Hand and UE Disorders and Injuries

Question 1

Dupuytren’s Disease

Answer 1

-leads to flexion contractures of digits 4 and 5
-conservative tx usually not successful
OT intervention post-surgery
-wound care, edema, extension orthosis dorsal or volar
-AROM -> PROM -> strengthening at 4 weeks
-occupation based tasks emphasizing flexion and extension

Question 2

Skier’s Thumb (Gamekeeper’s Thumb)

Answer 2

-rupture of the ulnar collateral ligament of the MCP joint of the thumb
-most common cause fall while grasping ski pole
OT Intervention:
- conservative: thumb orthosis (hand or wrist based with free IP joint) for 6-12 weeks
-AROM at 2-4 weeks after physician’s order -> AAROM and lat pinch strengthening at 6 or more weeks when approved by physician

Question 3

Complex regional pain syndrome

Answer 3

vasomotor dysfunction as a result of an abnormal reflex
symptoms: severe pain, edema, discoloration, osteoporosis, sudomotor changes, blotchy/shiny skin, temperature changes, trophic changes, and vasomotor instability
intervention:
- decrease pain and hypersensitivity prior to ADLs (heat packs, head fluidotherapy, TENS before AROM or ADLs)
- edema management
-AROM to involved joints
-Pain-free ADL strats
- stress-loading: weightbearing and joint distraction activities (scrubbing and carrying)
- orthotics to prevent contractures and increase ability to participate

Question 4

Intra-articular fracture vs extra-articular

Answer 4

intra: extends into the surface of a joint
extra: doesn’t extend into joint

Question 5

closed vs open fracture

Answer 5

closed doesn’t break skin, open does

Question 6

dorsal displacement vs volar displacement fracture

Answer 6

fracture projects toward the dorsal or volar aspect

Question 7

head vs shaft vs neck vs base fracture

Answer 7

describes the location of the fracture on a metacarpal

Question 8

complete vs incomplete fracture

Answer 8

full or partial fracture of the bone

Question 9

transverse vs spinal vs oblique fracture

Answer 9

transverse: perpendicular to the long axis of a bone
spinal: rotatory mechanism
oblique: at an angle

Question 10

comminuted fracture

Answer 10

fracture split into more than 2 pieces

Question 11

Colles’ fracture

Answer 11

distal radius fracture with dorsal displacement

Question 12

Smith’s fracture

Answer 12

distal radius fracture with volar displacement

Question 13

Boxer’s fracture

Answer 13

fracture of the 5th metacarpal
intervention: ulnar gutter orthosis

Question 14

distal phalanx fracture

Answer 14

most common finger fracture, may result in mallet finger (usually involves terminal extensor tendon)

Question 15

de Quervain’s

Answer 15

CTD
Finkelstein’s test
pain and swelling over radial styloid
Treatment: thumb spica orthosis (IP free), activity/work modification, ice massage over radial wrist, gentle AROM of wrist and thumb to prevent stiffness
post-op tx: thumb spica orthosis and gentle AROM (2 weeks)-> strengthening, ADL, role activities (2-6 weeks)-> unrestricted activity (6 weeks)

Question 16

Lateral epicondylitis

Answer 16

CTD
degenerative changes of the tendon’s origin as a result of repetitive microtrauma
tennis elbow, overuse of wrist extensors
Conservative Tx: elbow strap, wrist orthosis, ice and deep friction massage, stretching, activity/work mod, begin with eccentric exercises for wrist extensors, strengthen proximal

Question 17

Trigger Finger

Answer 17

CTD
Most common in the A1 pulley
caused by repetition and tools placed too far apart
conservative tx: hand or finger-based trigger finger orthosis (MCP extended, IP joints free), scar massage, edema control, tendon gliding, activity/work mod

Question 18

Duran Protocol

Answer 18

Early passive mobilization for flexor tendon repair to digits
0-4 weeks: dorsal blocking orthosis (wrist 10-30 degrees flex, mcp joints in 40-60 degrees flex, and IP joints extended); passive flex of PIP joint, DIP joint, and to DPC within confines of dorsal blocking orthosis

2.5 weeks: passive place/active hold exercises may be approved, manage edema with elevation, massage scar when incision healed

4-6 weeks: AROM that includes wrist AROM with fingers relaxed and tendon gliding

6-8 weeks: gentle strengthening

12 weeks: return to functional activity

Question 19

Kleinert Protocol

Answer 19

not commonly used
Early passive mobilization for flexor tendon repair
passive flexion using rubber band traction and active extension to the hood of the dorsal blocking orthosis
3-4 weeks: out of orthosis and rubber band traction attached to wrist band
6 weeks: AROM

Question 20

Mallet finger deformity

Answer 20

extensor tendon injury, unable to straighten DIP
Tx:
0-8 weeks: DIP extension orthosis
6-8 weeks: gentle AROM, some surgeons will have ROM restrictions, monitor for a lag
Orthotic should be worn at night and between exercises

Question 21

Boutonniere deformity

Answer 21

finger is flexed at PIP and extended at DIP
Tx: 0-6 weeks: PIP extension orthosis (DIP free)
-AROM of DIP while in orthosis

Question 22

carpal tunnel syndrome (CTS)

Answer 22

median nerve compression
symptoms: numbness and tingling of the thumb, IF, MF, and rad half of RF, paresthesias at night, complaints of dropping, positive tinel’s, positive phalen’s
Conservative tx: wrist orthosis in neutral at night and during the day if performing repetitive activities, median n gliding, activity mod, ergonomics
surgical intervention: carpal tunnel release
post-op Tx: edema control, AROM: wrist and tendon gliding, scar management, nerve and tendon gliding exercises, sensory re-education or desensitization, strengthening of thenar muscles (6 weeks post-op), ergonomic/work/activity mod

Question 23

Tinel’s sign

Answer 23

positive test will result in tingling when nerve is tapped

at wrist: carpal tunnel
at elbow: cubital tunnel syndrome

Question 24

Phalen’s sign

Answer 24

tingling feeling when wrists pressed together upside down (upside down/backward prayer hands)

carpal tunnel

Question 25

Cubital tunnel syndrome

Answer 25

an ulnar nerve compression at the elbow. sensory and/or motor problems etiology: pressure at the elbow and extreme elbow flexion symptoms: numbness and tingling on ulnar aspect of forearm and hand, pain at elbow with extreme position of elbow flex, weakness of power grip, positive froment's sign, positive tinel's at elbow, advanced results in claw hand deformity-- atrophy of FCU, FDP to digits IV and V, and ulnar nerve innervated intrinsic muscles of the hand conservative tx: elbow orthosis at 30 degrees flexion, elbow pad to dec compression of nerve when leaning on elbows, ulnar nerve glides, activity/work mod Post-op tx: edema control, scar management, AROM and nerve gliding (2 weeks post-op), strengthening (4 weeks post-op), MCP flexion anticlaw orthosis if clawing noted

Question 26

Froment's sign

Answer 26

Holding paper in lat key pinch positive: curling thumb to compensate positive: ulnar nerve compression or cubital tunnel syndrome

Question 27

radial nerve palsy

Answer 27

radial nerve compression, Saturday night palsy (sleeping with pressure on radial nerve) or compression as a result of humeral shaft fracture symptoms: weakness or paralysis of extensors to the wrist, MCPs, and thumb; wrist drop conservative tx: dynamic wrist and MCP extension orthosis, work/activity mod, strengthening wrist and finger extensors when motor function returns post-op tx: AROM, strengthening (6-8 weeks post-op), ADL and meaningful role activities

Question 28

Median nerve laceration

Answer 28

sensory loss to middle palm (thumb to rad half RF); palmar surface of thumb, IF, MF, rad half RF, and dorsal surface IF, MF, rad half RF (MP and DP) functional loss: loss of thumb opposition, weakness of pinch Tx: dorsal protection orthosis-- wrist at 30 degrees flexion, include elbow at 90 degrees if high lesion; begin A/PROM of digits with wrist in flexed position in orthosis at 5-7 days post repair; scar management when incision is healed; AROM of wrist out of orthosis when approved by physician (around 4 weeks post repair) include elbow if high lesion; begin strengthening when approved (around 6-8 weeks) -use web spacer orthosis to prevent thumb adduction contracture, opponens orthosis to improve functioning -sensory re-education: educate on safe use of the hand using vision, use different/graded textures and vibration

Question 29

Ulnar nerve laceration

Answer 29

Sensory loss: ulnar aspects of palmar and dorsal surfaces, ulnar half of RF and LF on palmar and dorsal surfaces functional loss: loss of power grip, decreased pinch strength Tx: dorsal protection orthosis-- wrist at 30 degrees flexion, include elbow at 90 degrees if high lesion; begin A/PROM of digits with wrist in flexed position in orthosis at 5-7 days post repair; scar management when incision is healed; AROM of wrist out of orthosis when approved by physician (around 4 weeks post repair) include elbow if high lesion; begin strengthening when approved (around 6-8 weeks) -MCP flexion block orthosis -sensory re-education: educate on safe use of the hand using vision, use different/graded textures and vibration

Question 30

Radial nerve injury

Answer 30

sensory loss (high lesion at level of the humerus): medial aspect of dorsal forearm; radial aspect of dorsal palm, thumb, IF, MF, and radial half of RF functional loss: inability to extend digits to release objects, difficulty manipulating objects deformity: wrist drop Tx: dynamic extension orthosis, ROM, sensory re-education if needed, home program, activity mod, neuromuscular electrical stimulation (NMES) to aide in muscle re-education

Question 31

rotator cuff tendonitis

Answer 31

affecting supraspinatus (abduction and flexion), infraspinatus & teres minor (external rotation), subscapularis (internal rotation) conservative OT: activity mod (avoid above shoulder level activities until pain subsides), educate in sleeping posture, decrease pain, restore pain-free ROM, strengthening: below shoulder level, occupation and role specific training post-op OT: PROM (0-6 weeks); AAROM/AROM (6-8 weeks), pt will be in sling or abduction orthosis btwn exercises, dec pain with ice progress to heat, strengthen begin with isometrics, progress to isotonic; below should strengthening at 8-10 weeks, activity mod progress as tolerated, leisure and work activities at 12 weeks post-op

Question 32

Adhesive capsulitis

Answer 32

aka frozen shoulder linked to diabetes and Parkinson's conservative tx: freezing stage- address pain through ice packs, e-stim, and positioning; gentle pain-free A/PROM (try to maintain functional movements such as reaching behind back or head); educate in HEP with gentle exercises such as table glides and pain free functional movement frozen stage- can use hot packs to begin session and then conclude with ice, continue A/PROM and can begin gentle pain-free stretching, continue HEP to increase ROM thawing stage- continue as above with more emphasis on stretching, focus is on restoring ROM and function Post-op tx: PROM immediately following surgery, pain relief using PAMs, encourage use of extremity for all ADL and role activities

Question 33

RA

Answer 33

usually attacks small joints of the hands deformities: ulnar drift and subluxation of MCPs; boutonniere; swan neck; zig zag

Question 34

OA

Answer 34

degenerative joint disease wear and tear on large weightbearing joints

Question 35

Swan neck deformity orthosis

Answer 35

silver rings, 3-point oval 8, or digital orthosis in slight PIP flexion

Question 36

Boutonniere deformity orthosis

Answer 36

silver rings, 3 point oval 8, or PIP extension orthosis

Question 37

Posterolateral Precautions

Answer 37

after posterior hip replacement - do not flex beyond 90 degrees -do not adduct or cross legs -do not internally rotate -do not pivot at hip -sit only on raised chair or raised toilet seat -transfer sit to stand by keeping operated hip in slight abduction and extended out in front

Question 38

Anterolateral precautions

Answer 38

after anterior hip replacement - do not externally rotate -do not extend hip -precautions vary for anterior (THA) -some surgeons follow a no restrictions protocol