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Hand and Upper Extremity Disorders Part I

Includes fractures, repetitive stress injuries, complex regional pain syndrome, dupytren's disease and skier's thumb.
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Dupytren's Disease
-disease of the fascia of the palm and digits that results in flexion deformities of the involved digits.
-etiology unknown
-conservative treatment has not been successful
-surgery is required (3 options: fasciotomy with Z plasty, aponeurotomy, McCash procedure <open palm>
OT intervention for Dupytren's Disease
1. wound care: dressing changes. Whirlpool if infection is suspected.
2. edema control: elevation above the heart
3. extension splint: initially at all times except to remove for ROM and bathing
4. A/PROM and progress to strengthening when wounds are healed
5. scar management (massage, scar pad, and compression garments.
6. functional tasks that emphasize flexion (gripping) and extension (release).
Skier's Thumb (Gamekeeper's Thumb)
-Rupture of the ulnar collateral ligament of the MCP joint of the thumb.
-most common etiology is a fall while skiing with the thumb held in a skii pole.
OT intervention for Skier's Thumb
1. Conservatuve treatment including a thumb splint 4-6 weeks
2. AROM and pinch strengthening (at 6 weeks)
3. Focus on ADL that require opposition and pinch strength
4. post-operative, treatment includes thumb splint for 6 weeks, followed by AROM. PROM can begin at 8 weeks and strengthening at 10 weeks.
Complx Regional Pain Syndrome (CRPS)
-Type I formerly known as reflex sympathetic dystrophy (RSD)
-Type II formerly known as causalgia
-Vasomotor dysfunction as a result of an abnormal reflex
-It can be localized to one specific area or spread to other parts of the extremity.
-Etiology: may follow trauma or surgery, but actual cause is unknown.
-symptoms include: severe pain, edema, discoloration, osteoporosis, sudomotor changes, and vasomotor instability.
OT intervention for CRPS
1. modalities to decrease pain
2. AROM to involved joints
3. ADL to encourage pain-free active use
4. Stress loading (weight bearing and joint distraction activities, including scrubbing and carrying activities)
5. splinting to prevent contractures and enable ability to engage in leisure/productive activities.
6. encourage self management
Interventions to AVOID with CRPS
PROM, passive stretching, joint mobilization, dynamic splinting, and casting.
Types of Fractures
1. intraarticular versus extraarticular
2. closed versus open
3. dorsal displacement versus volar displacement
4. midshaft versus neck versus base
5. complete versus incomplete
6. transverse versus spiral versus oblique.
7. comminuted.
Medical treatment for fractures
1. closed reduction: types of stabilization include short arm cast (SAC), long arm cast (LAC), splint, sling, or fracture base.
2. Open reduction internal fixation (ORIF), types include nails, screws, plates, or wire.
3. External fixation
4. Athrodesis: fusion
5. Athroplasty: joint replacement
Colles' fracture
fracture of the distal radius with dorsal displacement
Smith's fracture
fracture of the distal radius with volar displacement
carpal fractures
most common is scaphoid fracture (60% of carpal fractures). The proximal scaphoid has a poor blood supply and may become necrotic.
metacarpal fractures
classified according to location (head,neck, shaft, or base). a common complication is rotational deformities. A Boxer's fracture is a fracture of the 5th metacarpal (requires an ulnar gutter splint.
proximal phalanx fractures
most common with thumb and index. a common complication is loss of PIP A/PROM.
middle phalanx fractures
not commonly fractured
distal phalynx fracture
most common finger fracture. May result in mallet finger (which involves terminal extensor tendon).
elbow fracture
involvement of the radial head may result in limited forearm rotation
humerus fractures: nondisplaced vs. displaced
- etiology: fall onto an outstretched upper extremity
- fractures of the greater tuberosity may result in rotator cuff injuries
- humeral shaft fractures may cause injury to the radial nerve resulting in wrist drop
OT evaluation for UE fractures
-history should include mechanism of injury and fracture management.
-results of special tests (x-ray, MRI, CT scans)
-edema
-pain
-AROM- note: do not assess PROM or strength until ordered by a physician (exceptions are humerus fractures which often begin with PROM or AAROM).
-sensation
-roles, occupations, ADL and activities related to roles.
OT intervention for fractures during the immobilization phase of UE fractures:
stabilization and healing are the goals.
1. AROM of joints above and below the stabilized part
2. edema control: elevation, retrograde massage, and compression garments.
3. Light ADL and role activities with no resistance, progress as tolerated
OT intervention for fractures during the mobilization phase of UE fractures:
consolidation is the goal.
1. edema control: elevation, retrograde massage, contrast baths, and compression garments.
2. AROM
With humerus fractures, OT intervention during the mobilization phase consists of:
(a). Often begins with PROM or AAROM
1. light functional/purposeful activity
2. pain management: positioning and physical agent modalities
3. strengthening: begin with isometrics when approved by physician.
Cumulative Trauma Disorders (CTD)
-AKA repetitive strain injuries (RSI), overuse syndromes, and/ormusculoskeletal disorders.
-risk factors: repetition, static position, awkward postures, forceful exertions, and vibration.
-non-work risk factors: acute trauma, pregnancy, diabetes, arthritis, and wrist size/shape.
Most common types of CTD
DeQuervain's, lateral and medial epicondylitis, trigger finger, nerve compressions.
DeQuervain's
- Stenosing tenosynuvitis of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB).
-pain and swelling over the radial styloid
-positive finkelstein's test
Conservative treatment of DeQuervain's
-thumb spica splint
-activity/work modification
-ice massage over radial wrist
-gentle AROM of wrist and thumb to prevent stiffness
Post operative treatment
-thumb spica splint and gentle AROM (0-2 weeks)
-strengthening, ADL, and role activities (2-6 weeks)
-unrestricted activity (6 weeks)
Lateral and medial epicondylitis
-degeneration of the tendon origin as a result of repetitive microtrauma
Lateral epicondylitis
AKA tennis elbow. Overuse of wrist extensors, especially the extensor carpi radialis brevis.
Medial epicondylitis
AKA golfer's elbow. overuse of wrist flexors.
conservative treatment of lateral and medial epicondylitis
-elbow strap, wrist splint
-ice and deep friction massage
-stretching
-activity/work modification
-as pain decreases, begin strengthening
Trigger finger
- Tenosynuvitis of the finger flexors: most commonly is the A1 Pulley.
- Caused by repetition and the use of tools that are placed too far apart
Conservative treatment of trigger finger
-hand based trigger finger splint (MCP extended, IP joint is free)
-scar massage
-edema control
-tendon gliding
-activity/work modification: avoid repetitive gripping activities and using tools with handles too far apart.