Studying Smarter For The CHT Exam - A Hand Fracture Case
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[00:00:00] Right? So when you're thinking about treatment, you want to think about the symptoms, right? So we have scar, we have edema, we have decreased range of motion, um, we have increased contractures, right? Uh, that kind of stuff. So I want you to think about what you're technically allowed to do, right? And from what you're allowed to do, do technically, then you have to make the decision what you're actually going to do.
All right. What is, what is what called impaired sensation? Oh yeah. Impaired sensation. All right. I always forget that because I kind of don't do shit about it because when you do everything else, the sensation will come back. But it is, you have to think about it. So thank you, Michelle, for saying that to me.
I really appreciate that. So we can talk about all of this here. Right. So technically, what are you allowed to do? [00:01:00] And think through, okay, scar management. Well, there's, um, you know, massage, um, there's, uh, you know, vibration, you know, things like that, like, like sensation, there's D desensitization, right?
Because that comes with a scar as well. Um, I think about, um, methods that can be, you know, spoken about in the book. There's tools that you can use, right? Now, it doesn't matter whether you use it or not. You're allowed to use tools. You're allowed to do ultrasound, right? Technically, um, on scarring. What's the best technique, right?
the hurts and the position, like stretching the scar and things like that. So I want you to keep that in mind and look at what the book is telling you in terms of, in terms of saying, I'm allowed to move. You look at edema. What are some things as well that textbook wise you're allowed to do? Well, you're allowed to co [00:02:00] band wrap.
You're allowed to wear gloves, right? Compression.
Compression gloves, you know, if he's got more, you know, uh, edema right here. Uh, I think there's an example in the chapter where they, they do, um, how do you call it? The chips, the sponges, and then you put it underneath the glove to help you. Will test questions ask what's the best that we can do, um, or more concerned with us knowing what we're allowed?
Both. Both because what you're allowed kind of goes back to a protocol and what the best answer is, is based on the scenario of that particular question. Always tell yourself there's clues in the questions and there's clues in the answer. And if you haven't yet seen the video on, you know, practice questions, the strategy, the strategy for it.
And I actually had a really great call and talk with one of the members. Let me just make sure we have this, this, um, We have this video, [00:03:00] uh, and, and Michelle, Michelle, I'm going to say, Michelle, uh, don't tell her I called her other on name. Megan does a really great job. If you guys are, uh, make sure to come on the Saturday calls with her.
She'll go over a lot of this with you. Um, but the strategy that I use and I teach is what she carries through is we scan the question. Write this down. Scan the question so you can have an idea of the question. Scan the question. Then you read your answers. Do not pick. Read the answers. Then you read the question fully to understand what the question has, is asking you, the clues in the question, and then when you go back to the answer you're going to rule out two, and number five you pick the best answer.
The clues are in the question. That's your strategy. Right. Clues are in the question. So when you and I are talking on this week, I'm pointing out to you that from a treatment perspective, do [00:04:00] not think that based on what you do, don't go say Huang said, she does this. And so that that's the best answer, the clues in the question.
And I want you to always think through in a case like this, what's the problem. What are you like, you know, what are you going to be able to work on? There's a DEMA. What are a DEMA techniques, but DEMA techniques is fricking movement for God's sakes. Right. Movement, um, pumps the fluid out. The thing with, with the, with the hand is there's not that, uh, that's much, uh, pumping like it is in the leg because there's not that much muscle.
So it just requires a lot of work. And a lot of times we tend to be in a very dependent position with how we work versus a, uh, position that's gravity helpful. Right. So then a decreased range of motion. So what are you allowed to do? Right. So if you have contractures, And your decreased range of motion.
What are some exercises? Yes, there's blocking, um, to get the, you know, but get a little bit more specific. Well, [00:05:00] if I look back again at my structures, if I don't have a lot of MP flexion, because my intrinsics are really tight, my boulder plate is not moving well, my flexor, my superficialis is not gliding through, and then my profundus.
My per fundus flexes my DIP. It secondarily helps to flex my PIP. Thirdly, it helps to flex my mp, and fourthly, it helps to flex my wrist. If I look at my superficialis, it flexes my PIP, and secondarily it flexes my mp. And thirdly, it flexes my wrist. Right. When you're working with hands, understand synergistic risk motion, which is another way of saying risk tenodesis.
When your wrist is in flexion, your fingers go into extension, but the PIPs kind of stay in this mild flexed position. And then when you go into wrist extension, your fingers curl into a slight [00:06:00] flexion and the PIPs go into better into more flexion, right? So when you're working on a hand and you're saying to me, like the MPs don't even move, if you can't get into flexion, then if you were to stretch into extension, what would you be stretching?
You'd be stretching your intrinsic muscles. You'd be stretching your roller plates. You'd be stretching your, um, bowler plate. So if you stretch your bowler plate to go more distal, then when you get them, we'll then go more proximal, right? To get into flexion. A lot of times we forget to work extension because everyone keeps telling us we need flexion.
You cannot get flexion without extension. If you go into extension, you'll stretch all the flexors so that they can get better flexion. If you then go into isolated. PIP extension. I'm gonna even though you have yet to tell me the measurements. Flexion is, you know, [00:07:00] what's, what's his natural attitude of his hand sitting in?
Is he PIP in 30 degrees, 40 degrees or 50 degrees flexion? Yeah, how are his fingers, because they're not, they're not completely extended. They're probably they take on a very flexion. stiff curled position, where if you get real specific, you're going to say MPs are kind of stuck between that 20, 30 degrees of extension can't get full extension, but can't get full flexion.
And then the PIPs tend to sit in this 30 degree flexion position. And then the DIP, even a little bit more, right? So then from a, from a therapy standpoint, I need to do passive. How can you get active if you don't have passive? Right from a joint stiffness position. How do you get active if you don't have passive, so you get passive range of motion when you get more passive isolated, then you're going to stretch the bowler plate and you're going to stretch some of that profound is.
And then when you go into a flexion, you're going to stretch the extensor tendon [00:08:00] and then passively here. And then you could follow up with active blocking. This is hook. This is straight fist, this, uh, full fist. And then this is straight fist. Understand that a hook fist moves a tendon a certain way, right?
This is the most, um, shit. What is it? Somebody help me. Um, this is the most, uh, uh, profundus against superficialis. You're equal, right? And then full is, uh, they're moving together. And then, and then, um, straight is, is the superficialis most against the profundus, right? That's your tendon blocking. So, so this is called differential fisting, right?
Blocking is here, but you can't get really good blocking unless you have really good PIP extension, right? So technically speaking, you can work individual joints and then [00:09:00] you can work composites. you have to get extension in order to get flexion. Um, all of the passive motion, because in the, in the book, it doesn't tell you what to do first necessarily.
It's just saying you need flexion and extension. You need to do passive to get better active. You need to do different activities to let's say stretch out the collateral ligaments of the MPs because the collateral ligaments of the MP, the way it's built it's like buckets, it like holds the liquid in. So, the metacarpals sort of get squeezed together, and they get really tight.
So one thing to do is to put a little bit of abduction in there. So this is one of my favorite exercises to do. If you can do nothing else, put your fingers in between your other ones, class hand. So your fingers will give your metacarpal ligaments that stretch it needs. And from there, you can even go into passive MP stretch, right?
You can block it for hook fisting, like all sorts of things. But the [00:10:00] technical thing is like, you're allowed to move. And then what are you going to do? There's always splinting in hands, so don't forget. From a range of motion to a contracture standpoint, what splints could you technically do, right? If you have a joint, you know, a contracture, then what can you do to get better extension?
Because PIP is always a problem. Like once it gets tight, it's really tight and then you can't move through it, right? So, um, there are splinting considerations, right? So would you use a static or, uh, or a static progressive slash dynamic? So if you have someone who's three months, six months out, you can do a static progressive.
As long as there's no blood flow issue. There's no, um, you know, especially because I'm, I'm thinking of your scenario and if I get the scenario on the exam where it's like, it's a circumferential thing, there's some things that you have to consider, which always it's [00:11:00] a splinting principle, which is that you can't do a split when it then hurts the fingers in other ways, right?
So look, there's a video all on splinting principles. Um, and you have to understand the splinting principles to then apply it to injuries like this. There's a split in there in the question, And don't forget, uh, don't forget plaster casting. Don't forget controlled motion. You know, I'm talking about constraint motion.
You know what, what somebody tell me, you know, it's in that chapter CMMS or something like where they constrain you. And then you're wearing that cast for a while so that it blocks your movement. And then, you know, so that's the same idea as, as a splint or, um, thank you, Carrie full fist, max, maximum excursion to the profundus straight fist, maximum excursion to the superficiality hook is a differential between the two.
Yeah. I said that just a little differently than [00:12:00] you. I'm gonna have to listen back. But yeah, so think about this, the, the splinting aspect. Like with someone like that, with all the fingers like messed up, you got, what can you rule out? The most popular splint right now. Relative motion splint. Ruled out.
You can't use it. Not good. Right. Is that a guy, you know, is it really going to be that helpful compared to like, if you have someone who's like PIP contract, can you then get him into, um, better extension? Right. So there's going to be clues in your questions. You have to understand the principles of splinting, which then allow you to apply it to a case like this and say, I'm technique, I'm allowed to do static progressive.
So maybe I do a, um, a block splint and I connect his fingers so I can pull into, you know, flexion. Maybe I do, uh, you know, he's too, he's too contracted, you know, in both directions. So, um, I might have to get better extension because if he starts falling beyond 30 [00:13:00] degrees here, getting flexion is not necessarily going to help if he can't get extension.
Right. So it's, it's definitely a challenging case. It's something that these, you know, patients like this, uh, the correct home exercise program is one that is continuous. Hey, listen, I know it's a lot of work, uh, but I need you to do everything, uh, like one or two things. Like this is what I do one or two exercises every two hours.
That you're awake every hour of you can give one simple exercise is if I can reduce your swelling a little bit if I can stretch out these muscles your intrinsics a little bit, can I move it now have to go back to a little bit to testing evaluation, does he have glide does he have profound is, does he have superficialis right, we're going to go into testing next time, excuse me.
Because you have to test is a joint contractor the PIP, or is it like a muscle tendon issue where he's tight. So we're going to do that. Um, do that next time. [00:14:00] Right, but send your questions in I know y'all people got like cases like this but thank you. I hope this is helpful Katie to break it down like in terms of how you want to think about it, because it's, it isn't always about what you do, it's about what you can do.
Based on the scenario of the question and that's why the exam prep is so laser focused to making sure that you're always thinking about that, even though yes, at the end of the day, you're going to take it back to your practice and take it back to your patients, right?
