Shoulder ext due to anterior capsule repair Bankart general guidelines open thru subscap, antertior capsule split, repair w/anchors, then capsule repair: sling 3-4 wks (open) sling 1-2 wks (arthro) 2 weeks Codman & PROM to shldr- exceptions below NO ER >NEUTRAL X 2 WEEKS due to subscap repair 3-6 weeks Active ER/IR - no 90/90 5-6 weeks Passive ER in adducted position 6-8 weeks Active and Passive ER including 90/90, isometrics 8 weeks isotonic 12 weeks 90/90 ok (4-6 weeks per ASHT)
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SLAP txmt is mostly surgical: txmt of type II
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Biceps tendon which was torn out is anchored into bicipital tunnel and the superior labrum tear is repaired to the top of the GH jt- the SGHL repaired! AVOID: ER>0 due to SGHL which restrains ER at adducted 0 position, shoulder EXTENSION due to biceps repair, NO 90/90 due to stress on the anterior capsule and ligaments *MOST RESTRICTED OF THE SURGERIES DUE TO THE MULTIPLE STRUCTURES REPAIRED- BICEPS, CAPSULE, LABRUM, SGHL - 3-4 weeks immobilized, initiate A/AA/PROM *EXCEPT FOLLOWING RESTRICTIONS {for 4 wks: ER >neutral or shld extension w/elbow ext. for 8 weeks: >90/90 contraindicated } @ 6-8 weeks: start strengthening regain post. capsule length, respect the biceps tendon & no strain until post-op 3-4 month, type I and III- progress as pain allows, because only arthoscopic debridement
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Greater tuberosity humerus fracture:
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non-displaced: ASAP active ex. to avoid stiffness displaced/avulsed: surgery w/immobilized 2-3 weeks
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Neck of the humerus fracture: (proximal)
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types: unimpacted, angulated impacted, comminuted *impact/non-displ: sling 7-10 days, out freq. for exer. *significant displace= immobilized 2-3 weeks *hemiarthoplasty or ORIF in the old w/ang. > 45 deg
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Total shoulder arthroplasty post op txmt:
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SUBSCAPULARIS is cut to expose the joint AVOID: NO ER> what got in OR: typically 0-30 is safe If RTC repair needed, recovery is more restricted/long, no Active IR due to subscapularis repair post op day 1-3 PROM only, codmans Dont exceed O.R. external rotation x 6 wks (30 is safe) 2-3 weeks Scapula strength 3-6 weeks AROM but NO 90/90 abd/ER 5-6 weeks Passive ER 6-8 weeks RTC isometrics @ 6, isotonic @ 8 12 weeks reg. activity, sports 6 months timeline delayed with RTC repair (same protocol as Bankart repair)
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ACROMIOPLASTY
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CORACOACROMIAL LIGAMENT may be removed, bone is shaved down AVOID: Shoulder FLEX or EXT for 3 weeks to avoid humeral head hitting acromion, no 90/90, IR/ER ok at 0 only Sling x 2 weeks, pendulums, PROM immediately post-op- IR/ER at side, NO SHLDR EXTENSION OR FLEXION to protect repaired deltoid, NO AROM except scap. 3 wks wean sling, P/A shldr ext., full PROM by 3 wks 4-6 wks isometrics 6-8 wks isotonic 3-6 mo. sports
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Biceps tenodesis procedure protocol: fixation of long biceps tendon in the groove
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post op day 2 PROM w/progressive elb. ext. as pain allows, w/full ext not achieved for 5-6 wks NO resistive elbow flexion 2-3 weeks AROM 4-6 weeks strengthening 2-3 months heavy resistance Starts with PROM including elbow/shldr extension! AVOID: FULL elbow extension, Shoulder extension w/combined elbow ext, NO resistive elbow flexion! AROM starts @ 2-3 weeks!
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General Rehab of shoulder fractures:
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early mobilization is essential once safe to do so= pendulum, A/AAROM Once stable PROM as needed if pain ok Low jt mobs early- capsular pattern seen w/sling use Can start strength when 1)stable 2) have 50% of ROM back 3)pain low
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Shoulder repairs of labrum general info:
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sling plus PROM 1st
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Humerus shaft fracture:
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2 week immobilized then brace splint 3-4 weeks AROM- codman's & surrounding jts 4-5 weeks AAROM 6 weeks PROM 8 weeks strength/ DC splint *IMPORTANT- due to angulation issues, no early AROM except codman's- wait until 3-4 weeks for AROM No early PROM to avoid angulation, just like other FXs AVOID: ER and ABDUCTION of shoulder for angulation precautions somewhat early motion, watch for radial nerve palsy- strength when 50% of ROM, once stable PROM ok SARMIENTO BRACE SPLINT
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Shoulder fractures of humerus gen. info:
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sling plus early AROM
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Shoulder RTC repairs general info:
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0-4 wk PROM, 4-8 wk AAROM, 8 wk AROM, 6-8 wk isometrics, 8 - 16 wk isotonic- NO EXT until at least 6 weeks NO ABDUCTION OR SHOULDER EXTENSION sling/pillow x 4 weeks- NO CODMAN"S
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PIP joint arthoplasty post op txmt plan: general guidelines
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3-5 days digit extension splint 3-5 days AROM avoiding lateral forces 3 weeks PROM 6 weeks light strength 6 weeks splint to nights only
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Finger joint arthrodesis txmt protocol:
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casted and pinned up to 6 weeks=fx healing time @ 6 weeks, when clinically healed can do stregthening, scar management, jt protection principles, edema cntrl -needs around 3 visits to achieve goals
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Main points of this protocol: Immediate short arc active motion protocol ( ICAM Evans)
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what flexor zone areas used for? I and II flexor zones AKA Short Arc Motion or SAM: a early active controlled motion protocol using MAMT DBS w/RB traction and pulley bar: think there is also another splint for DIP jt in 40-45 flexion that's dorsal *starts 1-3 days post repair In therapy ONLY exercises: <30gm pressure * place and hold gentle, loose fist, pt holds w/low pressure=15-20 grams force * passive wrist tenodesis by therapist HEP exercises: In splint: 10-20 passive fists, active IP extension to splint Out of splint: Hold MPs at 90 and actively ext IPs Night: straps IPs into full extension At 3 wks, patient begins ACTIVE place and hold OOS with wrist extended to decrease pull on flexors- 4 weeks AROM OOS 6 weeks D/C splint, begin blocking, resistance 6-8 weeks depending on adhesions
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Arthoscopic Subacromial decompression ONLY txmt plan: not open or RCT repair
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PROM immediately post-op 4-5 days progress to AROM as pain and motion will allow: 3-4 weeks resistive exercises begin
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Clavice fracture:
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firgure of 8 1 week A/PROM 4-6 weeks A/AAROM 6 weeks strength
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Blatt capsulodesis for scaphoid trouble:
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scaphoid pinned to capitate and metacarpal 6-8 weeks TSS, IP free, A/AA/gentle PROM 8-10 weeks PROM, strength 12 weeks unrestricted 20% loss of grip
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Anterior decompression of ulnar nerve:
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least invasive 3-5 days A/PROM 2 weeks desensitization
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Ant. Transposition of ulnar nerve: ant to medial epicondyle
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2 weeks LAS 90 FA/wrist 0, AROM @ 5-10 days 3 weeks AAROM, dc splint, add night splint @ 30 6 weeks PROM, dc night splint, strength
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Ant. Intramuscular Transposition: put in flexor muscle mass ant. to med. epic.- SAME PROTOCOLS Ant. SUBmuscular transposition:
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2 weeks LAS 90 FA slight pro., wrist 0, 5- 10 days AROM in protected pronated position 3 weeks unrestricted AROM 5 weeks AAROM 6 weeks PROM 8-10 work cond. Epicondylectomy protocol the same
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Radial tunnel; post op txmt surgical
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3-5 days AROM 2 weeks PROM 3 weeks strength hand only 6 weeks strength ALL
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Digital nerve repair:
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5-7 days DBS, MP 30 flex, A/PROM in splint 4 weeks MP to 20 5 weeks MP to 10 6 weeks DC splint, A/PROM 8 weeks strength
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Large nerve repair at wrist level: same general protocol for all nerves
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10-14 days DBS wrist 30 flex or ext depending on if median/ulnar or radial, A/PROM to hand only 4 weeks DBS wrist modified to 20 flex or ext 5 weeks DBS wrist modified to 10 flex or ext 6 weeks DC splint, strength, A/PROM to wrist 8 weeks work cond. Radial nerve exceptions- if injury is above elbow, a dorsal hand outrigger splint is needed instead, plus elbow splint 2 weeks elbow @ 90-100 flex 4 weeks elbow 60 flexion 5 weeks elbow 30 flexion 6 weeks DC elbow splint, A/PROM unrestricted
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Distal humerus fracture:
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2 weeks immobilized then hinged brace for med/lat stability and AROM no PROM to avoid angulation of fracture
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Wrist salvage procedures:
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1. STT fusion- 30/30 flexion/ext ~50%motion (up to 8-16 weeks immobilized) 2. Dorsal capsulodesis 3. 4 corner fusion- LTHC fused, scaphoid excised -50% motion, 80% grip (immobilized 6-7 wks) 4. Prox row carpectomy (PRC): 4 wks AROM,6 strength - 50% wrist motion, 80% grip 5. Total wrist fusion: 6-8 wks cast, cock-up 8-12 wks, 10-12 wks strength
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What is the main difference between early passive and early active motion protocols?
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place and hold done early in EAM- done much later around 3-4 weeks with EPM
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SHOULDER FX VERSUS SHOULDER REPAIR SURGERIES?
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SHLDR FX= EARLY AROM, WAIT ON PROM- AROM ACTUALLY HELPS FX ALIGNMENT, WHILE PROM WOULD CAUSE DEFORMATION - CODMAN'S OK SHOULDER REPAIR SURGERIES= INVOLVES MUSCLE REPAIRS, SO LIKE OTHER TENDON ISSUES YOU DO PROM FIRST THEN AROM LATER TO AVOID PULL OF CONTRACTILE TISSUE WHICH CAN DAMAGE REPAIR
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Steindler flexorplasty:
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for brachial plexus injury to restore elbow flexion function- transposes the flexor/pronator origin more proximally on the humerus giving ability to flex against weight up to 5#
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MCP extensor tendon versus ligament:
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MP extensor tendon- put @ 0 degrees ext so dont over stretch and get extensor lag MP ligament: put at 30 flexion for collateral lig stretch so dont loose flexion
