what are requirements to become a certified hand therapist?
five years of practice as a PT or OT
4000 hours direct practice experience in hand therapy
what are the requirements to become recertified as a certified hand therapist
take exam or have 80 hours ceu, 36 of which must be hand/upper extremity related
have 2000 hours clinical experience in hand therapy
the certificate to become a hand therapists comes from
hand certified therapy commission
what are the bones that articulate with the radius
scaphoid
lunate
distal ulna
what does FOOSH stand for
fall
on
out
stretched
hand
this occurs more frequently in the wintertime because of ice and snow
true or false – joints with pre-existing but asymptomatic osteoarthritis are very susceptible to stiffness even if not involved in the trauma
true
true or false – a fall on the outstretched hand may also injure the proximal joints
true– elbow and shoulder
if the patient has a fractured wrist don't forget to check these joints
what are the three common types of distal radius fractures
Colles Fracture
Smith's Fracture
Barton's displacement
which distal radius fracture is the most common type of fracture
Colles fracture
what is the mechanism of injury for a Colles Fracture
fall with the wrist extended
dinner for deformity is associated with what kind of distal radius fracture
Colles
Dorsal Angulation
what is a reverse colles fracture?
a Smith's fracture – volar angulation
fall with the wrist flexed
what is the mechanism of injury for a Barton's fracture
fall on extended wrist and pronated forearm
usually falling backwards
what is a Bartons fracture
displaced, unstable fracture
carpal displacement with the fragment of radius distinguishes this from Colle's and Smith's
what does this picture represent and what kind of fracture is it associated with
dinner for deformity
Colle's fracture
what is seen in the emergency room – we don't see this very much
distal radius fractures objective findings should include
observations– atrophy, swelling, deformity, scars, color
limited range of motion– wrist, forearm, hand, shoulder
weakness– finger extensors stronger
sensory status– check for median nerve compromise, complaints of numbness and tingling
what is the treatment for distal radial fractures
immobilization – cast or splint it
close reduction and cast
ORIF - open reduction internal fixation
external fixator
what are some observations to consider when looking at distal radius fractures – objective findings
atrophy
swelling
deformity
scars
color
what is one observation we can make this picture
right-hand has a mild amount swelling because there are less wrinkles in the hand
what is being measured in this picture
volume– this is part of objective findings
what are some limitations to be concerned about when looking at distal radius fractures – objective findings
range of motion of wrist, forearm, hand, shoulder
patients have usually been in a cast and therefore have not used their extensors or flexors
what are some weaknesses that are observed in distal radius fractures– objective findings
finger extensors are usually stronger than wrist extensors
because the patient has been in cast and has been able to move fingers but not wrist
what are some sensory concerns you should have when considering distal radius fractures – objective findings
check median nerve because it is very close to the bones of the forearm, compact space, very common to have swelling and compression in that area.
Perform Semmes Weinstein Test
what does this picture represents
Semmes Weinsten monofilament test
test sensation of the hand
used to track the sensation of the handhas the nerve recovers from injury
distal radius fracture management – what is the main goal
main goal is to have functional range of motion
true or false – it is very rare for a patient to return to full range of motion
true
if they do they are probably 15 or very young
what are the functional ranges of motion for the wrist
extension – 40°
flexion – 40°
ulnar and radial deviation – total of 40°
supination – 45°
pronation – 45°
how long does it take to gain full grip strength
months – very slow to return
what is the general treatment for distal radius fractures
modalities – moist heat or paraffin bath
active range of motion of all involved joints
joint mobilization techniques
home exercise program – active range of motion addressing all involved joints
treatment continued
true or false – Most treatments for the hand are started with a hot pack, paraffin bath, fluidotherapy, or some kind of
true
treatment continued
True or false – for the hand it is preferred that you do active range of motion rather than passive range of motion
true
when we see the patient the fracture is not strong enough for the hand to withstand passive stretching
treatment continued
what are the three exercises used for active range of motion in the treatment of distal radius fracture
intrinsic stretching
tendon gliding
isolate wrist extensors
the first picture demonstrates a tight intrinsic muscle
Flexing the IP joint and the MP joint– they have full range of motion
The second picture shows the finger being brought into extension
The IP flexion is tight = tight intrinsic muscles
This is not the same as joint tightness which would mean that the MP joint was tied in flexion and extension
what is tended gliding
mobilization of the nerves in the upper extremity
Explain this Tendon Glide
flexor digitorum superficialis
maximum excursion occurs in straight fist position
MP and PIP joints maximally flexed and DIP straight
explain this to glide
FDP
Maximum excursion of FDP occurs in fist position
explain this tendon glide
maximum excursion between FDS and FDP occurs in hook position
MP extended withPIP and DIP flexed
why are tendon glides so important
prevents formation of adhesions after trauma or surgery
Forces each digital joint through full potential range
Aides tendon and cartilage nutrition
valuable in treating inflammatory tendon disorders
true or false – patients with distal radial fractures are often splinted to help reduce median nerve pain
true
when can you start using weights in the treatment of distal radial fractures
after about six weeks – low weights
elbow curls
supination/pronation
wrist curls
putty, gripper- must be careful with this because they can overdo it real easy
which motion is most often restricted in the wrist
supination – joint mobilization
splints are often used to help facilitate supination
carpal tunnel syndrome
what are the anatomical structures associated with carpal tunnel syndrome
transverse carpal ligament
Carpals
FDP
FDS
FPL
Medain nerve
what are the causes of carpal tunnel syndrome
repetitive motion
trauma – foosh
bony deformity
Congenital disorders
Lifestyle – obesity, sedentary
It is important to remember that many things cause carpal tunnel syndrome and it's not just from one thing, must look at full picture
what is the etiology of carpal tunnel syndrome
compression of the median nerve in the carpal tunnel
what are the signs and symptoms of carpal tunnel
pain in paresthesia, usually worse at night
Weakness – dropping things
In advance cases atrophy of the thenar area to reach recurrent motor branch of median nerve involvement
sometimes, edema and/or radiating pain
What does this picture demonstrate
atrophy in the thenar eminence– right side
true or false – when assessing carpal tunnel syndrome you should always do a full upper quarter screen
true – to help you gain a better understanding of condition
what is tinel sign
tapping on the nerve
what test is this
phalen's– hold for 30 to 60 seconds
Positive – reproduces parathesias
what is a way to make the median nerve glide
put hand in supination with passive wrist and finger extension followed by active composite fist, this may be an effective procedure to produce median nerve excursion
what are the goals of carpal tunnel syndrome
decrease pain
Decrease parathesias
Independence in self management - education
how often should tendon gliding performed during the dayin the treatment of carpal tunnel syndrome
three or four times a day
what are some things that need to be addressed while treating a patient with carpal tunnel syndrome
exercised correct posture
Exercise to improve neural gliding
exercise to improve tendon gliding
Education positions/activities to avoid
Night splint, especially if a phalen's, reverse Phalens are positive
what is the benefit of splinting
promotes the wrist to be in neutral position, which allows for more space and decreases compression
what kind of treatment is this
ASYTM
augmented soft tissue mobilization
this is good for patient that wants to get better but doesn't want surgery
other than ASYTM what are some other conservative measures for the treatment of carpal tunnel syndrome
NSAIDS
steroid injections
vitamin B6
if all conservative treatments fell for the treatment of carpal tunnel syndrome what is the last resort
carpal tunnel syndrome surgical intervention
release the transverse carpal ligament
tenosynovectomy
neurolysis
what is the "safest" type of carpal tunnel release which is performed by a surgeon
full carpal tunnel release – with ligament reconstruction, without ligament reconstruction, or without a license
incisions are small
surgeons are able to see what they are doing
what kind of surgery was performed in this picture
scars may be hypersensitive
may have edema
decreased range of motion and tendon excursion of fingers
what is the management for carpal tunnel syndrome
moist heat, active range of motion, tendon gliding exercises
continue night splint
desensitize – Rice, towel rubbing, scar massage
progress to grip and wrist strengthening at 4 to 6 weeks post surgery
Flexor Tendon Injuries
where is no man's land
zone II
most common flexor tendon laceration that we see
usually caused by a knife while patient is cutting an orange or Apple
want to treat these patients as soon as possible– usually get these patients within one week post–op
what are the goals for flexor tendon injuries
prevent rupture
prevent tendon adherence, scar adherence
maintain range of motion uninvolved joints
promote tendon gliding
functional range of motion and strength
why is a dorsal blocking splint so important after flexor tendon repair
the splint helps promote flexion of the wrist which decreases stress on the flexor tendons
what are some of the characteristics of poor soul talking splint
20 to 30° wrist flexion
MCP 70 to 80°
rubber band traction with Palmer pulley
start active extension in split with MPs Blocked
passive flexion of all finger joints
Edema control – elevation, Coban
what kind of splint is this
dorsal blocking splint
rubber band provides passive flexion of the singer
patient is instructed to actively extent finger
"never ever ever take this splint off"
needs 4 to 5 cm of excursion
what happens three weeks post-op
start scar tissue massage– hypersensitive
what happens 3 to 4 weeks postop
start gentle place/hold
what happens 4 to 5 weeks postop
started active range of motion
avoid forceful extension, simultaneously your and wrist extension
what happened 6 weeks post op
start gentle joint blocking
start straightening without stress to repair proximal muscles without dripping
what happens 10 weeks postop
start light grip stengthening
what happens 12 weeks postop
no restrictions
this picture represents a scar in what's zone
zone II
when isTenolysis indicated
if there is not adequate range of motion and tendon excursion
when is tenolysis done
when this car softens, around 4 to 6 months post injury
what is an important component for the success of tenolysis
good passive range of motion program
try to recall the zones of the hand on your own hand
what zone is the scar in on the left hand?
zone III
these are easier to treat because there is more room
extensor tendon injuries
true or false – on the extensor side of the hand there are more zones than on the flexor side
true
try to imagine the zones of the hand on your own hand
complex because of the extensor intrinsic muscles of the hand
what is the etiology of extensor tendon injuries
char projects
crush
rupture
tendon adherence common
true or false – most tendon injuries can be treated conservatively
truth
name the three extensor tendon laceration we covered in class
mallet finger
boutonniere
Swan neck deformity
what is a mallet finger
rupture/laceration of terminal tendon as it inserts into the distal phalanx
most likely a basketball injury
often avulvion fracture -should receive the x-ray
the patient will not be able to expand DIP
true or false – mallet finger is always treated surgically
false – mallet finger has a very conservative treatment and is hardly ever operated on surgically
true or false – this x-ray is an x-ray of a mallet finger
what is the treatment for mallet finger
splints 6 to 8 weeks
gradually decrease use of splint and watch for extensor lag
should not flex the GIP joint
therapeutically we can't do much for this they just need to wear the splint
typical mallet finger splint
what kind of injuries this
boutonniere deformity
rupture/laceration of central slip over the PIP joint
what is the management of nonsurgical boutonniere deformities
active range of motion
splinting
caution – don't do passive forceful flexion on a mallet finger or boutonniere tendon are thin and fragile
explain how you would splint a boutonniere deformity
what is a swan neck deformity
hyperextension of the PIP flexion of the PIP
this is very common in rheumatoid arthritic patients
Inflammatory Conditions
what are two inflammatory conditions
DeQuervain's Tenosynovitis
Stenosing Tenosynovitis -trigger finger
what to muscles does DeQuervain's tenosynovitis affect
extensor pollicus brevis
abductor pollicus longus
common causes of DeQuervain's Tenosynovitis
trauma
repetitive motion
tight cast, poorly fitting splint
This is also common in new mothers – they are the easiest to treat
what are some objective findings for DEQuervain's tenosynovitis
tenderness of the first dorsal compartment
positive Finkelstein's
what kind of test is this
active finkestein test
this test is normally done passively with the assistance of the therapist
what is the management for DeQuervain's Tenosynovitis
splints limiting wrist and thumb range of motion– with the thumb up (thumbs up sign)
stretching
ASTYM – outcomes studies show 80% success rate with average of eight visits
what is another name for stenosing tenosynovitis
trigger finger
what is trigger finger
flexor tendon catching on pulley system, usually at A1
what is trigger finger usually caused by
trauma directly over the pulley
repetitive gripping-using a screwdriver causes pressure directly over the pulley
usually seen in 60 to 80's years age group
often in diabetic patients or rheumatoid arthritis
what are some of the signs and symptoms of trigger finger
painful locking of involve finger– often the ring finger