UE injuries and orthopedics

UE evaluaition

Observe the entirety of the upper extremity
► Positioning, guarding, edema, bruising, overall skin condition
► Proximal to Distal Evaluation:
► Cervical spine, shoulder complex
► Elbow/Wrist assessment
► Provocative Testing: A test to elicit a response indicating a
specific condition or irritation of a group of muscles/nerves.
► Peripheral nerve assessment

Thoracic Outlet Syndrome:

parasthesias with prolonged positioning/activity above the shoulder level or behind the plane
of the body

Neural tension

parasthesias with reaching in positions that place tension on the brachial plexus nerves

Carpal Tunnel

pain/numbness in thumb, index and middle fingers

Cubital Tunnel

Compression of ulnar nerve at the elbow

Ulnar nerve impairment

paralysis of the adductor pollicis longus

External rotation lag sign

(supraspinatus or infraspinatus issues)

Jobe test/ empty hand test

rotator cuff or bursitis

Neer Test

subacromial issues

Hawkins-Kennedy test

subacromial or labral issues

speed’s test

Subacromial or labral or biceps pathology

Drop arm test

rotator cuff

cozen’s test

lateral epicondylitis

Finkelstein’s Test

de Quervain’s tenosynovitis

Murphy’s sign

lunate issues

Edema Measurement

Volumetrics

measurements

ink markings/border markings

Strength

Grip strength, pinch strength

Functional Assessment

Observe the client in a functional task- standardized tests can
also be utilized
► Jepsen Hand Function Test
► Box and Blocks
► Minnesota Manual Dexterity Test
► Nine-hole peg test
► Quantitative Test of Hand Function
► Purdue Pegboard
► Minnesota Manual Dexterity Test

Rotator Cuff Pathology and Disease

70% of shoulder disorders related to RC disease

Elbow overuse injuries

Medial and Lateral Epicondylitis/osis

Wrist overuse injuries

DeQuervains- common for new mothers

Wrist tendonitis- ECU and FCR most common

Finger overuse injuries

Trigger finger

Stage 1

► ***Identify positions that exacerbate and relieve symptoms
► Activity modification to promote position of neither
compression or stretch
► Pain relieving modalities
► Heat
► Cold
► Ultrasound (0.8-2.0 W/cm², 100% ds, thermal)
► E-stim
► Taping
► Relaxation exercises

Stage 2

► Joint mobilization
► AC, SC, scapulothoracic joints
► Soft tissue mobilization (STM)
► Deep stretching
► Soft tissue manipulations
► Peripheral nerve mobilization
► Nerve glides:
► Ulnar
► Radial
► Median

Stage 3

► Conditioning and strengthening
► Muscles necessary to maintain postural correction
► ADL
► Activities that promote tolerance of neural tension
► Restoration of functional ROM
► Aerobic exercise
► Increase aerobic capacity

Operative treatment

Surgery: last resort

Neurolysis (decompression)

Rib resection

Radial Nerve Palsy

High
► Crutch Palsy
► Axilla
► Saturday Night Palsy
► Mid-humeral compression or
shaft
► Timelines and healing
► A few days – 4 months

Clinical presentation, wrist drop

Median Nerve palsy

High (proximal)
► Pronator Syndrome
► Low
► Carpal Tunnel Syndrome

Orthotic Intervention
► Neutral wrist brace – for Capal Tunnel
► Static thenar web spacer
► For Median Nerve Palsy

Ulnar Nerve palsy

► High
► Cubital Tunnel
Syndrome
► Low
► Guyon’s Canal

Clinical presentation
► “Claw hand deformity

Intervention

► PREVENTION!!!
► Conservative management
► Positioning for decompression
► Rest for healing and recovery
► Surgical Intervention
► Surgical release or decompression’
► Splinting
► Edema management
► Scar management

Sensory Loss

► EDUCATION – in burns/injuries due to sensory loss
► Burns / Cold injuries
► temperature
► duration

Evaluation

► Observation and palpation
► Assessment of sensory function
► Assessment of motor function
► Assessment of autonomic function
► Presence of sweating indicates incomplete nerve damage
► Trophic changes (nail, abnormal hair growth, color, etc.)
► Assessment of pain

Orthopedics

► Bone Involvement
► I.e. a “fracture” of the bone
► Priority becomes stabilization/immobilization
► Important: know when it is OK to begin PROM, AROM, strengthening.
► This can vary from case to case, person to person.
► Why??

Stages of healing

► Inflammatory Stage (1-7 days)
► Repair Phase ( 0-8 weeks)
► Remodelling Phase (> 8 weeks)

Proximal Humeral Fracture

► Most common fracture of the humerus
► Non-surgical – sling for short period then move
► Surgical – pendulums and PROM – Surgeon will direct

Elbow

► Radial Head FX
► Most common
► Leads to elbow flexion contracture
► Olecranon FX
► May lead to nerve injury
► Distal Humeral FX
► Uncommon

Timeline and Healing

► 1 week gentle ROM in stable range
► 8-12 weeks may begin strengthening
► *Initial goal of therapy is to RESTORE motion while protecting
elbow from harmful stress
► General saying for elbow fractures:
► Move immediately
► Surgery and move immediately - often in restricted range

Orthoses

► Indications
► Manage pain
► Support unstable structures
► Restrict motion
► Provide rest
► Prevent loss of motion
► GENERALLY – immobilize one joint above and below the fx
and the finger(s) beside the fractured finger

Wrist Fractures

► 1-6 Weeks
► Gripping
► Remember that most daily activities require 20 lbs of grip strength & 5-7
lbs of pinch strength
► Encourage early use of involved hand for pain free, light tasks
► MOVE fingers –

Distal Radius fx- orthosis

Casts

Schaphoid Fx

► Non-op Operative
► 6 weeks above elbow 6-8 weeks forearm thumb
spica
► 6 additional below elbow

Operative- 6-8 weeks forearm thumb

Treatment considerations

► Strengthening
► Resumption of Functional Activities
► Home Exercise Program
► PROM/ Dynamic & Static Progressive Orthoses

Hand Fractures

► ORIF
► Advantages
► Callus formation avoided
► Therapist can access injured area sooner
► Disadvantages
► Dissection through soft tissue increase liklihood of scar formation and
adhesions
► Increased potential for infection
► Hardware can interfere with soft tissue mobility

Secondary Healing

► AROM (7-8 weeks)
► Controlled AROM of proximal and distal structures 5-6 weeks
► Light ADL
► PROM (3-6 weeks after AROM)

Early Mobilization

► Location of fracture
► Fracture pattern and amount of displacement
► Type of reduction and hardware used
► Surrounding soft tissue damage
► Patient’s functional demands

Flexor Tendon Injuries

► Usually occurs from trauma
► Open laceration
► Closed rupture: “jersey finger”
► Requires surgical repair
► ASAP
► Late repairs may need graft due to retraction

Zone 2- high risk

Complications

► Adhesions
► Ruptures
► Anatomy of FDS & FDP

Post-operative treatment

► Immobilization – likely due to multi trauma
► Immediate passive flexion – 2 strand repair
► Immediate active flexion – 4 strand or more

Orthotic Intervention

► Dorsal blocking splint
► Static or dynamic

Extensor Tendon Injury

► Less complex than flexor tendon injuries
► Fewer complications
► Traumatic origin
► Open
► Closed

Zones

injury discussed in relation in zone of injury

Orthoses

► Dependent on zone of injury and strength of repair
► Mallet – zone 1

Boutonniere – zone 3

and strength of repair