HSS hand therapy

• shoulder girdle
• elbow
• wrist
• hand

• at least 5 yrs of clinical experience
• at least 4,000 hours direct treatment of upper quadrant
• demonstrated competancy (on a test?) in advanced clinical skills and theory in upper quadrant rehab

• 2 & 3: median n (C8-T1)
• 4 & 5: ulnar n (C8-T1)

radial (C6-8)

median C6-7

• 2 & 3: ulnar (C7-T1)
• 4 & 5: median (C7-T1)

same as the lumbricals

radial C5-7

radial C7-8

ulnar C7-T1

radial C6-8

median C6-T1

ulnar C7-T1

it's a questionaire - Disabilities of the Arm, Shoulder, and Hand  -- about how much the injury is troubling you.

limitations: doesn't consider handedness (so if you mashed your left hand but you're a righty, you may appear not too impaired, since your handwriting and stuff isn't affected), doesn't consider location too well (if you smushed a distal phalanx you may be able to do ADL pretty well despite it being a major fracture)

0 = perfect, 100 = most impaired

• keloid: extends outside original wound bed
• hypertrophic: raised, but stays within wound bed

• purple, reddish, pink -- treatable
• white -- mature, not treatable

• 1: ext:  fingers fully
• 2: flex: make a fist
• if can't make a fist, measure how far each finger stops from distal palmar crease (DPC)
• 3: opposition: thumb to tip of each finger

• dynamometer
• shoulder add, neutral rot, elbow flexed to 90, forearm and wrist neutral
• take average of 3 trials

• lateral pinch/key pinch - tests thenar muscles
• tip pinch - thumb vs 1 finger
• 3 point pinch - thumb vs 2 fingers

if it's a fracture, tendon repair/transfer, ligament strain/repair, don't do until MD approves strength and resistance training

• palmar - med is ulnar n., lat is median n., prox lat corner is radial n.
• dorsal - radial half up to prox phalange is radial n., upper parts of digits 2 and 3 are median n., ulnar side is ulnar n.

• innervation density
• regeneration ... nerve laceration

btwn digit tips and distal palmar crease

moving before static, by 2-6 mo

• nerve threshold
• used late in nerve laceration or compression injury (I think more the latter than the former)
• good for carpal tunnel or cubital at elbow

severe compression injury

• pain and temp
• 30 cycles/sec vibration
• moving light touch
• 256 cps vibration
• static light touch
• localization of light touch

happens after surgery vs healing w/o surgery

• 1-2 weeks for both, but in primary you can do gentle AROM, while in secondary its just protective
• in primary start moving 7-10 days after operation

• primary: 2-6 wks, full A/PROM
• secondary: 3-6 weeks, continued protection, maybe move a little

• primary: 6 weeks +, continue motion, strengthening
• secondary: 6 weeks +, move a lot, PROM at 6 weeks when cast comes off, strengthening at 12-14 weeks

• wrist ext 20-30 degrees
• 70 degree MTP flexion
• IP jts extended
• thumb half abducted

duck looking skyward

this promotes healing and prevents unnecessary shortening of tissues

2/3 of the arm

• distal radius breaks 
• extra-articular (outside the capsule)
• dorsal displacement of distal fragment

• extra-articular fracture of distal radius
• volar displacement of distal fragment

• intra-articular fracture/dislocation
• dorsal dislocation of the carpals
• radial fragment can be dorsal or volar

chip off the ulnar styloid process

EPL

• protective phase (cast, splint)
• ROM: full digit motion, tendon gliding; AROM of shoulder and elbow; only wear sling in busy areas where arm could get jossled
• edema: elevate distal limb; AROM of digits

• open palm
• duck fist (lumbar)
• straight fist
• full fist
• hook fist

it's the quad set of hand therapy

• keep limb elevated at all times
• should never be in a dependent pos

• I: cast or splint
• II: full time splint
• III: splint usually discontinued, though may need splinting to regain ROM

• I: elevation and AROM of fingers
• II: contrast baths, compression wrapping, retrograde massage
• III: none

• I: tendon gliding & AROM of shoulder and elbow
• II: A/AAROM and gentle PROM of wrist motions and forearm pron/sup
• III: aggressive PROM, joint mobs as needed

• II - try at least (tho the case study does it in I)
• III - wrist and forearm, grip and pinch

• wrist extensors (encourage tenodesis)
• flex fingers while doing wrist extension so you don't get compensation from EDC

• 1st and 5th
• men
• 10-29 y/o
• MVAs, bike accidents, crush or direct blow to hand

inverse

• head / neck -- digits
• base -- wrist

• bc the digital extensor tendons run atop the metacarpals
• scar tissue wants to stick to these and limit their ROM

• closed reduction percutaneous pinning
• for unstable metacarpal fracures

closed reduction and splint cast immob for 3-4 weeks (an exception to the 6 wk rule)

• 4th or 5th metacarpal neck
• "fight bite"
• usually with an open wound on the metacarpal head, so it requires antibiotics

• I: bulky post-op cast or ulnar gutter splint
• II: full time splint use
• III: usually discontinued unless for gaining ROM

• I: elevate distal limb, AROM of digits
• II: contrast baths, compression wrapping, retrograde massage
• III: none

• I: tendon gliding, AROM of shoulder and elbow
• II: A/AAROM and gentle PROM - digit flex/ext, tendon gliding, blocking exercises (do light functional activities and dexterity tasks)
• III: aggressive PROM, joint mobs as necessary

II: scar massage, silicone sheets or pads

• II: light functional activities and dexterity tasks
• III: resistive EC ther-ex to facilitate glide
• grip and pince

• fingers straight up
• fist
• high fist

• isolates the long extensor tendons
• hand flat on table, lift only the affected finger

• MCP jt is held in extension via splint or hand
• pt flexes PIP and DIP jts to gain ROM in them

• roll a velcroed dowel by extending fingers
• breaks up scar tissue
• (pip and dip ext due to lumbrical and interossei pull on the lateral bands)

composite flexion (to increase grasp)

• replacement of 1st metacarpal-trapezium jt
• women > men 10-15:1
• pre-op complaints include pain at CMC jt and mvment/slipping in jt

• 1st - DIPs
• 2nd - trapezium-metacarpal

anterior oblique

saddle sign -- metacarpal subluxed off the trapezium

• trapezium excision
• hemitrap excision
• hematoma and distraction arthroplasty
• implant arthroplasty
• TM arthrodesis
• LRTI: ligament reconstruction tendon interposition

surgical immobilization of a joint by fusion of adjacent bones

• trap excision
• AOL reconstruction
• fascial interposition

half the FCR gets balled up and put there to stabilize the 1st and 2nd metacarpals, and K wires stabilize the metacarpals

• I: bulky post op cast or forearm based thumb spica for 4-6 wks
• II: full time splint
• III: splint use begins to taper off

• I: ROM of uninvolved jts
• II: AROM of thumb, CMC jts, wrist
• III: focus on functional ROM and end range ROM

when K wire is removed

• II: light functional activities
• III: wrist, grip, light pinch resistance

• no thumb or wrist ROM - usually AROM is held for 3-4 wks post op
• no CMC ROM
• absolutely no pinch

12-14 wks