Working notes: Be aware that the following compilation are my working notes and that they are

not compiled in a scholarly or referenced manner. Much of the information is fairly common and in
the public domain. I am sharing as I think they might be of use in recalling some of the course
content discussed. If you have questions, please feel free to ask.
Upper extremity anatomy review: The skeletal system. How many bones are in the hand? 27
Proximal Row: Scaphoid, Lunate, Triquetrum, Pisiform (What is a unique feature of the scaphoid? It
derives its primary blood supply from the radial artery to the distal pole.)
Distal Row: Trapezium, Trapezoid, Capitate, Hamate
The muscles of the upper extremity:

First, think of the muscles simply. That is, think of how they function as a group. Then think of them
individually and how many of them may substitute for other prime movers. This will help you look
at how your patient is moving and functioning. It will help you help them recover from whatever it
is that brought them to you in the first place.
I like to think of the muscles from proximal to distal and by their innervation. This can be
particularly useful when someone is presenting with a nerve injury. Granted, an EMG/NCV will be
more definitive in determing the extent and level of injury, but I have found that knowing the
nerves, muscles and function can accurately predict the level of injury and estimated time of
recovery.
The vascular system of the upper extremity: It can be useful to know how to do an Allens test.

Lets say you have a volar ganglion very close to the radial artery in your wrist and you have an
occluded ulnar artery. Surgical removal of this benign cyst would not be indicated.
The lymphatic system of the upper extremity: The lymphatic system functions to drain tissue fluid,
plasma proteins and other cellular debris back into the blood stream, and is also involved in
immune defense. Once this collection of substances enters the lymphatic vessels it is known as
lymph; lymph is subsequently filtered by lymph nodes and directed into the venous system.

The Brachial Plexus: The literal root of our upper extremity function. Ive heard CHTs say, a secret
to passing their specialy certification exam is knowing the brachial plexus.
The following slideshow may be viewed at: http://image.slidesharecdn.com/4-
5cervicalbrachialplexus-120130181444-phpapp01/95/cervical-and-brachial-plexus-56-
728.jpg?cb=1357596608

An easy way to draw the brachial plexus in < 5 minutes and remember it!
Muscles of the arm proximal to distal
Ulnar Innervated Muscles:
Flexor carpi ulnaris
Flexor digitorum profundus (ring & small)
Flexor carpi ulnaris
Palmaris brevis
Flexor pollicis brevis (deep)
Adductor digiti minimi
Adductor pollicis
Interossei
Opponens digiti minimi
Flexor digit minimi
Lumbricals (ring & small)

Median Innervated Muscles:

Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor digitorum profundus (index & long)
Flexor pollicis brevis
Pronator quadratus
Abductor pollicis brevis
Flexor pollicis brevis (superficial)
Opponens pollicis
Lumbricals (index & long)

Radial Innervated Muscles:

Triceps
Anconeus
Brachioradialis
Extensor carpiradialis longus
Extensor carpiradialis brevis
Supinator
Extensor digitorum communis
Extensor digitorum minimi
Extensor carpi ulnaris
Abductor pollicis longus
Extensor pollicis brevis
Extensor pollicis longus
Extensor indicis proprius

Common hand problems and the tests to identify/diagnose them:

Carpal Tunnel Syndrome
Median nerve compression at the wrist, carpal tunnel syndrome. Image shows shaded area where
numbness, the primary symptom occurs. Identify/screen by report, Phalens, Reverse Phalens and
Tinels. Most objectively through EMG/NCV testing.
Cubital Tunnel Syndrome

Cubital tunnel syndrome is characterized by numbness in the ulnar distribution distal to the elbow
in the shaded area below:
In advanced cases it can also present with weakness on the ulnar side of the hand and even
clawing of the ring and small with the MCPs hyperextended and the PIPs flexed. This condition
is identified through presentation and a tinels at cubital tunnel.
Radial Tunnel Syndrome

Guyons Canal Syndrome, a compression of the ulnar nerve in the hand. Hamate and Pisiform.
DeQuervains Tenosynovitis
 A test called the Finkelstein test can help your doctor
confirm de Quervain's tenosynovitis. To do this test, you bend your thumb down across the palm of
your #hand, and then cover your #thumb with your #fingers. Next, bend your wrist toward your
little finger.

Thoracic Outlet Syndrome (Ask me about the Macarena exercises, good for treatment and anytime
you are tired)
Common nerve injuries to the upper extremity
Injuries to the Radial Nerve:

In the Axilla
How it commonly occurs: Dislocation of humerus at the glenohumeral joint or fractures of proximal
humerus. Can also happen via excessive pressure on the axilla, e.g. a badly fitting crutch.
Motor functions: Triceps brachii and muscles in posterior compartment are paralyzed. The patient
is unable to extend the forearm, wrist and fingers. Unopposed flexion of wrist occurs, known as
wrist drop.
Sensory functions: All four cutaneous branches of the radial nerve are affected. There will be a loss
of sensation over the lateral and posterior upper arm, posterior forearm, and dorsal surface of the
lateral three and a half digits.
In the Radial Groove
How it commonly occurs: Fracture of the shaft of the humerus damaging the radial nerve when it
is bound in the radial groove.
Motor functions: The triceps brachii may be weakened, but is not paralyzed. The deep branch of the
radial nerve is affected, so the muscles in the posterior compartment of the forearm are paralyzed.
The patient is unable to extend the wrist and fingers. Unopposed flexion of wrist occurs, known as
wrist drop.
Sensory functions: The cutaneous branches to the arm and forearm have already arisen. The
superficial branch of the radial nerve will be damaged, resulting in sensory loss on the dorsal
surface of the lateral three and half digits, and their associated palm area.
Deep Branch of Radial Nerve
How it commonly occurs: Fractures of the radial head, or a posterior dislocation of the radius at the
elbow joint.
Motor functions: Muscles in posterior compartment of the forearm are affected except for the
supinator and extensor carpi radialis longus. The extensor carpi radialis longus is a strong extensor
at the wrist, and so wrist drop does not occur.
Sensory functions: None, as it is a motor nerve.
Superficial Branch of the Radial Nerve
How it commonly occurs: Stabbing or laceration of the forearm.
Motor functions: None, as it is a sensory nerve.
Sensory functions: There will be sensory loss affecting the dorsal surface of the lateral three and
half digits and their associated palm area.
Injuries to the Ulnar Nerve:

Damaged at the Elbow

How it commonly occurs: The nerve is most vulnerable to injury at the medial epicondyle, so
fracture of the medial epicondyle is the most common way of damaging the ulnar nerve
Motor functions: Flexor carpi ulnaris and medial half of flexor digitorum profundus paralyzed.
Flexion of the wrist can still occur, but is accompanied by abduction. The interossei are paralyzed,
so abduction and adduction of the fingers cannot occur. Movement of the little and ring fingers is
greatly reduced, due to paralysis of the medial two lumbricals.
Sensory functions: All sensory branches are affected, so there will be a loss of sensation over the
areas that the ulnar nerve innervates.
Characteristic signs: Patient cannot grip paper placed between fingers.
Damaged at the Wrist
How it commonly occurs: Lacerations to the wrist
Motor functions: The interossei are paralyzed, so abduction and adduction of the fingers cannot
occur. Movement of the little and ring fingers is greatly reduced, due to paralysis of the medial two
lumbricals. The two muscles in the forearm are unaffected
Sensory functions: The palmar branch and superficial branch are usually severed, but the dorsal
branch is unaffected. Sensory loss over palmar side of medial one and a half fingers only.
Characteristic signs: Patient cannot grip paper placed between fingers. For long-term cases, a hand
deformity called Ulnar Claw develops.
Ulnar claw consists of:
Hyper-extension of the metacarpophalangeal joints of the little and ring fingers this is because of
the paralysis of the medial two lumbricals, and the now unopposed action of the extensor muscles
Flexion at the interphalangeal joints (if the lesion has occurred close to the elbow, this might not be
evident, as the flexor digitorum profundus will be paralyzed)

Injuries to the Median Nerve:

The median nerve is particularly vulnerable to damage at the elbow and wrist. In this section, we
shall examine how such injuries can occur, and the sensori-motor deficits that can result.
Damaged at the Elbow
How it commonly occurs: Supracondylar fracture of the humerus.
Motor functions: The flexors and pronators in the forearm are paralyzed, with the exception of the
flexor carpi ulnaris and medial half of flexor digitorum profundus. The forearm constantly
supinated, and flexion is weak (often accompanied by adduction, because of the pull of the flexor
carpi ulnaris).
Flexion at the thumb is also prevented, as both the longus and brevis muscles are paralyzed.
The lateral two lumbrical muscles are paralyzed, and the patient will not be able to flex at the MCP
joints or extend at IP joints of the index and middle fingers.
Sensory functions: Lack of sensation over the areas that the median nerve innervates.
Characteristic signs: The thenar eminence is wasted, due to atrophy of the thenar muscles. If patient
tries to make a fist, only the little and ring fingers can flex completely. This results in a
characteristic shape of the hand, known as hand of benediction.
Damaged at the Wrist
How it commonly occurs: Lacerations just proximal to the flexor retinaculum.
Motor functions: Thenar muscles paralyzed, as are the lateral two lumbricals. This affects
opposition of the thumb and flexion of the index and middle fingers.
Sensory functions: Same as an injury at the elbow. Characteristic signs: Same as an injury at the
elbow.
Evaluation and screening tests:
OT evaluation 97003 ~$146 Reevaluation 97002 ~$81
Finger goniometry is important for objective data. It is recommended that you also measure the
unaffected side to compare numbers. Divide the TAM of the affected side by the TAM of the
unaffected for a percentage number to compare: (i.e. Right
injured index finger AROM MCP -10/40 PIP -20/40 DIP 0/10 TAM 60 degrees or 24% Left
unaffected index finger AROM MCP 0/90 PIP 0/90 DIP 0/75 TAM 255 = 60/255 is 24%)
 MMT

Resource, Karnath chapter link: http://www.turner-white.com/pdf/hp_jan03_upper.pdf

FIG. 5-27 Elbow flexion: 1, flexion in supination without resistance; 2, flexion in neutral without
resistance; 3, flexion in pronation without resistance; 4, flexion in supination with resistance. The
brachialis is the baseline flexor. The biceps is the reserve flexor. It is the flexor of the supine
forearm, especially when resistance is encountered. Its action is minimal in pronation. The
brachioradialis is more active in neutral and against resistance. The pronator teres is active only
against resistance. + + + , Maximum activity; + + , mild activity; + , minimal activity; -, no activity.
See illustration below:
Link to above: http://www.oandplibrary.org/popup.asp?frmItemId=53C20962-2612-419B-BD9A-
88FE83DFABB4&frmType=image&frmId=27
 Date of completion
www.orthopaedicscores.com April 12, 2016

The Disabilities of the Arm, Shoulder and Hand Score(QuickDash)

Clinician's name (or ref) Patient's name (or ref

INSTRUCTIONS: This questionnaire asks about your symptoms as well as your ability to perform certain activities.
Please answer every question , based on your condition in the last week. If you did not have the opportunity to
perform an activity in the past week, please make your best estimate on which response would be the most
accurate. It doesn't matter which hand or arm you use to perform the activity; please answer based on you ability
regardless of how you perform the task.
Please rate your ability to do the following activities in the last week.
No Mild Moderate Severe
1. Open a tight or new jar Unable
difficulty difficulty difficulty difficulty
Do heavy household
No Mild Moderate Severe
2. chores (eg wash walls, Unable
difficulty difficulty difficulty difficulty
wash floors)
Carry a shopping bag or No Mild Moderate Severe
3. Unable
briefcase difficulty difficulty difficulty difficulty
No Mild Moderate Severe
4. Wash your back Unable
difficulty difficulty difficulty difficulty
No Mild Moderate Severe
5. Use a knife to cut food Unable
difficulty difficulty difficulty difficulty
Recreational activities in
which you take some
force or impact through No Mild Moderate Severe
6. Unable
your arm, shoulder or difficulty difficulty difficulty difficulty
hand (eg golf,
hammering, tennis, etc)

During the past week, to

what extent has your arm,
shoulder or hand problem
Not at Quite a
7. interfered with your Slightly Moderately Extremely
all bit
normal social activities
with family, friends,
neighbours or groups?

During the past week,

were you limited in your
Not
work or other regular daily Slightly Moderately Very
8. limited Unable
activities as a result of limited limited limited
at all
your arm, shoulder or
hand problem?
Please rate the severity of the following symptoms in the last week
Arm, shoulder or hand
9. None Mild Moderate Severe Extreme
pain
Tingling (pins and
10. needles) in your arm, None Mild Moderate Severe Extreme
shoulder or hand
 During the past week,
So much
how much difficulty have
No Mild Moderate Severe difficulty I
11. you had sleeping because
difficulty difficulty difficulty difficulty can't
of the pain in your arm,
sleep
shoulder or hand?
Thank you very much for completing all the questions in this questionnaire.
The Disabilies of the Arm, Shoulder and
Reset
0
Hand (quickdash) Score
To save this data please print or
Nb: This page cannot be saved due to patient data protection so please ( NB. A DASH score may not be calculated
print the filled in form before closing the window. if there are greater than 1 missing items.)
There are two further small sections to this score. They are both optional. Just click below to
select
WORK MODULE SPORTS/PERFORMING ARTS MODULE
Reference for Score: Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome
measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative
Group (UECG)
Am J Ind Med. 1996 Jun;29(6):602-8. Erratum in: Am J Ind Med 1996 Sep;30(3):372.
The Institute for Work & Health are the copyright owners of the DASH and QuickDASH Outcome
Measures (http://www.dash.iwh.on.ca/)

http://www.orthopaedicscore.com/
Therapeutic exercises and activities:
Therapuetic Exercise 97110 ~$62 every 15 min Therapeutic Activity 97530 ~$70 every 15 min
Where possible, I like to make the activities purposeful and meaningful to the patient. Often
constraints such as limited time and limited equipment require one to use more rote activities.
With a little imagination and thought, even these can be made purposeful through guided
simulation (ie. Theraputty may be turned as if one is turning a knob or a key).

Wrist and forearm therapeutic exerciser. Many pieces of equipment can be easily fabricated by the
savvy OT on a budget. Sometimes your patients will even make them for you, which I think is the
ultimate home program for wood workers or generally handy folks recovering from their condition.

Almost everything around us may be useful for therapeutic activity.

Theraputty exercises.
TENs and NMES can treat symptoms and augment therapeutic program.

Think about the muscles we use and the postures we assume when we hold common occupational
and recreational tools. Bring these items into the clinic for purposeful, therapeutic activities to
facilitate recovery. (Hammering as picture below may be modified with anti-vibratory glove is that
sensation is interfering with function)
When a patient tells you that they have pain or difficulty with routine daily activities, your
successful understanding and ability to articulate their problem depends on a good understanding
of anatomy and physiology. Many times this understanding can lead to successful outcomes with
minimal intervention. What kinds of problems might the person pictured below describe? What
might be some effective interventions?

Carpet layers most important tools are their hands. Ive seen them present with ulnar nerve
problems at Guyons canal because they use the heel of their hands as hammers. Sometimes this
action results in a broken hook of the hamate bone.
If practicing joint protection for someone with rheumatoid arthritis, what is the recommended
method for opening or closing a jar without adaptive equipment?

Massage and manual therapy to carpal tunnel

Treatment modalities: Ultrasound 97035 ~$36, Low level Laser No code, but self-pay with ABN
~$29, Transcutaneous Nerve Stimulation and E-stim attended 97032 ~$37

I have the US Pro 1000 and 2000 Portable Ultrasound (conversion) Units, that use high frequency
sound waves or acoustic energy to elicit deep thermal and non-thermal effects.
Strong and durable for professional grade clinic use in a portable package. Three intensity level
settings: Low (30%), Medium (40%) and High (50%). Three time modes: 5, 10 and 15 minutes.
Low Level Laser Therapy LLLT (aka cold laser) is a well-established (in other countries FDA
approved use in the US in therapy for pain relief and rehabilitation of numerous injuries. The laser
light penetrates tissue where it is absorbed by cells and effectively stimulates healing and rapid
pain relief.

The LaserTouchOne device that I use combines LLLT with Micro-Current Electrical Stimulation that
sends small amounts of electrical current to the cells which stimulates repair and healing it
promotes the production of ATP (the cells energy molecule) and protein, as well as assists in the
absorption of nutrients and the elimination of wastes. When injured cells are able to repair,
increased mobility and pain relief are achieved.
Many studies conclude that LLLT delivered at low doses tends to work better than the same
wavelength at high levels and that LLLT stimulates the ATP production, a molecule necessary for
cellular repair and healing. ATP is what the body needs to repair cells and reduce pain. The results
of this study indicate that electrical stimulation of the tissue resulted in remarkably increased ATP
(Adenosine TriPhosphate; A cellular energy molecule) concentrations in the skin.
Studies also indicate that LLT plus exercise to be more effective than laser alone at decreasing
musculoskeletal pain. (Australian Journal of Physiotherapy 2007 Vol.53)
Cold therapies significantly cool the skin and superficial structures, dampening pain. Once the
treatment ends, blood flow will actually increase to the area.

Heat therapies, like the paraffin bath 97018 ~$31 (conduction), are appropriate once swelling has
subsided. This treatment increases blood flow, cellular metabolism and increases elasticity of
collagenous structures. It can also reduce pain.
Convection modalities such as above are effective, but expensive and impractical for some. I share
the benefits, but often encourage use with home program at places like the YMCA.

Having a hard copy of information on treatment approaches, such as PAMs is a reasonable thing to
do. Sometimes to reinforce a treatment, Ill share with a patient something from the literature and
let them read it while receiving treatment. I think this shows respect of your patient and helps
them cognitively engage and buy in to what you are offering. I had Dr. Bracciano as a professor
with my Creighton studies.
Splinting: Custom and prefabricated orthotics, serial casting:
The PIP is one of the most easily contracted joints, in a bad way, after injury. The elbow is a close
second in terms of bad. The knee is probably third.
Static finger L3933 ~$185
Hand based; finger hand thumb spica L3913 ~$235 Prefab ~$85

Wrist-based custom L3906 ~$445

Wrist thumb spica L3808 ~$315

Elbow long arm L3763 ~$660

Dynamic WHFO L3905 ~$865

Hand-based ulnar gutter L3919 ~$235

Elbow only L3702 ~$255

Prefab finger spring L3925 ~$180

Prefab wrist L3908 ~$85

Sustainable Therapy Solutions Occupational Therapy
Services
(Prices effective January 1, 2016) Prices are low in part because this office does not bill insurance, though
HSA and Flex spending cards are welcome if you have them. If you have insurance you may submit the note
and receipt from this office as an out of network visit. If they were going to cover this service, they will likely
cover what you paid as it is so economical.

Evaluation: This is a comprehensive evaluation of your OT- orthopedic

wellness and functional performance. Generally 1 hour. Your cost $40
(Compare to 97003 $180)
Treatment: This is a complete treatment of your OT- orthopedic wellness
needs and includes all appropriate methods and modalities. Generally 45
minutes. Your cost $35 (Compare to 977110 or 97530 $65 every 15 minutes)
House calls: This is available if it is more convenient for you to be seen in an
alternative location within Monroe County. The cost for this service is just
added to the regular cost. Your cost $10 per visit (Nothing offered elsewhere
for compare)

Package Deals: This is the best value for those needing multiple therapy
visits. This is a package of up to 8 visits and includes the comprehensive
evaluation and complete treatment sessions for $200 prepaid. If you require a
custom splint, it will be available at half the regular price with the purchase of
a package and will not count as one of your 8 prepaid visits. Your cost $25 per
visit. Once you have purchased a package, all follow-up may be purchased
individually at $25 per visit. (Compare to $2000 and more)
Custom fabricated orthotic splints: Made of the highest quality materials
right here in the office in generally 30 minutes. With Package
Finger Your cost $15 (Compare to $185 as allowed by Medicare) $7.50
Hand Your cost $35 (Compare to $235 as allowed by Medicare) $17.50
Wrist Your cost $50 (Compare to $441 as allowed by Medicare) $25
Elbow Your cost $80 (Compare to $651 as allowed by Medicare) $40