Nerve and tendon injuries, fractures, other UE diagnoses

Question 1

low lesion radial nerve

Answer 1

“saturday night palsy” wrist drop
fx deficit: manipulating objects, release
intervention: dynamic wrist and MCP extension splint

Question 2

high lesion radial nerve

Answer 2

loss of triceps
intervention: dynamic extension splint

Question 3

ulnar nerve injury

Answer 3

CLAW HAND
loss of lumbricals
hyperextension of MCP joints and flexion of IP joints of ring and pinky fingers
fx deficit: loss of power grip
intervention: MCP flexion block splint

Question 4

low lesion median nerve

Answer 4

APE HAND
flattening of thenar eminence and thumb adduction with clawing of index and middle fingers
intervention: dorsal blocking with wrist in 30 deg flexion; maintain thumb webspace (C bar)

Question 5

high lesion median nerve

Answer 5

HAND OF BENEDICTION
when attempting to make a fist, unable to do so because thumb index and middle fingers are paralyzed
fx deficit: loss of opposition and palmar abduction
intervention: dorsal blocking with wrist in 30 deg flexion and include elbow in 90 deg flexion

Question 6

difference between claw hand, ape hand, and hand of benediction

Answer 6

claw hand (ulnar) and ape hand (median low) are permanent, fixed positions at rest. hand of benediction (median high) is an active sign.

Question 7

flexor tendon injury

Answer 7

deep cuts to the PALMAR side of the hand, jersey finger (gets caught and tendon pulls on bone), RA (weakens tendons and can tear)
needs sutures, 12 weeks healing

Question 8

early mobilization reason and types

Answer 8

prevent adhesion formation
duran and kleinert protocols

Question 9

type of splint for flexor tendon injuries

Answer 9

dorsal blocking splint
wrist in 20-30 deg FLEXION
MCPs 50-70 deg flexion
IPs extended

Question 10

Duran protocol

Answer 10

passive flexion and extension of fingers
duran = do it yourself (while hand is in the splint)

Question 11

Kleinert protocol

Answer 11

passive flexion and active extension via rubber band traction

Question 12

post op of flexor tendon injuries weekly progression with both protocols

Answer 12

4-6 weeks: flexor tendon gliding exercises (prevent scar adhesions)
6 weeks: d/c splint, continue tendon gliding
8 weeks: strengthening
12 weeks: resume normal activities

Question 13

tendon gliding exercises

Answer 13

1. straight hand
2. hook/claw
3. full fist
4. table top
5. straight fist (thumb out and DIP ext)

Question 14

zone 2 flexor tendon injuries

Answer 14

no man’s land; hard to dx and treat due to complications
metacarpal space

Question 15

extensor tendon injury zone 1

Answer 15

mallet finger
flexed DIP; inability to extend
intervention: DIP extension splint

Question 16

extensor tendon injury zones 2 & 3

Answer 16

Boutienere deformity
flexed PIP and hyperextension of DIP (inability to extend PIP)
intervention: PIP extension splint with DIP free to move

Question 17

extensor tendon injury zones 5, 6, 7

Answer 17

volar wrist splint with wrist in 20 deg ext

Question 18

De Quervains

Answer 18

tenosynovitis of abductor policis longus and extensor policis brevis (pass through the 1st dorsal wrist compartment; abduct and extend the thumb)

Question 19

risk factors de quervains

Answer 19

RA, diabetes, pregnancy, women 4x likely, ages 35-55, repetition and overuse

Question 20

test and intervention for de quervains

Answer 20

Finklestein’s (hold thumb in fist and ulnarly deviate)

forearm thumb spica cast (IP free), steroid injection, activity modification, ice massage over radial wrist, gentle AROM of wrist and thumb to prevent stiffness

surgery to release first dorsal compartment

Question 21

Dupuytren’s

Answer 21

• disease of the fascia of the palm and digits; becomes contracted and results in flexion deformities in the digits
  intervention: fasciotomy with z-plasty, aponeurotomy, enzyme injections

OT intervention: wound/scar care, edema control, extension splint (full is ideal, but consult with surgeon), ROM and progress to strengthening, grip/release

Question 22

Skier’s/gamekeepers thumb

Answer 22

• rupture of ulnar collateral ligament of MCP joint of the thumb
• most common cause is fall while skiing with thumb held in the ski pole
• intervention: thumb splint 4-6 weeks, AROM and pinch strength at 6 weeks, PROM 8 weeks, strengthen at 10

Question 23

complex regional pain syndrome (CRPS)

Answer 23

• vasomotor dysfunction as a result of an abnormal reflex
  may follow trauma or surgery, but actual cause is unknown
  s/s: severe pain, edema, discoloration, temp and tropic changes, vasomotor instability

intervention:
1. Stress loading: compress the joint, then distract it
2. Reduce pain with gentle AROM and desensitization
modalities to reduce pain, splinting to prevent contractures

• Modalities to decrease pain: use contrast baths to facilitate opening and closing of vessels is preferred modality
• edema management
• ADLs to encourage pain free active use

Question 24

colles fracture

Answer 24

fracture of distal radius with dorsal displacement

Question 25

smith's fracture

Answer 25

fracture of distal radius with volar displacement

Question 26

carpal fractures

Answer 26

(scaphoid most common)

Question 27

boxer's fracture

Answer 27

fracture of 5th metacarpal ulnar gutter splint

Question 28

proximal phalanx fx

Answer 28

most common is thumb and index

Question 29

distal phalanx fx

Answer 29

most common finger fx mallet finger

Question 30

OT evaluation for fractures

Answer 30

occupational profile, history of injury, special test results, edema, pain, AROM (*no PROM or strength until ordered by physician)

Question 31

intervention for fractures

Answer 31

1. immobilization phase: stabilization and healing (splint and one arm techniques, AROM, edema control, light ADLs) 2. mobilization phase: consolidation is the goal (edema control, AROM then PROm then strength - usually start with isometric exercises)

Question 32

cumulative trauma disorders

Answer 32

repetitive strain injuries ex: de quervains, lateral and medial epicondylitis, trigger finger

Question 33

lateral epicondylitis medial epicondylitis

Answer 33

tennis elbow - overuse of wrist extensors golfer's elbow - overuse of wrist flexors tx: - elbow strap, wrist splint - ice and deep friction massage - stretching - activity/work modification - as pain decreases, add strengthening. begin with isometric exercises, then progress to isotonic and eccentric

Question 34

trigger finger

Answer 34

tenosynovitis of finger flexors (most common A1 pulley) tx: - hand or finger based trigger finger splint (MCP extended, IP free) - scar massage - edema control - tendon gliding - activity modification (avoid repetitive gripping activities)

Question 35

carpal tunnel

Answer 35

compression of median nerve etiology: repetition, awkward postures, vibrations, pregnancy s/s: tingling (at night) and numbness of thumb, index, middle, and radial 1/2 ring finger, weakness

Question 36

carpal tunnel tests

Answer 36

tinel's sign (tapping) phalen's (dorsal hands together) durkan's (press thumbs on carpal tunnel, have s/s)

Question 37

tx carpal tunnel

Answer 37

conservative: splint in neutral, nerve gliding, activity modification, modalities surgical: carpal tunnel release

Question 38

pronator teres syndrome

Answer 38

compression of median nerve between 2 heads of pronator teres - positive tinel’s sign at the FOREARM, not the elbow, no night symptoms

Question 39

Guyon's canal

Answer 39

ULNAR nerve compression at the wrist s/s: numbness and tingling in ulnar nerve distributions of the hand, motor weakness, positive tinnels at the canal impairs hypothenar muscles - difficulty turning key/lateral pinch

Question 40

cubital tunnel syndrome

Answer 40

ulnar nerve compression at the elbow weakness, numbness on ulnar elbow/forearm, positive tinels at elbow

Question 41

adhesive capsulitis

Answer 41

frozen shoulder restricted passive shoulder ROM etiology: inflammation, immobility, diabetes, parkinsons conservative intervention: active use through light ADLs, PROM, modalities surgical: arthroscopic

Question 42

positioning and isometric

Answer 42

o Positioning: start at BOS (pelvis) o Isometric: M, but no movement o Isotonic: move a G&T to your mouth

Question 43

CRPS interventions to avoid or use with caution

Answer 43

PROM, passive stretching, joint mobilization, dynamic splinting, and casting

Question 44

fracture that is exception with PROM

Answer 44

humerus fractures often begin with PROM or AAROM

Question 45

intervention for pronator trees syndrome

Answer 45

conservative: elbow splint at 90 deg with forearm in neutral, avoid activities that include repetitive forearm pronation and supination surgical: decompression

Question 46

guyon's canal intervention

Answer 46

conservative: wrist splint in neutral, work/activity modification surgical: decompression

Question 47

cubital tunnel intervention

Answer 47

conservative: elbow splint at 30 deg of flexion, especially at night, elbow pad to decrease compression of nerve when leaning on elbows, activity/work modification surgical: decompression or transposition

Question 48

sensory reeducation

Answer 48

begin when individual demonstrates a level of diminished protective sensation (4.31) on femmes-weinstein