hand and upper extremity disorders and injuries – Flashcards

-Disease of the fascia of the palm and digits: 1) fascia becomes thick and contracted 2) results in flexion deformities of the involved digits -Etiology: unknown -Conservative treatment had not been successful -Surgical release is required: 1) fasciotomy with Z plasty 2) aponeurotomy 3) McCash procedure (open palm) -Occupational therapy intervention: 1) wound care - dressing changes, whirlpool if infection is suspected 2) edema control - elevation above the heart 3) extension splint - initially at all times except to remove for ROM and bathing 4) A/PROM, and progress to strengthening when wounds are healed 5) scar management (massage, scar pad, and compression garment) 6) functional tasks that emphasize flexion (gripping) and extension (release)

-Rupture of the ulnar collateral ligament of the MCP joint of the thumb -Etiology: most common cause is a fall while skiing with the thumb held in a ski pole -Occupational therapy intervention: 1) conservative treatment including a thumb splint (for 4 to 6 weeks) 2) AROM and pinch strengthening (at 6 weeks) 3) focus on ADL that require opposition and pinch strength 4) post-operative treatment includes thumb splint for 6 weeks, followed by AROM, PROM can begin at 8 weeks and strengthening at 10 weeks

-Type I formerly known as reflex sympathetic dystrophy (RSD) -Type II formerly known as causalgia -Vasomotor dysfunction as a result of an abnormal reflex -It can be localized to one specific area or spread to other parts of the extremity -Etiology: may follow trauma (eg. Colles' fracture) or surgery, but actual cause is unknown -Symptoms include severe pain, edema, discoloration, osteoporosis, sudomotor changes, temperature changes, trophic changes, and vasomotor instability -Occupational therapy intervention: 1) modalities to decrease pain 2) AROM to involved joints 3) ADL to encourage pain-free active use 4) stress loading (weight bearing and joint distraction activities, including scrubbing and carrying activities) 5) splinting to prevent contractures and enable ability to engage in leisure/productive activities 6) interventions to avoid include passive range of motion, passive stretching, joint mobilization, dynamic splinting, and casting 7) encourage self management

-Intraarticular versus extraarticular -Closed versus open -Dorsal displacement versus volar displacement -Midshaft versus neck versus base -Complete versus incomplete -Transverse versus spiral versus oblique -Comminuted

-Closed reduction: types of stabilization include short arm cast (SAC), long arm cast (LAC), splint, sling, or fracture brace -Open reduction internal fixation (ORIF): types include nails, screws, plates, or wire -External fixation -Arthrodesis: fusion -Arthroplasty: joint replacement

-Colles' fracture: fracture of the distal radius with dorsal displacement -Smith's fracture: fracture of the distal radius with volar displacement -Carpal fractures: most common is scaphoid fracture (60% of carpal fractures). The proximal scaphoid has a poor blood supply and may become necrotic -Metacarpal fractures: classified according to location (head, neck, shaft, or base). A common complication is rotational deformities. A Boxer's fracture is a fracture of the fifth metacarpal (requires an ulnar gutter splint) -Proximal phalanx fractures: most common with thumb and index. A common complication is loss of PIP A/PROM -Middle phalanx fractures: not commonly fractured -Distal phalanx fractures: most common finger fracture. May result in mallet finger (which involves terminal extensor tendon) -Elbow fracture: involvement of the radial head may result in limited rotation of the forearm -Humerus fractures: nondisplaced vs. displaced fractures - 1) etiology - fall onto an outstretched upper extremity 2) fractures of the greater tuberosity may result in rotator cuff injuries 3) humeral shaft fractures may cause injury to the radial nerve resulting in wrist drop

-History should include mechanism of injury and fracture management -Results of special tests (X-rays, MRI, and CT scan) -Edema -Pain -AROM: 1) do not assess PROM or strength until ordered by physician 2) exceptions are humerus fractures which often begin with PROM or AAROM -Sensation -Roles, occupations, ADL and activities related to roles

-Immobilization phase: stabilization and healing are the goals: 1) AROM of joints above and below the stabilized part 2) edema control - elevation, retrograde massage, and compression garments 3) light ADL and role activities with no resistance, progress as tolerated -Mobilization phase: consolidation is the goal 1) edema control - elevation, retrograde massage, contrast baths, and compression garments 2) AROM (progress to PROM when approved by physician [4 to 8 weeks]; exceptions are humerus fractures which often begin with PROM or AAROM) 3) light functional/purposeful activity 4) pain management - positioning and physical agent modalities 5) strengthening - being with isometrics when approved by physician

-Also known as repetitive strain injuries (RSI), overuse syndromes, and/or musculoskeletal disorders -Risk factors: repetition, static position, awkward postures, forceful exertions, and vibration -Non-work risk factors: acute trauma, pregnancy, diabetes, arthritis, and wrist size and shape -Most common types: 1) DeQuervain's - a) stenosing tenosynovitis of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) b) pain and swelling over the radial styloid c) positive Finkelstein's Test d) conservative treatment - thumb spica splint (IP joint free); activity/work modification; ice massage over radial wrist; gentle AROM of wrist and thumb to prevent stiffness e) post operative treatment - thumb spica splint and gentle AROM (0-2 weeks); strengthening, ADL, and role activities (2-6 weeks); unrestricted activity (6 weeks) 2) Lateral and medial epicondylitis: a) degeneration of the tendon origin as a result of repetitive microtrauma b) lateral epicondylitis - overuse of wrist extensors, especially the extensor carpi radialis brevis. Also called tennis elbow c) medial epicondylitis - overuse of wrist flexors. Also called golfer's elbow d) conservative treatment - 1) elbow strap, wrist splint 2) ice and deep friction massage 3) stretching 4) activity/work modification 5) as pain decreases, begin strengthening 3) Trigger finger: a) tenosynovitis of the finger flexors - most commonly is the A1 pulley b) caused by repetition and the use of tools that are placed too far apart c) conservative treatment - 1) hand based trigger finger splint (MCP extended, IP joint free) 2) scar massage 3) edema control 4) tendon gliding 5) activity/work modification - avoid repetitive gripping activities and using tools with handles too far apart

-Rationale for early mobilization: 1) prevents adhesion formation 2) facilitates wound/tendon healing -Occupational therapy goals: 1) increase tendon excursion 2) improve strength at repair site 3) increase joint ROM 4) prevent adhesions 5) facilitate resumption of meaningful roles, occupations, and activities

-Active extension of digit with passive flexion using rubber traction -Protocol: 1) 0-4 weeks - dorsal block splint. Passive flexion and active extension within limits of splint 2) 4-6 weeks - wristlet. Place/hold exercises. Scar management 3) 6-8 weeks - AROM. Tendon gliding and differential tendon gliding. Light ADL and role activities. D/C splint 4) 8-12 weeks - strengthening and work and leisure activities

-Passive flexion and extension of digit -Protocol: 1) 0-4 1/2 weeks - dorsal blocking splint. Exercises in splint include passive flexion of PIP joint, DIP joint and to DPC. 10 reps every hour 2) 4 1/2-6 weeks - active flexion and extension within limits of splint 3) 6-8 weeks - tendon gliding and differential tendon gliding, scar management, light ADL and role activities 4) 8-12 weeks - strengthening and work activities

-Zone I and II: 1) mallet finger deformity 2) 0-6 weeks - DIP extension splint -Zone III and IV: 1) boutonneire deformity 2) 0-4 weeks - PIP extension splint (DIP free); AROM of DIP while in splint 3) 4-6 weeks - begin AROM of DIP and flexion of digits to the DPC -Zone V, VI, and VII: 1) 0-2 weeks - volar wrist splint with wrist in 30 degrees of extension, MCPs in 0-10 degrees of flexion, and IP joints in full extension 2) 2-3 weeks - shorten splint to allow flexion and extension of IP joints 3) 4 weeks - remove splint to begin MCP active flexion and extension 4) 5 weeks - begin active wrist ROM. Wear splint in between exercise sessions 5) 6 weeks - discharge splint

-Three major nerves: median, ulnar, and radial -Two types of nerve injuries: 1) compression 2) laceration

-A median nerve compression -Etiology: repetition, awkward postures, vibration, anatomical anomalies, and pregnancy -Symptoms: 1) numbness and tingling of the thumb, index, middle, and radial half of the ring fingers 2) paresthesias usually occur at night 3) person will complain of dropping things 4) positive Tinel's sign at wrist. Positive Phalen's sign 5) advanced stage of CTS can result in muscle atrophy of the thenar eminence -Conservative treatment: 1) wrist splint in neutral; should be worn at night and during the day if performing repetitive activity 2) median nerve glides 3) activity modification; avoid activities with extreme positions of wrist flexion, wrist flexion with repetitive finger flexion, and wrist flexion with a static grip 4) ergonomics - appropriate workstation design, CTS is the most common work related injury of the upper extremity -Surgical intervention: carpal tunnel release (CTR) -Post-operative treatment of CTR: 1) edema control - elevation, retrograde massage, compression glove and/or contrast bath 2) AROM 3) nerve and tendon gliding exercises 4) sensory reeducation 5) strengthening of thenar muscles 6) work/activity modification

-A median nerve compression between two heads of pronator teres -Etiology: repetitive pronation and supination and excessive pressure on volar forearm -Symptoms: same as CTS and also aching pain in proximal forearm - 1) positive Tinel's sign at the forearm 2) not night symptoms -Conservative treatment: 1) elbow splint at 90 degrees with forearm in neutral 2) avoid activities that include repetitive forearm pronation and supination -Surgical intervention: decompresssion -Post-operative treatment: 1) AROM 2) nerve gliding 3) strengthening ( 2 weeks post-operative) 4) sensory reeducation 5) work/activity modification

-An ulnar nerve compression at the wrist -Etiology: repetition, ganglion, pressure, and fascia thickening -Symptoms: 1) numbness and tingling in the ulnar nerve distribution of the hand 2) motor weakness of ulnar nerve-innervated musculature 3) positive Tinel's sign at Guyon's canal 4) advanced stages can lead to atrophy of ulnar nerve-innervated musculature in the hand -Conservative treatment: 1) wrist splint in neutral 2) work/activity modification -Surgical treatment: decompression -Post-operative intervention: 1) edema control 2) AROM 3) nerve gliding 4) strengthening (2-4 weeks); focus on power grip 5) sensory reeducation

-An ulnar nerve compression at the elbow -Etiology: second most common compression; pressure at elbow (leaning on elbow) and extreme elbow flexion -Symptoms: 1) numbness and tingling along ulnar aspect of forearm and hand 2) pain at elbow with extreme position of elbow flexion 3) weakness of power grip 4) positive Tinel's sign at elbow 5) advanced stages can lead to atrophy of FCU, FDP to digits IV and V and ulnar nerve-innervated intrinsic muscles of the hand -Conservative treatment: 1) elbow splint to prevent positions of extreme flexion (especially at night) 2) elbow pad to decrease compression of nerve when leaning on elbows 3) activity/work modification -Surgical intervention: decompression or transposition -Post-operative treatment: 1) edema control 2) scar management 3) AROM and nerve gliding (2 weeks post-operative) 4) strengthening (4 weeks post-operative) 5) MCP flexion splint if clawing noted

-A radial nerve compression -Etiology: Saturday night palsy, a term used to describe sleeping in a position that places stress on the radial nerve. Also, compression as a result of humeral shaft fracture -Symptoms: weakness or paralysis of extensors to the wrist, MCPs, and thumb; wrist drop -Conservative treatment: 1) dynamic extension splint 2) work/activity modification 3) strengthening wrist and finger extensors when motor functions returns -Surgical intervention: decompression -Post-operative treatment: 1) ROM 2) nerve gliding 3) strengthening (6-8 weeks post-operative) 4) ADL and meaningful role activities

-Sensory loss: 1) central palm (thumb to radial 1/2 of ring finger) 2) palmar surface of thumb, index, middle, and radial 1/2 of ring fingers 3) dorsal surface of index, middle, and radial 1/2 of ring fingers (middle and distal phalanges) -Motor loss for a low lesion at the wrist: 1) lumbricals I and II (MCP flexion of digits II and III) 2) opponens pollicis (opposition) 3) abductor pollicis brevis (abduction) 4) flexor pollicis brevis (flexion of thumb MCP) -Motor loss for high lesion at or proximal to the elbow: 1) same as for low lesion at wrist 2) FDP to index and middle fingers, and FPL (flexion of tip of index, middle fingers, and thumb) 3) FCR (inability to flex to radial aspect of wrist) -Deformity: 1) flattening of thenar eminence, "ape hand" 2) clawing of index and middle fingers for a low lesion 3) benediction sign for a high-lesion -Functional loss: 1) loss of thumb opposition 2) weakness of pinch -Occupational therapy intervention: 1) dorsal protection splint with wrist positioned in 30 degree flexion if a low lesion. Include elbow (90 degree flexion) if a high lesion 2) begin A/PROM of digits with wrist in flexed position at two weeks post-operative 3) scar management 4) AROM of wrist 4 weeks; include elbow if a high lesion 5) begin strengthening at 9 weeks -Splinting consideration: C-bar to prevent thumb adduction contracture -Sensory reeducation: begin when individual demonstrates a level of diminished protective sensation (4.31) on Semmes-Weinstein

-Sensory loss: 1) ulnar aspects of palmar and dorsal surfaces 2) ulnar 1/2 of ring and little fingers on palmar and dorsal surfaces -Motor loss for low lesion at the wrist: 1) palmar and dorsal interossei (adduction and abduction of MCP joints) 2) Lumbricals III and IV (MCP flexion of digits 4 and 5) 3) FPB and adductor pollicis (flexion and adduction of tumb) 4) ADM, ODM, FDM (abduction, opposition, and flexion of 5th digit) -Motor loss for high lesion wrist or above: 1) same as with low lesion, including FCU (flexion towards ulnar wrist) 2) FDP IV and V (flexion of DIPs of ring and little fingers) -Deformity: 1) claw hand 2) flattened metacarpal arch 3) + Froment's sign (assessment of thumb adductor while laterally pinching paper) -Functional loss: 1) loss of power grip 2) decreased pinch strength -Occupational therapy intervention: 1) similar to median nerve repair 2) splinting consideration - MCP flexion block splint 3) sensory reeducation - same as median nerve

-Sensory loss high lesions at the level of the humerus: medical aspect of dorsal forearm. Radial aspect of dorsal palm, thumb, and index, middle and radial 1/2 of ring phalanges -Motor loss low lesion at the level of the forearm: 1) loss of wrist extension due to absent or impaired innervation to ECU 2) EDC, EI, EDM (MCP extension) 3) EPB, EPL, APL (thumb extension) -Motor loss high lesion at the level of the humerus: 1) all the above, including ECRB, ECRL, and brachioradialis 2) if level of the axilla, loss of triceps (elbow extension) -Functional loss: 1) inability to extend digits to release objects 2) difficulty manipulating objects -Deformity: wrist drop -Occupational therapy intervention: 1) dynamic extension splint 2) ROM 3) sensory reeducation if needed 4) instruct in home program 5) activity modification

-Anatomy of rotator cuff: 1) supraspinatus (function - abduction and flexion) 2) infraspinatus and teres minor (function - external rotation) 3) subscapularis (function - internal rotation) -The rotator cuff functions together to control the head of the humerus in the glenoid fossa -Site of impingement: coracoacromial arch (acromion, coracoacromial ligament, and coracoid process) -Etiology: 1) repetitive overuse 2) curved or hooked acromion 3) weakness of rotator cuff 4) weakness of scapula musculature 5) ligament and capsule tightness 6) trauma -Occupational therapy conservative intervention: 1) activity modification - avoid above shoulder level activities until pain subsides 2) educate in sleeping posture - avoid sleeping with arm overhead or combined adduction and internal rotation 3) decrease pain - positioning, modalities, and rest 4) restore pain free ROM 5) strengthening - below shoulder level 6) occupational and role specific training -Surgical interventions: 1) arthroscopic surgery 2) open repair - small, medium, large, and massive tears -Occupational therapy post-operative intervention: 1) PROM (0-6 weeks); progress to AA/AROM 2) decrease pain - being with ice, progress to heat 3) strengthening (6 weeks post-operative) - begin with isometrics, progress to isotonic (below shoulder level) 4) activity modification - light ADL and meaningful role activities; progress as tolerated 5) leisure and work activities (8-12 weeks post-operative)

-Also known as frozen shoulder -Restricted passive shoulder range of motion: greatest limitation is external rotation, then abduction, internal rotation, and flexion -Anatomy: glenohumeral ligaments and joint capsule -Etiology: 1) inflammation and immobility 2) linked to diabetes mellitus and Parkinson's disease -Occupational therapy conservative intervention: 1) encourage active use through ADL and role activities 2) PROM 3) modalities -Surgical interventions: manipulation and arthroscopic surgery -Occupational therapy post-operative intervention: 1) PROM immediately following surgery 2) pain relief - modalities 3) encourage use of extremity for all ADL and role activities

-Anterior dislocation most common -Etiology: 1) trauma 2) repetitive overuse -Occupational therapy intervention: 1) regain ROM - avoid combined abduction and external rotation with anterior dislocation 2) pain free ADL and role activities 3) strengthen rotator cuff

-An inflammation of a joint or joints

-Systemic, symmetrical and affects many joints -Most commonly attacks the small joints of the hands -Characterized by remissions and exacerbations -Begins in the acute phase as an inflammatory process of the synovial lining -Etiology is unknown but there are two main theories: 1) infection theory 2) autoimmune theory -Symptoms: 1) pain 2) stiffness 3) limited range of motion 4) fatigue 5) weight loss 6) limited activities of daily living status, diminished ability to perform role activities 7) swelling 8) deformities -Types of deformities common with rheumatoid arthritis: 1) ulnar deviation and subluxation of the wrists and MCP joints 2) boutonniere deformity - flexion of PIP joint and hyperextension of DIP joint 3) swan neck deformity - hyperextension of PIP joint and flexion of DIP joint

-Degenerative joint disease: 1) not systemic but wear and tear 2) commonly affects large weight bearing joints 3) attacks hyaline cartilage -Etiology: 1) genetic 2) trauma 3) inflammation 4) cumulative trauma 5) endocrine and metabolic disease -Symptoms: 1) pain 2) stiffness 3) limited range of motion 4) bone spurs -Types of bone spurs: 1) Heberden's nodes at the DIP joints 2) Bouchard's nodes at the PIP joints

-Occupational role requirements and expectations -ROM (focus on AROM): 1) PROM should be avoided, especially in the inflammatory stage 2) note deformities and nodules -Muscle strength: 1) avoid muscle testing unless requested by physician 2) document strength in relation to function -Grip strength: use sphygmomanometer -ADL and role activities: note if ADL and role activity deficits are related to pain, limitation in motion, deformity, weakness, or fatigue -Pain: use pain scales -Edema: volumeter or tape measure

-Splinting: 1) resting hand splints in the acute stage 2) wrist splint only if arthritis specific to wrist 3) ulnar drift splint to prevent deformity 4) silver ring splints to prevent boutonniere and swan neck deformities 5) dynamic MCP extension splint with radial pull for post-operative MCP arthroplasties 6) hand base thumb splint for CMC arthritis -Joint protection techniques -Energy conservation techniques -ROM (focus on AROM): 1) gentle PROM if person unable to perform AROM 2) all exercises should be pain free -Heat modalities: 1) hot packs can be used before exercise 2) paraffin is recommended for the hands -Strengthening: 1) avoid during inflammatory stage 2) gentle strengthening while avoiding positions of deformity -ADL and role activities: 1) joint protection and energy conservation techniques should be incorporated 2) adaptive equipment should be provided to prevent deformity, decrease stress on small joints, and extend reach

-Etiology: an autosomal dominant inherited disorder -Signs and symptoms: 1) fractures in utero, and during the birthing process in the most severe cases 2) brittle bones that fracture easily 3) multiple fractures as the child grows 4) deformities of the arms and legs 5) developmental growth problems 6) eye abnormalities (ie blue sclera, cataracts) 7) risk of hearing impairments -Medical management: 1) cast and braces 2) pain management 3) audiological consultation 4) activity restrictions due to high risk of fractures and actual fracture occurrence -Occupational therapy evaluation: 1) activity interests that can be safely pursued 2) environmental risk factors -Occupational therapy intervention: 1) activity adaptation and assistive device prescription to facilitate safe participation in daily occupations 2) environmental modifications to maintain safety 3) preventive positioning and protective splinting/padding 4) activities to increase muscle strength 5) weight bearing activities to facilitate bone growth 6) family, caregiver and teacher education regarding proper handling, positioning, safety, and activity/environmental modification

-Etiology: 1) trauma 2) osteoporosis 3) pathological fractures (ie. cancer) -Types: 1) femoral neck fracture 2) intertrochanteric fracture 3) subtrochanteric fracture -Medical management: 1) closed reduction for minimally displaced fractures 2) open reduction internal fixation (ORIF) 3) joint replacement -Occupational therapy evaluation: 1) review precautions and weight bearing status before initiating evaluation 2) occupational role requirements and expectations 3) ADL focus on dressing, bathing and transfers 4) ROM and strength of upper extremities 5) conduct other assessments as needed, (eg. cognitive) -Occupational therapy intervention: 1) bed mobility and bedside ADL 2) upper extremity strengthening 3) functional ambulation and transfers with appropriate weight bearing status and appropriate ambulation device (ie. walker, crutches) (the type of ambulation device is determined by the person's weight bearing status) 4) instruct in and practice use of assistive devices for use in the home (eg. shower chair, elevated commode seat) 5) practice role activities (eg. small meal preparation) using proper weight bearing status and ambulatory device -Precautions: 1) weight bearing status and the amount of ROM allowed at the hip will be determined by the surgeon 2) time frames for beginning OT intervention are also determined by the surgeon -Complications: 1) avascular necrosis 2) non-union 3) degenerative joint disease 4) the result of complications can be the need for a total hip replacement

-Etiology: 1) trauma, from hip fracture 2) disease, most often arthritis; surgery is then elective -Types: 1) total hip joint implant - replaces acetabulum and femoral head 2) Austin Moore - partial hip replacement. Replaces femoral head 3) hybrid cemented total hip arthroplasty -Surgical procedures: 1) cemented or uncemented 2) anterolateral or posterolateral (more common) -Occupational therapy evaluation: 1) review precautions and weight bearing status before initiating evaluation 2) occupational role requirements and expectations 3) ADL - focus on dressing, bathing, and transfers 4) ROM and strength of upper extremities 5) conduct other assessments as needed (eg. cognitive) -Occupational therapy intervention: 1) educate the individual in hip precautions (a) do not flex beyond 90 degrees b) do not adduct or cross legs [do not internally rotate (for anterolateral approach avoid external rotation)] c) do not pivot at hip d) sit only on raised chair and raised toilet seat e) transfer sit to stand by keeping operated hip in slight abduction and extended out in front) 2) instruct in and practice use of long handled equipment 3) provide transfer training (practice with tub bench, raised toilet seat; practice car transfers; practice bed to chair transfers) 4) practice role activities [eg. small meal preparation] using proper weight bearing status and ambulatory device

-Etiology: congenital, peripheral vascular disease, trauma, cancer, and infection

-Upper extremity level of amputation: 1) forequarter = loss of clavicle, scapula and entire upper extremity 2) shoulder disarticulation = loss of entire upper extremity 3) above-elbow (AE)(long or short) = amputation above the elbow at any level on the upper arm 4) elbow disarticulation = amputation of the upper extremity distal to the elbow joint 5) below-elbow (BE)(long or short) = amputation below the elbow at any level of the forearm 6) wrist disarticulation = amputation distal to the wrist joint. Loss of entire hand 7) finger amputation = amputation of digit(s) at any level -Lower extremity level of amputation: 1) hemipelvectomy = amputation of half of pelvis and entire lower extremity 2) hip disarticulation = amputation at the hip joint. Loss of the entire lower extremity 3) above-knee amputation (transfemoral) = amputation above knee at any level on the thigh 4) knee disarcticulation = amputation at the knee joint 5) below-knee amputation (transtibial) = amputation below knee at any level on the calf. Most common 6) complete tarsal = amputation at the ankle 7) partial tarsal = amputation of metatarsals and phalanges 8) complete phalanges = amputation of toe(s)

-Function to grasp and maintain hold on an object -The two main types of TDs are the hook and the hand: 1) voluntary opening (VO) = hook remains closed until tension is placed on cable and then it opens 2) voluntary closing (VC) = hook remains opened until tension is placed on cable and then it closes -Determination of the most appropriate TD is based upon the person's interests, roles, and preferences (TDs can be interchangeably used with prosthesis if the shaft size is the same

-Cosmesis: considered poor; does not replicate a hand -Pinch force: contingent on number of rubber bands, but more bands also increase the effort required to open -Prehension patter: precise, fine pinch possible -Weight: lighter in weight than hands; aluminum models are even lighter; range from 3-0-8.7 oz -Durability: very durable; stainless steel models are even more rugged -Reliability: little servicing needed -Feedback: some proprioceptive feedback experienced from tension on shoulder harness and limb pressure in socket when operating TD or elbow -Effort to activate: more effort to open -Use in various planes: difficult at high planes for AE -Visibility of items being grasped: very good visibility -Cost: low cost

-Cosmesis: poor cosmesis -Pinch force: considered excellent for strong grasp; can achieve >50 lb, contingent on amount of force the individual can exert on the cable -Prehension pattern: fine pinch possible -Weight: heavier than VO hooks, but some models are lighter than hands. Range: 10-16 oz -Durability: very durable stainless steel TD -Reliability: little servicing needed -Feedback: better proprioceptive feedback -Effort to activate: more effort to sustain grasp; can have manual lock -Use in various planes: similar to VO hook -Visibility of items being grasped: better visibility than hands but less than VO hook -Cost: higher cost than VO but lower than myoelectric

-Cosmesis: cosmetically appealing -Pinch force: strong pinch; proportional control allows for variable pinch force up to about 25 lb -Prehension pattern: cylindrical grasp rather than fine pinch; hand configuration is identical for myoelectric and BP hands -Weight: heaviest 16.8 oz -Durability: less durable; glove is delicate; control systems may need servicing -Reliability: most servicing needed -Feedback: some feedback through intensity of muscle contraction, particularly for proportional control -Effort to activate: low effort to activate -Use in various planes: very good for BE -Visibility of items being grasped: less visibility than hooks -Cost: higher cost for TD and systems

-Cosmesis: cosmetically appealing -Pinch force: pinch force stronger than VO hook but less than myoelectric hands -Prehension pattern: cylindrical grasp identical to myoelectric hand -Weight: heavy range: 10.0-13.8 oz -Durability: less durable; glove is delicate; spring mechanism may need repairs -Reliability: needs more servicing than VO and VC TD but less than myoelectric -Feedback: feedback similar to VO hook -Effort to activate: effort to activate -Use in various planes: similar to VO hook -Visibility of items being grasped: less visibility; similar to myoelectric hand -Cost: higher cost than BP hook but lower than myoelectric

-Neuromas: nerve endings adhered to scar tissue (these can be very painful and hypersensitive) -Skin breakdown -Phantom limb syndrome: sensation of the presence of the amputated limb -Phantom limb pain: sensation of the presence of the amputated limb but is also painful -Infection -Knee flexion contractures in transtibial amputation -Psychological impairments due to shock/grief

-Change of dominance activities, if needed -ROM of uninvolved joints -Prepare limb for a prosthesis -Desensitization -Wrapping to shape and shrink the residual limb: 1) wrap distal to proximal 2) tension should decrease with proximal wrapping -ADL training, including education in skin care -Supportive counseling to facilitate adjustment -Individualize treatment to enhance physical and psychological adjustment

-Functional training with prosthesis: practice engagement in activities of interest and occupational role activities -Donning and doffing the prosthesis -Increased prosthetic wearing tolerance -Individualize treatment to enhance physical and psychological adjustment

-Wrapping to shape residual limb and decrease swelling -Desensitization -Strengthening (UE) with the focus on triceps -Transfer training, stand pivot -ADL training; LE dressing is the most difficult -Standing tolerance -W/C mobility

-Involves the epidermis only -Minimal pain and edema, but not blisters -Healing time is 3 to 7 days

-Second degree burns involve the epidermis and upper portion of dermis (eg. sunburn) -Appearance: red, blistering, and wet -Painful, no grafting necessary, heals on its own -Healing time is 7 to 21 days

-Deep second degree burn involving the epidermis and deep portion of dermis; hair follicles and sweat glands -Appearance: red, white, and elastic -Sensation may be impaired -Potential to convert to full thickness burn due to infection -Healing time is 21 to 35 days

-Third degree burn involving the epidermis and dermis; hair follicles, sweat glands, and nerve endings -Appearance: white, waxy, leathery, and non-elastic -Pain free, requires skin graft -Hypertrophic scar -Healing time can take months

-Involves fat, muscle, and bone -Electrical burn: destruction of nerve along pathway

-Evaluation: 1) occupational therapy history and roles 2) ROM, 72 hours post-operative 3) sensation, when wounds are healed 4) strength, when wounds are healed 5) ADL and meaningful role activities, as soon as possible -Intervention: 1) wound care and debridement, sterile whirlpool, and dressing changes 2) gentle AROM and PROM to individual's tolerance 3) edema control 4) splinting, if necessary 5) ADL and role activities

-Evaluation: same as for superficial partial-thickness burns -Intervention: 1) wound care and debridement, sterile whirlpool, and dressing changes 2) gentle AROM and PROM to individual's tolerance 3) edema control 4) splinting 5) occupational role activities and ADL 6) strengthening (when wounds are healed)

-Evaluation: 1) ROM (5 to 7 days post-operative) 2) same as for superficial and deep partial-thickness burns -Post-operative intervention: 1) 72 hours: dressing changes, splint at all times 2) five to seven days: begin AROM, light ADL and meaningful activities, sterile whirlpool 3) over seven days: PROM as tolerated, ADL and meaningful activities 4) when wounds are healed, use massage 5) order compression garments 6) provide otoform/elastomer inserts 7) strengthening

-Neck: neutral to slight extension -Chest/abdomen: trunk extension and scapula retraction -Axilla: shoulder abduction 90 degrees and external rotation (airplane splint) -Elbow: extension -Forearm: neutral to supination -Wrist: 30-45 degrees extension -Hand: MCPs 70 degree flexion, IP extension, and thumb abducted -Knee: knee extension, anterior burn, mild flexion -Ankle: 5 degree dorsiflexion

-Burns to dorsum of hand: 1) wrist in 30 to 45 degrees extension 2) MCP joints in 70 to 90 degrees flexion 3) IP joints in full extension 4) thumb abducted and extended -Burns to volar surface of hand: 1) wrist in 0 to 30 degrees extension 2) MCP joints in neutral and abducted 3) IP joints in full extension 4) thumb abducted and extended

-Most common with deep second and third degree burns -Appears six to eight weeks after wound closure -One to two years to mature -Compression garments should be worn 24 hours daily: 1) applied when wounds are healed 2) recommendation is to wear 24 hours a day for 1-2 years until scare is matured -Additional intervention include ROM, skin care, ADL, role activities, and patient/family education

-Personal sensation of hurt that can significantly affect an individual's quality of life

-Acute pain has a recent onset and usually lasts for a short duration -Chronic pain is of a long duration and can lead to depression -Myofascial pain is specific to muscles, tendons, or fascia: 1) myofascial pain syndrome (MPS) - persistent, deep aching pains in muscle, nonarticular in origin; characterized by well-defined, highly sensitive tender spots (trigger points) -Fibromyalgia syndrome (FMS) is a musculoskeletal pain and fatigue disorder that can vary in intensity: 1) widespread pain accompanied by tenderness of muscles and adjacent soft tissues 2) nonarticular rheumatic disease of unknown origin -Low back pain: 1) most common work related injury 2) location - lumbar lordosis 3) etiology - a) poor posture = seated and standing b) repetitive bending using poor body mechanics c) heavy lifting d) sleeping with poor posture 4) symptoms - a) pain b) difficulty with self care activities and other role activities (especially lower extremity activities) c) difficulty sleeping

-Determine location of pain: localized or diffuse -Evaluate intensity of pain: 1) pain intensity scale of 0-10 is most commonly used 2) identify the time of day the pain is most intense -Determine the onset and duration of pain: 1) gradual or sudden onset 2) the length of time pain has been experienced -Description of pain: common descriptors include sharp, throbbing, tender, burning, and shooting -Functional assessment of pain: 1) pain scales that commonly address function (McGill Pain Questionnaire, Pain Disability Index, Functional Intereference Estimate)

-Utilize physical agent modalities and massage in preparation for functional activities -Teach proper positioning techniques -Splint in the resting position -Gentle ROM -Teach relaxation exercises -Utilize proper body mechanics during self-care, leisure, and work activities -Correct environmental factors -Correct standing and seated postures -Modify activities and provide ADL training and adaptive equipment, as needed -Provide alternative exercise programs (eg. aquatic therapy, Tai-Chi, Aichi)

-Body motion to activate TD: 1) shoulder glenohumeral flexion on side of TD to be activated 2) scapular abduction (forward roll of shoulder) on side to be activated; bilateral scapular abduction for midline use or with limited strength -Instruction or intervention: therapist manually guides the patient through the motion pattern (note: for AE amputation, keep elbow locked in 90 degrees of flexion and teach TD control only) -Wrist unit rotation: 1) manual prepositioning of TD for supination, pronation or mid-position 2) for unilateral amputation, the TD is rotated in the wrist unit by using the sound hand 3) for bilateral amputation, the TD is rotated by pushing or pulling using the contralateral TD, between the knees, or against a stationary object -Instruction or intervention: the patient must analyze the task and predetermine how to grasp the object to avoid excessive or awkward body movement such as twisting and bending, eg. when carrying a tray, the fingers of the hook must be turned with the hook tips toward the person's midline (body) so the hook is in the mid-position similar to the holding pattern of the sound hand; a jar is held with the finger-tips down (pronated) toward the floor, while the sound arm opens the top

-Body motion to activate elbow lock and unlock -Instruction or intervention: therapist manually guides the patient through these motion patterns; the patient views himself in mirror for visual feedback -Practice motions: 1) scapular depression (push residual limb into socket end) 2) humeral extension/hyperextension 3) humeral abduction -Instruction or intervention: begin with the elbow unit in an unlocked position and the elbow in flexion (arm adducted); the forearm is passively pushed back into extension to lock; listen for "click" sounds; this motion may have to be exaggerated during the initial stages -Practice TD activation with elbow locked -Instruction or intervention: lock elbow; use humeral flexion with scapular abduction to activate TD -Practice elbow flexion and lock at different levels, from full flexion to full extension -Instruction or intervention: unlock elbow and gravity will pull forearm into extension; use humeral flexion to flex elbow at desired height; when locking the elbow unit, flex the elbow slightly higher than desired, which allows for gravity to pull downward as patient locks elbow

-Instruction or intervention: unilateral - patient reaches over to rotate upper arm unit -Bilateral - patient pulls or pushes against a stationary object in that environment or with opposite prosthesis