quiz #2 – hand therapy

  1. 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
  2. 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
  3. the certificate to become a hand therapists comes from
    hand certified therapy commission
  4. what are the bones that articulate with the radius
    • scaphoid
    • lunate
    • distal ulna
  5. what does FOOSH stand for
    • fall
    • on
    • out
    • stretched
    • hand

    this occurs more frequently in the wintertime because of ice and snow
  6. true or false – joints with pre-existing but asymptomatic osteoarthritis are very susceptible to stiffness even if not involved in the trauma
  7. 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
  8. what are the three common types of distal radius fractures
    • Colles Fracture
    • Smith's Fracture
    • Barton's displacement
  9. which distal radius fracture is the most common type of fracture
    Colles fracture
  10. what is the mechanism of injury for a Colles Fracture
    fall with the wrist extended
  11. dinner for deformity is associated with what kind of distal radius fracture
    • Colles
    • Dorsal Angulation
  12. what is a reverse colles fracture?
    • a Smith's fracture – volar angulation
    • fall with the wrist flexed
  13. what is the mechanism of injury for a Barton's fracture
    • fall on extended wrist and pronated forearm
    • usually falling backwards
  14. what is a Bartons fracture
    • displaced, unstable fracture
    • carpal displacement with the fragment of radius distinguishes this from Colle's and Smith's
  15. what does this picture represent and what kind of fracture is it associated with
    Image Upload 1
    • dinner for deformity
    • Colle's fracture
    • what is seen in the emergency room – we don't see this very much
  16. 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
  17. what is the treatment for distal radial fractures
    • immobilization – cast or splint it
    • close reduction and cast
    • ORIF - open reduction internal fixation
    • external fixator
  18. what are some observations to consider when looking at distal radius fractures – objective findings
    • atrophy
    • swelling
    • deformity
    • scars
    • color
  19. what is one observation we can make this picture
    Image Upload 2
    right-hand has a mild amount swelling because there are less wrinkles in the hand
  20. what is being measured in this picture
    Image Upload 3
    volume– this is part of objective findings
  21. 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
  22. 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
  23. 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
  24. what does this picture represents
    Image Upload 4
    • Semmes Weinsten monofilament test
    • test sensation of the hand
    • used to track the sensation of the handhas the nerve recovers from injury
  25. distal radius fracture management – what is the main goal
    main goal is to have functional range of motion
  26. 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
  27. 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°
  28. how long does it take to gain full grip strength
    months – very slow to return
  29. 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
  30. treatment continued

    true or false – Most treatments for the hand are started with a hot pack, paraffin bath, fluidotherapy, or some kind of
  31. 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
  32. 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
  33. Image Upload 5Image Upload 6
    • 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
  34. what is tended gliding
    mobilization of the nerves in the upper extremity
  35. Explain this Tendon Glide

    Image Upload 7
    • flexor digitorum superficialis
    • maximum excursion occurs in straight fist position
    • MP and PIP joints maximally flexed and DIP straight
  36. explain this to glide
    Image Upload 8
    • FDP
    • Maximum excursion of FDP occurs in fist position
  37. Image Upload 9
    explain this tendon glide
    • maximum excursion between FDS and FDP occurs in hook position
    • MP extended withPIP and DIP flexed
  38. 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
  39. true or false – patients with distal radial fractures are often splinted to help reduce median nerve pain
  40. 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
  41. which motion is most often restricted in the wrist
    • supination – joint mobilization
    • splints are often used to help facilitate supination
  42. carpal tunnel syndrome
  43. what are the anatomical structures associated with carpal tunnel syndrome
    • transverse carpal ligament
    • Carpals
    • FDP
    • FDS
    • FPL
    • Medain nerve
  44. 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
  45. what is the etiology of carpal tunnel syndrome
    compression of the median nerve in the carpal tunnel
  46. 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
  47. Image Upload 10
    What does this picture demonstrate
    atrophy in the thenar eminence– right side
  48. 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
  49. what is tinel sign
    tapping on the nerve
  50. what test is this
    Image Upload 11
    • phalen's– hold for 30 to 60 seconds
    • Positive – reproduces parathesias
  51. 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
  52. what are the goals of carpal tunnel syndrome
    • decrease pain
    • Decrease parathesias
    • Independence in self management - education
  53. how often should tendon gliding performed during the dayin the treatment of carpal tunnel syndrome
    three or four times a day
  54. 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
  55. what is the benefit of splinting
    promotes the wrist to be in neutral position, which allows for more space and decreases compression
  56. what kind of treatment is this
    Image Upload 12
    • ASYTM
    • augmented soft tissue mobilization
    • this is good for patient that wants to get better but doesn't want surgery
  57. other than ASYTM what are some other conservative measures for the treatment of carpal tunnel syndrome
    • NSAIDS
    • steroid injections
    • vitamin B6
  58. 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
  59. 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
  60. what kind of surgery was performed in this picture
    Image Upload 13
    • scars may be hypersensitive
    • may have edema
    • decreased range of motion and tendon excursion of fingers
  61. 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
  62. Flexor Tendon Injuries
  63. where is no man's land
    Image Upload 14
    • 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
  64. 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
  65. 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
  66. 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
  67. what kind of splint is this
    Image Upload 15
    • 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
  68. what happens three weeks post-op
    start scar tissue massage– hypersensitive
  69. what happens 3 to 4 weeks postop
    start gentle place/hold
  70. what happens 4 to 5 weeks postop
    • started active range of motion
    • avoid forceful extension, simultaneously your and wrist extension
  71. what happened 6 weeks post op
    • start gentle joint blocking
    • start straightening without stress to repair proximal muscles without dripping
  72. what happens 10 weeks postop
    start light grip stengthening
  73. what happens 12 weeks postop
    no restrictions
  74. this picture represents a scar in what's zone
    Image Upload 16
    zone II
  75. when isTenolysis indicated
    if there is not adequate range of motion and tendon excursion
  76. when is tenolysis done
    when this car softens, around 4 to 6 months post injury
  77. what is an important component for the success of tenolysis
    good passive range of motion program
  78. try to recall the zones of the hand on your own hand
    Image Upload 17
  79. what zone is the scar in on the left hand?
    Image Upload 18
    • zone III
    • these are easier to treat because there is more room
  80. extensor tendon injuries
  81. true or false – on the extensor side of the hand there are more zones than on the flexor side
  82. try to imagine the zones of the hand on your own hand
    • Image Upload 19
    • complex because of the extensor intrinsic muscles of the hand
  83. what is the etiology of extensor tendon injuries
    • char projects
    • crush
    • rupture
    • tendon adherence common
  84. true or false – most tendon injuries can be treated conservatively
  85. name the three extensor tendon laceration we covered in class
    • mallet finger
    • boutonniere
    • Swan neck deformity
  86. 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
  87. true or false – mallet finger is always treated surgically
    false – mallet finger has a very conservative treatment and is hardly ever operated on surgically
  88. true or false – this x-ray is an x-ray of a mallet finger
    Image Upload 20
  89. 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
  90. typical mallet finger splint
    Image Upload 21
  91. what kind of injuries this
    Image Upload 22
    • boutonniere deformity
    • rupture/laceration of central slip over the PIP joint
  92. 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
  93. explain how you would splint a boutonniere deformity
    Image Upload 23
  94. what is a swan neck deformity
    • hyperextension of the PIP flexion of the PIP
    • Image Upload 24
    • this is very common in rheumatoid arthritic patients
  95. Inflammatory Conditions
  96. what are two inflammatory conditions
    • DeQuervain's Tenosynovitis
    • Stenosing Tenosynovitis -trigger finger
  97. what to muscles does DeQuervain's tenosynovitis affect
    • extensor pollicus brevis
    • abductor pollicus longus
  98. 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
  99. what are some objective findings for DEQuervain's tenosynovitis
    • tenderness of the first dorsal compartment
    • positive Finkelstein's
  100. what kind of test is this
    Image Upload 25
    • active finkestein test
    • this test is normally done passively with the assistance of the therapist
  101. 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
  102. what is another name for stenosing tenosynovitis
    trigger finger
  103. what is trigger finger
    • flexor tendon catching on pulley system, usually at A1
    • Image Upload 26
  104. 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
  105. what are some of the signs and symptoms of trigger finger
    • painful locking of involve finger– often the ring finger
    • tenderness of pulley, nodule
    • occasionally secondary joint stiffness
Card Set
quiz #2 – hand therapy