Case studiesIn Segamat Hospital

LECTURE: HDO 123 CAREER DEVELOPMENT AND MEDICOLEGAL ASPECT IN HEALTH CARENAME : ROCHELLE HERAMISI.D. NO. 01-201007-01423LECTURER: MISS. SAKINAH BINTI RASLI

Contents• Demographic• Definition of the diagnosis• Sign and symptoms• History (Personal,family,medical and social)• Occupational Performance Components (Cognitive,sensory,fine and gross motor)• Problem Identification• Precaution and Contraindication• Activities/treatment procedures• Assistive/adaptive equipment (orthotics and prothetics)• Planning for discharge• Home Programmes• Follows up plans• References

Case studies in Segamat Hospital

Demographic Data• Patient name: Mr. MT• Race: Indonesian• Age: 29 years old • Religion: Islam• Birthday: 14/12/1982• Resident in Malaysia: Batu 7 Jalan Muar

8500 Segamat Johor• Marital status: married (wife in

indonesia)

Continue

• Occupation: construction worker in housing industry

• Date of refer: Oct 31 2011• Date of accident: Oct 29, 2011• Referred to the OT department for: Splinting

and Physical rehabilitation• Referred by: Orthopedics MODiagnosis:• Tendon cut right hand middle finger • FDS/FDP right hand ring finger• FDP tendon cut

Definition of Diagnosis:• Tendons are what let you bend and straighten your fingers. In a

sense, you operate your fingers by remote control - the muscles which move your fingers are located up in your forearm, not in your fingers.

• flexor tendons are smooth, flexible, thick strings which bend your fingers - they look a bit like clothesline rope.

• They work like a bicycle brake cable to bend your fingers, sliding in and out of the finger as it straightens and bends.

• This is a very precision mechanism, and it doesn't take much to gum up the works. Even a cut only part way into the tendon can be a big problem

Flexor tendon cut• Fingers have special creases which let the skin fold when you make a fist - at these

points, the tendons are just beneath the skin, and are easily injured by even a small cut in the skin.

• flexor tendons are very close to the surface of the skin, a deep cut will most likely hit a flexor tendon. In these cases, the tendon is often cut into two pieces.

• Like a rubber band, tendons are under tension as they connect the muscle to the bone. If a tendon is torn or cut, the ends of the tendon will pull far apart, making it impossible for the tendon to heal on its own.

• Because the nerves to the fingers are also very close to the tendons, a cut may damage them, as well. This will result in numbness on one or both sides of the finger. If blood vessels are also cut, the finger may have no blood supply. This requires immediate surgery.

Signs and symptoms of a cut tendon

• An inability to bend one or more joints of the finger • Pain when you bend your finger • An open injury, such as a cut, on the palm side of

the hand, particularly in the joint area where the skin folds as the finger bends

• Mild swelling over the joint closest to your fingertip • Tenderness along the finger on the palm side of the

hand

Flexor digitorium surficials

• (flexor digitorum sublimis) is an extrinsic flexor muscle of the fingers which lies in anterior compartment of forearm and  causes flexion at the proximal interphalangeal joints.

• The muscle originates from two heads  the humeroulnar and radial. Between these two heads median nerve and ulnar artery pass.

• Near wrist, it divides into four tendons which travel through the carpal tunnel formed by the flexor retinaculum.

• The flexor digitorum superficialis, it has long tendons that run down the arm and through carpal tunnel and attach to the palmar side of the phalanges of the fingers.

Flexor sublimis digitorumPosition • Under preceding muscles on front of forearmOrigin• Inner condyle of humerus.internal lateral ligaments of elbow.Anterior border of

radiusInsertion• By the four tendons into of second phalangesAction• Flexes finger from secondphalanx,also flexes wrist and elbowNerve Supply• Median

Flexor digitorum profundus originates upper 3/4 of anterior & medial

surfaces of ulna, interosseous membrane and deep fascia of the forearm.

• The muscle fans out into four tendons (one to each of the second to fifth fingers) to the palmer base of distal phalanx.

• Flexor digitorum profundus lies deep to superficialis, but it attaches more distally.

• This reason profundus is also called the perforating muscle.The lumbricals of the hand arise from the radial side of its tendons

• These tendons, along with those of flexor digitorum profundus, are enclosed by a common flexor sheath. The tendons attach to the anterior margins on the bases of the middle phalanges of the four fingers.

Flexor Digitorum Profundus

Position • Ulnar side of forearm,under

superficial flexors

Origin• Upper three fourth of shaft of ulnar

Insertion• By the four tendons into front of

second phalanges

Action• Flexes third phalanx also flexes

wrist

Nerve supply• Ulnar anterior interosseous  

Case History • Accident happen on Oct 29,2011 at contruction of housing work

industry • During that time he was alone working in the up stairs then the

right hand slide that cause he was fell down to got injury • At the time finger of patient had cut right tendon injury• Patients has sent to Segamat hospital for treatment • Patient has been an operation for tendon repair Family History • His married to Indonesian but she stay her country• He has a daughter and still support his family• He has 8 years working here in MalaysiaMedical History • Accident: patient fell during his work, and as a result injured his

right hand• Patient was unable to relate to me full details of the accident

because of the language barrier

Personal History • He takes medicine painkiller• He was first time accident in this case • He can speak malay little bitSocial History• He was went out his friends after finish working• He was sending financial support to his family Pre morbid• He can speak malay little bit but can understand by sign

language using my hand Post morbidAfter the accident• Due to his condition after that accident• He always complain feel pain his hand• He likes to stay home and watching movie

Subjective Assessment (was done on Oct 31 2011)

• Sources; base on Observation and interviewed patient during treatment

• Full medical history and operation report • Affected hand; Right hand• Dominant hand; left hand • Patient still on bandage • Edema of the finger • Flexion deformity and stiffness of forearm• Complain pain when move his arm• We can understand by sign language • Unable to hold anything by using of right hand• He was feel sore and not feel comfortable• He was shy to speak

Activity Criteria Initial ass.

Personal hygiene

Unable to perform task (0)Substantial help required (1)Moderate help required (3)Minimal help required (4)Fully Independent (5)

3/5He need assistant for wear t shirt only

Bathing 3/5He unable to put shampoo

Feeding 10/10He able to eat by using the dominant hand

Toilet 8/10He unable to zipper or buttoning pans

Objective Assessment OPA – ADL assessmentResults of Modified Barthel Index

Unable to perform task (0) Substantial help required (2)

Moderate help required (5)Minimal help required (8)Fully Independent (10)

Stair/climbing 8/10 He needs

assistant for climbing (scared)

Dressing 10/10 Pt can do the task

Bowel control 10/10Pt can do the task

Bladder control 10/10

Pt can do the taskChair/Bed Transfer 15/15

Pt can do the task

Unable to perform task(0)Substantial help required (3Moderate help required (8)Minimal help required (12)Fully Independent (15)

Ambulation 15 /15

Total score(100) 92

results minimal

Problem Identification

– Moderated help required for personal hygine to shaving his

mustard– Moderated help required for bathing to put shampoo– Minimal help for toilet if he wear pans to zipper or buttoning– Unable to climbing up stair (scared)

Occupational Performance Area(OPA)– Improve of muscles strength and ROM – The MBI results is minimal 92/100 – Patient pain when move his right hand side forearm– Poor of pinch strength– Poor of grip with the right hand

Occupational Performance Component– Range of Motion(ROM)

• Done by using Upper Limb Assessment Form and measure with finger goniometer.

Movements 2nd digit 3rd digit 4th digit 5th digit

R L R L R L R L

MP Flexion(0 to 90) 5-20 0-90 5-15 0-90 0-79 0-90 0-82 0-90

MCP Extension(0 to 15-45)

5-3 0-40 5-4 0-38 0-10 0-42 0-10 0-40

PIP Flexion(0 to 110) 0 0-105

0 0-105

0-85 0-106

0-82 0-102

DIP Flexion(0 to 80) 0 0-80 0 0-80 0-70 0-80 0-72 0-80

Abduction(0 to 25) 0-15 0-20 0-12 0-22 0-22 0-23 0-23 0-22

Flexor tendon repair or graft early passive mobilization therapy

0 - 5 days:. 3 - 5 days:

Postoperative dressing

The postoperative dressing is removed. A light dressing and edema control are applied as needed. A full Kliernert Dorsal Blocking splint is fitted to the wrist and

digits for controlling wear in the following position: Wrist: 20 degrees of flexion MCP's: 45 degrees of flexion PIP/DIP: full extension

Movements Right Left

MP Flexion(0 to 50) 0-40 0 to 50

IP Flexion(0 to 80-90) 0-82 0-85

Abduction(0 to 50) 0-46 0-48

Thumb

Right(LBS) Left(LBS)

Key Pinch 3 7

2 point 2 6

3 point 2 8

Pinch Grip (Pinch Grip Gauge)**Affected side: Right hand

Problem of patientsMotor• Flexor tendon injuries of the hand • Zone I (jersey finger) Lack of active flexion of the distal interphalangeal joint

most commonly in the ring finger• Zone II Lack of active flexion of the proximal interphalangeal joint• Zone III IV and V Lack of active flexion of finger at all jointsSensory • The patients may have tenderness to touch• The patient may experience pain with or without movementCognitive• There are no specific cognitive problems related directly to the tendon injuryPsychological• He was shy to talk and confused

Psychosocial• He want stay at home watch movie

Muscle tone• Not affected

Interpersonal • He has may express feelings of anger at the situation that

caused the accident• He has feel guilty about causing an accident• He has fear that his finger will be unuseable• He has fear being unable to return to work• Mr. M.T. has fear that his hand and finger will be disfigured• The person may have difficulty participating in some social

activities during rehabilitation because of the injury or a requirement to wear a splint

Self care • The person may be unable to perform some activities of daily

living due to an inability to use the finger in the normal or accustomed manner.

• Productivity• Mr. M.T. is usually unable to perform some productivite

activities due to an inability to use the injured finger in the normal or accustomed manner

• Leisure• He has be unable to perform some favorite leisure

activities due to an inability to use the injured finger in the normal or accustomed manner.

goals

1 weeks

Controlled passive mobilization is initiated 2 x day (Modified Duran program) with the splint on as follows: 8 repetitions of passive flexion and active

extension of the PIP joint. 8 repetitions of passive flexion and active extension to the DIP

joint.

Optional: Controlled active mobilization is initiated 2 x day with the splint on as follows:

• 8 repetitions of active unresisted composite flexion and extension of the PIP and DIP joints with the wrist and MCP joints supported in flexion.

4 weeks:

The Klienert Dorsal Blocking splint is removed every 2 hours for the following exercises: 10 repetitions of active flexion and extension to the wrist. 10 repetitions of active flexion and extension to the digits. Passive exercises are continued as needed. The Dorsal Blocking splint is re-applied. Electrical stimulation of the muscle may be used with the

splint on, to increase tendon excursion.

5 weeks: The Kliernert Dorsal Blocking splint is discontinued. Active exercises are done hourly as follows: • 12 repetitions of PIP blocking. • 12 repetitions of DIP blocking. • 12 repetitions of active composite flexion and extension. • Continue passive flexion as needed.

6 weeks: • Passive extension exercises are initiated to the wrist and digits. • Dynamic extension splinting may be applied as indicated

8 weeks: • Gentle strengthening is initiated beginning with foam, then

putty and hand helper. Light grasping is allowed. • No lifting or heavy use of the hand is allowed.

10 - 12 weeks: • May return to work with full use of hand, including sports. • PROM continuesNOTE: Generally the greatest achievement in total motion is seen by this period

Problem Weak ROM of wrist ( flexion and extension)

Treatment E-Z Exerboard

Purpose activity To train the patient wrist flexion and extension

Procedure Firstly, ask the patient to sit down on the chair and make sure that

patient sit in the right position After that, ask the patient to move up and down his wrist together the

hook to train his flexion and extension

Time 10-15 min per session

Treatment

Home programmers• Full flexion of DIP and PIP and active extension should be

achieved • Active flexion exercises are initiated with in the limits of the

extension blocking splint, consisting of eight to ten repetitions of DIP and PIP flexion and five to ten full finger flexion repetitions.

• At the moment he need to stable hand wear to klienert protocol for the mobilization

Precaution/contraindication• Should not stretch the joint especially finger• Avoid giving resistance fossil• Resistance should be given only 2th to 3th months• Respect the pain

Follow up Plans• After 2 weeks give the appointment for follow up

plans

References• http://orthoinfo.aaos.org/topic.cfm?topic=a00015 • Notes of Anatomy and Physiology 2• http://boneandspine.com/definitions/flexor-digitorum-superficialis/ • Notes in O.T intervention• Notes in Biomechanics and kinesology• http://www.eatonhand.com/hw/hw012.htm • http://boneandspine.com/definitions/flexor-digitorum-profundus/ • http://www.rci.rutgers.edu/~uzwiak/AnatPhys/APFallLect15.html

T

hanks