CHP 6 musculoskeletal system disorders

hand muscles by median nerve (7)

1. abductor pollicis brevis

   • palmar abduction

2. opponens pollicis

   • opposition

3. flexor pollicis brevis

   • thumb MCP flexion, deep hand innervated by ulnar N

4. lumbricals (radial)

   • MCP flexion; IP ext of digits II and III

5. flexor digitorum superficialis (sublimis) (FDS)

   • flexion of proximal PIP

6. flexor digitorum profundus (FDP)

   • flexion of distal DIP to digits 2&3

7. flexor pollicis longus (FPL)

   • flexion of IP joint of thumb

muscles by ulnar n (10)

1. abductor digiti minimi

   • abduction of digit 5

2. opponens digiti minimi

   • opposition of digit 5

3. flexor digiti minimi

   • flex of MCP and opposition of digit 5

4. adductor

   • adducts CMC thumb

5. lumbricals (ulnar)

   • MCP flex; IP ext of digits 4&5

6. palmar interossei

   • adduction and assistance with MCP flexion and ext of IP of digits 2-5

7. dorsal interossei

   • abduction and assist with MCP flexion and IP ext of digits 2-5

8. flexor digitorum profundus

   • flexion of DIP joints to digits 4-5

9. flexor carpi ulnaris (FCU)

   • flex of wrist and ulnar deviation

10. flexor pollicis brevis

    • flex wrist

pollicis =

THUMB contributions

muscles innervated by median n (4)

• NO hand

• overall movements

• Movements

  • wrist flex, pronation

MUSCLES

1. flexor carpi radialis (FCR)

   • flexion of wrist and radial deviation

2. Palmaris longus (PL)

   • flexion of wrist

3. pronator teres

   • forearm pronation

4. pronator quadratus

   • forearm pronation

muscles innervated by radial n (13)

• overall movements

• BEST

  • EXTENSION, supination

1. extensor carpi radialis brevis (ECRB)

   • ext of wrist and radial deviation

2. extensor carpi radialis longus (ECRL)

   • ext of wrist and radial deviation

3. extensor carpi ulnaris (ECU)

   • ext of wrist and ulnar deviation

   • EXT over rules ULANRIS

4. supinator

   • forearm supination

5. brachioradialis

   • elbow flex with forearm neutral

6. triceps

   • elbow ext

7. anconeus

   • elbow ext

8. extensor digitorum communis (EDC)

   • ext of MCP and ext of IP

9. extensor digiti minimi (EDM)

   • ext of MCP of digit 5 and ext of IP

10. extensor indicis proprius (EIP)

    • ext of MCP of digit 2 and ext of IP

11. extensor pollicis longus (EPL)

    • ext of IP joint of thumb

12. extensor pollicis brevis (EPB)

    • ext of MCP and CMC thumb

13. abductor pollicis longus (APL)

    • abduction and ext of CMC

Rock, Paper, Scissors

Rock = Median

• flex of most digits

Paper = Radial

• ext

Scissor = Ulnar

• flex of digits 4-5

musculocutaneous n muscles (3)

• MOVEMENTS

  • elbow flex, shoulder flex

MUSCLE

1. biceps

   • elbow flex with forearm supinated

2. brachialis

   • elbow flex

3. coracobrachialis

   • shoulder flex

rotator cuff muscles (4)

• nerves & movements

• SITS

• Subscapularis

  • subscapular n

  • IR

• supraspinatus

  • suprascapular n

  • abduction and shoulder elevation

• Infraspinatus

  • suprascapular n

  • ER

• Teres minor

  • axillary n

  • ER

shoulder flexion muscles (2)

• anterior deltoid

  • axillary n

• coracobrachialis

  • musculocutaneous n

shoulder abduction muscles (2)

• middle deltoid

  • axillary n

• supraspinatus

  • suprascapular n

horizontal abduction muscles (1)

• posterior deltoid

  • axillary n

horizontal adduction muscles (1)

• pectoralis major

  • lateral pectoral n

shoulder ext muscles (3)

• latissimus dorsi

  • thoracodorsal n

• teres major

  • subscapular n

• posterior deltoid

  • axillary n

upward rotation of scapula muscles (2)

• trapezius (UML)

  • spinal accessory n (CNXI/11)

• serratus anterior

  • long thoracic n

downward scapular rotation muscles (4)

• levator scapulae

  • C3-C4

• rhomboids (both)

  • dorsal scapular n

• serratus anterior

  • long thoracic n

• latissimus dorsi

  • thoracodorsal n

scapula adduction muscles (2)

• middle trapezius

  • spinal accessory n (CN11)

• rhomboid major

  • dorsal scapular n

scapular abduction muscles (1)

• serratus anterior

  • long thoracic n

scapular elevation muscles (2)

• trapezius (upper)

  • spinal accessory n (CN11)

• levator scapulae

  • C3-C4

scapula depression muscles

• trapezius (lower)

  • spinal accessory n (CN11)

dupuytren’s disease

• what

• cause

• tx

• OT intervention

• disease of fascia of palm and digits

  • fascia becomes thick and contracts; develops cords and bands that extend into digits

• CAUSE: unknown

• TX: conservative tx has NOT been successful > medical tx used

• OT intervention:

  • wound care after surgery, edema control, orthosis, AROM/PROM, scar management, occupation-based

skier’s thumb (gamekeeper’s thumb)

• rupture of ulnar collateral ligament of MCP joint of thumb

• CAUSE: falling with thumb held on pole

• OT:

  • conservative tx for partial tear > thumb orthosis

  • AROM at 2-4wks

  • AAROM and strengthening at 6-12wks

Complex Regional Pain Syndrome (CRPS)

• vasomotor dysfunction as result of abnormal reflex

• localized or general

• CAUSE: may follow trauma or surgery but actual cause unknown

• SX:

  • severe pain, edema, discoloration, osteoporosis, sweating, blotchy skin, temp changes, trophic changes, vasomotor instability

• OT:

  • modalities for pain and hypersensitivity

    • TENS during ADLs or prior to AROM

  • edema management

  • stress loading (scrubbing! and carrying!)

  • orthotics, ADLs, mental health

closed reduction

• NON SURGICAL treatment for fractures

• types of stabilization include:

  • short arm cast (SAC)

  • long arm cast (LAC)

  • orthosis

  • sling

  • fracture brace

open reduction internal fixation (ORIF)

• SURGICAL fracture tx

• TYPES:

  • nails, screws, plates, or wire

arthrodesis

• fusion

arthroplasty

• joint replacement

most common UE fractures (7)

1. colles fx:

   • fx of distal radius with dorsal displacement

2. smiths fx

   • fx of distal radius with volar displacement

3. carpal fx

   • most common is scaphoid fx, proximal scaphoid has poor blood supply and may become necrotic

4. metacarpal fx

5. phalanx fx (proximal, middle, distal)

6. elbow fx

7. humerus fx

OT intervention for fractures

1. immobilization phase: stabilization and healing

   • AROM of joints above/below fx

   • edema control

   • light ADL

2. mobilization phase: consolidation

   • edema control: retrograde, elevation, compression

   • orthosis

   • AROM, light ADLs, strengthening

   • pain management

cumulative trauma disorders (CTDs)

• risk factors

• types (4)

• AKA repetitive strain injuries (RSI), overuse syndromes

• RISK FACTORS:

  • repetition, static position, awkward postures, forceful exertions, vibration

  • acute trauma, pregnancy, diabetes, arthritis, wrist anatomy

• TYPES:

  • de Quervain’s

  • lateral epicondylitis

  • trigger finger

  • nerve compression

de Quervain’s

• what

• sx

• tx

• stenosing tenosynovitis of abductor pollicis longus and extensor pollicis brevis

• sx: pain and swelling over radial styloid

• positive finkelstein’s test

• conservative tx

  • thumb spica orthosis (IP joint free)

  • activity modification

  • ice massage over radial wrist

  • gentle AROM

• post op tx

  • thumb spica orthosis and gentle ARM (0-2wks)

  • strengthening, ADL (2-6wks)

  • unrestricted ax (6wk)

lateral epicondylitis

• what

• tx

• AKA tennis elbow

• degenerative changes of tendon’s origin as result of repetitive microtrauma

  • overuse of wrist extensors (extensor carpi radialis brevis)

• conservative tx

  • elbow strap, wrist orthosis

  • ice and deep friction massage

  • stretching

  • activity modification

  • as pain decreases > add strengthening

trigger finger

• tenosynovitis of finger flexors (A1 pulley)

• caused by repetition and use of tools that are placed too far apart

• conservative tx

  • hand or finger based trigger finger orthosis

  • scar massage

  • edema control

  • tendon gliding

  • activity modification

tendon repairs

• early mobilization prevents adhesion and facilitates wound/tendon healing

• OT GOALS:

  • incr tendon excursion

  • improve strength at repair site

  • incr joint ROM

  • prevent adhesion

  • facilitates resumption of meaningful roles

duran protocol

• passive flexion and extension of digits

  1. 0-4wks dorsal blocking orthosis

     • exercise in orthosis for passive flexion

  2. 2.5wks passive place/active hold exercises

     • manage edema, scar management

  3. 4-6wks AROM with wrist and fingers relaxes, tendon gliding

  4. 6-8wks gentle strengthening

  5. 12wks return to regular fxn

early active mobilization for flexor tendon repairs general principles

• min of 4 strands in procedure

• close communication with surgeon

• experienced OT

• orthosis used

• 6wks begin light ADL

• 8wks gentle strengthening

Zones I and II

• mallet finger deformity

• 0-8wks: DIP extension orthosis

• 6-8wks: gentle AROM

• orthotics worn at night and btw exercises

Zones III and IV

• boutonniere deformity

• 0-6wks: PIP extension orthosis (DIP free)

  • AROM of DIP

two common types of nerve injuries

• compression or nerve entrapment

• laceration or avulsion injury

carpal tunnel syndrome (CTS)

• median n compression

• CAUSE:

  • narrowing of carpal canal due to swelling/pregnancy, inflammation, hypertrophy and anatomical anomalies, cumulative trauma

• SX:

  • numbness and tingling of thumb, index, middle, and radial half of ring fingers

  • paresthesias at night

  • dropping things

  • positive tinel’s test, positive phalens sign

  • atrophy at thenar eminence

• conservative tx

  • wrist orthosis in neutral

  • median nerve gliding

  • activity modification, ergonomics

• post op tx

  • edema control, AROM, scar management, nerve & tendon glides, sensory re-education, strengthening, ergonomic/work modification

cubital tunnel syndrome

• ulnar n compression at elbow

  • 2nd most common compression

• CAUSE:

  • pressure at elbow and extreme elbow flexion

• SX:

  • numbness and tingling along ulnar aspect of forearm and hand

  • pain at elbow with elbow flexion

  • weakness of power grip

  • froment’s sign, tinels sign

• conservative tx

  • elbow orthosis at 30deg flex

  • elbow pads

  • ulnar nerve gliding

• post op tx

  • edema control, scar management, AROM (2wks), strengthening (4wks)

radial nerve palsy

• radial n compression

• CAUSE:

  • Saturday night palsy, compression due to humeral shaft fx

• SX:

  • weakness or paralysis of extensors at wrist, MCPs, and thumb

  • wrist drop

• conservation tx

  • dynamic wrist and MCP extension orthosis

  • work/activity mod

  • strengthening

• post op tx

  • AROM, strengthening (6-8wks), ADLs

median n laceration

• sensory loss to

  • central palm, digits 1-3, and half of digit 4

  • dorsal middle & distal phalanges of digits 2,3, and half 4

• motor loss

  • LOW

    • MCP flexion of digits 2-3

    • thumb opposition, abduction and flexion of MCP (weak pinch)

  • HIGH

    • flex of DIP at digits 1-3

    • flex of radial wrist

• deformity

  • flat thenar eminence

  • claw of index and middle finger

• OT tx

  • orthosis, A/PROM, strengthening, scar management, sensory re-education

ulnar n laceration

• sensory loss

  • ulnar aspect of palmar and dorsal surface

• motor loss: loss power grip, decr pinch

  • LOW

    • adduction and abduction of MCP

    • MCP flex of digits 4-5

    • flex and adduct of thumb

    • abduction, opposition, and flexion of digit 5

  • HIGH

    • flexion of ulnar wrist

    • flex of DIP of digits 4-5

• deformity

  • claw hand

  • flat metacarpal arch

  • froments sign

radial nerve lacerations

• sensory loss

  • dorsal forearm, radial dorsal palm, half of digits 1-3

• motor loss: loss of extension

  • LOW

    • wrist ext

    • MCP ext

    • thumb ext

  • HIGH

    • elbow ext

• deformity

  • wrist drop

rotator cuff tendonitis

• impingement at coracoacromial arch

• CAUSE:

  • overuse, curved acromion, weakness of RTC, weak scapula, ligament tightness, trauma

• conservative tx

  • activity mod to limit should use (no above shoulder height)

  • sleep positioning

  • decr pain w/ positioning, modalities, rest

  • strengthen

• post op tx (arthroscopic, open repair)

  • PROM (0-6wk)

  • AAROM/AROM (6-8wks)

  • strengthening (8-10wks)

  • resume activity (12wks)

adhesive capsulitis

• frozen shoulder

• STAGES:

  • freezing: shoulder becomes painful at end ranges

    • OT: address pain w/modalities, gentle A/PROM, home exercise program

  • frozen: less pain, loss of motion, capsule pattern

    • OT: modalities (heat > cold), A/PROM, HEP

  • thawing: pain subsides and ROM returns

    • OT: stretching, ROM, function

• restricted PROM of shoulder

• capsular pattern: greatest limitation is ER > abduction > IR > flexion

• CAUSE:

  • inflammation, immobility, diabetes, parkinsons

shoulder dislocation

• anterior most common

• CAUSE:

  • trauma, overuse

• OT

  • ROM (avoid abduction + ER)

  • strengthen

rheumatoid arthritis (RA)

• systemic, symmetrical, and widespread affect

  • most common in small joints of hands

• remissions and exacerbations

• phases

  • acute: inflammatory process of synovial lining

• unknown cause

• SX:

  • pain, stiffness, limited ROM, fatigue, weight loss, inflammation/swelling, social isolation, deformities

• deformities common

  • ulnar drift with sublux of MCP

  • boutonniere

  • swan neck

  • zig zag

boutonniere deformity

• flexion of PIP joint and hyperextension of DIP

swan neck deformity

• witch finger

• hyperextension of PIP and flexion of DIP

osteoarthritis (OA)

• degenerative joint disease

  • not systemic but wear and tear

  • commonly affects large weightbearing joints

  • attacks hyaline cartilage

• CAUSE: genetics, trauma, CTD, endocrine/metabolic diseases

• SX:

  • pain, stiffness, limited ROM, bone spurs

    • heberden’s nodes at DIP

    • bouchards nodes at PIP

osteogenesis imperfecta (OI)

• dysfunction of one of several genes responsible for producing collagen for development of bone structure and strength

• present at birth, no cure

• mild to severe

  • type 1: mild

  • type 4,5,6: moderate

  • type 2,3,7,8: severe (2 is most)

• SX:

  • brittle, malformed bones

  • growth problems, loose joints

• OT:

  • education, activity mod

  • weightbearing, protective splinting, positioning

arthrogryposis multiplex congenita (AMC)

• congenital joint contractures involving two or more joints

  • detected in utero or at birth

  • often a RESULT of other diagnosis

  • NON progressive, no cure

• unknown cause

• SX:

  • joint contractures, limited ROM

  • vary due to source diagnosis

  • typical cognitive development

• OT

  • gentle ROM, weight bearing, strengthening

  • activity/enviro mod, training

hip fractures

• due to trauma, osteoporosis, or pathological finds (cancer)

• types

  • femoral neck, interochanteric, subtrochanteric

• get weightbearing status!! from surgeon

• common complications: avascular necrosis, nonunion, degenerative joint disease

posterior approach hip precautions & adaptive equipment

PRECAUTIONS:!!!!!

• no hip flexion greater than 90 degrees

• no internal rotation (toes in)

• no adduction (crossing legs or feet)

violation of precautions could result in dislocation

AE:

• hip kit (reacher, shoe horn, sock aide, LH sponge)

• adduction wedge

• raised commode

anterior approach hip precautions & adaptive equipment

PRECAUTIONS:

• no hip extension

• no external rotation (toes out)

• no adduction

some surgeons have a no precautions approach for anterior

AE:

• hip kit (reacher, shoe horn, sock aide, LH sponge)

• adduction wedge

total hip arthroplasty

• caused by trauma or disease (arthritis)

• types

  • total hip joint implant

  • hemiarthroplasty

• posterior or anterior approach

UE amputations

1. forequarter: loss of scapula, clavicle, and UE

2. shoulder disarticulation: entire UE

3. transhumeral (long & short)

4. elbow disarticulation: distal to elbow joint

5. transradial (long and short)

6. wrist disarticulation: distal to wrist joint

7. transmetacarpal

8. finger

LE amputations

1. hemipelvectomy: half of pelvis and entire LE

2. hip disarticulation: at hip joint

3. above knee: any level on thigh

4. knee disarticulation: at knee joint

5. below knee: any level on calf

6. ankle (syme)

7. ray (metatarsal)

8. transmetatarsal

9. complete phalanges

spinal precautions and adaptive equipment

PRECAUTIONS: BLT

- no bending

- no lifting more than 5lbs

- no trunk rotation (twisting)

AE:

- back brace

body powered prostheses

• use specific muscles to place tension on cable that opens or closes TD (terminal device)

• two main types:

  • hook: used for functional ax

  • hand: used for cosmetic appearance

• two main ways of operation:

  • voluntary closing: hook remains open until tension is placed on cable and closes

  • voluntary opening: hook remains closed until tension is placed on cable and opens

    • more common

• PROS:

  • durable, provides prop feedback, less maintenance cost

• CONS:

  • restrictive harness, decreased grip, force exerted on residual limb, can be difficult to control

myoelectric (electrically powered) prostheses

• muscle contractions of two different muscle groups are used to control TD

• types:

  • hook: allows pinch and FM manipulation (opposition)

  • hand: cosmetic appearances with pinch fxn

• PROS

  • improved cosmesis, can be fitted early in recovery

  • incr and proportional grip, larger fxn

  • minimal/no harness, minimal effort for control

• CONS

  • incr cost, high maintenance, susceptible to environment

  • lack of sensory feedback, incr weight

hybrid prosthesis

• combo of body powered and electrically powered

• most common for elbow or above elbow amputations

• PROS:

  • simultaneous control of elbow and wrist

  • less weight, incr grip

• CON

  • harness, may be difficult to operate

passive prosthesis

• static, used for cosmetic appearances, can be passively adjusted to assist with carrying or grasping

• PRO

  • no harness or cables

  • cosmetic restoration

  • low maintenance, lightweight

• CON

  • no active grasping fxn

activity specific prosthesis

• generally no harness or control cable

• designed for specific work or leisure task

• PRO

  • allows enhanced fxn and task specific participation

  • minimal harness or cabling

  • durable, low maintenance, reduce wear and tear on primary prosthesis

• CON

  • no active grasp

  • limited to specific task

complications of amputations

• neuromas: nerve endings adhere to scar tissue

• skin breakdown

• phantom limb:

  • syndrome: sensation of presence of limb

  • pain: painful sensation of presence of limb

• infection

• contractures

• psychological trauma

pre-prosthetic training phase

• begin: postsurgical period ends

• end: patient receives preparatory or definitive prosthesis

• intervention focus:

  • emotional support

  • stabilize limb volume

  • wrapping

    • distal to proximal

  • desensitize sensitive areas of residual limb

  • activities to strengthen motor patterns in preparation to operate the prescribed device

  • determine optimal type of prosthesis to meet patients goals

prosthetic training phase

• begin: delivery of temporary or definitive prosthesis

• end: pt demonstrates a successful functional outcome with proper prosthetic use

• intervention focus:

  • control training

  • balance

  • repetitive drills

  • don/doff prosthesis

  • wear tolerance: start 15-30 min 3x daily

  • functional training to learn to integrate the prosthesis as an assistive tool in daily activities that align with patient goals

burn levels

1. superficial: dry red, 3-7 days
2. superficial partial-thickness: moist red, 7-21 days
3. deep partial thickness: mottled, 21-35 days, graft
4. full thickness: dry white, months, graft

superficial burns

• epidermis only

• PRESENTS: dry, crinkle, red, little painful, no blisters

• OUTCOME: heal spontaneously in 3-7 days; no scar

EX: sunburn, short flash burns

superficial partial-thickness burn

• epidermis & upper level dermis

• PRESENTS: blistered, red, weepy, moist; hair follicles intact; very painful

• OUTCOME: heals spontaneously within 7-21 days; no grafts; minimal to no scar

EX: scalds, radiation

deep partial thickness burn

• epidermis & severe damage to dermis, hair follicles, and sweat glands

• PRESENTS: blotchy, large pink blisters, mottled white, pink, to cherry red; damage to BV's; painful

• OUTCOME: 3-5 weeks to heal (21-35 days); scarring increased; often grafted

EX: immersion scalds, flames

full thickness burn

• epidermis & dermis destroyed

  • may include fascia, muscle, tendon, and bone

• PRESENT: white or waxy (adipose showing); dry, leathery, non-pliable until debrided; no sensation

• OUTCOME: surgical intervention; can damage underlying structures; months to heal

EX: electrical, chemical, flame, scald

rule of nines

a method used in calculating body surface area affected by burns

HEAD: 9%

ARMS: 9% each

GROIN: 1%

TORSO: 36%

LEGS: 18% each

what is included in the primary survey when assessing a patient with burn injury

- ABCs

Airway with C-spine immobilization

Breathing and ventilation

Circulation and hemorrhage control

Disability and deformity

Exposure and environmental control

Fluids and foley

emergent burn phase

• 72 hours post burn

• focus on stabilization

• fluid resuscitation

• inhalation injury: possible trach/vent

• compartment syndrome

• wound care

• nutrition: metabolic rate increase with burns; important to increase protein, vitamins, etc

• contracture formation

anticontracture positioning for burns

• contractures will form in position of comfort

  • skin will seize up > contracture forms

  • EX: burn to back of knee will result in knee flexion contractures; burn to anterior neck will result in neck flexion

• anterior neck

  • contracture: neck flexion

  • position: remove pillows, extend neck with splint or collar

• axilla

  • contracture: adduction

  • position: 120 abduct with slight ER (gorilla stance)

antideformity splint

AKA SAFE POSITION SPLINT

-20 deg wrist ext

-90 deg MCP flex

-PIP/DIP 0 deg ext (full)

for burns to hand or dorsal hand

acute burn phase

• after emergent until wounds closed

• support and psychosocial adjustment (anxiety, depression, PTSD)

• medical management: skin graft

  • ROM contraindicated following graft

• initial eval & interventions

  • wound care, education, gentle mobility, pain, sensation, splints

rehabilitation burn phase

• until scar maturation (6 months to 2 yrs)

• intervention focus: general OT burn focuses

  • sensation, pain, scar, strength

  • pressure therapy: compression to healed wounds using gloves, bandages, or wraps

    • 2hr > 23hr wear tolerance for 1-2yrs until scars mature

myofascial pain syndrome

• persistent, deep aching pain in muscles, nonarticular in origin

• well defined, highly sensitive tender spots )trigger points)

fibromyalgia syndrome

• musculoskeletal pain and fatigue disorder that can very in intensity

• SX:

  • widespread pain accompanied by tenderness of muscles and adjacent soft tissues

  • rheumatic disease of unknown origin

low back pain

• most common work related injury

• causes

  • poor posture

  • repetitive bending using poor body mechanics

  • heavy lifting

  • poor sleep posture

• SX:

  • pain, difficulty with self-care, difficulty sleeping

visual analog scale

having individuals mark a point along a straight line that represents a continuum between two extremes