Transcript for:
OT NBCOT Exam Prep - Upper Extremity Disorders

hi i'm jeff the ot dude welcome to this episode of the nbcot exam prep course from the ot dude academy if you're just watching this from youtube be sure to enroll in the free course to get the most out of it including study guides interactive games quizzes and more for example after watching and reviewing this video quiz your knowledge with the splints matching game for these upper extremity conditions the link is in the description this video will go over the upper extremity disorders including the conditions and injuries including for the hands there will be a lot of information so feel free to take breaks and watch this in several sessions let's get functional let's review some general ot interventions when working with fractures before you even work with the patient you'll want to identify the weight bearing precautions and how they will affect functions such as adls starting from the most strict is non-weight bearing then touchdown weight bearing for balance partial weight bearing which is about up to 50 weight bearing weight bearing as tolerated and finally full weight bearing in real life patients often have poly trauma and multiple fractures are possible in different locations at the same time so therefore they will often have multiple weight-bearing precautions that apply to them at any given time and adding to more of the complication for you and your patient that you need to follow during therapy and outside of it too with fracture interventions i want you to think about orthopedics and their healing phases for example callous formation takes about two to three weeks and bone union takes about four to six weeks characteristics and considerations such as for surgery by the orthopedist and therefore ot management include unstable versus stable fracture displaced versus non-displaced open versus closed combinated or not and rotational spiral fractures two common surgical approaches are orif and x-fixes otherwise conservative management is usually a cast or protection of some kind the goal of orthopedics is straightening and alignment of the bones right so you can either immobilize such as in the very beginning of the healing phase or allow for mobilization if the bones are stable three immobilization techniques include casting bracing and rot favorite splinting as an ot you will want to encourage active range of motion and strengthening of surrounding structures as they are not affected and have no limitations compared to the fractured ones typically patients can start early mobilization of the affected structures but only with orders and when cleared by an orthopedist more evidence is also building for the intervention of early mobilization for many conditions but especially for fractures especially after external fixation typically early mobilization is a good thing to do as long as there are no contra indications or if the surgeon's protocol does not prohibit it one thing to watch out for though is a recent administration of blood thinners in which the patient would be on bed rest until say 24 hours later other interventions include patient education including education for safety and falls caregiver education modalities for pain as well as promoting mobility and function wound care pain management edema management and psychosocial such as the fear of falls or anxiety with having things like an x-fix coming out of your body i'd be probably a little bit freaked out too as patients are expected to heal and have a good prognosis overall oftentimes with the majority of fractures they can use adapted strategies and adaptive equipment for the promotion of adls and other interventions set by the goals such as for managing at home an evaluation should ask questions such as the environment any dme barriers and so on upon discharge you'll want to provide a home exercise program hep that includes range of motion and strengthening with that out of the way let's start with fractures of the upper extremity we will go proximal to distal and end at the hand and the digits outcome measures you can use include the monofilament two-point discrimination grip strength mmt range of motion remember with the mmt to not just go through the motions automatically and do testing of all the joints pay attention to the contraindications for example if they are bearing in the elbow then you don't want to crank on the elbow for mmt you can always do nt in your documentation for not test it some others to consider but you don't have to memorize this include the 9-hole peg boxing blocks tests purdue pegboard fugle meyer wolf motor function test the dash able hand jepson taylor hand function test michigan hand outcome questionnaire and crawford small parts dexterity test you should also make good use of observation and watch for edema color changes the presence and strength of the pulses such as distally temperature and temperature changes pain and infection such as drainage from pin sites like x-fixes and remember that these tests should not replace the evaluation of real occupations what we do as ots such as four adls all right let's get into it a humorous fracture typically occurs at the surgical neck or mid shaft a mid shaft may have radial nerve involvement and what happens with the wrist when you have a radial nerve injury it is responsible for wrist extension so a mid shaft humeral fracture with a radial nerve involvement results in wrist drop the orthopedic management of a humorous fracture includes the use of like a brace or shoulder sling like the ones you often see on tv with like the white fabric and research provides strong evidence for the use of immobilization slings for non-displaced humeral fractures but not really doesn't specify which specific kinds of slings but an important one to remember for a humorous fracture is the sarmiento brace it allows for function which is important so with occupations you can begin things like adaptive adl training to remember this the sarmi brace sounds kind of like the brand of cheese sargento that i eat that i get from like costco and if you look at their logo it kind of has these two squiggly lines kind of looks like too humeri fractures in the elbow typically occur at the olecranon from high velocity falls or a direct blow to the elbow elbow fractures have some of the highest complication rates due to fracture dislocation injuries that may involve multiple fragments and adding to the healing times overall for the prognosis and elbow fractures have a high risk of leading to contractures such as volkmen's contractures and subsequently loss of function a sign of volkmann's contracture is ischemia involving bluish or pale skin decreased hand sensation and severe pain there may be radial nerve involvement and decreased elbow range of motion as well as forearm supination and pronation early rehab after olecranon fractures includes casting it about 60 degrees of elbow flexion and advancing it to 90 degrees as tolerated a posterior posterior i don't know elbow splint may be fabricated to replace the post-operative plaster ones that the surgeon may use and once full active range of motion is achieved the braces discontinued as the patient has regained full range of motion of the elbow right they can begin with full active range of motion and advance to passive range of motion to regain extension and strengthening it is not until this stage that they actually are typically allowed to do some weight bearing through the elbow though moving on to the forearm one classification to know for fractures of the forearm is the type 1 to type 3 system type 1 to 3. type one is for non-displaced type two is for displaced and type three is for community with non-displaced or type one fractures of the forearm they can often benefit from a long arm sling next is the radius and more commonly the distal radius is fractured as people often reach out to them and use their wrists to catch or break their fault an extended risk results in a caulis fracture with dorsal displacement of the wrist because a collise fracture results in dorsal wrist displacement you would use a volar wrist splint for temporary immobilization alcolics fracture may compress on the median nerve and less commonly a flexed wrist fracture usually occurs from high energy trauma and this results in a smith's fracture resulting in volar or palmer displacement of the wrist let's review metacarpal fractures they are named after the location of their fractures for example a bennett's fracture involves the first metacarpal base of the thumb a thumb spica splint would be used for bennett's fractures here's a picture of singer tony bennett unrelated to the bandit fracture with two thumbs up to help you remember this the most common type is boxers fracture involving the fourth or fifth metacarpal named after typically when one throws a punch that connects with the fourth and fifth rather than the second or third knuckles an ulnar gutter splint can be used for a boxer's fracture with wrist fractures a complication is nerve injuries two common nerves that may be injured include the median and ulnar nerves for example patients with median nerve injuries experience similar symptoms as carpal tunnel syndrome carpal tunnel syndrome is due to the compression of the median nerve that runs through the carpal tunnel both types of compression may result in numbness on their associated sides of the innervations of the hand median nerve injuries affect say the first to fourth digits and ulnar affects well the ulnar side such as the fourth and fifth digits moving on to the carpals remember the mnemonic so long to pinky here comes the thumb the most common fracture of the carpals is scaphoid fracture which you would use a thumb spika splint for the top of scaffolding for construction projects resembles sharp spikes scaphoid scaffold spikes spika splint lunate fractures are rare and are also immobilized with the thumb spika splint as well with lunate fractures there is a risk of kinebox disease which is a vascular necrosis of the lunate resulting in lunate osteonecrosis or even death of that location kinebox can result in wrist plane and later stages carpal arthritis a thumb spika splint is also used for most of the remaining carpal fractures as well to remember kind box with the lunate fracture there is an emphasis on the o in the pronunciation and spelling and of all the carpal bones the lunate kind of resembles a circular shape that looks like the letter o fractures in the phalanxes are also possible the proximal is the most common with the thumb and index involving the loss of pip motion that's it for fractures of the upper extremities for the nvcot let's review the upper extremity syndromes and traumas for everything else the muscles tendons nerves of the upper arms let's review the two big c's or c's first complex regional pain syndrome crps and ctd for cumulative trauma disorder crps is considered a vasomotor dysfunction and the hallmark is pain that is disproportionate to the injury there is type 1 with onset after a noxious event and type 2 after a nerve injury in addition to pain symptoms of crps include swelling stiffness contractures skin discoloration that's blue or shiny red sweating hair growth temperature changes muscle spasms and weakness crps may progress through three stages the traumatic stage dystrophic stage which results in the glossy appearance and redness of and heat and the last atrophic stage with the skin cooling down to be dry and cool and a decrease in experience of paint again crps has two types and three stages for ot treatment the big contraindication you must remember is absolutely no passive range of motion or painful intervention you can use gentle active range of motion but again no passive range of motion you can remember this rhyme with com no prom with com no prom com being the calm in complex also respect and manage pain you can use tens continuous passive motion cpm and splinting for pain control address edema early on and sensitivity issues using desensitization techniques tendon glides may also be incorporated as well for patients you may want to provide what's called a vasel motor challenge as this is a vasomotor dysfunction makes sense and this includes things like stress loading i.e floor scrubbing temperature biofeedback and positional changes and remember no splints and no casting one side note is regarding the orthopedics or the surgeons guidelines and protocols as an ot you must follow each individual surgeon's protocol and each one has their own sometimes after surgery when it comes to og practice and interventions like immobilization with splints the types of exercises such as tendon glides and blocking exercises progressive exercises stretching activities strengthening and so on despite what you learned or reviewed that is textbook or typical for ot conditions and interventions the other big c is cumulative trauma disorder ctd the disorder basically defines what it is repetitive trauma rsi for repetitive strain injury overuse syndrome it's the same thing it involves soft tissue trauma from repetitive forces over and over it is a broad umbrella term for more specific diagnoses that you are probably already familiar with or learned in ot school such as epicondylitis carpal tunnel syndrome and tendonitis symptoms include pain inflammation muscle fatigue and sensory impairment ctd has a scale from one to five based on how quickly the pain resolves after a triggering activity grade 1 resolves quickly after the activity all the way up to grade 5 which results in the inability to work due to the severity of the pain even with no activity ot treatment involves the two m's modify and move or movement modify activity demands to avoid repetitive motions and modify performance patterns to incorporate rest modify the context and the environment and use movement different kinds not the same repetitive ones that cause the disorders if the ctd for the patient is a worker's comp case then functional capacity evaluation fce and work hardening may be used let's review the flexor and extensor tendons the tendon zones are kind of similar for the extensor and flexor tendons but they have specific landmark differences on the hand based on which side of the hand you're looking at so for extensor tendons they are divided into zones starting from one just going distal to proximal from the thumb towards the wrist the zone for the other digits besides the thumb also start distally from zone 1 to zone 7 approximately ending at the carpal bones and wrist as well the flexor tendon zones similarly start from zone 1 at the fingertip going to zone 5 at the wrist complications of tendons in the hand are pain edema and loss of function at the tendon injury site thankfully the intervention for tendon repairs is easy to remember tendon glides to promote excursion you'll want to start this early and combine this with modalities which not only can help with the pain but also to promote motion and function common modalities include heat and nmes the usual range of motion is incorporated as well but strengthening begins later on until the healing and recovery after surgery two protocols to remember are duran and kleinert the duran protocol is an early mobilization protocol that uses passive range of motion of the digits exercises are done with wearing a dorsal blocking splint the duran does not use any rubber bands or any active mus muscle contractions in contrast the client protocol does use rubber bands as traction for the digits and instead of passive range of motion the patient performs active digit extension combined with passive digit function from the rubber bands note that extension is active but flexion is still passive for range of motion to remember the kleiner versus duran think of the brand calvin klein for klein earth underwear and the elastic band part that holds it in place in your body kind of for the underwear it has a natural kind of tension that keeps it below your waist right think of this as passive flexion flexion because it goes towards your body from the article of clothing but to take off the underwear you have to actively pull outwards against the underwear band right which you can think of as extension as it is external from your body remembering that the klein art protocol has this band and the different active passive range of motions then you know that the durant protocol is the one without it so no rubber band and no active range of motion in flexion extension one common question is well what happens if the patient cannot follow the protocol such as due to cognition or motivation or something like that then protection such as with a cast may be an option in the first few weeks so that was that for the attendance let's review some nerve injuries it's the major three that you already know median ulnar and radial as these are our nerves remember that there can be both sensory and motor deficits such as sensory loss on the affected side so now's a good time to review hand signs and some tests that may be present with some of these conditions keep in mind that some of these signs may be present with multiple conditions so they are a general kind of clue and not a definitive test or a diagnosis but the nbc ot might go into these and give you a clue of what's going on and mention it like the sign so remembering these signs actually can tell you or clue you in on the deficit and what it kind of looks like and give you more of a visual when you're kind of just looking at text on the screen i encourage you to even make the sign in person and visualize it kind of like counting with your fingers instead of doing mental math for like a math problem or like adding a check so reduce your mental cognition and just use your physical hand and muscle memory and to reduce the brain power during the real exam tinel sign is a pretty broad test for many things like the median and older nerves to name a few to no signs may indicate one carpal tunnel syndrome for the median nerve compression at the wrists two guillains canal for the ulnar nerve and the wrist and three cubital tunnel for the ulnar nerve at the elbow to nil kind of sounds like tunnel and this reminds me of like carpal tunnel or cubital tunnel when you do these tests fromments is the one where you kind of pinch a paper and you pull away to test for pin strength and it kind of sticks up for a positive sign ferment sign may indicate ulnar nerve palsy and a weak pinch grasp of the thumb think of from like when you send a letter it is from you handing it to your favorite crush or something gene sign involves thumb hyper extension at the mcp that may be present with a claw deformity kind of looks like a pair of jeans i don't know wartenberg's sign involves the fifth digit having a space from the fourth digit when you try to adduct them and it kind of forms a w when you separate the thumb from the other three fingers in the middle you have a w finkelstein's test think of it as the opposite of the thumbs up when you tuck your thumb inside your fingers kind of like a turtle your thumb acts and tries to be smaller like a pinky finky rhymes with pinky so finkelstein finky pinky phalen's test is a test for carpal tunnel when you flex both of your wrists and push or dorsum of your hands against each other to remember this if you have really bad carpal tunnel syndrome and you use the pen to write or type an essay like for an exam you would fail phalanx test failing the test a median nerve laceration or compression results in the hand of benediction or pope sign due to the wasting of the thenar eminence and atrophy and when the patient tries to form a fist there is poor thumb opposition and also poor pointer and middle finger flexion at the mcp and pip forming this bishop's hand but it works over here so that's why you get flexion and to me this kind of makes sense because of the nerve laceration on the median side of the hand with the flexion so it affects these which innervates and it's also called a pan because of the wasting of the dnr eminence the splint for conservative treatment or non-op is a static thenar splint that promotes the web space post-operatively you can use a dorsal blocking split and you should also promote active range of motion passive range of motion and tendon glides ulnar nerve laceration or compression results in the claw hand or claw deformity there is wasting of the hypothenar eminence and the intrinsic muscles of the hand it results in a weak power grip a claw hand deformity is formed because of the inability to extend the fingers at the ulnar side for digits 4 and 5 at the ip joints and they remain in flexion the splint used is an anti-claw splint for non-operative and a dorsal blocking splint for post-operative patients one way you can remember this easily is that a dorsal blocking splint is used for both post-op median and ulnar nerve traumas and if you think about it like the anatomy for the median and older nerve side for the non-op splints it kind of makes sense that the dnr splint would be used because it is near the thumb in web space and the anti-claw for the owner because of the claw deformity radial nerve involvement can cause weakness in the wrist extensors so wrist drop and you would use a dorsal splint it's also called saturday night palsy from being intoxicated and resting on a chair or something at the axilla and compressing on the radial nerve a more serious laceration results in difficulty with fine motor tasks such as releasing treatment includes range of motion strengthening and nerve glides now let's go from proximal to distal again for more specific conditions rotator cuff tendinitis involves inflammation or irritation of the tendons and muscles of the shoulder joint it also is called impingement syndrome swimmer's shoulder pitcher shoulder or tennis shoulder and above shoulder level exercises should be avoided and especially when sleeping as it can be accidentally put in this position of comfort for some people unconsciously above shoulder level like sleeping like this for example and ot treatment includes pain management and strengthening a rotator cuff tear results in weakness on mmt in shoulder abduction and external rotation someone with a rotator cuff tear would have a positive drop arm test and trouble with above shoulder activities they may hike their shoulders using their upper trapezius muscles to substitute or compensate for the deficit treatment begins with an arm sling and ot intervention for daily tasks and sling use is gradually reduced to incorporate range of motion stretching and strengthening with a focus on progressive tendon forces for non-surgical patients of rotator cuff tears they should avoid sleeping with the arm above shoulder level as well as abducted and internally rotated start with passive range of motion and progress to active range of motion strengthen the scapula and rotator cuff and use isometric exercises for the surgical repair patient of a rotator cuff tear a common range of motion exercise for the shoulder are pendulum exercises but they sh i can't do the sitting down but they should be pain free ice is a good modality to use as well before during and after therapies to help with pain and also for swelling you can start with passive range of motion in the shoulder for flexion extension and abduction keep in mind that internal and external shoulder rotation should be performed with the shoulder only adducted and not abducted an abductor pillow also makes for a great shoulder immobilizer in between exercises adhesive capsulitis is also known as frozen shoulder adhesive capsulitis results in decreased shoulder range of motion especially external rotation to remember this think about water and like in chemistry changing from a liquid to a solid the adhesive part holds the molecules together like water molecules turning to ice and when frozen in the freezer frozen shoulder research supports various stretches such as abduction and internal external rotation and some others however evidence supporting the use of pams is kind of limited for frozen shoulder sub acromial impingement syndrome results in shoulder pain and functional disability for the shoulder at around 90 degrees into shoulder flow almost knocked over my water bottle into shoulder flexion for treatment of pain pams using laser and also elastic taping can provide significant short-term relief according to the research now let's review lateral and medial epicondylitis lateral epicondylitis is also known as tennis elbow due to cumulative trauma and wrist extensor overuse medial epicondylitis is also known as golfer's elbow and is due to wrist flexor overuse the elbow splint is used for both of these two conditions nice a wrist splint may also be used as well to help immobilize the wrist and to keep it from overuse the cause of these conditions in the first place and patients should also stretch and progress to strengthening now let's review nerve compression syndromes there's median nerve compression ulnar nerve compression and you guessed it radial nerve compression at the different parts of the upper extremity such as the elbow forearm and at the wrist the median nerve compression syndrome is called pronator teres syndrome named for the muscle at the forearm it's kind of like carpal tunnel for the median nerve except that it occurs at the elbow in fact pronator terror syndrome has the same symptoms as carpal tunnel syndrome since it happens at the elbow the splint would be you guessed it an elbow splint in 90 degrees with the forearm in neutral ulnar nerve compression of the elbow is called cubital tunnel syndrome this one is kind of a tongue twister cubital tunnel syndrome symptoms includes pain at the elbow and numbness and tingling along the ulnar side of the forearm and hand a positive tinel sign may indicate cubital tunnel syndrome as well treatment includes the use of an elbow splint as well at night patients can wear a splint or a pad so long as it prevents elbow flexion to remember the elbow syndromes remember the anatomy of the pronator tears muscle and the cubital tunnel and where it's at radial tunnel syndrome it involves the radial nerve at the forearm near the head of the radius distal to the humerus it results in pain at the lateral forearm due to radial nerve compression a long arm splint will be usable for radial tunnel syndrome now we are at the wrist carpal tunnel we kind of went over already for median nerve compression but it would have a positive tinel sign and a positive valence sign treatment for non-surgical includes a wrist splint in neutral carpal tunnel often gets relief from median nerve glides and of course joint protection okay what about ulnar nerve compression at the wrist this is called guillains canal syndrome remember how to nail sign also indicates ulnar nerve compression at the wrist and a neutral wrist splint would be used for guions canal syndrome and it has the same interventions as the other non-splint interventions for carpal tunnel moving towards the end of the video and we are at the thumb and fingertips now game keepers or skiers thumb results in the rupture of the ulnar collateral ligament of the mcp of the thumb use a thumb spika splint and focus on thumb range of motion and strengthening this one is kind of easy to remember because of the gatekeeper's name and the skier's name from the ski poles the queer veins tenocynovitis results in an inflamed tendon at the base of the thumb from ctd cumulative trauma a common cause is repetitive carrying of heavy grocery bags by the handles to remember this the queer veins kind of sounds like a hard alcohol brand to me or something oh yeah isn't there like a dawn cue brand i don't know but because i don't drink anymore but i remember how heavy those alcohol bottles are so carrying them like functionally in grocery bags over time would injure this area of the thumb and main symptoms of de quervains or don q are pain and tenderness at the wrist often below the base of the thumb it may be indicated by a positive finkelstein's test the splint you would use is a thumb spike a splint dupertranscontracture is the thickening and shrinking of the palmar fascia most common in the fourth and fifth digits it results in flexion deformity and it seems that hand splinting for duputrens is controversial and inconclusive so i won't give you any wrong information last for this video we will review boutonnieres swan neck deformities and male finger as well as trigger finger for these you'll want to know how to describe them anatomically or how to recognize it anatomically at which joint in the digits and in which direction that the deformities are in boutonniere's deformity is characterized by pip flexion and dip hyper extension swan neck deformity is characterized by hyperextension at the pip and flexion at the dip which is opposites of the boutonniere deformity mallet finger is characterized by lack of dip extension splints used for all three deformities are ip extension splints or sometimes called 8 or ring splits for which they look kind of like those cool rings on your finger trigger finger you should know for the exam that the medical term is called stenosing tino sinovitis trigger finger often occurs when inflammation narrows the space that surrounds the flexor tendon in the affected finger if stenosing tino synovitis is severe enough a finger may become locked in a bent trigger position requiring external force to extend a splint that therefore prevents mcp flexion at the specific finger would be used that pretty much wraps it up some other important splints you might want to review are the resting hand splint and wrist up splits and don't forget to check out the splints matching game in my nbcot exam prep course to quiz your knowledge of the splints for upper extremity conditions if you found this video helpful give it a thumbs up and share it with your study groups i'm jeff the ot dude thanks for watching and good luck studying