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הסס ליד > Test 1: Hand > Flashcards

Test 1: Hand Flashcards

1
Q

Functional Outcome Measures: insurance companies need to see this to check progress: these are subjective

3

A
  1. Disability of the Arm, Shoulder, and Hand (DASH):
    - –Measure disability and monitors sx and function in the UE
    - –Does not account for hand dominance: score high on DASH if the injury is on non-dominant hand but still need the therapy
    - –100 point scale
  2. Patient-Rated Wrist/Hand Evaluation (PRWHE):
    - –Assess wrist pain and disability
  3. Michigan Hand Outcomes Questionnaire (MHQ)
    - –Hand specific and assesses changes in hand function
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2
Q

Disability of the Arm, Shoulder, and Hand (DASH):

-a weakness

A

Measure disability and monitors sx and function in the UE

—Does not account for hand dominance: score high on DASH if the injury is on non-dominant hand but still need the therapy

—100 point scale

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3
Q

Patient-Rated Wrist/Hand Evaluation (PRWHE):

A

—Assess wrist PAIN and DISABILITY

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4
Q

Michigan Hand Outcomes Questionnaire (MHQ)

A

—Hand specific and assesses CHANGE in hand FUNCTION

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5
Q

Wound Assessment

4 things

A
  1. Length, width, depth: document this
  2. Color:
    - -Red: we want his healthy granulation tissue, healing
    - -Yellow: doesn’t mean it has to be infection but we don’t know what is under it. Antibacterial help infection.
    - -Black:
  3. Drainage:
    Amount
    Description: bloody vs serous (clear/ straw yellow)
  4. Odor: infection if bad odor
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6
Q

Scar Assessment

A
  1. Color:
    Dark: immature / new / vasculirized →
    light: doesn’t need vascularize anymore and color fades
  2. Size
  3. Texture: Flat vs raised/ Keloid vs hypertrophic
    [(Keloid = the scar goes beyond the original wound bed—but people think this is hypertrophic scar (thicker or raised, not extended beyond the woundbed)]
  4. Mobility / adhesion
  5. Sensitivity: Insensate vs hypersensitive
    - -Around scar nerve endings cut don’t be concerned if some numb
    * ***Hypersensitive is a concern: it will get worse over time and we need to work on desensitization
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7
Q

Edema Assessment

A
  1. location
  2. skin changes
  3. Qualify via palpation

Pitting: free fluid that can be displaced by pressure; soft→ can treat: it is still soft

Brawny: hard because fluid wasn’t able to move out of the swollen area and everything gets fibrotic and stiff → hard to treat

  1. Quantify with objective measures:
    - Circumferential (the ring)
    - Volumetric (use volume meter: beaker with water and measure water displaced)
  • Contraindications:
    a. Open wounds
    b. external hardware
    c. unstable vascular
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8
Q

Edema Assessment

A
  1. location
  2. skin changes
  3. Qualify via palpation

Pitting: free fluid that can be displaced by pressure; soft→ can treat: it is still soft

Brawny: hard because fluid wasn’t able to move out of the swollen area and everything gets fibrotic and stiff → hard to treat

  1. Quantify with objective measures:
    - Circumferential (the ring)
    - Volumetric (use volume meter: beaker with water and measure water displaced)
  • Contraindications:
    a. Open wounds
    b. external hardware
    c. unstable vascular
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9
Q

ROM

A
  1. Measurements are taken according to ASHT guidelines,Assess the entire upper quadrant, Compare to the other side

Wrist:
-wrist flexion: stationary radius, moving 3rd mc

  • extension: stationary radius, moving btwn 2n/3rd mc
  • RD/ UD: axis: capitate/ moving 3rd MC

Digits:
dorsum of digit
measure in a composite fist
digit to distal palmar crease and use ruler to see how far digit is from distal palmar crease

Opposition: thumb to tip of each finger → touch tip of each finger to tip of thumb
a. If not then measure distance between the tip of thumb and finger that they cannot get to

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10
Q

Wrist ROM

flexion

extension

radial deviation

ulnar deviation

A
  1. Flexion measured with goniometer placed dorsally
    Stationary arm: radius
    Movement arm: 3rd metacarpal
  2. Extension measured volarly:
    Stationary arm: radius
    Movement arm between 2nd and 3rd Metacarpal
  3. Radial and Ulnar Deviation:
    Axis: capitate
    Movement arm along 3rd metacarpal

Fingers should be relaxed during all wrist ROM measurements to allow for natural tenodesis

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11
Q

Digit ROM

A

Goniometer placed along the dorsum of digit
Typically measured in composite fist

COMPOSITE ROM (cm):

  1. Flexion: digit tip to distal palmar crease (DPC)→ composite flexion is a full fist
    a. Ruler at distal palmar crease and see where the fingers lie on the ruler and document that
  2. Opposition: thumb to tip of each finger → touch tip of each finger to tip of thumb
    a. If not then measure distance between the tip of thumb and finger that they cannot get to
  3. Thumb measurements should include radial and palmar abduction, opposition, MP and IP ROM
  4. Hyperextension indicated with (+), lack of extension indicated with (-)
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12
Q

Digit ROM

A

Goniometer placed along the dorsum of digit
Typically measured in composite fist

COMPOSITE ROM (cm):

  1. Flexion: digit tip to distal palmar crease (DPC)→ composite flexion is a full fist
    a. Ruler at distal palmar crease and see where the fingers lie on the ruler and document that
  2. Opposition: thumb to tip of each finger → touch tip of each finger to tip of thumb
    a. If not then measure distance between the tip of thumb and finger that they cannot get to
  3. Thumb measurements should include radial and palmar abduction, opposition, MP and IP ROM
  4. Hyperextension indicated with (+), lack of extension indicated with (-)
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13
Q

Hand ROM

A
  1. A/PROM of involved joints
  2. Composite ROM:
  3. Flexion: digit tip to distal palmar crease (DPC)
  4. Opposition: thumb to tip of each finger
  5. Passive length tests:
    Extrinsic extensor tightness (ie ED)
    Extrinsic flexor tightness
    Intrinsic tightness (ie lumbricals, interossei)
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14
Q

Bunnel Littler Test:

A

intrinsic tightness: assess IP ROM:
1. See if can make a fist: yes

  1. Can they flex IP joints alone: no - abnormal

If make fist and not a hook fist / claw: intrinsic tight

Full fist but not full hook fist with MP extended

  • This is because of where the lumbricals and interossei originate and insert
  • When MP straight intrinsics on stretch
  1. **Assess IP joint flexion with MP flexed vs straight: if there is a difference it is positive for intrinsic tightness
    most people who have swelling in hand have intrinsic tightness-better to catch it early before joints get stiff
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15
Q

Measure Grip Strength

A
  1. American Society of hand Therapists (ASHT)
  2. Jamar Dynamometer: gold standard for assessing grip strength
    - -Average 3 trials
    - -Handle in second position
    - -Shoulder adducted in neutral rotation, elbow flexed to 90 degrees, forearm neutral and wrist in neutral

Grip strength = average of 3 trials

Studies have been done challenging the 3 trial protocol

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16
Q

Measure Grip Strength

A
  1. American Society of hand Therapists (ASHT)
  2. Jamar Dynamometer: gold standard for assessing grip strength
    - -Average 3 trials
    - -Handle in second position
    - -Shoulder adducted in neutral rotation, elbow flexed to 90 degrees, forearm neutral and wrist in neutral

Grip strength = average of 3 trials

Studies have been done challenging the 3 trial protocol

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17
Q

Pinch Strength:

A
  1. Lateral pinch: key pinch: rest the gage on fist and thumb rests down: ulnar nerve
  2. Tip pinch: use thumb and index finger squeeze: not functional
  3. 3 point pinch: functional: assess median nerve
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18
Q

Pinch Strength:

A
  1. Lateral pinch: key pinch: rest the gage on fist and thumb rests down: ULNAR NERVE
  2. Tip pinch: use thumb and index finger squeeze: not functional
  3. 3 point pinch: functional: assess MEDIAN NERVE
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19
Q

Which pinch Ulnar Nerve?

A

Lateral pinch: key pinch: rest the gage on fist and thumb rests down: ULNAR NERVE

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20
Q

Which pinch median nerve?

A

3 point pinch: functional: assess MEDIAN NERVE

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21
Q

Pinch Strength:

A
  1. Lateral pinch: key pinch: rest the gage on fist and thumb rests down: ULNAR NERVE
  2. Tip pinch: use thumb and index finger squeeze: not functional
  3. 3 point pinch: functional: assess MEDIAN NERVE
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22
Q

Which pinch median nerve?

A

3 point pinch: functional: assess MEDIAN NERVE

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23
Q

which pinch not funcitonal?

A

Tip pinch: use thumb and index finger squeeze: not functional

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24
Q

which 3 cases not to assess grip and pinch without md approve?

A
  1. Fractures
  2. Tendon repairs / transfers
  3. Ligament sprains and repairs
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25
Q

Sensation

what nerves

what roots

A

note where the split is at the ring finger for the nerves

  1. Peripheral nerve:
  2. Radial nerve
  3. Ulnar nerve
  4. Median nerve
  5. Nerves: want to rule out cervical neuropathy
  6. C6: thumb, index finger
  7. C7: middle finger
  8. C8: ring, small finger
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26
Q

Bunnel Littler Test:

what is it

A

intrinsic tightness: assess IP ROM:
1. See if can make a fist: yes

  1. Can they flex IP joints alone: no - abnormal

If make fist and not a hook fist / claw: intrinsic tight

Full fist but not full hook fist with MP extended

  • This is because of where the lumbricals and interossei originate and insert
  • When MP straight intrinsics on stretch
  1. **Assess IP joint flexion with MP flexed vs straight: if there is a difference it is positive for intrinsic tightness
    most people who have swelling in hand have intrinsic tightness-better to catch it early before joints get stiff
How well did you know this?
1
Not at all
2
3
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27
Q

Measure Grip Strength

how

A
  1. American Society of hand Therapists (ASHT)
  2. Jamar Dynamometer: gold standard for assessing grip strength
    - -Average 3 trials
    - -Handle in second position
    - -Shoulder adducted in neutral rotation, elbow flexed to 90 degrees, forearm neutral and wrist in neutral

Grip strength = average of 3 trials

Studies have been done challenging the 3 trial protocol

How well did you know this?
1
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28
Q

Pinch Strength:

3 types

A
  1. Lateral pinch: key pinch: rest the gage on fist and thumb rests down: ULNAR NERVE
  2. Tip pinch: use thumb and index finger squeeze: not functional
  3. 3 point pinch: functional: assess MEDIAN NERVE
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29
Q

Sensation

what nerves

what roots

A

note where the split is at the ring finger for the nerves

  1. Peripheral nerve:
  2. Radial nerve
  3. Ulnar nerve
  4. Median nerve
  5. Nerves: want to rule out cervical neuropathy
  6. C6: thumb, index finger
  7. C7: middle finger
  8. C8: ring, small finger
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30
Q

Sensation Threshold Test

what is it

A

Sammes Weinstein monofilaments: if someone had a nerve compression injury like carpal tunnel or cubital tunnel syndrome: assess threshold: how much sensory input need to recognize sensory input: measures ability to determine slight touch

Identifies sensory impairments in nerve compression injuries

5 categories:

  1. normal
  2. diminished light touch
  3. diminished protective sensation
  4. loss of protective sensation
  5. un-testable

reliable and valid

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31
Q

Two-Point Discrimination:

what it assess
when it is helpful

A

static and moving two-point discrimination — innervations density

  1. Measures INNERVATION DENSITY – how many nerve endings are in an area after a nerve laceration (not helpful for compression issues like carpal tunnel)
  2. Helpful when assessing nerve regeneration after nerve laceration
  3. Area between the digit tips and the distal palmar crease tested
  4. Relates to patients ability to determine if they are sensate and what they can feel
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32
Q

Sensation Threshold Test

what is it

A

Sammes Weinstein monofilaments: if someone had a nerve compression injury like carpal tunnel or cubital tunnel syndrome: assess THRESHOLD: how much sensory input need to recognize sensory input: measures ability to determine slight touch

Identifies sensory impairments in nerve compression injuries

5 categories:

  1. normal
  2. diminished light touch
  3. diminished protective sensation
  4. loss of protective sensation
  5. un-testable

reliable and valid

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33
Q

Two-Point Discrimination:

what it assess
when it is helpful

A

static and moving two-point discrimination — innervations density

  1. Measures INNERVATION DENSITY – how many nerve endings are in an area after a nerve laceration (not helpful for compression issues like carpal tunnel)
  2. Helpful when assessing nerve regeneration after nerve laceration
  3. Area between the digit tips and the distal palmar crease tested
  4. Relates to patients ability to determine if they are sensate and what they can feel
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34
Q

Sensory Return: moving 2 point discrimination always returns before static** [memorize]

A

Pain and temperature (return first)

  1. *30 cps vibration
  2. *Moving light touch
  3. *256 cps vibration
  4. *Static light touch
  5. *Localization of light touch (return last, most sophisticated)
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35
Q

Two-Point Discrimination:

what it assess
when it is helpful

A

static and moving two-point discrimination — innervations density

  1. Measures INNERVATION DENSITY – how many nerve endings are in an area after a nerve laceration (not helpful for compression issues like carpal tunnel)
  2. Helpful when assessing nerve regeneration after nerve laceration
  3. Area between the digit tips and the distal palmar crease tested
  4. Relates to patients ability to determine IF they are sensate and WHAT they can feel
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36
Q

Sensory Return: moving 2 point discrimination always returns before static** [memorize]

A

Pain and temperature (return first)

  1. *30 cps vibration
  2. *Moving light touch
  3. *256 cps vibration
  4. *Static light touch
  5. *Localization of light touch (return last, most sophisticated)
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37
Q

Sensory Return: moving 2 point discrimination always returns before static** [memorize]

A

Pain and temperature (return first)

  1. *30 cps vibration
  2. *Moving light touch
  3. *256 cps vibration
  4. *Static light touch
  5. *Localization of light touch (return last, most sophisticated)
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38
Q

Primary Vs Secondary Healing

A

Primary: surgery

Secondary: no surgery

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39
Q

Primary healing:

A

After Surgery: 2 ends have been surgically joined by hardware => no boney callus: therapy can start in 7-14 days after surgery (earlier)

  1. Inflammation phase 1-2 weeks:
    Rest and gentle AROM
  2. Reparative phase 2-6 weeks:
    Full A/PROM
  3. Remodeling phase 6 weeks+:Continue motion
  4. Strengthening at 8 weeks
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40
Q

Secondary Healing

A

No surgery: the fx fragments are left to heal on its own: bony callous forms: Immobilized longer (in cast) so mobilized after primary healers – therapy starts after cast removed (start later than s/p surgery)

  1. Inflammation phase 1-2 weeks:
    Protect
  2. Reparative phase 3-6 weeks:
    Continued protection
    Maybe move a little
  3. Remodeling phase 6wks +:
    Move a lot
    PROM at 6 weeks
  4. Strengthening at 12-14 weeks:
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41
Q

Primary healing:

A

After Surgery: 2 ends have been surgically joined by hardware => no boney callus: therapy can start in 7-14 days after surgery (earlier)

  1. Inflammation phase 1-2 weeks:
    Rest and gentle AROM
  2. Reparative phase 2-6 weeks:
    Full A/PROM
  3. Remodeling phase 6 weeks+:Continue motion

Strengthening at 8 weeks

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42
Q

Secondary Healing

A

No surgery: the fx fragments are left to heal on its own: bony callous forms: Immobilized longer (in cast) so mobilized after primary healers – therapy starts after cast removed (start later than s/p surgery)

  1. Inflammation phase 1-2 weeks:
    Protect
  2. Reparative phase 3-6 weeks:
    Continued protection
    Maybe move a little
  3. Remodeling phase 6wks +:
    Move a lot
    PROM at 6 weeks
  4. Strengthening at 12-14 weeks:

Strengthening at 12-14 weeks

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43
Q

Primary Vs Secondary Healing

A

Primary: surgery (strengthen 6 weeks)

Secondary: no surgery (strengthen 12-14 weeks)

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44
Q

Secondary Healing

A

No surgery: the fx fragments are left to heal on its own: bony callous forms: Immobilized longer (in cast) so mobilized after primary healers – therapy starts after cast removed (start later than s/p surgery)

  1. Inflammation phase 1-2 weeks:
    Protect
  2. Reparative phase 3-6 weeks:
    Continued protection
    Maybe move a little
  3. Remodeling phase 6wks +:
    Move a lot
    PROM at 6 weeks
  4. Strengthening at 12-14 weeks:

Strengthening at 12-14 weeks

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45
Q

Is primary healing faster than secondary healing?

What is outcome of fx depend on?

what is the most common complication of most fractures?

A

Primary healing is not faster healing, its faster moving (ROM)—can safely move patient sooner

The outcome of any fracture is influenced by the choice of treatment as well as the TYPE & DURATION OF IMMOBILIZATION—if someone was immobilized for too long, not good

[The most common complication of hand fractures is not mal-union or infection.]
MOST COMMON COMPLICATION is joint contracture & tendon adhesions

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46
Q

Most common complication of fracture

is not

is

A

IS NOT:
The most common complication of hand fractures is not mal-union or infection

MOST COMMON COMPLICATION is joint CONTRACTURE & tendon ADHESION

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47
Q

Most common complication of fracture

is not

is

A

IS NOT:
The most common complication of hand fractures is not mal-union or infection

MOST COMMON COMPLICATION is joint CONTRACTURE & tendon ADHESION

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48
Q

How to splint fracture in the hand?

wrist

MP

IP

THUMB

A

Splint affected area in “safe “ hand position
1. Wrist slight extension (20-30deg)

  1. MP: ~70 degrees flexion
    keeps collaterals taught (lengthened when MP flexed)
    Don’t want a contracture
  2. IP: extended
  3. Thumb abduction: some palmar abduction for function
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49
Q

How to splint fracture in the hand?

wrist

MP

IP

THUMB

A

Splint affected area in “safe “ hand position
1. Wrist slight extension (20-30deg)

  1. MP: ~70 degrees flexion
    keeps collaterals taught (lengthened when MP flexed)
    Don’t want a contracture
  2. IP: extended
  3. Thumb abduction: some palmar abduction for function-keeps them functional post splint

Structures to be included in splint:
—Joints above and below fracture site –for fingers: if injure PIP splint the DIP and MP and adjacent fingers (if it is a wrist we don’t immobilize the elbow)

—Adjacent finger(s)
Ie if 4th prox phalanx do 3rd, 4th, and 5th fingers

50
Q

What structures to be included in a hand splint?

what joints?
what fingers?

A

Structures to be included in splint:
—Joints above and below fracture site –for fingers: if injure PIP splint the DIP and MP and adjacent fingers (if it is a wrist we don’t immobilize the elbow)

—Adjacent finger(s)
Ie if 4th prox phalanx do 3rd, 4th, and 5th fingers

51
Q

What structures to be included in a hand splint?

what joints?
what fingers?

A

Structures to be included in splint:
—Joints above and below fracture site –for fingers: if injure PIP splint the DIP and MP and adjacent fingers (if it is a wrist we don’t immobilize the elbow)

—Adjacent finger(s)
Ie if 4th prox phalanx do 3rd, 4th, and 5th fingers

52
Q

pt 45 w/o femal non-displaced MC fx 5th. What structures do u include in splint??

A

Non-displaced means fx but the fragments are still aligned, will be able to heal in secondary healing, anatomy will be restored.

Include in the splint: wrist (will come 2/3 down forearm), include proximal phalanx (MP joint will be splinted), but not all the way to fingertips: splint pinky and 4th

53
Q

Fracture Rehab

Surgical Vs Conservative

A

—SURGICAL MANAGEMENT
Primary healing = Surgical management
Rehab begins 7-10 days post-op

—CONSERVATIVE MANAGEMENT
Secondary healing = conservative management
Rehab (of most involved area) begins once cast is removed ~ 6wks after injury

54
Q

Fracture Rehab

Surgical Vs Conservative

A

—SURGICAL MANAGEMENT
Primary healing = Surgical management
Rehab begins 7-10 days post-op

—CONSERVATIVE MANAGEMENT
Secondary healing = conservative management
Rehab (of most involved area) begins once cast is removed ~ 6wks after injury

55
Q

Distal Radius Fractures

3 types

A
  1. Colles fracture: most common
    - –Extra-articular
    - –Dorsal displacement of fragment
  2. Smiths fracture:
    - –Extra-articular
    - –Volar displacement of fragment
  3. Bartons fracture: Gets stiff easier because in joint
    - –Intra-articular fracture/dislocation
    - –Dorsal dislocation of carpus on radius
    - –Radial fragment can be dorsal or volar
56
Q

Colles fracture

A

most common

  • –Extra-articular
  • –DORSAL displacement of fragment
57
Q

Smiths fracture

A
  • –Extra-articular

- –VOLAR displacement of fragment

58
Q

Bartons fracture:

A

Gets stiff easier because in joint
—Intra-articular fracture/dislocation

(?—Dorsal dislocation of carpus on radius)

—Radial fragment can be DORSAL or VOLAR

59
Q

Bartons fracture:

A

Gets stiff easier because in joint
—Intra-articular fracture/dislocation

(?—Dorsal dislocation of carpus on radius)

—Radial fragment can be DORSAL or VOLAR

60
Q

Does the ulna articulate with the carpus?

A

radius articulate with carpus, ulna does NOT articulate with the carpus

61
Q

Triangulofibrocartilage Complex: TFCC

A
  1. Acts as meniscus
  2. Shock absorber in the wrist
  3. Does not have good healing potential
62
Q

Distal radioulnar joint force distribution :

most likely to fracture____

A

80% more likely to fx radius

FOOSH more likely to fx radius, once force placed through the wrist: 80% ground reaction force goes through radius 20% goes through ulna

63
Q

How to break ulna styloid?

A

Most people who FOOSH break ulna styloid also—it heals on its own, no surgical inervention

64
Q

How to rupture EPL?

A

EPL can rupture after radial fracture: gets frayed by Lister’s Tubercle

  1. This may happen 1 year s/p radial fx (usually not acute)
  2. Get thumb pain and this is because the EPL is ruptured

Usually chronic, about 1 year post Presents as thumb pain Surgical fixation CRPP External fixation ORIF Dorsal plating => slower to regain ROM Volar fixed-angle plating

65
Q

How to rupture EPL?

what is the sign in the patient?

A

EPL can rupture after radial fracture: gets frayed by Lister’s Tubercle

This may happen 1 year s/p radial fx (usually not acute)

Get THUMB PAIN and this is because the EPL is ruptured

Usually chronic, about 1 year post Presents as thumb pain Surgical fixation CRPP External fixation ORIF Dorsal plating => slower to regain ROM Volar fixed-angle plating

66
Q

How to rupture EPL?

what is the sign in the patient?

A

EPL can rupture after radial fracture: gets frayed by Lister’s Tubercle

This may happen 1 year s/p radial fx (usually not acute)

Get THUMB PAIN and this is because the EPL is ruptured

Usually chronic, about 1 year post Presents as thumb pain Surgical fixation CRPP External fixation ORIF Dorsal plating => slower to regain ROM Volar fixed-angle plating

67
Q

Options for surgical fixation

Distal Radius Fx

A
  1. CRPP
  2. External Fixation
  3. ORIF

—Dorsal plating: ROM returns slower

—Volar fixed angle plating: ROM returns quicker

68
Q

Options for surgical fixation

Distal Radius Fx

A
  1. CRPP
  2. External Fixation
  3. ORIF
    - –Dorsal plating: ROM returns slower
    - –Volar fixed angle plating: ROM returns quicker
69
Q

Rehab

Distal Radius Fracture

Phase I

Phase II

Phase III

A

Phase I (immobilize, ROM DIGITS ASAP, tendon glides, edema elevation and AROM digits)

Phase II: Conserv 6wk/ surgery 2wk
(immobilize splint, control edema, scar management surgery, ROM DIGITS, wrist [fingers flexed], forearm, PRAYERS STRETCH, light functional activities and dexterity tasks)

Phase III: Conserv 12-14 wk/ surg 8wk: strengthening
(only splint for static progressive stretch, ROM aggressive, STRENGTHEN: most forces go through radius-strengthen in neutral wrist: GRIP STRENGTH)

70
Q

Rehab

Distal Radius Fracture

Phase I

Phase II

Phase III

A

Phase I (immobilize, ROM DIGITS ASAP, tendon glides, edema elevation and AROM digits)

Phase II: Conserv 6wk/ surgery 2wk
(immobilize splint, control edema, scar management surgery, ROM DIGITS, wrist [fingers flexed], forearm, PRAYERS STRETCH, light functional activities and dexterity tasks)

Phase III: Conservative 12-14 wk/ surg 8wk: strengthening
(only splint for static progressive stretch, ROM aggressive, STRENGTHEN: most forces go through radius-strengthen in neutral wrist: GRIP STRENGTH)

71
Q

After radial fracture when allowed to make a fist?

A

?

Forearm & Wrist ROM

72
Q

After radial fracture when allowed to make a fist?

A

?

Forearm & Wrist ROM

73
Q

T/F

elbow joint allow for rotation of forearm in any degree of elbow flexion or extension

A

TRUE

elbow joint allow for rotation of forearm in any degree of elbow flexion or extension

74
Q

What creates bony stability at elbow joint?

A

configuration of trochlea (humerus) and the olecranon (ulna) create bony stability of the joint

75
Q

What creates bony stability at elbow joint?

A

configuration of trochlea (humerus) and the olecranon (ulna) create bony stability of the joint

76
Q

what motions of elbow most limit function

A

outward reach

bring hand to face , ear, and head

77
Q

what motions of elbow most limit function

A

outward reach

bring hand to face , ear, and head

78
Q

What motion do medial and lateral ligament complexes do at the elbow?

A

prevent motion of ulna pronation & supination, it should stay stationary when the radius moves, we do not want the ulna to rotate

79
Q

What ligament links the radius and ulna and provides forearm stability and maintains a kinematic link between radius and ulna during rotation?

what joint mechanics need this?

A

Interosseous ligament:
link between radius and ulna (link during forearm rotation)

provides forearm stability and maintains a kinematic link btwn r & U during rotation

need for proximal radial ulnar joint mechanics

80
Q

TFCC

to what does it provide stability?

why would an issue cause an issue to the proximal elbow joint?

A

Provides stability of DRUJ (distal radioulnar joint): if issue will also cause issue at the elbow proximally

  1. Axial force transmission
  2. forearm stability
81
Q

TFCC

to what does it provide stability?

why would an issue cause an issue to the proximal elbow joint?

A

Provides stability of DRUJ (distal radioulnar joint): if issue will also cause issue at the elbow proximally

  1. Axial force transmission
  2. forearm stability
82
Q

Is VARUS or VALGUS more important at the elbow? What ligament?

A

Varus force (most important to us) –most happen in life, long healing time-long protective period

  • –Gaps radiocapitellar joint, compresses the medial elbow
  • –LCL, RCL
83
Q

UCL: which force tears it? WHen?

A

Valgus force: Laterally directed force on forearm w/ stable humerus

Gaps the ulnarhumeral joint and compress radiocapitellar joint

This is the force that is applied when throwing a ball-we can live without

  1. In overhead athletes
  2. Tommy John surgery because cannot stabilize against a valgus force

UCL/MCL

84
Q

UCL: which force tears it? WHen?

A

Valgus force: Laterally directed force on forearm w/ stable humerus

Gaps the ulnarhumeral joint and compress radiocapitellar joint

This is the force that is applied when throwing a ball-we can live without

  1. In overhead athletes
  2. Tommy John surgery because cannot stabilize against a valgus force

UCL/MCL

85
Q

Special things to consider tx elbow

A

The elbow adversely responds to “outside interference”:

  1. Initial trauma—injury
  2. Surgical procedure
  3. Therapy: LESS IS MORE: Very slow, nothing aggressive, Need patience, less is more, Very limited therapies available: Counterproductive inflammatory response
    Leads to further motion limitation
86
Q

Why is less more in tx elbow? What should we do

A
  1. elbows are coaxed and not coerced
  2. fx stability and healing comes first
  3. LESS IS MORE: Very slow, nothing aggressive, Need patience, less is more, Very limited therapies available

1) Avoid excessive stretching/ROM
We do it but less aggressively –manual soft tissue techniques and PROM but less aggressively

Counterproductive inflammatory response

Leads to further motion limitation

87
Q

goal in tx elbow: do we want fx heal or mobility??

A

Fracture stability and healing comes first
—May have to immobilize “too long”: If it is immobilized for very long, ie 8 weeks, we can deal with the stiffness later, but we cannot heal it later

—Contracture release if necessary
Release tissue scarred down, or extra growth like HO

HO occurs commonly in men

88
Q

Elbow fx

4 tx pearls

A

a. Understand the anatomy of –protection, ROM uninvolved joint

b. Watch for trouble:
Nerve irritation (ulnar n.):
Hematoma:
Structure that need special protection

c. Restore ROM, prevent joint stiffness & influence scar remodeling
d. Splinting options: to regain ROM

89
Q

What can go wrong in an elbow fx?

A
  1. Nerve irritation (ulnar n.):
    ie numb in 4th or 5th finger
  2. Hematoma:
    look like a golf ball –accumulation of swelling or fluid near surgical site
  3. Swelling & fluid near surgical site (can look like a golf ball)
    a. Structure that need special protection
  4. Structures that need special protection:
    ie lateral collateral ligament
90
Q

Elbow splint after fracture to get ROM

A

Splinting options:
to regain ROM: ie elbow extension (night) or flexion (day) due to stiffness

Very common after elbow fx

Sleep with elbow extension

During the day flexion

91
Q

Distal Humerus Fx

why we dont like to treat it

A

bad fracture to pass through radius and ulna and end up at distal humerus. If fall on elbow break olecronon on ulna more likely.

a. Among the most complex fractures to manage effectively
b. Complex structural anatomy w/ unique orientation of articular surfaces w/ cancellous bone
c. Relatively uncommon so surgeons rarely gain much experience—harder to get it fixed proprerly
d. Often see pain & loss of ROM
e. Capsule is sensitive to trauma/surgery

92
Q

Radial Head Fracture:

Minimally Displaced

Displaced

Comminuted

A

(remember this is at elbow)

Minimally displaced :

  1. 2mm displacement
  2. may have mechanical block
  3. if full motion treat with protected motion, if motion limited need ORIF

Comminuted:

    • mechanical block
  2. ORIF vs excision vs. replacement
93
Q

Radial Head Fracture

Minimally Displaced

A

(fall on outstretched arm and distal radius did not break, only radial head broke, minimal like a hairline fracture, do not need splint and treat with early ROM)

1.

94
Q

Radial Head Fracture

Displaced

A
  1. > 2mm displacement
  2. may have mechanical block
  3. if full motion treat with protected motion, if motion limited need ORIF
95
Q

Radial head fracture

Comminuted

A
    • mechanical block

2. ORIF vs excision vs. replacement

96
Q

Radial head fracture

Comminuted

A
    • mechanical block

2. ORIF vs excision vs. replacement

97
Q

Radial Head Fracture

  1. how common
  2. why preserve radial head important
  3. if suspect injury to IOL (interosseous), why save radial head?
  4. who should get excision ?
  5. what to check for?
A
  1. Most common elbow fracture in adults
  2. Preservation of radial head is important for acute and long term stability
  3. In patients w/ suspected injury to IOL, saving the radial head may prevent pathological proximal migration of radius
  4. Excision should be limited to patients w/ grossly comminuted fractures in those w/ low demand
  5. Must check for dislocated/ unstable DRUJ (distal radial ulnar joint)
    - –Due diligence is to check IOL (interosseous ligament) and DRUJ
    - –Make sure the interosseous membrane is not disrupted, make syre not instabilities
98
Q

Olecranon Fracture

common?

mechanism

surgery?

what nerve susceptible?

why need to mobilize the tissue near it?

A

Common adult elbow fracture

MECHANISM
Often occurs from a fall onto a bent elbow or direct blow
(Prone to trauma because of the superficial nature of bone)

Most require surgical fixation because most are displaced as a result of the triceps pulling on the bone

Ulnar nerve is susceptible to injury—close to the olecronon
(Painful due to bony nature of where it is)

Large incision on thin, tight skin in that area and not forgiving—need to mobilize the tissue

  1. Scar is sensitive
  2. Triceps get bound down
99
Q

Complications of Elbow Fractures (10)

A
  1. Scar tissue formation
    (f too much may need another surgery to remove)
  2. HO: formation of bone within nonosseous structures
    (If pushing and pushing on ROM and getting nowhere may be HO => may need a second surgery to remove the bone)
  3. Articular mal-alignment
  4. Improper placement of hardware
  5. Nerve injury
  6. Malunion or nonunion
  7. Instability
  8. Loss of ROM
  9. Vascular injury
  10. Myositis ossificans
100
Q

Complications of Elbow Fractures (10)

A
  1. Scar tissue formation
    (f too much may need another surgery to remove)
  2. HO: formation of bone within nonosseous structures
    (If pushing and pushing on ROM and getting nowhere may be HO => may need a second surgery to remove the bone)
  3. Articular mal-alignment
  4. Improper placement of hardware
  5. Nerve injury
  6. Malunion or nonunion
  7. Instability
  8. Loss of ROM
  9. Vascular injury
  10. Myositis ossificans
101
Q

Elbow Fracture Rehab

Phase I

Phase II

Phase II

A

Phase I: week 0-2: immobilize, edema control, AROM of other joints and elbow when allowed

Phase II: week 2-8: immobilize, edema, scar management, light functional activity, ROM all joints

Phase II: week 8+:
edema control, end range ROM (can use splint static progressive splint 30-40 minutes), strengthening

102
Q

Elbow Fracture Rehab

Phase I

Phase II

Phase II

A

Phase I: week 0-2: immobilize, edema control, AROM of other joints and elbow when allowed

Phase II: week 2-8: immobilize, edema, scar management, light functional activity, ROM all joints

Phase II: week 8+:
edema control, end range ROM (can use splint static progressive splint 30-40 minutes), strengthening

103
Q

MC fractures

which MC most common injury
why

A

1st & 5th are most commonly injured—because most mobile

104
Q

MC fractures

who

A

1st & 5th are most commonly injured—because most mobile

Most in men ages 10-29

Common:

  1. MVA,
  2. Bicycle accident
  3. crush
  4. direct blow to hand
105
Q

What is compromised in MC injury?

A

Injury can compromise structural support of hand—that’s what we need the metacarpals for

medical management must maintain or restore the 3 arches of the hand

  1. longitudinal arch (3rd to carpus)
  2. distal palmar arch
  3. proximal palmar arch
106
Q

Weakest part of the MC?

A

neck

most likely to fracture neck because weakest part and it is where we move a lot

107
Q

does MC have good blood supply?

A

Excellent blood supply

108
Q

relationship between length of the MC and its CMC motion

A

Inverse relationship between length of the MC and its CMC motion

109
Q

implication of location of digital extensor tendons

A

superficial over MC—can get stuck down after injury—need to do tendon glides for extensor tendons which can scar and get stuck down

110
Q

How to manage CRPP

A

MC fracture surgical management: can be splinted and don’t need casting (splinting is removable to shower etc)

CRPP: closed reduction percutanous pinning, there will be pins

  1. Unstable fracture
  2. Ie metacarpal neck fractureNote- most MC neck fractures can be managed via closed reduction & splint or cast immobilization for 3-4 weeks.
111
Q

How to manage ORIF

A

b. ORIF: see a scar in the length of the metacarpal where it was plated
- —Irreducible fractures or those that cannot be reduced via closed techniques

112
Q

Boxer’s Fracture

A

Fracture of 4th or 5th MC neck

One of the most common hand fractures

“fight bite”: hit someone in the face: skin broke if they hit a tooth, can become infected

113
Q

MC Fracture Rehab

Phase I

Phase II

Phase III

A

Phase 1: (protective immobilize cast/gutter splint, edema control, woundcare, ROM of DIGITS/elbow/shoulder, tendon glides)

Phase 2: (immobilization splint, edema control, manage scar w massage and silicone pad, ROM DIGITS + EDC glides, differential glides, blocking MP exercise and flex IP, light functional activities)

Phase 3: STRENGTH, joint mobilization if needed
(static passive splint if need, aggressive ROM, STRENGTHEN GRIP and pinch, EDC resistive to facilitate glide, MCP extension to break up scarring)

114
Q

If the EDC tendons bound down, what happens during A/PROM of Digits?

A

If the tendons are bound down : limited digit AROM extension

If the tendons are bound down: limited digit PROM and AROM flexion

115
Q

CMC joint arthroplasty

  • -what replaced
  • -who most common in
  • -preop complaints
A

a. Replacement of 1st metacarpal trapezium joint
b. Women get it more than men 10-15:1
c. Pre-op complaints often include PAIN at the CMC joint and movement or SLIPPING in the joint

116
Q

Most common site of OA in the hand?

A

DIP joints are most common site of hand OA

Trapezium is 2nd most common site of hand OA

117
Q

why is the 1st metacarpal adducted into palm due to subluxation of 1st CMC:

A

the hand usually looks like: 1st metacarpal adducted into palm because subluxation of 1st CMC: ANTERIOR OBLIQUE LIGAMENT is stretched out and does not hold the joint in place.

118
Q

Saddle sign:

A

the bump when 1st metacarpal subluxed off the trapezium

1st MC subluxed off TM

1st metacarpal adducted into palm because subluxation of 1st CMC: ANTERIOR OBLIQUE LIGAMENT is stretched out and does not hold the joint in place.

119
Q

3 fundamental principles of CMC joint arthroplasty:

A
  1. Trapezium excision [because this is the the damaged part of the joint]
  2. AOL reconstruction (anterior oblique ligament)
  3. Fascial interposition (anchovy)
120
Q

Surgical technique: Ligament reconstruction tendon interposition

1st CMC

A

a. Trapezium excision
b. Small piece of 1st MC excised
c. FCR tendon harvested—split the tendon: leave half and take half and fold it and anchovy it
d. FCR routed through hole at base of 1st MC
e. FCR folded on itself btwn 1st MC and scaphoid
f. K wire(s) placed to stabilize MC

g. IMMOBILIZE: Cast for a few weeks, then splint forearm based thumb spica splint

121
Q

Rehab: Ligament reconstruction tendon interposition

1st CMC

Phase I

Phase II

Phase III

A

LRTI: Phase I: (protect immobilization with bulky post-op cast or forearm based thumb spica, Pin/wound care, Edema Control, Joint Protection, ROM) *no thumb/wrist ROM

mmobilization up to 8 wks but usually they don’t need a lot of therapy—let it be immobilized in the beginning, it will just hurt to mobilize them right away

LRTI: Phase II: Full time splint, Edema control, Scar management, AROM (Thumb MP, CMC joints, Wrist), Light functional activities

LRTI: Phase III: Splint begins to taper, ROM, Focus on functional ROM vs. end range ROM, Strengthening, Wrist, Grip, Light pinch resistance)

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