OT Session Note

Specialty of Clinician: Occupational Therapist OT Session Note Injury side: Right Upper Extremity Date of Injury/Surgery: 1 November 2023 Diagnosis: Right distal radius fracture, status post open reduction internal fixation (ORIF) Weeks post op: 3 weeks Subjective: Patient reports persistent moderate pain (4/10 at rest, 6/10 with activity) in her right wrist, particularly during gripping and lifting. She describes difficulty with activities of daily living (ADLs) such as dressing herself, preparing meals, and typing at work. She expresses frustration with the limitations and relies heavily on her left hand. She has been diligent with her home exercises but feels her wrist stiffness is not improving as quickly as she hoped. Patient's primary goals are to regain full pain-free range of motion in her wrist and hand, improve grip strength to be able to open jars and carry groceries, and return to work as an administrative assistant without discomfort within the next month. She is also concerned about the appearance of her surgical scar. Objective: How the injury occurred or describe the onset of the symptoms: Patient sustained the injury after falling directly onto her outstretched right hand while walking her dog. She reported immediate pain and deformity in her right wrist. Wound Status: Scar is well-approximated, linear, and non-tender to palpation. It appears mature with no signs of dehiscence or infection. Pliability is fair, but some adherence noted to underlying tissue, particularly proximally near the styloid process. No active wound observed. The incision line is clean, dry, and intact, approximately 5 cm in length, with minimal erythema at the distal end. No drainage present. Appears to be in the proliferative healing stage. Skin Functions - Scarring: Scar Quality: Vancouver Scar Scale score of 4 (VSS: Pigmentation 1, Vascularity 1, Pliability 1, Height 1). Scar is slightly raised, pinkish, and moderately firm with some adherence to deeper structures. Texture & Colour: The scar tissue is firm with a slightly irregular texture, pinkish-red in colour. Surrounding skin is intact with normal turgor and sensation, no signs of oedema or discolouration. Range of motion measurements for specific joints with degrees: Right Wrist Flexion: 45 degrees (pain with end range) Right Wrist Extension: 30 degrees (pain with end range) Right Wrist Radial Deviation: 10 degrees Right Wrist Ulnar Deviation: 15 degrees Right Forearm Supination: 70 degrees Right Forearm Pronation: 75 degrees Finger AROM within functional limits. Grip strength measurements for right and left hands with average values: Right Hand Grip: 8 kg (Average of 3 trials: 7.5 kg, 8.2 kg, 8.3 kg) Left Hand Grip: 30 kg (Average of 3 trials: 29.8 kg, 30.5 kg, 29.7 kg) Pinch strength measurements including lateral, tip, and palmar pinch with values: Right Lateral Pinch: 2 kg Right Tip Pinch: 1.5 kg Right Palmar Pinch: 2.5 kg Left Lateral Pinch: 6 kg Left Tip Pinch: 5 kg Left Palmar Pinch: 7 kg Sensation: * Two-Point Discrimination (right index finger): 7 mm static, 9 mm moving * Semmes-Weinstein Monofilaments (right hand): Green (2.83) perceived across all digits and palm, indicating normal sensation. Dexterity: * Nine-Hole Peg Test (right hand): 65 seconds (patient struggled with fine motor manipulation and dropping pegs, required visual compensation). Patient-Reported Outcome Measure: * QuickDASH score: 62.5 (out of 100), indicating significant disability. Additional outcome measures and functional assessments performed: * COPM: identified difficulties with meal preparation and dressing. Assessment: Patient presents with good adherence to home exercise programme but continues to experience moderate pain and significant functional limitations 3 weeks post-ORIF for a right distal radius fracture. Right wrist range of motion remains restricted, particularly in flexion and extension, with notable grip and pinch strength deficits compared to the left unaffected hand. Scar adherence is contributing to restricted tissue mobility. The QuickDASH score reflects a high level of perceived disability, impacting daily activities and work-related tasks. Patient demonstrates good motivation but requires ongoing therapeutic intervention to improve functional independence and return to prior level of function. Compared to the previous session, the patient has made slight improvements in wrist flexion and extension (increased by 5 degrees each) and grip strength (increased by 1 kg). However, scar adherence has become more prominent, and pain levels remain consistent with the last report, indicating a need for focused scar management and pain modulation strategies. Treatment: * Manual therapy: Soft tissue mobilisation and scar massage to improve scar pliability and reduce adherence, specifically around the distal radius. Gentle passive range of motion to right wrist (flexion, extension, radial/ulnar deviation). * Therapeutic exercises: Active assisted range of motion exercises for wrist flexion/extension, forearm pronation/supination. Tendon gliding exercises for finger flexors and extensors. Isomeric exercises for wrist extensors. * Modalities: Warm compress applied to wrist for 10 minutes prior to exercises to improve tissue extensibility and reduce pain. * Functional tasks: Practiced simulated gripping tasks using therapeutic putty and manipulated small objects to improve fine motor control and dexterity. Patient education provided on correct scar massage techniques and frequency (5-10 minutes, 3-4 times daily), emphasising firm but gentle pressure to desensitise and mobilise the scar. Home exercise programme was reviewed and progressed to include light resistance exercises with elastic bands for wrist extension and forearm supination/pronation. Advised on adaptive strategies for dressing (e.g., button hooks) and meal preparation (e.g., anti-slip mats). Plan: Continue occupational therapy twice weekly for the next 4 weeks, transitioning to once weekly for 4 weeks thereafter, depending on progress. Goals for upcoming sessions and anticipated interventions: * Increase right wrist flexion to 60 degrees and extension to 45 degrees. * Improve right hand grip strength to 15 kg. * Reduce scar adherence and improve overall pliability. * Progress to more complex fine motor and dexterity tasks. * Address workstation ergonomics and task modification for return to work. Recommendations for the patient to continue daily home exercise programme and scar massage. Referrals to hand surgeon for follow-up at 6 weeks post-op. Consider custom splinting if range of motion plateaus. Final Summary: This session focused on improving right wrist range of motion, managing scar adherence, and enhancing grip strength for a patient 3 weeks post-ORIF for a distal radius fracture. Treatment included manual therapy, therapeutic exercises, and patient education on scar management and a progressive home exercise programme. The plan involves continued occupational therapy to achieve functional goals, with a focus on improving mobility, strength, and dexterity to facilitate a safe return to work and daily activities. Follow-up with the hand surgeon is scheduled, and adaptations for daily tasks were discussed.