Conditions Unit 3 - Musculoskeletal Conditions Cont.

Fractures of the Forearm, Wrist, and Digits

Introduction to Fractures

Fractures are most often caused by trauma, osteoporosis, and overuse. This guide will cover the various types of fractures in the upper extremity, starting from the forearm and progressing down to the hand.

Common Upper Extremity Fractures

One of the most common fractures in the upper extremity is the distal radius fracture, which comes in two main types:

  • Colles' Fracture: Characterized by dorsal displacement of the distal radius, typically resulting from a fall on an outstretched hand (FOOSH). The broken piece of bone points upwards.

  • Smith's Fracture: In this type, there is volar displacement of the distal radius caused by a fall on the back of the hand.

Distal Radius Fractures

The distal radius fracture is primarily confirmed via X-ray. Post-operative images may show a plate attached to the distal radius to ensure stability during healing.

Characteristics of Specific Fractures
Colles' Fracture

  • Orientation: Dorsal displacement

  • Mechanism: Fall on an outstretched hand

  • Outcome: Bone fragment points upwards

Smith's Fracture

  • Orientation: Volar displacement

  • Mechanism: Fall on the back of the hand

Scaphoid Fracture

The scaphoid is the most commonly fractured carpal bone, comprising about 60% of carpal fractures, generally from a fall when the wrist is in radial deviation. Proper management often includes immobilization in a cast for 8 to 10 weeks.

Interventions for Distal Radius and Scaphoid Fractures

Medical Management

  1. Distal Radius Fracture:

    • Immobilization and surgical fixation as needed.

  2. Scaphoid Fracture:

    • Managed with a cast; interventions focus on preventing complications like edema, joint contractures, nerve compression, tendon rupture, stiffness, CRPS, and pain.

Role of Therapists

Therapists play a crucial role in normalizing edema, ensuring range of motion is restored in uncasted joints, and promoting functional engagement throughout recovery.

Pharmacological Management

Pain management may involve Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and/or opioids. In some cases, medications to enhance bone density may also be beneficial.

Health and Safety Management

When using adaptive devices (like wheelchairs, orthosis), it is vital to understand how to maximize their safe use, ensuring environments are hazard-free. Protocols may vary depending on a physician's approach to healing, necessitating close adherence to specific orders and precautionary monitoring for complex regional pain syndrome (CRPS).

Precautions and Contraindications

Weight-bearing restrictions dictate appropriate usage of adaptive equipment. For instance:

  • A patient with a distal radius fracture who cannot place weight on their upper extremity should avoid a standard walker unless it has weight-bearing modifications.

  • Certain devices can induce complications in contexts for which they are not suited, further emphasizing interdisciplinary communication for adaptive equipment selection.

Soft Tissue Injuries

Types of Soft Tissue Injuries

  1. Sprains: Injuries to ligaments, graded as follows:

    • Grade 1: Mild sprain, minimal ligament damage, low functional impact with quick recovery.

    • Grade 2: Moderate sprain with partial ligament tearing; joint linkage is compromised.

    • Grade 3: Severe sprain, complete ligament tear, leading to joint dysfunction.

  2. Strains: Injuries to muscles or tendons.

Overuse Injuries

Ex. Tendinitis: Inflammation or irritation of tendon covering; worsens with use. Bursitis: Irritation of bursa sacs causing pain, often accompanying tendonitis.

Considerations for Therapeutic Management of Soft Tissue Injuries

Individuals with soft-tissue injuries often present in various contexts throughout their lifespan but particularly among adults and the elderly.

Tendon and Ligament Injuries

Tendon Injury Mechanisms

Tendons, which connect muscles to bones, are typically avascular but rich in collagen, giving them tensile strength. Common conditions include:

  • Tendinitis: Inflammation from microtears; discomfort with movement.

  • Tendinosis: Result of repetitive microtears degrading collagen fibers.

Specific Soft Tissue Conditions

Adhesive Capsulitis/Frozen Shoulder: Created by surgery immobilization or trauma, leading to inflammation and adhesions, which losses motion in the shoulder.

Clinical Management Strategies

Diagnostics

Diagnostic approaches include imaging and provocative testing, while conservative management may incorporate the RICE method (Rest, Ice, Compression, Elevation).

Interventions

Include:

  • Medical (e.g., surgery for severe cases, pharmacological pain management)

  • Therapeutic (e.g., ultrasound, active assistive therapy where safe; orthosis fabrication for protective positioning).

Monitoring and Adjustments

With acute injuries, the use of heat is typically discouraged as it can precipitate increased inflammation. Professionals should also monitor for increased pain/swelling and avoid vigorous activities while performing motion exercises.

Nerve Injuries

Overview of Nerve Injury Mechanisms

Injuries to nerve fibers can disrupt feedback loops to the central nervous system, with classifications of nerve injuries including:

  1. Neuropraxia: Occurs with long-standing compression damaging the myelin sheath. Typically resolves in weeks to months.

  2. Axonotmesis: Involves axon disruption but endoneurial tubes remain intact. Recovery is possible with degeneration occurring distal to the injury site. Healing rate is estimated at 1 mm/day.

  3. Neurotmesis: Characterized by a complete nerve disruption. Requires surgical intervention for potential recovery.

Types of Nerve Injuries Discussed

  • Radial Nerve Injury: Common following humeral fractures, presenting with wrist drop.

  • Median Nerve Injury: Can result from laceration or compression (carpal tunnel syndrome), affecting thumb opposition.

  • Ulnar Nerve Injury: Can lead to claw hand presentation following a laceration or chronic elbow flexion from cubital tunnel syndrome.

Interventions for Nerve Injuries

  1. Radial Nerve Injury: Focused on sensory re-education, monitoring for sensory loss and wrist drop.

  2. Median Nerve Injury: Same as above with an additional focus on protecting the hand.

  3. Ulnar Nerve Injury: Emphasis on preventing pressure within the Guyon canal and modifying activities to prevent discomfort.

Impact of Nerve Injuries on Occupational Performance

Each specific nerve injury correlates with distinct impacts on motor, sensory, and occupational functions essential for daily activities. Proper management underscores capturing functional output lost due to these injuries.

Learning Activities and Case Studies

Engaging with case studies like Amara, with De Quervain’s tenosynovitis, and Lena, with carpal tunnel syndrome, enhances understanding of the practical implications of these injuries, relevant interventions, and expected occupational impacts.

References

Hock, N. (2022). „Orthopedics” in B. J. Atchison & D. P. Dirette (Eds.). Conditions in occupational therapy: Effect on occupational performance (6th ed., pp. 551-571). Wolters Kluwer.
Gutman, S. A., & Westover, L. A. (2022). „Musculoskeletal pain” in B. J. Atchison & D. P. Dirette (Eds.). Conditions in occupational therapy: Effect on occupational performance (6th ed., pp. 571-603). Wolters Kluwer.