Hand and Upper Extremity

NBCOT Study Notes

Review Anatomy of Hand, Forearm, and
Upper Arm
 OT Evaluation of Hand and UE
• Establish rapport and review PMH and hx of current condition
• Establish occupational profile
• OBSERVE posture, spontaneous use of UE and hand, guarding, scarring, wounds, and skin condition.
• PALPATE gently, checking for pain, adhesions, edema, & use provocative nerve testing to elicit symptoms
and clarify injury.
• Specific testing
• ROM using goniometer
• Strength using MMT, dynamometer, and pinch gauge
• Edema using volumeter or centimeter tape
• Vascular: using observation of color, skin temp., and Allen’s test
• Sensation using Seimmes Weinstein monofilaments for nerve compression and two point discrimination for nerve
laceration and recovery.
• Coordination using a variety of tests including but not limited to O’Conner Dexterity Test, Nine Hole Peg Test,
Minnesota Rate of Manipulation, Purdue Pegboard, Jebsen-Taylor Hand Function Test, Crawfod Small Parts Dexterity
test.
• Interview Client to determine pain, splints, and functional use. Use ADL/I ADL checklist to uncover
dysfunction and set goals.
• Use QuickDASH to measure outcomes before and after intervention.
Hand Fractures
• Types of Fx
• Proximal fx is a fx to the metacarpals. E.g: Boxer’s fx (fx to 4th and 5th metacarpals).
• Carpal fx are fx to individual carpal bones
• Scaphoid fx are the most common and most missed carpal fx
• Lunate fx are associated with Keinbock’s disease
• Avulsion injuries occur when tendons separate from bone and insertion and remove
bone matter.
• Mallet finger is avulsion of the terminal tendon (you see flexion of DIP)  Tx splinted in full
extension for 6 wks.
• Boutonniere deformity is disruption of central slip of extensor tendon & creates flexion of the PIP
and hyperextension of the DIP  Tx includes splinting PIP in extension and isolated DIP exercises.
• Swan Neck deformity is injury to MCP, PIP, or DIP causing hyperextension of PIP and flexion of
DIP.  Tx includes splinting of PIP in slight flexion.
Fracture Healing
• Three Steps to Fx Healing
1. Inflammation– provides cellular activity needed for healing
2. Repair– forms callus for stabilization.
3. Remodeling– deposits bone

Complications of Hand Fx include:

• Misaligned fx, pain, decreased nutrition to area, decreased healing potential.
• Age and bone disease affect healing process.
• Safe time frame for movement vs. protection depends on fx type, stage in
healing process, and physician orders.
OT Evaluation of Hand Fx
• Visual exam and observation, client interview, and complete medical
history, past and current condition.
• Sensory assessments
• ROM using goniometer if client is able
• Strength using dynamometer or pinch gauge
• ADL/I ADL checklist
• QuickDASH
Hand Intervention
• Splinting based on Client and Condition.
• Orthotic fabrication can be used as prescribed by physician.
• Thermoplastic and casting orthoses are commonly used to support
healing structures.
• Modalities for pain relief include ultrasound, heat, cryotherapy, paraffin,
and transcutaneous electrical nerve stimulation
(TENS).
• Home Exercise Programs (HEP) for continued progress toward goals.
***MOST SEVERE COMPLICATION OF HAND FX IS COMPLEX REGIONAL
PAIN SYNDROME (CRPS)***
Wrist Fractures

•Types of Wrist Fx
• Colles Fx– fx of the distal radius with dorsal
displacement. *Most common wrist fx*
• Smith’s Fx– fx of distal radius with palmar
displacement.
• Bennet’s Fx- fx of the first metacarpal base.
Nerve Associations with Wrist Fractures
• Median Nerve Injury
• Carpal tunnel like symptoms
palmar numbness and first digit to
half of fourth digit.
• Generalized Weakness and Pain
• Ulnar Nerve Injury
• Ulnar Claw Deformity and
numbness of the ulnar side of the
hand and the fifth and half of the
fourth digits
• Generalized Weakness and Pain on
Ulnar Side of Hand.
Wrist Fracture Interventions

ROM is allowed in Orthotics are used to A HEP to increase Therapeutic exercises

early phases of healing protect extremity from progression toward may include:
and repair motion OR allow goals
protected motion. AROM with wrist extended
and fingers flexed
Blocking exercises
Tendon and nerve gliding
exercises
Strengthening exercises using
theraplast (theraputty)
Complications of Wrist Fracture

Carpal Tunnel Syndrome ***** Most primary and

may be caused by wrist severe complication of
fx if it compresses distal radius fx are
median nerve. CRPS*****
 • Radial head fx account for 33% of elbow fx caused by forceful
load through outstretched arm.
• Three types
• Type I (nondisplaced): can be treated with long arm sling.
• Type II (displaced with single fragment): non-operative tx with
immobilization for 2-3 weeks and early motion with medical
clearance.
• Type III (comminuted): needs surgery with immobilization and
Fractures of early motion within 1st week post-op as medically prescribed.

the Forearm
Fracture of Upper Arm
• Proximal humeral fx are the most common fx of the upper arm and
may involve the articular surface, greater/lesser tuberosity, or surgical
neck.
• Location
• Anatomical head
• Anatomical neck
• Anatomical shaft
Upper Arm Fracture
Intervention
• Humeral fracture brace orthosis can be worn for
support.
• ROM may begin as early as 2 weeks after
nonoperative fx as medically prescribed.
• A sling is used to immobilize when non-operative.
• ROM protocol with aggressive stretching can begin
4-6 weeks as prescribed by MD.
• Home management includes HEP which can
include sling for comfort and sleeping for first 6
weeks.
Complex Definition: pain
disproportionate to an
Symptoms:
 Allodynia
Regional injury that does/does not  Hyperalgia
occur due to sympathetic
Pain nervous system.
 Hyperpathia
 Edema
Syndrome Types:  Contractures
 Type I: caused by  Bluish or red shiny skin
noxious event (trauma).
 Abnormal sweating or hair
 Type II: caused by nerve growth
injury.  Muscle Spasms
 Decreased strength
 Decreased activity tolerance.
 Stellate or sympathetic block: injection of local
anesthetic into front of nech or lumbar region in back
to block pain

Intrathecal analgesic: injection of pain meds into spinal

cord.

CRPS:
Medical Removal of neuroma: surgery to remove thickened
nerve

Treatment
Installation of spinal cord stimulator: a small electrical
pulse generator is placed in the back to control pain

Installation of a peripheral nerve stimulator: electrodes

placed on the peripheral nerves to send electrical
impulses to control pain.
CRPS: Occupational Therapy Intervention
1. Gentle, pain-free AROM for short periods NO PROM OR PAINFUL TX.
2. Stress loading: weight bearing activities (scrubbing and carrying) within a small
range of movement for gradually increasing periods of time. These activities
“load” the affected joints or extremity. This, in turn, provides inhibitory
proprioceptive input to the nervous system, through the use of deep pressure.
3. Pain control  TENS, splinting (static and dynamic as tolerated), continuous
passive motion
4. Edema control elevation, massage, contrast bath, compression.
5. Densensitizing techniques
6. Blocked exercises; tendon gliding
7. Joint Protection; energy conservation.
Cumulative Trauma Disorder
Diagnoses include:
• Tendinitis
Definition: trauma to soft
• Nerve compression syndrome
tissue caused by repeated
• Myofascial pain
force AKA overuse • Cervical, thoracic, or lumbar osteoarthritis
syndrome or repetitive • Nerve root impingement
strain injury. • Thoracic outlet syndrome
• Rotator cuff tear
• Bursitis
• Epicondylitis
*IT IS A MECHANISM OF • Cubital tunnel syndrome
INJURY; NOT A DIAGNOSIS. • Carpal tunnel syndrome
• De Quervain syndrome.
Cumulative Trauma Disorder (Cont.)
Work-Related Risk Factors: Symptoms:
 Repetition  Muscle fatigue
High force Pain
Direct Pressure Chronic inflammation
Vibration Sensory impairment
Cold environment Decreased ability to work
Poor posture
Female gender
Prolonged static position
Cumulative Trauma Disorder: Grades
• Grade I: pain after activity resolves quickly
• Grade II: pain during activity resolves when activity stops
• Grade III: pain persists after activity; affects work productivity;
objective weakness and sensory loss
• Grade IV: use of extremity results in pain up to 75% of the time
work is limited
• Grade V: Unrelenting pain unable to work
Cumulative Trauma Disorder: OT
Intervention
I. Acute Phase: Reduce inflammation and III. Return to Work
pain through
• Static splinting
• Assessment of job site, tools used,
• Ice and body positioning
• Contrast baths • Therapy using work simulator, weight
• Ultrasound phonophoresis, iontophoresis well, elastic bands, putty, functional
• High-voltage electric and interferential activities, and strengthening activities.
stimulation
II. Sub-Acute Phase: Slow stretching, • Functional Capacity Eval
myofascial release, progressive resistive • Work Hardening
exercises, proper body mechanics, education
on identifying triggers and returning to acute • *see return to work section in AOTA
phase with flare-ups, static splint during PDFs*
painful activities
Extensor Tendon Zones
Finger extensor zones:
Zone I: DIP joint
Zone II: Middle phalanx
Zone III: PIP joint
Zone IV: Proximal phalanx
Zone V: MCP joint
Zone VI: metacarpal phalangeal
bone
Zone VII: carpal bones and wrist
Thumb extensor zones:
Zone I: IP joint
Zone II: proximal phalanx
Zone III: MCP joint
Zone IV: 1st metacarpal
Zone V: wrist under thumb
 • Exercise promotes tendon • Tendon Glides to
excursion and prevents promote excursion
adhesions. and prevent
• Modalities use only
Intervention when cleared by MD:
adhesions.
for Extensor • Heat to prepare tissue • ROM
Tendon for motion • Strengthening NOT
• NMES to promote initiated until late
Injuries tendon excursion and phase  8-12 weeks
activation
post-op.
• HEP to ensure safety and
progression toward goals.
Flexor Tendons
•Zone I: fingertip to center portion of middle
phalanx
•Zone II: center portion of middle phalanx to distal
palmar crease AKA “No Man’s Land”
•Zone III: distal palmar crease to the transverse
carpal ligament.
•Zone IV: overlies the transverse carpal ligament
•Zone V: extends beyond level of wrist.
 Nerve involvement, usually laceration is
common because mechanism by which
tendons are injured.

Complication Edema must be therapeutically controlled

to maintain motion, reduce pain & joint
s of Flexor stiffness.

Tendon
Injuries Pain is common at injury site

ADL dysfunction measured by checklist

Protocols
• Duran Protocol: Early passive
ROM in splint
Kleinert
Protocol
• Involves active extension
of digits with passive
flexion via traction,
usually with rubber band
from finger to forearm
client may perform active
extension.
Other Protocols
• Early Active Motion Protocol
begins within days of surgery to
prevent adhesions and promote
tendon gliding and excursion.
• Immobilization Protocol is
advisable only for patients who
are unable to care for
themselves or do not have the
cognitive capacity to ensure
safety post-op. Sometimes used
with children to prevent repair
rupture.
Interventions for Flexor Tendon Injury
• Modalities • HEP
• Heat to gradually prepare tissues • Tendon Glides
for motion
• NMES to promote tendon • ROM
excursion and activation. • Strengthening 8-12 week post
• Only use modalities as prescribed op.
by MD.
• If client cannot follow protocol
extremity is casted in protected
position for 6 weeks.
• Dorsal Block Splint: Wrist 20-30 degree flexion
MCP 50-70 degree flexion
IP full extension
• Early active motion protocol begins within days of surgery
• 0-4 weeks completed duran and Kleinert protocols
• Dorsal Block Splint removed for exercises after week 4 if medically cleared.
• 4-6 weeks can begin tendon gliding with splint off
• After 6 weeks can remove splint and leave it off. NO RESISTIVE EXERCISES OR
STRENGTHENING
• 8-12 weeks post op: can begin gradual strengthening.
Nerve Injuries and
Syndromes
Radial Nerve Injury

• Symptoms: posture of hand is “wrist drop.”

Possible lack of finger and thumb extension.
• Non-operative treatment
• Wrist cock-up splint with or without dynamic
finger and thumb extension assist
• AROM
• Isotonic strengthening exercises upon muscle
reinnervation.
• Operative treatment:
• Static wrist extension splint 30 degrees
• After 4 weeks adjust splint to 10-20 degrees
extension.
 Radial Tunnel Syndrome
• Entrapment of the radial nerve in an area extending
from the radial head to the supinator muscle
• Symptoms: burning pain in lateral forearm
• Non operative tx:
• Long arm splint elbow flex, forearm supinated, wrist
neutral
• Pain management: TENS or massage
• Pain free ROM, nerve glides
• Activity mods to avoid forceful wrist extension and
supination.
• Operative Tx:
• Long arm splint, elbow flexed, forearm supinated, wrist
neutral for 2 weeks
• Wrist cock up for 2 more weeks
• Passive and active pronation/supination
• Hand strengthening at 3 weeks
• Resistive exercises at 6 weeks
Anterior Interosseous Syndrome
• Compression to anterior
interosseous nerve
• Results in motor loss involving
the flexor digitorum longus,
profundus to the index finger,
and pronator teres.
 Pronator syndrome
• Entrapment of the proximal median nerve between the heads
of the pronator muscles.
• Symptoms: deep pain proximal forearm with activity.
• Non operative tx:
• Splint elbow 90-100 degrees flexion, forearm neutral
• TENS for pain. Gentle prolonged stretching supination and
elbow, wrist, and finger extension.
• Activity mod to avoid repetitive forearm rotation with
resistance and prolonged elbow flexion.
• Operative tx:
• Half cast
• AROM all UE joints while in cast
• Muscle strengthening after 1 week.
• Full AROM by 8 weeks.
Median Nerve Injury

• Causes Ape Hand Deformity

• Symptoms: Ape hand, sensory loss in index
middle, and radial side of ring finger, loss of pinch,
thumb opposition, index finger MCP and PIP
flexion, and decreased pronation.
• Non op tx: static thenar spacer splint
• Operative tx:
• Dorsal block splint for 4-6 weeks AROM/PROM
in splint; tendon gliding, scar massage
• After 6 weeks, discontinue splint and begin
strengthening.
Double Crush Syndrome
• Occurs when a peripheral nerve
is entrapped in more than one
location
• Symptoms: intermittent diffuse
arm pain with paresthesia (pins
and needles) with specific
posturing.
• Non-operative treatment:
• Treat according to each nerve
injury
• Avoid movements or posture that
aggravate injury
• Nerve gliding
• Exercises for scapular stability
• Core strengthening.
Carpal Tunnel Syndrome
• Entrapment of median nerve in carpal tunnel.
• *Most common nerve compression injury of the UE*
• Causes
• Tenosynovitis,
• Cumulative Trauma Disorder
• Fluid retention from pregnancy or endocrine malfunctions.
• Ganglions, tumors
• Diabetes
• RA
• Trauma  wrist fx or lunate dislocation.
Carpal Tunnel Syndrome Impairments
• Sensory impairment numbness, tingling in thumb, index, and middle
fingers especially at night.
• Motor impairments include
• Fine motor impairments
• Atrophy of adductor pollicis
Carpal Tunnel Syndrome
Provocative Tests
• Tinel’s Sign: tap on median nerve at wrist to
elicit symptoms
• Phalen’s sign: holding wrist in full flexion for 1
minute to elicit changes in sensation
• Moberg Pick Up Test: timed test involving
picking up, holding, manipulating, and
identifying small objects. Used in cognitively
impaired adults and children to determine
median nerve function.
• Semmes-Weinstein Monofilament: used for
sensory testing
Carpal Tunnel OT Intervention
• Non-operative Treatment:
• A carpal tunnel splint or wrist cock-up splint at 0-
10 extension to relieve pressure from medial
nerve and control edema.
• Prefab can be used if it is adjustable.
• Nerve and tendon glides
• Activity modifications including ergonomic
handles, gel pads, pads on handles
• Client education on avoidance of posture and
positions that aggravate condition (wrist flexion
for long periods).
• Ergonomic keyboard if applicable
• Postural retraining and proximal conditioning.
Carpal Tunnel OT Intervention
• Operative Treatment:
• Surgical treatment is traditional open carpal tunnel release surgery or
endoscopic release. Some clients may not need therapy post op.
• Wound care and scar mobilization for more complex cases.
• Pain management is use of gel pads on scar
• Pain on either side of surgical release= pillar pain
• Splinting is provided ONLY to clients who sleep with wrist flexed or will engage
in too much activity too soon (e.g. returning to work)
• AROM of wrist, thumb and fingers begins 1-2 post op.
• Strengthening in 3-6 weeks.
Cubital Tunnel Syndrome
• Proximal ulnar nerve compression at the elbow between the medial
epicondyle and the olecranon process. This is the second most common
nerve compression injury of the UE.
• Causes:
• Fracture or dislocation of elbow
• Osteoarthritis
• Rheumatoid Arthritis
• Diabetes
• Alcohol Abuse
• Tourniquets
• Assembly line work
 Cubital Tunnel
Syndrome Impairments
• Sensory: decreased in little
finger and ulnar half of ring
finger.
• Motor: decreased grip and pinch
strength due to weak interossei,
adductor pollicus and flexor carpi
ulnaris muscles.
Cubital tunnel
Provocative Testing
• Tinel’s sign: tap over cubital tunnel to
elicit syndrome
• Froment’s sign: flexion of IP of thumb
when doing lateral pinch
• Wartenberg’s sign: fifth finger held
abducted from fourth.
• Elbow flexion test: holding the elbow in
flexion for 5 min with wrist neutral to
elicit symptoms.
Cubital Tunnel OT Intervention
• Non-operative treatment:
• Splint: Elbow in flexion 30-60 for 3 weeks.
• Ulnar nerve glides
• Pain and edema control
• Proximal conditioning
• Ergonomic and posture training.
Cubital Tunnel OT Intervention
• Operative Treament:
1. Phase One: Protection Phase = 0-3 weeks
• Splint elbow at 70-90 degrees flexion
• Wound care and edema control
• Pain management
• AROM of uninvolved joints
• Teach one-handed techniques.
2. Phase Two: Active Phase = 3+ weeks
• Discontinue splint and add elbow ROM in pronation first then supination; add wrist
motion with elbow flexed then extended
• Ulnar nerve gliding
• Desensitization techniques.
De Quervain Syndrome
• Caused by cumulative microtrauma resulting in tenosynovitis of the thumb muscle tendon
unit abductor pollicis longus, extensor pollicis brevis, and the tendons in the first dorsal
compartment of the wrist.
• Causes:
• Forceful repetitive thumb abduction with wirst ulnar deviation
• CMC osteoarthritis
• Scaphoid fx
• Intersection syndrome
• Radial nerve neuritis.
• High risk individuals include:
• Women ages 35-55
• Women in late pregnancy
• Mothers with young children
• People who keyboard, piano, knitting, needlepoint, racket sport.
De Quervain Syndrome
OT Intervention
• Non-operative treatment:
• Medical tx = corticosteroid injections
• Forearm based thumb spica splint
with wrist in neutral and thumb
radially abducted for 3 WEEKS.
• Activity modification and avoidance of
pinch
• After 3 WEEKS progress to soft
splint and isometric exercises
• Computer ergonomic edu.
• Strengthening exercises.
De Quervain Syndrome OT Intervention
• Operative Treatment:
• Medical Tx: Surgical release of first dorsal compartment
• Forearm based spica splint with wrist at 20 degree extension and thumb
radically abducted for 3 WEEKS.
• Gentle ROM and tendon gliding
• Grip and pinch strengthening at 2 weeks.
• Scar management and desensitization techniques
Claw Hand Deformity
• Distal ulnar nerve compression or lesion at the wrist.
• Causes
• Ganglion
• Neuritis
• Arthritis
• Carpal fractures at Guyon’s canal.
Claw Hand Deformity
Impairments
• Sensory: in the little finger and ulnar side of the
ring finger plus the palmar ulnar hand if sensory
loss is on the dorsal side of the hand the injury is
proximal to the Guyon’s canal.
• Motor: Loss of intrinsic ulnar innervated muscles
(interossei and adductor pollicis, flexor and
abductor digiti minimi) and resulting motor loss
result in deformity in which MCPs hyperextend
and the IP’s flex, hand arches are flattened, and
pinch strength is lost.
Evaluation:
Provocative Tests for
Claw Hand
• Froment’s sign
• Wartenberg’s
• Jeanne’s sign: hyper extension of thumb
MCP.
• Semmes Weinstein monofilament used
to test loss of sensation.
Claw Hand Deformity OT Intervention
• Non-operative treatment:
• An ulnar nerve palsy or anticlaw splint is used and dynamic PIP extension
assist may be added if contractures are present.
• Padded antivibration glove during activity
• activity modification including ergonomic handles, gel pads, or padding on
handles of vibratory equipment (lawnmower)
• Client edu about avoidance of postures and activity that aggravate condition
such as ulnar deviation with wrist flexion.
Claw Hand Deformity OT Intervention
• Post-operative tx:
• Bulky Dressing for 3-10 days
• Dorsal Blocking Splint maintaining the wrist at 20-30 degrees flexion and MCP block to 45
degrees extension to protect nerve repair. Splint adjusted 3-6 for wrist to neutral. Stop splint
after 6 weeks. Pre op splint until muscle function returns.
• Wound care and scar mobilization.
• AROM of wrist and hand being at 6 weeks; resume ADLs, muscle strengthening and work
conditioning
• Sensory re-edu 10-12 weeks once protective sensation returns
• Tendon transfer done is nerve hasn’t regenerated after 1 year.
• Post-op
• Electromyography biofeedback
• NMES
• Edu about avoiding substitution of movement patterns.
Digital stenosing tenosynovitis
AKA trigger finger
• Occurs when with sheath or nodules near A1
pulley.
• Treatment includes splinting at the MCP joint
at 0 degrees for 3-6 weeks OR surgically
releasing A1 pulley.
Sensory Re-education after Nerve Injury
Protective reeducation educates clients to visually compensate for sensory loss and to avoid
working with machinery and temperatures below 60 degrees.

Discriminative reeducation uses motivation and repetition in a vision-tactile matching process

in which clients ID objects with and without vision.

Sensory recovery begins with pain perception and progresses to vibration of 30 cycles per
second, moving touch, and constant touch.

Desensitization is a process of applying different textures and tactile stimulation to reeducate

the nervous system so clients can tolerate sensations during functional use of UE.