Hand Rehabilitation

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Hand Rehabilitation
2014-03-10 00:55:52
Hand Module
Occupational Therapy Modules
Hand therapy
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  1. Assessment of the Hand - General
    • - Documentation: keep accurate record of evaluation
    • parameters
    • - Patient record: for a continuum of care, so they go into patients chart and understand what to do
    • - Program evaluation: to determine if program is working
  2. Goals of Assessment
    • 1. Predict rehab potential - can you help
    • 2. Comparative information- is the person getting better or worse
    • 3. Treatment planning and evaluation - plan what treatment plan is going to be based on assessment evaluation, then decide if plan is a good plan later on in treatment
    • 4. Set treatment priorities - identify what are the big priorities
    • 5. Inventive - is treatment actually making a difference, give objective information of proof, e.g. increased 20 degrees
    • 6. Define functional capacity - some people will never be normal again, but can define what functional capacity is after rehab, you always will have to discharge (you may get repeat customers)
  3. Assessment Procedures
    • 1. History – age, dominance, occupation, avocations, mechanism of injury, level of injury, date of injury, date of repair or surgery date, patient’s subjective complaints
    • 2. Past Medical History
    • 3. Medications
    • 4. Physical examination – inspection, edema, ROM, muscle testing, grip strength, pinch strength, sensibility, fine motor manipulation tests, psychological aspects, functional performance measures
  4. Assessment – History
    • 1. Age - children will always do well, treatment protocols may change because of age, some older people the tissue is older and may not respond as well
    • 2. Dominance - will most likely be on dominant hand and will impact their ADLs, the dominant hand will rehab better than the non-dominant because will continue to only use dominant hand
    • 3. Occupation - a lot of workers comp people, so have to have common goals. Other injuries include farm injuries, table saws, etc. Keep occupations in mind and goal to get back to as soon as you can
    • 4. Avocations - what are their hobbies, can you get them back to it, incorporate it in to therapy
    • 5. Mechanism of injury - what problems you expect to see, a wound from knife vs. table saw, is tendon going to stick to bone, is there scar tissue, a knife will be an easier rehab process 
    • 6. Level of injury - need to know the structures involved, e.g. flexor tendons are more difficult than tendons in palm or wrist.
    • 7. Date of injury –
    • 8. Date of repair - usually 7 days after injury; if it is longer, need to figure out what’s the date and why 
    • 9. Patient's subjective report of the problem - more important with less traumatic injuries, e.g. a cumulative problem - wrist pain, but the bigger problem may be that he has to walk with a cane and that’s when they can’t handle it; lots of time it is pretty obvious
    • though
  5. Assessment - Past Medical History
    - address any other medical problems they have that may regarding hand problems, e.g. if see scar; if you think are not doing well, ask e.g. if have diabetes it will affect how they are treated
  6. Assessment – Medications
    - Are you taking pain medications, usually hand injuries aren't painful; are they on antibiotics, so chance of infection is going to be less
  7. Assessment - Physical examination
    • 1. Inspection
    • 2. Edema
    • 3. ROM
    • 4. Muscle testing
    • 5. Grip Strength
    • 6. Pinch Strength
    • 7. Sensibility
    • 8. Fine Motor Manipulation Tests
    • 9. Psychological Aspects
    • 10. Functional Performance Measures
  8. Physical Examination – Inspection
    - is there a lot of swelling, what is normal to expect with an injury
  9. Physical Examination – Edema
    • - observations (are wrinkles in knuckles present, decreased longitudinal creases, compare to other hand; look at hills and valleys of metacarpal hands - edema present by decreased hills and valleys - not objective)
    • 1. circumferential measurement - measure girth of what want to measure, norms based on other hand; repeat measure on both hands; compare change; use if measuring small portion 
    • 2. volumeter - water displacement, only works if hands are the same; on repeat measures have the volume of hands changed; procedures to follow
    • 3. subjective description - it’s good today, but yesterday was bad. What does activity do? Does sleep help? What did you eat or drink?
  10. Physical Examination – ROM
    • - measured with goniometer (Digital ROM)
    • - Composite extension/composite flexion-standardized format (ASHT) - extension/flexion i.e. 20/80
    • - Active ROM (passive ROM) - Active (passive) i.e.20(15)/80(?)
    • - Procedure: measure in wrist neutral position; composite flex/ext vs. isolated joints - they know when they can get most
    • movement so don't allow them to use these positions; measure dorsally; no external blocking - don't let them hold finger in a position with other hand; hyperextension is measured as a "+" - anything past 0;
    • - TAM: Total Active Motion Example
    • o TAM = total of all active flexion measurements - total of all active extension lags (i.e. total of AROM of MCP, PIP and DIP
    • o E.g. 15(8)/ 67(82) -25(-13)/83(100) -10(0)/46(53)
    • o (67+83+46) - (15+25+10)
    • o 196-50
    • o TAM 146 degrees

    • - TPM: Total Passive Motion Example
    • o TPM = total of all passive flexion measurements - total of all joint flexion contractures (i.e. total of all PROM of MCP, PIP, and DIP)
    • o e.g. -15(8)/67(82) -25(-13)/83(100) -10(0)/46(53)
    • o (82+100+53)-(8+13+0)
    • o  235-21
    • o  TPM 214 degrees

    • - Normal for D2-D5 is 260 degrees
    • o MCP = 85
    • o PIP = 110
    • o DIP = 65
    • o Some variance; use corresponding normal digit on the opposite hand for comparison;   

    • - measurements may be affected by:
    • 1)edema/body prominences
    • 2)Wrist position
    • 3)inter/intra-rater reliability - reading goniometer, timid therapist and how much push it
    • 4) Pre-measurement activities - what was done before, measurement, were they stretched on heated up
    • 5) individual circumstances - patient holding back on ROM because worried you won't stop, they don't want you measuring range, etc. -  more relationships

    • - ROM can also be measured in terms of distance from the distal palmar crease - Measurement of tip to the DPC (distal palmer crease)
    • - Wrist ROM
    • - Forearm pronated; Wrist flexion: dorsal placement of goniometer (3rd MC/forearm); volar placement of goniometer (between too long and ring fingers/forearm); Alternatively,
    • measure radially along 2nd MC and radius (radial syloid as axis) - 2nd is a stable part of the hand
  11. Physical Examination – Muscle Testing
    - Brachial plexus and nerve injuries; purpose of assessment:

    1) guide treatment - why strengthen muscle if have nerve or tendon injury

    2) dictate splinting needs - training regime, when do you want muscles to be working

    3) diagnostically - what muscles are moving determine injury; diagnostic reasons

    4) progress report - indication of progress; measure progress
  12. Physical Examination – Grip Strength
    - tool: Jamar dynamometer

    - standardized position - 90 degrees of elbow not on arm rest, by their sides, support Jamar in hands, forearm in mid position, wrist in a little bit of extension

    • - Methods:
    • 1) 3 trial method - level 2 position (right and then left until 3 trials are complete
    • 2) 5 level method - Right left on all 5 levels with one trial on each of the levels - used when have a nerve dysfunction
    • a. level 1 - intrinsic muscles, least strength
    • b. level 2 - strongest level for woman
    • c. level 3 - strongest for men - both levels are between extrinsic and intrinsic muscles
    • d. level 4 - more extrinsic; 2nd weakest
    • e. level 5 - all extrinsic; 3rd weakest
  13. Physical Examination – Pinch Strength
    - tool: Jamar pinchmeter

    - standardized position - forearm stays in the mid position, so move tool to keep this position

    - observations of how they perform the test - how they hold on to grip tester

    • - methods:
    • 1) key pinch, tripod, tip to tip pinch - in order of strengths; 3 trials
    • 2) dominant vs. non-dominant - consider norms
    • 3) injured vs. non-injured - compare
  14. Physical Examination – Sensibility
    - sensation versus sensibility - sensation is brain understanding stimulus from environment, sensibility is attaching meaning to that e.g. hard, soft  - how brain connects meaning

    • 1. Objective tests
    • A. Sudomoter Tests
    • (1)   Ninhydrin - hand is wiped with alcohol than put under heat lamp that causes sweat glands to produce fluid then press hand onto a bond paper and spray agent - it is a sweat test
    • (2)   wrinkle test - de-nervated skin does not wrinkle - think age- hard to get objective
    • info from a child - may be to get a toy in water 
    • (3)   observations for
    • (a)    vasomotor function
    • (b)   Pilomotor function
    • (c)     trophic changes
    • B. nerve conduction velocity and EMGS - measure activity of nerve by electrodes at
    • proximal and distal ends

    • 2. threshold or modality tests (what
    • OTs often use) – 4 classic cutaneous functions:
    • (1)   pain - pin prick
    • (2)   hot/cold - done with test tubes
    • (3)   touch/pressure - semmes Weinstein monofilaments - calibrated so apply pressure until it bends - biggest one is deep pressure and have to apply pressure until it bends
    • (4)   vibration - vibrometer, tuning forks

    • 3. functional tests (applying meaning)
    • (1)   static two point discrimination - tell difference of 1 point or 2 points; need this to
    • determine if a quarter is in hand for e.g.
    • (2)   moving two point discrimination
    • (3)   localization - touch person at a point and know they are feeling it there
    • (4)   Moberg pick up test - picking up small common objects with or without vision, without vision brain and have to communicate with others - e.g. key bolts pins
  15. Physical Examination – Fine Motor/Manipulation Tests
    - defines functional capabilities; normal date helpful; use standardized tests for assessment purpose only (can’t tell if learned or if they got better)

    • 1. jebsen-tayor hand function: prehension and manipulation; norms for both dominant
    • and non-dominant; several sub tests simulating ADLs

    2. Minnesota Rate of Manipulation (MRMT): 5b subsets; assesses both unilateral and bilateral skills; endurances a factor - there are 60 discs - may need strengthening of upper body; dependent on good proximal function

    3. Purdue Pegboard (fine level of function): assesses tip-pinch dexterity while reaching; assesses both unilateral and bilateral function

    4. Pennsylvania Bimanual Work Sample: assesses bilateral manipulation of small objects

    • 5. Bennett Hand tool Dexterity Test: standardized - timed and normed; work simulation aspect (moving bolts); purely
    • bilateral

    6. Crawford small parts test: unilateral test of fine motor skills

    7. Valpar Worksample

    8. BTE Work Simulation (non-standardized): assess physical demands of the workers job
  16. Physical Examination – Psychological Aspects
    - the spoken words (is there blame or anger - this also needs to be dealt with)

    • - observation:
    • o posture
    • o hiding (pain, embarrassed etc)
    • o emotional status (do they burst into tears)
    • o ? secondary gains (want injury to be worse than what it is - e.g. collecting money)
    • o dark glasses (those who wear them inside - do they need them for a reason if no, take them off so can read people’s eyes - is there substance abuse)
  17. Physical
    Examination – Functional Performance Measures
    • - functional limitation vs. physical disability:
    • functional - unable to do up buttons; physical: unable to get dressed (or yes
    • can get dressed because clothing has been adapted)

    A. Injured workers survey: excellent for WCB clients; if the patient responds affirmatively to certain questions this would indicate a need for a referral for psychological interventions (e.g. nightmares)

    B. DAS: Disability of Shoulder and Hand: the Dash would measure: physical disability (the impact of the disease on how a person function), symptoms (subjective evidence of disease based on the patient's perception)
  18. Examination
    • -WCB - everything is relevant so measure everything with precision for e.g.
  19. The significance of hand rehabilitation
    • - hand injuries are often trivialized by patient and health care workers
    • - visually representing a small part of the body, injuries to that part are construed as small as well
    • - hand uses a larger part of the motor and sensory cortex of the brain (can show patients on a diagram)
    • - the team: captures patient in the centre, but communicate well with the rest of the team- external resources, the surgeon,
    • WCB/insurance, nursing, support staff, the OR/ER, PT/PTA, OT/OTA
  20. Characteristics of a wound
    • Three similarities:
    • 1. Host tissue injury
    • 2. Contamination by living organisms - bugs and viruses getting in 
    • 3. Presence of foreign bodies - in more devastating injuries have grain vs. paper cut have paper
    • - Tidy vs. untidy - is how you separate them such as a paper cut/or clean cut with knife vs. a post pounder that has destroyed all tissue
    • - Debridement:  removal of the dead tissue or foreign bodies (if serious may require surgery)
  21. Wound Closure
    • 1. Primary wound closure (suture technique - may be dissolvable sutures)
    • 2. Delayed wound closure (contaminated wounds - bacteria grows in a no oxygen environment; keep an eye to ensure aren't developing an infection, may need to open wound and leave open until know got all bacteria and then close it)
    • 3. Secondary intense healing (untidy wounds - the body will close the wound itself, but the whole time the wound is open you are at risk of developing infections)
    • - e.g. McCash procedure for Dupuytren's - leave wound open for drainage
    • - OT example of Secondary intense healing- can splint and immobilize to help stop movement which will prevent wound closure, so put in a position of protection
    • - pressure on wounds prevents it from getting oxygen and you want oxygen so tissue can live and heal
    • - the longer you leave to close the more scar tissue will develop in the process of contraction
  22. Phases of Wound Healing
    • ? 4 phases:
    • 1. haemostasis (at moment of injury, blood vessels are sealed off, and normally is included in inflammation stage) or: haemostats is included in inflammation stage. Constriction of the damage vessels, platelet aggregation to form clots to 'seal' the leaky vessels
    • 2. inflammation (Phase I: Inflammatory)
    • 3. proliferation (Phase II: Proliferative/Fibroblastic)
    • 4. maturation (Phase III: Maturation)
  23. Phase 1: Inflammatory phase
    • - 2-3 days duration
    • - histamines released from damaged cells
    • - results in vasodilatation and increased vascular permeability --> localized tissue edema
    • - phagocytosis - clean up cells (break up clots and clean injury, but process of enzyme break down cause’s body to send more fluid to the area)
    • - fibrin network formation
    • - enzymatic activity with increased osmolarity (brings fluid to injury) => more edema

    • - Steroid administration => decreases cellular phase and increases wound healing time (so get client’s history)
    • - large amounts of cellular debris or ongoing infection => prolongs inflammation phase and delays next phase (lots of cells in area to clean up)
  24. Phase II: Proliferative/Fibroblastic phase
    • - 2-6 weeks
    • - begins after resolution of phase 1
    • - fibroblastic proliferation (fibroblast is a cell that begins to form scar tissue)
    • - endothelial budding of new capillaries (body wants to form new vascular bed to help with the healing of the tissue - small budding of capillaries)
    • - GRANULATION TISSUE (allow tissue to close wounds)
    • - thin scar epithelium (epithelium is top layer of skin and will cross the granulation tissue, but is thin and fragile)
    • - contraction begins (type of fibroblast that wants to make wound smaller, so it begins to contract)

    - Hyper-granulation tissue - proud tissue, cauterize it to make it settle down
  25. Phase III: Maturation/Remodelling
    • - begins at 3 weeks or at the end of Phase II
    • - continues for 6m to 2 years
    • - tensile strength progressively increases: 15% normal tensile strength at 3 weeks and 50% normal tensile strength at 6 weeks
    • - new scar is red, raised, think and rigid (because of collagen and lots of oxygen)
  26. Scar Formation
    • - day 4 and 5 only minimal amounts of collagen present in the wound (by the 4th or 5th day some collagen is already present in the wound)
    • - by week 2 there is a moderate amount of collagen in the wound (by the end of week 2 the wound is comprised of a rich capillary network, a large number of fibroblasts and a moderate number of collagen fibres)
    • - at 3-6 weeks fibroblasts and blood vessels diminish slowly (3-6 weeks post-injury the number of fibroblasts and blood vessels diminishes slowly; collagen increases – adds strength to the wound)
    • - as cell population decreases, scar collagen fibres increase
    • - the wound evolves from a predominantly cellular wound to extra-cellular
    • - collage fibres are responsible for the characteristic physical properties of scar
    • 1. thick
    • 2. raised
    • 3. inelastic

    • - by 3 weeks a normal 1 degree repaired wound has less than 15% of ultimate tensile strength
    • - strength increases linearly for at least 3 months
    • - tendons will heal at an even slower rate
    • - MASS HEALING AFFECT => all tissue is bound together as one wound by scar
    • - Effective scar remodelling determines the success of surgical procedures and therapists attempts to restore function and cosmetics
  27. Scar Remodelling
    • - refers to the changes made over time in wound colour, texture, firmness and build
    • - it requires altering collagen fibre organization
    • - randomly matted collagen becomes organized in a parallel fashion
    • - physical forces become very important (to help realign collagen fibres) - e.g. pressure therapy on scar tissue to reduce vascularity to take colour out of wound and collage fire realign in a parallel fashion
    • - our treatment programs remain empirical (don't know how it works but does)

    • - Factors affecting scar remodelling
    • 1. age (heals better if younger)
    • 2. total quantity of scar (big wound vs. small wound)
    • 3. previous injury or surgery (is there scar tissue)
    • 4. biological condition of tissue at the time of injury (is there a wound process that started and now going into and disturbing it again)
  28. Wound Contracture
    • - forces of contraction act to close the wound until met by an opposing force or until balanced by an equal tension in the surrounding skin
    • - early tissue replacement will reduce contraction but is less effective if the process has already begun
    • - Most effective:
    • 1. immediate coverage
    • 2. imposing outside force (AROM- fisting and stretching skin, or splinting - against forces of contraction)
  29. Controlling wound healing process
    • - Limited control by the therapist (are you a high scar former, are you old and tissue going to heal slower? all depends on factors)
    • - inhibit collagen bonding
    • - inhibit synthesis and deposition of scar collagen
  30. Splinting
    • - splinting is used to provide appropriate tension and re-establish balance of motion lost in the presence of edema and immobilization
    • - splinting needs are dictated by phases of wound healing

    • - Types of Splints
    • 1. static (no moveable parts)
    • 2. dynamic (moveable pats with force application)
    • 3. serial static/static progressive (static splinting remodelled over time; static splints with build in means for the patient to progress the force imparted on his/her tissue)
  31. Splinting and Wound Healing
    • 1. Splinting Inflammatory phase:
    • - tissue needs support and immobilization (allow it to go through stages of wound healing, 2-3 days later done with inflammatory stage, move to favourable position like a protective splint - but bad for flexor or extensor or palm burn, if need lymphatic flow to heart don't you straps but soft material)
    • - static splinting is most appropriate

    • 2. Splinting Proliferative phase:
    • - dynamic splinting is used to alter the direction and alignment of new collagen being laid down
    • - dynamic splinting must NOT delay or re-establish the inflammatory phase
    • - dynamic splinting may be alternated with periods of static splinting
    • - Dynamic splinting: PROM is responsive to a manual stretch; applies a specific force to a specific tightness (joint, tendon adhesions, skin, muscle-tendon tightness) - consider these when meeting clients with splints made, what are they trying to do

    • 3. Splinting Maturation phase:
    • - tissue is more resistance to external forces
    • - force applied by a dynamic splint would have to e applied the majority of the time
    • - serial static splinting (or static progressive) places the tissue in elongated positions and allows the tissue to 'grow to this new length
  32. Wound Management Goals
    - delayed wound closure is often seen in: crush injuries, post-op Dupuyntren's disease, mangling injures

    • - goals of wounds management:
    • 1. debridement of necrotic tissue
    • 2. promotion of wound healing
  33. Wound Management Stages
    • 1. cleansing the wound:
    • a) whirlpool
    • b) debridement

    • 2. promoting wound healing
    • a) protect the wound - dressing changes, handling the wound gently, kept wounds moist (too much and get maceration - white and wrinkly), laser, splinting

    • 3. dressings
    • a) non-adherent: adapt or sofra-tulle (Pr), polysporin, not Neosporin (helps keep the wound moist and promote re-epithelization) - can develop a sensitivity
    • b) promote mobility: reduce dressing size to allow for increased ROM, use tape that stretches (mefix) and or Coban

    4. wound closure: once healed than more aggressive scar management may begin: conformers, digisleeves, gloves, gelsheets (process of occlusion), ultrasound (dependent on tissue healing), massage (started early)
  34. Simplifying clinical decision making for open wounds
    • - black wounds - escar, indicative of a deep wound, never remove, let surgeon decide
    • - yellow wounds - help to evolve into a red wound, need to debride, spray with a solution to cleanse
    • - red wounds - wonderful granulation wound
  35. Black Wounds
    • - Description – covered with think, necrotic tissue or eschar- Cellular
    • Activity – autolysis, collagenase activity; defence, phagocytosis; macrophage cell-
    • Debridement – surgical, preferred; mechanical, whirlpool, dressings; chemical, enzymatic digestion
    • - Cleansing – whirlpool; irrigation; soap and water scrubs
    • - Topical Treatment – topical antimicrobials with low WBC or cellulites
    • - Dressing – wet to dry for necrotic tissue; proteolytic enzyme to debride; synthetic dressing, autolysis; dress to soften eschar
    • - Desired goal – remove debris and mechanical obstruction to allow epithelialisation, collagen deposition to proceed; evolve to clean, red wound
  36. Yellow Wounds
    • - Description – generating exudates, looks creamy, will contain pus, debris and viscous surface exudate
    • - Cellular Activity – immune response, defence; phagocytosis; macrophage cell
    • - Debridement – separate wound debris with aggressive scrubs, irrigation or whirlpool
    • - Cleansing – use no antiseptics; soap and water (ivory/dove); surfactant soaked spounge
    • - Topical Treatment – tropical antimicrobials to control bacterial contamination; silver sulfadiazine, bactroban, polysporin; not neosporin
    • - Dressing – wet to dry-wide mesh to absorb drainage; wet to wet-saturated with medicants; hydrocolloid or semi-permeable forearm dressings, hydro gels
    • - Desired goal – light debridement without disruption new cells; exudates absorption; bacterial control; evolve to red wound
  37. Red Wounds
    • - Description – uninfected, properly healing with definite boarders, may he pink or beefy red, granulated tissue and neovascularization
    • - Cellular Activity – endothelial cells-angiogenesis; fibroblast cells-collagen and ground substance; myofibroblasts – wound contraction; epidermal cells-migration and mitosis of epithelium
    • - Debridement – N/A- avoid any tissue trauma or stripping of new cells
    • - Cleansing – no antiseptics; rings lactate; sterile saline, water
    • - Topical Treatment – N/A for simple wounds; vitamin A for patients on steroids antimicrobials for immune-suppressed
    • - Dressing – occlusive or semi-occlusive dressings; semi-permeable films; protect wound fluids and prevent desiccation
    • - Desired goal – protect new cells; keep wound moist and clean to speed healing; promote epithelialisation, granulation tissue formation, angiogenesis, wound contraction
  38. Goal: wound closure
    • - achieve wound closure ASAP
    • - do not compromise wound closure for mobility
    • - open wounds: at risk for infection, limit mobility and delay PROM, increase scar formation
  39. Anatomy of Nerve
    • - axons require myelin sheaths that are produced by Schwann cells, make smallest component of peripheral nerve called a nerve fibre
    • - these fibres are bound together then in an endoneurium
    • - these are grouped together in fascicles
    • - and then bound together by epineurim and then epineral sheath
    • - a nerve is comprised of axons of multiple neurons bundled in connective tissue fascicles (never bundles) surrounded by perineurium.
    • - Each fascile itself is comprised of endoneurium containing multiple neurons surrounded with myelin produced by Schwann cells
    • - The outer layer (epineurium)
    • - Axon, Schwann cells, endonerium, fascicule/funiculi/nerve bundles, perineurium, epineral sheath
  40. Response to injury
    • 1. Mechanism - crush, thermal (common is electricity), chemical or ischemia (compression)
    • 2. Wallerian degeneration - axons will die distal to the point of injury, and will also die a short distance proximal to injury
    • 3. Endonerial tubes - regenerating axon grow down the endoneurial to terminal end points
    • 4. Rate of regeneration: (at best expect a 90% recovery of nerve and less in digits)
    • - 1 mm/day (average)
    • - more rapid if more proximal
    • - ? 1 cm/day in children
    • - ? 3-4 mm in brachial plexus
    • - ? <.5mm/day in digits due to nutrition transfer

    5. Retrograde effect on cell body - (sensory>motor) sensory is less favourable than motor recovery, again based on nutrition transfer
  41. Nerve lesions: Classification (2 Methods)
    • 1. Sir Herbert Seddon's
    • - neuropraxia (1) e.g. carpal tunnel syndrome
    • - Axonotmesis (2 or 3rd): axon injured and die back; proximal to distal recovery
    • - Neuotmesis (4 or 5th): massive disruption; surgical repair required e.g. traction injury

    • 2. Sir Sidney Sunderlands
    • - 1st degree lesion: global recovery; everything at once; CTS: D3 axons more volar => 1st to go
    • - 2nd degree lesion (minor 3rd): - endoneurial tubes intact; 100% recovery
    • - 3rd degree lesion: disrupt. of endoneurial tube (nerve fibre); epineurium and perineurium intact; minimal disruption
    • - 4th degree: epinerium intact; extensive fibrosis within (severe 3 degree can be caused y traction & crush)
    • - 5th degree: nerve laceration; epineurium cut
    • - ?6th degree: (Susan McKinnon); mismatch; neuroma in continuity
  42. Factors affecting prognosis
    • 1. amount of scarring/internal disorganization
    • 2. nature of the injury: cut/crush/avulsion
    • 3. level of the injury (proximal or distal)
    • 4. age: excellent up to 15 years old; at 55 recovery falls off quickly (less likely to nerve graft b/c have to take from other part of body)
    • 5. mixed vs. unmixed nerves (surgeons have to match up fascicles, so may have sensory nerve on motor)
    • 6. motor vs. sensory recovery (motor recovery is better, functional outcomes are less in sensory)
  43. Tissue response
    • - degeneration of muscle tissues noted within one week
    • - the entire muscle becomes an end place
    • - end results: 80-90% loss of fibre bulk although fibres still present
    • - at 3 months: interstitial fibrosis occurs reducing chances of recovery
  44. Post-op Management of nerve repair
    • 1. 5-7 days
    • - wound management
    • - ? protective splinting (tension on a nerve repair can pull it apart, need to protect it, think of anatomy of nerve and where it runs, what movement do you block to prevent stretching)
    • - ?AROM (ask surgeon), if repair site is protected

    • 2. 10-14 days
    • - wound/scar management (sutures come out, begin with gentle scar massage but be aware of nerve repair which only heals in 3 weeks)
    • - ROM exercises (in affected and unaffected part)

    • 3. 4-6 weeks
    • - serially adjust 10 degrees each week (to help prevent flexion deformity)
    • - scar management

    • 4. 6 weeks
    • - discontinue protective splinting
    • - unrestricted A/PROM
    • - splinting for deformity (if have to put hand in position where scar tissue develop, such as flexion deformity
    • - progressive strengthening

    • 5. 8 weeks
    • - work conditioning
  45. Post-op Results
    • - age is significant factor
    • - therapists: keep muscles stretched and moving to decrease fibrosis (movement and massage muscle bellies); ? external stimulation - nothing known to help

    • - post op results: 2pd grading criteria
    • o S4: 2pd < 6mm; normal is 4
    • o S3+: 2pd < 7-15 mm
    • o S3: 2pd > 15 mm by not hypersensitive
    • o S2: hypersensitive
  46. Problems of Nerve injuries
    • - re-established continuity
    • - degeneration: nerve is attached but the distal part of nerve has already regenerated
    • - wrong receptor: connected to wrong nerve
    • - no connection: nerve repair that should have been done but wasn't, may grow into a bundle of nerve fibres which may be uncomfortable because of stimulation
    • - misdirection: connection to wrong nerve
  47. Treatment of Nerve Injuries
    • - assess: pain & temperature, light touch, M2pd, S2pd
    • - splinting: keep nerve gliding (mobile in tissues)
    • - sensory re-education (so brain knows what is experiencing)
    • - goal:
    • o maximize motor and sensibility recovery
    • o to assist in compensation for residual deficits
  48. Nerve Palsies
    • 1. Radial Nerve Palsy
    • 2. Ulnar Nerve Palsy
    • 3. Median Nerve Palsy
  49. Radial Nerve injury
    - test function to determine the level of injury in the nerve

    • - Functional problems (motor)
    • o loss of elbow extension
    • o total wrist drop, no digital extension
    • o PIN (posterior interosseous nerve): weakness/paralysis of finger and thumb extension and ECU (ECRL may be preserved)-

    • Treatment
    • o splinting:
    • 1) to prevent contracture
    • 2) facilitate function (make sure flexor tendons don't get tight) e.g. Radial nerve palsies - dynamics splint (radial nerve gives wrist drop think of suspension splint, use the movements that work) e.g. Peripheral Nerve Injuries - radial nerve injuries (give a wrist splint for a stable wrist)

    • o ROM:
    • 1) PROM
    • 2) Facilitation
    • 3) wean from splint as AROM increases
    • 4) functional hand program

    • o Sensory:
    • 1) minimal loss due to overlap from other nerves
    • 2) desensitization (look for radial nerve sensory loss on web of thumb - they are notorious for hypersensitivity program)
  50. Radial Nerve Muscles
    • - Triceps- Brachioradialis
    • - Extensor carpi radialis longus
    • - Extensor carpi radialis brevis
    • - Anconeus
    • - Supinator
    • - Extensor digitorum communis
    • - Extensor digiti minimi
    • - Extensor carpi ulnaris
    • - Abductor pollicis longus
    • - Extensor pollicis longus
    • - Extensor ollicis brevis
    • - Extensor indicis proprius
  51. Ulnar nerve palsy
    • - Functional problems (motor)
    • o inability to perform thumb lateral pinch against resistance
    • o decreased grip strength
    • o 'claw hand’ - without lumbrical and interosci the patient is unable to extend their IP joints (take away intrinsic muscles and IPs don't extend anymore, so no extension on ulnar 2 digits, other digits have movement because intrinsic muscles enervated by median nerve)
    • o decreased cylindrical grasp (hook grasp) - can't extend IP joints
    • o decreased wrist flexion (higher lesions)
    •  pic of wasting in metacarpal bones, typical of ulnar nerve palsy

    • - Treatment
    • o splinting: anti-claw splint to restore normal grasp (mold splint with MCP in flexion, use a mechanical block to limit MCP extension, so translate movement in IP joints)
    • o ROM:
    •  PROM - IP joint are risk of contracture
    •  Same as radial nerve - exercise muscles as they regenerate and wean out of splint

    • - Sensory
    • 1) patient education (boarder of hand, little finger and ulnar side of hand - caution them on sensation here so don't damage, skin is not well nourished so wounds will take time to heal too)
    • 2) sensory re-education program - provide brain with info on how to interpret
  52. Ulnar Nerve Muscles
    • - flexor carpi ulnaris
    • - flexor digitorum profundus
    • - adductor pollicis
    • - deep head of flexor pollicis brevis
    • - interossei
    • - Palmaris brevis
    • - Digit minim – adbuctor, opponens, flexor
    • - Little lumbrical
    • - Ring lumbrical
  53. Median nerve palsy
    • - Functional problems (motor)
    • o decreased thumb tip to finger tip prehension (can't touch finger tips)
    • o loss of pulp to pulp prehension
    • o loss of thumb tip and index tip flexion (decreased writing skills)
    • o loss of wrist flexion strength

    • - Treatment
    • o splinting: 1) to assist thumb for tip prehension, 2) to prevent contracture of the 1st webs space. Note: lateral pinch may be used to substitute for absent tip to tip prehension therefore an opponent’s splint won't be wore: watch the 1st web space (because adductor muscle is innervated by another nerve) - if don't wear splint make sure stretch out first web space
    • o ROM: 1) same as previous - wean and stretch out when get motor recovery, not to point to complete exhaustion but point where can strengthen it

    • - sensory problems:
    • 1) patient education (moisturize, avoid injury)
    • 2) sensory re-education program - may be beneficial up to 2 years
    • 3) desensitization programs
  54. Median Nerve Mucles
    • - proator teres
    • - flexor carpi radialis
    • - Palmaris longus
    • - Flexor digitorum superficialis
    • - Flexor digitorum profundus
    • - Flexor pollicis longus
    • - Prontator quadrates
    • - Abductor pollicis brevis
    • - Opponens pollicis
    • - Index lumbrical
    • - Middle lumbrical
  55. Splinting for nerve palsies
    • - Recovery of function
    • - predicted sequence:
    • 1) deep pressure (pain prick - basic protective sensation)
    • 2) moving touch
    • 3) static light touch
    • 4) discriminative (functional) touch (put meaning to it)
  56. Sensibility testing - Tests
    • 1. Tinel's sign - tapping in pathway of nerve in distal to proximal direction (what’s the distal most point that is activate) - they feel a little electric shock, axons are advancing faster than their myelin sheath
    • 2. mapping - of their hand, mark where they have a change, move pencil softy across their hand, and wait till they notice a change in sensation, not everyone is textbook (vision occluded)
    • 3. protective sensation - hot/cold, pin prick, if is intact can move into light touch
    • 4. light touch
    • 5. discriminative sensation (test of innervations density): apply pressure but not to point of skin blanching, be careful to apply same amount of pressure when doing 2 points and 1, if too wide report as untestable; with myofilaments - apply allow to bend and bounce off and stay away from hair follicles b/c this is what tells it is there (sensation on back of hand is less functional); tuning fork test
    • - tell when feel vibration and looks for early detection of nerve depression)
    • a. static 2-point discrimination (Normal<6mm so 5mm)
    • b. moving 2-pt discrim. (N<4mm so 3mm)
    • c. localization (as time goes on get better)
    • d. modified Moberg pick-up test (small objects and pick up items e.g. keys, screw, nail with dominate and non-dominate hand with and without vision)
  57. Sensory re-education
    • - Place: quiet environment to facilitate concentration
    • - Goal: train in tasks to improve the identification of the nature/location of stimulus or performance of a task with vision occluded (looks at how brain works vs. how hand works)
    • - Exercises
    • o exercised must be simple, repetitive and transferable (home, work, etc.)
    • o 15 minutes max in rehab; 5-10 minutes max. at home but 3-4x/day
    • o more frequent for less time more effective
  58. Sensory Re-education Method
    • - perform task with eyes closed (pick up object)
    • - verify response
    • - if correct: move to next task
    • - if incorrect: repeat task, eyes open, repeat task eyes closed
    • - Early Phase and Late Phase has different methods
  59. Early Phase Sensory Re-ed
    • - begin prior to 30 Hz vib. and moving touch perception reaching the proximal phalanx area (approx. 4-6 months post repair at the wrist)
    • - goal: re-education of moving touch and misdirected fibres
    • - technique: stroking the area with a soft cloth with and without visualization and re-enforcing with verbalization; progress to constant touch
  60. Late Phase Sensory Re-ed
    • - late phase sensory re-ed: perception of constant touch; perception of 256 Hz vibration
    • - when to begin: pt. can perceive moving &constant touch at the fingertips with good localization; often 6-8 months after nerve repair at the level of the wrist
    • - never too late to begin
    • - goal: recover functional sensation; achieve tactilegnosis; attempt to regain near normal standard & moving 2pd
    • - technique: familiar household objects; various shapes and sizes; move from gross to fine differentiation of objects
    • - method: attempt task, vision occluded; check response; if correct, go to next task; if incorrect repeat task while using vision to reinforce tactile experience; perform same task with vision occluded(e.g. difference between washer and nickel)
  61. Median Nerve Compression: Carpal Tunnel
    - compression of the median nerve at the level of the carpal tunnel
  62. CTS Pathology
    • - alteration in the osseous margins
    • - fractures, dislocations, joint changes (trauma)
    • - tenosynovitis (most common)
    • - thickening of the transverse carpal ligament
    • - post-traumatic, tumour, systemic disease
  63. Evaluation of carpal tunnel - clinical signs
    • 1. Sensory loss/diminished sensation (first thing notice finger tips, especially in long finger then index finger)
    • 2. Muscle atrophy (in thenar area)
    • 3. Positive Tinel's sign (may have demylinated, at point of compression, at wrist)
    • 4. Positive Phalen's sign (presses hard at compression and flexes wrist, if pain then positive)
  64. Evaluation of Carpal Tunnel - examination
    • 1. visual inspection - hydration changes/dryness of skin, feel sticky or dry
    • 2. subjective report - what person is complaining about is it at night for example, complain about driving (sustained grip)
    • 3. semmes-Weinstein monofilaments
    • 4. vibrometry - early detection of compression
    • 5. nerve conduction studies - are they mild, moderate or severe CTS; if mild and severe best method is CT release
    • 6. strength - if squeeze things it hurts and release, so may be confused as strength problem
    • 7. coordination - diminished light touch so have problems with manipulation
    • 8. endurance - with motor component of nerve they may have endurance problem
  65. Treatment of CTS – Conservative Management
    • 1. splinting neutral with 10 degree of flexion
    • 2. medication - anti-inflammatory
    • 3. patient education - what time do you get symptoms, how long they last, (teach proper night sleeping position, adapt environments, driving, eliminate prolonged grip etc)
    • 4. edema control
    • 5. ROM exercises: nerve gliding and tendon gliding
  66. Treatment of CTS Surgical/post-surgical management
    1. Post op week 1: ?splinting (USA sometimes doesn’t agree)

    • 2. Post op week 1-3:
    • a) edema control
    • b) maintain ROM
    • c) scar management
    • d) protected use of hand
    •  post op complications include infection, increased or no relief from symptoms and pillar pain

    • 3. post op weeks 3-8:
    • a) edema control
    • b) scar management
    • c) reducing hypersensitivity of scar
    • d) increased functional use of hand (no heavy resistive activities)
    • e) obtain full PROM
    • f) nerve gliding exercises (p. 27)
    • g) desensitization

    4. post op week 8: increase strength

    5. post op week 8-12: work hardening (if needed); (WCB is pre authorized for 6 weeks)
  67. Treatement of CTS – Patients with Pain Control Problems
    • - chronic patients with pain control problems:
    • 1) TENS (trans electrical nerve sensation)
    • 2) Acupuncture
    • 3) contrast baths
    • 4) pain centre management
  68. Nerve Gliding program - see handout
    • 1. Starting position 1- wrist in neutral, fingers and thumb in flexion (fist)
    • 2. Position 2 – wrist in neutral, fingers and thumb extended (open hand)
    • 3. Position 3 – thumb in neutral, wrist and fingers extended (wrist extension)
    • 4. Position 4 – wrist, fingers, and thumb extended (thumb out)
    • 5. Position 5 – same as position 4, with fore-arm in supination (palm up)
    • 6. Position 6 – same as position 5, other hand gently stretching thumb
    •  Do each position without symptoms before moving on to next position
  69. Median Nerve Compression Syndromes
    • 1. Carpal Tunnel Syndrome – proactive tests included:
    • a) Phalen’s test: the wrists are passively flexed and held for 30 seconds; a positive result is one in which numbness and tingling are reproduced in the median nerve distribution; a reverse Phalen’s test is performed by passively extending the wrists; the test is again positive if the symptoms are reproduced
    • b) Tinel’s sign: produced by gently percussions from distal to proximal along the nerve trunk; a positive result causes a tingling sensation which radiates distally in the nerve distribution at the site of compression

    2. Pronator Sydrome – characterised by pain in the forearm on resistance to pronation and flexion of the long and ring finger flexor digitorum superficialis (complain of resistance of FDS D3 & D4); Tinel’s sign may also be positive at the site of compression

    3. Anteriro interosseous syndrome – usually no sensory abnormalities; muscle weakness or paralysis may be observed in the motor distribution of the nerve (FDP D2/D3, FPL) => weak tip to tip pinch
  70. Radial Nerve Compression Syndromes
    1. Posterior interosseous syndrome – usually no sensory abnormalities; muscle weakness or paralysis may be observed in the motor distribution of the nerve (EDC, EDM, ECU, APL, EPB, EIP, EPL); usually motor weakness; may confuse with tennis elbow – if strap makes pain worse than may be nerve

    2. Superficial radial nerve compression (Wartenburg’s Syndrome) – characterized by pain along the radial forearm; possible positive Tinel’s sign at the site of compression; hyperesthesia in the distribution of the nerve
  71. Ulnar Nerve Compression Syndromes
    1. Guyon’s canal – possible Tinel’s sign at the site of compression; possible muscle weakness depending on the severity of compression (happens if bang thing with the heal/palm of hand)

    2. Cubital Tunnel – possible Tinel’s sign at the site of compression; possible muscle weakness depending on the severity of compression; compression pain and sensory symptoms may also be reproduced by full elbow flexion (when sleeping put towel in elbow so don’t allow flexion)
  72. Dupuytren’s Disease Mechanism of contracture
    dypuytren identified that the contracture (permanent shortening of a muscle or joint) involved the palmar and digital fascia of the hand
  73. Characteristics of Dupytren’s Disease
    • - Genetic in origin
    • - Vikings diseases (origin – Northern European)
    • - Occurs primarily in people of northern European origin
    • - Associated with other dieses such as epilepsy, diabetes and alcoholism (doesn’t cause but high incidence)
    • - Male>Female, usually early 50’s
    • - May also affect feed (Ledderhose disease) or the penis (Peyronie’s)

    • - Characteristics
    • o Nodule develops at DPC (distal palmar crease) in line with D4
    • o Disease progresses at variable rate
    • o Nodules enlarge; others forms; cords form
  74. Dupytren’s Disease Etiology
    • - Elusive
    • - Macrophage migration (trauma?): clean up cells, so some type of trauma in the hand
    • - Growth factor release
    • - Fibroblast proliferation
    • - Endothelial proliferation (capillary occlusion?): argue that occlusion of small vessels of persons hand from, trauma, genetics, alcoholism etc.
    • - Superoxide free radical release: wound process
  75. Dupytren’s Disease Patahology
    • - Known pathological changes similar to scare contracture
    • - ?Why begins in hand (Not sure, always starts on radial side)
    • - ?progression for no reason (not sure)
  76. Dupytren’s Disease Treatment
    • - No proven non-surgical method
    • - Disease tissue must be surgically removed (or dealt with)
  77. Dupytren’s Disease Indications for surgery
    • 1. Presence of nodule: not an indication (if affects function like work)
    • 2. Skin involvement (if hygiene is an issue, may develop a pit that collects things)
    • 3. Joint contracture
    • a. MCP joint contracture: no urgency if only MP join involved (because joint won’t get contracted, if released then hand is good)
    • b. PIP joint contracture: if contracture > 15 degree (maybe greater); ‘flat palm’ test – if can’t put flat on table you are ready for surgery (just releasing disease doen’t fix problem, often associated contractures)
    • c. DIP jointd. Thumb webspace
  78. Dupytren’s Disease Surgery
    • 1. Radical excision – take away all fascia in hand
    • 2. Regional fasciectomy – only diseased fascia removed
    • 3. Subcutaneous fasciectomy of luck – interrupting the cords, diseased cords are still left in place
    • 4. Needle aponeurotomy – need inserted into finger and it is used to break cords (new treatment approach)
    • 5. Xiaflex (collagenase clostridium histolyticum) – substance injected into cord of affected finger that break downs the fascia so can then move fingers; breaks down collagen – but risk of breaking down tendon) (new treatment approach)
  79. Dupytren’s Disease Post Op Complications
    • 1. Hematoma – pooling of blood under the skin that can lead to necrosis
    • 2. Skin necrosis
    • 3. Infection
    • 4. Neurovascular damage – may cut nerve, or occlusion from releasing of blood that may lead to damage
    • 5. Dupuytren’s flare/CRPS (RSD): (complex regional pain syndrome)
    • a. 20% females; 4.2% overall
    • b. Diffuse swelling, redness, limited ROM, glassy appearance, pain => ?associated CTS
  80. Dupytren’s Disease Post-Op Therapy – Early Phase (0-2 weeks post-op)
    • 1. Wound management
    • a) Education, light dressing
    • b) Splinting to protect wound and avoid stress

    • 2. Edema control
    • a) Elevation – hand above elbow, hand above heart
    • b) Early AROM – gently fisting and hand moving (if painful then did too much with hand)
    • c) ADL’s

    • 3. Splinting
    • a) Static splinting
    • b) Dorsal or volar: composite extension – support surgery out of flexion
    • c) Continous splinting removed 4x/day for gentle AROM

    • 4. ROM exercise
    • a) Only involved digits included in splint
    • b) AROM of uninvolved digits
    • c) Gentle PROM of unaffected joint to prevent stiffness
  81. Dupytren’s Disease Rehabiliation Phase (2 weeks to D/C; wound closure to discharge)
    • 1. Wound management
    • a. Sutures removed
    • b. Residual wounds may require (help to resovle)
    • i. Whirlpool
    • ii. Debridement
    • iii. Dressings

    • 2. Scar management
    • a. Massage – any where closed wound
    • b. Pressure technique – digi sleeve, compression glove etc.

    • 3. Edema control
    • a. Pressure
    • b. Elevation
    • c. Retrograde massaged. String wrapping
    •  All combined with AROM exercises

    • 4. ROM exercises
    • a. Avoid pain and edema
    • b. Progressive resistive exercises

    • 5. Work Hardening (many pts. are retired)
    • a. BTE – type of program; BTE's Workforce Solutions provides employers with superior processes and technology, to optimize productivity – from job assessment, employment screening, to evaluation and treatment, to job-matching and return to work
    • b. Labourers will not return to work within two months
  82. Edema Management
    • - Delay wound healing, causes pain and stiffness and increases scar
    • - Biomechanically alters hand function by impacting the longitudinal and transverse arches of the hand
    • - Retrograde venous and lymphatic flow is dependent primarily on AROM
    • - Chronic edmea causes soft tissue fibrosis
    • - Tissue nutrition is compromised
    • - Massive healing affect reduced tissue glide
    • - The end result may become the ‘Stiff Hand”
  83. Prevention of Edema
    • - Proper splinting in the position of protection
    • - Compressive dressings
    • - Positioning of the extremity in elevation (considering sleeping & diet before bed)
    • - No ice for at least 3 weeks
    • - Leave post-op dressings for the first 3-5 days (don’t want to immobilize the more proximal joints)
    • - Active exercise program unless contraindicated
    • - Early edema is treated with AROM, compression and elevation
    • - Problematic edema occurs 1-2 weeks post op or injury... if left untreated it will engulf joint capsules, collateral ligaments and all other fibro-elastic components of the hand
    • - Edema + immobilization = stiffness in hand
  84. Treatment of Edema
    • 1. Elevation
    • a. Hand above the elbow, elbow above the heart
    • b. Pillows at night/rest

    • 2. Active motion
    • a. Must be forceful
    • b. Most effective: elevation & AROM
  85. Techniques for reduction of edema
    • 1. Retrograde massage: milk edema out of hand
    • 2. Intermittent compression pump: if not contra-indicated
    • 3. String wrapping: soft cord, wrap distal to proximal, leave up to 5 minutes, follow by AROM exercises, short duration affect
    • 4. Coban wrapping: wrap distal to proximal, may left on for exercise, very effective way to apply dressings
    • 5. Elastic bandage wraps: use old burn scar garment material
    • 6. Isotoner (compression) gloves:
  86. Pain
    • - Individual tolerance levels must be respected
    • - The therapist must differentiate the pain
    • - Not all severe pain is indicative of a CRPS (complex regional pain syndrome)
    • - Some pain is predictable
  87. Sources of Pain
    • - Edema
    • - Hypersensitivity
    • - Patterns of movement – make sure are moving properly
    • - Circulation
    • - Normal pain
  88. Assessment of pain
    • - Severity (Visual analogue scale – VAS)
    • - Duration
  89. Strategies to manage pain
    • - Differentiate the pain
    • - Educate
    • - Make the tissue ‘happy’
    • - Correct the problem: change patterns of movement; desensitize; edema management
  90. Treatment for pain
    • - Contrast bath (3 to 1, hot and cold – as hot to as cold) – vaso constriction and dialation – pumping of hand to reduce edema and pain
    • - Heat
    • - Occasionally cold
    • - TENS
    • - Laser
    • - ADL’s
    • - Functional hand program
    • - Mask the pain – burry sensitive part in a bandage or wrap for example
    • - Pharmacology – don’t want them to rely on medications for pain
    • - Acupuncture – can get expensive, additional cost in the community
  91. Abduction of the 2nd through 5th fingers
    • At MCP joints
    • - dorsal interossei (2nd-4th)
    • - abductor digiti minim (5th)
  92. Abduction of Thumb
    • Bringing thumb forward (first carpometacarpal and MCP joints)
    • -abductor pollicis longus
    • - abductor pollicis brevis 
    • (snuff box)
  93. Adduction of then 2nd through 5th fingers
    • At MCP
    • - palmar interossei (2nd, 4th, 5th)
    • - extensor indicis (2nd)
  94. Adduction of Thumb
    • First Carpometacarpal and MCP Joint
    • - adductor pollicis
    • - palmar interossei (1st)
  95. Extension of the 2nd through 5th Finger
    • MCP, PIP & DIP
    • - extensor digitorum
    • - lumbricals
    • - dorsal interossei (2nd-4th, assists
    • - palmar interossei (2nd, 4th, 5th, assists)
    • - extensor indicis (2nd)
  96. Flexion of the 2nd through 5th fingers
    • - flexor digitorum superficialis
    • - flexor digitorum profundus
    • - flexor digiti minimi brevis (5th)
    • - lumbricals
    • - dorsal interossei (2nd-4th, assists)
    • - palmar interossei (2nd, 4th, 5th, assists)
  97. Extension of the Thumb
    • At carpometacarpal and MCP joint
    • - extensor pollicis longus
    • - extensor pollicis brevis
    • - abductor pollicis longus
    • - palmar interossei (1st, assists)
  98. Flexion of the Thumb
    • - flexor pollicis longus
    • - flexor pllicis brevis
    • - adductor pollicis (assists)
    • - palmar interossei (1st, assists)
  99. Opposition of Thumb
    • - opponens pollicis
    • - flexor pollicis brevis (assists)
    • - abductor pollicis brevis (assists)
  100. Nerves of the Hand