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80 Cards in this Set
- Front
- Back
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What is Dupuytren's disease
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Dz. of fascia
fascia becomes thick and contracted Flexion deformities of involved digits |
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Treatment of Dupuytren's dz.
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Surgical release required
-Fasciotomy w/ Z-plasty -Aponoeurotomy McCash procedure (open palm) |
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OT intervention for Dupuytren's dz.
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1. Wound care (dressing changes, whirl pool if suspect infection)
2. Edema control - elevate above heart 3. Extension splint - initially at all times except for ROM and bathing 4. A/PROM - progress to strengthening when wounds heal 5. scar management (massage, scar pad, compression garment) 6. Purposeful activity with emphasis on flexion (gripping) and extension (release) |
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What splint may be used s/p surgical procedure for Dupuytrens?
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Extension splint
http://www.readinghandsurgery.com/Images/D-Dupuytren's%20release.jpg |
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What is skiers thumb (or gamekeepers thumb)?
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rupture of the collateral ligament of the MCP jt. of the thumb
Commonly caused during fall holding a ski pole http://www.hughston.com/hha/b_14_1_2a.jpg |
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OT intervention for skiers/gamekeepers thumb
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Conservative: thumb spilnt 4-6 wks
AROM and pinch strengthening at 6 wks focus on ADLs requiring opposition and pinch strength Post op treatment: thumb splint for 6 wks, followed by AROM. Begin PROM at 8 wks. Strengthening at 10 wks |
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What is Complex regional pain syndrome? (CRPS)?
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Type I - formerly reflex sympathetic dystrophy (no nerve damage)
Type II- formerly casualgia (nerve damage) It is VASOMOTOR DYSFUNCTION in result of abnormal reflex Can be localized or spread throughout extremity Cause unknown, but may follow trauma |
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Symptoms of complex regional pain syndrome
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severe pain,
edema, discoloration, osteoporosis, sudomotor changes, temperature changes, trophic changes, vasomotor instability |
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OT intervention for complex regional pain syndrome
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1. modalities to decrease pain
2. edema management: elevation, manual edema mobilization, compression glove 3. AROM to involved jts. 4. ADL to encourage pain free use 5. Stress loading (WB'ing, joint distraction -- activities such as scrubbing, carrying) 6. Splinting - prevent contractures, enable engagement in occupations 4. encourage self mangement 5. AVOID/PROCEED WITH CAUTION: PROM, passive stretching, joint mobilization, dynamic splinting, casting |
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What interventions should be avoided in cases of CRPS?
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PROM
Passive stretching joint mobilization dynamic splinting casting |
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7 classifiers for fractures
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1. intraarticular v. extraarticular
2. open v. closed 3. dorsally or volarly displaced 4. midshaft v. neck v. base 5. complete v. incomplete 6. transverse v. spiral v. oblique 7. comminuted |
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Name some ways a joint may be stabilized following closed reduction.
Open reduction? |
Closed reduction: short arm cast, long arm cast, sling, splint, fracture brace
Open reduction: internal fixators: screws, nails, plates, wires |
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Arthrodesis
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Joint fusion procedure
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Arthroplasty
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joint replacement
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Colles fracture
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Fracture of distal radius with dorsal displacement
(fall on outstretched hand) |
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Smith's fracture
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distal radius fracture with volar displacement
(As falling while holding a football) |
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Carpal fractures
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most common is scaphoid
Proximal scaphoid has poor blood supply and can become necrotic |
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Metacarpal fractures
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classified by location (head, neck, shaft, base)
Complication: rotational deformity |
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Boxer's fracture
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Fracture of 5th metacarpal. Requires ulnar gutter splint
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Proximal phalanx fracture
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most commonly thumb or index.
Complication: loss of PIP ROM |
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Distal phalanx fracture
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most common finger fracture
may result in mallet finger |
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Mallet finger
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involves damage to terminal extensor tendon
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Elbow fracture with radial head involvement may ____.
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limit forearm rotation
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Humerus fractures - classification and complications
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-can be displaced or non-displaced
Fx of greater tuberosity may lead to rotator cuff injury Humeral shaft fractures may injure radial nerve, resulting in wrist drop |
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One possible presentation of radial nerve injury is ____.
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wrist drop
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OT evaluation of fractures
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1. Mechanism of injury
2. current fracture management 3. results of x-ray, MRI, CT etc. 4. edema 5. pain 6. AROM DO NOT ASSESS PROM OR STRENGTH WITHOUT ORDERS 7.sensation 8. roles/occupations/ADLs |
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You get a new UE fracture patient and the MD's order says only "evaluate and treat." What should be avoided?
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Do not test PROM or strength without orders to do so.
(Bone healing) |
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OT intervention for UE fractures: 2 phases
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1. IMMOBILIZATION PHASE
goals = stabilize and heal -AROM of surrounding joints -Edema control (elevation, retrograde massage, compression garments) -Light ADL/activities with NO RESISTANCE. progress as tolerated 2. MOBILIZATION PHASE goal = consolidation -edema control - elevation, retrograde massage, contrast baths, compression garment -AROM (progress to PROM when approved by MD at 4-6wks) -Exception: humerus Fx's often begin with PROM or AAROM -light occupation based activities -pain management: positioning or PAMs -Strengthening: begin with isometrics when approved by physician |
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Edema management techniques for fracture
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elevation
retrograde massage compression garment contrast bath at mobilization phase |
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What type of strengthening should you typically begin with after UE fracture?
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isometrics
(following physician's orders to strengthen) |
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When would you begin treatment of a UE fracture with PROM or AAROM?
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humeral fracture.
Typically PROM does not start for 4-8 wks Should always have physician's request before implementing PROM |
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Cumulative trauma disorders (CTDs)
Risk factors and common types |
Risk factors:
-repetition -static position -awkward postures -forceful extertions -vibration -acute trauma -pregnancy -diabetes -arthritis -wrist size and shape Common types: -DeQuervains -Lateral epicondylitis (wrist extensors) and medial epicondylitis (wrist flexors) -trigger finger -Nerve compressions |
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What is DeQuervain's
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stenosing tenosynovitis of APL and EPB
causes pain and swelling over radial styloid Sign: positive finklestein's test (adduct thumb in palm with wrist in neutral >> ulnarly deviate >> positive if pain at radial styloid) |
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Treatment of DeQuervain's
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Conservative:
1. Thumb spica splint (IP joint free) 2. activity modifications 3. ice massage at radial wrist 4. gentle AROM of wrist and thumb to prevent stiffness Post-Op treatment 0-2 wks: thumb spica with gentle AROM 2-6 wks: strengthening, ADL, role activities 6 wks: unrestricted activity |
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What are medial/lateral epicondylitis?
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-Degeneration of tendon origin following repetitive microtrauma
Lateral: overuse of wrist extensors/ ECRB. Tennis elbow. Medial: overuse of wrist flexors. Golfer's elbow |
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Treatment for medial/lateral epicondylitis
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Conservative treatment
-elbow strap, wrist splint -ice and deep friction massage -stretching -activity mods -when pain decreases, strengthen. start with isometrics, then go to concentrics and eccentrics |
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Trigger Finger
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Tenosynovitis of finger flexors (commonly A1 pulley)
Causes: repetition and use of tools placed too far apart |
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Treatment of Trigger finger
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-Hand based trigger finger splint (MCP extended, IP jts free)
-scar massage -edema control -tendon gliding -activity mods: avoid repetitive gripping of items with handles to far appart |
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Treatment following tendon repair
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EARLY MOBILIZATION
-prevents adhesions -facilitates wound/tendon healing Goals: 1. increase tendon excursion 2. improve strength at repair site 3. increase joint ROM 4. prevent adhesions 5. facilitate resumption of occupation |
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What is the Klinert protocol?
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an early mobilization program for flexor tendons following surgical repair
Involves passive flexion using a rubber band for traction and active extension to hood of dorsal block splint http://ars.els-cdn.com/content/image/1-s2.0-S0894113005000347-gr1.jpg |
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Zones of extensor tendon injury
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http://www.boneandjoint.org.uk/sites/default/files/styles/large/public/FO_ET-1.jpg
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Zones of flexor tendon injury
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http://www.netterimages.com/image/10454.htm
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Phases of the Klinert Protocol
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Early: 0-4 wks
-Dorsal block splint. Wrist at 20-30* flexion, MPs at 50-60* flexion, IPs extended -Passive flexion and active extension within limits of splint (facilitated by rubber band pulley) Intermediate: 4-7 wks -Continue dorsal block splint with wrist now in neutral -place and hold exercises -differential flexor tendon glides -scar management 6-8 wks: AROM D/C splint differential tendon glides light occupation based activity 8-12 wks: strengthening. resume work and leisure |
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What is the Duran Protocol
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Use following flexor tendon repairs
Passive flexion and extension of digit -Dorsal block splint with wrist and MP jts flexed, fingers strapped in IP extension when not exercising |
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Phases of the duran protocol
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0-4.5 wks: dorsal block splint. Exercises in splint: passive flexion of PIP and DIP to DCP (distal palmar crease)
10 reps hourly 4.5-6 wks: active flexion and extension within limits of splint 6-8 wks: tendon gliding and differential tendon gliding, scar management, and light occupation 8-12 wks: strengthening and work |
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Early Mobilization Program for Extensor Tendons - zone I and II
(following tendon repair) |
Mallet finger deformity
0-6 wks: Treat with DIP extension splint |
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Early mobilization program for extensor tendons in zones III and IV
(following tendon repair) |
Boutonniere deformity
0-4 wks: PIP extension splint (DIP free). AROM of DIP while in splint 4-6 wks: begin AROM of DIP and flexion of digits to DCP (distal palmar crease) |
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Early mobilization program for extensor tendons in zones V, VI, VII
(following tendon repair) |
(base of proximal phalanx through carpals)
0-2 wks: volar wrist splint. Wrist = 20-30* extension, MCPs 0-10* flexion, IPs in full extension 2-3 wks: shorten splint for flexion/extension of IPs 4 wks: remove splint to begin active MCP flexion/extension 5 wks: active wist ROM, wear splint when not exercising 6 wks: D/C splint |
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Nerve distribution of the hand
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Ulnar: 5th and half of 4th digit and corresponding surfaces of palm/dorsum of hand
Median: Volar = half of thumb through half of 4th digit and corresponding aspects of palm Dorsal = 1/2 of thumb, P2 and P3 of index and middle, half of P2 and P3 of ring finger Radial: volar: radial half of thumb dorsal = half of thumb, P1 of index, middle, and half of ring, and corresponding dorsum of hand http://www.orthopaedia.com/download/attachments/46432323/Nerves+of+the+Hand.jpg?version=1&modificationDate=1290722896000 |
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2 types of peripheral nerve injuries
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compression
laceration (partial or complete) |
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what is carpal tunnel?
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-median nerve compession
-numbness/tingling in median nerve distribution (thumb, index, middle, and 1/2 of ring fingers) Paresthesias often occur at night May drop things Positive tinel's sign at wrist Positive Phalens test Advanced stages may cause atrophy of thenar eminence |
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Conservative treatment of carpal tunnel
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1. wrist splint in neutral (worn at night and while performing repetitive activity)
2. median nerve gliding and differential tendon gliding exercises 3. activity mods: avoid extreme wrist flexion, wrist flexion with repetitive finger flexion, and frist flexion with static grip 4. ergonomics/workstation design |
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Post-op treatment of carpal tunnel syndrome
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following carpal tunnel release
1. edema control: elevate, retrograde massage, compression glove, contrast bath 2. AROM 3. nerve gliding exercises 4. sensory re-education 5. 6 wks post-op, strengthen thenar muscles 6. work/activity mods |
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Pronator Teres Syndrome
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Occurs at proximal volar forearm
Median nerve compression between 2 heads of pronator teres from repetitive pronation/supination and excessive pressure on volar forearm Sx present like CTS with additional aching pain in forearm (no night symptoms) Positive Tinel's sign at forearm |
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Conservative treatment for pronator teres syndrome
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Elbow splint at 90* with forearm in neutral
avoid activities requiring repetitive pronation/supination |
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OT intervention for pronator teres syndrome post-operatively
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Surgery: decompression
1. AROM 2. Nerve gliding 3. Strengthening 2 wks post-op 4. sensory re-education 5. activity mods |
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Guyon's Canal Injury
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Ulnar nerve compression at wrist
Result of repetition, ganglion, fascia thickening -Numbness/tingling in ulnar nerve distribution -motor weakness in ulnar innervated muscles -Positive tinel's sign at guyons canal Advanced stages can lead to atrophy of ulnar innervated hand muscles |
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treatment of Guyons Canal injury
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Conservative:
splint wrist in neutral -activity mods s/p surgical decompression: -edema control -AROM -nerve gliding -strengthening at 2-4 wks sensory re-education |
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Cubital tunnel syndrome
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ulnar nerve compression at teh elbow
from pressure at elbow and extreme elbow flexion Sx: -numbness/tingling along ulnar forearm and hand -pain with extreme elbow flexion -weak power grip -positive tinel's at elbow Advanced stages: atrophy of FCU, FDP to digits 4 & 5, and intrinsics |
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Cubital Tunnel syndrome :treatments
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Elbow splints to prevent extreme flexion
elbow pads to prevent nerve compression when leaning Surgeries: decompression or transposition S/P surgery: -edema control -scar management -AROM, nerve gliding (2 wks post op) -strengthening (4 wks post op) -MCP flexion splint if clawing observed |
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Radial Nerve palsy
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Radial nerve compression
"saturday night palsy" - from sleeping position placing stress on radial N. also from humeral shaft Fx Sx: weakness/paralysis of wrist extensors, MCPs, and thumb; wrist drop |
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Treating Radial N. Palsy
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Dynamic extension splint
activity mods strengthen wrist/finger extensors upon motor return S/P surgery (decompression) -ROM -Nerve glides -strengthening 6-8 wks post op -ADL/role activites |
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Treatment of Radial Nerve Palsy
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Conservative:
-Dynamic extension splint -activity mods -strengthening of wrist/finger extensors following motor return Following surgical decompression: --ROM -Nerve gliding -strengthening 6-8 wks post op -meaningful activity resumption |
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Median Nerve laceration
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Sensory and motor loss
Sensory loss: Central palm- thumb to radial 1/2 of ring finger Palmar surface of thumb, index, middle, aradial 1/2 of ring finger Dorsal surface of index, middle, and 1/2 ring finger (middle and distal phalanges) Motor Loss for low lesion at wrist: -lumbricals 1 & 2 (MCP flexion digits 2&3) -opponens pollicis (opposition) -Abductor pollicis brevis (abduction) -Flexor pollicis brevis- flexion thumb MCP) Motor loss for high lesions (at or proximal to elbow) -all of the above -FDP to index and middle fingers, FPL (thumb IP) -FCR (can't flex radial wrist) |
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Deformities/functional loss associated with median nerve laceration
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-flattening of thenar eminence (ape hand)
-clawing of middle and index fingers for low lesion -benediction sign for high lesion -lose thumb opposition -weak pinch |
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OT intervention for median N. laceration
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Dorsal protection splint: wrist in 30* flexion for low lesion
-Include elbow at 90* flexion for high lesion -Begin A/PROM with wrist in flexion 2 wks post-op -Strengthen at 9 wks -C bar splint may be used to prevent thumb contracture (maintains open webspace) -Sensory re-ed if found to be diminished by Semmes Weinstein (4.31) |
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What number indicated diminished protective sensation on Semmes Weinstein?
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4.31
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Ulnar nerve laceration
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Sensory and motor loss
Sensory loss: ulnar aspect of palm and dorsum -ulnar half of ring and little finger Motor loss for low lesion at wrist: -Palmar and dorsal interossei (ad/abduction of MCPs) -Lumbricals 3 & 4 (MCP flexion digits 4 &5) -FPB and adductor pollicis (flexion and adduction of thumb) -ADM, ODM, FDM (abduction, opposition, flexion of 5th digit) Motor loss for high lesion (wrist or above) same as above, including FCU (flexion toward ulnar wrist) FDP digits 4 & 5 (flexion DIP and ring/little fingers) |
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Deformities and functional losses from ulnar nerve laceration
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-claw hand
-flattened metacarpal arch - (+) froment's sign (assess thumb adductor while laterally pinching paper) Lose power grip Decrease pinch strength |
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OT intervention for ulnar nerve laceration
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Dorsal protection splint with wrist positioned at 30* flexion
-begin A/PROM with wrsit in flexion 2 wks post op -scar managemetn -AROM of wrist at 4 wks -strengthen at 9 wks -MCP flexion block splint -sensory re-education if 4.31 on Semmes Weinstein |
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Radial Nerve Laceration
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Sensory and Motor loss
sensory loss: If high lesion at level of humerus: Medial aspect of dorsal forearm, radial aspect of dorsal palm, thumb, index, middle, and radial 1/2 of ring fingers Motor loss If low lesion at level of forearm: -lose wrist extension 2/2 impaired ECU -EDC, EI, EDM, (MCP extension) -EPB, EPL, APL (thumb extension) -Motor loss if high lesion at level of humerus -all of the above including ECRB, ECRL, and brachioradialis -at level of axilla, loss of triceps (elbow extension) |
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Functional loss and deformity for radial nerve laceration
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Inability to extend digits/ release objects
difficulty manipulating objects wrist drop |
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OT intervention for radial nerve laceration
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-dynamic extension splint
-ROM -sensory education PRN -home program -activity mods |
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Site of rotator cuff impingement
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coracoacromial arch
(includes acromion, coracoacromial ligament, and coracoid process) |
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Casues of rotator cuff impingement
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-repetitive overuse
-curved or hooked acromion -weak RC muscles -weak scapular muscles -ligament and capsule tightness -trauma |
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OT intervention for RTC tendonitis
(conservative) |
-Activity mods - no above shoulder activity until pain subsides
-Sleeping posture - don't sleep with arm overhead or combined adduction/IR decrease pain: positioning, modalities, rest restore pain free ROM strengthening below shoulder level occupation specific intervention |
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RTC Tendonitis
OT intervention post-op |
-PROM 0-6 wks, progress to AROM
-decrease pain (ice first, then progress to heat) -Strengthening 6 wks post op. Start with isometrics, progress to isotonics (all below Sh. level) -acitvity mods, light ADL/occupation. progress as tolerated -leisure and work 8-12 wks post op |
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Adhesive capsulitis
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-frozen shoulder
-restricts PROM (greatest limitation is ER, then Abduction, IR and flexion) Inflammation and immobility |
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OT intervention for adhesive capsulitis
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-encourage active use
-PROM -modalities s/p surgery: -immediate PROM -pain relief: modalities -encourage use for ADL |
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Shoulder dislocations
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Anterior displacement most common
from trauma or repetitive overuse OT intervention: regain ROM AVOID ABDUCTION AND ER with anterior dislocation strengthen RTC |
