Hand Occupational Therapy Lecture Notes PDF

Hand Occupational Therapy  HAND ANATOMY HAND FUNCTION CLINICAL CONDITIONS THE HAND The important structures of the hand can be divided into several categories. These include bones and joints ligaments and tendons muscles nerves blood ve...

Hand Occupational Therapy  HAND ANATOMY HAND FUNCTION CLINICAL CONDITIONS THE HAND The important structures of the hand can be divided into several categories. These include bones and joints ligaments and tendons muscles nerves blood vessels  There are 27 bones within the wrist and hand  “SHE LOOKS TOO PRETTY, TRY TO CATCH HER” Range of Motion Range of Motion FIST SPHERICAL LATERAL PREHENSION TIP TO TIP DORSAL VIEW 1 Extensor digitorum 2 Extensor digiti minimi 3 Extensor carpi ulnaris 4 Extensor retinaculum 5 First dorsal interosseous muscle 6 Abductor digit minimi 7 Extensor digitorum tendons VOLAR VIEW 1 Abductor pollicis brevis 2 Adductor pollicis 3 Lumbricals 4 Flexor digit minimi 5 Abductor digit minimi 6 Flexor retinaculum 7 Antebrachial fascia 8 Flexor pollicis longus 9 Flexor digitorum superficialis 10 Flexor carpi ulnaris  WRIST EXTENSION EXTENSOR CARPI RADIALIS LONGUS EXTENSOR CARPI ULNARIS EXTENSOR CARPI RADIALIS BREVIS  WRIST FLEXION FLEXOR CARPI RADIALIS FLEXOR CARPI ULNARIS  WRIST ULNAR DEVIATION FLEXOR CARPI ULNARIS EXTENSOR CARPI ULNARIS  WRIST RADIAL DEVIATION FLEXOR CARPI RADIALIS ABDUCTOR POLLICIS LONGUS EXTENSOR CARPI RADIALIS LONGUS EXTENSOR POLLICIS BREVIS  FINGER EXTENSION EXTENSOR DIGITORUM EXTENSOR DIGITI MINIMI COMMUNIS EXTENSOR INDICES  FINGER FLEXION FLEXOR DIGITORUM PROFUNDUS LUMBRICALS FLEXOR DIGITORUM SUPERFICIALIS  FINGER FLEXION PALMAR INTEROSSEI DORSAL INTEROSSEI  FINGER FLEXION FLEXOR DIGITI MINIMI  FINGER ABDUCTION DORSAL INTEROSSEI ABDUCTOR DIGITI MINIMI  FINGER ADDUCTION PALMAR INTEROSSEI  THUMB EXTENSION EXTENSOR POLLICIS LONGUS EXTENSOR POLLICIS BREVIS ABDUCTOR POLLICIS LONGUS  THUMB FLEXION FLEXOR POLLICIS BREVIS FLEXOR POLLICIS LONGUS OPPONENS POLLICIS  THUMB ABDUCTION ABDUCTOR POLLICIS LONGUS ABDUCTOR POLLICIS BREVIS  THUMB ADDUCTION ADDUCTOR POLLICIS  OPPOSITION OF THUMB AND LITTLE FINGER OPPONENS POLLICIS ABDUCTOR POLLICIS BREVIS FLEXOR POLLICIS BREVIS OPPONENS DIGITI MINIMI ARTERIES OF THE HAND There are two arteries entering the hand and these are the: 1. radial 2. ulnar. Together, the branches of these arteries form two arterial arches: 1. superificial 2. deep. ARTERIES OF THE HAND The deep arterial arch is formed mainly by the deep branch of the radial artery and is finished by the deep branch of the ulnar artery. VEINS OF THE HAND The dorsal venous plexus of the hand and the ensuing cephalic (1) and basilic (2) veins drain the superficial aspects of the hand. The cephalic vein ends up in the axillary vein just before it becomes the subclavian and the basilic vein joins the brachial vein to become the axillary vein. Cutaneous Nerves of the Dorsal Aspect of the Forearm NERVES OF THE HAND There are 4 nerves coming into the general area of the hand: posterior antebrachial cutaneous radial ulnar median NERVES OF THE HAND NERVES OF THE HAND Questions and Answers CLINICAL IMPLICATIONS CLINICAL IMPLICATIONS CLINICAL IMPLICATIONS CLINICAL IMPLICATIONS CLINICAL IMPLICATIONS CLINICAL IMPLICATIONS Hand Occupational Therapy WHAT DO WE DO ABOUT IT? Types of Fractures  Hand Fractures A fracture occurs when enough force is applied to a bone to break it. Fractures may be simple with the bone pieces aligned and stable. Other fractures are unstable and the bone fragments tend to displace or shift. How does a fracture affect the hand? A fracture may cause pain, stiffness, and loss of movement. Some fractures will cause an obvious deformity, such as a crooked finger, but many fractures do not. Because of the close relationship of bones to ligaments and tendons, the hand may be stiff and weak after the fracture heals. How are hand fractures treated? A splint or cast may be used to treat a fracture that is not displaced, or to protect a fracture that has been set. Some displaced fractures may need to be set and then held in place with wires or pins without making an incision. This is called closed reduction and internal fixation Other fractures may need surgery to set the bone (open reduction). Once the bone fragments are set, they are held together with pins, plates, or screws Fractures that have been set may be held in place by an “external fixator,” a set of metal bars outside the body attached to pins which are placed in the bone above and below the fracture site, in effect keeping it in traction until the bone heals. Problems with fracture healing include stiffness, shift in position, infection, slow healing, or complete failure to heal.  Treatment of fractures Types of treatment Cast immobilization-A plaster or fiberglass cast is the most common type of fracture treatment, because most broken bones can heal successfully once they have been repositioned and a cast has been applied to keep the broken ends in proper position while they heal. Functional cast or brace-The cast or brace allows limited or "controlled" movement of nearby joints. This treatment is desirable for some but not all fractures. Traction-Traction is usually used to align a bone or bones by a gentle, steady pulling action. The pulling force may be transmitted to the bone through skin tapes or a metal pin through a bone. Open reduction and internal fixation- During this operation, the bone fragments are first repositioned (reduced) into their normal alignment, and then held together with special screws or by attaching metal plates to the outer surface of the bone. The fragments may also be held together by inserting rods down through the marrow space in the center of the bone. These methods of treatment can reposition the fracture fragments very exactly. Because of the risks of surgery, however, and possible complications, such as infection, they are used only when such treatment is to be the most likely to restore the broken bone to normal function. External fixation-In this type of treatment, pins or screws are placed into the broken bone above and below the fracture site. The pins or screws are connected to a metal bar or bars outside the skin. This device is a stabilizing frame that holds the bones in the proper position so they can heal. After an appropriate period of time, the external fixation device is removed.  Hand Fractures The healing process As soon as a fracture occurs, the body acts to protect the injured area, forming a protective blood clot and callus or fibrous tissue. New "threads" of bone cells start to grow on both sides of the fracture line. These threads grow toward each other. The fracture is closed and the callus is absorbed.  DeQuervains DeQuervain's stenosing tenosynovitis is an irritation and swelling of the sheath or tunnel which surrounds the thumb tendons as they pass from the wrist to the thumb. Pain when grasping or pinching and tenderness over the tunnel are the most common symptoms. Sometimes a lump or thickening can be felt in this area. If the hand is made into a fist with the thumb "tucked in" and bent towards the little finger, the pain gets worse (Finkelstein test). Many cases improve with short periods of rest in a splint, followed by stretching exercises designed to get the tendons gliding. Injection with steroids and/or taking anti-inflammatory medications. More severe cases or those that do not respond to other treatment may require surgery. Modification of the activities which caused the symptoms initially also may be required.  De Quervains FINKELSTEIN TEST ABDUCTOR POLLICIS LONGUS AND EXTENSOR POLLICIS BREVIS  Dupuytrens Dupuytren's contracture is a hereditary thickening of the tough tissue called fascia that lies just below the skin of your palm. This condition may vary from small lumps or bands to very thick bands which may eventually pull the fingers into the palm. The mainstay of treatment is surgical and is recommended if there is progressive contracture drawing the fingers into the hand. Sometimes a steriod injection will be used in a painful nodule. Small nodules or lumps in the palm do not need treatment until they are very large and interfere with hand function. Even with successful surgical removal, the bands may reappear or occur in other fingers. Dupuytrens Dupuytrens Sprains  Thumb Sprains These types of injuries are common in sports and falls. The thumb is jammed into another player, the ground, or the ball. The thumb may be bent in an extreme position, causing a sprain. The thumb will usually swell and may show bruising. It is usually very painful to move. The most common ligament to be injured in the thumb is the ulnar collateral ligament. Injury to this ligament is sometimes called “skier’s thumb” because it is a common skiing injury. It occurs when the skier falls and the pole acts as a fulcrum in the hand to bend the thumb in an extreme position. This ligament may also be injured by jamming the thumb on the ground when falling or by jamming the thumb on a ball or other player. How are thumb sprains treated? X-rays are usually taken to make sure the bones of the thumb and hand are not fractured. The thumb is then examined to determine whether the ligament is torn. If the ligament is partially torn, it is usually treated in a cast or splint. Radial collateral ligament injuries are frequently treated this way as well. The end of a completely torn ulnar collateral ligament often gets trapped behind a tendon. Complete ulnar collateral ligament tears are most commonly treated with surgery to repair the ligament. Sometimes the remaining ligament tissue is of poor quality and the ligament must be reconstructed.  Trigger finger Trigger finger is an irritation of the digital sheath which surrounds the flexor tendons. When the tendon sheath becomes thickened or swollen it pinches the tendon and prevents it from gliding smoothly. In some cases the tendon catches and then suddenly releases as though a "trigger" were released. Sometimes the swelling can be treated with rest, activity modification, oral anti-inflammatories, or steroid injections. The tendon sheath will then return to its normal, pain-free condition. More severe cases may require surgery to release the tendon.  Carpal tunnel syndrome Common symptoms of carpal tunnel syndrome are numbness and tingling in the hand, especially at night; pain with prolonged gripping such as holding a steering wheel; or clumsiness in handling objects. Sometimes the pain can go all the way up to the shoulder. These symptoms are caused by pressure on the median nerve as it enters the hand through a tunnel in the wrist. Mild cases can be treated with a splint or brace to rest the wrist. Steroid injections into the carpal canal to decrease swelling may be used in addition to splinting. Those cases that do not respond to nonsurgical treatment and those that are diagnosed late often require surgery. TINELS SIGN  Mallet Finger Mallet finger injuries occur when the tip of a finger or the thumb is forcefully bent. This condition is also known as baseball finger. It happens when a ball or other object strikes the tip of the digit. The force tears the thin tendon that allows you to straighten the finger. The force of the blow may even pull away a piece of bone along with the tendon. A person with this injury has pain, swelling and bruising of the fingertip. The fingertip may droop noticeably. Occasionally, blood collects beneath the nail and the nail can even become detached from beneath the skin fold at the base of the nail. Mallet Finger Boutonniere Deformity  Boutonniere deformity If you jam your finger while playing volleyball or basketball, you might notice that it takes on an odd appearance. The middle joint bends down and the fingertip end joint bends back. This is the characteristic shape of a boutonnière deformity, an injury to the tendons that straighten the fingers. Several tendons work together to straighten the finger. The tendons run along the side and top of the finger. The tendon on the top attaches to the middle bone of the finger (the central slip of tendon). A forceful blow to the bent finger or a cut on the top of the finger can sever the central slip from its attachment to the bone. The tear looks like a buttonhole ("boutonnière" in French); in some cases, the bone can actually pop through the opening. Signs and symptoms Inability to straighten the finger at the middle joint and bend the fingertip. Swelling and pain on the top of the middle joint of the finger. Diagnosis and treatment For the tendon or bone to heal properly, a splint is applied to straighten the finger at the middle joint. This keeps the ends of the tendon from separating as they heal. It is important to keep wearing the splint for the recommended length of time, usually six weeks. After the immobilization period, you may still have to wear the splint at night, and recommended exercises to improve strength and flexibility in your fingers. If you participate in sports, you may have to wear protective splinting or taping for several weeks after the splint is removed. Extensor tendon Extensor Tendon Repair Zone 1- DIP JOINT Zone 2- MIDDLE PHALANX Zone 3- PIP JOINT Zone 4-PROXIMAL PHALANX Zone 5- MCP JOINT Zone 6- DORSUM OF HAND Zone 7- WRIST Zone 8- DORSAL FOREARM  Extensor tendon injuries Extensor tendons, located on the back of the hand and fingers, allow you to straighten your fingers and thumb. These tendons are attached to muscles in the forearm. As the tendons continue into the fingers, they become flat and thin. In the fingers, these tendons are joined by smaller tendons from the muscles in the hand. It is these small-muscle tendons that allow delicate finger motions and coordination. Extensor tendons are just under the skin, directly on the bone, on the back of the hands and fingers. Because of their location, they can be easily injured even by a minor cut. Jamming a finger may cause these thin tendons to rip apart from their attachment to bone. After this type of injury, you may have a hard time straightening one or more joints. Treatment is necessary to return use to the tendon. How are extensor tendon injuries treated? Cuts that split the tendon may need stitches, but tears caused by jamming injuries are usually treated with splints. Splints stop the healing ends of the tendons from pulling apart and should be worn at all times until the tendon is fully healed. What are the common extensor tendon injuries? Mallet finger refers to the droop of the end joint where an extensor tendon has been cut or separated from the bone. Sometimes a piece of bone is pulled off with the tendon, but the result is the same: a fingertip that cannot be straightened. Whether the tendon injury is caused by a cut or jammed finger, splinting is necessary. Often the cut tendon requires stitches. Splinting is done to keep the fingertip straight until the tendon is healed. The size of the splint and length of time you will have to wear it is determined by the type and location of your injury. The splint should remain in place constantly during this time. The tendon may take four to eight weeks, or longer in some patients, to heal completely. Removing the splint early may result in drooping of the fingertip, which may then require additional splinting. Boutonnière deformity describes the bent-down (flexed) position of the middle joint of the finger from a cut or tear of the extensor tendon. Treatment involves splinting the middle joint in a straight position until the injured tendon is fully healed. Sometimes, stitches are necessary when the tendon has been cut. If this injury is not treated, or if the splint is not worn properly, the finger can quickly become even more bent-down and finally stiffen in this position. Be sure to follow your physician’s instructions and wear your splint for a minimum of four-to-eight weeks. Lacerations or cuts on the back of the hand that go through the extensor tendons cause difficulty in straightening the finger at the large joint where the fingers join the hand. These injuries are usually treated by stitching the tendon ends together. Splinting for a tendon injury in this area may include the wrist and part of the finger. Dynamic splinting, which is a splint with slings that allows some finger motion, may be used for injuries of this kind. The dynamic splint allows early movement and protects the healing tendon. Flexor tendon FLEXOR TENDON INJURIES Zone 1-middle of middle phalanx to finger tip (flexor digitorum profundus) Zone 2-middle of middle phalanx to distal palmar crease (flexor tendon superficialis and profundus) Zone 3- distal palmar crease to distal edge of flexor carpal igament (lumbrical zone) Zone 4- the zone under the carpal ligament Zone 5- proximal to wrist joint  Flexor tendon injuries The muscles that bend or flex the fingers are called flexor muscles. These flexor muscles move the fingers through cord-like extensions called tendons, which connect the muscles to bone. The flexor muscles start from the elbow and forearm regions, turn into tendons just past the middle of the forearm, and attach into the bones of the fingers. In the finger, the tendons pass through fibrous rings called pulleys, which guide the tendons and keep them close to the bones, enabling the tendons to move the joints much more effectively. Deep cuts on the palm side of the wrist, hand, or fingers can injure the flexor tendons and nearby nerves and blood vessels. When a tendon is cut, it acts like a rubber band, and its cut ends pull away from each other. A tendon that has not been cut completely through may still allow the fingers to bend, but can cause pain or catching and may eventually tear all the way through. When tendons are cut completely through, the finger joints cannot bend on their own Tendon healing Tendons are made of living cells. If the cut ends of the tendon can be brought back together, healing begins through the cells inside as well as the tissue outside of the tendon. Because the cut ends of a tendon usually separate after an injury, it is not likely that a cut tendon will heal without surgery. There are many ways to repair a cut tendon, and certain types of cuts need a specific type of repair. In the finger, it is important to preserve certain pulleys, and there is very little space between the tendon and pulley in which to perform a repair. Nearby nerves and blood vessels may need to be repaired as well. If unprotected finger motion begins too soon, the tendon repair is likely to pull apart. After four-to-six weeks, the fingers are allowed to move slowly and without resistance. Healing takes place during the first three months after the repair. In most cases, full and normal movement of the injured area does not return after surgery. If it is hard to bend the finger using its own muscle power, it could mean that the repaired tendon has pulled apart or is bogged down in scar tissue. Scarring of the tendon repair is a normal part of the healing process. But in some cases, the scarring can make bending and straightening of the finger very difficult. Hand therapy after surgery If a program of controlled, limited motion is selected as therapy for the first several weeks after surgery, it is important to work closely with a hand therapist and your surgeon to understand the therapy and follow set guidelines. The tendon repair might pull apart if your hand is used too soon or if therapy guidelines are not followed. In addition to regaining motion of the finger after a tendon injury, therapy will be helpful in softening scars and building grip strength.  Splinting Static splints- have no moving To prevent deformity by parts and are primarily used to substituting for weak or absent provide support and muscle strength occurring after immobilization peripheral nerve injuries or Dynamic splints- use devices such neuromuscular disease as rubber bands, velcro strips, or springs to alter the range of To support, protect, or immobilize passive motion of one or more joints to allow healing following joints tendon, nerve, joint, vascular, or sort tissue injury or inflammation Correction of an existing deformity To provide directional control and serve as a basis for the attachment of specialized outrigger devices to facilitate and enhance hand function. Flexor tendon  Experiential Challenges Proper positioning Premature wear of materials Client non-compliance Improper splint care Improper material usage / splint Sensitivity Material usage Questions and Answers