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Slide 1
HAND
THERAPY
KEVIN CHEN, OTR/L
LORA STUBIN-AMELIO, MA, OTR/L, CHT
ANN MARIE FERETTI, ADV. MS, OTR/L, CHT
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Slide 2 ANATOMY IN HAND THERAPY
OBJECTIVES
• Explore the relationships between anatomy of the
hand and wrist and function
• Explain isolated and combined motions of the hand
that are commonly impaired and how they affect
overall function
• Review special tests used to assess symptoms and
dysfunction in the hand and wrist
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Slide 3 ANATOMY
• Understanding of normal anatomy is essential to
treatment of common upper extremity disorders
• Delicate balance between form and function
• Upper extremity operates as a kinematic chain
• Appreciate the complexity of the upper extremity
• Dynamic relationship of various anatomic systems
• Distal mobility with proximal stability
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Slide 4 CERVICAL
ALIGNMENT
• Proper alignment is necessary for neurologic and
vascular function of upper extremity
• Misalignment may manifest as sensory, motor or
autonomic dysfunction
• Cervical spine has valuable mobility, which also
makes it vulnerable to injury
• Vertebrae, muscles, soft tissue, vasculature, nerve
root and nerves included in evaluation for proper
alignment and function of upper extremity
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Slide 5
Tank & Gest 2008
Zizik 4
BONES OF THE UPPER EXTREMITY
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Slide 6 BONES OF THE FOREARM
Radius
Ulna
6.8A
Zizik 2
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Slide 7 UPPER EXTREMITY
FRACTURES
• Distal Humerus
• Radial Head
• Proximal Ulna
• Olecranon **
• Coronoid
• Both Bone Forearm Fractures
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Slide 8 ANATOMYIn distal 1/3 of the volar
forearm, the flexor
tendons arise from the
flexor muscle group
• Superficial group-
FCR, FCU, PL
• Middle group- FDS
• Deep group- FDP, FPL
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Slide 9 ANTERIOR (VOLAR)
FOREARM ANATOMY
1. PT
2. FCR
3. PL
4. FDS
5. FCU
TRY IT!
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Slide 10 POSTERIOR (DORSAL)
FOREARM ANATOMY
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Slide 11 FOREARM & WRIST
TENDONITIS
• Lateral Epicondylitis
• Medial Epicondylitis
• Wrist Extensor Tendonitis
• Wrist Flexor Tendonitis
• deQuervain’s Tenosynovitis- 1st dorsal compartment
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Slide 12 BONES OF THE HAND
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Slide 13 HAND FRACTURES
• Distal Phalanx
• Middle Phalanx
• Proximal Phalanx
• Metacarpal (neck, shaft, base)
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Slide 14
Zizik 6
BONES OF THE HAND
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Slide 15 CARPAL BONES
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Slide 16 BONES OF WRIST AND HAND
Carpals
•Proximal row: Scaphoid, Lunate, Triquetrum,
Pisiform
•Distal row: Trapezium, Trapezoid, Capitate,
Hamate
Metacarpals
Phalanges
Zizik5
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Slide 17 WRIST FRACTURES• Distal Radius **
• Scaphoid **
• Lunate
• Triquetrum
• Pisiform
• Trapezium
• Trapezoid
• Trapezoid
• Capitate
• Hamate
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Slide 18 DISTAL RADIAL
ULNAR JOINT (DRUJ)
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Slide 19
• What does a TFCC
injury look like?
• Mechanism of injury
• fall on an outstretched
hand
• twisting injury
• Press test positive
• Look for pain with
weight bearing
especially pushing up
from a chair- easy to
check during evaluation
TFCC
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Slide 20 HAND ARCHES
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Slide 21 LIGAMENTS
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Slide 22 VOLAR PLATES
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Slide 23 ARTICULATIONS:
VOLAR PLATE
• Promotes stability & positioning of long flexors
• MCP: medial & lateral edges of plate serve as
attachments for fibrous parts of flexor digital
tendon sheath (A1 pulley)
• PIP: sides proximal attachment are longer than
central part (check-rein ligaments) tighten when
middle phalanx extends & limits hyperextension
& attachment for fibrous parts of flexor digital
tendon sheath (A3 pulley)
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Slide 24 VOLAR PLATE
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Slide 25 The “jammed finger”
Dorsal dislocations are
most common
Volar plate injury
Increased edema
Stiff PIP
Can progress pseudo-
bouttonniere
PIP INJURY
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Slide 26 COLLATERAL
LIGAMENTS
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Slide 27 ARTICULATIONS:
COLLATERAL LIGAMENTS
• MCP
• True part -is loose in extension & taut in flexion
• PIP: similar to MCP jt., from attachment of dorsal
tubercle of proximal phalanx, the true part attaches
side of base of middle phalanx & accessory
attaches to volar plate
• True taut in all motions, accessory stabilizes volar
plate
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Slide 28 VOLAR PLATE &
COLLATERAL LIGAMENTS
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Slide 29 THUMB
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Slide 30 RADIAL & ULNAR
COLLATERAL
LIGAMENTS
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Slide 31 THUMB LIGAMENT
INJURIES
• UCL
• Skier’s thumb
• Gamekeeper’s thumb
• RCL
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Slide 32 EXTENSOR
MECHANISM
• EDC, Dorsal & Volar Interossei, Lumbricals
• Central Slip
• Terminal Tendon
• Sagittal Bands
• Transverse Fibers & Oblique Fibers
• Lateral Bands
• Transverse Retinacular Ligament
• Triangular Lig & Oblique Retinacular Lig
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Slide 33 DORSAL APPARATUS
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Slide 34 EXTENSOR
MECHANISM
• EDC, Dorsal & Volar Interossei, Lumbricals
• Central Slip
• Terminal Tendon
• Sagittal Bands
• Transverse Fibers & Oblique Fibers
• Lateral Bands
• Transverse Retinacular Ligament
• Triangular Lig & Oblique Retinacular Lig
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Slide 35 EXTENSOR TENDONS
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Slide 36 EXTENSOR
COMPARTMENTS
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Slide 37 WHY WE NEED TO
KNOW THE ANATOMY!
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Slide 38 FLEXOR ANATOMY
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Slide 39 FLEXOR TENDON ANATOMY
• FDS Flexor Digitorum Superficialis
• FDP Flexor Digitorum Profundus
• FPL Flexor Pollicis Longus
• Digital Flexor Sheath
• Zones
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Slide 40 FDS
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Slide 41 FDS FYI
• Origin: two muscle bellies
• Medial epicondyle
• Radial shaft
• Tendon arise from separate muscle bundles
therefore they act independently
• FDS of small digit absent in 21% of people
• Median Nerve (C7, C8, T1)
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Slide 42 FDP FYI
• Origin - Ulna & interosseous membrane
• Common muscle origin for several tendons
therefore simultaneous flexion of multiple digits
• Median Nerve (C8, T1) to index & middle
• Ulnar Nerve (C7, C8, T1) to ring & small
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Slide 43 LUMBRICALS &
INTEROSSEI:
INTELLIGENT INTRINSICS
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Slide 44 LUMBRICALS &
INTEROSSEI
•Interossei:
-Prime MCP flexors
-Prime Abd/adductors
-Secondary IP extensors (PIP >DIP)
•Lumbricals:
-Prime IP extensors (DIP > PIP)
-Weak MCP flexors
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Slide 45 LUMBRICALS
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Slide 46 LUMBRICALS
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Slide 47 TENDON INJURIES
• Flexor Tendons
• What zone?
• How was it repaired?
• How many strand suture
• When was it repaired?
• Protocol- immobilization, early passive, early active?
• Extensor Tendons
• What zone?
• How was it repaired?
• When was it repaired?
• Protocol- immobilization, early passive, early active?
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Slide 48 TENDON INJURIES
• Flexor Tendons
• Jersey finger
• Zone 2- No-Man’s land
• Spaghetti wrist
• Extensor Tendons
• Mallet finger
• Spontaneous rupture (common in RA)
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Slide 49 UPPER EXTREMITY
NERVES
Radial, Median, Ulnar
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Slide 50 PERIPHERAL NERVE
C1 – C8
C5 – T1
• Brachial plexus
• Musculocutaneous
• Axillary
• Radial
• Median
• Ulnar
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Slide 51 NEUROLOGIC
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Slide 52 DIVISIONS
Below the clavicle each trunk divides into an anterior & posterior division, located deep to middle third of the clavicle & extends distally to lateral border of 1st rib
Fibers in anterior division- anterior (volar) aspect of UE
Fibers in posterior division- posterior (dorsal) aspect of UE
Nerve off anterior division of upper & middle trunks
Lateral Anterior (Lateral Pectoral) Thoracic-upper pecs
**Kendall states this nerve is off of lateral cord**
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Slide 53 CORDS
The Anterior and Posterior Divisions form 3 cords: lateral, posterior, & medial (cords are below clavicle in axilla behind pectoralis minor tendon)
Lateral Cord (anterior division of upper & middle trunk)
Lateral Pectoral (see division slide)
Medial Cord (anterior division of lower trunk)
Medial Pectoral (Anterior Thoracic)-
Pectoralis Major & Minor
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Slide 54 TERMINAL BRANCHES
Main
Musculocutaneous
Axillary
Radial
Ulnar
Median
Secondary
Thoracodorsal
Subscapular nerves
Long thoracic
Dorsal scapular
Medial cutaneous
Medial and lateral pectoral nerves
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Slide 55 BRANCHES
3 cords give rise to 5 terminal branches, although other branches arise more proximal (techniquelyfrom cord)
Lateral cord gives rise to 2 branches
Median nerve (lateral head)- PT, FCR, PL, FDS, FDP
(index & middle) FPL, PQ, Lumbricles (index & middle), OPP, FPB (super), & APB
Musculocutaneous (becomes lateral cutaneous in forearm)- Corocobrachialis, Biceps, Brachialis, & sensation of volar & dorsal lateral forearm
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Slide 56
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Slide 57 BRANCHES
Medial cord gives rise to 4 branches & Medial
Pectoral
Medial Brachial Cutaneous- sensation of
volar/dorsal medial arm
Medial Antebrachial Cutaneous- sensation of
volar/dorsal medial forearm
Ulnar Nerve- FCU, FDP (ring & little), ADM,
ODM, FDM, Lumbricals (ring & small), PAD, DAB,
FPB (deep) ADD
Medial Nerve (medial head)
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Slide 58
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Slide 59
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Slide 60 UPPER EXTREMITY NERVES
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Slide 61
RVE
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Slide 62 MEDIAN NERVE
• Pronator Teres
• Flexor Carpi Radialis
• Palmaris Longus
• Flexor Digitorum Superficialis
• Flexor Digitorum Profundus (index, middle)
• Flexor Pollicis Longus
• Pronator Quadratus
• Abductor Pollicis Brevis
• Flexor Pollicis Brevis (superficial)
• 1st & 2nd Lumbricals
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Slide 63 MEDIAN NERVE
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Slide 64 MEDIAN NERVE
INJURIES
• Carpal Tunnel
• Anterior Interosseous Nerve
• Pronator Syndrome
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Slide 65 ULNAR NERVE
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Slide 66 ULNAR NERVE
• Flexor Carpi Ulnaris
• Flexor Digitorum Profundus (ring, small)
• Palmaris Brevis
• Abductor Digiti Quinti
• Opponens Digiti Quinti
• Flexor Digit Quinti
• 3rd & 4th Lumbricals
• Palmar & Dorsal Interossei
• Adductor Pollicis
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Slide 67 ULNAR NERVE
INJURIES
• Guyon’s Canal
• Cubital Tunnel
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Slide 68 ULNAR NERVE
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Slide 69
ULNAR NERVE
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Slide 70
RADIAL NERVE
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Slide 71 RADIAL NERVE
• Triceps,
• Anconeous
• Brachioradialis
• Extensor Carpi
Radialis Longus
• Extensor Carpi
Radialis Brevis
• Supinator
• Extensor Digitorum
• Extensor Digiti Quinti
• Extensor Carpi Ulnaris
• Abductor Pollicis
Longus
• Extensor Pollicis
Longus
• Extensor Pollicis Brevis
• Extensor Indicis
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Slide 72 RADIAL NERVE
INJURIES
• Radial Nerve Palsy
• Posterior Interosseous Nerve (PIN)
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Slide 73 NERVE INNERVATION
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Slide 74
BREAK
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Slide 75 HANDS ON LAB FOR
ASSESSMENT SKILLS OF
THE HAND AND WRIST
OBJECTIVES
At the end of this session, participants will be
able to:
• Locate key structures in the hand, wrist and forearm
through visual assessment and palpation
• Review common pathology of structures in the
hand, wrist and forearm
• Perform special tests used to assess conditions of
the hand, wrist and forearm
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Slide 76 THERAPEUTIC EVALUATION OF
THE HAND AND WRIST
● Overview:
○ Anatomy and Function
○ Assessment Techniques
○ Symptomatic ROM and Dysfunction
○ Special Tests
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Slide 77 THERAPEUTIC EVALUATION OF
THE HAND AND WRIST
● Assessment techniques
○ Pain
○ Wound & scar status
○ Vascular status
○ ROM
○ Edema
○ Sensation
○ Strength
○ Special tests
○ Functional limitations/Functional outcomes
○ Orthotics
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Slide 78 ASSESSMENT TECHNIQUES:
INITIAL OBSERVATIONS
● Initial Observations and Presentation
○ How the patient walks in
■ Are they keeping the UE within their periphery?
■ Are they using the UE functionally? Are they
supposed to? Are they breaking post-operative
precautions already?
■ Resting position - are there any obvious
deformities?
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Slide 79 EVALUATION
● History- current condition, medical history, establish
rapport, build trust
● Interview- Pain, function, use of orthosis
● Observation- Nonverbal behavior, spontaneous use
of upper extremity vs. guarding, conscious vs. non-
conscious protection, look for inconsistency btwn
formal data & non formal data, continued therapy is
contingent on patient showing progress.
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Slide 80 ASSESSMENT TECHNIQUES:
INITIAL OBSERVATIONS
● Initial Observations and Presentation
○ How the patient walks in
■ Are they keeping the UE within their periphery?
■ Are they using the UE functionally? Are they
supposed to? Are they breaking post-operative
precautions already?
■ Resting position - are there any obvious
deformities?
Boutonniere’s and
Swan Neck DeformityUlnar Claw/Hand of
BenedictionWartenberg’s Sign
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Slide 81 ASSESSMENT TECHNIQUES:
INITIAL OBSERVATIONS
● Initial Observations and Presentation
○ Localized inflammation/edema
○ Previous scars
● Wound/Tissue Healing
○ Did they have surgery and how is the wound?
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Slide 82 PHASES OF WOUND HEALING
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Slide 83 INFLAMMATORY PHASE
Usually lasts for less than a week. Inflammation is a vascularand cellular response.
Increased vascularity, venous congestion
Cellular response causes influx of WBC (macrophages) phagocytosis and release of proteolytic collagenolytic enzymes.
(Jacobs & Austin 2014)
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Slide 84 PROLIFERATION (FIBROPLASIA)
PHASE•Begins 4-5 days after the injury and lasts for 2-6 weeks
•Fibroblasts begin synthesizing collagen which becomes scar tissue
•Scar formation is randomly laid down scar.
•Granulation tissue with angiogenesis gives a red appearance.
•New collagen along with granulating tissue together give new growing tissue.
•“One wound one scar” principle
•From 3– 6 weeks has fibroblasts produced collagen gains tensile strength (load/cross sectional area) .
•(Jacobs & Austin 2014)
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Slide 85 (REMODELING) MATURATION
PHASEUsually lasts 6-8 weeks after
injury to 2 years.
Collagen fibers become more
organized (if given tension)
continues to gain tensile
strength
The scar will contract during
this phase unless subjected
to stress.
(Jacobs & Austin 2014)
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Slide 86 WOUND HEALING
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Slide 87 ASSESSMENT TECHNIQUES:
WOUND HEALING
Appearance:
● Color
● Temperature
● Drainage (if any)
● Tenderness to
palpation (TTP)
Observations?
1/31/2018
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Slide 88 WOUND HEALING
Observations?2/14/2018
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Slide 89 WOUND HEALING
1/31/2018 2/14/2018
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Slide 90 WOUND HEALING
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Slide 91 WOUND ASSESSMENT
• Size
• Depth
• Color
• Red, yellow, black, combinations
• Drainage
• Odor
• Temperature
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Slide 92 WOUND HEALING/TISSUE
HEALING
• Other tissue follows the same healing phases
• Bone, tendon, nerve
• Acute/Inflammatory
• Fibroplasia/Proliferation
• Maturation/Remodeling
• Where does a protocol come from?
• How do you know when a patient is ready to advance the protocol?
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Slide 93 THERAPEUTIC EVALUATION OF
THE HAND AND WRIST
● Hand dominance - which would play an
obvious role on function
● Pain○ Where? - “Can you point to the location of pain?”
○ When does it hurt?
○ What does it feel like?
○ How much?
○ Is the pain reproducible?
● Edema○ Circumferential edema
○ Volumetric
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Slide 94 PAIN
Level
•Scales • Numeric, visual analog, verbal rating, graphic
representation, pain questionnaire
Location
•Referred
Type
•Throbbing, aching, sharp, stabbing, shooting, burning, hypersensitivity
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Slide 95 PAIN
Frequency
• Constant versus intermittent
Cause
• At rest, during motion, end ranges, during activities,
lifting or carrying, during evaluation
Duration
• Acute versus chronic (> 6 mo)
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Slide 96 CLINICAL PROBLEM
SOLVING
• Especially necessary if no firm diagnosis
is given by MD
• Use all data from evaluation to rule in/out
diagnoses
• Provocative testing
• Reproduce the specific pain complaint
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Slide 97 CLINICAL PROBLEM
SOLVING
Pain
•AROM not PROM = muscle or tendon problem
•PROM = joint problems such as joint structures,
ligament injury, cartilage injury, inflammation
• Joint limitation due to pain
• Pain with distraction eased with compression =
ligament or joint capsule problem
• Pain with compression eased with distraction = joint
surface problem, inflammation, surface spur
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Slide 98 SCAR ASSESSMENT
Color
• Red, pink, white
Size
Depth
• Flat versus raised
Adhesions
• Mild, moderate, severe hypomobility
• Direction
Vancouver Burn Scar Assessment
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Slide 99 VASCULAR STATUS
ASSESSMENT
Observation
• Color, trophic changes, pain level
Palpation
• Pulses, capillary refill assessment, modified Allen’s
test
Temperature
Injuries to nerves, blood vessels, diseases
(Raynaud’s)
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Slide 100 OBSERVATION
Color
• Pallor (white/grayish)
• Arterial interruption
• Cyanosis (blue)
• Chronic venous insufficiency (dusky blue)
• Venous blockage (purple-blue)
• Erythema (red)
• Normal inflammatory phase
• infection
• Loss of outflow of blood from hand
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Slide 101 PALPATION TESTS OF
VASCULAR ASSESSMENT
• Capillary refill test
• Peripheral pulse palpation
• Modified Allen’s test
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Slide 102 CAPILLARY REFILL TEST
• Number of seconds for color to return to normal
• Normal time = < 2 seconds
• Compare to same digit on opposite hand
TRY IT!
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Slide 103 MODIFIED ALLEN’S TEST
• Assesses status of blood supply in hand
• Radial and ulnar arteries
• Occlude both arteries until hand is white
• Time to return to normal color after release of one artery
occlusion
• Repeat after same to other artery
• Normal response is < 5 seconds
• Compare to opposite extremity
TRY IT!
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Slide 104 RANGE OF MOTION
ASSESSMENT
• Isolated
• Shoulder
• Elbow
• Wrist
• Forearm
• Composite
• Digits
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Slide 105 METHODS
AROM or PROM
Joint stiffness, intrinsic tightness, extrinsic
tightness
Limitations in PROM- what does it mean?
• Joint capsule tightness
• ligamentous tightness
• decreased joint space
• bone spur
• muscle/tendon tightness
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Slide 106 AROM
Limitations in AROM- what does it mean?
• Weakness of muscle
• Loss of tendon continuity
• Adhesions of tendon
• Inflammation or constriction of tendon
• Decreased tendon mechanical efficiency
• Disrupted nerve supply to muscle
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Slide 107 FOREARM RANGE OF MOTION
Pronation and Supination
• Measured with elbow flexed at 90, arm adducted to
body, goniometer fixed arm perpendicular to the floor,
moving arm in contact with volar forearm for
supination, dorsal forearm for pronation
TRY IT!
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Slide 108 WRIST RANGE OF MOTION
Motions measured are flexion, extension, radial and ulnar deviation
Unless patient not able to assume posture, elbow is on table with forearm in air so digit tips point to ceiling
Measurement for flexion on dorsal 3rd metacarpal with digits relaxed
Measurement for extension on volar 3rd metacarpal with digits relaxed
TRY IT!
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Slide 109 WRIST RANGE OF MOTION
Radial and ulnar deviation
Measured with palm flat on table with goniometer on
3rd metacarpal, dorsum of forearm and axis at wrist
TRY IT!
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Slide 110 DIGITAL RANGE OF MOTION
• Motions measured are MP, PIP and DIP flexion and extension, thumb MP and IP flexion
• Hand position is same as wrist flexion and extension posture
• Motion measured is composite unless contraindicated
• “0” is neutral
• ”+”is hyperextension
• “‐”is an extension deficit
• Measurements should be written as extension/flexion (e.g. ‐10/85).
TRY IT!
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Slide 111
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Slide 112 DIGITAL RANGE OF MOTION
• When all fingers are involved
• Tip to DPC can be a useful
measurement
• Distance from fingertip to distal palmar
crease, normal is zero- finger should
be able to touch DPC in a full fist
TRY IT!
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Slide 113 CLINICAL PROBLEM SOLVING
Joint stiffness
• AROM = PROM no matter joint position
Intrinsic tightness
• IP flexion > with MP flexed than MP extended
Extrinsic tightness
• Extensor – proximal joints in extension allows more flexion
of distal joints
• With digits in full flexion, bring wrist into flexion - will feel
digits extend due to extrinsic tightness
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Slide 114 CLINICAL PROBLEM SOLVING
Extrinsic tightness
• Flexor – if proximal joints in flexion allows more
extension in distal joints
• With distal joints extended, bring wrist into more
extension – will feel distal joints flex if tightness of
extrinsics
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Slide 115 CLINICAL PROBLEM SOLVING
Intrinsic tightness
• Bunnell-Littler test
• Passive flexion of MP and PIP joints of one finger
while observing/measuring the range of passive
PIP joint flexion.
• Passive extension of MP joint with passive flexion
of the PIP joint while observing/measuring the
range of passive PIP joint flexion
• POSITIVE = less PIP flexion with the MP
extended than with it flexed
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Slide 116 SWELLING/EDEMA
• Common sequela of injury
• Normal reduction should begin at 2 weeks post
injury
• Increased edema occurs due to injury and
subsequent surgery or positioning
• Important to remove asap – gelling, brawny,
adhesions, function
• First pathway
•Elevation, ice, compression
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Slide 117 CIRCUMFERENTIAL
MEASUREMENT
• Digits
• Proximal phalanx
• Middle phalanx
• Distal phalanx
• DPC
• Wrist
• Elbow
• Axilla
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Slide 118 VOLUMETER
Works well to compare to contralateral side
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Slide 119 CHARACTERISTICS OF EDEMA
Edema
• Loss of wrinkles, joint creases
• May be shiny, taut skin
• Color
• Erythema
• Cyanosis
• Pallor
• Palpation
• Pitting
• Brawny
• More chronic in nature,
more difficult to clear
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Slide 120 STRENGTH TESTING
Contraindications
• Deferred in trauma patients until strengthening is
allowed (resistance)
Grasp and pinch
• Maximally resistive tests
• Grasp – gross
• Dynamometer
• Pinch
• 2 point, 3 point and lateral
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Slide 121 GRIP STRENGTH TEST
Jamar dynamometer
Standard testing posture
• Shoulder adducted, elbow at 90 , forearm and wrist
neutral
• 3 trials on 2nd handle
• With a large male hand, may also test grasp on 3rd
handle
• Compare to opposite extremity
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Slide 122 5 LEVEL GRIP TEST
5 Level grip test
• 1to 3 trials on each of the 5 different handle width
settings
• Should be bell curve
• May use to identify malingerer, person not trying his
hardest
• Always compare to non involved extremity
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Slide 123 PINCH STRENGTH TEST
Pinchmeter
• Lateral (key) pinch
• Radial aspect of index finger and thumb on
top of pinchmeter
• 3 point pinch (3 jaw chuck)
• 2nd and 3rd digits on top with thumb under
pinchmeter
• 2 point pinch (tip to tip)
• 2nd digit tip on top with thumb under
pinchmeter
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Slide 124 FUNCTIONAL OUTCOME
MEASURESShoulder
• SPADI, Penn
Elbow
• PREE
Wrist
• PRWE, PRWHE
General
• DASH, UEFI
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Slide 125 COORDINATION
• Ability to manipulate items in hand and in
environment
• Standardized tests available
• O’Connor Dexterity
• Nine-hole Peg
• Jebsen-Taylor Hand Function
• Minnesota Rate of Manipulation
• Crawford Small Parts Dexterity
• Perdue Pegboard
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Slide 126 9 HOLE PEG TEST
Using 1 hand, place all pegs in one at a time, then take all
pegs out one at a time, time how long from start to finish
Repeat with other hand
Norms:
Men= 19 seconds
Women= 18 seconds
TRY IT!
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Slide 127 SPECIAL TESTS
• Tinel’s- nerve irritation
• Phalen’s- median nerve compression
• Ulnar Flexion
• Finklestein- 1st dorsal compartment
• Grind Test- 1st CMC joint
• Watson’s- scapho-lunate
• Press test- TFCC pain
• Cozin’s test- lateral epicondylitis TRY IT!
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Slide 128 TESTS
• Finklestein- 1st dorsal compartment APL, EPB; flex
thumb, wrap fingers around thumb, ulnarly deviate
wrist + if pain
• Froment’s- hyper flexion of IP jt with pinch (UN)
• Jeanne’s- MCP hyperextension with pinch (UN)
• “O” sign- loss of “O” with no FPL flexion along with
no index FDP
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Slide 129 SENSATION
• Threshold density
• Ability to perceive light touch
• Used for compression injuries
• Innervation density
• Number of nerve endings in an area tested
• 2 point discrimination
• Used after nerve laceration
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Slide 130 THERAPEUTIC EVALUATION OF
THE HAND AND WRIST
● ROM - goniometry
● Distance to DPC
● Grip and Prehension Strength
○ Dynamometer and Pinchmeter
● Sensation
○ Semmes Weinstein
○ Vibration Testing
○ Discriminator
● Fine motor
● Special Testing
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Slide 131 HANDS ON LAB FOR
ASSESSMENT SKILLS OF THE
HAND AND WRIST
● ROM
• Wrist flexion, extension, ulnar/radial deviation
• Supination/pronation, finger flexion/extension
• Edema- circumferential
• Sensation- Semmes Weinstein monofilaments
• Coordination- 9 hole peg test
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Slide 132 TREATMENT PLANNING FOR
COMMON CONDITIONS OF THE
HAND AND WRIST
OBJECTIVESAt the end of this session, learners will be able to:
• Describe tissue healing and relationship to protocols for specific conditions
• Discuss common complications with hand and wrist conditions (i.e. stiff hand, edema management, scar management)
• Explain the use of manual therapy and therapeutic exercise
• Custom orthotic/splint fabrication- when is it needed?
• Use of functional activities for improved outcomes
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Slide 133 HOW DOES IT ALL WORK
TOGETHER?
To function effectively
Tendons and muscles must all work together
Normal digital motion- flexion
Tendon gliding
full extension
hook fist
duck fist
full fist
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Slide 134 NORMAL DIGITAL MOTION-FLEXION
• Wrist stabilized allows FDP to transmit power to fingers
• Finger flexion starts FDP while MCP’s are held extended by EDC
• IP’s hook then MP flexion
(Arbuckle & McGrouther, 1995)
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Slide 135 NORMAL DIGITAL
MOTION-FLEXION
• Always slightly more PIP than DIP
flexion
• Initially more PIP flexion than MP flexion;
as MCP’s reach end range slight
decrease in PIP flexion but a tight fist
brings the PIP to maximum (FDS)
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Slide 136 WHO ARE THE
WORKERS?
• EDC
• FDS
• FDP
• Interosseous
• Lumbricals
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Slide 137 FULL EXTENSION
• EDC fires
• FDS silent
• FDP silent
• Interosseous fires
• Lumbricals fire
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Slide 138 HOOK FIST
• EDC fires
• FDP fires
• FDS fires
• Interosseous silent
• Lumbricals silent
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Slide 139 DUCK FIST
• EDC silent
• FDS silent
• FDP silent
• Interosseous fires
• Lumbricals fire
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Slide 140 STRAIGHT FIST
• EDC silent
• FDP silent
• FDS fires
• Interosseous fires
• Lumbricals fire
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Slide 141 FULL FIST
• EDC silent
• FDP fires
• FDS fires
• Interosseous silent until end range then
fires
• Lumbricals silent
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Slide 142 “THE STATUS AND STAGE OF A HEALING
WOUND DIRECTS THE SPECIFICS OF
SPLINT SELECTION, FABRICATION AND
PATIENT USE” Jacobs & Austin, 2014
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Slide 143 WHAT IS THE PURPOSE OF
SPLINTING/ORTHOTIC INTERVENTION?
Alignment:
• Functional position
Correct deformities
Support:
• Relieve pain
• Promote healing
Prevention
Improve function
Restrict motion of a movable body part
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Slide 144 STATIC SPLINTS
• Have no moving parts
• Static splints- have a firm base and immobilize the joints they cross.
• Protection- i.e. healing Fxs (structures)
• Immobilization- for rest, i.e. CTS, tenosynovitis
• Stabilization- i.e. joint sublux
• Prevent further deformity i.e. joint sublux
• Blocking- i.e. exercise, ulnar claw
• Position- i.e. flaccid hand, spastic hand
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Slide 145 PROTECTION SPLINT-IMMOBILIZE
FOR HEALING
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Slide 146 STABILIZATION SPLINT- SUPPORT
PAINFUL JOINTS
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Slide 147 IMMOBILIZATION SPLINT- RESTRICT
MOBILITY
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Slide 148 PREVENTION SPLINT
SUBLUXATION, DEVIATION
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Slide 149 BLOCKING SPLINT
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Slide 150 POSITIONING SPLINT- MODIFY TONE,
REST TISSUES
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Slide 151 DYNAMIC SPLINTS
• Moving parts
• Dynamic splints (rubberbands, springs, spring wire, & coils)
• Substitute for loss of motor function- i.e. radial nerve palsy, tenodesis
• Correct deformity- i.e. joint contracture
• Provide controlled motion- flexor/extensor tendon injuries, joint arthroplasty
• Aid in fracture alignment
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Slide 152 SUBSTITUTE FOR LOSS OF MOTOR
FUNCTION
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Slide 153 CORRECT DEFORMITY
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Slide 154 PROVIDE CONTROLLED MOTION
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Slide 155 STATIC PROGRESSIVE SPLINTS
• Parts that can be moved, but do not move on the
patient during use, it is modified with adjustments
• Static Progressive Splints- “achieve mobilization
by applying unidirectional, low-load force to the
tissue’s maximum end ROM until the tissues
accommodates” (Jacobs & Austin, p.10, 2014).
• Static progressive splints have dynamic like
components, but no springs or rubber bands.
• Static progressive splints use non-elastic
components.
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Slide 156 STATIC PROGRESSIVE SPLINTING
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Slide 157 STATIC PROGRESSIVE SPLINTING
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Slide 158 STATIC PROGRESSIVE SPLINTING
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Slide 159 SERIAL STATIC SPLINTING
• Serial static splinting or casts- are applied to tissue at the maximum elongation length; usually the tissue are held at this position for long period of time. Then, the splints are remolded or re-casted to accommodate changes in tissue length.
• Correct deformity- i.e. pip joint flexion contractures
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Slide 160 CASE EXAMPLE 1
74 yr old female comes in
with diagnosis of R
dominant wrist fx s/p ORIF
3 weeks ago. She has pain
6/10 during activity, 2/10 at
rest, difficulty with all
grasping, lifting, carrying,
cannot wash her face or eat
with a spoon
Edema wrist R= 17.4 cm, L= 15.2 cm
AROM
Wrist flexion = 20
Wrist extension = 30
Supination = 40
Pronation = 60
Fingers tip to DPC = 3.0 cm
Grip strength R= 5 lbs, L= 35 lbs
Sensation- 4.31 in R thumb, 3.61 in 2nd/3rd, normal in 4th/5th
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Slide 161 CASE EXAMPLE 2
Pt is a 30 yr old male who
presents with pain in L
arm/hand, numbness and
tingling in 5th finger,
positive Wartenburg sign,
positive Froment’s test,
positive Tinel’s at the
elbow, pt works as an
electrician
AROM is WFL
Grip strength R= 85 lbs, L=
75 lbs
Positive Tinel’s
Symptoms are worse at
night
Pain in forearm with work
activities 6/10
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Slide 162 CASE EXAMPLE 3
Pt is a 65 yr old
woman coming to PT
for her shoulder
impingment/pain.
She complains of
pain in thumb/wrist
area that limits her
from opening jars,
writing, knitting and
working in the
garden
Pain in R hand 5/10 with
grasping and moving
c/o aching pain at night 5/10
Lateral pinch R= 6 lbs, L=
10 lbs, pinch test is painful
Positive grind test
AROM is WFL except thumb
opposition is limited
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