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TMPOTStudyGuideUEInjuryInterventionsandOrthoticManagement.pdf

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TMPOT'S

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UE INJURY, INTERVENTIONS & ORTHOTIC MANAGEMENT

All of the information on TMPOT's Study Guide & PDF's is referenced using reliable resources. Take all steps necessary to ascertain that information you receive from TMPOT is correct and has been verified by checking references.

The anti-deformity (intrinsic-plus or safe position) position is typically recommended after hand injuries unless it is contraindicated by the diagnosis.

Some burn or crush injuries to the hand may not tolerate anti-deformity position and may warrant a functional position.

The functional position (also named mid-joint position) is not the same as the anti-deformity position. The functional position (mid-joint) actually places the hand in a resting or neutral position. Allows “rest” to digital joints affected by arthritis, to position digits post stroke, for contractures of burned hands and to control edema of traumatic hand injuries.

Our goal is to promote a functional hand as well as reduce any restrictions that may impact function. Wrist will be positioned in extension up to 30 degrees.

This is considered a functional position and facilitates a stronger grip. Flexion of the wrist decreases grip.

Metacarpal Joints (MCP's/MP's) will be positioned in flexion 50-80 degrees MP flexion allows us to pick up things and to functionally grasp or use our hand. The primary responsibility of the lumbricals is to flex the MCP’s. Maintaining the MCP joints in flexion helps prevent contracture of the collateral ligaments and volar plates. Shortening of the collateral ligaments and contraction/adherence of the volar plate results in limited MP flexion and loss of functional grasp patterns.

Interphalangeal Joints (DIP &PIP) will be fully extended or neutral. Lumbricals and interossei produces flexion of the MCP's and extension of the IP’s

The interossei and lumbricals allows a person to put their hand in the

Thumb should be positioned in palmar or radial abduction or opposition. Intrinsic Plus/Anti Deformity/Safe Position (image 1.1): is considered an optimal position; placing the hand in wrist extension, MP flexion, IP extension, and thumb abduction.

This position maintains the length of the collateral ligaments and volar plates which are vulnerable to shortening with injury and swelling. During swelling, the hand will go into a predictable, deforming posture involving wrist flexion, MP hyperextension, IP’s in flexion and the thumb adducted which is named 'claw hand' or 'intrinsic minus'.

It is important to understand optimal positioning of the upper extremity and the complex anatomy. Utilize your Kinesiology textbooks to learn about upper extremity function and movement.

Important Facts:

Optimal Positioning of the Hand & Wrist:

which contribute to precise finger movements required for coordination.

intrinsic plus position.

Upper Extremity Injuries Optimal Positioning and a Functional Grasp

Image 1.1

Bulky Dressings are applied at the time of surgery to change the tissue pressure. Consists of appropriate wound care dressing, fluffy gauze sponges, and rolled-on gauze. Elevation of the hand above the heart by placing pillows so that the elbow is above the shoulder, and the hand is above the elbow and wrist. *Extreme elevation of the right arm must be avoided in stroke clients with right-sided heart weakness. Cold packs cause vasoconstriction and reduces the outflow of fluid in the acute stage.

Contraindicated for vascular and tissue ischemia reasons or diseases such as Raynauld’s. Always place a dry towel between the skin and the cold pack.

Retrograde Massage with elevation is the best. Pressure is kept light to avoid damaging lymphatic structures.

Compression can be in the form of an elastic glove, Coban, lightly spiral-layered on a digit, or low-stretch finger bandage wraps.

Make sure it is not too tight make sure it cannot roll down which can cause distal swelling. High Voltage Pulsed Current (HVPC) is a frequently used modality to reduce acute edema. Elastic Taping (similar to the original Kinesio Tex tape) reduces edema because the skin is pulled in the opposite direction putting a stretch on the initial lymphatic structures ultimately creating a pull, increasing space, and increasing lymph and fluid flow. Manual Edema Mobilization is shown to be appropriate in the acute stage.

Contraindicated for cardiac, pulmonary, kidney disease. Exercise involving proximal trunk and shoulder motion when balanced with rest of involved structures is excellent.

Limited active motion of uninvolved areas should be included.

Contrast Baths is performed by having the client immerse the hand in warm water for 3 minutes and then in cold water for 1 minute. Repeat four times, ending on cold. *currently there is no research available to support this practice.

Temperatures for contrast baths should be set between 71.6° F (22° C) and 98.6° F (37° C). Electrical Modalities such as high-voltage pulse current (HVPC) but further study is needed. Thermal Modalities will increase lymph flow. Proximal MEM routine while the hot packs are on the extremity, followed by proximal to distal exercise after removal of the hot packs creates the negative pressure vacuum to absorb and move the lymph from the area. A Fluidotherapy machine (at 98° F (36.6° C) to 100° F (37.7° C) will accomplish the same benefit.

Therapists are recommended to keep heat to tissue at body temperature or just slightly above. Pneumatic Pump is used for post trauma/surgery chronic edema such as a massive crush injury to the entire arm.

Pressures should never be greater than 40 mm Hg. A low-stretch bandaging or garment system is applied to the extremity after using the pneumatic pump.

Several techniques can be used to reduce excessive edema. Reducing edema is almost always the first priority. Address edema and the client will gain motion. Reduction Techniques for Acute Edema:

Reduction Techniques for Subacute and Chronic Edema:

Upper Extremity Injuries Edema Management Techniques

Elastic Taping. See the Reduction Techniques for Acute Edema section. Myofascial Release entails sustaining a very light gentle pressure on soft tissue resulting in elongation or softening of the fascia and its ground substances.

Formal coursework is needed before doing the technique. Exercise should start at the trunk followed by shoulder and elbow exercise (if not contraindicated). Next, exercise is completed at the wrist and then at the hand/fingers. Low-Stretch Bandages, Gloves, Massage, and Chip Bags with light compression. Manual Edema Mobilization is used in treatment for acute and persistent subacute edema by decongesting the most proximal edema and moving that edema proximally which creates a space into which the more distal edema can move by means of a proximal negative pressure vacuum.

MEM is a modification of manual lymphatic drainage (MLD) techniques. MEM can be combined with other edema reduction techniques, but it should be done before those techniques are performed. More traditional edema reduction techniques will be more effective after MEM because then there is a space cleared to which the edema can be moved proximally. MEM is a treatment for clients with an overloaded but intact lymphatic system. Contraindicated if infection, a blood clot, or cancer is present; over areas of inflammation; congestive heart failure. A home MEM program is essential for long-term edema reduction. Patients are given a simplified version that can easily be incorporated into ADL tasks. The MEM technique includes specific guidelines and precautions requiring a 2-day course/training.

Low-Stretch Bandaging are bandages that are rolled on and provide a light counterforce. Low-stretch finger wraps are often used when a client’s hand is so edematous that it does not fit into an elastic glove. Wrapped distal-to-proximal in a spiral pattern improving lymphatic flow and edema reduction.

Chip Bags consist of stockinette bags filled with various densities and sizes of foam and they can be worn under low-stretch bandages, loose elastic gloves, or orthoses. Self-Adherent Wrap creates a squeezing effect, pushing fluid distal or proximal, or both.

A small stockinette or powder can be put on the wrap to keep it from sticking.

Lymphedema is a chronic edema that results when a permanent mechanical obstruction of the lymphatic system creates a lymphatic overload. Clients with lymphedema must be treated with a full manual lymphatic drainage (MLT) program performed by a trained and credentialed therapist. MEM is not appropriate for these clients.

Take circumferential measurements. Always use the same measuring device and take measurements at the same time of day and after the same amount of hand activity.

Edema rebound tests to determine whether treatment reduced edema. Volumeters have been shown to provide reliable, valid edema measurements. Tissue Quality Assessment:

Acute edema: Tissue pits deeply, rebounds rather quickly, and can be easily moved around. Subacute edema (early stage chronic edema): Tissue pits, is very slow to rebound, and has a viscous (thick, sticky) quality. Chronic edema: Tissue pits minimally and has a hard feeling. Severe edema: Tissue has no elasticity and is shiny, taut, and cannot be lifted.

Reduction Techniques for Chronic Edema:

Lymphedema:

Evaluation of Edematous Tissue:

Color, temperature, and sensory changes may be signs of a problem. Immediately notify the physician of these signs.

Upper Extremity Injuries Edema Management Techniques

With extrinsic extensor tightness, PIP and DIP flexion is limited with the MP and wrist flexed. Why? Because the extrinsic extensor muscles are being fully stretched across the back of the wrist, MP's, and IP's. With extrinsic flexor tightness, passive composite digit extension is limited with the wrist extended. Why? The muscles are being stretched across the inside of the wrist all the way to the fingertips. With intrinsic or interosseous tightness, PIP and DIP flexion is limited with the MP joint hyperextended or extended. Why? The muscles are being fully stretched across the inside of the hand all the way to the fingertips while flexed.

Lumbricals: Flex the MCP joint and extend the IP joints extend. Dorsal Interrosei: Abduct digits. DAB > Dorsal ABduct Palmer Interrosei: Adduct digits. PAD> Palmer ADDuct Thenar muscles: Move the thumb. AFO> Abductor Pollicis Brevis, Flexor Pollicis Brevis, Opponens Pollicis. Adductor Pollicis Muscle: ADDucts the thumb. Hypothenar Muscles: Move the pinky. AFO> Abductor Digiti Minimi, Flexor Digiti Minimi, Opponens Digiti Minimi.

Superficial (4)- All flex the wrist. Pronator Teres (PT): Pronates forearm. Median nerve pierces through the belly of this muscle. Flexor Carpi Radialis (FCR): Flexes the wrist and Palmaris Longus (PL): Flexes the wrist. Flexi Carpi Ulnaris (FCU)*: Flexes the wrist. Innervated by the ulnar nerve hence the name 'ulnaris'.

Intermediate (1) Flexor Digitorum Superficialis (FDS): Primarily flexes the PIP joint.

Deep (3) Flexor Pollicis Longus (FPL): Flexes the thumb. Flexor Digitorum Profundus (FDP): Flex the DIP joints of digit 2-5. *The ulnar half innervated by ulnar nerve. Pronator Quadratus (PQ): Pronates the forearm.

Carpi Muscles (3) all extend the wrist Extensor Carpi Radialus Longus (ECR), Extensor Carpi Radialis Brevis (ECRB), Extensor Carpi Ulnaris (ECU)

Pollicis Muscles (3) Abductor Pollicis Brevis (APB): Abducts the thumb. Extensor Pollicis Brevis (EPB): Extends the thumb. Extensor Pollicis: Extends the thumb.

Digit Muscles (3) Extensor Digitorum Communis (EDC): Extend the MCP. Extensor Digiti Minimi (EDM): Extends the pinky. Extensor Indices (EI): Extra extender of the index and pinky finger.

Others (3) Brachioradialis: Considered an extensor BUT it flexes the elbow. Supinator: Supinates the forearm Anconeus: Assists in extending the elbow.

The intrinsic and extrinsic muscles work in harmony to allow the hand to smoothly transition from dexterity to power tasks. Extrinsic muscle groups are the long flexors (located on the underside of the forearm) and extensors (located on the back of the forearm). They are called extrinsic because the muscle belly is located on the forearm. The intrinsic group are the smaller muscles located within the hand itself. Intrinsic tightness is one of the largest pitfalls found in the treatment of hand injured patients.

Important Facts:

Intrinsic Muscles: Originate in the hand. They are small and have a lot of dexterity.

Forearm Flexor Muscles: (Most are innervated by the median nerve)

Forearm Extensor Muscles: All innervated by the radial nerve

Upper Extremity Injuries Intrinsic & Extrinsic Muscle Tightness

During the acute or inflammatory phases, tissues should be positioned for rest, comfort and support using immobilization orthoses. Orthosis should be applied at rest, with activity and exercise being emphasized during waking hours. Ex. Static orthosis. During the proliferative phase is when strength of the injured tissues is increasing, therefore active motion is usually initiated in this phase and the focus of orthotic intervention will still be protection while allowing controlled active movement. The orthosis may restrict certain motions in specific directions while allowing motion in the other direction such as a dorsal blocking splint following a flexor tendon repair. During the maturation phase clients are encouraged to move and increase participation in functional activities. Joint stiffness or contractures are identified in this stage of healing. Orthotic intervention is going to address limitations in range of motion using mobilization orthoses.

Static orthoses are non-movable and place tissues in a stress-free position to promote rest and healing. Static orthoses also maintain structures or joints near end range to promote tissue lengthening. For example, a therapist may fabricate a static wrist splint to position the wrist in maximum tolerable extension to increase ROM of a stiff wrist. No direct influence on joint mobility. Can be used as an alternative to mobilization devices when ease of application and compliance are potential issues. Serial static orthoses or casts applied with the tissue at its near maximum length (tolerable end range), which promotes tissue remodeling/elongation, and once the joint gains ROM, the therapist remolds the orthosis (typically every 3-6 days) to place the joint in the new tolerable end range. Generally circumferential and nonremovable. Dropout allows motion in one direction while blocking motion in the another direction. For example, a therapist may fabricate a dorsal-forearm based dynamic extension orthosis with a volar block to prevent MCP joint flexion for client with an extensor tendon injury. Dynamic (mobilization) uses self-adjusting or elastic components (rubber bands, spring, coils) to provide a gentle force that does not overpower the joint in order for the client to actively move against the resistance of the line of pull (active- resistive exercise). Dynamic forces should be applied to the targeted tissue because this provides better opportunity for contracture resolution and/or tissue elongation. For less mature scar tissue because it may not offer enough time within the orthosis (because it is removable) or enough force to overcome a dense contracture. Not for nighttime use. Static Progressive uses inelastic components (velcro, hook-and-loop, outrigger line, hinges, nylon cord) to apply an adjustable amount of tension/force/torque to a joint in effort to position the joint in as close to end range as possible. The joint position is constant. Adjustments are made as the tissue lengthens. For mature, dense scar tissue. Pressure Orthoses (Air Orthoses) exert continuous or intermittent pressure to the area to which they are applied. Should not exceed 40mmHg

Low-temperature thermoplastic (LTT) materials are most commonly used. They soften in water between 135F and 180F degrees and can be placed directly on a patient's skin while the material is still moldable. *High-temperature thermoplastic cannot touch a person's skin while moldable without causing injury. LLT can also be used to adapt devices for improved function (ex. built up pen). Plastic materials are highly conforming/drapable and have a low resistance to stretch. Requires great skill to prevent overstretching and fingerprints. It is recommended to position the client in a gravity-assisted position to prevent overstretching of the material.

Full stretch or maximal ROM increases in tightness and can be uncomfortable for clients. Each joint should be posi-tioned in 5 to 10 degrees less than the available range.

The Biomechanical (ex. to increase ROM), Sensorimotor (ex. to manage spasticity), and Rehabilitation (ex. to maximize grasp) approaches can each incorporate orthosis as an intervention. OT's must stay up to date on orthotic techniques and materials by reading professional literature, reading the manufacturer's information, taking continuing education courses, and attending professional conferences.

Important Facts:

Orthotic Designs include:

Orthotic Materials include:

Submaximal Vs End Range:

Upper Extremity Injuries Introduction to Orthotics

Rubber materials are more resistant to stretching and fingerprints and are less conforming. Memory is the ability for the material to return to it's preheated shape, size, and thickness when reheated allowing for reshaping without stretching (serial static orthoses). Great for novel therapist who are likely to make errors. Not good for spot heating due to shrinkage, best to remold the entire orthosis. Drape/Contour is how the material conforms to the shape without manual assistance. Becomes extremely drapable when heated, so care must be taken (remove from pan in horizontal plane) when handling to avoid positions whereby gravity will take affect and cause overstretching (such as a vertical plane). Requires therapist to use light touch and strokes during shaping. Low drape materials require firm touch. Persons with painful joints or soft-tissue can tolerate materials with high drape. Elasticity is a material resistant to stretch and it rebounds to the original shape during molding. Good for uncooperative clients, high tone, large surface areas, and over multiple joints. Neoprene is more breathable and provides hugging support with flexibility for function BUT they retain moisture next to the skin increasing the possibility of skin breakdown.

Conformability is a performance characteristic that distributes pressure best and reduces the orthosis migrating (moving) due to it conforming or fitting onto contoured areas. Flexibility is a performance characteristic that takes repeated stress and is important for circumferential splints because they must be pulled open to don/doff. Durability is a materials shelf life. Rigidity results in strength and resistance to repeated stress and is important in medium to large orthoses to support the weight of larger joints (elbow and forearm). LTT cannot tolerate weight bearing, High-temperature material can. Perforations allow air exchange and can reduce the weight of the orthoses. Cannot be stretched and must be cut between perforations to prevent sharp edges. Thickness: For most of the conditions that we treat, 1/8th inch thickness provides the proper amount of support. Thinner material such as 1/16th inch is going to work well with clients that may be prone to skin breakdown or for skin that is thinner. When considering the pediatric population 1/8th inch is best for larger limbs or for children with spasticity. But smaller hands may require materials that are thinner such as 1/12th or 1/16th inch.

Heat gun to push out areas of the thermoplastic material that may irritate the bony prominences. Padding must be added before the orthosis is formed to provide sufficient space for the thickness of the padding that you are adding otherwise the pressure may increase over that area. Self adhesive gel disc adheres to the persons skin prior to molding the orthosis. Once the orthosis is cooled, the gel disk is removed and adhered to the corresponding area inside the orthosis.

Fabricated is preferred because it is a unique fit, can be adjusted, and they have a variety of designs. Prefabricated saves time and effort and they offer sophisticated technology. But they can be expensive and offer limited control over the therapeutic position. Selecting an orthosis requires the therapist to consider the diagnosis, medical complications, goals, orthotic design, occupational performance, client's or caregivers ability to adhere to orthotic instructions, motivation, comfort, environment, and health literacy.

Performance Characteristic:

Making Adjustments: Therapist can modify portions of the orthoses that may potentially cause pressure areas or any kind.

Prefabricated Vs. Fabricated:

Upper Extremity Injuries Introduction to Orthotics Part 2

Wrist immobilization orthosis provide support to the wrist while allowing full MCP flx and thumb mobility. Wrist immobilization orthoses can be used as a base for a mobilization and static progressive orthosis. The forearm trough should be two-thirds the length and one-half the circumference of the forearm. Wrist immobilization orthoses should be removed for hygiene and exercises if appropriate. When the goal is functional hand use avoid extreme wrist flexion or extension because either position disrupts the normal functional position of the hand. An exception to this rule is when the orthotic goal is to increase PROM.

Volar wrist immobilization orthoses are in contact with the palmer and forearm side of the hand and have dorsal wrist straps to secure it in place. They promote rest because the weight of the hand is on the splint. But the palmer bar interferes with sensory input or tactile sensibility to the hand which may impact grasp and the ability for the hand to conform around objects. Keep this in mind when a question is promoting engagement in functional activities. Volar orthosis may be indicated for chronic edema. Dorsal wrist immobilization orthoses are in contact with the back of the forearm and provides pressure distribution which is better tolerated by client's with edema. They can be fabricated with a large palmer bar that supports the entire hand. The large palmer bar distributes pressure and is necessary for comfort and function. But, the large palmer bar interferes with sensory input of the hand. A thinner palmer bar is better. Ulnar wrist immobilization orthosis is easier to don/doff and provides more protection of the ulnar side of the hand. Circumferential wrist immobilization orthosis wraps around the entire joint and provides good forearm support, controls edema, provides good pressure distribution, and does not have edges which can be an irritant to some clients.

Carpal Tunnel Syndrome: The orthoses can be Volar, Dorsal, or Ulnar gutter as long as the wrist is in NEUTRAL or slight extension. Promote nighttime wear so the client can be active during the day, unless activities aggravate symptoms. Then the orthosis needs to be worn during the day. Carpal Tunnel Release: The orthosis will be Volar with the wrist in NEUTRAL or slightly extended. Can include padding to reduce trauma from vibration, leather for added durability, and metal internal pieces that act to position the wrist. Radial Nerve Palsy: Volar or Dorsal orthosis with the wrist in 30 degrees ext. Day wear to substitute for motor loss. Tendinosis: Volar or Dorsal orthosis at 20-30 degrees ext. Wear during painful activities or continuously during acute flare-ups. Rheumatoid Arthritis: Volar orthosis in 30 degrees ext or less. During the early stages the client may tolerate more of a neutral position. Wear continuously. Wrist Fracture: Dorsal, Volar, or Circumstantial orthosis with maximum passive ext. the client can tolerate up to 30 degrees. The orthosis is fabricated after cast removal. Complex Regional Pain Syndrome (CRPS): Volar orthosis in extension based on what the client can tolerate. A circumferential orthosis prevents pressure on the edges and helps with edema. Wrist Contracture: Serial static orthotic in the maximal amount of extension that the client can tolerate. CVA: Serpentine orthosis positions the thumb, hand and wrist in an optimal position and allows active wrist function in those with moderate tone. Inhibits the thumb-in-palm reflex by placing the thumb in abduction. Worn during day, removed at night. Requires mod to max assist to don/doff.

Maintaining the wrist in proper alignment is essential the health and functional abilities of the hand. When answering questions related to the wrist, it is important to pay attention to the position of the wrist mentioned in the answers. In most occasions the wrist will be in an optimal position close to 30 degrees of extension. There are exceptions such as Carpal Tunnel. When there is pain mentioned the degree of extension may be lower because we never force the ideal position. When you are not familiar with the name of the splint try to find the position it is placing the wrist in to help you get to the correct answer.

Important Facts:

Types of Wrist Orthosis:

Conditions & Wrist Immobilization Orthosis:

Upper Extremity Injuries Wrist Immobilization Orthoses

Hand-based thumb immobilization orthoses can be fabricated for people who have low median nerve injury, UCL or RCL injury of the MCP joint, CMC arthritis, and the potential for a first web space contracture. Thumb immobilization orthoses can be forearm based which stabilizes the wrist and thumb and beneficial for painful wrist or hand based which only stabilizes the thumb while the wrist is free. IP joint is usually left free for functional movement, unless there is extreme pain in that joint or unless the client is engaged in rigorous activity which can place stress on the joint. The opponens bar and C bar positions the thumb, usually in palmar abduction. The thumb post, which is an extension of the C bar, immobilizes the MP only or both the MCP and IP joints. Neoprene and soft materials are alternatives that are flexible or conformable to the fluctuations in a client’s tone.

Volar Forearm-Based Thumb Immobilization Orthosis: stabilizes the wrist and thumb on volar surface. Radial Gutter Immobilization Orthosis: stabilizes the wrist and thumb by providing support on the radial side of the hand while stabilizing the thumb. This design allows some wrist flexion and extension but limits deviation. Hand-Based Thumb Immobilization Orthosis: stabilizes the MCP (Ex. Thumb Spica). Dorsal Hand-Based Thumb Immobilization Orthosis: Stabilizes the MCP. Add padding because the dorsal hand is bony. Dorsal-Volar Thumb Immobilization Orthosis: Provides added protection, stability, and pain and edema control. Figure-Eight Thumb Wrap/Thumb Loop: Neoprene strip is wrapped around thumb web space and the hand to provide radial/palmer abduction while pulling the wrist into ext and radial deviation.

De Quervain Tenosynovitis: Forearm or Radial gutter. Wrist 15 degrees ext and thumb CMC 40-45 degrees palmar abduction. Nighttime wear or during activities that cause pain. Rheumatoid Arthritis: Forearm based with wrist in 20-30 degrees ext and thumb CMC 40-45 degrees palmar abduction. Wear continuously during pain and inflammation. Osteoarthritis in CMC joint: Hand-based orthosis with MCP's free. A forearm-based orthosis can be provided if the client needs more support. Wear continuously during acute flare-up. Skier's/Gamekeeper's/UCL injury: Hand-based orthosis with MCP immobilized, thumb CMC abducted 40 degrees, thumb MCP joint neutral. Important to place thumb CMC joint in a position of comfort. Will wear 3 to 4 weeks for Grade I, 4 to 5 weeks for Grade II, for Grade III, after immobilization follow protocol for Grade III. Golfer's Thumb/RCL injury: Hand-based thumb orthosis with MCP immobilized in palmar abduction and neutral. Wearing schedule is the same as UCL injury. See above. Scaphoid Fracture: Forearm Volar or Dorsal-Volar thumb immobilization with wrist in neutral and thumb CMC palmar abduction and MCP in 0-10 degrees flx. Depends on healing stage and location of fracture. Some clients may benefit from a combination dorsal/volar thumb orthosis for added stability, protection, and pain and edema control. Hypertonicity: Thumb loop orthosis or figure-eight thumb wrap. Wearing schedule depends on therapeutic need. Thumb flexed and adducted into the palm: Short opponens, C-bar orthosis, or Neoprene thumb extension design.

The purpose of a thumb immobilization orthoses is to protect, rest, and position the carpometacarpal (CMC), metacarpophalangeal (MCP), and/or interphalangeal (IP) while allowing the other digits to be free during the healing phase. Or to position in a functional position. Do not let the names of thumb orthotics confuse you, most of them do the same thing which is immobilize the thumb. A thumb palmar abduction immobilization orthosis is also named thumb spica, or short (hand based) or long (includes the wrist) opponens orthosis, or CMC-MCP immobilization orthosis, or the thumb gauntlet orthosis.

Important Facts:

Types of Thumb Orthosis:

Conditions & Thumb Immobilization Orthosis:

Upper Extremity Injuries Thumb Immobilization Orthoses

Hand immobilization orthoses immobilize the hand and the wrist. They may or may not involve the thumb. Four main components: forearm trough, pan, thumb trough, and the C bar. Have client removes the orthoses for exercises, hygiene, and ADL's.

Functional (mid-joint or resting hand) position to relieve stress on the wrist and hand. 20-30 degrees wrist ext, MCP 35-45 degrees flx, thumb 45 abduction. Anti-deformity (intrinsic plus or safe position) places hand in an optimal position to avoid contractures. 15-30 degrees wrist extension, MCP 50-80 degrees flexion, thumb palmar abduction.

Rheumatoid Arthritis (Acute exacerbation): Place in as close to the functional position as possible until exacerbation is over. Wrist neutral or 20-30 degrees of ext (based on tolerance), 15-20 MCP flx, PIP/DIP slight flx, and 5-10 degrees ulnar deviation. Thumb in a position of comfort between radial and palmar abduction. Ex. Resting hand splint. Hand Burns (Dorsal): Wrist 0 degrees or neutral, MCP's 50-80 degrees flx, PIP/DIP full ext, thumb palmar abduction and ext. Worn immediately after burn injury over dressings. Adjust frequently as bandage bulk changes. Ex. Anti- deformity splint. Hand Burns (Volar/Circumferential): Wrist 15-30 degrees ext, MCP's 50-80 degrees flx, PIP/DIP full ext, thumb palmar abduction and ext. Worn immediately after burn injury over dressings. Adjust frequently as bandage bulk changes. Ex. Anti-deformity splint. Dupuytren Disease Contracture: Wrist in neutral or slight extension, MCP, PIP, and DIP's in full ext. Worn after surgery during the day and at nighttime. Crush Injuries of the Hand: Wrist 0-30 degrees of ext, MCP's 60-80 degrees of flx, PIP/DIP full ext, thumb palmar abduction and ext. Worn after injury to reduce pain and prevent tissue shortening and contracture. Worn at nighttime and during the day during painful periods. The

Complex Regional Pain Syndrome (CRPS): Ideal position wrist 20 degrees of ext, MCP's 70 degrees of flx, PIP 0-10 degrees ext, thumb palmar abduction. Do not force ideal position, adjust to client's comfort. Worn at all times and weaned when pain reduces, and motion improves. Acquired Brain Injury: Place hypertonic muscles on low-load, prolonged stretch. Wrist 20 degrees of ext. Can decrease to 10 degrees of wrist ext if the joint is flexing out of the orthosis or fingers are clawing. Worn 2-4 hours during the day and at night. CVA:

Finger spreader/finger abduction orthosis is fabricated to position the fingers and thumb in abduction. Firm Cone fabricated of low-temperature plastic or purchased commercially.

Positioned with the narrow end of the cone toward the radial side of the hand in the web space to place stretch on the shortened long flexors and is graded progressively to increase stress to the soft tissues to promote a more normal resting length. Prevention of maceration of tissue in patients with moderate to severe flexion of the digits.

Does not provide wrist support unless stated.

Hand immobilization orthoses are also known as resting hand orthoses or resting pan orthoses. It preserves a balance between extrinsic and intrinsic muscles, and provides rest to the wrist, digits, and thumb.

Important Facts:

Types of Hand Immobilization Orthoses:

Conditions & Wrist Immobilization Orthosis:

client may be in too much pain to tolerate the optimal position and may need to be placed in a functional position.

Upper Extremity Injuries Hand Immobilization Orthoses

During a ROM assessment, normal elbow flexion is going to produce a soft end feel and elbow extension is going to produce a hard end feel. During elbow flexion and extension, the medial collateral ligament (stabilized by supination) and lateral collateral ligaments (stabilized by pronation) contributes to the stability of the elbow joint. If they become injured, it will alter elbow alignment and ROM. Joint reduction and stability is greatest when the elbow is flexed. That is why you will notice most fractures and elbow instability will place the elbow in flexion to heal. Flexion of the elbow places pressure on the cubital tunnel, that is why we promote elbow extension (or slight flexion) and educate our clients on avoiding sustained or repetitive flexion.

Posterior Elbow Orthosis: Common for postraumatic and post-surgical conditions especially when positioning at 70- 120 degrees of flx. Easy to wear. Anterior Elbow Orthosis: Indicated when there is a posterior wound and to correct elbow flexion contractures to slowly gain extension. Static Progressive Extension Orthosis: For extension limited by flexion contractures. Static Progressive Flexion Orthosis: Addresses limited flexion due to extension contractures. For clients who cannot achieve 90 degrees of flexion. Sugar Tong Orthosis: Immobilizes the forearm and wrist following a forearm fracture. Inflatable/Air Orthosis: used for clients s/p stroke to reduce tone, facilitate muscle activity around a joint, facilitate sensory input, control edema, and reduce pain. Literature states that the effects are questionable. Some therapists use them with functional weight bearing activities. They should not exceed 40 mm Hg of pressure.

Distal Humerus Fracture & Proximal Radius Fracture: Posterior elbow orthosis in 90 degrees of flexion and forearm in neutral. Proximal Ulnar Fracture: Braced or dorsally positioned in 30-45 degrees of flexion to minimize tension on the triceps. Elbow Arthroplasty: After removal of postoperative dressing fit client for a posterior elbow orthosis in 90 degrees of flexion. Elbow Instability: After removal of postoperative dressing fit client for a posterior elbow orthosis in 120 degrees of flexion with forearm in neutral. Wear continuously. Biceps Repair: (Partial tears) Posterior elbow orthosis in 90 degrees of flexion with the forearm in neutral to supination. (Full tears) place forearm in supination to minimize bicep activity. Triceps Repair: Posterior elbow orthosis in 90 degrees of flexion with the forearm in neutral. Cubital Tunnel Syndrome: (Conservative) Anterior elbow extension orthosis with the elbow position in -30 extension or posterior elbow orthosis in -30 extension with padding at the olecranon and medial epicondyle to create space between orthosis and cubital tunnel area. Nighttime wear. Cubital Tunnel Syndrome: (Postoperative) Posterior long arm orthosis with the elbow positioned in 70-90 degrees of flexion and forearm in neutral. Nighttime wear. Tennis Elbow: Combination of counterforce brace and wrist immobilization orthosis with the wrist in 20-30 degrees extension.

Elbow immobilization orthoses protect and support the healing structures following injury to the bones, muscles, ligaments, and related soft tissues. The elbow is considered a simple hinge joint and is notorious for developing contractures with prolonged immobilization. That is why most protocols promote early AROM once structures are healed.

Important Facts:

Types of Elbow & Forearm Orthosis:

Conditions & Elbow Immobilization Orthosis:

Upper Extremity Injuries Elbow & Forearm Immobilization Orthoses

Shoulder immobilization can lead to adhesive capsulitis (frozen shoulder). Slings are used to decrease or prevent subluxation and pain. Pouch slings should only be worn while the client is in an upright position such as when walking, transferring, and during functional training. Shoulder saddle sling can be worn all day because it does not block distal function or hold the UE in a flexor pattern.

Adduction & Internal Rotation Sling (conventional sling): Positions arm in shoulder adduction and internal rotation with the forearm across the abdomen. Not appropriate for long term use and should only be used during functional mobility. Proximal Humerus Cap Orthosis: Provides circumferential compression while allowing gravity to assist with bone alignment. Allows for full ROM of the elbow, wrist, and hand. Chest straps can be added. Abduction and/or External Rotation Sling: Brace that supports the shoulder in varying degrees of abduction and external rotation. Significantly more expensive. Shoulder Figure Eight Orthosis: Places healing clavicle or AC joint in proper anatomical alignment and prevents superior migration of the proximal clavicle.

Proximal Humerus Fracture: Can be one-part or two-part (conservative management) or three-part or four-part (surgically managed). Immobilization uses a traditional sling or a proximal cap. Shoulder Subluxation & Instability: Traditional sling. Rotator Cuff Repairs: Slight abduction and in neutral to slightly externally rotated position. Currently there is no agreement in the literature upon optimal position following rotator cuff repair. Labrum Repairs: Abduction and external rotation. There is no universally accepted position. Axilla Contractures: Airplane orthosis to increase tissue elasticity and prevent further contracture. Poor adherence due to discomfort and decreased function. Clavicle Fractures/Dislocation: Figure eight orthosis. Brachial Plexus Injury: Positioning pillow of the affected upper extremity: shoulder exter nally rotated 45 degrees, 90 degrees of elbow flexion, and forearm neutral. Sling only while ambulating.

The shoulder is complex and composed of four joints: sternoclavicular joint, acromioclavicular joint, scapulothoracic joint, and glenohumeral joint.

Important Facts:

Types of Shoulder Orthosis:

Conditions & Shoulder Immobilization Orthosis:

Upper Extremity Injuries Shoulder Orthoses

For optimal results, mobilization orthotic intervention should start once pain and edema are reduced. Increase passive joint motion by 10 degrees per week. If no improvement is noted, re-evaluate to check orthosis, home program, and for intervention adherence. Ongoing assessment of pain and inflammation is essential before and after a dynamic orthosis is applied. Both static progressive splinting and dynamic splints may be appropriate to improve ROM.

Serial Static Orthosis positions a joint near end-range to overcome loss in motion. Provides low-load, prolonged stretch at end-range positioning. Useful for joints with hard end feel or muscle-tendon shortening. Dynamic Orthosis uses a static base and an elastic (rubber bands, springs, coils) component to apply tension that does not overpower the joints ability to actively move against the line of pull. The active motion lubricates joints, assists in flexibility of ligaments, activates muscle fibers, and maximizes tendon gliding. Can also substitute a dynamic action for active function. Static Progressive Orthosis includes a static orthotic base that uses inelastic (hinges, screws, nylon cord, strapping material) to apply torque (force) to a joint in order to position it in close to end range for a specific period of time as the tissue lengthens. Hard end feel may only respond to static progressive mobilization.

Forearm-based disperses pressure more effectively than a hand-based orthosis when promoting MCP flexion. Outriggers can be high or low. High is bulky and may decrease wearing compliance. Low is more aesthetically pleasing but force distribution is decreased and that can increase discomfort.

A low-profile outrigger requires adjustments more frequently. Outriggers should maintain a 90 degree angle of pull and be perpendicular to the axis of rotation. As motion increases, adjustments are needed to the outrigger to maintain the 90 degree angle. High-profile outrigger results in slightly less deviation from the 90-degree angle of pull than the low- profile outrigger.

Rubber bands are more readily available and easy to adjust but lose tension over time. A longer rubber band provides more constant tension than a shorter rubber band. Springs offer more consistent tension. Elastic thread is the easiest to apply and adjust and saves time during fabrication. Copper wire makes a good outrigger due to its durability and ease to form with pliers.

Mobilization orthoses move or mobilize joints. They provide constant or adjustable tension with the goals to correct deformities, substitute for loss of motor activity, to control motion, and facilitation of wound healing.

Important Facts:

Types of Mobilization Orthoses:

Principles to Remember:

Upper Extremity Injuries Mobilization Orthoses

Our ultimate goal is to return our clients to functional hand use. Spasticity or hypertonic muscles lead to contractures and tissue shortening. The onset of contractures is time dependent with prolonged disuse or immobility. There is much debate on how stretch should be applied to muscles. Submaximal (5-10 degrees below maximal) or maximal stretch (tolerable end range). Composite means the entire kinetic chain of a digit including MCP, PIP, and DIP is positioned as a unit.

Ex. the entire hand can be in composite extension or in composite flexion (fist). Studies have shown that low-load prolonged stretch is key in resolving soft-tissue contractures and regaining passive motion by encouraging tissue remodeling and elongation. When a client is not making progress, re-evaluate to determine barriers and to ensure your client can incorporate therapeutic activities into their lifestyle.

Orthotics increases AROM and PROM by providing a sustained passive stretch by placing low-load prolonged stress on a tight joint. Manual edema mobilization helps with edema control. Performed with light pressure starting proximally- to-distal, then distal-to-proximal. Beneficial for clients with persistent edema following surgery or trauma in those with intact but overwhelmed lymphatic systems. Taping lifts the skin which promotes edema reduction and prevents stiffness in the hand. Early active mobilization will prevent the edema and disuse. If motion is contraindicated in a specific joint, active mobilization should be performed to surrounding joints. Physical agents can be coupled with treatment and may modulate pain and edema.

Resting Hand Orthosis: Wrist in 20-25 degrees extension, fingers spread, thumb in opposition. Cone Orthosis: Smaller end placed radially and the larger end placed ulnarly to provide maximum palmar contact which provides pressure to flexor tendons and desensitizes hypersensitive skin. Can include a forearm trough. Finger Spreader/Ball Orthosis: Maintains fingers and thumb in abduction and extension. Casts: Preferred when sustained and prolonged stretch is needed.

Spasticity is an increase in muscle tone. There is a loss of normal reciprocal inhibition and abnormal co- activation of agonist and antagonist muscles during active movement. Stiffness is limiting joint mobility and can be caused by non-use, muscle tightness, tendon adhesions, scars, tissue loss, and other factors.

Important Facts:

Interventions:

Orthosis:

Upper Extremity Injuries Stiffness/Spasticity Management

Splinting is not yet indicated. Non-functional. Total paralysis. Educate family and staff on positioning the UE on a pillow, use a sling for ambulation, elevation for edema management. SROM/PROM Incorporate weight-bearing into functional activities. Initiate bilateral hand over hand tasks.

Splinting not typically indicated. If fisted hand is noted during functional activities and ambulation, splinting is indicated. Resting mitt splint is better than a resting hand splint because it can be adapted in later levels. Stabilizer. May or may not need support at elbow or hand. Use strategies listed in previous levels.

Use strategies listed in previous levels. Most likely can begin gross assist with hand over hand tasks.

Splinting is now indicated. Resting mitt splint is better than a resting hand splint because it can be adapted in later levels. And it places hand in a reflex-inhibiting position of thumb ABduction. Reflex-inhibiting position (arm ABducted and externally rotated on a pillow) is helpful. Monitor skin especially in the palm and axilla. Can act as a gross assist during activities with increasing independence such as grasping toothpaste while other hand removes lid. Grasp-release and reaching tasks can be incorporated into simple self care task. Can isolate movement to perform tasks that deviate from limb synergies.

May have some gross assist depending on where the tone is. Non-functional. May need to aggressively address ROM by educated family and staff (nursing care). Address pain. Reflex-inhibiting position (arm ABducted and externally rotated on a pillow) is indicated.

Non-functional because of tone. Orthotic management is a MUST to prevent further deformity. Focus OT treatment on tone reduction and PROM. Discuss with the physician the use of anti-spasticity medications (Baclofen or Zanaflex).

May exhibit decreased fine motor control. Home exercise plan with intrinsic strengthening and functional tasks. No OT may be warranted.

0 - FLACCID:

1 - Slight increase in tone at end range:

1+ - Slight increase in tone at the beginning of the range:

2 - Marked increase in tone through the entire ROM, BUT arm can easily be passively moved.

3 - Tone evident throughout all ROM and PROM is difficult.

4 - Rigid in flexion and extension.

No abnormal tone.

MODIFIED ASHWORTH SCALE Treatment Issues

CRPS type 1 can occur spontaneously with no evidence of a nerve injury. CRPS type 2 occurs with nerve injury. Both types present with allodynia (when a stimulus that is not usually painful is painful), hyperaglesia (increased sensitivity of painful stimuli beyond the nerve or tissue innervation), motor disturbances (tremors, spasms, dystonia, bradykinesia), changes in vascular tone, fluctuating skin temperature, nail/skin color changes, hypo/hyperhidrosis (sweating changes), and distal edema. Purpose of treatment is to improve cortical organization and re-route sensorimotor pathways. By changing the disorganization, symptoms should improve.

ADL's (with focus on how much or little the client uses the affected limb), ROM, coordination, edema, pain, sensation, and vasomotor changes.

Psychosocial: be gentle with physical touch or possibly not touch client if they are too fearful or hypersensitive. Educate client about CRPS, symptoms, and setbacks due to fluctuating nature.

Relaxation including CBT, mindfulness, diaphragmatic breathing, and gentle yoga.

Premedicate for therapy. Start with the client imagining normal motor function then use Mirror feedback therapy (non-involved hand placed in front of a mirror and involved hand behind the mirror in same position, touching the healthy hand gives the illusion that the involved hand is being touched) to reduce pain and re-route the sensorimotor pathways. Isometric and gentle flexibility exercises then progress to gentle AROM. Once AROM is tolerated progress to graded weight-bearing or stress-loading activities. Including:

Placing hand on one's own leg or a tabletop, or carrying a light weight bag. Symptoms may increase in the short term but should improve after several days.

Promote functional use of the limb. Sensory Re-education:

Desensitization starts outside the painful area and slowly progresses into the painful area. Use textures, vibration, pressure, percussion, or retrograde massage. Techniques should not exacerbate symptoms. Ex. placing hands in dry beans. If measures fail, provide protection to hypersensitive areas for functional tasks. Contrast baths.

Edema management is important and involves elevation and active motion. Compression is poorly tolerated.

Orthoses are only suggested if it is painful for the person to perform functional movements or if the person is posturing in flexion. To increase wrist extension to a more functional position, the therapist may need to provide serial wrist orthoses. Wrist immobilization orthoses addresses pain relief and for regaining a functional resting wrist position. Volar orthosis should be placed in extension based on what the client can tolerate. Circumferential prevents pressure on the edges and helps with edema.

Immobilization may increase the pain cycle. Only splint if there is an unstable fracture or muscle shortening. Manual therapy should not be attempted in the early stages of intervention. Icing. Heating modalities may decrease pain but must be used with caution.

CRPS occurs after an injury or surgery with symptoms such as burning pain that cannot be explained by the initial injury. Pain usually starts in the injured limb and spreads to other body parts. Pain, sensory, motor, and trophic changes typically occur.

Important Facts:

Evaluation:

Treatment:

Orthotic management:

Contraindications:

Complex Regional Pain Syndrome Evaluation, Treatment, & Contraindications

Radial nerves are commonly injured following mid-shaft humeral fractures. Wrist drop is the most common deformity caused by radial nerve injury.

Crutch Palsy (axilla level): Results in paresis of tricep function, weakness of supination, loss of digit MCP extension, thumb extension, and thumb radial abduction. Monitor for elbow flexion contractures since elbow extension will be impacted. Saturday Night Palsy: Results in wrist drop and lack of finger MCP extension.

Wrist cock up with the wrist in a functional position. Dorsal mobilization orthosis that dynamically holds MCP joints in extension but allows for full digit flexion. This leave the palm of the hand free for sensory input.

Posterior Interosseous Nerve Syndrome (PINS): Involves some wrist extensors and all four digit extensors. Symptomatic at night and with activities that engage the extensors such as with typing. And activities that engage forearm pronation with engagement of the extensors such as with pulling a suitcase will also exacerbate pain. Radial Tunnel Syndrome (RTS): Presents with pain, but no clear palsy or motor loss.

The goal is to position the upper extremity in elbow flexion, forearm supination, and wrist extension to reduce strain on the radial tunnel. Common wrist brace to position the wrist in extension which prevents active use of the muscles. Educate clients on avoiding prolonged positions of pronation with elbow extension during daily and work tasks.

Rest, orthotic management, activity modification, gentle stretching, nerve gliding, and anti-inflammatory medications. Long arm orthosis with wrist in extension, elbow in flexion, and forearm in pronation to neutral. Wrist immobilizing orthosis during day time. Wrist Immobilization Orthosis: Wrist in 30-40 degrees extension (wrist cock up). Mobilization Dorsal-Based MCP Extension Orthosis: Wrist in 30-40 degrees extension and MCP's in dynamic extension. Tenodesis Orthosis: Dorsal-based using active wrist extension to generate to aid passive finger flexion. Low-Profile Radial Nerve Palsy Orthosis with Radial and Ulnar Deviation: Wrist in 20-30 degrees extension and MCP's in neutral. Low-Profile Radial Nerve Palsy Orthosis: Wrist in 10-20 degrees extension and MCP's in neutral.

Nerve conditions have a huge impact on function and a person's quality of life and can occur from trauma or compression. Function after a nerve injury can require or be enhanced by orthotic intervention. Nerve injuries are categorized by the extent of damage to the axon sheath (neurapraxia, axonotmesis, neurotmesis). An intact radial nerve allows for elbow extension and is essential to the tenodesis action. It powers all wrist extension, all MCP joint extension, and thumb extension/radial abduction. The posterior branch of the brachial plexus impacts the radial nerve.

Important Facts:

Radial Nerve Injury: High

Common Orthoses:

Radial Nerve Injury: Low

Common Orthoses: PINS

Common Orthoses: RTS

Upper Extremity Injuries Radial Nerve Injury

Ape hand is the most common deformity caused by median nerve injury.

Pronator Syndrome: Results in diffuse forearm pain aggravated by resisted elbow flexion and forearm pronation and dysesthesia in the radial three and one-half digits of the hand. Anterior Interosseous Syndrome: Results in paralysis of the FPL to the thumb and the FDP to the index and long finger which results in a collapsed DIP when attempting to make an 'OK or 'O' sign (Ballentine's sign). Both will present with a negative Tinel's sign.

Rest, orthotic management, activity modification, and anti-inflammatory medications. Long arm orthosis with the elbow in 90 degrees flexion and forearm and wrist in neutral. Avoid pronation and supination. Oval-8: Stabilize the IP joint of the thumb and index finger in flexion using a custom tip orthosis or figure- eight finger splint to enhance pinch.

Carpal Tunnel Syndrome (CTS): Results in paresis of the thenar muscles with consequent weakness or loss of thumb opposition. There is sensory loss in the tips of the thumb, index, and long finger. Complaints of dropping things and difficulty with fine motor activities. Numbness and tingling are worse at night due to bending the wrist while sleeping. Positive Tinel's sign.

The goal is to position the wrist in NEUTRAL. At night only unless the client engages in activities during the day that exacerbate symptoms using Dorsal, Volar-Based, or Ulnar Wrist Orthosis Client education on avoiding wrist flexion. Can include lumbrical stretches in HEP if there is a positive Berger's test which means that the lumbricals are taking up space in the carpal canal. Thumb Web Space Orthosis or C Bar Orthosis in 40-45 degrees of palmer abduction can prevent a thumb adduction contracture. Be cautious of prefabricated wrist cock-up orthoses because they may position in too much extension.

Wrist control positioning for 2 to 3 weeks postoperative to decrease incision tension and to prevent overuse and inflammation.

Position orthosis in about 25° of extension, because this prevents wound site tension. Modalities are helpful in addressing scar tenderness.

Pain on either side of the incision is a normal postoperative occurrence. Intervention strategies may include gel pads that are positioned across the irritated site, education about the etiology and prognosis for pain resolution, and manual therapy/scar massage.

Nerve conditions have a huge impact on function and a person's quality of life and can occur from trauma or compression. Function after a nerve injury can require or be enhanced by orthotic intervention. Nerve injuries are categorized by the extent of damage to the axon sheath (neurapraxia, axonotmesis, neurotmesis). The median nerve allows for forearm pronation, thumb, index, and long digit flexion; and thenar palmar abduction and opposition. It allows for grasping and precision pinch. Fine motor coordination is not possible without intact sensation along the radial volar aspect of the hand.

Important Facts:

Median Nerve Injury: High/Proximal

Common Orthoses:

Median Nerve Injury: Low/Distal

Common Orthoses for CTS:

Postoperative Management of Carpal Tunnel Release:

Upper Extremity Injuries Median Nerve Injury

Claw Hand is the most common deformity of the ulnar nerve. It presents with the MCP's pulled into hyperextension and the IP joints assume a position of flexion.

Cubital Tunnel Syndrome: Results in sensory and motor dysfunction. Decreased sensation in the ulnar digits and decreased innervation to the ulnar digits which may result in clawing of small and ring finger in severe cases due to increased elbow flexion. The balance between extrinsic and intrinsic muscles is lost because of paralysis of the intrinsics of the hand. This results in flattening of the normal arches of the hand. The cubital tunnel is roomiest when the elbow is extended. When the elbow is flexed greater than 100 to 110 degrees pressure increases on the ulnar nerve. Test: Pain with elbow flexion/extension. Client's will lose the ability to abduct and adduct the digits and paralysis of the thenar adductor. Froment's sign, Jeanne's sign, and Wartenberg's sign.

Restrict the elbow from flexing using a long orthosis with the elbow positioned in 30-70 (30-45 is better) degrees of flexion, forearm and wrist in neutral, and digits free. Anterior long arm orthosis over an elbow pad at night. Towel splint is an economic solution. Padded elbow sleeve during the day time to cushion when leaning on the elbow.

Guyon's Canal: Results in sensory loss (palmar ulnar aspect of hand and little finger and ulnar border of ring finger) and motor paresis affecting intrinsic ulnar-innervated muscles including interossei and adductor pollicis. Pain worse at night and exacerbated by prolonged wrist flexion or extension. Similar functional deficits as with High ulnar nerve.

Figure-Eight Orthosis or Hand-Based Anti-claw orthosis placing the MCP's into flexion (30-45) with IP's free: Prevents overstretching of the lumbricals and interossei of the 4th and 5th digit. Mobilizing ulnar gutter orthosis that places 4th and 5th MCP's in flexion. Dynamic PIP Extension Orthosis such as a Spring Coil Splint: Use prior to the anti-claw orthosis if a PIP flexion contracture develops. Flexion Mobilization Orthosis: Rubber bands are attached to a soft wrist cuff and use traction to pull the 4th and 5th digits (by finger loops) into 30-45 degrees MCP flexion.

Nerve conditions have a huge impact on function and a person's quality of life and can occur from trauma or compression. Function after a nerve injury can require or be enhanced by orthotic intervention. Nerve injuries are categorized by the extent of damage to the axon sheath (neurapraxia, axonotmesis, neurotmesis). The ulnar nerve allows strong wrist flexion, ulnar deviation, and power grip via full flexion of the fourth and fifth digits. Ulnar nerve integrity is necessary for powerful tip and lateral key pinch. The hypothenar muscles and interossei muscles allow the hand to powerfully cup and object such as a doorknob or basketball. Educate client on avoiding prolonged ulnar deviation and wrist flexion.

Important Facts:

Ulnar Nerve Injury: High/Proximal

Common Orthoses:

Ulnar Nerve Injury: Low/Distal

Common Orthoses:

Upper Extremity Injuries Ulnar Nerve Injury

Shoulders need to be taught how to move in order to prevent substitution and compensatory patterns of movement. Therefore, most protocols start with PROM>AAROM>AROM>Resisted strength training. Your clients begin treatment while they're still in the immobilizer by performing grasping exercises and ROM of the surrounding joints to prevent edema and joint stiffness.

One Part: One part fractures or simple fractures are initially treated by sling immobilization for 1 to 3 weeks and then your client can start passive movements. It takes 1-3 weeks for the humeral shaft and head to move as a unit.

Initiate passive range of motion exercises in the clinic and pendulum and tabletop exercises at home. Your client will continue to wear the sling immobilizer during the day and while sleeping for support and protection for the first six weeks post injury. 4-6 weeks start more aggressive stretching starting with AAROM progressing to AROM in sitting focusing on proper glenohumeral and scapulothoracic movements to prevent substitution patterns such as scapular elevation and trunk leaning. 8 to 12 weeks post op start resistive training and diagonal movement to promote functional use of the arm without substitution. Introduce open chain and closed chain exercises. Open chain is when the extremity is free to move in space. Close chain is when the extremity working is working against a stationary or mobile surface (rolling a weighted ball against a wall).

2 to 4 part fractures which are more complex will require 4 to 6 weeks of immobilization. When the shoulder fracture is considered complex it will require surgical intervention (open reduction internal fixation or ORIF). The surgeon goes in and reduce or bring together all of the displaced fracture fragments. Early motion is indicated.

An arthroplasty is indicated when there is a four part fracture. If the fracture has been surgically repaired or mechanically stabilized it is considered stable immediately. Therefore, the client can begin motion exercises post-op day one following hemiarthroplasty and early motion is indicated following ORIF.

If the case is noncomplicated, the condition can stabilize in 2 to 6 weeks. Complex cases take up to a year to resolve.

Resist external rotation with the client's shoulder in neutral and elbow flexed in 90. Palpate the RC insertions. The Hawkins-Kennedy and Neer impingment tests are commonly used.

Initially focus on rest and antiinflammatory modalities. Eary ROM exercises such as pendulum and wand-assisted elevation. Maintaining full pain-free internal and external rotation are critical to preventing frozen shoulder. Strengthening the healty portion of the RC and scapular muscles is safe (internal rotation, adduction, and etension). Isometrics and resistant bands can be used. As pain subsides and and RC function improves, began strengthening UE elevators and external rotators.

Proximal humerus fractures are the most common fractures of the humerus and most occur because of a fall in the elderly population.

Important Facts

Fracture Categories:

Rotator Cuff

Evaluation Methods:

Nonoperative Treatment:

Upper Extremity Injuries Shoulder Injuries

Rigid fixation (plates) eliminates the need for prolonged immobilization and is stable enough to allow early wrist motion. Your clients perform AROM of all surrounding joints while they're still in the cast: shoulder, elbow, and finger (promotes tendon excursion and tissue lengthening) exercises which prevents stiffness. Move through full available ROM, wiggling the fingers is not enough.

In cast for 2-8 weeks in slight flexion and ulnar deviation because this position uses the supporting soft tissues surrounding the joint to stabilize the fracture. Closed treatment (cast) can start AROM when cast is removed around 6 weeks.

Will require surgery to stabilize fracture. The benefit is that early wrist movement is allowed (within a few days of surgery). Complications include CRPS, Malunion (malalignment and pain), soft-tissue injury (ligament tears), tendon irritation/rupture (adherence of tendons), and nerve compression or irritation (median nerve most commonly involved but the radial and ulnar can be affected). AROM of the wrist following ORIF can start 7-10 days post-op.

Referral in the acute phase will be based on edema, poor finger motion, concerns with elbow and shoulder motion, initiation of early wrist ROM following rigid fixation, and functional management while in the cast. Most clients are referred in the subacute phase (at 6 weeks) once the cast is removed.

Acute Phase (0-6 weeks): Primary goal is protection of the healing fracture. The client is immobilized (in a cast or orthosis following ORIF) and would ideally be referred to hand therapy within the first week of casting or surgery. Moderate to severe swelling is a silent enemy and will alter the normal gliding of joints and tendons. Avoid placing the arm across the chest (guarded position) or flexing the elbow (sling). Low grade compression can be used in the acute phase (edema gloves, coban wraps, elasticized compression bandages, or other compression wraps. Gentle PROM of the wrist can be started if there is stiffness, surgeon is consulted, and pain/swelling are under control. Individual finger blocking exercises at IP's promote gliding of the FDS, FDP, and FPL such as going from full composite fist in flexion to a hook. Hook works on intrinsic tightness. If there is pain/swelling, gentle PROM to the digits can be gradually progressed. Pain is controlled with medication, ice, heat (if edema is resolving), contrasts baths, and graded motor imagery. Orthosis used at night with fingers placed in comfortable extension. Encourage light functional use, no weight bearing, lifting/carrying only 1-2 lbs. Scar management starts when scar is oink. Massage with unscented lotion in circular motion and enough pressure to blanch skin. Graded desensitization can be used if the scar is hypersensitive.

Distal radius fractures are the most common fractures of the upper extremity and usually result from a fall on outstretched hand (FOOSH). The most common type is the Colles' fracture.

Important Facts

Non-operative Treatment of DRF: For stable and closed reduction

Surgical Treatment of DRF: For unstable fractures

Assessment of Wrist Fractures:

Treatment Guidelines: Start with AROM. NO strengthening in the acute phase

Upper Extremity Injuries Distal Radius Fracture (Acute Phase 0-6 weeks)

Clients may compensate for weak wrist extensors by extending the digits (EDC), have clients make a fist when performing wrist extension exercises. Your clients perform AROM of all surrounding joints while they are still in the cast: shoulder, elbow, and finger (promotes tendon excursion and tissue lengthening) exercises which prevents stiffness. Move through full available ROM, wiggling the fingers is not enough.

Worn during heavier tasks, at night, and in public. Serial static splinting use is decreased over time as pain decreases and motion/strength improves.

If edema is persisting in this phase then elevation will not help. Incorporate manual edema mobilization. Or compression.

Flexion/extension, ulnar/radial deviation, and forearm rotation should be added to the home program. Focus on isolated wrist extension and maintaining extension while gripping is important. PROM can be added if the physician confirms and pain/swelling are controlled. Educate on prolonged gentle stretching holding for 30 seconds which promotes elongation and scar remodeling. Avoid aggressive stretching. Prayer position, wrist flexion with other hand, supination/pronation using a dowel or hammer are all PROM exercises. Manual joint mobilization for challenging wrist IF the therapist is trained. Moist heat prior to exercises ONLY IF edema is resolving.

Expected mild pain can be managed with rest and activity modification. More intense persistent pain in the acute phase may indicate CRPS. Strategies include ice, moist heat, electric modalities (TENS), contrast baths, and graded motor imagery.

See acute phase strategies. If painful neuromas develop contact physician.

Supination and extension are often limited. When traditional stretching does not improve ROM to a functional level or progress has plateaued, dynamic and static progressive splints should be considered. The longer the tissue is held at tolerable end range (low load prolonged stretch) the more the range will improve.

Educate on functional use and adaptations. Avoid overuse and the risk of persistent joint pain and tendonitis. Gradually add heavier tasks.

At 8-10 weeks dependent on pain, swelling, and progression of bony healing. If in doubt confirm with Dr. Isometrics should be introduced first, followed by open kinetic chain ex (grip strengthening with sponge or theraputty, wrist curls at 1lb, forearm rotation with a weight), then closed chain ex (wall push ups and pull ups). Home exercises are performed every other day with enough repetitions to fatigue muscles.

Important Facts

Cast/Orthotic Use: Goal is to support soft tissues and maintain wrist in extension to facilitate finger motion.

Edema Management:

Range of Motion:

Pain Management:

Scar management and desensitization:

Orthosis to Address Adherence and Tissue Shortening:

Functional Use:

Strengthening:

Upper Extremity Injuries Distal Radius Fracture (Sub-Acute Phase 6+ weeks)

A tendon protected position is with all the other joints that the tendon crosses supported passively in flexion to provide slack to the tendon. Immobilization technique can lead to adherence but in the presence of other injuries such a fracture, it is necessary or if treating a child or client with cognitive deficits. Tendon glide exercises include hook fist, straight fist, and composite fist which maximizes isolated gliding of the flexor digitorum superficialis and the flexor digitorum profundus tendons and stretches the intrinsic musculature and glides the extensor mechanism. Rupture occurs when extension or active flexion is too strong for the repair to with stand (grasp and pinch must be avoided in the early and intermediate phases unless adhesions are present). During the inflammatory phase (0 to 2 weeks following repair), the tendon is very weak and collagen is forming at the repair site. During the intermediate phase (2 to 6 weeks following repair) the tendon repair gains tensile strength. During the late phase (6 weeks following repair) tensile strength continues to strengthen and the tendon repair begins to remodel in alignment with the tension placed on it. After approximately 8 weeks, the patient may begin light resistive exercises (soft clay, woodworking, macramé) light ADL, and other activities. Most functional activities can resume at 12 weeks after repair and normal use of the hand at 12 to 14 weeks after repair.

There are three basic approaches from the most conservative to least conservative: 1) immobilization which carefully keeps the wrist in flexion, 2) immediate passive motion (benefits of this approach over immobilization are improved circulation for tendon healing, decreased joint stiffness, partial distal gliding of the flexor tendon, and in some cases, a limited amount of proximal gliding of the repaired tendon), and 3) immediate active motion (benefit of this approach is to achieve flexor tendon gliding prior to the formation of dense flexor tendon adhesions). Each approach protects the flexor tendon repair with a dorsal blocking orthosis that places the wrist and/or MP joints in flexion to protect the repaired tendon from too much stretch for 6 weeks postoperatively. Early Phase: limited gliding of the flexor tendon occurs so adhesions/stiffness are common.

Immobilization Protocol uses a dorsal blocking orthosis or cast. Orthosis: Wrist 20° to 30° flexion MP joints 50° to 60° flexion with IP joints straight Exercise: Immobilized, passive flexion by therapist if referred early

Immediate passive motion Protocol uses dorsal blocking orthosis with static IP positioning or dorsal blocking orthosis with elastic traction.

Orthosis: Wrist 20° to 30° flexion MP joints 50° to 60° flexion with IP joints straight Exercise: Passive flexion, duran passive exercises, active IP extension in orthosis

Immediate active motion Protocol uses a dorsal blocking orthosis with MP and wrist flexion (static or with elastic traction) or a wrist hinge orthosis for exercise, dorsal blocking orthosis with elastic traction (wrist neutral).

Exercise: Wrist tenodesis, passive digital flexion, active IP extension with MP joints flexed, place and active hold in flexion.

Important Facts

Flexor Tendon Repair Protocol:

Upper Extremity Injuries Flexor Tendon Injury

Intermediate Phase: Initiate within 3 to 4 days following repair. Immobilization Protocol

Orthosis: Adjust dorsal blocking orthosis to wrist neutral. Exercise: Passive flexion, duran passive exercises, active digital extension with wrist flexed, wrist tenodesis exercise, gentle active digital flexion, assess tendon gliding at 3 weeks, if adherent add: tendon gliding with straight and hook fist, blocking exercises.

Immediate passive flexion motion Protocol Orthosis: Remove orthosis for bathing and exercises. Remove elastic traction from fingertips Exercise: Wrist tenodesis, place and active hold digital flexion, gentle active digital flexion, finger extension with wrist flexed, gradually bring wrist to neutral, assess tendon gliding, if adherent add gentle blocking and tendon gliding.

Immediate active flexion motion Protocol Continue orthosis wear to 6 weeks, if elastic traction was used discontinue at 4 weeks Exercise: Continue with early phase exercises and add gentle active flexion, straight fist composite fist, blocking if adhesions present, passive IP extension if needed.

Late Phase: Immobilization Protocol

Orthosis: No orthosis or in extension at night, if needed Exercise: Full active flexion and extension, blocking, light resistance

Immediate passive flexion motion Protocol Orthosis: No orthosis or in extension at night, if loss of ROM Exercise: Finger extension with wrist neutral, gradually extend wrist, light resistance if adherent; if minimal adhesions, delay resistance until 8 to12 weeks, passive IP extension if needed

Immediate active flexion motion Protocol Hand-based dorsal blocking orthosis during heavy activities or work; Dynamic IP extension orthosis after 8 to10 weeks if IP flexion contracture exists Exercise: Intermediate phase exercises and add hook fist, light gripping at 8 weeks if adhesions present, delay if good to excellent tendon gliding.

Kleinert technique is an early active motion technique that uses early active extension but passive flexion: After surgical repair, rubberbands are attached to the nails of the involved fingers. A dorsal blocking splint is fabricated with the MCP joints held in about 60 degrees of flexion and the PIPs in gentle flexion. The patient must be able to fully extend the IP joints actively within the splint; to prevent joint contractures. The splint is worn hours a day for 3 weeks. Duran and Houser’s technique uses passive flexion of the fingers to improve tendon gliding and active IP extension within a dorsal blocking orthosis. With the MP and PIP joints flexed, the DIP joint is passively extended. This moves the flexor digitorum profundus (FDP) repair distally, away from the flexor digitorum superficialis (FDS) repair. Then, with the DIP and MP flexed, the PIP joint is extended passively. This moves both repairs distally away from the site of repair and any surrounding tissues to which they might otherwise form adhesions.

*Resistance is initiated in this phase only in the presence of significant flexor tendon adhesions that prevent active flexion more than passive flexion. If active flexion is not limited significantly, resistance is deferred until the late phase or until the surgeon has determined the tendon is near or at full tensile strength.

*If a client has good early active motion, delay resistive exercises because good active motion of the repaired tendon indicates lack of adhesions. If a client presents with adhesions that limit active motion more than passive motion, resistive exercises can be initiated because resistance places tension on the scar to improve proximal gliding of the tendon. Specific Techniques:

Upper Extremity Injuries Flexor Tendon Injury

Common presentation for BP for infants is a weak arm positioned in an internal rotation with the shoulder adducted, elbow extended, forearm pronated, fingers and wrist flexed.

When the entire brachial plexus has been injured, the entire extremity is flaccid. But the most common presentation is Erb’s palsy where the C5/C6 nerve roots are damaged resulting in good hand function but limited shoulder function. The arm is held with the shoulder internally rotated, elbow extended, forearm pronated, and wrist flexed.

ROM exercises are critical and must be taught to the parents/caregivers to be performed routinely to preserve ROM, prevent joint contractures, and to help the child progress through normal developmental milestones and in sensory stimulation to the affected upper extremity to enhance sensory perception and prevent neglect of the affected upper extremity.

ROM exercises should be performed at every diaper change. Tummy time at each diaper change to promote symmetrical head rotation and positioning

Therapy session should begin with PROM exercises to prepare for activity. Followed by AROM exercises by stroking tapping or vibrating the muscle belly.

AROM exercises can occur in gravity eliminated positions, progressing to antigravity positions, and then ultimately reaching weight-bearing positions (if developmentally appropriate). Weight-bearing activities include:

Toddlers: crawling through tunnels, rolling over the top of balls, or side-sitting. 5 to 6 year olds: climbing monkey bars, jumping rope, throwing catching balls, and using swings. Older kids will have difficulty with the use of playground equipment, lunch room activities such as opening containers, carrying objects, and any type of bi-manual activity.

Splinting can address tightness of the finger joints or significant atrophy of the thenar eminence. Intrinsic plus or an elbow flexion splint may be indicated if there is subluxation. Worn 22 hours a day for the first month then weaned to bedtime.

For complex fractures or nerve damage begin AROM immediately after the cast is removed. Progress to include PROM and light strengthening as the physician indicates adequate bone healing. If there is stiffness use static progressive or dynamic splinting to improve joint mobility (check with MD to ensure healing has occurred).

Resting Hand Orthosis prevents or reduces contracture or deformity. For children with mod to severe tone or severely decreased tone (no active movement). Can add finger separators, elastomer (silicone putty) for positioning fingers. Volar covers the palm of the hand. Dorsal avoids sensory input on the hand and forearm.

Dorsal Wrist Immobilization Orthosis provides wrist support while keeping the palmer surface of the hand free for sensory input and play. Can support the wrist in extension for weight bearing. Soft splints/neoprene are used to position the UE, prevent contracture, decrease pain or improve joint position for function.

Ex. Soft Thumb Orthosis with a thumb loop (neoprene material) is addresses mild spasticity or increased tone. Anti-Swan Neck Orthosis prevents hyperextension of the PIP joint. Static splints prevent motion in the affected joints. Ex. wrist and thumb spica splint. Static progressive splinting requires serial adjustments to reposition the splint to change the joint angle when mobility is limited by joint tightness with a soft end feel.

Static progressive elbow extension splint to increase elbow extension. Typically worn when sleeping to allow for AROM and functional use of the affected arm when awake.

Dynamic splints apply a dynamic force to a joint for motion that is absent or very weak. Apply light sustained force to increase joint mobility when there is limited active motion secondary to joint tightness.

Brachial Plexus:

Fractures:

Pediatric Orthoses:

Upper Extremity Injuries Pediatric Injuries

Once a physician reports sufficient fracture healing, most protocols begin strengthening using isometric exercises and then progress to isotonic exercises because isometrics are just contractions and place no tension on the joint or ligaments. Isotonic muscle activation generally is initiated following isometric strengthening. Exercises that are dosed at high repetitions are to improve vascularization and endurance (low-load, high-repetition). Avoid pain because pain indicates that the tissue is being irritated. If a client lacks both ROM and strength, focus on restoration of the available joint ROM prior to emphasis on progressive strengthening.

The client does not exert any effort to move independently, but rather an outside force, usually the practitioner. Precautions include: inflammation, limited sensation for pain, and prolonged immobilization.

When a muscle is activated to move a joint from flexion to extension and vice versa the involved muscles begin to shorten (concentric) or lengthen (eccentric). Client moves the joint through available range of motion without any assistance. The muscle shortens and lengthens.

When muscles are grade Poor: Move in gravity eliminated plane When muscles are grade Fair: Move in against gravity plane

Client moves the joint as far as possible, then an outside force such as a practitioner or equipment assists with moving the joint through the rest of the range. Indicated for muscle grade Trace, Poor minus, and Fair minus

An isotonic contraction against resistance using wrist weights, dumbbells, Thera-Band, Theraputty, elastic bands, springs, or weights. Precautions include: inflammation, unstable joint, recent or unhealed fracture, and conditions that are exacerbated by fatigue.

A static form of exercise when a muscle contracts without joint motion. The purpose is to increase strength and endurance of the muscles at specific joint angles. It is a safe way to begin strengthening after an injury. Client contracts the muscle and holds the position for 5 seconds. Used when motion of a joint is prohibited. Precautions include: clients with cardiac conditions and high blood pressure.

An isometric contraction against a load (holding a grocery bag maintaining elbow flexion). Resistance could be an immovable surface (a wall pushup). Precautions include: clients with cardiac conditions and high blood pressure.

Open chain exercises are defined as working against resistance where the extremity is free to move in space resulting in movement of the distal segment. Most functional activities of the upper extremity are open chain.

Overhead dumbbell punches, leg Closed chain exercises are defined as working against resistance with the extremity working against a stationary or mobile but motion-constrained object or surface.

Closed chain exercises impart a degree of stability during the exercise motion. Wall pushups, seated press-ups, weight shifting in quadruped, or prone press-ups resting on elbows.

It is essential to educate clients on each component of the exercise program and what is being accomplished.

Important Facts

Passive Range of Motion

Isotonic Active Exercise

Isotonic Active Assistive Exercise

Isotonic Resistive Exercise

Isometric without Resistance

Isometric Resistive Exercise

Open and Closed Chain Exercises

Client Education

Upper Extremity Injuries Types of Exercise