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Upper Extremity: KEY POINTSEric Wilson, PT, DSc, DPT, OCS, SCS, CSCS, PES, FAAOMPTPresentsFlight Surgeon Graduate, Dive Medical OfficerDeveloped & Presented By:Eric Wilson's OCS Prep Course1Deputy Program Director, USAF Tactical Sports & Orthopedic Manual Physical Therapy Fellowship

• Shoulder– SICK Scapula– Scapula dyskinesia rehab– SC & AC joints– Evidence-based exam algorithm– Dislocations– Frozen shoulder• Elbow– Lateral Elbow Pain• Wrist/Hand– Jersey finger– Carpal fracture• Scaphoid fracture– Scapholunate ligament injury– Distal Radius Fractures– Boxer’s fracture– Mallet finger– Overuse injuries• deQuervains Tenosynovitis• Intersection Syndrome• ECU Tendonitis• ECU SubluxationEric Wilson's OCS Prep Course2UE Key Points: Overview

SICK Scapula: Overhead Athletes• S: Scapula malposition• I: Inferior medial border prominence• C: Coracoid pain and malposition• K: dysKinesis of scapula movement3Burkhart, 2003Eric Wilson's OCS Prep Course

Diagnosing SICK Scapula• Throwing shoulder is objectively measured in three categories– Infra – visual appearance of a dropped scapula due to scapula tilting or protraction– Lateral displacement– Abduction4Burkhart, 2003Eric Wilson's OCS Prep Course

Diagnosing SICK Scapula: Infra5Burkhart, 2003Eric Wilson's OCS Prep Course

Diagnosing SICK Scapula: Lateral Displacement6Burkhart, 2003Eric Wilson's OCS Prep Course

Diagnosing SICK Scapula: Abduction7Burkhart, 2003Eric Wilson's OCS Prep Course

SICK Scapula: Mechanics• Pec minor and short head of biceps become adaptively tight– Lowers leading edge of scapula– Decreases ability achieve full fwd flexion• As scapula tilts & rotates laterally, traction on Levator Scapula creates pain/muscle spasm– Can often be corrected with Scapula Retraction Test8Burkhart, 2003Eric Wilson's OCS Prep Course

Scapula Dyskinesia Rehab Progression1. Scapula orientation 2. Scapula co-contraction3. General strengthening9Ellenbecker, 2010Eric Wilson's OCS Prep Course

Scapula Orientation• Scapular setting exercises• Begin in neutral• Teach posterior tilt and upward rotation10Ellenbecker, 2010Eric Wilson's OCS Prep Course

Co-Contraction Exercises• Inferior Glide• Low Row• Lawn Mower• Robbery11Ellenbecker, 2010, Kibler 2008Eric Wilson's OCS Prep Course

Inferior Glide12Kibler 2008Eric Wilson's OCS Prep Course

Low Row13Kibler 2008Eric Wilson's OCS Prep Course

Lawn Mower14Kibler 2008Eric Wilson's OCS Prep Course

Lawn Mower15Kibler 2008Eric Wilson's OCS Prep Course

Lawn Mower16Kibler 2008Eric Wilson's OCS Prep Course

Robbery17Kibler 2008Eric Wilson's OCS Prep Course

Robbery18Kibler 2008Eric Wilson's OCS Prep Course

Co-contraction19Kibler 2008Eric Wilson's OCS Prep Course

Co-contraction Kinetic Chain Variations• Pushup variation – extend contralateral hip to increase lower trapezius activity• Low Row – one leg stance on contralateral leg improves lower trapezius/upper trapezius ratio (more lower trap)20Ellenbecker, 2010Eric Wilson's OCS Prep Course

General Strengthening• 3x15-20 reps create fatigue response• 4 wks training resulted in 8-10% increased isokinetic strength of IR/ER in healthy subjects21Ellenbecker, 2010Eric Wilson's OCS Prep Course

• Serratus Anterior– Diagonal exercise with a combination of shoulder flexion, horizontal flexion, and external rotation (100% MVIC)– Shoulder abduction in the plane of the scapula above 120° (96% MVIC)Eric Wilson's OCS Prep Course22

• Upper Trap: – A) Shoulder Shrug (119% MVIC)• Middle Trap: – B) Prone Arm Raise Overhead (101% MVIC)– C) Prone Shoulder Horizontal Extension w/ER (87% MVIC)• Lower Trap: – C) Prone Arm Raise Overhead (97% MVIC)– D) Alternate: Prone Shoulder ER at 90 ABD (79% MVIC)Eric Wilson's OCS Prep CourseA B C D23

AC/SC JointEric Wilson's OCS Prep Course24

SC Joint Osteokinematics• Frontal Plane: elevation/depression• Sagittal Plane: posterior rotation• Transverse Plane: retraction/protractionEric Wilson's OCS Prep CourseFrom: Neumann, Ch 5, 200225

SC Joint: Frontal Plane Arthrokinematics • Elevation: – 45 degrees– Convex surface of head rolls SUPERIORLY and slides INFERIORLY on concavity of sternum• Depression– 10 degrees– Convex surface of head rolls INFERIORLY and slides SUPERIORLY on concavity of sternumEric Wilson's OCS Prep CourseFrom: Neumann, Ch 5, 200226

SC Joint: RetractionEric Wilson's OCS Prep CourseFrom: Neumann, Ch 5, 200227

AC Joint Osteokinematics• Primary motions: Upward/downward rotation• Secondary motions (fine tune):– Transverse/Sagittal Plane rotational adjustments• AC joint space– 50%: inferomedial– 20%: inferior– Rare cases: inferolateral or incongruent Eric Wilson's OCS Prep CourseFrom: Neumann, Ch 5, 200228

Clavicle Moving w/Scapula• Scapulothoracic Elevation– SC Elevation + AC Downward rotation• Scapulorthoracic Protraction– SC Protraction + AC slight horizontal plane adjustmentsEric Wilson's OCS Prep CourseFrom: Neumann, Ch 5, 200229

• Dominant motions during elevation– SC: Posterior rotation (31°)– Scapula: Posterior tilt (21°)Eric Wilson's OCS Prep Course30

AC Injury Classification• Rockwood’s 6 Types1. Acromioclavicular lig sprain ,AC joint intact2. Acromioclavicular lig tear, coracoclavicular lig intact, AC joint subluxed3. Acromioclavicular/ coracoclavicular lig torn, 100% dislocation in joint4. Complete dislocation w/posterior displacement of distal clavicle into or through Trapezius muscle5. Exaggerated superior dislocation of the joint of 100-300%, increasing coracoclavicular lig distance 2-3x, including disruption of deltotrapezial fascia6. Complete dislocation with inferior displacement of distal clavicle into a subacromial or subcoracoid positionEric Wilson's OCS Prep CourseFrom: DeLee, 2 ed, Vol I, 200331

Radiologic Evaluation of AC Joint• XR – bilateral weighted/non-weighted viewsEric Wilson's OCS Prep Course32

Radiology33• Need bilateral view, weighted & unweighted for comparison and to assess for clavicle fractureEric Wilson's OCS Prep Course

• Lack of evidence to support tx options• General consensus– Nonoperative care: Rockwood Type I, II– Initial nonoperative care: Rockwood Type III– Operative care: Rockwood Type IV, V, VI• Basics of nonoperative care– Immobilize (sling) 3-7 days, ice, NSAIDs– Begin ROM then scapular stabilization exercises– Avoid heavy lifting & contact sportsEric Wilson's OCS Prep Course34

• May want to briefly review this CPG• Focus is narrow (return to work)• May not be that applicable to the exam but still has excellent information that is clinically applicableEric Wilson's OCS Prep Course35

• Systematic Review providing elegant algorithm to assist in guiding shoulder examEric Wilson's OCS Prep Course36

Rules in/out intra-articular and rotator cuff pathologiesEric Wilson's OCS Prep Course37

Internal Rotation Resisted Strength TestZaslov (J Shoulder Elbow Surg, 2001)• Patient stands shoulder 90° abd and 80° ER• Examiner resists IR then ER• Positive: – Greater weakness w/ IR = Posterior Impingement(intra-articular)– Greater weakness w/ ER = Secondary Impingement (rotator cuff impairment)• Sn 0.86, -LR .13• Sp 0.96, +LR 2238Eric Wilson's OCS Prep Course

Internal Rotation Resisted Strength Test39Eric Wilson's OCS Prep Course

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Combined Special Test DataAuthor Tests +LR -LR +PTP -PTPImpingement/TendinopathyHegedusHK, Neer, painful arc, empty can, infra MMT (≥3/5) 2.93 .34 - -BeiderwolfHK, painful arc, infra MMT (3/3) 10.5 - 95.5% -HK, painful arc, infra MMT (2/3) 5.03 - 91% -Supraspinatus TendinopathyBeiderwolfERLS 15.5-34.5 .2-.32 88% 13%HegedusAge≥65. infra MMT, night pain 9.8 .54 - -Infraspinatus TearBeiderwolfERLS 15.5-34.5 .2-.32 88% 13%BeiderwolfDropping Sign 0.0 0.0 - -Subscapularis Tear (or Tendinopathy)*BeiderwolfIRLS 24.3 .03 92% 1.4%HegedusLift Off Test* 3.13 .6 - -HegedusResisted IR* 10 .53 - -Eric Wilson's OCS Prep Course44

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Combined Special Test DataAuthor Tests +LR -LR +PTP -PTPHegedusAnterior InstabilityBeiderwolfApprehension 20-53 .29-.47 91-96%12-19%BeiderwolfAnterior Release 8.3-58 .09-.37 80-96%4-15%HegedusApprehension + Relocation 39 .19 - -SLAPBeiderwolfBiceps Load I & II 30 .10 93% 5.3%HegedusPassive distraction + Active compression 7 .11+PTP: +Post-Test Probability-PTP: -Post-Test ProbabilityEric Wilson's OCS Prep Course46

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Extra-Articular Pathology• IRRST Screening Test = inconclusive• Long head of biceps tendinopathy can have concomitant subacromial impingement, SLAP• AC Joint: Tests NOT to use– O’Brian, Paxinos, AC joint palpation, cross-body adduction, AC resisted extension, Neer, Hawkins-Kennedy, Painful arc, drop arm sign, SpeedsEric Wilson's OCS Prep Course48

Shoulder DislocationsWang, JOSPT, 2009• Clinical examination (acute/subacute)• Radiological examination• Immobilization• Surgery• Post-operative goals49Eric Wilson's OCS Prep Course

Shoulder Dislocations: Clinical ExamAcute• Pre-/Post-Reduction neurovascular exam– Axillary, Suprascapular, Long Thoracic nerves• Axillary nerve injured 42% anterior dislocations• Characteristic patient presentation– Arm held against trunk, supported by other arm, pt will resist efforts to have the arm moved• Observation/Appearance– Sharp deltoid contour, more prominent acromion– Palpable fullness below coracoid and/or axilla50Eric Wilson's OCS Prep Course

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Shoulder Dislocations: Clinical ExamSubacute (dislocation has been reduced)• Load/shift test• Apprehension/relocation test• Sulcus test (>2cm compared to involved indicative of MDI)52Eric Wilson's OCS Prep Course

Radiological ExaminationPlain Films• Pre-reduction: – AP w/ slight IR – greater tuberosity fracture• Post-reduction:– Scapular AP – glenoid fossa fx– West Point Modified Axillary view – avulsions IGHL, bony Bankart lesion, anterior-inferior glenoid deficiency– Stryker Notch view – Hill-Sachs lesion53Eric Wilson's OCS Prep Course

Radiological ExaminationMRI• Labral, RC tears, articular cartilage– Contrast enhancement is best, in acute injury the hemarthrosis acts as a contrast medium54Eric Wilson's OCS Prep Course

ManagementAges • 15-25: acute repair usually best to decrease change of recurrence– Rates decrease from 80-90% to 3-15% in young, contact athletes• 25-40: usually do well w/ conservative care• >40: usually do well w/ conservative care due to 10-15% recurrence rates, but often have concomitant soft tissue injuries55Eric Wilson's OCS Prep Course

Frozen Shoulder56Eric Wilson's OCS Prep Course

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From KelleyEric Wilson's OCS Prep Course58

From KelleyEric Wilson's OCS Prep Course59

From KelleyEric Wilson's OCS Prep Course60

From KelleyEric Wilson's OCS Prep Course61

Irritability ClassificationHigh Irritability Moderate Irritability Low IrritabilityHigh Pain (≥ 7/10) Moderate pain (4-6/10) Low Pain (≤ 3/10)Consistent night/resting painIntermittent night/resting painNo resting or night painHigh disability on DASH, ASES, PSSModerate disability on DASH, ASES, PSSLow disability on DASH, ASES, PSSPain prior to end ROM Pain at end of ROM Minimal pain at end ROM with overpressureAROM < PROM (due to pain)AROM similar to PROM AROM = PROMDASH: Disabilities of the Arm, Shoulder and HandASES: American Shoulder and Elbow Surgeons ScorePSS: Penn Shoulder Score62Eric Wilson's OCS Prep Course

Matched InterventionsHigh Irritability Moderate Irritability Low IrritabilityModalities Heat, ice, e-stim Heat, ice, e-stim ---Activity Modification Yes Yes ---ROM/Stretch Short duration (1-5 sec) painfree P/AAROMShort duration (5-15 sec), PROM, AAROM to AROMEndrange/over pressure, increased duration, cyclic loadingManual Techniques Low grade mobs Low to high grade mobilizationsHigh grade, sustained holdStrengthen --- --- Low to high resistance end rangesFunctional Activities --- Basic High DemandPatient Education Yes Yes YesOther Intra-articular steroid injection--- ---63Eric Wilson's OCS Prep Course

Lateral Epicondylitis• History– 75% in dominant arm– Peak occurrence 4th and 5th decades– Overuse– Ext Carpi Rad Brevis• Physical Exam– (+)TP anterior epicondyle– Pain with resisted wrist, 3rd, & 2nd digit extension– Decreased grip strength (primarily with elbow ext.)– Grasp/lift objects with elbow extended causes pain• Differential Diagnosis– Radial Tunnel Syndrome• Treatment– Anti-inflammatory meds– Stretching wrist extensors– Eccentric-based strengthening exercises64Eric Wilson's OCS Prep Course

Wrist HVLA & Lateral EpicondylitisStruijs et al, Phys Ther, 2003• N=31 randomized 2 groups– Wrist HVLA (BIW, max 9 tx over 6 wks) (PA scaphoid)– US, friction massage, stretch/strengthening• TIW 1st wk then BIW 2nd wk then QW x 4 wks, max 9 x 6 wks• Epicondylitis=pain between 6 wks and 6 months with pain for the past 2 wks • Outcome: GROC @ 3wks – sig for HVLA group• Outcome: VAS pain @ 6 wks – sig for HVLA group65Eric Wilson's OCS Prep Course

LE: EBP Treatment• Manual Therapy– Mulligans (MWM) elbow– Manipulation PA scaphoid– Manipulation PA radial head– Mobilizations cervical/thoracic spine• Exercise– Sensorimotor training to wrist extensors– Eccentric or eccentric/concentric combo to extensor tendons (optimal dosage unknown)– Strength training entire UE (deficits only)• Other– Counterforce braces66Eric Wilson's OCS Prep Course

Upper Extremity: Wrist & Hand - TraumaEric Wilson, PT, DSc, DPT, OCS, SCS, CSCS, PES, FAAOMPTPresentsFlight Surgeon Graduate, Dive Medical OfficerDeveloped & Presented By:Eric Wilson's OCS Prep Course67Program Director, USAF Tactical Sports & Orthopedic Manual Physical Therapy Fellowship

FDP Avulsion “Jersey Finger”• History– Often initially missed– Often no serious c/o– ↓’d motion/strength– Pain in finger/palm– 4th finger most common– MOI: forced finger extension against active flexion• Physical Exam– Loss of AROM at DIP• “make a fist”– Fingertip cannot touch palm• Block PIP into extension & ask for DIP flexion– (+) TP• Treatment– Surgical referral68Eric Wilson's OCS Prep Course

FDP Avulsion “Jersey Finger”69Yoong, 2011Eric Wilson's OCS Prep Course

Carpal Fractures70Eric Wilson's OCS Prep Course

6 Criteria to Diagnose Wrist Fx in ERCevik, Ulus Travma Acil Cerrahi Derg, 2003 (n=55 pts in ER <24hr trauma)1. Edema in the wrist: PPV 95.2%2. Tenderness localized to the wrist: Sn 0.94; PPV 67.3%3. Pain w/AROM flexion or extension: Sn 0.97; PPV 77.3%4. Pain w/PROM flexion or extension: Sn 0.94; PPV 91.7%5. Pain w/grip: PPV 89.6%6. Pain w/wrist supination: PPV 96%71Eric Wilson's OCS Prep Course

Scaphoid Fracture• Most common carpal fx– 70% of all carpal fx– Most prevalent 15-30yo population• Dorsal vasculature supply 70-80%• Proximal pole fx have worse prognosis for healing• Initial XR often do not show fx• Contact sport athlete w/radial wrist pain has a scaphoid fx until proven otherwise72Rettig, 2003Eric Wilson's OCS Prep Course

Scaphoid Fracture: Blood Supply73Rettig, 20031. Dorsal scaphoid branch of radial artery2. Volar scaphoid branchProximalPoleEric Wilson's OCS Prep Course

Scaphoid FractureLocation• Tuberosity 17%• Distal pole 12%• Waist 66%• Proximal pole 5%Healing Rates• Waist 80-90%• Proximal pole 60-70%74Eric Wilson's OCS Prep Course

Scaphoid FractureExam (acute)• TTP anatomic snuffbox• Wrist extension: limited ROM & pain• Swelling• XR negative, advanced imaging– MRI, CT, Bone Scan• Ortho referral to determine course of treatment75Rettig, 2003Eric Wilson's OCS Prep Course

Scaphoid Fracture• Axial Load of Thumb (Waeckerle, 1997)– Sn .89, -LR .02– Sp .98, +LR 4976Eric Wilson's OCS Prep Course

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Scapholunate Injury• Most common wrist ligament injury• MOI: excessive wrist extension and UD– Fall on pronated hand– Common in collision/contact sports• Scaphoid Shift test (often not possible w/acute injuries)• TTP• Standard XR + Stress Views (clenched fist, supinated view in UD)• Surgery is primary treatment79Rettig, 2003Eric Wilson's OCS Prep Course

Scapholunate Injury• Scaphoid Shift/Watson’s Test (LaStayo, 1995)– Sn .69, -LR .47– Sp .66, +LR 2.080Eric Wilson's OCS Prep Course

Watson’s (Scaphoid Shift) Test• Examiner’s thumb over palmar scaphoid• Place wrist in ulnar deviation• PROM into radial deviation placing a dorsal-directed pressure on Scaphoid (prevents scaphoid flexion)• Release pressure with thumb• (+) relocating “thunk” and/or pain reproduction as scaphoid flexes and strikes radius81Eric Wilson's OCS Prep Course

Distal Radius Fracture• Epidemiology: Make up 1/6 of all fractures seen in Emergency Room• Mechanism of Injury:• Falls• Motor Vehicle Crash• Athletic Events • Clinical Exam:• Variable deformity of the wrist with hand displacement• Swelling, ecchymosis, focal tenderness• Painful range of motion• Neurovascular exam of the wrist/ hand (esp median nerve function)• “Dinner fork” deformity, due to shape of forearm after fx82Eric Wilson's OCS Prep Course

Dinner Fork Deformity83Eric Wilson's OCS Prep Course

Distal Radius Fracture• Non-operative management:– All should undergo closed reduction• Splint: non- to minimally-displaced without articular involvement• Cast: Once swelling is resolving– Wear for approximately 6 weeks or until union evident on plain films• Referral:– High energy injury – Displacement– Articular involvement– Distal Radius/ Ulna incongruity– Metaphyseal comminution85Eric Wilson's OCS Prep Course

Distal Radius FracturesColles’ Fracture: •Dorsal Angulation•Dorsal Displacement•Fracture Shortening•Extra-articularSmith’s Fracture (reverse Colles)•Volar Angulation•Volar Displacement•Extra-articularBarton’s Fracture•Volar or Dorsal Displacement•Intra-articular86Eric Wilson's OCS Prep Course

Boxer’s Fracture87Eric Wilson's OCS Prep Course

Boxer’s Fracture• History– Pain at fx site, dorsal swelling, deformity– MOI• Direct impact to metacarpal shaft/head• Physical Exam– Deformity: rotational malalignment of finger in flexion: 1.5cm overlap=5° rotation– Decreased metacarpal height– Loss of MCP/PIP extension• 7° ext loss = 2mm short• Physical Exam (cont)– Extrinsic vs Intrinsic tightness• Ext: ↓’d PIP flex in MCP flex• Intr: ↓’d PIP flex in MCP ext– Chronic: Loss of motion and grip strength• Differential Diagnosis– Contusion, MCP dislocation• Treatment– Splinting– Prognosis: Non-operative >90%88Eric Wilson's OCS Prep Course

Mallet Finger• Mechanism– Avulsion of distal slip of extensor tendon– Rapid, forced flexion of distal phalanx (ball striking tip of finger)• Physical Exam– ↓’d AROM DIP ext– Normal PROM DIP ext– (+)TP dorsal DIP• Treatment– Splint 6-8wks full extension– Night Splint 3-4 weeks89Eric Wilson's OCS Prep Course

Overuse/Chronic Wrist Pain• Can often be difficult to distinguish due to lack of MOI• Pain can often be diffuse/poorly localized• Further complicated if our knowledge of the pertinent anatomy is subpar– true for most of us90Eric Wilson's OCS Prep Course

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Overuse/Chronic Conditions• deQuervain’s Tenosynovitis• Intersection Syndrome• ECU Tendinitis• ECU Subluxation92Eric Wilson's OCS Prep Course

Dorsal Wrist Compartments93Eric Wilson's OCS Prep Course

deQuervains Tenosynovitis• Most common overuse injury at the wrist• Stenosing tenosynovitis 1st dorsal compartment APL, EPB• +Finkelstein’s test• Rest during initial stages (25-72% cure rate)– Thumb spica splint• Corticosteroid injection reported cure rates of 62/80/100%Retig, Am J Sports Med, 200494Eric Wilson's OCS Prep Course

Intersection Syndrome• Texter ’s/Gamer’s Thumb• Inflammatory condition• 1st dorsal compartment (APL, EPB) and 2nd dorsal compartment (ECRL/B)• 4-6cm proximal radiocarpal joint• Dx: extend wrist, circumduct thumb• Tx: rest, splinting, nsaids, +/- injectionRetig, Am J Sports Med, 200495Eric Wilson's OCS Prep Course

ECU Tendonitis• 2nd to deQuervains in freq in athletes• Racquet sports, nondom hand tennis 2-hand backhand (extensive ulnar deviation)• Often as compensation for other ulnar-sided wrist pathology (TFCC injury)• Tx: rest, splint, nsaids, injectionsRetig, Am J Sports Med, 200496Eric Wilson's OCS Prep Course

Subluxation of ECU• Should be considered in diff dx of ulnar-sided wrist pain • Rupture of subsheath – typically due to sudden flexion/UD stress• Dx: AROM UD in full supination – observe ECU tendon sublux ulnarly over styloid• Tx– Acute: cast x 6 wks (pronation & extension)– Chronic: reconstruction of sheathRetig, Am J Sports Med, 200497Eric Wilson's OCS Prep Course

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Upper Extremity: NeuropathiesEric Wilson, PT, DSc, DPT, OCS, SCS, CSCS, PES, FAAOMPTPresentsFlight Surgeon Graduate, Dive Medical OfficerBasic Certification in Electrodiagnostic TestingDeveloped & Presented By:Eric Wilson's OCS Prep Course1Deputy Program Director, USAF Tactical Sports & Orthopedic Manual Physical Therapy Fellowship

• Epineurium:– The outer covering of the nerve, made of collagen and elastic fibers. – External to epineurium is mesoneurium, a flimsy layer of tissue. – The epineurium is continuous with interfascicular epineurium, which invests the different fascicles.• Perineurium:– Surrounds each fascicle. – The perineurial cells have tight junctions, and form the majority of the Blood-Nerve barrier.• Endoneurium:– Encircles each axons within a fascicle. – Microvessels are found within the endoneurium. – Their endothelial cells have tight junctions, which provide the second portion of the blood-nerve barrier.Eric Wilson's OCS Prep CourseBasic Structure of a Peripheral Nerve2

Injuries to Peripheral Nerves: A Primer• Two broad categories– Those affecting myelin– Those affecting axons• Rarely injured in isolation, typically some combinationEric Wilson's OCS Prep Course3

Seddon Classification• Neurapraxia: conduction block, only myelin affected• Axonotmesis: injury to axons, stroma (supporting connective tissue) is intact• Neurotmesis: complete injury involving myelin, axon, and all supporting structuresSunderland Classification• Grade I: Neuropraxia• Grade II: Axonotmesis. Loss of axon continuity with preservation of endoneurium & fascicular structure.• Grade III: Mixed axonotmesis/ neurotmesis- loss of axons and endoneurium with retained fascicles and perineurium• Grade IV: Loss of fascicles, continuity maintained only by epineurium.• Grade V: Neurotmesis• For effective re-innervation to occur, axons have to reach distal sites approximately similar to their original innervation sites.Eric Wilson's OCS Prep CourseClassifications of Nerve Injury4

Schwann CellAxonEndoneuriumNode ofRanvier1-2mmMyelinated Neuron (PNS)5Eric Wilson's OCS Prep Course

Compression (Neurapraxia)Compression of endoneurium(edema, sitting on toilet, etc)Increased internodal distance (>2mm) produces conduction block6Eric Wilson's OCS Prep Course

Wallerian Degeneration• Wallerian degeneration can be defined as the loss of both axon and myelin distal to the injury with proliferation of the columns of Schwann cells which will support subsequent regenerative efforts from the proximal nerve.– Strictly speaking, this term applies only to myelinated fibers.– It is simply the process of degeneration of an axon and its myelin sheath from a site distal to an injury (classically a transection) to the end organ.– It may be noted as early as 12 hrs after injury.– Waller was one of the first scientists to describe this phenomenon as well as subsequent proximally stump axonal sprouting which could lead to end organ reinnervation.– Proximal degenerative changes occur with complete degeneration back to the next intact node of Ranvier.Eric Wilson's OCS Prep Course7

Wallerian Degeneration• Within 1 hr after severing the nerve, the stump seals off both proximally and distally.– As a result of the interrupted axoplasmic transport, organelles accumulate at the stump sites by about 5-6 hr.– Within 12 hrs, Wallerian degeneration is noted.– Initially, there is an inflammatory phase during which macrophages and Schwann cells phagocytose axonal and myelin debris.– The inflammatory phase is followed by proliferation of fibroblasts which grow into the side of laceration in addition to proliferating Schwann cells.– The proximal axonal stump produces a profusion of fibers which enter the fibrotic area of scarring resulting in a neuroma.– A neuroma in continuity results from an incomplete nerve lesion while a stump neuroma is caused by a completely transected nerve.Eric Wilson's OCS Prep Course8

• EMGs initially normal, but 2-3 weeks later show fibrillations and denervation potentials. • Recovery occurs only after the axons have regenerated. • After 2-3 days, stimulation of either proximal or distal nerve fails to elicit muscle contraction. • Proximal lesions grow at 2-3mm/day, with distal lesions regenerating at about 1mm/day.Eric Wilson's OCS Prep CourseWallerian Degeneration9

Effects on Muscle Denervation• Muscle begins to change by the 3rd week. • The muscle fibers kink, and their cross-striations decrease. • Atrophy may be evident clinically within weeks, and persists unless re-innervation occurs. • With continued denervation, fibrosis occurs. • By 2-3 yrs, the muscle can be completely replaced by scar & fat.Eric Wilson's OCS Prep Course10

Clinical Exam Pearls• Thorough exam is required, findings of exam should equal Electrodiagnostic Exam (EDX) -no surprisesEric Wilson's OCS Prep Course11

Autonomic Function & Sensory Nerves• One way to test sensory loss is by gauging sweating, because the sympathetics follow the sensory component of a nerve. – Thus, loss of sweating occurs in the sensory distribution of the nerve.Eric Wilson's OCS Prep Course12

Sensory Function• Must be assessed in the autonomous/target zones (no dermatome overlap) as much as possible. – Sensory return in non-autonomous zones precedes motor return. – In the autonomous areas, it usually follows motor recovery. – Sensory displacement = when axons regenerate to a different area, so that when that newly area is stimulated, the brain perceives sensory input from the old sensory field.• 2-point discrimination in the normal finger pad is usually 3-5mmEric Wilson's OCS Prep Course13

Differentiation Sensory Injury• Sensory NERVE ROOT (dermatome)– Symptoms typically proximal to distal– Transient• Peripheral Sensory problem– Symptoms typically distal to proximal– *Double crush injuries will go both ways• 11% in CTSEric Wilson's OCS Prep Course14

Tinel Sign• Provides some evidence favoring n. regeneration. – Percussion must be performed over the course of the nerve DISTAL to the injury site. – A positive Tinel sign implies only fine-fiber regeneration, and is not predictive of the quantity or quality of the new fibers. – In combat injuries, many patients with advancing Tinel signs failed to recover useful function. – Absence of a Tinel sign 4-6 weeks after injury is a significant negative finding, suggesting neural interruption or extremely poor axonal regrowth.– “Advancing Tinel Sign”: paresthesias elicited by tapping along course of a nerve (suggest exposed Na channels)Eric Wilson's OCS Prep Course15

Common UE Neuropathies• Median• Ulnar• Radial• Axillary• Suprascapular• Long Thoracic• Spinal AccessoryEric Wilson's OCS Prep Course16

Upper Extremity InnervationDoral Neal & Fields, Am Fam Phys, 2010Eric Wilson's OCS Prep Course17

Eric Wilson's OCS Prep CourseUE Common Entrapment Sites18

Thumb• Extension / abduction (longus) -> radial nerve• Adduction / flexion (but mostly median) -> ulnar nerve• Flexion / opposition / abduction (brevis) -> median nerveEric Wilson's OCS Prep CourseThumb flex/ext: in plane parallel to palm Thumb ABD/ADD: in plane perpendicular to palm19

Median• Carpal Tunnel• AIN• Pronator Teres• Ligament of StruthersEric Wilson's OCS Prep Course20

Median InnervationMedian (4/3/4)• 4 -> forearm: pronator teres, FCR, palmaris longus, FDS• 3 -> AIN: FDP I/II, pronator quadratus, FPL• 4 -> hand: lumbricals I/II, OP/AbPB/FPB (LOAF muscles)Eric Wilson's OCS Prep Course21

Carpal Tunnel• Etiology: compression at carpal tunnel• General Components• Median nerve distribution 4 +/- fingers– May be perceived more proximally in FA/shdr– May mimic cerv radic• Repetitive hand use incr symptoms• Thenar muscle atrophy severe casesEric Wilson's OCS Prep Course22

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Eric Wilson's OCS Prep Course26CPR

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Carpal Tunnel Syndrome• History– Pain, numbness, paresthesias median nerve distribution on palmar aspect of hand– Night symptoms– ADL’s (driving, typing, holding cup) exacerbate• Differential Diagnosis– Thoracic Outlet Syndrome– Cervical Radiculopathy• Significant % of pop. present with double crush– Pronator Teres Syndrome– Systemic Neuropathy• Diabetes, alcoholism, hypothyroidism)– CRPSEric Wilson's OCS Prep Course30

Carpal Tunnel Syndrome: DiagnosisCPR: (Wainner, 2005)• Age >45• Reports shaking hands relieves symptoms• Wrist Ratio Index >.67• Reduced median sensory field first digit• Symptom Severity Scale score >1.9Eric Wilson's OCS Prep Course31

CTS CPR: Diagnostic Values• > 2 positive tests: – Sn .98, -LR .14, Sp .14, +LR= 1.1• > 3 positive tests: – Sn .98, -LR .04, Sp .54, +LR= 2.1• > 4 positive tests: – Sn .77, -LR .28, Sp .83, +LR= 4.6• If 5 positive tests: – Sn .18, -LR .83, Sp .99, +LR= 18.3• Pre-Test Probability: 34%• Post-Test: 4 of 5: 70%• Post-Test: 5 of 5: 90%Eric Wilson's OCS Prep Course32

CTS CPR: Test Descriptions• Wrist ratio index:• A set of calipers is used to measure the anterior-posterior (AP) and medial-lateral (ML) wrist width. The wrist ratio index is calculated by dividing the AP by the ML wrist width. This criterion is satisfied if the index is > .67– Reliability: ICC = .77-.865• Median Sensory Field 1:• Sensory testing is performed with the end of a straight paperclip. If sensation is reduced in the median sensory field of digit 1 as compared to the thenar eminence the test is considered positive.– Reliability: ICC = .485• The Brigham and Women’s Hospital Hand Severity Scale:• This criterion is satisfied if the Symptom Severity Score is ≥ 1.9.Adapted from: Flynn, Cleland, Whitman: User’s Guide to the MSK Exam, 2008Eric Wilson's OCS Prep Course33

• Neural mobs did NOT show significant effects for Carpal Tunnel• Most studies had low risk of bias (strong findings)• 7/12 studies focused on Tensioning techniques– 390/652 total subjects• Authors believe “sliding” techniques would show better outcomesEric Wilson's OCS Prep Course34

• Similar results as Basson et al (2017)• Majority of studies assessed Tensioning Eric Wilson's OCS Prep Course35

• N=100 females (50/50 each group)• 1° DV: Boston Carpal Tunnel Questionnaire • 2° DV: AROM C-spine, Pinch-Tip Grip, Symptom Severity subscale BCTQ• F/u: 1, 3, 6, 12 months• 94 subjects completed f/uEric Wilson's OCS Prep Course36

Conservative Care• 3 sessions x 30 min each, QW• C-spine: lateral glides, PA glides• Soft tissue mobs: scalenes, costoclavicle space, pec minor, biceps, bicipital aponeurosis, pronator teres, transverse carpal ligament, palmar aponeurosis, lumbricals• PTs NLT 10 years OMPT experienceSurgery• Endoscopic decompression and release of carpal tunnel• Surgeons NLT 15 yrsexperience focusing on hand surgeryEric Wilson's OCS Prep CourseInterventions37

Outcomes• Manual therapy and surgery had similar effectiveness for improving self-reported function, symptom severity, and pinch-tip grip force on the symptomatic hand in women with CTS. Neither manual therapy nor surgery resulted in changes in cervical range of motion. • No data on optimal dosage Eric Wilson's OCS Prep Course38

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CTS: TreatmentAkalin APMR, 2002• N=28 pts/36 hands• Gps 1&2: custom volar wrist splint worn all night, as much as possible day, x4 wks• Gp 2: Nerve/tendon gliding exercises• Results: both gps w/ stat sig improvement but no differences between gps• 5-11 mo f/u (avg 8 mo): Good/Excellent results– Gp 1: 72%, Gp 2: 93% (no stat sig diff)Eric Wilson's OCS Prep Course43

Tendon GlidesFigure 1: The five discrete positions in which fingers are placed in tendongliding exercises: 1, straight; 2, hook; 3, fist;4,tabletop;5,straightfist.Eric Wilson's OCS Prep Course44

Nerve GlidesF igure 2: The median nerve gliding program: 1, wrist in neutral position,fingers and thumb in flexion; 2, wrist in neutral position, fingers and thumbextended; 3, wrist and fingers extended, thumb in neutral position; 4, wrist,fingers, and thumb extended; 5, forearm in supination; 6, the opposite handapplies a gentle stretch to the thumb.Eric Wilson's OCS Prep Course45

ResultsEric Wilson's OCS Prep Course46

ResultsEric Wilson's OCS Prep Course47

• N=21, randomized into 3 groups• 7-neural dynamics (ULTT-A tensioning)• 7- Carpal mobs (PA/AP Maitland mobs, grade, freq, amp– all individualized to pt• 7- No Treatment• Pre/Post test design• No significant differences between groups 1,2Eric Wilson's OCS Prep Course48

Surgical CasesEric Wilson's OCS Prep Course49

AIN Syndrome• Etiology: – Neuralgic amyotrophy (idiopathic brachial plexopathy)– Trauma– Other forms rare• Pure motor nerve – largest branch of Median– FDP, FPL, Pronator QuadratusEric Wilson's OCS Prep Course50

Anterior Interosseous Nerve Entrapment• History– Entrapment of median nerve between two heads of pronator teres– NO SENSORY LOSS (differentiate with PT Syndrome)– Weakness/Paralysis of:• Flexor Pollicus Longus• Flexor Digitorum Profundus(lateral half)• Pronator Quadratus (variable)• Physical Exam– Pinch deformity (pad-pad instead of tip-tip)• FPL & FDP weakness causes an extension deformity at IP of thumb and DIP at index finger• Differential Diagnosis– Pronator Teres Syndrome• Treatment– Address compression site– PROM 1-3 digitsEric Wilson's OCS Prep Course51

Pronator Teres Syndrome• Etiology– Trauma, entrapment between two heads of PT or by fibrous band connecting PT w/tendinous arch of FDS• Pain/tenderness over PT• Median nerve symptoms• Severe: weakness/atrophy of Median muscles distal to PT (FCR, PL, FDS, APB, FPB, OP, 1-2 LumbricalsEric Wilson's OCS Prep Course52

Pronator Teres Syndrome• History– Median nerve compression between heads of pronator teresmuscle– Paresthesias 1-3 digits increased with activity– Weakness in forearm & hand muscles (median nerve)• Physical Exam– (+)TP proximal forearm over Pronator Teres– Pain with resisted elbow flexion, forearm supination, and 3rddigit PIP flexion– Resisted pronation with elbow 90° is weak and painful• Differential Diagnosis– Medial Epicondylitis• Treatment– Splint 4-6 weeks– Nerve glidingEric Wilson's OCS Prep Course53

Ligament of Struthers Syndrome• Etiology: entrapment by Struther’s ligament, joins supracondylar process (bony spur) on anteromedial aspect of lower humerus w/medial epicondyle of humerus– Supracondylar process present in 0.3-2.7% pop; Median nerve (sometimes Brachial artery) deviate medially to pass under it• DX– XR showing bony spur– Weakness of PT (diff dx from PT syndrome)Eric Wilson's OCS Prep Course54

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Ulnar Nerve• Guyon’s Canal• Cubital Tunnel• Retrocondylar GrooveEric Wilson's OCS Prep Course56

Ulnar InnervationUlnar (2/8)• 2 -> forearm: FCU, FDP III/IV• 8 -> hand (3/2/2/1)– 3 -> minimi -> opponens, flexor, abductor– 2 -> interossi -> palmar, dorsal (PAD, DAB)– 2 -> pollicis -> adductor, FPB– 1 -> lumbricals III/IVEric Wilson's OCS Prep Course57

Guyon’s Canal• Etiology: entrapment, formed by Pisiform (med) and Hook of Hamate (lateral), floor transverse carpal ligament, roof piso-hamate ligament• Superficial (sensory) and deep (motor) divisions within the canal• Four distinct patterns (this depth should notbeneeded for the OCS Exam)Eric Wilson's OCS Prep Course58

Guyon’s Canal Patterns1. Deep branch to hypothenar, weakness of interossei & lumbricals; no sensory deficits2. Lesion at/proximal to hypothenarmotor branch, weakness of interossei, lumbricals, hypothenarmuscles; no sensory deficits3. Lesion at/proximal to bifurcation into deep/superficial branches; motor of #2, sensory to distal palm, 5thdigit, ulnar side of 4thdigit4. Lesion to sensory branch, deficits only to distal palm, 5thdigit, ulnar side of 4thdigitEric Wilson's OCS Prep Course59

Cubital Tunnel• Etiology: entrapment tunnel formed by tendinous arch connecting humeral and ulnar heads of FCU 1-2cm distal to med epicondyle• Ulnar nerve, DUC nerve deficits• Pain/tenderness at elbow• FDI initial motor finding, other intrinsic muscle weakness can occur• Variable weakness FCU, FDPEric Wilson's OCS Prep Course60

Dorsal Ulnar Cutaneous NerveEric Wilson's OCS Prep Course61

Cubital Tunnel SyndromeHistory– 2ndmost common neuropathy (CTS)– Sensory changes 4-5 digits– Medial elbow painPhysical Exam– Elbow Flexion Test• AROM elbow flexion• Hold for 60 seconds• (+) paresthesias (ulnar n. dist)• Sn .75, -LR .25• Sp .99, +LR 75– Wartenberg’s Sign• Pt hand on table, examiner passively spreads fingers• Ask pt to bring fingers together• (+) inability to adduct 5thdigit• Ulnar Nerve Compression Test (Novak, 1994)• 60’’ pressure prox cub tunnel at 20°• Sn .89, -LR .11• Sp .98, +LR 44.5Physical Exam (cont)– Froment’s Sign• Pt grasps paper between 1st& 2ndfingers (key chuck)• Examiner attempts to pull paper• (+) distal phalanx (thumb) flexes due to ADD Pollicus weakness– Chronic: intrinsic ms atrophyDifferential Diagnosis– Cervical Radiculopathy– Ulnar compression at wrist– Thoracic Outlet SyndromeTreatment– Rest, avoid elbow flexion ADL’s– Night splinting (elbow <30° flexion x 4-6 weeksEric Wilson's OCS Prep Course62

Ulnar Nerve Compression TestFroment’s SignEric Wilson's OCS Prep Course63Test IllustrationsFrom: Flynn, Cleland, Whitman: User’s Guide to the MSK Exam, 2008

Retrocondylar Groove• Typically due to repeated compression or trauma• Symptoms similar to Cubital Tunnel, but hx of trauma/compression at elbow(s)• Typically requires surgical transposition of the nerve whereas Cubital Tunnel may only require decompression of tunnel without transpositionEric Wilson's OCS Prep Course64

Radial Nerve• PIN (Supinator) Syndrome• Entrapment at the arm• Entrapment at the axillaEric Wilson's OCS Prep Course65

Radial InnervationRadial (4/8)• 4 -> triceps, brachioradialis, ECRL, ECRB• 8 -> PIN (2/3/3), gives off SSR– 2 -> supinator, ECU (key to distinguish prox. radial from prox. PIN lesion…)– 3 -> extensor digiti -> minimi / indicis / communis– 3 -> pollicis -> EPL / EPB / AbPLEric Wilson's OCS Prep Course66

PIN (Supinator) Syndrome• Etiology: compression between two layers of Supinator muscle in arcade of Frohse– Trauma • Normal Supinator and ECRB/L • Weakness ECU – AROM wrist extension=radial deviation of wrist• Weakness of finger/thumb extension• Thumb ABD can be normal, APB is Median • Pain in lateral upper forearm• No sensory deficits, Superficial Radial Sensory nerve branches proximal to arcade of FrohseEric Wilson's OCS Prep Course67

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Posterior Interosseous Nerve Entrapment• History– Compression of Radial Nerve or PIN at Arcade of Frohse– Pain at proximal extensor muscles– Pain increased with resisted supination• Physical Exam– (+)TP distal to lateral epicondyle– Pain with resisted supination• Differential Diagnosis– Lateral Epicondylitis– LCL instability• Treatment– No resisted supination or wrist extension activities– Long-arm splint • (elbow 90°, forearm neutral)Eric Wilson's OCS Prep Course69

Entrapment at arm• Etiology: compression at spiral/Radial groove– Saturday night palsy – sleep w/arm draped over bed/chair/etc– Honeymooner’s palsy – spouse sleeping on arm– Fracture; repetitive use/contraction• Diff Dx: lead poisoning, porphyria, diabetes, periarteritis nodosa• Drop wrist• Normal Triceps, weakness brachioradialis/other muscles supplied distal to spiral groove• Pain is atypical, but may be reported at Superficial Radial Sensory distributionEric Wilson's OCS Prep Course70

Dorsal Ulnar Cutaneous NerveEric Wilson's OCS Prep Course71

Entrapment at axilla• Etiology: crutch palsy• Weakness of entire Radial nerve• Pain at Super Rad Sensory & posterior cutaneous nerve of forearmEric Wilson's OCS Prep Course72

Axillary nerve: Shoulder• Etiology: typically w/inferior shoulder dislocation (nerve stretched across head of Humerus); fx of surgical neck of Humerus• Weakness of Deltoid, but chronic weakness can be overcome, w/time, by other shoulder girdle muscles• Weakness of Teres Minor hard to differentiate due to Infraspinatus• Small sensory loss at lateral aspect of upper armEric Wilson's OCS Prep Course73

Suprascapular nerve• Etiology: Trauma, entrapment to nerve at suprascapular > spinoglenoid notch, Neuralgic Amyotrophy– Trauma often involved nerve as well as upper trunk of brachial plexus• Excessive scapular protraction causative• Pain posterolateral shoulder• Supra/infraspinatus muscle weaknessEric Wilson's OCS Prep Course74

Suprascapular NerveEric Wilson's OCS Prep Course75

Long Thoracic nerve• Etiology: Trauma to posterior triangle of neck or traction causing angle between neck/shoulder to be forcibly increased– Nerve attaches to Middle Scalene & SA– Compression of shoulder or chest wall or neck is contralaterally sidebent• Winging of scapula– Push against wall (elbow 0, shoulder 90)Eric Wilson's OCS Prep Course76

Spinal Accessory (CN XI)• Etiology: trauma to Upper Trapezius• Generalized shoulder pain• Inability to elevate involved shoulder, shoulder “sag” may be evidentEric Wilson's OCS Prep Course77

Symptoms of UE Nerve InjuriesNeal & Fields, Am Fam Phys, 2010Eric Wilson's OCS Prep Course78

Neal & Fields, Am Fam Phys, 2010Eric Wilson's OCS Prep Course79

Neal & Fields, Am Fam Phys, 2010Eric Wilson's OCS Prep Course80

Neal & Fields, Am Fam Phys, 2010Eric Wilson's OCS Prep Course81

Anastomoses• Riche-Cannou• Martin-GruberEric Wilson's OCS Prep Course82

Riche-Cannou• Anastomosis is at the hand level between motor branch of the ulnar nerve and the recurrent branch of the median nerve.• With high ulnar injuries, the patient will not exhibit claw-handEric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.83

Martin-Gruber Anastomosis• Forearm level• 15-20% of population• Generally motor fibers only• Median nerve innervating ulnar intrinsic muscles that are typically innervated by ulnar nerveEric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.84

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Basics of Examination• Stages of Recovery• 2-point discrimination• Monofilaments• VibrationEric Wilson's OCS Prep Course86

Stages of Recovery1. Pain/temperature2. 30Hz vibration3. Moving touch4. Static touch5. 256Hz vibration6. 2-point discrimination7. Localization to touch8. StereognosisEric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.87

2-Point Discrimination• Ability to perceive difference of 2 stimuli• Indications for testing– Nerve lacerations w/repairs or grafts– Nerve compressions s/p surgical release– Long-standing nerve compression w/motor changes– Use w/other testing for battery of tests• Limiting Factors– No force control– No inter-rater reliability– Skin topography can alter results– Vibration of examiner’s hand– Controlling velocity of points– Patient/examiner bias– Assumed to be objective because results have numerical valueEric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.88

2-Point Discrimination• Pt responses: “one” or “two”• Static testing: sides of fingers (start 5mm)• Dynamic testing: across width of pulps, traced proximal->distal (start 8mm)• Use just enough pressure to blanch skin• Ensure points perpendicular to skin• Random order of testing• Results– Clinical: 3/3; Gold Standard 7/10– Always compare to contralateral sideEric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.89

2-Point Discrimination• Norms for hand (all measures in mm)• Static– Normal: 0-6– Fair: 7-10– Poor: 11-15– Non-functional: 16+• Dynamic– Normal: 2-3– Fair: 4-6– Poor: 7-9Eric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.90

Monofilaments• Purpose: functionally discriminate textures, light/deep touch• Standard method– Apply perpendicular to skin– Bend 1.5 seconds– Remove 1.5 seconds• Repeat x3 trials for + response (1.65-4.08)• Repeat x1 trial for + response (4.17-6.65)• Start at ‘normal’ threshold, increase until pt feels stimulus• Test DISTAL to PROXIMAL along nerve pathway, volar then dorsal surface• Complete one UE then the other UEEric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.91

Monofilaments• Norms– Normal: 1.65-2.83– Diminished light touch: 3.22-3.61– Diminished protective sensation: 3.84-4.31– Loss of protective sensation: 4.56-6.65– Untestable: >6.65• Indications– Mapping nerve recovery– Mapping high nerve lesions– Assessing nerve compressions • *False Positive Rates due to anastomosesEric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.92

Vibration• Tuning forks: 30 & 256 Hz• Force application is not controllable • Amplitude varies• Strike force cannot be replicated• Responses from patient are subjectiveEric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.93

Wrinkle Test• Correlates w/complete nerve laceration• *Typically used w/children that cannot cooperate w/formal sensory testing methods• Hand placed in warm water x30minutes• (+) Result: hand shows no wrinkling when removed from water• (+) results correlate w/absence of sensibility Eric Wilson's OCS Prep CourseAmerican Society of Hand Therapists. “ASHT Test Prep for the CHT Exam.” 2006.94

QuestionsEric Wilson's OCS Prep Course97