Upper extremity

Question 1

Nerve roots of the axillary nerve

Answer 1

C5, C6

Question 2

Nerve roots of the radial nerve

Answer 2

C5, C6, C7, C8, T1

Question 3

Nerve roots of the median nerve

Answer 3

C5, C6, C7, C8, T1

Question 4

Nerve roots of the ulnar nerve

Answer 4

C8, T1

Question 5

Cords of the brachial plexus innervating the axillary nerve

Answer 5

Posterior

Question 6

Cords of the brachial plexus innervating the radial nerve

Answer 6

Posterior

Question 7

Cords of the brachial plexus innervating the median nerve

Answer 7

Medial and Lateral

Question 8

Cords of the brachial plexus innervating the ulnar nerve

Answer 8

Medial

Question 9

Sensory Distribution of Axillary Nerve

Answer 9

Skin over distal portion of deltoid muscle

Question 10

Sensory Distribution of Radial Nerve

Answer 10

Dorsal surface of forearm

Dorsal aspect of the radial half of the hand

Question 11

Sensory Distribution for the Median Nerve

Answer 11

Skin on palmar aspect of the thumb

Palmar aspect lateral 2.5 fingers

Question 12

Sensory Distribution of the Ulnar Nerve

Answer 12

Skin of 5th finger, 4th finger (1/2 palmar, full dorsal), Medial half of the hand (palmar and dorsal)

Question 13

Motor Distribution for the Axillary Nerve

Answer 13

Deltoid

Teres Minor

Question 14

Motor Distribution for the Radial Nerve

Answer 14

Triceps Brachii
Anconeus
Brachioradialis
Ext Carp Rad Long

All other Extensor-Supinator muscles of the forearm

Question 15

Motor Distribution for the Median Nerve

Answer 15

Flexor-Pronator Muscles of the Forearm

1st and 2nd Lumbricals

All Thenar (Thumb) Muscles EXCEPT ADDuctor Pollicus

Question 16

Motor Distribution of the Ulnar Nerve

Answer 16

Flex Carp ULNARIS

Flex Carp Digitorum Profundus (ulnar head)

Adductor Pollicis

3rd and 4th Lumbricals

Plamar and Dorsal Interossei

Hypothenar Muscles (Everything Minimi!!!)

Question 17

Mallet Finger

Answer 17

Hyperflexion of DIP joint

Avulsion of the Extensor Digitorum Tendon

Orthotic Treatment
Hold DIPJ in extension/prevent flexion
Hyperextend and immobilize DIP to allow reinsertion

Mallet Finger Cap

Question 18

Boutonniere Deformity (Secondary to RA, or from trauma)

Answer 18

DIPJ hyperextended, PIPIJ flexed, MCPJ extended

Orthotic Treatment
3PPS to aid extension at PIPJ and allow flexion at DIPJ

Dynamic
(with spring wire) or
Static
Boutenniere splint (ex. Digisplint)

Question 19

Swan Neck Deformity (contracture of intrinsic hand muscles)

Answer 19

PIPJ hyperextended, DIPJ flexed, MCPJ flexed

3PPS to prevent hyperextension at PIPJ and also allow flexion at the PIPJ

Swan Neck Splint
Static (ex. Digisplint)

Question 20

RA deformities of the MCPJ, Metacarpal Ulnar Deviation (MUD)

Answer 20

Volar subluxation and ulnar deviation of the proximal phalanges

Align wrist in excessive ulnar deviation to provide optimal alignment of long finger extesnor tendons (reduces the lateral pull)

Static WHO (plastic or leather)

Question 21

Game Keeper’s Thumb / Skier’s thumb

Answer 21

AKA skier’s thumb, UCL (Ulnar collateral ligament) tear

UCL is torn at its insertion site into prox phalanx

Common cause - falling on outstretched hand

Instability of the MCP joint

Pain
Swelling
Weakness of pinch grasp, poor ability to grasp objects (tying shoes, tearing paper etc.)

Question 22

Thumb OA

Answer 22

Most common form of osteoarthritis affecting the hand

Cushioning cartilage wears away from adjoining ends of bones making up thumb CMC joint

Severe hand pain
Swelling
Decreased strength/ROM
Difficultly performing ADLs (turning doorknobs, opening jars)

Orthotic Treatment

Hold thumb in opposition to index and middle finger for stabilization with functional pinch/grasp ability

Static Short opponens orthotic (Thumb Post Splint)

Question 23

De Quervain’s Tenosynovitis

Answer 23

Inflammation of the Ext Pol Brevis and Abd Pol Long tendons

Prevent excursion of EPB and AbPL tendons

Stabilize and thumb and wrist in neutral position as these long tendons cross the wrist joint

Static Long Opponens Orthosis

Question 24

Ulnar Nerve Palsy

Answer 24

4th an 5th MCPJ hyperextension, PIPJ hyperflexion

Need MCPJ flexion and PIPJ extension assist

Prevent hyperextension at 4th and 5th MCPJs, and allow weak extension of PIPJs

Dynamic Orthosis
Ulnar Nerve Palsy Orthoses (i.e spring wire) encourage joint mobility and augment hand function

Static Orthosis
for positioning and prevention of contracture

Question 25

Median Nerve Palsy

Answer 25

Loss of opposition of the thumb Need MPJ flexion, CMCJ Abduction, CMCJ pronation Static or Dynamic positioning of thumb for function Static thumb post or Dynamic thumb positioning with elastic component

Question 26

Radial Nerve Palsy

Answer 26

Loss of wrist and MCPJ extension Need to assist wrist and MCPJ extension, allow MCPJ flex-ext Stabilize wrist in functional position while fingers and thumb extend at MCPJs Static WHO (dorsal shell) with Dynamic MCPJ extension assist (spring wires), stabilize 1st CMCJ, Dynamic wrist extension component

Question 27

Medial and Ulnar Nerve Palsy (intrinsic minus hand)

Answer 27

Loss of wrist and finger flexion, thumb opposition Need to pinch or grasp of fingers in release Stabilize thumb for pinch, prevent hyperextension of MCPJs, allow weak IPJ extension by extensor communis Dynamic Positioning of the thumb and 4 MCPJs to encourage joint mobility and augment hand function Static Positioning of thumb and fingers to prevent contracture

Question 28

Carpal Tunnel Syndrome

Answer 28

Compression of the median nerve within the carpal tunnel Resulting muscle weakness and sensory disturbances (tingling and numbness) Stabilization of wrist required to prevent tension or compression of the median nerve, wrist positioned in neutral position for rest and functional use Static WHO - plastic or leather design

Question 29

OA/RA of the wrist

Answer 29

Destruction of joint space = painful ROM Need functional position of wrist, prevention of pain Stabilize the wrist in 25 degrees of extension and 5 degrees of ulnar deviation Functional WHO, gauntlet, leather or plastic design

Question 30

Zig Zag Deformity

Answer 30

Radial deviation of wrist with Ulnar deviation of fingers Usually caused by rheumatoid arthritis Correction of deformity Excessive (>5 degrees) ulnar deviation to counteract the ulnar deviation of the fingers Function WHO, gauntlet, leather or plastic design

Question 31

Dupuytren's contracture

Answer 31

Fixed flexion contraction of the hand due to palmar fibromatosis Inherited proliferative connective tissue disorder affecting palmar fascia Fingers bent towards palm, cannot fully extend Ring and little finger most commonly affected Index and thumb usually spared Contractures progress slowly, usually painless Orthotic treatment to prevent further contracture

Question 32

Lesions Affecting the Axillary Nerve

Answer 32

Rarely affected alone May be involved in Spinal cord and brachial plexus lesions Fractures and dislocations of the head of the humerus Violent blows on the shoulder Bullet, stab, and other wounds Pressure or stretching of the shoulder during sleep Deltoid paralysis - inability to protract/retract arm, abduct it to horizontal position Teres MInor paralysis - weakness of external rotation - atrophy of affected muscles - sensation lost over deltoid prominence - pain is present in neuritis

Question 33

Lesions affecting radial nerve

Answer 33

Most commonly injured peripheral nerve Involved in cervical and brachial lesions Peripheral injuries may affect the trunk or some of the branches of the nerve as in ``` Dislocations of the shoulder Fractures of the humerus Callus formation around the fracture Pressure from crutch Violent blows on the arm Tuberculosis of the bone Fractures of the neck of the radius Toxic or infectious neuritis (inflammation of nerve) ```

Question 34

Lesions affecting Median Nerve

Answer 34

Cervical cord and brachial plexus lesions Lacerations of the arm, forearm, wrist, hand due to auto accidents, stab wounds, bullets, etc. Prolonged compression in sleep/anesthesia Dislocations of ulna, fractures to elbow and distal radius Toxic or infectious neuritis

Question 35

Lesions affecting Ulnar Nerve

Answer 35

Cervical cord and brachial plexus lesions Fractures/Dislocations of the head of the humerus Direct lacerating trauma in lacerating wounds (eg. knife, auto accident etc.) Pressure on nerve during sleep Drunkenness, general anesthesia Callus formaiton Neurinoma (tumor) Toxicity (lead)

Question 36

Median/Ulnar Nerve Lesion

Answer 36

Frequently injured together If lesion complete, functional disturbances are constant If one or both nerves are only partially involved, symptoms differ widely Classified according to varied appearance and functions of the hand

Question 37

SCI with C8 Escape

Answer 37

Loss of Opposition of intrinsic hand and muscle function Stabilize thumb for weak opposition Static thumb post

Question 38

SCI with C7 Escape

Answer 38

Loss of Pronation Wrist Flexion Finger flexion and extension (but maintains ext car rad l & b, and ext car ulnaris) FInger flexion and extension for pinch and grasp Stabilize thumb for pinch against fingers Harness action of Extensor Carpi Radialis for Tenodesis splint Wrist driven flexor hinge hand orthosis (Tendodesis splint) Ideal for this level of injury

Question 39

SCI with C6 Escape

Answer 39

Loss of Pronation Wrist flexion FInger flexion and extension (Only Ex car radialis l&b left) Stabilize thumb for pinch against fingers Harness action of Extensor Carpi Radialis for Tenodesis splint Wrist driven flexor hinge hand orthosis (Tendodesis splint)

Question 40

SCI with C5 escape

Answer 40

Loss of all hand and finger function No longer wirst flexion and finger flex/ext for grasp and pinch External power need to flex wrist and hand

Question 41

SCI C4 and above

Answer 41

Loss of all upper extremity function No longer shoulder, elbow, wrist and finger motion External power mobile arm support with power drive flexor hinge hand

Question 42

Brachial plexus injury C8-T1

Answer 42

Loss of intrinsic hand muscles and long finger flexors Grasp and pinch Stabilize the wrist Tenodesis splint

Question 43

Brachial plexus injury C5-C6

Answer 43

Loss of shoulder and elbow function weakness of wrist and finger extensors Stabilize shoulder in slight abduction Elbow supported in adjustable flexion/extension Wrist and hand supported in neutral or functional position if some hand function remains SEWHO- Shoulder Elbow Wrist Hand Orthosis ("Airplane") Elbow orthosis WHFO to augment hand function

Question 44

Brachial plexus injury- complete flail arm

Answer 44

Loss of upper extremity function Support weight of flail arm by stabilizing shoulder joint Flex elbow for functional positioning of hand in front of the body Stabilize the wrist and hand SEWHO- Shoulder elbow wrist hand orthosis ("gun slinger") Shoulder stabilizer or positioner Elbow joint, possibly adjustable Static WHFO WHO with MCPJ flexion by external cable or power

Question 45

Elbow Trauma (burns/dislocation), surgery, self abusive patients

Answer 45

Contracture of skin and soft tissues Joint instability Dynamic Elbow Orthosis - apply extension assist or stretch Static Elbow Orthosis- maintain position, support protect Hinged Elbow Orthosis- M/L and hyper extension support

Question 46

CVA (Stroke) involvement

Answer 46

Hemiplegia and Spasticity Harris Hemi-sling for GH subluxation Spasticity leads to pronation, wrist flexion, thumb flexion and adduction Static WHFO or resting hand splint Maintains wrist/hands in neutral position Prevent development of contractures Keep palm open and dry (hygiene)