quiz #2 � hand therapy

what are requirements to become a certified hand therapist?

five years of practice as a PT or OT4000 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 relatedhave 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

scaphoidlunatedistal ulna

what does FOOSH stand for

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 False


true or false � a fall on the outstretched hand may also injure the proximal joints
True False

true� elbow and shoulderif the patient has a fractured wrist don't forget to check these joints

what are the three common types of distal radius fractures

Colles FractureSmith's FractureBarton'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

CollesDorsal Angulation

what is a reverse colles fracture?

a Smith's fracture � volar angulationfall with the wrist flexed

what is the mechanism of injury for a Barton's fracture

fall on extended wrist and pronated forearmusually falling backwards

what is a Bartons fracture

displaced, unstable fracturecarpal 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 deformityColle's fracturewhat 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, colorlimited range of motion� wrist, forearm, hand, shoulderweakness� finger extensors strongersensory status� check for median nerve compromise, complaints of numbness and tingling

what is the treatment for distal radial fractures

immobilization � cast or splint itclose reduction and castORIF - open reduction internal fixationexternal fixator

what are some observations to consider when looking at distal radius fractures � objective findings


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, shoulderpatients 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 extensorsbecause 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 testtest sensation of the handused 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 False

trueif 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 bathactive range of motion of all involved jointsjoint mobilization techniqueshome 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 False


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 False

truewhen 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 stretchingtendon glidingisolate wrist extensors

the first picture demonstrates a tight intrinsic muscleFlexing the IP joint and the MP joint� they have full range of motion
The second picture shows the finger being brought into extensionThe 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 positionMP and PIP joints maximally flexed and DIP straight

explain this to glide

FDPMaximum excursion of FDP occurs in fist position

explain this tendon glide

maximum excursion between FDS and FDP occurs in hook positionMP extended withPIP and DIP flexed

why are tendon glides so important

prevents formation of adhesions after trauma or surgeryForces each digital joint through full potential rangeAides tendon and cartilage nutritionvaluable in treating inflammatory tendon disorders

true or false � patients with distal radial fractures are often splinted to help reduce median nerve pain
True False


when can you start using weights in the treatment of distal radial fractures

after about six weeks � low weightselbow curlssupination/pronationwrist curlsputty, gripper- must be careful with this because they can overdo it real easy

which motion is most often restricted in the wrist

supination � joint mobilizationsplints are often used to help facilitate supination

carpal tunnel syndrome

what are the anatomical structures associated with carpal tunnel syndrome

transverse carpal ligamentCarpalsFDPFDSFPLMedain nerve

what are the causes of carpal tunnel syndrome

repetitive motiontrauma � fooshbony deformityCongenital disordersLifestyle � obesity, sedentaryIt 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 nightWeakness � dropping thingsIn advance cases atrophy of the thenar area to reach recurrent motor branch of median nerve involvementsometimes, 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 False

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 secondsPositive � 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 painDecrease parathesiasIndependence 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 postureExercise to improve neural glidingexercise to improve tendon glidingEducation positions/activities to avoidNight 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

ASYTMaugmented soft tissue mobilizationthis 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

NSAIDSsteroid injectionsvitamin B6

if all conservative treatments fell for the treatment of carpal tunnel syndrome what is the last resort

carpal tunnel syndrome surgical interventionrelease the transverse carpal ligamenttenosynovectomyneurolysis

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 licenseincisions are smallsurgeons are able to see what they are doing

what kind of surgery was performed in this picture

scars may be hypersensitivemay have edemadecreased range of motion and tendon excursion of fingers

what is the management for carpal tunnel syndrome

moist heat, active range of motion, tendon gliding exercisescontinue night splintdesensitize � Rice, towel rubbing, scar massageprogress to grip and wrist strengthening at 4 to 6 weeks post surgery

Flexor Tendon Injuries

where is no man's land

zone IImost common flexor tendon laceration that we seeusually caused by a knife while patient is cutting an orange or Applewant 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 ruptureprevent tendon adherence, scar adherencemaintain range of motion uninvolved jointspromote tendon glidingfunctional 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 flexionMCP 70 to 80�rubber band traction with Palmer pulleystart active extension in split with MPs Blockedpassive flexion of all finger jointsEdema control � elevation, Coban

what kind of splint is this

dorsal blocking splintrubber band provides passive flexion of the singerpatient 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 motionavoid forceful extension, simultaneously your and wrist extension

what happened 6 weeks post op

start gentle joint blockingstart 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 IIIthese 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 False


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 projectscrushrupturetendon adherence common

true or false � most tendon injuries can be treated conservatively


name the three extensor tendon laceration we covered in class

mallet fingerboutonniereSwan neck deformity

what is a mallet finger

rupture/laceration of terminal tendon as it inserts into the distal phalanxmost likely a basketball injuryoften avulvion fracture -should receive the x-raythe patient will not be able to expand DIP

true or false � mallet finger is always treated surgically
True False

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 weeksgradually decrease use of splint and watch for extensor lagshould not flex the GIP jointtherapeutically we can't do much for this they just need to wear the splint

typical mallet finger splint

what kind of injuries this

boutonniere deformityrupture/laceration of central slip over the PIP joint

what is the management of nonsurgical boutonniere deformities

active range of motionsplinting
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 PIPthis is very common in rheumatoid arthritic patients

Inflammatory Conditions

what are two inflammatory conditions

DeQuervain's TenosynovitisStenosing Tenosynovitis -trigger finger

what to muscles does DeQuervain's tenosynovitis affect

extensor pollicus brevisabductor pollicus longus

common causes of DeQuervain's Tenosynovitis

traumarepetitive motiontight 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 compartmentpositive Finkelstein's

what kind of test is this

active finkestein testthis 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)stretchingASTYM � 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 pulleyrepetitive gripping-using a screwdriver causes pressure directly over the pulleyusually seen in 60 to 80's years age groupoften 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 fingertenderness of pulley, noduleoccasionally secondary joint stiffness