Wrist and Hand Examination: Difference between revisions

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= Red Flags<br>  =
= Red Flags<br>  =


This section deals with screening the patient for possible serious pathologies that could cause wrist or hand pain. These conditions could warrant a referral, or consultation. <br><br>


'''Infections'''<br>


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<span style="font-size: 12pt;">This section deals with
'''Fracture/dislocation:'''
screening the patient for possible serious pathologies that could&nbsp;<span style=""></span><span style=""></span>cause wrist or hand pain.<span style="">&nbsp; </span>These conditions could warrant a referral, or consultation. <span style="">&nbsp;</span><o:p></o:p></span>


'''<span style="font-size: 12pt;">Infections<o:p></o:p></span>'''
Top five physical findings which are most useful in screening for wrist fracture.1 <br>


<span style="font-size: 12pt;">Heat
*Localized tenderness (Sensitivity [Sn] 94%)
<o:p></o:p></span>
*Pain on active motion (Sn 97%)
*Pain on passive motion (Sn 94%)
*Pain on grip (Sn 71%)
*Pain on supination (Sn 68%)
*Bottom line: Any one of the above findings associated with a history of trauma should be sent for radiographs


<span style="font-size: 12pt;">Swelling<o:p></o:p></span>
Colles fracture<br> Scaphoid fracture<br> <u>Additional potentially serious conditions </u><br>


<span style="font-size: 12pt;">Pain
*Scapholunate instability
<o:p></o:p></span>
*Arthritedes
*Rheumatoid Arthritis
*Lyme disease
*Tuberculosis


<span style="font-size: 12pt;">Redness
<br>Peripheral Vascular Disease<br>Peripheral Neuropathy:<br>
<o:p></o:p></span>


<span style="font-size: 12pt;">Inflammation</span>
*Hx: Older age, &gt;65. The risk is same for men/women.
*Risk factors include hypertension, hypercholesterolemia, obesity, diabetes, and smoking. Commonly affects lower extremity over upper extremity.


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Upper extremity nerve injuries involving<br>  
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*Median
 
*Radial
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'''<span style="font-size: 12pt;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Fracture/dislocation:<o:p></o:p></span>'''
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><span style="font-size: 12pt;">Top five physical
findings
which are most useful in screening for wrist fracture.<sup>1</sup> <o:p></o:p></span>
===
 
<span style="font-size: 12pt;">Localized tenderness (Sensitivity [Sn] 94%)<o:p></o:p></span>
 
<span style="font-size: 12pt;">Pain on active motion (Sn 97%)<o:p></o:p></span>
 
<span style="font-size: 12pt;">Pain on passive motion (Sn 94%)<o:p></o:p></span>
 
<span style="font-size: 12pt;">Pain on grip (Sn 71%)<o:p></o:p></span>
 
<span style="font-size: 12pt;">Pain on supination (Sn 68%)<o:p></o:p></span>
 
<u><span style="font-size: 12pt;">Bottom
line:</span></u><span style="font-size: 12pt;"> Any one of the above
findings
associated with a history of trauma should be sent for radiographs <o:p></o:p></span>
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span>[http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DColles_Fracture&sa=D&sntz=1&usg=AFQjCNGqO9lv9pXHpuNYdLqBhH_XLkThpA <span style="font-size: 12pt; color: rgb(0, 0, 153);">Colles</span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DColles_Fracture&sa=D&sntz=1&usg=AFQjCNGqO9lv9pXHpuNYdLqBhH_XLkThpA <span style="font-size: 12pt; color: rgb(0, 0, 153);"> </span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DColles_Fracture&sa=D&sntz=1&usg=AFQjCNGqO9lv9pXHpuNYdLqBhH_XLkThpA <span style="font-size: 12pt; color: rgb(0, 0, 153);">fracture</span>]<span style="font-size: 12pt;"><o:p></o:p></span>
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>[http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DScaphoid_Fracture&sa=D&sntz=1&usg=AFQjCNE8EDjkb2vcxny6EG30oYvZG9YP2g <span style="font-size: 12pt; color: rgb(0, 0, 153);">Scaphoid</span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DScaphoid_Fracture&sa=D&sntz=1&usg=AFQjCNE8EDjkb2vcxny6EG30oYvZG9YP2g <span style="font-size: 12pt; color: rgb(0, 0, 153);"> </span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DScaphoid_Fracture&sa=D&sntz=1&usg=AFQjCNE8EDjkb2vcxny6EG30oYvZG9YP2g <span style="font-size: 12pt; color: rgb(0, 0, 153);">fracture</span>]<span style="font-size: 12pt;"><o:p></o:p></span>
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span><u>Additional potentially serious conditions<span style=""> </span><o:p></o:p></u></span>
 
[http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DScapholunate_dissociation&sa=D&sntz=1&usg=AFQjCNFM8NCSRvNozGAjeVU2VuLx2DKJKQ <span style="font-size: 12pt; color: rgb(0, 0, 153);">Scapholunate</span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DScapholunate_dissociation&sa=D&sntz=1&usg=AFQjCNFM8NCSRvNozGAjeVU2VuLx2DKJKQ <span style="font-size: 12pt; color: rgb(0, 0, 153);"> </span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DScapholunate_dissociation&sa=D&sntz=1&usg=AFQjCNFM8NCSRvNozGAjeVU2VuLx2DKJKQ <span style="font-size: 12pt; color: rgb(0, 0, 153);">instability</span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DScapholunate_dissociation&sa=D&sntz=1&usg=AFQjCNFM8NCSRvNozGAjeVU2VuLx2DKJKQ <span style="font-size: 12pt; color: rgb(0, 0, 153);"> </span>]<span style="font-size: 12pt;"><o:p></o:p></span>
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>Arthritedes <o:p></o:p></span>
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>[http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DRheumatoid_Arthritis&sa=D&sntz=1&usg=AFQjCNGxrV6pOmdDWtlkA4xLAw0Da_1z3A <span style="font-size: 12pt; color: rgb(0, 0, 153);">Rheumatoid</span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DRheumatoid_Arthritis&sa=D&sntz=1&usg=AFQjCNGxrV6pOmdDWtlkA4xLAw0Da_1z3A <span style="font-size: 12pt; color: rgb(0, 0, 153);"> </span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DRheumatoid_Arthritis&sa=D&sntz=1&usg=AFQjCNGxrV6pOmdDWtlkA4xLAw0Da_1z3A <span style="font-size: 12pt; color: rgb(0, 0, 153);">Arthritis</span>]<span style="font-size: 12pt;"><o:p></o:p></span>
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>[http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DLyme_Disease&sa=D&sntz=1&usg=AFQjCNFUQ6MqYA1hCLEBMsZ6BDjLMB9yPQ <span style="font-size: 12pt; color: rgb(0, 0, 153);">Lyme</span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DLyme_Disease&sa=D&sntz=1&usg=AFQjCNFUQ6MqYA1hCLEBMsZ6BDjLMB9yPQ <span style="font-size: 12pt; color: rgb(0, 0, 153);"> </span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DLyme_Disease&sa=D&sntz=1&usg=AFQjCNFUQ6MqYA1hCLEBMsZ6BDjLMB9yPQ <span style="font-size: 12pt; color: rgb(0, 0, 153);">disease</span>][http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DLyme_Disease&sa=D&sntz=1&usg=AFQjCNFUQ6MqYA1hCLEBMsZ6BDjLMB9yPQ <span style="font-size: 12pt; color: rgb(0, 0, 153);"> </span>]<span style="font-size: 12pt;"><o:p></o:p></span>
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span>[http://www.google.com/url?q=http%3A%2F%2Fwww.physio-pedia.com%2Findex.php5%3Ftitle%3DTuberculosis&sa=D&sntz=1&usg=AFQjCNFMWqZruyWxhqHVhHT_vd0vBXxjHg <span style="font-size: 12pt; color: rgb(0, 0, 153);">Tuberculosis</span>]<span style="font-size: 12pt;"><o:p></o:p></span>
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span></span><u><span style="font-size: 12pt; color: rgb(0, 0, 153);"><o:p></o:p></span></u>
 
<span style="font-size: 12pt;">Peripheral
Vascular Disease<o:p></o:p></span>
 
<span style="font-size: 12pt;">Peripheral
Neuropathy:<o:p></o:p></span>
 
<span style="font-size: 12pt;">Hx: Older age, &gt;65.<span style="">&nbsp; </span>The risk is same for men/women.<o:p></o:p></span>
 
<span style="font-size: 12pt;">Risk factors include hypertension,
hypercholesterolemia, obesity, diabetes, and smoking. Commonly affects
lower
extremity over upper extremity.<o:p></o:p></span>
 
<span style="font-size: 12pt;">Upper extremity
nerve injuries
involving<o:p></o:p></span>
 
<span style="font-size: 12pt;"><span style="">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span>Median<o:p></o:p></span>
 
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= Differential Diagnosis <br>  =
= Differential Diagnosis <br>  =

Revision as of 19:01, 20 March 2011

Welcome to Temple University's Evidence-Based Practice project. This project was created by and for the students at Temple University in Philidelphia, and is part of the Orthopaedic curriculum. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

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Subjective[edit | edit source]

Thorough history taking is an important first step in treating the patient. Each physical therapist will develop their own style and technique, but a good interview will include the basic elements discussed below.

History
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Clinical Presentation
        Mechanism of the injury-
                How the injury occurred and what was the cause.
        Location of the pain
        Timeline-
                When is the pain at its worse and when is it relieved?
        Presence and location of numbness and tingling.
        Aggravating and relieving factors.
        Were any diagnostic test/imaging performed and what were the results?

Red Flags
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This section deals with screening the patient for possible serious pathologies that could cause wrist or hand pain. These conditions could warrant a referral, or consultation.

Infections

  • Heat
  • Swelling
  • Pain
  • Redness
  • Inflammation

Fracture/dislocation:

Top five physical findings which are most useful in screening for wrist fracture.1

  • Localized tenderness (Sensitivity [Sn] 94%)
  • Pain on active motion (Sn 97%)
  • Pain on passive motion (Sn 94%)
  • Pain on grip (Sn 71%)
  • Pain on supination (Sn 68%)
  • Bottom line: Any one of the above findings associated with a history of trauma should be sent for radiographs

Colles fracture
Scaphoid fracture
Additional potentially serious conditions

  • Scapholunate instability
  • Arthritedes
  • Rheumatoid Arthritis
  • Lyme disease
  • Tuberculosis


Peripheral Vascular Disease
Peripheral Neuropathy:

  • Hx: Older age, >65. The risk is same for men/women.
  • Risk factors include hypertension, hypercholesterolemia, obesity, diabetes, and smoking. Commonly affects lower extremity over upper extremity.

Upper extremity nerve injuries involving

  • Median
  • Radial
  • Ulnar

Differential Diagnosis
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mso-level-text:○; mso-level-tab-stop:1.0in; mso-level-number-position:left; margin-left:1.25in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l1:level3 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:1.5in; mso-level-number-position:right; margin-left:1.75in; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l1:level4 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:2.0in; mso-level-number-position:left; margin-left:2.25in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l1:level5 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:2.5in; mso-level-number-position:left; margin-left:2.75in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l1:level6 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:3.0in; mso-level-number-position:right; margin-left:3.25in; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l1:level7 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:3.5in; mso-level-number-position:left; margin-left:3.75in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l1:level8 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:4.0in; mso-level-number-position:left; margin-left:4.25in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l1:level9 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:4.5in; mso-level-number-position:right; margin-left:4.75in; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l2 {mso-list-id:3; mso-list-type:hybrid; mso-list-template-ids:3 -1 -1 -1 -1 -1 -1 -1 -1 -1;} @list l2:level1 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:1.0in; mso-level-number-position:left; margin-left:1.25in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l2:level2 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:1.5in; mso-level-number-position:left; margin-left:1.75in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l2:level3 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:2.0in; mso-level-number-position:right; margin-left:2.25in; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l2:level4 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:2.5in; mso-level-number-position:left; margin-left:2.75in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l2:level5 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:3.0in; mso-level-number-position:left; margin-left:3.25in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l2:level6 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:3.5in; mso-level-number-position:right; margin-left:3.75in; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l2:level7 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:4.0in; mso-level-number-position:left; margin-left:4.25in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l2:level8 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:4.5in; mso-level-number-position:left; margin-left:4.75in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l2:level9 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:5.0in; mso-level-number-position:right; margin-left:5.25in; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l3 {mso-list-id:4; mso-list-type:hybrid; mso-list-template-ids:4 -1 -1 -1 -1 -1 -1 -1 -1 -1;} @list l3:level1 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:2.0in; mso-level-number-position:left; margin-left:2.25in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l3:level2 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:2.5in; mso-level-number-position:left; margin-left:2.75in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l3:level3 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:3.0in; mso-level-number-position:right; margin-left:3.25in; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l3:level4 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:3.5in; mso-level-number-position:left; margin-left:3.75in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l3:level5 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:4.0in; mso-level-number-position:left; margin-left:4.25in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l3:level6 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:4.5in; mso-level-number-position:right; margin-left:4.75in; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l3:level7 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:5.0in; mso-level-number-position:left; margin-left:5.25in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l3:level8 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:5.5in; mso-level-number-position:left; margin-left:5.75in; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l3:level9 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:6.0in; mso-level-number-position:right; margin-left:6.25in; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l4 {mso-list-id:5; mso-list-type:hybrid; mso-list-template-ids:5 -1 -1 -1 -1 -1 -1 -1 -1 -1;} @list l4:level1 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l4:level2 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l4:level3 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:1.25in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l4:level4 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:1.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l4:level5 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:2.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l4:level6 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:2.75in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l4:level7 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:3.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l4:level8 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:3.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l4:level9 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:4.25in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:12.0pt; mso-bidi-font-size:12.0pt; mso-ascii-font-family:"Times New Roman"; mso-fareast-font-family:"Times New Roman"; mso-hansi-font-family:"Times New Roman"; mso-bidi-font-family:"Times New Roman"; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l5 {mso-list-id:6; mso-list-type:hybrid; mso-list-template-ids:6 -1 -1 -1 -1 -1 -1 -1 -1 -1;} @list l5:level1 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l5:level2 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l5:level3 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:1.25in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l5:level4 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:1.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l5:level5 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:2.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l5:level6 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:2.75in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l5:level7 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:3.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l5:level8 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:3.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l5:level9 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:4.25in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l6 {mso-list-id:7; mso-list-type:hybrid; mso-list-template-ids:7 -1 -1 -1 -1 -1 -1 -1 -1 -1;} @list l6:level1 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l6:level2 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l6:level3 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:1.25in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l6:level4 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:1.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l6:level5 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:2.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l6:level6 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:2.75in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l6:level7 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:3.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l6:level8 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:3.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l6:level9 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:4.25in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l7 {mso-list-id:8; mso-list-type:hybrid; mso-list-template-ids:8 -1 -1 -1 -1 -1 -1 -1 -1 -1;} @list l7:level1 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l7:level2 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l7:level3 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:1.25in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l7:level4 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:1.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l7:level5 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:2.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l7:level6 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:2.75in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l7:level7 {mso-level-number-format:bullet; mso-level-text:●; mso-level-tab-stop:3.25in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l7:level8 {mso-level-number-format:bullet; mso-level-text:○; mso-level-tab-stop:3.75in; mso-level-number-position:left; text-indent:-.25in; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l7:level9 {mso-level-number-format:bullet; mso-level-text:■; mso-level-tab-stop:4.25in; mso-level-number-position:right; text-indent:-9.0pt; mso-ansi-font-size:11.0pt; mso-bidi-font-size:11.0pt; mso-ascii-font-family:Arial; mso-fareast-font-family:Arial; mso-hansi-font-family:Arial; mso-bidi-font-family:Arial; color:black; mso-ansi-font-weight:normal; mso-bidi-font-weight:normal; mso-ansi-font-style:normal; mso-bidi-font-style:normal; text-decoration:none; text-underline:none; text-decoration:none; text-line-through:none;} @list l8 {mso-list-id:9; 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Carpal Tunnel Syndrome

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Anterior Interosseous Syndrome<o:p></o:p>

[[../../../../index.php5?title=Posterior_Interosseus_Syndrome|Posterior Interousseous Syndrome]]

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Fractures <o:p></o:p>

Distal Radial Fractures

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Osteoarthritis<o:p></o:p>

First Carpometacarpal Osteoarthritis<o:p></o:p>

Thumb CMC grind test

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Hand and Wrist Osteoarthritis

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DeQuervain Syndrome<o:p></o:p>

Finklestein’s Test:

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Radial Tunnel Syndrome      <o:p></o:p>

Compression of the Ulnar nerve at Guyon’s canal<o:p></o:p>

Non-specific wrist pain (mechanical wrist pain)<o:p></o:p>

Can include wrist strain, sprain, joint dysfunction, repetitive injuries or h/o trauma without specific identified diagnosis. <o:p></o:p>

       <o:p></o:p>

Trigger Finger<o:p></o:p>

            Complex Regional Pain Syndrome

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Triangular Fibrocartilaginous Complex <o:p></o:p>

Dupuytren’s Contracture


Outcome Measures
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DASH: <o:p></o:p>

Quick DASH <o:p></o:p>

Symptom Severity Scale<o:p></o:p>

Patient Specific Functional Scale <o:p></o:p>


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Objective[edit | edit source]

Observation[edit | edit source]

  • Posture
  • Movement Patterns

Functional Tests
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Palpation[edit | edit source]

  • supine
  • prone
  • seated

Neurologic Assessment
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Movement Testing[edit | edit source]

  • AROM, PROM, and Overpressure
  • Passive Intervertebral Motion
  • Muscle Strength

Special Tests[edit | edit source]

References[edit | edit source]

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