Chapter 20: Rehabilitation of Wrist, Hand and Finger Injuries

1. Chapter 20: Rehabilitation of Wrist, Hand and Finger Injuries

2. 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

3. 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)

4. 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

5. 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)

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. Injury Mechanism • Hyperextension force or compressive load force • Rehabilitation Concerns • Possible fracture involvement • Surgical intervention • ROM concerns • Pain, swelling, stiffness or loss of reduction

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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