Occupational Therapy Upper Limb Injuries

1. Occupational Therapy
Upper Limb Injuries

2. Hand Therapy Concepts
Tissue healing
- Anti-deformity positioning
- Typical/predictable deforming hand positions following
injury &/or disuse
- Flexed wrist, hyperextended MPs, flexed PIPs & DIPs,
adducted thumb
- Anti-deformity position
- Wrist extension, MP flexion, PIP & DIP extension,
thumb abduction & opposition

3. Wound Healing (following trauma & or surgery)
Phases of wound healing
- Hemostasis & Inflammation
- Proliferation & Fibroplasia
- Scar maturation/ Remodeling
- Wound contracture

5. Hand Therapy Concepts
Myth of “No Pain, No Gain”
- Better to consider “no pain, more gain”
- Can cause irreversible damage if tissues are forced &
damage occurs
PROM can injure tissues
- Can disturb healing tissues - further inflammation
increase scar production
- If clinically appropriate, PROM should be gentle &
pain-free
- Low-load, long-duration splinting can be safer & more
effective to increase PROM

6. Hand Therapy Concepts
Be careful applying heat
- Do not use heat in presence of edema or if limb appears
to be inflamed
- Safer to warm up tissues with aerobic exercise.
- If applying heat, elevate hand/UE, be gentle with
exercise & promote active movement in conjunction
with heat.
- Monitor carefully for any signs of inflammation.

7. Hand Therapy Concepts
- Isolated Exercise, Purposeful Activity & Therapeutic
Occupation
- Focus on occupational performance, not just exercise
- Incorporate Occupations-as-end (e.g. dressing, home
occupations, etc.) & Occupations-as-means (e.g.
therapeutic use of activity) into intervention

8. Isolated Exercises in Hand Therapy

9. Purposeful Activity & Therapeutic Occupation

10. Assessment of Hand & Upper Limb Function
Physical Examination & Biomechanical/ Sensory-Motor
Assessment
- Edema
- ROM
- MMT
- Grip & Pinch Strength
- Sensibility/Sensation
- Pain

11. Assessment of Hand & Upper Limb Function
Dexterity & Hand Function Assessment (Standardized)
- Minnesota Rate of Manipulation Test
(MRMT)/Minnesota Manual Dexterity Test (MMDT)
- Purdue Pegboard
- Crawford Small Parts Dexterity Test
- O’Connor Finger & Tweezer Dexterity Tests
- 9-Hole Peg Test
- Jebsen Test of Hand Function
- Sollerman Test of Hand Dexterity

12. Assessment of Hand & Upper Limb Function
9-Hole Pec Test
Minnesota Manual Dexterity Test

13. Assessment of Hand & Upper Limb Function
Grooved Pegboard
Jamar Dynamometer

14. Assessment of Hand & Upper Limb Function
Pinch Gauge
Crawford Small Parts Dexterity Test

15. Assessment of Hand & Upper Limb Function
Purdue Pegboard
O’Connor Finger Dexterity Test

16. Assessment of Hand & Upper Limb Function
Sollerman’s Test of Hand Grip
O’Connor Tweezer Dexterity Test

17. Assessment of Hand & Upper Limb Function
E-Link Biometrics

18. Basic Intervention
- Edema control
- Scar management
- Compression (gloves, Coban wrap, Tubigrip)
- Silicone gel over scar
- Exercises
- Tendon gliding, blocking, place-and-hold
Orthotic intervention/Splints
- Static
- Dynamic

19. Hand Exercises

20. Peripheral Nerve Injuries – SEDDON classification

21. Peripheral Nerve Injuries – SEDDON classification

22. Peripheral Nerve Injuries – SEDDON classification

23. Peripheral Nerve Injuries – Neuropraxia
- Contusion/compression of nerve; no wallerian
degeneration
- Function recovers in a few days/weeks
- Conduction intact distal and proximally but not over
area of injury
- Sensory motor problems distal to injury area

24. Classification of nerve injuries (Seddon Classification)
1.Neuropraxia 2.Axonotmesis 3.Neurotmesis
- Neuropraxia Injuries due to pressure Local conduction
block only
- This is the mildest for of nerve injury.
- Mild, blunt blows, including some low-velocity missile
injuries close to the nerve
- Recovery takes place without wallerian degeneration

25. Peripheral Nerve Injuries – Axontomesis
- Loss of continuity of the axon and myelin due to loss of
blood supply. Preserved connective tissue.
- No conduction distal to the injury site = Sensory motor
deficits distal to injury site
- No surgical intervention required; recovery depends on
level of injury (1-2mm regrowth/day)
- Crush or stretch injuries Eg fracture or dislocation

26. Peripheral Nerve Injuries – Neurotmesis
- Total disruption for the entire nerve fiber.
- Most severe Laceration of nerve & fibrous tissue =
Trauma
- Surgical intervention required; nerve grafting may be
required if gap between nerve endings
- No conduction distal to the injury site
- Complete recovery is impossible

31. Radial Nerve Injury
- Typical presentation – wrist drop
- Maintain ROM
- Orthosis – prevent deformity & promote function

32. Median Nerve Injuries
- Thumb rests in adduction - Can lead to contracture so
splint to maintain thumb abduction & opposition
- Sensory loss – compensation & re-education as nerve
regenerates
- Assistive devices to compensate for functional loss

33. Median Nerve Injuries
Median & Ulnar nerve lesion

34. Carpal Tunnel Syndrome
- Most common Upper extremity nerve entrapment
- Compression of median nerve at wrist
- Most common in women 40-60 years, frequently
bilateral
- Fairly common in pregnancy (transient)
- Associated with repetitive use
Typical symptoms
- Hand numbness, particularly at night
- Pain & paresthesia in median n. distribution
- Clumsiness & weakness

35. Carpal Tunnel Syndrome

36. Carpal Tunnel Syndrome
Intervention
- Night splinting – wrist in neutral
- Nerve & tendon gliding exercises
- Padded gloves, built-up handles
- Ergonomic interventions

37. Ulnar Nerve Injury
- Laceration – at wrist
- Loss of most hand intrinsic – claw deformity
- Flattening of hand, loss of ulnar transverse metacarpal
arch
- Fine manipulation skills & power grip compromised
- Compression – Cubital Tunnel Syndrome
- 2nd most common nerve entrapment
- Between medial epicondyle & olecranon

38. Common complaints
- Proximal & medial forearm pain (aching or sharp)
- Sensory loss & weakness in affected muscles
- Grip & pinch strength decreased
- Clumsiness, dropping things
Intervention
- Edema control, splinting, positioning guidelines, built
up handles, sensory compensation & re-education

39. Fractures
- Colles – dist. Radius
- Most common wrist fracture
- Results in limitation of wrist flexion & extension,
pronation & supination
- Scaphoid
- 2nd most common wrist fracture
- Poor blood supply can result in non-union of fracture
- Requires prolonged immobilization (may be several
months in cast)
- Fingers
- May be repaired with Kirschner wires, plates or screws

40. Flexor Tendon Injuries
- Surgical repair is complex
- Hand therapy for tendon repairs is a highly specialized
area
- Significant client education following repair

41. Extensor Tendon Injuries
- Hand therapy for tendon repairs is a highly specialized
area
- Multiple complex orthoses needed – balance rest &
movement

42. Cumulative Trauma Disorders
Includes range of disorders
- Lateral epicondylitis (tennis elbow)
Common extensor origin
- Medial epicondylitis (golfer’s elbow)
Common flexor origin
- De Quervain’s tenosynovitis
- Tendinitis of AbPL & EPB
- Carpal Tunnel Syndrome
- Tenosynovitis/Tendinitis of various muscle of wrist &
hand
- Occupational Overuse Syndrome (OOS); Repetitive
Strain Injury (RSI); Cumulative Trauma Disorder
(CTD)

43. Cumulative Trauma Disorders
Interventions
- Education regarding joint position/protection, posture
- Ergonomic interventions
- Treat acute phase – ice, compression, elevation, rest if
necessary
- Orthotic intervention individualized
- Consider soft splints
- Biofeedback to reduce muscle effort used