Flexor and Extensor Tendon Laceration vs. Occupational Therapy

Editor's Notes

• #3: A tendon is part of the muscle that attaches the muscle to bone. It is a strong, fibrous connective tissue that is responsible for transferring the forces generated by the muscle to the bone, thus producing movement at the joint (Benjamin C Wood, 2012). Tendon lacerations occur when the tendons (such as in the forearm that pass through the wrist joint and into the hand) experience a traumatic cut—severing the connection between the muscle and bone, thus losing its function (Department of Rehabilitation Services , 2007).
• #4: Tendons in the wrist include the flexor tendons that bend the fingers and wrist are the: flexor digitorumprofundus and superficialis, flexor pollicislongus, flexor carpi radialis and ulnaris, Palmaris longus. The extensor tendons that extend the fingers and wrist are the: extensor digitorum, extensor indicis, extensor digit minimi, abductor pollicislongus, extensor pollicisbrevis, extensor carpi ulnaris, extensor carpi radialisbrevis and longus (Wood, 2012; Henry, 2012).
• #5: Extensor chart
• #6: Flexor chart
• #7: Flexor tendons are divided into 5 zones. Zone 1 is distal and Zone 5 is proximal. The five zones are: Zone 1—containing flexor digitorumprofundus only distal to the insertion of flexor digitorumsuperficialis; Zone 2—also known as “No Man’s Land”—from insertion of flexor digitorumsuperficialis to the proximal edge of the A1 pulley; Zone 3—from the proximal edge if the A1 pulley to the distal edge of the carpal tunnel; Zone 4—within the carpal tunnel; and Zone 5—proximal to the carpal tunnel (Wood, 2012; Henry, 2012). A flexor tendon that has been injured between the distal palmar crease and the insertion of the flexor digitorumsuperficialis (Zone 2) is considered the most difficult to treat due to the fact that the tendons lie in their sheaths in this area beneath the fibrous pulley system, and any scarring will cause adhesions (Poole, 2013, p. 605).
• #8: Extensor tendons are divided into 8 zones. Zones 1, 3 and 5 lie over the DIP, PIP and MCP joints (Al-Qattan, 2007).
• #9: Tendon lacerations are caused by a severe traumatic injury that cuts open the wrist (Al-Qattan, 2007). The most common mechanisms of injury include, but are not limited to: accidental laceration with broken glass, kitchen knives or table saws, motor vehicle accidents, and suicide attempts, crush injury, avulsions, burns, animal or human bites, and deep abrasions (Henry, 2012).
• #10: Patients who have tendon lacerations may experience an inability to bend the wrist or one or more of the joints in the finger. Other signs and symptoms of tendon lacerations include pain when bending the finger; an open injury like a cut on the palm side of the hand—particularly in the area where the skin folds as the fingers bend; mild swelling over the joint closest to the fingertip; tenderness along the effected fingers on the palm side of the hand (Wood, 2012; Henry, 2012; R. G. Xie, 2008).
• #11: FlexorMost common complications of tendon grafting include rupture, adhesion, flexion contracture, recurvatum deformity (swan neck), bowstringing, lumbrical plus, and quadriga syndrome. The rupture rate after tenolysis is high (21% in Lister's series). This is most commonly at the proximal repair site (Wood, 2012). A recent meta-analysis of 29 studies examining the incidence of complications following tendon repair demonstrated a 6% reoperation rate, and a 4% rate of tendon rupture and adhesion formation. The study found that use of a modified Kessler technique reduces the development of adhesions by 57%, and the presence of an epitendinous suture decreases the rate of reoperation by 84%. The swan neck deformity results from excision of the flexor digitorumsuperficialis. It can be prevented by retaining the part of the flexor digitorumsuperficialis to which the V2 vinculum attaches. It is corrected by either capsulodesis or by the construction of a spiral oblique retinacular ligament. Lumbrical plus occurs when the graft is too long and the tension then is taken up by the lumbrical insertion, resulting in paradoxical extension of the IP joints with forced flexion. The division of the lumbrical corrects this complication. Because the grafted finger reaches the palm prior to the other fingers, this places a block on further flexion of the other fingers (the quadriga syndrome) (Wood, 2012).ExtensorComplications that impair finger and hand movement by hindering the ability of the tendon to glide smoothly include adhesions between repaired tendons and surrounding tissue, stretching (attenuation) or rupture of the repair (most common between 7 and 10 days following surgery), and joint or soft tissue contractures. Other potential complications following surgery include infection, nerve and blood vessel damage, and delayed healing due to underlying medical conditions (Al-Qattan, 2007). In some cases, the severity of tendon damage is underestimated at the time of the original evaluation, especially if a hand surgeon was not involved at this stage. This may result in long-term disability from what initially was thought to be a rather insignificant injury. Joint stiffness and tendon adhesions are common complications of even excellent repairs of extensor tendon lacerations. The longer the immobilization period lasts, the higher the chance of joint capsule fibrosis and of forming volar plate adhesions (check-rein ligaments). These issues are mainly treated with hand therapy for stretching out the scarring. Tendon adhesions are always a risk of tendon repair, especially at the site of the repair (Xie, 2008). Extensor tendons have fewer challenges with this complication than flexor tendons because only one major extensor tendon group is present (vs 2 flexor groups) and because the fibrous-osseous tunnel created by the pulley system does not exist in the extensor system. Most postoperative tendon adhesions can be addressed with therapy; occasionally, tenolysis (surgical clearing of surrounding tendon scar) has to be performed to regain function (Henry, 2012). Misdiagnosis or failure to repair significant partial lacerations (>30% of tendon) can result in extension triggering. The partially torn surface can get transitionally caught on nearby structures such as other tendon slips, extensor aponeurosis or the extensor retinaculum. With forced flexion or extension most patients can clear temporary impediment to extensor tendon gliding. However, symptoms worsen over time, and surgical revision of the partial laceration surface is required (Al-Qattan, 2007). Delayed rupture or failure of tendon repair is a relatively uncommon occurrence. Usually, the cause is a technical error or an underestimation of the repair effectiveness or related injuries that leads to an inappropriate level of early postoperative activity. When tendon repair rupture is diagnosed, early return for revision repair is essential. Tendon grafts maybe required for revision. The patient must informed of the decreased overall function expected in a revision repair and the increased likelihood of further necessary surgery (eg, tenolysis) (Department of Rehabilitation Services , 2007). Untreated extensor tendon lacerations in certain regions lead to imbalance of forces at the proximal interphalangeal (PIP) joint and cause significant deformities that impact the function of the affected finger and entire hand (Henry, 2012). A complete laceration at the terminal tendon overlying the distal interphalangeal (DIP) joint causes a lack of extension of the distal phalanx. This chronically flexed position of the DIP joint is called a mallet finger deformity. A chronic mallet finger that persists over time can lead to further deformity at the PIP joint. The PIP volar plate becomes lax as the individual repeatedly hyperextends the PIP joint in order to compensate for the DIP chronic flexion when attempting to grasp large objects. Over time, a malpositioning of the lateral bands and fixed imbalance of the dynamic and static forces around the PIP joint result in a new deformity, called the swan-neck deformity, that presents with flexion of the DIP joint and hyperextension of the PIP joint. Treatment for this deformity is mostly surgical and should be avoided by proper treatment of the mallet finger before it progresses (Al-Qattan, 2007). Complete central slip lacerations can also result in imbalance at the PIP joint if left untreated. Without extension forces over the PIP joint, it becomes chronically flexed, and the lateral bands slip volar to the central axis of the PIP. This causes a chronic flexion of the PIP joint and extension of the DIP joint as the lateral bands tighten in the malposition. This condition is called a boutonniere deformity and can be effectively treated with therapy if caught in the early stages. As with all surgical procedures, infection and wound dehiscence are possible complications (Henry, 2012). The risk of infection is increased in a contaminated wound (eg, fight bite) that is not properly cleaned before tendon repair (Xie, 2008).Other complicationsOther potential complications following surgery include infection, nerve and blood vessel damage, and delayed healing due to underlying medical conditions. In some cases, the severity of tendon damage is underestimated at the time of the original evaluation, especially if a hand surgeon was not involved at this stage (Department of Rehabilitation Services , 2007). This may result in long-term disability from what initially was thought to be a rather insignificant injury.Complications that impair finger and hand movement by hindering the ability of the tendon to glide smoothly include adhesions between repaired tendons and surrounding tissue, stretching (attenuation) or rupture of the repair (most common between 7 and 10 days following surgery), and joint or soft tissue contractures (Department of Rehabilitation Services , 2007; Xie, 2008).
• #12: This is an illustrations of injuries and deformities.
• #13: A history and physical will be completed initially to determine if the patient has a laceration. Examination of the wound will reveal the damage to the tendon. The healthcare provider can also detect the injury by demonstrating weakness or failure to move the involved extremity. However, utilization of bedside ultrasonography in the emergency room is more sensitive and precise than physical examination for identifying tendon lacerations. In one study, sensitivity, specificity, and accuracy of US were 100%, 95%, and 97%, respectively (Henry, 2012). Bedside ultrasonography in the emergency department takes significantly less time to implement than the traditional method of utilizing wound exploration techniques or MRIs. A 3-view x-ray of the hand, wrist, or forearm must be performed on all but the most benign tendon laceration injuries to exclude foreign bodies or bony injury (R. G. Xie, 2008). Also, in all blunt trauma cases, radiographs are used to assess for possible fractures or dislocations(Department of Rehabilitation Services , 2007).
• #14: The history of tendon reconstruction dates back to the times of Hippocrates and Galen. “Interestingly, Galen (131-201 AD), in his ArsParva, stated that tendons were composed of both ligaments and nerves. He warned, therefore, that placing sutures in tendons would lead to pain, twitching, and eventual convulsions. This erroneous concept was not refuted until 1682, when Meekren observed that tendons are insensitive and described the successful repair of incompletely severed tendons.” (Ginard I Henry, 2012).
• #15: Immediate surgical repair of the tendon is indicated in lacerations. Delaying surgery can lead to shortening of the tendon, formation of scar tissue and decreased blood flow, which can lead to a poor outcome. Following surgery the patient’s wrist will be put in an immobilizing device. Over the next 2-4 weeks hand therapy will be initiated. The surgeon will determine the hand therapy timeline and program (Department of Rehabilitation Services , 2007). Once the decision for surgical intervention has been made, the general principles of definitive wound debridement, early tendon repair, and early range of motion hand therapy guide the treatment plan for all extensor tendon injuries. As in all hand surgery, meticulous handling of the tissues and thorough knowledge of the relevant anatomy is vital. In an extensor injury of any area, all the pertinent structures must be carefully dissected and examined. However, because scar formation occurs at every along the entire plane of dissection, judicious restraint must be used in determining the extent of dissection (Department of Rehabilitation Services , 2007).The objectives are to maintain the blood supply as completely as possible, obtain adequate exposure, and obtain optimal scar contracture. Bunnell developed the midlateral incision as the stationary line, either volar or dorsal to the neurovascular bundle. Littler demonstrated the diamonds of skin-to-skin contact during digital flexion. The Bruner zigzag incision avoids these areas. Preservation of the vincula is difficult if the dorsal midlateral incision is used, and hence either the Bruner or the volar midlateral incision is recommended. Midlateral incisions should not be made on surfaces exposed to much contact (eg, ulnar border of little finger, radial border of index finger). The distal extent of either incision is over the pulp of the phalanx (Al-Qattan, 2007).
• #16: Information from the AOTA’s website.
• #18: This treatment strategy completely immobilizes the tendon for 3 ½ weeks after tendon repair. Immobilization may not yield consistently desirable results due to the fact that it often leads to scar adherence and can lead to a higher incidence of tendon rupture (Wood, 2012). Nevertheless, if there are other injuries (e.g., a fractured phalanx that cannot be moved), this technique may be required. Furthermore, if a patient seems unable to participate fully in the treatment (e.g., a person with cognitive impairments), the immobilization method may be chosen (Poole, 2013, p. 605).
• #19: “Durand and Houser suggest the use of controlled passive motion, which allows 3 to 5 mm of tendon excursion, to achieve optimal results after tendon repair”. They found this technique adequate to prevent adherence of the repaired tendons (Wood, 2012; Poole, 2013, p. 605). On the third postoperative day, the patient starts a twice-daily exercise routine of passive flexion and extension of 6 to 8 repetitions per tendon (Xie, 2008). It’s important to have the wrist flexed and the MCPs in 70 degrees of flexion during passive exercise. “After 4 ½ weeks the protective dorsal splint is removed and the rubber band traction is attached to a wristband. Active extension and passive flexion are done for 1 additional week and gradually increased over the next several weeks” (Poole, 2013, p. 605).
• #20: “Dr. Harold Kleinert, a pioneer of flexion tendon surgery, was an early advocate of rubber band traction after repair of flexor tendons. This technique is often called the Kleinert techniques” (Poole, 2013, p. 605). Once the tendon is surgically repaired, rubber bands are attached to the nails of the involved digits with a suture through the nail or with a hook held in place with cyanoacrylate glue. A dorsal blocking splint is constructed with the MCP joints held in about 60 degrees of flexion and the PIPs in gentile flexion (Poole, 2013, p. 605). The patient must have the ability to fully extend the interphalangeal (IP) joints actively within the splint; if not, joint contractures will develop (Wood, 2012). Kleinert’s original protocol has been modified over the years yet it still remains the foundation for most of the early active motion protocols detailed in the literature. Both his protocols and the Washington approach utilize early active extension and passive flexion. The Indian and MAMTT (minimal-active muscle-tendon tension) protocols permit early gentile supervised active flexion of the involved tendon. “There is some evidence that early active motion such as “place-and-hold” exercises do result in greater finger motion after a Zone II tendon injury” (Poole, 2013, p. 605).In the Kleinhert and Washington protocols the patient wears the splint 24 hours a day for 3 weeks and is taught to actively extend the digits several times a day in the splint, permitting the elastic bands to pull the digits into flexion (Wood, 2012). The movement of the tendon through the tendon sheath and pulley system minimizes scar adhesions while enhancing tendon nutrition and blood flow. The dorsal blocking splint is discontinued at 3 weeks, depending on the surgeon’s decision (Poole, 2013, pp. 605, 607).To be effective, all of the early mobilization methods necessitate a motivated patient who thoroughly comprehends the program. Some early active mobilization techniques presently allow early active extension and flexion of the repaired tendons, as well as other changes. “Only the most experienced surgeon should attempt these treatments” (Poole, 2013, p. 607).
• #22: Though each protocol has a specific and sometimes slightly different time line, when active flexion is begun out of the splint after any of the postoperative management techniques described previously, patients should be instructed in exercises to facilitate differential tendon gliding (Poole, 2013, p. 607).“Wehbe recommends three positions—hook fist, straight fist, and composite fist—to maximize isolated gliding of the flexor digitorumsuperficialis and the flexor digitorumprofundus tendons, as well as stretching the of the intrinsic musculature and gliding of the extensor mechanism” (Poole, 2013, p. 607). These tendon glide exercises should be repeated for 10 repetitions in per position, two to three times daily. Isolated exercises to assist tendon gliding may be performed with a blocking splint or by using the other hand (Xie, 2008). The MCP joint is held in extension during blocking, so the intrinsic muscles that act on it cannot overcome the repaired flexor tendons. It is important not to hyperextend the PIP joint because this would overstretch the repaired tendons (Poole, 2013, p. 607).“After 6 to 8 weeks, passive extension may be started and a volar finger splint may be necessary to correct a flexion contracture at a PIP joint. Alternately, the therapist may fabricate a cylindrical plaster splint to apply constant static pressure on the contracture” (Poole, 2013, p. 607).After roughly 8 weeks, the patient can initiate light resistive exercises, light ADL, and other activities (Wood, 2012). The patient must avoid lifting with or applying excessive resistance to the involved hand. Participating in sports activities should be discouraged. However, activities such as working with soft clay, woodworking, and macramé are excellent. Full resistance and normal work activities may begin again at 3 months after the surgery (Poole, 2013, pp. 607, 608).Though performance of ADL is generally not an issue, therapy practitioners should ask patients about any complications they may have or anticipate. “Disuse and neglect of a finger, especially the index finger, are common and should be prevented” (Poole, 2013, p. 608).Gains in finger flexion and extension may continue to be recorded for 6 months or more after the surgical repair has taken place (Xie, 2008). A digit with flexible joints and slight scarring preoperatively will function better after surgery than one that is stiff and scarred or that has trophic skin changes. “A ‘functional’ to ‘excellent’ result is obtained when there is minimal extension lag at the PIP and DIP joints and the finger can flex to the palm” (Poole, 2013, p. 608).
• #23: This is an illustration of tendon gliding exercises.
• #24: This is an illustration of tendon gliding exercises.
• #26: The immobilization method maintains the tendon in a shortened position by way of splinting or casting. “Tendons are immobilized for three weeks; in week 4, gentle active motion of the repaired tendon is introduced” (Poole, 2013, p. 609).
• #27: Extensor tendons damaged proximal to the MCP joints frequently become adherent to the structures above and below them. This will require the occupational therapist to initiate a splinting program. A removable volar splint is utilized between exercise periods to protect the tendon for two additional weeks. Dynamic flexion splinting may be started 6 weeks after surgery to recover flexion if required (Poole, 2013, p. 609).Extensor tendons injured proximal to the MCP joint may be immobilized for 3 weeks. After this, the digit might be placed in a removable volar splint that is worn between exercise periods for an additional two weeks (Hall, 2010). Progressive ROM is initiated after 3 weeks, and if full flexion is not recovered promptly, dynamic flexion may be initiated after 6 weeks (Poole, 2013, p. 609). Extensor tendon injuries that occur distal to the MCP joint necessitate a longer period of immobilization—usually for 6 weeks. A progressive exercise program is then initiated with dynamic splinting during the day and static splinting at night to preserve extension (Poole, 2013, p. 609).
• #28: The early passive motion method reverses what was done for the flexor tendons (Hall, 2010). The extensor tendons are held in extension by dynamic, gentle rubber band traction, and the patient is permitted to actively flex the fingers, thus passively moving the surgically repaired extensor tendons. “These splints must have a dorsal component to provide a block to flexion so as not to move the tendons too much, which could lead to overstretching or rupture of the extensor tendon. This method facilitates tendon strength and can prevent the scarring that ultimately limits motion and function” (Poole, 2013, p. 609).
• #29: The early active short arc program, developed by Evans, permits the tendon to actively move 3 days after surgery. The therapist must take care to make sure that the stress applied by early active motion does not override the strength of the surgical repair. “The splinting program is quite complex and specific and requires a skilled occupational therapist” (Poole, 2013, p. 609).
• #30: Information from the AOTA’s website.
• #31: Consider whether vincula (flexor tendons) or mesotendons (extensor tendons) were damaged. Vincula provide 70% of nutritional support to flexor tendons in zones 1 and 2. Mesotendons provide 30% of nutritional support to the extensor tendons via vascular perfusion in all zones. Synovial diffusion provides the remaining 70%. (p449 rehab of the hand). Any fractures, pulley, nerve and/or artery repairs may indicate a longer immobilization phase or other modifications to the program. Therapist must assess the patient’s cognitive status to determine ability to understand and comply with a complex home program. Monitor for any signs of infection. Any positive findings should be reported to the referring MD immediately. Send the patient to emergency room if referring MD is not available. Consider specific details of the tendon repair (e.g. number of strands, type of suture, whether epitenon/tendon sheaths were repaired.) Repair of epitenon adds 10-50% strength to the repair and reduces gap formation. Also, consider that immediately after surgery, postoperative edema and inflammation will increase the stress placed on the tendon repair site with active motion. Therefore, it is advised to wait at least 72 hours before initiating any active motion of the repaired tendon. Biomechanically, the immobilized tendon loses strength after repair: 50% at the end of week one, 33% at the end of week three, and 20% at the end of week six. 4 Tendons that move as they heal have better motion and strength than those that do not move. The difference is not improved by adding a load over and above the amount needed to initiate tendon gliding (Department of Rehabilitation Services , 2007).
• #32: The patient must not remove the splint under any circumstance. Failure to follow this advice could result in rupture of the repaired tendon requiring further surgery and a delay in your recovery. If patents have any problems with the splint such as discomfort or poor fitting, they should be encouraged to contact one of the hand therapists. Patients should not attempt to adjust the splint yourself. Patients must keep their hand elevated at all times; this is particularly important during the early recovery period; the therapist should advise the patient when this is no longer necessary (Department of Rehabilitation Services , 2007). Patients must carefully follow the exercise regime. Before the patients discharge from hospital the hand therapists will see the patient and the exercise regime will be explained to them. To optimize your recovery it is advised to follow the regime exactly as instructed. Failure to do so may result in stiffness of the fingers and/or rupture of the repaired tendons and require further surgery. Either of these complications may increase the likelihood of the patient developing permanently stiff fingers (American Occupational Therapy Association, Inc., 2007).
• #33: The patient should be encouraged not to: use the injured hand for anything other than performing your exercise regime; use the hand for driving for at least 10 weeks following surgery; operate machinery of any sort whilst wearing a protective splint; participate in any sporting activities. The patient should be instructed to contact the hospital in the event of the following: sudden increase in pain, swelling and redness of the injured fingers; a sudden inability to move the injured fingers (this may suggest that the tendons have ruptured, this is sometimes associated with a ‘snap’); keep all hospital appointments; your injury should be well healed and the hand back to nearly full strength after three months, providing the instructions from the surgical and hand therapy team are followed carefully (American Occupational Therapy Association, Inc., 2007; Department of Rehabilitation Services , 2007).
• #34: The outcomes of treatment depend on the cause, type, site, and extent of the tendon laceration, length of time between injury and repair, and the type of repair. If the damaged tendon can be restored to its normal length with adequate strength, good function should return. Fractures, infection, involvement of more than one tendon, or concomitant injuries to the hand make it more difficult to achieve complete restoration of finger and hand function (Wood, 2012). Staged reconstruction of a flexor tendon repair following initial surgery is often necessary for complex cases and results in prolonged incapacitation. Proper postoperative splinting, hand therapy, and excellent compliance with treatment plans are essential to the success of any tendon laceration repair (Xie, 2008). If normal tendon function cannot be completely restored or if there are concomitant injuries to the joints, manual dexterity may be compromised (Wood, 2012; Henry, 2012).
• #35: Tendons do not heal as well as other body tissues, so recovery is guarded in extensive or more complicated cases. Smoking may affect tendon strength. Late tendon repair is not very successful and sometimes not even possible. If repair and treatment are initiated immediately, individuals with a laceration the tendons in the wrist generally do well. Delay can result in the formation of scar tissue and retraction of the tendons (Al-Qattan, 2007). Other factors that can affect recovery are: age—older individuals are generally weaker and take longer to heal affecting the functional outcome; strength and health—individuals who are strong and in good health prior to the injury generally do better following surgical repair; and tissue quality prior to the surgical repair—will effect healing and recovery following surgery. Poor circulation and presence of scar tissue will also interfere with the healing process (Wood, 2012; Henry, 2012).The healing time for a tendon repair will take up to 8-12 weeks but restoration of function and ability to accept full activity, load and stress can take up to one year (Department of Rehabilitation Services , 2007).
• #36: Now I willdiscuss ways the OTPF may apply to individuals with flexor and extensor tendon lacerations.
• #37: Tendon injuries will compromise the ability to perform IADL’s (drive, manage finances, self-administer medications, make a meal, etc.). Due to limitations of the involved extremity, the patient would have difficulty with all areas of occupation, including grooming, oral hygiene, bathing, toilet hygiene, dressing, meal preparation, feeding and eating, driving, administering medications, and using the telephone. The patient may have trouble resting and sleeping due to pain and discomfort from the splint. Patient may be unable to work. Patient should be educated in one-handed techniques to dampen occupational disruption. Family may be available to provide the patient with some assistance. Patient may experience anxiety about the recovery timeframe and uncertainty of the prognosis. If the patients recovery is less than complete, his or her job should be analyzed to see if it can be adapted to allow him or her perform it (American Occupational Therapy Association, 2008).Full resistance and normal work activities may resume at 3 months after surgery. Although performance of ADL is generally not a problem, therapy providers should ask patients about any problems they may have or anticipate (Xie, 2008)
• #38: The motor skills of manipulating, stabilization and coordination are disrupted. The abilities to move, transport, lift, calibrate, and grip are lost in the affected hand due to medical precautions. The patient may experience reduced activity tolerance due to increased demands of performing activities one-handed. Skills related to handling and holding are challenging because the involved hand cannot be used to stabilize. Disturbances in timing of tasks will result from one-handed performance. The patient may need to rely on others more. His/her relationship with others may change due to his/her temporary dependent occupational status. (American Occupational Therapy Association, 2008).
• #39: Habits, routines, roles and rituals may be altered. It will take longer to perform tasks. Some previous habits and routines may not be possible while the tendon is healing (e.g., adhering to daily housework schedule). Loss of the worker role and changes in the performance of parent and household maintainer roles may be psychologically devastating (American Occupational Therapy Association, 2008)
• #41: Having the use of only one have is restrictive and will affect the patient’s ability to carry things for long distances or up and down stairs. The patient may experience difficulty negotiating and navigating his or her physical environment. Decisions regarding workforce involvement can be emotional and may negatively affect occupational identity and self-worth. Relationships with spouse, friends, and caregivers may become strained. Relationships with systems (e.g., economic or institutional) that are influential in establishing norms, role expectations, and social routines may be negatively impacted. Because the patient is not going to work every day, he or she may be at risk for isolation and occupational alienation (American Occupational Therapy Association, 2008).
• #42: Since this is an orthopedic disorder, the biomechanical frame of reference is appropriate. “The goals of [this] approach are to evaluate specific physical limitations in ROM, strength, and endurance; restore these functions; and prevent or reduce deformity…Biomechanical principles are also applied in ergonomics and work hardening, with an emphasis on proper positioning and the optimum fit between the biomechanics of the individual and the work environment.” (Early, 2013, p.10)