This document discusses concepts in occupational therapy for upper limb injuries. It covers tissue healing principles like anti-deformity positioning. It also discusses wound healing phases and concepts like avoiding pain with movement. Assessment tools are outlined including standardized dexterity tests. Peripheral nerve injury classifications and common injuries like carpal tunnel syndrome and tendon injuries are explained. Treatment approaches include edema control, splinting and exercises.

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