THERAPY OBJECTIVES HAND - cdn.ymaws.com · Slide 4 CERVICAL ALIGNMENT Proper alignment is necessary...

Slide 1

HAND

THERAPY

KEVIN CHEN, OTR/L

LORA STUBIN-AMELIO, MA, OTR/L, CHT

ANN MARIE FERETTI, ADV. MS, OTR/L, CHT

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Slide 2 ANATOMY IN HAND THERAPY

OBJECTIVES

• Explore the relationships between anatomy of the

hand and wrist and function

• Explain isolated and combined motions of the hand

that are commonly impaired and how they affect

overall function

• Review special tests used to assess symptoms and

dysfunction in the hand and wrist

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Slide 3 ANATOMY

• Understanding of normal anatomy is essential to

treatment of common upper extremity disorders

• Delicate balance between form and function

• Upper extremity operates as a kinematic chain

• Appreciate the complexity of the upper extremity

• Dynamic relationship of various anatomic systems

• Distal mobility with proximal stability

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Slide 4 CERVICAL

ALIGNMENT

• Proper alignment is necessary for neurologic and

vascular function of upper extremity

• Misalignment may manifest as sensory, motor or

autonomic dysfunction

• Cervical spine has valuable mobility, which also

makes it vulnerable to injury

• Vertebrae, muscles, soft tissue, vasculature, nerve

root and nerves included in evaluation for proper

alignment and function of upper extremity

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Slide 5

Tank & Gest 2008

Zizik 4

BONES OF THE UPPER EXTREMITY

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Slide 6 BONES OF THE FOREARM

Radius

Ulna

6.8A

Zizik 2

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Slide 7 UPPER EXTREMITY

FRACTURES

• Distal Humerus

• Radial Head

• Proximal Ulna

• Olecranon **

• Coronoid

• Both Bone Forearm Fractures

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Slide 8 ANATOMYIn distal 1/3 of the volar

forearm, the flexor

tendons arise from the

flexor muscle group

• Superficial group-

FCR, FCU, PL

• Middle group- FDS

• Deep group- FDP, FPL

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Slide 9 ANTERIOR (VOLAR)

FOREARM ANATOMY

1. PT

2. FCR

3. PL

4. FDS

5. FCU

TRY IT!

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Slide 10 POSTERIOR (DORSAL)

FOREARM ANATOMY

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Slide 11 FOREARM & WRIST

TENDONITIS

• Lateral Epicondylitis

• Medial Epicondylitis

• Wrist Extensor Tendonitis

• Wrist Flexor Tendonitis

• deQuervain’s Tenosynovitis- 1st dorsal compartment

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Slide 12 BONES OF THE HAND

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Slide 13 HAND FRACTURES

• Distal Phalanx

• Middle Phalanx

• Proximal Phalanx

• Metacarpal (neck, shaft, base)

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Slide 14

Zizik 6

BONES OF THE HAND

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Slide 15 CARPAL BONES

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Slide 16 BONES OF WRIST AND HAND

Carpals

•Proximal row: Scaphoid, Lunate, Triquetrum,

Pisiform

•Distal row: Trapezium, Trapezoid, Capitate,

Hamate

Metacarpals

Phalanges

Zizik5

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Slide 17 WRIST FRACTURES• Distal Radius **

• Scaphoid **

• Lunate

• Triquetrum

• Pisiform

• Trapezium

• Trapezoid

• Trapezoid

• Capitate

• Hamate

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Slide 18 DISTAL RADIAL

ULNAR JOINT (DRUJ)

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Slide 19

• What does a TFCC

injury look like?

• Mechanism of injury

• fall on an outstretched

hand

• twisting injury

• Press test positive

• Look for pain with

weight bearing

especially pushing up

from a chair- easy to

check during evaluation

TFCC

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Slide 20 HAND ARCHES

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Slide 21 LIGAMENTS

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Slide 22 VOLAR PLATES

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Slide 23 ARTICULATIONS:

VOLAR PLATE

• Promotes stability & positioning of long flexors

• MCP: medial & lateral edges of plate serve as

attachments for fibrous parts of flexor digital

tendon sheath (A1 pulley)

• PIP: sides proximal attachment are longer than

central part (check-rein ligaments) tighten when

middle phalanx extends & limits hyperextension

& attachment for fibrous parts of flexor digital

tendon sheath (A3 pulley)

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Slide 24 VOLAR PLATE

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Slide 25 The “jammed finger”

Dorsal dislocations are

most common

Volar plate injury

Increased edema

Stiff PIP

Can progress pseudo-

bouttonniere

PIP INJURY

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Slide 26 COLLATERAL

LIGAMENTS

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Slide 27 ARTICULATIONS:

COLLATERAL LIGAMENTS

• MCP

• True part -is loose in extension & taut in flexion

• PIP: similar to MCP jt., from attachment of dorsal

tubercle of proximal phalanx, the true part attaches

side of base of middle phalanx & accessory

attaches to volar plate

• True taut in all motions, accessory stabilizes volar

plate

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Slide 28 VOLAR PLATE &

COLLATERAL LIGAMENTS

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Slide 29 THUMB

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Slide 30 RADIAL & ULNAR

COLLATERAL

LIGAMENTS

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Slide 31 THUMB LIGAMENT

INJURIES

• UCL

• Skier’s thumb

• Gamekeeper’s thumb

• RCL

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Slide 32 EXTENSOR

MECHANISM

• EDC, Dorsal & Volar Interossei, Lumbricals

• Central Slip

• Terminal Tendon

• Sagittal Bands

• Transverse Fibers & Oblique Fibers

• Lateral Bands

• Transverse Retinacular Ligament

• Triangular Lig & Oblique Retinacular Lig

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Slide 33 DORSAL APPARATUS

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Slide 34 EXTENSOR

MECHANISM

• EDC, Dorsal & Volar Interossei, Lumbricals

• Central Slip

• Terminal Tendon

• Sagittal Bands

• Transverse Fibers & Oblique Fibers

• Lateral Bands

• Transverse Retinacular Ligament

• Triangular Lig & Oblique Retinacular Lig

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Slide 35 EXTENSOR TENDONS

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Slide 36 EXTENSOR

COMPARTMENTS

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Slide 37 WHY WE NEED TO

KNOW THE ANATOMY!

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Slide 38 FLEXOR ANATOMY

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Slide 39 FLEXOR TENDON ANATOMY

• FDS Flexor Digitorum Superficialis

• FDP Flexor Digitorum Profundus

• FPL Flexor Pollicis Longus

• Digital Flexor Sheath

• Zones

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Slide 40 FDS

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Slide 41 FDS FYI

• Origin: two muscle bellies

• Medial epicondyle

• Radial shaft

• Tendon arise from separate muscle bundles

therefore they act independently

• FDS of small digit absent in 21% of people

• Median Nerve (C7, C8, T1)

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Slide 42 FDP FYI

• Origin - Ulna & interosseous membrane

• Common muscle origin for several tendons

therefore simultaneous flexion of multiple digits

• Median Nerve (C8, T1) to index & middle

• Ulnar Nerve (C7, C8, T1) to ring & small

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Slide 43 LUMBRICALS &

INTEROSSEI:

INTELLIGENT INTRINSICS

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Slide 44 LUMBRICALS &

INTEROSSEI

•Interossei:

-Prime MCP flexors

-Prime Abd/adductors

-Secondary IP extensors (PIP >DIP)

•Lumbricals:

-Prime IP extensors (DIP > PIP)

-Weak MCP flexors

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Slide 45 LUMBRICALS

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Slide 46 LUMBRICALS

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Slide 47 TENDON INJURIES

• Flexor Tendons

• What zone?

• How was it repaired?

• How many strand suture

• When was it repaired?

• Protocol- immobilization, early passive, early active?

• Extensor Tendons

• What zone?

• How was it repaired?

• When was it repaired?

• Protocol- immobilization, early passive, early active?

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Slide 48 TENDON INJURIES

• Flexor Tendons

• Jersey finger

• Zone 2- No-Man’s land

• Spaghetti wrist

• Extensor Tendons

• Mallet finger

• Spontaneous rupture (common in RA)

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Slide 49 UPPER EXTREMITY

NERVES

Radial, Median, Ulnar

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Slide 50 PERIPHERAL NERVE

C1 – C8

C5 – T1

• Brachial plexus

• Musculocutaneous

• Axillary

• Radial

• Median

• Ulnar

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Slide 51 NEUROLOGIC

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Slide 52 DIVISIONS

Below the clavicle each trunk divides into an anterior & posterior division, located deep to middle third of the clavicle & extends distally to lateral border of 1st rib

Fibers in anterior division- anterior (volar) aspect of UE

Fibers in posterior division- posterior (dorsal) aspect of UE

Nerve off anterior division of upper & middle trunks

Lateral Anterior (Lateral Pectoral) Thoracic-upper pecs

**Kendall states this nerve is off of lateral cord**

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Slide 53 CORDS

The Anterior and Posterior Divisions form 3 cords: lateral, posterior, & medial (cords are below clavicle in axilla behind pectoralis minor tendon)

Lateral Cord (anterior division of upper & middle trunk)

Lateral Pectoral (see division slide)

Medial Cord (anterior division of lower trunk)

Medial Pectoral (Anterior Thoracic)-

Pectoralis Major & Minor

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Slide 54 TERMINAL BRANCHES

Main

Musculocutaneous

Axillary

Radial

Ulnar

Median

Secondary

Thoracodorsal

Subscapular nerves

Long thoracic

Dorsal scapular

Medial cutaneous

Medial and lateral pectoral nerves

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Slide 55 BRANCHES

3 cords give rise to 5 terminal branches, although other branches arise more proximal (techniquelyfrom cord)

Lateral cord gives rise to 2 branches

Median nerve (lateral head)- PT, FCR, PL, FDS, FDP

(index & middle) FPL, PQ, Lumbricles (index & middle), OPP, FPB (super), & APB

Musculocutaneous (becomes lateral cutaneous in forearm)- Corocobrachialis, Biceps, Brachialis, & sensation of volar & dorsal lateral forearm

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Slide 56

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Slide 57 BRANCHES

Medial cord gives rise to 4 branches & Medial

Pectoral

Medial Brachial Cutaneous- sensation of

volar/dorsal medial arm

Medial Antebrachial Cutaneous- sensation of

volar/dorsal medial forearm

Ulnar Nerve- FCU, FDP (ring & little), ADM,

ODM, FDM, Lumbricals (ring & small), PAD, DAB,

FPB (deep) ADD

Medial Nerve (medial head)

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Slide 58

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Slide 59

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Slide 60 UPPER EXTREMITY NERVES

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Slide 61

RVE

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Slide 62 MEDIAN NERVE

• Pronator Teres

• Flexor Carpi Radialis

• Palmaris Longus

• Flexor Digitorum Superficialis

• Flexor Digitorum Profundus (index, middle)

• Flexor Pollicis Longus

• Pronator Quadratus

• Abductor Pollicis Brevis

• Flexor Pollicis Brevis (superficial)

• 1st & 2nd Lumbricals

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INJURIES

• Carpal Tunnel

• Anterior Interosseous Nerve

• Pronator Syndrome

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Slide 65 ULNAR NERVE

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• Flexor Carpi Ulnaris

• Flexor Digitorum Profundus (ring, small)

• Palmaris Brevis

• Abductor Digiti Quinti

• Opponens Digiti Quinti

• Flexor Digit Quinti

• 3rd & 4th Lumbricals

• Palmar & Dorsal Interossei

• Adductor Pollicis

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INJURIES

• Guyon’s Canal

• Cubital Tunnel

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Slide 69

ULNAR NERVE

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Slide 70

RADIAL NERVE

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Slide 71 RADIAL NERVE

• Triceps,

• Anconeous

• Brachioradialis

• Extensor Carpi

Radialis Longus

• Extensor Carpi

Radialis Brevis

• Supinator

• Extensor Digitorum

• Extensor Digiti Quinti

• Extensor Carpi Ulnaris

• Abductor Pollicis

Longus

• Extensor Pollicis

Longus

• Extensor Pollicis Brevis

• Extensor Indicis

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Slide 72 RADIAL NERVE

INJURIES

• Radial Nerve Palsy

• Posterior Interosseous Nerve (PIN)

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Slide 73 NERVE INNERVATION

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Slide 74

BREAK

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Slide 75 HANDS ON LAB FOR

ASSESSMENT SKILLS OF

THE HAND AND WRIST

OBJECTIVES

At the end of this session, participants will be

able to:

• Locate key structures in the hand, wrist and forearm

through visual assessment and palpation

• Review common pathology of structures in the

hand, wrist and forearm

• Perform special tests used to assess conditions of

the hand, wrist and forearm

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Slide 76 THERAPEUTIC EVALUATION OF

THE HAND AND WRIST

● Overview:

○ Anatomy and Function

○ Assessment Techniques

○ Symptomatic ROM and Dysfunction

○ Special Tests

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THE HAND AND WRIST

● Assessment techniques

○ Pain

○ Wound & scar status

○ Vascular status

○ ROM

○ Edema

○ Sensation

○ Strength

○ Special tests

○ Functional limitations/Functional outcomes

○ Orthotics

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Slide 78 ASSESSMENT TECHNIQUES:

INITIAL OBSERVATIONS

● Initial Observations and Presentation

○ How the patient walks in

■ Are they keeping the UE within their periphery?

■ Are they using the UE functionally? Are they

supposed to? Are they breaking post-operative

precautions already?

■ Resting position - are there any obvious

deformities?

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Slide 79 EVALUATION

● History- current condition, medical history, establish

rapport, build trust

● Interview- Pain, function, use of orthosis

● Observation- Nonverbal behavior, spontaneous use

of upper extremity vs. guarding, conscious vs. non-

conscious protection, look for inconsistency btwn

formal data & non formal data, continued therapy is

contingent on patient showing progress.

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○ How the patient walks in

■ Are they keeping the UE within their periphery?

■ Are they using the UE functionally? Are they

supposed to? Are they breaking post-operative

precautions already?

■ Resting position - are there any obvious

deformities?

Boutonniere’s and

Swan Neck DeformityUlnar Claw/Hand of

BenedictionWartenberg’s Sign

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○ Localized inflammation/edema

○ Previous scars

● Wound/Tissue Healing

○ Did they have surgery and how is the wound?

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Slide 82 PHASES OF WOUND HEALING

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Slide 83 INFLAMMATORY PHASE

Usually lasts for less than a week. Inflammation is a vascularand cellular response.

Increased vascularity, venous congestion

Cellular response causes influx of WBC (macrophages) phagocytosis and release of proteolytic collagenolytic enzymes.

(Jacobs & Austin 2014)

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Slide 84 PROLIFERATION (FIBROPLASIA)

PHASE•Begins 4-5 days after the injury and lasts for 2-6 weeks

•Fibroblasts begin synthesizing collagen which becomes scar tissue

•Scar formation is randomly laid down scar.

•Granulation tissue with angiogenesis gives a red appearance.

•New collagen along with granulating tissue together give new growing tissue.

•“One wound one scar” principle

•From 3– 6 weeks has fibroblasts produced collagen gains tensile strength (load/cross sectional area) .

•(Jacobs & Austin 2014)

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Slide 85 (REMODELING) MATURATION

PHASEUsually lasts 6-8 weeks after

injury to 2 years.

Collagen fibers become more

organized (if given tension)

continues to gain tensile

strength

The scar will contract during

this phase unless subjected

to stress.

(Jacobs & Austin 2014)

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Slide 86 WOUND HEALING

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WOUND HEALING

Appearance:

● Color

● Temperature

● Drainage (if any)

● Tenderness to

palpation (TTP)

Observations?

1/31/2018

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Observations?2/14/2018

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1/31/2018 2/14/2018

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Slide 91 WOUND ASSESSMENT

• Size

• Depth

• Color

• Red, yellow, black, combinations

• Drainage

• Odor

• Temperature

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Slide 92 WOUND HEALING/TISSUE

HEALING

• Other tissue follows the same healing phases

• Bone, tendon, nerve

• Acute/Inflammatory

• Fibroplasia/Proliferation

• Maturation/Remodeling

• Where does a protocol come from?

• How do you know when a patient is ready to advance the protocol?

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THE HAND AND WRIST

● Hand dominance - which would play an

obvious role on function

● Pain○ Where? - “Can you point to the location of pain?”

○ When does it hurt?

○ What does it feel like?

○ How much?

○ Is the pain reproducible?

● Edema○ Circumferential edema

○ Volumetric

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Slide 94 PAIN

Level

•Scales • Numeric, visual analog, verbal rating, graphic

representation, pain questionnaire

Location

•Referred

Type

•Throbbing, aching, sharp, stabbing, shooting, burning, hypersensitivity

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Slide 95 PAIN

Frequency

• Constant versus intermittent

Cause

• At rest, during motion, end ranges, during activities,

lifting or carrying, during evaluation

Duration

• Acute versus chronic (> 6 mo)

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Slide 96 CLINICAL PROBLEM

SOLVING

• Especially necessary if no firm diagnosis

is given by MD

• Use all data from evaluation to rule in/out

diagnoses

• Provocative testing

• Reproduce the specific pain complaint

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Slide 97 CLINICAL PROBLEM

SOLVING

Pain

•AROM not PROM = muscle or tendon problem

•PROM = joint problems such as joint structures,

ligament injury, cartilage injury, inflammation

• Joint limitation due to pain

• Pain with distraction eased with compression =

ligament or joint capsule problem

• Pain with compression eased with distraction = joint

surface problem, inflammation, surface spur

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Slide 98 SCAR ASSESSMENT

Color

• Red, pink, white

Size

Depth

• Flat versus raised

Adhesions

• Mild, moderate, severe hypomobility

• Direction

Vancouver Burn Scar Assessment

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Slide 99 VASCULAR STATUS

ASSESSMENT

Observation

• Color, trophic changes, pain level

Palpation

• Pulses, capillary refill assessment, modified Allen’s

test

Temperature

Injuries to nerves, blood vessels, diseases

(Raynaud’s)

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Slide 100 OBSERVATION

Color

• Pallor (white/grayish)

• Arterial interruption

• Cyanosis (blue)

• Chronic venous insufficiency (dusky blue)

• Venous blockage (purple-blue)

• Erythema (red)

• Normal inflammatory phase

• infection

• Loss of outflow of blood from hand

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Slide 101 PALPATION TESTS OF

VASCULAR ASSESSMENT

• Capillary refill test

• Peripheral pulse palpation

• Modified Allen’s test

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Slide 102 CAPILLARY REFILL TEST

• Number of seconds for color to return to normal

• Normal time = < 2 seconds

• Compare to same digit on opposite hand

TRY IT!

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Slide 103 MODIFIED ALLEN’S TEST

• Assesses status of blood supply in hand

• Radial and ulnar arteries

• Occlude both arteries until hand is white

• Time to return to normal color after release of one artery

occlusion

• Repeat after same to other artery

• Normal response is < 5 seconds

• Compare to opposite extremity

TRY IT!

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Slide 104 RANGE OF MOTION

ASSESSMENT

• Isolated

• Shoulder

• Elbow

• Wrist

• Forearm

• Composite

• Digits

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Slide 105 METHODS

AROM or PROM

Joint stiffness, intrinsic tightness, extrinsic

tightness

Limitations in PROM- what does it mean?

• Joint capsule tightness

• ligamentous tightness

• decreased joint space

• bone spur

• muscle/tendon tightness

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Slide 106 AROM

Limitations in AROM- what does it mean?

• Weakness of muscle

• Loss of tendon continuity

• Adhesions of tendon

• Inflammation or constriction of tendon

• Decreased tendon mechanical efficiency

• Disrupted nerve supply to muscle

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Slide 107 FOREARM RANGE OF MOTION

Pronation and Supination

• Measured with elbow flexed at 90, arm adducted to

body, goniometer fixed arm perpendicular to the floor,

moving arm in contact with volar forearm for

supination, dorsal forearm for pronation

TRY IT!

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Slide 108 WRIST RANGE OF MOTION

Motions measured are flexion, extension, radial and ulnar deviation

Unless patient not able to assume posture, elbow is on table with forearm in air so digit tips point to ceiling

Measurement for flexion on dorsal 3rd metacarpal with digits relaxed

Measurement for extension on volar 3rd metacarpal with digits relaxed

TRY IT!

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Slide 109 WRIST RANGE OF MOTION

Radial and ulnar deviation

Measured with palm flat on table with goniometer on

3rd metacarpal, dorsum of forearm and axis at wrist

TRY IT!

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Slide 110 DIGITAL RANGE OF MOTION

• Motions measured are MP, PIP and DIP flexion and extension, thumb MP and IP flexion

• Hand position is same as wrist flexion and extension posture

• Motion measured is composite unless contraindicated

• “0” is neutral

• ”+”is hyperextension

• “‐”is an extension deficit

• Measurements should be written as extension/flexion (e.g. ‐10/85).

TRY IT!

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Slide 111

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Slide 112 DIGITAL RANGE OF MOTION

• When all fingers are involved

• Tip to DPC can be a useful

measurement

• Distance from fingertip to distal palmar

crease, normal is zero- finger should

be able to touch DPC in a full fist

TRY IT!

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Slide 113 CLINICAL PROBLEM SOLVING

Joint stiffness

• AROM = PROM no matter joint position

Intrinsic tightness

• IP flexion > with MP flexed than MP extended

Extrinsic tightness

• Extensor – proximal joints in extension allows more flexion

of distal joints

• With digits in full flexion, bring wrist into flexion - will feel

digits extend due to extrinsic tightness

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Extrinsic tightness

• Flexor – if proximal joints in flexion allows more

extension in distal joints

• With distal joints extended, bring wrist into more

extension – will feel distal joints flex if tightness of

extrinsics

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Intrinsic tightness

• Bunnell-Littler test

• Passive flexion of MP and PIP joints of one finger

while observing/measuring the range of passive

PIP joint flexion.

• Passive extension of MP joint with passive flexion

of the PIP joint while observing/measuring the

range of passive PIP joint flexion

• POSITIVE = less PIP flexion with the MP

extended than with it flexed

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Slide 116 SWELLING/EDEMA

• Common sequela of injury

• Normal reduction should begin at 2 weeks post

injury

• Increased edema occurs due to injury and

subsequent surgery or positioning

• Important to remove asap – gelling, brawny,

adhesions, function

• First pathway

•Elevation, ice, compression

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Slide 117 CIRCUMFERENTIAL

MEASUREMENT

• Digits

• Proximal phalanx

• Middle phalanx

• Distal phalanx

• DPC

• Wrist

• Elbow

• Axilla

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Slide 118 VOLUMETER

Works well to compare to contralateral side

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Slide 119 CHARACTERISTICS OF EDEMA

Edema

• Loss of wrinkles, joint creases

• May be shiny, taut skin

• Color

• Erythema

• Cyanosis

• Pallor

• Palpation

• Pitting

• Brawny

• More chronic in nature,

more difficult to clear

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Slide 120 STRENGTH TESTING

Contraindications

• Deferred in trauma patients until strengthening is

allowed (resistance)

Grasp and pinch

• Maximally resistive tests

• Grasp – gross

• Dynamometer

• Pinch

• 2 point, 3 point and lateral

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Slide 121 GRIP STRENGTH TEST

Jamar dynamometer

Standard testing posture

• Shoulder adducted, elbow at 90 , forearm and wrist

neutral

• 3 trials on 2nd handle

• With a large male hand, may also test grasp on 3rd

handle

• Compare to opposite extremity

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Slide 122 5 LEVEL GRIP TEST

5 Level grip test

• 1to 3 trials on each of the 5 different handle width

settings

• Should be bell curve

• May use to identify malingerer, person not trying his

hardest

• Always compare to non involved extremity

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Slide 123 PINCH STRENGTH TEST

Pinchmeter

• Lateral (key) pinch

• Radial aspect of index finger and thumb on

top of pinchmeter

• 3 point pinch (3 jaw chuck)

• 2nd and 3rd digits on top with thumb under

pinchmeter

• 2 point pinch (tip to tip)

• 2nd digit tip on top with thumb under

pinchmeter

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Slide 124 FUNCTIONAL OUTCOME

MEASURESShoulder

• SPADI, Penn

Elbow

• PREE

Wrist

• PRWE, PRWHE

General

• DASH, UEFI

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Slide 125 COORDINATION

• Ability to manipulate items in hand and in

environment

• Standardized tests available

• O’Connor Dexterity

• Nine-hole Peg

• Jebsen-Taylor Hand Function

• Minnesota Rate of Manipulation

• Crawford Small Parts Dexterity

• Perdue Pegboard

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Slide 126 9 HOLE PEG TEST

Using 1 hand, place all pegs in one at a time, then take all

pegs out one at a time, time how long from start to finish

Repeat with other hand

Norms:

Men= 19 seconds

Women= 18 seconds

TRY IT!

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Slide 127 SPECIAL TESTS

• Tinel’s- nerve irritation

• Phalen’s- median nerve compression

• Ulnar Flexion

• Finklestein- 1st dorsal compartment

• Grind Test- 1st CMC joint

• Watson’s- scapho-lunate

• Press test- TFCC pain

• Cozin’s test- lateral epicondylitis TRY IT!

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Slide 128 TESTS

• Finklestein- 1st dorsal compartment APL, EPB; flex

thumb, wrap fingers around thumb, ulnarly deviate

wrist + if pain

• Froment’s- hyper flexion of IP jt with pinch (UN)

• Jeanne’s- MCP hyperextension with pinch (UN)

• “O” sign- loss of “O” with no FPL flexion along with

no index FDP

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Slide 129 SENSATION

• Threshold density

• Ability to perceive light touch

• Used for compression injuries

• Innervation density

• Number of nerve endings in an area tested

• 2 point discrimination

• Used after nerve laceration

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THE HAND AND WRIST

● ROM - goniometry

● Distance to DPC

● Grip and Prehension Strength

○ Dynamometer and Pinchmeter

● Sensation

○ Semmes Weinstein

○ Vibration Testing

○ Discriminator

● Fine motor

● Special Testing

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Slide 131 HANDS ON LAB FOR

ASSESSMENT SKILLS OF THE

HAND AND WRIST

● ROM

• Wrist flexion, extension, ulnar/radial deviation

• Supination/pronation, finger flexion/extension

• Edema- circumferential

• Sensation- Semmes Weinstein monofilaments

• Coordination- 9 hole peg test

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Slide 132 TREATMENT PLANNING FOR

COMMON CONDITIONS OF THE

HAND AND WRIST

OBJECTIVESAt the end of this session, learners will be able to:

• Describe tissue healing and relationship to protocols for specific conditions

• Discuss common complications with hand and wrist conditions (i.e. stiff hand, edema management, scar management)

• Explain the use of manual therapy and therapeutic exercise

• Custom orthotic/splint fabrication- when is it needed?

• Use of functional activities for improved outcomes

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Slide 133 HOW DOES IT ALL WORK

TOGETHER?

To function effectively

Tendons and muscles must all work together

Normal digital motion- flexion

Tendon gliding

full extension

hook fist

duck fist

full fist

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Slide 134 NORMAL DIGITAL MOTION-FLEXION

• Wrist stabilized allows FDP to transmit power to fingers

• Finger flexion starts FDP while MCP’s are held extended by EDC

• IP’s hook then MP flexion

(Arbuckle & McGrouther, 1995)

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Slide 135 NORMAL DIGITAL

MOTION-FLEXION

• Always slightly more PIP than DIP

flexion

• Initially more PIP flexion than MP flexion;

as MCP’s reach end range slight

decrease in PIP flexion but a tight fist

brings the PIP to maximum (FDS)

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Slide 136 WHO ARE THE

WORKERS?

• EDC

• FDS

• FDP

• Interosseous

• Lumbricals

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Slide 137 FULL EXTENSION

• EDC fires

• FDS silent

• FDP silent

• Interosseous fires

• Lumbricals fire

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Slide 138 HOOK FIST

• EDC fires

• FDP fires

• FDS fires

• Interosseous silent

• Lumbricals silent

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Slide 139 DUCK FIST

• EDC silent

• FDS silent

• FDP silent


• Lumbricals fire

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Slide 140 STRAIGHT FIST

• EDC silent

• FDP silent

• FDS fires


• Lumbricals fire

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Slide 141 FULL FIST

• EDC silent

• FDP fires

• FDS fires

• Interosseous silent until end range then

fires

• Lumbricals silent

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Slide 142 “THE STATUS AND STAGE OF A HEALING

WOUND DIRECTS THE SPECIFICS OF

SPLINT SELECTION, FABRICATION AND

PATIENT USE” Jacobs & Austin, 2014

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Slide 143 WHAT IS THE PURPOSE OF

SPLINTING/ORTHOTIC INTERVENTION?

Alignment:

• Functional position

Correct deformities

Support:

• Relieve pain

• Promote healing

Prevention

Improve function

Restrict motion of a movable body part

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Slide 144 STATIC SPLINTS

• Have no moving parts

• Static splints- have a firm base and immobilize the joints they cross.

• Protection- i.e. healing Fxs (structures)

• Immobilization- for rest, i.e. CTS, tenosynovitis

• Stabilization- i.e. joint sublux

• Prevent further deformity i.e. joint sublux

• Blocking- i.e. exercise, ulnar claw

• Position- i.e. flaccid hand, spastic hand

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Slide 145 PROTECTION SPLINT-IMMOBILIZE

FOR HEALING

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Slide 146 STABILIZATION SPLINT- SUPPORT

PAINFUL JOINTS

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Slide 147 IMMOBILIZATION SPLINT- RESTRICT

MOBILITY

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Slide 148 PREVENTION SPLINT

SUBLUXATION, DEVIATION

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Slide 149 BLOCKING SPLINT

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Slide 150 POSITIONING SPLINT- MODIFY TONE,

REST TISSUES

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Slide 151 DYNAMIC SPLINTS

• Moving parts

• Dynamic splints (rubberbands, springs, spring wire, & coils)

• Substitute for loss of motor function- i.e. radial nerve palsy, tenodesis

• Correct deformity- i.e. joint contracture

• Provide controlled motion- flexor/extensor tendon injuries, joint arthroplasty

• Aid in fracture alignment

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Slide 152 SUBSTITUTE FOR LOSS OF MOTOR

FUNCTION

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Slide 153 CORRECT DEFORMITY

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Slide 154 PROVIDE CONTROLLED MOTION

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Slide 155 STATIC PROGRESSIVE SPLINTS

• Parts that can be moved, but do not move on the

patient during use, it is modified with adjustments

• Static Progressive Splints- “achieve mobilization

by applying unidirectional, low-load force to the

tissue’s maximum end ROM until the tissues

accommodates” (Jacobs & Austin, p.10, 2014).

• Static progressive splints have dynamic like

components, but no springs or rubber bands.

• Static progressive splints use non-elastic

components.

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Slide 156 STATIC PROGRESSIVE SPLINTING

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Slide 159 SERIAL STATIC SPLINTING

• Serial static splinting or casts- are applied to tissue at the maximum elongation length; usually the tissue are held at this position for long period of time. Then, the splints are remolded or re-casted to accommodate changes in tissue length.

• Correct deformity- i.e. pip joint flexion contractures

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Slide 160 CASE EXAMPLE 1

74 yr old female comes in

with diagnosis of R

dominant wrist fx s/p ORIF

3 weeks ago. She has pain

6/10 during activity, 2/10 at

rest, difficulty with all

grasping, lifting, carrying,

cannot wash her face or eat

with a spoon

Edema wrist R= 17.4 cm, L= 15.2 cm

AROM

Wrist flexion = 20

Wrist extension = 30

Supination = 40

Pronation = 60

Fingers tip to DPC = 3.0 cm

Grip strength R= 5 lbs, L= 35 lbs

Sensation- 4.31 in R thumb, 3.61 in 2nd/3rd, normal in 4th/5th

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Pt is a 30 yr old male who

presents with pain in L

arm/hand, numbness and

tingling in 5th finger,

positive Wartenburg sign,

positive Froment’s test,

positive Tinel’s at the

elbow, pt works as an

electrician

AROM is WFL

Grip strength R= 85 lbs, L=

75 lbs

Positive Tinel’s

Symptoms are worse at

night

Pain in forearm with work

activities 6/10

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Pt is a 65 yr old

woman coming to PT

for her shoulder

impingment/pain.

She complains of

pain in thumb/wrist

area that limits her

from opening jars,

writing, knitting and

working in the

garden

Pain in R hand 5/10 with

grasping and moving

c/o aching pain at night 5/10

Lateral pinch R= 6 lbs, L=

10 lbs, pinch test is painful

Positive grind test

AROM is WFL except thumb

opposition is limited

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