Chapter 20: Rehabilitation of Wrist, Hand and Finger Injuries - PowerPoint PPT Presentation

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Chapter 20: Rehabilitation of Wrist, Hand and Finger Injuries

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Chapter 20: Rehabilitation of Wrist, Hand and Finger Injuries Rehabilitation Techniques for Specific Injuries Distal Radius Fractures Pathomechanics Simple extra ... – PowerPoint PPT presentation

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Title: 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, NSAIDs, 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
Boxers 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
DeQuervains 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
  • NSAIDs 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 (Gamekeepers
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
  • Stesners 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 ADLs 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
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