Level II Fieldwork Assignments

Weeks 1-2:
Diagnosis and Cards/Weekly Topics
1. Clinical anatomy of the hand
a. Bones:
i. Phalanges: 14 total bones, 3 in each finger and 2 in thumb
ii. Metacarpal: 5 bones

iii.
iv. Carpal: 8 carpal bones of the wrist (scaphoid, lunate, triquetrum, pisiform,
trapezium, trapezoid, capitate, hamate)

v.
b. Muscles:
i. Thenar group: median nerve innervates all muscles of thenar group
1. Opponens pollicis- Opposes the thumb, by medially rotating and
flexing the metacarpal on the trapezium
2. Abductor pollicis brevis- Abducts the thumb
3. Flexor pollicis brevis- Flexes the metacarpophalangeal joint of the
thumb
ii. Hypothenar group: ulnar nerve innervates all muscles of the hypothenar
group
1. Opponens digiti minimi- It rotates the metacarpal of the little finger
towards the palm, producing opposition
2. Abductor digiti minimi- Abducts the little finger
3. Flexor digiti minimi brevis- Flexes the metacarpophalangeal joint
of the little finger
iii. Lumbricals: 1&2 are innervated by median nerve 3&4 are innervated by
ulnar nerve
1. Flexion at the MCP joint and extension at the interphalangeal (IP)
joints of each digit
 iv. Interossei: innervated by ulnar nerve
1. Dorsal interossei- Abduction of the digits. Assists in flexion at the
metacarpophalangeal joints and extension at the interphalangeal
joints
2. Palmar interossei- Adduction of the digits. Assists in flexion at the
metacarpophalangeal joints and extension at the interphalangeal
joints
v. Other muscles of the palm: innervated by the ulnar nerve
1. Palmaris brevis- Wrinkles the skin of the hypothenar eminence
and deepens the curvature of the hand, improving grip
2. Adductor pollicis- Adductor of the thumb
c. Skin:
i. Palmar: thick, less pliable
ii. Dorsal: thinner, more pliable
2. Carpal tunnel syndrome, conservative and surgical
a. Diagnosis: medical condition due to compression of the median nerve as it
travels through the wrist at the carpal tunnel
b. Symptoms: Pain, numbness and tingling in the thumb, index finger, middle
finger and the thumb side of the ring finger. Symptoms typically start gradually
and during the night. Pain may extend up the arm. Weak grip strength may
occur, and after a long period of time the muscles at the base of the thumb may
waste away
c. Etiology:
i. Anatomic factors-fractures, dislocations
ii. Nerve damaging conditions chronic illness-diabetes/Inflammatory
conditions: RA-Tendinosis/ Medications/Obesity is a risk factor
iii. Body Fluid changes-Third trimester of pregnancy/menopause
iv. Workplace factors involving vibrating tools, repetitive activity, and undue
pressure on the tunnel itself.
d. Trophic changes: including dry skin, hair loss, discoloration, brittle fingernails,
and different types of ulcerations to the skin-in turn causing slow healing to the
tissues
e. Provocative testing:
i. Tinel’s sign at the wrist
ii. Phalen’s Test
iii. Reverse Phalen’s Test
iv. Carpal Compression test (Pressure over the retinaculum for 15 seconds)
v. Positive sign: (Pain /Paresthesia/Numbness)
vi. Complete sensory testing of all affected areas-Assess for sensory loss
(Semmes Weinstein)
3. OA thumb CMC joint, conservative and surgical
a. Osteoarthritis of the CMC joint of the thumb
i. Conservative:
ii. Surgical:
 1. LRTI
4. Distal radius fracture, non-surgical and surgical (Colles Fracture)
a. Diagnosis: Dorsally displaced- known as Colles’ Fracture (1/6th of all fractures
treated in the emergency room). Typically from a fall on an outstretched hand
(low energy trauma). Common among low bone density individuals/secondary to
osteoporosis
b. Prognosis: The goal of fracture treatment is to obtain union of the fracture in the
most anatomical position compatible with maximal functional return of the
involved extremity. There are two types of fracture treatment: Conservative or
Surgical
c. Conservative Outcomes: Reduction- If displaced, under general anesthesia
i. Steps of reduction:1) traction 2) align fragments 3) reverse mechanism of
injury.
ii. Immobilization POP-Cast-Slab-Traction (fixed or balanced-depends on
type of injury)
iii. Rehabilitation- That’s OT & PT!
d. Surgical Outcomes: Open reduction internal fixation (ORIF). When closed
reduction fails/when there is a large articular fragment needing to be positioned.
They traction for when fracture fragments are held apart (screws, wires, plate
and screws, intramedullary nails).
i. Percutaneous Pinning- Client is asleep-fracture is reduced- pins are
inserted into the bone to hold the fracture in position until the bone heals.
ii. External Fixation-Severe soft tissue damage-contaminated fractures-soft
tissues are swollen-client has numerous (multiple) injuries- ununited
fractures that need compressed, Infected fractures
e. Associated Deficits:
i. Pain,Bruising, Stiffness, Numbness along nerve path, Unable to move
without experiencing significant discomfort, Weakness, Loss of
movement, Significant limitations in occupational performance
f. Evaluation:
i. History intake- Occupational Performance Profile, Complete a DASH
assessment, Pain assessment, Measure Edema, ROM assessment as
indicated by protocol timing, Determine Painful arc of motion (is this
happening?),Sensory Testing, Determine safety concerns, Functional
Motion is based on the healing stages of fractures. We need to evaluate
this as part of the assessment process, Will always evaluate occupational
performance in ADL and IADLs as appropriate
g. Intervention:
i. Acute Stage Phase 1: Depends on when they report to OT. 2 weeks -
External Fixator (while in place)- Obtain and maintain all ROM of all
uninvolved joints. Prevent wound and/or pin tract infection. Resolve pain
and edema (positioning). Encourage use of the extremity in light
functional activities (what types of functional activities would you use in
this case?)
 ii.Protocols Cast Phase II (2-6 weeks): At two weeks the cast is usually
removed- fitted with removable splint. AROM- forearm rotation and wrist
(NO PASSIVE MOTION). Hand exercises: intrinsic stretches, thumb IP
blocking exercises. Edema Reduction-Isotone, compression glove. Scar
management (elastomer over the scar). Monitor for signs of CRPS- begin
desensitization techniques. At this stage you can begin exercises for the
elbow, shoulder, and stress no use of the affected wrist without the splint
on
iii. Protocols (ORIF) Phase III (Weeks 6 to 12): (external fixator is removed
by surgeon after radiological union is demonstrated). OT treatment
includes: Fabricate protective wrist splint, Soft tissue and scar
mobilization. AROM wrist motions: forearm motions, pay attention to
extensor tendons, progress to passive stretching and resistive exercises.
Continue all therapeutic interventions and maintain HEP\
iv. Protocols (ORIF) Last Phase IV Begin PROM at (6-8 weeks): Weight
bearing (as cleared by doctor). Wean from splint Increase exercise based
on AROM and tolerance
5. Dupuytren’s contracture
a. Diagnosis: Hand deformity that usually develops over years. The condition
affects a layer of tissue that lies in the palmar aspect of the hand. Tissue knots
form under the skin, eventually creating a thick cord that can pull one or more
fingers into a bent position. At one point the affected fingers can not be
straightened completely, which can complicate everyday activities such as
placing your hands in your pockets, putting on gloves or shaking hands.
Dupuytren's contracture mainly affects the two fingers farthest from the thumb,
and occurs most often in older men of Northern European (Scandinavian)
descent
b. Prognosis and Outcomes: Treatment involves removing or breaking apart the
tissue that is pulling the fingers toward the palm. The choice of procedure
depends on the severity of your symptoms. Needling (percutaneous release) -
needle is inserted through the skin. It punctures and breaks the tissue that's
contracting a finger. Contractures often recur but the procedure can be done
numerous times. Enzyme injections are another method. Surgery for advanced
cases is the last option and yields rather promising outcomes
c. Associated Deficits:
i. Pain is different in each stage, but needs to be measured
ii. Limitations in use of the hand; ROM impaired
iii. Hard, fibrosis tissue buildup in the palmar area
iv. Sensory is impaired in the palmar area
v. Sometimes Edema (but not all the time)
vi. Weakness/decreased grip and pinch strength
vii. Tightness and loss of flexibility over time
viii. Occupational performance in ADLs and IADLs is limited secondary to
pain/stiffness/weakness.
 d. Evaluation:
i. Pain
ii. Measures: AROM, Distal palmar crease measures, Pad to pad
iii. Edema
iv. Grip & pinch strength
v. Sensory testing (think safety)
vi. Determine if there is a history of chronic overuse of the wrist and hand
vii. Occupational Performance with ADLs and IADLs
viii. Work evaluation
e. Intervention:
i. Education
ii. Acute Stage:Tendon Glides, Protection (splinting)
iii. PAMs (phonophoresis, iontophoresis, e-stimulation, ice massage)
iv. Teach transverse friction massage/Augmented soft tissue mobilization
(ASTM) Graston Technique
v. Provide AROM, AAROM, PROM, and stretching exercises
vi. Eccentric/concentric, isometric/isotonic exercises
vii. Splinting (hand-based dorsal extension splint), to be worn initially at all
times (with the exception of ROM and bathing). There is not a lot of
evidence to support this approach, if only treated conservatively
Caseload: 2-4 patients per day
Additional Assignments:
1. Explain basic tissue healing (stages and clinical significance) in: Bone Tendon Artery
Nerve Ligament
2. Demonstrate proficiency: goniometry (shoulder to hand), SOAP notes, strength testing,
two point discrimination
3. Differentiate and recognize: intrinsic and extrinsic muscle tightness, oblique
retinacular ligament tightness, joint stiffness vs. muscle tendon tightness
4. Review basic splinting principles (static and dynamic)
5. Begin practicing forearm based thumb spica and finger gutter orthoses

Weeks 3-4:
Diagnosis Cards/Weekly Topics:
1. Clinical anatomy of the wrist (wrist zones and relevant pathology)
2. Metacarpal and Phalangeal Fractures (e.g. boxer’s fx)
3. Scaphoid fracture, non-surgical and surgical
4. Ulnar wrist pain
5. TFCC tears (conservative and surgical)
Caseload: 4-5 patients per day + initiate treating walk-ins
Additional Assignments:
1. Describe appropriate use of modalities, including parameters, outcomes, and contra-
indications: Hot packs Cold packs Fluidotherapy Paraffin Ultrasound Neuromuscular
electrical stimulation TENS Iontophoresis
2. Demonstrate understanding of use of protocols.
 3. Begin practicing ulnar gutter, Dupuytren’s extension orthoses.

Week 5-6:
Students are required to complete a project on a topic agreed upon by the student and staff.
The project will include a presentation on the topic and something to be left for clinic use (such
as a treatment tool, home program, etc.). Discuss project ideas, to be presented in weeks 10-
12.
Diagnosis Cards/Weekly Topics:
1. Clinical Anatomy of the Elbow
2. Lateral and Medial Epicondylitis
3. Elbow fractures (e.g. radial head, olecranon, extra-articular and intra-articular)
4. Elbow ligament injuries (e.g. LCL complex, UCL)
Caseload: 5-6 patients
Additional Assignments:
1. Describe nerve pathways, innervations, and sensory distribution patterns
2. Describe and demonstrate the following sensory testing, explain clinical and functional
significance: Sharp/dull Light touch 2-Point Discrimination Nerve Conduction
testing/EMG
3. Begin practicing radial gutter orthosis and resting wrist orthosis.

Week 7-8:
Diagnosis Cards/Weekly Topics:
1. Median nerve palsy (low and high)
2. Radial nerve palsy (low and high)
3. Ulnar nerve palsy (low and high)
Additional Assignments:
1. Demonstrate proficiency in the following special tests and explain clinical significance:
Tinel's (wrist and elbow) Phalen's, Finklestein, Grind test, Allen vascular test
2. Explain nerve regeneration and clinical significance

Week 9-10:
Caseload: 7-8 patients, in addition to walk-ins, treating up to 10 patients.
Diagnosis cards/Weekly Topics:
1. Flexor tendon repairs, all zones including the thumb
2. Extensor tendon repairs- all zones including thumb
3. Boutonniere deformity (true and pseudo)
4. Swan Neck deformity
5. Mallet finger (conservative, surgical)
Additional Assignments
1. Schedule surgery observation in weeks 9-12.
2. Demonstrate and explain joint mobilization techniques relevant from elbow to hand.
3. Fabricate a dynamic or static progressive orthosis

Week 11-12:
Diagnosis Cards/Weekly Topics:
1. Clinical Anatomy of the Shoulder
2. Impingement
3. Rotator Cuff tears (small to massive)
4. Total shoulder, Arthroplasty/Hemiarthroplasty
Additional Assignments
1. Present project.
2. Initiate closure with patients.