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Regaining Function After Common Hand InjuriesLisa Choe OTR/L, CHT, MHAFlorida Orthopaedic Institute

Mallet Boutonniere Distal Radius Fractures Elbow Fractures

Terminal Tendon rupture◦ With or without fracture

Conservative Treatment◦ Immobilization of DIPj only for 6-8 weeks◦ DIP in full extension to slight hyperextension◦ PIPj should be free to allow for full ROM◦ Many splint options

OT: 5-8 visits typical◦ Pt Ed◦ Splint Management

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Rupture of the central slip Conservative Treatment◦ Immobilization of the PIPj only◦ PIPj should be in full extension◦ DIPj to be free to allow for blocking exercises◦ Many splints to choose from

OT: 8-12 visits typical◦ Pt Ed◦ Splint Management◦ Progressive AROM protocol

Splint Options

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Treat with:◦ Cast◦ ORIF Percutaneous pins Plating system

◦ Reestablishing anatomical angles◦ Early motion

ORIF vs. Conservative Management◦ When to start? Early if internal ridged stabilized◦ Active vs. PROM

Uninvolved joint ROM Pain management Edema management Soft tissue repairs◦ Ligaments◦ Tendons◦ Capsule

Pt should be educated on finger, elbow and shoulder ROM from beginning to avoid stiffness

Don’t forget to get isolated wrist extension! Major limitations are supination and wrist

extension◦ Hand to mouth and weight bearing/push off

Initiate dynamic or static progressive splinting after sufficient healing

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Isolated wrist extension is very important for functional use.

Teach it early!!!!

6-8 weeks post fracture Need to customize for patient age/activity level Progressive loading ◦ Light grip◦ Wrist isometrics◦ Progressive resistive exercises Tbands Free weights

◦ Closed kinetic chain activities Wall push ups Theraball exercises Pushing or pulling activities

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Watch out for RED FLAGS◦ CTS◦ RSD/CRPS◦ Fracture disease –acute pain and persistent edema

leading to stiffness tendon adhesion capsular and ligamentous contracture◦ Intrinsic tightness – hook fist HEP

Radial Head Fractures (Conservative Mgmt)◦ Immobilize in early stages for pain management◦ Sling for 7-10 days◦ Gentle finger ROM for edema management and

avoiding stiff fingers◦ Start therapy 7-10 days for early ROM to prevent

long term stiffness Proximal Ulna/Distal Humeral Fractures◦ Simple vs. Complex Fractures

OT: 6-18 visits depending on severity

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ORIF vs. Conservative Management◦ When to start and how? ◦ Closed chain◦ Active vs. PROM◦ Strengthening concerns

Uninvolved joint ROM Pain management Edema management Soft tissue repairs◦ Ligaments◦ Tendons◦ Capsule

AROM

PROM

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Passive ROM

Carpal Tunnel SyndromeCubital Tunnel Syndrome

Conservative Management◦ Steroid Injections◦ NSAIDs◦ Vitamin B6 (?)◦ Tendon Gliding Exercises◦ Median Nerve Glides◦ Ultrasound to CT◦ Iontophoresis◦ Splinting ◦ Activity modifications

OT: 6-8 sessions

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Recommended position NEUTRAL wrist (In off the shelf splints, bend the metal stay to neutral)

Conservative Management◦ Neural Mobilization◦ Muscle length and myofascial mobility Upper extremity stretches

◦ Orthoses – ≈60 degrees flexion◦ Protection from compression/contusion◦ Activity modification/Ergonomics No resting on elbows No flexion greater than 90 Postural awareness Core strengthening

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Splinting Options

DeQuervain’s Lateral Epicondylitis Medial Epicondylitis

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Arthritis◦ Trapezometacarpal◦ Radioscaphoid◦ Scaphotrapizial

Scaphoid fractures Wartenburg’s Syndrome – DRSN neuritis Intersection syndrome ◦ More proximal where APL/EPB overlap with wrist

extensors

Loss of function ◦ Opening jars◦ Wringing the hands◦ Cutting with scissors◦ Playing piano◦ Typing◦ Needlepoint/crochet◦ Cooking/stirring

Thumb Spica splint 3 wk trial◦ Wrist in neutral to 20 degrees of extension and

thumb in radial abduction Rest Cortisone injection Activity modification/joint protection Gentle painfree AROM Pain modalities as previously stated Visits: 8-12

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Common name: Tennis Elbow/Golfers Elbow

Overuse problem or direct trauma

Pressure Pain Threshold Differential Diagnosis ROM Grip Strength (fa neutral vs. supinated)◦ Elbow flexed to 90◦ Elbow extended◦ Special tests

Visits: 8-12

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Common extensor tendon Cervical discs (C5–C7)Radial nerve Facet joints (C5–C7)Posterior interosseous nerve Nerve roots (C5–C7)Musculocutaneous nerve Brachial plexus (upper trunk)

Radial head Spinal cord connective tissues (dura)

Distal humerus Neuroplastic changes in CNSRadiohumeral joint* Glenohumeral joint pathologySuperior radioulnar joint Wrist complex pathology

Fascia Remote nerve entrapment (UN,RN,MN)

Vascular Trigger points

Rest Splinting◦ Counterforce Brace◦ Wrist support brace

Pain free movement Forearm stretches Closed chain ROM Activity avoidance NSAIDs Cortisone injection

Counterforce Brace Wrist Cock-up

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Start with your elbow bent to 90 degrees and extend while stretching to get a maximum stretch without pain.

Hold stretch for 30 seconds,Complete 1-3 times6-8 times a day

Extensor Stretches

Flexor-Pronator Stretches

Start with your elbow bent to 90 degrees and extend while stretching to get a maximum stretch without pain.

Hold stretch for 30 seconds,Complete 1-3 times6-8 times a day

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Soft Tissue Mobilization (STM)◦ Transverse friction massage◦ Instrument Assisted Soft Tissue Mobilization◦ Manual massage/STM

Modalities for pain◦ US◦ IFC◦ TENS◦ Iontophoresis/phonophoresis◦ Laser◦ Heat/ice

Instrument Assisted Soft Tissue Mobilization Tools

Proximal strengthening◦ Triceps◦ Bicep◦ Rotator cuff◦ Para scapular ms

Distal strengthening◦ Isometric wrist, elbow, forearm (multi-angled)◦ Intrinsic hand strengthening◦ Wrist PRE’s Start with concentric isotonic contractions Progress to eccentric contractions Low weights low reps to start

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Distal Strengthening

Lift techniques Reduce aggravating activity Avoid awkward posturing Limit repetitive grasp Larger handles for tools Job analysis Ergonomic assessment Websites for information◦ Racquet Research: www.racquetresearch.com◦ Tennis.com: www.tennis.com

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Patient Education◦ Joint protection/energy conservation◦ Adaptive equipment◦ Safe strengthening and ROM exercises◦ Pain modalities for home

Splinting 1-3 sessions of OT

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Occupational Therapy/Hand Therapy◦ Treat the upper extremity◦ Evaluation◦ Find functional deficits◦ Customize home exercise programs to focus on

these deficits ROM Strength STM/Joint mobilization

◦ Modalities for symptoms◦ Patient education for prevention and self

management

Lisa Choe OTR/L, CHT, MHAFlorida Orthopaedic Institute