1. Upper Extremity Rehabilitation Workshop MBINGO BAPTIST HOSPITAL Kenneth Nshiom, PT/OCO Morag Crocker, OT November 29, 2014 Timothy Fanfon, PT

2. Agenda 8:00 am – Anatomy review 9:00 am – Physical assessment 10:00 am – short break 10:10 am – Upper extremity conditions 12:30 pm – lunch break 1:00 pm – Splinting review & practice

3. Anatomy Timothy Fanfon

4. Bones of the Arm  Humerus  Radius –Shape of distal portion of bone allows for rotation with pronation/supination  Ulna  Bony landmarks = Radial & ulnar styloid processes –Potential pressure points when splinting

5. Bones of the hand  Carpal bones  Metacarpals  Phalanges –Proximal –Middle –Distal

6. Carpal Bones

7. Joints of the Hand  MCP = Metacarpal-Phalangeal Joint –Flexion, extension & some ulnar/radial movt.  PIP = Proximal Inter-Phalangeal Joint –Flexion & extension only  DIP = Distal Inter-Phalangeal Joint –Flexion & extension only  CMC = Carpometacarpal Joint –Flexion, extension, adduction, abduction & opposition

8. Joints of the Hand CMC joint @ base of thumb

9. Planes/directions of movement  Flexion & extension (elbow, wrist, fingers)  Adduction & abduction (fingers)  Radial & ulnar deviation  Pronation & supinations (forearm & hand)

10. Muscles of the Upper Arm  Biceps –Flexion  Triceps –Extension

11. Muscles of the (Volar) Forearm  Flexor Carpi Radialis (FCR) –Flexes wrist –Wrist radial deviation  Flexor Carpi Ulnaris (FCU) –Flexes wrist –Wrist ulnar deviation

12. Muscles of the (Volar) Forearm  Flexor Digitorum Superficialis (FDS) –Flexes wrist –Flexes PIP joints  Splits at level of PIP joint to allow Flexor digitorum profundus to pass to distal phalanx  Attaches on middle phalanx

13. Muscles of the (Volar) Forearm  Flexor Digitorum Profundus (FDP) –Flexes wrist –Flexes DIP joints  Passes through split in FDS to attach to distal phalanx

14. Muscles of the (Volar) Forearm  Flexor Pollicis Longus (FPL) –Flexes distal phalanx of thumb  Flexor Pollicis Brevis (FPB) –Flexes proximal phalanx of thumb (pollicis = relating to thumb)

15. Muscles of the (Dorsal) Forearm  Extensor Carpi Radialis Longus (ECRL)  Extensor Carpi Radialis Brevis (ECRB)  Both muscles –Extend the wrist –Radially deviate the wrist (abducts or moves the hand in the direction of the thumb)

16. Muscles of the (Dorsal) Forearm  Extensor Digitorum Communis (EDC) –Extends the wrist and fingers 2-5 at the MCP & PIP joints  Attaches to the phalanges through the extensor mechanism and dorsal hood

17. Muscles of the (Dorsal) Forearm  Extensor Digiti Minimi (EDM)  Extensor Indicis (EI) –Additional extensor muscles for the index finger (EI, indicis = index finger) and little finger (digiti minimi = little digit/finger)

18. Muscles of the (Dorsal) Forearm  Extensor Pollicis Longus (EPL) –Extends distal phalanx of thumb at IP joint  Extensor Pollicis Brevis (EPB) –Extends proximal phalanx of thumb at MCP joint  Abductor Pollicis Longus (APL) –Extends, abducts & rotates the thumb at the CMC joint (pollicis = relating to thumb)

19. Muscles that Rotate the Forearm  Pronators: –Pronator teres –Pronator quadratus  Supinators: –Supinator  Bringing the forearm to neutral: –Brachioradialis –Also assists with elbow flexion –“beer drinking muscle”

20. Muscles of the (Volar/Palmar) Hand  Thenar muscles = muscles moving the thumb –Flexor Pollicis Brevis –Abductor Pollicis Brevis –Opponens Pollicis –Adductor Pollicis

21. Muscles of the (Volar/Palmar) Hand  Hypothenar muscles = muscles moving the little finger –Flexor Digiti Minimi –Abductor Digiti Minimi –Opponens Digiti Minimi

22. Intrinsic Muscles of the Hand  Lumbricals –Origin on FDP tendon, inserts on proximal phalanx of digits 2-5 –Flexes MCP joints and extends IP joints  Dorsal Interossei –Abducts digits 1, 2 & 4 –Flexes MCP joints and extends IP joints  Palmar Interossei –Abducts the fingers towards 3 rd digit –Flexes MCP joints and extends IP joints

23. Brachial Plexus  Network of nerve fibers that goes through the neck, the axilla (armpit) and into the arm and hand  Responsible for all the cutaneous (skin) and muscular innervation of the upper limb (except the trapezius muscle)

24. Radial Nerve  The radial nerve innervates the following muscles, in this order: –Triceps –Anconeus –Brachioradialis –Extensor Carpi Radialis Longus –Extensor Carpi Radias Brevis –Supinator  Posterior Interosseous Nerve (branch of radial nerve) –Extensor Digitorum (Communis) –Extensor Digiti Minimi –Extensor Carpi Ulnaris –Abductor Pollicis Longus –Extensor Pollicis Longus –Extensor Pollicis Brevis –Extensor Indicis

25. Median Nerve  The median nerve innervates the following muscles, in this order: –Pronator Teres –Flexor Carpi Radialis –Palmaris Longus –Flexor Digitorum Superficialis  Anterior Interosseous Nerve (branch of median nerve) –Flexor Digitorum Profundus (index and middle) –Flexor Pollicis Longus –Pronator Quadratus  Palmar Recurrent Motor Branch (branch of median nerve) –Abductor Pollicis Brevis –Opponens Pollicis –Flexor Pollicis Brevis  Common Palmar Digital Nerve (branch of median nerve) –Lumbricals 1 & 2

26. Ulnar Nerve  The Ulnar nerve innervates the following muscles, in this order: –Flexor Carpi Ulnaris (FCU) –Flexor Digitorum Profundus (ring and small fingers)  Deep Branch of Ulnar Nerve: –Abductor Digiti Minimi –Opponens Digiti Minimi –Flexor Digiti Minimi –3rd and 4thLumbricals –Dorsal Interossei –Palmar Interossei –Flexor Pollicis Brevis –Adductor Pollicis

27. Physical Assessment Kenneth Nshiom

28. Physical Assessment  Inspection/Observation  Palpation  ROM  Muscle Strenght  Neurovascular  Special Tests

29. Observation  Posture and alignment  Swelling/edema, ecchymosis  Changes in skin, nails or hair (or arm/hand)  Contractures and other deformities  Functional range of motion (& right vs. left UE)  Observe the contours and take note of abnormal prominences, atrophy, etc

30. Palpation  Palpate the skin and feel the temperature.  Palpate subcutaneous landmarks  Palpate the muscles, joints, tendons, nerves and ligaments noting areas of tenderness.  Palpate and feel the pulses

31. Range of Motion  Shoulder  Elbow –Flexion = 145-150° –Extension = 0° for men/0-15° for women  Forearm –Pronation = 70-80° –Supination = 80-90°  Wrist –Flexion –Extension –Ulnar deviation –Radial deviation

32. Range of Motion  Fingers -flexion-extension-abduction/adduction

33. Neuromuscular  Peripheral nerves = all of the nerves that lie outside of the brain and spinal cord –Motor nerves –Sensory nerves  Injury causes loss of sensation, movement or both  Look for specific dermatome or myotome patterns if you think the injury is at the nerve root  NB: Some cervical problems present as UE problems, so do not forget to assess the C-Spine

34. Strength  To test muscle strength, use the manual muscle testing grading system: –Grade 0 = no muscle contraction visible or palpable –Grade 1 = no movement but there is a flicker (or palpable) of muscle contraction –Grade 2 = full range of motion with no gravity –Grade 3 = full range of motion against gravity (no extra resistance) –Grade 4 = full range of motion against gravity, with moderate resistance –Grade 5 = full range of motion against gravity, with maximum resistance  Remember that disuse, immobilization, and other medical conditions can cause muscle weakness, even when the nerve is intact.

35. Sensory Testing  Monofilaments (small fibres of different sizes) or other fine pointed tools (pin, paper clip etc.)  Cotton ball (moving light touch) –The patient should not look at the injured area and then tell the therapist when they think the therapist is touching their skin with the pointed tool (E.g. “tell me when you feel me touch your hand”).  Sensory testing should be done before use of heat, ice or splinting (potential for tissue damage)

36. Vascular Exam  Peripheral pulses  Capillary refill  Cynosis

37. Special Tests  Apprehension Test  Crank Test  Speed Test  Hawkins and Kennedy Test  Neer Test  Full can and Empty can Tests  Finkelstein Test  Tinel and Phalen Sign, Duran's Test

38. Specific Conditions Morag Crocker

39. Tendonitis  Tendonitis = Inflammation, swelling and irritation of a tendon (attaches muscle to bone); usually used to describe more acute tendon inflammation.  Tenosynovitis = inflammation of the sheath (called synovium) that surrounds a tendon.  Tendinopathy = term to describe problems with either the tendon or the tendon sheath

40. Tendonitis  Cause: –Overuse –Direct injury to tendon –Rheumatic disease –Infection (very rare)  Presentation: –Tenderness with pressure on the tendon –Pain with movement –Stiffness after rest – Visible swelling and local warmth (may or may not be present)

41. Tendonitis  Common areas are elbow (lateral epicondylitis), biceps, wrist & thumb  Treatment: –Rest (from aggravating activity) –Ice –NSAID’s (topical or oral) –Changing activities (avoid repetition & awkward positions) –Splinting (to assist with rest) –Gentle stretching (& muscle strengthening) –Gradual return to activity

42. DeQuervain’s Tenosynovitis  Tendons affected: –Abductor Pollicis Longus (APL) –Extensor Pollicis Longus (EPL)  Radial side of wrist, over MCP & CMC joints  move the thumb away from the plane of the hand  Tendon & sheath affected; irritation and thickening in sheath

43. DeQuervain’s Tenosynovitis  Cause: –repetitive movements requiring pinching or grasping, particularly in combination with wrist movement –repetitive movements requiring pinching or grasping, particularly in combination with wrist movement  Special tests: –Finkelstein’s test = examining therapist grasps the thumb, applies traction, and ulnarly deviates the hand sharply. A resulting sharp pain along the distal radius, close to the wrist, is considered a positive test. –Eichoff’s test =

44. DeQuervain’s Tenosynovitis  Treatment: –Rest, ice, NSAID’s etc –Splinting:  Splint should prevent isolated thumb extension or radial abduction

45. Trigger Finger  Tendons affected: –Flexor Digitorum Superficialis (FDS) –Flexor Digitorum Profundus (FDP) –Volar (palm) surface of the hand, where FDP & FDS tendons enter the flexor tendon sheath –Most commonly affects the ring finger, just proximal to MCP joint

46. Trigger Finger  Symptoms: –Causes clicking, catching (“triggering”) of fingers with joint flexion –May also cause stiffness, pain, tenderness and swelling in the palm of the hand  Causes: –Repetitive or forceful grasping (finger flexion) causes thickening of the flexor tendons (and/or narrowing of the flexor tendon sheath) –Tendon gets stuck when gliding through the tendon sheath

47. Trigger Finger  Treatment: –Rest, ice, NSAID’s etc –Splinting:  Several types but splint must prevent some degree of finger flexion, so that the thickened part of the tendon does not go through the sheath and catch

48. Safety Position  Safe position when hand must be immobilized –Maintains length of soft tissues to prevent contracture –Prevents intrinsic muscles from being overpowered by stronger flexor & extensor muscles

49. Safety Position  Used for: –Traumatic injury/acute condition –Burns –Crush injury –Inflammatory joint disease –Prevent contracture –Reduce pain & inflammation –Or any condition causing significant swelling, as this can cause “clawing” (MCP extension & IP flexion)

50. Safety Position  Position of joints: –Wrist position = 30° extension –MCP position = 70° flexion –IP position = full extension (if possible) –Thumb position = full abduction  Why? –Intrinsic muscles flex MCP joints and extend IP joints –If intrinsic muscles weakened, they are overpowered by EDC and FDP/FDS, leading to MCP joint hyperextension & IP joint flexion –Will eventually cause contracture –With crush or burn, scar tissue will also contract as the hand heals

51. Nerve Injuries  Complete nerve laceration requires surgical repair to restore innervation –The body does try to repair itself by sprouting new axons (part of the nerve) from the injured nerve, which can eventually bridge the gap between the cut ends of the nerve  Nerve damage (not completely cut or crushed) can be repaired/regrow –Typically at a rate on 1-2 mm per day

52. Nerve Injuries  Goal of physiotherapy treatment is to prevent problems from developing during the time that the patient does not have sensation or full motor control: –For lack of sensation, they must learn to use visual observation –Splints and passive movement exercises are used to maintain tissue length (in the hope that the patient eventually regains muscle innervation) –Splints also used to maintain function while the patient does not have proper muscle control  As a nerve re-grows, altered sensation can be uncomfortable: –Graded desensitization exercises

53. Carpal Tunnel Syndrome  Form of median nerve injury –Compression of median nerve as it passes through the carpal tunnel (created by curve of carpal bones and carpal ligament)  Signs & symptoms: –Numbness and tingling of the radial 3 ½ fingers –clumsiness, due to weakened muscles –Pain (or altered sensation) especially at night –Atrophy of thenar muscles

54. Carpal Tunnel Syndrome  Causes: –Repetitive movements (ex. Typing, weeding/farming) –Vibrations (ex. tool use) –Inflammation of the flexor tendon sheaths (ex. rheumatoid arthritis)  Special tests: –Durkan’s test: press with both thumbs over the carpal tunnel for 30 seconds. –Phalen’s test: patient flexes own wrists for about 60 seconds. –Tinel’s test: tap the median nerve over the volar carpal tunnel

55. Carpal Tunnel Syndrome  Treatment: –Rest (from aggravating activities) –NSAID’s –Splinting in neutral wrist position  Nighttime and for aggravating activities –Steroid injection –Carpal tunnel release surgery

56. Median Nerve Injury  Injury at distal forearm, wrist or hand: –Affects: thenar muscles –Lose: thumb abduction & opposition –Potential for adduction contracture  Splinting goals: –Maintain thumb abduction & opposition

57. Ulnar Nerve  The Ulnar nerve innervates the following muscles, in this order: –Flexor Carpi Ulnaris (FCU) –Flexor Digitorum Profundus (ring and small fingers)  Deep Branch of Ulnar Nerve: –Abductor Digiti Minimi –Opponens Digiti Minimi –Flexor Digiti Minimi –3rd and 4thLumbricals –Dorsal Interossei –Palmar Interossei –Flexor Pollicis Brevis –Adductor Pollicis

58. Ulnar Nerve Palsy  Injury at level of distal forearm, wrist or hand: –Lose: intrinsic muscle power – dorsal interossei, palmar interossei, lumbricals 3 & 4 –Weak intrinsic muscles are overpowered by flexors (FDS, FDP) & extensors (EDC), causing clawing of little and ring fingers  An injury higher up (level of humerus to proximal forearm) results in same clawing as above but to lesser degree

59. Splints for Ulnar Nerve Palsy  Splinting goals: –Resting hand/safety position –As wrist movement not affected, no need to support wrist

60. Radial Nerve  The radial nerve innervates the following muscles, in this order: –Triceps –Anconeus –Brachioradialis –Extensor Carpi Radialis Longus –Extensor Carpi Radias Brevis –Supinator  Posterior Interosseous Nerve (branch of radial nerve) –Extensor Digitorum (Communis) –Extensor Digiti Minimi –Extensor Carpi Ulnaris –Abductor Pollicis Longus –Extensor Pollicis Longus –Extensor Pollicis Brevis –Extensor Indicis

61. Radial Nerve Palsy  Most commonly injured below level of triceps muscle innervation  Injury at level of middle humerus to middle (to distal) forearm: –Lose: wrist, finger & thumb extension –Loss of wrist extension results in hand weakness (strongest grip requires slight wrist extension) and poor functional grasp  Splinting goals: –Dynamic splint to use tenodesis effect OR –Splint to maintain wrist and finger extension

62. Splints for Radial Nerve Palsy

63. Brachial Plexus Injury

64. Shoulder Conditions

65. Stroke  CNS injury –Hemorrhagic –Ischemic  Causes: –Loss of sensation (and/or) –Loss of motor control (and/or) –Neglect –Pain 40% of stroke patients experience pain in the affected side, within 6 months of stroke.

66. Stroke  Causes of pain: 1.Complex Regional Pain Syndrome (CRPS) –Severe shoulder and hand pain plus a swollen hand –Usually develops approximately 1 month or more after stroke –Extremely sensitive hand –Changes in nails and skin. –Causes unknown:  Malfunctioning pain pathways  Autonomic nervous system  Limited limb movement –Treatment is difficult: neuropathic pain meds & mobilize limb early 2.Spasticity 3.Shoulder subluxation

67. Spasticity

69. Arthritis  Glenohumeral joint  AC joint  Thumb CMC joint  OA of the IP joints  RA of the MP joints  GA of elbow and wrist

70. Contractures