Rehabilitation of Wrist Hand and Finger INjuries

Document Sample
Rehabilitation of Wrist Hand and Finger INjuries Powered By Docstoc
					 Chapter 20: Rehabilitation of
Wrist, Hand and Finger Injuries
    Rehabilitation Techniques for
         Specific Injuries
Distal Radius Fractures
• Pathomechanics
  – Simple extra-articular, non-displaced fractures tend to
    heal without incident
     • Full or near full recovery
  – More involved fractures (intra-articular, comminuted)
     • Full return may not be as likely
  – If volar tilt of radius is disrupted could lead to
    alterations in function
     •   Mid-carpal instability
     •   Decreased strength,
     •   Increased ulnar loading
     •   Dysfunctional distal radioulnar joint
  – Disruption of normal anatomic length of radius
     •   Possible distal radioulnar joint problems
     •   Decreased mobility
     •   Decreased power
     •   Will require repair via external fixation
• Injury Mechanism
  – Generally the result of fall on outstretched hand
• Rehabilitation Concerns
  – Early and proper reduction/immobilization
  – Early ROM to non-involved joints is critical
     • Prevent atrophy and aid in muscle pumping
  – Complications of carpal tunnel
  – Possible tendon rupture (extensor pollicus longus)
• Rehabilitation Progression
  – Early mobilization of unaffected joints – above and
    below injury
  – After immobilization is complete wrist ROM must
    begin
  – Putty exercises can be used 1-2 weeks following
    immobilization
– Begin active motion (flexion, extension, radial
  and ulnar deviation) immediately
   • Focus on wrist not finger motion
– PROM – start dependent on physician
  preference
– Work on pronation and supination
   • Apply force at radius, not hand (unnecessary torque
     across carpus)
– Active motion can be
  progressed to
  strengthening
   • Light weight,
     TheraBand, tubing
– Work in conjunction
  with closed-kinetic
  chain exercises
– Progress to unstable
  surfaces (push-ups on
  ball, physioball walks
– Continue progression
  to plyometric activities
  and sports-specific
  skills
• Criteria for Return
   – Non-displaced fracture may be able to return 2-3
     weeks following initial injury with protection
      • Should exhibit early signs of healing and no pain
   – With ORIF athlete may be able to return to play after
     3 weeks (with protection)
      • Should be able to go without protection at 6 weeks
   – With displaced fracture athlete will probably be out of
     competition for 6 weeks
   – Return to competition will also be dependent on sport
     and position
      • Should not return if strength and function are not adequate to
        prevent re-injury
                 Wrist Sprain
• Pathomechanics
  – Minor trauma to wrist
  – Diagnosis of exclusion
• Injury Mechanism
  – Result of fall or landing on outstretched hand
  – Twisting motion
  – Some impact (striking ground with club)
• Rehabilitation Concerns
  – Rule out more serious injury
  – Pain, swelling management, ROM and strengthening
• Rehabilitation Progression
   – May require some immobilization
   – Following decrease in pain and swelling return of
     ROM and strength is essential
   – Progression of exercises similar to distal radius
     fracture scenario
   – May require joint mobilizations to enhance
     arthrokinematics
• Criteria for Return
   – Return when comfortable
   – Taping may be necessary for support and decreased
     pain
     Carpal Tunnel Syndrome
• Pathomechanics
  – Compression of median nerve
     • Decreased space due to tendon inflammation
     • Excessive wrist flexion and extension
     • Present with neurological signs and symptoms
• Injury Mechanism
  – Sustained grip and repetitive action of thrower and
    racquet
  – Discomfort due to tenosynovitis
  – Pressure due to lipoma, diabetes or pregnancy
  – May be result of acute trauma as well
• Rehabilitation Concerns
  – Conservative symptomatic treatment
     • Rest, NSAID’s, task modification
     • Splinting and rest
     • Soft tissue work to relieve adhesions and improve symptoms
  – Carpal tunnel release
     • Requires wound care, soft tissue massage and ROM
       exercises
     • Tendon gliding – comprehensive approach
     • Wrist ROM will also require attention
• Rehabilitation Progression
  – Involves grip strength – avoid symptom aggravation
  – Introduce exercises 2-4 weeks post surgery
  – Maintain upper body conditioning
• Criteria for Return to Play
   –   Can continue to play with carpal tunnel
   –   May need to modify in order to continue to perform
   –   Base activity level on symptoms
   –   Athlete typically able to return to play following suture
       removal if surgery required
        • Rarely necessary in athletes
               Ganglion Cysts
• Pathology
  – Etiology is unclear
  – Synovial cyst arising
    from synovial lining
  – Most commonly on
    dorsal aspect of hand
  – Treatable with
    primarily via aspiration
  – Some cases require
    surgery
• Injury Mechanism
  – Most often the result of repeated wrist
    hyperextensions
  – Pain is indication for treatment
• Rehabilitation Concerns
  – Rehabilitation generally not required following
    aspiration
  – Surgical instances may require work on ROM,
    strengthening and scar management
• Rehabilitation Progression
  – Following excision and regaining ROM strengthening
    may be performed
     • Grip strength, wrist flexion and extension
• Criteria for Return to Play
   – Activity is limited by pain
   – If asymptomatic, athlete can participate
   – If symptomatic, aspiration can occur with immediate
     return to play
   – In instances of surgical excision, return generally
     occurs within 10 days (following suture removal
              Boxer’s Fracture
• Pathomechanics
  – Fracture of 5th metacarpal neck
  – Perfect anatomic reduction is not necessary (due to
    high level of mobility)
     • Increased angulation may result imbalance of the
       intrinsic/extrinsic hand muscles
     • Clawing or mass in palm
• Injury Mechanism
  – Often the result of contact against an object with a
    closed fist
• Rehabilitation
  Concerns
  – Skin integrity
  – Proper immobilization,
    pain and edema
    control
     • Involved and
       uninvolved joints
  – ORIF
     • Active motion can begin
       within 72 hours of
       procedure
  – Immobilization options
• Rehabilitation Progression
   – Uninvolved joints ROM should be maintained during
     splinting
   – After 4 weeks of splinting, MCP ROM should begin
   – At 4-6 weeks gentle resistance may begin with
     increasing intensity by week 6
• Criteria for Return
   – Signs of fracture healing
      • Stable, no pain with movement
      • 3-4 weeks with protection
   – Always dependent on sport, position and athlete
 DeQuervain’s Tenosynovitis and
           Tendinitis
• Pathomechanics
  – Inflammation in first
    dorsal compartment
     • Abductor pollicus
       longus and extensor
       pollicus brevis
  – Aggravated by wrist
    radial and ulnar
    deviation, flexion,
    abduction, adduction
    and extension of the
    thumb
• Injury Mechanism
  –   Caused by overuse
  –   Weakness or poor body mechanics/posture
  –   Repeated wrist radial and ulnar deviation
  –   Occasionally result of direct blow
• Rehabilitation Concerns
  – Rule out fracture or ligament injury if the result of
    direct blow or fall on outstretched hand
  – Assess mechanics
       • Poor shoulder strength/mechanics
  – Treat pain and swelling – remove aggravating
    activities
  – Splinting and immobilization
• Rehabilitation Progression
  –   NSAID’s and modalities for pain
  –   Immobilization
  –   Pain-free stretching should begin immediately
  –   With decreased pain strengthening exercises can
      begin
       • Begin with isometrics and move to gravity dependent/light
         weight exercises
       • Weight bearing and plyometrics
 Ulnar Collateral Ligament Sprain
     (Gamekeeper’s Thumb)
• Pathomechanics
  – Stretching or tearing of
    ulnar collateral
    ligament
     • Grade III will require
       surgery
  – Be aware of disrupted
    stability
     • May require surgery
       depending on
       angulation
  – Stesner’s lesion
• Injury Mechanism
  – Torsional load applied to the thumb
  – Forced abduction or fall on outstretched hand
• Rehabilitation Concerns
  – Early diagnosis and treatment are critical
       • Avoid instances of chronic instability, weakness and arthritis
         sequelae
  –   Immobilization (spica) for grade I and II injuries
  –   Surgical care followed by immobilization
  –   Avoid radial stresses on thumb
  –   Condition of uninvolved joints
• Rehabilitation Progression
   – Following 5-6 weeks of protective
     splinting, AROM exercises for flexion
     and extension begin
   – Putty exercises for strength for 2-6
     weeks following immobilization
• Criteria for Return
   – Length of time to return determined by
     sport, position and thumb involvement
     in sport
   – Possible splinting and taping options
   – Pain should be reduced and strength
     should be sufficient for return
   – With surgical intervention – time loss
     minimum of 2 weeks
       Finger Joint Dislocation
• Pathomechanics
  – MCP dorsal or palmar dislocations
     • Hyperextension moment with rotation
  – Reduction
  – PIP dislocation volarly – rare and irreducible
     • Generally associated with fracture
  – Incident of injury PIP vs. DIP
     • Dorsal vs. Volar
  – X-ray should be taken prior to reduction
     • Assess possibility of fracture
  – Open vs. Closed reduction
• Injury Mechanism
  – Hyperextension force
    or compressive load
    force
• Rehabilitation
  Concerns
  – Possible fracture
    involvement
  – Surgical intervention
  – ROM concerns
  – Pain, swelling,
    stiffness or loss of
    reduction
• Rehabilitation Progression
  – Simple dorsal MCP
     • Splint at 50 degrees of flexion, 7-10 days
     • Begin AROM immediately after
     • Progress from increased range to strengthening
  – Irreducible MCP dislocation
     • Open reduction
     • When motion is allowed, active flexion and extension should
       begin
     • Stiffness due to scar tissue adhesions with tendon
     • Progress from ADL’s to strengthening and functional return
  – PIP dislocation – with reduction
     •   Wrapping for edema reduction
     •   Early flexion and extension exercises
     •   Buddy taping to encourage ROM
     •   If stiffness develops referral may be necessary
– DIP dislocation –
  closed and reduced
   • Splint in neutral for 1-2
     weeks
   • AROM begins at 2-3
     weeks with protective
     splinting between
     treatment sessions for
     4-6 weeks
   • Putty for strengthening
– Open or irreducible
  fractures will require
  wound management
   • Then treat like mallet
     finger and progress
     accordingly
• Criteria for Return
   – Dependent on complexity of injury
   – MCP
      • With support can return almost immediately if simple
      • With surgical intervention athlete will be out a minimum of 2-3
        weeks
   – PIP
      • Without fracture and with appropriate protection can return
        almost immediately
      • If more severe injury, time will increase with relation to sport
   – DIP
      • Simple – may return immediately with appropriate protection
      • Fracture/surgical – 10 days with protection following suture
        removal
• Criteria for Return
   – Dependent on sport and position played
   – Must involve input from all associated with injury
     repair
   – Play without protection generally by weeks 10-12
   – Avoid early return due to chance of re-injury
   – Some protective taping may be applied early for
     protection
                Mallet Finger
• Pathomechanics
  – Avulsion of terminal
    extensor tendon
  – With or without
    fracture
  – May require ORIF
    depending on severity
• Injury Mechanism
  – Forced DIP flexion
    while held in extension
• Rehabilitation Concerns
  – Few concerns
  – Splinting and immobilization will be require
    immediately following injury (6-8 weeks)
     • Neutral to slight hyperextension
  – Maintain ROM in non-injured joints
• Rehabilitation Progression
  – After 6-8 weeks of splinting, ROM exercises can
    begin (night splinting may continue for 2 weeks)
  – Do not attempt to passively flex finger for 4 weeks
  – Blocked DIP exercises are important
• Criteria for Return
   – Permitted immediately
     if appropriate splinting
     occurs
   – If unable to participate
     due to rules
     associated with
     activity, athlete will be
     out for 6-8 weeks
          Boutonniere Deformity
• Pathomechanics
   – PIP flexion with DIP
     extension
   – Interruption of central slip
   – Lateral slippage of
     extensor muscle
   – When flexed deformity is
     present, injury becomes
     difficult to treat
• Injury Mechanism
   – Extended finger is forcibly
     flexed
• Rehabilitation Concerns
  – Early and proper diagnosis
  – Appropriate splinting
     • Full extension
     • Splint modification due to changes in swelling
  – Avoid passive PIP flexion following splint removal
  – Be aware that injury will present as PIP flexion
    contracture initially prior to DIP hyperextension
• Rehabilitation
  Progression
   – Splinting for 6 weeks
   – Continued protection for 2-
     4 weeks when not
     exercising
   – Gentle PIP flexion
     exercises
   – Slow increase in ROM and
     addition of strengthen
     exercises
       • May take up to 10-12
         weeks
• Criteria for Return
   – Return to activity when finger is comfortable
   – Affected finger must be splinted in full extension
   – If sport does not allow for splinting of digits athlete will
     be out for 8 weeks