Hand Therapy Assessment: Occupational Therapy

Referring Physician: Dr. Eleanor Vance Diagnosis: Right wrist fracture, Carpal Tunnel Syndrome Chief Complaint: - Patient reports pain and limited function in their right wrist following a fall. History of Present Illness: - Patient fell on outstretched right hand three weeks ago. Initial X-rays revealed a distal radius fracture. Patient underwent closed reduction and casting. Cast removed one week ago. Patient now experiencing pain, stiffness, and weakness in the right wrist and hand. Also reports tingling and numbness in the thumb, index, and middle fingers, especially at night. Pain Assessment: - Pain intensity: 6/10 at rest, 8/10 with activity. - Pain quality: Aching and sharp. - Aggravating factors: Wrist movements, gripping, and prolonged use. - Relieving factors: Rest, ice, and over-the-counter pain medication. Previous Treatments: - Closed reduction and casting of right wrist fracture. - Over-the-counter pain medication (ibuprofen). Observation: - Mild swelling and bruising around the right wrist. - Slight atrophy of thenar eminence. Range of Motion (ROM): - Wrist Flexion: 30 degrees - Wrist Extension: 40 degrees - Wrist Radial Deviation: 10 degrees - Wrist Ulnar Deviation: 15 degrees - Elbow Flexion/Extension: Full range of motion. - Finger flexion and extension limited due to pain and swelling. Strength Testing: - Grip strength: 15 lbs (affected hand), 40 lbs (unaffected hand) - Pinch strength: 5 lbs Sensory Testing: - Diminished light touch sensation in the thumb, index, and middle fingers. - Positive Tinel's sign at the wrist. Functional Assessment: - Difficulty with activities of daily living, including dressing, cooking, and personal hygiene. - Unable to perform work-related tasks requiring fine motor skills. Special Tests: - Positive Phalen's test. - Positive Tinel's sign at the wrist. Diagnosis: - Right wrist fracture, status post closed reduction. - Carpal Tunnel Syndrome. Functional Limitations: - Limited wrist and hand movement. - Decreased grip and pinch strength. - Difficulty with fine motor tasks. - Impaired ability to perform activities of daily living. Prognosis: - Good prognosis with appropriate therapy and adherence to the treatment plan. Treatment Goals: 1. **Short-term**: Reduce pain and inflammation, improve wrist ROM, and increase grip strength. 2. **Long-term**: Restore full wrist and hand function, return to pre-injury activity level. Interventions: 1. Manual therapy to address joint restrictions and soft tissue tightness. 2. Therapeutic exercises to improve ROM and strength. 3. Nerve gliding exercises. 4. Activity modification and ergonomic training. 5. Splinting for carpal tunnel syndrome. Modalities: - Ice packs for pain and inflammation. - Ultrasound for pain relief and tissue healing. Education: - Provide education on proper posture and ergonomic recommendations. - Instruct the patient on activity modification to avoid aggravating symptoms. - Educate on home exercise program. Frequency and Duration: - Therapy sessions twice per week for 6 weeks. Follow-up: - Re-assessment in 2 weeks.