Upper Extremity Rehabilitation Workshop MBINGO BAPTIST HOSPITAL Kenneth Nshiom, PT/OCO Morag Crocker, OT November 29, 2014 Timothy Fanfon, PT

Upper Extremity Upper Extremity RehabilitationRehabilitation WorkshopWorkshop

MBINGOMBINGO BAPTISTBAPTIST HOSPITALHOSPITAL

Kenneth Nshiom, PT/OCO Kenneth Nshiom, PT/OCO

Morag Crocker, OTMorag Crocker, OT

November 29, 2014November 29, 2014

Timothy Fanfon, PTTimothy Fanfon, PT

AgendaAgenda

8:00 am – Anatomy review8:00 am – Anatomy review

9:00 am – Physical assessment9:00 am – Physical assessment

10:00 am – short break10:00 am – short break

10:10 am – Upper extremity conditions10:10 am – Upper extremity conditions

12:30 pm – lunch break12:30 pm – lunch break

1:00 pm – Splinting review & practice1:00 pm – Splinting review & practice

AnatomyAnatomyTimothy FanfonTimothy Fanfon

Bones of the ArmBones of the Arm

HumerusHumerus RadiusRadius

– Shape of distal portion of bone allows Shape of distal portion of bone allows for rotation with pronation/supinationfor rotation with pronation/supination

UlnaUlna Bony landmarks = Radial & ulnar Bony landmarks = Radial & ulnar

styloid processesstyloid processes– Potential pressure points when splintingPotential pressure points when splinting

Bones of the handBones of the hand

Carpal bonesCarpal bones MetacarpalsMetacarpals PhalangesPhalanges

– ProximalProximal– MiddleMiddle– DistalDistal

Carpal BonesCarpal Bones

Joints of the HandJoints of the Hand

MCP = MCP = Metacarpal-Phalangeal JointMetacarpal-Phalangeal Joint– Flexion, extension & some ulnar/radial movt.Flexion, extension & some ulnar/radial movt.

PIP = PIP = Proximal Inter-Phalangeal JointProximal Inter-Phalangeal Joint– Flexion & extension onlyFlexion & extension only

DIP = DIP = Distal Inter-Phalangeal JointDistal Inter-Phalangeal Joint– Flexion & extension onlyFlexion & extension only

CMC = CMC = Carpometacarpal JointCarpometacarpal Joint– Flexion, extension, adduction, abduction & Flexion, extension, adduction, abduction &

oppositionopposition

Joints of the HandJoints of the Hand

CMC joint @ base of thumb

Planes/directions of movementPlanes/directions of movement

Flexion & extension Flexion & extension (elbow, wrist, fingers)(elbow, wrist, fingers)

Adduction & abduction Adduction & abduction (fingers)(fingers)

Radial & ulnar deviation Radial & ulnar deviation Pronation & supinations Pronation & supinations

(forearm & hand)(forearm & hand)

Muscles of the Upper ArmMuscles of the Upper Arm

BicepsBiceps– FlexionFlexion

TricepsTriceps– ExtensionExtension

Muscles of the (Volar) ForearmMuscles of the (Volar) Forearm

Flexor Carpi Radialis (FCR)Flexor Carpi Radialis (FCR)– Flexes wristFlexes wrist– Wrist radial deviationWrist radial deviation

Flexor Carpi Ulnaris (FCU)Flexor Carpi Ulnaris (FCU)– Flexes wristFlexes wrist– Wrist ulnar deviation Wrist ulnar deviation


Flexor Digitorum Superficialis Flexor Digitorum Superficialis (FDS)(FDS)– Flexes wristFlexes wrist– Flexes PIP jointsFlexes PIP joints

Splits at level of PIP joint to allow Splits at level of PIP joint to allow Flexor digitorum profundus to pass to Flexor digitorum profundus to pass to distal phalanxdistal phalanx

Attaches on middle phalanxAttaches on middle phalanx


Flexor Digitorum Profundus Flexor Digitorum Profundus (FDP)(FDP)– Flexes wristFlexes wrist– Flexes DIP jointsFlexes DIP joints

Passes through split in FDS to Passes through split in FDS to attach to distal phalanxattach to distal phalanx


Flexor Pollicis Longus (FPL)Flexor Pollicis Longus (FPL)– Flexes distal phalanx of thumbFlexes distal phalanx of thumb

Flexor Pollicis Brevis (FPB)Flexor Pollicis Brevis (FPB)– Flexes proximal phalanx of Flexes proximal phalanx of

thumbthumb

(pollicis = relating to thumb)(pollicis = relating to thumb)

Muscles of the (Dorsal) ForearmMuscles of the (Dorsal) Forearm

Extensor Carpi Radialis Longus Extensor Carpi Radialis Longus (ECRL)(ECRL)

Extensor Carpi Radialis Brevis Extensor Carpi Radialis Brevis (ECRB)(ECRB)

Both musclesBoth muscles– Extend the wristExtend the wrist– Radially deviate the wrist (abducts Radially deviate the wrist (abducts

or moves the hand in the direction or moves the hand in the direction of the thumb)of the thumb)


Extensor Digitorum Communis Extensor Digitorum Communis (EDC)(EDC)– Extends the wrist and fingers 2-5 at Extends the wrist and fingers 2-5 at

the MCP & PIP jointsthe MCP & PIP joints

Attaches to the phalanges Attaches to the phalanges through the extensor through the extensor mechanism and dorsal hoodmechanism and dorsal hood


Extensor Digiti Minimi Extensor Digiti Minimi (EDM)(EDM)

Extensor Indicis (EI)Extensor Indicis (EI)– Additional extensor muscles Additional extensor muscles

for the index finger (EI, for the index finger (EI, indicis = index finger) and indicis = index finger) and little finger (digiti minimi = little finger (digiti minimi = little digit/finger)little digit/finger)


Extensor Pollicis Longus (EPL)Extensor Pollicis Longus (EPL)– Extends distal phalanx of thumb Extends distal phalanx of thumb

at IP jointat IP joint

Extensor Pollicis Brevis (EPB)Extensor Pollicis Brevis (EPB)– Extends proximal phalanx of Extends proximal phalanx of

thumb at MCP jointthumb at MCP joint

Abductor Pollicis Longus (APL)Abductor Pollicis Longus (APL)– Extends, abducts & rotates the Extends, abducts & rotates the

thumb at the CMC jointthumb at the CMC joint

(pollicis = relating to thumb)(pollicis = relating to thumb)

Muscles that Rotate the ForearmMuscles that Rotate the Forearm

Pronators:Pronators:– Pronator teresPronator teres– Pronator quadratusPronator quadratus

Supinators:Supinators:– SupinatorSupinator

Bringing the forearm to neutral:Bringing the forearm to neutral:– BrachioradialisBrachioradialis– Also assists with elbow flexionAlso assists with elbow flexion– ““beer drinking muscle”beer drinking muscle”

Muscles of the (Volar/Palmar) HandMuscles of the (Volar/Palmar) Hand

Thenar muscles = muscles Thenar muscles = muscles moving the thumbmoving the thumb– Flexor Pollicis BrevisFlexor Pollicis Brevis– Abductor Pollicis BrevisAbductor Pollicis Brevis– Opponens Pollicis Opponens Pollicis – Adductor PollicisAdductor Pollicis

Muscles of the (Volar/Palmar) HandMuscles of the (Volar/Palmar) Hand

Hypothenar muscles = Hypothenar muscles = muscles moving the little muscles moving the little fingerfinger– Flexor Digiti Minimi Flexor Digiti Minimi – Abductor Digiti Minimi Abductor Digiti Minimi – Opponens Digiti MinimiOpponens Digiti Minimi

Intrinsic Muscles of the HandIntrinsic Muscles of the Hand LumbricalsLumbricals

– Origin on FDP tendon, inserts on Origin on FDP tendon, inserts on proximal phalanx of digits 2-5proximal phalanx of digits 2-5

– Flexes MCP joints and extends IP jointsFlexes MCP joints and extends IP joints Dorsal InterosseiDorsal Interossei

– Abducts digits 1, 2 & 4 Abducts digits 1, 2 & 4 – Flexes MCP joints and extends IP jointsFlexes MCP joints and extends IP joints

Palmar InterosseiPalmar Interossei– Abducts the fingers towards 3Abducts the fingers towards 3rdrd digit digit– Flexes MCP joints and extends IP jointsFlexes MCP joints and extends IP joints

Brachial PlexusBrachial Plexus Network of nerve fibers that goes through the neck, Network of nerve fibers that goes through the neck,

the axilla (armpit) and into the arm and handthe axilla (armpit) and into the arm and hand Responsible for all the cutaneous (skin) and muscular Responsible for all the cutaneous (skin) and muscular

innervation of the upper limb (except the trapezius innervation of the upper limb (except the trapezius

muscle)muscle)

Radial NerveRadial Nerve The radial nerve innervates the following muscles, in this The radial nerve innervates the following muscles, in this

order:order:– TricepsTriceps– AnconeusAnconeus– BrachioradialisBrachioradialis– Extensor Carpi Radialis LongusExtensor Carpi Radialis Longus– Extensor Carpi Radias BrevisExtensor Carpi Radias Brevis– SupinatorSupinator

Posterior Interosseous Nerve (branch Posterior Interosseous Nerve (branch of radial nerve)of radial nerve)– Extensor Digitorum (Communis)Extensor Digitorum (Communis)– Extensor Digiti MinimiExtensor Digiti Minimi– Extensor Carpi UlnarisExtensor Carpi Ulnaris– Abductor Pollicis LongusAbductor Pollicis Longus– Extensor Pollicis LongusExtensor Pollicis Longus– Extensor Pollicis BrevisExtensor Pollicis Brevis– Extensor IndicisExtensor Indicis

Median NerveMedian Nerve The median nerve innervates the following muscles, in this The median nerve innervates the following muscles, in this

order:order:– Pronator TeresPronator Teres– Flexor Carpi RadialisFlexor Carpi Radialis– Palmaris LongusPalmaris Longus– Flexor Digitorum SuperficialisFlexor Digitorum Superficialis

Anterior Interosseous Nerve (branch of Anterior Interosseous Nerve (branch of median nerve)median nerve)– Flexor Digitorum Profundus (index and middle)Flexor Digitorum Profundus (index and middle)– Flexor Pollicis LongusFlexor Pollicis Longus– Pronator QuadratusPronator Quadratus

Palmar Recurrent Motor Branch (branch of Palmar Recurrent Motor Branch (branch of median nerve)median nerve)– Abductor Pollicis BrevisAbductor Pollicis Brevis– Opponens PollicisOpponens Pollicis– Flexor Pollicis BrevisFlexor Pollicis Brevis

Common Palmar Digital Nerve (branch of Common Palmar Digital Nerve (branch of median nerve)median nerve)– Lumbricals 1 & 2Lumbricals 1 & 2

Ulnar NerveUlnar Nerve

The Ulnar nerve innervates the following muscles, The Ulnar nerve innervates the following muscles, in this order:in this order:– Flexor Carpi Ulnaris (FCU)Flexor Carpi Ulnaris (FCU)– Flexor Digitorum Profundus (ring and small Flexor Digitorum Profundus (ring and small

fingers)fingers)

Deep Branch of Ulnar Nerve:Deep Branch of Ulnar Nerve:– Abductor Digiti MinimiAbductor Digiti Minimi– Opponens Digiti MinimiOpponens Digiti Minimi– Flexor Digiti MinimiFlexor Digiti Minimi– 3rd and 4thLumbricals3rd and 4thLumbricals– Dorsal InterosseiDorsal Interossei– Palmar InterosseiPalmar Interossei– Flexor Pollicis BrevisFlexor Pollicis Brevis– Adductor PollicisAdductor Pollicis

Physical AssessmentPhysical AssessmentKenneth NshiomKenneth Nshiom

Physical AssessmentPhysical Assessment

Inspection/ObservationInspection/Observation PalpationPalpation ROMROM Muscle StrenghtMuscle Strenght NeurovascularNeurovascular Special TestsSpecial Tests

ObservationObservation Posture and alignmentPosture and alignment Swelling/edema, ecchymosisSwelling/edema, ecchymosis Changes in skin, nails or hair (or Changes in skin, nails or hair (or

arm/hand)arm/hand) Contractures and other deformitiesContractures and other deformities Functional range of motion (& right vs. Functional range of motion (& right vs.

left UE)left UE) Observe the contours and take note of Observe the contours and take note of

abnormal prominences, atrophy, etcabnormal prominences, atrophy, etc

PalpationPalpation

Palpate the skin and feel the Palpate the skin and feel the temperature.temperature.

Palpate subcutaneous landmarksPalpate subcutaneous landmarks Palpate the muscles, joints, tendons, Palpate the muscles, joints, tendons,

nerves and ligaments noting areas of nerves and ligaments noting areas of tenderness.tenderness.

Palpate and feel the pulsesPalpate and feel the pulses

Range of MotionRange of Motion ShoulderShoulder ElbowElbow

– Flexion = 145-150°Flexion = 145-150°– Extension = 0° for men/0-15° for womenExtension = 0° for men/0-15° for women

ForearmForearm– Pronation = 70-80°Pronation = 70-80°– Supination = 80-90°Supination = 80-90°

Wrist Wrist – FlexionFlexion– ExtensionExtension– Ulnar deviationUlnar deviation– Radial deviationRadial deviation

Range of MotionRange of Motion Fingers Fingers

-flexion-flexion

-extension-extension

-abduction/adduction-abduction/adduction

Neuromuscular Neuromuscular Peripheral nerves = all of the nerves Peripheral nerves = all of the nerves

that lie outside of the brain and that lie outside of the brain and spinal cord spinal cord – Motor nervesMotor nerves– Sensory nervesSensory nerves

Injury causes loss of sensation, Injury causes loss of sensation, movement or bothmovement or both

Look for specific dermatome or Look for specific dermatome or myotome patterns if you think the myotome patterns if you think the injury is at the nerve rootinjury is at the nerve root

NB: Some cervical problems present NB: Some cervical problems present as UE problems, so do not forget to as UE problems, so do not forget to assess the C-Spineassess the C-Spine

StrengthStrength To test muscle strength, use the manual muscle To test muscle strength, use the manual muscle

testing grading system:testing grading system:– Grade 0 = no muscle contraction visible or palpableGrade 0 = no muscle contraction visible or palpable– Grade 1 = no movement but there is a flicker (or palpable) Grade 1 = no movement but there is a flicker (or palpable)

of muscle contractionof muscle contraction– Grade 2 = full range of motion with no gravity Grade 2 = full range of motion with no gravity – Grade 3 = full range of motion against gravity (no extra Grade 3 = full range of motion against gravity (no extra

resistance)resistance)– Grade 4 = full range of motion against gravity, with Grade 4 = full range of motion against gravity, with

moderate resistancemoderate resistance– Grade 5 = full range of motion against gravity, with Grade 5 = full range of motion against gravity, with

maximum resistancemaximum resistance

Remember that disuse, immobilization, and other Remember that disuse, immobilization, and other medical conditions can cause muscle weakness, medical conditions can cause muscle weakness, even when the nerve is intact. even when the nerve is intact.

Sensory TestingSensory Testing

Monofilaments (small fibres of different Monofilaments (small fibres of different sizes) or other fine pointed tools (pin, paper sizes) or other fine pointed tools (pin, paper clip etc.) clip etc.)

Cotton ball (moving light touch)Cotton ball (moving light touch)– The patient should not look at the injured area The patient should not look at the injured area

and then tell the therapist when they think the and then tell the therapist when they think the therapist is touching their skin with the pointed therapist is touching their skin with the pointed tool (E.g. “tell me when you feel me touch your tool (E.g. “tell me when you feel me touch your hand”). hand”).

Sensory testing should be done before use of Sensory testing should be done before use of heat, ice or splinting (potential for tissue heat, ice or splinting (potential for tissue damage)damage)

Vascular ExamVascular Exam

Peripheral pulsesPeripheral pulses Capillary refillCapillary refill CynosisCynosis

Special TestsSpecial Tests

Apprehension TestApprehension Test Crank TestCrank Test Speed TestSpeed Test Hawkins and Kennedy TestHawkins and Kennedy Test Neer TestNeer Test Full can and Empty can TestsFull can and Empty can Tests Finkelstein TestFinkelstein Test Tinel and Phalen Sign, Duran's TestTinel and Phalen Sign, Duran's Test

Specific ConditionsSpecific ConditionsMorag CrockerMorag Crocker

TendonitisTendonitis

Tendonitis Tendonitis = = Inflammation, swelling and Inflammation, swelling and irritation of a tendon (attaches muscle to irritation of a tendon (attaches muscle to bone); usually used to describe more acute bone); usually used to describe more acute tendon inflammation. tendon inflammation.

TenosynovitisTenosynovitis = = inflammation of the inflammation of the sheath (called synovium) sheath (called synovium) that surrounds a tendon.that surrounds a tendon.

Tendinopathy = term to Tendinopathy = term to describe problems with describe problems with either the tendon or the either the tendon or the tendon sheathtendon sheath

TendonitisTendonitis Cause:Cause:

– OveruseOveruse– Direct injury to tendonDirect injury to tendon– Rheumatic diseaseRheumatic disease– Infection (very rare)Infection (very rare)

Presentation:Presentation:– Tenderness with pressure on the tendonTenderness with pressure on the tendon– Pain with movementPain with movement– Stiffness after restStiffness after rest– Visible swelling and local warmth (may or Visible swelling and local warmth (may or

may not be present) may not be present)

TendonitisTendonitis Common areas are elbow (lateral Common areas are elbow (lateral

epicondylitis), biceps, wrist & thumb epicondylitis), biceps, wrist & thumb Treatment:Treatment:

– Rest (from aggravating activity)Rest (from aggravating activity)– IceIce– NSAID’s (topical or oral)NSAID’s (topical or oral)– Changing activities (avoid repetition & Changing activities (avoid repetition &

awkward positions)awkward positions)– Splinting (to assist with rest) Splinting (to assist with rest) – Gentle stretching (& muscle strengthening)Gentle stretching (& muscle strengthening)– Gradual return to activityGradual return to activity

DeQuervain’s TenosynovitisDeQuervain’s Tenosynovitis

Tendons affected:Tendons affected:– Abductor Pollicis Longus (APL)Abductor Pollicis Longus (APL)– Extensor Pollicis Longus (EPL)Extensor Pollicis Longus (EPL)

Radial side of wrist, over MCP & CMC jointsRadial side of wrist, over MCP & CMC joints move the thumb away from the plane of the handmove the thumb away from the plane of the hand

Tendon & sheath Tendon & sheath affected; irritationaffected; irritationand thickening inand thickening insheathsheath


Cause:Cause:– repetitive movements requiring pinching or repetitive movements requiring pinching or

grasping, particularly in combination with wrist grasping, particularly in combination with wrist movementmovement

Special tests:Special tests:– Finkelstein’s test = examining therapistFinkelstein’s test = examining therapist

grasps the thumb, applies traction, grasps the thumb, applies traction, and ulnarly deviates the hand sharply. and ulnarly deviates the hand sharply. A resulting sharp pain along the distal A resulting sharp pain along the distal radius, close to the wrist, is considered radius, close to the wrist, is considered a positive test. a positive test.

– Eichoff’s test =Eichoff’s test =


Treatment:Treatment:– Rest, ice, NSAID’s etc Rest, ice, NSAID’s etc – Splinting:Splinting:

Splint should Splint should prevent isolated thumb extension or prevent isolated thumb extension or radial abduction radial abduction

Trigger FingerTrigger Finger Tendons affected:Tendons affected:

– Flexor Digitorum Superficialis (FDS)Flexor Digitorum Superficialis (FDS)– Flexor Digitorum Profundus (FDP)Flexor Digitorum Profundus (FDP)– Volar (palm) surface of Volar (palm) surface of

the hand, where FDP & the hand, where FDP & FDS tendons enter the FDS tendons enter the flexor tendon sheath flexor tendon sheath

– Most commonly affects Most commonly affects the ring finger, just the ring finger, just proximal to MCP joint proximal to MCP joint

Trigger FingerTrigger Finger

Symptoms:Symptoms:– Causes clicking, catching (“triggering”) of Causes clicking, catching (“triggering”) of

fingers with joint flexionfingers with joint flexion– May also cause stiffness, pain, tenderness and May also cause stiffness, pain, tenderness and

swelling in the palm of the handswelling in the palm of the hand Causes:Causes:

– Repetitive or forceful grasping (finger flexion) Repetitive or forceful grasping (finger flexion) causes thickening of the flexor tendons (and/or causes thickening of the flexor tendons (and/or narrowing of the flexor tendon sheath)narrowing of the flexor tendon sheath)

– Tendon gets stuck when gliding through the Tendon gets stuck when gliding through the tendon sheath tendon sheath

Trigger FingerTrigger Finger

Treatment:Treatment:– Rest, ice, NSAID’s etc Rest, ice, NSAID’s etc – Splinting:Splinting:

Several types but splint must prevent some degree Several types but splint must prevent some degree of finger flexion, so that the thickened part of the of finger flexion, so that the thickened part of the tendon does not go through the sheath and catch tendon does not go through the sheath and catch

Safety PositionSafety Position

Safe position when hand must be Safe position when hand must be immobilizedimmobilized– Maintains length of soft tissues to prevent Maintains length of soft tissues to prevent

contracturecontracture– Prevents intrinsic muscles from being Prevents intrinsic muscles from being

overpowered by stronger flexor & extensor overpowered by stronger flexor & extensor musclesmuscles

Safety PositionSafety Position

Used for:Used for:– Traumatic injury/acute conditionTraumatic injury/acute condition– BurnsBurns– Crush injuryCrush injury– Inflammatory joint diseaseInflammatory joint disease– Prevent contracturePrevent contracture– Reduce pain & inflammationReduce pain & inflammation– Or any condition causing significant swelling, Or any condition causing significant swelling,

as this can cause “clawing” (MCP extension & as this can cause “clawing” (MCP extension & IP flexion)IP flexion)

Safety PositionSafety Position Position of joints:Position of joints:

– Wrist position = 30° extension Wrist position = 30° extension – MCP position = 70° flexionMCP position = 70° flexion– IP position = full extension (if possible)IP position = full extension (if possible)– Thumb position = full abductionThumb position = full abduction

Why?Why?– Intrinsic muscles flex MCP joints and extend IP jointsIntrinsic muscles flex MCP joints and extend IP joints– If intrinsic muscles weakened, If intrinsic muscles weakened,

they are overpowered by EDC and FDP/FDS, leading to MCP they are overpowered by EDC and FDP/FDS, leading to MCP joint hyperextension & IP joint flexionjoint hyperextension & IP joint flexion

– Will eventually cause contractureWill eventually cause contracture– With crush or burn, scar tissue will With crush or burn, scar tissue will

also contract as the hand healsalso contract as the hand heals

Nerve InjuriesNerve Injuries

Complete nerve laceration requires Complete nerve laceration requires surgical repair to restore innervation surgical repair to restore innervation – The body does try to repair itself by The body does try to repair itself by

sprouting new axons (part of the nerve) sprouting new axons (part of the nerve) from the injured nerve, which can from the injured nerve, which can eventually bridge the gap between the eventually bridge the gap between the cut ends of the nervecut ends of the nerve

Nerve damage (not completely cut or Nerve damage (not completely cut or crushed) can be repaired/regrowcrushed) can be repaired/regrow– Typically at a rate on 1-2 mm per day Typically at a rate on 1-2 mm per day

Nerve InjuriesNerve Injuries Goal of physiotherapy treatment is to Goal of physiotherapy treatment is to

prevent problems from developing during prevent problems from developing during the time that the patient does not have the time that the patient does not have sensation or full motor control:sensation or full motor control:– For lack of sensation, they must learn to use For lack of sensation, they must learn to use

visual observationvisual observation– Splints and passive movement exercises are Splints and passive movement exercises are

used to maintain tissue length (in the hope that used to maintain tissue length (in the hope that the patient eventually regains muscle the patient eventually regains muscle innervation) innervation)

– Splints also used to maintain function while the Splints also used to maintain function while the patient does not have proper muscle controlpatient does not have proper muscle control

As a nerve re-grows, altered sensation can As a nerve re-grows, altered sensation can be uncomfortable:be uncomfortable:– Graded desensitization exercises Graded desensitization exercises

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

Form of median nerve injuryForm of median nerve injury– Compression of median nerve as it Compression of median nerve as it

passes through the carpal tunnel passes through the carpal tunnel (created by curve of carpal bones (created by curve of carpal bones and carpal ligament)and carpal ligament)

Signs & symptoms:Signs & symptoms:– Numbness and tingling of the radial Numbness and tingling of the radial

3 ½ fingers3 ½ fingers– clumsiness, due to weakened musclesclumsiness, due to weakened muscles– Pain (or altered sensation) especially at Pain (or altered sensation) especially at

night night – Atrophy of thenar musclesAtrophy of thenar muscles


Causes:Causes:– Repetitive movements (ex. Typing, weeding/farming)Repetitive movements (ex. Typing, weeding/farming)– Vibrations (ex. tool use)Vibrations (ex. tool use)– Inflammation of the flexor tendon sheaths (ex. rheumatoid Inflammation of the flexor tendon sheaths (ex. rheumatoid

arthritis)arthritis)

Special tests:Special tests:– Durkan’s test: press with both thumbs over the Durkan’s test: press with both thumbs over the

carpal tunnel for 30 seconds.carpal tunnel for 30 seconds.– Phalen’s test: patient flexes own wrists for Phalen’s test: patient flexes own wrists for

about 60 seconds. about 60 seconds. – Tinel’s test: tap the median nerve over the volar carpal Tinel’s test: tap the median nerve over the volar carpal

tunnel tunnel


Treatment:Treatment:– Rest (from aggravating activities)Rest (from aggravating activities)– NSAID’sNSAID’s– Splinting in neutral wrist position Splinting in neutral wrist position

Nighttime and for aggravating activitiesNighttime and for aggravating activities

– Steroid injectionSteroid injection– Carpal tunnel release surgeryCarpal tunnel release surgery

Median Nerve InjuryMedian Nerve Injury Injury at distal forearm, wrist or hand:Injury at distal forearm, wrist or hand:

– Affects: thenar musclesAffects: thenar muscles– Lose: thumb abduction & oppositionLose: thumb abduction & opposition– Potential for adduction contracturePotential for adduction contracture

Splinting goals:Splinting goals:– Maintain thumb abduction & oppositionMaintain thumb abduction & opposition

Ulnar NerveUlnar Nerve The Ulnar nerve innervates the The Ulnar nerve innervates the

following muscles, in this order:following muscles, in this order:– Flexor Carpi Ulnaris (FCU)Flexor Carpi Ulnaris (FCU)– Flexor Digitorum Profundus (ring and small Flexor Digitorum Profundus (ring and small

fingers)fingers)

Deep Branch of Ulnar Nerve:Deep Branch of Ulnar Nerve:– Abductor Digiti MinimiAbductor Digiti Minimi– Opponens Digiti MinimiOpponens Digiti Minimi– Flexor Digiti MinimiFlexor Digiti Minimi– 3rd and 4thLumbricals3rd and 4thLumbricals– Dorsal InterosseiDorsal Interossei– Palmar InterosseiPalmar Interossei– Flexor Pollicis BrevisFlexor Pollicis Brevis– Adductor PollicisAdductor Pollicis

Ulnar Nerve PalsyUlnar Nerve Palsy Injury at level of distal forearm, wrist or hand:Injury at level of distal forearm, wrist or hand:

– Lose: intrinsic muscle power – dorsal interossei, palmar Lose: intrinsic muscle power – dorsal interossei, palmar interossei, lumbricals 3 & 4interossei, lumbricals 3 & 4

– Weak intrinsic muscles are overpowered by flexors (FDS, Weak intrinsic muscles are overpowered by flexors (FDS, FDP) & extensors (EDC), FDP) & extensors (EDC), causing clawing of little and ring causing clawing of little and ring fingersfingers

An injury higher up (level of humerus to proximal An injury higher up (level of humerus to proximal forearm) results in same clawing as above but to forearm) results in same clawing as above but to lesser degreelesser degree

Splints for Ulnar Nerve PalsySplints for Ulnar Nerve Palsy

Splinting goals:Splinting goals:– Resting hand/safety positionResting hand/safety position– As wrist movement not affected, no need to As wrist movement not affected, no need to

support wristsupport wrist

Radial NerveRadial Nerve The radial nerve innervates the following The radial nerve innervates the following

muscles, in this order:muscles, in this order:– TricepsTriceps– AnconeusAnconeus– BrachioradialisBrachioradialis– Extensor Carpi Radialis LongusExtensor Carpi Radialis Longus– Extensor Carpi Radias BrevisExtensor Carpi Radias Brevis– SupinatorSupinator

Posterior Interosseous Nerve (branch Posterior Interosseous Nerve (branch of radial nerve)of radial nerve)– Extensor Digitorum (Communis)Extensor Digitorum (Communis)– Extensor Digiti MinimiExtensor Digiti Minimi– Extensor Carpi UlnarisExtensor Carpi Ulnaris– Abductor Pollicis LongusAbductor Pollicis Longus– Extensor Pollicis LongusExtensor Pollicis Longus– Extensor Pollicis BrevisExtensor Pollicis Brevis– Extensor IndicisExtensor Indicis

Radial Nerve PalsyRadial Nerve Palsy Most commonly injured below level of Most commonly injured below level of

triceps muscle innervationtriceps muscle innervation Injury at level of middle humerus to middle Injury at level of middle humerus to middle

(to distal) forearm:(to distal) forearm:– Lose: wrist, finger & thumb extensionLose: wrist, finger & thumb extension– Loss of wrist extension results in hand weakness Loss of wrist extension results in hand weakness

(strongest grip requires slight wrist extension) (strongest grip requires slight wrist extension) and poor functional graspand poor functional grasp

Splinting goals:Splinting goals:– Dynamic splint to use tenodesis effect ORDynamic splint to use tenodesis effect OR– Splint to maintain wrist and finger extensionSplint to maintain wrist and finger extension

Splints for Radial Nerve PalsySplints for Radial Nerve Palsy

Brachial Plexus InjuryBrachial Plexus Injury

Shoulder ConditionsShoulder Conditions

StrokeStroke

CNS injuryCNS injury–HemorrhagicHemorrhagic–Ischemic Ischemic

Causes:Causes:–Loss of sensation (and/or)Loss of sensation (and/or)–Loss of motor control (and/or)Loss of motor control (and/or)–NeglectNeglect–Pain Pain

40% of stroke patients experience pain in the 40% of stroke patients experience pain in the affected side, within 6 months of stroke.affected side, within 6 months of stroke.

StrokeStroke Causes of pain:Causes of pain:

1.1. Complex Regional Pain Syndrome (CRPS)Complex Regional Pain Syndrome (CRPS)– Severe shoulder and hand pain plus a swollen hand Severe shoulder and hand pain plus a swollen hand – Usually develops approximately 1 month or more after Usually develops approximately 1 month or more after

strokestroke– Extremely sensitive handExtremely sensitive hand– Changes in nails and skin. Changes in nails and skin. – Causes unknown: Causes unknown:

Malfunctioning pain pathwaysMalfunctioning pain pathways Autonomic nervous system Autonomic nervous system Limited limb movementLimited limb movement

– Treatment is difficult: neuropathic pain meds & mobilize Treatment is difficult: neuropathic pain meds & mobilize limb earlylimb early

2.2. SpasticitySpasticity

3.3. Shoulder subluxationShoulder subluxation

SpasticitySpasticity

ArthritisArthritis

Glenohumeral jointGlenohumeral joint AC jointAC joint Thumb CMC jointThumb CMC joint OA of the IP jointsOA of the IP joints RA of the MP jointsRA of the MP joints GA of elbow and wristGA of elbow and wrist

ContracturesContractures

Documents

Upper Extremity Rehabilitation Workshop MBINGO BAPTIST HOSPITAL Kenneth Nshiom, PT/OCO Morag Crocker, OT November 29, 2014 Timothy Fanfon, PT