Transcript Orthopedic limitations and Hand Injuries

Ch 41 and 42 in Trombly
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Orthopedic Conditions
 Caused by injuries, diseases and deformities of
joints and related structures
 Caused by trauma, cumulative trauma, or
congenital anomaly
 Rising incidence related to many competitive and
recreational sports as well as increase in the elderly
population and a concurrent home injuries and
falls
 Prevention= jt protection, positioning
 Remediation= ROM, strength, nerve re-education
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Evaluation in OT
 Assessment of roles
 Controlled ROM w/in precautions
 Non-resistive activities for 1st 4-6 wks.
 Orthopedic protocol for specific condition/
specific physician
 ID tasks that client is having difficulty with
 Measure ROM early, strength later
 Note skin color, sensation, pain level, edema
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Intervention for fractures
 Medical Treatment
 Mobilization vs. Resting
 Splint, Cast, Brace,
 ORIF vs. External Fixator
 Early mobility when possible
 PROM, AAROM, AROM
 Splinting
 Scar tissue and wound management
 Connective tissue work
 Passive stretch, dynamic splinting, myofascial release
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Shoulder Fx
 Isometric exercises while immobilized moving toward
isotonic ex
 Pain control
 Wall climbing
 Codmans exercises
 Scapular mobilization
 Jt. Replacements- AAROM daily, skateboard, Pulley
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Elbow Fx
 Complication: Volkmann’s ischemia
 Pale, bluish skin
 Absence of radial pulse
 Decreased hand sensation
 Splinting 90-100 degrees of flexion
 Full ROM not always achieved
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Forearm fractures
 Radius or ulna short cast
 AROM as soon as possible per MD protocol
 Manage edema, pain, nerve damage
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Hip fractures
 Common in Older adults
 ORIF (femur fx) vs. THR
 Wt. Bearing status
 NWB, TTWB, PWB, 50% WB, FWB
 Precautions:
 No extremes in flexion, adduction, IR/ER
 Sleep w/abduction wedge
 Use LH equip for reaching,dressing, bathing
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Low Back Pain
 Acute pain- proportional to physical findings
 Chronic pain- lasts for months/ years
 Results in personality changes
 Disproportionate to physical problem
 Goal to get people back to function, manage pain,
reduce illness behavior, reduce disuse
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Intervention for LBP
 Positioning
 Adaptive equipment
 Reconditioning
 Strengthening
 Environmental modification
 Body mechanics
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Body mechanics
 Neutral pelvis, prop foot
 Bend at the knees to lift, do half-kneel, squat or golfer’s
lift
 Avoid twisting, excessive bending or reaching
 Sit to work if possible
 Balance load
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Ch 42 in Trombly
Hand Therapy
 Originated during WWII
 Is done by OT/PT, nurses, orthopedics, Workman’s
comp and voc specialists, PA
 CHT-Certified Hand Therapist- Must have 5 years
working with hands. Sit for national exam by ASHT
 Though tx could focus on specific anatomic structures,
the function is what’s important
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Psychosocial factors
 Adaptive responses
 Emotional factors
 Support systems
 Motivation
 Type of injury (e.g. traumatic vs. repetitive)
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Hand Therapy Concepts
 Tissue healing
 Antideformity positioning
 Attend to Pain
 PROM can be injurious
 Judicious use of heat & cold
 Isolated exercise vs. purposeful activity vs. therapeutic
occupation
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Tissue Healing
 Sequence: Inflammation, fibroplasia, maturation and
remodeling
 Vasoconstriction to vasodilation
 WBC’s promote phagocytes removing dead tissue or
foreign body
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Interventions during tissue healing
phases
 Inflammation phase: rest is advised, edema
management, pain control and positioning
 Fibroplasia phase- starts at 4 days to 6 weeks.
Formation of scar tissue. Begin AROM, Splint
 Maturation phase-may last for years. Gentle
resistive activity, avoid inflammation, dynamic or
static splinting, scar tissue management
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Antideformity Positioning
 Position to avoid: Wrist flexed, MP jts stiffen in
hyperextension and DIP’s flexed, adducted thumb
 Called the Intrinsic Plus position
 Wrist in neutral or extension
 MP’s in Flexion
 IP’s in Extension
 Allows collateral ligaments at the MP joints and
the volar plate at the IP joints to maintain their
lengths
 Flexor and extensor tendon repair not conducive to
these positions
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Attend to Pain
 Myth of No-Pain, No Gain
 Pain induced by therapy can cause CRPS or Complex
regional pain syndrome
 Watch for pt’s body language, face,
 Use visual and verbal analog scales
 Change treatment to a “hand’s off approach”
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PROM
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Can be injurious to delicate tissues in the hand
Can incite inflammation and trigger CRPS
Gentle and Pain-Free
Low load-long duration splinting may be more
effective than PROM
 Can cause inflammation if PROM is done after heat
application
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Judicious use of heat
 Do not use on inflamed or edematous extremities
 May degrade collagen and contribute to
microscopic tears
 Heat can have a rebound effect, with stiffening
following its use
 Use aerobic exercise to warm up tissue
 Elevate the extremity in conjunction with heat
 Monitor frequently for signs of inflammation
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Exercise vs. Occupation
 Isolate for discrete components that are involved
 Integrate pt directed goals into hand therapy
 Encourage use of UE in ADL’s
 Purposeful activity- not only exercise, produces
coordinated movement patterns in multiple
planes, leads to better movement quality
 Occupational as means-get benefit of improved
quality of movement & return to occupation
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Evaluation in Hand Therapy
 History
 Injury, work and leisure interests, roles, Physician
recommendations and precautions
 Pain Acute vs. chronic
 Intensity
 Type of pain
 Myofascial/ Trigger points vs. joint
 Analogs, draw on a body
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Evaluation (continued)
 Physical Exam
 Observe, Cervical screening, posture, guarding, atrophy,
edema
 Wounds
 Universal precautions
 Stage, type, (red, yellow, black)
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Red-revascularizing
Yellow-exuidate- needs cleansing and debreidment
Black-necrotic- needs debriedment
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Evaluation (continued)
 Types of Debridement
 Chemical (e.g. peroxide)
 Manual (suture scissors, scrubbing)
 Surgical (scrubbing under anesthesia (burns)
 Scar Assessment
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Hypertrophic
Tenodermodesis
Contracture- wound or scar crossing a joint
Mature- flat and softer and has neutral color, does not
blanch to touch
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Evaluation
 Vascular Assessment
 Cyanosis, erythemia, pallor, gangrene, grayish,
blanching within 2 seconds of release of pressure
 Edema
 Circumferential measurement
 Volumeter
 Range of Motion
 PROM, ROM
 TAM or TROM
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Evaluation (continued)
 Grip and Pinch
 10-15% difference in strength between dominant and
non-dominant hands
 No relationship w/increase and increase function
 Bell shaped curve
 MMT
 Sensibility
 Dexterity and Hand function
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Jebsen
MMRT
Box and Block
Purdue Pegboard
Nine Hole
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Clinical Decision Making
 ADL and functional Implications
 Goals
 Quality of movement
 Structures
 Joint vs. musculotendinous
 Lag vs. contracture (extensor lag in spite of PROM
available)
 Intrinsic vs. extrinsic tightness (PROM of DIP vs. PIP)
 Tightness of extrinsic extensors or extrinsic flexors
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Interventions
 Edema
 Elevation
 Compression
 Manual edema mobilization (different than retrograde
massage)
 Lymphedema pumps
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Intervention (continued)
 Scar management
 Compression
 Silicone gel
 Manual edema mobilization vs. friction massage
 Tendon Gliding exercises (figure 42.3)
 Blocking exercises
 Place and Hold
 End feel and Splinting
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Interventions
 Splinting
 Blocking
 Buddy strapping
 Dynamic vs. static
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Common conditions
 Stiff hand
 Result of fracture
 Decrease PROM/AROM if painful or swollen
 Static splinting during acute inflammatory phase,
dynamic when joint has a soft end feel
 Tendonitis
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More than half of occupational illnesses
Tx= RICE (rest, ice, compression, elevation)
Splinting @ night
Gradual mobilization balanced w/rest
Prevent reinjury though education
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Types of Tendonitis
 Lateral Epicondylitis
 Proximal conditioning and scapular stabilizing
 Built up handles
 Splinting
 Counterforce strap-reduces load on the tendon
 Medial epicondylitis- Golfers elbow
 Involves the FCR
 Proximal conditioning, avoid end ranges, built up
handles, and splinting as well as counterforce strap
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Types of Tendonitis
 DeQuervains Disease
 APL and EPB at first dorsal compartment
 Avoid wrist deviation (esp w/pinching)
 Forearm thumb spica
 Others (less common)
 Intersection syndrome
 EPL tendonitis
 ECU, FCR, FCU tendonitis
 Flexor Tendonsynovitis or trigger finger
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Nerve Injuries
 Median nerve compression- CTS
 Steroid injection
 Night splinting in neutral
 Exercises for tendon gliding
 Aerobic exercises
 Proximal conditioning
 Ergonomic modification
 Postural training
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Nerve Injuries (continued)
 Cubital Tunnel Syndrome
 Between the medial epicondyle and the olecranon
 Ulnar nerve entrapment
 Proximal and medial forearm pain
 Radial Nerve Compression
 Purely motor, inability to ext MP jts.
 Can be entrapped at the supinator muscle
 Nerve laceration
 Surgical intervention w/protective splinting
 Sensory re-ed
 Reduction/prevention of a neuroma
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Types of nerve injuries
 Low median- OP and APB of thumb
 Hi Median- FDP to IF and MF and DGS to all digits
and pronation
 Low ulnar- intrinsic loss= claw hand
 Hi Ulnar- FDP of RF and SF and FDU
 Low radial-MP ext is affected
 Hi Radial-supinator, wrist and finger ext out
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Fractures
 Distal Radius fx- most common
 Scaphoid- FOOSH, may accompany EPL and EPB
stretching and ligamentous injury. Avascular necrosis
is a risk.
 Non Articular Hand Fx
 Distal phalanx, Middle, Proximal, Metacarpal Fx
(Fixation with wires, screws)
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Collateral Ligament Injury
 PIP joint sprain
 Skier Thumb-collateral ligament of the thumb
w/acute radial deviation
 Flexor Tendon Injury
 Zones of the hand
 Passive Flexion-active extension protocol
 Chow advocates early motion
 Extensor Tendon Injury
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Less common
7 zones in the dorsum of the hand
In zones 3 and 4 can lead to boutonniere deformity
Tenolysis- surgical procedure to release tendon adhesion.
Therapy begins a few hours after surgery
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Complex Regional Pain Syndrome
 CRPS- used to be called RSD
 Type 1- follows noxious event, pain, edema, abnormal skin
color, pseudomotor activity
 Type 2-develops after a nerve injury
 Pain is disproportionate to the injury
 Four cardinal symptoms
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Pain, swelling, stiffness, discoloration
 Secondary symptoms
 Osseous demineralization
 Sudomotor and temperature changes
 Trophic changes
 Vasomotor instability
 Palmar fascitis
 Pilomotor activity
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Management of CRPS
 Management of pain through medications,
sympathetic blocks, modalities
 Vaso motor challenge through stress loading
(scrubbing)
 change positions, temperature biofeedback, contrast,
vibration, desensitization, water aerobics
 Patient Directed therapy
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Arthritis
 Osteoarthritis or DJD
 Heberden’s nodes (@ DIP)
 Bouchard’s nodes at the PIP
 Thumb CMC arthroplasty is common
 TX includes splinting, pain mgmt, jt. Prot.
 Rheumatoid (a systemic disease)
 Tx reduce inflammation
 Jt. Protection
 Splinting,
 Energy Conservation
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