Hands PRT1 PDF

Assessment Treatment Pain VAS – 0-10 score (Analogue scale, verbal) Heat :(Heat pack:be mindful not to use in inflamma=on phase...

Assessment Treatment Pain VAS – 0-10 score (Analogue scale, verbal) Heat :(Heat pack:be mindful not to use in inflamma=on phase Get client to rank pain 1-10. Also inquire about: loca=on of (vasodilator) Parafin wax pain (get client to point to self to to body chart) Bath: cannot be used on open wounds, precau=ons clients with Type of pain: Sharp, aching, throbbing nerve injury. Hypersensi=vity and young children. Interview: Dura=on of pain, How long has pain been present, Electro modali9es : TENS Machine only for chronic pain. Cannot be Frequency of pain, Sleep paIerns, Influences on pain: used on people with epilepsy, open wounds, near a tumour/cancer, if Precipita=ng ac=vi=es, Symptom relief you have a pacemaker or cochlear implant. Cannot use electrodes on your head or chest, front of neck or during pregnancy Ice therapy: Not commonly used post surgery or in the presence of wounds. Useful for closed injuries. Contraindica=ons for re- implanta=ons and nerve injuries Oedema Observa=on RICE: Rest, Ice – not to use with wounds/nerve injuries compression Palpa=on And Eleva=on Circumferen=al measurement (Jobst finger tape) Coband: adhesive Volumeter (not to use with wounds) Record quan=ty of Oedema gloves (compression) displaced water, compare against result for unaffected limb Educa=on on hygiene Chip/foam bag: when oedema moves from fluid state to thick oedema Movement!!! Scar Interview, History of injury, Length of =me to achieve wound Compression: Jobst garments, Second Skin garments closure, Ethnicity, Age of pa=ent, Scarring poten=al, check Topical applica=on: mSilicon-gel products previous scars Moulds & Inserts: Otoform Observa=on: colour, size, flat/raised (adhesions) Splin=ng for stretch: Serial splin=ng Skin-Care: Moisturizers Massage Vibra=on Sensa9on Screening, Ask Client : “When I touch your hand does it feel Desensi9sa9on: the same as the other side”, Light touch with coIon wool Graded exposure to s=muli Semes Weinstein Monofilament Tes9ng: Vibra=on using massager Five Monofilaments, Measures touch threshold (Predicts loss Percussion over hypersensi=ve area of Protec=ve sensa=on) Grade from least noxious s=muli to most noxious s=muli Two point Discrimina9on Apply textures to areas surrounding hypersensi=ve area Assessed with a Disk-Criminator Use of sensory paddle during day Sta=c Two Point Discrimina=on: Measures innerva=on density Moving Two Point Discrimina=on: Assess progress of return of nerve func=on (Recogni=on of shapes and texturesàAssess following repair of Median and Ulnar nerve Strength, Manual Muscle tes=ng Exercise PuIy Func9on and Jamar Dynamometer Strengthening Dexterity Pinch meter (lateral, three point, two point) Thera puIy exercises Func9on/dexterity Ask pa=ent/client Ac=ve and passive stretching observa=on Tendon Gliding Exercises Sollerman Hand Func=on Blocking Exercises Nine Hole Peg Test Resis=ve Exercise Minnesota Test Place and Hold Ex’s Purdue Pegboard Buddy straps DASH Cas=ng Range of Mo9on Screen with Func=onal Ac=ve Mo=on Scan: Use Goniometer, Warm up hand and wrist by squeezing sponge in warm water ruler, span diagrams. Consider Inter-rater and Intra-rater If unable to immerse hand in water use a hot pack to warm =ssues reliability Paraffin Wax bat Trophic changes Screen through client/pa=ent report Watch for signs of Vascular Observa=ons: Check colour Complex Regional Pain Syndrome (CRPS) Compare to other limb ↑ pain Specific palpa=on tests ↑ oedema ↓ ROM Changes in skin texture Waxy appearance, hardened nails  Splint Diagnosis Effect on each join Purpose Anatomical and Biomechanical principles evident: Func9on ( ASH ) CMC joint Arthritis Immobilise CMC joint Arthri=s- limits movement Applica=on to disperse pressure. Immobilise- Ulnar Ulnar Collateral MCP joint of of arthri=c CMC joint, hence, Contour to longitudinal, proximal and distal transverse arches. Collateral ligament Hand- ligament injury ( thumb reduces pain Awareness of bony prominences especially MCP of thumb. injury, CMC joint based Skier’s thumb) Limit CMC Ulnar Collateral ligament injury ( Distal edge of palmar sec=on of splint should lie proximal to the Arthritis Mobilise- Thumb Post movement of Skier’s thumb)- prevents radial distal palmar crease to ensure finger MCP flexion is not limited by the Restrict movement thumb devia=on at the MCP joint splint. Splint should accommodate the principles of dual obliquity with the radial side of the splint being longer and higher than the ulnar Capener PIP Flexion contracture Dynamic PIP PIP Flexion contracture- increase Reciprocal parallel forces, three points of pressure Immobilise- Ulnar Splint following intra-articular extension PROM into extension of PIP joint Increase area of force applica=on to disperse pressure Collateral ligament fracture of the proximal force Boutonnière deformity following Force of trac=on is applied perpendicular to the long axis of the bone injury, CMC joint phalanx injury to central slip- maintain being mobilised Arthritis Mobilise- extension of PIP joint to allow Acceptable pressures for dynamic splin=ng ie, force 100-300gm Restrict movement- healing of the tear in the central slip Contour to disperse pressure Finger Fractured middle Posi=on DIP and PIP Fractured middle phalanx without Addi=onal strength through contour Immobilise- Extension phalanx with or joints in extension ORIF – Immobilise bones in Increase area of force applica=on to disperse pressure Fractured middle Splint without ORIF with straps applied extension for healing phalanx Flexion contracture over DIP and PIP Fractured middle phalanx with ORIF Mobilise- Flexion of PIP and DIP joints splint can – support bones in extension, splint contracture joints following a exert a sta=c force removed for AROM following dislocation fracture into extension at Following a fracture or laceration to of PIP joint Restrict DIP and PIP joints volar surface of the finger- increase movement extension of PIP and DIP joints Thumb De Quervains Immobilise wrist, support and Immobilise joints Increase the area of force application to disperse pressure Immobilise – Wrist, Spica CMC and MCP of Awareness of bony prominences especially MCP of thumb st st 1 CMCJ, 1 MCPJ thumb Mobilise Restrict movement MCP Ulnar nerve palsy locks extension of Prevent hyperextension of MCP joints of Reciprocal parallel forces/ ensure three points of pressure Immobilise Extension MCP joints of ring ring and little fingers Contour to distribute pressure Mobilise Block and little fingers Restrict movement Splint PIP Swan Neck Deformity Blocks extension at Prevents hyperextension at the PIP joint reciprocal parallel forces/ ensure three points of pressure Extension PIP joint Contour to distribute pressure Block Splint Elbow Burns to anterior surface Prevents Prevents flexion of elbow joint Reciprocal parallel forces /ensure three points of pressure Immobilise – prevent Splint of elbow splint will flexion/extension of Increase the area of force applica=on to disperse pressure movement at the prevent flexion the elbow elbow contractures of skin Can be used to Mobilise Olecranon fracture apply slight Restrict movement Elbow extension extension force on deficit elbow  Splint Diagnosis Effect on each join Purpose Anatomical and Biomechanical principles evident: Func9on ( ASH ) Wrist Fracture of Scaphoid Prevents movement immobilise wrist, thumb CMC and MCP joints Increase the area of force applica=on to disperse pressure Immobilise Gauntlet at wrist, thumb CMC Contour to longitudinal, proximal and distal transverse arches Mobilise with and MCP joints Awareness of bony prominences especially MCP of thumb Restrict Thumb Distal edge of palmar sec=on of splint should lie proximal to the distal movement post palmar crease to ensure finger MCP flexion is not limited by the splint Splint should accommodate the principles of dual obliquity with the radial side of the splint being longer and higher than the ulnar side of the splint Wrist Fractures of Immobilise wrist Fractures of radius and/or ulna and Increase the area of force application to disperse pressure Splint radius and/or carpal bones- support/ protect healing Contour to longitudinal, proximal and distal transverse arches ulna structures, reduce pain Awareness of bony prominences especially ulnar styloid Fractures of Carpal Tunnel syndrome- position wrist Distal edge of palmar section of splint should lie proximal to the distal triquetrum, to assist to reduce inflammation in palmar crease to ensure finger MCP flexion is not limited by the splint lunate and carpal tunnel and assist to relieve Ensure splint curves around thenar eminence and does not limit thumb hamate Carpal symptoms movement Tunnel Arthritis of wrist-reduce movement in Splint should accommodate the principles of dual obliquity with the radial syndrome arthritic joints and hence reduce pain side of the splint being longer and higher than the ulnar side of the splint Arthritis of joints of the wrist Finger PIP Central slip tear Blocks PIP joint Allow healing of tear in central slip by increase area of force application to disperse pressure Splint Boutonierrre extension prevent PIP flexion Reciprocal parallel forces/three points of pressure Deformity Improve Boutonierrre deformity by promoting healing of central slip, migration of lateral bands back into position so the bands sit dorsal to axis of movement of the PIP joint. Allows flexion of the DIP joint to encourage dorsal movement of the lateral bands. Dorsal Flexor tendon repair Prevents extension Prevent rupture of repaired flexor tendons by Awareness of bony prominences especially ulnar styloid, metacarpal heads Blocking of the wrist, preventing composite extension Distal edge of palmar section of splint should lie proximal to the distal Splint positions MCP joints palmar crease to ensure finger MCP flexion is not limited by the splint in 70 degrees Splint should accommodate the principles of dual obliquity with the radial flexion allows full side of the splint being longer and higher than the ulnar side of the splint extension and Palmar bar of the splint should accommodate the principles of dual flexion of the IP obliquity with the radial side being longer and higher than the ulnar side of joints the splint Palmar bar should not limit digit MCP flexion the distal edge of palmar bar of should lie proximal to the distal palmar crease Splint Diagnosis Effect on each join Purpose Anatomical and Biomechanical principles Func9on ( ASH Splint Ulnar Fractures of the metacarpal or Protect and For Fractures of the metacarpal or proximal phalanx of Increase the area of Force application to disperse Immobilise- when Gutter proximal phalanx of little and/or support little and/or ring fingers treated with closed reduction pressure used for fracture of ring fingers treated with closed MCP in flex, and immobilization. Splint is for immobilization for Contour to longitudinal, proximal and distal proximal phalanx reduction and immobilization. PIP and DIP healing. transverse arches with closed Splint is worn continuously, in Fractures of the metacarpal or proximal phalanx of little Awareness of bony prominences especially ulnar reduction and removed only once per day for skin extension and/or ring fingers treated with ORIF. Splint is for styloid and MCP heads immobilization hygiene and hand is not moved protection, pain relief and assists in positioning joints at Splint should accommodate the principles of dual when splint is off. angles that prevents shortening of joint ligaments and obliquity with the radial side of the splint being Restrict movement- Fractures of the metacarpal or joint structures. longer and higher than the ulnar side of the splint proximal phalanx of little and/or ring fingers treated with ORIF. Splint is worn throughout the day but is removed regularly for AROM exercises. Mallet Mallet finger injury immobilise Mallet finger injury – position DIP joint in Circumferential to increase surface area to immobilise- Tuft Finger DIP joint in hyperextension to position extensor tendon with or reduce pressure fractures and mallet Fracture of distal phalanx ( tuft finger injuries Style Splint extension without bone avulsion fragment back onto it’s insertion Reciprocal parallel forces/three points of fracture) on the distal phalanx to permit healing pressure Mobilise Protective splint for finger tip Fracture of distal phalanx ( tuft fracture)- stabilize and Restrict movement- lacerations/amputations protect fracture segments to allow healing Protective splint for nail bed Protective splint for finger tip lacerations/amputations- repairs protect and assist with pain and encourage healing by preventing re-injury. Splint is removed is removed for AROM exercises. Protective splint for nail bed repairs- protect and assist with pain and encourage healing by preventing re- injury. Splint is removed for AROM exercises Hand- Fractures of the proximal phalanx protect and For Fractures of the proximal phalanx treated with Increase the area of Force application to disperse Immobilise- when based MCP of little, ring, and/or middle fingers support closed reduction and immobilization. Splint is for pressure used for fracture of Flex PIP ext treated with closed reduction and MCP in immobilization for healing. Contour to longitudinal, proximal and distal proximal phalanx Splin immobilization. Splint is worn flexion PIP Fractures of the proximal phalanx of little and/or ring transverse arches with closed continuously, removed only once in fingers treated with ORIF. Splint is for protection, pain Awareness of bony prominences especially ulnar reduction and per day for skin hygiene and hand extension relief and assists in positioning joints at angles that styloid and MCP heads immobilization is not moved when splint is off. prevents shortening of joint ligaments and joint Splint should accommodate the principles of dual Fractures of the proximal phalanx structures obliquity with the radial side of the splint being Mobilise of little, ring and/or middle fingers longer and higher than the ulnar side of the splint Restrict movement- treated with ORIF. Splint is worn throughout the day but is removed regularly for AROM exercises.  Wound Healing Normal Func9on requires: Abnormal Func9on: Hand Therapy: Principles of Wound Healing Phases of wound healing smooth gliding between the joint surfaces Injuries and impairments to Influences the response of the body to The hand is made up of different structures 1. Inflamma=on phase of some very small and delicate bones the hand and upper limb injury or impairment: and systems including Skeletal, 2. Fibroplasia or prolifera=ve phase excursion and glide of tendons over long create disrup=ons to these 1. through movement encourage Neurovascular Integumentary, Muscular 3. Matura=on or Remodelling phase distances under an intricate arrangements processes structures, such as tendons, to move and Som =ssue of pulleys Prevent joint surfaces from and glide and hence prevent All wounds undergo an inflammatory support of an underlying bone framework moving easily over each adhesions process as a normal part of healing. via strong ligaments to hold bones together other 2. immobilize to allow healing and Wound healing follows three key but also allow required movement Adhere structures together =ghtening of structures that need to overlapping stages that are predictable and nerve supply to skin, muscles and joints and prevent tendons from provide stability, e.g. bone and sequen=al gliding ligaments Healing of Major Structures Factors to Consider in Healing Structures with good blood supply such as structures involved Phase Treatment goals Type of splints/casts muscle heal faster compared to structures =ming of healing Inflamma9on Begins immediately following injury Manage pain Sta=c splin=ng to that do not have a good blood supply, such as mechanism of injury phase Con=nues for approximately 4 days and oedema. immobilize for tendons. surgical interven=on Vascular and cellular response is to destroy bacteria and clear wound Rest or gentle healing. Think about the colour of the structures, red health of pa=ent 1-4 days of dead & dying cells mo=on Cas=ng to coloured structures have good blood supply. mental health of pa=ent Migra=on of white blood cells to the injured area and phagocytosis Low rep’s immobilize White or opaque structures have poor blood pa=ent mo=va=on Ini=ally vasoconstric=on then vasodila=on No/minimal supply. Causing Redness, Oedema, Heat and Pain ADL’s Fibroplasia Ini=ally a loose matrix of collagen, fibrin and blood vessels is formed Con=nue edema Immobiliza=on Skin Days Simple wounds heal quickly. Can tolerate mo=on in 2 to phase Collagen increases rapidly for approximately three weeks management. splin=ng 5 days. Complex or open wounds can take weeks Skin Healing process does not differen=ate between various structures and Increase or Sta=c progressive grams and flaps 1-2 weeks+ Commences 4 will bind everything together maintain joint splin=ng Blood Days Blood vessels that have been surgically repaired require days amer é Collagen, é Fibrin, Developing Adhesions mobility and som Dynamic splin=ng Vessels one to two weeks of immobiliza=on or protec=on from surgery. Encourage wound to differen=ate between structures =ssue mobility. full ROM in a direc=on that would stretch the repair Last for 2-6 Allow movement and glide between structures with splin=ng and Low to mod rep’s Nerves 3-4 Recovery involves axonal regenera=on usually takes weeks controlled range of mo=on exercises/ac=vi=es Light ADL’s weeks months. Protect repaired nerve from tension for 3 to 4 weeks. Amer complete transec=on, axonal regenera=on Matura9on May last from several months to a year or more Mobility Sta=c progressive phase Reorganiza=on of the matrix of collagen, fibrin and blood vessels Strengthening splin=ng may occur at 1mm per day, amer 3-to-4-week latent 3-6 weeks Remodelling of the wound, with an increase in tensile strength Endurance Serial sta=c period Muscles Muscles and musculotendinous junc=ons are vascular exercise splin=ng structures, therefore they heal more quickly High rep’s Serial cas=ng Generally, immobilise for 2-3 weeks, then begin gradual Resis=ve ADL’s / 2-3 mobilisa=on. Muscles fibres can form adhesions and Months shorten as they heal Inflammatory process of bones Consequences of Immobilisa9on Wound Healing Principles Tendons Blood supply to tendons is small and fragile. 1. Inflamma9on: oedema, bleeding into Without being used or moved the diseased or Treatment aims to apply controlled range of mo=on With early protected mo=on can heal intrinsically (from marrow cavity, forma=on of fracture injured hand will become s9ff and will lose exercises to achieve smooth gliding between the within). Requires 6-12 weeks protec=on haematoma range of mo9on and func9on various structures of the hand. Bone Weeks to Months to years 2. Fibroblas9c phase: Forma=on of Forma=on of adhesions between folds of Treatment or Interven9ons Varies depending which bone has been fractured fracture callus to bridge the gap synovial lining Effec=ve oedema management Surgical fixa=on can affect stability between the two bone ends. Clinical Atrophy of car=lage of joint surfaces Immobilize injured =ssues if required. Ar=cular surface/ joints: Car=lage has poor blood supply union is achieved when the fracture Osteoporosis of bones Protected mobiliza=on, limit extreme ROM. : Nutri=on is through diffusion and compression via joint callus is strong enough to prevent Wound healing process creates scar =ssue Maintain ROM of uninvolved joints mo=on movement at the fracture site that binds all structures together Pain management to allow ROM. Car=lage heals slowly, without true regenera=on of 3. Remodelling phase: Gradual changes Scar management hyaline car=lage in shape of nearly the formed bone Desensi=za=on Ligaments: Avascular structures, slow to heal. Scarring can limit Assistance with ADL mo=on and cause contractures Injury causes instability Strengthening of the joint Nerve Injuries Condi9on Sensory Impact Motor Impact Assessments Treatment Post Op Treatment Median Carpal Tunnel Syndrome: Compression of Altered/Decreased Dropping objects Interview Educa=on Tendon Gliding exercises ( no Nerve the median nerve at the carpal tunnel sensa=on over the radial Notable was=ng of the Pain Ax Analogue scale Orthoses: Fabricate contraindica=ons) Can be managed non-surgically in mild aspect of the volar surface thenar eminence in severe Impact on occupa=onal Night-=me wear with Oedema Management cases but more severe cases need surgical involving the thumb, index cases. (as innerva=on by performance and wrist in neutral (gives o Rest interven=on finger, middle finger and median nerve= was=ng and par=cipa=on nerve maximum amount o Compression radial side of the ring finger concaving) History of of space to heal) o Eleva=on Waking at night with dysfunc=on/symptoms Task Analysis: Ac=vity Desensi=sa=on/Sensory Re- numbness and =ngling (progression over =me) modifica=on. Night-=me educa=on( around surgery site) Dropping objects (motor acutely/ chronic sleeping posi=ons- try Wound/Scar management and sensory Observa=on of hand not to seep with flexed o Dressings Ulnar High Altered/Decreased Decreased gross grip Sensory assessments wrist (splint should help) o Contact Nerve Cubital Tunnel compression sensa=on over the ulnar strength Screening Ongoing observa=on of media Lacera=on aspect of the volar and Decreased strength Semmes-Weinstein symptom o Scar dorsal surfaces involving the abduc=on/adduc=on Monofilaments severity/return of motor Massage Low ulnar side of the ring finger Notable was=ng of the 2pt discrimina=on and sensory func=on Ac=vity Modifica=on Guyon’s Canal Compression and the liIle finger hypothenar eminence and Tinel’s and Phalen’s Pain Management Gentle grading Can be managed non-surgically in Waking at night with intrinsic in severe cases. Comparison to other Range of Mo=on: mild cases but more severe cases may numbness and =ngling in Claw Deformi=es muscle side but be cau=ous as Tendon Gliding exercises need surgical interven=on the hand waystage can omen have CTS on ( no contraindica=ons) Dropping objects (motor Claw: 4th and 5th lumbricals bilaterally – causa=on= Oedema Management: and sensory are innovated by ulnar pregnancy/ Rest, Compression and nerve osteoarthri=s may Eleva=on Radial Compression Injury occur on both sides Desensi=sa=on/Sensory nerve Commonly known as “Saturday Re-educa=on( around Night Palsy” Grip Strength surgery site) Compression occurs at the level of Gross grip (Jamar) Wound/Scar the humerus Pinch Strength management: Dressings, Motor and Sensory loss MMT Contact media and Scar Lacera=on Wound/Scar if post op Massage Most common following humerus Motor and Sensory loss Observa=on Ac=vity Modifica=on fracture Measurement, Gentle grading Long recovery period photographs if Management largely the same as required. compression except longer =me ROM frame and post-surgical Screening wound/scar/pain management Goniometry Digital Lacera=on Loss of sensa=on over the No motor involvement Nerve Quite common ulnar or radial aspect of the Lacera9on Omen isolated to one finger but can finger distal to the be more than one in some lacera=on (depending on circumstances which digital nerve was Omen occurs in conjunc=on with lacerated. damage to other structures, namely tendon injuries. (2 either side)  Nerves Nerve Recovery Nerve Latency: 3-4 weeks of dormancy (Once nerve has been cut, nerve goes into dormant period known as Wallerian degenera=on where the nerve starts to heal Slow Recovery – 1mm/day Sensory End Organ Viability: 6 months Motor End Point Viability: 3 years- muscles will become atrophy and weak Central Nervous System Remapping- neuroplas=city – a lot of incoordina=on sensory reorganisa=ons Overarching principles Motor and/or Sensory Loss (median ulnar and nerves motor and sensory, digital nerve is sensory only) Compensa=on for motor/sensory loss (if present) (compensatory as cannot speed up nerve healing) Educa=on for protec=on using other mechanism if sensory loss (e.g cau=ous around heat-burning) Orthosis and adap=ons to ac=vates Impact on func=on dependant on loca=on of nerve disrup=on Can be quite a complex assessment phase Omen long-=me frames if lacera=on of nerves occur/ proximal (closer to spine) Affec9ng Recovery Nature of Injury -Dirty lacera=on, Crush vs sharp, lacera=on vs compression Age General Health – Diabetes, Nutri=on, Peripheral Vascular Disease, Smoking Mixed vs unmixed (more than one nerve? Or mul=ple- present with more complica=ons) Motor vs Sensory – Motor end plates 3yrs? Sensory end organs 6mths?  Tendon Injury Management of Tendon Repairs Consequences of immobilisa9on Without being used or moved diseases/ injured hands will becomes s=ff and will lose ROM. Wound OT Role: Tendon Injury Time Frames Assessment of client & injury related factors healing process created scar =ssue that binds all structures together Therapy aims to move the repaired Research has found when the tendon repair Evalua=on of tendon func=on and healing (adhesions) tendons sufficiently to prevent is immobilised somening occurs in the ini=al Liaise with surgeon to determine protocol adhesions to surrounding structures ~5 days post-op Constant review of progress Wound healing principles: Aim to achieve controlled smooth gliding of At the same =me ensuring the tension The same tendons when mobilised in the Modify protocol as required mo=on without tendon rupture of the movement does not cause the ini=al ~5 days post-op did not somen repaired tendon to rupture or stretch Indica=ons for passive & ac=ve mobilisa=on Treatment/ interven9ons: Tendon Repair Aim protocols Effec=ve oedema management § Aim: to move the repaired tendons sufficiently to prevent Immobilise injured =ssues if required adhesions to surrounding structures Healing (Tendons 2-3 Months) Protected mobilisa=on, limit extreme ROM § At the same =me ensuring the tension of the movement does not Phase Treatment Goals Type of orthosis Maintain ROM of uninvolved joints cause the repaired tendon to rupture or stretch 1. Inflammatory Manage pain and oedema Immobilisa=on splin=ng Pain management to allow ROM phase Rest or gentle mo=on Serial sta=c splin=ng Scar management Tendon healing: (Graded approach, of control movement and Wound care if necessary Desensi=sa=on restric=ng force) 2. Proliferate or Assistance with ADL Con=nue oedema Serial sta=c splin=ng Ini=ally the suture holds the two ends of the tendon together fibroplasia phase Strengthening (occurs late in healing process, do not spart management Sta=c progressive As tendon progresses through the wound healing process scar Increase or maintain joint splin=ng resis=ve strengthening before 8 weeks ) (earliest – squeezing =ssue develops and behind to join the two ends of to the tendon sponge/ bucket of rice. Introduce puxng 9-10 weeks) mobility and som =ssue Dynamic splin=ng together mobility Without movement of the tendon the scar =ssue that develops Orthosis 3. Remodelling or Mobility Serial sta=c splin=ng between the ends of the severed sec=ons will not only bind the Used to protect a healing tendon by preven=ng or limi=ng matura=on phase Strengthening (late) Sta=c progressive two ends of the tendon together but will also bind the severed the ROM into the direc=on that would tear apart the Endurance (late) splin=ng tendon ends to surrounding structures including; tendon sheath, repair bone, pulleys. Joint posi=ons are also chosen that reduce the possibility of =ghtening of joint ligaments that may create problems Treatment choices Flexor Extensor Flexor Tendon Zones Extensor Tendon Zones when commencing ROM Immobilisa9on May be appropriate Appropriate for non- Zone 1,3= not a lot of som =ssue Odd zones on joints Immobilise in a splint or cast for 3- for non-compliant & compliant & mul=- Zone 2= Annular ligaments (A1,A2,A4 Zone 1 and 2= Mobilisa=on, only isolate DIP Tendon Nutri9on 4 weeks. If pa=ent presents 10 days mul=-trauma pa=ents trauma pa=ents pulley)- lacera=on = worse adhesions, Zone 3 and 4, 5 and 6, 7 and 8= Early ac=ve Poor / small blood supply post-surgery flexor= Cheaper and easier reduced ROM protocols Nutrients are provided to tendons directly immobilisa=on/ passive to implement Used through blood supplied via blood vessels to Followed by ac=ve and passive in Zone 1 /2 injuries the tendons and vincula. mobiliza=on (6-8 week) Nutrients are also provided via diffusion Immediate (Early) Passive Tolerated by two § Not commonly used into the tendon from the synovial fluid Mobilisa9on strand suture § Expensive and surrounding the tendon Use other hand or rubber bands technique. requires high level Movement of the tendon within the fingers to create glide of the Tolerated if infec=on of therapist skill tendon sheath is thought to assist with repaired tendon. (not used much. present (infec=on can diffusion of nutrients Not used in flexor as contractures result in slower with FDP) Use other hand to flex, healing and weaker Blood Supply: Flexor Tendons then use extensor muscles to repair) Long and short Vincula extend to splint Blood vessels at musculotendinous junc=on Includes protected ac=ve and the tendon inser=on mobilisa=on of uninjured structures Immediate (Early) Ac9ve Use for all flexor Short Arc mo=on Jersey finger Mallet Finger Mobilisa9on tendons if able to (SAM) – Zone 3 Protected ac=ve ROM of repaired Requires four strand Rela=ve mo=on on tendon suture technique. (RM) Zone 4-7 Includes protected ac=ve Need to commence mobilisa=on of uninjured before 5-7 days post- structures op for advantage of Includes protected passive ROM of reduced somening of repaired tendon the ends of the Flexor tendon Zone 1 Extensor zone one Injury Tendon to tendon repairs No dynamic components (elas=c repaired tendon FDS is working, FDP is not Nil extension of DIP Zplasty= reduce adhesions bands etc.) Nil flexion at DIP Mobilisa=on required (scare =ssue) along en=rety of tendons  Orthosis Func9ons of an orthoses Ortho9c Precau9ons Wri`en Instruc9ons including: Immobiliza=on Impaired Skin integrity American Society of Hand Therapists § Wearing schedule for day and night Mobiliza=on Pain Func9ons of a Splint § Possible complica=ons Restric=on Swelling Immobilize § Precau=ons S=ffness Mobilize § Cleaning instruc=ons Purpose of Orthoses Sensory Disturbances Restrict § Contact details for therapist Support a painful joint Increased stress on unsplinted joints Purpose of Splin9ng § Date for review appointment Immobilize for healing Func=onal limita=ons Support a painful joint Restrict unwanted mo=on Immobilize for healing Consider pa9ent factors Prevent contractures Splint Precau9ons Protect =ssues § Have pa=ent demonstrate to you removing and reapplying the Subs=tute for weak or absent muscles Splin=ng material may Provide stability splint completely Restore mobility § S=ck to nail polish on finger nails § Ask pa=ent to explain to you : Restrict unwanted mo=on § Bond to acrylic nails § How omen the splint will be worn Restore mobility Materials § Splints melt if lem on § The length of =me of each wear Subs=tute for weak or absent muscles Low temperature thermoplas=cs: § the dashboard of the car § What precau=ons to be aware of Prevent contractures primary resource § For 24/24 hour wear guidelines for self care with Modify Tone splint on Plaster of Paris Neoprene Splints during inflamma9on Leather Inflamma9on Phase Lycra Support a Painful Use splints to rest, immobilise or protect healing =ssues. Joint Low Temperature Thermoplas9cs Use posi=ons that prevent shortening of =ssues e.g posi=on of § Either Rubber based or Plas=c based or combina=on safe immobilisa=on (especially ligament =ssues to prevent joint of both Plas=c/rubber combina=ons contrac=on)- safety posi=on of immobilisa=on § Somen at 60-70 degrees (working temperature) : Fibroplasia Phase Immobilize for become more malleable, and are able to be moulded Use splints to rest and protect healing =ssues. Healing) and shaped. Become hard and rigid once cooled Also use splints to facilitate organisa=on and differen=a=on of (for fractures scar =ssue. immobilise joint Characteris9cs of Low Temperature Thermoplas9cs above and below § Ac9va9on Temperature: when plas=c become som, maluable and responds to moulding Matura9on or Remodelling Phase Restrict Unwanted § Mouldability: way it sits and confirms to upper limb Remodelling of =ssues is a normal process our Mo9on § Drapability bodies con=nually undergo. § Elas9c memory: how well they adhere to other fabrics Use splints to apply forces to encourage =ssue to § Coa=ngs & self adherence lengthen or shorten. § Transparency when heated Use splints to apply forces to modify adhesions and separate § Perfora9ons: how many holes= breathability as result =ssues. skin to prevent trapped moisture or skin degrada=on Prevent as result of splint being in stature for prolonged =me Influence of mobilising splints on 9ssues Contractures § Gentle stretch with low load stress applied § Tissues lengthen and grow in response Materials used for splints made in class: § Need to posi=on joints and =ssues at end range Mallet Finger splint: Orfit Colours 2.00mm § The =me the joint is held at end range or TERT is Thumb abduc9on splint: Ezeform 3.2 mm rubber based important product PIP extension block splint: Orfit Colours 2.00mm Serial Sta9c Splints Volar forearm/hand res9ng splint Ezeform 3.2mm Described as mobilising because designed to mobilise or rubber based product lengthen =ssues Subs9tute for Weak Wrist Extension splint: Orfit Colours 2.00mm Moulded in one posi=on at the end range or Absent Muscles Thumbpost splint>Orfit Colours 2.00mm Removed and remoulded at new end range Worn for up to 10 to 24 hours per day Possible loss of AROM in opposite direc=on Sta9c Progressive Splints Restore Mobility Construc=on similar to dynamic splints Except mobilising force is not dynamic Tissues posi=oned at end range for prescribed =me Adjustments are made as =ssues lengthen  Fractures OT Role Fracture with No Internal Fixa9on (no surgery) Fracture: A structural break or disrup=on of the con=nuity of a bone, Bone sec9ons Immobilize the joint below and above the fracture epiphyseal plate or a car=laginous joint surface Use posi=ons of immobiliza=on that prevent s=ffness of Interven9on is based on: joints Cor9cal vs cancellous bone 1. Degree of injury Maintain ROM of uninvolved structures Cor9cal: denser (white) 2. Type of surgery Cancellous: more Pours Reduce Oedema 3. Stage of healing Reduce pain 4. Client’s co- Pa=ent/client educa=on opera=on Provide compensatory techniques for ADL Metaphysis: spongey bone, mix Maintain Occupa=onal Roles Primary vs Secondary Bone Healing Primary: Open-reduc=on Internal Fixa=on (ORIF) – where between cor=cal bone and callouses bone Fracture with Internal Fixa9on (surgery) surgeons has opened and a hardware to supply stability. Brace or support the healing bone Stable fracture type= no stability metal required Diaphysis: high level of cor=cal bone (strength), but low levels Use posi=ons of support that prevent s=ffness of joints of cancellous bone (spongey), If deemed safe by surgeon - commence safe AROM out Advantages low vascularity. Long bone e.g. of brace/support – no func=onal use Stability humerus midsham, take longer Maintain ROM of uninvolved structures anatomical realignment to heal due to poor blood Reduce Oedema = early ROM (can do exercises earlier) supply) Reduce Pain beIer access for oedema management (can Wound/scar management take splint/ orthosis on and off due to stability Pa=ent/client educa=on of hardware (wires, plates etc)- use pressure Provide compensatory techniques for ADL garments Disadvantages Maintain Occupa=onal Roles Scarring (Open reduc=on)= adhesions = decrease ROM (but is omen counteracted by EAP) Crucial factors in recovery Risk of infec=on as result of wound Immobiliza=on as short as possible Opera=ve risk – anaesthe=c, damage to other Immobilized longer if unstable anatomical structures Safe posi=on (near to close-packed) Costs Treatment towards func=onal outcomes Secondary Bone healing Body’s natural mechanisms of healing = similar Close-packed joint posi9on to wound healing) Ar=cular surface maximally congruent, Primary goes through however without compressed hardwire we need to be aware as no stability (bone touching bone (maximums provided by plate amounts = maximum stability) Ligaments with maximum stretch= Factors Affec9ng treatment protocols stability Factors affec9ng fracture healing Fibrous capsule/ligament max The type of fracture - eg. spiral, transverse, complete, displaced, pathological. Inadequate reduc=on= instability spiralized/taut Stability - a stable fracture will resist displacement when exposed to physiological (reduc=on, placing displaced bones/ fractures back into anatomical alignment) No further philological movement load, an unstable fracture will not (FESS, 2003). Unstable fractures must have alignment maintained by external supports (splints, plaster, surgical fixa=on) un=l Nico=ne: hinders the process of bone healing by causing the blood vessels to possible sufficient healing has occurred. constrict, which therefore lowers the amount of nutrients that are able to be Accessory movement min/nil Fixa9on - surgical op=ons include Kirschner wires (K wire), wiring, lag screws, supplied to the bones. plates, intermedullary fixa=on and external fixa=on. K wires commonly require Inadequate Immobiliza=on: can cause displacement Close-packed posi9on in hand addi=onal external support as they do not provide rigid external support. Loss of blood supply Semi-prona=on Associated sod 9ssue involvement - Other =ssues may have been involved and Infec=on Wrist Extension consider needs to be given to =ssue healing principles of these structures. Intra Adequate nutri=on”: (including calcium intake) will help the bone healing process. MCP (2 to 5 finger full Flex)* ar=cular fractures present with addi=onal problems due to the risk of ar=cular Weight bearing stress on bone , amer the bone has healed sufficiently to bear IPs Extended scarring and s=ffness and where possible mo=on should be started early and this weight, helps to build bone strength. 1 st MCP opposi=on (opposed) like may require distrac=on splin=ng. Use of an9-inflammatories hinder bone healing due to inhibi=on of holding cup, safety posi=on of Pa9ent related factors including compliance, associated disease and PMH, age, prostaglandins which are hormones that contribute to bone forma=on. immobiliza=on func=onal demands Age Close-packed joint posi=on shorten intrinsic muscles  Fractures Healing 8meframes Inflamma'on Stage Gentle, so* movement (Too aggressive PROM = further damage) = decreased adhesion (1 – 5 days) Gentle ac>ve movement the best, within the pain threshold of the client, it will promote growth (beBer circula>on and nutrients to the injured site) to Haematoma forms against inflamma>on. around fracture (big Three to four short gentle treatment will be enough collec>on of blood, Too aggressive damage the structures (ligaments/tendons are is loose, joints are less protest, car>lage between joint may erose because to improper building rich use of passive movement at this stage, resul>ng in OA environment for healing) Fibroblas'c Stage ABen>on to specific goals (ADLS), managing expecta>ons of return to work/ sport) Graded treatment: increase ac>ve range of mo>on towards 6 week (6 days to 4-6 weeks) Protec>on of healing structures Regain Max ROM, muscle power as soon as possible Hard callous forms, Immobiliza>on for ~6 weeks = permanent s>ffness and decreased elas>city of >ssue detectable (cloudy) on It is the most important stage to regain func>ons. Once this period is over, the improvement will be minimal. Xray, strong for early "push to get the maximal outcome, but allow the healing to con>nue" ac>ve mo>on- not near Ac>ve movement is s>ll the best, but "passive stretching or pushing" of joints by pa>ent (with the pain limits) can be used at this stage. If limita>ons of ROM is due to clinically healed change of joint integrity, passive stretching can cause more harm than good. Educa>on of the pa>ent either to accept the deficit or work hard to build up the muscle power “s>cky bone: – osteoclast for another opera>on (talk to the surgeon first before). and osteoblasts Repe>>ve and medium resis>ve ac>vi>es is best to build up power. Again, medium dosage, but regular. Rather than large dosage and cause pain and rest for two days. Frequency of the treatment ac>vity per day start from every two hours up to as many as pa>ent can afford. Pain does not come or stay very short a*er the exercise period. Constant feedback and monitor if you rely the treatment to be carried out by pa>ent at home Remodeling Stage increase ac>vity and resistance to ac>ve movement (4-6 weeks onward) passive stretching (serial correc>on splin>ng?) Mineralisa>on of bone incorporate program in daily tasks aBen>on employment requirement and solving social, domes>c psychological problems Return to previous roles Work site visit, environmental adapta>on at home/work may required for some pa>ent with permanent damage (shi*ing to rehabilita>on and psychosocial frame of reference) Pa>ent can put effort more vigorous training; however, individual difference is there (Bony to complete modelling 6 weeks in inner range, 8 weeks is medium range and 12 weeks is the outer range). It all depends on site of fracture, age, type of surgery etc.... passive stretching to gain max ROM, however, avoid if it is bony structure limita>on. So* >ssue/joint s>ffness (immobilisa>on/adhesion) response well to serial correc>on splint. Check X-ray joint alignment/surgeon  Classifica9on of burns: Burn Injuries Scar management: Primary goal: achieve flat, smooth, supple and cosme=cally acceptable Seriousness of burn is determined by the area and depth of burn. scare. Minimise scarring: Compression, silicone products, massage and physical agent Acute Burn Management modali=es Depth Colour Blisters Capillary Sensa9on First aid to Stop the burning process and Cool the burn wound (not ice as Classifica9on of scars Refill can burn =ssue) (ideal 20 minutes of cool running water within first 3 Hypertrophic scars Keloid scars Epidermal Red No Present Present hours of injury) raised scars that remain within raised scars that expand beyond the Superficial Pale Pink Small Present Painful the boundaries of the original borders of the original wound Occupa9onal therapy role in the acute phase wounds Raised, Itchy Tender but are frequently Dermal Developing an occupa=onal profile Pink or red, Inflamed, Raised, firmer, more purple than pink / red, Mid Dermal Dark Pink Present Sluggish +/- Wound management: wound dressings. Dressing is used to protect Firm/ Tender and Itchy more nodular and omen painful Deep Dermal Blotchy Red +/- Absent Absent wound and provide op=mal environment for healing. infec=on control, Full Thickness White No Absent Absent comfort, wound immobilisa=on, fluid absorp=on, early pressure Risk factors for adverse scarring: Age: hypertrophic more room under 20, kaloid 20-30 yr, 3 Main classifica=ons: Superficial, Mid and Deep Posi=oning: to maintain joint range to counteract contracture of burns- Ethnicity: darks skinned Scar loca=on: upper back, shoulders, anterior chesr and upper (neck=extension, elbow in extension) arms more suscep=ble to scars Depth Exercises: PROM / AROM – especially burns over joints Superficial Ability to heal self spontaneously through Pain management Scar assessment Vancouver Scar Scale (VSS), Manchester Scar Scale (MSS), Pa=ent and Bur process of epithelisa9on Oedema management Observer Scar Assessment Scale (POSAS) and Sony Brook Scar Evalua=on Scale SBSES May involve the epidermis and superficial Facilitate independence in ac=vi=es of daily living (showering, dressing dermis. and ea=ng)- assis=ve devices (build up cutlery ect Scar management contact media some=mes used in conjunc=on with compression commonly caused by the sun or minor flash Fabrica=on of orthoses Silicones Hydrocolloids burns from an explosion. reacts with cell fibres to somen and work to somen and flaIen scars. heal quickly and leave no cosme=c blemish Orthoses flaIen scarring and keep the scar Are occlusive, which means they Leaves Blister Immobilise and protect key structures in the hand- allows forma=on of moist, and assist with the reduce the amount of oxygen to the Sensory nerves are exposed= incredibly painful skin gram to take before degrada=on of excess collagen. surface of the skin, keeping the Heals within 14 days, leaving slight colour Posi=on to prevent deformity : Place structures of the hand in Only used over healed areas. area moist, which assist with the defect lengthened posi=ons e.g. an=-deformity or safe immobilisa=on posi=on Should be worn for at least 12 hours degrada=on of collagen in scars. Mid- Number of survival epithelisa=on cells capable Prevent contractures and regain normal movement daily E.g. Duoderm (hydrocolloid dressing: dermal of reepitheliza=on is reduced Splin=ng for stretch, Restore mobility: serial sta=c splints / casts, sta=c Cici-care: self adhesive silicone gel ideal for sotwning som web spacess burns Rapid spontaneous burn healing is unlikely to progressive splints, dynamic splints. shee=ng: most effec=ve of contact media, occur Movement : promote stretch of remodelling scare =ssue and reduce loss very expensive however can be reduced Capillary refill delayed of Range of mo=on. need to be done against contrac=le liens if scare , 3- to up to 6 weeks Oedema and blistering may be present 6 =mes a day. Essen=al in managing scaring and returning to Otoform: like puIy that hardens with addic=on of catalyst. can be moulded into shape Pain is present / less severe than superficial independence. specific shape of scare= enhance compression. Durable and last 6 weeks burns Healing =mes are variable The OT role in the reconstruc9ve and rehabilita9on phase Skin Grads Deep Characterised by early development of Enabling comple=on of self care tasks and home management ac=vi=es ReCell: a small splint skin gram 1cm by 1 cm is taken using a recell kit , being converted dermal extensive listers that rupture early to expose burns Pain management into suspension of cells which is sprayed onto the wound to assist healing deep, damaged dermis Maintain range of mo=on Split Skin Gram (SSG): harves=ng of skin from same pa=ent, but only part way into the May appear Red blotchy coloura=on due to excava=on of red blood cells from damaged Strength and endurance dermis to transfer to and cover a wound. Doesn’t bring own blood supply, but is vessels Minimise scarring dependent on the blood supply of recipient =ssue Greatly reduced capillary return and sensa=on Sensa=on Full Thickness Skin Gram: harvested to base of dermis, takes own blood supply Full Destroy both epidermis and dermis and may Psychosocial adjustment thickness penetrate more deeply into underlying Compression: helps control scar matura=on, can be provided through a variety of means burns structures. Other Treatment considera9ons including orthoses, compression