University of Santo Tomas

College of Rehabilitation Sciences

Department of Occupational Therapy

OCCUPATIONAL THERAPY ADULT CASE PRESENTATION

Clinical Education 2

BACKGROUND INFORMATION
Name: Mark Concepcion
Age / Sex: 21 / M
Date of Birth: 19-Sep-1997
Occupation: Student
Diagnosis: ⓇFDP, FDS tendon rupture; Median & Ulnar nerve transection
Rehab Doctor-in-charge: Gaerlan Inciong M.D. FPARM
Date of Initial Evaluation: 27-Feb-2019
Precautions: Flexor Tendon Injury Repair
Medications: -
Source: Patient (90%), Medical Chart (10%)

BACKGROUND INFORMATION
A. Overview of the Case
This is the case of M.C., a 21 y/o M diagnosed with Flexor Digitorum Profundus, Flexor Digitorum Superficialis tendon rupture, median
and ulnar nerve transection. He was referred for Occupational Therapy by his doctor last February 27, 2019.
B. Outline of Presentation
I. Medical-Surgical Background
Definition of Condition
Epidemiology
Etiology
Types and classifications
Signs and Symptoms (Clinical and Classical Picture)
Medical/Surgical/Rehabilitation Interventions
Prognosis and Functional Outcomes
Risk factors
II. OT Evaluation
Subjective Information
Objective Information
OT Impression
Prioritized Problem List
III. OT Intervention
LTGs, STGs, and Plan of Action for each problem
Frames of Reference Used
Conduct of Therapy
Recommendations
Conclusion

MEDICAL-SURGICAL BACKGROUND
A. Definition of the Condition
I. Flexor Tendon Rupture
Tendons are tissues that serve as the connection between muscle and bone. Muscle contraction causes tendons to pull on body parts
resulting in movement. Flexor tendons are tissues that help control movement of the hand through thumb and finger flexion and
opposition. Flexor tendon rupture is the term used to describe a condition or injury that occurs on the volar side of the fingers, hand,
wrist or forearm due to direct trauma, eccentric loading and/or advanced age wherein the tendons in the area snap. It includes severe
pain, marked weakness, immediate bruising, deformity and inability to move and use the affected structures. The origin, insertion,
action, and nerve supply of the flexor muscles used in thumb and finger flexion and opposition are summarized in Table 1.

Case Presentation – M.C. | pg. 1

 Muscle Origin Insertion Nerve Supply Action
Humeroulnar Medial epicondyle of Flexes middle
Flexor head the humerus phalanx of fingers
Middle phalanx of
Digitorum Median nerve and assists in flexing
Oblique line on anterior medial four fingers
Superficialis proximal phalanx and
Radial head surface of shaft of
hand
radius
Flexes distal phalanx
Ulnar nerve
of fingers and assists
Anteromedial surface Distal phalanx of (medial half);
Flexor Digitorum Profundus in flexing the
of shaft of ulna medial four fingers Median nerve
proximal and middle
(lateral half)
phalanges and hand
Anterior
Anterior surface of interosseous Flexes distal phalanx
Distal phalanx of
Flexor Pollicis Longus shaft branch of of
thumb
of radius median thumb
nerve
Flexes
Base of proximal
Flexor Pollicis Brevis Flexor retinaculum Median nerve metacarpophalangeal
phalanx of thumb
joint of thumb
Pulls thumb medially
Shaft of metacarpal
Opponens Pollicis Flexor retinaculum Median nerve and forward across
bone of thumb
palm
Table 1. OINA of Flexor Tendons

II. Peripheral Nerve Injury

The term peripheral nervous system refers to all nerves and neurons that lie outside the brain and spinal cord e.g. median and ulnar
nerves. Peripheral nerve injury is thus defined as any injury, partial or complete, to the nerves that are part of the peripheral nervous
system. These injuries are set apart from central nervous system injuries by the series of cellular responses to damage, known
collectively as Wallerian degeneration, that allow axon growth, regeneration, and reestablishment of synaptic connections.
Symptoms typically include weakness or paralysis of muscles innervated by the motor branches the injured nerve, as well as
sensory loss to areas innervated by the sensory branches of the injured nerve.
B. Epidemiology
I. Flexor Tendon Rupture
According to Clinical Orthopedic Surgery (2014), results of population surveys generally suggest that tendon injuries mostly occur
in most cultures in about older adults ranging from 20-29 years of age. There was a significant association between injury rate and
age. Males had a higher incidence than females. Typically, flexor tendon injuries involved are zone two of the index finger. Work-
related injuries account for 24.9% of acute traumatic tendon injuries. Most common occurs to those working in construction and
extraction occupations (44.2%) followed by food preparation and serving related occupations (14.4%) and transportation and
material moving occupations (12.5%).
II. Peripheral Nerve Injury
According to the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (2018), results of population surveys
suggests that about 3.3% of all trauma patients with upper limb affection revealed additional nerve injuries. Males (78.6%) had a
higher incidence of PNI (73.2%) and tended to be significantly younger than trauma patients without nerve lesions (mean age =
40.6 years vs. 47.2 years). Motorcycle accidents were the most frequently encountered cause of peripheral nerve injuries which
accounts for 32.5% of all cases. The ulnar nerve is reported to be the most commonly injured nerve.
C. Etiology of the Condition
I. Flexor Tendon Rupture
Flexor tendon ruptures are typically caused by direct trauma, eccentric loading of muscles while being stretched in the opposite
direction, advanced age, and certain health condition. Flexor tendons typically rupture due to direct trauma secondary to cuts or
lacerations on the arms, hands, or fingers and during sports activities such as rock climbing, wrestling, and rugby. Tendons may
also rupture during eccentric loading while being stretched in the opposite direction due to the increased tensile stress on the tendon.
Advanced age can also cause tendon rupture due to decreased blood supply that tends to weaken tendons. Pathological states and
conditions such as those due to gout, hyperparathyroidism, and rheumatoid arthritis may also cause weakening of the tendons
making them more like to tear.
II. Peripheral Nerve Injury
Peripheral nerve injuries may be caused by compressive force, fractured bones, lacerations, stretching, contusion or crush injuries
resulting in disruption of the nerves.
D. Types or Classifications of the Condition

Case Presentation – M.C. | pg. 2

 I. Flexor Tendon Rupture
Flexor tendon injuries are typically classified based on the Verdan Zone of the
injured area. Verdan Zones refer to specific and systematic delineations of areas in
the hand and thumb. These “zones” are commonly used by therapists and in hand
repair and rehabilitation protocol literature.
Flexor Zone I
The flexor zone I extends from the flexor digitorum profundus to the flexor
digitorum superficialis tendon on the middle phalanx. A tendon laceration in
this zone is usually close to its insertion. The most common condition
associated with zone is the jersey finger. Jersey finger is caused by an injury to
the FDP from its insertion at the base of the distal phalanges.
Flexor Zone II
The flexor zone II extends from the proximal end of the digital fibrous sheath
to the distal end of the A1 pulley or until the distal palmar crease. The flexor
zone 2 is also known as the “no man’s land” which means that any structure
that would be repaired in this zone may not have a good prognosis due to
adhesion formation at the Camper’s chiasm.
Flexor Zone III
The flexor zone III extends from the proximal end of the finger pulley system
to the distal end of the transverse carpal ligament or at the level of the Figure 1. Verdan Flexor Zones
lumbricals. The lumbricals muscle originates at zone III which prevents the
profundus tendons from over-retracting.
Flexor Zone IV
The flexor zone IV is at the level of the carpal tunnel which extends from the distal to the proximal borders of the transverse
carpal ligament. This zone has rare occurrence of tendon injuries because of the protection given by the transverse carpal
ligament.
Flexor Zone V
The flexor zone V is at the level of the muscle-tendon junction which extends from the proximal border of the transverse
carpal ligament to the musculotendinous junctions. This zone has a poor site of repair because tendons become thinner when it
fans out into the muscle belly.
II. Median Nerve Transection
Low-Level Median Nerve Injury
The transection of the median nerve at the level of the wrist would result to a low-level median nerve lesion. The low-level
median nerve transection leads to the denervation of the opponens pollicis, flexor pollicis brevis, abductor pollicis brevis, and
lumbricals to the index and fingers. The muscles of the thenar eminence are paralyzed and atrophy causing the area to “flatten”
and look “apelike”. Without the presence of thumb abduction and opposition, the thumb rests in adduction which could lead to
contraction. The loss of opposition and sensation in the lateral fingers cause the most serious disability due to the loss of the
delicate pincer-like actions of the hand. Sensory, vasomotor, and trophic changes also occur. These are the same as those
experienced with a high-level median nerve injury, discussed in the succeeding section.
High-Level Median Nerve Injury
A median nerve transection or laceration near, at, or above the elbow results to a high-level median nerve lesion. Together with
the motor loss related to a low-level median nerve lesion, there would also be a denervation of the flexor digitorum profundus
to the index and long fingers, flexor digitorum superficialis to all digits, flexor pollicis longus, flexor carpi radialis, palmaris
longus, pronator teres, and pronator quadratus. This results in the forearm being kept in supine paired with weak wrist flexion
accompanied by adduction. No flexion is possible at the interphalangeal joints of the second and third digits, while weak
flexion is produced at the metacarpophalangeal joints by the interossei. When instructed to make a fist, the index and middle
finger tend to remain straight while a weakened flexion occurs at the ring and little finger due to the loss of the flexor
digitorum superficialis. Flexion of the terminal phalanx of the thumb is also absent due to the paralysis of the flexor pollicis
longus. Sensory loss occurs on the lateral half or less of the palm and the palmar aspect and distal dorsal surface of the lateral
3½ fingers. Loss of sympathetic control also occurs, which causes arteriolar dilatation and absence of sweating resulting in
warm and drier than normal hands. In the long-term, skin may become dry and scaly; nails may crack easily; and the pulp of
the fingers may atrophy.

Figure 2. Cutaneous Sensory Innervation Areas of the Figure 3. Ape/Simian Hand Deformity with thenar
Hand wasting

Case Presentation – M.C. | pg. 3

 Nerve
Muscle Origin Insertion Action
Supply
Pulls thumb medially
Shaft of metacarpal Median
Opponens Pollicis Flexor retinaculum and forward across
bone of thumb nerve
palm
Scaphoid,
Base of proximal Median
Abductor Pollicis Brevis trapezium, Abduction of thumb
phalanx of thumb nerve
flexor retinaculum
Flexes
Flexor Pollicis Brevis Base of proximal Median
Flexor retinaculum metacarpophalangeal
(superficial head) phalanx of thumb nerve
joint of thumb
Anterior
Anterior surface of interosseous
Distal phalanx of Flexes distal phalanx of
Flexor Pollicis Longus shaft branch of
thumb thumb
of radius median
nerve
Median
nerve
Flex
(lateral
metacarpophalangeal
Tendons of flexor Extensor expansion two);
joints and extend
Lumbricals digitorum of medial four Deep
interphalangeal joints
profundus fingers branch of
of fingers except
ulnar nerve
thumb
(medial
two)
Humeroulnar Medial epicondyle
Flexes middle phalanx
Flexor head of the humerus
Middle phalanx of Median of fingers and assists in
Digitorum
Oblique line on medial four fingers nerve flexing proximal
Superficialis
Radial head anterior surface of phalanx and hand
shaft of radius
Ulnar nerve
Flexes distal phalanx of
(medial
Anteromedial fingers and assists in
Distal phalanx of half);
Flexor Digitorum Profundus surface of shaft of flexing the proximal
medial four fingers Median
ulna and middle phalanges
nerve
and hand
(lateral half)
Medial epicondyle
Humeral
of
head Lateral aspect of
Pronator humerus Median Pronation and flexion of
shaft
Teres Medial border of nerve forearm
of radius
Ulnar head coronoid process of
ulna
Anterior
Anterior surface of Anterior surface of interosseous
Pronator Quadratus shaft shaft branch of Pronates forearm
of ulna of radius median
nerve
Medial epicondyle Bases of second and
Median Flexes and abducts
Flexor Carpi Radialis of third metacarpal
nerve hand at wrist joint
humerus bones
Table 2. OINA of Muscles Affected by a Median Nerve Injury

III. Ulnar Nerve Transection

Low-Level Ulnar Nerve Injury
A transection or laceration of the ulnar nerve at the level of the wrist results to a low-level ulnar nerve lesion and would result,
primarily, to the paralysis and wasting of the intrinsic muscles of the hand, except for those in the thenar eminence and the first
two lumbricals. The ring and little fingers assume a “claw hand” deformity which is discussed in depth in the next section. The
deformity is more marked in low-level ulnar nerve injuries since the flexor digitorum profundus muscle is not paralyzed,
resulting in a greater amount of flexion of the terminal phalanges as compared to a high-level ulnar nerve injury. Vasomotor
and trophic changes also occur. These are the same as those experienced with a high-level ulnar nerve injury, discussed in the
succeeding section. For sensation, the posterior cutaneous branch of the ulnar nerve is usually unaffected. This means that the
loss of sensation is confined to the palmar surface of the medial third of the hand and the medial one and a half fingers and to
the dorsal aspects of the middle and distal phalanges.
Case Presentation – M.C. | pg. 4
High-Level Ulnar Nerve Injury

Case Presentation – M.C. | pg. 5

A high-level ulnar nerve lesion is acquired when there has been a transection or laceration at or proximal to the elbow. Aside
from the muscles paralyzed in a low-level ulnar nerve lesion., the flexor carpi ulnaris and medial half of the flexor digitorum
profundus are also paralyzed. As a result, wrist flexion tends to cause abduction due to the absent action of the flexor carpi
ulnaris. The patient will also be unable to adduct and abduct the fingers. The loss of the adductor pollicis muscle also makes
adducting the thumb impossible. The metacarpophalangeal joints also become hyperextended due to the paralysis of the
lumbricals and interosseous muscles. Although, hyperextension is lesser in the second and third digits since the lumbricals that
service these digits are supplied by the median nerve. The interphalangeal joints, on the other hand, become flexed also due to
the loss of the action by the lumbricals and interossei. In the long term, there imbalances cause a “claw hand” deformity. The
clawing, however, is less apparent in high-level lesions since there is also the paralysis of the flexor digitorum profundus
muscles which would cause a more marked flexion of the interphalangeal joints, such as in a low-level ulnar nerve injury.
Figure 4. Claw Hand Deformity

Upon examination, a hollowing between the metacarpal bones is seen, which is due to atrophy of the dorsal interossei. Loss of
sympathetic control also occurs, which causes arteriolar dilatation and absence of sweating resulting in warm and drier than
normal hands.
Muscle Origin Insertion Nerve Supply Action
Abductor Digiti Minimi Pisiform bone Base of proximal Abducts little finger
phalanx of little
Flexor Digiti Minimi Flexes little finger
finger Deep branch of
Flexor retinaculum ulnar nerve Pulls 5th metacarpal
Medial border fifth
Opponens Digiti Minimi forward as in cupping
metacarpal bone
the palm
Flex
Median nerve
metacarpophalangeal
Tendons of flexor Extensor expansion (lateral two);
joints and extend
Lumbricals digitorum of medial four Deep branch of
interphalangeal joints
profundus fingers ulnar nerve
of fingers except
(medial two)
thumb
Dorsal interossei
Proximal phalanges abduct
of index, fingers from center
Contiguous sides
middle, and of third finger; both
Dorsal of shafts of
ring fingers and palmar and dorsal flex
metacarpal bones
dorsal extensor metacarpophalangeal
expansion joints and extend
Deep branch of
Interossei interphalangeal joints
ulnar nerve
First arises from base Proximal phalanges
of 1st metacarpal; of thumb and
Palmar interossei
remaining three index, ring, and
adduct
Palmar from anterior little fingers and
fingers toward center
surface of shafts dorsal extensor
of third finger
of 2nd, 4th, and 5th expansion of each
metacarpals finger
Flexes
Flexor Pollicis Brevis Base of proximal
Flexor retinaculum Median nerve metacarpophalangeal
(deep head) phalanx of thumb
joint of thumb
Oblique head; 2nd
and 3rd metacarpal
Base of proximal Deep branch of
Adductor Pollicis bones; transverse Adduction of thumb
phalanx of thumb ulnar nerve
head; 3rd
metacarpal bone
Flexes distal phalanx
of fingers and assists
Flexor Digitorum Anteromedial surface Distal phalanx of Ulnar nerve
in flexing the
Profundus of shaft of ulna medial four fingers (medial half);
proximal and middle
phalanges and hand
Humeral Medial epicondyle of
head Humerus
Flexor Pisiform bone, hook of
Medial aspect of Flexes and adducts
Carpi the hamate, base at Ulnar nerve
Ulnar olecranon process hand at wrist joint
Ulnaris fifth metacarpal bone
Head and posterior border
of ulna
Table 3. OINA of Muscles Affected in an Ulnar Nerve Injury

Case Presentation – M.C. | pg. 6

E. Diagnostic Criteria
I. Flexor Tendon Rupture
In order to diagnose a flexor tendon injury, complete history is first taken. The doctor also does a physical examination of the hand
which includes the assessment of range of motion. Inability to actively flex the fingers is indicative of a tendon rupture. Imaging
techniques such as x-ray, CT scans and MRI may also be used to check for bone involvement or in closed injuries. The objectives
of these diagnostic tests are to check for tendon injuries, find the location of the injury, and know the severity of the damage.

II. Peripheral Nerve Injury

Seddon classifies nerve injuries based on severity and on how
intact the axon is. Seddon’s classifications are called neurapraxia,
axonotmesis, and neurotmesis. In neurapraxia, there is contusion
of the nerve without Wallerian degeneration meaning that the
axon remains fully intact. Nerve function after this insult with
recover in days to weeks spontaneously. Axonotmesis is when
Wallerian degeneration occurs but the endo-, epi-, and
perineurium, along with the Schwann cells remain intact.
Recovery for this classification usually lasts 6 months. Lastly, the
most severe injury, such as in this case, is classified as
neurotmesis. Neurotmesis refers to the complete laceration or
transection of the nerve and fibrous tissues. Microsurgical
intervention is typically needed and nerve grafts may sometimes
Figure 5. Seddon's Classification of Nerve Injuries
be needed to address the gap between nerve endings.
Aside from a physical examination, a neurological assessment is
also part of the process of diagnosing peripheral nerve injuries. Electromyography, Nerve conduction studies, as well as imaging
(e.g. x-ray, CT scan, MRI) may be used. Electromyography records muscle electrical activity at rest and in active contraction.
Reduced muscle activity can indicate nerve injury. Nerve conduction studies measure how well electrical signals pass through the
nerves. Abnormal or absent conduction is indicative of nerve damage. The diagnostic tests previously discussed are useful in
distinguishing upper or lower motor neuron diseases, as well s primary muscle disorders. Imaging techniques are used to view nerve
lesions and damage to other anatomical structures. Aside from these general diagnostics tests and criteria, certain tests that can be
done specific for the median and ulnar nerve
Median Nerve Transection
Manual Muscle Testing
Manual Muscle Testing is performed in the muscles innervated by the motor branch of the median nerve. Paralysis of
the innervated muscles are indicative of a median nerve transection.
Sensory Evaluation
Sensory evaluation is performed on the different areas of the hand. Absent sensation on the cutaneous innervation of
median nerve is indicative of median nerve transection.
Tinel Sign
The examiner taps points on the index finger to the forearm in a distal to proximal manner. A positive response is
tingling or paresthesia. The most distal point at which the tingling or paresthesia is felt is indicative of the extent of the
nerve regeneration.
Ninhydrin Sweat Test
The patient’s hand is thoroughly cleaned and wiped with alcohol. The patient waits for 5 to 30 minutes without putting
the finger tips into contact with any surface, allowing the sweating process to occur. The fingertips are then pressed on
an untouched good quality bond paper for 15 seconds then traced with a pencil. The paper is then sprayed with
triketohydrindene (Ninhydrin) reagent and allowed to dry for 24 hours. Sweat areas then turn purple. A positive
response is the lack of color change from white to purple. This is indicative of a nerve lesion.
Wrinkle Test
The patient’s fingers are placed in warm water for 5-20 minutes. After which, the finger is removed from the water and
the skin on the pulp is observed for the presence of wrinkling. A positive response is the absence of wrinkling which is
indicative of denervation.
Ulnar Nerve Transection
Manual Muscle Testing
Manual Muscle Testing is performed in the muscles innervated by the ulnar nerve. Paralysis of the innervated muscles
are indicative of an ulnar nerve transection.
Sensory Evaluation
Sensory evaluation is performed on the different areas of the hand. Absent sensation on the cutaneous innervation of
ulnar nerve is indicative of ulnar nerve transection.
Froment’s & Jeanne’s Sign
The patient is asked to grasp a piece of paper between the thumb and index finger. The examiner then attempts to pull
away the paper. A positive response to the Froment’s Sign test is the flexion of the terminal phalanx of the thumb, due
to the loss of the adductor pollicis muscle. A positive Jeanne’s sign test is if the metacarpophalangeal joint of the thumb
also hyperextends. Positive responses to both tests are indicative of ulnar nerve paralysis.
Case Presentation – M.C. | pg. 7
 Wartenberg Sign
The patient sits with hands rested on a table with the fingers spread apart passively by the examiner. The patient is then
asked to bring all the fingers together again. Inability to squeeze the little finger to the other fingers is a positive
response, indicative of ulnar nerve injury.
Ninhydrin Sweat Test
The patient’s hand is thoroughly cleaned and wiped with alcohol. The patient waits for 5 to 30 minutes without putting
the finger tips into contact with any surface, allowing the sweating process to occur. The fingertips are then pressed on
an untouched good quality bond paper for 15 seconds then traced with a pencil. The paper is then sprayed with
triketohydrindene (Ninhydrin) reagent and allowed to dry for 24 hours. Sweat areas then turn purple. A positive
response is the lack of color change from white to purple. This is indicative of a nerve lesion.
Wrinkle Test
The patient’s fingers are placed in warm water for 5-20 minutes. After which, the finger is removed from the water and
the skin on the pulp is observed for the presence of wrinkling. A positive response is the absence of wrinkling which is
indicative of denervation.
F. Signs and Symptoms
Classical Picture Clinical Picture
Flexor Tendon Rupture
Pain on flexion Client did not experience pain during flexion.
Limitation of motion Limited PROM and AROM.
Edema Visual observation shows no edema but further assessment in
required.
Loss of active flexion Weak active flexion
Extrinsic flexor tightness (+) Extrinsic flexor tightness as evidenced by the hand’s resting
position with the MCP in slight extension and the IPs in slight
flexion.
High-Level Median Nerve Transection
Simian Hand Deformity Not present.
Loss of thumb abduction Weak thumb adduction
Loss of opposition Limited opposition
Weak wrist flexion Requires further assessment
Benediction Sign / Deformity (+) Benediction Sign as evidenced by slight lag of the index and
long fingers when making a fist
Absent thumb flexion Absent thumb flexion as evidenced by trick motions using thumb
adduction during theraputty exercises.
Weak metacarpophalangeal flexion Weak metacarpophalangeal flexion
Absent flexion at interphalangeal joint Weak flexion at interphalangeal joints
Wrist kept in supine; gravity-assisted pronation Client capable of active pronation.
Sensory loss on the lateral half or less of the palm and the palmar Sensory loss on the lateral half or less of the palm and the palmar
aspect and distal dorsal surface of the lateral 3½ fingers. aspect and distal dorsal surface of the lateral 3½ fingers.
Vasomotor changes Normal hand warmth, however, presence of normal sweating
requires further assessment.
High-Level Ulnar Nerve Transection
Claw Hand Deformity Slight claw hand deformity as evidenced by hyperextended
metacarpophalangeal joints and flexed interphalangeal joints
during typing activity.
Wrist flexion causes wrist abduction Wrist flexion occurs without wrist abduction due to the paralysis
of the flexor carpi radialis secondary to median nerve damage
Loss of thumb adduction Weak thumb adduction
Flexed interphalangeal joints Slight interphalangeal joint flexion
Loss of little finger abduction Requires further assessment.
Hollowing between the metacarpal bones No hollowing noted.
Sensory loss to the palmar surface of the medial third of the hand Sensory loss to the palmar surface of the medial third of the hand
and the medial one and a half fingers and to the dorsal aspects of and the medial one and a half fingers and to the dorsal aspects of
the middle and distal phalanges the middle and distal phalanges
Vasomotor changes Normal hand warmth, however, presence of normal sweating
requires further assessment.
Table 4. Classical vs. Clinical Picture

Case Presentation – M.C. | pg. 8

G. General Medical/Surgical/Rehabilitation Interventions
I. Flexor Tendon Rupture
A non-operative treatment is indicated for one who has acquired less than 50% tendon laceration. Management includes wound care
and early range of motion (ROM) exercises, with outcomes possibly associated with gap formations and triggering. An operative
treatment is indicated for one who has acquired more than 50% tendon laceration. Repairs must be performed within the first two
weeks after injury because tendon ends and sheaths have the tendency to become scarred and retracted proximally. Maximum
strength of tendons is regained 6 months post-surgery, but never achieves 100% strength. Early mobilization allows for increased
ROM, but decreased tendon strength repair, while immobilization allows for increased tendon strength at the expense of ROM.
In general, the key to a successful flexor tendon repair is close adherence to a regimented hand therapy rehabilitation program.
Various protocols exist to manage the repair: Active Assisted ROM, Passive ROM, and immobilization.
Early active motion protocol is indicated for intelligent, compliant patients with a 4-strand repair who can comply with regular hand
therapy. These patients usually have zones 1 and/or 2 flexor tendon injuries. The outcome results to better overall motion because
greater tendon gliding prevents adhesion formation. The protocol starts with using a dorsal blocking splint positioning the wrist at
10° flexion, MCPs at 70° flexion and IPs in neutral at 24-48 hours post-operation (post-op). 2 days to 4 weeks post-op, the patient
wears a hinged tenodesis splint positioning the wrist 30° extension, for place and hold exercises, but returns to dorsal blocking
splint after exercises. 6 weeks post-op, the dorsal blocking splint is discontinued, and finger flexion exercises are given. 8 weeks
post-op, light strengthening exercises, using soft foam balls or putty for example, are given. 10-14 weeks post-op, progressive
resistive strengthening exercises are given, with work stimulation and reconditioning as additional. Return to full unrestricted
activity is usually achieved at 14 weeks.
Passive motion protocol, on the other hand, are indicated for those less compliant, with a 2-strand repair. These patients usually
have zones 3, 4 and/or 5 flexor tendon injuries. Two techniques exist in this protocol, i.e. Kleinert technique and Duran technique.
In the Kleinert technique, digits are required to be maintained in flexion through the use of an elastic band attached to the level of
the wrist. This is for the purpose of preventing movement of the digits against flexion resistance. In the Duran technique, on the
other hand, passive flexion is achieved by manipulation from the therapist or with the use of the uninjured hand. 0-3 weeks post-op,
a dorsal blocking splint, positioning the hand similar to that of the early motion protocol, is worn, with PROM exercises practiced.
Edema management is also indicated during this timeframe. 3-6 weeks post-op, the wrist is neutrally positioned in splint, passive
flexion and active extension exercises, and place and hold exercises are practiced, and soft tissue mobilization is done on scarred
areas. 6-9 weeks post-op, the patient weans from wearing a splint, and active blocking exercises for DIP and PIP flexion is
practiced. Light functional activities, usually ADL activities, are provided. 9-12 weeks post-op, light resistive exercises are begun,
and full resistive exercises with work conditioning is given 12-16 weeks post-op.
II. Median and Ulnar Nerve Transection
A non-operative treatment of median and/or ulnar nerve complete or partial lacerations is appropriate when the patient’s associated
injuries or medical comorbidities prevent anesthesia and a lengthy microsurgical repair. Isolated median and/or ulnar nerve
complete and partial lacerations should be repaired early, but repair is not an emergency. Irrigation, debridement, and closure of the
skin laceration with a scheduled operative nerve repair 1-3 few weeks is reasonable. An operative treatment, on the other hand, is
indicated for acute patients with complete nerve lacerations that are usually caused by sharp lacerations from broken glass, knives,
saws, or vehicular accidents.
The use of exercises post-immobilization period aims to recover the motion and muscle function lost during the phase of
immobilization. Passive and active-assisted ROM exercises are introduced depending on the patient's progress as well as on specific
precautions relevant to the individual cases. In recovery phase, before an evidence of muscle reinnervation, passive exercises are
important to maintain joint ROM and muscle-tendon length. The motor retraining begins at the earliest evidence of muscle
reinnervation and progressive resistive exercise is also used to increase strength and endurance in muscle. Key exercises for median
nerve injury involve the thenar intrinsic muscles and finger abduction and adduction exercises are key with ulnar nerve injury and
also the intrinsic plus exercise. The use of splints in peripheral-nerve injury to the hand, follow some principles like: to keep the
denervated muscles from remaining in an overstretched position; to prevent a joint stiffness; the development of strong movement
substitution patterns and to maximize functional use of the hand. Sensory re-education is a process of reprogramming the brain
through a new learning process with progressive challenges, exploring the aid of vision trough exercises with opened and closed
eyes. The proposed alternative sensory stimuli feed the somatosensory cortex and is essential to preserve the cortical map of the
hand and to facilitate sensory recovery.
The impact of the condition on the client’s occupational performance usually affects participation in all occupations given that his
hand is affected. Without proper intervention, one might not be able to do activities that require pinching or gripping patterns of
movement. Functional loss on thumb opposition, flexion, and adduction, finger flexion, abduction and adduction, inability to extend
the IP joints of the 4th and 5th fingers, and weak or no pinch or grip can result from the laceration of the flexor tendons and median
and ulnar nerves. Sensory loss may also complicate one to acquire ulcers if not checked upon. Occupational therapy aims to prevent
adhesion and contractures, and increase tendon excursion, strength at repair sites, and joint ROM on the involved fingers in an
attempt to help one resume back to meaningful roles.
H. Prognosis and Functional Outcomes
Early treatment of an acute traumatic case typically has a better prognosis than after the injury has become chronic. Since tendons are
vulnerable because they are relatively avascular, cell damage may become chronic. Zone V, if associated with neurovascular injury often
carries a worse prognosis. Zone V is typically a poor site of repair because tendons in this area become thinner and fan out into its muscle
belly. Poor prognosis is typically present if the endoneurium is breached and surgery may be required, i.e. a neurotmesis typ e of nerve
injury. Nerve conduction returns to normal only with regeneration.

Case Presentation – M.C. | pg. 9

 According to one study, functional results were excellent in 92.8% of the digits, good in 1.4%, and poor in 5.8%. Grip strength recovered to
an average of 77% and pinch strength to 74% of the uninjured hand. Of 15 patients who were employed at the time of injury, 13 returned to
their original occupations. Satisfactory functional results can be obtained when proper surgical technique is coupled with careful
postoperative management in patients with zone V flexor tendon injuries. Early motion of the fingers seems to improve outcome in these
patients. Recovery in thenar muscle function was good after median nerve repair. Concomitant nerve cut, in particular, of the ulnar nerve
were associated with a high rate of poor results. Patients with ulnar nerve lesions showed some degrees of clawing of the 4th and 5th
fingers.
According to the American Academy of Orthopaedic Surgeons (AAOS), advances in medical science and flexor tendon surgery results in
good return of function and high patient satisfaction. However, despite extensive therapy, some patients still report long-term stiffness.
Adding to that, since the injury is in Zone V, direct tendon repair results in less complications, but Orthobullets states that this often carries
a worse prognosis due to the associated neurovascular injury, as is the case of the client.
I. Risk Factors
I. Flexor Tendon Rupture
There are several factors that can increase the risk for flexor tendon injuries:
 Cuts to the arm, hand or fingers.
 Participation in high-risk contact sports, such as football, wrestling, rugby and rock climbing.
 Chronic inflammatory disorders, such as rheumatoid arthritis where muscles are weakened and more likely to tear.
The frequency of reoperation to flexor tendon repairs are usually associated with patients at an older age with workers’
compensation as compared to those with other forms of insurance. Patients who had concomitant nerve repair during the index
procedure were 26% less likely to undergo reoperation.
II. Median and Ulnar Nerve Transection
There are several factors that can increase the risk for median and ulnar nerve injuries:
 Anatomic factors: A wrist fracture or dislocation, or arthritis that deforms the small bones in the wrist, can alter the space
within the carpal tunnel or Guyon’s canal and put pressure on the median or ulnar nerve and cut them
 Nerve-damaging conditions: Some chronic illnesses, such as diabetes, increase your risk of nerve damage, including damage
to your median and ulnar nerve, eventually getting weak enough to get cut
 Sharp lacerations from broken glass, knives, saws, or vehicular accidents are also risk factors

OT EVALUATION
A. Subjective Information
I. Chief Complaint
According to client, “Hirap mag-type at magsulat para sa school.”
II. Rehabilitation Goals
According to client, “Gamitin ang dalawang kamay para sa school at para makapag-basketball.”
III. History of Present Illness
~2 mos. PTIE, on December 8, 2018, client was @ his aunt’s birthday party where he drank alcohol & became intoxicated. Pt. fell
over, broke some glass, & cut himself on the Ⓡ FA. Pt. was rushed by his mother & aunt to JRRMMC. He was given unrecalled
medications via IV & had an x-ray. Pt. received the dx. of FDP, FDS rupture & underwent a ~10 hr. tendon repair surgery. Post-op,
pt. was confined, given antibiotics & painkillers, & received PT services. P̅ discharge, pt. became unable to do or was D with
occupations using UE.
~1 mo. PTIE, pt. was referred to OT & PT. PT program: e-stim, US, and grip ax. OT program: ther ex, ADL/IADL training, SI. Pt.
receiving tx 3x/wk. Pt. now I in occupations thru use of ⓁUE.
IV. Past Medical History
No prior hospitalizations, medications, and/or relevant medical history.
B. Objective Information
I. Standardized Tests
Goniometry
Goniometry is performed to measure the available range of motion (ROM) in a joint. A goniometer is used to measures the
available in the joint. Standard measurement positioning and procedures are discussed by Levange (2011). The results gathered
from this standardized test is then compared to an established set of norms. It is worth noting, however, that the norms
established by the American Association of Orthopedic Surgeons (AAOS) and used in this test have not yet been culturally
adapted for the Philippines.
Manual Muscle Testing
Manual Muscle Testing is a standardized assessment used to measure muscle strength. Hislop (2007) discussed the
standardized positioning and procedures for testing specific muscles or muscle groups. Manual Muscle Testing is a criterion-
referenced assessment that yields a numerical grade with equivalent word ratings e.g. 1 = Trace.
Edema
Testing for edema requires the use of either tape measure or volumeter. With the use of a tape measure for edema testing,
circumferential measurement or figure of eight measurement can be done. Circumferential measurement places the tape
measure around the extremity and measures the edema. It is significant that the limb should not be resting on the table as this
may alter the shape of the limb. In figure of eight measurement, the patient's hand is positioned in pronation with the hand over
the edge of the table. The wrist should be in neutral and the fingers abducted. The zero on the tape measure is placed on the
Case Presentation – M.C. | pg. 10
 ulnar aspect of the wrist. The tape measure is then passed across the volar aspect of the forearm just distal to the radial styloid
process. It is then taken diagonally across the dorsum of the hand to the 5th MCP joint. It should be then passed across the
volar aspect of the palm to the 2nd MCP joint. After which, it goes diagonally back to the starting point. With the use of a
volumeter, patient is asked to insert hand on the volumeter filled with water. There is a mark on the bottom part to which 2nd
webspace of the hand is placed. The therapist takes note of the amount of water displaced.
Hand Dexterity
Jebsen Test of Hand Function
This standardized assessment tool is a norm-based performance test which assesses gross and fine motor functions of
an individual. It determines the speed and quality of performance as well as a patient’s potential ability to use one’s
non-dominant side. The assessment tool consists of 7 subtests which include writing a short sentence, simulated page-
turning, lifting small common objects, simulated feeding, stacking checkers, lifting large light objects, and lifting large
heavy objects. The tool requires performing the subtests utilizing both hands in which the patient’s non-dominant hand
is tested first. One of the protocols of the tool is ensuring that the individual would not cross the midline when
performing the subtests. Time in completing each subtest will be recorded. To record the standard score for each
subtest, subtract mean time from actual time and divide by standard deviation. The accepted standard deviation is -2 to
+2.
Moberg Pick-Up Test
This standardized assessment tool is norm-referenced. The tool involves picking up, holding, manipulating and
identifying small objects. To administer the tool, the patient is shown 10 objects on a table and is asked to place these
objects in a box. Uninjured hand is tested first, then injured hand. It is done with vision included first, after which with
vision occluded. This is done for three times. Each trial is timed and average will be calculated. The test will be
discontinued if it takes longer than 3 minutes. The test also involves patient’s ability to perceive constant touch,
precision grip, cutaneous feedback and peripheral receptors and cognitive function.
Grip and Pinch Strength
Testing for grip and pinch strength requires the use of a dynamometer and pinch gauge. The patient is asked to hold the
dynamometer in his hand to be tested, with the arm and elbow at 90-degree angle. The patient squeezes the dynamometer with
maximum isometric effort, which is maintained for about 5 seconds. No other body movement is allowed. The subject should
be strongly encouraged to give a maximum effort. This is done three times. The mean score for each hand is then computed.
The results are then compared to established norms. It is worth noting, however, that the norms used in this test have not yet
been culturally adapted for the Philippines.
II. Summary of Standardized Test Results
Goniometry
All joints of BUE and/or BLE are WNL/WFL upon PROM/AROM except for the following:
Norms Difference
Joint PROM AROM Cause of LOM
(AAOS) (N-PROM)
Ⓡ Thumb IP 0 - 70 ˚ 0 - 45 ˚ 0 - 80 ˚ 10 ˚ Flexor tendon adhesion Commented [an1]: Add CMC flexion
MCP 0 - 60 ˚ 0 - 45 ˚ 0 - 90 ˚ 30 ˚ Flexor tendon adhesion
Ⓡ2nd Digit PIP 0 - 50 ˚ 0 - 50 ˚ 0 - 100 ˚ 50 ˚ Flexor tendon adhesion
DIP 0-5˚ 0˚ 0 - 90 ˚ 85 ˚ Flexor tendon adhesion
MCP 0 - 45 ˚ 0 - 40 ˚ 0 - 90 ˚ 45 ˚ Flexor tendon adhesion
FLEXION

Ⓡ3rd Digit PIP 0 - 60 ˚ 0 - 20 ˚ 0 - 100 ˚ 40 ˚ Flexor tendon adhesion

DIP 0-5˚ 0-0˚ 0 - 90 ˚ 85 ˚ Flexor tendon adhesion
MCP 0 - 45 ˚ 0 - 35 ˚ 0 - 90 ˚ 45 ˚ Flexor tendon adhesion
Ⓡ4th Digit PIP 0 - 60 ˚ 0 - 60 ˚ 0 - 100 ˚ 40 ˚ Flexor tendon adhesion
DIP 0 - 45 ˚ 0 - 20 ˚ 0 - 90 ˚ 45 ˚ Flexor tendon adhesion
MCP 0 - 60 ˚ 0 - 45 ˚ 0 - 90 ˚ 30 ˚ Flexor tendon adhesion
Ⓡ5th Digit PIP 0 - 60 ˚ 0 - 55 ˚ 0 - 100 ˚ 40 ˚ Flexor tendon adhesion
DIP 0-5˚ 0˚ 0 - 90 ˚ 85 ˚ Flexor tendon adhesion
Table 5. Results of Goniometry

Manual Muscle Testing

All major muscle groups on both Ⓛ and Ⓡ side are considered WNL except:
Muscle Group Muscle Grade
Finger Flexors 3+ Fair Plus
Wrist Ulnar & Radial Deviators 2+ Poor Plus
Thumb Flexors 2+ Poor Plus
Thumb Adductors 2- Poor Minus Commented [BAD2]: Clarify if palmar, radial or
Thumb Opposition 2+ Poor Plus both
Table 6. Results of Manual Muscle Testing

Edema
Visual observation showed no edema and thus volumetry was not performed. However, further assessment may be needed.
Hand Dexterity

Case Presentation – M.C. | pg. 11

 Objective measures were not used due to time constraints and thus requires further assessment.
Grip and Pinch Strength
Standardized grip and pinch strength were not assessed using the dynamometer and pinch gauge due to time constraints.
Functional evaluation was used in its place and thus needs further assessment.
III. Other Areas for Testing
Range of Motion
Joint Grade
Flexion & Extension WFL
ⓇWrist
Radial & Ulnar Deviation WFL
Radial Adduction & Abduction WFL
Ⓡ Thumb Palmar Adduction & Abduction WFL
Opposition Limited
Table 7. Results of Function ROM Assessment

Muscle Tone
All major muscle groups on both Ⓛ and Ⓡ side are considered normotonic.
Muscle Bulk
No noticeable muscle bulk asymmetry.
Functional Sensory Evaluation
Superficial Sensations
Grade Sensation Stimulus
A cotton swab is used to
lightly touch (light touch) or
press hard enough to cause
skin blanching (pressure).
Pt. is asked to say whether
he felt the stimuli. If yes, he
was asked to point to the
location using the other
hand. 3 positive stimuli and
a non-representational
Light Touch stimulus were introduced
& Pressure per sub-area in a random
manner while visually
occluded.
Client has intact (+) light touch
and pressure sensation on the
areas innervated by the radial
nerve while all the other areas
have absent light touch and
pressure sensation.
A paper clip with the
straightened edge (sharp
pain) & the curved end (dull
pain) was used to lightly
poke the client. Pt. is asked
to say whether he felt the
stimuli and to describe it
was “sharp” or “dull”. 3
positive stimuli and a non-
representational stimulus
Superficial were introduced per sub-
Pain area in a random manner
while visually occluded.
Client has (+) protective sensation
(+S, +D) on the areas innervated
by the radial nerve while (-
)protective sensation (-S, -D) on
all the other areas of right hand
innervated by the median and
ulnar nerve.
Case Presentation – M.C. | pg. 12
Response
The client was able to feel
the stimuli and point within
the allowed margin of error
on the areas innervated by
the radial nerve. (10 mm for
digit tips, 11 mm for
proximal phalanx, and 20
mm for palm)
However, the client was not
able to recognize and
localize the stimuli or
identified the non-
representational stimulus as
a positive stimulus for all
other areas of the right
hand.
Client has correct response
to sharp (+S) and dull (+D)
stimulus given by the
therapist on the areas
innervated by the radial
nerve while client reports to
either have an incorrect
response or no response at
all to a dull and sharp
stimulus given by the
therapist on all the other
areas of right hand
innervated by the median
and ulnar nerve.
 Subtest 1 Client was able to correctly
2 identical test tubes with identify the temperature of
hot water & cold water were both hot and cold water
touched against the client’s when placed on the areas
skin. Pt. is asked to say innervated by the radial
whether “hot or cold”. 3 nerve. However, client was
positive stimuli and a non- unable to correctly identify
representational stimulus if the water is cold or hot on
were introduced per sub- all other areas of right hand
area in a random manner innervated by the median
while visually occluded. and ulnar nerve.
Thermal
Subtest 2
Needs further assessment
Client has intact (+) thermal for radial nerve innervation.
sensation on the areas innervated
by the radial nerve while all the
other areas of right hand
innervated by median and ulnar
nerve have absent thermal
sensation.

Table 8. Results of Superficial Sensation Tests

Deep Sensations
Grade Sensation Stimulus Response
Client was asked to identify whether Client was able to identify position
the joints were in a position which is correctly in 3/3 instances.
“nakasara” or “nakabukas”. The
wrist and MCP joints were used. 3
+ Proprioception
positive stimuli and a non-
representational stimulus were
introduced per joint in a random
manner while visually occluded.
Client was asked to identify whether Client was able to identify motion
the joints were in a motion which is correctly in 3/3 instances.
“pasara” or “pabukas”. The wrist
and MCP joints were used. 3
+ Kinesthesia
positive stimuli and a non-
representational stimulus were
introduced per joint in a random
manner while visually occluded.
A tuning fork was used. Client was Client was not able to identify vibrating
- Vibration asked to identify whether the stimuli stimuli in 3/3 instances.
in the bony prominences were
Case Presentation – M.C. | pg. 13
 “vibrating” or not. The PIP bony
prominence, MCP bony prominence,
and radial styloid process were used.
3 positive stimuli and a non-
representational stimulus were
introduced per joint in a random
manner while visually occluded.
Table 9. Results of Deep Sensation Tests

Combined Sensations
Grade Sensation Stimulus Response
3 common objects (key, Client was unable to Commented [BAD3]: Client was unable to
paper clip, coin) were recognize any objects manipulate object. Client did not manipulate despite
presented to the client. because client was not cue and promts
He was then asked to able to manipulate.
identify the object he is Inability to manipulate
currently holding. because of difficulty in
Initially, objects were flexing fingers.
0 Stereognosis given to the patient and
he was allowed to
manipulate and feel the
objects with no
occlusion. After which
test was done while
client was visually
occluded.
Static Client was able to
A reshaped paper clip identify whether the
was used. Client was stimuli were presented
asked to identify whether was “one” or “two”
the stimuli presented was having a distance of 6
“one” or “two”. 10 mm in the areas
positive stimuli and a innervated by the radial
non-representational nerve. For all the
stimulus were introduced remaining areas, client
per area in a random was not able to
2-Point
manner. Initially, a few distinguish any points.
Discrimination
trials were given to the
patient with no
occlusion. After which,
Areas innervated by radial nerve are test was done while
normal while all other areas are client was visually
anesthetic on right hand. occluded.

Dynamic
Was not assessed due to
time constraints.
Table 10. Results of Combined Sensation Tests

Handedness
The client reports and was observed to be right-handed.
RGCR Patterns
Pattern Left Right Functional Justification
Reach G G Able to reach for items placed on table. Commented [BAD4]: Refer to emilia’s paper
Grasp G G Able to assume grasp on objects presented.
Carry G P Difficulty maintaining grasp to carry object from table to bag.
Release G P Difficulty releasing grasp on objects back to the bag.
Table 11. Results of RGCR Assessment

In-Hand Manipulation Skills

Pattern Left Right Functional Justification
Translation G P Cannot move key from palm to fingers
Shifting G P Cannot drop coins one-by-one into a cup
Simple Rotation G P Unable to rotate a jar lid using fingers. Uses compensatory wrist motions
Case Presentation – M.C. | pg. 14
 Complex Rotation G P (radial & ulnar deviation) top twist open the lid.
Table 12. Results of In-Hand Manipulation Assessment

Prehension Patterns
13

GPP L R Response
Cylindrical G F Client was able to use L hand to stabilize the jar while R hand was opening the
lid. With the R Hand, client was able to hold the jar but with slight difficulty.
2 nd and 3rd digits of the R hand were pressed more against the jar than the 4 th
and 5th digits.
Spherical G F Client was able to hold and take the stress ball out of the paper bag and return it
back inside. Client had slight difficulty maintaining grasp in R hand when
placing ball back inside bag.
Hook G G Client was able to assume, maintain and use hook grasp in both L and R hands
while lifting a paper bag with items inside, against gravity for approximately 5
seconds.
Disk G F Client was able to hold the jar by the lid when taking it out of the bag while
using the L hand. With the R hand, client was able to hold lid of jar with fingers
but with palm slightly touched lid.
FPP L R Response
Pad to Pad G A Upon instruction to hold card, client was able to hold it using L hand. Using R
hand, client held card using lateral pinch. Client compensated by pressing card
against 1st web space.
Tip to Tip G A Client cannot assume or maintain pinch when asked to get 3 beans out of a
container.
Lateral G A Client assumed to hold card via lateral pinch but compensated with thumb IP
flexion.
Tripod G A Client cannot assume or maintain tripod grasp to hold a pencil.
Table 13. Result of Prehension Patterns Assessment

Other Pertinent Findings

Hypertrophic Scar on the Ⓡ FA.
Skin condition requires further assessment.
IV. Description on Areas of Occupation
ADLs
Based on the interview, client is independent in feeding and bathing. He uses his non-dominant hand only and thus, has a
slower pace of performing activities.
Education
Based on the interview, the client is independent in formal education participation but has difficulties in typing and is unable to
write. Based on observation, the client uses his non-dominant hand or the index fingers only to type. This greatly slows down
his typing speed.
Work
Based on the interview, the client is independent in job performance as an OJT IT but has a slow speed and short endurance for
typing. This is due to his use of the non-dominant hand or index fingers only instead of the normal typing method.
Leisure
Based on the interview, the client is not able to play basketball anymore.
Social Participation
Based on observation, the client is independent and capable of social participation. He is able to hold conversations, joke
around with others, and even interact with the therapists and interns with no difficulty.
C. Strengths and Weaknesses
Strengths Weaknesses
• Intact Sensations (Superficial, Deep, •Weak grip strength
Combined) on radial nerve innervation o 2+ thumb MP and IP
• I in feeding and bathing flexors
• (+) Proprioception o 3+ finger MP flexors
• (+) Kinesthesia o 3+ finger PIP and DIP
• G reach & grasp flexors
• G cylindrical grasp • LOM in fingers
• Motivated • Impaired Sensations (Superficial, Deep,

Case Presentation – M.C. | pg. 15

 • Compliant & cooperative Combined) on median & ulnar nerve
• Early Mobilization innervation
 Early repair of Tendon Injury • (-) Vibration
 (-) Muscle Atrophy • P carry & release
• F spherical, hook, disc GPP
• A lateral, tripod, tip to tip FPP
• P pad to pad FPP

Table 14. Assessment of Strengths and Weaknesses

D. Prioritized Problem List

1. Client has LOM in finger flexion which results in difficulty performing ADL tasks, educational and work participation.
2. Client has weak grip strength which results in difficulty performing ADL tasks and educational participation.
3. Client has impaired sensation which results in difficulty performing ADL tasks, leisure, educational and work participation.
4. Client has impaired Ⓡhand function results in difficulty during ADL tasks, leisure, educational and work participation. Commented [BD5]: problem statement

Due to the condition of the patient, LOM is the most urgent problem that needs to be addressed since tendon repair are prone to
adhesions which can affect available PROM in the long run. The weak grip strength is prioritized next since this is a pre-requisite
for other client factors, such as prehension patterns and in-hand manipulation skills, to be addressed. Impaired sensation is
prioritized third as this would be necessary for the patient’s safety and for functional use of the hand. Lastly, impaired Ⓡ hand
function, which includes GPP/FPP, RGCR, In-Hand Manipulation skills, etc., will be addressed last as this would be easier to
address once the pre-requisite client factors of ROM, strength have been improved. Intact sensation would also allow for a more
functional hand use.

E. OT Impression
1. The client has LOM as evidenced by which potentially affects performance in ADL tasks, educational, and work
participation.
2. The client has weak grip strength which potentially affects performance in ADL tasks and educational
participation.
3. The client has impaired sensations which potentially affects ADL tasks, leisure, educational participation, and
work participation.
4. The client has impaired right hand function which potentially affects ADL tasks, leisure, educational participation,
and work participation.

F. Rehabilitation Potential
According to the American Academy of Orthopaedic Surgeons (AAOS), advances in medical science and flexor tendon surgery results in
good return of function and high patient satisfaction. However, despite extensive therapy, some patients still report long-term stiffness.
Adding to that, since the injury is in Zone V, direct tendon repair results in less complications but Orthobullets states that this often carri es
a worse prognosis due to the associated neurovascular injury, as is the case with the client. This means that the client has a guarded medical
prognosis. However, the client received early surgical and rehabilitation interventions. The client is also motivated and cooperative with his
home exercises. If the client maintains this positive behavior and remains compliant to the treatment, tendon adhesions and complications
can be avoided, thus the client has a guarded rehabilitation potential.

OT INTERVENTION
A. LTGs, STGs, and Plan of Action
Problem 1: Client has LOM in finger flexion which results in difficulty in performing ADL tasks, educational and work
participation.

LTG 1: Client will improve ROM of Ⓡ hand to a functional position necessary for effective occupational performance in 3 months
of OT sessions.
STG 1: Given ROMex, the client will improve the ROM of all MCP flexion to 0-71˚ in 1 month of OT sessions.
STG 2: Given ROMex, the client will improve the ROM of all PIP flexion to 0-87˚ in 1 month of OT sessions.
STG 3: Given ROMex, the client will improve the ROM of all DIP flexion to 0-64˚ in 1 month of OT sessions.
POA:
TUS:
Active Friendliness
The therapist will maintain a friendly attitude towards the client and take the initiative to initiate interactions. This
distracts the client from the pain and fatigue that may come with activities given.
Encouraging Mode
The therapist will use positive reinforcements to promote client performance and participation in the activities.

TUG:
Case Presentation – M.C. | pg. 16
 Dyadic Group
A dyadic group composed of the therapist and the patient will be utilized to allow for close observation and maintenance
of the quality of the exercise being done by the client.

TUA:
First, client will be given 3 sets of 10 reps passive ROM exercises for the R hand to prepare targeted joints for
occupation-based activities and to serve as a gentle passive stretch to prevent contractures. Client will be asked to hold the flexed
position for 10 seconds. Client will then be asked to do functional activities beginning with light prehension activities suc h as
writing or typing. If there is a continuous presence of contracture, a cock-up resting splint may be advised to be worn at night and
will be educated on care for splint.

Problem 2: Client has weak grip strength which results in difficulty in performing ADL tasks and educational participation.
LTG 2: Client will improve grip strength of Ⓡ necessary for independent performance of occupations in 3 months of OT sessions.
STG 1: Given active assistive exercises, client will improve MMT grade of thumb flexors from 2+ to 3 necessary for
gripping objects, in 1 week of OT sessions
STG 2: Given active assistive exercises, client will improve MMT grade of thumb flexors from 3 to 4 necessary for
gripping objects, in 1 week of OT sessions
STG 3: Given active assistive exercises, client will improve MMT grade of thumb flexors from 4 to 5 necessary for
gripping objects, in 1 week of OT sessions
STG 4: Given active resistive exercises, client will be able to hold and lift a glass filled with water independently
using the Ⓡ hand for 15 seconds in 1 week of OT sessions.
STG 5: Given active resistive exercises, client will be able to hold and lift a dipper filled with water independently
using the Ⓡ hand for 15 seconds in 1 week of OT sessions.
STG 6: Given active resistive exercises, client will be able to grip a brush to groom his hair using his Ⓡ hand
independently in 1 week of OT sessions.
STG 7: Given active resistive exercises, client will be able to grip utensils for feeding using his Ⓡ hand
independently in 1 week of OT sessions. Commented [BAD6]: power web
POA:
TUS:
Active Friendliness
The therapist will maintain a friendly attitude towards the client and take the initiative to initiate interactions. This distracts the
client from the pain and fatigue that may come with activities given.
Encouraging Mode
The therapist will use positive reinforcements to promote client performance and participation in the activities.
TUG:
Dyadic Group
A dyadic group composed of the therapist and the patient will be utilized to allow for close observation and maintenance of the
quality of the exercise being done by the client.
TUA:
To prepare the muscles of the R hand for functional activities, client will be given low-intensity active resistive exercises such as
grasping, raking, and pinching theraputty 10 times each. Client will then be tasked to do occupation-based activities using the R
hand such as lifting a glass of water to drink, bathing using a dipper, brushing hair and feeding with utensils using the right hand.
The client will begin with an empty glass of water and the amount of water will be increased as client’s strength improves. A
gardening task may also be given which will include lifting bags of soil, shoveling, pushing a wheelbarrow and watering the plants.

Problem 3: Client has impaired sensation which results in difficulty performing ADL tasks, leisure, educational and work
participation.
LTG 3: Client will improve protopathic sensation necessary for safe occupational participation in 6 months of OT sessions.
STG 1: Client will be able to recognize and localize light tough and pressure 5/5 instances given sensory re-education in
2 months of OT sessions.
STG 2: Client will be able to perceive and describe pain 5/5 instances given sensory re-education in 2 months of OT
sessions.
STG 3: Client will be able to perceive and describe temperature 5/5 instances given sensory re-education in 2 months of
OT sessions.
POA:
TUS:
Active Friendliness
The therapist will maintain a friendly attitude towards the client and take the initiative to initiate interactions. This distracts the
client from the pain and fatigue that may come with activities given.
Encouraging Mode
The therapist will use positive reinforcements to promote client performance and participation in the activities.
TUG:
Dyadic Group
A dyadic group composed of the therapist and the patient will be utilized to allow for close observation and maintenance of the
quality of the exercise being done by the client.
Case Presentation – M.C. | pg. 17
 TUA:
To expose the client to different sensations, the client would be given sensory re-education. Objects or materials to be presented will
be following gross to fine discrimination. This will allow the client to clearly delineate the difference of one object to another.
Client will then be asked to do occupation-based activities that relates to the client’s work. An example of this would be searching
objects placed inside a bag with varying objects with varying textures. Commented [de7]: not sure if tama itoo or pano
isingit ung sa temperature
not sure if tama itoo or pano isingit ung sa temperature

Problem 4: Client has impaired Ⓡhand function results in difficulty during ADL tasks, leisure, educational and work participation. Commented [BD8]: problem statement
LTG 4: Client will improve hand functions necessary for functional performance from P to G in 6 months of OT sessions.
STG 1: Client will be able to improve GPPs from F to G in 1 month of OT sessions. Commented [BAD9]: thumb
STG 2: Client will be able to improve RGCR from F to G in 1 month of OT sessions.
STG 3: Client will be able to improve FPPs from A to F in 1 month of OT sessions. Commented [BAD10]: per grasp
STG 4: Client will be able to improve FPPs from F to G in 1 month of OT sessions. Commented [BAD11]: per component
STG 5: Client will be able to improve in-hand manipulation skills from P to F in 1 month of OT sessions.
STG 6: Client will be able to improve in-hand manipulation skills from F to G in 1 month of OT sessions.

For RGCR:
LTG: Client will be able to improve RGCR from F to G in 1 month of OT sessions. Commented [BD12]: per component
STG: Client will be able to reach to grasp a variety of size objects using the client’s affected hand??
Client will be able to grasp an object using
Client will be able to maintain to carrying an object using
Client wil be able to voluntary release objects using chuchu Commented [de13]: hello! di ko sure itoo pero
parang ganyan alam ko if need hiwahiwalayin so
another LTG pa tayo
POA:
TUS:
Active Friendliness
The therapist will maintain a friendly attitude towards the client and take the initiative to initiate interactions. This distracts the
client from the pain and fatigue that may come with activities given.
Encouraging Mode
The therapist will use positive reinforcements to promote client performance and participation in the activities.
TUG:
Dyadic Group
A dyadic group composed of the therapist and the patient will be utilized to allow for close observation and maintenance of the
quality of the exercise being done by the client.
TUA:
Activities that require individual and precise movements of the hand structures will be utilized. The can include writing tasks,
typing, art making, etc.
The client would be given strengthening exercises and active resistive devices that would utilize the client’s movements in hand
structures.

For GPP: strengthening exercises, active resistive exercises. RGCR (ball game)
For FPP: PROMs, AROMs, Active assistive exercises, active resistive. EZ board, occupation based
office desk works (organize: coins, pencils chuchu)
For in hand manipulation: finger ROM exercises, strengthening excercises. Sorting, filing and
labeling (pencils, files, paperclips, coins). IT’s task (office works

B. Frames of Reference Used

I. Biomechanical Frame of Reference
The Biomech FoR will be used since the client’s weakness and LOM are in line with the FoR’s defined dysfunction. Therapeutic
exercises and interventions will help improve these client factors allowing the client to improve his performance of occupations.
The client may also benefit from the FoR’s belief in the principle of rest and stress. Following the principles of biomech, a plan can
be devised so that the structures affected are rested and biomechanical integrity is preserved while also providing enough stress to
increase the capacity of the soft tissues.
II. Sensory Integration Frame of Reference
SI FoR will be used as a complementary FoR. The principles of SI will be followed in the sensory re-education of the client
following the lacerations of the median and ulnar nerve.
C. Conduct of Therapy
Problem Goal/Objective Management Response Analysis
Case Presentation – M.C. | pg. 18
LOM To improve MCP, PROMex:
PIP, and DIP Ⓡ MCPs, PIPs, and DIPs
Flexion ROM AROMex:
Ⓡ MCPs, PIPs, and DIPs
3 sets, 10 reps
Weak To improve muscle Active Resistive Exercises:
Grip strength of flexor, Pt was asked to ball up then
Strength extensor, and grip the kinetic sand
intrinsic hand forcefully. After, the kinetic
muscles sand was flattened on the table
and the client was asked to
remove sand from the edges
using a raking motion (PIP,
DIP flexion) of the fingers.
Client was also asked to push
the sand back in by doing the
opposite motion (PIP, DIP
extension). Next, the client
was asked to push cork into
the sand using the different
fingers.
Impaired To promote use of Typing Games & Practice
Ⓡ Hand Ⓡ hand Sets:
Function The client was given a game
where bars with a word
(names) were falling. The
client needs to type the word
before the bar falls. If unable
to do so, the unfinished bars
will stack up. The game ends
when the box is filled with
bars. The client was also given
guided typing practice sets
which show a letter to be
typed and what finger to use.
Case Presentation – M.C. | pg. 19
The client was able to tolerate The client showed some
PROM thru the available difficulty in flexing his fingers
ROM on his ® MCP, PIP, and due to the adhesions. The
DIP joints. The client was able client exhibited compensatory
to flex his fingers with motions since the therapist
difficulty. The client showed was not able to properly
compensatory movements position and orient the client
such as shoulder elevation and about the motion being
wrist flexion. The client was practiced.
then given max verbal
prompts, and shoulder and
wrist stabilization by the
therapist.
The client was able to ball up The client exhibited difficulty
the kinetic sand but had forcefully gripping the sand
difficulty in gripping the sand due to his weakness and
with force. The client also had tendon adhesions. The client
difficulties raking and pushing exhibited compensatory
the sand. Finally, the client movements because the
had difficulties pushing the therapist failed to position the
cork into the sand. The client client and the materials
showed compensatory motions properly.
such as shoulder elevation,
elbow extension, and wrist
flexion. The client also
exhibited trick motions such
adducting instead of flexing
the thumb. The client was then
given max verbal prompts, and
shoulder and wrist
stabilization by the therapist.
The client was also positioned
so that the elbow is slightly
flexed and rested on the table.
The client was able to type the The client was using the
words, using the index fingers unaffected hand initially
of both hands, in the falling because he was not properly
bar before these fall to the instructed about using the
bottom of the box. The client affected hand. The initial
was given max verbal prompts activity also did not naturally
to use the unaffected hand. require him to use the affected
The client exhibited hand. The client was only able
compensatory motions such as to properly use the affected
shoulder elevation, elbow hand when the activity was
extension, and ulnar. The shifted from the game to the
client was then given max guided typing activity. The
verbal prompts, and shoulder client exhibited compensatory
and wrist stabilization by the motions because the therapist
therapist. The client also failed to position the materials
oriented the laptop more properly.
towards the unaffected hand.
The client was then positioned
so that the elbow is slightly
flexed and rested on the table
and the laptop is in the
midline. The client was then
given a typing set that
indicated a letter and which
finger would be used to type it.
The client was able to use the
indicated fingers to type but
his speed slowed down.
D. Recommendations
I. Tendon Gliding Exercises

Figure 6. Tendon Gliding Exercises

Differential tendon gliding exercises will be given to the client to help avoid the adherence of the repaired tendons to scar tissue.
Client would have to perform 10 repetitions of position A. Straight; B. Hook; C. Fist; D. Tabletop; and E. Straight fist. two to three
times a day.
II. Compression Garments
Client will be given compression garments for scar management. The custom-made compression garment would be worn 24 hours
to be removed only when bathing or for other hygiene purposes.
III. Instructions to the Client
The client should use his affected hand for light ADL activities but should avoid heavy lifting and excessive resistance. The client
must not yet play basketball or any other sport activity with the affected hand. Since the client has impaired sensation on the hand,
he must compensate by using his other senses, special vision. He must check his hand for injury often and compensate using his
vision to maintain safe interaction with his environment.
IV. Instructions to the Caregiver
The caregiver must do the heavy lifting instead of the client.
E. Conclusion
I. Summary of Achieved Goals
With the interventions provided, the therapist was able to address the goals regarding the improvement of range of motion, grip
strength, and functional use of the hand. The use of ROM exercises is able to increase the range of motion in the different joints of
the client’s hand. Using theraputty or other similar materials also allowed the therapist to target different motions and improve the
strength of the paretic muscles, which in turn will help improve the client’s grip strength. The materials used during the preparatory
activities also allowed the patient to improve his gross prehension skills, especially spherical grasp. The therapist, however, was not
able to achieve any goals towards improving sensation. Instructions were given on how to compensate for the impaired sensation in
order to be able to safely perform tasks but it would have been better if sensation was improved.
II. Group Insight
With the group’s experience in the clinical visits, we realized that we have many more things to learn and experience. It opened us
to the fact that we have to share our skills and knowledge that we have acquired from years of learning what and how OT can help
individuals. The group also learned the essence of time management to be able probe more if ever gathered information would not
be enough. We should be prepared at all times and should be ready with whatever changes are to happen. The group realized that
we have to know how to adapt and think quickly if ever circumstance would arise. We should be able to compose ourselves and not
panic to proceed with the OT session. Otherwise, it could be a burden to not only to each of us, but to the patient as well. We also
realized that learning and simulating treatment sessions is helpful but still very different from the real thing. Practicing treating
patients made us more self-aware of our actions and mistakes. For example, in our case we planned out our activities but we were
unable to notice without cues the effect of the improper positioning on the our treatment. Being able to communicate effectively
with the patient also plays an important part in the intervention process because through effective communication, the patient would
be knowledgeable on how he/ she could take part during the intervention process and most especially on his/ her progress. The
clinical visits, lectures, laboratory sessions, learned knowledge from the professors have prepared us well to what internship has in
store for us.

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Prepared By: Noted By:

Alviz, John Ephraim C.
Cruz, Angeline Gabrielle S.
Decena, Ben Andrei A. ____________________________________
Dema-ala, Jhunne Irene Marie J. Charles T. Bermejo, MSOT, OTR, OTRP
Gonzales, Aej Nicole M. Course Coordinator
Li, Audrye Heather D.
Pasha, Hannah D.
Group 4 – 4 OTB

Case Presentation – M.C. | pg. 21