Elbow, Wrist, Hand Pathology

Elbow, Wrist, Hand Pathology

• Michael Garrison, PT, DSc, OCS, SCS is a Clinical Associate Professor.

Altering Outcome Measures

• Tasks 1-6 of the QuickDASH can be replicated in the clinic.
• MCID is achieved after performing the tasks.
• An effect size of 0.6 was achieved following the tasks
• In comparison, the Carpal tunnel release effect size = 0.7.
• Also, the ASAD effect size = 0.9.
• PROMs are used in reimbursement models.
• PROMs are often used to assess quality of care.
• Physical Therapy research often includes interventions that are linked to PROM.
• PROM is only a part of the overall examination.

Agenda

• Biceps injuries ranging from SLAP tears to distal biceps ruptures
• Elbow dislocation and post-traumatic stiffness
• Ulnar collateral ligament injuries
• Nerve compressions
• Medial and lateral epicondylitis
• Carpal tunnel and cubital tunnel syndromes
• Wrist and hand injuries/tendinopathies
• Flexor tendon repair

Biceps Injuries

• The long head (LH) of the biceps plays a significant role in shoulder function.
• It may be a common source of anterior shoulder pain.
• It may also contribute to anterior shoulder stability.
• Biceps injuries are differentiated with tendon sheath injection
• Biceps injuries are treated surgically with either tenodesis or tenotomy.
• Proximal biceps ruptures may be therapeutic.
• Distal biceps ruptures are considered an orthopedic urgency.
• Biceps injuries can complicate symptoms associated with SLAP lesions.

SLAP Lesions

• SLAP lesions are Superior Labral Anterior Posterior lesions.
• The Snyder Classification is used to categorize SLAP lesions.
• Normal vs symptomatic anatomy must be considered.
• SLAP lesions are difficult to distinguish on advanced imaging.
• Tears are noted in 72% asymptomatic subjects over 40
• Common treatment trends involve debriding or repairing the tear, dependent on the type of tear.
• Another treatment trend is releasing the LH biceps, either with tenodesis or tenotomy.
• Rehab implications depend on whether a BT or labral repair was performed.
• Examination considerations include the patient's age and onset of symptoms.
• The location of pain is typically in the anterior shoulder.
• The chief complaint may be pain vs instability.
• The patient's physical demands should be considered.
• Special tests include active compression and Speeds tests.
• Management options include pain management through debridement and biceps tenodesis.
• There is a trend towards biceps procedures for all SLAP lesions.
• SLAP lesions are often seen with other shoulder issues.

Evolving Treatment for SLAP Lesions

• SLAP repair has highly variable results.
• Over 35 less than 50% successful
• Repairs often result in need for 2nd procedure
• Younger and higher demand patients were previously thought to benefit from repair.
• Previous thought repair is beneficial
• Throwers and overhead occupations
• Recent evidence suggests tenodesis is helpful.
• Military members under the age of 35
• No benefit to repair vs biceps tenodesis

Current Trends in SLAP Lesion Treatment

• A trial of nonoperative care including addressing impairments like GIRD, posterior cuff tightness, and scapular dyskinesis is recommended.
• Typically, 8 weeks is adequate of nonoperative care
• Identify the source of symptoms.
• A trial of injection can be helpful for diagnosis.
• Specific injections can help with diagnostics:
• Pain – SAPs, LHB tendonitis, ACJ
• Instability – larger labral tear
• Diagnosis is often difficult.
• Often requires MRA or 3T MRI
• Variable anatomy

SLAP Lesion Postoperative Management

• Options include repair vs debridement alone.
• Associated procedures may include:
• RCR – size, shape, quality, patient demands
• Instability procedure
• SAD, DCE and biceps tenodesis
• A period of immobilization may be required.
• Maintain motion – prevent stiff shoulder
• Progress based on impairments and healing
• Center patient care on functional goals

SLAP repair versus biceps tenodesis postoperative management:

• Sling for 2-4 weeks in SLAP repair
• Immediate passive motion after biceps tenodesis
• Motion restriction for SLAP repair: 4-6 weeks
  • Repair typically for younger and less likely to tighten the joint capsule
  • Repair typically for those with high demand that allow time for healing
• Full motion at 6-8 weeks
• Strength progressions at 6-8 weeks
• Return to Sports (RTS): biceps at 3 months and SLAP repair at 6 months

Distal Biceps Ruptures

• Hook test
• Visible deformity
• Ecchymosis
• Palpable gap
• Tobacco use is a risk factor.
• MOI: Mechanism of distal biceps injury
• Supination weakness
• Tenderness to palpation (TTP)radial tuberosity

Distal Bicep Rupture

• Early surgical repair is advocated.
• Inferior outcomes if delayed by > 4 weeks
  • Tendon retraction
  • Need for graft
• The short head (SH) attaches distally and acts more as an elbow flexor.
• The Long head (LH) is a strong supinator.
• There is a 40-60% loss of supination strength.
• There is a 30% loss of elbow flexion.
• Non-operative management may be considered for older patient with co-morbidities.

Distal Bicep Postop

• Complications include rupture, infection, and fracture.
  • Tendon integrity is crucial for strength return
  • Check for PIN throughout the Post op visit
• Period of immobilization – avoid end range extension Several weeks of controlled motion - brace
• Full motion by 6-8 weeks
• Return to work or sport
  • Dependent on job
  • Most return fully within 2-4 months

Ulnar Collateral Ligament (UCL)

• Bony constraint provides for approx 50% valgus stability
• Soft tissue provides for the other approx 50% valgus stability
• Some soft tissue elements
  • Flexor pronator mass, FCU, joint capsule
  • UCL contains anterior and posterior bands
• Reciprocal function
• AB is tight in extension, laxer in flexion
• PB tight in flexion, laxer in extension
• The anterior bundle provides the most valgus resistance.

UCL Injury

• This is more common with overhead throwers: baseball, football, and javelin.
• Can also affect gymnastics, and wrestling
• Attenuation injury: Constant strain and stretch
• Will not tighten or heal without surgery
• Acute traumatic injury: 1 time event
• Can heal with period of bracing

Risk Factors for UCL Injury

• Fatigue
  • High pitch counts, >100 innings per year
  • Pitching on consecutive days, multiple teams
• High velocity pitching
• Glenohumeral Internal Rotation Deficit (GIRD)
• Hip internal rotation deficits
• Decreased rotator cuff strength
• Core weakness

UCL Injury Management

• Risk factors are preventable.
• UCLR and revisions are increasing in frequency.
• UCLR – Tommy John surgery
• Nonoperative management attempted for most
  • Timing for athletes can dictate treatment
• Double bundle reconstructions
• Patients may benefit from some preop rehab
  • Address any shoulder or hip deficits
  • Emphasize conditioning and explain rehab process

UCLR Postop Rehab

• Consists of a period of immobilization
• Bracing and return of motion by 6-8 weeks
  • Monitor motion progress
  • Can depend on concomitant procedures
  • Ulnar nerve involvement
  • Hamstring autograft - rehab graft site
• Return to throwing
  • Prefer 10-18 months return to full throwing
    • Can depend on timing and career trajectory
    • Dependent on position – pitcher vs DH

UCL Summary

• There is a Rise in high school athletes with UCL injuries.
• Patient must be willing to stop throwing before this surgery.
• Non-op trial appropriate for most patients
• Risk factors can be addressed.
• Surgery is an option if non-op Rx fails.
• Most athletes return to sport – 80%.
• Return to sport may not equal a return to Performance Level Of Function (PLOF).
• Postop return to throwing – 12 – 18 months.

Elbow Dislocation

• Posterolateral dislocations are the most common.
• Dislocation is named for direction of the ulna to the humerus.
• Simple elbow dislocations: -No fracture, immediate motion, hinged brace -Can return to sport in weeks
• Complex elbow dislocations: -Associated with fracture -Controlled motion when cleared by ortho -Surgical fixation allows for early motion

Terrible Triad Elbow Injury

• Elbow dislocation
• Radial head fracture
• Coronoid fracture
• FOOSH with rotation
• Majority treated operatively
  • ORIF
  • LCL reconstruction
  • UCL reconstruction
• Pain, instability, stiffness

Stiff Elbow

• Capsular Pattern is identifiable when the loss of flexion is greater than the loss of extension
• Avoidance of prolonged immobilization
• There is Elbow predisposition to contracture
  • Congruity of ulnohumeral articulation
  • There is Three articulations in one capsule
  • Blending of ligaments with the capsule
• Elbow motion for ADLs
  • 100-degree arc: extension/flexion 30 to 130
  • 50-degree rotation: 50 pronation, and 50 supination Functional impact – patient dependent

Stiff Elbow Physical Therapy Management

• Motion exercises based on impairments
• TherEx integrated with functional tasks
• Dynamic splinting
• Low load long duration flexibility
• Weighted stretching
• Mobilization with movement.
• Contract relax techniques

Epicondylitis

• Lateral epicondylitis – pain with extension, supination
• Medial epicondylitis – pain with flexion, pronation
• Most common in the age - 4th and 5th decades
• Repetitive stress – sport, occupation, recreation
• Ergonmic considerations are relevant
• Increased risk associated with tobacco usage
• Inadequate physical conditioning predisposes to this
• Impairments beyond the elbow

Lateral Epicondylitis

• Degenerative condition of the ECRB
• Causes: repetitve wrist extension
• Rule out the cervical spine, TOS
• Special provocative tests – Mill's, Maudsley, Cozen's
• Tendernes at the lateral epicondyle
• Rx = reassurance, strenthening,
  • Eccentric for chronic conditions
  • Loading of the tendon is important

Medial Epicondylitis

• Is a degenerative condition vs Inflammatory
  • Inflammatory – use anti-inflammatory methods
  • Degenerative – load tendons, some discomfort
• Overuse in sports and occupational tasks
• Rule out cervical spine and TOS
• Rule out other medial elbow conditions
• Special provocative tests– Resisted pronation and flexion
• Tendernes at the lateral epicondyle
• Rx = education and resistance training

Physical Therapy Management

• Education: understanding the natural history, reassurance, etc.
• Local Rx - ice, heat, medicated patches
• Grip modifications
  • Type of grip – palms down, hammer, palm up
  • Size of grip – larger grip = less strain
• Wrist splinting / FSB - possibly may use but there limited evidence
• Eccentric vs concentric training
• There should be No role for passive interventions in isolation
• Need to Objectively measure progress

Posterior Elbow Pain

• Olecranon bursitis
• Primarily inflammatory
• Septic bursitis
  • Open wound
  • Previous aspiration
• Compressive wrapping, elevation, NSAIDs
• Tricep tendonitis
  • Relative rest, and address impairments
  • Progressive tendon loading
• Tricep rupture – pop, swelling, weakness

Nerve Entrapments

• Ulnar nerve
  • Cubital tunnel syndrome
  • Guyon's canal
• Median nerve
  • Carpal tunnel syndrome
  • Pronator syndrome
• Radial nerve
  • Radial nerve proper injury with humeral fx
  • Posterior Interosseous Nerve (PIN) entrapment at radial tunnel

Cubital Tunnel Syndrome

• Differential Diagnosis: Cervical spine (C8-T1), TOS, brachial plexus
• Associated with UCL injuries
• Pressure vs tension
• 2nd most common UE compression neuropathy
• Anatomy
  • Roof – flexor carpi ulnaris (FCU) and Osborne's ligament
  • Floor – Capsule and UCL
  • Medial - Medial epicondyle
  • Lateral - Olecranon

Cubital Tunnel Syndrome

• Causes: Compression vs traction mechanisms
• Narrows during elbow flexion
  • Pain with prolonged postures, AM pain
  • Role for night splinting
• Traction with valgus stress
  • Highly associated with throwing and UCL injury
  • Transposition procedures with UCLR Risk of complications increases
  • Decompression – Arcade of Struthers to flexor carpi ulnaris (FCU)
  • Transposition – alleviate tension

Cubital Tunnel Syndrome Non-Operative Treatment

• Education must have position awareness of the diagnosis
• Patient must be active part of treatment plan
  • Ergonomic changes
  • Compliance with night splinting
  • Activity modification – resting elbow
• Towel wrap more tolerable at night
• Patients are encouraed get: Soft padding to eliminate compression
• Patients are refered Physcialy Therapy (PT) without motor involvement
• Continued monitoring of neuro for worsening

Guyon's Canal

• Hook of hamate and pisiform
• Handlebar palsy, computer use
• Distinguish from other entrapment sites
• Zones of injury
  • Zone I – motor and sensory
  • Zone II – motor only
  • Zone III – sensory only
• Sparing of Flexor Carpi Ulnaris (FCU) and Flexor Digitorum Profundus(FDP) 4&5
• Hypothenar and intrinsic weakness

Ulnar Neuropathy

• Froment sign
  • Loss of adductor pollicis
  • Compensatory FPL (AIN)
• Wartenberg
  • Unopposed 5th digit ABD
  • Extensor Digitorum Minimi (EDM) and Extensor Carpi Ulnaris (EDC)– radial nerve innervation
• Tinel's sign
• Pressure provocation test
• Elbow flexion test

Pronator Syndrome

• Median nerve – C5 – T1 root levels
  • Two heads of pronator teres
  • Proximal aspect of Flexor Digitorum Superficialis (FDS)
• Volar forearm pain, pronator tenderness
• Numbness of first three digits
• Exacerbated by repetitive physical activity
• Differentiate from carpal tunnel compression
  • Sparing of the palmar cutaneous branch
  • Forearm pain

Anterior Interosseous Nerve (AIN)

• Terminal motor branch of median nerve
• AIN compression usually transient neuritis
• Motor only palsy – Motor innervation to the deep anterior forearm
• Flexor Digitorum Profundis (FDP) to index and middle finger
• Pronator quadratus and and Flexor Pollicis Longus (FPL) weakness
• OK sign – inability to flex thumb IP joint

Carpal Tunnel Syndrome (CTS)

• Most common compressive neuropathy
• Accounts for nearly ~50% of work injuries
• Compression of the median nerve
• Repetitive wrist motions, pregnancy, DM, RA
• Pain and tingling at night
• Thenar atrophy
• Special Provocative Tests including Phalen's, reverse Phalen's, Tinel's, compression
• Rule out cervical radiculopathy

CTS

• Pregnancy has shown to be risk related due to edema and hormones
• Symptom presentation has be shown to
  • Intermittent nocturnal paresthesia
• Progression to thenar weakness and atrophy

CTS physical examination will show

• positive Phalen's and Tinel's

• AbPB strength on – hand dynamometry vs MMT

• Pinch dynamometry

• Should Distinguished from cervical radiculopathy, TOS

CTS-6 Symptom Scale

• Numbness predominantly or exclusively in median nerve distribution: 3.5 points
• Nocturnal symptoms: 4 points
• Thenar atrophy or weakness: 5 points
• Positive Phalen's test: 5 points
• Loss of 2-point discrimination (>5 mm): 4.5 points
• Positive Tinel sign: 4 points
• CTS-6 (as reference standard clinical tool)

  • 12 = 0.80 probably of carpal tunnel syndrome

  • 5 = 0.25 probably of carpal tunnel syndrome

CTS Treatment

• Activity modification and education Avoidance of repetitive stress
• Ergonomic considerations Splinting and night splinting
• Impairment based rehab interventions Therapeutic exercise: ROM, nerve mobility, light strengthening Mobilizations: median nerve, other joint dysfunction
• Aggressive observation, reassurance
• Surgical release

Radial Nerve

• C5-T1 nerve roots, C-spine, TOS
• Humeral shaft fractures
  • 10 – 20% of fractures
  • Nerve status dictates initial management
• Saturday night palsy
  • Compressive neuropraxia
  • Also seen with improper crutch use
• Radial tunnel syndrome – pain only
• PIN entrapment – motor loss only

Radial Tunnel Syndrome (RTS)

• Commonly confused with lateral epicondylitis
• Provocation tests
• Resisted supination
• Resisted wrist extension
• Middle finger extension
• Elbow extension, pronation, wrist flexion
• Radial tunnel palpation – 3 cm distal to LE
• Painful condition – no motor or sensory loss

PIN Syndrome

• Distinct from Radial Tunnel Syndrome (RTS) – significant motor loss
• Arcade of Frohse
  • Common site of compression
  • Supinator arch, superior portion of the supinator
• Weakness of thumb and finger extensors.
• Radial deviation during extension
  • Extensor Carpi Ulnaris (ECU) is innervated by the Posterior Interosseous Nerve(PIN)
  • Extensor Carpi Radialis Longus (ECRL) - Radial nerve proper innervation is intact after PIN lesion Complication after distal biceps repair

Extensor Compartments

• ECRL – Radial

Proximal / Distal Innervations

• Ulnar nerve
  • Proximal – Extensor Carpi Ulnaris (FCU)
• Distal = ulnar side Interosseous
• Median nerve
• Proximal – pronator teres
• Distal = lumbricals 1st and 2nd
• Radial nerve – triceps and Extensor Indices

Innervations

• Understand what the functional implications are
• Ulnar nerve – fine motor tasks
• Median nerve – pronation weakness
• Turning a key – ulnar nerve
• Buttoning a shirt – AIN
• Writing - median nerve (CTS), AIN
• Unscrewing top on a jar - CTS, AIN
• Swiping a key card – ulnar nerve

Hand Deformities

• Claw Hand can exist
  • Injury to ulnar nerve
  • Loss of interossei
  • Loss of lumbricals 4 and 5
  • Digits 2 and 3 is mostly unaffected
  • EDX action unopposed – Hyperextension at the MCP
  • Hyperflexion at the IP joints
• Ape Hand
  • High median nerve injury
  • Thumb normally ventral to rest of digits
  • Thenar muscles paralyzed
  • Unopposed adductor pollicis
  • Hand position in the same plane
• Sign of Benediction
  • High median nerve injury
  • Active sign when making fist
  • Resting position is ape's hand
  • Loss of FDS, FPL, FPB, FDP 2 and 3
  • FDP 4 and 5 remain innervated
  • Similar appearance to claw hand
    • Claw hand – ulnar nerve, resting position
    • Benediction – median nerve, making fist

Scaphoid fracture

• Most commonly injured carpal bone
• Hyperextension, radial deviation, pronation
• Can be disabling pain with swelling
• Can also be chronic with remote Hx of injury
• Anatomic snuff box tenderness
• EPL (ulnar border), EPB (radial border) Radial styloid – proximal border
• Testing with axial thumb loading

Scaphoid fracture

• Risk of AVN due to retrograde blood supply
• Proximal and displaced fractures – ortho
• Fractures not always present on 1st Xray Treat like fracture – thumb spica
• Xray again if symptomatic
• Advanced imaging
  • No Xray evidence
  • Still symptomatic

Scaphoid Study Points

• This affects the entire Proximal carpal row
• This is the Most commonly bone injured of carpals bones
• Anatomic snuffbox tenderness
• Risk of AVN due to retrograde blood supply
• Treat like it's a fracture
• Fracture is commonly not present on acute imaging due to swelling or pt guarding
• Need to consider additional imaging after 2 weeks such as CT or MRI

Scapholunate Injuries

• Range of hyperextension injuries
• Sprain with no SL widening
• Unstable dissociation
• Clenched fist view to demonstrate widening
• Terry Thomas sign: widening greater than 3-5mm requires
  • Additional imaging
• In most cases: Normal initial films – treat all the injuries as a potential sprain
• Ortho for separation
• Watson Scaphoid Test

Kienbock's Disease

• Avascular necrosis of the lunate.
• Can be caused from Traum
• Can be caused with Skeletal variations – ulna bone too short
• Unknown cases can be cause which in effect. rarely affects both wrists
• Causes Pain, and swelling stiffness
• Early stages – splinting, activity modification
• Restore motion and limit functional loss
• Later stages – surgical options

DeQuervain's Tenosynovitis

• Repetitive stress injury, thumb extension and Abd
• Involves the 1st EXT compartment – EPB, AbPL
• Positive Finkelstein's provocative test
• Requires the use of a Thumb spica
• Can be improved with Ergonomic adjustments
• Can be reduced after Anti-inflammatory treatments
• Can be rehabed with the development of Impairments based treatment plan Requires the proper knowledge with what Indications are present when use the appropriate Injections, and surgical release

Intersection Syndrome

• Repetitive use injury – 1st and 2nd compartments
• AbPL, EPB and ECRL, ECRB
  • Is seen Common among rowers, clenched fist, thumb Abd
  • 4-6 cm proximal to Lister's tubercle
• Activity modification, reassurance, CSI

Ulnar Sided Wrist Injury

• Triangular fibrocartilage complex
• Soft tissue complex
• Supports DRUJ with gripping and rotating
• Provides cushion during weightbearing
• Hyperextension injuries
• Repetitive stress – rotation and grabbing Diagnosis
• Palpation
• Mechanical symptoms
• Imaging

TFCC Management

• Period of immobilization
• NSAIDS
• Cortisone injection
• Impairment based rehab
• Surgical options •Debridement •Repair with sutures (open or arthroscopic) •Correction of ulnar variance

Ulnar Abutment Syndrome

Ulnar neutral wrist: 20% of force goes through the ulna: Majority of force through the DRUJ

• Ulnar positive wrist – anatomy meets activity: Increased ulnocarpal forces: Increased incidence of ulnar sided wrist pain: Can be related to TFCC injury Short period of immobilization: Management of inflammation: Activity modification: NSAIDs and/or injection: Impairment based rehab: TFCC evaluationDistal ulnar shortening osteotomy: Amount dependent on level of variance: May be combined with TFCC repair/debridement

Forearm Fractures

• Colles fracture
• Distal radius fracture
• Dorsal angulation of distal segment
• FOOSH mechanism -Classic dinner fork deformity
• Smith fracture
• Distal radius fracture Volara angulation of distal segment Fall
  • Fall on flexed wrist

Colles, Barton, Monteggia Fractures

• Barton fracture
  • Intra-articular distal radius fracture
  • Associated radiocarpal dislocation
• MVAs and sports are prevalent in your population
• Osteoporosis and falls in older population
• Monteggia fracture •Proximal 1/3 of the ulna and radial dislocation
• Most common are in Children and Adolescents of 4-10 years old -Rare in adults
• FOOSH with pronation

Hand and Finger Injuries

• Gamekeeper's Thumb: UCL injury of the thumb. Acute injury from Skiier's thumb. Chronic insufficiency. ABD stress of the 1st MCP joint.
• Hand and Finger Injuries
• Stress examination that can create pain and in stability for 6-8 weeks
• Thumb Spica
• Plain films to find and get a r/o in the even of bony avulsion in the injury
• Impairment based rehab and can be useful for a proper and safe progression
• Avoid any stress on the UCL and heal it.
• Stener lesion,
• Adductor aponeurosis between torn UCL and PP,
• Surgery as an option necessary

Hand and Finger Injuries

• Central-Slip Rupture: Forced PIP flexion. Lateral bands migrate volarly.
• Boutonniere deformity - Common in basket ball sports - Physical examination History of PIP injury - jamming or dislocation tenderness to the central slip insertion of DIP stiffness with PIP in extension. Physical Therapy management: • Role for splinting and can have many role to provide to acute phase PIP in the full extension the ability to achieve DIP free to move. Hand and Finger Injuries: Jersey Finger: Forceful hyperextension of the DIP joint and Early examination and management can critical with proper awareness. Delayed management is equal to retraction or can go without pain
• Delayed management can lead to retraction: - early exam is a must
• Delayed exam = Retraction
• May present late as “jammed finger” Eval: hold PIP / ask DIP flexion

Mallet Finger/Swan Neck/RA/OA

• Hand and Finger Injuries:
• Mallet or baseball Finger: Forceful: forceful flexion of the exttended DIP joint - Disruption of terminal extensor tendon - Known as baseball finger
• finger and management is critical
• Fingertip that and drop is in flexion - Unable to extend DIP hold DIP extension •Hand and Finger Injuries: - DIP has its limits due to small bone density - - Encored for proper use that limits risk by keeping it full strength and wearing down 24/7 for up to 6 weeks - PIP can have many role to keep joint free to move.
• Pain if there is a history or even a simple exam during the exam*
• Swan Neck Deformity: Is an Hyperextenson of the PIP (Direct to tear of the volar plate)
• indirect injury: Mallet finger and deformity and have unopposed can have have oppsoe extensors, and will lead toward joint plate laxity test can help test. -rheumatoird can be an in dication on exam: Volar plate tenderness and an injury can mean that a double ring can give some help. Osteoarthritis Rheumatoid arthritis systemic auto immune disoreder Inflamamotry reaction ins ynovial tissue Hand deformioty Mcp ulnar deviaiton Supportive Rx Med rx in RA

Dupuytren's Contracture

• Genetic component
• Palmar fascia contracture
• Build-up of collagen tissue
• Tobacco(Tob) and alcohol (ETOH) increase risk
• Table-top test
• Splinting, ROM in early stages
• Surgical release
• Injectable medications
• Recurrence is common (20-30%)

Flexor Tendons

• FDP: FDS; FPL In the hand 5 annules pulley’s exist
• Thicker and stiffer (Pulley)
• Keep tendons close to the bone
• 3 cruciates pulley's exist
• Flexiable and collapsible
  • allows for tension without pully distoriton
• There 2 annular and 1 olbique are in the Thumb area

Flexor Tendon Healing and Rehab

• There are 2 pathways for tendon healing
  • (intrinsic) Proliferation of Ecm
  • extrensic: healing from from surrounding synoivom (pulley)
• Tendons Have a low abiltiy healing, so is important to be aware of
• Exterinsic tendonds heal faster with sheath extreinsic are a delicate ballance:
• Balance, and must heal as much as possible :Mainttain motion and adhesisons
• rehab is a deliacte call balance
• Protect and Repair time foor healing:
• Maintain maintttian motion and prevent asheeion

Flexor Ten Rehab

• Some Surgeries and perofmred widwaide a and integrity through out rom
• Ensure no addession tough out

Coordination and Surgon

• The are of most and importamce and is must must cordinate and surgeon EARLY- 3/5days start-early time is very important!
• improve's heaaling redcue adhesisonds
• Enhaances the final ###Early ROM and Splinting
• Protecctivre dosrsal splint for 8 weeeks
• Active Extenteion is allowed ( and should be to avoid adhesions)
• Early Arom with robust Repair
• Most return to normal acxtioviues att thhree e month
• Protective night splinting

Trigger Finger

• Trigger finger; inflammation control that causes pain and or disability because (en-trapment) - Thickenss and tendon
• Night splinting and and pulley realese
• Night-time splinting Pulleyin thw A1 area and cause narrow areas pulley
• Pulley inflammation control at level one realese A1.

This lesson covers elbow, wrist, and hand pathology, including biceps injuries, elbow dislocation, ulnar collateral ligament injuries, nerve compressions, and carpal tunnel syndrome. Outcome measures are discussed with tasks to replicate in the clinic. PROMs (patient-reported outcome measures) are used in reimbursement models and to assess quality of care.