HSS hand therapy

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  1. "hand therapy" involves which body parts
    • shoulder girdle
    • elbow
    • wrist
    • hand
  2. CHT = certified hand therapist
    85% are OTs, we're 15%
    3 qualifications?
    • 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
  3. lumbrical innervation
    • 2 & 3: median n (C8-T1)
    • 4 & 5: ulnar n (C8-T1)
  4. extensor digitorum communis innervation
    radial (C6-8)
  5. pronator teres innervation
    median C6-7
  6. flexor digitorum profundus innervation
    • 2 & 3: ulnar (C7-T1)
    • 4 & 5: median (C7-T1)

    same as the lumbricals
  7. supinator innervation
    radial C5-7
  8. APL innervation
    radial C7-8
  9. flexor carpi ulnaris innervation
    ulnar C7-T1
  10. extensor carpi ulnaris innervation
    radial C6-8
  11. opponens pollicis innervation
    median C6-T1
  12. flexor digiti minimi
    ulnar C7-T1
  13. What's DASH?
    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
  14. keloid vs hypertrophic scar tissue
    • keloid: extends outside original wound bed
    • hypertrophic: raised, but stays within wound bed
  15. coloring of scar tissue that can be treated, color that can't
    • purple, reddish, pink -- treatable
    • white -- mature, not treatable
  16. If there's a distal radial fracture and you want to do a quick test on the hand, what do you do? (3 steps) -- this is composite ROM
    • 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
  17. how does American Society of Hand Therapists (ASHT) recomend testing grip strength?
    • dynamometer
    • shoulder add, neutral rot, elbow flexed to 90, forearm and wrist neutral
    • take average of 3 trials
  18. 3 ways to teest pinch strength
    • lateral pinch/key pinch - tests thenar muscles
    • tip pinch - thumb vs 1 finger
    • 3 point pinch - thumb vs 2 fingers
  19. contraind for grip and pinch tests
    if it's a fracture, tendon repair/transfer, ligament strain/repair, don't do until MD approves strength and resistance training
  20. sensation nerve distribution on dorsal and palmar hand
    • 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.
  21. 2 point discrim is a measure of __
    useful in testing __ after __
    • innervation density
    • regeneration ... nerve laceration
  22. where do you do 2 point discrim to test for regen after nerve laceration?
    btwn digit tips and distal palmar crease
  23. which kind of 2 pt discrim returns first?
    moving before static, by 2-6 mo
  24. monofilament testing / threshold testing looks at what about the nerve?
    • 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
  25. when would a pt lose protective sensation (hot/cold/pain)?
    severe compression injury
  26. 6 sensations in hand and order of their return
    • pain and temp
    • 30 cycles/sec vibration
    • moving light touch
    • 256 cps vibration
    • static light touch
    • localization of light touch
  27. primary healing vs secondary healing
    happens after surgery vs healing w/o surgery
  28. inflam phase in primary and secondary healing
    • 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
  29. reparative phase in primary and secondary healing
    • primary: 2-6 wks, full A/PROM
    • secondary: 3-6 weeks, continued protection, maybe move a little
  30. remodeling phase in primary and secondary healing
    • 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
  31. position of hand for splinting
    • 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
  32. for a metacarpal fracture, how much of the arm goes in the cast/
    2/3 of the arm
  33. colles fracture
    • distal radius breaks 
    • extra-articular (outside the capsule)
    • dorsal displacement of distal fragment
  34. smiths fracture
    • extra-articular fracture of distal radius
    • volar displacement of distal fragment
  35. bartons fracture
    • intra-articular fracture/dislocation
    • dorsal dislocation of the carpals
    • radial fragment can be dorsal or volar
  36. an extra little fracture common in radius fractures?
    chip off the ulnar styloid process
  37. which tendon runs around listers tubercle at a 35 degree angle?
  38. distal radius fracture rehab
    phase I
    ROM & edema work?
    • 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
  39. tendon gliding
    • open palm
    • duck fist (lumbar)
    • straight fist
    • full fist
    • hook fist

    it's the quad set of hand therapy
  40. edema control, basic rule
    • keep limb elevated at all times
    • should never be in a dependent pos
  41. distal radius fracture rehab
    phase I, II, III -- how does the protective immobilization change?
    • I: cast or splint
    • II: full time splint
    • III: splint usually discontinued, though may need splinting to regain ROM
  42. distal radius fracture rehab
    phases I, II, III 
    edema control?
    • I: elevation and AROM of fingers
    • II: contrast baths, compression wrapping, retrograde massage
    • III: none
  43. distal radius fracture rehab
    phases I, II, III
    • 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
  44. distal radius fracture rehab
    when to try ADL?
    when to do strengthening exercises?
    • II - try at least (tho the case study does it in I)
    • III - wrist and forearm, grip and pinch
  45. what muscles do you need to isolate asap during AROM after distal radius fracture? how to isolate it?
    • wrist extensors (encourage tenodesis)
    • flex fingers while doing wrist extension so you don't get compensation from EDC
  46. which metacarpals are most commonly fractured? by whom and when? what accidents?
    • 1st and 5th
    • men
    • 10-29 y/o
    • MVAs, bike accidents, crush or direct blow to hand
  47. rel btwn length of metacarpal and its CMC motion?
  48. metacarpal fracture where causes stiffness where?
    • head / neck -- digits
    • base -- wrist
  49. in a metacarpal fracture why is it so important to work on dorsal scar tissue?
    • bc the digital extensor tendons run atop the metacarpals
    • scar tissue wants to stick to these and limit their ROM
  50. CRPP
    • closed reduction percutaneous pinning
    • for unstable metacarpal fracures
  51. most metacarpal neck fractures can be managed via...?
    closed reduction and splint cast immob for 3-4 weeks (an exception to the 6 wk rule)
  52. boxer's fracture
    • 4th or 5th metacarpal neck
    • "fight bite"
    • usually with an open wound on the metacarpal head, so it requires antibiotics
  53. metacarpal fracture rehab
    phases I, II, III
    protective immobilization?
    • I: bulky post-op cast or ulnar gutter splint
    • II: full time splint use
    • III: usually discontinued unless for gaining ROM
  54. metacarpal fracture rehab
    phases I, II, III
    edema control
    • I: elevate distal limb, AROM of digits
    • II: contrast baths, compression wrapping, retrograde massage
    • III: none
  55. metacarpal fracture rehab 
    phases I, II, III
    • 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
  56. metacarpal fracture rehab 
    phases I, II, III
    scar management
    II: scar massage, silicone sheets or pads
  57. metacarpal fracture rehab 
    phases I, II, III
    progressive strengthening exercises
    • II: light functional activities and dexterity tasks
    • III: resistive EC ther-ex to facilitate glide
    • grip and pince
  58. EDC glides starting in phase I after metacarpal fracture
    • fingers straight up
    • fist
    • high fist
  59. differential tendon gliding
    what for
    • isolates the long extensor tendons
    • hand flat on table, lift only the affected finger
  60. blocking exercises after metacarpal fracture
    • MCP jt is held in extension via splint or hand
    • pt flexes PIP and DIP jts to gain ROM in them
  61. resistive EDC glides - how and why?
    • 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)
  62. 4 wk goal for metacarpal neck fracture
    composite flexion (to increase grasp)
  63. CMC jt arthroplasty
    • replacement of 1st metacarpal-trapezium jt
    • women > men 10-15:1
    • pre-op complaints include pain at CMC jt and mvment/slipping in jt
  64. 1st and 2nd most common hand jts for OA
    • 1st - DIPs
    • 2nd - trapezium-metacarpal
  65. troubled ligament when pt needs a replacement of the 1st metacarpal trapezium jt
    anterior oblique
  66. sign of trouble in the metacarpal trapezium jonit?
    saddle sign -- metacarpal subluxed off the trapezium
  67. surgical options for cmc jt arthroplasty
    • trapezium excision
    • hemitrap excision
    • hematoma and distraction arthroplasty
    • implant arthroplasty
    • TM arthrodesis
    • LRTI: ligament reconstruction tendon interposition
  68. arthrodesis
    surgical immobilization of a joint by fusion of adjacent bones
  69. ligament reconstruction tendon interposition (LRTI) 3 fundamental priciples for CMC jt artrhoplasty
    • trap excision
    • AOL reconstruction
    • fascial interposition
  70. what happens in a trap excision?
    half the FCR gets balled up and put there to stabilize the 1st and 2nd metacarpals, and K wires stabilize the metacarpals
  71. CMC arthroplasty / LRTI rehab 
    phases I, II, III
    protective immobilization
    • 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
  72. CMC arthroplasty / LRTI rehab 
    phases I, II, III
    • I: ROM of uninvolved jts
    • II: AROM of thumb, CMC jts, wrist
    • III: focus on functional ROM and end range ROM
  73. CMC arthroplasty / LRTI rehab 
    when does phase II begin?
    when K wire is removed
  74. CMC arthroplasty / LRTI rehab 
    phases I, II, III
    • II: light functional activities
    • III: wrist, grip, light pinch resistance
  75. CMC arthroplasty / LRTI rehab 
    phases I precautions
    • no thumb or wrist ROM - usually AROM is held for 3-4 wks post op
    • no CMC ROM
    • absolutely no pinch
  76. in secondary healing, when does strengthening begin?
    12-14 wks
Card Set
HSS hand therapy
apring 2013
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